RESIDUAL

RIDGE
RESORPTION
CONTENTS:
 Introduction
 Pathology
 Pathophysiology
 Pathogeneis
 Changes in maxilla and mandible
 Etiology
 Management
 references
Introduction

Residual ridge is a term used to describe the

shape of the clinical alveolar ridge after healing
of bone and soft tissues after tooth extractions.
It consists of the denture-bearing mucosa,
submucosa and periosteum, and the underlying
residual alveolar bone.
Consequences of RRR
•Apparent loss of sulcus width and depth.
•Displacement of the muscle attachment closer to the
crest of the residual ridge.
•Loss of vertical dimension of occlusion.
•Reduction of lower face height.
•An anterior rotation of the mandible.

•Increase in relative prognathia.

•Changes in inter-alveolar ridge relationship.
•Morphological changes such as sharp, spiny, uneven
residual ridges.
•Resorption of the mandibular canal wall and exposure of
the mandibular nerve.
•Location of the mental foramina close to the top of the
mandibular residual ridge.
Basic concept of bone:
A basic concept of bone structure and its functional
elements must be clear before bone resorption can be
understood. The structural elements of bone are:
a) Osteocytes found in bone lacunae.
b) The intercellular substance or bone matrix consisting of
fibrils and calcified cementing substance.
c) Osteoblasts.
d) Osteoclasts
(a) Osteocytes:
These are small, flattened and rounded cells
embedded in the bone lacunae.
They are the main cells, of the developed bone and
are derived from the matured osteoblasts.
Function:

help to maintain bone as a living tissue because of

their metabolic activity.

Calcified cementing substance:

Consists of mainly polymerized glycoproteins and
mineral salts namely CaCo3 and phosphate which
are bound to these protein substances.
(c) Osteoblasts:
Concerned with bone formation and are situated on the
outer surface of bone in a continuous layer.
Functions:
• Responsible for synthesis of bone matrix.
• Role in calcification.
(d) Osteoclasts:
They are the giant multinucleated cells found in the
lacunae of bone matrix.
Functions:
• Responsible for bone resorption during bone
remodeling. Bone resorption always requires the
simultaneous elimination of organic and inorganic
components of the intercellular substance.
Mechanism of bone resorption
•The organic components of the intercellular substance
are removed by proteolytic action of the osteoclasts.
•Then, the Ca salts (inorganic) are dissolved by a
chelating action of the osteoclasts.
•As resorption takes place, the osteocytes released may
revert to osteoblasts or become osteoclasts, depending
on the physiologic and pathologic demands.
• Histologically, bone apposition and resorption take
place in close approximation, making possible the bone
balance of shape and size.
Pathology of RRR
Gross pathology:

In order to provide a simplified method for categorizing

the most common residual ridge configurations, a system
of six orders of RR form has been described.

Order 1 - Pre extraction

Order 2 - Post extraction
Order 3 - High, well-rounded
Order 4 - Knife edge
Order 5 - Low, well-rounded
Order 6 - Depressed
•It is clear that RRR does not stop with the residual
ridge , but may well go below where the apices of the
teeth were, sometimes leaving only a thin cortical plate
on the inferior border of the mandible or virtually no
maxillary alveolar process on the upper jaw.

•Sometimes a knife edge ridge maybe masked by a

redundant or inflamed soft tissue, which can be detected
by palpation or by Lateral cephalometric radiographs.
Microscopic pathology:
• Studies have revealed evidence of osteoclastic activity
on the external surface of the crest of the residual ridges.
The scalloped margins of Howship’s Lacunae sometimes
contain visible osteoclasts .
•Studies have shown total absence of periosteal lamellar
bone on the crest of the residual ridge, and a presence of
cortical layer consisting of an endosteal type of bone, or no
cortical layer but simply a medullary type of trabecular
bone.
•Varying degrees of inflammatory cells ,including
lymphocytes and plasma cells, have also been seen.
PATHOPHYSIOLOGY OF RRR
•It is a normal function of bone to undergo constant
remodeling throughout life through the process of bone
resorption and bone formation.

•Growth : ↑ Bone formation.

•Osteoporosis/localized periodontal disease: ↑ Bone

resorption.
•RRR is a localized pathologic loss of bone that is not
built back by simply removing the causative factors.
•Yet, the physiologic process of internal bone
remodeling goes on even in the presence of this
pathologic external osteoclastic activity that is
responsible for the loss of so much of bone substance.
•It has been shown that remodeling takes place in 3
dimensions such that certain portions of bone become
narrower to the extent that all existing cortical bone in
that area is removed by external osteoclastic activity
and is replaced by a new cortical layer that is formed
by simultaneous endosteal bone formation.
•Even if a great deal of RR is removed in total, there is
often a cortical layer of bone over the crest of the ridge.
This means that new bone has been laid down inside the
RR in advance of the external osteoclastic removal of
bone.
•The mechanism of the reduction of the mandibular
residual ridge actually represents a modified version of
the Enlow’s “V” principle, showing external resorption
accompanied by endosteal deposition.
Based on the clinical fact that :
•RRR is not inevitable
• Its rate varies
• The rate of resorption is greater that the rate of
formation in some patients ,

….RRR should be considered a pathologic

process.
Pathogenesis of RRR
Order I: pre-extraction: The tooth is in its socket with thin
labial and lingual cortical plates merged with the lamina
dura.

Order II: postextraction: The healing period includes clot

formation and organisation, filling of the socket with the
trabecular bone and epithelisation over the socket site. The
edges of the residual ridge are still sharp.

Order III: High , well rounded residual ridge: The cortical

plates are rounded off by external osteoclastic resorption,
narrowing of the crest of the ridge begins and remodelling
of the internal trabecular structure takes place.
Order IV: Knife edge RR : Sharp narrowing of the labio-
lingual diameter of the crest of the ridge with a
compensatory internal remodelling leading to a sharp
crest of the ridge.
Order V: Low well rounded RR : Progressive labio lingual
narrowing of knife edge ridge leads to a widely rounded
and lower residual ridge.
Order VI: Depressed RR: Eventually further progression of
the resorption leads to a flat, depressed ridge.
•RRR is chronic, progressive, irreversible and
cumulative. Usually, RRR proceeds slowly over a
long period of time flowing from one stage
imperceptibly to the next. Autonomous regrowth
has not been reported. Annual increaments of
bone loss have a cumulative effect leaving less and
less residual ridge.
Changes In The
Maxilla And The
Mandible
•Maxillary teeth are generally directed downward
and outward, so bone reduction generally is upward
and inward. Since the outer cortical plate is thinner
than the inner cortical plate, resorption from the
outer cortex tends to be greater and more rapid. As
the maxilla becomes smaller in all dimensions, the
denture bearing area (basal seat) decreases.
•The bone of the maxillae resorbs primarily from the
occlusal surface and from the buccal and labial
surfaces.
•Thus the maxillary residual ridge looses height and
maxillary arch becomes narrower from side to side
and shorter anteroposteriorly.
•The anterior Mandibular teeth generally incline
upward and forward to the occlusal plane, whereas the
posterior teeth are either vertical or incline slightly
lingually.
•The mandibular ridge resorbs primarily from the
occlusal surface.
•Because the mandible is wider at its inferior border
than at the residual alveolar ridge in the posterior part
of the mouth, resorption, in effect, moves the left and
right ridges progressively farther apart.
•The mandibular arch appears to become wider, while
the maxillary arch becomes narrower.
•Thus, RRR is centripetal in maxilla and centrifugal
in mandible.
•The cross section shrinkage in the molar region, is
downward and outward. In the anterior region it is
first downward and backward ,and then moves
forward.
•The surface of the arches maybe resorbed out of
parallelism which can result in diminished stability of
dentures.
•Severe ridge resorption can also result in increased
inter arch space.
Epidemiology of RRR:
•To date, it would appear that RRR is world-wide,
occurs in males and females, young and old, sickness
and in health, with and without dentures and is
unrelated to the primary reason for the extraction of
the teeth (Caries / periodontal disease).
•Rate of RRR is variable
-between persons.
-within the same person at diff. times.
-within the same person at diff. sites.
Etiology of RRR
It is postulated that RRR is a multifactorial,
biomechanical disease that results from a
combination of:
• Anatomic.
• Metabolic.
• Functional.
• Prosthetic factors.
ANATOMIC FACTORS:
It is postulated that RRR varies with the quantity and
quality of the bone of the residual ridges:
RRR α anatomic factors

The amount of bone:

• It is not a good prognostic factor for the rate of RRR,
because it has been seen that some large ridges resorb
rapidly and some knife edge ridges may remain with little
changes for long periods of time.
•Although the broad ridge may have a greater potential for
bone loss, the rate of vertical bone loss may actually be
slower than that of a small ridge because there is more
bone to be resorbed per unit of time and because the rate
of resorption also depends on the density of bone.
Quality of bone:
On theoretic grounds, the denser the bone, the slower
the rate of resorption because there is more bone to be
resorbed per unit of time.

METABOLIC FACTORS.
Generally, body metabolism is the net sum of all the
building up (anabolism) and the tearing down (catabolism)
going on it the body.

RRR α bone resorption factors

bone formation factors
•In equilibrium the two antagonistic actions (of
osteoblasts and osteoclasts) are in balance. In
growth, although resorption is constantly taking
place in the remodeling of bones as they grow,
increased osteoblastic activity more than makes up
for the bone destruction.
•Whereas in osteopor
FUNCTIONAL FACTORS
•Forces within the physiological limits are beneficial
in their massaging effect. On the other hand,
increased or sustained pressure produces bone
resorption.
•Bone that is used as by regular physical activity
will tend to strengthen within certain limits , while
bone that is in disuse will tend to atrophy.
Disuse atrophy

•It is directly proportional to the extent of disuse.

•It does not result from the direct loss of non

functional bone, but the lack of replacement of bone
not needed for function.
•After the loss of natural teeth, bone cannot be
stimulated by a denture base as the teeth did
internally. The lack of internal stimuli contributes
to the disuse atrophy.
PROSTHETIC FACTORS
 Excessive stress resulting from artificial
environment:

• Human tissues have not evolved in nature to

accept ranges of artificial things and the denture
acts as an artificial entity.

 Abuse of tissues from lack of rest:

• Abused tissues are always manifested with a
slung, glistering surface..
 Long continued use of ill fitting dentures:
• In ill fitting dentures, there is an improper relation of
the denture base to the supporting tissue. Ill fitting
dentures may be due to :
• Long use
• Loss of bone
• Incorrect occlusion
• Incorrect jaw relation
 UNDER EXTENDED DENTURES:
• Lead to less retentive dentures and increase load
per unit area. Common sites are:
• Lingual flange
• Buccal shelf area
• Retromylohyoid area
• Retromolar pad
 Faulty improper procedures employing
compression forces:

 Before impression procedures, care has to be

taken on selection of trays. If the tray selected is
too large, it will distort the tissues around the
borders of the impression, away from the tissues.
If it is too small, the border tissues will collapse
inward onto the residual ridge. This will reduce
the support of the lips by the denture flange.
 Error in relating maxilla to the cranial landmarks
(orientation relation):
The plane of the maxilla should be oriented to the facial
reference line (Camper’s plane or ala tragus line). If not,
may cause instability of denture leading to resorption.
 Lack of freeway space due to increased vertical
dimension of occlusion:
Freeway space is present in the teeth in the physiologic
rest position. It is normally 2-8mm but in complete
dentures it is around 2mm. At times, due to lack of
freeway space the bone resorbs because of increased
vertical height in an attempt to create the space.
 Incorrect Centric relation record:
If the Centric relation is not recorded properly, the
mandibular teeth will not occlude properly with those on
the maxillary arch. This proper occlusion is essential to
the health of bony support. Otherwise, during eccentric
movement, it causes pressure on bone due to failure of
denture stability. Hence resorption of base occurs.
Faults in selection and placement of posterior teeth:
The selection of proper tooth size is based on :
•Space available for the teeth.
•When the ridge is weak, resorbed and covered
by only lining mucosa, then the use of the
posterior teeth should be smaller. This will limit
the occlusal surface, which in turn will minimize
the forces directed to such a ridge.
 If occlusal corrections are not done:
• These errors which may be caused due to processing
techniques if not corrected causes premature contacts
resulting in increased stress.
 Overclosure
• The loss of proper vertical dimension after the insertion
of complete dentures results in the triggering of a cyclic
series of events detrimental to the health of the residual
alveolar ridge.
Bone resorption and Ca homeostasis:
The only sources of Ca for the body are
•Diet
•Bone reservoir.
•Ca homeostasis is maintained by controlling Ca
obtained from these 2 sources.
Osteoporosis and RRR
•Osteoporosis is characterized by low bone mass and micro
architectural deterioration of the bone, which leads to
increased bone fragility and risk of fracture.
•It has two forms.
•The more prevalent Type I (post menopausal) affects
women for a decade or so after menopause.
•Both cortical and trabecular bone are affected.
Treatment for osteoporosis
•Estrogen replacement therapy
•Ca supplement
•Good nutrition and regular exercise

Detection of bone loss i.e. radiographs

•Digital subtraction radiography
•Dual energy x-ray absorptiometry
Methods of evaluation of bone loss in RRR
• Radiographs:
- Cephalometrics .
- Panoramic.
• Tetracycline labeling
• Mercury porosimetry
• Anatomic studies
• Remount jig procedure
Management of RRR
Systemic evaluation
Diet
Tissue treatment therapy
Pre prosthetic surgery
Prosthetic management:
-Impression techniques.
-Denture base selection.
-Teeth selection and arrangement.
-Implant supported prosthesis.
Systemic evaluation
•Any systemic condition that can contribute to the
degeneration of the bone condition should be
corrected and stabilized, for e.g.: osteoporosis,
hyperparathyroidism, diabetes mellitus.
•In cases where limited help can be given, the patient
should be counseled about its effect on dental health.
Diet.
•Patients with bone disease need a diet high in
proteins, vitamins and mineral content.
•Should reduce or stop intake of refined
carbohydrates, white flour, and white sugar.

Tissue Treatment Therapy.

•Soft conditioning materials can be used to
rejuvenate the tissue-bearing area.
•Hypertrophied tissues, previously treated by
surgery, can be reconditioned by using this material.
Pre-prosthetic surgery
It aims at providing a good healthy surface for the
insertion of the dentures.
It includes the following surgical procedures:
•Ridge correction.
•Ridge extension/vestibuloplasty.
•Ridge augmentation
•Surgical correction of maxillomandibular relation.
Ridge Corrective surgery
Soft tissue deformities
•Labial frenectomy.
•Lingual frenectomy.
•High buccal frenal attachments.
•Hyperplasia of soft tissues.
Bony deformities
•Sharp irregular ridge.
•Alveoloplasty.
•Alveolectomy.
•Excision of tori and genial tubercles.
Ridge extension surgery/vestibuloplasty
•Labial.

•Lingual.

•High mental foramen.

•Zygomaticoplasty.

•Tuberoplasty.
Ridge augmentation
It is aimed at :
•Increase in the ridge height and width
providing a large denture bearing area ,
•Protection of neuro vascular bundles
•Restoration of proper maxillomandibular arch
relationship.
Ridge augmentation has been tried with:
•Bone transplants
•Autogenous and homogenous cartilage
•Hydroxylapatite
•Acrylic implants.
Prosthetic management.
Impression technique
In patients with severely resorbed ridges, lack of ideal
amount of supporting structures decreases support and
the encroachment of the surrounding mobile tissues onto
the denture border reduces both stability and retention.
Thus the main aim of the impression procedure is to
gain maximum area of coverage.
• Selective pressure technique:

• This technique is most widely advocated to manage

RRR.
• Winkler describes a technique which uses tissue
conditioners. An over extended primary impression of
alginate is made.
3 applications of conditioning material are used – each
application approximately 3-10 minutes. The third and
final wash is made with a light bodied material. This
technique results in the impression that has tissue
placing effect with relatively thick, buccal, lingual and
sublingual crescent area borders.

•Miller used mouth-temperature waxes instead of tissue

conditioners .
Mucodynamic technique.
It is intended to integrate the changes in the shape of
the vestibules when functional movements are made. A
highly viscous thermoplastic reversible impression
material is placed in the custom tray, then carefully
adapted to the residual ridge and held with light and
uniform pressure while the functional movements are
made.
Selection of denture base
For degenerative ridge patients there are three types of
denture bases:
•Methyl methacrylate resin denture bases
•Cast metal bases
•Processed resilient , lined denture bases
Methyl methacrylate resin denture bases
•These are the standard bases normally used.
•These bases are quickly and easily processed.
•Dimensionally stable.
•But in a short time the base appears to soften and change
color, and is not strong.
Cast metal bases.
•Main advantage is the great accuracy of fit to the
tissues by surface tension, than acrylic denture bases.
•They maybe of gold, chromium cobalt or aluminium.
Processed resilient , lined denture bases.
Its greatest advantage is its cushioning effect on the
mucosa and its ability to distort and spring back.
Limitations:
•They can be used only under a hard-processed
acrylic resin base, and the lining works best when
there is a 2 mm thickness.

•Deterioration of the liner in some mouths.

In spite of this , it can be held up well in dentures

by proper cleansing and brushing with soft tooth
brush.
Teeth selection and arrangement
Teeth can be selected acc. to their form and size:
•Anatomic or cuspal teeth
•Semi anatomic teeth
•Non anatomic or zero degree teeth.
The following requirements have to be met during
teeth arrangement:
•Unlocking of the cusps mesio distally to accommodate
the settling of denture bases.
•Non anatomic teeth have known to cause fewer
denture sore spots and lesser ridge resorption.
•Semi anatomic reverse curve posterior teeth favor
the lower ridge
•Anatomic posterior teeth cause more denture
soreness and ridge resorption.
•Few studies state that anatomic posterior occlusion
favors lower dentures and non anatomic posterior
teeth favor upper denture.
Implant supported prosthesis.
The various problems associated with RRR and stability
of removable soft tissue borne dentures have aroused
interest in dental implantology to provide stable
mechanical support to the dental prosthesis.

Maintenance of alveolar bone

•Maintenance of occlusal vertical dimension.
•Height of alveolar bone is found to be maintained as
long as the implant remains healthy.
•Improved psychological health.
Prosthodontic classification of implants.
FP-1 : Fixed prosthesis replacing only crown.
FP-2 : Fixed prosthesis replacing crown and
portion of root.
FP-3 : Fixed prosthesis replacing missing crowns
and portion of the edentulous site.
RP-4 : Removable prosthesis : overdenture
supported by implants.
RP-5 : Removable prosthesis : overdenture
supported by both soft tissue and implant.
References:
•Ortman HR: Factors of bone resorption of the residual
ridge. J Prosthetic Dent 1962;12,3:429-440.
•Atwood DA: Reduction of residual ridges: A major oral
disease entity. J Prosthetic Dent 1971;26:266-279.
•Atwood DA: Some clinical factors related to rate of
resorption of residual ridges. J Prosthetic Dent
2001;86:119-125.
•Wendt DC: The degenerative denture ridge – Care and
treatment. J Prosthetic Dent 1974;32,5:477-492.
•Ortman HR : The role of occlusion in preservation and
prevention in complete denture prosthodontics. J
Prosthetic Dent 1971;25,2:121-138.
•Sobolik FC : Alveolar bone resorption. J Prosthetic Dent
•Jahangiri L, Devlin H, Ting K et al :Current perspectives
in residual ridge remodelling and its clinical implications:
A review. J Prosthetic Dent 1998;80;224-237.
•Atwood DA : Post extraction changes in the adult
mandible as illustrated by microradiographs of midsagittal
sections and serial cephalometric roentgenograms. J
Prosthetic Dent 1963;13:810-824.
•Winkler S : Essentials of complete denture
prosthodontics. 2nd edition,2000.
•Boucher CO : Prosthodontic treatment for edentulous
patients. 12th edition,2004.
•Alfred H G :Color Atlas of Dental Medicine – Complete
Denture and Overdenture Prosthetics.2nd edition,1993.
•Misch CE : Contemporary implant dentistry. 2nd
edition,1999.
•Eroshenko VP : di Fiore’s Atlas of histology. 7th
edition.1993.
• Questions
• Definition of RRR
• Pathophysiology of RRR
• Managment of RRR