Residual Ridge Resorption Seminar PART 2

• The residual ridge consists of the denture bearing mucosa, the sub mucosa,
periosteum and underlying residual alveolar bone.
Following extraction of teeth, the empty dental alveoli is filled with blood
which sequentially clots, organized and is replaced by new bone.
21/07/2023 residual ridge resorption 1

• Histologic evidence of active bone formation in the bottom of the socket and
bone resorption at the edge of the socket are seen as early as 2 weeks after the
tooth extraction, and the socket is progressively filled with newly formed bone
in about 6 months.
• Rapid bone remodeling subsides by this time but continuous bone resorption
may persist at the external surface of the crestal area of the residual alveolar
bone, resulting in considerable morphologic changes of bone and overlying soft
tissues over the years.
• This phenomenon has been described as the REDUCTION OF RESIDUAL RIDGES
or RESIDUAL RIDGE RESORPTION (RRR).

• Once healing process is over one might expect that the treatment
of edentulous patients consists of 2 phases i.e. construction of
prosthesis and early post insertion adjustment phase.
• This may be complicated by a fact that the residual ridges resorb.

CLASSIFICATIONS

Classifications for mandibular ridges
I) Atwoods classification
Six orders of mandibular anterior residual ridge forms based on their pattern
of resorption :-
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

:
MISCH’S CLASSIFICATION Based on bone density.
D5- A very soft bone, with incomplete mineralization

Seibert’s classification

EPIDEMIOLOGY

• To date it has appeared that RRR is world wide
• Occur in
males and females
young and old
sick and healthy
in denture users or not
teeth extracted or other cause (periodontal etc)
• Studies also suggest increased knife edge tendency (KET) in

mandibular residual ridge in women compared to men.
• KET = Change in area /Change in height

AETIOLOGY

According to Winkler
ANATOMICAL FACTORS METABOLIC FACTORS
RRR
MECHANICAL FACTORS
Another factor, the time

since extraction can also
be included

Leila Jahangiri 1998
• Anatomic
• Prosthodontic.
• Metabolic.
• Functional.
• Others.
Leila jahangiri textbook of clinical cases in prosthodontics-edition 1 2011

Anatomical factors
• quality of bone
• quantity of bone
• Muscle attachments
• Shape of residual alveolar ridge
RRR α anatomic factors

Metabolic factors
Local factors Systemic factors

1 endotoxins from plaque 1 osteoporosis
2 osteoclast activating factor 2 role of calcium
3 prostaglandins 3 role of phosphorous
4 human gingival bone resorption 4 body mass index
stimulating factor 5 fluorine
5 heparin (co factor for bone
resorption)
6 trauma due to ill fitting
dentures(changes in vascular
tension)

PROSTAGLANDINS: MEDIATOR OF RRR
• PG’s are released from many kinds of cells including inflammatory cells such
as neutrophilic granulocytes and macrophages as well as local mesenchymal
cells such as osteoblasts and cells of the periodontal ligament. Mechanical
stimulation of osteoblastic cells in vitro caused a significant elevation cAMP
and PG synthesis.
• These findings may suggest the connective tissue contraction associated

with extraction site towards the crest of the residual ridge stimulates PG
synthesis.
• The phenomenon may explain a mechanism of localized bone resorption at

the crest area of the residual ridges by the PG activities. The continuous and
localized bone resorption in ridges may be caused by continuous synthesis of
local PG.
Role of calcium
Ca is the principal constituent of the skeleton.
When the intake of calcium from dietary sources is less than the
metabolic requirements and the obligatory loss of the mineral,
then calcium is withdrawn from the skeleton to maintain the critical
concentration of the element in the blood and tissue fluids.
The parathyroid gland controls the dissolution of bone for the

provision of calcium
The primary source of available calcium is trabecular bone,

not cortical bone.

• The sites of trabecular bone which supply mobile calcium are the jaws. ribs,
bodies of the vertebrae, and the ends of the long bones.
• A significant finding from animal experimentation and from the examination of

human necropsy specimens is that, when skeletal depletion of calcium occurs
as a result of stimulation of the parathyroid gland, alveolar bone is affected
first, the ribs and the vertebrae are affected second, and the long bones third.
• Prolonged depletion results in disorganization and loss of trabeculae, followed

by cortical remodelling or structural failure.
• Under these conditions , alveolar bone becomes susceptible to diseases like

osteoporosis.

A subsequent preliminary study of 35 edentulous patients
suggested a positive correlation between total serum calcium
levels and of residual mandibular edentulous ridge height
irrespective of length of denture use.
Zmystowska E, Ledzion S, Jedrzejewski K: Factors affecting mandibular residual ridge resorption in edentulous patients: a
preliminary report. Folia Morphol 2007;66:346-352

Role of phosphorus: -
For many species of experimental and domestic animals, an excess of

phosphorus in the diet causes a secondary hyperparathyroidism which in
turn results in abnormal bone resorption. The problem is compounded
when calcium intake is inadequate at the same time.
The diets of subjects with minimal bone resorption were compared with
the diets of subjects with severe alveolar destruction. The results indicate a
positive correlation among low calcium intake, calcium/phosphorus
imbalance, and severe ridge resorption.
Studies of residual ridge resorption. Part II. The relationship of dietary calcium and phosphorus to residual
ridge resorption*- Kenneth E. Wical, D.D.S., M.S.D., and Charles C. Swoope, D.D.S., M.S.D.
University of Washington, School of Dentistry, Seattle, Wash.

• Bone mineral density and RRR
• Low bone density in the skeleton is accepted as a predisposing factor for

rapid RRR.
• High local BMD values has been seen as an indication that bony tissues
are protected against RRR
• Klemetti and Vainio reported that the remaining height of the edentulous
mandibles was more dependent on the BMD values of the femoral bone
• The height of the maxillary ridge, on the other hand, seemed to be more
closely related to the lumbar values.
• This may be because the amount of cortical bone in the femoral neck,
approximately 75% is similar to that in the mandible and the bone in both
the lumbar spine and the maxilla is primarily trabecular.

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.
The Type II ( senile or idiopathic) attacks males and females at any age for
no obvious reason.
RRR maybe a manifestation of Type I osteoporosis .
Both cortical and trabecular bone are affected.

Kribbs et al. indicated that in postmenopausal women with osteoporosis the
height of the edentulous alveolar ridge is correlated with the total amount of
calcium in the body.
This finding suggests that individuals with severe osteoporosis retain less
alveolar bone once the teeth are extracted.

BMI and residual ridge resorption
• The jaws of heavy subjects are probably more massive and thick than the jaws
of smaller individuals.
• The size of an individual may play an important role in the density of the
residual ridges.
• Heavy subjects with large jaws have more bone substance to be lost, hence
slow rate of resorption
Klemetti E, Vainio P, Lassila V, et al: Relationship between body mass index and the remaining alveolar
ridge. J Oral Rehabil 1997;24:808-812

Fluorine and RRR
• A study evaluated 230 postmenopausal in Finland.
• The use of fluoridated water for more than 10 years was found to
positively correlate with improved retention of the residual ridges in
both dental arches.
E.Klemetti ,H.Kroger & l.Lassila, et al Fluoridated drinking water, oestrogen therapy and
residual ridge resorption J Oral Rehabil 199724; 47-51

RRR α bone resorption factors
bone formation factors

• A study at the University of Iowa suggested that RRR was associated with the
length of time edentulous in women, but no corresponding association was
found in the male patients studied.
• Similar findings were reported by Xie et al.
Nahri TO, Ettinger RL, Lam EWM: Radiographic findings, ridge resorption, and subjective
complaints of complete denture wearers. Int J Prosthodont 1997;10:183-189
Xie Q, Ainamo A, Tilvis R: Association of residual ridge resorption with systemic factors in home-
living elderly subjects. Acta Odontol Scand 1997;55:299-305

Mechanical factors
• Force factors play an important role in the aetiology
of RRR
Extraction of teeth
residual ridges are subjected to

different types of forces
RRR
Source of forces on denture
• Mastication
• Swallowing
• Talking
• Smoking
• Clenching and grinding (parafunctional habits)
All these can place pathological loads on the residual

ridge causing resorption

Force related factors on which
RRR depends
• Amount of force
• Frequency of force
• Duration of force
• Direction of force
• Area over which force is distributed (force per unit
area)
RRR α force

• Damping effect or energy absorption
This effect may take place in mucoperiosteum which is

considered as a viscoelastic material
RRR α 1
damping effect

PROSTHETIC FACTORS
 Excessive stress resulting from artificial environment:
 Abuse of tissues from lack of rest:

 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:
 Application of unacceptable pressure over the basal seat areas which

cannot tolerate them leads to RRR
 Pressure, within limits can be applied over the stress bearing areas and the
other areas which are not intended to take up pressure must be relieved to
 If not, unwanted pressures may lead to RRR

 Error in relating maxilla to the cranial landmarks (orientation relation):
.
 Lack of freeway space due to increased vertical dimension of occlusion:
 Overclosure

 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 :
Capacity of ridges to receive and resist the forces of mastication.
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.

 Premature contacts:
 These errors which may be caused due to processing techniques if not
corrected causes premature contacts resulting in increased stress.
 Selective grinding should be done to minimize lateral stress and

resulting tissue trauma.

• The so-called combination syndrome (combination of complete and
partial removable dentures) can also cause the resorption process.
• Patients with an upper complete and lower partial denture, combined

with lower frontal natural teeth risk bone structure loss in the frontal
part of the maxilla caused by the loading of the lower frontal natural
teeth on the upper complete denture.
Resorptive Changes of Maxillary and Mandibular Bone Structures in Removable Denture Wearers. Acta Stomatol
Croat, Vol. 36, br. 2, 2002
 Disuse atrophy
• RRR directly proportional to the extent of disuse.
• 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.

RRR α anatomical factors + bone resorption factors + force factors + 1
bone formation factors damping effect time

PATHOGENESIS

Pathogenesis sequence
extraction of teeth
rounding of sharp edges by external osteoclastic activity
high well round ridges
Resorption from labial and lingual aspects
knife edged ridges
becomes shorter and disappears

low well rounded or flat ridges
Further resorption
depressed ridges
Involve the basal bone also

According to misch
• Bone loses width, then height, then width, and
then height again

PATHOLOGY

This involves
a. Macroscopic pathology (gross)
b. Microscopic pathology
Gross pathology
This is expressed by patients – “my gums have shrunk”
Clinically noticed as
 Basic structural change is reduction of bony ridge
 Wide variations in shape and size of residual ridges
 Dry specimen studies reveal external cortical surface of maxilla and
mandible are smooth but porous crestal area.
 Resorption does not stop with residual ridges but also involves basal
bone

B)microscopic pathology
Evidence of osteoclastic activity on external surface of crest of the
ridge
Scalloped margins of howships lacunae contain visible osteoclast

PATHOPHYSIOLOGY OF RRR

Bone In normal conditions Bone In residual ridge resorption
Normal function of bone is to undergo remodelling Loss of bone occur that is not built back
where the bone resorption and formation are in To date the process of RRR has not been reversed
equilibrium such that the ridge increased in size
According to Enlows principle it is clearly illustrated The endosteal bone growth fails to keep in pace
that normal growth pattern of long bones shows with the external osteoclastic activity which results
remodelling taking place in 3 dimensions that in the absence of cortical layer and exposure of
certain portions of bone become narrower to an medullary layer to external surface of bone
extent that the entire cortical bone layer is removed resulting in defects of ridge
and replaced by a new cortical layer and
simultaneous endosteal bone formation

• Some would postulate that residual ridge resorption is a physiological process on
the premise that the removal of tooth eliminates the raison d’etre for alveolar
bone
• But clinical facts that

RRR is inevitable
RRR varies from person to person and in different sites in same
individual
RRR also proceeds beyond the alveolar bone i.e. to basal bone
• So RRR must be practically considered as a pathological process

PATTERNS AND RATE OF RESORPTION

Maxilla resorbs in upward and inward direction
Mandible resorbs in downward and outward
direction
[OR]
The maxilla resorbs in a superioposterior direction,

the mandible resorbs in an inferioanterior direction
[OR]

The mandibular arch appears to become wider, while the maxillary arch
becomes narrower so
Maxilla resorbs centripetally
Mandible resorbs centrifugally
[OR]

• Rate of resorption is more in first 3-6 months after extraction
• Rate of resorption in mandibular edentulous to that of maxilla is 4:1
• Resorption is almost even all around in the maxillary but may be more
in the labial and buccal direction than palatal
• Mandible resorption proceeds more in labio-lingual and vertical

directions.
• Unlike in maxilla, the speed of bone loss in mandible is different in

different parts of the jaw: distal parts of the residual ridge disappear
faster than the anterior parts.
Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed-
longitudinal study covering 25 years. J Prosthet Dent 2003;89:427-435

• Carlson and Pearson at al
• Post extraction study of mandibular bone loss
Patients with First 2years First 5 years 3-5 years
Least RRR 0.75 0.4 0.13

Mean RRR 2.75 1.36 0.5
Most RRR 4.5 2.9 1.8
Measurement in mm
Carlsson GE et al histological changes of upper alveolar process after extraction with or with out insertion of a
immediate full denture. Acta odontol scand 1976 25:21-43

According to boucher: -
The reduction in residual ridge height in the mid sagittal
plane in the first year is
2-3 mm for maxilla
4-5 mm for mandible
Not only does the volume of the ridge decrease, but also
the density of the basal portion decreases as a result of the
diminished function

According to Misch: -
• After the initial loss of teeth the average first-year bone loss is
more than 4 mm in height and 30% in width.
• Although the rate is slower, bone loss from tooth extraction

continues throughout life

• Tylman and Tylman (1960) found that in the maxillae, the labial
and the buccal alveolar plates resorb much faster than the palatal
plates, while in the mandible the amount of bone resorbed in the
lingual and labial are approximately the same.

In case of implant placed ridges maxilla shows more resorption than
mandible.
Why more bone loss in maxilla with implants???

• Poor bone quality in maxilla

RATIONALE FOR GREATER
RESORPTION OF MANDIBLE
THAN MAXILLA

• Woelfel et al have cited a patient with a projected maxillary denture
area of 4.2 in2 and a projected mandibular denture area of 2.3 in2
(ratio 1.8:1)
• When such patient bites with a pressure of 50lb, it is calculated to

be that
12lb/in2 is under maxillary denture and
21 lb/in2 is under the mandibular denture
• So it is logistic to postulate that this difference may cause greater

resorption in mandible
Woelfel. The effects of complete denture on alveolar mucosa. Journal of Prosthetic Dentistry 1963; 13:103-7.

• According to Frost , bones which are subjected largely to compression loads
and no significant bending loads, are composed largely of cancellous bone,
which is ideally constructed for absorption and dissipation of energy
(damping effect).
• The fact that the maxillary residual ridge is broader flatter and more
cancellous than its mandibular counterpart which may be a factor for
differences in RRR of two jaws.
• He also states that the trabecular pattern in bones like maxilla and
vertebral body are oriented parallel to the direction of compression
deformation thus allowing a maximum resistance to deformation
Frost. The remodeling of the edentulous mandible Journal of Prosthetic Dentistry. 1976; 36:685

Atwood DA: reduction of residual ridges: a major oral disease entity. J prosthodontic dentistry 1971;26:266-279
1
2
3
Anterior vertical bone loss in mm

maxilla
4
5
6
7
8
9
10
11
12
13
mandible
14
15
16
Maxilla 3mm in first 3years 17
Immeasurable there after 18
total
Mandible 14.5mm in 19 19
years 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Time in years

CONSEQUENCES OF RRR

Soft tissue changes
• Apparent loss of sulcus width and depth.
• Displacement of the muscle attachment closer to the crest of the

residual ridge.

• Muscle attachments, such as those of the vestibule, will be located more toward
the centre of the residual ridge and will be more apparent when the alveolar
bone resorbs.
• This change of location is also visible in the anterior region of the mandible where
bone resorption can rapidly reach the mucogingival junction, at which the strong
mentalis muscle is attached

Changes in mandible
• An anterior rotation of the mandible.
• Increase in relative prognathism.
• 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.
• Mylohyoid ridge become prominent.

Changes in maxilla
• In maxillary arch resorption may bring sinus close to crest
• Incisive foramen moves more towards crest of the ridge.
• Zygomatic process becomes close to crest of ridge in molar region.

• Changes in inter-alveolar ridge relationship.
• Loss of vertical dimension of occlusion.
• Reduction of lower face height

• Morphological changes such as sharp, spiny, uneven
residual ridges.
• As a compensation for this resorption i.e. to

maintain the shape of ridge soft tissue overgrowth is
seen

• In fixed partial dentures
Very minimal bone loss i.e. approximately 0mm if adequate plaque control is
maintained
• In partially edentulous patients

Loss of periodontal attachment and marginal bone loss in and around the teeth
In distal extension cases vertical ridge resorption was seen around 5 years after
placing partial denture

According to Misch
• Decreased width of supporting bone.
• Decreased height of supporting bone.
• Progressive decreased in keratinized mucosa surface.
• Prominent superior genial tubercles and sore spots and
increased denture movements.
• Muscle attachments near crest.
• Elevation of prosthesis with mylohyoid and buccinator.

• Forward movement of prosthesis from anatomical inclination
(angulation of mandible with moderate to advanced bone loss)
• Thinning of mucosa with sensitivity to abrasion
• Loss of basal bone
• Paraesthesia from dehiscent mandibular neurovascular canal

• More active role of tongue in mastication

• Effect of bone loss on aesthetic appearance of lower one third of face
• Increased risk of mandibular body fracture from advanced bone loss. (Atrophic
ridge fractures)
• Increased denture movement and sore spots during function caused by loss of
anterior ridge and nasal spine

• The contents of the mandibular canal and mental foramen eventually become
dehiscent and serve as part of the support area of the prosthesis.
• As result, acute pain and transient to permanent paresthesia of the areas
supplied by the mandibular nerve are possible.

Aesthetic consequences of bone loss
• Decreased facial height.
• Loss of labiomental angle.
• Deepening of vertical lines in lip and face

• Rotation of chin forward giving a prognathic appearance.
• Decreased horizontal labial angle of lip making patient look
unhappy.
• Loss of tone in muscle and facial expression.

• Deepening of nasolabial groove
• Increase in columella-philtrum angle

• Thinning of vermilion border of lips from loss of
muscle tone
• Increased length of maxillary lip so that fewer teeth

show at rest and smiling which ages the smile

• Ptosis of buccinator muscle attachment which leads to
jowls at side of face
• Ptosis of mentalis muscle attachment

leading to witch’s chin

These consequences provide serious problems to the clinician on how to
provide adequate support, stability and retention of the denture.

• To be continued……………..

AIDS TO DETECT AND MEASURE RRR

Clinically
• Visible as change in morphology of ridges(height and
width of ridge changes)
• Some time the underlying ridge resorption is covered

by soft tissue so, palpating the ridges can reveal the
resorption rate to some extent

• Radiographic : widely used to detect bone resorption and formation by taking periodic radiographs.
Cephalometric: - lateral cephalograms
Panoramic: - OPG
Radiomorphometric indices
• mandibular cortical index
(normal cortex, mild or severe erosions on endosteal margin of the mandible),
• panoramic mandibular index: -The PMI, as described by Benson etal,2:9 is the ratio of the thickness
of the mandibular cortex to the distance between the mental foramen and the inferior mandibular
cortex.

• Placing radiopaque markers in dentures and taking
periodic radiographs- where the marker helps to
reorient the radiograph
Prediction of further residual ridge resorption by a simple biochemical and radiographic evaluation: A
pilot study. Journal of orofacial sciences 2012 vol 4 issue 1 pg 32-34
88
21/07/2023 residual ridge resorption
Tetracycline labeling :
• Injected into the body through oral or pariental administration and should
be repeated after every week for 5 weeks. This tetracycline is taken up by
the bone, only in the new sites of bone formation tetracycline can be readily
identified in the bone as tetracycline calcium chelate formed is fluoroscent
and can be viewed by fluorescence microscopy.
Mercury porosimetry :
• Osteocytes are also capable of bone resorption (i.e. periosteocytic lacunar
bone resorption).
• To determine the quantitative importance of osteocytic resorption mercury
porosimetry was used to makes a comparison between osteocytic and
osteoclastic bone resorption.
• In this method mercury is introduced into pores by pressure and a measure
of the pore volume as a function of pore diameter is obtained

• Anatomic studies: - dried jaw bone studies
• Remount jig method

Proportional area measurement method
• The area was bounded by a line joining gonion to the lowest

point of the mental foramen and the crest of the residual
ridge and was expressed as a proportion of an area that was
not dependent on the ridge.
• The use of proportions rather than actual measurements
minimized errors related to magnification and distortion.
konstantinos kordatzis et al, by quintessence publishing co 2003

MANAGEMENT

Prevention

• Preserve natural teeth by proper reinforcement of oral hygiene and
prophylaxis
• Preserve remaining natural teeth to consider overdenture therapy as :
Transfer of occlusal loads to periodontal ligament of retained roots.
Proprioceptive feedback from PL to muscles of mastication may help to
decrease the occlusal forces
A comparison of conventional immediate dentures and overdentures
showed half the bone loss (o.9mm) in the overdenture group compared
to1.8mm.

• Reduce iatrogenic trauma during extraction.
Preservation of the labial cortical plate aids in preventing
RRR
• Placement of immediate dentures decreases rate of RRR
• Avoid single complete denture syndrome by

preservation and occlusal equilibration of remaining
natural teeth to reduce horizontal torqueing forces on
edentulous ridge

• Adequate design and occlusion of removable partial
dentures and plaque control
• Teeth that support FPD’s do not exhibit significantly

higher marginal bone loss if adequate oral hygiene is
maintained. Mean annual rate of bone loss is close to
0mm for up to 15 yrs.

• Implant supported prosthesis
• Minimal bone loss values observed in implant supported
overdentures and fixed complete prostheses(0-0.08 mm)

Advantages offered by implant supported 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.
There is 20 fold decrease in the loss of structure with implants when

compared with resorption that occurs with removable prosthesis.

Root submergence technique (RST)
To preserve the alveolar bone resorption by retaining the natural

tooth, the concept of the root submergence technique (RST) emerged.
It is a procedure where the tooth is surgically decoronated, and the
root is submerged at the level or below the alveolar crest instead of
extraction.
This technique was introduced in the late 1960s to prevent residual

ridge resorption in complete denture patients.
In 1961, Bjorn was the first person to publish a report of root

submergence.

RST has been described for both vital and non-vital teeth.
Guyer (1975) submerged vital root for the first time in humans and reported vitality
of the pulpal tissue maintained through the apices and collateral occlusal circulation
from the soft tissue.
The advantage of RST is that it preserves the alveolar bone resorption thereby
maintaining the soft tissue profile thus giving aesthetically more favourable result.
It is relatively simple and easy procedure with good proprioceptive, perceptive, and
physiologic patient response.

Criteria for retention:-
1. No more than 1mm horizontal mobility

2. No infrabony pocket that could not be reduced at time of
surgery.
3. Sufficient healthy muco-gingival tissue
4. Selected teeth should be asymptomatic.

Procedure
• JPD 1979;41:12-15
Ridge preservation or Socket preservation
is a procedure in which graft material or scaffold is placed in the socket of an extracted
tooth at the time of extraction to preserve the alveolar ridge.
After extraction, jaw bones have to be preserved to keep sockets in its original shape.
Without socket preservation, the bone quickly resorbs.
The jaw bone will never revert to its original shape once bone is lost and tissue contour
has changed.

Socket Preservation differs from Ridge Augmentation; in Socket
Preservation, the graft or scaffold is placed inside the tooth socket
immediately after extraction, whereas the Ridge Augmentation
grafting procedure is done to bring back the lost bone after the
bone has resorbed and there is insufficient ridge height or width
for further treatment procedure.

Diet
Patients with bone disease need a diet high in proteins, vitamins and
mineral content.
Diet containing calcium is to be advised.
In all dietary prescriptions , the consistency of food prescribed must take
into account the patients ability to masticate.
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.

Impression technique
• Selective pressure/minimal pressure impression technique must be used.

• Maximum coverage of the denture bearing area provides a SNOWSHOE
EFFECT, which distributes applied forces over as wide an area as possible
• This helps in preservation of the ridge
Syllabus of complete denture Charles M Hartwell 4th edition

Centralization of occlusion
• Concept of bringing the working occlusal surfaces
towards centre of the denture foundation
• This produces a favourable leverage thus
minimizing RRR

Teeth selection and arrangement
•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.

Few studies state that anatomic posterior occlusion arranged by following
compensating curves and selective grinding reduces lateral forces on denture
baring area thus reduces RRR
Minimal occlusal stop areas for reduced pressure during function.

Tooth material
•Acrylic resin teeth absorbs more forces than porcelain teeth thus
providing a cushioning effect
•So there is minimum RRR

Treatment
Systemic evaluation
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.
Any dental treatment should follow only after the condition is under control
and the patient is fit for treatment.
In cases where limited help can be given, the patient should be counseled
about its effect on dental health.

Pre-prosthetic surgery
It aims at providing a good healthy surface for the insertion of the
dentures.
It includes all the surgical procedures by virtue of which an ideal smooth,
healthy U shaped ridge , without any unfavorable undercuts or bony
growths and with sufficient vestibular depth is achieved.
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
•Alveoloplasty.
•Alveolectomy.

•Excision of tori and genial tubercles.
•Sharp irregular ridge

Ridge extension surgery/vestibuloplasty
Goals:-
To increase the size of denture bearing area
To increase the height of residual alveolar ridge

maxilla mandible
Labial vestibuloplasty Labial vestibuloplasty
A)Mucosal advancement vestibuloplasty A)Kazanjian’s technique

closed submucous vestibuloplasty B)Godwin’s technique
(Obwegeser) C)Lipswitch technique
open view submucous vestibuloplasty D)Clark’s technique
B)Pocket inlay vestibuloplasty
C)Grafting vestibuloplasty
Obwegeser’s skin graft technique
Lingual vestibuloplasty
Trauner’s technique
Caldwell’s technique
Combination of buccal and lingual vestibuloplasty- Obwegeser (1963)

Tuberoplasty.
• The tuberosity, hamular notch region helps in retention of denture and

also aids in peripheral seal of maxillary denture
• This procedure is done to increase the depth between hamular notch
and distal aspect of maxilla
• Pterygoid plate and Hamulus are repositioned in posterior direction

•Surgical repositioning of nerve- (inferior alveolar nerve)

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.

Mandibular augmentation
Inferior border augmentation
superior border augmentation
Interpositional grafts
Visor osteotomy
Onlay grafts

Maxillary augmentation
Onlay bone grafting

Sinus lift

Distraction osteogenesis

PROSTHODONTIC MANAGEMENT

Denture base
Processed resilient lined denture bases.
Its greatest advantage is its cushioning effect on the mucosa and its ability to
distort and spring back.
Indications:
Patients with severely undercut ridges, but for whom surgery is
contraindicated.
Patients with flat ridge and delicate tissues.(nerves close to crest of ridges)

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.
•These denture bases can be used in severe ridge resorbed conditions to improve stability
This denture base is opted when other treatment options do not provide a solution

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. For e.g., in
mandibular ridge, obtaining a fairly long retromylohyoid flange
helps to achieve a better border seal and retention.
Selection of proper trays and the correct impression procedure is
very essential for an accurate impression.

For flat ridges For flabby ridges
• Admixed technique • William H Filler technique
• Functional impression technique • Hobkirk technique
• technique by inkler • Double spacer technique
• Millers modification of this • Splint Method’ By Allan Mack
technique • Modified Fluid wax impression: (Tan
• Dynamic impression method (G. technique
Tryde, K.Olsson, Jenson) • Selective pressure impression or
• Flange technique by Frank Lott and window technique
Bernard Levin • Zafurulla khan technique
• Cocktail impression • Selective displacive technique
• Impression using elastomers • Jone D Walter technique
• Arthur and Freese technique
• Two-step impression for atrophic
mandibular ridge

Pronged dentures
• Combined surgical and prosthodontic

approach for atrophic maxilla
• Indicated in severely atrophic maxilla

Liquid-supported dentures
In a flabby ridge condition, denture should be able to withstand masticatory
forces and have flexible tissue surface to reduce stress concentration and
trauma on the underlying tissues.
A Liquid-supported denture can hence be a solution for this problem.

• Extreme resorption of the maxillary and mandibular denture bearing areas
results in sunken appearance of cheeks, unstable and non retentive
dentures with associated pain and discomfort.
• Rehabilitation of a patient with atrophic ridges using a hollow maxillary
complete denture with cheek plumpers attached to it and the recording of
neutral zone to ensure a stable mandibular denture.
Management of Compromised Ridges: A Case Report J Indian Prosthodont Soc. 2011 Jun; 11(2): 125–129

connecting line between the midridge line of the maxillary and mandibular
residual ridges are at an angle of more than 80 degrees.
An angle less than 80 degrees necessitates a cross bite or reverse occlusion
arrangement of posterior teeth.
A prognathic mandible necessitates the arrangement of anterior teeth in a
reverse occlusion.

Implant supported dentures
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.
When sufficient amount of support is not attained from alveolar bone adjacent bones
like zygomatic bone and pterygoid bone are taken

Custom endosteal dental implants
• Severely atrophic jaws require patient-specific solutions to support the dental prosthesis
assembly (bar, dentition), such as the custom endosteal dental implant (CEI)
• A Custom Endosteal Implant is a cast surgical-grade titanium metal frame which is custom-
designed to fit snugly to your jawbone.
• Once the implant is placed on the bone, synthetic bone is placed over and around the
implant and then your gums are closed over it.
• Then, removable dentures or fixed partial bridgework are anchored to the implant posts or
a bar above the gums.

Summary

Residual ridge resorption is a chronic, progressive, irreversible, and disabling disease
, of multifactorial origin.
Much is known about its pathology and pathophysiology, but a lot remains to know
about its pathogenesis, epidemiology and etiology.
RRR requires a multiple approach for diagnosis and treatment planning.
The cause must be detected, by the aid of a physician, and then eliminated or
stabilized before dentures are constructed.
Construction of a stable functioning denture and a regular follow up treatment can

help in the restoration of function, and thus, the restoration of the physical and mental
vitality of the patient.

Conclusion

The preservation of supporting tissues is a sacred trust that cannot be
ignored.
The application of the basic concepts and the advances made in the basic
sciences will help to keep this trust in the hands of the dental profession.
As prosthodontists, we need to perform the most meticulous and intelligent
prosthodontic care of the patient within our capabilities.
…and then , it would not seem a nebulous hope that some day there will be
control over residual ridge resorption.

References
Winkler S : Essentials of complete denture prosthodontics. 2nd edition,2000. Pg no:22-38
Boucher CO : Prosthodontic treatment for edentulous patients. 12th edition,2004.
Misch CE : DENTAL IMPLANT PROSTHETICS. 2nd edition,2005.
John J Sharry Complete denture prosthodontics, third edition
Neelima Anil Malik Textbook of oral and maxillofacial surgery 2nd edition
S M Balaji textbook of oral and maxillofacial surgery 2nd edition
Atwood DA : a cephalometric study of the clinical rest position of the mandible. Part II the
variability in the rate of bone loss following the removal of occlusal contacts JPD 1957;7:544-552

• Atwood DA : post extraction changes in the adult mandible as illustrated by
microradiographs of mid sagital sections and cephalometric roentgenograms JPD
1963;13:810-824
• Atwood DA reduction of residual ridges :a major oral disease entity JPD 1971;26:266-
279
• Benson BW, Prihoda TJ, Glass BJ. Variations in adult cortical bone mass as measured by a
panoramic mandibular index. Oral Surgery Oral Med Oral Pathology 1991;71:349-56.
• MANAGEMENT OF HIGHLY RESORBED MANDIBULAR RIDGE International Journal of
Dental and Health Sciences Volume 01,Issue 04 512-522
• Endosseous alveolar distractor (LEADTM) in the management of residual alveolar ridge
resorption 123Journal of Maxillofacial Oral Surgery 8(4):324–328
• E.Klemetti et al Relationship between body mass index and the remaining alveolar ridge
Journal of Oral Rehabilitation 1997 24; 808-812
• Nandita Nitin Keni, BDS, et al Management of flabby ridges using liquid supported
denture: a case report Journal of Adv Prosthodontics 2011;3:43-6
•


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Residual Ridge Resorption Seminar PART 2

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• The residual ridge consists of the denture bearing mucosa, the sub mucosa,

periosteum and underlying residual alveolar bone.

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D5- A very soft bone, with incomplete mineralization

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• Studies also suggest increased knife edge tendency (KET) in

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ANATOMICAL FACTORS METABOLIC FACTORS

Another factor, the time

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Leila jahangiri textbook of clinical cases in prosthodontics-edition 1 2011

RRR α anatomic factors

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Local factors Systemic factors

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• These findings may suggest the connective tissue contraction associated

• The phenomenon may explain a mechanism of localized bone resorption at

Ca is the principal constituent of the skeleton.

The parathyroid gland controls the dissolution of bone for the

The primary source of available calcium is trabecular bone,

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• A significant finding from animal experimentation and from the examination of

• Prolonged depletion results in disorganization and loss of trabeculae, followed

• Under these conditions , alveolar bone becomes susceptible to diseases like

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For many species of experimental and domestic animals, an excess of

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• Low bone density in the skeleton is accepted as a predisposing factor for

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• A study evaluated 230 postmenopausal in Finland.

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residual ridges are subjected to

All these can place pathological loads on the residual

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This effect may take place in mucoperiosteum which is

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 Excessive stress resulting from artificial environment:

 Abuse of tissues from lack of rest:

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 UNDER EXTENDED DENTURES:

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 Application of unacceptable pressure over the basal seat areas which

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 Lack of freeway space due to increased vertical dimension of occlusion:

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This proper occlusion is essential to the health of bony support.

Otherwise, during eccentric movement, it causes pressure on bone due to

Hence resorption of base occurs.

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