RESIDUAL RIDGE

RESORPTION

ASHA C S, SECOND YEAR MD

RESIDUAL RIDGE RESORPTION

CONTENTS
• INTRODUCTION • MANAGEMENT

• CLASSIFICATION • CONCLUSION

• PATHOPHYSIOLOGY • REFERENCES

• PATHOGENESIS

• EPIDEMIOLOGY

• ETIOLOGY

• CONSEQUENCES OF
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RRR
RESIDUAL RIDGE

INTRODUCTION
RESORPTION

Residual ridge is a term used to describe the shape of the clinical alveolar ridge
after healing of bone and soft tissues following tooth extraction.

•It consists of the denture-bearing mucosa, submucosa, periosteum and the

underlying residual alveolar bone

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PRESRRRENTATION TITLE

RESIDUAL ALVEOLAR RIDGE:

Portion of the alveolar ridge and its soft tissue covering

which remains following the loss of teeth

-’GPT8’

RESIDUAL RIDGE RESORPTION:

A term used for diminishing quality and quantity of

residual ridge after the teeth are extracted.
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-’GPT9’
 Tooth extraction-cascade of inflammatory
reactions- extraction socket closed by the
blood clot.

 Epithelial tissue proliferation -migration -

tissue integrity is quickly restored.
PRESENTATION TITLE

 The most striking feature of the extraction wound healing - a life-long

catabolic remodeling.

 The size of the residual ridge is reduced most rapidly in the first 6 months

 The rate of RRR is different among persons and even at different sites in
the same person.

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 ACCORDING TO BOUCHER,
PRESENTATION TITLE

• First year after tooth extraction, the reduction in residual ridge

height:

1. 2-3 mm for maxilla

2. 4-5 mm for mandible

• Annual rate of reduction in height

1. 0.1-0.2 mm for mandible

7 2. 4 times less in the maxilla

PRESENTATION TITLE

The sequence of resorptive events is considered to be:

Creation of a Digestion of the

Attachment of ruffled border and organic
Fall in pH to 2.5-3
osteoclasts to a sealed acidic Dissolution of the components of the
in the osteoclast
mineralized environment Hydroxyapatite matrix by
resorption space
surface of bone through action of proteolytic
the proton pump enzymes

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PRESENTATION TITLE

• 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

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approximation, making possible the bone balance of shape and size
PRESENTATION TITLE

PATHOLOGY OF RRR

Gross Pathology:

• Reduction in the size of the bony ridge under

the mucoperiosteum.

• It is primarily a localized loss of bone

structure
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PRESENTATION TITLE

Microscopic Pathology :

• Microscopic studies have revealed evidence

of osteoclastic activity on the external
surface of the crest of residual ridges.

• The scalloped margins of Howship’s lacunae

sometimes contain visible osteoclasts.

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PRESENTATION TITLE

• Wide variation in the

configuration, density, and
porosity of not only the
residual ridges but also the
entire cross-section of the
anterior mandible

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PRESENTATION TITLE

• Microradiographic evidence of mandibular

osteoporosis including increased variation in
the density of osteons, increased number of
incompletely closed osteons, increased
endosteal porosity, and increased number of
plugged osteons

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PRESENTATION TITLE
DIRECTION OF BONE RESORPTION

• Maxilla resorbs upward and inward to become progressively

smaller

• Mandible resorbs outward and becomes progressively wider

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according to edentulous age
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PRESENTATION TITLE
PRESENTATION TITLE

CONSEQUENCES OF RRR
• Apparent loss of sulcus width and depth.

• Displacement of the muscle attachment

closer to the crest of the residual ridge

• Morphological changes such as sharp,

spiny, uneven residual ridges.

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PRESENTATION TITLE

• Loss of vertical dimension of

occlusion.

• Reduction of lower face height.

• An anterior rotation of the

mandible.

• Changes in inter-alveolar ridge

relationship

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 • Resorption of the mandibular canal wall and exposure of the
PRESENTATION TITLE

mandibular nerve.

• Location of the mental foramina close to the top of the

mandibular residual ridge.

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PRESENTATION TITLE

PATHOGENESIS OF RRR

RRR is chronic, progressive, irreversible, and

cumulative

Immediately following the extraction, any sharp

edges remaining are rounded off by external
osteoclastic resorption, leaving a high, well-
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rounded residual ridge.

PRESENTATION TITLE

 Resorption continues from the labial and lingual

aspects -become knife-edged.

 knife edge becomes shorter and disappears- low well-

rounded or flat ridge.

20  Later, depressed ridge.

PRESENTATION TITLE

ATWOOD’S CLASSIFICATION(1983)
Order I: pre-extraction
Order II: post-extraction
Order III: high , well
rounded
Order IV: knife edge
Order V: low well rounded
Order VI: depressed.

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 PRESENTATION TITLE

WICAL AND SWOOPE CLASSIFICATION

Class 1: up to 1/3rd of the original vertical height lost

Class 2: from 1/3rd to 2/3rd of the vertical height lost
Class 3: 2/3rd or more of the mandibular height lost

The original alveolar crest height= 3 times the distance from inferior border of mandible to lower
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edge of mental foramen
PRESENTATION TITLE

AMERICAN COLLEGE OF PROSTHODONTIST

• Based on bone height(mandible only)

• Type I : Residual bone height of 21 mm or greater measured at the least

vertical height of the mandible.

• Type II : Residual bone height of 16 - 20 mm measured at least vertical

height of the mandible.

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PRESENTATION TITLE

• Type III : Residual alveolar bone height of 11 - 15 mm measured

at the least vertical height of the mandible.

• Type IV : Residual vertical bone height of 10 mm or less

measured at the least vertical height of the mandible.

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PRESENTATION TITLE

PATHOPHYSIOLOGY OF RRR

• 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 bone substance
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PRESENTATION TITLE

• It is clear that RRR does not stop with the residual ridge but
may go well below the apices of the teeth

• One can more accurately determine the amount of underlying

bone by palpation in the mouth.

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PRESENTATION TITLE

• Lateral cephalometric radiograph

provide the most accurate method
for determining the amount of
residual ridge and the rate of RRR
over a period of time

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 EPIDEMIOLOGY
PRESENTATION TITLE

• RRR is worldwide, occur in males and females, young and old,

sickness and in health, with and without denture and is
unrelated to the primary reason for the
extraction(caries/periodontal disease)

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 ETIOLOGY
PRESENTATION TITLE

•I T I S P O S T U L AT E D T H AT R R R I S A
MU LT I FA CTO RI A L , B I O ME C H A N I C A L
DISEASE TH AT R E S U LT S FROM A
C O MBI N ATI O N O F :

•A N ATO MI C

•META BO L I C

•MECH A N I CA L

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PRESENTATION TITLE
ANATOMIC FACTORS
• It is postulated that RRR varies with the quantity and quality of the bone of
the residual ridges

• RRR α Anatomic factors

• i.e, the more bone there is, the more RRR ultimately be

• evaluate the present status of the residual ridge to determine what has gone
on before(amount and density of bone)

• large well-rounded ridges and broad palates would seem to be favorable

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anatomic factors
 METABOLIC FACTORS
PRESENTATION TITLE

• R R R varies directly with certain systemic or localized bone

resorptive factors and inversely with certain bone formation factors:

RRR α BONE RESORPTION FACTOR/BONE FORMATION

FACTORS

R R R is a localized loss of bone on the crest of the residual ridge.

Therefore, certain local bone resorbing factors could be very
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 BONE RESORBING FACTORS
PRESENTATION TITLE

LOCAL SYSTEMIC
Endotoxins from dental Incorrect amount of circulating estrogen,
plaque growth hormone,calcium ,phosphorous.

Osteoclast activating factor Osteoporosis

Prostaglandins Hypophosphetemia
Human gingival bone Vitamin D deficiency
resorption factor

Trauma due to ill fitting Parathormone and calcitonin

dentures which leads to
increased vascularity and
changes in oxygen
32 tension.
 MECHANICAL FACTORS
PRESENTATION TITLE

• DISUSE V/S ABUSE

Bone that is used by regular physical activity will attend to

strengthen within certain limits, than the bone that is in
“disuse atrophy”; while others postulated that due to
denture wearing RRR is caused due to an “ abuse” bone
resorption.

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PRESENTATION TITLE

• Wolff’s law of bone transformation (1892) :

• “Every Change In The Form And Function Of Bone , Or Of Their

Function Alone, is Followed By Certain Definite Changes In Their
Internal Architecture, And Equally Definite Alteration In Their
External Conformation, In Accordance With Mathematical Laws.”,

• Bone remodels in response to the forces applied.

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PRESENTATION TITLE

RRR α FORCE

the amount of force,

the frequency of force,

the duration of force,

the direction of force,

the area over which the force is distributed

damping effect of the underlying bone.

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PRESENTATION TITLE

RRR α 1/Damping effect

• The amount of force applied to the bone may be affected

inversely by the damping effect or energy absorption.

• may vary from patient to patient and also from maxilla to

mandible.

• Cancellous bone helps in the absorption and dissipation of forces

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PRESENTATION TITLE

In addition to the 3 major categories of factors (anatomic,

metabolic and mechanical) the importance of time since
extraction is also important.

This can be added to the formula by an inverse relation

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PRESENTATION TITLE

a) Intensive Denture wearing:

 long continued use of ill-fitting

denture

 use of under extended denture

 excessive stress resulting from

PROSTHETIC artificial environment

FACTORS  abuse of tissues from lack of

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rest.
PRESENTATION TITLE

b) Unstable occlusal condition

 Incorrect centric relation

record

 error in relating maxilla to the

cranial landmarks(orientation
relation)

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PRESENTATION TITLE
TREATMENT OF RRR IS IDEALLY
MANAGEMENT BY PREVENTING IT
OF RRR
•Prevention of loss of natural teeth
edentulous residual ridge receives
vertical, diagonal and horizontal loads
applied by a denture with a surface
area much smaller than the total area
of the periodontal ligament of all the
natural teeth that had been present
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PRESENTATION TITLE

• PRECAUTIONS DURING EXTRACTION TO REDUCE RRR

• When a tooth is removed the labial plate should be preserved.

• The labial periosteal covering should remain intact as its inner

layer is responsible for remodeling of bone.

• If a bone has to be removed it must be the palatal plate.

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 • PROPER DESIGN OF DENTURE AND MAINTENANCE
PRESENTATION TITLE

Modification of impression procedures

 Centralization of occlusal contacts to increase stability and
maximize compressive forces.
Provision of adequate tongue room to improve stability of denture
in speech and mastication.

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PRESENTATION TITLE

Adequate interocclusal distance during jaw rest to decrease

the frequency and duration of tooth contact.

 Occlusal table should be narrow.

arrangement of teeth in neutral zone

Implant and tooth supported overdentures if possible

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PRESENTATION TITLE

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
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PRESENTATION TITLE

DIET
• Patients with bone disease need a diet high in proteins, vitamins
and mineral content.

• Denture patients with excessive RRR report lower calcium

intake and poorer calcium phosphorus ratio, along with less
vitamin D.

• In all dietary prescriptions , the consistency of food prescribed

must taken into account the patients ability to masticate.
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 TISSUE TREATMENT THERAPY
PRESENTATION TITLE

• PRE-PROSTHETIC SURGERY

• 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.
• •Ridge correction.
•Ridge extension/vestibuloplasty.
•Ridge augmentation
•Surgical correction of maxillomandibular relation
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PRESENTATION TITLE CONCLUSION

Residual ridge resorption is a chronic, progressive, irreversible,

and disabling disease , of multifactorial origin.

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.

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PRESENTATION TITLE

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

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 PRESENTATION TITLE

REFERENCES
•WINKLER S : ESSENTIALS OF COMPLETE DENTURE
PROSTHODONTICS. 2ND EDITION,2000.
• B O U C H E R : P R O S T H O D O N T I C T R E AT M E N T F O R

E D E N T U L O U S PAT I E N T S . 1 2 T H E D I T I O N , 2 0 0 4 .

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THANK YOU