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Residual ridge resorption (RRR)

Success of most of the prosthesis in the mouth is mainly determined by the amount of
support it gets from the underlying residual ridges. Unfortunately this support
diminishes as the age of the patient progresses. This is the concern of every
prosthdontist. One should be aware of the various aspects of this reduction of residual
ridges for effective rehabilitation of the edentulous patients.

Review of literature:

 Atwood 1962 -Studied clinical factors related to rate of resorption of residual


ridges and classified it in to Anatomic, Metabolic, Functional and Prosthetic
factors.

 Atwood in 1963 – Described the post extraction changes in the adult mandible
as illustrated by serial cephalometric radiograph. He grouped mandibular
ridges in to six orders of anatomic form. They are I Pre- extraction, II
Immediately after extraction, III High well rounded; IV Knife edged V Low
well rounded and VI Depressed.

 Krishan Kapur et al 1963 –Studied the effects of CD on alveolar mucosa. They


found that Denture appears to stimulate keratinization.

 Studies on rate of RRR – important studies on rate of RRR were conducted by:

o Carlsson and Persson(1967), Tallgren (1972) and Atwood (1971)

Odzimers et al 1972 – Studied the Cushioning properties of soft tissue forming the
basal seat of the denture. They found that Kinetic energy of impact is converted in

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to energy of elasticity by soft tissues. Disperse the mechanical energy of occlusal
load and prevents injury to bone.

 Western society of Periodontics 1995- Studied the Changes in mandibular


ridge height in relation to aging and length of edentulous period. They
concluded that Mandibular resorption continues with time. Important finding
was early mean reduction in height followed by slower mean reduction in
height as period of edentulism increases.

 Klemetti 1996 – Concluded that duration of edentulousness and skeletal


mineral status are the important factors in determining RRR.

 Jahangiri et al 1998 –Published a paper on “Current prospects in residual ridge


remodeling and its clinical implications”. They concluded that Genetic and
environmental regulatory factors affects the quantity and quality of bone by
altering the gene expression event taking place in the bone cell.

 Sasaki et al 2005 – Studied the Biological response induced by mechanical


stresses on bone metabolism by bone scintigraphy at residual alveolar bone
beneath denture. They found that mechanical forces increase bone turnover
below the denture.

Definition: Term used for the diminishing quantity and quality of the residual ridge
after teeth are removed. (GPT 8 EDN Jun 2005)

Many authors consider RRR as a pathological process hence it can be studied like any
other pathological disease with etiology, pathology, Pathophysiology, pathogenesis,
epidemiology, prevention and treatment.

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Etiology of RRR:

It is postulated that RRR is a multifactorial, biomechanical disease that results from


combination of anatomic, metabolic and mechanical determinants. Since all these
factors vary from one patient to the next, these different cofactors may combine in an
infinite variety of ways, thus explaining the variations in RRR between patients. Each
of the major co- variables will be discussed separately and then will be brought
together in a combined formula.

Anatomic Factors:
It is postulated that RRR varies with the quantity and quality of the bone of the
residual ridges:

RRR α. anatomic factors

It is probably safe to state that the more bone there is, the, more RRR there will be.
Another way to evaluate the anatomic factors is to consider the mechanical factors
that would be favorable to stability and retention of a denture. Thus, large well-
rounded ridges and broad palate would seem to be favorable anatomic factor.

Still another anatomic factor to consider is the density of the ridge. However, here
again one must interpret carefully, for the density at any given moment does not
signify the current metabolic activity of the bone, and bone can be resorbed by
osteoclastic activity regardless of its degree of calcification..

Metabolic factors:

RRR involves bone cells that are under the influences of both local and systemic
factors that very likely can affect the rate of RRR.
It is further postulated that RRR varies directly with certain systemic or localized
bone resorptive factors and inversely with certain bone formation factors:

Bone resorption factors

RRR α ------------------------------

Bone formation factors

RRR is a localized loss of bone on the crest of the residual ridge. Therefore, certain

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local bone resorbing factors could be very important. It is quite possible that some of
the local biochemical factors that have been studied in relation to periodontal disease
could play an important role in RRR. These factors include Endotoxins from dental
plaque, Osteoclast resorbing factor prostaglandins human gingival bone-resorption
stimulating factor and others. Heparin, which has been shown to be a cofactor in bone
resorption, has been associated with mast cells that have been observed in
microscopic sections of residual ridges close to the bone margin. Other possible local
bone resorption factors could be related to trauma (especially under ill fitting den-
tures), which leads to increased or decreased vascularity and changes in oxygen
tension.

Systemic factors are correct amounts of circulating estrogen. Thyroxin, growth


hormone, androgens, calcium, phosphorus, vitamin D, protein, fluoride,

Mechanical Factors:
Through mechanisms not yet clearly understood, the remodeling of bone is influenced
by force factors. 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. The
extraction of teeth in the adult is not a normal condition, but is carried out as
treatment for certain pathologic conditions. Masticatory and non masticatory force is
ordinarily transmitted to the dentoalveolar bone through the periodontal ligament.
Once the teeth are removed, the residual alveolar ridge is subjected to entirely
different types of forces. Some postulate that RRR is an inevitable "disuse atrophy."
Others postulate that RRR is an "abuse" bone resorption due to excessive force
transmitted through dentures. Perhaps there is truth in both hypotheses. The fact is
that with or without dentures some patients have little or no RRR and some have
severe RRR.

Various factors associated with the force are frequency of force, the duration of
force, direction of force, the area over which force is distributed (force per unit area),
and the damping effect of the underlying tissue.
Abnormal parafunctional forces from clenching and grinding of teeth may last up to
several hours per day. In some patients it is quite likely that this can place pathologic
loading on residual ridges.

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RRR varies inversely with the damping effect. It is the energy absorbing capacity of
the mucoperiosteum. Mucoperiosteum is considered as a Viscoelastic material.

Prosthetic factors include:


1. broad-area of coverage (to reduce the force per unit area) and
decreased number of dental units..
2. Decreased buccolingual width of teeth.
3. Improved tooth form (to decrease the amount of force required to penetrate
a bolus of food).
4. Avoidance of inclined plane (to minimize dislodgement of dentures and
shear forces).
5. Centralization of occlusal contacts (to increase stability of dentures and to
maximize compressive load.
6. Adequate interocclusal distance during rest jaw relation (to decrease the
frequency and duration of tooth contacts.

other factors are the effect of surgical trauma (from tissue reflection, dissection of
mucoperiosteum, alveolectomy, alveolotomy, excessive removal of attached gingiva,
the tension resulting from close approximation of stretched opposing tissues, and
finally the excessive loading of a ridge by an overly retentive denture that "fits tight"
on insertion but is followed by rapid loosening.

Mathematical expression of these etiological factors is:

RRR = Anatomical factors× mechanical factors ×bone resorption factors

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Bone deposition factors× damping effect ×time

Reasons for difference in resorption rate between maxilla and mandible:

Anterior mandible resorbs 4 times faster than the anterior maxilla probable
explanation is as under.

Woelfel et a1 have cited a patient with a projected maxillary denture area of 4.2 in2
and a projected mandibular denture area of 2.3 in 2: (ratio 1.8:1). If such a patient bites

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with a pressure of 50 lbs, this calculates out to 12 lbs/in 2 under the maxillary denture
and 21 lbs/in 2 under the mandibular denture. It is logical to postulate that such
differences could be causally related to differences in RRR in the two jaws.

The "damping effect' may take place in the mucoperiosteum, since the overlying
mucoperiosteum varies in its viscoelastic properties from patient to patient and from
maxilla to mandible, its energy absorption qualities may influence the rate of RRR.

Cancellous bone is ideally constructed for the absorption and dissipation of energy.
The fact that the maxillary residual ridge is frequently broader, flatter, and more
cancellous than its mandibular counterpart is of interest and may be a factor in the
frequently observed differences in the RRR of the two jaws.

Trabeculae in maxilla are oriented parallel to the direction of compression


deformation, allowing for maximal resistance to deformation. The stronger these
trabeculae are, the greater is the resistance.

Pathology:
Frequent lay expression of RRR is my gums have shrunk. Basic structural change is a
reduction in the size of the bony ridge under the mucoperiosteum. It is primarily a
localized loss of bone structure.

Gross anatomic studies of dried jawbones differentiate the various stages of RRR
in the individual patient. Shape of the mandibular ridge at different stages is given by
Atwood and he classified the ridge shape in to six orders of anatomical form, They are
Order I – Pre-extraction, Order II - post extraction, Order II- high, well-rounded,
Order IV -Knife edge, Order V –low well rounded and Order VI. - Depressed. This
self-descriptive system is useful clinically as well as for research purposes and helps
one to different stages of RRR in individual patients.

Another gross finding seen on dry specimens is that while external cortical surfaces
of the maxilla and mandible are uniformly smooth, the Crestal areas of residual
ridges have a different appearance and show many more porosities and imperfections
no matter at what stage of residual ridge configuration Bones with the most severe

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RRR (Orders V and VI) may display the gross porosity of medullary bone on the
crest of the ridge and eventually may even display the uncovering of the inferior
alveolar canal on the mandible. RRR doesn’t stop with the residual ridge; it may go
well below to involve the basal bone.

Lateral cephalometric radiographs provide most accurate method_ of determining


.the amount of residual ridge and the rate, of RRR over a period of time .The
panoramic radiographic technique described by Wical and Swoope is a simple, useful
method for arriving at a gross estimate of the amount of RRR to date in a given
patient .Original height of alveolar crest is three times the distance between the lower
border of the mandible and lower margin of the mental foramen.

Clinically, the soft tissues, overlying residual ridges that have undergone RRR may
range from normal to inflamed, edematous, ulcerated, indented, or otherwise abused.

Microscopic Pathology:
Microscopic studies have revealed evidence of osteoclastic activity on the_external
surface of the residual ridges. The margins of Howship's lacunae some times contain
visible osteoclasts.

A microradiograph of edentulous mandibles has shown wide variation in the con-


figuration, density, and porosity of not only the residual ridges but also the entire
cross-section of the anterior mandible. In addition, some times there may be evidence
of mandibular osteoporosis including increased variation in the density of osteons.
Increased number of incompletely closed osteons. Increased end-osteal porosity, and
increased number of plugged osteons.

Microscopic studies of the muco-periosteum have shown varying degrees kera


tinzation, acanthosis, edema, and varying degrees of inflammatory cells.

Pathophysiology of RRR:
It is a normal function of bone to undergo constant remodeling throughout life
through the processes of bone resorption and bone formation this process is called as

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bone remodeling. RRR is a localized pathologic loss of bone that is not brought 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.

Some would postulate that this is a physiologic process, on the premise that the
removal of the tooth eliminates the raison d'etre for the alveolar bone. Yet the
clinical _facts are that RRR is not inevitable, that the rate of RRR varies, RRR can
proceed far beyond the alveolar bone, and that the rate of resorption in some
patients is so much greater than the rate of formation that the patient ends up with
no cortical bone on the crest of the ridge. From_ a practical point of view RRR
should be considered a pathologic process.

Pathogenesis of RRR
RRR is chronic, progressive, irreversible and cumulative. When life history is
examined we see that Immediately following the extraction (Order II), any sharp
edges remaining are rounded of by external osteoclastic resorption leaving a high
well rounded residual ridge As the process continues labial and lingual aspects of
the ridge are resorbed the crest of the ridge becomes increasingly narrow, ultimately
becoming knife-edged. As the process continues knife edge becomes shorter and
ultimately disappears, leaving low well-rounded ridge" eventuallly this too resorbs
leaving a depressed ridge.

Carlsson and Persson (1967) studied the subjects for a period of 5 Years after
extraction .they concluded that Pattern of resorption for given patient is established
early. The difference between the maximum and minimum resorption is 7.25 folds.

Tallgren in (1972) studied Patient’s who were at various post extraction period over
25 years. It was basically a mixed longitudinal study. The significant finding was
maximum resorption during first three months, slowing after six months, almost
completed within one to two years.

Atwood (1971) studied One subject over 19 years and found that Anterior maxillary

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RRR was 3 mm during first 3 years later almost remained uniform for throughout 19
years. Where as Anterior mandibular resorption was Total of 14.5 mm during 19 years
and Rate being 0.4 mm per year.

Management of RRR:

Best way of preventing the RRR is by Preserving the natural tooth. Ideally one would
treat RRR by preventing it. Preventive measures can be taken during the impression
procedures, teeth arrangement and occlusal loading, and use of tooth supported
overdentures whenever indicated.

Impression procedures:

 One of the important objectives of impression making is the


preservation of the remaining tissues.

 Extend the impression to include all of the basal seat within the
physiologic limits of the limiting structures.

 Selective distribution of the force over the denture bearing area.


Compress the areas which can take up the occlusal load and relive the
areas which can’t take up the occlusal load.

 Pressure in the technique reflected as pressure in the denture base


leading to Soft tissue damage and resorption of the bone .Always avoid
the pressure points in the impression.

 Mucocompressive technique found to increase RRR

 Excessive –ve pressure between the denture base and tissue due to
excessive relief areas can increase the bone resorption

 Horizontal movement of the denture base during function found to


reduce the vertical height of the ridges.

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 Maximum intimate contact of the denture base and the tissues should
be maintained which distributes force over wider area. This is called as
Snow shoe effect.

Occlusion:

 Buccolingual width of the tooth should be as minimum as possible.

 Porcelain teeth causes more trauma to the denture bearing area when
compared to the resin teeth.

 Coincidence of centric relation with centric occlusion –If both don’t


coincide there can be horizontal movement of the denture leading to
resorption.

 Lack of interocclusal distance leads to soreness of tissue and resorption


of bone.

Tooth supported overdentures:

Presence of teeth makes huge difference in maintaining the integrity of the alveolar
bone. Alveolar ridge morphology is determined by the presence of PDL. Where as
absence of PDL leads to Variable, inevitable, time dependent RRR. One should use
the option of tooth supported overdenture where ever it is indicated.

Treatment of RRR: Once the resorption has already taken place following
procedures can be carried out to compensate for the loss of alveolar bone.

Vestibuloplasty – series of surgical procedures designed to restore alveolar ridge


height and\width by lowering muscle attachments and unattached mucosa from the
ridge crest of maxilla or mandible to a deeper position. There are three different
Vestibuloplasty techniques.

 Mucosal advancement- Sub mucosal dissection is carried out followed by

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the insertion of over extended surgical stent.

 Secondary epithelialization – Apically displaced flap is raised and it is


moved to the desired depth of sulcus. Later exposed tissue heals by
granulation and sec epithelialization.

 Using epithelial or mucosal grafts to cover the exposed tissue.

Ridge Augmentation:

Ridge augmentation can be carried out either by use of autogenous bone grafts such as
iliac grafts or with Hydroxyapatite materials

 Bony augmentation with autogenous grafts has failed to produce long term
clinical success.

 Hydroxyapatite has a chemical structure similar to the bone so blends with the
bone structure. Its use is not widely accepted due to potential Prosthodontic
problems associated with it. Improper placement of the graft material leads to
shift of the ridge crest and obliteration of the inter ridge space.

Osseointegrated dental implants:

Two decades of studies on osseointegration has provided sufficient evidence to


support this form of the treatment modality. Denture bearing area is no longer the
prime or exclusive source of support. Now the focus has shifted to endosseous
one. It seems to provide promising results in case of maladaptive denture
behavior.

Summary:
.RRR has a complex multifactorial etiology. Because of this it has remained as a
poorly understood subject. What is perhaps needed at this point are some large
epidemiological studies that will allow multifactorial analysis of large population
groups. Until this is done, it would seem prudently professional to analyze our pa-

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tients in regard to these various possible cofactors to the best of our ability, to seek
consultation concerning possible metabolic factors when suspected, and to perform
the most meticulous and intelligent prosthodontic care of the patient .

References:
 Essentials of complete denture prosthodontics II Edn Sheldon Winkler

 Prosthodontic treatment of edentulous patients, 12th Edn Zarb and Bolender

 Clinical removable partial prosthodontics,II Edn Stewart, Rudd and Kuebker

 Text book of CD 5TH Edn Rahn and Heartwell

 Journal of prosthetic dentistry

 Glossary of Prosthodontic terminology, 8th Edn, Jul 2005

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