residual ridge resorption in cd patients

residual ridge resorption in completely edentulous patients

1. RESIDUAL RIDGE
RESORPTION

2. TABLE OF CONTENTS:
•Introduction
•Definitions
•Review of literature
•Pathophysiology
•Pathogenesis
•Epidemiology
•Etiology
•prevention
•Treatment
•Summary and conclusion
•References
Prosthodontic management
Surgical management

3. INTRODUCTION
RRR is chronic progressive, irreversible and cumulative.
We should consider RRR as a pathology, rather than a normal
physiologic process. Because of its wide variation in rate of RRR
from person to person and with in a person. So we should
understand the process RRR so that we can take measures to
prevent and manage it effectively.

4. •Afterextractionofteeth-cascadeofinflammatoryprocess-
sockettemporarilyclosedbybloodclotting-epithelialtissue
beginsproliferation&evidenceofboneformationisseenin
10days&socketfilledprogressivelywithnewlyformedbone
in6months
•RESIDUALALVEOLARRIDGE
undergoeslifelongcatabolic
remodeling
•SizeofRESIDUALRIDGE
REDUCEDMORERAPIDLYIN
FIRST6MONTHS butboneresorptionactivitycontinues
throughoutlife

5. •ALVEOLARBONE:bonyportionofmandible/maxillainwhichroots
ofteethareheldbyfibersofPDL
•ALVEOLARPROCESS:cancellous&compactbonystructurethat
surrounds&supportsteeth
•RESIDUALBONE:componentofmaxilla/mandiblethatremains
afterteetharelost
•RESIDUALRIDGE:portionofresidualbone&itssofttissuecovering
thatremainsafterremovalofteeth
•RESIDUALRIDGERESORPTION:diminishingquantity&qualityof
residualridgeafterteethareremoved
(GPT-8:JPD-VOL:94)

6. CLASSIFICATIONS
ATWOOD-1962

7. A. Most of alveolar ridge present
B. Moderate residual ridge resorption
c. Advanced residual ridge resorption&
only basal bone remaining
D. Some resorption of basal bone has taken place
E. Extreme resorption of basal bone has taken place
ZARB & LEKHOLM
1985
(for residual bone
morphology)

9. Class 1: Alveolar ridge is adequate in height but
inadequate in width usually with lateral
deficiency/undercut regions
Class 2: Alveolar ridge is deficient in both height
& width –knife edge appearance
Class 3: Alveolar ridge resorbed to level of basilar
bone-concave form on posterior region of
mandible; sharp, bony ridge with bulbous
,mobile soft tissue in maxilla
Class 4:resorption of basilar bone producing
pencil-thin flat maxilla/mandible
(JPD-1989-VOL61:NO.2-PG
228)
KENT-1982

10. To determine the amount of bone loss there are
severalmethods
•Clinical examination by visualization –The problem with
this is sometimes the knife edge ridge may be masked by
redundant or inflamed soft tissue.
•One can more accurately determine the amount of bone
loss by palpatin in the month than by attempting to take
measurement in stone cast.
•To determine the rate of bone resorption over a long
period of time, the test method is to have a lateral
cephalometric radiograph.
•According to VICAL et al the orthopanoromic radiograph is
the simplest and useful method.

12. •The panoramic radiograph technique
described by WICAL & SWOOPE in 1974 is a
simple, useful method for arriving at a
gross estimate of the mount of RRR to date
in a given patient.
•A method of predicting original alveolar
crest height is based on measurement of
the distance from inferior border of the
mandible to the lower edge of the mental
foramen. They found that the distance
from original crest to the lower edge of
mental foramen 3 times to inferior border
of mandible.

13. •

14. GROSS STRUCTURE OF
ALVELOLAR PROCESS
•Surrounds&supportsteeth
•Composedof2parts:a)Alveolarboneproper
B)Supportingalveolar
bone
Alveolarboneproper-truealveolarbone/laminadura
Cribriformplate
-Consistsofthinlamellae
Ofbonesurroundingroot
Supportingalveolarbone-surroundsalveolarbone&gives
supporttosocket
-Madeupofcorticalplate&trabecularbone
-Corticalplatesaremadeofcompactbone
-Corticalplateisthinnerinmaxillathanmandible
-Foundtobethickestinpremolar/molarregionof
Mandible&onbuccalaspectofmaxillarycanine

15. GPT-
8
•Resorption:the loss of tissue substance by
physiologic or pathologic processes.
•Residual bone: that component of maxillary
or mandibular bone that remains after the
teeth are lost.
•Residual ridge: the portion of the residual
bone and its soft tissue covering that remains
after the removal of teeth
•Residual ridge resorption*: a term used for
the diminishing quantity and quality of the
residual ridge after teeth are removed.
Ortman HR. Factors of bone resorption of the residual ridge. JPD 1962;12:429-40.
Atwood DA. Some clinical factors related to rate of resorption of residual ridges. JPD1962;12:441-50.
*

16. REVIEW OF
LITERATURE:

17. JOHN O. NEUFELD1958
DID A MICROSCOPIC STUDY OF MANDIBULAR
SPECIMENS,
SHOWED THAT
 THE TRABECULAR PATTERN OF THE BODY OF THE
MANDIBLE, UPON THE LOSS OF THE TEETH AND THE
REMAINS OF THE ALVEOLAR PROCESS, IS REORGANIZED
IN A MORE OR LESS RANDOM MANNER.
 IN SOME OF THE SPECIMENS STUDIED, THE
TRABECULAR PATTERN WILL REARRANGE ITSELF IN
SUCH A MANNER THAT IT WOULD INDICATE
RESISTANCE TO STRESSES APPLIED THROUGH SUCH AN
APPLIANCE
•John O. Neufeld. Changes in the trabecular pattern of the mandible
following the loss of teeth. J Prosthet Dent. 1958;8; 685-697

18. There was no appreciable change in the trabeculae in the
angle of the mandible between the dentulous and edentulous
conditions
There was no appreciable difference in the trabecular
patterns of the condyle and neck of the condyloid process in the
dentulous and edentulous mandibles
The greatest change in the trabecular pattern of the
mandible throughout the life of individual was in its alveolar
process
There was an extreme variation in the structure of the
mandible from one individual to another.

19. JAIM PIETROKOVSKE AND MAURY MASSLER RESIDUAL RIDGE
REMODELING AFTER TOOTH EXTRACTION IN MONKEYS..
JPD;1971;26;119
•Jaim Pietrokovski et al in 1971 studied to
correlate the gross and microscopic aspects of
wound healing and remodeling of the residual
ridge subsequent to extraction of teeth in the
rhesus Monkey.
•Clinical photographs and histologic specimens
showed that the resorption of the edentulous
ridge occurred more rapidly at the crest of the
buccal alveolar plate resulting, in residual
ridges with crest located lingually and palatally
as well as apically in relation to their original
position.

20. •The muscle attachments located along
the external bony walls of the socket at
several regions of the jaws seemed to
limit the level of resorption of the
alveolar crest in an apical direction.

21. KENNETH E. WICAL AND CHARLES C. SWOOPE. STUDIES OF RESIDUAL
RIDGE RESORPTION. USES PANAROMIC RADIOGRAPHS FOR
EVALUATION AND CLASSIFICATION OF MANDIBULAR RESORPTION.
JPD;1974;32;7
•Wical and Swoope in 1974 described a method of
estimating the severity of mandibular bone
resorption by using the mental foramen and the
inferior border of the mandible, as they appear in
panoramic radiographs, as reference points.

22. CECILE G. MICHAEL AND WADIE M. BARSOUM. COMPARING RIDGE
RESORPTION WITH VARIOUS SURGICAL TECHNIQUES IN IMMEDIATE
DENTURES. JPD;1976;35;142
•Michael and Barsoum in 1976 studied
residual ridges following three surgical
techniques of simple tooth extraction and
labial plate and intraseptal alveoloplasty.
•They concluded that
•Simple tooth extraction is the best
surgical approach to be followed to
preserve as much of the residual alveolar
ridge as possible.

23. JULIAN B. WOELFEL, CHESTER M. WINTER AND TAKAYOSHI IGARASHI.
FIVE-YEAR CEPHALOMETRIC STUDY OF MANDIBULAR RIDGE
RESORPTION WITH DIFFERENT POOSTERIOR OCCLUSAL FORMS.
JPD;1978;39;602
•Julian B. Woelfel et al in 1978 did study on
mandibular ridge resorption with different posterior
occlusal forms
( 0
0
, 22
0
and 33
0
cusps)
•They found that
•After 5 year of placement of dentures the reduction
of occlusal vertical dimension (nasion to menton) was
•3.6mm for the nonanatomic group
•3.2mm for the semianatomic group and
•2.8mm for the anatomic group.

24. DON G. GARVER AND ROBERT K. FENSTER. VITAL ROOT
RETENTION IN HUMANS: A FINAL REPORT. JPD 1980;43;368
•Don G Garver et al in 1980 studied the
value of vital root retention in the
preservation of residual ridge resorption.
•They concluded that
•Vital root retention in humans appears to
be valid means of retaining residual bony
ridge tissues to a greater degree than
when patients rendered totally
edentulous.

25. THOMAS W. BREHM AND BEHRUZ J. ABADI. PATIENT RESPONSE TO
VARIATIONS IN COMPLETE DENTURE TECHNIQUE: RESIDUAL RIDGE
RESORPTION-CAST EVALUATION. JPD;1982;47;491
•Thomas W. Brehm et al in 1982 investigated
the patient response to variations in denture
techniques.
•1. standard technique did not use a face bow
transfer. The maxillary cast was mounted
arbitrarily. The mandibular cast was mounted
in centric relation. The teeth were arranged in
tight centric occlusion coincidental with
centric relation, but no attempt was made to
balance the occlusion. After processing,
occlusal corrections were made on the
articulator prior to polishing the dentures.
The corrections were made in centric
occlusion only. The dentures were placed and
all further occlusal corrections were done in
the mouth.

26. •2. The complex technique involved location of
the true hinge axis for face bow transfer to
mount the maxillary cast on a semi-adjustable
articulator. The mandibular cast was mounted
in centric relation. Protrusive and lateral
records were made, and the denture teeth
were adjusted to a balanced occlusion. After
processing, the dentures were remounted
using new centric relation records. All occlusal
corrections were made on the articulator.

27. •At 10 year recall, alveolar ridge
topography was examined. They
concluded that,
•In general, alveolar ridge change was
evidenced by reduction in size following
denture wearing.
•The changes were so small that they
were statistically insignificant.

28. DEWEY H. BELL. PARTICLES VERSUS SOLID FORMS OF HYDROXYAPATITE AS A
TREATMENT MODALITY TO PRESERVE RESIDUAL ALVEOLAR RIDGES. JPD;
1986;56;322
•Dewey H. Bell(1986) compared the
implantation of hydroxyapatite in particles
form and solid form (cones simulating the
roots of teeth) into the extraction sockets of
human teeth to delay alveolar ridge
resorption as a treatment modality to
preserve residual alveolar ridges.
•Data from the study suggest that
•the implantation of particlesinto the
extraction sockets of human teeth to delay
alveolar ridge resorption is a more prudent,
forgiving, considerate, problem-free and
predictable procedure than the implantation
of cones.

29. R. P. BLANK, H. A. DIEHL AND G.T. BALLARD. CALCIUM METABOLISM
AND OSTEOPOROTIC RIDGE RESORPTION: A PROTEIN CONNECTION.
JPD;1987;58;590
•R. P. Blank et al. in 1987 studied the
interrelationship between osteoporosis and
dietary protein and calcium metabolism.
•They concluded that
•Positive calcium balance promoted by the
suggested treatment regimen may help to
preserve ridge integrity and at the same time
prevent the serious debilitating effects of
generalized osteoporosis.

30. NINA VON WOWERN AND GINA KOLLERUP. SYMPTOMATIC
OSTEOPOROSIS: A RISK FACTOR FOR RESIDUAL RIDGE REDUCTION
OF THE JAWS. JPD;1992;67;656
•Nina von Wowern et al in 1992 did a to
clarify if symptomatic osteoporosis is a
risk factor for severe residual ridge
reduction of the jaws with respect to age,
menopausal age, and period of
edentulousness.
•They found that
•Osteoporotic edentulous women patients
show a larger degree of maxillary atrophy
than age matched normal women with the
same length of edentulousness, but they
do not show a significantly larger degree
of mandibular atrophy.

31. JOHN W. UNGER, CHARLES W. ELLINGER AND JOHN C. GUNSOLLEY. AN ANA LYSIS OF
THE EFFECT OF MANDIBULAR LENGTH ON RESIDUAL RIDGE LOSS IN THE ED ENTULOUS
PATIENT. JPD;1995;71;827
•John W. Unger et al, in 1995 studied the
relationship of mandibular length to residual
ridge loss. Tracings made form cephalometric
films taken at initial insertion of complete
dentures and at 20 years after placement were
measured.
•Mandibular length was determined to have no
statistical relationship to the reduction in
residual ridge height in either the maxillae or the
mandible.
•Alveolar bone loss in the one jaw had no
relationship to the amount of loss in the other
jaw.

32. TOSHIHIRO HIRAI, TSUTOMU ISHIJIMA, YOSHIKO HASHIKAWA AND TOSHIHI KO
YAJIMA. OSTEOPOROSIS AND REDUCTION OF RESSIDUAL RIDGE IN EDENTU LOUS
PATIENTS. JPD;1996;73;49
•Toshihiro Hirai et al in 1996 investigated the
relationship between height of the mandibular
residual ridge and the severity of osteoporosis in
elderly edentulous patients.
•They found that
•The parathyroid hormone level was high in the
patients with a low residual ridge and the
calcitonin level was low.
•Osteoporosis strongly affects reduction of the
residual ridge in edentulous patients.

33. GROSS PATHOLOGY
•RRR Is primarily a localized loss of bone
structure.
•In some cases it may leave excessive and
redundant overlying mucoperiosteum and
some cases not.

34. THE CAREFUL SUPERIMPOSITION OF PORTIONS OF
TRACINGS OF LATERAL CEPHALOGRAMS CLEARLY SHOWS
THE GROSS REDUCTION OF BONE IN SIZE AND SHAPE THAT
OCCURS ON THE LABIAL, CRESTAL, AND LINGUAL ASPECTS
OF THE RESIDUAL RIDGE.
Atwood DA: Postextraction changes in the adult mandible as illustrated by microradiographs
of midsadittal section and serial cephalometric roentgenograms. JPD;1963;13;810

35. •Gross anatomic studies of dried jaw bones have shown a
wide variety of shapes and sizes of residual ridges.
•In order to provide a simplified method for categorizing
the most common residual ride configuration, a system of
SIX ORDERSof residual ridge form has been described.
Atwood DA: Postextraction changes in the adult mandible as illustrated by microradiographs
of midsadittal section and serial cephalometric roentgenograms. JPD;1963;13;810

36. •Another gross finding seen on dry specimens is that while
external cortical surfaces of the maxilla and mandible are
uniformly sooth, the crestal areas of residual ridges have a
different appearance and show many porosities and
imperfections no matter at what stage of residual ridge
configuration.
Uncovering of the inferior alveolar
canal on the mandible

37. Atwood DA: Reduction of residual ridges: A major oral disease entity. JPD;1971;26;266
Gross bone loss of residual ridges was revealed by superimposition
of portions of two cephalometric radiographs made 16 years apart.
The actual bone loss in the anterior part of the ridge of the mandible
was 13 mm in height (41% reduction) and 60 square mm in cross-
sectional area (24% reduction)

38. Atwood DA: Reduction of residual ridges: A major oral disease entity. JPD;1971;26;266
•Although complete resorption of body of mandible has not been
recorded severe resorption can occur leaving only a thin cortical plate
in the inferior border.

39. CLINICAL EXAMINATION
•Usually one can visually judge the residual ridge
form.
•Sometimes a knife-edge ridge may be masked by
redundant or inflamed soft tissues.
•One can more accurately determine the amount
of underlying bone by palpation in mouth than
by attempting to take measurements on stone
casts.

40. KENNETH E. WICAL AND CHARLES C. SWOOPE. STUDIES OF RESIDUAL RIDG E RESORPTION.
USES PANAROMIC RADIOGRAPHS FOR EVALUATION AND CLASSIFICATION OF
MANDIBULAR RESORPTION. JPD;1974;32;7
•Lateral cephalometric radiographs provide the most accurate
method for 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.

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

42. MICROSCOPIC PATHOLOGY

43. •Microscopic studies have revealed
evidence of osteoclastic activity on the
external surface of the crest of residual
ridges.
•Frequently, the scalloped external
surface seems inactive, without visible
bone-resorbing cells, and is covered by
fibrous nonosteogenic periosteum.

44. •A microradiographic
study of edentulous
mandibles has
shown wide variation
in the configuration,
density, and porosity
of not only the
residual ridges but
also the entire
cross-section of the
anterior mandible.
Atwood DA: Reduction of residual ridges: A major oral disease entity. JPD;1971;26;266

45. •In addition there was microradiographic evidence of
mandibular osteoporosis including increased variation
in the density of osteons, increased number in
incompletely closed osteons, increased endosteal
porosity, and increased number of plugged osteons in
about half the specimens.

46. •Presence of smooth
periosteal lamellar
bone on the lingual,
inferior, and labial
surfaces of the
mandible, and the
total absence of such
lamellations on the
crest of the residual
ridge.

47. Compacted bone on the
crest of a low well-rounded
residual ridge showing a
whorled convoluted type of
endosteal bone.
Trabecular bone continuous
with medullary bone.
There is absence of cortical
layer of bone in this area.

48. •No studies to date have shown
periosteal lamellar bone covering the
crest of residual ridges, but several have
shown new bone formation and reversal
lines inside the residual ridge and, at
most minute areas of bony repair on the
periosteal side of a small percent of
specimens.

49. HISTOLOGY
Mucoperiosteum have shown varying
degrees of
•Keratinization
•Acanthosis,
•Edema
•Architectural pattern of mucosal epithelium
in the same mouth and between subjects.

50. •Varying degrees of inflammatory cells
have been found in areas that have
appeared from clinically normal all the
way to frankly inflamed in edentulous
patients who were either denture or
nondenture wearers.
•Inflammatory cells included
lymphocytes and plasma cells.

51. PATHOPHYSIOLOGY OF RRR

52. •It is normal function of bone to undergo
constant remodeling throughout life
through the processes of bone
resorption and bone formation.
•Except during growth, when bone
formation exceeds bone resorption,
bone resorption and bone formation are
normally in equilibrium.

53. •Osteoporosis is a generalized disease of bone
in which bone is in negative balance, because
bone resorption exceeds bone formation.
•In periodontal disease, there is a localized
destruction of bone around teeth, due to
certain pathologic processes.
•In both osteoporosis and localized periodontal
disease, when bone matrix is lost it does not
ordinarily return.

54. •RRR is a localized pathologic loss of
bone that is not built back by simply
removing the causative factors.
•Yet physiologic process of internal bone
remodeling goes on even in the
presence of this pathologic external
osteoclastic activity that is responsible
of loss of bone substance.

55. •It is clear that a great deal of residual ridge may be
removed in toto, and yet 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 residual ridge in advance of the external
osteoclastic removal of bone.

56. •If endosteal bone growth fails to keep pace
with the external osteoclastic activity, one
would end up with an absence of a cortical
layer and exposure of the medullary layer
to the external surface of the bone,
resulting in defects on the crest of the
ridge.
•From a practical point of view , RRR should
be considered a pathologic process.

57. PATHOGENESIS OF RRR

59. RATE OF RRR
Tallgren A.: the continuing reduction of the residual alviolar ridges in complete denture
wearers: A mixed longitudinal study covering 25 years. JPD;192;27;120

60. •Tallgren and Atwood and Coy
found that the mean ratio of
anterior maxillary RRR to anterior
mandibular RRR was 1:4.
•However, there are many
exceptions to this mean.

61. PATTERN OF RESORPTION:
-
-
- -

62. EPIDEMIOLOGY OF RRR

63. •To date RRR is world wide, occurs in
males and females, young and old , in
sickness and in health, with and with
out dentures, and is unrelated to the
primary reason for the extraction of the
teeth (caries or periodontal disease)

64. ETIOLOGY

65. JULIAN B. WOELFEL ET AL IN 1976
1.Metabolic –basal metabolism, blood content and
pressure, general health (major organ dysfunction)
2.Psychologic –esthetics, attitude, reaction to stress,
amount of sleep, mental block, insecure with dentures,
expects too much, etc
3.Physiologic –muscle and joint dysfunction, tissue
response to trauma, learning skill in manipulating
dentures
4.Biologic –tissue health, saliva content, calcium
homeostasis, oral hygiene, oral bacterial flora, drug or

66. 5. Anatomic –size, shape, form, and space
between ridges; muscle attachments; action
of tongue
6. Mechanical –vertical dimension, incisal
overlap, occlusion (centric relation and
occlusion), type of teeth and articulator used,
jaw relations recorded, tissue extension
(coverage) and displacement, knowledge and
skill of dentist
7. Habits –food intake, masticatory, bruxism,
sleeps with dentures, holds pipe, nibbles
with anterior teeth, sucks fingers or bites
nails or chews gum

67. 8. Social conditions –frequency of denture
care: rearing or upbringing; income;
importance of good dentures to self, co-
worker, friends, and family; willingness to
accept and follow professional
recommendations
9. Ecological –water, air and food pollution
and its effect on general and oral health.

68. •Numerous descriptive studies have
been done to elucidate a pathologic
cause of the severe form of RRR.
•These observations in edentulous
patients are not conclusive and, to
date no single factor has been found
to contribute to the severe form of
RRR.

69. •Anatomic factor
•Prosthetic factor
•Metabolic and systemic
factor
•Other factor

70. ANATOMIC FACTOR
RRR αanatomic factors

71. •More bone more RRR
•Present status of residual ridge
•Shape and form of ridge
•Trabeculae pattern
•Cicatrizing mucoperiosteum

72. •Mandible
•( Tallgren) and ( Atwood and Coy)
•4 times more than maxilla
Surface area of maxillary
denture area –4.2 square
inches
Surface area of mandibular
denture area –2.3 square
inches

73. DAMPING EFFECT OR ENERGY
ABSORPTION
RRR α
1
Damping effect
Damping effect can take place in the mucoperiosteum and bone

74. •Gibbsetalsaysthatinindividualswith
healthydentitionthebitingforcewould
average162lbs,whereasinedentulous
subject35lbs.
•Asaresult,theoverallloadingofthe
edentulousmandibleisconsiderably
lessthaninthedentulousmandible.
•Whethersuchfacthasresultedinan
overallincreaseinosteoporoticchanges
insuchmandibles.

75. PROSTHETIC FACTOR
•Immediate denture
•Wictorin, Johnson
•Decreased resorption
•Carlsson et al
•No correlation

76. •Zero degree teeth
•Winter et al and Woelfel et al
•Increased resorption
•ill-fitting dentures -which leads to increased or
decreased vascularity and changes in oxygen
tension.

77. •Broad coverage area –to reduce the force per unit
area
•Decreased number of teeth
•Improved tooth form-to decrease the amount of
force required to penetrate a bolus of food
•Avoidance of inclined planes –to minimize
dislodgement of dentures and shear forces

78. •Centralization of occlusal contact -to
increase stability of denture in speech and
mastication
•Provision of adequate tongue room –to
improve stability of dentures and to
maximize compressive forces
•Adequate inter occlusal distance during
rest jaw relation –to decrease the
frequency and duration of tooth contacts

79. METABOLIC AND SYSTEMIC
FACTOR
•Age and sex –
•Wictorin; Carlsson; Atwood and Coy;
Winter et al
•No correlation

80. •Osteoporosis –
•Atwood and Coy; Mercier and Inoue;
Kribbs et al; Ortman et al
•No correlation with ridge height
•Von Wowern and Kellen
•Smaller maxillary ridge
•Nishimura et al
•Knife edge type mandible

81. •Calcium and Vitamin D supplement
•Wical and Brussee
•Decreased resorption
•Zinc sulfate supplement
•Mesrobian and Shaklar
•Better extraction healing in hamsters

82. •Dichloromethane diphosphonate
supplement
•Olson and Hagen
•Decreased RRR in rats
•Sodium fluoride supplement
•Fenton and El-Kassem
•No correlation (but better calcification)
•Indomethacin supplement
•Nishimura et al
•Decreased RRR in rats

83. RRR α
Bone resorption factors
Bone formation factors
•Resorption factors
•endotoxins from dental plaque ( not properly cleaning
their dentures)
•Osteoclast-activating factor
•Prostaglandins
•human gingival bone-resorption stimulation factor

84. •Heparin,hasbeenshowntobea
cofactorinboneresorption,has
beenassociatedwithmastcells
thathavebeenobservedin
microscopicsectionsofresidual
ridgesclosetothebonemargin.

85. FUNCTIONAL FACTOR
•Intensive denture wearing
•Campbell; Carlsson et al
•Increased RRR
•Regular denture wearing
•Tallgren; Nicol et al; Bergman and Carlsson
•No correlation with the rate of RRR

86. PRESERVATION OF RESIDUAL
RIDGE

87. PRESERVATION OF RESIDUAL
ALVEOLAR RIDGES
•Overdenture
•Submerged roots
•Implantation of
•Roots of teeth
•Cartilage
•synthetic bone,
•hydroxyapatite into the root sockets immediately after the
extraction of teeth.

88. TOOTH SUPPORTED
OVERDENTURES

89. SUBMUCOSAL ROOT
RETENTION

90. SUBMERGED ROOT RETENTION
•Submucosal root retention eliminates oral
hygiene obligations for the pt’s while possibly
delaying residual ridge resorption
•An undisturbed root attached to the alveolar
bone by PDL could be considered the ‘ideal’
submerged implant

91. 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.Supporting alveolar bone equal to 1/3 of
total root length
5.Selected teeth should be asymptomatic.

93. PROCEDURE [GARVER ET AL
JPD1978]

96. PROCEDURE 2 JPD
1979;41:12-15

99. IMPLANTATION

100. CALCITITE HYDROXYAPATITE ALVEOLAR
RIDGE MAINTAINERS

102. HOMOLOGOUS VITAL
COSTAL CHONDRAL
CARTILAGE
•Shaped to size and form of root
•successful results
Lam RV; Effect of root implant on resorption of residual ridges.
JPD;1972;27;311

103. SYNTHETIC BONE GRAFT
MATERIAL
The Clinical Applications of Synthetic Bone Alloplast
• Jim Grisdale, J Can Dent Assoc 1999; 65:559-62

104. GIOVANNI SERINO SALVATORE BIANCUGIOVANNA IEZZIADRIANO PIATTELLI
RIDGE PRESERVATION FOLLOWING TOOTH EXTRACTION USING A POLYLACTID E
AND POLYGLYCOLIDE
SPONGE AS SPACE FILLER: A CLINICAL AND HISTOLOGICAL STUDY IN HU MANS
CLIN. ORAL IMPL. RES. 14, 2003 / 651–658
Polylactide and polyglycolide sponge as space filler

106. RECOMMENDED DAILY
ALLOWENCE
•800mg of calcium for men and nonpregnant
women.
•Protein 50-60 gm

107. DIAGNOSTIC CLASSIFICATION
OF
COMPLETE EDENTULISM

108. CLASS I
•Residual bone height of 21 mm or greater measured at the least
vertical height of the mandible
•Residual ridge morphology that resists horizontal and vertical
movement of the denture
•Location of muscle attachments that are conducive to denture base
stability and retention

109. CLASS II
•Residual bone height of 16-20 mm
measured at the least vertical height of the
mandible
•Residual ridge morphology that resists
horizontal and vertical movement of the
denture base

110. CLASS III
•Residual bone height of 11-15 mm measured at
the least vertical height of the mandible
•Residual ridge morphology has minimum influence
to
resist horizontal or vertical movement of the
denture base
•Location of muscle attachments with moderate

111. CLASS III
characterized by the need for
surgical revision of denture
supporting structures to allow
for adequate prosthodontic
function.

112. CLASS IV
•Residual bone height of least vertical height of the
mandible
•Residual ridge offers no resistance to horizontal or
vertical movement
•Location of muscle attachments with significant
influence on denture base stability and retention

113. CLASS IV
•This classification level depicts the most debilitated
edentulous condition.
•Surgical reconstruction is almost always indicated but
can not always be accomplished due to the patient’s
health, desires, past dental history and financial
considerations.
•When surgical revision is not selected, prosthodontic
techniques of a specialized nature must be used in
order to achieve an adequate treatment outcome.

114. •Implants
•Health
•Financial means
•Psychological stamina for traumatic procedures
•Prosthodontic techniques of a specialized nature must be
used order to achieve an adequate treatment outcome.
•Ridge augmentation procedures

115. IMPLANTS
•Endosteal implant
1.Blade vent –linkow 1967
2.Hollow cylinder-
3.Screw implant
•Subperiosteal implant –Goldeberg 1945
•Mucosal insert –Dahl 1943
•Mandibular staple implant –tivanium ( titanium
plus vanadium)

119. PROSTHODONTIC TECHNIQUES
OF A SPECIALIZED NATURE
FOR SEVERELY RESORBED
RIDGES

120. CASE HISTORY
•Accurate medical history
•No of dentures till date
•Parafunctional habits
•Extra oral and intraoral examination of
1.Soft tissue
2.Bone architecture
3.Denture
4.Tongue size and movement
5.Salivary flow
6.Radiograph

121. BERNARD LEVIN 1982
Preliminary impression with heavy mix of alginate using
25% less water than the manufacturers recommendations

122. Mark the outline for the custom tray

124. RESIN IS REMOVED 1 MM OVER THE
RIDGE AND FINAL IMPRESSION MADE
USING ELASTOMERIC IMPRESSION
MATERIAL

126. FISH 1932
•Sublingual fold space extending from premolar to
premolar on each side was recoreded
•This tongue rest increasing the stability and
support

127. BOUCHER 1958
•Made use of reteromylohyoide fossa by extension
of distolingual flage across the mylohyoid muscle
and ridge
•Also recommended by narin 1964

128. BRILL 1967
•Gain facial and border seal by adapting existing
denture with a viscoelastic gel to eliminate space
between cheek and tongue and the denture
border contour

129. DYNAMIC IMPRESSION
TECHNIQUE

130. DYNAMIC IMPRESSION BY
RUSSELL AND LENCH1934
•Use of tissue conditioning material for flat
mandibular ridge
•Primary impression
•Resin custom tray
•Border moulding
•Occlussalrims are adjusted
•Borders are reduced by 2-3 mm
•Three application of conditioning material
are used

131. KLEIN 1957
1.When mandibular ridge is completely resorbed and thin
rib of soft tissue along the crest---
o3 mm of compound is trimmed over the
crest of the ridge in PI
oClear acrylic resin tray
o3 holes are made on the tray for escapement
of excess material

132. 2. Almost complete resorption with a spiny ridge
of dense bony tissue along the crest of alveolar
ridge
oAfter PI impression compound is scrapped away fron
crest of ridge, mylohyoid ridge and posterior flange
oPI is again completed using physiologic wax
oArea of mylohyoid ridge is relieved using 0.001 inch
tin foil and custom tray is made
oIn final cast knife edge thin ridge is relieved using
0.001 inch tin foil
oThus forces of mastication will be transferred along
the slopes of the ridge rather on the crest

133. 3. Flat or concave ridge
Impression of lingual border is recorded accurately
with the impression wax

134. CARL O BOUCHER1970
•Two step technique
•First preliminary modeling compound and low
heat wax impression made to determine the
border extension
•Final impression is made using centric occlusion
pressure and ZOE impression paste over base
plate

135. MCCORD JF AND TYSON KW
1997-ADMIXED TECHNIQUE
•Controlled pressure technique
•3 part by weight impression compound and
seven part by weight green stick compound
for border moulding and impression
•Central ridge area is relieved and final
impression made using light body rubber
base material

136. TEETH SELECTION
•It should give maximum penetrating ability viz
anatomical teeth provided denture is stable and
proper centric relation is recorded
•Semianatomic teeth can be used where ever
possible
•Reduced number of teeth
•Reduced buccolingual width
•Sears suggested non anatomic teeth

137. TEETH ARRANGEMENT AND
OCCLUSION
•Provide generous freeway space
•Neutrocentricconcept-during chewing no
displacement
•Neutral zone utilization
•In case of non anatomic teeth arrangement
increase horizontal overlap
•Avoid Christensen phenomenon
•George murrell1974 lingulizedocclusion
•Occlussalramp

138. NEUTRAL ZONE CONCEPT
•Materials used
oTissue conditioner
oZOE paste
oImpression compound
oSoft wax
oModeling wax

139. •Tissue conditioner
oPMMA and aromatic
ethyl alcohol 0.3:2.2
•Resilient liners
oVelum rubber
oVinyl acrylic polymer
oAcrylic polymr
oSilicone elastomer

140. DEVICES
•Springs
•Magnets
•Suction chambers

141. DENTURE ADHESIVE
•Substances which swell on moisturing and become
viscous
oCarbonyl methyl cellulose

142. RIDGE AUGMENTATION

143. MANDIBULAR AUGUMENTATION
Superior Border Augmentation

144. Rib graft

146. INFERIOR BORDER AUGMENTATION

148. INTERPOSITIONAL GRAFTS -
•Procedure of choice for mandibular augmentation is
combination of visor osteotomy & interpositional grafts.
•This procedure involves the movement of pedicle of bone
along with its blood supply.

151. TRANSPOSITIONAL VESTIBULOPLASTY

152. MAXILLA

154. REFERENCES

155. BIBLIOGRAPHY
•ORBAN’S ORAL HISTOLOGY & EMBRYOLOGY -BHASKAR.
•ORAL HISTOLOGY –TEN CATE
•ESSENTIALS OF ORAL HISTOLOGY & EMBRYOLOGY -AVERY
•WHEELER’S DENTAL ANATOMY PHYSIOLOGY & OCCLUSION
•CARRANZA’S CLINICAL PERIODONTOLOGY -NEWMAN
•BOUCHER’S PROSTHODONTICS
•ESSENTIALS OF COMPLETE DENTURE PROSTHODONTICS -WINKLER
•SYLLABUS OF COMPLETE DENTURE -HEARTWELL
•FIXED PROSTHODONTICS -TYLMAN’S
•CONTEMPORARY IMPLANT DENTISTRY -MISCH
•MEDICAL PHYSIOLOGY -CHAUDHARY
•HUMAN EMBRYOLOGY -I.B. SINGH
•COMPLETE DENTURE PROSTHODONTICS -SHARRY
•J.P.D.1972: 27; 120-132
•J.P.D.1978: 39(5);495
•J.P.D.1978: 39(6);601
•J.P.D.1998: 80; 224-237
•J.P.D.1998: 80;362-366
•INT-J. PROSTHO 2003: 16; 19-24