residual ridge resorpion with management

7/21/2019 Residual Ridge Resorpion With Management

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Residual Ridge

Resorption

Akshay Gupta


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Introduction

Definition

Cells of bone

Pathology of residual ridge resorption

ClassificationPatho physiology

Pathogenesis

EtiologyConsequences

Management


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INTRODUCTION

A major oral disease ent i ty

ATWOOD (1971)

It is ch ron ic progressive

irreversib le and disabl ing

disease probably o f

mult i facto r ial o r ig in.


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Definition (GPT8)

Residual bonethat component of maxilla

or mandible ,once used to support the rootsof the teeth, that remains after the teeth are

lost.

Residual ridgeportion of the Residualbone and its soft tissue covering that

remains often after removal of teeth

Residual ridge resorption(alveolarresorption)a term to describe the

diminishing quality and quantity of Residual

ridge after the teeth are removed.


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Cells of bone

(1)Osteoprogenitor cellsmigratory stem

cells, mesenchymal in origin,which

develop into osteoblast prior to bone

formation.

(2) Osteoblastsnon mitotic cells

responsible for synthesis of bone matrix.

(3)Osteocytesmajor type of cells of

mature bone

(4) Osteoclastscells found in areas of

bone resorption in Howships lacunae .


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Pathology of residual ridge

resorption

GROSS PATHOLOGY

My Gums Have Shrunk

Reduction in size of bony ridge under theperiosteum.

Lammiein RRR cicatrizing

mucoperiosteum result in pressure

resorption of the underlying bone.this

atrophying mucosa acts as a molding force

that effects a change in the ridge form(JPD

1986)


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ClassificationATWOOD 1963

Order I:pre extraction

Order II:post extraction

Order III:high,well roundedOrder IV:knife edge

Order V:low well rounded

Order VI:depressed


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Order V /VI shows gross porosity ofmedullary bone


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FALSCHUSELL 1986

-fully preserved

-moderately wide and high

-narrow and wide

-sharp and high

-wide and reduced in height-severely atrophic


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MISH &JUDY

-abundant bone

-barely sufficient bone-barely sufficient bone with inadequate width

-compromised bone with inadequate width

-compromised bone with inadequate height-deficient bonecompletely flat bone

Basal bone atrophy

Nasal spine may be

resorbed.


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DIAGNOSIS

Visualization

Palpation

Panoramic radiograph(Wical &Swoope)

JPD 1974;32;13

2 ratios

(a)b/w the total height of mandible &the amount

of bone below the lower edge of foramen3:1

(b) b/w the total height of mandible &the amount

of bone below the upper edge of foramen

2.34:1


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Extent of bone loss

Class Iupto 1/3 rd of vertical height lost

Class II -upto 1/3 rd to 2/3 rd of vertical

height lost

Class III2/3rdor more of mandibular height

lost.

Limitations :

Distorted images of mental foramen

Location of mental foramen

Magnified images


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Lateral cephalometric

radiograph(Atwood) JPD1963


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Microscopic pathology

Crest of the residual ridge

Osteoclastic activity

Total absence of periosteal lamellarbone

Thin or no Cortical layer

Interior of residual ridge shows new bone

formation and reversal lines


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Pathophysiology of RRRPhysiological process- removal of tooth

Localized pathologic loss of bone

Irreversible

Can extend beyond the alveolar boneRate of RRR varies

-between different individuals

-within same person at diff times-within same person at diff sites

more rapid in first 6 months after

extraction


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Car lsson, Pearsson 1967:Pattern of RRR,

established early and maintained through the later

stages

Tallgren, 1972; Atwood and Coy, 1971:Ratio of

RRR in maxillary anterior to mandibular anterior is

1:4

Thus it is more apt to treat a particular patient as

the situation exists rather than going by this

average meanRRR mucosal, functional, psychological,

esthetic and economic problems

- cumulative- dental cr ipple


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Boucher: Annual rate of reduction in height

-Mandible: 0.1 -0.2 mm/ year, Maxilla : 4 times less

Boucher: Reduction in RR in midsagittal plane

Maxilla: 23 mm, Mandible: 4-5 mm

Immediate Dentures:1.8 mm bone loss in first yrOverdentures:0.9mm bone loss in first year


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ETIOLOGY OF RRRMultifactorial disease

1. Anatomic

2. Metabolic

3. Mechanical

4. Prosthetic


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ANATOMIC FACTORS

Amount of bone

Quality of bone

Density of the ridge

Short and square face

Long alveolar process

Bones with muscle attachment


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Metabolic Factors

RRR Bone resorption factors

Bone formation factors

Local factors:

Endotoxins

Osteoclast activating factors

Prostaglandins- messengers ( PG E 2 )

Human gingival bone resorption stim.factor

Heparin


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Trauma

Systemic Factors:

Decreased bone formation

Patients having excess amounts of

glucocorticoid hormones

Increased resorption

Hypophosphatemia- duodenal ulcer, impairedrenal tubular reabsorption

Estrogen and testerone ANABOLIC


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Estrogen and testeroneANABOLIC

HORMONES.

Adrenal glucocorticoid.including cortisoneand hydrocortisone. ANTIANABOLIC

HORMONES

Excess of ANTIANABOLIC HORMONES

results in faster resorption.

Estrogen antagonizes the effect of PTH retard

bone resorption.

Calcitonin inhibits bone resorption


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Wical and Swoope, JPD 1974:

Calcium-Phosphorus ratio above 0.7 in a group with

minimal resorption

Increased Phosphorus- Sec. Hyperparathyroidism

Vit D- increases Calcium absorption from gut,

reabsorption from kidney

Protein deficiency- decreased matrix formation-

osteoporosis


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RRR & OSTEOPOROSIS

Type I/ Post menopausal Type II/ Senile

-Extensive corticosteroid therapy can cause

secondary form of disease.

-Acute/chronic oral manifestations.

-Vertebral osteoporosis and periodontal disease.

-Lactose intolerance becomes more prominent.

-750 to 1000 mg/day calcium

-375 IU VIT D2 suggested.


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Disuse atrophy

Whendon 1984Vebelhart,Domenech1995

Constant mechanical stimuli maintain

Coupled cellular activity b/w osteoblast &osteoclast.

Immobilise bone cannot sustain coupled

remodelling process & result in loss of bone

mass.

In denture wearers mechanical stress are

transmitted through denture base.


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Mechanical Factors

Amount of forcemore in parafunctional habit

Frequency of force

Duration of force

Direction of force

Area over which force is distributed

Damping effect of underlying tissue(Atwood1979)


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RRR x 1/damping effect

mucoperiosteum viscoelastic

bone- maxilla has more cancellous bone

Boucher :

Teeth contact during swallowing are usually

longer duration than with chewing .

Surface area of mandible is 12 sqcm & that

of maxilla is 23 sqcm.

P th ti F t


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Prosthetic Factors

Broad area of coverage

Decreased number of dental units

Decreased bucco-lingual width of teeth

Improved tooth form

Avoiding inclined plane

Provision of adequate tongue space

Adequate inter-occlusal space

Oth F t


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Other Factors

Sex- RRR is more in females( ratio 5:1)

Racial factors-

Garns 1970:Blacks have higher bone density;

Osteoporosis is more in short and high weight females

Time since extraction

RRR x 1/ Time: Carrson and Person, 1967


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RRR Anatomical Factors +

Bone resorption factorsBone formation factors +

Force factorsdamping effect factors +

1

Time


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Consequences of RRR

Apparent loss of sulcus depth and width

Displacement of muscle attachments

Loss of VDO

Anterior rotation of mandible

Altered inter-ridge relationship

Altered location of mental foramen

Altered facial esthetics

Decreased masticatory function


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SUMMARY

T


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Thank youThank you


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Techniques correct alveolar atrophy

Techniques to compensate for problems


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LOWERING THE MENTAL

FORAMEN

Incision along alveolar crest

Mucoperiosteum carefully reflected until

neurovascular bundle emerges from the

foramen.

Vertical grove inferior to foramen 5 to

10mm.

Cortical bridge below nerve removed when

grove completed.


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Freed nerve carefully moved into a new

position

Mucosal flap placed and sutered.


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Pong Dentures

2 skinned lined pockets in piriform

aperture created.

Horizontal incisions 1cm long down in this

region.

Piriform aperture exposed and nasal

mucosa elevated from floor of nose on

each side to create pocket.

Fabricated pongs inserted to check fit.


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Partial thickness skin graft taken and drapedover pongs.

Stent/denture placed till 10 days in vestibularmucosa.

Patient must keep dentures or separate prongsin place for 1 year until all fibrotic changes havetaken place

Adjustments made by disclosing areas ofoverextension with pressure paste and grindingareas in question.


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Zygomaticoplasty

Removal or compression of bone at butteress of

zygoma to provide vestibular height and lateral

stability.

Horizontal incision made below process. Mucoperiosteum reflected and a horizontal cut

made with bur at upper aspect of buttress.

3 or 4 vertical cuts made inferior to base of

process

Bone pressed medially into maxillary antrum.


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5 to 8 mm of alveolar height can be

achieved.

TUBEROPLASTY

Transverse incision from buccal vestibule

to palatal side made just at distal aspect of

tuberosity.

Pterygomaxillary exposed

Lateral and medial pterygoid separatedfrom tuberosity.

Segment pushed posteriorly.


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VESTIBULOPLASTY

Attempts to expose and make available for

denture construction that bone which is

still present.

Assumption is bone resorption will have

end point and support for denture will

distribute masticatory forces and slow

resorptive process

Cl k(1953)


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Clark(1953)

Flap was pedicled from lip

Raw surface is on bone resulting in lesscontracture and better healing

How 1966 and kethley and gamble 1978

described lipswitch procedure Labial mucosa flap developed and

extended to crest of ridge from an initial lip

incision.

Tissue Graft Vestibuloplasty


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Tissue Graft Vestibuloplasty INDICATIONS

insufficient bone to complement for relapse ofa secondary epithlization

Vestibular depth is needed after bone graft

augmentation.

ADVANTAGES

Reduces wound contracture

Coverage for denuded areaRapid healing

Early construction of prosthesis


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Types of graft materials

Palatal mucosa

severely atrophicmandible

Buccalmucosa-holding down muscleattachments and creating smoothvestibule when bone loss has been

moderate.

Skinfor wide coverage


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Lingual vestibuloplasty

residual ridge resorpion with management

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