Journal

of Dentistry,

13,

No. 2, 1985,

pp. 91-101

Printed

m Great

Britain

The prosthetic treatment in the presence

of gross resorption of the mandibular
alveolar ridge*
L. Golds, 6%
Kings College School of Medicine

8 Dentistry

ABSTRACT
Grossmandibular

alveolar resorption is a localized pathologic process, not reversed by removal of causative

factors. despite the internal bone remodelling and deposition that goes on even in the presence of pathologic
external osteoclastic activity responsible for the loss ofbone substance. It affects both sexes, young and old. with
or without dentures, for which many aetiological factors have been proposed.

An ideal treatment is preventive, i.e. retaining all teeth or, failing this, certain teeth which may serve as
additional retentive aids for an overdenture covering the otherwise markedly resorbed ridge (Basker et al., 1983).
However,
condition

an effective long-term solution for gross mandibular

remains a well-recognized
problem in prosthetic

alveolar resorption

has yet to be evolved. and the

treatment.

INTRODUCTION
Despite recent improvements in the oral hygiene and dental health of the general population,
with reduction from 30 per cent to 20 per cent of the population who are edentate, extraction of
teeth due to decay or periodontal disease is frequent (Adult Dental Health, 1978).
Due, however, to the continuing process of reduction of the residual ridge, prosthetic
treatment of the totally or partially edentate patient is a continuing one. In order to ensure
satisfactory appearance and function the denture may require relining or reconstruction long
before it has worn out. The rate at which the ridges change shape and size varies both between
individuals and at different times in the same individual (Atwood, 197 1). While some patients
show minimal ridge reduction over many years, others may show gross ridge resorption over a
short time, possibly at an early age, giving rise to the term presenile atrophy (Forman, 1976)
(see Table I).

Reduction of bone in size and shape occurs on the labial, crestal and lingual aspects of the
residual alveolus to give a ridge form which may be categorized according to its configuration.
Gross resorption ofthe alveolar ridge could be described as Type V-knife edge, or Type VIdepressed (Atwood, 1979). The mandible is peculiarly susceptible to resorption, showing a
fourfold increase in resorption rate when compared to the maxilla as a control (Tallgren,
1972).
In addition to the requirement for replacement, particular problems arise in the construction
of a satisfactory prosthesis for the grossly resorbed mandibular ridge. These problems may be
morphological,
due to the decreased area available for support and encroachment
of
surrounding mobile tissues onto the denture border, thereby reducing the support, stability and
physical retention of the denture. For this reason the tissues are readily traumatized and the
*Awarded
Prosthetic

the Undergraduate
Dentistry, Cardiff

Essay
1984.

Prize at the Annual

Conference

of the British

Society

for the Study of

92

Journal of Dentistry,

Tab/e /. Rates of bone loss in the anterior mandible (mm/l

0.75
2.75
4.50
6.00

1~/NO. 2 (1985)

year)

Rate of loss (mm/l

First
First
2 years
5 years
Patient with least ridge resorption
Average ridge resorption
Patient with most ridge resorption
Difference between extremes

Vol.

0.40
1.36
2.90
7.25

year)
3rd-5th
years
0.13
0.50
1.80

Carlsson (1967)

complaint of looseness of a lower denture that is also uncomfortable to wear is commonplace.

These difficulties are exacerbated by poor neuromuscular
control (a compensation usually
acquired by experienced denture wearers) and by faulty construction of the dentures.

AETIOLOGY

OF MANDIBULAR

ATROPHY

Gross mandibular atrophy has been described as a multifactorial biomechanical

disease
resulting from a combination of anatomic, metabolic and mechanical determinants varying
with time from patient to patient in an infinite number of combinations (Atwood, 1979).
Although there has been no satisfactory explanation for progressive mandibular atrophy
resulting in disproportionate
mandibular alveolar loss, many local or systemic factors have
been postulated. Previous studies have shown no correlation between systemic osteoporosis
and ridge resorption (Atwood, 197 1). However, osteoporosis of the mandible does occur and
marked ridge resorption may arise in the absence of generalized bone disease, with usual blood
concentrations
of calcium, phosphate and alkaline phosphatase (Henrikson et al., 1974).
Hence, a localized osteoporotic process may be the contributing factor to resorption in patients
who may be more susceptible to local factors.
Lammie ( 1956) postulated a process of pressure-produced
resorption, resulting from a loss
of underlying bone due to cicatrization of the mucoperiosteum.
Atwood (197 1 ), however,
proposed that localized pathologic osteoporotic processes in bone subjected to repeated excess
pressure lead to gross porosity of medullary bone on the ridge crest, and bone loss.
Parafunctional clenching and grinding habits may cause pressure resorption, due to periods of
mucoperiosteal
ischaemia and decreased pH leading to bone loss. Accompanying
chronic
inflammatory changes in the overlying mucoperiosteum
accelerate the process (Whinnery,
1975), and the damping of force transmission by the viscoelastic
mucoperiosteum may be
inadequate to prevent bone resorption (Picton and Wills, 1978).
In contrast, relative disuse of a bone may be a powerful contributory factor in localized
osteoporosis and the mandible may only take approximately one-third of the capable lifting
load when full dentures are worn (see Table ZZ).
Gross ridge resorption has also been attributed to alteration in mandibular blood supply with
changes in capillary wall thickness (Barrett et al., 1969), and abnormality in the inferior dental
artery (Cohen, 1969). Other factors such as periodontal disease existing before dental
extraction, surgical injury and excess loading from a well fitting denture have been proposed
(Michael and Barnom, 1976). The aetiology of the condition thus remains uncertain, but it is
likely to be multifactorial.

Golds: Gross mandibular

Tab/e Il. Average

biting loads on natural teeth and tissue-borne

Watt and MacGregor

dentures

No. of
measurements

Av. biting
load
(kg)

Approx. % age
of natural
tooth load

215
28

21.7
7.4

100
33

Natural teeth
Tissue-borne dentures

CHANGES

93

alveolar resorption

(1976).

IN THE ORAL MUCOUS

MEMBRANE

While not having been widely studied (in contrast to maxillary palatal tissues: Watson and
Macdonald, 1983) mucosa overlying the grossly resorbed ridge shows structural change. it
may become thin and atrophic (with an increased susceptibility to bruising and damage on
occlusal loading) or fibrous in character, to give a flabby ridge with increased amounts of
mobile and redundant tissue (Hickey and Zarb, 1980). Tissues surrounding the ridge may be
altered, with the quantity of attached gingiva associated with the ridge much reduced.
Increased support is required from the surrounding non-keratinized
moveable mucogingiva.
which is now subjected to excess loading and parakeratinization
(Storer, 1965).

CLINICAL

TREATMENT

Prior to denture construction an accurate medical history should be taken to record previous
and existing systemic conditions that may contribute to mandibular atrophy. For example,
menopausal and post-menopausal hormone imbalance may cause increased resorption (due to
induced osteoporotic changes) and blood dyscrasias may render the mucosa more friable with
inflammation
possibly causing bone loss. On identification
of these and other factors
appropriate medical advice should be sought to clarify the prognosis.
Another important consideration is the patients biological rather than chronological age,
which may prejudice operative procedures, especially if surgery is considered. In old age the
reduced capability of the patient to adapt to the demands of becoming totally edentate (on
removal of teeth remaining in an otherwise grossly resorbed ridge) or to modify existing motor
skills to control a prosthesis of markedly different shape is well recognized (Fish, 1969).
Likewise, case management is prejudiced by mental deterioration, e.g., senile dementia, in
which case the only solution to the problem of the atrophic mandible may be to avoid provision
of a lower denture!
Problems of an emotional nature in addition to those associated with reduced ridge contour
may prevent a satisfactory result.
A comprehensive dental history, including a record ofprevious prosthodontic treatment with
the number of dentures made and the frequency of denture rebasing should be appreciated, in
order to estimate both the apparent rate of progression of ridge resorption and the capability of
the individual to cope with previous dentures. A disclosure of parafunctional oral habits, for
example, bruxing, should also be investigated and attempts made to educate the patient to
avoid this activity, prior to further prosthetic treatment.

94

CLINICAL

Journal of Dentistry,

Vol. 1 ~/NO. 2 (1985)

EXAMINATION

Careful inspection of existing and any previous, dentures intraorally and extraorally should be
made with attention to their design. The contour of the arch, border extension of the base,
vertical dimension and centric relation of the jaws should be recorded, with note of patients
comments on aesthetics and function, as an aid to assessing muscle coordination and denture
control. The compatibility of anterior and posterior tooth position and occlusal plane level with
denture stability should also be examined.
Intraoral examination should determine the ridge form and extent of resorption. Assessment
of mucosal form on and surrounding the ridge should be made, together with palpation to locate
any tender areas of mucosa to evaluate any additional prosthetic problems likely to be
encountered.
Changes in the width and depth of the sulcus arising with border activity should be assessed
to estimate the likely form of the denture-bearing
area contributing to support and stability in
the denture, since in the case of gross ridge resorption the superficial position of the moveable
tissues brings them into close proximity with the denture border which may all too easily be
overextended.
The tongue appears to become larger, filling the space vacated by the teeth, and more
powerful on wearing loose or otherwise inadequate dentures. With marked resorption the
tissues of the floor of the mouth, which are very mobile, lie in close association with the residual
ridge, so that active tongue movements may increase the tendency to denture displacement.
In particular, the sublingual glands may be forced over the residual ridge crest into areas
normally occupied by the lower dentures (Beresin and Schiesser, 1978). A small or defensive
retracted tongue may prejudice lower denture control by dropping away from the lower
anterior teeth (Liddelow, 197 1). With the floor of the mouth failing to contact the anterior
lingual border of the denture there is a loss of retentive seal. The broadened, retracted tongue
may contact the lower posterior teeth, or the distolingual border in the retromylohyoid fossa,
acting against these sites to compromise denture stability.
On examination assessment should be made of saliva present. Alteration in the quantity or
quality, that is the viscosity, may prejudice physical retention of the denture, associated with
cohesive and adhesive properties of the saliva from between the denture and the mucosa. This
problem is found, for example, in the elderly and those receiving certain anti-depressant
drugs.
Additional aids to diagnosis may be employed, including radiographs to assess the degree of
ridge resorption (which may not be completely evident on clinical examination).
An
inadequate bone thickness will indicate an increased risk of spontaneous fracture of the
mandible. Bony irregularities may be detected, together with the position of the mental nerve
trunk and relation of the roof of the inferior dental canal to the jaw surface. A superficial
position of the mental foramen or dehiscence of the canal is a cause of pain referred to the ear.
Diagnostic models may also be taken to allow case evaluation in the absence of the
patient.

TECHNIQUES

IN DENTURE

CONSTRUCTION

Principles employed should give maximal support, retention and stability of the denture while
creating a pleasing appearance. In the provision of such a prosthesis a number of principles
must be satisfied (Atwood, 1979). A broad area coverage, with maximal denture-base

Golds:

Gross

mandibular

alveolar

resorption

95

extension, decreases the force experienced per unit area of the mucosa beneath the denture and
the likelihood of its trauma. However, in the grossly resorbed ridge the area of tissue available
for support is reduced and extension of the base is critical to avoid interference with movement
of the border structures.
Specialist techniques to determine accurately a denture extension with reference to
functioning tissue at its denture border have been evolved. Fish (1932) recommended a
technique using the sublingual fold space, extending from premolar to premolar region on each
side, bounded anteriorly by the alveolar ridge and posteriorly by the sublingual gland orifices.
By recording this area when elevated, a horizontal flange may be positioned to act as a tongue
rest.
Devising a different form of denture base Boucher (1958) made use of the retromylohyoid
fossa by extension of the distolingual flange across the mylohyoid ridge and muscle in its
elevated position. This technique is recommended by Naim (1964).
Brill (1967) sought to gain facial and border seal by adapting an existing denture with a
viscoelastic gel, to eliminate the space between the cheek or tongue and the denture border and
the polished surface contours. However, no use was made of the retromylohyoid fossa by this
technique.
Where, despite continuing alveolar resorption, the same denture is worn for an extended
period, there is excess transfer of masticatory load to the peripheral areas which are said to
become fibrous and corniced and the ridge plays no role in denture support (Watt and
Macgregor, 1976). Loading by a new denture made from a conventional impression will make
use of the ridge for support, and this is said to evoke pain in many cases. Hence the peripheral
areas alone should be used for support with minimal displacement of the ridge tissue (Appleby,
1957).
Similarly, surface contours of the resorbed ridge may prejudice denture support and the
sharp superficial aspect of the mylohyoid ridge is unfavourable for support due to painful
loading of the covering mobile mucosa. In cases of nerve dehiscence and ridge irregularity the
cast should be relieved before construction of the conventional base, where surgery is thought
to be inappropriate. The reduced capability of the thinned mucosa to support vertical load may
be eased by use of soft lining on the denture fitting surface.
Fibrous tissue, flabby ridge overlying the residual ridge, may compromise denture stability
and special techniques have been devised which either load other sites and avoid displacement
(Osborne, 1964) or remove such redundant tissue.
Apart from maintenance of seal between the mucosa and denture border region, retention is
determined by another feature of the denture influencing surface tension and viscosity of the
saliva. This is the accuracy of fit of the impression surface, which decreases the saliva film
thickness (Lindstrom et al., 1979).
In addition to the use of these techniques described to attain accurate denture-border
extension and maximum support, the construction of the denture base should be made in
advance of adding the denture body and arch. The extension of the base should be checked to
test retention and avoid potential destabilization
of the denture. A common site for
overextension is in the mylohyoid region where crossing of the superficial fibres of the muscle
attached to the distal position of the ridge may impede its elevation, causing loosening of the
denture base and ulceration of the overlying mucosa.
Retention, due to muscular forces, relies on a patients ability to acquire necessary skills
(Culver and Watt, 1973) and on a denture polished surface design, such that functional muscle

96

Journal

of Dentistry.

Vol.

1 ~/NO.

2 (1985)

pressure exerted does not cause denture displacement (Shepperd, 1963). In addition to this
active muscular fixation relaxed soft tissues may help maintain the denture in position by
acting on the denture polished surface. Employing techniques locating the zone of least
interference (or minimum conflict orthe neutral zone) the denture is sited so that soft-tissuedisplacing forces, from the tongue on one side and the lips and cheeks on the other, are
minimized. The potential conflict of unsuitable polished surface contours with habitual tongue
posture and functional activity of the surrounding musculature is eliminated. Provision of
adequate tongue space improves seating forces acting on the denture, as well as facilitating
speech and mastication (Fish, 1932; Beresin and Schiesser, 1978). This zone is created after
jaw relations have been established by the use of a viscoelastic material which is moulded
during speech (Neil1 and Glaysher, 1982).
The surface contours of the grossly resorbed ridge offer minimal resistance to forces
generated by investing tissue and occlusion so that the denture is easily unstabilized, since
frictional contact between upper and lower teeth may be greater than that between the mucosa
and the denture-fitting
surface, causing lateral and anterioposterior
denture shift (Chick,
1949). Impression techniques should ensure that the denture-fitting surface is smooth, and
does not cause frictional abrasion of the underlying mucosa (Watt and MacGregor,
1976).
Increased denture stability, together with reduction in force/unit area applied to the mucosa,
may be achieved with a reduction in length of the occlusal table by reducing the number of
teeth. By limiting the occlusal table to the horizontal part of the ridge there is a reduction in
forces applied to the sloping part of the supporting tissues. Denture displacement during
mastication (the ski-slope effect) is therefore minimized. Extension of the arch to the
posterior aspect of the denture (occupied by the tongue on the lingual part and buccinator on
the buccal part) is also avoided by this modification in design.
Similarly, a tooth mould should be selected to give a maximum penetrating capacity. Tooth
form enhanced with cutting blades may limit the force applied to the mucosa by decreasing the
force required to penetrate a food bolus. This may increase comfort, especially in those who are
poorly force-tolerant. Otherwise, in avoiding pain the patient may move the mandible or lift the
denture from the mucosa, resulting in instability.
The provision of a generous freeway space is said to decrease the frequency and duration of
functional and particularly parafunctional tooth contact. In cases of marked ridge loss the
vertical dimension may be further reduced in order to place the occlusal table closer to the
alveolar ridge and create a more stable lower denture by reduction in the height of the denture
(Watt and MacGregor, 1976).
As already mentioned, destabilizing forces from the lips, cheeks and tongue act on the
denture polished surfaces and dental arch. Additional forces will be generated by the teeth
during contact. In designing the occlusion for the subject it is accepted that the occlusion should
be balanced in centric relation. However, there is disagreement about the tooth contact
required in eccentric positions of the lower jaw.
Anatomical articulation uses artificial teeth with cuspal inclines and occlusal compensating
curves comparable to those found with natural teeth. In any eccentric jaw position balance of
the teeth will stabilize the denture base. However, continued resorption and settling of the
denture destroys the accuracy ofthis balance, and forces on the cusp slopes tend to resolve with
horizontal forces against the mandible, which may favour further resorption (Ortman, 197 1).
In advanced resorption this is likely to result in displacement of the denture.

97

Golds, Gross mandibular alveolar resorption

The use of the neutrocentric

concepts of tooth arrangement
have evolved so that chopping
movements are encouraged in chewing, tending to seat the denture and avoid horizontal
displacement
(Devan, 1935). Use of these teeth are indicated in cases of flat or knife-edge
ridges where there is a marked grinding or shearing action in chewing, or where debilitation
has compromised coordination. In this method centric occlusion may be created as an area,
which may be important where there is difficulty in establishing entirely accurate records due
to lack of retention of the denture.
Alternatively,
the choice of non-anatomic teeth may be considered with the use of a flat
occlusal table (Sears, 195 7). Where vertical overlap of the incisor and canine teeth is required
for aesthetic reasons, increased horizontal overlap should be used in design to avoid denture
displacement due to tooth contact in excursive jaw movements. Loss of posterior tooth contact
on protrusive jaw movement due to Christensens phenomenon may be avoided by use of
compensating curves (Christensen,
196 1). However, exaggerated occlusal planes should be
avoided to minimise denture dislodgement.

THE ROLE OF SUPPORTIVE

MINOR

SURGERY

Despite careful techniques using methods applicable to the grossly resorbed ridge to produce a
denture that is retentive and stable, adverse tissue morphology in association with poor
neuromuscular
skills may produce a denture of inadequate function. For this reason
preprosthetic surgery techniques have been developed to improve the ridge form. However. by
its very nature, the grossly resorbed ridge may limit the use of these techniques. Supportive
procedures should be carried out that accept the overall ridge shape while modifying areas of
soft or hard tissue that compromise the denture support and stability. Bony contouring must be
restricted, e.g., reduction of sharp mylohyoid ridges, so as not to reduce the already minimal
support or promote increased bone resorption associated with surgical trauma.
Mental, and possibly inferior dental, nerve dehiscence due to continuing ridge resorption
must be considered in choosing the denture-base
design and material together with the
possibility of surgery, or ridge augmentation. Prominent general tubercles (attachments for
geniohyoid and glossus muscles) may cause pain due to posterior denture displacement by the
lip pressure. Though bony reduction, with maintenance
of muscle attachment, may be
attempted, bony prominences can be important for denture support and stability in the
otherwise grossly resorbed ridge.
Fibrous or flabby ridge response in soft tissue may severely prejudice denture stability due
to tissue mobility and chronic tissue irritation. With careful consideration of the underlying
bone morphology, fibrous tissue reduction may be undertaken as well as frenoplasty. and
replacement of unstable muscle attachments where encroachment of mobile tissues onto the
denture border causes instability.
The value of ridge extension procedures, including sulcus deepening by vestibuloplasty with
the sulcus being lined with split-skin grafts (Laney et al., 1968), are limited in cases of marked
ridge resorption since 12 mm or more of bone depth is required to achieve effective sulcus
deepening(Kruger,
1958). Hopkins et al. (1980), on the other hand, consider the treatment to
be effective in improving comfort and chin contour. A disadvantage is the high incidence of
numbness of the lower lip.
A technique more commonly employed in the treatment of the grossly resorbed ridge is
augmentation. indicated where ridge resorption is so advanced that there is increased risk of

98

Journal of Dentistry,

Vol. 1 ~/NO. 2 (1985)

spontaneous fracture of the residual bone, or where attempts to wear well-constructed dentures
have failed (Kruger, 1958). Implantation is one type of augmentation. Endosseus implantation, a process in which metal implants are partially buried in bone, requires adequate height of
the alveolus and cancellous rather than compact bone for its support Such opportunities rarely
exist with marked bone loss and, until recent developments, have proved unreliable (Linkow,
1979). A method of augmentation more frequently employed is subperiosteal implantation. A
metal framework is closely adapted to, and seated on, solid cortical bone beneath the
periosteum, avoiding any exposed anatomical features such as blood vessels and nerves which
are evident on the impression taken of the bone surface on periosteal reflection. Areas of the
soundest compact bone, i.e., areas of muscle attachment, are utilized for support and a small
number of posts protrude through the mucosa on which the denture superstructure
is
constructed and supported.
While showing increased success, problems may arise due to framework faults, for example
metal porosity (leading to metal weakness and possible fracture); poor adaptation of the metal
substructure to bone contours, either initially or on continuing bone resorption. Infection is a
problem increased by the continuity of the metal framework with the oral environment (Mack,
1960). The procedure is normally restricted to selected cases in which the jaw form is stable.
Both meticulous oral surgery and prosthetic techniques are required.
As alternatives to implantation, transplantation
of rib or hip tissue (homograft) have been
used in ridge augmentation(see
for example, Forman, 1976). However, despite many attempts
to prolong the functional life of the grafts, by their positioning above and below the residual
ridge to give direct or indirect functional loading respectively, they show relatively rapid
resorption (Davis et al., 1975; Baker et al., 1979). While rib grafts create good ridge form, they
undergo relatively rapid resorption. Iliac crest bone grafts show early revascularization
and
reduced resorption, but are difficult to form in an ideal edentulous ridge shape (Fonseca et al.,
1980).

RECENT FINDINGS
Due to the relatively short-term effect of augmentation, new methods have arisen from recent
research. Leake (1974) has described the combination of implanted cancellous bone chips,
supported in an exogenous polymethane and Dacron shell inserted to rest on the compact bone
beneath the mucosa. This is a method requiring early functional loading. Alternatively,
a
purely exogenous material, such as aluminous porcelain, may be used (Pederson and Haanaes,
1979).
Important in previous implantation work has been the biocompatibility between implant and
adjacent tissue and the existence of an interface between the two (Albrektson,
1983).
However, the association of unalloyed titanium with bone and connective-tissue elements, and
fibroblast ingrowth into irregularities in the metal surface have been observed. Albrektson
whereby unalloyed titanium fixtures
(1983) describes the technique of osseointegration,
which serve as root analogues are implanted into the anterior mandibular ridge, covered with
mucosa and allowed to osseointegrate for four-six months. They are then surgically uncovered
and exposed to the oral cavity through titanium cylinders which are covered with a periodontal
pack. A metal framework carrying the denture superstructure
is then attached to the
osseointegrated
fixtures. (For a diagram, see Branemark (1983) and for rationale and
proposed mechanism see Zarb and Symington ( 1983).) Clinical results report a lack of marked

Golds:

Gross

mandibular

alveolar

resorption

99

tissue reaction with decreased bone loss on loading, giving a predictable prognosis (Adell,
1983).
In the grossly resorbed ridge residual bone may not be sufficient to support implants for
direct osseointegration.
Albrektson (1983) has described a method whereby implants are
placed directly into the iliac crest which, following osseointegration,
are transplanted en bloc
with the bone into the resorbed ridge. After a period of integration to the mandibular bone a
prosthesis may be fitted.
Kent et al. (1983) have described the use of non-resorbable
particulate hydroxyapatite,
alone or in combination with finely crushed autogenous cancellous bone, to augment deficient
alveolar ridges of various configurations.
Delivered subperiostally
by syringe injection,
augmentation results in a stable soft-tissue base of improved ridge height and contour. This
enables construction
of a retentive stable denture, with a reduced requirement
for
vestibuloplasty and a lower incidence of adverse reaction.
Despite the loss of alveolar ridge contour on resorption, there is often a cortical bone layer
over the ridge crest with new bone being laid down inside the ridge in advance of pathological
osteoclastic activity (Atwood, 1963). By reversal of the resorptive process, with new bone
deposition, an improvement of ridge contour could be stimulated. However, there are no
reports of spontaneous increase in residual ridge size in edentate subjects from clinical or
radiographic studies.
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J Prosthet. Dent. 50, 257.

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Albrektson T. (1983) Direct bone anchorage of dental implants. J. Prosthet. Dent. 50, 255.
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titanium implant. Actu Odontol. Stand 52, 155.
Appleby R C. ( 1957) TechniquesforDlflcult
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Atwood
D. A. (1963) Post extraction
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