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Treatment of the mandibular compromised ridge: A literature

Dennis E. Jennings, D.D.S.*
Rhoades Dental Clinic, Fort Sam Houston, Tex.

Restoration of the mandibular compromised ridge requires various treatment

modalities. The simplest approach often is to extend the denture base adequately
for proper use of all available supporting tissues. If the patient is incapable of
wearing a conventional denture, the surgical approach becomes necessary. Surgical
avenues include vestibular extension procedures that increase vestibular depth and
augmentation procedures, which include (1) overlay grafts of rib or the crest of the
ilium, (2) osteotomy grafts to include the visor osteotomy and the interpositional
bone graft, (3) alloplastic grafts of which hydroxyapatite augmentation is the most
common, and (4) various types of implants to restore the compromised ridge. The
ultimate goal, regardless of the treatment modality chosen, is to restore the patient
to a level of masticatory function. (J PROSTHET DENT 1989;61:575-9.)

T reatment of the severely resorbed mandibular ridge was tongue position. The ideal tongue is forward and resting
has been a problem confronting dentistry for many years. on the top of the lower anterior ridge when the patient ca-
The denture patient with such a ridge often loses hope of sually opens the mouth. Such a position will effectively form
normal function and does not wear the denture. Under- a lingual border seal. A retruded tongue makes it almost im-
standing the available procedures can often help to return possible to establish this seal. Second, ill-fitting dentures
the denture patient to a state of masticatory function. distort the tissues over the ridge, set up irritations, and cause
To understand abnormal ridge contours, a definition of resorption of the bone. Treatment of the tissue is essential
the ideal ridge form for denture fabrication is necessary. before making new dentures. Third, there should be proper
Goodselll defined the ideal denture-supporting ridge as pos- use of the lingual spaces for retention of the denture. The
sessing (1) adequate bone support for dentures, (2) bone sublingual crescent space is the anterior part of the floor of
covered by adequate soft tissue, (3) no undercuts or over- the mouth above the sublingual gland. Tissue bounding this
hanging protuberances, (4) no sharp ridges, (5) adequate space moves freely, so that the anterior lingual flange can be
buccal and lingual sulci, (6) no scar bands to prevent normal extended horizontally. The sublingual fossa follows the my-
seating of a denture, (7) no muscle fibers or frenula to inter- lohyoid muscle extending down from the mylohyoid ridge,
fere with the periphery of the prosthesis, (8) satisfactory close to the lingual surface of the body of the mandible, when
ridge relationships between the maxillae and mandible, (9) the muscle is relaxed. In swallowing, the muscle raises the
no soft tissue folds, redundancies, or hypertrophies on the tongue and brings the floor of the mouth upward. Frequently
ridge or sulci, and (10) a ridge free of neoplastic disease. this muscle is flabby, allowing extension of the lingual flange
The severely resorbed mandibular ridge often lacks most vertically in the premolar-molar region. The retromylohyoid
of the criteria for an ideal ridge form. Golds2 stated that the fossa is located below and behind the retromolar pad. The
resorbed mandibular ridge presents difficulty in making an problem with extension into this region is that it may
adequate prosthesis because of decreased support and the develop a sore throat in the denture wearer. With careful at-
encroachment of surrounding mobile tissues onto the den- tention to anatomic form, a number of denture patients can
ture border, thereby reducing the stability and retention of function without undergoing surgical intervention.
the denture. Many techniques have been developed to deal with the
Shanahan3 listed three important factors in dealing with problem of the compromised ridge. In the 193Os, Page and
a patient with an unfavorable mandibular ridge. The first Jones advocated the principle of mucostatics.4 In 1957,
Faber5 advocated using metal bases for snugness of fit of the
The views expressed herein are those of the author and do not re- mandibular denture. In 1960, Behrman6 wrote of implanting
flect the views of the U.S. Army or the Department of Defense. platinum-cobalt magnets to increase mandibular denture
*Major, U.S. Army (DC); senior prosthodontic resident. stability. In 1966, Lott and Levin7 put forth the flange



technique, which provided much greater denture-bearing more horizontal stability, (3) there is increased vertical sta-
surface for stabilization. In 1969, Strain8 emphasized the bility during functional loading, resulting in improved mas-
necessity to duplicate in the base the contours of nature to ticatory performance, (4) natural teeth that are unaccept-
help stabilize the lower denture. Each technique had merit, able as abutments for conventional dentures can be main-
but no technique was applicable to all conditions. In a study tained as supporting elements in complete overdentures, and
conducted by Levin et a1.gin 1970, it appeared that the ex- (5) patient acceptance is excellent.18l I9
perience of the denture wearer was more important than the Although the overdenture is the treatment of choice for
technique used or the flange extension. Renaud et al.1 be- patients with some remaining dentition, most denture ser-
lieved that increased efficiency after rehabilitation could be vice provided today deals with the edentulous patient. The
partly due to acquired self-confidence in mastication. How- ideal ridge described by Goodsell rarely presents itself to
ever, proper coverage of all available denture-bearing surface the dentist; thus surgical intervention is often required. The
is fundamental to good denture construction. surgical procedures discussed will be grouped into (1) exten-
sion procedures, (2) autologous overlay grafts, (3) osteotomy
ALVEOLARATROPHY procedures, (4) alloplastic grafts, and (5) implant proce-
Guernseyll stated that progressive atrophy of the alveolar dures.
bone following extraction of the teeth is a physiologic occur-
rence. The causes included (1) disuse atrophy, (2) localized
excessive pressure during incising and unilateral function Kazanjian20 in 1935 developed a vestibular extension pro-
under a denture, (3) periodontal bone loss before extraction cedure by which a horizontal incision was made on the sur-
of the teeth, (4) hyperparathyroidism, and (5) hypogo- face of the lip approximately 1.5 cm from the ridge crest. The
nadism. Meyers12 added nutritional deficiencies and tissue mucous membrane was undermined and freed from the per-
resistance to stress as other etiologic factors affecting alve- iosteum as far down the external side of the periosteum as
olar ridge resorption. Mercier13 believed the most significant necessary. The dissected tissue was then sutured to the un-
factors influencing ridge resorption to be related to the habit disturbed periosteum at the depth of the vestibule. In 1953,
of wearing the dentures both night and day and the number Clarkzl varied from the original Kazanjian technique by not
of years of denture wear. In a classic article, Tallgren14 found elevating the mucosa to the crest of the ridge, and the mu-
that the reduction of the mandibular anterior ridge height cosal flap was sutured through the floor of the mouth to the
was four times that of the maxillary ridge. Thus it becomes chin. In 1961, Kethley and Gamble22 developed the lip-
imperative to first consider prevention and preservation of switch procedure, which was a variation of the original Ka-
the mandibular ridge and second to consider, when prevei:- zanjian technique. The mucosa was reflected from the inci-
tion fails, the surgical avenues available to the prosthodon- sion in the lip to the crest of the ridge. The periosteum was
tist before making new dentures. reflected from the crest of the ridge inferiorly. The mucosal
flap was then sutured to the bone and the periosteum was
PREVENTIVE PROSTHODONTICS sutured to the lip-thus the name lipswitch. The disad-
The greatest way to preserve the mandibular anterior vantage of this procedure is that nonkeratinized mucosa is
ridge comes from the maintenance of one or more endodon- used for denture retention but this appears not to be a sig-
tically treated roots and the placement of an overdenture. nificant problem. Friedlander and Renner23 in 1977 advo-
This was graphically demonstrated in a 5-year study by cated resecting the submucous connective tissue, mentalis
Crum and Rooney15 in which cephalometric radiographs muscle, the incisive muscle of the lower lip, and the anterior
showed an average of 0.6 mm of vertical bone loss in the an- fibers of the buccinator muscle. The mental nerve and peri-
terior part of the mandible of overdenture patients com- osteum was left intact and the flap was sutured to the peri-
pared with 5.2 mm bone loss in the conventional denture osteum. Resection was performed to prevent relapse. In
wearer. Preservation of the ridge can be attributed to several 1981, Burton and Holton24 dealt with relapse by incision of
factors. First, masticatory force is transmitted to the root the mentalis muscle, suturing the flap to the base of the pe-
and periodontal ligament, thus simulating normal physio- riosteum, and allowing the dissected mucosal flap of the lip
logic function. Second, it has been shown that removal of the to granulate in. Vestibular extension procedures cannot be
coronal and pulpal tissues in the apical canal make no change done on the severely resorbed mandible because 15 mm of
in the proprioceptive response of the patient.16, I7 Thus, the bone is a prerequisite. 25 Nevertheless, the results can be
patient is better able to apply appropriate masticatory force dramatic, as demonstrated by Bolender and Swenson28 who
without overstressing the tissue. Third, retained roots greatly found a mean gain of 7 mm in vestibular depth.
increase lateral stability of the denture thus reducing trauma A more frequently used vestibular extension procedure
to the edentulous ridge. was first reported by Macintosh and Obwegeser,27 who used
The advantages of the overdenture over the conventional a split-thickness skin graft. Yrastorza28 stated that vestibu-
denture are: (1) soft tissues of the residual ridges are spared loplasty was indicated when the mucogingival fold approx-
abuse due to support of abutment teeth, (2) the denture has imated the crest of the ridge or the tissues in the floor of the

576 MAY 1889 VOLUME 61 NUMBER 6


mouth welled up over the ridge. A skin graft of 0.41 mm is of 12 patients who underwent visor osteotomy. He reported
obtained from the lateral surface of the thigh. A stent is used an initial resorption of 2 mm in 6 months. By 6 months, rapid
to maintain the graft held in place by circummandibular su- resorption ceased. By year 3, an additional 1 mm loss of bone
tures. The stent is removed in 10 days. Complications of the had occurred. By year 5, the author reported a stable vesti-
procedure include paresthesia of the lower lip, possible bular depth with little flange adjustments. Mercieri3 in 1985
thickening of the skin graft, and hyperkeratinization unless published an article describing the disadvantages of the vi-
the graft site is routinely massaged. sor osteotomy, which included (1) paresthesia of the lower
lip, (2) scarcity of available bone for mobilization, and (3) a
AUTOLOGOUSOVERLAYGRAFTS resultant ridge that was rarely retentive.
In 1970, Davis et a1.2goutlined a procedure in which trans- The second type of osteotomy procedure used for recon-
oral autogenous bone grafts (8th or 9th ribs) were grafted to struction of the mandibular atrophic ridge is the interposi-
atrophic mandibles. It was a variation of that described by tional bone graft. Bell et al .36 described this technique in a
Macintosh and ObwegeseF who commonly used the crest of 1977 article. In this procedure, a horizontal osteotomy is
the ilium. Davis et aL30 conducted a follow-up study in 1984 made the entire length of the mandible and a graft (either
on 19 such grafted patients and found the rate of resorption iliac crest or rib) is placed between the two sections. This
in the first 2 years to be 42%. During the next 2 years surgical procedure was thought to decrease the resorption of
resorption totalled 56%. The author stated that approxi- the graft sites recorded with the autologous overlay
mately 34% of the augmented bone is retained for an graft.30, 31In 1978, Bell and Buckles37 published a follow-up
extended period, thus reducing the possibility of fracture study of interpositional bone grafting. The authors reported
and increasing denture stability. Wang et als follow-up little if any resorption but stated that 9 to 10 mm of vertical
studysl in 1976 of patients receiving either iliac crest or rib mandibular bone was necessary for horizontal resection. As
grafts was somewhat less encouraging. They found a 28% is true with overlay grafts, the morbidity of the procedure is
resorption rate at 6 months, 45% at 1 year, 78% at 2 years, a major disadvantage.
and 89% at 3 years. Although vertical height approached
presurgical measurements, horizontal width was increased. ALLOPLASTIC GRAFTS
Because of the morbidity of the surgical procedure, these It soon become evident to those performing grafting pro-
operations are primarily reserved for the patient with such cedures in the mandible that resorption of the graft site was
a resorbed ridge that traumatic fracture is a possibility. a major problem. Alternatives to autologous bone became of
primary interest. One such material used by Pedersen3s in
OSTEOTOMY GRAFTS 1976 consisted of porous ceramic implants with a pore size
Primarily two types of osteotomy procedures are used in of 100 to 750 nm. The material was accepted biologically and
reconstruction of the mandibular atrophic ridge. The first is the 15-month results showed radiographic evidence of aug-
the visor osteotomy, which was developed originally by mentation.
Htile32 in 1975. The technique of augmentation consisted of The most popular alloplastic material used today is
a sagittal osteotomy of the body and symphysis of the man- hydroxyapatite (HA). Jarcho et aLsg published a study of
dible to create a lingually pedicled bone flap. The bone flap HAs biocompatibility and stated that HA was biocompat-
was elevated in the anterior region by hinging it posteriorly ible and nonbiodegradable. HA showed no evidence of local
in a visor fashion; hence, the name. Hiirles procedures2 pri- or systemic inflammatory or foreign body response. Kent et
marily augmented the anterior mandible. In 1977, Peterson aL40 developed the hydroxyapatite technique for augment-
and Slade33 wrote of a modified visor osteotomy. This pro- ing alveolar ridges. In 1983, Kent et a1.41reported only a
cedure included an osteotomy from one retromolar pad to 6.5% decrease in mandibular augmented ridge height after
the other. The lingual segment was elevated to a superior 4 years. The original technique described was an elevation of
position and secured with intraosseous sutures, thus aug- the periosteum on the ridge crest and a tunnelling with
menting the entire ridge. Cancellous bone or a marrow graft hydroxyapatite.42 A secondary split-thickness skin graft
was placed on the buccal aspect of the elevated segment. procedure was required in most patients. Techniques were
Peterson also advocated a simultaneous buccal vestibulo- soon developed in an attempt to eliminate the second surgi-
plasty by means of a lingually based Kazanjian flap. The ad- cal procedure.42s 43
vantages of this procedure over the prior autologous overlay Hydroxyapatite has been used for (1) grafting procedures
graft techniques were believed to be (1) minimal resorption alone; (2) in combination with autogenous cancellous bone44;
at 6 months, (2) early construction of dentures, (3) reduced (3) in combination with allogenic freeze-dried rib; and (4) in
morbidity (no iliac crest or rib need be sacrificed), and (4) combination with marrow.44 Block and Kent45 stated that
increased lingual vestibular length. In 1979, Hiirle34 pub- the clinical impression of ridge stability demonstrated by
lished a 3-year follow-up study of 10 visor osteotomy patients who have had ridge augmentation with HA in com-
patients. The author found an increased mandibular height bination with autogenous cancellous bone has not differed
of 63 % . In 1983, Peterson35 published a long-term follow-up greatly from those for whom HA particles alone were used.


They also reported a 10 mm gain in ridge height with only plant. A transosseous implant is attached to the inferior
a 4% to 10% reduction in a period of up to 4 years. border of the mandible between the mental foramen and
Desjardins& and Lamhert4 published articles that dealt contains two transosseous pins with either three or five
with the problems of hydroxyapatite augmentation. These endosseous pins for stability and retention. Cranin et al.53
included (1) diffusion of material (stems were developed in listed the advantages of the implant as (1) a simple surgery
order to try to compensate for this diffusion), (2) irregular in an uncomplicated anatomic site, (2) an implant with a
distribution and extension of the material, (3) incorrect po- permucosal portion free of geometric complexities, (3) a fix-
sition of material with excessive increase in width of the ation site farthest from the unpredictable alveolar ridge, and
ridge, which becomes a problem in placing denture teeth out (4) the use of a footplate located at the dense and stable in-
of the neutral zone, (4) excessive increase in alveolar ridge ferior mandibular border. To consider a staple bone implant
height with mandibular ridge to high before placement of one must have (1) an adequate labiolingual width of at least
denture teeth, (5) paresthesia, and (6) migration of the ma- 5 mm, (2) an adequate vertical height of at least 25 mm, and
terial after placement. (3) no physical or psychologic contraindications. The im-
The tunnelling procedure has given way to a full-thickness plant itself is made of 90 % titanium, 5 % aluminum, and 4 %
flap, controlled placement of the hydroxyapatite material, vanadium. Cranin et a1.53reported a 17-year success rate of
and surgical stent fixation to decrease some of the problems 81.7 %. Smal154believed that implants, in general, failed be-
associated with HA augmentation. cause of either metal fatigue or metallic corrosion, which
could be prevented by a thin oxide layer present on passive
IMPLANTS metals such as titanium, aluminum, or chromium. Lang et
The failures and shortcomings of augmentation grafting al.55 in 1967 reported that after placing different metallic
procedures have resulted in the advent of numerous forms of implants for a g-month duration, titanium was found to be
implants. The three broad categories are (1) subperiosteal, the most tissue compatible and nonmutogenic.
(2) transosteal, and (3) endosteal. Sma1156in 1978 stated that the prosthodontist (compared
The subperiosteal implant was developed by Golberg and with the oral surgeon) carries the greater responsibility be-
Gershkoff as reported by Metz@ and later advanced by Kra- cause the prosthodontist must adapt the mandibular staple
tochvil and Boyne4g in 1972. The typical subperiosteal to a functional role without violating design principles. The
implant involves two surgical procedures. The first is to re- principles are that (1) the staple is designed for a stabilizing
flect a flap and make an impression of the residual ridge. device and must never be loaded with compressive force, (2)
Before the second procedure, a frame that accurately fits the the use of stress-breaking devices such as the Dalbo or Ceka
bone is fabricated. During the second surgical procedure, a attachments are indicated, (3) the copings and bar should
full-thickness flap is reflected, and the frame is fixed to the never be loaded, and (4) the final prosthesis must be tissue
underlying bone. Recently, CT scan modeling of the mandi- borne. Techniques for use of the staple bone implant
ble has been used to eliminate the first surgical procedure.50 vary,57p58 but all should follow the criteria established by
Bloomquist51 in 1982 published a study of the long-term re- Sma1l.56
sults of subperiosteal implants. The author reported 5-year What appears now as the most popular (if economically
success rates of up to 90 % . Failure normally occurred at the feasible) treatment of the mandibular compromised ridge is
mucosal-metal junction. A recent advent with the subperi- the use of endosseous implants. Much of the clinical and
osteal implant is the use of HA coating. Kay et a150reported laboratory research is credited to P.I. Branemarksg and the
that HA coatings applied to the struts of the subperiosteal use of pure titanium implants. Osseointegration of pure ti-
implants can enhance the performance of the implant, tanium implant@ appears possible because (1) titanium is
apparently by creating a faster and stronger attachment to a passive metal and an oxide layer forms easily on the metal,
bone, providing an environment for overlying soft tissue (2) this oxide layer does not break down under physiologic
healing (thus decreasing failure at the mucosal-metal junc- conditions, and (3) the modulus of elasticity of pure titanium
tion), and inhibiting metallic ion release. is closer to that of bone than any other important implant
In 1972, Cram et a1.52listed the drawbacks to the subper- metal.
iosteal implant as being (1) a two-stage surgical procedure,
(2) dependence on the skill of the operator, and (3) the ex- CONCLUSION
pense involved. They advocated use of the ramus frame If the prosthodontist is to successfully treat the patient
implant, which is thrust posteriorly into the ramus of the possessing a poor mandibular alveolar ridge, it becomes nec-
mandible where it is lodged between the buccal and lingual essary to understand the limitations of the patient, the
plates of cortical bone and anteriorly is fixed into the sym- available prosthodontic techniques, the limitations of the
physis. The long-term success rates of the ramus frame tend oral surgeon, and the capabilities of the laboratory techni-
to be poor but it did address some of the drawbacks of the cian. Treatment may include the routine or the more
subperiosteal implant. sophisticated prosthodontic techniques using advanced
Small and Kobernick are credited by Metz48 with the de- instrumentatio# or the aid of the oral surgeon to do exten-
velopment of the staple bone implant, a transosseous im- sion procedures, augmentation procedures, or implant pro-

578 MAY 1999 VOLUME 61 NUMBER 5


cedures. Although definitely more challenging, the severely 32. H5rle F. Visor osteotomy to increase the absolute height of the atrophied
mandible. A preliminary report. J Maxillofac Surg 1975;3:257-60.
resorbed mandibular ridge can be restored to a level of mas- 33. Peterson LJ, Slade EW Jr. Mandibular ridge augmentation by a modified
ticatory function. visor osteotomy: preliminary report. J Oral Surg 1977;35:999-1004.
34. Hiirle F. Follow-up investigation of surgical correction of the atrophic al-
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