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The alveolar process is the bone that forms and supports the tooth
sockets (alveoli). It forms when the tooth erupts in order to provide the
osseous attachment to the forming periodontal ligament; it disappears
gradually when the tooth is lost. The process of residual ridge resorption
starts soon after the dental extraction / lost following the extraction of teeth,
the bony socket and adjacent soft tissues undergo a series of tissue repair
reactions including acute inflammation. Rapid restoration of epithelial
integration, and connective tissue remodelling. Histologic evidence of
active bone formation in the bottom of the socket and prone resorption at
the edge of the socket are seen as early as 2 weeks after the tooth extraction,
and the socket is progressively filled with newly formed bone in about 6
months. Rapid bone remodelling subsides by this time but continuous bone
resorption may persist at the external surface of the crestal area of the
residual alveolar bone, resulting in considerable morphologic changes of
bone and overlying soft tissues over the years. This phenomenon has been
described as the REDUCTION OF RESIDUAL RIDGES or RESIDUAL
RIDGE RESORPTION (RRR).
1
vasculature. Bone growth occurs by apposition of an organic matrix that is
deposited by osteoblasts.
All parts are interrelated in the support of the tooth. Occlusal forces
that are transmitted from the periodontal ligament to the inner wall of the
alveolus are supported by the cancellous trabeculae, which in turn are
buttressed by the labial and lingual cortical plates.
2
Most of the facial and lingual portions of the sockets are formed by
compact bone alone; cancellous bone surrounds the lamina dura in apical,
apicolingual and interradicular areas.
Osteoclasts are large, multinucleated cells that are often seen on the
surface of bone within eroded bony depressive referred to as Howship’s
lacunae. The main function of these cells is consisted to be resorption of
bone, when they are active, as opposed to resting, they possess an
elaborately developed ruffled border from which hydrolytic enzymes are
believed to be secreted. These enzymes digest the organic portion of bone,
the activity of osteoclasts and the morphology of the ruffled border can be
3
modified and regulated by hormones, such as para hormone and calcitonin.
The origin of osteoclasts is still a matter of speculation and controversy.
4
physiologic liability of alveolar bone is maintained by a sensitive balance
between bone formation influences. Bone is resorbed in areas of pressure
and formed in areas of tension.
The cellular activity that affects the height, contour and density of
alveolar bone is manifested by three areas:
i) Adjacent to the PL, ii) In relation to the periosteum of the facial and
lingual plates and iii) along the endosteal surface of the marrow
spaces.
5
remodeling of the small primary trabeculae produced secondary trabeculae
that resembled the original cancellous bone pattern. The delayed tooth
socket healing often observed in poorly controlled diabetes inevitably
causes a poor alveolar ridge contour. A dense network of collage fibers
normal fills the socket soon after tooth extractions and the defect in diabetes
mellitus may be due to a reduced collagen production and an absence of
these fibers.
6
considered to be a reiterated process of tissue embryogenesis. In embryos,
maxillofacial bone including tooth bearing alveolar process, is formed
through intramembranous bone formation, which is different from
endochondral ossification. In intramembraneous bone formation examined
in calvaria, the intramembranous bone formation, which is different from
endochondral ossification. In intramembranous bone formation examined in
calvaria, the initial ectomesenchymal cells directly differentiate into
osteoblasts, by passing the deposition and resorption of hypertrophic
cartilage matrix; osteoblasts can directly deposit osteoid tissue, which is
then calcified.
In recent years, type II collagen has been further investigated and its
two alternative splicing variants of type IIA and type IIB are found to have
differing cell origins. Type IIA is found in noncartilaginous tissues, whereas
type IIB has a strong association with chondrocytes and cartilage tissue
formation. The expression of type II procollagen mRNA has been identified
in the healing extraction sockets in experimental animals by the method of
RNA transfer blot analysis and is situ hyridization.
7
Analysis of studies on the uncomplicated healing of extraction
wounds have shown that after the clot formation, granulation tissue is
gradually replaced by connective tissues and later by intramembranous
bone, without cartilage formation. A cluster of cells that are associated with
the early socket wound healing have been shown to express type II collagen
mRNA. A puzzling finding is that investigators have failed to detect the
presence of protein collagen type II by way of immunohistochemical
studies in actively healing extraction sockets. This may be suggestive of
either lack of collagen type II translation or difficulties in detecting this
protein in the healing socket. Some of the questions that need to be
answered in the extraction socket of what are the role of these cells in the
socket healing if type II collagen protein is synthesized. Do systemic or
local factors influence the gene expression pattern during socket healing.
8
Further analysis of residual ridge remodeling in rats have revealed
that the 1 (IX) collagen mRNA, which was expressed in the extraction
socket, was different and markedly shorter than that of cartilage. The short
form of type IX collagen omits the multiple exons, that encode the Amino
terminal globular domain (in above figure). Therefore this alternation
expression of the short form of type IX collagen, which lacks the interactive
peptide structure, may explain why cartilage tissue is not assumed in the
extraction socket. However, the function of the short form of type Ix
collagen in residual ridge remodeling remains to be classified.
9
a specific molecule. Several transgenic mice have been generated with
defective type II collagen. The introduced mutated pro 1 (II) collagen
chains appears to be included in a procollagen molecule and prevent folding
into a stable triple helix. Transgenic mice with functionally impaired Type
II collagen result in chondrodysplasia into dwarfism, short and thick limbs,
a short snout, a cranial bulge, a cleft palate, delayed mineralization of bone,
and a severe retardation of growth for practically all bones. Because type II
collage comprises the major constituent of cartilage, the principal
consequence of this mutation is anticipated to cause disorganization of the
growth plate. However, it is interesting to note that both endochondral
bones and intramembranous bones are affected by the Type II collagen
mutation.
10
may play diverse biologic roles in various tissues, including localized bone
remodelling.
These data suggest that there may be two distinct bone remodelling
prcoesses. In the trabecular bone remodelling. The presence of type II and
IX collagen precursors seems to be necessary. In the cortical bone
remodelling, type II and IX collagen precursors may not be prerequisite.
Successful socket healing may use the former process, which require the
transient expression of template collagens, including type II and IX.
11
part of a process that leads to edentulous bone loss, where atrophy implies a
passive process. Therefore, the term remodelling is used to describe the
physiological process of bone loss. Since in our topic were are including
even the pathologic process of the bone loss, thus it would be apt to
consider it as residual ridge resorption.
1. Activation phase.
2. Resorption phase.
3. Formation phase.
12
absence of stress, but it does so in a less organized manner. This specific
factor responsible for resorption is yet to be determined. But, there is 8-10
days delay period. The resorbed surface is morphologically identified as
cement line.
13
skeleton, activation occurs about once every 10 seconds and the total
number of BMU in operation at any time has been estimated to be 35
million remodelling is conceivably initiated at a particular site either by
mechanical triggers conveying some type of message to cells initiating
formation or resorption or by unknown sensory mechanisms that indicate to
the cells. The need to initiate a remodelling sequence that bone in a certain
area has to be replaced.
14
- It was observed histologically, the mandibular ridge resorbs more
readily than the maxillary ridge. However, the mandibular ridges
contained more supporting bone than did the maxillary ridges.
Obviously, the supporting bone offered no resistance to the resorption.
Connective tissue was studied in the ridge crest, buccal and lingual
region. The feature observed were:
Observations:
1. The thickness of C.T. was found to be decreased from the normal in the
ridge crest region in both non denture and denture wearing groups. In
other regions (lingual and buccal) the thickness was considered normal
and no difference was noted between groups except for increased
thickness in the lingual region of the non dentuer wearing groups.
15
3. Inflammation in C.T. was slightly greater in denture wearers group. But
was not a prominent findings.
6. Small blood vessels in close contact with the bone margin in areas of
bone resorption, sometimes, in the lacunae with positive correlation
between the degree of inflammation, vascular reactions and bone
resorption.
16
7. Marked diapharase activity in areas of bone remodelling either
formation or resorption.
11. Lack of periosteal lamellar bone on the external surface of the crest of
the ridge.
17
According to the literature rate of bone loss is generally greatest
immediately following tooth extraction. Mandibular bone loss occurs at a
more rapid rate when compared to that of maxillary.
1. Anatomic
2. Prosthodontic.
3. Metabolic.
4. Functional.
5. Others.
1. Anatomic :
18
Although the broad high ridge may have a greater potential bone
loss. The rate of vertical bone loss may actually be slower than that of a
small ridge because there is more bone to be resorbed per unit of time and
because the rate of resorption also depends on the density of the bone.
Wolf’s law
2. Prosthodontic factors
19
ii. The alignment of the denture teeth / occlusal pattern.
- One of the earliest opponents of the anatomic tooth form was French
who coined the term “cusp trauma” as one of the most serious defects
that had to be guarded against in complete denture construction. Soon
after, Sear’s developed his non anatomic tooth form which initiated the
introduction of many new designs to denture teeth throughout the years.
20
More recent studies have shown that there is no statistical difference
in the chewing performance in denture teeth with cuspal ranging from 0 to
30 degree.
v) Tooth material – the material from which the denture teeth are made
may have some effect on the forces transmitted through the denture
base material to the supporting ridges.
21
It is said that porcelain tooth when placed causes more resorbtion of
ridge than acrylic tooth.
22
disease and senoscence. Bone has its own specific metabolism and
undergoes equivalent changes. At no time during life is none static, but
rather it is constantly rebuilding, resorbing and remodelling subject to
functional and metabolic stresses.
23
One of the most interesting metabolic phenomena concerns the
antagonistic effects of the “Antianabolic Hormones” (the adrenal
glucocorticid hormones including cortison and hydrocortisone). According
to Reifenstein in the young person, there is a relative predominance of
anabolic hormones resulting in continued growth and maturation of the
skeleton, he further states, as people get older, especially women past the
menopause, the anabolic hormones are so reduced that the antianabolic
hormones are in relative excess, with the result that bone resorption may
take place faster than bone formation and that bone mass may be reduced.
Systemic Factors
Hormone : The three main principal hormones that regulate the plasma
concentration of calcium are:
24
2. Hypophosphatemia : Since low phosphorous concentration in the
incubation medium of bone culture also has been found to enhance
bone resorption; these effects of hypophosphatemia may represent a
direct effect of serum phosphorous on bone to enhance bone
resorption. Recently, however, it has been show that
hypophosphatemia enhances the synthesis of 1.25
dihydroxycholicaliferol, which is the active metabolite of vit. D and
which has been shown to stimulate bone resorption. Thus, it is
possible that the increased resorption seen in person with
hypophosphatema is in past of the result of excess, 1,25
dihydroxycholicalciferol. In any case it is clear that
hypophosphatemia mediates directly, or indirectly a marked increase
in bone resorption. Moreover, in experimental animals suggest that
normal levels of serum phosphorous influence the basal level of bone
resorption through further work is required to be certain of the point.
In addition to these results in experimental animals, it was found be
means of certain studies that hypophosphatemia in a human subject
was associated with increased boner resorption. Since phosphorous
is ubiquitous in nature, hypophosphatemia rarely, if ever occurs as a
result of a deficiency of phosphorous intake. Hypophosphatemia
may occur in patients with duodenal ulcers who are treated with
antacids containing aluminium hydroxide gel, which binds
phosphorous and renders it unabsorbable varying degree of
hypophosphatemia are also seen in patients with impaired of renal
tubular resorption of phosphorus, although we would expect
hypophosphatamia of either glot or renal origin to result in increased
resorption further clinical studies will be necessary to settle this
issue. This can be included in bone loss due to increased resorption.
25
Parathyroid Hormone
The cause of high PTH secretion can be divided into two categories:
26
1. Primary hyper parathyroidism.
2. Secondary hypoparathyroidism.
27
Estrogen and Rogen Deficiencies
28
usually found in edentulous patient. The clinical and pathophysiologic
viscos of osteoporosis has been refined recently to the concept of type I and
type II osteoporosis. Type I osteoporosis is defined as the specific
consequence of menopausal estrogen deprivation, and characteristically
presents the bone mass loss, notably in the trabecular bone. Type II
osteoporosis reflects a composite of age related changes in intestinal, renal
and hormonal function. Both cortical and trabecular bone are affected in
type II osteoporosis. In either case, one of clinical manifestations of
osteoporosis is observed as less radiographic bone density. The maxillary
residual ridge was reported to be significantly smaller in postmenopausal
osteoporotic women while their edentulous mandible remained the same as
the age-matched controls. A knife edged ridge is formed when bone
resorption occurs at the labial and lingual surface of the residual ridge in
preference to the occlusal surface. Postmenopausal women with lower bone
densitometeric scores exhibited a tendency to develop a knife edge ridge in
the mandible.
Islands of langerhans
29
word of caution and explanation to diabetic patients is necessary so that
they can appreciate their prosthetic difficulties.
Thyroid hormones : The thyroid glands are responsible for the regulation of
the rate of metabolism. Hyperthyroidism increases the metabolic rate so that
a negative nitrogen balance results. Such a balance is equivalent to protein
deficiency, which can be a direct cause of osteoporosis. Thyroxine also has
a direct influence on the kidneys, causing an increased excretion of Ca and
phosphorous. This depletion of Ca and phosphorous results in decreased
bone apposition and increased osteoclastic activity to marshal these
elements from the bone to compensate for their depletion.
Age : As the age advances there is decreased bone formation and increased
resorption.
30
administration of such steroids are considered very dangerous to bone
tissue.
The normal forces to the bone are removed along with their resultant
trajectories when the teeth are removed. Hence, it is to be expected that
remodeling of bone will take place when the teeth are removed. Neufeld
found in edentulous patients as compared with dentulous patients that the
trabecular wire finer and the cortex thinner, with the cortex over the crest of
31
the ridge being incomplete in all patients and the over all size quite possibly
smaller. Neufeld also found that instead of the usual trajectories present in
the dentulous mandible, the trabecular pattern in the edentulous mandible
was, in general, random, except that in some specimens the trabecular near
the crest of the ridge were somewhat perpendicular, suggesting the
development of trajectories to the compressive force of a denture.
Disuse Atrophy : the use of natural teeth transmits stresses to the supporting
alveolar process within a certain range, this is physiologically helpful,
serving to increase the density and strength of the alveolar process.
However, pressure exerted on a tooth, which is out a line in the dental arch,
causes traumatic forces to be transmitted to the supporting process. In this,
situation, resorption and reduced density of structure are observed in the
bone, with eventual loosening and loss of the involved teeth.
32
A large protein deficit followed by metabolic derangements develops
from disuse. The deficiency is in the formation of the new protein matrix
with no disturbance of calcification.
Disuse atrophy does not result from the direct loss of nonfunctional
bone, but rather from the lack of replacement of bone not needed for
function. Some stimuli are present from the action of the denture. But the
nature of the stimuli is not normal, the response of the bone varies with the
degree, the internal and the tissue tolerance to the stimulation.
33
bone such as the periosteum, the blood supply to the bone is aggravated and
it is a target for resorption. The denture bearing bone has a complex blood
supply from two sources, the main supply is internal from the interdental
arteries that pass through canals in the interalveolar septa. After extraction,
if bone loss that slight, the blood supply is not greatly disturbed. However,
if extensive surgical procedure removed large amounts of alveolar bone.
The internal blood supply can be vastly altered by the bone callus. The
other blood supply comes externally from the periosteum. Arteries from the
periosteal network enter the bone as arterioles in the numerous Volkman
canals which open from the outer surface of compact prone.
OTHERS
34
is over loaded by complete denture where forces generated are transmitted
directly to alveolar prone.
Carbohydrate : They provide the chief source of energy. They are related
only, indirectly to bone resorption though association with diabetes and by
substitution for more favourable foods.
Fat : Fats are organic substance that yield heat and energy and only
secondarily build up repair tissue.
35
There is a damage of Hyper vitaminosis A, but experiments are
inconclusive as to the mechanism. Some reports indicate an acceleration of
matrix remodeling while others seem to conclude that excess vit. A
accelerate the activity of the osteoclasts. The general function of Vit. A in
regard to bone is its influence on the activity and position of the osteoblasts
and osteoclasts.
Biological factors : such as tissue health, saliva content, oral hygiene, oral
bacterial flora, drug or alcohol intake.
36
DIAGNOSTIC AIDS TO DETECT RRR
37
enlarges as a result of osteoclastic resorption and vascular canal
volume, which enlarges as a result of osteoclastic resorption.
Even among individuals of the same sex there exist large variations
in the morphologic characteristics of the residual ridge and associated
bones, and these can be related to their original anatomic features. There are
however, certain patterns of resorption and some persistant anatomic
structures that can be recognized from one case to another. These structures
are palpable when they become protruberant, they are the genial tubercles,
the external oblique line and the mylohyoid crest for the mandible or for the
maxilla, the nasal spine, and the pterygoid plates.
The usual changes that take place after dental extraction are those of
a ridge initially wide enough at the crest to accommodate the natural teeth
38
that changes to one that is narrow and sharp, then-flat, and finally concave.
These four stages of resorption correspond to the classification of residual
ridges unable to adequately maintain denture in place.
Group III : Absence of residual ridge and resorption to the level of the basal
bone.
Mandibular changes :
In the premolar molar region, bone loss is more rapid than anteriorly
because of the resorptive nature of the posterior dorsum and a lower
position of reversal lines. Hence bone resorption of the basal bone is more
frequent in this region. Typical patterns of resorption are recognized and
outlined by the presence of this structure that resist resorption, the external
oblique line and the mylohyoid crest, the concavities seen from the different
planes may be present; a lateral dishing of the crest from the cuspid to the
retromolar region and a longitudinal midbody concavity.
39
The dishing of the crest is best revealed by the lateral cephalogram.
In more advanced stages of atrophy these posterior bilateral concavities are
more pronounced, with erosion of the basal bone, they may become
associated with a roundly shaped anterior basal bone, a frequent finding,
described as the sphenoid anteriors basal bone with posterior concavities.
On the medial side of the residual ridge the bone contour forms a gradual
slope toward the mylohyoid crest. In very advanced stages, the concavity
occupies the major portion of the dorsum of the corpus. It is more
commonly located between the dense external oblique line and the
mylohyoid crest.
The position of the teeth in the alveolar basal bone complex may also
play a role in these changes the lingual inclination of the molars and the
more facial position of the premolars, canine and incisors, which result in
the presence of more bone on the lingual side of their roots. Contribute to
the frequent occurrence in resorbed mandibles of another structures, the
paralingual crest. This palpable crest, originating at the myolohyoid crest,
itself extending anteiorly in a downward direction, may become a true
lingual shelf. It may fuse with another structure that becomes protuberant
and palpable in advanced stages of atrophy: the genial tubercles.
40
Maxillary changes : Patterns of resorption in the maxilla differ from those
in the mandible. Maxillary ridge resorbs usually more evenly than the
mandibular ones because of larger denture bearing areas, with the palate
providing a more equal distribution of mechanical forces. When the anterior
maxillary bone disappears at a faster rate than the posterior part, it is more
often due to excessive forces originating from natural mandibular incisors
and inadequate posterior prosthetic support.
41
Residual anterior maxillary triangle and persistence of ori anterior
bone contour slope throughout different stages of atrophy
Intermaxillary changes
The relationship that existed between the two maxilla when teeth
were present might have undergone a change after ridge resorption, with an
increase of interridge distance as the most obvious change in the vertical
bone, especially in the anterior region.
42
Soft tissue changes
Soft tissue changes also occur after teeth are lost and dentures are
worn. A crestal scar bond representing the remnants of the attached gingiva
is usually present all along the crest. It is more prominent and hyperplastic
when some residual ridge remains. It then acts as a protective cushion
between the sharp residual ridge and the denture base. Heavy fibrous tissue
will develop in the tuberosity regions, especially when maxillary molars
were removed at an early age or when the maxillary denture was not
rebased in the first years after teeth were extracted. This tissue puts up the
space left by lost bone.
ANATOMICAL CONSIDERATION
Mental foramen becomes more close to the denture bearing areas, the
alveolar process decreases in size, the change of denture impingement on
the mental nerve increases with bone loss and the nerve is more vulnerable
to the injury during surgical grafting or implantation procedures.
Progressive bone loss leaves the nerve near superior surface of the
mandible.
43
The ultimate result of complete alveolar bone loss is concave
superior surface of the mandible. This concave surface represents the upper
surface of the cortical plate of the mandibular inferior, border. In severe
cases, the genion tubercles may be superior to the crest of the mandible,
pressure on the mucosa on this area cause sharp pain.
44
Posteriorly, as the maxillary tuberosity decrease in height it
approaches the level of the mucosa that is draped from the muco-gingiva
junction on the posterior aspect of the maxillary tuberosity i.e. hamulus.
This change oblitrate the posterior slope of the tuberosity. As the mandible
becomes smaller as the teeth removed, resistance to the fracture is reduced.
Fracture in extremely small edentulous mandibles are especially omnions,
because of the lack of bone mass for fixation and due to the changes in
blood supply. As RRR occurs, major source of blood supply to the mandible
change from centrifugal to centripetal (periosteal) the inferior alveolar
vessels become smaller and less significant in the nourishment of the
mandible. Therefore, the surgical procedure that elevate the mandibular
periosteum compromise the blood supply more as the mandible becomes
smaller.
CLINICAL SIGNIFICANCE
2) Efficiency of mastication.
3) Phonetics.
45
Appearance
Commonly seen men are taller, have greater facial heights and just
more jaw bone to resorb after dental extraction. The ratio of potential units
of bone to resorb to the years of resorption acts in their favour.
But one should not assume. However, that men have an advantages
in treatment over women because men usually have more bone left after the
same number of years of denture wear. Not only the volume of bone but
also its form must be examined. A large residual basal bone does not
necessarily means a more favourable ridge for denture construction or one
superior to a but for the convenience of understanding and implementing
certain parameters so that the proper care is taken for the prevention of the
further residual bone resorbtion. Thus, following Devan’s scientific words.
Its perpetual preservation of what remains of the oral masticatory apparatus
rather than a meticulous restoration of what is missing.
Impression Procedures
- If the tray selected is too large, it will distort the tissue around the
borders of the impression away from the bone.
- If it is too small, the border tissues, will collapse inward onto the
residual ridge. This will reduce the support for the denture and prevent
the proper support of the lips by the denture flange.
46
- As we are know the commonly used two procedures for the final
impression procedure are:
47
be improved in a functional state. However, as with all functional
impression techniques, the amount of functional placement is unknown,
the functional movement probably would not be the same in extent or
direction with each functional load because the patient is more often at
rest than in occlusal function, it is not practical to make the impression
of the tissue in a functional state.
Jaw relation
48
arch, thus proper occlusion is essential to the health of bony support.
Otherwise during eccentric movement it causes pressure on bone due to
failure of the factor stability. Hence cause resorption of bone.
49
The arrangement of individual teeth in complete denture include a
myriad of possibilities ranging from a flat occlusal plane with 0 degree teeth
to a curved configuration which allows anatomic teeth to glide and pass
over each other in close harmony with mandibular movements. Advocates
of cuspless flat plane occlusion, reverse pitch occlusion, and variations of
the reverse pitch occlusion i.e. (pleasure curve) consider such occlusal
schemes to be effective in helping to preserve the underlying ridges.
Tooth material : As it is said the material from which the denture teeth are
made may have some effect on the forces transmitted through the denture
base material to the supporting ridges.
50
anteriors. Because of the abrasion of the posterior teeth, the anterior teeth
develop interfering contacts during mastication that will continually
traumatic the anterior part of the upper and lower denture foundation. This
is potentially dangerous to the health of the supportive tissues and should
always be considered when selecting the tooth materials.
Size of posterior teeth: the selection of the proper tooth size or mold is
based upon D the capacity of the ridges to receive and resist the forces of
mastication and space available for the teeth and the esthetic requirements.
The inverse ridge relationship that may result from severe loss of
bone will create problems in constructing the denture and placing teeth. In
order to use the buccal shelf, a stable dentin bearing area, the posterior
mandibular teeth must be placed closes to the vestibular side and the
maxillary teeth outside the ridge it one wishes to correct the crossbite
51
relationship, both dentures consequently will be mounted outside their
original bearing areas.
1. Resin base.
52
- After curing the dentures the lab remounting has to be done and
selective grinding for working balancing contacts and for protrusive
balance has to be carried out in order ot remove any interference.
When these problems exist, the old dentures are duplicated, the
duplicated dentures are then lined with soft resin for impression purposes.
The soft lined dentures are then articulated with a face-bow and centric
relation records. The upper denture is converted via a laboratory duplicators
to a self curing resin base, the occlusion is surveyed, and if nearly correct
and with an acceptable vertical dimension, the dentures are ground in to a
balanced occlusion. When the occlusion is less than acceptable, the lower
denture is removed from the cast and the lining removed the lower denture
is positioned into centric occlusion against the upper denture and luted to it
with sticky wax. The lower cast is lubricated soft lining resin is placed on
the basal surface of the lower denture, the articulation is closed to a
predetermined vertical dimension and the resin is allowed to cure, the sticky
was is removed, the occlusion is checked, and mucin imperfections are
eliminated. By this means, the old lower dentures which has often moved
53
forward into a prognathic relation with collapsed vertical dimension can be
corrected. In doing so we have supported the mandible and maxilla and
established a good centric occlusion and occlusal vertical dimension we
have relieved the strain on the musculature and the temporomandibular
joints.
- Usually the problem associated with denture wearer is one, bone loss
that affects ridge form and increases muscle interferences. Before
hydroxyapatite become available this loss could not be replaced, except
in extreme atrophy when ridge augmentation with bone graft was used,
with all the uncertainties of resorption and inadequate gain of ridge
form.
54
contour was deficient little gain could be expected from extension
techniques unless extensive detachment of the chin and tongue
musculature was done. Hydroxyapatite has opened up a new in
preprosthetic reconstructive surgery. It offers numerous possibilities.
This material not only can be used to reconstruct an ideal ridge form
with less relationships with the help of dependable techniques.
55
3) Augmentations with alloplastic materials such as proplast
calcium aluminate ceramic material to increase the vertical
height of the mandible and.
56
group twice the anteriors slope of the mandible is favourable to again of
denture bearing area.
Many patients with ridges that have been reduced to the basal bone
may have better masticatory function than those patients in the two previous
groups, the mandibular denture rests on a painless flat or frequently serves
to stabilize the denture may exist these patients with above average muscles
coordination and the capacity to provide the equilibrium of the orofacial
muscles necessary to retain the denture in place, may benefit from the
refinement of excellent prosthodontic treatment using a conventional
approach. However, for those group III patients with a severe functional
handicap a ridge augmentation with implements procedure should be
considered.
57
emphasize to importance of including the attachments of the muscles
of the floor of the mouth in the dissection. The original description of
the total lowering of the floor of the mouth with vestibuloplasty and
split thickness skin graft was presented by Obwerzer in 1963 which
still serves as the standard approach.
58
Maxillary augmentation for utilization of implants:
3. Corticancellous onlay block graft obtained from the ilum and fixed
to the remaining alveolar and / or maxillary sinus floor with wires or
screws.
Mandibular augmentation
59
The permanence of the bony reconstruction of the mandible has
historically been a problem. pichler and Traunec, in 1948 whole that
clementschitch may have been the pioneer in the construction of the
alveolus of the mandible using blocks of autologous ilium. Many other
followed, using autologous ilium, but it was found that the grafted area
tended to resorts after a four months and had often completely disappeared.
Thus, the problem of the retention of the grafted bone for strength of
the mandible has substantially been solved by the addition of dense HA to
the bone graft material. However, when this type of grafting system is used
for implant sites when the implants are to be placed after graft maturation,
the dense HA presents a problem on that it is difficult to through it.
Therefore, dense HA and bone are best used when a graft is to be placed
around a implant.
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Another splints to substitute the porous form HA for the dense form
as porous can be drilled. It was generally considered that the porous form of
HA would be long lasting it is sometimes reform non resorbed. Hence it
appears appropriate to use porous HA mixed with the bone graft in areas
where implants are to be placed and dense HA mixed with the bone graft
when strengthening only is require.
CONCLUSION
Resorption of alveolar bone seems inevitable when teeth are lost, yet
variability exists between persons. Both between and within the jaws and
over time. It would seem that bone that has undergo higher rates of
resorption initially will continue to resorbs excessively compared with bone
that has undergone lower rates of resorption.
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Understanding of the myriad of significant technical factors but also on the
understanding of the complex interrelationship of these technical factors
with anatomic metabolic, and functional factors. This is what makes
prosthodontics challenging. This is what makes prosthodontics fun.
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REFERENCES
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12) Turck D. : A histologic comparison of the edentulous denture and
non denture bearing tissue. J.P.D., 15 : 419, 1965.
13) Pietro Kovski : The bony residual ridge in man. J.P.D., 34 : 456,
1975.
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CONTENTS
1) Introduction
9) Clinical Significance
10) Conclusion
11) References
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CONTENTS
Introduction
Functions of Maxillofacial Structures
Establishment of Vertical Maxillomandibular Relations for
Complete Dentures
Methods of Determining Vertical Relation
Physiological Methods
Phonetics As a Guide
Tests of Vertical Jaw relations with occlusion rims
The speaking method
The closest speaking space and the free-way space
Technique with existing dentures
Technique without records or dentures
Phonetics in orientation of anterior teeth
Labiodental Sounds
Dental and alveolar sounds
Palatal and velar sounds
Patient adaptation in phonetics
Palatal contour of the Denture
Palatography for proper palatal contour
Discussion
Conclusion
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