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Problems

&management of reduc3on of residual ridge

R R R :is a localized loss of bone on the crest of residual ridge

stage of ridge forms


Order I - Pre-extrac3on Order II - Post-extrac3on Order III - high, well-rounded Order IV - knife edge Order V - low, well-rounded Order VI - depressed

E3ology of RRR
Anatomic factors Metabolic factors Mechanical factors Systemic factor

Anatomic factors
The anatomic factors includes things such as size and shape of the ridge, the type of bone and the type of If a ridge has existed as high and well rounded (order III) for several years, it will likely to con3nue to do so. If a residual ridge has gone from an order II to an order IV in span of 2 years, it will probably con3nue to resort rapidly. If a low depressed ridge (order VI) has existed for many years, future Residual Ridge Resorp3on will probably he at a low rate. mucoperiosteum.

rounded ridges and broad palates would seem to be favorable anatomic factors.

Metabolic factors
These factors include endotoxins form dental plague (plague occurring in edentulous mouth, especially in pa3ent. Who do not properly clean their dentures.), osteoclast-ac3va3ng factor (OAF), etc. Heparin which has been shown to be a cofactor in bone resorp3on, has been associated with mast cells that has been observed in microscopic sec3ons of residual ridge close to the bone margin. Other possible local bone resump3on factor could be related to trauma (especially under ill-Qng dentures) which leads to increased or decreased vascularity and changes in oxygen tension.

Mechanical Factors
Bone that is used by regular physical ac3vity, will tend to strengthen within certain limits, while bone that is in desire will tend to atrophy. Residual Ridge Resorp3on & Force As said, there is tendency for there to be more Residual Ridge Resorp3on in the mandible than in maxilla. WOELFEL et al in his study on a pa3ent made maxillary denture of area 4.2 in (ra3o 1.8 :1). If pa3ent bites with a pressure of 501b, so pressure under maxillary denture is 121b in 2 and under mandibular denture is 21 Ib/in2. So it can be said that there is more of mandibular ridge resorp3on than in the maxilla.

The amount of force applied to the bone may be aected inversely by damping eect or energy absorp3on. The damping eect may take place in the mucoperiosteum which is considered to be viscoelas3c. Overlying mucoperiosteum varies in its viscoelas3c property from pa3ent to pa3ent and from maxilla to mandible, so its energy absorp3on quali3es may inuence the rate of Residual Ridge Resorp3on. Damping eect of bone itself should be considered since maxillary residual ridge is frequently broader, a`er and more cancellous than mandible, it may be a factor in the dierences in the Residual Ridge Resorp3on of two jaws.

SYSTEMIC FACTORS IN ALVEOLAR BONE LOSS


Most den3sts consider alveolar bone resarp3on to be a local problem and systemic factors are considered to be of secondary importance. But experimental studies and biologic sciences have shown that alveolar bone reduc3on is basically a systemic disease. i) Bone loss due to decreased forma3on ii) Bone loss due to increased resorp3on iii) Bone loss due to unknown causes.

i) Bone loss due to decreased forma3on


This is seen mainly in pa3ent with excess amount of glucocor3coid hormones. Glucocor3coids inhibit bone forma3on as it suppress external Ca absorp3on). and cause severe osteoporosis Excess glucocos3coids are due to ; Excess secre3on of cor3sol by adrenal glands (Cushings syndrome) & in treatment for pa3ent with Rhematoid Arthri3s with large amounts of glucocor3coids.

ii. Bone loss due to increased resorp3on


a) Hypophyosphatemia : Eect of hypophosphatemia has a direct eect of serum phosphorous on bone to enhance . bone resorp3on. It may occur in pa3ent with duodenal where who are treated with antacids containing aluminum hydroxide gel which binds phosphorous and is unabsorbable b) High parathyroid Hormones (PTH) : It is one of the most important systemic factors inuencing the rate of osteoclas3c bone resorp3on. A slight decrease in serum calcium concentra3on s3mulates the parathysiod gland to secrete PTH, which causes resorp3on.

Treatment of grossly resorbed mandibular ridge

2.Prosthodon+c treatment
* History and examina3on: - Medical history - Dental history - Examina3on of the exis3ng dentures. * Intraoral examina3on a. The health of the ridge and the surrounding 3ssue. b.Ves3bular depth.

Alveolingual sulcus:
The alveololingual sulcus (the space between the residual ridge and the tongue) extends posteriorly from the lingual frenum to the retromylohyoid curtain. Part of it is available for the lingual ange of the denture. The alveolingual sulcus can be considered in three regions: - Sublingual crescent space. - sublingual fossa. - Retromylohyoid fossa.

c. Tonicity of the 3ssue. d. Tongue posi3on. e. Buccal shelf. f. Buccal pad of fat. g. Iden3ca3on of the interarch-space problems. * Radiographic examina3on.

Impression objec3ves:
1.A broad area coverage, with maximal denture base extension, deceases the force experienced per unit area of the mucosa beneath the denture likehood of its trauma. However in the grossly resorbed ridge the area of 3ssue available for support is reduced and extension of the base is cri3cal to avoid interference with movement of the border structures. 2.A controlled pressure technique would decrease occlusal loading over the aected area and distribute forces more to primary support areas like the mandibular buccal shelf. 3.Impression technique should ensure that the denture Qng surface is smooth and does not cause fric3onal abrasion of the underlying mucosa.

Impression materials and techniques:


- An impression material with adequate ow proper3es should be used to void uneven pressure during impression procedures that could result in a localized rebounding eect on the compressed 3ssues under the denture and/or sore spots. Either of these condi3ons could result in uneven sea3ng of the nished denture and loss of in3mate 3ssue contact. - The impression material should also provide adequate reproduc3on of surface detail to prevent small irregulari3es capable of entrapping air. - The elimina3on of dislodging forces by accurate border molding that prevents overextension should be accomplished.

- A slight generalized pressure on the soj 3ssues is desirable. Use of a moderately viscous light bodied impression material with sucient ow, elimina3on of full arch relief spacers in the tray and use of a nonperforated custom tray are among those modica3ons in in technique that can lead to an impression recording of the 3ssues in a mildly displaced form. - Special impression techniques to determine accurately a denture extension with reference to func3oning 3ssue at its denture border have been evolved.

- Complete lower dentures made from sta3c impressions and dentures that are not stable may be used eec3vely for making dynamic impressions. Ajer the occlusion of the denture (which is to serve as a tray) has been tested for deec3ve occlusal contacts, the border extension are adjusted and severe undercuts are reduced. The 3ssue condi3oning material is mixed carefully and placed over the en3re impression surface of the denture. The denture is inserted into the mouth. Ajer the material has set for 3 to 4 minutes, the pa3ent sucks and swallow several 3mes, and the impression material is allowed to cure for 10 minutes.

Fibrous 3ssue Flappy ridge Overlying the residual ridge, may compromise denture stability and special techniques have been devised which either load other sites and avoid displacement, or surgically remove such redundant 3ssue.

Ver3cal dimension of occlusion:


In cases of marked ridge loss the ver3cal 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 reduc3on in the height of the denture.

Denture occlusion
General considera3ons 1.the teeth should be set over the center of the ridges so that the forces applied to the teeth when occluding and chewing are directed straight through the ridges to seat the dentures rmly on them. 2.Destabilizing forces from the lips, cheeks, an tongue act on the denture polished surfaces and dental arch. Addi3onal forces will be generated by the teeth during contact.It is accepted that the occlusion should be balanced in centric rela3on. 3.Increased denture stability , together with reduc3on in force per unit area applied to the mucosa, may be achieved with a reduc3on in length of the occlusal table by reducing the number of teeth.

4. Decrease bucco-lingual width of the teeth 5.stresses to the anterior ridges can be reduced by removal of anterior tooth contacts in centric rela3on closure. 6 .improve tooth form to reduce the amount of force required to penetrate the bolos of food 7 . avoidance of inclined planes to minimize dislodgement of the denture and shear force

Shaping of polished surfacePost -the buccal surface of the lower denture should be concave,to face up and out. the mandibular lingual ange should slope toward the tongue. The use of soj liners Post inser3on follow up

Surgical management
1.enlargement of denture-bearing areas a.Ves3buloplasty b.Ridge augmenta3on c.Disrac3on 2.Implants a.Subperiostal b.Transosseous c.Endosseous

Gra2ing Procedures
In the case of severe atrophy of the edentulous mandible, it is possible to augment the mandible prior to the placement of endosseous implants. Various techniques and materials have been developed to increase mandibular height. Onlay techniques as well as interposi3on of the graj in the inter-foraminal area are used.

Autogenous materials, such as bone and car3lage, and allogenic materials, such as hydroxyapa3te or bone subs3tutes, as well as combina3ons of these materials, are used for ridge augmenta3on The most signicant complica3ons that occur following grajing procedures in the mandible are sensory disturbances of the mental nerve, wound dehiscence, infec3ons of the grajed area, and, with autogenous bone grajs, donor area morbidity

Between four and eight weeks ajer the last day of ac3ve distrac3on, mineraliza3on of the newly formed bone matrix in the distrac3on area has progressed suciently to allow for the placement of endosseous implants with sucient primary stability.

In comparison with grajing procedures, the advantages of distrac3on osteogenesis are the absence of donor site morbidity, the presence of vital bone in the distrac3on area, and the gain of soj 3ssues. Possible complica3ons of the distrac3on technique for the edentulous (severely resorbed) mandible are fracture of the mandible, infec3on, and necrosis of the superior fragment, but such complica3ons are rarely reported in the literature.

Ridge augmentation by subperiosteal injection of hydroxyapatite

Distrac3on osteogenesis
is a technique of gradual bone-lengthening, allowing natural healing mechanisms to generate new bone. When applied to the reconstruc3on of a severely resorbed edentulous mandible, an osteotomy in the inter-foraminal area of the mandible is made, ajer which the distrac3on device is placed. Five to seven days ajer surgery, ac3ve distrac3on is started at a rate of 0.5 to 1 mm per day.

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