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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.
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.
- 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.
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.
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.