Prosthetic Concerns AboutAtrophic Alveolar Ridges...chief complaint now was dissatisfaction with the...
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Prosthetic Concerns About Atrophic Alveolar Ridges Robert Schneider, D.D.S., Iowa City, Iowa As a prosthodontist, I rou- tinely see patients that require extensive prosthodontic recon- struction due to their atypical oral anatomy. Frequently, this situation was created at the time of tooth extraction and is the result of residual ridge resorp- tion. Residual ridge resorption is a major oral disease entity as described by Tallgren in the early seventies 1. Following tooth extraction, patients can expect to lose a significant portion of their residual ridge due to normal physiologic activity". This resorption is unpredictable and can be a very challenging situa- tion when fabricating replace- ment prostheses. The challenges range from functional to esthetic depending on the location and severity of the resorption. Newer advances in bone physiology have let us appreciate a more in- depth picture of bone healing. In the past, it was assumed there was no need to treat an extraction site for future prosthetic consid- erations. However, today we know this is not the case. It is well documented that without augmentation, the maximum osseous fill or regeneration in the extraction socket will be minimal'. Because of this lack of optimal bone fill and unpre- dictability in the total resorption of the alveolar ridge, the prostho- dontic treatment of these patients has been less than optimal and frequently compromised. To illustrate these concems and dif- ficulties, two patients exhibiting significant residual ridge resorp- tion with significant prosthodon- tic challenges both in function, esthetics, and patient expectation, will be discussed. PATIENT#l This patient presented with a history of periodontal problems and treatments. His mandibular anterior teeth had been extracted and a removable partial denture (RPD) fabricat- ed approximately five years previous to being seen in my office. His chief complaint now was dissatisfaction with the instability of the RPD. Due to the sig- nificant amount of residual ridge resorp- tion (RRR) (Figure 1), it was likely that a new RPD would yield simi- lar results for this patient. After being advised of my con- cems, the patient chose to be restored with a composite retained fixed partial denture. However, the esthetic results were, in my opinion, compromised because of the severity of the RRR. The replacement teeth were unnaturally long (Figure 2), but due to the patient's lip line, it was acceptable to him. I believe the severity of the resorption was due to several factors: (1) pre-exist- ing periodontal disease that went untreated for several years, (2) an ill-fitting RPD and, (3) most importantly, the lack of augmen- tation of the sockets at the time of extraction. Figure 1. Residual Ridge Resorption. Figure 2. Composite retained fixed partial.
Transcript of Prosthetic Concerns AboutAtrophic Alveolar Ridges...chief complaint now was dissatisfaction with the...
Prosthetic Concerns About Atrophic Alveolar RidgesRobert Schneider, D.D.S., Iowa City, Iowa
As a prosthodontist, I rou-tinely see patients that requireextensive prosthodontic recon-struction due to their atypicaloral anatomy. Frequently, thissituation was created at the timeof tooth extraction and is theresult of residual ridge resorp-tion. Residual ridge resorption isa major oral disease entity asdescribed by Tallgren in the earlyseventies 1. Following toothextraction, patients can expect tolose a significant portion of theirresidual ridge due to normalphysiologic activity". Thisresorption is unpredictable andcan be a very challenging situa-tion when fabricating replace-ment prostheses. The challengesrange from functional to estheticdepending on the location andseverity of the resorption. Neweradvances in bone physiologyhave let us appreciate a more in-depth picture of bone healing. Inthe past, it was assumed therewas no need to treat an extractionsite for future prosthetic consid-erations. However, today weknow this is not the case. It iswell documented that withoutaugmentation, the maximumosseous fill or regeneration in theextraction socket will beminimal'. Because of this lackof optimal bone fill and unpre-dictability in the total resorptionof the alveolar ridge, the prostho-dontic treatment of these patientshas been less than optimal and
frequently compromised. Toillustrate these concems and dif-ficulties, two patients exhibitingsignificant residual ridge resorp-tion with significant prosthodon-tic challenges both in function,esthetics, and patient expectation,will be discussed.
PATIENT#lThis patient presented with a
history of periodontal problemsand treatments. His mandibularanterior teeth had been extractedand a removable partialdenture (RPD) fabricat-ed approximately fiveyears previous to beingseen in my office. Hischief complaint nowwas dissatisfaction withthe instability of theRPD. Due to the sig-nificant amount ofresidual ridge resorp-tion (RRR) (Figure 1),it was likely that a newRPD would yield simi-lar results for thispatient. After beingadvised of my con-cems, the patient choseto be restored with acomposite retainedfixed partial denture.However, the estheticresults were, in myopinion, compromisedbecause of the severityof the RRR. Thereplacement teeth were
unnaturally long (Figure 2), butdue to the patient's lip line, it wasacceptable to him. I believe theseverity of the resorption was dueto several factors: (1) pre-exist-ing periodontal disease that wentuntreated for several years, (2) anill-fitting RPD and, (3) mostimportantly, the lack of augmen-tation of the sockets at the timeof extraction.
Figure 1. Residual Ridge Resorption.
Figure 2. Composite retained fixed partial.
PATIENT#2This patient was first seen in
my office by referral from a peri-odontist. The periodontist hadstabilized the patient's periodon-tal condition making the patientready for prosthodontic evalua-tion and treatment. Due to theseverity of the residual ridgeresorption in the anterior maxilla(Figure 3) and the patient's smileline, restoration with an anteriorfixed prosthesis was not indicat-ed. The pontics would have beenexcessively long and no doubt,esthetically unacceptable to thepatient. The altemative treatmentwas to fabricate a fixed prosthe-sis incorporating a tissue bar thatwould provide both direct andindirect retention with the finalremovable prosthesis. The resid-ual ridge would provide very lit-tle support for the basis of theRPD. Through the use of a diag-nostic wax-up, and fabrication ofa provisional restoration fabricat-ed from the wax-up, an optimalesthetic result was finallyachieved through modification ofthe fixed provisional restorationand temporary removable partialdenture. The final prosthesis wasfabricated only after the patientapproved the temporary provi-sional restoration (Figure 4).
CONCLUSIONOver the last several
years, research has pro-víded much insight intothe problem of residualridge resorption. Todaywe know much more thanwe did in the past. It hasbecome clear that ridgemaintenance and preser-vation will dramaticallyimprove the quality ofrestorative dentistry pro-vided for the patient, inaddition to lessening thecomplexity of the treat-ment plan for the doctor.With recent well-docu-mented research advances,and after years of clinicalexperience, I routinelyrecornmend extractionsocket( s) be grafted witha synthetic resorbablehydroxylapatite bonesubstitute (OsteoGraf ®/
LD-300, CeraMed Dental,Lakewood, Colorado) to preservethe alveolar ridge for futureprosthodontic restoration. In thepast, there was little or nothingthat could be done about this situ-ation. However, today there areoptions available to patients thatwill alleviate most of these prob-lems.'i'
Figure 3. Residual Ridge Resorption (RRR).
Figure 4. Final Fixed Prosthesis.
REFERENCESl. Tallgren A. The Continuing Reduction
of the Alveolar Ridges in CompleteDenture Wearers. J Prosthet Dent.27,2:120-132.1972.
2. Misch CE and Dietsch F. BoneGrafting Materials in Implant Dentistry.Implant Dentistry. 2(3): 158-166. 1993.
3. Rosenlicht J. Ridge Preservation:Addressing a Major Problem inDentistry. Dentistry Today. September1993.
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