Trauma; preprosthetic surgery Invited review

Reconstructive preprosthetic surgery

I. Anatomical considerations
J. I. Cawood, R. A. Howell." Reconstructive preprosthetic surgery. I. Anatomical considerations. Int. J. Oral Maxillofac. Surg. 1991; 20." 75-82. Abstract. When considering preprosthetic surgery of the edentulous jaws, it is important that the clinician fully understands the anatomical consequences of reduction of the residual ridges. Based on a classification of the edentulous jaws, changes in the relationship of the jaws to each other, in muscle relations and function, in the oral mucosa and in facial morphology have been measured relative to the stage of resorption of the edentulous jaws.

J. I. C a w o o d 1, R. A . H o w e l l 2 1Maxillofaeial Unit, Royal Infirmary, Chester, and aLiverpool Dental Hospital, UK

Key words: preprosthetic surgery; edentulous jaws; classification; anatomy; alveolar resorption. Accepted for publication 1 December 1990

Reduction of the residual ridge is a chronic progressive process whose rate varies not only between different individuals but within the same individual at different times 1. In a detailed longitudinal study, TALLGREN observed that 8 although the greater proportion of bone loss occurred within the first year of tooth loss, the process continued at a slower rate over the 25 years for which the subjects were followed (Fig. 1). She also noted that, in general, the amount of bone loss in the mandible is four times greater than in the maxilla. Using clearly defined, reproducible reference points of the edentulous jaws, CAWOOD & HOWELL4 analysed patterns of alveolar resorption from a sample of 300 dried skulls. Based on this objective study, a pathophysiological classification of alveolar resorption was established which describes 6 stages of resorption (Fig. 2A, B, C, D) and (Fig. 14, A, B, C, D, E, F).

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Fig. 1. Mean reduction in anterior height of the alveolar ridges over 25 years (after
TALLGRENS).

v Vl IV Fig. 2. A: classification of anterior mandible (anterior to mental foramina); B: classification of posterior mandible (posterior to mental foramina); C: classification of anterior maxilla; D: classification of posterior maxilla.

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Class I - dentate. Class II - post extraction. Class I I I - rounded ridge, adequate height and width. Class IV - knife edge ridge, adequate height, inadequate width. Class V - flat ridge, inadequate height and width. Class VI - depressed ridge with varying degrees of basal bone loss, that may be extensive but follows no predictable pattern. The main conclusions arising from the study were: [i] Basal bone does not change shape significantly unless subjected to harmful local effects such as the overloading of ill-fitting dentures. [ii] Alveolar bone changes shape significantly. [iii] In general, changes of shape of the alveolar bone follow a predictable pattern. [iv] Pattern of bone loss varies with site. Anterior mandible (anterior to mental foramina) bone loss is mainly horizontal from the labial aspect. Posterior mandible (posterior to mental foramina) bone loss is mainly vertical. Anterior maxilla bone loss is mainly horizontal from the labial aspect. Posterior maxilla bone loss is mainly horizontal from the buccal aspect. [v] Stage of bone loss can vary anteriorly and posteriorly and between jaws (Fig. 15, A, B).

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Loss of teeth and reduction of the residual ridge lead to changes in the relationship of the jaws to each other, in muscle relations and function, in the oral mucosa and in facial morphology. The classification of the edentulous jaws 4 forms a basis for a systematic assessment relating the stage of resorption to changes in the shape and relationship of the jaws and soft tissue integument.

Fig. 3. Changes between Class I and Class VI jaw relations. A: anteroposterior and vertical interarch changes and associated prognathism of the mandible; B: transverse and vertical interarch changes. Note the reverse relationship of the edentulous and dentate jaws due to resorption patterns causing the maxillary arch to become progressively narrower and the mandibular arch to become progressively broader; C: lateral cephalometric tracings of orthognathic face (Class I) and edentulous face (Class V), illustrating changes in anterior facial proportions of the edentulous face due to the autorotation of the mandible causing a decrease in lower face height and increase of chin prominence. UFH: upper face height: LFH: lower face height.

Interarch changes

With progressive resorption from Class I to Class VI, there are 3 dimensional changes in jaw relations. Anteroposteriorly, the mandibular and maxillary arches become shorter (Fig. 3A). Transversely, due to the pattern of resorption,

the maxillary arch becomes progressively narrower, whilst the mandibular arch becomes progressively broader. (Fig. 3B). Vertically, the interarch distance increases, although this is counteracted to some extent by the vertical shortening of the lower face caused by the closing movement or autorotation of the mandible producing a more prominent chin and prognathic jaw (Fig. 3C, D).

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Muscle changes

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The attachments of the circumoral and floor of mouth musculature delineate the extent of the vestibular and lingual sulci. With continued loss of alveolar bone from Class I to Class VI, these muscles become progressively superficial (Fig. 4A, B, C, D, E, F).

BUCCAL

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Fig. 4. Attachment of the circumoral and floor of mouth musculature, showing how they become increasingly superficial as bone loss progresses. A: dentate mandible (Class I), buccal aspect; B: edentulous mandible (Class V), buccal aspect: (1) mentalis, (2) depressor labii inferioris, (3) depressor anguli oris, (4) buccinator; C: dentate mandible, lingual aspect; D: edentulous mandible, lingual aspect: (5) genioglossus (superior) and geniohyoid (inferior), (6) digastric (anterior belly), (7) mylohyoid. E: dentate maxilla (Class I), buccal aspect; F: edentulous maxilla (Class V), buccal aspect: (1) dilator naris, (2) compressor naris, (3) depressor septi, (4) buccinator, (5) levator anguli oris.

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Cawood and Howell

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Fig. 6. Progressivereduction of residual ridges from Class I to Class VI showing vertical ridge resorption of the posterior mandible, decreasing attached mucosa (heavy line) and changing muscle relations.

There is quantitative and qualitative reduction of the soft tissue support as well. WATT & MACGREGOR compared the 9 area ofperiodontium supporting a tooth with the small area of mucoperiosteum remaining after tooth loss. They calculated that the mean surface area is reduced from 45 to 23 cm squared in the edentulous maxilla and to 12 cm squared in the edentulous mandible. In the edentulous jaw, the mucosa covering the residual ridge is partly attached and partly unattached. The attached mucosa corresponds to the attached gingiva originally surrounding the natural teeth. Unlike the periodontal ligament, the mucosa is not a specialized supporting tissue, and excessive pressure causes pain and a pathological response 1. As the attached mucosa is bound to bone it is more able than the unattached mucosa to withstand loading pressure. CAWOOD & HOWELL measured the 5 amount of attached and unattached mucosa relative to t h e stage of jaw resorption. As can be seen in (Fig. 5A, B) the amount of attached and unattached mucosa diminishes significantly from Class I to Class VI. The progressive muscle and mucosal changes that accompany jaw atrophy are illustrated in Fig. 6. It should be noted that as a result of alveolar bone loss, the inferior alveolar canal becomes relatively superficial. Changes in mandibular blood supply are seen. Initially, the blood supply is primarily centrifugal. With loss of teeth and the periodontium, the blood supply of the edentulous mandible becomes centripetal (Fig 7).

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Fig. 7. Mandibular blood supply: centrifugal in the dentate jaw, centripetal in the edentulous
jaw.

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Facial changes

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Fig. 8. The '<facialcurtain" and the "dental bulge". Loss of anterior teeth causes collapse of circumoral muscles and shortening of the buccinator distorting the face (after WATT & MAcGREoOR9).

Fig. 9. Muscles of facial expression which decussate to form the modiolus lateral to the commissure.

These intraoral changes are also reflected in the facial morphology. WAXY & MACGREGOR liken the circu9 moral and facial musculature to a curtain draped between the maxilla and mandible (Fig. 8). Loss of anterior teeth removes the "dental bulge" and causes shortening of the buccinator muscle and consequent distortion of the facial curtain. The muscles of facial expression decussate to form the modiolus (Fig. 9) and intersect the fibres of the orbicularis oris muscle. With tooth loss and reduction of the residual ridge, there is a change in direction and a loss of tone of the muscles of facial expression. The modiolus collapses inwards and backwards (Fig. 10A, B). The orbicularis oris also collapses with inversion of the "J" shape arrangement of the muscle fibres (Fig. l l a , B). CAWOOD examined changes of the edentulous facial form by measuring the nasolabial angle, commissure width, lower face height and chin prominence relative to the stage of jaw atrophy. As can be seen in (Fig. 12A, B, C, D) facial form alters from Class I to Class VI. The nasolabial angle increases and the commissure width decreases significantly. These changes occur soon after tooth loss but continue to change with increasing jaw atrophy. Reduction of the lower face height and concomitant increase in the chin prominence occur late and are associated with advanced jaw atrophy namely Class V and VI (Fig. 13, A, B).

ORBICULARIS ORIS CHANGES

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Fig. 10. Collapse of elevator and depressor muscles and modiolus following loss of "dental bulge" and atrophy of edentulous jaws. A: frontal view showing medial displacement of modiolus and related muscles; B: lateral view showing posterior displacement of modiolus and related muscles. OO: orbicutaris oris; LA: levator anguli oris; ZM: zygomaticus major and minor; B: buccinator; DA: depressor anguti oris.

Fig. 11. Orbicularis oris muscle and relationship of elevator muscles. A: dentate (Class I), elevator muscles intersect "J" shape arrangement of orbicularis oris muscle fibres; B: edentulous (Class VI), showing associated collapse and distortion of orbicularis muscle fibres.

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Fig. 12. Differences between mean values of lower face morphology and progressive resorption of the edentulous jaws. A: nasolabial angle; B: commissure width; C: lower face height; D: chin prominence. Note that the increase in nasolabial angle and decrease in commissure width occur as an early manifestation of tooth loss whilst the decrease in lower face height and increase in chin prominence occur as a late change associated with advanced atrophy of the jaws.

Fig. 13. A: dentate face (Class I) - frontal and lateral; B: edentulous face (Class VI) frontal and lateral showing characteristic changes of lower face height, commissure width, nasolabial angle and chin prominence.

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Fig. 14. A: Class III mandible; B: Class III maxilla, note rounded ridge form of adequate height and width; C: Class IV mandible; D: Class IV maxilla, note knife edge ridge form of adequate height and inadequate width. The unsupported attached mucosa spills over the knife edge bony ridge; E: Class V mandible, flat ridge form of inadequate height and width, note loss of sulcus, prominence of genial tubercles relative to the residual ridge and thin strip of residual attached mucosa; F: Class V maxilla, flat ridge form of inadequate height and width, note loss of sulcus depth. Residual mucosa is flabby due to loss of supporting bone.

Awareness of the pattern of resorption of the edentulous jaws and associated soft tissue changes enables clinicians to anticipate and possibly avert future problems.

Fig. 15. Variations of ridge forms. A: anterior mandible - Class IV; posterior mandible Class V; B: anterior maxilla - Class V; posterior maxilla - Class III; anterior mandible Class I; posterior mandible - Class V

'The same manner that the blinde man worketh in hewygne of a log, so doth. a cyrurgeon that knoweth not the nathomye.' The Questyonary of Cyrurgeons, Trans. Guy De Chauliac (1363).

References Discussion There is a need for an internationally accepted classification that describes the stages of resorption of the residual ridges simply and accurately to improve communication between clinicians. Previous attempts to classify the edentulousjaws are unsatisfactory since they are too subjective in nature and incomplete 2,3,6,7. The classification proposed overcomes these objections since it has been derived from objective measurements from which 6 stages of resorption can be clearly identified. Determination o f the particular stage of resorption is accomplished simply and quickly by manual and visual inspection alone (Fig. 14A, B, C, D, E, F). Furthermore, the classification is versatile allowing the distinction between different stages of resorption occurring anteriorly and posteriorly and between jaws (Fig. 15A, B). Tooth loss results in irreversible changes in shape and relationship of the jaws and soft tissue integument. Until now it has not been possible to quantify these changes sequentially. Using the classification and the 6 distinct stages of resorption as a basis for comparison, it was possible to measure the changes in the relationship of the jaws to each other, the muscle relations, the mucosal changes and the alteration of facial form relative to the particular stage of reduction o f the residual ridge. 1. ATWOODDA, CoY WA. Clinical cephalometric and densitometric study of reduction of residual ridges. J Prosthet Dent 1971: 26: 210-95. 2. ATWOODDA. Post extraction changes in the adult mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. J Prosthet Dent 1963: 13: 810-24. 3. BRaNEMARKPI, ZARRG, AL~R~KTSSONT. (eds). Tissue-integrated protheses. Osseointegration in clinical dentistry. Berlin: Quintessence, 1985. 4. CAWOOD JI, HOWELL RA. A classification of the edentulous jaws. Int J Oral Maxillofac Surg 1988: 17: 232-6. 5. CAWOOD JI, HOWELL RA. Anatomical considerations in the selection of patients for preprosthetic surgery of the edentulous jaws. In: Williams DF, ed. Current

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8. TALLGRENA. The continuing resorption of the residual alveolar ridges in complete denture wearers: A mixed longitudinal study covering 25 years. J Prosthet Dent 1972: 27: 120-32. 9. WATT DM, MACGREGORAR. (eds). Designing complete dentures. Philadelphia: W. B. Saunders, 1976: 4-14.' 10. WILKm ND. The role of the prosthodontist in preprosthetic surgery. J Prosthet Dent 1975: 33: 386-96. Address: J. L Cawood Maxillofacial Unit Royal Infirmary Chester CH1 2AZ UK

perspectives on implantable devices. Connecticut: JAI Press, 1989: Vol 1: 139-80. 6. KENTJN, Q ~ JH, ZIDEMF, Gu~ed~ IR, BOYr, PJ. Alveolar ridge augmentation rE using non-resorbable hydroxyapatite with" or without autogenous cancellous bone. J Oral Maxillofac Surg 1983: 41: 629-42. 7. MERCIER P, LAmNTANT R. Residual alveolar ridge atrophy: Classification and influence of facial morphology. J Prosthet Dent 1979: 41: 90-100.