SECTIONEDITORS

Treatment of the mandibular compromised ridge: A literature

review
Dennis E. Jennings, D.D.S.*
Rhoades Dental Clinic, Fort Sam Houston, Tex.

Restoration of the mandibular compromised ridge requires various treatment

modalities. The simplest approach often is to extend the denture base adequately
for proper use of all available supporting tissues. If the patient is incapable of
wearing a conventional denture, the surgical approach becomes necessary. Surgical
avenues include vestibular extension procedures that increase vestibular depth and
augmentation procedures, which include (1) overlay grafts of rib or the crest of the
ilium, (2) osteotomy grafts to include the visor osteotomy and the interpositional
bone graft, (3) alloplastic grafts of which hydroxyapatite augmentation is the most
common, and (4) various types of implants to restore the compromised ridge. The
ultimate goal, regardless of the treatment modality chosen, is to restore the patient
to a level of masticatory function. (J PROSTHET DENT 1989;61:575-9.)

T reatment of the severely resorbed mandibular ridge was tongue position. The ideal tongue is forward and resting
has been a problem confronting dentistry for many years. on the top of the lower anterior ridge when the patient ca-
The denture patient with such a ridge often loses hope of sually opens the mouth. Such a position will effectively form
normal function and does not wear the denture. Under- a lingual border seal. A retruded tongue makes it almost im-
standing the available procedures can often help to return possible to establish this seal. Second, ill-fitting dentures
the denture patient to a state of masticatory function. distort the tissues over the ridge, set up irritations, and cause
To understand abnormal ridge contours, a definition of resorption of the bone. Treatment of the tissue is essential
the ideal ridge form for denture fabrication is necessary. before making new dentures. Third, there should be proper
Goodselll defined the ideal denture-supporting ridge as pos- use of the lingual spaces for retention of the denture. The
sessing (1) adequate bone support for dentures, (2) bone sublingual crescent space is the anterior part of the floor of
covered by adequate soft tissue, (3) no undercuts or over- the mouth above the sublingual gland. Tissue bounding this
hanging protuberances, (4) no sharp ridges, (5) adequate space moves freely, so that the anterior lingual flange can be
buccal and lingual sulci, (6) no scar bands to prevent normal extended horizontally. The sublingual fossa follows the my-
seating of a denture, (7) no muscle fibers or frenula to inter- lohyoid muscle extending down from the mylohyoid ridge,
fere with the periphery of the prosthesis, (8) satisfactory close to the lingual surface of the body of the mandible, when
ridge relationships between the maxillae and mandible, (9) the muscle is relaxed. In swallowing, the muscle raises the
no soft tissue folds, redundancies, or hypertrophies on the tongue and brings the floor of the mouth upward. Frequently
ridge or sulci, and (10) a ridge free of neoplastic disease. this muscle is flabby, allowing extension of the lingual flange
The severely resorbed mandibular ridge often lacks most vertically in the premolar-molar region. The retromylohyoid
of the criteria for an ideal ridge form. Golds2 stated that the fossa is located below and behind the retromolar pad. The
resorbed mandibular ridge presents difficulty in making an problem with extension into this region is that it may
adequate prosthesis because of decreased support and the develop a sore throat in the denture wearer. With careful at-
encroachment of surrounding mobile tissues onto the den- tention to anatomic form, a number of denture patients can
ture border, thereby reducing the stability and retention of function without undergoing surgical intervention.
the denture. Many techniques have been developed to deal with the
Shanahan3 listed three important factors in dealing with problem of the compromised ridge. In the 193Os, Page and
a patient with an unfavorable mandibular ridge. The first Jones advocated the principle of mucostatics.4 In 1957,
Faber5 advocated using metal bases for snugness of fit of the
The views expressed herein are those of the author and do not re- mandibular denture. In 1960, Behrman6 wrote of implanting
flect the views of the U.S. Army or the Department of Defense. platinum-cobalt magnets to increase mandibular denture
*Major, U.S. Army (DC); senior prosthodontic resident. stability. In 1966, Lott and Levin7 put forth the flange

THEJOURNAL OF PROSTHETIC DENTISTRY 575


technique, which provided much greater denture-bearing
surface for stabilization. In 1969, Strain8 emphasized the
necessity to duplicate in the base the contours of nature to
help stabilize the lower denture. Each technique had merit,
but no technique was applicable to all conditions. In a study
conducted by Levin et a1.gin 1970, it appeared that the ex-
perience of the denture wearer was more important than the
technique used or the flange extension. Renaud et al.1 be-
lieved that increased efficiency after rehabilitation could be
partly due to acquired self-confidence in mastication. How-
ever, proper coverage of all available denture-bearing surface
is fundamental to good denture construction.
ALVEOLARATROPHY
Guernseyll stated that progressive atrophy of the alveolar
bone following extraction of the teeth is a physiologic occur-
rence. The causes included (1) disuse atrophy, (2) localized
excessive pressure during incising and unilateral function
under a denture, (3) periodontal bone loss before extraction
of the teeth, (4) hyperparathyroidism, and (5) hypogo-
nadism. Meyers12 added nutritional deficiencies and tissue
resistance to stress as other etiologic factors affecting alve-
olar ridge resorption. Mercier13 believed the most significant
factors influencing ridge resorption to be related to the habit
of wearing the dentures both night and day and the number
of years of denture wear. In a classic article, Tallgren14 found
that the reduction of the mandibular anterior ridge height
was four times that of the maxillary ridge. Thus it becomes
imperative to first consider prevention and preservation of
the mandibular ridge and second to consider, when prevei:-
tion fails, the surgical avenues available to the prosthodon-
tist before making new dentures.
PREVENTIVE PROSTHODONTICS
The greatest way to preserve the mandibular anterior
ridge comes from the maintenance of one or more endodon-
tically treated roots and the placement of an overdenture.
This was graphically demonstrated in a 5-year study by
Crum and Rooney15 in which cephalometric radiographs
showed an average of 0.6 mm of vertical bone loss in the an-
terior part of the mandible of overdenture patients com-
pared with 5.2 mm bone loss in the conventional denture
wearer. Preservation of the ridge can be attributed to several
factors. First, masticatory force is transmitted to the root
and periodontal ligament, thus simulating normal physio-
logic function. Second, it has been shown that removal of the
coronal and pulpal tissues in the apical canal make no change
in the proprioceptive response of the patient.16, I7 Thus, the
patient is better able to apply appropriate masticatory force
without overstressing the tissue. Third, retained roots greatly
increase lateral stability of the denture thus reducing trauma
to the edentulous ridge.
The advantages of the overdenture over the conventional
denture are: (1) soft tissues of the residual ridges are spared
abuse due to support of abutment teeth, (2) the denture has
576
JENNINGS
more horizontal stability, (3) there is increased vertical sta-
bility during functional loading, resulting in improved mas-
ticatory performance, (4) natural teeth that are unaccept-
able as abutments for conventional dentures can be main-
tained as supporting elements in complete overdentures, and
(5) patient acceptance is excellent.18l I9
Although the overdenture is the treatment of choice for
patients with some remaining dentition, most denture ser-
vice provided today deals with the edentulous patient. The
ideal ridge described by Goodsell rarely presents itself to
the dentist; thus surgical intervention is often required. The
surgical procedures discussed will be grouped into (1) exten-
sion procedures, (2) autologous overlay grafts, (3) osteotomy
procedures, (4) alloplastic grafts, and (5) implant proce-
dures.
EXTENSION PROCEDURES
Kazanjian20 in 1935 developed a vestibular extension pro-
cedure by which a horizontal incision was made on the sur-
face of the lip approximately 1.5 cm from the ridge crest. The
mucous membrane was undermined and freed from the per-
iosteum as far down the external side of the periosteum as
necessary. The dissected tissue was then sutured to the un-
disturbed periosteum at the depth of the vestibule. In 1953,
Clarkzl varied from the original Kazanjian technique by not
elevating the mucosa to the crest of the ridge, and the mu-
cosal flap was sutured through the floor of the mouth to the
chin. In 1961, Kethley and Gamble22 developed the lip-
switch procedure, which was a variation of the original Ka-
zanjian technique. The mucosa was reflected from the inci-
sion in the lip to the crest of the ridge. The periosteum was
reflected from the crest of the ridge inferiorly. The mucosal
flap was then sutured to the bone and the periosteum was
sutured to the lip-thus the name lipswitch. The disad-
vantage of this procedure is that nonkeratinized mucosa is
used for denture retention but this appears not to be a sig-
nificant problem. Friedlander and Renner23 in 1977 advo-
cated resecting the submucous connective tissue, mentalis
muscle, the incisive muscle of the lower lip, and the anterior
fibers of the buccinator muscle. The mental nerve and peri-
osteum was left intact and the flap was sutured to the peri-
osteum. Resection was performed to prevent relapse. In
1981, Burton and Holton24 dealt with relapse by incision of
the mentalis muscle, suturing the flap to the base of the pe-
riosteum, and allowing the dissected mucosal flap of the lip
to granulate in. Vestibular extension procedures cannot be
done on the severely resorbed mandible because 15 mm of
bone is a prerequisite. 25 Nevertheless, the results can be
dramatic, as demonstrated by Bolender and Swenson28 who
found a mean gain of 7 mm in vestibular depth.
A more frequently used vestibular extension procedure
was first reported by Macintosh and Obwegeser,27 who used
a split-thickness skin graft. Yrastorza28 stated that vestibu-
loplasty was indicated when the mucogingival fold approx-
imated the crest of the ridge or the tissues in the floor of the
MAY 1889 VOLUME 61 NUMBER 6
TREATMENT OF MANDIBULAR COMPROMISED RIDGE
mouth welled up over the ridge. A skin graft of 0.41 mm is
obtained from the lateral surface of the thigh. A stent is used
to maintain the graft held in place by circummandibular su-
tures. The stent is removed in 10 days. Complications of the
procedure include paresthesia of the lower lip, possible
thickening of the skin graft, and hyperkeratinization unless
the graft site is routinely massaged.
AUTOLOGOUSOVERLAYGRAFTS
In 1970, Davis et a1.2goutlined a procedure in which trans-
oral autogenous bone grafts (8th or 9th ribs) were grafted to
atrophic mandibles. It was a variation of that described by
Macintosh and ObwegeseF who commonly used the crest of
the ilium. Davis et aL30 conducted a follow-up study in 1984
on 19 such grafted patients and found the rate of resorption
in the first 2 years to be 42%. During the next 2 years
resorption totalled 56%. The author stated that approxi-
mately 34% of the augmented bone is retained for an
extended period, thus reducing the possibility of fracture
and increasing denture stability. Wang et als follow-up
studysl in 1976 of patients receiving either iliac crest or rib
grafts was somewhat less encouraging. They found a 28%
resorption rate at 6 months, 45% at 1 year, 78% at 2 years,
and 89% at 3 years. Although vertical height approached
presurgical measurements, horizontal width was increased.
Because of the morbidity of the surgical procedure, these
operations are primarily reserved for the patient with such
a resorbed ridge that traumatic fracture is a possibility.
OSTEOTOMY GRAFTS
Primarily two types of osteotomy procedures are used in
reconstruction of the mandibular atrophic ridge. The first is
the visor osteotomy, which was developed originally by
Htile32 in 1975. The technique of augmentation consisted of
a sagittal osteotomy of the body and symphysis of the man-
dible to create a lingually pedicled bone flap. The bone flap
was elevated in the anterior region by hinging it posteriorly
in a visor fashion; hence, the name. Hiirles procedures2 pri-
marily augmented the anterior mandible. In 1977, Peterson
and Slade33 wrote of a modified visor osteotomy. This pro-
cedure included an osteotomy from one retromolar pad to
the other. The lingual segment was elevated to a superior
position and secured with intraosseous sutures, thus aug-
menting the entire ridge. Cancellous bone or a marrow graft
was placed on the buccal aspect of the elevated segment.
Peterson also advocated a simultaneous buccal vestibulo-
plasty by means of a lingually based Kazanjian flap. The ad-
vantages of this procedure over the prior autologous overlay
graft techniques were believed to be (1) minimal resorption
at 6 months, (2) early construction of dentures, (3) reduced
morbidity (no iliac crest or rib need be sacrificed), and (4)
increased lingual vestibular length. In 1979, Hiirle34 pub-
lished a 3-year follow-up study of 10 visor osteotomy
patients. The author found an increased mandibular height
of 63 % . In 1983, Peterson35 published a long-term follow-up
THE JOURNAL OF PROSTHETIC DENTISTRY
of 12 patients who underwent visor osteotomy. He reported
an initial resorption of 2 mm in 6 months. By 6 months, rapid
resorption ceased. By year 3, an additional 1 mm loss of bone
had occurred. By year 5, the author reported a stable vesti-
bular depth with little flange adjustments. Mercieri3 in 1985
published an article describing the disadvantages of the vi-
sor osteotomy, which included (1) paresthesia of the lower
lip, (2) scarcity of available bone for mobilization, and (3) a
resultant ridge that was rarely retentive.
The second type of osteotomy procedure used for recon-
struction of the mandibular atrophic ridge is the interposi-
tional bone graft. Bell et al .36 described this technique in a
1977 article. In this procedure, a horizontal osteotomy is
made the entire length of the mandible and a graft (either
iliac crest or rib) is placed between the two sections. This
surgical procedure was thought to decrease the resorption of
the graft sites recorded with the autologous overlay
graft.30, 31In 1978, Bell and Buckles37 published a follow-up
study of interpositional bone grafting. The authors reported
little if any resorption but stated that 9 to 10 mm of vertical
mandibular bone was necessary for horizontal resection. As
is true with overlay grafts, the morbidity of the procedure is
a major disadvantage.
ALLOPLASTIC GRAFTS
It soon become evident to those performing grafting pro-
cedures in the mandible that resorption of the graft site was
a major problem. Alternatives to autologous bone became of
primary interest. One such material used by Pedersen3s in
1976 consisted of porous ceramic implants with a pore size
of 100 to 750 nm. The material was accepted biologically and
the 15-month results showed radiographic evidence of aug-
mentation.
The most popular alloplastic material used today is
hydroxyapatite (HA). Jarcho et aLsg published a study of
HAs biocompatibility and stated that HA was biocompat-
ible and nonbiodegradable. HA showed no evidence of local
or systemic inflammatory or foreign body response. Kent et
aL40 developed the hydroxyapatite technique for augment-
ing alveolar ridges. In 1983, Kent et a1.41reported only a
6.5% decrease in mandibular augmented ridge height after
4 years. The original technique described was an elevation of
the periosteum on the ridge crest and a tunnelling with
hydroxyapatite.42 A secondary split-thickness skin graft
procedure was required in most patients. Techniques were
soon developed in an attempt to eliminate the second surgi-
cal procedure.42s 43
Hydroxyapatite has been used for (1) grafting procedures
alone; (2) in combination with autogenous cancellous bone44;
(3) in combination with allogenic freeze-dried rib; and (4) in
combination with marrow.44 Block and Kent45 stated that
the clinical impression of ridge stability demonstrated by
patients who have had ridge augmentation with HA in com-
bination with autogenous cancellous bone has not differed
greatly from those for whom HA particles alone were used.
577
They also reported a 10 mm gain in ridge height with only
a 4% to 10% reduction in a period of up to 4 years.
Desjardins& and Lamhert4 published articles that dealt
with the problems of hydroxyapatite augmentation. These
included (1) diffusion of material (stems were developed in
order to try to compensate for this diffusion), (2) irregular
distribution and extension of the material, (3) incorrect po-
sition of material with excessive increase in width of the
ridge, which becomes a problem in placing denture teeth out
of the neutral zone, (4) excessive increase in alveolar ridge
height with mandibular ridge to high before placement of
denture teeth, (5) paresthesia, and (6) migration of the ma-
terial after placement.
The tunnelling procedure has given way to a full-thickness
flap, controlled placement of the hydroxyapatite material,
and surgical stent fixation to decrease some of the problems
associated with HA augmentation.
IMPLANTS
The failures and shortcomings of augmentation grafting
procedures have resulted in the advent of numerous forms of
implants. The three broad categories are (1) subperiosteal,
(2) transosteal, and (3) endosteal.
The subperiosteal implant was developed by Golberg and
Gershkoff as reported by Metz@ and later advanced by Kra-
tochvil and Boyne4g in 1972. The typical subperiosteal
implant involves two surgical procedures. The first is to re-
flect a flap and make an impression of the residual ridge.
Before the second procedure, a frame that accurately fits the
bone is fabricated. During the second surgical procedure, a
full-thickness flap is reflected, and the frame is fixed to the
underlying bone. Recently, CT scan modeling of the mandi-
ble has been used to eliminate the first surgical procedure.50
Bloomquist51 in 1982 published a study of the long-term re-
sults of subperiosteal implants. The author reported 5-year
success rates of up to 90 % . Failure normally occurred at the
mucosal-metal junction. A recent advent with the subperi-
osteal implant is the use of HA coating. Kay et a150reported
that HA coatings applied to the struts of the subperiosteal
implants can enhance the performance of the implant,
apparently by creating a faster and stronger attachment to
bone, providing an environment for overlying soft tissue
healing (thus decreasing failure at the mucosal-metal junc-
tion), and inhibiting metallic ion release.
In 1972, Cram et a1.52listed the drawbacks to the subper-
iosteal implant as being (1) a two-stage surgical procedure,
(2) dependence on the skill of the operator, and (3) the ex-
pense involved. They advocated use of the ramus frame
implant, which is thrust posteriorly into the ramus of the
mandible where it is lodged between the buccal and lingual
plates of cortical bone and anteriorly is fixed into the sym-
physis. The long-term success rates of the ramus frame tend
to be poor but it did address some of the drawbacks of the
subperiosteal implant.
Small and Kobernick are credited by Metz48 with the de-
velopment of the staple bone implant, a transosseous im-
578
plant. A transosseous implant is attached to the inferior
border of the mandible between the mental foramen and
contains two transosseous pins with either three or five
endosseous pins for stability and retention. Cranin et al.53
listed the advantages of the implant as (1) a simple surgery
in an uncomplicated anatomic site, (2) an implant with a
permucosal portion free of geometric complexities, (3) a fix-
ation site farthest from the unpredictable alveolar ridge, and
(4) the use of a footplate located at the dense and stable in-
ferior mandibular border. To consider a staple bone implant
one must have (1) an adequate labiolingual width of at least
5 mm, (2) an adequate vertical height of at least 25 mm, and
(3) no physical or psychologic contraindications. The im-
plant itself is made of 90 % titanium, 5 % aluminum, and 4 %
vanadium. Cranin et a1.53reported a 17-year success rate of
81.7 %. Smal154believed that implants, in general, failed be-
cause of either metal fatigue or metallic corrosion, which
could be prevented by a thin oxide layer present on passive
metals such as titanium, aluminum, or chromium. Lang et
al.55 in 1967 reported that after placing different metallic
implants for a g-month duration, titanium was found to be
the most tissue compatible and nonmutogenic.
Sma1156in 1978 stated that the prosthodontist (compared
with the oral surgeon) carries the greater responsibility be-
cause the prosthodontist must adapt the mandibular staple
to a functional role without violating design principles. The
principles are that (1) the staple is designed for a stabilizing
device and must never be loaded with compressive force, (2)
the use of stress-breaking devices such as the Dalbo or Ceka
attachments are indicated, (3) the copings and bar should
never be loaded, and (4) the final prosthesis must be tissue
borne. Techniques for use of the staple bone implant
vary,57p58 but all should follow the criteria established by
Sma1l.56
What appears now as the most popular (if economically
feasible) treatment of the mandibular compromised ridge is
the use of endosseous implants. Much of the clinical and
laboratory research is credited to P.I. Branemarksg and the
use of pure titanium implants. Osseointegration of pure ti-
tanium implant@ appears possible because (1) titanium is
a passive metal and an oxide layer forms easily on the metal,
(2) this oxide layer does not break down under physiologic
conditions, and (3) the modulus of elasticity of pure titanium
is closer to that of bone than any other important implant
metal.
CONCLUSION
If the prosthodontist is to successfully treat the patient
possessing a poor mandibular alveolar ridge, it becomes nec-
essary to understand the limitations of the patient, the
available prosthodontic techniques, the limitations of the
oral surgeon, and the capabilities of the laboratory techni-
cian. Treatment may include the routine or the more
sophisticated prosthodontic techniques using advanced
instrumentatio# or the aid of the oral surgeon to do exten-
sion procedures, augmentation procedures, or implant pro-
MAY 1999 VOLUME 61 NUMBER 5
TREATMENT OF MANDIBULAR COMPROMISED RIDGE

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