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The continuing reduction of the residual alvealar

ridges in complete denture wearers: A


mixed-longitudinal study covering 25 years

Antje Tallgren, L.D.S., Odont.Dr.*


The Royal Dental College, Copenhagen, Denmark

1 he effect of the wearing of complete dentures on facial morphology has been


the object of a series of longitudinal studies by the present author.l-* The resorption
of the residual alveolar ridges during a seven-year period of denture wear was found
to have caused a pronounced reduction of the pre-extraction morphologic face
height and an accompanying although less marked reduction in the rest fact
height.2 In subjects provided with complete upper and partial lower free-end den-
tures, the decrease in facial height was, on the average, only half that noted in
the complete denture group. The adaptive changes in the rest face height to the
alterations in the morphologic face height have been confirmed in several other
studies.5-10
A study of the morphologic changes in the facial skeleton during seven years
of complete denture wear3 revealed that the decrease in facial height was mainly
due to a pronounced reduction of the mandibular ridge and a consequent forward-
upward rotation of the mandible. The change in mandibular position was accom-
panied by a marked increase in mandibular prognathism, i.e., a forward positioning
of the chin in relation to the upper part of the face. The reduction of the residual
alveolar ridges was most rapid during the first year of denture wear.* This is in
accordance with findings by other authors for various categories of denture
wearers.11-15 Despite the marked alveolar bone loss and resultant alterations in jaw
relationship, no dimensional changes were found in the cranial base, the upper part
of the face, or the basal parts of the mandible. Nor was there any evidence of
remodelling changes in the gonial process.3

This study was supported by a United States Public Health Service research grant
DE-02858 from the National Institute of Dental Research, National Institutes of Health,
Bethesda, Md., and by the Danish Medical Research Council.
Presented before the Greater New York Academy of Prosthodontics, New York, N. Y.
*Research Associate, Institute of Orthodontics, Royal Dental College, Copenhagen, and
Lecturer in Prosthetics, University of Turku, Finland.

120
Reduction of ridges in denture wearers 121

A study of the positional changes of the complete dentures due to the alveolar
resorption* revealed particularly marked changes of the lower denture. In addition
to a pronounced settling on the basal seat, the lower denture displayed also a for-
ward slide on the residual ridge. The upward rotation of the mandible and the
forward slide of the lower denture led to a reduction in the horizontal overlap, and
in some patients, even to a horizontal overlap of the lower teeth over the upper ones.
The resorption of the residual ridges and the changes in jaw and occlusal re-
lationships showed great individual variation. Analysis of the relationship between
morphologic characteristics of the facial skeleton and the anterior bone loss during
seven years of denture wearlG revealed a marked association between the mandibular
shape and the resorption, especially of the lower ridge.
In order to investigate the continuing reduction of the residual ridges during
protracted wearing of dentures, a cephalometric radiographic follow-up study was
made of two groups of complete denture wearers-those with 15 and those with
25 years’ experience with denture wear. Furthermore, the individual variations in
mandibular bone loss were subjected to closer analysis.

MATERIAL AND METHODS


Samples studied
The two groups studied consisted of subjects who had been provided with com-
plete maxillary and mandibular dentures at the Institute of Dentistry, University
of Helsinki. The first sample (Group A) comprised nine subjects from a sample of
11 complete denture wearers, previously followed during seven years of denture
wear.2, 3 The nine subjects (seven women and two men) were examined after a
total of 13.5 years of denture wear, and six of these also after a total of 15 years of
denture wear. The mean age of the nine subjects who were examined after 13.5
years was 63.7 years (range 33 to 76 years). The reductions of the sample were in
two instances due to death, one subject had moved to another area of the country
and was not able to attend, and two subjects did not respond to repeated attempts
at follow-up.
The second sample (Group C) consisted of 20 subjects from a previous sample
of 45 subjects, who at the initial examination1 had been wearing complete dentures
for ten years. These 20 subjects, all women, were re-examined 15 years after the
first examination, that is, after a total of 25 years of denture wear. The mean age
of the subjects at the 25 year stage was 72.1 years (range 59 to 88 years). The re-
duction of the initial sample was in 11 instances due to death, four subjects could not
be traced, six subjects did not respond to repeated attempts at follow-up, and four
subjects were unable to attend due to illness or old age.

Prosthetic treatment
Details regarding the prosthetic treatment have been given in a previous pub-
1ication.l In both groups, the treatment undertaken was of the conventional type,
the dentures being constructed tw? to four months after extraction. In Group C,
all dentures were made of vulcanite; in Group A, the dentures were made of acrylic
resin. In both groups the dentures were provided with porcelain teeth (cusp angula-
tion about 15 degrees) .
122 Tallgren J. Prosthet. Dent.
February, 1972

Fig. 1. Measurements of alveolar resorption. The anterior height of the upper and lower
alveolar ridges at two stages of observation (a and b). The difference a - b represents the
reduction in height of the alveolar ridges between the stages of observation. The shaded area
represents the area of resorption.
Fig. 2. The shape of the mandibular base in terms of the P-angle and the gonial angle
(RL-ML) .

For the subjects in Group A no rebasing of the dentures had been done during
the first seven years of denture wearing. For subjects Nos. 17, 31, 32 and 53 (see
Fig. 6), the dentures were remade or rebased between the seven-year and the
13.5 year controls, and for subject No. 2, the dentures were rebased after the 13.5
year control.
In Group C, seven of the 20 subjects (Nos. 4, 7, 12, 19, 29, 43, and 45-see
Fig. 7) were still using their 25-year-old vulcanite dentures without any corrections
of the dentures having been made. For the remaining 13 subjects, new dentures of
acrylic resin had been made during the period between the two radiographic ex-
aminations.

Radiographic procedure
The standardized radiographic cephalometric procedure for obtaining the pro-
file head films has been accounted for in previous publications.l, 2 The film series
of each subject obtained in the present follow-up study consisted of two or three
radiographs made in the rest position of the mandible and one radiograph made
with the teeth in occlusion. The rest position exposures were made both with and
without the dentures in the mouth.
The enlargement of the structures in the median plane was the same as in
previous recordings (6.6 per cent) . No corrections have been made for this enlarge-
ment.

Measurements
The variables studied were the reduction in anterior height of the bony alveolar
ridges and the anterior resorption areas (Fig. 1). Furthermore, the shape of the
mandible was measured in terms of the P-angle (LindegHrd17) and the gonial
angle, RL-ML (Fig. 2). For details regarding measurements and method errors
the reader is referred to a previous article. 3 A brief survey of methods of measure-
ment is given below.
Reduction of ridges in denture wearers 123

ANTERIOR HEIGHT OF ALVEOLAR RIDGES


HEIGHT
mm
30 -

MANDIBLE

RoUPC
7 MAXILLA

GROUP C

, I I
I I t I
BE Al’Jzlyr. lY%. 1yrs. 10yrs. 13syrs. 25yrs.

Fig. 3. The mean reduction in anterior height of the bony alveolar ridges in 9 subjects of
Group A during 13.5 years of complete denture wearing (3 years: n = 6), and in Group C
between the 10 year and 25 year stages of denture wearing (n = 20). The diagram is based
on the mean height of the residual alveolar ridges at the different stages of observation.
BE = Before extraction. AI = After insertion.

All measurements were obtained from the rest position films without dentures,
the other films from the same series being used as an additional check of bony
contours and of measuring points. The linear and angular measurements were made
directly on the films according to the method of Bjork and So10w.~~ The measure-
ments of the resorption areas (Fig. 1) were made on contour tracings by planimeter,
the mean of three .registrations of each area bein g used in the subsequent analysis.
The statistical methods used in the present study have been reported else-
where.3’ lG Examination of the relationship between pairs of variables was per-
formed graphically and by calculation of correlation coefficients. The 5 and 1 per
cent significance limits for the correlation coefficients for the sample size of 20 are
0.44 and 0.56. All calculations were carried out at NEUCC, the Northern Europe
University Computing Centre in Copenhagen.

RESULTS
Reduction in height of the alveolar ridges
The mean reduction in anterior height of the bony alveolar ridges in Groups A
and C is shown in Table I and Fig. 3. The mean rate of reduction in the two
samples is given in Table I and is presented graphically in Figs. 4 and 5. The mean
124 Tallgren J. Prosthet. Dent.
February, 1972

MEAN RATE OF REDUCTION OF ALVEOLAR RIDGES


mmtyear

MAXILLA

GROUP A
El

GROUP C

0
EEAl’hlyr. 3yrs. 7yrs. 10yrs. 13.5yc5. 15yrs. 25yrs.

Fig. 4. The mean rate of reduction in anterior height of the maxillary and mandibular
alveolar ridges (mm/year) in Groups A and C. Based on Table I. BE = Before extraction.
AI = After insertion.

Table I. Mean reduction and mean rate of reduction in anterior height of the bony
alveolar ridges in Group A and Group C during the total period of observation
(BE, before extraction; AI, after insertion)

Reduction 1 Rate of reduction


Observa- (mm.) (mndyr.)
Difference,
tion
Maxilla Mandible mand.-max. Maxilla Mandible
period
(yr.) No. F 1 s IF s 2 jY T

Group A:
BE-AI 11 1.27* 1.68 1.41* 1.63 0.14 5.08 5.64
AIS 11 0.50** 0.50 1.14*** 0.67 0.64* 1 .oo 2.28
S-1 11 0.23 0.41 1.27*** 0.72 1.04** 0.46 2.54
AI-1 11 0.73*(” 0.75 2.41*** 0.89 1.68”Y’ 0.73 2.41
1-3 7 0.21 0.39 2.21*** 0.91 2.00X” 0.11 1.11
3-7 7 0.86” 0.85 2.71*** 1.11 1.85** 0.22 0.68
AI-7 11 1.73”‘s 0.98 6.55*** 2.52 4.82*** 0.25 0.94
7-13.5 9 0.39” 0.33 1.44*** 0.58 1.05** 0.06 0.22
AI-13.5 9 2.22*** 1.09 7.72*“* 2.88 5.50**
13.5-15 6 0.08 0.20 0.33” 0.26 0.25 0.05 0.22

Group C:
lo-25 20 0.75*** 0.53 3.00*** 1.53 2.25*** 0.05 0.20
*Denotes the 5 per cent level of significance.
**Denotes the 1 per cent level of significance.
***Denotes the 0.1 per cent level of significance.
Volume 27 Reduction ridges in denture
Number 2
of wearers 125

MEAN RATE OF REDUCTION OFALVEOLAR RIDGES


mm/year

MANDIBLE

q GROUP A

(!J GROUP C

0
EEAl’hlyr. 3yrs. 7yrs. 10yrs. 13.5yrs.15yrs. zsyrs.

Fig. 5. See legend for Fig. 4.

changes reported below are all significant at least at the 5 per cent level if not
otherwise stated.
Regarding the previously reported reduction of the alveolar ridges in Group
A during seven years of denture wear, it should be noted that during the pre-
insertion period no significant difference between the maxillary and mandibular
reduction was found. Owing to a marked reduction of the lower ridge but only
slight reduction of the upper ridge during the subsequent years of denture wear,
the relationship between the mandibular and maxillary reduction gradually in-
creased to approximately 4: 1 at the seven-year stage.4
The present follow-up study revealed a continuing reduction of the residual
ridges. In Group A the mean decrease in anterior height of the lower ridge be-
tween the seven-year and 13.5 year controls was 1.4 mm. and that of the upper
ridge was 0.4 mm. In three of the nine subjects no further reduction of the upper
ridge was observed during this period, while the lower ridge was reduced in all
subjects. The mean decrease in mandibular height during the total period of 13.5
years was 7.7 mm. and the maxillary reduction was 2.2 mm. Of the six subjects
examined at the 15 year stage of denture wear, four subjects showed a further
reduction of the lower ridge, while only one subject displayed reduction of the
upper ridge.
In Group C the mean reduction in anterior height of the lower residual ridge
between the 10 year and 25 year stages of denture wear was 3 mm. and that of
the upper ridge was 0.8 mm. Regarding the individual results, all subjects dis-
played reduction of the lower ridge, while in three subjects no reduction of the
upper ridge was found.
126 Tdgren J. Prosthet. Dent.
February, 1972

A 53 Q A51 A2 A 38 A Al7

Q A31 63 A32

5cm
I I
Fig. 6. Individual tracings of the anterior bone loss of the lower ridge during 13.5 years of
complete denture wearing (Group A). The tracings show the bony contour of the anterior
residual ridge at the stage of insertion of the dentures, at the 1 year, 7 year and 13.5 year
stages of observation. Sequence according to magnitude of bone loss at the 7 year stage Sub-
jects Nos. A53 and A2 are men.

Table II. Resorption areas in the anterior region of the bony alveolar ridges in
Groups A and C (AI after insertion)

Maxilla Mandible
Observation
(mm.l) (mm.2)
period
Group (yr.) No. Min. 1 Max. ( 5F ( s Min. ( Max. F ( s
A AI-13.5 9 10.3 47.7 27.84 12.74 20.3 120.0 58.59 36.89
C IO-25 20 0.0 22.3 6.40 5.17 3.7 55.3 23.93 13.61

The mean rates of reduction for the upper and for the lower ridge during the
follow-up periods were of the same magnitude in the two samples (Table I, Figs.
4 and 5). As also seen in Fig. 3, the mean curves for the respective maxillary and
mandibular reduction run parallel. Judging from the mean alveolar reduction in
the two samples studied, the average reduction in anterior height of the lower
ridge during a 25 year period of complete denture wear would amount to some
9 to 10 mm. and the reduction of the upper ridge to some 2.5 to 3 mm.

Individual variation in alveolar bone loss


The magnitude of alveolar resorption showed great individual variation in both
samples of denture wearers. The means and variabilities for the resorbed areas in
the anterior region of the residual ridges are given in Table II.
The anterior bone loss of the lower ridge in the nine subjects of Group A is
shown in Fig. 6. The tracings show the bony contour of the residual ridge at the
stage of insertion of the dentures, at the one-year, the seven-year, and the 13.5 year
stages of denture wearing. The marked alveolar bone loss during the first year of
denture wearing and the gradual decrease in the rate of resorption is clearly
noticeable.
Reduction of ridges in denture wearers 127

0c 0 29 Cl9 8 C32 b C4

0 c LO a c0 0 c42 0 Cl&

0 C23 c3 c 15 c7 C6 0 CL3

0 c 33 8 c Ll

5 cm
I i
Fig. 7. Individual tracings of the anterior bone loss of the lower ridge between the 10 year
and 25 year stages of complete denture wear (Group C, women). Sequence according to
magnitude of bone loss.

Regarding the shape of the individual resorption areas, each subject displayed
more or less the same resorption pattern throughout the period of denture wear.
In some subjects a “flat” pattern with mainly vertical bone loss was noted, while
other subjects displayed a more “sharp” pattern with marked horizontal bone loss.
The anterior mandibular bone loss in the 20 subjects of Group C between the
10 and 25 year stages of denture wear is shown in Fig. 7. Like the findings in
Group A, the magnitude and pattern of resorption showed great individual varia-
tion. Analysis of the relationship between the anterior mandibular bone loss and
the shape of the mandible (Figs. 8 and 9) revealed a marked positive correlation
with the P-angle (r = 0.75”“) and a marked negative correlation (-0.63”“) with
the gonial angle (RL-ML) . A p renounced mandibular bone loss thus was seen
in subjects with a marked mandibular base bend (a large p-angle and a small gonial
angle), while a less marked resorption was seen in subjects with a flattened man-
dibular base (a small P-angle and a large gonial angle) . No association was ob-
served between the mandibular bone loss and the height of the lower ridge at the
10 year stage (r = -0.01).

**Significant at the 1 per cent level.


120 Tallgren ,I. l’rosthet. Dent.
February, 1972

mm21
1

.
.

.
.
. .
.
.
. l

i I I -L -__
20 2L 26 32 degrees

MANDIBULAR SHAPE iJ3 -ANGLE)

Fig. 8. Diagram illustrating the relationship between the mandibular shape (P-angle) and the
anterior bone loss of the lower ridge between the 10 year and 25 year stages of complete
denture wear (r = 0.75**).

.
.
.
.
l
.
. . .
.
.
.
.
. . .
.
,i-----------LL
11L 116 122 126 130 13L
J
degree t5

MANDIBULAR SHAPE (RL - ML)


Fig. 9. Diagram illustrating the relationship between the gonial angle (RL-ML) and the
anterior bone loss of the lower ridge between the 10 year and 25 year stages of complete
denture wear (r = -0.63**).
V&me
Number
27
2
Reduction of ridges in denture wearers 129

P-angle 23.5’ P-angle 23.0’


RL-ML 132.5’ RL-ML 133.5’

p-angle 30.0’ P-angle 30.5-


5cm
RL-ML 116.5’ I 4 RL-ML 113.5’

Fig. 10. Tracings of four complete denture wearers (Group C) illustrating the relationship
between the mandibular shape and the anterior bone loss of the lower ridge. Subjects Nos.
C7 and C29 with a flattened mandibular base displayed small mandibular bone loss, while
subjects Nos. Cl2 and C41 with a marked mandibular base bend displayed large mandibular
bone loss. The marked difference between the mandibular and maxillary resorption is also seen.

The relationship observed between the mandibular resorption and the shape
of the mandible is further illustrated by the tracings (Fig. 10) of two subjects with
a small mandibular resorption and of two subjects with a pronounced resorption.
The marked difference between the mandibular and the maxillary bone loss is also
seen. It may be noted that subjects Nos. 7, 29, and 12 still used their original
25-year-old dentures without any corrections having been made, while for subject
No. 41 new dentures had been made at the 14 year stage of denture wearing.

DISCUSSION
The present follow-up study of two groups of complete denture wearers to the
15 year and 25 year stages of denture wear revealed a continuing reduction of the
residual ridges, particularly marked on the lower ridge. In both samples, the mean
reduction in anterior height of the lower ridge during the follow-up periods was
about four times greater than that of the upper. The same relationship between
the mandibular and maxillary reduction was previously observed at the seven-year
stage of denture wear.3, *
The difference between the jaws in alveolar reduction increased gradually dur-
130 Tallgren J. Prosthet. Dent.
February: 1972

ing the first years of denture wear. This would seem to indicate that the lower
ridge is more likely to respond to the various functional forces transmitted through
the dentures than the upper ridge. The most likely reason for this is in the smaller
area and less advantageous shape of the lower basal seat. In regard to the less
marked resorption of the upper ridge, the resistance offered by the hard palate
to the influence of the dentures on the alveolar ridge may play an important part.
The reduction of the residual ridges during the protracted wearing of dentures
was slight as compared to the rapid reduction during the first year of denture
wear. Thus, the mean rate of reduction for both the upper and lower ridge dur-
ing the follow-up periods was less than one tenth of that observed during the
initial year. Moreover, the rates for the maxillary and for the mandibular re-
duction were found to be of the same magnitude in the two samples. These findings
seem to indicate that during extended wearing of complete dentures. the rate of
anterior reduction for the residual ridges and the relationship between the maxillary
and mandibular reduction, on the average, remains fairly constant.
Regarding the variability in resorption, a few subjects in both samples dis-
played no further reduction of the upper ridge after the respective seven-year and
ten-year stages of observation, whereas the lower ridge showed a continued reduc-
tion in all subjects. The magnitude of alveolar bone loss, however> showed great
individual variation.
The marked correlations observed in the present follow-up study between the
shape of the mandible and the anterior bone loss of the lower ridge confirmed
previous findings from a seven-year study.16 A pronounced mandibular bone loss
was observed in subjects with a marked mandibular base bend and a less marked
resorption in subjects with a flattened mandibular base.
A pronounced resorption of the residual ridges related to the shape of the
mandible may be due to an interaction of various factors-anatomic, functional
and prosthetic. In regard to the load transmitted to the tissues underlying the
dentures, one factor especially to be considered is the muscular force. Attention is
drawn to electromyographic findings, in young individuals with natural teeth, of
a relationship between the mandibular shape and jaw muscular activity. In sub-
jects with a marked mandibular base bend and a small gonial angle MolleP ob-
served strong activity of the masseter and the anterior temporal muscles in the forced
closure. A similar relationship between the size of the gonial angle and the messeter
activity during chewing was observed by WitP and Ahlgren.*l A marked response
of the lower lip and mentalis muscles, observed electromyographicallyZ’ in long-
term complete denture wearers with impaired retention and stability of the lower
denture, may be considered a contributing factor with regard to the anterior man-
dibular resorption.
As pointed out by Atwood, 23 the various prosthetic factors are difficult to evaluate
due to the great number of variables included. This is especially true in a long-term
investigation like the present one. However, the findings in a previous seven-year
study= of a pronounced mandibular bone loss in subjects with a more lingual
placement of the artificial lower incisors than that of the natural teeth should be
considered. Regarding rebasing or remaking of the dentures, an interesting ob-
servation in the present study was that of the seven subjects in Group C, who had
Reduction of ridges in denture wearers 131

been using their original dentures during 25 years without any corrections, four
subjects were among the five who showed the smallest mandibular resorption in
the whole group.
With regard to the shape of the resorbed mandibular areas great variability was
observed. The individual resorption pattern, on the other band, seemed to be fairly
consistent throughout the period of denture wear.

SUMMARY AND CONCLUSIONS


This mixed-longitudinal study of edentulous individuals covering 25 years of
complete denture wearing revealed a continued reduction of the residual ridges
throughout the observation period.
The reduction of the lower ridge was particularly marked, the mean reduction
in anterior ridge height being approximately four times as great as that of the
upper ridge.
The magnitude and pattern of alveolar bone loss showed great individual
variation.
Correlations between the shape of the mandible and the anterior mandibular
bone loss indicated a pronounced resorption in subjects with a marked mandibular
base bend, and a less marked resorption in subjects with a flattened mandibular
base. These findings suggest that careful examination of the mandibular shape can
provide valuable information on the response of the residual ridges to the wearing
of dentures.
Regarding the clinical consequences of the alveolar bone loss it should be
emphasized that by regular control and prosthetic measures marked instability
of the dentures and undesirable changes in jaw and occlusal relationships can
be prevented. As the rate of resorption is most rapid during the first year of denture
wear, regular control during the first year and thereafter at least once a year is ad-
visable.
However, with the continuing resorption over years, the prosthetic replacement
of the lost tissues will give rise to increasing treatment problems and may cause
the patient extreme difficulties in management of the dentures.
The continuing resorption, especially of the lower ridge, therefore, constitutes
a serious prosthodontic problem.

References
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and Prosthetic Treatment; A Roentgen Cephalometric Study Mainly on Finnish Women,
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.I. Prosthet. Dent.
132 Tallgren Felmary, 1972

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Covering 5 Years, Odontol. Revy 18: 27-54, 1967.
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Acta Odont. Stand. 28: 251-270, 1970.
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metric Investigation on Scandinavian Adults, Acta Psychiat. (Copenhagen) Suppl. 86,
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18. BjBrk, A., and Solow, B.: Measurement on Radiographs, J. Dent. Res. 41: 672-683, 1962.
19. Moller, E.: The Chewing Apparatus; An Electromyographic Study of the Action of the
Muscles of Mastication and Its Correlation to Facial Morphology, Acta Physiol. Stand.
69: Suppl. 280, pp. l-229, 1966.
20. Witt, E.: Kieferwinkel und Kaumuskulatur, Fortschr. Kieferorthop. 24: 295-300, 1963.
21. Ahlgren, J.: Mechanism of Mastication; A Quantitative Cinematographic and Electro-
myographic Study of Masticatory Movements in Children, With Special Reference to
Occlusion of the Teeth, Acta Odont. Stand. 24: Suppl. 44, I-109, 1966.
22. Tallgren, A.: An Electromyographic Study of the Behaviour of Certain Facial and Jaw
Muscles in Long-Term Complete Denture Wearers, Odontol. Tidskr. 71: 425-444, 1963.
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J. PROSTHET. DENT. 12: 441-450, 1962.

INSTITUTE OF ORTHODONTICS
THE ROYAL DENTAL COLLEGE
JAGTVEJ 160
2100 COPENHAGEN, DENMARK

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