Original article

Responses of jawbone to pressure*

Gunnar E. Carlsson
Faculty of Odontology, Go teborg University, Go teborg, Sweden

Gerodontology 2004; 21; 6570 Responses of jawbone to pressure Objective: To provide a literature review of bone resorption of edentulous jaws focusing on responses to pressure. Background: After the extraction of all teeth in a jaw there is a continuous reduction of the residual ridge. The individual variation of bone resorption is great, and the aetiology is complex and not yet well understood. Materials and methods: A search of the literature published up to May 2003 on bone resorption and pressure was performed using PubMed/Medline. Results: Animal studies have demonstrated that excessive and constant pressure induces bone resorption. Recent experimental research has indicated that bone resorption is a pressure-regulated phenomenon with a lower threshold for continuous than for intermittent pressure. Clinical studies have suggested that residual ridge resorption is due more to the effects of denture wearing than to disuse atrophy. However, the results of leaving out dentures at night are not conclusive. Nor does the literature offer any strong evidence for the so-called combination syndrome, which has been described as a result of unfavourable loading. Clinical studies using multivariate analyses indicate that female gender and systemic factors may be of greater importance than oral and denture factors. Implant-supported prostheses have a bone preserving effect rather than the continuing resorption under complete dentures. Conclusions: The best way to reduce bone resorption is to avoid total extraction, preserve a few teeth and fabricate overdentures. In edentulous jaws, placement of implant-supported prostheses will lead to less bone loss and may even promote bone growth. To increase our knowledge of residual ridge resorption extended experimental, clinical and statistical methods will be needed, preferably including collaboration between dental and medical researchers. Keywords: resorption, edentulous, dentures, bone. Accepted 8 December 2003

Introduction
Residual ridge resorption
The continuous reduction of residual ridges in edentulous subjects has been called a major oral
*This paper was presented at the Gerodontology Symposium entitled Micro and macro changes in oral mucosa and jawbone supporting dental prostheses in frail elders (Organizer MI MacEntee) at the IADR, Gothenburg, Sweden in June 2003, sponsored by the Geriatric Oral Research Group, Prosthodontic Research Group, Craniofacial biology Research Group, and the Oral Medicine and Pathology Research Group, of the International Association of Dental Research. Financial support was provided by Dentsply International Trubyte Division.
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disease entity1. It appears to be a process encountered in all complete denture wearers. Albeit there is considerable interindividual variation in the rate of bone loss after tooth extraction and the wearing of complete dentures, residual ridge resorption may proceed throughout the lifetime of the denture wearer2,3. The causes of the high individual variations are not well understood4. More than a quarter century ago, 63 different factors that could possibly be related to bone resorption under removable dentures were listed in a 5-year study of mandibular ridge resorption5. No single dominant factor to explain the variability of bone loss was found (it should be acknowledged that, as usual at that time, the analysis did not include multivariate statistics). Even today, at the beginning of the new millennium, it is admitted that little is known about
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which factors are most important for the observed variations in residual ridge resorption6. A conclusion of the large number of available studies is that a single dominant factor for residual ridge resorption will not be found. Factors considered of possible importance and often used in correlation analyses are, e.g. gender, age, facial morphology, duration of edentulousness, denture wearing habits, number of dentures worn, oral hygiene, oral parafunctions, occlusal loading, denture quality, nutrition, general health, medication, systemic diseases, and osteoporosis. The results of such analyses have not been conclusive. Some studies have reported statistically signicant correlations between residual ridge resorption and some of these factors; others have failed to corroborate the ndings4. The aetiology of residual ridge resorption is complex and it must be acknowledged that the high individual variation usually cannot be fully explained. In the following, the focus will be on the inuence of pressure on the jawbone according to a review of the literature.

threshold-regulated phenomenon with a lower threshold for continuous than for intermittent pressure.

Clinical studies
Prosthodontic factors. In early prosthodontic texts, disuse atrophy of edentulous jaws was often suggested to be of signicant importance, implying that good-quality dentures should prevent residual ridge resorption whereas lack of dentures would lead to increased bone loss. This concept was questioned already in the 1960s when studies showed that denture-wearing jaws lost more bone than those without dentures11,12. According to this opinion, leaving out the dentures at night might reduce bone resorption. Less bone loss was also found in those who took out the dentures at night compared with those who wore the dentures day and night13. However, this result has not been corroborated in other studies14,15. Such non-conclusive results are often seen in the literature on denture-related bone resorption. Probable explanations are, among other things, the enormous individual variation in the rate of bone loss reported in many studies. This great variation makes size and selection of samples critical for establishing comparable results. Although most authors agree today that the residual ridge resorption is more related to using than not using dentures, the effect probably varies with the quality and function the dentures. The disuse atrophy concept has not been entirely abandoned as seen in a recent paper suggesting that dentures do not give adequate functional stimulation to the bone which may be as important or more important than pressure via the denture6. Trauma to the denture-wearing tissues may be caused by many factors such as defective occlusion, poor t of the dentures, and unfavourable loading. Most of these early reports gave no strong evidence as they were more often of an anecdotal character than based on systematic studies. An extensive literature review on occlusal considerations in complete dentures concluded that occlusal characteristics play only a minor role in determining success or failure of a denture treatment16. Even though not focusing on bone resorption, this review indicates that systematic studies would most probably have difculties to show signicant effects of occlusal variation (e.g. tooth form, tooth arrangement, occlusal scheme) on residual ridge resorption. A series of studies reporting the outcome of two different techniques for fabricating complete dentures, a complex and a simplied method, found no signicant differences between the randomly
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Bone resorption and pressure

Animal studies
It is well established by a number of animal studies that excessive and constant pressure gives rise to bone resorption7,8. In fact, in May 2003, PubMed/ Medline gave 207 references on bone resorption/ pressure/animal, most of which however were related to the orthopaedic literature. In a study using experimental dentures to load continuous pressure to the palate of the molar region of rats it was demonstrated that the lowest pressure (1.5 kPa) did not cause bone resorption, whereas when higher pressure was used (3.4 and 4.9 kPa) bone resorption was observed9. This prompted a series of studies by the same group of researchers at the Okayama University Dental School. One of these investigations10 aimed at elucidating whether osteoclastic bone resorption is a pressure-threshold regulated or merely a proportionally pressuredependent phenomenon. The experimental dentures exerted a dened amount of continuous or intermittent compressive pressure on the rat hard palate. No bone resorption was observed when the continuous pressure was 1.96 kPa or when the intermittent pressure was 9.8 kPa. Higher pressure continuous pressure 6.86 kPa, intermittent pressure 9.6 kPa caused signicant bone resorption in all rats studied. It was concluded that osteoclastic bone resorption was a pressure-

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divided groups regarding short- and long-term changes, including residual ridge resorption17. Combination syndrome. The so-called combination syndrome can be mentioned as an example of lack of unequivocal results regarding unfavourable loading. According to this concept, a patient who wears a maxillary complete denture and has a reduced mandibular dentition with only anterior teeth (or a mandibular overdenture on anterior natural teeth or implants) runs the risk, among others, of an increased bone loss in the maxillary anterior ridge. The term was rst used by Kelly18, and has been accepted in the prosthodontic literature. The Glossary of Prosthodontic Terms19 denes combination syndrome as the characteristic features that occur when an edentulous maxilla is opposed by natural mandibular anterior teeth, including loss of bone from the anterior portion of the maxillary ridge, overgrowth of the tuberosities, papillary hyperplasia of the hard palatal mucosa, extrusion of mandibular anterior teeth, and loss of alveolar bone and ridge height beneath the mandibular removable partial denture bases, also called anterior hyperfunction syndrome. Although the combination syndrome concept has been supported over the years by several anecdotal observations reported in the literature and by the clinical experience of many prosthodontists, there is a surprising lack of evidence for this opinion in systematic studies. It is obvious that the combination syndrome does not occur in all patients. In a Belgian study, patients had suffered an even greater mean bone loss in the maxilla in the group with mandibular complete dentures than in those with implant-supported overdentures or xed prostheses20. A critical review of the related literature recently concluded21: Bone resorption of the anterior part of the edentulous maxilla in association with remaining anterior mandibular teeth has been the subject of a limited number of studies of acceptable quality but the results have not been conclusive. No epidemiological study of the various features related to combination syndrome has been published. There is no evidence that a mandibular removable partial denture can prevent the development of the events described. Based on this review of the literature it may therefore be concluded that the combination syndrome does not meet the criteria to be accepted as a medical syndrome. The single features associated with the combination
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syndrome exist but to what extent or in which combinations has not been claried. The idea of an increased risk for residual ridge resorption in the maxilla opposing anterior mandibular teeth is however not abandoned by all clinicians. A recent study reported the expected great individual variation in bone loss but a relatively higher resorption in the anterior than in the posterior part of the maxilla in edentulous patients provided with a mandibular two-implant overdenture22. Other factors. Multivariate analyses related to residual ridge resorption are still rare and those presented have not emphasised the importance of occlusal loading. In a study applying such statistics, female gender and systemic factors seemed to be of greater importance than oral and denture factors, especially in the mandible23. It was also found that asthma was a signicant risk factor for severe residual ridge resorption, the mechanism probably being the corticosteroid treatment of the asthmatic patients. On the other hand, alcohol intake was correlated to a lesser degree of maxillary residual ridge resorption. In another Finnish investigation24 analysing the effects of uoridated drinking water and oestrogen therapy on residual ridge resorption, it was found that those who had used uoridated water for long periods of time (>10 years) had higher ridges than those who had used uoridated water for shorter periods. The results from studies of patients undergoing hormone replacement therapy were inconclusive. These researchers concluded, based on this and other studies, that systemic factors control the nal stage of residual ridge resorption, while local factors (surgical method, healing capacity, bite force, etc.) dominate the rst phase after extraction. Age and gender. The literature regarding the inuence of age and gender is not conclusive. In crosssectional studies, elderly people show on average more resorbed ridges than younger individuals, but this may often be related to the longer period of edentulism in the elderly. In prospective studies, age has not proven to be of signicant importance when confounding factors such as length of edentulism and osteoporosis were controlled4,13,25. Osteoporosis. Numerous studies have focused on the relationship between osteoporosis and bone resorption, published especially in the medical literature. A review concerning dental investigations26 concluded that osteoporosis of the jaws may involve

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the risk of minor accentuation of bone loss in complete denture wearers, in subjects with periodontitis, and in peri-implant areas. However, since implant supported prostheses conserve bone because of their positive load-related effect on the jaw they can be recommended also in osteoporotic patients.

Management of bone resorption

The consequences of residual ridge resorption are obvious, sometimes less so for the patient, though, than for the prosthodontist, who encounters increasing problems in the fabrication of wellfunctioning complete dentures. Many prosthodontic and surgical treatments have been attempted in cases of severe residual ridge resorption, but none has been completely predictable. There is no strong evidence to support the recommendation to leave out the dentures at night. Although it may seem logical to let the denture-supporting tissues rest at night, the psychosocial implications are too negative for many individuals. The best treatment is to avoid total tooth extraction, preserve a few teeth and make overdentures, which are associated with much lower rates of bone resorption32,33. The placement of dental implants and the insertion of an implant-supported prosthesis have been shown to substantially reduce bone loss in the edentulous jaw, and with xed restorations even promoting bone growth, indicating the importance of altered functional stimulus to the bone tissue6,2931.

Bone resorption and dental implants

The placement of dental implants and the insertion of an implant-supported prosthesis in edentulous mandibles have been shown to substantially reduce bone loss in comparison to that in denture-wearing jaws. The explanations have focused on the different stress distributions to the bone through a denture or through anteriorly placed implants. The results have been interpreted as an evidence of more adequate functional stimulus to the bone tissue with implantsupported xed prostheses27,28. Several more recent studies have reported that patients with such xed prostheses demonstrated bone apposition and enhanced the bone of the posterior portion of the mandible6,2931. This interesting nding suggests that the bone preserving effect of a xed implantsupported prosthesis vs. the continuing resorption with a complete denture should be included in the decision making for the edentulous mandible. In this context, it should also be emphasised that implant success does not seem to depend on age, even among elders above 80 years of age25.

Conclusions
The aetiology of jawbone resorption is still not fully understood. The best explanation that can be offered today is that combinations of anatomical, metabolic, psychosocial, mechanical and, most probably, also unknown or yet-to-be-analysed factors are of importance for residual ridge resorption. However, an excellent method to avoid jawbone resorption exists: improved preventive dental cares to get people keep their natural teeth and avoid total extraction. In edentulous jaws, the insertion of implant-supported prosthesis can reduce bone loss and may even promote bone growth. New knowledge of the aetiology of residual ridge resorption may emerge when multivariate statistical analyses are applied to research data, and new methods and previously unanalysed variables are included. Collaboration between dental and medical researchers would seem recommendable for further progress in this eld.

Research methods
A variety of scientic methods has been used in studies of bone resorption, both in animal experimentation and human clinical investigations. Animal studies have usually used rats and some pressure-inducing device or orthodontic forces. Evaluations of bone changes have been done with histomorphometry, histochemistry and other micromorphological or biochemical methods. In human studies of residual ridge resorption, radiographic methods have predominated, previously cephalometry, at present more often panoramic radiography. Measurements of cast of the jaws were often used in earlier studies but seem to have been abandoned because of orientation problems. Bone mineral content and density (BMC/BMD) can be measured by specially constructed jawbone scanners. They have been used for studying jaw osteoporosis but may be relevant for analysis of bone response to different types of prosthodontic treatment.

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Correspondence to: Professor Gunnar E Carlsson, Faculty of Odontology, University of Go teborg, PO Box 450, SE40530 Go teborg, Sweden. E-mail: g_carlsson@odontologi.gu.se

2004 The Gerodontology Association, Gerodontology 2004; 21: 6570