Vol 10, No 3, 2012 259

ORIGINAL ARTICLE
T
he major objective of any prosthetic rehabilita-
tion is to preserve remaining natural teeth and
tissues, which includes residual ridge preservation
in the fabrication of the complete dental prosthe-
sis. The measures taken by the prosthodontist in
reducing the forces transmitted to the residual al-
veolar ridge are the use of the selective pressure
impression technique, incorporation of compensa-
tory curves, achievement of balanced occlusion,
periodic check-ups, relining and rebasing if and
when required, making new dentures if necessary
and using of soft reliners. However, still the well-
documented fact remains that once the teeth are
lost, there is a continuous, irreversible process of
residual ridge resorption, and it becomes diffcult to
retain and stabilise complete dentures (Klemetti,
1996).
Submergence of Vital Roots for the Preservation
of Residual Ridge: A Clinical Study
Anil Sharma
a
/Sukhvinder Singh Oberoi
b
/Sudhanshu Saxena
c
Purpose: To test the value of submerging vital roots for the preservation of the residual ridge.
Materials and Methods: The study sample consisted of 10 patients whose bone height on both submerged and control
sites was measured with the help of OPG tracings and the use of grids, from the immediate post-operative period to 3
months, 6 months and 9 months post-operatively. Statistical analysis was performed using the t-test and one-way ANOVA.
Results: The amount of bone loss was signifcantly greater in the control area in comparison to the submerged area from
the immediate post-operative period to 3 months, 6 months and 9 months post-operatively.
Conclusion: Although the retained roots do not prevent the resorption of residual ridge, they aid in decreasing the resorp-
tive pattern, thereby preserving the residual ridge to some extent. This may be an expedient and inexpensive way to
preserve residual ridge, requiring minimal specialised training.
Key words: prosthetic factors, residual ridge, surgical technique, vital roots
Oral Health Prev Dent 2012;10: 259-265 Submitted for publication: 04.03.11; accepted for publication: 08.06.11
a
Professor and Head, Department of Prosthodontics, I.T.S Dental
College, Hospital and Research Centre, Greater Noida, India.
b
Senior Resident, Department of Public Health Dentistry, Maulana
Azad Institute of Dental Sciences, New Delhi, India.
c
Senior Lecturer, Department of Public Health Dentistry, Peoples
Dental College and Hospital, Bhopal, India.
Correspondence: Professor Anil Sharma, Department of Prosthodon-
tics, I.T.S Dental College, Hospital and Research Centre, Greater Noi-
da, India. Tel: +91-098-1120-6062. Email: drsharmaanil@gmail.com
In recent years, the dental profession has ex-
tended the concept of preventive dentistry in re-
movable prosthodontics by the use of overden-
tures. This method of treatment preserves the
residual ridge by retaining periodontically compro-
mised teeth which, although they cannot be used
as removable partial denture (RPD)/ fxed dental
prosthesis (FDP) abutments, are reduced to obtain
a satisfactory crown-root ratio to support remova-
ble dentures (Brewer, 1975).
Fractured roots and retained root studies were
probably the genesis for the submerged root con-
cept (Johnson and Jensen, 1997; Rodd et al,
2002). Various studies of roots remaining after in-
complete exodontia showed that nearly all such
roots remained vital and asymptomatic (Simpson,
1959; Herd, 1973; Glickman, 1974).
Clinical reports suggest that vital root retention
may be an alternative method to conventional over-
denture and implant treatment, one which also ap-
pears to retard the resorption of residual ridge
(Mead, 1929; Graver et al, 1978; Graver et al,
1979; Dravid, 1980; Graver and Muir, 1983;
Hughes et al, 1991). By maintaining the natural
tooth root, a greater amount of surrounding tissue
may also be preserved. Thus, the root submer-
gence technique also maintains the natural attach-
Sharma et al
260 Oral Health & Preventive Dentistry
ment apparatus of the tooth at the pontic site,
which in turn allows for complete preservation of
the alveolar bone frame and assists in creation of
an esthetic result (Marinello and Potashnick, 1994;
Salama et al, 2007). Other studies have shown
that roots which are endodontically treated and
submerged are also acceptable (Howell, 1970; Wal-
lace et al, 1994; Harper, 2002; Hiremath et al,
2010), but this entails extra expense for the pa-
tient and more clinical time than vital root submer-
gence, which is a simple clinical procedure that can
be carried out by an average dental surgeon in his/
her own clinic (Fareed, 1989).
The overall purpose of this study was to test the
value of submerging vital roots for the preservation
of residual ridges. This was accomplished by meas-
uring the amount of bone height in the submerged
and control sites and comparing the amount of
bone loss from the immediate post-operative period
to 3 months, 3-6 months, 6-9 months and the total
amount of bone loss after 9 months.
MATERIALS AND METHODS
This study was done at the K.L.E. Societys Insti-
tute of Dental Sciences, Belgaum, Karnataka, In-
dia. The study sample consisted of 10 patients,
seven males and three females, with an age range
of 4060 years.
The study was performed by a single investigator.
The intra-examiner reliability was calculated by du-
plicate measurements and was found to be 87%.
For the uniform interpretation of the results, the av-
erage of the 2 measurements was taken.
There was one root per patient for control and
submerged sites, except for one patient who had 2
roots, so that the fnal data analysed consisted of
11 readings. The proposed treatment procedures
including possible complications were explained
and discussed with each patient. Informed written
consent was obtained from each patient before
starting the study.
Inclusion criteria
Patients were included if they: were scheduled to
receive complete dentures (maxillary and mandibu-
lar), having isolated natural teeth between the 2nd
premolars on either side; were partially edentulous
with teeth recommended for extraction which were
not suitable for use as FDP or RPD abutments, but
suitable for the proposed vital root retention; lacked
signifcant medical problems that may have compli-
cated the surgical procedure or interfered with the
post operative management.
The inclusion criteria for teeth were as follows:
no more than 1 mm horizontal mobility; periosteum
lacking infrabony pockets which could not be treat-
ed or reduced; suffcient healthy mucocogingival
tissue present for fnal closure of the surgical site;
supporting alveolar bone equal to approximately
one-third of the length of the total root length; car-
ies free and asymptomatic.
Study design
A split-mouth design was chosen one of the sides
with a retained root stump was taken as the sub-
merged site, and the contralateral side where the
root stump was removed was chosen as the control
site. On the submerged side, the roots were sub-
merged by raising the faps, and on the control side,
the roots were extracted as a part of the study.
Thus, the control site became edentulous because
of the extraction of the root stump.
Surgical procedure
Each patient was pre-medicated with oral antibiot-
ics one day before the surgical procedure and con-
tinued for 4 days (Cap. Amoxycillin, 500 mg, 3
times a day for 5 days). The patient was scrubbed
and pre-procedural hexidine mouthwash was given
to decrease the oral bacterial fora. Local anaesthe-
sia was administered to the patient, and an internal
bevel incision was made apical to the free gingival
margin and was directed to an area at or near the
crest of alveolar bone.
A buccal fap was elevated and subgingival calcu-
lus and granulomatous tissue were removed with a
spoon excavator. Using a straight diamond bur (No.
0.081), the selected teeth were sectioned horizon-
tally at the residual bone level. The confrmation of
pulp vitality was made by observing bleeding from
the pulp chamber.
Subsequently, using a large round diamond bur
(No. 0.010), the roots were ground 24 mm below
the residual ridge level and then fattened by a large
inverted cone bur (No. 0.006). All sectioning and
rounding procedures were carried out under con-
stant irrigation with physiological saline.
Sharma et al
Vol 10, No 3, 2012 261
The sharp bony margins were smoothed with the
help of a bone fle. A periosteal releasing incison
was made at the depth of the vestibule and the fap
was advanced towards the lingual mucoperiostium.
The incison line was closed with 3.0 black silk su-
ture in a horizontal mattress.
Post-operatively, the patients were asked to con-
tinue with the antibiotics for four days and take an-
algesic antinfammatory drugs as needed. The pa-
tients were also advised to take B-complex capsules
and use hexidine mouthwash for 4 weeks post-op-
eratively. Patients were recalled after 24 h for a
check-up, the sutures were removed after 1 week
and the impressions were made for complete den-
tures after 8 weeks.
Denture technique
The prosthetic management of the patients in-
volved fabrication of the denture in a step-wise
manner using the standardised procedure to en-
sure a successful prosthesis. The denture was fab-
ricated 8 weeks after the submergence of roots on
the submerged site and extraction of the root
stumps on the control site.
Measurements
The technique for taking orthopantomogrammes
(OPG) was standardised. The OPGs were taken
using the standard equipment with the standard ex-
posure and standard exposure time. A grid was
placed over the tracings and stabilised with the
help of pins in the same position every time. Sub-
sequently, tracings were done.
The measurements of the bone height on the
submerged side and its contralateral (control) side
were made immediately post-operatively, and was
followed-up every 3 months until the last appoint-
ment at 9 months. The measurements were made
from the crest of the ridge to the inferior border of
the mandible in the lower arch and from the crest of
the ridge to the foor of nasal cavity in the upper
arch.
These reference points for measuring bone
height were taken because in an average patient
with no major medical problems, the compact bone
does not undergo any major changes. If there was
more than one root on the same side, then meas-
urements over each submerged root were made
and were divided by the number of submerged roots
to give a mean bone height of the submerged area.
Similarly, measurements of the control side were
taken after the extraction of the teeth, so that the
control side was edentulous. The bone loss was
calculated from the immediate post-operative
period to 3 months, 36 months, 69 months, as
well as the immediate post-operative period to 6
months and the immediate post-operative period to
9 months.
Statistical analysis
Statistical analysis was performed using the SPSS
software version 16.0 and the mean bone height
per person per root was calculated. The t-test was
used to compare mean bone loss between the con-
trol and submerged groups at different time inter-
vals, and one-way ANOVA was used for comparison
at various intervals within the control and sub-
merged groups.
RESULTS
Table 1 depicts the bone height (in mm) of the indi-
vidual patients in detail along with the site. The
overall bone height of the submerged and control
area immediately post-operatively, at 3 months, 6
months and 9 months post-operatively showed no
signifcant difference at any of the intervals
(P > 0.05) (Table 2).
The difference in the amount of bone loss be-
tween the submerged and control area from the im-
mediate post-operative period to 3 months, 6
months and 9 months post-operatively was com-
pared using the unpaired t-test. There was signif-
cantly more bone loss in the control area in com-
parison to the submerged area from the immediate
post-operative period to 3 months, 6 months and 9
months post-operatively (P < 0.05) (Table 3).
The comparison of differences in the amount of
bone loss between the submerged and control are-
as from the immediate post-operative period to 3, 6
and 9 months post-operatively was done using one-
way ANOVA test. There was a signifcant difference
in the amount of bone lost from the immediate
post-operative period to 3 months, 6 months and 9
months post-operatively among both the submerged
and control areas (P < 0.05). (Table 4, Fig 1).
Additionally, comparison within the submerged
and control area at different intervals was done
using the Tukey HSD post-hoc test. In the sub-
Sharma et al
262 Oral Health & Preventive Dentistry
merged area, there was a signifcant difference in
the amount of bone lost from the immediate post-
operative period to 3 months and 6 months post-
operatively (P < 0.05), but there was no signifcant
difference from 3 months to 6 months post-opera-
tively (P > 0.05). In the control group, there was a
signifcant difference in the amount of bone lost
from the immediate post-operative period to 3
months and 6 months post-operatively as well as
from 3 months post-operatively to 6 months post-
operatively (P < 0.05) (Table 4, Fig 1).
The difference in the amount of bone lost from 3
to 6 months and 6 to 9 months among submerged
and control area was compared using the unpaired
t-test. There was signifcantly greater bone loss in
the control area in comparison to the submerged
area from 3 to 6 months and 6 to 9 months post-
operatively (P < 0.05) (Table 5).
Table 3 Comparison of the difference in the amount of
bone lost in submerged and control area
Groups
Mean bone
loss (mm)
P-value
Immediately
post-operatively
to 3 months
Submerged 0.70.4
0.109
Control 1.10.7
Immediately
post-operatively
to 6 months
Submerged 1.50.6
0.013*
Control 2.30.7
Immediately
post-operatively
to 9 months
Submerged 2.10.7
0.001*
Control 3.30.8
* The mean difference is signifcant at the 0.05 level.
Table 2 Mean bone height of submerged and control
area
Groups
Mean bone
loss (mm)
P-value
Immediately
post-operatively
Submerged 27.98.0
0.858
Control 27.47.3
At 3 months
Submerged 27.38.0
0.769
Control 26.37.4
At 6 months
Submerged 26.47.9
0.682
Control 25.17.1
At 9 months
Submerged 25.97.8
0.572
Control 24.17.0
Table 1 Description of bone height of submerged and control area of the individual samples
Patient
Roots
submerged Submerged area (mm) Control area (mm)
Immediately
post-
operatively
3
months
6
months
9
months
Immediately
post-
operatively
3
months
6
months
9
months
1 11,12,13 18 17.6 17 17 18 17 16 15.5
2 33, 34, 35 35 34.6 33.6 33 34 33.5 32 31
3a 22, 23 24 23 22 21 23 21 20.5 19
3b 43, 45 34 33 31.5 31 31 29 27.5 27
4 33 31 31 30.5 29 31 30.5 29 27
5 34, 35 31.5 30.5 29.5 29 31 30 28.5 27
6 34, 35 41 40 39 38.5 40 38.5 37 36
7 34 32 31.5 31 31 31 30.5 29.5 29
8 33, 34, 35 26 25 24.5 24 25 24.5 23.5 22
9 23, 25 16 15 14.5 14 17 16.5 15.5 14.5
10 21, 22, 23 19 18.5 17.5 17 20 18 17 16.5
Sharma et al
Vol 10, No 3, 2012 263
Table 4 Difference in the mean amount of bone lost
among the submerged and control areas from immedi-
ately post-operatively to 3, 6 and 9 months
Intervals
Mean bone loss (mm)
Submerged area Control area
Immediately
post-operatively
to 3 months
0.70.4 1.10.7
Immediately
post-operatively
to 6 months
1.50.6 2.30.7
Immediately
post-operatively
to 9 months
2.10.7 3.30.8
ANOVA 17.842 27.824
P-value 0.000* 0.000*
Tukey post-hoc
HSD test
2>1 2>1
3>1 3>1,2
* The mean difference is signifcant at the 0.05 level.
Table 5 Difference in the amount of bone lost from 3 to
6 months and 6 to 9 months in submerged and control
area (in mm)
Mean (mm) P-value
From 3 to
6 months
Submerged area 0.80.3
0.013*
Control area 1.20.3
From 6 to
9 months
Submerged area 0.50.3
0.001*
Control area 1.10.5
* The mean difference is signifcant at the 0.05 level.
Fig 1Difference in the amount of bone lost between the submerged and control areas from immediately post-operatively to
3, 6 and 9 months (in mm).
Submerged Control Submerged Control Submerged Control
Immediately postoperative Immediately postoperative Immediately postoperative
to 3 months to 5 months to 9 months
M
e
a
n

B
o
n
e

L
o
s
s

(
i
n

m
m
)
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0
0.71
1.09
1.54
2.27
2.09
3.32
Sharma et al
264 Oral Health & Preventive Dentistry
DISCUSSION
For years, it has been axiomatic that all retained
roots should be removed since all were considered
to be pathological (Mead, 1929; Mead, 1954).
However, many patients have been found to have
retained roots where no clinical or radiographic ab-
normality is present. In fact, it is an interesting ob-
servation that in those patients in whom either the
roots were accidently left inside the bone due to
incomplete exodontias or purposely retained, the
resorption of alveolar bone around the roots is not
only decreased, but led to the formation of new
bone over the roots (Ground 1978a and b; von
Wowern and Winther, 1981).
A signifcant difference was seen in bone loss
between submerged and control sides, with more
bone loss over the control side, which may also be
attributed to the irregular edges of the bone left
after extraction. These edges are rounded off by
external resorption, leaving a high, well-rounded
ridge as compared to the submerged area, where
the alveolar bone is supported by the tooth roots
and has smooth bony margins, decreasing the re-
sorption in this area.
In general, the rate of reduction of the residual
ridge varies between different individuals and is
usually more rapid in the frst 6 months following
extraction. It was also seen that from 6 to 9 months,
the bone resorption continued in both the sub-
merged and control areas, but was greater on the
control side (1.05 0.52 mm) than on the sub-
merged side (0.45 0.27 mm). The total amount
of bone lost from the immediate post-operative
period to 9 months was greater on the control side
(3.32 0.75 mm) than on the submerged side
(2.09 0.66 mm). This shows that the reduction
of the residual ridge is chronic, progressive, irre-
versible and cumulative.
We observed a decrease in residual ridge resorp-
tion on the submerged side, which may be attribut-
ed to the presence of roots within the alveoli, which
continuously provide a physiological stimulus to the
bone. This resulted in a decrease in resorption as
compared to control side, where there is no physi-
ological stimulus to the bone due to absence of
roots. This decrease in the rate of resorption of the
residual ridge may also be due to the difference in
distribution of forces over the submerged and the
control sides.
However, there are certain problems related to
vital root submergence which should be addressed.
Murry and Adkins (1979) have suggested dividing
the post-operative clinical problems of vital root
submergence into two categories: problems related
to the surgical technique and problems related to
prosthetic factors. The surgical complications can
be due to improper surgical techniques, improper
sterilisation, use of insuffcient coolant, incomplete
debridement of the surgical site, failure to achieve
complete closure over submerged roots, incom-
plete removal of the crevicular epithelium or im-
proper rounding of the bony margins.
Longitudinal cephalometric studies have provid-
ed excellent visualisation of the gross pattern of
bone loss (Tallgren 1970; Weinmann and Sicher,
1955). The superimposition of the tracings of ceph-
alograms made in such studies clearly shows that
the reduction of the ridge occurs labially on the
crest and lingually. The rate of reduction and the
total amount of bone vary from individual to indi-
vidual, within the same individual at different times
and even at the same time in different parts of the
ridge. Similarly, there may be many anatomic, bio-
logical and metabolic factors that may also effect
reduction of the residual ridge (Weinmann and Si-
cher, 1955; Ortman, 1962). These changes are in
accordance with Wolffs law, which states that eve-
ry change in the function of the bone is followed by
defnite changes in internal architecture and exter-
nal shape (Wolff, 1892).
Craddock states that resorption of bone follow-
ing tooth extraction takes place in two phases. The
early resorption is part of the healing process and
takes place very rapidly. The second phase is the
inevitable resorption that goes on indefnitely (Crad-
dock, 1951). Thus, the retained roots do not pre-
vent the resorption of the residual ridge, but rather
aid in decreasing the resorptive pattern, thereby
preserving the residual ridge to some extent.
This may be an expedient and inexpensive way to
preserve the residual ridge, requiring minimal spe-
cialised training. Since both objective and subjective
fndings clearly indicate the signifcant benefts of
tooth root retention, even the extraction of the few
remaining natural teeth should be considered a seri-
ous decision. It enabled us to observe a sequence
of treatment for a number of otherwise condemned
teeth (Masterson, 1979; Graver and Fenster, 1980).
CONCLUSION
The success of submerged roots in preventing the
resorption of the residual ridge was dependent
upon proper surgical procedure, which leads to the
Sharma et al
Vol 10, No 3, 2012 265
proper closure of mucosa over the retained roots.
Problems related to prosthetic factors were over-
come by simply reducing the localised pressure
over the submerged roots.
Although residual ridge resorption is an irrevers-
ible process, the resorption can be minimised or
reduced with the help of vital root retention, which
aids in preserving the residual ridge to some extent
and is obviously preferable to the totally edentulous
ridge.
Further research work and detailed studies are
required in this feld to delineate the proper mecha-
nism and ways of preserving the residual ridge, as
well as to determine the effect of the submerged
root in preventing the residual ridge resorption.
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