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Review Article
Residual ridge resorption: A major
oral disease entity in relation to
bone density
Opinder Pal Singh, Ravneet Kaur1, Sonia Madaan Nanda2, Eish Sethi3
Department of Prosthodontics and Crown and Bridge, National Dental College and Hospital, Gulabgarh,
Dera Bassi, 3Department of Oral and Maxillofacial Surgery, Desh Bhagat Dental College, Muktsar, Punjab,
1
Department of Prosthodontics and Crown and Bridge, Bhojia Dental College, Baddi, Himachal Pradesh,
2
Department of Prosthodontics and Crown and Bridge, PGIDS, Rohtak, Haryana, India

ABSTRACT
Residual ridge resorption (RRR) is a common and often incapacitating problem, particularly
for persons with edentulous mandible. Reduction of residual ridges needs to be recognized
for what it is: A major unsolved oral disease that causes physical, psychologic, and economic
problems for millions of people all over the world. RRR is a chronic, progressive, irreversible,
and disabling disease, probably of multifactorial origin. Most resorption occurs in the alveolar
process, whereas the basal portion remains relatively intact. At present, the relative importance
of various cofactors is not known. Not only does the volume of the ridge decrease, but also the
density of the basal portion decreases as a result of the diminished function. After the age of
40 years, the bone mineral density of the skeleton decreases, so that by the age of 65 years
approximately one‑third of the bone minerals have been lost. This article reviews the literature
on RRR and components that may affect the rate of resorption. The following article presents
information from English peer‑reviewed journals identified by a Medline search covering the
years from 1960 to 2010 and attempts to integrate information available in the dental literature.

Key words: Bone mineral density, edentulous alveolar ridge, residual bone, resorption

Introduction by the blood clot. Epithelial tissue began

Address for correspondence:
Dr. Opinder Pal Singh,
Department of Prosthodontics and
Crown and Bridge, National Dental
College and Hospital, Gulabgarh,
Dera Bassi, Punjab, India.
E‑mail: opinderbhalla@gmail.com
Date of Submission: 18‑06‑2015
Date of Acceptance: 23‑09‑2015
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.176383
Quick Response Code:
Edentulous alveolar ridge is the portion
of the residual bone and its soft tissue
covering that remains after the removal of
teeth.[1] It consists of the denture‑bearing
mucosa, submucosa, periosteum, and
the underlying residual alveolar bone.
The residual ridges are formed after
the extraction of teeth by cortical and
trabecular bone, connective tissue, and
covering epithelium. The edentulous arch
is a vital structure present during the
entire life of the patient, regardless of
tooth presence or function.[2] This often
leads to a situation where there is no
longer sufficient support for the proper
functioning of removable complete
dentures. The problem is worse in the
mandible as long as it does not interfere
its proliferation and migration within the
1st  week and disrupted tissue integrity is
quickly restored by newly formed bone in
about 6 months.[3] The primary function
of the edentulous alveolar ridge is that
it forms a major area of support for the
complete denture.
The rate of the contour changes of the
alveolar ridge reaches peak activity within
3–4  weeks after tooth extractions and
thereafter is less marked though continues
up to the 4th and 5th months. Changes of
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with the placement of implants. After tooth

extraction, a cascade of inflammatory
reactions is immediately activated, and
the extraction socket is temporarily closed
How to cite this article: Singh OP, Kaur R,
Nanda SM, Sethi E. Residual ridge resorption: A
major oral disease entity in relation to bone density.
Indian J Oral Sci 2016;7:3-6.

© 2016 Indian Journal of Oral Sciences | Published by Wolters Kluwer ‑ Medknow 3

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Singh, et al.: Residual ridge resorption
the internal bony structure result in external changes in the
shape of the ridges in accordance with the Wolff ’s law.[4]
The size of the residual ridge is reduced most rapidly in the
first 6 months, but the bone resorption activity continues
throughout life at a slower rate, resulting in the removal of a
large amount of jaw structure.[5,6] This unique phenomenon
has been described as residual ridge resorption  (RRR).
The rate of RRR is different among persons and even at
different sites in the same person. Annual increments of
bone loss have a cumulative effect, leaving the less residual
ridge.[7]
Anatomic changes will invariably take place within the
edentulous alveolar ridge following dental extractions. The
loss of teeth and the loss or change in function within and
around the socket results in a series of adaptive alterations
of an edentulous portion of the edentulous portion of the
ridge. Success in prosthodontics is partly dependent on the
size of remaining edentulous tissues.
The factors that affect the tissues of the alveolar ridges are
quite different from those that affect other hard and soft
tissues in the human body. Much work has been done to
understand the biochemical aspects of bone resorption
caused by periodontal disease and its association with
RRR after extraction of teeth. Endotoxins from dental
plaque,[8] osteoclast‑activating factor, prostaglandins, and
human gingival bone resorption‑stimulating factor are all
components that may have a significant effect on the rate
of RRR.
Review of the Literature
After the age of 40 years, the bone mineral density (BMD)
of the skeleton decreases, so that by the age of 65 years
approximately one third of the bone minerals have been
lost.[9] Decreased physical activity, lowered secretion of
estrogen, diet, race, and heredity may all play a role in
age‑related bone loss. Age‑related loss is also seen in
the mandible. Clinically significant osteoporosis is more
common in short, lightweight, nulliparous women than in
tall, heavy women who have given birth. During the last
20  years, new developments in imaging have facilitated
determining BMD not only in the skeleton but also in the
jaws. These studies show that in some phases of alveolar
resorption generalized mineral loss from the skeleton
affects the speed of RRR and the bone density of the jaws.
Kribbs et al.[10] indicated that in postmenopausal women
with osteoporosis the height of the edentulous alveolar
ridge is correlated with the total amount of calcium in
the body. This finding suggests that individuals with severe
osteoporosis retain less alveolar bone once the teeth are
extracted. Von Wowern and Melsen[11] reported that in
healthy individuals the density of the bone in the iliac crest
4 Indian Journal of Oral Sciences  Vol. 7  Issue 1  Jan-Apr 2016
is not correlated with the bone mass of the mandible but
with the BMD of the metacarpal bones. Von Wowern
found that in both young dentate people and old edentate
people the mineral content of the bones of the forearm
correlated with that of the mandible. On the other hand,
Von Wowern et al.[12] found no relationship between the
mineral content in the mandible and that of the lumbar
spine. Kribbs[13] suggested that the bone mass of the
mandible depends more on the status of the bony tissues
in the whole skeleton than on age.
Low bone density in the skeleton is accepted as a
predisposing factor for rapid RRR in the mandible but,
because skeletal BMD is correlated with mandibular BMD,
high local BMD values has been seen as an indication that
bony tissues are protected against RRR.
The cortical and trabecular portions of the mandible seem
to behave differently with age. The cortical bone mass
diminishes considerably over the years, but the trabecular
portion shows marked individual variation in all age groups.
Von Wowern and Kollerup[14] suggested that symptomatic
osteoporosis might be a severe risk factor for RRR in the
maxilla but not in the mandible. The differing amounts of
trabecular and cortical bone in the maxilla and mandible
may actually play a role in determining how sensitive the
structures are to the various systemic or local resorptive
factors. Klemetti and Vainio[15] reported that the remaining
height of the edentulous mandibles was more dependent
on the BMD values of the femoral neck than on the BMD
of the lumbar spine. The height of the maxillary ridge, on
the other hand, seemed to be more closely related to the
lumbar values. This may be because the amount of cortical
bone in the femoral neck, approximately 75% is similar to
that in the mandible and the bone in both the lumbar spine
and the maxilla is primarily trabecular.
Several previous reports confirm that the alveolar process
and the basal portion behave differently over the years.
According to Von Wowern and Stoltze, the age‑related
increase in cortical porosity and thinning occur primarily
in the alveolar process, whereas the basal portion remains
more intact. Atkinson and Woodhead stated that the buccal
cortex of the alveolar process of the mandible becomes
more porotic with age than the basal portion does. These
results were confirmed by Klemetti and Vainio[15] according
to their results, functional stress caused by the masticatory
muscles is involved in maintaining BMD in edentulous
areas of the mandible. After extraction of teeth, those
individuals who are physically active or are bruxers may
lose smaller amounts of minerals from those regions of
the mandible where the muscles are attached. In addition,
the BMD of the cortical bone in the edentulous mandible
is not lowered by mechanical stress caused by the remaining
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Singh, et al.: Residual ridge resorption
natural teeth in the maxilla, but the BMD of the trabecular
portion is lowered. If the teeth in the maxilla were extracted
early in life during the rapid phase of bone metabolism,
the ridges would be less disposed to the occlusal trauma
caused by the presence of the mandibular incisors than for
individuals who lost their teeth in middle or old age. This
finding also indicates that local biochemical inheritance
from the dentate period may affect the rate of RRR.
Tan et al.[16] described a technique for making a definitive
impression for highly displaced residual ridges. The
technique is especially available for mandibular edentulous
ridges. The choice of impression materials, as well as
the design of the impression tray, focuses on preventing
distortion of the displaceable residual ridges during
impression making. Using an impression tray with an
opening, modeling plastic impression compound and
impression wax were used to accurately capture the
shape of the residual ridge and place pressure on denture
load‑bearing areas. Nampo et al.[17] proposed a new method
for alveolar bone repair using extracted teeth for the graft
material. They found that material made from extracted
teeth may have potential as a bone graft material for jaw
bone formation because it is highly predictable and shows
less resorption after grafting.
Kassolis et al. [18] conducted a study to examine the
histopathologic features of alveolar bone specimens
obtained from edentulous ridges during dental implant
therapy. The authors found that the edentulous jaw could
contain regions of nonviable bone and microbial biofilm
formation for 1  year or more after tooth extraction
and mucosal healing. Regions of necrotic bone and
subclinical infection may contribute to the development of
untoward clinical events, such as bisphosphonate‑related
osteonecrosis of the jaws and early implant failure. Reich
et al.[19] studied the natural etiopathology of jaw atrophy
after tooth loss, unaltered by prosthetic procedures, in a
historical population without modern dental treatment.
The potential association between age and frequency of
atrophy was analyzed. The authors found that atrophy
in at least one jaw segment was present in 45.2% of the
analyzed jaw segments.
Discussion
Most of the bone mass in the mandible consists of
cortical bone in the basal portion, the trabecular bone
exhibits marked individual variation in BMD, whereas
the BMD values for cortical bone are more likely to
be correlated with those of the skeleton. [20] On the
other hand, the BMD and thickness of the cortical
bone mass in the mandible is affected by the forces
of the masticatory muscles in the basal portion where
Indian Journal of Oral Sciences  Vol. 7  Issue 1  Jan-Apr 2016
the muscles are attached. Physical activity and good
physical or muscular condition are correlated with high
skeletal BMD. According to accepted clinical findings,
most RRR occurs in the alveolar process, the part of
the mandible where the roots of the teeth were situated,
and the basal portion remains more intact. On the other
hand, even modern radiologic measurements of BMD in
edentulous mandibles usually provide information about
the BMD of the basal portion. Because of this paradox,
radiologic BMD measurements may not depict the ability
of osteoporosis to cause RRR, but rather the impact of
muscle function on bone density.
With age and progressive atrophy of the ridge, muscular
function decreases to protect the bony structures of the
ridges, especially in the mandible.[21] Functional stress and
irritation also decrease in those regions where the muscles
are attached. Not until this phase does real osteoporosis
develop in the mandible. The volume of the ridge and
the BMD of the basal portion decrease as a result of
reduced function. Bone tissues may develop rapid RRR
in individuals with osteoporosis, low density, and low
metabolism of the bone, even when biting forces are low
or normal. However, owing to muscle tonus, the measured
bone density may be moderately high. For individuals with
high skeletal and mandibular BMD, the muscular activity
may cause enough pressure against the alveolar ridges to
provoke RRR. The rate of RRR may also be affected by
biochemical inheritance from the dentate period, the effect
of which is focused on those structures where the roots
of the teeth were situated. The primary health effects of
generalized bone loss in the skeleton are fractures of the
long bones and spine. Because of its similar etiology, RRR
might be compared with skeletal fractures; osteoporosis
predisposes bone to the injurious impact of mechanical
forces.
Conclusion
Based on the review of the literature, occlusal forces must
be considered to be the major cause of RRR because these
forces are able to cause rapid and thorough resorption
without systemic bone loss, namely, osteoporosis. The
success of prosthetic rehabilitation is dependent to a
large extent on the size of remaining edentulous tissues.
Therefore, a good knowledge about the healing process at
extraction sites, the various factors that may be responsible
for the resorption of the residual ridges including the
contour changes caused by bone resorption and evaluation
of status of edentulous alveolar ridge is essential for
successful complete denture.
Financial support and sponsorship
Nil.
5
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Singh, et al.: Residual ridge resorption

Conflicts of interest
There are no conflicts of interest.
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