The effect of prosthodontic treatment on alveolar bone loss: A review of the

literature
Chris C. L. Wyatt, DMD, MSca
Faculty of Dentistry, The University of British Columbia, Vancouver, British Columbia, Canada
Statement of problem. Complete, fixed partial, removable partial, and implant-supported dentures have
been used to comfortably and esthetically replace missing teeth. However, it is not certain what effect these
prostheses have on the residual ridge.
Purpose. This article compares various prosthetic treatments to restore completely and partially edentulous
mouths for their ability to preserve residual alveolar bone.
Material and methods. A review of the literature was performed to discuss the effect of tooth replace-
ment on residual alveolar bone.
Results. The literature seems to indicate that the presence of a dental prosthesis affects the size and form
of the residual alveolar ridge and bone.
Conclusion. An implant-supported fixed prosthesis to restore missing teeth in partially or completely
edentulous jaws seems to be the best means of preserving residual alveolar bone. (J Prosthet Dent
1998;80:362-6.)

CLINICAL IMPLICATIONS
After dental extractions, the residual alveolar bone undergoes a period of accelerated
resorption, followed by minimal yet progressive bone loss. The use of implant-supported
fixed prosthesis to restore missing teeth in the partially or completely edentulous jaw is
the recommended treatment choice to preserve residual alveolar bone.

T eeth may be lost because of trauma, caries, peri-

odontal disease, congenital defects, and iatrogenic
treatment. Tooth loss has a negative impact on masti-
catory function, esthetics, and self-image.1-4 After den-
tal extractions, the residual alveolar bone undergoes a
period of accelerated resorption for about 10 weeks,
followed by a slower, but progressive resorption there-
after.5,6 Yet maintenance of the dentition does not
guarantee immunity from bone loss. Periodontal
attachment and bone loss occurs over time,7,8 except
on those teeth free of bacterial plaque.9
Fixed partial dentures (FPDs), removable partial
dentures (RPDs), complete dentures (CDs), and
implant-supported dentures can replace missing teeth
comfortably and esthetically, but it is not known
whether they differ in their ability to preserve the resid-
ual ridge. The volume and contour of remaining alveo-
lar bone and covering mucosa is one key to successful
prosthetic rehabilitation. The residual ridge influences
gingival esthetics and pontic dimensions for FPDs; it
provides support and stability for RPDs and CDs; and
the underlying bone is a prerequisite for the placement
of oral implants.
Bone loss adjacent to endosseous implants, particu-
larly during the healing and remodeling periods, has
been documented.10 Placement of implants requires
aAssistant Professor, Department of Oral Health Sciences.
modification of bony topography; however, dissection
of the mucoperiosteum when inserting the implant also
results in bone resorption.11-13 Occlusal forces placed
on implants, along with the presence of microflora, are
the probable causes of marginal bone loss surrounding
implants. The distribution of forces placed on implants
will vary depending on the design of the prosthesis.
Parafunctional occlusal forces have been associated
with bone loss of greater than 1 mm per year adjacent
to implants.14 In addition, greater marginal bone loss
has been documented around anterior compared with
posterior implants when supporting long posterior can-
tilevers.15,16 Marginal bone loss adjacent to implants
has been associated with poor oral hygiene, at least in
those persons who smoke.15,17 However, no associa-
tion has been found between failed implants and peri-
odontal, gingival, and plaque indices.14,18-25 Whether
the accumulation of plaque around an implant results
in bone loss, as in periodontitis, remains to be seen.
The purpose of this article is to compare the
prosthodontic treatment modalities used to restore
completely and partially edentulous patients and their
ability to preserve residual alveolar bone.
COMPLETE DENTURES
Clinical reports have implied that a well-fitting den-
ture preserves alveolar bone,26,27 but longitudinal stud-
ies question this belief.6,28,29 Campbell30 determined

362 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 80 NUMBER 3

WYATT
that edentulous patients wearing dentures had, on aver-
age, smaller residual ridges than those not wearing den-
tures. Increased residual ridge resorption seen in den-
ture wearers was attributed to pressure from the pros-
theses. Dentures may help to preserve the buccal plate
of bone when inserted immediately after teeth are
extracted,31 at least during the first 20 weeks after
extraction,32-35 and possibly for up to 3 years.36 The
horizontal dimension (cross-section) of the residual
ridge is maintained to some extent, yet the vertical
dimension undergoes resorption, especially in the
mandible. Overall, progressive and irreversible alveolar
bone loss results from the extraction of teeth, regard-
less of how soon after extractions a denture is provid-
ed.6
Loss of alveolar bone from an edentulous ridge is
more pronounced in the mandible than the maxilla,37
particularly in the early (3 months) postextraction
period.6,28,38 The mean reduction in anterior maxil-
lary vertical radiographic bone height during the first
year after extraction has varied between 2 and
4 mm,28,39,40 compared with 4 to 6 mm in the
mandible.28,40,41 In a follow-up study of edentulous
patients over an average of 2.5 years, Atwood and
Coy29 found a mean annual bone loss of 0.4 mm in
the mandible and 0.1 mm in the maxilla. Even though
Tallgren et al.28 documented a slightly lower mean
annual bone loss over 25 years (0.20 mm in the
mandible and 0.05 mm in the maxilla), the same 4-
fold difference in resorption remained between the
jaws. The differential residual ridge resorption seen
between the maxilla and the mandible has been attrib-
uted to the mandible providing a smaller surface area
of support for the denture.6
The alveolar bone in the posterior part of the
mandible is slightly more at risk to resorption, with an
average vertical bone loss over a 5-year period of
1.5 mm in the incisor region, 1.6 mm in the premolar
region, and 1.6 mm for the molar region.42 The differ-
ence in occlusal forces, between the anterior region
where lighter forces for incising food occurs compared
with the posterior region where heavier forces are
required for trituration, may be responsible.42
For the maxilla, the extent of alveolar bone resorp-
tion seems to be a function of composition of the
opposing dentition. Patients with most of their
mandibular teeth experience less resorption of the max-
illary anterior residual ridge over 5 years than patients
with only mandibular anterior teeth.43 The anterior
maxilla may experience increased compressive forces
when solely opposed by mandibular anterior teeth. This
phenomenon, often called the “combination” syn-
drome, has yet to be scientifically validated. In the sit-
uation of complete maxillary and mandibular dentures,
the decreased stability of mandibular dentures com-
pared with natural teeth may place increased lateral
SEPTEMBER1998
THE JOURNAL OF PROSTHETIC DENTISTRY
forces on the opposing maxillary denture that may
accelerate residual ridge resorption.44
Parafunctional forces may accelerate bone loss of
edentulous ridges and have been associated with sore-
ness of the denture-bearing mucosa.45 Significantly
greater bone loss after 1 year has been reported in the
anterior mandible for patients wearing their dentures
day and night compared with wearing dentures only
during the day.41,46
Even though the rate of resorption varies between
persons and within a given person over time, those per-
sons with higher initial rates of bone resorption tend to
lose more bone in the future.41,47 Overall, bone loss in
the edentulous maxilla and mandible shows marked
variation between different sites independent of age
and sex, preextraction periodontal status, or height of
the alveolar ridge.6,48-50
OVERDENTURES
Overdentures are designed to distribute the mastica-
tory load between the edentulous ridge and the abut-
ments. The overdenture transfers occlusal forces to the
alveolar bone through the periodontal ligament of the
retained tooth roots.51 Proprioceptive feedback, from
the periodontal ligament to the muscles of mastication,
may act to prevent occlusal overload and thereby prevent
bone resorption because of excessive forces. The short-
term and long-term preservation of alveolar bone has
been documented not only adjacent to the overdenture
abutments but also adjacent to the edentulous ridges. A
comparison of immediate conventional dentures and
immediate overdentures found half as much bone loss
(0.9 mm compared with 1.8 mm) in the anterior
mandible over the first year in the overdenture group52;
surprisingly, the bone loss was also slowed in the posteri-
or mandible. The increased stability that resulted from
the use of overdentures may limit lateral forces placed on
residual bone. Crum and Rooney53 measured a mean
vertical bone loss in the anterior of the mandible of
5.2 mm after 5 years for immediate dentures compared
with 0.6 mm for immediate overdentures. Similarly, bone
loss adjacent to overdenture abutment roots in the max-
illa, especially for dentures opposing mandibular anterior
teeth, has also been documented.54
REMOVABLE PARTIAL DENTURES
RPDs have been associated with loss of periodontal
attachment and marginal bone loss adjacent to abut-
ments.55,56 However, in patients free of periodontal
disease when the prosthesis was inserted and where
adequate plaque control is maintained, there is little, if
any, difference in marginal bone loss between abut-
ments and corresponding uninvolved teeth.57-60
Occlusal problems have been documented to occur
within 5 years as a result of accelerated vertical residual
ridge resorption with distal extension RPDs.60-62
363
THE JOURNAL OF PROSTHETIC DENTISTRY
FIXED PARTIAL DENTURES
Teeth that support FPDs do not experience signifi-
cantly greater rates of marginal bone loss than unin-
volved teeth. The mean annual rate of bone loss in
either case is close to 0 mm for up to 15 years.63-67 In
all reports, authors emphasized that subjects were free
of periodontal disease and adequate plaque control was
maintained throughout the period of observation.
IMPLANT-SUPPORTED PROSTHESES
The majority of the bone loss (about 1 to 2 mm)
adjacent to endosseous implants supporting complete
fixed prostheses occurs during healing and remodeling
periods.16,18,20 Minimal, if any, annual bone loss (0 to
0.08 mm) occurs in subsequent years.10,15-20,68 Studies
to date are inconclusive with respect to differences
between maxillary and mandibular bone loss.16,69
Mean annual bone loss surrounding implants that
support overdentures is more or less the same as that
found in implant-supported fixed complete prostheses,
possibly with more bone loss occurring in the maxilla
compared with the mandible.23,70-72 This difference
has been attributed to poorer bone quality in the max-
illa and increased mucosal irritation surrounding the
shorter abutments required for these prostheses.70
The presence of an implant overdenture may affect
bone loss at sites remote from the implants. Jacobs et
al.73 reported an 11% reduction in bone height distal to
implants supporting overdentures compared with a 4%
reduction adjacent to implants associated with fixed
prostheses after 10 years. This disparity may be due to
differences in anterior and posterior support. Anterior-
ly, the implants take the occlusal load, but posteriorly,
it is taken by the residual ridge. Patients with maxillary
dentures undergo a 4% vertical bone loss in the anteri-
or maxilla opposing mandibular implant-supported
overdentures or fixed prostheses compared with 13%
for those opposing conventional mandibular den-
tures.74 This finding was attributed to increased insta-
bility of the conventional mandibular dentures, which
caused unfavorable stress distribution to the opposing
arch.
Mean annual bone loss (0.05 to 0.10 mm) for
implants supporting FPDs is similar to other implant
treatments.75-78 Higher mean annual bone losses
(0.10 to 1.01 mm) have been documented adjacent to
implant-supported single tooth prostheses in partially
edentulous mouths.79-82 Greater bone remodeling may
occur adjacent to implants in partially edentulous
mouths because these implants are more likely to be
surrounded by alveolar rather than basal bone.78
DISCUSSION
The emphasis on tooth replacement has overshad-
owed the need for preservation of alveolar bone. The
best prosthodontic treatment would preserve or even
364
WYATT
replace missing alveolar bone to provide support for
RPDs, esthetically pleasing pontics for FPDs, or to pro-
vide stable bone sites for implants.
Resorption of alveolar bone seems inevitable when
teeth are lost, yet variability exists between persons,
both between and within the jaws, and over time. It
would seem that bone that has undergone higher rates
of resorption initially will continue to resorb excessive-
ly compared with bone that has undergone lower rates
of resorption.
Whether wearing a RPD, either supported by
mucosa or teeth, is associated with residual ridge
resorption has not been clarified. Immediate dentures
seem to preserve the buccal plate of bone leave a resid-
ual ridge of greater width, yet the edentulous ridge is
still subject to vertical bone loss. The composition of
the opposing dentition and the presence of parafunc-
tional occlusal forces also influences the resorption of
the residual alveolar bone. With appropriate plaque
control, roots or teeth, supporting RPDs, and over-
dentures may act as effective means of preserving adja-
cent alveolar bone. Unfortunately, distal extension
RPDs are still prone to ongoing residual ridge resorp-
tion in posterior regions.
The use of endosseous implants to support fixed or
removable prostheses has been shown to preserve adja-
cent remaining alveolar bone. The reported mean
annual bone loss is minimal and similar to healthy nat-
ural teeth. However, as with natural teeth, implants are
not immune to bone loss, primarily due to excessive
occlusal force. Implant-supported overdentures may
also preserve adjacent bone, yet bone loss in distal
extension areas is similar to that observed with remov-
able prostheses and may result in changes in occlusion
and excessive forces being placed on the implants.
CONCLUSIONS
The use of implant-supported fixed prostheses
to replace missing teeth in partially or completely
edentulous jaws is a highly successful prosthodontic
treatment. An often-overlooked benefit of implant-
supported fixed prosthetic treatment is the preservation
of residual alveolar bone.
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Copyright © 1998 by The Editorial Council of The Journal of Prosthetic
Dentistry.
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VOLUME 80 NUMBER 3