C L IN IC A L
PRACTICE
MANAGING AND TREATING THE ATROPHIC MANDIBLE
RONALD L. ETTINGER, B.D.S., M.D.S., D.D.SC.
Q he c h aracter of dental
practice h a s changed since the
developm ent of high-speed
handpieces, b e tte r restorative
m ate ria ls and preventive and
conservative tre a tm e n t
options. Consequently, d entists
are m ore likely to conserve
teeth . Recent U.S. national
d a ta show th a t the g reatest
decline in n um ber of tee th
ex tracted h a s been in th e group
aged 55-64 y e a rs.1
W eintraub and B u rt2 have
projected a continuous decline
in th e prevalence of edentulous
ad u lts, to a low of about 15
percent of th e ad u lt population
by th e y ear 2020. B ut M eskin
a n d oth ers3 estim ated a
co n stan t subpopulation of
about 9 m illion older adults
who will need complete
d en tu res in th e next 30 years.
Thus, edentulous p a tie n ts will
still be a significant p a rt of
m any p rivate practices.
TH E EDENTULO US
P O P U L A T IO N
The changes in the age and
disease p a tte rn s of th e U.S.
population will be su b sta n tia l
b u t should follow the existing
tre n d s.3'8 U sing this inform a­
tion, we can profile the
edentulous population of th e
n ex t few decades. For instance:
*■ M any will be old, possibly
m edically or physically frail,
234 JADA, Vol. 124, July 1993
A B S T R A C T
Changes in age and disease
patterns suggest that in the
near future complete denture
wearers will be older and have
worn dentures for a longer
time, but will also be more
physically fragile. Some
diagnostic issues related to
support problems for
mandibular complete dentures
are evaluated and treatment
modes suggested.
and tak in g m edications th a t
m ay have xerostom ic potential.
A significant num ber will have
neurom uscular deficits,
m aking it difficult to learn to
ad ap t to a lower d en tu re.910
™ N early 50 percent will have
been edentulous for m ore th a n
30 y e a rs.1114
■■ M ost will be w earing
dentures m ore th a n 20 years
old.1114
■■ A significant num ber will be
in lower income groups.111215
■■ More th a n 60 percent will
perceive th a t they have no
tre a tm e n t needs.16'20 O lder
persons have lower
expectations of d entures and
are more to le ran t of functional
deficiencies.2123 Changes u n d er
dentures tend to be slow and
progressive, and people
accommodate to these slow
changes and the deteriorating
fit of th e dentures by lim iting
th e type of food they e a t.24-26
™ More th a n 30 percent will
have denture-related soft
tissue lesions th a t will need
biopsy, tre a tm e n t or clinical
follow-up.11' 27
™ M any m ay be m ildly con­
fused. The risk of dem entia
increases w ith age—about 3
percent betw een the ages of 65
to 74—b u t increases from 9 to
19 percent by age 75 to 84 and
rises to 28 to 47 percent a fter
age 85.28'29
B o n e str u c tu r e . A person
can tolerate d entures only
w hen the rep a ir process of th e
oral m ucosa outpaces th e
tra u m a induced by th e
dentures in function.30 As every
complete denture moves in
function, th e h e a lth and
resistance of th e denture-
supporting tissues are critical
to successful d en tu re w earing.
One consequence of loss of
tee th and long-term denture
w earing is resorption of the
residual bone a t th e ra te of 0.1
m illim eters each y ear for the
m axilla. The rate in the
m andible is four tim es th a t
ra te .31'33
The rate varies, however,
betw een individuals and also

a t different tim es w ithin the
sam e individual. This
catastro p h e can be avoided by
m ain ta in in g te e th w ithin the
arch, reducing them and using
th em as overdenture a b u t­
m ents. W hen Crum and
Rooney observed 16 p a tie n ts
for five years, th ey found a
significant reduction in
m an d ib u lar bone loss (0.6 mm
com pared w ith 5.2 mm) in
people w earing overdentures
com pared w ith conventional
com plete dentures.
D IA G N O S IS
The diagnosis of th e p a tie n t’s
d en tu re problem depends on
clear com m unication betw een
th e d e n tist and th e p a tie n t and
a careful exam ination of the
p a tie n t and dentures. As older
p a tie n ts are often unable to
give a clear account of th eir
difficulties, question them
system atically to g ath er the
ap propriate inform ation.14'30'35
M any are tak in g m edications
th a t m ay cause xerostom ia,
changing th e oral environm ent
and resu ltin g in tissues more
susceptible to tra u m a and
infection. In consultation w ith
p a tie n ts ’ physicians, it m ay be
possible to suggest m edications
th a t are less xerostom ic or can
be ta k e n in reduced dos­
ages.10'36'40 T reatin g xerostom ia
w ith artificial saliva and
pilocarpine m ay help.37'40
P a tie n ts w ith cognitive or
neurom uscular deficits will
have difficulty w ith the
new skills involved in w earing
new d e n tu re s.30 Functional
te e th should be m aintained as
long as possible. T eeth w ith
poor periodontal support can
be u sed to stabilize
dentures as overdenture
ab u tm en ts, especially on the
m an d ib u lar arch.41
Figure 1. Periapical radiograph of
the mandibular arch showing the
mental foramen exposed on the
crest of the residual ridge. To
avoid pain or paresthesia, this
area needs to be selectively
relieved in the denture.
DENTURE PROBLEMS
P a tie n ts ’ acceptance and
tolerance of complete dentures
will depend on th e d e n tist’s
u n d e rsta n d in g of th eir dental
and d en tu re history, as well as
th e ir expectations. For some
p atien ts, complete d entures are
a psychological and social
necessity; for others, they are
sim ply functional tools. Expec­
tatio n s of fam ily and
significant others will also
influence the d e n tist’s ability
to solve complete denture
problem s.
W hen elderly persons
experience discom fort w ith
dentures, they ten d to m ake
selective choices such as
changing th e ir dietary p a tte rn s
(for exam ple, avoiding fru it
and vegetables), using
d en tu res sparingly, swallowing
larg e r boluses of food or
seeking tre a tm e n t.24'26 Most
com plaints in th e elderly are
related to th e support and
CLINICAL PRACTICE
stability of th e d en tu res a t re st
and in function (Table l) .11'42'43
S u p p o rt p rob lem s.
Support is defined as th e oral
tissues on which th e d en tu res
rest. They bear the m asticatory
load w hen th e d entures are in
function.44 Support problem s
often can be diagnosed from
pain w hen th e tissu es are
firmly palpated. If discomfort
is associated w ith a p ressu re
area on th e denture, use some
form of disclosing paste to
identify the area. Often, older
patien ts com plain of discom fort
w ithout signs of ulceration
b eneath d e n tu re s.44 This
requires diagnostic tools such a
panoram ic radiograph and
extensive skills to solve the
problem. For instance:
■■ The p a tie n t m ay com plain of
diffuse pain in th e an terio r
region. This m ay be caused by
the uneven p a tte rn of bony
resorption resu ltin g in a knife-
edged ridge or “spiny crest.”
The tissu e above th is bone is
th in and sharp, so com pressing
the tissues onto the periosteum
causes pain, and occasionally
ulceration. A denture restin g
on th is kind of a m andibular
ridge rocks easily and m ay not
be p a rticu larly stable because
the bone continues to resorb
unevenly.
■■ The p a tie n t m ay com plain of
in te rm itte n t p ain during
eating, paresth esia, hyper­
esth esia or a b u rn in g sensation
over th e d istribution of the
m ental nerve. P alp atio n m ay
show th e m en tal foram ina are
located on th e crest of th e
ridge, which exposes the
unprotected neurovascular
complex to pressure from the
den tu re (Figure 1). F irm
palpation on th e neurovascular
bundle m ay elicit th e com­
plaint. The sym ptom s are
JADA, Vol. 124, July 1993 235
'CLINICAL PRACTICE

usually associated w ith a new
d en tu re replacing one worn for
m any years. B ut symptom s can
re su lt from resorption beneath
a den tu re worn for some tim e.
« The p a tie n t m ay complain of
localized pain anyw here on the
crest of the ridge, which can be
triggered by pressure.
M arsland and Fox45 described a
plexus of nerves in th e deeper
p a rts of th e subepithelial
connective tissu e, which
consisted of num erous bundles
of m yelinated fibers following a
general course parallel to the
surface. In an aged edentulous
person, the epithelium becomes
th in , th e innervation comes to
lie in a papilla or as a fibril in
th e epithelium close to the
surface. These coiled nerve
fibers have th e appearance of
“am p u tatio n n eu ro m ata”
(Figure 2). If th ey are n e a r the
surface or overlie a sharp bony
prom inence, they may form
trig g er zones eliciting painful
reactions w hen stim ulated.
These zones are more common
in th e m andible th a n in the
m axilla.
■■ The p a tie n t m ay feel pain on
th e lingual border of the
d en tu re in the anterior region.
No ulceration is visible but
th e re is discom fort during
palpation. The genial tubercles
m ay become sh arp and prom i­
n e n t w hen the ligam ents of the
geniohyoid and genioglossus
become calcified. W hen p res­
nosis. No tre a tm e n t is usually
required except reassu ran ce by
the den tist.4647
■■ P a tie n ts m ay com plain of
rad ia tin g pain w hen they bite
down on th e ir dentures. Often
nothing can be seen in the
m outh, b u t palpation m ay elicit
a response. R adiographs will
help discover if a foreign body
such as a piece of am algam
(Figure 3) or a partially
erupted tooth or root fragm ent
is the cause. If a clinically
sym ptom less tooth or root
fragm ent is com pletely covered
by bone and shows no pathosis
on radiographs, it should not
be removed. Tell th e p atien t
about it, note it on the p a tie n t’s
c h art and check it during
a n n u al visits.
™ The p a tie n t m ay com plain of
pain or sensitivity associated
w ith a lobulated torus (Figure
4) or exostosis. If th e tori are
large, reduce d en tu re borders
“ C L O S E -C O IL
since th e m ucosa over the tori
is often th in , sensitive and
susceptible to irritatio n . B ut a
m andibular den tu re w ith
extensions reduced to avoid
tori m ay be u n stab le and
painful.
■■ The p a tie n ts’ dentures seem
to be moving, and they may
complain th a t they cannot eat.
E xam ination m ay show large
and fibrous ridges th a t can
leave insufficient space for ade­
quate extension of th e denture
bases betw een th e residual
ridges. Clinical evaluation will
indicate if th e p a tie n t can
tolerate an increased vertical
dim ension of occlusion. If this
excess tissue is inflam m atory,
th en it m ay resolve by
reduction of inflam m ation.
There is a controversy among
clinicians as to w h eth er a
“flabby” ridge should be
surgically reduced or removed.
If it is surgically reduced, will
♦-S T R A T U M BASALE
'S M Y E LIN A TE D
AXON

sure is applied to th e area, NERVE ENDING

pain is felt. If th e tubercles

become very large, ulceration RE SID UAL BONE

m ay occur. Occasionally, one

a tta ch m e n t m ay break. D uring
AMPUTATION NEUROMATA
talk in g or eating, the p atien t
will have a sh a rp pain and
com plain of swelling. A careful
history of th e accident and a Figure 2. A line drawing of a plexus of nerves in the subepithelial
connective tissue papilla overlying a sharp bony ridge. These nerve
hem atom a in th e floor of the fibers have the appearance of “amputation neuromata” and can elicit
m outh will establish the diag­ painful responses when stimulated.

236 JADA, Vol. 124, July 1993


Figure 3. A periapical radiograph of the mandibular
ridge showing a piece of amalgam lying in the
tissue above the periosteum. Pressure on the
denture caused severe pain for the patient.
th ere be enough tissu e to
support th e denture? If not, we
need to ask if th e re is enough
bone so th a t a sulcus
deepening and graft procedure
can be done. Finally, do the
p atien ts u n d e rsta n d the
problem , and can th ey phys­
ically and em otionally tolerate
th e surgical m orbidity
associated w ith th e procedure?
TREATM ENT
The first priority is to restore
optim um h e a lth to oral
tissues.35 Once th is is achieved,
several tre a tm e n t approaches
can be followed: th e surgical
rem oval of specific irrita n ts
and/or recontouring of th e
resid u al bone; m axim um
extension of th e denture bases
to use all th e available
d enture-bearing area; the
deepening of the sulcus
surgically, usually w ith a skin
or m ucosal graft; in selected
p atien ts, th e use of im plants.
M outh p r e p a r a tio n .
R estoring the oral tissues to a
h ealth y s ta te m ay initially
en ta il d e n tu re ad ju stm en t
w here physical tra u m a exists,
use of anti-fungal agents for an
infection and stabilization of
the fit of th e d en tu re w ith
Figure 4. Occlusal view of the mandibular arch
showing a large lobulated mandibular torus,
tissu e conditioners and/or
occlusal pivots.3548'51 Provide
n u tritio n a l counseling if th e
p a tie n t’s diet is in ad eq u ate.26
C onsulting w ith p a tie n ts’
physicians can evaluate the
stab ility of th e ir m edical
problem s and the potential side
effects of any m edications.
U neven resorption or
fracture of labial or buccal bone
during extraction m ay leave
the p a tie n t w ith a residual
ridge of hills and valleys often
called a “roller coaster” ridge.
Such a ridge usually has sh arp
spiny crests or spicules of bone,
which can cause severe pain if
th e periosteum is compressed
betw een th e den tu re and the
bone (Figure 5). In th is s itu a ­
tion, periapical radiographs
will help to determ ine the
ex ten t of th e problem. The
m ost effective tre a tm e n t is to
lift a flap and surgically reduce
th e bone u n til a smooth ridge
is achieved. Lobulated tori and
exostosis th a t interfere w ith
th e appropriate placem ent of
den tu re borders can also be
surgically rem oved.5253
E x te n s io n o f th e d e n tu r e
b a se. In th e resorbed
m andible, use as m uch of the
retrom olar pad as the p a tie n t
CLINICAL PRACTICE
can tolerate. On th e buccal
surface, the extension should
be to th e external oblique ridge
and on th e lingual, down to the
mylohyoid ridge and extend to
use as m uch of the tissu e over
the sublingual glands as
possible. F ish 54 and B rill55 have
described th e benefits of
extending th e den tu re base
under th e tongue, b u t few
p atien ts can to lerate these
extensions.
S p e c ia l im p r e ssio n
te c h n iq u e s . If a p a tie n t h as
been w earing a d en tu re for
some tim e, th e residual bone
beneath th e d en tu re m ay be
resorbed and/or replaced w ith
fibrous tissue. The only contact
such a den tu re h as w ith th e
tissues is a t th e periphery. If a
sta n d a rd im pression is m ade,
th e movable soft tissu e will be
displaced. W hen th e new
denture is loaded, th e p a tie n t
will complain of pain caused by
compression of soft tissues
betw een th e den tu re and the
bone.
A selective loading tech­
nique during im pression m ak ­
ing can avoid th is problem .49,56
W ith th is technique, m ake an
im pression of the edentulous
tissues u n d er constant load,
JADA, Vol. 124, July 1993 237
CLINICAL PRACTICE
TABLE
DENTURE-RELATED PROBLEMS BY TYPE OF DENTURE: ODDS RATIO.
TYPE OF N = 880
DENTURE
PU 59
PL 98
CTJ 300
CL 223
P C.OOOl
P, partial denture; U, maxillary arch; C, complete denture; L, mandibular arch.
ModifiedfromHunt and others. Gerodontics 1985.“
tak in g into account th e various
underlying m ucosal densities.
The im pression can be m ade in
two ways. F irst, m ake a special
tra y from an accurate study
cast in w hich th e areas of
mobile tissu e a re selectively
relieved. On th e m andible, th e
u sual problem a re a is th e crest
of th e resid u al ridge. A fter
careful border m olding w ith
low fusing compound, place
escape holes in the relief a re a
to allow th e im pression
m ate ria l to flow out. W hile the
im pression m aterial is setting,
m ain ta in loading a t a constant
p ressu re and in th e sam e
direction. A silicone or
polysulfide im pression
m aterial is k in d er th a n zinc
oxide-eugenol for p a tie n ts w ith
a dry m outh problem. This
technique is effective, but
requires skill and experience.
The second technique is the
sectional or tw o-tray
technique, a m odification of a
technique used for im m ediate
d e n tu re s.57 From a study cast,
th e mobile tissue is identified
and the special tra y cut away
from those areas. The tra y is
carefully border m olded and an
im pression m ade w ith e ith e r a
silicone or a polysulfide
m aterial. The im pression is
238 JADA, Vol. 124, July 1993
IN A D E Q U A T E IN A D E Q U A T E
O C C L U S IO N R E T E N T IO N
1.00 1.00
1.89 2.12
4.13 3.82
9.56 10.65
< .0001
removed, excess m aterial
trim m ed aw ay and the im pres­
sion reseated. An outsize stock
tra y is th en used to m ake an
alginate im pression over the
im pression tra y in the m outh.
The flabby or mobile tissue is
not distorted by th e alginate
and th u s recorded in an
u ndistorted form. If th e tissue
is very displaceable, instead of
using a second tra y , paint
quick-setting im pression
p laste r over th e tissues in
sufficient b ulk to be lifted off
w ith th e special im pression
tray.
Occasionally, an all­
compound final im pression
m ay be used to record th e form
of a severely resorbed residual
ridge w hen surgical alterations
are not possible. As the
m an d ib u lar d en tu re will move
considerably u n d e r function, a
more accurate im pression
m aterial will reproduce fine
details of th e tissu e surface,
which can have an irrita tin g
“sandpaper” effect on the
m ucosa.30
S u r g ic a l d e e p e n in g o f th e
su lcu s. If th ere is adequate
basal bone b u t resorption has
caused loss of sulcular depth,
surgical deepening can restore
function by enlarging the
IN A D E Q U A T E MUCOSAL
S T A B IL IT Y L E S IO N S
1.00 1.00
1.06 1.37
3.16 2.37
7.84 3.62
c.OOOl <.003
support a re a and elim inating
dislodging m uscle attachm ents.
A cquiring th e added support
for a stable d en tu re base is
usually possible only if a
m ucosal or skin graft is used to
preserve the established
depth.53 A p a la tal graft gives
an excellent denture-bearing
surface, b u t th e donor site
heals slowly and can be very
uncom fortable.59,60 A skin graft
tends to overreact w ith hyper­
keratosis w hen trau m atized .61
Occasionally if th e donor site of
th e full-thickness skin graft is
not carefully chosen, th ere m ay
be undesirable grow th of h a ir
and sebaceous glands in the
m outh.60'62
Porous hydroxylapatite
particles have been used as
bone su b stitu te s to restore a
wide convex m an d ib u lar ridge
and increase th e height of the
ridge.63 In our experience,
extending a denture-bearing
a re a u n d e r a graft w ith
hydroxylapatite granules
h a s n ’t been successful in
elderly p a tie n ts because of
pain associated w ith slow
healing of th e surgical site and
a chronic periostitis;
dehiscences in th e m ucosa
resu ltin g in discom fort and the
continuous loss of granules into

th e m outh; or foreign body
reaction w hen th e granules
w ere tra p p e d betw een the
periosteum and th e mucosa.
T H E U S E O F IM P L A N T S
The long-term success and
predictability of osseointe-
g rated im plants have m ade
th is a useful option for some
functionally independent
elderly persons.6468 There are
factors, however, th a t m ay
lim it th e ir use. The m ost
im p o rta n t factor is cost. The
expense and lack of im plant
inclusion w ithin m any third-
p a rty contracts precludes th eir
use for m any older persons.
O ther factors are the inability
of an individual to m aintain
long-term oral hygiene, the
am ount of a ttach ed tissue
available to m ain ta in th e
h e a lth and in teg rity of the
p eri-im plant tissues. The
stress associated w ith the
surgical procedures often
elim inates its use for p atients
who are frail or m edically
comprom ised. U nfortunately,
th e quality of th e bone in
p a tie n ts w ith th e g rea test
am ount of resorption, women
w ith osteoporosis, resu lts in a
poor prognosis for
osseointegration.
A L T E R N A T IV E
APPROACHES
If a p a tie n t is frail and cannot
to lerate extensive tre a tm e n t or
surgery, a m ore conservative
approach m ay be required.
R esilient soft liners m ay help
such a p a tie n t,69 as they can
elim inate irrita tio n s and
reduce inflam m ation.70 If tissue
conditioners help th e p a tie n t to
function comfortably, they m ay
be used as a functional
im pression for a reline of the
m an d ib u lar den tu re w ith a
silicone
resilie n t liner.
To get the
b est resu lt
w ith tissu e
conditioners,
th e denture
base needs to
be adequately
extended and
th e occlusion
stabilized in
centric re la ­
tion.71 This Figure 5. Mandibular ridge after a mucoperiosteal
u sually m eans flap had been raised. The bony crest is thin, sharp
and uneven (Photograph, courtesy of Dr. Poh Hong
rem ounting Tan, University of Singapore).
and carrying
o ut selective
grinding before using the
tissu e conditioner. Since a
large discrepancy often exists
because of w ear of posterior
resin teeth , tooth-colored,
chem ically cured acrylic resins
can be used to provisionally
restore occlusal contacts.30
A fter some weeks of using the
tissue conditioner and w hen
th e p a tie n t is comfortable, the
m an d ib u lar denture can be re ­
lined using standard techniques.
If possible, the lower
d e n tu re should be left out of
th e m outh for 48 hours before
th e final im pression to allow
th e tissu e s to “rebound.”72 The
tissu e conditioner in the
d en tu re is reduced and new
m ate ria l placed in the m outh
u n d e r functional loading. The
p a tie n t is dism issed for a t least
two hours and encouraged to
ta lk and e a t w ith the dentures
in place to obtain a functional
im pression.
Inform th e laboratory as to
th e thickness of specific areas
if a silicone resilien t liner is
used. Its thickness is related to
th e condition of the tissues
b en eath it, so th a t sharp,
mobile a reas, which norm ally
a re relieved, have a thicker
CLINICAL PRACTICE
covering of resilie n t m ate ria l.49
Finally, if p a tie n ts are so frail
and th e ir tissue so te n d e r th a t
they can no longer to lerate
even th e in te rm itte n t use of a
resilient liner, they will not be
able to w ear m an d ib u lar
dentures. Ritchie and E v e rett73
have suggested m odifying th e
m axillary d en tu res in these
situations. The posterior
occlusal table can be rese t a t a
position lower th a n the
“norm al” occlusal plane. The
posterior te e th are arran g ed to
m ake even contact w ith the
m andibular edentulous ridge
when th e m outh is in a
m axim um closed position. The
final position will be
determ ined by th e p a tie n t, th e
criterion being acceptance of
the esthetic compromise.
C O N C L U S IO N S
Once th e te e th have been
extracted, th e resid u al bone
rem aining resorbs a t a varying
rate. The am ount of resorption
will depend on:
■■ th e age of the person w hen
th e te e th w ere extracted;
» th e bone stru c tu re a t th e
tim e of extraction;
■■ the tra u m a of th e extraction
JADA, Vol. 124, July 1993 239
CLINICAL PRACTICE
especially dental education. J Dent Educ
process; 1986;50:162-6.
■■ th e gender (fem ales have 7. Bailit HL. Environmental issues in
less bone and lose it faster); dentistry: reflections on the practice of
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the management of the atrophic mandible. O ne of the tools you need is the ability to w rite well:
Chicago: Quintessence; 1984:41-4.
63. Kent JN, Quinn JH, Zide MF, Guerra
to be able to put together a report of research that's
LR, Boyne PJ. Alveolar ridge augmentation w orth publishing, to write a grant proposal that's
using non-resorbable hydroxylapatite with or fundable, to prepare a paper or exhibit for presenta­
without autogenous cancellous bone. J Oral
Maxillofac Surg 1983;41:629-42.
tion that's w ell received.
64. Branemark PI, Breine U, Adell R, W e don't guarantee that you' 11w rite a best seller or
Hansson BO, Lindstrom J, Olsson A. Intra- get a m illion-dollar grant, but w e can guarantee that
osseous anchorage of dental prostheses. I.
Experimental studies. Scand J Plast Reconstr if you join us, you'll learn h ow to im prove your
Surg 1969;3:81-100. w riting, enhance the quality of your presentations,
65. Adell R, Lekholm U, Rockier B, and keep up-to-date w ith d evelopm en ts in areas like
Branemark PI. A 15-year study of
osseointegrated implants in the treatm ent of desktop publishing.
the edentulous jaw. Int J Oral Maxillofac W e're an organization founded by physicians 50
Surg 1981;6:387-416.
66. Adell R. Clinical results of years ago, and w e're over 3000 strong. A m ong our
osseointegrated implants supporting fixed m em bers are people like you, for w hom w riting has
prostheses in edentulous jaws. J Prosthet becom e an increasingly important part of life. Find
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67. Kirsh A, Mentag PJ. The IMZ
out m ore about us.
endosseous two phase implant system: A Send this coupon or call AMW A's national office at
complete oral rehabilitation treatm ent 301-493-0003.
concepts. J Oral Implantol 1986;12:576-8.
68. Zarb GA, Schmitt A. The longitudinal
clinical effectiveness of osseointegrated dental E x ecu tiv e D ire c to r, A M W A J k '\ \
implants. The Toronto Study: P art I. Surgical
Results. J Prosthet Dent 1990;63:451-7.
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69. Woelfel JB, Paffenbarger GC. Evalua­ B e th e sd a , M D 20814 MEA S S O O A ® V V \
tion of complete dentures lined with resilient
silicone rubber. JADA 1968;76:582-90. Please send information about AMWA to:
70. Tassarotti B. A clinical and histologic
evaluation of a conditioning m aterial. J N a m e ____________________________________________
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71. Klein IE, Miglino JC. Uses and abuses A d d re ss__________________________________________
of the tissue treatm ent materials. J Prosthet
Dent 1966;16:5-12.
72. Kydd WL, Daly CH. The biologic and
mechanical effects of stress on oral mucosa.
J Prosthet Dent 1982;47:317-29.
73. Ritchie GM, Fletcher AM. Complete Title (or sp ecia lty )-------------------------------------------
denture replacements for geriatric patients.
Dent Update 1974;1:287-93. C ity_________________________ S tate____ Z ip .

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