Evaluation of Correlation between Residual Ridge Resorption and Bone Density in Women Wearing Removable Complete Dentures: 1-Year Clinical Prospective Study

Abstract

Objective

Residual ridge resorption (RRR) is considered to be a continuous and highly complex process with a multifactorial etiology. This study aims to assess the rate of mandibular RRR in women with complete edentulism and its correlation with bone density and to investigate the effect of complete denture wearing on RRR.

Materials and Methods

This randomized prospective clinical study included 60 women aged 50 to 80 years old (mean: 63.37 ± 6.32) with complete edentulism. The study groups were divided according to T-score values of DXA scan (dual-energy X-ray absorptiometry) into two groups: 30 women with low bone density osteoporosis/osteopenia and 30 women with normal bone density. The mandibular ratio index (MRI) measured on panoramic radiography (orthopantomogram [OPG]) 2D using Sidexis SG program is used to investigate the correlation of RRR with vertebral bone mineral density of L1–L4. MRI is categorized into three grades: class I ≥ 2.34; class II 1.67–2.33; and class III ≤ 1.66. Duration of complete edentulism is divided into three periods: 0–5, 5–10, >10 years. All participants received complete dentures. Measurements were evaluated before treatment and 1 year after prosthodontic treatment with complete dentures.

Results

The correlation analysis between DXA test values and MRI showed a moderately positive yet insignificant correlation, R = 0.32 (p > 0.05). For each unit increase in T-score value, MRI increases by 0.04 (B = 0.04), a nonsignificant difference at p > 0.05. Patients with edentulous period >10 years have an average of 0.01 mm (B = 0.01) resorption compared with patients with edentulous period of 1 to 10 years, nonsignificant at p > 0.05 (p = 0.97). For each year of increasing age, MRI decreases by 0.0004 mm (B = 0.0004) and is not significant at p >0.05 (p = 0.97). One year after wearing dentures, the value of MRI for Z = 2.52 and p <0.05 (p = 0.01) is significantly higher.

Conclusion

There is no significant correlation between osteoporosis and RRR. However, wearing dentures affects the resorption of the residual ridge. Age and duration of edentulism do not have a significant impact on RRR.

 

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Keywords

mandibula - residual ridge resorption - bone density - complete dentures

Introduction

Residual ridge resorption (RRR) is a chronic, progressive, irreversible, and highly complex process with a multifactorial etiology. Bone loss varies from person to person, with its intensity being highest during the first 6 months after tooth extraction.[1]

The factors influencing RRR, as categorized by Atwood, include anatomical factors (mass, shape, density of the alveolar ridge), metabolic factors (nutrition, hormonal factors), functional factors (intensity, duration, and direction of masticatory forces), and prosthetic factors (denture fabrication techniques, prosthetic design and principles).[1] [2]

It is believed that RRR is exacerbated by imbalances in cellular activity, specifically between bone-forming cells (osteoblasts) and bone-resorbing cells (osteoclasts) Systemic factors are thought to play a role in the rate and intensity of RRR, including osteoporosis.[3] [4] Anatomical changes affect the alveolar ridge in horizontal and vertical directions. Trabecular bone is more affected by metabolic changes and consequently, resorptive processes are significantly greater in trabecular regions than in cortical areas.[5] [6]

Osteoporosis is a metabolic bone disease characterized by microarchitectural disruption of bone structure and loss of bone mass density. The disease affects women three times more than men.[7] [8] Systemic bone density loss is considered a risk factor for oral bone loss, including alveolar ridge resorption.[9] The highest rate of RRR has been reported in women especially after the menopause due to drastic decrease in the level of the hormone estrogen as a promoter of bone formation processes.[10]

Continued ridge reduction is evident in both denture wearers and nondenture wearers, but mandibular resorption is directly related to the period of denture wearing/duration of edentulism.[11] [12]

It is crucial to assess the degree of RRR before planning prosthetic rehabilitation to ensure proper prosthetic treatment planning, stability, and retention. The multifactorial nature makes predicting the extent of RRR very challenging.[13]

One of the methods for measuring the degree of alveolar ridge resorption is the method described by Wical and Swoope, modified by Ortman et al. Using this method, the ratio between the two distances (distance Ia: from the upper edge of the alveolar ridge to the lower edge of the mandible, and distance Ib: from the lower edge of the mental foramen to the lower edge of the mandible) represents the degree of alveolar ridge resorption, which is categorized in to three categories: class I (mild) ≥2.34; class II (moderate) 1.67–2.33; class III (severe) ≤1.66.[14]

The objective of the study is to investigate the correlation between general bone density and RRR, analyze the impact of duration of complete edentulism on RRR, and determine the impact of wearing a complete denture on RRR.

 

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Materials and Methods

The research was conducted at the Specialized Dental Polyclinic, Department of Mobile Prosthodontic in Pristina. The study was approved by the Ethics Committee of the Kosovo Dental Chamber (Prot No:15/10.06.2021). An information letter regarding the research was provided to all patients for consent, and they all signed the written consent agreeing to participate in the study.

Inclusion Criteria

• Women aged 50 to 80 years.

• Women who were examined to assess general bone density.

• Women with complete edentulism in both jaws.

 

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Exclusion Criteria

• Patients who have undergone oral surgical procedures (sulcus deepening, alveolar ridge leveling, etc.).

• Patients suffering from systemic diseases that affect bone metabolism: hyperparathyroidism, metastatic carcinoma, diabetes, renal insufficiency, and liver diseases.

• Patients with partial edentulism and other forms of prosthetic treatment.

 

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Structure of the Research Sample

The participants of the study were 60 postmenopausal women with complete edentulism in both jaws, aged 50 to 80 years. Patients were allocated into two groups based on the body's bone mineral density (BMD) measured by the dual-energy X-ray absorptiometry (DXA) test.: 30 women in study group with low BMD osteopenia/osteoporosis (N1) and 30 women in control group with normal BMD (N2).

 

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Research Methodology

The patients were examined using the DXA test by a nuclear medicine specialist from the University Clinical Center in Pristina. The overall bone density examination - DXA was performed using the MEDILINNK device, model: MEDIX DR 2020. Allocation of patients was done according to the World Health Organization T-score scale, which indicates the number of standard deviations above or below the mean for a healthy 30-year-old adult patient of the same sex and ethnicity, where normal BMD has ≥ − 1.0, osteopenia has −1.0 to −2.5, osteoporosis has ≤ − 2.5 standard deviations ([Fig. 1]).

Fig. 1 Bone density assessment using the DXA test (medical reports presented with patient consent). DXA, dual-energy X-ray absorptiometry.

To determine RRR, radiological assessment was performed using panoramic radiography (orthopantomogram [OPG]) with a Sirona Ortho Phos E2D, conducted by a single radiology technician to ensure consistent reference points. The mandibular ratio index (MRI) was measured using the Sidexis SG Software system. Measurements were taken twice, with a three-week interval between assessments.

The duration of edentulism was categorized into three groups: 0 to 5, 5 to 10, >10 years. All participants received complete dentures. Measurements for MRI were performed before treatment and 1 year after wearing complete dentures.

Examining and Assessment Technique Using Panoramic Radiography

In the OPG, assessment of the MRI was conducted. Initially, the mental foramen was identified as the recommended reference point. Using the Sidexis SG Software system, two measurement lines were drawn: Ia: this is the distance from the lower edge of the mandibular body to the upper edge of the mandibular ridge. This measurement is taken near the mental foramen. Ib: this line measures the distance between the lower edge of the mandibular body and the lower margin of the mental foramen. According to the values obtained from the Ia/Ib ratio (right) + Ia/Ib ratio (left)/2, we obtained the MRI values ([Fig. 2]).

Fig. 2 The identification of reference points and radiomorphometric measurements using the software program.

 

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Statistical Analysis

SPSS software package, version 23.0 and statistical software Statistica 7.1 for Windows were used to process research data. Descriptive statistics included mean, standard deviation range, and maximum and minimum for numerical variables. Independent samples t-test was used to check the differences between sample groups. Difference and relation were analyzed using Fisher's exact test and Pearson chi-square (p) test. The Mann–Whitney U-test was used to analyze the difference between two research groups. The multiple regression statistical analysis was used to analyze the relationship between the dependent variable and the independent variables. Values of p <0.05 were considered statistically significant.

 

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Results

The study included a total of 60 female subjects. The average age of patients in the study group varied at 63.37 ± 6.32, in the control group, and 62.90 ± 7.07 with nonsignificant difference ([Table 1]). The mean ± standard deviation values of the DXA test for the study group N1 range at −2.98 ± 0.76, and for the control group N2, −1.16 ± 0.40. From 60 examined women in our study, 30% (n = 30) had osteoporosis, 70% (n = 21) osteopenia, and 30% (n = 9) resulted with normal bone density ([Table 1]).

Table 1 Demographic and clinical characteristics of the patients

Characteristics	N1: group with low bone density	N2: group with normal bone density	p-Value	Z- adjusted t-value
	(T-score −1.0 to −2.5 < − 2.5)	(T-score > 2.5)
Number of patients	30	30
Sex	F (female)	F (female)
Mean, age, years (SD)
Mean ± SD	63.37 ± 6.32	62.90 ± 7.07	p > 0.0005 p = 0.73	Z = 0.33
Min/max	52/76	51/77
Median (IQR)	61	61
DXA test
Mean ± SD	−2.98 ± 0.76	−1.16 ± 0.40	p < 0.001 p = (0.000)	Z = −6.68
Min/max	1.90/− 2.5	−2.10/− 0.40
Median (IQR)	−2.70	−1.10
Bone status, T-score values	Cumulative count (percent)	Cumulative count (percent)
T score < − 2.5	30 (100%)	0 (0.00%)	p < 0.001 (p = 0.000)	Z = − 6.68
T score −1.0 to −2.5	0 (0.00%)	21 (70%)
T score > − 1	0 (0.00%)	9 (30%)
Length of period of edentulism	Cumulative count (percent)	Cumulative count (percent)
0–5 years	3 (10.00%)	0 (0.00%)	p > 0.05 (p = 0.347)
5–10 years	2 (6.67%)	8 (26.67%)
>10 years	22 (73.33%)	22 (73.33%)
Missing	0 (0.00%)	30

Abbreviations: DXA, dual-energy X-ray absorptiometry; IQR, interquartile range; SD, standard deviation.

Note: Z = Mann–Whitney U-test. P = Pearson chi-square (significant for p < 0.05). T-test: grouping t/p.

The values of MRI in the study group vary within the range of 1.93 ± 0.34 mm. In the control group, the values vary in the range of 1.96 ± 0.28 mm. One year after wearing complete dentures, the values of MRI vary within the range 1.98 ± 0.33 for the study group ([Table 2]).

Table 2 Mandibular resorption index—descriptive data for the two study groups

Variable	Valid N	Mean	Confidence—95.00%	Median	Minimum	Maximum	Std. Dev.
MRI—before prosthetic rehabilitation
MRI—study group	30	1.93	1.80	2.05	1.10	2.90	0.34
MRI—control group	30	1.96	2.07	1.90	1.60	2.80	0.28
Variable	Valid N	Mean	Confidence—95.00%	Median	Minimum	Maximum	Std. Dev
MRI-1 year after wearing complete dentures
MRI—study group	30	1.98	1.85	2.10	1.10	2.90	0.33
MRI—control group	30	1.96	2.07	1.90	1.60	2.80	0.30

Abbreviation: MRI, mandibular ratio index.

A moderately strong positive insignificant correlation was determined between DXA test values and MRI values, R = 0.32 (p > 0.05). With the increase in DXA test values, the values of MRI increase insignificantly ([Table 3] and [Fig. 3]).

Table 3 Cross-analysis between T-score values and MRI

DXA test	MRI index			Total
	Class I > 2.34 mm	Class II 1.7–2.33 mm	Class III < 1.66 mm
T-score < − 2.5 Count %	3 10.0%	21 70.0%	6 20.0%	30 100%
T- score −1 to −2.5 Count %	1 4.8%	18 85.7%	2 9.5%	21 100.0%
T- score > − 1 Count %	1 11.1%	7 77.8%	1 11.1%	9 100.0%
Total Count %	5 8.3%	46 76.7%	9 15.0%	60 100.0%

Abbreviations: DXA, dual-energy X-ray absorptiometry; MRI, mandibular ratio index.

Fig. 3 Correlation between DXA test values and MRI values. DXA, dual-energy X-ray absorptiometry; MRI, mandibular ratio index.

One year after wearing the complete prosthesis the statistical data show an increase in alveolar ridge resorption. The ratio of patients classified as Class III on MRI (ridge height < 1.66 mm) increased from 20% (n = 6) prior to prosthetic rehabilitation to 30% (n = 9) at the one-year follow-up. ([Tables 4] and [5]).

Table 4 Distribution of the MRI values before prosthodontic rehabilitation and 1 year after wearing complete dentures

MRI—before prosthetic rehabilitation	N1: study group (low bone mass)		N2: control group (normal bone mass)		p-Level	Z-adjusted
	Frequency	Percent %	Frequency	Percent %
Class I: >2.34 mm	3	10.00	2	6.67	0.79	0.27
Class II: 1.67–2.33 mm	21	70.00	25	83.33
Class III: <1.66 mm	6	20.00	3	10.00
Missing	0	0.00	0	0.00
MRI—1 year after wearing complete dentures	N1: study group		N2: control group		p -Level	Z -adjusted
	Frequency	Percent %	Frequency	Percent %
Class I: >2.34 mm	1	3.33	2	6.66	0.85	−0.19
Class II: 1.67–2.33 mm	20	66.66	25	83.33
Class III: <1.66 mm	9	30.00	3	10.00

Abbreviations: MRI, mandibular ratio index.

Note: Z = Mann–Whitney U-test (significant for p < 0.05). P = Pearson chi-square.

Table 5 Comparative analysis of the MRI values before prosthodontic rehabilitation and 1 year after wearing complete dentures

Pair of variables	Valid N	T	Z	p-Level
MRI and MRI/1 year after wearing complete denture
MRI—study group	30	9.50	2.31	0.02
MRI—control group	30	0.00	2.05	0.01

Abbreviations: MRI, mandibular ratio index.

The data from the multiple regression analysis between the values of MRI as a dependent variable and age, DXA test, and length of edentulism period in the study group are presented in [Table 6]. For each unit increase in T-score value, MRI (mean) increases by 0.04 (B = 0.04), a nonsignificant difference at p >0.05 with unchanged values for other parameters. Patients with edentulous period >10 years have an average of 0.01 mm (B = 0.01) resorption compared with patients with edentulous period of 1 to 10 years, nonsignificant at p >0.05 (p = 0.97). For each year of increasing age, the mandibular resorption index decreases by 0.0004 mm (B = 0.0004) and is not significant at p >0.05 (p = 0.97; [Table 6]).

Table 6 Multiple regression analysis between MRI values, age, DXA test, and duration of edentulism

Regression summary for dependent variable: МRI/average R = 0.33; F (6.23) = 0.48; p > 0.05
N = 30	Beta	Std. Err. of B	B	Std. Err. of B	t (23)	p-Level
Intercept			1.62	1.62	0.93	0.09
Age	−0.01	0.21	−0.0004	−0.0004	0.01	0.97
DXA test	0.09	0.22	0.04	0.04	0.10	0.70
Length of period of edentulism (1)	−0.01	0.21	−0.01	−0.01	0.19	0.97

Abbreviation: DXA, dual-energy X-ray absorptiometry.

 

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Discussion

The critical issue in the treatment of complete edentulism is bone resorption, especially in the mandible where the rate of resorption is twice more pronounced than in the maxilla and where anatomical support is very limited, particularly in cases of rehabilitation with complete dentures.[3] [4]

Osteoporosis is a severe disease that garners special attention due to its progressive yet latent development. Bone mass loss begins around age 35 and peaks upon entering menopause.[7] [8]

The relationship between osteoporosis and changes in oral bones has been recognized since the 1960s.[4] Given that RRR is a very complex and multifactorial process, many authors do not attribute the impact solely to osteoporosis.[3] [6]

Many studies have been conducted on the relationship between RRR and skeletal BMD, resulting in conflicting results. However, only a few studies used multiple analyses such as and BMD, age, duration of edentulism, and influence of dentures to analyze the effect of each as analyzed in our study.[12] [13] [14]

The method used to evaluate RRR in our study has several advantages, such as simplicity due to the relevant anatomical structures used as reference points, optimal degree of accuracy, and possibilities of comparison of radiographs at different intervals enabling evaluation at different time periods.[14] [15]

Difficulties in identifying the mental foramen with clear visibility of upper and lower boundaries as a reference point are very common, especially when resorptive processes are pronounced.[15] [16] In our research, we also encountered these difficulties. Even after a second examination, full consensus was not reached on the effective visibility of the reference point. Ultimately, we include in our research only OPGs from patients with clearly visible anatomical structures that meet the guidelines and criteria for performing radio-morphometric measurements.

Many authors, who have analyzed the most appropriate measurement methodology for evaluation of MRI, have given priority to measurements made with digital methods due to their advantages in technical aspects, reliability, and accuracy. Arifin et al developed a computer-aided system for measuring radio-morphometric indices on dental panoramic radiographs and clarify the diagnostic efficacy of the digital system.[16] [17] To achieve the most accurate assessment, we have also used the digital method.

In our study, a moderately strong positive insignificant correlation was determined between DXA test values and MRI values. With the increase in DXA test values, the values of MRI increase insignificantly. Our study data show that 20% of patients with T-score < − 2.5 have MRI class III, which represents the highest degree of RRR, while 70% have MRI class II. Our data are consistent with the findings of von Wowern and Kollerup, who caried out a study with an aim to determine whether symptomatic osteoporosis was associated with greater reduction in residual bone in edentulous patients. They reported that osteoporosis in women is not associated with mandibular atrophy.[18] Klemetti and Vainio investigated the relationship between bone density and the rate of alveolar ridge resorption in 77 women by measuring several reference points on the lower jaw. The study reported that RRR in some regions of the mandible was influenced by the overall loss of bone density.[19] Moreover, Ortman et al conducted a study of 459 edentulous patients using the Wical and Swoope method. The data demonstrated a significantly larger percentage of women with class III RRR (p less than 0.01), but this difference could not be related only to systemic bone loss and menopause.[20] Another prospective, cross-sectional study by Springe et al in 45 edentulous postmenopausal women found no statistically significant relationship between BMD and mandibular bone high at the midline and both mental foramina regions.[21]

No significant association between the subject's age, duration of edentulism, and RRR was found in the present study. 0.01 mm (B = 0.01) is the difference in mean values of RRR between the length of period of edentulism >10 years and the period 1 to 10 years. Our data are in line with a study conducted by Xie at al, who investigated the influence of local factors in 177 elderly patients, including duration of edentulism, the time of wearing the prosthesis, the condition of the prosthesis, and oral hygiene habits. No significant association was found between degree of resorption and duration of edentulism in either the mandible or the maxilla. RRR was related to denture quality (p < 0.05).[22]

In the complex multifactorial mechanism of RRR, the pressure developed under the removable prosthesis plays an important role, being an additional factor of an intensive process of resorption of the edentulous arch. These data have been verified by a study conducted by Campbell.[11] According to our data, wearing dentures can affect RRR in women with osteoporosis. The data we obtained from the comparative analysis show significantly increased values of alveolar resorption compared with the values 1 year ago (Z = 2.31). Statistically significant results were reported also from a prospective 5-year case–control study by Alsaggaf and Fenlon, who investigated the effects of denture on RRR in edentulous patients from two study groups. The residual alveolar ridges of those wearing dentures were resorbed significantly more over a 5-year period of denture wear than those not wearing dentures.[23] According to Al-Jabrah and Al-Shumailan, 44.3% of the mandibular ridges had resorbed in patients who had been wearing conventional dentures for 20 years or more.[24] Moreover, some studies reported different results. From their 5-year prospective study with five reference points in maxilla and mandibula, Kovačić et al reported low rate of resorption (8%) in patients wearing dentures. However, they reported a significant relationship with the duration of edentulism, while Zmysłowska et al reported a high rate of RRR (45%).[25] [26]

Women have a higher risk for a higher degree of resorption according to Kordatzis at al. However, their data did not find any association with factors such as the period of edentulism and the number of dentures used.[23] [27] In the literature, there are numerous experimental data that have produced clear conclusions about the correlation of estrogen deficiency in postmenopausal women, which can accelerate RRR, which affects a significant loss of bone mass in the edentulous jaw.[7] [8] However, more research is required to confirm the mechanism of this relation.[28] [29] [30] [31] [32] [33] [34] [35] [36]

One of the limitations of this study was the method used to measure RRR. Although it is a reliable method, it provides data about RRR in the region of mental foramen. RRR in other areas is not assessed. The small sample size was another limitation.

Being a complex multifactorial process, a prospective study design that includes a wider range of local and systemic factors would be even more useful in assessing their impact on the rate of RRR.

 

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Conclusion

Assessing bone quality before prosthetic rehabilitation is highly beneficial for patients with osteoporosis.

Residual alveolar ridge resorption is not significantly correlated with DXA measurements. Age and duration of edentulism do not have a significant impact on residual alveolar ridge resorption. Wearing dentures can affect RRR.

Recommendations should be followed during the fabrication of removable dentures, focusing on protecting the jawbone from excessive masticatory force loads. A pressure-free impression (the open-mouth technique) should be applied to minimize pressure on the alveolar ridge. Acrylic teeth with semi-anatomical cusps (25°–33°) should be used to reduce stress on the remaining bone and reduce unwanted horizontal force.

 

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Conflict of Interest

None declared.

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Artikel online veröffentlicht:
01. September 2025