Trauma; PreprostheticSurgery
A classification of the edentulous
jaws
J. I. C a w o o d ~ a n d R. A. H o w e l l 2
~Maxillofacial Unit, Royal Infirmary, Chester,
UK, 2Liverpool Dental Hospital, Liverpool, UK
J. L Cawood and R. A. Howell." A classification o f the edentulous jaws. Int. J. Oral
Maxillofac. Surg. 1988; 17:232-236
Abstract. A classification of the edentulous jaws has been developed based on
a randomised cross-sectional study from a sample of 300 dried skulls. It was
noted that whilst the shape of the basalar process of the mandible and maxilla
remains relatively stable, changes in shape of the alveolar process is highly
significant in both the vertical and horizontal axes. In general, the changes of shape
of the alveolar process follows a predictable pattern Such a classification serves
to simplify description of the residual ridge and thereby assist communication
between clinicians; aid selection of the appropriate surgical prosthodontic technique; offer an objective baseline from which to evaluate and compare different
treatment methods; and help in deciding on interceptive techniques to preserve
the alveolar process. An awareness of the pattern of resorption that takes place
in various parts of the edentulous jaws, enables clinicians to anticipate and avert
future problems.
When considering preprosthetic surgery
of the edentulous jaws, it is essential
that both the surgeon and prosthodontist possess a detailed knowledge of the
changing anatomical form of the jaws,
following tooth loss.
To date, attempts to describe and
classify these changes are unsatisfactory,, 2, 4, 5. They have been either too
subjective or incomplete. Several studies
refer to changes in vertical dimension
occurring in the anterior region of the
edentulous mandible, but make no reference to the changes in the horizontal
dimension or to changes occurring posteriorly. There is a paucity of objective
data relating to the bony changes in the
edentulous maxilla.
For these reasons, the authors undertook a study firstly to measure the
changes in shape of the edentulous jaws
and secondly to classify these changes
if possible.
processes based on the presence of reversal
lines, which delineate the most inferior extent
to which alveolar reduction is likely to progress. This subdivision coincides with the
Key words: classification; edentulous jaws;
preprosthetic surgery.
Accepted for publication 5 January 1988
line connecting the mental and mandibular
foramina (Figs. 1A, B). Three points S, M
and K on this line were selected. S indicates
the intersect through symphysismenti with a
horizontal line connecting the mental foramina, M the mental foramen and K the mid-
1A
2A
"x
/TLv/
1B
2B
iiiii!iii!iii!
] BASAL
Material and M e t h o d s
A randomised cross-sectional study of the
Greig Collection was carried out at the Royal
College of Surgeons of Edinburgh which
comprises 300 dried skulls.
Mandibular study
As demonstrated by ENLOW et al.3, there is a
subdivision between the alveolar and basalar
Fig. 1. (A) Remodeling changes (shaded) in
the mandible in relation to loss of the teeth
(after ENLOWet al.3). (B) The line connecting
mental and mandibular foramina delineates
the boundary between the alveolar process
and basalar process. 3 reference points S, M
and K were selected. (B).
Fig. 2. Measurements of the height (A) and
width (13)of the alveolar process and basalar
process were taken at points S, M and K.
A classification of the edentulous jaws
point of the line connecting the mental and
mandibular foramina.
Twelve variables were analysed, namely,
height and width of alveolar and basalar processes at points S, M and K respectively (figs.
2A, B). The mandibles were grouped into 4
categories. Group 1 were dentate, groups 2,
3 and 4 were edentulous with moderate, severe or extreme resorption respectively.
Group effect was determined by 1-factor
233
analysis variant. Associations between variables were measured using Pearsen's productmoment correlation co-efficient and by
Spearman's rank-correlation co-efficient.
whereas the m e a n value of basal
m e a s u r e m e n t s are n o t significantly different, see also Tables 1A, B.
Results
Fig. 3. Differences between mean values of
As c a n be seen in Figs. 3 A - F , the m e a n
values o f alveolar m e a s u r e m e n t s are significantly different between groups,
mandibular measurements for groups. S vertical (A); S horizontal (B); M vertical (C); M
horizontal (D); K vertical (E); K horizontal
(F).
3A
S
IVIIV]
VERTICAL
GROUP
EFFECT
ALVEOLAR
BASAL
3D
M
HORIZONTAL
GROUP
15
EFFECT
ALVEOLAR
"15
BASAL
[MS
P < O-OO1
GROUP
GROUP
3B
MM
HORIZONTAL
GROUP
EFFECT
3E
ALVEOLAR
BASAL
VERTICAL
GROUP
EFFECT
ALVEOLAR
BASAL
MM
15
2O
5
0
p<o.oon
~ P < O.OO1
-5
GROUP
GROUP
EFFECT
GROUP
3C
MIV
-~
3F
IV]
VERTICAL
ALVEOLAR
BASAL
15
~[Ms
BROUR
HORIZONTAL
GROUP
MM
<
O-GO1
EFFECT
ALVEOLAR
BASAL
15
GROUP
--~
Cawood & Howell
234
Table 3A. Vertical maxillary
measurements (mm) (n = 30)
Maxillary study
O f the 4 processes o f the maxillary bone,
the alveolar a n d palatal (basalar) processes are relevant to this study. The
incisive f o r a m e n (I) a n d the greater palatine f o r a m i n a ( G P ) are located at the
j u n c t i o n o f the alveolar a n d b a s a l a r processes. Figs. 4 A - D show the maxillary
alveolar a n d b a s a l a r linear m e a s u r e m e n t s r e c o r d e d in the vertical a n d horiz o n t a l axes.
T h e 11 variables s h o w n in Table 2
were analysed to d e t e r m i n e a n y changes
in s h a p e o f the b a s a l a r a n d alveolar processes o f the maxillae.
I n order to d e t e r m i n e g r o u p effect,
the maxillae were subdivided into 3
groups. G r o u p 1 were dentate, groups
2 a n d 3 were e d e n t u l o u s w i t h m o d e r a t e
a n d severe r e s o r p t i o n respectively.
alveolar
Group
Anterior
I-C
mean SD
Posterior
GP-C
mean
SD
1
2
3
11.20+1.30
6.77+_2.01
1.09+_ 1.45
12.40+_0.89
10.46+_2.96
6.46+_2.54
Table 3D. Horizontal maxillary
measurement (mm) (n = 30)
basalar
Group
I-GP
mean SD
GP-GP
mean
SD
1
2
3
39.60+-2.70
39.23+_2.62
39.00+_2.28
30.60+_ 1.82
32.46+_2.37
33.18___1.94
Table 3B. Horizontal maxillary alveolar measurements (mm) (n = 30)
Group
IC
SD
I-B
mean SD
GP-C
mean
SD
GP-B
mean
SD
10.00+2.65
6.46_+ 1.66
3.36 +_1.75
10.00_+2.00
7.15 +_1.52
3.91 +_1.81
9.20_+ 1.64
6.92 +_1.38
4.73 -t- 1.10
13.80+_2.59
10.69 -t-2.25
8.27 ___1.85
mean
1
2
3
Table 3C. Vertical maxillary basalar measurements (mm) (n = 30)
Results
In general, the m e a n values o f the maxillary alveolar m e a s u r e m e n t s are significantly different between groups; the
m e a n values o f basal m e a s u r e m e n t s are
n o t (Tables 3 A - D ) .
Group
Anterior
N-ANS
ANS-I
mean SD
mean SD
Posterior
PNS-S
mean SD
1
2
3
49.80-+3.27
51.23+_3.24
50.01 +_2.10
25.80+0.84
25.92+_ 1.89
25.36 -t- 1.29
13.20_ 1.30
13.15+ 1.52
11.36 +_2.46
ALWOLA.
4C
4A
ES~ ~ASAL
PNS
ANS
C
4B
~~i~
ALVEOLAR
[~
BASAL
~_
~ ~
4D
[]
ct
I
..::.::~.
GP
:;.:;.::.'~.::~:::::::::,.;
~'.;g.:.:;;
~.~:~$.~:':;::~:~.'.:..:,:.
~:.~.-'~:::::::::.;:
;.:~
..'-.~':':::::~
C
HORIZONTAL
B C
GP
GP
C
VERTICAL
Fig. 4. Maxillary measurements (see Table
2). Vertical (A); horizontal (B); anterior (C);
posterior (D).
A classification of the edentulous.jaws
5A
Classification of the edentulous jaws
MANDIBLE
ANTERIOR
Since changes in dimension of the basalar process were not significant, regardless of the degree of atrophy of the
alveolar process, it was possible to produce composite diagrams showing the
most commonly observed changes in
shape of the alveolar process of the
mandible (Figs. 5A, B) and the maxilla
(Figs. 6A, B) and to develop a descriptive classification of these changes.
Class I - dentate.
Class II - i m m e d i a t e l y post extraction.
Class I I I - well-rounded ridge form,
adequate in height and
width.
Class IV - knife-edge ridge form, adequate in height and inadequate in width.
Class V
flat ridge form, inadequate
in height and width.
Class VI - depressed ridge form, with
some basalar loss evident.
MM
35
25
LABIAL
t5
15
MM
II
IV
III
VI
5B
MANOIBLE
POSTERIOR
MM
25
15
235
::i:i:i:i~i~:~:;~:i!ii (.1
=.'~===:===:===:===: ==.========U============
~!~nl:::::::::::::::::::::::::::::::::::::
3
15
IV
III
II
VI
Conclusions
Fig. 5. (A) Classification of anterior mandible (anterior to mental foramina). (B) Classification
of posterior mandible (posterior to mental foramina).
6A
ANTERIOR
MAXILLA
MM
10
20
i
lO
i
o
II
III
IV
Vl
6B
POSTERIOR
MAXILLA
Arising from these morphological studies of edentulous jaws, the following
conclusions have been drawn.
(i) Basal bone does not change shape
significantly, unless subjected to harmful local effects such as the overloading
of ill fitting dentures.
(ii) Alveolar bone changes shape significantly in both the horizontal and
vertical axes.
(iii) In general, changes of shape of
the alveolar bone follows a predictable
pattern.
(iv) Pattern of bone loss varies with
sites. Anterior mandible - bone loss is
vertical and horizontal (from the labial
aspect). Posterior mandible - bone loss
is mainly vertical. Anterior maxilla bone loss is both vertical and horizontal
(from the labial aspect). Posterior maxilla - bone loss is both vertical and horizontal (from the buccal aspect).
(v) Stage of bone loss can vary anteriorly and posteriorly and between
jaws.
MM
T
10
Io
i i ~.
II
i i i
l i L
III
IV
vI
Fig. 6. (A) Classification of anterior maxilla (B). Classification of posterior maxilla.
236
Cawood & Howell
t r e a t m e n t m e t h o d s ; help in deciding on
interceptive techniques to preserve the
alveolar process. A n awareness o f the
p a t t e r n o f resorption that takes place in
the various parts o f the e d e n t u l o u s jaw
enables clinicians to anticipate a n d avert future problems.
Such a classification serves to simplify description o f the residual ridge
and thereby assist c o m m u n i c a t i o n between clinicians: aid selection o f the app r o p r i a t e s u r g i c a l / p r o s t h o d o n t i c technique; offer an objective baseline f r o m
which to evaluate and c o m p a r e different
Acknowledgements The authors acknowledge the valuable assistance of Mr. C. West,
Medical Biostatician, University of Liverpool, Mr. R F. Wragg, Senior Registrar in
Restorative Dentistry, Glasgow Dental Hospital and Miss S. L. Maudsley, Medical Secretary.
References
Table 1A. Vertical mandibular alveolar measurements (mm) (n =45)
S
Group
I
2
3
4
SD
M
mean
SD
17.50+ 1.44
10.00_+ 1.76
9.21 __+0.94
3.40+ 1.58
16,92_+ 1.11
10.75+ i.36
7.21 ___0.73
2.80__ 1.21
mean
K
mean
SD
7,00+ 1.03
4.00+ 1.26
0.50__+0.67
-- 1.60+ 1.13
Table lB. Horizontal mandibular alveolar measurements (mm) (n=45)
S
Group
1
2
3
4
SD
M
mean
SD
mean
11.33 ___1.33
7.80__ 1.46
6.29 _ 0.87
3.50+ 1.63
10.83 ___0.70
5.20_+0.85
4.86 _ 0.46
3.00_+0.76
11.67 + 0.60
4.50+0.74
4.64 0.39
3.80_+0.66
mean
K
SD
Table 2. Maxillary alveolar and basalar measurements
Site
Vertical
alveolar
basal
N
ANS
I
C
B
Anterior
Horizontal
I-C
ANS-I
N-ANS
= nasion.
=anterior nasal spine.
= incisive foramen.
=crest of alveolar process
(adjacent to I or GP).
= widest part of alveolar process
(adjacent to I or GP).
Vertical
I-C
I-B
I-GP
GP-C
PNS-S
GP
PNS
S
Posterior Horizontal
GP-C
GP-B
GP-GP
= greater palatine foramen.
=posterior nasal spine.
=tunction of vomer with body
of sphenoid bone.
N-ANS= anterior nasal height.
S-PNS =posterior nasal height.
1. Atwood, D. A.: Postextraction changes
in the adult mandible as illustrated by
microradiographs of midsagittal sections
and serial cephalometric roentgenograms. J. Prosthet. Dent. 1963: 13:
810-824.
2. Branemark, E I., Zarb, G. & Albrektsson, T. (eds.): Tissue-integrated prostheses. Osseointegration in clinical dentistry. Berlin: Quintessence, 1985.
3. Enlow, D. H., Bianco, H. J. & Eklund,
S.: The remodeling of the edentulous
mandible. J. Prosthet. Dent. 1976: 36:
685-693.
4. Kent, J. N., Quinn, J. H., Zide, M. E,
Guerra, I. R. & Boyne, E J.: Alveolar
ridge augmentation using non-resorbable
hydroxylapatite with or without autogenous cancellous bone. J. Oral Max-fae.
Surg. 1983: 41: 629-642.
5. Mercier, E & Lafontant, R.: Residual alveolar ridge atrophy: classification and
influence of facial morphology. J. Prosthet. Dent. 1979: 41: 90-100.
Address:
J. L Cawood
Maxillofacial Unit
Royal Infirmary
Chester, CH1 2AZ
UK
