combination 1 syndrome
TRANSCRIPT
Combination syndrome
Combination syndrom e
Anterior hyperfunction syndrome
“syndrome” is set of symptoms which occur together.
The glossary of prosthodontic terms defines Combination Syndrome
as: “the characteristic features that occur when an edentulous maxilla is
opposed by natural mandibular anterior teeth, including loss of bone from
the anterior portion of the maxillary ridge, overgrowth of the tuberosities,
papillary hyperplasia of the hard palatal mucosa, extrusion of mandibular
anterior teeth and loss of alveolar bone and ridge height beneath the
mandibular removable partial denture bases. Also called anterior
hyperfunction syndrome.
Ellsworth Kelly was the first person to use the term “combination
syndrome.”it was in 1972,and found in patients wearing a complete
maxillary denture, opposing a mandibular distal extension prosthesis. The
group of complications occurring in these patients are interlinked to one
another and collectively represent a syndrome
Typical clinical changes in an edentulous maxillaopposed by natural teeth, note in particular the displaceable
tissue in the anterior part of the residual ridge.
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Combination syndrome
Problems associated with the provision of a complete denture opposed
by a natural denture were described classically by Tillman in 1961 and
Kelly in1972. Tillman described the complete lower denture opposed by an
upper removable partial denture (RPD), while Kelly described the opposite
scenario. Conventional wisdom would indicate that the latter condition was
most prevalent in clinical practice. This is most likely to be the result of the
usual pattern of tooth loss in which maxillary teeth tend to be lost before
mandibular teeth.
Patient with edentulous maxillae and remaining mandibular anterior teeth.
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Combination syndrome
Clinical change s
Five signs or symptoms commonly occurred in this situation. They
include:
1. Loss of bone from the anterior part of the maxillary ridge.
2. Overgrowth of the tuberosities.
3. Papillary hyperplasia in the hard palate.
4. Extrusion of the lower anterior teeth.
5. The loss of bone under the partial denture bases
Five potential clinical changes referred to as the ‘combination
Syndrome.
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Combination syndrome
Saunders et al later described six additional signs associated with the
syndrome [Figure 3]. They include:
1. Loss of vertical dimension of occlusion.
2. Occlusal plane discrepancy.
3. Anterior spatial repositioning of the mandible.
4. Poor adaptation of the prostheses.
5. Epulis fissuratum.
6. Periodontal changes
Six additional clinical changes often found in patients with edentulous
maxillae and partially edentulous mandibles
Pathogenesi s
The Combination syndrome progresses in a sequential manner.
According to Kelly, the early loss of bone from the anterior part of the
maxillary jaw is the key to the other changes of the combination
syndrome.
With the anterior loss of bone, flabby hyperplastic connective
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Combination syndrome
tissue makes up the anterior part of the ridge. This does not support the
denture base and may fold forward with the formation of epulis
fissuratum in the maxillary labial sulcus. The posterior residual ridge
becomes larger with the development of enlarged fibrous tuberosities. With
these changes, the occlusal plane migrates up in the anterior region and
down in the back. After a time, the natural lower anterior teeth migrate
upward,
The anterior teeth on the complete denture disappear under
the patients' lips and both dentures migrate downward in the posterior
region. The aesthetics are poor, with the patient showing none of the upper
anterior teeth and too much of the lower anterior teeth and the occlusal
plane drops down to expose the upper posterior teeth.
Excessive bony resorption under the lower removable partial
denture bases occurs to permit these changes and inflammatory papillary
hyperplasia often develops in the palate
Diagnostic mounting reveals occlusal plane discrepancy and need for
tuberosity reduction
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Combination syndrome
However, Saunders suggest that the sequence of events is initiated by the
loss of mandibular posterior support, resulting in gradual decrease of
occlusal load posteriorly and an increased occlusal load anteriorly.
Eventually, this increased pressure results in resorption of the maxillary
anterior residual ridge
MECHANICS, WHICH PRODUCE THE COMBINATION SYNDROME
Kelly’s theory suggests that negative pressure within the
maxillary denture pulls the tuberosities down, as the anterior ridge is
driven upward by the anterior occlusion. The functional load will then
direct stress to the mandibular distal extension and cause bony
resorption of the posterior mandibular ridge. The upward tipping
movement of the anterior portion of the maxillary denture and the
simultaneous downward movement of the posterior portion, will
decrease antagonistic forces on the mandibular anterior teeth and lead to
their supraeruption.
Eventually an occlusal plane discrepancy will occur and the
patient may have a loss of vertical dimension of occlusion. In addition,
the chronic stress and movement of the denture will often result in an ill-
fitting prosthesis and contribute to the formation of palatal papillary
hyperplasia
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Combination syndrome
PREVALENCE AMONG DENTURE PATIENT S
Shen and Gongloff in 1989, reviewed records of 150 maxillary
edentulous patients Among patients who had complete maxillary
dentures and mandibular anterior natural teeth, one in four
demonstrated changes consistent with the diagnosis of combination
syndrome.
The changes associated with the syndrome are more likely to be
found inpatients who stress the maxillary ridge, such as in angle class III
jaw relationships and parafunctional habits and in patients who have
functioned mainly with mandibular anterior teeth for long periods.
Prevention of combination syndrom e
• Avoid combination of complete maxillary dentures opposing class I
mandibular RPD.
• Retaining weak posterior teeth as abutments by means of endodontic
and periodontic techniques.
• An overdenture on the lower teeth.
When signs of the combination syndrome have not yet appeared, the
status of the remaining mandibular anterior teeth determine the
prosthetic restoration of the lower jaw. Teeth that are relatively caries
free with minimal restorations may, with a slight alteration of contour,
support an RPD with an occlusal plane conducive to a bilateral balanced
articulation.
Two treatment approaches are suggested for patients with an
edentulous maxilla and some remaining anterior mandibular teeth. A
well-designed mandibular RPD is suggested for low-risk patients and an
overdenture for high-risk patients. The evaluation of the risk of
developing the combination syndrome is based on past dental history
and the condition of the remaining mandibular anterior teeth.
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Combination syndrome
Treatment plannin g
When planning treatment for patients with edentulous maxillae and a
partially edentulous mandible, the risk of development of the combination
syndrome must be recognized.
Systemic and dental considerations
• Review medical, dental history.
• Thorough clinical and radiographic evaluation of both hard and
soft tissues associated with pros thesis wear.
• Resolution of any inflammation, if present.
• Evaluation of patient’s caries susceptibility, periodontal status
and oral hygiene.
• Factors to be considered in tooth to be used as abutment.
(Tooth vitality, morphologic changes, number of roots, bony support,
mobility, crown- root ratio, presence and position of existing restorations,
position of teeth in the arch, the availability of retention and guide
planes.)
Basic treatment objectiv e
Saunders et al in 1979 stated that the basic treatment objective
in treating these patients is to develop an occlusal scheme that discourages
excessive occlusal pressure on the maxillary anterior region, in both centric
and eccentric positions.
They also stated some specific treatment objectives:
• The mandibular RPD should provide positive occlusal support from the
remaining natural teeth and have maximum coverage of the basal seat
beneath the distal extension bases.
• The design should be rigid and should provide maximum stability
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Combination syndrome
while minimizing excessive stress on remaining teeth.
• The occlusal scheme should be at a proper vertical and centric relation
position.
• Anterior teeth should be used for cosmetic and phonetic purpose only.
•Posterior teeth should be in balanced occlusion. Patient education and
frequent recall and maintenance care are essential, if the development
of this insidious syndrome is to be avoided.
Malposed, tilted or over-erupted teeth in the opposing arch are
prone to induce unfavorable occlusal contacts, which in turn may lead to
compromised denture stability. This may then cause discomfort, trauma
(which may result increased alveolar resorption) and social
embarrassments a result of movement of the prosthesis. Some authors
have recommended that the opposing dentition should be modified to give
a more favourable occlusal plane and geometry.
It is suggested that this might be achieved either by re-shaping the
occlusal surfaces by grinding, by provision of a removable onlay appliance
or alternatively more extensive fixed restorations.
Treatment approache s
• In 1985, Stephen M. Schmitt described a treatment approach that
attempted to minimize the destructive changes, by using the treatment
objectives of Saunders et al.
- The prosthesis is made in 2 stages.
- Mandibular RPD is completed first.
- Acrylic resin teeth are used to replace the maxillary anterior teeth.
- Cast gold occlusal surfaces for posterior denture teeth. Or using either
alight-cured composite resin, or amalgam.
• Mandibular overdenture provided better prognosis in patients who already
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Combination syndrome
had combination syndrome and whose mandibular anterior teeth were
structurally or periodontally compromised.
An upper complete denture illustrating the use of amalgam
to form customised occlusal surfaces opposing natural teeth.
Modalities of Treatment for the Combination Syndrome
prosthodontic treatment is designed to provide posterior occlusal
support and to minimize occlusal pressures in the anterior maxilla.
Kelly said that before proceeding with the prosthetic treatment, gross
changes that have already taken place should be surgically treated. These
include conditions like:
• Flabby (hyperplastic) tissue
• Papillary hyperplasia
• Enlarged tuberosities
Lower partial denture base should be fully extended and should cover
retromolar pad and buccal shelf area
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Combination syndrome
Supraerupted Teeth
Teeth that are considerably supraerupted would require alteration by
shortening, crowning, or placing them under an overdenture to obtain a
harmonious occlusion. If the incisal edges of the mandibular anterior
teeth are compared with the level of the resorbed posterior residual
ridges, the teeth may be mistakenly interpreted as being extruded. The
level of the incisal edges of the mandibular anterior teeth should be
assessed in comparison to the proposed posterior occlusal plane
Compared with the excessively resorbed posterior
ridge, these teeth seem extruded.
When viewed together with the proposed occlusal plane
provided by the recording base and occlusal rim, the teeth are
not extruded.
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Combination syndrome
Mandibular posterior alveolar ridge conservation:
The mandibular posterior alveolar ridge may also be conserved
by leaving teeth or roots. At the same time, retained anterior maxillary
roots will absorb occlusal forces exerted by anterior mandibular teeth.
Long rooted maxillary canines strategically placed at the corners of the
maxillary arch are favored. When labial undercuts are present and
cannot be surgically corrected, the peripheral seal of the denture may be
compromised. The reduction in retention can be compensated for by
incorporating precision attachments into the roots of the anterior teeth
The use of the mandibular RPD
The maxillary impression is made in a specially designed tray
using a combination of elastomeric impression materia and impression
plaster without distorting the anterior residual ridge
The mandibular RPD is supported anteriorly by cingulum rests
on the canines with a lingual plate as the major connector.
The lingual plate delays the overeruption of the mandibular teeth,
preventing undesirable anterior pressure on the anterior part of the
maxillary denture. It also facilitates accurate positioning of the RPD
during relining procedures. Optimum fit of the denture base is achieved
using the altered cast technique.
Posteriorly, maximum support is obtained by extending the
denture base to cover the retromolar pad. The attachments of the
buccinator, superior constrictor, and temporalis muscles to the retromolar
pad and the overlying firmly bound masticatory mumsa provide a stress-
bearing region that is relatively resistant to resorptive change thereby
maintaining posterior occlusal contact.
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Combination syndrome
Coverage of the horizontal buccal shelf with its superior layer
of cortical bone, submucous layer with glandular connective tissue, and
buccinator muscle fibers provides primary- support for the denture base.
Maximum occlusal support posteriorly with no contact
anteriorly in centric occlusion and a balanced articulation in eccentric
movements further reduce pressure on the anterior maxillary ridge.
limitations
Despite the lingual plate, the mandibular anterior teeth may
continue to erupt, in the absence of anterior tooth contact,
overloading of the mandibular posterior ridge and consequent rapid
alveolar resorption may occur. Posterior occlusal contact must be
maintained by constant relining of the distal extension denture base
to compensate for its resorption.
The restoration of the posterior occlusion within RPD will
not entirely delay a progressing combination syndrome. Therefore, it
is advocated for situations that may eventually develop a
combination syndrome but nevertheless have shown a stable
Occlusion in the past.
An upper complete denture, opposed by a partially dentate lower arch
which has been restored with a tooth and mucosal borne partial denture.
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Combination syndrome
The use of the teeth supported overdenture .
This more radical approach is also required when mandibular
anterior teeth have large structural defects or a weakened
periodontium and are unable To withstand normal occlusal loading.
An optimum anterior tooth relationship with minimum incisal
guidance and no contact in centric occlusion may be difficult to
create when there is a step in the occlusal plane because of the
overeruption of the anterior dental complex. The teeth are treated
endodontically and reduced to the gingival level, and an overdenture
is constructed that is supported and retained by the roots of the
residual teeth.
All teeth in the mandibular jaw are, therefore, part of one
restoration enabling the occlusal load to be shared more evenly
between the posterior edentulous ridge and the remaining anterior
roots. The traumatizing edge-to-edge relationship of the incisal teeth
is replaced by a horizontal and vertical overlap, while maintaining
phonetics and esthetics
Additional retention for the mandibular denture may be provided by
stud attachments cemented to the retained roots. Support is
maintained posteriorly by maximum tissue coverage
Mandibular implant-supported overdenture
offers significant improvement in retention, stability, function and comfort for
the patient and a more stable and durable occlusion.
I mplant supported fixed prosthesis .
•In 2001, Wennerberg et al reported excellent long term results with
mandibular implant supported fixed prostheses, opposing maxillary
complete dentures.
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Combination syndrome
Implants used to support and retain mandibular prosthesis
Augmentation of maxilla
- Augmentation of maxilla with resorbable hydroxyapatite in
conjunction with a guided tissue regeneration technique and
vestibuloplasty.
- Day after Surgery, the soft tissue takes on the created shape of the
inner surface of the denture. The denture must fit grafted tissue loosely
Grafting SOFT TISSUE with HydroxylapatiteGrafting SOFT TISSUE with Hydroxylapatite
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Combination syndrome
Patient’s maxillary dental arch six months post-operatively
Maxillary tissue is no longer loose, now has load bearing capabilities
reducing enlarged tuberosities
Kelly' who advises reducing enlarged tuberosities to allow
the lower RPD to extend over the retromolar pad. Even weak posterior
teeth should be retained as abutments with endodontic and
periodontic techniques.
splinting the remaining mandibular anterior teeth
Saunders also advocate splinting the remaining mandibular anterior
teeth to provide the RPD with positive occlusal support, rigidity, and
stability, while minimizing excessive stress on the teeth.
implants beneath the distal extension base
Keltjens advocate placing implants beneath the distal extension base
of mandibular RPD to provide a stable posterior support.
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Combination syndrome
combination syndrome does not meet the criteria to be accepted as
a medical syndrome
Sigvard Palmqvist et al in 2003, reviewed the literature on the
combination syndrome and related features such as alveolar bone
loss, bone resorption, maxillary tuberosities, denture stomatitis and
maxillary abnormalities, all combined with removable partial denture
variables.
They concluded that combination syndrome does not meet the
criteria to be accepted as a medical syndrome. The single features
associated with the combination syndrome exist, but to what extent or in
which combination has not been clarified.
No epidemiologic study of “combination syndrome.” Compared
with the main feature," loss of bone from the anterior portion of the
edentulous maxilla,” findings such as “papillary hyperplasia of the hard
palatal mucosa” seem to be rare. Enlarged tuberosities may also have
other causes than those described by Kelly as part of the combination
syndrome.
Enlarged tuberosities are often seen together with supraerupted
maxillary molars. In situations where mandibular molars have been lost,
the opposing maxillary molars may supraerupted together with the alveolar
process. The supraeruption may create enlarged tuberosities without
influence of a denture.
There seems to be no prospective study of the “combination
syndrome” in spite of the fact that many people have been provided with a
complete maxillary denture opposed by anterior mandibular teeth with or
without aclassI mandibular RPD. A long-term 21-year study of patients
wearing complete maxillary dentures provided no support for a systematic
development of the “combination syndrome.”
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Combination syndrome
This does not mean that the observations made by Kelly2 were
false. In the title of his article, he emphasized the negative role of the
mandibular RPD. The same view was expressed by Keltjens etal,55 who
found the traditional treatment for an edentulous maxilla opposed by a
partially edentulous mandible with a complete denture and a Class I
mandibular RPD to be “fundamentally inadequate.” The authors also
suggested use of implants for distal support.
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