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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 1

Combination 1 Syndrome

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Page 1: Combination 1 Syndrome

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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 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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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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