COMBINATION SYNDROME

An excerpt from Clinical Update, a publication of the Navy Postgraduate Dental School
in Bethesda, aryland, vol! "#, No! $
Commander %regory &! 'eating, DC, USN
Purpose
(apid bone resorption and subse)uent soft tissue changes beneath removable prostheses
are often perplexing and disheartening to both patient and clinician! *he purpose of this
Clinical Update is to define the term combination syndrome and present current
prevention, treatment, and maintenance strategies employed in preserving bone!
Background
+n "#,-, 'elly
"
coined the term combination syndrome, a descriptive term recogni.ing
five characteristic changes occurring /ith time and often combined in a combination
case0a mandibular distal extension removable partial denture opposing a maxillary
complete denture! *he five characteristic features typically present in patients diagnosed
/ith combination syndrome are1
"2
Bone loss in the anterior aspect of the maxillary ridge!
-2
*uberosity do/ngro/th or overgro/th 3/ith or /ithout sinus pneumati.ation2!
$2
Palatal papillary hyperplasia!
42
5ypereruption of the mandibular anterior teeth!
62
Bone loss beneath the removable partial denture bases!
72
8ther investigators have identified at least six associated changes that may also occur!
-,$
a! Decrease in occlusal vertical dimension!
b! 8cclusal plane discrepancies!
c! Anterior repositioning of the mandible!
d! Poor adaptation of one or both prostheses!
e! 9puli formation!
f! Periodontal changes!
Discussion
Although longitudinal studies indicate that generali.ed resorptive patterns occur /ith
time,
4
bone resorption beneath removable prostheses is complex and poorly understood!
*he rate of resorption is affected by many variables and predisposing factors, such as
extraction history, )uality and use of the prosthesis, parafunctional forces, and systemic
diseases li:e diabetes and osteoporosis!
6
Also, considerable variation in resorptive rates
exists among individuals! ost astonishing are the extreme cases0the person /hose bone
resorbs rapidly and continuously despite extreme preventive measures and the person
/hose edentulous ridges respond very favorably despite heavy functional and
parafunctional forces! *he typical patient, ho/ever, falls bet/een these extremes and is
able to tolerate moderate, intermittent, compressive forces! Patients /ith a high ;ran:furt
mandibular plane angle and severe parafunctional forces, such as heavy clenching or
grinding, demonstrate the most trauma to the residual ridges!
4
Normal, functional forces
load the denture0bearing areas for about
6
minutes a day as opposed to ",!6 minutes a day
for those demonstrating parafunction!
7
*allgren<s longitudinal study4 sho/ed that, on
average in edentulous patients after the first
,
years, the mandible resorbed four times
faster than the maxilla, probably because the mandible has a smaller bearing area, a less
advantageous shape for broad stress distribution, and it lac:s the secondary bearing area
afforded by the hard palate! Also, most of the bone resorption in both arches occurred
during the first year!
4
Numerous studies of ridge preservation clearly demonstrate the
advantages of immediate dentures, retaining overdenture abutments, and utili.ing such
concepts as broad stress distribution, peripheral seal, minimal anterior tooth contact, and
balanced occlusal schemes!
,
*o mitigate bone loss, the most critical time period is during
the first year after initial delivery!
4
Sadly, during this time, recall and maintenance are
often overloo:ed or brushed aside by practitioner and=or patient because the patient has
>ust been recently restored! +nitial changes to the bearing bone are greatest early,
especially in immediate and recent extraction cases, and occur to some degree in all
cases! Such changes usually are painless and do not initially degrade function, comfort,
or support, and they remain unobserved by the patient!
A "Typical" Scenario
A revie/ of the hard and soft tissue changes occurring /ith time in a typical combination
case /ill elucidate ho/ and /hy such unto/ard changes occur!
?oss of mandibular posterior support occurs first as the ne/ mandibular (PD loads the
primary denture0bearing areas, and initial resorption begins! Buccal shelf areas and the
posterior crest of the ridge resorb faster if immature extraction sites are present, the
patient has never /orn a distal extension (PD before, or a corrected cast techni)ue or
suitable post0delivery reline /as not done! 8bviously, if the patient refuses to /ear the
mandibular prosthesis or one /as not fabricated, then the advantages of prosthodontically
augmented posterior support are gone! An exception to this may be found in a severe
Angle<s Class =", division ", malocclusion case in /hich sufficient posterior support may
exist if enough premolars are present!
@
As mandibular posterior support is lost the occlusal load shifts anteriorly! Aith artificial
tooth /ear, for/ard0posturing of the mandible, and increased anterior protrusive contact,
the maxillary anterior ridge resorbs in response to unto/ard forces generated by the
remaining natural teeth through the displaced maxillary denture base! &arying degrees of
soft tissue change and support occur, especially in the maxillary anterior ridge area!
Aith continuing /ear and displacement of the maxillary complete denture superiorly and
anteriorly, the occlusal plane drops posteriorly, and the occlusal vertical dimension
decreases! 8ften, epuli form at the maxillary labial flange, and fibrous connective tissue
overgro/th occurs, overlaying the tuberosities! Because of poor adaptation to the
underlying mucosa and probable poor oral hygiene, inflammatory papillary and palatal
hyperplasia occur, and the patient may notice decreased retention of the complete denture
and see: a reline! +f a reline is done /ithout correcting the etiologic conditions and=or
/ithout proper tissue conditioning, the pathologic processes are perpetuated, often at an
accelerated rate!
Depending on the periodontal support, the remaining natural teeth may flare, extrude,
and=or become more mobile! BPneumati.ationB of the tuberosities 3the mechanism of this
is not clearly understood2 may occur, and the shifted plane of occlusion and lac: of
posterior support may result in mucosal stripping at the ma>or connector and further
stress placed on the natural teeth! *hese events, usually occurring together, are the
hallmar: of combination syndrome, /hich /ill occur unless proper diagnosis, treatment
planning, execution of treatment, and proactive recall and maintenance are done!
Planned Pros!odonics and Pre"enion
*he concept of Bplanned prosthodontics B encourages astute clinical evaluation that
discerns not only the early signs and symptoms of combination syndrome, but also
recogni.es the possibility of the syndrome<s occurring and the treatment potential of the
patient!
*o satisfy the fundamental criteria of support, function, and esthetics in rehabilitating
these patients and preventing or limiting further degradation /ith time, the follo/ing
concepts should be considered!,
"!
Preserve overdenture abutments in the mandibular posterior
and=or maxillary anterior! +f these abutments and overlaying prosthesis are
physiologically ad>usted to be loaded only under forceful biting pressure, they
/ill serve a very useful proprioceptive, bone0sparing function!
#
-!
Consider restoring the mandibular posterior occlusion utili.ing
current implantology techni)ues! *hen, restore the maxillary arch /ith a single0
unit denture!
$!
Stay abreast of research involving implant fixtures, such as
overdenture abutments, and consider using this treatment modality /hen
indicated!
"C0"$
4!
Correct plane of occlusion discrepancies and vertical
dimension problems prior to definitive treatment!
6!
*issue0condition prior to impression ma:ing!
7!
Utili.e acceptable impression techni)ues, and apply the
principle of broad stress distribution!
,
,!
+f possible, BhardenB surfaces of artificial teeth to prevent
premature /ear! Consider amalgam inserts or metallic occlusal surfaces!
"4
@!
aintain careful records of pla)ue control, mobility patterns,
and poc:et depths!
#!
9ducate your patientD Demand meticulous oral hygiene and
care of the prostheses, and be sure the patient leaves the prostheses out of the
mouth daily for at least @ hours! 9mphasi.e the vital importance of recall,
maintenance, and a/areness of parafunctional habits!
Recall and Mainenance
Bone resorption beneath complete dentures, distal extension removable partial dentures,
and extensive 'ennedy Class +& removable partial dentures occurs painlessly and most
extensively during the first year of functional use! (ecall and maintenance visits during
this period are critical to limiting initial bone loss and preserving remaining bone!
9ducating the patient in oral hygiene and prosthesis home care techni)ues and in the
importance of maintenance visits is vital to success!
After post0delivery visits at -40hours, "0/ee:, and "0month, maintenance appointments
should be scheduled at $ months, 7 months, and " year during the first year!
9ach maintenance appointment should include, but not be limited to, the follo/ing1
"! 9xtraoral observations /ith the prostheses /orn! S/allo/ing should be easy,
unstrained, and /ith light posterior bracing! ?oo: carefully for for/ard thrusting of
the mandible! +f deemed necessary by observation, )uery the patient about tongue
position and possible tongue thrusting!
-! &erify that the &D8, &D(, and closest0spea:ing space are /ithin normal limits!
$! +ntraorally, evaluate the prostheses for stability and retention! As: the patient about
comfort and function!
4! As: the patient to remove the prostheses, /atching for removal problems, and
assess cleanliness! Chec: the finished and intaglio surfaces for possible tampering
by the patient! ?oo: for /ear in areas you /ould hope to see it00the more posterior
the better!
6! &isually observe and palpate intraoral structures as you conduct an oral cancer
screening examination! Chec: and record mobility patterns, poc:et depths, and
pla)ue control efforts!
7! As: the patient to insert the prostheses, and /atch for insertion problems! Place
cotton rolls bilaterally in the premolar areas and have the patient close gently for
about "C minutes! &erify that centric relation position and maximum intercuspal
position 3centric occlusal position, if cuspless teeth are used2 are coincident and that
eccentric movements are easy and maintain balance! Protrusive contacts should
still be very light, if at all!
,! (emove the prostheses and chec: primary and secondary denture0bearing areas!
Apply disclosing /ax to the peripheries, crest of the ridge areas, and buccal shelf
areas of the (PD and reinsert it! Apply the /ax to the premaxillary area and
hamular notches of the CD and to any periphery areas that appear to be insulting the
vestibular mucosa, and reinsert the denture! (earticulate the patient in centric
relation position, and have him=her bite firmly on the posterior teeth for a fe/
minutes!
@! &erify that intimate contact occurs in all primary denture0bearing areas!
#! Disclosing /ax gives a satisfying three0dimensional representation that can be
measured /ith a periodontal probe or explorer! Pressure0indicator paste is not as
useful for this purpose!
"C! Assess the need for relining, if alveolar resorption has occurred
enough to /arrant it! (ecord your assessment in the patient record and follo/ up
/ith treatment, if indicated!
""! +f C( and C8 are not coincident, the patient has inade)uate
posterior contact, the patient postures for/ard to function, and=or the articulation in
excursions is not balanced, do a patient remount using a periphery or putty cast for
the CD, a cast made /ith a pic:up impression of the (PD 3poured in stone and=or
lo/0fusing metal2, a facebo/ transfer, and repeatable records! Assess the need for
e)uilibration, relining, rebasing, and=or rema:ing!
"-! 9xpect to see early resorption in all immediate cases and those
in /hich extractions /ere made /ithin 7 months of delivery!
"$! (etention, although not as important as support and stability, is
significant and of concern to the patient! 8verdenture abutments may need to be
reduced in height, repolished, and corresponding areas in the prosthesis
physiologically relined and ad>usted!
"4! Both prostheses should be thoroughly cleaned and lightly
repolished! Areas that retain calculus despite the patient<s heroic efforts at cleaning
should be recontoured and repolished to be less pla)ue0retentive!
"6! (evie/ and reinforce pla)ue control and the care and cleaning
of the prostheses! Do a prophylaxis of the remaining natural teeth or appoint the
patient!
"7! 9ncourage the patient to as: )uestions and become involved in
treatment and maintenanceD
(ecall and maintenance for combination case patients cannot be overemphasi.ed! *he
goal of getting through the first year /ith minimal bone resorption and other changes to
hard and soft tissues is achievable only through careful recall, maintenance, and follo/0
up treatment! Semiannual maintenance appointments should be conducted after the
critical first year!
Conclusions
Support and function suffer if supporting bone is lost! Ahen a patient<s tooth loss pattern
approaches that encountered in a combination case0a fe/ remaining natural teeth, usually
in the mandibular anterior, opposing an edentulous maxilla0/arning bu..ers should go
off in the mind of the educated clinician, because the challenge to successfully restore the
patient /hile preserving supporting bone and protecting the mucosa re)uires astute
diagnosis, sensible treatment planning, careful treatment, and proactive maintenance!
Re#erences
1. Kelly E Changes caused by a mandibular removable partial denture opposing a
maxillary complete denture. J Prosthet Dent 197!!7.!1"#$%#.
. &ruce '( Complete dentures opposing natural teeth. J Prosthet Dent 1971!).""*$
%%.
+. ,aunders -'! .illis 'E! Des/ardins 'P. -he maxillary complete denture opposing the
mandibular bilateral distal$extension partial denture0 -reatment considerations. J
Prosthet Dent 1979!!"101"$*.
". -allgren 1. -he continuing reduction o2 the residual alveolar ridges in complete
denture 3earers0 1 mixed$longitudinal study covering % years. J Prosthet Dent
1!97!!7.!1#$+.
%. ,tahl ,,! (isan J4! 4iller ,C. -he in2luence o2 systemic diseases on alveolar bone. J
1m Dent 1ssoc 19%!"%.77.
). 5eart3ell C4! 'ahn 16. ,yllabus o2 complete dentures. "th ed. 7ea 8 9ebiger
19*%!!""
7. &oucher C6. 1 critical analysis o2 mid$century impression techni:ues 2or 2ull
dentures. J Prosthet Dent 19%1;l<0"7$91.
*. Ellinger C(! 'ayson J5! 5enderson D. ,ingle complete dentures. J Prosthet Dent
1971!!)0"$1#.
9. Carlsson .E! -hilander 5! 5edegard &. 5istologic changes in the upper alveolar
process a2ter extractions 3ith or 3ithout insertion o2 an immediate 2ull denture. 1cta
6dont ,cand 19)7!!%01+$").
1#. 7ing:uist 7 (! 'oc=ler &! Carlsson .E. &one resorption around 2ixtures in
edentulous patients treated 3ith mandibular 2ixed tissue$integrated prostheses. J
Prosthet Dent 19**>%90%9$)+.
11. Eng:uist &! &ergendal -! Kallus -! 7inden ?. 1 retrospective multicenter evaluation
o2 osseointegrated implants supporting overdentures. @nt J 6ral 4ax 9ac @mpl
19**>+019$+".
1. von (o3ern A! 5arder 9! 5/orting$5ansen E! .ot2redsen K. @-B implants 3ith
overdentures0 1 prevention o2 bone loss in edentulous mandiblesC @nt J 6ral 4ax 9ac
lmpl 199#!!%01+%$9.
1+. ,ennerby 7! Carlsson .E! &ergman &! (ar2vinge J. 4andibular bone resorption in
patients treated 3ith tissue$integrated prostheses and in complete denture 3earers. 1cta
6dont ,cand 19**>")01+%$"#.
1". (allace D. -he use o2 gold occlusal sur2aces in complete and partial dentures. J
Prosthet Dent 19)"> 1"0+)$++.
Dr! 'eating is an instructor in Prosthodontics at the Naval Dental School *he opinions or
assertions contained in this article are the private ones of the /riter and are not to be
construed as official or as reflecting the vie/s of the Department of the Navy!