Changes caused by a mandibular removable partial denture opposing a

maxillary complete denture

Ellisworth Kelly
J Prosthet Dent 2003;90:213-9.
Although many advances have been made in denture prosthetics, the great problem is still
with us: coping with the resorption of the residual alveolar ridge and managing or
preventing the secondary soft tissue changes brought on by bone loss. The resorption
occurring beneath denture bases has been investigated and we have some knowledge of
the rate of resorption of the residual bony ridge. Investigators agree that individual
differences in the rate of resorption of the ridges are very great. Underlying metabolic,
hormonal, and nutritional causes account for this difference and we know very little about
these factors. From clinical experience and clinical studies.
COMPLETE UPPER DENTURES OPPOSING PARTIAL LOWER DENTURES

Completely edentulous maxillae and partially edentulous mandibles with only anterior
teeth remaining are common situations. In the past two years,135 of 495 patients treated
in the prosthodontic clinic at the school of Dentistry of the University of California
received complete maxillary dentures opposing mandibular partial dentures. This
represents 26 per cent of the denture patients. Some of the partial dentures had distal
support but most of them did not.
THE COMBINATION SYNDROME

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, a flabby
hyperplastic connective tissue makes up the anterior part of the ridge. This hyperplastic
tissue does not support the denture base and usually it folds forward, forming a
characteristic deep fold or crease. As bone and ridge height are lost anteriorly, the
posterior residual ridge becomes larger with the development of enlarged tuberosities.
These enlarged tuberosities are usually made up of fibrous tissue, but in some patients the
bone height seems to have increased also. 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 lip, and both dentures migrate downward in the posterior region. The
esthetics 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.
MECHANICS WHICH PRODUCE THE COMBINATION SYNDROME

The resorption of the bone in the anterior region initiates the changes which we call the
combination syndrome. Natural anterior maxillary teeth have increased bony resorption
under maxillary dentures. While bone is being lost in the anterior region in the upper jaw,
bony resorption also occurs under the mandibular partial denture bases. The maxillary
denture then moves up in the anterior region and down in the posterior region in function.
This tipping action is illustrated in the diagram, which was traced from cephalometric
radiographs of a patient who had been wearing anterior to the tuberosity.

PATIENT HISTORIES WITH a complete upper denture opposing a lower partial

denture for 16 years. The fulcrum of movement in this patient is in the cuspid-first
bicuspid region. Our patients show that at first the fulcrum is well to the posterior,
CEPHALOMETRIC RADIOGRAPHS

In an effort to find answers to some of these questions, we started a study of 20 patients

who were receiving complete maxillary dentures opposing distal-extension removable
partial dentures. Only six of these patients have returned faithfully over a three-year
period so no conclusions can be drawn from this preliminary report. We made serial
cephalometric radiographs with a 0.25 mm. diameter lead wire outlining the soft tissue on
the right side of the ridge .All of the patients received maxillary complete immediate
dentures opposing Class I lower partial dentures. All were first-time denture wearers. The
immediate dentures were constructed after the posterior teeth had been extracted and a
healing period allowed. The first radiograph was made after the initial healing of the
anterior part of the maxillary ridge had taken place, and after the anterior section of the
immediate denture had been re- fitted with cold-curing acrylic resin. This was unsually
about four weeks after insertion of the dentures. A second radiograph was made after six
to eight months. The patients were seen regularly over the first few months, and the
dentures refitted and serviced as needed. After the first year, the third radiograph was
made. At this time, the maxillary denture was relined or a new denture was constructed.
After this, the patients were called annually for examination and radiographs.
SUMMARY

Almost inevitable degenerative changes develop in the edentulous regions of wearers of

complete upper and partial lower dentures. We have followed six patients over a threeyear period with cephalometric radiographs determine if these changes could be detected.
In all six subjects, early changes that could become gross changes were apparent. In one
of them degenerative clinical change is beginning to appear. This problem might be
solved with treatment planning to avoid the combination of complete upper dentures
against distal-extension partial lower dentures. The is not attractive to patients. Preserving
posterior teeth to serve as abutments to support lower partial dentures and to provide a
more stable occlusion is a better alternative. Ill-fitting dentures have been blamed for all
of the lesions of the edentulous tissues, yet the most perfect denture will be ill-fitting after
bone is lost from the anterior part of the ridge. Removable dentures need periodic
attention at least as often as the natural teeth.