NAMA : Anggun Amanda Saveria

NIM : 31101500478
LI LBM 2 BLOK 19

1. Patogenesis terjadinya combination syndrome?

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 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. (Sridharan
Rajendran 2012)
Sumber: Sridharan Rajendran, B., 2012. Combination syndrome. Int J Prosthodont Restor Dent, 2(1),
pp.156–160.

2. Apa saja pertimbangan yang perlu dilakukan untuk perawatan combination syndrome?
- Review medical, dental history.
- Thorough clinical and radiographic evaluation of both hard and soft tissues associated with
prosthesis 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, crownroot ratio, presence and position of
existing restorations, position of teeth in the arch, the availability of retention and guide
planes.)
Kelly[2] 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. (Sridharan Rajendran 2012)
Sumber: Sridharan Rajendran, B., 2012. Combination syndrome. Int J Prosthodont Restor Dent, 2(1),
pp.156–160.

3. Bagaimana gambaran radiograf dari combination syndrome? Gambar

Sumber: Cabianca, M. et al., 2013. Combination Syndrome: Treatment With Dental Implants.
International Journal of Dental Clinics, 2(1), pp.67–71. Available at:
http://ejum.fsktm.um.edu.my/ArticleInformation.aspx?ArticleID=670%5Cnhttp://dx.doi.org/10.
1016/S2212-4268(12)60016-5%5Cnhttp://www.prosthod.org.tw/doc/mgzp/1-1/apd_mgz_p1-1-
4.pdf%5Cnhttp://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00.

4. Apa saja pemeriksaan sebelum dilakukan perawatan combination syndrome?

(Resende et al. 2014)

(Cabianca et al. 2013)

Sumber: Cabianca, M. et al., 2013. Combination Syndrome: Treatment With Dental Implants.
International Journal of Dental Clinics, 2(1), pp.67–71. Available at:
http://ejum.fsktm.um.edu.my/ArticleInformation.aspx?ArticleID=670%5Cnhttp://dx.doi.org/10.
1016/S2212-4268(12)60016-5%5Cnhttp://www.prosthod.org.tw/doc/mgzp/1-1/apd_mgz_p1-1-
4.pdf%5Cnhttp://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00.
Resende, C.M.B.M. de et al., 2014. Signs of Combination Syndrome and removable partial denture
wearing. Revista de Odontologia da UNESP, 43(6), pp.390–395. Available at:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-
25772014000600390&lng=en&tlng=en.

5. Bagaimana cara melakukan prosedur MMR dan dimensi vertikal? Free way space
 Pengertian relasi vertikal : Jarak vertikal rahang atas dan rahang bawah yang dapat memberikan
ekspresi normal pada wajah seseorang.
1. Relasi vertikal posisi istirahat : adalah suatu hubungan rahang atas dimana otototot membuka
dan menutup mulut dalam keadaan seimbang. Relasi vertikal ini diukur pada waktu rahang bawah
dalam keadaan istirahat fisiologis.
2. Relasi vertikal oklusi : adalah suatu hubungan rahang bawah terhadap rahang atas, gigi geligi
atau oklusal rim dioklusikan. Relasi vertikal ini diukur sewaktu gigi dalam oklusi sentrik.
Yang dimaksud dengan FREE WAY SPACE adalah celah yang terdapat antara rahang atas dan
rahang bawah dalam keadaan istirahat yang merupakan selisih antara relasi vertikal istirahat dan
relasi vertikal oklusi keadaan normal berkisar antara 2-4 mm.
Cara pengukuran relasi vertikal:
1. Relasi vertikal posisi istirahat
a. Tentukan dua titik pada wajah penderita sejajar dengan median line, yaitu pada dagu dan di atas
bibir/hidung. Pengukuran dilakukan dengan menggunakan rol dan kaliper.
b. Pasien disuruh menghiting satu hingga sepuluh serta mempertahankan posisi rahangnya pada
hitungan ke sepuluh, pada saat tersebut jarak kedua titik diukur.
c. Kemudian penderita disuruh mengucapkan beberapa kata yang berakhiran “ S “ dan diukur
kembali jarak kedua titik tersebut.
d. Seterusnya penderita disuruh menelan dan dalam keadaan rileks dilakukan pengukuran yang
ketiga. Apabila jarak ketiga pengukuran tersebut sama, inilah merupakan relasi vertical posisi
istirahat.
2. Relasi vertikal oklusi
Pengukuran dilakukan setelah oklusal rim diletakkan dalam mulut penderita. Oklusal rim rahang
atas dimasukkan, kemudian perhatikan kembali bentuk wajah penderita apakah sudah sesuai
dengan ekspresi normal dari penderita.
Kemudian masukkan oklusal rim rahang bawah, pasien disuruh menghentikan rahang atas dan
rahang bawah dalam keadaan sentrik oklusi, ukur kembali jarak antara kedua titik tersebut, akan
berkurang 2-4 mm dari jarak relasi vertikal posisi istirahat. Inilah yang disebut jarak relasi
vertikal oklusi.
TEST KETEPATAN RELASI VERTIKAL MELAUI FONETIK
Posisi “S” menunjukkan hubungan gigi depan rahang bawah terhadap gigi depan rahang atas yang
dapat menghasilkan suara “S” sewaktu berbicara. Hal ini merupakan posisi yang tepat bila jarak
antara tepi insisal gigi depan rahang bawah dan rahang atas kira-kira 1-1,5 mm sewaktu huruf “S”
diucapkan.
Jika terjadi kontak antara tepi insisal gigi depan rahang atas dan rahang bawah, menunjukkan
relasi vertikal yang tinggi. Bila jarak ucapan melebihi dari 1-1,5 mm. Kemungkinan tepi insisal
gigi depan rahang bawah berkontak dengan palatum, pada saat pasien dalam relasi sentrik.
Keadaan ini menunjukkan relasi vertikal yang rendah.
Kehilangan gigi bagian belakang akan mempengaruhi pengucapan pada pasien sewaktu
mengucapkan huruf tertentu. Bila huruf “TH” dan “T” tidak jelas diucapkan oleh pasien, biasanya
disebabkan karena relasi vertikal yang tinggi. Kontrol fonetik pada pasien yang kehilangan gigi
bagian belakang dapat dikoreksi dengan menyebutkan huruf “TH” dan “T”, dimana jarak maksilo
mandibular kira-kira 1,5 mm. Keadaan ini juga membantu dalam meneliti kembali jarak relasi
vertikal yang telah ditentukan. (Space & Space 2009)
Sumber: Space, F.W.A.Y. & Space, F.W.A.Y., 2009. Hubungan Rahang Pada Pembuatan Gigi-. ,
pp.1–5.

6. Perawatan untuk combination syndrome?

 Treatment approaches
• In 1985, Stephen M. Schmitt[5] 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.
• Mandibular overdenture provided better prognosis in patients who already had combination
syndrome and whose mandibular anterior teeth were structurally or periodontally compromised.
• Mandibular implant-supported overdenture offers significant improvement in retention, stability,
function and comfort for the patient and a more stable and durable occlusion
• Implant supported fixed prosthesis.
• Some form of stabilization of the maxillary arch.
- retention of maxillary overdenture abutments.
- maxillary osseointegrated implants.
- augumention of maxilla with resorbable hydroxyapatite in conjunction with a guided tissue
regeneration technique and vestibuloplasty.
• In 2001, Wennerberg et al reported excellent longterm results with mandibular implant
supported fixed prostheses, opposing maxillary complete dentures.
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. (Sridharan Rajendran 2012)
Sumber: Sridharan Rajendran, B., 2012. Combination syndrome. Int J Prosthodont Restor Dent, 2(1),
pp.156–160.

7. Apakah yang menyebabkan pasien merasakan sakit saat makan?

8. Berapa lama jangka waktu ketahanan dari gigi tiruan?

Increasing pressure on the premaxillary alveolar ridge and loss of adequate posterior occlusal
contacts are impor tant factors in relation to combination syndrome. The bone loss in the midline
of the maxilla observed by Kelly (1972) was 0.43 mm/year. López-Roldán etal (2009)8 and
Barber et al (1990)9 reported similar results (0.32 mm/year and 0.36 mm/year, respectively)
among patients wearing a maxillary complete denture and mandibular overdentures on two
implants, a situation in which the prosthetics are biomechanically similar to Kelly's cases.
The ef fect of mandibular status on maxillary ridge resorption has been widely discussed and
investigated. Carlsson etal (1967) compared bone resorption of the anterior maxillary alveolar
ridge among patients with maxillary complete dentures and three dierent mandibular statuses: (1)
a mandibular complete denture; (2) mandibular anterior teeth with bilateral extension RPD;
and (3) mandibular teeth only. Greater bone resorption was found in the groups that had anterior
mandibular teeth with or without an RPD when compared to the group with mandibular teeth
only. However, small and insignificant changes of the bone height were described over five-years
of follow-up in patients with a maxillary complete denture opposed by a bar-retained mandibular
RPD. (Cabianca et al. 2013)
Sumber: Cabianca, M. et al., 2013. Combination Syndrome: Treatment With Dental Implants.
International Journal of Dental Clinics, 2(1), pp.67–71. Available at:
http://ejum.fsktm.um.edu.my/ArticleInformation.aspx?ArticleID=670%5Cnhttp://dx.doi.org/10.
1016/S2212-4268(12)60016-5%5Cnhttp://www.prosthod.org.tw/doc/mgzp/1-1/apd_mgz_p1-1-
4.pdf%5Cnhttp://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00.