Combination Syndrome

PURPOSE
Rapid bone resorption and subsequent soft tissue changes beneath removable prostheses are often perplexing and disheartening to both patient and clinician. The 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
In 1972, Kelly1 coined the term combination syndrome, a descriptive term recognizing five characteristic changes occurring with time and often combined in a combination case-a mandibular distal extension removable partial denture opposing a maxillary complete denture. The five characteristic features typically present in patients diagnosed with combination syndrome are: 1) Bone loss in the anterior aspect of the maxillary ridge. 2) Tuberosity down growth or overgrowth (with or without sinus pneumatization). 3) Palatal papillary hyperplasia. 4) Hyper eruption of the mandibular anterior teeth. 5) Bone loss beneath the removable partial denture bases. 6) Other investigators have identified at least six associated changes that may also occur. 2,3 a. b. d. Decrease in occlusal vertical dimension. Occlusal plane discrepancies. Poor adaptation of one or both prostheses.

c.Anterior repositioning of the mandible. e.Epuli formation. f. Periodontal changes.

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Combination Syndrome
DISCUSSION Although longitudinal studies indicate that generalized resorptive patterns occur with time,4 bone resorption beneath removable prostheses is complex and poorly understood. The rate of resorption is affected by many variables and predisposing factors, such as extraction history, quality and use of the prosthesis, parafunctional forces, and systemic diseases like diabetes and osteoporosis.5 Also, considerable variation in resorptive rates exists among individuals. Most astonishing are the extreme cases-the person whose bone resorbs rapidly and continuously despite extreme preventive measures and the person whose edentulous ridges respond very favorably despite heavy functional and parafunctional forces. The typical patient, however, falls between these extremes and is able to tolerate moderate, intermittent, compressive forces. Patients with a high Frankfurt 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 denture-bearing areas for about 5 minutes a day as opposed to 17.5 minutes a day for those demonstrating parafunction.
6

Tallgren's longitudinal study4 showed that, on

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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 lacks 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 utilizing such concepts as broad stress distribution, peripheral seal, minimal anterior tooth contact, and balanced occlusal schemes.7 To 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 overlooked or brushed aside by practitioner and/or patient because the patient has just been recently restored. Initial 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.
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Combination Syndrome
A "TYPICAL" SCENARIO A review of the hard and soft tissue changes occurring with time in a typical combination case will elucidate how and why such untoward changes occur. Loss of mandibular posterior support occurs first as the new mandibular RPD loads the primary denture-bearing 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 worn a distal extension RPD before, or a corrected cast technique or suitable post-delivery reline was not done. Obviously, if the patient refuses to wear the mandibular prosthesis or one was 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 /1, division 1, malocclusion case in which sufficient posterior support may exist if enough premolars are present.8 As mandibular posterior support is lost the occlusal load shifts anteriorly. With artificial tooth wear, forward-posturing of the mandible, and increased anterior protrusive contact, the maxillary anterior ridge resorbs in response to untoward forces generated by the remaining natural teeth through the displaced maxillary denture base. Varying degrees of soft tissue change and support occur, especially in the maxillary anterior ridge area. With continuing wear and displacement of the maxillary complete denture superiorly and anteriorly, the occlusal plane drops posteriorly, and the occlusal vertical dimension decreases. Often, epuli form at the maxillary labial flange and fibrous connective tissue overgrowth 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 seek a reline. If a reline is done without correcting the etiologic conditions and/or without proper tissue conditioning, the pathologic processes are perpetuated, often at an accelerated rate.
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Combination Syndrome
Depending on the periodontal support, the remaining natural teeth may flare, extrude, and/or become more mobile. "Pneumatization" of the tuberosities (the mechanism of this is not clearly understood) may occur, and the shifted plane of occlusion and lack of posterior support may result in mucosal stripping at the major connector and further stress placed on the natural teeth. These events, usually occurring together, are the hallmark of combination syndrome, which will occur unless proper diagnosis, treatment planning, execution of treatment, and proactive recall and maintenance are done. PLANNED PROSTHODONTICS AND PREVENTION The concept of "planned prosthodontics encourages astute clinical evaluation that discerns not only the early signs and symptoms of combination syndrome, but also recognizes the possibility of the syndrome's occurring and the treatment potential of the patient. To satisfy the fundamental criteria of support, function, and esthetics in rehabilitating these patients and preventing or limiting further degradation with time, the following concepts should be considered., 1. Preserve overdenture abutments in the mandibular posterior and/or maxillary anterior. If these abutments and overlaying prosthesis are physiologically adjusted to be loaded only under forceful biting pressure, they will serve a very useful proprioceptive, bone-sparing function. 9 2. unit denture. 3. indicated. 10-13 Stay abreast of research involving implant fixtures, such as overdenture abutments, and consider using this treatment modality when Consider restoring the mandibular posterior occlusion utilizing current implantology techniques. Then, restore the maxillary arch with a single-

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Combination Syndrome
4. 5. 6. 7. 8. and pocket depths. 9. Educate your patient! 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 8 hours. Emphasize the vital importance of recall, maintenance, and awareness of parafunctional habits. RECALL AND MAINTENANCE Bone resorption beneath complete dentures, distal extension removable partial dentures, and extensive Kennedy Class IV removable partial dentures occurs painlessly and most extensively during the first year of functional use. Recall and maintenance visits during this period are critical to limiting initial bone loss and preserving remaining bone. Educating the patient in oral hygiene and prosthesis home care techniques and in the importance of maintenance visits is vital to success. After post-delivery visits at 24-hours, 1-week, and 1-month, maintenance appointments should be scheduled at 3 months, 6 months, and 1 year during the first year. Each maintenance appointment should include, but not be limited to, the following: 1. Extraoral observations with the prostheses worn. Swallowing should be easy, Correct plane of occlusion discrepancies and vertical dimension problems prior to definitive treatment. Tissue-condition prior to impression making. Utilize acceptable impression techniques, and apply the principle of broad stress distribution. 7 If possible, "harden" surfaces of artificial teeth to prevent premature wear. Consider amalgam inserts or metallic occlusal surfaces. 14 Maintain careful records of plaque control, mobility patterns,

unstrained, and with light posterior bracing. Look carefully for forward thrusting of

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Combination Syndrome
the mandible. If deemed necessary by observation, query the patient about tongue position and possible tongue thrusting. 2. Verify that the VDO, VDR, and closest-speaking space are within normal limits. 3. Intraorally, evaluate the prostheses for stability and retention. Ask the patient about comfort and function. 4. Ask the patient to remove the prostheses, watching for removal problems, and assess cleanliness. Check the finished and intaglio surfaces for possible tampering by the patient. Look for wear in areas you would hope to see it--the more posterior the better. 5. Visually observe and palpate intraoral structures as you conduct an oral cancer screening examination. Check and record mobility patterns, pocket depths, and plaque control efforts. 6. Ask the patient to insert the prostheses, and watch for insertion problems. Place cotton rolls bilaterally in the premolar areas and have the patient close gently for about 10 minutes. Verify that centric relation position and maximum intercuspal position (centric occlusal position, if cuspless teeth are used) are coincident and that eccentric movements are easy and maintain balance. Protrusive contacts should still be very light, if at all. 7. Remove the prostheses and check primary and secondary denture-bearing areas. Apply disclosing wax to the peripheries, crest of the ridge areas, and buccal shelf areas of the RPD and reinsert it. Apply the wax 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. Rearticulate the patient in centric relation position, and have him/her bite firmly on the posterior teeth for a few minutes. 8. Verify that intimate contact occurs in all primary denture-bearing areas. 9. Disclosing wax gives a satisfying three-dimensional representation that can be measured with a periodontal probe or explorer. Pressure-indicator paste is not as useful for this purpose.

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Combination Syndrome
10. Assess the need for relining, if alveolar resorption has occurred enough to warrant it. Record your assessment in the patient record and follow up with treatment, if indicated. 11. If CR and CO are not coincident, the patient has inadequate posterior contact, the patient postures forward 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 with a pickup impression of the RPD (poured in stone and/or low-fusing metal), a facebow transfer, and repeatable records. Assess the need for equilibration, relining, rebasing, and/or remaking. 12. 13. Expect to see early resorption in all immediate cases and those Retention, although not as important as support and stability, is in which extractions were made within 6 months of delivery. significant and of concern to the patient. Overdenture abutments may need to be reduced in height, repolished, and corresponding areas in the prosthesis physiologically relined and adjusted. 14. 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 plaque-retentive. 15. patient. 16. Encourage the patient to ask questions and become involved in treatment and maintenance! Recall and maintenance for combination case patients cannot be overemphasized. The goal of getting through the first year with minimal bone resorption and other changes to hard and soft tissues is achievable only through careful recall, maintenance, and followup treatment. Semiannual maintenance appointments should be conducted after the critical first year. CONCLUSIONS
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Review and reinforce plaque control and the care and cleaning

of the prostheses. Do a prophylaxis of the remaining natural teeth or appoint the

Combination Syndrome
Support and function suffer if supporting bone is lost. When a patient's tooth loss pattern approaches that encountered in a combination case-a few remaining natural teeth, usually in the mandibular anterior, opposing an edentulous maxilla-warning buzzers should go off in the mind of the educated clinician, because the challenge to successfully restore the patient while preserving supporting bone and protecting the mucosa requires astute diagnosis, sensible treatment planning, careful treatment, and proactive maintenance. REFERENCES 1. Kelly E Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent 1972,,27.,140-50. 2. Bruce RW Complete dentures opposing natural teeth. J Prosthet Dent 1971,26.44855. 3. Saunders TR, Gillis RE, Desjardins RP. The maxillary complete denture opposing the mandibular bilateral distal-extension partial denture: Treatment considerations. Prosthet Dent 1979,,41:124-8. 4. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed-longitudinal study covering 25 years. 1,972,,27.,120-32. 5. Stahl SS, Wisan JM, Miller SC. The influence of systemic diseases on alveolar bone. J Am Dent Assoc 1952,45.277. 6. Heartwell CM, Rahn AO. Syllabus of complete dentures. 4th ed. Lea & Febiger 1985,,44 J Prosthet Dent J

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7. Boucher CO. A critical analysis of mid-century impression techniques for full dentures. J Prosthet Dent 1951(l):472-91. 8. Ellinger CW, Rayson JH, Henderson D. Single complete dentures. J Prosthet Dent 1971,,26:4-10. 9. Carlsson GE, Thilander H, Hedegard B. Histologic changes in the upper alveolar process after extractions with or without insertion of an immediate full denture. Acta Odont Scand 1967,,25:123-46. 10. Lingquist L W, Rockler B, Carlsson GE. Prosthet Dent 1988;59:59-63. 11. Engquist B, Bergendal T, Kallus T, Linden U. A retrospective multicenter evaluation of osseointegrated implants supporting overdentures. 1988;3:129-34. 12. von Wowern N, Harder F, Hjorting-Hansen E, Gotfredsen K. IT/ implants with overdentures: A prevention of bone loss in edentulous mandibles? Int J Oral Max Fac lmpl 1990,,5:135-9. 13. Sennerby L, Carlsson GE, Bergman B, Warfvinge J. Mandibular bone resorption in patients treated with tissue-integrated prostheses and in complete denture wearers. Acta Odont Scand 1988; 46:135-40. 14. Wallace D. The use of gold occlusal surfaces in complete and partial dentures. J Prosthet Dent 1964; 14:326-33. Int J Oral Max Fac Impl Bone resorption around fixtures in J

edentulous patients treated with mandibular fixed tissue-integrated prostheses.

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