R E M O V A B L E RPER M

O SOTVHA
OB L N
DO E T IPCRS O S T H O D O N T I C S

The ‘Combination Syndrome’

Revisited
CHRISTOPHER D. LYNCH AND P. FINBARR ALLEN

palate;
Abstract: The ‘combination syndrome’ may present a considerable clinical and
l Extrusion of the lower anterior
technical challenge to the dental practitioner. This clinical scenario classically relates
to changes found in the mouth following use of a maxillary complete denture that has teeth;
opposed natural mandibular anterior teeth. l Resorption of mandibular bone
While this condition was first recognized over 30 years ago, the associated under the partial denture bases (if
difficulties still pervade the practice of prosthetic dentistry today. The purpose of this worn).
article is to describe treatment of two patients who exhibited clinical features of this
condition, and review some of the relevant literature on this condition. Kelly proposed that this scenario was
caused by what is commonly termed
Dent Update 2004; 31: 410–420 insufficient ‘posterior occlusal support’,
Clinical Relevance: For a variety of sound dental, medical and financial reasons, leading to increased occlusal forces on
conventional prosthodontics still has much to offer in the oral rehabilitation of patients the anterior part of the maxillary
presenting with combination syndrome. complete denture by remaining anterior
natural teeth. He felt that these forces
led to resorption of the maxillary labial
plate, and subsequent ‘tipping’
downwards of the posterior section of
the maxillary complete denture into

T he prosthodontic rehabilitation of
an edentulous arch which opposes
natural or restored teeth may present a
considerable clinical challenge to the
dental practitioner. Potential clinical
problems encountered may include:
l Exaggerated horizontal inter-ridge
discrepancies (artificial teeth are
usually set ‘off’ a resorbed ridge in
complete denture prosthdontics,
however, this is more exaggerated
when opposing natural teeth to
produce a satisfactory occlusion);1
l Problems of varying support
(anterior maxillary ‘flabby ridge’
thought to be caused by differential
Christopher D. Lynch, BDS, MFD RCSI,
Registrar in Restorative Dentistry and
P. Finbarr Allen, BDS, MSc, FDS RCPS, PhD,
Senior Lecturer/Consultant, Department of
Restorative Dentistry, National University of
Ireland, Cork, Ireland.
forces on an edentulous ridge
caused by a partially dentate
opposing arch);2
l Enlarged maxillary tuberosities
(limiting the correct orientation of
the occlusal plane and the amount
of inter-ridge space available for
positioning prosthetic teeth).1,2
This scenario was first described by
Ellsworth Kelly in 1972, who described
the ‘changes caused by a mandibular
removable partial denture opposing a
maxillary complete denture’.2 Naming
this condition the ‘combination
syndrome’, he described the common
clinical features, namely:
l Resorption of the maxillary labial
plate (leading to a flabby maxillary
anterior ridge);
l Overgrowth of the maxillary
tuberosities;
l Papillary hyperplasia of the hard
which the tuberosities enlarged due to
‘negative pressure’. Kelly advised the
prevention of this condition through the
use of impression techniques that
distributed forces evenly across the
edentulous ridge, and by the provision
of an appropriate occlusal scheme.
Recognizing the significance of this
latter factor, he advocated retention of
natural mandibular posterior teeth
(including those that were ‘weakened’
and requiring ‘endodontic and
periodontic’ treatments). Failing this,
‘endosseous endodontic implants’ and
removable prostheses were indicated.2
Although this condition was first
described over 30 years ago, the
problems described then are still
pertinent today. Epidemiological studies
report that ‘flabby ridges’ have been
observed in up to one-quarter of
edentulous maxillae – most frequently in
the anterior maxilla3 – and that such
‘flabby ridges’ may also be found in

410 Dental Update – September 2004


Figure 1. Dental panoramic tomograph of patient in Case Report 1.
association with enlarged maxillary
tuberosities.1,2 Such enlarged
tuberosities pose significant difficulty in
achieving a correctly oriented occlusal
plane – and this can adversely affect the
stability and retention of the final
Figure 2. Primary maxillary cast made from
preliminary alginate impression.
Figure 3. Spaced maxillary custom tray
including tissue stops.
Dental Update – September 2004
R E M OVA B L E P R O S T H O D O N T I C S
configuration for a similar length of time.
He reported that he had worn one
mandibular removable partial denture for
one year without success. Following
clinical and radiographic examination, it
was evident that insufficient maxillary
bone was available for placement of
dental implants, and the prognosis for
successful implant treatment was limited
by the patient’s medical history.
Following discussion with the patient
regarding these factors, it was agreed to
provide him with a new complete
maxillary denture (utilizing a mucostatic
impression technique), and a mandibular
removable partial denture. However, as
the mandibular neutral zone was
compromised by lateral spreading of the
tongue, it was considered essential that
the tongue space should be maximized in
the lower denture, and it was planned to
prosthesis. achieve this by reducing the size of the
The purpose of this article is to occlusal table. Balanced articulation
describe the prosthodontic management would also be indicated for these
of two patients who presented with prostheses to ensure even distribution
features of the ‘combination syndrome’. of occlusal forces on the residual ridges,
and to avoid the introduction of
‘interfering’ or displacing contacts.
CASE REPORT 1
A 60-year-old male was referred to the
Department of Restorative Dentistry of
the Cork University Dental School and
Hospital (Cork, Ireland) for specialist
dental implant treatment to overcome his
difficulty with his existing maxillary
complete denture. The patient had a
complicated medical history including
rheumatoid arthritis, diabetes mellitus,
sarcoidosis and mobility difficulties. The
patient reported that his maxillary
complete denture was ‘loose’. On
examination, the patient had an Figure 4. Completed maxillary impression
recorded using impression plaster.
edentulous maxilla and five natural
mandibular anterior teeth. The entire
maxillary ridge was quite mobile –
offering compromised support for any
complete denture resting on it (Figure 1).
The lower anterior teeth were over-
erupted and periodontally involved. The
maxillary tuberosities were enlarged,
thereby reducing the amount of inter-
ridge space available for placement of
prosthetic teeth. The patient reported
that his maxillary arch had been
edentulous for over 40 years, and he Figure 5. A heat-cured transparent acrylic
had had his existing mandibular dental baseplate was fabricated on the resulting cast.
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Figure 6. (a) The completed prostheses. (b) The completed mandibular removable partial
denture. Note the narrow bucco-lingual width of the mandibular prosthetic teeth, and the
omission of the mandibular molar prosthetic teeth.
Considering the significance of this
point, it was decided that incorporation
of shallow-angled posterior prosthetic
teeth would be useful.
Non-surgical periodontal treatment
was completed as necessary on the
standing natural teeth. A preliminary
impression of the maxillary and
mandibular arches was made with a low
viscosity irreversible hydrocolloid
material (Alginate; Dentsply Ltd-UK,
Weybridge, Surrey, UK), thus ensuring
minimal distortion of the displaceable
(‘flabby’) tissues (Figure 2).
A spaced custom tray (three thickness
of wax) was fabricated for the maxillary
impression. Tissue stops were included
in the design of the custom tray (Figure
3) and modified using greenstick plastic
impression compound (Green
Impression Compound; Kerr UK Ltd,
Peterborough, UK) to ensure accurate
location of the impression tray. Careful
attention was paid to border moulding
the impression with greenstick plastic
impression compound accurately (Green
Impression Compound). An impression
of the maxillary arch was made using
impression plaster (Impression Plaster;
Kerr UK Ltd, Peterborough, UK) (Figure
4). When complete, the impression was
re-seated in the mouth to ensure its
accuracy. A heat-cured transparent
acrylic baseplate was fabricated on the
resulting cast, and was tried in the
mouth to ensure accuracy of fit and
adequate retention before addition of a
wax occlusal rim (Figure 5).
A Kennedy Class I removable partial
denture was designed for the lower arch.
412
Owing to the lack of labial undercuts on
the abutment teeth, consideration was
given to the provision of a ‘swing-lock’
denture. This was contra-indicated,
however, by the patient’s limited
dexterity (caused by rheumatoid
arthritis). Artificial undercuts were
created using composite resin for
retaining gingivally approaching clasps.
Fabrication of this prosthesis was
carried out in the usual manner.
At the occlusal registration stage,
careful attention was paid to the
position of the labial surface of the
maxillary rim. The upper lip was found to
be ‘tight’ and exerting a powerful
posterior displacing force on the wax
rim. The palatal position and shape of
the wax rim was limited by the position
of the over-erupted mandibular anterior
teeth. Consideration was also given to
the bucco-lingual shape and distal
extent of the mandibular wax rim to
avoid ‘cramping’ the tongue. To avoid
encroaching on the neutral zone and to
improve the stability of the mandibular
removable partial denture, it was
decided not to replace teeth distal to the
mandibular second premolars. It was
noted that the posterior inter-ridge
space was reduced but, as the
prosthetic mandibular molar teeth were
omitted, it was possible to orient the
occlusal plane correctly. Following face-
bow transfer, the technician was
instructed to arrange the teeth in
balanced articulation on a semi-
adjustable articulator (Denar Anamark
Fossae; Teledyne Water Pik, Fort
Collins, Colorado, USA), paying
attention to even tooth contact in
excursive movements. Protrusive
occlusal balance was included at this
stage to prevent ‘incisal locking’ and
destabilization of the maxillary denture.
The stability of this tooth arrangement
was confirmed at the ‘try-in’ stage. The
‘altered-cast’ technique was carried out
for the mandibular removable partial
denture. The dentures were delivered
and, at subsequent review
appointments, the patient reported
satisfaction with stability, aesthetics and
function of both the maxillary complete
denture and mandibular removable
partial denture (Figures 6a, b).
In summary, the key points of this
treatment were:
l Recognition of abnormal oral
anatomy (upper flabby ridge);
l Identification of the necessity of
specialized impression technique;
l ‘Early’ assessment of stability/
retention/fit of complete denture by
fabricating a heat-cured transparent
baseplate prior to occlusal
registration;
l Omission of mandibular posterior
prosthetic teeth;
l Selection of shallow-angled cusped
teeth;
l Face-bow transfer – particularly
useful in this case, allowing suitable
orientation of the occlusal plane, and
locating the arc of closure nearer to
the hinge axis, reducing the
likelihood of a premature contact;
l Arrangement of teeth on a semi-
adjustable articulator to ensure
balanced articulation.
Figure 7. Intra-oral view of maxillary ridge of
patient in Case Report 2.
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Figure 8. Dental panoramic tomograph of patient in Case Report 2.
CASE REPORT 2
A 70-year-old male was referred to the
Department of Restorative Dentistry of
the Cork University Dental School and
Hospital, (Cork, Ireland) for specialist
restorative dental treatment. On
examination, the patient had an
edentulous maxilla (Figure 7), and seven
teeth remaining in his mandibular arch
(namely, 7 3 2 | 2 3 4 5). The anterior
portion of the maxillary ridge was found
to be displaceable. The periodontal
status of the mandibular teeth was poor
– with almost 50% bone loss around
each tooth (Figure 8). Extensive caries
was evident in 3|, 2| and |2. The patient
reported that he had worn four maxillary
complete dentures over the last 40
years, wearing his existing prosthesis
for over 10 years, and this had recently
become ‘loose’.
As a provisional treatment plan, it was
decided to extract the 2| and |2 and to
add these to the patient’s existing RPD.
The 3| was to be retained as a possible
overdenture abutment for a future
prosthesis. Non-surgical periodontal
treatment was also performed. The
patient was discharged. At a review
appointment held after six months, the
patient demonstrated good oral hygiene,
and the periodontal status of the
remaining mandibular teeth was judged
to be stable. It was decided to formulate
Dental Update – September 2004
R E M OVA B L E P R O S T H O D O N T I C S
stabilizing ‘interferences’.
A duplicate impression of the existing
maxillary complete denture was made
using a polyvinylsiloxane putty material
(Provil Novo; Heraeus Kulzer, Hanau,
Germany). The duplicate was made
using a cold-cure acrylic base and wax
teeth. The labial surfaces of the anterior
teeth were adjusted so as to avoid the
posterior displacing effect of the upper
lip (as described also in Case Report 1).
Tooth selection took place and the
maxillomandibular relationship was
recorded. Using face-bow transfer, the
casts were mounted on a semi-
adjustable articulator and the teeth were
arranged in balanced articulation.
Shallow-angled posterior teeth were
again used to avoid introduction of de-
stabilizing occlusal ‘interferences’. At
the subsequent clinical appointment, the
peripheral extent of the cold-cure acrylic
a definitive treatment plan for this base was examined and adjusted where
patient. necessary. The base over the flabby
The maxillary complete denture was to tissues was then perforated and an
be replaced. As this prosthesis had impression was made using light-bodied
served the patient reasonably well for silicone (Extrude® polyvinylsiloxane
many years (and considering the
patient’s age), it was decided to use a
‘modified copy denture’ technique –
thereby retaining the more favourable
features of his prosthesis, and
improving on those that were less than
adequate. Careful thought had to be
given to the impression technique
utilized for the fitting surface of this
denture – a standard wash impression in
the duplicate base would cause
compression of the flabby tissues,
leading to possible future difficulties
Figure 9. Cast post and core, fabricated in
with the prosthesis. It was decided to palladium-cobalt for retaining magnetic precision
provide the patient with a mandibular attachment.
removable partial denture, maintaining
the 3| as an overdenture. As the
prognosis of 7| was guarded (a 9 mm
pocket was detected on its lingual
surface), it was felt that the
incorporation of a magnetic retention
system on 3| would provide suitable
retention for the RPD even after the
eventual loss of 7|. Given the difficulties
of the displaceable tissues on the
maxillary anterior ridge, it was again
necessary to ensure a proper occlusal
scheme and balanced articulation was Figure 10. Framework design of the
designed for the prostheses to avoid de- mandibular RPD.
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R E M OVA B L E P R O S T H O D O N T I C S
Figure 11. Magnetic attachment included on
the fitting surface of the mandibular RPD.
Figure 12. Intra-oral view of completed
dentures.
impression material; Kerr, Romulus, MI,
USA), thus avoiding compression of the
flabby tissues.
Following non-surgical periodontal
treatment of the mandibular teeth, and
endodontic treatment of the 3|, the 3|
was de-coronated and prepared for a
cast post and core. This was fabricated
in palladium-cobalt (Figure 9) and
cemented in place. Following this, the
master impression for the chrome cobalt
RPD was made, and fabrication of the
RPD continued in the usual manner
(Figure 10). At the ‘try-in’ stage, a cobalt
samarium magnetic attachment (Dyna
Magnetic System, available from Zahn
Laboratory – a Henry Schein Company,
Gillingham, Kent, UK) was included in
the fitting surface of the RPD to seat
against the cast post and core on 3|
(Figure 11).
The maxillary complete denture and
mandibular removable partial denture
were completed and delivered in the
usual manner (Figures 12, 13a, 13b, 14).
At subsequent review appointments, the
patient reported satisfaction with
stability, aesthetics and function of
prostheses.
In summary, the key points of this
416
treatment were:
l Recognition of abnormal oral
anatomy (upper anterior flabby
ridge);
l Identification of necessity of
specialized impression technique
(selective pressure);
l Use of a magnetic precision
attachment to aid retention of the
mandibular prosthesis;
l Selection of shallow-angled cusped
teeth;
l Face-bow transfer;
l Arrangement of teeth on a semi-
adjustable articulator to ensure
balanced articulation.
DISCUSSION
The cases described are timely as they
demonstrate how the management of
poor denture-bearing areas can be
accomplished by expanding on the basic
principles of complete denture
construction, and without recourse to
surgical implant procedures. In the
scenarios described, both patients were
elderly, had limited bone available for
retaining implants, and one patient had a
complex medical history. Contemporary
opinions warn that treatment outcomes
associated with the use of implants in
the maxilla may not be as predictable as
in the mandible owing to variable bone
quality.4
There is considerable variation in
opinion in the dental literature as to the
most appropriate choice of impression
technique for complete dentures.5 When
making definitive impressions for
complete dentures, it is recommended
a b
Figure 13. (a) Lateral view of patient’s right-hand side. Note even occlusal contacts. (b) Lateral
view of patient’s left-hand side. Note even occlusal contacts.
that these should ‘record the entire
functional denture-bearing area to
ensure maximum support, retention and
stability for the denture during use’.6 It
follows that the definitive impression
should accurately record the tissues of
the denture-bearing areas, in addition to
recording the functional width and
depth of related sulci.5,7,8 Two broad
categories of impression techniques are
generally described: the mucostatic
(non-displacive) approach,9 or the
mucocompressive (displacive)
approach.10 Some authors have
concluded that, while mucostatic
impressions record the denture-bearing
areas at rest (hence the fitting surface of
the resultant denture represents the
undisplaced denture-bearing areas and
is theoretically more retentive), occlusal
forces will not be as evenly distributed
across the denture-supporting tissues
as they are when an impression is
recorded using a mucocompressive
(tissue-displacing) impression
technique. While there is no evidence to
indicate that one technique produces
better long-term results than another,7
certain clinical scenarios may be more
suited to one particular technique. In the
first clinical report described above, the
entire maxillary ridge was mobile – hence
a mucocompressive approach would
considerably compress the denture-
bearing area, and the resulting
prosthesis would not be accurately
adapted to the underlying tissues at
rest.
A particular problem may be
encountered when the denture-bearing
area contains both mobile and non-
mobile tissues. Most ‘conventional’
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Figure 14. Completed maxillary denture.
impression techniques for maxillary
complete dentures could be considered
to some degree as ‘mucocompressive’
impressions (i.e. using close-fitting
custom trays and high viscosity
impression materials; the denture-
bearing area is compressed).7,8 This
technique has been regarded as useful
in gaining optimal support from the
underlying denture-supporting areas.7,8
However, where extensive ‘flabby’ areas
are encountered and compressed during
impression making, these will tend to
‘recoil’ and dislodge the resulting
overlying complete denture when it is
not subjected to occlusal loading.8 A
number of techniques have been
described for making impressions of
denture-bearing areas containing both
displaceable and non-displaceable
tissues, including the use of separate
impression materials in a single
impression tray;5 use of two separate
trays and impression materials which are
then related intra-orally;11 and the
selective manipulation of the
thermoplastic properties of compound
impression material.12 In the second
clinical report described, it was decided
not to use any of these techniques. As
the patient was elderly (70 years old),
and had worn his existing prosthesis for
some time, it was felt the benefits gained
by the use of a specialized impression
technique would be negated by the
introduction of a new prosthesis that
had a new polished surface. Therefore, it
was decided to copy the patient’s
existing prosthesis – maintaining the
polished surface to which he was
accustomed – and to perforate the cold
cure base over the area of the flabby
tissues when recording the master
impression. In the case described, this
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R E M OVA B L E P R O S T H O D O N T I C S
technique proved quite effective, as it
reduced compressing the anterior mobile
tissues, while gaining optimal support in
the conventional manner from the
posterior non-mobile regions.
Some authorities advocate surgical
removal of mobile tissues prior to
impression making. Neither the patients
nor the authors were enthused by this
prospect. Such a procedure would lead
to reduction in the depth of the sulcus
available for retention and, as one
author has noted, while the flabby ridge
may provide poor retention for the
denture, it may still be better than no
ridge at all.3 The authors were also
reminded of the principal aim of
prosthodontic therapy cited by DeVan,
‘the preservation of what remains, not
the meticulous replacement of that
which has been lost’.13
Magnetic retention systems, such as
the cobalt-samarium Dyna system used
in the case described, are useful
adjuncts to overdenture therapy. These
are indicated where there is a need for
more ‘active’ retention than that
achieved by simply covering underlying
roots; and where the stresses induced
by a precision attachment system would
damage roots that are already
periodontally compromised.14 The use of
magnets reduces lateral stresses on the
root – by its nature it is ‘self-limiting’ –
i.e. once the displacing force exceeds
the force of attraction, the magnet
disengages. Some disadvantages of the
use of a magnetic retention system
include an increase in the bulk of the
denture surrounding the magnet; there
is less bracing imparted to the
prosthesis compared with a stud type
attachment; and that, over time, the
magnet may corrode, or lose its power,
and may need to be replaced.14
Two further points bear mentioning
from the clinical reports described: first,
the use of a well border-moulded
selective pressure impression technique
overcame the retentive inadequacies of
the denture-bearing area without the
need for surgical intervention. In a
‘conventional’ completed denture
scenario, failure to achieve adequate
peripheral seal of a complete denture in
terms of both the functional depth and
width of the sulcus may result in loss of
retention. The significance of adequate
border-moulding in the scenarios
described, where the amount of denture
support available is already
compromised, is evident.
Proper orientation of the occlusal
plane and provision of proper balancing
tooth contacts in excursive movements
prevented ‘tipping’ of the denture and
loss of the much-sought retention
during function. Arranging the teeth on
a semi-adjustable articulator and use of
shallow-angled prosthetic teeth was
particularly effective in achieving this
occlusal scheme. An incorrectly oriented
occlusal plane will subject the resulting
denture to unfavourable forces,1 further
destabilizing a denture that is already
relying on poor denture-bearing tissues.
It also follows that the occlusal scheme
for any dentures resting on displaceable
tissues should be carefully designed to
avoid incorporation of occlusal
interferences, the presence of which will
negate the retention of the denture.
CONCLUSION
The cases described demonstrate how a
‘difficult’ denture case can be treated in
the dental surgery without resorting to
surgically invasive techniques.
The cases described have some
important points for the clinician:
l Recognition of aberrant anatomy of
the denture-bearing areas (e.g.
‘flabby ridges’);
l Understanding that specialized
impression techniques should be
considered;
l That both retention and stability are
essential features for success, e.g.
incorporation of occlusal
interferences will negate any ‘hard-
earned’ retention;
l A magnetic retention system is a
useful adjunct where ‘conventional’
retention is not readily available.
Appropriate choice of prosthodontic
technique, combined with the skill of the
practitioner, increases the possibility of
the management of the combination
syndrome, while also avoiding invasive
419
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and expensive surgical procedures.
ACKNOWLEDGEMENT
The authors are indebted to Mr Tim Clark and the
staff of the Dentacast of Exeter laboratory (PO
Box 21, 18B Cowick Rd, Exeter, EX2 9BE, UK )
for technical support in the cases described.
R EFERENCES
1. Carr AB. Single complete dentures opposing
natural or restored teeth. In: Zarb GA, Bolender
CL, Carlsson GE, eds. Boucher’s Prosthodontic
Treatment for Edentulous Patients 11th edn. St
Louis: Mosby, 1997; pp.460–468.
2. Kelly E. Changes caused by a mandibular
removable partial denture opposing a maxillary
BOOK REVIEW
A Clinical Guide to Orthodontics. By D.
Roberts-Harry and J. Sandy. BDJ Books,
2003 (96pp., £34.95p/b; £49.95h/b). ISBN
0-904588-78-5; 0-904588-81-5.
This book is produced from a series of
publications by the authors, which
previously appeared in the British Dental
Journal. It is divided into 12 chapters on
what they regard as key subjects in
orthodontics. Each chapter is headed with
an ‘in brief’ summary of the issues
covered, and I found this a useful tool for
quick reference. They are also supported
by references for further reading. Excellent
clinical photographs and illustrations
accompany the text throughout the book
to explain the topics discussed.
The book opens with the question –
ABSTRACT
HOW DIAGNOSTIC ARE YOUR
RADIOGRAPHS?
Reliability of Digital Radiography of
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P. Eickholz. American Journal of
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Although the technique of diagnosing
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420
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3. Carlsson GE. Clinical morbidity and sequelae of
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5. McCord JF, Grant AA. Impression making. Br
Dent J 2000; 188: 484–492.
6. The British Society for the Study of Prosthetic
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8. Basker RM, Davenport JC. Prosthetic Treatment of
the Edentulous Patient 4th edn. Oxford: Blackwell
Who needs orthodontics? Two chapters
then follow, covering the examination of
the patient, which supplies the practitioner
with enough information to reach a list of
treatment aims. Treatment planning is
written in a clear and concise manner
accompanied by illustrations, which give
the reader an insight into the tooth
movements to be expected in each
scenario. Appliance choice is covered well,
and the illustrations here, yet again,
provide a clear picture of what one would
expect to achieve with each appliance
type. I particularly liked the chapter on
‘fact and fantasy in orthodontics’ which
summarized some of the controversial
subjects within orthodontics that have
been a source of much discussion over
recent years.
Extractions are discussed with reference
to specific tooth types, which I thought
monitoring the progress of such lesions
can be difficult due to variations in the
radiographic procedure. Furthermore,
radiographs may not always show the
true extent of the lesion, nor indicate the
need for clinical intervention. This study
investigated the reproducibility and
variability that could be achieved by the
digitization of such images in relation to
the type of film, tissue scatter and time
of exposure.
The authors found that, in general,
the use of filters to reduce scatter had a
small but insignificant effect on the
Publishing Co., 2002.
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J Prosthet Dent 1952; 2: 210–218.
14. Basker RM, Harrison A, Ralph JP, Watson CJ.
Overdentures in General Dental Practice 3rd edn.
London: British Dental Assocation, 1993; pp.60–
61.
particularly helpful. Anchorage control,
and impacted teeth are well documented,
as well as a chapter on the histological
nature of tooth movement – a subject of
importance, but a little out of place in what
is overall a ‘clinical’ textbook (root
resorption is already discussed in brief in
the section on ‘risks’).
The book closes with an overview of
combined treatment, which describes
some cases requiring a multi-disciplinary
approach. This provides the reader with
an idea of what may be involved in the
treatment of more complex cases.
This book is easy to read, and an
excellent source of information for the
undergraduate and the general dental
practitioner with a special interest in
orthodontics.
Angharad Brown
University Dental Hospital, Cardiff
diagnostic quality of the image.
However, careful digital manipulation of
the radiographic image resulted in a
statistically significant improvement of
the validity of the image.
This paper is particularly relevant as
more and more practitioners make the
move to digital radiography. If the images
are more consistent, as this paper would
suggest, digital manipulation must result
in improved diagnosis.
Peter Carrotte
Glasgow Dental School
Dental Update – September 2004