The use of linear occlusion to treat a patient with combination syndrome: A

clinical report
William S. Jameson, BS, DDSa
Veterans Administration Medical Center, Tucson, Ariz.

The seventh edition of the Glossary of

Prosthodontic Terms defines combination syndrome as
“the characteristic features that occur when an eden-
tulous maxilla is opposed by natural mandibular
anterior teeth, including loss of bone from the ante-
rior portion of the maxillary ridge, overgrowth of the
tuberosities, papillary hyperplasia of the hard palate’s
mucosa, extrusion of the lower anterior teeth, and
loss of alveolar bone and ridge height beneath the
mandibular removable partial denture bases—also
called anterior hyperfunction syndrome.” 1 This
matches the findings of Kelly 2 on the pattern of
residual ridge resorption as observed in a group of
patients wearing maxillary complete dentures oppos-
ing distal-extension removable partial dentures Fig. 1. Mounted casts of patient who wore complete maxil-
(RPDs). In a similar group of patients, Saunders et lary denture and mandibular RPD for 7 years. Patient was
completely edentulous and exhibited manifestations of
al3 noted an associated loss of vertical dimension of
combination syndrome.
occlusion, occlusal plane discrepancy, anterior reposi-
tioning of the mandible, poor adaptation of the
prostheses, epulis fissuratum, and periodontal
changes. Shen et al4 found that, of patients with a
maxillary complete denture opposing a bilateral dis-
tal-extension RPD, 1 in 4 patients exhibited alveolar
ridge changes consistent with those described in the
definition of combination syndrome. They also
found that completely edentulous patients who had
worn bilateral distal-extension RPDs for 5 years
before the loss of the remaining anterior mandibular
teeth frequently exhibited these same characteristics
(Fig. 1).
Various surgical procedures to correct some of the
undesirable conditions associated with combination
syndrome and to improve prosthetic function are
described in the literature.5-7 Saunders et al3 suggest- Fig. 2. Wear faucets on lingual of maxillary anterior teeth
ed that the anterior teeth of the maxillary complete suggest anterior hyperfunction.
denture be arranged for cosmetic and phonetic pur-
poses only and recommended that balanced occlusion,
with the use of proper cuspal angulation in conjunc- CLINICAL REPORT
tion with condylar and incisal guidances, be used for
the posterior occlusal scheme. A female patient presented with a maxillary com-
The purpose of this clinical report is to present an plete denture opposing a mandibular Class I RPD with
alternative approach to treating a patient who requires the remaining natural anterior teeth (canine to canine)
a new prosthesis and who exhibits conditions consis- supported by a porcelain-fused-to-metal restoration.
tent with combination syndrome. Clinically, the patient displayed loss of vertical dimen-
sion of occlusion, anterior repositioning of the
mandible (with wear faucets evident on the lingual of
aProsthetic Consultant, Dental Clinic. the maxillary anterior teeth) (Fig. 2), loss of bone from
J Prosthet Dent 2001;85:15-9. the anterior part of the maxillary ridge, overgrowth of

JANUARY 2001 THE JOURNAL OF PROSTHETIC DENTISTRY 15

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Mandibular stable recording base was fabricated to
verify complete seating during procedure. Extension of VLC
material below wax in posterior firmly anchored luting
medium.
the maxillary tuberosities, and loss of bone under the
RPD extension bases. The patient, for financial reasons
and on the advice of her rheumatologist, elected not to
undergo surgery to reduce the maxillary tuberosities
or to replace the mandibular anterior splint.
To use the existing mandibular restorations, it would
have been necessary to remove the 1 remaining extra-
coronal matrix on the distal of the left canine to
fabricate the new removable prosthesis with conven-
tional clasping. This approach would have compromised
the establishment of the horizontal occlusal plane from
the incisal of the maxillary central incisors to the top of
the retromolar papillae. If vertical overlap of the maxil-
lary anterior teeth had resulted, the amount of incisal
reduction of the mandibular porcelain-to-metal restora-
tions would have been limited. Additional reduction to
eliminate anterior contact in protrusive would have
been at the expense of the maxillary anterior teeth and
desired esthetic composition. All of these disadvantages
were avoided, however, by reestablishing the height of
the mandibular restorations to the new horizontal
occlusal plane.
At the first clinical appointment after the consulta-
tion, cingulum rest preparations were accomplished on
both mandibular canines without penetrating the gold.
Irreversible hydrocolloid impressions (Accu-Dent
System 2 for the RPD and System 1 for the complete
denture; Ivoclar North America, Inc, Amherst, N.Y.)
were made and master casts formed. The maxillary
anterior mold selection was determined by Alameter
and Papillameter measurements8 (Geneva Dental, Inc,
Beverly Hills, Calif.). The patient’s gender and the
operator’s impression of her personality classification
(Mold Selection Guide, Geneva Dental, Inc) were
recorded.9,10
16
JAMESON
Fig. 4. Positive seating of stable recording bases on their
respective master casts was confirmed before mounting
procedure. Note horizontal orientation transferred from
ECB on front and papillameter measurement on side of
maxillary cast.
The mandibular master cast was evaluated for critical
landmarks such as retromolar papilla, crest of the external
oblique ridge, mylohoid ridge, and frenum attachments,
and the myostatic outline11,12 was drawn on the cast. The
acrylic-retention component of the RPD framework
design was confined within this outline. The master cast
then was surveyed and designed, and block-out proce-
dures were accomplished and duplicated (PolyPour
vinyl polysiloxane duplicating material, GC Laboratory
Technology, Inc, Lockport, Ill.). A refractory cast was
produced and the framework wax-up accomplished.
After the duplication procedure, while the block-out
wax was still in place, a stable base was made with visi-
ble light-cure (VLC) material (Paladisc LC, Herraeus
Kulzer, Irvine, Calif.). The base was designed to fit over
the incisal edges of the anterior teeth but not involve
their labial surfaces. VLC material was added in the
edentulous areas to assist in the attachment of wax to
support the recording bar and scribing screw of the ver-
tical and centric recorder (Geneva Dental, Inc) (Fig. 3).
The casting was made with type IV gold (ArgenCo 52,
Argen Corp, San Diego, Calif.) and inspected for dis-
crepancies before the metal finishing was accomplished.
An esthetic control base (ECB) or wax-rim–type trial
stable base and an additional stable base for the maxil-
lary recording plate were made with autopolymerizing
methyl methacrylate material (C-Plast, Geneva Dental,
Inc). The ECB was used to critique the desired lip sup-
port, lip length, high lip line, midline, buccal corridor,
and anterior plane of orientation to the horizon; it was
modified accordingly during the second clinical
appointment.
At the second clinical appointment, vertical dimension
of rest was determined, and an intraoral needlepoint trac-
ing was produced at that vertical dimension. The
VOLUME 85 NUMBER 1
JAMESON
Fig. 5. Mandibular anterior teeth were reduced to permit
proper positioning of silver template when establishing hor-
izontal plane of occlusion. Maxillary central incisors and
monoplane posterior teeth contacted template.
Fig. 6. Frontal view of maxillary tooth arrangement. Note
drawn lines that indicate buccal extent in posterior position
and midline in anterior position. Incisal pin was lowered to
contact incisal table before removing template.
recording bases were luted together with fast-setting
impression plaster (Plastogum, Harry J. Bosworth Co,
Skokie, Ill.) at the apex of the tracing. A face-bow was
not used because, with the linear occlusion concept,
the blades are set to the monoplane teeth within the
single horizontal plane. Final occlusal adjustments to
the blades are accomplished by using the patient as the
ultimate articulator. The maxillary anterior teeth were
arranged by using the ECB and dentogenic principles
and concepts.13 An alternate approach would use a lab-
oratory to arrange the anterior teeth on the ECB with
an additional appointment needed to verify its accept-
ability before establishing the horizontal occlusal plane.
The master casts were positioned in their stable
bases (Fig. 4) and mounted in a semiadjustable articu-
lator. Once mounted, the recording bases were
JANUARY 2001
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Ridge formed at mesial edge of occlusal surface of
first premolar, which slants to contact area. Ridge was
intended to function as bilateral fulcrum of protrusive sta-
bility and enhance esthetics by mimicking buccal cusp.
removed, and the ECB and arranged anterior teeth
were luted to the maxillary master cast. The silver tem-
plate (Geneva Dental, Inc) was positioned such that it
contacted the central incisors in the anterior position
and the top of the retromolar papillas in the posterior
position to establish the horizontal plane. Because the
RPD framework casting had been accomplished, the
mandibular anterior teeth were reduced until the tem-
plate could be positioned correctly (Fig. 5). Because of
this reduction on the cast, anterior clearance on the
finished prosthesis needed to be achieved intraorally
when the final denture was delivered.
The use of an alternative tooth form and occlusal
concept (linear occlusion),14 with its inherent absence
of anterior vertical overlap, had been agreed on by
both the patient and the practitioner. This enhanced
the suggestion by Saunders et al3 to minimize anterior
contact in eccentric positions. The seventh edition of
The Glossary of Prosthodontic Terms defines linear
occlusion as “the occlusal arrangement of artificial
teeth, as viewed in the horizontal plane, wherein the
masticatory surfaces of the mandibular posterior artifi-
cial teeth have a straight, long, narrow occlusal form
resembling that of a line, usually articulating with
opposing monoplane teeth.”1 According to this con-
cept, there is no need for the traditional 2- to 3-mm
interocclusal rest space. This is not to say that no inter-
occlusal clearance is needed, just that less is required.
For this reason, the centric relation record was made at
the vertical dimension of rest, which allowed the teeth
to be arranged at a vertical height that reduced verti-
cal overlap of the anterior teeth. With this concept,
0.020 of an inch of vertical clearance was provided
during the arrangement of the anterior teeth. The
clearance was created by establishing the horizontal
plane of occlusion from the incisal edge of the maxil-
17
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 8. Increase in vertical dimension of occlusion demon-
strated by anterior markings performed with old denture
and trial tooth arrangement, both in centric occlusion.
Minor reduction in anterior incisal length for protrusive
clearance was necessary and accomplished at delivery.
Fig. 9. Finished prostheses in mouth at time of delivery.
lary central incisors to the top of the retromolar papil-
la with a silver template (Geneva Dental, Inc).
The maxillary first premolars were esthetically posi-
tioned, and a line was drawn from their buccal cusp tips
to a point 4 mm lateral to a line marking the crest of
mandibular residual ridge. The buccal cusp tips of the
remainder of the monoplane posterior teeth were
arranged so that they touched this line (Fig. 6). With
this accomplished, the template was removed, the RPD
framework was placed on the mandibular cast, and the
bladed posteriors were arranged over the crest of the
residual ridge. After processing of the maxillary pros-
thesis, the occlusal one third of the first premolar was
reduced at a 45-degree angle to form a ridge that acted
as a point of posterior contact for the mandibular
blades in a protrusive position of the mandible (bilater-
al fulcrum of protrusive stability)15 (Fig. 7).
At the third (verification) appointment, the tooth
arrangement was checked for esthetics, phonetics, and
18
JAMESON
correctness of the centric relation record (Fig. 8).
After the tissues had relaxed and adapted to the new
prosthesis, the patient was permitted to view the tooth
arrangement in a full-length mirror from 9, 6, and
then 3 feet. This gradual visual accommodation to her
appearance helped the patient to see herself as others
view her. Because she was satisfied with her appear-
ance, permission to process was requested and
received.
Processing was accomplished with injection mold-
ing (Ivocap, Ivoclar Williams).16 After recovery and
before remounting, the maxillary denture was milled
flat on 220-grit Wet-or-Dry sandpaper (Household
Products Division, 3M, St Paul, Minn.) on a 0.25-in
thick plate glass slab. Flatness was verified by placing
a black template (Geneva Dental, Inc), which is
anodized aluminum milled to be true within 0.0002
of an inch, against the flattened occlusal surfaces with-
out allowing light to be transmitted between the
template and the occlusal surfaces. Both casts then
were remounted in the articulator, and the blades were
reduced vertically with Silky Stones (Geneva Dental,
Inc) until uniform contact was achieved on both sides.
The blades were reduced on their buccal and lingual
inclines until a narrow, straight line was produced. The
ground porcelain was smoothed and repolished with
Brasseler Pre-Polisher and High-Shine porcelain pol-
ishing wheels (Brasseler USA, Savannah, Ga.). The
prostheses then were recovered, finished, and pol-
ished.
The finished prostheses were fitted with pressure
indicator paste and delivered at the next appointment.
Because of the occlusal anatomy, it is relatively easy to
detect “first point of contact” should an occlusal pre-
maturity exist. For this reason, no remount procedures
were carried out. Minimal occlusal adjustment was
needed on the blades. The maxillary central incisors
were marked in protrusive and reduced until the artic-
ulating paper could be pulled between the anterior
teeth without dragging or tearing.
SUMMARY
Using linear occlusion concepts and alternative
tooth form, a functional and esthetically pleasing pros-
thesis was fabricated. The patient experienced no
problems phonetically and was pleased with her
appearance as well as her ability to chew (Fig. 9).
Anterior contact was eliminated, thereby reducing the
potential for further bone loss caused by anterior
hyperfunction syndrome.
REFERENCES
1. VanBlarcom CW. The glossary of prosthodontic terms. 7th ed. J Prosthet
Dent 1999;81:60, 81.
2. Kelly E. Changes caused by a mandibular removable partial denture
opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50.
VOLUME 85 NUMBER 1
JAMESON THE JOURNAL OF PROSTHETIC DENTISTRY

3. Saunders TR, Gillis RE Jr, Desjardins RP. The maxillary complete denture 12. Jameson WS. Fabrication and use of a metal reinforcing frame in a frac-
opposing the mandibular bilateral distal-extension partial denture: treat- ture-prone mandibular complete denture. J Prosthet Dent 2000;83:476-9.
ment considerations. J Prosthet Dent 1979;41:124-8. 13. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic con-
4. Shen K, Gongloff RK. Prevalence of the “combination syndrome” among cept. J Prosthet Dent 1958;8:558-81.
denture patients. J Prosthet Dent 1989;62:642-4. 14. Frush JP. Linear occlusion. Ill Dent J 1966;35:788-94.
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ual ridges. J Prosthet Dent 1962;12:441-50. 16. Strohaver RA. Comparison of changes in vertical dimension between
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7. Hall HD. Vestibuloplasty, mucosal grafts (palatal and buccal). J Oral Surg Reprint requests to:
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8. Massad JJ, Goljan KR. A method of prognosticating complete denture 11401 CALLE VAQUEROS
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9. Frush JP, Fisher RD. How dentogenic restorations interpret the sex factor. FAX: (520)749-1511
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10. Frush JP, Fisher RD. How dentogenics interprets the personality factor. J 10/1/112436
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