COMBINATION SYNDROME

Syndrome

refers to the association of several clinically

recognizable features, signs (observed by a

physician), symptoms (reported by the patient),

phenomena or characteristics that often occur

together, so that the presence of one feature alerts the

physician to the presence of the others.

 Tillman in 1961 described the complete lower

denture opposed by an upper removable partial denture (RPD)

Ellsworth

Kelly 1972

found in patients wearing a complete maxillary denture, opposing a mandibular distal extension prosthesis

Ellsworth Kelly
SYMPTOMS

Overgrowth of the tuberosities the hard palate

Papillary hyperplasia in

Supraerupted anteriors

 Saunders

et al
SEQUENCE

Pathogenesis
early loss of bone
Excessive bony resorption under the lower
flabby hyperplastic connective tissue makes up the anterior part of the ridge

the occlusal plane drops down

Teeth disappe ar under the patient s' lips

Does not support denture base

Formation of epulis fissuratum occlusa l plane migrat es

enlarged fibrous tuberosities

MECHANICS, WHICH PRODUCE THE COMBINATION SYNDROME

Kellys theory suggests that negative pressure within the

maxillary denture pulls the tuberosities down, as the

anterior ridge is driven upward by the anterior occlusion.

The functional load will then direct the stress to the mandibular distal extension and cause bony resorption of

the posterior mandibular ridge.

The upward tipping movement of the anterior portion of

the maxillary denture and the simultaneous downward movement of the posterior portion, will decrease antagonistic forces on the mandibular anterior teeth and lead to their supraeruption

Eventually an occlusal plane discrepancy will occur and the patient may have a loss of vertical dimension of occlusion.

In addition, the chronic stress and movement of the denture will often result in an ill-fitting prosthesis and contribute to the formation of palatal papillary

hyperplasia

PREVALENCE AMONG DENTURE PATIENTS

Shen and Gongloff in 1989, reviewed records of 150 maxillary edentulous patients, one in four demonstrated changes consistent with the diagnosis of combination syndrome.

The changes associated with the syndrome are more likely to be

found in patients who stress the maxillary ridge, such as in Angle class III jaw relationships and parafunctional habits and in

patients who have functioned mainly with mandibular anterior

teeth for long periods.

Prevention of combination syndrome

Avoid combination of complete maxillary dentures

opposing class I mandibular RPD.

Retaining weak posterior teeth as abutments by means of endodontic and periodontic techniques.

An overdenture on the lower teeth.

TREATMENT OBJECTIVE
Basic treatment objective

Saunders et al in 1979 is to develop an occlusal scheme that discourages excessive occlusal pressure on the maxillary anterior region, in both centric and eccentric positions.

Specific treatment objectives:

1. The mandibular RPD should provide positive occlusal

support from the remaining natural teeth and have

maximum coverage of the basal seat

2. The design should be rigid and should provide maximum stability

3. The occlusal scheme should be at a proper vertical and centric relation position.

4. Anterior teeth should be used for cosmetic and phonetic purpose only.

5. Posterior teeth should be in balanced occlusion.

TREATMENT PLANING
2-Systemic and dental considerations Review medical, dental history.

Thorough clinical and radiographic evaluation Resolution of any inflammation, if present. Evaluation of patients oral hygiene.

3-Gross changes
should be surgically treated. Flabby (hyperplastic) tissue Papillary hyperplasia

Enlarged tuberosities

4-Supraerupted Teeth
Teeth that are considerably supraerupted would require

alteration by shortening, crowning, or placing them

under an overdenture to obtain a harmonious

occlusion

 5-Mandibular

posterior alveolar ridge conservation

by leaving teeth or roots. At the same time, retained

anterior maxillary roots will absorb occlusal forces exerted by anterior mandibular teeth

6-Augmentation of maxilla
Augmentation of maxilla with resorbable

hydroxyapatite in conjunction with a guided tissue

regeneration technique and vestibuloplasty.

7- Reducing enlarged tuberosities

Kelly

advices, to allow the lower RPD to extend over the

retromolar pad.

Even weak posterior teeth should be retained as

abutments techniques. with endodontic and periodontic

 8-

Splinting the remaining mandibular anterior teeth

Saunders
to provide the RPD with positive occlusal support, rigidity, and stability, while minimizing excessive stress on the teeth.

MODALITIES OF TREATMENT

FOR THE COMBINATION SYNDROME

A-

The use of the Mandibular RPD

The mandibular RPD is supported anteriorly by cingulum rests on the canines with a lingual plate as the major connector.

Lingual plate delays over eruption of teeth, preventing

undesirable anterior pressure on the anterior part of

maxillary denture

Posteriorly, maximum support is obtained by extending the denture base to cover the retromolar pad.

Maximum occlusal support posteriorly with no contact anteriorly in centric occlusion and a balanced

articulation reduces pressure on the anterior maxillary

ridge

Limitations

mandibular anterior teeth may continue to erupt, in

the absence of anterior tooth contact

Posterior occlusal contact must be maintained by

constant relining of the distal extension denture base

B-The use of the teeth supported overdenture

The teeth are treated endodontically and reduced to

the gingival level, and an overdenture is constructed

that is supported and retained by the roots of the

residual teeth.

C- Mandibular implant-supported overdenture

offers significant improvement in retention, stability,

function and comfort for the patient and a more stable

and durable occlusion

D-Implant supported fixed prosthesis. In 2001, Wennerberg reported excellent long term

results with mandibular implant supported fixed

prostheses, opposing maxillary complete dentures

E- Implants beneath the distal extension base

Keltjens advocate placing implants beneath the distal extension base of mandibular RPD to provide a stable posterior support.

CONCLUSION :

The problems involved in providing comport, function, proper esthetics and retention is a vigorous challenge for practising dentist. The damage to the edentulous ridge

and inability to wear the denture may be avoided by

good prosthetic treatment which include adequate denture base, correct jaw relation record and proper occlusion.

REFERENCES

Kelly E. changes caused by a mandibular removable partial denture opposing a maxillary complete denture .J prosthet Dent 27:140-150 ;1972 Shan Kand Gongloff RK. prevalence of the combination syndrome among denture patients .J prosthet Dent 62:642-644;1989 Tillman EJ. Removable partial upper and complete lower denture .J prosthet Dent 11:1098-1104;1961

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