96 CPD Dentistry 2001; 2(3):96-101

Papers 1 hour validated CPD

Combination syndrome revisited

Philip W Smith, J Fraser McCord & Nick J A Grey

Abstract The use of accepted prosthodontic techniques

Problems of denture instability are aggravated when a directed towards ensuring denture stability, tends to
complete denture is opposed by an arch containing all or some be successful in many cases. In some situations
natural teeth. Two scenarios are possible, first of all when the success may be limited by atrophic denture bearing
maxillary arch is edentulous and the second is when the tissues, unfavourable peri-denture musculature and
mandibular arch is edentulous. The former clinical scenario poor/unrealistic patient perceptions.
has been termed the combination syndrome. The aim of this Problems associated with the provision of a
article is to describe treatment options, specifically where complete denture opposed by a natural denture were
“conventional” prosthodontic management is concerned. described classically by Tillman in 19614 and Kelly in
1972.5 Tillman described the complete lower
Keywords denture opposed by an upper removable partial
Denture stability, combination syndrome. denture (RPD), while Kelly described the opposite
scenario. Conventional wisdom would indicate that
Introduction the latter condition was most prevalent in clinical
The world-wide success of dental health practice. This is most likely to be the result of the
education and preventive dental strategies means usual pattern of tooth loss in which maxillary teeth
that the number of edentulous individuals is tend to be lost before mandibular teeth.1
decreasing, and data would suggest that the age at Kelly considered that there were five changes
which edentulousness occurs is advancing.1 which tended to occur in the cases which he studied
However, in the future there is likely to be a (Figure 1). These are:
Philip W Smith significant number of patients in need of
BDS MDS PhD FDS
DRD MRD RCS(Ed)
prosthodontic treatment. It is possible that a number
FDS(Rest) of potential prosthodontic problems may be
Honorary Consultant Unit encountered in an elderly partially dentate
of Prosthodontics
population. One such clinical scenario could be the
J Fraser McCord provision of complete dentures in one arch while the
BDS DDS FDS DRD opposing arch is either intact, or has some remaining
RCS(Ed) FDS RCS(Eng) natural teeth, or an implant supported prosthesis.
Professor and Head of Unit
of Prosthodontics For conventional complete dentures to function
acceptably, the clinician should prescribe dentures
Nick J A Grey which exhibit good stability. Denture stability has
BDS MSc PhD DRD
been defined2 as “that quality of maintaining a
MRD RCS(Ed) FDS(Rest)
Consultant in Restorative constant character or position in the presence of
Figure 1. Typical clinical changes in an edentulous maxilla
Dentistry forces that threaten to disturb it”. Where complete opposed by natural teeth, note in particular the displaceable
Edinburgh Dental Institute dentures are concerned, stability may be considered tissue in the anterior part of the residual ridge.
Correspondence: to be a paradigm of muscle balance and occlusal
Philip W Smith factors, coupled with good retention and appropriate • Loss of bone from the anterior part of the
Unit of Prosthodontics utilisation of support. The relationship between maxillary ridge
University Dental Hospital
of Manchester
retention, stability and support, has been • Overgrowth of the tuberosities
Higher Cambridge Street comprehensively reviewed by Jacobson and Krol.3 • Papillary hyperplasia in the hard palate
Manchester M15 6FH These authors stated that stability was the most • Extrusion of the lower anterior teeth
Tel: 0161 275 6629 significant property in providing for the physiologic • The loss of bone under any (mandibular) partial
Fax: 0161 275 7822
E-mail comfort of the patient. denture bases.
psmith@fs1.den.man.ac.uk

Rila Publications Ltd

CPD Dentistry 2001; 2(3):96-101
Kelly based his observations, presumably, on his
considerable clinical experience, backed up by serial
cephalometric observations of 20 patients. However only
six of the latter returned faithfully over a 3 year follow-up
period. Whether all five clinical conditions are related as
Kelly proposed, the potential for adverse morphological
changes to occur in such a situation cannot be disregarded.
Kelly suggested avoidance of this clinical scenario in
the first instance, in what is perhaps the first instance of
preventive prosthodontics being advocated.
Reference has been made previously to the difficulties
encountered by having to provide a replacement complete
denture in one arch while the opposing arch contains a
natural (or essentially natural) dentition; this challenging
clinical combination was termed the combination
syndrome by Kelly, with reference to the maxillary arch
being edentulous. In a development of the theme
propounded by Kelly, Saunders et al;6 stated that six other
changes are commonly associated with this clinical scenario:
• loss of vertical dimension of occlusion
• occlusal plane discrepancy
• anterior spatial repositioning of the mandible
• poor adaptation of the prostheses
• epulis fissuratum
• adverse periodontal changes
To these factors a seventh factor might also be added,
namely the fact that a number of patients may elect not to
wear a lower prosthesis which was provided with the
intention of providing posterior occlusion. This would
appear to be especially true of free-end saddle partial
dentures.
Saunders et al; recommended that the essential
objective of treatment planning in these cases was “to
provide an occlusal scheme that could best discourage
excessive occlusal pressures in the maxillary anterior
region in both centric and eccentric occlusal contacts”.
They listed the restorative and prosthodontic objectives
but did not relate how to achieve this. How the occlusion
might be managed to cope with the combination
syndrome has been described by Kelly and also reviewed
by Lauciello7. Basically, two methods emerge from the
literature that may be employed to fashion the occlusion:
• a functionally-generated path
• an articulator which has been programmed to
reproduce the patient’s mandibular movements.
Malposed, tilted or over-erupted teeth in the opposing
arch are prone to induce unfavourable occlusal contacts,
which in turn may lead to compromised denture stability.
This may then cause discomfort, trauma (which may result
in increased alveolar resorption) and social embarrassment
as a result of movement of the prosthesis. Some authors8, 9
have recommended that the opposing dentition should be
modified to give a more favourable occlusal plane and
geometry. It is suggested that this might be achieved either
by re-shaping the occlusal surfaces by grinding, by provision
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97
Combination syndrome revisited
of a removable onlay appliance or alternatively more
extensive fixed restorations. However, for a variety of
reasons, many patients, and some clinicians, are wary of
embarking on extensive restoration of the opposing teeth in
an attempt to increase the chance of improved stability of
the opposing complete denture. Therefore, the clinician is
often faced with the task of fashioning the complete denture
in such a way that it produces a clinically acceptable result,
without recourse to modifying the opposing natural teeth.
At the time that Tillman and Kelly wrote their
respective articles, dental implantology had not advanced to
the levels of sophistication, and clinically-acceptable
success rates, recently reported for endosseous implants.10,11
There can be no disputing that implant-supported and/or
retained prostheses would be the treatment of choice in
many cases exhibiting ‘combination syndrome’.
However, this form of treatment may be ruled out
either because a patient cannot afford implant therapy or
implant treatment may be contra-indicated for other valid
medico-dental reasons.
An added factor for general dental practitioners to
consider is that many implant–related treatment plans
require surgical and restorative expertise which may
require skills above many non-specialist practitioners.
For these reasons, the purpose of this article is to
highlight useful conventional clinical techniques to help in
the provision of complete dentures opposing a partially or
wholly dentate arch. Although not specifically the
combination syndrome detailed by Kelly, we shall describe
two “combination” “scenarios”, one for the edentulous
maxillary arch and the second for the edentulous
mandibular arch.
A. Complete maxillary denture opposed by a
dentate/partly dentate mandibular arch
In this situation (Figure 2), the displacing forces on the
upper denture resulting from mandibular movements have
to be harnessed, and a variety of ways of maximising the
retentive forces and reducing the displacing forces may be
utilised.
Figure 2. An upper complete denture, opposed by a partially dentate
lower arch which has been restored with a tooth and mucosal borne
partial denture.
98
Combination syndrome revisited
The retaining forces are maximised by ensuring that a
peripheral seal is present. This is the function of the special
tray, which, in conjunction with a suitable border
moulding technique, should demonstrate a peripheral seal
prior to the recording of the definitive impression. In
addition there is commonly readily displaceable tissue in
the region of the maxillary anterior ridge. This can be
accounted for by using an impression technique that aims
to use the firmer tissues to support the upper denture.
This requires a two-stage impression which uses a close
fitting special tray. The first step involves developing
peripheral seal, and subsequently a window is made in the
tray corresponding to the area of displaceable tissue. The
tray is loaded with medium body polyvinylsiloxane (PVS)
and an impression made in the usual way, although the
excess material escapes through the window. The
impression is removed and inspected, and the impression
material, which has f lowed through the window, is
removed. The tray is then carefully re-seated, and the
second stage is completed, which involves syringing light
bodied (PVS) through the tray window and over the
exposed ridge tissue, to complete the upper impression
(Figure 3).
Displacing forces are reduced by co-ordinating the
maxillary teeth and maxillary plane of occlusion to
harmonise with mandibular teeth during mandibular
movements. These are achieved via
• Using a facebow to transfer the plane of the upper arch
to the condylar axis.
• Using a central-bearing screw to create an arrowhead
(gothic arch) tracing (Figure 4), which is used to
determine the retruded jaw position.
• Setting the articulator condylar angles to accord to the
border tracings on the arrowhead tracing.
• Establishing, carefully, at trial insertion, that RCP is
reproducible.
Figure 3. Upper impression made to take account of displaceable
tissue in anterior maxilla.
CPD Dentistry 2001; 2(3):96-101
• Ensuring that the technician “mills” the occlusion to
suit the patient. The latter will inevitably be necessary,
as (denture tooth) cuspal inclines will be unlikely to
equal those of the patient, and this technique develops
a customised occlusal architecture for the upper
denture. On occasion, however, the clinician may
need to refine the laboratory produced occlusal form
and use the patient to “mill-in” the occlusion in the
chair. A technique sometimes used by the authors of
this article is to make a paste of silicon carbide (The
Carborundum Company Ltd., Trafford Park,
Manchester, England UK) and toothpaste, which is
placed on the occlusal surfaces of the complete
denture. The patient is then directed to trace out the
border movements with the denture stabilised in situ
and with the teeth in occlusion.
The reader will probably be familiar with the above
techniques perhaps with the exception of the gothic arch
tracing, and the latter will be described in more detail. The
gothic arch tracing is produced by a stylus (usually fixed to
an acrylic plate retained by the mandibular teeth) which
traces out a path on a f lat metal plate (fixed horizontally to
an upper baseplate) during mandibular excursive
movements. The shape produced is rather like an
arrowhead, which points posteriorly, the apex of the arrow
represents a reproducible retruded jaw position. Although
this technique is helpful in determining the retruded jaw
relationship, there are limitations to its usefulness:
• It requires normally functioning TMJs
• The bases must be sufficiently stable
• There should be sufficient vertical space to
accommodate the apparatus
There are other techniques available whereby the
desired morphology maxillary occlusal surfaces are
generated intra-orally. Perhaps the first author to describe
such a technique was Stansbury in 1951.12 He
Figure 4. A gothic arch tracing recorded for a patient with an
edentulous maxillary arch opposed by natural teeth. Note the apex of
the arrowhead represents the retruded jaw relationship.
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CPD Dentistry 2001; 2(3):96-101
recommended the use of a narrow compound maxillary
rim which had carding wax placed buccal and palatal to the
rim. The wax was subsequently “moulded” by the
mandibular teeth in border movements. Vig13, in 1964,
updated this when he used an acrylic rim with an acrylic
fin which engaged the central fossae of the lower teeth.
Soft wax was then added incrementally to form the buccal
and palatal forms of the maxillary posterior teeth; again the
form of the maxillary cusps was generated via the patient
making lateral and protrusive mandibular movements.
Customised gold occlusal surfaces, created by making
a functionally-generated path in the processed dentures,
may also be used, but are potentially expensive, in terms of
both material and laboratory time. Another approach,
which has been used with some success by the authors of
this article, is to functionally-generate the occlusal
anatomy of the maxillary denture teeth using either a
light-cured composite resin, or amalgam (Figure 5). When
using the former we use resin recommended for posterior
composite restorations, as it tends to exhibit more
appropriate wear properties.
Figure 5. An upper complete denture illustrating the use of amalgam
to form customised occlusal surfaces opposing natural teeth.
As with most complete denture problems, patient co-
operation is essential if success is to be achieved. For this
reason, patients should be made aware of the potential
problems of denture stability at the first clinical visit and
be conditioned to their contribution to denture success.
B. Complete mandibular denture opposed by
a dentate/partly dentate maxillary arch
This extreme of the prosthodontic-problem spectrum
has, in the past, been avoided by rendering the maxillary
arch edentulous. Most patients, and for that matter many
dentists, are disinclined to accept such a treatment plan
unless it is absolutely necessary. Clinical experience would
certainly suggest that this problem is more difficult to
manage than the edentulous maxilla, and although similar
techniques are recommended, success tends to be more
elusive. Two major problems appear to operate here,
namely the impaired support potential of the mandibular
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99
Combination syndrome revisited
denture-bearing tissues and the lack of stability of the
mandibular denture.
Moderately severe residual ridge resorption tends to be
the rule in such cases and the difficulties of managing this
condition, per se, have been discussed by McCord et al;14. In
essence, reductions in both quality and quantity of the
denture-bearing tissues tend to be accompanied by
unfavourable peri-denture anatomical forces, i.e. muscle
attachments encroaching on the residual ridges. As a
result, the displacing forces tend to overwhelm retaining
features of the mandibular denture and only immense
physiological control of the denture will maintain denture
stability.
Treatment strategies
Two “conventional” strategies are possible here,
namely prosthodontic alone and a combination of
prosthodontics and pre-prosthetic surgery.
Prosthodontic treatment alone
Treatment should be aimed at using an appropriate
selective pressure impression technique that satisfies
prosthodontic norms whilst allowing the clinician to
satisfy him / herself that the denture-bearing tissues can
withstand a degree of functional loading.15 Using an
appropriately extended special tray with 1mm spacing, an
admix of impression compound and tracing compound
may be used to make an impression, which may be
moulded to effect a peripheral seal and, simultaneously,
produce a selective-pressure impression of the denture-
bearing area (Figure 6).
Figure 6. A lower impression made using an admix of greenstick and
red impression compounds to take account of atrophic tissues in a
mandible opposed by natural teeth.
At the next clinical stage, the clinician must decide on
the occlusal configuration of the denture. This will
involve three related yet distinct procedures.
• The first phase, advocated by Tillman4, is to record the
relationship of the maxillary occlusal plane to the
condylar axis; this requires a facebow transfer.
100
Combination syndrome revisited
Figure 7. Lateral view of a completed ‘gothic arch’ jaw registration
for a mandibular complete denture opposed by a natural maxillary
dentition, used to articulate casts in RCP.
• The second phase is to record appropriate maxillo-
mandibular relations. One technique useful in these
cases is to use a device that allows the production of an
arrowhead (gothic arch) tracing (see above), thereby
ensuring good reproducibility of mandibular
movements when transferred to the articulator.16
Figure 7 shows articulation of a dentate upper and
edentulous lower cast, after jaw relations were
recorded using a gothic arch tracing to determine a
reproducible retruded jaw relationship. The main
limiting factor in using gothic arch tracings in the
lower jaw is lack of stability of the recording base.
• The third phase relates to what Tillman termed an
“accurately conceived occlusion”. Debate exists
whether anatomical or non-anatomical teeth should be
selected; in neither case has there been a scientifically-
based trial to validate the choice of one over the other.
However, clinical experience would tend to support
the premise that any “tripping” of the occlusal surface
of the lower denture against the maxillary natural teeth
&/or RPD, during mandibular movements, will result
in instability of the complete denture. Although a
technique was described for creating a functionally-
generated occlusal form for maxillary dentures, such a
technique for mandibular dentures may be prone to
error unless the prosthesis was sufficiently stable. Such
conditions are usually only met when the appliance in
question is some form of overdenture. Clearly, any
technique which relies on articulator-based
customisation of the occlusal form will require the use
of a facebow transfer, and a gothic arch tracing to
reduce errors in transferring jaw relationships to the
articulator. The philosophy here is to eliminate all
points of first contact until balancing contacts are
achieved with the objective of imparting denture
stability (Figure 8). On occasions a ‘check’ occlusal
record taken after the denture has been processed may
be helpful to allow the dental technician to produce
CPD Dentistry 2001; 2(3):96-101
Figure 8. A lower complete denture opposing a natural upper
dentition illustrating customised occlusal surfaces in the lower
prosthesis to harmonise with the irregular natural occlusal plane.
even occlusal contact in the retruded position. In
addition to this, mild chairside customisation may be
required, via a carborundum-toothpaste mix (vide
supra).
• The use of soft linings has also been advocated as a
possible means of reducing the discomfort beneath a
mandibular complete denture opposed by the natural
dentition.17 The use of soft linings has been recently
reviewed18, and despite their shortcomings as regards
long term clinical performance, it is apparent that their
compliant nature would allow more even distribution
of occlusally generated forces in this type of adverse
clinical situation. Clinical experience suggests that a
soft lining needs to have a minimum thickness of 3mm
to be effective. Therefore, caution needs to be
exercised to ensure that the denture base either has
sufficient bulk to impart the necessary strength, or
alternative methods have been employed to strengthen
the prosthesis, for e.g. the incorporation of a cast metal
lingual plate.
Prosthodontic/pre-prosthetic surgery
Undoubtedly, the surgical intervention with the
greatest potential to improve the stability of any prosthesis
is the successful placement of osseointegrated implants. In
all such cases, the prosthodontist should have planned the
prosthesis in consultation with the oral surgeon who
places the fixtures. However, on occasion alternative
surgical procedures not involving the placement of dental
implants may be considered appropriate. These may
involve vestibuloplasty to increase the relative height of the
anterior mandible, in addition to minor hard or soft tissue
surgery. The indications for such procedures, particularly
with the advent of osseo-integration, are now apparently
less than previously. The details of such procedures are
beyond the scope of this article, and the reader is advised
to consult standard surgical texts for further information.
Rila Publications Ltd
CPD Dentistry 2001; 2(3):96-101 101

Combination syndrome revisited

Conclusion • Recording impressions that satisfy the parameters of

The prosthodontic treatment of partially-dentate
patients is likely to pose increasingly more difficult clinical
problems. Two clinical problems likely to be encountered
are the “combination scenarios”, when an edentulous arch
is opposed by a partially-dentate or even fully-dentate
arch. The identification of such problems is an important
component of the treatment planning. Other important
areas which deserve earnest consideration are:
References
1. Todd J, Lader D. Adult Dental Health, 1988. United Kingdom, London.
OPCS. HMSO.
2. American Academy of Prosthodontists. Glossary of Prosthodontic Terms,
6th ed. J Prosthet Dent 1994; 71: 41-112.
3. Jacobson T E, Krol A J. A contemporary review of the factors involved in
complete denture retention, stability and support. J Prosthet Dent 1983; 49:
5-15.
4. Tillman E J. Removable partial upper and complete lower dentures. J.
Prosthet Dent 1961; 11: 1097-1104.
5. Kelly E. Changes caused by a mandibular removable partial denture
opposing a maxillary complete denture. J Prosthet Dent 1972; 27: 140-150.
6. Saunders T R, Gillis R E, Desjardins R P. The maxillary complete denture
opposing the mandibular bilateral distal-extension partial denture.
Treatment considerations. J Prosthet Dent 1979 ;41: 124-128.
7. Lauciello F R in Essentials of Complete Denture Prosthodontics, 2nd.
edn. Ed Winkler S. Mosby, St. Louis, 1988: 417-426.
8. Watt D M, MacGregor A R in Designing Complete Dentures, Saunders,
Philadelphia, 1976; p164.
9. MacGregor A R in Clinical Dental Prosthetics, 3rd edn. Wright, London
1990:97-307.
support, retention and stability.
• Conveyance of appropriate functionally-related patient
data, e.g. facebow and inter-maxillary relations.
• Creation of appropriate occlusal form.
• Informing the patient of his/her contribution to
denture success.
10. Adell R, Lekholm U, Rockler B, et al; A 15-year study of osseointegrated
implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;6: 387-416.
11. Van Steenberghe D, Quirynen M, Calberson, et al; A prospective evaluation
of the fate of 697 consecutive intra-oral fixtures ad modum Branemark in
the treatment of edentulism. J Head Neck Pathol 1987; 6: 53-58.
12. Stansbury C B. Single denture construction against a non-modified
natural dentition. J Prosthet Dent 1951; 1: 332-336.
13. Vig R G. A modified chew in and functional impression technique. J.
Prosthet Dent 1964; 14: 214-220.
14. McCord J F, Grant A A, Quayle A A. Treatment options for the
edentulous mandible. Eur J Prosthodont Rest Dent 1992; 1: 19-23.
15. McCord J F, Tyson K W. A conservative prosthodontic option for the
treatment of edentulous patients with atrophic (f lat) mandibular ridges. Br
Dent J 1997; 182: 469-472.
16. El Gherani-A S, Winstanley R B. The value of the Gothic Arch tracing in
the positioning of denture teeth. J Oral Rehab 1988; 15(4): 367-377.
17. Hickey J C, Zarb G A, Bolender C L. Boucher’s Prosthodontic Treatment
for Edentulous Patients, 9th edn. St. Louis: CV Mosby, 1985; p560.
18. Braden M, Wright P S, Parker S. Soft lining materials- A review. Eur J
Prosthodont Rest Dent 1995; 3: 163-174.

MCQ Answers to 2001, Vol 2 No 2

(K Marshall)
• Research has shown that in
general dental practice:
1. Small particle aerosols only remain in
the atmosphere for a short time.False
2. The use of rubber dam may reduce
contaminated aerosols by up to
98.5%.True
3. The dental team, other than the
dentist and nurse, are at no increased
risk from Hepatitis B. False
4. Saliva contains 150 million microbes
per millilitre. True
5. Pre-operative chlorhexidine rinse can
assist in reducing contamination.
True
(T F Walsh & A Rawlinson)
• Which of the following are
correct?
6. Chronic gingivitis may be present
with or without the loss of
periodontal attachment having
occurred. True
7. Patients suffering from necrotising
gingivitis have conf luent ulcers
affecting the tongue and cheeks in
addition to gingival tissues. False
8. Adult periodontitis is usually
recognised in patients between 30 and
40 years of age. True
9. Juvenile periodontitis is very common
amongst Caucasian teenagers. False
10. In rapidly progressive periodontitis
there may be acute inf lammation and
marginal proliferation of the gingival
tissues in an active phase. True
(J P J Fearon & C C Youngson)
•. The most significant causes of
pulpal trauma during crowning
are:
11. Lack of adequate cooling of the bur.
True
12. Bacterial contamination of the water-
line. False
13. Over-reduction of the tooth
substance. True
14. Irritant cements being used to lute the
crown. False
15. Crowns being cemented “high” in
occlusion. False
• During crown fabrication
beneficial circumstances for the
pulpodentinal complex include:
16. Dentinal tubular f luid outf low. True
17. A decrease in pulpal blood f low after
administration of local. False
18. In the short term, the development of
a smear layer. True
19. Formation of primary dentine. False
20. Formation of tertiary dentine. True
• Factors that would tend to
compromise the pulpal vitality
include:
21. Careful crowning of a tooth for a
young rather than old adult. False
22. A long time interval between
temporary and definitive crown
placement. True
23. Removing the smear layer and placing
a bonding system on the preparation.
False
24. Preparation well into dentine to
improve the outward tubular f luid
f low. True
25. Acid etching the dentine to remove
the smear layer. False
• In a definitive crown which are
the most significant threats to the
pulp?
26. Inward pressure caused during
cementation. False
27. Bacterial microleakage. True
28. Dissolution of a smear layer
subsequent to cementation using
conventional cement. True
29. Irritation from the cement lute. False
30. The material used to construct the
crown. False
(D A Keetley)
• Today some tooth preparation is
provided for Resin Retained
Bridges for the following reasons:
31. To allow the metal to be contained
within the contour of the tooth, so as
to avoid making changes to the
existing occlusion. True
32. To ensure that any stresses created are
directed away from the adhesive.
True
33. To provide a good area for bonding.
True
34. To give clear unambiguous finishing
lines for the technician & to allow
positive seating of the appliance on
fitting. True
35. Rest seats can provide additional
retention. False
• With regard to cementation of
Resin Retained Bridges:
36. Hooks from the wing can be extended
over the incisal edge to aid location.
True
37. Most microfilled composites will
bond adequately to base metal
castings. False
38. Glass ionomer cements are now
considered to give the best in use
longevity. False
39. An advantage of these bridges is that
they can be cemented by most
professionals complementary to
dentistry (PCDs). False
40. If the bridge fails it cannot be
cemented again with the same degree
of success. True
• Treatment Planning:
41. Is synonymous with the plan of
treatment. False
42. Is easier with resin retained bridges
because they are non-invasive. False
43. May involve a multidisciplinary
approach. True
44. Requires articulated study models and
a surveyor. True
45. Is usually provided at the patients first
visit. False
• The design of a modern resin
retained bridge:
46. Often involves two wings per pontic.
False
47. May even use two small premolar
sized teeth to replace a molar. True
48. Is aided greatly by surveying the study
models prior to preparation of the
tooth. True
49. May involve keeping the metal wing
clear of the incisal edge to improve
aesthetics. True
50. Involves construction of the wing in a
base metal. This is grit basted with
aluminum oxide to aid bonding.
True

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