96CPD Dentistry 2001; 2(3):96-101Rila Publications Ltd
Combination syndrome revisited
Philip W Smith, J Fraser McCord & Nick J A Grey
Philip W Smith
BDS MDS PhD FDSDRD MRD RCS(Ed)FDS(Rest)Honorary Consultant Unitof Prosthodontics
J Fraser McCord
BDS DDS FDS DRDRCS(Ed) FDS RCS(Eng)Professor and Head of Unitof Prosthodontics
Nick J A Grey
BDS MSc PhD DRDMRD RCS(Ed) FDS(Rest)Consultant in RestorativeDentistry Edinburgh Dental Institute
Philip W SmithUnit of ProsthodonticsUniversity Dental Hospitalof ManchesterHigher Cambridge StreetManchester M15 6FHTel: 0161 275 6629Fax: 0161 275 7822 Eemail@example.com
1 hour validated CPD
Problems of denture instability are aggravated when acomplete denture is opposed by an arch containing all or somenatural teeth. Two scenarios are possible, first of all when themaxillary arch is edentulous and the second is when themandibular arch is edentulous. The former clinical scenariohas been termed the combination syndrome. The aim of thisarticle is to describe treatment options, specifically where“conventional” prosthodontic management is concerned.
Denture stability, combination syndrome.
The world-wide success of dental healtheducation and preventive dental strategies meansthat the number of edentulous individuals isdecreasing, and data would suggest that the age at which edentulousness occurs is advancing.
However, in the future there is likely to be asignificant number of patients in need of prosthodontic treatment. It is possible that a numberof potential prosthodontic problems may beencountered in an elderly partially dentatepopulation. One such clinical scenario could be theprovision of complete dentures in one arch while theopposing arch is either intact, or has some remainingnatural teeth, or an implant supported prosthesis.For conventional complete dentures to functionacceptably, the clinician should prescribe dentures which exhibit good stability. Denture stability hasbeen defined
as “that quality of maintaining aconstant character or position in the presence of forces that threaten to disturb it”. Where completedentures are concerned, stability may be consideredto be a paradigm of muscle balance and occlusalfactors, coupled with good retention and appropriateutilisation of support. The relationship betweenretention, stability and support, has beencomprehensively reviewed by Jacobson and Krol.
These authors stated that stability was the mostsignificant property in providing for the physiologiccomfort of the patient.The use of accepted prosthodontic techniquesdirected towards ensuring denture stability, tends tobe successful in many cases. In some situationssuccess may be limited by atrophic denture bearingtissues, unfavourable peri-denture musculature andpoor/unrealistic patient perceptions.Problems associated with the provision of acomplete denture opposed by a natural denture weredescribed classically by Tillman in 1961
and Kelly in1972.
Tillman described the complete lowerdenture opposed by an upper removable partialdenture (RPD), while Kelly described the oppositescenario. Conventional wisdom would indicate thatthe latter condition was most prevalent in clinicalpractice. This is most likely to be the result of theusual pattern of tooth loss in which maxillary teethtend to be lost before mandibular teeth.
Kelly considered that there were five changes which tended to occur in the cases which he studied(Figure 1). These are:•Loss of bone from the anterior part of themaxillary ridge•Overgrowth of the tuberosities•Papillary hyperplasia in the hard palate•Extrusion of the lower anterior teeth•The loss of bone under any (mandibular) partialdenture bases.
Typical clinical changes in an edentulous maxillaopposed by natural teeth, note in particular the displaceabletissue in the anterior part of the residual ridge.