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Comb Syndrome[1]

Comb Syndrome[1]

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combination syndrome
combination syndrome

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96CPD Dentistry 2001; 2(3):96-101Rila Publications Ltd
Papers
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
Correspondence:
Philip W SmithUnit of ProsthodonticsUniversity Dental Hospitalof ManchesterHigher Cambridge StreetManchester M15 6FHTel: 0161 275 6629Fax: 0161 275 7822 E-mailpsmith@fs1.den.man.ac.uk
1 hour validated CPD
Abstract
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.
Keywords
 Denture stability, combination syndrome.
Introduction
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.
1
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
2
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.
3
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
4
and Kelly in1972.
5
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.
1
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 ridgeOvergrowth of the tuberositiesPapillary hyperplasia in the hard palateExtrusion of the lower anterior teethThe loss of bone under any (mandibular) partialdenture bases.
Figure 1.
Typical clinical changes in an edentulous maxillaopposed by natural teeth, note in particular the displaceabletissue in the anterior part of the residual ridge.
 
97CPD Dentistry 2001; 2(3):96-101Rila Publications Ltd
Combination syndrome revisited
Kelly based his observations, presumably, on hisconsiderable clinical experience, backed up by serialcephalometric observations of 20 patients. However onlysix of the latter returned faithfully over a 3 year follow-upperiod. Whether all five clinical conditions are related asKelly proposed, the potential for adverse morphologicalchanges to occur in such a situation cannot be disregarded.Kelly suggested avoidance of this clinical scenario inthe first instance, in what is perhaps the first instance of preventive prosthodontics being advocated.Reference has been made previously to the difficultiesencountered by having to provide a replacement completedenture in one arch while the opposing arch contains anatural (or essentially natural) dentition; this challengingclinical combination was termed the combinationsyndrome by Kelly, with reference to the maxillary archbeing edentulous. In a development of the themepropounded by Kelly, Saunders
et al;
6
stated that six otherchanges are commonly associated with this clinical scenario:loss of vertical dimension of occlusionocclusal plane discrepancyanterior spatial repositioning of the mandiblepoor adaptation of the prosthesesepulis fissuratumadverse periodontal changesTo 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 theintention of providing posterior occlusion. This wouldappear to be especially true of free-end saddle partialdentures.Saunders
et al
; recommended that the essentialobjective of treatment planning in these cases was “toprovide an occlusal scheme that could best discourageexcessive occlusal pressures in the maxillary anteriorregion in both centric and eccentric occlusal contacts”.They listed the restorative and prosthodontic objectivesbut did not relate how to achieve this. How the occlusionmight be managed to cope with the combinationsyndrome has been described by Kelly and also reviewedby Lauciello
7
. Basically, two methods emerge from theliterature that may be employed to fashion the occlusion:a functionally-generated pathan articulator which has been programmed toreproduce the patient’s mandibular movements.Malposed, tilted or over-erupted teeth in the opposingarch are prone to induce unfavourable occlusal contacts, which in turn may lead to compromised denture stability.This may then cause discomfort, trauma (which may resultin increased alveolar resorption) and social embarrassmentas a result of movement of the prosthesis. Some authors
8, 9
have recommended that the opposing dentition should bemodified to give a more favourable occlusal plane andgeometry. It is suggested that this might be achieved eitherby re-shaping the occlusal surfaces by grinding, by provisionof a removable onlay appliance or alternatively moreextensive fixed restorations. However, for a variety of reasons, many patients, and some clinicians, are wary of embarking on extensive restoration of the opposing teeth inan attempt to increase the chance of improved stability of the opposing complete denture. Therefore, the clinician isoften faced with the task of fashioning the complete denturein 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 theirrespective articles, dental implantology had not advanced tothe levels of sophistication, and clinically-acceptablesuccess rates, recently reported for endosseous implants.
10,11
There can be no disputing that implant-supported and/orretained prostheses would be the treatment of choice inmany cases exhibiting ‘combination syndrome’.However, this form of treatment may be ruled outeither because a patient cannot afford implant therapy orimplant treatment may be contra-indicated for other validmedico-dental reasons.An added factor for general dental practitioners toconsider is that many implant–related treatment plansrequire surgical and restorative expertise which mayrequire skills above many non-specialist practitioners.For these reasons, the purpose of this article is tohighlight useful conventional clinical techniques to help inthe provision of complete dentures opposing a partially or wholly dentate arch. Although not specifically thecombination syndrome detailed by Kelly, we shall describetwo “combination” “scenarios”, one for the edentulousmaxillary arch and the second for the edentulousmandibular arch.
A. Complete maxillary denture opposed by adentate/partly dentate mandibular arch
In this situation (Figure 2), the displacing forces on theupper denture resulting from mandibular movements haveto be harnessed, and a variety of ways of maximising theretentive forces and reducing the displacing forces may beutilised.
Figure 2.
An upper complete denture, opposed by a partially dentatelower arch which has been restored with a tooth and mucosal bornepartial denture.
 
98CPD Dentistry 2001; 2(3):96-101Rila Publications Ltd
Combination syndrome revisited
The retaining forces are maximised by ensuring that aperipheral seal is present. This is the function of the specialtray, which, in conjunction with a suitable bordermoulding technique, should demonstrate a peripheral sealprior to the recording of the definitive impression. Inaddition there is commonly readily displaceable tissue inthe region of the maxillary anterior ridge. This can beaccounted for by using an impression technique that aimsto use the firmer tissues to support the upper denture.This requires a two-stage impression which uses a closefitting special tray. The first step involves developingperipheral seal, and subsequently a window is made in thetray corresponding to the area of displaceable tissue. Thetray is loaded with medium body polyvinylsiloxane (PVS)and an impression made in the usual way, although theexcess material escapes through the window. Theimpression is removed and inspected, and the impressionmaterial, which has flowed through the window, isremoved. The tray is then carefully re-seated, and thesecond stage is completed, which involves syringing lightbodied (PVS) through the tray window and over theexposed ridge tissue, to complete the upper impression(Figure 3).Displacing forces are reduced by co-ordinating themaxillary teeth and maxillary plane of occlusion toharmonise with mandibular teeth during mandibularmovements. These are achieved viaUsing a facebow to transfer the plane of the upper archto the condylar axis.Using a central-bearing screw to create an arrowhead(gothic arch) tracing (Figure 4), which is used todetermine the retruded jaw position.Setting the articulator condylar angles to accord to theborder tracings on the arrowhead tracing.Establishing, carefully, at trial insertion, that RCP isreproducible.Ensuring that the technician “mills” the occlusion tosuit the patient. The latter will inevitably be necessary,as (denture tooth) cuspal inclines will be unlikely toequal those of the patient, and this technique developsa customised occlusal architecture for the upperdenture. On occasion, however, the clinician mayneed to refine the laboratory produced occlusal formand use the patient to “mill-in” the occlusion in thechair. A technique sometimes used by the authors of this article is to make a paste of silicon carbide (TheCarborundum Company Ltd., Trafford Park,Manchester, England UK) and toothpaste, which isplaced on the occlusal surfaces of the completedenture. The patient is then directed to trace out theborder movements with the denture stabilised
in situ
and with the teeth in occlusion.The reader will probably be familiar with the abovetechniques perhaps with the exception of the gothic archtracing, and the latter will be described in more detail. Thegothic arch tracing is produced by a stylus (usually fixed toan acrylic plate retained by the mandibular teeth) whichtraces out a path on a flat metal plate (fixed horizontally toan upper baseplate) during mandibular excursivemovements. The shape produced is rather like anarrowhead, which points posteriorly, the apex of the arrowrepresents a reproducible retruded jaw position. Althoughthis technique is helpful in determining the retruded jawrelationship, there are limitations to its usefulness:It requires normally functioning TMJsThe bases must be sufficiently stableThere should be sufficient vertical space toaccommodate the apparatusThere are other techniques available whereby thedesired morphology maxillary occlusal surfaces aregenerated intra-orally. Perhaps the first author to describesuch a technique was Stansbury in 1951.
12
He
Figure 3.
Upper impression made to take account of displaceabletissue in anterior maxilla.
Figure 4.
A gothic arch tracing recorded for a patient with anedentulous maxillary arch opposed by natural teeth. Note the apex of the arrowhead represents the retruded jaw relationship.

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