The combination syndrome: A literature review

Sigvard Palmqvist, LDS, Odont Dr,a Gunnar E. Carlsson, LDS, Odont Dr, Dr Odont hc,b and
Bengt Öwall, LDS, Odont Dr, Dr Med hcc
School of Dentistry, University of Copenhagen, Copenhagen, Denmark; and School of Dentistry,
Göteborg University, Göteborg, Sweden
Although combination syndrome is recognized by many clinicians, documented observations seem to
be rare. The aim of this article was to critically review the literature regarding combination syndrome
to evaluate the evidence for this concept. A search of the dental literature with Medline/PubMed
through July 2002, focusing on the combination syndrome and related features, was undertaken and
combined with a hand search of older references and textbooks on removable prosthodontics.
(J Prosthet Dent 2003;90:270-5.)

L oss of bone of the anterior edentulous maxilla

when opposed by natural mandibular anterior teeth is 1
of several features of the combination syndrome. Al-
though recognized by many clinicians, documented ob-
servations seem to be rare.
The Glossary of Prosthodontic Terms1 defines com-
bination syndrome as “the characteristic features that
occur when an edentulous maxilla is opposed by natural
mandibular anterior teeth, including loss of bone from
the anterior portion of the maxillary ridge, overgrowth
of the tuberosities, papillary hyperplasia of the hard pal-
atal mucosa, extrusion of mandibular anterior teeth, and
loss of alveolar bone and ridge height beneath the man-
dibular removable partial denture bases, also called an-
terior hyperfunction syndrome.”
Ellsworth Kelly2 was the first person to use the term
“combination syndrome.” He followed a small group of
patients wearing a complete maxillary denture opposed
by mandibular anterior teeth and a distal extension distal
removable partial denture (RPD). Of the 6 patients fol-
lowed up for 3 years, all showed a reduction of the
anterior bone in the maxilla along with enlarged tuber-
osities. For 5 patients there was an increased bone level
of the tuberosities. Kelly2 blamed the mandibular RPD
and the lack of a posterior seal in the maxillary denture
for these changes. He discussed “excessive bony resorp-
tion under the mandibular removable partial denture
bases” but provided no values. Kelly2 discussed various
possibilities to avoid combination syndrome, including
extraction of the mandibular teeth, but did not advocate
this solution. Instead, he proposed using the roots of
anterior mandibular teeth to support an overdenture.
He also mentioned the option of using endodontic im-
a
Professor emeritus, Department of Prosthetic Dentistry, University
of Copenhagen.
b
Professor emeritus, Department of Prosthetic Dentistry, Göteborg
University.
c
Professor and Chair, Department of Prosthetic Dentistry, University
of Copenhagen.
plants to preserve questionable roots for support in the
posterior part of the mandible.
A few years later, further characteristics were added to
the combination syndrome: loss of vertical dimension of
occlusion, occlusal plane discrepancy, anterior spatial re-
positioning of the mandible, poor adaptation of the
prostheses, epulis fissuratum, and periodontal changes.3
However, these changes are not generally associated
with combination syndrome.
In spite of his emphasis on the negative role of the
mandibular RPD, Kelly2 wrote: “The early loss of bone
from the anterior part of the maxillary jaw is the key to
the other changes of the combination syndrome.” This
view was previously published in The American Text-
Book of Prosthetic Dentistry4 in 1907 in the following
manner: “One of the most commonly observed cases of
this sort (localized adsorption) is that in which a full
upper plate denture is antagonized only by six or eight
lower natural teeth, there being no teeth posterior to
this point, adsorption of the alveolar process in the max-
illa in front occurring as a result of the undue pressure on
it.” Clinicians have recognized a number of the afore-
mentioned features in some patients, but documented
observations are rare. About 25 years after the publica-
tion of Kelly’s2 article, a review of sequelae of treatment
with complete dentures argued that there was a lack of
evidence for the combination syndrome.5 Today, ac-
cepting the principle of evidence-based dentistry, a crit-
ical review of the documentation behind the concept of
“combination syndrome” seems warranted. The aim of
this article was to evaluate the evidence for this concept.
LITERATURE REVIEW
A search of medical and dental literature through July
2002 was undertaken by use of Medline/PubMed. The
focus of the search was on combination syndrome and
related features such as alveolar bone loss, bone resorp-
tion, maxillary tuberosities, denture stomatitis, and
maxillary abnormalities, all combined with removable
partial denture variables. Along with the articles found

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PALMQVIST, CARLSSON, AND ÖWALL THE JOURNAL OF PROSTHETIC DENTISTRY

in Medline/PubMed, those found by a hand search of vestigations of series of patients. No longitudinal study
older references were also considered. In addition, some with the extraction of the anterior maxillary teeth as the
common textbooks on removable prosthodontics were starting point and randomly chosen mandibular status
scrutinized for additional documentation. exists. Most studies comprise only small groups of pa-
tients. However, some cautious conclusions may be
Residual ridge resorption— general aspects drawn by comparing results from available studies of
various designs.
After extraction of teeth, a remodeling process of the
Most studies have used radiographic cephalometry
alveolar bone occurs, including bone resorption and a
for measurement of residual ridge height. With this
changed contour.6,7 The loss of bone in the maxilla was
technique, 1 study7 compared bone resorption of the
reported to be less if an immediate denture technique
anterior maxilla in patients wearing a complete maxillary
was used compared with a healing period without den-
denture with different mandibular status: (1) mandibu-
ture.8,9 For the mandible, no difference or a smaller
lar complete denture; (2) anterior mandibular teeth and
difference in resorption rate during this initial stage was
a Class I mandibular RPD; and (3) natural mandibular
found between the immediate technique and a healing
teeth only. No statistically significant differences were
period without denture.9,10 After the initial remodeling
found between these groups. However, the smallest
phase, there is continuous bone resorption under den-
resorbed area of the maxillary residual ridge, calculated
ture bases. It is inevitable and has been called “a major
from the radiographs for the period between 6 months
oral disease entity.”11 The initial prosthetic technique
and 5 years after extraction, was noted for group 3 (nat-
probably has no long-term influence on residual ridge
ural teeth only). Grouping the subjects with complete
resorption, which is more pronounced in the mandible
dentures together with those with natural teeth includ-
than in the maxilla and has been demonstrated to occur
ing molars, and comparing them with a group having
for up to 30 years.11-14 Bone resorption under dentures
only anterior teeth (with or without an RPD) showed
can affect not only the alveolar bone but also, in some
slightly greater bone resorption in the latter group
situations, the basal bone.11-13 However, great individ-
which was significantly different (P⬍.05). However,
ual differences have been noted, and factors other than
there were considerable individual variations in the ex-
the wearing of removable dentures may be involved in
tent of the changes in all groups. In a 21-year follow-up
the resorption process.15-17
of the same patients, the individual variations were still
There are clear indications and little doubt that the
very large, and there was no support for systematic de-
removable denture plays an important causative role in
velopment of “combination syndrome.”13
the bone resorption process. This is supported by studies
At the same center, other groups of patients with a
showing significant differences in residual alveolar bone
maxillary complete denture and various prosthodontic
between edentulous subjects wearing or not wearing
solutions for the partially edentulous mandible were also
removable dentures.18,19 Subjects not wearing dentures
followed.25,26 The first group had no posterior teeth and
had more remaining bone. In groups of patients who
no RPD; the second group had a Class I mandibular
had been wearing complete mandibular dentures for
RPD; the third group had an RPD retained by a bar
different lengths of time, the continuous bone resorp-
splint uniting crowns, primarily on the canines. Over a
tion stopped in the areas distal to the mandibular foram-
5-year period there was a significant reduction of the
ina after the patients had been provided with fixed pros-
measured height of the anterior maxillary bone in the
theses supported by implants placed anterior to the
first 2 groups with similar mean values for both groups.
foramina.20 In another study, a fixed implant-supported
In the bar splint group no significant reduction in bone
prosthesis of the same design produced bone apposition
height was noted in the anterior maxilla. When evaluat-
in the posterior parts of the mandible, whereas an over-
ing the horizontal dimension and calculating the ante-
denture supported by 2 implants resulted in a continu-
rior bone area of the maxillary residual ridge on the
ous resorption of the same areas.21 Moreover, animal
radiographs, a reduction was noted in all groups without
studies have shown that continuous pressure from an
significant differences between them.
experimental denture caused bone resorption when ex-
Only small and statistically insignificant changes in
ceeding a threshold value, and that the resorbed bone
the bone height of the edentulous maxilla were found
was not reshaped when pressure was discontinued.22-24
during a 5-year observation period in a patient group
where the complete maxillary denture was opposed by a
Maxillary ridge resorption in relation to bar-retained mandibular RPD.27 The bone resorption
mandibular status under complete maxillary dentures was also studied dur-
Mandibular natural teeth with or without RPD. Bone ing a 5-year period in patients wearing either a conven-
resorption in the anterior part of the edentulous maxilla, tional complete mandibular denture or an overdenture
the main feature of the “combination syndrome,” has supported by roots of the mandibular canines.28 Similar
been the subject of many clinical reports and some in- values were noted for both groups. An earlier longitudi-

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THE JOURNAL OF PROSTHETIC DENTISTRY
nal study over 7 years found no significant difference in
maxillary bone resorption in patients wearing a complete
maxillary denture opposed by either a complete mandib-
ular denture or natural teeth and a removable partial
denture, even if somewhat higher values were noted in
the latter group.29
Examination records were reviewed in 150 consecu-
tive denture patients at a dental school with regard to
“prevalence of symptoms associated with combination
syndrome.”30 All patients had a maxillary complete den-
ture; however, the mandibular status differed. “Maxil-
lary anterior alveolar bone loss” was nearly nonexistent
in the group with complete mandibular dentures as well
as in the group with natural dentition including bilateral
molars. In groups with unilateral or bilateral missing
molars, different percentages of maxillary anterior bone
loss were noted. However, the authors found no signif-
icant difference related to whether the patients wore an
RPD or not. This might partly be explained by the small
number of subjects in these 2 groups. In fact, the highest
percentage of “maxillary anterior alveolar bone loss”
(56%) was noted for the group wearing a Class I man-
dibular RPD. The authors listed 5 changes “most con-
sequential to denture wearing and most difficult to cor-
rect”: maxillary anterior bone loss, mandibular posterior
bone loss, maxillary alveolar ridge canting, tuberosity
enlargement, and hypermobile maxillary residual ridge.
All of these changes were prevalent in less than 7% of the
total sample but were found in 24% of the patients with
a bilateral distal-extension RPD. It should be noted,
however, that this was not an epidemiologic study of a
random sample, but findings in patients at a dental
school. Further, all variables presented in the article were
dichotomous, and the criteria were not clarified to the
readers. No epidemiologic study of the combination
syndrome was found.
Mandibular implant-supported or -retained prosthe-
ses. An Australian implant center reported on anterior
bone resorption beneath complete maxillary dentures
when opposed by implant-supported mandibular pros-
theses.31,32 The situation with a mandibular overden-
ture supported by 2 bar-connected implants resembled
the situation with natural anterior teeth and an RPD.
Maxillary changes similar to the combination syndrome,
anterior bone loss in the maxilla, and “posterior loss of
occlusal contact were observed.”31 The situation with a
fixed implant-supported prosthesis in the mandible32
“did not appear to promote a condition similar to com-
bination syndrome.” However, “loss of posterior occlu-
sal contact” was also observed in these patients.
The anterior bone loss under a maxillary complete
denture has also been studied when the mandibular
overdenture was supported by a transmandibular im-
plant with 4 posts penetrating the mandibular crest be-
tween the mental foramina.33,34 Some changes consis-
tent with signs associated with combination syndrome
272
PALMQVIST, CARLSSON, AND ÖWALL
were noted33 but maxillary bone resorption was smaller
compared with that reported by Kelly2 in the situation
with remaining anterior teeth and a Class I mandibular
RPD. According to the authors, a possible explanation
of these improved results could be that implants do not
supra-erupt as natural teeth do.34
Using panoramic radiographs, Jacobs et al35 followed
up 3 groups of patients, all with a complete maxillary
denture. In the mandible, 1 group had a complete den-
ture, another group an implant-retained overdenture,
and the third group had a fixed implant-supported pros-
thesis. The most pronounced annual bone resorption in
the maxilla was noted in the complete denture group
and was statistically significant compared with the over-
denture group. Bone resorption in the fixed implant-
supported prosthesis group demonstrated values in be-
tween the other 2 groups that were not significantly
different from the other groups.
The masticatory forces and deformation of the max-
illary complete denture during function have been stud-
ied in patients with either a complete denture or a fixed
implant-supported prosthesis in the mandible.36 The re-
sults showed a marked improvement in “chewing abil-
ity” after implant treatment, as indicated by changes in
measured masticatory forces. However, no significantly
increased levels of loading were measured by the strain
gauges placed in the maxillary dentures. The conclusion
was that there should be no increased risk of failure or
complications associated with loading clinically with the
type of fixed implant-supported prostheses that were
studied.
In another study of a group of patients with implant-
supported overdentures in the mandible, frequent mid-
line fractures of the opposing maxillary complete den-
ture was noted, indicating an increase in denture
deformation during function.37 However, this finding
has not been confirmed in more recent studies.38-40
Regarding changes of the edentulous maxilla in com-
plete denture wearers, there are also several studies in
which radiographs have not been used but measure-
ments have been performed on casts.41-43 The relevance
of these studies concerning bone resorption can be
questioned, and they are not included in this review.
Enlargement of the tuberosities
In a study of denture patients treated at a dental
school,30 “tuberosity elongation” was found in 5% of
patients with complete dentures in both jaws. In patients
with bilaterally missing mandibular molars, “tuberosity
elongation” was found in 22% of those wearing a remov-
able partial denture and in 56% of those with no RPD.
The groups were small, and the study was not longitu-
dinal, indicating that no conclusions can be drawn about
the development of the noted “elongations.”
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PALMQVIST, CARLSSON, AND ÖWALL
Papillary hyperplasia of the hard palate’s
mucosa
Epidemiologic studies of mucosal changes in denture
wearers mostly report low percentage figures for “pap-
illary hyperplasia of the hard palatal mucosa,” also called
“papillomatous stomatitis.”44,45 No study was found fo-
cusing specifically on changes in the maxillary mucosa
with respect to the mandibular dentition status.
Extrusion of mandibular anterior teeth
Kelly demonstrated extrusion of the mandibular an-
terior teeth in all 6 patients with combination syndrome
followed up for 3 years by means of profile radiographs.2
The amount of extrusion varied between 1.0 and 1.5
mm. No other reports have been found regarding extru-
sion of mandibular anterior teeth in combination with a
complete maxillary denture and a mandibular RPD.
Bone resorption under mandibular RPD bases
Continuous bone resorption in the mandible poste-
rior to the remaining anterior teeth has been demon-
strated in 2 groups of patients wearing different types of
Class I mandibular RPDs, whereas no change of the
bone level in the posterior region was noted for the
group not wearing an RPD.25,26 In patients who re-
ceived mandibular implant-supported fixed prostheses,
bone resorption in the posterior part of the mandible
practically ceased.20 This result has been confirmed in
recent studies, some even reporting bone apposition in
the posterior areas when a fixed implant-supported pros-
thesis was used.21,46
Most follow-up studies of removable partial dentures
have not included measurement of bone resorption be-
neath the distal extension bases.47-50 For example, the
longitudinal study over 25 years by Bergman et al49
provides no information on this point. However, it may
be indirectly concluded that there were considerable
changes of the supporting tissues judging from the fre-
quent relining of the RPDs during the first 10 years.48
Kelly2 provided values for the resorption in the edentu-
lous maxilla but not for the posterior, edentulous parts
of the mandible. A study of patients with a complete
maxillary denture opposed by a mandibular distal exten-
sion RPD retained by an anterior bar revealed more
bone resorption in the posterior mandible than in the
maxilla.27
DISCUSSION
Dorland’s Illustrated Medical Dictionary51 defines
“syndrome” as “a set of symptoms which occur togeth-
er; the sum of signs of any morbid state; a symptom
complex.” “Combination syndrome” is not included
among hundreds of syndromes listed in the dictionary.
From this review of the literature it seems obvious that
SEPTEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
“combination syndrome” does not meet the criteria to
be included in such a list. In a review of the literature, the
authors have found no epidemiologic study of “combi-
nation syndrome.” Compared with the main feature,
“loss of bone from the anterior portion of the edentu-
lous maxilla,” findings such as “papillary hyperplasia of
the hard palatal mucosa” seem to be rare.44,45 Enlarged
tuberosities may also have other causes than those de-
scribed by Kelly2 as part of the combination syndrome.
Enlarged tuberosities are often seen together with
supraerupted maxillary molars. In situations where man-
dibular molars have been lost, the opposing maxillary
molars may supraerupt together with the alveolar pro-
cess.52 The supraeruption may create enlarged tuberos-
ities without influence of a denture.
Not surprisingly, no randomized controlled trials
(RCTs) on combination syndrome were found. A re-
view of U.S. prosthodontic journals showed that less
than 2% of 3631 articles published over a 10-year period
could be classified as RCTs.53 A more extensive review
up to the end of year 2000 identified 92 RCTs in prosth-
odontics, but none related to combination syndrome.54
Perhaps somewhat more surprising, is that there
seems to be no prospective study of the “combination
syndrome” in spite of the fact that many people have
been provided with a complete maxillary denture op-
posed by anterior mandibular teeth with or without a
Class I mandibular RPD. A long-term 21-year study of
patients wearing complete maxillary dentures provided
no support for a systematic development of the “com-
bination syndrome.”13 This does not mean that the ob-
servations made by Kelly2 were false. In the title of his
article, he emphasized the negative role of the mandib-
ular RPD. The same view was expressed by Keltjens et
al,55 who found the traditional treatment for an edentu-
lous maxilla opposed by a partially edentulous mandible
with a complete denture and a Class I mandibular RPD
to be “fundamentally inadequate.” The authors also
suggested use of implants for distal support.
Loss of established posterior occlusal contacts has
been discussed as an important factor in relation to the
combination syndrome.30 However, loss of occlusal
contacts can be attributed not only to bone resorption
under mandibular distal extension bases but also to wear
of the artificial denture teeth, as well as to changes in
position of the anterior mandibular teeth. It can be spec-
ulated that such changes in occlusion facilitate parafunc-
tional activities such as clenching and thereby increase
the pressure on the maxillary anterior alveolar bone.
This speculative theory fits well with the result that pa-
tients who had been provided with Class I mandibular
RPDs had development of more signs and symptoms of
temporomandibular disorders over a 5-year period com-
pared with a matched group of patients treated with
cantilevered fixed partial dentures.56 It is also compati-
ble with results from in vivo measurements showing that
273
THE JOURNAL OF PROSTHETIC DENTISTRY
a fixed implant-supported prosthesis in the mandible
opposing a complete maxillary denture improved the
“chewing ability” but did not increase the levels of loads
transferred to the denture base.36
Loss of alveolar bone and residual ridge height be-
neath the mandibular removable partial denture bases
was included in the combination syndrome by Kelly.2
Reviewed articles have shown greater bone loss in the
mandible associated with an RPD compared with when
no RPD or a fixed prostheses supported by anterior
implants was provided.20,21,25,26,46 Compared with can-
tilevered fixed partial dentures, conventional Class I
mandibular RPDs have been shown to cause more car-
ious lesions, more plaque and gingivitis, as well as more
signs and symptoms of temporomandibular disor-
ders.56,57
The poor biologic outcome with Class I mandibular
RPDs constitutes a strong indirect support for the
“shortened dental arch” concept,58,59 indicating that
missing posterior teeth should not necessarily be re-
placed. It has been convincingly demonstrated that den-
titions consisting of only anterior and premolar teeth
can meet oral functional demands in most situa-
tions.60-63 Also in patients with dentitions associated
with the combination syndrome (edentulous maxilla,
bilaterally missing mandibular posterior teeth) it seems
reasonable to adopt the shortened dental arch concept.
This view is also in agreement with the well-documented
excellent long-term results with fixed mandibular pros-
theses supported by implants placed between the mental
foramina and opposing maxillary complete den-
tures.64,65
SUMMARY
Bone resorption of the anterior part of the edentu-
lous maxilla in association with remaining anterior man-
dibular teeth has been the subject of a limited number of
studies of acceptable quality, but the results have not
been conclusive. No epidemiologic study of the various
features related to combination syndrome has been pub-
lished. There is no evidence that a mandibular remov-
able partial denture can prevent the development of the
events described.
On the basis of this review of the literature it may
therefore be concluded that the “combination syn-
drome” does not meet the criteria to be accepted as a
medical syndrome. The single features associated with
the “combination syndrome” exist but to what extent or
in which combinations has not been clarified.
REFERENCES
1. The glossary of prosthodontic terms. J Prosthet Dent 1999;81:39-110.
2. Kelly E. Changes caused by a mandibular removable partial denture
opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50.
3. Saunders TR, Gillis RE Jr, Desjardins RP. The maxillary complete denture
opposing the mandibular bilateral distal-extension partial denture: treat-
ment considerations. J Prosthet Dent 1979;41:124-8.
274
PALMQVIST, CARLSSON, AND ÖWALL
4. Turner CR. The human dental mechanism; its structures, functions, and
relations. Changes in the jaws following the loss of teeth. In: Turner CR,
editor. The American text-book of prosthetic dentistry. London: Henry
Kimpton; 1907. p. 230-92.
5. Carlsson GE. Clinical morbidity and sequelae of treatment with complete
dentures. J Prosthet Dent 1998;79:17-23.
6. Carlsson GE, Thilander H, Hedegard B. Histologic changes in the upper
alveolar process after extractions with or without insertion of an immedi-
ate full denture. Acta Odontol Scand 1967;25:21-43.
7. Carlsson GE, Bergman B, Hedegard B. Changes in contour of the maxillary
alveolar process under immediate dentures. A longitudinal clinical and
x-ray cephalometric study covering 5 years. Acta Odontol Scand 1967;
25:45-75.
8. Wictorin L. Bone resorption in cases with complete upper denture. Acta
Radiol 1964;228 (Suppl):1-97.
9. Johnson K. A study of the dimensional changes occurring in the maxilla
following closed face immediate denture treatment. Aust Dent J 1969;14:
370-6.
10. Carlsson GE, Persson G. Morphologic changes of the mandible after
extraction and wearing of dentures. A longitudinal, clinical, and x-ray
cephalometric study covering 5 years. Odontol Rev 1967;18:27-54.
11. Atwood DA. Reduction of residual ridges: a major oral disease entity. J
Prosthet Dent 1971;26:266-79.
12. Tallgren A. The continuing reduction of residual alveolar ridges in com-
plete denture wearers: a mixed-longitudinal study covering 25 years. J
Prosthet Dent 1972;27:120-32.
13. Bergman B, Carlsson GE. Clinical long-term study of complete denture
wearers. J Prosthet Dent 1985;53:56-61.
14. Jackson RA, Ralph WJ. Continuing changes in the contour of the maxillary
residual alveolar ridge. J Oral Rehabil 1980;7:245-8.
15. Carlsson GE, Haraldson T. Fundamental aspects of mandibular atrophy.
In: Worthington P, Branemark PI, editors. Advanced osseointegration
surgery: maxillofacial applications. Chicago: Quintessence Publishing;
1992. p. 109-18.
16. Xie Q, Ainamo A, Tilvis R. Association of residual ridge resorption with
systemic factors in home-living elderly subjects. Acta Odontol Scand
1997;55:299-305.
17. Xie Q, Narhi TO, Nevalainen JM, Wolf J, Ainamo A. Oral status and
prosthetic factors related to residual ridge resorption in elderly subjects.
Acta Odontol Scand 1997;55:306-13.
18. Campbell RL. A comparative study of the resorption of the alveolar ridges
in denture-wearers and non-denture wearers. J Am Dent Assoc 1960;60:
143-53.
19. Jozefowicz W. The influence of wearing dentures on residual ridges: a
comparative study. J Prosthet Dent 1970;24:137-44.
20. Sennerby L, Carlsson GE, Bergman B, Warfvinge J. Mandibular bone
resorption in patients treated with tissue-integrated prostheses and in
complete-denture wearers. Acta Odontol Scand 1988;46:135-40.
21. Wright PS, Glantz PO, Randow K, Watson RM. The effects of fixed and
removable implant-stabilised prostheses on posterior mandibular residual
ridge resorption. Clin Oral Implants Res 2002;13:169-74.
22. Mori S, Sato T, Hara T, Nakashima K, Minagi S. Effect of continuous
pressure on histopathological changes in denture-supporting tissues.
J Oral Rehabil 1997;24:37-46.
23. Ohara K, Sato T, Imai Y, Hara T. Histomorphometric analysis of bone
dynamics in denture supporting tissue under masticatory pressure in rat.
J Oral Rehabil 2001;28:695-701.
24. Imai Y, Sato T, Mori S, Okamoto M. A histomorphometric analysis on
bone dynamics in denture supporting tissue under continuous pressure.
J Oral Rehabil 2002;29:72-9.
25. Carlsson GE, Ragnarson N, Astrand P. Changes in height of the alveolar
process in edentulous segments. A longitudinal clinical and radiographic
study of full upper denture cases with residual lower anteriors. Odontol
Tidskr 1967;75:193-208.
26. Carlsson GE, Ragnarson N, Astrand P. Changes in height of the alveolar
process in edentulous segments. II. A longitudinal clinical and radio-
graphic study over 5 years of full upper denture patients with residual
lower anteriors. Sven Tandlak Tidskr 1969;62:125-36.
27. Uctasli S, Hasanreisoglu U, Iseri H. Cephalometric evaluation of maxillary
complete, mandibular fixed-removable partial prosthesis: a 5-year longi-
tudinal study. J Oral Rehabil 1997;24:164-9.
28. Crum RJ, Rooney GE Jr. Alveolar bone loss in overdentures: a 5-year study.
J Prosthet Dent 1978;40:610-3.
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PALMQVIST, CARLSSON, AND ÖWALL
29. Tallgren A. The effect of denture wearing on facial morphology. A 7-year
longitudinal study. Acta Odontol Scand 1967;25:563-92.
30. Shen K, Gongloff RK. Prevalence of the “combination syndrome” among
denture patients. J Prosthet Dent 1989;62:642-4.
31. Lechner SK, Mammen A. Combination syndrome in relation to osseointe-
grated implant-supported overdentures: a survey. Int J Prosthodont 1996;
9:58-64.
32. Gupta S, Lechner SK, Duckmanton NA. Maxillary changes under com-
plete dentures opposing mandibular implant-supported fixed prostheses.
Int J Prosthodont 1999;12:492-7.
33. Maxson BB, Powers MP, Scott RF. Prosthodontic considerations for the
transmandibular implant. J Prosthet Dent 1990;63:554-8.
34. Barber HD, Scott RF, Maxson BB, Fonseca RJ. Evaluation of anterior
maxillary alveolar ridge resorption when opposed by the transmandibular
implant. J Oral Maxillofac Surg 1990;48:1283-7.
35. Jacobs R, van Steenberghe D, Nys M, Naert I. Maxillary bone resorption
in patients with mandibular implant-supported overdentures or fixed pros-
theses. J Prosthet Dent 1993;70:135-40.
36. Stafford D, Glantz PO, Lindqvist L, Strandman E. Influence of treatment
with osseointegrated mandibular bridges on the clinical deformation of
maxillary complete dentures. Swed Dent J Suppl 1985;28:117-35.
37. Haraldson T, Jemt T, Stalblad PA, Lekholm U. Oral function in subjects
with overdentures supported by osseointegrated implants. Scand J Dent
Res 1988;96:235-42.
38. Sadowsky SJ. Mandibular implant-retained overdentures: a literature re-
view. J Prosthet Dent 2001;86:468-73.
39. Chaffee NR, Felton DA, Cooper LF, Palmqvist U, Smith R. Prosthetic
complications in an implant-retained mandibular overdenture population:
initial analysis of a prospective study. J Prosthet Dent 2002;87:40-4.
40. Watson GK, Payne AG, Purton DG, Thomson WM. Mandibular overden-
tures: comparative evaluation of prosthodontic maintenance of three dif-
ferent implant systems during the first year of service. Int J Prosthodont
2002;15:259-66.
41. Carlsson GE. Measurements on casts of the edentulous maxilla. Odontol
Revy 1966;17:386-402.
42. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformi-
ties in partially edentulous patients. J Prosthet Dent 1987;57:191-4.
43. Narhi TO, Geertman ME, Hevinga M, Abdo H, Kalk W. Changes in the
edentulous maxilla in persons wearing implant-retained mandibular over-
dentures. J Prosthet Dent 2000;84:43-9.
44. MacEntee MI. The prevalence of edentulism and diseases related to den-
tures—a literature review. J Oral Rehabil 1985;12:195-207.
45. MacEntee MI, Glick N, Stolar E. Age, gender, dentures and mucosal
disorders. Oral Diseases 1998;4:32-6.
46. Murphy WM, Absi EG, Gregory MC, Williams KR. A prospective 5-year
study of two cast framework alloys for fixed implant-supported mandib-
ular prostheses. Int J Prosthodont 2002;15:133-8.
47. Carlsson GE, Hedegard B, Koivumaa KK. Late results of treatment with
partial dentures. An investigation by questionnaire and clinical examina-
tion 13 years after treatment. J Oral Rehabil 1976;3:267-72.
48. Bergman B, Hugoson A, Olsson CO. Caries, periodontal and prosthetic
findings in patients with removable partial dentures: a ten-year longitudi-
nal study. J Prosthet Dent 1982;48:506-14.
49. Bergman B, Hugoson A, Olsson CO. A 25 year longitudinal study of
patients treated with removable partial dentures. J Oral Rehabil 1995;22:
595-9.
50. Vermeulen AH, Keltjens HM, van’t Hof MA, Kayser AF. Ten-year evalu-
ation of removable partial dentures: survival rates based on retreatment,
not wearing and replacement. J Prosthet Dent 1996;76:267-72.
SEPTEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
51. Dorland WA. Dorland’s illustrated medical dictionary. 29th ed. Philadel-
phia: WB Saunders; 2000. p. 1748-71.
52. Compagnon D, Woda A. Supraeruption of the unopposed maxillary first
molar. J Prosthet Dent 1991;66:29-34.
53. Dumbrigue HB, Jones JS, Esquivel JF. Developing a register for random-
ized controlled trials in prosthodontics: results of a search from prosth-
odontic journals published in the United States. J Prosthet Dent 1999;82:
699-703.
54. Jokstad A, Esposito M, Coulthard P, Worthington HV. The reporting of
randomized controlled trials in prosthodontics. Int J Prosthodont 2002;15:
230-42.
55. Keltjens HM, Kayser AF, Hertel R, Battistuzzi PG. Distal extension remov-
able partial dentures supported by implants and residual teeth: consider-
ations and case reports. Int J Oral Maxillofac Implants 1993;8:208-13.
56. Budtz-Jorgensen E, Isidor F. A 5-year longitudinal study of cantilevered
fixed partial dentures compared with removable partial dentures in a
geriatric population. J Prosthet Dent 1990;64:42-7.
57. Jepson NJ, Moynihan PJ, Kelly PJ, Watson GW, Thomason JM. Caries
incidence following restoration of shortened lower dental arches in a
randomized control trial. Br Dent J 2001;191:140-4.
58. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil
1981;8:457-62.
59. Kayser AF. Teeth, tooth loss and prosthetic appliances. In: Owall B, Kayser
AF, Carlsson GE, editors. Prosthodontics: principles and management
strategies. London: Wolfe Publishing; 1996. p. 35-48.
60. Witter DJ, De Haan AF, Käyser AF, Van Rossum GM. A 6-year follow-up
study of oral function in shortened dental arches. Part II: Craniomandib-
ular dysfunction and oral comfort. J Oral Rehabil 1994;21:353-66.
61. Allen PF, Witter DF, Wilson NH, Kayser AF. Shortened dental arch
therapy: views of consultants in restorative dentistry in the United King-
dom. J Oral Rehabil 1996;23:481-5.
62. Witter DJ, van Palenstein Heldermann WH, Creugers NH, Kayser AF. The
shortened dental arch concept and its implications for oral health care.
Community Dent Oral Epidemiol 1999;27:249-58.
63. Witter DJ, Creugers NH, Kreulen CM, de Haan AF. Occlusal stability in
shortened dental arches. J Dent Res 2001;80:432-6.
64. Lindquist LW, Carlsson GE, Jemt T. A prospective 15-year follow-up study
of mandibular fixed prostheses supported by osseointegrated implants.
Clinical results and marginal bone loss. Clin Oral Implants Res 1996;7:
329-36.
65. Wennerberg A, Carlsson GE, Jemt T. Influence of occlusal factors on
treatment outcome: a study of 109 consecutive patients with mandibular
implant-supported fixed prostheses opposing maxillary complete den-
tures. Int J Prosthodont 2001;14:550-5.
Reprint requests to:
DR GUNNAR E. CARLSSON
DEPARTMENT OF PROSTHETIC DENTISTRY
FACULTY OF ODONTOLOGY, GÖTEBORG UNIVERSITY
BOX 450, SE 405 30
GÖTEBORG
SWEDEN
FAX: 46-31-773-3193
E-MAIL: g_carlsson@odontologi.gu.se
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Dentistry.
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