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Papers

Combination syndrome revisited

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

Abstract
Problems of denture instability are aggravated when a complete denture is opposed by an arch containing all or some natural teeth. Two scenarios are possible, first of all when the maxillary arch is edentulous and the second is when the mandibular arch is edentulous. The former clinical scenario has been termed the combination syndrome. The aim of this article is to describe treatment options, specifically where “conventional” prosthodontic management is concerned.

Keywords
Denture stability, combination syndrome.

Introduction
The world-wide success of dental health education and preventive dental strategies means that the number of edentulous individuals is decreasing, and data would suggest that the age at which edentulousness occurs is advancing.1 However, in the future there is likely to be a significant number of patients in need of prosthodontic treatment. It is possible that a number of potential prosthodontic problems may be encountered in an elderly partially dentate population. One such clinical scenario could be the provision of complete dentures in one arch while the opposing arch is either intact, or has some remaining natural teeth, or an implant supported prosthesis. For conventional complete dentures to function acceptably, the clinician should prescribe dentures which exhibit good stability. Denture stability has been defined2 as “that quality of maintaining a constant character or position in the presence of forces that threaten to disturb it”. Where complete dentures are concerned, stability may be considered to be a paradigm of muscle balance and occlusal factors, coupled with good retention and appropriate utilisation of support. The relationship between retention, stability and support, has been comprehensively reviewed by Jacobson and Krol.3 These authors stated that stability was the most significant property in providing for the physiologic comfort of the patient.

The use of accepted prosthodontic techniques directed towards ensuring denture stability, tends to be successful in many cases. In some situations success may be limited by atrophic denture bearing tissues, unfavourable peri-denture musculature and poor/unrealistic patient perceptions. Problems associated with the provision of a complete denture opposed by a natural denture were described classically by Tillman in 19614 and Kelly in 1972.5 Tillman described the complete lower denture opposed by an upper removable partial denture (RPD), while Kelly described the opposite scenario. Conventional wisdom would indicate that the latter condition was most prevalent in clinical practice. This is most likely to be the result of the usual pattern of tooth loss in which maxillary teeth tend 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:

Philip W Smith BDS MDS PhD FDS DRD MRD RCS(Ed) FDS(Rest) Honorary Consultant Unit of Prosthodontics J Fraser McCord BDS DDS FDS DRD RCS(Ed) FDS RCS(Eng) Professor and Head of Unit of Prosthodontics Nick J A Grey BDS MSc PhD DRD MRD RCS(Ed) FDS(Rest) Consultant in Restorative Dentistry Edinburgh Dental Institute Correspondence: Philip W Smith Unit of Prosthodontics University Dental Hospital of Manchester Higher Cambridge Street Manchester M15 6FH Tel: 0161 275 6629 Fax: 0161 275 7822 E-mail psmith@fs1.den.man.ac.uk

Figure 1. Typical clinical changes in an edentulous maxilla opposed by natural teeth, note in particular the displaceable tissue in the anterior part of the residual ridge.

• Loss of bone from the anterior part of the maxillary ridge • Overgrowth of the tuberosities • Papillary hyperplasia in the hard palate • Extrusion of the lower anterior teeth • The loss of bone under any (mandibular) partial denture bases.

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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 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.

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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.

• 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 3. Upper impression made to take account of displaceable tissue in anterior maxilla.

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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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.

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 denturebearing area (Figure 6).

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 cooperation 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
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.

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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.

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.

• The second phase is to record appropriate maxillomandibular 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 scientificallybased 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 functionallygenerated 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

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.

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Conclusion
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:
1. 2. 3. 4. 5. 6. 7. 8. 9. References Todd J, Lader D. Adult Dental Health, 1988. United Kingdom, London. OPCS. HMSO. American Academy of Prosthodontists. Glossary of Prosthodontic Terms, 6th ed. J Prosthet Dent 1994; 71: 41-112. 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. Tillman E J. Removable partial upper and complete lower dentures. J. Prosthet Dent 1961; 11: 1097-1104. Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent 1972; 27: 140-150. 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. Lauciello F R in Essentials of Complete Denture Prosthodontics, 2nd. edn. Ed Winkler S. Mosby, St. Louis, 1988: 417-426. Watt D M, MacGregor A R in Designing Complete Dentures, Saunders, Philadelphia, 1976; p164. MacGregor A R in Clinical Dental Prosthetics, 3rd edn. Wright, London 1990:97-307.

• Recording impressions that satisfy the parameters of 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
• 1. 2. 3. 4. 5. (K Marshall) Research has shown that in general dental practice: Small particle aerosols only remain in the atmosphere for a short time.False The use of rubber dam may reduce contaminated aerosols by up to 98.5%.True The dental team, other than the dentist and nurse, are at no increased risk from Hepatitis B. False Saliva contains 150 million microbes per millilitre. True Pre-operative chlorhexidine rinse can assist in reducing contamination. True 11. Lack of adequate cooling of the bur. True 12. Bacterial contamination of the waterline. 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 • 16. 17. 18. 19. 20. • 21. 22. 23. 24. 25. • During crown fabrication beneficial circumstances for the pulpodentinal complex include: Dentinal tubular f luid outf low. True A decrease in pulpal blood f low after administration of local. False In the short term, the development of a smear layer. True Formation of primary dentine. False Formation of tertiary dentine. True Factors that would tend to compromise the pulpal vitality include: Careful crowning of a tooth for a young rather than old adult. False A long time interval between temporary and definitive crown placement. True Removing the smear layer and placing a bonding system on the preparation. False Preparation well into dentine to improve the outward tubular f luid f low. True 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 • 31. (D A Keetley) Today some tooth preparation is provided for Resin Retained Bridges for the following reasons: To allow the metal to be contained within the contour of the tooth, so as to avoid making changes to the existing occlusion. True To ensure that any stresses created are directed away from the adhesive. True To provide a good area for bonding. True To give clear unambiguous finishing lines for the technician & to allow positive seating of the appliance on fitting. True Rest seats can provide additional retention. 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 • 46. 47. 48. 49. • 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 50. The design of a modern resin retained bridge: Often involves two wings per pontic. False May even use two small premolar sized teeth to replace a molar. True Is aided greatly by surveying the study models prior to preparation of the tooth. True May involve keeping the metal wing clear of the incisal edge to improve aesthetics. True Involves construction of the wing in a base metal. This is grit basted with aluminum oxide to aid bonding. 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:

32. 33. 34.

35.

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