KLEIN AND BRONER
DISCUSSION
The ideal impression can best be accomplished by
using zinc oxide-eugenol paste in a tray that is produced
from a tissue-placement preliminary impression with
proper physiologic borders. The effects of tissue place-
ment and possible distortion should be eliminated from
the formed impression tray. A heat-processed clear
acrylic resin tray undergoes less warpage than the
autopolymerizing materials and permits visual observa-
tion of ischemia caused by excessive loading. The use of
holes provides venting to minimize displacement by the
final impression material. The quality of the secondary
impression will depend on the incorporation of these
features into the secondary impression tray. The second-
ary impression material cannot be expected to compen-
sate for inadequacies in the tray. The advantages of this
technique are:
1. Reduction of the amount of time necessary to
complete a satisfactory impression because border mold-
ing is unnecessary
2. Elimination of potential pressure spots before the
impression material is inserted
3. Close approximation to physiologic and anatomic
ideals
4. Preservation of residual ridge because of reduction
of excessive displacement.
Roberts” stated, “The making of impressions for full
dentures is an important step in denture construction
because good impressions contribute to retention, stabil-
ity, and comfort of finished appliances. They are the
foundations on which we build our dentures and, as
such, merit our best effort.”
SUMMARY
A technique has been described with which a physio-
logic and anatomic registration of the attached and
unattached tissue of the denture-bearing areas can be
attained. Clear acrylic resin trays aid in eliminating
excessive displacement at the secondary impression
phase. Inadequacies of the mucostatic concept include:
Combination syndrome:
Stephen M. Schmitt, D.D.S., M.S.*
USAF Medical Center, Keesler Air Force Base, Miss.
The views and opinions expressed herein are those of the author and do
not necessarily reflect the views of the U.S. Air Force or Department
of Defense.
*Major, USAF (DC); Assistant Chairman, Department of Prostho-
dontics.
664
1. Failure to register the tissues, which are important
for retention and stability
2. Certain metal bases that are part of this procedure
can be implemented by only a small number of techni-
cians
3. Increased cost
There are two shortcomings of the tissue-loading
technique for complete denture impressions.
1. Resulting retention and stability lasts only for a
short period of time.
2. Unwanted ridge resorption and tissue changes
occur.
REFERENCES
1. Picton DCS, Wills DS: Viscoelastic properties of the periodontal
ligament and mucous membrane. J PROSTHET DENT 40:263,
1978.
2. Fournet SC, Tuller CS: A revolutionary mechanical principle
utilized to produce full lower dentures surpassing in stability the
best modern upper dentures. J Am Dent Assoc 23:1028, 1936.
3. Boucher CO, Hickey JC, Zarb GA: Prosthodontic Treatment for
Edentulous Patients, ed 7. St. Louis, 1975, The CV Mosby Co,
pp 133-158, 184-213.
4. Sharry JH: Complete Denture Prosthodontics, ed 3. New York
1974, McGraw-Hill Book Co, pp 191-211.
5. Heartwell CM, Rahn AO: Syllabus of Complete Dentures, ed 2.
Philadelphia, 1974, Lea & Febiger, pp 157-178.
6. Montieth BD: Management of loading forces on mandibular
distal-extension prosthesis. J PROSTHET DENT 52:673, 1984.
7. Page HL: Mucostatics-A capsule explanation. Chronicle of the
Omaha District Dental Society, April 1951, p 195.
8. Addison PI: Application of mucostatic principles to full denture
construction. NY J Dent 17:135, 1974.
9. Applegate OC: The partial denture base. J PROSTHET DENT
5~636, 1955.
10. Klein IE, Goldstein BM: Physiologic determinants of primary
impressions for complete dentures. J PROSTHET DENT 51:611,
1984.
11. Roberts AL: Principles of full denture impression making and
their application in practice. J PROSTHET DENT 1:213, 1951.
Ke,twint requests to:
DR. IRA E. KLEIN
19 WEST 44~~ ST.
NEW YORK, NY 10036
A treatment approach
T reating patients with edentulous maxillae and a
partially edentulous mandible is a common occurrence.
Many times only mandibular anterior teeth remain (Fig.
1) and specific degenerative changes are often seen.
NOVEMBER 1985 VOLUME 54 NUMBER 5
COMBINATION SYNDROME

Fig. 1. Patient with edentulous maxillae and remaining mandibular anterior teeth.
Fig. 2. Fit of framework is corrected in mouth with disclosing wax.
Fig. 3. Corrected master cast.
Fig. 4. Casts are mounted on articulator with interocclusal centric relation record.
Fig. 5. Record base with artificial teeth in mouth.
Fig. 6. Record base with modeling plastic and cusp-sulci ridge.

Kelly’ noted five destructive changes that occur in
these patients: (1) loss of bone from the anterior part of
the maxillary ridge, (2) overgrowth of the tuberosities,
(3) papillary hyperplasia in the hard palate, (4) extru-
sion of the lower anterior teeth, and (5) loss of bone
under the removable partial denture bases. He called
these changes the combination syndrome.
Saunders et al.2 described six changes that may also oc-
cur. They are ( 1) loss of vertical dimension of occlusion, (2)
occlusal plane discrepancy, (3) anterior spatial re-
positioning of the mandible, (4) poor adaptation of the
prosthesis, (5) epulis fissurata, and (4) periodontal
changes. They felt that the basic objective in treating these
patients was to develop an occlusal scheme that would

THE JOURNAL OF PROSTHETIC DENTISTRY 665

 SCHMITT

Fig. 7. Frontal view of cusp-sulci ridge and mandibular setup. A, Cusp-sulci ridge and
mandibular teeth in centric relation position. B, Right lateral position. C, Left lateral
position. D, Adjustment of mandibular right denture tooth.

discourage excessive occlusal pressure on the maxillary RATIONALE

anterior region in both centric and eccentric positions.
Saunders et a1.2 also stated some specific treatment
objectives. (1) The mandibular removable partial den-
ture should provide positive occlusal support from
remaining natural teeth and have maximum coverage of
the basal seat beneath the distal-extension bases. (2) The
design should be rigid and provide maximum stability
while minimizing excessive stress on remaining teeth. (3)
The occlusal scheme should be at the proper vertical and
centric relation position. (4) Anterior teeth should be
used for cosmetic and phonetic purposes only. (5)
Posterior teeth should be in balanced occlusion.
This article describes a treatment approach that
attempts to minimize the destructive changes noted by
using the treatment objectives of Saunders et a1.2This
approach is indicated for patients who are aware of their
present dental condition and want to reduce the inevita-
ble resulting destructive syndrome.
The prosthesis is made in two stages using a modifi-
cation of the complete denture construction technique
described by Meyer.3-6 The mandibular removable par-
tial denture is completed first. The tooth position, cusp
height, sulcus depth, and marginal ridge position of the
mandibular teeth will be determined using a cusp-sulci
analysis. The completed mandibular removable partial
denture is then used to construct a generated wax
occlusal path. This path will be used to create the
occlusal surfaces of the maxillary teeth. The maxillary
denture is completed and delivered to the patient. Acrylic
resin teeth are used to replace the maxillary anterior
teeth because they abrade more rapidly than porcelain
and tend to reduce stress concentration on the maxillary
anterior ridge. Cast gold occlusal surfaces are made for
the posterior denture teeth. Gold is used because it does
not abrade readily, can be accurately cast to a multitude
of tooth forms, and can be modified easily.

666 NOVEMBER 1985 VOLUME 54 NUMBER 5

COMBINATION SYNDROME

Fig. 8. Duplicated mandibular teeth with cast metal occlusal surface.

Fig. 9. Completed mandibular removable partial denture.

TECHNIQUE
Accurate casts are made and evaluated. It may be
necessary to mount them in an articulator to diagnose the
need for preprosthetic surgery or treatment of malposi-
tioned teeth. The mandibular cast is then surveyed and
the framework design carefully drawn on the cast. This
serves as a guide for clinical tooth preparation as well as
laboratory fabrication of the framework. If only six
anterior teeth are present, incisal rests are usually
required on the canine teeth. Cingulum rests are gener-
ally not used because the enamel is thin over the
cingulum of mandibular teeth. If cingulum rests are
required for esthetic purposes, then cast restorations are
indicated. The completed framework is fitted in the Fig. 10. Cuspal path wax and cusp-sulci ridge in centric
relation position.
mouth with disclosing wax (Kerr Manufacturing Co.,
Romulus, Mich.) and imperfections in the casting are
corrected (Fig. 2). Acrylic resin bases are added to the
framework, border molded with modeling plastic, and an checked for proper esthetic and phonetic placement. The
impression of the residual ridge is made with zinc oxide centric and vertical position of the setup should be
and eugenol or a light bodied rubber-base impression checked, and, most important, the movement of the
material. A corrected master cast is then made and mandibular teeth against opposing maxillary teeth
recovered (Fig. 3). A suitable technique is used to make should be tested in all eccentric positions. To evaluate
the maxillary impression, maxillary cast, and two record proper tooth position, it is important for the dentist to
bases. One record base will be used to make jaw relation understand how the compensating curve, plane of orien-
records and set the teeth (Figs. 4 and 5). The second base tation, condylar guidance, incisal guidance, and relative
will be used to analyze the occlusal surface of the cusp height can create a balanced occlusion.’ If the setup
mandibular teeth and record the movement of the is considered acceptable, then a more careful analysis of
restored mandibular arch in wax. the mandibular teeth can be made.
After the casts have been mounted in the proper
vertical and centric relation position, the mandibular CUSP AND SULCI ANALYSIS
acrylic resin denture teeth can be positioned in wax. Black modeling plastic (Impression Compound, Type
Their position can be determined either anatomically or I, Kerr Mfg. Co.) is added to the maxillary record base
with a mechanical guide such as the Broadrick occlusal in a manner similar to that described by Meyer.6 While
plane analyzer (Teledyne Hanau, Buffalo, N.Y.). The the modeling plastic is still warm, the upper cast and
maxillary teeth can be positioned against the already-set record base are closed in the articulator against the
mandibular teeth. The waxed setup is carried to the mandibular setup. The anatomy of the occlusal surface
mouth and evaluated. Anterior teeth should be carefully of the mandibular teeth should be recorded accurately in

THE JOURNAL OF PROSTHETIC DENTISTRY 667

 Figs. 11 through 18. For 1egends, see opposite page.

668 NOVEMBER 1985 VOLUME 54 NUMBER 5

COMBINATION SYNDROME

the modeling plastic (Fig. 6). The maxillary record base
is chilled and trimmed so that only a small ridge of
material remains in the central sulcus of the mandibular
teeth (Fig. 7, A). This ridge will be used to evaluate the
position and anatomy of the mandibular teeth. As the
dentist guides the patient’s teeth against this ridge, an
analysis can be made of (1) the initial position of the
teeth, (2) the steepness of compensating curve, (3) the
buccolingual tilt of the teeth, and (4) the potential for
protrusive balance with the required vertical and hori-
zontal overlap of the anterior teeth.
If correction in tooth position is required, it should be
made at this time, and the modeling plastic ridge should
be readapted to the new tooth positions. A more precise
analysis of the occlusal tooth form can then be made.
The patient is guided into centric relation and then to
a right lateral position with articulating paper over the
posterior teeth. Surfaces that contact first can be noted by
marks on the inclines of the denture teeth. One possible
contacting relationship is noted in Figure 7, B, where the
upper ridge on the right side contacts the mandibular
right molar tooth on the buccal incline of the lingual
cusp. Simultaneous contact on the opposite side is not
possible because of the steepness of the right lingual
cusp. This problem can be corrected by: (1) grinding the
buccal incline of the mandibular right lingual cusp until
simultaneous contact occurs on the opposite side, or (2)
making the fossae of the mandibular right molar more
shallow by adding inlay wax in the fossa and readapting
the upper ridge to the new fossa depth. To determine
which should be done, a left lateral movement is made
(Fig. 7, C). If it is noted that the upper ridge has
simultaneous contact on both sides, then the fossa depth
of the right molar is correct and the right lingual cusp
should be reduced (Fig. 7, 0): If, on the other hand,
there is contact only on the right side, then the fossa is too
deep and must be made more shallow. This analysis is
continued in right, left, and protrusive positions until
simultaneous contact is developed between the upper
sulci ridge and opposing mandibular teeth.
The occlusal surface of the denture teeth is duplicated
in gold using a technique described by Engelmeier (Fig.
8).B At the same time a stone core is made of the
mandibular setup so that each quadrant of denture teeth
can be repositioned in the mandibular waxup in the
same position as the original teeth. The mandibular
removable partial denture is then processed and adjusted
in the mouth (Fig. 9) before the maxillary denture
is made. Two benefits that result are: (1) the mandib-
ular arch can be treated as an intact arch, and (2) the
amount of processing error (change) is reduced
because the mandibular removable partial denture has
been completed.
GENERATED OCCLUSAL PATH
The maxillary setup and cusp-sulci ridge are checked
in the mouth against the restored mandibular arch for
proper vertical and centric position. If errors are noted,
the modeling plastic ridge is readapted to the mandibular
teeth. It is then possible to record the movement of the
mandibular arch in wax. This cuspal wax path is made
by melting medium hard baseplate wax with red counter
wax in a l/3 ratio by volume.’ The wax can be made
softer by increasing the amount of red counter wax. This
wax is then added to the ridge record base (Fig. 10).
This step can be done in the mouth or, more easily, with
the record base mounted against a stone cast in an
articulator. The wax is heated in a water bath (122” F)
and carried to the mouth. The patient is instructed to
close in centric relation and the wax is cooled. The wax
is reheated; and right, left, and protrusive movements are
carefully made against the wax until a smooth record of
the movement of the mandibular teeth is recorded (Fig.
11). If there are areas where cuspal paths are not
generated, additional wax is added and the movements
are repeated. This generated occlusal path is boxed (Fig.
12) and poured in improved dental stone. The stone cast
is then mounted in an articulator at a specific pin setting,
which is noted. The stone path and recorded movement
of mandibular teeth (red arrows working, blue arrows
protrusive and balancing) are shown in Fig. 13.
COMPLETION OF MAXILLARY TEETH AND
DENTURE
The occlusal and lingual surfaces of the maxillary
posterior denture teeth are ground away and retentive

Fig. 11. Recording movement of mandibular teeth against cusp-sulci ridge and cuspal
path wax.
Fig. 12. Generated occlusal path is boxed and poured in dental stone.
Fig. 13. Stone path and recorded movement of mandibular teeth. Red arrows indicate
working movement, blue arrows in c#!cate protrusive and balancing.
Fig. 14. Reduced surface of maxillary denture teeth.
Fig. 15. Maxillary teeth waxed to stone path.
Fig. 16. Completed waxup and duplicated teeth.
Fig. 17. Teeth positioned against stone path with sticky wax.
Fig. 18. Stone path sprayed with red marking medium.

THE JOURNAL OF PROSTHETIC DENTISTRY 669

 SCHMITT

Fig. 19. Processing errors noted in red on denture teeth.

Fig. 20. Completed prosthesis. A, Display of metal. B, Balanced occlusion. C, Esthetic
result.

grooves are placed in them (Fig. 14). Inlay wax is added
to the teeth and the articulator closed against the stone
path (Fig. 15). Care is taken to achieve intimate contact
with the stone path at the noted pin setting. Supplemen-
tal grooves are placed in the waxup, and the occlusal
surface is duplicated in gold (Fig. 16). Each quadrant of
teeth can then be held against the stone path with sticky
wax and the maxillary waxup completed (Fig. 17). After
the denture is processed, it is recovered and remounted.
Processing errors can be detected using Occlude (Pascal,
Bellevue, Wash.) on the stone path (Fig. 18). Premature
contacts can be located and removed from the occlusal
surfaces of the denture teeth (Fig. 19). The completed
denture is cleaned, polished, and delivered to the patient.
The completed prosthesis, its balanced occlusion, and
esthetic appearance are illustrated in Fig. 20.
SUMMARY
A method of treating patients who require a complete
maxillary denture opposing a mandibular bilateral dis-
tal-extension removable partial denture has been
described. This technique attempts to minimize the
destructive changes seen in these patients by carefully
distributing occlusal stress over the hard and soft tissues
and by developing an occlusal relationship that is stable
and balanced.
REFERENCES
1. Kelley E: Changes caused by a mandibular removable partial
denture opposing a maxillary complete denture. J PROSTHET
DENT 27~140, 1972.
2. Saunders TR, Gillis Jr RE, Desjardins RP: Maxillary complete
denture opposing mandibular bilateral distal extension partial
denture: Treatment considerations. J PR~THET DENT 41:124,
1979.
3. Meyer FS: A new, simple and accurate technique for obtaining
balanced and functional occlusion. J Am Dent Assoc 21:195,
1934.
4. Meyer FS: Balanced and functional occlusion in relation to
denture work. J Am Dent Assoc 221157, 1935.
5. Meyer FS: Something new in cusps and sulci analysis: Balanced
and functional occlusion and stress-breakers. J Am Dent Assoc
23~1204, 1936.
6. Meyer FS: The generated path technique in reconstructive

670 NOVEMBER 1985 VOLUME 54 NUMBER 5

COMBINATION SYNDROME
dentistry. Part I: Complete dentures. J PROSTHET DENT 9:354,
1959.
7. Hanau RL: Articulation defined, analyzed and formulated. J Am
Dent Assoc 13~1694, 1926.
8. Engelmeier RL: Fabricating denture teeth with custom anatomic
and nonanatomic metal occlusal surfaces. J PROSTHET DENT
43:X2, 1980.
0. Rudd KU, Morrows KM: The Generated Functional
Diagnostically restoring a reduced occlusal vertical
dimension without permanently altering the
existing dentures
Carl A. Han&en, D.D.S.*
University of Nebraska, College of Dentistry, Lincoln, Neb.
0 ccasionally a patient with complete dentures will
display an obviously reduced vertical dimension of
occlusion. When faced with the challenge of making new
dentures in this situation, it is desirable for the dentist to
reestablish the patient’s optimum vertical dimension of
occlusion. Pound,’ and Pound and Murrell,2 accomplish
this procedure by making preparatory or diagfiostic
dentures and adding or subtracting resin to mandibular
posterior dcclusal forms until a suitable vertical dimen-
sion of occlusion is reached. This approach is useful and
offers valuable diagnostic information. Unfortunately, it
also demands additional time and a higher fee. Another
approach is to alter the patient’s present dentures by
adding autopolymerizing resin to the mandibular poste-
rior teeth and adjusting jaw separation until an optimum
vertical relationship is achieved. This is more economi-
cal, but it permanently alters the occlusal surfaces of the
denture.
This article describes an alternative technique that
uses a mandibular removable onlay splint to diagnosti-
cally restore the vertical dimension of occlusion of a
complete denture. The occlusal surface of the denture is
not permanently changed.
PROCEDURE
Clinical phase No. 1
1. Inspect the polished surfaces of the lingual flange
regions immediately inferior to the mandibular second
*Assistant Professor, Department of Adult Restorative Dentistry
THE JOURNAL OF PROSTHETIC DENTISTRY
Concept in Complete Denture Prosthesis. Handout No. 3,
Department of Prosthodontics, Wilford Hal USAF Medical
Center, Lackland AFB, Texas.
Re~mll ?zquest.,
lo:
DR. STEPHEN M. SCHMITT
USAF MEDICAL CENTER/SGD
KEESLER AFB, MS 39534
Path
molars bilaterally. They should be slightly undercut in
relation to each other. If they are not, recontour and
polish them to provide minimal opposing undercuts.
2. Make irreversible hydrocolloid impressions of the
maxillary and mandibular complete dentures. Pour with
improved stone.
3. Obtain a face-bow record with the maxillary
denture in place.
4. Use a silicone putty (Optisil 2, Unitec Corp.,
Monrovia, Calif.) to record the maxillary-to-mandibular
jaw relationship with the mandible in, the terminal hinge
position at a vertical dimension of occlusion that appears
appropriate. A central bearing device can be used to
control jaw separation if desired (Fig. 1).
5. Record the shade of the patient’s denture teeth.
Laboratory procedures
1. Fabricate a thin plastic shell matrix on the cast of
the mandibular denture with O.OZinch thermoplastic
temporary splint material (5 x 5 inch, B&&lo Dental
Mfg. Co., Brooklyn, N.Y.) and a vacuum apparatus
(Acra Vat, Howmedica, Inc., Chicago, Ill.). Carefully
cut and remove the splint from the cast, and fill the
anterior portion with the appropriate shade of tooth-
colored autopolymerizing resin (Fig. 2). The polymer-
ized resin will not adhere to the thin matrix material.
2. On the same mandibular cast, fabricate a heavier
splint with thermoplastic resin (Clear 0.0%inch, 5 X 5
inch splint material, Buffalo Dental Mfg. Co.) as
described by McNeill.3
3. Cut the heavy resin splint material with a large
671