Removable

Prosthodontic
5

Dr. Tasnim Hamdan

Dr. Waseem Bahjat Mushtaha
BDS and Msc from University of
PhD in prosthodontics
Valencia, Spain
Unit 3.Combination
syndrome

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 Definition
Combination Syndrome/ Kelly Syndrome was originally termed by
Kelly in 1972 to describe the clinical scenario of a complete
maxillary denture opposed by six or eight anterior mandibular
teeth.
In addition, a mandibular removable partial denture was typically
present, to restore the missing posterior mandibular teeth

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 Clinical changes
Five potential changes wich lead to Combination Syndrome

1. Loss of bone from the

anterior part of the
maxillary ridge.
2. Papillary hyperplasia in
the hard palate.
3. Overgrowth of the
tuberosities.
4. Extrusion of the lower
anterior teeth.
5. The loss of bone under
the partial denture bases.
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 Additional Signs
Saunders et al. (1979) stated that the following six Additional
changes also occur over time:
1.Loss of vertical
dimension of occlusion.
2.Occlusal plane
discrepancy.
3. Anterior spatial
repositioning of the
mandible.
4. Poor adaptation of the
prostheses.
5.Epulis fissuratum.
6. Periodontal changes.
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Sequence of combination syndrome
1.Bone loss under the distal extension removable prosthesis

2.Decreased occlusal load posteriorly and increased occlusal

load anteriorly and resorption of bone in anterior maxilla
3. Fulcrum of rotation in the cuspid-bicuspid region
4.Change in occlusal plane-negative pressure in PPS,so there
will be fribrous growth of tuberosity and papillary
hyperplasia of the palate

5. Loss of stability
6.Resorption in the anterior maxilla causes labial flange to
irritate the labial mucosa- produces epulis fissuratum
7.Lower anterior supraerupts and poor oral hygiene
contributes to periodontal problem
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 Management and treatment
This syndrome periodically worsens. The patient has a tendency to
condense occlusal load on the natural dentition.

PURPOSE OF THE TREATMENT

Prevention of rapid resorption of the bone under the lower
removable prosthesis by increasing stability through extension up to
retromolar pad.
Prevention of excessive load in the anterior region by providing a
stable occlusal scheme.
Posterior occlusion free of interfering contacts during centric and
eccentric movements.
Minimum contact in the anterior region even in protrusive
movement.
Anterior teeth to be used only for phonetics and aesthetics.
Education of the patient. 8
SYSTEMIC AND DENTAL CONSIDERATIONS

1. Systemic factors
Systemic factors like diabetes and osteoporosis increase
the rate of resorption of the bone.

2. Dental factors
In case of class III jaw relationships, there will be
increased pressure in the anterior maxilla.
When lower anteriors are retained for a long time, the
patient is accustomed to biting in the anterior region.
Presence of parafunctional habits increases bone
resorption.
Type of occlusal scheme also has direct effect on the
development of the syndrome.

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 TREATMENT PLANNING

The practising dentist is therefore faced with four treatment areas

which relate to:
I. Soft tissue management: papillary hyperplasia and flabby
anterior ridge
II. Recording the definitive impression of the maxillary arch.
III. Restoration of the mandibular arch.
IV. Recording appropriate intermaxillary relations

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 I. Soft tissue management
Flabby ridge:
Recovery program : Reversibility of
flabby tissue
Surgical removal of the hypertrophic
tissues : Irreversibility of flabby tissue
Papillary hyperplasia in the hard palate :
combination of tissue conditioner and oral
hygiene measures.
Early lesions: cessation of denture use
for 2 to 4 weeks and antifungal mouth
rinse or gels may allow the lesion to
completely subside
Small lesions: also typically treated with
0.12% chlorhexidine mouthrinse or
antifungal mouthrinse/ gels
Aggressive and large papillary lesions:
surgical methods (laser, electrosurgery or
cryotherapy ) may be required before 11
fabricating a new denture.
II. Recording the definitive impression of the
maxillary arch
When a markedly displaceable tissue is present in the anterior
maxillary ridge, then the problem is essentially one of support;
the displaceable anterior (fibrous or flabby) ridge being more
susceptible to displacement / distortion during function.
For this reason a minimally displacing impression should be
used (i.e., using minimal pressure): windows technique
,controlled lateral pressure technique, selective displacement
technique,etc.

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 III. Restoring the mandibular arch
Whichever course of treatment is used, it should be
done at the same time as the replacement maxillary
complete denture.

1.Removable partial denture Kennedy class

I type : favored treatment option to restored the
missing posterior mandibular teeth.

2.Resin-bonded or conventional cantilevered

bridges: to extend short arches opposing
complete dentures has been recommended as
an alternative to a conventional Kennedy I
partial denture.
According to the principles the shortened
dental arch can maintain acceptable oral
function in reduced dentitions and can also be
used to avoid the biomechanical problems
inherent in the provision of Kennedy Class I 13
removable partial dentures.
IV. Recording appropriate intermaxillary relations
If the patient has only vertical mandibular movements, then a
conventional registration technique may be used using upper and lower
rims.
If, however, the patient has ruminatory (i.e. lateral and protrusive
excursive) movements, then it is recommended that an intra-oral (gothic
arch or arrowhead) tracing be recorded in addition to a facebow transfer to
better relate the maxillary denture to the mandibular axis and to
mandibular movement in the interests of stability of the maxillary denture.
If necessary, the maxillary denture teeth may be restored with composite,
amalgam or gold by having the patient create functionally-generated
occlusal surfaces.

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 PREVENTION
Retaining weaker posterior teeth by using combined endodontic and
periodontal techniques.
Fabricating a fixed prosthesis in the lower posterior region using
endosseous implants.
Planning for tooth-supported overdenture in the lower arch.
Regular recall visits and checks with frequent relining to compensate
for the resorption especially in the lower distal extension prosthesis.

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