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Specific oral destructive changes in the hard and soft tissues in patients with maxillary complete denture opposed by natural anterior teeth and a bilateral distal extension removable partial denture have been reported. The characteristic features that occur have been termed as combination syndrome by Kelly in 1972. Patient education and frequent recall and maintenance care are essential to prevent the development of this syndrome.
Keywords:Combination syndrome, Maxilla ridge resorption, Edentulism, Mandibular distal extension prosthesis
Abbreviations: CS: Combination syndrome; RPD: Removable partial denture; CD: Complete denture; GPT: Glossary of prosthodontic terms
Salvador [2] studied the prevalence index on signs of combination syndrome in patients rehabilitated with a maxillary complete denture opposing mandibular removable partial denture (Kennedy class I and class II). The overall prevalence index for combination syndrome was 25%. CS was not observed in patients with complete prosthesis and Kennedy class II RPDs.Kilicarslan [3] evaluated the prevalence and distribution of symptoms associated with combination syndrome among maxillary edentulous patients with different mandibular occlusal schemes - Natural dentition, Kennedy class II, Kennedy class I, Edentulous. When the symptoms of combination syndrome were examined, 50% of patients were found to have maxillary anterior alveolar bone loss. All five symptoms were identified in 9% of the patients studied, the majority (88.89%) were class I partially edentulous and the remainder (11.11%) were class II partially edentulous.
- 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 the partial denture bases.
- Loss of vertical dimension of occlusion
- Occlusal plane discrepancy.
- Anterior spatial repositioning of mandible
- Poor adaptation of prosthesis.
- Epulis fissuratum.
- Periodontal changes.
- Retaining weak posterior teeth as abutments by means of endodontic and periodontics techniques.
- Endosseous endodontic implants and the amputation of one lower molar root to preserve the other as an abutment are some of the methods that could be applied.
- An overlay denture on the lower may avoid the combination syndrome from developing.
- The mandibular removable partial denture should provide positive occlusal support from remaining natural teeth and have maximum coverage of the basal seat beneath the distal-extension bases.
- The design should be rigid and provide maximum stability while minimizing excessive stress on remaining teeth.
- The occlusal scheme should be at the proper vertical and centric relation position.
- Anterior teeth should be used for cosmetic and phonetic purposes only.
- Posterior teeth should be in balanced occlusion.
Treatment Approach
Stefen M. Schmitt [29] described a treatment approach that attempts to minimize the destructive changes noted by using the treatment objectives of Saunders et al. The prosthesis is made in two stages using a modification of the complete denture construction technique. The mandibular removable partial 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. Later, the maxillary denture is completed and delivered to the patient. Acrylic resin teeth are used to replace the maxillary anterior teeth. Cast gold occlusal surfaces are made for the posterior denture teeth.
- Treatment plan for the retention of maxillary overdenture abutments. The use of overdenture abutments stabilizes the maxillary denture and resists the strong anterior forces that can cause ridge resorption in the premaxilla [35].
- Placement of Osseo integrated implants with attachments in the anterior maxillary ridge will also improve the stability and long-term prognosis of the prosthesis. (Hansen 1990 and Jacobs 1993)
- The use of maxillary ridge augmentation with hydroxyapatite in combination with anterior vestibuloplasty to provide a hard- and soft-tissue base suitable for a stable and retentive maxillary denture to oppose mandibular implants [36]. Onlay augmentations of the premaxilla have also been accomplished with autogenous and allogeneic bone.
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