Combination Syn

8/3/2019 Combination Syn

1/33

COMBINATION

SYNDROME


2/33

Syndrome

refers to the association of several clinically

recognizable features, signs (observed by a

physician), symptoms (reported by the patient),

phenomena or characteristics that often occur

together, so that the presence of one feature alerts the

physician to the presence of the others.


3/33

Tillman in 1961 described the complete lower

denture opposed by an upper removable partialdenture (RPD)

Ellsworth Kelly 1972

found in patients wearing a complete maxillary

denture, opposing a mandibular distal extension

prosthesis


4/33

Ellsworth Kelly

SYMPTOMS


5/33

Overgrowth of the tuberosities Papillary hyperplasia inthe hard palate

Supraerupted anteriors


6/33

Saunders et al

SEQUENCE


7/33

early lossof bone

flabbyhyperplastic

connectivetissue makesup the

anterior partof the ridge

Does not

supportdenture

base

Formation

of epulisfissuratum

enlarged fibroustuberosities

occlusal planemigrat

es

Teethdisappe

arunderthe

patients' lips

theocclusal

planedropsdown

Excessive bonyresorption under

the lower

Pathogenesis


8/33


9/33

The upward tipping movement of the anterior portion of

the maxillary denture and the simultaneous downwardmovement of the posterior portion, will decrease

antagonistic forces on the mandibular anterior teeth and

lead to their supraeruption


10/33

Eventually an occlusal plane discrepancy will occur and

the patient may have a loss of vertical dimension of

occlusion.

In addition, the chronic stress and movement of the

denture will often result in an ill-fitting prosthesis and

contribute to the formation of palatal papillaryhyperplasia


11/33

PREVALENCE AMONG DENTURE PATIENTS

Shen and Gongloffin 1989, reviewed records of 150 maxillaryedentulous patients, one in four demonstrated changes consistent

with the diagnosis of combination syndrome.

The changes associated with the syndrome are more likely to be

found in patients who stress the maxillary ridge, such as in Angle

class III jaw relationships and parafunctional habits and inpatients who have functioned mainly with mandibular anterior

teeth for long periods.


12/33

Prevention of combination syndrome

Avoid combination of complete maxillary dentures

opposing class I mandibular RPD.

Retaining weak posterior teeth as abutments by means of

endodontic and periodontic techniques.

An overdenture on the lower teeth.


13/33

TREATMENT OBJECTIVE

Basic treatment objective

Saunders et al in 1979

is to develop an occlusal scheme that

discourages excessive occlusal pressure on the

maxillary anterior region, in both centric and

eccentric positions.


14/33

Specific treatment objectives:

1. The mandibularRPD should provide positive occlusal

support from the remaining natural teeth and have

maximum coverage of the basal seat

2. The designshould be rigid and should provide

maximum stability


15/33

3. The occlusal scheme should be at a proper vertical

and centric relation position.

4. Anterior teeth should be used for cosmetic and

phonetic purpose only.

5. Posterior teeth should be in balanced occlusion.


16/33

TREATMENT PLANING

2-Systemic and dental considerations Review medical, dental history.

Thorough clinical and radiographic evaluation

Resolution of any inflammation, if present.

Evaluation of patients oral hygiene.


17/33

3-Gross changes

should be surgically treated.

Flabby (hyperplastic) tissue

Papillary hyperplasia

Enlarged tuberosities


18/33

4-Supraerupted Teeth

Teeth that are considerably supraerupted would require

alteration by shortening, crowning, or placing them

under an overdenture to obtain a harmoniousocclusion


19/33

5-Mandibular posterior alveolarridge conservation

by leaving teeth or roots. At the same time, retained

anterior maxillary roots will absorb occlusal forces

exerted by anterior mandibular teeth


20/33

6-Augmentation of maxilla

Augmentation of maxilla with resorbable

hydroxyapatite in conjunction with a guided tissue

regeneration technique and vestibuloplasty.


21/33

7- Reducing enlarged tuberosities

Kelly

advices, to allow the lower RPD to extend over the

retromolar pad.

Even weak posterior teeth should be retained as

abutments with endodontic and periodontic

techniques.


22/33

8- Splinting the remaining mandibular

anterior teeth

Saunders

to provide the RPD with positive occlusal

support, rigidity, and stability, while minimizing

excessive stress on the teeth.


23/33

MODALITIES OF TREATMENT

FOR THE COMBINATION SYNDROME


24/33

A- The use of the Mandibular RPD

The mandibular RPD is supported anteriorly by

cingulum rests on the canines with a lingual plate as

the major connector.

Lingual plate delays over eruption of teeth, preventing

undesirable anterior pressure on the anterior part of

maxillary denture


25/33

Posteriorly, maximum support is obtained by extending

the denture base to cover the retromolar pad.

Maximum occlusal support posteriorly with no contact

anteriorly in centric occlusion and a balanced

articulation reduces pressure on the anterior maxillary

ridge


26/33

Limitations

mandibular anterior teeth may continue to erupt, in

the absence of anterior tooth contact

Posterior occlusal contact must be maintained by

constant relining of the distal extension denture base


27/33

B-The use of the teeth supported overdenture

The teeth are treated endodontically and reduced to

the gingival level, and an overdenture is constructed

that is supported and retained by the roots of the

residual teeth.


28/33

C- Mandibular implant-supported overdenture

offers significant improvement in retention, stability,

function and comfort for the patient and a more stable

and durable occlusion


29/33

D-Implant supported fixed prosthesis.

In 2001, Wennerberg reported excellent long term

results with mandibular implant supported fixed

prostheses, opposing maxillary complete dentures


30/33

E- Implants beneath the distal extension base

Keltjens advocate placing implants beneath the distal

extension base of mandibular RPD to provide a stable

posterior support.


31/33

CONCLUSION :

The problems involved in providing comport, function,

proper esthetics and retention is a vigorous challenge for

practising dentist. The damage to the edentulous ridge

and inability to wear the denture may be avoided by

good prosthetic treatment which include adequate

denture base, correct jaw relation record and proper

occlusion.


32/33

REFERENCES Kelly E. changes caused by a mandibular

removable partial denture opposing a maxillarycomplete denture .J prosthet Dent 27:140-150;1972

Shan Kand Gongloff RK. prevalence of thecombination syndrome among denture patients.J prosthet Dent 62:642-644;1989

Tillman EJ. Removable partial upper and

complete lower denture .J prosthet Dent11:1098-1104;1961


33/33

THANK YOU

Documents

Combination Syn