69
Combination Syndrome
8.1 Defining Features In response to the increased occlusal loads, the resorp-
tion of the anterior maxillary alveolar ridge can occur,
Combination syndrome (CS) can occur when a maxillary and a flabby ridge can replace the hard bony ridge. A
complete denture opposes a mandibular distal extension maxillary denture would then displace in the superior
removable partial denture or a dentate mandibular arch. and anterior direction, reducing the occlusal VD, and the
Characteristic features of CS include (Kelly, 1972): upper occlusal plane would drop posteriorly, resulting in
downgrowth of fibrous tissue in the tuberosity region.
●● bone loss in the anterior maxilla which is often replaced Tuberosity pneumatisation can also occur due to an
by a flabby ridge unknown mechanism. Inflammatory papillary hyperpla-
●● downgrowth of the maxillary tuberosity sia of the palate can occur as a result of poor denture
●● palatal papillary hyperplasia adaptation and poor oral hygiene.
●● overeruption of the mandibular anterior teeth Epulis can also form in the anterior maxilla due to the
●● bone loss in the mandibular distal extension areas irritation caused by the upper denture’s labial flange.
under the removable partial denture bases. Retention of the maxillary denture can then progres-
Other changes may include poor adaptation of the pros- sively deteriorate.
theses, epulis formation, discrepancies of the occlusal Due to the shift of the occlusal loads and changes in
plane, decrease in the vertical dimension (VD) and for- the occlusal plane, the remaining mandibular anterior
ward posturing of the mandible and periodontal prob- teeth may drift or overerupt and become mobile, espe-
lems associated with the remaining mandibular anterior cially if the teeth have poor periodontal condition. The
teeth. trauma caused by the lower partial denture can also
Different classifications have been proposed for cate- cause gingival recession on the lingual aspect of the
gorising combination syndrome based on the complete mandibular anterior teeth (Palmqvist et al., 2003;
or partial edentulous status of the maxilla and/or mandi- Tolstunov, 2011).
ble. The common feature of most CS cases is an edentu-
lous premaxilla with advanced ridge resorption in the
anterior maxilla and overeruption of the mandibular
anterior teeth (Rajendran, 2012; Tolstunov, 2007). 8.3 Clinical Assessment
Clinical assessment of a patient with a complete denture
includes:
8.2 Pathogenesis
●● thorough history of the existing dentures and assess-
Ridge resorption in the mandibular distal extension ment of the denture’s stability, retention, extension,
areas can occur much faster (by four times) than the occlusion, wear, aesthetics, phonetics and freeway
maxillae due to a smaller bearing area (Tallgren, 1972). space (FWS)
This process, combined with the wear of posterior artifi- ●● extraoral examination, including temporomandibular
cial teeth over time, would lead to the loss of posterior joints (TMJ), muscles of mastication and lip support
support in the mandible, encouraging the forward pos- ●● intraoral assessment including soft tissues, alveolar
turing of the mandible and significantly shifting the ridge height, width, flabby tissues, sulcus depth, neu-
occlusal loads to the anterior region. tral zone space available, tongue size and movements
Diseases and Conditions in Dentistry: An Evidence-Based Reference, First Edition. Keyvan Moharamzadeh.
© 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/moharamzadeh/diseases
70 Diseases and Conditions in Dentistry
●● assessment of any remaining teeth in terms of perio- ●● Correction of occlusal plane discrepancies and vertical
dontal, caries and periapical disease dimension problems prior to definitive treatment.
●● panoramic radiograph and three-dimensional imaging ●● Fabrication of a heat-cured transparent baseplate prior
if necessary to assess the bone available for potential to occlusal registration to assess the stability, retention
implant treatment and periapical radiographs of and fit of the denture base at an early stage.
remaining teeth if there is any suspected periapical or ●● Accurate bite registration, use of face-bow transfer to
periodontal pathology. enable suitable orientation of the occlusal plane and
mounting the casts on a semi-adjustable articulator to
ensure balanced articulation.
8.4 Prevention ●● Selection of teeth with shallow-angled cusps and hard-
ened surfaces for the posterior teeth and avoiding
Patient education is an important aspect of prevention steep anterior incisal guidance.
and includes maintaining good plaque control and peri- ●● Careful assessment of occlusion and the need for
odontal health of the remaining anterior teeth, denture check-record and occlusal adjustment if necessary.
care instructions to leave the prostheses out of the mouth
at night and regular recall and maintenance.
Ridge resorption can be minimised in denture wearers
by considering the following provisions: 8.6 Management of Flabby Ridge
●● retaining roots as overdenture abutments Surgical removal of the flabby tissue prior to denture fab-
●● broad stress distribution rication may result in reduced sulcus depth and is not
●● bilaterally balanced occlusion often recommended as a present flabby ridge would be
●● minimising anterior contacts better than an absent ridge.
●● effective border seal. Several impression techniques have been introduced
for mucostatic recording of denture bearing areas that
Altered cast impression technique by taking an impres-
contain displaceable flabby tissues (Allen, 2005).
sion of the free-end saddle areas under controlled pres-
sure can minimise displacement of the denture under ●● The minimally displacive technique involves the use of
occlusal loads. In this technique, close-fitting baseplates a single impression tray that has a window or multiple
are constructed on the metal framework to take impres- perforations over the flabby area. Impression of the
sion of the distal extension areas while the metal frame- compressible tissues is recorded using a heavy-body
work is seated and the pressure is applied only on the rest silicone or zinc-oxide eugenol (ZOE) impression mate-
seat areas. The saddle areas of the master cast are then rial. The flabby tissue is recorded with minimal dis-
sectioned and removed in the laboratory and the new placement using a low-viscosity silicone impression or
saddle areas are poured with the framework in place plaster impression material in the windowed or perfo-
(Sajjan, 2010). rated areas of the impression tray (Lynch and Allen,
It has been shown that appropriate conventional 2006).
impression taking using completely extended impres- ●● The two-tray technique uses two separate impression
sion, use of magnification, adjustment of the framework trays to record the flabby and non-flabby areas sepa-
to ensure complete seating, and coverage of the retromo- rately which are then related intraorally (Bindhoo
lar pads and buccal shelves can produce comparable et al., 2012).
impression outcomes to the altered cast impression ●● The selective pressure technique involves selective
technique (Frank et al., 2004). manipulation of the thermoplastic greenstick com-
pound impression material and application of pressure
over compressible areas and no pressure on the flabby
8.5 Treatment Considerations tissues (Duncan et al., 2004).
●● The copy denture technique copies the patient’s
The following considerations can be useful in manage- existing prosthesis, maintaining the polished sur-
ment of patients with CS (Cabianca, 2003; Langer et al., face and perforation of the base over the area of the
1995; Lynch and Allen, 2004; Schmitt, 1985). flabby tissues when recording the master impres-
●● Adopting a shortened dental arch approach with or sion. It is advisable to fabricate a clear acrylic base-
without fixed bridges in the lower arch. plate following the master impression to check the
●● Restoration of the posterior mandible with implant- mucosal contacts prior to adding wax blocks for bite
retained fixed prosthesis. registration.
Combination Syndrome 71
8.7 Management of Denture-Induced ●● Type 3 is inflammatory papillary or nodular hyperpla-
Stomatitis sia of the palate.
Treatment for denture-induced stomatitis includes the
Denture-induced stomatitis is a common condition that following.
can occur due to inflammation of oral mucosa under the
denture. Its aetiology is multifactorial and in approxi- ●● Oral hygiene and denture care instructions to remove
mately 90% of cases, fungal infections such as Candida the dentures at night, clean, disinfect and store them in
species are involved. Prolonged trauma from the den- an antiseptic solution overnight (Lombardi and Budtz-
ture with poor hygiene and dry mouth can exacerbate Jorgensen, 1993).
the condition. ●● Treatment of any underlying disease such as diabetes
Denture-induced stomatitis can be divided into three and HIV infection.
categories according to Newton’s classification. ●● Application of topical antifungal medications in the
form of oral gels, suspensions and lozenges. Antifungal
●● Type 1 is characterised by localised inflammation or medications can be effectively mixed with commer-
small area with erythema. cially available tissue conditioners to be used under the
●● Type 2 is diffused erythema of the mucosa covered by dentures (Iqbal and Zafar, 2016).
the denture. ●● The use of an antiseptic mouthrinse such as chlorhex-
idine is also recommended.
Case Study
A 57-year-old female patient presented with an eden
tulous maxillary arch and unstable and non-retentive
10-year-old upper complete denture against a dentate
mandibular dental arch.
Clinical examination confirmed the diagnosis of combi-
nation syndrome and a flabby ridge in the anterior maxil-
lae (Figure 8.1).
Figure 8.2 Special tray with a window over the flabby ridge.
●● Adjustment and border moulding of the special tray
and secondary impression using a combination of ZOE
impression material in the compressible areas and light-
body silicone impression material over the flabby ridge
area in the anterior region (Figure 8.3).
Figure 8.1 Edentulous maxillary arch with a flabby ridge in the
anterior region. ●● A clear acrylic baseplate was fabricated and tried in to
assess the tissue contacts and the stability, retention
and fit of the denture base at an early stage.
Treatment procedures included the following. ●● Bite registration using wax blocks added onto the
●● Primary impression with alginate material. baseplate.
●● Fabrication of a special tray with a window over the ●● Wax try-in and carving the post dam.
flabby ridge area (Figure 8.2). The special tray was ●● Denture insertion and occlusal adjustment using a pre-
spaced in the anterior region with displaceable tissues centric check record.
but close-fitting in the posterior compressible areas of ●● Review and maintenance.
the palate and the alveolar ridge.
72 Diseases and Conditions in Dentistry
Figure 8.4 Postoperative clinical photograph of the denture in
occlusion.
Figure 8.3 Master impression using a combination of ZOE and
light-body silicone impression materials.
A postoperative clinical photograph of the denture in
occlusion is shown in Figure 8.4 and the patient’s smile
is shown is Figure 8.5.
The flabby ridge impression technique used in this case
resulted in an accurate impression of the ridge without
displacement of the flabby areas. The assessment of the
interface between the ZOE and the light-body silicon
impression materials showed nice blending of the two Figure 8.5 Postoperative photograph of the patient’s smile.
materials without any steps or inaccuracies.
Due to the lingual inclination of the mandibular premo-
With careful adjustment of the wax rim, a satisfactory lip
lar teeth and a narrow mandibular arch, the maxillary pre-
support was achieved with a favourable smile line.
molar teeth were widened palatally to provide occlusion
The patient was very satisfied with the aesthetics, reten-
with the mandibular teeth while maintaining the wide
tion and function of the new maxillary denture.
maxillary arch-form.
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