Combination syndrome revised

AMRITA INSTITUTE OF MEDICAL SCIENCESAMRITA SCHOOL OF DENTISTRY

By Dheeraj Sudhir I Amrita School Of By Dheeraj Sudhir I Amrita School Of DentistryDentistry

MANDIBULAR MANDIBULAR DISTAL DISTAL EXTENSION EXTENSION DENTUREDENTURE

ORAL DESTRUCTIVE CHANGES

COMBINATION SYNDROME

MAXILLARY COMPLETE DENTURE

Scenario Of combination Syndrome

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. Extrusion of the lower anterior teeth.

5. The loss of bone under the partial denture bases.

Ellsworth kelly J Prosthet Dent 1972;27:140-50.

Five Potential Changes Which Leads to Combination Syndrome

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.

Saunders TR, Gillis RE Jr, Desjardins RP. J Prosthet

Dent 1979;41:124-8.  6 Additional Changes Observed inCombination Syndrome

Early loss of bone in the anterior part of maxilla Posteriorly,

enlarged fibrous tuberosities Migration of the occlusal

plane Migration of natural teeth Poor esthetics

Migration of denture Inflammatory papillary hyperplasia

on the palate

Ellsworth kelly J Prosthet Dent 1972;27:140-50

PROPRIOCEPTION

Negative pressure within the maxillary denture

Stress Re-direction

Decreased antagonistic force on mandibular anteriors

Loss of vertical dimension

ill fitting denture

• 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 Over denture on the lower teeth.

Saunders TR, Gillis RE Jr, Desjardins RP. J Prosthet Dent 1979;41:124-8.  

Positive occlusal support for mandibular RPD

Rigid and stable design

Use of anterior teeth

Status of artificial posterior teeth

Saunders TR, Gillis RE Jr, Desjardins RP. J Prosthet Dent 1979;41:124-8.

Implant supported fixed prosthesis

Maxillary Osseo integrated implants.

Augmentation of maxilla

CP Thiel et al 1996;75:107-

13.  Lower Implant Supported Prosthesis

MAXILLARY MAXILLARY DENTUREDENTURE

NEW ERA NEW ERA COMBINATIONCOMBINATION SYNDROMESYNDROME

IMPLANT IMPLANT SUPPORTEDSUPPORTEDMANDIBULARMANDIBULARDENTUREDENTURE

MECHANICSMECHANICS

Increased displacing forces to the upper denture from

the lower implant supported denture The force

comes in excess to the retention provided by upper

denture Significant change In the chewing pattern

Vertical chewing pattern Changes to a

ruminatory pattern

As the chewing pattern As the chewing pattern changes, the features of the changes, the features of the ideal occlusal prescription ideal occlusal prescription

also changes also changes

THE SCENARIO IN THE SCENARIO IN SHORT…SHORT…

Ineffective mastication

Very unretentive upper denture.

The ruminatory pattern of mastication

Unable to exert any control over the mandible

As the lower denture becomes more retentive…….

Wennerberg A, Carlsson GE, Jemt T. 2001;14:550-5.  

SOLUTIONSSOLUTIONS Principles of good retention and stability

Designing of the occlusion

Implants on the upper jaw

Wennerberg A, Carlsson GE, Jemt T. 2001;14:550-5.  

TREATMENT STRATEGIES TREATMENT STRATEGIES & PRINCIPLES& PRINCIPLES

The principle is to design and provide an occlusion that is ideal for the important criteria of denture success—STABILITY !

The basic equations are:-

Force > Retention = InstabilityForce < Retention = Stability

Wennerberg A, Carlsson GE, Jemt T. 2001;14:550-5.  

OCCLUSAL DESIGNINGOCCLUSAL DESIGNING

The occlusal prescription provided is a major factor in determining the size of the force applied to the dentures

The patients masticatory patterns defines the retentive capacity of the dentures

Wennerberg A, Carlsson GE, Jemt T. 2001;14:550-5.  

CONCLUSIONCONCLUSION Almost inevitable tissue changes occur in the

patients wearing upper complete and lower partial dentures.

The dentist should plan the treatment modalities with care and institute them with caution.

The patient should be educated well about the fact

that the longest life of the prosthesis can only be attained by frequent visits and maintenance care