Combination syndromeBy: Dr. Khalid A. El Banna

B.D.S., M.Sc.

What is combination syndrome?

Combination syndrome was first described by Kelly 1972.

also called “Anterior hyperfunction syndrome”

Definition

“characteristic features that occur when an edentulous maxilla is opposed by natural mandibular anterior teeth, including:

1. loss of bone from the anterior portion of maxillary ridge;

2. overgrowth of tuberosities;3. papillary hyperplasia of the hard palate mucosa; 4. extrusion of mandibular anterior teeth5. and loss of alveolar bone and ridge height

beneath the mandibular removable partial denture base”.

Saunders et al observed six additional changes in 1979:

1. Loss of vertical dimension of occlussion

2. Occlusal plane discrepancy3. Anterior spatial repositioning of the

mandible4. Development of epulis fissuratum5. Poor adaptation of the prosthesis6. Periodontal changes

Etiology Different theories:

1. anterior resorption first:› Proposed by Kelly 1972

2. posterior resorption first:› Proposed by McGivney and Castleberry

1995

Some researchers conveyed that mandibular implant-supported overdenture could generate increased forces on the maxillary ridge encouraging its resorption anteriorly resulting in one or all the symptoms of the combination syndromeLechner and Mamman 1995,Thiel et al 1996, Suzuki et al and Narhi et al 2000

Problems

Remaining teeth

Great force

Bone resorption

Unorganized occlusal plane

No balanced occlusion

Steep incisal guidance

Denture Fracture

Impaired Esthetics

“A single denture that occludes against natural teeth must often be the loser”

Kaddah et al 1998

These changes do not occur in all patients with upper single CD

› Three main factors:

1. Magnitude of force acting on the CD2. Instability of the denture foundation3. Lack of occlusal balance

Other factors: age,sex and max-mand relationship

Palmqvist et al 2003 concluded that it does not meet the criteria to be accepted as a medical syndrome as single features occurred, but to what extent or in which combination, was never clarified.

How to manage?

Avoid the situation

Retain maxillary roots for overdenture

Well constructed RPD

Tooth supported overdenture

Maximize area covered by denture base

Occlusal adjustment› Swenson’s technique

› Yurkstas technique

Soft lining of both dentures Type of food Decreasing occlusal table width Tooth material Extent of replacement of teeth

Balancing occlusion with no anterior contact in centric and minimal in eccentric

Protrusive contact

Working & balancing side contacts

Proper selection of cusp height and occlusal anatomy

Implant prosthodontics

Thank you

Thank you