Combination syndrome occurs when an edentulous maxilla is opposed by natural mandibular anterior teeth. Osteoporosis, loss of bone from the anterior portion of the maxillary ridge. A new approach to treating combination syndrome is proposed.
Combination syndrome occurs when an edentulous maxilla is opposed by natural mandibular anterior teeth. Osteoporosis, loss of bone from the anterior portion of the maxillary ridge. A new approach to treating combination syndrome is proposed.
Combination syndrome occurs when an edentulous maxilla is opposed by natural mandibular anterior teeth. Osteoporosis, loss of bone from the anterior portion of the maxillary ridge. A new approach to treating combination syndrome is proposed.
Combination syndrome occurs when an edentulous maxilla is opposed by natural mandibular anterior teeth. Osteoporosis, loss of bone from the anterior portion of the maxillary ridge. A new approach to treating combination syndrome is proposed.
Prosthodontic Terms defines combination syndrome as
the characteristic features that occur when an eden- tulous maxilla is opposed by natural mandibular anterior teeth, including loss of bone from the ante- rior portion of the maxillary ridge, overgrowth of the tuberosities, papillary hyperplasia of the hard palates mucosa, extrusion of the lower anterior teeth, and loss of alveolar bone and ridge height beneath the mandibular removable partial denture basesalso called anterior hyperfunction syndrome. 1 This matches the findings of Kelly 2 on the pattern of residual ridge resorption as observed in a group of patients wearing maxillary complete dentures oppos- ing distal-extension removable partial dentures (RPDs). In a similar group of patients, Saunders et al 3 noted an associated loss of vertical dimension of occlusion, occlusal plane discrepancy, anterior reposi- tioning of the mandible, poor adaptation of the prostheses, epulis fissuratum, and periodontal changes. Shen et al 4 found that, of patients with a maxillary complete denture opposing a bilateral dis- tal-extension RPD, 1 in 4 patients exhibited alveolar ridge changes consistent with those described in the definition of combination syndrome. They also found that completely edentulous patients who had worn bilateral distal-extension RPDs for 5 years before the loss of the remaining anterior mandibular teeth frequently exhibited these same characteristics (Fig. 1). Various surgical procedures to correct some of the undesirable conditions associated with combination syndrome and to improve prosthetic function are described in the literature. 5-7 Saunders et al 3 suggest- ed that the anterior teeth of the maxillary complete denture be arranged for cosmetic and phonetic pur- poses only and recommended that balanced occlusion, with the use of proper cuspal angulation in conjunc- tion with condylar and incisal guidances, be used for the posterior occlusal scheme. The purpose of this clinical report is to present an alternative approach to treating a patient who requires a new prosthesis and who exhibits conditions consis- tent with combination syndrome. CLINICAL REPORT A female patient presented with a maxillary com- plete denture opposing a mandibular Class I RPD with the remaining natural anterior teeth (canine to canine) supported by a porcelain-fused-to-metal restoration. Clinically, the patient displayed loss of vertical dimen- sion of occlusion, anterior repositioning of the mandible (with wear faucets evident on the lingual of the maxillary anterior teeth) (Fig. 2), loss of bone from the anterior part of the maxillary ridge, overgrowth of The use of linear occlusion to treat a patient with combination syndrome: A clinical report William S. Jameson, BS, DDS a Veterans Administration Medical Center, Tucson, Ariz. a Prosthetic Consultant, Dental Clinic. J Prosthet Dent 2001;85:15-9. JANUARY 2001 THE JOURNAL OF PROSTHETIC DENTISTRY 15 Fig. 1. Mounted casts of patient who wore complete maxil- lary denture and mandibular RPD for 7 years. Patient was completely edentulous and exhibited manifestations of combination syndrome. Fig. 2. Wear faucets on lingual of maxillary anterior teeth suggest anterior hyperfunction. the maxillary tuberosities, and loss of bone under the RPD extension bases. The patient, for financial reasons and on the advice of her rheumatologist, elected not to undergo surgery to reduce the maxillary tuberosities or to replace the mandibular anterior splint. To use the existing mandibular restorations, it would have been necessary to remove the 1 remaining extra- coronal matrix on the distal of the left canine to fabricate the new removable prosthesis with conven- tional clasping. This approach would have compromised the establishment of the horizontal occlusal plane from the incisal of the maxillary central incisors to the top of the retromolar papillae. If vertical overlap of the maxil- lary anterior teeth had resulted, the amount of incisal reduction of the mandibular porcelain-to-metal restora- tions would have been limited. Additional reduction to eliminate anterior contact in protrusive would have been at the expense of the maxillary anterior teeth and desired esthetic composition. All of these disadvantages were avoided, however, by reestablishing the height of the mandibular restorations to the new horizontal occlusal plane. At the first clinical appointment after the consulta- tion, cingulum rest preparations were accomplished on both mandibular canines without penetrating the gold. Irreversible hydrocolloid impressions (Accu-Dent System 2 for the RPD and System 1 for the complete denture; Ivoclar North America, Inc, Amherst, N.Y.) were made and master casts formed. The maxillary anterior mold selection was determined by Alameter and Papillameter measurements 8 (Geneva Dental, Inc, Beverly Hills, Calif.). The patients gender and the operators impression of her personality classification (Mold Selection Guide, Geneva Dental, Inc) were recorded. 9,10 THE JOURNAL OF PROSTHETIC DENTISTRY JAMESON 16 VOLUME 85 NUMBER 1 The mandibular master cast was evaluated for critical landmarks such as retromolar papilla, crest of the external oblique ridge, mylohoid ridge, and frenum attachments, and the myostatic outline 11,12 was drawn on the cast. The acrylic-retention component of the RPD framework design was confined within this outline. The master cast then was surveyed and designed, and block-out proce- dures were accomplished and duplicated (PolyPour vinyl polysiloxane duplicating material, GC Laboratory Technology, Inc, Lockport, Ill.). A refractory cast was produced and the framework wax-up accomplished. After the duplication procedure, while the block-out wax was still in place, a stable base was made with visi- ble light-cure (VLC) material (Paladisc LC, Herraeus Kulzer, Irvine, Calif.). The base was designed to fit over the incisal edges of the anterior teeth but not involve their labial surfaces. VLC material was added in the edentulous areas to assist in the attachment of wax to support the recording bar and scribing screw of the ver- tical and centric recorder (Geneva Dental, Inc) (Fig. 3). The casting was made with type IV gold (ArgenCo 52, Argen Corp, San Diego, Calif.) and inspected for dis- crepancies before the metal finishing was accomplished. An esthetic control base (ECB) or wax-rimtype trial stable base and an additional stable base for the maxil- lary recording plate were made with autopolymerizing methyl methacrylate material (C-Plast, Geneva Dental, Inc). The ECB was used to critique the desired lip sup- port, lip length, high lip line, midline, buccal corridor, and anterior plane of orientation to the horizon; it was modified accordingly during the second clinical appointment. At the second clinical appointment, vertical dimension of rest was determined, and an intraoral needlepoint trac- ing was produced at that vertical dimension. The Fig. 3. Mandibular stable recording base was fabricated to verify complete seating during procedure. Extension of VLC material below wax in posterior firmly anchored luting medium. Fig. 4. Positive seating of stable recording bases on their respective master casts was confirmed before mounting procedure. Note horizontal orientation transferred from ECB on front and papillameter measurement on side of maxillary cast. recording bases were luted together with fast-setting impression plaster (Plastogum, Harry J. Bosworth Co, Skokie, Ill.) at the apex of the tracing. A face-bow was not used because, with the linear occlusion concept, the blades are set to the monoplane teeth within the single horizontal plane. Final occlusal adjustments to the blades are accomplished by using the patient as the ultimate articulator. The maxillary anterior teeth were arranged by using the ECB and dentogenic principles and concepts. 13 An alternate approach would use a lab- oratory to arrange the anterior teeth on the ECB with an additional appointment needed to verify its accept- ability before establishing the horizontal occlusal plane. The master casts were positioned in their stable bases (Fig. 4) and mounted in a semiadjustable articu- lator. Once mounted, the recording bases were JAMESON THE JOURNAL OF PROSTHETIC DENTISTRY JANUARY 2001 17 removed, and the ECB and arranged anterior teeth were luted to the maxillary master cast. The silver tem- plate (Geneva Dental, Inc) was positioned such that it contacted the central incisors in the anterior position and the top of the retromolar papillas in the posterior position to establish the horizontal plane. Because the RPD framework casting had been accomplished, the mandibular anterior teeth were reduced until the tem- plate could be positioned correctly (Fig. 5). Because of this reduction on the cast, anterior clearance on the finished prosthesis needed to be achieved intraorally when the final denture was delivered. The use of an alternative tooth form and occlusal concept (linear occlusion), 14 with its inherent absence of anterior vertical overlap, had been agreed on by both the patient and the practitioner. This enhanced the suggestion by Saunders et al 3 to minimize anterior contact in eccentric positions. The seventh edition of The Glossary of Prosthodontic Terms defines linear occlusion as the occlusal arrangement of artificial teeth, as viewed in the horizontal plane, wherein the masticatory surfaces of the mandibular posterior artifi- cial teeth have a straight, long, narrow occlusal form resembling that of a line, usually articulating with opposing monoplane teeth. 1 According to this con- cept, there is no need for the traditional 2- to 3-mm interocclusal rest space. This is not to say that no inter- occlusal clearance is needed, just that less is required. For this reason, the centric relation record was made at the vertical dimension of rest, which allowed the teeth to be arranged at a vertical height that reduced verti- cal overlap of the anterior teeth. With this concept, 0.020 of an inch of vertical clearance was provided during the arrangement of the anterior teeth. The clearance was created by establishing the horizontal plane of occlusion from the incisal edge of the maxil- Fig. 5. Mandibular anterior teeth were reduced to permit proper positioning of silver template when establishing hor- izontal plane of occlusion. Maxillary central incisors and monoplane posterior teeth contacted template. Fig. 6. Frontal view of maxillary tooth arrangement. Note drawn lines that indicate buccal extent in posterior position and midline in anterior position. Incisal pin was lowered to contact incisal table before removing template. Fig. 7. Ridge formed at mesial edge of occlusal surface of first premolar, which slants to contact area. Ridge was intended to function as bilateral fulcrum of protrusive sta- bility and enhance esthetics by mimicking buccal cusp. lary central incisors to the top of the retromolar papil- la with a silver template (Geneva Dental, Inc). The maxillary first premolars were esthetically posi- tioned, and a line was drawn from their buccal cusp tips to a point 4 mm lateral to a line marking the crest of mandibular residual ridge. The buccal cusp tips of the remainder of the monoplane posterior teeth were arranged so that they touched this line (Fig. 6). With this accomplished, the template was removed, the RPD framework was placed on the mandibular cast, and the bladed posteriors were arranged over the crest of the residual ridge. After processing of the maxillary pros- thesis, the occlusal one third of the first premolar was reduced at a 45-degree angle to form a ridge that acted as a point of posterior contact for the mandibular blades in a protrusive position of the mandible (bilater- al fulcrum of protrusive stability) 15 (Fig. 7). At the third (verification) appointment, the tooth arrangement was checked for esthetics, phonetics, and correctness of the centric relation record (Fig. 8). After the tissues had relaxed and adapted to the new prosthesis, the patient was permitted to view the tooth arrangement in a full-length mirror from 9, 6, and then 3 feet. This gradual visual accommodation to her appearance helped the patient to see herself as others view her. Because she was satisfied with her appear- ance, permission to process was requested and received. Processing was accomplished with injection mold- ing (Ivocap, Ivoclar Williams). 16 After recovery and before remounting, the maxillary denture was milled flat on 220-grit Wet-or-Dry sandpaper (Household Products Division, 3M, St Paul, Minn.) on a 0.25-in thick plate glass slab. Flatness was verified by placing a black template (Geneva Dental, Inc), which is anodized aluminum milled to be true within 0.0002 of an inch, against the flattened occlusal surfaces with- out allowing light to be transmitted between the template and the occlusal surfaces. Both casts then were remounted in the articulator, and the blades were reduced vertically with Silky Stones (Geneva Dental, Inc) until uniform contact was achieved on both sides. The blades were reduced on their buccal and lingual inclines until a narrow, straight line was produced. The ground porcelain was smoothed and repolished with Brasseler Pre-Polisher and High-Shine porcelain pol- ishing wheels (Brasseler USA, Savannah, Ga.). The prostheses then were recovered, finished, and pol- ished. The finished prostheses were fitted with pressure indicator paste and delivered at the next appointment. Because of the occlusal anatomy, it is relatively easy to detect first point of contact should an occlusal pre- maturity exist. For this reason, no remount procedures were carried out. Minimal occlusal adjustment was needed on the blades. The maxillary central incisors were marked in protrusive and reduced until the artic- ulating paper could be pulled between the anterior teeth without dragging or tearing. SUMMARY Using linear occlusion concepts and alternative tooth form, a functional and esthetically pleasing pros- thesis was fabricated. The patient experienced no problems phonetically and was pleased with her appearance as well as her ability to chew (Fig. 9). Anterior contact was eliminated, thereby reducing the potential for further bone loss caused by anterior hyperfunction syndrome. REFERENCES 1. VanBlarcom CW. The glossary of prosthodontic terms. 7th ed. J Prosthet Dent 1999;81:60, 81. 2. Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50. THE JOURNAL OF PROSTHETIC DENTISTRY JAMESON 18 VOLUME 85 NUMBER 1 Fig. 8. Increase in vertical dimension of occlusion demon- strated by anterior markings performed with old denture and trial tooth arrangement, both in centric occlusion. Minor reduction in anterior incisal length for protrusive clearance was necessary and accomplished at delivery. Fig. 9. Finished prostheses in mouth at time of delivery. 3. Saunders TR, Gillis RE Jr, Desjardins RP. The maxillary complete denture opposing the mandibular bilateral distal-extension partial denture: treat- ment considerations. J Prosthet Dent 1979;41:124-8. 4. Shen K, Gongloff RK. Prevalence of the combination syndrome among denture patients. J Prosthet Dent 1989;62:642-4. 5. Atwood DA. Some clinical factors related to rate of resorption of resid- ual ridges. J Prosthet Dent 1962;12:441-50. 6. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27:120-32. 7. Hall HD. Vestibuloplasty, mucosal grafts (palatal and buccal). J Oral Surg 1971;29:786-91. 8. Massad JJ, Goljan KR. A method of prognosticating complete denture outcomes. Compendium 1994;15:900, 902-9; quiz 910. 9. Frush JP, Fisher RD. How dentogenic restorations interpret the sex factor. J Prosthet Dent 1956;6:160-72. 10. Frush JP, Fisher RD. How dentogenics interprets the personality factor. J Prosthet Dent 1956;6:441-9. 11. Massad JJ. A metal-based denture with soft liner to accommodate the severe- ly resorbed mandibular alveolar ridge. J Prosthet Dent 1987;57:707-11. 12. Jameson WS. Fabrication and use of a metal reinforcing frame in a frac- ture-prone mandibular complete denture. J Prosthet Dent 2000;83:476-9. 13. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic con- cept. J Prosthet Dent 1958;8:558-81. 14. Frush JP. Linear occlusion. Ill Dent J 1966;35:788-94. 15. Frush JP. Artificial denture.. US Patent 3,638,309, February 1, 1972. 16. Strohaver RA. Comparison of changes in vertical dimension between compression and injection molded complete dentures. J Prosthet Dent 1989;62:716-8. Reprint requests to: DR WILLIAM S. JAMESON 11401 CALLE VAQUEROS TUCSON, AZ 85749-8483 FAX: (520)749-1511 E-MAIL: [email protected] 10/1/112436 doi:10.1067/mpr.2001.112436 JAMESON THE JOURNAL OF PROSTHETIC DENTISTRY JANUARY 2001 19 Access to The Journal of Prosthetic Dentistry is reserved for print subscribers! Full-text access to The Journal of Prosthetic Dentistry Online is available for all print sub- scribers. To activate your individual online subscription, please visit The Journal of Prosthetic Dentistry Online, point your browser to http://www.mosby.com/prosdent, follow the prompts to activate online access here, and follow the instructions. To activate your account, you will need your subscriber account number, which you can find on your mailing label (note: the number of digits in your subscriber account number varies from 6 to 10). 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