CLASSIC ARTICLE

Changes caused by a mandibular removable partial denture opposing a

maxillary complete denture
Ellisworth Kelly, DDSa
School of Dentistry, University of California, San Francisco, Calif

A lthough many advances have been made in den-

ture prosthetics, the great problem is still with us: coping
arch to resist stress and when the lower anterior teeth
occlude anterior to the basal support, trauma is inevita-
with the resorption of the residual alveolar ridge and ble. Many of these patients have distal-extension partial
managing or preventing the secondary soft tissue lower dentures but this does not seem to prevent this
changes brought on by bone loss. type of destruction in the upper jaw. The degenerative
The resorption occurring beneath denture bases has changes in these patients include more than the loss of
been investigated1-9 and we have some knowledge of the bone. An overgrowth of the maxillary tuberosities often
rate of resorption of the residual bony ridge. Investi- occurs. These enlargements are usually fibrous but they
gators agree that individual differences in the rate of may be bony enlargements. Papillary hyperplasia of the
resorption of the ridges are very great. Underlying met- palatal mucosa may occur concurrently. The remaining
abolic, hormonal, and nutritional causes account for this mandibular anterior teeth seem to extrude along with
difference and we know very little about these factors. the bony process, and excessive bone loss occurs in the
From clinical experience and clinical studies,10,11 we posterior part of the ridge under the partial denture
have considerable knowledge of the prosthetic factors bases. These five changes may constitute a syndrome, as
which influence bony resorption. We know that moder- they are quite characteristic. These changes are (1) loss
ate, intermittent forces exerted on the bony ridge by a of bone from the anterior part of the maxillary ridge, (2)
prosthesis may be stimulating and help preserve rather overgrowth of the tuberosities, (3) papillary hyperplasia
than destroy the bony ridge.12 We know that excessive in the hard palate, (4) extrusion of the lower anterior
force causes resorption of the residual ridge. De Van13 teeth, and (5) the loss of bone under the partial denture
stated that compressive forces are well tolerated by the bases. I call this the “combination syndrome.”
edentulous ridges while shearing forces are not. This
concept has been utilized by many techniques which COMPLETE UPPER DENTURES
minimize the lateral forces exerted by dentures. The OPPOSING PARTIAL LOWER
principle of wide coverage with the complete or partial DENTURES
removable denture base to minimize the force per unit Completely edentulous maxillae and partially eden-
area is basic14 and has served us well. Yet we are not able tulous mandibles with only anterior teeth remaining are
to do anything for those people who are very susceptible common situations. In the past two years, 130 of 495
to bone loss because of underlying systemic causes and patients treated in the prosthodontic clinic at the School
who, in spite of our best efforts, often end up with very of Dentistry of the University of California received
little bone remaining. On the other hand, we do have complete maxillary dentures opposing mandibular par-
the knowledge to prevent excessive bone loss from trau- tial dentures. This represents 26 per cent of the denture
matic forces exerted by or on the denture bases. Obser- patients. Some of the partial dentures had distal support
vation of a number of denture patients will show that we but most of them did not.
are failing to put this knowledge into practice. Destruc-
tion of the residual ridge from occlusal trauma is not THE COMBINATION SYNDROME
uncommon. Very common is the almost total loss of
bone in the anterior part of the maxillae brought about The early loss of bone from the anterior part of the
by only natural anterior teeth remaining in the mandible maxillary jaw is the key to the other changes of the
and occluding with a compelte upper denture. The an- combination syndrome. With the anterior loss of bone, a
terior part of the maxillae is the weakest part of the upper flabby hyperplastic connective tissue makes up the ante-
rior part of the ridge. This hyperplastic tissue does not
support the denture base and usually it folds forward,
Read before the Academy of Denture Prosthetics in Detroit, Mich.
a
School of Dentistry, University of California, San Francisco, Calif.
forming a characteristic deep fold or crease (Fig. 1). As
Reprinted with permission from J Prosthet Dent 1972;27:140 –50. bone and ridge height are lost anteriorly, the posterior
J Prosthet Dent 2003;90:213-9. residual ridge becomes larger with the development of

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Fig. 1. Maxillary arch that has supported complete upper denture against 6 natural lower anterior teeth and Class I partial
denture for 14 years shows changes that this combination often effects.

Fig. 2. Mounted diagnostic casts show bony loss and rolled Fig. 3. With loss of anterior maxillary bone, overgrowth of
(hyperplastic) soft tissue in upper anterior region, enlarged tuberosities, and upward migration of lower anterior teeth,
tuberosities, and extruded lower anterior teeth. patient shows no upper anterior teeth but does show upper
posterior teeth because of dropping of distal end of occlusal
plane of dentures.

enlarged tuberosities. These enlarged tuberosities are Excessive bony resorption under the lower removable
usually made up of fibrous tissue, but in some patients partial denture bases occurs to permit these changes, and
the bone height seems to have increased also. With these often inflammatory papillary hyperplasia develops in the
changes, the occlusal plane migrates up in the anterior palate (Fig. 4).
region and down in the back. After a time, the natural The histopathology of the hyperplastic anterior
lower anterior teeth migrate upward, the anterior teeth ridge tissue, and the fibrous tissue which develops
on the complete denture disappear under the patient’s over the tuberosities is revealing. Microscopic exami-
lip, and both dentures migrate downward in the poste- nation of these tissues shows that the flabby tissue and
rior region. The esthetics are poor with the patient show- the hard tissue over the tuberosities are indistinguish-
ing none of the upper anterior teeth and too much of the able. They are made up of mature, dense, fibrous
lower anterior teeth, and the occlusal plane drops down to connective tissue. This tissue in both locations has
expose the upper posterior teeth (Figs. 2 and 3). dense bundles of collagen fibers, with relatively few

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upper denture opposing a lower partial denture for 16

years. The fulcrum of movement in this patient is in the
cuspid-first bicuspid region. Our patients show that at
first the fulcrum is well to the posterior, just anterior to
the tuberosity.
With the posterior palatal seal, a negative pressure is
produced posterior to the fulcrum line. This negative
pressure may account for the enlarged tuberosities and
the papillary hyperplasia. Carlsson1 observed one patient
who had an increase in the maxillary ridge height in the
molar region after wearing dentures for two years. He
postulated: “It may have been due to the development
of a fibrous part possibly1 owing to the suction effect
when the denture moved.” A number of authors15-17
have associated a void, a “suction chamber,” or other
form of negative pressure with inflammatory papillary
Fig. 4. Papillary hyperplasia in palate often accompanies hyperplasia of the palate. Wictorin5 states that to prevent
other changes of combination syndrome. bony resorption, mechanical forces must be distributed
over as large an area of the basal seat as possible, and the
denture must make as little movement as possible
against its basal seat, and that these factors are strongly
cellular elements, with very few inflammatory cells. It interconnected. With the lower anterior teeth causing
is rather avascular with an overlying epithelium that is trauma and bone loss from the anterior part of the max-
almost normal, but shows some evidence of hyperpla- illae, and with the denture base moving more and more
sia (Fig. 5). This is also the histopathology of a mature on its foundation, a very destructive situation exists.
epulis fissuratum if we discount the area of ulceration All kinds of questions come to mind. How fast do the
caused by the denture border. This similarity is sur- degenerative changes develop? Is excessive bone loss in
prising because the hyperplastic anterior tissue is the anterior part of the maxillae with the other changes
freely movable while the fibrous tissue over the tuber- that follow inevitable or does it occur only in neglected
osity is hard. However, all three of these conditions patients, those without proper follow-up treatment in
(the flabby anterior ridge, the fibrous tuberosity, and refitting the denture bases and readjustment of occlu-
the epulis fissuratum) are the result of prolonged sion? If it is from neglect, what kind, and what amount
trauma from the denture base. Therefore, the fact that of care is necessary to prevent it? Will the changes occur
the tissue response is the same is logical. in all patients or only in susceptible patients with under-
The difference in consistency of fibrous tuberosities lying metabolic, hormonal, or nutritional deficiency?
and flabby anterior ridges must be explained on a me-
chanical basis. The anterior bony ridge has virtually dis-
appeared and the connective tissue replacement is a nar- PATIENT HISTORIES WITH
row projection of tissue virtually unsupported on the CEPHALOMETRIC RADIOGRAPHS
labial or lingual surface. On the other hand the fibrous In an effort to find answers to some of these ques-
tissue over the tuberosity is supported by a broad base of tions, we started a study of 20 patients who were receiv-
bone below. ing complete maxillary dentures opposing distal-exten-
sion removable partial dentures. Only six of these
MECHANICS WHICH PRODUCE THE
patients have returned faithfully over a three-year period
COMBINATION SYNDROME
so no conclusions can be drawn from this preliminary
The resorption of the bone in the anterior region report.
initiates the changes which we call the combination syn- We made serial cephalometric radiographs with a
drome. Natural anterior maxillary teeth have increased 0.25 mm. diameter lead wire outlining the soft tissue on
bony resorption under maxillary dentures.4,5 While the right side of the ridge (Figs. 7 and 8). All of the
bone is being lost in the anterior region in the upper jaw, patients received maxillary complete immediate den-
bony resorption also occurs under the mandibular par- tures opposing Class I lower partial dentures. All were
tial denture bases. The maxillary denture then moves up first-time denture wearers. The immediate dentures
in the anterior region and down in the posterior region were constructed after the posterior teeth had been ex-
in function. This tipping action is illustrated in the dia- tracted and a healing period allowed. The first radio-
gram (Fig. 6) which was traced from cephalometric ra- graph was made after the initial healing of the anterior
diographs of a patient who had been wearing a complete part of the maxillary ridge had taken place, and after the

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Fig. 5. Histologic sections of lesions: A, Flabby (hyperplastic) anterior ridge (⫻100); B, fibrous tuberosity (⫻100); C, inflam-
matory papillary hyperplasia (⫻40); D, the same (⫻100). The similarity of A (hyperplastic ridge tissue) and B (fibrous tuberosity)
is discussed in text. Papillary hyperplasia shows (a) fibrous core, (b) hyperplastic epithelium, and (c) inflammatory cells.

anterior section of the immediate denture had been re- All of the patients showed a loss of 1 to 3 mm, of ridge
fitted with cold-curing acrylic resin. This was unsually height in the anterior region. All of the subjects showed
about four weeks after insertion of the dentures. a loss of the underlying bone as well. All of the subjects
A second radiograph was made after six to eight showed an increase of 1 to 2.5 mm. height of the tuber-
months. The patients were seen regularly over the first osity with all but one having a corresponding increase in
few months, and the dentures refitted and serviced as the height of the underlying bone. One subject had an
needed. After the first year, the third radiograph was increase in the height of the tuberosity but a slight loss of
made. At this time, the maxillary denture was relined underlying bone. All of the subjects show a 1.0 to 1.5
or a new denture was constructed. After this, the pa- mm. extrusion of the lower anterior teeth.
tients were called annually for examination and radio- This is significant since the measurements are very
graphs. accurate because of the stability of the bony landmarks at
Measurements were made directly on the radio- the midline.
graphs, using the sella-nasion line as a base. The results One patient is beginning to show signs of the deteri-
are expressed as millimeters of increase (plus) or milli- oration of the anterior part of the upper ridge which we
meters of decrease (minus) in the residual ridge height. attribute to trauma from the lower anterior teeth. This
Table I shows these data for the maxillary bone and soft patient has a flabby thickening of the tissue, inflamma-
tissue. tion of the incisive papilla, and the beginning of a fold
Tracings were made from the cephalometric radio- forming the labial surface of the ridge (Fig. 10).
graphs. These show the changes graphically but not as All of the subjects have been successful denture wear-
accurately as the measurements directly on the radio- ers, well satisfied with their prosthesis. They have re-
graphs (Fig. 9). ceived better than average follow-up treatment in refit-

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Fig. 6. Diagram made from tracings from 2 cephalometric ra-

diographs, one at physiologic rest position and the other with Fig. 7. Lateral cephalometric radiograph of one subject
teeth in centric occlusion. In this patient, with an advanced shows the lead wire outlining soft tissues of ridge.
combination syndrome, movement of denture base is very
great, causing positive pressure anterior to fulcrum (F) and neg-
ative pressure posterior to this position.

Table I. Each figure represents increase or decrease in

millimeters of ridge height over three-year period

Posterior tuberosity ridge

height Anterior ridge height

Patient Soft tissue Bony ridge Soft tissue Bony ridge

A, age 63 ⫹2.5 ⫹1.7 ⫺2.2 ⫺1.7

B, age 51 ⫹1.0 ⫹1.0 ⫺3.0 ⫺3.0
C, age 46 ⫹1.3 ⫹0.5 ⫺2.2 ⫺1.2
D, age 43 ⫹2.0 ⫹1.7 ⫺1.5 ⫺1.0
E, age 35 ⫹1.0 ⫺0.2 ⫺2.9 ⫺0.7
F, age 34 ⫹1.3 ⫹0.5 ⫺1.0 ⫺0.5

are impossible prosthodontic combinations. Treatment

planning should avoid the necessity for such a combina-
Fig. 8. Lead wire is in place after radiograph was made. Lead
tion. The same could be done to eliminate the combi-
wire adheres to and is very slightly embedded into soft tissue. nation of complete upper dentures opposing Class I
lower partial dentures. I do not advocate extracting
lower anterior teeth to accomplish this but rather to
retain weak posterior teeth as abutments by means of
ting the bases and equilibrating the occlusion. With the endodontic and periodontic techniques. Endosseous
loss of tissue demonstrated in the anterior part of the endodontic implants and the amputation of one lower
upper jaw, and with a positive change developing in the molar root to preserve the other as an abutment are
posterior part of the ridge, and with the lower anterior examples of some of the methods that could be applied.
tooth migration, it appears that any or all of these pa- An overlay denture on the lower may avoid the com-
tients could develop the typical signs of the combination bination syndrome from developing. Overlay dentures
syndrome. utilizing the lower tooth roots for stabilization provide a
complete denture occlusion.
PREVENTION OF THE COMBINATION
SYNDROME SURGICAL CORRECTION OF
Preventing the degenerative changes that complete
CHANGES IN THE BASAL SEAT
maxillary dentures opposing the Class I partial dentures Even after much damage has been done and gross
bring about may only be possible through treatment changes have taken place, many dentists and patients
planning to avoid this combination of prostheses. Com- prefer to remake the combination rather than sacrifice
plete lower dentures opposing natural maxillary teeth the remaining lower anterior teeth to make complete

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Fig. 9. Cephalometric tracings of each of the 6 subjects. They were made 3 years apart and show changes that have occurred.
Solid lines show initial outline of bone and soft tissue; dotted lines indicate these outlines 3 years later (Table I).

larged tuberosities can be reduced. This allows the distal

end of the occlusal plane to be raised to the proper level,
and allows the lower partial denture bases to be fully
extended. This is extremely important, and covering the
maximum area possible for support of partial denture
bases would help prevent the combination syndrome.
Covering the retromolar pad where muscle and raphe
attachments prevent or reduce resorption, and covering
the buccal shelf14 is necessary to retard bone loss. Often
this is not done with removable partial dentures.

SUMMARY
Almost inevitable degenerative changes develop in
the edentulous regions of wearers of complete upper
and partial lower dentures. We have followed six patients
Fig. 10. One subject, although given follow-up treatment,
over a three-year period with cephalometric radiographs
shows the beginning of degenerative changes. Soft tissue in
anterior part of maxillary ridge is thickened and soft. Note
to determine if these changes could be detected. In all
characteristic horizontal fold on labial surface of maxillary six subjects, early changes that could become gross
ridge. changes were apparent. In one of them degenerative
clinical change is beginning to appear.
This problem might be solved with treatment plan-
ning to avoid the combination of complete upper den-
dentures. Surgery can do much to rehabilitate these pa- tures against distal-extension partial lower dentures. The
tients. The flabby (hyperplastic) tissue can be removed, alternative of complete maxillary and mandibular den-
the papillary hyperplasia can be eliminated, and the en- tures is not attractive to patients. Preserving posterior

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teeth to serve as abutments to support lower partial den- 8. Atwood DA. Some Clinical Factors Related to Rate of Resorption of
Residual Ridges. J. Prosthet. Dent. 1962;12:441-450.
tures and to provide a more stable occlusion is a better 9. Atwood DA: Reduction of Residual Ridges as a Disease Entity, Essay
alternative. presented at meeting of the American Prosthodontic Society, Las Vegas,
Ill-fitting dentures have been blamed for all of the 1970.
10. Neufeld JO. Changes in the Trabecular Pattern of the Mandible Following
lesions of the edentulous tissues, yet the most perfect the Loss of Teeth. J. Prosthet. Dent. 1958;8:685-697.
denture will be ill-fitting after bone is lost from the 11. Applegate OC. Conditions Which May Influence the Choice of Partial or
anterior part of the ridge. Removable dentures need Complete Denture Service. J. Prosthet. Dent. 1957;7:182-196.
12. Carlsson GE, Thilander H, Hedegard B. Histologic Changes in the Upper
periodic attention at least as often as the natural teeth. Alveolar Process After Extractions With or Without Insertion of an Imme-
diate Full Denture. Acta Odont. Scand. 1967;25:123-146.
The author would like to express his appreciation to Dr Louis S.
13. De Van MM. An Analysis of Stress Counteraction on the Part of Alveolar
Hansen for his help and advice on oral pathology and to Dr Leonard
Bone With a View to Its Preservation. Dent. Cosmos 1935;77:109-123.
Chong for his help with the cephalometric radiographs and tracings. 14. Boucher CO. A Critical Analysis of Mid-Century Impression Techniques
for Full Dentures. J. Prosthet. Dent. 1951;1:472-491.
15. Fairchild JM. Inflammatory Hyperplasia of the Palate. J. Prosthet. Dent.
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