VOLUME-7, ISSUE-2, FEBRUARY-2018 • PRINT ISSN No 2277 - 8160

Original Research Paper Prosthodontics

COMBINATION SYNDROME - A REVIEW

Dr. Renu Gupta HOD, Department of prosthodontics, Govt. Dental College, Shimla, H.P.
Dr. R. P. Luthra Principal, Govt. Dental College, Shimla, H.P.
PG Student, Department of prosthodontics, Govt. Dental College, Shimla, H.P.
Dr. Rajender Singh* *Corresponding Author
ABSTRACT Combination syndrome, rst identi ed by Kelly in 1972, is found in patients wearing a complete maxillary denture,
opposing a mandibular distal extension prosthesis. The group of complications occurring in these patients are
interlinked to one another and collectively represent a syndrome. The manifestations include abby tissues in the anterior part of the
maxillary ridge, tilting of the occlusal plane posteriorly downwards, supraeruption of lower anteriors, brous overgrowth of tissues in
maxillary tuberosities, resorption in mandibular distal extension area and decreased vertical dimension of occlusion. Treatment modality is
determined by the apparent potential of the patient to develop the combination syndrome and the condition of the remaining mandibular
anterior teeth. Predictable prognosis is offered by overdentures, especially for patients who already have the syndrome and using xed
mandibular prosthesis over implants placed immediately after dental extractions.

KEYWORDS : Maxillary tuberosity, epulis ssuratum, mandibular distal extension prosthesis

Speci c oral destructive changes are often seen in patients with a

maxillary complete denture and a mandibular distal extension
partial denture.1 The group of complications which representing as a
syndrome are interlinked to one another progressing in a sequential
manner is known as 'combination syndrome' by Ellsworth Kelly in
1972.2

The Glossary of Prosthodontic Terms 3 de nes combination

syndrome as "the characteristic features that occur when an
edentulous maxillae is opposed by natural mandibular anterior Fig. 1. Five changes described Fig. 2. Six additional changes
teeth and a mandibular bilateral extension-base removable partial by Kelly described by Saunders et al
denture, including loss of bone from the anterior portion of the
maxillary ridge, hyperplasia of the tuberosities, papillary Classi cation of combination syndrome
hyperplasia of the hard palate's mucosa, supraeruption of the Kelly2 was the rst person to use the term ''combination syndrome.''
mandibular anterior teeth, and loss of alveolar bone and ridge He believed that the key to many symptoms of the combination
height beneath the mandibular removable partial denture bases; syndrome is the early loss of bone from the anterior part of the
maxillary jaw.4 Clinically relevant classi cation of combination
syn, anterior hyperfunction syndrome".
syndrome was proposed by Len Tolstunov.5 Three classes and 10
modi cations of CS are described below. An anterior maxillary
Clinical features resorption resulting from the force of anterior mandibular teeth is
Kelly2 originally described combination syndrome in a number of the key feature of this classi cation. Maxillary edentulous condition
patients with maxillary complete dentures opposing natural de nes the class, mandibular the modi cation within the class. (Fig.
mandibular teeth and a distal extension removable partial denture. 3 and 4)
He described ve signs or symptoms that commonly occurred in
this situation (Fig. 1). They include:- Ÿ Class I: Maxilla: completely edentulous alveolar ridge. Mandible:
Modi cation 1 (M1): partially edentulous ridge with preserved
Ÿ Loss of bone from anterior part of maxillary ridge. anterior teeth only. Modi cation 2 (M2): stable '' xed'' full
dentition (natural teeth or implant-supported crowns/bridges).
Ÿ Overgrowth of tuberosities.
Modi cation 3 (M3): partially edentulous ridge with preserved
Ÿ Papillary hyperplasia in the hard palate. teeth in anterior and one posterior region.
Ÿ Extrusion of lower anterior teeth. Ÿ Class II: Maxilla: partially edentulous alveolar ridge with teeth
Ÿ Loss of bone under partial denture base. present in both posterior regions, edentulous and atrophic
anterior region. Mandible: modi cations are the same as in Class
Saunders et al,1 in 1979 described 6 additional changes associated I (M1, M2, and M3).
with this syndrome (Fig. 2). They include:- Ÿ Class III: Maxilla: partially edentulous alveolar ridge with teeth
present in one posterior region only, edentulous and atrophic
Ÿ Loss of vertical dimension of occlusion. anterior and one posterior region.Mandible: modi cations are
Ÿ Occlusal plane discrepancy. consistent with Class I and II (M1, M2, M3A, and M3B).
Ÿ Anterior spatial repositioning of mandible.
This classi cation is based on what seems to be the dominant
Ÿ Poor adaptation of prosthesis. feature of most CS cases—an edentulous premaxilla with an
Ÿ Epulis ssuratum. advanced resorption of anterior maxillary bone and overgrowth of
Ÿ Periodontal changes. the anterior mandibular bone with extrusion (super-eruption) of
lower front teeth.

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VOLUME-7, ISSUE-2, FEBRUARY-2018 • PRINT ISSN No 2277 - 8160
area.
5. Mandible shifts anteriorly during occlusion.
6. The vertical dimension at occlusion is decreased. The retention
and stability of the denture is also reduced.
7. The tilt in the occlusal plane disoccludes the lower anteriors
causing them to supraerupt. This reduces the periodontal
support of the anterior teeth.
8. The supraerupted anteriors increase the amount of force acting
on the anterior part of the complete denture and the vicious
cycle continues.

Sequence 2 (Saunders et al)1

Fig. 3. Classi cation of combination syndrome: 3 classes and 10 1. Gradual resorption of the distal extension residual ridge in the
modi cations (10 clinical presentations of the combination mandible.
syndrome). 2. Tilting of the occlusal plane posteriorly downwards ands and
anteriorly upwards. Rest of the vicious cycle continues as
sequence 1.
3. In addition the chronic stress and movement of the denture will
often result in an ill- tting prosthesis and contribute to the
formation of palatal papillary hyperplasia.

Histopathological Changes
Histopathology of hyperplastic anterior ridge tissue and brous
tissue over tuberosities are indistinguishable with mature, dense
brous connective tissue consisting of bundles of collagen bers,
few cellular elements, and a very few in ammatory cells.2 This is also
similar to the histopathology of mature epulis ssuratum. Similarity
of histopathology of all three conditions (hyper plastic tissue,
brous tissue, epulis ssuratum) may be attributed to similar tissue
response to prolonged trauma from denture base.

Prevalance
Shen & Gongloff in 1989, reviewed records of 150 maxillary
edentulous patients who had maxillary complete dentures and
mandibular anterior natural teeth. One in four demonstrated
Fig. 4. Classi cation of combination syndrome (CS): 3 classes and 10 changes consistent with the diagnosis of combination syndrome.6
modi cations. M: CS modi cations (M1, M2, M3, A and B); shapes in
solid heavy lines represent bone-teeth complex that undergoes Mehmet Ali Kilicarslan et al in 2012, examined the clinical and
changes in the particular modi cation of CS (maxillary and prosthetic status of 100 maxillary edentulous patients with four
mandibular jaw/teeth shapes match, like a jigsaw puzzle); arrows: different mandibular occlusal schemes to evaluate the prevalence
the direction of alveolar remodeling (hypertrophy) and teeth of and oral risk factors for combination syndrome. Only nine
movement (super-eruption) in certain jaw regions (single patients were found to have all ve symptoms of combination
arrows—moderate degree: in cases of edentulous regions opposed syndrome. All of these patients used dentures. Eight of them had
each other, double arrows—severe degree: in cases when an Kennedy class I and one had Kennedy class II mandibular occlusal
edentulous region is opposed by teeth); 3 columns represent schemes.7
anterior and 2 posterior stomatognathic regions; basal row
represents bone (alveolar ridge), middle row represents dentition, Prevention of combination syndrome
and top row represents bone and teeth remodeling changes Ÿ Avoid combination of maxillary complete dentures opposing
(atrophy, hypertrophy, extrusion) in a particular modi cation of CS; class mandibular R.P.D
vertical thin solid lines: natural teeth ( xed dentition) or an implant Ÿ Retaining weak posterior teeth as abutments by means of
supported bridge in a speci c region of the jaws; oval represents no endodontic and periodontic treatment.
change status (no bone remodeling or teeth movement) in the Ÿ An over denture on the lower teeth.
region of preserved posterior occlusion
Treatment planning
Pathogenesis When planning treatment for patients with edentulous maxillae
Combination syndrome progresses in a sequential manner. The and a partially edentulous mandible, the risk of development of the
progress of the disease can occur in any of the following sequences. combination syndrome must be recognized.1

Sequence 1 (Ellisworth Kelly)2 Systemic and dental considerations

1. Patient tends to concentrate the occlusal load on the remaining Ÿ Review of medical and dental history.
natural teeth (mandibular anteriors) for proprioception. Hence Ÿ Through clinical and radiographic evaluation of both hard and
there is more force acting on the anterior portion the maxillary soft tissues, associated with prosthesis wear.
denture. Ÿ Resolution of any in ammation if present.
2. This leads to an increased resorption of anterior part of the Ÿ Evaluation of patients caries susceptibility, periodontal status
maxilla which gets replaced by abby tissue.The occlusal plane and oral hygiene.
gets tilted anteriorly upwards and posteriorly downwards. Ÿ Factors to be considered in tooth to be used as abutment
3. The labial phalange will displace and irritate the labial vestibule include tooth vitality, morphologic changes, number of roots,
leading to formation of epulis ssuratum. Posteriorly there will bony support, mobility, crown-root ratio, presence and position
be a brous overgrowth of the tissues in the maxillary of existing restorations, position of teeth in the arch, the
tuberosity. availability of retention and guide planes.
4. The shift of the occlusal plane posteriorly downwards produces
resorption in the mandibular distal extension denture bearing Kelly2 said that, before proceeding with the prosthetic treatment,

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gross changes that have already taken place should be surgically resorptive change, thereby maintaining posterior occlusal
treated. These include conditions like: contact. Coverage of the horizontal buccal shelf with its superior
layer of cortical bone, submucous layer with glandular
Ÿ Flabby(hyperplastic) tissue connective tissue, and buccinator muscle bers provides
Ÿ Papillary hyperplasia. primary- support for the denture base. Maximum occlusal
Ÿ Enlarged tuberosities. support posteriorly with no contact anteriorly in centric
occlusion and a balanced articulation in eccentric movements
Lower partial denture base should be fully extended and should further reduce pressure on the anterior maxillary ridge.
cover retromolar pad and buccal shelf area.
After treatment is completed, it is essential to maintain recall
Basic tratment objective appointments at 3, 6, and 12 months during the rst year to observe
Saunders et al1 in 1979 stated that, the basic treatment objectives in any changes in posterior support. If acrylic tooth wear and support
treating these patients is to develop an occlusal scheme that are lost in the posterior regions, accelerated premaxilla atrophy will
discourages excessive occlusal pressure in maxillary anterior develop from excessive forces. Bilateral balanced occlusion is
regions in both centric and eccentric positions.They also stated essential for long term success.12
some speci c objectives:-
CONCLUSION
Ÿ Mandibular R.P.D should provide positive occlusal support from Almost inevitable degenerative changes develop in the edentulous
the remaining anterior teeth and have maximum coverage of regions of wearers of complete upper and partial lower dentures.
basal seat beneath distal extension bases. The dentist should approach the treatment of these patients
Ÿ The design should be rigid and should provide maximum cautiously and the institution of correct treatment initiatives
stability while minimizing excessive stress on remaining teeth. essential. Every patient must be made aware from the outset, that
Ÿ The occlusal scheme should be at a proper vertical and centric the longest possible life of any prosthesis with the least possible
relation position. harm to the remaining tissues, can only be ensured by regular recall
Ÿ Anterior teeth should be used for cosmetic and phonetic and maintenance care.
purpose only.
Ÿ Posterior teeth should be in balanced occlusion. REFERENCES
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mandibular teeth were structurally or periodontally 10. Wennerberg A, Carlsson GE, Jemt T. In uence of occlusal factors on treatment
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9 12. Cabianca M. Combination Syndrome: Treatment With Dental Implants. Imp dent
Ÿ Some form of stabilization of the maxillary arch. 2003;12:300-305
- retention of maxillary overdenture abutments.
- maxillary osseointegrated implants.
- augumention of maxilla with resorbable hydroxyapatite in
conjunction with a guided tissue regeneration technique and
vestibuloplasty.
10
Ÿ Implant supported xed prosthesis.
Ÿ In 2001 Wennerberg et al reported excellent long term results
with mandibular implant supported xed prosthesis, opposing
maxillary complete dentures.10
11
Ÿ Yair Langer et al described an approach in which maxillary
impression is made in a specially designed tray using a
combination of elastomeric impression material and
impression plaster without distorting the anterior residual
ridge. The mandibular RPD is supported anteriorly by cingulum
rests on the canines with a lingual plate as the major connector.
The lingual plate delays the overeruption of the mandibular
teeth, preventing undesirable anterior pressure on the anterior
part of the maxillary denture. Optimum t of the denture base is
achieved using the altered cast technique. Posteriorly,
maximum support is obtained by extending the denture base
to cover the retromolar pad. The attachments of the buccinator,
superior constrictor, and temporalis muscles to the retromolar
pad and the overlying rmly bound masticatory mucosa
provide a stress-bearing region that is relatively resistant to

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