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Combination
syndrome associated with a mandibular
implant-supported
overdenture:
A clinical report
Cynthia
P. Thiel, DDS, Douglas
B. Evans, DDS, MS,b and
Robert
R. Burnett,
DDS, MSC
Wilford Hall Medical Center, Lackland Air Force Base, San Antonio, Tex.

t is well known that a maxillary

complete denture
opposing a mandibular
partial denture with only natural
anterior
teeth remaining
will often result in premature
anterior
occlusal contact and cause extensive intraoral
hard- and soft-tissue damage.lm4 The description
of combination syndrome by Kelly4 in 1972 outlined the specific
oral changes in those patients with a maxillary
complete
denture functioning
against a mandibular
Kennedy class
I removable
partial
denture. The five changes noted by
Kelly were (1) bone loss in the maxillary
anterior ridge, (2)
overgrowth
of the tuberosities,
(3) palatal papillary
hyperplasia, (4) supraeruption
of mandibular
anterior teeth, and
(5) bone loss beneath removable
partial
denture bases.
Kelly4 considered the early bone loss in the anterior maxilla to be the key to the other changes and noted that as resorption of the premaxilla
progressed, further tissue damage and denture instability
followed proportionately.
Other symptoms associated with combination
syndrome
include thle loss of the vertical dimension
of occlusion, occlusal plane discrepancy,
anterior spatial repositioning
of
the mandible,
poor adaptation
of the prostheses, epulis
fissurata, and periodontal
degradation.3
The changes in tissue form and health seen in combination syndrome can be attributed
to several factors. When
mandibular
anterior teeth are present, patients tend to favor these teeth functionally
because of the ability to generate maximum
force. Excessive anterior
functional
and
parafunctional
forces, particularly
when not counterballanced posteriorly
in excursive
movements,
constantly
overload
the anterior
ridge to result in alveolar
bone
resorption and possible development
of epulis fissurata. As

The views expressed in this article are those of the authors and
do not necessarily reflect the views of the United States Air
Force or the Department of Defense.
aLieutenant Colonel, U.S. Air Force, DC; Senior Resident, Department of General Dentistry.
bLieutenant Colonel, U.S. Air Force, DC; Chief, Fixed Prosthodontics, Department of General Dentistry.
cLieutenant Colonel, U.S. Air Force, DC; Assistant Chief, Periodontics, Department of General Dentistry.
J PROSTHET DENT 1996;75:107-13.
10/l/68928

FEBRUARY

1996

bone and ridge height are lost anteriorly,

tuberosities
in
the posterior region will often enlarge and grow downward.
One theory suggests that negative pressure within the
maxillary
denture pulls the tuberosities
down as the anterior ridge is driven upward by the anterior occlusion4 The
functional
load will then direct stress to the mandibular
distal extension and cause bony resorption
of the posterior
mandibular
ridge. The upward tipping movement of the
anterior portion of the maxillary
denture and the simultaneous downward
movement
of the posterior portion will
decrease antagonistic
forces on the mandibular
anterior
teeth and lead to tlheir supraeruption.
Eventually,
an occlusal plane discrepancy
will occur and the patient may
have a loss of vertical dimension
of occlusion. In addition,
the chronic stress a.nd movement of the denture will often
result in an ill-fitting
prosthesis and contribute
to the formation of palatal plapillary hyperplasia.
The implant-retained
overdenture
has become an accepted and predictatble treatment
modality for the edentulous patient because of its significant
improvement
in retention and stability.5, 6 The use of magnets, ball-andsocket attachments,
or bar-and-clip
retaining
elements
helps to satisfy functional
demands while providing
an esthetic restoration
that can be easily removed for cleaning
and maintenance.
For completely
edentulous
patients,
endosseous
implants have almost exclusively been placed in the anterior
region of the mandible because of dense bone patterns and
sparse innervation.
This location maximizes retention and
stability of the mandibular
denture and permits easy access for the patient and clinician. Maxillary
implants
are
not always reciprocally
placed, however, because the surface area and peripheral
seal of the maxillary
denture
usually provide sufficient retention
and stability on their
own.7 Additionally,
maxillary
implants
are not always
considered because of higher treatment
cost, longer integration time, greater anatomic challenges, and more risk
of complications
during denture fabrication
(such as impingement
of interocclusal
space).
Patients whose dentition
is restored with mandibular
implant-supported
prostheses
opposing
complete
dentures may face degenerative
tissue changes similarly
seen

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Fig. 1. Frontal
drome.

THIEL,

DENTISTRY

Implants

view of edentulous
support and retain

patient displaying
symptoms
mandibular
prostheses.

in the classic combination

syndrome. In these situations,
the implants rather than natural teeth encourage the patients to incise anteriorly
with maximum force. The generated forces may in fact become magnified, inasmuch as the
passive threshold
for tactile function of dental implants
has been reported to be approximately
50 times that of
natural
teeth.* As a result, extensive anterior
occlusal
forces produced before triggering
of periosteal mechanoreceptors adjacent to the dental implant may lead to resorption of the premaxilla.
Other authors have observed similar phenomena.
Maxson et a1.g reported findings consistent with combination
syndrome in a prospective study of 13 edentulous patients
whose dentitions were restored for 2 years with maxillary
complete dentures opposed by transmandibular
implantsupported
complete dentures.
The results of a related
study indicated
that substantial
vertical bone loss of the
anterior maxilla can occur in these situationslo
With the
use of cephalometric
analysis, significant
resorption of the
premaxilla
was observed 2 to 4 years after restoration
with
a maxillary
complete denture opposed by a transmandibular implant-supported
overdenture.
This clinical report describes the surgical and prosthodontic treatment
of a patient in whom symptoms of combination syndrome developed within 2 years of delivery of
an endosseous implant-retained
mandibular
overdenture
opposing a maxillary
complete denture.

CLINICAL
REPORT
Patient history
A 59-year-old
woman
prophylactic
maintenance

108

was evaluated
for routine
oral
of two endosseous implants in

of combination

EVANS,

AND BURNELT

syn-

the areas of the mandibular

canines (Fig. 1). The two 13 by
3.75 mm B&remark
implants had been placed with a period of 4 months healing time between the surgical stages.
Two 5.5 mm abutment cylinders were attached and splinted
together with a gold bar that supported
a mandibular
complete overdenture
with gold retention
clips. The implant-retained
mandibular
prosthesis was opposed on the
maxillary
arch by a conventional
complete denture unsupported with implants or abutment teeth. The stage II implant surgery was completed 26 months earlier and the
patient had worn the new bar-and-clip
denture
for 24
months. The patient had received periodic supportive
periodontal
therapy at intervals
of 3 to 8 months. At a routine maintenance
appointment
2 years after prosthesis
delivery, the patient reported the inability
to incise foods
as effectively as in the past and that her maxillary
denture
was less stable than before. Additionally,
she reported pain
on the palatal tissue and stated that the anterior maxillary
ridge was sore. The patient noticed and expressed concern
that she could move the anterior maxillary
ridge with her
fingers and had not been aware of this when she first received the prostheses. Extraorally,
the patient had and reported a recent history of chronic sores at the commissures
of the mouth, differentially
diagnosed as angular cheilitis
(Fig. 2).
Intraoral
examination
revealed redundant
tissue in the
anterior maxillary
alveolar ridge area, maxillary
palatal
papillary hyperplasia,
downgrowth
of the maxillary
tuberosities, and resorption
of the mandibular
posterior ridges
(Figs. 3 and 4). Clinical examination
of the prostheses revealed a loss of stability
and retention
in the maxillary
denture and early signs of an occlusal plane discrepancy

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Fig. 2. Angular

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cheilitis

that resulted

Fig. 3. Occlusal

view of maxillary

(Fig, 5). Further evaluation

noted vertical overlap of anterior teeth and a lack of protrusive
balance (Fig. 6).

Patient

treatment

The symptoms in this patient with a maxillary

complete
denture
opposed by an implant-supported
mandibular
overdenture
were consistent with combination
syndrome.
After the initial clinical and radiographic
examination,
a
clinical remount
and diagnostic
mounting
were accornplished to further
evaluate both the anatomic situation
and the existing dentures. A downgrowth
of the tuberosi-

FEBRUARY

1996

from loss of vertical

edentulous

dimension

OF PROSTHETIC

DENTISTRY

of occlusion.

arch.

ties and an occlusal plane discrepancy were confirmed. An

occlusal adjustment
was done on the articulator-mounted
dentures to eliminate
anterior guidance.
The patient was seen for excision of the epulis fissuraturn over the maxillary
alveolar ridge in the area from the
second right premolar to the first left premolar. Facial and
lingual flaps were .reflected revealing
a knife-edged
ridge
in the area from thie right to the left canine, which was reduced via alveoloplasty
(Fig. 7). Palatal papillary
hyperplasia and excessive fibrous tissue overlying the maxillary
tuberosity were surgically reduced and the maxillary
com-

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TRIEL,

DENTISTRY

Fig. 4. Soft, movable

tissue of maxillary

anterior

ridge displays

signs of underlying

EVANS,

AND BURNETT

bone

loss.

Fig. 5. Diagnostic
reduction.

mounting

reveals

occlusal

plete denture was relined with chairside

tissue conditioner.
After 4 weeks of healing, the maxillary
and mandibular
dentures
were permanently
relined (Fig. 8). Care was
taken to ensure proper vertical dimension and pIane of ocelusion. The denture relines were heat-processed
in the

110

plane discrepancy

and need for tuberosity

laboratory.
At the next appointment,
the dentures were
carefully
fitted to the tissues with pressure-indicating
paste. After fitting, face-bow and centric relation records
were made and a clinical remount was done. The interocclusal contacts of the dentures were adjusted to ensure simultaneous
centric stops with bilateral
and protrusive

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EVANS, AND BURNETT

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Fig. 6. Existing

Fig. 7. Surgical
alveolar

exposure

complete

dentures

demonstrates

DISCUSSION
Maxillary
dentures opposed by mandibular
osseointegrated implants
must be constructed
in such a way as to
preserve the maxillary
anterior edentulous
ridge. The ad-

1996

resorption

DENTISTRY

balance.

and knife-edged

maxillary

ridge.

balance. The patient

was then scheduled
for further
work-up and later placement of osseointegrated
implants
in the maxillary
canine regions.

FEBRUARY

marked

offer no protrusivse

OF PROSTBETIC

ditional function and stability offered by an implant-supported prosthesis allows patients to generate greater masticatory forces. Oftentimes, however, patients will posture
their mandibles forward to take advantage of the occlusal
forces generated and supported anteriorly
by the osseointegrated implants. This increases the potential
for forces
to concentrate in the premaxilla
region and cause anterior
residual ridge resorption.

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OF PROSTRETIC

Fig. 8. Tissues after correction

Many aspects of the prosthesis design are important
to
prevent the consequences
of combination
syndrome, including denture bases that fit well to the basal seat and offer maximal extension, border seal, and tissue detail; rigid
prosthesis components that offer maximum
stability; an
appropriate
plane of occlusion; and an occlusal scheme developed at the correct vertical dimension
and centric relation position.3, I1 A balanced occlusion, especially in protrusive excursions, is critical to achieve load distribution
over as broad a denture foundation
as possible.3, rl, l2 A
nonbalanced
occlusal scheme permits movement
of the
maxillary
denture, which can cause irritation
and inflammation of the mucosa and eventually
leads to bone resorption.r2 Special emp hasis should be placed on the position
and length of the anterior
teeth, following
primarily
esthetic
and phonetic
guidelines.
Functionally,
there
should be no occlusal contact on the anterior teeth in the
centric position and only the most minimal
contact when
the patient glides into a lateral or protrusive
eccentric
movement.3l 7j l1
Finally,
a strict recall schedule should be enforced to
monitor the tissues and the prostheses. Occlusal evaluation and adjustment
is paramount,
with relines or rebases
provided as needed.13 The patient should be educated and
informed of the potential complications
and should be discouraged from incising edge-to-edge.
Other treatment
modalities can be used to minimize the
detrimental
effects of combination
syndrome.
One approach is to treatment
plan for the retention of maxillary
overdenture
abutments.
The use of overdenture
abutments stabilizes the maxillary
denture and offers resistance to the strong anterior forces that can cause ridge resorption in the premaxilla.14
Gates et aLI5 described the

112

TBIEL,

DENTISTRY

of unfavorable

EVANS,

AND BURNETT

contours.

use of maxillary
ridge augmentation
with hydroxyapatite
in combination
with anterior vestibuloplasty
to provide a
hard- and soft-tissue base suitable for a stable and retentive maxillary
denture to oppose mandibular
implants.
Onlay augmentations
of the premaxilla
have also been accomplished
with autogenous
and allogeneic bone.
Placement
of osseointegrated
implants
with attachments in the anterior maxillary
ridge will also improve the
stability and long-term prognosis of the prosthesis.13, l4 As
with overdenture
abutments,
osseointegrated
implants in
the maxillary
anterior region will help support a maxillary
prosthesis and resist detrimental
forces to the bone. However, the predictability
of treatment
results is more favorable for mandibular
implant-retained
overdentures
than
for maxillary
implant-retained
overdentures.16

CONCLUSION
A clinical report of combination
syndrome
associated
with a mandibular
endosseous implant-retained
overdenture opposing a maxillary
complete denture unsupported
by implants or abutments demonstrated
the consequences
and tells how they may be prevented. The increased force
generation
permitted
by the osseointegrated
implants
coupled with anterior
functional
contact encourages
resorption of the anterior maxillary
ridge. Chronic ridge resorption can lead to any or all of the symptoms of combination syndrome. Maintenance
of anterior-posterior
occlusal stability, particularly
in protrusive
movements,
is
especially important.
It is farther recommended
that anterior teeth have no occlusal contact in centric position and
minimal contact during excursive mandibular
movements.
Treatment
planning
the retention
of maxillary
overdenture abutments
will minimize
the potential
for bone

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THIEL,

EVANS, AND BURNFXT

resorption.
Reported supplemental
methods of correcting
this problem include the use of maxillary
osseointegrated
implants
and augmentation
procedures
to regain lost
alveolar ridge. In addition
to prosthodontic
and surgical
correction,
it is critical to counsel the patient
on the
sequelae associated with this potentially
damaging
situation.
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Reprint requests to:
DR. CYNTHIA P. THIEL
82 DENTAL SQUADRONISGD
149 HART ST., STE. 4
SmPPARD AFB, TX 76311-3481

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