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
with the resorption of the residual alveolar ridge and
managing or preventing the secondary soft tissue
changes brought on by bone loss.
The resorption occurring beneath denture bases has
been investigated1-9 and we have some knowledge of the
rate of resorption of the residual bony ridge. Investi-
gators agree that individual differences in the rate of
resorption of the ridges are very great. Underlying met-
abolic, hormonal, and nutritional causes account for this
difference and we know very little about these factors.
From clinical experience and clinical studies,10,11 we
have considerable knowledge of the prosthetic factors
which influence bony resorption. We know that moder-
ate, intermittent forces exerted on the bony ridge by a
prosthesis may be stimulating and help preserve rather
than destroy the bony ridge.12 We know that excessive
force causes resorption of the residual ridge. De Van13
stated that compressive forces are well tolerated by the
edentulous ridges while shearing forces are not. This
concept has been utilized by many techniques which
minimize the lateral forces exerted by dentures. The
principle of wide coverage with the complete or partial
removable denture base to minimize the force per unit
area is basic14 and has served us well. Yet we are not able
to do anything for those people who are very susceptible
to bone loss because of underlying systemic causes and
who, in spite of our best efforts, often end up with very
little bone remaining. On the other hand, we do have
the knowledge to prevent excessive bone loss from trau-
matic forces exerted by or on the denture bases. Obser-
vation of a number of denture patients will show that we
are failing to put this knowledge into practice. Destruc-
tion of the residual ridge from occlusal trauma is not
uncommon. Very common is the almost total loss of
bone in the anterior part of the maxillae brought about
by only natural anterior teeth remaining in the mandible
and occluding with a compelte upper denture. The an-
terior part of the maxillae is the weakest part of the upper
Read before the Academy of Denture Prosthetics in Detroit, Mich.
a
School of Dentistry, University of California, San Francisco, Calif.
Reprinted with permission from J Prosthet Dent 1972;27:140 –50.
J Prosthet Dent 2003;90:213-9.
SEPTEMBER 2003
arch to resist stress and when the lower anterior teeth
occlude anterior to the basal support, trauma is inevita-
ble. Many of these patients have distal-extension partial
lower dentures but this does not seem to prevent this
type of destruction in the upper jaw. The degenerative
changes in these patients include more than the loss of
bone. An overgrowth of the maxillary tuberosities often
occurs. These enlargements are usually fibrous but they
may be bony enlargements. Papillary hyperplasia of the
palatal mucosa may occur concurrently. The remaining
mandibular anterior teeth seem to extrude along with
the bony process, and excessive bone loss occurs in the
posterior part of the ridge under the partial denture
bases. These five changes may constitute a syndrome, as
they are quite characteristic. These changes are (1) loss
of bone from the anterior part of the maxillary ridge, (2)
overgrowth of the tuberosities, (3) papillary hyperplasia
in the hard palate, (4) extrusion of the lower anterior
teeth, and (5) the loss of bone under the partial denture
bases. I call this the “combination syndrome.”
COMPLETE UPPER DENTURES
OPPOSING PARTIAL LOWER
DENTURES
Completely edentulous maxillae and partially eden-
tulous mandibles with only anterior teeth remaining are
common situations. In the past two years, 130 of 495
patients treated in the prosthodontic clinic at the School
of Dentistry of the University of California received
complete maxillary dentures opposing mandibular par-
tial dentures. This represents 26 per cent of the denture
patients. Some of the partial dentures had distal support
but most of them did not.
THE COMBINATION SYNDROME
The early loss of bone from the anterior part of the
maxillary jaw is the key to the other changes of the
combination syndrome. With the anterior loss of bone, a
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,
forming a characteristic deep fold or crease (Fig. 1). As
bone and ridge height are lost anteriorly, the posterior
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
(hyperplastic) soft tissue in upper anterior region, enlarged
tuberosities, and extruded lower anterior teeth.
enlarged tuberosities. These enlarged tuberosities are
usually made up of fibrous tissue, but in some patients
the bone height seems to have increased also. With these
changes, the occlusal plane migrates up in the anterior
region and down in the back. After a time, the natural
lower anterior teeth migrate upward, the anterior teeth
on the complete denture disappear under the patient’s
lip, and both dentures migrate downward in the poste-
rior region. The esthetics are poor with the patient show-
ing none of the upper anterior teeth and too much of the
lower anterior teeth, and the occlusal plane drops down to
expose the upper posterior teeth (Figs. 2 and 3).
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KELLY
Fig. 3. With loss of anterior maxillary bone, overgrowth of
tuberosities, and upward migration of 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.
Excessive bony resorption under the lower removable
partial denture bases occurs to permit these changes, and
often inflammatory papillary hyperplasia develops in the
palate (Fig. 4).
The histopathology of the hyperplastic anterior
ridge tissue, and the fibrous tissue which develops
over the tuberosities is revealing. Microscopic exami-
nation of these tissues shows that the flabby tissue and
the hard tissue over the tuberosities are indistinguish-
able. They are made up of mature, dense, fibrous
connective tissue. This tissue in both locations has
dense bundles of collagen fibers, with relatively few
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KELLY
Fig. 4. Papillary hyperplasia in palate often accompanies
other changes of combination syndrome.
cellular elements, with very few inflammatory cells. It
is rather avascular with an overlying epithelium that is
almost normal, but shows some evidence of hyperpla-
sia (Fig. 5). This is also the histopathology of a mature
epulis fissuratum if we discount the area of ulceration
caused by the denture border. This similarity is sur-
prising because the hyperplastic anterior tissue is
freely movable while the fibrous tissue over the tuber-
osity is hard. However, all three of these conditions
(the flabby anterior ridge, the fibrous tuberosity, and
the epulis fissuratum) are the result of prolonged
trauma from the denture base. Therefore, the fact that
the tissue response is the same is logical.
The difference in consistency of fibrous tuberosities
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-
row projection of tissue virtually unsupported on the
labial or lingual surface. On the other hand the fibrous
tissue over the tuberosity is supported by a broad base of
bone below.
MECHANICS WHICH PRODUCE THE
COMBINATION SYNDROME
The resorption of the bone in the anterior region
initiates the changes which we call the combination syn-
drome. Natural anterior maxillary teeth have increased
bony resorption under maxillary dentures.4,5 While
bone is being lost in the anterior region in the upper jaw,
bony resorption also occurs under the mandibular par-
tial denture bases. The maxillary denture then moves up
in the anterior region and down in the posterior region
in function. This tipping action is illustrated in the dia-
gram (Fig. 6) which was traced from cephalometric ra-
diographs of a patient who had been wearing a complete
SEPTEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
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
hyperplasia of the palate. Wictorin5 states that to prevent
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
interconnected. With the lower anterior teeth causing
trauma and bone loss from the anterior part of the max-
illae, and with the denture base moving more and more
on its foundation, a very destructive situation exists.
All kinds of questions come to mind. How fast do the
degenerative changes develop? Is excessive bone loss in
the anterior part of the maxillae with the other changes
that follow inevitable or does it occur only in neglected
patients, those without proper follow-up treatment in
refitting the denture bases and readjustment of occlu-
sion? If it is from neglect, what kind, and what amount
of care is necessary to prevent it? Will the changes occur
in all patients or only in susceptible patients with under-
lying metabolic, hormonal, or nutritional deficiency?
PATIENT HISTORIES WITH
CEPHALOMETRIC RADIOGRAPHS
In an effort to find answers to some of these ques-
tions, we started a study of 20 patients who were receiv-
ing complete maxillary dentures opposing distal-exten-
sion removable partial dentures. Only six of these
patients have returned faithfully over a three-year period
so no conclusions can be drawn from this preliminary
report.
We made serial cephalometric radiographs with a
0.25 mm. diameter lead wire outlining the soft tissue on
the right side of the ridge (Figs. 7 and 8). All of the
patients received maxillary complete immediate den-
tures opposing Class I lower partial dentures. All were
first-time denture wearers. The immediate dentures
were constructed after the posterior teeth had been ex-
tracted and a healing period allowed. The first radio-
graph was made after the initial healing of the anterior
part of the maxillary ridge had taken place, and after the
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THE JOURNAL OF PROSTHETIC DENTISTRY KELLY

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

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KELLY THE JOURNAL OF PROSTHETIC DENTISTRY

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

Fig. 8. Lead wire is in place after radiograph was made. Lead
wire adheres to and is very slightly embedded into soft tissue.
ting the bases and equilibrating the occlusion. With the
loss of tissue demonstrated in the anterior part of the
upper jaw, and with a positive change developing in the
posterior part of the ridge, and with the lower anterior
tooth migration, it appears that any or all of these pa-
tients could develop the typical signs of the combination
syndrome.
PREVENTION OF THE COMBINATION
SYNDROME
Preventing the degenerative changes that complete
maxillary dentures opposing the Class I partial dentures
bring about may only be possible through treatment
planning to avoid this combination of prostheses. Com-
plete lower dentures opposing natural maxillary teeth
planning should avoid the necessity for such a combina-
tion. The same could be done to eliminate the combi-
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
endodontic and periodontic techniques. Endosseous
endodontic implants and the amputation of one lower
molar root to preserve the other as an abutment are
examples of some of the methods that could be applied.
An overlay denture on the lower may avoid the com-
bination syndrome from developing. Overlay dentures
utilizing the lower tooth roots for stabilization provide a
complete denture occlusion.
SURGICAL CORRECTION OF
CHANGES IN THE BASAL SEAT
Even after much damage has been done and gross
changes have taken place, many dentists and patients
prefer to remake the combination rather than sacrifice
the remaining lower anterior teeth to make complete

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THE JOURNAL OF PROSTHETIC DENTISTRY
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).
Fig. 10. One subject, although given follow-up treatment,
shows the beginning of degenerative changes. Soft tissue in
anterior part of maxillary ridge is thickened and soft. Note
characteristic horizontal fold on labial surface of maxillary
ridge.
dentures. Surgery can do much to rehabilitate these pa-
tients. The flabby (hyperplastic) tissue can be removed,
the papillary hyperplasia can be eliminated, and the en-
218
KELLY
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
over a three-year period with cephalometric radiographs
to determine if these changes could be detected. In all
six subjects, early changes that could become gross
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-
tures against distal-extension partial lower dentures. The
alternative of complete maxillary and mandibular den-
tures is not attractive to patients. Preserving posterior
VOLUME 90 NUMBER 3
KELLY
teeth to serve as abutments to support lower partial den-
tures and to provide a more stable occlusion is a better
alternative.
Ill-fitting dentures have been blamed for all of the
lesions of the edentulous tissues, yet the most perfect
denture will be ill-fitting after bone is lost from the
anterior part of the ridge. Removable dentures need
periodic attention at least as often as the natural teeth.
The author would like to express his appreciation to Dr Louis S.
Hansen for his help and advice on oral pathology and to Dr Leonard
Chong for his help with the cephalometric radiographs and tracings.
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THE JOURNAL OF PROSTHETIC DENTISTRY
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Reprint requests to:
DR ELLSWORTH KELLY
UNIVERSITY OF CALIFORNIA
SCHOOL OF DENTISTRY
SAN FRANCISCO, CALIF.
Copyright © 2003 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2003/$30.00 ⫹ 0
doi:10.1016/S0022-3913(03)00240-3
219