COMBINATION SYNDROME

AND ASSOCIATED CHANGES

( Kelly’s Syndrome)
A Combination Syndrome
By Kelly (1972)
• Destructive Problems, That
May Be Encountered as a result
of long term use of A
Mandibular Distal Extension
Partial Denture Against A
Complete Maxillary Denture
This syndrome consists of:
1- Loss of bone from the maxillary anterior edentulous ridge.
2- Down growth of the maxillary tuberosities.
3- Papillary hyperplasia of the tissues of the hard palate.
4- Extrusion of the lower anterior teeth and,
5- Loss of bone beneath the removable partial denture bases.

It usually has six associated changes:

1- Loss of vertical dimension of occlusion.
2- occlusal plane discrepancy,
3- Anterior spatial resorption of the mandible.
4- Development of epulis fissuratum.
5- Poor adaptation of the prosthesis and,
6- Periodontal changes.
 THESE RETROGRADE CHANGES ARE PROBABLY
TRIGGED BY THE PATIENT’S FUNCTIONAL HABITS

• the patient tend to function on the remaining

anterior natural teeth with the maxillary denture
covering the anterior residual alveolar ridge.
• This portion of the ridge is composed of
cancellous bone and is subject to fairly rapid
resorption if excessive force is placed against it.
• As ridge resorption occurs and progresses, the
bony ridge is replaced by rebundant soft tissue,
initiating the combination syndrome and
associated changes.
Combination Syndrome
• A specific pattern of resorption when
anterior mandibular teeth are retained
and are opposed by a complete
maxillary denture. The premaxilla
undergoes severe resorption and is
usually accompanied by the
development of fibrous hyperplasia of
the maxillary tuberosity.
• When mandibular anterior teeth remain, patient
will attempt to function in protrusive
relationship top sense feeling of mastication.
Resorptive Changes Occur In The Maxillary Anterior Ridge
Settling Of The Maxillary Anterior Denture Base V. D. O.
Will Begin To Decrease . Lowers The Posterior O. P. As
Maxillary Denture Moves Superiorly And Anteriorly.

As bone is resorbed from maxillary anterior ridge, denture

will tip upward anteriorly and downward posteriorly.
 The Change In The
Angulation Of The Occlusal
Plane May Result In A
Protrusive Or Sliding
Contact Of The Mandibular
Teeth With The Denture,
Which Can Contribute To
The Loss Of Support For
The Remaining Natural
Teeth Or Precipitate
As denture settle as a result of
Periodontal Changes. ridge resorption, angulation of
occlusal plane changes.
The Labial Flange Of The Denture Produces A Low Grade
Irritation In The Surrounding Soft Tissues, Resulting In

Development Of Epulis Fissuratum, And Cause An

Associated Overgrowth Of Fibrous Tissue Covering The
Maxillary Tuberosities.
The Combination Syndrome Is
A Result Of Three Main Factors

• the great magnitude of forces

involved,
• the unsuitability of the denture
foundation to resist them, and
• the particularly unfavorable occlusal
relationship.
 CLASSIC “COMBINATION SYNDROME”

The normal biting pressure or forces are directed from the remaining lower
6 teeth and transmitted through the upper anterior denture, with resulting
resorption of bone and slow auto-rotation & tilting of the denture upward
and backward, with the upper anterior teeth becoming less visible and the
upper posterior teeth becoming more visible as the denture is rotated from
function with bone loss of the premaxilla.
 CLASSIC “COMBINATION SYNDROME”

• All maxillary teeth and all posterior mandibular missing.

• Advanced bone loss premaxilla and posterior mandible

• Seven mandibular anterior teeth present, long term use

lower Removable Partial Denture.

• Occlusal Vertical Dimension much less than ideal, need

to change 15mm for better facial aesthetics.

• Facial aesthetics has been altered dramatically.

 Original appearance
with upper and lower
prosthesis NOT in
place demonstrating
inadequate facial
support

Original appearance with

upper and lower prosthesis
in place demonstrating
inadequate facial support
and improper plane of
occlusion.
 Surgical Prosthetic

Correction of
COMBINATION SYNDROME
• The change in facial aesthetics from the resulting
combination syndrome is a challenge to restore with
traditions dentistry, as the prosthetic solutions are
limited, the age of the patient is often a limitation,
and financial costs are of concern. A technique that
decreases treatment time and costs with excellent
aesthetic result is presented below.
• The treatment time can be reduced to ONE
SURGICAL VISIT in many cases, with all treatment
completed in one week with follow-up visits needed
approximately once a week for several
weeks. Total Active Treatment Time for case
shown, about 2 weeks
SEQUENCE FOR ONE APPOINTMENT
SURGICAL TREATMENT
1. PRE-SURGICAL/ PROSTHETIC PLANNING: Prostheses completed prior
to surgery with image capturing & referencing.

2. SURGICAL/ PROSTHETIC PHASE:

a. Maxillary “PermaRidge” grafting completed first c upper immediate

denture ready for insertion.

b. Extractions, Alveoplasty, & insertion of mandibular implants &

healing abutments c immediate lower denture & soft liner ready for
insertion.

c. Minimal Invasive Surgical technique allowing surgical correction

and final implant connecting bar impression the day of surgery.

3. ANESTHETIC CONSIDERATIONS: Appointment length c surgery, need

for sedation dentistry.
Pre-operative radiograph for treatment planning
with diagram showing approximate position of
implant connecting bar and plane of occlusion
Pre-operative SimPlant 3-D image software
for treatment planning
 3-D moveable Sectional Oblique Image
translucent image with Aids In Determining
simulated implant Ideal Implant Diameter
placement.
Pre-operative SimPlant 3-D image software for treatment

planning.
 Grafting SOFT TISSUE with
Hydroxylapatite
for Reconstruction success

1. Soft Tissue Graft must not be loaded during healing by

immediate maxillary denture.

2. Vestibule, hard palate, and remaining non-grafted

tuberosities support the maxillary immediate denture.

3. KEY TO SUCCESSFUL GRAFTING: is the change in

occlusal forces with an unloaded HA graft. Six
surgical instruments are used to create an ideal site.
The denture supports the graft and the totally implant
supported mandibular prosthesis allows control of the
occlusal forces to the grafted ridge.
 SOFT TISSUE with Hydroxylapatite
1. Two incisions are made in
area of the cuspids
through keratinized
tissue to the bone.
2. A series of instruments
are first used in the
posterior segments to
tunnel and raise the
periosteum off the bone,
to the length required.
3. Next straight taper
instruments are used to
enlarge the tunnel and
dilate the tissue, creating
room for the
“Permaridge” HA graft.

4. Next a cutting osteotome is used to plane the bone in the tunnel,

smoothing out the rough areas, creating a smooth passage.
5. Finally the graft carriers are used to carry either the 4.5mm or 6.0mm
sections of the “Permaridge” HA graft. 4-0 gut sutures are then used
to close the two openings.
 Day after Surgery Patient's maxillary
dental arch six
The soft tissue takes
months post-
on the shape of the operatively. Maxilla
created shape ry tissue is no
of the inner surface longer loose and
now has load
of the denture
bearing capabilities
Day of surgery. Alveoplasty
with 3-D implant placement &
grafting. Immediate loading
length determined by by bone
density. Minimal Invasive
Surgery.
Day of Surgery. M.I.S.
Allows for final impression
for implant connecting
bar. Polyether material of
choice for impression.
Day of Surgery. M.I.S.
Allows for final impression
for implant connecting
bar. Polyether material of
choice for impression.

Soft liner placed day of surgery. Patient Day of surgery. Minimal Invasive Surgery
never without teeth. contributes to rapid healing. PRP Platelet
Rich Plasma increases rate of healing.
Post-Operative radiograph
taken day after surgery

Implant connecting Bar

constructed & placed on
third day
Impression taken day of
surgery. Bar inserted two
days later
Surgical|Prosthetic
Correction
of
COMBINATION
SYNDROME

Six months post operative