SECTION EDITORS
Prevalence of the ‘combination
patients
Kay Shen, D.M.D., M.A.,* and Richard K. Gongloff, D.M.D.**
University of California, San Francisco,School of Dentistry, and Veterans Administration
Medical Center, San Francisco,Calif.
The prevalence of symptoms associated with “combination
documented in 160 maxillary complete denture wearers. The five alveolar
changes that are most consequential to denture wearing
correct surgically were found in 7% of the population studied. However,
changes were found in 24% of patients who have natural
opposing complete maxillary dentures. This rate did not differ significantly
patients who do and do not wear a mandibular removable
PROSTHET DENT 1989;62:642-4.)
Alveolar bone resorption following tooth extraction
and denture wearing has been well documented.1*2 The role
of traumatic occlusal forces in hastening residual ridge de-
struction has also been elucidated. Kelly3 described a de-
structive pattern of residual ridge resorption and soft tis-
sue growth in a group of patients who were wearing com-
plete maxillary dentures opposing distal-extension
removable partial dentures (RPDs). The changes were (1)
loss of bone from the anterior part of the maxillary ridge,
(2) overgrowth of the maxillary tuberosities, (3) papillary
hyperplasia of the palate, (4) extrusion of the lower ante-
rior teeth, and (5) loss of bone under the RPD bases. He
called this complex of symptoms the “combination
syndrome.”
This syndrome was then further described by Saunders
et al4 to include (1) loss of vertical dimension of occlusion,
(2) occlusal plane discrepancy, (3) anterior spatial reposi-
tioning of the mandible, (4) poor adaptation of the pros-
theses, (5) epulis fissuratum, and (6) periodontal changes.
They noted the progressive difficulties that these patients
have wearing dentures and the eventual need for surgical
correction to improve prosthetic function.5-7 Their data
suggested that patients who have complete maxillary den-
tures with mandibular anterior natural teeth will inevita-
bly develop the combination syndrome to some degree.
*Assistant Clinical Professorand Coordinator of Geriatric Den-
tistry, University of California, San Francisco,Schoolof Den-
tistry.
**Associate Clinical Professor, University of California, San
Francisco,Schoolof Dentistry, and Chief, Oral and Maxillofa-
cial Surgery, Veterans Administration Center.
IO/I/16326
642
syndrome’ among denture
syndrome” were
ridge
and most dificult to
these
mandibular anterior teeth
between
partial denture. (J
They stressed the importance of adequate treatment plan-
ning for mandibular distal-extension RPDs.
To determine the prevalence of this syndrome, the clin-
ical records of a group of maxillary denture wearers were
reviewed and the incidence of abnormal residual ridge
changes and associated symptoms as described by Kelly3
and Saunders et al4 were recorded. Observations were also
made to determine whether these conditions existed in pa-
tients with occlusal schemes other than that described by
Kelly.3
MATERIAL AND METHODS
Oral and facial hard and soft tissue examinations were
reviewed on 150 consecutive complete maxillary denture
patients. All examinations were done by one dentist. The
presence or absence of the clinical symptoms consistent
with the diagnosis of combination syndrome as described
by Kelly3 and Saunders et al4 were recorded. Also recorded
were the mandibular occlusal scheme and the presence of
removable prosthodontic replacements.
RESULTS
All patients in the study were completely edentulous in
the maxillae. Table I lists the various mandibular occlusal
schemes observed. Ninety-one patients (61% ) were totally
edentulous. Of these, four patients (4 % ) wore no mandib-
ular prostheses (group V). The remaining 87 patients
(96 % ) wore both maxillary and mandibular complete den-
tures (group I).
Fifty-nine patients (39%) had natural teeth occluding
with their complete maxillary dentures. Twenty-one of
these (14 % ) had adequate natural teeth where no prosthe-
sis was necessary (group II). Thirteen patients (9%) had
unilateral posterior tooth loss extending at least distal of
the second premolar (group III). In this group, slightly less
DECEMBER lS80 VOLUME 62 NUMBER 6
 COMBINATION SYNDROME AMONG DENTURE PATIENTS

Table I. Distribution of mandibular occlusal schemes in all patients studied

Group Mandibular occlusal scheme Number of patients % Of total

I Complete dentures 81 58
II Natural dentition with bilateral molar(s) present* 21 14
III Natural dentition with unilateral missing molars? with or 13 9
without RPD
IV Natural dentition with bilateral missing molars? with or 2.5 17
without RPD
V Edentulous without mandibular denture 4 8
Total 150 100

All have a maxillary complete denture.

*With at least one molar.
jWith all molars missing.

Table II. Percentage of patients with symptoms seen in combination syndrome

”
Group

III IV

Symptoms I II RPD NP RPD NP V

Max. anterior alv. bone loss 5 0 0 14 56 13 0

Mand. posterior alv. bone loss 6 0 0 0 56 44 0
Max. ah. ridge canting 0 0 0 0 22 !56 0
Tuberosity elongation 5 0 0 0 22 56 0
Hypermobile ant. max. ridge 2 0 0 14 22 44 0
Mand. ant. dentoalveolar extrusion 5 0 0 0 11 25 0
Short face appearance 17 1 0 29 44 88 0
Papillary hyperplasia 8 0 17 0 56 1.3 0
Epulis fissuratum 1 0 0 0 0 6 0
Periodontal disease 0 48 33 29 78 1~00 0
RPD, Patients who use a mandibular RPD; NP, patients who use no mandibular prosthesis.

than a half wore a mandibular prosthesis. The remaining Table III. Distribution of patients with a minimum of
25 patients (17%) had bilateral posterior tooth loss ex- five pathologic alveolar ridge changes*
tending at least distal of the second premolar (group IV). Number of patients Percent
Of these, slightly more than a third wore a bilateral distal- with at least the within
Group five symptoms each group
extension RPD.
Table II contains 10 selected pathologic changes3*4 that I 4 5
represent the combination syndrome and records their oc- IV 6 24
currence in the various groups. With mand. RPD 2 22
Table III presents the distribution of patients who had Without mand. RPD 4 25
five or more symptoms of combination syndrome regarded
*Maxillary anterior bone loss, mandibular posterior bone loss, maxillary al-
as being of greatest significance. It shows that approxi- veolar ridge canting, tuberosity elongation, hypermobile anterior maxillary
mately 5 % of patients in group I and 26 % of patients in residual ridge in groups I and IV.
group IV had irreversible alveolar ridge changes appearing
in this significant quantity.
c and most difficult to correct (Table III). These five changes
DISCUSSION were (1) maxillary anterior bone loss, (2) mandibular pos-
Periodontal disease, while noted by Saunders et al4 as terior bone loss, (3) maxillary alveolar ridge canting, (4)
one of the changes seen in the combination syndrome, was tuberosity elongation (usually soft tissue), and (5) hyper-
not included in the final analysis because of its common mobility of the residual anterior maxillary ridge. Although
occurrence in patients with natural teeth. In analyzing the these five changes appeared in lessthan 7 % of all patients,
data, five alveolar ridge changes were selected that were they were present in 24% of patients with the occlusal
thought to be the most consequential to denture wearing scheme (bilateral distal-extension RPD) originally de-

THE JOURNAL OF PROSTHETIC DENTISTRY

 SEENANDGONGLOFT

scribed by Kelly.3 Moreover, all of the patients with mul- REFERENCES

tiple irreversible alveolar ridge change8 in group I (com- 1. Atwood DA. Some clinical factors related to rate of resorption of resid-
pletely edentulous) had at least a &year history of wearing ual ridges. J PROSTHET DENT 1962;12:441-50.
2. Tallgren A. The continuing reduction of the residual alveolar ridges in
a bilateral distal-extension RPD occluding against a com- complete denture wearers. A mixed longitudinal study covering 25
plete maxillary denture before the loss of their remaining years. J PROSTHET DENT 1972;27:120-36.
mandibular teeth. The absence of symptoms in groups II 3. Kelly E. Changes caused by a mandibular removabIe partial denture
opposing a maxillary complete denture. J PROSTHET DENT 1972;27:140-
and V implies that tissue change8 seen in the combination
50.
syndrome are concentrated in patients who have the 4. Saunders TR, Gillis RE, Desjardins RP. The maxillary complete den-
occlusal scheme originally described by Kelly.3 Finally, the ture opposing the mandibular bilateral distal-extension partial denture:
treatment considerations. J PROSTHET DENT 197%41:124-g.
prevalence of alveolar ridge damage does not change
5. Gongloff RK, Woodard KL. A surgical technique for the correction of
significantly whether or not a mandibular prosthesis is the hypermobile anterior maxillary ridge. J Oral Surg 1981;39:340-2.
worn (Table II). This finding is also consistent with the 6. Laskin DM. A sclerosing procedure for the hypermobile edentulous
ridge. J PR~WHET DENT 1970;23:274-8.
finding8 of Kelly.3
I. Hall HD. Vestibuloplasty, mucosal grafts (palatal and buccal). J Oral
Surg 1971;29:786-91.
SUMMARY
Reprint requests to:
Examination records of 150 maxillary edentulous pa- DR. RICHARD K. GONGLOFF
tients were reviewed. Among the patients who had com- DENTAL SERVICE (160)
plete maxillary dentures and anterior natural teeth, the VETERANS ADMINISTRATION MEDICAL CENTER
4150 CLEMENT ST.
incidence of pathologic alveolar ridge change8 consistent SAN FRANCISCO, CA 94121
with the diagnosis of combination syndrome was approx-
imately one in four. Also in this group, the presence or ab-
sence of a prosthetic replacement did not significantly af-
fect the incidence of pathologic changes.

Ten-year study of trends in removable prosthodontic service

Wayne L. Harvey, D.D.S., M.A.,* and Wm. Hoffman, Jr., D.D.S.**
University of Colorado, Schoolof Dentistry, Denver, Colo.

To gain an overview of where the field of removable prosthodontics may be

heading, an ex post facto research project was completed that randomly sampled
the charts of patients screened for removable prosthodontics during 1977-1979 and
1986-1987. The information showed that, overall, the number of complete dentures
was declining whereas the number of removable partial dentures was increasing.
The fastest growing prosthodontic service was the combination of the maxillary
complete denture opposing the mandibular removable partial denture. Curriculum
changes based on the results of the research were made. (J PROSTHETDENT
1989;62:644-6.)

I n view of the reduced number of removable prosth- METHODS

odontic patients, a study was made to assesschange8 in the
number and types of prosthodontic services needed and to
chart obvious trends. The information will be used to plot
future didactic and clinical curriculum development at a
dental school and may be useful to the dental practitioner.
*Professorand Chairman, Division of RemovableProsthodontics.
**AssociateProfessor,Division of RemovableProsthodontics.
10/l/12144
A random sample of 200 dental record8 was collected of
patients who had been screened for removable prosthodon-
tics at the Dental Clinic of the University of Colorado,
School of Dentistry from 1977 to 1979 and 1985 to 1987. A
frequency distribution analysis was made of the number of
major prosthodontic treatments needed during the two 3-
year periods. Before data collections, prosthodontic proce-
dures were categorized into two operational groups of mi-
nor and major treatments. The major prosthodontic treat-
ments were defined as (1) complete dentures, (2) complete
immediate dentures, (3) tooth-supported overdentures,

644 DECEMBER 1989 VOLUME 62 NUMBER 6