The combination syndrome: A literature review

Sigvard Palmqvist, Gunnar E. Carlsson, and Bengt O wall

J Prosthet Dent 2003;90:270-5.
Loss of bone of the anterior edentulous maxilla when opposed by natural mandibular
anterior teeth is 1 of several features of the combination syndrome. Although recognized
by many clinicians, documented observations seem to be rare. The Glossary of
Prosthodontic Terms1 defines combination syndrome as the characteristic features that
occur when an edentulous maxilla is opposed by natural mandibular anterior teeth,
including loss of bone from the anterior portion of the maxillary ridge, overgrowth of the
tuberosities, papillary hyperplasia of the hard palatal mucosa, extrusion of mandibular
anterior teeth, and loss of alveolar bone and ridge height beneath the mandibular
removable partial denture bases, also called anterior hyperfunction syndrome. Ellsworth
Kelly2 was the first person to use the term combination syndrome. He followed a small
group of patients wearing a complete maxillary denture opposed by mandibular anterior
teeth and a distal extension distal removable partial denture (RPD). Of the 6 patients
followed up for 3 years, all showed a reduction of the anterior bone in the maxilla along
with enlarged tuberosities. . For 5 patients there was an increased bone level of the
tuberosities. Kelly2 blamed the mandibular RPD and the lack of a posterior seal in the
maxillary denture for these changes. He discussed excessive bony resorption under the
mandibular removable partial denture bases but provided no values. Kelly2 discussed
various possibilities to avoid combination syndrome, including extraction of the
mandibular teeth, but did not advocate this solution. Instead, he proposed using the roots
of anterior mandibular teeth to support an overdenture. He also mentioned the option of
using endodontic implants to preserve questionable roots for support in the posterior part
of the mandible.
Residual ridge resorptiongeneral aspects

After extraction of teeth, a remodeling process of the alveolar bone occurs, including
bone resorption and a changed contour. The loss of bone in the maxilla was reported to be
less if an immediate denture technique was used compared with a healing period without
denture. For the mandible, no difference or a smaller difference in resorption rate during
this initial stage was found between the immediate technique and a healing period
without denture. After the initial remodeling phase, there is continuous bone resorption
under denture bases. It is inevitable and has been called a major oral disease entity. The
initial prosthetic technique probably has no long-term influence on residual ridge
resorption, which is more pronounced in the mandible than in the maxilla and has been
demonstrated to occur for up to 30 years. Bone resorption under dentures can affect not
only the alveolar bone but also, in some situations, the basal bone. However, great
individual differences have been noted, and factors other than the wearing of removable
dentures may be involved in the resorption process.
Maxillary ridge resorption in relation to mandibular status

Mandibular natural teeth with or without RPD. Bone resorption in the anterior part of the
edentulous maxilla, the main feature of the combination syndrome, has been the subject
of many clinical reports and some investigations of series of patients. No longitudinal
study with the extraction of the anterior maxillary teeth as the starting point

and randomly chosen mandibular status exists. Most studies comprise

only small groups of patients. However, comparing results from
available studies of various designs may draw some cautious
conclusions.
Enlargement of the tuberosities

In a study of denture patients treated at a dental school, tuberosity elongation was

found in 5% of patients with complete dentures in both jaws. In patients with bilaterally
missing mandibular molars, tuberosity elongation was found in 22% of those wearing a
removable partial denture and in 56% of those with no RPD. The groups were small, and
the study was not longitudinal, indicating that no conclusions can be drawn about the
development of the noted elongations.
Papillary hyperplasia of the hard palates mucosa

Epidemiologic studies of mucosal changes in denture wearers mostly report low

percentage figures for papillary hyperplasia of the hard palatal mucosa, also called
papillomatous stomatitis. No study was found focusing specifically on changes in the
maxillary mucosa with respect to the mandibular dentition status.
Extrusion of mandibular anterior teeth

Kelly demonstrated extrusion of the mandibular anterior teeth in all 6

patients with combination syndrome followed up for 3 years by means
of profile radiographs. The amount of extrusion varied between 1.0 and
1.5mm. No other reports have been found regarding extrusion of
mandibular anterior teeth in combination with complete maxillary
denture and a mandibular RPD.
Bone resorption under mandibular RPD bases

Continuous bone resorption in the mandible posterior to the remaining anterior teeth has
been demonstrated in 2 groups of patients wearing different types of Class I mandibular
RPDs, whereas no change of the bone level in the posterior region was noted for the
group not wearing an RPD. In patients who received mandibular implant-supported fixed
prostheses, bone resorption in the posterior part of the mandible practically ceased.20
This result has been confirmed in recent studies, some even reporting bone apposition in
the posterior areas when a fixed implant-supported prosthesis was used.
SUMMARY

Bone resorption of the anterior part of the edentulous maxilla in association with
remaining anterior mandibular teeth has been the subject of a limited number of studies
of acceptable quality, but the results have not been conclusive. No epidemiologic study of
the various features related to combination syndrome has been published. There is no
evidence that a mandibular removable partial denture can prevent the development of the
events described. On the basis of this review of the literature it may therefore be
concluded that the combination syndrome does not meet the criteria to be accepted as
medical syndrome. The single features associated with the combination syndrome exist
but to what extent or in which combinations has not been clarified.