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Whether these explanations are necessarily accurate o After recording the primary impression,
or not is almost of no consequence, as the clinician make a 2mm spaced, non-perforated custom
is, ultimately, faced with clinical difficulties which are tray.
of sufficient difficulty to present problems if an o After securing a peripheral seal with tracing
acceptable return to and of function are to be compound, record the impression in
achieved. medium- bodied polyvinyl siloxane (PVS)
In essence, the first three of these problem areas impression material.
are essentially of a clinical complexity as to require
treatment by a dental practitioner with some o Remove the area of the tray, including the
experience in Removable Prosthodontist, not PVS impression (Figure 3), re-insert the tray
necessarily a specialist in Prosthodontics. and inject light-bodied PVS into the area
corresponding to the fibrous ridge. The final
A New Presentation of Combination Syndrome 95
III. Recording appropriate intermaxillary relations. and light-bodied PVS (Reprosil, Dentsply, Milford,
If the patient has only vertical mandibular USA) injected over the flabby tissues of the anterior
movements, then a conventional registration maxillary ridge, care being taken to reduce
technique may be used using upper and lower rims. unnecessary hydraulic pressure (4) (Figure 4).
If, however, the patient has ruminatory (i.e. lateral The definitive impression for the mandibular
and protrusive excursive) movements, then it is arch was made using polyether impression material
recommended that an intra-oral (gothic arch or (Impregum, 3M ESPE, Seefeld, Germany) in an
arrowhead) tracing (2) be recorded in addition to a open window custom tray that accomodated the
facebow transfer to better relate the maxillary impression copings. Laboratory analogues were
denture to the mandibular axis and to mandibular attached to the impression copings and gingival
movement in the interests of stability of the mask material was syringed around the analogues;
maxillary denture. If necessary, the maxillary and the cast was poured in vacuum-mixed diestone
denture teeth may be restored with composite, (Figure 7).
amalgam or gold (Figure 6) by having the patient
create functionally-generated occlusal surfaces.
The above is a review of Kelly's form of
Combination Syndrome with an outline of possible
ways to treat patients with this clinical condition.
Currently, a new form of 2}Stcentury Combination
Syndrome is evolving and this case report highlights
how it may be treated in an attempt to overcome
future problems similar to those described by
Kelly (I).
CASE REPORT
Figure II: Completed mandibular implant-supported Figure 14: Final prostheses at 1 week recall appointment.
fixed prosthesis.
DISCUSSION
deterioration in the anterior maxillary ridge, no 7. Wennerberg A, Carlsson GE, 1emt T. Influence
anterior tooth contact in maximum occlusion was of occlusal factors on treatment outcome: a
planned for this patient. This follows the study of 109 consecutive patients with
recommendation made by Lang and Razzoog (5) mandibular implant-supported fixed prostheses
when providing patients with mandibular implant- opposing maxillary complete dentures. Int 1
supported fixed prosthesis. Prosthodont. 2001; 14: 550-5.
3. Witter 01, van Elteren P, Kayser AF. Migration 12. Brosky ME, Korioth TW, Hodges 11. The
of teeth in shortened dental arches. 1 Oral anterior cantilever in the implant-supported
Rehabi!. 1987; 14: 321-9. screw-retained mandibular prosthesis. 1 Prosthet
Dent. 2003; 89: 244-9.
4. AI-Ahmad A, Masri R, Driscoll CF, von
Fraunhofer 1, Romberg E. Pressure generated on 13. Rodriguez AM, Aquilino SA, Lund PS.
a simulated mandibular oral analog by Cantilever and implant biomechanics: a review
impression materials in custom trays of different of the literature, 1 Prosthodont 1994; 3: 114-8.
design. 1 Prosthodont. 2006; 15: 95-101.
14. Lang BR. Complete denture occlusion. Dent
5. Lang BR and Razzoog ME. Lingualised Clin North Am. 2004; 48: 641-65.
Occlusion: Tooth molds and an Occlusal scheme
for edentulous implant patients. Implant Dent. IS. Garcia LT, Bohnenkamp OM. Lingualized
1992; I: 204-211. occlusion: an occlusal solution for edentulous
patients. Pract Proced Aesthet Dent. 2005; 17: 5.
6. Lindquist LW, Carlsson GE, 1emt T. A
prospective IS-year follow-up study of 16. Barber HD, Scott RF, Maxson BB, Fonseca R1.
mandibular fixed prostheses supported by Evaluation of anterior maxillary alveolar ridge
osseointegrated implants. Clinical results and 6$ resorption when opposed by the
marginal bone loss. Clin Oral Implants Res. transmandibularimplant. 1 Oral Maxillofac
1996; 7: 329-36. Surg. 1990; 48: 1283-7.