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96 CPD Dentistry 2001; 2(3):96-101

Papers 1 hour validated CPD

Combination syndrome revisited

Philip W Smith, J Fraser McCord & Nick J A Grey

Abstract The use of accepted prosthodontic techniques


Problems of denture instability are aggravated when a directed towards ensuring denture stability, tends to
complete denture is opposed by an arch containing all or some be successful in many cases. In some situations
natural teeth. Two scenarios are possible, first of all when the success may be limited by atrophic denture bearing
maxillary arch is edentulous and the second is when the tissues, unfavourable peri-denture musculature and
mandibular arch is edentulous. The former clinical scenario poor/unrealistic patient perceptions.
has been termed the combination syndrome. The aim of this Problems associated with the provision of a
article is to describe treatment options, specifically where complete denture opposed by a natural denture were
“conventional” prosthodontic management is concerned. described classically by Tillman in 19614 and Kelly in
1972.5 Tillman described the complete lower
Keywords denture opposed by an upper removable partial
Denture stability, combination syndrome. denture (RPD), while Kelly described the opposite
scenario. Conventional wisdom would indicate that
Introduction the latter condition was most prevalent in clinical
The world-wide success of dental health practice. This is most likely to be the result of the
education and preventive dental strategies means usual pattern of tooth loss in which maxillary teeth
that the number of edentulous individuals is tend to be lost before mandibular teeth.1
decreasing, and data would suggest that the age at Kelly considered that there were five changes
which edentulousness occurs is advancing.1 which tended to occur in the cases which he studied
However, in the future there is likely to be a (Figure 1). These are:
Philip W Smith significant number of patients in need of
BDS MDS PhD FDS
DRD MRD RCS(Ed)
prosthodontic treatment. It is possible that a number
FDS(Rest) of potential prosthodontic problems may be
Honorary Consultant Unit encountered in an elderly partially dentate
of Prosthodontics
population. One such clinical scenario could be the
J Fraser McCord provision of complete dentures in one arch while the
BDS DDS FDS DRD opposing arch is either intact, or has some remaining
RCS(Ed) FDS RCS(Eng) natural teeth, or an implant supported prosthesis.
Professor and Head of Unit
of Prosthodontics For conventional complete dentures to function
acceptably, the clinician should prescribe dentures
Nick J A Grey which exhibit good stability. Denture stability has
BDS MSc PhD DRD
been defined2 as “that quality of maintaining a
MRD RCS(Ed) FDS(Rest)
Consultant in Restorative constant character or position in the presence of
Figure 1. Typical clinical changes in an edentulous maxilla
Dentistry forces that threaten to disturb it”. Where complete opposed by natural teeth, note in particular the displaceable
Edinburgh Dental Institute dentures are concerned, stability may be considered tissue in the anterior part of the residual ridge.
Correspondence: to be a paradigm of muscle balance and occlusal
Philip W Smith factors, coupled with good retention and appropriate • Loss of bone from the anterior part of the
Unit of Prosthodontics utilisation of support. The relationship between maxillary ridge
University Dental Hospital
of Manchester
retention, stability and support, has been • Overgrowth of the tuberosities
Higher Cambridge Street comprehensively reviewed by Jacobson and Krol.3 • Papillary hyperplasia in the hard palate
Manchester M15 6FH These authors stated that stability was the most • Extrusion of the lower anterior teeth
Tel: 0161 275 6629 significant property in providing for the physiologic • The loss of bone under any (mandibular) partial
Fax: 0161 275 7822
E-mail comfort of the patient. denture bases.
psmith@fs1.den.man.ac.uk

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CPD Dentistry 2001; 2(3):96-101 97

Combination syndrome revisited

Kelly based his observations, presumably, on his of a removable onlay appliance or alternatively more
considerable clinical experience, backed up by serial extensive fixed restorations. However, for a variety of
cephalometric observations of 20 patients. However only reasons, many patients, and some clinicians, are wary of
six of the latter returned faithfully over a 3 year follow-up embarking on extensive restoration of the opposing teeth in
period. Whether all five clinical conditions are related as an attempt to increase the chance of improved stability of
Kelly proposed, the potential for adverse morphological the opposing complete denture. Therefore, the clinician is
changes to occur in such a situation cannot be disregarded. often faced with the task of fashioning the complete denture
Kelly suggested avoidance of this clinical scenario in in such a way that it produces a clinically acceptable result,
the first instance, in what is perhaps the first instance of without recourse to modifying the opposing natural teeth.
preventive prosthodontics being advocated. At the time that Tillman and Kelly wrote their
Reference has been made previously to the difficulties respective articles, dental implantology had not advanced to
encountered by having to provide a replacement complete the levels of sophistication, and clinically-acceptable
denture in one arch while the opposing arch contains a success rates, recently reported for endosseous implants.10,11
natural (or essentially natural) dentition; this challenging There can be no disputing that implant-supported and/or
clinical combination was termed the combination retained prostheses would be the treatment of choice in
syndrome by Kelly, with reference to the maxillary arch many cases exhibiting ‘combination syndrome’.
being edentulous. In a development of the theme However, this form of treatment may be ruled out
propounded by Kelly, Saunders et al;6 stated that six other either because a patient cannot afford implant therapy or
changes are commonly associated with this clinical scenario: implant treatment may be contra-indicated for other valid
• loss of vertical dimension of occlusion medico-dental reasons.
• occlusal plane discrepancy An added factor for general dental practitioners to
• anterior spatial repositioning of the mandible consider is that many implant–related treatment plans
• poor adaptation of the prostheses require surgical and restorative expertise which may
• epulis fissuratum require skills above many non-specialist practitioners.
• adverse periodontal changes For these reasons, the purpose of this article is to
To these factors a seventh factor might also be added, highlight useful conventional clinical techniques to help in
namely the fact that a number of patients may elect not to the provision of complete dentures opposing a partially or
wear a lower prosthesis which was provided with the wholly dentate arch. Although not specifically the
intention of providing posterior occlusion. This would combination syndrome detailed by Kelly, we shall describe
appear to be especially true of free-end saddle partial two “combination” “scenarios”, one for the edentulous
dentures. maxillary arch and the second for the edentulous
Saunders et al; recommended that the essential mandibular arch.
objective of treatment planning in these cases was “to
provide an occlusal scheme that could best discourage A. Complete maxillary denture opposed by a
excessive occlusal pressures in the maxillary anterior dentate/partly dentate mandibular arch
region in both centric and eccentric occlusal contacts”. In this situation (Figure 2), the displacing forces on the
They listed the restorative and prosthodontic objectives upper denture resulting from mandibular movements have
but did not relate how to achieve this. How the occlusion to be harnessed, and a variety of ways of maximising the
might be managed to cope with the combination retentive forces and reducing the displacing forces may be
syndrome has been described by Kelly and also reviewed utilised.
by Lauciello7. Basically, two methods emerge from the
literature that may be employed to fashion the occlusion:
• a functionally-generated path
• an articulator which has been programmed to
reproduce the patient’s mandibular movements.
Malposed, tilted or over-erupted teeth in the opposing
arch are prone to induce unfavourable occlusal contacts,
which in turn may lead to compromised denture stability.
This may then cause discomfort, trauma (which may result
in increased alveolar resorption) and social embarrassment
as a result of movement of the prosthesis. Some authors8, 9
have recommended that the opposing dentition should be
modified to give a more favourable occlusal plane and
geometry. It is suggested that this might be achieved either
Figure 2. An upper complete denture, opposed by a partially dentate
by re-shaping the occlusal surfaces by grinding, by provision lower arch which has been restored with a tooth and mucosal borne
partial denture.
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98 CPD Dentistry 2001; 2(3):96-101

Combination syndrome revisited

The retaining forces are maximised by ensuring that a • Ensuring that the technician “mills” the occlusion to
peripheral seal is present. This is the function of the special suit the patient. The latter will inevitably be necessary,
tray, which, in conjunction with a suitable border as (denture tooth) cuspal inclines will be unlikely to
moulding technique, should demonstrate a peripheral seal equal those of the patient, and this technique develops
prior to the recording of the definitive impression. In a customised occlusal architecture for the upper
addition there is commonly readily displaceable tissue in denture. On occasion, however, the clinician may
the region of the maxillary anterior ridge. This can be need to refine the laboratory produced occlusal form
accounted for by using an impression technique that aims and use the patient to “mill-in” the occlusion in the
to use the firmer tissues to support the upper denture. chair. A technique sometimes used by the authors of
This requires a two-stage impression which uses a close this article is to make a paste of silicon carbide (The
fitting special tray. The first step involves developing Carborundum Company Ltd., Trafford Park,
peripheral seal, and subsequently a window is made in the Manchester, England UK) and toothpaste, which is
tray corresponding to the area of displaceable tissue. The placed on the occlusal surfaces of the complete
tray is loaded with medium body polyvinylsiloxane (PVS) denture. The patient is then directed to trace out the
and an impression made in the usual way, although the border movements with the denture stabilised in situ
excess material escapes through the window. The and with the teeth in occlusion.
impression is removed and inspected, and the impression The reader will probably be familiar with the above
material, which has f lowed through the window, is techniques perhaps with the exception of the gothic arch
removed. The tray is then carefully re-seated, and the tracing, and the latter will be described in more detail. The
second stage is completed, which involves syringing light gothic arch tracing is produced by a stylus (usually fixed to
bodied (PVS) through the tray window and over the an acrylic plate retained by the mandibular teeth) which
exposed ridge tissue, to complete the upper impression traces out a path on a f lat metal plate (fixed horizontally to
(Figure 3). an upper baseplate) during mandibular excursive
Displacing forces are reduced by co-ordinating the movements. The shape produced is rather like an
maxillary teeth and maxillary plane of occlusion to arrowhead, which points posteriorly, the apex of the arrow
harmonise with mandibular teeth during mandibular represents a reproducible retruded jaw position. Although
movements. These are achieved via this technique is helpful in determining the retruded jaw
• Using a facebow to transfer the plane of the upper arch relationship, there are limitations to its usefulness:
to the condylar axis. • It requires normally functioning TMJs
• Using a central-bearing screw to create an arrowhead • The bases must be sufficiently stable
(gothic arch) tracing (Figure 4), which is used to • There should be sufficient vertical space to
determine the retruded jaw position. accommodate the apparatus
• Setting the articulator condylar angles to accord to the There are other techniques available whereby the
border tracings on the arrowhead tracing. desired morphology maxillary occlusal surfaces are
• Establishing, carefully, at trial insertion, that RCP is generated intra-orally. Perhaps the first author to describe
reproducible. such a technique was Stansbury in 1951.12 He

Figure 3. Upper impression made to take account of displaceable Figure 4. A gothic arch tracing recorded for a patient with an
tissue in anterior maxilla. edentulous maxillary arch opposed by natural teeth. Note the apex of
the arrowhead represents the retruded jaw relationship.

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CPD Dentistry 2001; 2(3):96-101 99

Combination syndrome revisited

recommended the use of a narrow compound maxillary denture-bearing tissues and the lack of stability of the
rim which had carding wax placed buccal and palatal to the mandibular denture.
rim. The wax was subsequently “moulded” by the Moderately severe residual ridge resorption tends to be
mandibular teeth in border movements. Vig13, in 1964, the rule in such cases and the difficulties of managing this
updated this when he used an acrylic rim with an acrylic condition, per se, have been discussed by McCord et al;14. In
fin which engaged the central fossae of the lower teeth. essence, reductions in both quality and quantity of the
Soft wax was then added incrementally to form the buccal denture-bearing tissues tend to be accompanied by
and palatal forms of the maxillary posterior teeth; again the unfavourable peri-denture anatomical forces, i.e. muscle
form of the maxillary cusps was generated via the patient attachments encroaching on the residual ridges. As a
making lateral and protrusive mandibular movements. result, the displacing forces tend to overwhelm retaining
Customised gold occlusal surfaces, created by making features of the mandibular denture and only immense
a functionally-generated path in the processed dentures, physiological control of the denture will maintain denture
may also be used, but are potentially expensive, in terms of stability.
both material and laboratory time. Another approach,
which has been used with some success by the authors of Treatment strategies
this article, is to functionally-generate the occlusal Two “conventional” strategies are possible here,
anatomy of the maxillary denture teeth using either a namely prosthodontic alone and a combination of
light-cured composite resin, or amalgam (Figure 5). When prosthodontics and pre-prosthetic surgery.
using the former we use resin recommended for posterior
composite restorations, as it tends to exhibit more Prosthodontic treatment alone
appropriate wear properties. Treatment should be aimed at using an appropriate
selective pressure impression technique that satisfies
prosthodontic norms whilst allowing the clinician to
satisfy him / herself that the denture-bearing tissues can
withstand a degree of functional loading.15 Using an
appropriately extended special tray with 1mm spacing, an
admix of impression compound and tracing compound
may be used to make an impression, which may be
moulded to effect a peripheral seal and, simultaneously,
produce a selective-pressure impression of the denture-
bearing area (Figure 6).

Figure 5. An upper complete denture illustrating the use of amalgam


to form customised occlusal surfaces opposing natural teeth.
As with most complete denture problems, patient co-
operation is essential if success is to be achieved. For this
reason, patients should be made aware of the potential
problems of denture stability at the first clinical visit and
be conditioned to their contribution to denture success.

B. Complete mandibular denture opposed by


a dentate/partly dentate maxillary arch
This extreme of the prosthodontic-problem spectrum Figure 6. A lower impression made using an admix of greenstick and
has, in the past, been avoided by rendering the maxillary red impression compounds to take account of atrophic tissues in a
arch edentulous. Most patients, and for that matter many mandible opposed by natural teeth.
dentists, are disinclined to accept such a treatment plan
unless it is absolutely necessary. Clinical experience would At the next clinical stage, the clinician must decide on
certainly suggest that this problem is more difficult to the occlusal configuration of the denture. This will
manage than the edentulous maxilla, and although similar involve three related yet distinct procedures.
techniques are recommended, success tends to be more • The first phase, advocated by Tillman4, is to record the
elusive. Two major problems appear to operate here, relationship of the maxillary occlusal plane to the
namely the impaired support potential of the mandibular condylar axis; this requires a facebow transfer.

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100 CPD Dentistry 2001; 2(3):96-101

Combination syndrome revisited

Figure 7. Lateral view of a completed ‘gothic arch’ jaw registration Figure 8. A lower complete denture opposing a natural upper
for a mandibular complete denture opposed by a natural maxillary dentition illustrating customised occlusal surfaces in the lower
dentition, used to articulate casts in RCP. prosthesis to harmonise with the irregular natural occlusal plane.

• The second phase is to record appropriate maxillo- even occlusal contact in the retruded position. In
mandibular relations. One technique useful in these addition to this, mild chairside customisation may be
cases is to use a device that allows the production of an required, via a carborundum-toothpaste mix (vide
arrowhead (gothic arch) tracing (see above), thereby supra).
ensuring good reproducibility of mandibular • The use of soft linings has also been advocated as a
movements when transferred to the articulator.16 possible means of reducing the discomfort beneath a
Figure 7 shows articulation of a dentate upper and mandibular complete denture opposed by the natural
edentulous lower cast, after jaw relations were dentition.17 The use of soft linings has been recently
recorded using a gothic arch tracing to determine a reviewed18, and despite their shortcomings as regards
reproducible retruded jaw relationship. The main long term clinical performance, it is apparent that their
limiting factor in using gothic arch tracings in the compliant nature would allow more even distribution
lower jaw is lack of stability of the recording base. of occlusally generated forces in this type of adverse
• The third phase relates to what Tillman termed an clinical situation. Clinical experience suggests that a
“accurately conceived occlusion”. Debate exists soft lining needs to have a minimum thickness of 3mm
whether anatomical or non-anatomical teeth should be to be effective. Therefore, caution needs to be
selected; in neither case has there been a scientifically- exercised to ensure that the denture base either has
based trial to validate the choice of one over the other. sufficient bulk to impart the necessary strength, or
However, clinical experience would tend to support alternative methods have been employed to strengthen
the premise that any “tripping” of the occlusal surface the prosthesis, for e.g. the incorporation of a cast metal
of the lower denture against the maxillary natural teeth lingual plate.
&/or RPD, during mandibular movements, will result
in instability of the complete denture. Although a Prosthodontic/pre-prosthetic surgery
technique was described for creating a functionally- Undoubtedly, the surgical intervention with the
generated occlusal form for maxillary dentures, such a greatest potential to improve the stability of any prosthesis
technique for mandibular dentures may be prone to is the successful placement of osseointegrated implants. In
error unless the prosthesis was sufficiently stable. Such all such cases, the prosthodontist should have planned the
conditions are usually only met when the appliance in prosthesis in consultation with the oral surgeon who
question is some form of overdenture. Clearly, any places the fixtures. However, on occasion alternative
technique which relies on articulator-based surgical procedures not involving the placement of dental
customisation of the occlusal form will require the use implants may be considered appropriate. These may
of a facebow transfer, and a gothic arch tracing to involve vestibuloplasty to increase the relative height of the
reduce errors in transferring jaw relationships to the anterior mandible, in addition to minor hard or soft tissue
articulator. The philosophy here is to eliminate all surgery. The indications for such procedures, particularly
points of first contact until balancing contacts are with the advent of osseo-integration, are now apparently
achieved with the objective of imparting denture less than previously. The details of such procedures are
stability (Figure 8). On occasions a ‘check’ occlusal beyond the scope of this article, and the reader is advised
record taken after the denture has been processed may to consult standard surgical texts for further information.
be helpful to allow the dental technician to produce

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CPD Dentistry 2001; 2(3):96-101 101

Combination syndrome revisited

Conclusion • Recording impressions that satisfy the parameters of


The prosthodontic treatment of partially-dentate support, retention and stability.
patients is likely to pose increasingly more difficult clinical • Conveyance of appropriate functionally-related patient
problems. Two clinical problems likely to be encountered data, e.g. facebow and inter-maxillary relations.
are the “combination scenarios”, when an edentulous arch • Creation of appropriate occlusal form.
is opposed by a partially-dentate or even fully-dentate • Informing the patient of his/her contribution to
arch. The identification of such problems is an important denture success.
component of the treatment planning. Other important
areas which deserve earnest consideration are:
References
1. Todd J, Lader D. Adult Dental Health, 1988. United Kingdom, London. 10. Adell R, Lekholm U, Rockler B, et al; A 15-year study of osseointegrated
OPCS. HMSO. implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;6: 387-416.
2. American Academy of Prosthodontists. Glossary of Prosthodontic Terms, 11. Van Steenberghe D, Quirynen M, Calberson, et al; A prospective evaluation
6th ed. J Prosthet Dent 1994; 71: 41-112. of the fate of 697 consecutive intra-oral fixtures ad modum Branemark in
3. Jacobson T E, Krol A J. A contemporary review of the factors involved in the treatment of edentulism. J Head Neck Pathol 1987; 6: 53-58.
complete denture retention, stability and support. J Prosthet Dent 1983; 49: 12. Stansbury C B. Single denture construction against a non-modified
5-15. natural dentition. J Prosthet Dent 1951; 1: 332-336.
4. Tillman E J. Removable partial upper and complete lower dentures. J. 13. Vig R G. A modified chew in and functional impression technique. J.
Prosthet Dent 1961; 11: 1097-1104. Prosthet Dent 1964; 14: 214-220.
5. Kelly E. Changes caused by a mandibular removable partial denture 14. McCord J F, Grant A A, Quayle A A. Treatment options for the
opposing a maxillary complete denture. J Prosthet Dent 1972; 27: 140-150. edentulous mandible. Eur J Prosthodont Rest Dent 1992; 1: 19-23.
6. Saunders T R, Gillis R E, Desjardins R P. The maxillary complete denture 15. McCord J F, Tyson K W. A conservative prosthodontic option for the
opposing the mandibular bilateral distal-extension partial denture. treatment of edentulous patients with atrophic (f lat) mandibular ridges. Br
Treatment considerations. J Prosthet Dent 1979 ;41: 124-128. Dent J 1997; 182: 469-472.
7. Lauciello F R in Essentials of Complete Denture Prosthodontics, 2nd. 16. El Gherani-A S, Winstanley R B. The value of the Gothic Arch tracing in
edn. Ed Winkler S. Mosby, St. Louis, 1988: 417-426. the positioning of denture teeth. J Oral Rehab 1988; 15(4): 367-377.
8. Watt D M, MacGregor A R in Designing Complete Dentures, Saunders, 17. Hickey J C, Zarb G A, Bolender C L. Boucher’s Prosthodontic Treatment
Philadelphia, 1976; p164. for Edentulous Patients, 9th edn. St. Louis: CV Mosby, 1985; p560.
9. MacGregor A R in Clinical Dental Prosthetics, 3rd edn. Wright, London 18. Braden M, Wright P S, Parker S. Soft lining materials- A review. Eur J
1990:97-307. Prosthodont Rest Dent 1995; 3: 163-174.

MCQ Answers to 2001, Vol 2 No 2


(K Marshall) 11. Lack of adequate cooling of the bur. 26. Inward pressure caused during 39. An advantage of these bridges is that
• Research has shown that in True cementation. False they can be cemented by most
general dental practice: 12. Bacterial contamination of the water- 27. Bacterial microleakage. True professionals complementary to
1. Small particle aerosols only remain in line. False 28. Dissolution of a smear layer dentistry (PCDs). False
the atmosphere for a short time.False 13. Over-reduction of the tooth subsequent to cementation using 40. If the bridge fails it cannot be
2. The use of rubber dam may reduce substance. True conventional cement. True cemented again with the same degree
contaminated aerosols by up to 14. Irritant cements being used to lute the 29. Irritation from the cement lute. False of success. True
98.5%.True crown. False 30. The material used to construct the
3. The dental team, other than the 15. Crowns being cemented “high” in crown. False • Treatment Planning:
dentist and nurse, are at no increased occlusion. False 41. Is synonymous with the plan of
risk from Hepatitis B. False (D A Keetley) treatment. False
4. Saliva contains 150 million microbes • During crown fabrication • Today some tooth preparation is 42. Is easier with resin retained bridges
per millilitre. True beneficial circumstances for the provided for Resin Retained because they are non-invasive. False
5. Pre-operative chlorhexidine rinse can pulpodentinal complex include: Bridges for the following reasons: 43. May involve a multidisciplinary
assist in reducing contamination. 16. Dentinal tubular f luid outf low. True 31. To allow the metal to be contained approach. True
True 17. A decrease in pulpal blood f low after within the contour of the tooth, so as 44. Requires articulated study models and
administration of local. False to avoid making changes to the a surveyor. True
(T F Walsh & A Rawlinson) 18. In the short term, the development of existing occlusion. True 45. Is usually provided at the patients first
• Which of the following are a smear layer. True 32. To ensure that any stresses created are visit. False
correct? 19. Formation of primary dentine. False directed away from the adhesive.
6. Chronic gingivitis may be present 20. Formation of tertiary dentine. True True • The design of a modern resin
with or without the loss of 33. To provide a good area for bonding. retained bridge:
periodontal attachment having • Factors that would tend to True 46. Often involves two wings per pontic.
occurred. True compromise the pulpal vitality 34. To give clear unambiguous finishing False
7. Patients suffering from necrotising include: lines for the technician & to allow 47. May even use two small premolar
gingivitis have conf luent ulcers 21. Careful crowning of a tooth for a positive seating of the appliance on sized teeth to replace a molar. True
affecting the tongue and cheeks in young rather than old adult. False fitting. True 48. Is aided greatly by surveying the study
addition to gingival tissues. False 22. A long time interval between 35. Rest seats can provide additional models prior to preparation of the
8. Adult periodontitis is usually temporary and definitive crown retention. False tooth. True
recognised in patients between 30 and placement. True 49. May involve keeping the metal wing
40 years of age. True 23. Removing the smear layer and placing • With regard to cementation of clear of the incisal edge to improve
9. Juvenile periodontitis is very common a bonding system on the preparation. Resin Retained Bridges: aesthetics. True
amongst Caucasian teenagers. False False 36. Hooks from the wing can be extended 50. Involves construction of the wing in a
10. In rapidly progressive periodontitis 24. Preparation well into dentine to over the incisal edge to aid location. base metal. This is grit basted with
there may be acute inf lammation and improve the outward tubular f luid True aluminum oxide to aid bonding.
marginal proliferation of the gingival f low. True 37. Most microfilled composites will True
tissues in an active phase. True 25. Acid etching the dentine to remove bond adequately to base metal
the smear layer. False castings. False
(J P J Fearon & C C Youngson) 38. Glass ionomer cements are now
•. The most significant causes of • In a definitive crown which are considered to give the best in use
pulpal trauma during crowning the most significant threats to the longevity. False
are: pulp?

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