Review Article

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J Res Adv Dent 2015; 4:1:11-17.

Combination Syndrome: A Review of Classification and

Treatment Modalities
Kapil S Pal1* Shriprasad Sarapur2 Ajay Gaikwad3 Zeeshan Ali4

1SeniorLecturer, Department of Prosthodontics, RKDF Dental College and Research Centre, Bhopal, Madhya Pradesh, India.
2Professor, Department of Prosthodontics, RKDF Dental College and Research Centre, Bhopal, Madhya Pradesh, India.
3Reader, Department of Prosthodontics, RKDF Dental College and Research Centre, Bhopal, Madhya Pradesh, India.
4Post Graduate Student, Department of Prosthodontics, RKDF Dental College and Research Centre, Bhopal, Madhya Pradesh i, India.

ABSTRACT

Background: Combination syndrome (CS) is a dental condition that is commonly seen in patients with a
completely edentulous maxilla and partially edentulous mandible with preserved anterior teeth. This syndrome
consists of severe anterior maxillary resorption combined with hypertrophic and atrophic changes in different
quadrants of maxilla and mandible. All of these effects render prosthetic treatment more difficult. Choice of
treatment modality is made by keeping in mind that the requirement of stability and retention of the prosthesis
must be balanced along with the preservation of the health of the oral tissues for every patient., and although it is
preferable to use dental implants for functional support, complex cases still require conventional prosthetic
treatments for medical or financial reasons. This article presents a new classification of the combination
syndrome that includes a multitude of CS cases with partial and complete maxillary and mandibular edentulism
proposed by Len Tolstunov and also emphasize on the necessity of a multi-disciplinary approach for early
prevention and treatment of this complex condition is emphasized.

Keywords: resorbed maxilla, hypertrophic bone, implants.

INTRODUCTION syndrome [2]. The resulting chronic occlusal trauma

In 1972 Kelly collectively called the
sequential destructive changes in the hard and soft
tissues of the oral cavity seen in patients requiring
singular restoration of a completely edentulous arch
opposing a natural dentition as Combination
syndrome.[1] The GPT 8 defines it 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 tuberosity, 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 hyper function
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from the mandibular anterior teeth to the
premaxillary hard and soft tissue structures often
leads to a slow resorption of the anterior maxillary
alveolar ridge that is replaced with the fibrous
tissue.
Ellsworth Kelly followed up 6 patients for 3
years with a complete maxillary denture opposed
by mandibular anterior teeth and a distal extension
removable partial denture (RPD).[1] Kelly gave the
name ‘‘combination syndrome’’ to this condition. He
described 3 key features of CS: reduction of anterior
maxillary bone, enlargement of maxillary
tuberosities, and bone resorption under the
mandibular RPD bases. A lack of posterior occlusion
and the presence of excessive anterior occlusal

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function by super-erupted anterior mandibular
teeth led to the use of another name for this
condition, ‘‘an anterior hyperfunction
syndrome.’’[3] Other features that may be present
at the same time include loss of vertical dimension
of occlusion, occlusal plane discrepancy, anterior
spacial reposition of the mandible, poor adaptation
of the prosthesis, and others. [4, 5]
Shen and Gongloff [7] investigated the
prevalence of the combination syndrome in patients
who use complete maxillary dentures and found the
above changes most consequential to denture using
occurred in 24% of patients who had natural
mandibular anterior teeth opposing complete
maxillary dentures. Their study also stated that 5%
of their subjects with an edentulous mandible
developed combination syndrome. Those patients
who had even one mandibular molar present did
not show the combination syndrome. This supports
the opinion of Saunders et al [4] that the lack of
posterior occlusal support is the key factor in the
development of this phenomenon. In 2003 a study
by Palmqvist et al [5] concluded that combination
syndrome does not qualify to be a medical
syndrome and that there was no evidence to believe
that resorption of anterior maxilla was related to
the presence of natural anterior teeth in the
opposing arch.
CLASSIFICATION
Based on a literature review and the
author’s experience with a variety of combination
syndrome patients (complete and partial maxillary
and mandibular edentulous cases), a clinically
relevant classification of combination syndrome is
proposed. [13] Three classes and 10 modifications
of CS are described below. An anterior maxillary
resorption resulting from the force of anterior
mandibular teeth is the key feature of this
classification, and it is consistently present
throughout all classes and all modifications.
‘‘Maxillary edentulous condition’’ defines the class,
‘‘mandibular’’ defines the modification within the
class. A treatment for each category of patients with
CS is suggested.
CLASS I:
Maxilla: completely edentulous alveolar ridge.
Mandible:
Modification 1 (M1): partially edentulous ridge with
preserved anterior teeth only.
Modification2 (M2): stable ‘‘fixed’’ full dentition
(natural teeth or implant-supported
crowns/bridges).
Modification3 (M3): partially edentulous ridge with
preserved teeth in anterior and one posterior
region.
CLASS II:
Maxilla: partially edentulous alveolar ridge with
teeth present in both posterior regions, edentulous
and atrophic anterior region.
Mandible: modifications are the same as in Class I
(M1, M2, and M3).
CLASS III:
Maxilla: partially edentulous alveolar ridge with
teeth present in one posterior region only,
edentulous and atrophic anterior and one posterior
region.
Mandible: modifications are consistent with Class I
and II (M1, M2, M3A, and M3B).
This classification is based on what seems to be the
dominant feature of most CS cases - an edentulous
premaxilla with an advanced resorption of anterior
maxillary bone and overgrowth of the anterior
mandibular bone with extrusion (super-eruption) of
lower front teeth. An important consideration of
this CS classification is the fact that a slow
remodeling of bone with tendencies towards
atrophy or hypertrophy (overgrowth) depends on
unfavorable pairing of healthy teeth (or implant-
supported bridge) in one jaw opposed by an
edentulous region in the other jaw. A persistent
occlusal pressure of solid teeth on the edentulous
opposing alveolar ridge over time will cause a bone
atrophy of the edentulous region. A reverse effect of
hypertrophy of the alveolar bone with an extrusion
of teeth opposed by an edentulous jaw segment is
also evident and usually develops synchronously. A
pairing of healthy maxillary and mandibular teeth in
a stable occlusion in any dental region can usually
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Table 1: Classification of combination syndrome patients

Class CS Type of Maxillary Type of Mandibular Anterior Maxilla Anterior Mandible

Modification Edentulism Edentulism
I 1 Completely edentulous Partial edentulism with Severe atrophy Severe
arch anterior teeth present only hypertrophy;
(or recently removed teeth extrusion
2 Completely edentulous Fixed dentition Severe atrophy Severe
arch hypertrophy
3 Completely edentulous Partial edentulism with Severe atrophy Severe
arch anterior and posterior teeth hypertrophy
on one side
II 1 Partially edentulous arch Partial edentulism with Severe atrophy Severe
with posterior teeth anterior teeth present only (or hypertrophy
present on both sides recently removed)

2 Partially edentulous arch Fixed dentition Severe atrophy Severe

with posterior teeth hypertrophy
present on both sides
3 Partially edentulous arch Partial edentulism with Severe atrophy Severe
with posterior teeth anterior and posterior teeth hypertrophy
present on both sides on one side

III 1 Partial edentulous arch Partial edentulism with Severe atrophy Severe
with posterior teeth anterior teeth present only hypertrophy
present on one side (or recently removed)
only
Partial edentulous arch Severe atrophy Severe
2 with posterior teeth Fixed dentition hypertrophy
present on one side
only
3a Partial edentulous arch Partial edentulism with Severe atrophy Severe
with posterior teeth anterior and posterior teeth hypertrophy
present on one side only on one occluding side

3b Partial edentulous arch Partial edentulism with Severe atrophy Severe

with posterior teeth anterior and posterior teeth hypertrophy
present on one side on one non occluding side
only

show little or no bone changes or teeth extrusion
due to opposing forces that tend to cancel each
other and maintain an occlusal balance. The forces
of occlusal pressure causing bone remodeling
towards atrophy or hypertrophy can cause mild,
moderate, or severe changes. This depends on many
factors, including presence or absence of teeth,
history of tooth loss (trauma or extraction),
periodontal condition of present teeth, history of
edentulism and prosthetic treatment (removable or
fixed, denture quality), an implant treatment (if
done)—immediate or delayed, density of bone in
the region, presence of parafunctional habits
(bruxism), muscular facial biotype (brachycephalic),
jaw relationship, type of occlusion, dietary habits,
and other factors.[13]
AN OVERVIEW OF TREATMENT MODALITIES

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 Saunder et al (1979)[4] and Jameson
(2001)[3] suggested the use of an alternative tooth
form and occlusal concept (linear occlusion) and
minimum anterior contact for reducing further
bone loss caused by hyperfunction of anterior teeth.
Previous studies advocated osseointegrated implant
retained or implant-supported prostheses to change
the occlusal force distribution and decrease the
traumatic stress to the alveolar bone resulting from
combination syndrome. [6] Clinical reports show
that, in the absence of natural posterior tooth
support, an occlusal table cannot be stabilized
effectively on distal extension bases. The
mucoperiosteal foundation yields under occlusal
loads, rendering such sophisticated occlusal
schemes palliative [4].
Koper [8] developed a bilateral balanced
occlusion of the posterior teeth using pantographic
recordings transferred to a fully adjustable
articulator to stabilize the maxillary denture. The
posterior occlusal table was formed by cast metal
chewing platforms or hard resin posterior teeth.
Schniitt SM [9] used a generated wax
occlusal path to create the occlusal surfaces of the
posterior teeth that were cast in metal. Acrylic teeth
were used to replace the maxillary anterior teeth
because they abrade rapidly and tend to reduce
stress concentration on the maxillary anterior ridge.
Keltjens et al [10] advocated placing
implants beneath the distal extension base of a
mandibular removable partial denture to provide a
stable posterior support.
Thiel et al [11] supported the above theory
and stated that mandibular implant-supported
overdenture offers significant improvement in
retention, stability, function and comfort of the
patient. It also provides a more stable and durable
occlusion. Wennerberg et al [12] in 2001 reported
excellent long term results with mandibular implant
supported fixed prostheses, opposing maxillary
complete dentures.
Severe maxillary resorption is a dominant
feature of combination syndrome patients. These CS
patients as well as many other clinical cases of
extensive three dimensional maxillary bone loss
have guided dental clinicians and surgeons towards
the development of many innovative surgical and
prosthetic techniques of correction of maxillary
bone atrophy combined with immediate or delayed
placement of dental implants. These reconstructive
approaches for the compromised maxillary bone
include vertical alveolar distraction
osteogenesis[15’16], horizontal distraction in
combination with bilateral sinus lift/bone grafting
procedure[17,18], maxillary ridge-splitting
techniques followed by immediate dental
implants,[19] autogenous iliac crest[20] and
calvarial bone grafting,[21] reconstruction of the
resorbed edentulous maxilla with autogenous rib
grafts,[22] tibial grafting for maxillary bone
loss,[23] treatment of severe maxillary atrophy with
vascularized free fibula flap in combination with
dental implants,[24] interpositional bone grafting
with LeFort I osteotomy, [25] orthognathic surgery
with or without onlay bone grafting[26,27] use of
the osseoinductive effect of bone morphogenic
protein within endosseous dental implants placed
in the maxilla,[28] zygomatic implants with or
without sinus lift/bone graft[29,30]
pterygomaxillary implants combined with
zygomatic and conventional implants,[31] the
Marius implant bridge for the surgical prosthetic
rehabilitation of the resorbed completely
edentulous maxilla with 6 implants,[32] ‘‘all-on-4’’
maxillary edentulous rehabilitation with 4
strategically placed and immediately loaded
implants,[33] combination of short implants and
osteotome technique for the posterior maxilla,[34]
use of transitional implants and bone grafting
before placement of definitive implants, [35]optimal
use of the anatomic features of the maxillary arch
with tilted implants,[36] use of transmandibular
implant[37] and Tatum custom ramus frame
implant in CS patients,[38]and others
TREATMENT OPTIONS IN COMBINATION
SYNDROME [14]
Treatment Option 1: Planned Extractions
Followed by Immediate Dentures: This treatment
option is considered when arch relationship negates
an overdenture and requires an alveolectomy along
with extraction of the anterior teeth for patients
reporting with severe prognathic maxilla,
periodontally compromised proclined anterior
teeth present in the maxillary arch and missing
mandibular posterior teeth. The main advantage in
using this technique was the decrease in the
14
resorption rate of the maxillary anterior residual
ridge because ridges are subjected to early function
coupled with improved aesthetics of the patient. It
prevents formation of flabby tissues which could
also arise as a result of unplanned or uncontrolled
dental extractions
Treatment Option 2: Overdenture Prosthesis
with a Metallic Denture Base: Every effort should
be made to avoid the potentially destructive
occlusal forces exerted on the anterior maxillary
residual ridge. Retained anterior maxillary roots
will absorb occlusal forces exerted by anterior
mandibular teeth. Reinforcing the denture base
with a cast metal framework has been shown to
reduce fracture rates
Treatment Option 3: Conventional
prosthodontic techniques with special
consideration for flabby tissues: A magnitude of
impression techniques have been suggested in the
past to help record a suitable impression of a flabby
denture-bearing area .The material used for
impression are zinc oxide eugenol, greenstick
compound and Elastomeric material.
Treatment Option 4: Surgical Intervention:
Vestibuloplasty and Excision of Flabby Tissue
followed by Metallic Denture Base Prosthesis:
Treatment Option 5: Implant Placements:
implants like implant supported fixed ceramo-metal
prosthesis with gingival ceramic, implant supported
fixed ceramo-metal prosthesis, Implant supported
overdenture can be placed
Treatment planning for the Distal extension
partially edentulous Mandibular Arch
Treatment Option 1: Overdenture: The spatial
position of the mandibular anterior teeth is
important to the treatment plan
Treatment Option 2: A Removable Cast Partial
Denture
Treatment Option 3: Implant Supported Fixed
Prosthesis.
All these treatment forms were directed
towards the preservation of health of natural
dentition and its masticatory function. The nutshell
of the treatment modality shows a multidisciplinary
approach paramount to accomplish complex task of
comprehensive dental treatment of CS patient.
CONCLUSION
Treatment of patients with an edentulous
maxilla opposed to natural mandibular anterior
teeth and a distal-extension RPD is considered a
challenge for dental practitioners. Combination
syndrome has a prevalence rate of approximately
24% for denture patients [6]. Therefore, it is
necessary for dentists to understand the particular
problems of patients and provide a comprehensive
treatment plan. To prevent the occlusal problems
and enhance the treatment of combination
syndrome, its proposed that (1) the distal-extension
mandibular RPD may serve a negative role for the
deterioration of combination syndrome[5]; and (2)
the application of dental implants in edentulous
areas, especially at premolar or molar regions, could
provide better posterior support.[10].
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
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