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CLASSIC ARTICLE

Changes caused by a mandibular removable partial denture opposing a maxillary complete denture
Ellisworth Kelly, DDSa School of Dentistry, University of California, San Francisco, Calif

lthough many advances have been made in denture prosthetics, the great problem is still with us: coping with the resorption of the residual alveolar ridge and managing or preventing the secondary soft tissue changes brought on by bone loss. The resorption occurring beneath denture bases has been investigated1-9 and we have some knowledge of the rate of resorption of the residual bony ridge. Investigators agree that individual differences in the rate of resorption of the ridges are very great. Underlying metabolic, hormonal, and nutritional causes account for this difference and we know very little about these factors. From clinical experience and clinical studies,10,11 we have considerable knowledge of the prosthetic factors which inuence bony resorption. We know that moderate, intermittent forces exerted on the bony ridge by a prosthesis may be stimulating and help preserve rather than destroy the bony ridge.12 We know that excessive force causes resorption of the residual ridge. De Van13 stated that compressive forces are well tolerated by the edentulous ridges while shearing forces are not. This concept has been utilized by many techniques which minimize the lateral forces exerted by dentures. The principle of wide coverage with the complete or partial removable denture base to minimize the force per unit area is basic14 and has served us well. Yet we are not able to do anything for those people who are very susceptible to bone loss because of underlying systemic causes and who, in spite of our best efforts, often end up with very little bone remaining. On the other hand, we do have the knowledge to prevent excessive bone loss from traumatic forces exerted by or on the denture bases. Observation of a number of denture patients will show that we are failing to put this knowledge into practice. Destruction of the residual ridge from occlusal trauma is not uncommon. Very common is the almost total loss of bone in the anterior part of the maxillae brought about by only natural anterior teeth remaining in the mandible and occluding with a compelte upper denture. The anterior part of the maxillae is the weakest part of the upper
Read before the Academy of Denture Prosthetics in Detroit, Mich. a School of Dentistry, University of California, San Francisco, Calif. Reprinted with permission from J Prosthet Dent 1972;27:140 50. J Prosthet Dent 2003;90:213-9. SEPTEMBER 2003

arch to resist stress and when the lower anterior teeth occlude anterior to the basal support, trauma is inevitable. Many of these patients have distal-extension partial lower dentures but this does not seem to prevent this type of destruction in the upper jaw. The degenerative changes in these patients include more than the loss of bone. An overgrowth of the maxillary tuberosities often occurs. These enlargements are usually brous but they may be bony enlargements. Papillary hyperplasia of the palatal mucosa may occur concurrently. The remaining mandibular anterior teeth seem to extrude along with the bony process, and excessive bone loss occurs in the posterior part of the ridge under the partial denture bases. These ve changes may constitute a syndrome, as they are quite characteristic. These changes are (1) loss of bone from the anterior part of the maxillary ridge, (2) overgrowth of the tuberosities, (3) papillary hyperplasia in the hard palate, (4) extrusion of the lower anterior teeth, and (5) the loss of bone under the partial denture bases. I call this the combination syndrome.

COMPLETE UPPER DENTURES OPPOSING PARTIAL LOWER DENTURES


Completely edentulous maxillae and partially edentulous mandibles with only anterior teeth remaining are common situations. In the past two years, 130 of 495 patients treated in the prosthodontic clinic at the School of Dentistry of the University of California received complete maxillary dentures opposing mandibular partial dentures. This represents 26 per cent of the denture patients. Some of the partial dentures had distal support but most of them did not.

THE COMBINATION SYNDROME


The early loss of bone from the anterior part of the maxillary jaw is the key to the other changes of the combination syndrome. With the anterior loss of bone, a abby hyperplastic connective tissue makes up the anterior part of the ridge. This hyperplastic tissue does not support the denture base and usually it folds forward, forming a characteristic deep fold or crease (Fig. 1). As bone and ridge height are lost anteriorly, the posterior residual ridge becomes larger with the development of
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Fig. 1. Maxillary arch that has supported complete upper denture against 6 natural lower anterior teeth and Class I partial denture for 14 years shows changes that this combination often effects.

Fig. 2. Mounted diagnostic casts show bony loss and rolled (hyperplastic) soft tissue in upper anterior region, enlarged tuberosities, and extruded lower anterior teeth.

Fig. 3. With loss of anterior maxillary bone, overgrowth of tuberosities, and upward migration of lower anterior teeth, patient shows no upper anterior teeth but does show upper posterior teeth because of dropping of distal end of occlusal plane of dentures.

enlarged tuberosities. These enlarged tuberosities are usually made up of brous tissue, but in some patients the bone height seems to have increased also. With these changes, the occlusal plane migrates up in the anterior region and down in the back. After a time, the natural lower anterior teeth migrate upward, the anterior teeth on the complete denture disappear under the patients lip, and both dentures migrate downward in the posterior region. The esthetics are poor with the patient showing none of the upper anterior teeth and too much of the lower anterior teeth, and the occlusal plane drops down to expose the upper posterior teeth (Figs. 2 and 3).
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Excessive bony resorption under the lower removable partial denture bases occurs to permit these changes, and often inammatory papillary hyperplasia develops in the palate (Fig. 4). The histopathology of the hyperplastic anterior ridge tissue, and the brous tissue which develops over the tuberosities is revealing. Microscopic examination of these tissues shows that the abby tissue and the hard tissue over the tuberosities are indistinguishable. They are made up of mature, dense, brous connective tissue. This tissue in both locations has dense bundles of collagen bers, with relatively few
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Fig. 4. Papillary hyperplasia in palate often accompanies other changes of combination syndrome.

cellular elements, with very few inammatory cells. It is rather avascular with an overlying epithelium that is almost normal, but shows some evidence of hyperplasia (Fig. 5). This is also the histopathology of a mature epulis ssuratum if we discount the area of ulceration caused by the denture border. This similarity is surprising because the hyperplastic anterior tissue is freely movable while the brous tissue over the tuberosity is hard. However, all three of these conditions (the abby anterior ridge, the brous tuberosity, and the epulis ssuratum) are the result of prolonged trauma from the denture base. Therefore, the fact that the tissue response is the same is logical. The difference in consistency of brous tuberosities and abby anterior ridges must be explained on a mechanical basis. The anterior bony ridge has virtually disappeared and the connective tissue replacement is a narrow projection of tissue virtually unsupported on the labial or lingual surface. On the other hand the brous tissue over the tuberosity is supported by a broad base of bone below.

upper denture opposing a lower partial denture for 16 years. The fulcrum of movement in this patient is in the cuspid-rst bicuspid region. Our patients show that at rst the fulcrum is well to the posterior, just anterior to the tuberosity. With the posterior palatal seal, a negative pressure is produced posterior to the fulcrum line. This negative pressure may account for the enlarged tuberosities and the papillary hyperplasia. Carlsson1 observed one patient who had an increase in the maxillary ridge height in the molar region after wearing dentures for two years. He postulated: It may have been due to the development of a brous part possibly1 owing to the suction effect when the denture moved. A number of authors15-17 have associated a void, a suction chamber, or other form of negative pressure with inammatory papillary hyperplasia of the palate. Wictorin5 states that to prevent bony resorption, mechanical forces must be distributed over as large an area of the basal seat as possible, and the denture must make as little movement as possible against its basal seat, and that these factors are strongly interconnected. With the lower anterior teeth causing trauma and bone loss from the anterior part of the maxillae, and with the denture base moving more and more on its foundation, a very destructive situation exists. All kinds of questions come to mind. How fast do the degenerative changes develop? Is excessive bone loss in the anterior part of the maxillae with the other changes that follow inevitable or does it occur only in neglected patients, those without proper follow-up treatment in retting the denture bases and readjustment of occlusion? If it is from neglect, what kind, and what amount of care is necessary to prevent it? Will the changes occur in all patients or only in susceptible patients with underlying metabolic, hormonal, or nutritional deciency?

PATIENT HISTORIES WITH CEPHALOMETRIC RADIOGRAPHS


In an effort to nd answers to some of these questions, we started a study of 20 patients who were receiving complete maxillary dentures opposing distal-extension removable partial dentures. Only six of these patients have returned faithfully over a three-year period so no conclusions can be drawn from this preliminary report. We made serial cephalometric radiographs with a 0.25 mm. diameter lead wire outlining the soft tissue on the right side of the ridge (Figs. 7 and 8). All of the patients received maxillary complete immediate dentures opposing Class I lower partial dentures. All were rst-time denture wearers. The immediate dentures were constructed after the posterior teeth had been extracted and a healing period allowed. The rst radiograph was made after the initial healing of the anterior part of the maxillary ridge had taken place, and after the
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MECHANICS WHICH PRODUCE THE COMBINATION SYNDROME


The resorption of the bone in the anterior region initiates the changes which we call the combination syndrome. Natural anterior maxillary teeth have increased bony resorption under maxillary dentures.4,5 While bone is being lost in the anterior region in the upper jaw, bony resorption also occurs under the mandibular partial denture bases. The maxillary denture then moves up in the anterior region and down in the posterior region in function. This tipping action is illustrated in the diagram (Fig. 6) which was traced from cephalometric radiographs of a patient who had been wearing a complete
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Fig. 5. Histologic sections of lesions: A, Flabby (hyperplastic) anterior ridge (100); B, brous tuberosity (100); C, inammatory papillary hyperplasia (40); D, the same (100). The similarity of A (hyperplastic ridge tissue) and B (brous tuberosity) is discussed in text. Papillary hyperplasia shows (a) brous core, (b) hyperplastic epithelium, and (c) inammatory cells.

anterior section of the immediate denture had been retted with cold-curing acrylic resin. This was unsually about four weeks after insertion of the dentures. A second radiograph was made after six to eight months. The patients were seen regularly over the rst few months, and the dentures retted and serviced as needed. After the rst year, the third radiograph was made. At this time, the maxillary denture was relined or a new denture was constructed. After this, the patients were called annually for examination and radiographs. Measurements were made directly on the radiographs, using the sella-nasion line as a base. The results are expressed as millimeters of increase (plus) or millimeters of decrease (minus) in the residual ridge height. Table I shows these data for the maxillary bone and soft tissue. Tracings were made from the cephalometric radiographs. These show the changes graphically but not as accurately as the measurements directly on the radiographs (Fig. 9).
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All of the patients showed a loss of 1 to 3 mm, of ridge height in the anterior region. All of the subjects showed a loss of the underlying bone as well. All of the subjects showed an increase of 1 to 2.5 mm. height of the tuberosity with all but one having a corresponding increase in the height of the underlying bone. One subject had an increase in the height of the tuberosity but a slight loss of underlying bone. All of the subjects show a 1.0 to 1.5 mm. extrusion of the lower anterior teeth. This is signicant since the measurements are very accurate because of the stability of the bony landmarks at the midline. One patient is beginning to show signs of the deterioration of the anterior part of the upper ridge which we attribute to trauma from the lower anterior teeth. This patient has a abby thickening of the tissue, inammation of the incisive papilla, and the beginning of a fold forming the labial surface of the ridge (Fig. 10). All of the subjects have been successful denture wearers, well satised with their prosthesis. They have received better than average follow-up treatment in retVOLUME 90 NUMBER 3

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Fig. 6. Diagram made from tracings from 2 cephalometric radiographs, one at physiologic rest position and the other with teeth in centric occlusion. In this patient, with an advanced combination syndrome, movement of denture base is very great, causing positive pressure anterior to fulcrum (F) and negative pressure posterior to this position.

Fig. 7. Lateral cephalometric radiograph of one subject shows the lead wire outlining soft tissues of ridge.

Table I. Each gure represents increase or decrease in millimeters of ridge height over three-year period
Posterior tuberosity ridge height Patient Soft tissue Bony ridge Anterior ridge height Soft tissue Bony ridge

A, age 63 B, age 51 C, age 46 D, age 43 E, age 35 F, age 34

2.5 1.0 1.3 2.0 1.0 1.3

1.7 1.0 0.5 1.7 0.2 0.5

2.2 3.0 2.2 1.5 2.9 1.0

1.7 3.0 1.2 1.0 0.7 0.5

Fig. 8. Lead wire is in place after radiograph was made. Lead wire adheres to and is very slightly embedded into soft tissue.

ting the bases and equilibrating the occlusion. With the loss of tissue demonstrated in the anterior part of the upper jaw, and with a positive change developing in the posterior part of the ridge, and with the lower anterior tooth migration, it appears that any or all of these patients could develop the typical signs of the combination syndrome.

PREVENTION OF THE COMBINATION SYNDROME


Preventing the degenerative changes that complete maxillary dentures opposing the Class I partial dentures bring about may only be possible through treatment planning to avoid this combination of prostheses. Complete lower dentures opposing natural maxillary teeth
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are impossible prosthodontic combinations. Treatment planning should avoid the necessity for such a combination. The same could be done to eliminate the combination of complete upper dentures opposing Class I lower partial dentures. I do not advocate extracting lower anterior teeth to accomplish this but rather to retain weak posterior teeth as abutments by means of endodontic and periodontic techniques. Endosseous endodontic implants and the amputation of one lower molar root to preserve the other as an abutment are examples of some of the methods that could be applied. An overlay denture on the lower may avoid the combination syndrome from developing. Overlay dentures utilizing the lower tooth roots for stabilization provide a complete denture occlusion.

SURGICAL CORRECTION OF CHANGES IN THE BASAL SEAT


Even after much damage has been done and gross changes have taken place, many dentists and patients prefer to remake the combination rather than sacrice the remaining lower anterior teeth to make complete
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Fig. 9. Cephalometric tracings of each of the 6 subjects. They were made 3 years apart and show changes that have occurred. Solid lines show initial outline of bone and soft tissue; dotted lines indicate these outlines 3 years later (Table I).

larged tuberosities can be reduced. This allows the distal end of the occlusal plane to be raised to the proper level, and allows the lower partial denture bases to be fully extended. This is extremely important, and covering the maximum area possible for support of partial denture bases would help prevent the combination syndrome. Covering the retromolar pad where muscle and raphe attachments prevent or reduce resorption, and covering the buccal shelf14 is necessary to retard bone loss. Often this is not done with removable partial dentures.

SUMMARY
Almost inevitable degenerative changes develop in the edentulous regions of wearers of complete upper and partial lower dentures. We have followed six patients over a three-year period with cephalometric radiographs to determine if these changes could be detected. In all six subjects, early changes that could become gross changes were apparent. In one of them degenerative clinical change is beginning to appear. This problem might be solved with treatment planning to avoid the combination of complete upper dentures against distal-extension partial lower dentures. The alternative of complete maxillary and mandibular dentures is not attractive to patients. Preserving posterior
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Fig. 10. One subject, although given follow-up treatment, shows the beginning of degenerative changes. Soft tissue in anterior part of maxillary ridge is thickened and soft. Note characteristic horizontal fold on labial surface of maxillary ridge.

dentures. Surgery can do much to rehabilitate these patients. The abby (hyperplastic) tissue can be removed, the papillary hyperplasia can be eliminated, and the en218

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teeth to serve as abutments to support lower partial dentures and to provide a more stable occlusion is a better alternative. Ill-tting dentures have been blamed for all of the lesions of the edentulous tissues, yet the most perfect denture will be ill-tting after bone is lost from the anterior part of the ridge. Removable dentures need periodic attention at least as often as the natural teeth.
The author would like to express his appreciation to Dr Louis S. Hansen for his help and advice on oral pathology and to Dr Leonard Chong for his help with the cephalometric radiographs and tracings.

REFERENCES
1. Carlsson GE. Measurements on Casts of the Edentulous Maxilla. Odont. Revy. 1966;17:386-402. 2. Carlsson GE: Changes in the Jaws and Facial Prole after Extractions and Prosthetic Treatment, Trans. R. Schools Dent., Stockholm and Ume, No. 12: 16, 1967. 3. Carlsson GE, Persson G. Morphologic Changes of the Mandible after Extraction and Wearing of Dentures. Odont. Revy. 1967;18:27-54. 4. Carlsson GE, Bergman B, Hedegard B. Changes in Contour of the Maxillary Alveolar Process Under Immediate Dentures. Acta. Odont. Scand. 1967;25:1-31. 5. Wictorin L: Bone Resorption in Cases With Complete Upper Denture, Acta Radiol. Sppl. 228, 1964. 6. Hedegard B. Some Observations on Tissue Changes With Immediate Maxillary Dentures. Dent. Pract. 1962;13:70-78. 7. Atwood DA. A Cephalometric Study of the Clinical Rest Position of the Mandible II. The Variability in the Rate of Bone Loss Following the Removal of Occlusal Contacts. J. Prosthet. Dent. 1957;7:544-552.

8. Atwood DA. Some Clinical Factors Related to Rate of Resorption of Residual Ridges. J. Prosthet. Dent. 1962;12:441-450. 9. Atwood DA: Reduction of Residual Ridges as a Disease Entity, Essay presented at meeting of the American Prosthodontic Society, Las Vegas, 1970. 10. Neufeld JO. Changes in the Trabecular Pattern of the Mandible Following the Loss of Teeth. J. Prosthet. Dent. 1958;8:685-697. 11. Applegate OC. Conditions Which May Inuence the Choice of Partial or Complete Denture Service. J. Prosthet. Dent. 1957;7:182-196. 12. Carlsson GE, Thilander H, Hedegard B. Histologic Changes in the Upper Alveolar Process After Extractions With or Without Insertion of an Immediate Full Denture. Acta Odont. Scand. 1967;25:123-146. 13. De Van MM. An Analysis of Stress Counteraction on the Part of Alveolar Bone With a View to Its Preservation. Dent. Cosmos 1935;77:109-123. 14. Boucher CO. A Critical Analysis of Mid-Century Impression Techniques for Full Dentures. J. Prosthet. Dent. 1951;1:472-491. 15. Fairchild JM. Inammatory Hyperplasia of the Palate. J. Prosthet. Dent. 1967;17:232-237. 16. Hickey JC, Stromberg WR. Preparation of the Mouth for Complete Dentures. J. Prosthet. Dent. 1964;14:611-622. 17. Campbell RL. Relief Chambers in Complete Dentures. J. Prosthet. Dent. 1961;11:230-236. Reprint requests to: DR ELLSWORTH KELLY UNIVERSITY OF CALIFORNIA SCHOOL OF DENTISTRY SAN FRANCISCO, CALIF. Copyright 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 0

doi:10.1016/S0022-3913(03)00240-3

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