Prosthetic Management of Single Denture & Kelly's Syndrome

Prosthetic Management Of Single
Denture & Kelly ‘S Syndrome
Gilan Youssef Altonbary B.D.S, MSc. ,PhD.
Associate Professor Of Prosthodontics.
Faculty Of Dentistry ,Mansoura University, The Ohio State University ,USA
E-mail: gilanaltonbary@ gmail.com
Dr.Gilan Altonbary

SINGLE COMPLETE DENTURE
CONTENTS
✓ Definition
✓ Indication
✓ Various combinations of single complete denture
(maxillary or Mandibular)
✓ Problem associated with single complete denture
1) Common occlusal disharmonies & ways to adjust
them
• Mouth preparation techniques
2) Methods to achieve balanced /harmonious occlusion
3) Teeth wear (teeth selection)
4) Denture base fracture
5) Combination ( Kelly) syndrome
Dr.Gilan Altonbary

Definition:
A single complete denture is a complete denture that occludes
against some or all natural teeth, a fixed restoration, or a previously
constructed removable partial denture or a complete denture.
incidence of tooth loss: Maxillary > Mandibular arch
Dr.Gilan Altonbary

INDICATIONS:
A single complete denture may be desirable when it is to oppose any one of the
following:
Natural teeth that are sufficient in number
.A partially edentulous arch in which missing teeth have been or will be replaced by
removable partial denture.
A partially edentulous arch in which missing teeth have been or will be replaced by
fixed partial denture.
An existing complete denture.
Dr.Gilan Altonbary

Preservation of Residual Alveolar Ridge:
Force of jaw closure is greater with opposing natural teeth than with a complete
denture.
When the force is more the pressure is greater and bone resorption follows.
Stability of mandibular denture is very difficult due to tongue movements - denture
movement will increase the pressure and stress on the mucosa and bone
Necessity for retaining maxillary teeth:
• Maxillary dentition may needed to retain prosthesis . This situation is usually
associated with congenital defects cleft palate or stoma resulting from surgical or
accidental trauma.
Mental trauma: Some patients become depressed with the loss of teeth ;may lead to
more complicated psychological problems.
SO, Removal of remaining maxillary teeth even if indicated has to be carefully
analyzed and retained.
Dr.Gilan Altonbary

Dr.Gilan Altonbary
Maxillary teeth
extraction
Relining
for mandibular
single denture

Various
combinations
of maxillary
single
complete
denture:
1-Single Complete Maxillary Denture To
Oppose Natural Mandibular Teeth
2-Complete Maxillary Denture To Oppose A
Partially Edentulous Mandibular Arch With
Fixed Prosthesis
3-Complete Maxillary Denture To Oppose A
Partially Edentulous Arch And A Removable
Partial Denture
4- Single Complete Denture Opposing An
Existing Denture
Dr.Gilan Altonbary

2-
• if any fixed partial denture is acceptable, Composition of the artificial teeth to be used
• If the fixed partial dentures have Porcelain occlusals then → porcelain / resin
(reinforced)teeth
Enamel→ gold / resin teeth
Dr.Gilan Altonbary

✓ Problem associated with single complete denture
It is essential to obtain the occlusion and articulation that is
desired
Occlusal disharmonies and its adjustment:
• Malposed teeth
• Severely tipped teeth
• Supraerupted teeth
• Irregular occlusal plane
• Less space for teeth
Dr.Gilan Altonbary

Techniques to determine the necessary tooth modifications prior to
denture construction :
1. Swenson`s Technique
2. Yursktas Technique
3. Bruce Technique
4. Boucher Technique
Dr.Gilan Altonbary

2. YURKSTAS TECHNIQUE:
Uses a metal ‘U’ shaped occlusal template ,placed on the occlusal surfaces
of the remaining teeth and cusps are adjusted and identified.
Stone cast is modified to a more acceptable occlusal relationship and the
reduced areas are marked with a pencil. Necessary alterations done on the
natural teeth using the cast as a guide.
Dr.Gilan Altonbary

3. BRUCE TECHNIQUE
Dr.Gilan Altonbary

METHODS TO ACHIEVE HARMONIOUS BALANCED
OCCLUSION
1. Functional chew in techniques
2. Articulator equilibration techniques
1-Functional chew in technique
Most accurate method of recording occlusal patterns
To obtain functional chew in technique:
• Record bases should have good stability
• Patient should have good neuromuscular control and
mental competence to effectively co-operate
Dr.Gilan Altonbary

ARTICULATOR EQUILIBRATION TECHNIQUE
INDICATIONS:
1. The denture base lacks stability.
2. Patient is physically unable to perform a chew-in record.
Steps:
a) Upper cast mounted on the articulator using a face- bow with an
orbitale pointer
b) The lower cast is related to the upper by a centric interocclusal
record at an acceptable VD.
c) The bucco-lingual position of the teeth and their relation to the
upper arch is studied. Cusp-fossa relationship of the teeth is
essential.
Dr.Gilan Altonbary

d) At the time of wax try-in, eccentric records made and condylar
inclinations are set and posterior teeth are now balanced.
e) After denture is processed, then centric holding cusps are
achieved by selective grinding and then eccentric balance is
achieved.
f) However, perfectly balanced occlusion in all eccentric positions
may not be possible in many cases when working with natural
teeth in one arch.
Dr.Gilan Altonbary

Causes:
High occlusal forces due to strong mandibular elevator musculature
Flexure of denture base
Management:
1-Reinforcement of poly(methyl methacrylate) denture base with glass flake,
Reinforcement of acrylic denture base resin with high-performance polyethylene fiber in
woven form produced a substantial improvement of stiffness and impact strength
2-a cast metal base is best used to resist deformation and fracture.
Advantages: Very rigid, High thermal conductivity, High abrasion resistance, Less porous
than PMMA :and therefore easier to clean.
Disadvantages : More difficult to adjust tissue surface than a plastic base.
More difficult to reline the metal tissue surface.
Metal not esthetic.
Dr.Gilan Altonbary

Combination Syndrome
(Kelly’s Syndrome)
Dr.Gilan Altonbary

Ellsworth Kelly was the first person to use the term
‘Combination Syndrome’.
Kelly originally described Combination Syndrome as : a series of
destructive changes occurring in the jaws of the patients wearing a
complete maxillary denture opposed by a mandibular distal extension
partial denture.
Dr.Gilan Altonbary

Kelly described
five signs or
symptoms
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.
5- The loss of bone under the partial denture
bases.
Dr.Gilan Altonbary

Saunders et al, in 1979 described 6 additional changes
associated with this syndrome
They include:-
1) Loss of vertical dimension of occlusion.
2) Occlusal plane discrepancy.
3) Anterior spatial repositioning of mandible.
4) Poor adaptation of prosthesis.
5) Epulis fissuratum.
6) Periodontal changes.
Dr.Gilan Altonbary

Pathogenesis :
Combination syndrome progresses in a sequential
manner.
Kelly - Bone loss in the anterior maxilla is the first to
occur
Saunders - Bone loss under the removable prosthesis
was the root cause for the problem
Dr.Gilan Altonbary

The progress of the disease can occur in any of the following
sequences.
Sequence 1:
Dr.Gilan Altonbary

Sequence 1 (Ellisworth Kelly)
1. Patient tends to concentrate the occlusal load on the remaining natural teeth (mandibular
anteriors) for proprioception. Hence there is more force acting on the anterior portion the
maxillary denture.
2. This leads to an increased resorption of anterior part of the maxilla which gets replaced by
flabby tissue. The occlusal plane gets tilted anteriorly upwards and posteriorly downwards.
3. The labial flange will displace and irritate the labial vestibule leading to formation of epulis
fissuratum. Posteriorly there will be a fibrous overgrowth of the tissues in the maxillary
tuberosity.
Dr.Gilan Altonbary

4. The shift of the occlusal plane posteriorly downwards produce resorption in
the mandibular distal extension denture bearing area
5. Mandible shifts anteriorly during occlusion.
6. The vertical dimension at occlusion is decreased. The retention and stability
of the denture is also reduced.
7. The tilt in the occlusal plane disoccludes the lower anteriors causing them
to supraerupt. This reduces the periodontal support of the anterior teeth.
8. The supraerupted anteriors increase the amount of force acting on the
anterior part of the complete denture and the vicious cycle continues.
Dr.Gilan Altonbary

hyperplasia
Epulis fissuratum
Dr.Gilan Altonbary

Sequence 2
There is gradual resorption of the distal extension residual ridge in the mandible .
This leads to tilting of the occlusal plane posteriorly downwards and anteriorly
upwards
Rest of vicious cycle continues
Dr.Gilan Altonbary

Prevention of combination syndrome
• Avoid combination of maxillary complete dentures opposing class
mandibular R.P.D
• Retaining weak posterior teeth as abutments by means of endodontic and
periodontic treatment.
• An overdenture on the lower teeth
• Implants implant overdentures
implant fixed prostheses
Dr.Gilan Altonbary

Treatment approaches:
1-Stephen M. Schmitt, 1985 described a treatment approach that attempted to minimize
the destructive changes
-Mandibular R.P.D is completed first.
- Acrylic resin teeth are used to replace maxillary anterior teeth.
- Cast gold occlusal surfaces for posterior denture teeth.
After treatment is completed, it is essential to maintain recall
appointments at 3, 6, and 12 months during the first year to observe any
changes in posterior support.
RELINING of the mandibular RPD on condition that the VD is not changed
If acrylic tooth wear and support are lost in the posterior regions, accelerated
premaxilla atrophy will develop from excessive forces.
Bilateral balanced occlusion is essential for long term success.
Dr.Gilan Altonbary

• 2-Mandibular tooth overdenture produced better prognosis in patients who already
had combination syndrome and whose mandibular teeth were structurally or periodontally
compromised.
• 3- Mandibular implant supported overdenture offers significant improvement in retention,
stability, function and comfort for the patient and a more stable and durable occlusion
Dr.Gilan Altonbary

• 4-Some form of stabilization of the maxillary arch.
- retention of maxillary overdenture abutments instead of extraction
- maxillary osseointegrated implants.
- augmentation of maxilla with resorbable hydroxyapatite in
conjunction with a guided tissue regeneration technique and
vestibuloplasty.
Dr.Gilan Altonbary

5-Implant supported fixed prosthesis.
In 2001 Wennerberg et al, reported excellent long term results with
mandibular implant supported fixed prosthesis, opposing maxillary
complete dentures.
Dr.Gilan Altonbary

Prosthetic Management of Single Denture & Kelly's Syndrome

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