Single complete denture against natural tooth or removable partial dentures or fixed partial dentures.

1. SINGLE COMPLETE
DENTURE
Presented by: Dr. Rajvi Nahar
1st year POSTGRADUATE

2. CONTENTS
• Introduction
• Definitions
• Problems associated with single complete denture
• Diagnosis and treatment planning
• Various combinations of single complete denture
• Common occlusal disharmonies
• Techniques To Determine The Necessary Tooth Modifications Prior To
Denture Construction
• Methods used to achieve harmonious balanced occlusion
• Teeth Selection
• Potential adverse treatment outcomes
• Conclusion
• References

3. INTRODUCTION
• Many patients become edentulous in one arch while retaining some or all of their natural teeth
in the opposing arch. In this situation a single complete denture is fabricated.
• The single complete denture opposing all or some of the natural dentition is not an uncommon
occurrence. Causes for the loss of teeth from the dental arches like periodontal problems,
dental caries and trauma.
• The incidence of tooth loss is more in maxillary arch compared to mandibular arch.
• Dentist faces many difficulties in rehabilitating the patients with this clinical pattern.
• Malposed, tipped, or supraerupted teeth make it difficult to achieve a harmonious balanced
occlusion and also interfere in proper placement of artificial teeth to achieve adequate
esthetics.
• As a result of unfavorable occlusal relationships there is a tendency of denture to get
displaced, causing soreness, mucosal changes and ultimately ridge resorption.

4. INDICATIONS
• A single complete denture may be desirable when it is to oppose any one of them:
1. Natural teeth that are sufficient in number not to necessitate a fixed or removable partial
denture.
2. A partially edentulous arch in which missing teeth have been or will be replaced by RPD.
3. A partially edentulous arch in which missing teeth have been or will be replaced by FPD.
4. An existing Complete denture.
5. Implant supported Complete denture.
• The primary consideration for continued denture success with a single conventional
complete denture is the preservation of that which remains!!

5. DEFINITION
• Single complete denture is a prosthesis which replaces the lost natural teeth and its
associated structures functionally and esthetically as a single unit which opposes all or some
of the natural teeth.
• The making of a maxillary or mandibular denture as distinguished from a set of complete
dentures (GPT-1).
• 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.
• Single edentulous arch : Prevalence of the condition where edentulous arch opposes a
natural or restored dentition is quite common
• The reason for the loss of the maxillary teeth prior to the mandibular teeth are unclear and are
influenced by a combination of factors

6. PROBLEMS ASSOCIATED WITH SINGLE COMPLETE
DENTURE
1.
• Occlusal forces
2.
• Occlusal form of the natural teeth
3.
• Support of the denture base
4.
• Intermaxillary relations

7. OCCLUSAL FORCES
• These forces have been recorded as high as 198 lbs on a single molar tooth.
• This is in contrast with the forces which a complete denture - 26 lbs
• The occlusal form of the remaining natural teeth will dictate the occlusion of the denture
• The natural teeth may be over erupted or tilted and there cusps may be high and sharp.
• Denture will constantly be thrust or dragged horizontally on the ridge.
OCCLUSAL FORM OF THE
NATURAL TEETH

8. SUPPORT FOR THE DENTURE BASE
• Denture base should have the maximum extension within the functional anatomic limits.
• Lower complete denture opposing upper natural teeth should be normally avoided.
• When upper complete denture is being made to occlude with lower natural teeth, an error
may be made in recording the vertical dimension.
• The labio- lingual thickness of the wax rim, will usually not allow the lower incisor to close
beyond the occlusal surface.
• Increased vertical dimension may be recorded.
INTER MAXILLARY RELATIONS

9. • Occlusal problems and fracture of denture base account for structured difficulties and may
result from one or all of the following.
1. Occlusal stress on the maxillary denture and the underlying edentulous tissue from teeth
and musculature accustomed to opposing natural dentition.
2. The position of the mandibular teeth which may not be properly aligned for the
achievement of bilateral balance for stability.
3. Flexure of the denture base.
• Salient consideration includes:
1. Acceptable interocclusal distance
2. Stable jaw relationship with bilateral tooth contact in retruded position.
3. Stable tooth quadrant relationships with axially directed forces
4. Multidirectional freedom of tooth contact throughout a small range (with in 2 mm) of
mandibular movements.

10. • When only one arch is edentulous, tooth position in the dentate arch may preclude such
objectives being reached. Unfavorable force distribution may then cause adverse tissue
changes that compromise optimum function like –
Extensive morphological changes in denture foundation
Extreme jaw relationships
Excessively displaceable denture bearing tissue.
• To overcome these problems two things are necessary:-
1. Full use of the factors which favors success with no procedural errors.
2. The forces to which the denture is subject must be reduced as much as possible by
appropriate mouth preparation.

11. DIAGNOSIS AND TREATMENT
PLANNING
• The commonly sited long term goal in Prosthodontics is the preservation of that which
remains.
• This demands an appreciation of occlusal mechanics.
• For proper diagnosis and treatment planning – evaluate
• Edentulous arch - Frenii, sulcus, palate, mucosa, ridge, severe undercuts, tongue, lips,
temporomandibular joints, mouth opening
• Dentulous arch - number of teeth present, position of teeth, condition of teeth, endodontic
condition, restorative condition, condition of existing restoration and periodontal condition

12. • Carl F Driscoll & Radi M Masri Classification
• Class I – Patient for whom minor or no tooth reduction is all that is needed to obtain
balance.
• Class II – Patient for whom minor additions to the height of the teeth are needed to obtain
balance.
• Class III – Patient for whom both reduction and additions to the teeth are required to obtain
balance. The treatment of these patient involves change in the vertical dimension of
occlusion.
• Class IV – Patient who presents with occlusal discrepancies that require addition to the
width of the occluding surface.
• Class V – Patient who presents with combination syndrome

13. VARIOUS COMBINATIONS OF SINGLE
COMPLETE DENTURE
1. MANDIBULAR DENTURE TO OPPOSE NATURAL MAXILLARY TEETH.
2. SINGLE COMPLETE MAXILLARY DENTURE TO OPPOSE NATURAL MANDIBULAR TEETH.
3. COMPLETE MAXILLARY DENTURE TO OPPOSE A PARTIALLY EDENTULOUS
MANDIBULAR ARCH WITH FIXED PROSTHESIS.
4. COMPLETE MAXILLARY DENTURE TO OPPOSE A PARTIALLY EDENTULOUS ARCH AND
A REMOVABLE PARTIAL DENTURE.
5. SINGLE COMPLETE DENTURE OPPOSING AN EXISTING DENTURE.

14. MANDIBULAR DENTURE TO OPPOSE NATURAL
MAXILLARY TEETH
• This situation occurs due to:
1. Surgical trauma
2. Accidental trauma
• Greater challenge than maxillary single complete denture

15. • Factors which particularly have to be evaluated for this scenario are:
• Preservation of Residual Alveolar Ridge:
1. 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.
2. Stability of mandibular denture is very difficult due to tongue movements - denture
movement will increase the pressure and stress on the mucosa and bone, which is
detrimental to comfort and preservation.
3. Minimal availability of mucosa with tightly attached submucosa will lead to stress
concentration.
4. So the ultimate result is that tissues become not tolerable to dentures.

16. • Necessity for retaining maxillary teeth:
1. Maxillary dentition may needed to retain prosthesis .
2. This situation is usually associated with congenital defects cleft palate or stoma resulting
from surgical or accidental trauma.
• Mental trauma:
1. Some patients become depressed with the loss of teeth.
2. This depression may lead to more complicated psycological problems.
3. Removal of remaining maxillary teeth even if indicated has to be carefully analyzed and
retained.

17. SINGLE COMPLETE MAXILLARY DENTURE TO OPPOSE
NATURAL MANDIBULAR TEETH
• Most frequently encountered Problems:
1. Malposed, tipped & supraerupted teeth in lower
arch & unfavorable plane of occlusion.
2. Position of mandibular anterior teeth:
A. Reposition
B. Alteration

18. • More frequently encountered than the single mandibular denture.
• The occlusal forms of the natural teeth act as a guide in selecting the occlusal form for the
maxillary posterior teeth.
• However, if the natural teeth are abraded monoplane form may be the choice.
• Some times the position of mandibular teeth will not allow the maxillary anterior teeth to be
positioned in an esthetically acceptable manner or for balanced occlusion.
• This problem may be solved as follows.
1. Reposition of the natural teeth with orthodontic procedures
2. Alter the clinical crowns of the teeth by grinding or with restoration.
3. Accept balanced occlusion with the jaws in the terminal relation and not in the eccentric
position.

19. • According to Sharry:
If there is class II jaw relation, a complete denture
often may be constructed against lower anterior
teeth and premolars without replacing molars
Forces directed to middle posterior part of upper
denture.
But if class III jaw relation situation is different
because mandibular premolars would apply
occlusal forces against the anterior part of the
maxillary ridge Forces against the anterior part of
the maxillary ridge.

20. • Evical and Swoop developed useful system to determine and classify the amount of
mandibular resorption.
The amount of resorption can be calculated and classified into three patterns:
1. Class I approximately 2/3rd of the mandibular alveolar bone is present.
2. Class II approximately ½ - 2/3rd of bone is present.
3. Class III approximately 1/3rd or less than that.

21. Resorption
pattern
Angle class I II III
Class I (Mild) Consider Consider Strongly
Consider
Class II
(Moderate)
Consider Consider Consider
Class III
(Severe)
Do not retain Do not retain Do not
retain
Recommendations for retention of the remaining maxillary dentition when
opposing an edentulous mandible

22. COMPLETE MAXILLARY DENTURE TO OPPOSE A
PARTIALLY EDENTULOUS MANDIBULAR ARCH WITH FIXED
PROSTHESIS
• First it must be determined if the fixed restorations are acceptable if they can be made
acceptable or if they must be rejected.
• When the restorations are acceptable one must then decide what occlusal concept will be
pursued.
• Teeth in single complete denture are on a movable base and even though they function
against natural teeth they will function as a unit.

23. COMPLETE MAXILLARY DENTURE TO OPPOSE A
PARTIALLY EDENTULOUS ARCH AND A REMOVABLE
PARTIAL DENTURE
• Remaining mandibular teeth should be in an acceptable state of dental health.
• The partial denture should meet minimal acceptable requirements.
• When there is a removable partial denture, it must be evaluated critically.
1. The occlusal plane
2. Tooth arrangement for occlusion
3. Esthetics and material composition of the teeth
• Treatment plan is or should be formulated for both arches at
the same time.

24. SINGLE COMPLETE DENTURE OPPOSING AN EXISTING
DENTURE
• In this situation this following factors must be considered.
Duration of existing denture
Was the denture an immediate insertion at the time of teeth removal
• These two factors are directly related to the extent of bone resorption.
Does the denture meet the requirements of an acceptable denture?
Condition of opposing arch in relation to the existing denture.
A most serious consideration is the fact that the dentist assumes the responsibility for
both dentures as soon as he accepts the patient for treatment of the single complete
denture.

25. COMMON OCCLUSAL DISHARMONIES
• The most common occlusal adjustments involve the anterior teeth and the last molar
• Frequently natural lower incisors and cuspids are very long and there should be ground as
much as is practicable.
• If the molars are not severely lilted they may be reshaped by selective grinding
• Stephen’s recommends that the distal half of the occlusal surface should be ground flat and
the denture teeth set to occlude with only that area, leaving mesial cusps out of contact.
• The ideal treatment is to restore the tilted molar with cast gold crowns, onlays or fixed
bridge if a large edentulous space exists mesial to the molars.
• If a large space does exist mesial to the tilted molars another alternative treatment is to
design a removable partial denture that would restore the mesial half of the molar.
• If the molar are severely tilted forward and supra-erupted the modification is not possible,
extraction is necessary.
• Another disharmony exists when insufficient mandibular teeth are left to occlude with a
complete maxillary denture.

26. ADJUSTMENT FOR TILTED MOLAR
• If molars are not severely tilted
Can be reshaped by selective grinding
If more tooth structure is needed to be
removed
Restored with crown or Fixed partial
denture

27. If large space exist mesial to tilted
molar
Rpd restoring the mesial half of the
molars, lower the distal cusps
(Mesial half onlay mesial rest or
extended rest)
Orthodontic repositioning of tilted molar
If severely tilted and supraerupted
Extraction

28. Natural lower cuspids and insicors are
supraerupted
Selective grinding
Canine region, occlusal adjustment should aim at providing a definite distal slope
on the lower Canine so as to allow space for free passage of the upper artificial
canine between the lower canine and first premolar in lateral movements.

29. MOUTH PREPARATION
• It is essential to obtain the occlusion and articulation that is
desired Indications:
1. Malposed teeth
2. Severely tipped teeth
3. Supraerupted teeth
4. Irregular occlusal plane
5. Less space for teeth

30. TECHNIQUES TO DETERMINE THE NECESSARY TOOTH
MODIFICATIONS PRIOR TO DENTURE CONSTRUCTION
• Swenson`s Technique
• Yursktas Technique
• Bruce Technique
• Boucher Technique
• Han Kuang Tan’s technique
• Broadrick’s Flag

31. SWENSON'S TECHNIQUE
• Mount maxillary and mandibular casts at an
acceptable VD with a CR record.
• A maxillary base is made and denture teeth set.
• If interferences are there, adjusted on the cast
and mark with pencil.
• Natural teeth modified with this guide and a new
diagnostic cast made and mounted on the
articulator.
• If this occlusal modification is sufficient, denture
teeth are reset for trial.
• Disadvantage: Time consuming if it needs
several impressions and mountings before the
occlusion is finalized.

32. 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.

33. BRUCE TECHNIQUE:
• The lower diagnostic cast is mounted with the
upper with the proper CR record.
• Necessary modifications are made on the stone
cast.
• Acrylic resin template is fabricated on the modified
stone cast.
• Checked in the patient's mouth for interferences
and the interferences are removed.
• Process is repeated until the template seats
properly.
• Areas to be modified are marked with pencil on the
cast

34. • Clear acrylic resin template is formed over the corrected cast
• Initial modification done Template coated with Pressure indicating paste & placed over teeth
• Interferences can be seen through the clear template and can be removed accordingly.
• Process repeated till template fits the teeth perfectly.
• Advantage: Produces accurate results

35. BOUCHER'S TECHNIQUE:
• Casts are mounted on a programmed articulator.
• Artificial are arranged to obtain best possible balancing contacts.
• If a natural tooth prevents balancing, interferences are removed by moving porcelain
teeth over the mandibular stone teeth.
• Areas to be ground are marked on the cast.
• The denture is processed and will be used as a guide to modify natural opposing teeth.

36. HAN KUANG TAN’S
TECHNIQUE
A simple method of transferring diagnostic odontoplastic information from cast to the patients

37. THE BROADRICK OCCLUSAL PLANE
ANALYZER
• It is used for analyzing the Curves of Spee and Wilson
to develop an acceptable curve of occlusion. A flag or
semaphore is common to the art of dentistry and has
been used and described many times in writings and
teachings over the years. Here, then, is a practical
device which is used in conjunction with Hanau™ and
Denar® Articulators.
• A Broadrick Occlusal Plane Analyzer, consists of
(1) Card Index,
(2) Bow Compass with graphite leads, an extra center
point and a needle point,
(3) Scribing Knife and
(4) Plastic Record Cards

38. • The maxillary cast shall have been mounted by a
Facebow transfer and the mandibular cast mounted
in centric relation.
• The accessory Hanau-Mount Split-Cast Mounting
Plate is illustrated on the Upper Member of the
Hanau Articulator A.
• This split cast allows rapid cast removal and
accurate replacement during the survey.
• It also provides a visual guide for adjustment of the
Articulator to protrusive or lateral interocclusal
relation records.

39. METHODS TO ACHIEVE HARMONIOUS BALANCED
OCCLUSION
Many techniques have been described but all of them basically fall into two categories.
• There are basically two technique:-
1. Functional chew in techniques :Those that dynamically equilibrate the occlusion
by use of functional generated path.
2. Articulator equilibration techniques: Those that statistically equilibrate the
occlusion using an articulator programmed to simulate the patient’s jaw movement.

40. 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
• Mental competence to effectively co-operate.
a. Stansbury technique (1928)
b. Vig's technique (1964)
c. Sharry technique
d. Rudd technique

41. STANSBURY TECHNIQUE (1928)
• For upper complete denture opposing lower natural teeth:
• Compound maxillary occlusal rim trimmed buccally and lingually so that occlusion is free
in lateral excursions.
• Carding wax added buccally and lingually and patient instructed to perform chewing
movements.
• Carding wax gets functionally molded whereas the compound rim in the central fossa
maintains the VD.

42. • The generated occlusal rim is
removed from the mouth and
stone is vibrated into the wax
path of the cusps and this
record is secured to the lower
member of the articulator.
• The denture teeth are first set
to the lower cast of the
patient's teeth.
• After esthetics approved at try
in, lower cast chew in record
is secured and all the
interfering spots are ground.
• Thus in centric and eccentric
movements maximus
balanced occlusion is
established.

43. VIG'S TECHNIQUE (1964)
• Preliminary impressions and base
Upper and lower impressions are made,
casts poured and denture base fabricated
with cold cure resin.
• Registration and mounting
 Centric relation at acceptable vertical
dimension recorded
 Anterior teeth are arranged.
 Alginate impression of mandibular teeth is
made.

44. • Preparing the chewing apparatus:
 The wax occlusion rim posterior to cuspid is removed.
 A fin of resin in contact with the central grooves of lower posterior teeth.
• Functional impression and Chew-in
Tissue conditioning resin is added to the impression side.
After ½ hour,
The chewing pattern and impression surface are examined.
• If few areas expose : the resin is trimmed and relined
• If borders are exposed : resin is trimmed and relined
• If border unsupported : build with resin and reline
The wax on the occlusal surface is rebuilt and the base is inserted.

45. SHARRY TECHNIQUE
• Simple technique of using a maxillary rim of softened wax
• Lateral and protrusive chewing movements are made so that wax is abraded generating the
final paths of the lower cusps.
• Continued until the correct VD is achieved.
• Suggests a technique similar to Stansbury’s
• But suggests using two maxillary bases, one for recording the generated path and the other
for setting the teeth.
• Advantage - decreases the number of appointments necessary for the construction of the
upper denture
RUDD TECHNIQUE:

46. 2. ARTICULATOR EQUILIBRATION TECHNIQUES
• If the denture bases lack stability or if the patient is physically unable to perform a chew in
record the articulator equilibration method is preferred
• First the upper cast is mounted on the articulator using a face bow with an orbital pointer
• The lower cast is related to the upper by a centric inter occlusal record at an acceptable
vertical dimension.
• If the denture teeth apex to be placed too far to buccal when articulated with the lower
buccal cusp, they are rest to oppose the lingual cusps.
• Once the holding cusps have been selected the inclines of the remaining cusps are reduced
and vice-versa
• This allows for a cusp to fossa relationship between the upper and lower teeth in centric .

48. • At the time of wax try in eccentric records are made and the condylar inclinations are set
on the articulator
• The upper posterior teeth are arranged to be as close to being balanced as is possible at
this time.
• After the denture has been processed it is again related to the mounted lower cast with a
new centric intra-occlusal record.

49. • The condylar inclinations previously determined are reset on the articulator.
• Once the centric holding cusps are established by selective grinding, eccentric balance
is achieved.
• This is simply accomplished by selectively grinding the interfering buccal and lingual
cuspal inclines of the upper teeth.
• Once the centric contacts have been established it is advisable to use two colors of
articulating paper. One colour to mark the centric contacts and other to mark the
eccentric contacts.
• The eccentric contacts are selectively ground until a relatively continuous area of
contact is noted on the buccal and lingual cuspal inclines of the upper teeth.

50. TEETH SELECTION
• The most important aspects are to transmit the occlusal forces vertically.
• Non – anatomic teeth: If the cusps of the natural teeth have been reduced either naturally
or artificially to such a degree that their occlusal surface are fairly flat, then non anatomic
teeth maybe used on the denture.
• These teeth have flat occlusal surfaces with fissures and spillways carved into them which
help to provide an effective masticating surface.
• Anatomic teeth: If the cuspal form of the lower teeth has been retained anatomic teeth can
be used
• These should be arranged with a cusp to fossa relation.
• A small space distal to the cuspid looks quite natural in an upper denture, spaces between
the posterior teeth provide extra channel for the escape of food from the occlusal surfaces

51. ARTIFICIAL TEETH MATERIALS
• The materials available for occlusal posterior tooth forms are :
• Porcelain
• Acrylic teeth
• Gold
• Acrylic resin with amalgam stop
• IPN
Schultz
• Showed that the chewing efficiency of acrylic resin teeth was 26-35% less than that of
porcelain teeth.
• Chewing efficiency of acrylic resin teeth with gold occlusal surface is equal to that of
porcelain teeth.

52. 1. PORCELAIN TEETH
• Porcelain teeth wear slowly therefore the occlusal vertical dimension is maintained
however they are predisposed to fracture and chipping when opposed by natural teeth
and are more difficult to equilibrate.
• Also they cause rapid wear of opposing natural teeth.
• Advantages:
1. Maintains Vertical direction
2. Wears very slowly
• Disadvantages:
1. Fracture and chipping of natural teeth
2. Difficult to equilibrate
3. Cannot be used in decreased inter-occlusal distance

53. 2. ACRYLIC RESIN TEETH
• Since acrylic resin teeth
cause no wear of the
opposing natural teeth
they are the easiest to
equilibrate
• They are the teeth of
choice.
• The major disadvantage of
resin teeth is there wear,
which result in loss of
vertical dimension.

54. 3. GOLD OCCLUSAL:
• The best material for an artificial occlusion
opposing the natural teeth is gold
• A technique described by Wallace in 1964
• The occlusal surfaces of the posterior
acrylic denture teeth are then reduced by
about 1mm and a central channel is cut
posteriorly along them
• The wax patterns are cast in gold and
cemented with self cure acrylic resin.

55. Dentures made in usual
manner using acrylic
resin posterior teeth.
Remounted on articulator-
occlusal
disharmonies removed by
selective
Grinding
Denture finished and
patient is allowed
to wear them for 3-4
weeks
With dentures in mouth

Impression is made with
irreversible
hydrocolloid
Denture in impression
apply
petroleum jelly dental
stone
poured into the denture.
Buccal and palatal surfaces are
covered with clay, all undercuts
are blocked and lingual 1mm
reduction is done.
Counter die is
poured

56. Grooves are made 3mm
deep in the anterioposterior
direction. And a hole of
depth 3mm in the centre
Counter die
Wax patterns are made
and sprues are
attached
Castings are
cemented

57. 4. ACRYLIC RESIN WITH AMALGAM STOPS
• This method is established by Frank R. Lauciello.
• Advantages:
• Reduces occlusal wear of resin teeth
• Less expensive then gold
• Facilitates the final staeges of occlusal adjustment
Procedure:
• After the acrylic teeth have been balanced, occlusal preparations are made in the acrylic
teeth, extending to include as much of the articulating paper tracing as possible.
• Amalgam is condensed into the preparations and the articulator is gently closed, going side
to side, and back and forth until the incisal guide pin is again flush with the table.
• Thus the centric holding areas as well as some of the excursions are recorded in amalgam
by the articulator that has been programmed to closely simulate the patients jaw movements.

59. 5. INTER PENETRATING POLYMER NET WORK
(IPN)RESIN
• This material consist of an unfilled, highly cross linked inter penetrating polymer network.
• Prevents excessive wearing of artificial teeth
• Minimizes the disadvantage of acrylic resin teeth and porcelain
• A three year clinical study by ogle and his colleagues, has determined the wear of new
material to be significantly less when compared to acrylic resin teeth.

60. POTENTIAL ADVERSE TREATMENT OUTCOMES
• Most common adverse sequelae are:
1.Kelly’s combination syndrome
2.Denture fracture
3.Tooth wear

61. 1. KELLY'S COMBINATION SYNDROME
• 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 has been
described as "combination syndrome" by Kelly.
• According to GPT 8 :-
• The characteristic feature that occurs when a edentulous maxilla is opposed by natural
mandibular anterior teeth including loss of bone from the anterior portion of maxillary ridge
, overgrowth of the tuberosities ,papillary hyperplasia of hard palate ‘s mucosa , extrusion of
lower anterior teeth & loss of alveolar bone & ridge height beneath the mandible removable
dental prosthesis bases- also called as anterior hyperfunction syndrome.

62. • Description of
features Kelly (1972)
put forward five
features of
combination
syndrome:
1. Loss of bone in
anterior maxilla
and subsequent
replacement with
flabby fibrous
tissue
2. Down growth of
the tuberosities
3. Papillary
hyperplasia of the
palate
4. Lower incisors
supra eruption

63. • Saunders et al (1978)
added 6 more
additional features:
1. Loss of vertical
dimension
2. Occlusal plane
discrepancy
3. Anterior spatial
repositioning of the
mandible
4. Loss of stability and
refabrication of the
existing dentures
5. Epulis fissuratum
6. Periodontal problems
of the remaining teeth

65. • Mechanics:
• 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

66. • Systemic and Dental Considerations:
a. Systemic factors: Diabetes and osteoporosis increase the rate of resorption of the bone.
b. Dental factors:
1. In case of class III jaw relationships, there will be increased pressure in the anterior maxilla.
2. When lower anteriors are retained for a long time, the patient is accustomed to bite in the
anterior region.
3. Presence of parafunctional habits increases bone resorption.
4. Type of occlusal scheme also has direct effect on the development of the syndrome.
• Rationale:
1. Prevention of rapid resorption of the bone under the removable prosthesis
2. Prevention of excessive load in the anterior region
3. Providing stable occlusal scheme
4. Allowing anterior teeth only for phonetics and esthetics
5. Education of the patient

67. TREATMENT PLANNING
• Treatment planning plays an important role in the prevention and management of the
combination syndrome.
a. Prevention
1. Retain weaker posterior teeth by using combined endodontic and periodontal techniques.
2. Endosseous endodontic implants are used in the posterior mandibular region.
3. An overlay denture on the lower may avoid the combination syndrome.
b. Modifications in removable partial denture and complete dentures
1. Kelly - advocated covering of retromolar pad to have stability of the lower removable partial
denture
2. Schumitt - advocated construction of lower removable partial denture first and then to
construct the upper complete denture

68. c. Choice of occlusion
1. Anterior teeth - only for esthetics and phonetics
2. Posterior occlusion - free of supra contacts during centric and all eccentric positions
3. During protrusive movement, there should be minimum contact in the anterior region, when
posterior teeth are in contact.
d. Over dentures
1. Lower anterior teeth are treated endodontically and their height is reduced.
2. This can be used for proprioceptive sensation of the lower jaw and prevents resorption of
the underlying bone.
3. Langer advocated the use of "stud attachments" in over denture
e. Implant - supported prosthesis
1. Implants in the posterior region of the mandible to decrease the residual ridge resorption

69. f. Surgical consideration
1. Kelly advocated surgical excision of the maxillary tuberosity fibrous growth to establish
proper occlusion.
2. Treating the combination syndrome requires recognition of the factors involved.
3. Frequent recalls visits and check ups with frequent relining to compensate for the
resorption especially in the lower distal extension prosthesis.
4. Educating the patient about the possible outcome of the treatment and better
understanding of the syndrome so that patient cooperates with the dentist.

70. 2. DENTURE FRACTURE
• Specific conditions:
1. Heavy anterior occlusal contact
2. Deep labial frenal notches
3. High occlusal forces due to strong mandibular elevator musculature
4. If the clinician is unable to control these factors or the fracture potential is high, a cast
metal base is best used to resist deformation and fracture.

71. PREVENTION
Fiber Force is a fiberglass mesh composite resin
Metal meshwork

72. CARBON FIBRES Carbon fibers can be added to PMMA as loose strands or
in woven mat form.

73. 3. TOOTH WEAR
• Use of porcelain material opposing the natural teeth will wear away the tooth structure.
Hence the material selection is according to the opposing material to avoid this adverse
effect.

74. MAINTENANCE VISIT:
• Verification of occlusal contact relationships
• Condition of the supporting tissues
• And compulsory recalls for relining depending on the
supporting tissues.

75. RECENT ADVANCES
• An implant-supported fixed dental prosthesis is one of the treatment options for an individual
with a completely edentulous maxilla.
• However, a screw-retained or cemented prosthesis can make oral hygiene difficult, especially
for patients with a history of periodontal disease or disabilities.
• Compared with maxillary fixed dental prostheses, implant-supported overdentures offer
similar retention and function and facilitate esthetics, phonetics, and hygiene.
• The prosthetic rehabilitation of a patient was done with an edentulous maxilla and a severe
maxillomandibular discrepancy that involved the use of a novel prefabricated telescopic
system to retain an implant-supported removable dental prosthesis.

76. DIGITAL COMPLETE DENTURE
• The workflow presented provides a proof of concept that an optical intraoral scan of the
edentulous maxilla is feasible and that a functional single-arch maxillary denture can be
designed and fabricated using a digital protocol.
Preoperative conditions. Intraoral
scan of maxilla.

77. Occlusal records. A, Design
of baseplate for occlusion
rim. B, Occlusion rim made
with wax mounted on
baseplate obtained with 3-
dimensional printing,
adapted to patient in order to
register information for teeth
arrangement, as well as
maxillo-mandibular relation
Alignment of digitalcasts to
occlusal rim. A, Accuracy of
alignment:cross-sectionon
sagittaland frontal plane. B,
Frontal view of aligned casts.

78. Denture design.
A, Teeth selected from
available libraries and
position modified according
to desired occlusal concept
and information integrated in
occlusion rim.
B, Occlusion evaluated and
modified in virtual articulator:
digitally calculated dynamic
occlusion.
C, Finalizing design of both
teeth and denture base.
Production phase. A, Denture
base milled. B, Intaglio surface
of milled denture base.

79. Denture delivery.
A, Definitive denture ready to be
delivered.
B, Intraoral dynamic occlusion.
C. Patient with definitive denture.

80. CONCLUSION
• The problems involved in providing comport, function, proper esthetics and retention is a
vigorous challenge for practicing dentist.
• The damage to the edentulous ridge and inability to wear the denture may be avoided by
good prosthetic treatment which includes adequate denture base, correct jaw relation record
and proper occlusion.
• The patient who requires a single denture opposing a natural or restored dentition
challenges the clinician even more than the completely edentulous patient does.
• This is due to the biomechanical differences in the supporting tissues of the opposing
arches.
• So a proper evaluation, correction of the existing factors and proper sequence of denture
construction is necessary to give a more stable prosthesis.

81. REFERENCES
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5. Langer Y et al. Modalities of Treatment for the Combination Syndrome. JOP 1995: 4; 76 - 81.
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Prosthet Dent 1972: 27; 140 -150.
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system: A clinical report. The Journal of prosthetic dentistry. 2017 Mar 1;117(3):331-4.
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