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Combination Syndrome
&
corrective
treatment
COMBINATION SYNDROME,
is a
description of a dental condition that is the result of long term use of a few,
usually (6) remaining lower anterior teeth, #22-27 and a complete
upper denture with no other natural remaining teeth and a lower free end Kennedy
class I removable partial denture. The normal biting pressure or forces
are directed from the remaining lower 6 teeth and transmitted through the upper
anterior denture, with resulting resorption of bone and slow
auto-rotation & tilting
of the denture upward and backward,
with the upper anterior teeth becoming less visible and
the upper posterior teeth becoming more visible as the denture is rotated from
function with bone loss of the premaxilla.
There may be seven characteristics
associated with this syndrome: 1. Bone loss in the premaxilla.
2. Dropping of the posterior maxilla (tuberosities).
3. Extrusion of the lower anterior teeth.
4. Posterior bone loss in the mandible under the RPD. and
5. Papillary hyperplasia of the
maxilla. 6. Decreased Occlusal Vertical Dimension.
and 7.
Facial aesthetics often altered
dramatically.
The change in facial aesthetics from the resulting combination syndrome is a
challenge to restore with traditions dentistry,
as the prosthetic solutions are limited, the age of the
patient is often a limitation, and financial costs are of concern. A technique
that decreases treatment time and costs with excellent aesthetic result is
presented below.
The
treatment time can be reduced to ONE SURGICAL VISIT in many cases, with all
treatment completed in one week with follow-up visits needed
approximately once a week for several weeks.
All Surgery Done in One Day:
Total Active
Treatment Time for case shown, about 2 weeks
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"Classic "Combination Syndrome"
§1.
All maxillary teeth missing.
§2.
Advanced bone loss premaxilla with
soft tissue replacement.
§3.
Six or
more mandibular anterior teeth present, long term use
Kennedy class 1 RPD and advanced
bone loss posterior mandible.
4. OVD Much less than ideal, need to
change 15mm.
5.
Facial aesthetics altered dramatically
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Pre-Operative: Radiograph with Advance Bone Loss
Maxillae & Mandible
Original appearance WITHOUT Maxillary and
Mandibular prosthesis in place
and inadequate facial support
Original appearance WITH Maxillary and
Mandibular Prosthesis in Place Demonstrating
Inadequate Facial Support and Improper Plane of Occlusion.
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SEQUENCE FOR
ONE
APPOINTMENT
SURGICAL TREATMENT
§1.
PRE-SURGICAL/
PROSTHETIC
PLANNING:
Prostheses completed prior to surgery with image capturing &
referencing.
§2.
SURGICAL/
PROSTHETIC
PHASE:
§
a.
Maxillary “PermaRidge” grafting completed first c
upper immediate
denture ready for insertion.
§
b.
Extractions, Alveoplasty, & insertion of mandibular
implants & healing abutments c immediate lower denture &
soft liner ready for insertion.
§
c.
Minimal
Invasive
Surgical
technique allowing surgical correction and
final implant connecting bar impression
the day of surgery.
§3.
ANESTHETIC CONSIDERATIONS:
Appointment
length c surgery, need for sedation dentistry.
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Pre-operative Radiograph for Treatment
Planning with Diagram Showing
Approximate Position of Implant Connecting Bar and Plane of Occlusion.
Pre-operative: SimPlant 3-D image
Software Used for Treatment Planning.
Pre-operative:3-D
Moveable Translucent Image with Simulated Implant Placement.
Pre-operative: 3-D
Moveable Translucent Image Simulated Alveoplasty with Simplant Program
Pre-operative: Cross
Sectional Oblique Image Aids in Determining Ideal Implant
Diameter.
Pre-operative:
Fig 1. New OVD with Original Lower Teeth
Fig 2. Upper Denture Set-Up with New OVD
Pre-operative:
Fig 3. Lower Denture Set-Up with Denture Teeth Matching Original Tooth Position
  
Appearance At a Younger
Age Appearance as
Patient Presented
Smile at
Wax Try-in Prior
to Surgery
 
Pre-Operative Photograph
One Day Post Surgery
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Grafting
SOFT TISSUE
with
Hydroxylapatite
§1.
Two incisions are made in area of the cuspids through
keratinized tissue to the bone.
§
2. A series of instruments
are first used in the
posterior segments to tunnel and raise the periosteum off
the bone, to the length required, then in the anterior
segment.
§
3.
Next straight taper instruments
are used to enlarge the tunnel and dilate the tissue,
creating room for the “Permaridge” HA graft.
§
4.
Next a cutting osteotome is used to plane the bone in the
tunnel, smoothing out the rough areas, creating a smooth
passage.
§
5. Finally the graft
carriers are used to carry either the 4.5mm or 6.0mm
sections of the “Permaridge” HA graft.
4-0 gut sutures are then used to close the two
openings.
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.
.
Day After Surgery:
The Soft Tissue Takes on the Created Shape of the
Inner
Surface of the Denture.
The
Denture Must Fit Grafted Tissue Loosely on
Its Inner Denture Surface.
Six Months Post-Operatively:
Maxillary Tissue is No Longer Loose,
Now Has Load Bearing Capabilities.
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Grafting SOFT TISSUE with Hydroxylapatite for Reconstructive
Success
1. Soft Tissue Graft must
not be loaded during healing by immediate maxillary denture.
2.
Vestibule, hard palate, and remaining non-grafted tuberosities support
the maxillary immediate denture.
3. KEY TO
SUCCESSFUL GRAFTING: is the change in occlusal forces with an unloaded HA
graft. Six surgical instruments are used to create an ideal site. The denture supports the graft and the totally implant supported
mandibular prosthesis allows control of the occlusal forces to the
grafted ridge.
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Same Day of Surgery. Alveoplasty with 3-D
Implant Placement & Grafting.
Immediate Loading Length Determined by Bone Density.
(MIS) Minimal Invasive Surgery.
Day of Surgery. M.I.S. Allows for
Final Impression for Implant Connecting Bar.
Polyether Material of Choice for Final Impression.
Day of Surgery. M.I.S. Allows for
Final Impression for Implant Connecting Bar.
Polyether Material of Choice for Final Impression.
Day of Surgery: Minimal Invasive Surgery
Contributes to Rapid Healing.
PRP Platelet Rich Plasma used with Decreased Healing Time.
Day of Surgery: Soft
Liner Placed Day of Surgery, Patient Never Without Teeth.
Post-Op
Surgery: Radiograph Taken Day After Surgery
Post-Op
Surgery: Implant
Connecting Bar Constructed & Placed on Third Day.
Post-Op: Six
Months Follow-Up.
Third Day Following Surgery:
Final Impression Taken Day of Surgery. Bar Try-In & Jaw
Relationship Day 3.
Six Months Post-Op:
Completed Mandibular Implant Therapy with Posterior Supported Occlusion
Five Year Post-Op: Radiograph with Load
Bearing Maxillary HA Grafted Ridge
Five Year Post-Op: "I-CAT" Radiograph with
Cross Sectional Areas of Maxillary HA Grafted Ridge
Pre-Operative Picture
6-Months Post-Operative Picture
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SURGICAL/PROSTHETIC CORRECTION
"Classic "Combination Syndrome"
§1.
Maxillary teeth repositioned
for normal overjet/overbite and aesthetics.
§2.
Advanced bone loss premaxilla
corrected with H.A. soft tissue graft.
§3.
All
mandibular anterior teeth removed and replaced with implant
connecting bar and totally implant supported mandibular
overdenture.
4. OVD
More ideal, changed approximately 15mm.
5.
Facial aesthetics improved dramatically
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Rapid & Predictable
Correction
COMBINATION SYNDROME
Surgical/Prosthetic Considerations
KEYS TO SUCCESS ARE:
§
1.
Simplified HA grafting
procedure with the use of surgical
instruments to create ideal
sites.
2.
Immediate maxillary denture which supports the graft and
allows uneventful healing.
§
§
3.
Controlled occlusal forces on the “PermaRidge” HA graft
with denture support from tuberosities, hard palate &
vestibule.
4.
Finally, the
totally implant supported
fixed/removable mandibular prosthesis provides
control of the occlusal
forces.
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