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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.
Total Active
Treatment Time for case shown, about 2 weeks
"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
Original appearance with upper and lower prosthesis NOT in place
demonstrating inadequate facial support
Original appearance with upper and lower 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 for treatment planning.
3-D moveable translucent image with simulated implant placement.
Simulated Alveoplasty with Simplant program
Cross sectional oblique image aids in determining ideal implant
diameter.
Appearance at a younger age
Appearance as patient presented
Smile at wax try-in prior
to 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.
§
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.
of the inner surface of
the denture.
Patient’s maxillary dental arch six months
post-operatively
Maxillary tissue is no longer loose,
now has load bearing capabilities
Patient's maxillary dental arch six months post-operatively.
Maxilla
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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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Day of surgery. Alveoplasty with 3-D implant placement & grafting.
Immediate loading length determined by by bone density.
Minimal Invasive Surgery.
Day of Surgery. M.I.S. Allows for final impression for implant
connecting bar.
Polyether material of choice for impression.
Day of Surgery. M.I.S. Allows for final impression for implant
connecting bar.
Polyether material of choice for impression.
Day of surgery. Minimal Invasive Surgery contributes to rapid
healing.
PRP Platelet Rich Plasma increases rate of
healing.
Soft liner placed day of surgery. Patient never
without teeth.
Post-Operative radiograph taken day after surgery
Implant connecting Bar constructed & placed on third day
Impression taken day of surgery. Bar inserted two days later
Completed Mandibular Therapy with Posterior Supported Occlusion
Six Months Post-Op
Pre-Operative Picture
6-Months Post-Operative Picture
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