Reconstructive and Implant Dental Center - Kansas City                                                                                            Phone: 913-492-2233          Fax: 913-492-2234                 Office Information Video              




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

 Combination Syndrome   Combination Syndrome 1

"Classic "Combination Syndrome"

§1. All maxillary teeth missing.
§2. Advanced bone loss premaxilla with soft tissue replacement.
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

Combination Syndrome 2

Pre-Operative: Radiograph with Advance Bone Loss Maxillae & Mandible


Combination Syndrome 3     Combination Syndrome 4     Combination Syndrome 5

Original appearance WITHOUT Maxillary and Mandibular prosthesis in place and inadequate facial support


Combination Syndrome 6   Combination Syndrome 7   Combination Syndrome 8

Original appearance WITH Maxillary and Mandibular Prosthesis in Place Demonstrating
Inadequate Facial Support and Improper Plane of Occlusion.



§1. PRE-SURGICAL/ PROSTHETIC PLANNING: Prostheses completed prior to surgery with image capturing & referencing.
§  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. 


Combination Syndrome 9

Pre-operative Radiograph for Treatment Planning with Diagram Showing
Approximate Position of Implant Connecting Bar and Plane of Occlusion.


Combination Syndrome 10

Pre-operative:  SimPlant 3-D image Software Used for Treatment Planning.


Combination Syndrome 11

Pre-operative:3-D Moveable Translucent Image with Simulated Implant Placement.


Combination Syndrome 12

Pre-operative: 3-D Moveable Translucent Image Simulated Alveoplasty with Simplant Program


Combination Syndrome 13

Pre-operative: Cross Sectional Oblique Image Aids in Determining Ideal Implant Diameter.


Combination Syndrome 14    Combination Syndrome 15

Pre-operative: Fig 1. New OVD with Original Lower Teeth                Fig 2. Upper Denture Set-Up with New OVD

Combination Syndrome 16 

Pre-operative: Fig 3. Lower Denture Set-Up with Denture Teeth Matching Original Tooth Position


Combination Syndrome 17Combination Syndrome 18Combination Syndrome 19

       Appearance At a Younger Age       Appearance as Patient Presented        Smile at Wax Try-in Prior to Surgery        


Combination Syndrome 20   Combination Syndrome 21

Pre-Operative Photograph                             One Day Post Surgery

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.

Combination Syndrome 22

Day After Surgery: The Soft Tissue Takes on the Created Shape of the Inner Surface of the Denture. 
Denture Must Fit Grafted Tissue Loosely on Its Inner Denture Surface. 


Combination Syndrome 23

 Six Months Post-Operatively:  Maxillary Tissue is No Longer Loose, Now Has Load Bearing Capabilities.


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.


Combination Syndrome 24

Same Day of Surgery.  Alveoplasty with 3-D Implant Placement & Grafting. 

Immediate Loading Length Determined by Bone Density.  (MIS) Minimal Invasive Surgery.


Combination Syndrome 25

Day of Surgery.  M.I.S. Allows for Final Impression for Implant Connecting Bar. 
Polyether Material of Choice for Final Impression.


Combination Syndrome 26

Day of Surgery.   M.I.S. Allows for Final Impression for Implant Connecting Bar. 

Polyether Material of Choice for Final Impression.


Combination Syndrome 27

Day of Surgery:  Minimal Invasive Surgery Contributes to Rapid Healing. 

PRP Platelet Rich Plasma used with Decreased Healing Time.

Combination Syndrome 28

Day of Surgery: Soft Liner Placed Day of Surgery, Patient Never Without Teeth.


Combination Syndrome 29

Post-Op Surgery: Radiograph Taken Day After Surgery


Combination Syndrome 30    Combination Syndrome 31

Post-Op Surgery: Implant Connecting Bar Constructed & Placed on Third Day.  Post-Op:  Six Months Follow-Up.


Combination Syndrome 32

Third Day Following Surgery:  Final Impression Taken Day of Surgery.  Bar Try-In & Jaw Relationship Day 3


Combination Syndrome 33

Six Months Post-Op: Completed Mandibular Implant Therapy with Posterior Supported Occlusion


Combination Syndrome 34

Five Year Post-Op: Radiograph with Load Bearing Maxillary HA Grafted Ridge


Combination Syndrome 35

Five Year Post-Op: "I-CAT" Radiograph with Cross Sectional Areas of Maxillary HA Grafted Ridge 


Combination Syndrome 36   Combination Syndrome 37

             Pre-Operative Picture                                                       6-Months Post-Operative Picture      



"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.
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



Rapid & Predictable Correction
Surgical/Prosthetic Considerations



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.

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.