Changes

caused
denture oppesing

by a mcmd
a muxitkwy

Ellsworth
Kelly, D.D.S.*
School of Dentistry, Uniuersity

of California,

r remov
p4BHkll
compbe
de&we

San Francisco,

Calif.

lthough many advances have been made in denture prosthetics,

the great problem is still with us: coping with the resorption
of the residual alveolar ridge and
managing
or preventing
the secondary soft tissue changes brought
on by bone loss.
The resorption
occurring
beneath denture bases has been investigated*-
and we
have some knowledge
of the rate of resorption
of the residual bony ridge. Investigators agree that individual
differences
in the rate of resorption
of the ridges are
very great. Underlying
metabolic,
hormonal,
and nutritional
causes account for this
difference and we know very little about these factors.
knowledge
From clinical experience and clinical studies,lj l1 we have considerable
of the prosthetic
factors which influence
bony resorption.
We know that moderate,
intermittent
forces exerted on the bony ridge by a prosthesis may be stimulating
and
help preserve rather than destroy the bony ridge. l2 We know that excessive force
causes resorption
of the residual ridge. De Van I3 stated that compressive forces are
well tolerated by the edentulous
ridges while shearing forces are not. This concept has
been utilized
by many techniques
which minimize
the lateral forces exerted by
dentures. The principle
of wide coverage with the complete
or partial
removable
denture base to minimize
the force per unit area is basic14 and has served us well.
Yet we are not able to do anything for those people who are very susceptible to bone
loss because of underlying
systemic causes and who, in spite of our best efforts, often
end up with very little bone remaining.
On the other hand, we do have the knowledge
to prevent excessive bone loss from traumatic
forces exerted by or on the denture
bases. Observation
of a number of denture patients will show that we are failing to
put this knowledge
into practice.
Destruction
of the residual
ridge from occlusal
trauma
is not uncommon.
Very common is the almost total loss of bone in the
anterior part of the maxillae brought about by only natural anterior teeth remaining
in the mandible
and occluding
with a compelte
upper denture. The anterior
part
of the maxillae
is the weakest part of the upper arch to resist stress and when the
Read

before

*Professor

140

the Academy
of Removable

of Denture
Prosthodontics.

Prosthetics

in Detroit,

Mich.

Volume
Number

27
2

Partial

Fig. 1. A maxillary
anterior
teeth and
tion often effects.

arch that has supported

a Class I partial
denture

denture

opposing

complete denture

141

a complete
upper denture
against six natural
lower
for 14 years shows the changes that this combina-

lower anterior teeth occlude anterior to the basal support, trauma is inevitable. Many
of these patients have distal-extension
partial lower dentures but this does not seem
to prevent this type of destruction
in the upper jaw. The degenerative
changes, in
these patients include more than the loss of bone. An overgrowth
of the maxillary
tuberosities
often occurs. These enlargements
are usually fibrous but they may be
bony enlargements.
Papillary
hyperplasia
of the palatal mucosa may occur concurrently. The remaining
mandibular
anterior
teeth seem to extrude along with the
bony process, and excessive bone loss occurs in the posterior part of the ridge under
the partial
denture bases. These five changes may constitute
a syndrome,
as they
are quite characteristic.
These changes are (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, and (5) the loss of
bone under the partial denture bases. I call this the combination
syndrome.
COMPLETE

UPPER

DENTURES

OPPOSING

PARTIAL

LOWER

DENTURES

Completely
edentulous
maxillae
and partially
edentulous
mandibles
anterior
teeth remaining
are common situations.
In the past two years,
patients treated in the prosthodontic
clinic at the School of Dentistry of the
of California
received complete
maxillary
dentures
opposing
mandibular
dentures. This represents 26 per cent of the denture patients. Some of
dentures had distal support but most of them did not.
THE COMBINATION

with only
130 of 495
University
partial
the partial

SYNDROME

The early loss of bone from the anterior part of the maxillary
jaw is the key to
the other changes of the combination
syndrome. With the anterior
loss of bone, a
flabby hyperplastic
connective
tissue makes up the anterior
part of the ridge. This
hyperplastic
tissue does not support the denture base and usually it folds forward,

142

.I. Prosthet.
February,

Kelly

Fig. 2. Mounted
diagnostic
casts show bony loss and
upper anterior
region, enlarged
tuberosities,
and extruded

rolled
lower

(hyperplastic)
anterior
teeth.

soft

tissue

Dent.
1972

in

the

Fig. 3. With
the loss of anterior
maxillary
bone, overgrowth
of the tuberosities,
and upward
migration
of the lower anterior
teeth, the patient
shows no upper anterior
teeth but does show
upper
posterior
teeth because
of the dropping
of the distal end of the occlusal
plane of his
dentures.
a characteristic
deep fold or crease (Fig. 1). As bone and ridge height arc
lost anteriorly,
the posterior residual ridge becomes larger with the development
of
enlarged
tuberosities.
These enlarged
tuberosities
are usually made up of fibrous
tissue,
but in some patients the bone height seems to have increased also. With these
changes, the occlusal plane migrates up in the anterior region and down in the back.
After a time, the natural
lower anterior
teeth migrate upward,
the anterior
teeth
on the complete denture disappear under the patients lip, and both dentures migrate
downward
in the posterior
region. The esthetics are poor with the patient showing
none of the upper anterior teeth and too much of the lower anterior teeth, and the
occlusal plane drops down to expose the upper posterior teeth (Figs. 2 and 3 i .
Excessive bony resorption
under the lower removable partial denture bases occurs
to permit these changes, and often inflammatory
papillary
hyperplasia
develops in
the palate (Fig. 4).
The histopathology
of the hyperplastic
anterior ridge tissue, and the fibrous tissur
which develops over the tuberosities
is revealing.
Microscopic
examination
of these
tissues shows that the flabby tissue and the hard tissue over the tuberosities
are indistinguishable.
They are made up of mature, dense, fibrous connective
tissue. This
tissue in both locations has dense bundles of collagen fibers, with relatively few ceilular elements, with very few inflammatory
cells. It is rather avascular with an overlying epithelium
that is almost normal,
but shows some evidence of hyperplasia
(Fig. 5). This is also the histopathology
of a mature epulis fissuratum if we discount
the area of ulceration
caused by the denture border. This similarity
is surprising
because the hyperplastic
anterior
tissue is freely movable while the fibrous tissue
over the tuberosity is hard. However, all three of these conditions
(the flabby anterior
forming

Volume
Number

Partial

27
2

Fig. 4. Papillary
bination
syndrome.

hyperplasia

ridge, the fibrous

trauma from the
same is logical.
The difference
must be explained
appeared and the
ally unsupported
over the tuberosity
MECHANICS

in

the

palate

denture

often

opposing

accompanies

the

complete

other

denture

changes

143

of the com-

tuberosity,
and the epulis fissuratum)
are the result of prolonged
denture base. Therefore,
the fact that the tissue response is the
in consistency of fibrous tuberosities
and flabby anterior
ridges
on a mechanical
basis. The anterior bony ridge has virtually
disconnective tissue replacement
is a narrow projection
of tissue virtuon the labial or lingual surface. On the other hand the fibrous tissue
is supported by a broad base of bone below.

WHICH

PRODUCE

THE COMBINATION

SYNDROME

The resorption
of the bone in the anterior region initiates the changes which we
call the combination
syndrome.
Natural
anterior
maxillary
teeth have increased
bony resorption
under maxillary
dentures. + 5 While bone is being lost in the anterior
region in the upper jaw, bony resorption
also occurs under the mandibular
partial
denture
bases. The maxillary
denture then moves up in the anterior
region and
down in the posterior
region in function.
This tipping
action is illustrated
in the
diagram
(Fig. 6) which was traced from cephalometric
radiographs
of a patient who
had been wearing a complete upper denture opposing a lower partial denture for 16
years. The fulcrum of movement in this patient is in the cuspid-first
bicuspid region,
Our patients show that at first the fulcrum is well to the posterior, just anterior to
the tuberosity.
With the posterior palatal seal, a negative pressure is produced
posterior
to the
fulcrum
line. This negative pressure may account for the enlarged tuberosities
and
the papillary
hyperplasia.
Carlssonl observed one patient who had an increase in
the maxillary
ridge height in the molar region after wearing dentures for two years.
He postulated : It may have been due to the development
of a fibrous part possiblyl owing to the suction effect when the denture moved. A number of authors15-1r
have associated a void, a suction chamber,
or other form of negative pressure with

144

Kelly

Fig. 5, A & B. Histologic

sections
of the
(x100)
; (B) fibrous tuberosity
(x100).

lesions:

(A)

A flabby

(hyperplastic)

anterior

ridge

inflammatory
papillary
hyperplasia
of the palate. Wictorin
states that to prevent
bony resorption,
mechanical
forces must be distributed
over as large an area of the
basal seat as possible, and the denture must make as little movement
as possible
against its basal seat, and that these factors are strongly interconnected.
With the
lower anterior
teeth causing trauma and bone loss from the anterior
part of the
maxillae, and with the denture base moving more and more on its foundation,
a very
destructive
situation exists.
All kinds of questions come to mind. How fast do the degenerative
changes develop? Is excessive bone loss in the anterior
part of the maxillae
with the other
changes that follow inevitable
or does it occur only in neglected
patients, those
without proper follow-up
treatment in refitting the denture bases and readjustment
of

z%zr
2

Partial

denture

opposing

Fig. 5, C & D. (C)

Inflammatory
papillary
hyperplasia
similarity
of A (hyperplastic
ridge tissue)
and B (fibrous
The papillary
hyperplasia
shows (n) the fibrous
core, (b)
inflammatory
cells.

complete

denture

145

(x40) ; (D)
the same (x100).
The
tuberosity)
is discussed
in the text.
the hyperplastic
epithelium,
and (c)

occlusion? If it is from neglect, what kind, and what amount of care is necessary to
prevent it? Will the changes occur in all patients or only in susceptible patients with
underlying
metabolic, hormonal,
or nutritional
deficiency?
PATIENT

HISTORIES

WITH

CEPHALOMETRIC

RADIOGRAPHS

In an effort to find answers to some of these questions, we started a study of 20

patients who were receiving complete maxillary
dentures opposing distal-extension
removable
partial dentures. Only six of these patients have returned
faithfully
over

146

J. Prosthet.
Frbruary,

Kelly

Dent.
1972

Fig. 6. A diagram
made from tracings
from two cephalometric
radiographs,
one at physiologic
rest position
and the other with the teeth in centric
occlusion.
In this patient,
with an advanced
combination
syndrome,
the movement
of the denture
base is very great,
causing
positive
pressure anterior
to the fulcrum
(F) and negative
pressure
posterior
to this position.

Fig. 7. A lateral
cephalometric
the soft tissues of the ridge.
Fig. 8. The lead
and is very slightly

wire is in
embedded

radiograph

of one of the subjects

place after the radiograph

into the soft tissue.

shows

was made.

The

the lead wire

lead

wire

outlining
adheres

to

a three-year
period so no conclusions
can be drawn from this preliminary
report.
We made serial cephalometric
radiographs
with a 0.25 mm. diameter
lead wire
outlining
the soft tissue on the right side of the ridge (Figs. 7 and 8). All of the
patients
received maxillary
complete
immediate
dentures
opposing
Class I lower
partial dentures. All were first-time
denture wearers. The immediate
dentures were
constructed
after the posterior
teeth had been extracted
and a healing period allowed. The first radiograph
was made after the initial healing of the anterior part
of the maxillary
ridge had taken place, and after the anterior
section of the immediate denture
had been refitted with cold-curing
acrylic resin. This was usually
about four weeks after insertion of the dentures.

Volume
Number

27
2

Partial

denture

opposing

complete

denture

147

Fig. 9. Cephalometric
and show the
and soft tissue,

tracings
of each of the six subjects.
They were made three years apart,
changes
that have occurred.
The solid lines show the initial
outline
the bone
the dotted lines indicate
these outlines
three years later (Table I).

A second radiograph
was made after six to eight months. The patients were
seen regularly
over the first few months, and the dentures refitted and serviced as
needed. After the first year, the third radiograph
was made. At this time, the maxillary denture was relined or a new denture was constructed.
After this, the patients
were called annually for examination
and radiographs.
Measurements
were made directly on the radiographs,
using the sella-nasion
line
as a base. The results are expressed as millimeters
of increase (plus) or millimeters
of decrease (minus)
in the residual ridge height. Table I shows these data for the
maxillary
bone and soft tissue.
Tracings
were made from the cephalometric
radiographs.
These show the
changes graphically
but not as accurately as the measurements
directly on the radiographs (Fig. 9).
All of the patients showed a loss of 1 to 3 mm. of ridge height in the anterior
region. All of the subjects showed a loss of the underlying
bone as well. All of the
subjects showed an increase of 1 to 2.5 mm. height of the tuberosity with all but
one having a corresponding
increase in the height of the underlying
bone. One subject had an increase in the height of the tuberosity
but a slight loss of underlying
bone. All of the subjects show a 1 .O to 1.5 mm. extrusion of the lower anterior teeth.

148

J. Prosthet. Dent.
Februaty,
1972

Kelly

Fig. 10. One of the subjects,

although
given follow-up
treatment,
shows the beginning
of degenerative
changes.
The soft tissue in the anterior
part of the maxillary
ridge is thickened
and
soft. Note the characteristic
horizontal
fold on the labial surface
of the maxillary
ridge.

Table I. Each figure represents

over a period of three years
Posterior
Patient
A, age
B, age
C, age
D, age
E, age
F, age

an increase

tuberosity

Soft tissue
+2.5
+1.0
+1.3
12.0
cl.0
+1.3

63
51
46
43
35
34

or decrease

ridge
j

Bony

height
ridge

+1.7
+1.0
+0.5
+1.7
--0.2
+o..i

in millimeters

Anterior
Soft tissue
-2.2
-3.0
-2.2
-1.5
-2.9
-1 .o

of ridge height

ridge
1

height
Bony

ridge

-1.7
..~3.0
-1.2
-1.0
-0.7
--0.5

This is significant
since the measurements
are very accurate because of the stability
of the bony landmarks
at the midline.
One patient is beginning
to show signs of the deterioration
of the anterior part
of the upper ridge which we attribute
to trauma from the lower anterior teeth. This
patient has a flabby thickening
of the tissue, inflammation
of the incisive papilla, and
the beginning
of a fold forming the labial surface of the ridge (Fig. 10) .
All of the subjects have been successful denture wearers, well satisfied with their
prosthesis. They have received better than average follow-up
treatment
in refitting
the bases and equilibrating
the occlusion. With the loss of tissue demonstrated
in the
anterior part of the upper jaw, and with a positive change developing
in the posterior
part of the ridge, and with the lower anterior tooth migration,
it appears that any or
all of these patients could develop the typical signs of the combination
syndrome.
PREVENTION

OF THE

COMBiNATION

SYNDROME

Preventing
the degenerative
changes that complete maxillary
the Class I partial
dentures bring about may only be possible

dentures opposing
through
treatment

Volume
Number

Partial

27
2

denture

opposing

complete

denture

149

planning
to avoid this combination
of prostheses. Complete lower dentures opposing
natural maxillary
teeth are impossible prosthodontic
combinations.
Treatment
planning should avoid the necessity for such a combination.
The same could be done to
eliminate
the combination
of complete upper dentures opposing Class I lower partial
dentures. I do not advocate extracting
lower anterior
teeth to accomplish
this but
rather to retain weak posterior
teeth as abutments
by means of endodontic
and
periodontic
techniques.
Endosseous endodontic
implants and the amputation
of one
lower molar root to preserve the other as an abutment
are examples of some of the
methods that could be applied. An overlay denture on the lower may avoid the combination
syndrome
from developing.
Overlay
dentures
utilizing
the lower tooth
roots for stabilization
provide a complete denture occlusion.
SURGICAL

CORRECTION

OF CHANGES

IN THE BASAL

SEAT

Even after much damage has been done and gross changes have taken place,
many dentists and patients prefer to remake the combination
rather than sacrifice the
remaining
lower anterior teeth to make complete dentures. Surgery can do much to
rehabilitate
these patients.
The flabby (hyperplastic)
tissue can be removed, the
papillary
hyperplasia
can be eliminated,
and the enlarged
tuberosities
can be reduced. This allows the distal end of the occlusal plane to be raised to the proper
level, and allows the lower partial denture bases to be fully extended.
This is extremely
important,
and covering
the maximum
area possible for support
of
partial denture bases would help prevent the combination
syndrome. Covering the
retromolar
pad where muscle and raphe attachments
prevent or reduce resorption,
and covering the buccal shelfI is necessary to retard bone loss. Often this is not
done with removable partial dentures.
SUMMARY
Almost
inevitable
degenerative
changes develop in the edentulous
regions of
wearers of complete upper and partial lower dentures. We have followed six patients
over a three-year
period
with cephalometric
radiographs
to determine
if these
changes could be detected. In all six subjects, early changes that could become gross
changes were apparent.
In one of them degenerative
clinical change is beginning
to
appear.
This problem might be solved with treatment planning
to avoid the combination
of complete
upper dentures
against distal-extension
partial
lower dentures.
The
alternative
of complete maxillary
and mandibular
dentures is not attractive
to patients. Preserving
posterior
teeth to serve as abutments
to support lower partial
dentures and to provide a more stable occlusion is a better alternative.
Ill-fitting
dentures have been blamed for all of the lesions of the edentulous
tissues, yet the most perfect denture will be ill-fitting
after bone is lost from the
anterior
part of the ridge. Removable
dentures need periodic
attention
at least as
often as the natural teeth.

The author
would
like to express his appreciation
to Dr.
advice
on oral pathology
and to Dr. Leonard
Chong
for
radiographs
and tracings.

Louis S. Hansen
for his help and
his help with
the cephalometric

150

Kelly

J. Prosthet.
February,

Dent.
1972

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2.
3.
4.
5.
6.
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8.
9.
10.
11.
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13.
14.
15.
16.
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UNIVERSITY
OF CALIFORNIA
SCHOOL
OF DENTISTRY
SAN FRANCISCO,
CALIF. 94422