Treatment of a patient with combination syndrome
CASE STORY
A 58-year-old African American male presents with maxillary complete edentulism and mandibular partial edentulism, with remaining mandibular anterior teeth. His chief complaint is: “I need teeth to look better and to be able to chew my food.” The patient had an ill-fitting denture that is now lost. The patient has existing crowns on mandibular right and left canines and right first premolar (22, 27, 28), which were placed simultaneously with the removable partial denture approximately 6 years ago. The abutment teeth are now failing due to recurrent decay. He now presents with bone loss accompanied with excessive and hyperplastic (flabby) tissues in the maxillary anterior region. These tissues are especially sore as his mandibular teeth occlude and traumatize the area.
The patient requires soft tissue treatment in the maxilla as well as a new complete denture. He also requires new prosthetic reconstruction in the mandible, which includes survey crowns and a new removable partial denture, to restore form, function, and aesthetics.
Figure 1: Preoperative presentation.
Figure 2: Preoperative maxilla.
Figure 3: Final artificial tooth arrangement and try-in.
LEARNING GOALS AND OBJECTIVES
- Diagnose and manage combination syndrome.
- Select proper impression techniques.
- Establish an appropriate occlusal scheme.
- Manage and maintain patients with partial edentulism.
Medical History
- Physical exam 3 years ago: diagnosed with elevated blood pressure
- Patient reports he has not taken his blood pressure medication for about 1 year.
Dental History
- Multiple extractions due to caries, periodontal disease, and failed endodontic treatment
- Loss of maxillary complete denture 4 months ago; patient reports that he wore the denture only a few hours per day because it was loose and uncomfortable.
- Patient received regular dental care prior to retirement about 20 years ago; since then, patient has received only sporadic care with inadequate maintenance/follow-up visits.
- Last dental visit approximately 6 years ago when crowns in the mandible were delivered, but due to financial constraints, patient was unable to finish the planned dental work
Medications and Allergies
- Norvasc 10 mg/daily—patient has not taken this medication in over a year
- No known drug allergies
Review of Systems
- History of elevated blood pressure, which is controlled by diet and exercise only, since the patient has discontinued his medication
- Vital signs:
- Blood pressure: 140/90
- Heart rate: 68 beats/minute
- Respiratory rate: 18 breaths/minute
Social History
- Presently receives a modest retirement check from the U.S. Army and has basic medical and dental benefits
- Divorced and lives with a friend
- Smoking: 1 pack per day for the last 44 years
- Alcohol: 1 case of beer per week
- Recreational drugs: denies ever using
Significant Soft Tissue Examination Findings
- Lips: appear dry
- Mucosa: epulis fissuratum present in anterior maxilla
- Hard palate: Nicotinic stomatitis
Charting
Figure 4: Dental charting.
Clinical Findings/Problem List
- Edentulous maxillary arch with no prosthesis
- Partially edentulous mandibular arch
- Recurrent decay on teeth with existing crowns
- Inadequate oral hygiene
- Poor masticatory function
- Poorly controlled high blood pressure
- Heavy smoker
- Moderate alcohol consumption
Diagnosis
- Combination Syndrome
- Epulis fissuratum
- Nicotinic stomatitis
- Improper vertical dimension of occlusion
- Generalized moderate chronic periodontitis
- Caries
Clinical Decision-Making Determining Factors
- Combination Syndrome is a series of five findings described by Kelly in 1972 in pat/>
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