Maxillary Changes Under Complete Dentures Opposing Mandibular Implant-Supported Fixed Prostheses

Saurahb Gupta, BDS,

Sybille K. Lechner, MDS, FRACDS, FPFA Norton A. Duckmanton, MDS, FRACDS,

Purpose: The aim of fhis study was to determine whefher a condition similar to Combinafion Syndrome occurs In patients rehabiiifated with a maxillary complete denture opposing a mandibular implant-supported fixed prosthesis. Materials and Methods: Standardized clinical procedures measured fit, occlusal integrity, and bone loss in the anterior maxilla in 1 f edentulous subjects meeting these requiremenfs, from the patient pool of the Implanf Centre, Unifed Dental Hospital, Sydney, Results: A mean annual loss of 0,17 mm in tine anterior maxillary ridge height was not statistically signiticant (P > 0,05). However, Increased pressure in fhe anterior maxillary ridge during occlusion and loss of posterior occlusal contacts in retruded position were noted on one or bofh sides in all subjecfs. Conclusior): Loss of posterior occlusion could nof be relafed to anferior maxillary bone loss. However, fo maintain the integrity of ttie prosfheses and their supporting structures, it is imporfanf fo schedule periodic recall appointments for

review of the occlusion, Inl Prosthodont 1999,12:492^97.

sseointegrated implants are widely used in prosthodontic rehabilitation, ranging from a single-tooth replacement to implant-supported complete dentures; these treatments often lead to a marked improvement in chewing efficiency and alleviation of denture adaptation problems,'""^ However, there may also be disadvantages in the form of bone loss in the opposing jaw.^"^
'Graduate Student, Discipline of Removable Prosthodontics, Faculty of Dentistry, University o Sydney, Australia. ''Associate Professor and Head, Discipline of Removable Prosthodontics, Faculty of Dentistry, University of Sydney, Australia. 'Adiiini:t Associate Professor, Special Prosthodontics, United Dental Hospital, Sydney, Australia. Reprint requesfsi Dr Saurabh Gupta, 17 Civil Lines, Near Allahabad 8ani<, Moradabad iUPI 24400!, india. F<: + f9I-59If 415647/42329S. e-mail: saurg&yahoo.com

While little has been proven about tbe factors that are most important in the observed variations in residual ridge rsorption," host resistance is thought to be the major limiting factor,^'^"'^ However, excessive mechanical pressure and bite forces are also accepted as being associated with local areas of rsorption,'**-'^ and tbe mechanics of rsorption of ridges opposing implant-supported overdentures are assumed to be related to the types of excess stresses that are noted in Combination Syndrome,'^ Opinion is divided over the functional forces borne by the maxillary denture opposing implant-supported fixed partial dentures. Stafford et aP^ found tbat loading forces did not increase. However, Falk etal,^" measuring closing and chewing forces in 10 subiects, found them tobecomparableto those of parti,I ly restored natural dentitions, with greater forces in the posterior region of the maxillary denture opposing the

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cantilever units of the implant prosthesis. As a direct consequence of higher functional forces in such situations, midline fracture of the maxillary denture as well as increased incidence of relines and remakes are reported in a few studies.^-'^- However, Zarb and Schmitt-^ did not encounter midline fractures or the need for relining ofthe maxillary denture in 40 patients with similar prostheses. A difference of opinion is also evident in 2 studies investigating anterior maxillary bone loss under complete dentures opposing implant-supported fixed partial dentures, acobs et al^ reported an increased annual maxillary bone loss in 12 subjects with the abovementioned prostheses, while Henry et aP' did not observe increased bone loss and development of flabby ridges in the anterior maxilla in a 10-year follow-up study of 12 subjects. The aim of this study was to determine whether a condition similar to Combination Syndrome occurs in patients rehabilitated with a maxillary complete denture opposing a mandibular implant-supported fixed prostbesis. Materials and Methods Eleven edentulous subjects who bad been rehabilitated witb a mandibular osseointegrated implantsupported fixed prosthesis and a maxillary complete conventional denture were selected from the patient pool ofthe Implant Centre, United Dental Hospital, Sydney, Australia. The sample included 4 men and 7 women, their ages ranging from 53 to 74 years (mean 65.6 y). Selection criteria were that they had been wearing these prostheses for at least 21 months and their records did not show evidence of any systemic factors that might affect bone loss.-"" A subject information statement explaining the purpose of the study, procedures to be carried out, and duration ofthe appointment was written in plain language and mailed to the prospective subjects for their consent. Each subject was asked if he/she was satisfied with their upper denture. They were asked to grade their present chewing ability from the time of implant treatment as being the same, better, or poorer. Occurrences of remakes, relines, and repairs ofthe maxillary denture were recorded. Ciinicai Examination The maxillary denture was checked for stability and retention for each subject using conventional procedures for complete dentures,'" and results were recorded as adequate or poor.

Fig 1 Height o1 Ihe biock ot the Luxatemp cast (DMG| is measured to indicate the discrepancy between tootb surtaces in maximum occiusal contact and in centric reiatian.

The fit of the maxillary denture was evaluated using a pressure-disclosing paste Fit-checker (GC). The amount of material was standardized by having the length of the bead of base paste equal to the anteroposterior length ofthe denture, while the catalyst paste was half this measure. The fit was disclosed twice in each case: 1. Finger pressure; Index fingers were placed on either side, midway anteroposteriorly, to seat the denture, and moderate finger pressure was maintained until the material was set. 2. Biting pressure: The subject was asked to bite with moderate force and maintain this pressure until the material was set. Visual differences in thickness between the 2 disclosing impressions, especially in the anterior part of the ridge, were noted. The discrepancy between maxillary and mandibular teeth in the posterior region was determined by measuring the space between posterior tooth surfaces on casts of the prostheses articulated in centric relation, as described by Lechner and Mammen'' (Fig 1 ). Cephalometric Analysis Lateral head cephalograms were taken with the dentures in occlusion. A set of radiographs had been taken during the implant-supported fixed partial denture treatment (postoperative cephalogram}. A similar radiograph was taken atthe study appointment (followup cephalogram). Postoperative lateral cephalograms

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Table 1 Subject Data

Age Subject 1 2 3 4 5 6 7 8 Cepti alo metric -.h.,.. ,;rr, "eriod Duralion of denture wear (y-mo)

Sex F F F M M F M F M
F F

(Vl 73 74 74 61 68 70 56 59 60 63 53 3 Oi4-08 5-01 11-OQ 2-05 3-GO 3-01 3-02 6-05

9
10

11

MA

6-04 3-11 4-00 4-02 10-00 1-09 1-09 2-02 2-02 15-06 6-03

"Time elapsed between postoperative and current cephslometric radiographs. No postoperaliue radiograph was available tor subject 11

Fig 2 Landmariis and points for cephalometric evaluation. ANS - antenor nasai spine; PNS = posterior nasai spine: ANS-PNS = palatai piane; C^most anterior inferior point on maxiiia; dine = iine passing through C perpendicuiar to palatal piane; C - intersection ot palatal plane and C iine, F - point 10 mm posterior to C point aiong the paiatai plane: E line- line passing through E' point perpendicular to palatal piane: E ^ most inferior maxiliary point aiong tine E iine: Diine^ line passing through ANS perpendicuiar to paiatai piane: C-D/ine= line passing through C point parallel to palatal piane: D= intersection of D iine and C-D line.

had been taken at the time of stage 2 surgery rather than at the time of issue of the mandibular prosthesis, which in some cases had been considerably deiayed because of a variety of factors. The annual bone changes were therefore calculated for the interval between the 2 sets of radiographs (observation period), which ranged from 2.4 to 11.0 years (mean 5.2 years), and not for the duration of denture wear, although most dentures were worn for the majority of this period (Table 1 ). The cephalograms were analyzed using the system outlined by Scott et al-'' for vertical and horizontal measurements of the edentulous maxilla. Tracings for both the postoperative radiograph and the follow-up radiograph were made by the same examiner to minimize tracing errors, and radiographs were traced randomly. The relevant landmarks were identified and traced on tracing paper for both postoperative and follow-up radiographs (Fig 2). Cephalometric analysis was carried out for only 10 subjects, as the postoperative cephalogram for one subject was not available. The vertical and horizontal measurement values obtained for the follow-up radiograph were subtracted from those of the postoperative radiograph to obtain the effective annual change during the observation period. Means and standard deviations were calculated fur all measurements. The Student's itest {2-tailed paired means comparison) was used to statistically evaluate bone loss and check tbe significance (95% confidence level) of the resulting values in this group. Simple regression analysis was used to determine a linear relationship between the annual bone loss and the age of the subject and duration of wear of the prosthesis.

Results Subject Assessment of Fit of Maxillary Denture Eight subjects (73%) found the fit of their maxillary denture satisfactory, wbiletwo complained of a loose denture. One subject observed that the denture "seems to be going up in the front and down at the back." The maxillary denture was relined for one subject once, approximately 1 year before the study, and the denture felt loose again at the follow-up. A new maxillary denture was made for another subject 5 years before the present investigation. The denture had been remade three times and relined three times over 6 years for one subject, who reported that the present was the "most successful so far." Retention and Stability of Maxillary Denture The operator assessed the retention of the maxillary denture to be adequate in 9 subjects (82%). The stability of the denture was also found to be adequate in 9 subjects (82%). Retention and stability were observed to be poor in one subject. One subject had poor retention but adequate stability, while another exhibited adequate retention but excessive lateral rocking of the denture. Evaluation of Fit of Maxillary Denture The thickness of tbe film of Fit-checker in the maxillary denture was visually evaluated, revealing a thinner film of material in the anterior region under biting
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pressure than with finger pressure (Fig 3). This was observed in all 11 subjects. Posterior Occlusion A loss of posterior occlusion was observed on one or both sides of the denture in all subjects, ranging from 0 to 2,5 mm on the left and 0 to 2.0 mm on the right side of the prosthesis. The maximum discrepancy of 2.5 mm on the left and 2.0 mm on the right sides was observed in one subjecf, while the remainder were 1 mm or less. The values were different on the 2 sides for 10 subjects (91%). Cepbalometric Evaluation: Vertical Measurements C-C. Bone loss ranging from 1 to 4 mm was noted in 4 subjects (40%). No change was observed between postoperative and follow-up values in 3 subjects. A 1-mm increase was observed in 3 subjects (30%). The mean annual bone loss was 0.17 mm, but the difference was not found to be statistically significant (P> 0-05). E-E'. Bone loss ranging from 1 to 4 mm was noted in 6 subjects (60%), while 4 subjects (40%| showed no change. The mean annual bone loss was 0.3 mm, and the difference was found to be statistically significant (P<0.05). Cephalometric Evaluation: Horizontal Measurements ANS-PNS. Bone loss ranging from 1 to 4 mm was noted in 6 subjects (60%), and 4 subjects (40%] showed no change in values. The mean annual bone loss was 0.3 mm, and the difference was found to be statistically significant P< 0.05). ANS-C. Loss of bone in the posterior direction (horizontal plane) ranging from 2 to 3 mm was observed in 4 subjects (40%). Anterior movement of the crest ofthe ridge ranging from 1 to 4 mm was observed in 3 subjects (30%J. No change was observed in 3 subjects 130%). A mean annual posterior repositioning of the crest of the ridge was calculated at 0.02 mm, but the difference was not found to be statistically significant (P> 0.05|. C-D. The measurements were the same as ANS-C for all subjects.

Fig 3 iulaxillary denture with pressure-aisclosing paste after seating with biting force. Note heavy anterior contacts.

Discussion Pressure-disclosing paste revealed a greater amount of force in the anterior region on biting in all subjects, and lack ofposterior contacts was noted in all subjects. By allowing shunting of the denture in function, poor occlusion often translates into a perceived lack of fit^^^^; the absence of posterior support could therefore well account for the "looseness" of the maxillary denture described by some subjects even though the operator assessment was that the retention was adequate. However, the amount of bone loss noted in the anterior maxilla was equivocal, anda linear relationship could notbe established for annual vertical bone loss with respect to the age and sex of the subjects or duration of wear of the prosthesis. Loss of posterior occlusion could therefore not be attributed to bone loss in the anterior maxillary region as has been suggested in ridges opposing impiant-supported overdentures.^"'' It would havebeen interestingto compare the changes in the subject who showed maximum occlusal loss, but the postoperative cephalogram was not available. The radiographie evaluation indicates that the vertical measurements at the crest of the maxillary ridge (C-C) are nearly even in distribution among bone loss, no change, and increase in height of the ridge. The identification ofthe ANS point was difficult because ofthe thin isthmus of bone with a greater superimposition of soft tissue and a poor-quality radiograph. There seems, however, to be a significant reduction in the length of the palatal plane (ANS-PNS), as well as in the height of the anterior maxilla (E-E') posterior to the crest of the ridge. The horizontal change observed was probably a result ofthe posterior repositioning of the anterior nasal spine that may be related to the age of the subject and the pressure exerted by the maxillary denture. The crest of the

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ridge is known to move posteriorly be(-aLi...e ol ihe pattern ofresorption,-^ which shifts fhe E'point along the palatal plane because ofthe posterior repositioning of the C line. The paiafal contour narrows from the crest posteriorly in the superoinferior dimension, ' and this supports the significant reduction in the E-E' dimension. The posterior shift cf both the D line and the C line possibly accounts for the insignificani change observed in the ANS-C dimension. The indecisive nature of these measurements may be a result ofthe fact that, compared with a mandibular implant-supported overdenture, the implant-supported fixed prosthesis would show minimal deflection ofthe cantilever segment when opposing a complete denture. It is more probable that the lost posterior support is loss of actual tooth structure. Prostheses for all subjects had been made by one of 2 clinicians and, at the time of issue, all posterior teeth were in contact in centric relation. However, all had plastic teelh, which have been shown to be subject to wear,^'^-^' The difference in occlusal discrepancy between the 2 sides may thus be caused by tbe preferred chewing side ofthe subject. Visual comparison of the original casts to the present prostheses showed wear in some of the cases, although as the study was retrospective, no attempt could be made to evaluate any dimensional change in the plastic teeth. One subject did observe that the denture teeth seemed to be worn. The use of porcelain teeth in implant-supported complete dentures could overcome problems associated with plastic teeth. Another explanation for the observed ioss of posterior occlusal contact could conceivably be a tissuedirected deflection of the maxillary denture, indicating a loss of posterior maxillary ridge height. However, this possibility was considered marginal and was not investigated. The scope of this study, being retrospective, was limited in terms of the records available and their quality at the time of the study. Errors in this study coLtId aiso be attributed to the difficulty in identifying radiographie landmarks and problems associated with radiographie tracing.

scheduled to maintain occlusal harmony and the health cf the supporting tissues, Euture research could include a larger sample e to provide a clearer picture of bcne loss and a comparison between tbe effects of porcelain or plastic teeth on occlusal integrity. References
1. Lindquist LW, Carisson GE, Long-term effects on chewing with mandibular fixed prostfieses on osseo integrated implants. Acta Odontoi Scand 1985;43:39-45. Carlsson GE, Lindquist LW. Ten-year longitudinal study of masticatory function in edentulous patients treated with fised complete dentures on osseointegrated implants, Int | Prosthodont ]994;7:448-453, Lindquist LW, Carlsson CE, Cfantz P-O, Rehabilitation ofthe edentulous mandible with a tissue-integra led fixed prosthesis: A six-yeai longitudinal study. Quintessence Int 1987;IB:B9-96, Blomberg S, Lindquist LW, Psychological reactions to edentuiojsness and treatment wiih jawbone-anchored bridges. Acta Psychiatr Scand 1963:68:251-262. lacobs R, van Steenberghe D, Nys M, Naert I, Maxillary bone rsorption in patients with mandibular implant-supported overdent jres or fixed prostheses. | Prosthet Dent 1993; 70:13 5-140, Lechner SK, Mammen A, Combination Syndrome in relation to osseointegrated impiant-supported-ouerdentures: A survey. Int JPiosthodort1996;9:56-64, Barber H D , Scott RF, Maxson BB, Fonseca R), Evaluation of anterior maxillary aiveolai ridge rsorption when opposed by the transmandibular implant, J Oral Maxillofac Surg 1990;48: 1,283-1,287, Carlsson GE, Clinical morbidity and sequelae of treatment with complete dentures. | Prosthet Dent l99B;79:I7-23, Atwood DA. Reduction of residual ridges: A major oral disease entity, | Prosthet Deni 1 971 26:266-279, Watt DM, MacCregor AR, Designing Complete Dentures. Philadelphia: WB Saunders, 1976, Dawson PE, Evaluation, Diagnosis and Treatment of Occlusal Problems, St Louis: Mosby, 1974, Tallgren A, Tryde C, Mizutani H, Changes in jaw relations and activity of masticatory musdes in patients with immediate complete upper dentures, J Orai Rehabil 1986;13:311-324, Carlsson CE, Haraldson T, Fundamental aspects of mandibular atrophy. In: VWorthington P, Branemaik P-I (eds). Advanced OsseointegrationSurgery, Chicago: Quintessence, 1992:109-118. KelsEy CC. Alveolar bone rsorption under complete dentures, I Prosthet Dent 1 971 ;25:152-161, Cazit D, Ehrlich J, Kohen Y, Bab I, Effect of occlusal (mechanical) stimulus on bone remodeling in rat mandibular condyle, J Oral Pathol 19B7;16:395-398, Bugbee WD, Sychterz CJ, Engh CA, Bore remodeling around cementless hip implants. South Med I 19%;89:1,036-1,040, Tallgren A, The continuing reduction o f t h e alveolar ridges in complete denture wearers: A mixed-longitudinal study covering 25 years, J Prosthet Dent 1972;27:120-132, Kelly E, Changes caused by mandibular removable partiai dentures opposing a maxillary complete denture ] Prosthet Dent 1972;27:140-150. Stafford D, Glartz P-O, Lindqvist L, Strandmar E, Influence of treatment with osseointegrated mandibuiar bridges on thp clinical deformation of maxillary complete dentures, Swed DentJ 1985,-suppl 28:117-135,

2.

3,

4,

5,

6.

8. 9. 10, 11, 12,

13,

14, 15,

Conclusion
In this study, the rehabilitation of the edentulous mandible with an implant-supported fixed prosthesis occluding with a maxillary complete denture did not appear to promote a condition similar to Combination Syndrome, However, loss of posterior occlusion was observed in every case and must be anticipated as a sequela tc such treatment, especially witb opposing plastic teeth. Periodic recall appointments to review the occlusion should therefore be

16, 17,

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20,

2f.

22,

23,

Falk H, Laurell L, Lundgren D, Occlusal force patferns in denfilicin5 with mandibular implanl-supporfed fixed cantilever prosfheses occluded with complefe denfures, Inf ] Oral Maxillofac Implanfs f 989:4:55-62, Henr>' P|, Bower RC, Wall CD, Rehabilitadon of fhe edenf JIOUS mandible wilh osseoinlegrafed denial implants: f 0 year tollowup, Ausf DentJ f 995;40:f-9, Hemmings KW, Schmift A, Zarb GA. Complication; and maintenance requirements for fixed proitheses and overdenfures in the edentulous mandible: A 5-year reporf. Inf ) Oral Maxillofac Implants f 9 9 4 ; 9 : l 9 f - 1 9 6 , Zarb CA, Schmiff A, The longitudinal clinical effecdveness of Qsseointegrated dental implants: The Toronio study. Part 111: Problems and complicafions encountered, | Prosthet Dent f 990:64:135-f 94, M a m m e n A. C o m b i n a t i o n S y n d r o m e in Relation to Osseoirtegrated Implant Supported Overdeniures [thesisl, Sydney. Univ of Sydney, 1992. Scoff RF, Barber D, Masson BB, A techniquefor evaluating bony changes in the anterior edentulous maxilla: A moditication of a cephalometric analysis. Oral Surg Oral Med Oral Pathol f 99f; 71:25O-25f.

26,

Firteil D N , Finzer PC, Hoimes|B. The effect otciinical remount procedures on the comfort and success of complete dentures, 1 Prosthet Dent 1987;S7:53-57, Lechner SK, Champion H, Tong TK, Complete denture problem solving: A survey, Aust Dent | f 99.';;40.77-380. Vomm R. Analysis of referred patients over a period ot five years to a teaching hospital consultant sen/ice in dental prosthetics, BrDenfJ f985;f 59:304, Afwood DA, The problem of reduction of residual ridges. In: Wirikler Sled), Essentials of Complete Dentuie Prosthodontics, ed 2, Littleton, MA: PSG, f 988:22. Von Rarisch B, Longitudinal study on the abrasion ot plastic teeth m total prostheses, DtschZahnarztl 1979;34:6f 9-62f. Ogle R, Davis EL. Clinical wear study of fliree commercially avaiiable artificial tooth materials: Thirty-si!< month results, f Prosthet Dent ]998;79:145-151,

27, 2S,

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3f), 3f.

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25,

Literature

Abstract-

The impact of oral health on stated ability to eat certain foods; Findings from the National Diet afid Nutrition Survey of Older People in Great Britain.
Ttiis exfensive study used 2 representative samples of peopie aged 65 years and older: aSf free-living and 275 mstitufionai subjects fiad a denfal exam and were interviewed about ffieir abiiify fo eaf 16 key foods There were more diefary resfiictions reported by fhe institution sample, but in tfie tree-iiving people, many aiso had difticulfies eafing several ot fhe toods filoreof fhe edentulous subjecfs reported such ditliculfies. If was concluded that the seiection ot foods in older people is substantially affeofed by ffie number of feeffi, especially posferior occluding pairs of feeth, and the presence of complete dentures. Ttiose clinical parameters in turn affect how people feel about eafing. This was even more important in institutionalized peopie. Diefifians and caterers should consider caretuily fhe dentai barriers fo eafing essential foods. Sheifiam A, Steele JG, fHarcenes W, Fincfi S, Walls AWG, GeradoTtotogy 1999:1 S:11-20. References; 26, Reprints: Prof A, Sfieiliarr, Department of Epidemiology and Public hiealth, University College, London fuledical School, 1-19 Tomngfon Place, London WCIE6BV, United Kingdom Fax: + 44 (0)20 78f 3 0242, e-mail: A,Sfisiliam(>ucl.ac,uk,flW

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