Immediate Dentures Complete or removable partial denture fabricated for placement at the same appointment as extraction of natural teeth Occlusion May be Mutilated Makes Jaw Relations Difficult OVD, Midline & Incisal Edges May Require Change After Extractions, Prior to Placement Final Result Immediate Complete Denture • Conventional immediate denture • intended to be relined to serve long-term • Interim immediate denture (IID) (transitional): • after healing a second new complete denture is fabricated as a long-term prosthesis (Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.1) Advantages • Maintenance of • • • • • • Appearance Circumoral support Muscle tone Occlusal vertical dimension Jaw relationships Facial height • Tongue will not spread out as result of tooth loss Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.2.1 Advantages • Less postoperative pain & bleeding • extraction sites protected • Pressure from denture base • Easier to duplicate natural tooth shape & position (if desired) • Easier Adaptation • Speech, mastication rarely compromised • Nutrition can be maintained Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.2.1 Disadvantages • More challenging to set teeth – Less space for teeth as ridge resorption hasn’t occurred • Alveolar ridge undercuts around remaining teeth may make impressions more difficult • Unstable or inadequate occlusion can make recording centric position difficult Unstable Occlusion Explanation to Patients • Fit is usually not as good as traditional dentures (estimate ridge form) • Extractions and sore spots from immediate denture can result in more discomfort after initial insertion Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2013. 9.4.3.1 Explanation to Patients • Takes time to adapt to chewing and speaking • Appearance may be unpredictable if anterior try-in not possible (Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2013. 9.4.3.1) No Anterior Try-in Explanation to Patients • Should be worn for first 24 hours without removal • If removed, reinsertion can be difficult if significant swelling occurs • Patient should return to dental office for initial removal at 24-hours Explanation to Patients • Immediate dentures will normally “loosen” during healing due to ridge resorption & soft tissue remodeling • Relines/tissue conditioners will be required to improve the retention • Normally a permanent reline will be required 4-6 months after insertion Explanation to Patients • In some cases a remake may be required • Significant change in jaw position • Significant esthetic problem • May be cheaper/better to remake • In practice, the patient is normally responsible for fees for relines • Explain prior to beginning Dalhousie Faculty of Dentistry Policy • Immediate denture fee at Dalhousie includes • tissue conditioners • one permanent reline within first year of receiving immediate denture(s) • No additional fees for relines Dalhousie Protocols • Online on Removable Prosthodontics Website • http://removpros.dentistry.dal.ca/RemovSite/Imm ed_Dentures.html Too Difficult • No opposing occlusal contacts • Severely collapsed occlusal vertical dimension • Can’t register a repeatable jaw relationship (check at treatment planning appointment) • Vestibule too short - vestibuloplasty would be required • Refer Dalhousie Protocols • Sugery & Insertions Thursday afternoons only • Book at least 2 weeks prior to surgery • Book with Patient Services Staff • Identify as a Immediate Dent at time of booking • Only 2 immediate denture bookings per day • Email Dr. Knechtel to advise him of booking • • • • date of booking # of teeth to be extracted CD (single or set) RPD Dalhousie Protocols • At least one week prior, students must review medical history & clinical surgical details with supervising surgeon • At beginning of clinic inform both attending Surgeon and Dr. Knechtel that your patient has an immediate denture • This ensures the patient moves to top of rotation, so that insertion is as early in clinic as possible Dalhousie Protocols • Students must see patient the day after delivery, Friday morning to ensure patient comfortable • All immediate dentures insertions supervised by Dr. Knechtel. Technique • Examination/Diagnosis/Treatment Plan • Informed consent • • • • • Alternatives Pros/cons Prognosis Timing Costs Examination/Diagnosis/Treatment Plan • Beware of tissue undercuts • Especially anterior maxilla & tuberosities • Make notes to reduce at time of extractions • Compress socket • Bony reduction if necessary • If not reduced, denture may not seat • 2 piece tray for impression Examination/Diagnosis/Treatment Plan • Determine if OVD requires change at diagnosis appointment • Use physiologic rest, interocclusal space measurements Examination/Diagnosis/Treatment Plan • To improve esthetics & ensure adequate stability: • Decide whether you will need to imitate or change tooth arrangement prior to beginning • Helps avoid unexpected surprises Technique • Oral hygiene procedures • Reduce inflammation to speed healing • Reduced discomfort after extractions • Less soft tissue changes – better fit Technique • Preliminary extractions - posterior teeth • Keep one set of opposing teeth on each side of arch if OVD and centric are to be preserved • Wait 4 weeks for healing • If very few teeth remain • Consider extracting all at once • Skip preliminary extraction step • Less morbidity Extract All Teeth Single Appointment Technique After Preliminary Extractions • • • • • • Preliminary impressions - alginate Final impressions – 1 or 2 step Jaw relation records Tooth set-up and try-in Final extractions and insertion Post insertion care Examination/Diagnosis/Treatment Plan • Reconfirm decision to imitate or change tooth arrangement • Determine midlines, occlusal plane, vertical overlap, length of maxillary incisors • Mark on cast for laboratory to use for setup Preliminary impressions • Stock trays • Dentate or partially-edentulous • Irreversible Hydrocolloid • Mark vibrating line & hamular notches prior to impression • Can’t reseat intraorally Final Impressions • Use 2 piece custom tray if significant undercuts • If no large tissue undercuts use one piece custom tray Mark Posterior Border Prior to Impression • Vibrating line & hamular notches • Not able to reseat intraorally • tooth & tissue undercuts, embrasures • If don’t have correct posterior border, denture will not be retentive 2 Piece Impression Custom Tray – Ensure Alginate Not Too Thin Stock Tray 1 Piece Impression • Block out minor undercuts • Ensure tray flange not too far from vestibule • After border molding, should not lock into place Jaw relation records • Record base & occlusion rim used if unstable cast/contacts (wobbles, rocks) • Make facebow record with dentate bitefork • Use for centric & protrusion • If stable contacts, record base not needed Jaw Relation Records • Determine OVD • Use physiologic rest, interocclusal space measurements • Do NOT incorporate an overbite in occlusion rims • if anterior teeth are missing, use rims only to determine OVD, not incisal display • Once mounted, determine overbite, incisal display required Use occlusion rims for OVD, Jaw Relations Records Dentate Bitefork wth Wax/PVS Centric Record Use PVS Bite Registration Material, NOT Wax Tooth Set-up and Try-in Anterior Try-in Only Possible if Anterior Teeth Missing Extraction and Insertion • Have lab complete set up & modify cast as directed • use probing depths & radiographs to guide cast modification Do not create large socket convexities – grind teeth Final Setup Usually will not allow for Full Wax Try-in Extraction and Insertion • Always request a surgical stent (guide) • Prescribe fabrication of stent when sent for processing • Allows for identifying areas of impingement (blanching) Extraction and Insertion • Extract teeth • Prior to insertion, use surgical guide to assess ridge • Place pressure but DONOT Flex during insertion • check for over extensions, pressure (blanching) • Seat the denture • After stent show full seating, no blanching Extraction and Insertion THE DENTURE MUST BE FULLY SEATED • Otherwise occlusion will be unacceptable • Once fully seated, adjust occlusion as needed • Provide post insertion instructions • Verbal • Written – patient brochure Dalhousie Timeline for Insertion 0 -15 min - Inform surgeon & Dr. Knechtel patient is receiving an immediate denture - review med history - provide local anaesthesia 15 - 60 min - extractions 1 - 2 hour - insert and adjust - instructions Instructions to Patient • • • • • • Do not remove until 24 hour appointment If it comes loose/out replace immediately Soft/liquid diet for 24 hours Avoid vigorous rinsing Take analgesic as prescribed Expect red saliva 24 Hour Appointment • • • • Remove and clean denture Relieve sore spots Do not use PIP – use indelible stick Gross occlusal adjustment 1 Week Recall Appointment • Relieve sore spots • Use PIP • Refine occlusion – possible remount Continuing Care • Tissue conditioner to improve retention as needed • Remove any socket convexities to avoid healing defects • Reline or remake in 4 to 6 months • Postpone as long as patient can tolerate to ensure most of initial resorption complete X X Remove denture base convexities to avoid healing defects X