Immediate dentures/ lingual orthodontics courses


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Immediate dentures/ lingual orthodontics courses

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. CONTENTS Definitions Reasons for immediate denture replacement Physical factors Physiological factors Psychological factors Advantages and disadvantages of immediate dentures
  3. 3. Contraindications of immediate dentures  Preliminary points to be noted while fabricating an immediate denture prosthesis Basic over view of an immediate denture fabrication  Surgery and Immediate Denture Insertion  Surgical template
  4. 4. Review of literature An approach to immediate denture treatment Explanation to the Patient Concerning Immediate Dentures Conclusion References
  5. 5. Definition The glossary of prosthodontic terms ‘defines an immediate denture as a complete or removable partial denture constructed for insertion immediately following the removal of natural teeth.
  6. 6.  The Glossary of Prosthodontic Terms defines interim prosthesis as a prosthesis designed to enhance esthetics, stabilization and/or function for a limited period of time, after which it is replaced by a definitive prosthesis (Academy of Prosthondontics, 1999).
  7. 7. Interim Immediate Denture  An immediate denture after healing can be relined and refitted to be used as a definitive denture but an Interim immediate denture is worn only during the healing period to be replaced with a new prosthesis as soon as healing is complete.
  8. 8. One of the first references to immediate dentures in the literature was that of Richardson in 1860 (Seals, 1999).
  9. 9. Jiffy dentures;Raczka and Esposito ,1995  It is similar to interim immediate denture because it is replaced by a second denture after healing. It differs from interim immediate denture in that the denture “teeth” are usually made with tooth colored auto-polymerizing acrylic resin. The disadvantage in these materials are not long lasting (in wear and color stability).
  10. 10.  Immediate dentures are more challenging to make than routine complete dentures for both the dentist and the patient, because a try-in is not possible beforehand, the patient may not be completely comfortable with the resulting appearance and fit on the day the immediate denture is inserted.  The dentist must explain and the patient must fully understand the limitations of the procedure before beginning treatment.
  11. 11. PHYSICAL FACTORS:PHYSICAL FACTORS: 1) Disuse atrophy of the bony base1) Disuse atrophy of the bony base 2) Unfavourable trabeculation of the repairing2) Unfavourable trabeculation of the repairing bonebone 3) Possible damage to the ligaments3) Possible damage to the ligaments surrounding TMJsurrounding TMJ Reasons for immediate denture replacement
  12. 12. PHSYIOLOGICAL REASONSPHSYIOLOGICAL REASONS  Abnormal functioning of the mouth and mandible  Impaired communication  Abnormal deglutition PSYCHOLOGICAL REASONS:PSYCHOLOGICAL REASONS:  Humiliation.Humiliation.  Adverse subjective reactionsAdverse subjective reactions
  14. 14. Advantages The primary advantage of an immediate denture is the maintenance of a patient's appearance because there is no edentulous period. Circum-oral support, muscle tone, vertical dimension of occlusion, jaw relation, and face height can be maintained. The tongue will not spread out as a result of tooth loss.
  15. 15. Less postoperative pain is likely to be encountered because the extraction sites are protected. Some authors have discussed whether immediate dentures reduce residual ridge resorption (Heartwell, 1965; Johnson, 1966; Kelly, 1958; Campbell, 1960; Carlsson, 1967). It is easier to duplicate (if desired) the natural tooth shape and position, plus arch form and width.
  16. 16. If desired, the horizontal and vertical positions of the anterior teeth can be more accurately replicated. The patient is likely to adapt more easily to dentures at the same time recovery from surgery is progressing. Speech and mastication are rarely compromised, and nutrition can be maintained.
  17. 17. The availability of tissue-conditioning material allows for considerable versatility in the correction and refinement of the denture fitting surface, both at the insertion stage and at subsequent appointments. Overall, the patient's psychological and social well- being is preserved.
  18. 18. The most compelling reasons for the immediate denture prescription are that a patient does not have to go without teeth and that there is no interruption of a normal lifestyle of smiling, talking, eating, and socializing.
  19. 19. Disadvantages  Immediate dentures are a more challenging modality than complete dentures because the presence of teeth makes impressions and maxillomandibular positions more difficult to record.
  20. 20. Specific disadvantages include the following: 1. The anterior ridge undercut (often severe) that is caused by the presence of the remaining teeth may interfere with the impression procedures and therefore preclude also accurately capturing a posteriorly located undercut, which is important for retention. 2. The presence of different numbers of remaining teeth in various locations (anteriorly, posteriorly, or both) frequently leads to recording incorrectly the centric relation position or planning improperly the appropriate vertical dimension of occlusion.
  21. 21. 3. An occlusal adjustment, or even selective pretreatment extractions, may be needed to make accurate records at the proper vertical dimension of occlusion. 4. The inability to accomplish a denture tooth try-in in advance precludes knowing what the denture will actually look like on the day of insertion.
  22. 22. 5. Careful planning, operator experience, attention to details of the technique, and explanation to the patient best address this inherent problem. 6. Because this is a more difficult and demanding procedure, more chair time, additional appointments, and therefore increased costs are unavoidable. 7. Functional activities (e.g., speech and mastication) are likely to be impaired. However, this is a temporary inconvenience.
  23. 23. A few patients are not good candidates for immediate dentures.
  24. 24. They include:  Patients who are in poor general health or who are at poor surgical risks (e.g., post irradiation of the head and neck regions, systemic conditions that affect healing or blood clotting and psychological disorders).  Patients who are identified as uncooperative as they cannot understand and appreciate the scope, demands, and limitations to the course of immediate denture treatment
  25. 25.  Preliminary points to be noted while fabricating an immediate denture prosthesis:
  26. 26.  1. The patient's existing midline and need for modification of its position (existing teeth may have drifted, especially if a nearby tooth has been lost for some time).
  27. 27.  2. The desired vertical dimension of occlusion and amount of interocclusal distance (freeway space) for the immediate dentures and the need for conforming it to or changing it according to the patient's existing maximum inter-occlusal position.
  28. 28.  3. The present amount of horizontal and vertical overlap of anterior teeth.  4. An estimate of the Angle's classification of occlusion for the patient.  5. Display of posterior tooth in the buccal corridor.
  29. 29.  Basic over view of an immediate denture fabrication
  30. 30.  Preliminary examination….
  31. 31. Preliminary Impressions and Diagnostic Casts Impressions are made in irreversible hydrocolloid (alginate) in stock metal or plastic trays..
  32. 32.  There are two basic ways to fabricate the final impression tray, depending on the location of the remaining teeth and operator preference. Both are successful as long as they are done properly.
  33. 33. The process for tray fabrication is as follows:  1. The areas of the casts with remaining teeth are blocked out with two sheet wax thickness as for a fixed partial denture custom impression tray; undercuts in the edentulous areas are blocked out as for a complete denture custom tray. ….
  34. 34. A – undercuts in the edentulous area blocked out:
  35. 35. Campagna impression Technique:
  36. 36. Location of Posterior Limit and Jaw Relation Records  The procedures for locating the posterior limit and jaw relation records are identical to those for complete dentures.
  37. 37.  The occlusion rims are trimmed to the desired vertical dimension of occlusion. A face-bow transfer and a recording of centric relation are made.  The casts are mounted on the articulator.  Protrusive relation records are made, if desired, to transfer to the articulator in order.
  38. 38.  The anterior plane of occlusion (using the inter-pupilary line as a guide) is determined to simulate the natural appearance.  The remaining canines may not be coincident with this plane. Two teeth should be found that are parallel to the desired anterior plane of occlusion.  Posterior plane of occlusion with the ala-tragus plane should be located and noted.
  39. 39.
  40. 40.  If posterior teeth are still present at this stage, they may be extruded, which would distort the desired occlusal plane.  If posterior teeth are missing at this stage, it is easy to establish and record the ala-tragus line with the posterior tooth set up.
  41. 41. Setting the Denture Teeth/Verifying Jaw Relations and the Patient Try-in Appointment  The articulated casts are used for setting any anterior/posterior teeth that are missing so that a try-in can be accomplished with the patient.
  42. 42.  The midline or newly selected midline is recorded on the base area of the master casts.  A discussion of placement of diastema, rotated teeth, notches, and other natural arrangements should occur so that the patient is actively involved in the esthetic decisions.
  43. 43. Surgery and Immediate Denture Insertion 1. The patient can see the practitioner first for reduction of any overdenture abutments 2. The dentist performing the operation then extracts the remaining teeth, taking care to preserve the labial plate of bone where usually, no bone trimming is done.
  44. 44. 3. The surgical template is used as a guide to ensure that the prescribed bone trimming is done adequately. 4. The template should fit and be in contact with all tissue surfaces. Inadequately trimmed areas planned for bone reduction will blanch from the pressure and be seen through the clear template.
  45. 45. Processing and Finishing  The immediate dentures are processed and finished in the usual manner of complete dentures.  If desired, a laboratory remount can be accomplished before removing the dentures from their casts and finishing.
  46. 46.  Keep the undercut areas of the denture slightly thick at this point to allow for insertion over undercuts.  Using an upward/backward path of insertion of the immediate denture at placement may allow insertion without trimming; regardless, these areas can be thinned later before sending the patient home.
  47. 47.  It is best to keep all posterior undercuts at this point because often they do not need reduction but can be well managed by selecting an alternate path of insertion and withdrawal of the denture combined with judicious trimming of the width of the inside of the resin flange in these areas at the placement visit.
  48. 48.  Any bumps inside the immediate denture resulting from over-trimming of the cast should be reduced to allow for a convex ridge healing. These procedures are duplicated on the surgical template.  The procedures for fabrication of immediate dentures processing is similar to those for making complete dentures, with some modifications.
  49. 49.  If overdenture abutments are planned, endodontic treatment is preferably completed coincident with the immediate denture procedures.  The abutments can be morphologically modified when the denture is ready to be inserted.
  50. 50. Information Concerning An Immediate Denture: * Biting pressure on the denture will promote clotting and will decrease the initial flow of blood. Slight bleeding can last up to 2-3 days. * Use an ice compress on affected side for 20 minutes on repeatedly for the first 36 hours.
  51. 51. * Diet has to be limited to soft nourishing foods and plenty of fluids for the first week. * The denture should not be taken out on the day of insertion, but patient is advised to rinse the mouth with warm saline water before going to bed.
  52. 52. * After the first 24hours,patient should carefully remove the denture twice a day and clean the denture with a toothbrush and a low abrasive toothpaste or denture cleanser. * Due to the bone resorption leading to shrinkage that occurs within the first 6 months, patient may go through periods of loose fitting denture. Denture adhesives may be used during this time. A temporary reline of the denture may be done to provide a better fit.
  53. 53. * Following the bone resorption period (approximately 6 to 12 months) a more permanent reline will be placed. * Patients experience sore spots caused by uneven pressure being applied to the healing tissues by the denture. Therefore adjustments are made regularly.
  54. 54. Surgical Template
  55. 55. Surgical Templates:  A surgical template is a thin, transparent form duplicating the tissue surface of an immediate denture and is used as a guide for surgically shaping the alveolar process (Farmer, 1983).  It is a prescription for the surgical procedure and is essential when any amount of bone trimming is necessary.
  56. 56. Review of literature:
  57. 57. Walter j Demer 1972 “Minimising problems in placement of immediate dentures” …
  58. 58.  Distolingual undercut  Buccal and lingual undercuts in the bicuspid region  Sublingual undercuts  Incisive fossae and canine eminences  Distolingual and anterior combinations  Labial and lingual undercuts
  59. 59.  Extractions without alveoloplasty  Extraction with alveoloplasty Septal alveolectomy Radical alveolectomy
  60. 60. John P Dahlberg(1965) “Reconstructing the Natural Appearance By Immediate dentures
  61. 61. Antony S Gotlieb(2001) “An atypical chairside immediate denture”
  62. 62.
  63. 63.  Jonkman RE, van Waas MA, van 't Hof MA, Kalk W in 1997 The purpose of the study was to investigate denture satisfaction related to treatment modality, age, gender, denture quality, chewing ability, denture experience and patients' attitude towards denture wearing. CONCLUSIONS: They concluded that with respect to satisfaction the technical quality of the dentures, as well as patients' previous attitude towards wearing dentures are the most important factors in immediate denture treatment.
  64. 64. Ashok Soni et al (2000)  Trial anterior artificial tooth arrangement for an immediate denture patient :A clinical report  A technique is described that allows the esthetic try-in of the maxillary anterior artificial tooth before the extraction and completion of an immediate denture
  65. 65. Intra oral view  Posterior artificial tooth try in done with modified anterior wax up in anterior labial flange area.
  66. 66. Try in of posterior artificial tooth arrangement with processed maxillary denture.
  67. 67.  To relate the maxillary denture to remaining teeth and supporting tissues, an impression of the adjusted denture was made and a new maxillary cast fabricated.
  68. 68.  The maxillary artificial anterior teeth were arranged to reflect the position of the patients natural teeth.
  69. 69.  After decoronating anterior teeth the denture could be tried in the patients mouth.  Labial index of the completed anterior artificial tooth arrangement was made with impression plaster.
  70. 70.  After the separation of the index the teeth were fixed using autopolymerizing acrylic resin.  Denture was finished and inserted immediately after the extraction.
  71. 71. Majid B et al (2004)  Described fabrication of a clear surgical template that minimizes pressure caused by immediate complete dentures on a surgical area. The trimmed areas on the maxillary definitive stone cast were further trimmed on the duplicated stone cast for making the clear surgical template. The procedure provided proper seating of the immediate denture and reduced post operative soreness and denture adjustments.
  72. 72.
  73. 73. Michael M Woloch (1998)  Presented a clinical report which describes a procedure in which instead of extracting the remaining teeth at the time of denture placement, the teeth are decoronated and the immediate prosthesis placed as a conventional complete denture. Extractions can be performed at the clinician’s discretion.
  74. 74. Postoperative intraoral view Master cast
  75. 75. Teeth trimmed from master cast 1mm above the gingival margin  Teeth sectioned at gingival margin
  76. 76. Denture placed with pressure indicating paste  Immediate denture in place over remaining roots
  77. 77. An approach to Immediate Denture Treatment  A common situation is the immediate maxillary denture that will oppose a partially edentulous mandibular arch  Following is a step by step description of the construction of an immediate maxillary denture and an opposing mandibular partial denture
  78. 78. Partial Denture  mouth preparations  framework fabricated.
  79. 79. Immediate Denture -maxillary custom tray made -border moulding of the posterior edentulous area done -final impression made
  80. 80. tray Over impression with stock tray
  81. 81. Over impression with stock tray
  82. 82.  Try in of framework
  83. 83.  Record bases made on maxillary final cast and mandibular framework.  Jaw relation records
  84. 84.  posterior teeth set for try in and check record  anterior teeth set in stone sockets for patient viewing
  85. 85.  Arrangement of anterior teeth,done after the posterior try-in.  The anterior teeth are removed one at a time from the master cast.  Each tooth is reduced to the gingival margin with a rotary instrument and smoothened with a hand instrument .  Denture tooth is placed in its place this procedure is repeated with each tooth.
  86. 86. Cast trimming
  87. 87. Rule of Thirds
  88. 88. Master cast ready for tooth removal
  89. 89. Teeth removed, cast ready for trimming
  90. 90. Trimming and smoothening Incisive papilla is never trimmed Minimal trimming
  91. 91. Surgical template fabrication:
  92. 92. Denture is waxed up. Final waxing and carving done.
  93. 93. Denture is processed in the conventional manner
  94. 94. Flasking the denture
  95. 95. Dewaxing
  96. 96. Flasks ready for packing with acrylic
  97. 97. Dentures are cured and recovered
  98. 98. Surgery phase:  Anaesthetize teeth to be extracted  extract teeth
  99. 99.
  100. 100. Maxillary ridge after extraction and placement of sutures if required.
  101. 101. Delivery Appointment  Adjust maxillary denture for fit using template as a guide.
  102. 102. Surgical template
  103. 103. Immediate Denture Insertion done
  104. 104.  patient returns in 24 hours to have immediate denture removed  check for over extension, pressure spots, premature contacts
  105. 105.  Post delivery appointments  Patient remount in 7-10 days  Weekly or biweekly adjustments for several weeks  Temporary relining if necessary  Laboratory reline within 1 year
  106. 106. Remount Record  Centric relation record  Open incisal guide pin  Facebow if necessary Remount index
  107. 107. Conclusion • Patient education. • Meticulous treatment planning. • Staging extractions. • Good impression technique. • Tissue conditioners and remounts. ____________________________ = improve the predictability of the outcome.
  108. 108. Explanation to the Patient Concerning Immediate Dentures  1. They do not fit as well as complete dentures. They may need temporary linings with tissue conditioners and may require the use of denture adhesives.  2. They will cause discomfort. The pain of the extractions, in addition to the sore spots caused by the immediate denture, will make the first week or two after insertion difficult.  3. It will be difficult to eat and speak initially.
  109. 109.  4. The esthetics may be unpredictable. Without an anterior try-in, the appearance of the immediate denture may be different from what the patient or the dentist expected.  5. Many other denture factors are unpredictable such as the gagging tendency, increased saliva.
  110. 110.  6. Immediate dentures must be worn for the first 24 hours without being removed by the patient. If they are removed, they may not be able to be reinserted for 3 to 4 days. The dentist will remove them at the 24-hour visit.  7. Because supporting tissue changes are unpredictable, immediate dentures may become loose during the first 6-8 months.
  111. 111. As have been discussed, inspite of the difficulties faced by the dentist while fabricating the immediate denture prosthesis and the patient in getting adapted to it, this treatment modality still remains a very important form of prosthodontic treatment as it instills confidence in patients which is reflected in their smile..
  112. 112. References : 1. BOUCHER, S –prosthodontic treatment for edentulous patients 9th edition & 11th edition . 2. CHARLES HEARTWELL & ARTHUR O RAHN –Sylabuss of complete dentures 4th edition. 3. DENTAL CLINICS OF NORTH AMERICA- Complete dentures, april 1977, 21;2 4. JOHN J SHARRY- Complete denture prosthodontics 2nd edition. 5. JOHN N ADERSON ,ROY STORER – Immediate dentures & replacement dentures 3rd edition
  113. 113. 6. SHELDON WINKLER- Essentials of complete dentures 2nd edition 7. RUDD & MURROW – Dental lab procedures , complete dentures vol 1 8. ZARB, BOLENDER – Prosthodontic treatment for edentulous patients 12th edition. 9.. MM Devan “THE TRASITION FROM NATURAL TO ARTIFICIAL TEETH" JPD 1960 vol-1
  114. 114. 10. William B Lineberg “SURGICAL PREPARATION OF MOUTH FOR IMMEDIATE DENTURES “1963 vol 13 no 1 11. John P Dahlberg“Reconstructing the Natural Appearance By Immediate dentures”JPD 1965;205-210 12..M Heartwell IMMEDIATE COMPLETE DENTURE; AN EVALUATION 1965 vol 15 no 4 13. Asok Soni “Trial anterior artificial tooth arrangement for an immediate denture patient : A Clinical report ,JPD 2000 ;84 :260-263
  115. 115. 14. Anton S Gotleib “An atypical chairside immediate denture :A clinical report JPD 2001 :86 :241-243 15. Masjid Bissasu “A simple procedure for minimising adjustmentsof immediate complete denture :Aclinical Report :JPD 2004 ;92: 125-127 16. Jonkman RE, van Waas MA, van 't Hof MA, Kalk W J Dent. 1997 Mar;25(2):107-11.
  116. 116. Thank you.. For more details please visit