Immediate dentures/ lingual orthodontics courses

INDIAN DENTAL ACADEMY
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CONTENTS
Definitions
Reasons for immediate denture replacement
Physical factors
Physiological factors
Psychological factors
Advantages and disadvantages of immediate dentures

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

Review of literature
An approach to immediate denture treatment
Explanation to the Patient Concerning Immediate
Dentures
Conclusion
References

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.

 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).

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.

One of the first references to immediate dentures in the
literature was that of Richardson in 1860 (Seals,
1999).

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).

 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.

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

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

ADVANTAGES AND DISADVANTAGES
OF IMMEDIATE DENTURES

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.

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.

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.

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.

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.

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.

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.

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.

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.

A few patients are not good
candidates for immediate
dentures.

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

 Preliminary points to be noted while
fabricating an immediate denture prosthesis:

 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).

 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.

 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.

 Basic over view of an immediate denture
fabrication

 Preliminary examination….

Preliminary Impressions and
Diagnostic Casts
Impressions are made in irreversible
hydrocolloid (alginate) in stock metal or plastic
trays..

 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.

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. ….

A – undercuts in the edentulous area
blocked out:

Campagna impression Technique:

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.

 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.

 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.

 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.

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.

 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.

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.

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.

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.

 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.

 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.

 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.

 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.

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.

* 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.

* 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.

* 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.

Surgical Template

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.

Review of literature:

Walter j Demer 1972
“Minimising problems in placement of immediate
dentures” …

 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

 Extractions without alveoloplasty
 Extraction with alveoloplasty
Septal alveolectomy
Radical alveolectomy

John P Dahlberg(1965)
“Reconstructing the Natural Appearance By
Immediate dentures

Antony S Gotlieb(2001)
“An atypical chairside
immediate denture”

 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.

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

Intra oral view
 Posterior artificial tooth try
in done with modified
anterior wax up in anterior
labial flange area.

Try in of posterior artificial tooth
arrangement with processed maxillary
denture.

 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.

 The maxillary
artificial anterior
teeth were
arranged to reflect
the position of the
patients natural
teeth.

 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.

 After the
separation of the
index the teeth
were fixed using
autopolymerizing
acrylic resin.
 Denture was
finished and
inserted
immediately after
the extraction.

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.

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.

Postoperative
intraoral view
Master cast

Teeth trimmed from
master cast 1mm above
the gingival margin
 Teeth sectioned at
gingival margin

Denture placed with
pressure indicating paste
 Immediate denture in
place over remaining
roots

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

Partial Denture
 mouth preparations
 framework
fabricated.

Immediate Denture
-maxillary custom tray
made
-border moulding of the
posterior edentulous area
done
-final impression made

tray
Over impression with
stock tray

Over impression with stock tray

 Try in of framework

 Record bases made
on maxillary final cast
and mandibular
framework.
 Jaw relation records

 posterior teeth set for
try in and check
record
 anterior teeth set in
stone sockets for
patient viewing

 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.

Cast trimming

Rule of Thirds

Master cast ready for tooth removal

Teeth removed, cast ready for
trimming

Trimming and smoothening
Incisive papilla is never
trimmed
Minimal trimming

Surgical template fabrication:

Denture is waxed up.
Final waxing
and carving
done.

Denture is processed in the
conventional manner

Flasking the denture

Dewaxing

Flasks ready for packing with acrylic

Dentures are cured and recovered

Surgery phase:
 Anaesthetize teeth to
be extracted
 extract teeth

Maxillary ridge after extraction and
placement of sutures if required.

Delivery Appointment
 Adjust maxillary denture for fit using
template as a guide.

Surgical template

Immediate Denture Insertion done

 patient returns in 24
hours to have
immediate denture
removed
 check for over
extension, pressure
spots, premature
contacts

 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

Remount Record
 Centric relation record
 Open incisal guide pin
 Facebow if necessary
Remount index

Conclusion
• Patient education.
• Meticulous treatment planning.
• Staging extractions.
• Good impression technique.
• Tissue conditioners and remounts.
____________________________
= improve the predictability of the outcome.

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.

 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.

 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.

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..

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

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

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

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.

Thank you..
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Immediate dentures/ lingual orthodontics courses

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