A clinical pathway for complete immediate denture therapy: Successful prosthetic management for hopeless dentitionsBy K. David Stillwell, DDS, MAGDJamie Amir, BDSFeatured in General Dentistry, May-June 2008Pg. 380-389

Posted on Friday, May 09, 2008

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This article presents a rationale for utilizing complete immediate denture therapy, highlighting various advantages, disadvantages, and contraindications for this treatment.  Jerbi’s technique for presurgical cast carving is reviewed and a unique case report is detailed, involving a 22-year-old patient whose hopelessly debilitated dentition was treated by full-mouth extraction and placement of a maxillary and mandibular complete immediate denture.  In addition, a brief review of changing dietary patterns and social habits is presented in relation to the recent escalation of rampant dental caries in youth and young adult patient populations. 

 Received:  November 14, 2007

Accepted:  January 8, 2008 At some point in the course of practice, practitioners are likely to encounter a dentition so ravaged by caries or periodontal disease that extraction is the only reasonable treatment plan.  In the authors’ experience, the unique set of circumstances that find a patient whose remaining teeth must be judged hopeless usually involve a multifactorial set of life conditions, including unique genetic dental malformations, inherited predisposition to dental disease, poor professional care or limited access to care, psychosocial belief systems, financial limitations, lack of routine oral hygiene, poor systemic and topical fluoride exposure, and dietary/social habits.

New evidence indicates that changing diet patterns and social habits have caused rampant dental caries to escalate among youth and young adult patient populations.  Of particular importance are changes related to beverage intake and soft drink consumption, leading to dental erosion and increased caries, and social or habitual abuse of central nervous system (CNS) stimulant drugs (such as methamphetamine), which lead to severe xerostomia, bruxism, carbohydrate binging, and highly aggressive tooth decay.1-8

Once hopeless rampant caries has been diagnosed, dentists must develop a treatment plan to eliminate acute and chronic pain and infection while producing satisfactory dental rehabilitation.  Full-mouth extraction followed by placement of complete immediate dentures often is the most feasible option that will satisfy patient concerns about expedience, relief of pain and suffering, and cost.

This article will review a rationale for immediate denture therapy, including a technique for evaluating and carving the mounted pre-extraction casts prior to constructing a complete immediate denture.  Rationale for complete immediate denture therapyWhen multiple teeth are hopelessly compromised from a restorative or periodontal standpoint, selective extraction may be necessary to avoid jeopardizing surrounding teeth.9,10  In some cases, teeth may be salvageable but the patient may not have the time, financial resources, or motivation to undergo the necessary dental procedures to save them.

Ideally, certain strategic teeth should be considered for retention as overdenture abutments.  For patients with severely decayed and periodontally poor teeth where the indication for overdenture placement may not be obvious, retaining the roots of maxillary and/or mandibular canines can reduce alveolar bone loss during the first two years after extraction.11  Despite the very positive advantages of selective natural tooth retention, an individual on a subsistence-level fixed income may not be a candidate for any prosthetic treatment option other than full-mouth extraction and insertion of complete

dentures.Once the patient has been well-informed about the risks, hazards, and possible negative

consequences associated with irreversible tooth loss, the dentist must clearly communicate the treatment options of immediate versus delayed prosthetic replacement and obtain informed consent.  Most patients will request immediate replacement for the compelling reason that doing so means they are not required to go without teeth or interrupt the normal activities of smiling, talking, eating, and socializing.

According to Arbree, an immediate denture is fabricated before all remaining teeth have been removed, with insertion occurring immediately after their removal.  The same author stresses the importance of meticulous treatment planning, patient education, and clinical performance.12  Careful use of tissue conditioners during the postsurgical period can ensure a predictable treatment outcome, one that typically converts the complete immediate denture into a definitive prosthesis suitable for long-term wear.  Advantages, disadvantages, and contraindications for complete immediate denture therapy appear in Table 1.12  

 Production and evaluation of the pre-extraction master casts

The clinical procedures needed to produce a complete immediate denture are similar to those used to produce a conventional denture, although the process is complicated by the need to estimate the shape of the residual ridge before the natural teeth are removed.  In 1999, MacEntee listed several methods of making an impression for an immediate denture and outlined a dual impression technique that is considered particularly useful because it allows dentists to focus on the shape of the residual ridge and surrounding soft structures before moving on to the shape and position of the remaining natural teeth.13  More recently, Cagna and Massad published a specialized procedure of making an impression for complete immediate denture construction designed to take advantage of vinyl polysiloxane (VPS) material technology.14

Regardless of the final impression technique chosen, a careful and thorough visual examination of the mouth (including an evaluation of appropriate radiographic information) is required before the diagnostic mounting of the pre-surgical master casts is completed.  For the complete immediate denture to succeed, the re-extraction casts must be mounted in the most appropriate vertical and horizontal relationship.  Placing the casts accurately within the articulator makes it possible to control the esthetic and functional qualities of the treated case.

Once the casts are mounted, the preoperative prosthodontic situation should be analyzed.  A sequence of cast alterations (including cast carving) is planned.  The amount of cast carving and the degree of surgical sculpturing for the soft tissues represented by the presurgical cast is dictated by knowledge of the existing alveolar bone levels and gingival crest positions for the remaining teeth.  This knowledge is obtained through periodontal probing and accurate interpretation of the preoperative radiographs.  Patients may demonstrate bone loss with or without comparable gingival recession of soft tissue.  For the carving of the cast to be accurate, each individual case must be evaluated to determine the relationship of soft tissues to bone levels.15 

Dentists also should pay attention to the frenum areas and to the hard and soft tissue prominences; this will make it possible to assess whether additional surgery is required to provide a path of insertion for the denture after the teeth are extracted.  The existing occlusal pattern also must be analyzed to determine whether the current occlusal orientation of the natural teeth should be reproduced or altered on the denture.13  Carving the mounted pre-extraction castsThe goal of cast carving is to produce a master cast that closely represents the final shape of the surgical site immediately prior to the insertion of the complete immediate denture.  Ideally, the dentist who will perform the exodontia procedure should participate in removing the teeth from the mounted casts, as the cast carving procedure can help to educate the operator as to the extent of ridge re-contouring required at the time of tooth extraction. 

In 1966, Jerbi outlined a cast carving technique for an immediate denture.  This technique was a modification of the “rule of thirds” originally advanced by Kelly, in which the labial aspect of the ridge is divided into three equal bands of space between the gingival line and the depth of the vestibular space.  Jerbi’s cast carving technique defined a reliable and accurate pre-prosthetic method that remains valid today.  This technique was intended to ensure that the denture base would adapt to the area from which the teeth were extracted, to create space for acrylic flanges, to compensate for the loss of tooth structure and alveolar bone during extraction, and to allow for the creation of a surgical guide to direct the extent of alveoloplasty.15

The following steps are based on Jerbi’s technique. Step No. 1The mounted cast is divided into three equal bands:  the gingival third, the middle third, and the vestibular third.  The free gingival margin of all remaining teeth is outlined (Fig. 1). 

 Step No. 2The stone representation of the remaining clinical crowns must be trimmed to the gingival line (Fig. 2).  Key centric contacts are maintained to allow for verification of mounting and provide reference for denture tooth arrangement.  The tooth crown sites are cut down to approximately 1.0 mm from the level of the true anatomic crown, resulting in a slight subgingival scalloped pattern (Fig. 3). 

 Step No. 3The midline of the previously trimmed alveolar crest must be determined and marked in a bucco-lingual orientation (Fig. 4).  The gingival third of the buccal alveolus is marked, taking into

consideration known osseous defects and severe gingival recessions (Fig. 4).  Next, a flat cut should be made from the ridge mid-crest to the gingival third of the buccal alveolus (Fig. 5).  Work on a flat plane to connect the two scribed lines.  Soft tissues will collapse into the alveolus during the surgical procedure, so an appropriate amount of stone should be removed to represent the postsurgical tissue relationship accurately (Fig. 5).  Once the flat cut has been completed, a preliminary assessment of available intra-arch space can be made (Fig. 6). 

 

 Step No. 4The master cast must be evaluated critically (and corrected, if necessary) to determine that it has adequate space for tooth arrangement.  If alveoplasty is anticipated, additional stone must be removed from the master casts in amounts equal to the planned reduction of bone.  The cast must be trimmed to a final smooth contour by shaping and smoothing all stone surfaces (Fig. 7 and 8); at that point, the dentist may proceed to the usual prosthetic tooth arrangement and full wax-up for a complete immediate denture. 

 Case reportA 22-year-old woman had a chief complaint of pain in all areas of her mouth.  Her dental history included a single extraction performed one year earlier.  Other previous dental care was sporadic.

Her medical history was significant for a penicillin allergy; the patient also reported using a prescribed birth control medication.  The patient had smoked one pack of cigarettes per day for the previous six years and was risk-assessed as Class ASA 1.  The patient’s family history revealed that her mother had lost all of her teeth in her early twenties.  The patient expressed major concern over financial constraints, indicating that the Florida Medicaid program for adults was the only way she could afford dental treatment.  The patient’s dietary history revealed that she drank soda frequently throughout the day and had done so for as long as she could remember.

An extraoral examination revealed no significant findings.  Intraorally, soft tissues were within normal limits.  The dentition was extensively debilitated by dental caries, with most posterior teeth broken down to the gingival crest. 

Significant loss of occlusal vertical dimension was accompanied by alveolar compensation (due to expansion of the posterior osseous segments) (Fig. 9–11).  The maxillary lateral incisors were noted to be congenitally missing.  A dark staining was evident on most teeth, indicating the possible use of nonfiltered cigarettes or marijuana, both of which the patient denied.  The condition of the mouth also was heavily indicative of meth mouth syndrome but the patient also denied abusing methamphetamine.  A tentative clinical diagnosis of soda pop syndrome was recorded in the patient record.

 

 

 Radiographically, multiple foci of periapical infection were apparent and readily associated with

generalized extensive rampant dental caries (Fig. 12).  Impressions were generated using irreversible hydrocolloid materials and preliminary diagnostic casts were constructed with dental stone.  A face-bow transfer and an interocclusal centric recording were obtained and the casts were mounted in a semi-adjustable articulator. 

 

 At the consultation visit, four comprehensive treatment plans were considered and presented to

the patient (see Table 2).  Due to the overall poor condition of the patient’s dentition, her lack of motivation, and her financial constraints, it was decided to perform a full-mouth extraction with alveoloplasty followed by the delivery of maxillary and mandibular complete immediate dentures.  One surgical procedure was planned (non-staged) to hasten the recovery of pre-existing chronic oral infection and dental pain while also meeting the patient’s goal to never be without teeth.  A full explanation and disclosure of the procedures involved were relayed to the patient, who also was presented with the disadvantages of a non-staged surgical approach.  These included the need for

potentially extensive alveoloplasty to ensure adequate fit of the dentures, the additional cost of constructing surgical guides, the need for multiple postsurgical clinic visits to manage healing and adaptation, and mandatory laboratory relines of both dentures after adequate healing, with the likelihood that both dentures would need to be re-made.

 

 The patient consented to the surgical and prosthetic procedures and acknowledged the likelihood

that new complete dentures would need to be fabricated (as a replacement for the immediate dentures) following 6–12 months of observation.

Routine prosthodontic procedures were performed; final master impressions with full vestibular extensions were made and master casts were constructed using dental stone.  Both casts were placed on a semi-adjustable articulator using a custom inter-occlusal recording.  The patient was manipulated into a relaxed centric relation position; at that point, an anterior bite jig (created from self-cured dental acrylic) indexed the two remaining intact incisors (teeth No. 9 and 24) as the anterior point of reference at a slightly open vertical dimension.  With the anterior jig in place to preserve the approximated vertical dimension of occlusion, conventional VPS bite registration material was used to record the posterior bite relationship.

The mounted master casts were carved to their final form, utilizing the Jerbi method.  Before the cast carving began, a VPS putty matrix was adapted to the lingual surfaces of the mounted pre-extraction casts (Fig. 13 and 14) to preserve the patient midline and incisal length and evaluate the effectiveness of the recontouring procedures.  The carved master casts were used to fabricate surgical guides made from 1.5 mm clear splint pressure-formed material (Mini-Star S, Great Lakes Orthodontics, Tonawanda, NY; 800.828.7626) (Fig. 15). 

 

 For the surgical procedure, the patient underwent intravenous conscious sedation with Versed

(Roche Laboratories, Nutley, NJ; 800.526.6367) and fentanyl.  The teeth were extracted uneventfully. Using the surgical guides as a reference, moderately conservative alveoloplasty was performed in

all four quadrants.  The guides were tried in over the surgical fields repeatedly until tissue blanching ceased.  Soft tissue closure was accomplished using 4.0 vicryl sutures. 

At the conclusion of surgery, the patient was transported to the Comprehensive Dental Care Clinic, where the complete immediate dentures were delivered.  Soft reline material was placed to enhance prosthesis retention and postoperative comfort (Coe-Comfort, GC America, Alsip, IL; 800.323.7063).  Sutures were removed 20 days postsurgery.  Numerous tissue conditioning replacements and occlusal adjustments were necessary over the course of the next two months but overall healing proceeded without complications.

At the 60-day postsurgical recall visit, the occlusion was observed to be stable and the patient reported improved function and satisfaction with her appearance and speaking abilities (Fig. 16–18).  The patient was encouraged to consider conventional complete dentures after full bony healing was achieved, with the option of endosseous implant placement to reduce bone loss and improve retention and stability.  The patient was informed that both complete immediate dentures could be converted into definitive complete dentures after additional healing.  Despite aggressive efforts to reappoint the patient for this follow-up care, she was lost to recall after a follow-up visit ten weeks after surgery. 

 

DiscussionPatients who are about to lose all of their natural teeth in one or both jaws may create a dilemma for themselves and their dentists.  A conventional complete denture requires a significant postextraction waiting period before prosthetic impressions can be attempted on a reasonably stable residual ridge.  The patient must go without teeth for several weeks (leading to functional difficulty and social indignity) before receiving the denture.  The complete immediate denture offers a solution to this problem because it is constructed before the natural teeth are extracted and placed immediately afterward.13

The present case presented some uniquely challenging clinical conditions concerning the severe deterioration of the dentition, a loss of posterior restorative space created by alveolar expansion, and several significant constraints imposed by the patient’s demands and financial limitations.  The non-staged surgical procedure required removing 29 highly diseased teeth (with four quadrants of moderately complex alveoloplasty), followed by inserting the immediate dentures.  No presurgical esthetic try-in or maxillo-mandibular jaw relationship verification is possible in this type of case.  To control the prosthetic outcome, a judicious master cast carving procedure must be executed with meticulous attention given to incisal length, midline position, and acceptable occlusal vertical dimension.  The Jerbi technique provided a proven and reliable procedure worthy of review by all concerned dentists. 

It should be emphasized that the presurgical cast carving maneuvers are completed most effectively by the individual who is scheduled to complete the surgical exodontia and ridge contouring; at the very least, the dentist directing the case should train the technician in pre-prosthetic master cast preparations prior to fabricating the complete immediate denture. 

Likewise, all non-staged complete immediate denture deliveries should be guided by well-formed surgical stents constructed on the carved master casts to ensure that a sufficient amount of soft and hard tissue is removed to allow for full and complete seating of the prosthesis.  Inadequate tissue reduction will result in occlusal discrepancies during delivery; these discrepancies often are accompanied by an undesirable increase in vertical dimension, poor retention, poorly adapted vestibular extensions, and excess incisal length, which prevents proper phonetic and esthetic outcomes.  A methodical presurgical cast carving procedure and accurate surgical guides are essential for complete immediate denture fabrication.  Careful consideration of the relative advantages, disadvantages, and contraindications outlined in Table 1 will increase the likelihood of prosthetic success and consistent patient results.

The need for this type of radical prosthodontic intervention may increase if the clinical entities recently identified as soda pop syndrome and meth mouth syndrome continue to escalate in the patient population. Rampant dental caries among young adult patient populations is a major concern; during mass patient screenings in a university setting, the authors have consistently observed a

relationship between caries and increased soft drink consumption.  To compound the problem, many individuals who socially or habitually abuse stimulant drugs like methamphetamine often increase their consumption of carbonated beverages and soft drinks to combat the severe dry mouth often associated with such abuse.  Drug-induced xerostomia combined with elevated soda intake, compounded by frequent binging on highly refined carbohydrates and a reluctance to practice even the most cursory oral hygiene measures, is a predictable and increasingly common recipe for dental disaster. 

Large sample populations have demonstrated that the frequency of soft drink consumption among youth (aged 6.0–17) increased 48% over a 20-year period; the volume of daily soda intake more than doubled during that time.1  In 2003, Americans consumed 46 gallons of soft drinks on average compared to 21.6 gallons of milk (by contrast, the average milk consumption in 1966 was 33 gallons per year).  It is now well-known that prolonged exposure to soft drinks can lead to significant enamel erosion.  Colas, non-colas, diet colas, and diet non-colas are formulated using combinations of phosphoric and citric acids; repetitive exposure is capable of increasing enamel solubility to produce a risk of dental erosion that may be ten times greater than that of fruit juices.4

Meanwhile, a 2006 report examined a rapid growth of meth-amphetamine stimulant abuse and estimated that there are 25 million users worldwide.5  In that same study, approximately 12 million Americans aged 12 and older (4.9% of the 2004 U.S. population) reported trying the drug at least once in their life.  It has been observed that abusers experience a significant increase in the incidence of aggressive dental caries and generalized hypcalcification/demineralization defects.  The caries pattern has been described as distinctive, often located on the buccal smooth surfaces of posterior teeth and the interproximal surfaces of anterior teeth.  The affected teeth are blackened, stained, rotting, crumbling, or falling apart and often are unsalvageable.  Health professionals should be able to recognize patients who use methamphetamine and understand the risk factors associated with their profound oral effects so that preventive and treatment strategies may be implemented.5

 SummaryThe observant dental professional must remain vigilant in recognizing the patterns of dental disease associated with illicit drug use and repetitive soft drink consumption.  Early recognition and intervention may prevent the insidious progression of caries, which can devastate the entire dentition and lead to the lifelong handicapping effect of full-mouth extraction. 

When managing a hopeless dentition, the cast carving technique described by Jerbi can be an effective method of constructing a complete immediate denture.  Once the decision has been made to provide a staged or non-staged surgical approach, following the steps presented here should allow for a predictable result in what may be a daunting clinical situation for even the most experienced clinician. Author informationDr. Stillwell is a clinical associate professor, Department of Operative Dentistry, and director of Screening and Treatment Planning, University of Florida College of Dentistry in Gainesville, where Dr. Amir is a second-year resident in the Graduate Periodontology Program. References1.   French SA, Lin BH, Guthrie JF.  National trends in soft drink consumption among children and

adolescents age 6 to 17 years:  Prevalence, amounts, and sources, 1977/1978 to 1994/1998.  J Am Diet Assoc 2003;103:1326-1331.

2.   Nielsen SJ, Popkin BM.  Changes in beverage intake between 1977 and 2001.  Am J Prev Med 2004;27:205-210.

3.   Shenkin JD, Heller KE, Warren JJ, Marshall TA.  Soft drink consumption and caries risk in children and adolescents.  Gen Dent 2003;51:30-36.

4.   Jain P, Nihill P, Sobkowski J, Agustin MZ.  Commercial soft drinks:  pH and in vitro dissolution of enamel.  Gen Dent 2007;55:150-154.

5.   Klasser GD, Epstein JB.  The methamphetamine epidemic and dentistry.  Gen Dent 2006;54:431-439.

6.   Goodchild JH, Donaldson M, Mangini DJ.  Methamphetamine abuse and the impact on dental

health.  Dent Today 2007;124-131.7.   Curtis EK.  Meth mouth:  A review of methamphetamine abuse and its oral manifestations.  Gen

Dent 2006;54:125-129.8.   Brown A.  Meth mouth on rise in Florida.  Florida dentists can help meth abusers recover.  Today’s

FDA 2006;18:28-33.9.   Stefanic SJ, Nesbit SP.  Treatment planning in dentistry, ed. 2.  St. Louis:  Mosby

Elsevier;2007:197-211.10.  DeVore CH, Beck FM, Horton JE.  Retained “hopeless” teeth.  Effects on the proximal perio-

dontium of adjacent teeth.  J Periodontol 1988;59:647-651.11.  Van Waas MA, Jonkman RE, Kalk W, Van ‘t Hof MA, Plooij J, Van Os JH.  Differences two years

after tooth extraction in mandibular bone reduction in patients treated with immediate overdentures or with immediate complete dentures.  J Dent Res 1993;72:1001-1004. 

12.  Arbree AS.  Immediate dentures.  In:  Zarb GA, Bolender CL, Carlsson GE, eds.  Boucher’s prosthodontic treatment for edentulous patients, ed. 11.  St. Louis:  Mosby-Year Book Inc.;1997:415-442.

13.  MacEntee MI.  The complete denture—A clinical pathway.  Carol Stream, IL:  Quintessence Publishing Co.;1999:99-106.

14.  Cagna DR, Massad JJ.  Vinyl polysiloxane impression material in removable prosthodontics.  Part 2:  Immediate denture and reline impressions.  Compend Contin Educ Dent 2007;28:519-527.

15.  Jerbi FC.  Trimming the cast in the construction of immediate dentures.  J Prosthet Dent 1966;16:1047-1053.

General Dentistry, May-June 2008 , Volume 56 , Issue 4

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