Immediate denture

Prepared by:Dr. Ibrahim H. Al-

fahdawi

Immediate DentureDefinition:Is a denture constructed and fabricated

before the remaining natural teeth have removed to be placed and inserted immediately after removal of remaining natural teeth.

Is the most effective way of making the transition from the natural to the artificial dentition.

Immediate denture are more challenging to dentist and the patient because a try in is not possible before and, the patient may not be completely comfortable with the resulting appearance and fitness .

Indication: 1.hopless remaining teeth . 2.educated patient with daily

social activities ;Dr,lawyers,teachers.

3.patient with stable health condition.

Contraindication: 1.patient with poor general health

(systemic disease ) 2.patient is not wiling to accept the

treatment mentally and psychologically. 3.uncooprative patient. 4.patient at risk from bacterimia. 5.patient with genuine history of post

extraction hemorrhage . 6.the presence of oral sepsis .

Advantages of immediate denture:

A. advantages related to patient : 1.maintainance of dental appearance and facial

contour because there is no edentulous period. 2.minimizing disturbances of mastication and

speech. 3.less post-operative pain and bleeding

(protecting splint over the extracted sight ) 4.the patient is likely to adapt more easily to

denture 5.overall the patient”s psychological and social

well being is preserved .

Advantages of immediate denture: B.related to dentist : 1.transfer of the jaw relationship :if

the jaw relationship determined by the occlusion of the remaining of the natural teeth is acceptable in both horizontal and vertical planes.

2.achieving good appearance . 3.haemostasis .

Disadvantages of immediate denture

It is important for the dentist to fully explain to the patient the following limitations of immediate denture , treatment should not normally be started unless the patient fully appreciate and accepts these limitations .

1.inability to complete a comprehensive trail stage so patient esthetic may not be fulfilled specially when anterior teeth are to be replaced.

2.increased maintenance and more clinical visits. 3.short service life. 4. Immediate dentures are usually more expensive

because of the additional time required for their construction

Classification of immediate denture:

According to treatment plan. A. conventional immediate denture B. interim immediate denture According to flange design . A. flanged type. B. flangeless type (open face or

close fit )

According to flange design:

1.flanged type : A. complete

flange . b. partial flange . 2.open-faced .

Comparisons of flanged and open faced denture:

1.Appearance 2.stability 3.Strength 4.Maintenance 5.Heamostasis 6.Remodelling of the ridge 7.Tolerance of replacement denture

Appearance 1.appearance of flanged denture does not

altered after fitting where the appearance of open – face denture (although good initially) can deteriorate rapidly as resorption create a gap between the necks of the teeth and ridge

2.the flanged denture allows freedom in the positioning of teeth ,where,in open face denture teeth have to be positioned in the sockets of the natural teeth

*so on case of malpositional teeth we can do good alignment in flanged denture while we can not in open face type

stability In upper denture: a flange on an upper denture create a more

effective borders seal , therefore , better retention than is achieved with an open face denture

In lower denture: open face denture is not usually constructed

because of poor stability of lower denture during function , so flange denture is commonly used

*so flange denture is better from the point of stability

strength 1.the presence of labial flange

produces a stronger denture . 2.labial flange will make the denture

stiffer so the midline fatigue fracture cause by repeated flexing across the midline is reduced .

*so from the point of strength the flange denture is better .

maintenance 1.as the bone resorped following extraction

the denture become loose and a reline is required , so the presence of labial flange make it easer to add either a short – term soft lining materials or a cold curing relining materials as a chair side procedure.

2.as the color of some reline materials is not always ideal they may be visible when used with open face denture.

haemostasis 1.the flange denture cover the clot

completely and protect them more effectively .

2.the flange denture exerts pressure on both lingual and labial gingiva reducing post extraction hemorrhage .

Remodeling of the ridge: The consequence wearing of

ill fitting denture can lead to: If it is open face ,will produce

a scalloped ridge in the region of the socketed teeth

In flange denture ,distribution the functional loads more favorably to the underlying ridge, thus minimizing bone resorption

Tolerance of replacement denture When patient have got used to an

open face immediate denture there is difficulty to accept a denture with labial flange in future and patient will complain from the fullness of the lip

If flange denture had worn from the beginning this problem does not occur .

When the ridge morphology produce deeply undercut area it may not be possible to fit a full labial flange unless there is surgical reduction

In this case the using of partially flange denture or open face denture is preferable when surgical procedure is contraindication .

In these circumstances selection of the correct path of insertion of the denture is essential .

Preparation stage: Before the beginning of the procedure

the patient should be prepared : 1.proper patient selection . 2.maitaining good oral hygiene prior to

extraction to enhance healing . 3.if multiple extraction is needed

(posterior and anterior ) its advisable to extract posterior teeth keeping some to preserve vertical dimension .

4.study (primary ) cast ,to plan the treatment and to construct special tray .

Clinical and laboratory procedures:

1.properly selected stock tray and taking primary impression .

In case of hyper mobile anterior teeth impression materials can act as instrument of extraction ,so avoiding of the problem can done by:

1.applying a lubricant medium to the teeth .

2. in case of adjacent teeth to each others applying moulding soft wax into sub-contact point spaces and around the necks of teeth so that the impression material is prevented from locking into the undercuts .

Custom tray ,final impression and master cast:

There are many types of special trays and impression techniques .

There are two basic ways to fabricate the final impression tray ,depending on the location of the remaining teeth and operator preference ,both are succeful:

Type one: single full arch custom tray Type two: two trays or sectional

impression tray.

Single full arch custom impression tray It more closely resembles a routine custom

tray used for removable partial denture. This type of tray is effective when only anterior

teeth are remaining or when anterior and posterior teeth are remaining.

Two trays or sectional impression tray This method used only when the posterior

teeth are not present . It involve fabricating two trays on the same

cast ,one in the posterior which is made like in complete denture (close fitted )

The second tray placed in the anterior (backless tray) or we can use stock tray in combination with posterior tray .

Jaw relation Doing that by using record bases

and occlusion bit rims , and the vertical dimension recorded , centric relation is recoded also and transferring to articulator in the normal procedure used with complete or partial denture .

Setting the posterior teeth, verifying jaw relation ,and try-in of posterior teeth appointment A try-in procedure is not always possible

(especially when all teeth or number of posterior teeth are present)

But the mounting casts should still be confirmed at patient visit.

Try-in appointment: 1.Set the posterior teeth . 2.the denture base and posterior teeth are try-in the

mouth : -verifying vertical dimension of occlusion -centric relation as with complete denture 3.record land marks on the cast to confirm the patient”s

esthetic A : midline or newly selected midline is recorded on the

base area of the master cast. B :the anterior plane of occlusion C :ala-tragus plane should be located and noted . D :high lip line should be determined on the cast. 4.anterior teeth selection is confirmed with patient .

Setting the anterior teeth If the arrangement of the natural

anterior teeth is to be reproduced in denture a recording of their position must be obtained in one of the following ways

Setting of anterior teeth First way: produce a labial index of the natural teeth before

they are cut off the cast. The index can be produced quite simply by moulding silicone

putty against the labial surface of the teeth and ridge on the cast.

then the artificial teeth are then set into the index while its held against the cast.

Setting of anterior teeth Second way: remove teeth singly from the

cast and immediately wax an artificial teeth into position so that the adjecent teeth serve as a guide to the position of the artificial replacement .

Setting of anterior teeth Third way: scribe guidelines on the cast

recording the position , angulations and incisal level of the natural teeth .

In case of elimination moderate labial alveolar undercut (alvealoplasty) The denture is constructed on a working

cast which is trimmed to the anticipated contour of the ridge after surgery.

1.the gingival margins are marked and teeth removed.

2.guidlines are drawn on the cast .

3.all the part of the cast contained within these two lines is trimmed away and the edges are rounded over .

4.a clear acrylic template is processed on a duplication of this cast and is used as a guide to control the amount of bone removal at operation .

Surgical procedure: 1.extraction of the teeth . 2.removal of the associated interseptal bone and

reducing the undercut . 3.collape ( squeezing ) of the labial cortical plate

of the bone . 4.isertion of the clear acrylic template to check if

bone removal has been sufficient . 5.farther bone removal ,if necessory, until re-

insertion of the template cease to cause blanching .

6.suturing the socket and insertion of the immediate denture.

Arrangement of the anterior teeth in open face denture:

1.prepertion of tooth socket on the cast, 2-5mm depth depending on the amount

of the gingival retraction which depend on the degree of pocketing and bone loose that is present around the natural teeth.

2.the neck of the artificial tooth is placed in preparation site.

3.at the time of insertion the neck will just enter the socket of natural tooth after extraction.

Clinical report of try-in procedure of anterior teeth

Fig 1 Intra oral view of patient with

interim maxillary and mandibular R.P.D ,note presence of diastema between maxillary left central and lateral incisors

Step1: primary impression were made and cast were prepared .

Step2: final impression is made and stone cast is made .

Step3: jaw relation is recorded and vertical dimension also recorded .

Step4: arrangement of posterior teeth is done and tried in the patient mouth as seen in the fig 2

Posterior artificial teeth arranged with the processed maxillary denture as in the fig 3

To relate the new maxillary denture to remaining teeth and supporting tissue , an impression of the adjusted denture was made with an irreversible hydrocolloid impression material and new maxillary cast was fabricated as shown in fig 4,5

The maxillary denture was then inserted in the patient mouth and centric relation record was made to facilitated the mounting of the maxillary cast .

The maxillary artificial anterior teeth were arranged to reflect the position of the patient natural teeth , this duplicated the diastema between the maxillary left central and lateral incisors .

To place the completed artificial teeth arrangement in the patient mouth for esthetic observation , modifications had to be made to the remaining natural teeth .

Teeth will sectioned at the gingival margins .

The completed artificial teeth arrangement could then be tried in the mouth in a blood –free field

To preserve the final position of try in anterior teeth arrangement , a thin layer of separating medium was painted on the portion of stone cast and labial index of the completed anterior artificial teeth arrangement was made with plaster .

After plaster had set immersion of the cast in hot water this allowed the wax in the anterior region to soften and facilitated the separation of the labial index , remaining wax was eliminated by boiling , the anterior artificial teeth were secured to the labial index with sticky wax .

The exposed portion of the anterior maxillary cast , visible through the window in the processed denture was painted with separating medium .

Labial index containing the artificial teeth was placed back on the stone cast and autopolymerization acrylic resin .

After acrylic resin had set the denture should polished and adjusted , the remaining teeth were then extracted and the immediate maxillary denture was inserted .

Surgery and immediate denture insertion Before all immediate denture should be kept in

a chemical sterilizing solution in a bag for delivery .

Care should be taking to preserve the labial plate of bone , no bone trimming is done.

Surgery and immediate denture insertion Suture are placed

when necessary.

Insertion of the immediate denture is done ,denture should seats well with good firm bilateral occlusion contact ,no pressure area ..

If the denture will be found to be inadequately retentive ,this is frequently occur in case of both anterior and posterior teeth were extracted, tissue conditioning liner can be placed at this stage.

Material should not be allowed to get into extraction sites.

Some authors recommended that instead of extraction of remaining teeth decoronation of crowns (with puplectomy) should done and roots should be removed after several days through 2-3 weeks.

Advantages 1.better visualization (less blood) 2.shorter placement visit . 3.minimum pain and swelling . 4.easily distinguishing sore spots

at adjustment visit .

Disadvantages 1.no tissue collapse that can be

planned when setting denture. 2.root extraction may be more

difficult without the clinical crown . **Contraindication of this procedure: Acutely infected teeth and sever

bilateral undercut.

Post-operative care and patient instruction

First 24 hour : Patient should avoid removing the immediate

denture. Patient should avoid hard food and drinking hot

fluids or alcohol . Patient can partially control inflammation and

swelling by using ice pack . Patient should be reminded that the pain from

extraction will not reduced by removal the denture.

Analgesic , antibiotic , are prescribed to patient.

Patient should be seen after 24 hours for:

Denture should be rinsed and washing patient mouth with dilute mouth wash.

Quickly checking the tissue sore spots related to denture.

Adjustment of over extension and any gross occlusal discrepancy .

The denture should be kept out of patient mouth only for short time.

First post-operative week Patient should wear the denture at

night for first 7 days after extraction or until swelling reduction .

Suture removal if present and changing tissue conditioner if use .

Farther follow up care Patient should be seen one month

later, 4-6 months intervals . The major reason for frequency of

changing temporary liner depend on the rate and amount of bone resorption and ability of patient to keep the liner clean.

Relining may be necessary to achieve esthetic and occlusion requirement.