CAD - immediate complete dentures and additions

Question 1

What is an immediate denture?

Answer 1

A denture that is constructed prior to the extraction of natural teeth & inserted immediately after their removal.

Question 2

What do we need to consider prior to immediate dentures? [timing]

Answer 2

Stages of constructing a denture needs to take place prior to tooth removal. E.g. primary, secondary imps, a record of PPD, aesthetics (shape & colour of teeth), record of midline, incisal level, occlusion etc.

Question 3

How does the lab construct immediate dentures?

Answer 3

• Lab is taking an educated guess on model to make a denture. Teeth will be removed & gums are shaped to simulate what pts mouth will look like after xla.
• Lab can use recordings from a known distance- e.g. long axes of teeth, width of teeth, PPD, incisal level etc.
• It is an estimation of how denture will be fitted.

Not always well fitting for pt due to change in anatomy.

Question 4

Why is PPD useful for the lab?

Answer 4

• Periodontal pocketing affects the amount of collapse of the tissues after extraction
• Ridge is rounded off to pocket depth.

Question 5

List the 4 ways an immediate complete denture could be incorporated into a tx plan.

Answer 5

1. Remove all remaining teeth & provide immediate C/C dentures [a lot of xla’s, and guess work by lab]
2. Extract the posterior teeth first & then subsequently replace anterior teeth with dentures. [depends on mobility, over-eruption, aesthetics, function]
3. Provide a post immediate denture - (teeth extracted, and conventional stages of denture making followed. Disadv: not accurate - healing sockets, bone remodelling- affects primary & secondary imps – cost)
4. Take out worst teeth (e.g. painful, most mobile), make a transitional partial denture and progressively add to it

Question 6

What are the adv of removing all teeth & providing an immediate complete denture?

Answer 6

• Only one surgical procedure required (xla’s).
• Dentures available straight away so patient can go away- able to speak, eat and good aesthetics.

Question 7

What are the disadv of removing all teeth & providing an immediate complete denture?

Answer 7

• Initial fit of dentures will be poor [guess work with models and denture. Xla – open sockets, bleeding, swelling – denture fit compromised – poor retention]
• Rapid bone loss & remodelling of jaws – significant in first 6 months. Will soon become loose & ill fitting– warn pts in consent process. May need another denture.

Question 8

What are the adv of removing all posterior teeth & then subsequently removing anterior teeth to provide an immediate complete denture?

Answer 8

• Full healing of posterior sockets & well tolerated by patients. Reasonably economical.
• The final denture should be well fitting especially posteriorly. * but still an issue anteriorly*

Question 9

What are the disadv of removing all posterior teeth & then subsequently removing anterior teeth to provide an immediate complete denture?

Answer 9

• Tongue may spread to fill edentulous space if teeth not replaced. May feel like a constraint to pt if denture placed later on.
• Unprotected posterior sockets during healing.

Question 10

What factors should be considered in tx planning for a post- immediate denture?
- Case selection

Answer 10

Case selection:
- patient has little or no interest in remaining dentition.
- Very poor neglected mouth.
- Patients unable to cooperate or accept provisional dentures.
- Poor attendance, poor OH, in pain, and understand they will have no teeth for a while. Consent important.

Question 11

What are the adv of progressively adding teeth to partial dentures?

Answer 11

• Can remove hopeless prognosis teeth first, then add on to denture as pt loses more teeth.
• Patient keen to save as many teeth as possible. Pt can keep teeth for longer. Remaining teeth can maintain OVD & aesthetics.
• The task can be completed over a number of years. [more tolerable for pt, simpler procedures and better for lab in terms of guess work. Some pts can’t tolerate dentures – pt can get used to a denture so transition to ‘complete’ is easier].
• Minimal clinical charges.
• A planned training appliance.

Question 12

List the process of providing immediate dentures.

Answer 12

Visit 1: History, exam, rads, periodontal indices, tx plan & consent. Primary imps.

Visit 2: XLa of teeth. Secondary imps

Visit 3: Record occlusion – may need record rims, record of alar-tragal plane etc.

Visit 4: Try in – check occlusion, articulation & OVD

Visit 5: Fit [may need to do xla & fit if initially removing posterior teeth, then anterior teeth as well]

Question 13

How can XLA technique affect the denture?

Answer 13

• The teeth are carefully extracted to reduce trauma (prevent inflammation) and preserve bone (may affect fit of denture).

Question 14

What areas are checked on the denture at the fit appt?

Answer 14

• The denture is fitted, care is taken to identify pressure areas & the denture adjusted. – the patient will be numb!
• The occlusion is checked and simple adjustments completed.

Question 15

What are the post-op complicstion to pt after xla & fit of immediate denture?

Answer 15

• Can be very uncomfortable for the patient.
• Swelling, post operative pain & trauma from the denture make eating very difficult.
• Patients complain of pain, excess salivation, loss of taste, unable to eat.
• If denture has been removed they can be very difficult to re-insert. (due to swelling post-op)

Question 16

What is the purpose of a 24 hr review after the immediate denture is fitted?

Answer 16

• Remove dentures & look for any areas where they have been rubbing
• Check occlusion
• Can use tissue conditioner if loose or sore – gel lining for comfort.

Question 17

What changes can we expect at 1 week immediate denture review?

Answer 17

• Initial swelling will now be reducing and the dentures will become loose.
• At this stage the occlusion can be more accurately assessed and adjustments made.
• Contaminated tissue conditioner may need replacement.
• The patient should be free of most pain and discomfort. – may be able to eat during normal function.

Question 18

What changes can we expect at 3 month immediate denture review?

Answer 18

• Patient will complain that the dentures feel loose and food gets under the denture.
• A chair side reline may be required.
• The occlusion will require further adjustments.
• A gap is often present between denture and underlying soft tissue. This indicates the degree of alveolar resorption.

Question 19

What changes can we expect at 6 month immediate denture review?

Answer 19

• Patient complains of looseness and food getting under the denture.
• A further chair side reline may be required, or if fit is very poor commence new denture construction [initial consent important: after 6 months may need new denture due to healing -> cost, time].
• The occlusion needs adjustments.
• A gap is often present between denture and underlying soft tissue. This indicates the degree of alveolar resorption.

Question 20

What are the benefits of immediate dentures?

Answer 20

• Tooth size, shape, position can be maintained
• Jaw relationship maintained
• No period without teeth
• Sockets protected (less likely for food trapping causing inflammation & discomfort)

Question 21

What are the adv of open face immediate denture?

Answer 21

• Upper incisors may need extracting, to be replaced by immediate denture. ST are supported and bone in place.
• Over time, after xla, the alveolar bone resorbs and ridge remodels. Lip support is lost over time.
• Ideally a full flange placed for full lip support, border seal etc.

Question 22

What are the 3 designs for an anterior flange?

Answer 22

1. Full flange
2. Part flange (covers socket)
3. Socket fitted ( goes into xla socket – natural appearance)

[2 & 3 can be used when there’s a prominent alveolar bone anteriorly].

Question 23

What are the adv of a full flange?

Answer 23

• Aids healing & protects clot.
• Increased retention & stability (border seal).
• Easy to reline & adjust.
• Reduced alveolar bone loss.
• Improved lip support.

Question 24

What are the downsides of a full flange?

Answer 24

• If flange is placed where bone is not resorbed, it could push the top lip out – poor aesthetics, may not be comfortable for the patient. In these cases, a socket fitted denture may be a better option.

Question 25

What is a socket fitted flange & when is it used?

Answer 25

• Used if marked bony undercut present.
• Can help with aesthetic problems such as too much lip support. Often looks very natural.

Question 26

What are the disadv of a socket fitted flange?

Answer 26

• Reduced retention & stability (due to lack of flange)
• Not so easy to reline & adjust. (gap develops between denture and ridge over time as socket heals, bone remodels – poor aesthetics)
• Not suitable for lower jaw. (thinner bony ridge)

Question 27

What are the disadv of socket fitting dentures & part flange dentures when they don’t spread the load fully over ST?

Answer 27

Socket fitted dentures & part flange dentures don’t spread the load well compared to full flange. Doesn’t allow healing of smooth ridge = may impact denture fit & future denture design – discomfort, aesthetics etc.

Question 28

What are the adv of a part flange?

Answer 28

• Used if marked bony undercut present.
• Helps aesthetic problems - such as too much lip support.
• Aids healing & protects clot. Reduced retention & stability. Easy to reline & adjust.

Question 29

What are the common complications of immediate dentures?

Answer 29

• Poor Fit - Shape of mouth was an estimation when making immediate dentures. Bone loss over months.
• Long periods of discomfort
• Food getting under dentures -Irritation, infections of mucosa
• Bone loss - may increase bone loss if denture not evenly supported over entire ridge. Pressure greater in some areas than others
• Ridge damage from poorly designed dentures.

Question 30

What are the disadvantages of immediates compared to conventional?

Answer 30

• No proper try in of anteriors – guesswork involved
• No period for assessment of whether or not patient can tolerate dentures
• Usually poor initial fit which subsequently deteriorates
• High maintenance- temporary relines needed, cost, time
• Problems with bony undercuts (may affect path of insertion for denture)

*Requires planning with pt, dentist guide & lab – shade, mould, lip support, incisal level etc will ensure pt is happy.

Question 31

What is an immediate addition to dentures?

Answer 31

• Denture present, and extraction is required.
• Can add tooth to existing denture, to fit on the day the tooth is planned to be extracted.

Question 32

Describe the process of making immediate additions.

Answer 32

• Need to arrange 2 appropriate sessions on clinic. (check how long the lab will need)

*Warn patient they will have to be without their denture for 48 hours (check with lab).

1. First appointment to take an impression [imp of denture in pts mouth – full arch & opposing arch with denture in place]. Imp and denture sent to lab, with relevant PPD. Specify which tooth is to be cut off model and added to denture, and if you want a flange, whether there is an anterior bony undercut etc. Need opposing model, record of occlusion for correct bite.
2. Second appointment to extract tooth and fit the denture [check correct tooth added to denture prior to xla. Disinfect denture in perform for 10 mins & rinse well. Check for blanching when fitting denture as pt numb – can’t tell]. Check occlusion.