Immediate denture
All the dentures that you made in this year is a conventional dentures for edentulous patients which means they have been extracted their teeth then they seek to fabricate a dentures
Now we deal with patients whose don’t want to extract their teeth before fabricate the denture( he can't go out and continue to exercise their life without teeth) so in this case you fabricate the denture first then teeth extraction and denture insertion done at the same day
Immediate denture :
* is complete denture or removable partial denture fabricate for replacement immediately after the removal of natural teeth
*it is a denture constructed before the extraction of the teeth which it replaces and fitted immediately after the teeth extraction
Keep in your mind that in immediate denture you will deal with dentate patient means you will fabricate denture for dentate patient not for edentulous patient and teeth extraction will be at the delivery stage and it can be complete or partial
again the patient come to you and he still has his teeth , the teeth need to be extracted but the patient refuse to life as edentulous , he want to receive his denture immediately after the extraction but as you do and as you know , denture needs from 5 to 6 visits to be finished so what can
you do??? it is immediate denture means you will not extract the teeth , you just take an impression inorder to fabricate denture for the patient as what we do in partial denture then at the time of delivery you will extract the teeth and patient get his denture and go home with teeth and don’t life as edentulous .sooooooo
denture making => teeth extraction => denture insertion
Type of immediate denture
*transitional /interim
*conventional
*post immediate
transitional /interim; you remember in RPD there is one type of it which called transitional partial denture and the reason why we fabricate it because there are some of teeth will going to be extracted sooooooo once you diced to extract the teeth ,the transitional partial denture have to be converted to complete denture which called transitional immediate complete denture and as we said its immediate means at the same time where you extract the teeth patient will get his denture
conventional immediate complete denture; here the patient come to extract his teeth (don’t have RPD)but he want to receive his denture immediately after extraction soooo what you will do for him is conventional immediate denture
usually when we say immediate complete denture we mean the conventional type
now how to make immediate denture
Technique
· Patient examination and diagnosis then put your treatment plane
· Informed consent ; means you have to explain for your patient what the advantages and disadvantages of immediate denture ,it is more expensive ,the denture may need to rebase in a few month and it is necessary to replace the denture at a later period
· Oral hygiene procedure ; the teeth should scaled and cleaned and oral hygiene brought up
· Extract some posterior teeth so you need to decide which teeth need to be extracted and which teeth retained as guide to correct jaw relation , regarding to the anterior teeth keep the incisor and canine without extraction to coincide with stable intercuspal occlusion
Note; the extraction of posterior teeth done through more than two visits , one side at each visit and interdentally and interradicular bone should be smoothen after the extraction .this unilateral extraction and care of each part promote healing and reduce the time of partially edentulous and give me a better support
· Wait 4-8 weeks for healing
· Take prelimary impression and as you know you take an impression for patient with teeth ( remember anterior teeth still there and some posterior teeth )so we use an elastic material which is alginate or rubber base and use stock tray for dentate patient (don’t forget that you deal with dentate patient ) then we send it to the lab to fabricate special tray with spacer (we need spacer for alginate impression that will use in final impression )
Note;
1. in immediate denture we totally exclude ZO eugenol material cause you deal with dentate patient and the best impression taken by alginate
2. if the patient has transitional partial denture we take the impression while he wear his denture , the same thing in the final impression
3. in post immediate denture , patient may have bridge or implants so we take the impression over it
· Take the final impression by alginate or elastomer or we can use alternative impression which is a compression impression , it composition of impression past (compound impression) for edentulous part and alginate for dentate part which means , take the impression by compound for edentulous part then put alginate over the compound and retake the impression then we send it to the lab to make record block
· Jaw relation record then mount the casts together and start to set up the teeth (the only missing teeth is set and the teeth that are not extracted we don’t set it ) and go for tray-in visit but here in immediate denture , not all the teeth is set so the tray- in is consider partially not completely tray-in cause I can't check the aesthetic and phonetics ,that’s why we consider tray-in visit is lost in immediate complete denture ,actually we do this visit but we miss some steps as aesthetic and phonetics because the anterior teeth still natural , it is not a part of the denture and in this visit I just check the teeth that is stetted in the edentulous area which is the posterior teeth
Now I finish tray- in and determine the post dam area we go to insertion visit and as we said we insert the denture and extract the teeth at the same visit sooo until now the denture not complete it still partial and I want to get it for the patient complete but how????
Again until now I do all the steps for the patient and the next visit is the extraction and insertion but the denture is still partial it is not complete and next visit the patient will get his complete denture not partial, so how to convert the denture into complete ????
We ask the technician to remove the remaining teeth from master cast which is usually canines and incisors and then add teeth and acrylic to the existing denture but to remove teeth from the cast I need reference point means I need to tell the technician how much he cut from the tooth and how much he go in the dental pocket!!!!!
Assume the patient has periodontal problem he will has pocket depth more than healthy patient so you need to tell your technician how much he go deep in dental pocket
Another thing you need to think about it is the design of immediate denture cause patient will wear the denture at the same time of extraction and the main problem here is maxillary prominence ,so we need to think how to fit the denture in this prominent premaxilla ,we have 4 options,
1. Open face design (without anterior flange) it give me natural appearance and it easy to insert , exactly reproduction of the teeth position and easier to set the teeth and no interference with lip musculature but it give me poor retention , the natural appearance is not long maintained ,short life denture , difficult to rebase and irregularity of anterior ridge may develop
2. Labial flange without alveolectomy ; good retention and support ,easy to rebase , give me strong denture and rapid healing with smooth ridges but it difficult on case of undercut and poor appearance
3. Labial flange with alveolectomy; it indicate in case of
1-prominent pre-maxilla which prevent denture insertion and give me poor appearance
2-limited anterior interalveolar space and deep vertical overlap
4. Labial flange with alveoletomy ; we use it if the alveolectomy is carried out and we need to eliminate the undercut but sometimes the undercut can't be completely eliminated
Alveolectomy is totally remove of labial plate( you will remove from the cortical bone )
Alveoletomy just remove the interseptal bone(the bone that remain between the sockets of the teeth after extraction ) and collapse the labial plate into the palatal plate so labial plate will pushed backward so you cut from sponge bone
So you need to tell the technician which design you select and he will adjust it on the cast how??
If you decide to do alvectomy the technician should trim all labial plate from the cast or if you decide to do alvelotomy he will trim less from the cast and if you don’t want to any of them just tell the technician how much he cut from the socket and he will adjust it
again you need to tell your technician how much he cut from the teeth and how much he go deep on the packet and which design you decide to do and he will adjust all of these on the cast .
After he cut the teeth from the cast and adjust the design and the deep of socket , start to set the teeth and do all the processing ,packing and fasking
Now the denture is ready to insert in patient mouth and we go to the next visit (extraction and insertion )
· Extraction and insertion
we send patient to the surgeon to extract his remaining teeth resulting in residual ridge but did you think the residual ridge that remain after teeth extract is the same ridge that the technician was designed on the cast as you tell him ?????????? really it not because sometimes extraction leave bone spicules or high spot in some area so who we can make the ridge of the patient similar to ridge in the cast ?????
After the technician cut the teeth from the cast and adjust the design he should take impression for the cast to acts as a surgical guide by acrylic or silicon , so after teeth extraction, the surgeon will take this guide and adapt it on the ridge and trim from the bone or from the tissues where there is pressure , this way will help us specially if the design is alveolctomy cause it more likely to leave spicules
So by this way the ridge have been adjusted in the clinic exactly as has been adjusted in the lab on the cast
· Post insertion care
After denture inserted to patient mouth you have to instruct your patient to keep the denture inside his mouth for 24 hours and come next day without remove it and tell him if it loose-out suddenly during this time put it back immediately because there is injury in the tissue caused by the extraction and remove the denture may cause edema in addition to avoid rising first day
So the patient will came back after 24 hours and usually there is high spot (red spot ) we relive it , don’t use pressure indicating past cause it may causing pressure over the healing socket , alternative of it we use indelible pencil
After that patient can get his denture off and start to rise his mouth by water and salt or to clean the denture and sleep while get it off
3-5 days ,bring your patient again , use pressure indicting past and do slight refine the occlusion
Follow up, you can use tissue condition if need and remove any socket convexities to avoid healing defect
You may notice that the denture become loose , this is because the patient used his denture so there will be some changes on the alveolar ridge ( as you know bone resorption following extraction of the teeth is rapid at first ,but it continues at a reduced rate throughout life )and this will cause loss in retention , to improve that we use tissue conditioner
And keep in your mind immediate denture need to be reline and rebase 3 months later on (only necessary in the area of extraction) and replace by a new denture during 6 to 12 months(6-12 months is the time of the residual ridges resorption and after that the denture become loss and should to replace it)
Post immediate denture
rarely used , Its idea is the patient don’t want to extract his posterior teeth( usually he has extensive bridge from 3 to 7 or implant or there is pathology such as a large cyst ) means he want to extract all his teeth in the delivery stage and this will eliminate tray- in stage so you need to be more accurate and there is a high chance of error
after we show the types and technique of immediate denture what is the advantages and disadvantages of it
Advantages
* self esteem => one of the main problem with complete denture is the patient become disappointment once they loss their teeth and they can't socialized and eating or speaking but when the denture is immediate the edentulous period is eliminated and this has a great social and psychological significant
* jaw relation are kept => cause the patient still has his teeth so you can check centric relation and vertical diminition perfectly
* function is maintained => patient keep eating and speaking and do all the function until the insert visit and after that he will start using his denture so he will not leave your clinic with any gap or any tooth loss during the procedure
* aesthetic => cause he never life as a edentulous
* less resorption with rapid healing => as you know as long as patient become edentulous bone become more resorp and this is caused by the load on alveolar ridge but when the patient get denture immediately after teeth extraction the resorp will be less
Notes
Bone resorption is happen due to the load over the ridge which stimulate bone resorp and this load is less if the patient wear his denture immediately
* a very natural and functional result can be obtained as lip position .occlusal plane , vertical height and occlusion can all be exactly
* functional mastication and tone of facial muscles is maintained
* size .shape ,shade and position of teeth can be accurately reproduced
*no unnatural mandibular movement will developed and change in tongue shape is prevented
*little interference with speech , diet ,TMJ and its function
*socket are protected and healing is quickened
Disadvantages
*if there is slight malocclusion the denture become unstable means if natural teeth are maloccluded then the accurate reproduction is not possible so the result is prosthetic malocclusion and irregular occlusal plane
*it need more time and more appointment in addition it more cost
* there is no try- in stage ; as we said previously that actually you do tray-in visit but it lost some steps as aesthetic and phonetics so you need to be more accurate in your work
*can't be made for all type of patient some of them is irresponsible and wear immediate denture for long time will damage the oral cavity
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