Immediate denture

immediate denture According to Glossary of Prosthodontics terms It is a partial or complete denture, that’s fabricated to replace natural teeth immediately after extraction

1. IMMEDIATE DENTURE Prepared by Dr .Ibrahim Muneim Hussein B.D.S

2. Definition Advantages of immediate denture Disadvantage of immediate denture Indication of immediate denture Contraindication of immediate denture Types of immediate denture Treatment Sequence Methods of construction of immediate denture Alevoloplasty Digital immediate denture

3. WHAT IS AN IMMEDIATE DENTURE ?

4. According to Glossary of Prosthodontics terms It is a partial or complete denture , that’s fabricated to replace natural teeth immediately after extraction Definition

5. 1. Avoid any change in patient’s appearance and Prevent changes of the facial and oral musculature. Advantages of Immediate Dentures

6. Advantages of Immediate Dentures 2. Promotes better healing and The denture can prevents swelling. 3. Promotes better ridge form. 4. Prevents collapse of facial musculature. 5. Hastens patient adaptation to dentures. 6. A surgical stent and protective bandage helps to reduce bleeding. 7. Protect the tissues at sensitive extracted sites from irritation.

7. 8. Establish the speech patterns more easily. 9. Prevents patient embarrassment. 10. Promotes patient health. 11. Provides a guide for optimal patient esthetics. 12. Provides a guide for V.D.O. Advantages of Immediate Dentures

8. Challenging Factors and disadvantages of Immediate Dentures 4. Increased denture maintenance. 5. Increased treatment time and cost. Increased complexity of clinical procedures. Limited evaluation of trial dentures. Increased patient discomfort.

9. Indications for immediate denture Physical reasons: 1. Disuse atrophy of the bony base 2. Unfavorable trabeculation of the repairing bone 3. Damage of the temporomandibular joints

10. Indications for immediate denture Physiologic reasons: 1.Abnormal functioning of the mouth and mandible 2. Impaired enunciation 3.Abnormal deglutition

11. Indications for immediate denture Psychologic reasons: 1. Humiliation 2. adverse subjective reactions 3. serving the indifferent patient

12. Patient is unavailable for appointment. Patient is debilitated or with Systemic conditions (poor surgical risk). Acute infections that require drainage. Emotionally disturbed or diminished mental capacity and Indifferent patients. Patient who have undergone Radiation therapy. Patient with a severe Gagging reflex. Patients with extensive bone loss. Contraindications of Immediate Dentures

13. Types Immediate Dentures Partial Immediate Denture Transitional Immediate Denture Conventional Complete Immediate Denture

14. Differentiate between Immediate & Interim Dentures !

15. Interim immediate denture A dental prosthesis to be used for a short interval of time for reasons of esthetics, mastication, occlusal support, or convenience, until more definitive prosthetic therapy can be provided.

16. Interim immediate denture may be : A removable partial denture can serve as an interim prosthesis to which artificial teeth will be added as natural teeth are lost. A transitional denture may become an interim complete denture when all of the natural teeth have been removed from the dental arch.

17. Immediate Partial Denture

18. Immediate Treatment Partial Denture: A partial acrylic resin denture that is placed at the same appointment of extraction to restore esthetic and function immediately.

19. Immediate treatment partial support stability retention

20. Immediate Transitional Denture

21. Immediate Transitional Dentures Indications Multiple extractions Esthetics Function If conventional ICD contraindicated

22. Immediate Transitional Dentures Problems Intensive post insertion care Short-term solution More expensive After healing, a second denture is made

23. Immediate Complete Denture

24. Conventional Complete Immediate Dentures A complete removable denture or over-denture fabricated for placement immediately after the removal of natural teeth

25. Maxillary six anteriors are still. Remove all posterior teeth about 1-3 months before making immediate denture. Predictable, a stable ridge contour. Conventional Immediate Complete Dentures

26. Conventional Immediate Complete Dentures Rationale Allows for posterior segment to heal and stabilize. Maintains anterior teeth for appearance, some function. After healing, it is relined with acrylic resin.

27. Conventional Immediate Complete Dentures Indications Maxilla anterior teeth present Cooperative patient Not Recommended Both jaws simultaneously Mandibular arch

28. It is not advisable to attempt to construct an immediate denture to replace more than six or eight teeth in an arch : First, there is considerable blood loss during the removal of teeth and associated alveolectomy . Second, the denture will be subject to a greater degree of procedural errors and will fit only for a short time. (The six anterior teeth and perhaps the premolars)

29. Immediate Denture Treatment Sequence

30. Oral examination and informed consent The panoramic radiograph provides a useful diagnostic aid. After reviewing the dental and medical history of the patient, head and neck examination is performed. During the normal intraoral examination, the dentist should include and record periodontal probing, a full charting of all the teeth, need for frenum release, tori reduction or any other hard and soft tissue surgery if necessary . When possible, teeth should be selected for retention as overdenture abutments.

31. The normal and the common anatomic abnormal difficulties of the mouth relative to immediate denture insertion is classified as: 1-Hard tissues (exostoses, spiculae , mylohyoid ridges, knife-edge ridges, maxillary tuberosity and alveolar contour) 2-Soft tissues (abnormal frenula and ligament and muscle attachments) 3-Ridge relation (faulty ridge relationship). Also notation of following factors help in later visits like Existing midline and need for modification of its position Patient's existing vertical dimension of occlusion and amount of interocclusal distance and the need for conforming to or changing it 3. Horizontal and vertical overlap of anterior teeth 4. Type of angle's classification of occlusion for the patient 5. Display of posterior tooth in the buccal corridor

32. 1st Clinical Appointment - clinical Examination & preliminary impressions Lab procedures - custom tray fabrication

33. 2nd Clinical Appointment - Master impressions Lab procedures - master cast, record base & occlusion rim fabrication if indicated

34. 3rd Clinical Appointment - Maxillomandibular relation records, and tooth selection Lab procedures – Cast trimming, Setting of the teeth & wax trial + denture fabrication

35. 4th Clinical Appointment - Wax trial denture try- in (confirm mounting & esthetics) if indicated Lab procedures - process dentures

36. 5th Clinical Appointment - Extractions & denture insertion, adjust tissue surface & flanges, adjust occlusion & care instructions

37. 6th Clinical Appointments - 24 hour post-insertion checks, adjust dentures & reinforce care instructions

38. 7th & 8 th Clinical Appointments - 72 hour, and one week post-insertion checks adjust dentures, clinical remount & reinforce care instructions

39. Placement of the denture - After completion of the surgical procedures, the patient is instructed to close against sterile gauze until the cessation of the bleeding. As soon as the patient has recovered from the immediate effects of the operation, the denture is inserted . - Pressure-disclosing material will aid in locating pressure points, - check the occlusion, even gross occlusal disharmonies in an immediate denture are corrected in the mouth. Final occlusal adjustment will be delayed until all swelling and edema have subsided and the patient is comfortable.

40. Impression Techniques

41. Fundamentals for impression making: Area coverage Borders Valve seal without interference of function Accurate adaptation of the underlying tissues without injurious displacement. Preserve the maximum ridge bulk.

42. Selecting & Arranging artificial teeth:

43. Special Lab work for Immed . Comp. Dent. For tooth set-up: Anterior teeth: Cut anterior teeth off cast at gingival level. Set anterior teeth on cast for patient viewing. Posterior teeth: Arrange posterior teeth on record base in (balanced/ monoplane/ lingualized ) occlusion, and wax-up for try-in evaluation.

44. Set-up the anterior teeth: Immediate Denture Laboratory Project

45. Use a sharp pencil to mark the gingival outline buccally and lingually Preserve the incisal edge position and tooth angulation information prior removal of stone teeth.

46. Different Methods For Cast Trimming Immediate Denture Laboratory Project

47. The teeth are removed from the cast in a manner that They are not cut below the gingival crest 1-

48. The terminal 5 mm of gingiva should be trimmed in the manner shown above so that the denture gingiva may not appear too thick. 2mm

49. Remove stone tooth without obliterating the gingival outline mark and shape into a gentle convex shape. Place a subgingival esthetic convenience groove at the labial gingival sulcus to aid in esthetic positioning of the denture teeth. Esthetic convenience groove 2-

50. Modify the undersurface of denture tooth until the desired incisal edge position is reproduced in the setup

51. 3- The Alternating Tooth Setup Technique Trim and set only one anterior tooth at a time. Alternate from side to side to keep natural neighboring tooth as angulation , length, and contour orientation.

52. 15 mm Complete the anterior teeth setup

53. During the Setting-up of Anterior teeth: The study model can be used to compare the tooth arrangement incorporated in the replacement teeth.

54. Set-up the posterior teeth: Immediate Denture Laboratory Project

55. Sectional wax-up Anterior segment for patient viewing. Posterior segment for check record.

56. Immediate Complete Denture Try-In

57. Usually the Posterior segment only tried as a “removable” section used for: Confirmation of horizontal and vertical relationships Tooth shade

58. Post Extraction Instructions

59. Include the following points: Do not remove denture Keep head elevated Small amounts of blood in saliva is normal Diet: soft and warm, not hot Avoid: Spitting, rinsing Strenuous activity Alcohol, smoking

60. Post-placement Care .Pressure-indicating paste is used to locate pressure areas .overextensions of the denture borders are reduced. .The occlusion is checked for interceptive occlusal contacts. .patient should be seen every 24hours for the first three days, then every other day for one week. The first 24 hours  Patient should Not to remove the dentures from the mouth during the first 24 hours,  Patient should be reminded that the pain from extraction will not reduce by removal the denture.  ice packs may be held on the face to combat swelling.  eat a soft diet  Analgesic, antibiotic, must be prescribed to patient depending on the case.  return for a scheduled appointment.  1st Adjustment must be seen after 24 hours:-  Remove denture 5 times per day  Rinse the mouth with warm saline  Avoid mouthwash containing alcohol

61. Post Insertion Management Recall next day Remove denture Apply topical anesthetic to traumatized mucosa Locate over extensions and pressure areas and adjust Reappoint 1 week

62. The dentures should be worn at night for the first week only, after this period, the dentures should be week only, after this period, the dentures should be removed at night . Proper nourishment is essential to the overall treatment of the patient and must not be neglected. • 1 st week after extraction and denture insertion:- I-Instruct your patient to wear the denture day and night for first 7 days after extraction or until swelling reduction. 2-Remove the denture 4 or 5 times a day after the first day, and rinse the mouth with warm salt water. Do this for the first week. 3- The denture must be cleaned and rinsed after meal as early as possible and when removal and insertion of the denture is with little or tolerable pain .

63. Further follow up care:- 1- 2nd week is the next call, this is depend on the case. Then the patient should be seen one month later, 4-6 months intervals. 2-A denture adhesive will be necessary to help hold the denture in place. 3- Relining may be necessary to achieve esthetic and occlusion corrections. 4- Frequent or periodic recall mainly for changing temporary liner, this is depend on the rate and amount of bone resorption and ability of patient to keep the liner clean

64. Post Insertion Management Healing, shrinkage, resorption Patient remount Relines Interim – within first 12 months Definitive – 12 months +

65. Post Insertion Management Occlusal adjustment & Remount when: Healing edema resolved Traumatized mucosal lesions healed Usually within 14-21 days

66. Post Insertion Management Reline Short term – tissue conditioners Mid-term – intermediate direct liners Long-term – standard reline protocol

67. THERE ARE 2MAIN METHODS OF CONSTRUCTION Immediate Complete Denture

68. 1 Without surgery ( Without Alveoloplasty ). A- Partially flanged type B- Socket type C- Completely flanged type 2 with surgery (Surgical Alveoloplasty ) Must be …Completely flanged type

69. 1-Anterior teeth socketed immediate denture (open face design) Advantages: a-Very natural appearance b-Easy to insert c-Exact reproduction of tooth position d-Easier to set teeth in laboratory e-Not interference with lip musculature Disadvantages: a-Poor retention and inadequate support b-Natural appearance is not long maintained c-Denture has short life

70. 2-labial flange without alveolectomy immediate denture . Advantages: a-Good retention and support b-Rapid healing with smooth ridge c-Easy in rebasing d-Stronger denture Disadvantages: a-Poor appearance due to labial fullness b-Difficult in case of undercuts c-Lack of space around necks of teeth and so denture teeth are often shortened after final waxing

71. 3-labial flange with alveolectomy immediate denture Indications: a-Prominent premaxilla which prevent insertion of a flanged denture b-limited anterior inter-alveolar space and deep vertical overlap Contraindications: a-Fairly severe surgical task b-Increase in resorption following labial cortical bone removal

72. 4-labial flange with alveolotomy immediate denture. Advantages: a-No cortical bone is removed and post-surgical resorption is reduced b-Surgery is less traumatic than alveolectomy c-Less interference with facial form Disadvantages: a-The undercut cannot always be completely eliminated

73. Unless it is necessary, one should avoid alveolectomy in the anterior region. If it must be performed because of marked undercuts, a transparent tray should be prepared for use during the surgical procedures. It must be adapted to the cast after the necessary - cast alveolectomy " has been performed.

74. Comparisons of flanged and open faced denture 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. 3. 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. 4.The presence of labial flange produces a stronger denture, 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 .

75. 5. As the bone resorbed fallowing extraction the denture become loose and a reline is required , so the presence of labial flange make it easier to add either a short term soft lining materials or a cold curing relining materials as a chair side procedure, as the color of some reline materials is not always ideal they may be visible when used with open face denture. 6. The flange denture cover the clot completely and protect them more effectively, the flange denture exerts pressure on both lingual and labial gingiva reducing post extraction hemorrhage. 7. 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. 8. 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. 9. 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 contra indication.

76. Alveoloplasty “ The recontouring or reduction of a portion of the alveolar process ”

77. Goals of alveoloplasty Eliminate bony projections that result in undercuts. Improve the path of insertion of the prosthesis. Eliminate bony sources of irritation . Increase space between the residual ridges (inter arch space I.R.S). Improve denture stability by removal of excess tissue.

78. Disadvantages of Aleveoloplasty Accelerates bone loss Increased post-operative pain

79. Types of Alveoloplasty Simple alveoloplasty Buccal or labial cortical reduction Intraseptal alveolectomy and cortical plate in-fracture . Buccal or Labial Cortical Recontouring

80. Surgical techniques include Simple Excision Cryosurgery Electrosurgery

81. Immediate Complete Denture Master Cast Trim Trimmed areas sanded smooth Avoid removing incisive papilla

82. Immediate Complete Denture Surgical Template Fabricated after cast trim Used to locate the pressure areas on mucosa at time of surgery Denture trimmed according to blanched mucosa observed under template

83. Fabrication of Surgical Template A clear surgical template duplicating the surface of the immediate denture after modification of the stone cast is used at the time denture placement as a guide for surgically shaping the alveolar process. The clear template allows the dentist to visualize the adaptation of the denture base to the residual ridge. Blanching of the soft tissue as seen through the template indicates excessive pressure . .When the extractions and alveolectomy are being done, the surgical template can be inserted in the patient's mouth from time to time to assess if sufficient bone has been removed.

84. Then continue the construction of Immediate. Denture. steps as usual, according to the planned trimmed R.R. & new position of the anterior teeth.

85. Digital Immediate Denture the conventional methods for fabricating immediate dentures and complete dentures have not changed for the past 50 years and involve multiple clinical appointments and lengthy laboratory schedules Several commercial manufacturers currently fabricate complete dentures using computer-aided design and computer-aided manufacturing (CAD/CAM) technology. The use of computer – aided engineering (CAE) and computer – aided design/computer - aided manufacturing ( CAD/CAM ) technology to fabricate complete dentures was in troduced in 2011.

86. Digital dentures fabricated using CAD/CAM technology can reduce clinical appointments, provide high accuracy in denture fit, allow less polymerization shrinkage of the denture base, and facilitate easier duplication of dentures. This technique not only reduced treatment time, clinical visits, and dental expenses but also maintained the patient’s appearance, mastication, occlusal vertical dimension, and maxillomandibular relationship. A full digital workflow can be used to produce immediate denture

87. Thank you

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