immediate den

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82 DentalUpdate March 2010

Geoffrey St George

Immediate Dentures: 1. Treatment PlanningAbstract: The treatment planning, clinical stages and construction of immediate dentures pose challenges to both dentist, dental technician and patient. In this two-part series, the various principles for successfully providing patients with immediate dentures will be discussed. This first paper examines the advantages and disadvantages, as well as the treatment planning involved in providing immediate dentures.Clinical Relevance: Although the provision of immediate dentures is common in dental practice, it is a treatment option which is not without problems. This article will show how careful planning, prior to treatment starting, can prevent unforeseen complications occurring.Dent Update 2010; 37: 82–91

An immediate denture is a complete or partial removable denture constructed for insertion immediately, following the removal or alteration of natural teeth. It is an effective way of maintaining aesthetics and function when transferring from a natural to artificial dentition. An immediate denture can also be termed a transitional denture owing to its limited life span. This is in contrast to what is sometimes called a ‘classic’ immediate denture, where teeth are removed and dentures are constructed and fitted after a short healing period.

The 1998 UK Adult Dental Health Survey1 showed that the population of the UK was retaining its teeth for longer, with a corresponding decrease in the proportion of

the population which was edentulous. Despite this, there are patients who, even with modern preventive and restorative dentistry, will still lose teeth because of caries, periodontal disease, or other causes, eg trauma.

Immediate dentures, whilst offering a solution for patients with a failing dentition, present problems clinically. Teeth requiring extraction are often in unfavourable positions, mobile, and create difficulties with accurate impression-taking and jaw registration. There also may be limited or no opportunity to assess aesthetics, or phonetics, prior to insertion of the dentures. However, their construction for those about to be rendered edentulous, or partly-dentate is considered essential owing to the aesthetic and functional demands of the patient.

Advantages and disadvantages

Advantages

There are many reasons why immediate dentures are prescribed following the extraction of teeth:n Maintaining appearance

Most patients would prefer extraction of teeth and immediate placement of a denture, following tooth extraction. For many, this is the primary reason they

Geoffrey St George, BDS, DGDP(UK), MSc, FDS(Rest Dent), Consultant in Restorative Dentistry, Sela Hussain, BDS, MSc, MFGDP(UK), MFDS RCS(Edin) FDS(Rest Dent), Consultant in Restorative Dentistry and Richard Welfare, BDS, MSc, FDS RCS(Eng), Consultant in Restorative Dentistry, Endodontic Unit, Eastman Dental Hospital, University College Hospitals NHS Trust, 256 Gray’s Inn Road, London WC1X 8LD.

are fitted. Appearance is maintained, which benefits patients psychologically, and allows them to face everyday life without the embarrassment of missing teeth.n Duplication of existing teeth and jaw relationship

The existing tooth shapes, colour, position, arch form and inter-occlusal relationship can all be replicated by copying the patient’s natural dentition directly into an immediate denture. This also maintains the existing occlusal vertical dimension, if correct, and soft tissue support.n Maintain function

The patient is never without teeth, so has to adapt less to the shape of an immediate denture than when fitted with a new denture after resorption of their edentulous ridges has occurred. This is particularly important in patients with large numbers of teeth missing in multiple quadrants of the mouth. They allow a gentle introduction to denture wearing, prior to the construction of complete dentures.n Prevention of tongue spread

Loss of posterior teeth may allow the tongue to relax and expand into edentulous sites, making future denture wearing difficult to tolerate.

Despite the benefit of preventing tongue spread, and the minimal interference

Sela Hussain and Richard Welfare

March 2010 DentalUpdate 83

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with function already mentioned, a survey of denture wearers showed that immediate dentures resulted in more problems than dentures fitted after a period of edentulousness.2 This may have been due to the problems associated with socket healing and bony remodelling.n Reduction in resorption of alveolar bone

There is some evidence3,4,5 that an immediate denture, whether partial or complete, can reduce the rate of alveolar resorption around extraction sites.n Protection of tooth sockets

Sockets are covered with denture flanges, reducing blood clot disturbance and bleeding.

Disadvantages

n DiscomfortOwing to the difficulty in

predicting exactly the pattern of tissue changes following extraction, denture fitting surfaces often cause trauma to the healing sockets. These are easily adjusted at subsequent visits. With careful planning, most patients find this a small problem and are

generally satisfied.6

n Increased cost and number of visitsConstruction of immediate

dentures requires longer laboratory and chair-time, and additional appointments for adjustments and relines, as hard and soft tissues remodel following tooth loss. In the longer term, a definitive denture will also need to be constructed. These extra stages result in increased costs to dentist and patient.n Inability to assess aesthetics at the try-in stage

A try-in stage is only possible when teeth are missing, which then allows some assessment of aesthetics. However, when teeth are extracted at the time of denture insertion, no prior check can be made. The best that can be achieved is the copying of the existing natural tooth set-up, if it is deemed satisfactory. If the remaining teeth are in an unfavourable position (Figure 1a) or missing, then photographs taken prior to tooth movement (Figure 1b) may help in copying the appearance of missing natural teeth, as well as helping communication with the technician.

Treatment planning

A number of factors need to be considered before treatment starts:n Dental history;n Medical history;n Oral examination;n Jaw relations and occlusion;n Radiographic investigation;n Surgical procedures.

Dental history

It needs to be established if the patient is a regular attender, and is keen to retain some teeth, or whether removal of all remaining teeth is in the patient’s best interest. It is important to evaluate each patient’s needs and expectations, as well as how he/she would cope psychologically to being rendered edentulous. Immediate dentures may allow patients to cope with the transition to edentulousness less traumatically.

It is imperative to discuss the limitations of complete and partial immediate dentures, the patient’s thoughts about having teeth extracted, and when this should occur. It is the authors’ experience that treatment is generally more successful when the patient requests to have the teeth extracted than

when they are told to have them extracted. Financial aspects also need to be discussed, as a new definitive prosthesis may be needed at a later stage.

Medical history

A thorough medical history needs to be taken, as many patients who require immediate dentures are elderly and suffering from diseases which need special management as a result of their impact on health, or their control with medications. When teeth are to be extracted, the following needs to be borne in mind:

Bleeding disorders and patients receiving warfarin

Patients with a bleeding disorder or taking a medication such as warfarin can still have multiple extractions, provided there is careful treatment planning, atraumatic extractions, and liaison with their physician is carried out. However, if, following careful consideration, the patient’s general dental practitioner feels there are additional medical reasons why the patient should be cared for in a hospital setting, then a referral should be made.

Immediate dentures may encourage haemorrhage in patients with these disorders, despite their perceived protection of blood clots in extraction sockets. This is more likely with poorly supported open-faced dentures, which are pushed into healing sockets. Well-supported prostheses are more likely to protect denture sockets and assist in rapid healing.

Patients at risk of bacterial endocarditis

There is no evidence to show that patients who are at risk of developing bacterial endocarditis go on to develop the signs and symptoms of this disease more frequently following the wearing of immediate dentures. Despite this, all precautions should be taken to minimize a bacteraemia7 by ensuring good oral and denture hygiene, providing good post-operative care, and ensuring that sensible denture design is provided.

Oral examination

The oral examination of the patient needs to be thorough, and the following factors need to be assessed.

Figure 1. (a) Teeth in an unfavourable position prior to extraction and denture construction. (b) Using photographs taken prior to tooth movement, an assessment of future denture aesthetics can be made.

a

b

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Presence of oral disease

The tissues of the mouth need to be examined for the presence of any disease, as well as any local factors that may affect the design of the dentures, eg the presence of tori or other bony undercuts.

Many patients who require immediate dentures may have failing dentitions. A thorough examination of the remaining teeth should be performed. Carious lesions and restorations need to be investigated, both clinically and radiographically. Untreated periodontal disease may have little long-term significance if teeth are to be extracted. However, if periodontal treatment is performed prior to impression-taking, any subsequent gingival shrinkage will occur prior to impression-taking and denture construction, ensuring the completed denture is better adapted to the underlying soft tissues at the time of insertion.

Number of teeth and their prognosis

If dental arches are intact, then the number of clinical stages prior to insertion of dentures are limited to impression-taking and shade-taking, as no try-in is possible. However, careful planning is needed when the vast majority of teeth will eventually need extraction, as a decision has to be made of how to stage the extractions.

The staged extraction of teeth over more than one visit allows the healing of tooth sockets, which can provide areas of firm support after a complete immediate denture is fitted. After the first wave of extractions, edentulous spaces may or may not be restored with partial immediate dentures. When an immediate denture is provided after the first wave of extractions, the patient can accommodate to a smaller, better retained denture and develop his/her denture wearing skills before being provided with the final complete denture.

Traditionally, when rendering a patient edentulous, the posterior teeth were extracted first then the anterior teeth were extracted at a later date. This approach is unhelpful as the temporary retention of a few occluding posterior teeth is advantageous as it maintains both the existing jaw relation and occlusal face height. In practice, a combination of anterior and posterior teeth with the worst prognoses are usually extracted first, whilst teeth with better prognoses are extracted at a later stage.

Teeth missing and no previous denture

If the patient’s remaining teeth need extracting, then edentulous ridges will provide good tissue support for the immediate dentures. The exact benefit will depend on the number of teeth needing extraction, compared to the size of any ridges present.

Partial denture present

A decision needs to be made whether to use the patient’s existing denture and add additional denture teeth to it, or construct a completely new denture. This will depend on the condition of the existing denture, and whether the patient is willing to part with it for a day or more, for the laboratory stages to be completed. The design of denture also influences decision-making, as cobalt-chrome dentures with a skeleton design, and little acrylic in areas of proposed tooth replacement, may not be suitable for the addition of extra teeth.

Presence of bridgework

Edentulous ridges under bridge pontics provide firm areas of support for the future denture, following removal of the bridge. However, extra time has to be devoted to sectioning bridges at the extraction appointment.

Overdentures

If strategic teeth have a good prognosis, and the patient is able to maintain them, then these teeth can be retained, reduced in height, and can be kept as overdenture abutments. Depending on the size of the pulps, root canal treatment may be necessary to prevent endodontic complications, as well as offering the possibility of additional retention of the prosthesis, if an intra-radicular precision attachment is cemented. The retention of roots benefits the patient psychologically, as well as maintaining alveolar bone.

Future planning

Teeth with a guarded prognosis should always be treatment planned when designing immediate dentures. It should be possible to add extra teeth to dentures relatively easily, whether they are made from acrylic or metal, by incorporating features which will allow further acrylic additions.

Jaw relations and occlusion

The recording of jaw relations involves decision making as to whether an existing relationship is to be maintained, or changed. This is best achieved with mounted diagnostic casts, which enables static and dynamic occlusion to be evaluated. As was previously mentioned, patients attending for extraction and immediate dentures often suffer from periodontal disease, multiple carious lesions, drifting and overeruption of teeth. This results in occlusal discrepancies and interferences in the retruded contact position (RCP). This may need to be addressed prior to impression-taking and subsequent jaw registration, to facilitate accurate record-taking. When a number of natural teeth are to be retained, a conformative approach is chosen, which maintains the existing jaw relationship. Problems arise when patients with unsatisfactory jaw relationships are rendered edentulous, and where existing jaw relations are unsatisfactory in patients requiring partial immediate dentures.

Maintaining jaw relations

Maintaining the jaw relationship is an option when a satisfactory occlusal vertical dimension (OVD) is already present, and removal of teeth will not result in the displacement of the mandible posteriorly, ie when the patient’s intercuspal position (ICP) is equal to his/her retruded contact position. The jaw relationship may also be maintained where only some of the remaining teeth are to be removed, and the intercuspal position will be retained by the remaining teeth. When all the posterior teeth have already been lost, the mandible may have fully re-positioned so that any slide between RCP and ICP has been eliminated. Therefore, the current jaw relationship can be replicated into immediate dentures, following the removal of the patient’s remaining teeth.

Changing jaw relations

Where natural tooth-to-tooth contacts occur, approximately 90% of dentitions have a small discrepancy (1.25 mm +/- 1.00 mm) between ICP and RCP.8 This presents as a slide when the mandible is manipulated into the RCP, and jaw closure

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results in re-positioning anteriorly into the ICP. Ideally, this slide should be eliminated before jaw relations are taken by tooth adjustment, if the teeth maintaining the current ICP are removed.

With a reduced OVD the jaw relation will need to be established on record

blocks, which extend on to the occlusal surfaces of posterior teeth to establish the correct dimension. If a few posterior teeth are missing, then this is not necessary as the natural teeth can be temporarily left separated.

When posterior teeth are missing, the mandible may re-position posteriorly, as previously mentioned or, if anterior teeth have lost bony support as a result of periodontal disease, the teeth may splay, resulting in an anterior displacement. Any tendency to posture forwards should be prevented, and the mandible should be gently manipulated posteriorly to a reproducible position, ie RCP (Figure 2).

Radiographic investigation

It is important to ensure a full radiographic survey is made of the dentition and jaws prior to starting treatment. Particular attention needs to be paid to prospective abutment teeth in terms of root length, size and shape, as well as crown:root ratios. The extent of any carious lesions in these teeth and restorations present need to be assessed, to ensure that the teeth will still be viable as abutments, or better suited as overdenture teeth, or even extracted. The residual ridge, including the extent of the tuberosity, and superficial location of the mental nerve should also be evaluated. Alveolar bone height and width can also be assessed for future implant therapy.

Denture types

There are basically two types of immediate denture in common use, based on the presence or absence of a flange:n Socketed design andn Labial flange.

Socketed design

The denture teeth are set in the sockets of the extracted teeth after preparation of the cast (Figure 3). This approach allows tooth position to be copied exactly and can produce a natural looking appearance. The absence of a flange eliminates problems of insertion and subsequent adjustment in areas of undercut. It also reduces a possible source of retention if an undercut is engaged, peripheral seal in a complete denture, and support for the denture. A lack of support may result in

damage to the residual ridge in the mandible, so this design of denture is best avoided in this case. Despite a natural appearance initially, resorption of the underlying ridge soon produces a space between the teeth and the ridge (Figure 4), which is compounded if removal of teeth has been traumatic. This is corrected with a reline, which is more difficult to perform than if a flange was present.

Labial flange

As previously mentioned, a flange may contribute to the retention and support of an immediate denture at the expense of aesthetics, owing to its increased bulk if located anteriorly, which may ‘plump’ out the lips. The extra acrylic of the flange increases the strength of the denture, and is easier to reline. Deep undercuts may mean the path of insertion needs to be carefully selected, or the flange relieved to allow the denture to be inserted, which may reduce its contribution to retention. Stone models should always be analysed on a dental surveyor to see if a flange can still pass into an undercut, as undercuts less than 2 mm are usually covered with displaceable tissue.

Surgical procedures

Radiographic examination and clinical findings are used to assess the complexity of any extractions planned. The type of extraction will influence the design of the denture, and laboratory procedure carried out. A complex surgical extraction is likely to produce a greater surgical defect whose final shape will be more difficult to predict. Therefore, the denture in this case should be planned to have a flange, which is more easily relined if more supporting tissues are removed than anticipated. Problematic extractions, or those associated with large pathological lesions, may produce denture-bearing areas which rapidly lose their close fit. More advanced surgical procedures, including alveolectomy or alveolotomy, require careful planning and greater surgery time to complete.

Simple extraction

The residual ridge shape following this type of extraction is predictable, and allows a well-fitting denture to be constructed immediately after extraction. However, the

a

b

Figure 2. (a) Lack of posterior support, resulting in a patient posturing forward. (b) The same patient manipulated into the retruded contact position.

Figure 3. A socketed denture.

Figure 4. Space that has occurred between a denture and the edentulous ridge after extraction.


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depth of pocket around each tooth will influence the collapse of soft tissue into the socket. This is taken into account by measuring probing depths around teeth scheduled for extraction, and appropriately preparing the stone model on which the denture is made.

Surgical extraction

Bone removal during extraction will reduce the denture-supporting areas of the mouth immediately post-extraction. Removing one tooth may have little effect, if the denture is well supported elsewhere. However, in an aesthetic area, a space appearing between a denture and the extraction site may be unacceptable (Figure 4). In this case, the cast should be prepared to a greater extent, to anticipate greater soft tissue collapse into the surgical defect. Over-preparation can always be corrected by the removal of excess acrylic from the denture’s fitting surface. A localized reline may be indicated earlier with a surgical extraction.

Alveolotomy

Alveolotomy and alveolectomy were routinely carried out when tooth extraction was common. The alveolotomy allowed a flange to be fitted to a denture in the presence of a prominent pre-maxilla. The removal of interdental septae with Rongeur forceps and the collapse of the labial plate require careful cast preparation. A surgical template was commonly constructed from the altered cast produced, to enable the ridge to be contoured to fit the denture. Nowadays it is rarely carried out, owing to the reduced numbers of immediate dentures being made, which replace all anterior teeth at the same time. This technique has been largely abandoned in preference for altering the denture design to cope with the undercuts, which prevents unnecessary destruction of the alveolar ridge.

Alveolectomy

This procedure involved the removal of the anterior cortical plate, which was a particularly destructive technique and has therefore fallen out of favour. It was also used to reduce a prominent pre-maxilla. This technique also needed careful cast preparation. An alternative to both the alveolectomy and alveolotomy is to construct

an open-face denture, and gradually to extend its anterior flange with chemically or light-cured acrylic as bony resorption occurs. Alternatively, the anterior flange can be extended to the most prominent part of the maxilla, and extended following further resorption.

Immediate dentures and implants

Patients who require extraction of their remaining teeth and implant placement may have the implants and a conventional denture inserted following a period of healing and the patient remaining edentulous. Alternatively, the implants can be placed at the time of tooth extraction in the tooth sockets, or in the adjacent edentulous sites, and a denture inserted immediately. In both these scenarios, once implants have been placed, care needs to be taken in the design, construction and fitting of the immediate denture. Finally, it is also possible to consider immediate loading of the implants and using them to support an immediate fixed bridge, but this is beyond the scope of this paper.

When placing implants, a one-stage or a traditional two-stage surgical approach can be adopted. One-stage implant placement involves the simultaneous placement of healing abutments at the time of fixture insertion (Figure 5). A two-stage procedure is when fixtures are submerged below soft tissues at the time of surgery, then a further surgical procedure to connect the healing abutment is required. In this case, loading of the implant is said to be minimized during healing, which favours osseo-integration. This is because forces are dissipated through soft tissues and not applied directly to the implant via the healing abutment.

Both one-stage and two-stage implants present problems when immediate dentures are used.

One-stage surgery

It can be difficult to estimate soft tissue and healing abutment contours after surgery, and then construct an accurately fitting immediate denture. This problem is compounded by swelling which occurs post-operatively. Invariably, relining of the denture will need to be carried out. However, experienced operators may be better at predicting soft tissue changes. Failure or inability to make the denture sufficiently thick

could result in a denture that is too thin once adjustments are carried out, increasing the chance of fracture.

To aid adjustment, light-bodied silicone impression material is used as a pressure-indicating paste to prevent contact of the denture with the implant.9

A healing abutment which extends above the gingiva in a patient with a reduced inter-occlusal space may allow only a thin section of denture acrylic to fit between the healing abutment and the opposing tooth. This can result in the denture tooth fracturing from the denture. This is a particular problem with single tooth implants.

Aesthetics may be poor if an incorrectly placed implant or excessively long healing abutment is chosen. A gap of at least 1.5 mm is required between the fitting surface of the pontic and the cover screw/healing abutment of the implant.10 This can lead to poor aesthetics and cause food debris to accumulate underneath the prosthesis if a temporary reline is not used.

Overloading of the implant can occur unless the denture is accurately adjusted. The exposed implant fixture is subjected to biomechanical stimuli and micro-movement from the denture, which has been shown to induce a fibrous connective tissue interface between the implant and the bone, affecting successful osseointegration.11

Lower success rates have been reported for immediately loaded mandibular implants (80%) compared to those for a two-stage protocol (96%).12 It has also been shown that more crestal bone is lost in the one-stage group. This has been attributed to early occlusal loading during the healing phase, interfering with new bone formation.11 It has also been shown that, with immediately placed and loaded implants, there is

Figure 5. One-stage implant placement.

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more crestal bone loss if the prosthesis is insufficiently adjusted and fitting incorrectly.12

Submerging the implants also prevents infection and epithelial down-growth.12 If the overlying soft tissues are thin then, by having the immediate denture overlying the implant surgical site, there is a risk of exposure of the cover screw (Figure 6).

Two-stage surgery

If soft tissue management is poor, there is the potential for tissue conditioner to flow into the wound and delay or prevent healing.

Despite the absence of a healing abutment, there is often a change in the soft tissue contour, even with a submerged implant, which is difficult to predict completely.

Although the factors that facilitate osseo-integration are more favourable with this form of surgery, some of the previous problems discussed which are associated with one-stage surgery simply re-appear at the second surgical stage.

Soft-tissue borne immediate prostheses can cause uncontrolled implant loading. This can lead to implant exposure, marginal bone loss and/or failed integration, as well as prosthesis fracture.13

Two-stage surgery allows for soft tissue shaping of the extraction site to be carried out (Figure 7a). This is achieved by ensuring the fitting surface of the denture teeth of the immediate denture are ovate in shape (Figure 7b). The fitting surface can be added to with chairside acrylic or visible light-cured composite.

In cases where denture retention has been poor, eg complete dentures, patients can see a dramatic increase in retention if the tops of the healing abutments are above the crest of the edentulous ridge. If the denture

is then relined with a tissue conditioner, the restricted path of removal of the prosthesis, in combination with the restriction in lateral movement, gives the patient his/her first experience of the benefits of implant treatment (Figure 8).

If a more rigid relining material is used at the time of fit, or is used to replace a soft-lining material at the chairside or in the laboratory, then care should be taken if the healing abutments are undercut relative to each other. At the chairside, a snap-setting material can prevent the denture’s removal or re-insertion. A slow-setting material, eg self-cured, can be repeatedly removed and re-inserted to distort and eliminate the undercuts.

With patients now demanding fixed restorations to replace extracted teeth at the time of surgery, modern alternatives to immediate dentures have included:n Immediate ‘same day’ teeth

Implants such as the Brånemark ‘Novum’ or 3i ‘Diem’ systems allow the immediate loading of implants with a fixed-prosthesis at the time of extraction.n Conventional bridgework

This is only realistic when implants are to be placed and there are suitable adjacent teeth which require crowning.n Resin-retained bridgework

This option has gained in popularity,14 owing to the predictable retention rates possible with resin-retained bridgework15 (Figure 9).

Conclusion

Despite these alternatives, immediate dentures still have a place in modern dentistry, including implant therapy. It is important to remember though that the transition from an immediate denture to an implant-retained fixed prosthesis is not

without problems. It can be impossible to provide the same degree of lip support and replacement of interdental papillae with the fixed prosthesis as that provided by the flange of a denture. Therefore, the patient should be warned of this difference, or a transitional denture constructed which doesn’t provide soft tissue replacement to the same degree as a conventional denture with a flange. This will aid transition to the final fixed prosthesis.

The second paper in this series will discuss the clinical and laboratory stages necessary to construct a successful immediate denture.

Figure 6. Exposure of a cover screw due to thin overlying mucosa.

a b

Figure 7. (a) Gingival contour following placement of a denture with ovate pontics. (b) Ovate pontics on a denture.

Figure 8. Relined denture over healing abutments.

Figure 9. Resin-retained bridge over implants.


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References

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the dissatisfied denture patient. Eur J Prosthodont Rest Dent 1993; 2: 73−78.

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10. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of endosseous screw-shaped implants placed at the time of tooth extraction without augmentation. J Periodontol 1998; 69: 920−926.

11. Albrektsson T, Brånemark, PI, Hansson HA,

Lindstrom J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthopaed Scand 1981; 52: 155−170.

12. Balshi TJ, Wolfinger GJ. Immediate loading of Brånemark implants in edentulous mandibles: a preliminary report. Implant Dent 1997; 6: 83−88.

13. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000; 11(Suppl): 156−158.

14. Banerji S, Sethi A, Dunne SM, Millar BJ. Clinical performance of Rochette

bridges used as immediate provisional restorations for single unit implants in general practice. Br Dent J 2005; 199: 771−775.

15. Djemal S, Setchell D, King P, Wickens J. Long-term survival characteristics of 832 resin-retained bridges and splints provided in a post-graduate teaching hospital between 1978 and 1993. J Oral Rehab 1999; 26: 302−320.

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