Clinical Considerations for Immediate Denture Cases
Clinical Considerations for Immediate Denture Cases
By Dr. Hudnall DMD
It is truly amazing to have the technology and expertise available to us to provide our patients with excellent dental care. Several generations have benefited from emerging technologies and education about dental health. Cosmetics and procedures that enhance appearance are advertised to the masses. Dentistry is no exception. To hear advertisers talk, you would think dental disease is a thing of the past. So why do we still see patients with advanced periodontal disease or rampant tooth decay that requires the removal of all of their natural teeth in order to improve their appearance and overall well-being?
One word – fear.
Fear of pain, fear of having no teeth, fear of the expense, fear of what Aunt Martha said the dentist did to her, fear of the unknown, fear that dentistry will be performed as portrayed in horror films, fear of looking like a clown, and…you get the idea. The list goes on. A lot of fear exists in the general population when it comes dentistry. Is it any wonder dental treatment is often deferred until the situation becomes so bad that the patient is reluctantly forced to take action?
Over the last five decades, there has been tremendous progress in the treatment and prevention of dental disease as well as new ways to restore or replace teeth that are lost to disease. But one thing hasn’t really changed. And that is immediate dentures. Despite the availability of dental centers with modern dental labs on-site that replace your smile within a day, immediate dentures are basically made the same way they were in the 1950’s.
We all were probably taught the “ideal” way to transition to dentures – extract all of the teeth and allow the gums to heal for 6-8 weeks before taking impressions for permanent dentures. The second best choice is to remove the posterior teeth and allow healing for 6-8 weeks. Then take impressions for immediate dentures, extracting the 12 anterior teeth at delivery. In today’s appearance-conscious society, how many of your patients are willing to go without some or all of their teeth for 6-8 weeks?
You might be surprised. Believe it or not, some people are willing to go without their teeth if they believe it will benefit them in the long run. As clinicians it is important to offer all of the options and not allow our own biases to get in the way of other people’s choices. The same applies to discussing the cost of various treatment options. Never underestimate your patient. People will often surprise you and choose the best treatment option and come up with the money to pay for it.
A patient who is willing to go without their teeth can make the construction of dentures much easier for all involved – the patient, the dental professional and the denture laboratory. After all, you are starting without mobile or decayed teeth in the way. But what about those who don’t want to be without their teeth or don’t anyone to know they have transitioned from their natural teeth to dentures? What are the considerations?
Why Immediate Dentures?
Immediate dentures enable the patient to continue to engage in their everyday life without the embarrassment of being edentulous for a period of time. When it comes to making immediate dentures, communication with everyone involved is paramount. We must first remember we are dealing with an individual person who has certain expectations that often go unspoken. Establishing realistic expectations and treatment outcomes is key when it comes to working with an immediate denture patient. It is life-changing for them.
An immediate denture isn’t a replacement for their teeth but rather a replacement for having no teeth at all. The immediate denture serves as a Band-Aid and is a best guess before moving on to a better, more long-term solution. When a replacement set of dentures is fabricated, the permanent dentures will not be an exact duplicate of the immediate denture. This is because the ridges and tissue that support the dentures have healed and changed dramatically, requiring the teeth to be positioned slightly differently. I have worked with patients who liked the look of their immediate dentures so much they were never truly satisfied with any final dentures. Never mind that their immediate dentures no longer fit correctly. Setting patient expectations before any treatment is performed and reinforcing that conversation at each and every step is key for a good outcome.
Equally important is communication with your dental laboratory. After all, the lab technician has not met the patient. The next best thing is a picture. A series of good digital photographs can show the lip line at repose, the lips at full smile, the profile, and the appearance of the teeth with the soft tissue retracted in a way that it is impossible to communicate with study models or written instructions alone. Written directions may be used to supplement the photos. It is important to note if the patient is happy with their current tooth color, size, shape, profile, midline position, and smile line.
Some patients have never been happy with their smile and are ready for a change. I once had a patient bring me a picture of Reba McEntire and asked that her new teeth look like Reba’s. Talk about a drastic change for her. Have you ever looked at Reba McEntire’s teeth closely? I did warn the patient that the tooth shape was quite a bit different than her own. With some discussion, we made her immediate dentures as she requested then compromised on the tooth mold somewhat for the permanent denture to obtain the look that she really had in mind.
Clinical considerations for traditional immediate dentures include how to take good impressions and a bite registration that accurately represent the current state of the patient’s mouth. It sounds easy. But mobile and extruded teeth can present a clinical challenge. Creative adaptation of custom impression trays is often required in these cases.
The degree of inflamed tissue and bone loss may mean that once the teeth are removed the gum tissue may shrink much more than expected – like letting the air out of a tire. This translates to immediate dentures that fit more loosely than the lab technician could have reasonably predicted. Relines may be necessary sooner than later in order for the dentures to fit reasonably well. If an immediate denture can be made to fit comfortably, it is possible to extend the time before a replacement final denture is fabricated thus allowing additional healing before the final appliance is made.
After using the same basic technique for 60-plus years, immediate dentures are finally moving toward the digital age. Scanned impressions have allowed denture laboratories to make CAD/CAM 3D printed models without the need to pour impressions from stone. This has reduced one source of errors.
More recently, numerous case studies report employing intraoral scanning to capture all of the patient’s teeth, hard tissue, and the adjacent periphery of soft tissue in order to create totally impression-free digital images for immediate dentures. The current generation of intraoral scanners on the market capture the details of hard tissue quite well. But they are less precise when scanning soft tissue. In reality, immediate dentures don’t have to be exact because the tissue is expected to change and shrink as it heals. Relines remain a part of the immediate denture protocol and a necessary procedure to compensate for shrinkage and to improve comfort and fit.
Benefits of scanned impressions include eliminating the difficulty of taking traditional impressions of mobile teeth, more accurate occlusion, fewer appointments, and improved patient comfort during the impression phase of the procedure. 3D technology also allows the laboratory to fabricate a clear surgical stent as a template for bone recontouring without compromising the fit of the immediate dentures.
Additional technological advancements are on the horizon. Dental equipment manufacturers are currently working on improved scanning technology that will allow soft tissue to be scanned and digitized accurately. Technology is finally beginning to address and improve upon what clinicians and lab technicians have been doing the same way for decades. Are you ready to take the next logical step with immediate denture cases in your practice? Totally “impression-less” dentures will become the standard in the not too distant future.
Stomadent Dental Laboratory is on the forefront of new technology. We invest our time, energy and talent on training and resources that advance dentistry into the digital age.
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