Practical Tips in Dealing with Patients Requiring Immediate Dentures
Before implants became mainstream, there were not a lot of treatment solutions for patients with terminal dentition. Fortunately, with the development of immediate placement and immediate loading of implants in the last two decades, there have been new interests among the dental professionals in how these patients can be treated with predictability. Some of the treatment solutions have helped these patient restore their function, their smile and more importantly their confidence.
Unfortunately, there are always those patients who may not be candidates for implant supported solutions either for financial reasons or for medical reasons. We see many of these cases at the dental school setting. And for these patients with such compromised dentitions, one of the treatment solutions is to consider immediate dentures. But the comfort and the patient satisfaction can be unpredictable with these immediate dentures. In addition, planning such treatment and executing this treatment in a dental school setting is challenging. I see so many barriers to treating these patients effectively. So I hope to offer some pearls here to help the students navigate these cases in the hope to improve patient care as well as to have a better learning experience.
These patients may have come to the dental school as their last resort. They are often anxious and have limited funds. Part of knowing how to manage these cases effectively is to have a really good communication and be understanding of their fear and concerns. When I see these patients in my practice, I slowed down a lot just to listen to their concerns. I also find that it is necessary to repeat explaining the treatment. It’s not just a filling or a crown. The treatment plan can be quite extensive and a lay person may not be able to understand this well the first time around. I often will repeat myself at every appointment the key information I want the patient to understand.
The key information I want to convey to the patient is that they may not like wearing these immediate dentures. I refer them as temporary dentures even if they are planned as conventional immediate dentures designed to be used as a permanent prosthesis. If they happen to look good and feel good after a certain period of healing, I may be able to reline them. But I don’t want them to think this will be their final denture. I often will tell these patients they need to consider implants if possible. The aesthetic outcome can be unpredictable as there is often no teeth try in. However, to alleviate their fear, I will tell them I will do everything I can to make the immediate dentures as naturally looking as possible.
Treatment Planning Considerations:
Deciding how to plan the treatment and deciding what teeth to keep or what teeth to extract can be difficult. Most prosthodontic textbooks will talk about phasing posterior teeth extraction first followed by anterior teeth extraction so to facilitate jaw relation record and to minimize post surgical healing and changes. I find that most patients don’t fit into this clinical scenario. There are a lot more to consider than just separating the posterior teeth from the anterior teeth. For me, aside from looking at the restorative and periodontal condition of the teeth, I look at other prosthetic parameters before deciding which teeth to keep and how best to phase the treatment:
To keep or not to keep.
Many times, you may want to keep some strategic teeth to stabilize the transitional prosthesis. While this thought is well intended, I find that there are many reasons I may not want to keep some of these teeth even if they are restorable or periodontally healthy. Some questions I always are:
1/Are the teeth distributed in the arch that will help support my prosthesis? Bilaterally positioned in key locations such as canines and molars will be ideal. If the remaining teeth are unilaterally positioned, the possible prosthetic movement may be unfavorable to these remaining teeth.
2/Are these teeth extruded and interfering with the ideal occlusal plane and aesthetic development? They may be in the wrong place in the mouth that may not be worth saving, especially if you want to improve the aesthetic outcome for the patient.
3/Is there any prosthetic space? Many compromised dentition have bite collapse. You may have to evaluate the existing occlusal relationship and see if there is prosthetic space for your planned prosthesis at the current occlusal relationship.
There are no fast rules. The decision to keep some of the teeth should be made after careful consideration and understanding the limitations and advantages if you decide to keep some key abutments. But I find that the above prosthetic considerations are often overlooked and it would help to re-evaluate your case through these prosthetic lenses again before finalizing the treatment plan.
Once you have committed to a treatment plan, the challenge in taking impression for these cases lies in the fact that some of these teeth are periodontally involved. The literature is full of many case reports of how best to tackle this problem with some two piece impressions: one in bordering moulding and taking impression of the denture bearing area using a sectional tray and the other in taking a pick up impression of the remaining teeth such that they won’t get locked in the impression. I find these techniques quite difficult to tackle for the dental students and young dentists. But I do want to share some techniques here that you may want to consider:
1/This technique involves syringing light body PVS material around the periodontally involved which serves to stabilize them at the same time.[i] You will let it set first. Then you will take an alginate impression overlying that area as well as capturing all the critical denture bearing area. The alginate material will be easy to remove. The set PVS material will remain on the teeth and you will need to slowly tease it off around the periodontally involved teeth. The end result will allow you to glue the pieces of PVS back together into the alginate impression that can be poured together.
2/Other techniques available you may want to look at involve pouring tooth colour acrylic right directly into the teeth portion of the impression or inserting the patient’s failed bridge into the impression before pouring up the rest of the impression with stone.[ii] [iii] This method creates a model with all the patient’s existing occlusal and incisal position and may allow you to save some steps in the denture fabrication process.
Please look up these articles for very useful pictures to give you better ideas how to take impression for these cases.
Jaw Relation Record.
Patients with compromised dentition may have an acquired bite that may be different from their centric relation. Some of the extruded teeth may be in occlusal trauma exhibiting excessive mobility. Trying to take an accurate jaw relation record will require more time than just asking the patient to bite. You need time to re-train the patient to close properly. You need to factor that your model may not be a true representation because of the mobility of the teeth. Therefore, you may see more errors or discrepancy at this stage. I factor this into my delivery stage that I may need to do more post-insertion adjustment.
Teeth Set up.
Because the teeth are often in the wrong place in the mouth, while arranging your teeth set up, you may or may not want to follow the patient’s existing tooth positions. There are aesthetic and functional considerations when it comes to deciding how best to arrange the set up. Traditional complete denture principles rely on properly contoured occlusal rims. However, in immediate dentures, your patient’s remaining teeth precludes you from using a set of occlusal rims and you have to guide the technicians how best to do the set up. I often provide the technician a picture of the patient’s facial smile and indicate the desired midline and desired incisal position as well as occlusal plane orientation. I also like to ask the technician to arrange the set up one segment at a time so I can be sure the teeth arrangement is where I want them to be before removing all other reference points in the model. This may take a bit more time but the final outcome will be more predictable.
In spite of all the difficulties in the planning and the execution of these types of cases, if you take the time to do it properly, the end result can be life changing for the patient. The patient will often be so appreciative that you take the time to walk with them in this unknown journey and will often return to you for more treatment. This can be very satisfying for you as a dentist. I hope you will find these tips helpful. Thanks for reading.
[i] Mense C, Berteretche MV. Impression for an immediate denture with mobile teeth: A clinical approach. J Prosthet Dent. 2019 Nov;122(5):498-499. doi: 10.1016/j.prosdent.2019.06.015. Epub 2019 Oct 23. Erratum in: J Prosthet Dent. 2020 Feb;123(2):366. PMID: 31653401.)
[ii] Gotlieb, A., & Askinas, S. (2001). An atypical chairside immediate denture: A clinical report. The Journal of Prosthetic Dentistry, 86(3), 241–243. https://doi.org/10.1067/mpr.2001.117977
[iii] Gooya, A., Ejlali, M., & Adli, A. (2013). Fabricating an Interim Immediate Partial Denture in One Appointment (Modified Jiffy Denture). A Clinical Report. Journal of Prosthodontics, 22(4), 330–333. https://doi.org/10.1111/j.1532-849X.2012.00950.x