Prosthodontics

Geoffrey St George Nicholas J Lewis, Cameron Malton and Richard Welfare

Immediate Dentures: 2. Clinical Stages of Construction

Abstract: Immediate dentures remain an important tool for providing patients with an instant replacement option for extracted teeth. The second paper in this series of two aims to cover the clinical and laboratory stages of immediate denture construction. It looks at the clinical techniques that can be used to facilitate the accurate construction of immediate dentures, as well as some of the problems that can compromise their final outcome. Clinical Relevance: This paper covers the clinical and laboratory stages of immediate denture construction. Dent Update 2010; 37: 154160

Impressions
Materials

The materials of choice for immediate denture impressions are the elastomeric impression materials. They include visco-elastic irreversible hydrocolloid (alginate), elastic addition and condensationcured silicones, and polyethers. Impression compound may also be used in edentulous areas of the mouth, to customize a stock tray. Although some of these materials are perceived to be better than others, all are capable of accurately recording the details of the mouth as long as they are used appropriately. The number of teeth, their

Figure 1. A sectioned stock tray, showing deficiencies in extension and fit.

Figure 2. A stock tray, customized with impression compound and greenstick.

mobility, and the degree of undercut present will determine which material to use.

Customizing trays

Geoffrey St George, BDS, DGDP(UK), MSc, FDS(Rest Dent), Consultant in Restorative Dentistry, Nicholas J Lewis, BDS(Hons), MFDS RCS(Edin) MSc, FDS(Rest Dent), Consultant in Restorative Dentistry, Cameron Malton, Head of Prosthetic Laboratories and Richard Welfare, BDS, MSc, FDS RCS(Eng), Consultant in Restorative Dentistry, Endodontic Unit, Eastman Dental Hospital, University College Hospitals NHS Trust, 256 Grays Inn Road, London WC1X 8LD.

Primary impressions are made using stock impression trays, which usually have to be customized with greenstick or impression compound, where the extension or fit of the tray is deficient (Figure 1). Adding greenstick and impression compound to a poor fitting and under-extended tray periphery allows a flowable impression material to be fully supported, and reduces the bulk of impression material used (Figure 2). This can produce an accurate record of the patients remaining teeth, denture-bearing areas, and functional sulcus.

The most common areas for under-extension are: n Where there is proclination of teeth, creating undercuts; n The tuberosity region in the maxillary arch; n The disto-lingual areas in the mandibular arch. The use of metal Rimlock trays offers a number of advantages: n They are made from stainless steel and are therefore resistant to distortion; n They are re-usable and can be sterilized in the autoclave; n Denture adhesive is not required, unless areas have been customized with impression compound, because the impression material is held in place by a retentive rim (Figure 3). April 2010

154 DentalUpdate

Prosthodontics

Figure 3. The retentive rim (arrows) of the Rimlock tray.

Figure 4. Uniform thickness of impression material produced with a special tray.

Special trays

be checked, and corrected if necessary. In all Figure 5. Combination impression technique If a good quality primary complete immediate dentures, when a good using zinc oxide/eugenol and alginate. impression is taken, then a definitive peripheral seal is required, border moulding impression may not be needed. However, a with a suitable material is needed. The most well-fitting special tray is often constructed common types used are: where there has been gingival recession to produce an impression which is of uniform n Greenstick this requires practice to be between adjacent teeth, which allows thickness and fully extended (Figure 4). used effectively; impression material to lock into undercuts. Correctly extending the tray will prevent overn Impression putty used with silicone These problems are overcome as follows: extension of the final denture. Special trays impression materials; n Blocking-out undercuts TM can be constructed from cold-cure acrylic or n Acrylic light-cured materials, eg Stick Triangular inter-dental areas are light-cured resin, with an adequate space for (Stick Tech Ltd, Turku, Finland) may be used, best blocked out with wax (Figure 6a) or impression material incorporated between the especially when trays are grossly undertemporary cement which can be removed tray and the dental tissues. extended. after the impressions are taken. The type of impression material to n Splinting teeth be used with the custom tray should be stated Undercut areas Very mobile teeth may be on the laboratory prescription. This will allow A common problem with temporarily splinted together (Figure 6b) the technician to provide the appropriate impression taking is when very mobile teeth with composite resin to prevent their spacer in the special tray: need to be recorded in an impression, or unintentional extraction. n Alginate 3 mm; n Polyether 1.5 mm; n Silicones 1.5 mm. a b Despite the theoretical accuracy of special trays, their bulk can often interfere with the shape of the final impression, producing a poorly contoured denture periphery. The reduced spacer thickness when using silicones, compared to alginate, results in a smaller tray, which may be advantageous. However, a spaced tray may still distort the sulcus around a lone standing tooth, when the adjacent alveolar ridge is narrow following resorption. Zinc oxide/eugenol may be used in edentulous areas when a combination impression technique is used (Figure 5). Areas with little or no undercut, eg edentulous ridges, are recorded with this material, whereas the undercut regions (eg toothbearing areas) are best recorded with an elastomeric material. Figure 6. Blocking out inter-dental undercuts with wax (a) and splinting teeth together with composite The extension of the tray should (b) prior to impression taking. April 2010 DentalUpdate 155

Prosthodontics

Single, isolated, mobile teeth may be important to patients prior to their extraction, providing retention and stability for a partial denture, and maintaining aesthetics. To ensure that they are not removed when taking impressions, one of the following methods can be used: n Perforating the tray over the tooth in question and retaining it in position with a suitable instrument, eg an amalgam condenser. Plastic trays may be used instead of metal trays to allow holes to be made easily over the tooth. The same can be done with the special tray (Figure 7). n Covering the tooth with a copper ring. Soni1 described a technique where a loose fitting copper ring was placed over the mobile tooth (Figure 8a). The most coronal part of the ring is blocked off with composite resin, and the whole ring is then picked up in the impression (Figure 8b). The resulting impression is less accurate around the tooth, though this is insignificant following its extraction and soft tissue shrinkage. An alternative to a copper ring is an over-sized temporary metal crown. Patients should always be warned of the possibility of the small risk of the loss of a tooth when taking an impression.
Special techniques Two-part impressions

b
Figure 7. Perforated tray to allow an amalgam plugger to stabilize a mobile tooth.

teeth and labial sulcus, accurately locating with the first tray. n The Campagna2 technique. This involves using a custom tray, constructed on a primary model, which has an accurately fitting peripheral border around the whole mouth. The tray is perforated over the remaining teeth, over which a second impression is taken (Figure 5). This technique has the potential for producing a more accurate impression of the labial sulcus, compared to other methods. The labial sulcus is a common area of overextension in mandibular impressions.
Over-impressions for the addition of teeth or flanges

Figure 8. Technique showing the customized copper ring (a) and its location in the final impression (b).

With a classic immediate denture, an impression tray is used to record the posterior edentulous sections of the mouth only. Following the trimming of excess impression material from the tray, a second impression is then taken in the same impression tray to record the remaining teeth. This allows different materials to be used for both edentulous and dentate areas of the mouth. An alternative technique is to record the posterior parts of the mouth with a custom tray, then record the anterior portion using one of the following techniques: n Elastomeric putty, moulded by hand. n A stock tray which locates on the first tray and records an over-impression of the anterior teeth and labial sulcus. The two are held together by constructing handles on the first tray, which are undercut buccally and lingually. The second impression flows into these undercuts and locks the two together. The combination of two trays produces a bulky impression. n A second custom tray which is used to record an over-impression of the anterior

Impressions are commonly needed for the immediate addition of teeth or a flange to an existing denture. When teeth are to be added to existing dentures, an impression is taken over the top of the denture and natural teeth. In those cases where the denture may move during impression taking, it is advisable to secure the denture in place with denture adhesive. The denture is usually removed in the impression, but if it remains in the mouth, it should be re-inserted into the impression. Plaster is poured into the impression, and the resultant cast with denture attached can be trimmed, for tooth addition, as described later. Flanges may be added by using lightcured acrylic in the mouth, or taking an over-impression of the denture in situ and transferring this to the laboratory for the addition.

Registration/try-in
A jaw registration to record the

relationship of the maxilla to the mandible at the desired occlusal face height is necessary only when teeth are missing and hand articulation is not possible. When teeth are missing in both jaws, it may be possible, and preferable, to use one record block to record the occlusal relationship. One in each jaw should be used if a single block does not produce stable contacts. Record blocks with acrylic bases are preferred to solid wax bases, as they are less prone to distortion. The wax record blocks are tried in to see that they are well adapted to the underlying soft tissues and are correctly extended. The wax is trimmed (level with the occlusal plane) in a similar fashion to a standard denture registration, to ensure optimal aesthetics and functional tooth positions. The registration should then be recorded using a suitable material: n Softened wax; n Bite registration paste (Figure 9) (zinc oxide/ eugenol or silicone); n Staples used when a maxillary record block opposes a mandibular record block. Once the registration has been recorded, the bases should be placed on the master casts and the models articulated. This is to ensure that the tooth/record block contacts in the mouth can be reproduced between the opposing casts. It may be April 2010

156 DentalUpdate

Prosthodontics

Figure 9. Bite registration paste.

Figure 10. Using the facebow to mount a maxillary cast.

The registration procedure is then followed by a face-bow transfer record which records the position of the maxillary arch in relation to the condylar hinge axis, as well as supporting the maxillary cast on the articulator during mounting in the laboratory (Figure 10). In those cases where teeth are mobile and easily displaced, it is possible that the cast will not exactly replicate the position of the teeth in the mouth. In these circumstances, the record rim may need relieving around the displaced teeth. When articulating the casts it may also be necessary to modify (or remove if going straight to a finish) the stone teeth to allow the correct articulation of the models. A try-in should be completed to check occlusal relationships and aesthetics, and adjustments made where necessary. This stage will only be possible when teeth are missing and can be used to give the patient an indication of the appearance of the final prosthesis. When all or most of the teeth are present, the casts with the mounted dentures can be used following tooth removal, cast preparation, and wax-up and tooth placement, to give a patient an indication of the aesthetics of the final denture.

recommended to remove the teeth in a controlled manner, and to minimize trauma to the underlying tissues, especially the buccal and lingual bony plates. A tooth that is difficult to remove may be best approached surgically with the planned removal of a small amount of bone, rather than risk the fracture and then removal of a large piece of buccal or lingual bone plate. If a piece of the buccal or lingual bone plates does fracture, it is best to ensure that the fragment stays attached to its overlying periosteum. It can then be returned to its original position rather than removing it and producing a large defect in the alveolar ridge (Figure 11). Small, loose fragments should be removed as they may form bony sequestrae, which could cause post-extraction pain and infection. Sharp socket margins should also be smoothed to prevent pain and soft tissue trauma when loaded by the denture. Plaque, calculus and tooth fragments should be flushed from the socket with saline, and firm pressure applied to the socket until haemostasis is achieved.
Denture adjustments

Extractions and denture insertion

Figure 11. Alveolar ridge defect after extraction.

Figure 12. Pressure indicating paste, indicating a denture high spot (arrow).

possible to use the remaining natural teeth in the mouth in order to select the shade, mould and set-up for the immediate denture. In cases where this is not feasible, then a conventional approach to tooth selection should be carried out.

A large part of the success attributed to immediate dentures lies with good extraction technique. This ranges from careful pre-operative assessment of teeth, to the after-care of the extraction sockets. Teeth should be assessed clinically and radiographically, to determine potential complications and the possible effects of extraction on the residual alveolar ridges. Teeth with caries, which are free of periodontal disease, are often more difficult to extract because they are firmly held in the jaws and also because of the tendency of their crowns to fracture. However, as long as surgery is not required, these extractions produce fewer initial changes in soft and hard tissues than those extracted as a result of periodontal disease. This will influence the length of appointment time at extraction and the frequency of visits afterwards for adjustments, relines and replacement. Teeth should be extracted with the least amount of trauma possible. The use of luxators, followed by forceps, is

The denture is tried in and an initial check made to ensure that it seats in its correct position. If it doesnt seat correctly, then the remaining teeth, soft tissues and undercuts are checked. The patients remaining teeth are inspected visually to reveal interferences on the denture, which are adjusted. Soft tissues may prevent seating due to undercuts being present, or the remaining soft tissues not matching those on the prepared cast. Pressure-indicating paste, made from zinc oxide powder and Vaseline, should be brushed on to the fitting surface of the denture to reveal inaccuracies (Figure 12), which are removed. This method may give false positive results, therefore has to be used with some degree of clinical judgement, and the input of the patient, telling you where the sore spot is located. Discrepancies in adaptation can also be revealed if the denture base is made from clear acrylic, or the prepared master cast is duplicated and a clear hard acrylic surgical splint is constructed. High spots are compressed and show through the clear acrylic as blanched areas on the gingivae. Once the denture is seated, retention is checked. Following this the occlusion is also adjusted if necessary. April 2010

158 DentalUpdate

Prosthodontics

should be cleaned as normal, taking care not to traumatize any sockets. If pain is a problem, then brushing can be supplemented with a 0.2% chlorhexidine mouthrinse.

and rebase/reline/replacement.
Adjustments

Overdentures tooth preparation and insertion

If the immediate prosthesis is an overdenture, then at the time of insertion the teeth scheduled for extraction need to be removed as described above, while those chosen as abutments need to be reduced in height. Generally, the abutment teeth are domed, using a high speed bur, ensuring the surface exposed in the mouth is convex, slightly supra-gingival, cleansable, with no sharp edges or surfaces which may trap plaque. This is done in one of two ways: n Abutments remain vital In patients teeth where the dental pulps have laid down considerable amounts of secondary dentine, the teeth are anaesthetized and simply reduced in height to the desired shape. The exposed dentinal surface remaining can then be protected with a layer of dentine-bonded resin, to eliminate any sensitivity. n Abutments are root-filled If the health of the pulps in the abutments will be compromised following tooth adjustment, the teeth should be rootfilled prior to the insertion stage. The coronal access cavity created should be filled with a suitable material, eg zinc oxide/eugenol and glass ionomer, to a level below the proposed final abutment height. At the time of insertion, the teeth can then be prepared, as above, with no danger of contamination of the root-filling material. Following both methods, oral hygiene should be given, showing the patient how to keep the newly created tooth surfaces clean. When the denture is tried in, the same techniques, described above, are used to detect any high spots in the mouth. Around the abutment teeth, a light-bodied silicone material is preferable to pressure-indicating paste, when being used to locate areas of the fitting surface to adjust.

Soft tissues are checked for trauma, and the tooth sockets inspected to ensure they are filled with healthy blood clots. Pressure indicating paste is used to check for high spots, and the appropriate area is adjusted on the denture. The occlusion should also be adjusted as necessary.
Rebase/reline/replacement

Figure 13. Marking of the cast and tooth positioning for an open-faced denture.

Post-operative care

Instructions should be given verbally, and re-enforced with an instruction leaflet that is taken home. The following information should be included.
Treatment of complications

The most common complications are those of pain and haemorrhage of extraction sockets. Pain is due either to inflammation following the extraction, or due to denture trauma, and is usually controlled with antiinflammatory medication, and denture adjustment, respectively. The patient should be instructed to contact the surgery if the pain is severe, or associated with other symptoms such as exposed bony fragments. They should be reassured that most pain disappears after a few days, especially if the cause is due to the denture traumatizing the tissues of the socket, which resolves as gingival tissues shrink. Patients should be advised to leave the denture out only if the pain becomes too great. However, the denture should still be worn at least the day before the review appointment to ensure any sore areas are still visible, to allow identification of denture surfaces needing adjustment. Haemorrhage is prevented by telling patients not to rinse for several hours after the extractions, not to take part in any vigorous exercise, and to leave the denture in place to protect the sockets. If it is a problem, then firm pressure should be applied to the socket with some clean, damp gauze. If bleeding doesnt stop after this, the patient should be instructed to seek further help.
Oral hygiene

Following regular review, a decision needs to be made when to replace the denture. The exact time at which an immediate denture will need replacing will be determined by a reduction in retention, closeness of fit, and aesthetics due to gaps appearing between dentures and soft tissues. Although more costly, it is better to replace the immediate complete denture using a duplicate technique, preserving the original details recorded from the natural teeth. It also keeps the original denture intact, which can be used as a spare, or rebased once the new denture is functioning satisfactorily.

Laboratory stages
Pouring the cast

It is not unusual to fracture isolated stone teeth from their cast when removing impressions. Great care is needed in these cases to avoid breakage, and it may be necessary to cut the impression tray off and gently remove the impression material.
Cast preparation

Review
Following discharge from the surgery, the patient should ideally be seen the following day. In reality, this is usually extended to a few days later for adjustments

The patients remaining teeth April 2010

Cast preparation is carried out to mimic the changes that will occur clinically in the soft and hard tissues following tooth extraction. The amount of collapse will be determined by the underlying bony support. When periodontal disease is present there is a greater degree of collapse owing to the increased amount of unsupported gingival tissues present. Healthy periodontal tissues will remain supported, therefore they retain their original shape better and produce a smaller change in the gingival tissues. Even so, alveolar bone rarely extends to the cemento-enamel junction of teeth, so casts still need preparation, even in the absence of periodontal disease. It is important to prepare casts DentalUpdate 159

Prosthodontics

to be removed from the cast to reduce a prominent undercut when a septal alveolotomy is performed (Figure 14c). After the removal of teeth and preparation of sockets, further stone is removed from the centre of the sockets to a line which is level with the muco-gingival junction. This corresponds to the level at which the labial plate will be fractured. The palatal aspects are adjusted in a similar way to the flanged denture, the cast smoothed and a flange is added. With an alveolectomy, even more stone is removed, and the teeth may be re-positioned differently from their initial location on the cast.
Overdenture

Figure 14. Cross-section of a cast prepared for an open-faced denture (a), a denture with a flange (b), and a septal alveolotomy (c). The pink wax represents the amount of stone removal.

sufficiently to ensure that the newly fitted denture is closely adapted to the underlying tissues, otherwise a gap may exist under the fitting surface. Over-preparation of the model could, on the other hand, cause trauma to tooth sockets.
Open-faced denture

The teeth to be extracted are removed one tooth at a time from the cast, using adjacent teeth as a guide to the position and size of the replacement tooth. It is also wise to have a duplicate, unaltered cast which can be used as a reference following the removal of the teeth. The artificial teeth are placed in the sockets of the natural teeth, with the cast prepared so that they appear to emerge from the surrounding gingivae. To aid positioning of the teeth and cast preparation, it is common to draw lines around the gingival margins, and along their long axes, marking the depth of any periodontal pockets, and marking the original tooth length using callipers (Figure 13). Any inter-dental papillae present are left, as these will be supported by the denture teeth. A tooth is cut off the cast, following the gingival margin. The first tooth to be removed should be the most malpositioned, then the remaining, correctly positioned teeth can act as a guide to correct placement. A groove following the contour

of the socket wall is then cut into the stone palatal to the labial gingival margin (Figure 14a), the depth of which is related to any existing pocketing, eg a healthy gingival sulcus needs a 23 mm deep groove, whereas deeper pockets require deeper grooves. It is therefore important to provide details of periodontal pocketing to the technician when filling out the laboratory prescription. The denture tooth is then chosen to fit the prepared space. It is ground until it accurately fits the cast, and then joined to the denture with wax (Figure 13). With posterior teeth, no grooves (sockets) are cut, but the buccal and palatal gingival margins are prepared to allow for some tissue collapse.
Flanged denture

With an overdenture, the cast is prepared depending on whether it is to have a flange or remain open-faced. The abutment teeth are prepared in the same way as they are in the mouth, though care has to be taken that they are not over-adjusted, as this will prevent the final denture seating in the mouth.

Conclusion
Although the number of patients losing individual teeth as a result of caries and periodontal disease, or requiring a dental clearance, has decreased substantially over the past few decades, and despite new methods of replacing missing teeth, there is still a demand for well constructed immediate dentures. There are a number of problems associated with their construction which have been highlighted in both of our articles. However, following a thorough examination, careful treatment planning, and a high standard of laboratory construction and clinical care, it should be possible to provide patients with successful immediate dentures.

The cast is prepared in a similar way to the open-faced denture initially. Stone is then trimmed from the labial gingival margin until the bottom of the crevice is reached. Further carving is carried out past the depth of the recess for another few millimetres (Figure 14a). The same procedure is carried out palatally, and the trimmed cast is smoothed with sandpaper. A flange can then be added labially (Figure 14b).
Alveolotomy/Alveolectomy

References
1. Soni A. Use of loose fitting copper bands over extremely mobile teeth while making impressions for immediate dentures. J Prosthet Dent 1999; 81: 638639. Campagna SJ. An impression technique for complete dentures. J Prosthet Dent 1968; 20: 196. April 2010

2. Greater amounts of stone need

160 DentalUpdate