**Complete Dentures** Preclinical **Insertion, Post- Operative Review & Immediate Dentures**    # Complete Denture Overview ## Treatment Schedule | Visit | Operator | Procedure | | :------- | :----------- | :------------------------------------------- | | Visit 1 | Clinician | Patient evaluation & primary impressions | | | Laboratory | Diagnostic casts & special trays | | Visit 2 | Clinician | Secondary impressions | | | Laboratory | Bead & box, master casts, base & rims | | Visit 3 | Clinician | Contour rims, OVD, MMR, shade & mould selection | | | Laboratory | Articulation & tooth setting | | Visit 4 | Clinician | Wax try-in | | | Laboratory | Finalisation & processing | | Visit 5 | Clinician | **Assessment & issue** | | | | **Instructions for care** | | Visit 6 | Clinician | Post operative review, post insertion instructions | **Assessment & Issue** **Extra-oral Examination of Dentures** **Intra-oral Examination of Dentures** **Instructions to the Patient** **Assessment & Issue** **Extra-oral Examination of dentures** 1. Sharp projections and acrylic nodules 2. Sharp edges 3. Over-extension into bony undercuts 4. Hand relate dentures to confirm stable occlusion **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** Oral Health Centre of Western Australia  **Assessment & Issue** Intra-Oral Examination of Dentures **1. Check extension, retention and stability** * Check retention * Check lateral stability * Check A – P stability psychologic comfort physiologic comfort retention stability support longevity success      **Assessment & Issue** **Intra-Oral Examination of Dentures** 1. Check extension, retention and stability 2. **Evaluate aesthetics** * Form, colour & contour of teeth * Midline * Lip line * Smile line * Buccal corridor    **Assessment & Issue** **Intra-Oral Examination of Dentures** 1. Check extension, retention and stability 2. Evaluate aesthetics **3.** **Evaluate phonetics** * Posterior border of denture * /ah/ sound establishes the vibrating line and thus the posterior extension of the denture * Occlusal vertical dimension * Distinct /s/ sound helps establish correct OVD * With insufficient vertical height /p/ and /b/ will be affected * With too great an OVD opposing teeth will click together * Height of the anterior teeth (and thus the occlusal plane) * Inability to enunciate /f/ or /v/ sounds indicates that the anterior teeth are either too far above or below the functional plane of occlusion * Overjet * May be established by using the /s/ sound * Labiolingual position of the mandibular anterior teeth * A lisp in the /s/ sound indicates that the teeth are placed too far lingually * Thickness of the anterior region of the palate * A lisp with the /t/ sound indicates excessive thickness * Thickness of the posterior palatal seal * Excessive thickness may cause difficulty in saying /g/ **Assessment & Issue** Intra-Oral Examination of Dentures **1. Check extension, retention and stability** **2. Evaluate aesthetics** **3. Evaluate phonetics** **4. Evaluate occlusion** **Centric occlusion (intercuspal position)** **Eccentric movements** **Occlusal vertical dimension** interocclusal clearance OVD RVD **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** **Oral Health Centre** **of Western Australia** **Working** **Balancing** **Protrusion**      **Assessment & Issue** **Intra-Oral Examination of Dentures** **Remount Procedure (if required)** 1. Check extension, retention and stability 2. Evaluate aesthetics 3. Evaluate phonetics 4. Evaluate occlusion * Occlusal vertical dimension * Centric occlusion * Eccentric movements 5. **Occlusal adjustment** **(not normally required at insertion appointment)** **Balanced occlusion:** Bilateral, simultaneous, anterior, and posterior occlusal contact of teeth in centric and eccentric positions. Balanced occlusion in complete dentures is unique, as it does not occur with natural teeth.  Complete Denture Overview Treatment Schedule | Visit | Operator | Procedure | |----------|-----------|------------------------------------------------| | Visit 1 | Clinician | Patient evaluation & primary impressions | | | Laboratory| Diagnostic casts & special trays | | Visit 2 | Clinician | Secondary impressions | | | Laboratory| Bead & box, master casts, base & rims | | Visit 3 | Clinician | Contour rims, OVD, MMR, shade & mould selection| | | Laboratory| Articulation & tooth setting | | Visit 4 | Clinician | Wax try-in | | | Laboratory| Finalisation & processing | | Visit 5 | Clinician | **Assessment & issue** | | | | **Instructions for Care** | | Visit 6 | Clinician | Post operative review, post insertion instructions| Assessment & Issue Instructions for Care - Insertion and removal of dentures  Rinse mouth out before putting dentures in.  Press upper denture against the roof of mouth.  Fit lower denture onto lower gums.  Bite down a few times to press the dentures into place - Limitations of the dentures  Adjustment period required (Habituation) i. Initial feeling of bulk – will pass with time ii. Practice reading aloud (10 – 15 mins per day) iii. Hypersalivation (swallow frequently)  Difficulty with eating i. Soft diet ii. Cut food into small portions iii. Chew with posterior teeth (bilateral mastication) iv. Avoid sticky foods (espec. chewing gum)  Risk of breakage (espec. with mishandled lower denture)  Retention issues i. Dental adhesives may be helpful • Expected tissue response Short term i. Initial discomfort ➢ Remove denture(s), replace when settled ➢ **Do not self-adjust** ii. Ulceration or severe soreness ➢ Discontinue use & make urgent appointment for remediation Long term i. Moderate to severe alveolar resorption • Care of the prosthesis and tissue  No night wear (or 8 hours respite every 24)  Store overnight in fresh cold water (+/- cleanser tablet)  Clean after every meal where possible  Use soft brush and non-abrasive soap (**no toothpaste**)  Enzymatic soaking denture cleaner weekly • Desirable follow-up treatment  Proper daily care  Routine dental visits – wear denture before any review appointments i. 24 hour check ii. One week follow-up (with subsequent weekly visits until symptom free) iii. Annual reviews  Maintenance as needed **Complete Denture Overview** **Treatment Schedule** | Visit | Operator | Procedure | |---|---|---| | Visit 1 | Clinician | Patient evaluation & primary impressions | | | Laboratory | Diagnostic casts & special trays | | Visit 2 | Clinician | Secondary impressions | | | Laboratory | Bead & box, master casts, base & rims | | Visit 3 | Clinician | Contour rims, OVD, MMR, shade & mould selection | | | Laboratory | Articulation & tooth setting | | Visit 4 | Clinician | Wax try-in | | | Laboratory | Finalisation & processing | | Visit 5 | Clinician | Assessment & issue Instructions for care | | Visit 6 | Clinician | **Post operative review, post insertion instructions** | # **Post-Operative Review** # **24 Hour Check** * Inquire about patient’s problems * Conduct a thorough examination * Check the denture for pressure areas and adjust as needed with PIP or Fit-Checker * Check borders for overextension and adjust as needed * Evaluate occlusion, refine as necessary and recheck, finish and polish * One week follow-up (and subsequent weekly visits until comfortable) **Post-Operative Review** **Common Problems** 1. Pain 2. Loss of retention and/or stability 3. Difficulty chewing 4. Nausea 5. Noise on eating and speaking 6. Poor aesthetics 7. Problems relating to speech **Post-Operative Review** **1. Pain** **History:** * How long has the pain been there? * Does the pain disappear after the dentures are removed? * Is the pain specific to a certain area or is it widespread? * Does the pain only occur during insertion and removal of the dentures? * Is the pain continuous whilst wearing the dentures, or does it increase only at certain times – such as when eating? **Post-Operative Review** 1. **Pain** May be: a. Localised (in a specific region of the supporting tissues) b. Generalised (involving a major part of the supporting tissues) c. Diffuse (involving all of the supporting tissues) d. Resulting from lip or cheek biting e. Pain in the tongue f. Pain that occurs at the TMJ **Post-Operative Review** **1a. Localised Pain** Appears in a specific region of the maxillary or mandibular dentures and can be due to: * Over-extended denture flanges * Deeply or sharply prepared posterior palatal seal area * Irregularities on the tissue surface of the denture * Premature occlusal contacts * Excessive undercuts on the denture bearing area * Irregularities and/or thin mucosa along the alveolar crest * Possible pathologies of the supporting tissues – such as tori * Pressure over the mental foramen following crestal resorption Post-Operative Review **1b. Generalised Pain** Involves a major part of the supportive tissues and manifests as hyperaemic areas. It may be due to: * The existence of thin mucosa * Reduced salivary flow, which may be due to: * Age-related salivary gland atrophy * Radiation therapy of the head and neck * Systemic diseases (diabetes mellitus, chronic nephritis, uraemia, Sjogren's syndrome) * Drugs (either prescribed or recreational) * Anatomical defects on the alveolar crests * Sharp margin of mandibular alveolar crest * Prominent genial tubercles **Post-Operative Review** **1c. Diffuse Pain** Involves **all** of the supportive tissues and manifests as fiery red hyperaemic areas. It may be due to: * Excessive occlusal vertical dimension. * Patient's allergy to Methyl Methacrylate. * Allergic reactions usually originate from the presence of excess monomer due to insufficient polymerisation or from acrylic resin pigments. * Allergy is commonly confused with denture stomatitis. An allergic reaction manifests soon after placement of a new denture, but denture stomatitis only occurs after a long period of denture use. * True denture allergies are very rare. If antihistamines are given to the patient and the symptoms resolve, then an acrylic allergy should be suspected. This can be confirmed by a patch test. **Post-Operative Review** **1d. Pain due to biting** **May be due to:** * Excessive interocclusal space * Occurs with an over-closed occlusal vertical dimension. Until the chewing muscles adapt to the new height the lips or cheeks may be bitten during function. * Lack of posterior overjet * The buccal surfaces of the lower posterior teeth need to be re-arranged, by grinding if the discrepancy is small, or by repositioning if the discrepancy is large. * Cheek impactions due to posterior baseplate contact * This often is best managed by thinning of the upper baseplate * Existence of cross-bite * Anterior teeth in an edge to edge position * Teeth outside of the neutral zone **Post-Operative Review** **1e. Pain the Tongue** May be due to: * A rough lingual surface of the mandibular denture or irregular areas on the mandibular teeth * Irregularities should be ground away and the denture repolished * Mandibular teeth lingually positioned * When tongue space is reduced there may be tongue pain related to cramps * If the lingual displacement is excessive, or the occlusal plane too low, the tongue may be bitten * On very rare occasions, where a diastema has been created between the lower incisors in response to a patient's request, the result may be pain along the anterior edge of the tongue. * If the existence of the diastema is non-negotiable then the addition of some transparent acrylic resin may solve the problem **Post-Operative Review** **1f. Pain in the TMJ** Is generally caused by: * Insufficient interocclusal clearance (freeway space) due to inaccurate jaw relation records. **Post-Operative Review** **2. Loss of Retention & Stability** A complaint of “loose” dentures can be due either to a loss of retention or of stability. Retention is resistance to displacement in a direction opposite to that of insertion Stability is resistance to horizontal displacement Retention can be maximised by : * Covering the entire denture-bearing area * Having minimal space between the denture and the tissue * Having optimal viscosity of the saliva Loss of retention may be due to: Physiological reasons * Loss of weight * Diabetes or periodontal disease * Tumours * Hyposalivation Anatomical problems * Presence of excessive undercuts in the denture bearing area Clinical errors **Post-Operative Review** **2. Loss of Retention** **Maxillary Denture** Loss of retention most often due to: * Lack of peripheral seal at: * Posterior palatal seal * Test by addition of impression compound or impression wax * Buccal and labial flanges * Over-extension will result in pain rather than movement * Test for under-extension by addition of impression compound * Lack of intimate tissue contact * Test with Fit-checker * Hyposalivation * Test with artificial saliva **Post-Operative Review** **2. Loss of Retention** **Mandibular Denture** Loss of retention most often due to: * Overextended labial and buccal flanges * Test for over-extension by gentle stretching of fraena areas * Over-extended lingual flanges * Test by guiding patient through specific tongue movements * Technical problems causing lack of intimate tissue contact * Test using Fit-checker, rebase if necessary **Post-Operative Review** **2. Loss of Stability** * Teeth placed along an inclined alveolar ridge (e.g. retromolar pad) * Premature occlusal contacts * Use of teeth with high cuspal angles on atrophic alveolar ridges * Position of artificial teeth * Incisors * Molars * Occlusal Plane * Faults in polished surfaces – generally should be concave * Anatomical reasons – such as tori or excessively resorbed alveolar ridges * Physiological reasons * Difficulty with habituation * Drugs * Systemic diseases **Post-Operative Review** **3. Difficulty Chewing** * Lack of denture experience * Patient needs time to develop the necessary muscular control * Incorrect position of occlusal plane * Should be a few mm below the back of the resting tongue * Excessive occlusal vertical dimension * Causes problems with manipulating the food bolus * Reduced occlusal vertical dimension * Results in reduced chewing force * Lack of balanced contacts in occlusion * Lack of balance prevents efficient chewing of food * Pain in the denture-bearing area * Causes reluctance to chew **Post-Operative Review** **4. Nausea** The glossopharyngeal nerve is responsible for the gag reflex and innervates the posterior third of the tongue and soft palate. With maxillary dentures the gag reflex may be initiated if: * The posterior border of the upper denture is overextended * The posterior denture base is thicker than normal * The denture lacks retention and moves under function * The occlusal vertical dimension is over-closed and the tongue is in constant contact with the upper denture * Premature occlusal contacts cause the dentures to drop during function **Post-Operative Review** **4. Nausea** With mandibular dentures the gag reflex may be initiated if: * The denture has insufficient tongue space * The denture base is over-extended in the posterior tongue region * There is insufficient interocclusal clearance * The teeth are positioned away from the neutral position and/or there is an excessively bulky denture reducing tongue space * Premature occlusal contacts cause the dentures to drop during function Post-Operative Review **5. Noise on Eating & Speaking** Noise can occur as a result of premature contacts of teeth. There are four main reasons for dentures causing noise: * Lack of retention of either denture * Excessive occlusal vertical dimension * Cuspal interferences * The use of porcelain teeth **Post-Operative Review** **6. Poor Aesthetics** Aesthetic problems are generally a result of not taking sufficient care at the trial insertion stage. Generally, the complaints fall into these categories: * Unsatisfactory lip and face support – either too great or too little * Incorrect occlusal vertical dimension - either open or closed * Reduced height of lower third of face * Colour, size and shape of teeth * The visibility of the teeth **Post-Operative Review** **7. Problems Relating to Speech** Patients need time for habituation when receiving a new denture. During this period some sounds may be pronounced incorrectly, such as: * The “s” sound – which is produced by the passage of air through the small space between the tongue and the anterior palate. Lisping means the space is too small. * The “t”, “d”, “l” & “”r” sounds – which rely on the ability of the dorsum of the tongue to seal against the posterior palate. * The “p”, “b”, “m”, and “n” sounds – which are verbalised while the upper and lower lips are touching each other. * The “f” and “v” sounds – which is caused by incorrect antero-posterior position of the maxillary incisors relative to the lower lip * The “g” and “k” sounds - which are articulated when the dorsum of the tongue is in contact with the posterior palate. A denture that is thick in this area may cause this problem. **Immediate Dentures** Preclinical Complete, Partial & Implant     **Immediate dentures** Any fixed or removable dental prosthesis fabricated for placement immediately following the removal of a natural tooth/teeth * Use of immediate dentures to follow the removal of natural teeth is not new (Richardson 1860) * Today the procedure is increasingly demanded by an appearance-conscious public **This may include:** ✓ Complete dentures ✓ Partial dentures i. Removable partial dentures ii. Fixed prosthesis ✓ Implant supported or retained prostheses   **Immediate dentures** **Advantages** - Prevent patient embarrassment - ✓ Insert at time of tooth extraction - Promote patient health - ✓ Prevent prolonged retention of diseased teeth - Provide guide for optimal aesthetics - ✓ Can copy the form, size, colour & arrangement of the natural teeth - Provide guide for occlusal vertical dimension - ✓ Remaining natural teeth may act as a guide - Promote better healing - ✓ Denture acts as a surgical stent - May promote better ridge form - Prevent collapse of facial musculature - Hasten patient adaptation to dentures  # Immediate dentures **Disadvantages** * **Increased complexity of clinical procedures** * ✓ Presence of natural teeth may compromise impression making * i. Mobile teeth – risk of involuntary extraction * ii. Deep undercuts * ✓ Record bases around natural teeth generally less stable and retentive * ✓ Natural teeth may prevent closure in centric relation * **Limited evaluation of trial dentures** * ✓ Aesthetic and phonetic qualities limited by presence of natural teeth * ✓ Impedes clinical evaluation of any desired positional change of anterior teeth * **Increased patient discomfort** * ✓ Combination of post-extraction pain with possible denture-related trauma * **Increased denture maintenance** * ✓ Rapid resorption for one month post extraction * ✓ Moderate resorption for next five months * ✓ Eight to twelve further months before residual ridge becomes more stable * **Increased number of patient visits** * ✓ Due to patient discomfort and continuing changes in ridge contour * **Increased treatment cost** * ✓ Increased complexity of clinical procedures * ✓ Increased number of patient visits * ✓ Increased need for denture maintenance * i. Soft liners * ii. Relines # Immediate dentures <br> ## <p style="color:#d87b22">Contraindications</p> * Radiation therapy to head & neck **may** be a contraindication * Any systemic condition that adversely affects blood clotting, wound healing or tissue regeneration * Aged or medically compromised patients who cannot tolerate multiple extractions * Excessively mobile teeth and large abscesses that require surgical drainage * Psychological disorder or diminished mental capacity * Patient who does not want the increased discomfort, time and expense **Immediate Complete Dentures** THE UNIVERSITY OF **WESTERN** **AUSTRALIA** Oral Health Centre of Western Australia **Immediate Complete Dentures** **Clinical Procedures** Examination & Diagnosis * Thorough visual, digital & radiographic examinations * Assess patient expectations re aesthetics & function * Where indicated arrange pre-prosthetic surgery prior to preliminary impressions * ✓ Tuberosity reduction * ✓ Tori reduction * ✓ Displaceable redundant tissue * ✓ Labial/buccal frenula (or at time of anterior tooth removal) **Immediate Complete Dentures** **Clinical Procedures** Treatment Planning (2 phase schedule preferred) * **Stage 1** ✓ Removal of posterior teeth - can retain first premolar as centric stop if needed ✓ Fabricate interim RPD i. Impression at 7 – 14 days after extraction of posteriors ii. Allows chewing on posterior teeth, rather than just anteriors iii. RPD teeth support musculature of lips and cheeks – muscle memory iv. Provides learning period and eases transition to complete denture v. A failed remaining tooth can be easily added to the denture ✓ Residual ridge healing – at least 6 months ✓ Impression for definitive denture and fabrication of surgical stent * **Stage 2** ✓ Removal of anterior teeth at the time of complete denture placement ✓ Maintenance as required **Immediate Complete Dentures** **Clinical Procedures** Impression Techniques * **Stage 1** * ✓ **Stock impression trays** * **Stage 2** * ✓ **Custom impression trays** * ✓ **Combination impression technique** * ✓ **Sectional tray technique**      **Immediate Complete Dentures** **Clinical Procedures** **Risk Mitigation during Impression-making** ✓ block undercuts in bridges (blue-wax, bite registration paste, alginate) ✓ splint mobile teeth if necessary (composite/fiberglass reinforcements) ✓ consider if extraction is more suitable **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** **Oral Health Centre** **of Western Australia**    **Immediate Complete Dentures** **Clinical Procedures** Maxillo-Mandibular Relationship Records - The recording technique used will depend on the distribution of the remaining natural teeth - Determine appropriate occlusal vertical dimension - Where there are insufficient occlusal stops an accurate baseplate is required - Extend base onto palatal and lingual surfaces of remaining teeth where possible - Use ball clasps for retention - Use of mesial hooks where possible to help resist posterior displacement of baseplate - Record the occlusal plane and required degree of lip support - Notched wax rims used in edentulous areas - Facebow record - Centric relation record - Tooth Selection - Measure pocket depths on remaining teeth (used to guide cast trimming in lab) - Post-operative instructions given to patient prior to denture insertion   **Immediate Complete Dentures** **Laboratory Procedures** **Arrangement of Anterior Teeth** * Primary aim is preservation of alveolar bone * Cast trimming is aided by marking the pocket depths on the cast and drawing a line through them * If arrangement of the natural tooth is to be copied, denture teeth are set individually * For deep pockets around the remaining teeth the cast is reduced prior to tooth arrangement * Correct placement of necks of teeth and minimal bulk in flange area contribute to patient comfort * With a correctly trimmed cast only minor osseous reduction is needed at the time of surgery THE UNIVERSITY OF **WESTERN** **AUSTRALIA** Oral Health Centre of Western Australia       # Immediate Complete Dentures **Laboratory Procedures** Fabrication of Clear Surgical Template * Can either be heat processed acrylic or vacuum-formed stent * Made from an alginate impression of the trimmed cast * Facilitates accurate bone trimming at the time of surgery * Palatal hole facilitates seating and allows clinician to check that the template is fully seated  # **Immediate Complete Dentures** The University of Western Australia | Oral Health Centre of Western Australia     **Immediate Partial Dentures** THE UNIVERSITY OF WESTERN AUSTRALIA Oral Health Centre of Western Australia **Immediate Removable Partial Dentures** **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** **Oral Health Centre** **of Western Australia**    **Immediate Removable Partial Dentures** **THE UNIVERSITY OF** **WESTERN** **AUSTRALIA** **Oral Health Centre** **of Western Australia**    **Immediate Removable Partial Dentures** THE UNIVERSITY OF **WESTERN** **AUSTRALIA** Oral Health Centre of Western Australia    **Thank** **You** Any questions? Contact me Dr Ian Lander ✉ ian.lander@uwa.edu.au THE UNIVERSITY OF **WESTERN** **AUSTRALIA** Oral Health Centre of Western Australia