4-Immediates 2024 - RAS(1).pdf

Immediates, Interims, Delayed Immediates and Provisional Dentures Ronni A Schnell, DMD, MAGD, FICD, FACD RS 532 ~ September 3, 2024 1  Immediate-- a definitive denture that inserted on the day of extractions. It’s further definitive follow...

Immediates, Interims, Delayed Immediates and Provisional Dentures Ronni A Schnell, DMD, MAGD, FICD, FACD RS 532 ~ September 3, 2024 1  Immediate-- a definitive denture that inserted on the day of extractions. It’s further definitive follow up is a reline or rebase after the tissue and bone healing. Interim-- is a provisional prosthesis (complete or partial) that is not definitive. It is inserted in the day of extractions. The definitive end treatment for example is a complete denture, a cast partial Glossary of denture, an implant restoration a 3-unit bridge, etc. Prosthodontic Provisional- an umbrella term for a temporary denture (partial or complete); it is used only for a Terms very short amount of time (1 week to check new VDO). or longer - up to 1 year. Vertical stops must used to protect the periodontium. JPD GPT-9 Transitional-- a provisional denture (partial or complete) that's used for a longer period of time (a couple months, maybe even up to 6-8 months). It is a prosthesis that may undergo the addition of teeth over time. It is not definitive.Although this term is used interchangeably with provisional - the provisional is the accepted term in the Glossary of Prosthodontic terms. 2  Immediate vs. Interim Dentures (Complete or Partial) Immediate Complete or Immediate Interim Complete or Interim Partial Cast Partial Dentures: Dentures: Long term (definitive), full arch replacement Short term (not-definitive), replacement of of teeth, bone and soft tissue in a partially teeth, bone and soft tissue used as a diagnostic dentate patient whose remaining teeth tool or when an Immediate Complete Denture is cannot be saved. Is placed immediately after not possible. NOTE: Interim CD’s are inserted extractions. immediately after extractions or while healing is Treatment followed by a lab processed reline still occurring. or rebase or a digital “reline” after This treatment is followed by a definitive approximately 6-8 months. prosthesis after approximately 6-8 months – a Until fully healed, chairside relines are done digital “reline” is also possible. Until fully healed, chairside relines are done any term related with immediate is definitive 3  Immediate vs. Interim Dentures (Complete or Partial) Most dentures fabricated for insertion on the same day following extraction in our treatment center are treatment planned as Interim dentures, as compared with Immediate dentures. Why? – Hard to predict boney changes – Two-stage extractions not followed – Short healing times – Inaccurate records – Many adjustments – We often see a significant change in jaw position – Patient should end up with a pair and a spare 4  Provisional Partial Denture Any temporary partial denture. Most often made with acrylic (sometimes with wire clasps) tissue supported, short term (temporary) prosthesis used for esthetics, occlusal support, maintaining space and to diagnose problems. 5  Provisional used for developing or maintaining VDO and Occlusion while other restorative procedures are being performed Provisionals worn longer than 1 month need to be supported by balls or Adams clasps Wrought Wire, Ball and Occlusal Embrasure Clasps help prevent vertical displacement 6 clasps like adam or any other that go through occlusal surfaces prevent not only horizontal but vertical displacement this is used for longer term interims  Delayed Immediates/Interims * Delayed Immediates/Interims uses CU/CL denture codes. Denture is not made ahead of time. Usually started at 6-8 weeks after all extractions and surgery is completed. Primary closure must be achieved. Will be definitively relined within 6-8 months of insertion. May be a patient compliance problem unless communication is extremely clear * Formerly known as a Remote Denture -old ACP term This is no longer an official ACP glossary term. It is a term we devised for a complete denture that is begun shortly after extractions but sooner than proper time and bone fill 7  Delayed Immediates/Interims * Unstable or Inadequate Occlusion can make recording centric position difficult 8 9  Severe periodontitis & tooth mobility Loss of VDO Possible tooth loss with impression removal Confounding medical history… diabetes. Pt requested GA OS did not wish to put patient through 2 stages of extractions Ridge contour not predictable due to Chronic inflammation/infection Excessive # teeth to be extracted 10 no way you can take a final impresion bc lossing teeth. no way you can reestablish VDO 11  Advantages of Immediate & Interim Prostheses vs. no prosthesis Esthetics - can be an advantage or a disadvantage, because you cannot predict - but it does provide emotional well-being. Esthetics are much more predictable when digitally- fabricated Surgical dressing Guides ridge formation during healing Maintains: – VDO – Mastication – Tongue size – Muscle tone – phonetics 12  Cost – Immediately: tissue conditioner first few weeks and soft liners 1/month Disadvantages of – 6-8 months: reline, rebase or remake – (2 sets of dentures or multiple relines) Immediate & Interim Prostheses Time – Overall greater number of visits to the definitive denture, vs. extraction and wait for unless done digitally healing or 1 vs. 2 Less accurate fit – During healing will require tissue conditioners every 1-2 weeks or soft liners every 4-6 weeks No anterior try in (in most cases) to evaluate esthetics Steep overbites may not be restorable (especially if there is natural opposing) Esthetic improvement may be limited if only one arch is done Occlusal correction may be limited if only one arch is done Healing problems in patients with ill-health (e.g. uncontrolled diabetes) No “spare – backup” prosthesis – if the immediate denture is definitively relined or rebased and not remade – (1 vs 2 prostheses at the end of tx) 13  Preparation Checklist √  Evaluate patient’s general health (for healing, ability to understand or respond to your instructions, coordination with regard to motor skills)  Make pre-treatment study casts for legal record, custom tray, tooth selection and arrangement (if possible)  Evaluate and correct occlusal plane of any teeth to remain – particularly the opposing arch  Space analysis (for alveoplasty @ extraction appointment)  Evaluate need for soft and/or hard tissue recontouring  (e.g. tuberosity reduction, torus removal, alveoplasty)  usually done @ stage 1  Surgical guide / bone recontouring template required  Evaluate need for gross debridement (no insertion over infected tissues) 14  Preparation Checklist √ (con’t)  Determine if treatment is to be upper, lower or both arches based on occlusion  Determine the need for posterior occlusal support (do not leave unopposed posterior occlusal table)  Determine staging order of two-stage extractions  (required if posterior teeth present or alveoplasty/torus or tuberosity reduction)  Explain everything to the patient and obtain consent!  healing time, tissue conditioner at day 3-7, relines at week 6, temporary and definitive prostheses, fees…  Allow average of 6-8 months healing before (definitive) reline, rebase or remake  Allow 6 weeks minimum healing for a “delayed immediate/interim” * denture  Always allow time for necessary adjustments and replacement of tissue conditioner… and then soft liners…  24hr, 48hr, 72hr, weekly, monthly 15 16  Diabetes (uncontrolled) Heart disease Obese CPAP 17 18  Approval Forms for: Immediates, Interims & Delayed Interim On Blackboard RS642 and in today’s folder 19  1. Yellow Card 2. Consent 3. Select Approval Form 20  1. Yellow Card 1. Patient Consent 2. Consent 2. Faculty Witness 3. Select Approval Form 21  Staging Extractions When is staging necessary…? Every case If OS deems that the patient cannot have two-stage surgery (if pt medically compromised), then the patient should have full mouth (FM) extractions without a denture insertion Hence… the delayed interim/immediate denture… 22  Staging Extractions Two-stage Extractions - Treatment of choice:  Stage 1: Extract posteriors - leaving one posterior stop » To have a reproducible occlusal reference » To maintain VDO Alveoplasty, torus removal and tuberosity reduction  Allow approximately 2-3 weeks for initial healing and then…  Fabricate Immediate/Interim denture(s) and bone recontouring template  Stage 2: When the dentures are insertion ready, extract remaining dentition and insert dentures 23 24  Treatment Workflow Treatment of choice: 2-stage extraction 1 posterior stop – should be left 1 2 Posterior Record Base & extractions Occlusion Rim save 1 posterior for extracted stop teeth Tooth set up 3 4 Removal of ant teeth on final and try in cast (or virtual removal) Set up, (wax up) and finalize immediate denture 25  Preliminary Tx Plan Stage 1: #5, 17, 28-32 Case #1 IU/IOL Stage 2: # 6-11, 13, 20, 21, 23-26 Full mouth extractions in 2 stages Remaining # 22 & 27 when to prep for overlay? Except for #22 and #27 prior to extractions – why? Staging must be done with MOUNTED CASTS! 1 posterior stop #13/20 26  Preliminary Tx Plan Stage 1: #2, 5, 15, 18-20, 28, 29-31 Case #2 QU/QL Stage 2: #6, 11, 12, 21-28 Full mouth extractions to provide aesthetics and for holding vertical & pts upper partial 1 posterior stop #12/21 27  IU/ITL Stage 1 extractions completed #5 & 28 remain as posterior stop 28  Preliminary Impressions in alginate for IU/IPL Custom tray Survey and Design* You must capture all teeth, folds and soft tissue landmarks Retromolar Pads are especially critical for determination of plane of occlusion 29  Survey and Design (PL)* Even though you are first fabricating a lower provisional, you must have a definitive (or at least a strong tentative design) mapped out for the cast partial lower. This is an integral part of the treatment plan. 30  Provisional Design Whatever 1. Ball wire rest (#18, #31) You must describe a design 2. Ball wire or for the transitional Adam’s clasp or provisional with (interproximally regard to the type between #27 and and location of #28) wire “rests” and 3. “C” shaped “clasps” wrought wire (#22 and #29) Faculty Signature 31  Custom Tray Block out is accomplished according to chart recommendations D A= Single wax for tissue relief B= Tissue stop(s) C= Wax relief (if needed / cannot be surveyed/tilted) D= Double wax relief for teeth and Tooth stop(s) 32 it needs tooth stops to allow impression material over the teeth so it can be removed  Border Mold and final impression using same techniques as complete dentures 34  Occlusal plane height of lower rim is established using RMP as a posterior reference; occlusal plane of upper rim is initially determined to be parallel to crest of ridge Retromolar Pad Crest of ridge 35  Interocclusal Records How do I restore this case? How do I articulate the final casts? – CR? – MIP? It depends… – Is there an existing natural posterior stop with an acceptable VDO? Yes? …then MIP… Why? …it’s reproducible No? …then CR… Why? …it’s reproducible 36  Try in and adjust each occlusion rim separately first. In this case, the lower rim required no adjustments since the occlusal plane had been determined by proper landmarks The upper occlusion rim required adjustment on the left side due to the opposing dentition. Adjust, until natural posterior stops touch once again. In this case #5,6 and #27,28 Soften and allow #21 & 22 to indent opposing baseplate wax Provide additional relief prior to the bite registration record 37  When both rims are in, all that should remain is an adjustment between the wax surfaces. Adjust until the natural posterior stop is in full contact Which rim would you adjust? When the bite record is made, check that the posterior stop is in contact If a natural posterior stop is present, the bite is in MIP (not CR), why? 38  Posterior Palatal Seal is recorded and the cast is scored These numbers are the compressible tissue depths. Cast is outlined and scored to one-half the depth. Heel of cast 39  Check occluding rims, record bases and casts… for Heel Interference If present, adjust, rims, RB or casts and retake bite record 40  Tooth & Denture Base Selection 41  Lab Rx Tooth selection: Upper central & Cuspids - 55F Upper Laterals – 54F Lingualized posteriors – 332 Shade C2 Set up for Split try-in: Use length of #9 for #8 Match upper midline to lower Shorten #7 & 10 as drawn Cuspids same length as #6 No anterior contact in occlusion Detailed communication with the lab is CRITICAL! 42  Request “Split Set-up” for try-in 43  Posterior try-in: √ Posterior stop / CR √ Excursions √ Post Dam 44  Surgical Guide / Bone Recontouring Template Used in conjunction with a surgical procedure A thin, transparent form duplicating the tissue surface (intaglio) of a dental prosthesis OR A duplicate of the immediate/interim denture, with or without a window and teeth Used as a guide for surgically shaping the alveolar process or for tuberosity reduction or torus removal 52  Modifications are made on the final cast – analog and in the virtual set-up - digital. Specifically, this case involves removal of teeth and reshaping of bone bilaterally. On your removable prosthetic flow sheets, you will see step 8 denoted as “mouth preparation”. This refers to the consultation regarding pre-prosthetic surgery and bone recontouring 53  Original cast in pink, duplicated and modified cast in yellow stone Vaccuform matrices fabricated on both casts Surgeon can view amount of bone reduction by comparing matrix from original cast on modified cast (& intraorally) 54  Note use of esthetic stippling Final case returned from lab, finished and polished and ready for insertion. OS appointment may now be scheduled Typically, guides are usually not created for (partial) provisionals due to the challenge of managing multiple undercuts Embrasure Ball Clasps Per Rx 57  Surgeon tries in the surgical stent and evaluates. Notice blanching of the tissue Extractions & Recontouring Denture(s) inserted Note Ball Clasps - must not interfere with the occlusion. 58  Instructions given to patient – but this should be a review – not the first time the patient will have heard them… 59  Insertion Sequence Before extraction: – Prep teeth for overdentures or section bridges as needed. – “Insert” prosthesis that does not require extraction Anesthetize patient (re-anesthetize if needed during procedure) Extract remaining teeth and recontour soft/hard tissues using bone recontouring template Evaluate ridge for smoothness following extractions or recontour Insert denture… 60  If denture does not seat: Reinsert surgical / bone recontouring template (do not use pastes at this stage) Adjust denture according to template diagnoses (e.g. tissue blanching) If both anterior & posterior are undercut… adjust posterior If only posterior has undercuts… adjust bilaterally If only anterior had undercuts… change path or grind minimally Thoroughly clean and polish denture after adjusting Insert & remove denture as few times as possible to minimize trauma 61 do not adjust on anterior if possible  If denture seats but is not retentive Place tissue conditioner (Coe-Comfort / super soft denture reline) under gentle occlusal load (in function) After tissue conditioner cures, remove any socket projections Adjust occlusion… – At least 2 posterior occlusal stops bilaterally – No anterior contact in centric – Occlusion will change over the next several days to weeks due to swelling and then shrinking of tissues 62  Insertion Sequence (con’t) Thoroughly clean & polish denture of debris after adjustment (it will act as a surgical dressing) Insert denture as soon as possible, before swelling begins Give patient home care instructions (see next slide) Re-appoint patient for 24-hour post-op evaluation Give patient emergency contact number (OS + Restorative) Dismiss patient only after hemostasis is ensured 63  Home Care Instructions Ice pack 10 min on / off for 2 hours, then 10 min each hour as needed – expect swelling and discomfort for the first 72 hours If there is significant swelling initially, patient may need to wear day and night up to 2 weeks post op – then begin to wear day only Pain medication to be taken as prescribed by OS Call OS emergency number in case of bleeding Do not remove denture for the first 24 hours Do not use adhesives should dentures become non-retentive prior to primary closure After 24-hour post-op, remove daily to clean denture and soft tissues; rinse mouth gently Eat slowly and chew bilaterally, taking small bites 64  Clinical Remount IS required… however… Is NOT done at the INSERTION visit of the immediate/interim denture IS done at SUBSEQUENT adjustment visits when swelling has decreased and tissues are healing so that the foundation is stable, and the occlusion is more stable 65  On Blackboard RS642 66  BMC Patients Protocol for joint GSDM / BMC cases is the same except for the insertion. We do not have the patient come back to the GSDM from BMC for insertion. The immediate/interim denture(s) are inserted at BMC by the attending, resident or yourself, as planned. The 24 post-op follow up is done back at the GSDM clinic, unless the patient is hospitalized or non-ambulatory. Patients may elect to have their extractions/surgery done at BMC for various reasons (i.e. general anesthesia & insurance coverage). Best thing is to discuss protocols with attending doctor in OS prior to the surgery day Most full mouth surgical extraction cases done under GA will not have interim/immediate dentures planned and inserted day of. A delayed immediate is what should be tx planned 67 68  IU/PL D5130- Immediate Complete Upper (Rebased-Definitive) D5214 – Cast Partial Lower 69  Pre-treatment IU/PL Patient still has posterior stops and a reproducible MIP 70  Restoration of lower IU arch has been completed with Perio and the fabrication of survey crowns #20 and 29. Rest seats, guide PL planes and undercuts have been PLANNED 71  Custom Trays & completed Border Even though Molding. lower is definitivefor Preparing and upper Final is not, final Impressions impressions are captured the same way 72  Instructions to lab for cast partial Lower Final Cast and Work Authorization (Lab Rx) for Lower Cast RPD 75  In the meantime, a record base and occlusion rim is prepared for the Interim Upper Denture while waiting for the lower RPD casting to return from the lab 76  Try in of lower cast partial framework. Evaluation: √ Rests – definitive determinant √Tissue Stops √ Occlusion 77  Adding Record Base and Occlusion Rim wax to develop lower occlusal plane: Match marginal ridges of adjacent natural teeth End wax at tuberosities or RM Pads (L) - 1/2-2/3 RM Pad (U) – parallel to posterior ridge crest 78  Intermaxillary Records Wax Try in Here, first, the lower is tried in, to establish the occlusal plane Again, adjust each arch individually then both together 79  Recording Facebow and Centric 80  Tooth Selection H= 10 mm W= 7.5 mm Canine to Canine = 50 mm 81  Presented 2 choices 83  Mark: Midline from facial landmarks Length of anterior from resting lip 84  Lab Rx – for tooth set up Please set up D-S Portrait mould 24E shade Portrait C1 for immediate Upper Denture and Cast Partial Lower Denture. Please return for Split Try in. Enclosed is a study model of patient’s current dentition and prostheses; Maxillary lip length marked on incisors Mand occlusion rim indicates occlusal plane 85  A Split Try in enables the technician to set up the teeth that cannot be tried in - directly on the cast and the teeth that can be tried in – on the record base. Allows the clinician to verify VDO, Centric & allows to pt to view the full setup on the articulator 86  Tooth try in √VDO, CR √Esthetics √Phonetics Occlusal view - May not be able to fully try-in / adjust anterior, due to interference by teeth to be extracted 87  Develop and record the POST DAM intra-orally and transfer to cast Remember the series of vertical dots used to aid in location of AVL 88  Lab Rx – for processing Tooth try in completed. Verified VDO, CR, esthetics and phonetics. Pt approves set up. Scored Post Dam. Please complete set up and wax up Fabricate surgical guide / bone recontouring template, base on duplicated and modified final cast Process in (denture base shade ? ) Pin =? Return finished, polished and hydrated for insertion 90  Next clinical visit…? Notice the ridge contour and the thinness of the denture base Oral surgery and insertion of IU/PL ?? Try in and adjustment of Cast Partial Lower ?? 91  Pre-Fit If one arch is treatment planned as an immediate or interim and one arch is treatment planned as a definitive cast partial, ICU/PL, then the definitive prosthesis may be pre-fit for the intaglio and borders, but not necessarily for the occlusion. This pre-fitting of the definitive prosthesis will save valuable time when time is of the essence. 92  Rest not fully seated within rest seat What would make a partial not seat after processing? What has changed since framework try in and tooth try in… ? Should we really need to adjust the metal at this stage? Why/why not? 93  What would make a partial not seat after processing? What has changed since framework and tooth try in…? Acrylic @ guide planes Acrylic covering clasp arms Acrylic in undercuts not consistent with the path of insertion Acrylic in other locations 94  Sorenson’s Paste Pressure Indicating Paste For Acrylic 95  Grind judiciously, not haphazardly! 96  Fit checker for metal 1. Fit Checker (not PIP) 3. Mark show thru with indelible 2. Metal show thru 4. Peel & Grind mark 97  Should this occlusal contact on the pre-fitted partial denture be adjusted now? 98  Extract remaining maxillary teeth Insert and evaluate maxillary surgical guide Day of Modify tissue/ridge if necessary Extractions / Insert and adjust (if necessary) maxillary immediate/interim denture Insertion Insert mandibular cast partial denture; adjustments generally not necessary- other than occlusion. Remember the prematurity on #24? Review patient take home instructions 99  Insertion & Post-op 24 hour (needed) 48 hour (if necessary) 72 hour (needed) 1 week after that Monthly… 100  @ 10 day suture removal Apply PIP (or Fit Checker) What caused this ulcer? Oral surgery? Denture? Pt was completely unaware & w/o sx Look for ‘evidence of movement of the Insert carefully paste and observe show-through 101  @ 1 month post-insertion 102 103  DIGITALLY-FABRICATED IMMEDIATE/INTERIM (COMPLETE) DENTURES 104  Digitally-fabricated Immediate/Interim Complete Dentures 2-Stage extractions a MUST The lab will do the virtual ridge recontouring Elastomeric impressions as usual Interocclusal records: – Use record bases and occlusion rims where needed Mark midline, maxillary central incisal edge position and occlusal plane and any other desired changes on occlusion rim or cast or photo where applicable Record and score Post Dam, select teeth and denture base shade and take photos 105  Repose and Smile Photos Without rims 106  Note: The Repose and Smile lower rim fractured in the midline. I used Photos a piece of the With rims pattern resin to fix it. This makes the lower lip protruded. 107  Scan and Digital Rx: Articulated casts with PPS carved into maxillary cast Tooth & Base mould & shade, Pt photos and Rx 108  INTERIM COMPLETE UPPER AND LOWER 109  Posteriors extracted 1 stop left for VDO & MIP Elastomeric PVS Impression Courtesy of Dr. Nadim Baba 110  PPS 111  Virtual Articulation & Ridge Recontouring prior to tooth set-up Requested at initial Rx 112  Bone Recontouring & Surgical Guides with Teeth Typical with digital interim cases that will also be followed up by implant placement Cut out provided at the level of bone reduction 113  Additional ridge recontours can be made by marking up directly on the Digital Preview Digital Preview 114 115  INTERIM COMPLETE UPPER AND LOWER 116  Interim U/L - Stage 1 Extractions Complete 117  Stage 2 Extractions & Insert Interim U/L 118  INTERIM COMPLETE UPPER AND LOWER Reduced vertical Alveoplasty needed 119  Interim U/L - Stage 1 Extractions Complete 120  Digital Preview 121  Digital Preview – Space Analysis 5mm clearance from residual ridge to occlusal plane… now what? 122  Stage 2 Extractions & Alveoplasty Bone Recontouring Templates for Alveoplasty Extraction Sites, Alveoplasty & Sutures 123  Insertion Interim U/L 124  INTERIM COMPLETE UPPER AND PROVISIONAL LOWER 125  Repose Smile Repose Smile W/O Occlusion Rims Drs. Dayana Escobar, Mohamad Srour & Jessy Ajram 126  Repose Smile Repose Smile Occlusal Rims 127  Mounted Models with Rims BOSTON UNIVERSITY HENRY M. GOLDMAN SCHOOL OF DENTAL MEDICINE 128  PPS BOSTON UNIVERSITY HENRY M. GOLDMAN SCHOOL OF DENTAL MEDICINE 129  Digital Preview 130  Partial BTI Try- in: If any adjustments are needed, BTI’s may be scanned intraorally to capture new CR 131  Partial BTI Try- in: Dr. Paula Aspinwal- Resendes GSDM2023 132 133  Intraoral or replace on model and scan 134  Partial BTI Try-in: 1. Esthetic Try-in 2. If there are sufficient posterior teeth to scan intraorally, in case a new CR record is needed 135  INTERIM COMPLETE UPPER BIOCOPY NATURAL DENTITION 136  Posteriors extracted Provisional lower fabricated Aluwax bite in CR for this case Since No posterior stops 137  Interocclusal Records Aluwax bite in CR with Record Bases & Occlusion Rims for this case Since no posterior stops PVS added later on the lingual for stabilization during the scanning process ONLY 138  DIGITAL PREVIEW 139  Monolithic Denture is still thin, even post-alveoplasty. Notice how her new teeth follow the ridge Monolithic denture will provide more strength and are characterized, just like her own 140  Before & After 1-week post- insertion 141  Next Week Relines, Rebases, Repairs, PPS You may pick up your maxillary PPS cast in Robinson – 3rd floor if you did not pick one up today in 670 144