CD Lec 10 - Interim & Immediate & Treatment Dentures, RRR - 2023 PDF

10/23/2023 Interim Dentures Immediate Dentures Delayed Immediate Dentures Treatment Dentures Ronni A Schnell, DMD, MAGD, FICD, FACD RS522 ~ 10/25/23 10/23/2023 Terminology These are not definitive prostheses • Interim Denture- is a provisional prosthesis (partial or complete) that is not defini...

10/23/2023 Interim Dentures Immediate Dentures Delayed Immediate Dentures Treatment Dentures Ronni A Schnell, DMD, MAGD, FICD, FACD RS522 ~ 10/25/23 10/23/2023 Terminology These are not definitive prostheses • Interim Denture- is a provisional prosthesis (partial or complete) that is not definitive. It is inserted in the day of extractions and designed to enhance esthetics, stabilize, and/or function for a limited period of time, after which it is to be replaced by a definitive denture • Provisional- syn, INTERIM PROSTHESIS - often such prostheses are used to assist in determination of the therapeutic effectiveness of a specific treatment plan or the form and function of the planned definitive prosthesis; an umbrella term for a temporary denture (partial or complete); it is used only for a very short amount of time (e.g. 1 week to assess for new VDO), or longer – during a lengthy treatment plan and will be replace with a definitive prosthesis • Transitional- a provisional denture (partial or complete) that is 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 as natural teeth are lost. It may become an interim complete removable prosthesis when all of the natural teeth in the dental arch have been extracted. It is not definitive. • Treatment Denture- a dental prosthesis used for the purpose of treating or conditioning the tissues that is called upon to support and retain it. GPT v9 10/23/2023 • Terminology This IS a definitive prostheses GPT v9 Immediate- a definitive denture that is inserted on the day of extractions. It’s further definitive follow up is a reline or rebase after the tissue and bone healing. 10/23/2023 How do we provide this patient with dentures on the day of extractions? Ideally, you would like to start the fabrication process with NO teeth remaining in the posterior, except for perhaps 1 pair of teeth that hold VDO for the patient 10/23/2023 Maxillary Interim Complete / Mandibular Interim Partial Bilateral Mandibular Torus Removal 10/23/2023 Staging of Extractions • Extractions are “staged” or removed in two separate appointments to allow for healing time between appointments and access to a partially healed ridge for the final impression. • Required if there is extensive pre-prosthetic treatment to be done e.g.: – Torus removal – Tuberosity reduction – Alveoplasty • Generally posterior extractions, along with bone recontouring is done at stage 1 with the following details: 10/23/2023 Staging of Extractions • Stage 1 extractions are extractions of teeth not holding vertical and/or teeth not desired for aesthetics. This allows for beginning of the healing process. – All posteriors, with the exception of 1 pair of vertical stops – Root tips (anteriors or posteriors) – Bone recontouring (see previous slide) • Stage 2 extractions are extractions of teeth that do hold vertical and are temporarily kept for aesthetics. – Remaining anteriors – Pair of teeth for vertical stop 10/23/2023 Right Left Note contact of Tuberosity with Retromolar Pad – particularly on Rt Reduction must be done at the first surgical stage 10/23/2023 Mounted Casts with Rims Posterior contact may now be seen after mounting 10/23/2023 Example of Interim Complete Upper Denture and Provisional Lower Partial 10/23/2023 1. Extract Posteriors +/- +/- → 2. Final impressions & IMR After 6-8 wks healing ← +/- 3. (Split) Try-in Posteriors 4. Remove and replace anteriors and complete 10/23/2023 Let’s look at our case. All posterior root tips have been extracted and tuberosity reduction completed (stage 1). They were not needed for aesthetics nor were they holding VDO. Final impression is made in a custom tray with 2 layers of block out. PVS border molding and final impression Final cast is created with all folds, teeth and land. 10/23/2023 A record base is made for the edentulous spaces and trimmed to the AVL 10/23/2023 Occlusion rim extends to beginning of tuberosity Occlusion rim made parallel to ridge Wrought wire clasps already embedded in the acrylic (mand) Posterior plane determined by retromolar pad if no posterior teeth present 10/23/2023 Centric relation is used since there are no posterior teeth to hold vertical Extraoral positioning of casts in CR Check for potential heel interferences 10/23/2023 Note anterior vertical overlap Heel interference prior to tuberosity reduction. Dentures are extremely close posteriorly *window created in the record bases* Note anterior horizontal overlap 20° teeth and a ramp will be selected to assist with anterior overjet/overlap 10/23/2023 Upper Posterior set-up Record base too thick over the ridge Note placement of “window” to make room for teeth accompanied by placement of tin foil 10/23/2023 Completed upper arch Completed U/L set-up 10/23/2023 Anterior set up for Immediates/Interims TO DUPLICATE ANTERIORS: SET ONE TOOTH AT A TIME TO CHANGE ANTERIORS: SET ONE SIDE AT A TIME 10/23/2023 Our case duplicates the anteriors We will start with replacement of missing central If space exists, then record base extended to anterior space and tooth try-in is possible If no space for base, then tooth luted directly to cast and anterior try-in is not possible. 10/23/2023 Replacement of canine which is to be extracted Canine ground off cast. This is referred to as ‘surgerizing the cast’ Note convex contour of site. How do we achieve this? 10/23/2023 “Ridge lapping” of canine Note lingual and gingival recontouring of denture tooth Lateral removed Note socket shape (too concave) 10/23/2023 Continuing on with surgerizing the cast Left lateral removed, denture lateral luted, then left central removed Right lateral removed Note convex contour of socket Note convex contour of socket 10/23/2023 Lateral luted & canine removed Note socket contour 10/23/2023 CanineSplit luted to cast Try-in Patient will have a try-in at this point to verify VDO and CR with the posterior removable section and view the anteriors set on the articulator. 10/23/2023 Following try-in, 2-3 layers of baseplate wax are added to area of cast without record base Wax & base are joined together 10/23/2023 Surgical Guide /Bone Recontouring Template • Any device used as a guide for surgically shaping the alveolar process or positioning of gingival tissues (GPT v9) • The surgical guide is used by the surgeon in order to re-contour the soft and hard tissue by viewing blanching of the tissue when it is placed over the post extraction site to ensure adequate trimming of bone and tissue. (Zarb, 2004) Duplicate final cast Duplicate denture base 10/23/2023 Surgical Guide /Bone Recontouring Template • Is transparent so surgeon can easily visualize inspect areas of stress. (Boucher) • 2 mm thick for rigidity. (Young, 1985) 10/23/2023 The teeth are surgerized from cast and also tissue, tori and exostoses Also called a bone recontouring template when: • Tuberosity reduction • Alveoplasty • Torus removal 10/23/2023 Duplicate of final cast, Vaccu-form template and denture Note: Interim Denture thinness prior to ridge resorption 10/23/2023 Lab Rx for Analog Processing Interim Complete Upper / Lower Wax-up completed Post Dam scored Process in acrylic shade ____________ Lab remount: Pin = +/- ___ Please fabricate surgical guide / bone recontouring template according to modifications made on final cast Return finished and polished and hydrated for insertion 10/23/2023 Interim/Immediate denture must be ready prior to surgery Notice incisive papilla waxed in and processed to aid in phonetics “L” sound 10/23/2023 Extraction of remaining teeth and sutures placed (these had been teeth planned for stage 2 extraction, initially kept for aesthetics) Use guide to check for blanching 10/23/2023 Insertion of Interim dentures over extraction sites Upper is full arch Lower is partial arch 10/23/2023 Bilateral simultaneous posterior contact No anterior contact in CO Note horizontal overjet 10/23/2023 Digital Clinical Example:  The Interim Complete Upper 10/23/2023 10/23/2023 10/23/2023 Case articulated for scanning first Then cast surgerized for bone recontouring template 10/23/2023 Digital preview with reference and tooth set-up Split try-ins are also possible for anterior teeth 10/23/2023 Insertion & Adjustment 10/23/2023 Immediate & Interim Denture Clinical and Laboratory Steps • • • Extract posteriors (leaving 1 stop to hold vertical) Final impressions and intermaxillary records with base & rim in posterior Select teeth, PPS, Photos, Rx Analog: • Set posteriors on rim • Try-in posteriors / view anteriors on cast (Split try-in) • Set anteriors on cast • Process denture & surgical guide • • • Digital: • Scan and virtual set-up • Digital preview & approve • No try-in, except in certain circumstances • Mill final denture(s) & surgical guide Extract anteriors (and posterior stop) Insert denture (using surgical guide) Clinical remount at a subsequent adjustment visit, when tissues are no longer swollen 10/23/2023 Complete vs. Immediate/Interim VISIT 1º Impr 2º Impr CR method Try-in Insertion Adjustment Complete Alginate PVS notch + wax ant. + post. known 24-48 hrs Immediate/Interim Alginate PVS* teeth + wax usually posteriors, but may include anteriors unknown 24 hrs - required * Caution with undercuts 10/23/2023 Advantages vs. Disadvantages of Treatment Planning Interim or Immediate Dentures vs. no denture • • • • • • • • • • Esthetics (teeth right away) Surgical dressing Ridge formation Maintains VDO (posterior try in) Maintains chewing Maintains tongue Maintains muscles Maintains speech Will be a “spare”, if relined definitively Acts as prototype for definitive – for esthetics and occlusion • Esthetics unpredictable – No anterior try-in if ant teeth present • Accuracy/fit unpredictable – High maintenance – Frequent relines until healed • Slow healing w/ ill patients • Overbites (natural to artificial dentition) • Occlusion – unpredictable • May be mitigated with 2-stage extractions, otherwise, the above is exacerbated 10/23/2023 Contraindications for Immediate/Interim Dentures • Patients in overall poor general health or those with mental incapacity that would prevent cooperation during the postsurgical healing phase. • Patients who appear unable to understand and appreciate the scope, demands, and limitations to the course of proposed treatment. • Patients with increased surgical risks or a history of surgical complications. • Patients exhibiting an uncooperative nature or extremely high treatment expectations. A clinical pathway for complete immediate denture therapy: Successful prosthetic management for hopeless dentitions By K. David Stillwell, DDS, MAGD Jamie Amir, BDS General Dentistry, May-June 2008 Pg. 380-389 10/23/2023 Contraindications for Immediate/Interim Dentures (con’t) • Serious medical issues, systemic disease, blood coagulation disorders, difficult wound healing, radiation in the head and neck area. • Elderly and ill persons find it difficult to endure extraction of more teeth at the same sitting. • Extensive reduction of the residual ridge during phase 2 • Medical consultation required for IV sedation and GA 10/23/2023 Contraindications for Immediate/Interim Dentures (con’t) • Uncontrolled diabetic Contraindicated • Controlled diabetic Consult with PCP • Uncontrolled hypertensive patient Contraindicated • Controlled hypertensive Consult with PCP • Immunocompromised patient Consult with PCP • Coumadin Consult with PCP Immediate/interim denture can act as a bandage. 10/23/2023 Delayed Immediate Denture* • Delayed Immediate 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. • Must be relined within 6-8 months of insertion. • Typically a patient compliance problem unless communication is extremely clear * This is not an official ACP glossary term. It is a term we use for a complete denture that is begun shortly after extractions but sooner than full bone fill (Remote Denture) 10/23/2023 10/23/2023 10/23/2023 6 weeks post-extraction 6 years post-extraction 10/23/2023 PRIMARY CLOSURE Surface of tissue must be intact for impressions to be taken safely Clot may be disturbed Suction from an impression taken prematurely will remove the blood clot that forms in the extraction socket Surface unstable Interior unstable Surface intact (primary closure) Interior unstable Surface intact Interior stable 10/23/2023 Healing & Impressions  Allow 6-8 months for ideal healing for complete denture impression  interim denture replaced by complete denture made with custom or Massad tray impression  Allow 2-3 weeks minimum before preliminary impression of a wound  delayed immediate denture becomes the complete denture made with processed reline impression  Allow 4-6 weeks minimum before final impression  Healing is not a standard. It is a range, particularly when there are health issues that complicate and slow the healing process, such as diabetes and immunosuppressed patients  No minimum required for Tissue Conditioner  interim denture or immediate denture becomes a treatment denture if lined with tissue conditioner 10/23/2023 Treatment Dentures are used to condition or medicate soft tissue Treatment Dentures are interim or immediate dentures that are lined with tissue conditioner in preparation for future therapy 10/23/2023 Uses for Tissue Conditioner To retain dentures: Interim/Immediates Ill-fitting To diagnose problems: Pressure VDO To condition tissues prior to final impressions: Red Redundant Inflamed To impress tissues: Relines Rebases 10/23/2023 Tissue Conditioner Types White tissue conditioner  Coe Comfort (~1wk) Pink tissue conditioner  Coe Soft (~1 mo) 10/23/2023 Rules for Tissue Conditioner • Use opposing occlusion during impression to maintain CO and VDO (in function) • If both U and L require TC, do one impression at a time Which one first? Why? • Replace tissue conditioner (white) approx every 1 week • Replace soft liner (pink) every 1 month 10/23/2023 Tissue conditioner Components: o Powder o Liquid (mma) o Lubricant Lubrication of area done below denture border Why? 10/23/2023 Denture coated with tissue conditioner Immerse in cool water prior to seating 10/23/2023 Patient occluding in function During setting of the material Seating of denture with tissue conditioner done in function and at VDO with opposing arch 10/23/2023 Desiccated tissue conditioner can cause mechanical injury to tissue Old tissue conditioner can cause infection due to colonization 10/23/2023 Next up today: Relines, Rebases and Repairs