RELINES, REPAIRS PDF

You're going to be receiving patients that might be coming back for troubleshooting early, or cases that have been recently inserted, cases that have probably inserted just immediate dentures and may need re lines or cases or patients, new patients that have some teeth that will need to be extracted...

You're going to be receiving patients that might be coming back for troubleshooting early, or cases that have been recently inserted, cases that have probably inserted just immediate dentures and may need re lines or cases or patients, new patients that have some teeth that will need to be extracted. And you're going to need to treatment plan interim or immediate dentures. So I do want to talk about these procedures. And then of course we're going to get a lot more detailed and granular in our next course. So let's talk about these procedures for now. Terminology. Of course you're going to have the slide up close and personal. But basically we've got interim dentures. We've got provisional dentures transitional dentures and treatment dentures. These are not definitive prostheses. This is what you need to know. There's always a procedure that needs to be done to create a more definitive prosthesis for our patients. Meaning a definitive re line, a definitive rebase, or a remake for interim dentures. Which are either complete or partial dentures. We always follow it up with a second prosthesis. Okay. So that those those prostheses need to have definitive treatment because the patient is undergoing a healing provisional prosthesis patients. These are interim prostheses, again such that they assist in determining whatever therapeutic procedures will need to come next. Transitional. Just think of the word transitional. It helps the patient transition translate from one state of their dentition to the other. Treatment. Dentures a dental prosthesis that's used to treat a patient's tissues, for example, that are in a state of inflammation. So all of these must have some kind of definitive treatment. Once that once healing has taken place, once that prosthesis has been used successfully to have done its job, whether it was successfully to treatment plan or successfully to provide posterior support and the like, versus an immediate denture, which is a definitive denture that's inserted on the day of surgery, but that will become the patient's final denture. And so what we're going to need to do is we're going to need to do procedures on that denture to keep the denture in the patient's mouth. But yet that's going to be the only denture that the patient is going to to receive from us. So we need to differentiate between the immediate denture and the interim denture. And you'd be surprised because most of the dentures that we do in our treatment center are not immediate dentures, so that we have the ability to do a follow up definitive denture for our patients. So let's let's talk about the different dentures that we do. So how do we provide this patient with dentures on the day of extractions. Having teeth presently okay. Ideally you'd like to start with the fabrication the fabrication process without the patient having teeth. But even a patient that whose teeth look like this, if you say to them well okay we know you need teeth, we know you need a denture, let's just go ahead and extract your teeth. The patient will look at you and say, I can't go without my teeth. In the meantime, this is what your patient looks like. So there are procedures that we can do to plan ahead, to actually begin fabrication of adventure with the patient's teeth still in their mouth, so that we can semi predict what the denture will look like and fit like in their mouth on the day of extractions and the day that we insert the denture. But what we have to do is we have to make that certain things happen before we actually start the denture. So the very, very first thing that we have to do is look to see what their dentition looks like. We have to take a set of study models. We have to articulate them, and we have to see which teeth are in occlusion, which teeth might hold our vertical even if it's one stop. Which teeth might hold our vertical and which which pair of teeth. Even if you ask the patient to close, which pair of teeth might be that repeatable position, when the patient closes down, the patient is going to go to that same spot each and every time. Okay, it might not be the official terminology of MIP, but that's going to be that patient centric occlusion position every single time. So that's going to be the patient's repeatable position. So what we do is what we call staging extractions. Now many patients of course are concerned about their function. But most patients who want to have either an interim or who want to have a denture inserted on the day of extractions, are concerned about their esthetics. So what we like to do is we like to take a look at the dentition. And if there teeth in the posterior that's not even in function, we will extract them first. Okay. So we do a two stage extraction because lots of times not only do we extract the teeth that are not in function, but we also are looking at things like the tuberosity. We look at things like exocytosis. We look at the Tory and see if there's any bone contouring that has to be done in addition to our tooth extractions, because if there are some pre prosthetic surgeries that has to be performed, we also do that at stage one extractions. So we make our assessment. We. If there is some extensive pre prosthetic treatment to be done like Taurus removal, tuberosity reduction, even alveolar plasti, if the ridge is very irregular and has to be smoothed out okay. So we'll treatment plan that for our stage one extractions. We'll also treatment plan posterior extractions that are either not in function or basically they're not responsible for holding vertical and will leave one posterior vertical stop generally towards the front. This way when we extract those posterior teeth and wait a couple of weeks for healing, now we have ridges in the posterior that we can impress. That will now be there for the denture on the day of insertion. That will be somewhat similar to the day that those tissues were impressed, because you can imagine if the patient has all of their teeth. And we're going to fabricate a denture on an impression that looks like this. And so what we're going to have to do is grind off all these teeth and make a denture. We're basically guessing what where the tooth position is going to be and what the ridge, primarily what the ridge is going to look like. Okay. And that's a really hard prediction. So. Stage one extraction again. Any bone re contouring all the posteriors except for one pair of vertical stops. Root tips, of course, because we don't need them. And as I said, bone contouring. Stage two extractions are all the remaining teeth, and if there's any bone contouring in the anterior, of course will accomplish that at the stage two extractions. Okay. So for example this patient has had their posterior teeth extracted only has remaining anterior teeth. But we have an issue back here where the tuberosity and the retro molar pad are in contact with one another. Okay. So it's important to either do a diagnostic mounting or carefully evaluate this internally, because this must be accomplished during one of the stage of extractions. If this was missed during stage one, it has to be done at stage two. Otherwise, if we go ahead and fabricate the dentures, if we go ahead and try to insert the dentures, now we're going to have a heel interference. And if we try to adjust, one or both of those arches are going to perforate. Okay. So that's going to be a problem, especially if we're going to restore this at the vertical that the patient presents at. And if this vertical is acceptable then we're going to have to do something back here. Because we can't just arbitrarily increase of patients vertical dimension just to make room for dentures because the tuberosity has overgrown, maybe because of a super erupted tooth that the patient once had. What kind of protective procedures can can be done in cases like that from here? A tuberosity reduction. Yeah, yeah. You look. You take a look at the radiographs and you see where the bone is. I mean of course you take a look at the bone in relationship to the sinus. And you know lots of times this can also be excess tissue. So sometimes you might do a distal wedge procedure and thin out the tissue. So it depends on what on what is there. Sometimes it needs bone. Sometimes it needs bone and tissue. Sometimes it just needs just tissue. Oh. So this is our case with our mounted case. And again you see this. And there's barely a millimeter in between the two. So this case was ready to go. And you know we were going ahead and taking some final impressions. And we noticed this. Okay. So this is this is not something that you want to find out midway into your denture fabrication. Okay. So let's see an example of an interim complete upper and a provisional lower partial denture. So what we'll do is let's say the patient has their full complement of teeth on the maxillary arch. So we're going to extract the posterior except for. Think I lost my pointer. Except for a pair of. Occlusal stops. And let's say we pick a premolar. Which is going to help the patient hold their vertical and help their centric. Okay. The posterior stops are out. We wait a few weeks until we have primary closure, and then we can take a final impression on the arch and make a set of record bases and occlusion rims. Here on the occlusion rims will mount. We'll set some teeth. And here we have our record base with our posterior tooth setup. At this point, where we have the teeth set on the posterior rim, that we can remove the posterior rim off the cast. And we can actually put that back in the patient's mouth to do what we call a split trying so we can try in the posteriors. Not necessarily for esthetics, but we can verify whether or not centric is correct. Vertical is correct. And you know, if there are any anterior missing teeth, we can add it to the rim as well. But in most cases, patients are generally missing posterior teeth because those are the extractions that we do. So we'll do a split trying. Once the split trying is done, we put the record base back on, remove the anterior teeth and go to process. Now that's like on one slide, basically the mechanics of it. And we're going to see a couple of cases to see what it looks like. So here's our case. All the posterior root tips have been extracted. The tuberosity reduction has been completed. And they were. This anterior tooth also had a root tip. And so this is out and everything has been extracted that has not been holding vertical. So here's our final cast. There's the record base. The record base has been cut back to the anterior vibrating line. Wax rims. Basically the wax rims. We set them up as though we were thinking of doing a complete denture, the same type of landmarks initially parallel to the ridge on the lower. We set it to two thirds the height of the retro molar pad, or anywhere from one half to two thirds, depending on the posterior teeth that we've decided to select. We go back into the patient's mouth. We go through the same procedures that we do in terms of inter occlusal records, and we determine our vertical and centric. If there is, again, that one stop that we're keeping for vertical and centric, we're going to take down the wax rims until we reach the natural stop. So what's important to know about interims and immediate dentures is that if there is a reproducible position, we're going to go back to that reproducible position and restore the case in that reproducible bite. If there is none, then we'll restore the case in centric. So here we go. And in this case the patient only had anterior teeth. So centric relation is used. And we're going to check that on the cast. Make sure there's no heel interference. Key them back in and mount it on the articulator. Notice that even with the tuberosity reduction we're really, really close. So we have to monitor that very closely. Again, we may have to do some additional trimming when we go back into oral surgery. Yes. Question. Yeah. When we do that the surgical contour of that tuberosity. Yep I won't be changing the video. So we compensate after. By by surgically removing this tuberosity does not change vertical dimension. This is soft tissue. So chances are if it's lightly touching on the cast what's happening into orally is that the tissue will probably compress a little bit. Yeah. So you're not touching vertical at all. Yeah. In the case of you have a patient that exists and they. What are the options that you have? Well, again I can't. We're going to touch upon that just a little bit. But I can't get too granular right now because this topic is very, very broad. So we're just talking about operational at this point. All right. But stay tuned. We are talking about when is a good time to do this and when is not. It's coming. So there is quite a bit of anterior overlap here. If we put the teeth exactly where they are, we know we're going to get into trouble because this is a natural dentition. So what we're going to do is we're going to have to play around with the posteriors a little bit, right, so that we're maybe introduce some additional cusps, some curves in order to help our anterior overlap. And we have to make sure that maybe we can have sufficient horizontal jet and maybe reduce the vertical overlap with the lower anterior teeth, something that is not going to evolve the anterior esthetics. Okay. But you know, converting a natural dentition with an interim or immediate denture is going to be tough esthetically, where you don't want to change a patient's esthetics to dramatically. So here's our upper posterior setup. Notice that we had to have a window placed on the right side. Because of the excess tuberosity area and the amount of bone that was here as well. Here's the completed upper arch and the upper and lower setup. We're going to be changing this around a little bit, and maybe adding some wax in the posterior to create a ramp for us to help disclose the anterior. Once the once the denture teeth go on into the anterior. So now just a couple of choices. If you want to mimic exactly the patient's esthetics or you want to change the patient's esthetics. So to duplicate the is what we're going to be doing is kind of setting one tooth at a time. So we'll take off let's say number nine and then place that tooth in place. And then exactly just one tooth at a time if we want to change the a.s. It's not working very well for me today. Here with me. Okay, here we go. If we want to change the esthetics, then as we remove the teeth from the cast, we can. We can change and remove one side at a time, get it to an ideal position and then change the other side. So we have different options. If we're doing this digitally again we can go directly over the teeth and place the teeth, morph them if you will. I've got a digital case also coming up a little bit later on. So here we're duplicating the patient's anterior. So we're going to do one tooth at a time. Here. The patient doesn't have any resort bone, so we're going to have to deal with the the bone situation and the flange that's going to go above and over this bone in this area. If we find that that's going to be an issue, we can talk about doing some alveolar plasti here. But that's a conversation a pre prosthetic of surgery that we would talk to the patient about. The canine. And as we remove the teeth from the cast, we're going to we call surgery as the cast and create a convex sight as the teeth come off the cast. Will Ridge lap the teeth, because basically, setting teeth off of a cast or onto a cast that doesn't have any bone reduction at this point is a little bit of a challenge. So it becomes a little bit easier when you're doing it digitally. But basically what we're doing is we're striving to place the teeth exactly where they came from, so that we don't change the esthetics as much as the patient would like or not like. Okay. So continuing with surgery, using the cast one tooth at a time, if there's a tooth size discrepancy, you can order a larger tooth and then trim it down if you need to. Here we go in the lateral is looted into place, the canines removed and again note the socket contours. Keep them convex. And then finally everything is set. We're going to wait and wait to close this dial until after we do the in. But this is not exactly the same case, but a different case. But this is what it would look like. Once the posteriors are set. We have the anterior set as well. But notice that the a.s are looted directly to the cast. The posteriors can be removed, and we'll take that portion and bring it to our patient. And that's the portion that we can do the try in, in our patients mouth, leaving the patients a.s of course, the way they are, the patient can see the anterior setup on the Articulator, but we can verify now that we've captured centric properly, we've captured the vertical properly, and we can feel comfortable enough to move forward into processing. Okay. So this is our split try in. Once everything is corrected and verified, we can go ahead, place the record base back on. Complete our wax up. Everything is joined together. And as we write our prescription, we're also going to include a request to add what is called either a surgical guide, a surgical stent, or a bone contouring template. And those three terms are kind of used interchangeably. But what it what it does is it basically allows the surgeon to see via a clear vacuum form or a clear matrix template, what the surgical site and what the Italian of the denture is going to look like. So basically it is the surface of the cast on which the denture is processed. So if you're doing this. Manually that you surgeries the cast, or if you have a tuberosity reduction or excess doses that has to be removed and you've manually re contoured the cast, that's the cast on which the denture is going to be processed. So what you want to tell the surgeon is this is the shape of my denture. I'm going to give it to you in a clear acrylic device so that you can insert it in the patient's mouth before you insert the denture, and see if there's any additional bone contouring that has to be done. Before you go ahead and insert the denture and say the denture is not seating all the way. This way you can look at it with a clear acrylic template and see where the tissue was blanching and be able to adjust further surgically. Okay, so it's a guide for surgical reshaping of the alveolus. Here. Here is one that is used on the lower where you can see it's not only for implant placement, but it's also it will show exactly where the bone needs to be reduced. It's usually about two millimeters thick for rigidity. And it helps again guide the surgeon. So here is a case. This is how the arch started. These are the teeth that needed to be extracted. Here's an excess doses that needed to be removed and a little bit of reshaping on the tuberosity. So as you can see the re contouring on the bone. And then the clear guide will be made on top of this. This is basically a duplicate of the cast on which the denture is also going to be made. So the intaglio of both are identical. Here's another guide. This is the internal aspect of the denture. Here's the duplicate cast. And there is your surgical guide. So notice all of these undercuts that are here. This is going to be a little bit of a challenge to insert. So here's the guide that will help the surgeon re contour the bone and the tissue okay. Sometimes what the surgeon will ask for is the before and the after. So you can put the reduction guide on on both casts to see the changes in between. And so this is just a sample lab prescription, which will just remind you to ask for that surgical guide according to the adjustments, according to the modifications made on the final cast. So here is our final denture backs a little bit of characterization and incisive papilla. The denture must be back. Prior to surgery. So coordination is key. Obviously you don't want to get your patient into oral surgery and then wonder where the denture is. So remember the denture is started before the extractions are done. We fabricate to completion the denture schedule. The patient for the surgery and the denture is with the oral surgeons prior to extraction day. Extraction of remaining teeth and sutures placed, and then the guide goes in just to see if we have a smooth insertion of the guide, and therefore we'll have a smooth insertion of the denture here in our treatment center. We don't do denture insertions in oral surgery. So oftentimes the patients will have the surgery will have the guide inserted. And then the patients come into the treatment center at which point we start the insertion. So we don't want to have to take the patient from the treatment center back to oral surgery and say, hey, we can't get our denture in. So typically, if they come back to the treatment center with the guide inserted, we know comfortably that that denture is going to go in as well. Here is the insertion of the interim upper over the extraction sites. Again the upper is full arch. The lower is a partial arch. We do have bilateral simultaneous contact. This canine is a little bit long for which we're going to have to do some adjustment. But the horizontal over jet is sufficient to accommodate for the vertical overlap. So we're okay with that. And we do have some we do have some accommodating occlusion in the posterior that we're not going to have incisal guidance. But we have to deal with this canine because it's not appropriate for for this. So this is might be a digital or it is a digital interim complete upper. So here we have a patient who only has four teeth remaining on the maxillary arch, but has an existing upper partial which he particularly likes. And he also likes the diet that was there because his natural teeth had a diastole. So we went ahead and. Prior to this had the posteriors extracted. Made some record bases. Only way that you can mount this case is with occlusion rims. So we saw that this, these this pair of premolars is our posterior stop. That's the patient's habitual occlusion. And so we kept him there. We kept those premolars and that that's the stop that the patient is going to go to. If you tell the patient to close, that's where he's going to close all the time. And so we're going to restore the patient at that. I mean, we there was no indication that the patient had lost vertical, so that we didn't have to bring him back to any therapeutic vertical. So we're restoring them at this video and at this position. Okay. We didn't have to capture a centric relation. Here is the case articulated and also surgery raised. Okay so the case was articulated it was scanned. And surgery surgeries for the bone contouring template. This is the digital preview. You can see the transparency of the wax rims. Here is the proposal. Some of the things that we suggested as we wrote back and suggested to move the teeth, we wanted to move the axial inclination of the teeth. So this was a digital preview with the reference and the two setup split trines are also possible digitally, but it also depends on how many teeth are missing. You can also do a split and for anterior teeth if you have sufficient room for the anterior tooth placement. So split triumphs are not just relegated for posterior, so just know that. But here we have our are trying. So we did for him a split try. And this was a full proposal. Notice that we have some looks here. And that was because we had to do a little bit of adjustment. There were a lot of teeth missing. The mounting was slightly off. We took a new bite and we had to re scan him. So for this case it worked out really well. And this was his final extraction and final insertion. So what we did was we provided a scan for his of his partial denture, and we were able to set the teeth exactly where his partial denture teeth were, including the size of his diet and the shape of the teeth. So you get yourself in the ballpark of the tooth. And then, as you know, in the sizing tab, you can lengthen it, you can widen it, you can deepen it in order. And the depth one is basically for occlusion, but it does get us a little bit closer esthetically. So here's kind of a workflow of our immediate and interim denture steps. It all starts with again our extracting the posteriors, leaving one stop to hold vertical final impressions and enter maxillary records with bases and RIM's select teeth post. If it's the upper photos and prescription, and then we can either take the analog workflow or the digital workflow. Okay, so we can go either way once the dentures are either processed or milled. You now have your analog denture again. So we take our analog denture to our analog patient. And we insert we extract the remaining anterior and posterior stop insert the denture and then at insertion. You know we talk about clinical remotes at all insertions. We don't do a clinical remount on the day of extraction. Because, you know, the definition of the clinical remount is to do an occlusal equilibration, okay. And there's a lot happening on the day of extraction, not the least of which is, you know, tissue going everywhere and bone going everywhere. And there's a lot of inflammation. And chances are the denture is not seating 100% like you expect it to see. And so we send the patient home with at least 1 or 2 stops on either side. So we do have bilateral contact, but we don't. It's not very possible to perfect the occlusion on the day of insertion. But once the tissue begins to heal and the inflammation goes down and the dentures stabilize, then at subsequent visits, we absolutely do clinical remount to refine the occlusion. And it affects both analog and digital in the same way. So we always do clinical recounts regardless of the processing method. So as far as complete versus interim, there's really in terms of the workflow, there's there's teeth involved. So our final our preliminary and final impressions, basically the same material. We make some custom trays. We have to block out the teeth for final impressions. Our centric relation. We have some teeth. So our record bases might not be complete. But they're partial record bases and occlusion rims. The tryin for complete dentures. Of course, their full try ins are split. Try ins for interims are usually posterior, but sometimes we can do anterior trines as well. Insertion is quite known for a complete denture, but somewhat unknown for interims. Again, we could make it much more predictable if we stage our extractions. The more ridge that is healed, the more ridge that is exposed. For our final impression for the next stage, the more predictable our insertion will go, because of course, we have more ridge available to us. Adjustments are predictably in 24 to 48 hours for our complete dentures. We have a 24 hour requirement. When we send the patient home with interims or immediate, we have the patient wear their denture when we send them home, and we tell them not to take their denture out for 24 hours. We ask them to sleep with them until they come back in to see us, at which point we take their dentures out for them, because what we're concerned about is swelling. Okay. So that's kind of a subtle nuance difference between or the major nuances between complete and immediate. Now getting a little bit more granular, there's obviously a lot of advantages of going with interims or immediate dentures esthetics teeth right away. Right. It acts as a surgical dressing. It allows for ridge formation. So the ridge re contours with the internal aspect of the denture, maintains video and chewing and the tongue and the muscles and vertical and speech and and once you have a denture, especially the interims because the interims are what we call temporaries or prototypes, it will act as a spare once the definitive is fabricated. So we call them prototypes and their prototype types for the esthetics and the occlusion, so that we do get a second chance to make a better product, a more definitive product once the patient heals. So that's our interim dentures. Versus no denture. Well, obviously. Esthetics. Esthetics can also be unpredictable. So, you know we don't. We let the patient know, obviously, that when we deliver the denture that they are going to have some teeth. But lots of times we don't know how the bone is going to react, especially when we do extract teeth. So, you know, sometimes the labial flange may be a little bit bulky for the patient that the patient may not prefer, and or the teeth may not be in the exact same position that they anticipated, maybe reproducing their esthetics they're disappointed with, or maybe some changes, or maybe they don't like the tooth shade. Or, you know, there's lots of different reasons. But again, if we do interims, then we have a second chance, because esthetics can be unpredictable and the definitive, we now have the opportunity to improve on what changes need to be made from the first accuracy and fit again. The closer we get to what the ridge looks like before our final impression for the final denture, the more accurate it becomes. I've seen a lot of cases with 12 teeth, and you know, the students have taken a bite and want to send it out for tooth setup. And I'm saying, well, what teeth are you do you want to set up. There's no teeth that you can set up. In this case you've got to take out some posterior teeth. Well, I was told that I don't have to. It's like, well, you know, you can't pretend it's. And it's on a lower arch. At least you've got the palate on the on the maxillary arch, but on the lower arch, if you don't take out posterior teeth, how on earth are you going to fit a lower denture without some kind of some kind of a clue or a landmark to what the impression is going to, or what the denture is going to relate to. So you will have to do frequent realigns until it's healed. But the closer you get to the to the ridge in your impression, the more predictable it heals. If your patients are ill, if they're slow healers, if they're uncontrolled diabetics, if they have other medical issues, then. Your. The prognosis may be a little poor for your insertion on the same day. So you know it's important to review the patient's medical history. And oral surgery will certainly be very conscious of that. And review the patient's meds and help you triage whether or not the patient should be given an immediate or an interim denture on that day, or whether it's more important to extract the teeth and allow for healing before before they embark on this procedure. Over bites like you saw in the first case. Natural to artificial dentition are difficult to resolve. So you've got to be very careful when you are setting teeth to make sure that you accommodate for over bites. Occlusion can be unpredictable, the same thing. But again, all of this may be mitigated with two stage extractions. Otherwise, you can exacerbate all of these issues. So contraindications for immediate or interim dentures. So patients with overall poor general health or those with, let's say mental incapacity that would prevent cooperation during the post-surgical healing phase. So it's very traumatic for a patient to go through full mouth extractions and insertion of one or both dentures on the same day. It's uncomfortable and then it's strange. It's foreign to have these dentures in their mouth and to try to negotiate. And so you really have to prepare your patient in advance. It's not something that you give patients post-op instructions on the day of insertion. So you have to have a very cooperative patient to go through something like this. And relatively healthy patients have to understand the scope of what you're putting them through and the limitations to the proposed treatment. Okay, patients with increased surgical risks or history of surgical complications, patients on Coumadin patients on Coumadin may not be able to go through full mouth extractions all at once, so patients may need to have 1 or 2 teeth extracted over the course of months. And so those patients we can't schedule for immediate or interim denture insertions. Patients exhibiting uncooperative nature or extremely high treatment expectations. Other contraindications. And I just mentioned systemic diseases, blood coagulation disorders, difficult wound healing radiation, head and neck area. So a lot of these patients, what we do is we extract their teeth and wait for healing. And again some of these patients are just not very healthy patients to begin with and understand a lot of these limitations and will accept treatment of just extractions and wait for healing. And we do have treatment options for them as well. In other words, not having to wait six months or eight months until they're ready for a definitive treatment. If a patient requires IV sedation or general anesthesia, that might also be a complication for them to have immediate placement. And so that requires consultation with our attendings to see if this is something that can be done in the O.R.. And a lot of our patients do have procedures done at BMC, and we're typically invited to observe the surgeries. But typically the oral surgeons are the ones who insert the dentures for us, the ones that you fabricate. So just a list of the different concerns that we have uncontrolled hypertensive patients and diabetics. And then the rest, you know, really need consults, medical clearances for for these procedures, especially if they're undergoing general anesthetic procedures. So if they don't, we have a procedure called a delayed immediate denture, formerly known as a remote denture. It used to be a glossary of prosodic term called a remote denture. And basically what it is it's a complete denture. However it started. The complete denture. So what we do is we allow the patients to have their teeth extracted. But rather than wait 6 to 8 months for healing, we start the denture pretty much just as soon as we can, pretty much just as soon as there's wound closure, and that we're not going to disturb anything. And we try to expedite the patient's denture as soon as possible. If we start the denture within one month of extractions, if the patient has healed sufficiently, because a lot of times, especially if there's any bone reduction, you know, the patient is still experiencing bony sequesters and things like that. But oftentimes we can start a denture way too soon, but at least get some teeth for the patient and inserted within a couple of months. Usually by the time we insert these dentures, the bone and the tissue has still, you know, undergone some remodeling over the course of the 4 to 6 weeks that it takes us to fabricate the denture. And even on the day of insertion of one of these delayed immediate, we still have to put in a re line just to even get these dentures to fit. But it's still a way for us to provide a denture for a patient who we really don't want for them to go without teeth, because it's not only esthetics, but, you know, to help them function, to give them some occlusion, and to help them eat, because it's important for our patients to keep up their nutrition, their nutritional intake. So this is something that we do offer our patients and we call those delayed immediately. But basically in Salud, we're putting in a conventional complete upper or lower treatment code because that's what it is. It's just that it started way too soon. So, you know, we take a look at this patient. This patient. We. There we go. This patient had these giant Tory, and we tried, we tried, try, tried to give him an immediate denture. We did even a partial. This is a partial BTI. Notice that it kind of looks like a BTI in terms of the shading and everything. This was the bone contouring template and this was the immediate denture. After the surgeon hollowed it out as much as possible to put it in his mouth. After. This was a week after surgery, so the teeth were extracted, the Tory were removed and just there was there was so much bone that had to be removed and. But just insufficient amount of bone in order to fit the denture that was fabricated. So. Sometimes things happen where we couldn't remove as much bone as we planned, and so we had this denture that just didn't fit. He came in as a trooper trying to wear the denture, but he was in just so much discomfort. And I'm saying don't don't even wear it. He was an upper denture wear. So he knew I mean he had his wherewithal that but he put the lower denture in just so that I wouldn't feel bad. I said, take this lower out. What I did was this is about ten days after he had the surgery. I kept him in the office. We did a scan of his lower arch because he was so sore and so sensitive. So I did an intra oral scan. We could quickly print it up a cast, a model. On our printer and made a record base and occlusion rim. I adjusted that and did a wash impression. And so basically this was my delayed immediate. I made him something that actually fit him because even this, even this hollow, hollow, hollow denture just didn't fit his mouth. So we did this adjustment. I scanned it, sent it off to the lab, and basically, I mean, everything else was in place because the same lab evident that we're working with, you know, had the tooth set up, had everything, and we managed to incorporate that in his previous file and the lab sent back, as you can see how much wider this denture is. Let me go back how much wider you notice how tapered this is. So this is. The new denture that they sent back. This was again the same bone contouring template. This is a new denture that was sent back. This is two weeks later where more healing has taken place. I literally just dropped it in his mouth. He closed down and it was like it was a perfect occlusion. Biggest smile on his face. And he's like, oh my gosh, this is what it feels like to have teeth because he didn't have teeth anyway for the longest time, only the lower interiors. So but this is basically a delayed immediate. I mean, chances are this is going to look completely different in another few weeks, and that's fine. And we'll refine him until he's ready to have a definitive liner or digital realign or something definitive on his lower denture. Okay. So that's that's what we need to help our patients along with. Okay. But the difference between ridges, you know, this could be six weeks post extraction where you just see the ridge has just not ready, and then, you know, not the same patient, but six years post extraction. And the ridges are completely different. So bone remodels over a patient's lifetime usually, I mean, 80% of what that ridge is going to look like happens in the first year. And then over the patient's lifetime, not only in height but in width, about a millimeter a year. So in terms of wounding and healing, primary closure takes place within. Ten days, maybe 12 days, but 3 to 6 days after wounding the surface is still unstable. The interior for sure is unstable. 6 to 12 days. Maybe you're going to get a surface covering that you can work with, like I did with this patient. The surface is intact 12 to 24 days. There's there's your primary closure, but the interior is still unstable. The bone is filling in and the surface is intact where the interior becomes stable. It says months to years. But really, 6 to 8 months is kind of like the goal in terms of doing something more definitive. So if if you are giving someone a definitive, then you'll be helping them along with some Re lines until such time as you will or temporary reliance until such time as the patient is ready to have something processed, a laboratory process, rebase, realign or remake. So we're going to allow 6 to 8 months for ideal healing. Ideal healing 2 to 3 weeks minimum before preliminary impressions, which means that between stage one and stage two you extract the posterior teeth. You can go ahead and take preliminary impressions after that in 2 to 3 weeks. And then final impressions can happen in 4 to 6 weeks for your interim or immediate denture. No minimum requirement for tissue conditioner, although if you have open sockets, we don't recommend it. So let's talk about tissue conditioner and then we'll take a break. So treatment dentures are used to condition or medicate soft tissue. So here's a set of dentures. And here you can see this white material. It's very soft and it's very porous. We will place this material inside an immediate or an interim denture or even a denture whose tissues are extremely inflamed, and you have to treat them in preparation for future therapy. I tend to stay away from soft liners, especially after extractions. Immediately after extractions. I started to move away from that during Covid only because removal of this material is just awful. It's very porous and if you don't stay on top of these, in other words, get your patient in every week. You're really committed and married to this material. So we try to keep our dentures very predictable. And that's why I'm a huge proponent of staging these extractions. To minimize the amount of tissue conditioner we use, we use tissue conditioner to retain dentures if we need to, to diagnose problems in terms of excess pressure, to condition tissues, if they are red or inflamed or redundant. And we can also use tissue conditioner for impressions. So if we get some good retention and we have success with that, we can use it as the impression material and either scan it or pore it. There are two types. One is soft and one is super soft. The super soft only lasts a week before they have to be peeled out and replaced. So you're basically married to this patient. The soft has to be replaced once a month. Again, it's a commitment okay. So we do have hard liners as well. And we'll talk about that in the next series of PowerPoints. Sure. Sorry. Chair side. Yeah. When you're placing the tissue conditioner, as in anything that you're placing in a patient's mouth like you did for your impressions on your betties, if there is an occlusion, the tissue conditioner needs to go in in occlusion, in function. Otherwise, you might disturb the relationship of the dentures to themselves. Okay, so you place the tissue conditioner in. If both arches need to be reclined, then what you need to do is decide on the least stable arch. First. Realign that against the most stable arch. Okay. You don't do them simultaneously. You don't mix up tissue conditioner, put them in both dentures and then try to stick them both into the patient's mouth at the same time. So at least stable arch first against the most stable arch. So this is kind of what it looks like. There's a powder and a liquid. You mix them up, you're going to lubricate the areas of the denture that you don't want it to stick to. Because this material is a PMMa, it just has a lot of plasticizers in it. And your denture is PMMa. You coat it with the tissue conditioner, immerse it in cold water prior to seeding it in the patient's mouth. You have the patient close into function and make sure the patient goes back down into vertical. You'll muscle trim just like you're taking a final impression. Just like that, you bring the lips down you go OU and E, and then if it's the lower patient, sticks their tongue out side to side, up to the roof of their mouth, and so that you get a nice border coating and a nice even coating internally as well. Okay, done in function, meaning in occlusion and at vertical in with the opposing arch. Okay. The downside of tissue conditioners. This has been in the mouth more than a week. Let me tell you, taking this out is the worst smell you have ever smelt in your life. Old tissue conditioner will colonize. It can cause infection both to the patient and to you. It's awful. So be wise when you treatment plan and use it. And make sure that you have good recall for your patient, because this isn't something that you want to place in the patient's mouth and forget about, okay, it's a diagnostic tool. No more than that. It can cause mechanical injury to the tissues as well. Okay. On that note, let's take a break. Come back in ten minutes and we're going to do re lines and re bases. One question regarding the patient. And after we work through the structure and or the structure of the remaining teeth to do an interview, interim prosthesis. How long does it take to experience how long it takes the patient to get comfortable? We just keep the structure and it just easier. Okay, let's get started. Sorry, the first PowerPoint took a little longer than I expected. Is there a class after this? Do you guys have a class after this? No. DMVs. Do you have a class after this? Right. Sorry. Good. But you know, no good. Okay. You could be late for my class, just in case. All right. Re lines re bases and repairs. So realign. So the replacement of the inner one millimeter of the denture base and re base is replacement of the entire denture base, saving only the teeth. Repairs, of course, can be pretty much anything from tooth loss to a flange fracture to a midline fracture or an incipient fracture. Okay, so let's take a look at a line or a rebase of a complete denture. The clinical steps of re lining or rebasing are identical. I'm not going to go into the really nitty gritty nuances because again, when we get into clinic we'll talk about it. But just want to show you an overview of what it's like and how to make a decision as far as what you're going to do and the material choices that you're going to pick. So here is our patient again, the one that just had the immediate denture. And this is a denture that the patient had been wearing for a while. You can notice that the little particles of tissue conditioner that were removed or soft liner that was removed. And so when do we do it? When the denture becomes ill fitting, there's ridge and tissue changes. There's healing extraction sites. And then there's physiologic changes of the bone and tissue that need to go ahead and improve the relationship of the intaglio of the denture to the tissue. So again, clinically, the steps to perform both a re line and the Re base are the same. It's just what happens in the lab when they get your final impression. Either they just change and put a new liner inside the denture, or they actually replace the entire denture base saving the teeth. So that's the Re base, but your steps are the same. So how do we what do we do? We evaluate the denture. We check the age of the denture and we compare it to the lifespan of the denture. Now the average denture will last. I mean depending on the patient's oral hygiene and how they care for it, anywhere from 7 to 10 years now, I'm sure you all know about somebody who has had their dentures for 30 years, but on average, most dentures should be replaced on anywhere from 7 to 10 years. We're going to look at a materials list and it will help us choose what we're going to select. We evaluate the contours of the denture. If the contours, the external contours are acceptable, then we might realign the denture and it might be an immediate, an interim or a complete if they're not acceptable. In other words, if it's gone through the mill in terms of adjustments or if there's been a previous fracture and we want to strengthen the base of the denture, then we might rebase it. If there is porosity, if we want to shade change, then we might rebase it. We want to assess the vertical. Do we want to maintain the vertical or do we want to increase the vertical. So these are important questions to ask. And also we always check the occlusion. We want to know what the occlusion looks like going in so that we can either improve it or reproduce it. Because all of anything that you put inside a patient's denture is always in function, whether it's a liner, whether it's an impression for a rebase or realign or repair, if it has an occlusion, all of what you put inside a patient's denture is always done with the patient biting always. So your hand should never be, you know, holding that denture in place ever. If there's an opposing occlusion, the patient should always be biting it into place. Okay. We assess the video, maintain it if it's acceptable, will increase it if the occlusion is showing signs of wear, but only slightly. Because if the occlusion is worn beyond 1 to 2mm, then we should be thinking about remaking the denture, especially if the denture is approaching its end of life, which is 7 to 10 years. So here we are. We're checking the occlusion. We want to establish a stable occlusion. If the occlusion is not stable, then we'll do a slight occlusal adjustment before we proceed to doing our impressions. Because again if you're taking the impression in function then your occlusion has to be stable okay. So again functional impression in occlusion. It's also called the closed mouth position. Um, in preparation for the re line or rebase, you want to remove any remnants of what has been inserted inside the denture in terms of liners or adhesives, and freshen up the denture base for mechanical adhesion of the impression material. You want to go ahead and if. If sorry. You want to check to make sure that the material is intact, check your vertical, and if you're not increasing vertical, you might typically place your tissue stops and remove some material around it so that you're not at risk of adding vertical to the interior of the denture. Okay. It's important because if you do add vertical, what's going to happen is the denture is going to come down and forward, and it's going to not only add vertical to the entire case, but it's also going to shift your tooth position. Your interiors are going to be more fascial and the incisal edges are going to be longer. So it's not only going to add vertical, but it's also going to change the esthetics and change the phonetics. So if you're not using an extra light viscosity material. You may have to identify 3 or 4 areas for tissue stops and create a reservoir for your impression material. So that's maintaining vertical. To increase vertical we're going to add 3 or 4 stops of compound. And in that situation you're going to add it until the denture is stable. And it's just like when you added your tissue stops in the Mr. with the PVS. So but again we're only adding 1 or 2mm in total thickness. Once the vertical has been established, you can either reduce the borders if you need to and or add compound in order to establish your new borders. Okay, so if you need to increase the width of your border, increase the height of your border, add your border molding. But again, when you add your border molding, it's done functionally. Okay. So you remember you go dynamic border molding. If it's as it's done functionally during border molding. And final impressions ensure the patient stays closed and in function throughout the set. Some patients do have difficulty in staying closed, so sometimes I will add some bite registration material and that will help guide the patient into biting. I don't have to worry about the kind of bite registration material that I do add for, especially if I'm doing an analog line because it's just holding the patient closed and it's just an aid, a guide for the patient to stay during the duration of the set of the material. Well evaluate the impression the same way you would evaluate any final impression. Make the final impression using any static impression material XlVi. This is light body rubber base. After the impression, you can trim the flash receipt in order to take an actual CR bite with locks to orient the denture, and as we send it to the lab, depending on what procedure is done. Many labs will use an Articulator in order to affect either the Re line or the Re base, so they will need a bite. Now, if it's a maxillary denture, they need a post dam. Okay, now you don't have a cast. In order to transmit the information to the lab, you're going to need to draw. Instead of drawing it on the cast, you're going to need to draw it on your impression itself in the outline. So mostly it's observational. You're going to take a look in the patient's mouth. You can have the patient say ah, find the anterior vibrating line, find the compressive tissue, and then you can place it back and transfer those lines. And if they don't fully transfer you can also draw it on the impression. And then using a piece of paper you can add the amount of scoring depths. Because at some point in time there will be if it's an analog Re line, there will be a cast on which the patient the technician, will score. And if it's a digital re line, the technician will then create the post dam in that software program itself. But they need the information will be box and pore if it's analog will scan if it's digital if it's analog. This is where you stop okay. We don't separate because this cast is going to hold vertical dimension until it gets to the lab. And then the lab has three different techniques in which to do the the process of re line rebase. And basically they need to hold vertical with either an articulator or a jig or a flask. So those are just the techniques. Notice that this is your your denture with the re line material. There's the cast. Once it's mounted on an articulator the pin holds the vertical. If they're processing it in a jig, these leveling screws hold the vertical. And if they're processing it in a flask similar to how you process a denture. This is probably a rebase because they need to ensure the wax up's been done and the entire denture base is going to be replaced. So once it's in the flask, then of course that's when the material is separated. So that's what's going to hold vertical depending on the procedure that's being done. So this is just the general summary. These are your clinical steps. Again the clinical steps are the same whether realign or rebase. If it's analog we beat box and paw and process. If it's digital we scan. But then it all comes out in the end. At insertion. Just like insertion for any denture, we get our analog denture, bring it to our analog patient, and do an insertion and a clinical remount just as we anticipate. Okay. This is a handout. You're going to find it in today's folder. And of course when we talk about re lines and re bases which is a whole two hour lecture next year this will be there too. So just as a placeholder and informational again this is overview. We don't need to get very granular okay. Let's talk about repairs. Repairs is replacement of teeth borders post dam augmentations and midline fractures and the like. So replacement of a fracture tooth or tooth loss is fairly simple. If we have the tooth and it's just come out, you can replace it. If we have to replace the tooth, we hopefully can find the similar tooth to tooth is looted on the facial with sticky wax and typically repaired from the lingual so that we don't see necessarily the transition on the facial. The bottom line for all repairs is if we want it to last for any length of time is usually most offices have and we can we typically do it in our lab, in the office. And we don't have a very big lab. But having a pressure cooker and using putting some warm water in 20 pounds of pressure for 20 minutes. So we affect the repair and then when it's done, we just give it back to the patient. We don't really make a big thing of it and and help the patient out. So incipient midline fractures is a weak area of the denture. It is a weak repair site which is liable to re fracture and an indication for a rebase. So a lot of times when things fracture, you really need to find out what is causing it before you just simply repair it. Okay. So you need to find out the cause in order to provide an acceptable solution. So first. If it's just an incipient repair, I would definitely repair it in advance, but then look further into it so I would actually open up that incipient fracture, further repair, prepare and bevel the repair site. And maybe not on the facial, but definitely on the lingual. I would add maybe some metal reinforcement, maybe some metal mesh. And there's the facial. And here's the palatal repair site okay. But midline midline incipient fractures get me nervous because a lot of a lot of times that tells me that there could be some kind of a fulcrum somewhere nearby, that incipient fracture or an occlusal problem. So I will look further into that before I'll just send the patient home and say, hey, you know, you're all set, and there's the repair. So we have to assess the problem. Why did this midline fracture occur? Did the patient drop the denture if it's a drop and it just started okay. So we'll tell the patient, you know, next time when you're brushing your denture and you're brushing it over a porcelain sink, make sure that you fill that sink a little bit with water. So when you drop the denture now it'll hit the water and not the porcelain. Okay. So maybe we can avoid that. But if it's not, all right, is an immediate denture fulcrum off of the palate because the ridge is remodeling and now there's no support of the ridge anymore, but only the palate, and there's maybe a shallow Taurus on the palate. And so now the occlusion is a little bit off. So that's an issue. Maybe it needs to be re lined. Maybe the occlusion needs to be adjusted. So we have to deal with the source of the problem and not just put a Band-Aid on it and fix the fracture. Is there an occlusal reason. Assessment is critical in order to apply the appropriate corrective procedure. And should there be a follow up procedure. So here we have a fracture through and through. What do you think? And this is very common on lower dentures with a certain situation with this lower denture. What do you think that is? Besides dropping. There's something on the intaglio of this lower denture that has weakened the denture. What do you think is. There's an abutment in here, so there's an implant and there's an attachment. So now the thickness of this denture base is very, very thin. And this is an analog denture. So what do you know about mill dentures. Mill dentures a little bit stronger. But also the teeth are one unit as well. So the teeth provide strength for a denture. But analog dentures the teeth don't provide the strength. And if you're coming up with an abutment, the denture base itself can be maybe 1 or 2mm thick. So patient is happily wearing their mandibular denture with attachments and chewing along, and all of a sudden it can fracture. All right. So now we know what the problem is. Now we can propose a solution. Do you think if I just fix this denture, just repaired it. It will be fine. No. So I've got to propose a solution that is going to strengthen this denture base if I rebase it. Might it fix the problem? It might if I thicken the denture base. But maybe I need to propose a solution that will change this analog denture to a digitally milled product, where not only am I getting strength from a stronger denture base, but the teeth are also now a little bit stronger too, because they're a single unit milled out of a single puck. Okay, so we have to think about those options. And there's it's a gold coping. It's not an attachment, but it's still it's now coming into the surface of the intaglio. So that's the that's the issue with this denture. So we can go ahead oppose the two. We can propose a fix right now. Put it in. We can add additional thickness to our denture and put it in the pressure cooker for a bit. But the second the patient begins to chew again it's going to put additional pressure on it. So again there's our repair site. But it's likely to fracture. So we have to propose a long term solu