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An atypical chairside immediate denture: A clinical report
An atypical chairside immediate denture: A clinical report Anton S. Gotlieb, DDS,a and Samuel W. Askinas, DDSb College of Dental Medicine, Nova Southeastern University, Ft. Lauderdale, Fla. This clinical report describes the fabrication of an immediate complete denture for a patient with an extensive fixed prosthesis that was no longer serviceable because of major loss of integrity of the supporting abutment teeth. The procedure, which was performed chairside, replicated the existing fixed prosthesis as part of an immediate complete denture. (J Prosthet Dent 2001;86:241-3.)
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here are many advantages to immediate, as opposed to conventional, complete dentures.1 From the patient’s point of view, chief among these advantages is the preservation of the person’s natural appearance and social mobility (loss of such mobility often results from the absence of anterior teeth). When a conventional complete denture is fabricated, there is normally a period of several weeks to months of edentulism for healing after extraction.2 This clinical report describes the chairside fabrication of an immediate maxillary complete denture.
attached fixed prosthesis during the removal of the impression. Wax strips (Utility wax strips, Hygienic, Akron, Ohio) then were placed on the occlusal surface of the maxillary impression tray to maintain the mobile fixed prosthesis in position during the impression procedure. Maxillary and mandibular irreversible hydrocolloid impressions (Integra, Kerr, Orange, Calif.) were made with the use of stock trays (TRA Tens, Teledyne Water Pik, Ft. Collins, Colo.) (Fig. 3). The mandibular cast was poured in dental stone (Microstone, Whip Mix, Louisville, Ky.).
CLINICAL REPORT The patient was a 78-year-old woman with no significant medical history. She was first seen on referral with a multiunit ceramometal fixed partial denture extending from the maxillary right first molar to the maxillary left first molar (Fig. 1). The latter tooth was an attenuated pontic cantilevered distal to the maxillary left second premolar abutment tooth. The prosthesis had been placed several years previously. The crowns of all abutment teeth, except the maxillary right first molar, had completely decayed to the gingivae, and the prosthesis was extremely mobile because it was attached to only a single intact abutment tooth. The patient was adamant that she could not be edentulous for any length of time, however brief, as her employment required meeting the public every day. After radiographic and clinical examinations were completed, the patient was appointed for the chairside fabrication of a maxillary immediate complete denture (Fig. 2). Consideration was given to incorporating the patient’s 12-unit fixed partial denture in the immediate prosthesis.3 Because of the denture’s weight and the associated problems of ensuring its attachment to the denture base, the decision was made to duplicate the denture with acrylic resin. The maxillary right first molar was anesthetized (Citanest Plain 4%, ASTRA, Westborough, Mass.) in anticipation of its possible odontectomy with its aAssociate bProfessor
Professor, Department of Restorative Dentistry. and Chairperson, Department of Restorative Dentistry.
SEPTEMBER 2001
Fig. 1. Patient at initial examination.
Fig. 2. Panoramic radiograph. THE JOURNAL OF PROSTHETIC DENTISTRY 241
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Maxillary impression with occlusal wax stops and vibrating line.
GOTLIEB AND ASKINAS
Fig. 5. Maxillary cast with acrylic resin dental arch and posterior palatal seal area outlined.
Fig. 4. Maxillary impression with tooth-colored acrylic resin in dental arch.
Fig. 6. Maxillary and mandibular casts hand articulated in maximum intercuspal position.
A slurry of PMMA (Alike, GC America, Alsip, Ill.) was prepared in a shade that matched the patient’s dentition and poured into the dental arch of the maxillary impression (Fig. 4).4 After polymerization, the acrylic resin was removed from the dental portion of the impression and trimmed to the gingival borders. Several retentive diatorics were prepared in the ridge laps of the acrylic resin dental arch to ensure accurate locking of the fixed prosthesis duplicate to the subsequent cast.5 The acrylic resin arch was reseated in the impression, and the maxillary cast was poured in dental stone. This maxillary cast was retrieved from the impression with the acrylic resin dental arch in place (Fig. 5). Both casts were hand articulated in maximum inter-
cuspal position to verify the integrity of the occlusal relationship (Fig. 6). The posterior border and posterior palatal seal were scored on the maxillary cast. Pink autopolymerizing PMMA resin (Acraweld, Schein, Philadelphia, Pa.) then was applied to the entire maxillary cast; PMMA polymer was alternately added and saturated with monomer to form the entire denture base. The maxillary cast and denture were placed in a pressure pot (Aquapress, Lang, Wheeling, Ill.) with warm water, and 20 psi of air pressure was applied during polymerization. The maxillary denture was separated from the cast, finished, and polished (Fig. 7). The patient was reanesthetized, and the maxillary right first molar with its
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Fig. 7. Maxillary denture separated from cast.
Fig. 8. Patient at 1 week after insertion.
attached fixed prosthesis was removed. The roots of 2 additional teeth were removed in the maxillary right quadrant, and 2 sutures were placed. Pressure-indicating paste (Mizzy, Cherry Hill, N.J.) was applied to the intaglio surface of the denture, which then was inserted and adjusted for impingements. This procedure was repeated until the denture was fully seated and the occlusion duplicated the patient’s original maxillomandibular relationship. The denture was relined with tissue conditioner (Coe Soft, GC America, Alsip, Ill.) to enhance retention, patient comfort, and patient confidence. The patient was dismissed after she made an appointment for the removal of the remaining maxillary retained roots. She was seen after 24 hours and again after 1 week (Fig. 8) and was comfortable at all times. The definitive prosthesis was delivered 1 month after the placement of the immediate denture.
was delivered 1 month after the chairside immediate denture was placed.
DISCUSSION Conventional immediate denture treatment requires a series of appointments. Replacement of the patient’s remaining teeth is accomplished by placing denture teeth on the cast to duplicate or refine the patient’s natural esthetics and establish an ideal maxillomandibular relationship. This conventional procedure may be difficult or impossible to accomplish when the remaining dentition in the arch includes extensive fixed prostheses linking anterior and posterior teeth. For the patient previously described, the esthetics and articulation of the immediate denture duplicated those of the preexisting maxillary fixed prosthesis. The patient was comfortable with both prostheses, although it was obvious that the occlusal relationship was less than ideal. This situation was ultimately resolved, as planned, when a new maxillary complete denture was fabricated after the maxilla had healed. It
SEPTEMBER 2001
SUMMARY The chairside fabrication of an immediate denture has been described. Conventional immediate denture procedures were not possible with this patient because the entire maxillary arch consisted of a fixed prosthesis attached to only 1 intact, but mobile, abutment tooth with a strong likelihood of spontaneously exfoliating. The patient, due to the requirements of her lifestyle and employment, emphasized the necessity for the most timely and efficacious restoration of the maxillary arch.
REFERENCES 1. Arbree NA. Immediate dentures. In: Zarb GA, Bolender CL, Carlsson GE, editors. Boucher’s prosthodontic treatment for edentulous patients. 11th ed. St. Louis (MO): Mosby; 1997. p. 415-42. 2. Livaditis GJ. Indexing procedures for converting removable partial dentures after extractions while the patient retains the prosthesis. J Prosthet Dent 1999;81:485-91. 3. Zalkind M, Hochman N. Converting a fixed partial denture to an interim complete denture: esthetic and functional considerations. Quintessence Int 1997;28:121-5. 4. Khan Z, Heaberle CB. One-appointment construction of an immediate transitional complete denture using visible light-cured resin. J Prosthet Dent 1992;68:500-2. 5. Mou SH, Chai T. The pontic-splinted procedure for tooth and denture base additions in denture repair. J Prosthet Dent 2001;85:126-8. Reprint requests to: DR ANTON S. GOTLIEB DEPARTMENT OF RESTORATIVE DENTISTRY NOVA SOUTHEASTERN UNIVERSITY COLLEGE 3200 S UNIVERSITY DR FT. LAUDERDALE, FL 33328 FAX: (954)262-1782 E-MAIL: [email protected]
OF
DENTAL MEDICINE
Copyright © 2001 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2001/$35.00 + 0. 10/1/117977
243
T
here are many advantages to immediate, as opposed to conventional, complete dentures.1 From the patient’s point of view, chief among these advantages is the preservation of the person’s natural appearance and social mobility (loss of such mobility often results from the absence of anterior teeth). When a conventional complete denture is fabricated, there is normally a period of several weeks to months of edentulism for healing after extraction.2 This clinical report describes the chairside fabrication of an immediate maxillary complete denture.
attached fixed prosthesis during the removal of the impression. Wax strips (Utility wax strips, Hygienic, Akron, Ohio) then were placed on the occlusal surface of the maxillary impression tray to maintain the mobile fixed prosthesis in position during the impression procedure. Maxillary and mandibular irreversible hydrocolloid impressions (Integra, Kerr, Orange, Calif.) were made with the use of stock trays (TRA Tens, Teledyne Water Pik, Ft. Collins, Colo.) (Fig. 3). The mandibular cast was poured in dental stone (Microstone, Whip Mix, Louisville, Ky.).
CLINICAL REPORT The patient was a 78-year-old woman with no significant medical history. She was first seen on referral with a multiunit ceramometal fixed partial denture extending from the maxillary right first molar to the maxillary left first molar (Fig. 1). The latter tooth was an attenuated pontic cantilevered distal to the maxillary left second premolar abutment tooth. The prosthesis had been placed several years previously. The crowns of all abutment teeth, except the maxillary right first molar, had completely decayed to the gingivae, and the prosthesis was extremely mobile because it was attached to only a single intact abutment tooth. The patient was adamant that she could not be edentulous for any length of time, however brief, as her employment required meeting the public every day. After radiographic and clinical examinations were completed, the patient was appointed for the chairside fabrication of a maxillary immediate complete denture (Fig. 2). Consideration was given to incorporating the patient’s 12-unit fixed partial denture in the immediate prosthesis.3 Because of the denture’s weight and the associated problems of ensuring its attachment to the denture base, the decision was made to duplicate the denture with acrylic resin. The maxillary right first molar was anesthetized (Citanest Plain 4%, ASTRA, Westborough, Mass.) in anticipation of its possible odontectomy with its aAssociate bProfessor
Professor, Department of Restorative Dentistry. and Chairperson, Department of Restorative Dentistry.
SEPTEMBER 2001
Fig. 1. Patient at initial examination.
Fig. 2. Panoramic radiograph. THE JOURNAL OF PROSTHETIC DENTISTRY 241
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Maxillary impression with occlusal wax stops and vibrating line.
GOTLIEB AND ASKINAS
Fig. 5. Maxillary cast with acrylic resin dental arch and posterior palatal seal area outlined.
Fig. 4. Maxillary impression with tooth-colored acrylic resin in dental arch.
Fig. 6. Maxillary and mandibular casts hand articulated in maximum intercuspal position.
A slurry of PMMA (Alike, GC America, Alsip, Ill.) was prepared in a shade that matched the patient’s dentition and poured into the dental arch of the maxillary impression (Fig. 4).4 After polymerization, the acrylic resin was removed from the dental portion of the impression and trimmed to the gingival borders. Several retentive diatorics were prepared in the ridge laps of the acrylic resin dental arch to ensure accurate locking of the fixed prosthesis duplicate to the subsequent cast.5 The acrylic resin arch was reseated in the impression, and the maxillary cast was poured in dental stone. This maxillary cast was retrieved from the impression with the acrylic resin dental arch in place (Fig. 5). Both casts were hand articulated in maximum inter-
cuspal position to verify the integrity of the occlusal relationship (Fig. 6). The posterior border and posterior palatal seal were scored on the maxillary cast. Pink autopolymerizing PMMA resin (Acraweld, Schein, Philadelphia, Pa.) then was applied to the entire maxillary cast; PMMA polymer was alternately added and saturated with monomer to form the entire denture base. The maxillary cast and denture were placed in a pressure pot (Aquapress, Lang, Wheeling, Ill.) with warm water, and 20 psi of air pressure was applied during polymerization. The maxillary denture was separated from the cast, finished, and polished (Fig. 7). The patient was reanesthetized, and the maxillary right first molar with its
242
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THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Maxillary denture separated from cast.
Fig. 8. Patient at 1 week after insertion.
attached fixed prosthesis was removed. The roots of 2 additional teeth were removed in the maxillary right quadrant, and 2 sutures were placed. Pressure-indicating paste (Mizzy, Cherry Hill, N.J.) was applied to the intaglio surface of the denture, which then was inserted and adjusted for impingements. This procedure was repeated until the denture was fully seated and the occlusion duplicated the patient’s original maxillomandibular relationship. The denture was relined with tissue conditioner (Coe Soft, GC America, Alsip, Ill.) to enhance retention, patient comfort, and patient confidence. The patient was dismissed after she made an appointment for the removal of the remaining maxillary retained roots. She was seen after 24 hours and again after 1 week (Fig. 8) and was comfortable at all times. The definitive prosthesis was delivered 1 month after the placement of the immediate denture.
was delivered 1 month after the chairside immediate denture was placed.
DISCUSSION Conventional immediate denture treatment requires a series of appointments. Replacement of the patient’s remaining teeth is accomplished by placing denture teeth on the cast to duplicate or refine the patient’s natural esthetics and establish an ideal maxillomandibular relationship. This conventional procedure may be difficult or impossible to accomplish when the remaining dentition in the arch includes extensive fixed prostheses linking anterior and posterior teeth. For the patient previously described, the esthetics and articulation of the immediate denture duplicated those of the preexisting maxillary fixed prosthesis. The patient was comfortable with both prostheses, although it was obvious that the occlusal relationship was less than ideal. This situation was ultimately resolved, as planned, when a new maxillary complete denture was fabricated after the maxilla had healed. It
SEPTEMBER 2001
SUMMARY The chairside fabrication of an immediate denture has been described. Conventional immediate denture procedures were not possible with this patient because the entire maxillary arch consisted of a fixed prosthesis attached to only 1 intact, but mobile, abutment tooth with a strong likelihood of spontaneously exfoliating. The patient, due to the requirements of her lifestyle and employment, emphasized the necessity for the most timely and efficacious restoration of the maxillary arch.
REFERENCES 1. Arbree NA. Immediate dentures. In: Zarb GA, Bolender CL, Carlsson GE, editors. Boucher’s prosthodontic treatment for edentulous patients. 11th ed. St. Louis (MO): Mosby; 1997. p. 415-42. 2. Livaditis GJ. Indexing procedures for converting removable partial dentures after extractions while the patient retains the prosthesis. J Prosthet Dent 1999;81:485-91. 3. Zalkind M, Hochman N. Converting a fixed partial denture to an interim complete denture: esthetic and functional considerations. Quintessence Int 1997;28:121-5. 4. Khan Z, Heaberle CB. One-appointment construction of an immediate transitional complete denture using visible light-cured resin. J Prosthet Dent 1992;68:500-2. 5. Mou SH, Chai T. The pontic-splinted procedure for tooth and denture base additions in denture repair. J Prosthet Dent 2001;85:126-8. Reprint requests to: DR ANTON S. GOTLIEB DEPARTMENT OF RESTORATIVE DENTISTRY NOVA SOUTHEASTERN UNIVERSITY COLLEGE 3200 S UNIVERSITY DR FT. LAUDERDALE, FL 33328 FAX: (954)262-1782 E-MAIL: [email protected]
OF
DENTAL MEDICINE
Copyright © 2001 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2001/$35.00 + 0. 10/1/117977
243