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Removable Prosthodontics
Immediate dentures
Miss Ursala Jogezai
BDS, BSc, MBA, PG cert (FHEA)
Dental Core Trainee (DCT2) Restorative dentistry
Birmingham Dental hospital
Mr. Dominic Laverty
Academic Clinical Fellow (ACF) Restorative Dentistry
BDS (Hons), MFDS RCS (Edin)
Birmingham Dental hospital
Professor A. Damien Walmsley
BDS, MSc, Phd, FDS RCS
Director of Internationalisation
Head of Teaching Unit of Prosthetic Dentistry
Birmingham Dental Hospital
1
Immediate dentures: Part 1
Abstract
This two part review article aims to provide a comprehensive summary on immediate
dentures. In the first part, after a brief introduction, the advantages and disadvantages of
immediate dentures are compared. There is a detailed discussion on assessment and
treatment planning which includes history taking, examination of the soft and hard tissues,
current prostheses, occlusion as well as discussion on investigations required and
formulating a diagnosis. The first part ends with a summary of types of immediate dentures
and denture designs.
Clinical relevance
Immediate dentures are commonly used to provide patients with tooth replacement
immediately following extractions to maintain aesthetics and function. Therefore, they are an
integral part of a dentist's armamentarium.
Objective
The reader will be able to understand and apply the basic principles underlying the
assessment, treatment planning and its execution for immediate dentures in their clinical
practice.
2
IMMEDIATE DENTURES: PART 1
An Immediate denture is a complete or partial removable prosthesis that is fitted immediately
after extraction or modification of teeth. The prosthesis replaces the missing/modified teeth
and where required, the adjacent hard and soft tissues. It is constructed prior to the
extraction of teeth and is used immediately to provide function and aesthetics which are lost
as a result of tooth removal and avoid the embarrassment patients may have with living
without teeth, while waiting for the tissues to heal prior to definitive tooth replacement.1 (See
image 1) Some clinicians take impressions on the day of the extractions and fit the dentures
a few days later. These dentures are fraught with challenges as the alveolar ridge begins to
resorb soon after. Therefore an immediate denture is only truly an immediate denture when
fitted on the day of the extractions.
The use of a removable prosthesis within the UK is currently around 19% of adults in the
general population 2 and in spite of this decreasing trend, as patients retain their natural
dentition into older age,2 there is still a need for prosthodontic replacement as teeth are lost
as a result of caries, periodontal disease, tooth wear or trauma. 3,4,5 The provision of an
immediate denture can be challenging and close co-operation between patient, technician,
and clinician is required.
Assessment and Treatment Planning
All patients should have a thorough history, clinical examination and any relevant
investigations carried out to attain a correct diagnosis and treatment plan.
The formulated diagnoses and treatment plan as well as the costs and timeframes involved
need to be thoroughly discussed with the patient to obtain informed consent before
proceeding with treatment. It is also vital that the clinician has a clear understanding of the
patient’s expectations of treatment and whether these can be achieved in the proposed
treatment, particularly in those patients who have never worn dentures before. Patients
need to be clearly made aware of the limitations of a removable prosthesis in general and
3
also the issues associated with an immediate denture. Denture wearing is a complex
phenomenon and while the technical ability of the clinician has a huge role to play in its
success, it is largely dependent on the patient’s psychological acceptance and
neuromuscular ability to cope with the dentures.6
History
A thorough history of the patient is required which will entail asking questions regarding any
presenting complaint or issue the patient is having, the patients’ medical history and briefly
exploring the patients' dental and social history. Taking a full and thorough history succinctly
is a key skill since correct diagnosis relies on it. This in turn enables us to propose an
appropriate treatment plan.
A detailed medical history should include information regarding all relevant conditions. This
would include, but not necessarily limited to, information regarding bleeding disorders such
as haemophilia, immuno-compromised patients, those with a history of head and neck
radiotherapy as well as those on anti-coagulants or bisphosphonates. In some situations
patients' medical background can complicate or impact the process of dental extractions that
the clinician needs to be aware of and be able to appropriately manage. There are also
medical conditions that may make provision of a removable prosthesis challenging which
include certain neuromuscular conditions. (See Table 1) The exact management of these
conditions goes beyond the scope of this article.7,8,9
Information regarding the patients' dental history such as frequency of attendance, previous
dental treatments and attitude towards dental treatment gives an indication of how well a
patient is likely to tolerate treatment. A brief understanding of the patient’s social history with
regards to their occupation, any hobbies or activities that they carry out and the availability
for appointments will help with planning treatment. Patients in certain professions may
struggle with removable prosthesis such as wind instrument players and public speakers and
the effect of the proposed treatment needs to be discussed.
4
Examination:
A comprehensive examination in a methodical sequence is required, this includes an
assessment of the;
Denture-bearing tissues/edentatespaces:
Examination of the denture bearing areas should be carried out in detail since this will have
an impact on the design of the final prosthesis. In cases of an immediate denture, it may be
difficult to ascertain the ridge shape in the areas where extractions will be carried out
however if there are any other edentulous spaces in the mouth, assessing them in detail will
give an idea of the kind of retention, stability and support that can be gained from the
denture base. (See image 2) The edentate ridges should be assessed on their height, width
and shape, the firmness of overlying tissue and any undercuts that may be present. Muscle
and freanal attachments should be checked along with the sulcus depth as well as noting the
shape of the palatal vault for the maxillary prosthesis.(Table 2) In addition to the visual
examination, palpating the denture bearing areas carefully is a useful method to determine if
there are areas of discomfort in the patients' mouth as these may require relief in the final
prosthesis.10
Dentition:
The dentition and its supporting structures should be evaluated which includes assessment
of the periodontal condition along with BPE (Basic periodontal examination) scores,
presence of caries, tooth surface loss as well as any restorations and their condition. Teeth
of hopeless prognosis should be planned for extraction and those with poor or dubious
prognosis should be noted down and form part of the treatment plan taking future tooth loss
or need for extractions into account.7
Ideally the primary disease within the mouth such as periodontal disease, caries and tooth
wear should be stable and aetiological factors controlled prior to embarking on tooth
replacement however this may not always be possible. Any sub-optimal or defective
5
restorations should be repaired or replaced where appropriate, as part of a comprehensive
treatment plan. Where possible, these restorations may be utilised to help retain or support
the prosthesis.
Current prosthesis:
Any prosthesis that the patient is currently wearing should be assessed and consideration
given as to whether the current prosthesis can be added to or not. It is sensible to assess
the existing prosthesis in detail, inside and outside of the patients' mouth. In situ, the
prosthesis should be evaluated for retention, stability and support with assessment of the
occlusion and peripheral extensions, paying close attention to areas that are over or under
extended around denture bearing tissues. The occlusion should be checked and the
occlusal vertical dimension (OVD) and free way space noted. Aesthetics should be
evaluated visually but it is also helpful to hear the patients' opinions on their existing denture.
If the patient is happy with the aesthetics then this can be used to guide the final prosthesis.
Any teeth that may be aiding the retention of the current prosthesis should be noted and
their condition assessed as some of these may require extractions due to a poor prognosis.
Similarly other aspects of the current prosthesis can be assessed based on the discussion
with the patient regarding the positive or negative experiences from their denture wear such
as, a lose mandibular prosthesis. This may be due to excessive resorption of the alveolar
ridge and making the patient aware of its impact in the final prosthesis is helpful.
Alternatively, a patient wearing a poorly retentive maxillary prosthesis due to lack of palatal
coverage may prefer the design to be copied again and therefore needs to be aware of the
limitations of the final result and the reasons associated with it. Allowing the patient to guide
the clinician towards the final design of the prosthesis often provides for a satisfactory result
for the patient.
6
Occlusion:
A detailed occlusal assessment for the patient is indicated. Things to evaluate include
assessing patients’ inter-cuspal position (ICP) and whether this is stable or not. In some
cases identifying the patients retruded contact position (RCP) can be useful as well as an
assessment of the occlusal vertical dimension (OVD) and freeway space (FWS) and this
should be assessed with and without the prosthesis in situ. A decision needs to be made on
whether to maintain the existing jaw relationship or to re-organise the occlusal relationship
when providing the prosthesis. In instances where the patient has a stable ICP and an
appropriate OVD, it is sensible to maintain existing jaw relations. This will often be the case
where patient has retained most of their natural teeth. In situations where teeth have been
lost to disease, this can lead to loss of OVD causing mandibular over closure. Consideration
needs to be given as to whether this is accepted or increase in OVD would be a more
sensible option. In complex situations or to assist the treatment planning process, it may be
useful to attain articulated study models particularly when a reorganised approach is
planned.
Investigations:
Appropriate Investigations should be undertaken to help diagnose and plan treatment. Any
teeth considered for extractions should have pre-operative radiographs to assist in the
planning of the extractions. (See image 3) It can be useful to have articulated study casts to
analyse and assist in the planning of the prosthesis prior to embarking on treatment and they
can also be waxed up to allow the proposed end result to be visualised.
Diagnosis and Treatment planning:
Once a thorough assessment has been undertaken, a diagnosis can be reached. This can
enable the clinician to develop a clear picture of the patients’ needs and develop an
appropriate treatment plan keeping in mind the patient’s wishes, suitability for treatments,
7
number of visits and the costs involved. The treatment plan should outline the nature of the
procedures involved and where possible a proposed denture design.
The teeth that have been proposed for extraction need to be planned. Where a large
number of teeth have been planned for extraction then a staged process of exodontia may
be considered. Historically, this entailed extracting the posterior followed by the anterior
teeth. This allowed the soft tissues of the extracted posterior teeth to heal prior to extracting
the remaining anterior teeth and fitting the immediate complete denture at the same time.
11,12
Staged extractions may be considered due to the patients' medical history or if there is a
concern about the patients tolerance to a removable prosthesis and a
transitional/acclimatisation approach is utilised whereby certain teeth are extracted and
these teeth added to the prosthesis over a period of time. Planning of immediate removable
dentures may be dictated by events such as painful teeth, associated pathology, teeth with
poor prognosis or those with limited prosthodontic use. These teeth are often the ones
extracted first. Where possible it is useful to retain teeth in opposing arches that provide
some form of tooth to tooth contact at an appropriate jaw relationship for as long as possible
to assist in the denture construction and aid in the acclimatisation for the patient. 7
Denture type:
In general, there are two types of immediate dentures that are described in the literature.
These are;
The conventional immediate denture- This is a definitive long term prosthesis that is
immediately provided to the patient.
The interim immediate denture13- This is a short term prosthesis utilised during the
healing phase immediately after extraction until a definitive long term tooth
replacement can be provided.1 (See image 4)
8
Immediate dentures like conventional prosthesis are most commonly fabricated from acrylic.
In general acrylic dentures are cheaper and quicker to construct and more amenable to
modification.
Denture design:
An important aspect of the design process is consideration for the type of flange to be used
particularly in the anterior region, with the options of either a full, partial or an open
faced/socketed (flangeless design).
The full flange will extend to the full width and depth of the sulcus, the advantage of this is
that it will maximise surface area for support and retention and for this reason where
possible, should be utilised as the first choice for immediate dentures. In patients with a
degree of bony undercut or a low smile line, a partial or an open faced/socketed or a partial
design is preferable. A partial flange design extends the labial flange border about 1mm
beyond maximum bulbosity of the ridge8,14,15 These are useful where an undercut of the
alveolar ridge is present but aesthetics dictate a flange hence a short or partial flange is a
reasonable compromise. (See image 5a & b)
Alternatively, the open faced/socketed design helps to maintain an acceptable appearance
in the immediate post extraction period in the anterior region by placing the necks of the
denture teeth into the sockets so that it appears like natural teeth emerging through the
gingivae8 thus avoiding any displacement of the overlying soft tissue which may happen with
a flanged design. (See images 6 & 7) This will help to maintain aesthetics. These types of
prostheses are easier to fit as well however, retention will be reduced particularly where a
complete immediate denture is fitted as a peripheral seal cannot be made. Other drawbacks
with this design include gaps appearing overtime between the border of the prosthesis and
the ridge during bony remodelling post-extraction which can be unsightly as well as being
more challenging to reline.7,16 Adding a flange to this design is difficult and usually a remake
is indicated early on.
9
Table 1: Diseases causing challenges to wear of a removable prosthesis
1
-
2
-
3
-
4
-
Parkinsons disease
Multiple sclerosis
Lichen planus
Oral pemphigoid
Table 2: Assessment of denture bearing tissues
1-
2-
3-
4-
5-
6-
Alveolar ridge height, width and shape
Shape of palatal vault
Presence of undercuts
Sulcus depth
Firmness of overlying tissues
Muscle and frenal attachments
Table 3: Advantages and disadvantages of immediate dentures
Advantages Disadvantages
10
To the patient To the patient
1- Maintaining appearance: IRD allows
aesthetic harmony of face to be
restored.17
2- Maintaining function: Transition from
natural teeth to dentures during eating
and speaking is made easier by IRD.17
Also allows retaining normal muscle
behaviour preventing abnormal habits to
develop which often follow a period of
edentulousness. 18
3- Allows adaptation to dentures: IRD
helps avoid challenges to adaptation if
edentulousness follows extractions
before definitive dentures are fitted. 2
4- Maintaining psychological well-being:
Having an IRD provides patient with
confidence and a sense of comfort.
1- Discomfort: Patient experiences
increased discomfort as extraction sites
are painful.7
2- Increased cost and multiple visits:
Provision of IRD adds to overall cost of
treatment as they require relines and
multiple visits. Often requires replacing
in 6-12 months.7
To the clinician To the clinician
1- Maintaining OVD: If at least two
opposing natural teeth are left in the
mouth after preparatory surgery, these
can act as occlusal stops to facilitate
recording of jaw relations.18
2- Reduced ridge resoprtion : Provision of
IRD can reduce the rate of alveolar
resorption. 19,20,21
3- Maintaining appearance: IRD allows
laboratory to match teeth as closely as
possible to patient’s natural dentition. 18
4- Hemostasis: IRD can provide support
and post –op protection of clots thereby
preventing dislodgement due to food. 2
5- Prevention of tongue spread : Loss of
posterior teeth may cause the tongue to
relax and spread into the spaces
whereas provision of an IRD may be
able to prevent that. 7
1- Inability to complete a wax try-in of the
entire denture base:The best that can
be achieved is the copying of the
existing natural tooth set-up, if it is
deemed satisfactory. 7
2- Difficulties with gross irregularities:
When there are marked irregularities of
natural teeth, provision of IRD may be
difficult e.g. class II div 1. Other
irregularities such as bulbous tori may
require pre-prosthetic surgery etc. 18
11
12
