Immediate Complete Bimaxillary Dentures: an Affordable Solution to Preserve your Smile
Bilel Nasri - DDS
Resident dentist, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- dr.nasri.bilel@gmail.com
Amel Labidi - DDS
Associate Professor, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- amellabidi16@yahoo.fr
Sana Bekri - DDS
Associate Professor, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- sanabekri2015@gmail.com
Yosra Mabrouk - DDS
Associate Professor, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- mabroukyosra2021@gmail.com
Hiba Triki - DDS
Professor, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- hiba.triki@hotmail.com
Lamia Mansour - DDS
Professor, Removable Prosthetics department, ABCDF laboratory, Faculty of Dental Medicine, University of Monastir | Tunisia
- mansourlamia64@yahoo.fr
Bilel Nasri, Amel Labidi, Sana Bekri, Yosra Mabrouk, Hiba Triki, Lamia Mansour. Immediate Complete Bimaxillary Dentures: an Affordable Solution to Preserve your Smile. Smile Dental Journal. 2022;17(2):6-12.
ABSTRACT
Today’s uncertain economic climate coupled with a larger aging population has produced a surge in demand for immediate complete dentures. This treatment is both one of the most challenging and rewarding in removable prosthodontics. It aims on one side to satisfy esthetic and functional requirements and on the other side to ensure the biological and psychological integration of the prosthesis. To be able to fulfill these tasks, the immediate complete prosthesis must be the fruit of a careful and rigorous procedure.
The aim of this case report was to expose the different clinical steps as well as the difficulties to be observed during the prosthetic rehabilitation.
KEYWORDS
Immediate Denture, Esthetics, Edentulous rehabilitation, Anterior teeth extraction, Surgical guide.
INTRODUCTION
The immediate complete removable prosthesis (ICP) is made before the last extractions session and inserted immediately afterwards. This type of prosthesis is recommended to ensure a less dramatic transition from partial to full edentulism.1
It is an interesting therapeutic choice when it is not possible to keep the natural teeth in the arch either because of periodontal lesions or due to significant caries progression particularly for patients with a profession requiring contact with the public.
The elaboration of the immediate total prosthesis follows a rigorous and well-defined clinical protocol.2 Indeed, it must meet the esthetic and functional requirements of the conventional complete prosthesis while overcoming the specific difficulties of the ICP.3
Through this clinical case, the therapeutic approach of the immediate prosthesis was detailed and thus by identifying the difficulties at each level and the appropriate means of management.
CLINICAL CASE REPORT
A 54 year-old patient consulted the prosthodontic department of the dental clinic of Monastir Tunisia. He wished to receive a prosthetic rehabilitation that restores both esthetics and function. In addition to hyperthyroidism, the patient was a heavy smoker.
The extraoral clinical examination (Fig. 1) did not reveal any notorious peculiarity neither on inspection nor on palpation.
The endobuccal examination (Fig. 2) illustrated poor oral hygiene, teeth mobility that disturbs the patient during function and Recessions graded from 1 to 3 according to Miller, uncovering the roots of all teeth.
The panoramic radiological examination (Fig. 3) revealed a generalized alveolysis, sign of severe periodontal disease.
Therapeutic Decision
Considering the patient’s esthetic demands, financial constraints and the severity of the periodontal lesions, we have opted for the realization of an immediate bi maxillary dentures.
THERAPEUTIC APPROACH
It follows three essential phases: pre-prosthetic, proper prosthetic and post-prosthetic phases which lead to the establishment and maintenance of a well elaborated prosthetic rehabilitation.
Pre-prosthetic Phase
Periodontal Remediation
The treatment begins with motivation for oral hygiene, followed by a session of supra- and sub-gingival scaling with a prescription of a Chlorhexidine mouthwash.
Extraction of Posterior Teeth
Classically, a bilateral posterior edentulism (Kennedy class I) was sought. This healed osteofibro-mucosal surface was necessary to guarantee a firm and stable support surface for the immediate full prosthesis (Fig. 4).
Prosthetic Phase Proper
Primary Impressions
The aim was to record all the anatomical surfaces touched by the prosthesis. The primary impression material was alginate. Soon after filling the undercut areas in the interdental spaces using high viscosity silicone, the impression was done with a double coating technique, alginate is first deposited at the bottom of the vestibule in the indented areas and then the commercial impression tray filled with alginate was inserted. In order to have enough working time, we mixed the alginate with ice water. (Fig. 5)
Anatomo-functional Impressions
It was supported by an individual impression tray made from a primary model. Given the mobility of the teeth and the presence of retentive areas, the impression tray made of cold-curing acrylic resin was windowed facing the teeth and combined with a removable cover (Fig. 6).
The individual impression tray has been set and adjusted in the mouth, eliminating any interference. The seals posteriorly as well as in the lateral edentulous areas were recorded with Kerr® thermoplastic paste in the same way as in a conventional full denture. In the anterior dentulous region, a “soft seal” is made with a high-viscosity silicone an elastomer that allows precise registration of the functional anterior limit, without over-extension or over-thickness, despite the quasi-constant undercut (Fig. 7). The impression was carried out using light silicone (Fig. 8).
The impressions were then casted in order to reproduce the entire recorded volumes and surfaces. (Fig. 9)
Recording of the Intermaxillary Relation
The maxillomandibular relationship was recorded and then transferred to the articulator using rigid baseplates made of self-curing resin with occlusal wax rims replacing missing teeth. Then it was clinically adjusted so as to be parallel to the bi-pupillary line anteriorly and Camper’s plane posteriorly using the Fox rule. Before the mounting of the maxillary model, the situation of the future ideal interincisal point as well as the smile line were materialized (Fig. 10). The transfer of the mandibular model was performed after adjustment of the occlusal rims all in centric relationship while maintaining the patient’s vertical dimension of occlusion (Fig. 11).
Selection and Mounting of Prosthetic Teeth
The choice of prosthetic teeth was guided by the remaining anterior teeth in the arch in terms of shape, shade and dimensions.
The mounting of the posterior teeth was carried out first according to an occlusal design that guarantees the occlusal stability of the complete prosthesis such as centring the forces within the support surfaces, respecting the prosthetic corridor, abiding to the occlusal plan (Fig. 12).
Esthetic and Functional Try-in
The previously recorded intermaxillary report as well as the occlusal plan and the OVD were verified via the fitting of the upper and lower posterior sectors.
The fitting of the 21 allowed us to validate the shade and the shape. Its position in 3 dimensions of the space allowed us to have a reference and a starting point during the mounting of the anterior teeth (Fig. 13).
Tooth extraction and ridge preparation
The bone regularization simulated on the plaster model wasn’t mutilating in order to maintain sufficient bone capital considering the resorption in the maxilla.
Nevertheless, during this maneuver, it was necessary to take into account different parameters, such as:
The depth of the periodontal pockets evaluated clinically (Fig. 14); the amount of residual bone evaluated radiologically, the thickness of the fibro-mucosa as well as the loss of substance related to the periodontal pocket and the loss of substance due to healing and corrective surgery.
During the preparation, the retro-incisal papilla, the mucous reflection line and the medial labial frenum were to be preserved and respected.
The preparation of the model was executed according to the following sequence:3
- Drawing of a line materializing the probing depths on the vestibular side of the plaster model. (Fig. 15)
- Horizontal Removal of the Coronal segment of the teeth doomed to be extracted. (Fig. 16)
- Beveling of the formed edges according to the probing line. (Fig. 17)
- Vertical removal of the vestibular alveolar undercuts according to the insertion axis.
- Polishing and rounding using fine-grained sandpaper
- Scribing the velo-palatal joint
Complete Mounting of the Prosthetic Teeth
The teeth were fitted according to the rules of full dentures ensuring a balanced occlusal pattern. The anterior teeth are then mounted following the pre-established aesthetic project (Fig. 19). The 21 was our reference point.
Polymerization
The laboratory proceeded to the finishing of the waxes stabilized dentures by an aesthetic shaping of the marginal gingiva and the realization of the stabilizing polished surfaces of the extrados. The models and their mock-ups were then muffled, and the prostheses were polymerized (Fig. 20).
The final occlusal adjustments were carried out on the articulator using the double base gear system.
The final finishing touches were then made with a fine polishing of the prosthesis.
Realization of the Surgical Template
The template was an exact replica of the prosthesis, but it was crafted with transparent resin (Fig. 21).
Surgical Phase
The surgical procedure was accomplished following the subsequent steps:
- Performing intra-sulcular and papillary incisions. (Fig. 22)
- Reflection of a full thickness flap
- Atraumatic extractions in order to preserve a maximum of bone capital
- Profound curettage of the alveoli along with a decontamination using Iodized Polyvidone
- Ridge regularization using gouge forceps, bone rasp and a surgical burr. These osteoplasties corresponded to those performed on the plaster model. (Fig. 23)
- Placement of the template in order to guide the regularization until we obtained a uniform pressure on the supporting tissues without whitening or interference with the mucosal tissue. (Fig. 24)
- Suture the flap edges using the O type. (Fig. 25)
Immediate Insertion of the Prosthesis
The prosthesis was then inserted in the mouth and the patient was invited to clench the teeth on cotton rolls for about ten minutes to seat the prosthesis, ensure homeostasis and limit postoperative edema.
Then, the absence of any premature occlusal contact was verified using an articulation paper. Static occlusion was controlled and adjusted to achieve the symmetrical posterior contacts and the absence of the anterior contacts. Retention and stability of the ICP was paramount in order to avoid postoperative bleeding (Fig. 26). The denture was fitted and kept comfortable by application of an appropriate tissue-conditioning material. (Fig. 27)
Post-prosthetic Phase
Immediately after surgery, an ice pack was applied to limit postoperative edema.
The patient wasn’t allowed to remove the immediate prosthesis during the first 48 hours. After 48 hours, the practitioner performed the adjustment of dynamic occlusion, removed and cleaned the prosthesis, detered the wound and finally instructed the patient on how to put in and remove the prosthesis.
The prosthetic follow-up was similar to that of a conventional full denture. The usual tips for cleaning the prosthesis and feeding were provided to the patient.
Control appointments are then scheduled at 4 days, 8 days, 15 days and then every month. During visits the tissue conditioning-material Fitt de Kerr® was renewed.
Furthermore, we kept this scheduling until the extraction sites have completely cicatrization thus the prosthesis was to be rebased.
DISCUSSION
The immediate prosthesis is a valuable alternative in certain clinical cases. In order, to guarantee the success of this prosthetic rehabilitation specific skills are required throughout the different phases of the procedure.
During the preprosthetic phase, the huge deposit of dental plaque and calculus was removed. The objective is to reduce the bacterial load and to obtain the settlement of the gingival inflammation with the disappearance of gingival bleeding. Oral hygiene prior to surgery and tooth brushing reduce the risk of postoperative complications.4
The anterior teeth must be retained to maintain esthetic integrity for the patient’s environment. However, recreating a Kennedy-Applegate Class I situation via the prior avulsion of the posterior teeth is crucial because it limits the risk of spontaneous extraction during the taking of impressions, creates a steady osteomucosal bearing surfaces and avoids posterior occlusal interference when recording the intermaxillary relations.5
Throughout the impressions, the presence of dental mobility made it necessary to fill these spaces with pink wax or high viscosity silicone to avoid tearing of the material and possible periodontal lesions to the mobile teeth.6
The anatomofunctionnal impression was taken using light silicone and a windowed individual tray. In fact, the light silicone is a fluid material during insertion but elastic after setting what allows easy removal of the impression without traumatizing teeth.7
As for The windowed impression tray, it has the advantage of ensuring comfort for the patient during the physiological registration of the peripheral joint as well as a smooth demoulding of the Master Cast without fracturing the teeth in the laboratory.2
The appropriate choice of individual impression tray type and impression material in addition to the use of the right technique is crucial to the success of the impression.
During the registration of intermaxillary report, the occlusal rims were slightly higher than the natural teeth but always strictly parallel to the Camper’s plan in order to avoid any error related to the difference in tissue depressibility between the natural teeth and the fibrous mucosa and prevent dental interferences that could induce a deviation and alter the recording.5
Before extracting the anterior teeth on the plaster model, a functional and esthetic try-in of the posterior mounting provides an opportunity to discuss the shade of prosthetic teeth with the patient and to prevent any errors done during the recording of the occlusion caused by an unmanaged reflex advancement or deviation of the mandible. If there is a problem, a Tench bite should be conducted which allows a correct repositioning of the prosthetic teeth.8
During the surgery, sewing tense edge to edge sutures and reflecting a flap that goes beyond the mucogingival line are contraindicated fearing a possible displacement of the functional mucosal reflection line recorded during the impression. The prosthetic edges would then be overextended and the prosthesis would be unstable. There is no risk of bleeding in presence of loose sutures due to the presence of the removable prosthesis that provides compression and guides the healing process.7
Once the surgery is achieved , the application of a tissue conditioner in the intrados of the prosthesis improves comfort of the patient during the healing by providing a better peripheral seal, as a result a better retention, and softening the occlusal forces transmitted by the prosthesis to the underlying tissues.9
The risk of the patient being disappointed by the esthetic result is not excluded due to the absence of a try-in of the anterior teeth. Nevertheless, the clinical sense of the practitioner, the esthetic analysis of the case, the respect of the esthetic reference points and their materialization on the record bases and silicone keys (if used) allows overcoming this inconvenience.
At last, balancing and maintenance sessions can be frequent and time consuming, but they are essential to ensure the integration of the prosthesis in the medium and long term.1
Finally, the patient must be given psychological support after losing his teeth. It is of the utmost importance to educate him to the fact that he should have this continuing care. The responsibility of the dentist is not completed when the denture is inserted, adjusted, and rebased. Professional surveillance should be maintained through the lifetime of the patient.
CONCLUSION
Because of these requirements, it is important to select the appropriate cases from a psychological point of view and to explain plainly the nature and difficulty of the procedure to the patient before the beginning of the treatment in order to obtain their informed consent.
The conventional methods for fabricating immediate dentures and complete dentures have not changed for the past 50 years and involve multiple clinical appointments and lengthy laboratory schedules. Each of these steps requires considerable human intervention and manipulation of materials, which can lead to processing errors, inaccuracies, and increased time and cost. Several commercial manufacturers in the United States currently fabricate complete dentures using computer aided design and computer-aided manufacturing (CAD/CAM) technology.
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