The new removable denture patient: Treatment procedures
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THE JOURNAL OF PROSTHETIC DENTISTRY RICH AND KURTZ
124 VOLUME 80 NUMBER 1THE JOURNAL OF PROSTHETIC DENTISTRY
Demographic data reveal that the incidence of theedentulous condition is falling.1 It is anticipated that, al-though the occurrence of the edentulous condition willfall, the growth of the population should serve to keepthe total number of edentulous persons constant.2 Thedata do not provide sufficient information about the typesof persons who will become edentulous. It can be pre-sumed that there will be a dramatic change in the type ofpatients who become fully or partially edentulous andrequire restoration with removable prostheses. In the past,patients generally lost teeth to neglect. Inadequate homecare combined with infrequent visits for professional treat-ment resulted in the loss of teeth with a subsequent par-tial or total edentulous condition. These patients werepsychologically prepared to wear removable prostheses.Their lack of concern for their teeth indicated that thiswas not an important aspect of their lives. The trend forthese patients was to become fully edentulous at an earlyage, and adapt easily to removable prostheses. Most den-tists never see these patients but invariably those patientsstruggling to accommodate to new dentures always seemto know a few. The new edentulous patient will not loseteeth because of neglect but rather because they will haveoutlived the life span of their teeth and fixed restorations.These patients will lose teeth at a much later stage in life.This is a time of life when the adaptation process may notbe as obliging as it once was. Many of these patients willhave gone to the dentist every 3 or 6 months for routinecare for most of their lives. They have not disregardedtheir teeth but rather have spent considerable effort inmaintaining their teeth in defiance of the ravages of car-ies and periodontal disease. Despite the best efforts ofmodern dentistry and meticulous home care, these pa-tients find themselves partially edentulous or, in the worstcase, fully edentulous.
aAttending Dentist, Department of Postgraduate Prosthodontics.bSenior Resident, Department of Postgraduate Prosthodontics.
The new removable denture patient: Treatment procedures
Benedict Rich, DDS,a and Kenneth S. Kurtz, DDSb
Montefiore Medical Center, Bronx, N.Y.
Dentists are beginning to see a new type of patient who requires removable prosthodontic rehabili-tation. These patients are the result of both increases in longevity and dental treatment that hasretained teeth, despite the onslaught of caries and periodontal disease. The current procedures fortransitioning patients into removable prostheses can be modified for this new group of patients.This article presents a transition procedure for patients who are receiving removable prostheses,which dissociates the surgical phase of treatment from the prosthetic stage. The patient’s existingteeth are incorporated into a removable prosthesis in a way that ensures the exact replication of thetooth position in the oral cavity. This method addresses many of the inadequacies of currentprocedures while at the same time requiring a minimum of chair time. Even with this procedure,this transition is still difficult for the patient. (J Prosthet Dent 1998;80:124-8.)
REVIEW OF THE LITERATURE
The most significant challenge for the patient and thedentist is the initial transition from the dentate to theedentate. Patients fear that it will be obvious to every-one who knows him or her that they are now wearing aremovable prosthesis. Perhaps the real fear is that thepatient will be constantly reminded of their disability.The resolution of this fear is not to reassure the patientthat no one will notice his or her teeth. This will not beeffective because the patient’s own experience is thatthey tend to be very conscious about other people’s teeth.The lack of a wax try-in stage in any of the transitionalmodalities contributes to the patient’s heightened anxi-ety. The Glossary of Prosthodontic Terms3 defines the fol-lowing type of prostheses that are used for the transi-tion:
immediate denture: a complete denture or re-movable partial denture fabricated for place-ment immediately following the removal of thenatural teeth.interim prosthesis: a fixed or removable prosthe-sis designed to enhance the esthetics, stabiliza-tion and/or function for a limited period oftime, after which it is to be replaced by a defini-tive prosthesis. Often such prostheses are usedto assist in determination of the therapeutic ef-fectiveness of a specific treatment plan or theform and function of the planned for definitiveprosthesis—syn PROVISIONAL PROSTHE-SIS, PROVISIONAL RESTORATION,TREATMENT PROSTHESIStransitional denture: a removable partial den-ture serving as an interim prosthesis to whichartificial teeth will be added as natural teeth arelost and that will be replaced after postextractiontissue changes have occurred. A transitionaldenture may become an interim complete den-ture when all of the natural teeth have been re-
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moved from the dental arch—called also tran-sitional partial denture.treatment denture 1: a dental prosthesis usedfor the purpose of beating or conditioning thetissues that are called on to support and retainit; 2: a dental prosthesis that is placed in prepa-ration for future therapy—see INTERIMPROSTHESIS
Rosen4 has suggested that the term conversion pros-thesis be adopted to describe the salvaging of a fixed res-toration to be incorporated into an immediate provi-sional removable partial denture or complete dentureprosthesis or overdenture.
The classical immediate denture procedure was firstdescribed by Sears,5 Jaffe,6 and Hooper.7 In this proce-dure, the first step is the removal of as many posteriorteeth as possible. An impression is made of the remain-ing teeth and edentulous ridges. If possible, this impres-sion is made in a custom border molded tray. However,because of the tenuous nature of the remaining teeth, astock tray with irreversible hydrocolloid may have to beused. The cast is articulated with its opposing member.The remaining teeth are removed from the cast and theresidual ridge is recontoured to an estimate of its formimmediately after the extractions. Denture teeth are setin wax and processed. It is impossible to try-in the im-mediate denture set up, as the anterior teeth are still inplace. The remaining teeth are removed and the pros-thesis is inserted. The difficulties with this procedureare as follows: (1) The patient does not get an opportu-nity to visualize the prosthesis before it is inserted. Thisonly contributes to the patient’s stress and tension aboutthe treatment. (2) The denture is made on a cast thathas been altered to a general idea of the form of theresidual ridge. The possibility of an intimate fit of theprosthesis to the tissues is nil. (3) Removing the teeth atthe time of insertion traumatizes the patient twice. Theremaining teeth are being removed with its attendantpsychological effects but also the patient must cope withpain and swelling while trying to adapt to a poorly fit-ting denture. (4) In many cases, the oral surgeon who isextracting the teeth, inserts the new prosthesis. Oralsurgeons are not trained in the insertion and adjustmentof dentures. This is best left to the prosthodontist whohas fabricated the prosthesis.
Campbell described an interim denture procedure in1934.8 Payne9 presented a practical procedure for theinterim prosthesis in 1964. Applebaum10 detailed thephilosophical and technical differences between the in-terim prosthesis and the immediate denture. The interimprosthesis does not require separate appointmentsfor the extraction of the anterior and posterior teeth. Allthe remaining teeth are extracted simultaneously andthe prosthesis is inserted. In this procedure, a cast ismade of the patient’s teeth. The teeth are removed from
the cast and replaced with artificial teeth. Baseplate waxis added to cover the palate and form the flanges. Thedenture is processed. The teeth are removed and thedenture is inserted at that time. Tissue conditioningmaterial is added as needed. The interim prosthesis ismodified with additional tissue conditioning material asthe ridges heal. After healing is complete, a definitivecomplete denture can be made for the patient. Fenton11
proposed constructing an interim overdenture prosthe-sis using the patient’s existing removable partial den-tures, crowns of natural teeth, and artificial teeth. Manyother authors have published modified procedures forthe construction of the interim prosthesis.12-18 Otherauthors have advocated the use of the patient’s naturalteeth or existing fixed crowns and bridges.19-21 As newmaterials have come on the market, dentists have incor-porated them into the interim prosthesis procedure.23,24
These procedures are a modification of the immediatedenture procedure and share the same shortcomings.
The immediate denture or interim prosthesis does notaddress the unique requirements of the new removabledenture wearer. This article will present an alternativeprocedure for making immediate removable partial pros-theses (RPDs). The procedure that is presented addressesthe disadvantages of the immediate denture and interimprosthesis. Although the transition from the dentate tothe edentate can never be easy, this procedure offers morecomfort for the patient.
The main difference between the procedure presentedin this article and those previously published is that thesurgical phase of the treatment is separated from theprosthetic aspect. This allows the patient to focus onadapting to the removable prosthesis without having toendure the postoperative discomfort of tooth removal.With this procedure, the prosthodontist who has fabri-cated the prosthesis inserts it and is available to adjust itat the time of insertion. There is a minimal amount ofbleeding so that pressure-indicating paste can be usedto adjust the denture base at the insertion visit. Becausethe base is stable, the occlusion is readily refined. Theintimacy of fit of the prosthesis is excellent because thereis no tissue shrinkage until the roots are removed. Thepatient benefits by adjusting to an intimately fitting pros-thesis versus a prosthesis that is in constant need of tis-sue conditioning or reline.
The patient used to illustrate this procedure was wear-ing an extensive fixed porcelain fused to metal prosthe-sis (FPD) (Fig. 1) that could not be salvaged. The max-illary right second premolar and the first and secondmolars were all that could be retained. The remainingmaxillary teeth are no longer suitable abutments for afixed partial denture. The treatment plan called for sec-tioning the existing prosthesis between the maxillaryright first and second premolars. Ultimately, after thor-
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ough healing has occurred, new porcelain fused to metalcrowns for the three remaining teeth and a definitiveRPD will be made.1. At a preliminary visit, make an irreversible hydro-
colloid impression of the arch to be treated and poura cast in dental stone. On this cast, make eitherwrought wire or cast clasps to fit the teeth that willbe saved and attach them to a baseplate made withautopolymerizing, heat-polymerizing, or light-po-lymerizing resin (Fig. 2). It may be necessary to cutchannels across the occlusal surfaces of the teeth tobe clasped to make room for the clasp to cross thissurface without interfering with the opposing oc-clusion. When this is necessary, it should be per-formed before the impression is made.
2. At the next visit, try-in the baseplate with the claspsattached, make any necessary adjustments to per-mit it to seat properly.
3. Anesthetize (locally) vital abutment teeth for the ex-isting FPD, except the teeth that will remain.
4. When adequate anesthesia has been obtained, notchthe lingual surfaces of the abutment teeth to betreated about half way through. Place the notch closeto the gingiva of each tooth.
5. Seat the baseplate with the clasps in the mouth andattach it to the teeth of the existing restoration thatwill become a part of the RPD withautopolymerizing acrylic resin. Because the base-plate was made to fit the existing FPD, the amountof resin in contact with the soft tissues is minimal(Fig. 3). In our experience, irritation of the soft tis-sues has not been a problem. Attaching the teeth ofthe existing FPD to the baseplate before complet-ing the sectioning of the abutments ensures the ex-act position of the teeth in the baseplate.
6. After the resin polymerizes, complete the section-ing of the notched teeth from the facial at the heightof the gingiva. The lingual cuts made in step 4 fa-cilitate the sectioning with little collateral damageto the adjacent structures.
7. Remove the baseplate with the FPD teeth attachedand set it aside to await further processing in step 9.
8. Roots that have been treated endodontically requireno further treatment at this time. Roots that havenot had endodontic treatment must undergo pulpot-omies and must be at least provisionally sealed. Theultimate fate of the remaining roots is not relevantat this time. These teeth may be slated for extrac-tion or overdenture abutments (Fig. 4). The goal atthis time is to transition the patient into a remov-able treatment prosthesis. After the patient is com-fortable, the roots can be treated at subsequent ap-pointments.
9. It is now necessary to make a labial flange for the
Fig. 2. Heat-polymerized acrylic resin baseplate with castclasps incorporated.
Fig. 1. Failing maxillary FPD that will be incorporated intoRPD by new process.
Fig. 3. Porcelain fused to metal prosthesis sectioned betweenfirst and second premolars and secured to baseplate intraorallywith autopolymerizing acrylic resin.
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prosthesis. Clean the crowns that are now attachedto the baseplate and remove residual debris, cement,and/or tooth structure. Place grooves or other re-tentive undercuts to ensure the continued attach-ment of the teeth to the resin baseplate. The labialflange may be made intraorally by placing the base-plate with the FPD teeth on it in the mouth andapplying a mix of autopolymerizing acrylic resinaround the facial surface to include the soft tissue.However, it is more desirable to make an impres-sion in irreversible hydrocolloid with the assemblyin the mouth. Then remove the impression with theassembly in it, pour a cast of quick set dental stone,and add the flange in the laboratory. This will avoidthe use of resin directly against the patient’s tissues.Whichever approach is used, the labial flange is thentrimmed to contour and polished (Figs. 5 and 6).
10. The prosthesis is now ready for the patient. Inspectthe flanges for excessive length and adjust accord-ingly. Use pressure-indicating paste to adjust theintaglio surface of the denture and adjust the occlu-sion. It may be appropriate to modify the occlusalscheme of the fixed prosthesis to one that is moreappropriate for a removable prosthesis.
Because no teeth were removed, there is little orno bleeding and a minimal amount of trauma to thetissues. Denture adhesives are given to every patientregardless of the clinical retention of the prosthesis.Many of these patients prefer to use an adhesive evenin the presence of what the dentist perceives as ad-equate retention. Most patients would like to havea fixed prosthesis and adhesives may bring themcloser to that goal. Dismiss the patient.
11. Schedule follow-up visits and see the patient as of-ten as necessary until the treatment prosthesis is
completely comfortable. After the patient has ac-commodated to the new prosthesis, initiate treat-ment of the remaining roots. When removal is indi-cated, the patient is spared the ordeal of having toadjust to the new prosthesis at the same time theextraction sites are healing. When the roots are tobe maintained as overdenture abutments,7 treatmentproceeds to that end. After adaptation and healingare completed, make the new crowns and a defini-tive RPD for the patient.
Dentists are beginning to see a new type of patientrequiring removable prosthodontic replacement. Thesepatients are the result of both increases in longevity anddental treatment that has retained teeth for these pa-tients, despite the onslaught of caries and periodontal
Fig. 4. Maxillary arch with fixed prosthesis removed. Secondpremolar and first and second molar crowns will be retainedand clasped. Crowns will be remade after healing occurs. Re-maining roots will either be extracted or treated and used forpartial overdenture abutments.
Fig. 5. Intaglio surface of completed treatment removable pros-thesis.
Fig. 6. Polished cameo surface of completed treatment RPDwith old porcelain fused to metal restoration firmly attachedto resin baseplate with autopolymerizing acrylic resin.
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diseases. The current procedures in the literature fortransitioning patients into removable prostheses are in-adequate for this new group of patients. A procedurehas been presented that dissociates the surgical phase oftreatment from the prosthetic stage. In addition, thepatient’s existing teeth are incorporated into a remov-able prosthesis in such a way as to ensure the exact rep-lication of the tooth position in the oral cavity. Evenwith this procedure, this transition is still difficult forthe patient.
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MONTEFIORE MEDICAL CENTER
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