So much success of an immediate denture case revolves around setting expectations correctly. We can go into the technicalities of record taking, and case planning, but proper expectations also deserve a place in the conversation.
Can you think of an immediate denture case that seated and delivered like a charm? Or how about the contrary, have you had one go extremely badly? There are many variables that can contribute to either outcome, but one thing that can help these cases go smoothly is to establish with the patient the expectation that the immediate denture, is an interim step. It is not the final denture! As the clinician, this is your chance to establish trust and rapport with the patient from the moment you meet them. That’s why you really must define “immediate denture,” and paint a full picture of what that means for them.
When it comes to immediate appliances, explain to Mrs. Smith that the immediate denture serves several purposes. Yes, it will replace teeth once they are extracted. Yes, they will be able to eat. And yes, it will serve as a band-aid for the healing process. Beyond that, she needs to know that her dentist, and the lab creating the denture, are going to do everything you can to make it look nice. But do things happen? Sometimes, is not enough bone taken out of the way for the denture to seat properly? Sometimes is the immediate not stable because it doesn’t extend through hamular notches? Sometimes have we not adequately estimated incisal edge positions based on super-erupted or broken down teeth? It must be communicated that the immediate denture is a “best guess.”
Through the inaccuracy of records, super-erupted teeth, and lack of information in impressions, there are many things that can hinder proper esthetics of the immediate appliance. It’s at this point in the treatment planning that she needs to know we really will try to make that appliance beautiful. But also, immediate dentures can’t always be tried in, and full anatomies can sometimes not be provided in the impressions. So, discrepancies can and will happen.
BUT THAT’S OK! Because once natural teeth are out of the way and bites and occlusions are stable, then we can really begin the more precise denture work. This is what the patient must understand! They need to be ok with multiple steps to get to the finished product.
With immediate complete dentures, here are some basic tips that will go a long way toward making your outcomes predictable.
- Explain in your lab script if the patient wishes to replicate tooth positioning that exists on study models, or if a new position is desired, such as a midline that needs to shift slightly to the patient’s left. (And always describe this direction from the patient’s point of view!)
- Explain in your lab script if the patient wants to replicate tooth shape and size.
- If you need to show the technician incisal edge lengths in relation to the patient’s lips, then be sure to take photographs, and take at least 5 images. One from straight on with retractors. One from the patient’s profile view with full smile. One from straight ahead with full smile. One at rest from straight ahead. And one at rest again from the profile view. This gives the technician a wonderful chance of really nailing the tooth positioning.
- Ask for a custom tray. This will help you achieve details in hard to reach areas such as hamular notches, and will also help you pick up the details of the vestibules and lingual floor.
- Indicate sex and age of the patient so the technician can factor that into the equation when selecting proper teeth to use.
The following images illustrate the study model we begin with, following the existing tooth positions, and the completed denture setup.
Under Promise and OVER DELIVER!
Have you ever heard of this concept? Inform the patient that immediate dentures are often less than ideal. Tell them that as they heal they will become ill fitting. There’s no need to sugar coat this! By doing so, you are doing a disservice to your patient, and creating a future conversation that is going to be uncomfortable.
You don’t score any extra points by sugar coating the realities of an immediate denture!
One clinician we get to work with is Dr. Brent Moses of Virginia Beach. He describes the immediate denture as “the most barbaric practice still existing in modern dentistry.” He says, “to think that we will extract teeth from a patient, place a hard piece of plastic on an open wound in order to allow it to heal is astonishing. The patient is in pain. The esthetics are average at best because of bone reduction, swollen tissue, etc. And as soon as the patient is out of pain, now the denture doesn’t fit anymore because of the tissue healing and settling down. I tell the patient that they are going to absolutely hate the immediate denture phase, in an attempt to establish a clear expectation. And if we are so lucky as to have the patient come back and say ‘it actually wasn’t as bad as you told me,’ then I have done my job, and we can move forward with the patient trusting me, and having confidence in knowing the direction we are going.”
If you tell her these things, and thus gain her trust and cement your credibility, when you see her on the day of surgery, and your immediate denture ends up being a home run, you have covered yourself for the bumps in the road that we know sometimes happen, but to her you look like a hero! And we would all rather look like heroes on the day of delivery, as opposed to the day we meet the patient and tell her a half-truth that we are going to give her an immediate denture that is fantastic.
If you are interested in further planning involving your denture cases, we’d be happy to assist. This is our specialty. A quick call between the lab, the restorative doctor, and the surgeon, can go miles toward ensuring predictable results, and more importantly meeting the expectations of our patients! Contact us at 757-271-5811 if you’d like to plan it out together.