Enhanced CPD DO C & DO D RemovableProsthodontics

Ursala Jogezai

Dominic Laverty and A Damien Walmsley

Immediate Dentures Part 1:

Assessment and Treatment
Planning
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.
CPD/Clinical Relevance: Immediate dentures are commonly used to provide patients with tooth replacement immediately following
extractions in order to maintain aesthetics and function. Therefore, they are an integral part of a dentist’s armamentarium.
Dent Update 2018; 45: 617–624

An immediate denture is a complete or while waiting for the tissues to heal prior Assessment and treatment
partial removable prosthesis that is fitted to definitive tooth replacement1 (Figure planning
immediately after extraction or modification 1). Some clinicians take impressions
All patients should have a
of teeth. The prosthesis replaces the missing/ on the day of the extractions and fit
thorough history, clinical examination and
modified teeth and, where required, the dentures a few days later. These
any relevant investigations carried out
the adjacent hard and soft tissues. It is dentures are fraught with challenges as in order to attain a correct diagnosis and
constructed prior to the extraction of teeth the alveolar ridge begins to resorb soon treatment plan. The formulated diagnoses
and is used immediately to provide function after extractions, therefore an immediate and treatment plan, as well as the costs
and aesthetics which are lost as a result of denture is only truly an immediate and timeframes involved, need to be
tooth removal and avoid the embarrassment denture when fitted on the day of the thoroughly discussed with the patient in
extractions. order to obtain informed consent before
patients may have with living without teeth,
The use of a removable proceeding with treatment. It is also vital
prosthesis within the UK is currently that the clinician has a clear understanding
Ursala Jogezai, BDS, BSc, MBA, around 19% of adults in the general of the patient’s expectations of treatment
PGcert(FHEA), Dental Core Trainee (DCT2), population2 and, in spite of a decreasing and whether these can be achieved in
Restorative Dentistry, Birmingham Dental trend, as patients retain their natural the proposed treatment, particularly in
Hospital, Dominic Laverty, BDS(Hons), dentition into older age,2 there is still those patients who have never worn
MFDS RCS(Edin), Academic Clinical Fellow a need for prosthodontic replacement dentures before. Patients need to be
(ACF), Restorative Dentistry, Birmingham as teeth are lost as a result of caries, clearly made aware of the limitations of a
Dental Hospital and A Damien periodontal disease, tooth wear removable prosthesis in general and also
Walmsley, BDS, MSc, PhD, FDS RCS, or trauma.3,4,5 The provision of an the issues associated with an immediate
Director of Internationalization, Head of immediate denture can be challenging. denture. Denture wearing is a complex
Teaching Unit of Prosthetic Dentistry, Close co-operation between patient, phenomenon and, while the technical
Birmingham Dental Hospital, 5 Mill Pool technician and clinician is therefore ability of the clinician has a huge role to
Way, Edgbaston, Birmingham B5 7EG, UK. required. play in its success, it is largely dependent
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 RemovableProsthodontics

a a situations, a patient’s medical background

can complicate or impact the process of
dental extractions that the clinician needs
to be aware of and be able to manage
appropriately. There are also medical
conditions that may make provision of a
removable prosthesis challenging. This
includes certain neuromuscular conditions
(Table 1). The exact management of these
conditions goes beyond the scope of this
b b article.7,8,9
Information regarding the
patient’s 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 his/her occupation, any
hobbies or activities and the availability
Figure 1. (a) Planned extraction for carious root c for appointments will help with planning
UR3. (b) Immediate upper denture fitted after the treatment. Patients in certain professions
extraction, restoring appearance. may struggle with removable prosthesis,
such as wind instrument players and public
speakers, and the effect of the proposed
1- Parkinson’s disease
treatment needs to be discussed.
2- Multiple sclerosis
3- Lichen planus Examination
4- Oral pemphigoid A comprehensive examination
in a methodical sequence is required, this
Table 1. Diseases causing challenges to the Figure 2. (a) Planned extractions for LR1, LR2, LL1
wearing of a removable prosthesis.
includes an assessment of the following:
and LL2. Existing edentulous spaces posteriorly  Denture-bearing tissues/edentate spaces;
aided retention, support and stability that would
 Dentition;
be gained from the final prosthesis. (b) Existing
1- Alveolar ridge height, width and  Current prosthesis; and
edentulous upper arch showing a pigmented
area on the patient's palate. (c) Final appearance
 Occlusion.
shape
Shape of palatal vault after fitting of an immediate lower partial denture
2-
and a conventional complete upper denture on Denture-bearing tissues/edentate spaces
3- Presence of undercuts the day of the extractions. Examination of the denture-
4- Sulcus depth bearing areas should be carried out in
5- Firmness of overlying tissues detail since this will have an impact on the
6- Muscle and frenal attachments design of the final prosthesis. In cases of an
medical history and briefly exploring the immediate denture, it may be difficult to
Table 2. Assessment of denture-bearing tissues. patient’s dental and social history. Taking a ascertain the ridge shape in the areas where
full and thorough history succinctly is a key extractions will be carried out. However, if
skill since correct diagnosis relies on it. This there are any other edentulous spaces in
in turn enables the clinician to propose an the mouth, assessing them in detail will give
on the patient’s psychological acceptance appropriate treatment plan. an idea of the kind of retention, stability
and neuromuscular ability to cope with the A detailed medical history and support that can be gained from the
dentures.6 should include information regarding all denture base (Figure 2). The edentate ridges
relevant conditions. This would include, but should be assessed on their height, width
not necessarily be limited to, information and shape, the firmness of overlying tissue
History regarding bleeding disorders such as and any undercuts that may be present.
A thorough history of the patient haemophilia, immuno-compromised Muscle and frenal attachments should be
is required. This will entail asking questions patients, those with a history of head and checked, along with the sulcus depth, plus
regarding any presenting complaint or issue neck radiotherapy, as well as those on anti- noting the shape of the palatal vault for the
which the patient is having, the patient’s coagulants or bisphosphonates. In some maxillary prosthesis (Table 2). In addition
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 RemovableProsthodontics

Advantages Disadvantages
To the patient To the patient
1. Maintaining appearance: Immediate dentures allow aesthetic 1. Discomfort: Patient experiences increased discomfort as extraction
harmony of the face to be restored.17 sites are painful.7

2. Maintaining function: Transition from natural teeth to 2. Increased cost and multiple visits: Provision of immediate dentures
dentures during eating and speaking is made easier by adds to overall cost of treatment as they require relines and multiple
immediate dentures.17 Also allows retaining normal muscle visits. Often requires replacing in 6−12 months.7
behaviour preventing abnormal habits to develop which often
follow a period of edentulousness.18

3. Allows adaptation to dentures: Immediate dentures help

avoid challenges to adaptation if edentulousness follows
extractions before definitive dentures are fitted.2

4. Maintaining psychological well-being: Having immediate

dentures provides patient with confidence and a sense of
comfort.

To the clinician To the clinician

1. Maintaining OVD: If at least two opposing natural teeth are 1. Inability to complete a wax try-in of the entire denture base: The
left in the mouth after preparatory surgery, these can act as best that can be achieved is the copying of the existing natural tooth
occlusal stops to facilitate recording of jaw relations.18 set-up, if it is deemed satisfactory.7

2. Reduced ridge resorption: Provision of immediate dentures 2. Difficulties with gross irregularities: When there are marked
can reduce the rate of alveolar resorption.19,20,21 irregularities of natural teeth, provision of immediate dentures may
be difficult, eg Class II div 1. Other irregularities such as bulbous tori
3. Maintaining appearance: Immediate dentures allows may require pre-prosthetic surgery, etc.18
laboratory to match teeth as closely as possible to patient’s
natural dentition.18

4. Haemostasis: Immediate dentures 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 immediate dentures may be able to prevent that.7

Table 3. Advantages and disadvantages of immediate dentures.

to the visual examination, palpating the should be planned for extraction and those Where possible, these restorations may
denture-bearing areas carefully is a useful with poor or dubious prognosis should be be utilized to help retain or support the
method to determine if there are areas of noted down and form part of the treatment prosthesis.
discomfort in the patient’s mouth as these plan, taking future tooth loss or need for
may require relief in the final prosthesis.10 extractions into account.7 Current prosthesis
Ideally, the primary disease within Any prosthesis that the patient
Dentition the mouth, such as periodontal disease, is currently wearing should be assessed
The dentition and its supporting caries and tooth wear, should be stable and consideration given as to whether the
structures should be evaluated, which and aetiological factors controlled prior to current prosthesis can be added to or not. It
includes assessment of the periodontal embarking on tooth replacement, although is sensible to assess the existing prosthesis
condition along with BPE (Basic Periodontal this may not always be possible. Any sub- in detail, inside and outside of the patient’s
Examination) scores, presence of caries, tooth optimal or defective restorations should be mouth. In situ, the prosthesis should be
surface loss, as well as any restorations and repaired or replaced, where appropriate, as evaluated for retention, stability and
their condition. Teeth of hopeless prognosis part of a comprehensive treatment plan. support, with assessment of the occlusion
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 RemovableProsthodontics

sensible to maintain existing jaw relations.

This will often be the case where a patient
has retained most of his/her 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 an 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 reorganized
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 (Figure 3). It is important 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 visualized.
Figure 3. Example of a radiograph used to aid in assessment and treatment planning. Note severely
periodontally-involved upper and lower incisors planned for extractions.
Diagnosis and treatment planning
Once a thorough assessment
has been undertaken, a diagnosis can be
reached. This can enable the clinician to
and peripheral extensions, paying close prosthesis, due to lack of palatal coverage, develop a clear picture of the patient’s
attention to areas that are over or under may prefer the design to be copied again and needs and develop an appropriate
extended around denture-bearing tissues. therefore needs to be aware of the limitations treatment plan, keeping in mind the
The occlusion should be checked and the of the final result and the reasons associated patient’s wishes, suitability for treatments,
occlusal vertical dimension (OVD) and with it. Allowing the patient to guide the number of visits and the costs involved. The
freeway space noted. Aesthetics should clinician towards the final design of the treatment plan should outline the nature
be evaluated visually but it is also helpful prosthesis often provides for a satisfactory of the procedures involved and, where
to hear the patient’s opinions on his/her result for the patient. possible, a proposed denture design.
existing denture. If the patient is happy The teeth that have been
with the aesthetics then this can be used Occlusion proposed for extraction need to be
to guide the final prosthesis. Any teeth that A detailed occlusal assessment for planned. Where a large number of teeth
may be aiding the retention of the current the patient is indicated. Things to evaluate have been planned for extraction then
prosthesis should be noted and their include assessing the patient’s inter-cuspal a staged process of exodontia may be
condition assessed as some of these may position (ICP) and whether this is stable or considered. Historically, this entailed
require extractions due to a poor prognosis. not. In some cases, identifying the patient’s extracting the posterior followed by the
Similarly, other aspects of the current retruded contact position (RCP) can be useful, anterior teeth. This allowed the soft tissues
prosthesis can be assessed based on the as well as an assessment of the occlusal of the extracted posterior teeth to heal prior
discussion with the patient regarding the vertical dimension (OVD) and freeway space to extracting the remaining anterior teeth
positive or negative experiences from (FWS), and this should be assessed with and and fitting the immediate complete denture
denture wear, such as a loose mandibular without the prosthesis in situ. A decision at the same time.11,12
prosthesis. This may be due to excessive needs to be made on whether to maintain Staged extractions may be
resorption of the alveolar ridge and making the existing jaw relationship or to re-organize considered due to the patient's medical
the patient aware of its impact in the the occlusal relationship when providing the history, or if there is concern about
final prosthesis is helpful. Alternatively, a prosthesis. In instances where the patient the patient's tolerance to a removable
patient wearing a poorly retentive maxillary has a stable ICP and an appropriate OVD, it is prosthesis. In such situations, a transitional/
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 RemovableProsthodontics

a b c a

d e b

f Figure 5. (a) Maxillary arch dental clearance

and multiple extractions in the mandible with a
bony undercut in the anterior region. (b) Flanged
design complete upper immediate denture and
Figure 4. (a–c) Extraction of UL1 due to failing partial flanged lower immediate denture.
root canal treatment and subsequent implant
(d, e) Interim/transitional upper immediate
denture replacing UL1 during healing phase
placement. (f) Definitive implant-supported A full flange will extend to the
crown. full width and depth of the sulcus: the
advantage of this is that it will maximize
surface area for support and retention and,
for this reason, where possible should be
acclimatization approach is utilized whereby that is immediately provided to the utilized as the first choice for immediate
certain teeth are extracted and these are patient. dentures. In patients with a degree of bony
added to the prosthesis over a period of 2. The interim immediate denture13 − undercut or a low smile line, a partial or an
time. Planning of immediate removable this is a short-term prosthesis utilized open faced/socketed or a partial design is
dentures may be dictated by events such as during the healing phase immediately preferable. A partial flange design extends
painful teeth, associated pathology, teeth after extraction until a definitive the labial flange border about 1 mm beyond
with poor prognosis or those with limited long-term tooth replacement can be maximum bulbosity of the ridge.8,14,15 These
prosthodontic use. These teeth are often provided1 (Figure 4). are useful in cases where an undercut of
the ones extracted first. Where possible, it Immediate dentures, like the alveolar ridge is present, but aesthetics
is useful to retain teeth in opposing arches conventional prostheses, are most dictate a flange, hence a short or partial
that provide some form of tooth to tooth commonly fabricated from acrylic. In flange is a reasonable compromise (Figure
contact at an appropriate jaw relationship general, acrylic dentures are cheaper 5).
for as long as possible, in order to assist and quicker to construct and more Alternatively, the open faced/
in the denture construction and aid in the amenable to modification. socketed design helps to maintain an
acclimatization for the patient.7 acceptable appearance in the immediate
Denture design post extraction period in the anterior
Denture type An important aspect of the region by placing the necks of the denture
In general, there are two types design process is consideration for the type teeth into the sockets so that these appear
of immediate dentures that are described in of flange to be used, particularly in the like natural teeth emerging through the
the literature. These are: anterior region, with the options of either gingivae,8 thus avoiding any displacement
1. The conventional immediate denture − a full, partial or an open faced/socketed of the overlying soft tissue which may
this is a definitive long-term prosthesis (flangeless design). happen with a flanged design (Figures 6
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 RemovableProsthodontics

a c a

Figure 7. (a) Flangeless design of an upper

complete immediate denture. (b) Flangeless/
socketed design.

b
d
the denture more challenging to reline.7,16
Adding a flange to this design is difficult
and usually a remake is indicated early on.

Conclusion
Immediate dentures play a
significant role in providing patients with
tooth replacement immediately after loss
of teeth, ensuring restoration of aesthetics
and function. A list of advantages and
disadvantages of immediate dentures
is given in Table 3. Since the success of
immediate dentures is greatly influenced
by patient factors, it is therefore helpful to
have a clear discussion regarding patient
expectations as well as to gain informed
consent. This should be followed by a
thorough history and examination of
the oral tissues, as well as any existing
prostheses. In the next part, the various
Figure 6. (a, b) Immediately post extraction of upper anterior teeth demonstrating collapse of the stages of denture construction, post-
upper lip. (c, d) Flangeless design restores appearance without displacing the soft tissues overlying the operative patient management, and any
alveolar ridges. future additions to the immediate dentures,
will be discussed.

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