Notes: Delivery and Maintenance of Complete Dentures and Immediate Dentures

Overview

  • Author and topic: Ting-Ling Chang, DDS; Division of Advanced Prosthodontics, UCLA. Topic: Delivery and Maintenance of the Complete Dentures and Immediate Dentures.
  • Key themes throughout: pre-delivery preparation, remounting accuracy, border and tissue adjustments, PIP (Pressure Indicating Paste) guided occlusal/bearing surface adjustments, centric relation (CR) remounts, post-delivery follow-ups, and planning for immediate dentures (including surgical stents and wax-ups).
  • Primary goal: achieve accurate fit, esthetics, occlusal harmony, and patient comfort through systematic remounting, border management, and stepwise adjustments.

Key Terminology and Surfaces

  • Intaglio surface: internal tissue-facing denture surface.
  • Polished surface / Cameo surface: outer, visible denture surface.
  • Occlusal surface: chewing surfaces of denture teeth.
  • Posterior Palatal Seal (PPS): seal bead on the denture palate aiding suction and seal.

Pre-delivery Preparation of Dentures

  • Fabrication of face bow remount jig to preserve the face bow mounting record.
  • Removing processed dentures from master casts for finishing.
  • Finishing/polishing dentures to proper contour and aesthetics.
  • Fabrication of clinical remount casts.
  • Mount the maxillary remount cast on the articulator preserving the facebow transfer record.
  • Critical note: Prior to insertion, old dentures must be left out of the mouth for 24 hours24\ \text{hours}.

Remount Jig and Articulator Setup

  • Processed upper denture attached to the upper member of the articulator; attach a mounting ring to the lower member.
  • Confine plaster with a paper cup from which the bottom has been removed.
  • Purpose of this jig: preserve the face bow mounting record.

Polished Dentures and Finishing Guidance

  • Borders should be rounded and smooth; palate should be highly polished with proper thickness.
  • Do not overpolish; be careful not to overpolish occlusal or incisal surfaces.

Tissue Inspection and Water Soak

  • Reexamine the tissue side; remove any bubbles with a Kingsley scraper or similar sharp instrument.
  • Prior to delivery, soak dentures in water for 72 hours72\ \text{hours}.

Purpose of Remount Casts

  • Provide casts with which to mount the clinical remount record.

Fabrication of the Remount Cast

  • Begin by blocking out undercuts on the undersurface of the dentures with moistened pumice.
  • Mix a small amount of impression plaster, place on the lab bench, and embed the denture into it as shown.
  • After the plaster sets, remove the dentures from the cast and trim them as shown.
  • Remount casts will be used to mount the clinical remount records on the articulator.

Remount Procedure on the Articulator

  • The maxillary remount cast is connected to the upper member of the articulator by the facebow transfer jig.
  • With the lower remount cast, you are ready to perform the clinical remount procedure.

Pressure Indicating Paste (PIP) Procedure

  • Zinc oxide Paste is used as a Pressure Indicating Paste (PIP) to detect improper adaptation; often placed in a disposable syringe for easy use.
  • PIP spray is used in xerostomia patients to prevent PIP from sticking to mucosa.
  • PIP sequence:
    • Dry denture surface.
    • Brush a thin, even layer of PIP onto the bearing surface.
    • Seat the denture with pressure in the first molar region.
    • Remove immediately.
    • Inspect and adjust bearing surface as necessary.
  • PIP pattern indicating torus or high-pressure areas: severe pressure on the portion of the denture that overlies the torus.
  • Adjustment is performed with an acrylic bur; brush marks should be largely obliterated and posterior palatal seal bead visible after finishing.
  • Mandibular denture PIP: use smooth, even brush strokes; avoid wiping off PIP in undercut areas; pay particular attention to the mylohyoid ridge region.
  • Areas of excessive tissue pressure on labial/buccal slopes are adjusted with an acrylic bur until brush marks are obliterated and tissue displacement is minimized.

Denture Placement Sequence (Clinical Remount & Occlusal Equilibration)

  • Steps include:
    • Adjust denture base and borders.
    • Remount in centric relation (CR).
    • Optional protrusive record.
    • Equilibrate in lateral excursion.
    • Provide patient education.
    • 24-hour follow-up.
  • Additional steps for border verification and esthetics: temper wax, apply disclosing wax to border, insert, and mold borders to verify length; use disclosing wax to check border length.
  • Border adjustments: reapply border mold and adjust until areas of overextension are eliminated.
  • Common overextended observations: flanges too thick or too long.
  • The Clinical Remount corrects for errors in the centric relation record; the aim is to ensure the remount more accurately seats the denture.
  • Technique note: seat the posterior palatal seal firmly; have the patient bite down on two cotton rolls for 5 minutes5\ \text{minutes}.

Anterior Setup for Immediate Dentures (Clinical Application)

  • Question: should we duplicate natural tooth positions? Natural esthetics can be appealing, but duplication may not be esthetic; apply complete denture guidelines to achieve optimal esthetics.
  • Anterior tooth selection uses remaining teeth as guide for shade and mold; rely on pre-extraction records.
  • Anterior tooth selection model involves form, size, and shade:
    • Form: square, tapering, or ovoid.
    • Size: Anterior 6 width; Central width; Central length.
  • Pre-extraction records include magnified photographs.
  • If duplication of natural dentition is desired: remove stone teeth alternately and set denture teeth following adjacent stone teeth for incisal edge position and MD & BL angulations.
  • If natural dentition is not esthetic: reestablish incisal edge position, dental midline, and esthetically ideal tooth alignment following complete denture guidelines; cut away stone teeth and set on one side first, then complete the other side.
  • Flared teeth distort arch form; use available edentulous space to provide esthetic wax try-in; if no space is available, discuss wax-try-in alternatives.
  • For supraerupted teeth, use a marker to assess and reestablish proper incisal edge position; for severely worn teeth, build up incisal edge with composite for evaluation.
  • Excessive vertical overlaps (deep bite): verify maxillary incisal edge position is correct and esthetic; lower anterior supraeruption is corrected by marking a reasonable incisal position on the stone teeth; set up according to complete denture guidelines; anterior denture teeth should have no occlusal contact in centric.

Posterior Tooth Arrangement for Immediate Dentures

  • Compare anatomic vs. monoplane arrangements.
  • Material choices: acrylic vs. porcelain.
  • Follow anatomic landmarks as references.

Immediate Denture Wax-Up & Festooning

  • Wax-up features: slightly concave polishing surface; avoid bulky anterior flanges; smooth palatal contour for tongue space; concave polishing surface to stabilize tongue and cheek.

Preparatory Steps for Immediate Denture Delivery Appointment

  • Key items: scaling, diagnostic cast, surgical stent, hydrated dentures.
  • Rehydration process: soak for 72 hours72\ \text{hours}; ensure cast contours reflect altered alveolar ridge.

Surgical Stent and Cast Replica Preparation

  • Surgical stent: clear soft acrylic reflecting shape/contour of the alveolar ridge after cast alterations; used during setup of denture teeth.
  • Before or during denture teeth setup, debulk shaded areas of the cast to remove excessive undercuts; wax festooning performed on debulked cast.
  • The mucosal surface of the processed denture represents the altered alveolar ridge; a cast replica is created by placing silicone putty inside the processed denture, then a surgical stent is fabricated by vacuuming an acrylic plate onto the cast replica.
  • Surgical stent: purpose is to guide and confirm surgical alterations (e.g., tuberosity/exostosis reductions).

Delivery of Immediate Dentures: Extraction and Insertion Appointment

  • Scheduling details: OS Monday AM & Tuesday PM; extraction and delivery appointment at 8:00 AM Monday or 1:00 PM Tuesday to allow adequate time for both extractions and ID delivery.
  • Doming procedure is preferably performed before extraction.
  • Completed extraction: use the clear surgical stent before suturing is finalized.
  • Insertion: seating, adjusting, and delivery of the prosthesis; use PIP to check adaptation and identify likely sore areas; evaluate what differentiates this from standard complete denture work.
  • Border length assessment: any indication of wide or long borders requires disclosing wax analysis.
  • Occlusal contacts: aim for reasonably good occlusal contacts; expect gross chairside adjustments; remount may not be performed at this appointment.

Post-Delivery Instructions and Follow-Up

  • Patient instructions at discharge include medication prescriptions, gauze, and cold packs; provide written postoperative instructions (Immediate Complete Denture Clinic syllabus references p. 74–75).
  • Critical 24-hour follow-up: dentures must remain in the mouth for the first 24 hours; only liquids or very soft food for the first 48 hours.
  • The patient should be contacted in the evening; if violated, reassess.
  • 24-hour check: remove and clean denture; make any necessary adjustments (consider tissue conditioner as necessary); denture may be out of the mouth briefly; avoid vigorous mouth rinse; wear denture at night for 5–7 days post-op.
  • 72 hours and 1-week check: clinical remount and occlusal equilibration.

Soft Liners and Relining Strategies for Immediate Dentures

  • Soft liner purpose: improve fit while extraction healing occurs.
  • Space requirement: 1–2 mm space for soft liner.
  • Application: spatulate soft liner on mixing pad after initial mix; working time 7–10 minutes7\text{--}10\ \text{minutes}; trim excess with heated scalpel; replacement every 2–4 weeks2\text{--}4\ \text{weeks}.
  • Highlights: soft relining may be necessary in ID cases.
  • Permanent relining of immediate dentures: wait at least 2 –3 extmonths2\ \text{--} 3\ ext{months} after extraction; ideally 6 extmonths6\ ext{months}.
  • In some settings, relining may be done by a specialty lab (e.g., MAXILLOFACIAL, ECOCK references appear in slides).
  • Insertion of relined dentures: follow the same guidelines as delivering a new denture; use PIP to check adaptation; border adjustments; clinical remount and occlusal equilibration as needed.

Post-Delivery Objectives and Review

  • Learning objectives include: reproducing existing esthetics in an immediate denture; what to prepare at delivery; scenarios for setup; purpose of surgical stents; goals of occlusal adjustment; important post-delivery instructions; timing of clinical remounts; when to consider soft vs hard relining; precautions during 24-hour check; and hard relining procedures.
  • Final review resources: learning objectives and recommended readings listed at the end of the module (Immediate Complete Denture Clinic Syllabus pp. 51–94; Complete Denture Clinical Syllabus pp. 49–58).

Illustrative Outcomes and Troubleshooting Notes

  • The goal of CR remounts and border adjustments is reproducible centric relation with stable borders to minimize sore spots and movement during closures.
  • Be vigilant for signs of tissue irritation, ulceration, frenum irritation, and posterior palatal seal issues; manage with disclosing wax, acrylic burs, and PIP.
  • When ulcers or mucosal lesions occur, document with PIP patterns; adjust accordingly and recheck at 24 hours.
  • Communication with patient: emphasize 24-hour check, soft diet window, and follow-up cadence; ensure patient understands post-delivery expectations and signs of potential problems.

References and Further Reading

  • Immediate Dentures clinic syllabus references: pp. 51–94 for detailed procedures, and Complete Denture Clinical Syllabus pp. 49–58 for foundational guidelines.
  • Additional topics include: fabrication of face-bow remount jig, remount cast technique, PIP usage and interpretation, border management, centric relation recording and remounting, occlusal equilibration (lingualized and monoplane schemes), and postoperative care.

Quick Reference Numbers and Timings

  • Border and border plastic handling: 24 hours24\ \text{hours} pre-insertion; 72 hours72\ \text{hours} soaking before delivery; border checks with disclosing wax; 24-hour follow-up schedule.
  • CR remount and equilibration: use CR as baseline; if CR is correct, minimal adjustment; otherwise adjust and remount.
  • Provisional and permanent relining intervals: soft relining 2–4 weeks2\text{--}4\ \text{weeks}; permanent relining after 2–3 months2\text{--}3\ \text{months}, ideally 6 months6\ \text{months}.
  • Compound material heating for posterior occlusal surfaces: 105ext∘105^ ext{\circ}C (approximate value for compound melting).
  • Occlusal adjustment sessions: follow with 24-hour and 72-hour follow-ups, plus 1-week check.
  • Post-delivery instruction durations: first 24 hours critical; soft diet for first 48 hours; night wear for 5–7 days post-op.