Implant-Retained Dentures in One Visit

INTRODUCTION
The Larell One Step Denture has created a new and innovative design process for making complete dentures in one visit, in about an hour. This, the third in a series of articles for Dentistry Today, demonstrates the use of this novel one-step denture technique in conjunction with dental implants. The first article¹ illustrated the use of Larell One Step Denture in complete dentures for the edentulous mouth. The second article² described their use for immediate denture cases.

The Larell system completely eliminates the need for a commercial laboratory, allowing the clinician to fabricate and deliver functional and aesthetic dentures in a single chairside appointment. It is worth repeating that this process is both highly profitable for the practitioner and very economical for the patient. By reducing the retail cost of dentures and by eliminating the need and costs associated with outside laboratory services, the practice can attract a significantly larger patient base due to the reduced time requirements and economic barriers. Being able to offer complete and immediate dentures to your patients in one visit, in as little as an hour, is an optimal practice builder. This treatment/business concept caters to the needs of a population who wants to access everything faster, more efficiently, and less expensively.

The number of edentulous persons in the United States alone is currently between 37 to 40 million,³ making this one of the most underserved patient populations in dentistry and, until now, difficult to effectively service and to realize profits from, given the many socio-economic barriers. It is the author’s opinion, and of those who have implemented this technique, that the Larell system has the ability to change all this. Access-to-care issues and cost of care continue to be the major factors preventing people from obtaining the oral healthcare they need. This includes dentures.⁴

One-Step Denture with Dental Implants
Because of ridge resorption, and the anatomy and physiology of the mouth, comfortably wearing full dentures (especially lower dentures) can be difficult. With the advent of dental implants to stabilize and retain complete dentures, the approach to denture care has changed dramatically. Since denture usage will continue to increase throughout the next decade,³ the use of dental implants to retain dentures will also increase markedly, with more opportunities available for practice expansion.

A significant feature of the Larell One Step Denture is its ease of use with implants, especially immediate-loaded small diameter implants (SDIs, also called mini dental implants). The dentures and implants are both able to be completed in as little as an hour’s time during a single office visit. A few examples of immediate loading SDIs currently used include those made by OCO Biomedical, Ossotanium, and 3M ESPE (IMTEC), to name a few. The Larell denture is also well suited for use in conjunction with LOCATOR (ZEST Anchors) attachments for immediate denture fabrication and implant placement and loading.

The Larell denture can also be utilized as an interim denture to stabilize and support function during the transitional process of conventional implant treatment with any of the implant manufacturers (such as Straumann USA, Biomet 3i, CAMLOG, and integrated dental systems). Many SDIs or narrow-body implants now allow for immediate loading after placement due to their superb mechanical retention upon placement. With the Larell system, it’s now possible to place 4 immediate-loaded implants in less than an hour, and then to immediately fabricate and attach a new complete set of dentures at the chair with predictable results. Before the introduction of this new Larell technique, dentures needed to be altered after fabrication to accommodate the housings for “pickup” (directly in the mouth); or impressions with analogs were taken and sent to the outside lab team for processing of the housings in the denture base.

With traditional dentures, the hollowing out of an existing or new denture can be done chairside to allow room for the housings. The housings are placed over the abutment (or head) of the implant in the mouth usually with a shim provided to block out the undercuts. Once the denture has been relieved, in order to allow room so that it seats passively without occlusal interference over the implant with housing, it is ready to be completed. This usually requires picking up the housings one by one directly in the mouth; or, all at once by mixing some acrylic or using the various products extruded in a gun cartridge that bond to methyl methacrylate (such as Secure [3M ESPE], or a mixed base and catalyst like the chairside product Reline [GC America]). This can be a trying process and leaves room for error, especially if the practitioner has never attempted it before, or if the patient shifts during the pickup procedure, or if the denture has not been seated properly over the housings. The Larell technique has taken the guesswork out of this procedure because the fitting is done directly in the mouth.

A Quick Refresher on the Larell One Step Denture Technique
The denture templates come in varying sizes with the teeth already in place. The Larell denture has a unique thermoplastic base that, once placed in boiling water for 40 seconds, can be adapted over a pour-up of a preliminary impression. Once the Larell denture has been adapted to the stone model and checked in the mouth for clearances and occlusion, it is ready for a permanent reline. When implants are involved, this reline can now be done directly over the implant housings all in one pickup. The use of Flexacryl (Lang Dental) is recommended for the intraoral relines used in this technique because of its low exothermic reaction and good bonding ability. In addition, Flexacryl finishes extremely well, exhibiting very minimal microporosity. The entire base is created inside the denture and the reline material is used just like impression material would be in a custom tray or denture. There is no need to do the housings individually with the Larell denture, though they can be retrofitted after the denture has been relined.

Figure 1. Implants in place in the mouth.	Figure 2. Quick-setting dental stone (Snap-Stone [Whip Mix]) model with implants.
Figure 3. Larell One Step Denture relined over implants.	Figure 4. Implant housing areas relieved on relined denture.

The following case report describes the dental implant housings being picked up after the denture was relined. For use over SDI housings, the author suggests placing them all in the mouth at one time, ensuring shims are in place for blocking out the undercuts. Once the Flexacryl is at a “peanut butter” consistency, then the denture can be seated in the mouth over the housings and underlying tissue. Have the patient move into occlusion, asking him or her to bite lightly together as the material flows over the tissues and around the implants and sets. Remove the denture once the flexacryl has hardened, and the housings will remain in the denture base along with the entire tissue-bearing surface of the denture. Remove the shims, trim the excess, and then polish the borders. The denture is now completed with a continuous base of material around the housings and tissue-bearing surface and can be delivered to the patient. This chairside procedure can be done immediately following placement of specified immediate loading implants, or following osseointegration of implants. The benefit of this new and exciting technique is the ability to offer implants and the loaded denture all in one visit, significantly reducing costs and time that were once associated with a traditional treatment approach, and opening up the door for a higher percentage of patients who will be willing to accept treatment.

This same procedure can be done easily over LOCATOR attachments with the Larell denture, eliminating the need for analogs and transfer copings. As long as the denture sits passively in the mouth over the implants with the housings attached, then simply follow the steps above to pick up the housings, trim, polish, and deliver the denture to the patient, all chairside. Eliminate any outside lab steps completely by simply picking up the housings directly in the mouth. The process is more accurate, ensures patient satisfaction without the wait, and at the same time, reduces the overall treatment cost.

Finally, the Larell One Step Denture can be utilized transitionally during conventional implant treatment as support for the implants and surrounding tissue. If conventional implants have been used and healing abutments are in place, take an alginate impression and pour a model. Once the model is completed, trim and adapt the Larell denture template (as previously described) to the model and go through the clinical procedures verifying bite, occlusion, and aesthetics. Once these are satisfied, use a chairside soft-liner (such as Mucopren [Kettenbach LP]) or any temporary soft-liner (such as COE-SOFT [GC America] or Visco-Gel [DENTSPLY International]). Place the material in the denture, then seat it and ask the patient to lightly bite until it has fully set. Trim the excess and deliver the denture. The soft-reline material will allow for patient comfort and support, with better retention around the healing abutments and surgical sites. In addition, a soft-reline material will also act as a tissue conditioner. This support will further ensure that no undue forces that could interfere with the implant integration will be placed on the healing abutments. Once the implant integration is completed, and the healing abutments removed, proceed with removing the soft-liner from the denture. Then, go through the process above to complete the denture over the implants or, in the case of a customized denture or fixed prosthesis, proceed to treatment.

CASE REPORT
A patient presented to our office with a broken denture. This implant-retained denture, opposed by natural dentition, had been in place for several years. It had been repaired multiple times and it was now irreparable. A new denture was needed and the request was to have it made immediately, if possible, for personal reasons. The Larell One Step Denture was the appropriate choice to replace this implant-retained denture. For the author, who has had considerable experience in using this technique, it was estimated that the entire case would take about 45 minutes from start to finish. An impression was taken of the lower jaw with implants in place (Figure 1) and poured in a quick-setting dental stone (Snap-Stone [Whip Mix]) (Figure 2). A new Larell One Step Denture, in an appropriate size and shade, was chosen and relined over the implants (Figure 3). (Note: The prosthesis was removed prior to the full polymerization of the hard reline material.) Next, the rough finish step was done, and the areas around the implants were relieved (Figure 4). The housings were then placed over the implants and picked up into the denture with additional hard reline material (Flexacryl) and allowed to harden (Figures 5 and 6). Next, excess material was removed from around the housings, and the tissue surface was then checked with pressure indicating paste and examined for any high spots and/or rough areas (Figure 7). Finally, the denture was then finished/polished and delivered in less than an hour (Figure 8). Although this case demonstrates the pickup of the housings after initial reline of the denture, the pickup can be done during the initial reline procedure.

DISCUSSION
Dental implants, when indicated, have become the standard of care for the restoration of missing teeth. The use of dental implants with overdentures offers much improved retention and stability. Immediate-load implants are often used in combination with dentures. Their simplified armamentarium and ease of placement have made them a viable and popular choice for general practitioners when treating denture patients. The ability to fabricate quality dentures in a single office visit, along with placement of immediate-load SDIs placed at the same time, has become a popular restorative technique with benefits for the patient and the doctor. The patient has the convenience of a single visit that provides stable and functional dentures. The dentist who offers the Larell One Step Denture can offer a great service that is both efficient and profitable.

The Larell One Step Denture can also be used with standard-diameter implants for denture retention. The process is the same as described in the case report above, but done at a later time, after the implants are fully integrated and uncovered (Figure 9). An additional use of the Larell denture template is its use as a provisional for all-on-4 dentures (Clear Choice [Nobel Biocare]). The advantage of this technique is the ability to easily fabricate a screw-retained provisional at the time of implant placement without excessive expense (Figure 10). The process takes 30 to 40 minutes and does not require a lab technician to be present.

Figure 5. Implant housings in place.	Figure 6. Housings picked up into denture.
Figure 7. Pressure indicating paste used on tissue surface.	Figure 8. Final implant-retained denture in place.
Figure 9. LOCATOR attachments (ZEST Anchors) in relined Larell denture.	Figure 10. Larell Template as all-on-4 (Clear Choice [Nobel Biocare]) provisional.

IN SUMMARY
This series of articles in Dentistry Today has described the use of the Larell One Step Denture in various clinical situations to address the needs of patients who need full dentures, immediate dentures, and implant-supported dentures. This novel technique can effectively reduce the fees for these services by eliminating lab costs while significantly increasing profits for the practice, all at a fraction of the time usually required with traditional lab-based fabrication and treatment approaches. Most importantly, patient acceptance and satisfaction are achieved at an optimal level because the clinician can control every step of the process in one efficient visit with fewer potential complications and adjustments.

The demand for dentures is continually rising, with the denture market in the United States currently at $7 to $8 billion per year.⁵ In the new economic situation that many people now find themselves, along with the lack of dental coverage for many of these patients, is impacting many dental offices. This technique offers a significant and positive opportunity for clinicians looking for another way to increase their patient base and income potential, while providing a great patient service at a reasonable cost.

References

1. Wallace LN. An innovative one-step approach to full dentures. Dent Today. 2012;31:88-91.
2. Wallace LN. One-step in-office immediate dentures. Dent Today. 2013;32:72-75.
3. Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020? J Prosthet Dent. 2002;87:5-8.
4. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000:2-3.
5. Palmer C. Growth in dental spending expected to slow in 2009. ADA News. February 26, 2009. ada.org/news/1103.aspx. Accessed April 16, 2014.

Dr. Wallace is a board-certified oral and maxillofacial surgeon with 25 years of private practice in the Chicago area. He is president of Larell Surgical Consultants, consulting in dentistry and oral and maxillofacial surgery to major medical insurance companies. He is the developer and founder of The Larell One Step Denture. He works with philanthropic organizations and private practitioners to adopt the one-step denture system. He can be reached at (831) 659-9300 or via email at larry@larell.com.

Disclosure: Dr. Wallace is the founder and CEO of the Larell One Step Denture.