An Innovative One-Step Approach to Full Dentures

Figure 1. Preoperative upper and lower edentulous arches.

Figures 2 and 3. Upper template adapted to model.

Figure 4. Upper template in the mouth. Note the 1 to 2 mm of space between the template and tissue.

Figure 5. Reline material being added to upper template.

Figure 6. Upper denture.

Figure 7. Lower template adapted to model.

Figure 8. Completed and delivered dentures.

INTRODUCTION
Dentures still play a significant role in dentistry. There are currently more than 33 million edentulous people in the United States.¹ This translates into a $7 billion dollar a year market in complete denture prosthetics.² By and large, dentures have been made with the same techniques for the past hundred years. Though we have made great progress since George Washington’s famous set of wood and ivory dentures, current techniques still typically entail multiple visits, multiple laboratory steps, and often significant cost, thus making the process of obtaining dentures very challenging for many segments of our population.
In 2000, the Surgeon General of the United States published a significant report entitled Oral Health in America: A Report of the Surgeon General.³ In this report, 2 major barriers were identified for the United States population seeking dental care: access to care and cost of care.³ Now, 12 years later, these issues are not only still present, but they present an even greater challenge than before.
This article will describe a new technique to enable the dentist to fabricate complete dentures in one visit, in about an hour. They will be able to be done at a much lower cost to the patient and with a higher profit margin for the dentist than using conventional denture fabrication techniques. The one-step dentures are not meant to replace conventional dentures, but to be an alternative in these difficult economic times.

Background
I am an oral and maxillofacial surgeon and was in private practice for 25 years in the Chicago suburbs. I saw thousands of patients who were, or about to become, edentulous or were missing significant numbers of teeth. The social, psychological, and financial impact on these people was real. Many people were wearing their dentures long past the useful life of the dentures. The reasons were twofold. First, they could not afford new dentures, and second, they were often unable to make the multiple visits necessary to obtain new dentures. These were the very issues described by the Surgeon General in his report³ that I referred to earlier. As my career progressed, attention in dentistry turned to first an emphasis on preventive dentistry, and then on to cosmetic dentistry—dental implants, veneers, etc. Dentures seemed to be left by the wayside, as dental schools were lowering the emphasis on complete dentures, some schools eliminated them from the curriculum, and some made complete dentures an elective. By anecdote, some dental schools are sharing denture patients between students. I have had some dental students tell me that they do not like making dentures because the technique is too cumbersome (and there are not enough cases to learn the techniques very well), takes too long, and the results are not consistent. At the same time, the problem is that the population needing dentures has been increasing, and will continue to increase at least through the year 2020.¹
To address all these issues, I have developed a method for fabricating dentures in one visit, in about an hour, and at a cost one third to one half the cost of conventional dentures. The technique is intuitive and easy to learn. They are not meant to completely replace custom dentures, but instead to be an alternative when access and cost are the central issues. The benefits to the patient are the convenience (one visit instead of 4 or 5) and the economic factor, with the cost being typically less than one-half the cost of conventional dentures. The benefits for the dentist are several as well: an easy-to-learn technique, no lab bill, freeing up of hours of chair time to do more production, lower overhead, and filling empty dental chairs (this will bring in patients who would normally not come in due to the cost and access factors).

CASE REPORT
Complete Dentures
Patient MK is a 32-year-old female who has been edentulous for 7 months and was not wearing dentures due to economic issues. She was working, but barely making ends meet. She felt hopeless, as she could not afford the cost of new dentures, and could not take multiple times off from work for the necessary dental visits to fabricate dentures. She did not socialize due to her lack of teeth. Because she was edentulous, she was unable to consume a healthy diet and was only able to eat soft foods that were high in carbohydrates. There were residual bone spicules and irregularities in the maxilla that needed to be corrected prior to having her dentures fabricated (Figure 1). Her medical history was unremarkable.
The patient was treatment planned to have one-visit upper and lower dentures (Larell One Step Dentures) constructed so there would not be a long healing time following the alveoloplasty. This meant that she would not have to take much time off of work; a plus for her, since finances were a real concern.
The technique, as applied to this patient, is as follows: an alginate impression was taken of the upper and lower jaws, and a quick-set stone model created (Snap Stone [Whip Mix]), taking about 5 minutes. Then, the denture templates, closest to the size of the patient’s arches, were chosen correlating to the stone models; one for the upper, and one for the lower. There are multiple sizes of templates available; each have the teeth in place and are finished on the outer surface, and unfinished on the inner surface. Close approximation of the template to the model is possible due to the characteristics of the template material.
The upper is to be completed first, with the initial task being the choice of a proper template. After selection, the template was heated in boiling water (to make it pliable) and then closely adapted to the model. In this particular case, the alveoloplasty was performed at the time of the denture placement. With the final arch form established, the final fit of the denture would be to the postalveoloplasty position. Next, the palate was checked for fit, and the flanges trimmed to accommodate the muscle attachments and to closely approximate the jaw structure (Figures 2 and 3). The template was then tried-in the mouth (Figure 4). The occlusal plane was checked with a Trubyte Occlusal Plane Plate [DENTSPLY International] for the proper Ala-Tragus plane and for parallelism to the pupillary plane. Lip support and upper incisor tooth show were visually determined. The template was then ready for a functional reline directly in the mouth (Figure 5). Our reline materials of choice are Flexacryl Hard Reline and Flexacryl Soft Reline (Lang Dental). Standard technique was used for a functional reline, with border molding as necessary. When required, additional material can be added to fill voids or add to flange or post dam areas. Finishing was then done and the upper denture, at this point, was nearly complete (Figure 6).
Next, our attention was turned to the lower arch. Similar steps were followed for loose fit of the template to the model (Figure 7), and then it was tried in the mouth. Tooth position was checked for proper occlusion. If the lower teeth need to be moved in a more medial or lateral position, the template is immersed in boiling water for 30 seconds to allow movement as needed. The goal, of course, is to get the teeth directly over the ridge. When heated, the teeth can be moved one to 2 mm to place them over the ridge, the ideal position. Sometimes this means an edge-to-edge bite, or even a slight crossbite. With the teeth being a monoplane design, this is not a significant issue. If none of the templates fit, they can be adapted with notches to achieve the proper fit.
After relining and finishing of the lower template was completed, pressure indicating paste (High Spot Indicating Paste [DUX Dental]) was applied to both the upper and lower tissue-bearing areas to check for even fit of the templates. Final polishing was then done, the occlusion was checked with articulating paper, and the patient was discharged with instructions (Figure 8).
The patient described has improved her diet and has decreased her blood sugar level. She is now taking less medication for her diabetes. Follow-up continues to show healthy mucosal tissue and acceptance of the dentures 3 years post-placement.
When fabricating dentures using this quick technique, we have found the number of adjustments necessary to be minimal (about 10% of the patients) due to the accuracy of the in-the-mouth functional reline.

DISCUSSION
This innovative denture technique using the Larell One Step Denture addresses the major barriers for denture care—access and cost. It is a technique that allows dentures to be fabricated in about an hour, with minimal follow-up adjustments. It is an efficient and cost-effective technique for the dentist that is very convenient for the patient, especially when the patient is in pain. While not a custom denture, it is a custom-comparable denture, providing good fit, function, and aesthetics. Patients have a very high rate of acceptance and few problems postplacement. An easily learned technique, it provides a great addition to the dentist’s armamentarium and treatment options.
From the practice management aspect, these one-step dentures can provide a substantial increase in production. The market is there, currently with 33 million edentulous in the United States and 3 to 4 million more becoming edentulous yearly. The global impact of edentulism is even greater.^4,5 Since any denture has a useful life of about 5 years, including the one-step denture presented here, it is a renewable market as well. By including these dentures into the schedule and fabricating an average of 3 sets per week (a total of about 4 hours per week), one can realize an increase of well more than $100,000 in gross production per year. For doctors experiencing less than full schedules during these economic times, learning and implementing this one-step dentures technique can be a real practice builder.
The case report described in this article was done in the dental office. While this is the most efficient place to fabricate dentures, it certainly is not the only possibility. With a mobile kit, consisting of the materials for office use and additional material for field use, these dentures can be fabricated in settings such as nursing homes, assisted living homes, mobile clinics, etc. We have utilized these dentures in Mission of Mercy philanthropic clinics in several areas, where up to 100 dentures were fabricated in 2 days by 3 dentists for those in need who could not afford medical or dental care. We have also done up to 50 dentures in one-and-a-half day clinics for Remote Area Medical, which provides free medical and dental services for those in need. These patients would not otherwise be able to get dentures as the clinics only run for 2 days, not nearly enough time for conventional dentures.
It is important to understand that not having proper dentition has serious medical implications. There is ample research to demonstrate that the presence of teeth increases nutrition and decreases levels of chronic disease,⁶ which helps to lower overall medical costs.⁷ There is also a direct impact on the quality of life and self-esteem of patients.⁸ These are not incidental issues and may be the best of the benefit to the patient.
If we can raise self-esteem and improve the quality of life for those in need, we will feel better about ourselves and enhance our profession.

CLOSING COMMENTS
In this article, we have discussed a new one-step technique for the efficient and economical fabrication of dentures for the completely edentulous patient. A future article will cover this technique as it relates to immediate dentures, which have their own unique characteristics and procedures.

References

1. 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.
2. Palmer C. Growth in dental spending expected to slow in 2009. ADA News. February 26, 2009. ada.org/news/1103.aspx. Accessed on March 7, 2012.
3. 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.
4. Petersen PE, Yamamoto T. Improving the oral health of older people: the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol. 2005;33:81-92.
5. Kinsella K, Wan H. US Census Bureau, International Population Reports, P95/09-1. An Aging World: 2008. Washington, DC: US Government Printing Office; 2009.
6. Laurin D, Brodeur JM, Leduc N, et al. Nutritional deficiencies and gastrointestinal disorders in the edentulous elderly: a literature review. J Can Dent Assoc. 1992;58:738-740.
7. Preoteasa E, Lonescu E, Băncescu G, et al. Epidemiologic aspects of the edentulous mouth (II). General and local features of the totally edentulous mouth [in Romanian]. Bacteriol Virusol Parazitol Epidemiol. 2005;50(1-2):27-34.
8. Hugo FN, Hilgert JB, de Sousa Mda L, et al. Oral status and its association with general quality of life in older independent-living south-Brazilians. Community Dent Oral Epidemiol. 2009;37:231-240.

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 larry@larell.com.

Disclosure: Dr. Wallace is the founder and CEO of The Larell One Step Denture. He has no financial interest in any of the other companies mentioned in this article and was not compensated for writing this article.