One-Step In-Office Immediate Dentures

INTRODUCTION
This article continues the introduction of an innovative technique to fabricate complete dentures in one visit (in about one hour), without the need for a dental lab. In my previous article in Dentistry Today,¹ I discussed the overview of the complete denture technique and how it is used for full dentures for the currently edentulous patient.¹ It is a technique that is intuitive and easy to learn, efficient and profitable for the dentist, and economical for the patient. You, as the dental practitioner, will be able to increase your patient base and income by capturing a larger segment of the dental patient market.
Another very important use for the Larell One Step Denture is as an immediate denture. The principles of complete dentures for the edentulous are easily adapted to the fabrication and placement of immediate dentures with the Larell technique. Immediate dentures serve many purposes, the most important of which is to be able to provide denture replacements for patients without having them be without teeth for any length of time. The classic technique for immediate dentures is to remove the posterior teeth first, perform necessary alveoloplasty, wait for healing, and then construct the denture that is delivered to the patient when the anterior teeth are removed. While this is still a widely used technique for immediate denture fabrication, there are drawbacks. Patients often present in pain and are seeking treatment without delay. The classic technique does cause time delay and often complicates treatment when dealing with the time span between the extractions, healing, and denture fabrication. Also, as most practitioners can attest, immediate dentures often do not fit upon placement. They are made from approximations of what the ridge will look like postextraction, many times not correct, leaving dentures that either cannot be placed because they are too small, or much too large due to incorrect estimation of the postextraction and alveoplasty ridge.
The technique protocol, as described herein, eliminates these problems and allows for instant fabrication with assured fit. This allows shorter treatment times and better fit of the denture, resulting in fewer postplacement problems and adjustments. Like all immediate dentures, there will be the need for a relining procedure due to shrinkage of the alveolar bone. What we are seeing is less shrinkage during the first 6 months due to the more accurate fit, and more comfort for the patient.

Clinical Technique
After diagnosis and treatment planning, the patient can have the dentures made in one visit. As with any denture, large undercuts, exostoses, or tori must be taken into consideration and removed prior to making the denture. The general health of the patient, the ability of the dentist to remove the teeth and perform the alveoloplasty, and the extent of the surgery, are all considerations for the practitioner.

The first step is to remove the teeth and do the alveoplasty, achieving smooth ridges that have been reduced in height and width if necessary. Any tori, exostoses, or undercuts will need to be removed. After the sutures have been placed and hemostasis has been achieved, an alginate impression is taken (a VPS alginate substitute may be used such as AlgiNot [Kerr]; Silginat [Kettenbach LP]; StatusBlue [DMG America]; COUNTER-FIT [CLINICIAN’S CHOICE]; Position Penta Quick [3M ESPE]; to name a few) of the edentulous ridge and immediately poured in quick setting stone (Snap Stone [Whip Mix]). The Larell denture template is then fit to the model in the same fashion as for the complete denture technique. The tooth side of the template is placed over the ridge to see that the teeth are over the ridge. It is then placed on the model in the standard fashion to determine general fit (palate, tuberosity, flanges, etc). As with the standard Larell technique, the flanges are trimmed to allow 2 mm to 3 mm between the height of the flanges and the height of the vestibular fold, to allow sufficient room for the reline material.
As an alternate procedure, the impression and model can be made from the pre-extraction ridge and the teeth, and then a proper alveoplasty can be done on the model. This is applicable when the doctor, who will be doing the extractions and bone trimming, is the same doctor fabricating the denture. The reasoning for this is that the doctor will be able to determine ahead of time the amount of alveoplasty to be done and complete it to his/her satisfaction, and the closest fit of the preformed template.
At this point, whichever technique has been chosen, the teeth are removed and the alveoplasty completed. The denture is now ready to be fitted and completed. The template is tried-in the mouth for fit, flange extension, and tooth show and lip support, just as with the standard Larell technique. The reline material (Flexacryl [Lang Dental]) is placed into the denture. The reline process is completed in the standard Larell technique fashion and the denture is finished and polished with the same process any denture.
The following case reports demonstrate the versatility of the Larell One Step denture. The first case is a classic immediate denture case. The second is an example of a case that shows the modifications that can be done to ensure the proper fit of the denture.

CASE REPORTS
Case 1
Diagnosis and Treatment Planning—A 73-year-old female presented for evaluation for immediate dentures. The dental history is one of intermittent tooth loss with current symptoms of pain and inability to function with the remaining teeth. Due to economic circumstances, a maxillary immediate denture was planned. The mandible would be addressed at a later date. The patient had 4 teeth remaining in the maxilla (Figure 1). The remaining lower 6 anterior teeth were to be retained for the present.

Clinical Protocol
It was appropriate to smooth the cusps of the lower canines to level the occlusion as best as possible to accommodate the upper denture (Figure 1). The alginate impression was taken of the upper jaw, the teeth removed on the model, and the alveoplasty areas were also smoothed to the final post ridge position.

Figure 1. Case 1: Patient pre-extraction dentition.	Figure 2. Postsurgical ridge.
Figure 3. Reline material being placed into adapted denture template.	Figure 4. Relined immediate denture in place.

Local anesthesia was administered, and the teeth were removed and the preplanned alveoplasty completed (Figure 2). After allowing for hemostasis, the appropriate sized denture template was chosen by placing the template upside down over the model of the post surgical ridge. To properly prepare this template, the frenum and other muscle attachments were relieved. The template was tried in the mouth and the flanges were reduced, leaving a 2- to 3-mm distance between the height of the flange and the height of the vestibular fold. The template flanges were checked to ensure that approximately one mm of space between the flange and the ridge was available to accommodate the reline material. The template was then relined using reline material (Flexacryl Hard [Lang Dental]) (Figure 3). With either reline process, as the ridge heals, the denture will need a reline (like any other immediate denture technique) due to ridge resorption.
Next, the denture template was border molded in the standard fashion, removed from the mouth, and then immersed in cold water. After 5 minutes, the acrylic was set and excess material removed from the border molded areas. Next, a rough finish was completed with grinding stones or barrel burs. The template was then ready for the post dam placement by mixing and hand placing reline material to the post dam area. It is allowed to set almost completely before placing in the mouth to prevent too much displacement of the material. After about 2 minutes, the template was removed and ready to finish. The mucosal surface of the template, as with the standard Larell technique, was checked with a pressure indicating paste (P.I.P. Paste [Henry Schein]). This is done a minimum of 3 times to ensure there are no high spots. Articulating paper was used to check the occlusion, making certain that a balanced occlusion had been obtained. This is not difficult as the monoplane teeth are easily balanced whether to an opposing Larell denture or natural dentition. The denture was then finished and polished in the standard fashion before delivery to the patient (Figure 4).

Case 2
Diagnosis and Treatment Planning—A 37-year-old male presented with pain in several areas in the mouth. Radiographs were taken (Figure 5) and consultation was done. The treatment plan would include removal of the remaining upper teeth, placing an immediate upper denture, and removing any hopeless teeth from the lower arch. (Most of the mandibular teeth were to be retained, with necessary restorations being done at a later date.) Since the patient was in pain, the Larell immediate technique was chosen because it would allow us to complete the extractions, alveoplasty and denture placement for the maxilla the following day.

Clinical Protocol
In this case study, on the initial model, the teeth were removed and the model was trimmed to the shape of the post extraction ridge. The Larell template was formed to the shape of the ridge and flanges reduced to allow the proper dimension for the reline material.

Figure 5. Case 2: Pretreatment radiographs.	Figure 6. Postextractions and alveoloplasty.
Figure 7. Unmodified template in place, showing modifications needed.	Figure 8. A diamond disc was used to create a notch for segmental movement.
Figure 9. Template modification was done to close open bite.	Figure 10. Palatal modification was needed to bring teeth over the ridge.
Figure 11. Notches were then filled in at the time of the template reline.	Figure 12. Final relined immediate denture (tissue side view).
Figure 13. Final relined immediate (palatal view).	Figure 14. The completed immediate denture.

Following the surgery (Figure 6), the template was tried-in the mouth. While the template fit well and the flanges and palate were properly adjusted, it was noted that there was an anterior open bite in the occlusion with the natural lower dentition, and, in addition, the posterior teeth were lateral to their ideal position (Figure 7). The template is easily modified for this situation. Distal to the canine teeth, a notch (approximately 2.0 mm deep; the amount of movement needed for the closure of the open bite) was placed with a diamond disc (Meisinger USA, double sided disc, Patterson Dental No. 918-220) (Figure 8). The notch was made slightly wider at the occlusal surface than the base of the denture tooth (Figures 8 and 9), allowing rotation of the segment as it is moved. The template was then immersed in boiling water for 30 seconds to become malleable, and the segment was then moved the desired amount. This can be repeated multiple times, if required, as the material has no memory and can be softened multiple times without complication (Figure 9). It was also noted that the patient had a very high palatal vault, in addition to the posterior teeth being lateral to the natural lower dentition. A central palatal notch was made into the template so that the segments could be brought medially when the template was heated (Figure 10).
Once these modifications were completed, the template was ready for reline. This was accomplished with the typical Larell reline technique. The notches were filled in (Figure 11) and the palatal notch was covered with a barrier material such as tape. This coverage will prevent excess reline material from extruding onto the palate, making finishing more efficient. The palate was covered to prevent seepage of the reline material. Once relined, the template was finished with standard Larell technique, a post dam was placed, and the final finish/polish was completed (Figures 12 and 13). The palatal surface was checked with P.I.P. Paste and the occlusion was adjusted using articulating paper. The final result was an immediate denture that fit well, had good occlusion, and was aesthetically pleasing (Figure 14). The entire denture procedure was accomplished in one 35-minute visit exclusive of the time to remove the teeth and smooth the alveolar bone. The surgery was accomplished under conscious sedation.

DISCUSSION
The Larell One Step Denture is ideally suited for immediate dentures whether opposing a denture or natural dentition. This technique allows for the teeth to be removed and a denture placed without the delay usually required for laboratory work. Excellent fit can be achieved with the easily modified thermoplastic templates. Whether the immediate is made opposing a denture or natural dentition, as in our case study, the occlusion can be adapted and adjusted easily. The close fit of the template prior to the reline step allows for a uniform reline layer with an exact fit to the postextraction ridge. The functional border molding allows for the necessary and proper relief of muscle attachments near the ridge.² This will be more comfortable for the patient with a smoother post placement period, allow for quicker more complete function due to the comfort of the fit, and will minimize the resorption of the alveolar ridge throughout time due to the fit and occlusion. The positioning of the teeth over the ridge allows for better mastication while still providing the necessary retention and support.³
As with any immediate denture, the resorption of the alveolar ridge postsurgery will necessitate another reline approximately 6 months following the placement of the denture. The same Larell template (placed at the time of the extractions) can be used by removing one to 2 mm of reline material, and repeating the process. The occlusion will have been set and the denture can then easily be relined.
The second case study presented emphasizes 2 key points. The first is that the occlusal surfaces can easily be modified, as was seen in the closure of the open bite. If the desired movement is one mm or less, this can be accomplished just by immersing the template in boiling water for 30 seconds and then moving the teeth by hand, usually done on the model. If an entire segment needs to be repositioned, it can be moved in any direction to create the desired occlusion by placing notches to allow for the movement of the template. The second key point is that the template base can also be adjusted for the unique aspects of the patient’s ridge. The integrity of the template is not disrupted as long as the cuts or notches do not completely separate sections of the template. The strength of the denture will come from the reline material and, since the template bonds with the reline material, there will be no movement of the segments after the reline. It is important to remember that all modifications and adjustments of the form of the template must be accomplished prior to the reline process as once the template is relined no more movement is possible. The monoplane occlusion of the Larell dentures allows for a balanced occlusion to be obtained, thus maintaining the best retention and support possible.⁴
Though we strive for a smooth, even postsurgical ridge, this cannot always be achieved. If there is an undercut, or other area requiring softer material, the soft reline can be used in conjunction with the hard reline material, both in the same template. Whether it is for support or retention, the soft and hard materials provide the comfort and results required by the patient.

CLOSING COMMENTS
It is the goal of the doctor to create a denture that meets the prosthodontic imperatives of fit, form, and function. The Larell One Step Denture offers a method to meet these requirements and satisfy these imperatives. Able to be used for 99% of all denture patients, the Larell denture offers a technique that provides a cost-effective denture for the patient and a profitable process for the practitioner because of its efficiency of time, no laboratory expense, and precise fit. The results are comparable to published studies of denture satisfaction and success.^5,6
The next article in this series will demonstrate how the Larell One Step Denture is used in combination with dental implants to provide a cost effective and stable implant retained denture.

Acknowledgement
The author wishes to thank Dr. Steven B. Alouf for the case studies and photos shown in this article.

References

1. Wallace LN. An innovative one-step approach to full dentures. Dent Today. 2012;31:88-91.
2. Stromberg WR, Hickey JC. Comparison of physiologically and manually formed denture bases. J Prosthet Dent. 1965;15:213-230.
3. Kapur KK, Soman S. The effect of denture factors on masticatory performance: Part III. The location of the food platforms. J Prosthet Dent. 1965;15:451-463.
4. Jones PM. The monoplane occlusion for complete dentures. J Am Dent Assoc. 1972;85:94-100.
5. Diehl RL, Foerster U, Sposetti VJ, et al. Factors associated with successful denture therapy. J Prosthodont. 1996;5:84-90.
6. Alouf SB, Miller S. Virginia Department of Health denture project, patient satisfaction survey (unpublished study, August 2011).

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 CEO and major shareholder in Larell Dentures, Inc.