72

DENTISTRYTODAY.COM • AUGUST 2013

INTRODUCTION This article continues the introduction ofan innovative technique to fabricate com-plete dentures in one visit (in about onehour), without the need for a dental lab. Inmy previous article in Dentistry Today,1 Idiscussed the overview of the completedenture technique and how it is used forfull dentures for the currently edentulouspatient.1 It is a technique that is intuitiveand easy to learn, efficient and profitablefor the dentist, and economical for thepatient. You, as the dental practitioner, willbe able to increase your patient base andincome by capturing a larger segment ofthe dental patient market.

Another very important use for theLarell One Step Denture is as an immediatedenture. The principles of complete den-tures for the edentulous are easily adaptedto the fabrication and placement of imme-diate dentures with the Larell technique.Immediate dentures serve many purposes,the most important of which is to be able toprovide denture replacements for patientswithout having them be without teeth forany length of time. The classic techniquefor immediate dentures is to remove theposterior teeth first, perform necessaryalveoloplasty, wait for healing, and thenconstruct the denture that is delivered tothe patient when the anterior teeth areremoved. While this is still a widely usedtechnique for immediate denture fabrica-tion, there are drawbacks. Patients oftenpresent in pain and are seeking treatmentwithout delay. The classic technique doescause time delay and often complicatestreatment when dealing with the time spanbetween the extractions, healing, and den-ture fabrication. Also, as most practitionerscan attest, immediate dentures often do notfit upon placement. They are made fromapproximations of what the ridge will looklike postextraction, many times not correct,leaving dentures that either cannot beplaced because they are too small, or muchtoo large due to incorrect estimation of thepostextraction and alveoplasty ridge.

The technique protocol, as describedherein, eliminates these problems and al -lows for instant fabrication with assured

fit. This allows shorter treatment times andbetter fit of the denture, resulting in fewerpostplacement problems and adjustments.Like all immediate dentures, there will bethe need for a relining procedure due toshrinkage of the alveolar bone. What weare seeing is less shrinkage during the first6 months due to the more accurate fit, andmore comfort for the patient.

Clinical TechniqueAfter diagnosis and treatment planning,the patient can have the dentures made inone visit. As with any denture, large under-cuts, exostoses, or tori must be taken intoconsideration and removed prior to makingthe denture. The general health of thepatient, the ability of the dentist to removethe teeth and perform the alveoloplasty,and the extent of the surgery, are all consid-erations for the practitioner.

The first step is to remove the teeth anddo the alveoplasty, achieving smooth ridgesthat have been reduced in height and widthif necessary. Any tori, exostoses, or under-cuts will need to be removed. After the

sutures have been placed and hemostasishas been achieved, an alginate impressionis taken (a VPS alginate substitute may beused such as AlgiNot [Kerr]; Silginat [Ket -tenbach LP]; StatusBlue [DMG America];COUNTER-FIT [CLINICIAN’S CHOICE];Position Penta Quick [3M ESPE]; to name afew) of the edentulous ridge and immedi-ately poured in quick setting stone (SnapStone [Whip Mix]). The Larell denture tem-plate is then fit to the model in the samefashion as for the complete denture tech-nique. The tooth side of the template isplaced over the ridge to see that the teethare over the ridge. It is then placed on themodel in the standard fashion to determinegeneral fit (palate, tuberosity, flanges, etc).As with the standard Larell technique, theflanges are trimmed to allow 2 mm to 3 mmbetween the height of the flanges and theheight of the vestibular fold, to allow suffi-cient room for the reline material.

As an alternate procedure, the impres-sion and model can be made from the pre-extraction ridge and the teeth, and then aproper alveoplasty can be done on the

Lawrence N.Wallace, DDS

One-Step In-Office Immediate Dentures

Figure 1. Case 1: Patient pre-extraction dentition. Figure 2. Postsurgical ridge.

Figure 3. Reline material being placed into adapteddenture template.

Figure 4. Relined immediate denture in place.

PROSTHODONTICS

73

AUGUST 2013 • DENTISTRYTODAY.COM

model. This is applicable when the doctor,who will be doing the extractions and bonetrimming, is the same doctor fabricatingthe denture. The reasoning for this is thatthe doctor will be able to determine aheadof time the amount of alveoplasty to bedone and complete it to his/her satisfac-tion, and the closest fit of the preformedtemplate.

At this point, whichever technique hasbeen chosen, the teeth are removed and thealveoplasty completed. The denture is nowready to be fitted and completed. The tem-plate is tried-in the mouth for fit, flangeextension, and tooth show and lip support,just as with the standard Larell technique.The reline material (Flexacryl [Lang Den -tal]) is placed into the denture. The relineprocess is completed in the standard Larelltechnique fashion and the denture is fin-ished and polished with the same pro cessany denture.

The following case reports demonstratethe versatility of the Larell One Step denture.The first case is a classic immediate denturecase. The second is an example of a case thatshows the modifications that can be done toensure the proper fit of the denture.

CASE REPORTS Case 1

Diagnosis and Treatment Planning—A 73-year-old female presented for evaluation forimmediate dentures. The dental history isone of intermittent tooth loss with currentsymptoms of pain and inability to functionwith the remaining teeth. Due to economiccircumstances, a maxillary immediate den-ture was planned. The mandible would beaddressed at a later date. The patient had 4teeth remaining in the maxilla (Figure 1).The remaining lower 6 anterior teeth wereto be retained for the present.

Clinical Protocol It was appropriate to smooth the cusps ofthe lower canines to level the occlusion asbest as possible to accommodate the upperdenture (Figure 1). The alginate impressionwas taken of the upper jaw, the teethremoved on the model, and the alveoplastyareas were also smoothed to the final postridge position.

Local anesthesia was administered, andthe teeth were removed and the preplannedalveoplasty completed (Figure 2). After al -lowing for hemostasis, the appropriatesized denture template was chosen by plac-ing the template upside down over themodel of the post surgical ridge. To proper-ly prepare this template, the frenum andother muscle attachments were re lieved.

The template was tried in the mouth andthe flanges were reduced, leaving a 2- to 3-mm distance between the height of theflange and the height of the vestibular fold.The template flanges were checked to en -sure that approximately one mm of spacebetween the flange and the ridge was avail-able to accommodate the reline material.The template was then re lined using relinematerial (Flexacryl Hard [Lang Dental])(Figure 3). With either reline process, as theridge heals, the denture will need a reline(like any other immediate denture tech-nique) due to ridge resorption.

Next, the denture template was bordermolded in the standard fashion, removedfrom the mouth, and then immersed in

cold water. After 5 minutes, the acrylic wasset and ex cess material removed from theborder molded areas. Next, a rough finishwas completed with grinding stones or bar-rel burs. The template was then ready forthe post dam placement by mixing andhand placing reline material to the postdam area. It is allowed to set almost com-pletely before placing in the mouth to pre-vent too much displacement of the materi-al. After about 2 minutes, the template wasremoved and ready to finish. The mucosalsurface of the template, as with the stan-dard Larell technique, was checked with apressure indicating paste (P.I.P. Paste [HenrySchein]). This is done a minimum of 3 timesto ensure there are no high spots. Articu -

Figure 5. Case 2: Pretreatment radiographs.

Figure 6. Postextractions and alveoloplasty. Figure 7. Unmodified template in place, showingmodifications needed.

Figure 8. A diamond disc was used to create anotch for segmental movement.

Figure 9. Template modification was done to closeopen bite.

PROSTHODONTICS74

lating paper was used to check theocclusion, making certain that a bal-anced occlusion had been ob tained.This is not difficult as the monoplaneteeth are easily balanced whether toan opposing Larell denture or naturaldentition. The denture was then fin-ished and polished in the standardfashion before delivery to the patient(Figure 4).

Case 2 Diagnosis and Treatment Planning—A37-year-old male presented with painin several areas in the mouth. Radio -graphs were taken (Figure 5) and con-sultation was done. The treatmentplan would include removal of theremaining upper teeth, placing animmediate upper denture, and remov-ing any hopeless teeth from the lowerarch. (Most of the mandibular teethwere to be retained, with necessaryrestorations being done at a laterdate.) Since the patient was in pain,the Larell immediate technique waschosen because it would allow us tocomplete the extractions, alveoplastyand denture placement for the maxil-la the following day.

Clinical ProtocolIn this case study, on the initial model,the teeth were removed and the modelwas trimmed to the shape of the postextraction ridge. The Larell templatewas formed to the shape of the ridgeand flanges reduced to allow the prop-er dimension for the reline material.

Following the surgery (Figure 6),the template was tried-in the mouth.While the template fit well and theflanges and palate were properlyadjusted, it was noted that there wasan anterior open bite in the occlusionwith the natural lower dentition, and,in addition, the posterior teeth werelateral to their ideal position (Figure7). The template is easily modified forthis situation. Distal to the canineteeth, a notch (approximately 2.0 mmdeep; the amount of movement need-ed for the closure of the open bite) wasplaced with a diamond disc (MeisingerUSA, double sided disc, PattersonDental No. 918-220) (Figure 8). Thenotch was made slightly wider at theocclusal surface than the base of thedenture tooth (Figures 8 and 9), allow-ing rotation of the segment as it ismoved. The template was then im -

mersed in boiling water for 30 secondsto become malleable, and the segmentwas then moved the desired amount.This can be repeated multiple times, ifrequired, as the material has no mem-ory and can be softened multipletimes without complication (Fig ure9). It was also noted that the patienthad a very high palatal vault, in addi-tion to the posterior teeth being lateralto the natural lower dentition. A cen-tral palatal notch was made into thetemplate so that the segments couldbe brought medially when the tem-plate was heated (Figure 10).

Once these modifications werecompleted, the template was ready forreline. This was accomplished withthe typical Larell reline technique.The notches were filled in (Figure 11)and the palatal notch was coveredwith a barrier material such as tape.This coverage will prevent excessreline material from extruding ontothe palate, making finishing more effi-cient. The palate was covered to pre-vent seepage of the reline material.Once relined, the template was fin-ished with standard Larell technique,a post dam was placed, and the finalfinish/polish was completed (Figures12 and 13). The palatal surface waschecked with P.I.P. Paste and the occlu-sion was adjusted using articulatingpaper. The final result was an immedi-ate denture that fit well, had goodocclusion, and was aesthetically pleas-ing (Figure 14). The entire denture pro-cedure was accomplished in one 35-minute visit exclusive of the time toremove the teeth and smooth the alve-olar bone. The surgery was accom-plished under conscious sedation.

DISCUSSION The Larell One Step Denture is ideallysuited for immediate dentures whetheropposing a denture or natural denti-tion. This technique allows for theteeth to be removed and a dentureplaced without the delay usuallyrequired for laboratory work. Excel -lent fit can be achieved with the easilymodified thermoplastic templates.Whether the immediate is madeopposing a denture or natural denti-tion, as in our case study, the occlu-sion can be adapted and adjusted easi-ly. The close fit of the template priorto the reline step allows for a uniformreline layer with an exact fit to the

postextraction ridge. The functionalborder molding allows for the neces-sary and proper relief of muscleattachments near the ridge.2 This willbe more comfortable for the patientwith a smoother post placement peri-od, allow for quicker more completefunction due to the comfort of the fit,and will minimize the resorption ofthe alveolar ridge throughout timedue to the fit and occlusion. The posi-tioning of the teeth over the ridgeallows for better mastication whilestill providing the necessary retentionand support.3

As with any immediate denture,the resorption of the alveolar ridgepostsurgery will necessitate anotherreline approximately 6 months follow-ing the placement of the denture. Thesame Larell template (placed at thetime of the extractions) can be used byremoving one to 2 mm of reline mate-rial, and repeating the process. Theocclusion will have been set and thedenture can then easily be relined.

The second case study presentedemphasizes 2 key points. The first isthat the occlusal surfaces can easily bemodified, as was seen in the closure ofthe open bite. If the desired move-ment is one mm or less, this can beaccomplished just by immersing thetemplate in boiling water for 30 sec-onds and then moving the teeth byhand, usually done on the model. If anentire segment needs to be reposi-tioned, it can be moved in any direc-tion to create the desired occlusion byplacing notches to allow for the move-ment of the template. The second keypoint is that the template base can

also be adjusted for the unique aspectsof the patient’s ridge. The integrity ofthe template is not disrupted as longas the cuts or notches do not com-pletely separate sections of the tem-plate. The strength of the denture willcome from the reline material and,since the template bonds with thereline material, there will be no move-ment of the segments after the reline.It is important to remember that allmodifications and adjustments of theform of the template must be accom-plished prior to the reline process asonce the template is relined no moremovement is possible. The mono-plane occlusion of the Larell denturesallows for a balanced occlusion to beobtained, thus maintaining the bestretention and support possible.4

Though we strive for a smooth,even postsurgical ridge, this cannotalways be achieved. If there is an under-cut, or other area requiring softer mate-rial, the soft reline can be used in con-junction with the hard reline material,both in the same template. Whether itis for support or retention, the soft andhard materials provide the comfort andresults required by the patient.

DENTISTRYTODAY.COM • AUGUST 2013

Figure 10. Palatal modification was neededto bring teeth over the ridge.

Figure 11. Notches were then filled in at thetime of the template reline.

Figure 12. Final relined immediate denture(tissue side view).

Figure 13. Final relined immediate (palatalview).

Figure 14. The completed immediate denture.

Though we strive for a smooth, even postsurgical ridge, this cannot always be achieved.

CLOSING COMMENTSIt is the goal of the doctor tocreate a denture that meetsthe prosthodontic impera-tives of fit, form, and func-tion. The Larell One StepDenture offers a method tomeet these requirements andsatisfy these imperatives.Able to be used for 99% of alldenture patients, the Larelldenture offers a techniquethat provides a cost-effectivedenture for the patient and aprofitable process for thepractitioner because of itsefficiency of time, no labora-tory expense, and precise fit.The results are comparable topublished studies of denturesatisfaction and success.5,6

The next article in thisseries will demonstrate howthe Larell One Step Dentureis used in combination withdental implants to provide acost effective and stable im -plant retained denture.�

Acknowledgement The author wishes to thankDr. Steven B. Alouf for the casestudies and photos shown inthis article.

References1. Wallace LN. An innovative one-step

approach to full dentures. DentToday. 2012;31:88-91.

2. Stromberg WR, Hickey JC. Com -parison of physiologically and manu-ally formed denture bases. J ProsthetDent. 1965;15:213-230.

3. Kapur KK, Soman S. The effect ofden ture factors on masticatory per-formance: Part III. The location of thefood platforms. J Prosthet Dent.1965;15:451-463.

4. Jones PM. The monoplane occlusionfor complete dentures. J Am DentAssoc. 1972;85:94-100.

5. Diehl RL, Foerster U, Sposetti VJ, etal. Factors associated with success-ful denture therapy. J Prosthodont.1996;5:84-90.

6. Alouf SB, Miller S. Virginia De part -ment of Health denture project, pa -tient satisfaction survey (unpub-lished study, August 2011).

Dr. Wallace is a board-certified oraland maxillofacial surgeon with 25years of private practice in theChicago area. He is president ofLarell Surgical Consultants, con-sulting in dentistry and oral andmaxillofacial surgery to major med-ical insurance companies. He is thedeveloper and founder of The LarellOne Step Denture. He works withphilanthropic organizations and pri-vate practitioners to adopt the onestep denture system. He can bereached at (831) 659-9300 orlarry@larell.com.

Disclosure: Dr. Wallace is the CEOand major shareholder in LarellDentures, Inc.