Dentures

People lose teeth for a variety of reasons and as humans only have two sets of teeth, they often need to be replaced with artificial teeth. Once the primary teeth exfoliate, we only get one chance to keep our permanent teeth healthy. Whether it be due to decay, periodontal disease, trauma, or other various reasons, once teeth are lost they need to be replaced. Those with missing teeth suffer multiple health consequences including, inability to properly chew, affected mental health, and increased reclusive behavior, especially in the elderly¹https://journals.sagepub.com/doi/10.1258/jrsm.2012.120008²https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1741-2358.2005.00059.x³https://journals.sagepub.com/doi/full/10.1177/0706743716632523. It is critical to replace missing teeth with a viable option. Those treatment options include:

1. Implants
2. Fixed Partial Dentures
3. Dentures 

Here we will discuss the last option and how dentures may be the right option for you.

What are Dentures?

Simply put, dentures are a removable prosthesisAn artificial body part, which is often lost due to disease or trauma. that replace missing teeth. They are made of a combination of various types of synthetic resin that are bonded to increase strength⁴http://www.quintpub.com/userhome/ijp/ijp_13_1_takahashi_14.pdf. An edentulous space spanning a few teeth can be replaced with a fixed partial denture, also called a bridge, but they won’t be discussed here since they are not removable. There are various types of dentures that are able to replace a single tooth up to an entire arch in the maxillaUpper jaw. or mandibleLower jaw.. Although there is wide variability in dentures, as a whole there are a few pros and cons that are applicable to all types of dentures.

Pros

There are several advantages dentures have over fixed partial dentures. They include:

• No additional surgery is required. Fabrication of dentures does not require additional surgery, however in order to get proper esthetics, facialThe ‘outside’ surface of the teeth that directly face either the lips or cheeks. support, and retention additional surgery may be required. This is the case when the ridge is misshapen due to exostosis, tori, or other outcroppings of bone.
• The ability to replace multiple teeth in a single treatment option. When there is an edentulous area spanning 4+ teeth, a single denture can replace all those missing teeth. 
• Dentures are the most cost effective treatment option for multiple edentulous areas. As the number of missing teeth increase in the maxilla or mandible, the cost and complexity to replace said missing teeth also increases when using implants or FPDs. The cost remains relatively the same with dentures, whether they replace 2 or 14 teeth. 
• Dentures can be rendered quickly. Some dental offices that have an in-house lab are able to fabricate dentures in less than a week. As opposed to implants, which take 3-4 months to complete, sometimes longer.

Able to improve facial esthetics in resorbed alveolar ridges, which is important in the psychology of patients⁵https://www.jidonline.com/article.asp?issn=2229-5194;year=2019;volume=9;issue=1;spage=25;epage=30;aulast=Venkatachalapathy. This gives lip support and acts as a ‘facelift’.

Cons

While it may seem that dentures are the best treatment option for a missing tooth, they come with significant disadvantages.

• Poor esthetics: While the esthetics can be fair, they do not look as natural as implants, FPDs, or natural teeth. Esthetics are even poorer with a partial denture when the claspsSmall extensions on partial dentures, made of plastic or metal, that grab onto natural teeth to increase retention of the partial denture. are visible
• Poor chewing ability: There are many factors that play into bite force such as age, gender, cranio-facial morphology, periodontal and dental status

What are the Different Types of Dentures

Depending on the edentulous space being treated, there are varying styles of dentures that are viable. They can generally split into two categories: complete and partial dentures. Within each category, there are several subcategories of dentures as well. There are also dentures that can be supported by implants to improve retention. 

Complete Dentures

A prosthesis that replaces all the teeth on either arch is a complete denture. When all the teeth are lost due to disease or trauma, this treatment option is the most economical way to replace the teeth for an entire jaw. There are two types of complete dentures: immediate and final, both with their advantages and disadvantages. While having slight differences and pros and cons, both types have a major disadvantage. With a lack of retaining abutment teeth or implants, the retention and stability is poor, especially on the mandible. Maxillary full dentures are typically able to create suction due to the large extensions in the vestibuleThe space between the cheeks/lips and the teeth/gums. It is the space where one would store nuts as a chipmunk would. and post palatal seal, however mandibular dentures lack both retentive features. Additionally the floor of the mouth moves during speech which can dislodge the denture. Luckily, as explained later, these issues can be resolved by adding implants to the treatment plan.

Immediate Complete Dentures

These dentures are delivered immediately after the remaining teeth have been removed. Depending on the extensiveness of the surgery, the gingiva, and more importantly bone, takes 6-12 months to heal and remodel. Immediate dentures are worn during this healing period and then are replaced or converted to final dentures. During the first few months of the healing period, the dentures are adjusted frequently to relieve sore spots. During this healing period, soft relines are done to make the dentures more comfortable and to compensate for shrinkage of the tissues as inflammation reduces during remodeling. 

Pros

Immediate complete dentures have several advantages; the primary one being a patient does not have to be without teeth for an extended period of time. As soon as the surgery is completed, the dentures are fitted and adjusted as necessary. They also act as a barrier to the open extraction sites and protect them from debris as the patient eats. It is during this healing period that the patient also learns to adjust to the new prosthetic. It is unreasonable to expect someone to be able to proficiently use dentures immediately after the surgery, just as one would not expect a recent leg amputee to be able to run right after surgery. Time and practice is needed to learn the following: masticationThe act of chewing., retention, and phoneticsThe study of how humans produce and perceive speech. This is affected by the position of teeth, lip tone, space in the mouth amongst other factors.. If the patient were to wait for the final dentures, learning how to use the prosthetic would likely be more difficult.

Cons

Since this particular style is designed to fit the tissues while the teeth are still present, they will ultimately be bulkier once the jaws heal and shrink. This means that as the gingiva heals and the bone remodels to stable levels, the dentures will be bulky due to increased thickness. This can lead to poorer facial esthetics as the lips appear fuller and patients often observe that it ‘sticks out’. Additionally the esthetics and function cannot be previewed prior to treatment since the wax-up cannot be inserted prior to extraction of the teeth. If the patient isn’t quite happy with the shape or color of the teeth, they are unable to change the esthetics. Luckily all this is easily circumvented by making a new set of final dentures. 

Final Complete Dentures

This is the type of denture most people think of when the subject matter is brought up. They are delivered once the maxilla and/or mandible have fully healed, including remodeling of the bone. By this time, the jaws are smooth with no large bony prominences. There are no temporary aspects, such as soft relines, and little professional maintenance needs to be done. However for some people, hard relines need to be completed every few years or after major physical change such as significant weight loss. The teeth and acrylic are also typically made out of higher quality materials.

Pros

Since final complete dentures are fabricated for jaws that have already fully healed, there will be some shrinkage over time when compared to immediately after extraction. This results in dentures that fit for many years and do not require continual hard or soft relining. I have patients who are satisfied with the fit of their dentures even after 10 years. Additionally there is a denture step called the ‘wax try in’ where the denture teeth are set in wax. The main purpose of this step is to preview the teeth in the mouth to ensure the shade, shape and placement of the teeth are satisfactory to both the patient and clinician. This is also where specific characterizations are possible, such as malpositioned teeth, diastemas, or even gold denture teeth.

Cons

The biggest disadvantage of final complete dentures compared to immediates are the additional time and cost needed for fabrication. While it is recommended for someone who needs a complete denture to go get an immediate and a final set, patients may opt to skip the immediate set and go 6-12 months without any oral prosthesis. The other disadvantages of final complete dentures are the same with removable prosthetics as a whole.

Partial Dentures

There are many circumstances in which a partial denture is appropriate. Outside of outlier cases of severe neglect, disease, or trauma, teeth are typically lost individually or in pairs. When this occurs, the remaining teeth are typically healthy or at least restorable. In these cases, a partial denture may be the best treatment option. The most common types of partial dentures are: cast partial dentures, flexible base partials, a combination of metal and flexible base partial, and immediate acrylic partials. These partials contain clasps that physically contact and anchor onto the existing dentition for retention. These clasps fit over the height of contour and seat passively without pressure on the dentition. The exception to this are anterior single tooth acrylic partials, also known as flippers, that gain its retention by extending into the lingual embrasure space. Additionally most removable oral prosthetics cover the palate to some degree which can impair taste and speech. There are many types of partial dentures, each with their own advantages and disadvantages.

Cast Partial Dentures

This type of a partial has a metal base, typically made out of base metal alloys including nickel, chromium and cobalt⁹https://pubmed.ncbi.nlm.nih.gov/1739881/. There are also compositions that do not include nickel due to allergies. The acrylic is typically made of polymethyl methacrylate (PMMA). Cast partial dentures have been a treatment of choice for many years due to its durability as well as ability to be modified. Additionally metal partials are tooth borne; transferring masticatory forces to the abutting teeth via rest seats . This relieves pressure off the gingiva and can result in less sore spots. 

Pros

Cast partials are a tried and true treatment option that has withstood the test of time. They have several advantages over flexible or acrylic partials. The metal framework is extremely durable and can last well over 10 years and even up to 25 years with proper maintenance¹⁰https://pubmed.ncbi.nlm.nih.gov/7472731/. In the event additional teeth are lost, more can be added to the partial when the framework allows. However the retention is affected if any abutment teeth are lost. Due to the physical properties of the metal framework, the metal can be strong even when thin. This is not possible with acrylic. This makes phonetics much easier than acrylic partials or full dentures which must be thicker for strength. Additionally in the event of a fracture of a clasp or the acrylic, it’s possible to replace or even add metal clasps and add acrylic to an existing partial. However the connection is not as strong as the original. 

Cons

While very durable, there are some disadvantages to metal partials. The primary disadvantage is poor aesthetics – when metal clasps are in the esthetic zone they are immediately spotted¹¹https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7008619/#ref5. Humans are able to pinpoint physical deviations from the norm, even if we do not know what we have spotted. Cast partials are also technically more difficult to fabricate and heavier than the alternatives¹²https://www.researchgate.net/profile/Deepak-Vikhe/publication/308364736_Flexible_denture_-A_flexible_substitute_for_Rigid_Denture. The PMMA acrylic is also brittle which can lead to fracture and people can even develop allergies to the acrylic¹³https://www.dentopedia.info/wp-content/uploads/2015/12/FLEXIBLE-PARTIAL-DENTURES.pdf. Additionally I have personal accounts from patients who have both cast and flexible partials who tell me flexible base partials are more comfortable.

Flexible Base Partials

This type of partial contains no metal and is instead made completely of a thermoplastic material. There are several types of thermoplastics including thermoplastic acetal, polycarbonate, acrylic, and nylon. As its name implies, this partial is flexible and commonly made of thermoplastic nylon due to its inherent flexibility¹³https://www.dentopedia.info/wp-content/uploads/2015/12/FLEXIBLE-PARTIAL-DENTURES.pdf. Flexible base partials are also typically tissue borne, which do not require any modifications to existing teeth via rest seats.

Pros

Flexible base partials are indicated in many scenarios, primarily when multiple teeth are missing. There are many scenarios where undercuts present a challenge when inserting a rigid material such as metal. A few examples are with mesialThe surface of the tooth that is between teeth and is closest to the midline. or distalThe surface of the tooth that is between the teeth and is furthest away from the midline. tipping of teeth into an edentulous space as well as bony projections such as exostoses. The flexibility allows the material to get under the height of contour to lock the partial in place. This property can also be useful for those who have limited opening due to systemic disease. The material itself has less allergic reactions to the monomers as there are little to no free monomers as opposed to PMMA acrylic¹³https://www.dentopedia.info/wp-content/uploads/2015/12/FLEXIBLE-PARTIAL-DENTURES.pdf. Additionally there is no chance of an allergic reaction to metals such as nickel as there is no metal. The esthetics are also superior to cast partials as the clasps are acrylic and are harder to detect compared to metal.

Cons

A big disadvantage of the thermoplastic material is the material is tougher to handle, leading to a high degree of difficulty when adding additional material to a finished prosthesis. This means if an additional natural tooth is lost, it cannot reliably be added to the partial. Additionally as the acrylic teeth are mechanically bonded they dislodge easier. Some flexible partials, such as Valplast, are also unstable chromatically, which leads to discoloration and staining¹³https://www.dentopedia.info/wp-content/uploads/2015/12/FLEXIBLE-PARTIAL-DENTURES.pdf.

Combination of Flexible Base and Metal

The idea behind this partial is to blend the best of both worlds with cast partials and flexible base partials. The metal framework is essentially the same as cast partials except the clasps are made of the flexible material instead of metal. This leads to a thin but strong metal framework on the palate, minimally affecting phonetics.

Immediate Partial Dentures

Very similar to immediate complete dentures, immediate partial dentures are placed immediately after extractions are completed. They are intended to be temporary to allow for healing and bone remodeling after surgery. Often they include clasps that are made of wrought wire. They also require soft relines to compensate for the shrinkage as healing occurs. There is also a specific type of immediate partial denture, commonly called a flipper, that typically replaces a single anterior tooth. Flippers may or may not have wrought wire clasps, due to gaining retention by extending into the lingual embrasure spaces. Another style of partial is called an Essix which is commonly used in combination with anterior implants. This style covers a majority of the dentition, similar to clear aligners, and has an acrylic tooth in the space where the implant was placed.

Pros

The biggest advantage of immediate partials is that the patient does not have to go without any teeth at a minimal cost. Similar to the immediate complete dentures, as the gingiva and alveolar bone heal and recede, the partials will require relining to compensate for the shrinkage. The main advantage of the essix style is the lack of pressure on the gingiva which aids in proper healing of the extraction and/or implant site. 

Cons

The disadvantages of immediate partial dentures are very similar to immediate complete dentures. Partials in and of themselves tend to not blend or match well to adjacent natural dentition and this disadvantage is compounded with immediate partials as the clasps are wrought wire and quality of the denture teeth is poorer than final partials. Additionally due to the shrinkage after extractions, immediate partials end up bulky. Even with all the disadvantages, immediate partials are a great stopgap to a more permanent solution.

Implant Supported Overdentures

Also known as ‘snap in dentures’, this style of denture is a fantastic option for those who choose not to do the full arch treatment option. This treatment option removes the biggest weakness of complete dentures, lack of stability and retention, by using implants. By attaching the dentures directly to the implants, the retention and stability is significantly improved¹⁴https://journals.lww.com/implantdent/Fulltext/2006/03000/Attachment_Systems_for_Implant_Retained.10.aspx. This results in significantly higher patient satisfaction when compared to traditional complete dentures¹⁵https://www.sciencedirect.com/science/article/abs/pii/0266435695900381¹⁶https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730927/. Maxillary overdentures require 4 implants and while mandibular overdentures only require 2, it is best to place 4 for increased stability and retention as well as to still have a functional prosthesis in the event of implant failure. In the end, many patients are satisfied with their quality of life with a mandibular overdenture and traditional maxillary denture.

Pros

As previously mentioned, the biggest advantage is the improved retention and stability of the now anchored dentures. This results in patients able to effectively bite and chew food with significantly less difficulty¹⁶https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730927/. Although not recommended, I have even had several patients who are able to bite into an apple; an impossible task without the aid of dentures. Due to the increased retention, the maxillary dentures can be made into a ‘U’ shape. This significantly improves comfort and taste for many patients and eliminates any gag reflex. Simply put, the addition of implants to full dentures significantly improves the quality of life.

Cons

There are few disadvantages to implant overdentures as opposed to other removable prosthetic treatment options. Instead the disadvantages come in the form of the ability to receive this type of treatment. Due to the atrophy from lack of stimulation to the bone, fully edentulous jaws can lack the required amount of bone, in both the height and width. While not impossible to regrow the bone in these cases, aggressive bone grafting is required. Another disadvantage is the fact that another surgery is required. The patient must be physically and mentally healthy enough to undergo another surgery. The implant risk factors must be addressed and mitigated to improve the odds of success. If the implant fails to osseointegrate, there is more bone loss than prior to the surgery. Lastly there is the hurdle of cost. Due to more challenging surgical and prosthetic factors, overdentures are costly and not easily attainable for many. However for those who are able to obtain overdentures, the quality of life is significantly better and is only second to the all on 4 treatment option.

Fixed Partial Dentures

Commonly known as bridges, the technical term of this treatment option is a fixed partial denture (FPD). This is a common non-surgical treatment option to replace missing teeth. FPDs are technically a prosthesis but the biggest difference between FPDs and the other treatment options mentioned here is that FPDs cannot be removed as they are cemented in place. More information on FPDs can be found on our dental crowns page.

How are Dentures Made?

Most dentures are most commonly made by a lab through a sequence of denture steps. While the impression sequence varies depending on the type of prosthesis made, the following is a general sequence:

1. Initial impressions
2. Final impressions
3. Frame try in (only for cast partial dentures)
4. Wax bite registration
5. Wax try in
6. Delivery 
7. Locator pick up (only with implant overdentures)
8. Follow up adjustments

Often steps can be paired or skipped depending on the prosthesis and skill of the dentist. Keep in mind this sequence is constantly changing as digital dentistry technology advances which even allows for prosthetic fabrication within the dental office itself. 

Like many processes in dentistry, impressions are initially made to replicate the soft and hard tissues of the mouth. The difficulty in impressions for removable prosthetics is the movement of soft tissues. The prosthesis must extend far enough to gain adequate retention and stability but not so far as to impinge on the musculature and soft tissues, causing sore spots. The technique of choice during the final impressions is called border molding, where the clinician manipulates the maximum soft tissue movement to indicate the extensions of the prosthesis. Border molding is especially important with full dentures. Impressions can be made out of several types of viscous material, such as alginate, polyvinyl siloxane [PVS] or can be captured digitally with an intra-oral scanner. Once the impressions are made, the vertical dimension of occlusion [VDO] needs to be measured.

Prior to measuring the VDO, cast partial dentures require an additional step called the frame try in. As the name implies, the metal framework is tried in the mouth to ensure accurate fit especially into the rest seats which are prepared prior to impressions. This is a simple and quick step and right after the VDO can easily be measured

The VDO is taken typically using wax and/or a measuring instrument. With an established occlusion, this step is straightforward as the VDO is replicated. This is the case with partial dentures and some immediate complete dentures. Warm wax is placed on top of a metal framework or resin base and the patient bites into their normal bite. Just as long as there is adequate, replicable bite, this step takes no longer than a few minutes. However this step is more technically challenging if a new VDO needs to be established, as with a fully edentulous patient. To the patient, the process of biting into warm wax feels the same. The clinician must establish an appropriate VDO for a good clinical outcome. If the VDO is too closed, the patient may have trouble biting down and may develop problems in the temporomandibular joint [TMJ]. If the VDO is too open, the dentures will make a clicking sound during speech/mastication and appear too bulky in addition to possible TMJ issues. Once this step is completed, the next step is to preview the teeth prior to finalization of the prosthesis.

The wax try in step is a quick step, but a crucial one. Denture teeth are placed in wax into the framework or acrylic base to give the patient a preview of the esthetics, occlusion and speech. During this stage, the color, shape, and position of the teeth are evaluated. Since the denture teeth are in wax, characterization can still occur. Should a patient choose larger, whiter, crooked or even gold teeth, they specific characterization still occurs at this stage. Often it can be a good idea to bring a family member or significant other to this appointment to have them preview the esthetics for feedback. Once the esthetics and occlusion is verified and approved, the dentures are then fabricated. This process exchanges the wax for acrylic, then the denture is finished and polished and ready for delivery.

The delivery process is also straightforward. The dentures are placed intraorally and several functions are checked. Here are a few examples:

• Esthetics of the teeth and acrylic
• Occlusion
• Retention
• Immediate sore spots
• Correct extensions into the vestibule and to the post palatal seat on maxillary complete dentures
• No interference with muscle movement, particularly with speech
• Speech itself, particularly sibilants and fricatives
• Adequate lip support

If any of these attributes require adjusting, they are completed and the patient is dismissed. Often additional denture adjustment appointments are made as brand new dentures often require a few adjustments until they are adequately comfortable. 

Depending on the dentist’s personal preference, overdentures may require an additional step. Implant overdentures have an attachment called a locator on the intaglio of the denture. This is where the denture attaches and retains onto the implants. This is how overdentures got the nickname ‘snap on’ dentures as they can audibly click as they snap onto implants. The process of attaching the locators to the dentures can be completed in a lab setting, however if there are any inaccuracies during the impression stage, the overdenture may not seat correctly. This is why dentists may choose to complete this step intraorally with a procedure called a ‘chairside pickup’. This process ensures the correct fit by curing acrylic resin to connect the locators and denture together. While it takes more time, there is no chance of distortion with the placement of the locators.

How Much Do Dentures Typically Cost?

While the actual amount will vary depending on various factors such as insurance coverage, location of the dental office, fabrication by a general dentist or specialist, and quality and type of denture, dentures range from a few hundred dollars to a few thousand. Immediate partials, intended to be temporary, are cheaper than overdentures which are more technically difficult to fabricate. A good range for many final dentures is a $1,000 – $2,000 but again this depends on many factors.

Insurance Coverage

Generally insurance will cover most dentures and will cover them at 50% of the contracted rate if there are any remaining benefits for the covered period. One important factor to keep in mind is many insurances will only cover one prosthetic per a given time period. This becomes important when considering immediate and final dentures as insurances may only cover one and not the other. Let’s run through a scenario to illustrate the complexities. 

John Doe tripped and fractured several anterior teeth necessitating their removal. John’s best short term option is an immediate partial denture. If the partial’s contracted rate is $800 and his insurance covers one denture every 7 years, his partial will be covered at $400 and his out of pocket [OOP] expense is $400. Once John heals and wishes for a more permanent solution, he has a few options: implants, bridge, or permanent partial. If John chooses a permanent partial, his insurance may not cover it at all since he had one made recently. If a cast partial’s contracted rate is $1800, then John may have to pay the full $1800 himself, with a total cost of $2200. Alternatively if John paid for the immediate partial himself and had the final partial covered at 50% by insurance, his total OOP would be $1700 ($800 + $900). However there are several intricacies to keep in mind in order to not commit insurance fraud. Ask your dental office should you have any further questions.

How to Take Care of Your Dentures

Dentures require regular maintenance in order to prevent malodor, accumulation of plaque or calculus, and poor esthetics¹⁷https://www.nature.com/articles/4808788. While there are many methods and commercial products available, it has been found that mechanical, chemical, or a combination of the two reduces bacterial growth significantly¹⁸https://www.sciencedirect.com/science/article/pii/S1991790211000808. The cleaning regimen must occur daily to ensure removal of the bacterial biofilm¹⁹https://www.tandfonline.com/doi/full/10.1080/20002297.2018.1538437. In a practical sense, this means that the dentures are daily brushed to remove plaque and food debris and/or placed in a cleaning solution overnight. It is important to not wear the dentures during sleep to prevent candidiasis, a fungal infection that requires antifungal medication. 

See here for the best cleaning solutions.

Other helpful tips to keep your dentures clean and last as long as possible include:

• Immediate denture removal and rinse both the denture and mouth after eating. As soon as you are done eating, remove the denture and rinse off any food debris. Also vigorously swish your mouth with water. Once the denture and mouth is free of food debris, place the denture back inside the mouth and go about your day.
• Fill the sink basin with water prior to cleaning or rinsing. In the event that the dentures slip out during cleaning and fall, they will land in water which prevents fracture of the teeth, flangesThe portion of a prosthetic, typically dentures, that extends into the cheek pockets (vestibule). , or even metal clasps. 
• Daily cleaning of the oral cavity. Use a soft toothbrush to gently brush the gums, tongue, cheeks and hard palate. Rinse with an antibacterial mouth rinse for the best effect. This is especially important for those who use denture adhesives to ensure complete removal of the adhesive. 
• Nightly soaking of the dentures. Many dentures require moisture to prevent desiccation and brittleness. This is especially important for flexible partials, where the clasps are particularly susceptible to desiccation and fracture.
• Rinse after nightly soaking and prior to placing in your mouth. Some of the solutions may be harmful if ingested or comes into contact with oral mucosa. Be sure to thoroughly rinse off with water.
• See your dentist for regular checkups. Your dentist will be able to check your dentures for wear and tear, fractures, proper fit, and any abnormalities including fungal infections. Depending on the number of teeth present and oral cavity, the number of visits may be as little as once per year. 

Avoid cleaning your dentures with the following: harsh or abrasive cleaning materials, toothpastes, bleaching or whitening products, and hot water. These materials may degrade, warp, miscolor, or roughen up the denture itself which shortens its life span.

Frequently Asked Questions About Dentures