A Flipper Shouldn’t Be Your First Choice: Alternative Implant Provisional Restorations

[drsushant]

 by Dr. Chris

 

 by Dr. Chris

 

When a patient needs a tooth to be extracted and an implant is planned, and if the tooth is in the esthetic zone, the restorative dentist will almost always need to use a provisional to meet the patient’s esthetic demands.  But all too often the dentist will rely on a flipper (provisional removable partial denture) to temporarily fill the space.  This is sometimes the worst possible option available.

The best possible option in ideal circumstances would be to immediately load the implant. We frequently are not allowed to immediately load the implant and must find a way to temporize that does not involve engaging the implant.

First let’s discuss the two main qualifications for a great provisional:

(a) Fixed, Not Removable – It is always better to have the temporary be doctor-removable.  Cement will guarantee that the patient cannot take it out on their own.  Not only do patients like that, but it will help preserve any emergence profile sculpting you’re doing.  Which leads me to…

(b) Pontic Contouring – Implants are cylindrical; teeth are not.  To achieve the ultimate in esthetics, you must preserve or reclaim the gingival contours that surround teeth and roots.  I discuss how to do this with a customized implant temporary abutment in this post. However you are at an advantage when you can begin to sculpt the three dimensional emergence profile in the provisional stage.

        

[drsushant]

 Let’s quickly run through the four choices we have.

(1) Fixed Partial Denture (Bridge)

This is my number one choice!  Here’s why:

Pros of FPD

It’s fixed in place with cement; I can remove it when I want to but the patient cannot.  It’s tooth-supported, so that means there’s no unpredictable pontic pressure on the soft tissue.  Since it’s tooth supported and retrievable, I can contour the pontic site exactly the way I want.  I can add and subtract material over time, developing a gorgeous emergence profile for my future implant.  As an added bonus, I have a lot of control over the lengths of the interproximal contacts because, by definition, the adjacent natural teeth are being committed to crowns.  Therefore if I don’t generate the papilla height I’d like to see, I can easily just lengthen the contacts to prevent the dreaded black triangle.

Cons of FPD

But that is also the greatest problem with the FPD provisional: I can’t always commit the adjacent teeth to crowns.  I will not prep virgin or mildly restored adjacent teeth for an implant provisional under most circumstances.  This is the greatest limiting factor with this technique.

(2) Resin-Bonded Bridge

Also known as the Maryland bridge, the resin-bonded bridge is not frequently used as a permanent restoration due to concerns over long term bonding.  However, it’s utility as a provisional is underrated.

Pros of Resin-Bonded Bridge

Like the FPD, it’s fixed in place and tooth-supported.  So we have a happy patient and no unpredictable pressure on the soft tissue.  Notice the perforated “wings” in the second picture.  Having experimented with a few designs, I’ve found the perforations make the provisional easier to remove without sacrificing retentiveness during normal function.

Also, the adjacent teeth are not converted into crowns, which is a big plus.  This is an extra-coronal retentive element, so no preparation of the adjacent teeth is necessary.  Just make sure the patient’s occlusion permits the thickness of the wings.

Cons of Resin-Bonded Bridge

Unfortunately, these are still unpredictable to remove.  This means taking it in and out to play with the emergence profile is more challenging.  There is a chance you will fracture one of the retentive wings as you remove it.  I’ve even had to cut these off because they are so well bonded into place.  Either way, you sacrifice the resin-bonded bridge and will need a back-up to send the patient home with.  I’ve tried using different cements but they really don’t work.  You must etch and bond these into place to prevent them from exfoliating.  Also, be very careful if you’re inserting one over a fresh surgical site.  In the image above, you can see I’ve used a rubber dam as a barrier to the etch I’m about to use.

(3) Essix

The Essix has proven to be a useful tool in my armamentarium, but I’ve learned to only use it in the short term.

Pros of Essix

This is very cost effective.  You can easily fabricate one in your office using a Vaccu-form machine in a pinch.  But if you want these to last a while, have a dental lab make one using a strong material.  It must be rigid and thick; no bleaching tray material allowed if you want it to last.

Can you contour pontics?  Kind of.  Yes, you can, because it’s easy to add or subtract material to the tooth sitting in the tray.  But, no, you can’t, because this is a removable appliance.  Patients are theoretically supposed to remove this when they eat, sleep, and do home care.  If they’re doing that like they’re supposed to, the soft tissue can rebound.  Tissue contouring with an Essix is not as predictable as an FPD.

Cons of Essix

Yup, it’s a removable appliance.  And the reason you want them to take it out when they eat and sleep is that it will fracture.  Usually right in between # 8 and 9.  I tell my patients that an Essix is kind of like Invisalign to describe the slight problem with ethetics.  It’s bulky, it can affect speech, and you should remove it when you eat; all esthetic issues.

Does it place unpredictable pressure on the soft tissue?  Sometimes.  Yes, it is technically tooth-supported.  If you’re using a rigid material and only one tooth is missing, then you’ll probably be alright.  However the longer the span and the less rigid the material, the more the appliance will bounce up and down on the extraction socket/graft/implant.

(4) Flipper

The acrylic removable partial denture is very commonly used but offers only one real advantage…

Pros of Flipper

…it’s cheap to make.  A lab can make this quickly and inexpensively.  That is the only advantage in my book.

Cons of Flipper

The main problem is that it is tissue supported, thus it places unpredictable soft tissue pressure on the pontic site.  This can lead to flattened gingival architecture, graft dehiscence, or even implant failure if it can engage a recently placed fixture.

Being soft tissue supported and removable, you definitely cannot do any pontic contouring.  Not gonna happen.

Notice that I listed esthetics as a con.  Some of you may say that a nice flipper is capable of recreating beautiful, pink acrylic papilla.  Very true.  But look at the above picture.  If the patient has a high smile line, then your esthetics are down the drain.

But even more important is the false promise of papilla.  Even with a more normal smile line, you may be promising your patient a papilla in the provisional that you cannot deliver in the final implant prosthesis.  If you need pink acrylic to make the provisional look good, that’s a good indication that you should do some hard and/or soft tissue grafting to restore missing periodontal anatomy.

        

[drmithila]

Frequently Asked Questions

 

Are implants always successful?

Modern implant techniques have been in use since the 1950’s. Improvements in procedures and materials have given implants a ten year average success rate of 93 percent or better. This enviable success rate is improving every year!

Can failed implants be replaced?

In the unlikely event an implant fails it can usually be replaced by another. In fact, most patients wouldn’t have it any other way!

Is everyone a candidate for implant treatment?

In general, anyone healthy enough to undergo routine tooth extraction or oral surgery is probably able to receive an implant. There are some health conditions that warrant special consideration. Certain chronic diseases, heavy smoking or alcohol abuse may contraindicate implant treatment. After careful evaluation of your health history, your dentist will alert you to any conditions that may effect your treatment. Remember, age is not a factor.

Will others know I have dental implants?

Today’s implant treatment enables you to have your new teeth look, feel and function like your own. Even though others will be unaware you have dental implants, many patients are so pleased they tell everyone they know. Dental implants offer some of the finest restorative results possible in modern dentistry.

How long does complete treatment take?

Depending of the type of implant and replacement teeth selected, the total time can be as little as a few weeks to six or more months. If bone grafting is necessary, further time may be needed. Your dentist will discuss your options with you and advise you of the time requirements.

Will I need to be hospitalized?

Most implant procedures are performed in the dental office under local anesthesia. Although, some patients may desire pre-medication or IV sedation to control apprehension. Hospitalization may be necessary for complex surgical procedures or general health reasons.

Is there pain or discomfort?

Many patients report implant surgery less troublesome than having teeth removed. With modern anesthesia and close attention to post operative care you can expect minimal discomfort.

Will I be without replacement teeth at any time?

Immediately following surgery you may be instructed not to wear replacement teeth in the surgical area. If required, this period is usually short, and temporary teeth are soon provided so you can quickly "get on" with your life.

How much does implant treatment cost?

The cost of implant treatment depends upon the number and type of implants placed and the type of replacement teeth needed. For example, replacement of a single tooth with implant treatment costs about as much as a dental bridge. The bridge necessitates "cutting down" adjacent teeth for crowns. Implant treatment does not. More complex treatment, such as bone grafting, will add to the cost. The cost can vary in different countries, so it’s is best to consult your dentist. The improvement in your self confidence, comfort, eating habits and appearence will make dental implant treatment one of the best investments you’ve ever made!

Are implant supported teeth as strong as my natural teeth?

Yes. Research shows that in many cases implants are actually stronger then natural teeth. Compared to removable teeth, studies show implant supported teeth have 100 percent or better chewing efficiency. Dental implants can make it possible for you to enjoy your favorite foods, improve your nutrition and your appearance!

 

        

[drsushant]

DEFEND Temporary Crown and Bridge Material is fast and accurate, especially when used in conjunction with a quality vinyl polysiloxane impression material. A syringeable bis-acryl composite indicated for chairside provisional restorations, it is available in 6 shades: A1, A2, A3, A3.5, B1, and Bleach BL. All are delivered in 76-g cartridges designed to fit a 10:1-style automix gun

 

 

        

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