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. I’ll discuss why in another post but I’ve already discussed my technique in this post. But the point here is that we frequently are not allowed to immediately load the implant and must find a way to temporize that does not involve engaging the implant.
I do still use flippers as provisionals! Sometimes it is the best option in less-then-ideal circumstances. But I only resort to a flipper when I’ve exhausted the possibility of using a better provisional.
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.
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.
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.
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.
UPDATE: Check out this post on Snap-On Smile to see why I’m using it more and more in my practice.