An Esthetic Implant Temporization Alternative Utilizing the Essix Matrix Drs. Christopher J. Baer and Gary M.

Radz

A common frustration for dentists and patients is dealing with the edentulous

space present during the osseointegration phase of dental implant therapy. Certainly, there have been advancements in immediate load temporary technique, but often times this technique can not be used1,2. When immediate provisionalization is not an option, it often leaves us with the traditional option of using a removable appliance to help the patient thru the healing stage of the implant placement or sometimes using a bonded type provisional3,4,5. """"""""""" Commonly, a ipper type of an acrylic appliance has been used. Patient response to this type of appliance is usually less than positive. In an attempt to create a more comfortable and tolerable interim appliance the clinician may consider using an acrylic clear tray material (Essix, Raintree/Dentsply) to provide the patient with an esthetic, comfortable, removable alternative to the traditional ipper appliance. ! The Essix tray material (Raintree/Dentsply) is not only useful for minor tooth movement, but due to the rigidity of the material, the fact it can bond to acrylic and composite, is clear, and can be fabricated using much of the same equipment already present in the ofce used to fabricate bleach trays, makes it an ideal material for fabricating this type of temporary prosthetic. The material gives you the potential create one of the most esthetic temporary tooth replacements quickly and inexpensively, utilizing techniques that staff are already familiar with to fabricate bleach trays or Essix trays for minor tooth movement. ! The following is a quick and inexpensive alternative to provide patients with a more comfortable tting prosthesis which will serve not only to protect Fig. 3 Fig. 2 Fig. 1

the implant site but also provide the patients with a comfortable, esthetic temporary solution. ! The rst step is to take a preliminary impression of the proposed implant site which is done prior to extraction of the tooth in the proposed implant site (Fig. 1). If the tooth is already absent, the impression can be made of the arch, poured up and waxed up or a denture tooth placed in the site. The same would be true for multiple teeth. Once this has been done the cast is duplicated, and a solid model is poured and trimmed to similar dimensions as for a bleaching tray. ! Using the Essix Vacuum Thermoforming Fig. 5 Machine (Essix, Raintree/Dentsply) or similar device, the Essix A+ 0.75mm material is sucked down over the fully dentate model as would be done for a bleaching tray. A ne tipped instrument (Accentuator Tool by Essix, Raintree/Dentsply) is then used to make sure the material is adapted into the interproximal undercuts (Fig. 2), and a coolant material (Freeze Spray, Raintree/Dentsply) is sprayed onto the Essix tray material to ensure quick cooling of the material while still under vacuum (Fig. 3). The vacuum is turned off and the plastic is ready for trimming. ! Using sectioning disc (Essix Wheel Saw, Raintree/Dentsply), cut through the Essix tray material to remove the excess not supported by the cast. The matrix and model can now be carefully separated using a at tipped instrument (Cast Removing Instrument, Raintree/Dentsply). Trim the matrix to allow approximately 1-2 mm past the gingival margins using scissors (Ultra-Trim Fig. 8 Fig. 7 Fig. 6 Fig. 4

Scissors, Ultradent). Often the original cast is destroyed during the removal from the matrix and this is reason for the duplication process. Using a heated pair of Essix pliers (Thermoplier, Raintree/Dentsply), a dimple is made into the lingual of the tooth(teeth) to be replaced (Fig. 4). Using a laboratory handpiece and an acrylic bur (Fig. 5), the center of the dimple is removed to allow the tip of your automix temporary material of choice access into the matrix. ! If the tooth/teeth to be replaced are still present on the model, then it/they must be carefully removed to avoid damaging the adjacent teeth. Remove the tooth down to the gingival margin on the buccal and lingual. If the patient was already edentulous then the wax-up can simply be removed from the site. It is recommended any undercuts adjacent to the edentulous site are blocked out with wax or composite (Fig. 6). The Essix matrix can be placed on the master cast with the tooth to be replaced removed, to check for t.(Fig. 7). Vaseline or a model release agent is then be applied to the edentulous model to help prevent the temporary material from adhering to the model or blockout. A Bis-Acrylic temporary material such as (Integrity, Dentsply/Caulk) can be used inside the Essix matrix and will bond to the matrix, providing increased retention (Fig. 8). Once this has been injected into the lingual access hole created, wipe off any excess and allow to cure for at least 5 minutes. After curing, Fig. 12 Fig. 11 Fig. 10 Fig. 9

remove the matrix, destroying the model if needed. Use an acrylic bur to remove any excess material (Fig. 9) and smooth the tissue born portion of temporary surface using composite polishing points (Enhance and PoGo, Dentsply/ Caulk). Trim any rough edges of the Essix tray with the polishing brushes (Essix, Raintree/Dentsply) for use in a cordless Dremel lab engine(Appliance Trimming Kit, Raintree/Dentsply). If sufcient block-out has been done, there is minimal trimming involved and the seating appointment will be minimized (Fig 10). ! When the patient comes in for the seat appointment, make sure that the tray ts well, there is no pressure on the implant site, and no rough edges they can feel with their tongue. If the implant has been placed, make sure that there is no contact between the pontic and the healing abutment or implant xture (Figures 11 and 12/ Note Figure 12 you can see where the temporary material was trimmed to make sure no tissue was impinged, easier cleansibility, and there was no contact with the implant abutment). Check the occlusion on the Essix matrix and adjust so there is even contact. (If needed, the entire occlusal surface can be trimmed off, leaving only the buccal and lingual contours.) It typically takes no more than 5-10 minutes for this appointment. ! This matrix will typically last about 4-6 months. The duplicate cast of the full arch with teeth is kept on hand to make an additional matrix if required. If this occurs, the matrix can be made and trimmed in advance and then providing undercuts are blocked out, the prosthesis can be fabricated in the mouth or off a new impression that is poured in quick set stone (Figs. 13 and 14). ! This is a quick, effective, and esthetic temporary solution for patients undergoing implant therapy. It can also be used as a temporary for patients with congenitally missing teeth following orthodontics or even for a patient who comes in for an emergency, having lost a tooth and needing a quick replacement. It can be completed Fig. 14 Fig. 13

in the ofce without signicant cost and easily be done from impression to seat within an hour. ! If impressions are going to be made to allow fabrication of a surgical stent for implant placement, this is again an esthetic, and cost effective temporary solution for single or multiple tooth replacement. Patients appreciate not having an appliance resembling a denture and with a majority of patients this is more durable than the traditional acrylic ipper.

References: 1. Degidi M, Gehrke P, Spanel A, Piattelli A. Syncrystallization: a technique for temporization of ! immediately loaded implants with metal-reinforced acrylic resin restorations. Clin Implant Dent ! Relat Res. 2006;8(3):123-34. 2. Palattella P, Torsello F, Cordaro L. Two-year prospective clinical comparison of immediate replacement ! vs. immediate restoration of single tooth in the esthetic zone. Clin Oral Implants Res. 2008 ! Nov;19(11):1148-53 3. McArdle BF. Using a xed provisional prosthesis during post-extraction healing and implant ! placement. Compend Contin Educ Dent. 2006 Mar;27(3):179-84; quiz 185, 195. 4. Moscovitch MS, Saba S. The use of a provisional restoration in implant dentistry: a clinical report. Int J ! Oral Maxillofac Implant 1996;11(3):3959. 5. Chee WW, Donovan T. Use of provisional restorations to enhance soft-tissue contours for implant ! restorations. Compend Contin Educ Dent 1998;19(5):4819.

Figures: Figure 1 - Master cast from a preliminary impression of the proposed implant area 23 and 26 Figure 2 - Using a ne tipped instrument to ensure the Essix material goes into the untercuts Figure 3 - Application of Freeze Spray to facilitate cooling of the Essix Material Figure 4 - Using Essix pliers to create a dimple in the lingual of the tray Figure 5 - Creating an access hole for temporary material in the dimple created by the Essix pliers Figure 6 - Undercuts blocked out with red wax prior to addition of temporary material Figure 7 - Making sure undercuts are blocked out and tray seats properly Figure 8 - Injecting temporary material (Integrity,Dentsply/Caulk) through the access hole made in the ! ! lingual of the tray

Figure 9 - Trimming of excess temporary material (Integrity,Dentsply/Caulk) with laboratory handpiece Figure 10 - The nal trimmed Essix tray with provisional material

Figure 11 - Two Bone Level Implants (Straumann) with healing abutments, prior to tray insertion Figure 12 - Final Essix tray in place. Note the premolar region and the different extensions of material ! ! for patient comfort. Temporary trimmed to allow patient access for cleansing.

Figure 13 - New model poured up in quickset stone to fabricate a new Essix provisional Figure 14 - New appliance fabricated on the model of the patient#s existing edentulous area with ! ! healing abutments in place.