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6 | CERECDOCTORS.COM | QUARTER 4 | 2014
Fig. 12: Essix appliance modified
Fig. 13: Essix appliance modified
Fig. 14: Provisional in place
Fig. 15: Tissue six weeks post surgery
Fig. 16: Composite added to Essix
appliance for better support
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up in relation to the facial crest as
mentioned in the previous paragraph
(Fig. 10). Cortical-cancellous bone
matrix is then placed anywhere there
is a bone to implant distance of greater
than 1.5-2 mm. Personally, I will place
bone anywhere there is a gap between
the implant and the crest. The graft
material is transferred using a stainless
steel carrier much like what is used for
restorative material (Fig. 11). This is the
easiest way I have found to place the
graft material in small increments in
hard-to-reach places. Next comes the
temporization phase.
A MODIFIED ESSIX APPLIANCE
FOR ESTHETIC IMPLANT
REHABILITATION
One of the difficult areas when doing
multiple anterior implants is the tempo-
rary stage. If you get primary stability
and don’t have to do any augmentation
of the soft tissue or osseous structures,
then making a temporary abutment is
possible. But what happens when you
can’t place an immediate temporary
on the implant? For single units it is
easy enough to fabricate a Maryland
bridge to use as a temporary while the
site heals.
That being said, when there are
multiple implants involved, there are
really only a couple of options.
One is to make a flipper appliance for
the patient to wear. The downside to a
flipper is undue pressure on the healing
gingival tissues. Also, it does nothing
to help start training the tissue to have
proper esthetic contours, especially in
the papillae area.
The other option is to have an Essix
appliance made. For those who do not
know what an Essix appliance is, they
are a thermal plastic, clear matrix made
from a duplicate model of either the
original dentition or a wax up of the
proposed final restorations.
The Essix has the advantage of being
supported by the surrounding teeth,
which keeps the pressure off the soft
tissue. The disadvantage is you are
wearing what looks like an orthodontic
or clear aligner all the time. Also, it is
harder to have an ovate design that will
lead to proper soft tissue healing.
For this, we used a modified Essix
appliance that my assistant and I
created in our lab. We create a standard
Essix and build the teeth in composite.
The difference is we cut the facial
plastic away from the composite teeth.
The thermal plastic is a much thicker
plastic to give more rigidity to the appli-
ance. The lingual portion of the thermal
plastic is kept in place and the composite
is either formed around it much like
splinting teeth, or holes can be drilled
through it to allow for purchase points
in the plastic. Bonding agent can also
be used to get some retention of the
composite to the thermal plastic matrix
(Figs. 12-13).
This Essix design allows for much
nicer esthetics by being able to develop
the embrasures on the facial and incisal
aspect of the appliance. The other
advantage — and the most important
for final prosthesis fabrication — is the
development of an ovate pontic site. In
this case, we placed 2-mm-tall healing
abutments to allow the tissue to just
barely cover the implants but allow our
ovate pontics to maintain the gingival
architecture based on our final pros-
thetic design (Fig. 14).
Guided surgery allows us to place
implants with a high amount of preci-
sion, but the final outcome depends on
proper treatment planning from the
diagnostic phase forward. Each step of
the process is of vital importance for
the final outcome to be achieved and the
patient’s expectations to be met.
For questions and more information,
Dr. O’Bryan can be reached at
drobryan@onemorereasontosmile.com.
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