Why Use an Essix Retainer Versus a Flipper During Dental Implant Therapy 

Lee Ann Brady, DMD 

When it comes to choosing a provisional during implant therapy in the anterior aesthetic zone, we have two removable options. One is called a “flipper.” It’s an interim partial denture composed of an acrylic base and a denture tooth. The other is an Essix retainer.  

There is no question that both options are taxing for the patient for the three to five months that the patient is edentulous and must deal with having this removable device to replace the tooth. So, I always tell my patients that they are going to have to manage the provisional for that time, but it’s worth it because, in the end, they have replaced the tooth with an implant with all the benefits of an implant versus an alternative prosthetic solution. 

In my practice, I use Essix retainers in nearly 100% of the cases. Why? Because an Essix retainer is tooth-borne. The pressure is placed on the teeth and not on the surgical site. In the case of a flipper, the prosthesis is primarily tissue-borne with a little pressure placed on the adjacent teeth. We really don’t want any pressure on the surgical site while it is healing. Pressure can induce biological problems in bone grafts and connective tissue, which affect the long-term outcome. From an aesthetic perspective, the most challenging thing about anterior implant aesthetics is replicating the size, shape, and position of the tissues of the alveolar ridge and papilla. I want to do everything I can to eliminate pressure on the healing tissue. 

In my practice, we do Essix retainers that don’t have a full solid tooth in them. Instead, we simply paint flowable on the facial so that there’s zero pressure anywhere around that surgical site after extraction, after grafting, and after implant placement.  

In addition to explaining the improved outcomes associated with using an Essix retainer, I assure my patients that the retainer will be more comfortable to wear than a denture and be easily removed by them for eating, for drinking liquids other than water that are likely to stain the retainer, for teeth cleaning, and for cleaning the prosthesis. When out in public, such as in a restaurant, patients may carefully eat while wearing the Essix retainer.  

Explaining Dentistry in a Way Patients Understand 

Clayton Davis, DMD 

Here are some of the ways I communicate with patients to help them understand dentistry. I hope some of these will be helpful to you in enabling your patients to make good decisions about their treatment.  

Occlusal Disease: In helping patients understand occlusal disease and the destruction it can cause, I have long said to them, “The human masticatory system is designed to chew things up. When it is out of alignment, it will chew itself up.” I tell them, “Your teeth are aging at an accelerated rate. We need to see if we can find a way to slow down the aging process of your teeth.” The idea of slowing down aging is very attractive to patients, and if you relate it to their teeth, they get it.  

Occlusal Equilibration: Typically, I come at this from the standpoint of helping them understand that teeth are sensors for the muscles, and when the brain becomes aware our back teeth are rubbing against each other, it sends the same response to the muscles as when there’s food between our teeth. In other words, the brain tells the muscles it’s time to chew, and this accelerates wear rates on the teeth. Equilibration is really a conservative treatment to reduce force and destruction of the teeth.  

Diseases of the Jaw Joints: Regarding jaw joints and adaptive changes and breakdown, patients understand that joints have cartilage associated with them. Saying there has been cartilage damage in your jaw joint gets the message across simply. 

Treatment Presentation: When patients say, “I know you want to do a crown on that tooth,” I jokingly say, “Oh, don’t do it for me. Do it for yourself.” I never say, “You need to get this work done.” Instead, I say, “I think you are going to want to have this work done.” 

Conservative Treatment: I have always enjoyed John Kois’s saying that no dentistry is better than no dentistry, so when talking about conservative dentistry, I’ll tell patients, “No dentistry is better than no dentistry. We certainly don’t intend to do any dentistry that doesn’t need to be done.” Another way I speak about conservative dentistry is to say, “Conservative dentistry is dentistry that minimizes treatment. In the case of a cracked tooth, a crown is actually more conservative than a filling because it minimizes risk.” 

Moving Forward with Treatment: I love Mary Osborne’s leading question for patients after they’ve been shown their issues and treatment possibilities have been discussed. The question is “Where would you like to go from here?” With amazing regularity, the patients choose a really good starting point for their next steps toward improved health, steps that feel right to them. Always remember, people tend to support that which they help create. 

Dental Insurance: I typically speak of dental insurance as a coupon that can be applied to their dental bills. I’ll say, “Every plan sets limits on how much it pays. The way dental insurance works, it’s as if your employer has provided a coupon to go toward your dental bills.” 

Presenting Optimal Care: If I want to present optimal care to a patient who is ready to hear it, I ask permission by saying, “Mrs. Jones, if I were the patient and a doctor did not tell me what optimal treatment would be for my problems because the doctor was concerned that I couldn’t afford it or that I would not want it, I would think, ‘How dare you make that judgment for me. You tell me what optimal care would be, and I’ll decide for myself if I want it.’ So, with that in mind, Mrs. Jones, would it be okay with you if I presented you with the optimal solutions for your problems?” 

Replacing a failed restoration starts with a careful examination of the patient’s needs, desires, and current oral health. My patient in this case presented with a six unit anterior bridge, decay, and many esthetic issues. After an esthetic evaluation and comprehensive exam, it was time to move on to treatment planning.

Failed Restoration: Treatment Plan

To treatment plan this case, I relied on an advanced facially-generated treatment planning system for communicating with the rest of the team. Communication is essential to a reliable outcome.

First, a diagnostic work-up was generated. Then, the interdisciplinary team together developed a final treatment plan and sequence, with the incisal edge position of the upper right central as reference.

We chose orthodontic extrusion of the upper teeth to handle proclination in the anterior and the gingival discrepancy. Additionally, we treatment panned the maxillary right canine for over-extrusion by 2 mm. This was done to achieve adequate restorative ferrule through crown lengthening, not to mention re-treatment endodontic therapy with post and core.

We talked about implant therapy, but ultimately it was not a workable solution. Root proximity on the upper right and the gingival tissues meant it wasn’t ideal as a first option. For the final treatment, we decided on placing a six unit anterior bridge. I then discussed the outcome with the patient and she decided conservative therapy for the posterior esthetics of direct composite veneers was best. This enabled us to create consistent contour and shade.

Next up was the lab, which made a pre-orthodontic wax-up based on periodontal surgery and planned tooth movement. I gave them the proper information by using PowerPoint and digital photography with the proposed tooth positions. After this, the post and core endodontic re-treatment was done for the upper right canine.

To be continued…

What’s your approach to treatment planning? 

Like with any big purchase or expensive commitment, it’s not surprising patients would want to try on a new smile before going all in. You wouldn’t expect someone to purchase a sports car without first riding it around the dealership, would you?

Think of your cosmetic treatment as a high-end experience and your patients will too. Even the most hesitant spenders will be much more interested in moving forward if they’ve gotten a taste of how beautiful their smile really can be. This is where the ‘trial smile’ comes in.

Cosmetic Case Acceptance: Let Patients Try Their Smile

There’s no need to feel daunted by the process of creating a trial smile. Patients want to find a dentist who will offer them the kind of care they feel they deserve and who are willing to give them exactly what they want. You’d be surprised how hard it can be to find someone who will listen to a patient’s expectations instead of delivering what they personally feel is best.

With esthetics, the patient should have the primary say. Invite your patients who have given indications of wanting cosmetic treatments to communicate their preferences in a very tangible manner. All you have to do is first conduct a co-discovery appointment complete with high-quality digital images and an occlusal exam as well. Then, temporarily put composite on their unprepared teeth.

With this strong foundation already in place, your patient can see the potential outcome of smile design. When you pitch a trial smile to them, you can even call it a ‘demo.’ If the patient loves what they see, it’s no problem to move on to a diagnostic wax-up using a model of their demo smile.

What case acceptance techniques do you find most effective? We’d love to know your thoughts in the comments section below!

Photo courtesy of Matt Roberts CDT, CMR Laboratory.

The Aesthetics Course taught by Matt Roberts, CDT, Dr. Frankie Shull, Dr. Susan Hollar, Dr. JA Reynolds and Mr. Michael Roberts is just the place to learn to use digital technology to help patients want an aesthetic makeover.

Consistent case acceptance is a skill it can take years to develop. Part of the reason it can seem so challenging is that a patient’s true motivations may not be clear from the outset. We have to hone that sixth sense that can tell us what information or guidance would truly speak to a patient.

Two aspects of case acceptance in particular often go ignored because they either seem too obvious or are just not as fun to dive into: offering individualized options and making sure patients understand insurance.

Individualized Options for Case Acceptance

You may think the concept of individualized options is a no brainer, but that isn’t necessarily the case from a patient’s perspective. If you’re willing to provide this extra level of specificity, you can put many ‘maybe’ patients right into the ‘yes’ category.

We accept that car and other big purchases are often paid in installments, so why not do the same with a large investment like dentistry? Offering financing or other piecemeal payment options to patients is a game changer. It also makes comprehensive dental care accessible to a broader demographic. That in and of itself is valuable.

When dealing with patients, break the payment options down into easily understandable terms. Tell them the total fee, but decrease the stress by making it clear that there are different ways they can arrange to pay, including pre-pay, pay as you go, and Care Credit. Using a term like Care Credit is helpful because everyone is familiar with the idea of credit. When they ask for more information, you can lay out the details of payment plans.

Understanding Insurance for Case Acceptance

The real role of insurance is a mystery to most patients. Some may deliberately avoid understanding it because of how convoluted and frustrating it can be. They may have an entitlement mindset complete with the belief that the only healthcare they can indulge in is the kind covered by insurance.

Before you ever even look in a patient’s mouth, my advice is to have the insurance talk in low-stress language. Explain the actual definition of insurance and describe how dental insurance functions more as a maintenance plan. Use analogies to clarify the fact that just like with car insurance, its more of a backup fund than a way to pay for necessary yearly interventions such as a new tire or oil changes.

Dr. Crete discusses an anterior esthetic case from the initial conversation to finished treatment plan for a patient who lacked smile confidence.

Patient Profile

Drew became a new patient at my practice as a 20-year-old junior in college. His reasoning was: “Just to get my teeth cleaned.” During his initial hygiene appointment, he mentioned the “spot” on his front tooth (#9 – small pit filled with composite 10 years prior).  

He asked: “Can you put some new bond on there and make it match better? Even when my dentist did it the first time, it was always obvious.”

I heard his question as a window to ask further questions and find out a little bit more about him. At Pankey, we call this, ‘knowing your patient.’ It can start with an introduction to a new patient during a hygiene examination.  

Asking the Right Questions for Case Acceptance

I began by asking, “Do you know why you had the bonding done?” and “Did you have a cavity?”  

His answer was, “No, I have been playing hockey since I was really little. I was not always good about wearing my mouth guard and I chipped my teeth a lot.”   

Further questioning revealed he was referring to the enhanced mamelons and pitted enamel areas of his anterior teeth as “chips.”

His parents had elected not to have the chips repaired because they were told it was cosmetic treatment and their insurance would likely not pay anything.  

The Value of Open Dialogue

I then asked a few more open-ended questions like, “Is there anything about your smile you would change?”  

His answer: “Well, I always feel like I have little teeth and it makes me look like a little kid. I wanted braces when I was in junior high but my dentist told me I had a good bite and braces wouldn’t fix all the spaces I have.”  

Further dialogue with Drew revealed a significant concern he had about graduating from business school in a year and having to go through interviews looking like a little kid. He said, ”I worry no one will want to hire me because I look so young.”

To be continued…