By Daren Becker, DMD 

A 16-year-old girl presented with the worst case of ectodermal dysplasia I had ever seen.. She was missing all of her lower teeth except for her 12-year molars. She presented with a lower denture (made by a previous dentist) on two temporary implants in the canine position.  She had only a few maxillary teeth that were malformed; some of these were still her primary teeth.  The appearance of her smile made her look like she was a 9 year old child. 

She was embarrassed by her smile and realized she would need implants and restorative dentistry down the road. At the time, she was too young. Our hearts went out to her. 

Another dentist had recommended direct bonding, which certainly could have worked, but I thought that we could get a better aesthetic result for her with significantly less time in the chair. So, we captured preclinical digital impression scans with our iTero scanner and along with Matt Roberts at CMR Dental Lab in Idaho, we designed a digital wax-up for an improved occlusion and smile. From there, we had milled PMMA (Polymethyl Methacrylate) overlays created that we direct bonded onto the existing dentition as a long-term temporary solution. We did not need to prep any teeth, and we quickly gave her a broad beautiful smile that looked natural and age appropriate. 

She was in tears. We were in tears. Her mom and sister were in tears. It was the best day ever! 

Soon after, she got a part as an extra in a series filmed here in Georgia, and is thinking about a career in acting. Seeing her life change with simple, comfortable clinical procedures has been priceless. 

By Lee Ann Brady, DMD 

Cleaning the larger gingival embrasures around a posterior dental implant can be a challenge for patients. In my practice, posterior implant patients are some of the individuals we give X-Floss samples to try at home.  

X-Floss is a dental floss made by iDontix® that is designed to make flossing easier for individuals with bridges, braces, implants, or larger-than-normal gingival embrasures. It resembles yarn, has a thick texture, and has a hard end, making it easy to push under orthodontic wires, bridges, or in embrasure spaces. It effectively cleans larger spaces while remaining gentle on the gums. The soft material minimizes the risk of injury during flossing, even in subgingival areas, and it is conveniently available on Amazon and in drugstores.  

There are two varieties. Green X-Floss from is too thick for some spaces. Blue X-Floss Lite is less thick and just right for some spaces. You and your hygienist may want to give samples of both to your patients to try. Some of your patients are likely to more effectively and consistently floss once they are using this type of floss.  

By Lee Ann Brady, DMD 

A patient chipped a tooth on her lower hybrid denture and loosened an implant screw. The denture had been placed 18 years ago, so she had an old titanium bar with denture teeth and pink acrylic. That day, I put the screw back in and smoothed out where the tooth was chipped. During this visit we had a great conversation about the future of her hybrid denture. 

I have had a similar conversation with several patients in recent months. They have the original, traditional bar retained hybrid denture that is nearing the end of its lifespan. And so, what are the options? 

1. If the bar is in great shape, new denture teeth and a new denture base can be milled and placed over the existing titanium bar. 

1. Alternatively, we can get rid of the bar and go to something that is all zirconia. 

If there is a preference for the first option, the first requirement is to make sure the titanium bar is in good condition. After 18 years, we would take it off and have the laboratory examine it under microscopy.  

If converting to all-zirconia and the patient has had upper and lower dentures, we must consider if one arch can be converted without converting the second arch. A zirconia arch is going to wear an opposing original denture fast if there is parafunction, and the zirconia arch is likely to fracture the opposing original prosthetic teeth. 

We have options today we can think about with our patients, but many have in their minds that when they got their hybrid dentures years ago, the dentures would last. All the time, energy, and dollars to freshen up or replace their denture is a big deal to them. Shifting their mindset from “I thought I was done investing in dentistry” to “My denture is at the end of its lifespan” is a big hurdle. So, the earlier we can start those conversations before they need to invest, the easier they can transition their minds to accept care with grace when the time comes. 

When your bar retained hybrid denture patients visit for perio maintenance and your exams, inform them of the lifespan of their denture is at most 20 years and set expectations for discussing the best available options at some point in the future.  

Lee Ann Brady, DMD 

I’m a big fan of retraction pastes, which are aluminum-based hemostatic agents. Their attributes make them highly effective when I need them, but they are also technique sensitive. 

• They are great for hemostasis within sixty seconds
• For a stringent retraction, you can leave them in place for two to five minutes
• They are so thick and viscous you can see them and easily rinse them off
• They do not cause prep discoloration like liquid hemostatic agents do
• They can interfere with the set of VPS or polyether impression materials but are less likely to do that than the liquids because they are so easily rinsed off

We must still be careful, though, to remove retraction paste from the sulcus. If residue is left behind, the impression material will not fully polymerize around the margin. So, while I love retraction pastes for hemostasis, I don’t use them unless I need them. I still prefer a two-cord technique using plain cord and epinephrine. When I do use a retraction paste, I am extremely methodical about rinsing the paste out of the sulcus. 

By Lee Ann Brady, DMD 

When a crown comes off and we are going to put it back in the mouth, we need to remove the old resin cement that is inside the crown. What is the best way to go about this? 

First, we need to know if the crown is made of zirconia or lithium disilicate. If you have a radiograph of that restoration, you can tell immediately which one of those two things it is. If you don’t, you can always attempt to X-ray it. (That’s what I do.) Alternatively, you can assume the crown is made of lithium disilicate, which is the more technique-sensitive material when it comes to removing cement. 

For crowns confirmed to be zirconia, employing 30-micron aluminum oxide air abrasion effectively clears out the old resin cement. Subsequently, re-etching the inside of the zirconia prepares it for reseating. For crowns presumed to be lithium disilicate, this approach should be avoided to prevent crack propagation. 

In the case of lithium disilicate crowns, two alternative methods can be employed: 

1. The crown can be placed in a porcelain oven to liquefy and evaporate the old resin. However, caution must be exercised to avoid rapid heating of the hydrated ceramic that has been in the oral environment. Rapid dehydration will introduce cracks and lead to crown fracturing. 

1. An alternative method involves using a brown silicone point in a high-speed handpiece, adjusted to lowest speed. A brown silicone point at slow speed effectively removes resin without damaging ceramic. 

How will you know when all the resin has been removed? When etching lithium disilicate, whether using red 5% hydrofluoric acid or Monobond Etch & Prime from Ivoclar Vivadent, any remaining resin will be evident because the dye sticks to it after the etching solution is rinsed off.  

By Lee Ann Brady, DMD 

For addressing the access hole of a screw-retained implant crown, my preferred method involves applying Teflon tape over the hole followed by temporary filling material, such as Telio Inlay from Ivoclar Vivadent. 

I emphasize to patients the importance of maintaining accessibility to the screw for potential adjustments without jeopardizing the integrity of the ceramic crown. Hence, immediately after seating the crown, I ensure no adjustments are needed before doing the filling. 

Patients are scheduled for a final post-op appointment with the surgeon after the restoration is in place. If there are no issues requiring crown removal, the Teflon tape and Telio Inlay may remain indefinitely, monitored during hygiene recall appointments. As long as the temporary filling remains intact, replacement is unnecessary. 

In cases where the Telio Inlay dislodges but the Teflon tape remains intact, I inform the patient of our plan to reapply the temporary filling. However, if repeated dislodgment occurs, leading to inconvenience, we consider transitioning to a permanent filling. In such instances, fresh Teflon tape is applied, and the access hole is filled with composite that precisely matches the crown’s color. 

Even if years pass and the Telio Inlay needs replacement, I opt for a temporary filling for ease of identification if removal is necessary. Only if frequent filling replacements prove bothersome do I consider switching to a permanent filling because I prioritize easy retrievability of the screw. 

By Lee Ann Brady, DMD 

One of the most common ways that we temporize a patient who is having maxillary anterior implant dentistry is with an Essix retainer. Some patients will wear it 24 hours a day and others for less. Hopefully they are taking it out to rinse, brush, and floss, but the reality is they are wearing a removable device that covers all of the tooth surfaces for a lot of hours every day, and we’re increasing their risk of caries, decalcification, and gingivitis. 

In addition to discussing the normal oral hygiene to be done at home, in our practice, we typically dispense a product like Clinpro 5000 from 3M or MI Paste from GC America. These are high calcium and fluoride products that provide fluoride treatments inside the Essex retainer. 

• If a patient is sleeping in the Essix, the instructions are to brush and floss the teeth and then use a toothbrush to spread a little bit of Clinpro or MI Paste on the inside of the retainer before going to sleep. 
•  If they are not wearing the Essix during sleep, the instructions are the same but to wear the Essix for up to an hour every evening before removing it to go to sleep. 

If the patient’s caries risk is high, I prefer using 10% carbamide peroxide gel instead of Clinpro or MI Paste. This is the active ingredient we us in perio trays to help prevent gingivitis. This is also the means by which patients can whiten their teeth while wearing an Essix retainer. 

To prevent damage to the Essix, instruct patients to rinse it with cold water and, when not wearing it, to store it in the provided container.  

Gary M. DeWood, DDS, MS 

Many dentists believe that provisional restorations don’t really matter. After all, they are not really a stand-in for the final restoration. I would respectfully disagree. I am a proponent of creating functional, durable, and highly esthetic provisional restorations, every time. They have the potential to impact your dental practice a lot more than you might think. Whether you print them, form them, or free-hand them, a GREAT temporary is a great billboard for your practice. 

1. Make the provisional as Esthetic as the final restoration.

I contend that the more your provisionals look like what you are hoping for when you seat the final restorations, the more people will talk about them, AND you. 

I was able to build a referral restorative practice by creating provisionals that made patients want to come to my practice and specialists want to send people. For much of our career, almost the entire team of the oral surgery office we worked with, and many of the team members from the other specialty practices we worked with, were our patients in Pemberville, Ohio. 

Front teeth or back teeth, when you make them look like teeth, people will like it and they will show and tell other people. “This is just the temporary?!” was not an uncommon question or exclamation from our patients.  

2. A GREAT guide makes a GREAT provisional restoration.

Your wax-up** cast/model serves as your vision, as your preparation guide fabrication device, and as your provisional former. When the preparation is appropriately reduced for the material selected, the temporary can mimic the restoration. 

** The wax-up might be created with wax then duplicated with impression material and stone to create a cast, or it might be scanned to be duplicated with resin and printed or milled to create a model. 

3. 3. Use that provisional to highlight the talents of your team members.

You might LOVE to make those provisionals, but if your assistant is equally excited when it comes to recreating nature for the patient to appreciate, then it could be an opportunity for patients to see that your assistant does much more than set-up, clean up, and hand you an instrument. My dental partner, Cheryl, (who is also my wife) and I actively sought out things that could help our patients experience our team as much more than our helpers. 

As we all know, dental assistants are an integral and vital part of what the practice is and are a powerful force in how and why patients ask for dentistry. Assistants who fabricate provisionals have an opportunity to be seen differently, and we were always looking for ways to create partnership with them in our treatment. 

4. 4. Take pictures of them.

Photographs of the temporary will make it easier for the lab to design the outcome. They will be able to see what you are thinking, able to visualize what you want, AND maybe even more importantly, see what you do not want. With anterior provisionals, I have frequently noted to my ceramist, “Please put the incisal edge in exactly this position vertically and horizontally in the face, then use your artistry to create the tooth that belongs in the face you see in the photographs of the patient before, prepared, and temporized.” 

There were many times when the technician was able to see and create effects that I might have not recognized as being “just the thing that would make these teeth extraordinary.” And don’t forget to show the patient the photograph. 

5. 5. Love the material you make the temporary with.

The better the provisional material is at holding tooth position and functional contact, the less adjustment we’re going to have, so using a high-quality material is important. There are a lot of them out there. I like bis-acryl materials that polymerize with a hard surface, have little or no oxygen inhibited layer, and can be polished easily. The polish is more about feeling smooth than about the shine. Ask you patients how their provisional tooth “feels” when you are done, so they sing your praises. 

6. 6. Use high-quality core material.

When you use a good core material the prep will be smoother, making it easier to fabricate nice provisionals. Ideal prep form goes a long way toward better provisionals. 

7. ASK your patient to tell people.

As noted above, when you can elicit an emotional response about the awesomeness of your provisional, ask the patient to tell other people, “….and this is just the TEMPORARY!” 

Kelley Brummett, DMD 

Resin-based temporary cements are wonderful due to their translucency and their ease of cleanup after light curing. My favorite is TempoCem from DMG.  

To prevent resin-based temporary cement from bonding to the newly placed composite, some dentists apply Vaseline on the prep before placing the provisional. 

Instead of Vaseline, I use glycerin. We keep glycerin in a little syringe in the room, and we put just a smidge in a little dapping dish so I can coat the top of the prep with it. Since beginning to use glycerin, I have not had difficulty retrieving bonded provisionals. 

If your provisionals come off, just get a new and stronger temporary cement. No! I am just kidding! If the provisional comes loose, it is often because you do not have enough space, so excursive interferences are high. When this happens, I engage with the patient in checking their occlusion, and continue to work out the determinants of their occlusion.  

Figuring these things out while the patient is in a provisional that is retrievable due to the ease of the temporary cement used, helps me continue to make progress on their occlusion before moving forward with the final restoration.  

It is not a failure of cement; it is a growth opportunity for discovery and patient engagement! 

Christopher Mazzola, DDS 

This is an example of a clinical study that can help us in our everyday practice of dentistry. Although the findings do not surprise us, keeping the findings in mind will guide us in decisions we make when performing treatments our patients are counting on to be long lasting. 

Dr. Markus Blatz is co-founder and past President of the International Academy for Adhesive Dentistry (IAAD) and Chairman of the Department of Preventive and Restorative Sciences and Assistant Dean for Digital Innovation and Professional Development at the University of Pennsylvania School of Dental Medicine in Philadelphia. He and a research team from the University of Coimbra, in Portugal, studied the effect of rubber dam isolation on bond strength to enamel. Their goal was to test two hypotheses. 

Hypothesis 1: Rubber dam isolation improves sheer bond strength independent of the adhesive system used. 

Hypothesis 2: A highly filled 3-step etch and rinse adhesive will provide higher bond strength values than an isopropyl-based universal adhesive. 

For their tests, they used OptiBond FL from Kerr for the 3-step etch and rinse adhesive and Prime & Bond Universal Adhesive for the isopropyl-based universal adhesive. 

The mesial, distal, lingual, and vestibular enamel surfaces of thirty human third molars were prepared (total n = 120 surfaces). A custom splint was made to fit a volunteer’s maxilla, holding the specimens in place in the oral cavity. Four composite resin cylinders were bonded to each tooth with one of two bonding agents (OptiBond FL and Prime & Bond) with or without rubber dam isolation. Shear bond strength was tested in a universal testing machine and failure modes were assessed. 

Both hypotheses were supported by the results reported in the Journal of Esthetic and Restorative Dentistry in November of 2022. 

• With the rubber dam in place, both of the adhesives performed better than without the rubber dam in place, resulting in approximately twice as much shear bond strength with the rubber dam. 
• The 3-step OptiBond FL system resulted in a more resilient bond than the Prime & Bond Universal adhesive. The OptiBond FL group with rubber dam presented the highest mean bond strength values. Fracture modes for specimens bonded without rubber dam isolation were adhesive and cohesive within enamel, while rubber dam experimental groups revealed only cohesive fractures. 

For the benefit of our patients, we shouldn’t cut corners that will impact the longevity of a restoration. My thoughts are that whenever we have basic pure enamel bonding it should be under a rubber dam, using a total etch, 3-step adhesive system. But considering dentin likes to be moist, we may need to make other clinical judgments.