Dallas Duo Completes the First Full – Mouth Zirconia Crown Case

Dallas based duo completes the first full – mouth zirconia case in Texas

Dallas Duo Completes the First Full – Mouth Zirconia Crown Case 1

Dr. Erik Harrington and Dr. Allen Rapolla completed a case on a 4-year-old patient with type 1 Dentinogenesis Imperfecta at Children’s Medical Center in Dallas, Texas. Dentinogenesis Imperfecta is a genetic disorder (an autosomal dominant trait) affecting tooth development. Patients have a type of dentin dysplasia that causes teeth to be discolored, sometimes turning them blue-gray or yellow-brown in color. These teeth have an opalescent sheen and are typically weaker than normal, making them prone to rapid wear, breakage, loss, and a demonstrated higher risk for carries. 

Anticipating the Case 

Shift Magazine: What were your feelings when you decided to do a 19-unit case using Zirconia crowns instead of the standard SSC’s? 

ALLEN RAPOLLA: We were definitely excited about the case because it would be our first time doing a case of this extent. We were also excited about what we potentially would be able to accomplish. I’d done two cases before this and felt comfortable working with a two to four-unit case. After completing the Sprig University, I had more confidence that I would be able to do other similar cases. However, one of the main concerns I had facing a 19-unit case was this—would I be able to get all the units to work together? Another thought that was going through my head was whether I would be able to deliver the same results that I had seen presented in previous articles. 

ERIK HARRINGTON: I had placed probably 40–50 crowns prior to this case so I felt relatively comfortable using Zirconia crowns. But I would also mention another area of concern—the issue of how to speak with parents about what treatment options are available and what they may expect. This discussion should include what plan B might look like if you can’t get the crown on for whatever reason. When you’re placing some of your first crowns, you’re going to want to have a backup plan. As you gain more experience, plan B recedes further and further in the rear-view mirror. You just won’t need to go to it. But these are some of the concerns you need to be aware of when you recommend Zirconia crowns. 

Shift Magazine: Did you or your staff discuss with the parents the option of using Zirconia crowns? What was the parents’ reaction to the Zirconia option: joy, hesitation, concern, or questions? 

ALLEN RAPOLLA: We had first seen the patient in the office prior to my taking the Sprig University course. Initially we did not discuss the option of Zirconia crowns. At the time the Mom understood that her daughter had a rare condition that affected her daughter’s dentition and required some kind of full-coverage restoration. At first, she was okay when we recommended silver crowns, but truthfully, she was not 100% on board with them being all silver. After further review, we discussed with her the option of using natural, tooth-colored Zirconia, a product we had recently started using. She was excited, joyful, and completely on board with this new option. 

Shift Magazine: Were there any concerns about the time that it was going to take in the operating room? 

ALLEN RAPOLLA: Yes, we definitely had concerns about the time. Firstly, because of my limited experience, and secondly, due to the number of units that we were going to complete. While taking the Sprig University course, you learn all the steps needed to complete the prep in order to ensure a good fit and a successful placement of the Zirconia crown. But when you have 19 units, you’re in an environment where you are also concerned about limiting the time the patient is under general anesthesia. You are also mindful of the anesthesiologist’s time and of the time using the OR. Time was a big concern. 

ERIK HARRINGTON: For the record, the case took just a little over two and a half hours to complete all 19 teeth. 

Shift Magazine: What was the biggest mental challenge when facing a 19-unit case? 

ALLEN RAPOLLA: The mere fact that the case involves 19 teeth—that was daunting. As a practitioner with limited experience using Zirconia crowns, I had to look at each prep on its own. Over the course of placing 19 crowns, I would need to do my best to maintain the occlusion, minimize bleeding, while monitoring the amount of the time being spent in the OR. These concerns running through my head were mentally taxing and physically draining. 

ERIK HARRINGTON: In addition, you’re fearful, especially at the very beginning. You haven’t done too many of these, and you’re fearful. I can’t emphasize enough how much our decision to be together on this case meant to us. Let’s just say you are going to do an IV case that has eight crowns. You may want to invite one of your colleagues just to be with you in the room that afternoon. Not that you’re asking to split the case like we did on this one, but it’s reassuring just to have another set of specialist eyes there with you while you approach this learning curve. I can’t emphasize enough what it felt like to have a colleague in the room while doing a case this large. 

Execution of the Case 

Shift Magazine: Did you look at the mouth as a whole or did you concentrate on quadrants? Secondly, did you prep all the teeth sequentially; meaning all occlusal, then also supragingival, and then finish by doing the subgingival prep on every tooth? Or did you tackle the case one preparation at a time? 

ERIK HARRINGTON: As a practice philosophy, we look at all mouths as a whole. We believe the mouth is a window to the body. To specifically answer the question, we did tend to focus more on sextants or proceeding half of the mouth at a time. Let me clarify. In the OR, we use a groundbreaking dental innovation of the last decade—the Isolite. This device divides the mouth into right vs. left halves. In this case we started with the left side of the mouth. Then, we divide it up into smaller sections. I focus on the posterior sextant and then move to the anterior. In terms of prepping the teeth, we did not prep them one at a time. We did it sequentially—almost exactly as we learned to do at the Sprig University. The steps we followed in prepping one tooth after another were: the occlusal reduction, the proximal reduction, the subgingival prep, creating the “race track,” and doing the “ring around the rosy” five times. We did this using the same bur and completing each step on each of the 19 teeth before proceeding to the next step. 

Shift Magazine: During the case, what were your biggest challenges, and what went better than you had expected? 

ERIK HARRINGTON: Obviously we were concerned with so many teeth that we needed to focus on. The biggest challenges we anticipated as we proceeded were tissue response and the spacing of each individual crown. Fortunately, we lucked out in this case. We did not face any challenging space issues, and the bleeding was easy to control. So, our case ended up being better than expected. However, these issues of spacing and tissue bleeding were the two biggest concerns we thought we would have to face. As a recommendation to others, we immediately agreed that in the future when working on similar cases, it would be prudent to recommend adopting a soft tissue management program (like chlorhexidine) in the days prior to the procedure. 

Shift Magazine: What was your sequence of cementation while placing the 19 crowns? 

ERIK HARRINGTON: Once we prepped all the teeth, we placed the crowns on passively to make sure each of them fit. After removing the crowns and cleaning them, we cleaned the surrounding soft tissue, keeping gauze in those areas where we felt bleeding was a potential problem. Then we cemented the crowns, proceeding from the posterior to the anterior, starting with the maxilla then moving to the mandible, one tooth at a time. Since we started on the left, we seated tooth J first using resin-modified glass ionomer cement. Then we tack cured the buccal and lingual aspects of the tooth for about two seconds. Taking an explorer, we removed the just slightly solidified cement from the margins of the crown. This process allowed us to clean up tooth J rather quickly and move on to tooth I, using the same procedure. Subsequently, we proceeded to the canine, eventually completing the rest of that half of the mouth. 

Shift Magazine: Did your hands-on continuing education training in the use of pediatric Zirconia crowns prior to doing the case help you in your execution and in giving you more confidence in the face of what could have been a very challenging experience? 

ERIK HARRINGTON: This is a really easy question to answer. Absolutely. The Sprig University course was the tipping point following which we certainly felt confident going into this case. We were understandably nervous, but the hands-on training received during the course enabled us to complete the case with confidence. 

Allen Rapolla: I just wanted to follow up on that. Since Zirconia crowns are relatively new to the market, it is important to realize that they require a slightly different approach to prepping compared to the process used in prepping for porcelain veneered SSCs or plain SSCs. Had I not attended Sprig University I would not have had the same degree of confidence to take on this new approach to prepping. The hands-on experience helped to 1) build my confidence, 2) answer any questions I had, and 3) gave me the opportunity to figure out—in a comfortable learning environment—okay, this didn’t work, but here is a better alternative. Definitely an absolutely positive experience. 

Shift Magazine: What was your personal reaction when you cemented the final crown, and what went through your mind? What feelings and emotions did you experience? 

ERIK HARRINGTON: When we were cementing that last crown I almost wanted to cry. I was very proud of both of us and our accomplishment after taking on the case. I also wanted to cry because of the dramatic visual difference between what the teeth looked like before and how they appeared after we placed the Zirconia crowns. It takes your breath away. When you look at the before and after pictures and realize how the family’s reality has now been altered for the good, you just sit back in awe. 

Also, because of the beautiful tissue response, just the way the teeth look in the tissue makes you proud that we can now offer this biocompatible alternative to SSCs. 

ALLEN RAPOLLA: Initially, I had a vague idea of what the results might look like. But it wasn’t until after all of the Zirconia crowns had been cemented and I saw them in the mouth that I actually truly understood the beauty and innovation of this product. I am definitely very excited and am looking forward to using these crowns more in our practice. 

Dallas Duo Completes the First Full – Mouth Zirconia Crown Case 2
Dallas Duo Completes the First Full – Mouth Zirconia Crown Case 3

Reflecting on the Case 

Shift Magazine: Looking back at your initial expectations, how did they line up with the reality of actually completing a 19-unit case? 

ALLEN RAPOLLA: Again, piggybacking off the previous answer, I did have some initial expectations. I knew that Zirconia was a great product. I’d done some research and been through the Sprig University, but it wasn’t until I saw the results that I understood the life-altering impact of a smile recreated with Zirconia crowns. You can see the brown, yellow, translucent teeth that our patient presented with. Then to compare that with the results afterward—such real-looking crowns with great anatomy. Words fail to describe my feelings and the feelings of joy the parents expressed when they saw their child’s smile for the first time after she came out from surgery. It’s just another level of reality than what I initially expected. 

ERIK HARRINGTON: I will also reiterate, doctor-to-doctor, that the soft tissue response, the way the gums react to this product is different and far better than a response to either SSCs or veneered SSCs. In our experience, looking back post-operatively, the response of Zirconia is nearly as biological as that of natural dentition. 

Shift Magazine: Why do you think that so many dentists are nervous to tackle larger cases when using pediatric Zirconia crowns? 

ALLEN RAPOLLA: Zirconia is a relatively new product, so you’ve got to go through a learning curve. You’ve got to see how it works in your hands; see what you need to do to place the crowns successfully. This process is going to take time. First, you’re nervous when you have such a large case like this. Because of the learning curve, it’s easy to be intimidated. Secondly, because you’re working through the new steps, questions that come to mind are, “What if I can’t get it to fit? What if I’ve done all the things that I’ve been taught, and it’s just not fitting?” These questions create some feelings of stress and being overwhelmed. I think when you add to these feelings’ thoughts about the number of units involved in the case, the stress increases exponentially. 

ERIK HARRINGTON: I think it’s the same fear we all have, the fear of the unknown. You don’t know what’s going to happen. 

Shift Magazine: Many dentists are extremely happy with their decision to adopt the use of Zirconia anterior pediatric crowns but do not yet use posterior Zirconia crowns. What would you say is the biggest advantage they’re missing out on by not having posterior Zirconia crowns available in their offices? 

ALLEN RAPOLLA: For me, the tissue response is so important. We all have used SSCs for years now, and always see a little bit of bleeding and gingivitis as a result. But I was most amazed with the tissue response to Zirconia, not only in the posterior but in the anterior as well. The second thing that impresses me is the parent response to the esthetics. When you are evaluating the smile zone and you see a full-coverage white restoration that is very natural-looking and see the parents’ joy and excitement with their child’s restoration—these responses are incomparable. 

Shift Magazine: We all know how challenging cases can be that have existing space loss. When using posterior pediatric Zirconia crowns, how important have you found it to have space-loss crowns available? 

ERIK HARRINGTON: I absolutely think it’s a necessity to have the space-loss crown kit at your disposal. Your best approach is to really lean into your 

Zirconia crown training, which I think Sprig University does best. When you understand how you are supposed to prep the teeth, you are really reducing the chance that you might need to reach into the space-loss kit. However, because of crowding and space-loss issues, having that adjunct—having that kit with slightly different anatomy—is absolutely crucial at times when you need it. I think you would be remiss not to have the space-loss kit available. 

Dallas Duo Completes the First Full – Mouth Zirconia Crown Case 4

Looking to the Future 

Shift Magazine: Over the last few years it seems that the field of pediatric dentistry has seen some revolutionary products come to market. How does it feel as a pediatric dentist to see exciting innovations coming into your field, arguably for the very first time in a very long time, and does it give you hope for the future, anticipating what could be coming next? 

ERIK HARRINGTON: Yes, it does give me hope for the future, anticipating what is to come. It has been hard as a pediatric dentist—being in a medical-related field—to look into the eyes of parents and honestly tell them that the best that we have to offer is the same that we had 50 years ago, namely silver crowns. Zirconia crowns have taken a quantum leap in providing our patients an option that is just that much closer to what natural teeth look like. It is very exciting to see these innovations coming into the field. I am very appreciative of pioneers like Dr. Fisher and Dr. Hansen for taking the risk and showing the courage to bring Zirconia crowns to market. 

Shift Magazine: Pediatric Zirconia crowns are changing how parents and dentists view cosmetic dentistry for children. What do you think will be the major challenge for offices that are late adopters of this new technology, and do you think offices that embrace changes in technology have a competitive advantage over those that stick with the status quo? 

ERIK HARRINGTON: Early adopters absolutely have an advantage. The major challenges for late-adopter offices are exactly that—they’re late adopters. I feel like the only reason these people have touch-tone telephones is because rotary telephones just aren’t made anymore. When any product comes to market, for it to have mass market appeal, there must be a tipping point—a point at which a certain percentage of the population demands a certain service or product. Usually that tends to be around 17–20% of the population. When you compare esthetic Zirconia crowns to SSCs, in my eyes, it is clear which product is superior in terms of strength and esthetics. I won’t claim the same superiority when it comes to the ease of placement or how to technically place them, but we can get there. I know we can get there. Once parents realize that esthetic Zirconia crowns are an option—a viable option (albeit sometimes advisable on a case-by-case basis)—they will make their wishes known. They will demand the services and create the market which late adopters can no longer ignore. Those offices that embrace changes in technology will clearly have a competitive advantage because they demonstrate the courage, take the risk, and follow the uncomfortable steps necessary to move our profession forward. I know it’s what the public demands. I know it’s what we—many of us being parents ourselves—demand of our own profession. It’s what we would want for our own children. 

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