Advanced Pediatric Zirconia: Clinical Pearls — Transcript
[00:00:14] Welcome and what tonight covers
Hey, thank you everyone for signing on. I know after a long day’s work, sometimes the last thing you want to do is listen to more things about what we already did for the day. But in the interest of everybody’s time, I want to make this fun and enjoyable.
One of the hard things about doing these webinars is I don’t get to interact with you guys, but you can write questions in chat and ask questions at the end. We will be happy to answer as many of those as we can. I hope you guys find this enjoyable, and I don’t want to waste anybody’s time, so we’re going to get rolling.
This is a webinar on anterior crown preparation: our technique, some advanced zirconia options that we use, and some pearls for these that I’ve figured out over the years.
[00:01:01] About me and my why
My name is Dustin Janssen. I’m a pediatric dentist and I own Parkview Pediatric Dentistry in Lubbock, Texas. I grew up here, so after completing my residency I came back to Lubbock to open this practice. I started in 2009 out of dental school as a general dentist and practiced for a few years, then I went back to the University of Washington and Seattle Children’s for my pediatric residency. In 2013 I opened my private practice, Parkview Pediatric Dentistry.
This is my family. These are my three girls and my dog, who is also a female. I have lots of females that work with me in the office, and I am surrounded by them. The best advice I have is I say yes to what they tell me to do and listen a lot.
But I put this picture in here because I think it’s the most important thing that I want to say this evening. Some of us have our own kids, some of us don’t, and that is awesome too. But when you have your own children, you realize what an amazing gift it is to raise and lead that child. And what I know is people walk into my practice each and every day and trust me to care for their kids, some of their most valuable assets. So what I want to do is make sure that I treat each and every one of those kids just like I would treat my own children. What an amazing honor it is to get to do that.
So before anything else, regardless of anything else that I say, if you leave with nothing more than that, please remember tomorrow, with a renewed sense, what an amazing gift we’ve been given each and every day to care for other people’s kiddos. Remember that. Man, it’s such a beautiful thing. These are my kiddos and my family, and they are a lot of my why behind what I do.
[00:02:44] Our practice, Sprig’s first decade, and a cocktail
One quick thing I wanted to mention: as a pediatric dentist in Lubbock, Texas, we have an amazing opportunity to care for a really large population that is in need of care, and we don’t have many pediatric dentists in the area. We currently have four board-certified pediatric dentists and two practices. This is our brand-new building that we just built, part of our hygiene bay and some of our waiting room. We’re actually building out a brand-new 10,000-square-foot building.
We have a great fee-for-service and Medicaid-based office. We have a really awesome opportunity for care at a children’s hospital, as well as anesthesia in our office. We try to provide minimally invasive dentistry and a preventive-based approach. We have lots of new patients coming in to see us each and every month. We love building relationships with our patients, and our doctors get to treat the patients that they see. I think we’ve got a highly desirable and trusted office with tons of Google reviews. I’m happy to talk about those at the end; I think that’s a really important part of practice that each and every one of us can use to add value to our practice.
Anyway, if anybody on this webinar, or anyone you know, is interested in a different opportunity for practice, I would love to chat with you. Even if it’s not about coming to work with us here, but just helping in your own practice, it’s something I really love doing. So please feel free to reach out. It’s dustyjanssen@gmail.com.
Sprig has been around for over 10 years now, and in these 10 years a lot has gone on. In 2006 they developed the first pediatric zirconia crown. In 2009 it was seated on a pediatric patient. In 2013 they introduced the first zirconia preparation CE course, and I got to teach that course a long time ago now. They rebranded in 2017 as Sprig Oral Health to offer further products and tools for your toolkit. They’ve continued their growth internationally, and in 2020 celebrated a decade of time-tested results and smiles. So really cool for Sprig, to see the growth they’ve had as a company, and I’ve had a great time getting to teach during that time.
It’s a long day, and I know we’ve had a good day. I like to make cocktails. If I wasn’t a pediatric dentist, I might be a bartender. This is a cocktail that I made this evening, and I hope you made yourself one. I really like to make a John Wayne Manhattan. It’s a little twist on a traditional Manhattan: instead of the sweet vermouth, you switch that out with amaretto. This is my cocktail of choice for the evening. Cheers to you guys. Thanks for signing on and doing this thing with me.
[00:05:29] My journey into zirconia, and the evidence
Let’s talk a little bit about my journey into zirconia. When I was in residency, we had a couple of treatment options: one was strip crowns, two was a resin-faced stainless steel crown. Most people wanted strip crowns, so that’s what we gave, and as a first-year resident what I did was repair the previous residents’ failed or chipped strip crowns. I have a picture of when I was doing that. It looks something like that: you’re wrestling a little alligator trying to get a broken strip crown back on. I was like, man, this is impossible. There has to be a better option.
So I was looking for change. I was searching around, and at that time Sprig had just come to market. I was able to speak with the owners of Sprig and convinced them to let me have the crowns to use in residency. They said, “Hey, you can have the crowns, but you’ve got to take pictures.” So I took lots of pictures of the treatments that I did and sent them back, and that’s how I ended up in this role of teaching. Beyond the teaching role, even if that’s never something you want to do, take pictures of the things you do so you can show your other patients what you’ve done.
This was a kiddo I recently saw for a follow-up. I got to put crowns on the two front teeth as well as the canines, and it turned out really great. That was a quick two-week follow-up.
These crowns are backed by time-proven results, but also by some scientific evidence. There are a lot of different levels of scientific evidence. Some of what we’re going to talk about is case studies, some is super smart people talking about them, and sometimes it’s people who are sort of smart but have done it a long time. And don’t forget, tonight you get to hear from this guy, who is the bottom of the pyramid. But here I am every day doing these crowns, and if I can do them, I feel like you guys can too.
This is the first article I wanted to talk about, a clinical evaluation with parent satisfaction of these crowns. They evaluated 53 crowns on 18 children between the ages of two and six at a four-year follow-up. They found that 96% of the crowns were intact, 64% had no inflammation and 32% only mild. 64% had no noticeable aesthetics from the primary dentition, so they looked great; most of the time you couldn’t even see the difference. 100% did not show any wear to the opposing dentition, and there was no recurrent caries noted on those crowns. So ultimately this showed that these zirconia crowns were a clinically acceptable restoration in the maxillary anterior dentition. Again, these were only anterior crowns placed in this study.
This was a kid that I got to work on, and sweet Mom sent this to me on Facebook: “Thank you for those beautiful pearly whites. Going on three years and they still look gorgeous. I truly wish she could keep them forever.” Sweet, beautiful little girl that I got to take care of, and I love getting these pictures back.
This was a 29-month follow-up of a pediatric zirconia crown, a case report with really good pictures of that crown. There wasn’t any attrition to the antagonist, which is a big thing we always worry about, all the way through 20-plus months. There wasn’t any gingival inflammation noted on that crown either.
Then this was a really cool picture. One of the things we’ve heard for years and years is how well you can adapt a stainless steel crown. And listen, I think I put on a nice-looking stainless steel crown, but I know I don’t get perfect margins. I know there’s a cement margin there and I’m counting on that, and we’re counting on the same thing with the EZCrown. These are some great pictures of exfoliated zirconia crowns with a very similar-looking cement margin at the time of exfoliation. So great aesthetics as well as adaptation to those teeth. The good of this study: no loss of retention, no fractures, no real wear noted on the opposing dentition, periodontal health was excellent, and realistically those teeth exfoliated without a problem.
[00:09:33] The trade-off: no flex, but strong
All that being said, I’m not here to tell you that there are no cons associated with zirconia crowns. Zirconia crowns have lots of pros, but there are cons as well, and things we need to be aware of if we’re using these crowns in our practice. There’s nothing perfect, and zirconia is no different.
One of the big cons of zirconia is it’s not flexible. It does not flex, so there needs to be a passive fit when you put the crown on. There can be no snap-down; there is no ability for that crown to flex as you put it on. There needs to be no pressure on the intaglio surface of the crown, otherwise it will break. So it does take a little longer to prepare a tooth for that reason.
Now, as a pro, zirconia is really strong. It’s biocompatible, it’s aesthetic, and it’s plaque resistant.
So how strong does a pediatric zirconia crown need to be? Crowns get stronger as they get thicker. That makes sense, right? You make a thicker crown, you have a stronger crown. Well, we only need them to be so thick, because the thicker they are, the more tooth you have to take away to put the crown on.
This article looked at the strength of zirconia crowns and found a positive correlation between increased crown thickness and increased fracture resistance. Makes sense. What they actually found was that the Sprig crowns were the strongest. Now, that’s not necessarily something we want to keep chasing, because strength is related to thickness. So following this, Sprig was able to thin the crowns in areas to allow you to take away less tooth structure.
This is a kiddo who was not one of my cases, but one of our colleagues placed these crowns under general anesthesia. A few days later the kid fell on the concrete and had this traumatic luxation, a nice bonk of those teeth. However, in a few weeks the tooth returned back to normal and the crown is still present. We know that would never happen with a strip crown, and even a resin-faced crown would have fractured off that facing. The crown is still there, with really nice radiographs showing it still present. Good things happen when you don’t have to replace a crown every time a kid knocks it or bites on a rock or does all the things that kids do.
The crowns have high strength, and that strength comes when the crowns are seated. Before the crowns are seated, pressure on the crown, squeezing it, will break the crown. However, after seating, when you have cement under the crown, those crowns become extremely strong. The goal for Sprig was a crown strong enough to withstand the maximum bite force, but to get rid of any unnecessary weight to keep reduction to an absolute minimum. I think they did a good job of that. Those crowns can be seated even in really tight places.
[00:12:06] Gum health, aesthetics and plaque resistance
The next pro of zirconia is biocompatibility. We see really nice gingival health on these crowns. In the picture on the left you can see the pre-veneered stainless steel crowns, and you can see the puffy gum tissue associated with them. They also build up plaque, which we’ll talk about in a minute. Zirconia crowns don’t build up plaque, so you can see teeth D to G there have really nice gingival contours, but also nice healthy gingival tissues.
This is a nice study on the healing response and gingival response to zirconia. You can see it as an abutment, with nice tissue growth around that zirconia implant abutment.
We can also talk about aesthetics. This is a great picture, because you can see tooth S there with a nice zirconia crown. There are actually two zirconia crowns in the picture: tooth R also has a zirconia crown. Really beautiful aesthetics. One of the things you notice on Sprig crowns is the chroma change. They use hand tinting to give a really nice effect in the mouth, where you don’t need multiple shades of a crown to make it look good on a kiddo’s tooth. It blends beautifully with natural teeth. It’s definitely requested by our parents as well as our children. And it is a solid white crown, obviously, not a facing where you can break off the white facing and end up with a stainless steel crown underneath, like this.
Another thing that looks great is the ability to resist plaque buildup. On zirconia crowns, plaque does not build up even when the kid doesn’t brush their teeth. I can’t imagine why this kid would have needed crowns in the first place, right? They obviously still don’t brush their teeth.
[00:14:33] Designing out hyperocclusion
Sprig also wanted to create a crown that didn’t have hyperocclusion. Think back to the days when we did dentures. Thank goodness I chose an area of dentistry where I don’t have to make dentures. But when you made dentures, you didn’t use teeth that had deep cusps and fossae, right? We used a flat occlusal plane, and that was important because it allowed for nice lateral movements that didn’t create excessive forces on the teeth.
If you think about this, hyperocclusion is not ideal. We need to remove some tooth structure, but the deeper that inner mesial ridge is, the more tooth you have to take away. So a flatter occlusal profile is important, and it decreases the problems with taking away too much tooth surface.
In the anterior, one of those things is the cingulum. The cingulum on a primary anterior tooth is really where we get a lot of the strength for the tooth. If you remove all of that cingulum, you now have a greater chance that the tooth breaks in half, and now we end up with a non-restorable tooth.
So the ideal design Sprig wanted was one that wasn’t too high, didn’t need adjustments, could minimize tooth reduction without pulp exposures, fit in areas of space loss, and blend seamlessly. That’s where they came to the V2 design of their crowns.
[00:15:56] The V2 design features
A couple of the pros of these: there’s less tooth reduction because they have a flat profile. They are easier and faster to seat because they have flat ridges. Now you can seat them back to back with much more success than with a curved distal or medial ridge. They retain a natural look. Even though, listen, outside of the mouth, I know if you look at this crown it doesn’t look anatomic. That’s by design, because it gives you much easier workability with that crown, and they follow the natural contours of the teeth.
As I said, it’s a flat-fit design. The Zir-Lock retention is absolutely the thing that sets these crowns apart, in that you can use any cement you want to seat these crowns. We are not relying on a chemical bond or cure between the zirconia and the cement. It is very difficult to bond to zirconia. If you’ve done it before as a general dentist, you use silane coupling agents, you have hydrofluoric acid and different things you need to do, with a perfect, ideal environment. That’s not what we ever get in a child’s mouth. So we want something that’s easy to use and that we can quickly bond to well. In this case you can use any cement you want, and in my case I use a Fuji I cement.
They also have a space loss design. If you’ve ever used a Howe plier to flatten a crown, that’s exactly what these space loss crowns give you: the crown squished flat, so you can get it into really tight spaces.
They also have the polychromatic finish, as I talked about, with the hand tint to the gingival third.
[00:17:39] Less reduction and mechanical retention
As we talked about, these design contours allow the occlusal table to be raised up, which decreases the prep needed and moves you further away from the pulpal tissue. Same thing in the buccal-lingual dimensions of the anterior and posterior crowns. They have flat profiles, and those flat profiles mean you have less tooth structure to take away, as well as an easier seat of the crown.
With a Sprig crown compared to a competitor crown, you only need to take away 1.3 millimeters of occlusal reduction, while the competitors need a half millimeter greater reduction. And a half millimeter is a half millimeter; that’s a half millimeter closer to the pulp tissue. I don’t know about you guys, but I sure don’t enjoy doing pulps, especially if I don’t have to. I will say that in all the Sprig crowns I have ever done, I have never had an iatrogenic pulp exposure from my preparation.
Another thing about the Sprig crowns is, listen, they know they don’t have this interesting anatomical shape. Well, an anatomical shape means you have to take away more tooth structure. If you have a smaller hole at the bottom and a bigger hole at the top, your lowest common denominator is that small hole, so you’re going to have to take away more tooth structure. The Sprig crown looks more like a teepee. That big, wide teepee means you have less tooth to take away, more tooth remains, and an easier fit for that crown.
Looking again at that flat-fit design contour, there’s no reason a crown needs to have a deep mesial margin or mesial fossa. You don’t need that. All you need is this flat occlusal table.
As I already talked about, the Zir-Lock retention is a key to this. Zir-Lock means you don’t need the chemical bond to the tooth. You’re relying on macro- and micro-mechanical retention of the crown to hold the cement in. I will tell you, if you’ve ever had one of these crowns come off, which doesn’t happen often, every time I’ve looked at the interior of the crown, you’ll see the cement on the interior of the crown, not on the tooth. Where the bond breaks is on the tooth.
This is a great picture of an exfoliated tooth. It looks awesome. Back to the retention: a very small cement gap around the entire tooth, and this is a tooth at the time of exfoliation still with complete cement retention right at that marginal lock. One of the extra things Sprig does is create an extra-deep ridge right at the margin to hold that cement in. And there’s a close-up of that picture; I think it shows it really nicely.
Other crowns are made a little differently. Some are made by injection molding. Others have some retentive grooves, but not to the depth or throughout the entire crown like the EZCrowns do.
[00:21:02] Space loss crowns
As I talked about already, Sprig’s space loss crowns are really important to give you the opportunity to seat crowns in a challenging environment, right? We’re not putting a crown on a tooth that is fully intact. These teeth usually have some mesial or distal tipping, so you’re trying to put a crown in a really challenging place. I think about the space loss crowns like a stainless steel crown where I took a Howe plier and squished it. Now you have a crown that will fit in that really tight space. Essentially, they’re pre-squished crowns just for you.
If you’re using these crowns, the ones in red are space loss and the blue are the Sprig traditional crowns. The Sprig traditional crowns are a little bit narrower and allow you to get in there. On this one you can see they have canine space loss crowns.
We always talk about space loss in the back being super challenging. But if you have a kid with lots of cavities and you’re restoring the top six or so in zirconia, I will tell you those space loss canines are a godsend. They allow you to get those teeth in place with a beautiful aesthetic result. I always say the canines are where I have a little extra room to take off, because you have such a small pulp chamber relative to the size of the entire crown, and you can take away a lot more tooth before you ever get to a pulp. So if you’re running into a situation where you need a little extra space, you can take that space from the canines and be able to fit all those crowns all the way across the front.
This was a really large case completed with all zirconia crowns, and you can see a really nice finish and aesthetic result, with really pretty tissue contours. This case was really made possible by the space loss crowns. As you can see, you can gain a few millimeters of space in each little area to get the extra room you need in the arch.
[00:23:11] Colour, polish and wear
Lastly, it’s about creating a really aesthetic crown. I think Sprig did a very good job of letting you avoid extra-bright, toilet-bowl-white crowns. You get a crown that will fit throughout the arch and throughout the population and really blend seamlessly.
They took a few things into consideration. One, they wanted to make it look really pretty, but two, they also wanted it to function well and not wear the opposing teeth. We know porcelains are much rougher, more like sandpaper to opposing dentition. So they mirror-polished all of the functioning surfaces, and those surfaces have ultra-low wear to the opposing dentition. On the facial surfaces, however, they created individually hand-finished surfaces with a polychromatic effect that really blends them with the natural arch. […]
This gives the gingival third a light stain and lets you really see that nice chroma change from top to bottom.
On these crowns you can see the nice polychromatic finish and this really smooth, ultra-low-wear surface compared to other crowns. This is an SEM view of these teeth, and you can see how much less wear these EZ zirconia crowns have compared to competitors.
[00:24:53] The prep technique: burs and principles
There are also different techniques we can use as clinicians to get through an efficient and atraumatic preparation. When I started doing this, I will tell you there was no such technique. We just tried our darnedest to remove tooth structure to the point where a crown would fit. Now there’s a great technique Sprig has developed to help clinicians get through that more easily.
They have a bur block you can get from Sprig with the different burs we use: a wheel, a barrel, a football, a flame, and then a second football that can be used to remove the zirconia if need be. I will tell you that’s not a bur I have ever used or had a need for. These are made with specific depth cuts in mind, so that you as a clinician don’t have to think about how deep you need to cut the tooth structure.
When you seat these crowns, we want passive finger-pressure seating. You’re not pressing these crowns on harder than that; otherwise, expect a fracture of those crowns.
When you prepare them, we want a cylindrical design. It needs to be a straight up-and-down preparation, not teepeed in. When you teepee in, that’s absolutely when you get closer to the pulp. That’s where you start having problems, and it does nothing to help you get the crown seated. It’s almost always the gingival third, or subgingival, where you need to take a little more tooth structure away.
[00:26:26] The anterior prep, step by step
For our anterior prep, step one is 1.5 millimeters of incisal reduction. That incisal reduction is exactly the thickness of that diamond, so when you take the one and a half millimeters away, it gives you a perfect depth cut for where you need to remove tooth to get a subgingival seat.
After you’ve taken that incisal reduction, the next thing is your supragingival axial reduction. This is EZPrep bur 2, a barrel diamond. Essentially you’re removing the axial portion of the tooth, just like if you were prepping a permanent zirconia or porcelain crown on an adult tooth. We remove that supragingivally, and now you have a chamfer margin right at the gum line. To give you a visual aid, you’re removing right about the thickness of the enamel, an enamel thickness all the way around the tooth, 360 degrees axially.
After you do that, you do one second plane of reduction in the incisal third, to roll that incisal edge back. This gives you a nice aesthetic seat, so the crown doesn’t flare too far out to the facial.
This is a bird’s-eye view of that preparation. You should be able to look down and see what we’d consider a racetrack all the way around that tooth, and that racetrack is what you’ll take away in a minute. The racetrack should be equally thick all the way around the tooth, about 0.8 millimeters thick.
At this point you can go to your EZPrep bur 3 and remove the cingulum. You’re removing about 0.75 to 1.2 millimeters of lingual enamel. You dish out that cingulum ever so slightly. Remember, we talked about how important it is to keep cingulum structure, so you’re not trying to take away every bit back there, but a little bit of cingulum reduction is going to allow the crown to seat nicely.
The last portion of this prep is exactly what would make every general dentist in the world cringe. You take that beautiful chamfer you just created and cut it off. You use your EZPrep bur 4 to do a subgingival axial reduction, and you entirely remove that chamfer all the way around. This is where we see a lot of people make an error: instead of just taking the chamfer off and keeping the bur perpendicular to the long axis of the tooth, that’s where we teepee things in. So please remember the long axis of the tooth, and circumferentially remove that tooth structure. When you do that, make sure you’re hugging the bur axially along the tooth. Do not taper it at all. The other thing is to get down two millimeters into the sulcus and make sure you get rid of all of those ledges.
[00:29:35] Common errors: “It’s the lingual, stupid”
The errors we see people make: first, you don’t get the full thickness of that initial bur 1. Make sure you get the full thickness of the occlusal or incisal reduction. If you’re not sure, you can always use the adjacent mesial marginal ridges as a guide.
The next thing is we don’t take enough axially. Please get the full thickness of that bur all through the facial and lingual. I’m going to tell you, when I was doing these before, one of our instructors used to say that when he was trying to seat these crowns and couldn’t seat them right away, he’d instructed his staff to say, “It’s the lingual, stupid.” He’d be prepping, couldn’t get them on, and the staff would say, “It’s the lingual, stupid.” Then he’d check the lingual and take a little more. We usually forget or miss a little bit on that lingual or palatal.
Sometimes if you’re tapering, if you think of that tapered bur, you also leave a lip in that subgingival area. If you leave a lip in the subgingival area, when you try to seat the crown either it won’t seat or you crack the crown, because you’re trying to press it over that little lip. You can see this one, on that upper crown, had a lip there. That’s what caused the crown to have a little tip to it and not fully seat.
So if you have that improper subgingival prep, you know you’re not parallel to the long axis when you’re preparing the tooth. We don’t want the undercut pressure of the tooth pushing out on the crown, creating that fracture of the tooth.
[00:31:14] Hemostasis and cementation
The other thing, when we’re seating a crown, is good tissue management. We know we’re going to have bleeding when we try to seat these crowns, and bleeding can be controlled. There are lots of ways to control bleeding. One of those is HemeRx, pellets made by Sprig. It’s an epi pellet you can put in the interproximal or tissue space to squeeze down those capillaries and slow or stop the bleeding. Bleeding is one of the causes of loss of retention. The other is movement of the crown during the initial seat.
This is a case I did, and you can see on tooth D I did not get good hemostasis. This did not cause crown loss; it just caused an area of darkening under there. I actually tried to take it off and it wasn’t coming off, so I told the parents we did such a great job of creating some characterization for this crown; I just didn’t want it to look perfect, so we gave it a little flair with a little different color. Sometimes it’s all about how you phrase things.
But realistically, I think it’s also important to take pictures. I take pictures of the crowns I do, so it’s easy to show parents what they looked like before versus what they look like now. In this case the kid had bombed-out, nasty-looking teeth that we put SDF on. I do the crowns and we have a little bit of black show-through, which can occur, and we’ll talk about how to minimize that. If they’re concerned about it, I love to show the pre pictures, to show how much improvement we’re talking about in those post pictures.
These are the HemeRx pellets. They let you really get in and quickly get hemostasis while you’re cleaning your crowns out and getting them ready to seat.
When you’re cementing, it’s important to know Sprig wanted to make this as easy as possible. The Zir-Lock crowns keep you from needing to worry about chemical bonding. With other crowns that have try-ins, you have to worry about chemical bonding and not getting any saliva or heme underneath the crown, because if you do, you’re going to lose that chemical bond and potentially debond the crown. With Sprig, that’s not something you need to worry about. No concerns with that.
It also allows you to use a really inexpensive cement. This shows the cost per unit of cementing these crowns. If you’re using a powder-liquid Ketac Cem compared to a BioCem, you’re talking about a cost of somewhere between $1.76 a unit all the way up to $8.29 a unit, even up to $11 a unit. So, huge savings by being able to use a GI cement, which is probably what we already have in our office and are already using to cement our stainless steel crowns.
So I say, figure out a technique that works for you. You always want to make sure you’re loading the crown fully. When you load the crown fully, you need to express out the extra cement, which also helps get any heme out from under there and push it away, creating that force outside the crown instead of drawing heme up in there. This is a different cement we use at times, RelyX. It lets you tack-cure and clean up. If you’re using a GI cement, I wait until you get to that tacky, putty-type stage, and then clean it away. You can always use a toothbrush as well to brush away extra cement.
[00:34:45] MTA tips, and what my friends think I do
Sprig also has a great product they’ve created, their SmartMTA. It’s individually packaged MTA for you to use in pulp situations. It’s not Portland cement based, so it does not stain, and it sets in less than five minutes, so you don’t always have to wait for it to set or place another barrier over your MTA.
I think MTA is a great option for pulp therapy. I learned this a long time ago. People said, “Well, how do you move MTA around?” And I will say MTA’s best friend is this guy. You probably have one around your office somewhere from the dental school days when you had to buy all your instruments. I have two amalgam carriers, and those are my MTA carriers these days. If you ever need to move MTA from your mixing pad into the tooth, the amalgam carrier is an awesome option.
This was a little graphic that floated around the internet a while back, and I didn’t think it really applied well to pediatric dentistry, because it’s completely different from what we do every day. So I created a pediatric dentist one. This is my “what my friends think we do.” My friends think I hang out at Chuck E. Cheese and play with kids all day long. Some people think it’s like Superman, and my mom thinks I can fix teeth using my x-ray vision. If you remember one of the early viral videos, there was David at the dentist, and David said really funny things after he was sedated. That doesn’t happen in my office. Kids act all kinds of crazy after they’ve been sedated, but apparently David acted funny, right? Other kids look at you with these big wide eyes, like, what the heck are you doing to me? I think I hang out with little Sally, checking her and her baby doll’s teeth and making sure she’s healthy. And some days, realistically, it just feels like you wrestle alligators.
[00:36:38] Clinical cases: SDF first, and a class III crossbite
Okay, I want to get to some clinical cases. I talked about some theory, some scientific studies, and a little bit about zirconia and what makes it a good restorative material. Now I want to show some clinical cases, and I hope these can be really helpful. These are cases I did in my practice, some many years ago and some more recently.
This was a kiddo with really poor oral hygiene. It was just awful: severe dental decay, large cavities on these anterior teeth. One of the rules in my practice is that unless you’re two-plus, and I usually like to get to two and a half, I will not take you to the operating room unless we have a severe case of abscess or otherwise. Usually that’s something we can take care of in the office. So my goal is to wait and try to improve hygiene. This was a kiddo with severe decay. I was able to place SDF months prior, and when we saw them in the operating room, realistically, they still hadn’t improved their hygiene, but we were in there getting ready to fix this kid’s teeth.
My first step was to pull out my EZPrep block and create my racetrack prep. You can see that full racetrack preparation on each one of those anterior teeth. I applied another coat of my Advantage Arrest SDF. I don’t do it this way any longer, but at that point in time I light-cured it after letting it set for about a minute. That gave it the dark black color already, so I could see exactly the color I was getting to. I used Traxodent for my hemostasis; that’s where you can also use those epi pellets. After I’d completed my final subgingival preparation, I placed my Traxodent, then rinsed it all off and grabbed my camera to take a picture. This is what I found: hemostasis. This is where we’re not getting bleeding, maybe a minimal ooze. Use a really nice hemostatic agent, Traxodent or your epi pellets, to get that before you seat your crowns. In this case I used the Ketac Cem Aplicaps. I use either this or the Fuji I.
This was an immediate post-op picture of this kiddo, cleaning off those letters on the palatal of those crowns as well. And then a two-week follow-up. Just two weeks, still a little bit of tissue healing, and oral hygiene still not great, but you can see really nice tissue healing for two weeks.
This was a kiddo who, when he walked into the office, his chin came in before he did, as his mom said. This is a true class III crossbite kiddo. I was taking care of him in the operating room, and I told Mom, “Listen, I’m going to try to correct that anterior crossbite. We’ll see what we can do with these crowns. I think I’m going to be able to get them out across the front.” But I know this is not something I could do with a resin-faced stainless steel, and most definitely not something I could do with a strip crown.
What we did is I opened his bite just a little bit. He had a few posterior crowns that we needed to seat, so after seating those posterior crowns I opened his bite about two millimeters, maybe three. If you’re not placing posterior crowns, you can always do that with bite turbos or bite blocks, to block the mouth open just a little bit. I use glass ionomer for that, and I think it works really well. I use a Band-Lok blue when I do that, and over time those kids wear them down and wear right back into their normal occlusion.
In this case we bumped his bite open a little, which gave me the opportunity to flare those front teeth when I seated them. When I seated these crowns, I prepped more on the palatal surface and less on the facial surface, which let me flare teeth E and F just a little bit. That little bit of flare let me seat the crowns right over, almost in an end-on occlusion for this kid. At a two-week follow-up you can see he was still pounding right on that end-on occlusion. But here we are three years later with those crowns still intact, and they actually continued to come out further and stay out of that full class III crossbite he had. Again, that’s not something you can do with other crowns, because they will break and fracture. These crowns held up beautifully for three years and all the way through exfoliation.
[00:40:58] Clinical cases: a Christmas wish and a trauma save
This was another kid I saw with really severe dental decay, around a year and a half old. Again, my philosophy is that we wait to get him into the operating room. We were able to place SDF at multiple visits, and you can see the nice solid tooth structure there, even how shiny that tooth structure looks. Greatly improved hygiene, really nice solid tooth structure. Here we are at a two-week follow-up for those crowns, and then further down, at the bottom, a four-year follow-up of these crowns on teeth B, D, E, F, G. I’m really happy with this kiddo’s case.
Another kiddo, a before and after: a two-year-old with a really tight anterior segment, really tight teeth, trying to fit these crowns in. You can see how beautifully those four crowns seated, and then at a two-week follow-up, how beautiful those crowns look as well as that gum tissue.
This is really one of my favorite cases. This kiddo came into my office around a year and a half old. We waited around a year before we were able to complete the treatment, and I’d placed SDF. This sweet little girl came into my office needing those crowns, and before we went back for her anesthesia, Mom said, “Did you want to tell Dr. Dusty something?” And she said, “I did. I asked that Santa would bring me pretty white crowns for Christmas on my front teeth.”
And I thought, oh my God. This was way early on in SDF use. I don’t even know if these crowns are going to last. I don’t know if I can save these. But this sweet little two-year-old asked Santa for pretty white teeth, and I just hoped I could deliver on that.
So we took our X-rays, and as you can see in the bottom-left image, tooth E looked like it had a shorter root. It looked like maybe it hadn’t continued development. And I thought, gosh, I just don’t know if I can save E. But this sweet little girl asked me to save it, so I’m going to try to do a pulp on that tooth, at least open the pulp tissue and see what it looks like. I opened it up, and I will tell you it was the healthiest pulp I’ve ever seen: beautiful, red, healthy pulp tissue. So I did a little MTA pulpotomy on tooth E.
You can see it right there. Look at that beautiful dentin bridge. I know that doesn’t make lots of people excited, but man, if you use MTA you can see that beautiful dentin bridge that’s formed on that tooth. This was, I can’t remember, six months to a year later. And now here we are four years later. This kid finally got rid of her pacifier, those teeth tipped backwards, and they’re looking great. You can see we’re really close to exfoliation in this picture. Still looking great.
This was a kiddo who came into the office, a little two-year-old who broke off teeth E and F. He had a complicated fracture on tooth F that was going to need either extraction, which is what I recommended, or pulpal therapy and a crown. This kiddo was really well behaved, and Mom just begged me to try to save them. I said, “Listen, it’s the middle of the day. He’s already eaten. I can’t sedate him, and I’m not taking him to the operating room for this. Let’s just see if we can save this tooth.” The kid laid back beautifully in the chair with a little laughing gas, and we were able to complete the pulpal therapy on that tooth, as well as the crowns, with just nitrous oxide. And here we are six months later, and there we are three years later. A really nice result on a two-year-old with a complicated fracture.
[00:44:36] Pearls for success
A couple of things I think are important for you to remember. Number one: always seat the crowns in the order you tried them in. Okay? If you try them in on teeth E, F, D, G, then seat them E, F, D, G. If for whatever reason you’re doing D, G, E, F, seat them that way. Same thing for posterior teeth: seat them in the exact order you tried them in.
Number two: control your hemostasis. You can do that by using Traxodent or hemostasisal or the HemeRx pellets. Those are all great things to do. But if you create less trauma when you’re prepping, you have less tissue bleeding to manage later. Again, as I said, use that EZPrep technique and decrease the contact you have with the gum tissue.
Hey, be confident in the things you do. If you’re going to treatment plan it, treatment plan it. If you don’t think you can do a zirconia crown on that one, then don’t tell Mom you can. Go practice more, get dummy teeth and work on those. But be confident, and when you say you’re going to do it, by gosh, go do it. Now, don’t be confident and do your first case on the mom who walks in and tells you her little baby girl has a modeling gig next week and needs pretty white crowns on her front teeth, even though she has huge cavities. That’s not the first case you should do, right? Pick a good case, be confident when you’re doing it, and don’t promise things you can’t deliver on.
I think the eruption of first molars against the distal of primary second molars probably makes those not a great first case, because if you’re not careful and you don’t prep enough on that distal, you create a big ridge back there that you’re going to catch the crown on. Again, try not to do these on kids who have horrible behavior and aren’t willing to have GA or sedation. Don’t put yourself in a situation where you’re not comfortable getting that one taken care of. And please, for goodness’ sake, don’t do it on the overbearing parents.
Have all the sizes. I think it’s really important. You’re not going to create this perfect crown environment by going and buying a box that has a size 3 and a size 4. Well, what if it’s a size 5, or what if it’s space loss? Please have all the sizes. If you’re going to commit to doing these, have all the sizes and all the tools in your toolkit, because that’s where you’re going to be successful. If you don’t have the sizes, you’re going to end up frustrated trying to make the crown fit like a size that you don’t have.
[00:47:18] Photos, parents and your team
Lastly, take pictures of what you do. It is very important that you can show other people. This goes along with being confident. If you’re confident in the treatment you’re providing, you can show them pictures of what you’ve done. And if you did it before, it’s not just a stock photo that Sprig provides; it’s your treatment. You can say, “I have done this treatment before. This is a case that I completed.” That makes parents feel much better about it, and it shows you’ve done this and you know what you’re doing.
I have a couple of different cameras around the office. Most of the pictures you see in my cases were taken with a Canon T3i with a 100-millimeter macro and ring flash. There are lots of other cameras you can use. Shofu makes a great one that’s really a point-and-shoot, and that works really nicely for people. Just get a good camera and take pictures. I think they even make new adapters for your iPhones that can take great pictures too. Get those in your charts and keep up with them.
This is a graphic I use in my office, because I want to show parents what these look like. You can see the large areas of decay, and I also get to talk about SDF in this case. This is what the cavities looked like, and this is what they look like completed. The nice thing is that in this case I only did three anterior crowns, right? I did them on D, E and F. I didn’t do G, and they blend really nicely. I also like to show parents how important it is to change our habits. You can look at teeth C and H and see previous facial white spots that have moved away from the gum lines. That’s an important thing to talk with parents about: how we’re changing our habits. And listen, I can be great at these crowns, but I don’t want to keep putting crowns on kids. I want to help incite change for these families and these kids, so we’re not continuing this process on more teeth.
You really need to train your team, because as soon as you walk away, these parents are asking questions: “Well, why should I do that? How does your doctor do this? Should I really do that treatment plan?” So make sure you train your team, so they know what to talk about and also know how to assist you when you’re completing these procedures.
You can create your own little typodont. I think it’s a great option to have resin-faced stainless steel crowns, regular stainless steel crowns and zirconia crowns, and be able to show parents exactly what the difference is and what these look like. It really brings something home when parents can hold that and see exactly what the crowns are going to look like.
Don’t make promises you can’t fulfill. Okay? I’m big about under-promising and over-producing. Talk about the differences between stainless steel crowns and zirconia: the differences in aesthetics, strength and biocompatibility. I always say the harder thing is it takes a little longer to prep, so behavior is more important. Sometimes we need to talk about sedation or anesthesia if that’s something we’re going to do.
Discuss cost. It’s important that the staff knows how to talk about it. We don’t need to say, “Oh gosh, zirconia crowns are more expensive.” In our office we say there’s only a small difference in the crowns, and there really is. I only have about a $50 price difference between my zirconia crowns and my stainless steel crowns. I don’t want price to be a reason people don’t want to use these, because I like using them.
And make sure your staff is helping you schedule them appropriately. Evaluate behavior, make sure you have time, and make sure you’ve talked to the parents about what they’re going to be expecting.
Your staff can help you eyeball the size of the crown. If I’m doing anterior crowns, you can use your perio probes and hold them up and look. But I will tell you, I use averages. Almost always in the front teeth I’m using 2s on the centrals and 3s on the laterals, or 3s on the centrals and 4s on the laterals. It happens that way almost every time: the laterals are one size larger than the centrals. And if you just hold the crown with cotton pliers, you can hold it up and look. You don’t have to get lots of dirty crowns; it’s fewer things to autoclave and clean up later.
You can remove the letters after you’ve placed the crowns, or remove part of them before you seat the crown. I don’t really recommend removing all of the letter, especially early on, because if you haven’t looked really carefully, in your GA or if you’re working with a patient who’s moving around, you might seat the crown backwards or in the wrong place. So don’t take the full letters off until you’ve actually seated the crown. They are hard to come off. Some parents who are super aesthetic-minded get super frustrated if they go home with a kid who has a blue letter on the crown, so I always try to remove it. Some people talk about leaving it to check hygiene down the road, but I like to remove mine.
Your staff is going to be helpful in keeping the kits stocked. To be successful, you need your crown kits full. If you know you’ve got big anesthesia days or big cases coming up, make sure you’ve got enough crowns in your kit. In my office we keep about six to nine of the anterior crowns we use most, the 2s, 3s and 4s. For posteriors, I don’t do as many, but we still do a lot, so we have anywhere from two to four per size.
[00:52:47] A seven-year molar case, and a closing challenge
This isn’t an anterior case, but I wanted to show it because this kiddo was recently back in the office, and I’ve got a six-year follow-up I really wanted to show you guys. This was a kiddo with severe hypoplasia on his second molars. He was told previously that the only way he could have these fixed was stainless steel crowns, and his mom was very averse to that. So we completed treatment for him with zirconia crowns on all four second molars.
He was very uncooperative. This pano, three years later, was the first time I was able to get a good X-ray of him. Then here you can see these teeth getting very close to exfoliation, and I was finally able to get some pictures as well. That was six years later. I saw him back the other day, and those teeth have fully exfoliated. So we were able to make it a full seven, eight years with these crowns and get them all the way out of there. I think that was a beautiful case, and something I like to show, because it’s not just me saying, “Hey, I placed these crowns six months ago and we hope they hold up.” This is at least six years, and in this case all the way to exfoliation, of success for this kid.
I think this is a really good quote. Will Rogers said, “Even if you’re on the right track, you’ll get run over if you just sit there.” Some of us graduated last year. Some of us are still in residency. Some of us graduated 10 or 10-plus years ago. Things change, and I think it’s great to try to be on the cusp. Sometimes you get on the cusp and you’re getting things that don’t last and don’t stay around. Well, Sprig is around. They’re here to stay, and zirconia crowns are an amazing alternative to some of the traditional methodologies we’ve used in the past. So you could be doing the right thing, but you’ll still get run over if you’re not moving on to some of our newer methodologies of treatment.
So I challenge you to get the kits and go to a course, and really get some hands-on opportunity to learn more about these. I’m going to turn it over and let the Sprig staff talk with you a little more about some of the upcoming workshops Sprig has to offer.
[00:55:05] Sprig workshops and promotion
Host (Sprig staff): Dr. Janssen, thank you so much. Good evening, everybody. I’m really excited to announce that SprigU registration has begun for Nashville, Tennessee on March 31st and Laguna Beach, California on September 15th. Both of these events will be taking place at the beautiful Ritz-Carlton properties. What’s really nice about these events is that you’ll get to learn from experts like Dusty, and the instructor-to-participant ratio is really small. You’ll get to prep anterior, posterior, back-to-back, space loss and cuspids as well. We will have more locations available soon, so please check your email and calendar for that. Thank you.
And lastly, for the next 30 days we’re kicking off our month of gratitude. We’re in partnership with Compassion Planet, and a portion of our proceeds in November will be donated to Compassion Planet. Please watch out every week; we’ll have giveaways. We’re also having a special promotion for the next 30 days: 15% off all starter kits, EZCrown refills, MTA, HemeRx and bur systems as well.
Dr. Janssen: Awesome. Absolutely. Hey, it’s also another good way to offset some taxes at the end of the year: stock up on your stuff while you get some discounts and have some of those proceeds going to charitable organizations. Seems like a great time to stock up on your crowns.
If you have questions and want to get in touch with Sprig about SprigU, or get in touch with me directly, my email address is at the bottom, and education@sprigusa.com gets you in touch with the Sprig team for any questions about SprigU, crown ordering or anything else. Again, thank you guys so much. We’re right at an hour. I tried really hard to get through a lot of material, and I want to leave some time for you guys to ask questions. Let me pull up the questions here and see if I can get through any you have.
[00:57:49] Q&A: Medicaid, insurance, and SDF under crowns
Question (Armin): Okay, this is a really good question. Armin saw that my office is a hybrid of fee-for-service and Medicaid, and their office is the same. How do you navigate D2929 zirconia crowns for Medicaid patients? Do you pre-authorize them, etc.?
I think that’s a really good question. In our practice, Texas Medicaid does not cover D2929. They do cover resin-faced steels, and they do cover strip crowns, and I don’t really like offering those. So what we’ve elected to do in our practice is give patients the opportunity to have zirconia crowns discounted down a substantial amount, to a very nominal number, for our Medicaid patients. We offer payment plans and let them pay those out. If that’s something they’re inclined to do, we give it to them at a significantly decreased fee, because I truly believe they’re a better restorative material and a better option for our patients. So that’s what we do.
You can also send pre-ops to private insurers. Some insurers don’t cover D2929, and you can write a narrative. Some insurers like it, some don’t, but you can write a narrative: “If code D2929 is not an approved benefit, please pay the alternate benefit of D2933.” So you can ask them, “Hey, listen, if you’re not going to cover the zirconia, at least cover that stainless steel.”
Question: A couple of questions about SDF came up: do you remove all SDF prior to cementing crowns, and why do you reapply SDF?
I do not remove all the SDF. That is absolutely not what I do. I like as much SDF under there as possible. SDF works to kill the bacteria and strengthen that area, so I am very pro having SDF under there. I do like to have a small cement layer between the SDF and the crown, otherwise you’ll get a little black show-through. So I try to remove enough that I have tooth, then cement, then crown, as opposed to the crown butting right up against the tooth. And I reapply because the literature shows multiple applications increase efficacy.
[01:00:30] Q&A: letters, masking SDF, and removing crowns
Question: How do you remove the blue letters, or the red letters?
I remove those with a discoid-cleoid. In my kits there’s always the huge discoid-cleoid, and I use that to lightly remove those letters. I think that’s the easiest, quickest way.
Question (Christine): Christine asked about masking that SDF.
Again, I don’t like to mask it by putting something down first. What I use is just the white nature of the Fuji cement. Making sure you have a thickness of that Fuji will help mask it.
Question (Christine): Really good question. Christine also asks about cutting crowns off. If you ever have to cut a crown off, how do you take a zirconia crown off?
I think the quickest way, if you have a Howe plier in your office, is to take the Howe plier, grab the bottom portion of the crown, and squish. If you squeeze that way, the crown will fracture and you can remove the pieces. I’ll do that with the Howe plier with a 2×2 underneath it, squish, and then move the tooth and the Howe plier. Let’s say for some reason you’re extracting the tooth: I’ll do that first. I’ll squish it, take the zirconia crown off, and then take the tooth out. Not always, but that’s an easier way to do it, unless you can get the forceps deeper on the tooth, not squishing on the crown, because otherwise it will fracture.
[01:02:06] Q&A: the bur kit, crowded anteriors, and space maintainers
Question: Another question just came in about the bur kit.
I’m going to tell you, I do not think you have to use the bur kit. I will say it’s a minimal expense to really improve your time seating the crown, as well as your success at not taking away too much, but taking away enough. If I was going to say one thing, it’s that the bur kit is absolutely good for you as a doctor newly learning this prep technique. Buy the bur kit. It’s not that expensive, and over time, if you don’t use it as much, great, use other burs. But I will tell you, I think the burs Sprig puts in there are great diamond burs, and they also give you a systematic approach to making sure you’re taking away the appropriate amount of tooth structure.
Question: Another question about crowded anteriors.
If you’ve got crowded anterior teeth, I think those can be really challenging. However, I will tell you that if they’re so crowded you can’t get anything in, you can always disc the mesials of the canines a little bit, to allow the laterals to move into the canine space some. And again, don’t forget: if you’ve got all the sizes of crowns, you can try different combinations. I’ve had crazy cases where the kids had weird-shaped teeth and I’ve put laterals on all of the teeth. I’ve used a lateral 6 for E and a lateral 4 for D, right? So don’t just think in one dimension, that the E crown has to go on tooth E. Sometimes the D crown fits better on tooth E, or the E crown fits better on tooth D. So sometimes I’m switching crowns around. It’s amazing how crazy the dentition can sometimes get, but I will tell you there has never been a time in my practice when I thought I could get the crowns on and didn’t get them seated. They can go on, and I did not have to pull the tooth to do that. Sometimes I just had to use different combinations to make them fit.
Question: Great question: can you cement a stainless steel space maintainer, a band and loop, over a zirconia crown?
Yes, you absolutely can. You’re going to rely a lot more on the undercut of the crown and/or the spacer to hold that cement on, but you absolutely can.
[01:04:57] Q&A: pulp therapy, and teeth B and I
Question: A quick question about pulpotomy versus pulpectomy in the anteriors.
There was a study completed at Baylor with Sue Seale a while back, I think around 2013, that showed equal success rates for pulpotomy versus pulpectomy in anterior teeth. So if you’re doing pulps in the anterior, there’s no difference, based on the literature, in success rates between pulpotomy and pulpectomy. I know for me, I sure don’t like doing pulpectomies. My take is that a pulpectomy is reserved for a necrotic tooth that I’m trying to perform heroics to save. If you have a vital tooth and you open that chamber, I would do a pulpotomy with MTA. That’s what I would do in my practice. I don’t do many of them, but when I do, that’s what I’d do. You do not have to cover the MTA if you’re using the SmartMTA. If you’re not, and it’s an MTA that doesn’t set up immediately, then using Lime-Lite or another glass ionomer over it is important.
Question: All right, quick question. This doesn’t have to do directly with anteriors, but I’d love to answer it. “I have problems prepping teeth B and I. Any tips?”
B and I are challenging. B and I are probably the hardest teeth. So, back to things to choose to do first and things not to do: B and I are not the first teeth I would choose. If you’re going to do a posterior, my favorites are L and S, and the lower canines and upper canines are great. But L and S are great posteriors to choose. Don’t do B and I first. B and I are like a joke the crown companies seem to play on us; the crowns never seem to fit right. Sprig did a good job of giving you extra room on the facial, where there’s that bulge on the mesial-facial of teeth B and I. Again, make sure you’ve taken a full racetrack. That’s my number one: a full racetrack all the way around B and I. A lot of times on teeth B and I, I think you’re going to use the space loss crowns. They let you get a tooth in that otherwise would be challenging. My guess is you probably underprepared the tooth or tried to teepee it in. Don’t forget to stay in the long axis of the tooth. And again, if you need to, make sure you have the space loss crowns.
Question: Steps for a pulpotomy with MTA.
Okay. Again, I’m not a big fan of lots and lots of […] pulpotomy uses. However, MTA is great. The big thing you need with it is good hemostasis, and that can be done with a cotton pellet. In my case, I’ll use the chlorhexidine cavity conditioner, or cavity cleaner. It’s 2% chlorhexidine gluconate and doesn’t have any dyes or anything in it. I’ll dip a cotton pellet in that and let it sit in the pulp until I have hemostasis, which should be just a little bit of time. As soon as I have that, I take it out. I then mix my MTA, and I like it to be a very putty consistency, if not even drier. Then you’re seating it in there and laying it over the floor. Again, with the Sprig MTA you don’t have to wait a long time; it will set up on its own and you can continue your prep. Or, if you’re using a different MTA or you want to, you can cover it with a liner like calcium hydroxide, or actually Lime-Lite or another glass ionomer, and then you’re done. That’s what I would do for MTA.
[01:09:01] Q&A: try-ins, residency, IRM, cement timing, and goodbye
Question (Kelly): Great question, and maybe I didn’t say this really clearly, so thank you, Kelly, for asking. It’s about other crowns needing the pink try-in crowns, and Sprig zirconia crowns not needing that.
There are no silane coupling agents, there’s nothing you need to do. If you have a crown that doesn’t fit, you take it, I throw it in our shaker, we shake it, we autoclave it. That’s it. There’s nothing else special to do. If it’s a crown I’ve tried in and it’s the one I’m using, I spray it out with water, dry it a little bit and give it to my staff to seat. Nothing special you need to use. You’re not using any chemical retention with zirconia, which is a challenging thing. No chemical retention. You’re using macro-mechanical retention to get them seated.
Question: Great question: somebody in residency who doesn’t get to offer Sprig or zirconia crowns.
I was very vocal about trying to improve that in my own residency at the University of Washington. One of my attendings, Dr. Millage, was awesome and so open to new techniques. His philosophy was that we should get to try everything we could to learn, because this is a great time to learn. So I got to learn a lot of new techniques, and I always try to bring that forward: residency is a time to learn. Talk to your attendings. Definitely never talk down about somebody else’s way of doing it, but ask, “Hey, these are some newer products. Is there any way we could get our hands on these?” Or even get in touch with Sprig and see if Sprig could come out to your residency and give a lecture. We’ve been able to do lectures for multiple residency programs, and that sometimes gets the ball rolling on using these in practice.
Question (Jasmine): Can IRM be placed over MTA for a pulpotomy?
No. Great question, thank you for asking, Jasmine. Do not use IRM. Not because IRM is bad over the MTA, but because you cannot bond to IRM. IRM creates a barrier where now part of the tooth is not bonded to, and that decreases the retention of your crown. So do not use IRM or any other zinc oxide-eugenol in that area.
Question (Maggie): All right. Maggie asked about the Ketac Cem Maxicaps or Fuji caps.
The Maxicaps are great. I use those in the operating room because I’m seating lots of crowns at once, and in the office I use the Fuji if I’m just doing one or two crowns here and there. If you’re hand-mixing the cement, you can mix a thicker cement so it’s more putty-like right away. If you’re using the Maxicaps or Fuji I, what I do is have my staff fill them, then I set the crowns up, put a little bit on my glove, and keep feeling it until it gets to that tacky, putty-like stage, and then I’m seating the crowns. From my experience, the Ketac takes a little longer. I think Ketac takes about a minute-ish, maybe a minute 15, before it gets to that point, where the Fuji really takes about 30 to 45 seconds to get to that thicker, putty-like consistency.
Okay, I think I got through all the questions you guys have. It is an hour and 15 minutes in, guys. Thank y’all so very much.
Question: Does Sprig have requirements about doing presentations?
I don’t know exactly about requirements for doing presentations. Again, if you have questions about presentations, or just want to get instructors in touch, please reach out to Sprig at the email we had earlier. I’ll pull it up again for you: education@sprigusa.com. Reach out to them if you have questions and want to get somebody in touch with your residency program. I’ve gotten to do multiple presentations for residencies, or at least get in touch with residency directors. I’d be happy to talk with them, and I know Sprig has great resources to speak with them also.
All right, guys, thank you all so much for your time this evening. It really was a pleasure getting to speak with you. I hope you had a cocktail or enjoyed this or something. Again, thank you for taking some time at the end of a long day to share with me on a webinar. If I can be of any help to you in your practice, or with questions you have about setting up a practice, please let me know. I love being a resource for that. And if any of you is interested in looking at Lubbock, Texas as a practice location, reach out. I’d love to chat with you as well. Thank you again for this evening, and I look forward to seeing you hopefully soon at an AAPD meeting or one of the other pediatric meetings. All right, take care.
