Advanced Zirconia Cases Made EZ — Transcript
[00:00:11] Welcome, about me, and a cocktail
Thank you guys so much for joining us tonight for a Sprig webinar, Advanced Zirconia Cases Made Easy. My name is Dustin Janssen. I have a couple of disclaimers to put on here. I am not an employee of Sprig. I am a practicing private pediatric dentist.
This is a little bit about me. I own Parkview Pediatric Dentistry in Lubbock, Texas, and that’s actually where I am right now, in my brand new office. If everybody wants, at the end maybe we can even take a tour of the office. Who knows? I opened Parkview Pediatric Dentistry in 2013. I went to Baylor Dental School, but I spent two years as a general dentist before I did my residency. We recently opened Parkview Therapy Services, and that includes myofunctional therapy, lactation therapy, and speech and feeding therapy.
This is actually my second office location that we built. Here are a couple of pictures of the waiting room and then the bay area there. And this is the building I’m in right now. This is not what it is now. In many things that we do, we have to have a vision of what we can create and then get to that finish point.
This building was actually three blocks down from my original location, not the one I just showed you a minute ago. It was a 10,000-square-foot building. It was a pool building that they had spas and hot tubs in, and before that it was actually a tire warehouse. We decided it was gonna be a great opportunity to turn that into a pediatric dental office. So with some vision and lots of work and time, we took this building and turned it into this. That’s the building I’m in right now, right down the street from the original building I started. This is where we house one of our locations for Parkview Pediatric Dentistry and Parkview Therapy Services.
This is our floor layout of this 10,000-square-foot space. Lots of rooms, multiple waiting rooms for our therapy as well as for our kiddos, and then a waiting room in the back for post-surgical stuff, entrances and exits for post-surgical, therapy rooms, and lots of treatment stuff there.
Just a couple of things about me. This would be my current cocktail, but it is not tonight. It’s one of my favorites, so I’ll tell you about it, and please make it yourself if you’re at home. Get the stuff sometime and make it; it’s a great light cocktail. It is made with mezcal. Not everybody loves mezcal, but it’s a lighter version of the mezcal. The thyme simple syrup tones that down. It’s called Just in Thyme. You add two ounces of mezcal with a thyme-blackberry simple syrup. The way you make that is you take a cup of water and a cup of sugar, boil that with five or six sprigs of thyme and some blackberries, and then strain that out. Now you’ve got a really beautiful simple syrup to add in here. Pour that all in a shaker, add the ice, and go to town. It’s a really, really beautiful cocktail.
[00:03:13] Sprig’s journey and tonight’s objectives
The journey with Sprig has been a ten-year journey where they have spent lots of years perfecting what they’ve done. It started in 2006 and was founded as EZ-Pedo. Then in 2009 they seated that first pediatric zirconia crown. In 2013 they introduced these CE courses, and I was actually able to teach that first CE course. What an awesome opportunity to see how many kiddos and people have been impacted since that original course. In 2017 Sprig rebranded to Sprig Oral Health Technologies and introduced SMART MTA, HemeRX and other things. Since then, in 2019 they had the opportunity to have international growth, and in 2019 had their first Sprig Live. 2020, celebrated a decade of smiles, and whoop, in 2023 introduced SMART MTA capsules and their first-ever humanitarian dental trip.
The objectives for tonight that I want to go over are to understand the benefits and reasons for our systematic prep technique, talk about some advanced case selections, and improve some confidence and case acceptance for you guys, so that y’all feel comfortable. And then also how to train your team to support your success.
This was a zirconia case that I completed when I was in residency. I did not take any pre pictures of these four zirconia crowns, ’cause they were so broken down that I didn’t think I was going to be able to save the teeth. In fact, we not only saved the teeth, but I think had a beautiful aesthetic outcome.
[00:04:44] Why the crowns are designed this way
So why do the Sprig crowns have the design that they do? They have a flat fit, a zirconia lock retention design, shape contouring, and this polychromatic finish. We’re gonna talk a little bit about those. The big thing is that these all have very specific reasons why they were introduced in the crown shape.
The flatter fit allows you to have less preparation, because the deeper that occlusal groove, the more reduction you have to have to fit a crown on. The space loss is interesting. It’s not just a half-size crown, right? It is actually a squished crown. Just like when you and I work in a chair and we grab a Howe plier to squish down an SSC, we’re doing that same thing here with our zirconia crown. It’s a squished-down version of that crown. That’s a really important thing that’s very different from anybody else in the way they create their crowns.
This ZirLock retention is a really amazing retentive feature that has zirconia ridges cut into the interior intaglio surface of the crown, which allows you to get a strong bond to that tooth. It also has a polychromatic finish. It is one color crown that will fit in all arches, because it has not just one plain flat color. It has a polychromatic color that is gonna give a beautiful finish to that crown.
[00:06:08] A systematic bur setup and the cylinder prep
Now, the clinical technique is something that we teach here, and I think you guys are gonna see how this can be a faster technique for you. It can decrease your chair time and decrease your stress.
With a systematic approach, what you need is a bur setup where you know what you’re doing. It can improve our speed and efficiency, save our chair time, and decrease that stress like we talked about. Sprig put together a bur block and a systematic approach to their burs so that you can use the approach we’re gonna talk about tonight. The size of the burs they give you in that block gives you an appropriate depth cut, so you know how deep you need to reduce, so that you’re not taking away too much or getting to the point of hitting a pulp.
When you’re thinking about our prep design, the big thing you need to understand is we need to create a cylinder. A cylinder is very important because if we create anything that has a teepee-type design, not only is it taking more time, but it’s getting you closer to cutting into the pulp, which is what you don’t want to do. That’s a very important aspect of this.
[00:07:25] Posterior prep, step by step
We’re gonna start with the posterior preparation and talk through it. I’m gonna go pretty quickly; we’ve got some videos that show this as well. In a posterior prep, you’re gonna take your donut bur and take off the thickness of that bur, which is 1.5 millimeters of depth, and create that 1.5-millimeter reduction all the way across the occlusal. If I wasn’t thinking about a depth bur, I would say I’m taking it down just past the occlusal grooves that you see in that tooth. You can use the marginal ridges on the adjacent teeth as a reference point.
Secondarily, we’re gonna have a supragingival chamfer margin, where we create a racetrack all the way around that tooth. That’s with our prep bur 002, and it creates that depth cut all the way around circumferentially. If you were looking down on the tooth, it would look like you were trying to prepare a PFM, if anybody remembers that. You’re gonna have this chamfer margin 360 degrees all the way around that tooth.
The big important point is to keep that bur perpendicular. Do not lean it in, because if you do, you’re going to get close to that pulp. If you get close to the pulp, now we’ve got an angry tooth, and now you’re gonna have a failing restoration. When people message me about these, the big thing I think occurs on a regular basis is most people over-prepare these teeth. Not because you needed to take it away, but because you took away too much at a point you didn’t need to, which is that superior portion of the tooth. You’re angling it in and getting that bur close to the pulp.
If you had a bird’s-eye view of this, now you’ve got your 0.8-millimeter supragingival chamfer margin all the way around that tooth. You need to make sure you have that depth cut all the way around to allow the crown to seat all the way down.
Now you’re gonna take that beautiful margin you had and cut it all the way off with your prep bur 004. That creates the subgingival axial reduction that goes two millimeters subgingivally, and it removes all of that chamfer you just created. That takes away any ledge, because now we need to get subgingival so that crown can fit all the way down over that tooth.
I like to start in the thickest area of the sulcus, usually at one of my line angles, and lightly feather into that margin. I think it does a great job without hamburgering away all of the tissue.
If you don’t do that, what will happen is when you try to seat that crown, you will end up with a ledge. When you try to seat it down, you won’t have a passive fit, and then you will crack the crown. These crowns are extremely strong; however, they are only strong once they are cemented. If you have an internal force pushing externally, that crown will break very, very easily.
[00:10:35] What a 29-month case report found
This was a case report published in one of the pediatric journals, showing a 29-month follow-up of a pediatric crown. I think that’s great. The funny thing is, this was in 2017, and we use it in presentations ’cause they took really great pictures. I’m gonna show you cases that have lived in the mouth and exfoliated over seven-plus years.
So here we’ve got a 29-month case. What they found was there was more preparation than a stainless steel crown. They found that subgingival reduction is a very important and crucial step. And EZ crowns had good integration in the arch, because they allowed for good aesthetics and very happy parents afterwards. The result showed no loss of retention, no fractures, no wear to the opposing dentition, excellent periodontal health, good marginal adaptation very similar to a stainless steel crown, which I can show you as well, and high parent satisfaction.
[00:11:33] Video: two posterior crowns in six minutes
This is a quick video that I did. It’s not some stock video; it’s just me working on a patient. Total time from starting prep to completion of back-to-back zirconia crowns was six minutes. I’m gonna flip over and show you guys that little video. […]
Awesome. Here we go. Initially, as we start off, we want that occlusal reduction. As you can see, I’m running that handpiece over and taking away occlusal. Everybody preps differently. I like a quick finger motion on my preparation. I don’t do long, slow, hard strokes. I do very light, quick movement strokes as I’m taking away, especially the occlusal surfaces. I’ll tell you, doing it that way is something I learned because I like to minimally numb patients. Instead of an extremely numb patient, I can very lightly numb, create less force and pressure on the tooth, and get a great result with less numbing and only very light circular infiltrations.
Now we’re on to prep two, my interproximal reduction. Some of this is sped up a little bit for time; my hand doesn’t move that fast. As I’m moving through this, you’re seeing me take away that circumferential step two and get that nice ring-around-the-rosy racetrack. We’ll see that all the way around one tooth, and now moving on to the second tooth.
We’re two minutes into the prep and I’m already on the second tooth, taking away that bulk reduction. I try not to get into the sulcus with this. If you get a little bit of bleeding, that’s okay. But if you stay above it, it allows you to see and not create heme everywhere and have to worry about seeing what you’re trying to see. Again, lightly touching around all of those surfaces, making sure I’ve got good reduction all the way around.
Finishing up on step two, now we’re on to step three, our subgingival reduction. I want you to watch how I get into this tooth. I’m gonna lightly get at that line angle and feather myself in very lightly into that sulcus. If I’m light getting in there, it doesn’t hamburger away that tissue and make it a bloody mess. I sped this up a little bit. I move my hands very carefully with very light strokes. This is also double speed, so you’re getting a little faster movement than usual.
Awesome. You can see I’m subgingival, making sure I’m getting all the way down there. You can use your explorer to feel that, but I just use the tip of that bur so I can feel whether I’m getting any ledges around those teeth as I’m prepping. Still lightly prepping both of those teeth, getting subgingival on all of that. And just finishing up here on […] that prep.
Perfect. Grabbed my crowns to try in. Now, do I always get the crown in the first time with the right size? No. I wish I did. I will tell you when I take my time and get a really good prep, I will. That is a nice little prep there. We’ve got a K3 and an L3 on those two. So six minutes for back-to-back zirconia crowns. I didn’t film the top ones, but that was four crowns there. Pretty quick and easy, I think.
[00:16:20] Check the racetrack, and how passive is passive
Perfect. How does everybody feel about that? Good? Seem like you can do it? I’m not some special master at this. I’m telling you, anybody can do that. You need to take your time. The first time I went through really quickly. But take your time and check back. The biggest step is to make sure you can look down over the prep, and you will see that racetrack. It should look equal size all the way around the tooth that you reduced. If it does not, fix it before you go to the next step. I promise you it will save time. It will save time.
Cornelius just asked: how passive do we want that fit to be? The answer is finger pressure. I should be able to push it down and it should seat down. You should not jam it down. If you’re jamming it down, you’re going to create a break in the crown, or later it will break because you never got it seated all the way down like it needs to be. Passive should not feel like it just floats in space. It should feel like it sinks down onto it and holds tight. It can have a little bit of play, but it shouldn’t just willy-nilly float around, if that makes sense.
[00:17:41] Anterior prep
That was a posterior prep. Do you use the 002 on posterior and anterior? Yes, you do, and I’m gonna go over that anterior prep right now. That 00 tuber is gonna be on both of those preps.
So here we are on an anterior prep. We’re gonna take away that same initial 1.5-millimeter reduction and use that as our axial depth cut of the occlusal. Now we’re gonna use the 002 bur and take away that 0.8 millimeters. You can actually do a little less on these anteriors, but 0.8 millimeters is still very, very conservative. In fact, it is so conservative that you are really just getting the enamel out. If you were to take that posterior and look down on it, you’d be right at the DEJ. It should be clear: the pulp does not live at the DEJ, right? So you are still a long way away from the pulp.
Now with that bur two, we’re gonna create that circumferential reduction. And this is the difference on the anterior prep: you are going to have a second plane of reduction. That’s what that second bar at the top is showing. You’re getting a slight angle. The only time we ever get out of the long axis of the tooth is this portion of the prep right here. That rollback of the incisal edge is gonna allow you to have a much more aesthetic look for this crown as it seats.
This is a good checkpoint. Let’s look down over the tooth. We’ve created that 0.8-millimeter supragingival chamfer margin, and the margin looks great. If it’s not pretty-looking and equidistant all the way around, do that ring-around-the-rosy. Make sure you’ve got it looking nice.
Next is a difference in the anterior prep. You’re gonna take your 003 bur, which is a cingulum reduction bur. It’s our football diamond, and you’re gonna dish out that cingulum just a little bit. That dish-out of the cingulum gives you the space you need for that crown to sit all the way down. We don’t need to take away a lot of cingulum. If you take away too much, you’re decreasing the strength of that tooth, and we want to keep that tooth nice and strong and keep its integrity.
Same thing as the posterior: we’re gonna extend the tip of the bur two millimeters subgingivally. For those of you who do stainless steel crowns, this seems like you’re going way deep. Please get down there. You just gotta get that bulge taken away from the tooth. If you don’t, you’re not going to get the crown to seat all the way, and that’s gonna be a problem.
So again, with that prep bur four, you should keep it subgingival. You should be able to hug the bur all the way around the tooth. That’s going to keep you from having that little lip that causes your crown not to seat all the way.
[00:20:42] Don’t taper the bur: common errors
Again, do not taper. I’ve said it once or twice or 500 times. If there’s one thing you can take away from this tonight, please do not taper your bur. Stay in the long axis of the tooth. Long axis. All right? If you do not, you will end up with some errors.
Inadequate occlusal reduction can be an error. You need to take the full thickness of the bur at 1.5 millimeters depth, and use the adjacent mesial marginal ridge as a guide. If you’re doing back-to-back cases, sometimes you can take a little more off the distal of that second molar. It allows you to cant the crown just a little bit, which tucks the distal portion against the tooth.
If you’re doing anteriors on a young patient, you’re gonna need to prep more subgingivally than you otherwise would have, because that tooth isn’t as erupted as you thought it might be. So prep a little more subgingival to get those guys to seat all the way down. Same thing for a badly broken-down tooth: you need to get more subgingival because you need that crown to hold on to the tooth a little bit more.
Another big error can be inadequate axial reduction. I’ll tell you, in that video and other times, if I’m being really careful and I take every step one by one and check, I end up with a very quickly, easily fitting crown. When I rush through, almost invariably I do not take away as much reduction as I need to, and you end up needing to go back and mess around with the crown some more. So if you can spend some time making sure you do the steps right at first, it will go much smoother.
Again, I might have said it: you gotta go sub-G and you do not taper that bur. Don’t taper the bur. Don’t taper the bur. All right?
The areas you can’t see are usually the areas where you end up tapering in. So the distolingual corners, depending on which side of the chair you’re sitting on. The corner you can’t see, spend a little extra time, get your mirror, look at it, and make sure you’ve taken away the appropriate amount.
Another error is using too big or too small a crown size. If it seems like it’s just floating in space, try a smaller crown size, or maybe the SL, the space-loss crown size. Spend a couple of seconds on that. These crowns are autoclavable. You do not need try-in crowns. If the crown doesn’t fit, throw it in the shaker, autoclave it, and it’s ready to go for the next patient. They use a great system so you don’t have to worry about using the try-in crowns.
[00:23:40] Video: an anterior case, sizing and the racetrack
Let’s do another video here. This will take me a second to flip it over. Everybody doing good? Thumbs up. Another video, an anterior start to finish. This one’s a little longer and I might skip through it a little. It’s about a ten-minute video, and I have a short attention span. That’s one of the many reasons I’m a pediatric dentist.
Step one: we’re going to work on selecting some crown sizes. You can do that before you start, and it’s a good thing to do. Grab a clean pair of cotton pliers. If you’re in GA, hold it up and look around. That’s gonna save you some stuff later. Almost always when I’m doing my anteriors, I’m using twos for centrals and threes for laterals, or threes for centrals and fours for laterals. That is a big thing to me. Twos for centrals, threes for laterals.
B on L: somebody just asked, do you ever use a B for an L? If you’ve got a weird-shaped L and you wanna put a B on it, you can. I will tell you that instead, what I usually end up doing is using a space loss. If I’m having to flip a top to a bottom, I will almost invariably end up with the space loss down there, and it ends up fitting really nicely. But there’s nothing wrong with flipping a B to the L, or vice versa, if something seems odd.
So this is that racetrack. As was asked earlier, are we gonna use that 002 bur on the anterior? This is our 002 bur. You can see they’re working in the long axis of the tooth the entire time, slowly moving their hand along the long axis and staying parallel to it. […]
All right, just touching up and getting long axis for all of those. Now we’re gonna get to step three. We’re gonna create that axial depth cut on the lingual, so they’re able to create that depth there. After they finish all this, you should be able to see that long axis all the way around.
[00:26:47] “I am an anti-pulp person”
Somebody just asked: would you do a pulpotomy or pulpectomy on D to G? The answer is absolutely not. You can hear from me about it if you want to. Everybody does it differently. I am an anti-pulp person, so I believe highly in indirect pulp caps and use of silver diamine fluoride. In this case they were removing decay and getting close to the pulp. If you get an exposure, complete that. But I would tell you that I do cases like this all day long with silver diamine fluoride. You’ll see some of those. And I do not pulp. I probably complete one pulpotomy a year total in my practice.
All right, so you’re gonna see that second plane of reduction we were talking about. This is the only step where you get out of the long axis of the tooth to complete the preparation, because you want that crown to roll back just a little bit. That’s gonna allow that crown to seat in a really nice fashion in the arch.
Now we’re moving on to prep bur three. You’re getting that diamond and taking away the cingulum just a little bit. There’s probably not much cingulum that needs to be taken away on D and G, as they are pretty broken down, but you’re still creating that small space. These are good checkpoints. Is there any bleeding happening here? No, not really. You’ve got clean margins, so make sure you’re able to keep those areas as clean as possible, ’cause it helps you see.
While this is happening, I’ll give you my two cents. Somebody’s asking more about pulps: would I extract if a tooth needs a pulp? If a tooth needs a pulp is a very interesting question. The question is, how do you diagnose indirect pulp caps? You diagnose indirect pulp caps by knowing the history of the tooth and taking appropriate clinical and radiographic signs. If it’s abscessed, it is necrotic and needs to be extracted; that does not need a pulp. Whether it needs a pulp is a very interesting question. Many times we are doing a pulp ’cause we are using it to diagnose the tooth. I think you can appropriately diagnose the tooth via silver diamine fluoride, via history, via those things, in the advanced state, before you start putting a bur to a tooth. So the answer is I do not need to extract lots of teeth, because I’ve created a diagnosis of the tooth and arrested dental decay before I ever started treating the tooth.
[00:29:41] Seating, hemostasis and cement in the video
All right. On this one, we wanna stay in the long axis, right? If you are not careful, in this portion right here you will create a teepee shape of the tooth and end up getting into that pulp horn up in that top corner. And that is a problem.
You can take your bur or an explorer and feel all the way around those teeth to make sure you’re not getting any ledges. Now they are seating those teeth. You can see there’s a little push and a little spring back, right? That’s fine. That is okay. If people are asking how tight they need to fit, this is appropriate. They are in there and loosely fitting, and they don’t have to be pressed down hard.
Now they’re using the HemeRX pellets. I think they’re gonna be your least expensive option and a very nice, quick option to get you hemostasis. You take the HemeRX pellets, break them apart, put them in those interproximal spaces, and push them down with cotton forceps or a cord packer, whatever you have. Let those set for around a minute. Then place a little direct pressure on that gauze for 30 seconds to a minute, and then you get to pull them off. That pressure hemostasis is gonna be great. Now you’re able to take those pellets out, and you can see what nice hemostasis you achieved with those pellets.
Now you’ve got a really clean, dry, optimal field to get that cemented. You can use any cement you want. Sprig recommends pure glass ionomer cement. It is also the least expensive cement, so hallelujah. Let’s use something that’s less expensive and not the most expensive cement on the market. It’s probably what you’re seating your stainless steel crowns with. For me, I use Fuji I cement. You can also use Ketac Cem; that works great as well. A nice thick mixture, a more set-up mixture, allows those crowns to get seated on there nicely.
In this case, this provider likes to seat the centrals, then the laterals. For me, I seat all four at once. Everybody does it differently. Some people seat right side, left side; some seat centrals, laterals, or vice versa. Do what works for you. I like all four at once, and then allow them to hold. What they did now is let that set up, and they’re cleaning that cement off, making sure they’ve got the excess off. Now we’re gonna get the laterals cemented and seated in here as well. Again, clean that extra cement and let that set up.
And there are some cemented crowns after that is set. They’re using some floss. I think you can use a toothbrush before this too, which gets away some of that excess cement so there’s less to floss away. I think that’s an important aspect of this. Awesome. And there again, using that toothbrush, finishing everything off. And there we go. Awesome.
[00:33:07] Tissue management and cementing technique
We talked a little about tissue management. These are the HemeRX pellets. They are fast-acting and they are precise. They allow you to get the epi right where you want it and really stop bleeding pretty quickly. Again, they are much less expensive than the alternatives, Hemodent or Traxodent or other options you can use. I’ve got one last video of those pellets, but actually the video that was already in there was pretty good; y’all saw the HemeRX pellets in there. So we’ll skip another video for you.
Let’s talk about cementing. This is a really cool picture, and Sprig does a great job of showing this one. This is a crown that’s cut in half, and you can see the depth of those retentive grooves on the intaglio surface. You can see how hard that cement is bonded in here from a macromechanical standpoint. So, man, I will tell you, you can use a cheap glass ionomer cement, and it is gonna be the best thing we can use in peds for a long time. And you’re gonna save lots of money.
You don’t need try-in crowns ’cause we’re not trying to get retention via a chemical bond. Chemically bonding to zirconia is extremely challenging to do. So you don’t need those try-in crowns. You don’t have an extra step, extra things to autoclave, all of that stuff. Those types of crowns are what’s called injection molded. These crowns are made on a CNC machine, so they’re actually milled crowns.
Find a technique that works best for you. I have used multiple different techniques and multiple different cements over the years, and I have landed on a pure glass ionomer cement. I use the Fuji I capsules. My staff doesn’t love mixing, and I don’t like them having to mix, so we just use a triturator, and it does a great job.
But you do wanna make sure you’re filling that crown full of cement, because if you don’t, you don’t get the hydrostatic pressure to push the cement out and push the blood out, and you can end up with voids under there. Then don’t move anything around. You really want to get it seated, hold it, and then clean up that cement. If you let too much of it set, and you’ve ever tried to clean off set-up glass ionomer cement, that stuff is as strong as all get-out.
As I said, don’t ever lift it up and put it back on. You can use Superfloss to clean up the cement. You can use a toothbrush; I like the toothbrush turned longways, pushing it into the interproximal spaces, and that cleans out the extra cement. You can also use your explorer, whatever you like. But do not turbo wash. Don’t power wash. If you do, the cement keeps coming out, and all you’re doing is rushing every bit of the cement out.
All right, that’s a down-and-dirty, quick how-you-do-this. Thumbs up for everybody? Everybody good? Any questions? Love it. Thank you. Everybody seemed good. I’m not sure if there’s a sideways thumb or not; I guess you got up or down. So we got lots of good ups. Awesome. Love it.
[00:36:26] Case: anterior crossbite correction, seven-year follow-up
Okay, cool. Let’s show some fun stuff. Those were some stock pieces on how to do this. My take is I love showing real cases of what I do, and that’s why I teach these courses, because I enjoy showing off the things I’ve gotten to do over lots of years in practice.
This is an anterior crossbite correction with seven years of follow-up. This is stuff people tell you can’t do, and I will tell you, you can. This kid walked into my office and his chin came in before he did, and so did his mom’s. They are a true Class III kiddo and family. He had decay on his posterior teeth, and decay on the lingual of E and F, so we talked about getting him fixed up.
I had him in the OR; he was very uncooperative. We had to fix all those posteriors, and when I was fixing the posteriors, we opened the bite up. I didn’t take away as much occlusal reduction on those posterior teeth, so you can see I got him opened up about two or three millimeters. That gave me the opportunity to place crowns on those anteriors. I used a little bit larger crown. They’re not huge, but they are a little larger than I would normally put on these. It allowed me to flare the crowns to the facial just a little bit. You can actually see that bruising on the facial. It’s because I prepped minimally on the facial and a little more on the lingual so I could push those crowns forward into that space.
You can look at a two-week follow-up there. I got him almost end-on on these teeth. At two weeks we were still there. Crowns weren’t broken; they were holding up and doing great. Let’s see what it looked like as he kept growing. There’s three years later.
A little bit about this. If you’re placing the crowns, as I said, open that bite a little. If you’re not doing any crowns on the back, you can do bite turbos. Blue Block: I’ll use resin-modified glass ionomer or an ortho block cement and block that up there. I don’t always do it on all those teeth. This was actually for my daughter, but it was a good visual, so you can see it on all those teeth. I’ll usually just put it on the second molars back there. You want to get at least end-on occlusion with those crowns when you seat them. Then make sure you give yourself plenty of time so those crowns are all the way set up before that kid’s occluding on them, because you don’t want them to wake up and pound on them right away. You really need that glass ionomer all the way set up.
And this is actually that kid seven years later. He comes in and he’s exfoliated those teeth. You can still see he tries to slide out into that Class III, but I got him untrapped early enough that we got that premaxilla to grow out just a little bit. He needs ortho and he’s probably still gonna be in headgear, but we got a lot of advancement just because I was able to get those crowns on there when he was a youngster.
[00:39:19] Case: severely decayed anteriors and a Christmas wish
As somebody asked earlier, what do you do on anterior teeth with really large decay? Let’s talk about some severely decayed anterior teeth. In this one I will tell you I did a pulp. This is one of my one pulps of the year. This was also probably eight or nine years ago, right after SDF had come out. I placed it on these teeth. My rule in my office is, if you have decay, you do not get to go to the hospital until you are at least two to two and a half years old. I really want you to have all of your teeth in before I take you to the operating room.
Oops, let’s see. I have a little question about cement. Let me see if I can pull it up really quick. “What kind of post-op instructions do you give?” Oh man, why is it not giving the whole question here? I’ll read it in a minute.
As far as the decay goes on this one, this kid came in, and if you look on this bottom X-ray down here, I was concerned that the root on tooth E had not fully continued to develop. I think some of it might have been the tube, but I was very, very concerned I wasn’t gonna be able to save this tooth. But this sweet little girl asked me beforehand if I would be able to save her teeth, because that’s what she wanted for Christmas. And I was like, oh my God, we have got to try.
So I opened that tooth up, and you know what I saw? The healthiest, most beautiful pulp I’ve ever seen. So instead of doing a pulpectomy, I did an MTA pulpotomy. MTA is not removing any of the bacteria in there. There’s no bacterial removal. All I’m removing is tooth structure, and then I’m closing it back off. Ultimately, the body is pretty dadgum good at creating its own indirect pulp cap by creating tertiary dentin and closing it off itself, which is why I don’t usually get in and do this. However, in this case I wasn’t sure, so I did a pulpotomy on tooth E.
You can look at that six months later, and I’m gonna show you another X-ray here. Boom. Look at this cool thing. What’s that? That is a nice, beautiful dentin bridge. So MTA works if you do it correctly. We got a great dentin bridge there, that tooth continuing to grow and develop, and these teeth look awesome. These crowns are seated.
And let’s look here: there’s four years later. If we go back, you can see we had a pacifier and an anterior open bite on those teeth. Here we are four years later, the pacifier’s finally gone, and those teeth are still functioning beautifully and looking really nice. Let’s see what it looks like seven years later. We’ve lost E and F, and we’ve still got D and G. I would call that a beautiful success. You can see brushing is still not an ideal thing for this kiddo; you’ve got plenty of plaque buildup. But man, I am super happy with what that is.
Somebody asked again about cement. If I’m using Ketac, I’ll use the Maxicaps if I’m in the operating room. But it’s just the regular, old-school Ketac Cem. You can use powder-liquid that you hand-mix; a lot of people use that. That’s your cheapest option of cement that you’re gonna get. […]
[00:42:29] Case: “not saveable” molars, seven years later
This was a cool case. This kiddo came into my office, and Mom is faculty at our university. She’s a researcher. She wants to know everything about this. This is one of the cases where I gave her the paper about SDF use and a paper on Sue Seale’s Meta-Analysis of indirect pulp cap therapy. She was told elsewhere that these teeth were not saveable and would have to be taken out, that there was no way to save them.
So what did I do? I saved them. I put SDF and did some Equia placement over that. You can see in the pictures there’s still a little bit of Equia around; it’s not fully there, but it’s not fully gone. It helped keep stuff out of these holes before we got the kiddo into anesthesia and got them fixed up.
This was our severe posterior decay. Everybody can agree that we’ve got pretty substantial decay on these teeth, right? All right, can you save them? She was told no before. Let’s see if we did. I did save them. Did I do pulps on them? No. Not a single one of these teeth received pulp therapy. All four of these lower crowns got treatment without pulpal therapy. Let’s look again at how large that decay is. Cool.
Let’s look at three years later. Are these teeth still here? Beautifully functioning and looking really nice in the arch. I don’t see any concerns. We’ve got our six-year molars erupting into place. Now we’re six years later. She’s lost one of them, and the other two are still doing great. We’re about to lose another one. And that’s what it looks like seven years later, with this tooth exfoliated. It is blue because I used a topical anesthetic there, one of my triple anesthetics, to finger-exfoliate that. That’s why it’s blue.
But tell me that you have a stainless steel crown that has better marginal adaptation and cement retention than that. I don’t. I think it looks beautiful, and I’m very, very happy with that. That is an exfoliated crown after seven years of use in the mouth. Hallelujah. I’m pretty happy with that one.
Everybody good with that? That’s cool, right? Man, that’s a big case. Seven years later from when this started. The crazy thing was, I used to have to tell people, “I’ve done some of these, and I think they’re gonna last, and I’ve had one in the mouth for a year or so.” Now I have seven-plus years of exfoliated posterior molars that have functioned beautifully and have fallen out. So we don’t have to live on “Is this gonna work?”
There are other white crowns that have come out that you see holes in after six months of use, like a hole in the occlusal surface of a white crown six months later. That is not, to me, a long-term restoration. This is a long-term restoration. I have seven years that I can show this has worked.
[00:45:18] Confidence and case selection: courses and your first case
So those are a couple of cases. I’ve got lots of cases I can show, but I don’t wanna waste your time, and I want to be cognizant of that as we get closer to the hour. I wanna talk about things you guys can do that improve acceptance and your confidence.
Number one, can you go to a course? Please go to a course if you can. Sprig has got lots of great instructors who are all practicing pediatric dentists who do this on a daily basis. There are a couple of upcoming courses already scheduled in 2025: a March course in Vegas and a Chicago course in October.
Another thing you can do: I want you to be honest with yourself and only treat cases that you want to treat. Know your limitations and know the material’s limitations. If this is your first case, do not do back-to-back lower zirconia crowns on a horribly behaved four-year-old whose mom doesn’t want to do anesthesia. That’s not the case. Okay?
The first case, in my opinion, is a very well-behaved five- to seven-year-old, maybe seven if they have delayed eruption and that kind of stuff, who has large decay on tooth L or S, and that’s the one you’re working on. Maybe it’s small on K and T, and maybe you’re putting SDF on and monitoring it, or doing a composite on that one. That’s what you’re doing, and you’re gonna do one zirconia crown to start with. Do that. That’s where you start, and then move forward from there. B and I are fine; they’re harder, though. We all know B and I are harder teeth. So start with L and S and then move on to the others. That’s my biggest recommendation.
[00:47:07] Photos and graphics that sell the treatment
The other thing you wanna do is get good graphics and show how you do what you do. You can take my pictures, and I can show them to you, and you can use them in your office. But if a parent says, “Can you show me a picture of one you’ve done?” you need to be able to say yes. So take pictures of all of the things that you do. It is great marketing. It is great for your confidence. It also allows you to look back and say, “Wow, I didn’t do a very good job on this.”
So let’s use graphics to show that. Get a good camera. You can get a DSLR camera. I use a Canon T3i or T5, with a 100-millimeter macro and a ring flash, and these are the settings I use. Take a picture of that, or mess with it, or talk to your local orthodontist or a general dentist who takes lots of pictures and figure that out. It’s not super costly, but there’s a pretty big learning curve using a DSLR.
Your other option, spending a little more money, is one of these Shofu EyeSpecials. It’s essentially point-and-shoot. You look at the tooth and take a picture of it, and it takes it really nicely. I don’t think it shoots as quickly as a DSLR where you can just snap, snap, snap, but it does a beautiful job of getting good images.
If you just want a good oral camera, I recommend a couple of these. I have all of these cameras, but I have one of these at every one of my computers. You can get them for 180 bucks apiece on Amazon or at daryoudental.com. You’re gonna get low-quality images, but you’re still gonna get a good visual of what’s going on.
Then take those pictures and put them together in a graphic. “Here’s a picture of cavities, Mom. This is what it looks like. This is what it looks like when I put silver diamine fluoride on.” This is a kid who was in my office. They walked around for over a year with black front teeth, but the parents bought into why we were doing this, ’cause we were working on getting that kid healthy. We were restoring health to those teeth, and after we restored health, we got to repair them with crowns.
And this is a picture of these. I didn’t use the prettiest case I’ve ever done. I wanna show it realistically; this was actually three crowns and not four. I want them to see, “Hey, this is what it can look like.” It doesn’t look perfect every time. I can get it pretty dadgum good. But this is a good case you can show of what it looks like when you’re doing these cases.
[00:49:25] Training your team and stocking your kits
You also need your team to fully understand and believe in what you’re doing and in your treatment plans. Because every one of us knows, as soon as we walk out of that room, our team is asked by the patients, “Should I really do this treatment? What do you think? Would you do this?” And if your team doesn’t believe in you and doesn’t give good answers to that, you can bet you’re not gonna have that treatment plan accepted.
So we wanna train your team. There are things they can do. You can have visual aids. What I did in my office is I made some typodonts and glued zirconia crowns on them and glued stainless steel crowns on them, so I can show, “This is what a stainless steel crown looks like. This is what a resin-faced stainless steel crown looks like. This is what it really looks like, and this is how much the cost difference is.” Let’s talk about behavior and evaluating how many crowns we need. Do we need to do nitrous, or can we do this with zirconia? What does that look like? I think that’s an important thing for us and our staff to be able to understand.
Another thing your staff can do is help you by eyeballing the sizes. If it’s a GA case and you’re not even in the room yet, but they’re there and they’ve started taking X-rays, or they’re waiting on you while you’re prepping something else, they can always hold up a crown and see what size we’re thinking. For me, in my area, I’m thinking my anteriors are three, plus or minus, and the posteriors are four, plus or minus. So I’m using twos, threes, or maybe fours on the anteriors, and threes, fours and fives on the posteriors. You can also use a perio probe if you have one of those. Not all pediatric dentists even know what that is! But perio probes can be great to use just to get a size.
Also, make sure you’ve got the whole kits. Don’t do a jigsaw puzzle with half of the pieces. You need all the pieces. If you’re gonna do these, get all of the crowns and be ready to have them in your kits, ’cause you don’t wanna be doing these and not have the size you need. For us, we have a large amount of the crowns we use the most. In the anteriors we’ll have six to nine crowns in each of the sizes we use. So in those twos, threes and fours, I have six to nine of those crowns in each of my offices and in my OR kits. In the posterior maybe I have fewer; I don’t do as many of those, so maybe two to four. And have somebody in charge of ordering, so they can keep an eye on those crowns and make sure they’re ordered.
[00:51:58] Strategy, not just tactics
I think this is a really great quote for us as we do these things: “Tactics without strategy is the noise before the storm.” You can have all of the tactics in the world, but if you don’t have a good strategy to get there, then you are going to have defeat. And defeat for us in this feels like sitting 45 minutes trying to get one crown seated on a kid who’s screaming in your chair. That is not fun for you, me, or anybody.
So the goal is, let’s have a strategy. My goal tonight is that I gave you some pieces of your strategy that can improve that. And if you’re new to this and trying to learn it, come to a course and spend some time. The courses are awesome. They are fun. Sprig makes these great, and you’re gonna learn a lot, and you’re gonna get to do that at a great location with some really great people.
[00:52:48] Q&A opens: the bristle bar
Man, I did good. We got four minutes to spare, and then some time for questions. I’ve got my question bar up here; I’m gonna make that really big and see if anybody has questions for me.
I’ll take up some time while you guys might be writing some stuff. I’m sitting here at my new office, and behind me is something we put together that we call our bristle bar. It says, “Get your shine on.” We’ve got our goodie bags hung up. It’s sort of like Halloween: the kids get to come over here and trick-or-treat through and pick out their toothbrushes and toothpastes and flossers and all their goodies. And then up here are some promo items that have our logos on them, and just some fun stuff all around. So this is our bristle bar here at our Parkview office. I think that’s a fun, cool thing. […]
[00:54:05] Q&A: switching brands, canines, removing a crown, deep bites
All right, I’ve got a couple of questions coming in. Let’s get these.
This is a great question. Somebody said, “I’m really interested in switching from Kinder Krowns to Sprig. It’s a big investment, I hear you, and I don’t wanna waste our current inventory. Do you know if Sprig offers any kind of buyback program?” I do not know that, but that is a great question, and I wanna make sure our Sprig team gets to see it. So Garrett, will you make sure to get that noted down? And Mary, if you want, Sprig has got some amazing people; give them a call and chat with them about it. Or email me. There we go, you can email me if you want, and I am more than happy to get you connected with them if I can.
Somebody else was asking about passive fit on canines, significantly reduced canines. I will tell you my favorite tooth is the canine. You need to reduce a little more on it. But think about the canine: it has the tiniest pulp chamber, so you have so much tooth you can reduce before you get there. If I’m in a squished condition where I’m maybe doing the top eight or the top ten crowns, the canine is where I can gain some space. I’ll almost always end up with a space-loss canine and just take away a little more on it. What I think you’re probably doing is not removing enough of the cingulum of that canine. You don’t need a lot, but take a little bit on that cingulum and narrow that top down with the second plane of reduction, and you should be able to get those canines down nicely.
Somebody was asking: if you didn’t seat the crown correctly and you realize it while the patient’s asleep, or later, how do you get it off? Can you cut it off? Do not cut it off. The best way to get a crown off is to take your Howe plier and squish it. Just grab the Howe plier over the top of the crown and squish, and that lateral force on the crown will completely shatter it and it’ll be off. Then you can put a brand new one on there. That works beautifully, in the OR or later on if you needed to remove one for something […].
Someone’s asking about a deep bite case. For a deep bite, you can actually open up the posterior with crowns or bite blocks. Something that’s discussed in the literature and is seen is that these crowns don’t bend, right? With a stainless steel crown, you’re gonna get intrusion of the crown itself, but this doesn’t happen on a Sprig crown. If you seat the crowns high in the posterior, you can end up with what they call a ghost tooth, where the root tissue just completely resorbs away. I have seen that happen, but never in my practice. The teeth I see it happen on are teeth that are pulped and where the crown is seated high. If you are not pulping the tooth, I have never seen one resorb those roots.
[00:57:30] Q&A: cement, seating order and timing
Yes, somebody asked about cement again. Fuji I or Ketac, either one is great to use. It’s more personal preference. In my office I use Fuji I. In the operating room I use Ketac Maxicaps, ’cause that’s what they have for me.
What’s the protocol on seating C to H? The number one important thing is, however you seated them when you were trying them in, seat them that way when you’re cementing. For me, that’s usually centrals, laterals, canines. Now, if I’ve got a first molar in there, that’s a whole different story. If a first molar is involved, I will probably seat the first molar, then the canine, then the anteriors. But again, seat them in the order you try them in. For me, I would fill those and seat all six at once in my hands. For you, early on, I would probably say seat half and then the other half. That’s how I would do it. […]
A couple of people asked: if you try to take a crown off, do you use a new crown? Yes. Crimp it, break it, take it off, and then put a new one on.
Ooh, somebody asked about a cement that doesn’t contain fluoride. Gosh, I don’t know. RelyX, no, RelyX contains fluoride. That’s a great question. I think a BioCem, or a serum-er cement, doesn’t have fluoride. But if you have a patient asking for that, you should be passing that cost on to them, ’cause you’re gonna go from seating something that costs a dollar a unit to something that could cost $12 to $15 a unit.
Somebody’s asking about average waiting time before removing the excess cement. I start doing that almost immediately. But I try to let the cement get a little thicker before I seat the crown. If it’s a Fuji cap, once I’ve mixed it, I’m probably letting it set for 30 to 45 seconds while I’m doing other things, and then I’m seating it. So it’s in that thick jelly or putty stage, I seat it on the tooth, and now I’m gonna start cleaning right away. If you seat it and it’s really runny, you just have to hold for the 30 to 45 seconds. I have a very short attention span, so everything I do is trying to be efficient and quick.
[01:00:23] Closing and a quick office tour
All right, any other questions? Those were all great questions tonight. Thank y’all so much for your time. I don’t see any other questions.
Again, thank you for your time. That is my cell phone on here if you wanna call or text me. I love talking to pediatric dentists. That’s my personal email, and that’s my website for Parkview Pediatric Dentistry. I live in Lubbock, Texas, and I love what I do. We have a great, growing practice here. If anybody here wants to move to Lubbock, Texas, talk to me. I love getting to care for kiddos. I’ve got a great practice where we care for kiddos with Medicaid and are out of network, everything else. It’s a cool model that I’ve loved to see grow, and I’m excited to always meet new pediatric dentists around the country who share the same passion for what I do here in Lubbock, Texas.
Anything else? Any other questions? All right. I have no affiliation with this company, but I wanna show you something that’s so super cool in my new office. Can I show you something? Is that a thumbs-up from some people still here? All right, let me show you. Let’s walk and talk.
This is something I put in the new office. I wasn’t sure if I wanted to or not, and I decided to, and it’s super cool. I found out about it first on Facebook from other offices that had one, and I thought, man, it can’t be as cool as they say it is. But it really is. Behind me is my LiteZilla. Man, it is super cool. I got the eight-foot by six-foot one with our logo on it, and kids come in here and are amazed by this thing.
In this new office we’re trying to do things that are not just more electronics. Kids are bombarded with electronics. If you can see in my corner here, I also have a library, so free books for kids to grab in our office. Instead of just playing on iPads, they can play with STEM learning tools and that kind of stuff. I wanna be a positive impact for kiddos, not just fix their teeth.
Yeah, absolutely, some other LiteZillas. Love it. Very, very cool. And thank you, if any of you who said you had one were the ones who posted about it in the Collaborative Pediatric Dentists group, ’cause that’s where I saw it first and decided to try it in the office. I’m really, really thankful I did.
Anyway, guys, thank y’all so much for your time tonight and for spending your evening with me. I wish you guys all the best, and reach out if I can help in any way. Thank you guys very much. Have a great night.