Anterior Crown Preparation Technique and Advanced Zirconia Clinical Pearls — Transcript
[00:00:15] Welcome and housekeeping
Good evening, everyone. Thank you so much for attending. It is 7:30, so we’ll get going here in the interest of making sure we’re good stewards of your time. Thank you for joining us for another Sprig webinar. I’m excited to be part of this. This is the third time around that we’ve been teaching this, and a couple of people had messaged and said they’d tried a couple of times in advance and hadn’t been able to get in yet. So we’re excited to keep doing this so that more and more people can learn about some pretty awesome technology and some difficult techniques that we’ve got here for Sprig. I’m super thankful to be part of that and here with you tonight. Hopefully you’ll enjoy it.
A couple of housekeeping things. If y’all have questions, please ask them in the questions portion. I’ll try to get to as many of those as we can at the end. We try to leave some time for that, and I think that will be helpful for everybody. Some of them I might have answered already, so I’ll skip over those at the end. But if you have them, please ask or write them down and make sure you get your questions answered.
I love interactive presentations. Obviously, this is not one of those. So if I make a joke, I only get to laugh to myself, and I have no idea if any one of you at home laughs. So bear with me. Hope you have a great time.
[00:01:47] About Dr. Dusty: “We don’t treat teeth, we treat kids”
My name is Dustin Janssen, and I go by Dusty. My patients call me Dr. Dusty. I’m the owner, and I started Parkview Pediatric Dentistry in Lubbock, Texas. I went to Baylor Dental and finished in 2009. Baylor doesn’t exist anymore; it’s owned by another school here in Texas. It’s Texas A&M College of Dentistry now. I spent two years as a general dentist, and I did my residency at the University of Washington from 2011 to 2013. I was in the Yakima portion of that program, so I had an awesome opportunity to care for lots of kiddos from a migrant worker population, as well as lots of kids with special needs and from the Native American populations there. I really had an amazing opportunity to get lots of education there for kids with severe dental decay. Then I came back to Lubbock ready to go, and opened my private practice in 2013.
This is my family. I have three little girls, a female dog and 30-something staff members who are all female. And I’ll tell you what, there’s a lot of estrogen that runs around, but I would not trade it for the world. I love my little girls at home.
This is a quick reminder to me to say to you what an amazing opportunity it is each and every day to do what we do. Regardless of all the other stuff in our lives, the things that go on and the difficulties of practice, at the end of the day what is such an amazing thing is that people who have sweet little girls like mine, and sweet little boys, walk in and they trust you to care for their child. What an amazing opportunity that is to impact their lives.
One of the founding principles of my practice is that we don’t treat teeth, we treat kids. I treat a whole kid, not just looking at one tooth and forgetting that there’s a kid attached to it. As I look at this picture of my sweet girls, it makes me humble to think that people walk in and trust me to do that. And each and every one of you on this webinar tonight is trusted by people who love and care for their kids and trust you to do the same. So thank you for doing that for kids in your community and in the populations you get to treat. What an amazing opportunity that is.
[00:04:13] Sprig’s story, and a cocktail
Sprig has been doing what they do for 10 years. In 2006, EZ-Pedo was founded, and they became the first pediatric zirconia crown. In 2009, three years later, that crown that was a dream became a reality and was seated on a patient. In 2013 they started the zirconia preparation CE courses, and I was fortunate enough at that time to teach the first course, in San Francisco. It was an amazing, fun thing. They have evolved substantially, and it’s such a cool thing to see the growth of those courses. In 2017 they rebranded as Sprig Oral Health Technologies to expand the scope and reach of the things they do, and they’ve continued with international growth. And in 2020, they’re celebrating 10 years of these amazing crowns placed in kiddos’ mouths.
So in celebration, and especially celebration of another day done, I like to make cocktails. If I wasn’t a pediatric dentist, I might be a mixologist bartender. So I made myself a little cocktail tonight. I hope you’ve poured one. If you haven’t, make sure you go pour yourself something. If you’re going to listen to me all night, you probably need a cocktail.
The cocktail I made is a variation of a Manhattan. I’m not a big fan of sweet vermouth, so the cocktail I make is called a John Wayne Manhattan. I like to use a high-proof bourbon. I like Booker’s. It’s a great bourbon; sometimes it’s harder to find, but I like Booker’s or Stagg, Stagg Jr., a couple of those big higher-proof bourbons. Then Disaronno and some orange bitters. I put that in a cocktail shaker and shake it, pour it over large ice cubes in a rocks glass, and garnish with an orange peel that you twist and wipe the rim with. Put in a couple of maraschino cherries, but not the bright red maraschino cherries, because those aren’t really maraschino cherries. You’ve got to find the Luxardo cherries. They’re outstanding. They’re a little more expensive, but you’ll absolutely love them. So hey, maybe you don’t have the stuff to make this drink, but I hope you make yourself a drink. Enjoy the presentation tonight.
Please be in touch with me. I’ll put my email on this. Email me; I would love to answer questions for you. Over the first two, I’ve gotten some great emails from people, so hopefully this can be beneficial to you. And again, if you have a cocktail, it makes me a little more bearable. So bear with me. Let’s have some fun tonight.
[00:06:48] My journey into zirconia
In residency, we had a couple of treatment options initially: strip crowns or resin-faced stainless steel crowns. While you could have beautiful aesthetics with strip crowns, resin-faced stainless steels really didn’t offer that, but they were still a good, strong restorative option. The problem was that the first-year residents got to spend time fixing the failed or chipping strip crowns, or the broken-down resin-faced stainless steels, from previous years. The residents who left did nothing wrong with these, but as kids do, they chew on rocks, they fall, they break their strip crowns, and things happen. And they’re usually still a pre-cooperative child. So that pre-cooperative child showed back up, and as a first-year I got to figure out how in the world I was going to fix those crowns. And I said, “There’s got to be a better option than this.”
I took a picture of me fixing one of those crowns one day, and it looks something like this. And you’re like, man, I’m tired of a rodeo to try to fix a broken front tooth on a three-year-old. So I asked for change. I had amazing faculty there who were open to new technologies and techniques, and they told me, “Hey, if you can get some of these crowns, why don’t we try them?” I had an amazing opportunity to try all three of the crowns that were on the market at the time.
When I got the Sprig crowns, they told me, “Hey, we’ll send you the crowns, but you’ve got to take pictures of them.” So I started taking pictures of my work. It’s something I’m going to recommend that you do as well. Taking pictures of your work is a beautiful way to learn, to grow, to critique your work and to get better. I think it’s a really fun thing to get to do.
This was a kiddo I saw today; I put this in about five minutes before the presentation. This is a kiddo I saw in my practice today as a follow-up from anesthesia. He was a really challenging kiddo, and I worked with mom substantially on our diet and our hygiene. Hygiene was horrendous. And they made a turn. One of the things I do is a lot of silver diamine fluoride placement. If you look closely, you might see a teeny tiny black spot on that lateral there. There are white spots all over the facials of these. This kiddo had some of the worst hygiene I’d ever seen. They were not involved and didn’t care about getting it. Over some time, with silver diamine fluoride placement and diet and hygiene counseling, they made some great changes, and those changes allowed me to get in and fix the large carious lesions. I left some of the white spots alone because they’ve made such great changes.
I like this because I think it’s a great representation of the beautiful aesthetics of these, even two weeks following placement. These are zirconia crowns on E and F. I left D and G alone. There are also zirconia crowns on C, H, M and R. So a really, really nice aesthetic result and beautiful tissue healing at a two-week follow-up.
[00:09:51] The evidence: what the research shows
These are not just things I’m going to talk about today. First, we’re going to talk about the hierarchy of what evidence looks like, and I want you to be fully aware and clear of what that is. At the top of this pyramid we’ve got our systematic reviews and meta-analyses. Then randomized controlled trials, cohort studies, case studies, expert opinions, super smart people, people who are sort of smart but have done it for a really long time, and then there’s this guy. Do not forget: I am this guy. I would say I have not done it a long time. Maybe so; I’m getting to that, I guess. But I’m still this guy. I’m just a pediatric dentist, a private practitioner who practices every day. I don’t travel around the world doing these. Nobody travels, I guess. But I’m here practicing, seeing kiddos, caring for the kiddos in our community. So I understand what it is to actually use these in my practice, not just talk about them.
This is a great presentation that shows what parent satisfaction with these pediatric zirconia crowns looks like. They evaluated 53 crowns on 18 kiddos between the ages of two and six. This was done at UT Memphis, with a four-year follow-up. Some of the great things they showed: at that time, 96% of these crowns were intact, 64% didn’t have inflammation, 32% had mild inflammation, 64% had no noticeable aesthetic difference from the primary dentition, and 100% showed no wear to the opposing dentition. That’s really nice, because that’s something we’ve always been concerned about: how are these crowns going to wear against the opposing dentition? The conclusion of this study was that they were a clinically acceptable restoration in the maxillary anterior dentition. Parents were super happy with the aesthetics, and it really fits with what Sprig has seen from their data as well.
This is a picture from a kiddo I treated, and it said, “Thank you, Dr. Dusty, for these beautiful pearly whites. Going on three years, and they still look gorgeous. I truly wish you could keep them forever.” I love this picture. A super sweet, fun little girl I had an amazing opportunity to care for.
[00:12:01] Case report: no wear, good adaptation
This was a quick case report with a 29-month follow-up of pediatric zirconia crowns. You can see that there was no attrition noted: three months before, as well as four months after placement, up to a 20-month follow-up, with no wear to the opposing teeth. They also didn’t show any gingival inflammation. We’ll talk in a little bit about the lack of ability of plaque to adhere to these crowns. And it shows really nice adaptation.
These were some of the exfoliated crowns. I think it’s an amazing opportunity to see an exfoliated tooth that still has cement retained, really nice margins, not a big, huge cement gap, and ultimately very similar looking to a stainless steel crown.
The findings were that preparation matters more than with a stainless steel crown, and it did require more subgingival preparation. But they had good integration: no loss of retention, fractures, wear to the opposing dentition or periodontal health concerns. Adaptation was good. The parents were happy. So again, this nice case report showed that the EZ-Pedo crown was a good restorative option for decayed posterior primary dentition.
[00:13:23] Pros, cons and how strong a crown needs to be
But in saying that, there are pros and there are cons. Zirconia is no different than SSC: nothing is perfect, and that isn’t a bad thing. It’s just different. There’s no perfect restorative material. Every material has a list of pros and cons, and zirconia isn’t any different.
The biggest con of zirconia currently is that it’s not a flexible material. Because of that, it requires a more precise preparation. You can’t get that pop over the undercuts of a tooth, because that will fracture the crown, or it won’t seat all the way. And because of that, it takes a little longer to prepare the teeth. It does not take lots longer. In my time doing these, I tell parents that I can do a stainless steel crown in less than a minute. A zirconia crown takes me three or four minutes. Sometimes that is a big deal. It’s not something to be taken lightly, but it’s also not something that’s going to take me forever to do.
The pros of zirconia: they have really nice high strength, they’re biocompatible, they’re aesthetic, and they’re resistant to plaque.
The question is: how strong do zirconia crowns need to be? In the Townsend study, they showed that all of the crowns they tested far exceeded the mean maximum bite force of children in the primary dentition. So what does that mean? All zirconia crowns on the market are strong enough not to break when kids are biting. They did find a positive correlation between crown thickness and increased fracture resistance. Well, that makes sense: if it’s thicker, it’s stronger. And that’s a great thing. At the time, they found that Sprig crowns were the strongest. However, Sprig crowns did show slightly thicker walls than the other crowns. Now, this didn’t mean they needed more preparation; they were just a little thicker. They retooled these crowns, and that was a version one crown. They now have their version two crowns, and we’ll talk about those in a minute, and some of the really cool differences as Sprig perfected the technique in which the crowns were made.
This is a great picture of a kiddo who fell, literally, I think, days after having these zirconia crowns placed. They fell, intruded and luxated those anterior teeth. No fractures to the zirconia crowns. You can see again some mad, angry tissue. This was a follow-up further down the road, as well as six months later. Crowns still intact. No fractures, still hanging on, doing a good job. That definitely is not the case if you were to put a strip crown on that tooth.
So zirconia crowns’ strength comes as a function of their thickness, and there’s a line that must be walked here. The goal is to create a crown that’s robust enough to withstand the bite forces, but doesn’t have unnecessary thickness that requires you to prepare the tooth more to make it fit.
[00:16:48] Biocompatibility, aesthetics and plaque resistance
Another thing we look at is how biocompatible these crowns are. Really nice to take a look at these. The picture on the left shows some resin-veneered stainless steel crowns, and you can see the tissue being unhappy, a little overgrown there. Then look at the replacement of those crowns with the Sprig zirconia crowns. It’s really nice how great the gingival adaptation is, how happy and healthy those crowns look in the mouth when you don’t have this puffy, inflamed gingival tissue. This is shown by a great study in 2008 looking at implant abutments. You can see how much more tissue growth and health there is around the zirconia abutment.
Aesthetics is something else we look at in these zirconia crowns, and something you can really appreciate in the Sprig crowns. In this picture, tooth R and tooth S are both zirconia crowns. Something Sprig does that I think is really nice, and that allows you to have one shade of crown, is that they hand-tint the gingival third to create a change in chroma. That change in chroma allows one shade of crown to blend nicely with the rest of the arch.
This is an interesting picture. I seem to see these on a semi-regular basis: kids who come in who’ve had these pre-veneered NuSmile crowns placed, and they’re chipping off. Even if the whole facial doesn’t chip, you’re seeing a bit of incisal edge chipping. Parents are never happy with them. They want me to cut them off, and gosh, it’s such a big mess to do so. So it’s so nice to have always worked with my Sprig crowns and not to have to deal with that. Again, you can see the difference in aesthetics and in the gingival health of those Sprig crowns placed on G and H.
Something else that’s really nice is the resistance to plaque we see on these zirconia crowns. Obviously, zirconia crowns were placed. Obviously, this kid still doesn’t brush their teeth. I mean, wow, it’s like he hasn’t brushed his teeth since they put the crowns on. But nonetheless: plaque everywhere, but the plaque doesn’t adhere to the zirconia crowns, which is really nice. What a cool restoration to be able to give, to help with gingival health and to help prevent plaque and bacterial accumulation on these kiddos.
[00:19:38] Sprig’s design philosophy and the V2 crown
The next thing Sprig was looking at when they created their design philosophy was that they didn’t want crowns to show up in hyperocclusion. If you seat a crown in hyperocclusion, there’s greater trauma to the tooth: in excursive movements, the teeth are going to hit differently on the cusp and fossa. Kids can adapt to it, obviously, but we don’t want them to have to, and it can definitely cause challenges for our kiddos later. So Sprig did some really cool things with the way they fabricated these crowns to decrease how much we have to prepare, but also to allow our kiddos to function normally and naturally.
On the anterior teeth, the cingulum is an area of the tooth that provides a lot of the strength that tooth needs. So if you have a crown that requires tons of cingulum preparation, you really decrease the strength and the integrity of that tooth, and even if the crown doesn’t break apart, you can actually break the tooth itself.
So when they were trying to create this ideal design, they wanted one that wasn’t going to be too high, that wouldn’t need adjustments, that minimized the reduction of the tooth so you don’t have pulp exposures just from your preparation, that fit in areas where we had space loss, and that really blended seamlessly with the natural teeth. That’s where they came up with the V2 design.
I hope you’re all drinking, because we’re trucking along here, and I find myself much more entertaining after I’ve had a drink anyway. All right: V2.
That started around 2010. What they did is create a modified anatomic design. If you were to hold the Sprig crowns up next to one of the other crowns, or even a strip crown former, they look very different. But this was done intentionally, with years of modifications to the crowns, where other companies have come out and said, “Well, these crowns don’t look great,” or “They’re not anatomic.” That was an intentional thing Sprig did to allow us as pediatric dentists to have faster and easier seating, to look aesthetic, to retain a natural look and to allow those gingival contours to look natural.
It allows us to have a flatter fit across the occlusal surface: instead of a deep central fossa, a flat occlusal plane. It allows the ZirLOCK to hold the cement in, so you don’t have loss of retention, because the cement doesn’t have to adhere to the crown through a chemical process. You get macro-mechanical retention through the ZirLOCK. They also did an awesome job of creating a space loss crown. Essentially, a space loss crown is a regular crown where you would have taken a Howe plier and squished the margins in. Those squished-in margins give you the opportunity to fit these crowns in some really challenging and difficult spaces. And they created that polychromatic finish to allow them to blend nicely with the rest of the dentition.
As we talk about that flat fit, you can see that graphic changing there. If you have a deeper central fossa, all that means is you’re going to have to prep closer to the pulp to allow the crown to seat fully. With a less deep central fossa, there’s less preparation, which means quicker seating, but you’re also further away from the pulp, which allows the tooth to maintain its integrity and vitality.
Sprig also relaxed these gingival contours. Out of the mouth, that might look odd, until you put it in the mouth and see the aesthetics blend beautifully. It allows you to have less preparation and to seat the crowns in really difficult, close spaces where otherwise you would have had to either depulp the tooth or prepare more to get these crowns to seat.
This flat-fit design contour means Sprig only needs 1.3 millimeters of reduction of the occlusal plane, where the competitors require 1.8 millimeters or more. The Sprig crowns look very different from the other crowns, and that difference is intentional. You can see that wide-open profile, which allows a really nice seating of this crown with minimal reduction.
This shows the difference in the occlusal plane on our posterior crowns that requires extra preparation. With that deeper central fossa on the crown on the left, all that’s happening there is just cement. We’re not helping that tooth any more by having a deeper central fossa. So this flatter occlusal plane is really helpful.
[00:23:23] ZirLOCK retention: no bonding to zirconia
There’s also some really awesome retention. As I mentioned earlier, we’re not trying to bond to zirconia. I know some of you are general dentists and some of you are pediatric dentists. It’s been a long time since I’ve thought about bonding ceramic materials, but for those of you who understand it better than me and do it on a regular basis, bonding zirconia is a very challenging thing to do. It requires lots of steps. It requires great isolation, and that’s not something we as pediatric dentists are used to. I’m not used to trying to get great isolation. I don’t pack cord. I don’t know the last time I packed cord. That’s not something we do.
Sprig allows us to work the way we work, which is in bloody, messy, wet, slobbery environments. As pediatric dentists, we’re not trying to bond to this crown. We just need to get a good cement underneath the crown and bond to the tooth. The best cement to bond to a tooth is a pure glass ionomer cement; we’ll talk about that in a little bit. Those grooves allow that cement to create macro-mechanical retention to hold the cement under the crown, keep it there, bond to the tooth structure and give us great retention of that crown.
The ZirLOCK increases the surface area by two times. It maximizes retention. It also creates what they call a margin lock feature: the last groove is even deeper, which helps hold the cement right at the margin. It will work with any glass ionomer or resin-modified glass ionomer cement. In my practice, I stick with a pure glass ionomer cement. I used to use a little resin-modified, but I find there’s less technique sensitivity when you go with a pure glass ionomer cement.
This is a great picture that was just back here; I wanted to increase the size so we could all look at it together. Look at the cement retention there. Look at the very small gap of cement on this anterior tooth. We’re not talking about big, huge margins here. We’re talking about a crown that was specifically made to fit that tooth very, very precisely. What an awesome fit. And I don’t think anybody other than pediatric dentists could get excited about looking at that.
This is a great picture of the interior, the intaglio surfaces, of other crowns. You can see the EZ crown has much deeper, much more pronounced ridges, or ZirLOCKs, that go all through the entire crown. That’s accomplished because this is a milled crown, not an injection-molded crown. It’s milled out of a block of zirconia, which really gives the opportunity to create these retentive grooves throughout the crown.
[00:28:24] Space loss crowns and the polychromatic finish
One of the other features we talked about earlier was the space loss crowns. As I alluded to earlier, this is essentially a crown that just received a Howe plier squish. If you think about putting crowns back to back, you’d usually put a 5 and then squish it down; a 5SL is exactly that crown. We can’t squish these crowns ourselves, so Sprig created that for us.
Sprig is also the only crown company that makes cuspids in a space loss version, and it’s awesome, awesome, awesome. In that case I showed you earlier: there is an H crown, but there are no M and R crowns, so you just alternate. If you’re going to use a C, you use it for the alternate side, and on the lower I usually end up using a space loss crown, because those lower cuspids are narrower in general. The space loss cuspids fit beautifully, allow a great aesthetic result and really allow the patients to come into full occlusion as well.
This was an amazing case: a beautiful transformation with 16 crowns placed on this kiddo. They got a crown on all teeth except those lower anteriors. What a great transformation, from a super-high caries risk kiddo to a beautiful restorative finish with really nice healing gingival tissues. These space loss crowns are what allow that to happen. You gain millimeters of space in really tight, difficult situations.
I also talked about the polychromatic finish, which I find such a nice thing with the Sprig crowns. There’s a hand-finished detail on the gingival portion that allows them to blend like natural teeth, and then a mirror polish on all the functioning surfaces. What does that mean? The functioning surfaces can be problematic if they have a porcelain coating or a poorly polished finish, because that makes them rougher than the opposing tooth structure, which means they’ll wear down the opposing structure. And we don’t want that to happen.
So, as I said, there’s gingival third staining. They create a really nice aesthetic glaze, and you can see from an SEM micrograph what this looks like and how beautifully polished it is compared with other crowns.
[00:31:13] The ASAP technique: why the crown fits the first time
Let’s talk a little about some of the clinical techniques. Sprig has coined this ASAP: the Accelerated Sub-gingival Atraumatic Preparation technique. It’s a systematic approach to improve your speed and efficiency, save chair time and money, and decrease your stress. Now let me say, that sounds like a sales pitch, and I’m not a salesman. I don’t work for Sprig. I don’t have anything to do with them other than doing some teaching that I enjoy and using the crowns.
What I want to tell you is, I’ve had people come into my office and watch me treat patients. And it’s really funny, because when they’ve watched me, they’ve left and commented, “Wow, the crown fits the first time you seat it down.” It doesn’t always work that way. I wasn’t sure why it always worked when I had somebody watching me, until I started thinking about it. Sometimes I get ahead of myself: I’m prepping too fast, I’m moving a little faster, and I’m not looking at the preparation as closely as I should. When I have somebody watching me, I do the preparation to a T. And it does not take me longer to do the preparation that way. Because if I’m trying to speed through it, I end up trying the crown on, the crown doesn’t fit, and then I have to decide: do I need to change the crown size, or do I need to prepare more? When people watch me, I do the preparation correctly with each step, because I’m showing them, and those crowns seat down almost to perfection.
So what I would say is: take the time, and do the preparations as you’re going to see here. You’ll be amazed how much more quickly the crowns seat. At least one person from each webinar I’ve taught has messaged me and said, “Oh my gosh. I did what you said. The crowns fit the first time.” So spend a little extra time doing this systematic approach.
These burs and this prep set allow you to do exactly the preparation needed to make sure that crown is going to fit.
[00:33:27] The anterior prep, step by step
We want these crowns to have a passive fit. You don’t want to jam the crowns down. If you push down and you’re getting binding of the crown, that means you need to remove a little more tooth structure. I know this is hard to realize and to think through. This is exactly the opposite of what we do with stainless steel crowns. You want the tooth to have a slight passive fit.
You want a cylindrical design: you want the tooth to fit over a cylinder. Because of that, you don’t want to teepee in. You want straight up-and-down walls, perpendicular to the long axis.
When we start our anterior prep, we like to start with the EZ-Prep Bur 1. This is our donut bur, and the full thickness of this bur is 1.5 to 2 millimeters. Take that bur and take the incisal edges down around 1.5 millimeters.
Then we use our Prep 2 bur, which is for our supragingival axial reduction. The thickness of this bur is 0.85 millimeters. Take this barrel diamond and create a chamfer or shoulder-like margin all the way around this tooth, right supragingival. I say right supragingival because I don’t want to hit the tissues: if I hit the tissues, I make them bleed, and if they bleed, I can’t see as well. So I like to stay very, very slightly supragingival as I prep this, so I’m not making it bleed at this point. For those of you who are general dentists or do regular preparations of adult crowns, this is a preparation just like you’d prepare for any other ceramic crown. You get this nice thick shoulder, and then comes the axial preparation, where you run up the incisal edge and create a slight second plane of reduction there.
When you look down on the tooth, it should look something like this. You should look down and see what we call a racetrack. The racetrack should be a circumferential 0.8 millimeters all the way around this anterior tooth. If it’s not, and it looks like you need to take some more, make it 0.8 millimeters all the way around.
Then you can do your lingual reduction with Bur 3. This is our football diamond, and the goal is to take about 0.75 millimeters of lingual enamel off the tooth. This creates a thinner incisal edge. You’re not going to take away too much cingulum, but you’re going to allow this crown to fit down the way we want it to, in a nice plane on the long axis of that tooth.
Now, this is the part where you throw everything you do in general dentistry out the window. We’re going to take that beautiful shoulder or chamfer margin, and you’re going to take it away. Take your EZ-Prep Bur 4, which is a flame diamond, and extend the tip of the bur a full 2 millimeters subgingivally. So we’re going to take it 2 millimeters subgingival. This is the part where, if you’ve done a good job of preparing in advance, you can hug the tooth with the bur. That keeps you from getting heavily into the tissue and allows very minimal tissue damage. Now, the tissue’s going to bleed, but it doesn’t just eat up the tissue like it used to when I did these preparations before we had this technique. Once you’ve created that subgingival preparation, two millimeters, you don’t want to taper it. You still want this nice cylinder to seat a crown on. Then you can start talking about seating the crowns.
[00:37:03] Common preparation errors
Now, we’ll see some errors in our preparation. One is not taking the full thickness. A good way to visualize that full thickness is to look at the marginal ridges of adjacent teeth. If you’re doing two teeth back to back, you can actually take a little more thickness on the distal of that second molar to allow the crown to seat down and hug the distal of that tooth a little. And sometimes you can take a little more than that two millimeters on a younger child, where you’re trying to seat the crown a little lower into the tissue because you know it’s going to erupt more. And sometimes on badly broken teeth.
Another error people make is not getting the full thickness of our second bur to get that 0.8 millimeters. Make sure you can see that racetrack. If you can see the racetrack, you’ve taken enough tooth structure. On the posterior teeth, the way I think about it is that 0.8 millimeters is about the thickness of the enamel. So after I’ve taken my occlusal, I can look down and take away essentially all the enamel, right to the DEJ, and then I know I’ve done my 0.8 millimeters.
Other times, if you over-taper the preparation, you end up with a little ledge right down subgingivally. You try to seat the crown, and you end up breaking the lip off, breaking the crown, or not being able to seat it all the way. You don’t know what it is, and it’s a teeny-tiny lip. A stainless steel crown would flex right over that, but our zirconia crowns do not. You can see on this upper tooth, tooth B, that it just didn’t seat quite all the way, and that was really secondary to a little lip that wasn’t removed.
Other times, we just forget to go as deep as we want to, and that keeps us from being able to seat the crown all the way down. So really make sure you’re getting that two millimeters of subgingival preparation on these crowns.
[00:39:15] Old habits, and managing the tissue
Some of us hold on to how we’ve done stuff. These are my two girls a few years back now, gosh, four years back. Claire thought she was giving Camille a hug, but she ended up doing a lot of strangling. We hold on to the old way pretty tightly. You can see a few years later, they still have similar attitudes to one another. So old habits can die hard. I know it’s hard to make changes, and I know it’s hard to think differently, that this crown is supposed to have a passive fit. But that is exactly what these crowns need.
We also have to think about managing the tissue. HemeRx is something Sprig makes: a great pellet to help with our tissue hemostasis. There are lots of other materials to use as well, and I’ll go over the type I use in just a minute. You can see on this tooth that tooth D did not get good hemostasis before it was seated. That can cause loss of retention. In this case it did not; this was a kiddo I treated, one of my earlier cases, and I did not get good heme control. That crown didn’t come off, but it did not look as good as I would have liked.
So tissue management can be achieved with HemeRx, a hemostatic pellet infused with epinephrine. I like these pellets specifically for really big bleeder spots, and the place that happens for me is the papilla. So I use Traxodent, and then if I have any bleeder spots after that, I use a little of the HemeRx to complete the hemostasis that’s needed.
[00:40:57] No try-in crowns, and choosing a cement
So now we’ve got the crowns and we’ve talked about our preps. We want them to fit right, we want them to look good, and we know they’re going to do that. Sprig has something different: we don’t need a try-in crown for Sprig crowns. Other crown companies do, and the reason is that they’re relying on a chemical bond to the zirconia, and if you have blood and saliva contamination, you cannot get that chemical bond. So those pink try-in crowns, to me, just add a step I don’t need in the first place. The ZirLOCK allows macro-mechanical retention. You don’t need a try-in crown. You don’t need extra steps. There are no extra crowns.
When I go to the operating room, I usually have eight cases that day. So the question for me was: do I need eight sets of try-in crowns to make this work for the day? That seems like a whole lot of extra stuff to have around, because I need a full set for each case anyway. I like to know that the crown I try in is the crown I’m seating in the mouth.
Another thing that’s really nice is you can use any cement you want to cement these crowns. Now, there are cements that are easier to work with, that are cheaper, and that are better to work with, and I’ll go through those. Sprig did a great cost comparison for you. If you use Ketac Cem powder-liquid, the whole price per unit of seating is $1.76. That goes all the way up to using Ceramir, which is $11 per crown to cement. That’s a whole lot.
So, a couple of things, back to dental materials. A pure glass ionomer cement bonds naturally to tooth structure. It’s the cheapest, it’s strong, it’s been used forever, and it bonds beautifully to tooth structure. In my practice, I use pure glass ionomer cements. I use Fuji I. I like Fuji I because it comes in pre-mixed caps; I use the auto-mix capsules, and I’m a big fan of those. In the operating room, I use the Ketac Cem Maxicap. That auto-mix capsule, as they said down here, is a GI. They said it’s $10 a cap, but with that I can fill four crowns, so it really decreases the cost substantially there as well.
So I’m a big fan of a pure glass ionomer cement. That’s what I would go with. For anybody who’s having difficulties, it always seems like they’re using a resin-modified one. Now, resin-modified glass ionomer cements are great, but they’re a resin cement and they still need a good environment. If you have saliva, if you have blood everywhere, you’re going to run into more concerns with a resin-modified cement.
So find a method that works best for you. I’ve used multiple methods before. This was a picture of one of the cases I did when I used a resin-modified glass ionomer cement. I used RelyX. I like RelyX if you’ve got really good hemostasis, and it works nicely because you can tack-cure it and gel-set it, so you can immediately clean up the excess cement. I think that’s a really nice thing. But if you’re not getting good hemostasis, you’re going to have problems with the resin-modified.
As you’re cleaning up and doing things with the crowns: once these crowns are seated, you can rotate and position them, but do not lift them and put them back on. You’ll definitely see concerns with the aesthetics if you do that, because you’ll end up getting some heme up there.
[00:45:00] Vital pulp therapy with MTA
Vital pulp therapy is something we get to talk a little about here. MTA is an amazing material. Sue Seale talked a lot about pulp therapy, and I got to learn a lot from Sue at Baylor. She has some amazing papers. One I reference all the time is a meta-analysis she did that looked at the different pulp therapies and showed that indirect pulp cap therapy and pulpotomy were similar, with indirect pulp cap therapy being a slightly better treatment option. That’s what I do primarily in my practice. But if pulps are done in my practice, which is a very minimal number, MTA is what I like. I really like the SmartMTA because I like the little capsules it comes in. It does a nice job of letting me have the small amount of product I want without contaminating the other things I use. It’s also nice because it sets up in less than five minutes.
What it does is create a really nice seal to entomb any bacteria in the tubules and prevent leakage, for good long-term clinical success. It allows hydroxyapatite formation for a nice dentin bridge. And the way the MTA is packaged here allows you to do these pulps for less than $5 per tooth.
In my opinion, MTA’s best friend is this guy. If you’ve got your dental equipment from dental school, or from some old practice you bought, and you’ve got some amalgam carriers around, pull those bad boys back out and get them ready to go. This is going to be your best friend to carry the MTA and place it over the pulp if you’re using it.
[00:46:49] What people think we do
I don’t know if you remember this, but this is a really interesting meme that popped up on the internet quite a while back. It was about dentistry: what your friends think you do and all that stuff. It didn’t really apply to pediatrics, so I decided I’d make my own. So, pediatric dentistry, here we go. My friends think I hang out at Chuck E. Cheese. My mom thinks I can fix teeth with my X-ray vision. Society maybe still remembers David After Dentist and his viral videos. Patients think I stare at them with these big wide eyes; they stare back at me with those wide eyes like, “What are you about to do to me?” I think I hang out with little Sally and her baby doll and keep her teeth healthy. And the reality is, as I said earlier, sometimes you just wrestle alligators.
All right. We’re 45 minutes into this, and we’re going to get to some clinical cases. Hopefully this is something you’ve been looking forward to. The first part is really important for everybody, whether you’re new to doing these or you’ve been doing them a long time: reviewing some of the cornerstone properties of the preparation and the crowns themselves. And now we can talk about some of the more challenging cases that we as pediatric dentists come across every day.
[00:48:10] Case: SDF while waiting for general anesthesia
This was a kiddo in my practice I saw with severe dental decay. It still takes me quite a while to get kids in for a general anesthesia appointment, even more so now with COVID, so it was a long time before I was able to treat this kiddo. What I did was place SDF months before my visit, and on the day of the visit I planned to place it again. In this case you can see how poor the hygiene still is. There’s still plaque all over those teeth, but they haven’t progressed substantially since the previous visit.
Again, I love my EZ-Prep bur block to help guide me. I started with my initial racetrack preparation, removed the axial tooth structure and created a nice cylinder on those maxillary anterior teeth. Then I placed another coat of my Advantage Arrest on the teeth. After that second application, I completed my subgingival preparation and used Traxodent. This is a picture with the Traxodent placed. That Traxodent helped me get some really nice hemostasis. And I say hemostasis, for me, was enough time to take this picture: de-glove, grab my camera, take the picture, re-glove and start working. That’s what I consider hemostasis in this case. This is a really nice, clean result for those gingival tissues.
In this case I used my Ketac Cem Maxicap and completed placement of those crowns. This was an immediate post-op picture. The gingival tissues don’t look perfect, but they sure look pretty healthy comparably. There’s the before, and there’s a two-week follow-up after. I think we’ve got a really nice aesthetic result. We still see some healing going on at two weeks, but again, a really nice aesthetic result from where we were. This is a kiddo who, in my practice, would have been treatment planned for extractions of those anterior teeth, because I know it’s going to take me months to get them in, and during those months they’re just going to see further progression of that dental decay.
[00:50:21] Case: correcting an anterior crossbite with zirconia
This is a fun case with a nice three-year follow-up. Something you can’t do with these pre-veneered crowns or your strip crowns is correct crossbites, because if you get these teeth in excursive movements where they’re hitting incorrectly, they’re going to break. But the zirconia crowns are so strong that I thought, “Gosh, I wonder if I can do this.” This was a kiddo who walked into my practice: his mom walked in first, and her chin came in before she did, and then he walked in and his chin came in before he did. So this is a true Class III kiddo and a Class III family. I had him in surgery. He had decay on E and F and on some of his posterior teeth.
What I did was open his bite by creating only a minimal preparation on the occlusal surfaces of those posterior molars. In this case, you can see I opened the bite about two millimeters. If you’re not doing posterior crowns and you’re just doing this, let’s say in the office with nitrous, I use bite turbos. I use a material from Reliance Orthodontics called Band-Lok Blue. It’s an RMGI, and I just bond it on the occlusal surfaces. I do this for kiddos with crossbites that we’re correcting that way, and other things. Ortho does it all the time: bite turbos, bite blocks, whatever you want to call them. It’s just opening that posterior bite up a little.
People ask: is that something you have to take off? Does it cause problems with their joints? Absolutely not, not on kiddos at all. I use an RMGI in this case because it’s softer than the tooth structure and it wears down, so I don’t even cut it off usually. I’ll blob it up a couple of millimeters and open their bite, and when I see them back in six months, they’ve usually worn back through it and they’re back down into a normal occlusion.
But anyway, in this case, I seated the crowns slightly high. That gave me about a two-millimeter opening of the bite, which then allowed me to prepare the teeth. When I prepared the teeth, as you can see, there’s some extra bruising, if you will, on the facials of E and F. That’s because I seated those teeth a little further facial than I usually would. I prepared less on the facial and more on the palatal, which allowed me to seat the crowns in a more buccal, or labial, direction. So I got those teeth just slightly over the incisal edge of the lower anteriors. I’m trying to slide these teeth outward. As I prepared, I prepared more palatally and less facially, or labially, and allowed the crown to seat out this way. So when he closes down, even if you can only get them end on, at a two-week follow-up he stayed in that nice occlusion we had him in, and the crowns have actually slid over ever so slightly.
Then people are going to ask: does this work? Does it stay long-term? I didn’t know if it would, but the good news is this was over three years ago. This kiddo has now grown; we’re three years later, and those crowns are still functioning for him. They’ve actually slid further out, and because of the way this is, it helped pull that maxilla forward a little in the anterior, so we’re not still sitting in this anterior-posterior dimension change of those anterior teeth. We actually got to pull that anterior a little forward, and it stayed that way. This kiddo is still going to need orthodontic care long-term. But at least we kept that anterior maxilla from being trapped behind the lower anterior teeth for years.
[00:54:08] Case: SDF in a two-year-old, four years on
This is a quick case I wanted to show you. This is a two-year-old I saw with severe decay on the maxillary anterior teeth as well as the posterior teeth. I was able to talk with the parents and work really hard with them on some habit changes, the habits that were causing this in the first place. SDF placements. This kiddo hung out with SDF on his anterior teeth, looking like that, for around six months to a year.
In a webinar I gave for AAPD, one of the things I talked about was SDF and zirconia crowns. People ask all the time how I get kiddos to walk around looking like this. The long and short of it is that I spend a lot of time talking about health. Health, not the aesthetics. Talk about returning health: “I want to get your kid healthy. I don’t want cavities to progress.”
I also have a rule in my practice: I don’t take kiddos to general anesthesia who are under two years old. I don’t think it’s wrong. I don’t think people who do it are wrong. I just think there are greater risks, so I try to decrease and mitigate that risk. I think there are better ways of managing this, and silver diamine fluoride is one of those ways.
If you look at this, you can see how great those habits were that changed. He’s got great, healthy tissue. He’s got strong teeth. Quite frankly, these teeth could probably stay like this forever, and they’d be just fine. Obviously, they don’t look good that way, and aesthetics is a concern, and I don’t blame them. So what we said was, “Hey, let’s get them arrested. Let’s get him older, and when he’s older, let’s get them fixed.”
I have a four-year follow-up picture here on the bottom. This is four years later, with crowns on teeth B, D, E, F, G and I. This kiddo looks different. These are large cavities where many people would have talked about just taking out those front teeth. Silver diamine fluoride not only allowed me to get our kid older before we did surgery, it also allowed me to change the habits and then have a good long-term aesthetic result without any pulpal therapy. Four years later, I think it’s looking awesome for him.
A quick before and after as well. Again, large anterior cavities on all surfaces of those teeth. You can see some of the hemorrhage control on that picture, where you’ve got some ecchymosis up along those. I tell parents that’s something to expect: it’s just the medicine we put down that helped stop the bleeding up there. And then you can see a two-week follow-up picture with some really nice anterior aesthetics.
[00:56:39] Case: “Pretty white teeth” for Christmas
This is one of my favorite cases I have ever done. Silver diamine fluoride had just come on the market, and I was not sure exactly how it was going to work. But I decided this was a great case because, again, I had a kid under two years old, and I said, “I want to stop these cavities from progressing.” So we placed silver diamine fluoride on multiple visits. This sweet little two-year-old came into my office right before Christmas, and mom said, “Tell Dr. Dusty what you asked Santa for.” And she said, “Pretty white teeth.” And I thought, “Oh my God, I hope I can save these.” Because I told the parents from the get-go, I don’t know if we’re going to be able to save these, based on the size of the cavity. She’d never even been cooperative enough for me to take a good X-ray.
So we got in and took an X-ray, and I was slightly concerned by the pulpal appearance of tooth E. I know that’s the picture where you can see the ET tube. I thought, “Gosh, tooth E really looks concerning to me. I don’t know if we can save that.” But I thought to myself, “Well, let’s open up the pulpal tissue and see what it looks like.” So I did a pulpotomy on tooth E, a pulpotomy with MTA. I opened it up, and it was the healthiest-looking pulp I’d ever seen. So although this was a huge cavity, and although I thought there was necrosis of that tooth and failure for the root to continue to develop, it was healthy as could be. I did my MTA pulpotomy on tooth E, and if you look right under the crown there, you can see that little bit of MTA.
This is a six-month follow-up, and I think it’s really cool because you can see that really awesome dentin bridge that formed under the MTA. You can also see the continued root development of all of those teeth.
And this is four years of follow-up. You can see before, those teeth had some nice flaring to them. She had a pacifier; finally, four years later, she got rid of it. So we got rid of our pacifier, and those teeth have come close to exfoliation. I saw this sweet little girl in my practice just the other day, and teeth E and F have exfoliated. So four-plus years later, those teeth have exfoliated: treatment success. She got what she asked for for Christmas. This Christmas, she might be asking for her two front teeth.
[00:59:09] Case: trauma in a two-year-old, treated under nitrous
This is a great case: a two-year-old who came into my practice with a complicated traumatic fracture on tooth F. I told mom that we needed to extract teeth E and F, that the prognosis wasn’t great. Based on him being a two-year-old, I didn’t recommend putting him to sleep to do this; I’d just recommend taking the teeth out. She said, “Is there any way you can fix them?” He was a pretty calm kid for just falling and breaking his front teeth off. It was a knee-to-knee exam. And I said, “Well, I’m sort of a glutton for punishment. Let’s try it.”
So we put him on nitrous. I said, “Here’s the deal. Worst-case scenario, we start on this and he flips out. He’s going to be numb already, and I’m just going to pop the teeth out. That’s what’s going to happen. But if he does great, I’ll save the teeth.” She said, “Okay. Let’s do what you can.” So I did a pulpotomy on tooth F with nitrous, with MTA, and then immediately placed crowns on teeth E and F with our EZ crowns. This was him. This was a six-month follow-up. And this was a three-year follow-up. Still hanging in, still doing great. So three years later, these teeth are still present. Pretty cool.
[01:00:26] Pearls for seating: order, hemostasis, confidence, sizes
As I think about some pearls I want you to remember as you’re seating crowns: number one, always seat in the order you tried in. If you try in the centrals and the laterals and then the canines, seat them centrals, laterals, canines. If you try them in canines, centrals, laterals, I don’t care: however you try them in, that’s the way you need to seat them. Don’t change that order, because sometimes the crowns seat in such a manner that if you do it differently, they won’t seat back to back again.
Number two: control hemostasis, especially in the maxillary anterior. Not controlling hemostasis can compromise retention, but it can also cause microleakage and staining that you’re going to see up underneath the crowns. There are a couple of ways to do that, and I don’t care what you use. Using some hemostatic agent, and that preparation technique, allows you to decrease the trauma to the gum tissues.
Number three: be confident. Confidence goes a long way. If you don’t think it’s a good case for a zirconia crown, don’t treatment plan it. Just don’t do it. Don’t tell them you’re going to do something you’re not going to do. There’s a time and a place to go forward and do those difficult cases: after you’ve done a lot of them, fine. The mom who walks in and wants her little three-year-old beauty pageant daughter to have zirconia crowns on the front because of her cavities? Go for it, but don’t do that as your first case. You’re not going to win those.
Don’t tell a mom that you’re going to do A, J, K and T with nitrous on a poorly cooperative three-year-old. Be confident, but make good choices. So when you say you’re going to do a zirconia crown, man up, woman up, do that zirconia crown. You’ve got it. But be confident when you’re going to do it. Don’t say you’re going to do it on ones you aren’t, but the ones you do, be confident and do a great job of it, because you can. There are definitely times you just don’t want to do those: when you’ve got horrible behavior, or with these overbearing parents, especially for your first time.
Another one: have all of the sizes. For goodness’ sake, it’s like trying to do a jigsaw puzzle without all the pieces. You need all of the sizes. The SL sizes, the space loss sizes, are super important. You need to have those there; those space loss sizes give you all the pieces to the puzzle. Have all the crowns. You don’t have to have a ton of each crown. I have lots of extras of the crowns I use all the time. The ones I don’t use often, I have one or two of in that box. Every now and then I’ve used them. Every now and then I’ve used the largest crown; every now and then I’ve used the smallest crown. But I’m sure glad I have them in there.
[01:03:24] Take pictures, and train your team
Take pictures. I told you this earlier and said I’d touch on it again. Take pictures of what you do. It instills confidence in your patients that you did this. Sure, you can use stock photos. You can use my photos; I don’t care about that. This is the photo I use. I like to show what it looks like to have SDF placed, and what it looks like to have the crowns placed on those teeth afterwards. This is a real patient. This is my patient. This is what people can look at and see: Dr. Dusty did that crown, did this treatment, and this is the way it turned out. Wow. This is not some stock photo from Sprig that says some doctor can do this. This says my doctor, sitting in front of me, can do this, has done this, and will do a great job for my kiddo. So take pictures. Take pictures of the things you do. It instills confidence in your patients.
It also allows you to be critical of yourself. I can look at this and say there are things I’d do slightly differently on this one later, but ultimately it allows me to be better each and every time I work. Take your own pictures. It will be invaluable to you as you work to grow as a practitioner.
You also want to train your team. A couple of things you can do. Visual aids are awesome. This one was put together by Sprig: it’s got zirconia crowns, stainless steel crowns and resin-faced stainless steel crowns, and it allows you to show a patient what it looks like to have this crown placed as opposed to other crowns. Don’t make promises you can’t fulfill. Underpromise and overproduce.
It’s important that you believe in what you’re telling them you can do. Talk about the benefits of zirconia crowns as opposed to stainless steel crowns. You can talk about the cost difference: there’s only an X dollar difference in these crowns. Some people have said they charge a ton more for their zirconia crowns. I don’t. I think mine are around $50 or so different from my stainless steel crowns. I don’t want to price people out of these. I want people to do these. I enjoy placing them for their kiddos. So talk about that.
But also evaluate the behavior, the number of crowns and the parents’ reactions. If you think you need to do this in anesthesia visits, go for it. If you think you can do this without, go for it. But make sure you make your presentation to parents specific to that child, because after you walk away, your team is going to continue that presentation. So they need to be confident, just like you are.
[01:05:56] Sizing, removing the letters, and stocking crowns
Your team can also help you with your sizes. Let’s say you’ve got a well-behaved kiddo, or even in anesthesia, before you start. You can take a perio probe, measure the size, look at these crowns and pre-size what you think. I like to eyeball it. In my hands, when I’m seating anterior E and F, they usually get a 3 and the laterals get 4s, or the centrals get 2s and the laterals get 3s. Almost always one size larger on the laterals than on the centrals. On the posteriors, I look and visualize about the same as I would for an SSC. A lot of my B, I, L and S crowns end up being 5s or 4s. Again, if you do that racetrack step, it gives you a really nice fit almost every time. And if you can do this before you hold up lots of crowns and end up getting all these crowns dirty, it gives your team less to do later in autoclaving more crowns.
You can remove the letters. You can do that with a spoon excavator after the cement is set, or do partial removal prior to cementation. Something I think is important is not removing them all the way. On the anteriors, I don’t remove them at all; I leave them alone. I like to be able to see them and make sure I have the crowns where they’re supposed to be, turned right and all that. On the posteriors, I’ll remove them with the spoon excavator, because they’re on the facial and people see them more. On the anteriors, they’re on the palatal side, and really nobody sees them. If you’re doing a prophy post-GA, just get your prophy paste. Prophy paste removes those really nicely.
And again, have your staff be able to order those kits; they have a full set for that. If you’re going to do a GA day, make sure you’ve got extra crowns on hand. Don’t be down to your last one. You don’t want to be without the pieces to the jigsaw puzzle. Sprig says to keep six to nine of the anterior crowns and two to four of the posterior crowns. And have one person who’s in charge of checking those trays and making sure they’re full with the appropriate number of crowns.
[01:08:10] A six-year follow-up, and closing thoughts
I know I’ve been talking about anterior cases, but I wanted to show you one last case because it’s a six-year follow-up. My practice has only been open for six years, so this is really cool for me to show you. This is a kiddo with severely hypoplastic second molars. They were breaking down. They were told they needed crowns, and mom was adamant that her kiddo was not going to have stainless steel crowns. So they asked if there was any other option, and somebody told them to come to my practice. This was right after I’d opened. They came in and got zirconia crowns on A, J, K and T. This was in 2014, and that was a pano we got to take three years later. This kid was not overly cooperative and was not super fond of pictures, so these pictures were taken in GA, and that pano three years later was about the best picture we got in those three years.
He’s grown up a ton now. I saw him just the other day and had some nice X-rays showing these teeth getting really close to exfoliating, and got to take some nice pictures. Again, six years later. Those are the pictures of those crowns. They look great. They look like the day I placed them. Pretty exciting to see something six years later that I placed in a pediatric patient. Man, I’ll tell you, kids just beat things up. If I’ve got a filling I did six years ago, I just cross my fingers and hope it makes it to exfoliation. And these look awesome.
A great quote from Will Rogers is, “Even if you’re on the right track, you get run over if you just sit there.” We’ve been in a crazy year. We’ve all been tasked with making changes in our everyday practice and how we do what we do. I’m super thankful to try to think outside the box as I move forward with my practice and how we care for kids. This is something I’ve been doing since I started my practice. It’s been a great practice builder. It’s been a great opportunity to give really nice aesthetic, long-lasting restorations for kiddos. And if you’re not doing this, somebody else is. So I think it’s a great opportunity to take the time to learn more.
[01:10:27] Hands-on courses, CE and staying in touch
Hands-on courses are coming up in 2021. Sprig canceled all of their courses in 2020 because of COVID, but they’ve got these coming up in 2021: March in Dallas, July in Wisconsin, November in Vegas and December in Miami. Great hands-on. A lot of the stuff we talked about here, but having the opportunity to sit and cut these on typodonts and have somebody look over your shoulder and show you can be really helpful. So hopefully these are things you might consider. If not, you’ve been doing these a long time, and hopefully you found the things we talked about tonight helpful.
My email is right here at the bottom: dustyjanssen@gmail. I would love to hear from you. If I can help in any way, please let me know. I post stuff on Facebook, some on Collaborative Pediatric Dentistry and some different places there. I love hearing about and seeing the cases people do. It’s amazing how we all have different ways to get to a final result for our kiddos, and I just love opportunities to interact with pediatric dentists who all share a great passion for what we do.
Lastly, maybe the only reason some of you showed up tonight was to get some CE. If you’re doing that, great. Either way, you registered with an email address, and that CE certificate is going to be emailed to you an hour after we finish this webinar. And in that, Sprig has promised me they’re going to send you some savings and a promo code for you to order stuff. So hopefully you get some discounts on some things. I’m not sure what that is, but I’m sure they’ve got awesome stuff for you. They really take care of their customers and really love to hear from you, so please get with them. And if there’s anything I can do on the clinical technique questions, please get those questions over to me.
So what I’m going to do now is pull up some of these questions, and let’s go through those.
[01:13:00] Q&A: SDF under crowns, opaquers and SDF technique
Daniel asked about research on SDF under a crown when using pure GI, compared with not using SDF.
I’m not sure exactly what the question is, but what I would say is this. The paper I was referencing from Sue Seale is a meta-analysis. They discuss indirect pulp cap therapy having a higher success rate than MTA pulpotomy. MTA pulpotomies were around 89% success at two years; indirect pulp cap therapy was 94%. That’s not statistically significant, but it is a higher number. The question is, does SDF hurt or hinder anything there? SDF can only help, in that it helps kill further bacteria under there. So do you have to do SDF? No. I used to not use SDF, because SDF hasn’t always been used. I still did indirect pulp caps, and I just used my GI cement as my barrier to further bacterial ingress. So SDF, to me, is just an extra step to help further arrest dental decay and prevent the bacteria from going.
A follow-up question: why did I place SDF a second time after I prepared?
For me, that was just further killing of bacteria. I’m not taking out decay, if you will. I am creating an indirect pulp cap. As Sue taught, if you are planning to complete an indirect pulp cap, you should never accidentally pulp the tooth, because there’s no amount of decay you need to remove. You just need to seal that decay off to prevent the bacteria from continuing to grow. So what that means to me is I complete an ideal preparation, and then I use SDF again to further help arrest the dental decay.
Also asked: do I use opaquers under the SDF for the zirconia crowns?
No, I do not. There can be a little bit of black show-through. However, as long as you have a little GI cement between the crown and the SDF, you won’t see it, or if you do, it’s very minimal.
Robert asked about my SDF technique: do you wait a minute before prepping or trying crowns? Do you rinse, et cetera?
That picture I showed was really black, and that was from a time when I would light-cure. I’d place the SDF, wait a minute, light-cure it, it would turn really black, and then I’d move on. I don’t do that any longer. It’s not recommended to light-cure, because you oxidize everything then, and you can prevent it from seeping deeper into the tubules. So what I do, Robert, is initial SDF placement at my first visit, and then when I’m doing the treatment, I use SDF again. I prepare my ideal preparation, whether that’s for a stainless steel crown, a zirconia crown or the like. Then I place the SDF again and wait, depending on the behavior of the kiddo, 30 seconds to a minute, and then I just begin prepping again. I finish my interproximal preparations and seat the crown. That’s really all I do. I don’t rinse it off intentionally. If I’m prepping more, I’ll be rinsing with the water spray, obviously, but I don’t intentionally rinse it off.
[01:16:51] Q&A: bite turbos, uncorrectable crossbites, pulpotomy vs pulpectomy
A question about my Band-Lok, opening the bite with those bite turbos.
I usually put it on the second primary molars. I put it on the most terminal tooth because you have to use less of it further back: less buildup is needed. And that’s the primary tooth we chew on, so it still lets them have that chewing surface on the posteriormost tooth. I usually do it on K and T.
Abraham asked about the anterior crossbite case: “What if you can’t get them over? Is the prognosis of those crowns still favorable, and would they get knocked off?”
I haven’t knocked them off. I’ve had patients with two or three millimeters of negative overjet, so there was no way to correct it, and I just placed the crowns. They did great, and they haven’t broken. There wasn’t anything problematic for those crowns long-term.
Another question about MTA pulpotomy versus pulpectomy with Vitapex.
Great question. There was a paper published in 2014, I do believe; I sent this to a few people last time. It was in the Pediatric Dentistry journal, and it was a split-mouth trial of pulpotomy versus pulpectomy in the anterior teeth, and it showed no significant difference. There’s a misnomer that you have to do pulpectomies. This paper showed the opposite, so a pulpectomy is not necessary; this paper would say so. I don’t like pulpectomies, and ultimately I do very few pulpotomies anyway. But if I do, I do MTA.
When using SDF to arrest caries, are you still anesthetizing? Do you prep with water?
Yes, definitely anesthetize. SDF is not magic. It doesn’t prevent the tooth from hurting if I’m prepping on it; it just arrests dental decay. So yes, I definitely numb. I do prep with water, and I use Isolite for almost all of my treatments.
[01:21:21] Q&A: cement timing, deep decay without pulpotomies, MTA washout and depth
As far as using the GI cement, do we have to wait for complete set?
One of the things I do, especially in the operating room when I’m seating these, is have that cement mixed early. When I start seating my crowns, the first thing my assistants do is fill my zirconia crowns with the GI cement. That allows the cement to get more of that putty-ish state before I’m seating it, which actually allows the crowns to seat pretty quickly.
A question about not doing pulpotomies: how do you do that with deep decay?
I think I addressed that a little; SDF helps too. But let me take a quick step back. Diagnosis of the pulp requires that you talk to the patient, and talking to the patient helps me diagnose the pulp. The diagnosis of the pulp comes from clinical, radiographic, and patient and parent questioning. It’s about whether that tooth has ever experienced spontaneous pain. Not “It hurts when I eat.” “It wakes me up in the middle of the night.” “Johnny was crying because his tooth was hurting.” Those types of things are spontaneous pain. That is not provoked pain. Provoked pain says, “Johnny was eating an apple and it hurt,” “Johnny was eating a piece of candy and it hurt his tooth.” Okay. You look at the X-ray and it doesn’t show furcation changes. You look at the tooth and it doesn’t show mobility or erythema. There’s no lymph node swelling. That’s a tooth that’s a candidate for indirect pulpal therapy.
In my case, it takes me a bit to get a patient back in, so I put SDF on at the initial visit. I see them back a month later for their treatment, and I get to ask them if they’ve had any pain or anything bothering them since then. Answer is no? Great. If I have a question, I’ll take another X-ray. As long as that’s the case, indirect pulpal therapy is all about the diagnosis in advance and sealing off the previous decay. SDF helps that, and the crown with GI cement furthers that. So absolutely, everybody trains differently. I know that’s something not everybody is keen on. It’s part of the way I trained and something I’ve done, and I will say, literally, I do probably fewer than five pulpotomies in my office a year.
“MTA washes out. What am I doing wrong?”
That’s a great question. I think that would be a great thing to send to Sprig themselves, and maybe they can go over that with you. It might be that you’re not taking that little bit of time to let it set up. You should be able to let that SmartMTA set; it sets really quickly, in about five minutes or less. The other thing would be: what are you doing after that? Are you spraying water all over it? Why is it washing out? Usually on a pulp, you should be able to place that, then have minimal preparation to complete, then seat your crown over it and fill that over with a GI.
How far down do you do the pulpotomy for MTA placement?
I’m imagining we’re talking about the anterior teeth there. I go to where I’ve got good heme control. Cvek, in an ’87 study I think it was, talked about the 2 millimeters of bacterial invasion there. My opinion with MTA really is that MTA is nice. It works. It only works because most of the time we didn’t have to take a pulp much further than that anyway, because there’s not that much bacterial ingress there. So 2 millimeters is a good number, based on the Cvek study back in the day. About 2 millimeters down. If you’re still getting heme control problems, then you need to take it down a little further. But that depends on you. In the trauma case I showed, I really did about 2 millimeters. In some of the other cases I’ve done, I’ll take it down right about to the CEJ. But again, it depends on what helps get good hemostasis there.
[01:23:28] Q&A: closing thanks, cavity conditioner, composite crowns, pulpal hemostasis
All right. I’ll wait just a second in case anybody has any other questions. I hope this was helpful for everyone tonight. Again, I’m a practitioner just like you. I am by far not anywhere close to perfect. I’ve learned this through lots of mess-ups, and lots of making parents mad because I don’t explain things well. I’ve learned all kinds of ways of how I explain this, and how I get on the same team as a parent when I’m doing this. And ultimately I’m just trying to love on kiddos and care for them. So I appreciate all of you showing up and being a part of this tonight. It really is fun. Even though I don’t get to do this in person and see reactions and talk directly, I’ve sure enjoyed getting to do these and seeing hundreds of people on a webinar learning about a technique I’ve used. I’m far from having perfected it, but I definitely spend a lot of time doing it. So thank you, those of y’all who have said thank you. I really hope this is helpful. I think I’ve got a couple of other questions that came in.
Any benefit to cavity conditioner?
I don’t use cavity conditioner before the GI cement. I will if I’m using EQUIA Forte on hypoplastic molars and that kind of stuff. Otherwise I don’t. You’re not going to hurt anything with the cavity conditioner at all. I just think it’s probably too much. I don’t use it, and I don’t have crowns fall off, so I think it’s probably a step beyond what you have to do.
Somebody said, “I don’t go to the OR. I do a lot of comp crowns without local.”
That would probably be an issue for me. If you’re going to do this crown, you’re going to have to numb. My question is: if you’re doing a composite crown without local, you’re probably not having to take away too much tooth structure. I’m going to tell you my favorite thing I started doing. If I have a cavity that’s that small, for a composite crown, I just do interproximal reductions. I do IPRs on those teeth. I’ve got years of doing IPRs. I haven’t done a Class III composite in probably five years, and it’s the greatest thing in my toolkit to not have to fix those things. So either I do an IPR or they get a zirconia crown.
On getting heme control in the pulp before placing MTA.
You can use a dry cotton pellet. I use a cotton pellet with cavity cleanser on it. The one I use is from Bisco, and it’s 1.2% or 2.4% or something chlorhexidine. You can use sodium hypochlorite as well. I like it because you’re killing some bacteria. It helps kill any bacteria that’s there before I put that down, and it helps a little with the hemostasis. I just dip it in that, squeeze the excess out and push that over the pulp.
[01:27:20] Q&A: strip crowns, covering MTA, and atypical resorption
[…] The question Dusty answers here, from Naveen, isn’t read aloud in the recording.
No. Hey, Naveen, if you’re doing those strip crowns and they’re working, great, man. That’s awesome. For some of my really young kids, I’ve actually started doing a lot with EQUIA Forte, and it’s awesome. I’ll do those without local at all and can get an awesome result with that too. That’s the beauty of what we do: everybody figures out what works best in their hands and can have great success with it. So it’s pretty cool how each and every one of us comes up with what works in our practices.
MTA pulp, then ZOE or IRM over it?
No, not ZOE or IRM. I’ll do the glass ionomer cement right over that.
Cool. I’ll hang on for two more minutes. You’re all asking some really good questions, and I’ll try to get to those, in the interest of your time too, so we can keep this right at the hour and a half.
Oh, nice. Somebody played a drinking game with “zirconia.” I hope I said zirconia a lot, then. Maybe right now, maybe tomorrow: your Thursday patients might not have enjoyed that as much, but cheers to that.
Stuart asked about atypical resorption on posterior crowns.
Oh, yeah, great question. I have not seen it. Now, I do know a lot of people have seen atypical resorption, and I submit my non-expert opinion, advice, whatever. The times I think atypical resorption occurs is when the crowns get seated high and you did a pulpotomy on them. If the crown is seated high and you did a pulpotomy on it, it seems as though the teeth will resorb atypically, and you end up with almost complete resorption of the roots. And that’s interesting. I submit that the reason this happens on a zirconia crown when it doesn’t on a stainless steel crown is that stainless steel crowns actually give: they’ll deform, and the crown itself intrudes. In the zirconia crown case, you have to actually intrude the tooth. And after pulpal therapy, the tooth doesn’t react as well as it should anyway. So that atypical resorption seems to occur if you seat the crown high and you do the pulp, and getting a better occlusion for that is good. I will say, back to me doing minimal pulps, it’s not something I’ve seen, because I don’t really pulp, and even if I do seat the crowns high, they’ll intrude slightly, and it seems to do well.
Do I place anything other than GI for my indirect pulp cap?
No. My SDF: SDF two times, at the initial visit and the seating visit, and then GI.
[01:30:57] Q&A: sedation cases, minimal-prep strip crowns, and goodnight
Naveen, good luck getting these zirconia crowns done. I’ll tell you, I think something for everybody is having them around and having them in your toolkit. It’s a great thing. I do a lot of these with nitrous. I do a lot of these with sedation. I had a kiddo the other day in a 20-minute midazolam sedation. I did two fillings, and then I did zirconia crowns on B, D, E, F, G and I in a 20-minute sedation with midazolam. So it absolutely can be done. Now again, that was not my first case, but it can be done. And if you’re just doing the four anterior crowns, if you’re doing Demerol-hydroxyzine sedations or heavier sedations, those are absolutely things you can do. Again, I think picking and choosing appropriate cases at first can really help you get comfortable with the more challenging cases.
Robert asked about strip crowns with EQUIA Forte.
I do a minimal prep on that, Robert, when I do the strip crown with EQUIA Forte. It’s a really minimal preparation. I’m essentially just trying to create enough room to get the strip crown formers on. I use the Nowak strip crown formers, and I do sort of a feather edge, just barely taking anything away. I think I’ve got a case, if you look; I put it on Collaborative Pediatric Dentistry. I think it’s been a bit. I think it’s a two-year follow-up of EQUIA Forte strip crowns I did on a kiddo with special needs who was nine or 10 months old and had super hypoplastic O&P when they came in. I actually came with plans A and B. Plan A was a whole zirconia crown over that. But they just didn’t fit quite right, and the kiddo was not cooperative enough for me to feel comfortable prepping away. So I did it with EQUIA Forte. The plan is that when those crowns break down, the kiddo will be older, and if need be, we can talk about doing zirconias on those teeth.
Awesome. Okay, well, it’s 9:03. Thank you so much for the kind words. Thank you so much for attending the presentation tonight. It’s really been fun doing this and even interacting with a few of you from afar. Hopefully I’ll see you at meetings and/or at a Sprig course in the future. If there’s anything I can do to help, please let me know. Have a great evening and a great day seeing patients tomorrow. And again, remember what an honor it is to get to do what we do every day. I love pediatric dentistry, and I love getting to talk with people who are passionate about it like I am. So you all have a great evening, and hope to see you all soon. If I’m at a meeting, come up and say hi. I look forward to staying in touch. You all take care.
