Back in the Saddle: Grabbing Zirconia Crowns by the Horns — Transcript
[00:00:11] Welcome: who this lecture is for
Dr. Truman: Well, it looks like we get to get back in the saddle and talk about zirconia crowns. We’re super excited to be on theme with AAPD for anybody that’s going this year. We’re certainly hoping to see you at the convention. But in the meantime, we’re going to talk about getting that box out of the closet and onto your patients.
When we were coming up with this lecture, we decided to make it for people who maybe haven’t placed a lot of zirconia crowns. Maybe you weren’t trained heavily in them, or you bought a box or a kit and haven’t used it forever. It’s probably collecting dust, and you’ve told everybody that they don’t work and that’s why you don’t do them. So we want to encourage people to get back into them and maybe look into placing a few more.
This is also for pros. Feel free to share any tips or tricks in the chat box. This is for everybody; we want everybody to learn together. Our goal is that this becomes a conversation towards the end, so write down questions and think about questions. Several of us are watching the chat and the question box, so if you think of anything, throw it in there and we’ll try our best to answer as much as we can.
This lecture is not intended to be the comprehensive course. You can go back to the Sprig resources to get all of the videos. We’re going to provide several tips that will help with getting more comfortable with Sprig EZCrowns, and we’re going to give you that encouragement and cheerleading to start introducing, or reintroducing, these zirks into your clinical practice.
Here’s what we’re going to go through today: tips and tricks we’ve picked up and learned from our own mistakes and other people’s mistakes. Case selection. How to select and size crowns. Not cheating: following the recipe that Sprig has outlined. Not being tempted to grab larger crown sizes. How to know if a crown is seated. Stocking your box, and how many crowns is enough. Bur choices. How to avoid dingy crowns. Cementation hacks. Photographing your cases. And understanding line angles and how they can impact the seating and position of the crowns.
[00:02:37] Case selection for your first case back
Dr. Sullivan: So, case selection. If you’re back to the beginning, this is going to be your first case, or your first case returning. It should ideally be a single tooth. Believe it or not, a posterior tooth is the most friendly tooth you can opt for. Personally, I like upper first molars, but lower first molars are great as well. Ideally pick one with minimal space loss, because it’s more challenging with space loss, and on a GA or sedated patient, because otherwise you’re either dealing with somebody who’s awake and you’re behavior managing, or you’re focused really on restoring those crowns.
You don’t want to start with a 2020 case or an anterior case with rotated teeth. Your canines probably aren’t your first stop. Posterior back-to-backs, heavily crowded cases, and cases where you might be considering jumping a crossbite of some kind: those are ones you want to work up to. Build your confidence first, then move forward.
Dr. Truman: Yep. But there’s a lot of wiggle room with this. Dr. Sullivan teaches a lot of dental students, and she has dental students that place these crowns. It’s not brain surgery, it’s mouth surgery. It can be done. It’s not as complex as I think a lot of us make it out to be, and it’s something that can be learned pretty easily if you follow what we’re going to talk to you about today.
[00:04:05] Selecting and sizing crowns before you start
Dr. Truman: First thing is how to select and size crowns. Last year in Toronto, we had a few people come up to the booth and mention, “I’ve started several cases, D to G, all the incisors, and I just can never get them all to fit. They don’t work. I don’t know what I’m doing wrong.” So this was a tip I gave to several people last year, and I showed them how to do it on one of the models we had out there. Huge game changer. If you take away one thing, this is huge: pick the right size crown before you start the case, not after you start the case. Space matters a lot more with a rigid crown than with a flexible crown like seal.
For anterior cases, it’s exactly what’s shown in that bottom picture: hold the incisal edge of the crown close to the incisal edge of the tooth. That gives you an estimate. But also look at the widest point of the crown, where your estimated contacts would be. Sometimes people line up the incisal edges and think they have a crown that works great, but then that crown bulges out towards the cervical portion, and they may have picked the wrong size. So make sure you’re doing a good estimate before you start.
What I like to do is pick out all my crowns before I start the case for zirconia and put them on my tray, so I force myself to use those crowns instead of reaching for a bigger crown or deciding that I wasn’t right when I started. Trust yourself at the beginning. Pick a crown that’s going to work.
For posterior cases you can do the same thing: flip the crown over and hold it over the occlusal surface of the tooth. It gives you a mesial-distal and buccal-lingual estimate of how big that crown’s going to be. Pick that crown, set it aside, and trust yourself.
The only two differences are mandibular incisors and mandibular canines. For mandibular incisors, we often recommend the maxillary lateral crowns. Sprig has a universal crown that looks like a lower incisor, but we’ve noticed the prep fits a little better with the maxillary lateral crowns. That’s a pro tip a lot of you should use. I think we have a case on here where we show one of those, and they look great.
For mandibular canines, we recommend using a Space-Loss crown from the maxillary arch. There are no mandibular canine crowns in the kit; they’re all maxillary crowns. But because that tooth is so much more narrow mesial-distally, we recommend the Space-Loss crown, because it gives you more of an anatomical crown.
[00:06:58] No cheat code: follow the recipe
Dr. Sullivan: Over and over again, when I get the opportunity to talk to residents or to private practitioners, everybody wants to know how to get faster. Everyone wants to know what’s the secret, what’s the cheat code. There really isn’t a cheat code. You need to follow the steps. The steps were designed because they will always deliver the correct amount of reduction and the correct amount of angulation, and it’s really important to commit to that.
Zirconia doesn’t have flex; it doesn’t have bend. Where we can fudge and adjust in stainless steel, here we have specific reduction requirements that have to be met. This is the time to think back to your general dentistry experiences. Anterior porcelain crown preps are exactly what we’re executing with an anterior zirconia crown prep, but we get rid of the margin and go subgingival.
So if you’re running into problems on most of your cases, go back to the beginning. Bake the cake by the recipe; follow your guide. It might feel like it’s taking you more time, but in the end, slow is fast. Cheating the steps ends up with unpredictable results, and you’re going to be frustrated because you don’t know why it’s not refining correctly. My mother always said, “Why didn’t you have time to do it right if you’ve got time to do it over?”
Dr. Truman: This is the recipe book. It’s on Sprig’s website and on the link we sent out at the beginning. Literally print this, have it in your office, have it next to you when you’re doing these cases, so you go step by step and make it as easy as possible for yourself.
It’s always the problem: people start prepping these and think they know what it needs to look like. They do their occlusal reduction, they prep some all the way around the tooth, and then it’s not fitting, and they don’t know why. They get frustrated, they’ve been working on it for an hour, the kid starts fidgeting, and now they’re losing the patient. Eventually they bail themselves out and put a stainless steel crown on. So like Vicki said, if you do exactly what this says, you are making enough reduction for the intaglio of the crowns, which are custom made.
We’re not going to go into detail on the prep guide, because it’s all over Sprig’s website and everybody has it. We wanted it in the slides to be comprehensive and to refresh everybody’s memory. We do an occlusal reduction. There’s a supragingival reduction where we create a chamfer margin all the way around the tooth. We verify that looking down from the occlusal or the incisal, and then we erase that subgingivally, sinking the bur and hugging the tooth, two millimeters. That’s something quick to get you back into that mindset if you haven’t brushed up on this in a while.
[00:10:11] Posterior, anterior and canine preps
Dr. Truman: This is the posterior prep, and here’s the anterior prep. I’ll give you a couple of seconds to look at that. The difference is that we have a two-plane reduction on the anterior that we don’t have on the posterior. I think that’s why the posterior prep, like Vicki was saying at the beginning, can be so much easier to start with: you’re just drawing a circle. You don’t have to worry about two planes and how it matches in the arch. It’s a little more forgiving, and so it’s not as technically challenging. Don’t get me wrong, posteriors have their own problems, and there’s a learning curve. […]
(The connection drops briefly.)
That fourth picture should show the canine prep looking down from the incisal; it’s the step with the exclamation point. This is the key point: the canine prep is so unique. It’s much different than a traditional anterior prep, because this is the corner of the arch. This is where things start turning, and you have to adjust for that in your prep. Otherwise your canine crowns are going to look tipped and tilted. You may be doing some interventional ortho, creating crossbites that weren’t there before, a functional shift, all that stuff. So be aware that as you’re prepping your canines, you’re turning in the mouth, and you have to match that as you’re prepping.
Dr. Sullivan: Just to really reemphasize that: from the center point of your crown prep, the mesiobuccal portion should draw with the anterior teeth, and the distobuccal portion should draw with the posterior teeth. The minute you make the canine look like an incisor is the minute it’s not going to look right to you. Keep in mind that this tooth draws against both the anterior and the posterior. It has to curve for you.
Dr. Truman: Yeah. We said we weren’t going to talk about that a lot, and then we talked about it a lot, so sorry. But go back and read through those. Have them printed out. Make it that foolproof: be so robotic about it, step by step, until it is second nature.
We talked about this already as we went through the picture, but canines are not an incisor prep. The incisal edge of a canine comes to a point and the incisors don’t, so you have to adjust for that in your prep. You can’t just do a flat top; you have to round everything, just like a canine is rounded. The canines have to draw against the anterior and the posterior; it’s the corner of the mouth, and things are turning at that point. You have to make your prep look like the tooth did before you started.
These canines have a flatter slope on the palatal surface; anatomically, the cingulums usually aren’t as pronounced on those teeth. So the prep looks almost like an oval if you look at the intaglio, and that has to go over that palatal portion. Make sure you have enough reduction on the palatal. A lot of times that will hold you up, and you’ll get a flare to your tooth that tips out facially and looks like a little vampire.
Vicki touched on this, but the mesial half of the canine prep needs to match the incisors, and the distal half has to match the posteriors. Think about it like a combo tooth, halfway between an anterior and a posterior.
The canine point, and Vicki talked about that fourth bullet point: the canine point has to be equidistant on both sides or it will look tipped and tilted. We work at a residency program, so there’s a lot of learning that happens, and we see a lot of tips, tilts and flares. Things you’ve never seen, we’ve been able to see. So make sure that incisal point is right where it was when you started. Otherwise, like I said, you’re going to be doing a little unintentional orthodontic movement on those canines.
[00:15:12] Don’t grab a bigger crown: socks on a rooster
Dr. Sullivan: The thing people do is think, “Well, it’s not going down, it’s binding somewhere,” so they grab a bigger crown. I do that with stainless steel all the time, right? It’s just easier. You grab the Howe plier, you crimp it, and you make it work. This is how back-to-back cases really go bad, and where you run into problems with anterior cases as well. With a stainless steel crown, you go for the bigger crown and you squish it. You cannot force zirconia to flex. I can’t say it enough. You’re going to break a few crowns and have to absorb that cost before it really sinks into your brain.
So remember where we started. You measure at the beginning and you trust your judgment. You don’t reach for the bigger crown. You follow the recipe. You feel with your finger where the crown is holding up or binding, and you make that adjustment to your prep.
An easy rule of thumb, since we’re looking to increase our speed and efficiency: get rid of the enamel. Remove that enamel all the way around the tooth completely, including that one millimeter below the gum line, so you’re only on dentin. This is not going to put you in a situation where you have an exposure; it just gets you the bulk reduction. Then really check that you didn’t tilt the bur while you were doing the cervical. If you’ve made this prep look like a teepee or a volcano, your crown is going to want to be a bigger size, because it’s trying to slip over the cervical. Since it can’t do that, you’re going to be frustrated. So watch that you’re not tipping.
Dr. Truman: Let’s go back to the slides so we can show what we’re talking about. Do you see that very last picture on the bottom right, where it says incorrect angulation is the number one cause of gingival bleeding? That’s true, but it’s also one of the main reasons crowns won’t seat, because that is an undercut. You’ve created an undercut by tipping into the tooth, a lot of times because you’re trying to avoid nicking the adjacent tooth. Make sure you’re getting all your reduction. Hold the bur parallel with the long axis of the tooth and trust its shape. That bur is tapered. Trust that if you stay with the long axis, you’re not going to have that flare. Run it all the way around, and you don’t create that extended, widened cervical portion. If the cervical portion is wider, the intaglio has to be wider to get around it. Our goal in the subgingival reduction is to remove that cervical bulge, so to speak, so we have a straight up-and-down prep and the crown can fit passively. That’s what Vicki’s talking about; it’s a visual for the visual learners.
Dr. Sullivan: One of the things I hear from people who don’t want to seat these crowns is that they’re like socks on a rooster. So we actually brought you a socks-on-a-rooster case, where the student went ahead and grabbed a bigger crown. These crowns have been in place for almost three years…
Dr. Truman: I think 18 months.
Dr. Sullivan: 18 months, yeah. As you can see, the gums are happy and they’re functioning great. But every time I look at these x-rays, I get a pit in my stomach.
Dr. Truman: This is a modified zirconia Hall crown…
Dr. Sullivan: Yes.
Dr. Truman: …is what we’re calling it. There’s no way this kid gets all of her permanent incisors in, and we’re going to have to fix those, but behavior’s poor. So now we have to age her up a little and manage it as it comes. It’s easier to prevent that problem by not picking a bigger crown. Everybody always wants to pick a bigger crown, and I think that’s because as pediatric dentists we do it all the time with stainless steel, because it’s pretty forgiving. It’s just not like that with zirconia. It’s a rigid crown. It does not want to flex; it can’t flex or it will break. That’s why you have to pick the crown from the beginning, trust yourself, and make your prep match it.
[00:19:41] How to know a crown is seated
Dr. Truman: How do I know if my crown is seated? Look at the very last bullet point: the pro tip is the pinky check. It’s using a soft touch on the occlusal or incisal surface of the crown once it’s seated and feeling that the crown is not rocking in any direction, but sits right on top of the occlusal or incisal portion of the prep, passively. That’s what we mean by a passive rest on the incisal or occlusal. It doesn’t rock. It doesn’t crunch in there. We don’t hear a flex as we’re trying to seat the crown. There’s no snap like there is with stainless steel. If there’s a snap, you have a problem.
You shouldn’t be able to see the crown margin. It should all be subgingival, because you’ve prepped two millimeters subgingival, so your whole crown margin should sit below the gingival tissue. And there shouldn’t be flaring, tipping or rotation of the crown unless the tooth started that way, which is not common. A lot of the rotations you start with can be corrected as you do your prep.
We’re trying to make these look beautiful. This is an aesthetic crown; that’s what parents are paying for, and it’s what everybody loves to see on Instagram and TikTok. So make sure they look great. Look at the case straight on. That’s why we usually say pick a GA or sedation case to start: you have more time to sit, look at the case straight on, come from different angles, and have your assistant and your anesthesiologist check, so everybody agrees those look good. It’s better to have more eyes on the case. That’s not to say you can’t do this with a nitrous patient; you definitely can. But sometimes it’s easier to have multiple eyes, slow down for a couple of cases, and really learn it. Then when you look at your prep, you can see: I’m a little flared. I’m tipped to the buccal, to the lingual, to the mesial or the distal. Or, oh man, they’re all rotated and not fitting together. Why is that? These are things to keep in the back of your mind.
Then the last two pro tips. First, slight blanching of the gingiva: if the crown is sitting subgingival, it will press on the gingiva and you’ll see a slight blanch. We’re not looking for stark paper white, just a little blanch to know it’s sitting all around in the gingiva. Second, the pinky check. Put your pinky or whatever finger you like on there and feel it. There is a tactile feel for whether the crown is seated. It’s a hard thing to teach people, but once you start feeling them, you’ll know where it’s being held up. We’ll go into “where’s my holdup” later in this PowerPoint, and we’ll come back to this tactile sensation. But this is how you know if your crowns are actually seated correctly.
This little slide I pulled off the Sprig site. A lot of times people leave little ledges because they didn’t go far enough subgingival. They feel like things are sitting well because the crown looks beautiful. They always look beautiful, until you take a post-op x-ray and realize you’re sitting on a ledge, or a kid comes back and part of the zirconia is chipped, cracked or missing. This is what happened. You can feel this before you cement the crown: run an explorer or perio probe around the tooth and check for a ledge. After you’ve done a few more, you can often feel it with your bur as you’re prepping.
[00:23:37] Training your eye: chair position and tipped crowns
Dr. Sullivan: One of the things we really wanted to help with is training your eye. The actual prep takes moments to understand. It’s basically a classic zirconia prep, just like you would do on a permanent tooth, only we erase the margin and go subgingival. What you actually want to do is train your eye to figure out what happened in the prep that caused the error you see in the final cementation.
Dr. Truman: Let me give you a background on this case. I jumped into it halfway through. I think this kid was three. They thought they were going to get, how many is this, an eight-pack plus fives, sixes and sevens, so we’re looking at about 15 crowns, done with moderate sedation. That’s awesome; some people can, and that’s amazing. They got E and F done, and that was the big win. I think most people can pick out the issue with this case, and I’ll let Vicki go on that. But then we took the patient to the OR and did the rest of the case, which is why the rest of the crowns look how they do versus E and F.
Dr. Sullivan: Right. What you’re going to notice is that E and F have a right-side tip. It’s especially obvious when you compare G and H, and downstairs, the position of O and Q has a far better straight-line drop. What happened when we were prepping E and F is that the provider was sitting at a nine o’clock position, not at 11 to 1. As a result, the bur and the motion drew more off the far edges and less off the near edges. So we created that natural tip, basically dragging the bur towards the position we were sitting in. As a left-handed practitioner, I’m going to tend to draw to the left. As a right-handed practitioner, you’re going to end up drawing to the right. You have to mentally correct for that.
Part of that is where you sit. If you sit at the 12 o’clock position, you’re looking at the case straight on. And part of it is your natural fear that you can’t see your angulation. If you can’t see the tip of your bur, keep in mind that your bur is a metal piece and your handpiece is a metal piece. They’re not going to bend and flex. If the head of your handpiece is in the correct alignment, your bur tip is in the correct alignment. You’re actually going to take it out of alignment the minute you tip it to look.
If you’ve got this, what you can do is grab a Howe plier and go as far down towards the edge as you can, meaning the cervical edge, not the incisal edge. Give it a little crunch; it’s going to shatter. Remove those pieces, clean up any cement that’s left, and put your crown on straight. You may need to re-prep slightly to create the proper line of draw, so keep that in mind.
Dr. Truman: It’s funny, because the provider didn’t notice that these tipped to the right, because they never stopped and looked at the case straight on, which is how everybody looks at this kid’s mouth. Of course Mom and Dad are going to see that E and F are tipped a little and the smile looks a little to the side. Some people like character. I hate it; I love symmetry, and it’s annoying to everybody else in my life. But they didn’t notice because they didn’t take a second to look at it straight on. So that’s a recommendation from this portion of the presentation: take a second look. The parents are going to look at it from straight in front of the kid, so make sure everything lines up really nicely.
Dr. Sullivan: One thing I would point out, though: look at how all of these crowns tuck under the gums. If you’re sitting on top of the gums or you have a little gum gap, you have not reduced properly at the subgingival level, right at the edge. If these don’t tuck, or don’t look like they’re growing out of the gum tissue, they’re not seated properly.
[00:28:05] Stock your box
Dr. Truman: This is a big one, and it’s one of my pet peeves. If you haven’t noticed, I have a lot of pet peeves; apparently I’m hard to please. Stock your box. A lot of times when people buy the kit, there’s a natural tendency to be a minimalist and have the fewest crowns. I can appreciate that; everybody’s trying to save a penny here or there. But it can end up hurting you. A fully stocked box lets you be ready for every case. If I were going to skip a certain size, I might skimp on the larger end of the crowns. I’d still have some, but I’d make sure sizes 1 to 4 of every tooth were loaded, fully stocked, because those are the ones you’re going to use the most.
In our program, for whatever reason, we always run out of C3s and C3 primes. It’s super annoying, because everybody loves to do those canine crowns. We go to the OR on Wednesday, so on Mondays and Tuesdays we do our prep to get everything ready. We look at our kit and realize, “Oh, I only have one canine crown, but I’m doing three cases and they all need canine zirconias. Hopefully none of them is a C3, otherwise we’re going to have big problems.” So don’t be like that. Have a fully stocked kit, so you can do a good job and be ready for every case you’re going to encounter.
The pro tip at the bottom: if you see four crowns a week, you should have a constant supply of eight crowns in each size. Sprig is really good about shipping crowns to you as fast as they possibly can, but there’s always a delay with the mail. So make sure you’re ready for your cases before you start planning them.
I didn’t tell you this, but that first picture is from the Sprig website. That kit is super weak. I’m hoping they’ll replace it with Vicki’s kit on the bottom there. That’s one of her kits, and that’s not even all of the crowns she has. Notice that she’s ready. That’s why she places so many: she has enough to be ready for them. You should have the same. Stock your box and start planning them.
[00:30:26] Bur choices
Dr. Sullivan: If you’re going to bake a cake, you need to make sure you have all of the pieces: eggs, milk, baking soda. You need the same thing with a bur block. You need to know you’ve got the right burs. Ideally you want coarse or extra-coarse burs that follow a proper order. For bulk reduction, you need that thicker 014 or 016, bur number two. That’s going to be as efficient as you possibly can be for removing the bulk. When you switch over to the flame tip, bur number four, that’s your time to stop touching the top of your prep. At this point you’re going subgingival and removing that last little bit.
You want new burs, in my opinion. Ideally, if you’re planning on doing more than four crowns, have an extra bur block ready to go. The wheel bur, bur number one, that comes in the EZ-Prep kit is set exactly at 1.5. That can be very helpful. The 014 and 016 tapered diamonds are set at the 0.8 you really need for proper reduction.
Think about how you prep teeth. You may be a rough-and-tumble heavyweight prepper, or you may be a very delicate flower. If you’re a light touch, you need to do the ring-around-the-rosy step about 10 or 20 times, not just three or four. If you’re getting chatter or feedback that you’re bouncing on your margin, go back until you don’t have that chatter anymore and you’re nice and smooth.
Dr. Truman: Yeah. That bur number one, the wheel, is such a workhorse; it’ll do the most teeth. The ones I always need extras of are bur number two and bur number four, that 014 and 016 tapered diamond. Those diamonds burn out so quick, and if you’re doing six or 12 crowns, you’re going to go through them. So always have backups of at least those. That’s why she says if you’re doing multiple crowns, have a couple of sets of burs. A worn bur can slow you down, and it can create a rough, ragged edge on your margin; you won’t get smooth because it’s jumping.
This is our new favorite bur. It just erases teeth. Google “spiral tapered diamond.” We’ve been working with this one a little, and it’s really good for your gross reduction. Creating your margin takes about five seconds. This seriously melts enamel; it just disappears. So it’s a really good one for gross reduction, not as good for subgingival. It shreds teeth, but it also shreds gums, and we’ve seen a lot of heme that we then had to manage. So it’s a time saver on the gross reduction, maybe not as much subgingivally, but a really good alternative. We’ve recommended this bur to a lot of people. A lot of people like it, others don’t, and that’s fine. I like it. I think it’s awesome.
[00:34:00] Avoiding dingy crowns
Dr. Sullivan: Dingy crowns. You’ve put all this time and effort into placing these beautiful crowns, and when the patient comes back for their two-week check, the parent has suddenly become a fashion critic: “It looks a little gray. It looks a little yellow.”
Dr. Truman: Because the cavities weren’t brown or yellow or black before.
Dr. Sullivan: Oh, completely. But now it matters.
Dr. Truman: Yes. We didn’t notice the chips and the breaks, and the SDF. Now we notice that this looks a little too yellow, comparatively.
Dr. Sullivan: So, heme control. You really have to take the time to make sure the gum tissue is not oozing blood. The other thing I see is that people don’t fill their crown completely full. There’s an RDA shortage out there nationwide, and a lot of us are getting general dentistry RDAs rather than pedo-specific RDAs. Those general dentistry RDAs are going to put in a thin, light, barely-there layer.
Dr. Truman: Just enough. Yep.
Dr. Sullivan: These things need to be completely full. We’re talking about the basic physics principle of fluid displacement: we want the cement to go out, ideally outside of the gums. So take the time to make sure you’ve got good stasis. You can use HemeRx pellets. Racemic epinephrine is fantastic. It doesn’t have a funky taste, and it doesn’t leave the brown bits that can get trapped underneath like a lot of the hemostatics do. You’re going to have a very clean surface and time to work. One of the things that drives me crazy is when you put in some kind of hemostatic, go to rinse, and it starts oozing again. That’s not going to happen with HemeRx.
Once you’ve done that, fill your crown fully, seat it, and don’t move. If you lean on this crown backwards, you’re going to lift the gum and lift the edge of the crown outside of the gum. If you lean on it forwards, you’re going to give yourself a flare. If you’ve done SDF on this tooth before placing the crowns, you may want to reduce your facial a little more so you can have a little bulk of cement there to hide gray show-through. As far as which cements, we’re going to go into that.
Dr. Truman: Yeah, we have a slide. I think that’s the next slide, actually, because we’ve found a fun trick in cementation that’s made a big difference in preventing these dingy crowns. Hopefully it’s the next one. That would be a great segue if we planned that. We’re pretty good. Take that.
[00:36:57] Cementation hacks
Dr. Truman: Cementation hacks. Again, pulling from the Sprig website: to prevent loss of adhesion between the cement and the dentin where moisture control is difficult, they recommend a non-resin-containing GI cement like Ketac for its ability to bond predictably to dentin in a moist environment. We all know glass works so well in moisture, in fact better in moisture. It bonds to enamel, and it bonds to dentin much better than a resin does, so we like something with GI. Dr. Andi, who lectures for Sprig, has a great slide on different bond strengths and which cements are the best, and to sum it up, it’s this slide: use glass ionomer, and use something a little thicker so it sticks better.
Our new favorite cement is EQUIA Forte HT, which is a glass ionomer. It’s the updated version of Fuji IX. It’s a great restorative material, but we’ve been using it as cement, and it’s just thick enough and sticky enough that it displaces the heme so well. There are multiple shades, which doesn’t really matter because it’s under your crowns; pick the shade you don’t use for restorative and use that for your cement.
We ran out of EQUIA Forte because we were using it so much, so we had to switch to Fuji II, which is an RMGI, because it has that dual cure. One thing I’ve been doing, which I learned from somebody else: load your Fuji II and, if you’re doing an anterior case, put E and F on to cement them at the same time. I do a tack cure, two seconds buccal and two seconds lingual, to get the cement a little set. Then I flick off the tacky cement using apical pressure to clear it out. Once I like how it looks, I do a full cure while my assistant loads the next crowns, D and G, and repeat the process. It’s not 100% glass, but it’s close enough, and I’ve had really good results with that. It also helps because I’m really impatient. I like to tweak a little to make it a little less tipped and tilted, so tack curing forces my crowns to stay exactly where they are. That doesn’t work for everybody, and that’s fine, but it’s something I like with Fuji II. I’m pretty sure Fuji II is a little cheaper than EQUIA Forte, but again, it’s not 100% glass, so you may have more debond issues.
Ketac cement: there’s triturated Ketac, and then there’s hand-mix. There’s a big difference, especially in bond strength for these types of crowns. I wish I had that graph from Dr. Andi, because it shows that. But hand-mix Ketac is just the stickiest stuff ever, and a lot of the old-school doctors (yes, I looked at you) love it because it works so well. You want it thick, like peanut butter or toothpaste. We don’t want it runny. We don’t want to be injecting it. We want it thick and dense.
Again, we work with dental students, residents and new providers. All the crowns that come back missing, or where we see a lot of heme inside them, they’re using RelyX. That’s a great cement, and if it works for you, that’s awesome; I’m not telling you not to use it. If you like your triturated Ketac, that’s totally fine, keep using it. But all the ones we have seen, and this is anecdotal, have been with those two cements. They’re a little too runny for what we’re trying to do. We like really thick, pasty cements, and this has been working really well for us. Knock on wood, we haven’t had a zirconia crown come off with this type of cement in a minute. Unless a kid is chewing on Jolly Ranchers the day after the OR, which has happened.
[00:41:17] Photographing your cases
Dr. Sullivan: One thing you need to do to get better is photograph your cases. You need to look at your cases so you can start training your eye. You need to track your progress. This is the time to be critical, preferably after everyone’s gone home for the night. Look at your photos pre and post. Look at the way the teeth sat. Look at how you cleaned up the cement.
One thing I’ve noticed watching students and residents is that when they first start doing these preps, they mulch the gums. The gums look like they’ve come out of an abattoir. But as you get over 20, maybe over 25 cases, you’ll notice that you trust where your bur is, you’re more confident about removing tooth structure, and you’re not beating up the gums as much. You’ll be able to see that happen if you’re tracking your progress.
You need before-and-after pictures for several reasons. You definitely need them for your own eye training. But parents will come back having forgotten what the situation was before, and you can show them again. Sometimes you need them for insurance claims. They can be a phenomenal marketing tool on websites and social media. You can have a book, or a running tape in your reception area showing before-and-after pictures. Parents are always very aware of any deficits they either perceive or actually have compared to every other parent in the room. So when you can provide them with picture-perfect teeth, it soothes the parent guilt associated with a decay situation.
[00:43:06] Case review: first cases and settling
Dr. Truman: Yep. We’re going to show you a few of our cases. Feel free to pick them apart, because we already have, and you’re not going to hurt our feelings. We already know what’s wrong with them, and that’s why we’re putting them on here: we’re constantly trying to improve and get better. That’s why we take before-and-after pictures, so we can track our progress, see where we’re getting better and what still needs work, and help you train your own eyes.
These were all done by a dental student. Arguably the handsomest dental student Dr. Sullivan has ever had the privilege of teaching.
Dr. Sullivan: Some would say.
Dr. Truman: Great guy, really. Good personality. Anyway, we did a lot of these in dental school, and I can pick out so many things wrong with all these cases. Every single parent was crying that these crowns were placed. They thought they were beautiful, and the whole time I’m looking at them thinking all I see is what’s wrong with them. Some parents are going to notice and be really nitpicky, and that’s totally fine. These were all done with nitrous only, so could behavior have been improved? Yes. But these kids did really well.
You can see in that first case there’s some tip and some tilt. Those crowns are maybe a little too big. There’s some dinginess on all of these, especially that bottom case; that D crown is super dingy. That’s actually a pretty good-looking case other than the dinginess of the crowns. Look over to the right and you’ll notice D is out of the arch, set back a little lingual. Did I create a crossbite? Who knows? But they look pretty good for a first few crowns, and you can do it. You have the training and the skills. Most of you are pediatric dentists, and you have the behavior management techniques to get this done with nitrous a lot of times. But there are things that can be improved.
Next slide. This is another case I did in dental school, and I was really worried about it. I was only prepping E. This kid had monster facial caries on E, so we planned a crown. You can tell by his face in the first picture that he loved every minute of it; he was so happy I got to do that for him. I maybe took a little extra off the incisal, so those edges don’t match up, and I worried about that forever. He came back a week later because his sibling had an appointment, and you can see that it totally settled. It looks just fine. These settle a little; there’s a little wiggle room. They’re not going to settle like an SSC or a Hall crown would, so don’t plan on that. But things do settle, and in his case it worked out really nicely. There’s a little difference in color, but the incisal edges lined up, and it was a total win for that kid.
Dr. Sullivan: And I’m pretty sure it was a total win for the parent.
Dr. Truman: Yeah. We were still criticizing it, but I’m pretty sure the parent was like, “Look how beautiful he is.”
Dr. Sullivan: Yeah, because it was a monster cavity. It was the only thing you noticed when this kid smiled.
Dr. Truman: Here are some more current cases we’ve done. You can see the gingiva on those canines right in the middle of this slide. Just beautiful. One of my buddies on here is in perio residency, and I think he’d appreciate the beautiful gingiva we’ve maintained. Gingiva and soft tissue just love zirconia. It is so highly polished, it looks natural, and you can see how beautifully it rolls into the tissue. You’ll notice we did a deep-bite case, and later we’ll show you an underbite case. There’s a back-to-back case on the bottom left. The lower E is ankylosed, and that was probably the hardest case I’ve ever done, surprisingly, because there was space loss, there was ankylosis, and I was trying to restore VDO and make it look nice. That case was the worst, but they look great. There are still things that can be improved on all of these cases, but overall I think we’re making progress.
[00:47:45] Case review: an underbite, healthy gingiva and a partial case
Dr. Truman: This was a fun case. I worked on it with one of my buddies: D through G. This little three-year-old was a pill. He was tough, and he came in with an underbite that was too much for us to jump, so we kept it. Some people are worried about that, but zirconia can take a beating. They’ve done studies on the compressive strength of zirconia, and it’s so much more than the bite force of a kid. Aside from trauma, not much is going to break these crowns.
He came back two weeks later for his checkup. The photo’s a little blurry; it was a rodeo trying to get this kid to take the picture. It took four of us to hold him down and take the post-op photo. Notice the parents are still brushing those teeth. They look beautiful, right? No plaque on those teeth. I’m joking. I probably should have brushed that off for the picture. But again, the gingiva looked beautiful, and things healed really well. One of the first-year residents said they thought we only did the canines for this case: “Oh, you did C and H.” I said no, we did D through G. So even a well-trained eye may not pick them up, because they look so natural.
This is another case that goes back to what Vicki was talking about: the more you do, the less you hack the gingiva. Some of these look like they’ve been through the shredder, with heme everywhere. This photo was right after we cemented, before I even did all my cement cleanup, because we wanted to show how amazing this case went. There was almost no heme. We were trying to restore D through G, and we’d done several rounds of SDF. This girl got sick between OR dates, so we kept pushing her case back, and F eventually abscessed. We did a sedation and extracted that, but Mom really wanted to save the rest. So you don’t always have to do D through G. You can pick cases where you’re doing a single crown, or a couple of crowns, or three like we did here, and it still turns out great.
I should have posted the settling picture from a couple of weeks later. It looks beautiful. This girl was walking around with the biggest smile on her face. Her mom says she shows everybody she knows. She goes up to strangers and shows them her princess teeth and how amazing they look. Those strangers are probably a little weirded out, but I think it’s amazing, because she’s so proud of how they look. They look awesome.
Dr. Sullivan: I also really want to note there’s a low frenum here, and that frenum did not get destroyed in the prep process. Yes, you can do frenectomies and continue on with your crown, but if you’re following the prep rules, you can get plenty of mesiofacial reduction without destroying the gum tissue.
Dr. Truman: Mm-hmm.
Dr. Sullivan: This is one of my cases. This little guy has D through G. This is a two-year follow-up, and he’s looking pretty happy. I believe this was done under nitrous. What I really like is that you’re not seeing any irritation in the gum tissue or any unevenness between the crowns. We left the gaps; Mommy liked the gaps and did not want everything sealed up. I did not go with bigger sizes. We stuck to the sizes that worked for him, and he’s pretty stoked with his smile.
[00:51:27] Questions: sequencing extractions and gingival healing
Dr. Truman: I’m going to read a question from the question box since we’re on this topic. Somebody asked: “Could you provide the steps when you have a case where you have to extract teeth adjacent to zirconia crowns? Extract first, complete zirks, wait, then extract?” Thanks. Our rule is we work white to red. Usually we do the crowns, the fillings, whatever, and then the extractions. Sometimes we’ll prep everything and get the whole crown ready to go, so the last thing we need to do is load it with cement and push it on. Then we do our extraction, maybe place a little Gelfoam for hemostasis, and then cement our crown. That usually doesn’t cause a problem. Hold a lot of good pressure while your assistant fills your crown with cement. Ben Popple has a good one on his Post-it pediatric notes: if you’ve ever seen Indiana Jones where he switches out the little statue, that’s exactly what you do. Take your cotton off and throw your crown on really quick, in one super smooth motion. That way you don’t get a lot of heme filling up, and your cement, especially if it’s thick, will displace it. Excellent question, but that’s usually how we sequence that.
Another question somebody had: how long do you tell parents it takes for the gingiva to heal after placement? I mean, two weeks? What do you usually say?
Dr. Sullivan: I prefer to tell them two weeks, because a lot of parents are very hesitant about keeping up hygiene, especially after a GA case. They’re not really in there brushing and cleaning things up, so the child takes longer to heal. In reality, most of my pediatric cases are well on their way to healing in about five days. But say 14, and the parent is happier because the kid’s comfortable quickly.
Dr. Truman: Yeah. I have another question here; let me come back to it when Vicki talks about one of her cases coming up, because she did exactly this. The question is: if you’re doing zirconia on the Cs, the canines, and SSCs on the Ds, the molars, what’s your sequence for cementation? She has a case coming up in about two slides where she does exactly that, so I’ll have her talk to you about it. I don’t want to forget it, but we’re going to come back to it.
[00:53:58] Case review: ectodermal dysplasia, and mixing zirconia with steel
Dr. Sullivan: This is one of my favorite cases. This little guy has ectodermal dysplasia. He was getting teased a lot for looking like a little vampire. We got a very nice result. This is directly after treatment, and he is not asleep. In fact, he was giving me the stink eye because he wasn’t too thrilled. But as you can see, we were able to create a nice natural smile. We removed the fang presentation without exposing the nerve tissue. That’s another thing I think is really important: just because these teeth look this way does not mean you need to go down to the nerve tissue to make them fit the intaglio surface.
Dr. Truman: Yeah, a lot of people ask that question, and some of you may have it: do I have to pulp every single tooth that I put a zirconia on? It depends. It depends which brand you’re using, and on a lot of things. I’ll tell you, with the technique Sprig teaches, I’ve never had to pulp a tooth to get a crown to fit. I know there are people who have, but I’ve never experienced that. I’ve done pulps when indicated, but I haven’t had to do them just to make a crown fit. Some people see a lot of abscesses. I think that happens if you’re heavy-handed and not keeping track of where the pulp is. But as long as you’re aware of that and using a really nice biocompatible cement, I don’t think you’ll have any problems.
Dr. Sullivan: I agree. In this case, again, Mommy wants the gap. So take your pre and post photos, and look at your pre picture. Most parents want you to return their smile to the way it looked. Of course not with the brown and the yellow and the chips, which they’ve forgotten about, but the shape itself is what they’re looking for. And again, watch that your gum tissue is over the top of your crown. If it’s sitting on top, as opposed to looking like the crown is growing out of the gums, you’re sitting on a ledge.
Dr. Truman: So maybe talk about this one. Did you do these canines? Yeah, you did. You have steel in the back, plus you did the canines, so talk about how you prepped and how you cemented.
Dr. Sullivan: For me, I prep in threes. I’ll prep A, B, C, I’ll prep H, I, J, and I’ll fit all of the crowns together. Then I cement my canines first, and then my steel. So for A, B, C, for example, I cement C first, A second, B third.
Dr. Truman: Yeah. Again, steel flexes; zirconia doesn’t. The reason I like that is that I know my zirk needs the space, so I put that on first. I’m a creature of habit; I always do my E crowns before my D crowns, so, like she said, A first. Then if I have to smash the B crown or the D crown to make it fit that space, that works so much better than trying to get the zirconia on at the end when there is no space.
Dr. Sullivan: Yes.
Dr. Truman: That’s usually how we’ve done it, and we’ve had really good results with that.
Dr. Sullivan: Also be aware: if you’re going to do a zirconia prep and the tooth in front of it or behind it has a stainless steel crown, you may need to cut off that stainless steel crown and replace it. It’s really hard not to nick or wear away the stainless steel on that mesial or distal surface. So if you’re in that situation, check the original stainless steel. If it’s got a hollow point, replace it.
Dr. Truman: Yeah, pop it off.
[00:57:45] Case review: an awake patient and a crossbite
Dr. Sullivan: I really like showing cases where the kid is not asleep. This is an ugly case in terms of the pre-op, and this child was not asleep, so it was a nice little rodeo for us.
Dr. Truman: Again, we’re back on theme with the rodeo.
Dr. Sullivan: Oh my gosh, we’re getting ready for Denver. I love it. As far as the result goes, you can see we brought all the incisal edges into a good location. It draws nicely. The canines are still a little longer. You’ll notice, or maybe you won’t, but I definitely notice, that the laterals look longer. It’s not that they’re longer; it’s where the gum tissue is sitting right now. I’m sorry I don’t have the six-week or three-month follow-up for you. But again, parents are going to be drawn to where the incisal edge is. They’re not necessarily going to be sensitive to how the gum tissue looks, at least once it’s healed. They are going to be sensitive to whether or not you’ve got long canines or long laterals.
Dr. Truman: Yeah, most parents notice E and F, and that’s pretty much it. If you can make any teeth look good, make E and F look good together. The rest of the teeth have a little wiggle room. If the incisal edges of the canines and the centrals don’t match up, and the parents aren’t dentists, they probably won’t know that’s supposed to happen. And we’ve already seen that a lot of these cases can settle and erupt into place, so it may not be a problem in a few weeks. It’s something you may need to monitor.
Dr. Sullivan: This is my crossbite case, and this is about a three-year follow-up. This was a 100% crossbite. My rule of thumb for flipping a crossbite is anything less than 50%. If it’s less than 50%, I’ll prep a little more off the lingual surface and a little less off the buccal surface, flare the teeth slightly, and jump the crossbite. This was much too much of a crossbite, so I did not do that. As you can see, the gum tissue is doing beautifully. We did not pulp these teeth. The crowns are not socks on a rooster; they’re sitting nicely on the teeth themselves, and clearly we’re not having any issues from having put her back in the bite she was going with.
Dr. Truman: Going back to that rule of jumping cases, that’s an advanced case. I think Dusty has a web series on that where you can learn more. If you’re looking to do more complex cases like that, it would be a great refresher course on what you can and can’t do and how you accomplish it. But it’s amazing what you can do with these crowns.
[01:00:42] It’s all in the angles
Dr. Sullivan: All the time you’re going to hear that it’s all in the angles. This is a master game of pool. When you’re troubleshooting your prep, start from the beginning. Where are you sitting? What’s your chair position? If you’re a right-handed dentist and you like to prep at the nine o’clock position, you’re going to tend to tip your teeth. You’re going to want to look at where the tip of the bur is, so you’re going to tip in the exact opposite direction that you should.
You’re going to want to be faster, so you’re going to cheat the uniform reduction. You’re going to fail to create a second plane of reduction on your anteriors, or fail to create a proper prow of a ship for your canines; you’ll either drop your buccal flare or your lingual flare. You’re going to fail to account for space loss, or for the long axis of the crown, when you take your initial picture. If the long axis of the tooth is tipped slightly, you have to make your prep draw with the long axis, otherwise it will look crooked.
You fail to tuck your crown under the gums. You destroy your gums. We had that happen the other day: unfortunately they were a little too aggressive with the bur and took a big chunk of gum tissue off.
Dr. Truman: But we billed for crown lengthening.
Dr. Sullivan: Yeah. So there we go.
Dr. Truman: Told her it was just to make it look a little more interesting.
Dr. Sullivan: Failure to reduce the cervical area. I cannot say enough that people fail to reduce that edge on the backside of their anterior crowns, or fail to reduce right below the gum tissue, and then you’ve got the crown lifting at the cervical margin. And finally, prepping side-by-side teeth while only accounting for the long axis of one of them. Really watch your positioning on S and T, or on A and B. If B is drawing in a specific way and you prep it that way, you may have literally tipped it into A, and then A won’t sit for you. Make sure you’re following the long axis for both teeth.
Dr. Truman: Yeah. It’s like when you’re doing bridges, right? Draw.
Dr. Sullivan: Yes. They both have to draw. They both have to seat in the same direction.
Dr. Truman: That’s a shout-out to the GPs on this lecture, by the way.
[01:03:07] Finding the holdup: the teeter-totter
Dr. Truman: This is something we touched on briefly at the beginning, and it has to do with our angles and our holdups. When you’re doing your pinky check, put your pinky on the incisal edge and imagine that edge is the junction point on this teeter-totter in the picture. If you set your finger there and feel it rocking in one direction, you can find out where your holdup is.
If you’re not taking notes, this is something you should write down. If you put your finger on the incisal or occlusal and feel your crown rocking buccal-lingual, there is a mesial-distal fulcrum point stopping you from seating that crown all the way. So if it’s rocking buccal-lingual, you need to reduce mesial and distal to free up the fulcrum, so you have a passive rest only on the occlusal or incisal. If you feel your crown rocking mesial to distal, then the buccal and lingual are the fulcrum, and those are the points that need to be reduced to free it up. That is a huge tip for checking whether it’s seated correctly, feeling for a ledge, or feeling whether your cervical is too bulged in one area, as long as you know your crown is the right size.
To correct this, it’s either ring around the rosy or hitting the mesial-distal or buccal-lingual wherever you’re feeling it. To play it safe, we usually say ring around the world: go around the whole thing and make the whole tooth a little smaller. That usually corrects it. Once you feel that passive rest, you know you’re solid.
The areas of concern are usually under-prepping. I like how we listed pretty much every part of the tooth. Line angles, the corners: anytime we turn from facial to distal or to lingual, anywhere we start to turn in the plane, that’s always a spot of under-reduction. We’re really good about straight cut-throughs and straight facials, but for whatever reason, we don’t do as well rounding that corner.
Subgingival ledges: Sprig has put that on pretty much every slide ever, because it’s a huge problem. Little pieces of zirconia will chip, crack or break because the crown is sitting on a ledge, or it won’t seat all the way because it’s sitting on a subgingival ledge. As pediatric dentists we’re not used to dealing with what’s under the gums, so sometimes we forget. But again, you can feel it with an explorer or perio probe, or with your bur as you’re prepping.
The straight facial: if it’s under-reduced, your crown’s not going to tuck. It’s going to flare out and look like Bucky Beaver, and everybody will know that kid has crowns. Or you’re out of the line of draw, and things don’t wrap around the arch. I know that’s a lot of little things, but they’re all areas to check if you’re having a holdup. Did I prep enough here? Did I do my pinky check? Am I rocking in one direction?
[01:06:31] Slow is fast: efficiency, rushing and starting over
Dr. Sullivan: Keep in mind: the longer you’re on this tooth, the more problems you’re likely to have. If you’re in an oral sedation case and you’re cutting dry, or overusing a dull bur that’s lost its diamonds, you’re going to overheat the teeth. If you bake the pulp, you’ll end up with ghost teeth or abscesses. It also makes you more stressed. The longer you’re irritating that young child, the more likely the child is to go south. Being efficient and fast reduces your overall stress, reduces the opportunity to lose patient cooperation, and gives the pulp more chances to survive. The faster and more efficient you can be, the less stress you’re putting on yourself and on the tooth.
Dr. Truman: Mm-hmm. People are always in a rush. We’re always trying to get to the next exam or the next patient, so we skip steps. We’ve hammered this into everybody’s brains: you can’t skip steps, because that’s when you under-reduce or over-reduce, you miss a ledge, you pick the wrong crown, you get blood under your crown. Then you have contamination, a potential debond, something chips or breaks later on. You’re saving time now, but you’ll create problems that take up more of your time in the future. So make sure you set enough time aside for this, especially as you’re getting back into it. I promise you, once you’ve done enough of them, it only adds a couple of minutes to do zirconia versus a stainless steel crown. It really does. It’s not that much more prep to the tooth; it’s understanding where the holdups are and how to correct them.
It’s just like everybody at the beginning, right? Probably nobody sat down and did an amazing, beautiful stainless steel crown from the very beginning that fit perfectly. There’s a learning curve. You have to do enough of them to understand where the holdups are, how to correct them, and how to pick the better option. Part of that is: don’t rush yourself. Set enough time aside that you do it right the first time. Learn the good habits from the beginning.
Dr. Sullivan: Keep in mind, don’t be afraid to start over. You’re not starting from the beginning. You’re starting from experience. You’ve already taken the first step. Pull the crown box down and get rocking and rolling.
Dr. Truman: Yep. You have a lot more clinical experience than when you were in residency, hopefully. You know a lot more about teeth, how to prep them, and how to manage behavior. So you’re not starting from the beginning; you have experience. Use that to your advantage and add this to your repertoire, your toolbox. It’s something patients are asking for. A lot of parents, if they can afford them, want white. Especially if you’re in a competitive market, this is something you have to learn and have to be good at.
[01:09:41] Closing Q&A
Dr. Truman: We have a few minutes for questions. I know we answered a few, but if you have more, put them in the chat box and we’ll go through as many as we can before Garrett shuts us off. He told us he was going to put the little thing on us and pull us off the stage.
Dr. Sullivan: Oh no, are we going to be lassoed? The rodeo?
Dr. Truman: We’ll be kicked out of the rodeo, but we’re happy.
A couple of people asked if they can get a copy of this PowerPoint. For three monthly payments of $29.99, I will send it. No. Let me talk to Garrett and ask him; I’m not sure what they do for that.
Somebody asked: do you take post-op x-rays after cementation? We don’t always; it’s not a rule we have. Some people do, and some people love to take a post-op x-ray of everything for insurance, and I think that’s a good idea. In the beginning, I think it’s wise. Later on it’s probably less wise, following ALARA, right? Do whatever you feel is prudent. But in the beginning, it’s good to see: do I have a huge glob of cement under the gingiva that I missed? Do I have a ledge that I missed? Is my crown oversized? Use it as a learning tool at the beginning. I don’t think you have to for every case, but in the beginning it’s a great idea.
Dr. Sullivan: I agree.
Dr. Truman: What else? […] I’m not seeing any other questions. If you find yourself with a burning question after the fact, definitely feel free to send us an email.
Guides for the subgingival bur?
Dr. Sullivan: Keep in mind that a healthy pediatric pocket is three to six millimeters, so you should be down two millimeters.
Dr. Truman: Yeah. If you need to, take out a perio probe, figure out what that looks like on your bur, and use that accordingly. Two millimeters is not an absolute rule. It’s a great guideline. Sometimes you don’t need as much, sometimes you need a little more, but it’s a good starting point. If you need to see that, measure initially; that’s a good idea.
HemeRx: the hemostatic agent we mentioned is called HemeRx. It’s a racemic epinephrine-soaked pellet, and Sprig sells them on their website. It’s tasteless and odorless, and it doesn’t really add to the systemic epi; some people worry about that for OR cases. Application time is pretty quick.
Dr. Sullivan: It’s about 30 seconds, and then things pretty much dry up. My one suggestion, which we learned the hard way: you’ve got to dampen these. Don’t blow them or blossom them with water, but dampen them, stretch them out a little, and pack them like cord. By the time you finish packing all four, give it a squeeze, and you’re ready to cement. You’re not going to have any blood.
Dr. Truman: Yeah. I’d also say don’t just shove these into a bloody pocket. Get a little pressure hemostasis, wipe things, and then put them in. Otherwise they’re going to look like nasty, bloody boogers in there. Wipe before you put them in and you’ll get a better effect.
All right, any other questions? Oh, somebody even put the link on that question. People are getting fancy in the question box. I love that.
