Preps, Processes, and Clinical Pearls: The Keys to Success for Incorporating Zirconia Crowns Into Your Practice — Transcript
[00:00:12] Welcome and housekeeping
All right, we’ll go ahead and get started and let everyone else keep working their way in. Thank you so much for being here tonight for our Sprig webinar. My name is Dr. Alex Otto, and we’re going to be talking about the preps, processes and clinical pearls to get you ready to incorporate zirconias into your practice. I’m going to share some of my keys to success for incorporating zirconia crowns in your practice.
We’ve got a lot to cover in an hour, so I’m going to go through as much as I can. If you have any questions throughout the presentation, please feel free to drop them in the chat box. I’m going to stick around for a bit afterwards and answer as many questions as I can. I’ll also share my personal email at the end, so I’m happy to email with you if there are any questions we don’t get to.
[00:00:56] From dental school to general dentist
I wanted to introduce myself and tell you a little bit about who I am. I’m a pediatric dentist, and I live and work in Buda, Texas, which is about 20 minutes south of Austin. I grew up in Naples, Florida, went to the University of Florida for undergrad, and then immediately went to dental school at VCU School of Dentistry in Richmond, Virginia. I love VCU and had an incredible experience in dental school there.
I didn’t get a ton of exposure to pediatric patients. I expected that I would like working with kids, but didn’t quite feel comfortable applying to pediatric residency right after dental school. So I decided to apply to general practice residencies and AEGDs to get more experience with all aspects of general dentistry, including pediatric dentistry. I picked Denver Health Medical Center because we got to see a lot of kids in routine clinic treatment appointments, and we also got to go to the operating room with a pediatric dentist and do cool full-mouth cases. I thought that would give me a really good idea of whether or not I liked working with kids. I learned during my year that I love working with kids.
But as I’m sure many of you have felt, I felt like I’d been in school for a million years at this point and was about $500,000 in debt. So I […] decided to be a general dentist for a couple of years and see how I felt about being a GP who saw kids. I spent the next five years working as a general dentist, and I was really fortunate to be able to work in some pediatric offices in Denver and in Dallas.
[00:02:22] Opening a practice and going back to residency
My time working in pediatric offices as a general dentist really cemented the fact that I love pediatric dentistry. This is what I wanted to do. I got to the point where I was ready and wanting to open my own practice, but the business side of dentistry really intimidated me, and I didn’t know if that was something I wanted to take on.
I spent a lot of time talking to my husband about this. He has an international MBA and degrees in finance and management. We came to the decision that we were going to open a practice together: he would run the whole business side of the practice, and I would obviously do the dentistry. Once we made that decision, I realized that I needed to, and wanted to, go back to pediatric residency. I wanted to open a pediatric practice and be the specialist who was the end of the road for the kids I treated. I wanted to be the pediatric dentist that other pediatric dentists refer to, be able to do the complicated cases, and go to the children’s hospital and get those credentials. So after five years of working as a general dentist, I decided to go back to residency.
I applied to programs all over the country and fell in love with the program in Alaska at Southcentral Foundation, which is part of the NYU Langone Health pediatric residency programs. I picked Alaska and had an incredible two years there. I got to see some super interesting cases. We only treat Alaska Native children, and a lot of the kiddos are flown in from villages and remote areas of Alaska and have some really unique needs and care. I had a really incredible faculty and experience there, and I absolutely loved living in Alaska for two years. We almost didn’t leave, we loved it so much. When we moved from Dallas, we actually sold everything we owned, moved into an RV and took a two-month-long RV trip across the country up to Alaska.
[00:04:15] Organized dentistry, family and Kids Tooth Team
I’m really passionate about organized dentistry. I was the national vice president of the American Student Dental Association when I was in dental school, and I’ve been really involved with the American Dental Association since then. I’m an ADA Success Program speaker, so I travel to dental schools across the country to teach dental students about how to find a job, practice management, and ethics and professionalism, which is awesome.
I’m proud to be a Fellow in the Academy of General Dentistry. That was something I worked on as a general dentist and then completed, taking my test while I was in pediatric residency. Even as a pediatric dentist, I really believe in lifelong learning and what the AGD stands for, so I’m proud to be in their group. I’m a Fellow in the American College of Dentists as well. And most recently, I joined the Sprig team. Sprig hosts Sprig Universities and also gives webinars like this. I’m really proud to be part of the Sprig group; they’re an incredible company, and I’ll talk a bit about them throughout the presentation.
This is my family. This is my husband, Tim, who I was telling you about. Like I said, he’s got the business degree and degrees in finance and management, so I’m super grateful that he wanted to do this with me. I applaud all of you dentists who are doing all the business part and all the clinical part by yourselves, because it is a lot. I feel like we both work 80 hours a week, and I just don’t know how a lot of dentists do this by themselves. It’s nice to have a partner who shares the passion we have for our company and wants it to grow, like he does.
These are our two fur children. Rambo is the golden retriever; my husband named him. Bremer is our Bernese mountain dog, named after our favorite winery in Napa, so go to Bremer Family Winery if you haven’t been there yet. And we’re expecting our first human child pretty soon. He’s actually due in 11 days. He’s being stubborn and is still breech, so we have a C-section planned for August 29th. He’ll be here very soon.
Together, my husband Tim and I founded Kids Tooth Team Pediatric Dentistry. That’s the name of our private practices. We also recently founded a nonprofit organization called Kids Tooth Team Outreach that I’ll tell you about in a second.
I wanted to show you a couple of pictures of our offices. This is the first office we opened, in Buda, Texas, which, like I said, is about 15 minutes south of Austin. It was just a shell, so Tim and I designed the whole space and built the office from the ground up. We opened it in September 2020 with zero patients when we opened the doors, and it’s been really fun to see our practice grow over the last couple of years. Then in July 2021 we bought an existing pediatric office in South Austin and converted it to Kids Tooth Team. That’s about 15 minutes north of the Buda office, closer to downtown Austin, and it’s been open a little over a year now. We’re opening our third office in Kyle, Texas, about 15 minutes south of Buda, this December. We’re getting all the permits and all that fun stuff going to open that office up.
[00:07:13] Anthem video and Kids Tooth Team Outreach
I always think it’s fun when practices share some of their marketing and what they’re doing, so I thought I’d share a couple of our little videos with you. Give me a second to pull this up. This is what we call our anthem video, just a cute little blurb about Kids Tooth Team.
[Anthem video plays. Only fragments are captioned (“If you tell my friends what you want to be when you grow up…”), then the transcript skips from 00:08:04 to 00:08:56.] […]
That’s our cute little anthem video I wanted to share. And then a little bit about Kids Tooth Team Outreach. We have a nonprofit organization that we started as a way to give back to the community, which has been so wonderful and so welcoming to us. St. David’s Foundation is an organization here in Austin that has the largest fleet of dental vans in the country. We’re really fortunate that a couple of years ago they decided to donate one of their vans to us. Every so often they’ll donate a van to a nonprofit that aligns with their mission and values, and we got to be that nonprofit.
They donated it to us in 2021, last December. We got it wrapped in our logo and started serving underserved communities in our area. We go to local elementary schools, women and children’s shelters, local preschools and areas in need, and donate free dental care. I’ve recruited some of my dentist friends in the area to volunteer their time, and we have a whole group of pre-dental students here on the UT Austin campus who come and volunteer their time too. We’ve already donated $25,000 worth of free dental care this year, and we have six more days lined up for the fall, so we’re super excited about this and watching it grow. If you have a Texas dental license and are looking for a volunteer opportunity, we’d love to have you, so please email me at the end if you’re interested in volunteering.
I’m going to show you a quick donation video from St. David’s Foundation from when they donated the van to us.
[Donation video plays, 00:10:35–00:12:40. A St. David’s Foundation speaker describes its 20-year dental program. Tim Otto describes their long-held goal of serving children in rural communities, “where pediatric dental specialists are needed the most,” and their excitement at seeing the van with their logo. A foundation representative recalls starting the journey with Dr. Alex Otto and Tim Otto in February 2019, and the Ottos describe expanding St. David’s mobile fleet’s reach as a dream come true.]
I just wanted to share a little bit about Kids Tooth Team Outreach. I submitted a video to Chip and Joanna Gaines to see if they would help me renovate and flip the van, but they have not responded yet. So that’s our next renovation project, to update the van. I feel like it could be a little bit cuter on the inside. But it’s amazing: it has two full operatories and a pano machine, so the majority of what we can do in our offices we can do on the van. We got a nitrous tank donated, so we’re really excited to see where this grows, and if anyone’s interested in helping, we would love your help.
A few things our practice has achieved: we’re really grateful to have been recognized as one of the top 10 Under 10 award recipients for the American Dental Association this year, in large part due to everything we’re doing with Kids Tooth Team Outreach. I’m grateful that our team, our office and Kids Tooth Team Outreach were recognized for that. We were also just awarded best pediatric dentist in our county, and also best dentist, which was really cute. I’m really proud of our team. We focus a lot on customer service and putting our patients first, so it’s nice to be recognized for those things.
[00:13:44] What we’ll cover, and disclosures
Now that you know who I am and a little bit about me and my practice, here’s what we’re going to talk about today. I’m going to tell you my story with zirconias. I know some of you are just getting started and thinking about incorporating this into your practices, so I’m going to tell you how I started and how I got to where I am. Then: what my philosophy of care is regarding zirconia crowns, who the kids are that I’m picking for these cases, a little about case selection and when I recommend these, and some of the administrative processes I use in my office, both for parent education and team education, to give you some ideas of things you can do to incorporate these better into your practices. Then we’ll go through the Sprig prep technique for anterior and posterior crowns, and some clinical pearls and keys to success for incorporating these.
Quick disclosures. I don’t have any conflicts of interest with any of the material I’m presenting. Everything I’m talking about today is my personal opinion, though I am presenting Sprig’s crown prep technique, so I’m giving credit to Sprig for that. I do get an honorarium for speaking, but all of my speaking engagement honorarium goes to Kids Tooth Team Outreach, so that’s where all of that goes.
[00:14:47] My zirconia story: from YouTube to residency
Some of you have probably been doing this a long time already. I did my first zirconia in 2015, when I was a GP working in a pedo office. My boss at the time, Dr. Lisa Fox, who’s in this picture and who I love, purchased a zirconia kit from NuSmile for the practice. I think I was aware that it was purchased, and I think we put some brochures up in the front. But I will never forget that first day a zirconia crown was on my schedule. The assistant told me about it in morning huddle, and I didn’t know how I was supposed to prep it or what I was supposed to do. As soon as she told me, I ran and locked myself in the office and went on YouTube. I don’t even think I searched “prep zirconia crown primary molar.” I think I searched “white crown baby tooth how to do this,” and some random YouTube video popped up. I spent the next hour trying to figure out how to put this crown on. I think I finally got it on. I really hope that crown is still on that kid, but I do not know.
It was something I didn’t feel super comfortable offering to families, even though we had the crown kit, so it wasn’t something I offered as a choice or talked about. The only times I did them were when they were put on my schedule by someone else. So the practice decided we should all do some workshops on this, figure out a little more and get more comfortable with it. We attended Sprig, which used to be called EZ-Pedo, so an EZ-Pedo workshop, and a NuSmile workshop at the AAPD that year in Seattle. I felt a little more comfortable after the workshops and at least knew sort of the prep technique, but it still seemed like a jump to go from that to incorporating it into the practice.
I did a couple more after that in Denver, and then in 2016 my husband got a job in Dallas, so we moved and I worked for another pediatric practice there. They also had a NuSmile kit, so I’d use them infrequently, but again, we never advertised them and I never really gave parents the choice. It was something I would do if it happened to be on my schedule, and it wasn’t something I felt super comfortable and confident doing at that time.
But by the time I decided to go back to residency, I noticed that parents were starting to request them and ask for them. So when I went back to residency, that was something I really wanted to focus on and get faster and better with. When I went to residency in Alaska, I made that clear: this is something I want to do. I want to be proficient. I want to do the white crowns as fast as I can do the silver crowns. I felt grateful that the faculty there let me run with it and practice these really often. A lot of residency programs I love, the faculty don’t really have training in zirconia crowns, and we only had one or two faculty members who had done any posterior zirconias. So I felt really grateful that they let me try, figure it out, practice and do it.
I got to do one of the first full-mouth zirconia cases there. Not all 20 teeth, but it was 12 or 14 teeth on a kid with a nickel allergy in the operating room. We used Kinder Krowns when I was in residency. I actually really liked the Kinder Krown anterior teeth, but as you can see in these pictures, the posteriors had a lot of occlusal anatomy, and I felt they were a little bulky and harder to work with. But I got some practice with a different brand with Kinder Krowns in residency, and I got to do a lot of anterior and posterior zirconias.
[00:18:16] Choosing a crown company
When I was finishing up in 2020, this was definitely something I felt comfortable starting to offer in my practice, and I wanted to start talking to crown companies to see who I wanted to use at Kids Tooth Team. I reached out to a few companies. One was NuSmile, because they were familiar; they’re a well-known company and I had used their product in the past. I’d never actually used their anterior; the offices I worked at only had their posterior zirconias. I felt like my assistants would always lose the pink try-in crown, and I didn’t like having to do the try-in crown every single time. But I was open to talking to them and learning more about what options they had for me.
I reached out to Kinder Krowns again because we had used them in residency, so they were familiar to me. I think the price point was a little less than some of the other companies, so that was a bonus. And like I said, I did like their anterior; they have a shorter anterior version that I thought looked nice on a lot of kiddos.
Then I reached out to Sprig because, as far as I knew, they were the only company that had space-loss crowns. I’d heard really good things about that, and I remembered them being nice at the workshop, so I thought they’d be a good company to reach out to and talk to as well.
The first company I mentioned did not respond to me for months. I emailed them and never got a response, so that was that. The second company responded within a couple of days. They offered me a resident discount, but nothing above and beyond that made it seem like this was definitely the company I wanted to go with. Sprig, on the other hand, responded within 24 hours. They asked to set up a video call with me. They sent me some sample crowns ahead of the call so I could compare the Sprig crowns to other crowns I’d worked with in the past and actually see and feel them. Because I’d told them I liked the Kinder Krown anterior, on the video call they showed me what that looked like next to theirs, which is actually the same length, and showed me with a little microscope and video how they compared and how they differed. They gave me the owner of the company’s cell phone number and said if you have any trouble with any of your crowns or any of your cases, please call; we’re happy to help. And they offered to help create a promo video for my website that we could put on there to help advertise this.
All that is to say, I had never actually placed a Sprig crown on an actual human before I went with their company and invested in an anterior and a posterior kit. But what I’ve learned, if anything, being a business owner, is that companies with customer service like this, that go above and beyond, are the ones that are going to take care of you when you need help or something doesn’t go right. So I’m super happy that we went with Sprig, and they’ve been nothing but wonderful to us and our office. That’s my experience of how I got to where I am.
[00:21:02] Website, results and healing
Like I said, Sprig made a really cute video for us. Shout out to Wonderist Agency, who does our website and has done our social media for a long time too. If you’re looking for website work, a brand renovation or social media help, they’re another incredible company we work with. We asked them to build out a whole page on our website about crowns, where we talk about zirconia crowns and why a child might need a crown. I think this is a great tool. If you don’t already have a spot on your website to talk about zirconias and crowns, parents have questions and look these things up, so this is a great tool to use. Sprig can make you a little video too. It has all these cute kids with their pretty white crowns, and then they put your logo and office information at the end of the video.
That was back in 2020, and I’ve exclusively been using Sprig since then. I’ve placed over 500 Sprig crowns, which has been in excess of $200,000 worth of revenue in our practice that we wouldn’t otherwise have had if we hadn’t been offering these crowns. I’ve done lots of full-mouth cases, not all 20 teeth, but 12-plus teeth cases, and I routinely place six to eight at a time. It’s gotten to the point where this is something I do, if not every day, absolutely every single week that we’re doing big cases.
These are a couple of kiddos I’ve seen since I started making the webinar, who came in and I could take some pictures of. You can see the posterior looks so beautiful. I really feel like the gum tissue heals so nicely around these zirconias, and if you come to one of our Sprig Universities we’ll go into more detail about why that is. The color is really nice, a beautiful shade match, and parents are really happy with these. This other kiddo got seven of his eight back teeth done; I didn’t do one of them, and it’s hard to tell which ones are crowns. Again, they healed really nicely. When I first got started, I used to have all of them come in for a two-week check just to make sure they were okay, but they all healed so nicely and I had so few issues that now I just see them for the six-month checkup afterwards.
[00:23:00] My philosophy of care
I wanted to share my philosophy of care: who I’m picking for these cases and why I’m recommending zirconias over something else. In general, if a child is going to be asleep in our office under GA or IV sedation, I only place crowns on those baby teeth. Even if it’s just an occlusal, and absolutely for class IIs: if they’re going to be asleep for treatment, we’re only placing the longest-lasting, best materials for these kids. I feel like the worst thing that could happen is a filling pops out, or a kid gets another interproximal lesion on the other side of the tooth you didn’t treat six months later, and then they’re having to go through this whole process again. So if they have any cavity on a tooth and they’re going to be asleep, we’re placing a crown.
The reality is these kids… A kid we saw a couple of weeks ago had a GP place a bunch of fillings, and they’re all breaking, falling out and getting abscesses around them. I don’t want a kid to have to undergo anesthesia again and go through this process again. So that’s our philosophy of care at Kids Tooth Team. When you explain it to a parent that way, “I only want your child to be asleep once; let’s do it the right way the first time, with things that last the longest,” parents have really little pushback about it.
So it’s about developing your scripts and your philosophy and being able to stick to that when you’re talking to parents, and not letting them dictate what they want you to do just because the filling maybe sounds less aggressive or they know more about what a filling is. It’s really educating them on why a full-coverage restoration, especially when they’re going to be asleep, is going to be the best option for them.
This is another kiddo, from a pediatric dentist in town who, and I quote, “does not do crowns on molars.” I think they don’t do crowns because they have a higher-end practice where parents don’t accept silver as an option, and I don’t think they offer white crowns. So instead of offering crowns, which would be a better long-term option, they’re placing these enormous fillings that are breaking, falling out and getting cavities around them. To me, it’s a lot more aggressive to have to touch a tooth multiple times, have a kid come back for treatment and retreatment, or take the tooth out for something that failed. My philosophy is: I want to do it right, and I want to do it right the first time. I don’t want your child to ever have to go through this again and continue to get treatment on that tooth. So crowns are the better option, in my opinion, especially for those high-risk kids.
Regardless of the sedation modality, if a tooth has an MOD, or if there’s an MO on a first molar, I’m putting a crown on, and it’s the only option I give parents. This is another kid from a great dentist in town. All the fillings look great, but these kids are so high caries risk that even if your MO looks great, they’re going to get decay on the other surface of that tooth. I feel like those MOs on first molars are just hard to get great contacts on, it’s easier to get recurrent decay on those, and they’re always so close to that mesiobuccal pulp horn. I feel like those have a higher failure rate. So for any MODs on primary teeth and any MOs on first molars, the only option I’m giving a parent is a crown.
I do still offer strip crowns. In Texas, Medicaid does not pay for zirconia crowns, so if I feel it’s an appropriate choice, there are Medicaid patients I’ll agree to do a strip crown for. I’ve done a zillion of those, and I feel like they work well in my hands too. But if the caries is into the pulp and we need to do a pulpectomy, I don’t offer strip crowns; I only offer zirconia. If the gums are inflamed and I know they’re going to be bleeding a ton and I’m not going to be able to do a good strip crown, I only offer zirconia. Typically, for our PPO or cash-paying patients, I’m really only offering zirconia for those front teeth, because I feel it’s a better treatment option and it’s going to last longer. But in general, any option I give a PPO or cash-paying patient is also an option I give our Medicaid patients. In our practice, it doesn’t matter what insurance you have; you’re getting the same options and an explanation of why this is a better choice for your kiddo.
So I’ll offer both in certain situations. But even for zirconias, I do crossbite corrections with my zirconia crowns. It’s not like you have to do a strip crown if you have an edge-to-edge or a crossbite. Those are some of the more advanced cases we can talk about in the Sprig Universities, but you don’t have to do strip crowns in a lot of those situations.
The reality in my practice is that for any kiddo who needs a crown, we’re now offering a white versus a silver crown option. It’s a really nice point to get to, because I no longer feel like I have to compromise by placing big fillings that are going to fail, or tell them silver is the only choice. In pretty much any situation, I’m going to offer them white or silver. Of course, if we need a Hall crown and we’re doing something a kid is not going to tolerate, there are still lots of times I potentially offer just silver. But in most instances, especially during anesthesia appointments, families are getting both choices.
[00:28:02] Showing parents what they’re choosing
This is a picture we have in our consent forms, so when a parent is consenting to a silver crown, they know the difference: this is what silver looks like right next to a white crown. I really want parents to be aware of what these are going to look like, so I’ve created a lot of forms and tools in our office for parent education and team education. I created this one for our assistants to have in the back when we’re treatment planning these cases.
We hear parents all the time say, “Oh, it’s just a back tooth, you’re not going to see it.” But the reality is you’re going to see those first molars when your kiddo is smiling, and you’re going to see the lower second molars when they open really big. If it is a cosmetic concern, I want parents to be aware: yes, it’s a back tooth, but in this particular area, and obviously for the canines, you’re going to see this silver. If silver’s okay with you and that’s the choice you want, that’s fine, but I want you to be aware of that before you consent and move forward with treatment. We show this to all parents when we’re talking about options, so they know what their choices are. It’s been really helpful for our team to articulate this better, and for parents to be aware of what it’s going to look like.
I know this seems like a lot, but I made this for our treatment coordinator, because she’s not a dental assistant, and it’s hard to keep track of all these teeth when a parent wants to know exactly which tooth you’re doing the white crown on and how old they’ll be when they lose it. So I made this for her so she could say, “Okay, for tooth C, this is what it’s going to look like in silver versus white. They’re going to have this tooth until they’re 11, and yes, it’s going to be visible.” Creating things like this for your practice is super helpful for your team so they can speak to parents about it. A lot of times we present our plan and walk away, and parents still have questions, so little things like this go a long way.
The other thing we always hear is, “They’re baby teeth, they’re going to fall out.” The reality is that some of them might not fall out until they’re 12, and they’re going to have them for eight more years. So articulating those points to parents when you’re presenting options is really important. I don’t think they know they’re going to have them for a long time, or how visible they’re going to be when they smile.
[00:30:20] Other options I still offer
Like I said, I do lots of zirconias, but I still offer lots of other options. We’re not a huge SDF practice. I typically don’t do GA until kiddos’ second molars are fully erupted, so if their second molars aren’t fully erupted, I usually do SDF on the teeth while we’re waiting, just buying ourselves a bit of time. I still do Hall crowns: if a kiddo has one interproximal lesion and would otherwise potentially need sedation, that’s an option for all kids. I still do tons of SSCs; we accept Medicaid in our practice, so SSCs are an everyday thing here as well. Like I said, strip crowns in the right situations. And I do class IIs every single day too. I feel like composites are still an appropriate choice in certain situations. But again, I’m not compromising on huge MODs, or huge class IIs where you need a pulp cap. Composites are really for kids who are lower caries risk and just have a couple of lesions.
[00:31:12] Administrative processes: philosophy, scripts and financials
As for administrative processes, I’ve shown you some of the pictures we use in our office and the ways I present. I think one of the most important things you can do is develop your own very clear philosophy of care about when you would recommend these, and really stick to it. Parents hear you say something, but if you then ask them what they want to do, sometimes they just won’t accept your recommendations, or they’ll ask why you can’t do fillings instead of crowns. Being able to say, “This is our philosophy of care. I don’t place fillings on a child who’s asleep for treatment, for this reason,” matters. If you’re clear and articulate about why that’s your philosophy of care, I find parents give really little pushback, because I have an explanation that makes sense, and they also want the longest-lasting, best thing for their child. They also want things that aren’t going to fall out or need treatment again in the future.
So develop your philosophy of care, explain it to your team and to your parents, and then really stick to it. I don’t make exceptions. If a parent says, “Well, I only want you to place fillings,” I say, “I really respect your choices as a parent, but we might not be the right practice for you, and I definitely recommend getting a second opinion, because I’m not going to compromise and place big fillings on teeth when a kiddo’s asleep.” Stick to that and have a reason for it. I think that’s the most important administrative process: getting your team on board and having your patients understand why you’re recommending these.
Again, create some parent and team education tools. Photos are the best way to do that. Sprig has a great resource section with marketing materials, and I’ve got a QR code at the end for where the resources are, so definitely check those out. And again, photos in your consent forms: anything you can show parents about what these look like is going to go a long way.
Once you have your philosophy of care and these tools in place, teach your team how to explain these to families and what your scripts are. My team says, “We’re one of the only offices in Austin that does these white crowns, and it’s something we’re really proud of. This is a really beautiful option for your child’s smile.” I think it’s really powerful to say “Dr. Alex recommends” or “I recommend this treatment.” Even as a patient, if a doctor says they recommend something, I don’t like going against my doctor’s recommendations. So say, “I recommend this. This is a beautiful, cosmetic option for your child’s teeth,” and make it clear they’re going to have these teeth for X number of years. None of this is pushy. It’s explaining to a parent the reality of how it’s going to look and how long they’re going to have it, and then giving them the options to make the decision themselves.
Then create a way to easily present the financials to your patients. For a while we were doing all-silver plans, all-white plans, half and half, just one tooth, and we really had to fine-tune how we present these options. If you overwhelm a family with too many treatment plans and too many options, they get paralyzed and don’t pick any of them. So make that financial presentation as concise and easy for them as possible. I’ve created explosion codes in our system. We use CareStack, another company we love, as our practice management software. I highly recommend them if you’re looking for a cloud-based platform. They make explosion codes super easy, and they make it really easy to create multiple plans very quickly for the financial presentation. Training the people on your team to do this, so it doesn’t feel like a clunky process, is really important and goes a long way.
[00:35:01] The prep: occlusal reduction and the racetrack
On to the prep technique. A lot of you said in the survey that this was the main thing you wanted to learn about. I picked a case I did a couple of weeks ago with a posterior and an anterior prep, so we could go through them at the same time. Again, if you have a chance to attend a Sprig University, we’ll go into more detail on each of these.
The first thing you start with is the donut or wheel bur, for the occlusal reduction. You go the full thickness of this stone bur, which is about a millimeter and a half. If you’re starting with one tooth at a time, use the adjacent tooth’s marginal ridge for reference and plow down the whole top of the tooth. You don’t need to put in any occlusal anatomy; make it a flat, full millimeter-and-a-half reduction. For posterior and anterior teeth, you’re taking off the full thickness of the bur.
Then we do something called a racetrack, which is basically a chamfer margin. This is not a prep your pros faculty is going to look at that has to be perfect. The racetrack is really a depth cut so you understand how much you need to reduce circumferentially around the tooth. You take the thicker diamond bur (I’ll show you the bur kit in a little bit; it’s a thick diamond bur), go all the way circumferentially around the tooth and create a visual similar to a racetrack. That racetrack margin ends up being about 0.8 millimeters wide. For this part, you’re staying above the gum line and creating a racetrack that goes all the way around, for anterior and for posterior.
For the anterior, as you’re creating the racetrack or chamfer margin, you’re also trying to create a thin incisal edge by tapering the incisal half lingually. So as you start the racetrack on the anterior teeth, you also start taking a little off the incisal half, because the final prep needs a thinner incisal edge. Once you do this, the racetrack should be visible. It’s hard to get an angle of all three teeth at the same time, but if you’re looking down on it occlusally, you should be able to see the racetrack all the way around the entire prep.
The most important part of creating the racetrack is keeping your bur upright. One of the more common mistakes is that people start tapering their bur, and that’s when you create ledges around the tooth. Those ledges can crack the crowns and lead to failure; that little red triangle there is what we’re trying to avoid. Keeping the bur upright is probably the most common thing I see people not doing correctly when we’re teaching. So keep it upright and do the racetrack around. Again, this is not an adult crown prep technique, and pros faculty is not going to look at it. It should take about a minute per tooth or less to get the racetrack done.
[00:38:02] Subgingival reduction and finishing
Once you’ve done the racetrack, you do your subgingival reduction with the thinner diamond bur. You go a full two millimeters subgingivally, which is more than you’d think you need to go. Drop that bur down two millimeters. What I tell my students is: you’re going to erase the racetrack. You go around exactly where that depth cut was and erase the whole area where the racetrack was with the bur. Again, keep the bur upright; you don’t want to taper it. Hug the bur around the root surface of the tooth and go around and around, what we call Ring Around the Rosie. Some instructors say do it five times. I feel like it’s probably at least 10 or 15 times per tooth to get everything nice and smooth, completely erase where the racetrack was, and go deep enough subgingivally.
After you’ve done the subgingival reduction and erased the racetrack all the way around, I get the diamond football bur out to reduce the cingulum on the anterior. You’re getting that bulky bit out of there, about a millimeter of reduction on the anterior cingulum. I also use the football diamond bur to make all the edges and corners nice and smooth, so there are no sharp edges on any of my posteriors. Again, you don’t need to put in occlusal anatomy or make this like you would a grown-up crown. It’s really a rough prep.
[00:39:42] The bur kit, the ledge check and try-in
I bought all these burs individually, and it took me about six months to figure out which ones I wanted and which actually worked well in my hands. Instead of doing that, I recommend getting the EZ-Prep bur kit. Sprig makes a bur block that has all of these in it already, so save yourself the hassle and get the bur kit. Those are the basic burs you’d use for the prep.
Once your subgingival reduction is done, everything’s nice and smooth and all the angles are rounded, I go back in with my explorer subgingivally and feel up and down the tooth, checking for any ledges. Those ledges are one of the most common causes of failure. As you can see in the illustration on the right, if you have those little ledges where the red marks are and you try to put the crown on, that’s what’s going to crack it and create issues. So check for ledges, and if everything looks good and you’re not feeling any ledges anywhere, go ahead and try on the crowns. You can see in this prep there’s a lot of space between each of the teeth; you’re reducing a significant amount circumferentially to get the space.
When you’re ready, try the crowns on with really light finger pressure. In theory, they should be the same crown size you’d use for an SSC. When I first started, I’d end up picking a slightly bigger crown size than I would for SSCs. That was before I was doing the Sprig prep technique and the racetrack. Now that I’m doing the technique this way, my crown sizes tend to be more similar to my SSC sizes. So I’d recommend going through this process every time, because it makes the sizes you’re going to get easier and more predictable.
When you’re trying it on, use light finger pressure. Never use a bite stick, and don’t use the end of your mirror. You can crack these if you push too hard, especially if you happen to have a little ledge. These have to fit passively. We’re used to SSCs snapping on; these should not snap on. It should be a very passive fit. If you feel like you’ve got the right size and it looks good everywhere, but you’re meeting a little resistance, we recommend doing the Ring Around the Rosie: go around circumferentially another five times and try it again. Still feel a little resistance? Do it again, five more times.
It’s really the circumferential reduction that I feel most people aren’t doing enough of. Doctors assume it’s the occlusal and keep reducing occlusally, and that’s when you get into the pulp and have issues. Typically they just need a bit more circumferential reduction. If you’re doing the Ring Around the Rosie and your bur gets caught on something because that area isn’t smooth, go back to that area, smooth it out, and go around circumferentially again before you try the crown on.
[00:42:31] Hemostasis
Once you’ve got the crown size you want and it’s still nice and passive, you’re ready to start seating the crowns. Take a second to make sure heme is well controlled. These don’t need to be bone dry like a strip crown, but you don’t want a lot of heme gushing as you’re trying to put the crowns on. In my practice, and we’ll talk about this more in a second, I usually do two crowns at a time when I’m cementing. I take a cotton roll and the end of my mirror, make a little well in the cotton roll, get it a tiny bit wet, and place it directly on top of the two teeth I’m working on. That little well gets into the gingiva, puts a little pressure there and cleans the top of the tooth too. I hold it there while my assistant is filling the crowns with cement, and as soon as she’s ready, I take the cotton roll off and put the crowns on. Other instructors hold 2x2s and put some pressure there.
You can use Heme RX pellets that have epinephrine in them, so if there’s a little spot that’s still bleeding, you can put a pellet in there to help control hemostasis. The instructions say no more than four per patient encounter, so if you’re doing a full mouth, you can’t use a lot of these, but it’s a really great tool if there’s a little spot that won’t stop bleeding. Some of the other Sprig instructors also use these for pulpotomies, which is pretty cool, so that’s an option too. If you’re going to use ViscoStat, I recommend the clear instead of the orange, because I feel the orange can stain a little. And if my cotton roll trick isn’t working, I usually take some lidocaine with epi, go into the PDL and achieve hemostasis with that.
[00:44:11] Cementing and cleanup
Once you’ve controlled the heme and you’ve got your crowns, you’re ready to cement. I use FujiCEM Evolve for my crowns. Everything in my practice is automix. Now that we have almost three offices, we have a lot of assistants, and I train assistants right out of dental assisting school. For me and my brainpower, it’s easier if everything is automix, so everything is reliable and consistent. A lot of instructors use Ketac Cem, which you mix together from powder and liquid. The point is you can use any resin-modified glass ionomer or glass ionomer you like. I personally like being able to hear the click and know it’s automix.
Either way, fill the crown almost all the way full. You don’t want it underfilled, because that can create a problem. You want there to be excess when you’re seating the crown. I know it’s hard to see that, like ten dollars of cement right there squeezing out, but you really want all that extra cement to get into the gum tissue, push out any excess heme and seat the crown. Once you’ve seated it, a common mistake is accidentally lifting it up again or moving it too much, and heme can get under there, which can definitely create a problem. So don’t lift it up after you’ve seated it.
Like I mentioned, I only do two at a time, because I’ve found that when I try to do more than that, I get heme under there and they don’t seat very well. Especially when you’re first getting started, do two at a time, again with light finger pressure. We don’t recommend air-water blasting these like we do for stainless steel crowns. I usually have a toothbrush with me, either with water or, if it’s an anesthesia case, a little cup of chlorhexidine, and I brush the crown after seating it to get the excess cement off, and use a 2×2 for anything else. Similar to an SSC, I take floss down and pull it out the side, or my assistant holds it. Then my assistant cures the facial, the lingual and the occlusal for about 10 seconds each.
After everything’s done curing, I take an explorer and push it interproximally to get any excess cement out of there. I’m pretty aggressive with floss afterward. I put some knots in it and floss up and down, because if this crown is going to pop off, I’d much rather it pop off while the kiddo is still in my chair than after they get home. Typically, if a crown comes off when I’m flossing after I’ve cemented it, it’s because I picked a crown that was too big and it’s not seating very well. That’s my cue to try the smaller size: re-prep it a little bit and go to the next size down.
Make sure everything’s nice and clean; I usually use the toothbrush again and 2x2s really well. Even if it looks great and you think everything’s awesome, when you first get started I definitely recommend taking a post-op x-ray. I’ve done lots of these, and on a case a couple of weeks ago I thought, okay, let’s take a post-op just to make sure, and there was a bunch of cement in between these areas. So especially when you’re doing multiple at a time, take a post-op x-ray and make sure there’s no cement left over.
And they look beautiful. When you first place them, they look a little white, mostly because the gum tissue is irritated. But when you see them again at the two-week or six-month checkup, they look like a really beautiful natural tooth.
[00:47:32] Why the crown design shapes the prep
I wanted to share a couple of things about why Sprig is a little different, and why our preps are the way they are because of how the crowns are made. We have a flatter occlusal design for our crowns, which I like. Some of the other ones I’ve worked with had a ton of bulky occlusal anatomy, which made it really hard to get the bite right for kiddos and to get them to fit really well. Having that flat design makes it a lot easier to get these crowns to fit, in my opinion.
We’re the only company that has a space-loss version, and that’s super helpful when you’re placing multiple crowns back to back. When I’m placing two posteriors and a canine, I almost always have to use at least one space-loss crown just to get them all to fit together. All of our posteriors and all of our canines come in a space-loss option, which is really nice. Then we have the locking retention internal grooves, which is why we can use resin-modified glass ionomer and GI cement, and that really helps retain these well. And they have a really beautiful finish as well.
I wanted to show a couple of different angles of what the prep should look like. They took an impression of the internal surface of the crown, so you can see how important it is not to taper and to keep that bur upright. Again, you don’t need to put in occlusal anatomy; it can be a flatter finish. Same with the anterior: you can see the thin incisal edge that’s required to get those crowns to fit the right way.
Another instructor presented this at the last Sprig University I was at, and I thought it was an interesting comparison. Most of the Sprig instructors use Ketac Cem, and that really does make it a more cost-effective option. I just can’t bring myself to make my assistants mix things on top of all the other things they’re doing, so I’ll probably still use automix for a while. But if you’re really looking to cut costs, they have great success with Ketac and a really high success rate. So there are definitely options that can bring your cost per crown down if you use different cements.
[00:49:52] The most common failures
What are the most common failures we see when I’m teaching these, or out in practice? There are definitely some people who aren’t reducing enough occlusally, but of the two, I feel it’s typically inadequate axial reduction: not reducing enough circumferentially all the way around the tooth. If you’re not getting a crown to fit, like I said, do the Ring Around the Rosie at least five more times. It’s really the axial reduction that I feel doctors aren’t doing enough of. Sometimes we see an over-tapered prep, or areas where you’re creating ledges, which can be a problem when you’re trying to seat the crown. If it cracks, that means you definitely have a ledge there.
I also feel the subgingival prep not going far enough subgingivally, that full two millimeters, is one of the more common mistakes I’m seeing. Especially in areas we don’t see as well, like the distolingual corners. So if you feel like it’s getting hung up and the crown isn’t seating exactly how you’d like, going back to that distolingual corner and making sure it looks good is usually where I recommend starting.
Like I said, sometimes we’re picking crowns that are too large. I realize that’s my mistake when I’m flossing and the crown pops off. Hemostasis can also be an issue. I’ll show you a couple of my failures, and achieving great hemostasis has been an issue a handful of times. Minimizing how many crowns you’re doing at once is really important there.
All that said, in my experience using Sprig over the last two and a half years, I haven’t had a single pulp exposure where I didn’t already intend to pulp that tooth based on caries into the pulp. I really feel that’s a myth about zirconia crowns: that you’re going to have to pulp all these teeth because you reduce so much you get into the pulp. I think that was an issue with earlier versions of zirconia crowns, but in my experience the new designs, especially Sprig’s, have really minimized this. I haven’t had any pulp exposures on my crown preps, and I haven’t had any with clinical or radiographic pulp failures. If I know the tooth needs a pulp, I’m doing the pulp, and we’ll talk about pulps in a bit. Being really picky about your pulps and making sure you do them well is a huge clinical pearl and an important part of the process.
I did have a handful I couldn’t get to fit. Honestly, they’re usually on special needs kiddos. I’ve had some cleft palate kiddos in my office where the tooth was really rotated or angled, and I could not quite get the crown to fit. But other than that, I’ve placed hundreds back to back with success and had a really good experience with them in my office.
[00:52:24] My failures, and what they taught me
That said, it’s not helpful to tell you all the things that go right. It’s a lot more helpful to tell you the mistakes I’ve made and the issues I’ve had. I always feel I learn more when presenters share the things that didn’t go as well. So I wanted to share some of my failures, so hopefully you can learn from them and not make the same mistakes.
This was a kid I did all eight back molars on, zirconias under GA. He got home about two hours later, and Mom called: his tooth cracked in half and the crown fell off. Your stomach sinks and you feel awful. They came back in, and I took a look and realized I just hadn’t reduced enough circumferentially. There was definitely a local area that was too bulky, and I had a ledge. We had only just opened, and I could only afford to have one of each crown size, so I didn’t have another crown in that size. I told Mom I could put a silver on, and as soon as I got the white one in, she could come back and I’d replace it; or if she was okay with silver, no charge, we’d reimburse her and put the silver one on. Luckily his tooth was okay, and she was fine with the silver. So I put the silver one on, and he came back for his six-month checkup and had totally worn through the silver crown. So I think it was insufficient reduction here, and he also could just be putting a lot of pressure on that one specific tooth.
I had one come in a month later where the canine crown had partially fractured. The facial was still intact, but the lingual had fractured off. I didn’t get an intraoral photo of this kiddo, but I realized there was a subgingival ledge on that tooth, and I hadn’t reduced the cingulum enough, so there wasn’t the thinner incisal edge you really need on anterior teeth. Luckily she let me take that off and get the cement off. I adjusted the prep a tiny bit and got a new one on there.
This kid and the next one are the same kiddo, who had two issues with her teeth. She came back a couple of weeks after GA, and Mom said one of her teeth looked a little gray, but the crown was still intact. I hadn’t had this happen before; I’d never had a comeback, and they’d all looked great. I was thinking in my head, is this a pulp issue showing through, is there some pulp necrosis? So we took an x-ray, and no, the pulp looked good. I realized what probably happened was that some heme got mixed in with the cement when I was cementing. On this particular kid, I remember I seated D through G all at the same time, so the heme must not have been well controlled. Unfortunately some of it got mixed in with her cement and gave the tooth a gray appearance. This was about a three-year-old, so I told Mom that as soon as she could tolerate it, I’d take this off and replace it at no charge, and Mom was happy with that.
Then she came in about two weeks later, and one had come off. It’s like, gosh, why couldn’t the gray one have come off so I could just replace it for her? But this one had come off with the cement still on the tooth; the crown had dislodged. Again, I knew I had cemented too many at once. But typically when these crowns come off, it’s a failure of the tooth to the cement, not the cement to the crown. Because the cement was still all the way on the tooth, it made me realize my assistants probably did not clean the inside of that crown as well as we should have. So it’s really important that your assistants clean the internal surfaces of your crowns really well.
One of the things I love about Sprig is that you don’t have to do a try-in crown. The crown you try in is the exact crown you’re going to cement. You just have to air-water rinse it to get all the blood and debris out of there and air dry it before you put the cement in. You don’t need to sandblast it or anything, but it does have to be really dry. Because this failure was a little weird, I realized the internal surfaces of all four of those crowns probably weren’t great, and we weren’t controlling heme as well as we should have.
But that’s it: four out of over 500 crowns are really the failures and issues I’ve had. I really try to document those, because that’s how I learn, and I don’t want to make the same mistakes twice. I feel like my failure rate for zirconias is less than it even is for SSCs; I feel like I have more kids who have SSC issues. So I feel great that I’m comfortable with these, and I keep growing and learning from them. Hopefully you can take a couple of tips from that and not make the same mistakes.
[00:57:02] Be picky about your pulps
I’ve been talking about some of my pros and things we’re doing throughout, but I want to take a second to talk about pulps. My friends who do these send me pictures and say, “Hey, look at this x-ray, why is my zirconia failing?” And typically it’s not the zirconia that’s failing; it’s the pulp or nerve treatment that’s failing. So I’m super picky with pulps in our offices. I want these to be perfect.
Indirect pulp caps: studies show these are a great tool for primary teeth. If you’re using a glass ionomer or resin-modified glass ionomer cement, it’s acting as an indirect pulp cap medicament. By the time I’m done prepping my crown, the caries excavation is usually almost completed, because you’re taking enough away that there typically isn’t a lot of caries left. I take out any mushy bits still in there with a spoon or a round bur, and I feel comfortable leaving a little affected dentin. As long as there’s a clear band of dentin between where the pulp is and where the caries is, it’s okay to leave that affected dentin and then use a resin-modified glass ionomer or GI cement when placing the crowns, which acts as an indirect pulp cap. I think the days of scooping out every last bit of decay are gone, and we can use indirect pulp caps to our advantage. We have fewer pulp exposures and fewer issues with pulps because of them.
I’m super picky about pulpotomies. I used formocresol for years and years. I don’t anymore; I just use MTA now. I do my pulpotomy procedure, take a cotton pellet with sterile water and put pressure on the pulp chamber. I let it sit there with pressure for about two or three minutes while I’m doing other stuff somewhere else. If I can’t control hemostasis in that timeframe, I either move on to a pulpectomy or I take the tooth out. I feel like some of the medicaments, like formocresol and ferric sulfate, can mask the true status of the pulp if we’re not careful about our pulps. I’ve found that achieving hemostasis with cotton pellet pressure and then placing a layer of MTA over it has been a really successful way for me to do pulpotomies. In the last couple of years, I’ve only had one or two fail.
I use NeoPutty MTA, because again, everything that can be automix in my office is. Sprig does have a Smart MTA that’s great and a lot more cost-effective; it comes in little capsules you can get multiple uses out of. So Sprig has a great MTA as well.
Like I said, we do a lot of pulpectomies in my practice. In Alaska, that was actually the only kind of nerve treatment we did in residency, which is kind of unique. The program had been doing pulpotomies a lot, sending these kids back to their villages, and realizing they were having failures: abscesses and more issues with the pulpotomies. So the program theorized, what if we do pulpectomies instead? Once they started exclusively doing pulpectomies, there was a lot lower failure rate, or fewer catastrophic failures like abscesses and big issues. The whole two years I was in residency, I think I maybe did one pulpotomy; every other nerve treatment was a pulpectomy. So all of us who went there got really fast at these, and it’s a really nice service to be able to offer our patients.
I feel a lot more comfortable moving on to a pulpectomy if I can’t get hemostasis with the pulpotomy, and I typically now do them for A, J, K and T. I only do pulpectomies for anteriors; I don’t do any pulpotomies there. If I can’t get hemostasis on A, J, K or T, I move on to a pulpectomy. If I can’t get hemostasis with the cotton pellet on the first molars, I typically take them out, because those guys are finicky, as we know, with all those little accessory canals, and I feel the success rate isn’t as good. So I tend to take out first molars if a pulpotomy doesn’t work.
That’s pulps. I think it’s really important to be super picky with pulps. These parents are paying a lot of money for these crowns, and if I’m going to do a nerve treatment, I really want to do something I feel is going to last and have a good success rate.
[01:00:56] Non-restorable teeth and sedation
It’s important to know what’s non-restorable. People may disagree with this, but there are teeth with interproximal lesions where, once you get the decay out, it’s all the way down to the bone level. Even though the pulp looks okay, these are really hard to restore. Even with the space-loss version, you’re spending a lot of time, and I don’t feel these are great teeth to restore. So in my practice I tend to take these teeth out instead of trying to restore them. Some of us are heroes and want to spend lots of time on teeth that are really broken down or down to the bone level, but I tend to take these teeth out.
Then there’s setting appropriate expectations with your patients for sedation, whether that’s nitrous or GA. I don’t think it’s wrong to offer parents an advanced level of sedation to accomplish this work. If you’ve given them the choice of silver versus white, they pick the white crown option, and they have eight to ten teeth needing crowns, I think it’s a truly appropriate choice to offer anesthesia. Know your patients and do the best job you can. In our practice, we don’t feel guilty or bad about offering that option to our families, so we can do our best job: nerve treatments that are going to last and restorations that are going to last a long time for those kiddos.
If you have anesthesia options in your office, that’s a great way to start practicing these crowns, because you have a captive audience and you can really take your time and do the job. Anesthesia is a great place to start doing these crowns if you can. But know your patients and what they’re capable of when you’re offering them, to set yourself up for success as you start incorporating these into your practice. And again, one of the most important things you can do is think through your philosophy of care and figure out your scripts for offering these to your patients and families, and start with that.
[01:02:51] Final thoughts and resources
My final two cents, which I’ve mentioned a couple of times: work with companies that share your values and care about you, your patients and your practice. I mentioned a few of the companies we work with. As a business owner, customer service is so important to us on a patient level that it’s natural for us to only work with companies that really care about us and our patients. All three of these companies, as soon as we started the outreach program and before we could even tell them about it, reached out and asked how they could help. Sprig emailed me as soon as they heard about the van and the program: what can we do to help, we want to get involved. Same with CareStack and Wonderist. Wonderist donated our whole outreach website to us, and CareStack donated the outreach program a whole separate office site. I’m really grateful to work with companies that don’t just care about selling me crowns or selling me things, but care about me, my team and my patients. That’s something to think about as you’re picking companies to work with.
Check out Sprig’s doctor resources. You can scan the QR code, which takes you directly there, or go to the website, sprigusa.com/resources. They have more details about the EZ-Crown technique, a whole video library of people actually doing these preps, some marketing resources and other great tools, so definitely check that out.
I’ve mentioned it a couple of times: I really recommend Sprig University if you haven’t been already. I think it’s a great way to get hands-on and feel more comfortable with the Sprig technique, and the instructor-to-student ratio is great. My problem with another company’s workshop was that there was one instructor for about 25 people, and I didn’t feel I got any feedback on my preps. At the Sprig Universities I’ve been to, we had about four students per instructor, so you really get real-time feedback, which is really nice. If you have an opportunity to do that, I think it’s really helpful. There’s also Sprig Live coming up pretty soon in Las Vegas. That’s more of a team-based event with some practice management, but a really cool event if you can go.
Thank you so much. I think I ran a little bit over, but thank you so much for listening. I’m happy to help you in any way I can. There’s my personal email, so please feel free to reach out with any questions or for advice on preps, and I hope I get to meet some of you at a Sprig University in the future. This concludes the main session, but I’m happy to hang around and answer chat questions. I’m going to open up the chat box now and see what we’ve got.
[01:05:21] Q&A: explosion codes, curing, cleaning and pulpectomy instruments
Chat question: What explosion codes do you use?
My explosion code is basically an SSC and a zirconia at the same time. When we’re planning a crown for a tooth, my assistant can click one button in CareStack and it plans both the SSC and the zirconia at the same time, instead of having to click multiple codes. The code for zirconia is D2929; that’s the ADA code you’d use for zirconia crowns.
Chat question: Do you tack cure first, then clean, then do a final cure?
I typically cure it all at the same time: 10 seconds on the buccal, 10 on the lingual and 10 on the occlusal. Then I get in there and clean it really well, do the explorer trick and the floss. Some instructors, if they’re doing the powder-liquid mix, wait until it gets to the gel phase and then seat the crowns, which is basically waiting for the tack cure, and then they move on without going back for a final cure. I don’t typically cure again after that initial cure, and that’s worked well for me. But it definitely couldn’t hurt to tack cure, clean, and cure a bit more. I’d just be a little more careful and not be super aggressive with the floss, like I am, if you’re only tack curing. But I typically cure it all at once and then clean it all up.
Chat question: Do you clean the tooth before cementing?
Yes. In addition to making sure hemostasis is achieved, like I said, I typically have a toothbrush handy with a little chlorhexidine, and I clean the tooth with chlorhexidine and air and water to get it nice and clean. Obviously you don’t want a lot of heme on the tooth itself or debris. It’s important to clean both the tooth and the crown before you cement it. You don’t want any blood or heme in the crown itself. Making sure there’s no blood in there is super important, so you don’t get gray teeth like the one I showed you.
Chat question: For your pulpectomies, do you use a barbed broach or files?
For posteriors, sometimes I’ll use a little barbed broach, and then I go to files. For anteriors, I typically always start with a broach to get as much out of there as I can, and then go on to files. Some of the broaches don’t fit as well in the little posterior canals, so for those I’ll typically go straight to files.
[01:08:02] Q&A: fees, rinsing and flared anterior crowns
Chat question: How much do you charge for the crowns?
I think we have $480 as our UCR for the crowns, and then we offer a 15% or 20% discount if insurance doesn’t cover it. Unfortunately, we don’t have a lot of insurances in Texas, or at least in our practice, that cover white crowns. So it ends up being about $408 per tooth. That’s something I coach our team on: it’s not up to us to decide whether that’s too expensive for a patient. It’s up to us to give them the choice. Part of our scripting is that it’s actually pretty reasonable and affordable to do these crowns. A grown-up crown is $1,500 to $2,000; these are only $400. If we’re making the decision for our patients that it’s too expensive and not offering it, we’re never going to know whether it’s something they wanted. That’s why, regardless of the insurance they have, we’re offering both to parents. I think that’s important for us to do.
Some insurances cover them a little, but be really careful. We’ve started collecting up front for these, because we’ve had some insurers say they’ll cover it and then they don’t, or they only cover a small part of it. So we typically collect up front and tell parents we’ll file insurance, and if they give us anything back, we’ll reimburse you whatever they give us. In our experience, they haven’t covered as much of these. So be careful to make sure you’re collecting for the services you provide.
Chat question: Do you not rinse the excess cement off after cementation?
I don’t rinse it like you normally would with an SSC, where you blast it with air and water and rinse it all off. We don’t recommend that for zirconia crowns, because too much water gets under the crown. I really think using a wet toothbrush, or gently wiping it off with a wet 2×2, is a lot better, with a lot less chance of breaking the seal where the cement is. Once you’ve cured everything and the cure is finalized, then you can do the air-water rinse and use some water in there. But until you’ve cured everything, I wouldn’t use a lot of excess water.
Chat question: Sometimes anterior teeth are too narrow faciolingually, and the Sprig crowns tend to be pretty flared out in that dimension, so there’s a gap when they’re seated. Do you have suggestions?
If you feel they’re getting flared facially, you’re probably not reducing enough circumferentially, and not reducing enough of the cingulum. If you’re not already doing the true Sprig technique, with the racetrack, going around, reducing the cingulum and getting that thin incisal edge, I’d go back to the basics on that and make sure you’re reducing enough, because there shouldn’t be a huge gap when you’re cementing anterior crowns. Go back through the Sprig resources, look through the technique again, practice, and make sure you’re reducing that plane enough, especially the facial plane, getting that thin incisal edge, and reducing some of the cingulum too.
Awesome. Thank you so much. If there were any questions I missed, please feel free to email me; I’m happy to chat more. Thank you so much for spending the evening with us. You’ll get an email shortly after the webinar with your CE credit. If you have any issues with that, please reach out to the Sprig team; they’re happy to make sure you get your CE credit for the webinar tonight. Thank you so much for coming, and I hope you have a wonderful night. If you’re ever in Austin, please let me know so we can meet up. Thank you.
