Setting Yourself Up for Success with Zirconia Crowns — Transcript
[00:00:10] Introduction and the two themes of the night
Good evening, everyone. My name’s Noah Turk, and I’m really excited to be here with you tonight. I’m gonna try and go from A to Z as far as zirconias go. And I really encourage questions. To be honest, I haven’t done many Zoom or online lectures; usually it’s in person. So I really thrive off of the participation of the crowd. Anything that you’ve got, please send my way and we’ll take a look and see what we can do. If you have questions at any point, we’ll see how it goes. Okay?
So, quick disclaimer: I don’t work for Sprig. I’m just really excited to be here and to share my journey, how I’ve come to this point. I’m a private practice pediatric dentist in and around the Toronto area in Ontario, Canada.
A little bit about what we’re gonna be covering tonight: how I got here, how come we’re here tonight and what we’re gonna be doing, why Sprig specifically for me, reviewing all sorts of different cases and questions, and setting ourselves up for success and not failure. There are two big things I always tell our patients and the doctors that we’re working with: setting ourselves up for success, not failure; and explanations versus excuses. Really important. You’ll be hearing me reference both of those throughout the night, and I think it’s really important to keep that in mind.
[00:01:35] Background: from stainless steel to a first zirconia case
In 2017 I graduated from Nova Southeastern University, from residency in pediatrics, at Joe DiMaggio Children’s Hospital. I came back to Toronto, where my wife and my family are all from, and associated for a little while. In 2019 I had the first opportunity to open my first practice. Fast forward five years, and we are at our fourth practice right now, with, I think, quite a decent-sized team. We’re spread out throughout the Greater Toronto Area; the offices are anywhere from 20 to 60 minutes apart from each other. We’re six pediatric dentists, two different anesthesia groups, a few residents that spend some time with us, and probably a support staff of about 25 to 30, depending on the year.
So, how did I get here? I think this one’s really important. If you guys are like me, a classically trained pediatric dentist, stainless steel crowns have been around for what, 70, 80 years almost. They were the gold, or the silver, standard for many, many years. They’ve been around for as long as we can remember, and they’re super important because they’re strong, they’re comprehensive, they’ve got good coverage, and they keep the strength of the tooth together. In residency we had a lot of that training. I graduated in 2017. I had the opportunity to hear some lectures from some zirconia crown companies and try one or two out in residency, but not many.
During our first office, Keswick Kids Dental, in 2019, I had a dad whose kid needed a whole bunch of crowns, and he was insistent that he did not want stainless steel crowns. He was going on and on about white crowns, and that’s all he wanted. He understood fillings were not gonna work and he needed crowns, but they had to be white. And I wasn’t against white crowns. I just thought, at least at the time, that they were a lot more work for myself, they were more invasive for the child, and they were expensive. I wanted to make sure that we had the right tools, and I didn’t want to do something that I would fail at, right? Setting ourselves up for success.
So I had a couple of conversations with the dad, and I finally said, you know what, I’m gonna go ahead. We’re gonna give it a try. So I’m like, well, what company am I gonna use? We’ll get there in a second. But basically, as you can see, a starter kit runs you three, $4,000, or a professional kit, depending on how many you use. And I said to myself at the time, I have to get anteriors, mandibular and maxillary. I’m gonna be in 10, $12,000 before I even do anything. And it’s just for this one kid. Nobody even asks for these. Why am I gonna be doing these? That’s the long and the short of it, but really there’s no other way to say it: I just got started. I jumped in, I dove into the deep end, I took my best bet with everything, and we just got started.
[00:04:43] Why Sprig crowns
So why did I choose EZCrowns at the time, or Sprig now? I love that they’re hand painted. They’ve got a beautiful natural sheen to them, and they really look, I’d like to say so natural, but they look even better than natural.
One of the really important things to me was that they had this space loss option. We’ll talk a little bit about that after. But for those of you that don’t know about Sprig crowns in particular, they have a mesiodistal squish. So they come a little more square for all those cases that come in with back-to-back crowns and big interproximal cavities, and all of a sudden there’s space loss, and we have to go ahead and upright those teeth and make them look natural. But we can’t actually move roots, right? This isn’t orthodontics. So we have to give some fake space, and that’s what that space loss option does.
I love that the insides of the crowns have these grooves, these lines, that we’ll see a picture of a little later on, that allow for a little better retention. They’re autoclavable, which was really great and convenient: you can give it a spray or rinse and toss it in the autoclave. They’ve got this very flat fit. When you’re doing a classic PFM or porcelain restoration in dental school, or if any of you are general dentists, you have to follow the contour of the occlusal plane. You don’t have to do that here. You just do a flat occlusal reduction, they pop right on top, and they don’t have a lot of surface contact. And there’s no try-in; there are some other crowns that have try-in options.
I like to do things as fast as possible, but with high quality. That carries over to a lot of my other work as well, especially under sedation. We’ll use premixed MTA; I’ll use Tempit, which is an IRM material that comes in a composite gun. Anything that we can accelerate rather than mixing by hand, anything that we can do to accelerate our time and minimize time in the chair for the child, that’s really important to me.
[00:06:37] Strip crowns, and explaining the trade-off to parents
Before I did this, the first couple of years I was doing a lot of strip crowns. There’s a whole bunch of different companies: 3M, Nowak; I was using Nowak. I really loved them because they’re not fused together, so they don’t really fracture when you push too hard. That’s really good. But you can see over here, this is one case that I found. This is a case that came in with caries interproximally all across the anteriors, not to mention the posteriors, but we’re just talking about the front. We trim, we fill either with composite or glass ionomer, and then you get this result over here. Sometimes better, sometimes worse; it just depends. This was a non-sedation option for a young child.
But the problem is they tend to chip, a lot, very quickly. And this picture, I apologize, is not my own. I didn’t really take a lot of photos back in the day when I started, especially with strip crowns, so I found this online. This is what you’ll see with strip crowns: a lot of plaque accumulation, inflamed gingiva, a lot of fractures, staining. And obviously these are not Sprig zirconia crowns, but you’ll see some zirconia crowns that don’t attract plaque. They look a lot healthier with the gums, they’re a lot stronger and they last a lot longer. To me, that was really important: to be able to give my patients an option that wouldn’t be breaking down on the regular.
One of the really important things, as I said earlier, is explanations versus excuses. When I’m talking to parents and explaining why we do what we do and how we do it, we explain: look, strip crowns are sometimes a little less invasive, and we have to do a little less preparation work. Sometimes we don’t need as much sedation, which is really important. But more often than not, they’re gonna break down over time. And if your child is 2, 3, 4 years old, they’re gonna be back in our office a bunch of times. Parents aren’t thrilled that they have to take time off work, and they have to keep paying for things over and over, not to mention the emotional stress of the child going back and forth.
[00:08:37] Audience polls
I think this is a good opportunity for us to pause for just a minute and see who’s in the audience. I have a couple of polls that I’m gonna throw out. Let’s find out who’s here today, and that’ll get us going.
I love that you guys are so engaged. I already see about 50% of you voted. We’re getting there. Amazing. It looks like we’re stuck around 70%. That’s probably because a bunch of you in Canada are watching the Leafs game tonight. First game of the season. Let’s see how that goes. I’m not holding my breath. I think it’s 57, 59 years since we’ve won a Stanley Cup.
So let’s take a look here. I’ll end the poll and share the results so we can take a look together. It looks like most of us have been practicing about three to 10 years, some of us under 20 years. There’s a good bunch of everyone: about five people in the crowd have been practicing more than 20 years. Welcome. That’s awesome. I’d love to hear your feedback and questions throughout. And a nice group have been practicing less than three years as well. Those may or may not be some residents that we know, so that’s exciting.
Let’s keep going. I have another question in the meantime, just about zirconia experience. Let’s see how this varies. […]
Okay, we’re looking good. Perfect. We’re gonna move on. As you can see, it’s a solid group of professionals here. It looks like most people have completed 20 or more, and I guess we’re here tonight to learn a little bit more and see what’s going on. There’s a handful that haven’t done any or have done a few. And one person, I’m not sure if it’s a joke or not: “Stainless steel crowns forever.” Honestly, tried and true, right? And that works for many people. Aesthetics, I feel, really is the major push for so many parents these days, in so many aspects of our lives, but in dentistry in particular.
We’re gonna do one last poll here just to get us started. What part of today’s presentation interests you the most? That way I have an idea of where to focus, and then we’ll keep going. […]
So as you can all see, it looks like we’re basically a 50-50 split. We want to know the steps of preparation, and whether anything that I do differs from the Sprig standard or the basic standard preparation steps; and then the clinical case review. I’ve got a lot of pictures, a lot of X-rays, a lot of things to share with everyone, and we’ll go from there.
[00:11:57] Anterior preparation in four steps
We’re gonna go through anterior preps, then we’re gonna talk about the posterior preps, and then we’ll see what we can do.
Anterior preparations: four major steps. I actually buy my burs from Sprig. I just find it very easy and convenient. If you’re in the States, it’s even more convenient. I’m in Canada, so everything’s more expensive here, and there are shipping delays. In general, I find buying burs from Sprig convenient also because I don’t have to think about which burs I need. I know there are some websites, especially in the States, that may have cheaper options, and that’s okay. You can take a look and compare burs.
The first step is the incisal edge reduction. We’re just gonna drop the incisal edge about one and a half millimeters. I call this the hockey puck, ’cause I’m Canadian, or the donut bur. Basically the thickness of this bur, its depth, allows you to see how much you have to reduce. Sometimes I’m lazy, to be honest, and I just use any diamond bur, like the 002, which I’m gonna show you in a minute. I’ll use the 002, I’ll just turn it sideways, and I’ll slice across. There’s no magic to this. It really is just following the steps and instructions. But once you’ve done a few, you can see what’s flexible and what works in your hand.
The second step is the axial depth cut. For anteriors, for incisors, there are actually two aspects to this, and I have a bunch of clinical pictures that we’re gonna take a look at. The first one is where we create that racetrack. For those of you that are familiar with the Sprig preparations, you’re gonna see some pictures in a minute. Basically you’re going around and around and around; we sing “Ring Around the Rosie” all the way around. You’re creating this nice visible racetrack that you can see when you look down the axial aspect of the tooth. What’s also important: we want to taper the incisal third or incisal half of the facial back across the midline so that our crowns seat nicely. So that’s done in two steps. Step one, you create this racetrack all the way around, which again we’ll see in photos in a moment.
Step number three is the lingual reduction. Sprig outlines that they use this football-shaped diamond bur to remove the cingulum. Sometimes I’ll use the football. Sometimes I’ll use the same 002 bur that I used for step number two. I’ll take the edge of the bur, place it right in my racetrack, taper back gently and remove that cingulum. I listened to a podcast a while ago, and one of the most important aspects of keeping your speed up in all areas of dentistry is: stop putting your handpiece down and stop changing your burs. It is important to have all of these burs, because I use them on the regular. But once you become comfortable, there are certain aspects that you can adjust to your own hand.
The last step: once you’ve created this beautiful racetrack and removed the cingulum, you’re actually gonna remove the entire thing. We are creating a feather-edge margin. This really is a shock, especially to those that have traditionally done PFMs or porcelain crowns or anything like that, because you just took all this time to create this beautiful margin. And the margin is stunning. It’s paragingival or supragingival. You can see everything. There’s minimal bleeding. And all of a sudden you take this feather-edge tapered bur, you stick it one to two millimeters underneath the margin, and you remove that whole racetrack. Again, we’re gonna see pictures of everything.
[00:15:38] Posterior preparation
Let’s run through the posterior prep section, then we’ll talk about some of the tools that I use, and then we’ll get onto pictures, which is awesome.
The posterior preps are very similar, except there’s really no cingulum reduction, right? We’re gonna use the same occlusal depth cut; that’s the equivalent of the incisal edge for the anteriors, just reducing the occlusal. I don’t know how that happened with the balloons. We’re gonna reduce about a millimeter and a half.
The second step is the axial depth cut, which again creates that racetrack all the way around. This is a simplified version, because there’s no caries in this perfect virgin tooth. We’re gonna see pictures after where you have to be flexible in how you create your depth cut, especially if you have space loss or caries. How deep is it? Sometimes it’s even deeper, three millimeters. And if you’re near the pulp, don’t worry. Sometimes it’s more because your caries are there, so you just have to work with every tooth.
Then you do your subgingival reduction, where you feather edge and remove that beautiful racetrack. We’ll take a look with some pictures as well.
[00:16:54] Tools that make life easier, and cementation
Before I go on, I want to remind everybody that there are a few things to make our lives easier. These are some of my personal favorites. There are some brands here; I don’t necessarily endorse any of them one way or the other, but let me talk about what I use, and there are a lot of different options online.
The first thing I have is a MouthWatch camera. These run about two, $300, and they plug in. I have them at every op. They’re good for everyday pictures. Every time a patient walks in the door and sits down, we’re taking pictures and showing parents. You’d be surprised how many parents have not looked in their child’s mouth, even if they’re brushing their teeth every day. They come in and say, “The other dentist said we’ve got two cavities.” That’s great, no problem. I take out the camera, we take a look, and all of a sudden there’s six. And they’re like, “Oh my God, I can see them. How did that get there? That’s terrible.” Recording pictures of everything you do is really important, to be able to show parents, but also from a legal perspective, to make sure that you’re CYA, right?
This other device is called a Smile Line. I actually bought this full price; it cost me almost a thousand dollars. It was a ridiculous purchase, but I use it for other things as well. I attach my phone to it and take pictures. It’s got LED lights on the front; it’s very bright. Almost all of the pictures you’re gonna see were taken with this device. They do have knockoffs on Amazon and eBay for like 50 to a hundred dollars, so I think I’m gonna get one for every practice so I don’t have to keep carrying this around, and I’ll see how those work.
Two other things I use as well. I use a little bit of clear ViscoStat. Not often, but when I do, it’s to slow some of the bleeding I have once I create that axial reduction and feather my racetrack. Sometimes you have a little bit of bleeding that you wanna slow down before you cement, or even afterwards.
For cement, I’m a big fan of resin-modified glass ionomer. I happen to use RelyX, and that just works in my hands, but I know there are a number of different options for cementing crowns, so whatever works for you guys is great. But I definitely stick with a glass ionomer. A resin-modified glass ionomer gives you the opportunity to sometimes do a little bit of a tack cure with your light, so that you’re not holding those crowns for 3, 4, 5, 6 minutes.
Now, I’m a safety person. I prefer to do things right once. So sometimes when I’m holding crowns on, especially if I’m holding six at a time, I won’t just hold them for two, three minutes; I’ll hold them for four or five minutes and make sure everything’s looking good before I let go and relieve that pressure, work on something else, then come back and clean everything up. You wanna make sure not to disturb that for as long as possible.
[00:19:54] Into the cases: “just shy of perfect”
Into the cases. There’s a ton of pictures, a ton of X-rays, all different stuff throughout. Again, feel free to ask questions as I go. Some of my pictures are great, some of them are not so great; I’m just throwing them out there. You’re gonna see some case failures of mine as well. I think it’s really important to recognize that not everything we do is perfect.
A lot of times I’m sitting there at the end of a sedation, before I’m cementing, adjusting each crown and making sure that everything seats nicely. And I say to myself, or my assistant, “I’m not really sure that this is exactly how I wanted it.” And my assistants are like, “They look amazing. Stop.” I remember when I was taking my clinical boards in Florida, the instructors used to say, “You don’t have to be perfect. You have to be just shy of perfect.” I don’t necessarily believe that, especially with zirconia crowns; we want them to look so perfect. But 99% of our patients that come in have cavities throughout their mouth, and when we put these zirconia crowns on, they just look amazing, and the parents are just amazed. So if your mesiodistal angle is canted half a degree, or your distal edge is dropped half a millimeter lower than your mesial edge, don’t freak out. Don’t worry. It’s obviously best to see if we can adjust these things before cementing, but we’ll talk about some other options afterwards.
[00:21:31] Case: crowded laterals and tilted centrals
So this case came in. You can already see with the anteriors that there’s a little bit of crowding on the laterals, just based on the X-ray. We had some interproximal caries reported from another dentist. I didn’t include posterior X-rays in this case because we did stainless steel crowns with the parents, but you can see there was some posterior stuff going on as well.
I take two images. This is with a mirror, just at the anterior. If you look at the bottom, this is the maxillary dentition through the mirror, and you can see it’s very tight; it’s a little crowded. Both laterals were pushed back a little, and there’s some space loss where the centrals actually tilted into each other.
We went ahead and prepared: we did our reduction of the incisal edge, then we did our racetrack. There’ll be other opportunities to see this throughout the night. But you can see that on my initial preparation there was actually no bleeding, which was really great. We just reduced the incisal edge and created this axial racetrack all the way around both teeth. In this situation, the parents just wanted the two anteriors. If you look up here, these preps are not done yet. They’re still a little square; they have to be tapered and adjusted. Once we were at this stage, we removed this beautiful racetrack. By coming underneath the gingiva, you’re gonna see bleeding, because you’re going under the gingiva. You can see from the facials that our gingiva still looks nice and scalloped.
Then you can see this is immediately after cementing both. There’s also a lingual picture to show you that we had to adjust our crowns a little bit, with a little angulation, a little bit of a V taper, just to get them in. But from the facial, I think they look just fine. And I didn’t put my cases in any particular order from greatest to least; they’re all just sprinkled throughout. So again, feel free to ask questions whenever you’d like.
[00:23:37] Case: deep anterior caries, and the myth that zirconias “pulp the teeth”
This is another case. Lots of cases coming up. This patient came to us from another office with lots of caries: interproximally on the maxillary anteriors, mandibular molars, canines. I remember the mom came to us and said the previous doctor wanted to take out the front four teeth. I don’t think this would’ve been a case to recommend that, but you can see that the interproximal, especially the mesial, caries are getting very close to the pulp, right? There’s a very thin line of dentin here, and the same throughout. We don’t know how this lateral’s gonna look.
This was under general anesthesia. There are basically three different ways we can do our zirconias, because most children end up requiring some type of sedation. We do many, many just under laughing gas, with nitrous; some with oral sedation, with midazolam; and many, especially our full-mouth cases and our younger children, under general anesthesia.
So it is important to remember, when we’re talking about our anteriors: for many years I’ve heard a lot of people say, “I don’t do zirconias because you’re gonna pulp the teeth.” I can tell you, I don’t find that the case. If I’m gonna pulp, it’s because the caries are in the pulp, not because of the preparation that I’m doing. It’s very, very rare. Honestly, I could probably count on one or two fingers the times it’s happened in the past five years that I’ve been doing this, and it’s been a lower mandibular D, right? That first primary molar has a very high pulp horn, and you can see it coming in the X-ray, but you have to reduce occlusally in order to seat your tooth. So there’s nothing to really do about it.
Most of my pictures are pretty clear. Some of them, like this one over here, may not have come through so clearly when we transferred everything to the slideshow. But just work with everything I have here, if you don’t mind. Let’s start at the top. You can see that not only do we have space loss based on the interproximal caries, but we also have crowding. We have rotation. Maybe this child was a thumb sucker earlier on and that caused a little bit of rotation, or maybe they just have crowded teeth. From the lingual it doesn’t look so bad, but from the facial we can see the caries come all the way across, and they drop all the way up to the cervical aspects of the canines. In this situation, the parents requested stainless steel for the posteriors, for the molars, but they did want zirconias for the front.
[00:26:22] The pre-op explanation, staining, and choosing stainless steel for upper second molars
In this situation, I wanna talk to you a little bit about my pre-op explanation, my pre-op discussions. I think this is really important. Remember, it comes down to explanations versus excuses. One of the things I always tell parents is: “Nothing we do on the front is going to look the same. Sometimes they’re a little longer, sometimes the teeth are a little shorter, a little taller, a little more squished, a little more spaced. That’s all normal. We have to work with your child’s mouth, whether it’s crowded or there’s space loss. Our goal is to not get on the nerve, and to preserve as much tooth structure as possible, so we can put on crowns so that they can smile and they can function.”
I also tell them that sometimes we get some staining underneath the crown. It’s very, very rare; to be honest, this was one of my first cases, towards the beginning. When it does happen, sometimes it gets a little darker, sometimes it gets a little lighter, and sometimes it just stays the same. It does not mean that there’s a failure or a potential infection. It just means when we were cementing, there was more blood than anticipated, and some of it got underneath, even with the cement pushing the blood out of the way.
On that point: when we’re filling our zirconia crowns, we fill them all the way up with cement, right up to the top. I know it’s expensive, especially with the RelyX and the premixed stuff. But we’re gonna fill it to the point where we even have a little convex bubble of cement, so that when we push it onto the tooth, any blood that’s there we’re gonna smush out of the way, for lack of a better clinical term.
You can see here we prepared our teeth, which I don’t think I attached. This was right after initial cementation, and here from the palatal aspect. I always leave our numbers on so that we can take pictures and write them down in our notes. Pro tip: if a crown ever comes off, which happens sometimes, especially when you place enough crowns, all you have to do is pop back to your notes, see which crown you used, grab that crown, and pop it right back on.
As you can see here, I think tooth E, so 51 for those international dentists, has a little bit of staining. This was immediately after cementation. This is one month later. I don’t see much of the staining. Sometimes it disappears, but there’s a little bit of a tinge that you may see, and that’s totally something I explain to parents. It does not happen often.
For some reason, these parents decided to do two zirconia molars for the lowers as well, but still have the second molars as stainless steel. When I’m explaining to parents the pros and cons of molars in zirconia, sometimes it’s an aesthetic concern for parents. If that’s the case, I’ll try and save them a few dollars as well. I’ll say: “Teeth 55 and 65, which are A and J, you will almost never see in your child’s mouth. If you don’t have any opposition to using stainless steel, which is surgical-grade stainless steel, and you’d like to save a few dollars or do something a little less invasive at the back there: the only time you’ll see A and J is when they laugh and go ‘ha ha ha’ at this angle. But remember, parents and friends are looking down at children, or at the same level, so you’ll never see those uppers.”
In this situation, for some reason, the parents chose to do L in zirconia and S in zirconia, but K and T in stainless steel. Anyways, let’s keep moving.
[00:30:05] Case: resorbing centrals the parents wanted to keep
This was a great case. It was interesting because the first thing my eyes are drawn to is the anterior 51 and 61, the E and the F: there’s resorption of the roots. The parents came to me, and they absolutely did not want to take these teeth out. You can see there are severe generalized caries throughout, including canines and molars, some of them close to the pulps, some of them in the pulps. They did not want to take any anterior teeth out if they could help it. They wanted to save them, full well knowing that these two teeth were gonna be out in about a year, maybe a little more. This patient was a little younger, about four and a half, five years old. The permanent anteriors were not ready to push out; they were a couple of years away. But the child had taken a hit to the mouth a little while earlier, and the teeth had resorbed a little. Now, there was no mobility on these teeth. That’s super important to remember for what we’re about to see.
It’s also important to recognize there’s some crowding as well; the laterals look a little flared. When you’re starting out with zirconias, in my opinion, I would not take on challenging crowded cases. I would try and stick with some simple spaced dentition, if possible. If you’re doing molars, don’t do back-to-back right off the bat, although I don’t find them that difficult. I think you just have to prepare enough and remove enough from the tooth. We’ll get there in a minute.
So in this situation, remember, we already had crowding with the laterals, as you can follow with my pointer, and there was space loss on the centrals. So I knew already that if I was gonna save all these teeth, I was gonna have to taper my anteriors a little bit, and the parents were well aware of this from my pre-op discussion. In this situation, the parents said they had no interest in any stainless steel in the mouth. They only wanted white. I understand that.
[00:32:07] White versus silver: how the consent conversation goes
Let me tell you what I explain to parents for white versus silver. When I’m explaining to parents that their child needs a crown, they’re almost always shocked when they hear “crowns.” That sounds like a lot; it’s invasive for a child. Obviously we go through the basics of explaining why a crown is necessary. The example that I use is : it’s like the rings of metal on a wine barrel that hold the barrel together. When there’s a lot of destruction of the tooth, like you can see down here, once we prepared everything there’s not a lot of tooth left. If we don’t cover that whole tooth with some type of full coverage, silver or white, the tooth will likely crack and break down over time.
“Now, we have two options for you: stainless steel, or white. Obviously white is beautiful, and stainless steel is silver. The silver crowns are surgical-grade stainless steel. They’ve been around about 70 to 80 years. For the most part, they’re a little less invasive, a little less aggressive of a preparation, and they’re a little bit cheaper.” I’m sorry to talk finance; I always tell parents this. “I’m sorry to talk finance. It is part of consent, and I think it’s important that you recognize that. The white crowns are beautiful. They’ve been around about 10, 15 years, give or take. They’re a little bit more of an aggressive preparation; we have to remove a little bit more tooth, and there’s a little bit more bleeding afterwards. But they look really beautiful after. And obviously they are a little bit more expensive, because they’re more technique sensitive, and the crown itself is just more expensive for us.”
One other thing I tell parents, especially when we’re dealing with a crowded anterior case: “With stainless steel crowns, I can squish them, I can squeeze them, I can adapt and adjust them to the size and shape of your tooth, and we have no issue putting that on. With zirconia crowns, even though we have a space loss crown, sometimes we can adapt to the size of the tooth, and sometimes there’s too much space loss or the tooth is too small. If that’s the case, we may have to put a stainless steel crown on.”
Now, I tell them this, but I’ve actually never, ever had to put a stainless steel crown on after telling the parents I’m able to do a white crown. But I think it’s important to give them that information beforehand. Because if you ever run into the situation of “Oh my God, I promised this zirconia crown, and all of a sudden I don’t think I’m gonna be able to do it. I can’t get the right fit. It’s not sitting passively. I’m not sure what the problem is. I can only do a stainless steel crown”: that’s an excuse, later on. If you explain it to them before, it becomes an explanation, and they become a partner in helping to treat their child.
[00:34:42] Space-loss molar crowns, follow-up, and the letters on the crowns
Let’s take a look at some of these molars here. I know I’m all over the place, but as things come to my mind, I think it’s really important to discuss these tips and tricks.
It’s really important that you notice the red versus blue letters. You can see red letters just on the edge here, and over here. Red means space loss. If you look at this tooth, tooth A, so 55, this was not a space loss crown. You can see it’s a little more square, and tooth B is a little more rectangular, right? It’s been squeezed and squished mesiodistally, because we had some space loss. As you can see here, when we had to remove all the caries, it looks like some of the teeth drifted into each other, into the space. So we had to use something a little more squat in order to get it on. That happens sometimes here as well. In this situation, it also looks to me like there may be some discoloration on the front teeth after we seated everything, but maybe not. We’ll take a look as we go.
I’m gonna go back a second. There do look to be some really large caries up here, and towards the bottom as well. And if you go back and forward, these are my preps. I find it really hard to take really good pictures of posterior preparations, so this is one of my attempts. You can see this is the racetrack, before I removed all of that beautiful margin, and I have this all the way around: here, and here, and here as well. We’ve reduced our occlusal tables, we’ve made a racetrack all the way around, including our canines, and you can see we did not pulp any of our teeth. That was really important in our final preparations.
This is four weeks later. All of my surgical cases, all of my sedation cases, anyone that I do extensive zirconia work on, I’ll see back two to four weeks later for a follow-up, to make sure that there are no concerns or questions, and that the gingiva and everything are healing well. I’ve seen patients three, four days later and everything looks amazing already, but these pictures are from a few weeks later. And again, we take pictures every six to 12 months when patients come back in, and when we see these patients 2, 3, 4 years later they still have the same look.
So this is how it turned out. I think it turned out pretty well. You can see this is three, four weeks later, and some of the letters are gone; some of them are still on the teeth. You can take the letters off before cementing. I’ve only ever done that once or twice, when I have a particular parent that’s very specific. I explain to them there’s gonna be some letters. One time a parent was like, “Is that a barcode?” No, it’s not a barcode. It’s just some letters that allow us to see the difference in sizes. For every tooth in the mouth we have six or seven sizes, and it’s important that we can put them back in the right space and identify the sizes. If you leave the letters on, I tell them that with a few weeks of good brushing, they come off. They don’t have to scrub.
So when they come back in a few weeks, if the letters are fully visible, usually there’s a lot of plaque going on. Zirconia crowns, especially the Sprig zirconia crowns, actually don’t attract a lot of plaque, even when brushing’s not great, which is really nice, but it sometimes makes it hard to tell when parents are doing a good job. We have to look at the gingiva to make sure that it’s not puffy and inflamed. As you can see here, everything looks really, really good. The gingiva is scalloped, and this is only a few weeks later. Remember, I had to tuck these two anterior teeth and make them a little bit of a V shape in order to make them fit, because of the space loss. But as you can see in the front, everything looks good. Remember, I always tell parents there could be some spacing, or there may not be spacing, and here it matches towards the bottom: they had a little bit of spacing on their incisors as well.
[00:38:34] Questions break and the pulpotomy poll
Before we move on, I wanna make sure that there are no questions. If anyone has a question, now’s a good time to stop us and ask. Otherwise, we’ll have plenty of time at the end as well, so not to worry. Somebody just asked if a recording will be sent out, and said the webinar’s great. I really appreciate the feedback. Like I said, I’m just a practitioner trying to share some information. We’ll definitely speak to Sprig and find out if it’s gonna be sent out. Thanks.
I had a couple more polls. I went through this one already, about taking photos of work, so I’m not gonna use that one. And I talked about pulps, but I’m gonna launch this one real quick and see if you guys have been paying attention. […]
As you guys can see, this is asking how often do you perform pulpotomies on zirconia restorations. Quite a bit, I see. One of the important things to remember: a lot of the newest research talks about indirect pulp caps and staying away from being in a closed space. We’re not supposed to be in the pulp space, right? I always tell parents that: “I don’t want to be there. You don’t want me to be there.” The success rate, even with high-quality MTA, is still only about 90 to 94% on the posteriors, and much lower on the anteriors.
So for the 90 to 94% on the posteriors, I tell parents: “Listen, that’s a great success rate. It used to be in the 70s. Now, 90 to 94% on a math test, that’s amazing. But for us, what that means is for every 10 teeth I fix, one of them is going to fail. And a failure means an abscess and an extraction, usually later on.”
[00:40:36] Q&A: case length, opposing crowns, letters, and gingiva tucked under the margin
Let’s take a quick moment. I’ve got a lot of questions popping up here, and I’m really excited to go through them.
How long did this case take? This case took me about an hour and a half, sometimes an hour 40 minutes. I try not to keep kids sleeping more than an hour and a half at most. It really just depends. The most important thing, as I was saying earlier, is changing burs less often. For a case like this, when you’re doing so many crowns, start with fresh burs. I actually change burs maybe two, even three times in a case like this: I’ll do my anteriors, I’ll do half the posteriors, and then the other half of the posteriors.
Opposing zirconias: any tips on placement? It’s important that you get a good occlusal reduction, and that all of your crowns, maxillary and mandibular, sit passively. That’s an individual tip for every time you place a zirconia: it has to be a passive fit. If it’s not passive, you’re gonna get either a fracture, which we’re actually gonna see, or a cap popping off or anything like that. I have no specific concerns about opposing zirconias; it’s the same as opposing stainless steels.
Remember Hall crowns, if anyone here does them on a regular basis. For anyone that’s not a pediatric dentist, or maybe not in the know about the Hall crown: it’s a technique that’s been used for a long time in Europe, where they do very selective caries removal, or none, and they take a stainless steel crown and pop it right over the top of the tooth with little or no removal of tooth structure. At that point, obviously, the occlusion is high, but the studies show that within a few weeks the occlusion completely adjusts by itself. We see that with all types of restorations, whether it’s a high filling in the primary dentition or a high zirconia crown. Because the alveolar bone is a lot less dense in children, the teeth actually recede a little and self-adjust, and that happens pretty quickly.
Sorry, again, taking a look at all these questions. How do you remove the letters off the crown? If you wanna remove them, the best way is with an explorer or a little spoon. Just scratch them off; really easy, no problem. Regular toothbrushing will take those letters off within a few weeks.
Do you ever have an anterior zirconia come back with the margin of the crown at the gingiva, as opposed to subgingival, when during initial cementation everything was subgingival? Absolutely. It doesn’t happen often, but it definitely can happen. You’ll see a couple of my photos with that. That’s definitely not a failure, and I think it’s important to explain to parents, again: explanations versus excuses. What often happens in the case you’re talking about, when during cementation everything was beautiful and they come back a few weeks later and the crown appears to be on top of the gingiva: the gingiva, that little sulcus, about a one-to-two-millimeter sulcus, actually got tucked underneath the crown. In an ideal situation we would have had a bit more of a sulcus, but it’s not always possible. What I suggest in those cases, if you have cooperation: very, very gently, with an explorer, I get under the facial a little and tease the sulcus back over the crown. I’ve done this a few times and it totally works; it’s no problem. But you have to know your patient. If the patient’s kicking and screaming, do not do this. It’s not worth it.
How much space loss is concerning, even when using space loss narrow crowns? This is a really difficult question to answer. You’re gonna get a feel for it as you do things. That’s why I always explain to parents that sometimes we won’t be able to put a zirconia on. Like I said, I’ve never had this happen, because I think case selection is the most important thing when you’re first starting out. Choose easier cases, things that don’t have severe space loss. You can almost always make things work.
I said a little earlier that when we’re making the racetrack on a virgin tooth, like on a typodont in a class, you take off that millimeter and a half and make a racetrack all around. But that’s not really realistic. Most patients that are getting zirconia crowns have big caries, and when they do, there’s a lot of space loss. Let’s go back here for a second. If you take a look at this tooth, when we prepared it we removed a lot more than one and a half millimeters; we probably had to remove two millimeters, sometimes three. When we’re doing the canines, we have to remove more.
So remember, if you take a look at the X-rays, you can visualize how much space there is to the pulp. I probably have two and a half, three millimeters until I get to my pulp horn over here. Same thing up here: look how much enamel and dentin there is. There’s a lot of space. Same thing over here. Remember, I didn’t end up pulping this. We did an indirect pulp cap and could stay away, because we’ve got a nice dentin bridge. Look how we have space loss, but look how much room. So when we did our preparation, we had to remove a lot of tooth in order to keep as much tooth structure as possible. So to answer that question again, how much is concerning is case by case. Case selection is so, so important for everybody.
[00:46:19] Q&A: back-to-back D and E, extractions, overgrowth, and washing off cement
A few more, and then I think we’re gonna keep going. How do you do D and E together? Troubleshooting when it doesn’t fit; how to decide when to give up and do stainless steel crowns? I don’t really think there’s a point where you have to give up, as long as your patient is cooperative. Again, hopefully you’re starting with some simpler and easier cases. Even when you’re doing back-to-back cases that have mesial and distal caries on the D and the E, but not a lot of space loss, or almost none, you wanna make sure that you prep enough for both teeth. You do the occlusal reduction of your molar, then your axial racetrack all the way around. I also find that rounding your margins, rather than tapering, helps a little with your seating.
Then make sure that between your D and your E, you take a little extra off on that racetrack. If you’d normally do the 002 bur, maybe do a 002 bur plus another half: maybe two millimeters instead of a millimeter, a millimeter and a half on each tooth. That’s gonna give you extra clearance. You just have to use the right space loss crowns. Sometimes we use two space loss crowns for the D and the E. More often than not, we’re using a space loss crown for the D and a regular-sized crown for the E.
When you need to extract and put a zirconia on two adjacent teeth, do you extract and wait for hemostasis to cement, or do you cement the zirconia and hope you don’t dislodge the crown when you extract? I don’t exactly understand that question, but what I can tell you is I always extract teeth first before putting crowns on, whether that’s stainless steel or zirconia. I learned this way back in residency: as amazing as you are at extractions, you’re inevitably gonna put a little bit of pressure on an adjacent tooth. So you always want to extract first.
I’ll often use some Gelfoam in the socket. Let’s say I have to extract a D, but I want to put a zirconia crown on an E. I’ll prepare my E: I’ll do my occlusal reduction and my axial reduction, remove the margin, and seat my crown, making sure it seats completely, so passive seating. Then I’ll extract my D and put a Gelfoam in, and I’ll do something else in the mouth. Or, if that’s all I’m doing, I’ll put the Gelfoam in and squeeze it with a two-by-two for maybe 10, 15 seconds. I’ll rinse everything, hold a two-by-two on the E, then take it off and quickly cement my crown right on top, and I’ll hold my E for a few minutes. Doing it that way, I haven’t had any issues.
Have you ever had gingival overgrowth around the margin of an anterior zirconia? I had a case where 51 and 61 were zirconias, and after two weeks the gingival margin around 51 was overgrown. I haven’t seen that personally, I’m sorry. Maybe there was a little bit of excess cement underneath, and it got inflamed. Sometimes what you can do is take a curette, or even an explorer, and clean up underneath there. You can put a little chlorhexidine on a two-by-two and rub the gingiva, or squirt a little chlorhexidine underneath with a syringe. You can prescribe some chlorhexidine and have them rub the gingiva for seven to 10 days. That usually works with any inflammation.
How long do you wait to wash off excess cement? I actually do things a little differently than Sprig recommends, and I hope nobody kills me here. Let’s say we’re doing anteriors. I’ll cement all my crowns and hold all of them on. I’ll give it 20, 30 seconds, and maybe I’ll do a tack cure with my light. Then after about 30 to 60 seconds of holding with full pressure (full pressure, so my crowns are fully, passively seated into the margin), I’ll take my air-water syringe, test it first, and do air and water together right in their mouth. It’s like a little car wash. I spray along the facial and along the lingual. I’m not going into the interproximal of every single tooth at this point. I’m just removing all that excess, hoping it gets caught up in the DryShield and sucked away. We’ll talk about that a little after as well.
[00:50:55] Case: photo documentation for parents and for legal protection
Let’s take a break from questions and get back to cases. I’m sure you’ll see a lot more and have some more questions. I’m mindful of everyone’s time as well; I know we’re coming up on the hour mark. I believe we have about another half hour, so there’ll be plenty of time for questions. Remember, this was about three weeks later, and the numbers were basically coming off at that point.
Another case. Let’s see what we did here. Taking a look at the X-rays, I assume this tooth is gonna be a pulp. The canines look like they’re gonna need crowns, up here as well, and across the front. And look: you can see there’s some space loss on teeth D and E, 52 and 51. It looks like there’s already some space invasion. We’ll take a look at how we solved this.
This is actually a good opportunity to see something. This was done a long time ago. I didn’t have my smile stick, smile light thing with my phone yet, and I took pictures with my MouthWatch. I wanna show you how I take pictures with the MouthWatch and how I mount them. Every case, zirconia, stainless steel, composites, glass ionomers, whatever it is, I take as many pictures as I can. This is a sedation case. I take X-rays: my PAs and my occlusals. Then I take pictures that go all the way around the mouth, and it’s all here.
You can see the quality is absolutely not the best. This is a screenshot of the computer screen in my office, so you can see exactly what I or the parents would see. This isn’t for educational purposes, for high-quality lectures. This is for parents. This is for legal, right? This is for divorced or separated parents, when the mom said one thing and the dad said something else. Or somebody comes in and says, “I didn’t want zirconia,” or “I wanted zirconia and I didn’t want stainless,” or vice versa, or “They didn’t have cavities; how come you did all these teeth?” And I’ll pull up the pictures and say, “Hey, let’s look together.” So these are the types of photos I keep on my desktop or in the patient’s file.
This is a very blurry picture. Sometimes I’ll use the MouthWatch to take a post-op picture like this; this was before I was taking better pictures. I even took an after picture here, just so I knew which letters were there. You can see that zirconia crowns sometimes look a little bulky from this angle, right? But they’re actually very pointed, knife-edge, and they look really, really good in real life. This patient ended up wanting stainless steel on all the back. You can see there’s bleeding, and that’s totally normal after cementation. This is a poor-quality picture, but it’s to show you that anything is better than nothing. Pictures are super important. You can see the cervical decay comes all the way down on the lower canines as well, with our space loss, even down here.
[00:54:03] Learning curve: two failures and what fixed them
Learning curve. Some great times when I messed up. I’m gonna take a quick drink, and you can take a look and see what’s going on here, and I’ll talk to it in a second.
There are two things I want to point out. This case on the right side of your screen, patient left. I’m always talking from the patient’s perspective. This is a D that I placed towards the beginning of when I started doing zirconia crowns. They were already missing the E; it had been extracted by a previous dentist. They came in with caries, they needed a crown, and they wanted white. Even though they knew they were gonna need braces and some type of distalization with silver, they still wanted white. And we’re like, okay, that’s fine, no problem.
This was a user error on my part. I’m wondering if anybody knows what happened here; it’s pretty straightforward. I did not have a passive fit. There was an undercut somewhere, or maybe I tapered too much. And when I seated my crown, I didn’t push hard enough to make sure that everything was seated passively. When you have a really good passive fit, you should be able to push on that crown with no resistance at all. It should bounce up a little; you should have a little spring back from the gingiva. In this situation, that obviously did not happen.
This patient came back about three months later and said there was a little crack on the tooth. I felt it with my explorer and everything was fine. The patient was still young, 6, 7 years old. I said to the parent, “Look, don’t fix what’s not broken at this time.” Not because I didn’t wanna replace it, but because the patient needed sedation with laughing gas to place this. I said, “If we don’t have to replace it, let’s wait.” They came back about four or five months later, so about eight months from the initial placement, and this whole piece had eventually broken off.
At that point I said to the parents, “What would you like to do? Your child is now about seven years old, and they need this tooth until about 10, 11 years old.” This is the cement underneath. I know it’s a poor picture; it’s from my MouthWatch again. But you can see the lines from the intaglio surface in the cement. It’s sealed with cement. I said to the parents, “Do you want me to remove this? I’ll replace it free of charge: nitrous, zirconia, everything. It is obviously my fault. I’ll take care of it.” And the parents actually said, “Can we leave it?” And I said sure, we’ll monitor and assess every six months when you’re in here. The patient is now nine. He still comes in for his regular maintenance, and it’s still there. It hasn’t fallen off. Nothing’s wrong with it. There’s no abscess, no infection, and the cement has basically sealed everything. Is it the most aesthetic? Obviously not. But the parents aren’t concerned about that. I told the parents, and I put a note in my chart: if you ever decide you wanna replace this crown, no problem. I’ll take care of it, because again, that’s my issue.
This is something that happened recently, which is actually a little annoying for me, since I’ve been doing this so long. Well, so long: five years, sorry. We did a full case of anteriors, and the patient came back with two canines broken: one had completely failed and disappeared, and the other one had broken. The first one, you can see here, is tooth 63, or H. You can see there’s a yellow, smaller tooth, and there’s no crown. And on the bottom here we have tooth 83, I believe, and you can see it broke; there’s half the crown still on.
So if you ever have a case where a zirconia crown breaks and you need to get the rest of it off, like this tooth or this one down here: you take a Howe plier and give it a gentle squeeze on the actual zirconia, and the whole thing shatters. Obviously, make sure you have good aspiration protection. I put a two-by-two around it and give it a squeeze, and then I use cotton pliers to pick away the little pieces. We prepped the tooth and popped a new crown on. That’s what we did: we put the patient on nitrous, we re-prepared, we re-cemented, and that was that.
[00:58:16] Q&A: tack curing, the six-minute hold, biologic width, and when a canine needs a crown
I have a few questions; I’m gonna take a quick peek before we move on. Someone asked if I light cure RelyX cement post-cementation. Sometimes I do, sometimes I don’t. To be honest, more often than not I do not. That tack cure is something I did towards the beginning, when I started doing all of this. I don’t do it as much anymore. I find that it doesn’t do as much as I’d like, and I’d rather hold those teeth for a while.
I have a small five, $10 timer next to every chair in the office, set to either three minutes or six minutes. I use a lot of glass ionomer for our smaller stuff as well, and I have a timer for that. But for this, I’ll keep the zirconia timer at three minutes. I set it once, at three minutes, and I won’t remove my fingers for the full three minutes. After that I’ll take my fingers off, take a look, and do a little car wash. I’ll often try to do something else in the mouth while not touching those teeth at all. At that point my assistant sets the timer again for another three minutes, and I won’t touch those teeth again until six minutes have gone by. If you seated them properly, I find you have no issue. I know that sounds like a long time. But remember, if you’re placing zirconia crowns on a patient under nitrous or oral sedation, you hopefully have some pretty decent cooperation, so it’s not an issue. And if you’re under anesthesia, you have a few more minutes. It’s really important to get a really good seat.
Are you ever worried about invading biologic width with primary teeth? Excellent question. I’m not, personally. Like I said with the question about opposing occlusal crowns, there’s a lot of forgiveness in pediatrics, with primary teeth and primary gingiva. I’ve placed probably close to 1,500 zirconia crowns at this point, anywhere from 30 to 40 a week on the regular. This is not me boasting; this is me telling you straight. I’ve seen my fair share of failures, but for the most part, 99%, we’ve got great success. I’ve never seen a biologic width issue present as such.
Let’s keep going. One more question before we do. When would a canine be a candidate: two surfaces, three surfaces, et cetera? I find it really has to do with the caries risk of the patient and how large the caries are. Take even a distolingual caries presentation on a canine: if it’s really large and wraps around onto the lingual, and the patient is a grinder, they’re often gonna pop out that distolingual composite or glass ionomer. If you’re gonna put a crown on it, you have comprehensive coverage and it’s strong.
If you have facial, cervical decay on a canine, that’s very difficult to repair in the primary dentition. So even if it’s just one surface, just the cervical facial of a canine, but it’s deep and it wraps all the way from the mesial aspect of the facial to the distal aspect, very often I’m gonna give the parents an option. I’ll say, “We can do a composite or a glass ionomer, but it’s very difficult to place with high success.” It’s a little technical, but the enamel rods tend to disappear at that cervical margin, and we have very little bonding strength. So I explain this to them, and very often they choose a crown. I give it to the parents; I let them choose.
[01:01:58] Case: saving every tooth in a toddler with severe caries
Another case. Taking a look here, again, you can see lots of caries, not just on the anteriors but the posteriors as well. Sometimes we can’t save every tooth. It really breaks my heart when we can’t, because I often try and promise as much as possible. In this case we were able to save everything, and we did not pulp any anteriors. Let’s take a look.
This is how it presented clinically: pretty soft caries on the anteriors. But as you can see, the linguals actually were not as mushy or soft as one would think, and we were able to remove a lot of that during selective caries removal and place our crowns. I’ll go back and forth a couple of times to toggle and show you. I’m not embarrassed to show you that sometimes, and again this was a while ago, my gingiva look a little beat up. It depends how many teeth you’re doing at the same time, how cooperative the child is, what’s going on. You wanna do your best, obviously, to avoid that. But it happens sometimes, and within a few days everything’s recovered beautifully. So don’t worry. Don’t beat yourself up if this happens to you.
So we started with this. Remember, this is how the caries looked on the facials of the anteriors. This was our caries removal. We created our racetrack; you can see there’s a nice margin all the way around the teeth. I try to keep it as supragingival or paragingival as possible to avoid bleeding, so I can take some pictures. Sometimes that doesn’t happen. Like you can see here, especially when the caries are so extreme, like over here and here, we have to go a little subgingival to remove the caries, and we get a little bleeding, but not much. So we were able to take our picture. I gently run an explorer over all our surfaces to make sure that we don’t have any pulp exposures and that everything’s looking strong.
You can see from the front there’s not a lot of tooth left, especially on some of the laterals, and there were even caries between the lower incisors. We removed our margins; that’s where we see some of this beat-up gingiva. And we cemented everything. Now, remember, I always forewarn parents: not everything will look the same. Not everything is gonna be spaced the same. It may be tighter, closer, less space, bigger, smaller; we’re just not sure.
As you can see in this situation, one of my gingival heights is a little taller and one is a little shorter. It looks like I buried this crown, the D, the G4, a little deeper in the gingiva, and that probably comes back to our biologic width question from earlier. But remember, look at what we started with. There was not a lot of tooth structure left. When we removed all of our caries, this is what we were left with. And when we removed our racetrack, our margin, and seated our crowns, sometimes we get different heights on the gingiva. Parents could not care less. What they care about is the incisal edge. They wanna make sure that, for the most part, everything looks pretty good. In this situation, when the child smiled, and when we took a look postoperatively, everything looked really good. And the parents, as you can imagine, going from this to this, were thrilled. I can always nitpick, but that’s really not necessary in this situation. I don’t have a post-op picture for this patient, because they weren’t cooperative. Unfortunately, they were only two, two and a half years old. You can imagine, with baby bottle rot.
[01:05:30] Case: anterior space loss, and choosing crown sizes
I’m gonna speed through the next few cases, probably finish up, and then we’ll have time for questions. So, another case, again anteriors. These parents chose stainless steel for everything at the back, but they wanted anterior zirconias. Again, this patient came to us, and another dentist said they wanted to take these teeth out. Another dentist said they wanted to do composites, and I don’t know how I would do that. In this situation, the parents said, “You know what? Let’s put the zirconia crowns.” I told them that there’s probably a little space loss. You can already see that, right? If you use your mind’s eye and draw this tooth, it should be over here, and this margin should be all the way over here. So all four of these teeth were invading each other’s space, and we probably had to make these teeth a little smaller in order to seat them.
This is the lingual view, right away. Somebody asked earlier about the gingiva sometimes ending up over the margin, tucked underneath. This was a case where during our initial seating everything was fine, and then a couple of minutes later, when I rinsed everything and took a picture, you can see on the D and the E it looks as if the margins were hidden again, right? The gingiva is above. So all I did was take an explorer, come underneath a little, pull it out a little, and make sure that everything lines up. Obviously, this is easy when they’re sedated. And remember, I said this is a case where maybe the gingiva and the incisal aspect look a little beat up. But you can see this is just three weeks later, and all the gingiva look fabulous. Everything healed beautifully. The parents are obviously beyond thrilled, going from this to here to here.
Really important to note: sometimes I’ll use one size on the centrals and go a size up on the laterals, so threes on the centrals and a size up on the laterals. Or sometimes they’ll be the same size all the way across: threes all the way across, or fours all the way across. For the most part, we’re using threes and fours for the centrals, sometimes twos; and threes and fours for the laterals, rarely twos. It’s so rare that we use fives or sixes for laterals. It just depends on the size of the teeth.
[01:08:01] Case: extensive baby-bottle caries, pulpotomies, and surface wear
Again, a lot of baby bottle rot. This patient came in, and another dentist wanted to take all their teeth out except for the last molars. Mom at this point had stopped the habit of breastfeeding through the night, when this patient was older and eating carby solids: Goldfish, Bear Paws, crackers, yogurt drinks, things that were just sitting on their teeth for hours and hours, and honey in the bottle at nighttime, all that stuff. So you can see the decay was quite extensive.
I told the parents, “I may not be able to save one of these anterior teeth, or any of them. I won’t know until I get in there. But know that I will do my best, as a dentist and also as a dad of four kids. I wanna make sure that we can save your child’s teeth and keep them strong. They’re important not just for smiling, but also for eating. And we’ll do our very best.”
So we went ahead and removed all of our caries. This was our initial reduction. We created our racetrack; you can see it all the way around here. In this situation, we had to pulp a couple of the molars. Let’s go back and see what we were looking at, right up here and over here. I could already tell that these would be nerve treatments. I explained to the parents that MTA, again, has that 90-plus percent success rate. We pulped, and then we did our preparations. We prepared everything and seated everything after removing our margins. Don’t worry if you see a little bit of bruising or discoloration. That’s totally normal, because you’re hurting the gingiva, right? You’re in there with a bur, coming all the way around and across. We seated them like this, and honestly, they looked really good right off the bat. The parents were thrilled that we were able to save everything.
This was almost a year later. They disappeared and never came back for their regular follow-up. The patient was more cooperative now, so they allowed us to take some good pictures. Honestly, I absolutely love this case. The result is spectacular. The parents are over the moon. You can see from the stainless steel crowns that the parents are obviously brushing much better. The gingiva are healthy, and they stopped their habits.
One thing to note over here, since someone was asking about opposing crowns: sometimes you get a little bit of wear, right? When zirconia crowns scratch, when they wear, you get a little bit of a dark color on the surface, and you cannot get rid of that. That is okay. It’s a normal part of crowns. Nothing is as good as natural teeth.
Same thing here: a lot of space loss right off the bat. I explained to the parents that the teeth were gonna look a little bit bigger in the front, and again, they were very happy with that. So a little bit of space loss; same thing over here. Lots of pictures; you guys can take a look. There are a bunch of questions. I’m gonna take a look while you guys are checking this out.
[01:11:16] Q&A: grinders, Class III bites, case selection, and pulpal blushing
Does attrition or grinding exclude a patient as a candidate? Absolutely not. We do grinding patients all the time. We’ll actually build their teeth back up sometimes and give them more occlusal height, and build up the back with stainless steel crowns or zirconia as well. Those patients will not have any issues. Sometimes we see a little bit of surface discoloration on the crowns when they grind against them. And I find that with stainless steel crowns, patients will sometimes grind through them. I have not seen that yet on properly placed zirconia crowns with a passive fit.
How do you place zirconia crowns in the anterior when the child is a Class III, so edge to edge or in a crossbite? Not an issue. As long as you can seat the zirconia crowns and let them set for at least six minutes, working on some other work and then coming back, it’s really not an issue. We’ve placed them on patients that are Class III, that are grinders, that have heavy thumb-sucking and pacifier habits. There’s really no modification to the prep. I know I’ve seen a webinar where someone was able to taper the anteriors forward a little to jump that edge-to-edge crossbite. That’s totally possible if it’s something the parents want, or if there’s only a small discrepancy. But it’s not always necessary.
Somebody wants me to speak more about case selection: when do we rule zirconias out with parents? I really haven’t ruled them out. What I rule out is this: if I pulp an anterior, I explain to them that success rates are not the best. If your child is 2, 3, 4 years old and they need to go under anesthesia, comprehensive definitive care often means not doing something with a lower success rate that could fail. Often we’re taking those teeth out. But I have not done that in a long, long time. We do our very best, as you can see from some of these cases, to avoid nerve treatments on our anterior teeth. Case selection is really just making sure that you start slow as a provider. Start with something you’re confident with, then build up: every day, every case, something more complex every single time. And you’ll learn what works and what doesn’t.
I’m looking at a bigger question here; hold on one second. I’m trying to figure out how to see the whole question. Basically, somebody said they recently completed a case, 52 to 62, no pulp exposures, and finished the molars. They do the molars afterwards and wait, so they have some hemostasis for the anteriors before cementing the anterior crowns. Sometimes they see quite a bit of the anteriors looking a little pink, like some pulpal blushing, and she gets nervous when she sees that. Have I had cases like this, cemented the crowns, and was everything good? I think the case we just showed was a little bit like that. I’m not sure if this is what you’re talking about, but to me this isn’t pulpal blushing. It’s just discoloration, as we remove more caries during selective caries removal and leave a little bit of caries behind. You shouldn’t have any issues.
Again, I tell parents: sometimes if we get close to the nerve, the tooth isn’t happy. Sometimes we do an occlusal filling and the tooth isn’t happy. So I always tell parents we’re gonna do our very best, and we’re not gonna get to the nerve if we can help it. And if we don’t get to the nerve but we get close, I’ll explain to them: “We got very close to the nerve. Sometimes those teeth don’t get happy and they get an abscess. We’ll work on that when the time comes. Hopefully we don’t have an issue.” And I do my best to follow up. I’ll always call parents that night, I’ll call them a week later, and I’ll see them a few weeks later and go from there.
[01:15:15] Q&A: nitrous-only workflow and try-in order
Somebody asked if I do this with nitrous only, in the clinic, and about workflow. Yes, we use nitrous all the time. I happen to be showing you bigger cases because I think they’re sometimes more interesting from a full-mouth perspective. But a lot of these cases, like anteriors, 52 to 62, or molars, we’ll do on nitrous. Today was a regular clinic day. I did two back-to-back molars, and two canines on two separate patients, and that’s it. The next couple of days are surgical days, and I have a whole bunch of anterior cases lined up, as well as some molars.
Everyone is different. For workflow: I’ll get them started on nitrous, get them marinated and real relaxed. We’ll give them a little freezing and make sure they’re comfortable. If we’re gonna work on something, we let that freezing kick in, so we’ll start working on something else first, or we’ll let them watch their show. I’ll come back and do my full preparation: occlusal reduction, axial reduction, remove the margin, feather edge, taper everything, and then try everything in. Sometimes a little clear ViscoStat. Sometimes we go straight to seating all the crowns, making sure everything seats passively with no concerns aesthetically, then cement everything, hold everything with a two-by-two, and rinse all the crowns off.
Once they’re tried on, I’ll turn them upside down, spray them out and dry them, making sure they’re completely clean, and hand them to my assistant. She’ll line them up one at a time. I always seat them in the exact same order that I tried them on. That’s really important, because if you seat them in a different order, you’re gonna get a different fit. And how do I know that? I tried it once before. It did not work out well. We had to redo them.
[01:16:59] Case: removing SDF staining on anteriors
Let’s keep going a little bit here; I wanna make sure we keep on time. Again, same thing. SDF was placed in this situation. I don’t do a lot of SDF in the anterior; the patient came to us with SDF. We promised that we could probably remove most of it, as you can see in the pictures afterwards. We did this case as well. Same thing: smaller caries in some areas, larger in the posteriors. You can’t see anything visually from the occlusals, but you can see this was a few weeks later. And look how awesome the teeth look. Honestly, I’m just thrilled with this result, as were the parents.
[01:17:34] Q&A: cleaning blood from a crown, pulpectomy vs pulpotomy, and cameras
Awesome. Thanks so much for joining. We’re not cutting you off; there’s plenty of time for more questions. Let me see if I can pull up questions as we go. I wanna see if I missed anything a little further down.
Justin, on the best way to clean a Sprig zirconia crown when it gets blood in it. Because we’re using a glass ionomer cement, there’s no chemical bond happening. So all we need to do is flip the crown upside down, in the mouth, over the DryShield, and do that car wash with the air-water syringe. I’ll spray the whole thing clean and look at it with my loupes. If there’s no blood in it, I’ll air dry the whole thing with my air syringe and pass it to my assistant.
When you pulp your anteriors in someone that is asymptomatic, with no pathology on the radiographs, are you performing an MTA pulpotomy, or are you leaning towards a pulpectomy? I do full pulpectomies in these cases. To be completely fair and honest, I’m doing a pulpectomy because that’s what I learned a few years ago. I have a great endo group in the city that I work with for some of our bigger kids, and I’ve discussed it with them. As far as I know, currently the best option for a good result is a pulpectomy.
The name of your intraoral camera? Which one? The MouthWatch: that’s the cheap two, $300 one that you can get online. We also have the Smile Line; I think it’s called the MD two. You can look it up. There’s also a knockoff of the MouthWatch called, I think, Dareyou. I haven’t bought them, but people say they’re just as good. They’re about a hundred bucks on eBay.
It looks like we’re coming to the end; we have about five, six minutes left. I wanna be mindful of everyone’s time, especially on the East Coast. It’s coming close to 10 o’clock here. So if anyone has any other questions, now is a great opportunity.
[01:19:49] Wrap-up and final questions: pulpectomy steps, cementing order, and lower incisors
Guys, this was amazing. I’m really looking forward to doing this in person with a lot of you in the future. We can get a lot more engagement going. I think it’s really important that I see your faces, which I haven’t been able to. So hopefully we can do that again. Please feel free to send me an email with questions, comments, feedback, positive or negative. Honestly, I’d love to hear it all. I think it’s really important that we learn from each other, and at any point if you have questions, I’m always happy to answer. My email is down below. That’s our newest practice, Toronto Kids Dental. It looks like there are a few more questions that I’ll hop on before we head off.
Please describe the material and steps used for a pulpectomy. I don’t have everything out here right now, but it’s pretty standard. I’ll clean everything out. I’ll use two files to go into the pulp, twist, and remove the whole pulp at once. I’ll use some chlorhexidine pellets, and chlorhexidine rinsing or bleach rinsing; it depends what I have on hand in the office. We’ll rinse everything, then I’ll use some paper points to make sure everything dries off. Then I’ll use a radiopaque filler with a long, thin tip. We’ll backfill and pull back. I’ll use a Lentulo spiral tip to get everything around and in there and make sure it’s fine. I’ll use some type of glass ionomer to seal the occlusal aspect or the incisal aspect. I’ll take a radiograph, obviously, and then we’ll cement.
When cementing a stainless steel crown beside a zirconia, which do you cement first? Great question. Excellent question. I almost exclusively cement stainless steel crowns first. Let’s talk about workflow for a quick second, because this hinges on it. Let’s say I’m doing D, E and C. Sometimes if you do D and E, C fits; or if you do E and then C, D will fit nicely. But sometimes, if you do the two molars and then put your canine on, the canine is hard to fit. If you’re doing molars in stainless steel, my best answer is always: put the E on first. Do your C in zirconia, and then the D, which is gonna be a stainless steel crown. It’s got great flexibility; just pop it right on and it’ll squeeze in between. But if you do your two molars first and then your zirconia on your canine, sometimes, especially if there’s space loss, you’re not gonna get a good fit. So we want that zirconia on first, and then the stainless steel crown, for that case. When I’m cementing a full arch at once, I’ll do my stainless steels first, and then zirconia, zirconia, zirconia.
I also try not to spare any expense when it comes to doing things in a convenient way for myself and a speedy, quality way for our patients. One of the things I do is try to minimize the amount of RelyX Luting cement that I waste. You can see it comes with a long syringe tip, and there’s a lot of waste that goes into that. So when I’m doing these full cases, or even a half mouth or just anteriors, I’ll try and cement everything at once. If I’m doing anteriors and all the posteriors, I’ll prep almost everything. I’ll cement E, D, C, E, D for uppers and lowers, and put my canines on. I’ll switch my DryShield, which is what I use for isolation and also as a bite block, to the other side after about a minute. As I’m doing that, we’re already working on cleaning everything up, and that bite block will hold my crowns in place. Then I’ll start cementing all my anteriors, zirconia, and posteriors all the way across. This takes a little fancy footwork, and it takes some time. But I don’t want to keep switching tips every six minutes for two crowns, two crowns, two crowns. Again, it comes as you get more comfortable with it.
How does MTA go into the pulp? I use an amalgam condenser. I’ll pick it up with the amalgam condenser and pop it in. I’ll use a little wet cotton pellet to condense it in near the pulp horns, and that’s it.
“Love, love, love Sprig.” Thanks so much. That’s great. Thank you, Doctor.
In one of your earlier cases, maybe the first or second, there were some clinical caries on the mandibular anteriors. Can you speak to technical difficulties with lower mandibular incisors? Absolutely. I don’t do them often, but I have done them. I actually find them a little bulky afterwards. As long as you warn parents and explain that they will look a little bulkier, parents are often thrilled. I haven’t actually ever seen a mandibular incisor abscess, so very often we’re doing some interproximal stripping, right? Some IPR, just to remove some of those interproximal caries. I’ve had a few patients on the spectrum that have come in and fractured even a permanent lower incisor, and we’ve been able to use the largest size, I think it’s called the U4, the lower incisor. I’ve been able to place that with really good long-term retention. We’re about three, four years since I’ve done that on a few of those cases, and they look great. They are bulkier in the lingual aspect, right? So they’re a little thicker. But when you’re looking straight on, you can’t really tell. And that’s really great. […]
Someone’s trying to clarify about the pulpectomy. I think the best bet for the steps is if you send me an email; I’m happy to write out the steps. Everything that I do: I don’t use Tempit. I don’t want something temporary, or something that’s gonna inflame the pulp. We want something that’s high quality for inside the pulp, and then a glass ionomer to seal everything, and then cement everything.
Well, like I said, thank you so much, everybody. This has been a pleasure on my end. I’m really excited to be able to chat with you guys about this. Anytime you have questions, please feel free to reach out, and I’ll do my best to get back to you. Thanks so much for coming out tonight. And go Leafs go. Thanks a lot.
