Top 10 Obstacles in Using Pediatric Zirconia Crowns and How to Overcome Them — Transcript (Cleaned)
[00:00:12] Introduction: background and why this work matters
Tonight is a new presentation that I am giving for the first time. Sprig and I had talked about trying to come up with obstacles that people see in using crowns and how we can overcome them. I hope these are helpful for you.
I’ll give a couple of disclaimers and we’ll start rolling. First off, I am not an employee of Sprig. I am a private practice pediatric dentist. I get to come on after work some days and do this fun stuff.
So, who am I? Some of you might have seen some of my webinars before, and I hope you’re back listening again, but I’ll tell you a little bit about me for those who haven’t. I graduated from Baylor Dental in 2009, spent a couple of years as a general dentist, did my residency at UDub, and then decided to open my private practice in my hometown of Lubbock, Texas, in 2013. Then I opened Parkview Therapy Services to serve as an adjunct to my practice for myofunctional therapy, lactation therapy and speech therapy in the office.
This is my second office. Just a quick picture of some of the fun stuff we get to do there. I’m super proud of how it turned out. And this is my newest office, which we opened about two months ago. This is what it looked like before. It was a pool warehouse, and before that a tire warehouse, about three blocks down from my original location. But with some vision and some great architects, we transformed it into this: our new 10,000-square-foot location.
This is the floor plan. We’ve got big waiting rooms, multiple waiting rooms, one of them for our therapy areas, and private rooms for our babies with feeding. We’ve got GA suites and recovery rooms in the back. You can’t see all of it on the screen, I don’t think, but it’s a really cool spot. I’m super proud of it and really thankful for the five amazing pediatric dentists I get to work with each and every day, and for the amazing team we have grown over the last ten and a half years.
This is a picture of my family. I have this in every presentation that I do. For me, it’s a hard stop to say first off how fortunate I am to get to be a dad. I love what I get to do, and I’m better at what I do because I’m a dad. But not just being a dad: I have these three amazing little girls, and I get to be their advocate. They’ve had different medical procedures done over their lifetimes, and it’s a big deal to have somebody you’re trusting your daughter’s care to. People do that each and every day for us as pediatric dentists, and it’s such an honor and a privilege.
So I take this quick second to say: if you were burned out today, if it was a hard day — I had a hard day in the office, I’ll be really honest. Around Christmas is always hard. Kids are less behaved and money’s tighter for people. Things are challenging. But at the end of the day, the parents of the kids that walk in trust me enough to care for them, and that’s a huge honor. I take it as an honor each and every day, and even on the hard days I don’t let that jade the fact that I am so fortunate to get to do this.
So thank you for spending some time after a long, hard day at work to hear a little more about these crowns and how they can impact your kiddos and your practice.
[00:04:04] My zirconia journey, a case nine years later, and the 10 obstacles
My journey in zirconia started way back in residency, in 2011. In residency we did strip crowns or resin-faced stainless steel crowns, and what we all did as first years was fix the stuff that broke: chipped strip crowns or broken resin-faced stainless steel crowns. I got tired of fixing those things, so I asked if we could do something different. They said we could, and my goal was to figure that out. Before that, I took a quick picture of me fixing one of those broken strip crowns. If you’ve ever done that, it feels like you’re wrestling a little alligator.
So my goal was to find something better. We looked for change, and that’s where I got introduced to Sprig crowns. In fact, I tried all three companies’ crowns that were producing zirconia crowns at the time. I fell in love with the Sprig crowns, started taking pictures of what I did, and that’s how I started teaching with Sprig almost 10 years ago.
I wanted to show a quick case. This was a pre-op photo: a traditional kiddo coming in with cavities on these front teeth, pretty big ones. Not great X-rays, but you can see the front ones here. This was a little 3-year-old with big cavities. This was pre-SDF, so I didn’t get to SDF these at all, but I’ll talk about that in a minute. This is what they looked like two years later with those top six as crowns. The parents elected to do SSCs on the molars.
I like to show this because it’s really cool. This was a post that mom made, not to me, but on Facebook. She had asked me to be her friend at the time, so she tagged me, and said: “Thank you for the beautiful pearly whites going on three years. They still look gorgeous. I truly wish you could keep them forever.”
Interestingly, they moved about five or six hours away from the practice. I saw them for a little while, they moved, and I hadn’t seen them until yesterday. Yesterday this sweet little girl came back to my practice. She needed an ortho extraction for an over-retained primary tooth. And there is that beautiful girl nine years later. I’m so fortunate to get to do what I do: a kid who, nine years later, is coming back to me even though they moved away and then moved back. She’s 14 now and sees a general dentist, so she doesn’t need my care, but she needed a tooth out and I’m helping with that. That’s how we get to impact kids’ lives, and I’m super thankful to get to do that.
Today we’re going to go through 10 different obstacles:
- Risk of pulp exposures
- Hyperocclusion
- Insufficient heme control
- Loss of retention
- Sizing and handling
- Cement cleanup
- Multi-unit cases
- Guiding the treatment planning decisions for parents
- Taking before and after photos
- Learning how and when to say no
We’ll do Q&A at the end and throughout, so if you have questions, pop them in the question box and I’ll try to answer them as I can.
[00:07:15] Obstacle 1: Pulp exposures
Let’s talk about pulp exposures first. I’ve got a quick question for you, and we’re going to do a poll, so I want everybody to jump on this. How often do you pulp a tooth when placing a zirconia crown? There’s no right and there’s no wrong, but I’m interested to see what everybody says.
I’ll give it another couple of seconds. They’re still coming in. This is really cool; they keep updating these softwares and they keep getting better at doing these fun things.
We started with this one because it’s probably the biggest hurdle: people feeling like, “I don’t like doing these because I have to pulp these teeth, and I do it all the time, and I hate doing that,” or feeling like it’s excessive.
All right, I think everybody’s done. Garrett, can we pop that poll up to show them?
Garrett: So right now when it goes to this, they can see it.
Oh, perfect. So you’re able to see that now. Here’s what we got: 7% of you said always, another 7% said often, 31% said sometimes, 48% said rarely and 7% said never. So we’re about half and half: half of us are sometimes, often or always, and the other half are rarely or never. That helps guide this a little bit.
Let me tell you what I see when I’m doing this, and why we end up getting those iatrogenic pulp exposures:
- Zirconia doesn’t flex, so we know we’re going to have to take away more tooth structure.
- The shape of the crown itself. Not all teeth are made equally; some have weird pieces and out-pockets, so you have to take away more.
- Sometimes we just over-prepare the tooth.
- We don’t know where we need to prep, so we keep prepping up around the pulp when we actually need to prep down below the gums.
Zirconia doesn’t flex, and that’s a big challenge. What we need is a consistent and conservative prep technique, and a crown with relaxed contours. That’s what Sprig did. If you look at this polyvinyl siloxane model, you’ll see straight, parallel walls with no taper. You want a preparation that is straight up and down on the long axis of the tooth. Same thing for the posterior teeth on a Sprig crown.
You can also see that the posterior crowns do not have a deep central fossa. The deeper the central fossa, the more you have to take away on the occlusal, which gets you nothing but closer to the pulp. Sprig decreased that cusp–fossa relationship. They also relaxed the contours of the crowns on the gingival portion, which allows the crown to seat with minimal reduction. And they came up with a prep technique that decreases the aggressiveness of the prep and gives you a systematic, simple and repeatable methodology, so you can repeat the process over and over with very predictable results.
If I were to answer that question, I would say I do not know that I have ever had to pulp a tooth for placing a Sprig crown. That doesn’t mean I’ve never pulped a tooth. There are absolutely teeth I’ve pulped because they had a really high pulp horn and I was doing a normal preparation and ended up in there. But I have not pulped a tooth just because it was a Sprig crown. I would probably have hit that pulp if I was doing a stainless steel crown too.
The reason is that most of the time, when I’m teaching this course in person and watching somebody prep, if the crown doesn’t fit, they start taking more off the coronal third, not the gingival third. The prep looks like this, and they keep taking in here, which gets you to the pulp, when what they needed to do was take the bottom part of the prep in. The problem is almost always in the gingival third of that coronal portion, or the subgingival portion, that you needed to take away.
So my answer is rarely to never. For the half of you who are rarely or never pulping, great. For the other half, I don’t think you’re wrong. You might be pulping because of large decay, and that’s one reason. But the second question is: is there a way you can prep more ideally and not have to pulp the tooth? My answer is yes. Whether that’s just trying with that goal in mind or coming to a hands-on course, I think that could be very helpful. If you’re going to pulp, so be it; that’s the way you practice. But I don’t want you to feel like you have to pulp a tooth every time you do a zirconia crown.
[00:13:36] Obstacle 2: Crowns that seat in hyperocclusion
Next, we’ve got crowns that seat in hyperocclusion. There are a few reasons I think this occurs.
Number one is hydrostatic pressure. This doesn’t happen with a stainless steel crown, because you snap it on the tooth and it pretty much stays there. These crowns have a relaxed fit, so they aren’t fitting super tight. Because of that, the hydrostatic forces of the heme can push the crown up. It can also happen because of inadequate preparation or because you didn’t angle the bur correctly, which goes back to what we were just talking about.
The hydrostatic pressure challenge can be overcome by holding the crown a little longer. After you’ve seated it, keep your finger on top of the crown and hold it down. It depends on which cement you use. For a Fuji I or a Ketac Cem, I think that’s a 30- to 60-second hold, depending on how thick the cement was when you seated it. During that time I’m doing cement cleanup. I’m holding the crowns down and using a toothbrush, which I’ll show in a minute, brushing along the margins and through the interproximal contacts, so I’m not wasting that time.
The second reason is that we just did not prep enough, and when we don’t prep enough, the crown will not come down. I rarely find it’s the occlusal preparation; each and every one of us is great at occlusal preparations. The problem is we all prep differently on the subgingival axial reduction, so you’re not getting enough circumferentially for the crown to seat all the way. It goes part of the way down and gets stuck.
That’s what you see here. On the top picture, the crown looks like it’s seated, but it’s got a little cant to it. That cant occurred because we didn’t take away enough of that distal ridge. That happened because instead of the bur being in the long axis, the bur got tilted in. You removed more on the coronal portion and less on the gingival third, and now the crown seats with a cant. So it’s very important that we keep the bur perpendicular.
The other thing we see is crowns seated in hyperocclusion that also had pulp therapy. We end up getting this ghost tooth appearance. You can see this crown on tooth L looks like a great prep and a great seat; everything looks good. However, there is no root left. It doesn’t look like an abscess; it looks like we just don’t have any root. What I have seen is that this happens primarily on teeth that were seated high and received pulp therapy. In my practice I am a minimal pulper of teeth, and we can talk about that later, but I believe it occurs secondary to pulp therapy plus a crown seating high.
I seat crowns high on a regular basis. I had a kid last week; we were doing great, and she started losing it right at the end. I would have liked to go around one more time and take a little more down so the crown would get a little further, but she was losing her mind. So we seated it, probably a millimeter and a half, maybe two millimeters high, and I told the parents, “Hey, listen, it’s going to feel funny for a couple of days, but let’s let this be. I’ve got another crown to do in a couple of weeks on the other side.” They said okay. Two weeks later that crown was in perfect occlusion. It had submerged itself one to two millimeters. Nothing problematic.
So if you’re not pulping the tooth, I have less concern about it seating marginally high than I do if you pulped it. If you pulped it, take away the appropriate amount of tooth structure and make sure you’re getting it into occlusion.
[00:17:45] Obstacle 3: Insufficient heme control
Insufficient heme control happens on front teeth more than back teeth. This was a case I did in residency, and I thought I did a good job: beautiful-looking crowns. Then I came back at a two-week follow-up and saw this dark, dark crown. This was before SDF. I think in this case I just didn’t do a good job of heme control. I probably got some of those hydrostatic forces pushing the crown up, so I pushed it back down, and that seeped the heme all the way up underneath in the cement.
The good news, if you will, is that it was bonded on there like crazy. It was not coming off; there was nothing I could do to get that crown off aside from breaking it. This was an uncooperative 2-year-old, so it stayed on. The parents were still very happy. These were huge areas of decay. But that is one problem.
I’ve said this multiple times, but bur angulation goes into this. If you’re angling the bur out instead of in, you’re taking too much tissue and creating more heme, and that heme is a problem for crown seating. There are different methods you can use to control the heme, which I’ll go over in a second. And you need to fill the crown all the way up. With a stainless steel crown, the crown doesn’t need to be full, because it’s going to squish away; we’ve got that snap fit. With these, you want the crown and the cement to squish the heme away and keep it from seeping back up underneath.
As I said, bur angulation is a problem. That little red line under there is your nemesis. If you angle the bur, you are going to create more problems than anything else.
There are great ways to control heme:
- Direct cotton pressure. Get a 2×2 and squeeze, or give it some time. Prep these first, go do your other things and come back; by then you’ll probably have good heme control.
- HemeRx. Those are great epi pellets provided by Sprig that you can put in those sites. You’re getting that epinephrine squeezing down those vessels.
- Traxodent, ViscoStat or any other hemostatic agent that you like.
The cement also needs to be one that can work in an environment with a little bit of heme. For me, that’s a pure glass ionomer cement. A pure glass ionomer also lets you wait until it reaches a thicker putty state before you seat it on the tooth, and that thicker putty will help squish away any of the heme too.
No questions yet; everybody seems to be doing good. Thumbs up. Any questions about those first three points? Cool.
[00:20:41] Obstacle 4: Loss of retention
We’ll move on to the next obstacle, which is loss of retention. Crowns can fall off for a few reasons: insufficient heme control; depending on the cement you use, a failure of the cement to the tooth or of the cement to the crown, which varies with the type of cement; or an incorrect crown size.
Cement failure occurs in one of two places. I will tell you that I have never had a Sprig crown come back to me that fell off without a full jacket of cement in the crown. The reason is the deep ridges Sprig mills into the crowns. Those create macro-mechanical retention of the cement in the crown. Because of that, you’re not trying to create a chemical bond, and it holds beautifully with our glass ionomer cement.
So when they come off, they come back with the cement in the crown. The margin broke between the cement and the tooth, and that can happen over time; we know that’s the case with a glass ionomer cement. But if you look at this picture behind me, you can see that the cement gap on this crown that exfoliated is very, very thin. Sprig’s crowns are made to fit very close on these teeth without a big, huge cement margin.
If you’re using a GI cement, you can still get some heme, and it will discolor, but it’s still going to stick on there, super strong. You can overcome that heme seep-in by having a thicker mix, whether that’s a hand mix or letting your triturated mix set for another 30 to 45 seconds before seating, so it gets to that tacky putty state.
If you’re using an RMGI, you’re getting some level of chemical bonding to the crown and to the tooth, and the problem is that it’s more risky when you have heme. An RMGI is still a good cement; there’s nothing wrong with it. It’s more expensive and a little more technique-sensitive than a pure glass ionomer. And if you’re using a resin cement or a Ceramir-type cement, you’re relying on a chemical bond to the tooth, and those cements need perfect isolation.
The other reason you can have a problem is the wrong crown size. You want a passive fit, but if you’re not careful, the crown can be way too big, and it looks like putting socks on a rooster. I don’t know if anybody here lives in the South, but that’s a saying in the South. It’s funny: I was teaching this course in Oklahoma a month or so ago, and somebody in the room beat me to it and said, “Oh, it looks like socks on a rooster.” Made me feel at home. So now you have a picture, and you can visualize socks on a rooster.
You want it to be passive, but if it’s too passive, there’s too large a cement gap. That will break down over time and you’ll lose the crown. So you need it big enough to be passive, but not so big that it’s like socks on a rooster.
[00:24:13] Obstacle 5: Sizing, placement and sterilization
Sizing is very similar to SSC sizing; there’s no special technique. If you try one in, or look at it and it’s dirty, you sterilize it and put it back in the tray.
As far as how you seat them, my best advice is always to seat them in whatever order you tried them in. I usually try centrals, then laterals, and I seat them centrals, then laterals. On posteriors, I seat second molar, then first molar, unless I try them in and they fit first molar then second molar; then that’s the order I seat them. Whatever way you try them in is the way you need to seat them.
As for taking the crown letters off: most of the parents I see who want these crowns are very aesthetically minded. The letters are very carefully baked onto the crowns, and holy cow, they are strong. The old Sprig letters came off pretty easily; the new ones are very strong. My recommendation is to scratch them off with a spoon excavator or a discoid-cleoid. I don’t usually do that on the anterior ones, because they’re on the palatal side and nobody sees them. But on any molars, I always scratch them off after I’ve seated the crown, because I don’t want a parent coming back two weeks later mad that there’s a blue letter on their kid’s tooth.
With these crowns, you get to seat the crown you tried in. There’s no special sterilization and no special try-in crowns. The one you try in is the one you put in the mouth. To sterilize them, they’re fully autoclavable. You can rinse and clean them however you like, then autoclave them. For us, they go in our shaker and then we autoclave them.
[00:26:14] Obstacle 6: Cement cleanup
Cement cleanup: everybody uses different cements. As I’ve said before, I’m a fan of minimizing the steps needed and the differences between procedures. I do everything I can to systematize what we do. I used to use RelyX and a pure glass ionomer, but I’ve changed, and now all I use is glass ionomer.
Glass ionomer has a challenge: there’s no tack-cure method, so you need perfect timing when you seat it. My goal is to get it to that tacky putty state and then seat the crown. With an RMGI, you can fill the crown, seat it and then tack-cure it. For some people that is absolutely what they like best, and I’ll show you pictures of both.
If it’s a pure GI, like Ketac Cem or Fuji I, you want to seat it while it’s in a putty state. Then I use a toothbrush and brush it away. I do not power-wash it. You can finish with Super Floss, knotted floss or toothbrush bristles placed in the interproximal space. The goal is never to lift the crown off and back. I don’t know if you can visualize this, but that’s the toothbrush, and I’m pushing it into the interproximal spaces, pushing and turning, pushing and turning. That’s how we get rid of the excess cement.
If you’re using an RMGI that you can tack-cure, you seat it, give it a couple of seconds of cure, flick away the extra cement and then use your Super Floss. This was an older case; you can see the crown letters are the black ones, so those aren’t the new ones. I used RelyX and tack-cured it, and then you’re flicking the cement off quick and easy because it’s nice and solid.
[00:28:11] Obstacle 7: Multi-unit cases, a six-minute video
Multi-unit cases: this is where I think everybody gets a little afraid. Before we talk about how to do them, I’m going to show you one of my cases. This was a back-to-back crown prep and seat. The whole thing, prep, size and seat, took six minutes. Let’s do a quick video and I’ll play that for you.
[…] (video starts; about 12 seconds without captions)
As I’m prepping here, I’ll talk through this. We’ve sped this up, so my hand doesn’t always move that fast, but you’re not sitting a whole six minutes listening to me. First, we’re doing occlusal reductions. I’m hitting the occlusal of the second molar and then moving on to the first molar.
The way I prep is very different from some people. Some people move in very slow, methodical steps. I am a light prep: light, light, light. That’s partly because I’m not using an electric handpiece. If you trained on electric handpieces, it never bogs down, so you just run through stuff. But if you’re not careful, that gets the tooth hotter. If I’m doing these on a kiddo who’s awake, I don’t want them to have more sensation, and I don’t want to have to numb super heavy. So I do very light infiltrations. If this kid were not under anesthesia, I’d do a very light infiltration. With more of a feather touch, I can work quickly without overheating any one area of the tooth, and I think that allows for less anesthetic and less sensitivity.
Here we’re doing the interproximal reduction and supragingival axial reduction. I’m breaking those planes and coming all the way around the tooth, creating my racetrack around both teeth. I think this is really the most important step. You’re making sure you get the full thickness of that bur. If I gave you a bird’s-eye view looking down, what you want to see is that you’ve taken away essentially all of the enamel. You should be pretty much right at the DEJ. The bur needs to be about 0.8 millimeters thick, and at 0.8 millimeters you’ve got essentially all of the enamel removed.
After that, you get into your subgingival reduction. At this point there’s barely any bleeding; we’ve got a little heme from me barely touching the tissues. Now we come in for the subgingival reduction. You can see I go very lightly into the sulcus and move around, taking away any little ledges all the way around the tooth in the subgingival portion.
[…] (about 10 seconds without captions)
Perfect. Finishing up on that second molar and moving on to the first. Same thing. As you can see, I’ve prepped this, and yes, there is heme, yes, it’s bleeding, but the tissue isn’t torn to hamburger. It doesn’t look like a big hot mess with blood gushing everywhere. That makes it much easier to control heme later and much easier to seat my crowns. Again, maintain the long-axis angulation of the bur and be careful with your gingival tissues.
There’s the prep. Now we’re going to try some crowns in. Grab me a couple of quick crowns. Like the way that one fit. Beautiful. Trying the second one; like the way it fit. Very good. Boom, boom.
You can see one of those was a K3 SL. I did these back to back, one of them a space-loss crown and the other not. And as you saw quickly at the end, I had the top ones to do too. This was actually a kid under anesthesia, and we did eight zirconia crowns on the posteriors.
[00:33:10] Multi-unit cases: the full kit, space loss, and knowing when not to
For multi-unit cases, you want to have all the crown sizes. Don’t just have sizes three, four and five; you want ones, twos, threes, fours, fives, sixes and sevens. I really do not think there’s ever a time it makes sense to have less than the full crown box, so please make sure you have that available. That’s super important.
Number two is space loss. Sometimes you’ve got back-to-back teeth, and maybe one has really severe decay and the other doesn’t. If they’ve tipped in really far, it might not be a good idea to try to do both as zirconia crowns. Sometimes make the case that you’re going to do a really great composite on the mesial of the second molar and a zirconia crown on the first molar, or vice versa. Let’s not treat every kid the same. Each kid brings a different case. There are textbooks, and then there’s the kid sitting in your chair.
There are absolutely times I realize that if I try to put back-to-back zirconia crowns on, it’s going to be much more challenging for that kid and it’s not worth it. So one can be a composite and the other a zirconia crown, and I can do that quicker, easier and faster, maybe without anesthesia instead of having to go all the way to anesthesia. Think outside the box; there’s no one way to do it.
The other option is sometimes one is a zirconia crown and one is a stainless steel crown. There are times I’m talking with a parent and I know trying to do two zirconias there is going to be really challenging, so we do the most anterior crown as a zirconia. If you do that and you’ve got a stainless steel crown opposing it, you’ll sometimes get some rub-off of the stainless steel crown on the occlusal surface. It will polish off, but be aware of it.
And always, always, always: you do not have to do the case. Hear me say that. You do not have to do the case. You are in control. I think this is the anti-Nike ad: just don’t do it. Sometimes you don’t need to. Don’t do the case when it doesn’t feel like the right thing in your hands. There are cases for you to do and cases for you not to do. If it’s your first case, it might not be the one to try. If it’s your 150th case, maybe you’re more confident and able to do it. But it is okay to say, “I have limitations, and today that is not the one I’m going to do.”
[00:36:00] Obstacle 8: Guiding treatment planning decisions
You need to be able to guide the treatment planning decisions. The problem I see with people who get burned out on these is that they start with the wrong case. A kid walks in, you decide this is going to be such a big one and it’s awesome, and maybe you choose this case to start with. This was a 20-unit case that Dr. Igowski did, if I remember correctly. This kiddo had DIOI, so we had significant breakdown of the teeth and she needed 20 crowns. She was able to get beautiful aesthetics and occlusion on those 20 crowns. Please, for goodness’ sake, this is not your first case.
What I tell people all the time in my practice is: do not oversell your ability. Undersell and over-deliver all day long. You will always be happier and sleep better at night if you undersell and over-deliver as opposed to the opposite.
The other question is how you’re going to guide this treatment plan if you’re a practice that sees Medicaid patients. That is a very interesting and challenging question. There are many states where Medicaid will cover D2929, and if you can do that, great. If you can’t, let’s talk about the options you have.
One option is to not do them: “I don’t offer them for patients with Medicaid.” That’s okay; that’s what you’ve chosen to do, and there’s nothing wrong with that. You can offer them at your normal price: “You have Medicaid. These crowns cost $400 apiece. If you want a white crown, I’ll offer it to you at $400.” Or, since you’re already seeing these patients and you know they need this care, can you offer them at a discounted price, or a slightly higher price than Medicaid would pay you? If Medicaid would pay you $150 for these crowns, will you offer it to them at that, since that’s what you’d get anyway? And you can offer them for free if that’s what you want to do. If this is a give-back, give it back.
In my practice, we offer them to our patients with Medicaid at a discounted price. Texas Medicaid doesn’t cover D2929, so if our patients would like a zirconia crown instead of a resin-faced stainless steel crown, we offer it at a heavily, heavily discounted price, essentially what Medicaid would pay me for the crown anyway. The reason is that I do not want to do a resin-faced stainless steel crown. I know they’re going to break. I know they’re not going to look good. I know I’m going to have to take away more tooth structure. I know the parents aren’t going to be happy with them. So why do them? I would be doing these for the exact same reimbursement I get for the resin-faced stainless steel crowns. So we offer it at that, and a lot of our patients take us up on it. Not everybody, we understand, but that’s worked in my practice.
[00:38:59] Obstacle 9: Before and after photos
I think it’s important to take before and after photos. If you want to show what you did, your patients need to be able to see it. I thought this was a great quote. It’s a Vince Lombardi quote: the dictionary is the only place that success comes before work. If you’re expecting to be successful before putting in the work, that doesn’t happen. You’re going to put in great work, but let’s not forget to take pictures of what you’ve done, so you can go back and critique yourself, and so you can show your patients that you’ve done this, you know what you’re doing, and you can do it again.
You need a good camera to do that, so here’s what I use. There are expensive ones and cheap ones; you can spend anywhere from $700 to $2,000 on a DSLR. You can get them on eBay, find ring flashes and a macro lens, and you’re set to go. These are the settings I use: we put it in M mode at 1/50, f/32 and ISO 200, with the three on the automatic white balance. It takes beautiful pictures. All the pictures I’ve shown were taken with it. It’s not super expensive, but there is a learning curve.
Another good camera is this Shofu. It’s a point-and-shoot, but it automatically adjusts the color and makes it look like a really beautiful intraoral photo. It doesn’t take images fast, so if you’re trying to go click, click, click, it won’t do that, but it takes really nice images.
And if you just want something so you can show insurance companies and show the parents a little bit, I have these too. This is a great intraoral camera for $180. I’ve got one at every chair in my office, and they integrate immediately into my software. If I want a picture of an occlusal or an intraoperative shot, this is what we grab.
After you’ve taken your pictures, you can put them together and use them as a resource for your patients, to show what you’re doing and what to expect postoperatively.
[00:41:29] Obstacle 10: Learning to say no, and communicating with parents
You also need to learn how to say no. I said this a little earlier, but you need to realize when this is not the right treatment for this patient, and why. Is it a contraindication — this is just really not the right crown for this kiddo? Or is it a parent consideration, where the parent is being outrageous or unruly, or just isn’t able to fully grasp what you’re trying to tell them?
When you can’t get this figured out with a parent, I will tell you it is always about communication. This was a really great book; I finished it probably six or eight months ago. I’ve always thought I was a good communicator with my patients, but this book challenged me in some new ways to understand what’s really going on. If you can take the principles of this book and apply them to your daily conversations with patients, I can tell you that you’ll become an exceptional provider without improving any of your clinical skills. But this is the greatest clinical skill you can have: being able to communicate.
You need to understand, for that parent, what’s really going on. Why are they pushing so hard for these zirconia crowns? Why won’t they let you do anesthesia for their kid when you know that’s the right thing to do? If all you do is look at the surface and think, “Gosh, you’re a bad parent because you won’t let me do this,” the problem is probably the provider. It’s really that you never got to the root of what was going on. If you listen for the cues they give you in the conversation, you get to understand what’s really going on.
What happens is you’re trying to have an analytical conversation with them, and they’re having an emotional reaction. You need to understand that, get into the conversation with them, hear their emotional reaction and address that. Maybe they don’t want to do anesthesia, and when you get to the root of it, it’s because their grandmother had an adverse event under anesthesia and passed away two weeks ago. I’ve had that happen. And you go, “Gosh, that’s really hard. That is an absolutely hard thing to take, and I’m so sorry that happened.” Now I can emotionally disengage from that, talk about it with them, get to what’s really going on, and address their concerns, as opposed to treating them like a bad parent because they’re not listening to you. What’s really happening is they’re not listening to you, but you’re not listening to them to find out what’s going on.
So if you take one thing away from this, I would say: learn how to communicate with your staff and with your patients. This is a phenomenal book. Check it out; I think you’ll love it.
[00:44:34] Bonus: Train your team
That was 10, but I put a couple of extra ones on here. You want to train your team and make sure they know what you’re doing. Your team does more than suck and spit, I guarantee you. As soon as you walk out of that room, your team had better believe in and understand the treatment plan you put together. When you walk out, the parent undoubtedly turns to your team member and says, “Should I do that? Why would they recommend that? Do you think I should do this?” You’re the doctor, right? But holy cow, you walked out, and now they’re talking to your team and asking them. If your team says, “I don’t know,” then oh my goodness gracious, there is no way they’re going to feel comfortable going forward with that treatment plan.
So you need a team that believes in you and understands why you’re doing this. Give them that insight and take good care of them. Let your team members know that you appreciate them and that they’re doing much more than suck and spit.
The other thing your team member needs to do is fill the crown all the way up with cement. They’re the ones mixing the cement and filling the crown, so make sure they fill it all the way up. You want to set yourself up for success. If a crown doesn’t have enough cement in it, it’s going to come off, or you’ll get heme or show-through of the SDF, and you want to make sure that doesn’t happen.
[00:46:06] Bonus: Do you need to remove decay after SDF?
Speaking of SDF, another great question we’ve gotten is whether you need to remove the decay after SDF placement. When you’re prepping the crown, do you need to remove the SDF? I will tell you the answer is no way. Nope. Keep calm and do not do it.
Let’s talk about SDF really quickly. What does SDF do? It kills bacteria and it hardens the lesion. We know from the literature that indirect pulp caps are as effective as, if not more effective than, pulp therapy. An IPC is considered anything that seals off the decay or bacteria from their food source and thus inactivates their progression. If we’re doing that, there is no reason to take away the decay below the SDF, because the SDF has already killed the bacteria. All you’re doing is spinning your wheels.
Look at a case like this. This was a kiddo I did crowns on, and you can see how hard that SDF is; it’s shiny across the surface. That is remineralized, strong tooth structure, and it does great. I did not take away decay. I prepped those teeth with an ideal crown prep and seated the crowns. Same thing here.
This was the initial visit, up top. Another provider had told them these teeth were unsavable, unfixable, and probably had to be extracted. What I did was place SDF and Equia. The Equia sort of came out, but you can see some of the Equia in there. The second picture is the day of treatment. You can see how dark black those are and how large these areas of decay are on these molars. Really, really large areas of decay.
Interestingly, I hear people say all the time that they can see the decay in the pulp. My question to you is: how can you see the decay in the pulp when you’re looking at a two-dimensional image of a three-dimensional tooth? On this bottom X-ray, it looks like every bit of that decay is in the pulp. However, on the upper bitewing you can see there’s actually some space between the decay and the pulp.
Not a single one of these teeth received pulp therapy or direct pulp therapy from me. I did not take away decay. I completed ideal preparations. This was a two-year-later pano. This was a three-year-later bitewing and clinical photos. This was a six-year-later bitewing. This was seven and a half years later: an exfoliated tooth. No pulps. Saved the teeth. Placed SDF. Completed ideal preparations, not decay-removal preparations.
[00:49:04] Bonus: Ankylosed teeth
These are interesting ones, a bit of the heroics you can do from time to time. You’ve got these ankylosed teeth; what do you need to do with them? There are a few reasons we want to treat them. You’ve got a tooth that’s submerged. Does it have decay on it? Or am I just trying to restore the occlusion to prevent the mesial tip of the distal molar?
If I’m putting a crown on to raise the roof, you do minimal occlusal preparation, if any. You just get your circumferential prep and let the crown sit higher, at the appropriate occlusal plane. However, if you’re doing it because there’s decay on the distal or mesial of that tooth, you’ll have to do more subgingival preparation to cover the depth of that decay.
[00:50:00] Wrap-up: the learning curve, contact details and Sprig courses
Ultimately, you’ve got this. You’ve been doing these; that’s probably why you’re on this webinar. I hope you’ve gotten a couple of tips or had some questions answered. There is a challenge. There is a curve. After you’ve done three of them, you’re getting started. You start feeling confident at 10. And after you’ve done 30, you’re not thinking about it anymore. It just shows up on your schedule, you walk in and do your preps just like you normally would, and you get it done.
Again, we need to have a strategy. That’s what I hope you’ve gained a little more of today. If all you have is tactics without strategy, it’s just noise before defeat.
All right, let’s do a little Q&A now and talk about your obstacles. This is my contact info: my cell phone, my email and the web address for my practice. Check it out. If anybody wants to come to Lubbock, Texas, hang out with me and watch me do this, give me a shout. If you want to come see our practice, come do that. And if you’re looking for a change and want to move to Lubbock, I’ve got a great, growing practice and am always interested in the right pediatric dentist coming to join us. I’ve got an amazing team I love working with each and every day.
If you’re interested in Sprig universities, you can get in touch with Cynthia at Sprig USA. There are a couple coming up in 2025. Las Vegas has already sold out, and there are some limited seats at the Chicago course. Scan that QR code or look on their website. Those are full-day workshops with eight CE units, and you get to do a lot of hands-on skills there.
[00:52:04] Q&A: Sequencing hemostasis in a GA case
All right, let’s pull up some questions. Does anybody have any questions or comments I can answer for you?
[…] (about 14 seconds without captions)
Looks like somebody raised their hand. I don’t know if we can make it so you can talk. I think it was Jacob. If you want to type it, there should be a question box, and it will show up here for me.
And if you don’t have questions and want to say something in chat, like “This is the greatest webinar I’ve ever taken, I’m so glad I did this,” that’s awesome. If you say, “Man, this is awful,” that’s okay too. I love feedback either way. Tell me what you think.
Awesome, thanks, Dusty. I think someone was able to unmute him. Sweet, love it. All right, Jacob, tell me your question.
Jacob: Appreciate it. Thanks for putting on the webinar; I’ve learned a lot. I think I might have missed a couple of things. I was in and out on the drive home from the West Coast, actually over at UDub, near your old stomping grounds. I wanted to get your take on your preferred technique for obtaining hemostasis. Right now I’m just working with anterior zirconia crowns. When you’re in GA, are you prepping and cementing before you go and do your posterior crowns or composites, or are you prepping, using some HemeRx, coming back to it later and cementing later?
Great question, thank you, Jacob. Over the years I’ve done different things, and I don’t think there’s one specific method that always works. But what I’ve come to for the last six or eight years: say I’m in GA and doing a case with 12 crowns, all my posteriors and my four anteriors. I prep all my posteriors and fit all of them first. Then I prep and fit my anteriors. At that point I go back and use either the HemeRx or Traxodent, which is a hemostatic retraction paste. It’s a lot more expensive than the HemeRx, but I have it at the hospital I work at and it’s built into the fees there, so I use it there.
I put the HemeRx or the Traxodent in, then I seat all eight posterior crowns. Then I rinse the Traxodent off and seat my anteriors. That gave the Traxodent a good minute or so to set and get good hemostasis, and now I can cement those anteriors. Whether it’s the Traxodent or the HemeRx, if you’ve given it a good minute of wait time, you’ll have really nice control, especially if you used the prep technique and were careful with the gingival tissue. They’ll look really nice and you won’t have heme control to worry about.
The other thing that helps, if you’re using a glass ionomer cement, is getting it to that thicker putty set. The putty will squish out any extra heme you have, and I think that also gives a good finish. Those are my tricks.
The other option, if you just want time on your side: prep the anteriors first, get them ready to seat and set them to the side. Now go do your posteriors. That gives you time, and at the end, if you’re still getting some heme, you can always use HemeRx, Traxodent or whatever. Now you’ve got both factors working for you: the chemical side as well as time.
Jacob: Great. Awesome. I appreciate it. Thanks so much.
Absolutely. Thanks so much, Jacob.
[00:56:28] Q&A: Sprig vs BioFlex, starting sizes, and strip crowns
I’ve got a couple of questions here in the chat. Great question: Jennifer asked how the Sprig crowns compare to the BioFlex crowns. My answer is they don’t compare. I have not specifically used the BioFlex crowns. I’ve used some other prototype crowns in the past that were very similar. The problem I’ve seen, and maybe you’ve seen it on some of the iPedo message boards or other pediatric and general message boards, is the post: “I placed these crowns six months ago and they all have holes in them.” That’s less than ideal. So I would say they don’t compare at all. Sprig crowns are never going to wear a hole in them. If I’m doing a crown, especially for a kid under anesthesia, man, I want something long-lasting, and based on where a BioFlex crown currently stands, it doesn’t seem like that’s the case. So if I’m looking for an aesthetic restoration, I’m going to use a Sprig crown.
The difference is that a BioFlex crown has some flex to it, and that’s definitely a pro. The problem is that if the crown flexes, it’s still going to flex once you seat it. If it flexes back and forth over time, you’re going to break that cement down, whether it’s a resin or an RMGI. You’ll break the bond, and over time you’ll lose the crown. That was the bigger problem I saw with the different prototypes of flexible white crowns I tried in the past. I can’t say the BioFlex crowns don’t have an application; I absolutely think there’s a place for them. It just hasn’t been one I’ve jumped to use in my practice.
Baron was asking about the sizing you start with. I think it’s absolutely great to start with whatever sizes you start with for stainless steel crowns. Baron says he starts with a size three on second molars and a five on firsts. I think that’s a great starting point. In my patient population, fives are very regularly what I use on first molars. But when I was in residency in Washington, we worked on a lot of Native American kiddos, and man, those kiddos had the largest teeth, so I was routinely using sevens. So for your population, whichever sizes you’re using are a great starting point. And there are definitely times you look at a tooth and think, “That is a weird-shaped tooth,” and that’s where a space-loss crown is really nice. There are times I’ve put a B crown on a lower L because that was just the way the tooth looked. But yes, starting with a size that fits similar to an SSC is a good starting point.
Rebecca was asking about anterior strip crowns or a porcelain-faced option as opposed to just zirconia. I would say absolutely: I like to have all the things in the bag. Strip crowns still have a place in my practice. What’s changed is that my strip crowns usually aren’t composite anymore; I’m using Equia Forte. I use them as temporary restorations on a severe fracture, and as long-standing restorations for a kid with special needs whom I know I’m not going to get to the OR for a while. I had a kiddo for four years with Equia strip crowns on her lower anteriors, and they lasted four years before they started breaking down. I can’t ask for better than that. I didn’t go to the OR; this was a kid with severe special needs who wasn’t a great candidate.
So I think taking something out of your toolkit is not advisable, but I love the idea of adding things to it. I do not like resin-faced stainless steel crowns, and if I had my druthers, I would 100% get rid of them. If Texas Medicaid approved D2929, I would never do a resin-faced stainless steel crown again. But it’s still nice to know that you can, and I fix them semi-regularly too. I had a kiddo the other day who broke one off. They were a well-behaved kiddo, so I made it a resin cutout crown: I cut the entire face off and put new composite in. It looks all right; it’s good for that kid and will serve better than the broken face. Having good options is a good thing. Don’t take things out of your cart; keep adding them, and then you get to be the authority, able to offer the best service customized to that patient.
[01:01:50] Q&A: Permanent teeth, where beginners should start, and closing
Richard asked about selective caries removal and SDF, and trying to stay out of the pulp on permanent teeth. Thank you, Richard, I appreciate that question; that’s a good one I didn’t touch on. I’m a hundred percent proponent of indirect pulp caps under SSCs on primary teeth. On permanent teeth, I have found that the indirect pulp cap methodology works less well than it does on a primary tooth.
So for me, in my hands, I use SDF as a medicament to slow or stop caries and get me to a place where I can restore. Then I remove decay to the point that it’s gone and I’m into only affected dentin over the deepest portion. Then we either place SDF again or do a pulp medicament. New literature supports the use of MTA in that case. I absolutely love MTA, and if we get any pulp exposures, I think the greatest thing you can do is get all the decay out, get a direct pulp exposure and place MTA over it. There’s some new literature supporting the improved success of pulpotomies on permanent teeth as opposed to full root canal treatments, and MTA shows great promise with those, including some good new endo literature supporting MTA for pulpotomy on permanent teeth. So for me, the long-term answer on permanent teeth is a direct pulp cap and full decay removal.
Thank you. Lisa asked: if we’re completely new to this, what’s the easiest thing to start with, posteriors or anteriors? Thinking about the cost of the kits and buying one kit first, where do you start? My take is that your first place should probably be the anteriors. The anteriors are easier to place, and I think you get more bang for your buck. A lot more patients come in asking for anterior crowns than posteriors, depending on your area. So if you’re going to start somewhere, starting with the anteriors is great.
As you move to the posteriors, I think the easiest ones to start with are the Ls and Ss. They’re almost always your easiest posteriors to place, because you’ve got some primate space to slide into and they’re a good-sized tooth. The only thing to remember on Ls and Ss is to stay in the long axis of the tooth. Don’t follow the buccal bulge and tilt your bur. That’s the biggest problem we see there.
All right, I think I got all the questions. I actually did like getting to interact with a human; that was really great, Garrett. I’m glad we were able to get him on audio. I felt like I got to call up a phone-a-friend. That’s the hardest thing about webinars: feeling like I’m talking to a brick wall.
Garrett: Yeah, we had a little radio show moment there.
I know, I like it. I like this. We could do this again. Okay, any other questions? A couple more seconds if anybody has anything else.
I really hope this was beneficial for you. Thank you all for spending some time with me this evening, especially those of you on the West Coast; I know it was hitting right after practice time today. Shoot me texts or emails anytime. I love getting to help out. After the last one of these, I had three or four different people reach out with questions, so take me up on it and let’s be in touch. We’re all a little bit crazy, and it’s nice to interact with some other crazy people like myself. Have an awesome evening, and thanks for spending an hour and 15 minutes of time with me. Y’all take care.
