Page 1

MAY 2016


Setting more on Page 58

A Texas-Sized accomplishment Dallas-based duo cOMPLETEs THE FIRST FULL-MOUTH ZIRCONIA CASE IN TEXAS.

10 essentials for a dynamic, successful pediatric practice.

PEDIATRIC ZIRCONIA GOES DOWN UNDER My experience introducing Pediatric Zirconia Crowns to Western Australia. more on Page 38

Hansen more on Page 42




E ZP E D O M agazi ne / M ay 2016











EZP ED O M ag az i n e / M a y 2016


Table of Contents


G ROW I NG T H ROUG H S ERV IC E Dr. Fisher's daughter reflects on her family's recent mission


trip to Palau.

10 ES SE NTIA LS For a dynamic, successful pediatric practice.


17 JOUR N EY TO EXC ELLENC E (Mis)Steps along the way and a final satisfying discovery.

TRE ND SE TTING How Zirconia crowns are changing pediatric dentistry and how one residency program keeps pace.

22 A TE XA S-SIZE D ACCOM PLISHM E NT Dallas-based duo completes the first full-mouth Zirconia case in Texas.


MY 20-Y EA R QU E ST How I finally discovered a quality white pediatric crown.



Pages 17–18 J O U R N E Y T O E XC E L L E N C E


BY ANDREW JASON SHANNON, DMD (Mis)Steps along the way and a final satisfying discovery.

My experience introducing pediatric Zirconia crowns to

Pages 20–21

Western Australia.

MY 20-YEAR QUEST B Y T E R R Y R A M S E Y, D D S How I finally discovered a quality white pediatric crown.

Pages 22–25 A T E X A S - S I Z E D ACCO M P L I S H M E N T E Z P E D O I N T E R V I E W S E R I K H A R R I N G TO N , D D S , P H D AND ALLEN RAPOLLA, DDS Dallas-based duo completes the first full-mouth


Zirconia case in Texas.

Pages 26–29 MAKING LEMONADE B Y E V E LY N E V U - T I E N , D D S A N D J E F F R E Y P. F I S H E R , D D S Turning a sour clinical situation into a sweet result.

Pages 30–31 THE 10 ESSENTIALS

A dentist in Romania places

B Y C AT H Y J A M E S O N , P H D

Zirconia crowns to last a

The 10 essentials for a dynamic, successful pediatric practice.


Pages 32–37 MAKING A PERMANENT DIFFERENCE B Y A N A V I N AU, D D S A dentist in Romania places Zirconia crowns to last a lifetime.

Pages 38–41 P E D I AT R I C Z I R CO N I A G O E S D O W N U N D E R BY MARK FOSTER, BDS, FICD My experience introducing pediatric Zirconia crowns to Western Australia.


Pages 42–49 BRENDA HANSEN B Y AU B R E Y G O O D E N , M S A mom's mission to help her son leads to a revolution in pediatric crowns.

BRE NDA HA NS E N A mom’s mission to help her

Pages 50–54

son leads to a revolution


in pediatric crowns.

B Y T I F FA N Y F I S H E R Dr. Fisher's daughter reflects on her family's recent mission trip to Palau.

Pages 58–61

26 MA KI NG LEMONA DE Turning a sour clinical situation into a sweet result.

TRENDSET TING B Y M A R T H A W E L L S , D M D, M S , AND LARRY DORMOIS, DDS, MS How Zirconia crowns are changing pediatric dentistry and how one residency program keeps pace.

Perfectly Natural

Every once in a while something comes along that changes everything about the way you practice. A product so advanced yet so simple, using it just seems entirely logical.




EZPEDO is proud to show you the real smiles of the children whose lives we have touched. So remember, if you see them in our ads, it’s because they’re our patients.

Contributors Mark Foster, BDS, FICD Mark Foster, BDS, FICD, has a dental practice that is limited to the treatment of children and special needs patients. He is a consultant at Princess Margaret Hospital for Children in Perth and a senior lecturer at the University of Western Australia.

Andrew Shannon, DMD Andrew Jason Shannon, DMD, is the owner of Tooth Town of Vienna located in Vienna, Virginia. He received his dental degree from Tufts University and then completed his residency through Luthren Medical Center at the Providence, Rhode Island site. He married his middle school sweetheart, Linda, and is the proud father to his beautiful daughter Charlotte.

Evelyne Vu-Tien, DDS Evelyne Vu-Tien, DDS, is a specialty graduate of Rady’s Children’s Hospital of San Diego and a Diplomate of the American Board of Pediatric Dentistry. She completed her dental training at the University of California, San Francisco and is currently in private practice in San Diego, California. Outside the office, she enjoys spending time with her husband and two daughters, Reagan and Josephine.

Cathy Jameson, PhD Cathy Jameson, PhD, is founder of Jameson Management, a management, marketing and hygiene coaching firm, helping dentists and teams increase productivity and profitability. As a speaker, she delivers enteraining and educational programs to audiences worldwide. Cathy is a best-selling author. Her most recent title is Creating a Healthy Work Environment.

Erik Harrington, DDS, PhD & Allen Rapolla, DDS Erik Kern Harrington, DDS, PhD​, and Allen Rapolla​, DDS,​are team members for Oral Health Industries, LLC (OHI), a for-profit entity in Texas. They are committed to special needs, underprivileged and special case management as an integral part of their patient care. They are​founding doctors of Window to the Body, Inc., a non-profit in Texas.

Aubrey Gooden, MS Aubrey is a communications professional based in Boston. She is a graduate of Oklahoma State University and earned her master’s degree from New York University. Currently she is a senior director at Gooden Group.

Ana Vinau, DDS Ana Vinau, DDS, works as a pediatric dentist at Dent Estet 4 Kids and is currently practicing at a clinic in Timisoara, Romania. She is a member of numerous pediatric dental teams, founded by Dr. Oana Taban in 2008. Dr. Vinau received her dental degree from the University of Dental Medicine and Pharmacy, "Victor Babes," Timisoara, and is currently getting her master's degree in periodontology.

Tiffany Fisher Tiffany Fisher, 17, is a high school junior attending a private school in Northern California. She enjoys horses, sings in choir, and discovered a deeper love for service while on a recent schoolsponsored trip to Palau. Her father is Dr. Jeff Fisher, EZPM Editor-in-Chief.

Martha Wells, DMD, MS & Larry Dormois, DDS, MS Martha Wells, DMD, MS, and Larry Dormois, DDS, MS, are both Associate Professors at The University of Tennessee Health Science Center, Memphis, Tenn. Dr. Wells is Program Director and Dr. Dormois is Chairman, respectively, of the Pediatric Dentistry Residency Program.

Terry Ramsey, DDS Terry Ramsey, DDS, graduated from Georgetown University Dental School in 1979. Following graduation, he enlisted in the U.S. Navy, where he served as a dental officer on the USS DENVER (LPD-9). Since finishing his pediatric dental residency at Virginia Commonwealth University in 1991, he has been a practicing pediatric dentist in Scottsdale, Arizona. He is a Fellow of the ABPD, AAPD and ICD.





I’ve always heard that a small amount of stress is actually good for us. It keeps us motivated. On our toes. But where do we draw the line? The truth is we all have different kinds of stress in our lives. There’s the kind we place on ourselves—always trying to improve, striving to get better. Then there’s the kind of stress we experience when we feel like we're letting someone down—forgetting an important deadline or doing something that causes close associates or family to feel unimportant or unappreciated. And then there’s our iPhones. I don’t even need to explain that one. We all must admit, if we are true to ourselves, that our era is characterized by an addiction to digital media. Email. Texting. Facebook. We’ve trained ourselves to check our smart phones every few minutes. Our constant dependence on these stimuli has virtually crippled our capacity to ever truly relax. So, what’s the solution? What should we be doing to help alleviate the stressors in our lives? I’m not claiming to have all the answers, but I am committed to trying a simple approach—one championed at Weimar Institute, a private healthcare and educational institution in the foothills of Northern California. They have developed a lifestyle enhancing program known by the acronym NEWSTART®, designed to restore health and balance in people’s daily lives. Their eight fundamental lifestyle stress-reducing principles are: Nutrition: Eat a well-balanced diet with plenty of fruits and veggies. Exercise: Take at least 30 minutes each day for a jog or a brisk walk. Water: Stay optimally hydrated by drinking adequate water each day. Sunshine: Spend some time outside in the sun but avoid overexposure. Temperance: Remember to do all things in moderation—be temperate. Air: Take advantage of pure, fresh air; breathe deeply out in nature. Rest: Get adequate sleep and plan time for relaxation and recreation. Trust: Trust in Divine Power; discover the peace of mind God imparts.

EZPEDO MAGAZINE Vol. 2 No. 1 May 2016



6140 Horseshoe Bar Road, Suite L

Loomis, CA 95650


+1 (888) 539 7336


+1 (916) 677 1447





M A G A Z I N E S TA F F JEFFREY FISHER, DDS Editor-in-Chief JAMES FISHER, MSPH, PhD Senior Consulting Editor ANN FISHER Copy Editor VLADIMIR SHCHERBAK Managing Editor D A N N Y VA K A R Y U K Art Director T I M OT H Y S H A M B R A Senior Designer

C O N T R I B U TO R S Andrew Shannon, DMD Terry Ramsey, DDS Mark Foster, BDS, FICD Ana Vinau, DDS Erik Harrington, DDS, PhD Allen Rapolla, DDS Aubrey Gooden, MS

You will notice a new emphasis on some of these principles in this issue. See Brenda’s article with some inspirational thoughts on good nutrition. Also, note Tiffany’s article highlighting recreation, sunlight, service, and the building of a new center for the promotion of healthy living on the island of Palau. EZPEDO is planning new and exciting things this year. Undoubtedly, there will be times that push the stress-o-meter to the limit. Stress is an inevitable part of life, but it’s how we react that makes the difference. If you find yourself like me, at times over stressed but wanting to adopt a more balanced lifestyle, this just might be the perfect time to join me in making a renewed commitment to managing those stressful times better. I’d love to hear your thoughts, too. So please don’t hesitate to share your ideas or suggestions by dropping me a line at editor@ezpedo.com. Let’s make 2016 the healthiest year ever!

Cathy Jameson, PhD Tiffany Fisher Evelyne Vu-Tien, DDS Martha Wells, DMD, MS Larry Dormois, DDS, MS

D I G I TA L E D I T I O N www.ezpedo.com/publications

For new subscriptions, subscribe at ezpedo.com For all other reader services, including letters to the editor, write to editor@ezpedo.com

Jeffrey P. Fisher, DDS Editor-in-Chief



P E O P L E , P L A C E S , A N D PARTIES Lindsey and Parker Robinson with John Hansen

Nolan and Alycia Gerlach.

Welcome reception at the Grove

Brenda Hansen

Susan Hinckfuss

Brenda Hansen and Lajuan Hall

EZPEDO sponsored the dinner on opening night for the CSPD/WSPD 2016 annual meeting held this year in Napa, California.

Sarah Hulland and Kari McMillan Frantz Valeria Pereira and Dr. Fisher with LLU residents

Caroline Hong, Diane Kozik, Donna and Mike Bartyczak, Jeff Fisher Vanesa and Eddy Correa

Phi Luong

Estella (Hui-Wan) Liu Paulo and Valeria Pereira, Je Fisher, Lora Greenwald

REMEMBER THE GOOD TIMES This yearĘźs CSPD/WSPD annual meeting was held at the Silverado Resort and Spa located in the heart of the worldfamous Napa Valley Wine Country. This event was a lot of fun and another great opportunity to connect with friends of EZPEDO.

James Kozik, Camille Nishikawa and Janelle Holden

Sarah Johnson, Jeff Fisher and Brenda Hansen

Joelle Speed

James Kozik, Diane Kozik, Donna and Mike Bartyczak

Valeria Pereira, Christine Kim, Jessica Machado, Hanieh Hassani, Linda Ngo, Jung-wei (Anna) Chen and Estella (Hui-Wan) Liu

Great food, great conversations

Je Fisher and Arlene Joyner-Tucker

Martha Ann Keels, John Hansen and Je Fisher

Ralph and Christy Zotovich

John and Brenda Hansen

Brenda talks about what makes EZPEDO so special.

LOVING AND CARING It was an absolute joy to spend quality time with a sizeable number of pediatric dentists. You are a loving, caring group of human beings, and we at EZPEDO highly value the care you are providing for our next generation of pediatric patients.

EZPEDO ra e winners Susan Hinckfuss , Shandra Suktalordcheep, Iveta Markova

Silverado Resort and Spa


Dr. Karan Estwick is a pediatric dentist in private practice and a proud user of EZPEDO crowns in Howell, New Jersey.


E ZP E D O M agazi ne / M ay 201 6

“I used your crowns today and the esthetics were, awesome sauce! I’m so happy that I switched from another brand.” PROGRAM DESTINATIONS FOR 2017




ot . k is n ss by luc cce Su ieved d. e ach learn ezpu.org at It’s line Re

er on gist

7 1/2 las 4 2/2 ver 1 Den 3/3 /21 anta Atl as 4 Veg 2 as 5/1 L cago 6/23 u Chi /4 olul a8 /3 Hon elphi 11 lad co Phi ncis /8 ra F 12 San sdale tt Sco


Discover the difference for yourself by attending EZPEDO University this year.

Register online at ezpu.org

EZP ED O M ag azi n e / M a y 2016



Instruction and inspiration for pediatric dental professionals from the pioneers of pediatric Zirconia crowns and the innovative leaders forging tomorrow's New Generation Technology. Learn more about our proven innovation and discover how to use EZPEDO crowns to help grow your practice.


EST. 2013

Join Us

Register online at ezpu.org



I GRADUATED FROM my pediatric dental residency in 2007. At the time there were very limited choices when it came to "white" pediatric crowns. To be honest, we didn't have much demand for these types of crowns in my residency program in Rhode Island. That soon changed when I moved back to Northern Virginia and started my own practice. We all know that the standard SSC is functional, but, for obvious reasons, it's not always the most esthetic option. After realizing that parents where not going to just always accept a SSC as the only option, I began my hunt for a crown that was functional, esthetic, durable, and easy to place. My first candidate was the esthetic-coated stainless steel crown. These crowns had been on the market for a long time and did satisfy some of the criteria I was looking

for. Quite frankly, they were my only choice at the time. The thick esthetic coating required me to prepare the tooth to fit the crown rather than adjust the crown to fit the tooth. This process took considerably more time and effort. While these crowns did prove to be a nice aesthetic option at initial placement, I soon learned that they did not hold up to the wear and tear that is seen in a child’s mouth. I found myself only offering these to parents that were strongly opposed to the dreaded "silver crowns." I even went so far as to have them sign a waiver stating they understood I could not guarantee that the white coating would not chip. Obviously, I wanted something better to offer my patients. So the search continued.

The wear and tear of the esthetic-coated stainless steel crown.

EZP ED O M ag azi n e / M a y 2016


After hearing a rumor of a new "porcelain pediatric crown" option from some of my colleagues, I thought I might give them a try. Later I opened up one of my pediatric dental magazines, noticed an ad for Tuff Kids Crowns, and placed an order for a starter kit. Zirconia crowns were new on the scene, and not much information was available on how to prepare the tooth for crown placement. After some trial and error, I was

able to complete my first Tuff Kids crown. The crowns did look much nicer than any other option I had tried up to that point, but when I went to reorder some replacement crowns, the company had disappeared. My search suddenly came to a dead end. In 2012, I visited a booth (Kinder Krowns) at the AAPD annual meeting in San Diego and was excited to see that prefabricated Zirconia crowns were now an option. I was very impressed with the overall esthetics of these new crowns and was anxious to start using them. I soon found that placing these crowns was not as easy as I would have liked. Given the rigid nature of Zirconia, a crown could not be crimped and was not adaptable to the tooth. This often required excessive reduction of tooth structure, and fitting crowns on teeth with space loss was almost impossible. These crowns also seemed very thin, and I fractured more than I would have liked trying to achieve an acceptable fit. The manufacturer of these crowns also recommended that I use a resin cement—one that I did not commonly use in my practice. This resin required the tooth to be isolated and dry during cementation. While isolation is not impossible, it proved to be a challenge, and I had cement failures requiring patients to return to my office. These crowns proved to be a step up from the estheticcoated stainless steel crowns I previously used, but I was not completely satisfied. Fast forward to 2014. I had received an email prior to the AAPD annual meeting from EZPEDO stating they were going to present small mini-clinics at the meeting in Boston. Not being completely satisfied with the crowns I had been using, I decided to give this a shot. I went through the 30-minute mini clinic which presented a very simple step-by-step process of how to prepare a tooth to fit an EZPEDO crown. I liked what I saw and decided to make the investment and try out these new crowns. I went all in, purchasing the anterior, posterior, and space-loss crown sets. The next week after the meeting, I had a patient that wanted a "white crown." I was excited to try out these new EZPEDO crowns. I followed the steps exactly as I had been shown. When I tried on my first EZPEDO crown, it fit 18

E ZP E D O M agazi ne / M ay 201 6

like a glove. Needless to say, I was excited with the idea that these new crowns could save me a lot of time and frustration. I cemented the crown with Ketac Cem, the cement that EZPEDO recommends and which also happens to be my cement of choice in my office. I was so happy that I emailed EZPEDO at the end of the day (we all love positive feedback, right?) and told them how delighted I was with these new crowns and expressed my overall satisfaction with my EZPEDO experience. I received an email back from Dr. John Hansen thanking me for the feedback and giving me his contact information to use if I had any further questions or comments. Why was I so excited? After multiple missteps on my journey searching for an ideal esthetic crown, I had discovered EZPEDO to be the best option out there by far. The aspect that is most valuable to me is the ease of placement. The engineering that has gone into fabricating a design that allows frustration-free placement as well as long-term retention does not go unnoticed. The fact that these crowns are also the most natural looking I have tried is just icing on the cake. Thanks to the natural look of EZPEDO crowns, I have no problem placing just one crown in an anterior region, where in the past, if I had done so, it would have been extremely obvious. Using these crowns to restore anterior teeth in children with heavy grinding has also saved a tremendous amount of chair time (fewer “re-do’s” of composites) and made parents happier with the outcome. Even with hard cases involving noticeable space loss, I have been able to find the right fit with the EZPEDO SLTM crowns. Adding Zirconia crowns to my practice has changed how I practice dentistry. I now have been using EZPEDO crowns for two years and can say they check all the boxes I was looking for—they are esthetic, durable, functional, and easy to place. I have completely phased out the use of all anterior esthetic-coated SSCs. The introduction of EZPEDO crowns to my practice has allowed me to step out of the past and into a bright new future. Thanks EZPEDO. 

Tooth Town of Vienna www.toothtownofvienna.com

Tooth K: Post-op

Tooth K: Post-op






(888) 539.7336

EZPEDO EZP ED O M ag azin e / M a y 2016



My 20-Year Quest

How I finally discovered a quality white pediatric crown By Terry C. Ramsey, DDS

During my pediatric dental residency program at the Medical College of Virginia (MCV) in the early 1990s, I began the quest to find a quality white crown, hoping it might be available at least for anterior teeth. The possibility of a white crown that would stand up to the stresses experienced by posterior teeth seemed too much to hope for. At MCV, residents were taught to use the strip crown technique for anterior teeth—an unsatisfactory option since the strip crown would discolor over time and invariably begin to chip and break down with wear. The only available alternative to the strip crown was a stainless steel crown with a window cut to hold a composite facing. This option was relatively satisfactory—until the composite chipped or the crown fell off. Once in private practice, I lost count of the number of times parents would ask me, “Can you provide my child with a white crown instead of a silver one?” These parents went on to express concerns over how a silver crown looked and the effect its appearance would have on their child. No alternatives were available for posterior teeth. For anterior teeth, the only option I could offer were the stainless steel crowns with composite or plastic bonded to them. While acceptable at first, the composite or plastic would eventually chip off revealing a black and white crown, leaving the child with what came to be called “zebra teeth.” Clearly, I had not yet found the object of my quest—a quality white crown.

What I like most of all, though, are the smiles displayed on the faces of children who proudly show off their beautiful white teeth. Finally, at the 2013 AAPD Annual Meeting in Orlando, Florida, I saw the EZPEDO booth, as well as booths of several other companies, displaying pediatric Zirconia crowns. I talked with representatives at all the booths and met doctors Jeff Fisher and John Hanson, founders and developers of EZPEDO Zirconia crowns. I appreciated the fact that I got to discuss the pros and cons of the crowns with the dentists who actually created them. After discussing the product with them, I purchased a starter kit and looked forward to finally placing white crowns that actually would work and hold up long term.


E ZP E D O M agazi ne / M ay 201 6

A few weeks later, I had the opportunity to place the crowns on primary first molars on a brother and sister. I anxiously waited for the six-month re-care appointment to see if the crowns would still be serviceable. At the re-care appointment, I not only found the crowns in remarkable condition, but the gingiva were awesome also. The children’s mother was incredibly happy and thanked me profusely for not putting stainless steel in her children’s mouths. With the knowledge that a product was now, in fact, on the market that provided not only esthetics but also durability, I began to incorporate EZPEDO Zirconia crowns into my practice. To increase my knowledge about the crowns and to improve my technique in using them, I signed up to attend the EZPEDO University—an all-day, hands-on program explaining the properties of Zirconia and the fundamentals of placing Zirconia crowns on pediatric teeth. During the course, we learned about the properties of the crowns, received helpful hints into the preparation of the teeth, and gained insight into the use of appropriate cementation techniques. The highlight of the EZPEDO University for me was being able to discuss the process with John and Jeff, who took an individual interest in the personal success of each participant. EZPEDO paid attention to every detail in the design of their crowns, not just the color and shape. I particularly like the space-loss crowns, specially developed to fit over teeth that are narrower due to decay. I also appreciate the extra retention of patented Zir-LockTM Ultra—the internal grooves milled into the crowns—and their crimp-lock margins. With these features, EZPEDO’s Zirconia crowns are unique. What I like most of all, though, are the smiles displayed on the faces of children who proudly show off their beautiful white teeth, and the satisfaction expressed by their parents over the natural-looking results created by using Zirconia crowns.

“I lost count of the number of times parents would ask me, “Can you provide my child with a white crown instead of a silver one?” CHIRP -CHIRP

EZP ED O M ag azin e / M a y 2016





ecently Dr. Erik Harrington and Dr. Allen Rapolla completed a case on a 4-year-old patient with type 1 dentinogenesis imperfecta at Children's Medical Center in Dallas, Texas. Dentinogenesis imperfecta is a genetic disorder (an autosomal dominant trait) affecting tooth development. Patients have a type of dentin dysplasia that causes teeth to be discolored, sometimes turning them blue-gray or yellow-brown in color. These teeth have an opalescent sheen and are typically weaker than normal, making them prone to rapid wear, breakage, loss, and a demonstrated higher risk for carries.

Anticipating the Case EZPM: What were your feelings when you decided to do a 19-unit case using Zirconia crowns instead of the standard SSC’s? ALLEN RAPOLLA: We were definitely excited about the case because it would be our first time doing a case of this extent. We were also excited about what we potentially would be able to accomplish. I'd done two cases before this, and felt comfortable working with a two- to four-unit case. After completing the EZPEDO University, I had more confidence that I would be able to do other similar cases. However, one of the main concerns I had facing a 19-unit case was this—would I be able to get all of the units to work together. Another thought that was going through my head was whether I would be able to deliver the same results that I had seen presented in previous articles. ERIK HARRINGTON: I had placed probably 40–50 crowns prior to this case so I felt relatively comfortable using Zirconia crowns. But I would also mention another area of concern—the issue of how to speak with parents about what treatment options are available and what they may expect. This discussion should include what plan B might look like if


E ZP E D O M agazi ne / M ay 201 6

you can't get the crown on for whatever reason. When you're placing some of your first crowns, you're going to want to have a backup plan. As you gain more experience, plan B recedes further and further in the rear view mirror. You just won't need to go to it. But these are some of the concerns you need to be aware of when you recommend Zirconia crowns. EZPM: Did you or your staff discuss with the parents the option of using Zirconia crowns? What was the parents' reaction to the Zirconia option: joy, hesitation, concern, or questions? ALLEN RAPOLLA: We had first seen the patient in the office prior to my taking the EZPEDO University course. Initially we did not discuss the option of Zirconia crowns. At the time the Mom understood that her daughter had a rare condition that affected her daughter’s

dentition and required some kind of full-coverage restoration. At first she was okay when we recommended silver crowns, but truthfully, she was not 100% on board with them being all silver. After further review, we discussed with her the option of using natural, tooth-colored Zirconia, a product we had recently started using. She was excited, joyful, and completely on board with this new option. EZPM: Were there any concerns about the time that it was going to take in the operating room? ALLEN RAPOLLA: Yes, we definitely had concerns about the time. Firstly, because of my limited experience, and secondly, due to the number of units that we

were going to complete. While taking the EZPEDO University course, you learn all the steps needed to complete the prep in order to ensure a good fit and a successful placement of the Zirconia crown. But when you have 19 units, you're in an environment where you are also concerned about limiting the time the patient is under general anesthesia. You are also mindful of the anesthesiologist’s time and of the time using the OR. Time was a big concern.

ERIK HARRINGTON: For the record, the case took just a little over two and a half hours to complete all 19 teeth. EZPM: What was the biggest mental challenge when facing a 19-unit case? ALLEN RAPOLLA: The mere fact that the case involves 19 teeth—that in itself was daunting. As a practitioner with limited experience using Zirconia crowns, I had to look at each prep on its own. Over the course of placing 19 crowns, I would need to do my best to maintain

the occlusion, minimize bleeding, while monitoring the amount of the time being spent in the OR. These concerns running through my head were mentally taxing and physically draining. ERIK HARRINGTON: In addition, you're fearful, especially at the very beginning. You haven't done too many of these, and you're fearful. I can't emphasize enough how much our decision to actually be together on this case meant to us. Let's just say you are going to do an IV case that has eight crowns. You may want to invite one of your colleagues just to be with you in the room that afternoon. Not that you're asking to split the case like we did on this one, but it’s reassuring just to have

another set of specialist eyes there with you while you approach this learning curve. I can't emphasize enough what it felt like to have a colleague in the room while doing a case this large.

Execution of the Case EZPM: Did you look at the mouth as a whole or did you concentrate on quadrants? Secondly, did you prep all the teeth sequentially; meaning all occlusal, then also supragingival, and then finish by doing the subgingival prep on every tooth? Or did you tackle the case one preparation at a time? ERIK HARRINGTON: As a practice philosophy, we look at all mouths as a whole. We believe the mouth is a window to the body. To specifically answer the question, we did tend to focus more on sextants or proceeding half of the mouth at a time. Let me clarify. In the OR, we use a groundbreaking dental innovation of the last decade—the Isolite. This device divides the mouth into right vs. left halves. In this case we started with the left side of the mouth. Then, we divide it up into smaller sections. I focus on the posterior sextant and then move to the anterior. In terms of prepping the teeth, we did not prep them one at a time. We did it sequentially—almost exactly as we learned to do at the EZPEDO University. The steps we followed in prepping one tooth after another were: the occlusal reduction, the proximal reduction, the subgingival prep, creating the “race track,” and doing the “ring around the rosy” five times. We did this using the same bur and completing each step on each of the 19 teeth before proceeding to the next step. EZPM: During the case, what were your biggest challenges, and what went better than you had expected? ERIK HARRINGTON: Obviously we were concerned with so many teeth that we needed to focus on. The biggest challenges we anticipated as we proceeded were tissue response and the spacing of each individual crown. Fortunately, we lucked out in this case. We did not face any challenging space issues, and the bleeding was easy to

EZP ED O M ag azin e / M a y 2016


control. So our case ended up being better than expected. However, these issues of spacing and tissue bleeding were the two biggest concerns we thought we would have to face. As a recommendation to others, we immediately agreed that in the future when working on similar cases, it would be prudent to recommend adopting a soft tissue management program (like chlorhexidine) in the days prior to the procedure. EZPM: What was your sequence of cementation while placing the 19 crowns? ERIK HARRINGTON: Once we prepped all the teeth, we placed the crowns on passively to make sure each of them fit. After removing the crowns and cleaning them, we cleaned the surrounding soft tissue, keeping gauze in those areas where we felt bleeding was a potential problem. Then we cemented the crowns, proceeding from the posterior to the anterior, starting with the maxilla then moving to the mandible, one tooth at a time. Since we started on the left, we seated tooth J first using resin-modified glass ionomer cement. Then we tack cured the buckle and lingual aspects of the tooth for about two seconds. Taking an explorer we removed the just slightly solidified cement from the margins of the crown. This process allowed us to clean up tooth J rather quickly and move on to tooth I, using the same procedure. Subsequently, we proceeded to the canine, eventually completing the rest of that half of the mouth. EZPM: Did your hands-on continuing education training in the use of pediatric Zirconia crowns prior to doing the case help you in your execution and in giving you more confidence in the face of what could have been a very challenging experience? ERIK HARRINGTON: This is a really easy question to answer. Absolutely. The EZPEDO University course was the tipping point following which we certainly felt confident going into


E ZP E D O M agazi ne / M ay 2016

this case. We were understandably nervous, but the hands-on training received during the course enabled us to complete the case with confidence. Allen Rapolla: I just wanted to follow up on that. Since Zirconia crowns are relatively new to the market, it is important to realize that they require a slightly different approach to prepping compared to the process used in prepping for porcelain veneered SSCs or plain SSCs. Had I not attended EZPEDO University I would not have had the same degree of confidence to take on this new approach to prepping. The hands-on experience helped to 1) build my confidence, 2) answer any questions I had, and 3) gave me the opportunity to figure out—in a comfortable learning environment—okay, this didn't work, but here is a better alternative. Definitely an absolutely positive experience. EZPM: What was your personal reaction when you cemented the final crown, and what went through your mind? What feelings and emotions did you experience? ERIK HARRINGTON: When we were cementing that last crown I almost wanted to cry. I was very proud of both

of us and our accomplishment after taking on the case. I also wanted to cry because of the dramatic visual difference between what the teeth looked like before and how they appeared after we placed the Zirconia crowns. It takes your breath away. When you look at the before and after pictures and realize how the family’s reality has now been altered for the good, you just sit back in awe. Also, because of the beautiful tissue response, just the way the teeth look in the tissue makes you proud that we can now offer this biocompatible alternative to SSCs. ALLEN RAPOLLA: Initially, I had a vague idea of what the results might look like. But it wasn't until after all of the Zirconia crowns had been cemented and I saw them in the mouth that I actually truly understood the beauty and innovation of this product. I am definitely very excited and am looking forward to using these crowns more in our practice.

Reflecting on the Case EZPM: Looking back at your initial expectations, how did they line up with the reality of actually completing a 19-unit case? ALLEN RAPOLLA: Again, piggybacking off the previous answer, I did have some initial expectations. I knew that Zirconia was a great product. I'd done some research and been through the EZPEDO University, but it wasn't until I actually

saw the results that I understood the life-altering impact of a smile recreated with Zirconia crowns. You can see the brown, yellow, translucent teeth that our patient presented with. Then to compare that with the results afterward—such real-looking crowns with great anatomy. Words fail to describe my feelings and the feelings of joy the parents expressed when they saw their child’s smile for the first time after she came out from surgery. It's just another level of reality than what I initially expected. ERIK HARRINGTON: I will also reiterate, doctor-to-doctor, that the soft tissue response, the way the gums react to this product is different and far better than a response to either SSCs or veneered SSCs. In our experience, looking back post-operatively, the response of Zirconia is nearly as biological as that of natural dentition. EZPM: Why do you think that so many dentists are nervous to tackle larger cases when using pediatric Zirconia crowns? ALLEN RAPOLLA: Zirconia is a relatively new product, so you've got to go through a learning curve. You've got to see how it works in your hands; see what you need to do to place the crowns successfully. This process is going to take time. First of all, you're nervous when you have such a large case like this. Because of the learning curve, it's easy to be intimidated. Secondly, because you're working through the new steps, questions that come to mind are, “What if I can't get it to fit? What if I've done all the things that I've been taught, and it's just not fitting?” These questions create some feelings of stress and being overwhelmed. I think when you add to these feelings thoughts about the number of units involved in the case, the stress increases exponentially. ERIK HARRINGTON: I think it's the same fear we all have, the fear of the unknown. You don't know what's going to happen.

EZPM: Many dentists are extremely happy with their decision to adopt the use of Zirconia anterior pediatric crowns but do not yet use posterior Zirconia crowns. What would you say is the biggest advantage they're missing out on by not having posterior Zirconia crowns available in their offices? ALLEN RAPOLLA: For me, the tissue response is so important. We all have used SSCs for years now, and always see a little bit of bleeding and gingivitis as a result. But I was most amazed with the tissue response to Zirconia, not only in the posterior but in the anterior as well. The second thing that impresses me is the parent response to the esthetics. When you are evaluating the smile zone and you see a full-coverage white restoration that is very natural-looking and see the parents’ joy and excitement with their child’s restoration—these responses are incomparable. EZPM: We all know how challenging cases can be that have existing space loss. When using posterior pediatric Zirconia crowns, how important have you found it to have space-loss crowns available? ERIK HARRINGTON: I absolutely think it's a necessity to have the space-loss crown kit at your disposal. Your best approach is to really lean into your

Zirconia crown training, which I think EZPEDO University does best. When you understand how you are supposed to prep the teeth, you are really reducing the chance that you might need to reach into the space-loss kit. However, because of crowding and space-loss issues, having that adjunct—having that kit with slightly different anatomy—is absolutely crucial at times when you need it. I think you would be remiss not to have the space-loss kit available.

Looking to the Future EZPM: Over the last few years it seems that the field of pediatric dentistry has seen some revolutionary products come to market. How does it feel as a pediatric dentist to see exciting innovations coming into your field, arguably for the very first time in a very long time, and does it give you hope for the future, anticipating what could be coming next? ERIK HARRINGTON: Yes, it does give me hope for the future, anticipating what is to come. It has been hard as a pediatric dentist—being in a medical-related field—to look into the eyes of parents and honestly tell them that the best that we have to offer is the same that we had 50 years ago, namely silver crowns. Zirconia crowns have taken a quantum leap in providing our patients an option that is just that much closer to what

Before Zirconia

natural teeth look like. It is very exciting to see these innovations coming into the field. I am very appreciative of pioneers like Dr. Fisher and Dr. Hansen for taking the risk and showing the courage to bring Zirconia crowns to market. EZPM: Pediatric Zirconia crowns are changing how parents and dentists view cosmetic dentistry for children. What do you think will be the major challenge for offices that are late adopters of this new technology, and do you think offices that embrace changes in technology have a competitive advantage over those that stick with the status quo? ERIK HARRINGTON: Early adopters absolutely have an advantage. The major challenges for late-adopter offices are exactly that—they're late adopters. I feel like the only reason these people have touch-tone telephones is because rotary telephones just aren’t made anymore. When any product comes to market, for it to have mass market appeal, there has to be a tipping point—a point at which a certain percentage of the population demands a certain service or product. Usually that tends to be around 17–20% of the population. When you compare esthetic Zirconia crowns to SSCs, in my eyes, it is clear which product is superior in terms of strength and esthetics. I won't claim the


You can see the brown, yellow, translucent teeth that our patient presented with. Then to compare that with the results afterward—such real-looking crowns with great anatomy. Words fail to describe my feelings and the feelings of joy the parents expressed when they saw their child’s smile for the first time after she came out from surgery.


same superiority when it comes to the ease of placement or how to technically place them, but we can get there. I know we can get there. Once parents realize that esthetic Zirconia crowns are an option—a viable option (albeit sometimes advisable on a case-by-case basis)—they will make their wishes known. They will demand the services and create the market which late adopters can no longer ignore. Those offices that embrace changes in technology will clearly have a competitive advantage because they demonstrate the courage, take the risk, and follow the uncomfortable steps necessary to move our profession forward. I know it's what the public demands. I know it's what we—many of us being parents ourselves—demand of our own profession. It’s what we would want for our own children. 

Two Surgeons Committed to Making a Di erence

Dentinogenesis imperfecta is a genetic disorder affecting tooth development. Children with this condition often are reluctant to smile and are often self-conscious of their teeth.

Dr. Harrington and Dr. Rapolla perform the first full-mouth rehabilitation case using Zirconia crowns in Texas.

What a Change It is exciting to see the di erence Zirconia crowns can make for patients—both in the immediate and long-term. The esthetics are amazing when you start using next generation technology for patient care.

EZP ED O M ag azin e / M a y 2016



E ZP E D O M agazi ne / M ay 201 6

Making Lemonade

Turning a sour clinical situation into a sweet result By Evelyne Vu-Tien, DDS, and Jeffrey P. Fisher, DDS

I reach for my phone. The voice on the other end is calm and collected, but I can tell something is wrong. There’s an urgency in the voice, and I know it must be something important. It’s one of many calls I receive each week as the co-owner of EZPEDO—an innovative pediatric healthcare technology company. Each call is unique. Each call is important. Each call provides me an opportunity to communicate with our customers—sharing advice with them, discussing treatment-plan options, or just letting them know we’re here for them. This particular call stuck out in my mind because it involved a situation every pediatric dentist dreads—getting a call from the parent whose child’s case was performed under general anesthia (GA) saying something has gone wrong with treatment. Maybe it’s a crown that came o , or a space-maintainer that came loose. Whatever the case, the first thing that goes through our minds is, “What am I going to do? Do I need to put the child back under GA? Are there any other alternatives?” This was the nature of the call I had just received from Dr. Evelyne Vu-Tien, a pediatric dentist in San Diego, California. In the conversation that follows, Dr. Vu-Tien and I discuss a case done under general anesthesia, after which a crown fracture was noticed post-operatively. We explore options regarding what to do when the patient is a young child whose cooperation is limited.

—Jeffrey P. Fisher, DDS EZP ED O M ag azin e / M a y 2016


Should i fix a broken crown? Dr. Fisher: What is your usual restoration choice when restoring lower cuspids, and how have pediatric Zirconia crowns affected that choice?

Dr. Vu-Tien:

When I find large interproximal decay in a cuspid or decay involving a cuspid incisal edge, I use Zirconia crowns because they are the most durable restoration out there. Especially in children where bruxing and lateral excursive forces constantly fracture large class III composite restorations, I find that Zirconia crowns are the fastest to place and are the strongest restoration available. I used to perform large strip-form type crowns. It would take me a long time to polish them down into proper occlusion. Also, they would frequently fracture after a few months or inevitably fail within one to two years after placement. In younger children under 5 years of age, placing a Zirconia crown gives me the peace of mind knowing that it will last them at least the next three to four years. Prior to this case, I had completed about a dozen cases using canine EZPEDO crowns, each with success and without incidence. So what happened next surprised me.

Dr. Fisher:

Tell us about your patient, Julie, and the particulars of her case.

Dr. Vu-Tien:

I saw Julie in November 2015, when she presented for her first initial exam at age 5. We discovered she had 12 cavities. She was extremely apprehensive and anxious, and it was difficult to coax her to open her mouth for a visual examination. Due to the severity and amount of decay, as well as her level of apprehension, her mother and I discussed monitored-anesthesia care for her treatment. We ended up placing six crowns and six posterior interproximal restorations. We placed EZPEDO crowns on teeth E, F, M, and R with no pulpotomies required. I decided to substitute upper canine crowns for the lowers, using a smaller size (Size 1 of C and H). I also used Fuji Cem for cementation instead of the recommended Ketac Cem. I did not hear any “snap” or “breaking” sounds upon seating the crowns, nor did I notice any fracture lines after the treatment was completed.

Dr. Fisher: In Julie’s case, when did you first notice the fracture in the crown, and what went through your head in the moments that followed?

Dr. Vu-Tien: I received an evening call from Julie’s mother one week after the surgery, alerting me that a piece of the “tooth” had broken o on the lower right area of the crown. I did not believe her at first. I had never had a canine crown fracture before. I immediately wondered if it was a piece of excess cement that I had failed to remove, or if it was a chip o a neighboring tooth. I tried to recall if I heard any “snap” or felt any “break” during cementation, but I could recall nothing. I asked her to text me a photo of the tooth right away. Sure enough, a diagonal piece of the crown was missing. Julie’s


E ZP E D O M agazi ne / M ay 201 6

mother said her daughter had been eating soft foods at the time and handed mom the chipped piece. I was worried how I would be able to restore the fragment chair side and wanted to look up what materials bond to Zirconia. Luckily, the cement under the crown was still present, and Julie was not having any pain or sensitivity. I did not want Julie to undergo anesthesia again to repair just one tooth, so I was trying to brainstorm ideas on how to “patch it” until she could tolerate a chair-side removal of the crown or until the tooth would exfoliate naturally in two to three years.

Dr. Fisher:

What are your thoughts on why the crown might have fractured?

Dr. Vu-Tien: It was puzzling, because I had placed two lower canine EZPEDO crowns, only one of which chipped. At the time I performed the case, I did not have the SL cuspid sizing, so I placed regular canine crowns instead. The other canine crown (M) did not fracture. I suspect that I may have twisted the lower right crown (R) upon cementation, which led to the failure and fracture of the crown. The regular-sized cuspid Zirconia crowns are more ideal for placing on maxillary primary cuspids, while the SL-sized cuspids— being somewhat narrower—are more suitable for use on lower canines. I also wondered if by using the Fuji Cem, which was less viscous than Ketac Cem—if it somehow contributed to decreased retention of the crown, resulting in failure where the chip occurred.

Dr. Fisher:

When you called me, you had a good idea of what you wanted to do to fix the problem. What was your idea?

Dr. Vu-Tien: When I called you, I wanted to review my options with you and discuss what experience you may have had with this type of fracture. Because of Julie’s anxiety level, the idea of removing the crown with a high-speed hand piece, requiring water, suction and re-cementation of a new crown was something highly unfeasible given her level of anxiety. Julie barely spoke any English, and it was challenging trying to communicate with her. Typical “tellshow-do” methods and voice control had not proved e ective. Rather, I opted to repair the tooth with composite to buy us some time until she was older and could better tolerate more definitive treatment. I did not want Julie to have to undergo anesthesia an additional time for repair of a crown fracture that was neither symptomatic nor carious.

A Crown repair

Fractured Zirconia crown

Repaired Zirconia crown

Dr. Fisher: What were the procedures you used to fix Julie’s broken crown?

Dr. Vu-Tien:

When Julie returned to the o ce, she was still very anxious. It was di cult to place the nitrous mask on her. Upon inspection of tooth R, we discovered the remaining unchipped area of the EZPEDO crown was intact and well cemented. Since cement still covered the exposed portion of tooth, I opted to bond composite to this exposed area. I first cleaned the area with chlorehexidine and used a size-2 round bur to roughen the cement and clear out any debris. I used a mouth prop and cotton roll isolation in lieu of a rubber dam because of Julie's behavioral issues. After placing a sectional matrix, I applied 35% phosphoric etchant and adper bond (Scotchbond) to the cleaned surface. I applied A1 flowable composite (Shofu) to the interface between the crown and tooth and followed up with Filtek Supreme color B1 over the open area. I then polished using football and flame-shaped carbide burs to contour the composite. Finally, I polished with a Shofu white point to achieve smoothness and shine. I advised Julie's mom that the composite restoration possibly could chip and stain and may need revisions in the future, but at this time it was a viable option we had chosen instead of replacing the entire crown while Julie is still young and apprehensive. Julie's mom was very happy with the result.

Dr. Fisher:

were there any challenges with the “zirconia repair,” and what did you learn from this case?

Dr. Vu-Tien:

Julie’s mom was very happy with the results and with the fact that we could achieve them without additional monitored anesthesia care. That joy was short-lived, however, because one month later, I got a call from Julie’s mom telling how the crown had fractured again. This situation allowed me an opportunity to reflect yet again on how I might have repaired the tooth better. I requested Julie to return, and we removed all the old cement to expose the dentin. I then followed the steps outlined above to ensure a good bond. This time, I took the tooth out of occlusion by 1–2 mm and rounded the edge of the canine with a new diamond and lots of water to prevent heating the tooth. Julie’s mom was pleased with the second repair.

process also allows you to review how you could have given more careful attention to the materials used or steps taken, possibly ensuring a better outcome. I am thankful for a humbling experiences such as this because I am able to learn and grow from my mistakes. I am so appreciative that you, Dr. Je , were always available to speak with me and o er support, guidance, and mentorship throughout the process. This is the only company I know of that is owned and managed by dentists with a passion for educating their dentist customers and ensuring that their product improves a patient’s overall health and well-being.

I want to encourage all of us to think outside the box. Often in the practice of dentistry we are presented with situations that are less than ideal. It’s just the nature of the profession, and we as practitioners need to be able to use critical thinking to solve these challenging situations. The above-mentioned case is just one example of any number of situations—many of which you might decide to resolve di erently. That’s the beauty of private dental practice. Our education has equipped us with tools to use in the treatment of our patients. It is up to us, as individual dentists, to use that knowledge to o er the best treatment we can to those seeking our help. As the horizon of pediatric dentistry continues to expand, we will be faced with more and more situations requiring us to exercise our critical-thinking skills. I want to encourage all of us to think outside the box. Think with a critical mind. Use the “tools” you have to evaluate every new product and technique that you encounter. Learn and decide for yourself how you will respond to the most important question you face every day in practice ... “What is the best for my patient?”♦

I contacted mom again one month later to check on Julie. I learned she was doing great, experiencing no issues and with the filling still intact.

Dr. Fisher:

having repaired a fractured zirconia crown now in your own practice, what would you advise your colleagues to do if they were to encounter a similar issue in their practice?

Dr. Vu-Tien

First o , I would pause and reflect back on the steps taken to complete the crown. Could the error have been caused by one of the following factors? 1) inadequate tooth preparation, 2) crown choice (SL vs. regular sizing), 3) cementation process, or 4) type of cement. Answering these questions allows you to critically evaluate each of the steps taken. You can then more accurately deduce how you might have performed the procedure better. This

EZP ED O M ag azin e / M a y 2016





for a dynamic, successful pediatric practice. By Cathy Jameson, PhD


Develop a practice that epitomizes excellent care of the business and of children. One goes hand in hand with the other.


Create and deliver a new patient “experience� that is fun for the kids as well as informative and motivational for the parents.


Plan, prepare, and present your recommendations professionally using visual aids—particularly photography.



E ZP E D O M agazi ne / M ay 201 6

Develop the role of a patient or surgical coordinator.


Stay in contact with your referring doctors and their teams through special events and/or courses. Make sure that your referral sources know that (1) you can see all children, not just children with special needs or behavioral challenges, and (2) you will send them back to their original practice, if that is their request.


Scheduling is the heartbeat of your practice. Be prepared. Know the school holidays and know your home-schooled children so that they may be called on short notice. Determine how many children from the same family can be seen at one visit. Learn proven ways to reduce broken appointments and no shows.


Communicate with your kids: know that your children hear everything, see everything, and are frightened of everything. Use your visual aids and digital teaching tools, as well as comforting words. Be interested in them personally. Make their day: know their sports teams, pets, special interests.


Communicate with the parents: know that they feel badly if their child has a cavity or other issues. Empathize while you educate.


School visits and community outreach are vital. Know your school nurses and teachers. They care about their students and will value your support of them and of the kids.


Turn to the AAPD for marketing support and practice-development tools.

* For information regarding Cathy’s lectures or the services of Jameson Consulting, see their Web site www.jamesonmanagement.com, or contact their E-mail at info@jamesonmanagement.com. Look for Cathy's full-feature practice management article in our next issue.

EZP ED O M ag azin e / M a y 2016


Making a Permanent 32

E ZP E D O M agazi ne / M ay 201 6

Hypodontia complicated by extensive decay.


A dentist in Romania places Zirconia crowns to last a lifetime By Ana Vinau, DDS

EZP ED O M ag azin e / M a y 2016


Patricia first came to our clinic with her mother when she was 7 years old. She was quite shy, and I could tell that she felt very uncomfortable. Her mother told me, “My daughter has experienced dental pain before and has to take medicine in order to calm the symptoms.” Patricia had experienced a lot of pain during prior treatment at another dental clinic and didn’t want to endure a similar experience again.

When I proceeded to examine Patricia, I could see several of her teeth were decayed. She told me her lower molars were giving her a hard time. I could see that teeth K and T were the I was nearly convinced most affected with evidence of massive dental destruction. I we would need to extract noticed that T also had a vestibular abscess. To be honest, I those teeth due to the was nearly convinced we would need to extract those teeth extensive damage. due to the extensive damage. Furthermore, lesions had already led to infection. FAST FORWARD For the next appointment I asked her mother to bring me a I took on the task of panoramic X-ray so I could see all Patricia’s teeth and assess resolving this case as a the amount of root resorption in order to know how to treat her personal challenge. teeth. When I received the X-ray, I was surprised, disappointed and challenged all at the same time. I saw that the adult permanent teeth were missing and noted accompanying extensive bone damage. Patricia’s parents were shocked and discouraged when they found out that she was experiencing hypodontia in addition to having decaying second primary molars. I knew right away that I needed a second opinion on this case, so I asked my friend, Dr. Teodorina Secara, our orthodontic specialist, for some advice. She advised me, “Try to keep the two damaged teeth in Patricia’s mouth if at all possible, given the fact that she already has too much space between her teeth.” The loss of these two primary molars would disrupt the relationship between the rest of her teeth, and in the end, impact her entire occlusion. I took on the task of resolving this case as a personal challenge. Because the permanent adult teeth were missing, I couldn’t afford losing the second primary molars. I didn’t know how this case would end up, so I started by taking it one step at a time. In the beginning, I treated the root canals of those two damaged and infected teeth with antibiotics and anti-inflammatory medications. After 10 days, I filled the root canals of both teeth using the standard procedure for permanent teeth. On K, I also encountered a furcal perforation and although it was very difficult to stop the hemorrhage, we managed eventually to place MTA


I was surprised, disappointed and challenged all at the same time.

Tooth T was missing its permanent successor and compromised by a vestibular abscess.

Tooth K showed massive decay and was complicated with a furcal perforation during endodontic treatment.

EZP ED O M ag azin e / M a y 2016


on it. We filled K with Equia GC and T with Gradia Direct GC. Everything was going well so far. Two weeks later, while I was treating the rest of Patricia’s teeth, I spotted through the enamel that K had begun to turn black underneath the Equia filling. Also, T, due to the extensive nature of the filling and the small remaining healthy dental structure left after removing the decay, had begun to exhibit fissure lines. It was just a matter of time until that tooth would break, requiring an extraction, in spite of all the hard work done to save it. This was not a scenario I was willing to accept. At that point, I knew I had to come up with an alternative idea in order to help Patricia retain her second primary molars, and I had to do it fast. At the time, we only had SSCs available in our clinic, and I had used them in the past. I knew I had to reinforce these damaged molars if we wanted to keep them. But, what I most wanted for Patricia was an esthetic solution for her situation that would prove durable over time, because these primary molars would never be replaced by permanent teeth. In addition to being esthetic, the ideal restoration would also need to be extremely strong, able to withstand all the bite forces over a lifetime. SSCs were not an option for me or for my patient. I refused to believe that I had reached the end of the road, so I began doing some research on the Internet to find what other esthetic pediatric options were available. That is when I discovered that such a restoration option did in fact exist, having all the characteristics that I had been hoping for. EZPEDO crowns also seemed to satisfy both the needs of my patient and the desires of her parents. Usually, when you diagnose a young patient with hypodontia and talk to the parents about it, they perceive the diagnosis as a handicap; or they feel ashamed for having done something wrong that led to the situation. Now, however, it was such a joy and a relief to be able to share the option of using Zirconia crowns when faced with such a difficult circumstance. After assessing Patricia’s situation, I shared the good news of my discovery with her parents and proposed using EZPEDO crowns. They were excited about the fact that the crowns had the same color as natural teeth and gave me permission to proceed. I told Patricia that she would no longer feel any pain. She was excited to learn that instead of two “injured” teeth, she would be getting two beautiful “pearl-like” teeth. Anticipating the case, I was nervous because this would be the first time I had ever used Zirconia crowns. However, I managed to seat both crowns in the same session. In the end, Patricia was extremely excited with the result. During the entire process of discovering Zirconia crowns and preparing for the

It was such a joy and a relief to be able to share the option of using Zirconia crowns.

Tooth T: 1) Initial exam 2) Interim 3) Immediate post-op crown placement. 4) Clinical follow-up after one year and six months.






IS THE AGENESIS OF ALL TEETH. Reported worldwide prevalence is 2.6 –11.3%. Women are affected more than males at a ratio of 3:2. Both genetic and environmental explanations for hypodontia have been reported.


E ZP E D O M agazi ne / M ay 201 6

Tooth K: 1) Initial exam 2) Interim 3) Immediate post-op crown placement. 4) Clinical follow-up after one year and six months.

case, I found the EZPEDO team to be most helpful and responsive in communicating with me. At Patricia’s two-week checkup, I was surprised to see how beautifully the gingival margin had healed and to discover that the crown contour was nearly perfect. I was impressed by the fact that both crowns looked so natural that you could barely notice any difference between the Zirconia crowns and Patricia’s natural teeth. I was thrilled with the result and so were her parents! But what I most anxiously wanted to see was how well these crowns would perform over time. Would my patient be able to use these two crowns à la longue (over the long term)? Therefore, I determined to monitor the EZPEDO crowns to see how they would hold up after prolonged use. I saw Patricia regularly for follow-up exams and carefully examined her. At six-month and one-year and six-month follow-up appointments, I took photos and X-rays of her teeth. They still looked impeccable. Her

One year and six months, post-op X-rays and clinical photos

first permanent molars erupted in their right places. I couldn’t detect any wear of the opposing teeth, and the crown margins were subgingivally placed, revealing healthy surrounding tissue. The X-rays showed that the bone had re-mineralized and healed. In summary, Patricia uses these new “teeth” as if they are her own natural ones. After we placed the Zirconia crowns, Patricia began taking personal responsibility and paying more attention to proper dental hygiene. She now enjoys coming to her appointments because she knows we will take pictures every time. I think Zirconia crowns are a necessity in this kind of situation when you have to deal with missing permanent teeth. When I promote these crowns to parents, I now feel confident recommending Zirconia crowns. At the same time, I am able to honor the trust which parents have placed in me by providing the best available solution when treating special dental conditions such as hypodontia. By incorporating all the benefits of Zirconia crowns into your practice, you, too, will increase your chance for success. Above all, you will live with a strong feeling of professional satisfaction knowing that you can overcome even the most difficult situation. ♦

I was surprised to see how beautifully the gingival margin had healed and to discover that the crown contour was nearly perfect.

One year and six months post-op A hypodontia case restored with Zirconia crowns.

EZP ED O M ag azin e / M a y 2016




Looking back over 25 years of clinical dental practice, I realized that stainless steel crowns (SSCs) had become my bench mark restoration for the management of severely broken down first and second primary molars. Having had such a high success rate using SSCs, it was difficult for me to consider using any other form of restoration. Over the years, however, parents often had asked me, “Do crowns come in any other color?” The answer up until about four years ago was always, “No.” Some companies have tried to powder coat the crowns or incorporate composite/porcelain facings. Many of these crowns have failed, resulting in the kits being placed into a cupboard to collect dust. Western Australia has a strong pediatric dentistry heritage established by my mentor, Dr. Peter Gregory, following his return in 1982 from Northwestern University Dental School and the Children’s Memorial Hospital in Chicago. Based on his training, Dr. Gregory strongly advocated

EZP ED O M ag azin e / M a y 2016


the use of SSCs and composite resin strip crowns by West Australian dentists. Both of these restorations continue to be the mainstay of clinical pediatric practice in Perth. Dentists in our community did not seriously consider moving away from this treatment modality to an alternative until relatively recently. In fact, I initially still placed composite resin crowns on a regular basis and was only looking for an alternative to the SSC. My restoration of choice for a primary canine, however, has now changed from a composite resin strip crown to an EZPEDO Zirconia crown. How did I make this switch, and what prompted my decision? My experience is as follows. I had noticed an increase in the number of parents seeking an alternative to SSCs based solely on esthetics. I also had noted that other parents were concerned more about the nickel content of SSCs and an associated possible allergic response.




Then in 2012, I attended the EAPD conference in Strasbourg, France, where several companies were showcasing their biocompatible Zirconia crowns for primary dentition. After much deliberation, I purchased a starter kit from the EZPEDO booth and returned to Australia.

attending EZPEDO University!), I then began offering Zirconia crowns to a select group of patients. I decided to limit my first 50 cases to patients whose treatment plan included only a single, full-coverage restoration on either a first or second primary molar. Parents of these patients had also requested an alternative to a SSC. Furthermore, I excluded patients if they had significant para function, dysplasia of the dentition, or special needs. Being the first dentist in Western Australia to offer this treatment, colleagues were eager to see my results. Because of this expectation, I needed to be confident in the long- term success of EZPEDO Zirconia crowns before recommending them. Also, a vast majority of the patients I treat have behavior management issues, requiring treatment under relative analgesia or general anesthetic. Thus, I faced the additional possible complication of having to repeat the treatment due to a restoration failure—an outcome that is in no one’s best interest. Would Zirconia crowns meet the test? I treated the first 50 consecutive patients over a period of 24 months using EZPEDO Version I crowns. The results were extremely encouraging with a 100% success rate (mean review time of 23 months). In 2015, I presented my results at the IAPD conference in Glasgow, Scotland. I am now continuing my study, using EZPEDO V2TM crowns and extending it to include the first 150 consecutive cases. I plan to share these study results later this year. After four and a half years, I can now confidently say, “I would be happy to place an EZPEDO crown, even if the patient was my own child.” Being able to make this statement has always been my yardstick by which to evaluate and recommend treatment. I am confident my patients are receiving the very best of care with EZPEDO products. 

Australia’s Therapeutic Goods Administration did not grant approval until later that year, so I was restricted to practicing on extracted teeth. I soon realized that I needed a professional kit and placed my order. Since I was one of the first dentists to adopt EZPEDO crowns in Australia, I relied heavily on “trial and error” practice, initially confined to the laboratory. Dr. John Hansen from EZPEDO was extremely helpful during this learning phase, and we spent a considerable amount of time on Skype discussing a number of clinical issues. Once I felt confident with my preparation technique (which I significantly modified after


E ZP E D O M agazi ne / M ay 201 6



Enamel hypoplasia on teeth A, C, H, J, K, L, T.

Mandibular view of enamel hypoplasia on teeth K, L, T.

Post-op Esthetic and durable restoration of teeth A, C, H, J, K, L, T with EZPEDO crowns.




Esthetic and durable restoration with EZPEDO crowns.

Occlusal view of enamel hypoplasia on teeth A, C, H, J.

Esthetic and durable restoration with EZPEDO crowns.

EZP ED O M ag azi n e / M a y 2016


A Mom’s Mission to Help her Son Leads to a Revolution in Pediatric Crowns BRENDA HANSEN TALKS CANDIDLY ABOUT HER DREAMS FOR EZPEDO By Aubrey Gooden, MS

Brenda and John Paul (now 15) relax on the couch with their dog Lola.


her 3-year-old son, John Paul, fell in the shower and chipped his four front teeth, Brenda Hansen’s life took an unexpected turn. Dismayed by the lack of satisfying options to restore her son’s teeth, Brenda reluctantly settled on strip and preveneered stainless steel crowns, which in her mind seemed almost prehistoric in a time when medical breakthroughs were grabbing headlines almost daily.

The strip crowns used to repair the damage repeatedly cracked or broke entirely, leading to dreadful and frequent trips to the pediatric dentist’s office. As for the metal crowns with a nickel component, neither Brenda nor her husband, who operated a thriving adult cosmetic and restorative dental practice, would consider this option. The prospect of subpar metal materials setting up residency in John Paul’s mouth was unacceptable to these two health-conscious individuals. “There was literally nothing on the market at that time besides pediatric crowns based on archaic technology and materials,” Brenda observes. “It’s difficult as a parent when you want to give your child the best, but the best doesn’t exist, and you know it. I simply wanted something for my son made of a more durable, natural material with technology that I could be confident in, but I had no choice.” The idea of entrepreneurship didn’t cross Brenda’s mind at first. In fact, it wasn’t even about innovation, invention or disruption of an entrenched benighted market. In Brenda’s case, her entrepreneurial fuse was ignited by the dire circumstances she discovered while simply seeking the best option to repair John Paul’s teeth. Frustrated by their own personal experience, Brenda’s husband, John Hansen, and family friend, fellow dentist and respected dental anesthesiologist, Jeff Fisher, set out to develop a new, stronger, safer and more esthetically pleasing crown made just for kids. Unaware their mission would morph into an idea that would eventually lead to an industry-altering invention and a vibrant company, Brenda, John and Jeff began to do what almost every driven team does when they are on a mission of change—brainstorm.


E ZP E D O M agazi ne / M ay 201 6

Brenda approached the exercise with the intensity of a mom out to save other moms and their children from the agonizing experience she and her son had endured. The team’s innovative ideas led to the formation of a new company, EZPEDO, with an extensive R&D process dedicated to creating and validating a new revolutionary crown for kids. The new crowns were made from Zirconia, a material with a virtually indestructible fine-grain translucent crystal structure. Important to Brenda and her partners, the crowns were also completely bio-inert and resistant to decay and plaque accumulation. Brenda inherently knew as a mom these features would appeal to likeminded parents who sought the best for their children.

Eating Healthy “My kids didn’t appreciate my war on gummy candy and boxed lunches when they were younger.” Fresh Veggies Spring is one of Brenda’s favorite times of year and a perfect time to make sure that there are plenty of fresh veggies around the house.

Brenda, now EZPEDO’s executive director, shepherds the company as it seeks to have an even greater impact. It’s a role she was well-suited to take on, having founded and managed another start-up from its inception until selling it to a large corporation. After that venture, Brenda helped build her husband’s dental practice into one of the top boutique cosmetic dentistry destinations in the country. In her role of building up EZPEDO’s infrastructure, running day-to-day operations, providing fiscal management, and building strategic partnerships, Brenda is widely regarded as a powerhouse within a company responsible for disrupting the pediatric dental industry with durable, white pediatric crowns.


“We have an incredible, forward-thinking group—Jeff Fisher, who is always coming up with new ideas; my husband, John, who has this inventor’s personality; and Vladimir Shcherbak, EZPEDO’s operations manager, with his engineering mind.” Brenda reflects that her predicted career trajectory did not include leading a dental-care company, but she would not have it any other way.



Born in Denver, Colorado, as the youngest of five children and raised in Sacramento, California, by parents who instilled in her the importance of a fulfilling career and family life, Brenda lives a life of happiness and hard work.

Brenda met her husband, John, at Sierra College. They have been together now for 31 years and counting. They have three beautiful children—two girls and one boy, now 22, 20 and 15 years old respectively. “As a mom, I know first-hand how challenging it can be to teach children about the importance of dental health at a young age. I would say good nutrition was my biggest contribution to my kids’ oral health,” she reflects. “Our family diet at home has always been important to us. My kids didn’t appreciate my war on gummy candy and boxed lunches when they were younger, but now that they are older and making food decisions for themselves, they, and their teeth, have an appreciation for the good nutrition techniques we taught them.”

When her husband attended dental school, Brenda began learning more about oral health and the dental industry. After they opened the boutique cosmetic and restorative practice, she quickly became familiar with the dynamics of running an office and enjoyed providing hospitality, customer service, graciousness and care to patients.

"Brenda is widely regarded as a powerhouse within a company responsible for disrupting the pediatric dental industry.�

Brenda with her son John Paul, now a confident, fun-loving teen.



Despite Brenda and her husband’s busy schedules with the practice and EZPEDO, they make a point to prioritize family time and personal wellbeing. Like busy moms everywhere, Brenda works to balance her demanding professional life with her roles as a wife and mother.

“I make dinner and spend time with my family nearly every night, and on a good day I’ll enjoy yoga as well. Structure for me is really the key to balance in my life,” Brenda says. Brenda’s kids believe in EZPEDO’s mission to improve oral health for all children, and for Brenda, the support of her whole family is a powerful motivator. Brenda also encourages parents to find a pediatric dentist for their children so they learn to enjoy going to the dentist from an early age. She tells parents that it is important to do their own research, but to be cautious of the source, especially online, since not all information is valid or trustworthy. She also tells parents to never be afraid to ask dentists, “What would you do if it were your child?”

THE ENTREPRENEUR’S JOURNEY Brenda often speaks with people who are interested in starting their own business, offering her candid advice and encouraging them to be realistic and understand how much work it really takes. “Owning and running your own business is a lot more work than you might realize and requires many sacrifices, but ultimately can be extremely rewarding. In my opinion, it’s important for emerging


companies to assemble a strong team of people, solve a real problem, differentiate from the competition, and continuously improve without losing sight of core values. That’s what we do at EZPEDO.” EZPEDO was not created without challenges. Brenda recalls the initial market reaction to EZPEDO: “In the beginning, the market was hesitant to accept us. We were new and the first company trying to disrupt the legacy pediatric dental industry. It takes time to build trust, and for us, it took data and favorable studies commissioned by independent organizations showing the proven success of our product to build on that trust.” “After just six years of selling the product, the market now trusts us; our customers trust us; and even the competitive dental environment is embracing us. We are seeing growth like never before.” Parents looking for a better alternative to old crowns call the EZPEDO office all the time asking where they can get EZPEDO crowns for their kids. “It’s up to us to educate pediatric dentists about our product, and it’s up to parents to keep asking dentists still only offering old pediatric crowns, ‘But isn’t there another option?’” “We are all about improving the dental profession, specifically pediatric dentistry, for our doctors, parents and patients. We want to educate and inspire; not close off or control the market. We are in business for the greater good.”



Brenda has become intimately familiar with the dental industry and global business trends. She flies from California to conferences as far as Serbia to share the story of EZPEDO with its growing global customer base.

“Dentistry, including pediatric dentistry, is moving toward a total health and wellness approach,” Brenda says. “It’s not about just fixing teeth anymore—it’s about understanding the patient's total body health and how dental procedures and materials affect it.” Under Brenda’s leadership, just as EZPEDO changed the landscape of the pediatric dental crown market, the company plans to continue disrupting the dental industry in new and creative ways. “If it weren’t for EZPEDO launching its first crown, the pediatric dentistry market would not have changed. We pioneered this disruption and don’t plan to slow down any time soon.” Dentists focused on the total health and wellness of their patients are increasingly dissatisfied with some of the available dental products, just as Brenda was after her son’s accident. That’s why EZPEDO focuses on bringing an innovative, technology-driven mindset to the pediatric dental market, creating more natural and more effective solutions that can improve the overall health and wellness of the next generation of dental patients. With this strong mission and EZPEDO’s talented team in place, Brenda believes the company will reach its full potential and give countless patients healthier options for their dental needs. “We look forward,” Brenda concludes, “to taking ownership of our commitment to innovation and technology in dentistry and evolving to help more children receive the oral health care they deserve.”


EZP ED O M ag azin e / M a y 2016


GROWING Through Service Dr. Fisher’s daughter reflects on her family’s recent mission trip to Palau By Tiffany Fisher

Palau. The name may conjure up images of a small, remote location deep down in the South Pacific—an archipelago dotted with numerous rocky islands. My trip and the opportunity to interact with Palau’s inhabitants— numbering just over twenty thousand—has changed my life. But first, let me tell you a bit about our trip.


E ZP E D O M agazi ne / M ay 201 6

Ti any Fisher, 17-yearold daughter of EZPEDO co-founder Je rey Fisher, recently joined her high school classmates on a twoweek mission trip to Palau where they helped construct a medical-dental center and conduct medicaldental clinics on this South PaciďŹ c island nation. Ti any was accompanied on the trip by her mom, dad, and younger brother.

EZP ED O M ag azi n e / M a y 2016



ur planning for the trip had begun six months earlier. August 19, 2015. I still remember the excitement I felt on the date when I first heard the news. My family and I had been given an opportunity to travel half way across the world. At the time, our departure seemed an eternity away. The six-month time lapse between August and our February 14 departure felt like a lifetime. I wanted to go. I wanted the sun and the sand. I couldn’t wait to get my hands dirty, to experience a new side of life. I was ready to work, to travel. The days passed, slowly. While i waited, my anticipation grew. i didn’t really know what was to come, but I knew it was going to be extraordinary.

we continued our journey to the small rocky islands of Palau. But, as each hour passed, my heart became more anxious. All I wanted was to set my feet on Palauan soil. Our arrival was anything but glamorous, but the small island airport amazed me with its cultural architecture. The locals were delightfully friendly. It was easy to forget the early hour as the native Palauans welcomed us with leis of shells, and loaded our luggage into the old red bus we would be traveling in. The island was dark, but I could already sense the beauty that surrounded me there on this South Pacific island. The morning of the first dental clinic, I could hardly contain my excitement. I woke up early and dressed in my scrubs, ready for a long day of work. I remember walking into the hot basement of the church where we would be working. I was flooded with relief when I opened the door to the makeshift dental office. We had an air conditioner! It seemed like such a novelty at the time, but

Early on the day of our departure I woke up to the sound of an angry alarm clock. Half asleep, I reached for the snooze button, It was 4:30 A.M., not exactly the most pleasant time of day. Yet none the less, I knew that the next three days of travel were not going to be much better. So I pulled myself out of bed and tried my best to wake up. Then excitement and adrenaline kicked in, and by the time we reached the airport in San Francisco, I felt like I could run a marathon. As I looked around the sea of people, I found myself surrounded by the bright teal T-shirts of my fellow classmates. There were 34 of us in our group; 34 insignificant people off to change the world. The next 52 hours were a nightmare. Sleeping on the airport floors, and being stranded in the Philippines became the least of our worries as

“I still remember the excitement I felt on the date when I first heard the news.”


A dental anesthesiologist, Dr. Fisher picks up a hand piece for the first time in over fifteen years to treat patients in Palau.


A little island girl gets a free dental exam.




s selve them y. S iarize e first da L il m O TO er friend fa ent on th m h d uip ny an al eq Tiffa the dent with

Tiffany an


d one of


E ZP E D O M agazi ne / M ay 201 6


her classm

ates help

IN MIS treat pati


ents in th

e dental


TURNING AN OLD JAPANESE HOUSE INTO A PLACE OF SERVICE The king of the island generously donated this old Japanese house, located on his property, to be used as the new location for Palau Adventist Wellness Center. In addition to o ering many surgical services, this much-needed medical/dental clinic will also be used to provide health education and reversing diabetes classes to the underserved people of Palau and the surrounding islands.

EZP ED O M ag azin e / M a y 2016


1 Being able to serve this island community out of love, not for profit, was such a fulfilling and eye-opening experience. Every time I loaded a local anesthetic, or cured a filling, I felt a sense of accomplishment. I was in some small way helping these people. I’m not a dentist, but being able to work alongside my dad as well as my fellow classmates allowed me to make a difference. The appreciative people of the island were being healed, one tooth at a time. As I look back on our journey, I remember some of the di culties we experienced like racing through airports to catch flights and being stranded in the Philippines for hours due to a missed connection. I also remember the feeling of the ocean air with its high humidity that prevented us from ever truly feeling “dry.” We also experienced many pleasant things as well. The tropical forests that sang to us each night never ceased to amaze me with their unique beauty. And in my mind’s eye I still see the friendly people, those whom we had gone to serve. The greetings from the school children each morning always made me smile. The mobs of people that flooded the church during our clinics had kept me focused. This place, filled with such a unique culture, was where I fell in love with service.



During my time on the islands, our team pulled many teeth, distributed many eye glasses, and touched countless lives. I saw love displayed on every busy face. I felt a new strength every day I spent there serving the people of Palau. Whether I was opening my mouth to sing, or telling little children to open their mouths in order for me to care for their dental needs, I knew I was there on a mission. I remember the fire I had burning in my heart while I served in Palau. It is a fire that still burns deep inside—one that creates a hunger for service. It created a love for people—a love that will stay with me the rest of my life. ♦

“ This place, filled with such a unique culture, was where I fell in love with service.” this small blessing would become a lifeline to those of us working in the dental clinics during the next week and a half. My dad and I arrived earlier than usual to aid in the setting up of all the equipment. With a suitcase full of instruments, a couple lawn chairs, and a hand-held X-ray camera, we set to work organizing our clinic. It was about an hour later when our first patient walked through the door. I still remember her. As she sat down in the lawn chair, I instantly noticed the smell of beetle nut on her breath. When she first opened her mouth, I was greeted with disturbing sights of decay. She was missing many teeth, and those still in place were badly infected. My clinic experience was going to be intense, and this was only just the start of what was to come. During the course of that first day, I was introduced to the world of clinical dentistry practice under the most basic conditions. My dad gave me a crash course, introducing me to all the instruments and their uses, as well as teaching me how to sterilize and clean all the equipment. In a matter of hours I had assisted with extractions, fillings, and root-canals. On my first day, I had just experienced a wide range of dental procedures. As the week went on, I met many more people and pulled quite a few teeth. Each person who came to sit down with us had a unique set of oral needs. Some students only needed a few fillings, while other individuals came in with much more severe dental needs. No matter the complexity of the treatment they needed, every patient we saw shared one common characteristic—an expression of deep gratitude and thanks. These people had very limited access to healthcare, and the only way for some of them to receive medical help was by traveling to the Philippines. We witnessed firsthand the urgent need for the medical-dental clinic others of our team were helping to construct.


E ZP E D O M agazi ne / M ay 2016


6 5


8 OUR TIME IN PALAU 1. A group of 34 people off to serve the world 2. Tiffany and a friend at the cultural center 3. Enjoying a waterfall on an afternoon hike 4. A group of students singing for church 5. The Fisher family experiencing the “Milky way” lagoon 6. Dr. Fisher evaluating radiographs with a student 7. Tanner, Tiffany’s brother, setting tile at the new clinic 8. Sharing memories with a friend

Next Generation Technology

EZPEDO EZP ED O M ag azin e / M a y 2016


A LOOK BEHIND THE SCENE True innovators create their own content and that’s exactly what we do at EZPEDO. So remember, the beautiful pictures of smiling children in our ads are not stock photos, they’re all unique because they’re our patients.


TRENDSETTIN How Zirconia crowns are changing pediatric dentistry and how one residency program keeps pace By Martha Wells, DMD, MS, and Larry Dormois, DDS, MS


E ZP E D O M agazi ne / M ay 201 6

Training the Next Generation The department of Pediatric Dentistry at the University of Tennessee (UT) has offered residents the opportunity to work with Zirconia crowns since 2011.

next highest rating. Pre-veneered SSCs received the lowest satisfaction rating. The drawback of resin composite strip crowns (lack of durability) and the color issues associated with preveneered SSCs were noted as problems, leaving Zirconia crowns having the greatest level of parental satisfaction. In spite of a growing interest in esthetics, a recent survey showed that 55% of pediatric dentists do not yet use Zirconia crowns in their practices.4 This article will address three possible reasons pediatric dentists may be reluctant to add this restoration option to their practice armamentarium: 1) lack of long-term, scientific evidence, 2) increased cost, and 3) inadequate training.

Lack of Long-term, Scientific Evidence and a Synopsis of Current Academic Research Currently, evaluation of clinical practice using Zirconia in the primary dentition is based primarily on case studies and anecdotal / personal evidence rather than on long-term scientific research. On the other hand, using strip crowns and pre-veneered SSCs is considered an established and acceptable technique even though research relating to these crowns has been of relatively low quality. No controlled, clinical data exist to suggest one type of restoration is superior to another.5 Researchers are beginning to report results regarding Zirconia crowns for primary teeth. Laboratory studies have confirmed that Zirconia crowns are strong enough to withstand the biting force of a child.6 Another laboratory study has examined the amount of tooth reduction necessary for anterior and posterior Zirconia crowns, and found that Zirconia preparations are much more aggressive than preparations for SSCs, but that the tooth reduction for anterior teeth across various brands is similar.7 For posterior teeth, Cheng crowns were found to require the most tooth reduction. One limitation of this study was that it was not able to show where the tooth reduction needed to occur. Was it from the incisal edge or the cervical third?


atients have fallen in love with esthetic dentistry, believing that a great smile is a feature that remains attractive regardless of age. A recent study by the American Academy of Cosmetic Dentistry noted that 86% of patients cite the reason for wanting cosmetic dentistry is to improve physical attractiveness and self-esteem.1 Other sources concur that this explosive interest in esthetic restoration options has trickled down into pediatric dentistry.2 The future of pediatric dentistry is rather clear: pediatric dentists will continue to see an increased demand for esthetic restorations. As the demand for esthetics increases, pediatric dentists have more reason than ever to explore alternative restorative solutions, especially for the stainless steel crown (SSC). Another study researches parental satisfaction levels of three anterior esthetic crown options for primary teeth.3 One year after placement, parents were most satisfied with Zirconia primary crown restorations, with resin composite strip crowns receiving the

In addition to the above mentioned studies, two other clinical studies have recently been published. A randomized controlled trial examined the durability of Zirconia crowns, strip crowns, and pre-veneered crowns.8 The study found strip crowns to have the lowest durability followed by pre-veneered crowns which experienced facing fracture issues. The Zirconia crowns—most durable of the three crowns tested —were f o u n d t o b e w e l l r e t a i n e d a n d biocompatible. However, the follow-up time in this study was only six months. Thus, long-term conclusions could not be drawn. The three authors of the above study also completed a

EZP ED O M ag azi n e / M a y 2016



E ZP E D O M agazi ne / M ay 20 1 6

Larry Dormois DDS, MS, is chairman of Pediatric Dentistry and Community Oral Health, and Martha Wells, DMD, MS, is program director of Pediatric Dentistry, both at the University of Tennessee Health Science Center in Memphis, Tennessee where they are also both associate professors. Dormois and Wells are both board certified pediatric dentists and members of the AAPD.

ound that parental satisfaction overall was highest for Zirconia crowns.3

A retrospective study of the clinical performance of Zirconia crowns examined 44 crowns in 18 children with a follow-up range of six to 37 months. The crowns were found to be well retained. Furthermore, the study showed that the crowns had acceptable to excellent color match and contour, none to mild gingival nflammation, and received high marks for parental satisfaction.9 Evidence is building to show that Zirconia crowns are a clinically acceptable restoration in primary dentition.

Cost Considerations

Another possible reason dentists are reluctant to use Zirconia restorations is the cost. Zirconia crowns are without question more expensive than SSCs. However, SSCs are not esthetic. If one only examines the esthetic crown options, one finds that Zirconia restorations are less than 25% more expensive than other available options. Zirconia crowns average $23 per crown while pre-veneered crowns average $18 and a strip crown form costs a mere $6. However, for strip crowns, the expenses associated with unit-dose bond and composite must also be factored into the equation, bringing the total cost of the restoration to around $21. Depending on which cement is used for pre-veneered crowns and Zirconia crowns, the average total cost of each restoration is $24 and $28, respectively. Hence, the cheapest restoration, the strip crown, is only $7 less expensive than a Zirconia crown, and that price does not actor in the possibility of additional chair-time required for strip crowns which are very technique-sensitive.

Inadequate Training

The majority (84%) of pediatric dentistry residents do not receive ormal training with Zirconia crowns during their residency.4 This lack of training is most likely due to the reasons previously discussed. However, the Department of Pediatric Dentistry at the University of Tennessee (UT) has offered residents the opportunity to work with Zirconia crowns since 2011. The program formally teaches the ooth-preparation technique, the properties of Zirconia, the types of cements available and their indications, and the various features of different Zirconia crown brands.

Faculty members have been and currently are involved in research regarding Zirconia crowns and various cements available for the crowns. They believe that providing training in esthetic restorations is nvaluable to residents who will most definitely face esthetic demands from parents. EZPEDO was the first brand of Zirconia crown used by UT, and the retrospective study quoted earlier

treated with EZPEDO crowns. Residency programs must balance novel techniques with evidencebased practice. However, as evidence continues to accumulate, training programs should be on the cutting edge, offering residents the science and the “why” behind the “how” of Zirconia restorations. What does all this mean for the practicing dentist? The ideal fullcoverage primary tooth restoration should be well-retained, durable, biocompatible, conservative, technique-insensitive, cost-effective, and esthetic. Zirconia crowns do check many of these boxes. As parents continue to seek dental practices that offer esthetic restorations and as almost half of pediatric dentists now offer Zirconia crowns in their practices, the time has come to seriously consider adding Zirconia to your toolbox, if you have not done so already. These restorations are continuing to change the future of pediatric dentistry. Footnotes: 1.

American Academy of Cosmetic Dentistry. Cosmetic dentistry: state of the industry survey 2015. American Academy of Cosmetic Dentistry, 2015. Available at: http://www.aacd.com/proxy/ files/Publications and Resources/AACD State of the Cosmetic Dentistry Industry 2015.pdf. Accessed February 2016.


Holan, G., Rahme, M.A., Ram, D. Parents' attitude toward their children's appearance in the case of esthetic defects of the anterior primary teeth. J Clin Pediatr Dent 2009;34(2):141–5.


Salami, A., Walia, T., Bashiri, R. Comparison of parental satisfaction with three tooth-colored fullcoronal restorations in primary maxillary incisors. J Clin Pediatr Dent 2015;39(5):423–8.


Bradley, K.O.D., Harvey, D., Oueis, H. A survey of pediatric dentists regarding zirconia crowns. American Academy of Pediatric Dentistry Poster #265. 2015.


Waggoner, W.F. Restoring primary anterior teeth: updated for 2014. Pediatr Dent 2015;37(2):163–70.


Townsend, J.A., Knoell, P., Yu, Q., et al. In vitro fracture resistance of three commercially available zirconia crowns for primary molars. Pediatr Dent 2014;36(5):125–9.


Clark, L., Wells, M.H., Harris, E.F., Lou, J. Comparison of amount of primary tooth reduction required for anterior and posterior zirconia and stainless steel crowns. Pediatr Dent 2016;38(1):42–6.


Walia, T., Salami, A.A., Bashiri, R., Hamoodi, O.M., Rashid, F. A randomised controlled trial of three aesthetic fullcoronal restorations in primary maxillary teeth. Eur J Paediatr Dent 2014;15(2):113–8. Holsinger, D.W.M., Donaldson, M., Scarbecz, M. Clinical evaluation and parental satisfaction with pediatric zirconia anterior crowns. American Academy of Pediatric Dentistry Poster #283. 2015.



IN EDUCATION As evidence continues to accumulate, training programs should be on the cutting edge, offering residents the science and the “why” behind the “how” of Zirconia restorations.

The University of Tennessee Health Science Center, Memphis, Tenn.

EZP ED O M ag azin e / M a y 2016


20 16


Symposium Lake Tahoe, California


Z 20 16



Lake Tahoe, California

My kind of place.


© Copyright 2016 EZPEDO MAGAZINE, a subsidiary of EZPEDO, Inc. All Rights Reserved.

Next generation technology or next generation care? Yes.

Time-proven results you’ve grown to trust. It’s exciting to see what is possible when you start using EZPEDO crowns. The esthetic difference is remarkable, and the results—they’re truly amazing. Discover for yourself what’s achievable when you start using the world’s highest-rated pediatric Zirconia crown. Find us at ezpedo.com | 888.539.7336 | +1.916.677.1477


Profile for Sprig

EZPEDO Magazine - Spring 2016  

A Pediatric magazine for both Doctors and Parents to stay up to date with the world of Pediatric Density.

EZPEDO Magazine - Spring 2016  

A Pediatric magazine for both Doctors and Parents to stay up to date with the world of Pediatric Density.

Profile for ezpedo

Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded

Recommendations could not be loaded