William Strupp, DDS
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The Achilles’ heel of crown and bridge dentistry is cementation. The greatest chances for biologic, cosmetic, profitability, and practice-building failures occur on the day of cementation. Understanding the clinical connections that drive these failures will assist in avoiding them. In addition, simplifying how cementation is done will further the chance for success and add infinitely to the bottom line of the practice and patient satisfaction.
According to scientific reports, pulp death within five years after crown placement occurs at an average rate of 10%. Contamination of the cement on the day of placement is one of the primary causes necessitating endodontic treatment. Most of these pulp deaths are iatrogenic with the etiology of microbial growth under the cement. I have termed this “cement sepsis.”
If the tissue around the abutment tooth is raw and bleeding at cementation because a provisional did not fit properly or because the patient failed to perform proper home care or because excess provisional cement was left in the sulcus, cement contamination and the resulting cement sepsis is very likely to occur.
Therefore, it is imperative to make certain that provisionals fit perfectly with perfect margins, contacts, and occlusion. Using an indirect technique with an assistant doing all the work is the best and simplest way this can be accomplished. The assistant should also be the point person responsible for training the patient in proper home care and encouraging the patient to comply. Frequently, patients will avoid brushing the provisionals because they are concerned that they will harm them in the process, when the exact opposite is true.
Delegating the removal of all of the provisional cement to the assistant is also very effective. After the assistant is done, I prefer to check the patient myself with my Designs for Vision 6X loupes to ensure there is no residual cement. Removing all of the cement is critical to achieving healthy pink tissue on the day of cementation.
We routinely schedule our patients for a follow-up appointment within one week of the preparations. We do an esthetic evaluation, check for residual cement, and reinforce the patient’s decision to have the treatment done. Photographs and models are made at this time, and esthetic analysis of the provisionals is done to direct the laboratory in the correct fabrication of the final case. Residual cement is almost always found and removed.
When the assistant makes a casual statement like, “This sure is working out great. I’ll bet you wish you had done this years ago,” buyer’s remorse will be avoided. Almost everyone has buyer’s remorse to some degree, and simple reinforcement from a third party with no vested interest will mitigate the damage the mindset can cause.
When these clinical factors are understood and mastered, tissue around the abutment teeth will be pink and healthy on the day of cementation. If not, the resulting inflamed “slab of meat” will create an environment that frequently causes cementation into a pool of blood and cement sepsis to occur. Likewise, simplifying the cementation protocol can add to the predictability of crown and bridge cases. We have done this in our office in two distinct ways:
First, we see the patient a few days before cementation to perform a precementation cleaning and/or chlorhexidine scrub. For large cases and patients with compromised home care, we do the cleaning combined with the chlorhexidine scrub. For small cases or patients with excellent home care, we will only have an assistant scrub the sulci around all the abutment teeth with chlorhexidine.
We always instruct and encourage our patients to perform excellent home care by explaining the compromised outcome that will result if they fail to do their part. Frequently, tissue that is inflamed and bleeding at this appointment will be pink and healthy on the day of cementation.
Second, we use only one cement (Panavia F 2.0), so only one cement protocol is necessary. This protocol involves always using anesthesia for placement, always air-abrading to remove excess cement after using a sonic scaler to remove the big pieces of Durelon, and then placing the case with Panavia F 2.0. It is a resin cement that will snap set in seconds under the crown, but will remain oxygen-inhibited so the excess can be partially light-cured and flaked away. No cement excess and no cement sepsis make this a great cement!
Dr. Bill Strupp is a practicing clinician and inspirational speaker, acclaimed for his practical and predictable presentation, “Simplifying Complex Cosmetic and Restorative Dentistry.” He is an accredited fellow and founding speaker of the AACD. He is a member of the AAFP, AOD, APS, AES, AAIP, IASD, AAOSH, FACD (president and founding speaker) and other organizations. Contact him by phone at (800) 235-2515, by email at Bill@strupp.com, or visit his website at www.strupp.com.