The Cosmetic Dentistry Blog

October 31, 2007

Why is porcelain fused to metal used on molars?

Filed under: Crowns for front teeth, Porcelain crowns — iowasmiles @ 8:34 am

Dr. Hall,
What could be the possible reasons for having a dentin-bonded all-porcelain crown on a central incisor and a porcelain fused to metal crown on the first molar? Also what would be the differences between the two different kinds of materials?

Thank you and much appreciated.
- Ranje from Alabama

Dear Ranje,
There are two reasons for using the all-porcelain crown on an incisor and porcelain fused to metal on a molar:

1. Porcelain fused to metal crowns are stronger than pure porcelain. Pure porcelain is plenty strong enough to serve on an incisor. They are usually strong enough to serve on a first molar, but there could be a risk of cracking of the crown on a first molar, and that’s why even some true cosmetic dentists will use porcelain fused to metal on molars.

2. And back on a first molar, it is very difficult for others to tell the difference between a porcelain fused to metal crown and an all-porcelain crown. All-porcelain has a lifelike translucency, where porcelain fused to metal is opaque and develops a dark line at the gumline. Unless you have a really wide smile, people simply aren’t going to see that on your first molar. In my practice, I never used porcelain fused to metal crowns on front teeth–they’re just ugly, especially after you’re used to the beauty of all porcelain crowns. Patients, after being told the difference, were always willing to pay a premium, beyond their insurance coverage, for the lifelike all-porcelain crown on a front tooth.

But we need a warning here. Do not ask your dentist to do an all-porcelain crown for you on a front tooth if he or she hasn’t brought it up. These crowns require special expertise. If your dentist knew how to do them well, he or she would not want to do any other type of crown for you. Take their failure to mention this option as evidence that they’re uncomfortable with the clinical requirements of the more beautiful crown, and if it’s important enough to you that this is what you want, find a true cosmetic dentist to do this right. The all-porcelain crown will break if it’s not bonded on properly. And your dentist is very unlikely to confess, when pressed, that he or she isn’t familiar with the bonding techniques–they simply won’t let on that this is an issue.

- Dr. Hall

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October 25, 2007

Saving a cracked tooth

Filed under: Fractured teeth — iowasmiles @ 8:04 am

Dr. Hall,
I have been reading your article on Restoration of fractured teeth.

In Sept 2007 I had a filling in #14 which caused a lot of pain. On Oct 1, 2007, an endodontist started a root canal, but quit after removing the pulp because she detected a vertical mesial to distal fracture. My dentist doesn’t believe her, wants a second opinion including its depth, position, and whether she can “describe” the tooth.

I need an endodontist who understands your article, but your categories do not cover this problem. I have called the endodontist and requested that she remove the temporary filling and collect the data my dentist requested, but she has refused to work on it any further. She feels that “no cracked tooth is worth saving.”
- Sharon in Illinois

Sharon,
I don’t know any endodontist to send you to.

As far as my research on saving fractured teeth, this is kind of a blockbuster, revolutionary idea, and it usually takes ideas like that some time to get credibility in the dental community. I think someone’s going to need to get inspired to duplicate my research, and maybe a couple of people to do this, before the idea takes hold. When you’ve got an idea like that, people who just read the study tend not to believe that you saw what you say you saw.

And then remember, there is a stringent set of requirements for actually saving the tooth, as far as the nature of the fracture, the timing in catching it, and the methods for treating it. The article makes all of that clear. It’s a minority of fractured teeth that can be saved.

And then the other obstacle is that there is a strong sentiment among dentists to take the safe course. It’s a much safer feeling for a dentist to just extract a fractured tooth. No one would ever give the dentist trouble over that. But you start saving teeth that might not make it and if it doesn’t make it, that’s when the dentist could have trouble. That’s one of the unintended consequences of the great compassion that trial lawyers have engendered for patients who have suffered from treatments–dentists have learned that it’s smart to play it safe.

A dentist has to have enough passion for saving teeth to be willing to risk that the treatment might go bad in order to pursue this kind of treatment or research. And I haven’t found many endodontists, curiously, with a passion for saving teeth. They tend to be perfectionists and conventional thinkers. Their dental school professors told them cracked teeth can’t be saved, so they’re not going to go out on a limb. I even had one tell me a tooth was cracked and couldn’t be saved when it wasn’t cracked at all.

I’d print out the article and share it with your general dentist and see what he or she can do. It sounds like your dentist is dedicated to saving teeth, because he or she isn’t giving up easily on this. – Dr. Hall

Related information from the www.mynewsmile.com web site:
Root canal treatment
Failed root canal treatment

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October 24, 2007

Is there danger of infection in my broken-off tooth?

Filed under: Extractions — iowasmiles @ 5:12 am

Dear dentist,
I broke one of my molars a few years ago, and since I was young and foolish, decided not to get it looked at. By the time I got around to it, it was already missing half of it. Again, I felt I didn’t need to do anything about it since it didn’t hurt. Awhile after that the rest of it fell out, leaving the rest of the tooth under my gum still there. Now I am getting intense pain from the hole, going from the tooth through my jaw into my chin. The pain doesn’t last all day, it comes and goes, but when it comes it’s very difficult to work, as my job requires me to be on the phone for the majority of the time, and this seems to aggravate it. What can I do to get rid of this? Is it dangerous to leave that much of a tooth in the mouth? I can see a small piece of it jutting up on the inside of the former tooth, and I want to know if theres a danger of infection or anything or if I need to go in and get it removed.
- Brian in Nova Scotia

Dear Brian,
You already HAVE an infection. That’s what’s going on, and that’s what’s causing the pain. Yes, you should get the tooth out–what’s left of it. It can be dangerous.

Infections in your jaw are close to your brain and have been know sometimes to spread to the brain. It doesn’t happen all the time, but it’s possible. So I wouldn’t mess with this.

And while you’re at it, I’d have the dentist look at your other teeth. Probably, the reason this molar broke originally was that it had a large cavity in it. Once upon a time that was a small cavity and only required a small, inexpensive filling. Then, when it doesn’t get attended to, it grows into a big cavity and the tooth needs a big filling instead of a small filling. Then, as time goes by, it needs a dental crown instead of a filling, and the cost is five to ten times what it originally would have been. Then it needs a root canal treatment AND a crown, and now the cost is ten to twenty times what it started to be. And then it needs to be extracted. And if missing teeth aren’t replaced, the remaining teeth tip over and drift into the empty spaces and screw up your bite, and you wake up one day and have TMJ disorder and need major reconstruction. And replacing a tooth requires a dental bridge or a dental implant, at a cost 15 to 40 times of what the little filling would have been.

It’s always cheapest and least complicated to have checkups and fix everything while they’re small problems. But God bless the people who procrastinate their dental care, because if everyone just had regular checkups very few people would need major dental work and dentistry wouldn’t be nearly as profitable as it is.
- Dr. Hall

Read more about tooth infection.

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October 22, 2007

Teeth next to my new crown are hurting

Filed under: Dental crowns, Pain in teeth — iowasmiles @ 8:45 am

Dr. Hall,
A molar was hurting. My dentist said it could be a fractured, so we put a crown on it. Now that tooth is fine, but the two teeth in front of the crown started hurting really bad when biting down on even cooked rice. I asked the dentist to adjust the temporary crown because I thought it maybe was too tight and crowding the other teeth. He did but hours later the two teeth are still sore. If I push down on the sore teeth for a while the pain goes away, but then comes back later. My dentist said he never has seen anything like that in 20 years. I have had lots of crowns and I haven’t had this experience either. I still think the bite is messed up, but he says maybe the other tooth is going bad. What do you think? Please help. I really hate teeth pain.
- Donna in Texas

Donna,
I think it’s your bite that’s off. If there were decay or infection in the teeth, pushing down on them wouldn’t make them feel better. They could have very easily been pushed out of alignment with the crown. Your dentist should be able to adjust your bite so that you can clench your teeth with no discomfort. It may require adjusting the other teeth.

Maybe he’s reluctant to do that because he didn’t treat those other teeth. But that could be the problem. The way your teeth come together in all your chewing motions is very complicated, and little shifts or a change in one tooth can affect the others.

When you push and a tooth feels better, that’s usually either a problem with the bite or with the gums.
- Dr. Hall

Donna’s reply three days later:

Dr. Hall,

Thank you so much. You were right. My tooth is fine now.
Once again thank you so much.
- Donna

Relevant pages in www.mynewsmile.com for further information:
TMJ and other occlusion problems
Dental crowns
Temporary crowns
 

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October 20, 2007

A toast to Dr. Hall at a pub in Ireland

Filed under: Thank yous — iowasmiles @ 10:54 pm

Dear Dr. Hall,
I’m sure you are a very busy man, so I would like to thank you wholeheartedly for taking the time to reply to me. Your answer to my question about dry socket has done a lot to reassure me and help me calm down. I had been really worried about it.

My dentist has prescribed antibiotics, as you suggested.

Last night, on the other side of the Atlantic Ocean, in a quiet pub in Galway, your name was spoken and glasses raised to toast your good health. Go Raibh Maith Agat!

- Patrick in Ireland

Patrick,
Thanks. When people like you are so gracious and kind, it really warms my heart.
Dr. Hall

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October 19, 2007

Another question about tooth decay from weightlifting

Filed under: Tooth decay — iowasmiles @ 5:09 am

Dr. Hall -
I saw your note to the effect that weightlifting will not affect tooth decay. But let me ask the question a different way. I have been lifting weights (squats) for a few months now and am beginning to get up to moderately sizeable weights. I am doing this to preserve/increase bone mass to avoid osteo problems ten or twenty years from now.

If I am building extra bone as a result of this exercise, the raw materials must come from somewhere. Obviously, preferably diet. But is it possible that it may take some calcium from the teeth to build the extra bone mass?

I have just found I have problems with two teeth after not having any material problems for some years. It just seems like a curious coincidence, that it has occurred a few months after starting some fairly serious weights exercises.
- Rodney in Ontario

Rodney,

Your body can’t extract calcium or anything else from your teeth. Once they’re formed, they’re done. Your body can and does take calcium from bones when they fall into disuse, but not teeth.

It’s conceivable that, if your diet isn’t providing enough calcium to build up these bones that your saliva could be deficient in calcium, and if that’s the case, you’re weakening one of your defenses against tooth decay. There is a constant repair process that goes on where your teeth have little acid attacks every day and your saliva provides the repair every day to rebuild the site of the attack.
- Dr. Hall
Related pages in the www.mynewsmile.com web site:
Bone loss from gum disease
What to look for in dental floss and flossing
Soft teeth
Supersmile toothpaste

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October 18, 2007

Trouble with Lumineers on the lower teeth

Filed under: Cosmetic dentistry mistakes, Lumineers — iowasmiles @ 8:07 pm

Dr. Hall
I’ve had Lumineers placed on my top and bottom teeth. It has been an ordeal. My top teeth are now fine and look great. My bottom teeth have been a nightmare of pain. I just had to have a tooth pulled after a root canal did nothing to ease the pain from the infection that started after the Lumineers. I am still in pain and have numbness and burning through half of my chin and jaw. I jumped into this cosmetic dentistry without fully researching it. I believed the ads put out by Lumineers by Cerinate. I had the money and I trusted the dentist’s expertise and now I am really paying for it with continual pain that has been going on since May 2007 – 5 months. Any suggestions? The scary thing is that I am continually having to take ibuprofen for pain and sometimes addictive painkillers like vicoden! I’ve also had to take a course of strong antibiotics which did not save my tooth. The upside is that the dentist is doing the corrective work for free and will put in a bridge where the tooth was pulled. I don’t know if my problems where due to the problems my teeth presented or if the doctor was poorly or inadequately trained. Any suggestions or opinions?
- Roberta in Texas

Roberta,
The Lumineers ads advocate a “no-prep” technique. People need to realize that when they get Lumineers and there is no shaving of the teeth to make space for the Lumineers, that the teeth will stick out just a little and will be about two millimeters longer.

On the upper, this can be done without hurting your bite. But on the lower, this will usually put the lower front teeth into traumatic occlusion and can cause real problems.

I don’t know all the facts of your case, but it appears from what you’ve told me that your dentist was also caught off guard by this, as you were. He probably didn’t have much training in cosmetic dentistry and relied on the advertising in dental journals that tells dentists how easy this is. You’re fortunate to have a caring and ethical dentist who looks like he is trying to take care of the problem for you. Judging just from what you’ve told me, I’d stick with him. He should be able to fix it. It sounds like your problems are within the basic dental school training that all dentists have. It will take some time and there will be pain in the meantime, but I believe he’ll be able to fix it.

I’d be sure to get the pain solved before putting the bridge in.

- Dr. Hall
Related topics from the www.mynewsmile.com web site:

Dental bridges
Porcelain veneers
Tooth infection

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October 13, 2007

A Lumineers story gone bad

Filed under: Gum disease, Lumineers — iowasmiles @ 6:00 pm

Dr Hall,
In July 2006 I got six lumineers to close the space between my two top front teeth. In September 2007 my dentist informed me that I have more than 50% bone loss in four of the teeth and that I will need to have them replaced with dental implants at a cost of $2,700 each. He is only willing to give me credit of $1,500 and that’s only if I let him do the procedure. The lumineers cost $720 each. My question is should my dentist have taken x-rays of my teeth prior to preforming this procedure to determine it this was appropriate as my last x-rays were done in 2003, and what recourse do I have If he was negligent. I faithfully, four times a year have periodontal maintenance, I don’t know how this was missed.

Thank you for you time.
- Lenore from Pennsylvania

Dear Lenore,
I’m known for being direct, so here goes. Yes, your dentist was definitely negligent. He missed the diagnosis because he neglected to perform a basic diagnostic procedure–taking xrays of the teeth on which he is doing major work. And he is admitting to you that he screwed up because he is telling you, a year later, that these teeth are in such bad shape that they are hopeless–they have to be extracted. And then to offer only $1500 credit toward an $11,000 follow-up procedure–he would still be making good money on the implants.

Here’s what I think you should do:
Demand a full refund for the Lumineers. Tell him that if he doesn’t cooperate, you will get a lawyer. Then go to another dentist for any further work. You will be being kind, because if you go directly to the lawyer, you will get more than a complete refund. You are in a very strong position on this.

And if he doesn’t cooperate, follow through with your threat and get a lawyer.

What you have told me causes me to question everything this dentist is telling you. I wouldn’t assume that the teeth have to be extracted. Maybe they do, maybe they don’t. But don’t have this dentist do the implants.

I believe that dentistry is one of the most ethical professions there is. Most dentists are in it for the love of helping people, and they bend over backwards for the patient. But I am not impressed with the ethics of this one. It is one thing to screw up. We have all screwed up. But to screw up and then to want to continue to make profits from your screw-up–that’s unacceptable. In my opinion, when he discovered he screwed up, he should have offered a complete refund and then go on to fix the problem.

- Dr. Hall

Read a post about another problem with Lumineers, only this dentist is fixing it for free, which is the decent thing to do.

Related pages in www.mynewsmile.com:
Read more about gum disease
What makes a cosmetic dentist different from a general dentist
Dental implants

We thank our advertisers who help fund this site.

October 11, 2007

Tooth sensitive to heat

Filed under: Pain in teeth — iowasmiles @ 8:07 pm

Dear Dr. Hall,
I recently had a small filling placed in tooth #14. At first, the dentist thought that the small crack in the tooth was anatomy, but since I was complaining about sensitivity to cold, the dentist filled it with a small, white filling. The filling was fine for two months. One day, my tooth was sensitive to sweet and cold. A few days later, warm or hot was an isssue, too. I returned to the dentist and she suggested that I see an endodontist for a root canal. Is there no other alternative for me? Maybe a different filling? Or is this what needs to be done? Thanks in advance for your time.
- Allison from North Carolina

Dear Allison,
If your tooth is sensitive to heat, you need to see your endodontist. The tooth needs root canal treatment.

But I would also ask your regular dentist to put a good strong temporary crown on this tooth before you split it clean in two. Like I’d have her do that tomorrow. A stainless steel crown would be good. And reduce the tooth so you don’t bite on it. There’s a really good chance that you have a nasty split in this tooth. These teeth can be saved if you get a crown on them right away. See my article on saving split teeth.

Sensitive to cold and sensitive to sweets – that signals that the pulp of the tooth is irritated. Sensitive to heat – that signals that the pulp is about dead.
- Dr. Hall

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October 10, 2007

What are the best materials for implants and crowns?

Filed under: Dental implants, Porcelain crowns — iowasmiles @ 12:59 pm

Hello,
I am planning on getting alot of cosmetic work done to my teeth. I need around 10 implants on the top front of my mouth.

1. I wanted to know what you think of Astra implants from the UK?

2. I would like to know what you thought about Cercon smart ceramic zirconium crowns? I think I read on your site that zirconium is not as aesthetic as all porcelain crowns, but isn’t zirconium clear? They say that these particular crowns are as tough as porcelain fused to metal crowns, do you have a comment on them?

3. I had one dentist tell me that white colored metal fused to porcelain, or gold fused to porcelain, will not show a black line, Is this true?

4. are zirconium abutments for my implants, more aesthetic pleasing then all white abutments?

Thank you for answering my questions. It’s hard to get real answers on the topic of cosmetic dentistry.
- Edward from Connecticut

Edward,
I’m going to answer your question differently from what you’re expecting. I think your focus is wrong. You’re focusing on the materials. You should be focusing on the artist.

You start off saying you want cosmetic work on your teeth. Does that mean you want a beautiful smile? If so, then I believe you’re headed for trouble. Because you’re trying to decide yourself what are the best materials, as if you are planning to micro-manage your cosmetic dentist.

Imagine with me that as part of your employment you are asked to commission a painting to grace the hallway that leads into your corporate offices. And then you busy your time finding out what brand of paints and brushes will produce the best results, and the light you want your artist to use, the stool for her to sit on, and everything else. You will be stifling your artist. What you want to do is find the best artist, and one maybe that you feel a “connection” with, who feels motivated to please you, and then turn her loose on your project, and then YOU get the ARTIST the materials she feels she needs to produce the results you want. Creativity needs an atmosphere of trust and needs freedom in which to operate, if you’re going to get a beautiful result. Your dentist artist also needs to have a strong rapport with you in order to feel motivated to create a beautiful smile that you love. If you go forward with this micromanaging philosophy, your dentist is going to want to kick you out the door and won’t care WHAT you think, in the end.

Additionally, there is no way that you can learn enough about dentistry in the time frame you have to make an intelligent decision on these materials. There are pros and cons of each of the materials, and they depend on the mechanics and the demands of your case. You need a deep background in dentistry to be able to evaluate the claims of the manufacturers of these different materials and devices as well as the independent research. And even then, you won’t really know how they work until you try them. There are many stories of dentists using new materials where the research made them look like fabulous materials, but in clinical use there was a completely unexpected issue that arose that created a disaster.

And, if that weren’t enough, there is the issue of what material works best in your dentist’s hands. Most dental materials and techniques have a learning curve, and they work best when the dentist is fully familiar with the technique and the quirks of the material. You push your dentist to use a material she isn’t familiar with, and you’re asking for trouble.

Having said that, there is one of your specific questions that I’d like to answer, and that is about porcelain fused to metal. No, it isn’t true that porcelain fused to gold or to a white metal won’t show a black line at the gumline. I don’t understand what this dentist has told you, if he’s saying that only metals that aren’t white or gold show the line. Every metal we use in crowns is either white in color or gold. The line may not be black – it may be gray – but it will show if it is above the gumline. That’s because the line is the cement line. I often did porcelain fused to gold alloy restorations, or fused to platinum alloy, and they would show that line. Even fused to pure gold. It’s the bonding technique that eliminates the line, and the bonding technique is used with pure ceramic. There are techniques that MINIMIZE the dark line, such as cutting the metal back at the margin, giving you what is called a porcelain butt margin, but they won’t eliminate it.

And zirconium is white, not clear. It’s zirconium oxide, actually, and it is opaque white. But used properly it can produce very esthetic results, if it is covered with a more translucent ceramic. And yes, it is very tough.
- Dr. Hall

Helpful pages from www.mynewsmile.com:
Porcelain fused to metal crowns
Various types of all-ceramic or all-porcelain crowns
Dental implants
The difference between a cosmetic dentist, who is an artist, and a general dentist
More blog postings on finding a cosmetic dentist you can trust and developing a good working relationship with that cosmetic dentist.

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