The Cosmetic Dentistry Blog

July 29, 2013

Some dental bridge engineering principles, and why this planned bridge will fail

Dr. Hall,
I had my upper 6 front teeth pulled due to periodontal disease. I was going to have 4 implants with two pontics, but asked for something less expensive. So we are talking about doing a permanent bridge. I have read about the Maryland Bridge and feel now that maybe the separate implants with two pontics would be better? They have charged me the same price so my question is …would 4 implants and two pontics be better?
- Jill from Pennsylvania
(Note from Dr. Hall – a pontic is the false tooth part of a dental bridge.)

Jill,
I can’t really prescribe anything specific for your case without seeing you, but I can be some help here by giving you some guidance from basic principles of bridges and restorative dentistry.

If you are accurately telling me what your dentist is telling you, then something is very wrong here. A permanent dental bridge replacing six missing upper front teeth on any patient with significant gum disease would be a disaster waiting to happen. It’s not going to last, and in the end will be by far the most expensive option. Other options would be far better in multiple ways. And I’ll explain why. I’m going to explain this in some detail here for you and then use this explanation as a blog post that will hopefully help others with similar questions.

Here is a diagram of your upper arch:

upper-arch

So you are saying that you have had the front teeth extracted, which would be teeth numbers 6 through 11.

Here are a couple of principles of doing bridgework that every dentist is taught in dental school.

First, any bridge needs to be supported by teeth that collectively have the same amount of support as the missing teeth. In other words, if the bridge is replacing two medium-sized teeth, it needs to be anchored by at least two medium-sized teeth. If four small teeth are missing, they could maybe be supported by two large teeth, if those supporting teeth are twice as large as the missing teeth. So, you are missing four medium-sized teeth (6, 8, 9, and 11) and two small teeth (7 and 10). To support that adequately, you need four medium-sized teeth (4, 5, 12, and 13) and probably one large tooth (3 or 14). So you are ending up with an extremely complicated 11-unit bridge, consisting of six false teeth supported by five existing teeth. Now I suspect that your dentist, especially if you are pressing to save money, may be planning something less than this. But breaking this rule would severely limit the lifespan of the bridge.

Second, when you start adding supporting teeth, you increase the likelihood of failure for two reasons. One is that each supporting tooth has to be prepared to be perfectly parallel to all the other teeth. Getting five prepared teeth to be all parallel to each other (or even four) so that the bridge fits perfectly is extremely demanding, and I would not ask a regular family dentist to do that. When you add to that complication the problem of having teeth on opposite sides of your mouth, making those parallel is a very tricky proposition. Another reason is that if you have any kind of trouble down the road with any of the supporting teeth – decay or gum disease or any other significant problem – the entire bridge will have to be re-done. How expensive is that going to be? Way more than implants.

Third, with six missing front teeth you have what is called a cantilever effect. Look at the diagram and imagine that tooth #4 is missing. This tooth could be replaced with a simple three-unit bridge – the missing tooth #4 supported by teeth #s 3 and 5. Notice that these teeth are pretty much in a straight line. There would be no tipping forces at all when chewing stress is borne by tooth #4. This is the type of stress these supporting teeth are designed to take. But now compare this with teeth #s 6 through 11. These are on a curve. The strongest bridge between teeth #s 5 and 12 would be on a straight line between the two teeth. But that kind of a bridge would go across the roof of your mouth and wouldn’t make any sense. So we have to loop the bridge out around the curve. Have you ever seen a highway bridge that curves out like that? Of course not. They always form a straight line between the supports. The reason for that is that when you’re out on that curve, you create tipping forces which put a large amount of stress on not only the supporting structures but the entire bridge. This force becomes a force that wants to twist and push the two closest anchors (#s 5 and 12) and actually pull the remaining anchors out of their sockets. These are stresses that these teeth are not designed to take, and the life expectancy of such a bridge would be pretty short. You would probably end up losing all of the anchor teeth, in addition to the six you are already missing. To compensate for that added stress factor, your dentist could try anchoring with six teeth instead of five. But then you increase the risk also and may end up losing all six of them.

The conclusion of all this is that a permanent bridge replacing six front teeth would be a bad idea for someone with healthy gums in the hands of some of the most expert dentists in the country. When you add the complicating factor that you have significant gum disease, and add that to the possibility that your dentist may be an average family dentist, you are courting disaster.

So what should you do?

Anything other than the fixed bridge. Don’t end up in our collection of cosmetic dentistry horror stories.

The most economical solution would be a removable partial denture. With today’s acrylics, this could be made to be very esthetic and could have clear acrylic clasps that would be virtually invisible to anyone else. There are some inconveniences to having a removable partial denture, but the cost would be a small fraction of the cost of any other option.

The most comfortable and highest quality solution would be using dental implants. Now whether or not you could support the false teeth with two or four implants would depend on how much bone support you have and the stress of your bite.

My advice? Get a second opinion from an excellent dentist. (See my posts about how to ask for a second opinion.) There is an excellent dentist near you with a national reputation. I’ll send you his name as well as another who is quite a bit further for you but whose fees would be considerably lower. Some dentists will give second opinions for free. But even if you pay $100 for it, that would be much more sensible rather than throwing $10,000 or more at a solution that may only last a few months, even if you don’t end up having the second dentist do the work.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

February 21, 2013

Sorting out LeAnn Rimes’ dental malpractice suit

I ran across a post on eonline.com that appears to be trying to poke fun at LeAnn Rimes for her dental malpractice lawsuit.

It posts this pair of photos, saying that the left one was taken before the disputed dental work, and the right one was taken after.LeAnn-Rimes

The implication is that her teeth appear to have problems “before” and look fine now. The comments get into a lot of ridicule of LeAnn, with some implying that she is just being litigious.

Here’s some added perspective, from a cosmetic dentistry expert. The “before” picture is NOT “before” any dental work was done. There is serious inflammation and swelling around her upper right central and lateral incisors revealing problems with the dental work on those teeth. The other teeth don’t have this inflammation around them, so I am confident that there is faulty dental work there.

Here is another pair of photographs. On the left is a very early photograph. The teeth seem to be smaller than in the “before” photograph above, which seems to bolster my point: LeAnn-Rimes

The “after” photograph, by the way, I believe was taken in 2010. The teeth look a little too large. And someone in my office remembers seeing her after the dental work was done and remarking to her son that the work didn’t look good and it appeared to affect her speech.

I get a lot of e-mails from patients who have been victimized by shoddy cosmetic dentistry. I can entirely believe that this happened to her.

When I am looking at photographs from dentists to possibly recommend on mynewsmile.com, I insist on photographs that show some gum tissue and that are enlarged enough to show whether or not the gums are inflamed. The presence of gum inflammation much less than what is displayed here will disqualify a dentist in my estimation and I will refuse to recommend them.

Click here to find a recommended cosmetic dentist and read some about how dentists qualify to be listed here.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

June 9, 2012

Why can’t my dentist get this color right on my implant crown?

Dear Dr Hall,
I was not happy with the color of the crown attached to my implant, so I returned to my dentist who said he thought it was fine and sent me away to “think about it.” I returned and he very reluctantly agreed to re-do the color. I recently had the revised crown attached again, but the color is worse – it is now quite noticeably darker. Both times I visited the lab for color assessment. And both times the dentist did not bother to check the color before attaching the crown. I am very disappointed, but do not want to return to this dentist as he obviously is not able to improve. He also had considerable difficulty with attaching the crown which resulted in considerable discomfort and left me wondering whether the attachment to the implant has been damaged. Post-procedure, I cannot eat on that side of the mouth at all. This implant has cost me a considerable sum. I would like to know what my options would be for correcting the color of this crown, and if the attachment has been damaged, would I need to get a whole new crown and implant, and who should pay for this? Is it possible to place a veneer over the crown? Thank you for your help.
- Mary from Australia

Mary,
Your case is a great illustration of the great difference between dentists when it comes to aesthetics. Only about 2% of dentists, from my experience, are very good at aesthetic dentistry, and I have people all of the time having a hard time believing that and wanting to know why. (And that 2% is in the US – probably less in Australia). But dentists become dentists because they like to fix things – they’re just not into works of beauty.

Your dentist clearly has a low degree of interest in the aesthetics of his work, and that is the reason this isn’t working. And you have given clear indication here in your e-mail of his indifference. Any dentist who is seriously trying to do beautiful cosmetic dentistry will be very attentive to your opinion and if you thought the color didn’t match well would not try to tell you that it was fine. Such a dentist would actually make sure the color was right in your eyes before cementing the porcelain crown and would not hesitate to send it back to the lab. But your dentist did not have enough confidence in his own color-matching skills to match the color himself but instead sent you to the laboratory. And then, after being burned once and having to re-do the crown, rather than trying it on and making sure you liked the color this time before permanently cementing it, he just puts it on.

You have figured out that you cannot rely on this dentist to get this right. If you want this done right, you have to find a dentist who actually wants to be good at aesthetic dentistry. I wish you had told me where in Australia you are and I could give you some guidance on that, because good cosmetic dentists are few and far between in Australia.

When a dentist sends you to the laboratory technician for the “color check”, that is a pretty good sign that the dentist knows he or she isn’t very good at tooth color, and those cases often end up looking very poor. All the technician can do is look at the tooth that needs to be matched and take notes about the color. Then he or she dismisses you, goes into the laboratory, and tries to follow the notes that were made. The dentist is supposed to have a higher level of skill than the technician, and should know how to make those notes and instruct the technician. And nowadays, with digital photography, it is very easy for a dentist to hold up a shade guide tooth to your tooth and snap a color-correct photograph and e-mail it to the technician, with notes. The technician can then use that photograph and the notes during the fabrication of your crown, and this is often the best way to get an accurate match.

Do not – absolutely do not try to get a veneer placed over the crown. The crown is difficult enough by itself. Get the crown re-done. If that is done correctly, it will not damage the implant at all. Trying to do a veneer over it and get the color right makes it all the more complicated. Besides which very few dentists know how to properly bond a veneer onto a porcelain crown. That could turn this from a simple bad dream into a true nightmare.

If you need any more help with this, please write back.
- Dr. Hall

P.S. – I see you found our website by searching on “dental catastrophe.” I had not thought of that search term before, but it is appropriate!

Click here to read my blog posting about how to ask for a refund from your dentist.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

June 1, 2012

A cosmetic dentistry horror story – but there is a silver lining

Hi Dr. Hall.
I got 8 porcelain veneers and 2 crowns 2 weeks ago. I am 48 and have tetracycline stained teeth. I am very disappointed in a few ways and don’t know what to do. First thing is that they are too white. I look silly. I am Italian with dark skin and I look like I have Chiclets in my mouth. My dentist gave me an option on the color so I realize I am stuck with that problem. I will probably not smile very often now.

But the worst things are that I feel like they are loose and may come off at any time. I can’t bite down hard as it hurts in my molars. And also I can’t relax my teeth as it feels like the upper teeth are too long and my entire face aches like I am clenching and grinding my teeth. Help me with some advice please. I have had 5 kids with dental issues I always took care of. They are grown and gone and I finally was able to do my own smile. I am so sad about it.

Thank you.
Jamie from Virginia

Jamie,
This is the sort of story have heard so much over the years, and is the reason I operate this website. 98 to 99% of dentists simply don’t know how to do beautiful cosmetic dentistry. They chose the field because they like to fix things, and they think like engineers, not like artists.

You’re kind to take the responsibility for the color of your porcelain veneers. But there are about three things a dentist who is truly passionate about doing beautiful cosmetic dentistry would have done differently in your case.

First of all, he or she would have been knowledgeable enough about the results you would get to predict how you would look when your case was done, and would have coached you to a more beautiful result. You’ve never had a smile makeover before – how are you supposed to know how a particular color will look once it is in your mouth? A truly artistic cosmetic dentist would be focused on creating a beautiful smile, and would steer you in that direction.

Second, every excellent cosmetic dentist I have ever asked, and I have interviewed a number of them on this subject, has some method for making sure that you will love your new smile before it is ever bonded permanently. They will often make a set of what they call provisional veneers in acrylic that will be temporarily cemented onto your teeth so you can “test drive” the final result, to make sure that you will be happy. In addition to this, they have a try-in with the actual veneers – they will use a try-in paste to insert the porcelain veneers to let you see exactly how they will look. You will get as much time to look at this as you want – will get to see it under different lights, have a friend or family member come in to give you feedback on how it looks – whatever it takes to make sure that this will make you proud to smile before these are bonded on permanently. Most recently, I interviewed a cosmetic dentist in the Boston area that we recommend on this site. In 30 years, he has never had a patient who has not been happy with their new smile. If he ever did, he would re-do the case.

And that brings me to the third thing an excellent cosmetic dentist would do. These dentists, as I said, are passionate about creating beautiful dental work. Most of them, if they heard you say what you just wrote to me – that you won’t be smiling much any more – would be so embarrassed that they would re-do the case for free. I had this happen to me. I was a young dentist and it was the first time I had done porcelain veneers on someone with tetracycline stains. When dentists are inexperienced with tetracycline stains, they will make one of two mistakes. These tetracycline-stained teeth are so dark on the inside that the color shows through most dental materials, and the dentist will have them made too translucent so that the gray-brown shows through. This is what I did. Or, they will make the teeth too opaque and white so that they look pasty and fake. This appears to be what your dentist did. Well, with the case that I did, after I gained more training and experience and knew better how to make this type of case look beautiful, I offered to the patient to re-do them for free, because I didn’t want work that I was responsible for not looking beautiful. The patient never complained, but I could tell she wasn’t excited about how they looked, and I wanted her to be excited. I’m not unique – that’s typical of artistic dentists who love to create beautiful smiles.

So what do you do at this point? There really isn’t much remedy other than doing the porcelain veneers over. And this time you need to be very careful about the dentist you pick to do them. Pick one from our list – that’s why I have this website. I personally check every dentist I list to make sure they can do beautiful smile makeovers.

But I need to say a word about how your mouth feels now. The porcelain veneers cannot be loose – if they were loose they would immediately fall off. But what I am worried about is that your teeth are getting loose. You say that your entire face aches, like you are clenching and grinding now. And you think that the upper teeth are too long. I can’t tell this from a distance, but it certainly sounds like your bite has been thrown off. This could potentially be very serious and could lead to serious TMJ disorder or breaking of the dental work, or premature wearing down of your teeth, or periodontitis leading to early tooth loss, or even breaking of your teeth. This could actually be the silver lining of your cloud, because this could give you grounds for asking this dentist to compensate you so you can have this re-done correctly. Here’s what I would suggest. Go to a dentist on our list of recommended dentists. See what he or she thinks of what has been done – if the work has indeed thrown your bite off to where it is causing serious problems. And then see if he or she will help you get some satisfaction from this other dentist. You need someone more than just a skilled cosmetic dentist – you need someone who will be understanding and willing to stick their neck out a little to help you get what you deserve.

Good luck,
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 30, 2012

I’m an adult with baby-sized teeth

Dr. Hall,
If you’re an adult with baby sized teeth. Can tooth bonding make them Adult size? If so, what is an estimate price for enlarging 4 teeth and closing a Gap?
Tiffany from California

Tiffany,
The best solution for making small teeth larger would be porcelain veneers. While dental bonding could be used, that’s not the best solution, and I’ll explain why.

The dental bonding material is relatively soft, compared to, say, tooth enamel, which is very hard. It will feel hard to the touch, but it is susceptible to scratching, and it can also absorb stains. So it won’t look that good for very long. Porcelain, however, is even harder than tooth enamel and less susceptible to staining. So what you would have with dental bonding would be a smile that would look really great for a year or two and then it would start to look dull and stained. But with porcelain veneers, with proper care they will stay shiny and bright for 10, 15, 20 years or more. Dental bonding can be less expensive – done well it may cost maybe 2/3 of what porcelain veneers would cost. But by the time you replace it or resurface it 4 or 5 times it ends up being considerably more expensive.

For a beautiful job, expect to pay $1000 to $2000 per tooth, maybe a little more on the higher end where you are in southern California.

And be very careful where you go for your porcelain veneers and absolutely do not try to look for bargains here. While many dentists claim to be able to place porcelain veneers, only about one in fifty is artistic enough to do a good job with them. If the procedure is too expensive for you, the best choice would be to do nothing. Your own natural, small teeth will look better than a poorly done set of porcelain veneers. But if you go ahead and get veneers and then don’t like how the final result looks, you will have no legal recourse. Look for our cosmetic dentistry horror stories section to read more, if you’re not convinced.

Dr. Hall

Links: Look for more blog posts about cosmetic dentistry horror stories.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

February 16, 2012

This bridge has been done three times, and has never really looked good.

Hello Dr.Hall!

I love your website, it has so much information and I hope it’ll help me to make my decisions. The reason I am emailing you is this: I don’t have my upper left lateral incisor since I was 16 y.o ( I am now 39), it was pulled out when I was 16 because it was very crooked, so my mom took me to the dentist in my country(Russia) & he pulled it out and put a bridge (crown on canine tooth).

It was so ugly that I went to another dentist same week who did a little better job & that’s how I had this bridge for about 10 years, although I didn’t like it because it was whiter then my own teeth, its bigger & bulkier.

After 10 years living in US I thought I’ll try to get a better bridge, I thought in US they do it better, so I went to my general dentist about 3 years ago & he promised me he would make it much better & I’ll be happy. After he did it, it seemed like a better one. I don’t know what was wrong with me, why I did not see right away but after some time I noticed that it still bigger, still whiter & longer then my teeth on the other side but I never told him anything. In addition he was recementing them twice after 1 month and 2 months later, after which he said I have an overbite I need to fix it with braces or it may keep falling off.

I went to orthodontist, got braces, looks like he straightened my other teeth, probably fixed overbite, anyway to make a long story short when he took them off about a months ago he offered to shave of the fake tooth because its too long and catching peoples eyes, i agreed trusting him that he will stop when metal will start showing but he never stopped to ask if I think its enough or not, finally he gave me the mirror where I could see that on the bottom of that tooth metal is very well showing, he asked me why did I get upset when it looks better now. that is the last drop, I felt abused, I trusted him but all he said “lets stay friends”. I am very disappointed & upset. He was recommended by some people & he is very nice, I didn’t expect that he would handle it like this, but again he said this is a bad bridge & I should change it anyway. I think this is none of his business, he shouldn’t have touched my teeth & suggest to do things that cost a lot of $$$ when I didn’t ask for his suggestions, I think he should have offered to compensate somehow because I didn’t plan to do any cosmetic job for a few years but now I feel that I need to do something right now.

I went to my new general dentist who suggested that I need to get another bridge maybe on all four or six front teeth so they’ll look even,also because I have a few fillings on my front teeth. I asked her about getting a bridge on one side & veneers on the other side, I don’t know maybe its not a good question,but I feel that I don’t want my teeth to be shaved off so much for a bridge,she did not recommend veneers because of my fillings. an additional information about my teeth so you can imagine it: my teeth are far not white at all & because of fillings the color is not even.

So my questions:
1.should I let my orthodontist know that I am really unhappy with what he has done & ask him to compensate somehow;
2.if I decide to get a bridge on all six front teeth will they be bulky/bigger;
3. should I get a bridge or veneers?

I know its probably hard or impossible to answer my questions without seeing them, but at least tell me what you think. Another thing, after reading your website, I see you don’t suggest to go to a general dentist,so I looked up here a cosmetic dentist in my area (name withheld). I could go there also, it’s an hour drive, but I don’t mind if its a better doctor. I am so disappointed with all previous work that I had that its hard to believe for me that I ever get results that I want & also another big things that I have to pay so much $$$ & not even sure that I will be happy with that. I would greatly appreciate if you could answer me.

Thanks you so much.
- Lynda from Maryland

Lynda,
Thanks for your question and I really think I can help you.

You’re a great illustration of the point I try to make on the website that 98% of dentists simply aren’t artistic. They have an engineering mentality. You’ve had three different bridges replacing this lateral incisor, and while each one has looked better than the one before, none of them have been really attractive. This is what you find with your average family dentist. They are nice, honest people but think like engineers and each dentist probably thought the work they did for you was fine, why are you complaining? And now this orthodontist says he can’t understand why it should bother you to show a little metal – he made the tooth shorter like you wanted.

Don’t let this happen any more. This is exactly the reason I run this website, to help people like you learn about cosmetic dentistry and get the work done right. The dentist you mentioned is an excellent cosmetic dentist and he would do a beautiful job for you, as would any dentist we recommend. Yes, it certainly would be worth it to take the hour drive and get this done right.

And besides that, this bridge shouldn’t have been coming loose all the time if it was made correctly. Your dentist is blaming it on your bite, but if it were made correctly with proper retention, it would stay on, in spite of your overbite.

Don’t let your dentist put a bridge across all your front teeth. That would be a terrible thing to do. All your front teeth would be ground down to pegs, and for the rest of your life, any time anything goes wrong with any one of those teeth you will need to get an entirely new bridge.

And yes, I would ask this orthodontist to compensate you for grinding down to the metal. Even an engineering-type dentist should recognize that this is a no-no, and I’ll bet he’s having some twinges of guilt over this. I think this is the type of thing that could be mentioned in a complaint to the dental board or to a peer review committee of dentists. But I would start by just asking nicely for some partial compensation for doing the new bridge. He has a point that the bridge needed to be re-done eventually, but you have a point, too, in that you were going to wait but now you have to do it right away. So maybe if he paid for half the bridge, that would be fair. There are ways to cover over the exposed metal with metal bonding techniques, but that is too sophisticated for your average dentist and requires equipment and materials that they don’t use, unless they are fairly expert cosmetic dentists.

And when you have this bridge re-done, an expert cosmetic dentist will recommend that it be done in all ceramic, not porcelain-fused-to-metal.

Dr. Hall
Click here to read about the cost of cosmetic dentistry.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

November 11, 2011

A dental horror story, and getting things fixed from here

In 2010 I changed going to the dentist I had gone to all my life as he was retiring. I am 62 now and I wanted to go to someone that was closer to my home. My insurance gave me a choice of dentists.

I went to my first appointment and my new dentist said I needed 4 crowns on my bottom back teeth replaced. He said they were over five years old, and they had decay. They had been on many years. Same with the four front teeth but he said he could put on whiter crowns but I would wait till the new year for more help from the insurance. I had the new crowns on my bottom teeth crowned in 2010 with CEREC porcelain and paid an extra $150.00 per tooth that they did not charge the insurance, just me. Now I find out that all porcelain crowns are usually put on just the front teeth.

Then the dental office said the front 4 were pre-authorized by the insurance. So I had all 8 front teeth prepared and got temp caps and waited for my crowns. They came back and he cemented them on. Then problems started. Besides finding out the work had not been pre authorized the back of one of my front teeth chipped off. I went in and he ground on it and sent me home. The next day half the tooth fell off. My husband left work and took me back and requested he redo both front teeth which he agreed to do. So I went back to the lab for color match again. The lab told me that they had not made any mistake on the first crowns and they were not very happy about it. So when the new crowns came in they were very thick on the backs and the dentist had to grind on them. After he ground for a while he stopped and said he could not grind anymore as it was getting too thin. So I went home and realized that everything I ate got stuck in between the two teeth. He said he would check with the lab but I would probably have to pay them to remake the crowns. I was shocked. A month went by and no word back. I finally called my insurance and they said to file a complaint. They did an investigation, sent me to a different dentist that said my bite was horribly off. The insurance finally said there was not enough evidence to show he did poor work on my front 2 teeth.

Then came a letter from my dentist that he would not see me anymore. I did not want to go back to him either but what about the problem and what about any guarantee on all the work previously done? I went on until it was time to go back for my checkup. I decided to go to a dentist that a friend went to and loved. He did his checkup and told me the blackish color on some of my new crowns was micro-leakage and bacteria under the crown had caused that. When putting on the crowns everything has to be as steralized as possible. So once again I filed a complaint with the insurance. In the meantime one of my front crowns broke off. I added to my complaint my tooth breaking off. So now I am waiting to hear back from the insurance again. This new dentist emailed his chart notes of his work. He did two root canals and crowns on my upper back teeth and he did not use all porcelain. He also included pictures of my teeth with the micro-leakage and the gap between my two front teeth and my bite being off with his recommendation. So I am waiting to hear back from the insurance and trying to decide whether or not to get an attorney involved as the insurance will only recover the money they paid if they agree with my complaint. In the meantime I have a temporary on my front tooth. This has been a nightmare. Will you please give me your thoughts on this?
- Corinne from Utah

Corinne,
If you go to a new dentist who says that all of a sudden you need a lot of work, something is wrong. Frequently, the old dentist was negligent in either not diagnosing correctly or in doing patchwork dentistry rather than comprehensive dentistry. But it could be that the new dentist is taking advantage of you. If that happens to anyone, I would recommend getting a second opinion from a dentist you know is up-to-date. Don’t rely on your insurance network – find another dentist on a private pay basis, a dentist who has a modern, clean office, that appears to be high quality, and get a second opinion and compare notes. Say as little as possible about your situation and nothing about what either dentist said. Don’t even identify the dentists, but make it clear that when you have the work done, you are going to use a dentist in your insurance network. You’re just looking for an honest opinion from a dentist you feel is up-to-date and who you know has no stake in the outcome. If you can take copies of your x-rays, do so, but remove any identification of the dentist. If you have to, just pay for additional x-rays. It’s worth it, to get to the truth.

Another problem people have is relying on dentists in their insurance network. These are not usually the best dentists. The dental insurance company usually picks them because they are the cheapest. (Read more about preferred providers here.) And while I am not in a position to say whether or not your crowns needed to be replaced, I am suspicious, from what this dentist said about the crowns being over five years old, that the dentist was merely taking advantage of a known insurance company standard that they will pay for replacement of a crown after five years, and maybe there really wasn’t any decay.

It appears that you were victimized by this dentist and all the crowns that you may not have needed and the poor workmanship. And if that is the case, I would seek some compensation from this dentist.

Here is what I would advise. Before going to an attorney, I would ask your husband to demand a refund of everything you paid and threaten, if the dentist doesn’t cooperate:
1. to go to an attorney and
2. file a complaint with the dental board.
I would also see if the dentist who examined the faulty dentistry would stand behind you on this dispute. That is key to getting any settlement from the dentist – having another dentist who can vouch for the faulty work.

If the dentist will settle with you, hopefully you can avoid going to court. But if the dentist resists, then I would talk to a lawyer.

About using porcelain crowns on back teeth, that isn’t an issue here. There are porcelains that work well on crowns on back teeth. I have a CEREC all-porcelain crown on one of my lower molars and it works fine. It depends on the strength of your bite, the position of the tooth, and the type of porcelain used.

Dr. Hall

 

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

August 30, 2011

Add one more disappointed dental patient to the long list.

I recently had a 7-unit permanent bridge {cuspid to 1st bicuspid} supported with implants placed in my mouth with temporary cement. Within 1 hour they fell out. I went back to the office and the dentist recemented them with permanent cement without telling me. I had not even seen what they looked like in my mouth. Now a couple of days later I am seeing that my smile is not normal because the teeth are too long. Also the teeth are very dry and not very smooth. I went back and complained and the dentist said there is nothing he can do. Removing them would destroy the bridge and pull out the implants. Is it true that nothing can be done to fix this? Shouldnt the bridge have been been put in with temp. cement for a week before it was permanently cemented. Is he liable for anything? He insisted on being paid in full before he started the work.
- Lynne from New York

Lynne,

I hate having to respond to these e-mails of patients like you who are so disappointed in how your dental work looks, because there really isn’t a whole lot you can do. And now you have this entire smile that cost you many thousands of dollars, and you don’t like it.

What your dentist told you is partly true. He said that removing the bridge would destroy the bridge and pull out the dental implants. I would put an “or” in there – it can be removed by destroying the bridge OR pulling out the implants. And maybe that’s what he actually said. It could be removed just by grinding off the bridge. That would destroy the bridge, yes, but it wouldn’t pull out the dental implants. And while I’m sure he doesn’t want to do that, he certainly could do that.

Should the bridge have been put in with temporary cement for a week so that you could see what it looked like before it was permanently cemented? That depends on whose rules you’re using. For your sake, yes, that would have been nice. But you have to realize, Lynne, that to the vast majority of dentists that isn’t necessary, because the appearance of the bridge in your mouth simply isn’t that important. The dentist looked at it, it looks fine to him, and so it gets put in.

Could you get this dentist to fix this now? Probably not. You have no leverage. If you threatened to sue, for example, this dentist would have dozens of other dentists who would back him up and say that the bridge was fine – there is no problem with it. You would be battling against the collective opinion of the entire dental profession, because to 90% of them, how this bridge looks to you isn’t that important.

On the issue of the teeth in the bridge not being very smooth, you might be able to get that fixed. Depending on how smooth you mean, the dentist might be able to polish those. Dry off the teeth and try to mark them with a pencil. If the pencil leaves a mark, then the glaze that should be on the teeth is gone. This would be considered a legitimate, functional complaint by most dentists, so you should be able to insist that the dentist fully polish these so they won’t take a pencil mark. There are special diamond polishing wheels and pastes that will be required to do this. A lot of dentists won’t know how, but they can easily look it up or talk to their dental supply representative to get these polishing instruments.

Your dentist, like most dentists, is an engineer and not an artist. If you want a beautiful smile, you need to go to an artist. And that’s the biggest purpose of this website, to educate people on the differences between a cosmetic dentist and an engineer dentist. A true cosmetic dentist would never have dreamed of permanently cementing this bridge in your mouth without you having a good look at it. And then if there was any hesitation in your voice when you talked about how you liked it, the cosmetic dentist would address all those issues before permanently cementing it.

Dr. Hall

 

 

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 12, 2011

Seems like this “cosmetic” dentist is in over his head

Dr. Hall,
I recently replaced my four veneers, two on each side of my front teeth. A few things did not come out as I wanted, but I was willing to overlook them because I just wanted to be DONE with this!!!!

The things I was willing to overlook:

1. When my dentist tried my two canine teeth on; they were too bulky and stuck too far out. So he polished the right one; this created a dark spot on the tooth. This was obvious, so he immediately agreed to replace it.
2. My left canine teeth still sticks out more than the others. But again, I was willing to overlook it because I felt too greedy asking for a perfect smile.

Before proceeding to cement my veneers the dentist showed me what they would look like and all look well. But later that day at night I noticed that my veneers looked darker; they looked grey! In day light my veneers look fine, but in artificial light they’re noticeably darker than my two front teeth. This is very noticeable especially since I whitened my two front teeth prior to the procedure. I immediately called my dentist to explain what happened. He told me he couldn’t do anything about it. He also stressed the fact that he showed them to me and I said it was fine. And this is true, but he showed them to me during day light- the windows were open and there were no artificial lights on. Had I known that the shade could change with different types of light, I would’ve asked him to close the windows and turn the lights on. But I never knew to do that, especially because my old veneers never changed in color depending on the light.

Please advise me what to do???? I can’t be stuck for 10 years with this problem. I’m extremely self-conscious about it and don’t even want to smile in public. Please help!!!! Thank you!
- Evelyn from California

Evelyn,
I’m not getting a lot of good vibes here about your “cosmetic dentist.” I’m wondering how you came to pick him.

The problem with your canine tooth concerns me. When it was tried on it was too bulky, so he polished it back and discovered that made a dark spot on the tooth. I’m sorry, but it sounds like he is learning as he goes. And so you are accepting that these two teeth are too bulky and are going to just live with it. Any dentist who has much passion at all for cosmetic dentistry would never tolerate that in a result but would do it over until it looked beautiful and you loved it.

The color problem you have is called color metamerism. Under one light, the porcelain matches your natural teeth. Under another light, they don’t. Apparently this is another surprise for your dentist who doesn’t appear to be aware of this principle. Excellent cosmetic dentists learn all these things.

It isn’t true that your dentist can’t do anything about it. He can replace the porcelain veneers. But if it were my front teeth, I wouldn’t let him do that but would try to get a refund. It seems like he is in over his head.

I’m guessing here, because I can’t see your case and don’t know your dentist, but what you are telling me leads me to believe that you asked the wrong dentist to do this artistic work for you. 98% of dentists are engineering types. They like to fix things, but they aren’t artistic and they have little passion or feeling for appearance-related dentistry. When I talk to a dentist, there is one question whose answer will tell me a lot about whether or not the dentist is an excellent cosmetic dentist, and that is, “What do you do if the patient doesn’t absolutely love what you did?” The really good cosmetic dentists won’t hesitate – they will send the case back to the lab if the patient has any doubt at all about how it looks. In fact, they will tell me that usually they are more demanding about the appearance of the work than the patient. That’s the kind of dentist you need.

I see from your city that you are about half an hour from an excellent cosmetic dentist that I recommend. I believe this office will give you a free consultation appointment just to take a quick look and verbally explain what some of your options might be. That’s what I would do.
- Dr. Hall

Click here to ask the dentist a question.

 

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

June 21, 2011

A cosmetic dentistry horror story – so many things turned out so wrong

Dear Dr. Hall,
Last year, I had gotten six veneers on top and two on bottom. After the dentist cemented them I realized that some of them had brush marks left from the lab. I told the dentist that I was unhappy. He tried shaving and polishing the veneers over several visits, and that only made them worse, as it destroyed the shine, made them fuzzy and irritated my mouth. After much arguing, he agreed to redo the four veneers that he had tried to polish, initially asking for a full price, but later agreeing to do it free of charge because I argued that it was his fault from initially not inspecting the veneers and later making the situation worse by trying to shave and polish them.

Second time around, when the veneers came back from the lab, some did not fit, all were a wrong shade and did not match the rest of my veneers. They had to be redone twice, to finally look decent. On the third attempt, the veneers fit, but were still a little off in color. The dentist told me “so what, the color is not that different.” There were also a small gap between two veneers, he also told me “so what, real teeth have gaps too.” Fed up with the unprofessionalism, I got the veneers cemented, since he told me that it was the best he could do. Two weeks later, the veneer that initially had a gap fell out. He put it back in. The next morning the veneer fell again. He just cemented it back on, telling me that this time around he etched the veneer better and it will not fall again. The gap got even bigger and I was very unhappy. I kept on insisting to get the veneer redone, he told me to “get out of his office” and that he is releasing me of his care.

One week after he cemented the veneer back on for the second time, the veneer fell again for the third time. I have visited several dentist and they all told me that in general my dentist has done a bad job and that all my veneers need to be redone. Out of the top six veneers, two old ones have huge spaces between the veneer and my gum and the yellow cement is showing. The four that he had redone also have visible spaces between the veneer and the gum, the veneers are discolored, one keeps on falling and one is crooked. Two of my teeth on top have become extremely sensitive, not only to cold and hot water, but even to air. One dentist told me it could be due to bad bonding. The cement on two bottom veneers has turned brown, one veneer is placed higher than the other.

I have seen three different densitst and they are all telling me to get the veneers redone, but I am concerned about redoing the veneers for the third time since I am only 28 years old. What are the risks of redoing the veneers three time in two years? What is the best solution in my case?

I have also sent a letter to my previous dentist, expressing my dissatisfaction and asked for a refund, but he has not responded. Should I pursue a civil action against him or file a complaint with the dental board? I would at least like to get a refund and be able to redo the veneers. I want to also make sure that this dentist does not do this to anyone else. He is extremely unprofessional and rude. I also feel that he should not represent himself as a cosmetic dentist, since he obviously scewed up my veneers. What is the best course of action? Thank you in advance for your time.

All the best,
Liana from California

Liana,

It sounds like you’ve been around and around with this dentist. I’d like to try to help you, but I need something more from you first.

Anyway, in general I think your frustration comes from working with the wrong dentist. You need to understand that a dental degree and a dental license don’t make a dentist an artist. Cosmetic dentistry is art, and they don’t teach it in dental school in the regular curriculum. Dental schools are designed to teach dentists how to fix teeth that are broken, not how to create beautiful smiles. And because the profession will not declare cosmetic dentistry a specialty, any dentist, without any extra training, can claim to be a cosmetic dentist, and it’s all legal.

The bonding technique is only a small part of what you need to have this done right. Remember that when they were done the first time, they were apparently bonded correctly, because they stayed on your teeth, but they were ugly and then he made them fuzzy and you asked to have them removed. If you hadn’t done that, they would still be on your teeth today, it seems to me. Is that right? So now you want to go to a different dentist who will bond them correctly. But how will they look, and, if they stay on, what will you do when you don’t like how they look?

You’re asking about the risks of doing porcelain veneers a third time and you are only 23. There isn’t a single answer to that question. If you are just going to a “dentist” to get this done, then the risks are high. It all depends on how you are picking the professional who is going to do this for you. In the hands of the wrong dentist, this is very risky. In the hands of the right dentist, there is practically no risk.

If you’d like me to help you with this, why don’t you write back and tell me the name of the dentist you plan to go to to have this fixed, and I’ll try to tell you something of the risks I think you’ll encounter. I have resources where I can look up a dentist’s training and get other information about them that helps me evaluate these things.

Once you find the right dentist to re-do this for you, I can help you work with the previous dentist. But your problem here is that cosmetic dentistry is not a legally distinct specialty, so to pursue any action against this dentist you need more of a case than that you just don’t like how they look. That is why it is so important to pick the right dentist in the first place, because when it comes to cosmetic dentistry, often you have no recourse. Yes, he was promoting himself as a cosmetic dentist, but MOST of the dentists who promote themselves as cosmetic dentists aren’t very good at it. I would think you could get a refund, though, but it will depend on how you go about it, and you need another dentist to back you up, first. So let me know and I’ll see what I can do to help.

Dr. Hall

Links: read more cosmetic dentistry horror stories.
Click here to ask the dentist a question.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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