Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

July 18, 2016

Would I let a rough hygienist clean my teeth?


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Dr. Hall,
All of my top teeth (except the molars) have porcelain crowns. I was advised years ago not to have a Cavitron used to clean the crowns. I recently had my teeth cleaned by a new hygienist who became very upset when I asked her not to use the machine. She scaled my crowns with so much force that it was painful and I really worried she would break them. The 4 center teeth do not have a metal lining behind the porcelain and I treat them very carefully. Which is the lesser of two evils – the Cavitron or a brutal hygienist scaling my porcelain crowns with hand instruments? Could there really be that much plaque on a porcelain surface?
– Elizabeth from Massachusetts

Elizabeth,
I’m getting a lot of these Cavitron questions lately. I think that’s because their use is getting more popular with dental hygienists.

The Cavitron by itself won’t hurt your porcelain crowns or other porcelain restorations. See my earlier post on this: Is the Cavitron safe for use with porcelain veneers? We used to give a blanket prohibition against using the Cavitron with porcelain crowns or veneers, but our observation of the care being used by dental hygienists has caused us to soften that. Used properly, there is no risk of damage from the Cavitron to crowns or any other restorations.

What bothers me most about what you told me is that your hygienist became upset when you asked her not to use the Cavitron. I talked to my own hygienist about this Cavitron issue and she said she gets a number of requests from patients to not use the Cavitron in certain places, or other requests, and she honors those requests. This haughty attitude and lack of sensitivity to the patient is not good. It’s kind of like you are in the way of her doing her job. She doesn’t seem to connect that you are paying for her services. Hygienists and dentists get a number of special requests like this from patients, and I believe the proper response is to honor those when possible. Yes, you may have made more work for her, but serving the patient is her job.

To answer your question, yes, the hygienist can do damage even without the Cavitron. Heavy scaling can nick the margins. If I were in your position, I wouldn’t let this hygienist touch my teeth any more, whether she used a Cavitron or a hand scaler or a toothpick. If that meant switching dentists, I would do it, and let the dentist know the reason. From what you’ve told me, I have serious questions about how much she cares about her patients, which for me is the first requirement of quality care. In rough hands, a Cavitron can do significant damage not just to restorations but even sometimes to your teeth.
– Dr. Hall

Question and answer go here.

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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, 2016

She’s reluctant to do the second half of her full-mouth reconstruction


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Dear Dr. Hall,
I have taken great comfort in the information you provide and the honest, intelligent, accessible manner in which you provide it.

I am 37 years old and had my entire lower arch redone with crowns and veneers over a year ago. My dentist is a cosmetic dentist listed on your website. She recommended a full smile makeover for my worn teeth. After years of clenching and grinding (I didn’t wear a nightguard until recent years), I was having a lot of sensitivity on my molars and my dentist said that I had a collapsed bite.

I know that my dentist did a good job, but the whole process was very hard for me emotionally. I never wanted “perfect” teeth and I do miss some of the quirkiness of my originals. Even though I went for a “darker” shade (m2 instead of m1), I still feel they are a bit white for me. Also, I have had a bit of gum inflammation, which I never had before. My dentist is having me treat this with baking soda and peroxide and may eventually do some procedure she thinks will help.

My dilemma is now that I am torn about doing the top teeth. My dentist is pushing for it. And indeed my top teeth are very worn, darker in color and contrast with the bottoms. However, my gums are very healthy on top and I have no pain at all in the teeth. I know that I cannot whiten the tips because I did Zoom whitening years ago and now I think my teeth are too worn and it may cause sensitivity.

I am agonizing over this decision and would be very grateful for any advice you might have.

My dentist seems to feel that my teeth will be better off if she completes the whole mouth, but I am so hesitant to go through such a big procedure when I not in pain anymore. The esthetic discrepancy does bother me a little, but maybe not enough to get this major work done.

Thank you for any words you have for me!!

Best,
Anna from Connecticut

Anna,
It’s hard for me to give a definitive answer as to what you should do without seeing your case and knowing everything that is going on dentally. But I’ll see if I can be of some help with some guiding principles.

There are points to be made in favor of both options–doing something and not doing anything.

First, I am not in favor of half-mouth dental reconstructions. I don’t know what the crowns on your lower teeth are made of, but most ceramics are somewhat abrasive to natural teeth. Some of the newer ceramics are very kind to natural dentition, but most of them will wear natural dentition more than they would otherwise wear, which can lead to sensitivity and other problems. You may want to ask your dentist about this, if this is an issue in your case.

The original problem was excessive wear of the teeth. I’m sure that wasn’t confined to the lower teeth–they both must have worn equally. And now your upper teeth are continuing to wear down. So it appears to me that your original problem is now half solved, and you need to finish the treatment.

Having said that, crowning and veneering all the teeth is a very aggressive step, and if you aren’t completely sold on the benefits, my inclination would be to leave well enough alone.

On the issue of the “quirkiness” of your natural teeth, a masterful smile makeover will include some “quirkiness.” If you discussed that with your dentist, I’m sure she could take care of that so that it wouldn’t be an issue. Knowing that is your preference, I think that most ceramists would love the opportunity to put some quirky features into your smile. My ceramist wanted to do that, but the barrier to doing that is that there are some obsessive patients who fuss over anything that they perceive as an imperfection in the smile makeover. I would want the smile to look natural–they would want all the teeth to be “perfect.” I would try to persuade them to have some imperfections in the teeth, but in the end the patients would get what they wanted.

If the only problem you need to fix is the color, I would do whitening. You mentioned that you worry that you would have too much sensitivity, that you had Zoom whitening before and are reluctant to do that now. However, there are a number of other options for whitening the teeth besides Zoom. Zoom, because of the light, is more harsh than other options. Kör whitening is gentle yet very effective. There is also Nite White or Day White, Boost, Opalescence, and other systems, all of which are also more gentle than Zoom.

On the issue of gum inflammation around the lower teeth–I’m assuming that is around the crowns. That is a factor that should be taken into consideration. You could be having a sensitivity reaction to the ceramic in the crowns or it could be something else. I would try to pin that down before doing the uppers. One excellent option could be doing porcelain onlays on the upper teeth rather than full crowns. Onlays stop short of the gumline so that gum inflammation shouldn’t be an issue. If not porcelain onlays, then porcelain crowns that only go very slightly into the gingival sulcus or even stop at the gingival margin. There should be a way to avoid this on the upper.

And then, about the overall result. I had a number of patients who were hesitant about moving forward with smile makeovers and had some misgivings about the procedure before starting. But once it was done and they saw themselves in the mirror with their beautiful smile and felt that great sense of confidence to where they couldn’t stop smiling, I don’t believe anyone would have ever given a second’s consideration to going back to the way they were. It was always a positive, life-changing experience. You mention that the esthetics of your smile bothers you some now. I would fix that.

I hope this is helpful.

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.

June 23, 2016

Follow-up on trouble speaking with new veneers


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This is a follow-up to the previous post, where Susan emailed Dr. Hall telling about problems she was having speaking with her new porcelain veneers.

Susan commented at the bottom of the post:

Thank you for the reply. I think I am going thru a bad nightmare. After complaining about my speech and bite, the dentist took off the front 4 four permanent veneers, to replace them. As he was taking them off he broke #9 [the upper left central incisor] after which I had to have the tooth pulled and an implant put in. I am currently 2 months with the implant temporary. I have to wait three months for it to heal. I asked him to make a matrix of the temporary veneers and the final veneers to see what is wrong. He said all the molars are each side were made too short and the lab made the mistake by using my original bite. Right now I have 9 temporaries in my mouth with the implant. He didn’t replace the 1st molars because he claims they are fine. My temporary veneers were 12.4 length for #9 and #10. Now they 11.8 and hitting my lip. Could it be those back 1st molars being too short? Or should I just run and find a new dentist?

And here is my answer:

Susan,

Again, I do have to qualify what I answer here by saying that not being able to see exactly what is going on, I may be missing something, but I CAN tell that something isn’t right here.

The molars being made too short—that would definitely explain your speech problems. But passing the mistake off onto the lab saying they used the wrong bite? No, that doesn’t work for me. It’s not the lab’s fault. The dentist gives instructions to the lab and the issue isn’t your bite, it’s the vertical dimension. And that has the potential to cause long-term problems. It is called bite collapse. You absolutely need to have your bite opened to its original position. What is starting out as just speech problems can easily progress to TMJ disorder with possible chronic headaches and jaw pain.

Cases like yours where the vertical dimension is altered need to be approached with great care, and a dentist needs more training than what they receive in dental school to pull this off. The dentist will replicate your bite on a machine called an articulator where he or she can carefully study all your bite movements. He or she will establish a vertical dimension by testing it in your mouth with temporary restorations, and then will send your case to the laboratory on the articulator with careful instructions on how to reconstruct your mouth.

And then I’m aghast at what happened to your front tooth. When you take off veneers, the way to do that is to grind them off. You can’t “pop them off” or remove them in any way like that if they’re bonded on properly. They become like a second enamel and the only way is to grind them off, which is a gentle process that is similar to preparing the teeth in the first place. I am again suspecting that he didn’t actually do porcelain veneers but did porcelain crowns and called them veneers. But even then, with front teeth, crowns should also be ground off, and there is no excuse for breaking a tooth.

I would not let this dentist touch your teeth any more—this is getting worse every time he sees you.
Actually, I do know an excellent cosmetic dentist in northern New Jersey. I will send you the name. I know her personally and have absolute confidence in her. She is AACD-accredited, which is no mean achievement, and a Master of the Academy of General Dentistry, and I believe she is one of the best cosmetic dentists in the entire state.

A couple of additional points:
1. You need to get tough with this dentist. As I said, not seeing your case personally I’m at a little bit of a disadvantage, but based on what you are telling me he has violated the standard of care and is very vulnerable legally. He seems to have got in way over his head and has done multiple things wrong. If I were you I would call him and say that you’re going to be nice and not take him to court where you could sue him out the wazoo, but to avoid that he needs to pay for everything that this new dentist needs to do to fix you up. Go to the new dentist first, confirm the details of what has been done wrong, and then confront him.
2. I can’t imagine that your bite and vertical dimension are the only problems with your case. You haven’t said anything about how your teeth look, but it is rare for functional incompetence in dentistry to be blended with artistic excellence. In my mind’s eye right now I can’t imagine that you have a beautiful smile. But based on what you have told me, your case needs to be completely re-done. That is your silver lining. The new dentist, in re-doing this, can give you a beautiful smile.

– 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.

May 23, 2016

A crack in my porcelain crown. Is this an emergency?


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Hi Dr. Hall,
I have had porcelain crowns on my front teeth for at least 16 yrs. One of them has always had a tiny defect that you could not see with the naked eye. Now I can see it and feel it. I am afraid it will break while I’m in public and I’ll lose it altogether. It is a horizontal fracture line. Near the bottom. I am not opposed to replacing but just wonder if I need to do it as an emergency.
Thanks for your help.
– Ruth from Ohio

Ruth,
I would find an expert cosmetic dentist and get the crown replaced. I wouldn’t call it an emergency, but this is a defect that I suspect will one day in the not-too-distant future result in a complete break.

You say this crown has always had this defect, but you couldn’t see it with the naked eye. Teeth and porcelain can have these lines that we call craze lines, and they are ordinarily of no particular concern. What gets my attention now with your situation is that you say you can now not only see this with the unaided eye, but you can feel it. So there has been some movement here resulting in a palpable discrepancy in the surface.

Depending on what your cosmetic dentist sees when these teeth are examined, he or she may recommend replacing all the front crowns, as they are all old. But if the other crowns look fine, there should be no need for that. See what you are told.

If you replace just one crown, that is going to require excellent color-matching skill on the part of your dentist. Be wary if the dentist tells you that the only way to guarantee a perfect match is to replace more than one crown–that’s a way for them to admit they don’t have the skill to match the new crown to the old ones.

– Dr. Hall

Question and answer go here.

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

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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.

May 7, 2016

The technician can’t get the color right on my two front teeth


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Dr. Hall,
I’m writing you from Germany. I’m a dental patient and getting two front crowns with e.max but my technician just won’t get them in the right colour.
My stumps are not dark and my teeth have a BL3 colour.

The problem with all the crowns I tried in was that they turned out too grey.

The technician has made a couple of sets of crowns already, and has experimented with pastes. When they tried in the first set of crowns they looked too grey. He then tried a bright white fit checker underneath, and they still looked grey.

So for the second set he made them with a bright white ingot and layered over it to cover the white. When we tried them in without any paste they looked grey again. This time he had a regular try-in paste in the colour light +. So he put that underneath the crown. The crown was not grey anymore but completely opaque and lifeless and had a terrible bright white. I did not like the crowns At all. The technician said he can’t do it better. I am so unhappy and don’t want to end up with two opaque front teeth that do not match my other teeth. Do you have any idea what went wrong? Did he use the wrong ingots? Or the wrong try in paste?
I thought maybe we should use a LT Bl3 ingot and a try in paste that is less opaque.
Please, please, if you have any suggestions I would love to hear from you.

Tilo's front teeth crowns

I do have photos of both crowns which I could send to you.

Thank you so much!

Tilo from Germany

I asked for photographs, and here is what Tilo sent me. The top photo is a view from the side that shows the color discrepancy.

And the bottom photo is a view from the front, with lips relaxed, that to me was even more revealing because it shows that the shape is all wrong:

Tilos-front-teeth-crowns-2

And here is what I wrote back to Tilo:

Tilo,
Let’s see if I can help you.

After seeing the photographs, I do think the problem is fundamental, that the dental lab technician isn’t very good with color. And more than that, the technician isn’t very good with aesthetics in general.

But I suspect it is even more than that. Your dentist is the one who selected this technician. Dentists who are accustomed to doing aesthetic work and who do it well will always choose a dental technician who can produce a high level of aesthetics.
Here is how I see your situation. This dentist and the technician I imagine have maybe done many crowns together, including crowns on front teeth. In their mind they have turned out fine. The patients maybe weren’t thrilled with the results, but they were willing to accept them. Now you come along and for you, the work simply isn’t good enough. They have been back and forth trying different colors, and it’s not good enough for you. If I am sizing up this situation correctly, you are becoming annoying to them. They think you should just accept what they have done–it’s good enough and you’re too demanding.

On the other hand, a dentist who does high quality aesthetic work would not put up with this level of work from his or her lab technician. It sounds to me that in this group of three–the dentist, the technician, and the patient–that you’re the lone voice thinking this isn’t good enough.

This Work Isn’t Good Enough

But you’re not completely alone, because I agree with you. The crowns simply aren’t good enough. But you may have to do more than get your dentist to pick another technician. Your dentist may not even know any technicians who are artistic enough for this case. I don’t know how things work in Germany, but I would brace yourself for maybe needing to find another dentist to finish this for you. I wouldn’t switch dentists immediately, but would ask your dentist if he knows how to find a technician with better aesthetic skills.

Having said that, let me get to the crowns. The problem isn’t just the shade and the grayness. The shape is a problem, too. They are too bulky and round-looking near the necks of the teeth. In the middle photograph of the second group where you have your lips relaxed, the crowns look awful! They are very prominent and make you look like a chipmunk!

Then, as you have written, there is a problem with the color. But it isn’t just the shade that is picked–the color is flat. The color of the crowns looks fairly uniform from the gumline to the biting edge. This is not how teeth look naturally. These crowns have kind of a uniform grayish tinge. If you look at your natural lateral incisors, you’ll see that they are kind of a very light creamy color near the gumline, with a very slight reddish-brown tinge. Toward the middle of the tooth they are lighter, with more white. Then, near the biting edge, they are fairly translucent with a more opaque halo at the very edge. So you see, it’s more involved than a simple color selection. Though I suspect that to your dentist and the lab technician, it’s a simple matter of selecting a shade. What I did when I was doing crowns on front teeth is that I would draw a large color map of the tooth and I would diagram the different color areas. I would have a basic background color that I would ask for, one that I would select from the standard shade guide, and then I had different tint tabs that I would use as a reference and explain to the technician where I wanted these color accents and variations. You are getting nothing like this from your team.

Maybe the best thing I can do for you is to encourage you to stick to your demands. Don’t let them cement these crowns permanently, but insist that they match and look natural in your mouth. There are dentists and technicians who can do this level of 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.

May 5, 2016

On the appearance of my front teeth, my dentist just says “trust me”


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Dr. Hall,

I had my top 4 front crowns replaced and the new crowns are gray in appearance. They kind of match the rear teeth but in many conversations with the Dr. having the new crowns match the bottom teeth and whiter than the old crowns was very important. When the color was being chosen, I stated that it looked dark. The response I got was “trust me.” At the time the crowns were being installed, I again said they looked dark and the response was “they are perfect, trust me.” In the dentist’s photographs they don’t look terrible although the gray is clearly visible. In natural light I am extremely unhappy with them. So much so that I now consciously try not to smile. We met with the dentist and he again claimed that they looked great but stated that he would discuss with his peers and “make it right.” The next correspondence we received was a certified letter stating that he would not re-do the work and in his opinion they looked great. He claimed that his peers felt the same way, although without looking at anything other than pictures taken with a bright flash I question how that can be determined. What should I do?
– Glen from Massachusetts

Glen,
I love your question and the situation you relate, because it illustrates so well the mentality of much of the dental profession. It’s an authoritarian attitude that is truly foreign to excellent cosmetic dentistry. What your dentist is telling you is that, as far as the appearance of your teeth, “the dentist knows best” and “who are you to tell me how your teeth should look?”

I have interviewed a number of great cosmetic dentists who create beautiful smiles. Some of them do celebrities. I will tell you that any smart celebrity simply wouldn’t trust a dentist with the attitude being displayed by your dentist.

When I do a website for a dentist who wants to promote himself or herself as a cosmetic dentist, I will have a long interview with them. One of the key things I ask them is how they create a smile design and what they do to make sure the patient is happy with any new smile they create. Without exception, these great cosmetic dentists are focused on how the patient perceives the appearance of the work. They view themselves as treating the self-perception of the patient. In the ethics of the cosmetic dentistry world, that is the problem the dentist is treating. If the teeth don’t look great but the patient has no sense of embarrassment over it and smiles broadly with no self-consciousness, then there is no problem. On the other hand, if the patient hesitates to smile or covers his or her mouth because they’re embarrassed over the appearance of the teeth, then that needs treatment. And the measure of whether or not that treatment is successful is that the patient now feels proud to smile. “After” photographs will typically show a relaxed, confident smile. Self-consciousness is gone. If that isn’t achieved, the cosmetic dentist would consider the treatment a failure. This is the universal attitude of these great cosmetic dentists.

However, to many in the dental profession, such concern over what the patient thinks is considered pandering to the patient and unprofessional. That is why this dentist, when you raised objections over how these crowns looked, replied simply, “trust me.” You see, your opinion doesn’t matter to him. And then, rather than making it right, he went to his peers. But any true cosmetic dentist would be appalled to let you out of his or her office with a smile they had created over which you were self-conscious.

You Are in the Wrong Dental Office

What to do? Well, for starters, you are absolutely in the wrong dental office. Any efforts you make in that office to get this right are going to be futile, because, based on what you have told me, this dentist is psychologically incapable of addressing your problem. So look for another dentist. Now there are many dentists who would have enough empathy with you to at least try to get this right for you, but if you really want to get it right, so that your front teeth look completely natural, you should go to an expert cosmetic dentist. If you let me know what city you are in, I could maybe find one for you close to you.

In my opinion, you should be able to get compensation from this first dentist to pay for re-doing the crowns, but I believe you are going to need to brace yourself to get tough with him. The first step is to find the dentist who will go to bat for you–you’re not going to get anywhere without a dentist who agrees with you. Then you would ask this new dentist to try to work with the first dentist to talk him into refunding your money. If that doesn’t work, you could go to a lawyer.

Informed Consent

Your dentist isn’t innocent here, in my opinion, and it seems that he senses that–hence the certified letter. However, he is bracing to defend himself on the wrong principle. The first principle of medical or dental malpractice is informed consent. If I have your story right, your dentist put these crowns in your mouth over your objections. That isn’t informed consent–it isn’t consent at all. That principle of informed consent is your leverage here and your case is analogous to the very first informed consent case that I was taught about in dental school.
informed consentMany years ago, there was a patient in Great Britain who had broken his leg and it had healed improperly. He went to a doctor for help. The doctor studied his case and consulted with his colleagues. They all agreed that the leg needed to be re-broken to heal properly, so they went to the patient and whacked his leg and re-broke it. The patient sued, because he wasn’t told what they were going to do and hadn’t consented. The doctors argued that it was their unanimous professional opinion that this was the treatment he needed. The court, however, ruled in favor of the patient, saying that regardless of how right they felt the treatment was, they needed to obtain the patient’s consent before proceeding.

This dentist of yours may argue that you nodded or gave him some signal that you would let him put these crowns in. But in my opinion, a strong-armed consent isn’t consent, and I think the dentist should be held liable, even if you did allow him to proceed.

This is the point you and your new dentist need to make to the first dentist, and hopefully he will be persuaded that what he did needs to be remedied, without your having to go to court.

And don’t get the idea that an expert cosmetic dentist is going to be way expensive. Interestingly, most good cosmetic dentists charge about the same for crowns that good general dentists charge.

– 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.

March 4, 2016

Fixing a broken front tooth on a 7-year-old

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Dr. Hall,
When I was about 7, I slipped on a monkey bar and it cracked and chipped my right upper front tooth. I didn’t get it fixed right away, but a couple of years later the dentist did a root canal and I also had it filled to kind of match my other front tooth. But now it looks horrible because it’s smaller than my other tooth and it’s discoloring. Would there be a way for my smaller discolored tooth to match my bigger front tooth? And to get rid of the discoloration?
– Vance in Arizona

Vance,
This could be a real problem, if you ask your family dentist to do this. But if you go to an expert cosmetic dentist, such as the ones I recommend on this website, it’s a fairly straightforward case that should require a single all-porcelain crown.

Many cosmetic dentists, me included, won’t recommend doing a porcelain crown on a patient in their teens or younger because often the tooth hasn’t fully erupted. If the tooth continues to erupt after the crown has been placed, the margin ends up very visible, which is not good. So they will repair the tooth with composite, if that is an option, and then do the crown in the patient’s late teens or maybe a little later. And since a composite filling isn’t as strong as a crown, making it a little smaller can keep the composite from breaking.

One problem, though, with composite on the front tooth is that it can be susceptible to staining. An expert cosmetic dentist will have a selection of highly stain-resistant composites to use, but most dentists will just stock all-purpose composites. And then, the tooth itself is subject to discoloration once it has had a root canal treatment.

Here is a photo. discolored front toothThis isn’t Vance, but is a photo of another patient who has had a root canal treatment on a front tooth and a composite repair, similar to what Vance would have had. The composite covers about 1/3 of the tooth, consisting of the lower left corner as we are looking at it. You can see that the composite, while it is lighter than the rest of the tooth, is darker than the adjacent tooth. So the composite has discolored some, and the tooth has discolored more.

When a front tooth has a root canal treatment, it also tends to become more brittle over time and more prone to breaking. Doing a crown on such a tooth will actually weaken it more against lateral stresses, which are the types of stresses to which front teeth are most susceptible. So it is wise to put a post in the tooth to strengthen it. A metal post can show through slightly. An expert cosmetic dentist would use a white or translucent fiberglass post. A general family dentist also would probably jump right in and do the crown, but an expert cosmetic dentist would probably want to bleach the tooth first because the darker tooth structure would have to be blocked out making it more opaque than the adjacent tooth, when you want these two front teeth to look exactly the same.

Done correctly, the dentist should get a perfect match with the adjacent natural tooth. It will likely take several try-in appointments to get the color match perfect, and it will require teamwork between the dentist and the ceramist to do this. The tendency of family dentists is to get the color “close enough” and be satisfied with that. But here is a photograph of a case done by one of our mynewsmile network dentists. One of these front four teeth is a porcelain crown, but it is impossible to tell, from the front, which one.

porcelain crown on a front tooth

My recommendation—go to one of our recommended cosmetic dentists and get this done right.

– 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.

November 17, 2015

What is the best crown for a front tooth?

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Dr. Hall,
What is the best crown for a front tooth?
– Asra from India

Asra,
The best crown for a front tooth is the one your expert cosmetic dentist is most comfortable with.
Creating a crown for a front tooth, if you want it to look perfectly natural, is a work of art, and you need to let your artist work with a medium that he or she is comfortable with, and also a laboratory technician that he or she is comfortable with. If I were doing it, I would do it with feldspathic porcelain, but other cosmetic dentists might select a different material.
But please note—the dentist needs to be an expert cosmetic dentist, an artist. In saying that I have cut out 98 to 99% of dentists. And actually, in India, you may only have a handful of dentists in the entire country who would qualify as expert cosmetic dentists. That’s an important qualification.
A dentist who is an artist, for example, would never select porcelain fused to metal for a front tooth.
Dr. Hall

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Click here to ask Dr. Hall a question of your own.

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 2, 2015

What is a porcelain upgrade?

Filed under: Porcelain crowns — Tags: , , — mesasmiles @ 2:54 pm

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Dr. Hall,
I have been looking on the internet without any help. I am having a new bridge put in with 3 porcelain crowns. Then on the list they gave me it also stated 3 porcelain upgrades. What is a porcelain upgrade what does it mean? I have looked and looked without an answer.
Thank you.
– Lisa from Florida

Lisa,
A “porcelain upgrade” could be any of a number of things. It is not something that is standard in the profession, but is peculiar to your dentist. There is some extra service in connection with this bridge that he or she is charging you for. Here are some possibilities:
1. The charge could be for a more expensive type of porcelain that is being included in your bridge.
2. It could be a charge for premium esthetic treatment of your bridge, if this is to go in the front of your mouth. In my practice, I charged more for a porcelain crown in the front of the mouth than for one on a back tooth, because it was quite a bit more work to get it to look beautiful and match the other teeth perfectly.
3. Although it is phrased as a “porcelain upgrade” it could be for a more expensive type of metal that is being used as a framework.
4. It could be for a metal-free bridge, meaning that they will use a high-strength ceramic as a framework for the bridge rather than metal.
5. It could simply be a way to jack up the fee, without any other rational explanation. You could have a dental insurance plan that restricts the fee that your dentist can charge and this could be his or her way to get around that.

The way they are putting it as an “upgrade” implies that it is an optional item. I would call the office and ask what it is for and then ask for an explanation as to why you should choose to have this upgrade rather than the standard service.

Dr. Hall

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Click here to ask Dr. Hall a question of your own.

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.

October 7, 2015

These crowns are not the color they appeared to be when they were tried in

 

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Dr. Hall,

I have just had two all porcelain crowns made for my two front teeth, #s 8 & 9. The crowns were a wonderful color match to adjacent teeth and I unreservedly authorized them to be cemented in. After the cementing procedure, I looked in the mirror and IMMEDIATELY noticed a slight grayish hue to the teeth. I inquired about this, and the dentist stated that the cementing product he used was transparent in color. I have looked at the teeth in different light conditions over the past several days and STILL see this. Is there something in the cement or its curing that could have caused this?
– Sara from Florida

Sara,
Did the dentist try in the crowns dry? Or was there some type of try-in paste used between the crown and the tooth under it?

That is one possibility that could account for a difference in perceived color between the crowns when they were tried in and when they were cemented. If the crowns are dry, they don’t transmit the underlying color of the tooth as well as they would with a bonding medium between the tooth and the crown. Darkness, stain, or metal posts in the teeth underneath could cause a gray tinge to the crowns. What I did in my practice when my bonding cement was going to be transparent was use a clear glycerin to accurately mimic what the resulting color would look like when it was bonded.

If that’s not the case, then the only other explanation I can think of for a discrepancy in the color like this would be color metamerism, which is the property certain materials have to appear one color under one light and another color under another. Some porcelains may match the teeth under a cool fluorescent light but then won’t match in, say, daylight or under incandescent light. But a clear bonding cement made by a reputable manufacturer will not change colors upon curing and won’t impact the color of the final result beyond helping transmit the underlying color.

If the grayness is only very slight, maybe it isn’t really noticeable, and since both very front teeth are the same, it shouldn’t be distracting. However, if the grayness is significant and noticeable to others, I think your dentist should fix this. At his expense. It could be a great learning experience for him.

Dr. Hall

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Click here to ask Dr. Hall a question of your own.

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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