Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

October 1, 2018

Better to do nothing than cheap cosmetic dentistry


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Dear Dr. Hall,
I reside in Henderson, NV. I have four porcelain fused to metal crowns on my front teeth since I was 24 yrs old. In 2015, I wanted to update dental work, I ‘Kör whitened‘ my teeth, which made those crowns look bad. I visited a cosmetic dentist, Dr. Featherstone who you have listed on your website. At that time, my paltry insurance would not co-operate, so I didn’t stay with Featherstone. His billing assistant actually had a credit application there to apply for a loan. Plus, she said, we had to pay in advance, and if there were money left over at the end, they’d refund it. My husband & I slunk out of there, glad to be free of that.

Next, I visited Dr. Michael Wilson, the only other one on your Nevada list. He would not do four, only eight, saying about four, “You won’t like it.” At first I agreed to do it, right then and there, he measured for a laboratory wax-up version, $800. I backed out the next morning, and a week later went and picked up the model. He was decent about it, and we left the door open.

Well, from there, I went to my general dentist, Dr. F. Those original crowns from when I was young were big and long and gave me a big smile, in every picture all my life. Now, Dr. F’s version are short, greenish (I picked the wrong shade). His words were, “I’ll make sure you get the teeth that you want.” But, he couldn’t please me, and ended up giving it to his assistant. I mean, it was excruciating, going over it again and again. You finally just settle. These teeth are too short, when I wake up in the morning with mouth agape, you can’t even see any teeth (thus, it makes you look like an old person). She remarked, “Oh, you probably are looking on the internet, and expect these perfect teeth.” Yes, exactly. I had your examples and pictures in hand.

Anyway, here I am, three years later, still not sure where to turn. Thank you for letting me vent. I live with this. My husband raises his voice at just the very mention of it.

Thank you very much.
– LaRae from Nevada

LaRae,
Quite the story you have.

I’m confident that either Dr. Featherstone or Dr. Wilson would have done a beautiful job for you. I’ve seen work from both of them and have interviewed them both. It’s too bad that they were too expensive for you. Your case illustrates a point I often make—if you can’t afford quality cosmetic dentistry, it’s better to do nothing and save up to have it done right than to go cheap. If the first dentist who did the Kör bleaching knew what he was doing and was honest with you, he would have told you that the crowns wouldn’t bleach and the results would commit you to re-doing the crowns. It would have been good to have had a complete plan from an expert cosmetic dentist from the start.

About Dr. Wilson wanting to do 8 crowns instead of 4—we see this where good cosmetic dentists will disagree on how to proceed with a case and in some cases will turn down a case unless they can do it the way they think will turn out the best. When I was practicing, I was more like Dr. Featherstone where I might compromise on a case because a patient didn’t want to spend more to get the “perfect” result.

– 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.

September 22, 2018

A crown or a veneer on a front root canal tooth?


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Hello Doctor Hall. About 2 years ago I had a root canal on a front tooth. I had a general dentist do the root canal. It wasn’t painful and I was very happy. He wanted to put a veneer on the tooth for a very low price. But, I decided not to do the restoration at that time.

I didn’t realize that lack of blood flow to the tooth would make it change color and about a year ago it started to change. I eventually had a porcelain crown put on by another general dentist. She filed down the tooth to a small fang and it really bothered me at the time. So far, the crown is stable. But I know these things don’t last forever. I just want to know if I was duped by the second dentist who did the crown rather than a veneer? Thank you for your time.
Gary from Florida

Gary,
I have a couple of points in response to your question.

First, about the choice of a crown versus a veneer. The simple answer that is taught in dental school to the question, “How do we restore a tooth after a root canal treatment?” is, “Do a crown.” Dental schools really don’t get into doing veneers much. So I wouldn’t say that the second dentist “duped” you—she just did what she was probably taught. But yes, it can be unsettling to have your front tooth ground down to a stub in preparation for a crown.

Here’s the explanation for that. Most teeth, when they need a root canal treatment, have an extensive amount of tooth structure missing and they really need a crown. I take it, from your initial decision to not do a restoration, that your tooth did not have extensive decay or a large break. Maybe it was just bumped in an accident. Also, after a root canal, a tooth tends to become more brittle and subject to fracture. A crown helps protect against fracture of the tooth.

But there is a difference here in the needs between a front tooth and a back tooth. Back teeth have chewing surfaces and cusps, and when you bite down, the pressure on the cusps tends to push them apart. Thus, when a back tooth breaks, it will likely split between the cusps. A crown will prevent that type of break.

Front teeth are subject to different stresses. There is no chewing surface, and the stress on a front tooth is almost all lateral. When you bite together, the lower front teeth push forward on the uppers, and the upper front teeth push backward on the lowers. Also, if you get hit in the face, the impact on the upper front teeth will be a lateral impact. Thus the most likely break of a front root canal tooth is snapping off at the gumline. A crown preparation, which will involve taking off about a millimeter of tooth structure all the way around, will actually weaken a tooth against this type of stress.

Here is a photograph of a crown preparation for a front tooth. This is a very conservative preparation. Most dentists will be more aggressive than this in removing tooth structure. But even with this conservative preparation, you can see that the natural tooth is going to be much stronger in resisting breaking off because of the thicker neck of the tooth.

photograph of a smile, showing the patient's left front tooth ground down and prepared for a crown

A veneer would leave the tooth much stronger. To prepare a tooth for a porcelain veneer, a dentist has to only remove about half a millimeter of enamel, and from the front of the tooth only. Below is a photograph of two front teeth prepared for porcelain veneers.
two front teeth, prepared for porcelain veneers, showing about half a millimeter of enamel removed

So why don’t most general dentists do veneers on front root canal teeth? With a much thinner layer of porcelain, it requires more skill on the part of both the dentist and the laboratory technician to block out the darker color of the underlying tooth. Most general dentists really don’t know how to do that.

Moving on from that point, I also wanted to make a comment about the discoloration of the tooth. It isn’t widely known that the source of the vast majority of the discoloration of a front root canal tooth is not the tooth drying out, but it comes from the root canal filling materials that are used inside the tooth. When I did a root canal treatment on a front tooth, I would clean out all the root canal filling materials from the inside of the crown of the tooth, place a white fiberglass post down into the root to strengthen the tooth, and then seal the opening I had made into the tooth using composite filling material. With that type of treatment, it could be five or ten years before any discoloration would set in and the tooth would need a veneer.

– 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.

September 21, 2018

Gap between my crown and my bridge


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I have a space between my 2 front teeth, however one of my front teeth is a crown and the other front tooth is part of a bridge. Can the gap between my front teeth be closed with Lumineers or any other procedure or would I have to get a new bridge and crown, possibly all in one structure to close the gap?
– Laura from Nevada

Laura,
Your question prompts me to ask a question of my own: Why did the dentist who made the crown and/or the bridge leave a gap between your front teeth? The easy way to fix this would have been to make them correctly in the first place.

At this point, yes, you pretty much need to have probably both of them re-made—depending on how big the gap is. Both front teeth need to be the same size—you don’t want to close the gap from just one side by making one side larger.

this microetcher has a long nozzle with a button on it, and at one end a small clear plastic bottle as a reservoir

A Micro-Etcher

.
But there is a procedure you might want to try before doing that. There are ways to bond composite to porcelain, and you could start with trying that—treating this as a dental bonding case. If the dentist has what is called a micro-etcher, which is a small sand-blasting handpiece, he or she could micro-etch the porcelain surfaces next to the gap. This would be followed by etching with a hydrofluoric acid gel and then priming the surface with a silane coupling agent. A bonding resin would then be applied followed by composite bonding material to match the shade of the crown and the bridge. The composite would be shaped and polished. In theory, this should work. However, my experience with bonding to porcelain was that after a few months, we would see staining along the margin between the composite and the porcelain. But it could be worth a try to try to avoid the expense of a complete re-do of your front teeth.
I would think it goes without saying that you need an expert cosmetic dentist to do this, such as we recommend on this website.

The company that makes Lumineers, a few years ago, tried to promote the idea of bonding Lumineers over the top of porcelain crowns, but I strongly discourage that. You would get the same risk of staining at the margins, and would spend the same amount of money as you would spend just re-doing the case completely. Click the link to read more about the problems with that approach.

– 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.

September 6, 2018

Matching the color on a crown for a front tooth


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Hi Dr. Hall,
I had a root canal done on my front tooth over 10 years ago. In the past few years I had noticed a blue discoloration at the top of the tooth. After trying internal bleaching, my dentist ended up doing a crown.

The first crown that came back from the lab looked very white. He redid it. The next tooth, which is in my mouth now, looks better but doesn’t match the other front tooth. The dentist permanently cemented it in, but when I got home and took some selfies I was unhappy with how unnaturally white it looks.

The dentist will give it another try but my question is — should I let him try again or go to someone else who specializes in cosmetic dentistry? I now live in Princeton, NJ and my dentist is in Brooklyn. Cost is a factor.
Thanks,
Ronnie

Ronnie,
Doing a crown on a single front tooth is a tricky procedure. The slightest variation in color between the two front teeth is usually very noticeable. And it isn’t just the overall color—any tooth has multiple colors in it. Even expert cosmetic dentists will often have multiple try-ins before they get the crown to match perfectly. When I was in practice, I charged about 40% more for crowning a single front tooth because we would typically send it back to the lab three or four times until we got it perfect and I would charge the extra fee because of all the extra appointments. Dentists with poor cosmetic dentistry skills sometimes ask patients to crown both front teeth in order to get the color right.

That your dentist would think that the crown would look right after one or two trips to the lab shows either inexperience or a low level of commitment to excellent cosmetic dentistry. I’m not meaning to imply condemnation with that comment because that is typical of the overwhelming majority of dentists—maybe 98% of them. So yes, if you want this done so that your two front teeth match perfectly, you need to raise your sights and go to an excellent cosmetic dentist such as we recommend. There are several excellent ones within reasonable driving distance of Princeton, say 15-30 miles.

However, depending on how big a factor cost is for you, and if your dentist is willing to work with you to get this right for no extra charge, you may want to stick with this dentist to save the money of having another dentist start over with you. And, I would add, if you are willing to make several more trips back to Brooklyn. To help the process, you or the dentist should get hold of a good digital camera that is capable of taking a clear photograph of the new crown in place next to your natural tooth under outside light, such as right next to a window. That will go a long way toward helping the ceramist pin down the right color. And be sure that the crown is only temporarily cemented until you have seen it under various lighting conditions.

If you want perfection—a crown so natural that you can’t distinguish it from the real tooth next to it—you need the expert cosmetic dentist. But if you are willing to accept some compromise of that ideal in order to save money—try letting your dentist have some more tries to get this closer.
– 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 23, 2018

What to do about gray crowns


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Hi Dr. Hall,

Due to a recent fall, I broke my 2 front teeth as well as the one to the left of my front teeth. I had 3 root canals and 3 porcelain crowns placed. I’ve had 2 attempts as the first permanent set were off in color, too big and thick. The 2nd permanent set matched in color and were closer in size and thickness to my natural shape. After they were permanently cemented they all had a grey hue close to the gumline on the tooth. The dentist has reluctantly agreed to redo my crowns stating he would try to make sure the core is as white as possible. I’m not sure what to think or if he can even fix the issue because he did say he couldn’t promise this issue would be resolved? What are your suggestions? Thank you!
– Nancy from San Antonio

Nancy,
Your problem is simply that your dentist doesn’t know enough about cosmetic dentistry.

One of the issues that family dentists have the most trouble with is color, so the problem he is having is not unusual.

If you have two or more crowns on your front teeth, this is a pretty simple color task for an expert cosmetic dentist. The fact that these crowns were too big and thick and the color was off on the first try makes me worry about the level of skill here. On the second try, having them be too gray at the gumline is not a great confidence builder, either. This isn’t a difficult situation. My advice would be to be fussy. It is possible to get the color and shape exactly right and in the right hands, no one should be able to tell that these are crowns on your front teeth and not your real teeth. Don’t settle for anything less than that.

You’re not giving me any clinical details about the types of crowns we’re dealing with, and there are several possibilities for getting this grayness that you’re seeing. Let me make an assumption of what I think is the most probable scenario. My best guess is that your dentist is using pure ceramic crowns of one type or another with a metal post and core to reinforce the inside of the tooth, and the gray color of the metal is showing through the translucent ceramic. There are several ways to deal with this. If I were doing your case, I would have used a fiberglass post and a composite core that was close to the color of your natural teeth. That’s the easiest way to get a natural translucency to the crowns. If we’re stuck with the metal core, then what I would have done would have been to bond an opaque layer on top of the metal to block out the metallic color and then bond the crown on top of that opaque layer. Another option would be to give clear instructions to the laboratory technician about the color and extent of the metal core, and let the technician incorporate opaquing into the crown.

The problem with many family dentists is that they don’t understand translucency and the impact of interior colors on the external appearance of the tooth.

Your case bothers me, though. You’ve had this accident, and you would think that you should be able to go to your family dentist and he would know enough to fix this. Or, if he didn’t, that he would know enough to refer you to someone with more expertise in cosmetic dentistry. But that is the state of cosmetic dentistry in America. Dental academia trivializes cosmetic concerns and the powers that be in the profession are adamant that cosmetic dentistry isn’t a legitimate specialty. If there were a higher level of respect in the profession for aesthetic skills, there would be more inclination to either refer these cases to a specialist, or maybe to train general dentists better in these color skills and you wouldn’t have situations like yours. Your case doesn’t require a high level of aesthetic skills—only a moderate level. The fact that your dentist has missed this twice and now is unsure that he can fix the color shows a fundamental lack of understanding of basic color management.

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.

December 26, 2016

Ugly e.max crowns are too thick


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Good morning, Dr. Hall.
My question: Can adhesive-bonded e.max crowns be safely removed without breaking the natural tooth which is already fragile?
History: I recently had the front six teeth re-crowned with e.max. The four front teeth have now been crowned for the 5th time (all by different dentists). I was happy with the first crowns I had, but after 15 years they needed to be replaced. I have yet to find a dentist who can replicate the smile I had before. I’m now stuck with e.max crowns that are thick and bulky with dark showing around the gum over my central incisor. My dentist said he would replace them but I know with each manipulation, I am risking the possibility of losing a tooth (or teeth).
My dentist said he made the e.max crowns thicker because my gums were thick (the gums have buttressed from years of clenching). He has now asked I have crown-lengthening and have some if the bone removed before replacing crowns.
I am so afraid of losing my teeth and having to have dental implants but I so want my old smile back.
Any advice would be greatly appreciated.
– Carol from Alabama

Carol,
If I’m getting this straight, your dentist gave you thick crowns because your gums are thick. If that is his true reasoning, I wouldn’t let him re-do your case. There is a gross misunderstanding of esthetic and functional principles here. Thick crowns will cause the gums to become inflamed and puffy, so this has the potential to be a functional disaster. Plus there is no aesthetic reason for your crowns to be made thick in this situation. The dentist should make sure there are natural contours to the teeth as they come out of the gum.

Let me explain.

I found this photograph showing thick crowns with puffy gums what happens when crowns are too thick. It creates a protected space where the crown meets the tooth and in that protected space, gum-disease causing bacteria multiply freely. Microscopic food particles will get trapped there, it is impossible to clean effectively, with resulting gum disease and puffy gums.

After almost 40 years of experience in dentistry, I must say I have never heard this aesthetic principle taught or even mentioned, that thick gums mean you need to do thick crowns. Rather, what I have heard is that you always need to have a natural emergence angle where the crown meets the tooth. You should not be able to feel any bulges as you run an explorer up from the root of the tooth onto the crown – the contour should be straight and smooth.

Now, as to your actual question about removing e.max crowns. These crowns are made of a very tough material – lithium disilicate – which makes them difficult to remove. And you say they were bonded on. The only way to get these off is to grind them off. Your dentist will need a supply of diamond burs to methodically grind these off your teeth. If the dentist is good and knows what he or she is doing, there should be no damage to your existing teeth. That isn’t a problem.

But I wouldn’t trust your current dentist to do that very carefully. His idea about thick crowns doesn’t show much care for precision in knowledge, which would make me worry about his being clinically careful. I would go to one of the dentists on our recommended list–I’m confident any one of them would do a great job for you here in carefully removing the existing crowns and replacing them with a beautiful smile.

Besides the functional mistake in your new smile, there was a serious aesthetic mistake, and I want to say something about that, too. No good cosmetic dentist would have ever bonded these crowns onto your teeth without a test-drive first, either duplicating the new smile in plastic so you could wear that as a temporary smile makeover, or temporarily cementing the new crowns, so he and you could make sure that you love this new smile before it was bonded permanently.

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.

December 9, 2016

Should my dentist grind on my porcelain crowns?


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Dr. Hall,
Earlier this year I got porcelain crowns on my 2 front teeth. One came loose and fell off. I had it “cemented” back on at the dentist & she ground down the porcelain to correct the bite after it was placed. Less than a week later the back side of my crown broke off where the bite adjustment had been made. What do you suggest? Should porcelain crowns ever be ground on or does this weaken them?
– Cheri from Minnesota

Cheri,
When you get a new porcelain crown, it isn’t uncommon for the dentist to have to adjust the crown to your bite, which is done by grinding on it some.
Having said that, something isn’t right about your experience here. Here are the three things that trouble me:

• First of all, one of the crowns came loose. This isn’t something that should be happening to a permanently cemented crown. Something wasn’t done right for a new crown to be falling off that soon.
• Second, the bite should have been adjusted when the crown was first placed. This is strange that the bite has to be adjusted after it is recemented. Something went wrong in the recementation process. The recemented crown must not have gotten back on straight for it to require new adjustments.
• And third, of course, you had the back of the crown break off. This wouldn’t happen unless the porcelain was ground so much as to be dangerously thin.

The fix is to have this crown replaced. But I would go somewhere else for this. I have real concerns about your current dentist being able to get this right. Oh, and she should compensate you for having to do this.

– Dr. Hall

For information on why crowns fall off, please see my earlier post, “The main reason your crown probably fell off.”

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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.

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

Do you have a comment? We’d love to hear from you. Enter your comment below.

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.

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

Do you have a comment? We’d love to hear from you. Enter your comment below.

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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