Getting four front implant teeth to look right

Dr. Hall:

I am missing my four front teeth. I have had a porcelain bridge and a removable partial denture, but I’ve just turned 50 and didn’t want to return to a partial. I wanted an esthetic and durable solution and something approaching the feel of natural teeth. I chose implants. Four separate implants for four separate crowns.

I’m about to have the crowns done and have some concerns. One, I don’t want the crowns to appear to ‘sit’ on the gums as the bridge did. I have a very high smile that shows a lot of gum. I thought there would be some sort of surgical step to shape the gums. Secondly, I don’t want anything fused to metal because, as above, I have a high smile and I’d be really disappointed after so much time and expense to have an obvious crown in the front of my smile. Or in my case, 6 obvious crowns. The dentist plans to crown the two next adjoining teeth as well in order to work more with size and color. I said Alberta but I also spend time in the southern US during the winter so location is not a barrier to having good work done. I have read here that all-porcelain is best but also that ceramic is preferred. So I’m confused. Your input would be most appreciated. From reading your responses to others, I realize I need to reschedule my ‘impression’ appointment in order to consult with my dentist on type of crown he intends to use. One thing that is clear to me is that I also need to whiten my natural teeth before having any crowns made or placed. Correct? Thanks in advance for any help you can provide.
Kelli from Alberta

Kelli,
You bring up some good questions about replacing your front teeth.

There are a lot of different issues to deal with when you are using dental implants to replace your four front teeth. I don’t know that I can deal with them all in an e-mail or a blog posting. But I can be helpful.

There are several things that bother me about what you told me your dentist has done or plans to do. The first is that he or she plans to put crowns on the two adjacent front teeth, the teeth adjacent to the space where your teeth were missing. You say it is in order to “work more with size and color.” I don’t know what that means exactly, but it sounds like it’s an appearance issue. And if your dentist is doing crowns on your canine teeth for appearance reasons, that says to me that he or she doesn’t know how to do porcelain veneers well, because, for appearance’s sake, that would be the treatment of choice.

I am also bothered that your dentist didn’t suggest whitening your teeth beforehand, that no building up of the gum was done in preparation for the implants, and that your dentist didn’t mention any options about the choice of crown.

Don’t think you can make up for deficiencies in your dentist by researching answers on our website. It won’t work out. I have a file full of horror stories of people who thought they could do that.

You’re asking me these questions about the type of crown. Yes, all-porcelain or all-ceramic is the best crown for putting on a natural front tooth. But you’re talking about putting a crown over a dental implant, so you already have a metal implant as a foundation for the crown, and the choice between all-ceramic (or all-porcelain – they are virtually the same) or porcelain fused to metal becomes less important and what becomes important is having this work done by someone who knows how to manipulate the color to mimic translucency and how to permanently conceal the border line between the implant and the crown.

But you’re seeming to think that I can give you a choice that will make this go right when you already have made the single determining choice in the outcome of this case, and that is that you have selected the dentist who is doing this. And I fear, from what I said above, that you have selected your basic, mechanically-oriented non-artist dentist. And if that is the case, there is really nothing I can do for you. Just reconcile yourself to the idea that you’re going to get a mediocre result, appearance-wise. It may be structurally sound, but fake-looking.

Here’s the bottom line. If your dentist is artistically inclined, he or she will care about your lip line and the appearance of the gums, and will have sought out the training necessary to get this to look right. If your dentist isn’t artistically inclined, which would be the case with 98% of the dentists, this is not something I can coach your dentist through. He or she probably won’t listen to me, for starters, and even if he or she did, this is a skill that is learned over years.

Additionally, it is asking for disaster to go to your dentist and specify that you want such-and-such a type of crown and a certain technique. The reason your dentist didn’t choose the type of crown or technique that produces a beautiful result is usually because these techniques are harder and require specialized training to use. And your dentist is trained in dental school to never let you think that they are unfamiliar or uncomfortable with any procedure they do, as it makes the patient very nervous. So they will either come up with an excuse as to why they think their way works better, which leaves you as you started, or they will bluff their way through, which is worse.

Think about this. YOU took the trouble to look up this information and found it on the Internet. So you know it isn’t that hard to find. So why doesn’t your dentist know this stuff? I’ll tell you why – it’s because it is low on his or her priority list. That tells you all you need to know.

So here is my advice:
1. Do NOT approach your dentist about the type of crown being done with the idea of asking him or her to do some other type than what they were planning. If he or she hasn’t given you any choices, there is a REASON for that.
2. Reconsider your choice of dentist. WHO does this work is critical. If the appearance of this work is really as high on your priorities list as it seems, you need to have this done by an artist, and you will not change your dentist into an artist by trying to direct his or her choices of materials. If you want help from me with this, share with me the name of your dentist, and I will tell you what I think, and, if necessary, I can refer you to an excellent cosmetic dentist. And let me know where in the US South you go during the winter.

– Dr. Hall