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How far back should my denture go?

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Dr. Hall, should the lower dentures cover the area where my wisdom teeth were? I am chewing on my wisdom teeth gums and can’t seem to get the dentist to understand. There are no parts of my new dentures covering this area.
– Carroll from Louisiana

(See Dr. Hall’s answer below.)


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Carroll,
Removable dentures are never completely comfortable, but this bit of discomfort is within the ability of your dentist to correct.

The short answer is yes, your denture should cover the area where your wisdom teeth were and maybe go even further back—as far back as possible. There is a pad of tissue just past where your wisdom teeth were that is called the retromolar pad, and we like the denture to cover that, if possible. Covering too much of the retromolar pad can cause the lower denture to interfere with the upper, and that is the limitation of how far back we want to go.

The problem in your case is that your dentist, in order to fix this, would have to start with new impressions, so it would be quite a bit of work and some extra laboratory work. I’m wondering if it isn’t so much that your dentist doesn’t understand what you are asking, but actually does understand and just doesn’t want to do it.

A photo of a lower impression tray, showing it extending only far enough in the back to register the teeth.

Photo courtesy of Midway Dental Supply

The first step in making a lower denture is the preliminary impression. This preliminary impression is made with a stock tray, and should register this retromolar area. In order to do this, dentists will use a stock tray specifically made for denture impressions. On the right, on the top, is a regular impression tray for the lower teeth.

a photo of a lower denture impression tray, showing flanges in the back designed to register the retromolar area

Photo courtesy of SurgicalExcel

Below that is an impression tray specifically made for taking an impression for a lower denture. You’ll see that at the back end of that tray are flanges that extend back further. Those are designed to help register this retromolar area, as well as wider parts of the mandible. The idea is for the impression to register as much of the mandible as possible. The further the denture extends into these areas, the more stable it will be. When taking this impression, the dentist should tug on your cheek some, as well as ask you to move your tongue a little, so that the impression also registers the limits of how far the denture will be able to go without interfering with movements of your tongue or cheeks. You can reference my page on the steps of creating a quality denture for further information on impression techniques.Was your dentist a little lazy or sloppy in getting this preliminary impression? While it looks like this is what happened, I don’t know all the details of your case, or if there were extenuating circumstances in your case that made your dentist want to keep your denture shorter.

You’ve probably already paid for the denture, so you don’t have a lot of leverage to get your dentist to re-do the denture. This doesn’t seem to me to be so bad as to be called malpractice, so I don’t think you have any legal recourse. You could try sharing this blog post. If that doesn’t work, you could threaten to post a negative online review and see how far that gets you.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. 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 advanced internet marketing for dentists.

After my new crowns my bite feels awkward

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After crowns my teeth feel dry.

When I was a child I chipped both my front teeth in an accident – and the dentist corrected it with filling material as well building up the two on either side (the lateral incisors) to correct some gaps. I had them redone once in my 20’s. At age 50 they were looking pretty worn out so I decided to finally bite the bullet and have crowns done.

In order to even everything out I needed 6 new crowns #6-11. I had them done in January 2018. It was a major change because all the spacing changed on my top teeth making them hit my lower teeth in awkward ways. Not only was the bite heavy in some areas, but I also felt the need to tap my teeth together constantly. Since the crowns I have been back maybe ten times for adjustments, but I continue to need to tap them and I think I have developed burning mouth syndrome. Usually when I wake up in the morning everything feels great but by mid-morning the back of my front teeth are burning and I feel the need to tap the teeth together. The ONE thing that relieves them is to chew gum, so I am now chewing a lot of gum! I don’t even really like gum. On one appointment I went back and the dentist husband (they are a husband/wife practice) told me NOTHING was wrong with my teeth and reluctantly referred me to a gum specialist. I instead went to another dentist who was recommended and he checked out my crowns. He did say they were very nice and seemed very well placed. Is there anything I can do to make this uncomfortable feeling stop and do I need to have more adjustments to stop the tapping together? I feel like they may have made my teeth a little bit longer and that is the root of the problem.
– Laura from Maine


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Laura,
You’re telling me several things about these crowns feeling funny, and I don’t have answers for everything you’re telling me, but I’ll share what I do know.

Let me start with the entire treatment plan, which was replacing some very successful composite bonding with six crowns. That seems to me to be very aggressive over-treatment. I think that an expert, ethical cosmetic dentist would have just replaced the bonding.

So right away I am suspicious of the ethics of your dentist. And from the experiences you had afterward it gives me the impression that she may have gotten in over her head here. Maybe not. I’m just being as honest as I can with my impressions here. So let’s go to your complaints.

You’re saying your teeth feel dry, there is a burning sensation, you want to tap your teeth together, you think your teeth are a little longer. I don’t have answers for all of that. But one comment you made particularly attracts my attention. You made the comment about your bite, apparently in reference to how the bite felt right after you got the new crowns: “making them hit my lower teeth in awkward ways.” That’s a red flag and is what gives me the idea that there is something wrong with the treatment, that your bite wasn’t right. When crowns are done right, the bite will feel completely natural and comfortable. But from the start you are saying that your bite felt awkward and now you are feeling that you want to tap your teeth together all the time.

And then referring you to a gum specialist. Really? What does this have to do with your gums? The bite is off. Another dentist checked the crowns. That’s nice to know that the crowns look fine. But each crown can look like it is perfect, and the bite can still be off. When you do all six front teeth, there are certain occlusal principles that have to be followed. Not only do they have to all meet simultaneously in what we call centric occlusion, but they also need to provide anterior guidance. In addition, the canine teeth are very important and in most cases they provide what is called canine protection–when you slide your jaw side to side they will be the teeth that force all of the teeth apart. And then add to that the effect that the shapes of these teeth have on your speech and you have a very complicated situation. Something in all of that function has not been done right for you, and what you need is a second opinion from a dentist who knows a lot about occlusion. That training is not generally supplied to general dental students in dental school. Post-graduate training for dentists in all these complex occlusion issues is provided at the Pankey Institute, the Dawson Academy, Spear Education Center and the Las Vegas Institute. I would get a second opinion from a dentist who is a graduate of one of these institutions.

About the burning sensation and the dry feeling, yes, that could be burning mouth syndrome, which in my opinion is caused by stress. If you had your bite fixed, maybe that would go away.

Do you have a comment or anything else to add? 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 A. 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 advanced internet marketing for dentists.

My experience with “this new crown feels funny.”

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A recent question I had from a visitor to the website about a crown that felt funny caused me to reflect on my own experience with this sensation a couple of years ago.

I had a crown that came off and my dentist at the time, rather than try to re-cement it, wanted to make a new crown. I was uncertain that was the right thing to do, but didn’t say anything, and went ahead and got the new crown. After I got it, the bite never felt quite right. It wasn’t painful—just a very slight feeling on it. A crown, if it is done right, should not be noticeable or feel any different when you tap your teeth together or chew. Anyway, I switched to another dentist shortly after this and he made some fine tune adjustments to the bite, but there was still a vague slight discomfort when I chewed on it.

After some time passed and this feeling persisted, I showed up again at my new dentist for a scheduled cleaning and asked the hygienist to take a periapical x-ray of this tooth to see if we could see anything that didn’t look right. To my grave dismay, the x-ray showed that the tooth under my crown was maybe half eaten away with decay. The tooth had a root canal treatment, so there wouldn’t be any toothache to warn me of the deep decay. The only symptom was this vague feeling I kept having.

The fix for the problem was to have what was left of the tooth extracted, a dental implant placed, and a new crown on the implant. Everything feels fine now. The take-away lesson is to pay attention to a new crown that just feels funny. It should blend in with the other teeth and the bite should be completely comfortable. If it’s not, it needs to be adjusted or fixed or re-done to make it right.

– Dr. Hall


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Question and answer go here.
 
 
 
 
 
 

Do you have a comment or anything else to add? 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 A. 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 advanced internet marketing for dentists.

Another full mouth reconstruction gone bad. This case could be a mess.

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Dr. Hall,
I have recently gotten ALL of my teeth crowned. My old teeth were ground down to almost nothing, the front ones were paper thin and chipping daily and on the bottom left I was missing #21 and top right missing #3 and #4. I have also in the past had many unfortunate traumas to my jaw so it clicked loudly all the time when opening.

The dentist said I needed to have my bite opened in order to get my front teeth restored (all I actually wanted in the beginning was just top/bottom front teeth done) He said it would not be possible to do without doing my whole mouth. Fast forward to now, got bottom done all at once and was told that would be the hardest part for me to endure, it wasn’t it was a piece of cake compared to the pain I had for 3 weeks with the top ones. So anyway now i have had the new top ones in for 2 days and I will say they LOOK beautiful no complaints on the smile but the left side teeth touch whilst the right side has a space and my teeth do not touch at all 19-21 bridge not touching but bridge 2-5 hits fast and hard and my jaw is killing me.

He did cement them in with permanent cement and now my question to you is can he file this bridge down enough so my other side will hit and then can he polish it so my ground down rough teeth will not ruin my new crowns on bottom, or does the fixed bridge need to come out and be re-done. We have spent so much money on this and while we do have insurance it covered next to nothing and my husband is in the military and we cannot afford to have all this redone. I am really stressed out and any help you can give would be appreciated.
Thank you 🙂
– Erin from Alabama


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Erin,
You have had what is called a full mouth reconstruction. This is a highly complex procedure because it re-does your entire mouth and your bite. Dental school alone doesn’t train a dentist enough to be able to perform this kind of a procedure – it requires advanced training and/or considerable experience. And there are several well-known institutes that provide this advanced training. There is the Pankey Institute in Florida, and the Dawson Center for Advanced Dental Study, also in Florida. Another is the Las Vegas Institute for Advanced Dental Studies.

But even with that advanced training, these complex procedures should proceed cautiously, especially in situations like yours where the bite is being opened. It should first be opened with temporary crowns and then the bite adjusted with the temporary crowns until you are comfortable with the new vertical dimension. When that is settled, then the permanent crowns are made to replicate the new opening.

But that isn’t all. The crowns and bridgework should be seated temporarily and adjusted to a comfortable bite BEFORE being cemented permanently. And you are a perfect illustration of why this should be done. Here you are, already with TMJ problems (you mentioned loud clicking in your jaw) and apparently over-closed. And now crowns are cemented and your bite is off. Yes, the case needs to be re-done, and the dentist who did this is responsible for that. And if you have lost trust in him, then you need to have this done somewhere else and have this dentist pay for it.

Here’s the problem. Yes, the bridge that is throwing your bite off could theoretically be ground down in your mouth to where your bite is even. But from the sounds of your description (the other side isn’t meeting at all), it would take a tremendous amount of bite adjustment, and he would likely be grinding all the way through the porcelain in some places. Plus, the whole object of the treatment was to open your bite, and now he is going in and grinding it down, so your vertical dimension is going to be off. And this amount of change in the bite is much more difficult to do correctly in the mouth than in the laboratory. The crowns should have been carefully crafted in the laboratory to provide the proper bite relationship with all the cusps, grooves, and other anatomical features precisely mapped out so that your jaw functions correctly.

Having said this, it doesn’t take much for the bridge to throw your bite off enough to be painful. Maybe the discrepancy is only a fraction of a millimeter and it just feels to you like it is a lot. In that case maybe it could be adjusted to fit. And maybe he did try it in temporarily and it fit fine, but in the final cementation something went wrong and it didn’t fully seat. But if that did happen, at least the bridge should be re-done.

I would suggest a second opinion. You want a dentist who has been trained at one of the three institutes I mentioned to help give you assurance that they know what they are talking about, and I would suggest going out of town for the second opinion, to avoid any conflicts with dentists who may be buddies or competitors, which would interfere with getting an honest second opinion.

– Dr. Hall

About David A. Hall

Dr. David A. 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 advanced internet marketing for dentists.

Did you really need that full mouth reconstruction? I’m suspicious.

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Dr Hall,
I have been going to a local female dentist here for the last 10 years and over the last few years she has put new crowns in the top front (6 or 8) teeth with the metal backed crowns and they leave a black stain across my gums (and chipping, breaking) all the time and she charges to repair these…. so she doesn’t back up her work.

I found a cosmetic dentist in nearby (town’s name withheld), Dr. (doctor’s name withheld) and he inspected my mouth and told me that not only did those horrible teeth need to come out but that my bite wasn’t right and the top teeth were wearing down the bottom to the point of my bite collapsing. Well yesterday Dr. (name withheld) gave me 28 new temporary crowns – will get my permanent ones next week. They will be porcelain and the temps look great it’s just that I find it difficult to eat and maybe it will take some time. I guess I need to get used to it and learn to deal with it.

One more thing is when I order my new permanent crowns I want to make a couple of changes, such as slightly lengthening my eye teeth or maybe offset them slightly to give me a less perfect smile or should I say maybe they won’t look like false teeth. Do you have any input on this situation? It will be about a week or more before I have this done but I want to come out with the best “natural” looking and less fake smile. Is there any other tips! or tricks that I could do as well?

Thanks,
– David from Mississippi

 

David,
I’m glad you e-mailed me. You could be in for a lot of trouble, and you should take your next steps very carefully. I would not let this dentist put your permanent crowns on until you get two big issues solved. I am highly suspicious of this whole situation. I’m going to give you my phone number, and I want you to call me about this. But let me explain your situation first.

1. The number one issue is that you need to be sure that your bite is comfortable with the temporary crowns before proceeding with the permanent crowns. If I were you, I would call the dental office and ask that the laboratory order be put on hold until you have temporary crowns that are comfortable to your bite. Your dentist is opening your bite with a full mouth reconstruction. This is a risky procedure, and could leave you with serious TMJ disorder if it’s not done right. Clue number one for your impending trouble is that you find it difficult to eat. Clue number two is Dr. (name withheld)’s website, where, when I read his bio, I don’t see any clue that he has the advanced training that would be necessary to do work of this complexity. Ordinary dental school education isn’t enough – there are institutes such as the Pankey Institute in Florida or the Las Vegas Institute for Advanced Dental Education that train dentists to do this. And when dentists go through the trouble to obtain this advanced education, it is highly unusual that they would have a website that wouldn’t mention it.

2. You have some matters you want addressed in the appearance of the teeth. Those need to be settled BEFORE the dental laboratory starts making them.

Here is what you need to do, and I am emphatic about this. DO NOT let Dr. (name withheld) or anyone on his staff talk you out of this.
1. Get the laboratory work put on hold until you get the two issues above solved, and until you can get a second opinion about this work.
2. Go get a second opinion. You are spending well up into five figures on this, plus you are putting the rest of your life on the line. If this work isn’t done right and you end up with TMJ disorder, that can make you miserable for the rest of your life until you would get the work re-done. Don’t take this lightly.

I’m going to recommend you go see an excellent dentist in Lafayette, Louisiana, for an opinion on this. I have looked for excellent cosmetic dentists in your part of Mississippi, and haven’t been able to find any, so I think it would be worth it to you to make the trip to Lafayette. I looked up directions on Google Maps, and I see this is a drive of several hours for you. But that’s a small thing when you’re talking about something so major. It is Dr. Mike Malone. He is highly expert in both cosmetic dentistry and reconstructive dentistry. He’s a past president of the American Academy of Cosmetic Dentistry and has been trained in advanced reconstructive dentistry at the Pankey Institute. But more than that, I have known him personally for many years, and he is a decent, honest dentist who will tell you what you need to do. Additionally, if you get out of the Jackson area, you avoid complications that can occur when the dentist giving the second opinion knows the first dentist. They might be buddies, which isn’t good, or they might be fierce competitors, which could be worse. And be sure you see Dr. Malone personally. He has two associates who do the general dentistry, and he does the advanced restorative. When you call, tell him that I referred you. His website is www.mikemalonedds.com, and the contact information can be found there.

I can’t make any declarations for sure without seeing you myself, but as I said in the beginning, I am highly suspicious. There are dentists who recommend full-mouth reconstructions purely for the profit involved. I certainly hope this isn’t the case with you, but you need to find out before this work proceeds any further. If the dental laboratory doesn’t make the crowns, that makes this whole thing a lot easier financially. You could transfer to another dentist, for example, for no additional expense. On the other hand, if the crowns are installed, then fixing you would involve starting all over from the beginning, preparing the teeth, and making new crowns from scratch.

Please call me on my cell phone, and you can talk to me about this.
– Dr. Hall

Link: Click here for information on getting a referral to an excellent cosmetic dentist.

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About David A. Hall

Dr. David A. 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 advanced internet marketing for dentists.

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