Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

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 28, 2017

I want to avoid getting a crown on my front tooth, after a root canal


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Hello Dr. Hall,
Back in May 21st I had my front upper tooth knocked out. It was put back in, bonded and set back into place. I had a root canal done on it as well. I’m noting that the color is slightly off (more yellow) than the rest of my teeth. My dentist said that I would probably have to get a crown after my last visit, but looking online I see that a crown for a front tooth may not be a good idea. How can I preserve the whiteness of this tooth without needing a crown? Thank you for your time.
– Joseph from Staten Island, NY

Joseph,
You’re right. A crown on a front tooth, while it strengthens it against chipping, actually weakens the tooth against lateral stresses. So if you have a heavy bite at all, it is at greater risk of breaking off.

After a root canal treatment, a tooth tends to discolor. But that discoloration can be greatly lessened by cleaning out the inside of the crown from any root canal filling materials such as gutta percha or cement. If it is starting to discolor already (four months after treatment), the dentist has left some of those materials inside the visible part of the tooth.

Here’s what I would do.

Go to one of our recommended cosmetic dentists in Manhattan, Queens, or New Jersey, and have them clean out the inside of the crown. Since the tooth has begun to discolor already, it would be a good idea to have them do internal bleaching. Then you could have them fit the tooth with a fiberglass post inside and seal the opening, and you should be good for several years before it starts to discolor.

Then, when it discolors, I would just have them do a single porcelain veneer to correct that. This would require a fair amount of expertise in appearance-related dentistry to match the color of the adjacent tooth, but I’m confident that any dentist we list would be able to get that to look great for you.

Oh, one other thing. Since this is a replanted front tooth, you want to have it x-rayed again to make sure you don’t have any external resorption. It’s possible that your body could be eating away at the root. That happens sometimes with these replanted teeth. Be sure to find that out before you invest much money into this tooth.

And just a comment about your dentist. It looks like he or she did a nice job of saving your tooth—did all the right things, and is probably an excellent dentist. But these demanding aesthetic problems are over the head of the vast majority of general dentists.

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.

August 22, 2015

Follow-up on crowns vs veneers for tetracycline stained teeth

Earlier this week I fielded a question from Michele from Florida. She wondered if she should get crowns or veneers for her severely tetracycline-stained teeth. I asked her some questions about the fees and the dentist she was talking about. Here is her reply, and my response to that reply:

Dr. Hall
Thanks for your input. The cosmetic dentist is Dr. A (name withheld to help preserve Michele’s identity). He wants to charge me $42,000 for a full mouth of veneers (two teeth require crowns due to damage). The other dentist wants $26,000 for crowns. My budget cannot go over $30,000. Also, I forgot to mention that I grind my teeth at night and wear an appliance. I’ve read that veneers don’t stand up to grinding as well as crowns.

My response:

I know the cosmetic dentist you went to, and he is really good. He would give you a stunning smile. I’m not surprised that his fees are high—he is worth it.
About your grinding (also called bruxism). If you wear your nightguard, you should have no problem with your veneers. If you grind your teeth, you are actually at higher risk with crowns because then you don’t just chip off the edge—you break off the entire tooth. I had several patients who had to deal with that and you end up with implants later in life. Once you break off a front tooth at the gumline, if you’re a grinder, there isn’t a whole lot you can do with it. You see, with a crown you grind off a full millimeter of the tooth, all the way around. So if you have an upper lateral incisor that is 5 or 6 millimeters in diameter (let’s say 5.5 mm) at the gumline, then you grind down 1 mm all the way around, you now have 3.5 mm diameter. So you used to have a cross-sectional area of 95 square mm – now you have 38 square mm. So you now have 40 % of the strength left, when you’re talking about resistance to breaking off at the gumline. People who grind break these teeth off when they’ve been prepared for crowns. The lower teeth are even worse. You actually cut the strength of lower incisors down to about 1/4th of their original strength.
Here are a couple of options I would suggest:
1. Do just the upper with Dr. A and do Kör Whitening on the lower. That way you get a stunning smile and cut the cost about in half. Kör, if you use it for long enough, will have a significant effect on the tetracycline stains and lighten them enough to be acceptable as lower teeth. Then at some later point, if you feel you need to improve the result even further, you could do the lower. I had a couple of cases of tetracycline stain that I treated where we did just the uppers and didn’t do anything to the lower. With most people, the lowers don’t show as much, especially if you are younger. And even when they do show, they are kind of in the shadows.
or
2. Check out Dr. B. He is in your city. I know him also, and he also does beautiful work and his fees might be within your budget. His work isn’t at the level of Dr. A, but it’s good. Call and find out what he charges per tooth for porcelain veneers. If that doesn’t work, you could find someone else that you could drive to see. I’m confident you could find someone who could do beautiful porcelain veneers and stay within your budget. Even if you needed to fly somewhere, if the fees were $15,000 less, it would be worth it.
The interesting thing about the costs of cosmetic dentistry is that really the fees are pretty comparable for a good general dentist and a good cosmetic dentist (with the exception of exceptional artists like Dr. A).

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.

October 3, 2007

I keep breaking off teeth – Is this a case of “gorilla bite?”

Filed under: TMJ — Tags: , — mesasmiles @ 7:03 am

Dr. Hall,
I had all 28 of my teeth crowned. I was told it was necessary to do because I was breaking my teeth off and it was blamed on my bite. Now that my bite has been “fixed,” I currently have five broken new crowns in my mouth and now I’m being told that I need to wear a mouthguard at night and one during the day to break a habit my dentist claims I have. The fact of the matter is, I have been breaking my teeth when I eat, not when I sleep. My dentist won’t listen to me and blames it on my habit that I don’t believe I even have. He also has no proof of this supposed habit. What are your thoughts? I have $50,000 into my mouth now and I don’t know where to go from here. (He initially blamed my problems with breaking teeth on my bite, which he supposedly corrected when he replaced all my teeth. Now the problem is being blamed on my “habit,” which I mentioned above.) Help!
– Cory in Minnesota

Cory,
I’d be inclined to look for a second opinion from a dentist who is more expert in occlusion matters. What you’ve had is called a full-mouth reconstruction, and this is a very complex area of dentistry that requires considerable advanced training. Two common sources for this advanced training are the Las Vegas Institute, and the L.D. Pankey Institute. Look for a dentist who has spent considerable time at either or both of these institutes.

Having said that, I would absolutely wear the nightguard. It may not make sense to you because, as you say, you’re breaking your teeth off when you eat. But you’re weakening them while you sleep. I had several patients like you who would break off teeth like that, and when they wore their nightguards they never broke off any more. Just do it. You’ve spent too much money to let it all go to waste. And be careful not to assume that you know what you do with your jaw when you’re sound asleep.

It may or may not be a “habit” that you have to break. So your dentist blaming it on a “habit,” apparently without a thorough occlusal examination, makes me think that his knowledge of occlusion isn’t deep enough. But he has heard that wearing a nightguard helps in that situation, so that much is good. But I worry that he thinks that you just need to re-train your habits and then you’ll be fine. It’s possible that you may need to wear this nightguard every night indefinitely to keep your teeth from breaking. And my guess is that you don’t need the one during the day. But these are just guesses.

It may just be that you have extra powerful jaw muscles. That was the case in most of the patients I saw who broke off teeth like this. It’s a situation some dentists call a “gorilla bite” – a patient with a jaw structure that causes extra intense biting pressures. I’m doing a little guesswork here, because I don’t have all the facts. Get the second opinion and then weigh that and hopefully you’ll get pointed in the right direction.
– Dr. Hall
Additional information: Read about TMJ disorder, bruxism, and TMJ symptoms.
You may also want to read more about dental crowns.

We thank our advertisers who help fund this site.

About David A. Hall

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

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