Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

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.

July 7, 2016

I had bonding to close black triangles, and it looks awful


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Dr. Hall,
I had dental bonding done to close two tiny black triangles I had on the teeth next to my front teeth, and it looks awful. I went back today to see if he could fix it and it still looks bad.

I thought my dentist was a cosmetic dentist but come to find out he’s not certified which I had no idea and the job looks terrible. Looks like whitish material lodged between my teeth and I am sad and regretting even doing it. Just thought if he said he would do it, it was an easy fix that would look nice. He said give it a couple weeks to get used to but he will refund me since I am not happy. I can’t even floss between the teeth except above the bonding.

He wants me to come back tomorrow to try and fix it. I am afraid to have him do anything else. And researched more and found that certain dentists are actually certified for this. Is this something I can get fixed and done correctly? I just wish he would have said this isn’t something he specializes in. I just want my teeth back to where they were before this now and want my gums to settle down. What do I do???

– Angie from St. Louis

Dear Angie,
Closing black triangles is really tricky. Fortunately, you a couple of excellent cosmetic dentists in the St. Louis area, and either of them could do a fine job on this for you.

Black triangles are usually caused by receding gums. Here is a photograph of a case where that occurred.

Black triangles from receding gums

Black triangles from receding gums.

In your case yours showed up after straightening your teeth with Clear Correct invisible braces. Now you said that they are tiny. Not seeing a photograph of your teeth, I can’t tell you my opinion about whether or not you need these areas bonded—you can figure that out, if you want to just have the bonding sanded off and go back to the way your teeth looked, or if you want the black triangles filled in somewhat.

If you have them filled in, I’ll let you know several issues that make fixing these black triangles tricky.

The first is that their shape can adversely affect the health of the gums. Simply adding bonding material to fill in the hole left by the gum–that will just create a food trap which will cause plaque and calculus to accumulate beneath it. This will cause gum disease. So the added composite has to be shaped skillfully so that there is no such trap created and then polished carefully to make it plaque-resistant. The best test of whether or not the shape is healthy is to floss between the teeth. If you can push the floss into the sulcus under the gum and then when you pull it up it pulls smoothly, that is a strong sign that the shape and the polish are excellent. In your case, you’re saying that you can’t even get the floss past the bonding material. This is a serious problem and needs to be resolved to avoid gum disease on these teeth.

The second issue is that this is a difficult area to bond anything. To get the final result shaped properly, the dentist should be working some slightly under the gumline. Gum tissue oozes fluids. And if the gum tissue isn’t healthy, this oozing is very difficult to control. Those fluids contaminate the bond between the composite and the tooth, making it so the composite doesn’t stick. There are techniques for retracting the gum and controlling this oozing during the procedure, and those techniques have to be meticulously applied.

The third issue is the esthetics of the case, and there are a couple of dimensions to esthetics at play here. You mentioned color. Teeth are quite a bit darker at the gumline than they are at the incisal edge, and many dentists won’t use a dark enough shade of composite here. Family dentists may not even stock appropriate shades, because they only stock general purpose composites that are used for fillings. Composites for esthetic work are different. And then the shape is another dimension. Just putting a blob of composite on the teeth to plug the hole isn’t good enough. The end result has to look natural, and it can’t be done in such a way as to compromise the health of the gums, as I mentioned above.

I respect your dentist for his honesty in acknowledging his inadequacy here. I would recommend that you have him remove all the bonding material, refund your money as he has offered, and then, if you want this fixed, go to someone who knows what they are doing. There are sandpaper strips that can be used to polish off all of the bonding. After it is removed, you should be able to floss easily, get the floss under the gum, and the surface will feel smooth as you rub the floss up and down on the tooth surface.

– Dr. Hall

Do you have a comment or a question 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 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 10, 2016

Getting porcelain veneers and crowns to match


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Dr. Hall,
My question is, how hard is it to get all veneers to match, when the tooth stubs are dark. I’m getting one crown, and the rest of the smile is porcelain veneers. In my case, the crown looks whiter than the adjacent veneers. Shouldn’t there be a way to make them more matched? Love my dentist, but I think it could be a dental lab issue. I paid a lot of $ & I’ve seen many cases where everything matches. Thanks!!
– Carol from Pittsburgh

Carol,
This is an issue that a lot of family dentists have trouble with. Dental schools tend to trivialize cosmetic dentistry and teach that it is easy to do–any dentist can do this. But there are some basic color concepts that they really don’t teach the dentists. And then the vast majority of dentists don’t have a passion for appearance-related dentistry, so they don’t take the trouble to get this extra training.

Porcelain is naturally translucent, just like enamel, which makes it an excellent dental material. But porcelain veneers are thin, and porcelain crowns are several times thicker than veneers. So if the underlying teeth are dark, as yours are, that dark color is going to shine through the porcelain veneers much more than it would with the crown. That is the basic problem here.

There are two basic ways around this. One way is to accomplish this with the porcelain. Another is for the dentist to apply the opaque to the teeth before sending the case to the lab.

Opaquers can be added to the porcelain, but this requires quite a bit of skill on the part of the laboratory, to make the entire case turn out correctly. If the crown is translucent, the veneers need to be opaqued in a way that makes them appear just as translucent as the crown. It can be done, but is tricky. It also requires good communication between the dentist and the laboratory–the dentist needs to either provide photos of the prepared teeth or a detailed description of their color so that the laboratory can make the proper adjustments. There are excellent esthetic dental laboratories that can do this well.

In my practice, I preferred dealing with the opacity issue myself, as part of the tooth preparation. I would shave a little extra from the dark teeth and then apply an opaque layer of composite onto the teeth. The deeper the opaque layer is, the more room is available to create the needed translucent effect with the porcelain. The composite bonds chemically to the porcelain veneer luting cement giving a strong, attractive result.

– Dr. Hall

Do you have a comment or a question 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 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

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.

June 9, 2012

Why can’t my dentist get this color right on my implant crown?

Dear Dr Hall,
I was not happy with the color of the crown attached to my implant, so I returned to my dentist who said he thought it was fine and sent me away to “think about it.” I returned and he very reluctantly agreed to re-do the color. I recently had the revised crown attached again, but the color is worse – it is now quite noticeably darker. Both times I visited the lab for color assessment. And both times the dentist did not bother to check the color before attaching the crown. I am very disappointed, but do not want to return to this dentist as he obviously is not able to improve. He also had considerable difficulty with attaching the crown which resulted in considerable discomfort and left me wondering whether the attachment to the implant has been damaged. Post-procedure, I cannot eat on that side of the mouth at all. This implant has cost me a considerable sum. I would like to know what my options would be for correcting the color of this crown, and if the attachment has been damaged, would I need to get a whole new crown and implant, and who should pay for this? Is it possible to place a veneer over the crown? Thank you for your help.
– Mary from Australia

Mary,
Your case is a great illustration of the great difference between dentists when it comes to aesthetics. Only about 2% of dentists, from my experience, are very good at aesthetic dentistry, and I have people all of the time having a hard time believing that and wanting to know why. (And that 2% is in the US – probably less in Australia). But dentists become dentists because they like to fix things – they’re just not into works of beauty.

Your dentist clearly has a low degree of interest in the aesthetics of his work, and that is the reason this isn’t working. And you have given clear indication here in your e-mail of his indifference. Any dentist who is seriously trying to do beautiful cosmetic dentistry will be very attentive to your opinion and if you thought the color didn’t match well would not try to tell you that it was fine. Such a dentist would actually make sure the color was right in your eyes before cementing the porcelain crown and would not hesitate to send it back to the lab. But your dentist did not have enough confidence in his own color-matching skills to match the color himself but instead sent you to the laboratory. And then, after being burned once and having to re-do the crown, rather than trying it on and making sure you liked the color this time before permanently cementing it, he just puts it on.

You have figured out that you cannot rely on this dentist to get this right. If you want this done right, you have to find a dentist who actually wants to be good at aesthetic dentistry. I wish you had told me where in Australia you are and I could give you some guidance on that, because good cosmetic dentists are few and far between in Australia.

When a dentist sends you to the laboratory technician for the “color check”, that is a pretty good sign that the dentist knows he or she isn’t very good at tooth color, and those cases often end up looking very poor. All the technician can do is look at the tooth that needs to be matched and take notes about the color. Then he or she dismisses you, goes into the laboratory, and tries to follow the notes that were made. The dentist is supposed to have a higher level of skill than the technician, and should know how to make those notes and instruct the technician. And nowadays, with digital photography, it is very easy for a dentist to hold up a shade guide tooth to your tooth and snap a color-correct photograph and e-mail it to the technician, with notes. The technician can then use that photograph and the notes during the fabrication of your crown, and this is often the best way to get an accurate match.

Do not – absolutely do not try to get a veneer placed over the crown. The crown is difficult enough by itself. Get the crown re-done. If that is done correctly, it will not damage the implant at all. Trying to do a veneer over it and get the color right makes it all the more complicated. Besides which very few dentists know how to properly bond a veneer onto a porcelain crown. That could turn this from a simple bad dream into a true nightmare.

If you need any more help with this, please write back.
– Dr. Hall

P.S. – I see you found our website by searching on “dental catastrophe.” I had not thought of that search term before, but it is appropriate!

Click here to read my blog posting about how to ask for a refund from your dentist.

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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 4, 2011

Replacing a single porcelain veneer. Will it match?

Filed under: Porcelain veneers — Tags: , , — mesasmiles @ 11:15 am

The following is a question I got from one of our visitors that is a follow-up after I answered her question about using a toothpaste with baking soda on porcelain veneers:

Dr. Hall,
I have one last question. One of my veneers on the front teeth apparently left some dentin exposed on that tooth. I had a lot of sensitivity but that has improved ( it has been about a month since they were put on). The dentist wants to replace this veneer and fit it properly. However, I am worried that the color won’t match and I don’t want to have to live with one tooth that is different. Also I’m worried about the risks of removing the veneer (possibly breaking the underlying tooth or surrounding veneers.

What are your thoughts? I’m considering just living with it the way it is, but if I had more confidence fixing it would be ok, I’d go ahead and have it replaced.

Thanks,
Monica from Maryland

Monica,
I don’t know who your dentist is, but I think I remember your saying that you had one of our recommended cosmetic dentists do this. Anyone we recommend should have no trouble matching your existing porcelain veneers. Excellent cosmetic dental laboratories, which are the ones that excellent cosmetic dentists use, will keep their color formulas for work they create so that they can perfectly match previous work.

And damaging the tooth is a non-issue. In fact, you pose more risk to the tooth by leaving this source of irritation than by re-doing the veneer. Exposed dentin has tubules that go straight to the pulp – this is why the tooth is sensitive. And open tubules are a risk for bacteria getting into the pulp. My advice would be to let your dentist do this for you.

– 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.

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