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.

September 11, 2017

Another dentist botches a tetracycline case


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Dr. Hall,
I had bonding done on my four front teeth almost 20 years ago to cover tetracycline stains. One chipped and I returned to my same general dentist to request veneers on the six front teeth as the solution. Instead, he talked me into six crowns, saying that they would last longer, serve as a better solution to the staining, and also help address my gummy smile. Foolishly, I listened without doing my homework, as I wanted the situation quickly corrected and he is a very reputable general dentist – not to mention a long-time family acquaintance. I trusted him. He is known as the best in the area.

Unfortunately, there is grey visible beneath a few of these luminescent crowns—and especially so in fluorescent light. I am horrified. He has said he will make it right and have the lab redo the problematic ones free of charge. However, I am now very concerned and thinking the better course of action might be to request a full refund and see a true cosmetic dentist. I think he is in over his head, despite trying to reassure me he does this work all the time.

I am now always going to be stuck with crowns versus my real teeth for the rest of my life and I am just sick about it. I think I would be justified in asking for a refund and entrust a re-do of the crowns to someone else. Your thoughts?
– Holly from Philadelphia

Holly,
This is tough, when you have a family acquaintance and supposedly reputable general dentist who seems to have little clue as to how difficult a procedure he has bitten off, probably with the best of intentions, but now you are suffering because of it.

Here is a list of his mistakes, all likely made with good intentions:
1. For lack of comfort with the porcelain veneers procedure, he recommended the highly aggressive porcelain crowns to fix your front teeth. And now that your teeth are ground down to stubs with crowns, there is no going back.
2. Based on the dental school mentality that there are six front teeth and the rest are back teeth, he tried to correct a very dark tetracycline-stained smile with fixing only six teeth. An excellent cosmetic dentist, in doing a smile makeover of dark teeth, will always include at least 8, maybe 10 or 12 teeth, depending on the width of the smile. Dental schools speak of anterior teeth and posterior teeth. Cosmetic dentists talk about the patient having 8 to 12 teeth in the “aesthetic zone.” Here’s a photograph of a patient with only six crowns on a background of dark teeth, but her smile is 10 teeth wide.

crowns on 6 anterior teeth, but the aesthetic zone is 10 teeth wide

The failure to cover all teeth in the aesthetic zone makes it obvious that this patient has crowns.

3. For lack of familiarity with the intense color issues involved in tetracycline stains, he didn’t adequately cover the teeth, and the dark color is showing through.

So should you let him go back and fix this now? Absolutely not. It’s likely that even his lab doesn’t know what they are doing. Tetracycline stains are one of the most difficult cosmetic dentistry procedures, and you need an experienced professional.

You’re in Philadelphia. We have several excellent cosmetic dentists in the area that I recommend, in downtown, the suburbs, and nearby. Being a trusted, reputable dentist, he would probably be willing to give you your refund, and I would ask for it. Done right, you could have a truly beautiful smile. And then you could go back to him for your general dentistry needs.

– 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.

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