Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

June 11, 2018

Another family dentist trying to do cosmetic dentistry


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Dr. Hall,
Last year, I had a tooth with composite bonding chip. My dentist retired and the new dentist suggested veneers. After realizing my teeth had fillings, he said he could only do crowns. Unfortunately, I didn’t question him because I knew nothing about this procedure at all. Now, I have six porcelain crowns on my front teeth that I hate. My front two teeth look gray in pictures and do not blend with the other four crowns. What can I do?
– Anna from a small town in central Georgia

Anna,
So you have another cosmetic dentistry horror story. You have spent a lot of money and probably look worse than before you started.

There isn’t a whole lot you can do except have at least these front two crowns re-done. Hopefully your dentist cares enough about his work that he will take care of this for you without charging you.

In re-doing them, you should insist on a try-in before they are bonded, and you should make sure to get a good look at the crowns before they are bonded or cemented into place. And when they are tried in, that should be done with a clear try-in paste that will help transmit the color of the underlying teeth through the porcelain of the crowns. Since your dentist clearly doesn’t have much expertise in cosmetic dentistry and so is unlikely to have try-in pastes, he can just use clear glycerin or any other clear water-soluble gel which should work just as well. Otherwise, you can get a false reading of what the actual final color will be.

If your dentist won’t do that for you or balks at any part of these instructions, you will have to go somewhere else. If that is the case, I would strongly recommend taking the two-hour drive to Atlanta where you can go to a real cosmetic dentist who knows what he or she is doing. Check our list of recommended cosmetic dentists—any one of them could do a beautiful job of 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.

April 16, 2018

Porcelain Veneers Gone Bad


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Dear Dr. Hall,
I recently went to a dentist to do a smile makeover, specifically because my four upper front teeth are misaligned and crowded. After he explained that cosmetic dentistry could correct the problem faster without the inconvenience of braces, I opted for that.

He said that a combination of bonding on #10 (left lateral incisor), a single veneer on #7 (right lateral incisor) and shaping would provide complete alignment, no crowding and an even smile. He also claimed he did shaping on the lower teeth – which I never discussed or mentioned about treating at a cost of 1.3k. He charged overall 9k for this work. When he declared it complete, the veneer was too small with a gap near the gum line, the teeth were still crowded and they remained uneven. When I asked him what would provide the outcome he originally described he said only 4 porcelain crowns on the upper teeth would, but at an additional cost of 7k, because he would need to do root canals in addition to placing crowns.

I went to another dentist for a second opinion and he advised me that his recommendation would have been to place 4 veneers to correct the original crowding and alignment problem. They also said that to correct the current problem I would still need the 4 veneers, no root canals necessary and no crowns necessary, just 4 veneers at a total cost of 4.5K.

My question is how do I successfully recover my 9K from the first dentist?
– Grant from New Jersey

Grant,
Well, I guess we’ll add your experience to our list of cosmetic dentistry horror stories.

Just from what you’re telling me it sounds like the first dentist took you for a ride, not delivering work that was promised and leaving you with a very poor smile makeover. In my opinion, you should be entitled to a refund of what you paid, if you go about it right. But before I get into that, I have a real concern about your second dentist. How do you know the second dentist will deliver the attractive smile you are wanting? Do you realize that smile makeovers are not taught in dental schools? You might want to check my blog post, Why you shouldn’t ask your family dentist to do porcelain veneers.

I strongly suggest getting a third opinion from a dentist you know can do smile makeovers. You’re there in the New York City metropolitan area where you have a varied selection of excellent cosmetic dentists. You can go to our list, or find an accredited cosmetic dentist.

Now back to your question of getting a refund from the first dentist.

Start, of course, by just asking for one, with some gentle pressure. I address some pointers about this in my blog post, How to ask for a refund. If that doesn’t work, you need to apply more leverage. There are a series of steps, each one applying a little more pressure.

The next step would be, after you find your expert cosmetic dentist who can do a beautiful job with this, is to see if that dentist will call on your behalf and say that a refund would be appropriate. Dentists tend to be sensitive about what other dentists say about their work.

Unfortunately, it seems to me from what you’ve told me about his conduct so far that your dentist is one who is going to require more pressure than that and you’ll need to play hardball. The next step in escalating pressure against the dentist is to complain to the dental board. The step after that is to contact an attorney. For each of these steps, it is very helpful to have the backing of another dentist to document the problems with the earlier work.

Good luck.

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.

March 17, 2018

Expectations way too high here for the Snap-On Smile


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Dear Dr. Hall,

I’m thinking about purchasing a Snap-on Smile for esthetic reasons and to prevent, as much as possible, the loss of tooth tissue. But I had my doubts about it looking natural. So I googled “snap on smile looks fake” in order to find possible comments about this on the internet. I found this post and your helpful answer. It’s great that such a knowledgeable doctor gives (free) advice!

First of all I would order the Snap-on Smile in the same yellowish color of my own teeth, and demand that the irregularities of my existing teeth are duplicated in the Snap-on Smile. I believe it’s mostly the whiteness and the uniformity of fake teeth which make them look so unnatural (like horse teeth).

Now, in the video ‘snap on smile part 2’ it shows the set of 6 small instruments with which “Snap-on Smile-dentists” can make subtle adjustments to the appliance. To make my snap-on look even more natural, I would be interested in getting the snap-on teeth flattened, including near the gums, and the “embrasures” and the vertical grooves between its teeth deepened. But, as you wrote, dentists “have an engineering mentality, and they simply aren’t artistic.” Therefore I would prefer to take my snap-on to a cosmetic dentist to get these adjustments made. Would a cosmetic dentist have the necessary instruments for a Snap-on-Smile? Or is the specific set of instruments needed which only Snap-on-Smile-dentists get? (Actually, I expect a cosmetic dentist to have even better instrumentaria! But I would like to be sure before I go ahead purchasing a Snap-on Smile, which, BTW, I hope my own “normal” dentist won’t mind me doing – I’ll ask him.)

Thank you in advance.
– Maylynn

Maylynn,
Your expectations with this Snap-On Smile are way too high, and you are headed for disaster with this plan of yours. I fear that you’re a budding cosmetic dentistry horror story. I’m glad you asked the question, though, because it gives me an opportunity to clarify this issue. Your question started as a comment on my earlier blog post where I answered Heather who said she was disappointed in her Snap-On Smile. I can see that while I told her she could get some improvement by getting a more artistic dentist to help her, I should have been more emphatic in my comments about the Snap-On Smile ending up looking bulky and not natural and her never getting to a beautiful smile.

We have had several dentists who are clients of our website design business who have tried marketing Snap-On Smiles. Some of them have quit doing it because patients are so disappointed in how they look. The ones who are successful in marketing them are better at tamping down patient expectations. We advise them to be sure to tell people they will NOT get an attractive smile, only an acceptable smile. The teeth will look bulky. They will not glisten like natural teeth. And while they may look natural from a distance, from up close it will be easy for someone to tell they’re not real.

And while you seem to be brimming with confidence that you can help your dentist get these looking just right, I would kindly remind you that you are not a professional, and some of your ideas are not correct. For just one item, whiteness is not the primary reason false teeth look fake. Monochromatic whiteness, with no variation in the color, yes, but I have made many sets of porcelain veneers that are nice and white and that even a skilled cosmetic dentist, from the front from twelve inches away, could not tell were not real. Also, your comments about how you are going to insist they be colored and shaped spell trouble for your relationship with this dentist who you think is going to make these under your supervision. And the dilemma you are in with your approach is that the more artistic the dentist you engage to do this for you, the more resistant they are going to be to your meddling in the process.

Snap-On Smile is for patients who have an ugly smile and want to upgrade to a smile somewhere between poor and mediocre—say from an “F” smile to a “C-.” DenMat’s marketing materials may lead you to higher expectations, but that’s their marketing. If that’s not where you are, you need to look into a different smile makeover technique.

– 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.

February 27, 2018

Another porcelain veneer horror story


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Hello Dr. Hall,
I have had 6 veneers done on my top teeth. They are too bulky and not natural looking.

When I first started the process I was very clear with the lab and the dentist what I wanted. He sent back the first set because they were too bulky yet continued to use the same lab. At this point most of this was paid for so it wasn’t like I could have just gone somewhere else. It was all very rushed. There was no style guide whatsoever provided either. I really tried to be patient and put my trust in this dentist professionally. He was nice and everything but that is totally irrelevant.

The day of the cementing I was totally stressed with this whole process and when they held up the veneers for me to see they kept falling out making it impossible to make a proper judgment call. I was unsure about it but they kept telling me that they could make adjustments after. Which was untrue. They were not able to, hence me reaching out to you.

I have tried for the last month or so to get a hold of the dentist, asking for a refund and I’m being avoided it seems. Any advice would be so appreciated, how do I get my refund? I’ve cried so much over this, literally. It’s my teeth not a haircut—teeth don’t grow back after all.
– Leanne from Toronto, Ontario

Leanne,
Your basic problem is that the vast majority of dentists, while they may know in theory how to place porcelain veneers, don’t have the artistic inclinations to do a smile makeover. At the same time, most dental laboratories, while they know the mechanics of making the porcelain veneers, don’t know enough about the artistic aspects of the work to do a smile makeover.

So you go in to this dentist and you say you want porcelain veneers, and he thinks he can do this and thinks his regular dental lab that he uses for crowns can do this. When the first set came back completely inadequate, he’s not going to sour this long-standing relationship with the lab by demanding a refund and switching labs.

Every excellent cosmetic dentist has had a first smile makeover. I had mine, and I will tell you honestly that I wasn’t proud of how it turned out. But I have learned over the years in talking with hundreds of cosmetic dentists that the excellent cosmetic dentists have a fundamental difference in attitude in that they will not be satisfied unless the patient is excited with the result, and they will go through whatever expense or work they have to until the result is beautiful and makes the patient happy. You will never have what happened to you, where they pressure you to accept the result. In my case, my first smile makeover patient was borderline satisfied with the result and didn’t object to my bonding the veneers. But the teeth didn’t have any sparkle, and when she came back for a checkup I told her that her results weren’t good enough, that I didn’t want a mediocre smile out there attributed to me, and I re-did them with a different lab completely at my expense. I have learned since that this is what all of the really good cosmetic dentists will do.

So your dentist, because he lacked this commitment to your satisfaction, either didn’t bother to learn about try-in pastes or decided to skip that step so that you weren’t able to see for yourself how this would turn out before they were bonded. And now, rather than wanting to fix it, he doesn’t want to be bothered.

To get satisfaction and to hopefully get a refund, you’re going to need to get an excellent cosmetic dentist on your side. We’re a little thin on recommended cosmetic dentists in the Toronto area, but we do have Dr. Goodlin there. I would go to him for an opinion, and see if he will work with you to try to get a refund from your dentist. A call from one dentist to another can be very persuasive. Your legal leverage in this case, unfortunately, isn’t that great if the veneers have stayed on and are functionally okay. Your dentist has probably met those two standards, which is how the profession at large will judge your case. Your best point to make, legally, is that you were pressured to have the veneers bonded on against your will with false promises. If you have to go to a lawyer to get enough pressure on this dentist to refund your money, that is the point your would want to make.

I wish you well and hope you end up getting the beautiful smile you thought you paid for. And a tip for others in your situation—even though you have paid for the work, you can switch to another dentist at any point. A dentist is ethically obligated to help facilitate that change, for whatever reason you feel you need to switch.
– 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 29, 2017

What is the difference between a prosthodontist and a cosmetic dentist – a horror story


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Dr. Hall,

I recently had a full mouth reconstruction done by a very reputable prosthodontist, and although it was primarily for functional purposes, aesthetics were of great importance as well. How many people have the opportunity to have all brand new white teeth that match? It was exciting: however it was also a long and painful road. I brought in old pictures of myself to show him the color I wanted and the way my original work looked 30 years ago, and I said “this is what I want”—pretty straightforward I thought. Throughout the treatment, he kept telling me to he wanted me to be happy but sometimes when I would tell him what I wanted he would tell me I was wrong but he always said trust me—I’ve been doing this a long time.

When the first set came in, they were not anywhere close to the right color so he told me I picked the wrong color. We did three try-ins. The 3rd time I told his assistant that the top teeth looked dark, that they were darker than the bottom ones and I said that several times. Now mind you, I was trying in an unfinished set of teeth because they had their own lab to do the finishing and I had never seen unfinished crowns and bridges so I had no idea what they looked like before they were finished. Anyway, his assistant assured me that once their lab finished, they would be fine that the top and bottom teeth would match and to trust her. The bottom teeth were veneers, crowns and implants.

Now, to clarify part of the cause or my problem; every time we did a try-in, I couldn’t look at the teeth with my mouth open or see how they looked when I talked or with different expressions because the teeth would fall out which made it difficult to truly see the color or to see if the bottom and top teeth matched. So the day came to have everything put in permanently and there were 3 things I wanted to check, one being color! It turned out that one of the teeth was a little sharp. I said that and he said, “Hope, we’ve done just about all we can for you and I don’t think we’ll ever be able to make you happy; so maybe you need to find someone else to finish the job.” I was standing there unable to speak because all of my teeth would fall out, and all I wanted to do was leave—take all the teeth out and leave—but I couldn’t do that. I had no teeth and no money. I just kept thinking don’t do it just leave but how could I? I had no teeth. If I took these out, I would simply have no teeth. What was I supposed to do?

From that point, everything is a blur. I remember wanting to leave, telling the assistant that I was afraid to say anything else to him, and tears rolling down the side of my face when he started putting the bottom teeth in. Then I remember asking if they would put the top teeth in with temporary cement and she said no, that he wouldn’t do that.

Now, after all of this time, effort, and about $50,000, I have teeth that don’t match. The top teeth are darker than the bottom ones and I don’t know what to do. If it was the other way around, and the bottom ones were darker, then I could probably live with it, but it’s not. This is completely unacceptable—I have to have it fixed somehow. I personally think that he should re-do all of the porcelain over gold crowns and bridges so they match the veneers. Those are at least closer to the color I wanted. I feel so stupid for letting this happen, but I was in shock—like a deer caught in headlights but worse!
How do I go about addressing this with him? I’m very picky and the difference in color is DEFINITELY something I would have noticed, but not under those circumstances. I just froze, and I truly don’t feel it was my fault—I was under enormous duress at that moment.

As you can see, I’m very emotional and wordy which is not the way to approach this. Do you think this is something he should fix, given the situation; if so, please help me. I do not know how to communicate with him, let alone get the result I believe is fair.

– Hope from Michigan

Dear Hope,
So you have a very reputable prosthodontist. He is undoubtedly very good at what he does, from a technical point of view. But you have to realize that your appearance concerns are frowned on by institutional dentistry. This is a classic example of the prosthodontist mentality. You’re trying to tell him what you want. His response is: “Trust me—I’ve been doing this a long time.” In other words, he knows best, he doesn’t need your input on the appearance, and you’re a troublemaker for not just accepting that.

I have had several requests from prosthodontists to be listed on this website as recommended cosmetic dentists, and I have turned them all down except one. These are dentists thoroughly steeped in the dental school mentality that focuses on functional issues and trivializes concerns over appearance. This prosthodontist thinks it’s pandering to listen to your appearance concerns. You’re talking to a brick wall here. You’re saying, “I don’t know how to communicate with him.” That’s not the problem. He doesn’t want your input—case closed.

How to Get This Fixed

Hope—brace yourself here for some tough medicine. You’re going to have to stiffen your spine and go after this dentist. The good news is that you have excellent legal leverage here. You need to have the will to stand up to him.

I don’t believe you need to sue this dentist, but my gut tells me, as arrogant as he appears to be, that you are going to need to go to a lawyer and at least threaten to sue. You can try telling him that’s what you’re going to do and see if he will make this right for you financially, but I wouldn’t hold my breath waiting for a favorable response. What you want is for him to pay to have an expert cosmetic dentist fix the upper teeth so they look acceptable to you.

You are correct that, if there is a discrepancy in color between the upper and lower teeth, the lowers should be the darker ones. A good cosmetic dentist can get away with pushing the shade of the upper teeth maybe half a shade to a full shade whiter on the Vita scale and it will still look good. But not the other way around.

Here’s Your Leverage

What he did to you was malpractice. No, there is no suggestion here that there is any lack in the quality of the work. But he forced these teeth on you without your consent. Informed consent is a cornerstone of ethical dental treatment. You did not want these crowns on your upper front teeth put in, but he did it anyway.

I can see, by the procedures you have explained to me for his trying in these crowns, that he doesn’t care about your input. You said that the work kept falling out if you tried to look at it. Now there are try-in pastes made specifically for the purpose of holding the work in well enough that you can see how it looks. He certainly knows of these materials, but he isn’t interested in them because to him, he is trying the work in only to check the fit and to make sure he likes it. His practice isn’t geared toward taking into account anything about what you think.

I’m sure he doesn’t think he did anything unethical, and it’s not going to be easy opening his eyes to that, but a letter from a lawyer, educating him on this principle of informed consent, will certainly trigger a call to his malpractice insurance carrier. They should let him know that he is on very shaky ground, and they should be able to prevail on him to make this right for you. Again, what you want to ask for is for him to pay an excellent cosmetic dentist to take out the crowns on your upper front teeth and replace them. Here’s how you do that. First, find a lawyer who understands well this principle of informed consent. Have the lawyer write the letter explaining what he did wrong (basically, he is guilty of assault). Then, before you settle on an amount, I can recommend for you an excellent cosmetic dentist who can give your dentist a figure of how many crowns would be involved in fixing this and how much it would cost.

He may argue that he had your consent. And I’m sure that he had you sign some kind of form before starting treatment. But you did not consent to putting in these particular crowns. Yes, you let him do it, but you were under duress at the time, and consent under duress is not consent—this is a key legal doctrine. You were intimidated, not given reasonable options, and your reaction as you have described it to me indicates that this was not a voluntary consent. Your lawyer I’m sure will be able to explain the advantages of his just settling this matter rather than going to court and having to pay emotional and possibly punitive damages on top of the cost of just replacing the work.

Hope, I’m sorry I don’t have an easier path for you, but I have received hundreds of complaints similar to yours and I’ve coached many of those people through situations like this, and you are simply not going to be able to transform this dentist into a listening, caring cosmetic dentist by anything you say. In his own eyes and the eyes of many of his peers he is very good at what he does, and you’re just a peon. He has been taught that it would be wrong to listen to you.

– 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.

August 19, 2014

How white are bleached teeth?

I’ve had this question come up in discussions with dental writers and with patients who have a misconception about teeth bleaching. They understand that teeth tend to accumulate stains over the years. They absorb the pigments from coffee, highly pigmented fruits, wine, and other sources. Bleaching, they think, is a way to remove all those stains.

They’re only partly right. Yes, bleaching will remove those stains, but it will whiten even the natural pigment in your teeth. Let me illustrate this with a couple of stories.

When I went to dental school, I learned about shade guides. The most popular one was the Vita shade guide. Here is a picture of it:
vita-shade-guide

It has a full spectrum of the range of shades a dentist is likely to encounter in natural teeth. When we needed a porcelain crown to match a patient’s other teeth, we could almost always find a shade in this guide that came pretty close to the patient’s natural tooth color.

In the 90’s, ivoclar-shade-guide-bleached-teeth when teeth bleaching became popular, we started to have a problem with this shade guide. We would have people who needed porcelain crowns, and when we tried to find a shade that matched them, they would be “off the chart.” Their teeth would be much whiter than the whitest natural shade on the shade guide. In response, shade guide manufacturers developed new whiter shades. Ivoclar was the first manufacturer that I remember doing this, and our office purchased this four-shade guide and used it to communicate with dental laboratories. You can see that shade guide at the right.

Vita also updated their shade guide, and here is a picture of the current version, with what they call the “bleached extension” shades on the left:
vita-shade-guide-bleached-extension

Serious cosmetic dentists will, of course, use this amplified shade guide because they are frequently dealing with patients who have bleached their teeth. Often, regular family dentists will only use the original A1-D4 shade guide. This led to a problem with one patient who e-mailed me around 2005. She had bleached her teeth, and was now getting porcelain veneers on four front teeth. Not knowing how specialized cosmetic dentistry is, she chose a regular family dentist to do these veneers. For the shade, this dentist selected the whitest shade on his chart. When the veneers came back from the lab, they were noticeably darker than her teeth. The dentist assured her that by using the whitest cement the veneers would match her teeth. She wrote to me, “Alas, this was not the result: there is at least an entire shade (if not more) of difference between my porcelain veneers and my other teeth.” I answered her that unfortunately, her dentist used the classical shade guide, and the whitest shade on that guide could be considerably darker than bleached teeth. For the full story, see the page under “Cosmetic Dentistry Horror Stories” where I discuss her question, can you bleach porcelain veneers?

When my own children got all of their permanent teeth in, I let them bleach their teeth if they wanted to. Even though they weren’t old enough to have any accumulated stains, they were able to whiten their teeth significantly.

So how white can you get your teeth? The results of studies seem to show that the longer you bleach, the whiter they will become, and no one, to my knowledge, has found the limit. The rate of whitening decreases the longer someone uses the bleaching gel, and everyone will hit a point where they don’t want to do it anymore. Some people get them so white that they seem to glow.

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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 29, 2013

Some dental bridge engineering principles, and why this planned bridge will fail

Dr. Hall,
I had my upper 6 front teeth pulled due to periodontal disease. I was going to have 4 implants with two pontics, but asked for something less expensive. So we are talking about doing a permanent bridge. I have read about the Maryland Bridge and feel now that maybe the separate implants with two pontics would be better? They have charged me the same price so my question is …would 4 implants and two pontics be better?
– Jill from Pennsylvania
(Note from Dr. Hall – a pontic is the false tooth part of a dental bridge.)

Jill,
I can’t really prescribe anything specific for your case without seeing you, but I can be some help here by giving you some guidance from basic principles of bridges and restorative dentistry.

If you are accurately telling me what your dentist is telling you, then something is very wrong here. A permanent dental bridge replacing six missing upper front teeth on any patient with significant gum disease would be a disaster waiting to happen. It’s not going to last, and in the end will be by far the most expensive option. Other options would be far better in multiple ways. And I’ll explain why. I’m going to explain this in some detail here for you and then use this explanation as a blog post that will hopefully help others with similar questions.

Here is a diagram of your upper arch:

upper-arch

So you are saying that you have had the front teeth extracted, which would be teeth numbers 6 through 11.

Here are a couple of principles of doing bridgework that every dentist is taught in dental school.

First, any bridge needs to be supported by teeth that collectively have the same amount of support as the missing teeth. In other words, if the bridge is replacing two medium-sized teeth, it needs to be anchored by at least two medium-sized teeth. If four small teeth are missing, they could maybe be supported by two large teeth, if those supporting teeth are twice as large as the missing teeth. So, you are missing four medium-sized teeth (6, 8, 9, and 11) and two small teeth (7 and 10). To support that adequately, you need four medium-sized teeth (4, 5, 12, and 13) and probably one large tooth (3 or 14). So you are ending up with an extremely complicated 11-unit bridge, consisting of six false teeth supported by five existing teeth. Now I suspect that your dentist, especially if you are pressing to save money, may be planning something less than this. But breaking this rule would severely limit the lifespan of the bridge.

Second, when you start adding supporting teeth, you increase the likelihood of failure for two reasons. One is that each supporting tooth has to be prepared to be perfectly parallel to all the other teeth. Getting five prepared teeth to be all parallel to each other (or even four) so that the bridge fits perfectly is extremely demanding, and I would not ask a regular family dentist to do that. When you add to that complication the problem of having teeth on opposite sides of your mouth, making those parallel is a very tricky proposition. Another reason is that if you have any kind of trouble down the road with any of the supporting teeth – decay or gum disease or any other significant problem – the entire bridge will have to be re-done. How expensive is that going to be? Way more than implants.

Third, with six missing front teeth you have what is called a cantilever effect. Look at the diagram and imagine that tooth #4 is missing. This tooth could be replaced with a simple three-unit bridge – the missing tooth #4 supported by teeth #s 3 and 5. Notice that these teeth are pretty much in a straight line. There would be no tipping forces at all when chewing stress is borne by tooth #4. This is the type of stress these supporting teeth are designed to take. But now compare this with teeth #s 6 through 11. These are on a curve. The strongest bridge between teeth #s 5 and 12 would be on a straight line between the two teeth. But that kind of a bridge would go across the roof of your mouth and wouldn’t make any sense. So we have to loop the bridge out around the curve. Have you ever seen a highway bridge that curves out like that? Of course not. They always form a straight line between the supports. The reason for that is that when you’re out on that curve, you create tipping forces which put a large amount of stress on not only the supporting structures but the entire bridge. This force becomes a force that wants to twist and push the two closest anchors (#s 5 and 12) and actually pull the remaining anchors out of their sockets. These are stresses that these teeth are not designed to take, and the life expectancy of such a bridge would be pretty short. You would probably end up losing all of the anchor teeth, in addition to the six you are already missing. To compensate for that added stress factor, your dentist could try anchoring with six teeth instead of five. But then you increase the risk also and may end up losing all six of them.

The conclusion of all this is that a permanent bridge replacing six front teeth would be a bad idea for someone with healthy gums in the hands of some of the most expert dentists in the country. When you add the complicating factor that you have significant gum disease, and add that to the possibility that your dentist may be an average family dentist, you are courting disaster.

So what should you do?

Anything other than the fixed bridge. Don’t end up in our collection of cosmetic dentistry horror stories.

The most economical solution would be a removable partial denture. With today’s acrylics, this could be made to be very esthetic and could have clear acrylic clasps that would be virtually invisible to anyone else. There are some inconveniences to having a removable partial denture, but the cost would be a small fraction of the cost of any other option.

The most comfortable and highest quality solution would be using dental implants. Now whether or not you could support the false teeth with two or four implants would depend on how much bone support you have and the stress of your bite.

My advice? Get a second opinion from an excellent dentist. (See my posts about how to ask for a second opinion.) There is an excellent dentist near you with a national reputation. I’ll send you his name as well as another who is quite a bit further for you but whose fees would be considerably lower. Some dentists will give second opinions for free. But even if you pay $100 for it, that would be much more sensible rather than throwing $10,000 or more at a solution that may only last a few months, even if you don’t end up having the second dentist do the work.

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.

February 21, 2013

Sorting out LeAnn Rimes’ dental malpractice suit

I ran across a post on eonline.com that appears to be trying to poke fun at LeAnn Rimes for her dental malpractice lawsuit.

It posts this pair of photos, saying that the left one was taken before the disputed dental work, and the right one was taken after.LeAnn-Rimes

The implication is that her teeth appear to have problems “before” and look fine now. The comments get into a lot of ridicule of LeAnn, with some implying that she is just being litigious.

Here’s some added perspective, from a cosmetic dentistry expert. The “before” picture is NOT “before” any dental work was done. There is serious inflammation and swelling around her upper right central and lateral incisors revealing problems with the dental work on those teeth. The other teeth don’t have this inflammation around them, so I am confident that there is faulty dental work there.

Here is another pair of photographs. On the left is a very early photograph. The teeth seem to be smaller than in the “before” photograph above, which seems to bolster my point: LeAnn-Rimes

The “after” photograph, by the way, I believe was taken in 2010. The teeth look a little too large. And someone in my office remembers seeing her after the dental work was done and remarking to her son that the work didn’t look good and it appeared to affect her speech.

I get a lot of e-mails from patients who have been victimized by shoddy cosmetic dentistry. I can entirely believe that this happened to her.

When I am looking at photographs from dentists to possibly recommend on mynewsmile.com, I insist on photographs that show some gum tissue and that are enlarged enough to show whether or not the gums are inflamed. The presence of gum inflammation much less than what is displayed here will disqualify a dentist in my estimation and I will refuse to recommend them.

Click here to find a recommended cosmetic dentist and read some about how dentists qualify to be listed here.

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.

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.

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.

June 1, 2012

A cosmetic dentistry horror story – but there is a silver lining

Hi Dr. Hall.
I got 8 porcelain veneers and 2 crowns 2 weeks ago. I am 48 and have tetracycline stained teeth. I am very disappointed in a few ways and don’t know what to do. First thing is that they are too white. I look silly. I am Italian with dark skin and I look like I have Chiclets in my mouth. My dentist gave me an option on the color so I realize I am stuck with that problem. I will probably not smile very often now.

But the worst things are that I feel like they are loose and may come off at any time. I can’t bite down hard as it hurts in my molars. And also I can’t relax my teeth as it feels like the upper teeth are too long and my entire face aches like I am clenching and grinding my teeth. Help me with some advice please. I have had 5 kids with dental issues I always took care of. They are grown and gone and I finally was able to do my own smile. I am so sad about it.

Thank you.
Jamie from Virginia

Jamie,
This is the sort of story have heard so much over the years, and is the reason I operate this website. 98 to 99% of dentists simply don’t know how to do beautiful cosmetic dentistry. They chose the field because they like to fix things, and they think like engineers, not like artists.

You’re kind to take the responsibility for the color of your porcelain veneers. But there are about three things a dentist who is truly passionate about doing beautiful cosmetic dentistry would have done differently in your case.

First of all, he or she would have been knowledgeable enough about the results you would get to predict how you would look when your case was done, and would have coached you to a more beautiful result. You’ve never had a smile makeover before – how are you supposed to know how a particular color will look once it is in your mouth? A truly artistic cosmetic dentist would be focused on creating a beautiful smile, and would steer you in that direction.

Second, every excellent cosmetic dentist I have ever asked, and I have interviewed a number of them on this subject, has some method for making sure that you will love your new smile before it is ever bonded permanently. They will often make a set of what they call provisional veneers in acrylic that will be temporarily cemented onto your teeth so you can “test drive” the final result, to make sure that you will be happy. In addition to this, they have a try-in with the actual veneers – they will use a try-in paste to insert the porcelain veneers to let you see exactly how they will look. You will get as much time to look at this as you want – will get to see it under different lights, have a friend or family member come in to give you feedback on how it looks – whatever it takes to make sure that this will make you proud to smile before these are bonded on permanently. Most recently, I interviewed a cosmetic dentist in the Boston area that we recommend on this site. In 30 years, he has never had a patient who has not been happy with their new smile. If he ever did, he would re-do the case.

And that brings me to the third thing an excellent cosmetic dentist would do. These dentists, as I said, are passionate about creating beautiful dental work. Most of them, if they heard you say what you just wrote to me – that you won’t be smiling much any more – would be so embarrassed that they would re-do the case for free. I had this happen to me. I was a young dentist and it was the first time I had done porcelain veneers on someone with tetracycline stains. When dentists are inexperienced with tetracycline stains, they will make one of two mistakes. These tetracycline-stained teeth are so dark on the inside that the color shows through most dental materials, and the dentist will have them made too translucent so that the gray-brown shows through. This is what I did. Or, they will make the teeth too opaque and white so that they look pasty and fake. This appears to be what your dentist did. Well, with the case that I did, after I gained more training and experience and knew better how to make this type of case look beautiful, I offered to the patient to re-do them for free, because I didn’t want work that I was responsible for not looking beautiful. The patient never complained, but I could tell she wasn’t excited about how they looked, and I wanted her to be excited. I’m not unique – that’s typical of artistic dentists who love to create beautiful smiles.

So what do you do at this point? There really isn’t much remedy other than doing the porcelain veneers over. And this time you need to be very careful about the dentist you pick to do them. Pick one from our list – that’s why I have this website. I personally check every dentist I list to make sure they can do beautiful smile makeovers.

But I need to say a word about how your mouth feels now. The porcelain veneers cannot be loose – if they were loose they would immediately fall off. But what I am worried about is that your teeth are getting loose. You say that your entire face aches, like you are clenching and grinding now. And you think that the upper teeth are too long. I can’t tell this from a distance, but it certainly sounds like your bite has been thrown off. This could potentially be very serious and could lead to serious TMJ disorder or breaking of the dental work, or premature wearing down of your teeth, or periodontitis leading to early tooth loss, or even breaking of your teeth. This could actually be the silver lining of your cloud, because this could give you grounds for asking this dentist to compensate you so you can have this re-done correctly. Here’s what I would suggest. Go to a dentist on our list of recommended dentists. See what he or she thinks of what has been done – if the work has indeed thrown your bite off to where it is causing serious problems. And then see if he or she will help you get some satisfaction from this other dentist. You need someone more than just a skilled cosmetic dentist – you need someone who will be understanding and willing to stick their neck out a little to help you get what you deserve.

Good luck,
Dr. Hall

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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