Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

March 7, 2019

All ceramic vs porcelain-fused-to-gold crowns


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Dr. Hall
I am having crowns replaced over tooth number 4 & 5. There is, as I believe, no cosmetic value of using pure porcelain versus Crown Porcelain fused to High Noble. There is a significant extra cost of $200.00 per each pure porcelain. In general, would a pure porcelain fused to a High Noble versus pure porcelain be just as effective over the long term?
– Garry from California

Garry,
First, I like to talk about terminology so we know exactly what we are talking about. We should be saying all-ceramic crowns, not all-porcelain. Porcelain is only one of various ceramics that have been used for crowns and even some dentists gloss over this terminology. Few dentists are placing all-porcelain crowns on back teeth these days because they are very technique sensitive and are much weaker than the newer high-strength ceramics, lithium disilicate and zirconia. The eMax crown, which I believe is the most popular crown being used by dentists today, features a lithium disilicate core with porcelain baked over it. Lithium disilicate has reasonable aesthetics—it is white and somewhat translucent—but it comes in blocks and is shaped by milling, so the technician doesn’t have the ability to manipulate the color the way porcelain color is manipulated. Porcelain comes in a paste and it is placed, shaped, and then baked. So the ceramist can apply various colors and translucencies of the paste in different layers over the lithium disilicate core with a great deal of control over the aesthetics.

My guess would be that your dentist is talking about putting all-ceramic crowns on your teeth numbers 4 and 5, which are the first and second premolars on your upper right. So your question is, should you get porcelain fused to high noble (otherwise called porcelain fused to gold) instead.

Cosmetic dentists consider upper first premolars to be in the smile zone on almost all patients. Practically everyone will show that first premolar prominently when they smile. It may not be prominent when you look at yourself straight on in the mirror, but it is very noticeable from the side. For me, I would not want a crown made of porcelain fused to gold or any other metal here because there will be a significant risk of a dark line showing at the gumline. The dark line comes from the metal foundation showing through right at the margin of the crown.

Behind that first premolar, in my smile, the teeth are all in the shadows, so the aesthetics is much less critical there. In my mouth, I do have a porcelain fused to gold crown on one of those teeth. I also have a crown on my upper left first premolar, and that crown is an eMax.

So my answer is that I disagree that there is no cosmetic value here. Having said that, if you were my patient and wanted the porcelain fused to gold crown on your first premolar, I wouldn’t fight you on that. But then I probably wouldn’t have the issue come up because I would charge the same fee for either crown. A porcelain fused to high noble crown is a premium crown, and I charged more for that than for a porcelain fused to noble (semi-precious metal) crown. But I don’t understand why the all-ceramic crown needs to be more than the porcelain fused to high noble.

– 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 11, 2013

Porcelain fused to metal crowns are ugly on front teeth. Why would a dentist do this?

Dr. Hall,
I had 4-front teeth crowned with porcelain over metal. I am VERY upset because I was not informed about the dark line that I now see?? I did go to dentist today & he is replacing 1-tooth w/ dark line, but after just a month of having these crowns, I noticed on the back of THIS PARTICULAR TOOTH a spot of METAL appeared. I think that is why he is replacing it. Is this a rare problem?? I wish that I had known my options!!?? How much does a crown w/ porcelain over metal cost?? I am in a small town near Tampa! I paid about $989 per crown; is that too much?
– Shirley from Tampa

Shirley,
Back in the early 1980s, putting porcelain fused to metal crowns on front teeth was a good idea. But not in 2013. There are now porcelain bonding techniques where porcelain can be bonded directly to the tooth instead of having to be bonded to a metal framework to give it strength. And there are new high-strength ceramics. So there is no longer any need for the metal foundation. All-ceramic crowns are plenty strong enough to serve just fine on front teeth.

In my opinion, a dentist who is serious about the appearance of his or her dental work wouldn’t even dream of putting a porcelain fused to metal crown on a front tooth. Not only does the metal make the crown look opaque, but you will have that awful dark line at the gumline. And if the dentist is successful in hiding that under the gum for now, in a few years the gums will often recede a little and the dark line will become visible.

So what you have is a dentist who doesn’t really care that much about how your smile looks. If you do, then you have a basic disconnect with this office. Now I want to be careful here, because many of these dentists who aren’t very concerned about the appearance of their work are excellent dentists. They are very engineering oriented and careful and thorough. They’re just not artistic. And this is the case with about 98% of dentists, maybe more – they simply aren’t artistically inclined at all.

So then what do you do about the four crowns you have? And my guess is that the dark line isn’t the only appearance-related problem with this work. They will have to be kind of opaque. I doubt they sparkle like natural teeth. And the shapes may not be natural. But replacing them with work from a truly artistic dentist will cost you another $1000 per tooth, and your insurance won’t cover that probably for another five years at least. But that is the only remedy. So when you’re ready to have them replaced, find an expert cosmetic dentist from our list and have this done right.

About the fee you paid – $989 is a typical fee for a crown. (Click here to read about costs of porcelain crowns.) The sad thing is that for that fee, or maybe just a little more, you could have had a beautiful all-ceramic crown that would have enhanced your smile rather than detracting from it. And about the metal on the back – remember that this is a porcelain fused to metal crown. They will often have a metal back. The metal back is actually gentler on the opposing teeth that chew against these teeth than the porcelain would be, and it shouldn’t be visible from the front. If you just have a spot of metal showing, then you probably had a thin layer of porcelain there over the metal. That shouldn’t cause any problem.

– 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 18, 2010

Allergic to the Metal in her Crowns

This is a follow-up e-mail from Carolyn in New Jersey. She asked about the types of metals that are used in porcelain-fused-to-metal crowns.

Dr. Hall,
Thank you very much for your informative answer.

At this point, my last concern is aesthetics. I seem to be reacting to a metal in my porcelain-fused-to-metal crowns. (Tongue inflammation where the tongue touches the metal parts of my crowns, inflammation in the skin on the lips and around the mouth, and general facial inflammation).

I saw the metal shell underneath each of these porcelain crowns just before they were placed in my mouth. I hadn’t been informed, first, that such a metal shell could or would exist under the porcelain, so there was no time to halt the procedure in order to seriously question the makeup of that shell. It was rough, grainy, and very dull silver-colored. I suppose this is the “black” that is now appearing near the gums. I’m guessing this would have to be a “base” metal. It certainly wasn’t “shiny.” More like the lowest grade of industrial steel.

In addition, I’d asked for a gold surface on top of some of the the porcelain crowns. I had no metal in my mouth prior to this and my goal was to have only gold, if any metal at all. I have a TMJ problem so a forgiving metal was needed on some surfaces.

Understanding completely that there is no “pure gold” for the mouth and that all gold comes as an alloy, I still cannot believe that these surfaces on top of the porcelain crowns are actually gold. They are quite dark silver now, “hot” to my tongue, they burn my tongue, and now the tongue is swollen in those places. I do have an all-gold crown, in the back of my mouth, to compare these dark silver metal surfaces to. The all-gold crown looks, feels, and acts like gold. It’s beautiful and feels good. These “gold” surfaces on top of the porcelain-fused-to-metal crowns, however, look and feel so dark and so hot. I’m suspecting an electrogalvanic reaction between the upper metallic surfaces and the baser metals at the gumline.

I’d questioned the gold content of these upper surfaces (because they looked silver) and received the answer that the colors can be different due to the fact that the gold comes as an alloy. But “this degree of different” is really strange. If my white gold ring began to look this way, I’d take it back to the jeweler for a refund.

So I’m trying to gather intelligent background information, independently, on what I might have received in my mouth that is causing my mouth and tongue to burn, and my facial/lip skin to become so inflamed with scaly red patches around the mouth. I realize that no one but my dentist can give me the chemical composition for sure. I just wanted to have a ballpark idea of what might be happening to me before I approached him on this.

In general terms in the profession: Is it possible for a patient who has paid in full for such crowns to go back, a mere two or three years later, and receive from the lab the exact metallic composition of each crown that they produced for me?

Any further information on any of these points would be greatly appreciated. I understand completely that only my dentist can give me the “bottom line” on my own case. I’m just looking for accurate ballpark info so that I do not permit myself to be led astray.

Does the black at the gumline, therefore, give evidence of a “base metal” having been used for the metal shell under the porcelain crown?

Thank you.
Carolyn

Carolyn,
No, the black line at the gumline doesn’t give any clue as to what metal you have in the crowns, nor does the rough appearance of the metal on the inside of the crown (it is left rough to be more retentive – a shiny surface would slip off the tooth more easily). But your sensitivity gives a strong clue. I would give at least 95% odds, based on your reactions, that nickel was used in your crown, as that is the metal that usually provokes this kind of reaction. That is one of the base metals.

And to answer your previous question, yes, the dentist should retain documentation of what alloy was used and its composition. The dental laboratory is required to send to the dentist what is called an identalloy certificate that lists the composition of the alloy that was used, and the dentist is required to retain this. The dentist bears responsibility for insuring that you don’t have this kind of reaction. Do you have any history of metal allergies, such as a reaction to any metals in earrings? We always asked whether people had any reaction to metals, and flagged the charts of those patients who had metal sensitivities, so I would know when to avoid base metals. Although we got to where we simply didn’t use them on anybody because of the risks involved, except for Medicaid patients, where the government specified that they wanted us to use base metals, because they were cheaper. If your dentist didn’t ask you this, then he or she is responsible for this and should make it right with you.
Dr. Hall

Dr. Hall,
Again, thanks so much. I very much appreciate your insight and your time.

The one overwhelming thing known about me by the dentist and his staff is my multiple chemical sensitivity. That reality looms larger than my name, at this point. I have been my dentist’s “chemical education,” with all the difficulties and humorous moments that implies.

Although mercury made me miserable (all those teeth fell apart and the mercury was incidentally removed before these metal-shelled crowns were installed) I never had a nickel allergy to report! I supposed now I will.

Carolyn

Links: Click here to ask Dr. Hall a question.

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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 30, 2010

What metals are in porcelain fused to metal crowns?

Dr. Hall,
I have 6 porcelain-fused-to-metal crowns. I have two questions:

1) What are the usual metals contained in the metal shell?

2) Is the metal shell the thing that begins to show at the gumline, causing the black lines? (I have those black lines.)

Thank you for your information.
– Carolyn from New Jersey

Carolyn,
There are two basic types of metals that are used in porcelain-fused-to-metal crowns – precious or noble metals and base metals. Noble metals used are gold, platinum, and palladium. Base metals would be chromium and nickel. Dentists will classify these crowns as porcelain fused to high noble, porcelain fused to noble, or porcelain fused to base metal.

The noble metals have less tendency to corrode, provoke less sensitivity, and are made to a more accurate fit.

The metal can show at the gumline, and this is what causes the dark, sometimes it’s even black, line at the gumline. Dentists may try to hide this under the gum, but after several years, sometimes the gum recedes and this line is visible anyway. The dentist may ask the dental lab to cut back the metal at this front part of the gumline and leave this margin all in porcelain. This is called a porcelain butt margin. The dentist will pay an extra fee for this – about $30 to $40, and they generally pass this on to the patient. While this makes this line more subdued, it will usually still be present. The reason is that there is still a lot of opaquer that has to be used in the crown to mask the metal. The contrast between the opaque crown and the natural tooth structure makes it difficult to blend colors here, and creates the effect of the dark line.

Patients generally prefer the all-porcelain crowns, which will eliminate any dark line. And the general natural translucency of the crown without any metal is much more natural-looking. But be careful. I would never ask a dentist who is more comfortable doing a porcelain-fused-to metal crown to do an all-porcelain crown. Dentists who are good at all-porcelain crowns will far prefer them for front teeth. If your dentist suggests a porcelain fused to metal crown for a front tooth and you are concerned about the esthetics so that you want all-porcelain, take that as a signal that you are in the wrong practice. This dentist places a low priority on esthetics and if you try to nudge them out of their comfort zone, the results could be disastrous.
Dr. Hall

Follow-up – in a subsequent e-mail exchange, it came out that Carolyn is probably allergic to the metal in her porcelain fused to metal crowns. Read the posting on dental metal allergy.

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 7, 2010

Porcelain Butt Margin explained

Dr. Hall,
I recently have had five porcelain fused metal crowns placed in my mouth. Each time, I have paid an extra $264.00 to my dentist for “extra covering” to keep any black from showing at the gum line. Unfortunately, the black shows on almost all of them, either on the inside or the oustside. Is this normal? Thanks in advance!
– Mary from California

Mary,

I’m guessing that what you are paying extra for is what is called a “porcelain butt margin.” It sounds like the dentist is doing an old-fashioned porcelain fused to metal crown, but is having the porcelain technician cut back the metal near the base of the crown on the front so that it isn’t so conspicuous, leaving it so the margin is all in porcelain.

The effect of this is to make the black line at the gumline that is typical with porcelain fused to metal crowns, to make that more subdued. It may be more gray than black, but it is still a darker area.

I’m surprised at the extra $264 fee for this. The dental laboratory will charge the dentist about $35 extra for this service, and there is no extra cost or labor for the dentist, so it appears that your dentist is getting quite a bit of profit margin on this “upgrade.”

The best thing is to have an all-porcelain crown. When pure porcelain is bonded onto the tooth, it can be made in such a way that the entire result looks absolutely natural and beautiful. But a lot of dentists haven’t learned anything other than what they were taught in dental school, and there they were taught to do porcelain-fused-to-metal crowns. And another problem is that the dentist feels that this looks good enough and that you’re being too fussy if you think this is a problem.

This is at the heart of why I do this website – to help people find dentists who are passionate about the appearance of their work and who know how to create beautiful dentistry. Tell your friends so they don’t make this same mistake and go to the wrong dentist, if they need work done on their front teeth that they want to look beautiful and natural.

Dr. Hall

other links:
Read about cosmetic dentistry costs.
Click here to find an expert cosmetic dentist.

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 31, 2007

Why is porcelain fused to metal used on molars?

Dr. Hall,
What could be the possible reasons for having a dentin-bonded all-porcelain crown on a central incisor and a porcelain fused to metal crown on the first molar? Also what would be the differences between the two different kinds of materials?

Thank you and much appreciated.
– Ranje from Alabama

Dear Ranje,
There are two reasons for using the all-porcelain crown on an incisor and porcelain fused to metal on a molar:

1. Porcelain fused to metal crowns are stronger than pure porcelain. Pure porcelain is plenty strong enough to serve on an incisor. They are usually strong enough to serve on a first molar, but there could be a risk of cracking of the crown on a first molar, and that’s why even some true cosmetic dentists will use porcelain fused to metal on molars.

2. And back on a first molar, it is very difficult for others to tell the difference between a porcelain fused to metal crown and an all-porcelain crown. All-porcelain has a lifelike translucency, where porcelain fused to metal is opaque and develops a dark line at the gumline. Unless you have a really wide smile, people simply aren’t going to see that on your first molar. In my practice, I never used porcelain fused to metal crowns on front teeth–they’re just ugly, especially after you’re used to the beauty of all porcelain crowns. Patients, after being told the difference, were always willing to pay a premium, beyond their insurance coverage, for the lifelike all-porcelain crown on a front tooth.

But we need a warning here. Do not ask your dentist to do an all-porcelain crown for you on a front tooth if he or she hasn’t brought it up. These crowns require special expertise. If your dentist knew how to do them well, he or she would not want to do any other type of crown for you. Take their failure to mention this option as evidence that they’re uncomfortable with the clinical requirements of the more beautiful crown, and if it’s important enough to you that this is what you want, find a true cosmetic dentist to do this right. The all-porcelain crown will break if it’s not bonded on properly. And your dentist is very unlikely to confess, when pressed, that he or she isn’t familiar with the bonding techniques–they simply won’t let on that this is an issue.

– 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.

October 10, 2007

What are the best materials for implants and crowns?

Hello,
I am planning on getting alot of cosmetic work done to my teeth. I need around 10 implants on the top front of my mouth.

1. I wanted to know what you think of Astra implants from the UK?

2. I would like to know what you thought about Cercon smart ceramic zirconium crowns? I think I read on your site that zirconium is not as aesthetic as all porcelain crowns, but isn’t zirconium clear? They say that these particular crowns are as tough as porcelain fused to metal crowns, do you have a comment on them?

3. I had one dentist tell me that white colored metal fused to porcelain, or gold fused to porcelain, will not show a black line, Is this true?

4. are zirconium abutments for my implants, more aesthetic pleasing then all white abutments?

Thank you for answering my questions. It’s hard to get real answers on the topic of cosmetic dentistry.
– Edward from Connecticut

Edward,
I’m going to answer your question differently from what you’re expecting. I think your focus is wrong. You’re focusing on the materials. You should be focusing on the artist.

You start off saying you want cosmetic work on your teeth. Does that mean you want a beautiful smile? If so, then I believe you’re headed for trouble. Because you’re trying to decide yourself what are the best materials, as if you are planning to micro-manage your cosmetic dentist.

Imagine with me that as part of your employment you are asked to commission a painting to grace the hallway that leads into your corporate offices. And then you busy your time finding out what brand of paints and brushes will produce the best results, and the light you want your artist to use, the stool for her to sit on, and everything else. You will be stifling your artist. What you want to do is find the best artist, and one maybe that you feel a “connection” with, who feels motivated to please you, and then turn her loose on your project, and then YOU get the ARTIST the materials she feels she needs to produce the results you want. Creativity needs an atmosphere of trust and needs freedom in which to operate, if you’re going to get a beautiful result. Your dentist artist also needs to have a strong rapport with you in order to feel motivated to create a beautiful smile that you love. If you go forward with this micromanaging philosophy, your dentist is going to want to kick you out the door and won’t care WHAT you think, in the end.

Additionally, there is no way that you can learn enough about dentistry in the time frame you have to make an intelligent decision on these materials. There are pros and cons of each of the materials, and they depend on the mechanics and the demands of your case. You need a deep background in dentistry to be able to evaluate the claims of the manufacturers of these different materials and devices as well as the independent research. And even then, you won’t really know how they work until you try them. There are many stories of dentists using new materials where the research made them look like fabulous materials, but in clinical use there was a completely unexpected issue that arose that created a disaster.

And, if that weren’t enough, there is the issue of what material works best in your dentist’s hands. Most dental materials and techniques have a learning curve, and they work best when the dentist is fully familiar with the technique and the quirks of the material. You push your dentist to use a material she isn’t familiar with, and you’re asking for trouble.

Having said that, there is one of your specific questions that I’d like to answer, and that is about porcelain fused to metal. No, it isn’t true that porcelain fused to gold or to a white metal won’t show a black line at the gumline. I don’t understand what this dentist has told you, if he’s saying that only metals that aren’t white or gold show the line. Every metal we use in crowns is either white in color or gold. The line may not be black – it may be gray – but it will show if it is above the gumline. That’s because the line is the cement line. I often did porcelain fused to gold alloy restorations, or fused to platinum alloy, and they would show that line. Even fused to pure gold. It’s the bonding technique that eliminates the line, and the bonding technique is used with pure ceramic. There are techniques that MINIMIZE the dark line, such as cutting the metal back at the margin, giving you what is called a porcelain butt margin, but they won’t eliminate it.

And zirconium is white, not clear. It’s zirconium oxide, actually, and it is opaque white. But used properly it can produce very esthetic results, if it is covered with a more translucent ceramic. And yes, it is very tough.
– Dr. Hall

Helpful pages from www.mynewsmile.com:
Porcelain fused to metal crowns
Various types of all-ceramic or all-porcelain crowns
Dental implants
The difference between a cosmetic dentist, who is an artist, and a general dentist
More blog postings on finding a cosmetic dentist you can trust and developing a good working relationship with that cosmetic 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.

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