Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

October 21, 2015

My new crown doesn’t feel quite right

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Dr. Hall,
I just got a new crown on an upper molar, and it does not feel like it meshes with the tooth below it. I think it needs a deeper indentation to accomodate the tooth below. Is there a risk of damaging the tooth in drilling away more of the surface of the crown? My dentist says to give it time to get used to it. It’s been two weeks and still is uncomfortable.
– Criss from New York

Criss,
I smile thinking about your dentist’s response, “Give it time to get used to it.” That’s a classic “I don’t know what to do” response. Now this could be a particularly difficult situation, or this could reveal a lack of knowledge of your dentist.

A new crown or onlay should not be noticeable when you bite or chew. It should be so perfectly comfortable that you don’t even know it’s there. But the occlusion between your upper and lower teeth is very complicated with all the various motions that are involved in chewing, and many dentists are simply not experts in that. There are post-graduate institutes dentists can attend such as the Texas Center for Occlusal Studies, the Pankey Institute, the Las Vegas Institute for Advanced Dental Studies, the Dawson Academy, and others. These institutes train dentists in the science of occlusion–how the upper and lower teeth mesh and are supposed to function together. Many dentists attend these institutes, or will attend other solitary courses where the same principles are taught. But many don’t feel that they need this training, that their basic dental school education was enough, and they go through their careers with a fairly rudimentary understanding of occlusion. Without this training, they may not be qualified to do a full-mouth reconstruction, but they can do single crowns or onlays. They may have some patients who experience what you are experiencing–the teeth don’t feel quite right, but for the most part they get by. Yes, in time, over a period of months, you will probably get used to it, and it may cause no further complications. But an occlusal problem like this can in some cases lead to unnatural stresses on the teeth which can contribute to bone loss around the affected teeth. Or in some cases it can be a precipitating factor to TMJ disorder.

Many dentists will simply adjust a new crown or onlay so that it isn’t high. They will ask you to bite on what it called bite registration paper, and that paper will leave marks where the crown or onlay hits prematurely and then will grind down those places. I’m assuming that your dentist has done that basic step and that this onlay isn’t “high”–you can clench together without discomfort–and what is wrong with your bite is more subtle.

What should you do? The best thing would be to get the tooth adjusted so that it is comfortable. No, that shouldn’t damage your new onlay. Such adjustments are fairly common with new dental work, and there should be plenty of thickness in the new onlay to accommodate any necessary adjustments. But if your dentist doesn’t know what the problem is, then I wouldn’t ask him or her to do that, as they could do more harm than good. But then going to another dentist to have this adjusted could be awkward and would involve extra fees.

Here’s what I would recommend. If you’re generally pretty happy with this dentist, then I would let this go and wait a few months to see if this tooth begins to feel like it fits better into your bite. However, I would be leery about having this dentist do another crown or onlay on one of your back teeth.

If you have other points of dissatisfaction with your dentist, this could be a way to find a dentist whom you feel will better meet your needs. Look for a dentist who has publicized his or her training at one of the institutes I mentioned above, ask for a second opinion on this onlay, and if you’re happy with what they do for you, you’ve found a new regular dentist.

– 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 14, 2013

Another full mouth reconstruction gone bad. This case could be a mess.

Dr. Hall,
I have recently gotten ALL of my teeth crowned. My old teeth were ground down to almost nothing, the front ones were paper thin and chipping daily and on the bottom left I was missing #21 and top right missing #3 and #4. I have also in the past had many unfortunate traumas to my jaw so it clicked loudly all the time when opening.

The dentist said I needed to have my bite opened in order to get my front teeth restored (all I actually wanted in the beginning was just top/bottom front teeth done) He said it would not be possible to do without doing my whole mouth. Fast forward to now, got bottom done all at once and was told that would be the hardest part for me to endure, it wasn’t it was a piece of cake compared to the pain I had for 3 weeks with the top ones. So anyway now i have had the new top ones in for 2 days and I will say they LOOK beautiful no complaints on the smile but the left side teeth touch whilst the right side has a space and my teeth do not touch at all 19-21 bridge not touching but bridge 2-5 hits fast and hard and my jaw is killing me.

He did cement them in with permanent cement and now my question to you is can he file this bridge down enough so my other side will hit and then can he polish it so my ground down rough teeth will not ruin my new crowns on bottom, or does the fixed bridge need to come out and be re-done. We have spent so much money on this and while we do have insurance it covered next to nothing and my husband is in the military and we cannot afford to have all this redone. I am really stressed out and any help you can give would be appreciated.
Thank you 🙂
– Erin from Alabama

Erin,
You have had what is called a full mouth reconstruction. This is a highly complex procedure because it re-does your entire mouth and your bite. Dental school alone doesn’t train a dentist enough to be able to perform this kind of a procedure – it requires advanced training and/or considerable experience. And there are several well-known institutes that provide this advanced training. There is the Pankey Institute in Florida, and the Dawson Center for Advanced Dental Study, also in Florida. Another is the Las Vegas Institute for Advanced Dental Studies.

But even with that advanced training, these complex procedures should proceed cautiously, especially in situations like yours where the bite is being opened. It should first be opened with temporary crowns and then the bite adjusted with the temporary crowns until you are comfortable with the new vertical dimension. When that is settled, then the permanent crowns are made to replicate the new opening.

But that isn’t all. The crowns and bridgework should be seated temporarily and adjusted to a comfortable bite BEFORE being cemented permanently. And you are a perfect illustration of why this should be done. Here you are, already with TMJ problems (you mentioned loud clicking in your jaw) and apparently over-closed. And now crowns are cemented and your bite is off. Yes, the case needs to be re-done, and the dentist who did this is responsible for that. And if you have lost trust in him, then you need to have this done somewhere else and have this dentist pay for it.

Here’s the problem. Yes, the bridge that is throwing your bite off could theoretically be ground down in your mouth to where your bite is even. But from the sounds of your description (the other side isn’t meeting at all), it would take a tremendous amount of bite adjustment, and he would likely be grinding all the way through the porcelain in some places. Plus, the whole object of the treatment was to open your bite, and now he is going in and grinding it down, so your vertical dimension is going to be off. And this amount of change in the bite is much more difficult to do correctly in the mouth than in the laboratory. The crowns should have been carefully crafted in the laboratory to provide the proper bite relationship with all the cusps, grooves, and other anatomical features precisely mapped out so that your jaw functions correctly.

Having said this, it doesn’t take much for the bridge to throw your bite off enough to be painful. Maybe the discrepancy is only a fraction of a millimeter and it just feels to you like it is a lot. In that case maybe it could be adjusted to fit. And maybe he did try it in temporarily and it fit fine, but in the final cementation something went wrong and it didn’t fully seat. But if that did happen, at least the bridge should be re-done.

I would suggest a second opinion. You want a dentist who has been trained at one of the three institutes I mentioned to help give you assurance that they know what they are talking about, and I would suggest going out of town for the second opinion, to avoid any conflicts with dentists who may be buddies or competitors, which would interfere with getting an honest second opinion.

– 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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