Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

May 29, 2018

I went directly to the dental lab to make my partial


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Dr. Hall,
I had an upper partial made by a dental lab. I did not go through a dentist.

The last partial I got, nine years ago, my dentist used this lab. They did such a good job that I decided to go directly to them this time. But this time it’s not working out so well. I have a front tooth missing that was supposed to be replaced using this partial, however, the tooth won’t stay fastened to the metal. There was so much plastic backing that all the pressure was on my one bottom front tooth. He ground down a lot to make my bite touch but now there is not way of holding this tooth in place. Also the plate is too short and is sitting in the cavity where my old tooth was and it creates a rocking motion when I chew.

I have been back at least nine times and the last time he told me to go away and stop bothering him. I asked for my money back but he refused. What can I do to get my money back?
– Bill

Bill,
A very interesting question, and there are some interesting points to make in answering you.

I must say that I’m not following you as far as understanding the problems you are having with the bite and the one tooth in this removable partial denture. The rocking I understand, and that is a fundamental problem that in most cases is due to a distorted framework—a problem that could have originated with a distorted impression. Fixing this would require starting over again. The impression is supposed to be taken by the dentist, who is trained and experienced in creating an accurate model of your teeth that will enable the technician to fabricate an accurate metal framework. Technicians aren’t trained to do this step, which is one of the reasons it is illegal for them to do that.

So the answer to how to get your money back is fairly simple—just threaten to report the technician to the authorities. This seems mean because, while it was illegal for him to make this removable partial without involving a dentist, you were the one who asked him to do it, so you should share in that responsibility. But he is the one who knows the law better and so bears the bulk of the responsibility. So just go to him and tell him that if he doesn’t refund your money you’ll tattle to the state dental board and agree to be a witness in his prosecution. My guess is that this will work magic. And hopefully that may save some other patient from making the same mistake you did.
– 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.

May 7, 2016

The technician can’t get the color right on my two front teeth


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Dr. Hall,
I’m writing you from Germany. I’m a dental patient and getting two front crowns with e.max but my technician just won’t get them in the right colour.
My stumps are not dark and my teeth have a BL3 colour.

The problem with all the crowns I tried in was that they turned out too grey.

The technician has made a couple of sets of crowns already, and has experimented with pastes. When they tried in the first set of crowns they looked too grey. He then tried a bright white fit checker underneath, and they still looked grey.

So for the second set he made them with a bright white ingot and layered over it to cover the white. When we tried them in without any paste they looked grey again. This time he had a regular try-in paste in the colour light +. So he put that underneath the crown. The crown was not grey anymore but completely opaque and lifeless and had a terrible bright white. I did not like the crowns At all. The technician said he can’t do it better. I am so unhappy and don’t want to end up with two opaque front teeth that do not match my other teeth. Do you have any idea what went wrong? Did he use the wrong ingots? Or the wrong try in paste?
I thought maybe we should use a LT Bl3 ingot and a try in paste that is less opaque.
Please, please, if you have any suggestions I would love to hear from you.

Tilo's front teeth crowns

I do have photos of both crowns which I could send to you.

Thank you so much!

Tilo from Germany

I asked for photographs, and here is what Tilo sent me. The top photo is a view from the side that shows the color discrepancy.

And the bottom photo is a view from the front, with lips relaxed, that to me was even more revealing because it shows that the shape is all wrong:

Tilos-front-teeth-crowns-2

And here is what I wrote back to Tilo:

Tilo,
Let’s see if I can help you.

After seeing the photographs, I do think the problem is fundamental, that the dental lab technician isn’t very good with color. And more than that, the technician isn’t very good with aesthetics in general.

But I suspect it is even more than that. Your dentist is the one who selected this technician. Dentists who are accustomed to doing aesthetic work and who do it well will always choose a dental technician who can produce a high level of aesthetics.
Here is how I see your situation. This dentist and the technician I imagine have maybe done many crowns together, including crowns on front teeth. In their mind they have turned out fine. The patients maybe weren’t thrilled with the results, but they were willing to accept them. Now you come along and for you, the work simply isn’t good enough. They have been back and forth trying different colors, and it’s not good enough for you. If I am sizing up this situation correctly, you are becoming annoying to them. They think you should just accept what they have done–it’s good enough and you’re too demanding.

On the other hand, a dentist who does high quality aesthetic work would not put up with this level of work from his or her lab technician. It sounds to me that in this group of three–the dentist, the technician, and the patient–that you’re the lone voice thinking this isn’t good enough.

This Work Isn’t Good Enough

But you’re not completely alone, because I agree with you. The crowns simply aren’t good enough. But you may have to do more than get your dentist to pick another technician. Your dentist may not even know any technicians who are artistic enough for this case. I don’t know how things work in Germany, but I would brace yourself for maybe needing to find another dentist to finish this for you. I wouldn’t switch dentists immediately, but would ask your dentist if he knows how to find a technician with better aesthetic skills.

Having said that, let me get to the crowns. The problem isn’t just the shade and the grayness. The shape is a problem, too. They are too bulky and round-looking near the necks of the teeth. In the middle photograph of the second group where you have your lips relaxed, the crowns look awful! They are very prominent and make you look like a chipmunk!

Then, as you have written, there is a problem with the color. But it isn’t just the shade that is picked–the color is flat. The color of the crowns looks fairly uniform from the gumline to the biting edge. This is not how teeth look naturally. These crowns have kind of a uniform grayish tinge. If you look at your natural lateral incisors, you’ll see that they are kind of a very light creamy color near the gumline, with a very slight reddish-brown tinge. Toward the middle of the tooth they are lighter, with more white. Then, near the biting edge, they are fairly translucent with a more opaque halo at the very edge. So you see, it’s more involved than a simple color selection. Though I suspect that to your dentist and the lab technician, it’s a simple matter of selecting a shade. What I did when I was doing crowns on front teeth is that I would draw a large color map of the tooth and I would diagram the different color areas. I would have a basic background color that I would ask for, one that I would select from the standard shade guide, and then I had different tint tabs that I would use as a reference and explain to the technician where I wanted these color accents and variations. You are getting nothing like this from your team.

Maybe the best thing I can do for you is to encourage you to stick to your demands. Don’t let them cement these crowns permanently, but insist that they match and look natural in your mouth. There are dentists and technicians who can do this level of work.

– Dr. Hall

Do you have a comment? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 14, 2015

This “expert” cosmetic dentist got it wrong, too

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Hi Dr. Hall,
I had my veneers redone twice already within 3 months. The first time was done in May by an inexperienced dentist and the veneers were very thick and bulky. I didn’t like them and went to a very well known cosmetic dentist to have them redone; this was in August. After redoing the veneers twice and paying 18k the second time, I’m still not happy with the result. The veneers are dull, dark, very opaque and have no texture. I want to redo these veneers. My question is: Is it safe for my teeth if I redo my veneers for the third time? I hate my veneers but at the same time, I don’t want to end up having a root canal or not have any enamel left.
–Anna from California

I asked for more detail, and Anna sent photographs of the work, plus this narrative:

Dr. Hall,
Having gone through this process twice, (the first time with a general dentist) I can honestly say that this cosmetic dentist is very skillful, meticulous and really good at what he does. His mock up for the temporary was beautiful and I was very impressed. I think the problem here is the lab or lab technician. I loved the temporary and expected the final result to be like the temporary or even better, but it wasn’t.

veneers-temporary

Anna’s temporary veneers

When I tried on the veneers, right away I saw the dullness, the opacity and the lack of texture. The color was also a few shades darker than the color I picked for the temporaries. I told the dentist I didn’t like them. He said he had to make some adjustments to the veneers so the surface looks dull, but the dullness will go away when he polishes them at the very end. Opacity: he said he could send them back to the lab to make them more translucent but it won’t look nice. Lastly, he said if I wanted to know whether remaking the veneers will be nicer than this, the answer is, no. So he left me no option and I caved to have the veneers cemented that day.

veneers-porcelain

Anna’s permanent veneers

My veneers are shiny, but lack the gloss and texture so therefore they look dull. And in close examination, I see a lot of tiny scratch marks/abrasions. I called the dentist the following day to let him know I wasn’t happy. My follow up appointment is in two weeks to see what we could do.

It’s disappointing that I paid a lot for these veneers but I feel like the quality is below average. This is the reason why I want them redone, but I don’t know if it’s worth it putting my teeth through the trauma for the third time. I’ve attached pictures of my temporary and my cemented veneers.

–Anna from California

Anna,
Thanks for that detail and the photos. That’s very helpful.

First, for the question you asked. No, there is no significant risk to your teeth for re-doing the porcelain veneers another time. In the first place, the preparation for porcelain veneers should be shallow, so there is little irritation to the teeth. When the teeth are prepared for veneers the first time, you do get some irritation to the teeth, but then they recover from that. And in the process of bonding the veneers, the bonding resin seals off the microscopic tubules in the teeth so that the second time, when the first set of veneers were ground off, there is less irritation. That irritation comes mostly from those tubules being opened up by the enamel being ground down, so sealing them off reduces that. The same thing for the third time. I am aware that some dentists will say that re-doing veneers is risky for the teeth, but they say that because they’re trying to talk the patient out of re-doing them–they want them to be quiet and just go away.

But then there is the question you didn’t ask, which is how are you going to make sure you get it right this time? Let me back up a little and explain what went wrong with your second set of porcelain veneers. To do that, I’m going to give you a little insight into how I screen the dentists I recommend on mynewsmile.com.

The first hurdle they need to cross to get recommended by me is that their work needs to pass inspection. I need to see good quality close-up photographs of their work. Knowing what to look for, I can judge whether they know what they are doing or not.

But it’s the second part where it gets interesting. If their work passes my inspection, then I need to interview them on the phone. The most important thing I ask them is about how they insure that a patient will love the new smile they create–your question. How do they avoid your situation, where they do a smile makeover and the patient isn’t happy? They will tell me some type of procedure they go through. Many of them have a procedure like you experienced–the dentist will talk to the patient, determine their smile design preferences, and from that create a wax model of their smile. From that wax model they will make a set of temporary veneers that the patient will wear to make sure they like the design and the color. Then they will have the laboratory technician make the permanent veneers to the same specifications. They can take an impression from which they make a model of the veneers to send to the lab, and they can also take a photograph to send.

But then comes the interesting part. I pose a hypothetical situation to them, and this is how I put it: “Say you go through all this, and then I assume you have some type of try-in of the veneers that come back from the laboratory. So you try them in, and you ask the patient how they like the veneers, and the patient says, ‘Oh, I guess they’re okay.'”

In order to qualify for me to recommend this cosmetic dentist, they need to pick up on this lukewarm response immediately and be highly disappointed that the patient isn’t more enthusiastic about how they look. And they have to be willing to send them back to the laboratory technician to be completely re-made, if necessary, and refuse to bond them on to the patient unless the patient is not just satisfied, but excited about how they look.

This clearly didn’t happen in your case. The dentist, rather than addressing your concern about the color and the luster of the veneers, he pushed you into having them bonded on and told you that the dullness would go away later. Wrong response. And the dullness didn’t go away, did it? He would have flunked my interview with a response like that. All the great cosmetic dentists I know would have stopped right there and sent them back to the lab to be remade so that they had more sparkle, more lifelike translucency, and a brighter color. All those things are do-able.

The other glaring error here is that the permanent veneers were not made to the color you and this cosmetic dentist had agreed upon with the temporary veneers. This is way off. I think you have grounds here for a legal complaint, because the end result was misrepresented. I agree with you that the final veneers look too dull and the color is off from what the temporaries were.

So what should you do?

In looking over this dentist’s work as displayed in photographs on his website, I believe he is capable of beautiful work. So I would recommend as a first step trying to assert your rights and telling him you need this re-done. This is not fixable by polishing or trimming–your case needs to be re-done. You may show him my email, if you think that will help.

If that doesn’t work, get back to me, and I’ll see if I can line you up with a cosmetic dentist who is not only a good artist, but actually listens to his or her patients. They may be able to help you put pressure on this dentist to give you a refund.

And about this being the lab’s fault–it’s the dentist who gives the instructions to the lab, and the dentist who has to take responsibility for the final result. It was your dentist who decided to not send these back to the lab and demand better work. So you can’t blame this on the lab.

I hope this is helpful.

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.

November 29, 2013

Agonizing over the choice of a dentist – part 2

Last week, I began a series of posts from a patient I call D, titled Agonizing over the choice of a dentist. Click the preceding link for the first e-mail in the installment.

Here is the reply I got from D, and my reply to that:

Hi Dr Hall,
Thank you for your quick reply. This helps because I am scheduled to see Dr. Willardsen on Friday and I will try to see Dr Latner first. I live very close to his office. I am only going to Willardsen because Vincent Devaud recommends him. I am definitely using Vincent for the lab work. He is definitely a step above others I have used. It isn’t cheap ($3200 a tooth!) but I have seen Vincent’s work and it’s amazing. Isn’t most of the artistry from the lab? The dentist just does the work?

Thanks for your time! I went and sent in a “like” on Facebook! Happy to do it!
– D

Dear D,
As far as picking the lab and then asking the dentist to work with that lab, if I were the patient I would never do that. A great cosmetic dentist definitely needs to be supported by a great ceramist, but it’s a team effort, a joint project, and it’s the dentist who supervises and instructs the ceramist and who drives the success of the case. I might make it as a suggestion to the dentist, but leave it up to the dentist whether they wanted to do that or not. It’s a teamwork and there is synergy there, and asking the dentist to work with a ceramist when they have never worked together before, there could be some rough spots. No matter how good the ceramist is, the case will not be beautiful without a great cosmetic dentist.

And I agree that Vincent Devaud’s work is beautiful but it isn’t without equal. Daniel Materdomini is at least as good, maybe better. And the ceramist I used was also from the LA area – Uri Yaroveski, who is also one of the best in the world. And there are other great ones.

Take your case for an illustration. Dr. Willardsen wants to do six teeth when you probably should do either two or eight. That’s a decision the dentist makes and the ceramist has nothing to do with, but it will fundamentally alter the beauty of the case.
– Dr. Hall

Read the next installment: Agonizing over the choice of a dentist, part 3.
And: Agonizing over the choice of a dentist, part 4.
Finally, my reflections on Why some people agonize over the choice of a 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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