Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

January 24, 2019

My dentist wants to do crowns for my tetracycline stains


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Dr Hall,

I have severe tetracycline staining on all my teeth. As I’m getting older, it’s starting to bother me more and I really would like to improve my smile. I’m 48 and have very healthy teeth. I’ve only had 2 cavities so far. I’d like to explore porcelain veneers, but every dentist I go to wants to give me a full mouth of crowns. What can I do?

Your help is much appreciated!
– Gregory from Seattle

Gregory,
Severe tetracycline staining is definitely one of the most challenging aesthetic problems a dentist will face. It is caused by taking the antibiotic tetracycline before the age of 12 which is when the permanent teeth are forming. A gray-brown color becomes embedded deeply in the teeth and, when the staining is severe as it is in your case, that color is very dark.

There are a couple of problems with trying to cover this stain with porcelain veneers. One is that to make the porcelain look lifelike it needs to be somewhat translucent. A translucent porcelain veneer, however, will allow the dark underlying color to show through. Click the link for an example of a case that was brought to my attention. Or, the dentist and/or the laboratory technician, in an attempt to prevent that, will use too much opaquer, leaving the veneers looking chalky and fake. Another is that dentists who aren’t experienced in treating tetracycline stains will cover the fronts of the teeth only, leaving dark shadows showing through on the edges.

This is why you truly need an expert cosmetic dentist for this. With dentists who aren’t passionate about cosmetic dentistry, their weakest skill is often color manipulation. So I wouldn’t go to any dentist to treat your tetracycline stains unless they can show you before-and-after photographs of a successful tetracycline case that they have treated. Or, if the dentist is AACD accredited, you can be pretty confident that they have the skills needed to do this right and give you a beautiful smile. If you have any doubts about the dentist, insist that you get a clear view of the case with a try-in before the veneers are bonded. Make sure that you see with your own eyes that he or she has successfully given you a beautiful smile that you are proud to display before they are permanently affixed to your teeth. Don’t accept any excuses like, “Oh, once they are bonded on they will look better.” I also have confidence in all the dentists I list on this site.

There are properties of some porcelains where they scatter light in a way that creates a perception of translucency while they are blocking out underlying color. These opalescent porcelains are used by some of the more sophisticated dental laboratories teaming up with expert cosmetic dentists. But don’t expect 98% of dentists to know about this.

The way that your everyday family dentist may get around all these difficulties is to grind your front teeth down to stubs and put crowns on them. You clearly don’t want that, and I would never want to do that to a patient when there is a much more conservative solution. And, in some cases, even the crowns won’t fully block out the very dark underlying color.

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.

August 17, 2016

Why you shouldn’t ask your family dentist to do porcelain veneers


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Dr. Hall,
2 days ago, I had a porcelain veneer placed on one of my upper 2 front teeth because it was chipped. I had bonding on this tooth before, but that fell off. This new dentist said bonding was out of the question because 1/5 of the tooth was chipped, and she recommended a crown. But I told her that I would like to do a veneer as it is less invasive than a crown.

Just before the veneer was placed, I had a chance to look at it on my tooth. It looked nice. It was lighter than my other tooth–I picked a few shades whiter anticipating bleaching my teeth afterwards. The shape looked perfect, so I signed the consent.

Once it was glued on, I had no chance to view it. The dentist and the assistant told me it looked great.

Once in the car, I looked in the mirror, and was in shock. The length of the tooth is a millimeter over to the next tooth and it looks like it is now placed a little forward. It looks like she put too much glue and that overall, the tooth looks protruded. On the back side of the tooth (closer to the tip of the tooth), I can feel a gap between the placed veneer and the back of my original tooth. When I bit in my sandwich I can feel the length difference of my teeth.

I called the dentist today and explained the issues. The assistant said the gap in the back of the tooth may be fixed but nothing could be done regarding the length. She even said it’s probably because the tooth moved. I told her I noticed right after the procedure when I got back to my car.

I have the feeling that I may need a second opinion. I made an appointment with the dentist, but I’m afraid to go.
I don’t know what to do, where to start. Any advice would be much appreciated.
Thank you so much in advance.
– Jennifer from Virginia

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Jennifer,
Unfortunately, I hear about this type of situation a lot.

Most dentists have an engineering mindset, and their appreciation of esthetics in a smile is very rudimentary. This is why they don’t take the time and trouble to learn proper techniques for doing esthetic procedures.

Let me tell you how I’m reading this situation. Admittedly, I’m making some assumptions, and I could be way off base as far as this individual dentist is concerned. But this will help you understand how many dentists think and also understand better how to get this done right.

First, the dentist says that bonding is out of the question. Why? And why so dogmatic about it? There’s no discussion of the pros and cons, just “out of the question.” It worked before, so it’s clearly not “out of the question.” With 1/5 of the tooth chipped, bonding would have been my first choice for repairing the tooth, and it would be the first choice of many cosmetic dentists. My guess is that she’s not that good at bonding. This is what dentists will do to deflect requests for procedures they don’t feel comfortable with.

So she recommends a crown. You perceived this as overkill (I would agree with you), so you asked her to do a porcelain veneer. Based on what happened to you as this procedure was completed, it seems to me that this dentist has limited or no experience with porcelain veneers. But your dentist, thinking that the artistic part is going to be done by the dental lab and not wanting to push you too hard, agrees to do the porcelain veneer, even though she doesn’t feel completely comfortable with that procedure either.

So the veneer is done and tried on. You said the shape, length, and thickness were fine when the veneer was tried on. You got a good look at it, which is appropriate. So far, so good. But then when the veneer was bonded on, this is where it gets odd. The instinct of the dentist would be to show you the final product. They had a mirror that they used before, why none now? That was always the last thing we did in my office whenever we did work on the front teeth–hand them a mirror so they can see the final product. Goodness, even my barber does that. But why didn’t your dentist? Because she’s embarrassed at how it turned out. They just told you it looked great. Ooooh, that part really annoys me, that they would try to tell you that.

This sounds like a case of getting the veneer positioned wrong when the bonding material was applied, and then when they got done curing it they saw that. This positioning of the restoration is something that is very different between veneers and crowns. It is very easy to seat a crown on a tooth–you just slip it on and it’s very easy to tell when it is fully seated and on correctly. With a veneer, the dentist doesn’t get that same feel for it being seated correctly and it is very easy to get the veneer seated in the wrong position.

It also bothers me that when you called with this rather serious issue (your smile has to look at least a little funny with one front tooth longer than the other) that they had the dental assistant answer your questions. And the dental assistant is not right. Of course something can be done if the veneer is too long. If it were otherwise okay, it could be trimmed. In your situation that wouldn’t be good enough–the veneer needs to be re-done. But trimming it would certainly help. And it’s ridiculous to attribute the problem to your tooth moving. Your tooth isn’t going to move like that regardless of how much time had elapsed since the veneer was bonded.

As I said, they probably just got the veneer seated wrong. That’s not a fatal mistake. That actually happened a once to me. The bigger problem to me is their reaction to it. They should have said something to you immediately. The correction, after the veneer is bonded, has to be to completely re-do the veneer. So if this had happened in my office, I would have trimmed and polished the veneer so it looked like the adjacent tooth, I would have told you what happened after showing you the result, and then made an appointment to re-do it.

Oh, and another point. If you’re going to bleach, the dentist should have bleached your teeth FIRST, then waited a couple of weeks for the bleached color to stabilize, then done the veneer. Your front teeth need to match exactly, and you can’t bleach teeth to match a certain color. The only way to get the teeth to match is to do the bleaching first. An expert cosmetic dentist would have told you that.

So, what to do from here?

First you need to get with a genuine cosmetic dentist. Go to our website, put in your city, and see what your options are. We have several near you in northern Virginia.

And of course your dentist should refund your money. It seems to me that she is embarrassed about this, and I believe she won’t put up much resistance to your request for a refund. If she does give you any trouble over that, you could file an ethical complaint with the dental society or the dental board. But my guess is that she will want to make this right for you. Be sure you get good documentation about how this looks–have the expert cosmetic dentist take photographs of the front and back of the tooth, because it should be fairly easy to show that the veneer isn’t seated fully. This is a clear error that any dentist should recognize.

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 5, 2016

On the appearance of my front teeth, my dentist just says “trust me”


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Dr. Hall,

I had my top 4 front crowns replaced and the new crowns are gray in appearance. They kind of match the rear teeth but in many conversations with the Dr. having the new crowns match the bottom teeth and whiter than the old crowns was very important. When the color was being chosen, I stated that it looked dark. The response I got was “trust me.” At the time the crowns were being installed, I again said they looked dark and the response was “they are perfect, trust me.” In the dentist’s photographs they don’t look terrible although the gray is clearly visible. In natural light I am extremely unhappy with them. So much so that I now consciously try not to smile. We met with the dentist and he again claimed that they looked great but stated that he would discuss with his peers and “make it right.” The next correspondence we received was a certified letter stating that he would not re-do the work and in his opinion they looked great. He claimed that his peers felt the same way, although without looking at anything other than pictures taken with a bright flash I question how that can be determined. What should I do?
– Glen from Massachusetts

Glen,
I love your question and the situation you relate, because it illustrates so well the mentality of much of the dental profession. It’s an authoritarian attitude that is truly foreign to excellent cosmetic dentistry. What your dentist is telling you is that, as far as the appearance of your teeth, “the dentist knows best” and “who are you to tell me how your teeth should look?”

I have interviewed a number of great cosmetic dentists who create beautiful smiles. Some of them do celebrities. I will tell you that any smart celebrity simply wouldn’t trust a dentist with the attitude being displayed by your dentist.

When I do a website for a dentist who wants to promote himself or herself as a cosmetic dentist, I will have a long interview with them. One of the key things I ask them is how they create a smile design and what they do to make sure the patient is happy with any new smile they create. Without exception, these great cosmetic dentists are focused on how the patient perceives the appearance of the work. They view themselves as treating the self-perception of the patient. In the ethics of the cosmetic dentistry world, that is the problem the dentist is treating. If the teeth don’t look great but the patient has no sense of embarrassment over it and smiles broadly with no self-consciousness, then there is no problem. On the other hand, if the patient hesitates to smile or covers his or her mouth because they’re embarrassed over the appearance of the teeth, then that needs treatment. And the measure of whether or not that treatment is successful is that the patient now feels proud to smile. “After” photographs will typically show a relaxed, confident smile. Self-consciousness is gone. If that isn’t achieved, the cosmetic dentist would consider the treatment a failure. This is the universal attitude of these great cosmetic dentists.

However, to many in the dental profession, such concern over what the patient thinks is considered pandering to the patient and unprofessional. That is why this dentist, when you raised objections over how these crowns looked, replied simply, “trust me.” You see, your opinion doesn’t matter to him. And then, rather than making it right, he went to his peers. But any true cosmetic dentist would be appalled to let you out of his or her office with a smile they had created over which you were self-conscious.

You Are in the Wrong Dental Office

What to do? Well, for starters, you are absolutely in the wrong dental office. Any efforts you make in that office to get this right are going to be futile, because, based on what you have told me, this dentist is psychologically incapable of addressing your problem. So look for another dentist. Now there are many dentists who would have enough empathy with you to at least try to get this right for you, but if you really want to get it right, so that your front teeth look completely natural, you should go to an expert cosmetic dentist. If you let me know what city you are in, I could maybe find one for you close to you.

In my opinion, you should be able to get compensation from this first dentist to pay for re-doing the crowns, but I believe you are going to need to brace yourself to get tough with him. The first step is to find the dentist who will go to bat for you–you’re not going to get anywhere without a dentist who agrees with you. Then you would ask this new dentist to try to work with the first dentist to talk him into refunding your money. If that doesn’t work, you could go to a lawyer.

Informed Consent

Your dentist isn’t innocent here, in my opinion, and it seems that he senses that–hence the certified letter. However, he is bracing to defend himself on the wrong principle. The first principle of medical or dental malpractice is informed consent. If I have your story right, your dentist put these crowns in your mouth over your objections. That isn’t informed consent–it isn’t consent at all. That principle of informed consent is your leverage here and your case is analogous to the very first informed consent case that I was taught about in dental school.
informed consentMany years ago, there was a patient in Great Britain who had broken his leg and it had healed improperly. He went to a doctor for help. The doctor studied his case and consulted with his colleagues. They all agreed that the leg needed to be re-broken to heal properly, so they went to the patient and whacked his leg and re-broke it. The patient sued, because he wasn’t told what they were going to do and hadn’t consented. The doctors argued that it was their unanimous professional opinion that this was the treatment he needed. The court, however, ruled in favor of the patient, saying that regardless of how right they felt the treatment was, they needed to obtain the patient’s consent before proceeding.

This dentist of yours may argue that you nodded or gave him some signal that you would let him put these crowns in. But in my opinion, a strong-armed consent isn’t consent, and I think the dentist should be held liable, even if you did allow him to proceed.

This is the point you and your new dentist need to make to the first dentist, and hopefully he will be persuaded that what he did needs to be remedied, without your having to go to court.

And don’t get the idea that an expert cosmetic dentist is going to be way expensive. Interestingly, most good cosmetic dentists charge about the same for crowns that good general dentists charge.

– 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 31, 2016

A smile makeover over a fractured tooth spells trouble for Aaron

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Dr. Hall,

I had a traumatic fall 12 years ago fracturing 2 front teeth and my smile was restored with root canals and Procera crowns by my family dentist. With age and time, I didn’t like the way my adjacent natural teeth looked with the Procera. Also, I had one left upper molar that had a pretty deep filling and was giving me trouble. I am 38 years old and that filling was almost 30 years old. I decided that it was time for a smile makeover. So I went to a cosmetic dentist here in Lexington who gave me a combination of porcelain crowns and porcelain veneers.

I love my new smile. After the restoration however, my #9 front fractured tooth began giving me trouble. It was tap and pressure sensitive, so I went back to my cosmetic dentist and she told me I need to get an implant and another restoration. I had a gum pimple at the time and was referred to a periodontist.

root fracture on tooth in a smile makeover

The x-ray of Aaron’s front tooth.

I went on a course of antibiotics immediately (Amoxicillin 500 mg). I saw a periodontist last week and he confirmed that extraction of my newly restored tooth was needed. I requested my x-ray, showed it to my family dentist, and he doesn’t necessarily agree that extraction is warranted. He is contacting the West Virginia University, University of Kentucky, and University of Louisville dental schools to see if this tooth can be saved by periodontics or endodontics. I really do not want to lose #9, especially after a $1500 crown was placed, and not to mention IT IS MY FRONT TOOTH. Wish me luck. Please feel free to comment. I have attached the x-ray.

– Aaron from Kentucky

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Aaron,

I actually have a couple of problems with your smile makeover. Not with its appearance. You also sent a photograph of your smile and it looks great! But it leaves me wondering if your dentist took x-rays before doing this smile makeover or, if she did, if she fully comprehended what she saw or gave it proper weight.

Root fracture on tooth #9

Your tooth #9 doesn’t look good at all. I have a fair amount of expertise in x-ray diagnosis and taught x-ray technique at the University of Minnesota, and I’ll tell you what I see. Right in the middle of the root there is a horizontal radiolucent line that looks like an old fracture. This must date from back to your original accident. The root canal filling crosses this fracture line, so the dentist who did the root canal either didn’t see the fracture or figured he or she could navigate through it, remove all the necrotic soft tissue, and hopefully get healing. And it looks like this happened to some extent, at least. The end of the root looks healthy. But just above the fracture line, the tooth looks moth-eaten. It appears that some of the root canal filling material is gone. If the pimple on your gum traces to that area, that spells trouble. And my guess is that it does. The moth-eaten appearance suggests that there is infection eating away at the root of your tooth. If this is the case, the tooth is unrestorable.

Does tooth#8 need root canal re-treatment?

If this weren’t enough, the other front tooth is suspicious. If I had done this case, I would have addressed the problem with #9 before starting, but I would have also recommended re-doing the root canal treatment on #8, because the root canal filling stops several millimeters short of the end of the tooth. Now that the crown is on that tooth, I wouldn’t do anything more than wait to see if it flares up. There aren’t any signs on the x-ray of any infection here, just evidence of a situation in which infection could develop.

So yes, I think you’re going to lose tooth #9. From everything I can tell, your dentist is an excellent cosmetic dentist, so I would have her stay with this case and finish it. But I think she missed the diagnosis here and should make concessions on the fee to get this fixed right. If I had made this mistake, I would ask you to pay for the extraction and the implant but then not charge you anything for the implant crown. That would make it so the total fee you pay would be equal to what you would have paid had the tooth been extracted in the first place and an implant placed, which is what should have been done.

– 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.

December 29, 2015

Another case of a porcelain veneer falling off

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Dr. Hall,
I had 5 porcelain veneers put on my front teeth 4 months ago. The one canine fell off in one piece after chewing on a piece of bread a week after it was permanently bonded. The tooth was extremely sensitive to air & I couldn’t tolerate the pain. The dentist said it fell off because my bite was off so he needed to shorten the veneer & the bottom tooth that slightly touched it. His defense was he didn’t see the issue before placing the veneer. He also said I didn’t need to be numb & proceeded onto rebonding it. The chemicals applied hurt so much I felt like dying, so I asked to be numbed before he could continue (same pain was experienced for bonding all other veneers.)

Today it has been 4 months later & that same veneer fell off while chewing a pancake. I felt the same intolerable sensitivity again. I asked the dentist why this happened when he said it would last 10 years? He replied because your bite is off so now we need to make it a full porcelain crown. I really don’t want to ruin my healthy natural tooth. Is it normal for the underlying tooth to be extremely painful w/the veneer falls off & should I be concerned about proceeding to a crown? He claims to have 1 year training in a cosmetic dentistry course & has 5 years experience in general dentistry. Please help I’m so stressed & afraid to bite w/the other front teeth.
– Kelly from Texas

(Note – I asked Kelly to tell me the name of her dentist so I could do a little research on him, but I won’t mention the name here.)

Kelly,
I think you should find another dentist—an expert cosmetic dentist—to put this veneer on right.
Your dentist claims to have a one-year training course in cosmetic dentistry. I think what he must be referring to is his General Practice Residency. It’s a stretch to call that training in cosmetic dentistry. Yes, it’s advanced training, but it’s in general dentistry.

He says that the veneer came off because your bite was off on that tooth. Now I can’t tell you anything about your bite from here, but the explanation doesn’t fully cut it, especially since it came off a second time after he adjusted your bite.

A properly bonded porcelain veneer will chip or crack before it will pop off. So there had to be something not quite right with the bonding. And then re-bonding a porcelain veneer is advanced cosmetic dentistry and I’m skeptical, after researching his credentials, that your dentist has the training to do that.

If you have the veneer, it should be a fairly straightforward and quick procedure for a dentist who knows what he or she is doing to rebond it. I can recommend someone close to you who can do this for you. Don’t let him turn this into a porcelain crown—that is way more aggressive than you need.

On the sensitivity, that doesn’t surprise me. Your dentist may have prepared your tooth deeper than usual, which leaves you with exposed dentin when your porcelain veneer falls off, which would make it quite sensitive. But even a tooth with a shallow veneer preparation can in some patients be quite sensitive.

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.

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.

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.

February 12, 2011

Replacing a broken veneer

Dr. Hall,
I recently had a broken veneer replaced. Initially, when the veneer came back from the lab it was a little too light. It was sent back to the lab and the technician baked a glaze onto the veneer making it darker. The dentist was then able to remove glaze as needed in order to achieve the desired shade. Everything looked fine, so we bonded the tooth in place and I was on my way.

However, after seeing the tooth in the sun it still appears a little too dark. My question is, can I return to the dentist and have them remove more of the glaze to lighten the tooth, despite it being bonded already?

Best regards,
David from Georgia.

Hello again Dr. Hall, I just emailed you about the shade of my replacement veneer. The case where a glaze was applied to a veneer that came back from the lab a bit too white and then polished off until the desired shade was achieved. I forgot to add that the veneer appears somewhat less glossy than the other veneers. Could this be a result of polishing the glaze off to change the shade?

Thanks for your time. Sincerely,
David from Georgia

David,
I do hope you’re in the hands of an expert cosmetic dentist. When you’re replacing one veneer, manipulating the color is very tricky and it requires special training and artistic sensitivity.

I am worried that your dentist isn’t as expert in this as might be needed for a job like this. Let me recap what has happened and explain what I would have done differently. You went to get the veneer replaced, and when there was difficulty with the first attempt at matching the shade, the technician baked some tint onto the surface of the veneer, and then the dentist polished some of the tint off until the veneer was the correct color. This is an okay technique, though not the best way to get that final match. In my office, I would have sent a photograph of the shade discrepancy back to the lab and a careful description of the color, and tried to nail the color, and maybe done a couple more trips back and forth to the lab to get it perfect. And my fee for a single front tooth was a little higher, because I would routinely expect at least two or three try ins, and I would keep at the task until the match was perfect. Any final manipulation chairside I would have done with tints UNDER the veneer. That is the way I think most expert cosmetic dentists would approach this task. The way your dentist did this makes me think he or she wasn’t familiar with this tinting process or doesn’t stock any of these tints that expert cosmetic dentists use. The problem with the way it was done is that as time goes on and if anything happens to this veneer, such as a hygienist that doesn’t understand porcelain chemistry giving you an acidulated fluoride treatment, or using an inappropriate polish on this veneer, it could abrade away more of the tint and change the color further.

But anyway, getting back to your two problems. One is that this veneer isn’t as glossy now as the rest of them. To solve this, there are special diamond polishing wheels and polishing pastes that will bring the glaze back to porcelain. I’d ask your dentist to arrange to get some of these. Again, this is something that an expert cosmetic dentist will usually have in his or her armamentarium.

The second problem isn’t exactly that the color doesn’t match, it’s that the color match changes depending on the environment. This is called color metamerism. It appears, from what you’re telling me, that there are some differences it the materials between the replacement veneer and your original veneers, and under the artificial light of the dentist’s office they match, but in natural sunlight they don’t. Again, expert cosmetic dentists are familiar with these issues, and they will either double check any critical shade matches next to a window, or they will have special color-correct fluorescent light fixtures in their office. Yes, you can go back and have your dentist polish away more of the tint to brighten your veneer a little more, but be careful, because then in artifical light it may not match. I think in your case, I would err on the side of matching in artificial light, because over time this new veneer may get lighter anyway, and if it doesn’t, you can always have it polished more later.

I hope this is helpful.

And this whole issue just underscores the main theme of this website. Use an expert cosmetic dentist, such as I recommend on this website, for these smile makeovers – not your family dentist or a dentist who SAYS he or she is a cosmetic dentist. There are so many skills required to do this work well, and 98% of dentists simply don’t have them.

Dr. Hall
Click here for referral to an expert cosmetic dentist.
Click here to ask the dentist a question.

David from Georgia had a follow-up question two days later, about completely re-doing this veneer. Read his question and my response.

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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