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Another family dentist trying to do cosmetic dentistry

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

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

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

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

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

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About David A. Hall

Dr. David A. 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 advanced internet marketing for dentists.

What to do about gray crowns

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Hi Dr. Hall,

Due to a recent fall, I broke my 2 front teeth as well as the one to the left of my front teeth. I had 3 root canals and 3 porcelain crowns placed. I’ve had 2 attempts as the first permanent set were off in color, too big and thick. The 2nd permanent set matched in color and were closer in size and thickness to my natural shape. After they were permanently cemented they all had a grey hue close to the gumline on the tooth. The dentist has reluctantly agreed to redo my crowns stating he would try to make sure the core is as white as possible. I’m not sure what to think or if he can even fix the issue because he did say he couldn’t promise this issue would be resolved? What are your suggestions? Thank you!
– Nancy from San Antonio

Nancy,
Your problem is simply that your dentist doesn’t know enough about cosmetic dentistry.

One of the issues that family dentists have the most trouble with is color, so the problem he is having is not unusual.

If you have two or more crowns on your front teeth, this is a pretty simple color task for an expert cosmetic dentist. The fact that these crowns were too big and thick and the color was off on the first try makes me worry about the level of skill here. On the second try, having them be too gray at the gumline is not a great confidence builder, either. This isn’t a difficult situation. My advice would be to be fussy. It is possible to get the color and shape exactly right and in the right hands, no one should be able to tell that these are crowns on your front teeth and not your real teeth. Don’t settle for anything less than that.

You’re not giving me any clinical details about the types of crowns we’re dealing with, and there are several possibilities for getting this grayness that you’re seeing. Let me make an assumption of what I think is the most probable scenario. My best guess is that your dentist is using pure ceramic crowns of one type or another with a metal post and core to reinforce the inside of the tooth, and the gray color of the metal is showing through the translucent ceramic. There are several ways to deal with this. If I were doing your case, I would have used a fiberglass post and a composite core that was close to the color of your natural teeth. That’s the easiest way to get a natural translucency to the crowns. If we’re stuck with the metal core, then what I would have done would have been to bond an opaque layer on top of the metal to block out the metallic color and then bond the crown on top of that opaque layer. Another option would be to give clear instructions to the laboratory technician about the color and extent of the metal core, and let the technician incorporate opaquing into the crown.

The problem with many family dentists is that they don’t understand translucency and the impact of interior colors on the external appearance of the tooth.

Your case bothers me, though. You’ve had this accident, and you would think that you should be able to go to your family dentist and he would know enough to fix this. Or, if he didn’t, that he would know enough to refer you to someone with more expertise in cosmetic dentistry. But that is the state of cosmetic dentistry in America. Dental academia trivializes cosmetic concerns and the powers that be in the profession are adamant that cosmetic dentistry isn’t a legitimate specialty. If there were a higher level of respect in the profession for aesthetic skills, there would be more inclination to either refer these cases to a specialist, or maybe to train general dentists better in these color skills and you wouldn’t have situations like yours. Your case doesn’t require a high level of aesthetic skills—only a moderate level. The fact that your dentist has missed this twice and now is unsure that he can fix the color shows a fundamental lack of understanding of basic color management.

Dr. Hall

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

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

About David A. Hall

Dr. David A. 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 advanced internet marketing for dentists.

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


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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

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 A. 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 advanced internet marketing for dentists.

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