Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

February 13, 2018

The hundred thousand dollar smile makeover


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Dear Dr. Hall,
I have had a terrible experience with my “smile-makeover.” It turned out horrible, so the dentist just refunded my money, and I am looking for a new dentist. I found your website while I was still his patient and was able to figure out that he had little to no knowledge of what you describe as a true cosmetic dentist.

So I made appointments with the first 3 cosmetic dentists on your list. I must say I was so disappointed with the 1st. While he rightly said my bite was off, I was there for a 2nd opinion of the 6 upper anterior crowns I had. He said I would first need to spend $300-400 with his hygienist, and then, to deal with my bite issues and everything the cost would range between $50,000 and $100,000. “About the price of a new car,” he said. I only wish I could replace my 6-yr-old car bought used, for 1/3 his idea of a new car. He never got to what type of smile I would end up with, as his idea was to build up my back teeth and have “an appliance” covering several teeth and add porcelain “where needed.”

My teeth and gums are pristine according to a general dentist I went to for opinion and a periodontist I also went to for opinion earlier. I don’t understand why I need all of this, and I can’t begin to afford this and want your opinion.
Thanks,
– Sally from Texas

Sally,
There’s a great variation in what some expert cosmetic dentists charge, and the fees you’ve been quoted are definitely on the high side, even if you actually need all the work that has been quoted. I would keep going down the list and get another opinion. Meanwhile, let me give you a little insight into what I think is going on in your case.

You said that you know your bite is off, and it appears that you’re being quoted a fee for a full-mouth reconstruction to rebuild your bite. Do you actually need that? I don’t know that, but I can tell you that some dentists are very fussy perfectionists and they insist that every patient accept what they call “ideal treatment.” Other dentists are more pragmatic and will consider other options for patients who can’t afford the ideal. Fortunately, you’re in the Dallas-Fort Worth area where we have several recommended cosmetic dentists. Go ahead and shop around for second opinions.

I want to tell you a story about this cost issue and dentists’ fee levels. There is a city where we have two recommended cosmetic dentists—let’s call them Dr. Smith and Dr. Jones. Dr. Smith is famous and has patients flying in from far and wide to see him. He does absolutely exquisite work. Dr. Jones also does very beautiful work and has won awards for the beauty of his work. Dr. Smith’s fees are about triple of what Dr. Jones charges. Is Dr. Jones an inferior dentist? I don’t think so because, guess what, Dr. Smith goes to Dr. Jones for his dental work.

So get another opinion or two.

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 3, 2018

My mouth seems to be collapsing


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Hi Dr. Hall,
I really hope you can help me.
I am not sure if my issue is related to my lips, teeth or jaw but I absolutely can’t stand my smile. It feels very forced to be able to show my upper teeth. When my mouth is in repose it is just empty space and you cannot see my teeth (especially my upper) and it makes me extremely self-conscious.
I also have jaw pain and wear a night guard and when I wear it my mouth feels more comfortable and I feel like it supports my lips better. It also gives an impression of upper tooth show that I would very much like. I also find I have difficult pronouncing certain words especially when it’s cold, almost as if my jaw tighten and I can’t open it properly to speak. P and T words are especially uncomfortable.

Are my only options veneers? Do I even have any options?

It’s very frustrating for me. I can attach pictures as well if need be.
– Laura from Toronto

Laura,
You’re going to need to be very careful how your proceed here, and if a dentist has told you that porcelain veneers will solve your problem, I would find another dentist. While that could help with your appearance, it could exacerbate your other problems—the jaw pain and trouble with pronunciation.

It sounds to me like you’ve worn your teeth down, making you overclosed. This could cause TMJ disorder, which would be characterized by jaw pain and possible tightness in your jaw. The fact that you feel better wearing a nightguard lends credence to that diagnosis, but you’ll need an examination by a dentist trained in TMJ therapy to confirm that.

The needed treatment, unfortunately, is likely to be extensive—probably a full-mouth reconstruction.

The problem is finding a dentist you can trust to do this. This is way beyond the capability of your average family dentist. I would look for a dentist with advanced training from one of three institutes:

  • The Pankey Institute in Florida
  • The Dawson Academy, also in Florida
  • The Las Vegas Institute for Advanced Dental Studies

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.

December 27, 2017

A case of collapsed bite


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Hi Dr. Hall,
I really hope you can help me.

I am not sure if my issue is related to my lips, teeth, or jaw, but I absolutely can’t stand my smile. It feels very forced to be able to show my upper teeth. When my mouth is in repose it is just empty space and you cannot see my teeth (especially my upper) and it makes me extremely self-conscious.

I also have jaw pain and wear a night guard and when I wear it my mouth feels more comfortable and I feel like it supports my lips better. It also gives an impression of upper tooth show that I would very much like. I also find I have difficulty pronouncing certain words especially when it’s cold, almost as if my jaw tightens and I can’t open it properly to speak. P and T words are especially uncomfortable.

Are my only options veneers? Do I even have any options?

It’s very frustrating for me. I can attach pictures as well if need be.
– Laura from Ontario

Laura,
I’m glad you’re emailing me now, before going to a dentist to have this fixed. It’s painful to have to write back to people after a problem like yours and the dentist messed up their mouth.

This is a very difficult problem and you need to be very careful in picking a dentist to treat this for you. While I can’t tell for sure just with your description, it sounds like you may have a collapsed bite plus some other complicating TMJ issues (TMJ disorder). Veneers wouldn’t be the answer, at least not as a sole treatment. Opening your bite with crowns could solve your problem, but it would need to be done methodically by a dentist with experience in full-mouth reconstruction.

The proper way to open a bite is to do it reversibly first, with some type of provisional restoration. When that provisional is successful, then permanent restorations should be made that duplicate what was done provisionally. By successful I mean that you are out of pain, are happy with your appearance, show your upper teeth normally, and have no speech difficulties. That’s a tall order, but a dentist with adequate training should be able to do this.

It’s a small minority of dentists who have the training needed to address this type of situation. There are several training institutes in the United States that train dentists in this level of complex restorative dentistry. Those would be the L.D. Pankey Institute and the Dawson Academy in Florida, and the Las Vegas Institute for Advanced Dental Studies in Nevada. There are others, but these are the best known. I don’t believe there are any such institutes in Canada.

To help cement this idea of being careful in picking a dentist to do this, you may want to visit other blog posts I wrote for patients where the dentist opened their bite and caused more problems than they started with.

I will email you privately with a dentist recommendation for you. It will involve some travel, but you need to get this done right.

– 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 31, 2017

After my porcelain veneers, I need root canal treatments


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Dear Dr. Hall,
I had full mouth smile makeover done (veneer crowns) in January 2017, 12 upper teeth and 10 lower teeth. After they put permanent crowns on, I felt sharp pain on teeth #5 and #13 (upper second premolars). The dentist did crown height adjustment 3-5 times, finally the pain went away, but tooth abscesses formed on top of both #5 and #13 teeth within 4-6 weeks. The dentist x-rayed and said the teeth nerves had died, and I need root canals. I was upset and didn’t realize that nerve damage could be a risk involved in veneer crowns. I remembered I asked if there is any risk doing smile makeover during consultation, I was told there is no risk. The X-ray showed that my teeth nerve are fine before the procedure. I am confused and don’t understand what is going on.

The dentist said he didn’t know why, it rarely happened, I am the unlucky one. He referred me to an endodontist to perform the root canal procedure, and the endodontist found more teeth showing no response to cold test, also my gum flared up, swollen and very painful. So far I have had root canals done on 4 teeth (#4, #5, #13, #14), and #12 needs a root canal too, just matter of time. The tooth #3 starts feel strange too. Dr. did agree to pay half of the cost of the 4 root canals, but I am worried it will be an ongoing nightmare. What if the crowned teeth one by one goes bad over the time? I am very frustrated and feel misled. It not only financially cost me, but also add lots of stress on me. Please tell me what i should do and I need some advice. Thanks!
Sincerely,
Jenny from Texas

Jenny,
To answer your question, I first need to lay down some terminology so we’re clear in what we’re talking about. I’m a big fan of clarity in communication, which requires precisely defining what words mean.

two front teeth, prepared for porcelain veneers

Porcelain Veneer Preparation

You’re saying you had “veneer crowns.” But a porcelain veneer is one thing and a porcelain crown is something very different. A porcelain veneer requires very light shaving of the front surfaces of the teeth—sometimes no shaving at all is required. I found this photograph that illustrates a typical porcelain veneer preparation. Maybe half a millimeter of tooth structure has been shaved off, and the porcelain will be bonded over this.

two front teeth, prepared for porcelain crowns

Porcelain Crown Preparation

This second photograph shows a typical porcelain crown preparation for the same two front teeth. Much more tooth structure has been removed.

It appears from your description that what you had done were porcelain crowns, not porcelain veneers. It is very rare that a porcelain veneer preparation on a tooth will end up making it need a root canal treatment. But a crown preparation will go much deeper into the tooth, increasing the risk of a pulp exposure, resulting in an infection of the pulp and the need for a root canal treatment.

A smile makeover, by itself, does not require any aggressive grinding down of the teeth, which is what must have been done in your case. If your teeth had large fillings or decay before getting your makeover, then grinding them down was necessary. If that is the case, it wouldn’t be surprising if some of those teeth ended up needing root canal treatments. Anytime there is a lot of decay or large old fillings, there is a risk of teeth getting infected. But I would call that procedure a full-mouth reconstruction, not a smile makeover.

But if this that you’re calling a smile makeover was just for aesthetic reasons, then your dentist was much more aggressive than he needed to be, and I believe he should be responsible for the cost of the damages he caused. If you weren’t told of any of these risks up front, he is especially vulnerable.

A smile makeover should be done with porcelain veneers whenever possible, to avoid problems like you are having. There is even a trend in recent years for excellent cosmetic dentists to place what are called ultra-thin porcelain veneers, which require even less preparation than is shown in the photograph above. Some even try to do the makeover without preparing the teeth at all. But many dentists who aren’t expert in cosmetic dentistry simply don’t know how to do porcelain veneers very well, and so they resort to full coverage crowns. Porcelain veneers aren’t taught in dental schools—they’re a cosmetic procedure for which a dentist should get post-graduate education.

As far as what you should do now, I don’t know what to tell you. You don’t really have any option, if you want to save these teeth, besides having the root canal treatments done. And it’s curious that your dentist is offering to pay half the cost of the root canal treatments. This seems to indicate that he is feeling some guilt over this. If that’s the case, I would press him to pay the whole thing.

About what to expect long term, it’s hard for me to tell for sure from here. My guess would be that any teeth that end up having problems, you will find out within the first few months and then things will stabilize.

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.

January 12, 2017

I have dry mouth ever since getting my new crowns


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Dr. Hall,
I had porcelain crowns for all upper and lower teeth. Ever since these were put in I have had dry mouth. This was a cosmetic procedure and I obviously regret doing it. I am wondering if there is anything I can do next. The dentist widened my bite so you can see more of my teeth when I smile and I try to remember to keep my mouth closed and breathe through my nose. I know the dentist can grind down the new crowns and try to match my original bite but not sure if that is really a good answer. Any ideas you have would be greatly appreciated.
– Randy from Pennsylvania

Randy,
So you had crowns on all your teeth–we would call that a full-mouth reconstruction. You wanted more teeth to show, so the dentist “opened your bite.” In lay terms, he or she made the crowns “taller” than your natural teeth were.

Unfortunately, this hasn’t worked out so well for you and now you are suffering from dry mouth–called xerostomia in clinical terms. This isn’t just an annoyance but is a real threat to the health of your teeth, which I will explain below. It’s caused by a condition that is called “lip incompetence,” which is defined as a lack of closure of the lips when the mouth is at rest. In other words, you have to consciously try to keep your mouth closed.

This was a serious mistake by your dentist, and in my opinion he or she should accept responsibility for getting this corrected. If he or she doesn’t, you have a valid case for malpractice damages. Was your dentist so attracted by the high fees from doing 28 crowns on you that they jumped into this case and got in over their head? That is possible. Dentists don’t get enough training in dental school on full-mouth reconstructions. This is a highly complex procedure, and there are several post-graduate training institutes that offer this advanced training.

The proper way to do a full-mouth reconstruction, especially if the bite is going to be opened, is to first open the bite temporarily by some mechanism. What I did was build up the back teeth with composite to test how far I could open the bite. It can also be done with temporary crowns, though that commits you to having crowns. As a patient, you should wear the temporary crowns or the buildups long enough that you can be sure you’re comfortable with the new opening. And the dentist should never open the bite beyond the point of lip competence. This is one of the key things that needs to be checked–with your mouth at rest, do your lips come together naturally or is it a strain to close them? This is the test that is used to discover how much you can open it. You never go past that point.

Saliva a Defense Against Decay

Many people don’t realize that your saliva has important defense mechanisms against decay. Besides its washing and buffering action, it contains antibodies that fight decay bacteria and minerals that help remineralize early decay lesions. A serious complication of dry mouth is a greatly increased decay rate. And don’t think that your crowns make you immune to decay. It isn’t hard for decay to get in at the margins where the crown meets the tooth. Also, dry mouth exacerbates gum disease.

What to Do Now

With what appears to be a lack of prudence and care by your dentist in doing this case, I wouldn’t ask him or her to fix it but would seek a second opinion. I will email you privately a dentist near you that I would recommend for this second opinion–I don’t want to publicly give any more clues about your location. Yes, the bite needs to be closed down, but grinding the teeth down may not work. It may be that your case needs to be completely re-done at the expense of your dentist. Proper shapes of the teeth need to be preserved in order for you to have a healthy bite. And if the crowns have a metal foundation under the porcelain, you don’t want to grind through to the metal.

So go to the dentist I recommend. If he feels that this is your dentist’s fault, ask him to help you get satisfaction from your current dentist. Based on what you’ve told me, it sounds like you could take this dentist to court for malpractice, but it’s always better to give them a chance to rectify the 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.

August 8, 2016

Jaw pain after a long dental appointment

Filed under: TMJ — Tags: , — mesasmiles @ 5:25 pm

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Dear Dr. Hall,
Last Wednesday I had my upper arch prepared for 4 crowns and the rest of the teeth veneers, and am now in the temporaries. I like the way they look … very natural. But I am very concerned about the terrible jaw pain that I am now having. My dentist suggested that I take Advil. I have been and it does help a lot, but it has been 4 days now and the jaw pain is very bad without the Advil. The aching seems to get worse throughout the day until it feels like my cheeks are a little numb and my back crowns ache as well. I’ve been trying to take Advil as little as possible as I really try to stay away from most meds, but I usually break down and take it around 4 … and then again around 10pm.

If you have any advice, I would appreciate it a lot. Is this normal at 4 days out? I know that it was a lot of trauma to my mouth, but I didn’t experience this with the bottom arch.

My dentist is on vacation and I’m not sure if I should try to see another dentist before she returns in two weeks.
Thank you so much.
– Adrienne from New York

Adrienne,
I don’t find your pain to be anything unusual, given the extent of what you have been through, and I don’t think another dentist would be able to do anything for you besides tell you to do what your dentist has told you. I wouldn’t be surprised if the pain continued a week or two. It sounds like you have had the second half of a full-mouth reconstruction, which isn’t unlike having major surgery.

To prepare your entire upper arch for crowns and veneers would have required your mouth to be propped open for quite a while, and doing that can provoke the kind of pain you seem to be telling me that you have. There isn’t a lot you can do for that at this point other than taking Advil, maybe applying warm towels to your jaw, and just resting your jaw until it gets better.

If she is gone for two weeks, I imagine she has made arrangements with some other dentist to take care of any emergencies or follow-up care for her. I would wait until it has been a week, and if it isn’t any better, I would pay a visit to that dentist to see if there is anything else that can be done to make you more comfortable. That other dentist may have access to your records or have made some special arrangement with her for follow-up.
– 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.

July 12, 2016

She’s reluctant to do the second half of her full-mouth reconstruction


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Dear Dr. Hall,
I have taken great comfort in the information you provide and the honest, intelligent, accessible manner in which you provide it.

I am 37 years old and had my entire lower arch redone with crowns and veneers over a year ago. My dentist is a cosmetic dentist listed on your website. She recommended a full smile makeover for my worn teeth. After years of clenching and grinding (I didn’t wear a nightguard until recent years), I was having a lot of sensitivity on my molars and my dentist said that I had a collapsed bite.

I know that my dentist did a good job, but the whole process was very hard for me emotionally. I never wanted “perfect” teeth and I do miss some of the quirkiness of my originals. Even though I went for a “darker” shade (m2 instead of m1), I still feel they are a bit white for me. Also, I have had a bit of gum inflammation, which I never had before. My dentist is having me treat this with baking soda and peroxide and may eventually do some procedure she thinks will help.

My dilemma is now that I am torn about doing the top teeth. My dentist is pushing for it. And indeed my top teeth are very worn, darker in color and contrast with the bottoms. However, my gums are very healthy on top and I have no pain at all in the teeth. I know that I cannot whiten the tips because I did Zoom whitening years ago and now I think my teeth are too worn and it may cause sensitivity.

I am agonizing over this decision and would be very grateful for any advice you might have.

My dentist seems to feel that my teeth will be better off if she completes the whole mouth, but I am so hesitant to go through such a big procedure when I not in pain anymore. The esthetic discrepancy does bother me a little, but maybe not enough to get this major work done.

Thank you for any words you have for me!!

Best,
Anna from Connecticut

Anna,
It’s hard for me to give a definitive answer as to what you should do without seeing your case and knowing everything that is going on dentally. But I’ll see if I can be of some help with some guiding principles.

There are points to be made in favor of both options–doing something and not doing anything.

First, I am not in favor of half-mouth dental reconstructions. I don’t know what the crowns on your lower teeth are made of, but most ceramics are somewhat abrasive to natural teeth. Some of the newer ceramics are very kind to natural dentition, but most of them will wear natural dentition more than they would otherwise wear, which can lead to sensitivity and other problems. You may want to ask your dentist about this, if this is an issue in your case.

The original problem was excessive wear of the teeth. I’m sure that wasn’t confined to the lower teeth–they both must have worn equally. And now your upper teeth are continuing to wear down. So it appears to me that your original problem is now half solved, and you need to finish the treatment.

Having said that, crowning and veneering all the teeth is a very aggressive step, and if you aren’t completely sold on the benefits, my inclination would be to leave well enough alone.

On the issue of the “quirkiness” of your natural teeth, a masterful smile makeover will include some “quirkiness.” If you discussed that with your dentist, I’m sure she could take care of that so that it wouldn’t be an issue. Knowing that is your preference, I think that most ceramists would love the opportunity to put some quirky features into your smile. My ceramist wanted to do that, but the barrier to doing that is that there are some obsessive patients who fuss over anything that they perceive as an imperfection in the smile makeover. I would want the smile to look natural–they would want all the teeth to be “perfect.” I would try to persuade them to have some imperfections in the teeth, but in the end the patients would get what they wanted.

If the only problem you need to fix is the color, I would do whitening. You mentioned that you worry that you would have too much sensitivity, that you had Zoom whitening before and are reluctant to do that now. However, there are a number of other options for whitening the teeth besides Zoom. Zoom, because of the light, is more harsh than other options. Kör whitening is gentle yet very effective. There is also Nite White or Day White, Boost, Opalescence, and other systems, all of which are also more gentle than Zoom.

On the issue of gum inflammation around the lower teeth–I’m assuming that is around the crowns. That is a factor that should be taken into consideration. You could be having a sensitivity reaction to the ceramic in the crowns or it could be something else. I would try to pin that down before doing the uppers. One excellent option could be doing porcelain onlays on the upper teeth rather than full crowns. Onlays stop short of the gumline so that gum inflammation shouldn’t be an issue. If not porcelain onlays, then porcelain crowns that only go very slightly into the gingival sulcus or even stop at the gingival margin. There should be a way to avoid this on the upper.

And then, about the overall result. I had a number of patients who were hesitant about moving forward with smile makeovers and had some misgivings about the procedure before starting. But once it was done and they saw themselves in the mirror with their beautiful smile and felt that great sense of confidence to where they couldn’t stop smiling, I don’t believe anyone would have ever given a second’s consideration to going back to the way they were. It was always a positive, life-changing experience. You mention that the esthetics of your smile bothers you some now. I would fix that.

I hope this is helpful.

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.

April 2, 2016

This full mouth reconstruction is going badly

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.

Here is a question from John from New York. It’s hard to follow. Don’t try to understand all of this—I summarize his problem in the first paragraph of my answer.

Dr. Hall,
had full mouth reconstruction, all crowns, one bridge, removable upper partial. No wax up done. First set temps occluded well, still original partial and not great occlusion on left side, as was with original teeth. When lower perms delivered, lost all occlusion, only 5 and 28 touched, dentist did not address issue, when upper perms delivered, occlusion worse as the six lower teeth no longer fit inside the front uppers. I could not chew and side to side was unassisted by proper mechanics. I addressed this after completion and a number of attempts to remedy the occlusion were tried by grinding down the right side, then by modifying the partial. At each step of treatment my bite got progressively worse, and at the end, all attempts to alter the partial also gave progressively worse results. If I were to place implants in 12 and 4, which would allow me to lose the partial, I would have to have 13, 11 and 6 crowns redone as they do not occlude. l have offered to pay at least the lab fees to correct the non occluding crowns, but for some reason the dentist chose to keep trying to fix the issue by modifying the partial, which also got progressively worse and is now very uncomfortable, causes pain on some teeth when chew, and because of adding material to the saddle, has a squeezing rubbery effect when bite down. I have tried to get help from two other very well qualified dentists but neither of them said they saw anything wrong, other than one who did admit that the partial was doing nothing, but did not mention that 13, 11 crowns and 12 on the partial were not occluding and that 5 and 28 were the only teeth touching. I want to fix my bite but between not wanting to pay to have at least three crowns redone and make a new partial, and hope any of the other crowns won’t need to be redone as well, and because of how my confidence has been shaken by what appeared to be the two dentists being more concerned about protecting the dentist who did the work than they were about my health and welfare, I am stuck trying to figure out what my best course would be. I’d appreciate some guidance. Thank you.
John

John,
I am having a hard time following your story, so I am not sure of the details of what happened to you. Here is the gist of what I am getting from you:
You had what you are calling a full mouth reconstruction which implies that every tooth in your mouth was treated, using a combination of crowns, bridges, and a removable upper partial. You say the first set of temps (I assume you’re talking about a temporary partial, temporary crowns and bridges) fit well. But the permanent partial is not occluding well, as well as some of the other dental work. I am having trouble sorting out what occludes and what doesn’t occlude, but regardless, I couldn’t be of much specific help without personally examining you. However I think I can be of some help with this matter of your occlusion.

And then I understand that you are wondering if the other dentists helping you are more concerned about protecting their colleague than helping you. I also know quite a bit about that subject.

Occlusion is a complex subject

On the subject of occlusion—that is a very complicated subject. How the teeth interact with each other, with all their bumps, ridges, and pits, is complicated enough. But then you have this complicated joint, the TMJ, that allows a hinge motion, sliding back and forth and side to side—no other joint in the body does anything close to that—and dealing with it is beyond the capacity of a dentist who has merely graduated from dental school. There are high-powered institutes that are devoted to nothing more than the post-graduate training of dentists in the subject of occlusion and how it affects the TMJ and associated muscles. You need to find a dentist with a higher level of expertise to sort out your problems and fix them. As I said, I don’t know clearly what has happened in your case, but I am strongly suspicious that your dentist has gotten in over his head.

So how do you find a dentist who can sort out your occlusion? Look for a dentist trained at one of these occlusion institutes I mentioned. The two most prestigious are in South Florida. One is the L.D. Pankey Institute, the other is the Peter Dawson Academy. Both of these teach conventional occlusal theory. Another respected institute is the Las Vegas Institute. It teaches a different, functional theory of occlusion that also seems to work well in practice. There are others, such as the Texas Center for Occlusal Studies, but these three are the most popular. A dentist trained at any one of these institutes should be able to help you.

True professionalism

On the other issue, yes, it is very common for dentists to band together and defend each other against the interests of the patient. I get occasional flak from other dentists who tell me that my criticism of some dentists is unprofessional (see the “hate mail” category in this blog). That is their thinking. My thinking is the opposite—that the highest professionalism is serving the patient and calling out mistakes when I see them. That is why I counsel patients seeking second opinions to go outside their local area.

My advice

I see you are in a suburb of Rochester, New York. My advice to you would be to do a search on the term “TMJ dentist” in Rochester, look at the doctor bio of each dentist you find, and select a dentist who is either Pankey or Dawson trained and enjoys working with this complex field of TMJ treatment. And before you make an appointment with the dentist, ask if he or she would be comfortable going to bat for you in getting some type of refund from your family dentist to help defray the cost of fixing what he or she messed up.

And, as you have learned, it might be easiest to select a dentist across town who doesn’t know your dentist.

Dr. Hall

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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 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.

March 5, 2013

Did you really need that full mouth reconstruction? I’m suspicious.

Dr Hall,
I have been going to a local female dentist here for the last 10 years and over the last few years she has put new crowns in the top front (6 or 8) teeth with the metal backed crowns and they leave a black stain across my gums (and chipping, breaking) all the time and she charges to repair these…. so she doesn’t back up her work.

I found a cosmetic dentist in nearby (town’s name withheld), Dr. (doctor’s name withheld) and he inspected my mouth and told me that not only did those horrible teeth need to come out but that my bite wasn’t right and the top teeth were wearing down the bottom to the point of my bite collapsing. Well yesterday Dr. (name withheld) gave me 28 new temporary crowns – will get my permanent ones next week. They will be porcelain and the temps look great it’s just that I find it difficult to eat and maybe it will take some time. I guess I need to get used to it and learn to deal with it.

One more thing is when I order my new permanent crowns I want to make a couple of changes, such as slightly lengthening my eye teeth or maybe offset them slightly to give me a less perfect smile or should I say maybe they won’t look like false teeth. Do you have any input on this situation? It will be about a week or more before I have this done but I want to come out with the best “natural” looking and less fake smile. Is there any other tips! or tricks that I could do as well?

Thanks,
– David from Mississippi

 

David,
I’m glad you e-mailed me. You could be in for a lot of trouble, and you should take your next steps very carefully. I would not let this dentist put your permanent crowns on until you get two big issues solved. I am highly suspicious of this whole situation. I’m going to give you my phone number, and I want you to call me about this. But let me explain your situation first.

1. The number one issue is that you need to be sure that your bite is comfortable with the temporary crowns before proceeding with the permanent crowns. If I were you, I would call the dental office and ask that the laboratory order be put on hold until you have temporary crowns that are comfortable to your bite. Your dentist is opening your bite with a full mouth reconstruction. This is a risky procedure, and could leave you with serious TMJ disorder if it’s not done right. Clue number one for your impending trouble is that you find it difficult to eat. Clue number two is Dr. (name withheld)’s website, where, when I read his bio, I don’t see any clue that he has the advanced training that would be necessary to do work of this complexity. Ordinary dental school education isn’t enough – there are institutes such as the Pankey Institute in Florida or the Las Vegas Institute for Advanced Dental Education that train dentists to do this. And when dentists go through the trouble to obtain this advanced education, it is highly unusual that they would have a website that wouldn’t mention it.

2. You have some matters you want addressed in the appearance of the teeth. Those need to be settled BEFORE the dental laboratory starts making them.

Here is what you need to do, and I am emphatic about this. DO NOT let Dr. (name withheld) or anyone on his staff talk you out of this.
1. Get the laboratory work put on hold until you get the two issues above solved, and until you can get a second opinion about this work.
2. Go get a second opinion. You are spending well up into five figures on this, plus you are putting the rest of your life on the line. If this work isn’t done right and you end up with TMJ disorder, that can make you miserable for the rest of your life until you would get the work re-done. Don’t take this lightly.

I’m going to recommend you go see an excellent dentist in Lafayette, Louisiana, for an opinion on this. I have looked for excellent cosmetic dentists in your part of Mississippi, and haven’t been able to find any, so I think it would be worth it to you to make the trip to Lafayette. I looked up directions on Google Maps, and I see this is a drive of several hours for you. But that’s a small thing when you’re talking about something so major. It is Dr. Mike Malone. He is highly expert in both cosmetic dentistry and reconstructive dentistry. He’s a past president of the American Academy of Cosmetic Dentistry and has been trained in advanced reconstructive dentistry at the Pankey Institute. But more than that, I have known him personally for many years, and he is a decent, honest dentist who will tell you what you need to do. Additionally, if you get out of the Jackson area, you avoid complications that can occur when the dentist giving the second opinion knows the first dentist. They might be buddies, which isn’t good, or they might be fierce competitors, which could be worse. And be sure you see Dr. Malone personally. He has two associates who do the general dentistry, and he does the advanced restorative. When you call, tell him that I referred you. His website is www.mikemalonedds.com, and the contact information can be found there.

I can’t make any declarations for sure without seeing you myself, but as I said in the beginning, I am highly suspicious. There are dentists who recommend full-mouth reconstructions purely for the profit involved. I certainly hope this isn’t the case with you, but you need to find out before this work proceeds any further. If the dental laboratory doesn’t make the crowns, that makes this whole thing a lot easier financially. You could transfer to another dentist, for example, for no additional expense. On the other hand, if the crowns are installed, then fixing you would involve starting all over from the beginning, preparing the teeth, and making new crowns from scratch.

Please call me on my cell phone, and you can talk to me about this.
– Dr. Hall

Link: Click here for information on getting a referral to an excellent cosmetic dentist.

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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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