Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

December 26, 2016

Ugly e.max crowns are too thick


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Good morning, Dr. Hall.
My question: Can adhesive-bonded e.max crowns be safely removed without breaking the natural tooth which is already fragile?
History: I recently had the front six teeth re-crowned with e.max. The four front teeth have now been crowned for the 5th time (all by different dentists). I was happy with the first crowns I had, but after 15 years they needed to be replaced. I have yet to find a dentist who can replicate the smile I had before. I’m now stuck with e.max crowns that are thick and bulky with dark showing around the gum over my central incisor. My dentist said he would replace them but I know with each manipulation, I am risking the possibility of losing a tooth (or teeth).
My dentist said he made the e.max crowns thicker because my gums were thick (the gums have buttressed from years of clenching). He has now asked I have crown-lengthening and have some if the bone removed before replacing crowns.
I am so afraid of losing my teeth and having to have dental implants but I so want my old smile back.
Any advice would be greatly appreciated.
– Carol from Alabama

Carol,
If I’m getting this straight, your dentist gave you thick crowns because your gums are thick. If that is his true reasoning, I wouldn’t let him re-do your case. There is a gross misunderstanding of esthetic and functional principles here. Thick crowns will cause the gums to become inflamed and puffy, so this has the potential to be a functional disaster. Plus there is no aesthetic reason for your crowns to be made thick in this situation. The dentist should make sure there are natural contours to the teeth as they come out of the gum.

Let me explain.

I found this photograph showing thick crowns with puffy gums what happens when crowns are too thick. It creates a protected space where the crown meets the tooth and in that protected space, gum-disease causing bacteria multiply freely. Microscopic food particles will get trapped there, it is impossible to clean effectively, with resulting gum disease and puffy gums.

After almost 40 years of experience in dentistry, I must say I have never heard this aesthetic principle taught or even mentioned, that thick gums mean you need to do thick crowns. Rather, what I have heard is that you always need to have a natural emergence angle where the crown meets the tooth. You should not be able to feel any bulges as you run an explorer up from the root of the tooth onto the crown – the contour should be straight and smooth.

Now, as to your actual question about removing e.max crowns. These crowns are made of a very tough material – lithium disilicate – which makes them difficult to remove. And you say they were bonded on. The only way to get these off is to grind them off. Your dentist will need a supply of diamond burs to methodically grind these off your teeth. If the dentist is good and knows what he or she is doing, there should be no damage to your existing teeth. That isn’t a problem.

But I wouldn’t trust your current dentist to do that very carefully. His idea about thick crowns doesn’t show much care for precision in knowledge, which would make me worry about his being clinically careful. I would go to one of the dentists on our recommended list–I’m confident any one of them would do a great job for you here in carefully removing the existing crowns and replacing them with a beautiful smile.

Besides the functional mistake in your new smile, there was a serious aesthetic mistake, and I want to say something about that, too. No good cosmetic dentist would have ever bonded these crowns onto your teeth without a test-drive first, either duplicating the new smile in plastic so you could wear that as a temporary smile makeover, or temporarily cementing the new crowns, so he and you could make sure that you love this new smile before it was bonded permanently.

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.

August 3, 2016

So does flossing really help?


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So the Drudge Report yesterday linked an article from the British newspaper The Guardian about flossing. The link said, “Smile! Now experts decide flossing makes no difference.” The article in The Guardian is titled “Everyone recommends flossing – but there’s hardly any proof it works.” I’m not going to give the article any respect by linking to it–if you want to read it you’ll have to Google it.

But I can sum up the article in one word–ridiculous.

There is strong evidence through multiple scientific studies that flossing helps prevent both gum disease and interproximal tooth decay. In my dental practice, I could tell whether or not a patient was flossing simply by examining their gums. In fact, the science is so carefully calibrated that dentists can predict how long it would take a patient with inflamed gums to bring the inflammation under control with daily flossing. Two weeks of regular, daily flossing would do the job. In my practice that timing worked every time.

And rarely do regular flossers get interproximal tooth decay.

But if you go back and re-read the article, it’s fairly easy to detect the slant in the writing. Notice that the article doesn’t say there is no proof. It is titled there is “hardly any proof.” Think that through. That means there is proof.

Further along in the article it says: “A major review last year concluded: ‘The majority of available studies fail to demonstrate that flossing is generally effective in plaque removal.'” Notice again the wording, which admits that there are studies that demonstrate the benefits of plaque removal, but it’s not a majority of studies, or rather, it’s not a majority of the studies that were available to the person that made this comment.

Let me play this same word game with the benefits of showering. I could say something like this: “The vast majority of studies published in American medical journals fail to demonstrate that showering prevents body odor.”

Well, you may respond, the vast majority of studies in American medical journals don’t even deal with the subject of showering.

Oh, you’re so smart.

And this article in The Guardian is so stupid.

Dr. Hall

Do you have a comment or a question 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 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 29, 2013

Some dental bridge engineering principles, and why this planned bridge will fail

Dr. Hall,
I had my upper 6 front teeth pulled due to periodontal disease. I was going to have 4 implants with two pontics, but asked for something less expensive. So we are talking about doing a permanent bridge. I have read about the Maryland Bridge and feel now that maybe the separate implants with two pontics would be better? They have charged me the same price so my question is …would 4 implants and two pontics be better?
– Jill from Pennsylvania
(Note from Dr. Hall – a pontic is the false tooth part of a dental bridge.)

Jill,
I can’t really prescribe anything specific for your case without seeing you, but I can be some help here by giving you some guidance from basic principles of bridges and restorative dentistry.

If you are accurately telling me what your dentist is telling you, then something is very wrong here. A permanent dental bridge replacing six missing upper front teeth on any patient with significant gum disease would be a disaster waiting to happen. It’s not going to last, and in the end will be by far the most expensive option. Other options would be far better in multiple ways. And I’ll explain why. I’m going to explain this in some detail here for you and then use this explanation as a blog post that will hopefully help others with similar questions.

Here is a diagram of your upper arch:

upper-arch

So you are saying that you have had the front teeth extracted, which would be teeth numbers 6 through 11.

Here are a couple of principles of doing bridgework that every dentist is taught in dental school.

First, any bridge needs to be supported by teeth that collectively have the same amount of support as the missing teeth. In other words, if the bridge is replacing two medium-sized teeth, it needs to be anchored by at least two medium-sized teeth. If four small teeth are missing, they could maybe be supported by two large teeth, if those supporting teeth are twice as large as the missing teeth. So, you are missing four medium-sized teeth (6, 8, 9, and 11) and two small teeth (7 and 10). To support that adequately, you need four medium-sized teeth (4, 5, 12, and 13) and probably one large tooth (3 or 14). So you are ending up with an extremely complicated 11-unit bridge, consisting of six false teeth supported by five existing teeth. Now I suspect that your dentist, especially if you are pressing to save money, may be planning something less than this. But breaking this rule would severely limit the lifespan of the bridge.

Second, when you start adding supporting teeth, you increase the likelihood of failure for two reasons. One is that each supporting tooth has to be prepared to be perfectly parallel to all the other teeth. Getting five prepared teeth to be all parallel to each other (or even four) so that the bridge fits perfectly is extremely demanding, and I would not ask a regular family dentist to do that. When you add to that complication the problem of having teeth on opposite sides of your mouth, making those parallel is a very tricky proposition. Another reason is that if you have any kind of trouble down the road with any of the supporting teeth – decay or gum disease or any other significant problem – the entire bridge will have to be re-done. How expensive is that going to be? Way more than implants.

Third, with six missing front teeth you have what is called a cantilever effect. Look at the diagram and imagine that tooth #4 is missing. This tooth could be replaced with a simple three-unit bridge – the missing tooth #4 supported by teeth #s 3 and 5. Notice that these teeth are pretty much in a straight line. There would be no tipping forces at all when chewing stress is borne by tooth #4. This is the type of stress these supporting teeth are designed to take. But now compare this with teeth #s 6 through 11. These are on a curve. The strongest bridge between teeth #s 5 and 12 would be on a straight line between the two teeth. But that kind of a bridge would go across the roof of your mouth and wouldn’t make any sense. So we have to loop the bridge out around the curve. Have you ever seen a highway bridge that curves out like that? Of course not. They always form a straight line between the supports. The reason for that is that when you’re out on that curve, you create tipping forces which put a large amount of stress on not only the supporting structures but the entire bridge. This force becomes a force that wants to twist and push the two closest anchors (#s 5 and 12) and actually pull the remaining anchors out of their sockets. These are stresses that these teeth are not designed to take, and the life expectancy of such a bridge would be pretty short. You would probably end up losing all of the anchor teeth, in addition to the six you are already missing. To compensate for that added stress factor, your dentist could try anchoring with six teeth instead of five. But then you increase the risk also and may end up losing all six of them.

The conclusion of all this is that a permanent bridge replacing six front teeth would be a bad idea for someone with healthy gums in the hands of some of the most expert dentists in the country. When you add the complicating factor that you have significant gum disease, and add that to the possibility that your dentist may be an average family dentist, you are courting disaster.

So what should you do?

Anything other than the fixed bridge. Don’t end up in our collection of cosmetic dentistry horror stories.

The most economical solution would be a removable partial denture. With today’s acrylics, this could be made to be very esthetic and could have clear acrylic clasps that would be virtually invisible to anyone else. There are some inconveniences to having a removable partial denture, but the cost would be a small fraction of the cost of any other option.

The most comfortable and highest quality solution would be using dental implants. Now whether or not you could support the false teeth with two or four implants would depend on how much bone support you have and the stress of your bite.

My advice? Get a second opinion from an excellent dentist. (See my posts about how to ask for a second opinion.) There is an excellent dentist near you with a national reputation. I’ll send you his name as well as another who is quite a bit further for you but whose fees would be considerably lower. Some dentists will give second opinions for free. But even if you pay $100 for it, that would be much more sensible rather than throwing $10,000 or more at a solution that may only last a few months, even if you don’t end up having the second dentist do the work.

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 6, 2012

Dentist said everything was fine – but she grinds her teeth, so it’s not fine

Filed under: TMJ — Tags: , , , , , — mesasmiles @ 8:39 am

Hello Dr. Hall, I was hoping you could help and provide a little insight. I have been grinding my teeth for some time now while I sleep. My last dental cleaning and checkup was 8 months ago and everything was fine. I have recently been feeling pain from my lower back teeth. The dull pain lasts for 2 secs and then stops. It feels like someone is pulling at my back tooth and letting go. I feel this pain on both sides of the mouth (all back lower teeth). I have never had a cavity before so I don’t know what to expect. Does this seem like cavities? Or could it be something else? could it be from clenching teeth while asleep? What should I do to help my situation, I feel this pulling sensation and it’s very hard to describe. Hope you can help.
– Mona from New York

Mona,

Your two statements seem to contradict each other. You said that in your checkup everything was fine, but then you said you’ve been grinding your teeth in your sleep for some time now. If you have a grinding problem, then everything is not fine.

I’m not sure what is wrong with your teeth because I don’t have all the details – like what brings this pain on. And it would be helpful to see the x-rays and actually see your mouth and check things like tooth mobility. But I’m worried that your dental examination may not have been as thorough as it should have been, just from your comment that everything was fine in your checkup. Now I don’t know this for sure, not having been there, but I know this is a common problem in much dental care – a focus on cavities and fillings, and not paying much attention to other important dental problems like TMJ, gum disease, or occlusion. You get this in budget dental clinics and chain practices. I think you should get another opinion from a dentist who is possibly more thorough.

Having said that, your pain doesn’t sound like it comes from tooth decay. It sounds like the pain some people get when they have gum disease. Or it could be from the trauma of your grinding. I would find out, because either of these problems could be serious. If it’s gum disease, by the time you start having pain you could have significant bone loss. If it’s the grinding, you can literally grind your teeth away, and the solution could be as simple as wearing a nightguard.

Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

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

January 5, 2012

Opaque, bulky veneers from a dentist we recommended. Uh-oh!

I had an e-mail exchange from one of our visitors. Her name is Robin, and I’m not even going to say the part of the country she is from, because of the sensitive nature of what I did and what I told her. You can read her initial question and my initial response on my post: A $30,000 cosmetic dentistry blunder.

Here’s what she wrote back, which really surprised me:

Dr. Hall,
Thank you so much for responding to my question. I don’t do Facebook, but I would be happy to write a very positive review for you if you will tell me where to do it.

The dentist who did my dental work is actually on your recommended list, although I did not find your site until after the work was completed. I will happily check out your other recommendations. Thank you for taking the time to help me.
– Robin

After getting this I wrote back to her and asked her to identify the dentist that did her work, she responded to that with the following additional information:

Yes. I want to be fair, so I’ll tell you that I sought a second opinion from a periodontist because [Dr. Unnamed] stated that the brown margins are visible due to gum recession. This did not make sense to me because my gums are in most excellent condition by all accounts. I am told this at every check up. The hygienists tell me with amazement that I have no bleeding and that my home care is excellent. [Dr. Undisclosed], a periodontist, confirmed this as she said “Wow. These are really good numbers.” She also said the veneers fit very well. Yes, I guess they fit well, but they look bulky, opaque and lifeless. I was so disappointed from the moment I first saw them. I don’t want to suggest that [Dr. Unnamed] is an incompetent dentist. He is just not an artist.

I also saw [Dr. Anonymous – another cosmetic dentist we recommend in her state]. His opinion is that I should have them redone, as he thought they look lifeless.
– Robin

This was my response to that:
Generally, there are a lot of general criteria for whether or not I recommend a specific cosmetic dentist, and those criteria are lumped together, weighed, and I make a judgment call on the ability of the dentist. But there is one absolute, and that is that they have to listen and they can’t seat a case without the patient loving it. [Dr. Unnamed] has a lot of beautiful cases to show off. But an excellent cosmetic dentist will always try in a case and make sure it meets the patient’s expectations, and even if the patient doesn’t really object and the only clue to their dissatisfaction is the tone in their voice, I would expect the dentist to stop right there, find out why the patient is hesitating or not enthusiastic about the work, and send it back to the lab to fix whatever the issue is. If a dentist doesn’t do this, I don’t want to list them. Seating a case in the face of patient misgivings is a big “no-no.” I didn’t want to say this up front for fear you might be alarmed and out of niceness would then not tell me your complete, honest opinion. But I am going to pull his listing. I list these dentists with my personal recommendation, and it’s an embarrassment to me, a stain on my reputation, and a disservice to the patient to not have the dentist measure up to the expectations I create.

About the gum recession and gum disease – recession is one thing and pockets and bleeding are another. You can have very healthy gums with no bleeding and still have recession. There is a way to tell if the upper front teeth are vulnerable to recession, and placing a case where the bone and the gums are healthy but thin can provoke recession if the dentist isn’t extremely careful. So maybe this is what happened if the margins weren’t showing when the case was first placed but they are showing now.

[I’m embarrassed and a little nervous about taking the risk of being so open with our readers, but at the same time I wanted to let you know that I take seriously the responsibility of recommending the dentists I recommend. I made a mistake in listing this particular dentist and I feel bad about it. But this sort of thing hasn’t happened before, and hopefully it won’t happen again.]

 

 

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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 21, 2011

Cement left around my new crown

Filed under: Dental crowns — Tags: , , , — mesasmiles @ 2:40 pm

Dr. Hall
Is it common for a dentist to leave cement in a mouth that had a crown? My gums were hurting from the temporary crown. After the permanent crown was put on he said in a few weeks my gums would heal. They didn’t. I finally took tweezers and anything else I could find and pulled out a piece of cement under my gums. NOW my gums are healing. I felt instant relief after extacting this piece of cement. A 7 week ordeal.
– Mona from Texas

Mona,
This is a “no-no”, for a dentist to leave cement around a crown, and it will cause gum inflammation until it is removed.

I wouldn’t assume that you got all the cement but would make an appointment with the dentist, explain what happened, and say you want it checked carefully for any residual cement. If cement is left in there long-term, it can contribute to irreversible gum disease.
– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

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

November 23, 2010

Which Crown Is Best? It Depends on the Situation.

Filed under: Porcelain crowns — Tags: , , — mesasmiles @ 2:29 pm

Dr. Hall,
My dentist is recommending ceramic crown for my molar because she says that ceramic is better on the gum than metal crown. She is recommending a Lava crown. But the Lava crown is very expensive ($1200). My insurance doesn’t pay for Lava crown but pays for all porcelain/ceramic substrate.

What is your recommendation?

thank you,
– James in California

James,
There is some confusion here. A Lava crown is a “porcelain / ceramic substrate” crown. It is a very strong ceramic, with porcelain baked over the ceramic core. And as far as being kind to the gum tissue, I think gold is the best in that property. Of the ceramic crowns, Empress is noted for being very compatible with the gum tissue.

As far as what I would recommend, that would be hard to say without knowing more about your situation, what your bite is like, and exactly which tooth we are talking about.

And I also want to clarify this for others, because I am often getting e-mails where people want to know what is the best crown?  They read that Empress is the best, or Lava crowns are the best, and so forth. And it really depends on the situation. Plus, the quality of the crown depends mostly on the skill of the dentist who is placing it. This is what is going to determine the preciseness of the fit, more than any other factor.

I have crowns on all my molars. On my second molars, I have gold crowns. That’s because they have the most stress on them, and gold will not break. Also, you can’t see them at all, so the function and longevity is more important there.

On my first molars, which are the ones closer to the front, I have a mixture of all-porcelain and porcelain-fused to metal crowns. Porcelain fused to metal doesn’t look as nice, but for a tooth that is in the shadows, as all of my first molars are, you can’t really tell the difference between the all-porcelain and porcelain fused to metal.

I have one crown on a premolar and I wouldn’t have anything other than a bonded all-porcelain crown there. It shows prominently in my smile, and the all-porcelain looks exactly like a natural tooth.

Where the gum has receded and a tooth shows prominently, it would be important to me to have a bonded all-porcelain crown. When you bond porcelain, you can feather out the edge so that the transition where the crown ends and the tooth begins is undetectable.

If you have gum disease and want to avoid any inflammation of the gums, the best way to do that is to keep the margin of the crown high and away from the gums, so that what touches the gums is natural tooth structure. But then you may have to balance that with esthetic considerations.

I hope this is helpful.

Dr. Hall

Click here to find a cosmetic dentist.

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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