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A full-mouth reconstruction horror story

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Hi Dr. Hall,
I found you by searching on crowns and dry mouth.

A couple of months ago my dentist removed my 18-year-old veneers and restoration of my upper teeth 7 veneers and bridge was to begin. I complained every day about my temporaries and requested that he take them down on 2 separate occasions. My bridge fell out 3 times before permanents arrived. A little over 3 weeks ago he delivered them. The appointment was over in 40 minutes.

I’m suffering with my lip sticking, air stuck in my front teeth blowing bubbles, and my mouth is so dry that I’m eating popsicles all day and night for relief from dryness and the sucking I’m doing of my tongue and lip. I suck on my tongue and back of teeth so hard it burns! I can’t seem to stop sucking. What is wrong with me?!?! The porcelain is tough and rigid. He said he had to open my bite so I can show my teeth but I’m not showing teeth at all actually, it’s really really odd and the dentist claims I’m going to have to adapt because his “checkpoints” are perfect and textbook case. All I wanted was B1 shade and the hand press style porcelain that I’ve known my adult life! Please help me if you can.

I’m 42 and my second time in veneers and I’m miserable. I gained 3 extra crowns and a substantial gap in my bridge. With almost a month in, this can’t be healing tissue, is it?

Sofie from Michigan


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Dear Sofie,
No, this isn’t a healing issue. This is a “dentist screwed up issue.” You need to get this fixed and I’ll be blunt as is my style—you need this new work taken out and started over again. And I wouldn’t have this guy doing it.

Opening the bite requires crown work on at least every tooth in one arch—most typically it is done with a full-mouth reconstruction meaning every tooth is restored. And it needs to be done with great care. It needs to be done with temporaries first. At least it looks like your dentist did that, but it sounds like he didn’t respond to your discomfort. You wear the temporaries at the proposed new opening to make sure you are comfortable with it and function properly. You’re telling me that you “complained every day” about your temporaries, but it looks like your dentist plunged ahead anyway.

Your body has a certain amount of jaw opening that it is comfortable with. This amount of opening is tied to the muscle tension in your jaw muscles, as well as reflexes that are part of speaking. Opening the bite is indicated when there is bite collapse—you have worn down your teeth to where your mouth is over-closed. In that case, we open the bite to restore your normal vertical dimension.

A big part of the problem in your case is that your dentist opened your bite when I’m guessing that you already had a comfortable bite. He was doing it to get more of the upper teeth to show. That puts him into risky territory from the start. If this is correct, that your bite was already comfortable, opening would put you beyond your normal opening, and that’s when you get into these issues that you are having: lip incompetence (the lips when relaxed don’t close all the way) leading to dry mouth, speaking problems, and other issues. He claims that your “’checkpoints’ are perfect and textbook case.” No, I’m sorry, that’s not the case. The main checkpoint is does your mouth when relaxed close naturally, and it doesn’t.

A Warning

A side note and warning for you. DO NOT EAT POPSICLES to keep your mouth wet. That is one of the worst things you can do, unless the popsicles are sugar-free. Your dry mouth doesn’t have the proper amount of saliva, and it’s your saliva that has your defenses against decay. You are risking rampant tooth decay getting in under your crowns and ruining your teeth. Get something sugar-free to suck on.

What to Do Now

I’m sorry to have to break this to you, but you need your whole case re-done. And I would not have this guy do it. I’m sorry again, but I wouldn’t trust him. What has happened in your case causes me to question his ethics. This is a serious breach of professional care and admittedly I don’t know all the facts in your case, but from what I know he is liable for malpractice. Maybe he is a really good guy and was just trying to do the right thing. But the stakes are high here and there is a small minority of dentists who know how to do this right.

I’ll tell you what I’ll do. I’ll email you privately with a recommendation for a very good dentist with strong ethics and well trained in cases like yours. I don’t want to give a name like this publicly lest the dentists I don’t recommend get offended. And then I would ask this new dentist to contact your current dentist and ask him nicely to refund your money to keep you from complaining to the dental board, putting his license in jeopardy; or from going to a lawyer.

– 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.

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


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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

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 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.

After my new crowns, my jaw and neck hurt all the time

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Dr Hall,
I recently had my six front teeth, from canine to canine, crowned. Doing this it closed a large gap between my two front teeth. Now I can’t speak clearly and because of the closure and the stress of trying to learn how to speak again my jaw and neck hurt all the time. Also, my mouth stays dry and my lips are numb what could this be caused by?? Also is it possible to get the space put back between the two new crowns on my front teeth?? Your advice would be appreciated.
– Paul from Georgia

Paul,
This sounds like a serious problem that needs to be addressed.
I am pretty confident your troubles have nothing to do with closing the gap between your two front teeth, but are because of other problems with the crowns. I closed many such gaps in my practice and never had any adverse feedback like you are giving me—no speech issues, pain, or dry mouth. It sounds to me that your dentist opened your bite too far.
It could be that your crowns are too thick and/or too long. This could cause a problem called lip incompetence which is the failure of the lips to close naturally, without effort when your teeth bite together. If your bite is correct, when you put your teeth together, your lips should naturally fall into place and be closed without your having to think about it. Your dry mouth and the numbness in your lips suggest to me that you may have this lip incompetence.
Also, if your crowns are too thick, they could throw off your bite leading to pain in your jaw and neck, besides causing speech problems.

Both the pain and the dry mouth are serious problems. The pain issue is obvious. The dry mouth less so but is just as important because it can lead to rampant tooth decay. The washing and buffering action of your saliva, plus the antibodies it contains are critical in fighting tooth decay. Don’t let this go on.

You really need a second opinion. I’m suspecting that your dentist got in over his or her head in doing this many crowns simultaneously on you. That’s my guess. I’d go to one of our recommended cosmetic dentists to evaluate the result and see what needs to be done to fix it.
– 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 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.

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


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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. In your case it appears to be 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, as you have explained it, 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

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 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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