Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

April 23, 2018

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

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About David A. Hall

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

May 7, 2016

The technician can’t get the color right on my two front teeth


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Dr. Hall,
I’m writing you from Germany. I’m a dental patient and getting two front crowns with e.max but my technician just won’t get them in the right colour.
My stumps are not dark and my teeth have a BL3 colour.

The problem with all the crowns I tried in was that they turned out too grey.

The technician has made a couple of sets of crowns already, and has experimented with pastes. When they tried in the first set of crowns they looked too grey. He then tried a bright white fit checker underneath, and they still looked grey.

So for the second set he made them with a bright white ingot and layered over it to cover the white. When we tried them in without any paste they looked grey again. This time he had a regular try-in paste in the colour light +. So he put that underneath the crown. The crown was not grey anymore but completely opaque and lifeless and had a terrible bright white. I did not like the crowns At all. The technician said he can’t do it better. I am so unhappy and don’t want to end up with two opaque front teeth that do not match my other teeth. Do you have any idea what went wrong? Did he use the wrong ingots? Or the wrong try in paste?
I thought maybe we should use a LT Bl3 ingot and a try in paste that is less opaque.
Please, please, if you have any suggestions I would love to hear from you.

Tilo's front teeth crowns

I do have photos of both crowns which I could send to you.

Thank you so much!

Tilo from Germany

I asked for photographs, and here is what Tilo sent me. The top photo is a view from the side that shows the color discrepancy.

And the bottom photo is a view from the front, with lips relaxed, that to me was even more revealing because it shows that the shape is all wrong:

Tilos-front-teeth-crowns-2

And here is what I wrote back to Tilo:

Tilo,
Let’s see if I can help you.

After seeing the photographs, I do think the problem is fundamental, that the dental lab technician isn’t very good with color. And more than that, the technician isn’t very good with aesthetics in general.

But I suspect it is even more than that. Your dentist is the one who selected this technician. Dentists who are accustomed to doing aesthetic work and who do it well will always choose a dental technician who can produce a high level of aesthetics.
Here is how I see your situation. This dentist and the technician I imagine have maybe done many crowns together, including crowns on front teeth. In their mind they have turned out fine. The patients maybe weren’t thrilled with the results, but they were willing to accept them. Now you come along and for you, the work simply isn’t good enough. They have been back and forth trying different colors, and it’s not good enough for you. If I am sizing up this situation correctly, you are becoming annoying to them. They think you should just accept what they have done–it’s good enough and you’re too demanding.

On the other hand, a dentist who does high quality aesthetic work would not put up with this level of work from his or her lab technician. It sounds to me that in this group of three–the dentist, the technician, and the patient–that you’re the lone voice thinking this isn’t good enough.

This Work Isn’t Good Enough

But you’re not completely alone, because I agree with you. The crowns simply aren’t good enough. But you may have to do more than get your dentist to pick another technician. Your dentist may not even know any technicians who are artistic enough for this case. I don’t know how things work in Germany, but I would brace yourself for maybe needing to find another dentist to finish this for you. I wouldn’t switch dentists immediately, but would ask your dentist if he knows how to find a technician with better aesthetic skills.

Having said that, let me get to the crowns. The problem isn’t just the shade and the grayness. The shape is a problem, too. They are too bulky and round-looking near the necks of the teeth. In the middle photograph of the second group where you have your lips relaxed, the crowns look awful! They are very prominent and make you look like a chipmunk!

Then, as you have written, there is a problem with the color. But it isn’t just the shade that is picked–the color is flat. The color of the crowns looks fairly uniform from the gumline to the biting edge. This is not how teeth look naturally. These crowns have kind of a uniform grayish tinge. If you look at your natural lateral incisors, you’ll see that they are kind of a very light creamy color near the gumline, with a very slight reddish-brown tinge. Toward the middle of the tooth they are lighter, with more white. Then, near the biting edge, they are fairly translucent with a more opaque halo at the very edge. So you see, it’s more involved than a simple color selection. Though I suspect that to your dentist and the lab technician, it’s a simple matter of selecting a shade. What I did when I was doing crowns on front teeth is that I would draw a large color map of the tooth and I would diagram the different color areas. I would have a basic background color that I would ask for, one that I would select from the standard shade guide, and then I had different tint tabs that I would use as a reference and explain to the technician where I wanted these color accents and variations. You are getting nothing like this from your team.

Maybe the best thing I can do for you is to encourage you to stick to your demands. Don’t let them cement these crowns permanently, but insist that they match and look natural in your mouth. There are dentists and technicians who can do this level of 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.

May 10, 2010

A seriously botched $25,000 smile makeover

Dr. Hall,
Recently I had $25,000 worth of porcelain crowns on both my top and bottom teeth-paid up front. I went for my consultation, picked my smile style, and told the consultant that I wanted a white bright smile that looked natural. I was given something to lighten my bottom teeth. I also had a metal bridge replaced so that it would match my upper teeth. All top teeth were crowned. After extensive xrays and mouth impressions, I was fitted with a temporary set of teeth. I was told that by wearing the temps, I would be able to see how my teeth would look, the shape and size, and color, in case I wanted to make any changes in my porcelain crowns. I was also told that I was the one who had to be happy. Two weeks later, when my crowns came in, the first thing I noticed as they were on the table was that they looked dark. I commented on this, but the girl who was to put them on said that they would look different in my mouth. When she put them in (not cemented) she told me to be careful when I sat up to look in the mirror because they were not in yet. From the moment I looked at them, I said “They are too dull!” I continued to say this, even as they were falling out and I could see I had no teeth left on top. By the way, I went in because my front teeth had been bonded years ago and had been chipped away by my bottom teeth. Other than that, I had strong, white teeth. As I continued to say I did not like them, she said suggested we go outside in the natural light with a mirror. Even on the outside, I kept saying I did not like them and that they looked dull. She told me that my eyes were playing tricks on me because I was used to the white temporaries and that once on, I would see a difference. We went back in and I looked in the big mirror above the sink in her lab. One of my front teeth feel on the floor and she picked it up and watched it off…. I was about to cry. Then the girl who cleans the teeth stepped in and said how I would love them once they were in and polished up. Never once did the doctor I paid the money to come in to see what was going on…Never once was I offered an option like, “Do you want them whiter?”

I was so frustrated and upset. I felt pushed against the wall about the matter, having no teeth in my mouth and being convinced that I was seeing things. Needless to say, she cemented them in. After they were in, the doctor came in and started trying to level my top and bottom teeth. Once he found out I was unhappy, I had to tell him, he told me to wear them a week and come back and he would finish … He said we want you to be happy.

After a week, I went back. In the light I had also discovered that the bridge I had replaced did not even match the other teeth. The girl said, You have a metal bridge (4 teeth @ $1700) so it’s going to be different. I explained to the doctor that I had tried to tell the girl before she put them in I was unhappy with the color… He said ” Well we have to be fair to everyone, the lab, the workers ,,, no way can we redo what we have done.” He then said maybe he could remove the stain on my porcelain crowns to match the white bridge. I am suppose to go back in a week. He said if the lab used a certain stain, this might be possible. I am so upset. I trusted these people. I don’t know what to do. My husband is going to go with me this next visit. I have to go back. I can’t eat with the crowns because they have not been level and are very painful. Any suggestions? Thanks for any help!
– Sandi from Texas

Sandi,
If I am sizing up correctly what was done to you, based on the story you have told, you are the victim of seriously unethical cosmetic dentistry. You were told that they would be sure you were happy with your smile makeover, but it sounds like they had no intention of actually honoring that promise.

Again, if I am sizing up this situation correctly, and if it happened the way you told me, you are dealing with very pushy people, and you are going to have to take a different tack if you are going to get anywhere. You have to be willing to get a lot more serious with your complaints and maybe get some legal help. Are you up to standing up for your own rights?

If these teeth were put in over your objections, then this is classic malpractice. A fundamental principle of health care is that all treatment is rendered with informed consent. When you didn’t consent to the treatment, and they put in the teeth anyway, legally, that amounts to assault. But if you are going to get anywhere, you have to have some steel in your spine and be willing to stand up to these people. And just having your husband go in with you to the appointment isn’t good enough.

My judgment would be that you will need to help this dentist see that he is legally on thin ice in order to get him to fix this. I would suggest getting a lawyer to write a letter that suggests that you may sue them unless they totally redo this for you and honor the promise they originally made that you had to be happy with how they look before they would put them in. Or, if you don’t want to do that, you could take this e-mail and that might help open their eyes. Then, if they don’t agree, you could go to a lawyer.

For additional help, I could line you up with a great cosmetic dentist not too far from you. If it were me, I wouldn’t settle for this dentist re-doing the work. I wouldn’t ever let him touch my teeth again. Instead, I would demand that he pay me to have the work re-done by someone more compassionate and skillful. At this point, do you trust him? I wouldn’t.

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.

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