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A simple case of two front tooth crowns turns into a nightmare

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Dr. Hall,
I very much appreciate you taking the time to lend me your expertise regarding my 19-year-old daughter’s teeth. She fell and broke her 2 front teeth when she was 12. One needed a root canal and both had crowns. One of the crowns (root-canaled tooth) had gotten grayer over the years. We went to a new dentist for porcelain veneers.

When the veneers came back from the lab, the dentist was not happy with the color match, so he gave her temporaries and we waited for the second set of veneers. Let me start by saying that they look a lot better than before. As he was able to elongate the teeth and he recontoured her gum tissue, however she is still not happy with her smile and is disappointed in a few things. We discussed some our concerns and the symmetry of the teeth was corrected.

The issue now is there is a gray tinge to the root-canaled tooth, so it is not matching the other veneered tooth. It is also bulky and sticks out further than the other front tooth giving the appearance of having one larger tooth from different angles. The dentist said the gray is not an issue that can be corrected because of what he had to work with and remarked that we have come a long way as to how they looked prior. Are our expectations of having two matching in color and depth to appear natural unrealistic? We have spent about $4000 and had higher expectations. As you know a smile is everything—especially to a 19-year-old!

I have before-and-after pics that I can send, if that would help.
Again, I appreciate your advice.
Best, Michele from New York

(See Dr. Hall’s answer below.)


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Michele,
To answer your basic question, no, it is not unreasonable to expect these two teeth to match. And doing that doesn’t require that sophisticated a level of skill with cosmetic dentistry. But I can clearly see from the photos you have sent that you are in the wrong dental office.

First of all, let me say that from the photograph you included of the prepared teeth, these are not porcelain veneers—they are porcelain crowns. Some dentists must think using the words “porcelain veneers” sounds cool or sophisticated and I get emails from patients saying they were told they were getting veneers when they are crowns.

photo of a thin wafer of a porcelain veneer being held up against a prepared front tooth

A porcelain veneer

A veneer is a thin porcelain wafer that covers the front of the tooth. These that your daughter got cover the whole tooth, all the way around.

Or, is the dentist trying to put porcelain veneers OVER the two crowns? That makes no sense because it would be the same amount of work to remove the crowns and re-do them, which is what needs to be done here.

But the bottom line is that these crowns are in no way near acceptable. They are so far off that I have no hope that your dentist could get this right. When you have one broken front tooth and need a crown, getting that to match the other front tooth perfectly—that is difficult and takes a fairly skilled cosmetic dentist teamed with an excellent ceramist to do it. That type of case is one of the required cases in becoming accredited in cosmetic dentistry. Dentists who aren’t that skilled, confronted with having to do a crown on one front tooth, will sometimes try to talk the patient into letting them do two crowns in order to get a perfect match, which is fairly easy. But here you have a dentist who can’t even get the two crowns to match.

The dentist is having a problem with the one tooth having a grayer color to start with. There are several things that can be done. If I were doing the case, I would have cleaned up and bleached that underlying tooth to get a closer match between the two. Then I would have used some opaque buildup material to finish making that tooth approximately the same color as the other. But even not doing any of that, there is enough tooth structure removed that a moderately good ceramist should be able to lay some opaque porcelain down first to cover the gray color and then put a more translucent layer over that.

The problem some dentists have in working with a ceramist is that they aren’t that fussy about their cosmetic dentistry and so haven’t sought out a good ceramist who produces highly aesthetic work. And then making the two teeth the same size, I’m having trouble imagining what could be the difficulty there. The only thing I can think of is that the dentist and ceramist, struggling with covering up the gray underlying color, have decided to make the one crown thicker in order to cover that up and they actually think that will look okay.

In my opinion, this dentist should give you a complete refund so that you can go to someone who can get this right. I will send you privately a recommendation for a dentist in your area. If you get any resistance to giving you a refund, go to the dentist I recommend and see if they will help you with that. Or check back with me and there are another couple of things you could do. You should demand perfection with this case. Your daughter should be excited to smile and no one should be able to tell that she has had any dental work done on her front teeth. This case isn’t that hard.

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.

No, these weren’t really da Vinci crowns

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My dentist sold me da Vinci crowns for my front teeth. He said they had to be made by da Vinci in California because they had found they did the best work. I waited a long time and they finally said they had come in the mail, so I went in that day to get them placed. Anyway, they weren’t happy with them and said they were going to have to get them worked on a little. To my surprise a “man from the lab” showed up in the door to take the teeth and work on them. I saw him. Now I am in Tennessee and the lab is in California. I don’t think he flew in that fast to work on my teeth. Why would the sell me da Vinci teeth made only in a lab in California then have the work done in this area? This area has never made any teeth that suited me. I told them that. Damn. I think I have a problem no matter what you tell me!

– Charlene from Tennessee


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Charlene,
It does sound like there is some funny business going on here. While it is possible that your dentist had the laboratory work done at da Vinci and then had a local technician do modifications, that doesn’t seem likely to me, since the local technician would charge extra where da Vinci would make adjustments for free.

But your question gives me an opportunity to say something about dental laboratories in general and da Vinci Dental Studios in particular. When I was practicing in Iowa and was getting into top level aesthetic work, I tried to find a dental laboratory in Iowa that would help me create beautiful smile makeovers. I couldn’t find one, so I ended up sending my smile makeover work to da Vinci. I did that for several years, but at one point it seemed to me that da Vinci was going through some upheavals, so I switched. Uri Yarovesky was one of the partners at da Vinci, and he split off to form his own laboratory, Opus One. I began sending my work to him, and was extremely pleased with the work he and his associates did for me.

In my opinion, the vast majority of dental laboratories don’t have ceramists with the artistic talent required to create a beautiful smile makeover. But I wouldn’t say that da Vinci is the best in that department. Yes, they are very good. And they have a name that lends itself to their branding as a dental laboratory that produces beautiful work. But they are a large laboratory, and not every ceramist there is what I would call a master ceramist. During the years I used them, while most of their work was truly beautiful, I got some cases from them that I wasn’t happy with and had to send back. And the very best cosmetic dentists usually have a very close relationship with a master ceramist working out of a small dental laboratory. And I will add that those master ceramists often have fees considerably higher than da Vinci.

Back to your situation. There are some very mediocre cosmetic dentists who advertise that they place da Vinci crowns and veneers. As I said, da Vinci is a fairly large dental laboratory and, unlike some master ceramists, will accept work from just about any dentist. Don’t be fooled thinking this is going to give you a beautiful smile. It’s not that easy. A great dental laboratory cannot make up for the deficiencies of a mediocre dentist, which is why many master ceramists are picky about the dentists they will work with. Larger labs like da Vinci are also picky in that their top ceramists will work with the big name cosmetic dentists, and they will refer the “lesser” dentists to their other ceramists.

Bottom line for all our readers—if a dentist advertises that he or she places da Vinci crowns or veneers, take that claim with a grain of salt. Not only is da Vinci no guarantee that you’ll end up with a beautiful smile, it sounds like you don’t even have a guarantee that the dentist will actually send the work to da Vinci.


– 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 two crowns on front teeth turns into a nightmare

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Dr. Hall,
My daughter fell and broke her two front teeth when she was 14. One tooth needed a root canal treatment. Both teeth needed crowns. She’s now 20 and the tooth with the root canal has been getting more gray, so we went to a new dentist to have the one crown replaced.

Besides doing the new crown, the dentist contoured her gum tissue to make the teeth longer. But we’re still not happy with a few things.

The problem is that this tooth still has a gray tinge to it. It is also bulky and sticks out further than the other front tooth. The dentist said that he can fix the gray and he points out that it looks much better than when we started, which is true. But we’ve spent about $2000 and we had higher expectations. Are we being reasonable? I don’t want my daughter to be self-conscious about her smile.

I have before-and-after photos that I can send, if you think that would help.

Thanks for your time,
– Melanie from Oregon

(See Dr. Hall’s answer below.)


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Melanie,
To answer your basic question, no, it is not unreasonable to expect these two teeth to match. It just requires a little more knowledge about color manipulation, and, unfortunately, that isn’t part of the curriculum of a lot of dental schools. So you need to find a dentist who has enough passion about appearance-related dentistry to have taken some post-graduate education where he or she would learn these things. I can clearly see from the photos you have sent that you are in the wrong dental office.

Here’s the before photo you sent of the damaged teeth. This was a nasty accident.

before close-up photograph of a smile showing two front teeth broken off at angles

Michele’s daughter’s two broken front teeth

And here is the after photo.

After close-up photograph of smile, with two crowns. One looks brighter and bulkier than the other.

Here are the two crowns

And here is a view of the two crowns from above, showing how much the one crown sticks out from the other.

Close-up photograph of the crowns, taken from above, showing one of the teeth sticking out further than the other.

After photograph taken from above.

The bottom line is that these crowns are in no way near acceptable. They are so far off that I have no hope that your dentist could get this right.

One solution (which I don’t recommend) would be to re-do both crowns. But I don’t think that your dentist would even get that right, seeing that he thinks that the answer to crowning a grayer tooth is to make the crown thicker.

There are several ways that expert cosmetic dentists address a situation like this, where you are crowning a severely discolored tooth. One is to communicate, with photographs or an excellent description, the amount of discoloration in the tooth and leave it entirely up to the ceramist to mask it. The ceramist should have at his or her disposal a selection of more opaque ceramics that can cover up the gray. An opaque layer would be in the most interior part of the crown, and then more translucent porcelain placed over that. The problem some dentists have in working with a ceramist is that they aren’t that fussy about their cosmetic dentistry and so haven’t sought out a good ceramist who produces highly aesthetic work.

When I had a case like this, though, my approach was to cover up the discoloration myself and send to the ceramist a case that was much easier to match. If all root canal materials were cleaned off this one tooth and then the tooth were bleached, that would get the color matching much closer. Then the dentist could cover over what remained with a white opaquer. But your dentist might not even have a bleaching agent that could bleach a root canal tooth or any white opaquers because he’s not really that into cosmetic dentistry.

And then making the two teeth the same size. That’s pretty fundamental, that your two front teeth should be the same size. Apparently, your dentist and his ceramist, struggling with covering up the gray underlying color and not having appropriate opaquers at their disposal, have decided to make the one crown thicker in order to cover that up and they actually think that will look okay.

In my opinion, this dentist should give you a complete refund so that you can go to someone who can get this right. I can recommend a dentist in your area, if you’d like. If you get any resistance to giving you a refund, go to the dentist I recommend and see if they will help you with that. Or check back with me and there are another couple of things you could do. You should demand perfection with this case. Your daughter should be excited to smile and no one should be able to tell that she has had any dental work done on her front teeth.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

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 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


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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 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.

Should I get my crowns done in Costa Rica?

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Dr. Hall,
I am debating on going to Costa Rica to get my 12 crowns replaced. I have 6 on the top and 6 on the bottom. In Costa Rica they do everything in a lab and it takes two weeks ( So I have to stay 2 weeks, which isn’t a bad thing except the time I can go it will be raining). I am just curious what my options are here in Arizona since I just moved here. I am looking for natural-looking teeth and would like a dentist that doesn’t make my teeth look like they came from a cookie cutter so to speak. In Costa Rica I can get all of my teeth done for around $6000. Not including the travel and hotels etc. Is there anything comparable to that here in Arizona that you know of?
– Tanya from Arizona
dentistry in Costa Rica
Tanya,
I have a question for you before you go to Costa Rica to have your crowns done. Do you think there is any possibility that anything could go wrong in the process of getting twelve crowns?

I’ll give you the answer to that question–yes, there are any number of things that could go wrong. Let me list some of them for you, off the top of my head:

These are the first twelve things that came to mind, of problems I have either seen or patients have told me about when they had multiple crowns done. It isn’t an exhaustive list.

And then here is a link to an earlier blog post I wrote about dentistry in Costa Rica. A woman wrote to me about crown and porcelain veneer work she had done there. She ended up having four of these things on the list go wrong, and some things that aren’t on my list. Another dentist told her that what was done to her by this Costa Rica dentist was criminal negligence. But when she tried to get satisfaction, SHE ended up being the person in legal trouble, because of the corrupt legal system in Costa Rica. She has an estimate of $35,000 to fix the damage this dentist caused.

Even with excellent dental care, with that many crowns there is often something that will go wrong during the treatment. It appears that if that happens to you in Costa Rica, you’ll end up stuck.

If you want to save some money and you’re in Arizona, one option could be to go to Dr. Isaías Íñiguez. He is actually AACD accredited and has a practice in Los Algodones, Mexico, just across the border from Yuma, Arizona. He charges Mexican fees for what I believe is high quality cosmetic dentistry. Check him out.

– 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.

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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.

I’m having trouble speaking after getting my porcelain veneers

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Dr. Hall,
I had 10 porcelain veneers placed and two crowns on each side 2nd to last tooth. The final temps looked and felt great. When the permanent teeth were put on I was having trouble speaking. Biggest problem is my tongue is very uncomfortable. It feels like it is too big for my arch and resting on the back of my bottom front teeth.
What is making my tongue sit low in my mouth. My dentist can’t figure it out. Could it be the back of front teeth are too thin? or maybe the two crowns that were put on premolars?

Thank you,
Susan from New Jersey

Susan,
It’s going to be hard for me, not seeing your case, to really tell what is wrong. But your question gives me a helpful starting point for saying something about smile makeovers and speech.

As far as your case, porcelain veneers, if that’s what they are, in most situations shouldn’t be affecting your tongue or your speech. They sit on the fronts of your teeth, so your tongue shouldn’t feel any difference. But some dentists actually do porcelain crowns for smile makeovers and call them porcelain veneers, so that’s a possibility for you. Crowns cover the entire tooth.

If you do get a smile makeover of porcelain crowns, that will have the potential to affect your speech. Expert cosmetic dentists are trained in the effect of the teeth on speech and will be careful about the contours of the crowns and how they affect your tongue. The thickness of the crowns on the lingual surfaces (the insides of the crowns) will affect the pronunciation of certain letters. The length of the front teeth and the positions of the incisal edges of those teeth will affect other letters. The height of back teeth will affect others. To assess all these effects, any new smile that changes any of these critical measurements in your mouth should be tested in provisional restorations first, and the provisionals should be adjusted to accommodate your speech to where they feel comfortable to you before the design is finalized in porcelain.

But you said that the temporary teeth looked and felt great and you only had trouble when the permanent teeth were put on. Something isn’t right there. What is usually done is that an impression is taken of the temporary smile makeover and that is sent to the dental laboratory so that the ceramist can duplicate that result in porcelain. That must not have happened exactly that way in your case. Either the dentist didn’t send those models to the ceramist (maybe only a photograph) or the ceramist didn’t follow the instructions.

Having said all that, ordinarily patients will adjust to new positions of the teeth and speaking will feel normal to you again after a while. If a couple of months go by and you still have problems, I would insist that it be fixed, even if it involves re-doing the case and/or referring to a different dentist.

Dr. Hall

Follow-up – Turns out, this was just the beginning of Susan’s problems. Read what happened to her when the dentist tried to fix the problems and what Dr. Hall said in response. See the follow-up to problems speaking with new porcelain veneers.

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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.

Getting porcelain veneers and crowns to match

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Dr. Hall,
My question is, how hard is it to get all veneers to match, when the tooth stubs are dark. I’m getting one crown, and the rest of the smile is porcelain veneers. In my case, the crown looks whiter than the adjacent veneers. Shouldn’t there be a way to make them more matched? Love my dentist, but I think it could be a dental lab issue. I paid a lot of $ & I’ve seen many cases where everything matches. Thanks!!
– Carol from Pittsburgh

Carol,
This is an issue that a lot of family dentists have trouble with. Dental schools tend to trivialize cosmetic dentistry and teach that it is easy to do–any dentist can do this. But there are some basic color concepts that they really don’t teach the dentists. And then the vast majority of dentists don’t have a passion for appearance-related dentistry, so they don’t take the trouble to get this extra training.

Porcelain is naturally translucent, just like enamel, which makes it an excellent dental material. But porcelain veneers are thin, and porcelain crowns are several times thicker than veneers. So if the underlying teeth are dark, as yours are, that dark color is going to shine through the porcelain veneers much more than it would with the crown. That is the basic problem here.

There are two basic ways around this. One way is to accomplish this with the porcelain. Another is for the dentist to apply the opaque to the teeth before sending the case to the lab.

Opaquers can be added to the porcelain, but this requires quite a bit of skill on the part of the laboratory, to make the entire case turn out correctly. If the crown is translucent, the veneers need to be opaqued in a way that makes them appear just as translucent as the crown. It can be done, but is tricky. It also requires good communication between the dentist and the laboratory–the dentist needs to either provide photos of the prepared teeth or a detailed description of their color so that the laboratory can make the proper adjustments. There are excellent esthetic dental laboratories that can do this well.

In my practice, I preferred dealing with the opacity issue myself, as part of the tooth preparation. I would shave a little extra from the dark teeth and then apply an opaque layer of composite onto the teeth. The deeper the opaque layer is, the more room is available to create the needed translucent effect with the porcelain. The composite bonds chemically to the porcelain veneer luting cement giving a strong, attractive result.

– 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.

The root of great cosmetic dentistry is empathy

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Dear Dr Hall
I am having 9 crowns replaced, I originally had a white bleach colour which I did love but wanted them replaced. The dentist I have now has put me in yellow temps which I hate and he cannot get the bite or shape correct and he wants me to move on to my finals, When I mention the shape he tells me he thinks they are perfect and raises his voice, I don’t know what to do, can you please advice me on any good cosmetic dentist in the UK.

Kind Regards
Yasmin from the UK

Yasmin,
I love your question because the way you have described your dentist gets at the foundation of the problem many dentists have in not being able to deliver good appearance-related dentistry. He is basically telling you with his response to your objections that he doesn’t care what you think about how it looks. You hate how it looks. He responds by raising his voice.

The root of great cosmetic dentistry is empathy. You want to look good and the dentist identifies with your desire and wants to help you feel good about your appearance. From that empathy springs the dentist’s desire to learn how to deliver beautiful dentistry and to hone his or her skills so that you can walk out of their office eager to show everyone your beautiful smile. Empathy also drives the willingness of the dentist to listen to you and to believe that your opinion of the appearance of the work is what really matters.

Some in the profession see cosmetic dentists as overly concerned with what the patient thinks, and they consider that pandering to the patient. They try to assert that because of their education dentists know what is best for the patient and to be too concerned with what the patient wants is a betrayal of the ideals of the profession. It’s a very different view of the doctor-patient relationship.

You can’t get around that fundamental problem with a dentist unless the the dentist has some type of “awakening” on the order of a spiritual conversion. That’s not to say that such a dentist can’t be an excellent dentist. It’s just that their priorities make them unsuited for appearance-related dentistry. So you have the right idea here–you need to find another dentist to get this to look right. You should have no problem switching in the middle of the procedure.

You’re up near Liverpool. I haven’t been able to find any really good cosmetic dentists in your part of the country, but there are several excellent ones in and around London. The one I think is the best and the one I recommend there is Dr. Tim Bradstock-Smith. He does beautiful work and is AACD-accredited. You’re going to have to live with this smile for a long time–I’d take the trouble to make the trip to get this done right.

I wish you well.
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.

Follow-up on crowns vs veneers for tetracycline stained teeth

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Earlier this week I fielded a question from Michele from Florida. She wondered if she should get crowns or veneers for her severely tetracycline-stained teeth. I asked her some questions about the fees and the dentist she was talking about. Here is her reply, and my response to that reply:

Dr. Hall
Thanks for your input. The cosmetic dentist is Dr. A (name withheld to help preserve Michele’s identity). He wants to charge me $42,000 for a full mouth of veneers (two teeth require crowns due to damage). The other dentist wants $26,000 for crowns. My budget cannot go over $30,000. Also, I forgot to mention that I grind my teeth at night and wear an appliance. I’ve read that veneers don’t stand up to grinding as well as crowns.

My response:

I know the cosmetic dentist you went to, and he is really good. He would give you a stunning smile. I’m not surprised that his fees are high—he is worth it.
About your grinding (also called bruxism). If you wear your nightguard, you should have no problem with your veneers. If you grind your teeth, you are actually at higher risk with crowns because then you don’t just chip off the edge—you break off the entire tooth. I had several patients who had to deal with that and you end up with implants later in life. Once you break off a front tooth at the gumline, if you’re a grinder, there isn’t a whole lot you can do with it. You see, with a crown you grind off a full millimeter of the tooth, all the way around. So if you have an upper lateral incisor that is 5 or 6 millimeters in diameter (let’s say 5.5 mm) at the gumline, then you grind down 1 mm all the way around, you now have 3.5 mm diameter. So you used to have a cross-sectional area of 95 square mm – now you have 38 square mm. So you now have 40 % of the strength left, when you’re talking about resistance to breaking off at the gumline. People who grind break these teeth off when they’ve been prepared for crowns. The lower teeth are even worse. You actually cut the strength of lower incisors down to about 1/4th of their original strength.
Here are a couple of options I would suggest:
1. Do just the upper with Dr. A and do Kör Whitening on the lower. That way you get a stunning smile and cut the cost about in half. Kör, if you use it for long enough, will have a significant effect on the tetracycline stains and lighten them enough to be acceptable as lower teeth. Then at some later point, if you feel you need to improve the result even further, you could do the lower. I had a couple of cases of tetracycline stain that I treated where we did just the uppers and didn’t do anything to the lower. With most people, the lowers don’t show as much, especially if you are younger. And even when they do show, they are kind of in the shadows.
or
2. Check out Dr. B. He is in your city. I know him also, and he also does beautiful work and his fees might be within your budget. His work isn’t at the level of Dr. A, but it’s good. Call and find out what he charges per tooth for porcelain veneers. If that doesn’t work, you could find someone else that you could drive to see. I’m confident you could find someone who could do beautiful porcelain veneers and stay within your budget. Even if you needed to fly somewhere, if the fees were $15,000 less, it would be worth it.
The interesting thing about the costs of cosmetic dentistry is that really the fees are pretty comparable for a good general dentist and a good cosmetic dentist (with the exception of exceptional artists like Dr. A).

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.

Can I switch from having crowns on my front teeth to having porcelain veneers?

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Dr. Hall,
If my top two front teeth were initially ground down for crowns and there is no crown on the teeth will veneers work on the teeth now?
– Tina from Kentucky

Tina,
Once a tooth has been prepared for a crown, a crown is the only restoration that will work for that tooth – it will always need a crown.

The difference between a crown and a porcelain veneer is that the veneer covers just the front of the tooth and not the back, whereas a crown covers the entire tooth. But the distinction is not cut and dried. Some veneers can also involve the sides of the tooth. And some dentists will talk about placing porcelain veneers and then prepare the teeth for crowns. I disagree with this practice, and most expert cosmetic dentists would feel the same way, but it happens. To make it more confusing, many dentists will charge the same fee for a veneer as for a crown. So if the dentist covers the entire front of the tooth, both sides, and half of the back of the tooth, is that a crown or a veneer? I would call it a crown, but some dentists would call it a veneer.

Removing a lot of tooth structure is aggressive dentistry. However, I like the philosophy of minimally invasive dentistry, meaning that the dentist removes the least possible tooth structure to accomplish the desired outcome. This is the practice of the great majority of excellent cosmetic dentists – the type of dentists we recommend on this website. So if you need a new smile, we would shave about half a millimeter of enamel from the front of the tooth, which is about the thickness of a fingernail. There would still be enamel covering the tooth – it would just be a little thinner. That allows for half a millimeter of porcelain, which is adequate for changing the look of the tooth – the shape and the color. If a tooth is out of alignment – say it protrudes out in front of the others – then more would need to be removed to leave it in line with the others. Likewise, if it is turned inward, there may need to be little or no enamel removed at all to give an attractive result.

A crown will strengthen a back tooth against tooth fracture in almost every situation in which it is used. However, on front teeth, since they are subject more to horizontal stresses, a crown can weaken an otherwise healthy tooth, making it more susceptible to lateral shearing forces. That is why I like to be as conservative as possible in treatments to front teeth. A well-placed, conservative porcelain veneer will not weaken a tooth.
– 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.

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