Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

March 7, 2019

All ceramic vs porcelain-fused-to-gold crowns


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Dr. Hall
I am having crowns replaced over tooth number 4 & 5. There is, as I believe, no cosmetic value of using pure porcelain versus Crown Porcelain fused to High Noble. There is a significant extra cost of $200.00 per each pure porcelain. In general, would a pure porcelain fused to a High Noble versus pure porcelain be just as effective over the long term?
– Garry from California

Garry,
First, I like to talk about terminology so we know exactly what we are talking about. We should be saying all-ceramic crowns, not all-porcelain. Porcelain is only one of various ceramics that have been used for crowns and even some dentists gloss over this terminology. Few dentists are placing all-porcelain crowns on back teeth these days because they are very technique sensitive and are much weaker than the newer high-strength ceramics, lithium disilicate and zirconia. The eMax crown, which I believe is the most popular crown being used by dentists today, features a lithium disilicate core with porcelain baked over it. Lithium disilicate has reasonable aesthetics—it is white and somewhat translucent—but it comes in blocks and is shaped by milling, so the technician doesn’t have the ability to manipulate the color the way porcelain color is manipulated. Porcelain comes in a paste and it is placed, shaped, and then baked. So the ceramist can apply various colors and translucencies of the paste in different layers over the lithium disilicate core with a great deal of control over the aesthetics.

My guess would be that your dentist is talking about putting all-ceramic crowns on your teeth numbers 4 and 5, which are the first and second premolars on your upper right. So your question is, should you get porcelain fused to high noble (otherwise called porcelain fused to gold) instead.

Cosmetic dentists consider upper first premolars to be in the smile zone on almost all patients. Practically everyone will show that first premolar prominently when they smile. It may not be prominent when you look at yourself straight on in the mirror, but it is very noticeable from the side. For me, I would not want a crown made of porcelain fused to gold or any other metal here because there will be a significant risk of a dark line showing at the gumline. The dark line comes from the metal foundation showing through right at the margin of the crown.

Behind that first premolar, in my smile, the teeth are all in the shadows, so the aesthetics is much less critical there. In my mouth, I do have a porcelain fused to gold crown on one of those teeth. I also have a crown on my upper left first premolar, and that crown is an eMax.

So my answer is that I disagree that there is no cosmetic value here. Having said that, if you were my patient and wanted the porcelain fused to gold crown on your first premolar, I wouldn’t fight you on that. But then I probably wouldn’t have the issue come up because I would charge the same fee for either crown. A porcelain fused to high noble crown is a premium crown, and I charged more for that than for a porcelain fused to noble (semi-precious metal) crown. But I don’t understand why the all-ceramic crown needs to be more than the porcelain fused to high noble.

– 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 4, 2017

Playing games with insurance (PPO) fees


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Dr. Hall-
My dentist’s treatment plan calls for two lower 3-crown bridges for the second back tooth forward on each side. The dentist advises porcelain fused to metal crown/bridges—due to it being a stronger material to resist grinding pressures—and wants 20% additional $$ above the PPO contract rate for the “upgraded” crown materials vs. all porcelain crown/bridges.

I have three questions:
1. Which type of crown is better and will have best chance against cracking?
2. The 20% “upcharge” labeled as “lab fees” is not a covered code by my insurance. Can a dentist charge above the PPO contract rate and refuse to use the “standard ” porcelain/ceramic crown which is covered by insurance? It seems to me that it is a “work-around” the contract rate, effectively avoiding the limited contract rate fee.
Though I may prefer to have the PFM bridges if they are indeed stronger. I simply may not be able to afford this mandated “upgrade” and I do not think I should have to switch dentists as a result of this, since he is an “in-network provider.”
3. I have all porcelain upper bridges on each side, so my other concern is will the lower PFM crowns grinding against the “all porcelain” upper crowns cause the upper to more likely crack sooner, as I will have stronger material grinding against softer material as opposed to a like material against a like material? Does that make sense?
Thank you.

-Tom from Ohio

Tom,
If you are communicating this accurately to me, then there is indeed some funny business going on with your dentist trying to get away with charging above the contract rate for your bridges. It certainly sounds to me like he or she is playing games with terminology and fees. Let’s address that first.

To sort this out, we need to clarify the terminology here.

First, for the benefit of readers who may not know, a PPO is a preferred provider organization, which is a network of dentist providers that have made an agreement with an insurance company to offer discounted fees to the subscribers of the plan being offered by the insurance company.

Then, as far as the types of crowns, my guess is that your dentist, for the crowns that are a part of the bridges, is using the procedure code D6740 – retainer crown porcelain/ceramic. Notice the term “ceramic” in this procedure code. That’s important. Porcelain isn’t strong enough to serve as a bridge even on the front teeth, much less on the back teeth. It will crack under chewing pressure. But there are other ceramics that are plenty strong enough, and many dentists are now offering these metal-free bridges. I can’t help but assume that we’re talking about one of these higher-strength ceramics here and not porcelain.

But now you’re saying that your dentist wants to “upgrade” to a porcelain fused to metal crown. A couple of problems with these games he or she seems to be playing with the terminology. First, to me the upgrade would be the other way around. The higher strength all ceramic crowns would generally be more expensive. Second, there are procedure codes for porcelain fused to metal crowns and I’m sure the insurance company would have that on their fee schedule. There are three codes for porcelain fused to metal crowns: D6750, D6751 and D6752 for porcelain fused to high noble, base metal, or noble metal respectively. Now it’s possible that the PPO will not pay for the bridge if the metal is high noble. But the noble metal is actually stronger and unless they are really cheap, they should have a fee for that.

And the idea that this “upgrade” is mandatory—that seems to me to be a violation of his contract with the insurance company. The dentist can offer you an upgrade as an option, but he or she has to give you the choice of doing the service that is covered by your plan.

About your other two questions:
The porcelain fused to metal is a little stronger, but the high-strength ceramic is plenty strong enough for a bridge on back teeth.

As far as compatibility with the upper bridges, yes, you are better off having similar materials chewing against each other. Neither one is going to “crack,” but they will wear. You would be best off contacting the dentist who did the upper bridges and finding out exactly what was used on the chewing surface and matching that. You have these high-strength ceramics, but they are often made of a framework veneered with a porcelain.

Then I have a final question for you. Let’s say you tell your dentist no, you want the porcelain/ceramic crowns because you understand that is your right under your insurance plan. Will he or she give you then the high-strength zirconia ceramic? Or will you get the porcelain which won’t hold up? Bottom line—do you trust this dentist?

– 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.

September 29, 2015

Is this dentist trying to scam the insurance company?

 

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Dr. Hall,
I had three crowns done – upper and lower first molars on the left side, and lower right second molar. They were porcelain fused to high noble metal, insurance code #D2750. For $150 each, the dentist suggested I upgrade to crowns with added porcelain, so there would be no black line on my gum line in the future. On his advice I agreed.

When I got the insurance paperwork I noticed there was a charge on all 3 crowns for pulp cap direct, insurance code #D3110. Nothing was ever said to me about the pulp cap direct, so when I questioned it, his office insurance lady said that the insurance takes care of that, and whatever they don’t take care of she will write that portion off at no cost to me.

Then, two months after getting the crowns, the one on the lower right fell off. To my surprise it was a very very small partial crown. I questioned why I paid for an upgrade when there was no gum line involved, since it was such a small crown. The insurance lady told me the crown was all porcelain and the metal would have shown, if the upgrade hadn’t been done. I also asked why there needed to be a build up and why it needed pulp cap direct. She told me he had to build up the tooth and the root was almost exposed which does not make sense to me. The dentist re cemented the crown and charged my insurance company, but did not charge me. I would appreciate your feedback on my issues. Thank you so much for your time.
– Tony from California

Tony,
I don’t know because I can’t verify any of this, but all of this sounds awfully suspicious to me, like this dentist has a scam operation to milk everything he can out of the insurance companies.

And you.

I’m an accredited cosmetic dentist who saw a lot of appearance-conscious patients, and I never did porcelain margins or anything like that for esthetic purposes on lower molars, and two of these teeth you reported to me were lower molars. One was a second molar. Even if there were a black line there, no one would ever see it. In my own mouth, I have gold crowns on both my lower second molars and no one knows but my dentist and me.

And for a crown to fall off after two months? In twenty years, I never had a crown that I did fall off.

You said that the crown that came off, when you looked at it, had no metal and the insurance lady told you it was all porcelain. That makes sense, since you say it was a very short “partial crown.” Being all porcelain, it could be bonded to the tooth, which would make it stay on. But it didn’t stay on. Furthermore, the procedure code you quoted me was for porcelain fused to high noble metal (i.e. porcelain fused to gold), which would get a higher reimbursement rate from the insurance company than what it appears was actually done. And it certainly sounds like the dentist just made up that all these teeth required direct pulp caps. A direct pulp cap is a serious situation where the decay goes down to the pulp of the tooth and the dentist puts a special coating directly on the pulp of the tooth to try to save it without doing a root canal treatment. That tooth should then be watched to make sure it heals well before doing anything major like a crown. A protocol that would make sense would be to do the buildup and wait a couple of weeks to make sure the tooth isn’t sensitive and responds properly. And I would certainly expect the dentist to tell you about this at the time to tell you to let him know if you have any sensitivity afterward. If you did, then further attention would be needed. If you didn’t, then the dentist is going to want to get credit for heroically saving your tooth and saving you from needing a root canal treatment.

And that this was done on all three teeth? That strains credibility.

And the notion that the practice would write off whatever the insurance company didn’t pay, that’s an indication that this procedure is all an invention to get a little more money from the insurance.

I think this is worth an investigation by the insurance company. I’d report to them that you weren’t aware of any pulp caps. And you could also report your suspicions to the California dental board, if you have a mind to.

I’m not saying this dentist has done anything wrong—I’m saying it’s suspicious and worth looking into by the insurance company and by the dental board. If alerted, the insurance company and the dental board can demand to see the actual records and x-rays of these finished procedures and can check other patients to see if this dentist can back up his claims of what he has done.

Dr. Hall

What do you think? Do you have a comment? 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.

March 1, 2013

Is she allergic to the metal in her crowns?

Dr. Hall,
I am 64 years old…had metal fused porcelain crowns (5 upper front teeth) placed 4 years ago. After countless dentist visits, a nightguard, a guard for my bottom teeth, tensing of the jaw, etc., I cannot stop grinding my teeth. I am constantly aware of these crowns with the sensations I feel in the roof of my mouth. Do you think that maybe I cannot tolerate the metal? Previous to these crowns, I had gold backed crowns for 42 years which I never had a grinding problem. I have no peace and I am ruining my bottom teeth. Could I be allergic to the metal? (only because it actually feels “itchy” at the roof of my mouth.)

– Mae in Pennsylvania

Mae,

I need a disclaimer because of not being able to examine you myself, but just going from what you are telling me, it sounds to me like you have two separate problems.

The itchy feeling around the metal backings to your new teeth could well be from a metal allergy. Here’s what I would do: Ask your dental office for information on the composition of the alloy used in the metal of your porcelain fused to metal crowns. The laboratory would have sent them what is called a “Identalloy” certificate, which lists all the metals in the alloy. If you see “Ni” among the metals listed – this stands for nickel, and nickel allergies are fairly common.

Are you sensitive to any metals in earrings, for example? Women who have nickel allergies need to wear hypoallergenic earrings, and they have to be careful with what metals are put in their mouth.

Let me explain these dental metal allergies. In the medical history that the dentist took before starting any treatment, he or she should have asked if you have any history of metal sensitivities, and if you have anything like that in your history, the dentist should have prescribed metals for use in your mouth that have no nickel in them. The problem is, those metals are more expensive than ones that do have nickel. There are three expense classifications of metals used in crown and bridge work. The highest is called “high noble.” The gold backing you used to have would be in this category. Other alloys have high platinum. This type of metal makes a finer margin and is more malleable, meaning that it can be made to fit the tooth the best. The second highest is called “noble.” These will have a higher silver content, but will have no nickel or beryllium, which are metals that can cause sensitivities in some patients. They are somewhat malleable and make a very nice fit to the tooth, but not as high quality as the high noble.

The lowest category is called “base metal.” These are very stiff alloys and tend to be cast with small gaps between the metal and the tooth, so they don’t fit quite as well and they aren’t malleable at all. They will have some nickel in them and sometimes some beryllium.

Your new crowns may have also disrupted your bite. The metal sensitivity shouldn’t be causing you to grind your teeth, But if you had crowns on five front teeth, that has a strong impact on your bite and your bite could be thrown off to where it is making you want to grind your teeth. If this is happening to you, I would wear a nightguard every night until the bite is adjusted to where you don’t grind any more.

A particular problem if you have porcelain crowns on your front teeth that don’t have a full metal backing is that the porcelain on the upper teeth is highly abrasive to your lower teeth, and you will gradually wear down your lower front teeth. So I would get this fixed.

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 30, 2010

What metals are in porcelain fused to metal crowns?

Dr. Hall,
I have 6 porcelain-fused-to-metal crowns. I have two questions:

1) What are the usual metals contained in the metal shell?

2) Is the metal shell the thing that begins to show at the gumline, causing the black lines? (I have those black lines.)

Thank you for your information.
– Carolyn from New Jersey

Carolyn,
There are two basic types of metals that are used in porcelain-fused-to-metal crowns – precious or noble metals and base metals. Noble metals used are gold, platinum, and palladium. Base metals would be chromium and nickel. Dentists will classify these crowns as porcelain fused to high noble, porcelain fused to noble, or porcelain fused to base metal.

The noble metals have less tendency to corrode, provoke less sensitivity, and are made to a more accurate fit.

The metal can show at the gumline, and this is what causes the dark, sometimes it’s even black, line at the gumline. Dentists may try to hide this under the gum, but after several years, sometimes the gum recedes and this line is visible anyway. The dentist may ask the dental lab to cut back the metal at this front part of the gumline and leave this margin all in porcelain. This is called a porcelain butt margin. The dentist will pay an extra fee for this – about $30 to $40, and they generally pass this on to the patient. While this makes this line more subdued, it will usually still be present. The reason is that there is still a lot of opaquer that has to be used in the crown to mask the metal. The contrast between the opaque crown and the natural tooth structure makes it difficult to blend colors here, and creates the effect of the dark line.

Patients generally prefer the all-porcelain crowns, which will eliminate any dark line. And the general natural translucency of the crown without any metal is much more natural-looking. But be careful. I would never ask a dentist who is more comfortable doing a porcelain-fused-to metal crown to do an all-porcelain crown. Dentists who are good at all-porcelain crowns will far prefer them for front teeth. If your dentist suggests a porcelain fused to metal crown for a front tooth and you are concerned about the esthetics so that you want all-porcelain, take that as a signal that you are in the wrong practice. This dentist places a low priority on esthetics and if you try to nudge them out of their comfort zone, the results could be disastrous.
Dr. Hall

Follow-up – in a subsequent e-mail exchange, it came out that Carolyn is probably allergic to the metal in her porcelain fused to metal crowns. Read the posting on dental metal allergy.

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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