Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

February 22, 2017

Should I get a radiolucent crown or a radiopaque crown?


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Hi Dr. Hall,

I came across your blog and read your very interesting response to a writer with root canal issues. I, too, seek your advice.

I had my lateral and central incisor teeth filed down for a bridge (missing the two teeth in-between). I changed my mind from having the bridge when I learned about some negatives surrounding it, and went back to the partial denture. I have been wearing the temporary crowns for almost 6 months now.

I ended up having to do a root canal on the central incisor and I have been told that the lateral will also need a root canal because it has been exposed for too long and I am getting sensitivity to cold. I am not keen on doing another root canal.

I read about pulp cap in your blog. That’s interesting. Does this need a special dentist to perform?

Could you also tell me which dental crown is radiolucent? I was interested in the eMax crowns (lithium disilicate) but I read that it is radiopaque and as such will block xrays and disallow evaluation of the tooth underneath over time. Could you please tell me if this is so? And if this is so, could you tell me which is the best material for my now vulnerable teeth. I have a lot of anxiety that I might lose them.

Thanks very much for your response.

Marcia

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Dear Marcia,

I hope that you aren’t trying to micro-manage your dentist and make all these clinical decisions for him or her. One thing I worry about in providing all this dental advice is that patients, thinking now that they are armed with sufficient knowledge, will try to tell the dentist what materials to use or will obsess over these decisions. I hope you’re not doing that. When you tell me that you have been wearing temporary crowns for 6 months and have all this anxiety I want to tell you to let go and let your dentist make these decisions. Do the best you can with the knowledge that I provide here to find a dentist you can trust and then trust him or her.

It sounds like you’ve been stewing over these decisions, wearing these temporary crowns for so long, and now one of the teeth became hypersensitive and needed a root canal and another is getting that way. It surely is time to let your dentist finish your case.

You’ve latched onto this question about whether a particular crown material is radiolucent or radiopaque and have decided that you want a radiolucent crown. But you don’t know enough to be getting into the weeds this deeply. There are a number of factors that go into selecting a material for a crown, and you have a very imperfect understanding of even this one factor.

But since you asked, let me explain a little about this issue.

Radiolucency of Crown Materials.

The only type of crown that is radiolucent is a plastic crown, which would be used as a temporary crown. A radiolucent crown is one that doesn’t block the x-rays at all. So yes, you are right, that with the x-rays you can see right through it. The problem is that decay is also radiolucent. Decay would tend to start at the margin of the crown, and with a radiolucent crown it would be impossible to tell for sure what is decay and what is just part of the crown.

But, you say, a radiopaque crown blocks the x-rays and so you couldn’t see under it. Here’s where oversimplification is getting you into trouble. There are many degrees of radiopacity. The ideal would be to have a crown that is partly radiopaque, just like tooth structure is. It doesn’t block the x-rays completely, only partially, so you can see through it to a certain extent but it doesn’t look just like decay.

To illustrate, here is an x-ray of a patient showing four types of crowns plus composite filling materials, and you can see the variations in radiopacity. None of the restorative materials used are radiolucent, for the reason I gave above—radiolucency causes the most complications for diagnosis.
radiolucent and radiopaque crowns
On the upper, starting with the canine on the left, we have a composite filling that is partly radiopaque. Next, on the premolar, is an eMax crown. Yes, it is radiopaque, but it has a very helpful partial level of radiopacity that makes it easy to tell what is going on with the tooth. Next, on the first molar, is a porcelain fused to metal crown. True, you can’t see through it, but you can see what is happening on the margins, which is where you would expect recurrent decay to start. Finally, on the second molar, is a gold crown.

On the lower, the premolar has a composite filling, the first molar has a CEREC crown which is made of lithium disilicate, and the second molar has a gold crown.

My preference for crowns on second molars is gold, even though it is totally radiopaque. I have heard many dental educators and researchers state the same preference. I’m not going to go into all the reasons here for that choice. I only want to make the point that this radiopacity is not a simple cut-and-dried issue nor is it the only factor to be used in the choice of a crown material.

– 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.

November 17, 2015

What is the best crown for a front tooth?

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Dr. Hall,
What is the best crown for a front tooth?
– Asra from India

Asra,
The best crown for a front tooth is the one your expert cosmetic dentist is most comfortable with.
Creating a crown for a front tooth, if you want it to look perfectly natural, is a work of art, and you need to let your artist work with a medium that he or she is comfortable with, and also a laboratory technician that he or she is comfortable with. If I were doing it, I would do it with feldspathic porcelain, but other cosmetic dentists might select a different material.
But please note—the dentist needs to be an expert cosmetic dentist, an artist. In saying that I have cut out 98 to 99% of dentists. And actually, in India, you may only have a handful of dentists in the entire country who would qualify as expert cosmetic dentists. That’s an important qualification.
A dentist who is an artist, for example, would never select porcelain fused to metal for a front tooth.
Dr. Hall

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 11, 2013

Porcelain fused to metal crowns are ugly on front teeth. Why would a dentist do this?

Dr. Hall,
I had 4-front teeth crowned with porcelain over metal. I am VERY upset because I was not informed about the dark line that I now see?? I did go to dentist today & he is replacing 1-tooth w/ dark line, but after just a month of having these crowns, I noticed on the back of THIS PARTICULAR TOOTH a spot of METAL appeared. I think that is why he is replacing it. Is this a rare problem?? I wish that I had known my options!!?? How much does a crown w/ porcelain over metal cost?? I am in a small town near Tampa! I paid about $989 per crown; is that too much?
– Shirley from Tampa

Shirley,
Back in the early 1980s, putting porcelain fused to metal crowns on front teeth was a good idea. But not in 2013. There are now porcelain bonding techniques where porcelain can be bonded directly to the tooth instead of having to be bonded to a metal framework to give it strength. And there are new high-strength ceramics. So there is no longer any need for the metal foundation. All-ceramic crowns are plenty strong enough to serve just fine on front teeth.

In my opinion, a dentist who is serious about the appearance of his or her dental work wouldn’t even dream of putting a porcelain fused to metal crown on a front tooth. Not only does the metal make the crown look opaque, but you will have that awful dark line at the gumline. And if the dentist is successful in hiding that under the gum for now, in a few years the gums will often recede a little and the dark line will become visible.

So what you have is a dentist who doesn’t really care that much about how your smile looks. If you do, then you have a basic disconnect with this office. Now I want to be careful here, because many of these dentists who aren’t very concerned about the appearance of their work are excellent dentists. They are very engineering oriented and careful and thorough. They’re just not artistic. And this is the case with about 98% of dentists, maybe more – they simply aren’t artistically inclined at all.

So then what do you do about the four crowns you have? And my guess is that the dark line isn’t the only appearance-related problem with this work. They will have to be kind of opaque. I doubt they sparkle like natural teeth. And the shapes may not be natural. But replacing them with work from a truly artistic dentist will cost you another $1000 per tooth, and your insurance won’t cover that probably for another five years at least. But that is the only remedy. So when you’re ready to have them replaced, find an expert cosmetic dentist from our list and have this done right.

About the fee you paid – $989 is a typical fee for a crown. (Click here to read about costs of porcelain crowns.) The sad thing is that for that fee, or maybe just a little more, you could have had a beautiful all-ceramic crown that would have enhanced your smile rather than detracting from it. And about the metal on the back – remember that this is a porcelain fused to metal crown. They will often have a metal back. The metal back is actually gentler on the opposing teeth that chew against these teeth than the porcelain would be, and it shouldn’t be visible from the front. If you just have a spot of metal showing, then you probably had a thin layer of porcelain there over the metal. That shouldn’t cause any problem.

– 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 19, 2011

My dentist won’t do the crowns unless I do the braces

Hi, I went to dentist today to inquire about replacing the crown on my two front teeth. They were put on about fifteen years ago and are discolored and embarrassing. I was told I need full ortho braces before I can get the crowns replaced. I do not have the money for that and I don’t see why I can’t just get new crowns and do the other stuff later. My front teeth in question are a little crooked and bucked out but not that terrible. What should I do?
– PJ from Wisconsin

Dear PJ,
I don’t like it when dentists put these restrictions on their treatment – they will only do the perfect treatment or nothing. People have budgets and sometimes less than ideal is the only thing within their budget.

You certainly should be able to get these crowns replaced without doing the orthodontic treatment. You could forgo the braces entirely, or you could do it later. The dentist should still be able to do great crowns and get them looking great.

I would find another dentist who is a more sympathetic and understanding type who will work with you and your budget.

And I would be sure to do all-porcelain crowns on your front teeth. Otherwise they will tend to look fake and will end up showing a dark line at the gumline. Make sure your dentist feels comfortable with this type of crown. Don’t press your dentist to do a certain type of crown – but ask what type the dentist recommends, all-porcelain or porcelain fused to metal. And if he recommends porcelain fused to metal, you’re in the wrong office. Just quietly exit and find a dentist who loves doing the all-porcelain.
– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

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

September 28, 2010

Ugly Porcelain-fused-to-metal crowns.

Filed under: Crowns for front teeth — Tags: , , — mesasmiles @ 6:59 pm

Dr. Hall,
I had porcelain fused to metal crowns on my front top teeth over 20 years ago, and they now look terrible because you can see the dark line when I smile, and i have a very big smile. Is there anything that I can now do to change this? Would Lumineers work for me? Your advise would really be appreciated. thank you, Joan from New York

Joan,
What you need would be very simple for an expert and artistic cosmetic dentist, but I can’t emphasize strongly enough how important it is that it be an expert cosmetic dentist. Be sure you understand fully the difference between the dentist on the corner who says he or she does cosmetic dentistry and the dentist who is truly artistic, who knows how to create beautiful smiles. See our page, What is a cosmetic dentist?

You need new, all-ceramic crowns, with no metal in them. And this is a great opportunity for you, because if you do this right, you can have an absolutely gorgeous smile.

– Dr. Hall

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.

June 7, 2010

Porcelain Butt Margin explained

Dr. Hall,
I recently have had five porcelain fused metal crowns placed in my mouth. Each time, I have paid an extra $264.00 to my dentist for “extra covering” to keep any black from showing at the gum line. Unfortunately, the black shows on almost all of them, either on the inside or the oustside. Is this normal? Thanks in advance!
– Mary from California

Mary,

I’m guessing that what you are paying extra for is what is called a “porcelain butt margin.” It sounds like the dentist is doing an old-fashioned porcelain fused to metal crown, but is having the porcelain technician cut back the metal near the base of the crown on the front so that it isn’t so conspicuous, leaving it so the margin is all in porcelain.

The effect of this is to make the black line at the gumline that is typical with porcelain fused to metal crowns, to make that more subdued. It may be more gray than black, but it is still a darker area.

I’m surprised at the extra $264 fee for this. The dental laboratory will charge the dentist about $35 extra for this service, and there is no extra cost or labor for the dentist, so it appears that your dentist is getting quite a bit of profit margin on this “upgrade.”

The best thing is to have an all-porcelain crown. When pure porcelain is bonded onto the tooth, it can be made in such a way that the entire result looks absolutely natural and beautiful. But a lot of dentists haven’t learned anything other than what they were taught in dental school, and there they were taught to do porcelain-fused-to-metal crowns. And another problem is that the dentist feels that this looks good enough and that you’re being too fussy if you think this is a problem.

This is at the heart of why I do this website – to help people find dentists who are passionate about the appearance of their work and who know how to create beautiful dentistry. Tell your friends so they don’t make this same mistake and go to the wrong dentist, if they need work done on their front teeth that they want to look beautiful and natural.

Dr. Hall

other links:
Read about cosmetic dentistry costs.
Click here to find an expert cosmetic dentist.

About David A. Hall

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

October 31, 2007

Why is porcelain fused to metal used on molars?

Dr. Hall,
What could be the possible reasons for having a dentin-bonded all-porcelain crown on a central incisor and a porcelain fused to metal crown on the first molar? Also what would be the differences between the two different kinds of materials?

Thank you and much appreciated.
– Ranje from Alabama

Dear Ranje,
There are two reasons for using the all-porcelain crown on an incisor and porcelain fused to metal on a molar:

1. Porcelain fused to metal crowns are stronger than pure porcelain. Pure porcelain is plenty strong enough to serve on an incisor. They are usually strong enough to serve on a first molar, but there could be a risk of cracking of the crown on a first molar, and that’s why even some true cosmetic dentists will use porcelain fused to metal on molars.

2. And back on a first molar, it is very difficult for others to tell the difference between a porcelain fused to metal crown and an all-porcelain crown. All-porcelain has a lifelike translucency, where porcelain fused to metal is opaque and develops a dark line at the gumline. Unless you have a really wide smile, people simply aren’t going to see that on your first molar. In my practice, I never used porcelain fused to metal crowns on front teeth–they’re just ugly, especially after you’re used to the beauty of all porcelain crowns. Patients, after being told the difference, were always willing to pay a premium, beyond their insurance coverage, for the lifelike all-porcelain crown on a front tooth.

But we need a warning here. Do not ask your dentist to do an all-porcelain crown for you on a front tooth if he or she hasn’t brought it up. These crowns require special expertise. If your dentist knew how to do them well, he or she would not want to do any other type of crown for you. Take their failure to mention this option as evidence that they’re uncomfortable with the clinical requirements of the more beautiful crown, and if it’s important enough to you that this is what you want, find a true cosmetic dentist to do this right. The all-porcelain crown will break if it’s not bonded on properly. And your dentist is very unlikely to confess, when pressed, that he or she isn’t familiar with the bonding techniques–they simply won’t let on that this is an issue.

– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

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

October 10, 2007

What are the best materials for implants and crowns?

Hello,
I am planning on getting alot of cosmetic work done to my teeth. I need around 10 implants on the top front of my mouth.

1. I wanted to know what you think of Astra implants from the UK?

2. I would like to know what you thought about Cercon smart ceramic zirconium crowns? I think I read on your site that zirconium is not as aesthetic as all porcelain crowns, but isn’t zirconium clear? They say that these particular crowns are as tough as porcelain fused to metal crowns, do you have a comment on them?

3. I had one dentist tell me that white colored metal fused to porcelain, or gold fused to porcelain, will not show a black line, Is this true?

4. are zirconium abutments for my implants, more aesthetic pleasing then all white abutments?

Thank you for answering my questions. It’s hard to get real answers on the topic of cosmetic dentistry.
– Edward from Connecticut

Edward,
I’m going to answer your question differently from what you’re expecting. I think your focus is wrong. You’re focusing on the materials. You should be focusing on the artist.

You start off saying you want cosmetic work on your teeth. Does that mean you want a beautiful smile? If so, then I believe you’re headed for trouble. Because you’re trying to decide yourself what are the best materials, as if you are planning to micro-manage your cosmetic dentist.

Imagine with me that as part of your employment you are asked to commission a painting to grace the hallway that leads into your corporate offices. And then you busy your time finding out what brand of paints and brushes will produce the best results, and the light you want your artist to use, the stool for her to sit on, and everything else. You will be stifling your artist. What you want to do is find the best artist, and one maybe that you feel a “connection” with, who feels motivated to please you, and then turn her loose on your project, and then YOU get the ARTIST the materials she feels she needs to produce the results you want. Creativity needs an atmosphere of trust and needs freedom in which to operate, if you’re going to get a beautiful result. Your dentist artist also needs to have a strong rapport with you in order to feel motivated to create a beautiful smile that you love. If you go forward with this micromanaging philosophy, your dentist is going to want to kick you out the door and won’t care WHAT you think, in the end.

Additionally, there is no way that you can learn enough about dentistry in the time frame you have to make an intelligent decision on these materials. There are pros and cons of each of the materials, and they depend on the mechanics and the demands of your case. You need a deep background in dentistry to be able to evaluate the claims of the manufacturers of these different materials and devices as well as the independent research. And even then, you won’t really know how they work until you try them. There are many stories of dentists using new materials where the research made them look like fabulous materials, but in clinical use there was a completely unexpected issue that arose that created a disaster.

And, if that weren’t enough, there is the issue of what material works best in your dentist’s hands. Most dental materials and techniques have a learning curve, and they work best when the dentist is fully familiar with the technique and the quirks of the material. You push your dentist to use a material she isn’t familiar with, and you’re asking for trouble.

Having said that, there is one of your specific questions that I’d like to answer, and that is about porcelain fused to metal. No, it isn’t true that porcelain fused to gold or to a white metal won’t show a black line at the gumline. I don’t understand what this dentist has told you, if he’s saying that only metals that aren’t white or gold show the line. Every metal we use in crowns is either white in color or gold. The line may not be black – it may be gray – but it will show if it is above the gumline. That’s because the line is the cement line. I often did porcelain fused to gold alloy restorations, or fused to platinum alloy, and they would show that line. Even fused to pure gold. It’s the bonding technique that eliminates the line, and the bonding technique is used with pure ceramic. There are techniques that MINIMIZE the dark line, such as cutting the metal back at the margin, giving you what is called a porcelain butt margin, but they won’t eliminate it.

And zirconium is white, not clear. It’s zirconium oxide, actually, and it is opaque white. But used properly it can produce very esthetic results, if it is covered with a more translucent ceramic. And yes, it is very tough.
– Dr. Hall

Helpful pages from www.mynewsmile.com:
Porcelain fused to metal crowns
Various types of all-ceramic or all-porcelain crowns
Dental implants
The difference between a cosmetic dentist, who is an artist, and a general dentist
More blog postings on finding a cosmetic dentist you can trust and developing a good working relationship with that cosmetic dentist.

We thank our advertisers who help fund this site.

About David A. Hall

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

April 21, 2007

Porcelain crowns on lower front teeth.

Filed under: Crowns for front teeth — Tags: , — mesasmiles @ 2:42 pm

Dear Dr. Hall,
I recently had root canal treatment performed on my bottom two front teeth. My dentist indicated that I will need to have crowns put in. But the two bottom front teeth have very short roots, and there may be issues of strengh and stability of these teeth. It order to address these two issues it was suggested by my dentist that I have four porcelain fused to gold crowns put in. Two crowns would be for the two bottom front teeth with short roots , and crowns for each tooth beside these teeth. The stability would come from metal the lab would use to connect all four crowns together. I was also told that you would not see the metal, and that the crowns would appear like four individual teeth.

I asked my dentist if the procedure can be done using all procelain crowns instead of porcelain fused to gold since all procelain crowns have a more natural appearance and there was my concern about the black line appearing on the gumline if the gums recede? She insisted that porcelain fused to gold crowns was the best method for this situation.

My question is: Is it possible to have this procedure done with all procelain crowns? Do I have any other options?

Awaiting your response. Thank you,
– Nancy from Quebec

Dear Nancy,
As we say on our web site, all porcelain crowns look much more natural than porcelain fused to metal crowns. With the metal in them, they tend to get a black line at the gumline.

But you need to be very careful about pushing your dentist to use a material or procedure he or she may not be comfortable with or disagrees with. It’s much better to find a dentist whose philosophy you’re comfortable with and then trust their judgment.

In the case of lower front teeth, where she wants to splint the teeth together, there are several factors that weigh against using all porcelain crowns:
1. The black line at the gumline rarely shows with lower front teeth, on most people.
2. With gold metal on the back of the crown, the dentist will have to grind away less tooth structure on the tongue side of these lower front teeth. Since these lower front teeth are so small, that’s a significant factor.
3. She can join the metal in each crown into a strong metal framework.

So I would tend to agree with your dentist in this situation, just based on what you’re telling me, without doing an exam myself, which admittedly limits me here. If you aren’t happy with that, though, I wouldn’t push your dentist, as I said, but would get a second opinion from our Montreal cosmetic dentist, and see if there is a more esthetic way to do it.
– 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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