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My new crown feels funny

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Hello Dr. Hall,
I moved, & went to a new dentist for a recommended crown. The dentist allowed the hygienist to attach the permanent crown, & did not check it, much to my surprise. It feels like there is “play” in it, & it is not fitted properly. Can this be corrected, & what should I do?

Kathy from Missouri
 


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Kathy,
I checked the dental regulations for Missouri and was able to verify that this is legal for a dentist to allow a dental assistant to cement a crown. And I’m suspecting that this auxiliary who cemented the crown was an expanded function dental assistant and not a dental hygienist. Dental hygienists specialize in cleaning teeth and screening examinations, and usually don’t perform other functions in a dental office. In Missouri, a dental assistant who has completed education in expanded functions can be certified to be able to place fillings once the tooth has been prepared by the dentist. They can perform adjustments on permanent crowns as long as they do it outside the mouth, and they can perform the final cementation of that crown.
It would seem to me, though, that the dentist would need to check the crown to make sure it fits properly. I can’t tell, by reading the regulations if that is specifically addressed by the dental board, but I suspect that some type of direct supervision of the dental assistant is required meaning that the dentist at some point needs to check the crown and make sure it meets certain clinical standards. And even if that isn’t spelled out clearly in the regulations, in my opinion a good dentist dedicated to providing quality work would want to check the crown before it is cemented. If I were the dentist in that situation, I can’t imagine doing anything less than that.
About your feeling that there is “play” in the crown—I don’t know how to evaluate that. If the crown is loose on the tooth in any way, it will fall off, so I’m sure that isn’t the case. But a new crown should not be noticeable to you. There shouldn’t be any type of strange feeling with a crown, a feeling that it isn’t quite right. It should feel so perfectly natural that you don’t notice it.
What to do at this point? I would start by making an appointment with the dentist to check the crown. There should be no charge for that. Then, if you don’t get a satisfactory answer, I would ask for a second opinion from another dentist. If you are interested, let me know and I could find you a quality dentist for that second opinion.
– 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.

My porcelain crowns are turning yellow

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Dr. Hall,
I have six porcelain crowns in the upper front. They are six months old and are turning yellow. I don’t smoke or drink any soda. I drink a cup of coffee every morning and water the rest of the day. I brush at least twice a day. They were beautiful when I first got them. I am super disappointed and don’t know what to do. Please help.
– Tonya from Ohio
 

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Tonya
Something is definitely wrong, and you need a second opinion about your case from an expert cosmetic dentist. Find someone from our list or ask around to find someone. You may want to check an earlier post in which I include some tips about how to ask for a second opinion. Porcelain is extremely stain-resistant, even more so than natural teeth, and neither smoking nor heavy coffee drinking will discolor it.
I’ll give you a couple of possibilities of what could be wrong, and hopefully an expert cosmetic dentist looking at your crowns can tell you which it is.

•You say the crowns are six months old. That would give you time to have had another checkup and cleaning. The hygienist cleaning your teeth could have damaged the surface of the crowns. There are two things he or she could have done to damage that surface. One would be by using a power cleaning instrument such as a Prophy Jet, which blasts sodium bicarbonate on your teeth to get them extra clean. This will remove the glaze of the porcelain leaving them vulnerable to stain. Another would be giving you a fluoride treatment with acidulated fluoride, which will etch away the glaze chemically.

•The crowns could have been put on with the glazed surface already damaged. If the dentist had to adjust the front surfaces of the crowns, he or she could have ground away the glaze. Or maybe the laboratory didn’t properly glaze them in the first place.

•The crowns could be actually made of another material, not porcelain. As outlandish as this sounds, I have had emails from patients complaining of porcelain crowns or porcelain veneers turning yellow and it was discovered that they were made of composite, not porcelain. If your dentist has misrepresented your treatment to this extent, I probably don’t need to tell you that you have a lot of leverage for getting your dentist to pay another dentist to get this done right for you. A simple refund may not be enough money because your crowns may be discounted—they need to pay the full fee for another dentist to do it right. Otherwise, you could get them in deep trouble.

Anyway, good luck with getting to the bottom of this. I’d be interested in finding out what you learn in your second opinion, if you wouldn’t mind getting back to me.
Thanks,
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.

Sinus perforation from a dental implant – did the surgeon do it right?

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Hi Dr. Hall,

First, thank you for taking the time to answer questions. 🙂

My question is about the impact of a sinus perforation, removal of an implant, and antibiotics. I just had a dental implant (tooth #2) removed last Wednesday, six months after it was placed, he suspected bone loss and the gum was not filling in correctly. Also, when he placed the implant it punctured the sinus by a few mm.

After the removal, the OS said there was no infection and it was very easy to remove because it did not integrate at all, and there was no need to give me intravenous antibiotics during the process (I was sedated). He put me on sinus precaution of Flonase, no blowing nose, and no sneezing with mouth closed. He said he did not repair the perforation in my sinus, he just cleaned the area and stitched the gums. He said it would heal on its own and we should wait a year to see if the hole fills up with sinus tissue or bone and start again from there.

The following week I had continual congestion, especially at night, even though I was using the Flonase. I also had odd crackling in my ear when I moved my jaw (not jaw popping and no pain- just crackling like a blown speaker) I went back to him five days later and he said everything looked great. I did not agree and I requested antibiotics because I felt like it was getting infected. He reluctantly complied and since then my congestion has cleared significantly and air no longer escapes through the site. My question is, was it detrimental to not have been given antibiotics from the beginning and how do you know the sinus has healed correctly and the bone is not compromised with a lingering infection and congestion in the first week?

Thank you so much for sharing your knowledge!
– Kelly M.

Kelly,
First, answering your question directly, there is no harm in not starting the antibiotics right away. The indiscriminate prescribing of antibiotics, “just in case you have an infection,” is leading to a serious public health problem by helping cultivate antibiotic-resistant bacteria. Then, when you really need the antibiotic, it doesn’t work. So I like the idea that your surgeon waited to see signs of infection before prescribing the antibiotic. And Flonase seems a good choice also.

But there is another, more significant issue that you bring up that I want to address, and that is the failure of this dental implant. The implant perforated the sinus by a few millimeters??? That’s kind of a biggie. A few millimeters in dentistry is a lot. And the implant didn’t integrate with the bone at all. That’s another biggie. I hope your dentist has a good explanation for these two kind of serious errors.

To be clear here, the idea of the implant perforating the sinus is an issue with oral surgeons, with many maintaining that it isn’t a big deal. Others say that it is an indication of sloppy surgery that just increases the risk of implant failure. Many surgeons will say that they have perforated the sinus many times with implant placement and the site heals and everything is fine. But others will point to cases where this has allowed infection to get in around the implant from the sinus cavity. And then they also point to the issue of how much bone support the implant has. For however much the implant pokes into the sinus, that is that much less bone that is supporting the implant. I believe almost all surgeons will agree that while they may be able to get away with an implant sticking into the sinus one or two millimeters, “a few millimeters” is too far.

I don’t know what prompted the removal of the implant, but you’re lucky that this happened just six months from its placement, hopefully before anything was attached to the implant. Others who have had a sinus perforation from a dental implant haven’t been so fortunate. They have had persistent nasal problems for years after the implant restoration, only resolved by removal of the dental appliance that was attached to the implant and then possible bone grafting to repair the defect created followed by re-doing the implant surgery,

The standard of care for implant surgery requires the dentist to take whatever x-rays are necessary—preferably three-dimensional ones—to insure that there is enough bone present to stabilize the implant. So my question is, what is your surgeon going to do to insure that this doesn’t happen again? In other words, if your implant ended up so far into your sinus, there’s not enough bone there to support the implant. That would call for some bone grafting. In the area of the sinus, this is usually done in what is called a sinus lift procedure. Has your dentist suggested that?

I want to be careful here, because I have an incomplete picture of what is going on with you. But just from what you have told me, if I were getting an implant and my surgeon, in placing the implant, punctured my sinus and there was no osseointegration of the implant with the bone, I wouldn’t want this surgeon doing any more work on me. For you, as a minimum, I would get some answers about this, and maybe a second opinion.

– 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.

A botched sinus perforation

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Hello Dr. Hall-
I had my right rear molar extracted because it felt sore when chewing and didn’t hit much on teeth below. The molar, I found out later, was in the sinus. Anyways, after the extraction, the dentist put a plasma plug into the socket and sewed that and something neon yellow into the tooth socket.

While recovering, about an hour after the extraction, I was feeling a lot of sensitivity in the right canine tooth. After carefully drinking a green smoothie, I noticed some of that liquid was in my nose with some blood. I went home to take it easy and did almost nothing and didn’t talk because certain words made me feel like air was going into the socket.

I called the dentist and went back. They did the exam and then they cut some of the tissue, scraped some bone and filled the area with collagen and sewed it in, this time with non dissolvable stitches and said come back in three weeks. I have been only drinking fluids, not bending, not looking down, just on bed rest eating healthy meals. Today is six days after surgery, and the packing has dissolved and most of my symptoms are back and my sinuses or ears are both aching. Yesterday the ear pain came and went. I am not talking because it feels sensitive speaking certain letters.

Do you think I should give this dull throb time to heal itself and keep taking it easy? Is this sounding like dry socket and a perforation? If I found food I drink in my nose – does this define a perforation? The dentist didn’t speak clear English so I am not sure what I have. I have been in so much pain from swelling and bruising. I took all 5 days of antibiotics and the sinus pills but the pressure and pain in my ears makes me think this is all causing a sinus infection? I also noted oral thrush as I have been taking antibiotics for a month. What should I do? I have no insurance. Is it definitely a sinus perforation if I saw my smoothy in my nose? Is it dry socket? Shall I give it a few more days? Yesterday I placed a small sterile gauze ball over the area. It was too uncomfortable and when I removed it, it had a bad odor. Thank you for this blog and for your help! What shall I do?
– Vanessa from California

Vanessa,
It certainly doesn’t sound to me like you are in good hands. I would find someplace to go for a second opinion.

With the pain and delayed healing, and you mention swelling, it sounds to me like, on top of the sinus perforation, you have an uncontrolled infection. If that is the case, you need a dentist who understands infection and knows how to pick the right antibiotic. I would tend to check with an oral surgeon, with that being the case. It also could be that you have a root tip or a bone fragment that went up into the sinus and that is what is causing the infection and complicating the healing.

And these sinus perforation repairs should not be falling out after a couple of days. I don’t understand that—if they sewed it closed, why is it coming out? Yes, when you have fluids or air passing between your mouth and your nose, that is a sinus perforation. Again, hopefully a dentist with a better command of the situation can get this fixed properly for you.
– 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.

The hundred thousand dollar smile makeover

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Dear Dr. Hall,
I have had a terrible experience with my “smile-makeover.” It turned out horrible, so the dentist just refunded my money, and I am looking for a new dentist. I found your website while I was still his patient and was able to figure out that he had little to no knowledge of what you describe as a true cosmetic dentist.

So I made appointments with the first 3 cosmetic dentists on your list. I must say I was so disappointed with the 1st. While he rightly said my bite was off, I was there for a 2nd opinion of the 6 upper anterior crowns I had. He said I would first need to spend $300-400 with his hygienist, and then, to deal with my bite issues and everything the cost would range between $50,000 and $100,000. “About the price of a new car,” he said. I only wish I could replace my 6-yr-old car bought used, for 1/3 his idea of a new car. He never got to what type of smile I would end up with, as his idea was to build up my back teeth and have “an appliance” covering several teeth and add porcelain “where needed.”

My teeth and gums are pristine according to a general dentist I went to for opinion and a periodontist I also went to for opinion earlier. I don’t understand why I need all of this, and I can’t begin to afford this and want your opinion.
Thanks,
– Sally from Texas


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Sally,
There’s a great variation in what some expert cosmetic dentists charge, and the fees you’ve been quoted are definitely on the high side, even if you actually need all the work that has been quoted. I would keep going down the list and get another opinion. Meanwhile, let me give you a little insight into what I think is going on in your case.

You said that you know your bite is off, and it appears that you’re being quoted a fee for a full-mouth reconstruction to rebuild your bite. Do you actually need that? I don’t know that, but I can tell you that some dentists are very fussy perfectionists and they insist that every patient accept what they call “ideal treatment.” Other dentists are more pragmatic and will consider other options for patients who can’t afford the ideal. Fortunately, you’re in the Dallas-Fort Worth area where we have several recommended cosmetic dentists. Go ahead and shop around for second opinions.

I want to tell you a story about this cost issue and dentists’ fee levels. There is a city where we have two recommended cosmetic dentists—let’s call them Dr. Expensive and Dr. Budget. Dr. Expensive is famous and has patients flying in from far and wide to see him. He does absolutely exquisite work. Dr. Budget also does very beautiful work and has won awards for the beauty of his work. Dr. Expensive’s fees are about triple of what Dr. Budget charges. Is Dr. Budget an inferior dentist? I don’t think so. I’ve seen his work and it is world class. And guess what, Dr. Expensive goes to Dr. Budget for his dental work.

So get another opinion or two.

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.

My veneers are too white AGAIN. What can I do?

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Dr.Hall,

I would appreciate your opinion. I had nine “ceramic” veneers done on my lower teeth, five weeks ago. When they first came back I told the dentist that the color was too white. My dentist sent them back and had the lab change the color. I asked that the new color should match my exiting teeth which are shade A-2.

When they came back, he glued them in without showing me or discussing the color.

I think they are still too white. My son was getting married five days after the permanent placement, so it seem futile to discuss at the time, especially since they were already placed.

Then three weeks after placement, one of the veneers broke in half (from the bottom). The dentist said my teeth will be replaced for two years w/o charge. Is the amount of time reasonable? Do I have reason to be concerned about the long term sustainability of this investment? Can an objective person look at my teeth and not notice the difference in color? If so, what is my possible recourse? Is ceramic more durable/stronger then porcelain? I had some gum coming through my teeth. Would veneers be made to “cover” them? This was not done.

Can one determine if the material that was used is defective? I have the broken half.

Thank you for your time and consideration,

Benjamin from New York


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Benjamin,
I’m not sure I’m understanding correctly what happened here. Are you saying that your dentist bonded on these veneers and you weren’t aware that he was doing that? You say that he put them on the second time without showing you. Did you agree to that, that he didn’t show you? Or did he do that without asking you?

If you didn’t give your consent to having them put on, the dentist could be in real trouble over this. Consent is key to any dental or medical treatment—you have to consent to any treatment done to you or it is malpractice. And even if you did give a passive nod to your dentist to go ahead and bond them, a good cosmetic dentist will never bond on a set of veneers without being absolutely sure that you love how they look. Further, missing the color twice? I would never put up with that in a situation like this. This is not a challenging color situation, what you have described to me.

And the veneer breaking after placement, this complicates your dentist’s situation. The veneer breaking isn’t because the veneer itself wasn’t strong enough—it’s because it wasn’t bonded properly. Porcelain veneers by themselves are very thin and fragile. They get their strength by being bonded to the underlying tooth. You can often break them in your fingers before they are bonded to the tooth, but once they are bonded they are very hard and strong enough to withstand normal biting forces and other functional stresses. Porcelain is one of several ceramics that are used for veneers, so I’m not sure what you’re meaning by ceramic veneers. Most other ceramics are stronger than porcelain, but, as I explained, that isn’t the problem. It’s the bonding strength.

About the color being noticeable—lower veneers that are whiter than uppers look particularly funny. You can usually get away with the lowers being a little darker than the uppers because they tend to be further back in the mouth and thus we expect them to look a little darker. If they’re whiter than your upper teeth, I wouldn’t put up with that.

I think you should go to an expert cosmetic dentist for a second opinion and then pursue getting a refund from your dentist and using the money to have this done right. I believe you have a fair amount of leverage with this dentist. You could report him to the dental board or even get a lawyer involved, and I think it would be in his best interest to do whatever he can to satisfy you. You also may want to read my post, “How to ask for a refund from your dentist.”

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.

Is this a salivary gland stone or a toothache?

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Dr. Hall,
I had a mercury filling replaced in my bottom back tooth closest to the ear. Now pain develops and radiates into my ear. Before the filling I was experiencing the same discomfort with some earache. My ear is good. The doctor suggested I have a salivary gland stone. I tend to believe it’s a dental problem.
– Bruce from Nova Scotia

Bruce,
A salivary gland stone? That seems like a stretch for your situation.
You can get calicifications in your salivary gland ducts, but the pain would not radiate to your ear. It would be in the soft tissue, in one of your salivary gland ducts, if you had pain. A couple of those ducts are under the tongue, and one is in the middle of each cheek. A salivary gland stone will cause swelling in that duct when you eat and maybe pain, and it would show up on an x-ray.
No, pain radiating to your ear sounds very much like a toothache. And if you have had a recent filling in a lower molar on that side, that would be the first tooth to check.
I would get a second opinion.
– 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.

This dentist wants to do gum surgery, while admitting she doesn’t understand the problem

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Dr. Hall,

My front teeth developed little ‘holes’ on the surface when I was a teenager and in my 20’s. I initially had some of them bonded. That was in the 80’s. This bonding yellowed with time. So my dentist suggested crowns and veneers. My 2 front upper teeth have veneers. The 2 teeth next to the front teeth on both sides have crowns. These were done in 2003.I had no problems with this until about 3 years ago. Suddenly the gums around these teeth became inflamed. I am now 49 years old. My dentist isn’t sure what is going on. We have tried an all natural antibacterial liquid (I forget the name) with no luck. I get my teeth cleaned faithfully every 6 months. Flossing every day doesn’t help resolve this. This inflammation improves at times and gets worse at times, but it never goes away completely. I do have other crowns in my mouth. On my bottom teeth on both sides I have 2 crowns and a bridge. I also have 2 other caps in molars on my upper teeth. There is also inflammation around those but not nearly as bad. The gums around the remainder of my natural teeth are just fine.
Could these changes be because I am in peri-menopause?
I find it odd that it took 10 years for this to occur. Also, my dentist suggested trimming back the gum tissue. She won’t guarantee that this will fix the problem. I think she wants to do it for cosmetic reasons. Or she may know there is a structural/mechanical problem with the fit of the crowns but doesn’t want to admit it. I don’t want to go through this gum procedure if it’s just a bandaid and the problem will return. So far all this inflammation has not caused full on gingivitis or bone damage (so they say). The gums sometimes get friable and look almost ulcerated. Also, on a side note a few months ago I developed lichen planus on the checks of my mouth (not in the front). This is very frustrating. Sometimes my gums are sore. Sometimes they look just terrible and you can see the red border around my front teeth. It seems my teeth have separated between 2nd and 3rd tooth on both sides counting from the front teeth.
Should I have this procedure? It’s only on the front teeth. What about the inflammation on the other crowns in the back? This is what makes me think it’s systemic. Again this is just around the crowns and veneers.
Any thoughts, suggestions?
Thanks for your time!
Donna from Philadelphia

Donna,

You have a very interesting question here.
When you have gum inflammation around teeth with crowns, there are about five possibilities that come to mind.

  • One is that the cement wasn’t fully cleaned out from around the crowns.
  • Another is that there is some problem with the fit of the crowns.
  • A third is that the crowns go too deeply under the gumline.
    For all three of these situations, the reaction would have been immediate–not delayed ten years.
  • Another possibility is to have some kind of allergic reaction to the material in the crowns. This would happen with porcelain fused to metal crowns where a cheap metal was used containing nickel or some base metal. Usually the metal sensitivity reaction is immediate, but it doesn’t have to be. But veneers should be all porcelain with no metal in them, and you are having the same reaction around the teeth with the veneers, so that seems highly unlikely.
  • The fifth possibility is simple gum disease, aggravated by some things that are going on with your general health. That’s not to say that the causes are simple, but that the disease is a common one and there are some straightforward things to do to address it.

Unfortunately, there are a lot of dentists who simply don’t pay that much attention to the health of the gums, and I am concerned that your dentist is saying that she doesn’t understand what is going on here.
I would recommend a second opinion for you. I don’t think this should be that mysterious–maybe to your dentist, but not to a dentist with strong knowledge about the gums. I would absolutely not let her do this gum surgery on you. I’m not impressed with her aggressive treatment for your yellowed bonding ten years ago. You’re a little suspicious that there might be some structural problem with the crowns that she doesn’t want to admit. That’s possible–there could be some irregularities in the fit of these crowns and veneers that aggravates the gum disease. Your being peri-menopause is probably a contributing factor, also. Hormone imbalances can exacerbate gum inflammation. You mentioned lichen planus. That condition is exacerbated by stress just as gum disease is. It’s possible that a good, thorough deep scaling of your teeth could take care of this, but I feel you need a dentist with more expertise.
Think about what your dentist is telling you–she doesn’t understand why this is happening and yet she wants to do gum surgery to address it. One of the most fundamental principles of health care is that you first diagnose, then you treat. Don’t let anyone attempt any kind of serious treatment here like gum surgery without first having a good diagnosis.
As I think over what you have told me, it’s a little puzzling why your dentist hasn’t referred you to a gum specialist (periodontist). You’re in Philadelphia. There have to be a number of gum specialists you could go see. Maybe she doesn’t want another dentist to see her work. Anyway, since she hasn’t referred you, just self-refer. Just find a periodontist with good reviews. If you have any doubts about who to pick, call a couple of well-respected general dentists and ask what periodontists they refer to. Don’t ask your dentist for a name because of this suspicion we have that she may be trying to hide something. But you do want the periodontist to contact your dentist after you’ve made the appointment and get records that will help him or her assess what is going on.
And then get back to me, if you would, on what they find out. I’d be interested to know what is discovered about your condition.

Dr. Hall

Read more about fixing a discolored tooth from a root canal treatment.

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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.

Some dental bridge engineering principles, and why this planned bridge will fail

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Dr. Hall,
I had my upper 6 front teeth pulled due to periodontal disease. I was going to have 4 implants with two pontics, but asked for something less expensive. So we are talking about doing a permanent bridge. I have read about the Maryland Bridge and feel now that maybe the separate implants with two pontics would be better? They have charged me the same price so my question is …would 4 implants and two pontics be better?
– Jill from Pennsylvania
(Note from Dr. Hall – a pontic is the false tooth part of a dental bridge.)

Jill,
I can’t really prescribe anything specific for your case without seeing you, but I can be some help here by giving you some guidance from basic principles of bridges and restorative dentistry.

If you are accurately telling me what your dentist is telling you, then something is very wrong here. A permanent dental bridge replacing six missing upper front teeth on any patient with significant gum disease would be a disaster waiting to happen. It’s not going to last, and in the end will be by far the most expensive option. Other options would be far better in multiple ways. And I’ll explain why. I’m going to explain this in some detail here for you and then use this explanation as a blog post that will hopefully help others with similar questions.

Here is a diagram of your upper arch:

upper-arch

So you are saying that you have had the front teeth extracted, which would be teeth numbers 6 through 11.

Here are a couple of principles of doing bridgework that every dentist is taught in dental school.

First, any bridge needs to be supported by teeth that collectively have the same amount of support as the missing teeth. In other words, if the bridge is replacing two medium-sized teeth, it needs to be anchored by at least two medium-sized teeth. If four small teeth are missing, they could maybe be supported by two large teeth, if those supporting teeth are twice as large as the missing teeth. So, you are missing four medium-sized teeth (6, 8, 9, and 11) and two small teeth (7 and 10). To support that adequately, you need four medium-sized teeth (4, 5, 12, and 13) and probably one large tooth (3 or 14). So you are ending up with an extremely complicated 11-unit bridge, consisting of six false teeth supported by five existing teeth. Now I suspect that your dentist, especially if you are pressing to save money, may be planning something less than this. But breaking this rule would severely limit the lifespan of the bridge.

Second, when you start adding supporting teeth, you increase the likelihood of failure for two reasons. One is that each supporting tooth has to be prepared to be perfectly parallel to all the other teeth. Getting five prepared teeth to be all parallel to each other (or even four) so that the bridge fits perfectly is extremely demanding, and I would not ask a regular family dentist to do that. When you add to that complication the problem of having teeth on opposite sides of your mouth, making those parallel is a very tricky proposition. Another reason is that if you have any kind of trouble down the road with any of the supporting teeth – decay or gum disease or any other significant problem – the entire bridge will have to be re-done. How expensive is that going to be? Way more than implants.

Third, with six missing front teeth you have what is called a cantilever effect. Look at the diagram and imagine that tooth #4 is missing. This tooth could be replaced with a simple three-unit bridge – the missing tooth #4 supported by teeth #s 3 and 5. Notice that these teeth are pretty much in a straight line. There would be no tipping forces at all when chewing stress is borne by tooth #4. This is the type of stress these supporting teeth are designed to take. But now compare this with teeth #s 6 through 11. These are on a curve. The strongest bridge between teeth #s 5 and 12 would be on a straight line between the two teeth. But that kind of a bridge would go across the roof of your mouth and wouldn’t make any sense. So we have to loop the bridge out around the curve. Have you ever seen a highway bridge that curves out like that? Of course not. They always form a straight line between the supports. The reason for that is that when you’re out on that curve, you create tipping forces which put a large amount of stress on not only the supporting structures but the entire bridge. This force becomes a force that wants to twist and push the two closest anchors (#s 5 and 12) and actually pull the remaining anchors out of their sockets. These are stresses that these teeth are not designed to take, and the life expectancy of such a bridge would be pretty short. You would probably end up losing all of the anchor teeth, in addition to the six you are already missing. To compensate for that added stress factor, your dentist could try anchoring with six teeth instead of five. But then you increase the risk also and may end up losing all six of them.

The conclusion of all this is that a permanent bridge replacing six front teeth would be a bad idea for someone with healthy gums in the hands of some of the most expert dentists in the country. When you add the complicating factor that you have significant gum disease, and add that to the possibility that your dentist may be an average family dentist, you are courting disaster.

So what should you do?

Anything other than the fixed bridge. Don’t end up in our collection of cosmetic dentistry horror stories.

The most economical solution would be a removable partial denture. With today’s acrylics, this could be made to be very esthetic and could have clear acrylic clasps that would be virtually invisible to anyone else. There are some inconveniences to having a removable partial denture, but the cost would be a small fraction of the cost of any other option.

The most comfortable and highest quality solution would be using dental implants. Now whether or not you could support the false teeth with two or four implants would depend on how much bone support you have and the stress of your bite.

My advice? Get a second opinion from an excellent dentist. (See my posts about how to ask for a second opinion.) There is an excellent dentist near you with a national reputation. I’ll send you his name as well as another who is quite a bit further for you but whose fees would be considerably lower. Some dentists will give second opinions for free. But even if you pay $100 for it, that would be much more sensible rather than throwing $10,000 or more at a solution that may only last a few months, even if you don’t end up having the second dentist do the 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.

How to treat a cracked tooth

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I have cracked a tooth. It is on the bottom next to the back. An endodontist looked at it and suggested a crown. but was asked by my regular dentist to take out the filling to see how deep the crack was.This was not done.So my dentist tried to mend the crack.I cannot stand pressure on one side of tooth and it did not work. Since one side of tooth feels strong we are now considering an onlay. Do you feel a cracked tooth can be mended like this? Or should I go with the crown. I hated drilling away so much of my tooth that was not damaged.
– Pamela from Kentucky

Pamela,

I’m not going to be able to give you a certain answer to your particular situation. There are many degrees of cracks in teeth, from a superficial crack that is just in the enamel, to a deep crack that goes all the way into the dentin and could even involve the pulp of the tooth. And there are different places a tooth could be cracked. The crack could be horizontal, involving a cusp or a corner of the tooth, or it could be vertical, down the middle.

And to be clear, here, we’re talking about cracks and not fractures. If the pieces of a tooth move independently, then the tooth is fractured. The idea of treating a cracked tooth is to keep it from fracturing.

And there are different kinds of onlays. Some would work well for any type of crack and some would have restrictions.

An onlay covers all or most of the chewing surface of a tooth. It is a very nice restoration. It is hard to do, so a lot of dentists don’t do them. Since it doesn’t go down below the gumline except between the teeth, it is very gentle to the gums and helps promote good gum health. They can be made out of gold, porcelain, or hardened composite.

A gold onlay covering the entire chewing surface of a tooth would completely protect any type of cracked tooth. I would feel very comfortable with that. If the onlay is made of porcelain, I would only use it to protect the tooth in the case of a minor crack – either a superficial crack or a horizontal crack involving just a cusp or a corner of the tooth. The porcelain is not strong enough to hold a tooth together that has a serious vertical crack. Some supposed experts teach that the bonding strength of porcelain to the tooth is strong enough for this situation, and I believed that at one time, until I used an all-porcelain crown on a tooth that had a serious vertical crack. The porcelain crown and the tooth both ended up cracking all the way through, and I ended up repairing the situation at my own expense.

And hardened composite is considerably weaker than porcelain. I would not recommend that for any type of crack in a tooth.

This idea of repairing the crack with some other technique than a crown – no, that wouldn’t work. It might hold for a short period, but it’s not a long-term solution. Now if you were putting pressure on your dentist to find a more economical solution, then I understand. But if this was the dentist’s first choice of treatment, it makes me a little skeptical. I’m not sure what you’re meaning when you say that this treatment didn’t work, and I’m not following you when you talk about the pressure on one side of the tooth. I can’t visualize what you’re saying. And I don’t understand what that means, that a side of the tooth feels strong. So maybe your dentist is right. But I have this skepticism and would suggest a second opinion.

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.

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