second opinion Archives - Cosmetic Dentistry Blog

The dentist keeps adjusting, but his bite is still off

Posted on December 5, 2022 by David A. Hall.

Hello Doctor Hall:

I have ten zirconia crowns and they have all been burred down trying to fix my occlusion – after the first adjustments I developed hives on the inside of my lips and gums, and no dentist seems to be able to figure out where these hives came from or how to deal with them. Is it possible that shaving the crowns may have released something that now is irritating my mouth? This has been going on for eight months, the entire case has been a mess, my bite is off, etc. But the thing that no one can tackle is why I have hives now? Is it possible that burring through the finished surface of the zirconia has made my mouth react like this? – Richard

(See Dr. Hall’s answer below.)

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Richard,
Zirconia is a very tough material, and this would be a difficult appointment, having them ground down to fix your occlusion.

Let me deal with your question directly, first, and then offer some other comments about your case.

Yes, theoretically you could have had an allergic reaction to all the zirconia dust, but that would go away once the dust had cleared out of your system. I wrote in an earlier post that we have no confirmed cases of zirconia allergy reported. If you were truly allergic to zirconia, you would have had a reaction before any of the grinding. Yours seems to be another case of burning mouth syndrome, which appears to be triggered by stressful dental experiences.

About your ten crowns that have apparently disrupted your bite. And you say that your bite is still off. It’s a nice feeling when your teeth all mesh together harmoniously and you can chew normally. When your bite is off, that can throw your jaw muscles into spasm and can lead to headaches and various other problems, associated with TMJ disorder. I would recommend that you get a second opinion, because I’m worried that your dentist is in over his or her head.

Training in the complexities of how the teeth meet together and mesh to provide a harmonious bite—this isn’t part of the regular dental curriculum. To study this in depth, dentists attend one of several post-graduate institutes. Four of those are:

The L.D. Pankey Institute in Florida
The Dawson Academy in Florida
Spear Education in Arizona
The Las Vegas Institute for Advanced Dental Studies in Nevada

I would find a dentist who has graduated from one of these institutes and get a second opinion on your case. I’m just guessing that the lack of harmony in your bite is an ongoing source of stress, and I wouldn’t be surprised to learn that is the cause of your hives.

– Dr. Hall

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About David A. Hall

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

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My crown has fallen off three times!

Posted on November 30, 2022 by David A. Hall.

Dr. Hall,
My crown has fallen off 3 times. I have returned to him again and he says I need a gingivectomy to keep the crown secure by giving the crown more tooth area to bond the crown. This sounds extreme to me. Also the base of my tooth is blackened where I recall it was not when he placed the crown the last round. I’m holding the loose crown now and need to decide soon!

Please advise!

– Nancy from San Francisco

(See Dr. Hall’s answer below.)

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Dear Nancy,

The procedure is called crown lengthening—trimming the gum and maybe some of the bone to expose more of the tooth so that it can retain a crown. Sometimes that is necessary, and I had occasion to do that in my practice.

My problem with your situation is that your dentist should have known up front that crown lengthening would have been required to retain the crown. Coming to you after the crown has fallen off three times makes me not trust him. Did he not realize when he first prepared your tooth that crown lengthening would be required? Or is it that crown lengthening isn’t actually required in your situation and this is just an excuse he is giving you?

It is possible to do a crown on a short tooth and have it stay on without doing crown lengthening and without having any problem. But the tooth has to be carefully prepared with only a very slight taper and possibly cutting some grooves into the sides of the tooth. I have a blog post about crown retention form that you can read here. It cuts into the excuses that many dentists use to explain why their crown fell off. In over twenty years of practice, I never had one of my crowns fall off, because I always prepared them with a tight draw. Many dentists don’t like to prepare a crown with a tight draw because it is more demanding and even a slight error can mean that the crown won’t fit at all.

It is when a tooth is “bombed out” with most of the crown either broken off or eaten away by decay that crown lengthening is required.

Bottom line—I wouldn’t trust this dentist to try again and would get a second opinion. He’s clearly planning to do a new crown for you, so I’d have another more expert dentist do it. I don’t know what the blackening of your tooth is, but something doesn’t sound right about that either.

Oh, and I think your dentist should refund you AND the insurance company, if insurance was involved. If he doesn’t, I’d complain to the dental board and to the insurance company. A crown isn’t serviceable if it won’t stay on, so there should be no fee for it.

– Dr. Hall

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Are the same-day crowns as good as the old-fashioned ones?

Posted on September 15, 2022 by David A. Hall.

Dr. Hall
I was reading on your site about removing a metal post in a tooth, which made me think of my experience. In May of this year I saw my dentist in The Netherlands for a checkup. I had a crown that was made by computer in 2017 and she said that this crown wasn’t fitting well and needed to be re-done. Also, the previous dentist had removed metal posts from my tooth before placing the crown. The new dentist said that the posts should have been vibrated out with ultrasonics and not by drilling.

My questions are:
1) Is the computerized-3D crown process as good as a ceramic old-fashioned crown?
2) Did drilling the posts out of the tooth damage my bone?

Thank you very much
Tessa from the Netherlands

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Tessa,
Yes, it’s nice if you can vibrate out the post with an ultrasonic device. Most dental offices have ultrasonic scalers. But I can tell you from experience that this may not work. So, if you want the metal posts out, there may be no option but to drill them out. No, this won’t damage the bone. How can drilling on a tooth damage the bone? Dentists are always drilling on teeth. The risk in drilling out the post is that the drill could slip and perforate the side of the root, which would damage the tooth to the point where it would have to be extracted. For any people who have experience drilling into metal, you know that it is very easy for the drill to skate along the surface of the metal, so this is a real risk. But it sounds like your dentist got through that without any unfortunate accidents.

And then telling you that this crown “isn’t fitting well” makes me wonder. I’m not sure what that means. Are there gaps at the margins of the crown? If so, why doesn’t she say that clearly? That’s what we look for when we’re checking a crown—we use an explorer and run it around the margin to see if there are gaps. If there aren’t any, then the crown is fine. Also, her statement that drilling out the posts would damage the bone, that makes me suspicious. Some dentists try to accuse a previous dentist of doing something wrong as a way to get you to believe that they are better and to justify their plans to re-do the dental work of the previous dentist. I don’t know if that is happening in your case, but I have enough suspicion to make it prudent, in my opinion, to seek a second opinion about this crown that supposedly “isn’t fitting well.”

About crowns made with a computer. This process was developed about 35 years ago by Dentsply Sirona, which is when CEREC crowns were introduced. In the early days there were issues with the accuracy of fit, but that is no longer an issue. When I needed a crown 15 years ago, I decided I wanted to experience this technology and so went to a colleague who had a CEREC machine. I have had no trouble with that crown. It fits just fine. The whole process, which includes optically scanned impressions of your teeth instead of impression paste is a highly precise process that creates a high quality crown.

– Dr. Hall

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I have to have all my teeth extracted. How can I keep my face from collapsing?

Posted on August 3, 2022 by David A. Hall.

Dr. Hall,
I just turned 40 & have to have the rest of my teeth (16) pulled. I am a crying mess. I recently found I have a severe calcium deficiency which I am slowly but steadily turning around, but I need dentures & can’t afford a full set of implants. I have 1 implant already.
Would you say all-on-4 would keep my face from collapsing? Or do you have other ideas for me? I am a single mom of a 1- & 3-year-old and don’t want to look like their grandma. Please help.
– Stephanie from Minnesota

(See Dr. Hall’s answer below.)

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Stephanie,
My first question for you is, Why do you have to have all your teeth extracted? You’re not giving me any details about this treatment plan, so my first response is to question it. Dentists vary in their desires to save existing teeth. Some view it as much simpler to extract teeth and do a denture. Saving teeth can be much more complicated. I would suggest getting a second opinion. Find a dentist who has strong views about trying to save teeth and see what he or she recommends for you.

Second, I’m not sure I understand this severe calcium deficiency you say you have. Is this something your dentist told you? A calcium deficiency doesn’t have anything to do with the health of your teeth, not at this point in your life. It can lead to cramps, nerve problems, or osteoporosis. But the teeth are all fully formed and will not be affected in adults by any calcium deficiency. I have heard this used as an excuse to explain problems with tooth decay, but there is no connection. The greatest contribution to decay problems is frequent snacking. There are other contributing factors, but that is the one that most often leads to rampant decay.

If you indeed do have to have all your teeth extracted, and you have no teeth or dental implants left in your jaw, you will, over a period of ten or twenty years, end up with facial collapse as your body gradually resorbs your jawbone, which it perceives you no longer need. You’re correct that this will leave your face looking sunken-in and old. But worse, it will leave you a dental cripple, unable to adequately retain any kind of removable lower denture and also impairing your having a satisfactory upper denture. The presence of any dental implants will prevent any bone resorption around those implants. Even two implants will be a great help, and a snap-on denture would be a tremendous improvement over a removable denture. Better would be four implants.

With freshly extracted teeth, you probably wouldn’t need the all-on-4 denture. What the all-on-4 denture does is eliminate the need for bone grafting when you have had a lot of bone resorption already. But if the teeth have just been extracted, there isn’t time for bone resorption. Though it would be best if the surgeon would place some bone graft material in the extraction socket—a relatively simple procedure.

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My new crowns are turning yellow

Posted on October 29, 2021 by David A. Hall.

Dear Dr. Hall
I was so thankful to find your website. I have been so upset for the last three weeks since these crowns have been in my mouth. I had 6 porcelain crowns on my upper front teeth. I selected color BL1, because I wanted really white teeth. My own teeth have always been very white.

But when I got the crowns, it didn’t seem to me that they were the color I selected. And now, on top of everything else, they are getting yellow. If I have a cup of coffee or something else, it seems like it stains the teeth a little. I have a consultation appointment this coming Monday about this, and I’m hoping you can give me some good advice. I haven’t been smiling because the crowns have yellow on them. I have been using Supersmile toothpaste, but it doesn’t seem to help.

My dream of beautiful white porcelain crowns is now a nightmare!

I have been looking at another dental office near me, [name redacted], and wondered if you would recommend this dentist.

Yours
Janyce in Miami, Florida

I found this blog searching for yellow crowns.

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Dear Janyce,
I have a couple of things to say about your case.

If these are truly porcelain crowns with the glaze intact, they will not stain or pick up any yellow color. I have known a case where a patient was told she was getting porcelain veneers, which soon began to stain, and it turned out they were made from a cheaper resin substitute. I would be very surprised if that were done with crowns, but I guess it’s possible. It’s also possible that something has happened to break the glaze on your crowns. That can happen with power polishing equipment such as the Prophy Jet, or it can happen with a fluoride treatment at a dental office, if they use acidulated fluoride instead of neutral fluoride. Acids in general, such as the citric acid present in lemons and other citrus fruits, ascorbic acid in vitamin C, or the hydrochloric acid that would come up from your stomach in acid reflux, will not affect the porcelain at all. But the acid in acidulated fluoride is hydrofluoric acid which will etch the glaze away and leave your crowns with a satin, slightly rough and porous surface that will pick up stain. And, if that is happened, Supersmile toothpaste won’t take the stain away, because it has become embedded in the pores of the porcelain. Supersmile dissolves the protein pellicle on your teeth to which stains attach themselves, so it is very effective on teeth, but it also has low abrasivity, so it won’t remove stains on a rough surface.

You may want a second opinion from an expert cosmetic dentist to determine if something like this has happened.

But I also wanted to add a point about the color of your crowns. Admittedly, I don’t know the full details of your case, but I want to make some generalized comments here for the benefit of the readers who could be making some not helpful assumptions from reading the sketchy details we have photo of the Ivoclar shade guide extension for bleached teeth, showing shades BL1, BL2, BL3, and BL4 about your case.

You said that the shade you picked was BL1. This shade is white beyond the whiteness of any natural teeth. On the right is a photo of the Ivoclar shade guide for bleached teeth. This shade guide was invented in the early 90s after bleaching began to become popular and the conventional shade guides that had been used for many years didn’t have samples matching these now super-white teeth that were whiter than any teeth that had been seen before. Your natural teeth could not have been this shade without having been bleached.

Here is the complete shade guide with the bleached shade extensions off to the left. The shade B1 is the color of very white natural teeth, and was the whitest shade we ever saw as dentists until the advent of teeth bleaching. The most common shade of adult teeth is probably A2.
a shade guide with the bleached tooth shade bl1 to bl4 on the left, and the rest showing the 15 natural shades A1 to D4
If you had not bleached your teeth, and you had come to me wanting 6 porcelain crowns on your upper front teeth, there is no way I would have given you crowns with a BL1 shade without addressing the color of the teeth further back. Otherwise, they would look fake because your darker premolars would be showing when you smiled, leaving you with a serious mismatch in colors. I would, of course, have told you that to give you the chance, if you were adamant about that request, to get that done by a different dentist. If you had wanted me to do it, there would be two ways we could get a match with the other teeth. For one, we could first bleach your teeth to see if we could get them that white. Or, we could do porcelain veneers on the remaining two or four upper teeth that show in your smile. You can get away with having the lower teeth be darker than your upper teeth, because lower teeth tend to be in the shadows anyway and it is natural for them to appear a little darker. But having a mismatch between the front six teeth and the premolars is not quality cosmetic dentistry.

About Getting a Second Opinion

It sounds like you’re already thinking about seeking a second opinion, which I think would be a good move. But I wouldn’t go to the dental office you suggested to me. I checked out their website, and there are two red flags. The first is that they have no smile gallery displayed. Any dentist in the Miami area who is serious about cosmetic dentistry is going to have photographs of successful cases, and is going to be eager to display those publicly. The office you suggested to me has no smile gallery. Also, while the information on the website about smile makeovers is fairly detailed, it shows to me a lack of artistic sensitivity and no depth of knowledge about the procedure. For example, it says that the color you want for the veneers will be picked after the teeth are prepared, an impression taken, and the case ready to send to the lab. But the final color is fundamental to the case and should be decided in the initial consultation, as well as the particular smile design you want, which isn’t mentioned. Finally, the doctor shows no cosmetic credentials—no post-graduate training in cosmetic dentistry or any accreditation. So I would definitely pick someone else. We have several recommended cosmetic dentists in the Miami area that you can check out.

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My new crown feels funny

Posted on July 26, 2019 by David A. Hall.

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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My porcelain crowns are turning yellow

Posted on July 11, 2019 by David A. Hall.

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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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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