Dr. Mike Malone’s Blog

This may seem like it is coming after the fact, but I am curious about something. I recently had a smile makeover done. I thought I was going to have all porcelain veneers placed, but when I look at the backs of my teeth, it looks like the porcelain goes all the way around. Is it normal to place porcelain crowns instead of porcelain veneers for purely cosmetic reasons? I thought crowns were just for teeth that were damaged. I guess the reason this concerns me is that maybe my teeth were in worse shape than I though, if they needed crowns.

I’ve since seen my general dentist, and she seemed very impressed with the work, so I am not concerned about the quality of the workmanship. Is this standard, to have crowns instead of veneers for a cosmetic smile makeover?

Thanks for your insight,

Ben in Oregon

Dear Ben,

Porcelain crowns and veneers differ only in degree–there really is no specific line of demarcation where a veneer becomes a crown. The fee for a porcelain veneer is usually the same or nearly the same as that for a porcelain crown, because the effort to place each type of restoration is about the same.

It is actually quite common to see porcelain crowns used on the front teeth for cosmetic reasons rather than protective ones. If your teeth were not weakened or damaged, your dentist might have decided to go with crowns to control your bite.

It is surprising that the dentist did not discuss this in detail with you during the course of your treatment. Typically, smile makeovers involve a great deal of give and take between the dentist and the patient, because the dentist will want to make absolutely sure he or she knows exactly what the patient wants.

The simplest solution is simply to ask your cosmetic dentist why he decided to go with porcelain crowns rather than veneers. Crowns are the more aggressive form of treatment, and require more reduction of the natural tooth structure. Veneers require only a little bit of shaving on the front of the tooth. For that reason alone, I would expect your dentist to have a sound reasoning for choosing the crowns. Most dentists will always pursue the least aggressive form of treatment and strive to preserve as much of the natural tooth structure as possible.

My son is six years old. I’ve just started to research dental information to address some serious problems with his teeth.

He has at least four cavities that I can see. Two of them are small in diameter, but seem to be quite deep, and two other teeth have actually started to chip away from the decay. I’m afraid there may be more, but he won’t let me get a really good look in his mouth to tell.

What are my options with these kinds of problems? I really don’t want to have any teeth pulled if we can possibly avoid it. They are all molars, and from what I have read so far that could really screw up the alignment of his teeth later on. Can they do some kind of porcelain crowns or white fillings? I don’t want them to look bad and make him embarrassed, either. I’ve read that with kids they often do some kind of metal crown, but those are so ugly!

I also wanted to ask about sleep dentistry (also called sedation dentistry). I think I am going to have to locate someone who does this kind of dentistry, because my son just will not open his mouth for the dentist or the hygienist. We’ve tried three different dentists with no luck. I was hoping he would mature enough to cooperate, but we just can’t wait any longer.

I appreciate your help,

Maranda in New Brunswick

Dear Maranda,

You’ll want to find a pediatric dentist who also performs sedation dentistry. I think you are correct in saying that you simply cannot put of your son’s dental care any longer.

You are also correct that removing the molars without also putting in some kind of space holder will cause a lot of problems down the road. Those molars are also important in helping him eat, so ideally your dentist will try to salvage the teeth rather than extracting them. In pediatric dentistry, much of the work is often geared toward short term maintenance and temporary fixes, because those teeth will not remain in place forever. Usually they will place a stainless steal crown, but if you are adamantly opposed to the steel, your dentist can work with you to find a suitable material.

Another issue that must be addressed is the eating pattern that probably produced this kind of severe decay in such a young child. The kind of decay you’ve described is caused by constant eating. If you want to put a stop to these kinds of serious dental problems, you’ll have to put a stop to the eating habits that produce them.

Last evening at t-ball practice my youngest daughter was hit in the mouth with a bat. One of her front teeth on the top broke right off, and the other one has a crack all the way across it. We took her to our family dentist first thing this morning, and he said he won’t have time to fix it for three weeks. Three weeks! That just seems crazy to me. Everything I’ve ever heard or read about damage to teeth says that you should “get to a dentist right away”. Well, what is the point of that if they aren’t going to fix it?

One of the reasons our dentist gave for the delay is that the root of the broken tooth needs time to “desensitize”. Is that customary? If it is, then I guess we will wait, but my instinct is to take her to a different dentist, one who will treat this with some urgency.

I hope you can answer this quickly. I don’t want to wait, but I’d like some expert advice about what to do.

Nora in Bar Harbor, Maine

Dear Nora,

Your instincts are correct – there is no reason to wait to address this.

If you have the piece of the tooth that broke off (and see this response promptly!), an expert cosmetic dentist might be able to reattach that portion of the tooth. If you don’t have the piece or it is too badly damaged, a likely procedure to repair both teeth is direct dental bonding.

For this reason, I strongly suggest you chose an expert cosmetic dentist for this procedure. Direct dental bonding requires more than excellent technical skills and training. It requires artistry. The bonding material must be color matched and placed with an eye to the gradients of color that comprise her natural teeth. Only truly gifted cosmetic dentists can do really beautiful direct bonding work.

You don’t say how old your daughter is, but because of your reference to t-ball I am guessing that she is under 10. Direct bonding is a great solution for younger patients. When she is older, she will probably need a single dental crown for the tooth that was broken, but your dentist will have to make that decision when the time comes. If the other tooth is severely damaged, both front teeth may need crowns.

I have porcelain fused to metal crowns on six of my top front teeth. What can be done to get rid of the the black line where the crowns meet my gums? It was not this bad when they were first placed but over the last two years it has really become noticeable. What are my options, from least expensive to most expensive?

Vienne from New Hampshire

Dear Vienne,

There really is not any inexpensive way to address this issue. The entire structure of your crowns is the problem. A dentist could try to drill away the black line and cover it over, but there is likely a serious color match issue between the roots of your natural teeth and the color of the veneers. Trying to blend those colors together in that tiny space would be incredibly difficult if not impossible, and the results would almost certainly be very unattractive.

Essentially, you have to options: live with the black line, or replace the porcelain-fused-to-metal crowns with all ceramic or all porcelain crowns. Be absolutely certain you chose a skilled, artistic, well-trained cosmetic dentist to do this procedure for you. I would hate to see you spend thousands of dollars to still be unhappy with the results.

My new dentist says I have “peg laterals” and suggests that I have porcelain crowns placed to correct them. My old dentist always said I would need braces to close those gaps in my teeth. I am confused about what to believe! My old dentist retired, and I don’t really know this new one very well yet. What are “peg laterals”, and what is usually done to correct them?

–Anthony in Topeka

Dear Anthony -

It is hard to develop trust with a new dentist. I would suggest you talk honesty with your dentist about your concerns regarding these apparent differences in opinion about how to address your dental issue.

Simply put, “peg laterals” are when your lateral incisors (the teeth on either side of your front teeth, or central incisors) are too small. This discrepancy in size makes them resemble small “pegs”, hence the term “peg laterals”. Without an examination, I could not presume to tell you how your particular case should be addressed, but I can tell you that you should really trust the dentist you choose to help you.

In some cases, a porcelain crown can be used, if there is adequate space surrounding the peg lateral. If there is not, some orthodontic work might be necessary to create a space for a natural looking crown or veneer. In your case, it could simply be that your teeth have shifted, and therefore the professional advice you have received has changed.

Whatever the case, it is very, very important that you trust your dentist. If you are unable to have an honest conversation with him about the best way to fix your peg laterals, then it is definitely time to seek a different dentist. We strongly recommend you find the services of an expert cosmetic dentist to help you with this - make sure they are accredited through the American Academy of Cosmetic Dentistry, and that they have pursued specialized training above and beyond that required by general dentistry schools.

When my daughter was 8 the dentist I used said she had a calcium deficiency because her front teeth were discolored. He put porcelain veneers on the front ones. She is 11 now and the veneers are discol ored and decaying. We started using another dentist and he said that we needed to put crowns on the front teeth and she also needs braces. I am concerened of how will they put braces on caps and why cant the veneers be replaced?

Thank You,
Suzanne in Alabama

Suzanne,
I’m not sure how many front teeth you’re talking about, and can’t tell whether your daughter needs crowns or not without an examination. But I can give you two possible reasons that the dentist wants to replace the porcelain veneers with crowns.

First would be that the dentist isn’t comfortable doing porcelain veneers. Many dentists aren’t. It isn’t taught in dental school, and many dentists just aren’t very excited about appearance-related dentistry because it is a very different field and they have to be artistic to enjoy that.

Or it could be that there is so much decay that now the teeth need porcelain crowns. Veneers only cover the fronts of the teeth. I would be surprised if your daughter at age 11 has that much tooth decay on these front teeth that she needs crowns, but maybe she does.

We really try to avoid doing porcelain crowns on young patients because when the teeth are young, they have very large pulp chambers, and the chances of irritating or injuring the tooth so that it needs a root canal treatment are large. And anytime we can do less grinding on the teeth to achieve the same result, the better it is.

As far as the braces go, the crowns wouldn’t be a problem. The orthodontist can work around that.

I think it would be prudent to seek a second opinion to see if she really needs crowns. Find a dentist who does a lot of porcelain veneers and see what he or she says.

I need a crown on my front tooth. The dentist suggests doing both front teeth so they match perfectly. Is this necessary?
- Laurie in South Dakota

Laurie,
It may be necessary for you, from this dentist, but it isn’t generally necessary. It is possible to match a front tooth crown perfectly to the tooth next to it, but it takes, skill, a strong knowledge of tooth color, translucency, and texture, and a certain amount of trouble. It may require sending the crown back to the dental laboratory more than once to get the color perfected. But it can be done.

Many dentists just aren’t good at that, and some just don’t want to take that trouble. So in your case, yes, it may be necessary to get both crowns if you want the front two teeth to match perfectly. But we don’t do it that way - we just match the single crown.

Read more about Louisiana porcelain crowns or Louisiana Zoom whitening.

My dentist stated I need to have a tooth onlay.

Now I got the estimate and Description say Onlay Porc/Ceram-4+Surface. What does that mean 4+ surface? I thought I was getting one tooth onlay.

My plan covers a Max of $1000 and they are billing me 1300. Plan will only pay 923.50. Why do I need 4 +surface on the onlay?

Any insight would be greatly appreciated.
- Hector in New York

Dear Hector,
You’re running into some very technical jargon here, and I can see where it may be hard to understand.

The 4+Surface refers to the number of surfaces of the tooth that are covered. Insurance plans reimburse more for restorations that cover more surfaces of the tooth. There are five surfaces on any back teeth - the chewing surface and the four sides. So you’re just reading the documentation of the dentist that this onlay covers four or more surfaces and thus entitles you to their maximum benefit for this tooth. Onlays usually cover four or five surfaces.

And $1300 sounds like a very reasonable fee for a porcelain onlay in New York. You are experiencing first-hand how dental insurance has not kept up with the times. Back in the 60s, their common $1000 maximum benefit for a year would cover a reasonable amount of dental work.  Today they have the same yearly limit and it covers very little.

And for those who don’t know what a porcelain onlay is, it is a very nice restoration. It usually covers the entire chewing surface of the tooth, so it reinforces a weakened tooth. But it only goes partway down any of the sides of the teeth. Since it usually doesn’t touch the gum tissue, it is very comfortable, and requires less grinding away of the tooth. If you are interested in having a porcelain onlay, ask Dr. Malone.

Related links:
A related restoration is a porcelain crown
Read about how to fix crooked teeth
Lafayette cosmetic dentist

I have severe tetracycline stains, and have had porcelain veneers for the past eighteen years. My teeth look gray with the porcelain veneers, but it is much better than the awful stains I had before.

I wanted to get new porcelain veneers, but my dentist says I should get crowns, so that the stain will be completely covered. What do you think?

- Ann from Louisiana

Ann,
I don’t think you need crowns.

Tetracycline stains are very difficult to treat, and you really need a lot of training and experience with cosmetic dentistry to do them right. The stain is very dark, and go to the core of the tooth. When general dentists try to fix them they end up at one extreme or another — either the veneers are too translucent so that the dark stain shows through, or they’re too opaque, so that they look chalky and fake. Or sometimes they get over-aggressive and grind the teeth down for crowns and then put an opaque crown over them. None of these approaches results in a truly beautiful smile.

But there are ways to make a beautiful smile with conservative porcelain veneers over tetracycline stained teeth. You may want to visit our smile gallery where we show Dawanna, who had brown tetracycline stains, that we treated with porcelain veneers.

So my advice is to stick with the porcelain veneers, but to go to an expert cosmetic dentist. We’d be happy to help you if you’d like to come here.

Related links:
Porcelain crowns

I have several old large silver fillings that are not bothering me but my dentist feels they all need crowned is this reasonable?
- Karen in Tennessee

Karen,
Yes, this sounds reasonable. Once a large silver amalgam filling has been in your mouth for a number of years, it begins to break down. It’s reasonable to take out the amalgam and do a crown before the tooth breaks.

And one of the disadvantages of the old-fashioned amalgam fillings is that it is very difficult to tell if they have decay under them until the decay has grown considerably. This is one of the reasons we like to do the white fillings in our office. The standard of care when you have large amalgam fillings would be to replace them with crowns when the margins of the filling begin to separate from the tooth or the margins develop defects.

If you wait until a tooth bothers you, that can be the most expensive way to do dentistry. Once they start bothering you, you will not only need crowns but may also need root canals.

Related links:
Read more about porcelain crowns