Tag: Second Opinions

Bad Fitting Crown Case Study

I love to help people and the best way I am currently able to do that is to be an advocate for patients who are the victim of poor dentistry. This may sound a bit harsh to many dentists but after seeing thousands of terrible crowns, unnecessary root canal treatments and patients being blown off by dentists, I feel I need to stand firm and help where I can.

This case came to me last week, January 2018. The patient had the following comment to my blog post about another bad fitting crown case.

This was her comment:


First of all thank you so much for your time and answering all the questions.

I have root canal done on upper left tooth(24) and large filling on the tooth next to it(25 I think) and few minor fillings after first ever visit to dentist. I did get second opinion before I got the first root canal. But ever since I got the root canal plus crown(for 24) and filling done on 25, the tooth 25 was feeling high all the time and they adjusted so many times, I was told that it needs root canal because it is feeling high even after so many adjustments, this time I trusted them and did not go for a second opinion. I got a root canal done and had crown in place. Bite still feels high and off, in fact they can see that the I’m biting high on crowns they adjusted so many times and still wasn’t feeling right, on top of that I was getting constant headache in my right temple, but I didn’t think headache would be related to bite.

Earlier they have suggested me to use night guard ordered one for me ,so I went to get a night guard at that time and I mentioned to the dentist I was seeing on that day about my headaches he looked at bite on my left and right side , said I’m biting high on couple of lower teeth adjusted on both sides. Ever since than my bite feels so weird and my headaches didn’t get any better , so I asked other dentist in their group to have a look and she said she can not see anything but smoothed that tooth on lower right. Still nothing changed.

So I mentioned to them about it and then they send me to some in their group who is specialized in bite and he checked my bite and looks fine , I’m biting bit high on of crowns. When I mentioned to him about feeling high lower right he has done some adjustment to upper right, After that my headaches are getting worst and my right jaw and temple hurts when I bite and I’m having neck pain as well. I was told to use night gaurd strictly for a week but it doesn’t seem to help either. I feel some pressure in the very back when I wear it and when I wake up my bite feels so different/ weird and always feeling high where the crowns are when I bite feeling pressure on tooth behind new crown, having constant jaw pain , headache.

I feel very unfortunate with these bite issues and feel like I should have never went to the dentist. Now I’m very afraid to let anyone touch my teeth.

Do you think crowns are causing these bite issues? if the bite is high on left side Can It cause headache on right temple? Can nightguard fix the bite problem? Please let me know your opinion. Thank you so much in advance.

After reading this I asked the patient to send me her x-rays and photos, which she did and I have permission to share this with you all as a learning experience.

This was my initial response to her via the comment on the blog:

This is a sad situation but an incredible good learning experience for everyone reading this. Let me address one issue at a time. First, the fact that the dentist said you need a root canal since the bite is high is not only not true it is ludicrous. If you went to the dentist without a bite issue and they placed a bad crown then doing a root canal due to the bite now being wrong is in my opinion unethical.

The second crown still was wrong and they never were able to correct the bite. This essentially means you need a good dentist to do it right. Getting the bite right is not rocket science.

Third, making a nightguard before fixing the bad crown is also a bad move. When you mentioned you are hitting on the back teeth with the biteguard in I can clearly picture the type of nightguard they made…it needs to be adjusted to fit correctly or it is just an expensive piece of plastic. You are clearly hitting on the back teeth first due to the nightguard which is making the situation worse.

You need to leave that group and find a dentist that puts you first, has experience and can solve your problem.

I am happy to help by looking at “new” X-rays of the crowns and photos. Ask your Dentist to take bite wings and send me the originals via email. Photos help as well. This will let me determine the quality of the work real quickly. I do free consults like this all the time so people can be helped and not neglected anymore. All information for free consults should go to info@idealdentistry DOT COM (spelled out to prevent spam). Sorry for your trouble.

Upon receiving the x-rays and photos it was very clear to me what the problem was. The fact the these x-rays and photos are available to all the dentists that were involved in the treatment of this patient and no resolution has been achieved is not only frustrating but terribly sad for the profession.

The basic, very basic issue is that the initial crown and filling the patient had done were not fitting correctly. In fact, the crown, as is clearly visible on the x-ray, does not seat all the way down onto the tooth resulting in a tooth that now is hitting all the opposing teeth first and allowing bacteria and consequentially decay invade around the edges. I circled the areas where the crown does not close all the way onto the tooth. The second, newer crown, the one to the left on the photo, fits even worse!

What are we looking at in these x-rays? The white part of the crown picture needs to touch against the gray part of the tooth. The black line between the two (circled) is empty space which means the crown never was seated all the way down. Often this is the case because the contacts between the crowns were not properly adjusted.

The following photo demonstrates the amount of reduction the dentist made, cutting the new crown down with a coarse diamond. You can still see the scratches in the surface of the two crowns form the diamond cutter. I wonder if this was ever polished out or if the rough surface was left like this?

You can also see, on the first picture above, the blue marking tape is still present. This type of marking tape is the thicker kind that I do not like to use. You can be much more precise using a thinner mylar type of occlusal tape.

So, I have to conclude that the decision was made not to redo the bad fitting crown but to rather try to cut a ton of porcelain off the crown, not polish it and tell the patient that a nightguard (which she did not need prior to any of this dentistry) will solve her problem. Wow.

Now that we know the crowns are bad, the fit is bad and the occlusion (the way they touch the opposing tooth) is bad, let’s address the nightguard solution….

I am a strong believer in properly adjusted nightguards. All to often I see patients coming to see me as a second opinion and they show me their nightguard that was never really adjusted right. The are essentially only hitting on the back few teeth which is making the entire situation even worse. A nightguard that is not properly adjusted is just an expensive piece of plastic! The general rule is that if the patient feels they are hitting wrong on the guard, then they are. Adjustments must be made until the guard is a therapeutic device which will then alleviate some grinding, reduce stress on the teeth, help evaluate joint and bite problems and many more things. Nightguards are amazing if they are used correctly. Often unfortunately they are just ordered by the dentist, delivered by an assistant and forgotten.

So, this patient was frustrated and did not know where to turn so she searched the web for bad fitting crowns, second opinions, and eventually came to my blog. I wish I could help more people receive answers and teach dentists how to solve these issues when they first come up. It does not take too much work to deliver a good fitting crown to start with and create a filling that fits properly. It is perceivable that both root canals and crowns could have been prevented with earlier interception and quality care. I ask that dentists select their dental labs not just on price, but quality. It saves a lot of time for both the dentist and the patient!

The solution? This patient needs to see a dentist that can redo these two crowns, correctly, using a quality dental laboratory and have a new, good fitting and properly adjusted nightguard made. This will cost a little more but would have been a lot cheaper had this top quality dentist been seen in the first place.

I welcome questions from patients AND dentists. Anything I can do to help improve the quality of dentistry, count me in.

Keep Smiling.

Second Opinion – New but Bad Fitting And Painful Crown

Case Report:

This young lady had this crown placed within the last year and has had constant pain since placement. Went back to see her dentist several times for “adjustments” without relief. Finally, after loosing confidence in her dentist she sought a second opinion.

After a thorough exam it was determined that the crown did not fit well – it did not seal around the tooth. Having not resolved the bad fitting crown in time it is very likely that she now will also need a root canal treatment as the tooth is dying because of the poor fitting crown.

The kicker is that when we requested the existing x-rays from the dentist who made this crown it was clear on those old x-rays that the crown did not fit. This is very disappointing to me as we, as a profession, need to strive for excellence at all time. This problem could have most likely been avoided had the x-ray been read properly and the bad fitting crown replaced sooner. Now the patient needs a new crown, with more cost, as well as probably a root canal treatment and a core buildup, both not the most comfortable procedures at times and expensive!

If you have a problem with recent dentistry that is not resolving, seek out a second opinion. Don’t just have a root canal treatment performed without discovering the actual cause of the problem. In this case, if the patient would have followed the recommendations of her old dentist she would have gotten the root canal treatment they prescribed and not redone the crown. This would have been a fatal mistake as the bad fitting crown would continue to decay and cause even more significant loss of tooth structure!

Keep Smiling.

Second Opinion Roundup

Here are some pictures of “second opinions” I have given and what my thoughts were.

When patients tell me that I am “more expensive” then another dentist in town, I can not help but imagine what type of dentistry this patient really want in their mouth. My answer, always, is to have the patient compare apples to apples, and oranges to oranges.

If you are looking for high quality dentistry that looks beautiful, is made by a top laboratory technician, and is designed and maintained to last (experience matters, but a lot of bad experience does not count!), then I am the dentist for you.  On the other hand, if you want the cheapest and are not really worried about what is put into your mouth/body, how it fits or functions, or how long it will last, then I most certainly am not.

I follow the golden rule – “Treat others the way you want to be treated”.  I would never put something into one of my patients mouths that I would not put into my families mouth, period.  After all, all you really own in this world is your body, right?! 

I am getting carried away, sorry.  I just wish people knew what I know about dentistry, how it affects everything about you from soul to function.  That would keep the following examples from ever happening.

Local “cosmetic” dentistry.  Upon closer examination (besides the fact that the veneers are not good looking), the “real” problem this lady had was ignored.  Below is the picture of the lower teeth.

Note all the gum tissue is pulling away from the teeth!  That is a great way to loose teeth rather quickly.  This person need to see a gum specialist as soon as possible, plus determine why the “recession” is happening.

Needless to say, this is not very good “cosmetic” dentistry.  The “black triangle”  is a result of tissue loss and is very difficult to remove.

This may be hard to see at first, but I will explain.  The above patient has 2 premolars, or the 2 teeth to the right of the turned tooth, that are bigger than the molars, or the far right teeth.  These are really big and bulky crowns!  The tissue cant breathe, so it gets inflamed, bleeds easily and gum disease is the result.

When tissue bleeds, bacteria seep into the bloodstream and attack your system from the inside.  This is an all too common “one size fits all” dental lab.  The good news you ask?  This patient saved a few bucks by going to a lower priced dentist!  (Except of course now it has to be redone).  This dentist did not make less money then a high quality dentist would, he/she just charged less and hired a cheap lab (possibly in China) to make the new crown.  Who suffered in the end?

This picture is from the same patient above, only it is his other side.  Note how “small” his own two premolars are!  Don’t let that other dentist get a hold of those perfect little teeth, all they need is to have the silver mercury removed, minimally, and the tooth can be restored without cutting it down to a little stump.

This patient, I call him patch, has been to the same dentist for many years.  He came to me after a recent filling “just fell out”.  Well, almost every single tooth has a bunch of plastic patches on it, most surrounded by decay.  A “new” bridge was placed on the lower right side of the above picture (the patients lower left).  Everything else was “ok”.  Really?!  Well, I hate to be the messenger sometimes, but there is a significant amount of decay that should have been treated a long time ago.  Of course the patient is shocked, but I need to tell the truth about what I see.  Now we are “fixing” the mouth, not patching.

This is a great example of “if it does not fit into the mouth, grind a little more!”.  The black spot on the big tooth is where the porcelain has been ground off to make the crown fit into the space.  And even worse, the tooth to the right of the big crown has a monster patch that is fractured.  That little tooth needs a crown, a buildup, and possibly a root canal.  Maybe the tooth is even fractured itself and then it can not be saved.  Was it worth placing a super large plastic filling where they really don’t work?  And that crown, if you look closely, you will see that where the top touches the tissue the tissue is red and swollen.  That is a portal for bacteria into your system, and it bleeds if you touch it.  Not a very healthy situation.

Now, here is the next level of “if it does not fit, grind a little more”.  The gold/black spots on the teeth above are where the porcelain crowns were ground through to the underlying metal to make them fit in the mouth.  Just because the patient can’t see these areas does not mean they don’t exist!  This weakens the crowns, and is just not acceptable.

Here is another final example of a mega tooth.  This white blob is significantly larger than the original tooth, inhibiting everything from the flow of food to tissue health.  There is just so much wrong with this tooth that I don’t know where to begin.

Moral of the story, you own your mouth/your body, nothing else.  Take good care of it and it will take good care of you.

Why chose a Cosmetic Dentist with experience?

This patient came to see me after spending a fortune at another office.  He was not happy with the final result.

Disclaimer: This is NOT my dentistry

The sad part is that yes, the aesthetics are not good, but there are many more problems than just the aesthetics…Now I need to meet with the patient and try to explain all the underlying issues that may not have been discussed before.  Not my favorite type of discussion.

  • The back teeth show severe wear and cannot support the bite as it functions right now
  • The front teeth, supported by implants, are possibly failing due to the distribution of load on them
  • The final aesthetics did not meet the patients expectations
  • The soft tissue/gums were not managed ideally which will/has resulted in poor aesthetics

This case is very complex, no matter how much experience you have.  The expectations of the patient need to be realistic as well.  In my opinion we need to focus on the reason behind the wear of the teeth so that we can make this patients dentistry last!  It makes no sense to only focus on the front teeth when the back teeth won’t work correctly!

If you have a complex case or very high expectations, make sure you see a dentist that has the experience and background to tackle the case!