Dental crowns?

What will my dental caps or crowns look like?

Abstract: As dentists are asked to provide a higher and higher level of aesthetic services, the potential for disappointment increases. Some suggestions as to how the dentist and patient can stay “on the same page” are …

… made in the collective determination of the end result and using reverse engineering to achieve the patient’s satisfaction.

Visualizing the end result.

Most people agree that a good way to achieve something is to decide where you want to be, see where you are now and decide  what you need to do, to get from one to the other. Makes sense, right?

If you were building a plane or a skyscraper, that’s what you’d do, all the way from blue print to paint, everything checked and double checked.

If you were preparing a meal, that’s what you’d do too. You’d buy the ingredients you needed and plan what and when you had to do in order to achieve the end result. What would the end meal look like if you didn’t have any plan or simply threw things in, or worse still just added what you had lots of to hand.

What would happen in the healing professions if we worked without an overall plan or limited what ingredients we put in by what we had, or cooked the way we cooked potatoes regardless of starter, main meal, desert, etc. … I think you know where I’m going with this.

The healing professions, medicine, dentistry, pharmacy, chiropractic, physiotherapy etc. are all in danger of being guided by what’s available, not what’s necessary to achieve the desired end point or result. In this article we’re reviewing cosmetic dentistry which is a ‘funny term’ really as and of itself, as I have yet to meet a non-cosmetic dentistry or a general dentist who claims he performs only non-cosmetic work!

If cosmetic is defined as involving or relating to treatment intended to “restore” or improve a person’s appearance. What do we dentists do if a front tooth breaks?

Or we’re missing a tooth (even if its not right at the front) and anyway, let’s face it most of us would consider teeth to have a strong cosmetic or aesthetic effect on us, with which I would agree.

Now we can discuss medicine later but as far as dentistry is concerned, I propose that there are three considerations, the first is that the dentist knows what and how he can achieve something, secondly, the patient knows what they want the result to look like, and finally that there is communication between them adequate or better, to achieve satisfaction for the result. We all love to hear, wow!

Unfortunately, and its largely as a result of undergraduate training, diagnosis can easily be compartmentalized into discipline gums, tooth decay, crooked teeth, function, comfort, etc. which is a good place to start, but the true mark of “clinical ability” is to balance all of these into a plan that provides exactly what the patient wants and needs in as affordable and practical a fashion as possible.

fWe dentists all know that some people don’t care, but after 40 years of practice I’ll tell you that this group of people is very, very small and often a reflection of either fear, what we think the patient is thinking or wants or a combination of the two.

Another problem is that in general practice we see many of our patients regularly and their check-up may become “hello Mrs. Jones, how are the kids”, (if you’re lucky), and so consequently clinical issues may be missed regularly too, as we develop a clinical “familiarity blindness”.

In general practice especially, this familiarity blindness can frequently be seen with issues such as tooth wear, a major cause of prematurely aged looks, but we’ll discuss those separately as they are of enormous significance as dentists continue search desperately for cavities, crowns to do.

Worse still, wrinkle correction, lip ‘plumping’ or straightening teeth regardless of long term consequences – sorry about being a “party pooper” but these articles are meant to ‘say it as it is’, not just smooth feathers.

Clinical dentistry – a clinical and aesthetic challenge.

So, let’s stay on track. You’re going to have a cap done on a front tooth, for whatever reason. First, you’ll know why and what the alternatives are and the pros and cons of each.

We forget that it is a fundamental responsibility of a doctor or dentist to provide all alternatives – yet rarely practiced as it takes time and we often think we know best, truthfully, we often do but that’s not the point. Giving our opinion is a part of, but not the the entire decision-making process.

So, you know why and what, the next thing to know is what will be the result. What will it look like. There are many factors that need to be fulfilled, shape, length, width, angles, colour and it many facets, like translucency, shading throughout the tooth itself, especially along its biting edge, etc.

Its relationship to the adjacent teeth and reflection of the same tooth on the opposite side are also factors. Crowning or veneering multiple (adjacent) teeth together, sometimes makes the job easier because matching what the dentist is doing to something else that they are doing, allows more overall control.

Restoring alternate (not adjacent, but next door-but-one neighbours) is difficult to do as so much ‘matching’ has to be done, and success in this area marks a skilful dentist.

Inlay, onlay and crown.

These factors should always be discussed before you start to give the dentist an opportunity to voice their concerns either in absolute terms or to their own experiences. So, the plan is set, the next thing to know is what the end result is going to look like before you start, which fortunately is not as difficult as it sounds actually.

Throughout the planning you must be involved if you want to ensure that you’ll be happy with the result, even the most capable dentist won’t mind ensuring you are happy before starting, and most of us know that a patient who is less anxious, is an easier patient to treat, which has certainly been my experience.

While most dentists will redo something that you’re not happy with, it’s a waste of your time and more expensive for the dentist and dental laboratory technician, assuming one is being used. Everyone is disappointed and would agree that to increase the chances of first-time success is preferable to simply doing it again if wrong.

It’s a truism that to do something over always takes more time than taking the time to do it right first time. Now, dentistry is not the easiest of jobs and there are many factors that may arise and result in a less-than-ideal result which needs resolution, but a good plan decreases this enormously.

How do you know how a result will look before you start?

Let’s take a sidestep. Several years ago, partial dentures to replace several but not all teeth were widely used and are still made to a lesser degree.

There are times when a crown was required on a tooth which was adjacent to the partial denture, and to simply crown or ‘cap’ this adjacent tooth without consideration to the existing denture to which it abuts, would likely result in the partial denture no longer fitting and requiring replacement.

Now this might have been the plan all along, but if it wasn’t, it can hardly be considered a well-planned clinical success.

The example of a partial denture

So, in order not to face this failure an impression (or imprint) is taken not only of the crown but of the crown with the denture in place. That way the crown can be formed or constructed to fit the partial denture with the minimum amount of adjustment if any. This often saves the replacement of the denture and associated cost, unless it needs replacing anyway.

Clinical dentistry – always start with the end in mind.

This clinical exercise can be taken a step further and a temporary crown made prior to the final one, to ensure the partial denture will fit well. The term “permanent crown” is perhaps a little misleading as nothing any doctor or dentist has to offer is going to be “forever”, so most dentists prefer the term, provisional (for temporary) and definitive (for permanent.

Once a provisional crown has been OK’d the definitive crown should be ‘perfect’ regarding its shape and depending on the materials used for the provisional, a fairly accurate shade can be assessed too.

Sometime further shading, if not too great is performed either at the chair-side or laboratory before the definitive crown is placed. Then again it is possible to provisionally cement or bond the crown to the tooth to ensure satisfaction before definitively joining the crown to the tooth (not so easy to remove afterwards!)

So, in other words, check the provisional crown. There is another aspect of this concept that is becoming more common – beyond the use of imaging which can be useful but its never the same as experiencing the smile in your mouth, to look at from side to side. It’s a stage developed from the earlier example and can be thought of as a “try before you buy”.

Tooth wear is endemic and often masked by cosmetics that don’t last or ‘night guards’ which do not address the problem and studies show, may even aggravate the original cause.

Tooth wear is endemic – often masked by cosmetics that fail or ‘night guards’ which do not address the cause and may actually aggravate it!

Looking mow at cosmetic smile improvement, at a smile design, a change of smile by crowning or veneering all the front/side teeth.

Assuming all else is good and healthy, an approach like this can provide a great service if performed by an experienced and skilful dentist. Maybe they seem to know what it’ll look like, but shouldn’t you know too? Before you start.

Dentistry – can you try before you buy?

This is how you do it. First the dentist takes imprints of your upper and lower teeth and ‘mounts’ them on a hinge apparatus (an articulator which need not be complex) so that you can see the short-comings and what you want to change – it helps the dentist to see this too and to see what is important to you.

The dentist may have pictures of past work or generic smiles to help or make an “investigation into the possibilities”. This may be performed by a team member.

Once you know what you’d like, the dentist must become involved as they will be performing the work and will want to know the details decided upon.

The casts of the teeth are sent to the laboratory where the practical skill begins. They will change the shape of the teeth, to more closely approximate what you want by adding and shaping the teeth in a white wax.

They can’t make teeth shorter or narrower, but these are rarely desired changes anyway. They change the shape by adding wax and carefully reshaping the teeth to make them look the same as those you chose, it is therefore referred to as a “diagnostic wax-up) for those reasons.

The value of a “diagnostic wax-up

A photo showing a diagnostic wax-up – its not mounted and so the overjet of the front teeth is not representative of its true jaw relationship.

When returned to the dentist and you see it,  the results should impress you immediately! The dentist will have looked already, but you should have a good look too.

If all is good, the dentist will take an imprint over the “wax-up” and then place some provisional material into the space where the “ideally shaped teeth” were, in a material close to the desired shade.

This is then placed in your mouth over your existing teeth, the ones you want “improved”. Carefully removing the imprint leaves the provisional material over your own teeth giving you, in effect, a smile (or more) of provisional teeth, exactly the same as that great result you saw on the diagnostic wax up. Now you can look, smile and reflect on what you think using a mirror, or someone you’ve bought with you.

A diagnostic wax up takes much guess-work out of what is a significant investment in time, money, expectation and hope.

Small changes are commonly required but generally most people are really impressed with their new smiles if they were happy about their initial requests and how that was reflected in the wax-up.

Once any small changes are made, and everything is checked (including making sure the smile is level and consistent with the face and lips, and that the bite with the opposing teeth is correct) a new imprint is taken to copy any small changes mage.

It is rare that another check is necessary but easily done if necessary. The provisional material is removed, often to the patients disappointment as they liked their new smile. ASK YOUR DENTIST.

If you’re not happy you can get impartial ‘second opinion’ advice.

Dr Stephen Bray 2019

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