Crowns instead of braces?

ruffles

i am very bothered about my two front teeth, they overlap slightly as my mouth is over crowded at the front . One is a very badly done crown since 2001 as i had it done in a dodgey dentist in spain after having a fall which broke the tooth, it is longer than the one next to it and so looks odd. One dentist said i could get it re crowned and then get braces to strighten them out but i was wondering as i DETEST the idea of braces, could i just crown the two of them with thinner crowns that fit better so the two are straight thereby solving the problem, the last dentist was insisting on braces but is this just because they are more expensive and he wants the business, i do realise crowns wil cost 400 - 500 euro. Any ideas on cronwns instead of braces?

lomb

post or pm a picture and il advise you what can be done. i wouldnt fit a good empress or procera all ceramic crown or good veneer for under 550 or 600 and i doubt anyone else reputable would either. the old pfm crowns have very poor aesthetics with black lines near the gingiva imho. orthodontics is the ideal though and the proper thing to professionally advise. i hope that helps.

Wight

lomb wrote:

the old pfm crowns have very poor aesthetics with black lines near the gingiva imho.

Bit of a generalisation there? PFMs have their place, and if carried out correctly with enough reduction and a good technician will give very good aesthetics. I agree you see a lot that don't match that description however. Certainly they're indicated much less the way porcelain/zirconia materials have developed but they still have their place in the armamentarium.


Ruffles:
You can "reposition" teeth to some extent with crowns, but depends on how far out of line the teeth are. If you "cut back" too far you'll hit the pulp and nerve in the tooth. Then you're into doing root canal treatment first. If the teeth are bodily out of the arch you're far better going for orthodontic approach. As Lomb says it all depends!

lomb

you are correct, but i have yet to see a good one done in the real world. i think one would need at least 2mm reduction facially for a good pfm, and that is a hell of alot. also good lab techs are few and far between and pfm crowns in general are low margin in some ways considering the work involved and are produced on an assembly line. i once sent a prescription off for a upper lateral insisor in pfm, and got back a premolar needless to say i changed labs after that:rolleyes:
the latest ceramics are strong and beautiful.

case_sensitive

I'm in a similar situation; I've had *really* badly bunched teeth since I was 11, and haven't been in a dentist since then (I'm 26). Thankfully I've never had any pain from cavities.

However now I want to do something about it, and adding to the problem of overcrowding, a few wisdom teeth have joined the party in the last few years.
I think I'd like to have them and possibly others excised, before having some sort of cosmetic surgery (veneers possibly) done to correct the crooked teeth.

A friend of mine had her top front 6 done in a dentist in Newry, and is delighted with the job he did, and all for about 2 grand, almost half of which she was able to recover in tax rebates.

My (puny) SSIA is maturing in about 9 months, and I've earmarked the bulk of it for this treatment (:-( no classic car for me after all!).
Any advice on how to proceed? Is there anywhere in the south that would perform this treatment for about €3-4000?

What about problems? Am I committing myself to a life of expensive dental care? What happens in 10-15 years? Do I have to have them re-done? Do they come with any 'warranty'? If they break or come loose, will the dentist/orthodontist fix it cheaply/free?

lomb

case_sensitive wrote:

What about problems? Am I committing myself to a life of expensive dental care? What happens in 10-15 years? Do I have to have them re-done? Do they come with any 'warranty'? If they break or come loose, will the dentist/orthodontist fix it cheaply/free?

usually instant orthodontics with heavily rotated teeth leads to prepartions well into dentine for veneers. eventually these veneers become crowns when they fail and they will. these crowns will probably fail at some point and become root canaled crowns and these sometimes snap and need to be removed. orthodontics+/- veneers is the best treatment for what you have. this minimises damage to your existing teeth. this treatment unfortunately takes time and money. usually any warranty only lasts a year. this is something to consider also.

eth0_

Lomb - do crowns and bridges usually last "only" ten years? Is it advisable to have them checked out every time you visit your dentist?

I feel a bit paranoid that my bridge and crown will fall out at some stage *shudder*

lomb

eth0_ wrote:

Lomb - do crowns and bridges usually last "only" ten years? Is it advisable to have them checked out every time you visit your dentist?

I feel a bit paranoid that my bridge and crown will fall out at some stage *shudder*

can last 'forever' but depends on condition of underlying teeth, whether they are small or large teeth originally(like if you crown the lower incisors theres nothing surer than they will snap sooner rather than later), whether there are posts in the teeth, hard decay left under the crowns or bridges that decides to progress , secondary decay caused by poor diet/oral hygiene/ flossing etc, how good margins were when cemented many crowns fitted dont actually 'fit' (>75% in the uk but from personal experiance more like 90+%), occlusion, number of teeth left and support either side, where the crown is in the arch, periodontal status and something called biological width, aesthetics and patient not liking them leading to replacement, vitality of tooth, or in case of root canaled teeth success of root treatment, type of cement used and 'washout' of same-again tight fiting crowns dont have this problem. the bulk of crowns done these days ive seen have huge marginal gaps, leading to cement washout, then either pulp death or decay or root canal failure from leakage. that and periodontal disease from bad margins.

long and short of it is there are alot of variables, you need a VERY competent dentist/lab to do good crown and bridge, ive seen crowns in a full mouth case done in the states last 40 years and still going strong. this is what seperates the men from the boys and unfortunately to get a good job means its going to cost $$$ and you are going to be sitting in a chair along time if you are getting this done. having said that paying alot is no gaurantee of anything but logic dictates that to get a reasonable job you have to pay otherwise the clinician isnt going to be doing it for too long before he either declares bankruptcy or cuts back on labour/lab bills/materials/training.
the average of 10 years i think is based on all the above factors. thats the bottom line.

edit/ also forgot retention and resistance form of preperations important factors to crowns staying on and not falling off. this means not overtapering the preperations and having good length. this sometimes means some dentists bury the finish line in the gum pocket causing a loss of 'biological width' whereas what was needed was initial crown lengthening via surgical flapping of the gums, removal of bone to 'lengthen' teeth and replacement of flap and then waiting and crowning teeth. i have seen a load of crowns that caused alot of gum inflamation due to finish line burying being replaced after crown lengthening recosting the patient thousands. so loads and loads of factors means that making sense of them is very difficult even for dentists

case_sensitive

Ok, I'm revisiting this topic, as it's only a few months off now, and I would like to get it sorted.
Lomb; I'll admit while I've done some reading, I didn't really get all of this;
"leads to prepartions well into dentine for veneers", nor
would you recommend braces of some description in conjunction with veneers?
My situation is quite similar to case 2:
http://www.londonsmile.co.uk/crowding
they appear to suggest that veneers could be the solution, however, are they likely to disintegrate, leaving me with the pointed tips they don't shave off my real teeth??

I've seen a documentary on veneer treatment, and the in-between phase where they pare down the teeth is horrifying.. being left with vampire teeth after biting into an apple would be awful.

A lot of the links in the stickies are dead or poor, web1.dental.tcd.ie is dead (18th Dec) and dentist.ie doesn't have what I'm looking for. What I really want are hard and dirty facts and figures; likely costs and lifespans of treatment, as well as a reliable, independent 'reviews/testimonials' site, along the lines of carsurvey.org.

Big_G

This is all very difficult for a person without dental training and the aid of a few good diagrams but I will make an attempt.

Veneers are not a cure all. The reason why most Irish dentists will recommend orthodontics first is because that is the most conservative option, ie the one that results in the least likely destruction of tooth structure. The minute you cut away part of a tooth surface, even if the preparation remains in enamel, you are reducing the prognosis of the tooth, at least in conservative dentistry theory.

Ideally veneer preparations remain in enamel, which is the outer layer of the tooth that is hard, which will help maintain the tooth's innate physical properties as well as it's biological properties also. Dentists call this the tooth's resistance.

When correcting the angulation of a tooth using indirect (lab-made) restorations, it is necessary to prepare the tooth to the corrected angulation using a bur. This can result in a preparation that extends into dentine which is less hard than enamel. This is not good as this significantly increases the flexure of the tooth and also increases the likelyhood of postoperative sensitivity. It also increases the difficulty of bonding ('gluing') porcelain to tooth and reduces bond strengths. This concept of angulations is difficult to explain without a diagram. Porcelain flexes very little, and therefore we want tooth to flex as little as porcelain does in order to prevent debonding, or breaking of the porcelain.

Using orthodontics to correct overcrowding is ideal, as it presents less of a long term risk as there is no surgical removal of tooth structure involved. Combination treatment may allow to correct for shade, which orthodontics alone does not allow.

We're back to old boots economics again (a term I'm very fond of). Using veneers to correct for angulation is likely to result in reduction of the lifespan of the tooth, during which many restorations on the teeth will have to be replaced, at significant cost. Using orthodontics is a higher initial cost but results in less per tooth retreatments over time, and usually does not result in significant reduction in prognosis of the tooth, and is therefore, IMO the better treatment option overall.

The obvious drawback is having to wear braces, which are not aesthetically pleasing. However, if it was me, I would want the best available treatment that I could afford, and if both these treatments fall into that category, go for ortho. Even if they both don't, still go for ortho.

In my opinion, if you wanted this done badly enough, and crucially, done properly, you would go for ortho. What's 2-3 years in terms of an expected lifespan of a tooth? Nothing. Just do it.

Also, as far as aesthetics are concerned, you will never get a porcelain fused to metal crown to look as good as all-ceramic/porcelain crowns. They just don't transmit light in the same way, with all-ceramic being closer to the way a real tooth transmits light. My dad is a ceramicist, and he would agree. To much opaque porcelain has to be used to block out metal. Only a dentist or technician might notice the difference and be able to quantify it though.

case_sensitive

The issue isn't really one of cost, though I'm rapidly finding out my €5k budget might not do what I thought it would. The main issue is braces, not only would I look daft for 3-5 years, but I'm a professional trainer; my appearance and voice are about 40% of my livelyhood, all but entirely ruling them out as an option.
Come on, how many grown adults do you see with braces and not at least remark about it?
Lingual orthodontics seemed like a possibility for a while, but I don't see the over-rotation of my teeth being solved invisibly!
Crowns/veneers do seem like a quick'n'dirty solution, but I'm worried by the lack of enthusiasm from the 3 or 4 professional dentists who post here for them.
On the other hand, you have a horde of clinics, particularly UK and Hungary-based scrambling over each other with promises of easy fixes.

I've resolved to go see at least one dentist/orthodontist in January, and hopefully I'll get some answers there.

btkm8unsl0w5r4

Case Sensitive....I think a lot of the discussion above is very generalised. Maybe if you could post a picture of your teeth with you lips and one without your lips covering your teeth we could explain what your options may be...I do a lot of bridge and crown work and would be happy to lend some general advice for you however really need a pic.

PS make sure we can see your face if you wish

btkm8unsl0w5r4

Some info here

Whats a veneer http://www.animated-teeth.com/porcelain_veneers/t1_porcelain_veneers.htm

Whats a crown
http://www.animated-teeth.com/dental_crowns/t1_dental_crowns_what_are.htm

Some case presentations
http://www.animated-teeth.com/cosmetic_dentistry/t_cosmetic_dentistry.htm

lomb

Big_G wrote:

you will never get a porcelain fused to metal crown to look as good as all-ceramic/porcelain crowns. They just don't transmit light in the same way, with all-ceramic being closer to the way a real tooth transmits light. My dad is a ceramicist, and he would agree. To much opaque porcelain has to be used to block out metal. Only a dentist or technician might notice the difference and be able to quantify it though.

i would agree but i have seen some p fused to m crowns that are amazingly good recently (not done by me though). im not a lab technician but i think there is more to it than opaquer. the old proceras had very opaque white cores and were supposed to be better than pfms .the key to good aesthetics with pfms is enough reduction and a shoulder margin so the grey at the gum is gone. i dont think they teach enough reduction in dental school, the problem i think is esthetics versus longeivity.
i have also found alot of crowns are made to fit by labs due to underpreperation or badly defined margins. all mine seem to fit better since ive gone to a 1mm+ shoulder margin. how can it not fit if you do this?

lomb

case_sensitive wrote:

What I really want are hard and dirty facts and figures; likely costs and lifespans of treatment, as well as a reliable, independent 'reviews/testimonials' site, along the lines of carsurvey.org.

forget about it, you will never compare costs and reviews/testimonials.
you cant compare dentistry, there are way too many variables, probably hundreds. also how can you compare prices, the maximum you pay in the uk on the nhs is 189 pounds for a course of treatment with the dentists getting another 50 from the government. you are supposed to get all the treatment required to achieve dental fitness supposedly. if this means you need 5 crowns and 5 root canals and 2 dentures then thats what you are supposed to get. are you going to get it. no! and if you did the crowns would fall off the next day... you get the picture.

btkm8unsl0w5r4

The PFM v All ceramic debate is an interesting one and would bore anyone else into a coma. It has been proven that a master ceramist when given adequate reduction can produce perfect aesthetics in PFM or ceramics. The ceramic companies show you how their high strength cores transmit light better but the fact is that in the mouth light is not transmitted through the teeth from the back of the mouth but refracted off the surface from the front. Now the average technician can get more value and chroma with all ceramic crowns but using the opalescence and meteramerism of modern veneering ceramic systems these results can also be simulated independent of the core material. I love all ceramic crowns don’t get me wrong and I love the way they always fit. However in posterior regions and large reconstructions I prefer PFM some of the time. Personally I would want my posterior occlusal stops and canine guiding surfaces in metal if possible. Not because of the wear rate debate (well polished or glazed ceramic is not so bad on to opposing teeth) but to prevent micro crack propagation from the fitting surface and expensive remakes.

SO to make a short story long....forget what the crowns are made of and concentrate on how and who makes them. You need good impressions, preparations, temporisation, soft tissue control and cementation...and a really good technician with a meticulous technique and good artistic eye. I really appreciate technician’s skills. I have had to make my own crowns and it is really hard....I particularly sucked at stacking porcelain...thank to lord for technicians.

lomb

when you say your all ceramics always fit, are you refering to cad milled ones like cerec/ procera or empress type ones or feldspathic.

when you say you prefer occlusal stops in metal , are you putting gold on the 2nd molars, or using pfms with metal occlusals, do you find people accept metal occlusals on the lower sixs?

also when doing pfms do you do 1-2mm metal bands near the gingiva on the interproximals and linguals? i currently do all ceramic shoulders on my pfms, but i have read that it takes a skillfull technician to create a good all ceramic margin, due to porcelein shrinkage. are the new margin porceleins any good.

where i practice people dont like crowns as they "fall off", i think they have got a bad reputation as they are done cheap and nasty:((

btkm8unsl0w5r4

Cad cam ceramics always fit (intaglio surface) because of the amount of spacer built in. However cast ceramics and slip cast ceramics also tend to require no adjustment as long as they fit on a solid model. I like gold on the 7 yes if I can. I like metal maxillary occlusals against mandibular ceramic occlusal or metal. My PFM have butt labial shoulders (1.5mm) and metal interproximals and linguals (0.5 reduction). I like heavy reduction on aesthetic areas. All ceramic margins are expensive and require skill to make however as you say newer low shrinkage shoulder porcelain is good but can be ugly.

lomb

thanks i find it hard to have fine enough control on the bur to get a nice .5mm chamfer. interestingly i have noticed that even those who underprep for pfms with ceramic at the margin and have a heavy taper say the average of whatever it is 20 degrees have the same reduction at the top of the plane as a 1mm shoulder margin with a minimal say 6 degree taper.

Big_G

Me being the youngest and least experienced here, I am expecting some serious laughs here but have you tried the Dr. Paddy B. Patented Fingerjig to add extra control to your drill skills? It works if you can get it in there. Which I have occasional trouble with - trying to get the shovels in.

btkm8unsl0w5r4

Presume that is the legend that is beausang himself

Big_G

You know it. What a legend. BTW, jokes aside that does work. From what I've been told, loupes open up a new world in dentistry also. Eager to try them myself. A retired dentist told me he was in practice 10 years before he got his first set of loupes and he said that he spent a couple of months replacing fillings that he thought were fine, but actually had poor margins, etc.

btkm8unsl0w5r4

Loupes are good alright...I use loupes and sometimes a microscope but I can still find room for improvement in my work with just my naked eyes...the are accessories really and are often not required...great masters can prep to a very high standard without them. I think that the key to proper crown preparation is to lock your wrist to stop non parallel movement. Correct and sharp burs. Good illumination and most importantly plenty of time.

lomb

also one of the best things to do is buy a proper fischers cord packer and not use a flat plastic like some of us were taught for placing retraction cord.
break the contacts and then slip the cord down, only takes a minutes, tuck in, and then prep down to above cord in esthetic regions, the cord will displace the free gingival margin by some .5mm . nothing but a butt shoulder, radial shoulder or very deep chamfer of 1mm-1.5mm bucally will do here if you want it to look well with no grey.
doing it this way and you wont nick the gingiva and cause bleeding and your impressions will be first rate. some people leave cord in for impressions(meaning no bleeding)having pushed it in deeper than recommended but you may get recession if you do this.
make provisonals using heavy body pvs, and then luxatemp or integrity(a 10:1 bisacryl) and nothing else(do not use alginate), i have found if i do a circumfrential shoulder i can peel the excess off the temporary with my finger nail, also when cementing in a few weeks ensure everything is dry, if not pack cord and then cement. do this and your fixed dentistry will last a long time and look good in the process.
if someone would have told me the above when i started it would have been alot easier so this is for the benefit of younger dentists and students reading.

btkm8unsl0w5r4

My greatest tip is to never impress the day of preparation....you never know how the gingiva will react to the preparation and the provisional. I never impress the same visit. Also coming back a week or two later allows me to judge my provisionals aesthetics....and I always find something to correct in the prep after the cord is packed.

Trim your own dies....this is the greatest learning experiance ever and show you how rubbish your prep are.

Metal Try ins on big cases....this really helps iron out any fit issues and allow you to verify your mounting and adjust the occlusion in the mouth.

Do your own staining...a small procelain furnace allows you to reglaze and stain which has really turned a few good crowns into great crowns.

Keep things seperate....use cantillevers where indicated....allow you dentistry to fail one at a time...dont preform round the house bridge work unless you are a sadist.

Never make a crown fit....it fits or it does not.....20 minutes with artic paper and rouge in monomer and if its still not there.and it fits on the master die...re-impress and re-make.

We should put up a tip for bridge and crown work sticky on the forum...would make a nice change from the " I am going to X country for cheaper treatment" thread.

lomb

a tips sticky is a good idea i think the forum is basically just people complaining about cost. not much point in that imho.

Big_G

That type of stuff is very helpful actually. Now if I could just figure out how to convince people to attend for regular check ups when they are not in pain I'd be sound.


Incidentally, what type of cord do you use? I am used to gingibraid 0a in the deepest part of the sulcus underneath a 1a or 2a. In my practice though they use the medium racestyptine twisted impregnated cord which I have to say, even with a cord packer, I find extremely difficult to pack in. It keeps untwisting and is FAR too thick IMO. Any recommendations?

I also did a good bit of gold work in college, but since have not been able to convince a single soul to go that route. What a pity. It seems only dentists will be getting gold in their mouths in future.

lomb

Big_G wrote:

That type of stuff is very helpful actually. Now if I could just figure out how to convince people to attend for regular check ups when they are not in pain I'd be sound.


Incidentally, what type of cord do you use? I am used to gingibraid 0a in the deepest part of the sulcus underneath a 1a or 2a. In my practice though they use the medium racestyptine twisted impregnated cord which I have to say, even with a cord packer, I find extremely difficult to pack in. It keeps untwisting and is FAR too thick IMO. Any recommendations?

I also did a good bit of gold work in college, but since have not been able to convince a single soul to go that route. What a pity. It seems only dentists will be getting gold in their mouths in future.

forget gold on the 6s and anterior imho no one is goign to appreciate your skills even though dentists will, having said that no one can see it on the seven and if you tell people it will hold their centric stops, that the force per area is highest on the seven due to the lever effect and that you dont want to weaken seven because of that and that its invisible for the most part they might go for it.

as far as cord goes get ultradents one which can be bought from optident in the uk. get size 00 , size 1 and size 2 and ultradents fischer cord packer.

rememeber to probe the attachment to see how much space u have also, if your decay was subgingival and in the attachment no amount of packing will work unless you strip the attachment, time for either perio surgery or electrosurgery or some use a ceramic bur to cut the attachment away. remember biologic width though. apparantly its had to retract the lower anteriors , so use the finest cord you have for that or preferably leave the margins supragingival whuich i do.
as far as check ups go, people for the most part arent particularly interested and many prefer a pain service. our ethics teach us to respect the patients wishes so i suppose we should:)

tk123

lomb wrote:

post or pm a picture and il advise you what can be done. i wouldnt fit a good empress or procera all ceramic crown or good veneer for under 550 or 600 and i doubt anyone else reputable would either. the old pfm crowns have very poor aesthetics with black lines near the gingiva imho. orthodontics is the ideal though and the proper thing to professionally advise. i hope that helps.

Sorry for hijacking but is that the going rate for a crown - it's less than I expected? I have a gap between my front teeth and my dentist said it could be easily fixed with 2 crowns. I was planning on making an appointment for next week but wasn't sure what it'd cost. I didn't ask the dentist at time time because I was forking out unexpectedly for a new night guard(the other one got flushed away!:rolleyes: )..