Digital smile makeovers

- Gum tissue complications associated with crown and veneer placement.

We're using this digital makeover as a forum for discussing some of the types of unexpected complications that can develop when restorations (like a set of crowns or veneers) are placed as part of a patient's makeover. The primary focus of this discussion is gum health.

With an elective makeover, the risk of gum problems over the long-term must be considered.

Dental restorations are sometimes placed just to satisfy a patient's vanity. It's not that the appearance of their smile is all that bad. It's just not as perfect as they'd like it to be.

And in this quest for perfection, and due to the relative ease and quickness with which veneers or crowns can provide it, they reject the idea of having any other type of dental work or treatment.

All alternatives should be considered.

Even though they might take longer, be less convenient, or can't offer the same perfect results, some alternative makeover approaches may offer advantages.

If applicable, they may provide a more-manageable, longer-lasting result than a set of veneers or crowns. This can be especially true in regard to gum tissue health and the way gum problems can ultimately affect the appearance of a person's smile.

[Side note. - We're not suggesting that the work involved with this case was just elective. Instead, it seems that major dental reconstruction has been performed.

But the extensive amount of treatment that this patient has had provides an example of the types of problems that placing a set of veneers or crowns can pose. A treatment approach that often is taken just for cosmetic purposes.]


Case dental history and concerns:

1) This person has had numerous dental crowns and bridges placed.

It seems that her upper front teeth have been crowned. Her back teeth on the right side (top and bottom) appear to be some combination of bridges and crowns.

A dental crown with receded gum line.

If plaque accumulates at the edge of a crown, the gum line may recede.

2) Gum risks associated with dental restorations. - Having crowns placed can result in a situation that makes it more difficult for a person to clean their teeth and keep their gums healthy. (This is true for bridges, veneers and bonding as well.) Here's why this can occur.

If a dental restoration's edge lies at or below the gum line, a minute ledge or micro-irregularity will exist where it ends. And this area will act as a refuge for bacteria, which, in turn, can cause gum tissue inflammation ("gum disease," gingivitis, periodontitis).

3) This case seems to show a hint of gum disease. - People can prevent this gum inflammation by being thorough with their daily brushing and flossing activities and removing bacteria from these areas. But despite their best intentions, that isn't always accomplished. (With this case, you can see some plaque and tartar accumulation between the lower front teeth. Teeth that are comparatively easier to clean.)

Look at this case's "before" picture and compare the color of the gum tissue on top and bottom. On top, the tissue looks dark red, even purplish, and it's possibly starting to recede (there's a small space between the center two teeth). These signs may hint at developing periodontal disease (gum disease).

In comparison, the gum tissue around the untreated lower teeth (even despite the presence of the plaque) has a healthier pink coloration and it seems to come up higher in between the teeth.

4) How the long-term effects of gum disease might affect the appearance of this smile. - In cases where gum disease is allowed to progress, a person's gum line often recedes. As a result, empty spaces form between the teeth, and the edges of their dental restorations start to show. Overall, the benefits of the makeover are lost.

That's why placing restorations solely for cosmetic purposes can, in some instances, make a poor choice. If the patient fails to understand that the restorations used to improve their smile have increased the effort required to keep their mouth healthy (and they're not willing to accept this responsibility), the long-term outcome of the appearance of their smile may be a disappointment for them.


Cosmetic dentistry solutions for this case:

1) Gum tissue considerations. - Any dentist providing treatment for this patient would first need to establish the health of their gums and make sure they know how to maintain this state by brushing and flossing. (Of course, it's the patient who ultimately must insure that these steps are performed daily.) A stable gum line is an important factor in helping to insure the long-term outlook for all of this patient's existing and future dental work.

2) This smile needs a more uniform color. - It seems the single greatest aesthetic improvement that could be made with this smile would be to give it a more uniform tooth color. Additionally, the center two upper teeth would probably look better if they were slightly longer.

  • Step #1 - Whiten the natural teeth.
  • Step #2 - Replacement crowns and bridges - Replace the existing dental work selectively, so to achieve a uniform tooth coloration and desired tooth shapes.

Do we really think that tooth-whitening treatments will work? - No, not to the degree we've illustrated in the "after" picture. But if it does, or if it can even come close to creating an acceptable result, look at what it provides. A way to resolve the appearance of this case without the need for more crowns (and therefore placing yet more teeth at increased risk for gum complications).

What if the results aren't good enough? - If the whitening treatments fail to give a result that's acceptable, then, if tooth color is a paramount (although elective) issue, the only solution would be to place crowns or veneers.

You would have to expect (just like discussed above) that placing restorations on the lower teeth may put them at greater risk for developing gum disease. (Especially since it's the lower teeth that show the most plaque and tartar accumulation in the "before" picture.) This treatment option seems a poor choice unless the patient is truly committed to maintaining their gum health by practicing effective brushing and flossing.


Smile makeover cases illustrating possible complications with crown placement.


Why some teeth with dental crowns just don't look right.

When you first look at this smile you might not notice much of a problem. But the issue we've decided to...

Click image.

Crown / Gum line concerns - Dental crows can be used to make major appearance changes with teeth but not right at the gum line where a tooth exits the jawbone. This makeover explains why and what solution is needed.

 

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Comments

I had veneers in done on my front teeth. This was actually without me deciding in favour of it. It learned about it from the dentist who suggested it and still had not made up my mind but she went ahead and stated work on my teeth so i had no option but to carry on with it. The problems which resulted: i could not floss because the thread would break whenever I tried. Later my gums started bleeding after 3 yrs. A new dentist gave me an ointment and mouthwash. It went away but came back a year later and one of the veneers also fell out. When to the original dentist who made the veneers to fix it back. She jabbed and scraped the gums saying she was cleaning them and then did a partial laser treatment at a cost of Rs 25000 and then fixed the veneer back. I now have a gum problem again and one veneer fallen out. Of course I can't go back to her.

If have got an opinion from 3 or 4 dentists and can't decide wha action to take. The opinions are:

1. From the x ray the gum disease is starting to affect the bone therefore

a) treat the gums with injected fibres which release medicine at regular intervals. When the gums are ok redo all the veneers
b) treat the gums for 2 to 4 days with ointment metrogyl and replace the veneer which fell out. Then remove all the veneers since they
are not properly done and are causing the gum problem. Put temporary fillings for 2-3 weeks till the gums are completely ok and then
replace with the correct veneers.
c) dont put back the veneer. put only a temporary bonding and then remove all the remaining and keep temporary filings for at leat a month or 2 months till the gums are completely healed. Then replace new veneers. The old ones were angled wrong and therefore created
a ledge for bacteria to collect also didn't allow me to floss.

Please advise which is the best option.

A fourth option says to leave the veneers as they are a take extra care for the gums. I am not very inclined to go for that since the veneers are obviously creating the problem.

For others reading, the fundamental problems with your situation are:
1) You can't floss between your veneers.
2) Each veneer's edge creates a ledge that harbors plaque.

As a result of both, gum disease (due to dental plaque accumulation) has developed around the veneered teeth, to the point where it has affected the level of the bone surrounding them too.

As a side note, in cases where bone damage has occurred, as the gums heal and become healthy again some degree of gum recession will likely occur.

That's not necessarily a problem in your case since the veneers will be replaced anyway. But it does mean that if your gums aren't in perfect health when the new veneers are made, and then later on if they do become fully healthy, you could experience some recession which might ruin the appearance of the new veneers.

That means you need a treatment solution that will create the ideal gum situation before your new veneers are made.

Option A - With this option, the dentist is relying solely on medicine to cure your gum problem.

Even if improved brushing can remove more plaque from the edges of your veneers, you'll still have the problem that you can't floss. Therefore plaque will continue to accumulate.

Considering that gum health is paramount for your case, what might be the more predictable approach would be to remove the source of the problem first (the plaque and the inability to remove it), then use medicines to aid the healing of your gums.

Options B and C - These options do that. Their plan seems to be to temporize the appearance of your tooth now, place temporary veneers on the other teeth (so to remove the ledges and so you can floss), then once the gums have healed make new veneers.

There is a difference in the time frame suggested for each option.

In general it takes 10 days to two weeks for gingivits (gum inflammation without the involvement of the underlying bone) to heal. Your situation seems more advanced than that, so the longer time frame seems the more realistic.

You may simply need to take the attitude that you'll put up with whatever it takes to get the job done right this time, even if doing so includes inconvenience or subpar appearance for a while. If so:

1) Let a dentist temporize your tooth with the lost veneer the best that they can.
2) Let them place temporary veneers or fillings on your other teeth (even if they are a nuisance to keep in place or don't look perfect). They must be a type of temporization that removes the ledges and allows you to floss.
(Side note: Your 4th option of leaving the veneers in place could substitute for temporary veners. If the dentist could trim off the ledges and make it so you could floss between them.)
3) Let your dentist treat your gum disease issues (cleaning around the teeth, the use of medicines if indicated).
4) Use this time period to develope the excellent homecare skills you'll need to practice for the rest of your life.
5) At that point when your gums are healthy and stabile (no further recession due to gum health issues is expected), have the new veneers made. (At whatever point in time that is, which will depend on both your initial conditions and how well your homecare keeps your teeth plaque free so healing can occur).

Good luck with this.

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