Potential gum problems associated with crown and veneer placement.

We're using this digital makeover as a forum for discussing some of the types of 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 necessarily 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 issues 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.

Why gum line recession may occur around crowns.

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). These conditions, in turn, can cause a person's gum line to recede.

3) This case seems to show signs of gum disease. - People can prevent 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 access and 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.

Dental crowns don't match the color of existing teeth.
A more uniform look.

Photo submitted by website visitor.

[How to view other cases.]

Treatment solutions:

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 - Utilize at-home or professional teeth-whitening treatments and see how much the natural (untreated) teeth will lighten. The shade of the existing dental crowns will be unaffected by the whitening process.
  • 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 whitening doesn't give a good enough result? -

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.

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