Excellent cosmetic dentists can be found everywhere.
The featured case indicates that there may be exceptions.
Smile makeover completed during a vacation abroad
Smile makeover redone in San Francisco
Excellent cosmetic dentists can be found all over the world. I have seen beautiful cosmetic dentistry and smile makeovers that were provided by the best cosmetic dentists available on planet Earth. However, I have been approached by a few patients who requested to have their dental work replaced immediately. The problems created were just too troublesome.
As much as we can see the best cosmetic dentistry possible at any part of the world, we also occasionally observe faulty work, where essential steps of smile design were ignored and not applied. The case described here is examplary of the kind of porcelain veneers that need to be replaced to eliminate severe discomfort and significant aesthetic shortcomings.
There is nothing wrong seeking professional help of cosmetic dentists in other countries. The savings may be enormous. The level of expertise of a foreign cosmetic dentist may be comparable to that of a cosmetic dentist who is accredited by the American Academy of Cosmetic Dentistry. The term "foreign" is relative. It appears that the best service is provided within the country the patient resides. Why? Because there is a sense of accountability that is directed by local licensing agencies, which protects the patient. There is also always recourse in case of a problem. The patient can return to the dentist to get the problem fixed. This is often unfeasible when the patient lives in a different country.
A comprehensive smile rejuvenation is never just a two-visit undertaking. It cannot be achieved in a two-week vacation. Just the simple planning phase commonly takes at least two weeks, if nothing else needs to be addressed. However, bite problems or necessary gum adjustments extend the smile design phase significantly. Once gum adjustments are necessary, the treatment phase will be stretched by additional three months, which is the time that the periodontal tissue needs to heal and stabilize at its new gingival heights.
Careful planning, a thorough communication between dentist, patient, and dental laboratory, trial smiles, and at least one follow-up after completion of a comprehensive smile makeover are indispensible steps towards an enduring and beautiful smile. The best cosmetic dentists worldwide apply this systematic plan. The delivery of an entire set of porcelain veneers requires a lot of endurance by the patient. In addition, local anesthesia will make a final assessment regarding comfort by the patient difficult on the day of insertion. Hence, a follow-up meeting should always be scheduled to ensure that everything is in order and any concern has been addressed.
The most common shortcomings of a rushed smile makeover are
- Delamination of Porcelain
- Loss of Entire Porcelain Veneers
- Uncleaned Cement at Gum Line and Between Teeth
- Bite Interferences
- Jaw Problems
- Poor Chaulky and Unnatural Appearance of Porcelain Veneers
- Monochromatic Color Schemes
- Unnatural Smile Lines
- Unnatural Tooth Proportions
- Lack of 3-D Effect or Porcelain Layering
- Ill-fitting and Leaky Margins
- Bleeding Gums
- Violation of the Biological Width
(poor quality of porcelain work by dental lab)
(poor quality of dental work by cosmetic dentist)
(negligence by cosmetic dentist)
(poor follow-up by cosmetic dentist)
(poor diagnostic work-up or introduction of iatrogenic problems by cosmetic dentist)
(poor quality of porcelain work by dental lab)
(poor quality of porcelain work by dental lab)
(poor smile design by cosmetic dentist and/or bad communication with dental lab)
(poor smile design by cosmetic dentist and/or bad communication with dental lab)
(poor quality of porcelain work by dental lab)
(poor quality of porcelain work by dental lab and negligent delivery by cosmetic dentist)
(negligence and poor follow-up by cosmetic dentist)
(introduction of unhealthy situation by cosmetic dentist)
Violation of Biological Width (See graphic explaining biological width below)
The upper image below displays the typical clinical appearance of unhappy gums whose biological width was violated. The lower image shows healthy gums whose biological width have been rehabilitated by a surgical crown lengthening procedure.
Porcelain Veneers done in Costa Rica.
Porcelain Veneers done in San Francisco.
The ill-fitting veneers has largely open margins that were filled with overhangs of dental cement. This contributed to the inflammation of the adjacent periodontal tissues. Cosmetic dentistry should start with healthy gums.
Bird's-Eye Views of Original Smile Makeover
and its Replacement in San Francisco
Porcelain laminates made abroad.
Note the open contacts between the teeth.
Porcelain laminates redone in San Francisco.
Note properly closed interproximal dental contacts
and proper three-dimensional contour of tooth anatomies.
The bird's-eye view images show principle design errors of the original smile design. The patient does not have any upper lateral incisors and had his canines to be reshaped to look like lateral incisors while maintaining individual natural tooth contour.
Biological Width Explained
This illustration demonstrates the biological width at the interface of the emerging tooth structure and the surrounding periodontal tissue. When designing smile with porcelain veneers, this relationship shall not be violated. If an alteration of the gumline is necessary to improve gummy smiles or irregular gingival margins, it should be done by reducing as much crestal bone as gingiva to maintain the biological width, which is the distance bewteen the crest of the alveolar bone and the gumline.
E.A. = Epithelial Attachement
C.T.A = Connective-Tissue Attachment
This illustration is based on a variety of studies:
Gargiulo AW et al. Dimensions and relations of the dentogingival junction in humans. J Periodontol 1961; 32: 261-7.
Ingber JS et al. The "biologic width"-a concept in periodontics and restorative dentistry. Alpha Omegan 1977; 70: 62-5.
Rosenberg ES et al. Crown lengthening revisited. Compend Contin Educ Dentistry 1999; 20: 527.
Jorgic-Srdjak K et al. Periodontal and prosthetic aspect of biological width part I: Violation of biologic width. Acta Stom Croat 2000; 34: 195-7.
Kois J. Altering gingival levels: The restorative connection, Part 1: Biologic variables. J Esthetic Dentistry 1994; 6: 3-9.
Kois JC. The restorative-periodontal interface: Biological parameters. Periodontol 2000. 1996; 11: 29-38.
Jorgic-Srdjak K et al. Periodontal and prosthetic aspect of biological width part II: Reconstruction of anatomy and function. Acta Stomatol Croat 2000; 34: 441-4.
Smukler H et al. Periodontal and dental considerations in clinical crown extension: A rationale basis for treatment. Int J Periodont Restor Dentistry 1997; 17: 464-77.
Robbins JW. Tissue management in restorative dentistry. Funct Esthet Restor Dentistry 2007; 1: 40-3.
Khuller N et al. Biologic width: Evaluation and correction of its violation. J Oral Health 2009; 3: 20-5.
Porcelain veneers at lower teeth
Lower veneers made by a dentist who ignored best porcelain veneer principles.
In comparison, veneers made by accredited cosmetic dentist in San Francisco.
The veneers above display leaky margins (red arrow) and large cement overhangs (blue arrow),
which make it impossible for the patient to floss.
The blue squares indicate the "boxy" outline of the prior porcelain veneers.
The replacement veneers made in by Dr. Jorg-Peter Rabanus, DDS,
San Francisco, display finer contours, correctly designed anatomical features,
perfect marginal fit, and no residual luting cement.