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Bad Fitting Crown Case Study

CASE STUDY

 

I love to help people and the best way I am currently able to do that is to be an advocate for patients who are the victim of poor dentistry. This may sound a bit harsh to many dentists but after seeing thousands of terrible crowns, unnecessary root canal treatments and patients being blown off by dentists, I feel I need to stand firm and help where I can.

This case came to me last week, January 2018. The patient had the following comment to my blog post about another bad fitting crown case. Click HERE to read the post.

This was her comment:

Hi Dr.Chris,

First of all thank you so much for your time and answering all the questions.

I have root canal done on upper left tooth(24) and large filling on the tooth next to it(25 I think) and few minor fillings after first ever visit to dentist. I did get second opinion before I got the first root canal. But ever since I got the root canal plus crown(for 24) and filling done on 25, the tooth 25 was feeling high all the time and they adjusted so many times, I was told that it needs root canal because it is feeling high even after so many adjustments, this time I trusted them and did not go for a second opinion. I got a root canal done and had crown in place. Bite still feels high and off, in fact they can see that the I’m biting high on crowns they adjusted so many times and still wasn’t feeling right, on top of that I was getting constant headache in my right temple, but I didn’t think headache would be related to bite.

Earlier they have suggested me to use night guard ordered one for me ,so I went to get a night guard at that time and I mentioned to the dentist I was seeing on that day about my headaches he looked at bite on my left and right side , said I’m biting high on couple of lower teeth adjusted on both sides. Ever since than my bite feels so weird and my headaches didn’t get any better , so I asked other dentist in their group to have a look and she said she can not see anything but smoothed that tooth on lower right. Still nothing changed.

So I mentioned to them about it and then they send me to some in their group who is specialized in bite and he checked my bite and looks fine , I’m biting bit high on of crowns. When I mentioned to him about feeling high lower right he has done some adjustment to upper right, After that my headaches are getting worst and my right jaw and temple hurts when I bite and I’m having neck pain as well. I was told to use night gaurd strictly for a week but it doesn’t seem to help either. I feel some pressure in the very back when I wear it and when I wake up my bite feels so different/ weird and always feeling high where the crowns are when I bite feeling pressure on tooth behind new crown, having constant jaw pain , headache.

I feel very unfortunate with these bite issues and feel like I should have never went to the dentist. Now I’m very afraid to let anyone touch my teeth.

Do you think crowns are causing these bite issues? if the bite is high on left side Can It cause headache on right temple? Can nightguard fix the bite problem? Please let me know your opinion. Thank you so much in advance.

After reading this I asked the patient to send me her x-rays and photos, which she did and I have permission to share this with you all as a learning experience.

This was my initial response to her via the comment on the blog:

This is a sad situation but an incredible good learning experience for everyone reading this. Let me address one issue at a time.
First, the fact that the dentist said you need a root canal since the bite is high is not only not true it is ludicrous. If you went to the dentist without a bite issue and they placed a bad crown then doing a root canal due to the bite now being wrong is in my opinion unethical.
The second crown still was wrong and they never were able to correct the bite. This essentially means you need a good dentist to do it right. Getting the bite right is not rocket science.
Third, making a nightguard before fixing the bad crown is also a bad move. When you mentioned you are hitting on the back teeth with the biteguard in I can clearly picture the type of nightguard they made…it needs to be adjusted to fit correctly or it is just an expensive piece of plastic. You are clearly hitting on the back teeth first due to the nightguard which is making the situation worse.
You need to leave that group and find a dentist that puts you first, has experience and can solve your problem.
I am happy to help by looking at “new” X-rays of the crowns and photos. Ask your Dentist to take bite wings and send me the originals via email. Photos help as well. This will let me determine the quality of the work real quickly. I do free consults like this all the time so people can be helped and not neglected anymore. All information for free consults should go to info@idealdentistry DOT COM (spelled out to prevent spam). Sorry for your trouble.

Upon receiving the x-rays and photos it was very clear to me what the problem was. The fact the these x-rays and photos are available to all the dentists that were involved in the treatment of this patient and no resolution has been achieved is not only frustrating but terribly sad for the profession.

The basic, very basic issue is that the initial crown and filling the patient had done were not fitting correctly. In fact, the crown, as is clearly visible on the x-ray, does not seat all the way down onto the tooth resulting in a tooth that now is hitting all the opposing teeth first and allowing bacteria and consequentially decay invade around the edges. I circled the areas where the crown does not close all the way onto the tooth. The second, newer crown, the one to the left on the photo, fits even worse!

What are we looking at in these x-rays? The white part of the crown picture needs to touch against the gray part of the tooth. The black line between the two (circled) is empty space which means the crown never was seated all the way down. Often this is the case because the contacts between the crowns were not properly adjusted.

The following photo demonstrates the amount of reduction the dentist made, cutting the new crown down with a coarse diamond. You can still see the scratches in the surface of the two crowns form the diamond cutter. I wonder if this was ever polished out or if the rough surface was left like this?

You can also see, on the first picture above, the blue marking tape is still present. This type of marking tape is the thicker kind that I do not like to use. You can be much more precise using a thinner mylar type of occlusal tape.

So, I have to conclude that the decision was made not to redo the bad fitting crown but to rather try to cut a ton of porcelain off the crown, not polish it and tell the patient that a nightguard (which she did not need prior to any of this dentistry) will solve her problem. Wow.

Now that we know the crowns are bad, the fit is bad and the occlusion (the way they touch the opposing tooth) is bad, let’s address the nightguard solution….

I am a strong believer in properly adjusted nightguards. All to often I see patients coming to see me as a second opinion and they show me their nightguard that was never really adjusted right. The are essentially only hitting on the back few teeth which is making the entire situation even worse. A nightguard that is not properly adjusted is just an expensive piece of plastic! The general rule is that if the patient feels they are hitting wrong on the guard, then they are. Adjustments must be made until the guard is a therapeutic device which will then alleviate some griding, reduce stress on the teeth, help evaluate joint and bite problems and many more things. Nightguards are amazing if they are used correctly. Often unfortunately they are just ordered by the dentist, delivered by an assistant and forgotten.

So, this patient was frustrated and did not know where to turn so she searched the web for bad fitting crowns, second opinions, and eventually came to my blog. I wish I could help more people receive answers and teach dentists how to solve these issues when they first come up. It does not take too much work to deliver a good fitting crown to start with and create a filling that fits properly. It is perceivable that both root canals and crowns could have been prevented with earlier interception and quality care. I ask that dentists select their dental labs not just on price, but quality. It saves a lot of time for both the dentist and the patient!

The solution? This patient needs to see a dentist that can redo these two crowns, correctly, using a quality dental laboratory and have a new, good fitting and properly adjusted nightguard made. This will cost a little more but would have been a lot cheaper had this top quality dentist been seen in the first place.  Now I know, most patients rely on their dental insurance as “insurance” for their dental needs, but that is an entirely new issue I tried to address in this blog post: DENTAL INSURANCE

I welcome questions from patients AND dentists. Anything I can do to help improve the quality of dentistry, count me in.

Keep Smiling,

Dr. Chris

 

posted in General Dentistry

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