Understanding and meeting different expectations
With mild amusement, Jesus Romero recalls a full-mouth restoration with 28 units that Bella Vita Dental Designs handled a few years ago. Romero's father, Bill Atkission, with whom he co-owns the laboratory, applied detailed characterization and coloring to create what most dental professionals would consider to be very esthetic restorations. After showing them to the patient, however, the dentist returned the case to the laboratory with a note: "I just want them plain white." So Atkission utilized a BL4 shade and sent them back, still relatively pleased with the esthetics. Again, however, the restorations were returned to the laboratory. "No," the dentist said. "Just plain." Finally, Atkission applied a BL1 shade with no stain, only glaze. "That was what they wanted," Romero says, before adding with a laugh, "Those may be the cases we do not show off on social media."
Esthetics are perhaps the most loosely defined element of a dental laboratory's work. Shade matching, incisal characterization, and other basic functions performed by the ceramist are only the start. Esthetics should take into account the patient's full face and what is inside their heads—their personal esthetic desires, which can vary based on generational, regional, socioeconomic, and various other factors.
"I embrace diversity," says Aki Yoshida, RDT, Owner of Gnathos Dental Studio in Weston, Massachusetts. "If there are 100 people, there are 100 people's tastes."
Perhaps the most commonly acknowledged discrepancies in esthetic preferences are gender-based and generational.
Matt Mills, Owner of Hybrid Technologies, LLC, in Orlando, Florida, says that women and men tend to have different preferences.
"Women, especially those who are younger, usually want shades in the bleached range and tooth shapes that are softer or rounded," Mills says. "Men tend to like more aggressively shaped teeth."
Atkission, whose laboratory is in Arden, North Carolina, says the Baby Boomer generation tends to value natural esthetics less than younger generations.
"Patients in their 50s and 60s often want straight, white teeth, regardless of whether they ever had them before," Atkission says.
In a possible resurgence of that trend, however, Mills has noticed patients in their late teens and early 20s requesting the "Hollywood smile."
"They all want perfect, bleached, symmetrical veneers," Mills says. "These are people who are putting up-close photographs of their smiles all over social media. A $20,000 smile is a status symbol for many younger patients."
Indeed, patients of all generations are being heavily influenced by social media and celebrities, according to Romero. Bella Vita Dental Designs had one patient who wanted their teeth to look like Jennifer Lopez's teeth.
"Esthetics tend to be a concept of what patients see, and what is popular or trending at the time," Romero says. "As people see things on Instagram, Facebook, or TikTok, they develop a vision in their mind of what they want."
Mills says older patients' esthetic desires tend to be a function of the type of case; full-mouth restorative cases often come with requests for the teeth to be "age-appropriate."
"Age-appropriate can mean incorporating wear, reduced tooth volume, crack lines, staining near the gingival margin, incisal effects, and other elements like that," Mills says.
Conversely, veneer cases typically are for patients who still have decent dentition and enamel to which to bond.
"These patients request brighter, whiter, youthful smiles almost every single time," Mills says.
Regional and Socioeconomic Differences
Cultural differences can play a significant part in patients' perceptions of esthetics. Atkission says he notices this often in his role as a beta tester for a software manufacturer based in Germany, as the American and European beta testers have very different requests for what the software should include.
"Europeans tend to prefer the natural look over the big, white smile," Atkission says.
Within the US, just as someone in Los Angeles might wear different styles of clothing than someone in a rural area, what is considered an esthetic smile can vary based on region.
"Patients in big cities seem to prefer restorations that look unnatural," Yoshida says. "The tendency also seems to be stronger for those who can afford it easily."
That trend may be fading, however, as technology connects even the most remote areas to the most metropolitan.
"The ability to have face-to-face conversations with anyone anywhere and to observe the latest trends worldwide on social media has made the regional element less significant," Romero says.
As Yoshida mentioned, cost still impacts patient requests, but Romero sees many dentists trying to accommodate requests for restorations that look high-end at a lower price point.
"We have some dentists who just provide PMMA temporaries instead of any final restorations," Romero says. "It is the concept of ‘Fake it till you make it.' It is Instagram vs reality."
The Technician's Influence
Depending on the technician's relationship with the dentist and the dentist's assessment of the particular patient, the technician can offer differing input on esthetics.
"If I see something that I really do not think will look good, then I will voice my opinion," Atkission says, adding that it is easiest to do that when he can communicate directly with the patient during a same-day process.
If the patient remains steadfast in their desire for an unnatural-looking restoration, subtle effects can be utilized to salvage some more lifelike esthetics.
"When a patient really wants restorations that look like a picket fence or the Chiclet effect, I try to enhance areas where they might not notice it as much, such as the gingival and incisal areas," Atkission says. "This makes the restoration look better overall, even though it is still super white."
One of the most challenging situations is the single central restoration. Matching an anterior crown to surrounding dentition is no easy feat in the first place, but the patient does not always appreciate that. Again, in these situations, a successful outcome may not necessarily be what the technician and dentist believe to be esthetic.
"Patients do not like seeing their flaws," Romero says, "so if we are matching two centrals but the laterals and canines have decalcification, we will place the white dots, lines, and specks to make it look good based off the photographs, but they might send the case back and say, ‘No, I wanted them white.' We provided a good match, but they wanted to enhance the restoration, even though it sticks out. So, we polish it all off and send it back white. This happens fairly regularly."
Of course, function is always the primary consideration and cannot be compromised by esthetic requests. Romero says those two elements often need to be reconciled, particularly when a patient references a photograph from social media.
"Often, the patient does not have the same mouth shape as the person in the photograph, so we need to explain the importance of ensuring that they can still talk and chew," Romero says.
Atkission notes that excursion is a common functional issue that must be monitored when accommodating esthetic requests.
"When the patient wants to lengthen teeth 2 mm to 3 mm, but they are only having the six maxillary anterior teeth restored, I worry about protrusion and extrusion," Atkission says. "Ultimately, that is the dentist's decision, but I at least talk to them about the potential problems.
Regardless of the exact esthetic requests, delivering a satisfactory restoration requires as much information as possible for the laboratory. Restorations must look esthetically exceptional not only in the mouth but also in the context of the patient's entire face.
"Lining up the teeth perfectly in relation to the patient's face is a high priority," Mills says. "We ask dentists for at least a full-face natural smile photograph and full-face retracted photograph, so we can import those into our CAD software and use them to determine the midline, incisal edge positions, proportions, etc. Photographs with the shade tabs also help, and we also ask for pre-operative photographs whenever possible to refer to for incisal shapes, incisal translucencies, shades, gradients of teeth, and more. We want to improve the esthetics but in a way that considers each patient's natural dentition as much as possible."
Yoshida and Atkission both try to meet with patients in person as often as possible, and in the absence of that option, they request full-face photography. Yoshida suggests creating a list of exactly what is needed from the dentist.
"The harmony between the shape of the teeth and the facial features is important," Yoshida says. "As anyone who has made dentures will understand, there is an important relationship between facial appearance and tooth shape. It is all about how detailed your communication is with the dentist and the patient."
Those details include not only angles and facial elements, but also factors such as the timing and lighting of the photography.
"A dentist may send good quality photographs, but if they were taken immediately after the teeth were prepared, they may show more fluorosis and decalcification than will be present when the teeth are hydrated," Atkission says. "We also had one dentist who was requesting an inordinate amount of D2 shades, and we eventually realized that it was due to the light from a large stained-glass window in his office that had a lot of blue in it."
Dentists also may have different tendencies simply based on their own preferences.
"Some dentists like certain contacts, for example," says Atkission's son Eric Atkission. "Each dentist has their own specific parameters."
The latest technology and materials can help technicians offer more options for esthetics.
"Every technician has a style, and when I was layering porcelain, changing my style to fit a specific esthetic request was difficult," Atkission says. "Now, CAD software allows me to have many styles. A master technician might have been able to do that with their hands, but now more of us can."
These CAD capabilities make it more feasible for technicians to provide quality restorations via a workflow whereby they supply a digital design to be milled in the dental office.
"Often, technicians would add anatomy by hand after milling," Romero says, "but that can be done in the software now when we know the dentist will likely be doing minimal post-milling work."
Mills says digital tools help to meet most of the patients' and dentists' esthetic desires in the digital waxup stage.
"With the digital tools at our disposal, I am seeing very little feedback from patients at the waxup stage," Mills says. "We are 90% there instead of 60% or 70% with analog."
New materials can help create new possibilities esthetically as well.
"In the past, a technician needed to cut back and layer porcelain to achieve certain esthetics," Romero says. "With today's liquid ceramics and stain-and-glaze sets, we can create the same effect as layering, but without the cutback or buildup."
Digital design previews and in-office milled or printed provisionals, meanwhile, can help in determining exactly what the patient wants.
"That helps us formulate a game plan," Romero says.
Music producer Terry McBride asserted at the National Association of Dental Laboratories' Vision 21 meeting in 2019 that changing attitudes toward body tattoos over the past several decades are proof that a trend can evolve from taboo to mainstream. McBride suggested that dental professionals should keep an open mind toward possibilities such as multi-colored teeth becoming fashionable.
Atkission says tooth tattoos do appear to be gaining in popularity, including more in the anterior, but that they remain very unusual. Conversely, Mills says veneers are replacing grills in the hip hop industry.
"The new trend is to have perfect teeth," Mills says.
Yoshida notes that in his experience, today's younger generations are aligned with most dental professionals in terms of their opinions of esthetics.
"In most cases, the problem is with older patients," Yoshida says with a laugh. "I have never had a request from a younger patient that I would consider to be ridiculous. Even if for some reason a young patient requires a prosthesis, they all tend to want something natural that suits them well."