Also, you may explore the website for the American Academy of Cosmetic Dentistry: aacd.com for more on dental esthetics. Since Cosmetic Dentistry is not a recognized specialty, this organization provides accreditation for those dentists that seek to build their expertise in this area in a responsible way.
Organization of this Chapter
Basics of Esthetics
Elements of Esthetics Related to Oral Structures
Bottom Line for Esthetics
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Basics of Dental Esthetics
The facial attractiveness of a person depends on two things: the physical relationships and characteristics of a person’s face, and cultural bias.
One cannot talk about appearance and its impact on others without acknowledging that cultural bias plays a pivotal role.
For example: before I even became a dentist I was in a small grocery store in a unique village in rural Pennsylvania, where they specialize in raising great mushrooms. The entire village, that is the people, were effectively imported from a similar village in Mexico, where they had perfected the art. In this grocery store there was a young woman checking people out that could not stop smiling. The striking thing to me is that each of her upper front teeth had a rim of gold around it! Of course, according to U.S. standards at the time, this was “weird”, but in relatively poor cultures the display of gold demonstrates success.
Sometimes procedures are done to teeth to make a statement, culturally. Gemstones can be inserted into teeth, or gold crowns can be placed on anterior teeth of rap music stars, etc. This is no different from displays of jewelry through ears. lips, noses and around necks, fingers and wrists – other than the permanence.
For this section I will take the ultimate esthetic standard as being the appearance of the teeth, gums, and support of facial structures the way they are designed. There are relatively few and rare deviations from the basic design of the teeth and gums and facial support from person to person and from culture to culture. Mostly people throughout the world have similar opinions as to when a person looks normal in that part of the appearance that is determined by oral structure. Certainly, this is NOT the case for the shapes of noses and lips and eyes and eyebrows, etc.
There is far greater individuality in extraoral form and esthetics than in intraoral form – and if there weren’t, we would all tend to “look” the same, and that would be extremely boring!
Elements of Dental Esthetics Related to Oral Structures
Below are listed Eleven things we need to be evaluating to determine if an individual person meets esthetic standards – strictly for that part of their appearance that relates to the oral structures.
In Chapter III.8 we will discuss ways in which people can DEVIATE from these “standards” of appearance and why..
In Chapter IV.5 we will discuss what we look for in a patient that comes to us for cosmetic procedures. Specifically what do we NOTE in their chart that relates to appearance, that might direct future procedures that are designed to IMPROVE appearance?
In Chapter V.18 we will look at the broad field of Cosmetic Dentistry – i.e. dentistry that is done ONLY for the purpose of making a person “look better”. This is a complex field, to be sure, and all the more so because dentists only have control of SOME of the areas that determine a person’s appearance – the teeth and jaw bones, and the parts of the face that may be influenced by the teeth and bones in this area.
- Cheek form can be altered by the dentition and oral function. For example if someone tends to clench their cheeks a lot, the muscles that are responsible for closing their jaw get strong. As with all muscles, when they get strong they become larger. So, as sometimes seen, a man with bulgy cheeks may have a clenching or grinding habit, and this habit may have something to do with deviations from ideal occlusion.
- The smile line can be altered by the dentition and jaw structure. If the arch is wider it tends to laterally enlarge the smile (this may happen with palatal expansion in early orthodontic treatment). Also, the show of the lowest parts (the incisal edges) of the upper front teeth depends on the vertical position of the lip, and this is altered by the location of the teeth, not just up and down but inward and outward as well.
- Upper lip support depends on the location of the maxillary anterior teeth, especially the incisors. This is the appearance of a person when in profile. If the teeth are too protruded, then the lip sticks out horizontally, farther than matches (looks good in relationship with) the lower lip. On the other hand, if the teeth are retruded, then the lip appears collapsed, giving the person a very noticeable and often unattractive appearance. When a dentist restores the maxillary anterior teeth, whether with crowns or veneers or in dentures, he/she makes certain to adjust the lip support for the best look in profile. A person may even want to have their profile changed from what they were born with by building the teeth out farther, strictly for cosmetic reasons.
- Pronunciation can also depend on oral structures. This is an audible form of esthetics – if someone cannot pronounce particular sounds well, then they are less appealing, because they are unusual (sad to say). The pronunciation depends on tooth position, on the shape of the palate and the size and extension of the tongue. Tooth position we can do something about, and we commonly work with evaluating the ability to make certain sounds when installing dentures that affect the palate or tongue (lingual) side of the upper anterior teeth.
- Tooth contours – Anterior shape – are an important part of esthetics. But tooth contours vary relatively little from person to person. This is not to say that there is NO variation, there certainly is. It may even be that slight deviations are more noticeable in some people because most people are so similar. In different parts of the world the teeth do tend to have regionally consistent shapes, but this often does not show in the appearance. As we will see later, when a person damages a tooth, it is all the more visible because of the relative similarity we are used to across the community we are in. Anterior shapes can involve the outline when seen from directly in front of the person, or the contour when seen from the side. Both are vital.
- Tooth contour – posterior shape – also represents an esthetic observable in many people. For some people you can see far back into the mouth, particularly on the lower arch, when they smile. You can see the facial (toward the outside) contours of the premolars and molars, and if the precise curvature of each tooth is not “normal”, this is disturbing to us on some level.
- Tooth contour – occlusal shape – can be seen when a person opens their mouth wide. Think of a singer hitting a high note, or someone screaming. I often think of Superman screaming over the death of Lois Lane – the camera shows his upper occlusal surfaces. Now – the shapes weren’t particularly noticeable as being different, but I did notice a couple of amalgam restorations! Superman?! Invulnerable to bullets, etc?! OK – anyway, if you do have occasion to see a person’s occlusal surfaces, more commonly on the lower of course, you may notice variations that don’t seem usual. The deviations from the norm of basic tooth occlusal design is unusual, but certainly we are used to seeing the result of wear (discussed in Chapter III.8).
- Tooth alignment is a large determination of esthetics. We are mostly used to seeing people and friends with crowded lower incisors, but when this shows up in the upper arch it can be more disturbing. We’ll discuss deviations more later in Chapter III.7, but for now, it is worth noting that when the teeth are aligned normally, as they are designed, it is unusual. Even when someone had braces as a kid, perfectly aligned teeth are seen more in advertising than in real life. But – the teeth are DESIGNED to be aligned and integrated into a uniform arch, with surfaces matching along the arch.
- Spaces between the teeth – particularly the front teeth. These spaces are called diastema. While some people make this work, David Letterman, for example – for others it doesn’t seem right for their personality.
- Tooth appearance depends on much more than just shape. Dentists commonly look at several factors – the shade, the transparency, and characteristic lines. The shade is actually broken down further into hue, chroma and value. Hue means the basic color, which varies in the light to middle yellows for young, natural teeth. Chroma is like saturation in photographic terms. Intense colors have a high chroma, but we don’t want this too high for teeth. Value is the brightness – ranging from black to white – but it is the brighter end that interests us the most, of course. When you restore a maxillary incisor corner with composite (plastic), if it is too transparent compared with the tooth, you can see the darkness of the back of the mouth through it, and the value drops in comparison with the tooth – not a good look. Which brings us to transparency – a BIG issue. Here’s the clincher – OLDER PEOPLE have more transparent teeth. So, things can change naturally, during life. The mineral content of the enamel changes over the decades, and in my hypothesis makes larger crystals of mineral within the enamel, rendering it more transparent. THIS is why older teeth appear more yellow – you can see the yellowish color of the dentin THROUGH the enamel. One can argue that the teeth were designed to change like this during life, and that more yellowish teeth looks natural, and nice, on older people (see the front page of this site). Many older people elect to have crowns or veneers done to make the teeth look more opaque and white again, as in youth, but often this is overdone to give an unnatural look. Characteristic lines are also important in older people – cracks form on visible surfaces which get a little staining. They are not open cracks, threatening to decay, but they are visible, esthetic features that form naturally and must be matched when restoring adjacent teeth or tooth surfaces.
- Gingival esthetics are very important when the gums can be seen. Of course, this is usual in conversation and even more in smiling and laughing. The gum line (gingival margin) is designed to cover the place where the enamel and root cementum meet – the CEJ. In fact, the connection between the gingival tissue and the tooth, in youth, is only on enamel. Now – in the section above I argued that whatever is most normal for older people looks natural – like the transparency and yellowish color typical of older teeth. Here, however, I may argue differently. While it is “normal” for people’s gingiva to recede over the decades, it is NOT necessarily going to happen to the extent to compromise esthetics. Changes in enamel are inevitable, hence normal – however, changes in the gingival level are generally related to your personal home care. My mother, at the age of 94, had anterior gingiva that still covered the CEJ! She was always considered a beautiful woman, and took care that she stayed looking that way.
Bottom Line for Dental Esthetics
It is probably fair to say that there are few people in this world that don’t really care what they look like. There will be a tendency to ignore it if we absolutely cannot do anything about it. But, we are social creatures for the most part, and the nature of our social interactions tends to follow initial connections made on the basis of appearance.
Now, that being said, it is certainly true that appearance is FAR MORE SUBTLE than just how the teeth look and how the shapes of the various components of the face look.
I’ve mentioned that there is a cultural bias to the social value of appearance.
But – there is also that mysterious “something” – that is a way more nuanced way of looking at someone’s visual impact on us.
I believe that a person’s personality – their kindness, caring and empathy, or on the other hand meanness, anger and lack of caring – will be completely expressed in their facial features. There is nothing that the Cosmetic Dentist of Plastic Surgeon can do about that!
For the oral structures it would be best if they do NOT DISTRACT from another person’s ability to SEE us for who we are.