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Is BL4 too light a shade, if I want a natural smile?

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Dr. Hall,
I’m getting ready to get my veneers would BL4 be too white or would it be natural looking? Thank you!
Wayfon from North Carolina

(See Dr. Hall’s answer below.)


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Wayfon,
For the benefit of our readers, the BL shades were developed by Ivoclar some years ago after tooth bleaching became popular, and they are whiter than teeth are found naturally. BL1 is the whitest, and BL4 is only slightly whiter than the whitest natural shade.

When I did a smile makeover for one of my patients, I had a little questionnaire I gave them where I asked them questions about how they wanted their new smile to look. One of those questions was about the color they wanted. I asked them to rate, on a scale of 1 to 10, whether they wanted a white color or a natural color. Marking a “1” indicated that they wanted bright white teeth. Marking a “10” indicated that they wanted a more subdued color that didn’t stand out and made it look like there was nothing artificial.

You sound to me like, had you been my patient, you would have marked something between a “4” and a “6”—you want it as white as you can go with keeping it still looking natural. With you feeling that way, I would have recommended, as your cosmetic dentist, a shade B1 on the classic shade guide. With a “7” or “8,” I would have suggested an A1 shade. With a “9” or “10,” I may have gone to maybe halfway between an A1 and an A2. While my patients generally ended up very satisfied, over the long term, with the color we had helped them choose, I did have one smile makeover patient in the early days of my practice who chose the A2 shade and then later told me that she regretted not getting something whiter.

To help you see this, I have an image here photo of the Ivoclar shade guide extension for bleached teeth, showing shades BL1, BL2, BL3, and BL4 alongside the classic Vita shade guide with shades A1 and B1 of the Ivoclar bleach shade guide with shade tabs for A1 and B1 on the classic shade guide pasted next to it, for comparison. A1 is typically the whitest we would see in patients, but there would be some with very white teeth who would have shade B1 naturally. B1 is a common shade of baby teeth but not very common in adult teeth. While keeping in mind that the photographs of these shade guides may have been taken under different lighting conditions, it is still apparent that the BL4 is noticeably whiter than the B1. So if you truly want your smile to look bright but natural, I wouldn’t go whiter than B1. With BL4 you will have lovely white teeth, but they may look somewhat whiter than natural and it may look to people like you have had work done on your teeth to make them that white. Having said that, I had some patients who really wanted bright white teeth that would almost light up a room. We would give them BL1, which we nicknamed “ballistic white,” (some offices call that “Hollywood white”) and they were very happy with them. It all depends on your personality. You have to decide what kind of impression you want to make with people. If you want your bright smile to be noticeable, I would go with the whiter look. If you want them looking lovely but not advertise that you have had work done, I would stick with B1.

I hope that’s helpful.
– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Dentist can’t get the color right on the implant crown

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Dr. Hall,
I have a similar problem to Mary from Australia in your post about the color of the implant crown, except my crown was done three times. Each of them offered a completely wrong color, but my dentist was fed up and told me to “be grateful” and stop asking for so much.

All I want is for my smile to look uniform, like it did with the flipper I used to have to wear. But she says “my color is complicated” because a1 is too grey/white and a2 is too yellow.

She emphasized that I was lucky my implants were still holding after having the crowns be manipulated. This has made me fearful of approaching someone else for a second opinion.

Is this the case? Am I at risk of losing the whole process if I continue to have them redone?

Thank you for your help!
Isabella

(See Dr. Hall’s answer below.)


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Isabella,
I’m struck by the attitude of your dentist, turning her problem on you, accusing you of asking for too much because you want your crown to match your other teeth. You say you were happy with the color of your flipper tooth, so you don’t sound to me about someone who is that hard to please.

To answer your question, no, you won’t damage the implant if your crown is removed by grinding it off. Go get your second opinion. You don’t say where you are, so I can’t give you any tips about how to find an excellent cosmetic dentist. And I don’t know which tooth you are talking about. It sounds like this might be a front tooth. That takes a certain amount of skill and patience on the part of the dentist to get a perfect match if you have a crown on one of your very front teeth. I will tell you that in my office it was normal to have at least two or three try-ins before we got a perfect match in a situation like that—sometimes considerably more than that.

From what you are saying, your dentist seems to be frustrated because your tooth isn’t a perfect match of one of the standard shade tabs of the Vita shade guide: “A1 is too grey/white and A2 is too yellow.” But while that degree of matching is okay for a back tooth, for a front tooth the dentist needs to customize that standard shade tab.line drawing of a front tooth with areas labeled for different colors Here is a color map that is typical of what I would draw out for the ceramist when I did a single crown on a front tooth. In the written instructions, I would specify a basic shade. Let’s assume that is A2 for this tooth. Then, besides the basic shade guide, I had a set of tint tabs with various tints of pink, yellow, blue, etc. I would then draw areas where the ceramist would need to add any of those tints to get an exact match with the natural tooth. And then, like I said, after the crown came back from the ceramist I would do an initial try-in, see what the color discrepancies were, and write about those. Later, with the convenience of digital photographs, I would just snap a photo of the try-in and the ceramist could then see where the color needed to be adjusted to get a perfect match. I wouldn’t even THINK of cementing the crown until we had a successful try-in, which is one of the things that really bugs me about your dentist—that she would cement a crown when you didn’t like the color. In fact, my appointments for front tooth crowns were always scheduled as a try-in, and not until we had a successful try-in would we actually cement it.

So it sounds to me like you are in the wrong dental office. While the vast majority of dentists aren’t concerned enough about aesthetics for the appearance-conscious patient, from what you’re telling me, your dentist seems to be at the extreme level of not caring about this issue. Your average dentist won’t ordinarily go past just finding the right shade tab to match your tooth and maybe go to fractions to communicate with the ceramist. For example, the dentist could tell the ceramist, “try a shade A1 1/2 – halfway between A1 and A2.” But if the crown has the right value (the degree of brightness), it will generally be an acceptable match for many people, even if all the right tints aren’t there. But your dentist doesn’t seem to even want to go through that trouble.

– Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below. Or click here to ask Dr. Hall a question.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

The difference between Hollywood white veneers and natural white

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Hi, Dr. Hall
I hope you can help answer my question. I recently got veneers and asked for white white, the Hollywood smile. As far as size and shape, he got that perfect, but my teeth are only one maybe 2 shades whiter than what I had before getting veneers. What I wanted was either a bl2 or bl3. I know this is considered fake looking, but this is what I wanted. I even showed pictures at my appointment. At the time, I did not know the names of the shades. In my appointment, after I showed him pictures of the color I wanted, he told his associate, do an A1. I assumed A1 was that bright “fake” white. He never showed me a color chart.

I now have had them for 5 days and am so unhappy and depressed as I feel I wasted money. My teeth were in good condition beforehand, straight and a tiny bit yellow, more an off white. I expressed my concerns with the dentist, and now he is saying that the color he actually submitted was an bl1 and has no idea where the A1 came from. I am 100 percent certain he said A1 at my appointment to his associate because I have never heard that before and I didn’t know any shade names. Could he be saying this because he does not want to redo them for me? I would hate to think he could be lying. I can guarantee I do not have a bl1 color. They look a dull natural white, very close to what I now see an A1 is. He is saying that my veneers could look darker than what I wanted because of my teeth underneath, but I whitened them at the dentist and again at home and they were not that bad beforehand. Even if they were black, I think a bl1 would have made my teeth look more white than what they are now. I want to add the veneers I had were the no preparation veneers. Please help! Thank you!

Mary from Studio City, California


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Mary,
I think you have this figured out—your dentist just doesn’t want to re-do the veneers. You could call him on his mistake by asking him to photocopy the work order he gave the dental laboratory and give that to you. If he alters it before copying it that would compound the mistake and give you tangible evidence that he has tried to deceive you, so I’m pretty sure he’ll refuse to give you this if you ask. And blaming it on the color of the teeth underneath is just admitting that he didn’t know what he was doing. A competent cosmetic dentist and dental laboratory will always take into account the shade of the underlying teeth and if the veneers are to be dramatically whiter than the underlying teeth, some opaquer is built into them so that they get the correct final result.

I am impressed that you’ve done your research and know all these names of the shades from dental shade guides. You now apparently know more about shade guides than your dentist did when he started your case!
a display of four teeth on tabs. Each tooth is labeled with a shade designation: bl1, bl2, bl3, and bl4

Here’s a little background on this tooth shade matter. Dentists, in dental school, are schooled in what is called the classical shade guide, where the whitest shades are A1 and B1. So if you were to ask one of these dentists what is the whitest shade of teeth, they would tell you either A1 or B1.

When tooth bleaching became popular in the 90s, shade guide manufacturers realized that they had to expand the shade guide to incorporate the new bleached teeth shades. Ivoclar, the maker of the second-most popular shade guide, was the first to respond and they invented the bleached shades 010, 020, 030, and 040. Later the names of these shades were changed to bl1, bl2, bl3, and bl4. That’s the bleached shade guide that you are referring to.
Vita, the manufacturer of the most popular dental shade guide, was a little slower to respond, but they finally came out with bleached shades M1, M2, and M3. Today, many cosmetic dentists use a combination shade guide made of the traditional Vita shades A1 to D4, with the Ivoclar bleached sides bl1 to bl4 tacked on.
a shade guide with the bleached tooth shade bl1 to bl4 on the left, and the rest showing the 15 natural shades A1 to D4

In my practice, we would always carefully discuss this issue of the final shade of the teeth that the patient wanted. Most patients wanted a natural white, but there were a number of them who wanted what you wanted. Some cosmetic dentists call this a “Hollywood white” color. In my office we called it “ballistic white.” Before they came out with the bleached teeth shade guides, we would communicate this to the laboratory as a B-zero color, and we made sure the laboratory understood what we were talking about.

Your dentist made a fundamental mistake in your case, and needs to make this right to you. There’s no point arguing about how it happened. The point is that you didn’t get what you asked for in a Hollywood white smile.

A fundamental principle of smile makeover dentistry is that the case is a failure if the patient doesn’t love how it looks. Every ethical cosmetic dentist I know would re-do the case if they missed the shade like your dentist did, leaving the patient unhappy with how the case looks. I think you just need to get tough with him, not accept any excuses, and I believe that he will relent and re-do them for you. Since, as you said, he got the shape right, I’m assuming that he is competent in cosmetic dentistry and you don’t need to switch dentists to get this done right.

But if you keep getting resistance, get back to me, and I will help line you up with a dentist for a second opinion. A call from another dentist will usually convince a reluctant dentist to rectify a mistake like this.

Good luck,
Dr. Hall

Do you have a comment or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

What is the difference between a prosthodontist and a cosmetic dentist – a horror story

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Dr. Hall,

I recently had a full mouth reconstruction done by a very reputable prosthodontist, and although it was primarily for functional purposes, aesthetics were of great importance as well. How many people have the opportunity to have all brand new white teeth that match? It was exciting: however it was also a long and painful road. I brought in old pictures of myself to show him the color I wanted and the way my original work looked 30 years ago, and I said “this is what I want”—pretty straightforward I thought. Throughout the treatment, he kept telling me to he wanted me to be happy but sometimes when I would tell him what I wanted he would tell me I was wrong but he always said trust me—I’ve been doing this a long time.

When the first set came in, they were not anywhere close to the right color so he told me I picked the wrong color. We did three try-ins. The 3rd time I told his assistant that the top teeth looked dark, that they were darker than the bottom ones and I said that several times. Now mind you, I was trying in an unfinished set of teeth because they had their own lab to do the finishing and I had never seen unfinished crowns and bridges so I had no idea what they looked like before they were finished. Anyway, his assistant assured me that once their lab finished, they would be fine that the top and bottom teeth would match and to trust her. The bottom teeth were veneers, crowns and implants.

Now, to clarify part of the cause or my problem; every time we did a try-in, I couldn’t look at the teeth with my mouth open or see how they looked when I talked or with different expressions because the teeth would fall out which made it difficult to truly see the color or to see if the bottom and top teeth matched. So the day came to have everything put in permanently and there were 3 things I wanted to check, one being color! It turned out that one of the teeth was a little sharp. I said that and he said, “Hope, we’ve done just about all we can for you and I don’t think we’ll ever be able to make you happy; so maybe you need to find someone else to finish the job.” I was standing there unable to speak because all of my teeth would fall out, and all I wanted to do was leave—take all the teeth out and leave—but I couldn’t do that. I had no teeth and no money. I just kept thinking don’t do it just leave but how could I? I had no teeth. If I took these out, I would simply have no teeth. What was I supposed to do?

From that point, everything is a blur. I remember wanting to leave, telling the assistant that I was afraid to say anything else to him, and tears rolling down the side of my face when he started putting the bottom teeth in. Then I remember asking if they would put the top teeth in with temporary cement and she said no, that he wouldn’t do that.

Now, after all of this time, effort, and about $50,000, I have teeth that don’t match. The top teeth are darker than the bottom ones and I don’t know what to do. If it was the other way around, and the bottom ones were darker, then I could probably live with it, but it’s not. This is completely unacceptable—I have to have it fixed somehow. I personally think that he should re-do all of the porcelain over gold crowns and bridges so they match the veneers. Those are at least closer to the color I wanted. I feel so stupid for letting this happen, but I was in shock—like a deer caught in headlights but worse!
How do I go about addressing this with him? I’m very picky and the difference in color is DEFINITELY something I would have noticed, but not under those circumstances. I just froze, and I truly don’t feel it was my fault—I was under enormous duress at that moment.

As you can see, I’m very emotional and wordy which is not the way to approach this. Do you think this is something he should fix, given the situation; if so, please help me. I do not know how to communicate with him, let alone get the result I believe is fair.

– Hope from Michigan

(See Dr. Hall’s answer below.)


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Dear Hope,
So you have a very reputable prosthodontist. He is undoubtedly very good at what he does, from a technical point of view. But you have to realize that your appearance concerns are frowned on by institutional dentistry. This is a classic example of the prosthodontist mentality. You’re trying to tell him what you want. His response is: “Trust me—I’ve been doing this a long time.” In other words, he knows best, he doesn’t need your input on the appearance, and you’re a troublemaker for not just accepting that.

I have had several requests from prosthodontists to be listed on this website as recommended cosmetic dentists, and I have turned them all down except one. These are dentists thoroughly steeped in the dental school mentality that focuses on functional issues and trivializes concerns over appearance. This prosthodontist thinks it’s pandering to listen to your appearance concerns. You’re talking to a brick wall here. You’re saying, “I don’t know how to communicate with him.” That’s not the problem. He doesn’t want your input—case closed.

How to Get This Fixed

Hope—brace yourself here for some tough medicine. You’re going to have to stiffen your spine and go after this dentist. The good news is that you have excellent legal leverage here. You need to have the will to stand up to him.

I don’t believe you need to sue this dentist, but my gut tells me, as arrogant as he appears to be, that you are going to need to go to a lawyer and at least threaten to sue. You can try telling him that’s what you’re going to do and see if he will make this right for you financially, but I wouldn’t hold my breath waiting for a favorable response. What you want is for him to pay to have an expert cosmetic dentist fix the upper teeth so they look acceptable to you.

You are correct that, if there is a discrepancy in color between the upper and lower teeth, the lowers should be the darker ones. A good cosmetic dentist can get away with pushing the shade of the upper teeth maybe half a shade to a full shade whiter on the Vita scale and it will still look good. But not the other way around.

Here’s Your Leverage

What he did to you was malpractice. No, there is no suggestion here that there is any lack in the quality of the work. But he forced these teeth on you without your consent. Informed consent is a cornerstone of ethical dental treatment. You did not want these crowns on your upper front teeth put in, but he did it anyway.

I can see, by the procedures you have explained to me for his trying in these crowns, that he doesn’t care about your input. You said that the work kept falling out if you tried to look at it. Now there are try-in pastes made specifically for the purpose of holding the work in well enough that you can see how it looks. He certainly knows of these materials, but he isn’t interested in them because to him, he is trying the work in only to check the fit and to make sure he likes it. His practice isn’t geared toward taking into account anything about what you think.

I’m sure he doesn’t think he did anything unethical, and it’s not going to be easy opening his eyes to that, but a letter from a lawyer, educating him on this principle of informed consent, will certainly trigger a call to his malpractice insurance carrier. They should let him know that he is on very shaky ground, and they should be able to prevail on him to make this right for you. Again, what you want to ask for is for him to pay an excellent cosmetic dentist to take out the crowns on your upper front teeth and replace them. Here’s how you do that. First, find a lawyer who understands well this principle of informed consent. Have the lawyer write the letter explaining what he did wrong (basically, he is guilty of assault). Then, before you settle on an amount, I can recommend for you an excellent cosmetic dentist who can give your dentist a figure of how many crowns would be involved in fixing this and how much it would cost.

He may argue that he had your consent. And I’m sure that he had you sign some kind of form before starting treatment. But you did not consent to putting in these particular crowns. Yes, you let him do it, but you were under duress at the time, and consent under duress is not consent—this is a key legal doctrine. You were intimidated, not given reasonable options, and your reaction as you have described it to me indicates that this was not a voluntary consent. Your lawyer I’m sure will be able to explain the advantages of his just settling this matter rather than going to court and having to pay emotional and possibly punitive damages on top of the cost of just replacing the work.

Hope, I’m sorry I don’t have an easier path for you, but I have received hundreds of complaints similar to yours and I’ve coached many of those people through situations like this, and you are simply not going to be able to transform this dentist into a listening, caring cosmetic dentist by anything you say. In his own eyes and the eyes of many of his peers he is very good at what he does, and you’re just a peon. He has been taught that it would be wrong to listen to you.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

How white are bleached teeth?

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I’ve had this question come up in discussions with dental writers and with patients who have a misconception about teeth bleaching. They understand that teeth tend to accumulate stains over the years. They absorb the pigments from coffee, highly pigmented fruits, wine, and other sources. Bleaching, they think, is a way to remove all those stains.

They’re only partly right. Yes, bleaching will remove those stains, but it will whiten even the natural pigment in your teeth. Let me illustrate this with a couple of stories.

When I went to dental school, I learned about shade guides. The most popular one was the Vita shade guide. Here is a picture of it:
vita-shade-guide

It has a full spectrum of the range of shades a dentist is likely to encounter in natural teeth. When we needed a porcelain crown to match a patient’s other teeth, we could almost always find a shade in this guide that came pretty close to the patient’s natural tooth color.

In the 90’s, ivoclar-shade-guide-bleached-teeth when teeth bleaching became popular, we started to have a problem with this shade guide. We would have people who needed porcelain crowns, and when we tried to find a shade that matched them, they would be “off the chart.” Their teeth would be much whiter than the whitest natural shade on the shade guide. In response, shade guide manufacturers developed new whiter shades. Ivoclar was the first manufacturer that I remember doing this, and our office purchased this four-shade guide and used it to communicate with dental laboratories. You can see that shade guide at the right.

Vita also updated their shade guide, and here is a picture of the current version, with what they call the “bleached extension” shades on the left:
vita-shade-guide-bleached-extension

Serious cosmetic dentists will, of course, use this amplified shade guide because they are frequently dealing with patients who have bleached their teeth. Often, regular family dentists will only use the original A1-D4 shade guide. This led to a problem with one patient who e-mailed me around 2005. She had bleached her teeth, and was now getting porcelain veneers on four front teeth. Not knowing how specialized cosmetic dentistry is, she chose a regular family dentist to do these veneers. For the shade, this dentist selected the whitest shade on his chart. When the veneers came back from the lab, they were noticeably darker than her teeth. The dentist assured her that by using the whitest cement the veneers would match her teeth. She wrote to me, “Alas, this was not the result: there is at least an entire shade (if not more) of difference between my porcelain veneers and my other teeth.” I answered her that unfortunately, her dentist used the classical shade guide, and the whitest shade on that guide could be considerably darker than bleached teeth. For the full story, see the page under “Cosmetic Dentistry Horror Stories” where I discuss her question, can you bleach porcelain veneers?

When my own children got all of their permanent teeth in, I let them bleach their teeth if they wanted to. Even though they weren’t old enough to have any accumulated stains, they were able to whiten their teeth significantly.

So how white can you get your teeth? The results of studies seem to show that the longer you bleach, the whiter they will become, and no one, to my knowledge, has found the limit. The rate of whitening decreases the longer someone uses the bleaching gel, and everyone will hit a point where they don’t want to do it anymore. Some people get them so white that they seem to glow.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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