PERSPECTIVES

O B S E R VAT I O N S

Veneer mania

bout 15 years ago, I published an article in JADA entitled Have Porcelain Veneers Arrived?1 At that time, I already had been placing fired ceramic veneers for about five years with excellent results. In spite of the obvious clinical success, I was cautious about recommending ceramic veneers for several years after their introduction because their longevity was unknown. The continued clinical acceptability and the reliability of this conservative therapy during the ensuing years were gratifying to me and somewhat unexpected. After placing thousands of ceramic veneers and watching them for up to 20 years, it has been my observation that properly placed ceramic veneers are not only clinically acceptable, but also long-lasting, beautiful and relatively nonproblematic during service. My purpose in this article is not to promote and extol ceramic

veneers, but instead to trace the evolution of this concept through the past 20-plus years and to comment on the current overuse of this esthetic restorative service. In my opinion, overtreatment with ceramic veneers is at an all-time high, and other more conservative treatment methods need to be presented to patients, considered and encouraged.
CERAMIC VENEERS IN 2006

In 2004, I described the technical state of ceramic veneers.2 It has not changed significantly since then. There are three identifiable degrees of tooth preparations for ceramic veneers: no preparation or slight tooth preparation, moderate tooth preparation and deep tooth preparation. In that article, I supported the no-to-moderate preparation mode, and I criticized the deeply cut preparation mode because of reported postoperative tooth sensitivity, some pulpal death and occasional debonding from dentin.

Gordon J. Christensen, DDS, MSD, PhD

Both fired-ceramic and pressed-ceramic veneers are popular, and the laboratory fabrication method for both produces excellent function and esthetics. In recent months, several dental laboratories have emphasized the no-preparation veneer. These conservative ceramic veneers are relatively easy to accomplish and are appealing to patients. Usually, their placement does not require local anesthetic administration, the technique is fast and nontraumatic, and the esthetic result for some types of unsightly clinical situations can be excellent. It is apparent that the various techniques for producing ceramic veneers are acceptable and that these restorations are serving well in most cases. Most of the ceramic veneers placed today are primarily for the purpose of upgrading patients appearance. Ceramic veneers may be the most adequate treatment alternative if one or more of the following situations are present: unacceptable or peculiar tooth contour, spacing of teeth, gingival recession showing dentin surfaces,
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malformed teeth, worn teeth or other unsightly situations. If teeth are significantly broken down or otherwise compromised, crowns are a better and stronger alternative than ceramic veneers.
ALTERNATIVES TO CERAMIC VENEERS

BLEACHING TEETH

Are there more conservative alternatives to the expensive and sometimes aggressive tooth preparations accomplished for the minimally unsightly conditions often treated with ceramic veneers? I have observed that many patients who have received veneers may not have been educated about more conservative treatment alternatives before accepting ceramic veneers. I contend that many of the patients who have been treated with ceramic veneers could have been treated with more conservative and potentially longer-lasting therapy. To satisfy the requirements for obtaining proper informed consent from patients, practitioners should provide information about all of the alternatives for treatment; the advantages, disadvantages, risks and relative costs of each treatment alternative; and a description of what happens if no treatment is accomplished. After such patient education is accomplished and if the patient still wants treatment that is not the most conservative therapy, then that is his or her own decision. I strongly suggest that the patient should be required to sign a document stating that he or she has received information about all of the treatment alternatives and their associated risks and costs, as described above, and that he or she has accepted the treatment indicated on the signed document.
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The relative ease and effectiveness of vital tooth bleaching is well-known and practiced worldwide. Judging by the photographs of patients before and after ceramic veneer placement I have seen published in dental periodicals and on the lecture circuit, some patients are accepting ceramic veneer treatment when simple, inexpensive bleaching procedures were an obvious alternative. If undesirable tooth color is the only reason for treatment, in most cases, bleaching is the most conservative and best alternative.
ORTHODONTIC THERAPY

tages and disadvantages of the various therapies is especially important. Patients are living into their 80s and 90s, and elective restoration of teeth, such as placing ceramic veneers at an early age, requires replacement of the restorations after several years, at a considerable additional expense. Orthodontic therapy, although requiring more time than simple placement of veneers, can be a lifetime fix of the clinical situation needing change without the need for redoing the procedure at a later time.
ESTHETIC RECONTOURING OF TEETH

Many of the patients who have minor-to-moderate tooth malpositioning have heard that they do not have to endure orthodontic therapy, and that they can achieve immediate results with ceramic veneers. The lay press and national television shows have encouraged such requests. Orthodontic therapy requires a few months to a few years for effective tooth movement and stabilization. Because of this time commitment, many patients decide to achieve the immediate results offered by ceramic veneers instead of the more conservative and less invasive orthodontic therapy. A serious, pertinent question should be asked of the profession: how many of these patients who select ceramic veneers have been given adequate education to be able to make an informed decision about whether to receive ceramic veneers instead of orthodontic therapy? Each clinician has a professional obligation to educate patients about all of the alternatives for the specific clinical situation for which they are seeking help. Explanation of the advan-

Many times, an unsightly appearance of the anterior teeth is related to unequal length of teeth or slightly rotated teeth. A few minutes of simple tooth contouring followed by smoothing and polishing of the affected tooth structure, as well as application of fluoride to the teeth can satisfy the unsightly condition at minimal expense without the need to treat the affected teeth again.
ESTHETIC RECONTOURING OF GINGIVAL TISSUES

Often, the gingival soft tissue is at an unequal level on the teeth in relation to the incisal edge of the teeth or the smile line. When smiling, the patient shows long teeth and short teeth. If adequate attached gingival tissue is present, a highly successful technique can be used to correct the clinical condition. The simple use of an electrosurgery unit or laser to harmonize the level of the gingival tissues can produce an excellent result. The gingival sulcus depth must be adequate for recontouring the gingival tissue to the needed level, while still maintaining a free gin-

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gival depth of at least 1 millimeter. Gingival recontouring is simple, easy, relatively nonpainful and inexpensive for the patient. Occasionally, repositioning the gingival tissues is necessary. This is a more extensive surgical procedure, but it may be more desirable than placing ceramic veneers. Often, both tooth and gingival recontouring are necessary to achieve an acceptable esthetic result.
DIRECTLY PLACED RESINBASED COMPOSITE VENEERS

When only a few teeth are involved in an unsightly oral situation, directly placed resin-based composite veneers can be used to provide an excellent appearance with good longevity. The microfill resins that have been available for many years provide smooth surfaces that become somewhat smoother after a short time. Durafill (Heraeus Kulzer, Armonk, N.Y.) and Renamel Microfill (Cosmedent, Chicago) are examples. Resin-based composites containing nanofillers (particles smaller than 100 nanometers) are now on the market. Although there are several nanohybrids containing both glass particles and nanofillers on the market, the only product that is nanofilled throughout is Filtek Supreme Plus (3M ESPE, St. Paul, Minn.). This product has been wellaccepted, and clinicians attending my continuing education courses report that it retains a smooth surface after months of service. If a patient has a relatively acceptable smile with only a few imperfections, use of resin-based composite veneers and/or restorations provides a conservative and esthetic result lasting for many years at a moderate cost. Years later, when these restorations

become stained or otherwise unacceptable, they can be replaced easily and conservatively. Bleaching teeth may be desirable before any of the above procedures is attempted. It is common knowledge that the bleaching procedure should be completed at least a few days before the color of the bleached teeth is matched with that of restorative resins, to allow the teeth to return to a relatively stable color situation. I prefer to wait at least two weeks after bleaching is completed before starting the restorative procedures, still recognizing that additional color will return to the teeth after months or years. Orthodontic therapy, tooth recontouring or gingival recontouring may require placement of one or more resin-based composite veneers after completion to finalize the treatment and to achieve an adequate esthetic result.
NATURAL TOOTH ANATOMY VERSUS AN ARTIFICIAL APPEARANCE

they create a false appearance for the patient. It is possible that some of these patients would have been better served by one or more of the conservative procedures discussed in this article instead of by ceramic veneers, thus retaining their normal tooth anatomy and contours.
CONCLUSION

Any artificial aspect of the body usually is obvious to the observer. An example is totally black hair on a 90-year-old person. Although the lay public is not uniformly well-educated in human anatomy or, more specifically, in shapes and sizes of human teeth, abnormal tooth conditions are readily detectable. Teeth that are too large, overcontoured, too long, too square or round, too white or without any imperfections are obviously unnatural to the untrained eye. In my opinion, many veneers shown in journals and advertisements (and as I have observed in patients and friends) violate the anatomy and/or color characteristics of natural teeth, and

There is no question that ceramic veneers are strong and beautiful, and that they serve well in the mouth for many years. However, some patients and dentists have come to accept ceramic veneers as the primary quick fix for slightly to moderately unacceptable smiles. Instead of placing ceramic veneers in such situations, I have suggested that more conservative procedures should be offered to patients as alternatives to ceramic veneers. These procedures include tooth bleaching, orthodontic therapy, esthetic recontouring of teeth and gingivae, directly placed resin-based composite veneers and restorations or a combination of these procedures. These less aggressive procedures maintain natural tooth anatomy, cost less than ceramic veneers, may not alter occlusion and can be repeated many times before compromising the potential longevity of the natural teeth. I
Dr. Christensen is the director, Practical Clinical Courses, and co-founder and senior consultant, CRA Foundation, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. Address reprint requests to Dr. Christensen. The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Christensen GJ. Have porcelain veneers arrived? JADA 1991;122(1):81. 2. Christensen GJ. What is a veneer? JADA 2004;135(11):1574-6.

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