As I have stated many times, ceramic veneers are beautiful, esthetically and functionally exceptional restorations that can be life-changing.1–4 Many dental publications have articles on ceramic veneers each month (a recent article by Terry5 is an example). The variations in clinical techniques range from extremely conservative, removing little or no tooth structure, to relatively radical, removing all of the facial enamel and most of the mesial and distal enamel.6–8 Laboratory techniques for veneers vary as well, from ceramic fired on platinum matrices or refractory dies to ceramic pressed on special dies. Advertisements about veneers appear in local newspapers. Lay television programs show the instant and desirable smile upgrades available with veneers. Full-page ads can be seen in many travel and airline magazines promoting the attractive characteristics of ceramic veneers and the dentists who claim expertise in this procedure. Patients are becoming knowledgeable about veneering teeth, and they are asking dentists for this instant upgrade in their smiles. Veneering teeth has become a significant and successful part of most dental practices.9
Is the current flurry of clinical treatment with veneers desirable or necessary? Are ceramic veneers really the treatment of choice for the plethora of veneered teeth all dentists see each month in dental publications?
In my opinion, as one of the initial promoters and educators about ceramic veneers and a past president of the American Academy of Esthetic Dentistry, I feel that the current trend toward ceramic veneers for everybody is a negative phenomenon that needs careful observation and correction by the profession. I believe the profession could return to several more conservative and longer-lasting esthetic treatments.
This article addresses alternatives for ceramic veneers that should be considered by dentists and patients before making the decision to place ceramic veneers.
The following alternatives for ceramic veneers will be discussed:
- – orthodontic therapy;
- – bleaching/whitening teeth;
- – periodontal plastic surgery;
- – tooth recontouring;
- – conservative resin-based composite restorations;
- – all-ceramic crowns;
- – a combination of the above therapies.
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ORTHODONTIC THERAPY
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One of the most objectionable reasons for veneer placement is correction of minor malalignment of anterior teeth in young adults. As one observes the "before" and "after" photographs of veneered teeth in current international dental journals, it is apparent that in some of these cases, minor orthodontic therapy would have been a better choice than placement of ceramic veneers. Slight irregularities in tooth alignment certainly do not require ceramic veneers for correction. Seldom have I seen a case in which ceramic veneers have been placed and then later removed to allow the natural teeth to again compose the smile. Even the most conservative ceramic veneer placement procedures remove some tooth structure, during either initial tooth preparation or finishing procedures. Ceramic veneers have a finite life expectancy. Veneers placed on a young adult will require replacement several times during life, each time requiring the removal of more tooth structure and potentially causing damage to pulp and/or supporting structures.
During the past several decades, the orthodontic alternative has been available to patients. Minor or even moderate tooth movement is simple, easy and relatively inexpensive—and, most importantly, the orthodontically treated patient retains his or her own tooth structure and tooth anatomy, which can serve for as long as a lifetime. The only negative aspects of orthodontic therapy are the time required to move the teeth and the objectionable display of metal during orthodontic therapy. By providing education and appealing to the patient’s logic, the clinician can overcome the patient’s negative feelings about the treatment time required for orthodontic therapy versus the faster but less permanent restorative options. And for some patients, the use of "plastic" tooth-moving techniques such as Invisalign (Santa Clara, Calif.) can eliminate the esthetic disadvantage of orthodontic therapy.
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BLEACHING/WHITENING TEETH
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Use of ceramic veneers or ceramic crowns to correct tooth discoloration is a responsible and highly effective procedure for patients with severe tooth discoloration. However, restorative therapy for minor or even moderate tooth discoloration usually is not indicated. If patients are educated about at-home and in-office bleaching techniques, and if their tooth coloration appears to be of a nature that can be lightened, only those who think illogically still may prefer expensive ceramic veneers that may require upkeep and eventual replacement.
Current bleaching techniques are simple, effective and relatively inexpensive when compared with the placement of ceramic veneers. Again, the time needed for the therapy is a negative factor to some patients who want an immediate "fix." Patients must be cautioned that some teeth bleach well and other teeth do not respond to bleaching techniques easily. Dentists should use good judgment to inform patients about the potential for bleaching to solve their dental esthetic challenge.
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PERIODONTAL PLASTIC SURGERY
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Frequently, patients complain that their smiles are unsightly because of irregularities in gingival tissues. Usually, the objectionable appearance is related to showing too much gingival tissue; irregularities of the gingival line, causing the appearance of short and long teeth; or display of different tooth colors and tooth lengths, caused by gingival recession on specific teeth. Some dentists are attempting to correct these and other periodontal irregularities by placing ceramic veneers. Periodontal plastic surgery, ranging from simple gingivectomy to soft-tissue grafting to osseous recontouring and repositioning of gingival tissues, often can correct smiles that have an objectionable appearance owing to periodontal disharmonies.
Placing ceramic veneers to correct such gingival conditions occasionally is desirable, but periodontal treatment provides a long-term solution to most such challenges and should be the treatment of choice in many cases.
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TOOTH RECONTOURING
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It is amazing to observe that a few minutes of tooth recontouring—such as shortening a central incisor, rounding pointed canines, reducing the contour of a slightly rotated anterior tooth or smoothing irregularities from incisal edges—can satisfy patients in terms of frustration with their smiles. Such simple treatment is nonpainful, fast, easy and effective in producing the desired result. Of course, affected tooth surfaces should be smoothed well with disks, as well as polished and treated with topical fluoride. A fee representing time necessary for the procedure certainly is appropriate, though some dentists do not bill for it, and patients are appreciative of the conservative, inexpensive treatment.
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CONSERVATIVE RESIN-BASED COMPOSITE RESTORATIONS
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Some examples in the current dental literature show six or eight ceramic veneers placed on the teeth of young adults for treatment of minor tooth irregularities, diastemas, slight tooth malalignment or discrepancies in tooth length.
For each of the preceding examples and others, simple placement of carefully color-matched, smooth-surface-retaining restorations of resin-based composite can provide excellent, moderate-longevity treatment. Such resin-base composite restorations are conservative, relatively inexpensive, effective in solving the esthetic challenge and pleasing to patients.
Few resin-based composites retain an extremely smooth surface during service. Some that do are the microfills Durafill (Heraeus Kulzer, Armonk, N.Y.) and Renamel Microfill (Cosmedent, Chicago), as well as the nanofill Filtek Supreme Plus (3M ESPE, St. Paul, Minn.). As experienced practitioners know, these materials get smoother over time, rather than become rougher as do microhybrid resin-based composite materials with larger-particle filler.
Conservative resin-based composites used for the correction of the aforementioned esthetic challenges are a strong, esthetic, long-lasting solution, rather than the more invasive, expensive ceramic veneer procedure.
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ALL-CERAMIC CROWNS
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How did the placement of all-ceramic crowns, a more aggressive and invasive concept, get into the discussion of conservative procedures? Numerous examples in the current literature show use of veneers on deeply discolored teeth or teeth with large previously placed resin-based composite restorations. When veneers are placed in these situations, deep tooth preparations usually must be made to cover the dark color and still produce translucence in the restoration, or to remove the old restorations. In spite of the "total-etch" production of optimum retention for ceramic veneers on enamel surfaces, it is well-known among practitioners that veneers’ ability to stay in place and function well when bonded to dentin is questionable. When ceramic veneers are placed primarily on dentin using a "total-etch" technique, they often debond, have more postoperative tooth sensitivity and, occasionally, cause pulpal death.
Conversely, when full-ceramic crowns are used in the situations described, "self-etch" primer containing resin cements are reported by practitioners to eliminate the postoperative tooth sensitivity and other problems described previously. Examples are RelyX Unicem (3M ESPE), Maxem (Kerr, Orange, Calif.), Embrace Wet-Bond (Pulpdent, Watertown, Mass.) and MonoCem (Shofu, San Marcos, Calif.). The well-known and long-used Panavia F (Kuraray America, New York City) and the newer product Multilink (Ivoclar Vivadent, Amherst, N.Y.) require a separate "self-etching" primer application, and it is well-known that they reduce the challenges previously described in relation to ceramic veneers placed on dentin. Additionally, full crowns provide more strength, better retention and, potentially, a better esthetic result and longer service than do ceramic veneers placed on dentin surfaces.
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A COMBINATION OF PROCEDURES
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Many patients have esthetic challenges that require careful thought, consultation with other dentists and use of several of the described alternatives to ceramic veneers. Admittedly, such combination of therapies requires more time than the two simple appointments for tooth preparation and seating of the ceramic veneers.
Would you, as a dentist or other dental professional, want veneers placed on your teeth if more conservative, longer-lasting techniques could be used? I doubt it, in spite of the potential extra time needed for combination treatments. I feel that in most cases, well-done ceramic veneers are the most beautiful, least invasive and longest lasting of all esthetic restorative dental procedures. However, I feel that they are being grossly overused at this time.
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SUMMARY
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Placement of ceramic veneers is an effective method of treating many dental esthetic and functional challenges. Veneers are beautiful. When correct tooth preparations are accomplished, they can be bonded effectively to tooth structure. Their esthetic and strength characteristics are closer to those of natural tooth structure than almost any dental restoration. However, they are being overused in the profession. This article presents several alternatives to ceramic veneers, some of which require more time than ceramic veneers, but most of which preserve the patient’s tooth structure and natural appearance for as long as a lifetime.
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ORTHODONTIC THERAPY
BLEACHING/WHITENING TEETH
