About 15 years ago, Ipublished an articlein JADA entitledHave PorcelainVeneers Arrived?1

At that time, I already had beenplacing fired ceramic veneers forabout five years with excellentresults. In spite of the obviousclinical success, I was cautiousabout recommending ceramicveneers for several years aftertheir introduction because theirlongevity was unknown. Thecontinued clinical acceptabilityand the reliability of this conser-vative therapy during theensuing years were gratifying tome and somewhat unexpected.After placing thousands ofceramic veneers and watchingthem for up to 20 years, it hasbeen my observation that prop-erly placed ceramic veneers arenot only clinically acceptable,but also long-lasting, beautifuland relatively nonproblematicduring service.

My purpose in this article isnot to promote and extol ceramic

veneers, but instead to trace theevolution of this concept throughthe past 20-plus years and tocomment on the current overuseof this esthetic restorativeservice. In my opinion, overtreat-ment with ceramic veneers is atan all-time high, and other moreconservative treatment methodsneed to be presented to patients,considered and encouraged.

CERAMIC VENEERS IN 2006

In 2004, I described the technicalstate of ceramic veneers.2 It hasnot changed significantly sincethen. There are three identifi-able degrees of tooth prepara-tions for ceramic veneers: nopreparation or slight toothpreparation, moderate toothpreparation and deep toothpreparation. In that article, Isupported the no-to-moderatepreparation mode, and I criti-cized the deeply cut preparationmode because of reported postop-erative tooth sensitivity, somepulpal death and occasionaldebonding from dentin.

Both fired-ceramic andpressed-ceramic veneers are pop-ular, and the laboratory fabrica-tion method for both producesexcellent function and esthetics.In recent months, several dentallaboratories have emphasizedthe no-preparation veneer. Theseconservative ceramic veneers arerelatively easy to accomplish andare appealing to patients. Usu-ally, their placement does notrequire local anesthetic adminis-tration, the technique is fast andnontraumatic, and the estheticresult for some types ofunsightly clinical situations canbe excellent. It is apparent thatthe various techniques for pro-ducing ceramic veneers areacceptable and that these resto-rations are serving well in mostcases.

Most of the ceramic veneersplaced today are primarily forthe purpose of upgradingpatients appearance. Ceramicveneers may be the mostadequate treatment alternativeif one or more of the followingsituations are present: unaccept-able or peculiar tooth contour,spacing of teeth, gingival reces-sion showing dentin surfaces,

JADA, Vol. 137 http://jada.ada.org August 2006 1161

Veneer mania

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Gordon J. Christensen, DDS, MSD, PhD

Copyright 2006 American Dental Association. All rights reserved.

1162 JADA, Vol. 137 http://jada.ada.org August 2006

malformed teeth, worn teeth orother unsightly situations. Ifteeth are significantly brokendown or otherwise compromised,crowns are a better and strongeralternative than ceramicveneers.

ALTERNATIVES TOCERAMIC VENEERS

Are there more conservativealternatives to the expensive andsometimes aggressive toothpreparations accomplished forthe minimally unsightly condi-tions often treated with ceramicveneers?

I have observed that manypatients who have receivedveneers may not have been edu-cated about more conservativetreatment alternatives beforeaccepting ceramic veneers. I con-tend that many of the patientswho have been treated withceramic veneers could have beentreated with more conservativeand potentially longer-lastingtherapy. To satisfy the require-ments for obtaining properinformed consent from patients,practitioners should provideinformation about all of the alter-natives for treatment; the advan-tages, disadvantages, risks andrelative costs of each treatmentalternative; and a description ofwhat happens if no treatment isaccomplished. After such patienteducation is accomplished and ifthe patient still wants treatmentthat is not the most conservativetherapy, then that is his or herown decision. I strongly suggestthat the patient should berequired to sign a documentstating that he or she hasreceived information about all ofthe treatment alternatives andtheir associated risks and costs,as described above, and that he orshe has accepted the treatmentindicated on the signed document.

BLEACHING TEETH

The relative ease and effective-ness of vital tooth bleaching iswell-known and practiced world-wide. Judging by the photographsof patients before and afterceramic veneer placement I haveseen published in dental periodi-cals and on the lecture circuit,some patients are acceptingceramic veneer treatment whensimple, inexpensive bleaching pro-cedures were an obvious alterna-tive. If undesirable tooth color isthe only reason for treatment, inmost cases, bleaching is the mostconservative and best alternative.

ORTHODONTIC THERAPY

Many of the patients who haveminor-to-moderate tooth malposi-tioning have heard that they donot have to endure orthodontictherapy, and that they canachieve immediate results withceramic veneers. The lay pressand national television showshave encouraged such requests.Orthodontic therapy requires afew months to a few years foreffective tooth movement and sta-bilization. Because of this timecommitment, many patientsdecide to achieve the immediateresults offered by ceramic veneersinstead of the more conservativeand less invasive orthodontictherapy.

A serious, pertinent questionshould be asked of the profession:how many of these patients whoselect ceramic veneers have beengiven adequate education to beable to make an informed decisionabout whether to receive ceramicveneers instead of orthodontictherapy? Each clinician has a pro-fessional obligation to educatepatients about all of the alterna-tives for the specific clinical situa-tion for which they are seekinghelp. Explanation of the advan-

tages and disadvantages of thevarious therapies is especiallyimportant. Patients are living intotheir 80s and 90s, and electiverestoration of teeth, such asplacing ceramic veneers at anearly age, requires replacement ofthe restorations after severalyears, at a considerable additionalexpense.

Orthodontic therapy, althoughrequiring more time than simpleplacement of veneers, can be alifetime fix of the clinical situa-tion needing change without theneed for redoing the procedure ata later time.

ESTHETIC RECONTOURINGOF TEETH

Many times, an unsightly appear-ance of the anterior teeth isrelated to unequal length of teethor slightly rotated teeth. A fewminutes of simple tooth con-touring followed by smoothing andpolishing of the affected toothstructure, as well as application offluoride to the teeth can satisfythe unsightly condition at minimalexpense without the need to treatthe affected teeth again.

ESTHETIC RECONTOURINGOF GINGIVAL TISSUES

Often, the gingival soft tissue is atan unequal level on the teeth inrelation to the incisal edge of theteeth or the smile line. Whensmiling, the patient shows longteeth and short teeth.

If adequate attached gingivaltissue is present, a highly suc-cessful technique can be used tocorrect the clinical condition. Thesimple use of an electrosurgeryunit or laser to harmonize thelevel of the gingival tissues canproduce an excellent result. Thegingival sulcus depth must beadequate for recontouring the gin-gival tissue to the needed level,while still maintaining a free gin-

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Copyright 2006 American Dental Association. All rights reserved.

gival depth of at least 1 mil-limeter. Gingival recontouring issimple, easy, relatively nonpainfuland inexpensive for the patient.

Occasionally, repositioning thegingival tissues is necessary. Thisis a more extensive surgical pro-cedure, but it may be more desir-able than placing ceramic veneers.

Often, both tooth and gingivalrecontouring are necessary toachieve an acceptable estheticresult.

DIRECTLY PLACED RESIN-BASED COMPOSITE VENEERS

When only a few teeth areinvolved in an unsightly oral situ-ation, directly placed resin-basedcomposite veneers can be used toprovide an excellent appearancewith good longevity. The microfillresins that have been available formany years provide smooth sur-faces that become somewhatsmoother after a short time.Durafill (Heraeus Kulzer,Armonk, N.Y.) and RenamelMicrofill (Cosmedent, Chicago)are examples.

Resin-based composites con-taining nanofillers (particlessmaller than 100 nanometers) arenow on the market. Althoughthere are several nanohybridscontaining both glass particlesand nanofillers on the market, theonly product that is nanofilledthroughout is Filtek SupremePlus (3M ESPE, St. Paul, Minn.).This product has been well-accepted, and clinicians attendingmy continuing education coursesreport that it retains a smoothsurface after months of service.

If a patient has a relativelyacceptable smile with only a fewimperfections, use of resin-basedcomposite veneers and/or restora-tions provides a conservative andesthetic result lasting for manyyears at a moderate cost. Yearslater, when these restorations

become stained or otherwise unac-ceptable, they can be replacedeasily and conservatively.

Bleaching teeth may be desir-able before any of the above pro-cedures is attempted. It iscommon knowledge that thebleaching procedure should becompleted at least a few daysbefore the color of the bleachedteeth is matched with that ofrestorative resins, to allow theteeth to return to a relativelystable color situation. I prefer towait at least two weeks afterbleaching is completed beforestarting the restorative pro-cedures, still recognizing thatadditional color will return to theteeth after months or years.

Orthodontic therapy, toothrecontouring or gingival recon-touring may require placement ofone or more resin-based compositeveneers after completion tofinalize the treatment and toachieve an adequate estheticresult.

NATURAL TOOTH ANATOMYVERSUS AN ARTIFICIALAPPEARANCE

Any artificial aspect of the bodyusually is obvious to theobserver. An example is totallyblack hair on a 90-year-oldperson. Although the lay publicis not uniformly well-educated inhuman anatomy or, more specifi-cally, in shapes and sizes ofhuman teeth, abnormal toothconditions are readily detectable.Teeth that are too large, over-contoured, too long, too squareor round, too white or withoutany imperfections are obviouslyunnatural to the untrained eye.

In my opinion, many veneersshown in journals and advertise-ments (and as I have observedin patients and friends) violatethe anatomy and/or color char-acteristics of natural teeth, and

they create a false appearancefor the patient. It is possiblethat some of these patientswould have been better servedby one or more of the conserva-tive procedures discussed inthis article instead of byceramic veneers, thus retainingtheir normal tooth anatomy and contours.

CONCLUSION

There is no question thatceramic veneers are strong andbeautiful, and that they servewell in the mouth for manyyears. However, some patientsand dentists have come toaccept ceramic veneers as theprimary quick fix for slightly tomoderately unacceptablesmiles. Instead of placingceramic veneers in such situa-tions, I have suggested thatmore conservative proceduresshould be offered to patients asalternatives to ceramic veneers.These procedures include toothbleaching, orthodontic therapy,esthetic recontouring of teethand gingivae, directly placedresin-based composite veneersand restorations or a combina-tion of these procedures. Theseless aggressive proceduresmaintain natural toothanatomy, cost less thanceramic veneers, may not alterocclusion and can be repeatedmany times before compro-mising the potential longevityof the natural teeth.

Dr. Christensen is the director, PracticalClinical Courses, and co-founder and seniorconsultant, CRA Foundation, 3707 N.Canyon Road, Suite 3D, Provo, Utah 84604.Address reprint requests to Dr. Christensen.

The views expressed are those of theauthor and do not necessarily reflect theopinions or official policies of the AmericanDental Association.

1. Christensen GJ. Have porcelain veneersarrived? JADA 1991;122(1):81.

2. Christensen GJ. What is a veneer?JADA 2004;135(11):1574-6.

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Copyright 2006 American Dental Association. All rights reserved.