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Facing the challenges of ceramic veneers

eneering teeth with ceramic has become a major part of esthetic dentistry, and many general dentists provide this service.1-3 Dental laboratories have become proficient at making both fired and pressed versions of ceramic veneers. Each month, articles are published in dental journals and magazines on yet another way to prepare teeth for veneers, the best methods to fabricate them in the laboratory and the best cementation procedures. Although these restorations have been a part of dental practice for more than 20 years, it is interesting to note that only a few articles have addressed their long-term service characteristics. What have practitioners learned from observing these restorations in service?

What are the problems that have been encountered during a period of service in the mouth that relate to tooth preparations, cements, occlusion, periodontal health and other factors? This article expresses my observations on the relatively long-term service characteristics of ceramic veneers. The conclusions come from having placed thousands of veneers myself, from research accomplished by Clinical Research Associates, from clinical study clubs for which I am mentor, from hands-on courses that I teach routinely and from discussing the subject with dentists around the world.
BULKY APPEARANCE

are acceptable before the placement of veneers, and the patient likes the teeths preoperative appearance, effort should be made to reproduce the same anatomy and shape for the finished veneers. Maintaining the original tooth shape often requires the clinician to remove a slight-to-moderate amount of enamel when making the tooth preparations. I suggest that the tooth preparations be made in enamel whenever possible to avoid problems I will discuss later. Bulky veneers are to be avoided, because they appear false to observers.
COLOR OF VENEERS

When the size and anatomical appearance of the natural teeth

Gordon J. Christensen, DDS, MSD, PhD

If veneers are thin (approximately 0.3 millimeters at the thinnest area), the color of the resultant veneer restoration is a combination of three colors: those of the remaining tooth structure, the cement and the ceramic. Thin veneers can be one of the most conservative and
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beautiful of all restorations if the teeth are relatively normal in color and dentists use try-on gels before cementation to determine the potential final color of the restoration. Some of the popular brands of resin-veneer cement have excellent try-on gels that match the color of the cements well, while other brands of try-on gels do not match the color of the set cement.1,2 I suggest comparing the try-on gel color with the color of the set cement to ensure that the desired veneer color is obtained. Although thin, opaque veneers used with opaque cements will lighten the color of darkly colored teeth, the final esthetic result can be disagreeably opaque. Usually, the color of darkly discolored teeth is not covered well with thin veneers, and thicker veneers or crowns provide more esthetic restorations. Color matching of veneers to the adjacent teeth is easier with deeper veneer preparations; however, I avoid deeply cut veneer preparations because they often result in other significant problems to be discussed later. Practitioners must decide whether tooth anatomy and color allow for thin or moderately thick veneers to be seated on enamel, or if crowns would provide stronger restorations with optimum color. The most conservative treatment should be accomplished, whether it is bleaching only, minor orthodontics, no-preparation veneers or slightly or moderately prepared enamel surfaces.
LONG-TERM COLOR STABILITY

desired in different locations on the veneers, such as darker cervical color and more translucent incisal color, fired-ceramic veneers can provide those characteristics over a long service period without color change. Pressed-ceramic veneers start out as monotone in color until superficial stains are fired on the external surfaces. Technicians and dentists are divided with regard to which type of veneer provides the best longterm service for patients. Practitioners must decide which type of ceramic veneer can be fabricated best by the laboratories they are using. Either fired or pressed veneers, properly constructed, can provide excellent color stability over many years.
POSTOPERATIVE TOOTH SENSITIVITY AND PULPAL DEATH

that there is a significant chance that some dentinal canals will not be plugged adequately to preclude pulp irritation and postoperative tooth sensitivity.3-8 If a significant amount of tooth structure must be removed to achieve proper anatomy and color, crowns would be a better choice than veneers for the following reason. All-ceramic or porcelain-fused-to-metal (PFM) crowns can be seated with resinmodified glass ionomer cement or resin cement that contains a self-etch primer. In either case, the cements do not cause pulpal damage, tooth sensitivity or pulpal death, while resin cements placed over total-etched and bonded surfaces have been shown to cause unpredictable problems.3
OVERHANGING CERAMIC OR RESIN CEMENT

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Fired-ceramic veneers can have internal colors fired into the ceramic. If color variation is
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It has been my observation that veneer tooth preparations cut deeply into dentin often produce postoperative tooth sensitivity and even pulpal death. However, some technicians prefer deep tooth preparations and encourage dentists to prepare teeth in that manner, because any desired tooth color and anatomy can be produced by the technician. Which tooth preparation technique is the best for veneers: no tooth preparation at all, a shallow or moderate tooth preparation in enamel only, or a tooth preparation extending into dentin? In my opinion, veneers are meant to be conservative restorations. When they are placed on deeply cut dentin surfaces, and a total-etch procedure is accomplished before placing the bonding agent and resin cement, I have found through clinical experience and research

I see many veneers placed in practices all over the United States that have significant overhangs. Roughness in the interproximal areas of some veneers will not allow floss to slide between them without objectionable catching. Such inadequate finishing does not allow or encourage proper oral hygiene, and soon, gingival tissue becomes red and swollen. Ceramic veneers should be finished carefully with finishing strips so that when a piece of floss is placed as far apically as can be done without pain, the floss exits without catching. Finishing to this level cannot avoid stimulating some blood flow and causing minor gingival irritation. However, it is better to have a little irritation at the seating appointmentirritation that will go away in a few daysthan to have chronic roughness, gingival bleeding

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and difficult cleaning for the service life of the veneers.

STAINS ON THE GINGIVAL MARGINS

Regardless of whether the veneers were placed slightly subgingivally or supragingivally, I have seen many coming from practices across the country with staining around the gingival margins. The stains may have been caused by at least two situations. Contamination of the gingival margin areas at the impression appointment results in an inaccurate die and often will not provide a wellfitting veneer. Also, moisture contamination at the time of seating interferes with the cement polymerization. Placing nonchemicalimpregnated gingival packing cords at the time of impressions and on seating precludes moisture from leaking into the marginal areas and prevents the objectionable gingival staining. Based on observing thousands of veneers accomplished in this manner, I have rarely seen postoperative gingival staining when using this technique.
DISCOLORATION UNDER VENEERS

being veneered, aluminum chloride should be used for tissue management. This chemistry does not cause postoperative discoloration under the veneers. A preventive technique that allows the clinician to make impressions and seat veneers without using styptics or vasoconstrictors is the patients use of 0.12 percent chlorhexidine gluconate as a rinse twice daily for two weeks preoperatively. After the rinse is used as described, the soft tissues are pink and firm and allow impressions to be made without bleeding occurring. To encourage optimal tissue adaptation, the patient should continue to use the rinse while the veneers are being fabricated and also for two weeks after the procedure.
DEBONDING OF VENEERS

margins placed slightly lingual to the incisal edge but not into the centric stop of the opposing arch of teeth, and configured as a butt joint, do not exhibit such chipping.
OPEN LINGUAL MARGINS

Some practitioners use ferric sulfate to control bleeding when making veneer impressions or seating veneers. Ferric salts can be used without difficulty for restorations that are opaque, such as PFM or all-metal crowns, or for any type of opaque all-ceramic crown. However, the iron salts impregnate the dentin, and the gray discolorations appear within weeks after the veneers have been seated. I suggest that when styptic agents are needed for teeth

If the internal surfaces of ceramic veneers have been etched properly with hydrofluoric acid and silanated, and if they are seated over enamel surfaces that have been etched properly with phosphoric acid, experienced clinicians know that they are extremely difficult to remove. However, if the veneers are seated over dentin surfaces, some come off during service. The dentist should avoid preparing teeth deeply into dentin for veneers. If the depth is needed to remove caries or to replace defective restorations, a crown would be a stronger and more appropriate restoration.
CHIPPING ON INCISAL EDGES

After several years of service, resin cement on the incisal/ lingual edges of ceramic veneers will wear more than the ceramic or the tooth, and some patients may complain that they can feel a juncture line as their tongue moves back and forth from the veneer to the tooth. Margins on the lingual incisal surface should be made as tight as possible by laboratory technicians to avoid this disagreeable situation. This is the only location on an anterior tooth veneer where the tooth/veneer interface can feel objectionable to patients. In extreme cases, the open margin can be further opened with a pointed diamond and the surface etched and repaired with resin. However, the clinician should not expect long-lasting service from this repair.
GINGIVAL RECESSION

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Veneers placed with margins exactly on the chewing surface of the incisal edge may develop chips on the incisal edge after a few years of service, and repair is difficult or impossible. Incisal

Avoiding gingival recession is impossible, but avoiding unsightly display of supragingival veneer margins is possible. Some clinicians recommend that veneer gingival margins should be placed supragingivally. In my opinion, such placement is acceptable occasionally if toothcolor change is not one of the reasons for the veneers. I prefer to place veneer gingival margins at the gingival crest or slightly subgingivally if the tooth color is different from the color of the veneer. Such placement of margins allows veneers to serve esthetically for many years. I have patients in
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my practice who have had ceramic veneers for 20 years that still are acceptable esthetically. Seldom do PFM crowns serve esthetically for this long, because as the gingiva recedes, there is display of metal and a chalky color of ceramic at the gingival margins, as well as display of the margin/tooth interface.
DENTAL CARIES

ished easily. However, when margins are placed interproximally, less radiopaque cement should be used to allow observation of caries on a radiograph.
SUMMARY

The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association. 1. Clinical Research Associates. Upper anterior veneers: state of the art (part 1). CRA Newsletter 2006;30(1):1-3. 2. Clinical Research Associates. Upper anterior veneers: state of the art (part 2). CRA Newsletter 2006;30(3):1-3. 3. Clinical Research Associates. Filled polymer crowns:1 and 2 year status reports. CRA Newsletter 1998;22(10):1. 4. Clinical Research Associates. Self-etch primer (SEP) adhesives update. CRA Newsletter 2003;27(11/12):1-5. 5. Casselli DS, Martins LR. Postoperative sensitivity in Class I composite resin restorations in vivo. J Adhes Dent 2006;8:53-8. 6. Baghdadi ZD. The clinical evaluation of single-bottle adhesive system with three restorative materials in children: six-month results. Gen Dent 2005;53:357-65. 7. Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A. Self-etching adhesives and postoperative sensitivity. Am J Dent 2004;17:191-5. 8. Perdigo J, Geraldeli S, Hodges JS. Totaletch versus self-etch adhesive: effect on postoperative sensitivity. JADA 2003;134:1621-9.

After placing thousands of veneers, I rarely have seen teeth develop subsequent caries on the veneer margins. Because many dentists place the interproximal margins of veneers in the contact area, carious lesions must be relatively large to be observed. I do not object to margins in the interproximal areas, because the tooth/cement/ ceramic interface can be fin-

Ceramic veneers are extremely popular and have been used for many years. In spite of their phenomenal success, they offer numerous challenges during service. In this column, I have identified and discussed several degenerative situations commonly observed, and I have described methods of preventing or reducing the problems. When properly placed, ceramic veneers are among the most beautiful and long-lasting of all dental restorations. I
Dr. Christensen is co-founder and senior consultant, Clinical Research Associates, 3707 N. Canyon Road, Suite 3D, Provo, Utah 84604. Address reprint requests to Dr. Christensen.

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