PERSPECTIVES
Veneer mania
bout 15 years ago, I
A 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 conser-
vative 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 prop-
erly 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
Gordon J. Christensen, DDS, MSD, PhD
Copyright 2006 American Dental Association. All rights reserved.
O B S E R VAT I O N S
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, overtreat-
ment 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 identifi-
able degrees of tooth prepara-
tions 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 criti-
cized the deeply cut preparation
mode because of reported postop-
erative tooth sensitivity, some
pulpal death and occasional
debonding from dentin.
JADA, Vol. 137 http://jada.ada.org
Both fired-ceramic and
pressed-ceramic veneers are pop-
ular, and the laboratory fabrica-
tion 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. Usu-
ally, their placement does not
require local anesthetic adminis-
tration, 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 pro-
ducing ceramic veneers are
acceptable and that these resto-
rations 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: unaccept-
able or peculiar tooth contour,
spacing of teeth, gingival reces-
sion showing dentin surfaces,
August 2006 1161
PERSPECTIVES OBSERVATIONS
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
Are there more conservative
alternatives to the expensive and
sometimes aggressive tooth
preparations accomplished for
the minimally unsightly condi-
tions often treated with ceramic
veneers?
I have observed that many
patients who have received
veneers may not have been edu-
cated about more conservative
treatment alternatives before
accepting ceramic veneers. I con-
tend 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 require-
ments for obtaining proper
informed consent from patients,
practitioners should provide
information about all of the alter-
natives for treatment; the advan-
tages, 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.
1162 JADA, Vol. 137 http://jada.ada.org August 2006
Copyright 2006 American Dental Association. All rights reserved.
BLEACHING TEETH
The relative ease and effective-
ness of vital tooth bleaching is
well-known and practiced world-
wide. Judging by the photographs
of patients before and after
ceramic veneer placement I have
seen published in dental periodi-
cals and on the lecture circuit,
some patients are accepting
ceramic veneer treatment when
simple, inexpensive bleaching pro-
cedures were an obvious alterna-
tive. If undesirable tooth color is
the only reason for treatment, in
most cases, bleaching is the most
conservative and best alternative.
ORTHODONTIC THERAPY
Many of the patients who have
minor-to-moderate tooth malposi-
tioning 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 sta-
bilization. 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 pro-
fessional obligation to educate
patients about all of the alterna-
tives for the specific clinical situa-
tion for which they are seeking
help. Explanation of the advan-
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 situa-
tion needing change without the
need for redoing the procedure at
a later time.
ESTHETIC RECONTOURING
OF TEETH
Many times, an unsightly appear-
ance of the anterior teeth is
related to unequal length of teeth
or slightly rotated teeth. A few
minutes of simple tooth con-
touring 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 suc-
cessful 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 gin-
gival tissue to the needed level,
while still maintaining a free gin-

gival depth of at least 1 mil-
limeter. 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 pro-
cedure, but it may be more desir-
able than placing ceramic veneers.
Often, both tooth and gingival
recontouring are necessary to
achieve an acceptable esthetic
result.
DIRECTLY PLACED RESIN-
BASED COMPOSITE VENEERS
When only a few teeth are
involved in an unsightly oral situ-
ation, 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 sur-
faces that become somewhat
smoother after a short time.
Durafill (Heraeus Kulzer,
Armonk, N.Y.) and Renamel
Microfill (Cosmedent, Chicago)
are examples.
Resin-based composites con-
taining 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 well-
accepted, 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 restora-
tions provides a conservative and
esthetic result lasting for many
years at a moderate cost. Years
later, when these restorations
Copyright 2006 American Dental Association. All rights reserved.
PERSPECTIVES
become stained or otherwise unac-
ceptable, they can be replaced
easily and conservatively.
Bleaching teeth may be desir-
able before any of the above pro-
cedures 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 pro-
cedures, still recognizing that
additional color will return to the
teeth after months or years.
Orthodontic therapy, tooth
recontouring or gingival recon-
touring 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
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 specifi-
cally, in shapes and sizes of
human teeth, abnormal tooth
conditions are readily detectable.
Teeth that are too large, over-
contoured, 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 advertise-
ments (and as I have observed
in patients and friends) violate
the anatomy and/or color char-
acteristics of natural teeth, and
JADA, Vol. 137 http://jada.ada.org
OBSERVATIONS
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 conserva-
tive procedures discussed in
this article instead of by
ceramic veneers, thus retaining
their normal tooth anatomy and
contours.
CONCLUSION
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 situa-
tions, 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 combina-
tion 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 compro-
mising the potential longevity
of the natural teeth.
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.
August 2006 1163