Cosmetic dentists want to make you look better and most have good intentions
Cosmetic dentists want to make you look better and most have good intentions, with some offering conservative, minimally invasive techniques such as tooth whitening or tooth coloured composite resin, which can be painted and bonded to reshape chipped and worn areas. Minor laser gum re-contouring can balance gum levels. Orthodontic treatment can align teeth without damage. These result in a great aesthetic benefit with minimal biological damage being done to the teeth and at minimal financial cost.
Sometimes they will place a limited number of thin shells of porcelain (veneers) in demanding cases. These veneers are bonded with a thin film of composite resin. The porcelain surface maintains a high luster and is very colour stable. Thin enamel can be strengthened by addition of bonded porcelain.
At gum level, enamel can be very thin but thicker towards the biting edge. Some enamel is usually reduced, so not to over-contour the restoration but care needs to be taken not to remove the entire enamel layer and expose the dentine. Dentine has high collagen content with small pores that contain cell processes connecting to the nerve. Veneers bond well to the outer enamel layer but the veneer- dentine bond is not as strong or stable as the enamel bond.
If the tooth is sticking out it is difficult to bring the tooth back into alignment without over-preparation with significant damage to the tooth. Over preparation (into the dentine) risks veneers popping off, nerve (pulp) pain and later infection.
Another concern is with areas that are hard to clean with overbuilding or rough edges, which can cause inflamed bleeding gums. If the veneers are placed too deep into the gum crevice, the gums can also continually bleed.
Healthy teeth before, and after an attack of “veneerial disease”
The anatomy of teeth
Several practices offer ten veneer packages heavily promoted on instagram. Does your cosmetic dentist have this “veneerial disease”, where often digital smile design is marketed as a way to create the ideal smile?
“Veneerial disease” was term coined by Dr Martin Kelleher, a respected specialist colleague from the United Kingdom drawing attention to the longer-term consequences of procedures that are undertaken in order to achieve seemingly beautiful short-term results. Dr Kelleher has noted a curious absence of porcelain in the daughters of dentists and has proposed the “daughter test”.
Sometimes the ideal smile design is proposed after digitally manipulating two dimensional images of the mouth on a computer screen. The smile designer may be a dental technician working for a ceramic laboratory. Often minor variations that give each of us that little bit of character that makes us each special are removed to conform to a series of predetermined golden proportions. This ideal concept may require significant compromise of healthy tissue.
Sufferers of this disease place multiple veneers to straighten teeth because they claim braces take three to four years. They veneer teeth to get rid of wrinkles and headaches. They veneer teeth to whiten them. They veneer teeth because the old veneers break. And they veneer teeth because the smile designer has encouraged them. Having the enamel of 10 healthy teeth blasted away is invasive and there is no going back. At the end of this Blog there is a link to a newspaper article written by an unhappy journalist in the United Kingdom titled, “Porcelain veneers could ruin your teeth, smile and your life.”
Patients are often interested in the ‘here and now’ and want instant gratification, but the long term consequences of cosmetic dental treatment need to be understood by patients.
Many often express short-term gratitude for providing a pleasing appearance after undertaking what are sometimes destructive procedures with sound enamel and other hard dental tissues replaced with porcelain veneers.
In just a few years, often there is a need for re-treatment with failure by fracture of these brittle ceramic restorations, veneers popping off when placed on grossly over-prepared dentin surfaces, or unsightly bleeding gums.
This concern was highlighted by several United Kingdom dental specialist bodies in 2015, who in combination reached a consensus that elective invasive cosmetic dental treatments can result in great benefit to patients but that these can also produce significant morbidities in teeth which were previously considered healthy. (British Endodontic Society, British Society for Restorative Dentistry, Restorative Dentistry UK, Dental Trauma UK, British Society of Prosthodontics and the British Society of Paediatric Dentistry: Br Dent J. May 2015).
An example of available data is; over a 12 year period when 588 veneers were placed in 66 patients at the University of New York, 42 veneers failed in 23 patients (Gurel). In over a third of patients at least one veneer failed. If the tooth was over prepared, reducing the enamel for bonding and bonded to dentine instead the failure rate was 10 times as high.
Other short term studies with a median 1.25 years in Turkey with 40 patients and 200 veneers 12 failed (Cötert). And another had 8.8% of veneers fail at 2 years (Oztürk).
Looking at the data it is obvious that veneers do not last a life time. Each veneer, if precisely made of quality material has about a 90% chance of survival at ten years. If poorly designed the failure rate is much greater. The longer the timeframe and the more veneers per patient the greater the risk an individual patient will need some retreatment. The replacement veneer then needs to match the colour and texture of the older veneers. Many younger patients may need corrective treatment several times throughout life. Each time a veneer is replaced there is risk of further damaging the teeth.
The fear expressed is that young people are being sucked into treatment that commits them to repetitive and expensive dental care that will drain tens of thousands of dollars from their accounts and eventually lead them to lose some of their teeth prematurely.
Minimally invasive approaches such as whitening, additive resin bonding and realigning, which are associated with lower risks and good fall-back positions, should be advocated and practised wherever possible as the first choice of treatment for patient seeking improvements in their dental appearance
There is potential for complications after porcelain veneers, however porcelain veneers in selected cases, with minimal subtraction of enamel can be an excellent treatment. The long term success rate is very much dependant on careful planning with minimal but precise preparation.
Patients seeking cosmetic dental improvement with veneers should be made fully aware of the associated risks, possible complications, the lack of permanence of restorations and their longer-term biological and financial costs. Good intentions are not enough.
Below is a link with one journalist’s experience of 10 porcelain veneers titled
“Porcelain veneers could ruin your teeth, smile and your life”
References
1.Alani A, Kelleher M, Hemmings K, Saunders M, Hunter M, Barclay S, Ashley M, Djemal S, Bishop K, Darbar U, Briggs P, Fearne J. Balancing the risks and benefits associated with cosmetic dentistry – a joint statement by UK specialist dental societies. Br Dent J. 2015 May 8;218(9):543-548.
2.Gurel G, Sesma N, Calamita MA, Coachman C, Morimoto S. Influence of enamel preservation on failure rates of porcelain laminate veneers. Int J Periodontics Restorative Dent. 2013 Jan-Feb;33(1):31-39.
3.Cötert HS, Dündar M, Oztürk B. The effect of various preparation designs on the survival of porcelain laminate veneers. J Adhes Dent. 2009 Oct;11(5):405-411.
4.Oztürk E, Bolay S. Survival of porcelain laminate veneers with different degrees of dentin exposure: 2-year clinical results. J Adhes Dent. 2014 Oct;16(5):481-489.
Don’t forget to share this via Twitter, Google+, Pinterest and LinkedIn.
