Dental veneers: dental hygiene knowledge and care of the ultimate smile.

Introduction

Dental veneers, also known as porcelain laminate veneers or composite veneers, are thin layers of restorative porcelain or composite resin, custom-designed to fit over anterior teeth to improve their shape, color and overall appearance. This article will compare and contrast porcelain and composite veneers, discuss their restorative benefits, as well as discuss the option between teeth whitening and veneers. An overview of the risks associated with the veneer process will be followed by a step-by-step discussion of the dental veneer procedure concluding with the role of the dental hygienist after placement. (1,2)

Porcelain vs. Composite Veneers

In today's fashion conscious world, porcelain and composite veneers remain some of the most popular choices for people seeking to improve the esthetics of their teeth. Porcelain veneers have several advantages when compared to composite veneers including durability, resistance to staining, and amount of tooth structure removed during the procedure.

Porcelain veneers are very durable. They are also very thin--usually between 0.5--0.7 millimeters--and brittle, although once bonded to healthy tooth structure, they can become quite strong. The bonding process increases durability and veneers made of porcelain can last often times between 10-15 years, depending on how well they are maintained. Many people choose porcelain veneers for their resistance to staining, an increasingly important concern in our esthetic conscious world. Porcelain veneers can also create a very life-like and natural tooth appearance. The translucent nature of the porcelain allows the veneers to mimic the light handling characteristics of enamel. This creates a sense of depth not possible with other cosmetic bonding materials, such as composite resin. Unlike other cosmetic dental bonding material, porcelain is a smooth and impervious ceramic which does not pick up permanent stain from things like cigarettes, coffee or dark staining liquids. Finally, porcelain veneers are a conservative restorative procedure and remove only a small amount of tooth structure during the process. Minimal tooth preparation such as drilling is required, resulting in a process which requires little or no anesthetic. (3,4)

Although porcelain veneers remain quite common, there are many reasons why people choose a composite veneer over its porcelain counterpart. Unlike composite veneers, porcelain veneers are not made on site and need to be created in a dental laboratory. This means that porcelain veneers generally require at least two visits. Cost is also a factor, with porcelain veneers being much more expensive than their composite counterpart. Creating porcelain veneers requires more time, expertise and resources in order to prepare and bond to the tooth surface. If broken, porcelain veneers, unlike composite veneers, cannot be repaired. They must be replaced. Along with cost, this is a major reason why people may choose composite veneers over the porcelain variety. (5)

Indications for Usage

In addition to their overall cosmetic effect, veneers can also protect the surface of a damaged tooth. In some instances, they may be used to replace the need for a dental crown, thus eliminating a more invasive tooth procedure. Due to the thinness of dental veneers, they may require very little tooth reshaping when bonded to the tooth. After bonding they are strong and durable. Most people, however, choose veneers for their cosmetic effect. They can be used to make teeth appear straighter and better aligned. Porcelain veneers may also last as long as 15 years and provide patients with a beautiful, vibrant smile. (1,6)

Veneers vs, Whitening

There are many options in the quest for white teeth. Veneers and teeth whitening through bleaching are the two most common options today. Many people want the white teeth of their favorite celebrities and the do-it-yourself teeth whitening kits represent a budding industry that has been able to capitalize on this very desire. While both options have the same goal in mind--whiter teeth--veneers and tooth whitening take very different approaches toward that end result. Color, convenience and cost are three factors which should be considered by a patient when choosing veneers or whitening through bleaching.

Tooth whitening through bleaching is an increasingly popular alternative to veneers. When used properly, high-quality bleaching agents can produce a bright and natural whiteness, at least initially and in the short term. In terms of coloring and pure esthetics, whitening usually works quite well. Unfortunately, people are sometimes disappointed with the process and the results that one gets from bleaching. Patients' focus on color usually involves some wishful thinking. Unfortunately, it can do nothing to repair the shape and contour of teeth nor the overall look of the patient when he or she smiles. (7)

In terms of actual color, the short-term effects of bleaching and veneers are roughly the same. Each treatment can provide white teeth. In the long term though, composite resin is much better than bleach, and porcelain is far superior to both. Since bleached teeth are otherwise normal, they will stain at a normal rate. Because of this, patients may need to repeat their treatment several times a year; even more so if they smoke, drink coffee, or if they have a genetic predisposition to staining. Composite veneers, when they are properly finished and polished, can be more stain resistant than ordinary teeth but less so than porcelain. It has been reported that they dull after a few years of brushing, wear and tear. In contrast, porcelain remains virtually stain-free and bright for the life of a veneer, often up to 15 years. Composite veneers have a much shorter lifespan and can last from three to five years. (7)

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We live in a busy world, and patients are increasingly concerned about the time teeth whitening takes. Veneers require a fair amount or preparation; impressions of the teeth must be done, tooth reduction must take place, and temporaries must be inserted. Teeth whitening, either at home or in the dental chair, can take as little as an hour, usually over a week or two.

In spite of the short-term impact of time and preparation of a veneer, in the long run, they are arguably less time consuming. Whitening is a process that needs to be done repeatedly and many take-home bleaching agents have a lifespan of six months to a year. Long-term whitening may cause much more hassle than the three- to five-year replacement period for composite veneers and certainly more than the 15 years for porcelain.

Although costs vary, an in-office whitening treatment can cost in excess of $500 while the bleaching kits found at your pharmacy are generally in the $50-$100 range. The initial investment in veneers is significantly greater (up to $2,000 per porcelain veneer). This cost is, however, partially offset by the costs associated with repeated whitening during the 15-year lifetime of a porcelain laminate veneer. Since most patients are interested in a beautiful smile, not just whiter teeth, veneers have the added effect of allowing the dentist to alter the composition of the smile while at the same time giving the patient a flawless white smile. Whitening can only tackle the color issue and cannot repair crooked, broken or cracked teeth. (7,8)

Contraindications for Usage

A dental veneer is only as good as the tooth to which it is being bonded. If an underlying tooth is weak, there is a greater risk for future complication. Accordingly, if a patient does not have proper oral hygiene or if the following conditions are present, they may not be an adequate candidate for the dental veneer procedure:

* Bruxism

* Bulimia

* Esophageal reflux disease

* Excessive alcohol consumption

* Absence of adequate saliva

* An occlusal disharmony such as edge-to-edge teeth

It is important to understand the potential contraindications associated with the process prior to undertaking the dental veneer procedure. (2,12)

The Dental Veneer Procedure

The veneer procedure requires several appointments. Gingival health is ever-important, and the first step in the veneer process must be to ensure that a patient's gingiva is in a proper state of health. During the first veneer appointment, teeth are prepared for the procedure by the removal of a small portion of the front tooth surface (approximately 0.3 to 0.5 millimeters) to create space for the veneer. Impressions are then taken and are used by a laboratory technician to create the veneers. Teeth may feel both rough and unusual to the tongue. Although this is normal, it is important that they be well-brushed since staining occurs more easily at this stage. Sometimes teeth are also covered by a temporary veneer. During this period, the teeth are also extra sensitive to the air as well as the cold, and it is absolutely essential that the gingiva be kept healthy. Patients should be encouraged to floss thoroughly every night. The second veneer appointment involves what is called the "try-in." The appearance as well as the fit of the porcelain is checked in the patient's mouth, ensuring that it meets both functional and esthetic requirements. The third veneer appointment is the bonding appointment, involving a multitude of steps which adhere the veneer to the tooth. Because veneers may feel slightly odd at first, many dentists request a follow-up appointment after a week or two to ensure that the patient is completely satisfied with the procedure. During this appointment, minor adjustments may be made to improve the fit of the veneers; however, the color cannot be changed after the veneers are bonded to the teeth. The result of this restoration is a durable, beautiful veneer that looks and acts like a real tooth. (6,9)

The Role of the Dental Hygienist in the Care of Veneers

After placement has occurred, the dental hygienist plays an important role in ensuring the success of the veneer procedure. Consider the following:

* Avoid use of the Prophy Jet or other power polishing equipment.

* Use a gentle prophy paste. Aluminum oxide (Rembrandt [R]) toothpaste is safe for cosmetic dental work. Avoid course pumice pastes.

* Take caution when using ultrasonic scalers on the margins of the veneers. They can cause chips and gouges in the porcelain or composite material.

* Use a neutral fluoride treatment. Avoid acidulated fluoride due to its ability to etch the veneer or composite surface.

Educating your patients to brush and floss daily to keep the veneers clean is the best approach to a lasting healthy smile. Supersmile [R] whitening toothpaste is frequently recommended because it is very gentle. It is effective at removing stains by dissolving them rather than by physical abrasive action. Encourage your patients to avoid frequent snacking, which can promote tooth decay. Lastly, caution your patients about the risks of subjecting their teeth to sharp impact or hard objects. Avoid biting on pins, nails, or staples. Recommend a mouth guard for contact sports and grinding. (9-11)

Conclusion

For patients whose teeth are crooked, stained or damaged, veneers are often an excellent option for those seeking a beautiful, bright, white smile with aligned, shapely teeth. Unlike teeth whitening products, veneers not only correct a defect in color, but also change the shape, width, length, and positional relationship of the tooth. Porcelain and composite veneers are available to patients today in a placement procedure which requires minimal inconvenience and can often be undertaken in a few short visits. Regarding esthetics as well as overall functionality, dental veneers truly represent a breakthrough in modern dental technology.

References

(1.) American Dental Association. Oral health topics: veneers. Available at www.ada.org/public/topics/veneers.asp. Accessed Jul. 27, 2008.

(2.) Lacy A. Porcelain veneers: problems and solutions. Dent Today 2002; 8: 4651. Available at www.dentistrytoday.com/ME2/.http://www.dentistrytoday. com/ME2/dirmod.asp?sid=&nm=&type=Publishing&mod=Publications%3A% 3AArticle&mid=8F3A7027421841978F18BE895F87F791&tier=4&id= 77FESAE0B2B94251AD5CB22DA4813713.

(3.) Materdomini D, Friedman MJ. The contact lens effect: enhancing porcelain veneer esthetics. J Esther Rest Dent 1995; 7: 99-103.

(4.) Miller L. Porcelain veneer protective plan: maintenance procedures for all porcelain restorations. J Esthet Rest Dent 1990; 2: 63-6.

(5.) Christensen GJ. What is a veneer? Resolving the confusion. J Am Dent Assoc 2004; 135(11): 1574-6.

(6.) Hirohito Y. Principles and practice of tooth whitening. J Mats Dent U Soc 2004; 30(2): 129-42.

(7.) Lowe E. Achieving total smile enhancement through tooth whitening and placement of a single anterior veneer restoration. Dent Today 2001; 20(12): 44-8.

(8.) Barghi N, Overton JD. Preserving principles of successful porcelain veneers. Cont Esthet 2007; 11(1): 48-51.

(9.) Greene S. Restorative dentistry. Available at http://www.qualitydentistry.com/ dental/restorative/veneers2. Accessed Jul. 27, 2008.

(10.) Hall D. Care of porcelain veneers. Cosmetic dentistry. Available at www.mynewsmile.com/porcelain-veneer-care. Accessed Jul. 2, 2008.

(11.) Johnstone G. Dental veneers, porcelain veneers. A consumer guide. Available at www.yourdentistryguide.com/veneers. Accessed Jul. 2, 2008.

(12.) Christensen, GJ. Veneer mania. J Am Dent Assoc 2006; 137(8): 1161-3.

By Katherine Russell, RDH, MS

Katherine Russell, RDH, MS, is an assistant professor at the Fones School of Dental Hygiene, University of Bridgeport, Bridgeport, Conn. She teaches Dental Materials, Dental Radiology, and Dental Hygiene Research in the AS and BS programs. In addition, she teaches in the BSDH Online Degree Completion Program. Prior to teaching, she worked in private practice for 16 years. She can be reached at [e-mail].

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