PERSPECTIVES
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Facing the challenges of ceramic veneers
eneering teeth with
V 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 pro-
cedures. Although these restora-
tions 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 charac-
teristics. What have practi-
tioners learned from observing
these restorations in service?
Gordon J. Christensen, DDS, MSD, PhD
Copyright ©2005 American Dental Association. All rights reserved.
O B S E R VAT I O N S
What are the problems that
have been encountered during a
period of service in the mouth
that relate to tooth prepara-
tions, cements, occlusion, peri-
odontal health and other
factors?
This article expresses my
observations on the relatively
long-term service characteris-
tics of ceramic veneers. The con-
clusions come from having
placed thousands of veneers
myself, from research accom-
plished by Clinical Research
Associates, from clinical study
clubs for which I am mentor,
from hands-on courses that I
teach routinely and from dis-
cussing the subject with den-
tists around the world.
BULKY APPEARANCE
When the size and anatomical
appearance of the natural teeth
JADA, Vol. 137 http://jada.ada.org
are acceptable before the place-
ment of veneers, and the patient
likes the teeth’s preoperative
appearance, effort should be
made to reproduce the same
anatomy and shape for the fin-
ished 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
If veneers are thin (approxi-
mately 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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PERSPECTIVES OBSERVATIONS
beautiful of all restorations if
the teeth are relatively normal
in color and dentists use try-on
gels before cementation to deter-
mine 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 disagree-
ably 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 signifi-
cant problems to be discussed
later. Practitioners must decide
whether tooth anatomy and
color allow for thin or moder-
ately 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 orthodon-
tics, no-preparation veneers or
slightly or moderately prepared
enamel surfaces.
LONG-TERM COLOR
STABILITY
Fired-ceramic veneers can have
internal colors fired into the
ceramic. If color variation is
662 JADA, Vol. 137 http://jada.ada.org May 2006
Copyright ©2005 American Dental Association. All rights reserved.
desired in different locations on
the veneers, such as darker cer-
vical color and more translucent
incisal color, fired-ceramic
veneers can provide those char-
acteristics 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. Techni-
cians and dentists are divided
with regard to which type of
veneer provides the best long-
term 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 pro-
vide excellent color stability over
many years.
POSTOPERATIVE
TOOTH SENSITIVITY
AND PULPAL DEATH
It has been my observation that
veneer tooth preparations cut
deeply into dentin often produce
postoperative tooth sensitivity
and even pulpal death. How-
ever, 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 prepa-
ration 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 sur-
faces, and a total-etch procedure
is accomplished before placing
the bonding agent and resin
cement, I have found through
clinical experience and research
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 fol-
lowing reason. All-ceramic or
porcelain-fused-to-metal (PFM)
crowns can be seated with resin-
modified glass ionomer cement
or resin cement that contains a
self-etch primer. In either case,
the cements do not cause pulpal
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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
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 fin-
ished 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. Fin-
ishing to this level cannot avoid
stimulating some blood flow and
causing minor gingival irrita-
tion. However, it is better to
have a little irritation at the
seating appointment—irritation
that will go away in a few
days—than to have chronic
roughness, gingival bleeding

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 supragingi-
vally, 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. Contamina-
tion of the gingival margin areas
at the impression appointment
results in an inaccurate die and
often will not provide a well-
fitting veneer. Also, moisture
contamination at the time of
seating interferes with the
cement polymerization. Placing
nonchemical–impregnated gin-
gival packing cords at the time
of impressions and on seating
precludes moisture from leaking
into the marginal areas and pre-
vents the objectionable gingival
staining. Based on observing
thousands of veneers accom-
plished in this manner, I have
rarely seen postoperative gin-
gival staining when using this
technique.
DISCOLORATION UNDER
VENEERS
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. How-
ever, the iron salts impregnate
the dentin, and the gray discol-
orations appear within weeks
after the veneers have been
seated.
I suggest that when styptic
agents are needed for teeth
Copyright ©2005 American Dental Association. All rights reserved.
PERSPECTIVES
being veneered, aluminum chlo-
ride should be used for tissue
management. This chemistry
does not cause postoperative dis-
coloration under the veneers. A
preventive technique that allows
the clinician to make impres-
sions and seat veneers without
using styptics or vasoconstric-
tors is the patient’s 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 occur-
ring. To encourage optimal
tissue adaptation, the patient
should continue to use the rinse
while the veneers are being fab-
ricated and also for two weeks
after the procedure.
DEBONDING OF VENEERS
If the internal surfaces of
ceramic veneers have been
etched properly with hydro-
fluoric acid and silanated, and if
they are seated over enamel sur-
faces 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
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
JADA, Vol. 137 http://jada.ada.org
OBSERVATIONS
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
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
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the lingual incisal surface
should be made as tight as pos-
sible by laboratory technicians
to avoid this disagreeable situa-
tion. 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
Avoiding gingival recession is
impossible, but avoiding
unsightly display of supragin-
gival veneer margins is possible.
Some clinicians recommend that
veneer gingival margins should
be placed supragingivally. In my
opinion, such placement is
acceptable occasionally if tooth-
color change is not one of the
reasons for the veneers.
I prefer to place veneer gin-
gival 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
May 2006 663
PERSPECTIVES OBSERVATIONS
my practice who have had
ceramic veneers for 20 years
that still are acceptable estheti-
cally. 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 dis-
play of the margin/tooth
interface.
DENTAL CARIES
After placing thousands of
veneers, I rarely have seen teeth
develop subsequent caries on
the veneer margins. Because
many dentists place the inter-
proximal margins of veneers in
the contact area, carious lesions
must be relatively large to be
observed. I do not object to mar-
gins in the interproximal areas,
because the tooth/cement/
ceramic interface can be fin-
Copyright ©2005 American Dental Association. All rights reserved.
ished easily. However, when
margins are placed interproxi-
mally, less radiopaque cement
should be used to allow observa-
tion of caries on a radiograph.
SUMMARY
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 com-
monly 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. ■
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.
JADA, Vol. 137 http://jada.ada.org
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental
Association.
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