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International Journal of Dental Health Concerns (2015), 1, 1-5
1
INTRODUCTION
Porcelain veneers are increasing in present esthetic dental
treatment because it is one of the conservative restorations of
unaesthetic anterior teeth. Although this technique was rst
described in 1940 by Dr. Charles Pincus, developments in
composite resin technology and acid etching of enamel and
ceramic were required for it to become widely recognized.[1-3]
Unfortunately, composite resins shows polymerization shrinkage,
thermal dimensional changes, staining and poor wear resistance
and used as veneers, have limited life of 4 years or less. The
acrylic laminates veneer was an attempt to overcome some of the
problems, but the long-term results were clinically unacceptable.
Recent clinical studies have shown very good long-term result
following the placement of anterior porcelain veneer. In one 5-year
study, 83% were satisfactory, while in 8-year study, 95-97% were
successful. However, the placement of porcelain is an irreversible
procedure because of necessity for tooth preparation. Therefore,
the criteria for porcelain veneer must be carefully reviewed before
the procedure is undertaken for its long term success.
The purpose of this article is to review the current literature
and to present the important parameters such as inclusion and
exclusion criteria, shade selection, tooth preparation, veneer
placement (cementation), patient maintenance for determining
long-term success of porcelain veneers.
METHOD FOR DATA COLLECTION
The literature source of present paper are published articles,
internet sources, manuals, and textbooks reference in relevant
papers and peer review articles, involving porcelain veneer by
reviewers. The search terms used were broad so as to ensure
the relevant studies were not missed, the search terms used
were, porcelain veneers, veneers in dentistry, Esthetics, enamel
bonding. Academic colleagues were also contacted to identify
relevant research. The search duration was for 3 months
between October 2014 and December 2014. Total of 150
articles were identied through search strategy, and 22 articles
met the inclusion criteria and they were included in the review.
The inclusion criterion were, articles which were in English
language, full-text articles, articles with online accessibility,
both review and case studies related to porcelain veneers.
Articles with only abstracts and incomplete information
and articles with veneers used for non-dental reasons were
excluded.
CASE SELECTION
Indications
The rst important parameter for long term success of porcelain
veneer is case selection.[4] The prime requirements in case
REVIEW ARTICLE
1Department of Prosthodontics, Jagadguru
Sri Shivarathreeswara Dental College and
Hospital, A Constituent College of Jagadguru
Sri Shivarathreeswara University, Mysore,
Karnataka, India.
2Department of Public Health Dentistry,
Jagadguru Sri Shivarathreeswara Dental
College and Hospital, A Constituent College
of Jagadguru Sri Shivarathreeswara University,
Mysore, Karnataka, India.
Correspondence: Dr. S. Sowmya, 332/1,
Near Kamakshi Hospital, Kuvempu Nagar,
Mysore - 570 023, Karnataka, India. Mobile:
+91-9886214888, Email: Sowmya.neelan@
gmail.com
How to Cite:
Sowmya S, Sunitha S, Dhakshaini MR,
Raghavendraswamy KN. Esthetics with veneers:
A review. Int J Dent Health Concern 2015;1:1-5.
Received: 15.01.2015
Accepted: 22.03.2015
ABSTRACT
Veneer is one of the most revolutionary techniques developed over the past 25 years.
When dental professionals realized that porcelain can bond onto the composite and
therefore onto the tooth surface, it changed everyone’s view. An attractive appearance
with veneer has shown to increase people’s self-condence, personal relationship, and
even the success in his or her career. Hence with veneer, it is possible to create amazing
esthetic results and yet retain considerable solid tooth structure. Successful result
depends not only on the clinical and laboratory technique used for veneer fabrication,
but also on an understanding of scientic background of the procedure involved since
the placement of porcelain is an irreversible procedure it requires conservative tooth
preparation. Therefore, the criteria for porcelain veneer must be carefully reviewed before
the procedure is undertaken for its long term success. The purpose of this article is to
present the most important parameters such as inclusion and exclusion criteria, shade
selection, tooth preparation, veneer placement(cementation), patient maintenance for
determining long-term success of porcelain veneers.
Key words: Enamel bonding, esthetics, porcelain veneer
Esthetics with Veneers: A Review
S. Sowmya1, S. Sunitha2, M. R. Dhakshaini1, K. N. Raghavendraswamy1
Doi: 10.15713/ins.ijdhc.11
Esthetics with Veneers… Sowmya, et al. I J D H C
2
selection are a high standard of oral hygiene and health and
presence of an adequate area of sound enamel available for
etching. Among the main reasons for placing veneer are:
• correction of unaesthetic surface defects such as hypoplastic
enamel or enamel lost by erosion[5,6] or abrasion
• masking of discoloration resulting from trauma
• endodontic treatment
• tetracycline stains
• repair of structural deciencies such as fractured incisal
edge,[4] diastema[7] and peg laterals.
CONTRAINDICATIONS
A decreased success[8] is seen when porcelain veneer is restored
in teeth:
• With inadequate enamel and tooth structure such as
amelogenesis and dentinogensis imperfecta
• When there is existing large restoration or root canal treated
teeth with less tooth structure
• Patient with oral habit[9] causing excessive stress on
restoration and excessive interdental spacing.
SHADE SELECTION PROCEDURE
The next important clinical parameter for the long term success
of porcelain veneer is shade selection procedure. Proper shade
selection is not only with matching the shade using shade guide,
but involves various technique with proper lighting.[10] Some of
the tips for shade selections are:
• Shade matching must be carried out in early hours of
appointment to avoid color fatigue
• If patient is wearing bright color clothing, drape in Neutral
colored cover, have patient remove lipstick and other
makeup
• Clean the teeth and remove all stains and debris
• Have patient’s mouth at dentist’s eye level
• Shade comparisons should be performed at 5 s interval so as
to not to fatigue eyes
• Use canine as reference
• Grind o the neck of the shade tabs because it is darker than
rest of tab
• If there is confusion between two shades then it is always
better to select a shade of lower chroma and higher
value.
PRELIMINARY TOOTH MODIFICATION
Before starting preparation and after establishing the desired
shade the preexisting restoration and defect should be corrected
and the anomalies contoured.[8]
TOOTH PREPARATION
Why We Need Preparation?
Shaini et al. reported that 90% of the restorations placed in their
patients were on unprepared teeth and concluded that this could
have been responsible for low success rate in their study.[11]
Hence, preparation is needed mainly to
• Get denite nish line
• Provide space
• Get uoride-rich layer
• Rough surface for better retention.
Today most authors agree on the importance of tooth preparation
to achieve long term success. Conservative intra enamel preparation
with facial reduction of enamel by 0.3-0.5 mm and nish line
placed at or close to the gingival margin are recommended. Tooth
preparation should not include any sharp internal angle, especially
at the incisal edge where the stress will be greatest, it should allow
for a path of insertion of the veneer which is free from undercuts.
CLINICAL STEP
Sequence of Tooth Preparation
Labial surface reduction
In-vitro tooth preparation analysis has shown that the cervical
portion is usually over prepared with dentin being exposed and
the mid-incisal portion is usually underprepared. This nding
conrms that careful depth control is necessary. Many dierent
designs of depth -control cutting diamond are marketed
exclusively for veneer preparation. The key to the success is the
placement of the cutting instrument in two to three dierent
planes along the convex labial surface. Three horizontal surface
depth cuts are prepared on the labial surface with three tiered
depth cutting diamond [Figures 1 and 2]. Using the depth cuts
as guide, labial surface is prepared to prevent over reduction
(0.3-0.5 mm). Pencil lines can be marked into the enamel guide
grooves [Figures 3 and 4]. For the standard preparation, chamfer
is placed at the height of gingival crest unless severe discoloration
mandates a subgingival margin to gain extra veneer thickness.
More success rate was seen with supragingival nish line because
it:
• Increases the area of enamel
• Moisture control is better
• Visual conrmation is excellent
• Accessibility is good
• Maintenance of hygiene is better.
PROXIMAL REDUCTION
The preparation will be extended lingually only if diastema or
peg lateral incisor has to be restored.[10] As much as possible the
contact area should be preserved because its
Esthetics with Veneers… Sowmya, et al. I J D H C
3
• Extremely dicult to reproduce
• Simplies the try-in
• Bonding is easy
• Saves clinical time and
• Provides better access.
INCISAL REDUCTION
There is no consensus on whether the incisal edge of the tooth
should be included in preparation for porcelain veneers.[11] In the
opinion of some authors incisal coverage in necessary in all cases
to enhance the mechanical resistance of veneer, even though this
involve the removal of 0.5-2.0 mm of intact incisal edge and may
place the vulnerable cavosurface margin in an area of opposing
tooth contact.[11] Other authors have suggested incorporating the
incisal edge into the preparation only when dictated by esthetic
or occlusal requirement.[12]
Hui et al. concluded from an in vitro study that porcelain
veneer fabricated to three dierent design, demonstrated that
the window type of preparation was strongest compared with an
overlapping and feathered design.[13]
GINGIVAL DISPLACEMENT AND IMPRESSION
TECHNIQUE
Gingival retraction is usually needed for maxillary teeth and dark
teeth. Apical inltration over the teeth with the local anesthetic
solution is also advised. However, care must be taken to prevent
a subsequent gingival recession. A single cord is used which
remains in place when impression is being made and no extra
hemostatic agent in the cord is needed because bleeding should
be minimal with healthy gingivae.
Impression technique: Any recognized elastomeric impression
material is suitable for recording the preparation. If the preparation
is limited to maxillary anterior teeth, an anterior stock tray is
adequate. However, an alginate impression is suggested prior to
preparation so that the custom tray is fabricated. A special tray
is extended 5 mm gingival from gingival margin and cover half
of palatal surface, adjacent unprepared teeth, and occlusal stop.
When lower anterior teeth are prepared, it is necessary to have a
custom tray of entire mandibular arch.[11,14]
Figure 1: Three tiered depth cutting diamond bur
Figure 2: Three horizontal surface depth cuts with pencil lines marked
Figure 3: Labial reduction
Figure 4: Complete labial reduction
Esthetics with Veneers… Sowmya, et al. I J D H C
4
PROVISIONAL RESTORATION
Patients seldom experience sensitivity as a result of the
preparation of enamel and are usually not unhappy about the
appearance, in which case temporary cover may be omitted. But,
if temporary restoration is needed then the materials used are
preformed acrylic resin veneer and composite resin. Temporary
veneer under functional stress may be “spot welded” for better
retention.[10]
LABORATORY PROCEDURE
Today four groups of ceramics are used for veneer: Feldspathic
porcelain, cast or pressed porcelain, heat-pressed and CAD-
CAM. Porcelain made of baked feldspathic porcelain allow a
minimal veneer thickness of 0.3 mm which means that the amount
of tooth substance that has to be removed for preparation can be
kept to a minimum. However, feldspathic porcelain are brittle,
and the sintering of porcelain particles creates microporosites
which results in low exural strength. Castable glass-ceramics
and heat - pressed leucite reinforced ceramic oer greater exural
strength when the veneer thickness is not <0.5 mm. Therefore,
the preparation must be 0.6-0.8 mm thick which conict with the
conservative nature of the restoration.[11,12]
TRY IN
The veneers are fragile and should be handled with care,
preferably with the nger and over a color constrating surface
such as a dark paper napkin. Inspect veneer for any crack and
imperfection on the model for appropriate t, then remove
provisional with a hemostat, break the brittle composite used
for luting the temporary restoration, and pumice all areas of
prepared surface.[15] Moisten the teeth and internal surface of
porcelain with water and place on teeth and evaluate t and
color. Adjustment are made with ne diamond bur and veried.
Special eect such as check lines, white hypoplastic patches
and translucent incisal edges are normally incorporated into the
porcelain during build up in laboratory, but some slight staining
modication may be made at the chairside, as further ring of
porcelain is not possible. There are a number of staining kits,
mainly in the form of lightly lled resins, which include coloring.
BONDING PROCEDURE
There are 3 basic ways of attaching porcelain laminates to the
surface of teeth.
• Chemical attachment: Cements (light activated composite
and coupling agent)
• Micromechanical attachment: Acid etching
• Combined attachments.
Recently, Dune and Millar reported that the clinical longevity
of ceramic veneer is more related to marginal adaptation.[16,17]
Hence, cementation(bond between tooth and porcelain) is one
of the most important parameter for success.[18]
Procedure: The teeth are isolated with cotton, lightly
repolished, and washed. The selected tooth is separated from its
neighbors with mylar strips, etched for 60 s, washed, and dried.
Light-cure bonding agent is applied to etched enamel and excess
blown o. The selected shade of cement is placed evenly on the
porcelain to cover the whole tting surface without trapping air.
A 10 s spot cure of the cement labio-incisaly, after the veneer
has properly positioned, permits removal of the unset excess
elsewhere before nal curing.
On completion of placement excess cured cement is removed
with ne, water-cooled diamond and interproximal clearances
conrmed with ne separating strips.
Excessive stress on newly placed veneer should be avoided as
it takes 24 h for the coupling agent to develop its maximum bond
strength. Final polishing is much better delayed to later visit.
Materdomini has reported that porcelain veneer esthetics can
be enhanced with the contact lens eect concept.[19] Concept:
When the veneer is cemented to tooth structure, it blends
optically with the substrate, becoming dicult to detect. To
achieve this eect; two elements must be controlled. The rst:
Translucency/opacity of porcelain veneer itself. The second,
translucency/opacity of luting composite. If either element
results in high opacity level, especially at the margin, the contact
lens eect will not be achieved.
PATIENT MAINTENANCE
The teeth should be professionally cleaned 3-4 times yearly.
Hygienist should be warned not to use ultrasonic scaling or air
abrasive. These procedures will prolong the life of veneers.[20]
FAILURES
The survival probability of porcelain veneers according to the
Kaplan - Meier survival estimation method was 97% at 5 years
and 91% at 10½ years.[21,22]
The failure rate signicantly increased when the nish line
crossed an existing lling, while no inuence was found for
the type of preparation of incisal edge, the location of gingival
preparation margin, or the amount of time the veneer was in use.
In another study done in 2012, it was found that the survival
rate to be 94.4% at 5 years, 93.5% at 10 years and 82.93% at
20 years. The maximum number of failures found by these
authors was a ceramic fracture. People with parafunctional habit
especially bruxisum and discoloration at the margins in smokers
showed more failures. Yet another study reported 97.5% survival
rate at 7 years.
Esthetics with Veneers… Sowmya, et al. I J D H C
5
RECOMMONDATIONS AND CONCLUSION
The porcelain veneer is very esthetic and conservative treatment
option for many indications. The success of porcelain veneer
depends very much on the method of fabrication and most
importantly case selection. The research in this eld has been
based on personal preference and anecdotal information, more
objective research is required so that porcelain veneer will
become better successful.
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