OBSERVATIONS GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.

What is a veneer?
Resolving the confusion

bout 20 years ago, by far the most popular veneers” seems to be a redun-

A direct resin veneers

were introduced to a
suspicious and
doubting profession.
To the surprise of many, these
veneers proved themselves able
to be placed successfully,
veneering technique. The
majority of practitioners prefer
to prepare teeth at one appoint-
ment, have laboratory techni-
cians make the veneer restora-
tions and seat the restorations
at a second appointment.2
dancy analogous to the term
“car automobile.”)
In this article, I will discuss
the currently popular types of
veneers, make suggestions
about situations in which each
type is most appropriate and
improving the color of discolored There is confusion about the encourage the ethical use of
teeth and straightening slightly definition of a veneer restora- veneers.
malpositioned teeth. While tion. In practice, veneer restora-
TYPES OF VENEERS
many of the early direct resin tions vary from a small amount
veneers that I placed have of directly placed resin-based Direct resin-based com-
lasted 20 years and were suc- composite on the facial surface posite. In my opinion, direct
cessful technically, the resin- of teeth to a restoration placed resin-based composite veneers
based composites of the time over teeth grossly cut, deeply should be used far more often
produced color and smoothness into dentin, with only a small because they require only min-
that were only minimally strip of enamel remaining on the imal or no tooth-structure
acceptable. Today, after signifi- lingual surface of the tooth. removal, and the colors and
cant improvements in resin- Confusion even exists about blending of the restorative
based composite materials, den- the name of these restorations. material with the tooth can
tists can place direct resin-based Both direct and indirect veneer match almost any tooth color
composite veneers that have restorations have been called and contour. The resin-based
nearly perfect contour, smooth- “veneers,” “laminates,” “lami- composites, or RBCs, available
ness and color.1 nate veneers” or just “composite today have excellent smooth-
A few years after the advent restorations.” After reading ness, strength and color, and
of direct resin veneers, the tech- formal definitions of the words, I they are relatively easy to use.
nique of bonding indirectly suggest that these restorations However, some dentists strongly
made ceramic veneers to acid- most appropriately are called prefer to have the veneers made
etched tooth enamel surfaces “veneers.” Checking your dic- in the laboratory, and it is not
was introduced. Because the tionary probably will verify that likely that their opinions will
indirect technique is easier and “veneer” is the correct ter- change.
requires less clinical time, it is minology. (The phrase “laminate Nevertheless, for those practi-

1574 JADA, Vol. 135, November 2004

Copyright ©2004 American Dental Association. All rights reserved.
 OBSERVATIONS

tioners who will place them, cedure for dentists when com- Thin, laboratory-made
direct RBC veneers are indi- pared with the technique ceramic veneers have composed
cated when teeth need restora- required for laboratory-made the majority of veneers placed to
tion of small-to-moderate–sized veneers. date. Minimal tooth reduction,
carious lesions, accompanied by Currently, placement of almost all in enamel and not
mild discoloration or malposi- “stock” indirect ceramic veneers, extending into dentin, provides
tioning, or when there are no without cutting tooth structure, excellent retention of these thin
carious lesions but a need to is being advertised and popular- ceramic veneers to acid-etched
cover mild discoloration or to ized. When good judgment is enamel. Properly made, etched
correct slight-to-moderate tooth used about when to accomplish ceramic placed over etched
malpositioning. the technique, the resultant enamel simply does not come off.
Direct RBC veneers require “stock” veneers can be strong, In cases of accidental breakage
artistic ability and dexterity, but long-lasting and esthetically or subsequent dental caries,
they are not accompanied by a acceptable. However, this tech- such veneers are extremely diffi-
laboratory bill, and the dentist nique cannot be adapted suc- cult to remove and must be cut
is in total control of the clinical cessfully to many teeth. from the acid-etched enamel.
procedure. Often, this type of When indirect ceramic
veneer is indicated rather than veneers are placed on deeply cut
more extensive veneers because teeth and bonded onto dentin
Whenever possible,
of the lower cost to the patient surfaces, the retention of the
and the potentially excellent clinicians should avoid dentin bonding is good at first.
esthetic result. When teeth are placing thick ceramic However, experienced veneer
severely discolored, or correction veneers bonded to deeply users know from clinical experi-
of significant tooth malposi- cut dentin surfaces to ence that many such veneers
tioning will be accomplished by prevent postoperative tooth come off only months or years
veneers instead of orthodontic after cementation. After years of
sensitivity and increase the
treatment, more extensive indi- clinical experience, it is my
rect placement veneers are veneers’ longevity. opinion that veneers bonded to
indicated. deeply cut dentin surfaces are
Indirect ceramic veneers far less successful and have
without tooth structure Indirect ceramic or resin- shorter longevity than thin
removal. One of the earliest based composite veneers ceramic veneers placed on mini-
suggestions regarding indirect with minimal tooth prepara- mally cut acid-etched enamel.
ceramic veneers indicated that tion. The technique of placing Unfortunately, laboratory
teeth could receive veneers fired-ceramic veneers over teeth technicians prefer to make thick
without anesthetic or removal of with minimal tooth reduction veneers, as it is easier for them
tooth structure. In some situa- (up to about 1 millimeter) has to create adequate color in
tions, this type of veneer can be dominated veneer procedures for porcelain when the veneers are
successful. It should be obvious about 15 years. Pressed-ceramic thick. As a result, technicians
that these veneers should not be veneers often are used, but they encourage dentists to prepare
placed on teeth in labial or require reduction of more tooth teeth deeply for veneers, often
buccal version or on teeth that structure. Indirect resin-based unaware of the clinical bonding
are large and highly contoured, composite veneers have been and retention disadvantages of
because the combination of the used minimally for several rea- thick veneers placed on deeply
facially oriented or large teeth sons: dentists’ ability to place cut dentin.3
and the thickness of the veneers direct resin-based composite Whenever possible, clinicians
creates an unsightly “buck- themselves; the difficulty in should avoid placing thick
toothed” appearance. This tech- bonding laboratory-made, fully ceramic veneers bonded to
nique certainly is less traumatic cured resin-based composite deeply cut dentin surfaces to
and more reversible for patients veneers to acid-etched tooth prevent postoperative tooth sen-
than are more extensive veneer structure; and the color unpre- sitivity and increase the
procedures, and it is a simple dictability and difficulty of color veneers’ longevity. There are
and less time-consuming pro- correction at seating. techniques that allow laboratory

JADA, Vol. 135, November 2004 1575

Copyright ©2004 American Dental Association. All rights reserved.
OBSERVATIONS

technicians to orthodontic treatment. Occa- is related to the desirable imme-

make thin sionally, dentists now are seeing diacy of the treatment, which
ceramic veneers in their practices or on nation- often requires only a few
that are beau- ally televised “makeover” pro- appointments. However, in my
tiful, strong and grams mouths with such opinion, the expense, tooth
long-lasting and veneers on all or most of the destruction and the questionable
Dr. Christensen is
that dentists co-founder and senior
teeth. Such treatment has been long-term service potential of
can seat with consultant of Clinical promoted to patients by propo- this treatment are significant
Research Associates,
confidence over 3707 N. Canyon Road, nents of this extreme veneer reasons for most patients to
properly acid- Suite No. 3D, Provo, concept as being necessary to avoid this treatment.
Utah 84604. He has a
etched enamel master’s degree in correct malocclusion, discol- When significant occlusal
surfaces. These restorative dentistry oration of teeth or temporo- changes are indicated, or teeth
and a doctorate in edu-
thin veneers cation and psychology. mandibular joint dysfunction. have severe caries, crowns often
have pre- He is board-certified Such radical therapy can are indicated instead of veneers.4
in prosthodontics.
dictable, long- Address reprint improve oral esthetics for an
CONCLUSIONS
lasting requests to unknown period, but the severe
Dr. Christensen.
strength; have removal of tooth structure, the There are several types of
lifelike esthetic qualities; are resultant postoperative tooth veneers used commonly in prac-
associated with almost nonexist- sensitivity, the enormous and tice today. Fired or pressed-
ent postoperative tooth sensi- unpredictable changes in occlu- ceramic veneers are the most
tivity; and involve minimal sion and the frequent release of popular. Thin ceramic veneers
trauma to and destruction of the veneer from dentin-bonded bonded to acid-etched enamel
tooth structure. surfaces should give practi- have been suggested as the most
Indirect ceramic veneers tioners reason to consider acceptable, predictable type of
placed over teeth prepared orthodontics or less severe veneer. Direct resin-based com-
primarily into dentin. In restorative treatment. posite veneers have been
recent years, there has been an I strongly suggest that before encouraged for the situations in
obvious trend to cut teeth deeply agreeing to radical veneer which they are indicated. Thick
into dentin surfaces and to place therapy, patients should be edu- ceramic veneers placed over
thick, fired or pressed ceramic cated about the availability of deeply cut dentin surfaces have
veneers. These veneers usually well-proven, long-lasting, alter- been discouraged because of the
are beautiful because they are native treatment concepts, such associated gross reduction of
about the thickness of a ceramic as orthodontic therapy, thin tooth structure, common postop-
crown, allowing incorporation of veneers bonded to enamel sur- erative tooth sensitivity, occa-
opaques and various colors and faces, tooth bleaching, mini- sional deficiency in retention
translucencies into the ceramic mally invasive tooth-colored and unpredictable longevity. ■
material. Usually, only a thin inlays and onlays and occasional
Educational information on topics discussed
strip of enamel remains on the crowns, Class II resin-based by Dr. Christensen in this article is available
lingual surfaces of teeth pre- composite restorations and min- through Practical Clinical Courses and can be
obtained by calling 1-800-223-6569.
pared for these types of veneers. imal occlusal equilibration.
Several well-known clini- Almost all of these conventional 1. Christensen GJ. Direct restorative
materials: what goes where? JADA
cians, some laboratories and a alternatives to extreme veneer 2003;134:1395-7.
small number of practitioners therapy are less radical, more 2. Christensen GJ. Have porcelain veneers
arrived? JADA 1991;122(1):81.
have promoted this type of predictable and reversible, and 3. Christensen GJ. Achieving optimum
veneer to correct malpositioned less expensive for patients. retention for restorations. JADA
2004;135:1143-5.
teeth or alleged occlusion prob- The patient’s motive to have 4. Christensen GJ. Ceramic veneers: state of
lems instead of accomplishing radical veneer therapy usually the art, 1999. JADA 1999;130:1121-3.

1576 JADA, Vol. 135, November 2004

Copyright ©2004 American Dental Association. All rights reserved.