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January 15, 2017
Smile makeovers with veneers are becoming very common, and our patients are demanding them more often. Many dentists now offer this service to meet patient demand.
Veneers are a wonderful service that can have a significant impact on our patients’ smiles and self esteem, and can even be a life-changing event. But when done poorly these can be devastating for the patient and dentist.
Veneers can be one of the more technically challenging procedures dentists perform. They typically involve multiple teeth, affect the patients’ occlusion, and deal with multiple colors of tooth structure. They need to be created in harmony with the soft tissue, can affect the patients’ speech, and require a working knowledge of many different dental materials. On top of that, we place veneers right where the patient and public can see them so that they are out there for everyone’s inspection. Truly, veneers can be one of the most stressful procedures we provide.
They can also be one of the most rewarding. To have the ability to positively change people’s smiles, to make them happy, and to improve their self-esteem is one of the wonderful gifts dentistry can provide.
Over the past 27 years I have placed literally thousands of veneers, and have replaced hundreds. Of the redos I’ve completed, I placed some of them, and many were placed by other dentists. Drawing from this experience I want to share some of the more common mistakes I’ve witnessed, and how to prevent them.
Common Mistake No. 1: Failure to address soft-tissue symmetry
In an ideal smile the patient should have gingival symmetry. In the ideal maxillary anterior arch form the gingival heights of the centrals should be 1 to 2 mm apical to the laterals, with the canines at the same height or just slightly lower than the centrals, then a gradual shortening of the gingival form moving posteriorly. Failure to address the gingival symmetry before starting treatment can affect the final esthetic outcome of the case.
Gingival changes can be made orthodontically or surgically. In a case where there is rotation and/or malposition of the teeth to be veneered, orthodontics is often the treatment method of choice.
If the teeth are in proper arch alignment, we either perform a gingivectomy using a laser (Waterlase MD, Biolase), or refer the patient to our periodontist for bony crown lengthening. Gingival issues need to be identified and addressed with the patient at the initial treatment planning. They will greatly affect the final outcome and often require additional time to complete treatment, and often involve a specialist.
Common Mistake No. 2: Failure to do a lab wax-up
Veneer cases can be very complex to design and achieve an optimal result. For years we we’ve required a lab wax-up of any veneer case we’re about to start, whether it is two or 20 veneers. The wax-up of the case allows the dentist to see the final visualization of the case. The wax-up can be duplicated and a preliminary prep model fabricated to allow the dentist to practice the prep design on a model before going to the mouth.
A wax-up allows the dentist and patient to see the final results in 3-D before treatment is started. This is often helpful to ensure patient satisfaction with the final result. The wax-up can also be used to make a matrix for the fabrication of the provisional restorations, which are not only highly esthetic, but allow for accurate inspection of new occlusal patterns and phonetics.
Common Mistake No. 3: Failure to work with an experienced esthetic ceramist
Porcelain veneers are an art form, and as much as we dentists would like to think that our wonderful preparations are what make beautiful veneers, we are in truth heavily reliant on our ceramists to create the real esthetics our patients want.
Figure 1 is an eight-year-old porcelain veneer case completed locally on Nos. 6 to 11. The patient came to our office to inquire if it was possible to improve the esthetics of her smile.
In our discussions on how to achieve her esthetic objectives, we agreed to replace the veneers on 6 to 11, and place new porcelain restorations on 4, 5, 12 and 13 to create the smile she wanted (Figure 2).
What was very interesting was that when we removed the old restorations at the preparation appointment, the preparations by the previous dentist were done extremely well. But because that dentist accepted less than esthetic work from the dental lab, the final esthetic result of the original veneers was a failure.
The need for an excellent esthetic ceramist cannot be understated. Any dentist who wants to place porcelain veneers needs to develop a great relationship with an artistic ceramist if he or she wants patients to rave about their new smiles.
Common Mistake No. 4: The rule of 4-8-10
Figure 1 is a good example of the 4-8-10 rule. All too often I see (and usually have to replace) veneers placed on Nos. 6 to 11. Dentists get caught in a trap laid by patients. A patient will come in for a consultation and request to have porcelain veneers placed on the anterior six teeth. The patient asks for this because when he or she looks in the mirror, all he or she sees is the anterior six teeth. The patient thinks that esthetically changing these teeth will make the difference he or she is looking for.
In reality, when a patient smiles, the anterior eight and often 10 teeth appear. By not considering this when discussing a smile makeover, dentists can often end up with a less than ideal result. The 4-8-10 rule means that in most veneer cases the most appropriate treatment plan is either treating teeth 7 to 10 or treating the anterior 8 to 10 teeth.
If the patient is happy with his or her teeth color or we can bleach the teeth to an acceptable shade, then often the best and most conservative approach is to veneer the anterior four teeth.
However, if the patient wants to make a dramatic change in the color of his or her teeth, then we need to evaluate all the teeth that show in the patients’ broadest smile. It is these teeth that will require veneers. In most people the first premolars are prominent in their smile, and in many patients the second premolars can be seen in a broad smile. The number of teeth displayed determines how many teeth need to be esthetically restored.
Common Mistake No. 5: Staining under veneers
A common problem I see when consulting with patients about redoing veneers that have recently been placed by other dentists is staining under the veneer.
Figure 3 is a dramatic example of a young lady who came into our office this summer. The four veneers were placed six months earlier, and within days the staining was noted. Although often blamed on “microleakage,” staining is the result of using a ferric sulfate solution as a hemostatic agent. Figure 4 shows what the prepared teeth looked like when we removed the original veneers. This black pigmentation is very typical of what will happen when ferric sulfates are used around all ceramic restorations.
Common Mistake No. 6: Failure to photograph the caseIf hemostatic agents are needed around veneers, the dentist should use products that contain aluminum chloride as the hemostatic agent. Viscostat CLEAR (Ultradent) and Expasyl (Kerr) both contain aluminum chloride and are excellent hemostatic materials.
Proper photography of any esthetic case is very important on many different levels. Most importantly, pre op and post op photography are your legal documentation of the case. In the very rare event that your cosmetic dentistry comes under legal scrutiny, X-rays and study models will be nowhere near as important as your photography of the case. I feel so strongly about this that I will not start a case without complete photo documentation.
The photography of the case will be extremely helpful in allowing your ceramist to see everything that you see clinically. From face shape, complexion and lip fullness, to stump shades and provisionalization, photos will help an experienced ceramist provide you and your patient with an even better result.
Before and after photos of completed cases are placed in our book of completed cases, displayed on the walls of our office and posted on our Web site. Photography of well-done cases can be a wonderful marketing tool.
Common Mistake No. 7: Take two “perfect” final full-arch impressions
It may sound unnecessary, but I feel it is very important with cosmetic cases to take two final full arch impressions. I have done this for the last 10 years, and for 10 years I have never had my ceramist ask me to bring the patient back to retake an impression. Even if the first impression looks perfect, I still take a second. When a model is poured up in the lab and trimmed under a microscope, there is always a chance that I did not see a void at a margin.
The last thing I want to do is call patients who have just given me a lot of money and trust me with their new smiles to tell them we have a problem and they need to return for another impression. This does nothing to build patient confidence in my ceramist or me. I have always felt it was well worth the time and effort to send two “perfect” impressions.
Common Mistake No. 8: Failure to communicate with the patient
Usually when I see one of my own patients or a patient for a second opinion who has an issue with the final esthetic outcome of a veneer case, the most common problem is miscommunication. I have learned the hard way that it is critical to take as much time as necessary to listen to and discuss the patient’s goals for cosmetic dentistry.
Common Mistake No. 9: Starting a case that should have never been startedTo be very clear about what the patient wants, we use diagnostic wax-ups, computer imaging, and our library of before and after photos. Conversely, we take a lot of time discussing our limitations as they specifically relate to the patient’s case. If we recommend orthodontics or periodontal surgery and the patient declines, we must be very clear (verbally and in writing) that this will have a negative effect on the outcome. Similarly, multiple missing teeth, previous dentistry in Hollywood, FL, a hyperactive upper lip, a poor skeletal relationship, etc., can have an impact on the final result and should be discussed and documented.
Mistake No. 8 leads to Mistake No. 9. During the course of communicating with a patient there can be clinical issues, psychological issues, philosophical issues or personality issues that indicate you are not the correct dentist for a particular patient. There are many different factors that can lead to declining a particular patients’ treatment. But the most important thing is to understand that it is appropriate and in everyone’s best interest to say no sometimes.
Certainly for all of us there can be clinical factors that make a case more challenging than we expected. But there are also personality issues that can come into play. If during the communication process you get the feeling you cannot make this person happy, chances are you probably can’t. Over the years I have learned the hard way that I do not have to treat everyone who comes into my office. My mentor, Dr. Ross Nash, says some of his best cosmetic cases are the ones he never started.
Common Mistake No. 10: Failure to have the proper education
Porcelain veneers may be one of the most difficult procedures we can perform. There are so many critical esthetic and functional considerations that must be accounted for to ensure a great result. This is certainly not the sort of procedure that can be learned with a one-weekend course. Veneers require a significant amount of time dedicated to learning and study.
We can gain tidbits of good information from journals. We can begin to get comfortable with basic concepts in a well-delivered lecture. But it is over-the-shoulder training, model work, and live patient education that can really help an inexperienced dentist become better quickly.
I had the honor of practicing with Dr. Ross Nash for five years. During that time I had the opportunity to watch and learn from one of the best how to do veneers correctly and conservatively. It is possible to get similar training with over-the-shoulder and live patient courses. Dr. Nash provides these courses. I have also had the opportunity to take other advanced training courses from Dr. Larry Rosenthal (Aesthetic Advantage), Dr. Bill Dickerson (LVI), Dr. David Hornbrook (the Hornbrook Group), Dr. John Cranham and Dr. Joe Blaes.
All of these dentists have helped me improve my technique and broaden my understanding of the complex issues involved in porcelain veneers.
I would strongly encourage any dentist who wants to provide porcelain veneers to get a good educational foundation before starting to prep teeth on paying patients. Many of the second opinions and redos I see in my office are cases done by dentists who lacked experience and training.
The above is a list of issues that I frequently see, and when you avoid these mistakes you will enjoy more consistent success with your porcelain veneer cases. One of the greatest services we can provide is taking an unhappy and self-conscious person and rebuilding their smile into something they have only dreamed of having. Professionally, it is the most rewarding service I provide.
Because of what we can now do with porcelain veneers to change people’s smiles, the entire perception of dentistry is dramatically changing in a positive direction. To continue this trend we need to do our best on each esthetic case.
These “mistakes” are easy to overcome if we recognize that they exist.
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