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Failed Dental Veneers: Cause and Effect
Advancements in Veneer Fabrication - Bonding Chemistry
Porcelain laminates are being used in more and more creative ways to address a number of cosmetic issues and, for some patients, even dental function problems related to bite and occlusion.
|Looking Feeling Great
Advancements in bonding chemistry have expanded how and where veneer products can be used in different locations in the jaw.
For some patients, custom veneer products can be used to adjust occlusal problems that were, at one time, only possible with crowns and onlays.
In the new treatment area of Adult Orthodontics, premium veneers and specialty cements are being used in combination with Invisalign to effectively manage certain types of tooth rotations.
Cosmetic dentists who have mastered the concept of Accelerated Orthodontics for adults are also incorporating the use of veneers in as little as 5 months to create nearly text-book perfect smiles. Perfect ortho alignment with perfect proportional sizing far exceeds what Instant Orthodontics can achieve.
New Problem Areas
Recent advancements in laminate fabrication that have created new treatment choices for patients have caused a new area of errors. Standard (full prep) veneers, No Prep veneers and now Minimal Prep veneers now require a level of vigilence (on part of the patient AND dentist) to assure that the thickness of the veneer does not create a resized or resurfaced tooth that violates the rule of proportions. Otherwise, veneers will create results that look like Chicletts (thick, bulky), piano keys (too long), cartoon character (goofy looking) teeth or even bulging teeth (see photos).
Veneers Gone Bad: Product Failure versus Bonding Failure
It is becoming more established that a bad or unsuccessful veneer treatment is typically not a product failure.... but rather a failed bonding relationship between a particular tooth and veneer.
Veneers that move, slide around or fall off entirely are mistakenly assumed to be caused soley by bad cementation. This unfortunately frequent problem is much more complex. The quality, integrity and strength of each laminate bond is dependent upon several factors... not just the cement product.
|Too Few - Leaking
Anatomy of a Dental Bond
Factors that determine how strong and permanent a particular bond will be can include: the location of the tooth (anterior-posterior), rotational factors (crooked-turned position), quality of existing tooth enamel, dentin health, contamination factors (saliva, breath, operatory air quality), bonding cement characteristics (traditional versus one-step, specialty cements for compromised dentin, colorized, stain blocking agents, etc) and lastly, bite and occlusal factors that for some patients... can cause veneers to fail repeatedly for certain types of bites.
|Size Cementation Color Shade Errors
Technique Sensitive - Expertise Requirements
Bonding chemistry provides a wider range of cosmetic and restorative procedures that dentists can perform today, compared to just a few years ago. But... the factors that play a determining role in how well a veneer endures hasn't changed much.
As with many technologies, practitioners who were proficient with early versions of a technology tend to acquire advanced abilities to apply the technology as advancements occur. In short, technical expertise increases.
Unfortunately however, many advancements create the impression that the application of it becomes "easier." Patients, and even some dentists, assume that the "process" of veneer bonding can be quicker. Instant Makeovers, a term popularized on TV makeover shows, may be partly at fault.
|Bulky Minimal Prep Mismatch
Veneer treatments frequently fail because of certain protocols (steps) not being followed or the alloted time frames for completing each step is shortened.
Patients, first of all, should assure themselves that their favored dentist has documented evidence (before and after pictures) of treatment needs and results similar to what is being sought. Many different brands of porcelain are used by different dentists.
Since different veneer products have different cosmetic and structural qualities, make sure the favored dentist has the resources to create the cosmetic and/or dental function desired.
If treatment involves 4 or more veneers, expect, and moreover, require, to have impressions and stone models made that enable you to "sculpt" the cosmetic effect you want... with precise detail. Occlusal issues should be closely monitored by the dentist.
Maintaining a watchful eye on bite characteristics that undergo unwanted change prevents veneer failure that is caused by unusual physical forces that are out of balance in the occlusal plane.
The diagnostic waxup (created by the patient and the dentist) creates the veneer temporaries that should be worn for several days to assure the veneers look good, feel good, don't disturb or change bite characteristics, produce no signs of sensitivity, have the desired Smile Line and proportional sizing desired.
The importance of following the standard protocol of veneer dentistry cannot be overemphasized. The pictures contained in the advancent blue sidebar reflects the event of leakage and bacteria accumulation that can destroy a veneer makeover.
These veneers are temporaries. The leakage was caused by the patient not following through with proper care during the period of veneer try-ins. Since temporaries are easily removed, the veneer specialist was able to re-prep the tooth structures.
Leakage failures with cemented veneers cannot, in most cases, cannot be retreated without new veneers.
Required: Temporaries for Try In
Veneer temporaries can and should be a tool used by the patient and dentist to assure all cosmetic and functional goals of treatment are being met. There is no substitute for wearing and "trying in" of temporary veneers.
Patients with uneven gingival tissues or certain gummy appearances that may become more evident with new veneers should discuss additional treatment before the final veneers are placed.
A "good" veneer dentist works closely with the patient to assure every critical step is initiated and completed, to the patient's satisfaction ... and to the doctor's satisfaction. All cosmetic and functional characteristics of each veneered tooth structure are evaluated on a unit by unit basis, and on an occlusal plane basis (bulk of unwanted bite changes occur if this step is not followed).
Replacing Veneers - Repair
Veneers that require replacement, as in the case of normal wear and tear (10-20 years of service), can be replaced with a choice of many new veneer products. The cosmetic qualities of today's veneers offer more dramatic results for many patients.
Repairing or fixing a veneer(s) is possible for single or multiple veneers. Most repair issues arise from a failure of not following a particular step, as outlined above, or skipping certain steps altogether.
Bad cases of inadequately prepared bonding surfaces may require special preparations or the use of hybrid bonding methods, depending upon the original cause of failure. Porcelain jacket veneers can be used to effectively treat certain occlusal issues that have caused failures. Laminated jackets also work well in managing certain types of tooth sensitivity issues
Veneer dentistry enables many experienced dentists the ability to recreate or create, for the first time, cosmetic and occlusal properties that Mother Nature overlooked. Given diligent control or management of potential failure factors, veneers can reasonably be expected to endure 10 to 20 years or more.
Today's new laminates can offer patients an almost unlimited ability to create almost any type of smile or smile line change imagineable, provided that recommended procedures are followed closely. When they aren't.... failures are certain to occur.
Material and Photography provided by:
Dr Ira Koeppel, Long Island NY