Recently I lectured for a day and a half to a study club outside Boston. As often happens, one dentist kept at me with questions. On the second day, I had spent a lot of time teaching how to successfully do veneers, inlays, and onlays. His hand went up again. He asked, “Why don’t you just keep going and spin that tooth down and do a full crown? The patient is probably going to need a crown eventually anyway.” I tried to answer his question but he was not having any of it. I saw that the audience wanted to move on, so I asked him if we could agree to disagree. I think I caught him by surprise, but he said “yes” and I was able to move on with neither one of us losing face.
Ask yourself these questions:
• If full crowns are so great and last so long, how come insurance companies approve a new crown after five years?
• Has dentistry come to such a place that full crowns only last five years? Perhaps we are doing something wrong.
• Is it the preparation?
• Is it the cement?
• Are there overhangs remaining on the crown because the lab cannot read the impression? I wonder.
So, why do I believe so strongly in veneers? My journey started back in the late 1970s when a few bold dentists were talking about some revolutionary ways to restore anterior teeth. These dentists were actually trying to make us believe that we could paste pieces of fired porcelain onto these teeth and they would stay there. Well, I was fascinated because I fractured the mesial corners of two upper centrals when I was 12 years old. My dentist, who also was our neighbor and instrumental in my going to dental school, told me that if I ever went to Hollywood, he would restore those centrals. All through dental school, my classmates wanted to crown those teeth. I just kept refusing.
I realized that veneers would provide a perfect solution to this problem. No PFM with a subsequent black line for me! So, in 1981 I had veneers placed on Nos. 8 and 9 and they looked great. My wife had centrals that lapped over each other. I had tried to do ortho on her when the children were young, but she was never that concerned about those teeth and she decided not to be treated. When veneers came along, here was a simple way to correct this situation. I prepped her centrals and laterals for veneers and they have looked great ever since. You would not believe how many people ask her about her teeth.
In the early days of veneers, two men stood out - Drs. Bob Ibsen and Bob Nixon. I listened to both of them. Dr. Ibsen’s course was free, and participants bought all the needed materials at the back of the room. Most of the dental companies did not have adhesives and cements. In those days, we were prepping only in enamel because we didn’t have any dentin adhesives. Veneers never came off! Dr. Nixon taught me a system of preparation and a system of cementation. Part of his course included a manual, which had all the steps to follow for successful veneers. He became my mentor, although he probably didn’t know it until much later.
In those early years, I had become very conscious of preserving as much tooth structure as I could. In the early 1980s, I quit doing amalgams because of the amount of tooth structure that had to be removed for the undercuts to hold the material in place. Minimally invasive dentistry seemed to be the way to go. I was doing a lot of veneers, inlays, and onlays using gold, porcelain, and lab-processed composite. It was exciting dentistry. Some of the restorative materials worked and others didn’t, but I learned things along the way and became the best I could possibly be.
We began to get our patients’ mouths back to good oral health. Our contract with our patients was to help them keep their teeth for the rest of their lives. Many of our patients could see and feel the connection between large amalgams with overhangs, teeth with broken down amalgams, and their oral health. They knew the reason for the irritated tissue around those teeth. The patients responded by having their teeth restored and then finding that their gingival tissues were healing.
Minimal dentistry is exciting and challenging. I know that it is very easy to put a bur or diamond on a tooth and very quickly spin it down into a crown prep. I have even seen dentists who leave old amalgam in the tooth they have prepped. Shame on them! I have seen too many teeth with undetected caries under old amalgams. All amalgam should be removed so the tooth can be examined for caries. It takes me very little time to do a quadrant of crowns, and I know for sure the teeth are free of caries.
Minimal dentistry requires new skills to produce the ideal preparations necessary for veneers, inlays, and onlays. You must learn the new techniques for temporization, because today’s patients want to look good while they wait for the permanent restorations. You must learn the latest techniques of adhesion, and then decide if these latest adhesives are better than the fourth-generation adhesives that they are compared with. You must learn how to cement these new restorative materials.
Actually, I find that veneers are much simpler than full crowns. I seated a case recently that required splinted PFMs. It took me much longer to adjust that case than six veneers. That is because with veneers, I leave most of the occlusal stops that are so important to having the correct balance. I find the same to be true of inlays and onlays.
I have heard a lot of naysayers tell me that veneers are hard to do; that the “Joe Average” dentist cannot master the technique. I can tell you that I have been teaching hands-on veneer courses for five years and I have not found that assertion to be true. If a dentist learns proper techniques and systems, he or she can go back to their practices and easily produce beautiful restorative dentistry.
It depends on the mind-set of the dentist. Does the dentist want to do ordinary dentistry or extraordinary dentistry? The decision is theirs to make. The difference is simply desire. The decision is to be the best that you can be. Nothing else is acceptable.
