In this monthly feature, Dr. Gordon Christensen addresses the most frequently asked questions from Dental Economics® readers. If you would like to submit a question to Dr. Christensen, please send an e-mail to firstname.lastname@example.org.
Recently, I was asked to provide a second opinion about the planned treatment for a 16-year-old girl, and I was frustrated by the first dentist’s treatment plan. The patient’s anterior teeth had a slightly gray tooth discoloration, minor pitting of the superficial enamel, and normal Class I occlusion and tooth positioning. The first treatment plan called for eight anterior pressed-ceramic veneers. This plan seemed quite radical for the degree of tooth discoloration and malformation. What is your opinion concerning ceramic veneers on a person who is 16 years of age?
Answer from Dr. Christensen ...
The answer to this question depends on the depth of the tooth preparation and the type of veneer to be placed on the teeth. I will answer your question by looking at the consequences of placing various types of indirect veneers at age 16, and also by considering other less radical possibilities for treatment.
In my opinion, 16 years of age is a premature time to consider cutting away enough tooth structure to place the currently popular, deeply prepared, pressed-ceramic veneers. Tooth pulps are still large at age 16, and the dentinal canals are wide open, making the likelihood of postoperative tooth sensitivity very possible. Even pulpal death can occur when deep tooth preparations are accomplished on teeth this immature. However, minimally or nonprepared teeth, as suggested for the DenMat Lumineer™ concept using pressed ceramic veneers, would not have the same negative consequences.
The position of the gingival tissues at age 16 is not mature, and will not reach its adult location for several years. Unavoidable gingival recession will require premature replacement of the veneers due to discolored tooth structure and restoration margins. This will result in subsequent patient dissatisfaction.
Adequately strong, pressed-ceramic veneers usually require placing ceramic over the incisal edges of the upper anterior teeth. In spite of the low abrasive characteristics of pressed ceramic compared to most feldspathic ceramics, there will be premature wear of the incisal edges of the opposing lower anterior teeth.
Placement of veneers on this young patient is a significant expense for the family, especially when replacement would be required a few years later. There is no doubt that the pressed-ceramic veneers would be beautiful, and that the patient and her parents would approve of the temporary esthetic result provided by the pressed-ceramic veneers. However, from your description of the patient, it sounds as though more conservative procedures are indicated.
Bleaching the teeth is a simple, atraumatic, relatively inexpensive beginning for a conservative esthetic treatment plan. The slightly gray color should be removed by seven to 10 days of bleaching with 10 to 20 percent carbamide peroxide in trays, or by simple in-office bleaching. Assuming the color of the teeth is satisfactory after the bleaching, enamel microabrasion (PREMA® by Premier) would probably remove the superficial pitting from the enamel. Smoothing the teeth and an application (5,000 ppm) of fluoride would complete this conservative treatment.
In the event that enamel microabrasion did not remove all of the superficial pitting condition, then thin, directly placed veneers - made with a microfill resin (Durafill ® VS by Heraeus Kulzer, Renamel by Cosmedent®) - or a nanofill resin (Filtek™ Supreme by 3M ESPE) would be indicated.
In my opinion, placement of deeply-prepared-pressed ceramic veneers at age 16 would not be the treatment of choice. More conservative indirect veneers, directly placed resin-bonded composite veneers, or just simple bleaching and microabrasion seem to be more appropriate.
See our video V1584, “Veneers: All Types,” and C902B, “Veneers for Lower Anterior Teeth,” for additional information on this topic. For more information, contact Practical Clinical Courses at (800) 223-6569, or visit our Web site at www.pccdental.com.
Are digital radiographs really better than those made by conventional film processing? I have read and heard about many conflicting comments. Also, the cost is so high to install digital radiography in my office that I do not want to purchase a system unless this concept has been shown to be better.
Answer from Dr. Christensen ...
Your question has a confusing answer. Yes and no are both correct. At the current stage of development of digital radiography in dentistry, comparisons of periapical radiographic images made by conventional radiography or the current generation of digital radiography are similar. In fact, on definitive observation, conventional radiographs made with D-speed film may actually look better. So why should you replace conventional film processing with digital radiography?
Digital radiographs can be enhanced by texturing the image, thus showing detail not observable on the original digital image. The gray/white in the image can be reversed, showing some characteristics not obvious on normal radiographic images. Digital radiographs can be programmed to show the image in various colors, allowing observation of certain conditions not seen with the gray tones of conventional radiographs.
Distances can be measured on the images, showing length of posts, degree of bone support, and many other features to aid clinical practice. When the digital image is placed on a monitor, it is automatically enlarged to the size of the monitor, and extra magnification provided by the computer program gives additional information.
Add to the described positive-imaging characteristics the availability of obtaining an immediate image with digital radiography, elimination of your developer, extremely low radiation, easy storage of the images in a computer, retrieving images from the computer in seconds, ability to send radiographic images by e-mail, and you see significant positive advantages of the current level of digital radiography as compared to conventional radiographic techniques.
It is expected that numerous improvements in digital radiography will be forthcoming. But as with all new technology, it does not seem to be advisable to wait for these advancements. Digital devices currently available are excellent for their stage of development. You and I must consider the purchase of any new technology on the basis of whether or not the technology will make the clinical procedure faster, easier, better, or less expensive than methods previously available.
With digital radiography, the technique is faster, it is easier once the software is mastered, and it is better when considering image enhancement and other desirable characteristics. However, it is not less expensive in the short run. It is anticipated that when the cost of purchasing digital-radiography devices is spread out over several years, it will actually be less expensive than conventional film-processing techniques. Of course, this statement takes into consideration the significant cost of conventional developers, film, developing and fixing solutions, the repair and maintenance of the developers, and staff time to keep developers functional. My advice is to get digital radiography!
Dr. Christensen is a practicing prosthodontist in Provo, Utah. He is the founder and director of Practical Clinical Courses, an international continuing-education organization for dental professionals initiated in 1981. He is a co-founder (with his wife, Rella) and senior consultant of Clinical Research Associates which, since 1976, has conducted research in all areas of dentistry and publishes its findings to the dental profession in the well-known “CRA Newsletter.” He is an adjunct professor at Brigham Young University and the University of Utah. Dr. Christensen has educational videos and hands-on courses on the above topics available through Practical Clinical Courses. Call (800) 223-6569 or (801) 226-6569.