Introduction

In the past, the only treatment available for misshapen or severely discolored anterior teeth was the placement of a full coverage crown. These were usually porcelain fused to metal designs, and their opacity did not offer a sufficiently esthetic result. With the advancement of bonded dentistry however, it became possible to replace only a small amount of the labial surface of the tooth with a semi-translucent material that is bonded to the tooth structure. Today, labial veneers are primarily made either directly from composite resins, or fabricated indirectly using porcelain. To varying degrees, these labial veneers maintain the translucency of the tooth, and minimize the amount of tooth structure that must be removed.

With this new tool however, comes new challenges. Weighing the indications for the procedure against its limitations requires careful consideration of the properties of the materials utilized. The design of the smile and shade selection must also be thoroughly understood if the clinician is to fully realize the esthetic potential that can be obtained. This mere possibility of a highly precise esthetic result, places the burden on the dentist to deliver a result that is precisely tailored to the patient's desires and expectations. Providing such a result requires excellent communication in order to understand these patient desires and to communicate those effectively to the dental laboratory if one will be used to fabricate the veneers.

Indications for Porcelain Veneers:

Since their introduction in the early 1980's, porcelain veneers have gained wide acceptance as a primary restoration in esthetic dentistry. Although there are obviously limitations to porcelain veneers, they may be used to modify a tooth's color, shape, length, alignment, interpoximal space, and to restore fractured and endodontically treated teeth.¹

Stains confined to the enamel usually have a good prognosis with porcelain veneers. This is due in part to the preparation itself, because when you are preparing the tooth you are essentially eliminating some of the stained enamel in the process. Veneers are indicated more often for extrinsic stains such as coffee, tea, cola, tobacco, and even fluorosis. These stains, if they are not excessively dark, have a very good prognosis with porcelain veneers, especially if they are pretreated using extrinsic bleaching procedures before the placement of the porcelain veneer.

However, it is difficult to mask out dark underlying stains with a natural looking porcelain veneer because of the translucency of the porcelain. If sufficient opacity is given to the porcelain in order to mask the dark color of the dentin underneath, then the final restoration commonly appears lifeless and monochromatic. Thus, porcelain veneers may not be indicated for darkly stained teeth or stains that are located deep within the dentin. For example, porcelain veneers will not produce an esthetic result when restoring dark tetracycline stained teeth, or teeth that have dark stains due to endodontic treatment (either pulpal remnants or sealer). These stains are not an absolute contraindication however. In fact, veneers may still be indicated in patients with severe staining who prefer an unnatural opaque appearance to the stain.

Dental abnormalities such as peg laterals and diastemas are other problems in which porcelain veneers may be indicated. Porcelain veneers are also used in the restoration of a fractured incisal edge of an incisor. This is only indicated if there is at least 50 percent of the clinical crown remaining and when the preparation of the remaining tooth is in enamel.

The restoration of noncarious cervical lesions is another possible indication for placing porcelain veneers. However, the patient must be advised about the risks of staining, microleakage, and/or veneer fracture when extending veneers down onto the root surface because of the poor bonding substrate.

Indications for Composite Veneers

Resin Composite is also used for veneering the labial surfaces of teeth and can be used to treat esthetic problems similar to those described above. Although more and more practitioners are opting for porcelain veneers, resin composite veneers offer several advantages. They are direct veneers so they can be placed in a single visit without lab involvement or laboratory fees; hence, the cost to the patient is usually less. Also, in many cases little or no tooth structure needs to be removed when placing direct resin veneers. However, resin composites are not without their disadvantages. Even though several manufactures have recently introduced resin composite kits with greatly expanded shade selections, they still don't maintain their appearance as well as ceramic veneers. Also, in order to achieve an acceptable esthetic result, resin veneers need to be placed in layers, which can be technique sensitive.

Contraindications and Limitations of Porcelain and Composite Veneers

Porcelain and composite veneers have limitations in many situations. These limitations must be considered so veneers are not placed in cases where they are likely to fail.

Porcelain veneers rely very heavily on bonding for their strength and retention. Since the bond to enamel is much stronger and more predictable than the bond to dentin,² veneers are contraindicated in situations where the enamel is irregular or there is an excessive amount of tooth structure missing with insufficient enamel remaining. Generally, if the preparation extends into dentin, then a PFM or Empress crown may be a better option.^3,4

In addition, one must remember that veneers are not reversible. If a veneer discolors, fractures, or is simply unaesthetic to the patient, the veneer must be redone.^3,4 In some cases where an adequately esthetic result might be difficult or impossible, less invasive treatments or no treatment at all should be considered. For example, some patient habits such as smoking or bruxing may preclude you from obtaining a successful restoration in the long term, whether composite or porcelain is utilized.

Due to the somewhat delicate nature of composite and porcelain veneers, occlusion must be carefully evaluated before they are placed. Patients with Class III or end-on-end occlusion may place too much stress on the veneers.² Occlusion should also be examined to evaluate potential problems with excessive wear of the veneers. Bruxers should be fitted with a night guard to help prevent such problems.^2,5 Abfracted teeth also need to be assessed for their ability to support and protect a veneer.²

Periodontal disease, regardless of its trigger, is also a contraindication for porcelain veneers. The porcelain surface feels very smooth, but compared to enamel it has an increased surface roughness which can lead to increased plaque retention.⁶ One must also consider the gingival extension of the veneer, if the veneer must go subgingival, irritation to the tissues is increased. These factors are generally not significant unless good oral hygiene is not practiced or the patient has, or is predisposed to, periodontal problems.⁶ The quality of oral hygiene must also be considered with respect to marginal integrity of the porcelain veneer. The weakest point of the veneer restoration is the resin cement at the margin. When polymerization forces are applied to the two bonded interfaces (porcelain/luting resin; luting resin/tooth), the interface with the lowest adhesive forces will fail first. This is typically the luting resin/tooth interface, which leads to the potential for microleakage at the margin. Again, this is usually not significant, but for those with poor oral hygiene it may precipitate problems such as secondary decay or staining.⁷

Smile Design

Because veneers are indicated primarily for the improvement of esthetics, the design of the smile as a whole should be examined in order to implement them effectively. Despite subjective and cultural variables, certain requirements must be met for a composition of elements to be considered esthetic. Important among them is the presence of symmetry, or the harmonious arrangement of several elements with respect to each other. Symmetry in a figure or body is the property of manifesting a mirror image on both sides of a central axis. If a composition has a symmetrical arrangement, harmony and visual balance exist. Dominance is another component of a composition, by virtue of its size, shape, and color that affect the perception of esthetics. In the anterior region of the mouth, for example, the central incisor is the largest and therefore the dominant tooth. Closely allied with harmony is the concept of proportion, defined in this context as regularity or evenness. These criteria can be used to analyze and enhance one's smile. In dentistry each individual smile must be treated uniquely, since symmetry, harmony, dominance, and proportion vary among individual smiles. A systematic evaluation of a person's facial and dental structures must precede any type of cosmetic dental treatment.³⁶ (1)

Various horizontally and vertically directed orientation lines can be determined in every face, the result of visible underlying anatomic structures. These lines provide an important basis for evaluation of esthetics. The most prominent horizontal lines run through the eyebrows, pupils, at the level of the nares, and angle of the mouth. These imaginary lines normally lie parallel to each other and suggest facial harmony to the observer. In a smile, the line connecting the incisal edges of the maxillary anterior teeth (incisal line) normally appears to be a straight line that parallels the horizontal orientation lines. If the incisal line is perceived disharmonious with the other facial features then symmetry and balance will be affected as well. Other elements of significance to esthetic composition of the face include the hairline, height and shape of forehead, shape and size of the nose and ears, prominence of the cheek bones, and shape and size of the chin and lips. Most importantly the lips form the anterior frame behind which the teeth appear during speech and laughter. The shape, height, and surface characteristics of the lips have a direct effect on the visibility and esthetics of teeth. When the dentist does not use smile design guidelines, there is no blueprint for tooth preparation and restoration. In the absence of a plan, teeth may be under prepared or over prepared leading to a compromise of the esthetic and functional results.³⁶

The golden proportion is used as a mathematical approach to develop ideal size and shape relationships for maxillary teeth. This proportion is used to determine the width of the teeth as they relate to each other. Only after the incisal edge position, incisal plane, gingival plane, and central incisor length have been determined can the golden proportion be applied. As applied to the maxillary teeth , the golden proportion requires 62% reduction in the viewing width of each tooth, beginning with the central incisor, and proceeding posteriorly. To apply the concept of the golden proportion, a viewing width is taken from a straight on photograph of a patient's smile. For example, if we arbitrarily assigned a lateral incisor viewing width of 1.0, in which case the central incisor width should be 1.6, and the cuspid .62.³⁷ This ratio would allow for a smile dominated by the central incisors, with the other teeth becoming progressively smaller.

Other harmonious factors in smile design include: Dental midline perpendicular to the incisal plane, axial tooth inclination of maxillary teeth tips mesially as teeth move posteriorly, and increase in incisal embrasures from anterior to posterior. Since esthetic dentistry has become the wave of the future, it is important to take into account the uniqueness of one's smile. And by adhering to smile design principles esthetically pleasing restorative cases can be achieved.

Biomaterials

The materials of choice for the esthetic anterior veneering process have been streamlined into two major categories: composite resins and porcelain ceramics. A thorough understanding of the properties of these materials will prove invaluable in utilizing them to their fullest potential.

Composite Veneering Materials

Most of today's composites contain a monomeric base that may be polymerized into a stable filling compound that may be placed and finished directly in the oral cavity. Aromatic dimethacrylate monomers may undergo free-radical addition polymerization to produce a rigid cross-linked polymer.⁸ Additional monomers of lower molecular weight (glycol dimethacrylate) can be added to decrease viscosity at a cost of greater polymerization shrinkage. Ceramic fillers of all shapes and sizes can be found in composites. Currently, filler size determines the type of composite being utilized, as illustrated below.

Type	Filler Content	Particle Size(µm)	Comments
Macrofilled	78% weight	1-35	Difficult to polish, rough surface finish
Microfilled	35-63% weight	0.04	Easy to polish, poor wear resistance and poor wear properties. Fracture under shear forces.
Hybrid	>80% weight	0.5-2 and 0.04	Better polish than macrofilled, less wear than microfilled
Continuum	86.8% weight	0.01-3	Contains synthetic zirconia/silica fillers.
Flowable	<60% weight	-	Small increments added to reach appropriate contour.
Packable	>86% weight	-	Intended to be 'packed' (handles analogously to amalgam). They do not finish nicely.

(adapted from Combe, 1999)⁸

Silane coupling agents bond the monomer to the fillers, and small quantities of a polymerization inhibitor are added to complete the composite resin.

Due to their esthetically prominent location, surface finish is a problem which must be carefully considered with composite veneers. Surface finishing may be accomplished with carbide finishing burs or diamond burs. In addition, Sof-lex (3M Espy) disks/finishing strips, and aluminum oxide may be used to maximize surface finishing. Resin Glazes or Surface Sealants are composite resins that have little or no filler. They contain highly reactive initiators that can overcome competition with oxygen and start polymerization. Fortify (Bisco) was the first and a study showed that used as a glaze after finishing a posterior composite reduced wear. Actually, any fluid resin placed over a composite that has been etched will fill in voids, cracks, marginal openings, and repair the surface. Similar resins (used for filling minor surface defects) are now becoming available as part of many composite kits. Optiguard (Kerr), Fuji Coat (G-C), ESPE-Coat (ESPE) are among those available for finishing composite veneers.⁹ These glazes create a smooth non-porous material that is less likely to stain over time than an 'unglazed' composite veneer.

Porcelain Veneers

The porcelain veneering process is indirect due to material properties. Dental porcelains are a combination of silica, kaolin, and feldspar. Depending on their ratios, a chroma continuum, ranging from nearly transparent to opaque can be established‹all on a single porcelain restoration. Early porcelain veneers developed from feldspathic porcelain were chromatic and opaque. Though feldspathic porcelain is still used to mask less-than-ideal tooth substrates, new advances in porcelains have minimized loss of tooth structure while still maximizing esthetics.

Newer leucite-reinforced and zirconia based porcelains have greatly aided in achieving porcelains that are both esthetic and durable. Porcelain frits are supplied to dental laboratories and reconstituted as slurries that are applied to prepared dies and heated to an appropriate fusion temperature. Ceramics are inherently brittle and cracks may form in areas of tension. Leucite and alumina particles are crack deflectors that prohibit propagation and strengthen the restoration. A major shortcoming of porcelain veneers are due to marginal discrepancies that occur during the firing process, which can volumetrically alter the restoration up to 30%.⁷ Optical properties of porcelain are excellent and may be further enhanced by staining, polishing, and individual characterization to provide overall harmony and balance to a patient's mouth. The resultant restoration is durable (though inherently brittle), rigid, hard, and virtually stain-proof .¹¹

Color Selection

Color is a very complex entity. Manipulation of the shade guides and materials is a challenge for the dentist, but is of utmost importance in the fabrication of composite or porcelain veneers. In order for the dentist to effectively manipulate and match the shade(s), he/she must understand the three dimensions of color. The dentist also needs to understand that there are many variables and learn to control these variables for accurate shade selection.¹² The Vita Lumin shade guide will be used as the example.

The three dimensions of color are hue, chroma and value. The first dimension, hue "is that quality by which we distinguish one color family from another."¹³ In the Vita Lumin shade guide, A1, A2, A3, A3.5 and A4 are similar in hue, as are the B, C and D shades. The first step is to choose the closest hue and then select an appropriate match of chroma and value. It is important to remember that determining the hue is also contingent on the level of chroma that the dentist will select. Reevaluating the hue selection may be necessary once the other two dimensions of color have been selected.

Chroma "is that quality by which we distinguish a strong color from a week one. Chroma describes the amount of hue in a color." Following selection of the hue, the chroma is chosen. If the hue is decided to be of the A family, there are five variations available listed from highest to lowest. These variations include A1, A2, A3, A3.5 and A4. While determining the most accurate hue and chroma, several comparisons are necessary. Observing the shade for an extended period of time results in retinal cone fatigue. To avoid this and determine a more accurate shade, glancing at a blue background relaxes the retinal cones allowing a more accurate assessment of the hue and chroma values. Determining the hue can be difficult if the chroma is low. In situations such as this, "the region with the highest chroma (i.e. the cervical region of the canines) should be used for initial hue selection."

Value "is the quality by which we distinguish a lighter color from a dark color." A light color is referred to as a high value and a dark color corresponds to a low value. When determining the value, the shade guide has the samples arranged in order of increasing value. The Vita Lumin shade guide values from highest to lowest as follows: B1 - A1 - B2 - D2 - A2 - C1 - C2 - D4 - A3 - D3 - B3 - A3.5 - B4 - C3 - A4 - C4. The dentist will be more accurate at assessing the value if he/she views the samples at a slight distance from the chair. If the value is lower than the hue and chroma previously selected, a change in that shade is usually required because increasing the value by adding stain is not possible. If the value is determined to be higher than the hue and chroma selected, the practitioner must determine if the difference can be altered through a staining process.

One of the most important variables in shade selection is the light source. The light source is the active stimulus and the object which is pigmented is the passive modifier of the light source. Once this concept is understood, we can begin to control the behavior of color. The desired qualities of light include 1) complete color content 2) intensity to overcome the influences of ambient room light 3) comfort to the eyes allowing accurate color perception and 4) standard, unchanging light in quantity and quality.¹⁴ It is also important to remember that ambient room light should not be so intense that slight color differences are washed away.

There are many components and variables involved in color. It is very complex and difficult to manipulate even under the best conditions. Once dimensions of color are understood and the practitioner has learned to control the variables, however, the accuracy of selecting a shade improves. The result is a patient that is satisfied with the esthetics of their restoration.

Finish Lines, Margins, and Gingiva

As with any restoration, principles for margin design must be well understood and adhered to in order to produce successful anterior veneers. Due to the esthetic nature of veneers however, the balance of hiding the margins behind the gingiva without encroaching upon the biological width merits special attention.

There are three requirements for successful margins. (1) They must fit as closely as possible against the finish line of the preparation. (2) They must have sufficient strength to withstand the forces of mastication. (3) They should be in areas where the dentist can finish and inspect them and the patient can clean them.¹⁵

In 1891 G.V. Black stated, "decay does not occur at margins as long as they are covered by healthy gum tissue."¹⁵ Today however, the weight of evidence makes the practice of routinely placing finish lines subgingivally no longer acceptable. This is because we have learned that the single most important factor concerning finish line is preservation of the periodontium. Finish lines should not be placed any closer than 2.0 millimeters away from the alveolar crest or bone resorption will occur.¹⁶ If the margin intrudes into this "biological width", inflammation will result and the alveolar bone will recede until it is once again 2.0 millimeters away from the margin of the restoration.¹⁷ Ideally, the finish line of the porcelain laminate veneer should be a slight chamfer placed within enamel at the level of the gingival crest or slightly subgingival.16 If the decision is made to place the finish line slightly subgingival, it is critical not to violate the biological width. Another consideration of finish line placement is that the finish line should be in enamel, as enamel provides optimal bonding and seal.¹⁸ Finish lines in cementum or glass ionomer have exhibited greater marginal leakage than those located on enamel, and are not recommended.¹⁹ Preparations designed with supragingival finish lines can be virtually invisible, so placing the finish line subgingivally is often not necessary.¹⁹

Due to the relatively thin enamel in the gingival half of the labial surface of the anterior teeth, great care should taken not to penetrate into the dentin. The desired reduction in this area is 0.3 millimeters. The finish line of the porcelain laminate veneer is commonly accomplished with a round-end tapered diamond bur, following the contour of the gingiva.¹⁶

Dentist Patient Communication: Reality and Perception

In order for elective procedures in esthetic dentistry to be successful, the dentist must be able to communicate with the dental staff, the lab technician, and most importantly the patient. Dentists need to effectively engage the patient in a discussion about wants and levels of expectations. Due to increased patient awareness of beauty and what constitutes an attractive smile, this communication is critical in delivering satisfactory results to patients requiring anterior veneers.²⁰

About one third of the adult population in the United States is dissatisfied with the color or shape of one or more of their natural or restored teeth.²¹ However, in a Dutch National Dental Survey it was found that when esthetic dental procedures were initiated, the reasons cited for treatment differed between the patient and dentist. It was found that the majority of patients desired treatment to improve tooth 'color', whereas the dentist cited the goals of modifying tooth 'shape' and 'position'.²¹ It is important that an agreement is reached between dentist and patient in order to assure that the patient's chief complaint is understood, addressed, and resolved in the treatment plan.

It is also important for dental practitioners to note that the patient may seek treatment for a dental appearance problem for a mixture of social and psychological reasons. Davis et al. found that a patient's motivation for treatment often centers around the hope to feel "less self-conscious, happier, more self-confident with respect to self, appearance or smiling and the implications these may have for social interaction". Patients reported the desire to "feel better about myself", "be accepted as I am", and feel "more self-confident, more relaxed and more outgoing."²² It is important that the dentist is able to address realistic and unrealistic treatment outcomes prior to initiating treatment in order to prevent patient dissatisfaction and disappointment at the completion of treatment. Patients have the right to be informed about the limitations as well as advantages of treatment in order to make fully informed choices.²³

Tools used to Achieve Effective Communication

Photographs
According to Cutbirth, "presenting quality photographs or slides of similar cases, personally completed by the dentist, is an excellent way for patients to determine if the procedures will meet their aesthetic objectives."²⁴ During the preclinical interview and the consultation appointment, the patient can inspect and compare these completed cases with photographs taken of their own dentition. This allows the dentist to understand the patient's "reasons for desiring esthetic improvement, and be certain the patient's motives are reasonable and expectations are attainable."²⁴

Case work-ups on stone models
This is a relatively easy technique that is done extraorally by the dentist or the laboratory technician. Preliminary impressions are taken, poured up in laboratory stone, and are mounted on an articulator. The teeth are prepared on the models as anticipated during treatment, and wax or composite is used to restore the teeth. The technician or dentist can be creative in the development of color, shape, and texture. Interference by the tongue, lips, cheeks, and saliva are eliminated thereby improving the ease of fabrication. However, there are important limitations of this technique. The color of the model stone may distort the composite shade thus affecting the final color of the buildup, and patients may find it difficult to relate colored wax to the final result. Patients also find it difficult to visualize the results in their own dentition and therefore this technique has a lesser impact on treatment acceptance.²⁵

Intraoral composite mock-ups
Intraoral composite mock-ups are a direct procedure that aid in patient education. Composite is placed over the surfaces of the anterior teeth before tooth preparation, and are contoured to look esthetic and attractive enough to positively influence the patient's treatment decisions. An advantage is that patients are able to immediately see what the proposed results of treatment will look like without sacrificing tooth structure. Using this technique can often influence treatment acceptance in a positive way. However, the major drawback of this technique is the extra chair time that is required to accomplish the process successfully. Patients are also often reluctant to pay for an exercise that they consider part of the marketing process.²⁵

Visual diagnostic try-in (VDT) technique
This technique is a combination of the stone model work-up and the intraoral diagnostic mock-up. The VDT is a "diagnostic, aesthetic, but non-functional approximation of the intended treatment that is designed to fit over the unprepared teeth of the patient."²⁵ Stone study models are generated and are then sent along with measurements, color, tooth shape, size, and appropriate slides to a dental laboratory where the VDTs are fabricated. According to Freedman and Kuleta, the VDT units are designed to provide: 1.) an immediately insertable educational tool that allows the patient to easily visualize the results of the proposed treatment, leading to increased treatment plan acceptance. 2.) a diagnostic template that the dentist can adjust and modify chair side to fit the patient's expectations. 3.) a template for the laboratory technician that is used during the construction of the final restoration. 4.) maximum conservation of tooth structure; the VDT thickness can be measured and then by subtracting the difference between the thickness of the VDT and the required dimension of the restoration the total amount of tooth preparation is calculated: [(Total amount of tooth preparation required)- (VDT dimension)=(Total required depth of preparation)].

Various materials may be used to fabricate the VDTs. However, to be effective the material should be strong, esthetic, adjustable, expandable, and polishable.²⁵ The VDTs can be temporarily bonded to the teeth with try-in paste or glycerin. Disadvantages of this technique include extra office visits for the patient, and increased laboratory and chair time, which incur additional cost to the patient.²⁶

Digital cosmetic imaging
This technique allows the dentist and patient to view the results of a cosmetic procedure with computer imaging, before a procedure is performed. The image is computer generated and consists of before and after (post-op) results that can be viewed on a computer monitor or can be printed on photo-quality paper to present to the patient.²⁷ A diagnostic series of photographs are taken of the patient, these images are then downloaded onto a computer, and through the use of computer software the images are modified until the desired results are achieved. Benefits of this technique include increased patient acceptance, ease of modification, lack of direct or indirect procedures, and decreased chair time. Disadvantage include needing extra equipment such as digital cameras, computers, and computer software.²⁸

Dentist-lab technician communication: Keys to success

Taking a deeper look into the aspects of dentist-technician communication explains the last crucial step to creating a superior aesthetic and functional restoration. The keys to success here are similar to the previous examples of patient-dentist communication. It is imperative that we as dentists strive to create a trusting working relationship with the lab of our choice. This means just plain getting to know them and having an open line of communication, including constructive criticism as well as the display of gratitude for a job well done.^29,30 Don't be afraid to stop by your lab just to say "Hi"; and know that if that lab has a problem with that, it may not be the lab you want to invest in. Lastly, if success is what you are looking for, you can't necessarily expect that if you aren't paying for it. Those rock-bottom priced, 'next-day-denture', types of places charge their prices for a reason.³¹

Once you have chosen a dependable lab and formed a relationship you're happy to work with, the next step is sending them work in a way that will ensure success. This involves many things, and new tools are making this quite a complicated gathering of information, but worth the prospective outcomes. Overall it is the dentist's responsibility for how their cases turn out. Therefore, writing a detailed description of each individual case is very important.³⁰ As stated previously there are tools and techniques that can be used not only for the patient's education and setting of expectations, but also forwarded to the lab for optimal congruent communication.²⁹

First, in the process of writing a prescription, a detailed description of the patients concerns and expectations must be forwarded to the technician.³² Then, the dentist has to include their objectives and goals, and any materials used as mock-ups with the patient (waxings and/or intraoral trial-run demonstrations).²⁹ A shade selection can be passed on to the lab in several ways. Our traditional color tabs can be used to "color map" each tooth as desired. Also, computer software now has the capability of color mapping for the clinician with the implementation of a digital photo.³³ The design is topped off with a detailed description of each tooth's desired outcome, as far as contour, surface texture, translucency, and other specialized characteristics the patient would benefit from. Design can be created by the technician with the help of several tools - models, digital photos, and trial mock-up outcomes to name just a few.²⁹

Digital photography has to be the largest step forward in dentist-patient-lab communication of all the advances we have seen in our small number of years. They allow the ability to mimic hue, chroma and value to an acceptable level verses the older film based photos.³⁴ They help tie together the message the patient and dentist is trying to make for the technician they choose to work with. Going digital has not only increased the success of communication, it has made it unbelievably faster! No longer do you have to wait for a 35mm roll of film to first get used to the maximum number of pictures, and then get developed.³⁵ Digital is quick, quality, and a huge benefactor to aesthetic dentistry. The only concern now is the expense, but we are already seeing the numbers fall. By the time we are all in practice I would bet a digital system will be on all our "to get" lists.

Again, the dentist involved does have the ultimate responsibility to create an outcome the patient is looking for. Using the new developments, and a team approach are the best advice research is now giving.³³ Using your resources wisely creates a situation where your odds of success are at their best.

Conclusion and Position

Like every procedure in dentistry, the success of your anterior veneers will depend heavily upon your understanding of, and adherence to, the principles involved in their production and application. What makes veneers quite different from other procedures however, is that their only purpose is to improve the esthetics of your patient's smile. If a patient fractures off half of their tooth, and you restore it with a PFM that is not very esthetic, the patient will sometimes be quite satisfied because their tooth is "fixed." Patients who are receiving veneers however, often have expectations of perfection.

For this reason, composite veneers should be considered with skepticism due to their compromised esthetics and tendency to discolor. Porcelain veneers however, can be a very good treatment option in many circumstances. Although, high patient expectations also mean that the application of veneers of any type requires greater attention to detail and principles than probably any other procedure in dentistry. Their success can only be assured if the dentist follows a defined protocol with each patient to ensure that all factors such as smile design, margin placement, material and shade selection, and communication between the patient, dentist, and lab, are rigorously controlled. Only when all of these factors are thoroughly considered, utilizing current evidence, can dentists have predictable results and happy patients when utilizing anterior veneers.

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