30

th
FOUNDATION
®
year
of continuous
service to CLINICIANS’ GUIDE TO DENTAL PRODUCTS & TECHNIQUES
dentistry

CRA
January 2006
STATUS UPPER ANTERIOR VENEERS— STATE OF THE ART (PART 1)
REPORT
Volume 30 Veneering of teeth has grown enormously in the last 20 years. Most clinicians agree veneers can be
Issue 1 the most beautiful & natural looking dental restorations, & their use will continue to grow. Report
below addresses veneer material options; tooth preparations; tissue management concepts; making
impressions; provisional restorations; & CRA conclusions. Future reports will address cements,
IN THIS ISSUE: finishing & occlusal equilibration, & special considerations for natural looking lower anterior veneers.

• UPPER ANTERIOR
VENEERS—
STATE OF THE
1. VENEER MATERIAL OPTIONS
ART (PART 1) Table below lists current veneer material options, their use as reported by respondents to CRA’s ’05 Product
Use Survey, & characteristics of each option.
Pages 1–3
Material Reported use Characteristics
• TETRIC Ceramic
EVOCERAM Pressed . . . . . . . . . . . . . . . 71.2% . . . . . . . . . . . Monochromatic, but easy to modify shade using surface stains; relatively easy
Universal to make
composite resin Fired . . . . . . . . . . . . . . . . . 61.5% . . . . . . . . . . . Offers best control of color
Milled (CAD-CAM). . . . . . . . 0.4% . . . . . . . . . . . Monochromatic, but 3 translucency blocks available & shade can be modified
Page 4
using surface stains; can be accomplished in 1 office visit
Resin
• CANKER COVER Direct† . . . . . . . . . . . . . . . . 62.0% . . . . . . . . . . . Characterization by resin layers, accomplished in 1 office visit, may not be as
Covers & aids durable as ceramic
healing Lab fabricated . . . . . . . . . . . 7.5% . . . . . . . . . . . Characterization by resin layers, easy for lab techs to make, good control of
Page 4 color, may not be as durable as ceramic
Milled (CAD-CAM). . . . . . . . 0.4% . . . . . . . . . . . Monochromatic, but can modify shade with surface stains; can be
accomplished in 1 office visit
• AQUASIL ULTRA † Resin brands reported most used were: EsthetX, 17.2%; Renamel, 10.0%; Filtek Supreme, 9.0%; TPH3, 9.0%; & Herculite, 7.3%. Many other brands
DIGIT were reported used by less than 4% of respondents.
Unit-dose
dispensing Summary: Many veneer material options are available today. Ceramic (pressed & fired) & direct resin are
Page 4 reported most used. CAD-CAM ceramic & resin, & direct resin are the only options for single office visit veneers.

• TELE-TALK
Training manual 2. TOOTH PREPARATIONS
Page 4 No one tooth preparation serves all cases. Many patients have malaligned or rotated teeth, caries,
crowding, restorations, intrinsic stains, &/or white spots. Patients’ desires & expectations need to be
discussed & understood. All alternatives should be explained to satisfy informed consent. Most clinicians
agree preparations should be as conservative as possible. For some cases, tooth bleaching & minimal
orthodontics may achieve patient’s desires without placing veneers.
A. No prep or very shallow preparation (0.0–0.3mm)
Example case of no prep veneers (Lumineers, using Cerinate porcelain by Den-Mat):

®
Indications Advantages Disadvantages
Since 1976 • Pre-treatment tooth color is • High esthetic potential • Potential for over contouring
CRA FOUNDATION® acceptable, teeth are in lingual • Little to no potential for post-op • Thin veneer may not block cement or
3707 N. Canyon Road #6 version, small or spaced teeth, sensitivity & debonding tooth color, affecting final color
Provo, Utah 84604 malformed teeth, or very thin • Preserves tooth structure
801-226-2121 veneers over relatively normal • No anesthesia required
tooth anatomy • Provisionals usually not
www.cr ane ws.or g
required
CRA Foundation® Newsletter Page 2 January 2006

B. Moderate depth of prep into enamel (0.5mm–slightly over 1mm)

67.6% of respondents to CRA’s ’05 Product Use Survey reported they cut minimal veneer preps, mostly in enamel.

Indications Advantages Disadvantages

• Acceptable tooth color with only mild to
moderate discoloration, malpositioned,
malformed, carious or restored teeth
• Excellent esthetic potential • When indicated there are no disadvantages
• Low or no potential for post-op sensitivity
potential
• If done correctly in enamel, no potential
for debond

Diagrams below show enamel prep characteristics:

CRA data show extending Proximal margins can be oriented interproximally or lingually.
restoration over the incisal edge
reduced breakage & improved
durability. Proximal Margins at Contact Lingual Proximal Margins

Ideal when teeth are in Indicated for previously

Up to 2/3 of the enamel can be good alignment & contact. restored or carious teeth,
removed & still have a strong, Tooth/veneer interface not diastemia closure or when
non-sensitive & highly esthetic visible, easy bonding & teeth have been stripped to
ceramic veneer. finishing. alleviate crowding.

C. Prep into dentin (can become essentially a facial 3/4 crown)

27.9% of respondents to CRA’s ’05 Product Use Survey reported they cut veneer preps into dentin.

Indications Advantages Disadvantages

• Highly restored teeth, darkly discolored
teeth, significant change needed in
occlusion
• Significant caries or tooth wear present
• Excellent esthetic potential, since
ceramic or resin is thick & blocks
underlying tooth color
• Debonding can occur as dentin bond
degrades over service period
• Frequent potential for post-op sensitivity
• Anesthetic use required at prep & at
veneer seating
• Can result in pulp death

Summary: Teeth can be prepared for veneers ranging from no prep or removal of tooth structure, to deeply into dentin.
Most dentists in CRA 2005 survey report use of moderate depth preparations into enamel only.

Photos below show the range of tooth reduction possible for veneers depending on situations described above.

No prep. Moderate depth prep in enamel. Deep prep into dentin.

CRA Foundation® Newsletter Page 3 January 2006

3. TISSUE MANAGEMENT CONCEPTS

A. No tissue management required— Indicated when veneer finish lines are supragingival. This is viable option for
teeth with no to moderate prep into enamel, with normal color, & fully errupted. Results in little to no tissue
trauma, but margins may become visible over time as gingiva recedes.
B. Tissue management required— Indicated when veneer finish lines are subgingival.
• Finish line slightly subgingival— Use of 1 or 2 conventional cords with or without a styptic or vasoconstrictor, or a strong
styptic material (i.e. Magic Foam Cord by Coltene Whaledent) is adequate. Styptics containing iron (ferric or ferrous)
should be avoided due to potential for subsequent discoloration of tooth structure. Aluminum chloride or other mild
agents have not shown discoloration potential. Some short-term soft tissue trauma is usually present.
• Finish line deeply subgingival— Conventional 2-cord technique with styptic or vasoconstrictor works well (avoid
those with iron salts due to potential discoloration of tooth structure). Some short-term soft tissue trauma is probable.
Method: Place 1st cord to fill 1/2 of sulcus, prep to cord, place 2nd cord & push cord apically,
remove 2nd cord, make impression.

4. MAKING IMPRESSIONS
Accurate impressions reduce finishing time at seating & improve quality of veneers. 80% of respondents to CRA’s ’05 Product
Use Survey reported use of VPS impression materials (most used were Aquasil at 13.6%, Imprint at 6.4%, & Splash at 6.0%).
Polyether impression material was reported used by 17% of respondents.

A. 1–3 Teeth— Double arch impressions that transfer centric occlusion relationship are easy &
predictable. Use VPS or polyether impression material & adequate impression trays (two well
proven example trays are the Anterior Triple Tray by Premier Dental & Quad Tray by Clinicians Choice).

B. 3+ Teeth— Rigidity & accuracy are critical. Properly adapted stock trays or light-cured custom
trays (Triad by Dentsply) used with VPS or polyether impression materials work well.

5. PROVISIONAL RESTORATIONS
Veneer provisionals are placed to reduce interim tooth sensitivity & for esthetics. Patient should be warned they are fragile.
Bis-acryl resins are most used (i.e. Integrity by Dentsply Caulk, Luxatemp by Zenith Dental, Protemp 3 Garant by 3M ESPE, & others).
Microfill or nanofill composite resins can also be used (i.e. Durafill by Heraeus Kulzer, Filtek Supreme by 3M ESPE, Renamel Microfill
by Cosmedent, & others). Final restorations should be placed as soon as possible.

Following method works well for CRA Evaluators:

1. Make a pre-op alginate impression.
2. Pour cast.
3. Place bonding agent & composite
resin on dry cast to create desired
contour & tooth length.
4. Make vacuum formed shell.
5. Prep teeth.
6. Place resin of choice in shell.
7. Insert loaded shell over prepared
teeth.
8. Allow resin to set or light cure.
9. Finish & polish connected
provisionals.
10. Etch small spot of enamel in center
of facial surface of each prep
(~2mm).
11. Cement provisional restorations with
either same resin cement to be
used for ceramic veneers, a resin
temporary cement (i.e.TempBond
Clear by Caulk), or other resin of
choice.
12. Cure resin provisional cement.
13. Adjust occlusion.

6. CRA CONCLUSIONS
Veneers, direct & indirect, comprise a major portion of dentistry today. This report has described a state-of-the-art
technique from preparation to temporization along with materials found useful by CRA Evaluators. Dentists should
provide complete patient education about the veneer concept, including alternatives, veneer advantages & disadvantages,
risks, & costs & document informed consent about veneer therapy before starting treatment. Treatment choice should
be the most conservative method consistent with patient needs & desires.
CRA Foundation® Newsletter Page 4 January 2006

CRA
CONFIRMED NOTEWORTHY
USEFUL

IMPROVED TETRIC CERAM UNIVERSAL COMPOSITE RESIN

$180 / Cavifil Intro Kit ($38.80 / ml)
$215 / Syringe Intro Kit ($41.34 / ml)
Ivoclar Vivadent
175 Pineview Dr. • Amherst, NY 14228 • USA
716-691-0010 • 800-533-6825 • Fax: 716-691-2285
www.ivoclarvivadent.us
SELF-ADHERING PATCH FOR CANKER SORE TO COVER & AID HEALING
$9.99 / Box of 6 patches ($1.67 / patch)
Quantum
754 Washington St • Eugene, OR 97401 • USA
541-345-5556 • 800-448-1448 • Fax: 541-345-9796
www.quantumhealth.com
TETRIC EVOCERAM
Universal nano-hybrid composite resin, light cured, 19 colors (11 enamel, 3 dentin,
1 incisal transparent, 4 bleach), & 53–61% filled by volume. CRA data show
volumetric shrinkage of 1.8%. Available in color-coded unit dose & syringe
dispensing. Advantages: 1) Non-sticky material was easy to handle; 2) Polished
to high luster easily; 3) Blended well with surrounding tooth structure; 4) Color-
coded dispensing; & 5) Good selection of colors. Main disadvantage noted
was material was hard to dispense & could crumble if dispensed too fast or was
not pre-heated.
of 22 CRA Evaluators stated they would incorporate this product
82% into their practice, & 91% rated it excellent or good & worthy of trial
by colleagues.
CANKER COVER
10mm circular patch provides physical barrier to surface irritants & delivery of
numbing & healing adjuncts. Contains menthol, beta carotene, & mineral salt.
Advantages: 1) Adhered to mucosal tissue well; 2) Reduced pain/discomfort
quickly; 3) Non-offensive taste; 4) Easy to apply; 5) Promoted healing; & 6) Color
coding identifies surface that adheres to oral tissue. Disadvantages: 1) Rigid so
will not conform to placement in muco-buccal fold; 2) Perceived as thick initially
but thins over time; & 3) Frequently stings ulcer when first applied.
of 20 CRA Evaluators stated they would incorporate this product
75% into their practice, & 95% rated it excellent or good & worthy of trial
by colleagues.

UNIT-DOSE DISPENSING OF VPS IMPRESSION MATERIAL

Aquasil Ultra Material in digit Targeted Delivery System
New dispensing option for Aquasil Ultra LV & XLV, Fast & Regular Set. System
includes syringe dispenser, small automix tips, intraoral tips, & unit dose volumes
of 1.64ml & 2.4ml. Advantages: 1) Easy to use delivery system; 2) Good intraoral
access; 3) Can reduce cross contamination; & 4) Sufficient material for 1 to 2
units. No main disadvantage was noted.
NOTE: Regisel Rigid VPS bite registration material also available in this dispensing.
of 13 CRA Evaluators who use VPS impression material routinely
$15 / 2 Syringes
$2.70–$3.05 / Unit
Dentsply Caulk
72% stated they would incorporate this product into their practice,
& 91% of 20 CRA Evaluators rated it excellent or good & worthy of
38 West Clarke Ave • Millford, DE 19963 • USA
302-422-4511 • 800-532-2855 • Fax: 302-422-3480 trial by colleagues.
www.dentsply.com

TRAINING AID FOR TELEPHONE COMMUNICATION SKILLS

TELE-TALK: LIFELINE TO YOUR PATIENTS
53 page spiral bound notebook addressing telephone communication skills
useful to staff when talking to current & prospective patients. Advantages:
1) Great for training new employees & as a review for current employees;
2) Practical approach covering everyday situations; 3) Easy to read; & 4) Well
organized. Main disadvantage noted was that the material was more common
sense than a presentation of new ideas.
of 25 CRA Evaluators stated they would purchase this product,
$20 / Book
Suzanne Boswell Presentations
80% & 84% rated it excellent or good & worthy of trial by colleagues.
12108 Amoretto Way • Raleigh, NC 27613 • USA
919-845-4189 • Fax: 919-845-4188
www.boswellpresentations.com

Products evaluated by CRA & reported in the CRA Newsletter have been selected on the basis of merit from hundreds of products under evaluation. CRA conducts research at 3 levels: (1) Multiple-user field
evaluations, (2) Controlled long-term clinical research, & (3) Basic science laboratory research. Over 400 clinical field evaluators are located throughout the world & 40 full-time employees work at the institute.
All professional staff volunteer their time. A product must meet at least one of the following standards to be reported in this publication: (1) Innovative & new on the market; (2) Less expensive, but meets the use
standards; (3) Unrecognized, valuable classic; or (4) Superior to others in its broad classification. Your results may differ from CRA Evaluators or other researchers on any product because of differences in
preferences, techniques, batches of products, & environments. CRA FOUNDATION® (CRA) is a tax-exempt, nonprofit education & research organization which uses a unique volunteer structure to produce
objective, factual data. All proceeds are used to support the work of the CRA FOUNDATION®. ©2006 This Newsletter or portions thereof may not be duplicated without permission of CRA. Annual English
subscription $65 in U.S. & $65 (U.S. Funds) in other languages &/or countries, or $7 per issue.