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Quo vadis, esthetic dentistry? Ceramic veneers and overtreatment—A

cautionary tale

Article in Journal of Esthetic and Restorative Dentistry · November 2021

DOI: 10.1111/jerd.12838

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Received: 13 October 2021 Accepted: 3 November 2021
DOI: 10.1111/jerd.12838

CLINICAL ARTICLE

Quo vadis, esthetic dentistry? Ceramic veneers and

overtreatment—A cautionary tale

Ronaldo Hirata DDS, MS1 | Camila S. Sampaio DDS, MS2 |

Oswaldo Scopin de Andrade DDS, MS | Sidney Kina DDS, MS4 | 3

Ronald E. Goldstein DDS5,6,7,8 | Andre V. Ritter DDS, MS, MBA, PhD9

1
Department of Molecular Pathobiology, New York University College of Dentistry, New York, New York, USA
2
Department of Biomaterials, School of Dentistry, Universidad de los Andes, Santiago, Chile
3
Advanced Program in Esthetic Dentistry, SENAC University, S~ao Paulo, Brazil
4
Department of Esthetic and Adhesive Dentistry, Catholic University of Murcia, Murcia, Spain
5
Private Practice, Atlanta, Georgia, USA
6
The Dental College of Georgia, Augusta University, Augusta, Georgia, USA
7
Prosthodontics, School of Dental Medicine, Boston University, Boston, Massachusetts, USA
8
Comprehensive Dentistry, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
9
Department of Cariology and Comprehensive Care, New York University College of Dentistry, New York, New York, USA

Correspondence
Andre V. Ritter, Professor, Department of
Cariology and Comprehensive Care, New York
University College of Dentistry, New York,
NY, USA.
Email: andre.ritter@nyu.edu
Abstract
The increased emphasis on orofacial esthetics, experienced both by dental profes-
sionals and the lay public, results in an environment where overtreatment can easily
occur. Patients on the one hand feel pressure from esthetic norms that are often
unrealistic, while dental professionals are compelled to deliver immediate results
many times without considering what is best for the ill-informed patient. This article
is an illustrated cautionary tale against overtreatment disguised as esthetic den-
tistry. Representative clinical examples illustrate how porcelain veneers are used
without following sound operatory principles, as well as how these cases have been
resolved.

KEYWORDS
dental esthetics, esthetic dentistry, esthetics, minimally invasive dentistry, overtreatment,
veneers

1 | I N T RO DU CT I O N esthetics. These elements are interdependent, and should be

Esthetic dentistry has been an area of interest for dental professionals
and the general public for many decades. The smile is perhaps the
most universal non-verbal communication tool, instantly conveying
emotions and transcending languages, cultures, and time. Since
orofacial esthetics is integral to a pleasant and harmonic smile, there
1,2
has long been a need for esthetics in dentistry.
Intraoral esthetic dentistry encompasses elements of pink (soft
tissues, gingiva, prosthetics) and white (teeth, restorative materials)
supported by the periodontium and various other orofacial elements.
There is no way of achieving optimal esthetic dentistry if these multi-
ple structures are not considered globally. In that context, we as a pro-
fession advanced esthetic dentistry significantly over the last 40+
years.3
While there is no question about the evolution of dental materials
and techniques supporting esthetic dentistry (too many to list here), it is
also important to recognize that the basic principles of non-maleficence
and preservation of tooth structure are sometimes challenged in the

J Esthet Restor Dent. 2021;1–8. wileyonlinelibrary.com/journal/jerd © 2021 Wiley Periodicals LLC. 1

2 HIRATA ET AL.

name of achieving an esthetic result at all cost. However, health and
tooth preservation should never be compromised in order to obtain an
immediate, short-term esthetic outcome. Sometimes sound tooth struc-
ture must be removed so as to achieve an adequate tooth preparation
resistance and retention form, but the principles of tooth preservation
should always be respected. Additionally, sound case selection and clini-
cal technique should always be exercised for any intervention in den-
tistry, but perhaps more importantly for situations where treatment is
being rendered to achieve an esthetic result, because the consequences
of not doing so can be catastrophic. To paraphrase Oscar Wilde, “it is
4
always with the best intentions that the worst work is done.”
Ceramic veneers are extensively used in esthetic dentistry since
they were introduced in the early 1980s.5–7 The possibility to adhere
partial ceramic restorations by etching procedures opened a window
6,8
of possibilities, and many of the principles applied today when
utilizing this treatment modality remain unchanged, such as enamel
and ceramic acid etching techniques, silanation procedures, and the
use of resin-based cements for bonding. When correctly indicated
and utilized, the conservative intra-enamel tooth preparation afforded
by the veneer technique presents an excellent alternative to the regu-
lar “full crown” preparation, which could frequently include endodon-
tic treatment and a post-and-core element. Additionally, “no-prep”
veneers have been used as it was initially proposed by Calamia,5,9
whereas no preparation has to be made on the dental structure prior
to fabrication and bonding of the veneers in most cases.
Despite the extensive documentation of the appropriate case
selection, material selection, and technique for ceramic veneers, over
the years many authors have alerted about a tendency of excessive
ceramic veneer treatment. These excesses may include recommending
and performing veneers when they are not needed, or when an

F I G U R E 1 (A–D) Case 1. (A, B) Show how the patient presented to the office; cracks were observed after only 3–4 months of placement of the
second set of veneers. Lower images show how gingival overcontour and volume excess on the cervical area led to gingival bleeding and inflammation

F I G U R E 2 Case 1. (A) Shows the preparations of the patient's teeth after removal of the veneers; (B) shows the new set of veneers made for
the patient. (C, D) Show healthy gingival contour, with no excesses, gingival bleeding or inflammation
HIRATA ET AL. 3

FIGURE 3 Case 2. Initial photos of the smile, plus buccal and occlusal views of the patient's teeth

F I G U R E 4 Case 2. (A) Shows preparations of the patient's central incisors, preserving the enamel closer to the cervical area. (B) Shows initial tissue
health after 1 week of cementation. (C) Image shows healthy gingival contour after 3 months, and (D) reveals good gingival health after 10 years
4 HIRATA ET AL.
alternative, even more conservative treatment option such as tooth
whitening or composite resin bonding would have been preferred,
particularly for very young patients but also for patients of all age
groups.10 But even more concerning is when treatment is performed
following an inappropriate technique, which can lead to serious con-
sequences for the patient.11 Ceramic veneers are frequently offered
as an esthetic solution with conservative preparations and minimal
intervention. If some problem occurs with the bonded veneers and
they have to be redone, their removal can be very challenging particu-
larly when the preparation was entirely intra-enamel and the adhesion
technique was done correctly. The only way to remove ceramic is by
using burs, even with research being done using a laser to debond
veneers after cementation.11,12
The purpose of this article is to illustrate with clinical examples how
excessive and/or inadequate treatment was provided under the guise
of esthetic dentistry. These examples all include treatment with ceramic
veneers used aggressively as a solution for esthetic issues. We will high-
light common mistakes of ceramic cosmetic treatment, noting ethical
aspects of decision making and clinical technique. We also present how
these cases were resolved, emphasizing sound principles of case selec-
tion and management. Our goal is to outline a cautionary tale and raise
awareness about the need to espouse ethical principles in everything
we do for our patients, including esthetic dentistry.
F I G U R E 5 Case 3. Initial presentation reveals overbuilt porcelain in all ceramic restorations. The resin cement used was bonding all ceramic
restorations due to excess in the interproximal area
1.1 | Clinical example 1
A 24-year-old patient presented with a previous dental history of
maxillary canine-to-canine ceramic veneers, made for the second time
3 months earlier (Figure 1A) by the same provider. Within a short time
after placement of the first set of veneers, the patient already experi-
enced ceramic fractures, gingival inflammation, color change, and
“bulky” contours which was the reason the dentist decided to replace
them. The second set of veneers, which is how the patient presented
to us, also presented cracks after only 3 months, gingival bleeding,
and a very bulky appearance (Figure 1B–D).
In the first appointment, the patient showed the photos of his teeth
before any treatment, which showed normal tooth anatomy and minor
diastemas. He mentioned he looked for a “good dentist” on Instagram,
and decided on his selected doctor because “he had many followers and
artists/patients.” At first, the patient was interested in “contact lenses” or
“no-prep veneers”—instead, the treatment he received was six ceramic
veneers. Burke and Kelleher described how “dental gurus” and “show-
men” could influence dentists' and even patients' decisions, based on the
power of lectures and social media.13 This influence is particularly true for
the younger generations of dentists and patients of all ages.
The new treatment planned corresponded to replacement of the
veneers (Figure 2A–D).
HIRATA ET AL.
1.2 | Clinical example 2
A 25-year-old patient presented with esthetic concerns, discomfort,
and reporting difficulty to adequately clean their teeth. Previous treat-
ment history involved laminate veneers on her maxillary anterior
teeth, made about 2 years earlier (Figure 3A). The patient reported
that the first set of ceramic veneers stayed in her mouth for less than
a year, and due to esthetic reasons and thermal sensitivity in some
teeth, they were removed and a new set was made. The patient's
desire was to remake the veneers for the third time.
Clinical exam showed ceramic veneers with inadequate surface
anatomy (Figure 3B). There was absence of proper tooth morphology,
as well as excess of resin cement in the interproximal areas. Caries
lesions were observed in a few sites (Figure 3C,D). Thermal sensitivity
caused extreme discomfort during air drying of the dental surfaces.
Careful evaluation and vitality test of the affected teeth resulted
in irreversible pulpitis for #8 and #9, which was explained to the
patient. Maxillary canines and lateral incisors had already been treated
endodontically, and due to the poor quality of the endodontic treat-
ment, retreatment was indicated. As the coronary remnant was com-
promised, the teeth were reconstructed internally with glass fiber
posts and dual-cured resin cement.
F I G U R E 6 Case 3. (A, B) Show excess of resin cement in the cervical margins, as well as overcontour. (C, D) Show the patient's teeth after
removal of the veneers (6C) and after teeth preparations (6D)
5
After endodontic treatment and internal reconstruction, the ante-
rior maxillary teeth were prepared for full ceramic crowns due to the
extent of the previous prosthetic treatment. Due to the wide access
to the pulp chambers, laminate veneers could not be indicated any-
more. This required a thin enamel layer close to the cervical area to be
made (Figure 4A).
Six full-coverage ceramic restorations were made in a ceramic
milled system. Good gingival health was observed throughout
10 years of control (Figure 4B–D). It is not uncommon for failed
veneers to require full contour restorations once the initial veneers
fail, particularly if the teeth require endodontic treatment.14
1.3 | Clinical example 3
A 28-year-old patient presented with previous treatment of ceramic
veneers in her maxillary and mandibular arches from premolar to pre-
molar, cemented 15 days earlier (Figure 5A,B). In the initial exam,
ceramics with excessive volume were observed in both arches
(Figure 5C,D), as well as poor margins and overcountour (Figure 6A,B).
Excess resin cement also was observed in the interproximal surfaces.
In addition, dental anatomy was lacking in all teeth.
6 HIRATA ET AL.
The proposed treatment was to remove the previous veneers
(Figure 6C,D) and perform new treatment with better marginal adap-
tation, and enhanced tooth morphology (Figure 7A–D).
2 | DISCUSSION
The disproportionate emphasis on esthetics over function and biology
presents challenges for our profession. While anyone with a dental
degree can “cut” teeth and “paste” ceramic restorations made by any-
one calling themselves a dental technician, it is very difficult for
patients to search for and find a team of health care professionals that
fully understands principles of tooth preparation, periodontal and
pulpal health, function, and durable dental esthetics. In addition to this
difficult “searching” task, the standards of happiness and beauty
portrayed in ubiquitous social media channels challenge our patients'
self-confidence, and in order to alleviate distress caused by body dys-
morphic disorders (BDD), many engage in an all-consuming quest for
15
esthetic treatments and retreatments. This influence is even more
decisive for the younger generations of dentists, since many of them
are inclined to work in the esthetic dentistry field.
As a result of advances in the field of adhesive dentistry and the
widespread availability of pressed and CAD/CAM ceramic systems,
ceramic restorations became extremely popular. This, concomitant
FIGURE 7 Case 3. Final ceramic restorations over the stone model and after cementation
with the explosion of and demand for esthetic procedures using
ceramics, created a type of “ iatrogenic epidemic” where over-
treatment is used under the guise of minimally invasive esthetic den-
tistry. Also, because of the easy access to dental laboratories,
clinicians tend to prefer ceramic restorations instead of other less
invasive treatment options that may require more sophisticated hands
skills as opposed to the cut-and-paste approach. Indirect restorative
procedures are prosthetic procedures that require specific knowledge
about dental and periodontal anatomy,16 and many dentists still face
it as a simple procedure.
In many cases, the simple addition of direct composite resin, with
or without tooth whitening, would be the best option instead of the
more invasive ceramic restorations. Composites are alternative to
ceramic treatment for many esthetic restorations,17 with significant
advantages such as tooth conservation, time savings, and lower repair
and replacement cost.18 As it relates to treatment decisions, Burke
and Kelleher proposed an unscientific but relevant test called “The
daughter's test”—knowing all the risks and advantages of a treatment
option, one should indicate restorative treatments for patients as it
was their own children.13 This test should be routinely utilized.
Another aspect related to ethical decisions in esthetic dentistry
relates to the dentist-patient relationship—to what extent should den-
tists please the patients' desires? In psychology, the Quasimodo disor-
der refers to a dysmorphic disorder where an individual thinks
HIRATA ET AL.
obsessively that they have defects, usually in their face. This phenom-
enon was first described in the late 1800's by Morselli,19 as an obses-
sive compulsive disorder with social reflex. It has been shown that
91% of the patients with this disorder submitted to a plastic surgery
procedure finished the treatment completely dissatisfied.20 In den-
tistry, De Jongh et al. raised a need for dental professionals to recog-
nize patients that are in constant demand for cosmetic dental
treatments and could possibly suffer from BDD, estimated in 15%.21
Compared to an average patient, patients with BDD are nine times
more likely to consider tooth whitening, six times more prone to an
orthodontic treatment, and present five times more tendency to be
dissatisfied with about a recent treatment.21 The term “bleachorexia”
has been coined for the addiction on dental bleaching treatments,
where patients are constantly repeating bleaching procedures and are
always dissatisfied with the results.22 The result of this psychological
aspect is that patients are often retreating dental esthetic restorations
simply because they are unhappy with the results which may be tech-
nically fine (which is not the case in the examples used in this article),
and most of the time due to a psychological anxiety. On the other
hand, dental professionals who are constantly willing to please
patients' desires keep making unnecessary interventions repeatedly,
which ultimately does not improve patient's health or wellbeing.
In the clinical cases described in this article, it is possible to
observe a trend toward overtreatment, which is one of the biggest
threats in esthetic dentistry, as noted on a survey by the American
Academy of Cosmetic Dentistry.23 One comment made by a survey
participant was: “We are developing a reputation of money-hungry
dentists.” As most problems of tooth shape and contour are now
treated with ceramic veneers, there is a strong possibility that in doing
so we are reducing the lifespan of the teeth receiving these suppos-
edly conservative esthetic procedures, given the relationship between
the number of times a tooth is restored and posterior extraction,24
partially because of the repetitive restorative cycle.25,26
Simonsen points out an ethical misconduct in which a thoughtful
consideration of potential harm versus potential benefit is not been
followed by dental professionals.10,27 Dentistry urgently needs role
models and credible teachers able to guide new dental students and
recent graduates, and it is most important that Ethical Esthetic Den-
tistry must be taught before graduation.28
3 | C O N CL U S I O N
Dental overtreatment leading to extensive tooth wear, restoration
overcontour and jeopardized gingival health are occurring more fre-
quently in esthetic dentistry, due to excessive and unnecessary cos-
metic procedures prescribed under the guise of minimally invasive
dentistry. The dentition is being unnecessarily treated when patients
are young, and as a result, young adults are facing a repetitive cycle of
treatments that might finally end in damaged surfaces of what once
was a sound tooth. Every day it is clearer and more important that
dental professionals must start to perform their treatments aiming not
only for esthetics, but also for ethics and health.
7
DISCLOS URE
The authors declare that they do not have any financial interest in the
companies whose materials are included in this article.
DATA AVAILABILITY STAT EMEN T
Data sharing not applicable to this article as no datasets were gener-
ated or analysed during the current study.
OR CID
Andre V. Ritter https://orcid.org/0000-0003-2266-4302
RE FE RE NCE S
1. Goldstein RE. Study of need for esthetics in dentistry. J Prosthet Dent.
1969;21(6):589-598.
2. Goldstein RE. Esthetics in dentistry. J Am Dent Assoc. 1982;104(3):
301-302.
3. Blatz MB, Chiche G, Bahat O, et al. Evolution of aesthetic dentistry.
J Dent Res. 2019;98(12):1294-1304.
4. Wilde O. The Plays of Oscar Wilde. Wordsworth Editions Ltd; 2000.
5. Calamia JR. Etched porcelain facial veneers: a new treatment modality
based on scientific and clinical evidence. N Y J Dent. 1983;53(6):
255-259.
6. Calamia JR. Etched porcelain veneers: the current state of the art.
Quintessence Int. 1985;16(1):5-12.
7. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent
Clin N Am. 1983;27(4):671-684.
8. Calamia JR. Materials and technique for etched porcelain facial
veneers. Alpha Omegan. 1988;81(4):48-51.
9. De Andrade OS, Hirata R, Celestrino M, et al. Ultimate ceramic
veneer: a laboratory-guided preparation technique for minimally inva-
sive laminate veneers. J Calif Dent Assoc. 2012;40(6):489-494.
10. Simonsen RJ. Commerce versus care: troubling trends in the ethics of
esthetic dentistry. Dent Clin N Am. 2007;51(2):281-287.
11. Albalkhi M, Swed E, Hamadah O. Efficiency of Er:YAG laser in
debonding of porcelain laminate veneers by contact and non-contact
laser application modes (in vitro study). J Esthet Restor Dent. 2018;
30(3):223-228.
12. Morford CK, Buu NC, Rechmann BM, et al. Er:YAG laser debonding
of porcelain veneers. Lasers Surg Med. 2011;43(10):965-974.
13. Burke FJ, Kelleher MG. The "daughter test" in elective esthetic den-
tistry. J Esthet Restor Dent. 2009;21(3):143-146.
14. Burke FJ, Lucarotti PS. Ten-year outcome of porcelain laminate
veneers placed within the general dental services in England and
Wales. J Dent. 2009;37(1):31-38.
15. Jefferys DE, Castle DJ. Body dysmorphic disorder—a fear of imagined
ugliness. Aust Fam Physician. 2003;32(9):722-725.
16. Lobo M, de Andrade OS, Barbosa JM, Hirata R. Periodontal consider-
ations for adhesive ceramic dental restorations: key points to avoid
gingival problems. Int J Esthet Dent. 2019;14(4):444-457.
17. Dunn J. Direct composite or bonded porcelain: a clinical choice for ante-
rior aesthetics. J Calif Dent Assoc. 1994;22(4):73-76. 78, 80–1 passim.
18. Nalbandian S, Millar BJ. The effect of veneers on cosmetic improve-
ment. Br Dent J. 2009;207(2):E3 discussion 72-3.
19. Morselli E. Sulla dismofofobia e sulla tafefobia. Bolletinno Della R
Accademia Di Genova. Vol 6; 1891:110-119.
20. Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and
cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e-180e.
21. De Jongh A, Oosterink FM, van Rood YR, Aartman IH. Preoccupation
with one's appearance: a motivating factor for cosmetic dental treat-
ment? Br Dent J. 2008;204(12):691-695. discussion 68.
22. Lee DK, Kastl C, Chan DCN. Bleachorexia-an addictive behavior to
tooth bleaching: a case report. Clin Case Rep. 2018;6(5):910-914.
8 HIRATA ET AL.

23. Goldstein RE. Attitudes and problems faced by both patients and 28. Greenberg JR. A call to all teachers of esthetic restorative dentistry.
dentists in esthetic dentistry today: an AAED membership survey. J Esthet Restor Dent. 2010;22(2):79-81.
J Esthet Restor Dent. 2007;19(3):164-170.
24. Caldas Junior Ade F, Silveira RC, Marcenes W. The impact of restor-
ative treatment on tooth loss prevention. Pesqui Odontol Bras. 2003;
17(2):166-170.
How to cite this article: Hirata R, Sampaio CS, de Andrade OS,
25. Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv
Dent Res. 1990;4:4-9. Kina S, Goldstein RE, Ritter AV. Quo vadis, esthetic dentistry?
26. Elderton RJ. Preventive (evidence-based) approach to quality general Ceramic veneers and overtreatment—A cautionary tale.
dental care. Med Princ Pract. 2003;12(Suppl 1):12-21. J Esthet Restor Dent. 2021;1-8. doi:10.1111/jerd.12838
27. Simonsen RJ. Overtreatment? You bet it is! J Esthet Restor Dent.
2007;19(5):235-236. discussion 37.

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