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The materials driving esthetic restorations
Allison M. DiMatteo, BA, MPS
New laboratory materials designed for anterior restorations boast formidable strength and outstanding esthetics. But do they live up to the hype? Are tried-and-true materials really fading into the twilight? Inside Dentistry looks at the changing face of anterior restorations and how dentists can make the most of these material advances to achieve predictable function and optimal esthetics.
The Anterior Restoration in 2016
Since the financial crisis of 2008, dentistry has experienced a downturn in elective cosmetic procedures—including indirect veneer restorations. Concurrently, industry observers have commented that traditional porcelain veneers have lost traction in the restorative landscape due to their cost prohibitive nature. However, regardless of the introduction of direct and indirect material innovations, that phenomenon has more to do with socioeconomics than material characteristics. In fact, dentists currently have multiple material options available that cost no more than the original materials that were introduced to create ideal esthetics in veneers. Simultaneously, patient demand for preventive, functional, and minimally invasive treatments has supported more thoughtful selection of the most appropriate patient- and case-specific restorations.
“It’s not a materials question. It’s really a socioeconomic issue for the patient,” explains Michael Gaglio, DDS, senior vice president of Ivoclar Vivadent North America. “Veneers have never been covered by insurance and are considered an elective and cosmetic procedure, even though we all know that by practicing conservative, esthetic dentistry, we can restore function and esthetics with veneers and preserve tooth structure.”
Due to attrition or wear of the incisal edges, a fair number of patients could benefit from veneers, explains John Weston, DDS, director of the Scripps Center for Dental Care, so the functional discussion or rationale (ie, improving how teeth work together and protect each other) makes a very compelling argument to treat versus wait. Dentistry is following trends of more conservative treatments, and most patients would prefer not to have their teeth shaved down, he says. Coincidentally, material improvements have helped make more conservative veneer preparations—if any preparations are needed at all—a reality, enabling fabrication using thinner, stronger ceramics.
“Today, dentists and patients are looking at treatments for reconstructive needs and factors other than strictly esthetics, and veneers still provide a viable solution with the versatile range of material options available,” explains George Tysowsky, DDS, senior vice president of Technology and Research for Ivoclar Vivadent. “They can be used very effectively for strong, no-prep veneers with high edge strength; bonded to reinforce the teeth; and for minimally invasive occlusal rehabilitation with tabletops/onlays design.”
Among today’s material innovations for anterior indications are high-translucency and multi-layered zirconia options for monolithic rather than cut-back and layered restorations. At least at this point, high translucency zirconias are not quite as translucent as lithium disilicate, explains John Burgess, DDS, MS, professor and assistant dean for Clinical Research at the University of Alabama at Birmingham. However, if dentists pick their cases well and don’t require a material with very high translucency for the anterior region, then they can use these materials predictably, he says.
Economically speaking, monolithic restorations may be less expensive than fully layered porcelain, but the actual cost savings to the patient may not be as significant, explains Amanda Seay, DDS, an accredited member of the American Academy of Cosmetic Dentistry. Whether monolithic or fully layered, the same level of treatment planning and care (ie, smile design, wax preparation, tooth preparation, provisionalization) is required as part of the overall treatment delivery, she says.
The question of material selection for cost efficiency then becomes one not of choosing between one indirect material or indirect restoration, but rather of choosing between a direct versus indirect restoration based on the indication (ie, direct composite veneer versus an indirect ceramic veneer), experts suggest.
“For quite a few years, ceramic veneers were the ultimate solution for anterior esthetics. They still are beautiful, but a changing economy has had an effect,” says Jon Fundingsland, professional services manager for 3M Oral Care. “Several clinicians that I work with have told me they are doing fewer ceramic veneers and more composite veneers due to the cost differential.”
That cost differential affects patients and dentists alike, and the introduction of universal nanohybrid direct composites (ie, those that can be used in the anterior and posterior due to their esthetics, strength, smoothness, stain resistance, and polishability) represents cost savings on multiple levels, explains Jason H. Goodchild, DMD, clinical education manager for DENTSPLY Global Restorative.