Dr Michael B Lewis

Porcelain veneers are custom-built porcelain shells that bond to the front and biting surface of teeth. Porcelain veneers are extremely conservative, and often require only minimal removal of tooth-structure. Under the right circumstances porcelain veneers are extremely durable, long-lasting restorations. They can alter the shape, colour, length and width of a tooth - achieving a dramatic difference to your smile.

Like dental crowns, a veneer can alter the colour, shape and appearance of a tooth when viewed from the front. It helps to compare a veneer to a “fake nail”, while a crown encompasses the whole tooth like a “thimble” which covers the entire finger. If only a cosmetic change is required veneers are may be the most conservative choice as they require less tooth removal than crowns. This is for two reasons: 1. Veneers only cover the part of the tooth that is visible to the outside world - hence the surface between the teeth and on the inside of the mouth can often be left untouched. 2. Veneers need to be enamel-bonded hence are quite superficial - Whilst a crown stays in place by height and taper of the crown preparation, a veneer preparation is non-retentive and relies entirely on the strength of adhesives. A veneer is a thin shell of ceramic and borrows its strength by being glued to the underlying enamel. When preparing a tooth for a veneer, the dentist must not prepare the tooth into dentine, as this will compromise the bonding of veneers and their associated longevity. If there is a functional reason that a crown may be required (i.e. heavily filled tooth or cracks in residual tooth structure) or enamel is not present at the gum-line (such as teeth with gum-recession) then a crown may still be the best choice. Also in the case of drastically discoloured teeth (such as tetracycline staining) then crowns may still be preferable over veneers. This is because crowns are generally thicker and have an increased ability to hide severe discolouration.

A Prosthodontist is a board-registered specialist in restorative treatment, including crowns, veneers and bridges. Any other stated qualification (i.e. cosmetic dentist, neuromuscular dentist, etc) is a self-dubbed title and just means the dentist has an interest in that procedure. It would be reasonable to expect that a Prosthodontist would be more skilled in both the diagnostic and procedural aspects of dental veneers. They are also highly aware of the biological costs of such procedures and will discuss other suitable, conservative alternatives where appropriate.

Treatment of a tooth with a veneer generally takes two visits which are three weeks apart: 1. At the first appointment, the tooth is shaped to receive a veneer. The tooth is shaped with a 0.5-0.7mm reduction from the final tooth outline in order to create space for the future veneer. At the conclusion of this appointment we make you a temporary veneer so that you can smile, talk and eat as well if not better than you did before while the final veneer is made. 2. At the second appointment the veneer is tried-in, adjusted and cemented. There is generally a three-week space between the preparation and cementation appointment - this is the time it takes to get a premium lab to make dental veneers that we would be comfortable to put our name to.

At Queensland Prosthodontics our focus is to produce the best veneerspossible for our patients - that is use the best materials, techniques and dental technicians we can source. If sending Dental work overseas or using chair-side milling machines improved our quality we would do it! Unfortunately this is not the case and all these approaches do is increase the profit-margin for the treating clinician - not the quality for the patient! Dental Laboratories that make “cheap veneers and crowns” often send their work to China (such as Southern Cross Dental Laboratory), use non-skilled labour or mill the veneers in the dental office using a CNC machine. Each of these cost-cutting measures compromises the longevity, biocompatibility and aesthetics of a crown. “Same –day veneers” are made in the dental surgery by a milling machine (i.e. Cerec, E4D). These veneers are literally carved out of a solid block of ceramic that is one flat colour. These types of restorations only take one appointment and are cheaper as they eliminate the expense of sending work to a dental laboratory. There are a number of drawbacks to this treatment approach: • Same-day veneers tend not to fit as well which is a problem for gum inflammation, dental decay and tooth-sensitivity. • They don’t look like natural teeth - the are milled out of a sold block of ceramic, hence they are one solid colour and tend to be quite opaque. • Milled ceramic requires a minimum thickness that is thicker than a cast-veneer, hence tooth-reduction has to be more aggressive. All our veneers, crowns and bridges are hand-made by premium dental laboratories and there is a fair bit of skill that goes into each and every tooth. As such our dental technicians charge a premium for their time, skill and use of the best materials and this cost is reflected in our fees.

If a veneer prematurely comes loose then one would question how adequately the adhesive has been applied to the tooth and/ or veneer. If this happens on multiple occasions then we would be suspicious that the dentist was a bit heavy-handed with the tooth preparation and the veneer is in-fact bonded to dentine. In theory veneers should be preferablyenamel-bonded. Unlike Dentine, enamel is not a living structure and cannot dissolve the bonding layer applied with dental adhesives. A second factor is ceramics and enamel are rigid, whilst the dentine is flexible. When Enamel and ceramics are bonded together they share strength from each other. When ceramic is bonded to dentine, the dentine can flex whilst the ceramic cannot resulting in eventual fracture of the adhesive layer and premature de-cementation. If this is the case often the only solution is to replace the veneer with a crown and extend the preparation underneath the gum line.

Having dental work done in developing-countries such as Thailand, Bali or India is obviously far less expensive than in Australia. Generally it is impossible to talk a patient out of going down this path as they view dental treatment as a “commodity" as opposed to a “skill-based service”. They think they are getting “like-for-like” for a fraction of the cost - but this is far from the case. Many overseas clinics have opulent waiting rooms and operatories which give the impression of quality however if we recall patients can only judge the quality of an experience, not the technical quality of the dental work they are receiving. Firstly it is important to state that the only thing that is cheaper overseas is labour. The cost of high quality materials (i.e. gold, branded ceramics) and main-brand dental components (i.e. Straumann, Nobel, Astra, etc) is standardised across the globe. So there is a baseline cost that cannot be avoided without using dodgy materials or counterfeit implant components. If the price of a procedure seems too good to be true, it probably is! It would be a falsity to say that Australia is the only place where quality dental care exists. However if you have a crown done in the town where you live the clinician is medico-legally accountable for their work. They will continue to see it year after year. If it fails you are likely to go back to them. In the case of travel-dentistry no-one is accountable. These crowns, bridges and implants only have to last the duration of your stay in their country. In the event of a dental emergency it is unlikely you will have the time or finances to drop everything and fly back to the country where you were treated to have that dental work rectified. In the event of negligence it would be impractical to take action against an overseas clinic with a foreign legal system. Clinics that hunt for dental tourism know this and exploit these loopholes. As I said before - it is a near impossibility to talk a patient out of going down the path of overseas dentistry if that is what they have set their mind to. And whilst there may be success stories I am unaware of them. In a nutshell it is all about risk - crowns, bridges and implants are irreversible, invasive procedures that require careful monitoring and maintenance for the duration of their lifespan. In the case of overseas dental work no-one is accountable and in the event of failure you will wind up in a worse predicament than when you started. Any initial savings pale in comparison to what it may cost to fix up such work.