Developing optimal dental aesthetics in a manner that is safe and preservative is a common dilemma faced by dentists and patients alike. The demand for ever-increasing cosmetic procedures has provoked us, here at The Harley Street Smile Clinic, to produce this page – explaining our proven and repeatable workflow, which satisfies today’s cosmetic standards, whilst maintaining an acceptable lifelong prognosis.
The following is accurate at the time of writing and has been written by one of our dentists.
Our experience and history
Within our clinic, all of our dentists are trained to prioritise the health of teeth first and foremost. We differ to other clinics in that we have placed over 40,000 ceramic veneers between us, and this has come from extensive training following initial dental training.
What is a veneer?
A veneer may be defined as anything that is covering something to improve its appearance. Within dentistry, a veneer is a thin layer of ceramic or composite resin placed on the outside surface of one or more teeth. The thickness may be as thin as 0.3mm and may be compared to a false fingernail, or contact lens.
Why would a veneer help improve appearances?
The nature of dental ceramic is such that one is able to create a veneer to any shape and colour, meaning any lack of adequate aesthetics in the natural tooth is compensated for by the ceramic. Depending on how many teeth are improved with veneers, this can drastically change the aesthetics of a smile. Severe discolouration, gaps and lost teeth may be managed in conjunction with veneers, and the specific restorations would be made clear to you by the dentist.
Is there anything else that a veneer can help with, besides cosmetics?
Sometimes natural teeth are not in ideal positions to allow even distribution of bite forces, which can cause teeth to wear, chip and/or break. Teeth also invariably drift over a lifetime, exacerbating the situation. Veneers can help improve your bite by altering the force distribution. This is something that is dependent on your specific dental situation, which can be made clear in our in-depth consultation process.
Are there downsides?
As with most things in life, veneers do not last forever, around 15 years according to the latest in peer-reviewed dental research. After they come to the end of their life, they would need to be replaced at a time of your choosing.
In addition, depending on the type of veneer, reshaping of your natural teeth is usually required, to allow the veneer to fit onto the tooth, and create the ideal aesthetic outcome. We usually aim to preserve around 70-95% of each tooth, which incurs an approximate 5% risk to the nerve within the tooth becoming aggravated as a result of the procedure. This is a low percentage; however, it is worth knowing about and understanding.
Does it hurt?
You will always be made ‘numb’ for the appointments, so it is not painful at all. We use a local anaesthesia that lasts around 3 hours and removes all sensation of pain.
What are the alternatives?
Veneers can be made from composite resin, which is an adhesive plastic resin applied directly to the tooth, as opposed to ceramic veneers, which are custom made by hand in a dental laboratory. Composite resin has the benefit of needing very little reshaping of the natural teeth and being more economical. The downsides are that they last 6-8 years, and need more maintenance, in the form of repolishing every two years and better than average home care. The material strength is also weaker than ceramic.
Other alternatives could be not having any treatment, whitening your teeth, having braces in some form, and/or seeing a specialist dentist if there is a specific area you need support in.
Materials: what is the difference between porcelain and ceramic?
Porcelain is usually a term used to refer to inorganic materials containing kaolinite (clay). This term has been adopted for describing veneers, and whilst this may be correct in some instances, the vast majority of dental materials no longer contain natural kaolinite. Ceramic refers to any inorganic material produced by the application of heat. This would encompass the previously known porcelain, metal-based ceramic and the more modern synthetic materials. For the purposes of clarity, the term ceramic is used throughout this document.
Which ‘ceramic’ do dentists use?
We use a range of ceramics depending on which will give the most optimal outcome. Ivoclar Vivadent produces IPS E.max Press and Empress, which are highly popular and effective materials. There are alternatives which we have seen excellent results from, namely Dentsply Sirona’s Celtra Press and GC Lisi. All three of these are regarded as reinforced ceramics in that they are composed of a lithium disilicate interspersed with silicon dioxide. Both of these components are synthetic and impart excellent strength in thin section as well as being highly aesthetic.
Whilst we are constantly staying abreast of new developments in ceramic technology, we believe that the material itself will not create the smile you desire, but the skill and quality of communication between the dentist, ceramist and you the patient.
There are alternative brands such as Lumineer, MAC, or Snap-on Smile type veneers that are variations on the classical process for veneers. Lumineer and MAC are brand names of variants of reinforced ceramic as described above. They are not layered in multiple layers and – as such – they are able to be very thin. However, they usually lack a lifelike quality and natural appearance. They may be branded as no-prep veneers, meaning no reshaping is done, allowing a theoretically reversible treatment. The reality is that in 99% of people, without some reshaping, final aesthetic results would be compromised – due to the limitations in the ceramic on an improperly shaped tooth.
Secondly, ceramic veneers are chemically bonded to the tooth underneath, meaning that removal of the veneer would require the use of a dental drill, which would inevitably affect the underlying tooth structure. Therefore, there is no truly reversible dental treatment that involves chemical bonding. This also applies to composite resin veneers.
Computer-aided design is used across dentistry in various shapes and forms, and this allows precision construction of certain stages. It is widely accepted within the dental community that the final stages of veneer/crown/bridge customisation require the work of a skilled ceramist, and this cannot be replicated by a CAD/CAM milling machine, such as those promoted by CEREC (Chairside Economic Restoration of Esthetic Ceramic, or Ceramic Reconstruction), E4D or Planmeca. These systems are useful for certain applications, however, for front teeth that require attention to detail, human touch cannot be replaced.
What is the process?
The process takes 4-6 weeks and may take longer depending on your current dental health and presence of missing or damaged teeth.
A consultation is our starting point to understand firstly what your aims are for your teeth and why you feel they might need improving. A dental health check comprises with an oral cancer screen, gum health screen, decay detection, and comprehensive bite assessment. We ordinarily ask our patients to move their teeth in ways to simulate chewing, so we can assess and record your current bite movements, such that we can make a plan to change something that is not working well, or maintain what you have and make it look better.
Following this, we always take clinical photos (below), so we can discuss your options with you.
The first stage is to take X-rays and create a 3D preview of what your new veneers will look like. This is the first of a ‘trial run’ to see the expected results before committing to a design. During this phase, whitening is often carried out to optimise the brightness of your natural teeth, so that the ceramic veneers match your natural teeth. X-rays are taken using ionising radiation to a level that is as low as possible, and each X-ray is around the radiation dose of eating a single banana.
Impressions are taken to reproduce your teeth outside of your mouth. Elastomeric materials are common within dentistry and can be in a vinylpolysiloxane, polyether, or hydrocolloid. Some situations necessitate a ‘bite fork’ to be taken, which is a piece of apparatus that records the position of your bite plane with the horizon, as well as the position of your upper jaw to the jaw joint. This allows us to replicate your jaw movements and predict what and how changes to your smile would influence your bite dynamics.
This visit is where your teeth are reshaped according to the final result you would like to achieve, and temporary veneers are fitted. These are a fixed prototype of what your teeth will look like, and gives you a chance to assess the shapes, colour and overall aesthetics through a two week period. During this time, we will ask for your feedback on whether you think we should change anything for the final ceramic veneers. You can change anything at this stage, and we will not proceed in custom manufacturing your veneers until we have your approval.
After the required changes are made to your temporary veneers, these are copied in ceramic. It is important to note that each ceramic veneer is handcrafted with multiple layers of ceramic, according to the precise colour and shade that has been chosen. This then goes through modifications to match your approved temporary veneers and is verified to be safe in accordance with your bite and gum positions. These are then returned to the dentist for inspection prior to your appointment and are shown to you prior to permanently cementing them. This is to allow you to give final approval, and if changes are needed, they can be made at this stage.
When approved, they go through a chemical disinfection and acid etching process, which enables a chemical adhesion to your tooth. The chemical reaction involves bonding an organic material (the tooth), to the cement (resin based) and then to the inorganic ceramic. Many different bonding systems exist, and this is a technique sensitive step, meaning it is critical to the long term survival of your veneers. The bonding agent we use is considered a Gold Standard within dentistry and has over 30 years of clinical data proving its efficacy.
- Recovery and maintenance
You will usually feel normal after a few days, and full healing will be complete in around 3-4 weeks. Routine dental health checks are advisable to ensure that cleaning is at an optimum and the rest of your teeth are being maintained. Ceramic veneers should be maintained as you would for natural teeth, with interdental cleaning being a favourable habit to adopt, by either using floss, interdental brushes or irrigators.
How would I find the best dentist for veneers?
The three main schemes in the UK are NHS, insurance-based and fee-for-service. Generally, the first two are aimed at maintaining dental health and function only, which excludes dental veneers for the purposes of cosmetic improvement. The fee-for-service or private model encompasses elective treatments, such as dental veneers.
There is no specialist register for cosmetic dentistry in London, and such procedures are not taught within dental schools in the UK. Therefore, it is worth doing research into the specific extra training and experience of any clinic that offers dental veneers. Your first set of veneers is an important decision to make, and we suggest choosing carefully!
To gauge their level of experience, have a look at their portfolio of previous cases, and reviews from recent patients. In addition, the British Academy of Cosmetic Dentistry and the British Academy of Aesthetic Dentistry have search tools where you can locate any dentist that is part of the academy.
Dental tourism is a growing industry, and many overseas providers are promoting dental treatment at large discounts. As with any dental treatment, the General Dental Council in the UK heavily regulated the proficiency and qualifications of a dentist to practice within this country. In addition, the protection of patients is their ultimate priority, and this protection would not exist if the treatment was sought outside the UK. This may pose a significant problem if there were any concerns regarding the treatment provided. Finally, whilst there are excellent dentists worldwide, the UK has always held internationally recognised teaching and research institutions, which provide undergraduate dental training at some of the highest standards in existence.