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JADA Continuing Education

An Ethical Quandary

Background. There is a clinical trend of using porcelain veneer restorations (PVRs) for the correction of malaligned anterior teeth. Use of PVRs for this purpose raises clinical and ethical dilemmas.

Types of Studies Reviewed. A literature review of four different topics (PVR preparation, enamel thickness of anterior teeth, dentinal bonding adhesive effectiveness and PVR long-term success) was conducted to determine the optimal preparation for a successful PVR. The amount of tooth malalignment that may be corrected with a PVR without adversely affecting its success was calculated.

Results. The optimal preparation for a successful PVR may have dentin exposed in the body of the preparation. However, most of the preparation must be in enamel, and all the margins must end in enamel. The strength of a dentin bond varies greatly owing to a multistep, technique-sensitive cementation process and is weaker than an enamel bond. It is not possible to correct atypical gingival esthetics (uneven gingival margins, uneven papillae, short papillae and bulbous gingivae) resulting from malaligned teeth through use of PVRs.

Conclusions and Clinical Implications. Aligning a healthy tooth with a PVR is not a conservative procedure and more conservative treatment options (such as orthodontics, bleaching, direct bonding and enamelplasty) should be offered to the patient. In addition, the inability to restoratively improve gingival relationships with PVRs may result in achieving less-than-optimal esthetics. A clinician should present only treatment options that involve predictable, conservative restorations or that preserve healthy tooth structure. Aligning teeth with PVRs may create ethical dilemmas that can be resolved with the help of the American Dental Association Principles of Ethics and Code of Professional Conduct.

Key Words: Esthetics; enamel bonding; dentin bonding; porcelain veneers; orthodontics; ethics

Abbreviations: CEJ: Cementoenamel junction • IP: Interproximal papillae • PVR: Porcelain veneer restoration