The Incisal Edge

Martin Kelleher has been a voice of reason and humour in restorative dentistry, I first encountered him when he was a registrar at The London Hospital and I was a grunt of a house surgeon. He helped me out when I was involved in a dispute over the use of a dental chair. I had been up for most of the weekend (oral surgery on call), the dental chairs were brand new and not yet commissioned – therefore in the opinion of a senior member of the restorative staff they were not real and could not be used for the taking of impressions. With typical Connacht firmness and charm (he hails from the Athenry of flying small birds legend) he took me in hand and lent me his surgery and the use of a nurse! Since then his forthright and sound opinions on subjects from the overuse of Gelb appliances through the wedging problems of gold inlays to the poor use of “composhite” influenced my clinical practice.

This book review is nearly two years old but well worth reproducing (without permission), over treatment is not a new phenomenon in dentistry whether it be premature dental clearances, full mouth “rehabs” or “veneereology”; here’s Martin’s take on the latter.

Book Review 
Veneer Visions. By Oliver Reichert di Lorenzen. Quintessence Publishing Co, New Malden, 2009 (522pp h/b, £90). ISBN 978-1- 85097-200-6.

This is a beautiful looking book produced by Quintessence with brief descriptions in English and German.

Page 16 opens with some over prescription for some very minor chipping of upper front teeth with the tooth surface loss being most notable on the upper central incisors. The patient had 10 veneers placed without any description of how this was done or how long they had been in position. A vast amount of red lipstick was added to the visual effect.

The book then starts to degenerate into obscene over prescription. The second case shows a virtually intact smile being over-treated with 14 ‘no prep veneers’. Again, no description is given of what was done, nor indeed any clinical information offered as justification for this amount of treatment.

Page 26 shows a case of probable ‘Sipper’s Gob’, where just the upper central incisors were eroded with no obvious erosion on the lower teeth. Apparently, the patient had her bite opened by 6.5 mm for 14 ‘no prep veneers’. Some directly applied composite, probably to the upper front teeth, could have been justified to treat the incisal erosion, but there can be no clinical justification for the treatment prescribed in which the upper lateral incisors end up being nearly twice the height of the two central incisors.

Page 28 shows a young man who had 28 ‘no-prep veneers’ for some very minor spacing which could realistically have been corrected with a bit of simple orthodontics and some retention. In this reviewer’s opinion, there can be little or no justification for this over prescription and over contouring, when either orthodontics or just simple composite bonding techniques would have produced a perfectly acceptable result.

The bright red lipstick makes another startling re-appearance on page 32, where the patient simply wanted whiter teeth, but instead she had 12 ‘no prep veneers’. A photograph was taken in black and white just to make it absolutely clear that the author never considered anything as obvious as nightguard vital bleaching. Apparently, the referring dentist was so ‘impressed’ (spelt ‘gullible’) that she decided to have 12 veneers herself. The difference in colour between the upper and lower teeth is very obvious on page 35. Simple nightguard bleaching would have done well in this case, with a fraction of the biologic or financial cost incurred with the treatment to cure her of the ‘porcelain deficiency disease’.

The next case was of a good looking, graceful lady in her mid 60s who had, indeed, a bit of darkening and erosion but was treated with multiple veneers which made her look like, in this reviewer’s opinion, as if she had suddenly acquired some very bad, very false, very white teeth.

A case of partial anodontia is presented on page 46 with the patient being treated with six veneers. I cannot see how the veneers placed on top of two prominent canine teeth could have been done with a ‘no preparation approach’ as stated by the author. The anatomy of the veneers were sadly very matt and unlike the natural anatomy of her beautiful natural teeth.

There is a nice case on page 49 of closure of a median diastema with some small bits of porcelain.
There could be some justification for the case on page 51 to improve the visibility with some porcelain veneers but, likewise, simpler techniques of direct bonding would have had the same effect.

The American and media ‘airhead’ obsession with wider buccal corridors appears on page 53 but, mercifully, without too much in the way of bright red lipstick.

Overall, this book demonstrates just how much one can overprescribe the porcelain technique if one is obsessed by doing ‘no preparation veneers’ and wishes to treat ‘porcelain deficiency disease.’ The book will appeal to some and the photography and layout is certainly of very good quality. What is a lot less impressive is an awareness of the probable need for maintenance and that veneers do not last a lifetime (Burke and Lucarotti. Ten-year outcome of porcelain laminate veneers placed within the general dental services in England and Wales. J Dent 2009; 37: 31–38). The book is very much a testament to the statement that ‘if all you have got is a hammer, everything looks like a nail’. There is certainly nothing in here for the thinking dentist but it will probably appeal to ‘airhead’ dentists or gullible patients as an atlas of dental art and nice dental photography. I doubt if a technician will get anything useful out of it technically and clinically as it only offers the briefest of descriptions about the procedures involved.

It is difficult to know at whom this book is aimed. It certainly does not give a balanced view of technique, treatment planning or option planning, including the negative aspects of treatment required for patient consent.

Sadly, the old adage that ‘the front and back of this book are too far apart’ applies.

Martin Kelleher King’s College Hospital NHS Foundation Trust

Page 118 DentalUpdate March 2011