Many clinicians embark on veneer cases with a high level of confidence, anticipating success when considering that tooth preparation and scanning or impression are simple and quick. However, while often considered a minimally-invasive procedure, veneers are not without significant risks, both to the patient and the practitioner. Indeed, the Dental Board of Australia has noted such risks in its communications to registrants, stating that:

“…procedures such as tooth veneers can be major life-long undertakings that are not risk free”.1 

The Board also notes that dissatisfaction with the outcome of veneer treatment can result in a notification being made about a practitioner’s care. A complaint may not necessarily be evidence of a clinical error or poor treatment. 

In other words, complaints and claims relating to veneer treatment may be based on subjective rather than clinical factors. In the absence of sound clinical grounds for a patient being unhappy with the treatment they have received, it can be incredibly difficult to determine what should be done (if anything) to assist the patient and attempt to resolve those concerns. This is especially so when the clinician has excellent records and the photographs of the completed case suggest the patient has a significantly improved and highly aesthetic smile. At Dental Protection we regularly speak to members who have encountered difficulties with a veneers case and who are seeking a quick resolution. Unfortunately, as we will explore below, quick fixes are not always possible.

We encourage clinicians to consider even the apparently simplest single or double veneer case as complex dentistry in the first instance. If the case proves to be simple after all, this can be a bonus. Approaching such treatment via this paradigm will assist in ensuring careful planning, consent, and clinical treatment all occur. This is especially important given most veneer treatment involves some tooth preparation and is therefore irreversible in nature.

What problems can arise in veneer cases? 

Dental veneers have a high probability of survival overall according to the dental literature, with a recent paper noting this to be greater than 90% over more than ten years.2. However, veneer survival does not necessarily equate with success, as many veneers may survive intraorally yet exhibit staining, chipping or other cosmetic or functional issues that have yet to lead to their loss. The significance of such complications can be remarkably subjective with some patients accepting these problems as an inevitable part of an ageing dentition, while others voicing immense dissatisfaction over the slightest irregularity.

Therefore, problems might best be examined from two perspectives – clinical factors and human factors. These factors may come into play either in isolation or together. 

Clinical factors 

Complaints and claims can arise from a variety of clinical factors, including: 

• An obvious poor aesthetic outcome – where the size, shape, shade, and other characteristics of the veneers do not sit harmoniously within the remaining dentition. Given that the primary reason for placement of veneers is to improve the appearance of a patient’s smile, any perceived failure to achieve this is likely to result in disappointment, frustration and (at times) a complaint.
  
  As anterior aesthetics are a combination of the interplay between hard and soft tissues, the veneers alone may not be the primary source of an aesthetic concern. At Dental Protection we have encountered cases of the veneers themselves looking ‘perfect‘ to a patient in terms of shade and shape (by the patient’s own admission) yet being rejected based on a perception of a lack of symmetry due to a difference in height between the gingival margins of the 12 and 22 teeth. Ironically, such a height discrepancy had never been raised by those patients as part of their concerns about their smiles until everything else was harmonious and beautiful.
  
  Patients often request very white veneers in order to obtain a more youthful, ‘Hollywood’ smile. Despite mock-ups being made to show patients and seek their approval, the actual aesthetics of such a smile can come into question on the day of issue or soon after with many instances of veneers being rejected because they seem too white, despite such a shade originally being demanded by the patient contrary to the dentist’s recommendations.
  
  To avoid the risk of shine through of darker underlying tooth structure, it is imperative that the dentist provides the laboratory with photographs of the teeth before and after preparation with accompanying shade tab information visible. This will enable the technician to select a material that will adequately mask the discolouration, ideally without appearing too opaque in the mouth. It is wise for the clinician, and often the patient, to consult with the laboratory to best determine the minimum thickness of ceramic necessary for masking, as this may impact on the depth of tooth preparation or may result in a decision not to proceed if this risks loss of too much tooth structure.
  
  Similarly, where direct veneers are placed, an opaquing layer may be required to mask out underlying tetracycline staining or similar heavy discolouration. Space needs to be allowed for that layer and/or the use of an opaque base shade of composite. Consideration of the space available for this needs to occur prior to embarking on the case as it may not be possible to adequately mask tooth colour without considerable bulk or placement of a dull, lifeless veneer. Loss of colour stability, marginal staining, minor chipping, air bubbles and dulling of the veneer surface are all common over time. This can result in patients expressing dissatisfaction with aesthetics from around 12 months after their placement. We recommend regular follow up of these cases and that a discussion around ongoing maintenance requirements for veneers occurs as part of the consent process.

• Premature failure. Veneers (whether composite or ceramic) can debond due to a failure in the adhesive (adhesive failure), a failure within the material itself leaving a thin layer of material attached to the tooth (cohesive failure) or a combination of the two. When more than one veneer debonds, patients may then have (quite understandable) doubts about how long the remainder of the veneers will last and we have found patients lodging a claim for the replacement of all six or eight veneers when only one has failed to date. Members can encounter difficulties explaining to patients the reasons for premature failure, especially if those risks were not discussed in the consent process and where instead a prediction was given that the veneers would typically last perhaps five or ten years.
  
  Failure can also arise from the development of cracks within the restorative material, staining in those cracks or around the margins, chipping of incisal edges or (typically) distoincisal corners, loss of surface lustre, colour change, marginal leakage, and caries. 
  
  At Dental Protection we strongly recommend that any warranty provisions on aesthetic treatments are clearly discussed and documented at the time of the consultation and planning of the case. The conversation should be supported with written information about the risks of failure, the costs of repair or replacement and who will be responsible for those costs should they arise. If a clinician provides a warranty or prediction of the lifespan of the veneers, any conditions inherent to that estimate ought to be expressly noted. For example, in patients with past tooth structure loss due to attrition or erosion, the clinician ought to expressly note the risks of parafunctional and dietary factors respectively and provide guidance on mitigation strategies during the consent process. We have encountered cases of dentists making patients nightguards to protect veneers from bruxism-related nocturnal forces, but where the use of that protection seems sporadic at best. Who is responsible for any failure then? The patient may insist that the guard was worn or was unable to be worn due to being too tight and uncomfortable, while the dentist may insist that the non-compliance has caused a debond without knowing for sure that this is the case.

• Pulpal symptoms. It can be difficult explaining to a patient why one or more of their teeth are sensitive following veneer preparation when the teeth had been asymptomatic until treatment began. Although prolonged sensitivity following veneer preparation and/or placement is uncommon, in situations where sensitivity persists for weeks it may become necessary to consider endodontic intervention.
  
  For this reason, at Dental Protection we recommend that the risk of pulpal symptoms arising during or subsequent to veneer placement should be expressly discussed with the patient as part of the consent process. That discussion should outline the implications of pulpal symptoms arising, who will be responsible for any costs, and also whether it may be necessary to then revise the restorative treatment plan.
  
  It goes without saying that dental veneers were once a stronghold of minimally invasive dentistry but seem to have diverged among some clinicians to become significantly invasive. It is becoming more commonplace for clinicians to prepare almost a ‘three-quarter’ preparation on anterior teeth so that multiple issues (such a slightly protruded, rotated or otherwise misaligned teeth) can be addressed restoratively without additional orthodontic correction. While this may seem helpful in terms of minimising time and cost for patients, aggressive tooth preparation is more likely to result in biological complications like pulpitis, besides causing obvious weakening of the teeth themselves.
  
  As with any planned crown and bridgework, preoperative radiographic assessment of teeth to be restored (and adjacent teeth where their condition might impact the treatment plan) is a routine aspect of planning but also best practice. It is also essential to establish the baseline condition of teeth prior to treatment with pulp sensibility testing and probing considered in conjunction with radiography to adequately establish the preoperative pulpal status of any teeth to be treated.

• Gingival recession and exposure of margins. This is more commonly seen in patients with thin soft tissue biotypes, active periodontal disease, aggressive toothbrushing habits or in bruxers. Careful management of the gingival margins may reduce this risk and careful atraumatic finishing of margins is essential, ensuring removal of all adhesive excess/flash to avoid later marginal inflammation and plaque traps.
  
  The possibility of recession occurring over time can be significant and cause patient dissatisfaction, especially in patients with a high smile line or with discoloured roots. Consent processes should include a discussion of this risk, its management, and how in certain situations replacement of the veneers in the future could be required simply due to the patient’s natural ageing.

• Tooth movement and/or poor fit. There remains some debate around whether the breaking of contact points between anterior teeth may allow tooth movement between the preparation and placement of indirect veneers. Certainly, there should be minimal movement if contact points are not opened during tooth preparation, but some tooth movement over time is always possible. This does not seem to be an issue for direct veneers for obvious reasons.
  
  We are aware of cases where a clinician has gone to fit veneers, only to find (after adhering several of them) that the remaining veneers won’t seat. This may be from tooth movement between appointments, inaccuracies between the impression/scan and the working model, path of insertion issues, clinician error in veneer placement, or technician error.

• Loss of temporaries. This is, in itself, rarely a major issue unless the patient has had a social engagement where it has caused embarrassment, or the teeth have been sensitive between appointments where tooth structure has been exposed. However, we have encountered cases where the repeated loss of temporary veneers has resulted in patients losing confidence in the clinician’s ability to complete the case, attributing such failure to be an indication that the final veneers will also be prematurely lost because the dentist lacks the skills and knowledge to adhere them correctly. 
  
  As mentioned above, premature loss of temporaries may in some instances increase the risk of minor tooth movements and hence increase the risk of misfits.

Of note, these clinical issues do not always occur in isolation, and it is not unknown for there to have been a history of problematic fit of veneers, requiring remaking, only for the patient to then experience sensitivity and gingival complications later. If one or more of those veneers subsequently is lost, it is almost inevitable that the patient will doubt the quality of the dentist’s care and question the longevity of their overall treatment. This may result in a request for a full refund, payment towards specialist retreatment, or an additional claim for compensation.

Patient factors 

These are strongly correlated with the subjective nature of complaints about the outcome of veneer treatment and can include the following: 

• Unrealistic expectations. Patients can see the outcome of cosmetic work online or in other media and assume that such treatment is not only a suitable option for them too, but that it will be a simple and routine process with a high probability of success.
  
  Expectations can also include that the result will be perfect on the first attempt. At Dental Protection we have numerous cases on our books where clinicians have remade veneers several times and yet are still unable to fulfil their patients’ expectations. This seems to be a product of shifting or evolving expectations rather than clinical ineptitude. Commonly a patient will consent at the issue appointment, the clinician will complete the procedure, and then several days later the patient will return, complaining of multiple ‘faults‘ with the treatment. This has been known to arise despite careful and repeated consultation with the patient and placement of trial smiles/mock-ups. Not only might this then involve the careful removal of such veneers, new scans/impressions, considerable clinical time and further laboratory fees if such cases are remade, but it is rare for patients to be willing to pay again towards those costs. Indeed, often such patients have not yet paid for the treatment in full and could be seeking to avoid payment by lodging spurious complaints about the care so far received.

• Body dysmorphia. This is tied into the issue of patient expectations and must be recognised as being a specific condition inherent in up to around 10% of dental patients seeking cosmetic treatment. In other words, not all patients with unrealistic expectations have body dysmorphic disorder (BDD) but most patients with BDD will have very high and often movable expectations and hence are likely to exhibit a preoccupation with imagined or slight defects in appearance.3 This is thought to be a product of biological, psychological and cultural factors and hence it might be argued that a purely biological approach to addressing concerns (via dental treatment alone) may not fulfil a BDD patient’s needs or wants.
  
  In discussion with Dental Protection members who have encountered such patients, common issues have included patients lacking self-awareness of the fickle nature of their expectations and inappropriate behaviour exhibited in the clinical setting. Members have reported patients taking literally hours to approve a trial shade in consultation with a ceramist or calling members at highly inappropriate hours to seek immediate treatment to address a flaw in their appearance that has only now been noticed.
  
  As dental practitioners we are unlikely to be qualified to make a diagnosis of BDD and so it can be appropriate to seek the assessment of a trained professional before embarking on treatment. Consideration should also be given to referral to a specialist prosthodontist.

• Financial barriers. A significant proportion of complaints about veneer treatment relate to financial issues, especially regarding costs incurred in record keeping and diagnostic services including virtual or direct mock-ups. These can prove to be problematic where the patient elects not to proceed with treatment yet has ‘sunk’ considerable funds into the case workup and now wants access to those records to take elsewhere or seeks a refund. Care must be taken to indicate whether these costs are fully refundable, rebatable against future veneer treatment, or billed irrespective of any decision to proceed with treatment. Additional fees for nightguards/splints, review/adjustment appointments, remakes and repairs can also create issues if not well understood.
  
  Further, patients may want to embark on payment plans through third party providers and experience later regret at incurring debt and late payment fees should they default on these payments.
  
  We have noted on occasion that patients may run out of funds midway through a long and expensive cosmetic treatment plan where the teeth have been prepared and temporised. Due to a lack of funds available to complete treatment or simply a change of mind, the patient might disappear, leaving the practice in debt for lab fees and time spent to date, or only return months later expecting continuation of care with no consideration that things may have changed.
  
  Detailed written financial consent obtained prior to commencement of any treatment, outlining all anticipated fees and charges, any fees for remakes or repairs outside of any applicable warranty period, and when fees fall due can be helpful here. Ensure that any refund terms and conditions are clearly stated including any risk of forfeiture of fees paid to date if a patient elects to not continue with treatment once it is underway.

• Critical comments from third parties. We are aware of members treating patients who initially express delight with their new smile, only to return a week or two later complaining of multiple cosmetic issues including dissatisfaction with the veneer shade or its match to natural teeth. Members understandably can feel frustrated and shocked to receive such feedback, often from a now demanding and confrontational patient who had previously been compliant and cooperative. When questioned about the basis for their newly found dissatisfaction, patients may reveal that their friends or family members do not like or approve of their new appearance, or that they are mindful of an (often undetectable) lisp or other functional issue. Whether this is a further example of buyer’s remorse remains unclear. This can be problematic if the patient has not yet settled their account, keeps returning on a weekly basis for repeated small alterations and refinements, or requests a remake or a refund having previously signed documentation indicating their approval of the veneers at try-in. 
  
  This risk can be minimised by having the patient attend for initial consultations and fitting appointments/direct veneer placement accompanied by key decision makers (e.g. spouse) and ensuring the patient consults with those other parties prior to completing the treatment.
  
  Members have reported patients going to another dentist to seek an opinion regarding their veneers following their placement, only to then receive critical feedback from that clinician. This can pose further difficulties if such comments indicate the presence of marginal deficiencies or other technical issues with the veneers. In such situations, we recommend members contact us to discuss options to resolve this criticism.
  
  As always, we do not recommend our members providing comments about another clinician’s treatment if asked by a patient to do so, especially where the pre-treatment appearance of the teeth is unknown/unable to be verified, nor the scope of the treatment offered and agreed to. Rather, we recommend that members advise such patients to return to the treating clinician to discuss their concerns and negotiate an amicable resolution.