A Cross-sectional Analysis of Dentists' Clinical Decision-making Regarding Laminate Veneers

1. INTRODUCTION

The goal of restorative procedures should be to provide a great smile aesthetics, considering the growing patient desire for aesthetic results [1]. Dental function and development, in addition to the restoration of natural dental aesthetics, must be regarded as in today's patients' demand for a smile that is both aesthetically attractive and has a healthy, harmonious tooth structure [2]. As a result, according to reports of previous studies, conservative therapies such as laminate veneers can yield the desired aesthetic benefits for the patient and have been adopted as the initial course of treatment [3, 4]. In this regard, laminate veneers are among the most conservative treatment options available and one of the most aesthetically acceptable methods for producing smiles that meet the patient's satisfaction [5]. Dentists may repair discolored, broken, damaged, and congenitally deformed teeth, diastemas, and cosmetic defects with laminate veneers, changing the tooth's position, shape, size, and color [6, 7].

Laminate veneers (LVs) were first utilized in cosmetic restoration procedures in the mid-1970s [5, 8]. According to the degree of teeth defects, only 3% to 12% of the tooth structure of the anterior teeth needs to be removed to prepare the tooth for LVs, which is less invasive than preparing the tooth for full ceramic crowns [9]. LVs are a legitimate and effective restorative therapeutic approach; however, clinical results can be influenced by several factors [10]. These elements include the design of the tooth preparation, the condition of the abutment tooth, the tooth's vitality, occlusion, adhesive bonding techniques, restorative materials, and adhesive materials [11].

Laminate veneers have been created using both direct and indirect methods, employing various materials for fabrication [5, 11]. Dentists prefer indirect laminate veneers over direct laminate veneers due to their superior resistance to discoloration and fractures [12]. Since the indirect approach offers exceptional abrasion resistance, proximal and occlusal contacts, reduced marginal leakage, and enhanced mechanical properties of the restoration compared to direct procedures, a large portion of the crown needs to be restored [13]. However, indirect laminate veneer restorations are limited by the need for an adhesive cementation technique and increased expenses [14]. As a result, in addition to the mechanical and aesthetic qualities, the cost of chair-side time must be considered when choosing between direct and indirect treatment options [8-14].

Composite resins and ceramics are two examples of the aesthetic restoration materials available to dentists [15]. Traditionally, composite resin is preferred for conservative and cosmetic operations [16]. Because composite laminate veneers use less invasive and more conservative treatment methods to cover discolored teeth, repair broken teeth, and fix unsightly tooth shapes, they are the preferred option [2]. Nevertheless, wear, marginal fracture, and marginal discoloration are frequent issues with composite veneers, which, over time, reduce the aesthetic results [17]. Indirect laminate veneer treatments have a significantly higher success rate than composite resin bonding methods, and their physical characteristics have substantially improved [18]. Because ceramic is aesthetically accepted and long-lasting, dentists also commonly utilize it in laminate veneers. Ceramic veneers have drawbacks, including marginal flaws, tooth sensitivity, debonding, and delicate construction [19]. Composites also exhibit outstanding mechanical and aesthetic properties, even though ceramics were often chosen for their desirable qualities, including color stability and strong fracture resistance [20]. In terms of clinical performance, randomized clinical research comparing the short-term survival rates of ceramic laminate veneers with indirect resin composite veneers found no statistically significant differences between the two materials. However, changes in surface quality were more frequent in the composite veneers, which were noted as a condition that may require further maintenance in the future [21].

Successful restorations now depend on preserving the tooth structure using minimally invasive techniques. It is emphasized that the load failure of laminate veneers is significantly influenced by the design of preparation and the quantity of surviving dental structure [22]. A reversible treatment method, the no-prep procedure, preserves the soft tissue's architecture by keeping all the original tooth structure [23]. On the other hand, no-prep laminate veneers do not necessitate anesthesia or intermediate provisional restorations. In addition, they are not associated with wear or postoperative sensitivity. Their advantages include minimal flexing stress, long-term margin integrity, longer-lasting restorations, and higher patient acceptance of treatment [13, 24-26]. This type of treatment is recommended when the tooth structure is sound enough to permit the addition of material. One common indication for no-prep laminate veneers includes diastema closure, abfractions, reshaping, and incisal edge and labial volume augmentation [27]. This method's primary contraindication is that it cannot be applied in cases of extreme discoloration, deformity, and malposition, as simply applying restorative material without first preparing the tooth would not provide the required shape and discoloration masking. The necessity for preparation should be carefully considered in these situations. The technique should be considered in terms of some potential limitations, such as periodontal complications and aesthetic outcomes, including gum inflammation resulting from over-contoured restorations, even though no-prep veneers were thought to be the best option because they preserve the most tooth structure [13, 16]. Therefore, a treatment plan with or without tooth preparation may be chosen based on the patient's clinical state and needs to give them the best appearance, functionality, and lifespan.

Veneer replacement in anterior teeth has gained popularity due to the rising desire for attractive smiles with a more conservative treatment approach [19]. The current study is based on a proposed hypothesis that the dental practitioner's clinical experience and gender will affect the clinical decision-making regarding the laminate's clinical workflow. The study aimed to address research gaps in cosmetic dentistry, explicitly focusing on laminate veneers. It explored practitioners' years of experience, gender variations in dental practice, including case selection, material choice, and preparation practices. It also examined variables that influence dentists' decisions to offer laminate veneers, enabling the customization of training programs and standards. The study will provide a platform for dentists to discuss their experiences and preferences, indicating areas for improvement in training, resources, and support. The purpose is to contribute to a more thorough understanding of cosmetic dental procedures and enhance patient outcomes.

Aim of the study: In addition to analyzing technique preferences, such as preparation designs, bonding methods, and material selection, the study compares male and female dentists to identify the frequency of performance of laminate veneers and clinical decision-making factors that influence dentists' practice for laminate veneers, such as dentists’ demographics, patients’ aesthetic demands, and clinical indications.

2. METHODS

This study used a cross-sectional design. The survey was directed at Saudi Arabian dentists working in the governmental and private sectors. A cross-sectional online survey was conducted between November 20, 2024, and February 20, 2025. The survey assessed the data on clinical decision-making and preferred techniques for laminate veneers. The Institutional Review Board (IRB) granted the study ethical approval # COD/IRB/2023/2 (Supplementary Document). The participants were informed of the study's goal, the confidentiality of their answers, and their freedom to discontinue participation at any time. Anonymity for participants was guaranteed, as no personally identifiable information was collected.

Saudi Arabian dentists holding professional licenses from the Saudi Commission for Health Specialties were included in the study. Dentists from both the governmental and private healthcare sectors were selected to provide comprehensive representation. Invitations to participate in the survey were distributed via Google Forms (Google LLC, United States) and disseminated through the social media platform WhatsApp (Meta Platforms Inc., United States). Consequently, the study sample comprised dentists with diverse educational backgrounds and skills, effectively reflecting the broader dental community in Saudi Arabia. The online survey was created, and responses were received anonymously, without any identifying data, and only the principal investigator had access to the data. Participation was voluntary, and participants received a bi-weekly reminder throughout the survey's duration to encourage completion of the online survey. Their electronic consent to participate was obtained before respondents' responses to the survey questions.

A thorough literature review and expert interaction were the foundation for developing the survey questionnaire. This study was conducted following the World Medical Association's Code of Ethics (Declaration of Helsinki). The survey had two main parts; the first part included demographic data such as age, gender, years of experience, practice sector (government or private), and educational background. The second part comprises clinical decision-making related questions, evaluating patient preferences, aesthetic requirements, and clinical indications related to the selection of laminate veneers. In addition to technique preferences, there are inquiries concerning the best methods for choosing materials, bonding, and preparation for laminate veneers.

3. RESULTS

4. DISCUSSION

The study demonstrated that laminate veneers are a popular procedure among dentists. 56% of participants conduct this procedure in their clinics, whereas 44% do not. This shows that most dentists perform this procedure and prefer it as a cosmetic treatment option. Factors such as variances in training, patient demographics, or preferences for other cosmetic dental operations might contribute to these results. Previous studies have demonstrated comparable results, such as those by Komine et al. (2024), which illustrate the variability in adoption depending on regional practices and clinical preferences [28]. Compared with prior studies, the findings demonstrate that direct laminate veneers benefit cosmetic dentistry [29, 30]. Clinical studies evaluating the longevity of porcelain veneers have found that patients are generally satisfied with the treatment, with a satisfaction rate ranging from 80% to 100% [31-33]. This finding aligns with most dentists who frequently practice indirect laminates, as confirmed by a randomized clinical trial that assessed the technique preference, patient acceptance, and clinical performance of ceramic laminate veneers made with Celtra Press and IPS e.max Press ceramic. They found that after one year of follow-up, dentists used both Celtra press laminate veneers and IPS e.max press laminate veneers, which showed successful clinical performance in anterior teeth requiring conservative labial laminate veneers with incisal wrap design in terms of color matching and color stability, fracture, sensitivity, and patient satisfaction [34, 35].

The study reveals that poor dental hygiene is the primary reason for rejecting laminate veneers, underscoring the importance of maintaining an effective oral care routine. Occlusion-related difficulties and inadequate remaining tooth structure are also essential concerns, limiting the durability and benefit of the veneers. Other considerations include patient expectations, expense, and possible consequences. Previous research has also identified comparable factors for veneer rejection, emphasizing the importance of maintaining adequate oral hygiene and addressing occlusal concerns [28]. The study stresses that careful patient evaluation and preparation are crucial for the success of laminate veneers, as addressing these issues can enhance patient outcomes and satisfaction with the procedure.

The study reveals a significant gender difference in the practice of laminate veneers, with male dentists reporting a higher frequency of performing these procedures than female dentists (59.8% vs. 40.2%). This showed that male dentists may be more engaged in cosmetic restoration operations, possibly due to characteristics such as training, confidence, or professional emphasis. Factors contributing to this higher engagement include increased training and education, a greater focus on cosmetic dentistry in professional contexts, and more hands-on experience. Previous research has also demonstrated gender variations in dental practice patterns, with female dentists more likely to work part-time and in metropolitan regions. In contrast, male dentists are more likely to work full-time and in rural areas. Female dentists are also more likely to work in pediatric and public health dentistry, which may explain their lower involvement in cosmetic treatments, such as laminate veneers [36]. Identifying these distinctions can help tailor training programs and professional development opportunities to ensure that all dentists are prepared to perform a range of treatments.

The study demonstrates gender variations in dental impression procedures. Male dentists tend to favor digital impressions and monophase procedures more than female dentists, whereas female dentists prefer conventional one-step and double-step techniques. This demonstrates that male dentists are more receptive to embracing contemporary technologies and simplified processes, likely due to variables such as training, familiarity with technology, or professional focus. Female dentists may prefer conventional procedures, as they might find them more reliable or easier to manage. Previous studies have also revealed gender variations in the utilization of digital technology in dentistry. Research by Yuzbasioglu et al. (2014) indicated that patients frequently preferred digital impressions due to their comfort and efficiency [37]. Another study by Terres Bustos & Tapia Ornelas (2023) highlighted the advantages of digital impressions, while also acknowledging the increased initial cost and learning curve associated with these technologies [38, 38]. Understanding these preferences can assist in customizing training programs and professional development to ensure that dentists are ready to employ both traditional and modern procedures efficiently.

The study reveals a significant gender difference in the choice of isolation procedures during cementation, with female dentists opting for rubber dam isolation (59.2%) and male dentists selecting cotton roll isolation (56.5%). This preference is related to rubber dams' superior moisture management, which is necessary for restorative treatments such as veneer cementation. Cotton roll isolation, more commonly employed by male dentists, is chosen due to its simplicity and convenience of use, but it is less successful in preventing moisture. Previous studies have also revealed the benefits of rubber dam isolation over cotton roll isolation, such as a decreased failure rate of restorations and more effective management of a dry field [39, 40]. Understanding these preferences can help in designing effective training programs and professional development to ensure that dentists can employ the most suitable approaches for their procedures.

The current study showed an insignificant correlation between years of experience and the clinical performance of laminate veneers. The results were supported by a 2009 study by Burque and Luccarotti, which found that the years that dentists utilized their skills after graduation exhibited no noticeable effect on the endurance of porcelain veneers. This clarifies that factors other than experience—such as implementing therapeutic standards —may be crucial for veneer treatments to be successful [41].

In the same regard, a prospective clinical research study was conducted in 2020 to assess the outcomes of minimally invasive ceramic restorations performed by dentists with varying degrees of proficiency. The study concluded that the professional experience of the dentist had no significant influence on either patient happiness or the success of the restorations. Instead, early failures have been attributed to noncompliance with clinical protocols [42]. Another opposing opinion was presented in an in vitro study, where the operator's expertise was found to affect dentin exposure after tooth preparation for laminate veneers. Excessive dentin preparation may reduce the lifespan of the veneer, suggesting that experienced practitioners may achieve superior outcomes [43]. This may be attributed to the individual variations in preparation limitations from the former study.

While this study provides valuable insights into the practice of laminate veneers among dentists in Saudi Arabia, it has certain limitations that should be addressed. Self-reported data may be subject to response bias, and convenience sampling may not accurately represent the broader community. Additionally, the cross-sectional design provides a snapshot of practices at a particular moment, and most participants were early-career dentists. Another limitation of the current study was related to the participating dentists' background, their prosthodontics educational degrees, and clinical experience regarding dental prosthodontics and esthetic restorative dentistry. This limitation should be carefully examined, as it may impact clinical decision-making and treatment preferences. The study's geographical focus may limit its relevance to other areas or countries with differing cultural, educational, or healthcare systems.

CONCLUSION

This study demonstrated significant variations in the practice of laminate veneers among dentists in Saudi Arabia. Among those variations, as shown in the results, 44% do not practice laminate veneers, which is considered a vast gap in the reported clinical experience of the dentists who responded to the survey. However, in correlation with the age distribution, it was also an impressive finding that 77% of individuals with less than 5 years of experience had a professional interest in the clinical practice of laminate veneers. The years of experience had a less substantial impact on treatment decision-making. However, further research is needed to correlate years of experience with the clinical protocols and materials used in clinical trials, as well as treatment preferences. Overall, the survey response was nearly equal from both male and female dentists, while gender-based conclusions were found related to the technique of executing laminate veneers. Male dentists were more likely to perform laminate veneers, manage a larger number of patients, and adopt modern procedures, such as digital impressions and CAD-CAM processes. In contrast, female dentists preferred conventional approaches, such as one-step and two-step impression techniques. In addition, cotton roll isolation and sending physical impressions to the lab are preferred over rubber dam isolation and digital impressions. Regarding laminate veneers retreatment, it was found that nearly half of the respondents perform these clinically, but concerning gender, it was more practiced by male dentists. These variations showed that although both males and females had the initiative of responding to the questionnaire, gender may influence clinical decision-making, method preferences, and the adoption of innovative technologies in the fabrication of laminate veneers.

REFERENCES