The Big Business of Veneers
What follows is a mostly comprehensive explanation of the process involved in manufacturing and installing the ideal human smile.
The practice of cosmetic dentistry unfolds in myriad ways every day, but for the purposes of this overview we will imagine the process from the perspective of the kind of person who is more likely than the average American to be in the market for veneers or other in-mouth improvements: somebody affluent, between the ages of 40 and 49, and female. Let’s call this character Mrs. Dalloway.
After decades of exposure to the gorgeous, face-flattering smiles ubiquitous among America’s celebrity population — the ones that dentists have been crafting since the advent of Hollywood but have only recently become grocery commodities that regular American people can go out and buy for themselves — Mrs. Dalloway decides to get her teeth done. Luckily, she is already surrounded by a dense cosmetic dentistry economy with options ranging from plastic clip-ins to custom porcelain renovations. She is intoxicated by the beauty logic that associates gorgeous teeth with things like attractiveness and hygiene and sometimes material wealth. Or maybe she just wants nicer teeth and it's not something that requires analysis, okay?
The advantages of good teeth are immeasurable. One of the best attempts to calculate these advantages was published in the Journal of Human Resources in 2010: "The Economic Value of Teeth." The authors, economists Sherry Glied and Matthew Neidell, looked at the impact of oral health on labor market outcomes. Their report found a positive relationship to the future earnings of women who grew up with access to fluoridated water in the 1960s and '70s — 4.5 percent more than their peers. (American municipalities started adding fluoride to their drinking water supplies in the mid-20th century in light of overwhelming evidence that the mineral helps prevent tooth decay.) Glied and Neidell noted that the effects from the time period they studied may not be generalizable today, but the report is still fascinating for what it explicitly states: "Consumer and possibly employer discrimination [are] the main channels through which oral health affects earnings." It is heartbreakingly easy to imagine a person with crooked or unwhite teeth making a poor impression at a job interview or on a date. There is no system linking oral health with earnings; other humans just prefer to look at nice teeth.
So, anyway, for whatever reason, Mrs. Dalloway says she wants to get veneers. A veneer is a small tooth facade, made of either porcelain or a resin composite. The latter is cheaper, but less durable and more prone to staining. Most cosmetic dentists begin at the end, by building a model of a patient's soon-to-be new smile. A series of consultations with Mrs. Dalloway's cosmetic dentist may actualize into a small, composite sculpture of what her teeth would look like if they were perfect or, using computer-aided design and computer-aided manufacturing (CAD/CAM) technology, the smile can be designed on a screen, carved from a single block of porcelain or composite, and returned in the form of individual installation-ready teeth. For those looking to replace or fix lost architecture, strategically placed veneers make it possible to cram years of orthodontia into a single, painless afternoon. They also come with a secret bonus that is capable of turning a luxurious procedure into a priceless one: They render the human face virtually customizable — at least the mandible to cheekbone area, which offers infinite, gorgeous possibilities. Adding volume to front teeth, for example, can slightly push the mouth open, creating an entirely new lip shape.
The size of the global cosmetic dentistry market by 2024: $28 billion.
Practitioners like Michael Apa, a cosmetic dentist on Manhattan's Upper East Side, fancy themselves artists more than clinicians, decrying the advent of digital technology in the same way Yves Saint Laurent might be tortured in the afterlife by the possibility of 3D-printed dresses. For a more God-given finish, Apa builds a smile by layering porcelain on the teeth of some of his patients (who include Chloë Sevigny, Huda Kattan, and a couple of elder Olsens, though we cannot confirm that all of them are veneers patients).
Such practitioners may also genuflect before a global council of elite cosmetic dentists known as the Oral Design International Foundation, headquartered in Zurich. It’s basically the United Nations of veneers. In 2013, over 30 years into its existence, the council's founder and unofficial chancellor issued an editorial against the "demonization" of digital technology and acknowledged a schism between those who value craftsmanship versus efficiency in the tooth-making community. But the rest of the letter thrums with anxiety about what the digital future will do to the highest levels of dental craftsmanship (and, you could extrapolate, to the careers of elite tooth artisans).
In one of my first interviews with Apa several years ago, he likened his construction of a smile to the construction of a Ferrari. More recently, he likens it to the construction of a Bugatti, an even more bewilderingly expensive machine. Less than 500 Bugattis exist today. The cars look and perform superlatively, but that isn't really the point. The average Bugatti shopper already owns a small fleet of transportation options, including, give or take, 42 cars, three helicopters, and three private jets.
Veneer installation is sculpture on the most minuscule of scales. Some cosmetic dentists wear magnifying equipment on their foreheads, while others invest in surgical-grade microscopes that descend from their office ceilings; the one in dentist Jon Marashi’s Los Angeles office magnifies up to 14x, even more precise than a jeweler's standard. ("It turns a fingernail into a football field," he says.) Most veneers are about half as thick as a credit card. Before a veneer is grafted onto its forever home, a tooth might be "reduced" (a dental term for filing off a fine layer of your original tooth) and then etched (a dental term for treating with a weak acid). A clear adhesive is painted over the original tooth and the two teeth, real and fake, unite in their eternal embrace until they become indistinguishable from each other.
Within minutes, Mrs. Dalloway can bite into an apple with the breezy confidence of somebody who isn't wearing 20 tiny porcelain hats on her teeth, and with a smile that can bring a dove to tears. The global cosmetic dentistry market is expected to be worth around $28 billion by 2024, nearly twice the size of the global pineapple industry. But this figure is easily dwarfed by other related markets, like oral care and hygiene ($54 billion by 2022). "The term 'cosmetic' dentistry has lost its cache," says Dennis Fasbinder, a clinical professor at the University of Michigan School of Dentistry. "Almost every dentist has to think cosmetically."
About 40 percent of dentists reported upwards of $1 million in practice revenue.
In 2019, the American Academy of Cosmetic Dentistry issued a survey on the "state of the industry." The overwhelming majority of respondents were dentists, although many identified themselves as general dentists, distinct from cosmetic. About 40 percent reported upwards of $1 million in practice profits; 12 percent generated over $2 million. The majority cited a growing over-the-counter whitening market as the biggest threat to their bleaching business as products designed to better your teeth at home continue to morph into new and bewildering possibilities, like a whitening tooth serum crafted from Alpine minerals, and Japanese charcoal mixed with Ayurvedic coconut oil in the hopes of purifying American mouths.
The human race is perhaps less than a decade away from mass-produced, commercially viable, direct-to-consumer veneers by the name of Grin or Polish or Smyles or Prrl. Many dentists look forward to a more democratic profession. Others, like Apa and probably some of the venerated ceramists of the Oral Design global council, see craftsmanship as part of the package and thus part of the price tag.
Americans will pay it, if they can: The CareCredit medical credit card was launched in 1987, in the early years of mainstream veneers, to help finance costly cosmetic, dental, and vision procedures. A couple of decades later, the company was ordered by the Consumer Financial Protection Bureau to refund about $34 million to customers who had been duped by the card’s vague and misleading terms and conditions. (If customers failed to pay off their balance within a certain promotional period, they paid almost 30 percent interest on perkier smiles, breasts, and jaw lines — 10 times what they would've paid on a mortgage.)
Health is sold at a premium; cosmetics are sold at a devil's bargain. Veneers of the CAD/CAM mail-order quality can cost $1,000 per tooth; Apa's rate is four times that. Marashi works at both ends of the spectrum, with his couture celebrity service alongside the direct-to-consumer Byte-brand aligners he helped launch in 2019. (Weeks into the COVID-19 pandemic, Byte reported being on track to do 10 times its usual sales compared with the same period in the previous year.) But even the best aligners take months and require a blood tithe in tooth pain and headaches caused by plastic trays shifting the natural hydroxyapatite formations in your mouth at the unhurried pace of a glacier carving a riverbed.
Once, in the back of a cab, a friend revealed to me that a handful of her front teeth were porcelain. She has one of the most beautiful smiles I've ever seen. "Three years after I got them, they're just a part of me," she says. "Getting veneers is kind of like betting on yourself. Will I be successful enough in 20 years to be able to afford another one, in case one of these breaks?"
The average life span of a veneer is 10 to 15 years. Does she worry? "Just whenever I'm thinking about any of the big things I need or want to save for," she says. "A house, my future kids' education, my teeth."
Note: A previous version of this article misstated dental practice revenues. 40% of dentists surveyed reported upwards of $1 million in practice revenue, not practice profits. This post has since been updated to reflect this correction.
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