A Conservative and Painless Smile Makeover

INTRODUCTION
Dentists are constantly striving to find more procedures to offer existing patients as well as to attract new patients. Two major barriers discourage patients from accepting a dental treatment: pain and money.

Veneers can be a prime example. They may be perceived by both dentists and patients as a very expensive and time-consuming procedure, requiring the removal of significant tooth structure. However, today, it is possible to improve almost any smile without the need to remove valuable natural tooth structure, using the strong porcelains available with reliable bonding systems that can opaque and modify hue, value, and chroma.¹ The average clinician no longer needs to announce at recall, “It is not that bad,” or “We will watch it,” but instead can offer a dynamic solution the patient will want. When patients are informed about how much their appearance can be improved without shots, needles, or any pain, they will want their smiles improved and strengthened. The use of 4.5x magnification and stronger porcelains and resin luting agents has expanded the patient base eligible for veneer placement using a noninvasive or minimally invasive technique.

A Brief Background
Interestingly, when we look back on the evolution of tooth preparation methods for the placement of veneers, we discover that the non-preparation (“no-prep”) or preparation-free (“prepless”) techniques were actually the original methods for preparing teeth to receive veneers.^2,3 In the mid-20th century, clinicians were developing more conservative techniques for preparation for caries⁴ that provided a foundation for no-prep techniques for veneers.

Figure 1a. Preoperative photo.	Figure 1b. Stone model showing the depth of the chip on the patient’s maxillary central incisor.

Figure 1c. Retracted view; before contouring and bonding.

Several factors caused a shift in the dental standard, from a preparation requiring significant tooth reduction, to a conservative preparation.^2,3,5 Restorative dentistry has historically relied on preparations designed with resistance and retention in mind, and that is still the standard in many restorative cases today. In prior years, due to a deserved lack of confidence that available materials were able to effectively adhere to enamel and/or dentin, many clinicians and dental laboratory technicians advocated the unnecessary removal of healthy tooth structure to create retention and resistant geometric forms,⁴ and this dental principle has endured to this day.

Proper shaping and contouring of porcelain during the finishing process requires aesthetic skills and an attention to detail. The general belief, often expressed by clinicians, that reducing tooth structure to achieve proper aesthetics is simpler and more efficient is incorrect. Correspondingly, laboratory technicians recommend, without regard for protecting the pulp, that dentists unnecessarily remove more natural tooth structure. How much tooth reduction should be made is solely the clinician’s decision after considering case design and potential for trauma to the pulp from an extensive prep. Painless, minimally invasive techniques are simpler and efficient, protect the pulp, and are more rewarding—if the time is taken to become proficient in the finishing techniques.

As dental materials and adhesives advanced during the last 3 decades, the prepless technique has gained support.^2,4 This shift toward more conservative and painless techniques is due to a realization among clinicians that traditional methods of veneer preparation result in many three quarters to seven eighths crowns, not “veneers,”^2,3 and that less tooth reduction decreases the risk of disturbing or damaging the pulp.6 Also, patients are aware that there are less invasive techniques now available to them.

With the advent of improved materials and adhesives, the understanding that tooth structure offers excellent support for bonded porcelain, and the knowledge that enamel provides an outstanding surface for retention when the proper principles of adhesion are used, this minimally invasive technique is an excellent treatment option.⁶

Figure 2a. After contouring and restoring the enamel defect with a bonded composite resin restoration.	Figure 2b. Occlusal view, after contouring.
Figure 2c. Our patient went home with no temporaries.	Figure 3. Dental rubber dam on lingual side of the teeth.

Figure 4. Preparing the teeth for veneer placement.

CASE REPORT
Diagnosis and Treatment Planning
A 35-year-old female, in excellent health, was referred to our office by a patient upon learning about our no-pain, no-shot porcelain veneer smile makeovers (Figure 1a). The patient, who was an editor for an online beauty magazine, felt self-conscious about her smile because her front central incisor was stained and chipped, and there was also generalized yellowing of the maxillary teeth from age (Figures 1b and 1c). She felt her smile drastically impacted her appearance and her ability to engage with her readers, but she was terrified of getting porcelain veneers after having researched the traditional veneer method. She stated, “I could not bring myself to pull the trigger on anything that would require grinding my teeth down.” After having braces as a teenager, and years of bleaching in her 20s, she presented with a defect on tooth No. 9 that worsened over time, collecting superficial stains that made the defect even more apparent.

The patient saw her dentist regularly and had a healthy dentition. She presented with a balanced occlusion, healthy gingival tissue, and dentition capable of supporting veneers.

When determining an aesthetic treatment plan, there are multiple aspects to evaluate and consider. These include the expectations of the patient, preferred shade, desired teeth shape and length, midline position, lip position and fullness, incisal edge position, occlusion, and the extent and location of any tooth contouring,⁵ if any is required.

The recommendation to the patient was a minimally invasive solution that would address both aesthetics and function. It was proposed that 10 prepless veneers be done on her maxillary teeth, from teeth Nos. 4 to 13 (second bicuspid to second bicuspid), with enamel contouring limited to nonsensitive (enamel) tooth structure. Bleaching options, to be chosen and done at a later date, were presented for her lowers to avoid a noticeable postoperative shade discrepancy between her veneers and lower arch.

The patient was excited that this conservative approach would still serve to strengthen, align, and further enhance her lip-line, while protecting her existing dentition. She eagerly consented to the treatment plan, as presented.

Figure 5a. Tooth overflowing with bonding adhesive.	Figure 5b. A Schure 349 Lumineer Instrument (DenMat) was used to remove excess cement without scratching any porcelain.

Figure 5c. Remove gingival ledge with an ultrafine football diamond (NeoDiamond 30 Micron Finishing Football No. 3923VF [Microcopy]).

Figure 5d. The lithium disilicate veneers (IPS e.max [Ivoclar Vivadent]) were placed supragingivally.

Figure 5e. The CeriSaw (DenMat) opens the contacts and removes excess materials interproximally.

Clinical Protocol
At the patient’s next visit, she chose shade 020. Then, minimal enamel contouring was performed using the patient’s sensory system to alert of any sensitivity. No analgesics of any kind were administered. A long ultrafine diamond (NeoDiamond 30 Micron Finishing Pointed Cone No. 3314.10VF [Microcopy]) was used to smooth the incisal edges, the upper right centrals were shortened, and the patient’s mesial of the upper left central and the upper left lateral were contoured to bring the arch into better alignment (Figures 2a and 2b). Magnification was used to avoid touching sensitive dentition (ZEISS 4.5x magnification [ZEISS]). It should be noted that restorations adjoining natural teeth can be blended with the enamel at the gingival margin, making the porcelain restorations indiscernible from the natural tooth.⁶

The labial defect on the maxillary left central was restored with a composite resin (A2) (such as Virtuoso Flowable [DenMat]) to allow a smooth, clean, and flat surface. As noted in Figure 2c, her teeth were minimally altered, and the patient was allowed to go home without any temporaries. The patient was very pleased that there was an immediate improvement in appearance, and she later reported that she had no postoperative pain/sensitivity problems.

A detailed vinyl polysiloxane (Precision [DenMat]) impression was taken, using heavy body for the tray and light body for the wash on the teeth. Several intraoral, facial, and close-up photos were taken before and after contouring. The impressions were sent to the lab for 10 lithium disilicate (IPS e.max [Ivoclar Vivadent]) veneers. A detailed prescription was sent to the lab team, requesting shade 020 with 50% translucency, smooth surface texture, an incisal wrap, square edges, and somewhat flat surfaces with slight rounding on the mesial and distal incisal edges.

Figure 6. Minimally invasive veneers are ideal for a variety of maladies.

After receiving the case back from the laboratory team, the patient was scheduled for the seating. (Only 1.5 hours was blocked off for the placement appointment.) Prior to any surface preparation, veneers are first treated with a citric acid solution, then rinsed and dried thoroughly. The inside of the veneer is then coated with silane for 30 seconds, then excess can be gently blown off. Try-in is the opportunity to ensure the veneer fits properly, determine whether any shade modification is necessary and verify the patient is satisfied with the appearance. After the try-in is complete, place a thin layer of Tenure S (DenMat) inside the veneer, gently blowing off the excess. To confirm fit and acceptance, each veneer was carefully placed on the patient’s teeth, one at a time, without adhesive. The fit was perfect, the patient liked the appearance of her new smile, and she wanted to proceed with placement.

An unconventional and time-saving step, which helps with postoperative cleanup, is to apply a layer of dental dam/barrier material along the lingual surface of the teeth to receive the veneers. It is also recommended to apply a layer to the 2 teeth beyond the most distal teeth to receive veneers (Figure 3). Brief light curing was carried out for 2 to 3 seconds per tooth with a PAC light (Sapphire Supreme Plasma Arc Curing Light [DenMat]) until the resin cement reached a rubbery state. This is a critical time saver that allows for easy cleanup of bonding material after placement.

When using the correct adhesives, porcelain veneers can be bonded to the following 5 surfaces: enamel, porcelain, dentin, composite, and metal. For this patient, bonding was only to enamel. First, the labial surfaces of the teeth that would receive veneers were etched for 30 seconds using a phosphoric acid gel (Etch’N’Seal [DenMat]) (Figure 4). The etchant was thoroughly rinsed off and the teeth were thoroughly dried. Next, a bonding agent (Tenure A and B [DenMat]) was applied to the etched surfaces and lightly air-thinned. This was followed by a resin liner bond enhancer (Tenure S); used to strengthen the bond and protect from contamination.

Bonding to enamel or porcelain creates a stronger bond than bonding to dentin. Also, the greater surface area from not reducing the teeth creates a more stable foundation for the adhesive to create a tighter bond. The bond becomes secure and stable when the adhesive bond transforms from monomer to polymer (this only occurs after, at minimum, a 5-second cure to each tooth). Without the necessary surface area and secured bond, the veneers would be seated on an unstable surface and have a higher probability of future pop-offs. This is why preserving as much of the natural (enamel) tooth structure as possible is highly recommended.

With the teeth etched and the lithium disilicate properly treated with silane, the veneers were ready to be seated. Starting at the incisal edge and working upward in a back-and-forth motion, a liberal amount of composite luting cement (Ultra-Bond [DenMat]) was slowly syringed onto the inside (concave surface) of each veneer, overfilling each one (Figure 5a). Carefully watching for bubbles as the composite is applied is strongly recommended, as bubbles cause voids. If bubbles do appear, break them with an explorer instrument and fill the voids with more composite. Applying excess material ensures no air bubbles are trapped under the veneer, helping to obtain a stronger bond. Each veneer was cured using a 9.0-mm curing tip followed by a final cure on both the labial and lingual of each tooth.

The step that really differentiates this painless porcelain veneer technique from the traditional veneer technique is the finishing. Excess resin cement was removed using a 12-fluted bur (FG No. 7902 12-blade Flame Carbide [Brasseler USA]) from around the margins. A Schure 349 Lumineer Instrument (DenMat) was used to remove cured cement on the labial surfaces, as well as from the interproximal areas on both the facial and lingual sides. This instrument is used because it does not scratch porcelain (Figure 5b). Then, an ultrafine American football-shaped diamond (NeoDiamond 30 Micron Finishing Football No. 3923VF [Microcopy]), with copious amounts of water and a light touch, were used to blend the porcelain ledge on the lingual margin to the tooth (Figure 5c). This technique reduces the possibility of gingival erosion by eliminating any foreign body under the gingival margin that could stimulate and exacerbate gum recession (Figure 5d). A long ultrafine diamond was used to further contour the shoulder of the porcelain to a feather-edge blending with the enamel at the gingival margin.

Occlusal equilibrium was achieved to eliminate any eccentric influences. A 30-fluted bur (FG No. 9903 30-blade Flame Carbide [Brasseler USA]) was used to polish the veneers along the gingival margin, and then a Dialite (Brasseler USA) polishing cup and porcelain polishing paste were used to reglaze the porcelain, creating a natural-looking sheen. The specially designed saw and sander instruments (CeriSaw and CeriSander [DenMat]) were used to open the easy-to-open interproximal contacts and smooth rough edges (Figure 5e). These instruments do not harm or erode the porcelain but simply remove the excess cement.

The patient was instructed to brush with an electric toothbrush (Sonicare [Philips Oral Healthcare]) and a nonabrasive whitening toothpaste. On the follow-up visit, the CeriSaw was used to open any interproximal contacts that were not opened at the initial visit. Dental floss was run through the interproximal surfaces to ensure that all the contacts were smooth.

CLOSING COMMENTS
The patient wanted to cover the chip on her front central and chose painless porcelain veneers because they did not require removal of any of her sensitive tooth structure. She did not have any extreme issues such as severe staining, overly crooked or missing teeth, or significant gingival recession. Prior experience as well as an initial laboratory wax-up assured us that prepless veneers would adequately fulfill the patient’s needs and wishes.

It is best to determine the most conservative clinical treatment for your patient and then select the optimal material and technician that allow you to treat according with your preferred bonding modality.^3,5 Moreover, carefully select the laboratory team for the technical work to ensure that they have the knowledge, skill, and the right materials to support the treatment modality that you have prescribed. It is important to know that they are able to successfully create beautiful restorations over margin- and shoulder-free preparations.

Remember, as with all dental procedures, it is important to do a thorough examination, to present a full treatment plan, and to obtain written consent prior to the start of treatment. It should be noted that, in this case, the initial exam and contouring appointment took less than an hour to complete, demonstrating that this veneer technique often allows the clinician to save valuable chair time.

As more dental professionals understand and learn a proper pain-free technique, they realize that invasive preparations for veneers are often unnecessary and can be traumatic to patients. Clinicians are also becoming more aware of the advantages of less reduction, the large variety of adequate adhesives available, and the benefits of using enamel as the foundation for bonding veneers (Figure 6). Finally, as illustrated in this article, patients are becoming increasingly aware of, and prefer, less invasive options. These facts—combined with the tremendous number of successful, noninvasive, and minimally invasive veneer cases that have been performed over many years—give great support and credibility to no-prep to minimal-prep veneer procedures.⁷

Through the use of a minimally invasive procedure, the patient presented herein was provided with a solution that restored her smile, addressed quality-of-life issues, and restored her self-confidence to continue a successful career centered on beauty and journalism. She was extremely pleased with the final results of her treatment, especially after waiting many years to find a solution that suited her (Figure 7). More than a year later, she still loves how natural her teeth look, no longer worries about smiling or taking photographs, and never has to worry about bonding falling off her front tooth. “They look amazing. I felt like I looked 5 to 10 years younger. If you do not have to grind down your teeth and get traditional veneers, I don’t know why you would do that!”

References

1. Ibsen RL, Weinberg S. A conservative and painless approach to anterior and posterior esthetic restorative dentistry. Dent Today. 2006;25:118-121.
2. Cho GC, Donovan TE, Chee WW. Clinical experiences with bonded porcelain laminate veneers. J Calif Dent Assoc. 1998;26:121-127.
3. Kwasniewski J. Diagnosis and Placement of No-Prep Veneers [DVD]. Newport Beach, CA: Glidewell Laboratories; 2008.
4. Malcmacher L. Back to the future with porcelain veneers. Dent Today. 2003;22:70-75.
5. Principles of tooth preparation. In: Terry DA, Leinfelder KF, Geller W, et al. Aesthetic & Restorative Dentistry: Material Selection & Technique. Stillwater, MN: Everest Publishing Media; 2009:45,70.
6. Al-Zain A. No-Preparation Porcelain Veneers. Indianapolis, IN: Indiana University School of Dentistry; 2009. dentistry.iu.edu/files/8713/7597/9229/Non_Preparation_Veneers.pdf. Accessed March 10, 2015.
7. Ibsen RL. Cuspid- and anterior-guided occlusion achieved with Cerinate porcelain withstands test of time. DentalTown. August 2003. dentaltown.com/images/dentaltown/magimages/aug03/aug03dtpg40.pdf. Accessed March 10, 2015.

Dr. Ibsen, a graduate of the University of Southern California School of Dentistry, has dedicated his career to the preservation of tooth structure in the practice of cosmetic dentistry. He now devotes his time to lecturing at dental meetings, educating dentists about SmileSimplicity Painless Smile Improvement, and is still active in his private practice. He can be reached at via email at the address robert@smilesimplicity.com or by calling (805) 925-3271.

Disclosure: Dr. Ibsen was the founder and former CEO of DenMat Corp and the developer of Rembrandt Toothpaste and LUMINEERS. In 2007, Credit Suisse acquired DenMat. Now, Dr. Ibsen has no affiliation with the company and no financial connection with any of the products mentioned in this article. He has received no compensation for writing this article. He has an ownership interest in RLI Education.