A Conservative and Painless Smile Makeover

AESTHETICS
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 denRobert L. Ibsen, tal treatment: pain and money.
DDS, OD
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.
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
DENTISTRYTODAY.COM • JUNE 2015
a
Figure 1a. Preoperative photo.
b
Figure 1b. Stone model showing the depth of the chip
on the patient’s maxillary central incisor.
c
Figure 1c. Retracted view; before contouring and
bonding.
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
CASE REPORT
Diagnosis and Treatment Planning
A 35-year-old female, in excellent health, was
referred to our office by a patient upon learning
a
Figure 2a. After contouring and restoring the
enamel defect with a bonded composite resin
restoration.
b
Figure 2b. Occlusal view, after contouring.
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.
Clinical Protocol
At the patient’s next visit, she chose shade
020. Then, minimal enamel contouring was
DENTISTRYTODAY.COM • JUNE 2015
c
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.
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.
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
a
Figure 5a. Tooth overflowing with bonding adhesive.
b
Figure 5b. A Schure 349 Lumineer Instrument
(DenMat) was used to remove excess cement without
scratching any porcelain.
d
DENTISTRYTODAY.COM • JUNE 2015
Figure 5c. Remove gingival ledge with an ultrafine football diamond (NeoDiamond 30 Micron Finishing Football
No. 3923VF [Microcopy]).
e
Figure 5d. The lithium disilicate veneers (IPS e.max [Ivoclar Vivadent]) were placed supragingivally.
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
c
Figure 5e. The CeriSaw (DenMat) opens the contacts
and removes excess materials interproximally.
Figure 6. Minimally invasive veneers are ideal for a variety of maladies.
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
a
b
c
Figures 7a to 7c. After contouring and final finishing.
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
DENTISTRYTODAY.COM • JUNE 2015
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!”F
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, Lein­
felder 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
[email protected] 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.