April 1, 2007
by Gary M. Radz, DDS
After years of calling on their professional organizations to put money and energy into building awareness of cosmetic dentistry, dentists woke up one morning and found themselves in the midst of a marketing blitz they had no idea was coming, launched by a highly unlikely source — the media.”1 This quote is from Dental Products Report in 2004, and yet in 2007 we continue to see an explosion in the exposure and popularity of cosmetic dentistry.
We, as dentists, are now seeing an increased and steady demand from our dental patients for elective services. Certainly for many of us this has been an opportunity to provide a service that is fun and professionally rewarding. What could be more rewarding than having a patient leave our offices with a new smile and thinking that we are miracle workers? But with this new demand for elective services, comes with it a professional obligation to minimize the trauma we create on a tooth, while still being able to make a positive cosmetic change.
The trend of the “smile makeover” while creating a boom for our practices, does also present an ethical question: Is tooth structure not sacred anymore? Recently Heymann and Swift stated, “Current ‘makeover’ trends promote this more aggressive tooth preparation with less consideration for conservative dental concepts, the needs of the patient, and interdisciplinary diagnosis and treatment planning.”2 They point out some legitimate concerns regarding over-diagnosising and/or over-preparing teeth.
With this in mind it is important that the dentist providing elective services be familiar and comfortable with stacked or feldspathic porcelain veneers. Stacked porcelain veneers can be created at a thickness of .5mm. This allows for a minimal amount of removal of tooth structure, while still having the ability to improve the appearance of the tooth.
Another important benefit from minimally invasive porcelain veneers is that the preparations remain almost entirely in enamel. This is important from a longevity standpoint. The longevity of a bonded veneer is a direct function to the amount of enamel substrate supporting it.3
The following case studies will demonstrate the esthetic potential of feldspathic porcelain veneers to make dramatic changes to a patients smile while leaving intact the maximum amount of tooth structure.
A 25-year-old male presented for esthetic improvement of his smile (Fig. 1).
The patient had recently completed vital night guard bleaching, yet still wanted to do more to improve his smile.
The patient was given the option of performing some limited bonding and enamelplasty or feldspathic porcelain veneers. After reviewing the benefits and limitations of each the patient chose to have feldspathic porcelain veneers placed on #’s 7-10.
In the case the goal of treatment was not to change color, rather just add porcelain to create a more symmetrical and ideal form. feldspathic porcelain veneers have the ability to achieve the goals of the case with minimal tooth reduction requirements.
Using a .3mm depth cutting diamond (Axis) depth cuts were placed in the facial surfaces of #’s 7-10. The using a medium grit diamond bur (KSO, Axis) a uniform reduction of .3mm of tooth structure is removed. A chamfer margin is placed at the height of tissue. Figure 2 shows the final conservative preparations. Note that the margins are place at or slightly above the height of tissue and the interproximal areas are all slightly open.
Final impression are taken with a full arch tray (Directed Flow impression tray, 3M/ ESPE) with a polyvinyl siloxane impression material (Honigum, Zenith/DMG) (Fig. 3). A bite registration is also obtained. The impression, bite registration, along with a CD containing all the case photography are sent to the ceramist along with a written prescription requesting for the fabrication of four feldspathic porcelain veneers (Avante, Pentron Ceramics) using a minimal thickness of porcelain.
With this particular case NO temporary restorations were places. Esthetically the patient was comfortable with the appearance of the prepared teeth. There was very minimal sensitivity to the teeth since the preparations were entirely in enamel.
In 10 days the patient returned for the delivery of the veneers. Once the veneers are verified for fit and esthetics, they are cemented into place using a translucent light cured resin cement (Nexus 2, Kerr).
At the patients next recall appointment we did a final evaluation of his veneers. The patient was very pleased with the overall esthetic result (Fig. 4)
This case is an excellent example of the esthetic results that can be obtained with minimal trauma to the existing dentition.
A 17-year-old female presented to the office with esthetic concerns. This young lady had completed orthagnathic surgery and three years of orthodontics. Now as she is almost completed with her cosmetic and functional rehabilitative dentistry she is wishing to complete her smile.
A frontal view does not reveal the area of concern (Fig. 5). But when you look at the lateral retracted photos shown in Figs. 6 & 7, the nature of the patients concern become more obvious.
The patient and mother are given the options of direct bonding or conservative feldspathic porcelain veneers. Upon reviewing the benefits and limitations of each the chose to have the cosmetic concern address with placing of porcelain veneers on #’s 6, 7, 10, and 11.
The preparation design is extremely conservative due to the age of the patient and the necessary tooth removal to create the desired esthetic outcome.
.3mm depth cuts are placed with a diamond depth cutting bur (Axis). The using a medium grit KSO diamond bur (Axis) the tooth is uniformly reduced .3mm on the facial surfaces of #’s 6, 7, 10, and 11.
Figures 8 & 9 show the final preparations just prior to taking the final impression. Note the conservative design of the preparations after removing only .3mm of tooth structure.
The ceramist is instruction to create minimal thickness feldspathic porcelain veneers (Avante, Pentron Ceramics) that are very translucent so that the natural color of the underlying tooth structure is pulled thru the ceramic.
The final restorations are cemented to place with translucent, light cure resin cement (Vitique, Zenith/DMG) after the patient and her mother had approved the final esthetics.
At the two week post op visit the highly esthetic result demonstrates the final improvement of the smile and the completion of a series of treatments from multiple dentists over the course of four years (Figs. 10 & 11).
A 48-year-old female presents with an old PFM crown on #9 that has had RCT completed over 20 years ago (Fig. 12).
Upon interviewing the patient to better understand her esthetic goals it was revealed that the patient is not only unhappy with the unaesthetic old crown, but that she is looking to have significantly improved esthetics with a special concern with improved symmetry in her smile.
Reviewing with the patient several options; together we decide that placing veneers on #’s 7, 8, and 10 along with replacing the crown on #9 would create the esthetic result that she was looking to achieve.
At the preparation appointment the old PFM crown was removed from #9. The preparation is then refined to accept a pressed ceramic full coverage crown (Empress, Ivoclar). #’s 7, 8, and 10 are prepared for minimal preparation feldspathic porcelain veneers (d.sign, Ivoclar) (Fig. 13) demonstrates the final preparations of 7-10.
Because of the extreme discoloration of #9 it is imperative that a digital photograph be taken of the shade of the final prepared tooth to assist the ceramist in his efforts to block out the deep discoloration of the endodontically treated tooth #9 (Fig. 14).
When the patient returns two weeks later the restorations are tried into place. After reviewing the restora
tions functionally and esthetically it is agreed to cement them to place. The feldspathic porcelain veneers are cemented to place with translucent light cure resin cement (Calibra, Dentsply/ Caulk) and the pressed ceramic crown is cemented to place using a dual cure version of the same cement system.
Figure 15 shows the final esthetic result. Even when using the feldspathic veneers in combination with a pressed ceramic material it is possible to achieve a highly esthetic result.
Elective, cosmetic dentistry can be highly rewarding to both the dentist and the patient. But the treating dentist is ethically obligated to use minimally invasive methods to create the desired end result.
Many beautiful and impactful smile makeovers can be accomplished with a combination of bleaching, bonding and recontouring. However, there are other times when the indirect options are required to meet the clinical situation or the patient’s expectations. When considering indirect options the dentist should always keep in mind the potential of the minimally invasive feldspathic porcelain veneer. Often times the desired end result can be created with the minimal tooth reduction requirements of feldspathic porcelain veneers.
All of the ceramic artistry presented is the work of William ‘CK’ Kim with Americus Dental Labs.
Dr. Radz maintains a full-time private practice in Denver, Colo. He is a clinical associate professor at the University of Colorado School of Dentistry. Dr. Radz recently received his fellowship from the Academy of Comprehensive Esthetics. He lectures internationally on the materials and techniques used in esthetic dentistry. Dr Radz is an international member of the Canadian Academy for Esthetic Dentistry (www.caed.ca).
Oral Health welcomes this original article.
1.Steve Diogo, Dental Products Report, “Makeover Mania”, June 2004, pp. 28-40.
2.Heymann HO, Swift EJ Jr., “Is Tooth Structure Not Sacred Anymore?”, J Esthet Restor Dent 2001; 13(5):283.
3.Friedman MJ. Porcelain Veneer Restorations: A Clinician’s opinion about a disturbing trend. J Esthet Restor Dent 2001;13(5):318-327.