In cosmetic dentistry today there may be no more debated or controversial subject than no-prep porcelain veneers. Many dentists would argue that it is not possible to achieve esthetics and soft tissue health without the removal of some tooth structure to make room for the porcelain restoration. Yet the volume of just one type of no-prep veneers (Lumineers by DenMat) being produced leaves evidence that many dentists are placing veneers on teeth that are not prepared.
The opponents of the no-prep concept would point to cases such as Figure 1. This is a case that presented to the authors’ office last year. A local dentist had placed eight no-prep veneers six weeks previous to this photograph. At the time of the consultation there were only 51/2 veneers remaining on the teeth. The margins were very bulky and the tissue around the remaining veneers bled easily. Esthetics, although subjective, were disappointing to the patient even prior to the fracture and debondings.
Figure 1 is an example of why many dentists reject the concept of a no-prep veneer. This case is a demonstration of a clinical failure on many levels. However, it would be incorrect to assume that this case and others like it are examples of the best results that no-prep veneers can produce. Just as we see a wide range of functionally and esthetically unacceptable, acceptable and excellent posterior PFM crowns; we can see the same range of variability in no-prep veneers.
The idea of not preparing a tooth and bonding porcelain to the etched enamel has been around for over 20 years. When porcelain veneers were originally being developed a no-prep design was widely accepted as a “preparation” option. However, in a short period of time as ceramists developed and refined their techniques, it became apparent that a better esthetic and biocompatible result could be created by removing some tooth structure and creating a gingival margin to finish the porcelain margin. Soon it became obvious that with existing materials and techniques of the day that the tooth preparation concept would provide a superior result.
DenMat and their Lumineer product brought back to dentistry the concept of returning to not preparing teeth for veneers. This idea was and is very appealing to patients. But also to the conservative- minded dentist, it provided a solution to their ethical concern of removing healthy tooth structure solely for the sake of improved esthetics. Today all dental practices in North America are well aware of the Lumineer product and the no-preparation concept.
Currently there are many different labs creating no-prep porcelain veneers. In general the no-prep porcelain veneers being produced today are stacked porcelain veneers. This is because for years ceramists have demonstrated the ability to create veneers at a thickness of .5mm. Traditionally, pressed ceramics are .8 -1.0mm thick, making it difficult to get a good esthetic result along with excellent marginal adaptation around the soft tissue. A majority of labs now promoting their “no-prep” veneers are using stacked porcelain.
Recently, with newer ceramics and techniques, a number of ceramists have developed the ability to create porcelain veneers at a minimal thickness of .3mm. This minimal thickness has now presented the opportunity to create the esthetics desired and the soft tissue response necessary for a no-prep concept to be successful on all levels.
Over the past five years, Dr. Dennis Wells, working with ceramist Mark Willes, have developed a no-prep veneer system called Durathin™.1 Within this system they have consistently demonstrated the ability to use exceptionally thin porcelain to create esthetic enhancements without the removal of tooth structure. Theirs is just one of several systems now available using ultrathin veneers and no tooth reduction.
For the past two years the author has worked with his ceramists (Americus Dental Labs, NY) and a new, highly esthetic porcelain (Venus, Heraeus) to incorporate and modify the concepts taught by Dr. Wells and others to create no-prep veneers that meet the patients’ and the dentists’ functional and esthetic expectations.
The following are two case studies to provide examples of one clinician’s early cases using the no-preparation concept. Working with an experienced lab and an excellent porcelain, it is the author’s objective to demonstrate the improved esthetics and appropriate, health soft tissue response. But also to dispel the myth that it is not possible to achieve these results without the preparation of teeth.
Case One
A 23-year-old female presented to the office for bleaching. After three weeks of take home bleaching the patient returned to the office. Though pleased with the results of the bleaching process she inquired as to suggestions for improving her smile (Fig. 2) .
Upon critical evaluation it was noted that the maxillary right canine was slightly rotated to the mesial. The maxillary right lateral incisor was proportionally small when compared to the centrals and was not symmetrical to the opposite maxillary lat- eral. Both laterals demonstrated an area of hypocalcification at the incisal edge. Both maxillary canines are more pointed than the patient would like and demonstrate very distinct distal lobes.
It was suggested to the patient that one way to improve an already attractive smile would be to do so in a very conservative manner. It was recommended to do some minor enamel recontouring on the maxillary canines. Additionally, it was suggested to place no-prep veneers on the maxillary laterals. The no-prep allows for noninvasive restorations to be placed and improve the smile by the means of addition of porcelain without the need for subtraction of tooth structure. The effect of placing the no-prep veneers on the maxillary laterals will be to: a) improve the symmetry of the two teeth, b) to increase the length and apparent width of the teeth to create better overall proportions, c) the increase in the size of the laterals will deemphasize the central incisors making them less prominent and creating a more mature appearance in the smile.
After discussing the above suggestions with the patient she expressed interest in pursuing this course of action and an appointment time was arranged.
At the first appointment the maxillary canines are first recon-toured to deemphasize the rotation of the right canine, slightly reduce the canine eminence of each, and lastly to soften the incisal edge by making it less pointed. Then a final impression is taken (FlexiTime, Heraeus), as well as a bite registration and opposing impression (Alginot, Kerr). The impressions, photographs and a written prescription are sent to the lab with the request of fabrication of Venus (Heraeus) porcelain no-prep veneers.
In two weeks the patient returns. The veneers are tried into place using a clear try-in medium. The veneers are evaluated for fit and esthetics. The patient is allowed the opportunity to preview the veneers. With her approval the veneers are cemented to place using a light-cure only, transparent composite resin cement (NX3, Kerr).
Once light cured to place the excess cement is carefully removed with a scaler, #12 scapel blade and 16-fluted carbide burs. The occlusion is evaluated and minor adjustments made. Lastly, the facial margins are all checked for any areas of minor overcontouring. Using a fine grit diamond bur a few areas of the facial margin are carefully smoothed and repolished.
In two weeks the patient returns for a post op exam. She is very pleased with the results (Fig. 3). The addition of the porcelain veneers has met our esthetic goals by creating a more natural ap- pearing proportion to the anterior teeth, taking some of the emphasis off the central incisors, and softening the appearance of the canines. Just as importantly, the soft tissue around the no-prep veneers is in excellent health.
This case demonstrates how using non-invasive methods can make a noticeable improvemen
t in an already attractive smile (Fig. 4) .
CASE TWO
A 26-year-old female presents to the office for a consultation on how to improve her smile. At first glance the patient appears to have a very attractive smile and many dentists would seriously consider not providing treatment to this patient (Fig. 5). However, through more discussion with the patient we were able to discover the things about her smile which she hoped to improve. Figures 6 and 7 show retracted lateral views of the patient. The patient’s concerns were with the small appearance of her maxillary laterals, the prominence of the maxillary centrals, and the very open incisal embrasures associated with the canines.
Having the option of doing non-invasion, addition-only, no-prep porcelain veneers allowed for the author to be comfortable providing a solution to the patient’s concerns. It was suggested to the patient that her esthetic objectives could be met by placing no-prep veneers on the maxillary canines and laterals. The centrals are already a bit pronounced and wide, placing veneers here would have created a negative impact on the patient’s smile and ultimately lead to an esthetic failure.
When the impressions are sent with the photographs to the lab the instructions request to have the porcelain veneers (Venus, Heraeus) be highly translucent. Since the underlying shade of the laterals and canines were an acceptable shade, and since no restorations are being placed on the centrals it very beneficial to have a highly translucent veneer to create a “contact-lens” effect and maintain an already desirable shade of the teeth.
The patient returns in two weeks. The veneers are tried in, and with the patient’s approval, cemented into place in a manner similar to the technique described in Case Study 1.
One week later the patient returns for a post operative visit.
Figures 8 and 9 demonstrate the highly esthetic results and the excellent soft tissue response. The patient’s post operative smile demonstrates how minor, non-invasive additions to the patient’s smile create a smile that is more mature in it’s appearance and has meet the patients esthetic goals (Fig. 10). The final result is a very natural appearing smile (Fig. 11)
Conclusions
To be able to create clinically acceptable, no-prep veneer cases, the first critical key to success is case selection. This concept cannot be successfully applied to all patients in all situations. Poor case selection will lead to less than acceptable results.
However, when applied to a case that lends itself to the no-preparation concept there can be no better restoration for a patient. We have the potential to do virtually “ideal” dentistry when we remove none of the patient’s natural teeth. Dentistry by addition is always more desirable than dentistry by subtraction, when possible.
But the clinician who is just starting to learn the no-prep concept should not be misled into thinking that this is an easier way to provide porcelain veneers. To consistently get excellent results requires good diagnostic skills to choose the right cases and experience with all the many intricacies of porcelain veneer placement and adjustment to ensure long term acceptable results.
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Dr. Radz maintains a full-time private practice in Denver, CO. He is a clinical associate professor at the University of Colorado School of Dentistry. Dr. Radz has 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
References
1. Durathin Live. Presented by Dr. Dennis Wells and Mark Willes, Brentwood, Tennessee; July, 26-28, 2007.
Acknowledgements
The author would like to recognize the artistic talents of the ceramists at the Americus labs and their dedication to the vision for the future of no-prep veneers.
The author would express his gratitude to his patients, Renee and Annette, for their willingness to participate in many clinical photos but also for making time to participate in the photography that is the cover of this month’s Oral Health journal.
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This case is a demonstration of a clinical failure on many levels
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A majority of labs now promoting
their “no-prep” veneers are using stacked porcelain
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Both maxillary canines are more pointed than the patient would like and demonstrate very distinct distal lobes
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Just as importantly, the soft tissue around the no-prep veneers is in excellent health
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Dentistry by addition is always more desirable than dentistry by subtraction
