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Written by Louis Malcmacher, DDS Tuesday, 01 March 2005 00:00
Porcelain veneers are an excellent conservative modality to create and restore aesthetics in the human dentition. The beauty of porcelain is unsurpassed because of the natural light transmission that occurs through the porcelain and ultimately through the tooth. It is color stable, strong once bonded to the tooth, and has the capacity to last for years.
The porcelain veneer originally was adopted as a very conservative treatment. It took the place of crowns in many instances because the clinician did not have to remove a lot, if any, tooth structure to restore the teeth and change the aesthetics. It was because of the conservative and aesthetic nature of this restoration that it gained in popularity. We all realize how aggressive a crown preparation is to the tooth, and in most circumstances there really is no choice but to be aggressive in the preparation when a tooth needs a crown. Porcelain veneers allowed us to change the color and the shape of teeth without removing good, sound tooth structure.
In recent years, porcelain veneer techniques have been taught that include aggressive preparations on par with full-coverage crowns. In fact, some of these preparations are really three-fourths or seven-eighths crown preparations as opposed to porcelain veneers. Many times this is due to the properties of the porcelain being used, which may require significant reduction of the tooth in order for that particular porcelain to be successful. My philosophy re-garding dental materials is that they should not determine the preparation for the treatment that I want to accomplish. If I am going to use porcelain veneers on a case, it is going to be a case where there will be no preparation or perhaps minimal preparation that does not break through the enamel. If three fourths of the tooth needs to be cut down, then I am going to finish that last quarter of the tooth and make it a complete crown preparation. There is nothing conservative about leaving a quarter of the tooth unprepared, nor are there any advantages to doing that.
From a practice management perspective, porcelain veneers have become household words in America. Thanks to TV shows such as Extreme Make-over and The Swan, patients actually come in asking for porcelain veneers by their proper name. It is absolutely amazing to watch patients who have been thinking about looking better over the years now come in and ask for cosmetic treatment. Aesthetic dentistry has never been as popular as it is these days, and it is up to us to take full advantage of this wonderful opportunity to give our patients a great smile. However, once the patient learns that some porcelain veneers require irreversible preparation of their perfectly healthy teeth, they are somewhat distressed and may be hesitant to proceed with treatment.
There seems to be a miscommunication going on between dentists and patients. Patients see porcelain veneers on TV, and it looks like a relatively simple procedure, because generally what they see is the “before and after” on a one-hour show. Their perception is that it takes only about 30 seconds to a minute to get beautiful porcelain veneers. What porcelain veneers mean to patients is a pleasant, painless, and permanent procedure to get a great-looking smile. To most dentists, however, it means preparing the teeth for porcelain crowns, impressions, making temporaries, having patients complain about the temporaries until they get their porcelain veneers, trying in, seating the porcelain crowns we call veneers, and then listening to the patients complain about their sensitive teeth for a couple of weeks (and often much longer than that).
However, with properly diagnosed and treatment planned cases, no-preparation porcelain veneers are easy, painless to the patient, and can achieve all the functional and especially aesthetic expectations of the dentist and the patient without using local anesthetic or temporization. This article will demonstrate some cases of no-preparation porcelain veneers.
ADVANTAGES OF NO-PREPARATION PORCELAIN VENEERS
The advantages of a no-preparation veneer are obvious. There will be no harm to the pulp and therefore no postoperative sensitivity. Many practitioners who have attended my lectures over the years have reported numerous cases of postoperative sensitivity after an aggressively prepared porcelain veneer case was cemented. We shouldn’t be surprised at all. When you remove most, if not all, of the enamel and some of the dentin from a healthy tooth, chances are you will get sensitivity unless you work very hard (and get very lucky) to seal the dentinal tubules properly. It is very disheartening to both the dentist and the patient when you have completed a beautiful aesthetic case and the patient can’t take a drink of hot coffee or cold soda. No-preparation veneers leave plenty of enamel on the tooth to protect it. Patients will have no postoperative sensitivity, which goes a long way toward keeping them happy and building your aesthetic practice.
|Figure 1. This photograph dramatically shows the difference between a three-quarter crown veneer standard preparation on a virgin tooth compared to a very minimally prepared tooth for a Cerinate Lumineer.|
The difference between a no-preparation veneer and a full preparation or three-fourths crown preparation is dramatically visualized in Figure 1. This patient had 6 traditionally prepared veneers, which he wanted redone because he wanted whiter teeth. He also wanted to place veneers on the bicuspids so he would have an attractive, full smile. Figure 1 shows the upper right cuspid with the old veneer removed, and what you see is a “veneer” preparation. The upper right bicuspid is a no-preparation veneer—notice that the enamel is intact and there will be no sensitivity with this procedure. Figure 2 shows the completed case after proper finishing. The results here are clear, and both have demonstrated a beautiful result. The difference is that the no-preparation tooth did not require a temporary or any tooth structure removal, will have no sensitivity, and will have a better chance at long-term success.
|Figure 2. This postoperative picture strongly makes the case for no- or minimal-preparation veneers.|
Another major advantage of no-prep porcelain veneers is that you will have plenty of enamel to which to bond. While bond strengths to dentin are certainly improving, they still do not rival the bond strengths of resin to enamel. The more enamel you have, the better bond you will have, and the longer any bonded restoration will last. An aggressively prepared tooth for a porcelain veneer that removes most of the enamel on the facial and the interproximal aspects is probably doomed to failure over the long term. I have personally seen cases of these types of veneers on patients that literally have popped off one by one within a year of being placed. Porcelain veneers are a tremendous practice builder, but not when they constantly fall off and cause an aesthetic emergency for the patient.
Another advantage of no-preparation porcelain veneers is ease of impression because you do not have to manage the gingival tissues. Supragingival placement of the porcelain veneers makes them easy to clean and maintain for the patient. The ease of placement for these kinds of veneers is unparalleled. Also, another major advantage is that no temporization is needed. The phone calls about chipped, loose, broken, or rough temporaries are eliminated because there are no temporaries to deal with.
Many dental professionals make the mistake of thinking that no-preparation veneers mean that you just place them and you are done. That is not true. Proper finishing is required. The margins of the veneers are finished against the natural tooth just like any other restoration that we place.
|Figure 3. This patient, a dentist, wants veneers but does not want to cut down these virgin teeth.|
|Figure 4. Left lateral view showing large diastema.|
|Figure 5. Right lateral view.|
The first case demonstrated is a common diastema that walks into every dental office routinely. This patient, who happens to be a dentist, wanted a great smile. The last thing he wanted to do was have virgin tooth structure reduced, so he opted for no-preparation porcelain veneers. Figures 3 through 5 show that the diastemas are evenly spaced, therefore no preparation is required because nature has prepared this case. This patient is an excellent candidate for no-preparation porcelain veneers. There is plenty of room for porcelain, and there is absolutely no need for any reduction of the teeth.
After a proper evaluation, diagnosis, and treatment plan, the first appointment was simply for a polyvinyl siloxane impression, since no preparation was needed.
The porcelain chosen for these veneers was Cerinate (DenMat). This porcelain has demonstrated strength even when made 0.3 mm thin, which is a very common thickness when doing no-preparation porcelain veneers. If a porcelain requires 0.8 to 1 mm of thickness when used for veneers, then obviously you would have to make that up in reduction of the tooth. No-preparation technique requires specialized porcelain that can be made “contact lens thin” and can be easily added to tooth structure with very little thickness associated with the veneer. Cerinate porcelain has long-term studies demonstrating its success as a veneer porcelain, particularly when used with a no-preparation or minimal preparation technique.
|Figure 6. No-preparation veneer try-in for patient approval.|
|Figure 7. Teeth are etched and demonstrate the frostiness of enamel. These veneers will be completely bonded to enamel.|
|Figure 8. Tenure Uni-Bond (Den-Mat) bonding agent has been applied to teeth.|
|Figure 9. Seating of the veneers.|
At the second appointment, Figure 6 demonstrates the porcelain laminate veneer try-in before seating (Cerinate Lumineers, DenMat). Proper fit and shade were established. The teeth were etched with a 37% phosphoric etch (Ultraetch, Ultradent), as shown in Figure 7. Note that there is no exposed dentin, which will eliminate the possibility of sensitivity. Figure 8 shows the teeth after the bonding agent has been placed (Tenure Uni-Bond, DenMat). The laminates were then filled with a resin cement (Ultrabond Plus, DenMat), and Figure 9 shows 2 out of the 3 veneers being placed on the teeth. One important note here is something we don’t think enough about when we use resin cements. Resin cements that you use should closely resemble the physical properties of the porcelain that is being used. If these physical properties are closely matched, there will be less long-term problems with pop-off and breakage.
|Figure 10. Plasma arc light (Virtuouso Sapphire, Den-Mat) activated for 5 seconds for each veneer.||Figure 11. Margins are finished with a dull 7901 12-fluted carbide bur.|
Figure 10 shows the porcelain veneers being cured for 5 seconds with a plasma arc light (Virtuoso Sapphire Light, Den-Mat). Proper finishing is essential in these cases. A no-prep technique does not mean no finishing. The margins of the porcelain veneer are ended approximately 0.5 mm from the gingival margin so that these margins can easily be finished against the enamel without having to involve the soft tissues. Figure 11 shows finishing of the porcelain veneer margin with a flame-shaped, dull 7901 bur (SS White).
|Figure 12. An interproximal saw (CeriSaw, Den-Mat) is used to clean and smooth the interproximal areas.||Figure 13. Occlusion is finalized once the veneers are cemented.|
Figure 12 demonstrates the interproximal finishing with a very thin interproximal saw (CeriSaw, Den-Mat). This thin blade will break open the interproximal contacts while maintaining them. The occlusion is adjusted so that equal occlusal contacts are on the linguals of the anterior teeth and proper cuspid guidance is established (Figure 13).
|Figure 14. The finished veneer case.||Figure 15. The patient before the placement of no-preparation Lumineers.||Figure 16. This dentist is very pleased with the aesthetic result and his decision not to have any tooth reduction for veneers.|
Figure 14 shows the seated veneer case. Note that proper inclination of the teeth and lip support are established with a minimal thickness of porcelain applied to the teeth. Compare the preoperative photograph in Figure 15 with Figure 16, which shows a very pleased patient.
I’ve had the pleasure over the years of treating many dentists. In my experience, there is no question that when dentists want porcelain veneers, they will choose a no-preparation technique because they do not want their teeth cut down solely for aesthetic reasons. There is certainly no reason we should not provide that same level of aesthetic care for all of our patients when possible.
|Figure 17. This patient with perfectly healthy teeth wanted aesthetic improvement without tooth reduction.|
The next case (Figure 17) shows a patient who wanted aesthetic improvement but did not want any preparation of his teeth. In looking at this case, you can see that the teeth have a fairly flat profile and are fairly straight up and down in the buccal-lingual direction. This case also has some very mild diastemas, and with those 2 considerations, it is a nearly perfect case for no-preparation porcelain veneers. Postoperative photos show 8 Cerinate Lumineers placed on the teeth. Because there are no temporaries to deal with between appointments and at the placement appointment, the time it takes to place these veneers is much less than what it would have taken to remove temporaries, clean up the teeth, and then prepare the teeth for the final bonding of the veneers. These 8 veneers were placed and finished in 38 minutes.
|Figure 18. Eight no-preparation Cerinate Lumineers placed and finished in only 38 minutes.||Figure 19. Full-face preoperative photo of the patient in Figure 17.||Figure 20. A very happy patient with his new veneers and no sensitivity because his teeth did not have any reduction whatsoever.|
Figure 18 is the retracted “after” photograph, and Figures 19 and 20 show the full-face preoperative and postoperative results. Note how natural looking no-preparation veneers look and what a wide, bright smile they have provided for the patient.
Hopefully this article has demonstrated that the best way to provide porcelain veneers is with a no-preparation technique. No-preparation porcelain veneers require specialized materials to keep the veneers 0.3 to 0.5 mm thin. Dramatic aesthetic results are easy to obtain with porcelain veneers and are so simple when they are done the way porcelain veneers should be done: by keeping them on enamel to ensure the best possible bond, by keeping them very thin, and by using a no- or minimal-preparation technique. Gingival health is excellent because the soft tissue is not involved, provisional restorations are not required, postoperative sensitivity is avoided, and most importantly, the patients are very pleased with this permanent and painless way to achieve outstanding aesthetic results.
The beautiful dentistry depicted in Figures 3 to 20 was done by Dr. Robert Ibsen in Santa Maria, Calif.
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