AESTHETICS

A Conservative and Painless Smile Makeover

INTRODUCTION a years, due to a deserved lack of confidence Dentists are constantly striv- that available materials were able to effec- ing to find more procedures tively adhere to enamel and/or dentin, many to offer existing patients as clinicians and dental laboratory technicians well as to attract new patients. advocated the unnecessary removal of healthy Two major barriers discourage tooth structure to create retention and resistant patients from accepting a den- geometric forms,4 and this dental principle has Robert L. Ibsen, tal treatment: pain and money. endured to this day. DDS, OD Veneers can be a prime exam- Proper shaping and contouring of porcelain­ ple. They may be perceived by during the finishing process requires aesthetic both dentists and patients­ as a very expensive skills and an attention to detail. The general and time-consuming procedure, requiring the belief, often expressed by clinicians, that reduc- removal of significant tooth structure. How- ing tooth structure to achieve proper aesthet- ever, today, it is possible to improve almost any ics is simpler and more efficient is incorrect. smile without the need to remove valuable Correspondingly,­ laboratory technicians rec- natural tooth structure, using the strong por- ommend, without regard for protecting the celains available with reliable bonding systems pulp, that dentists unnecessarily remove more that can opaque and modify hue, value, and natural tooth structure. How much tooth reduc- chroma.1 The average clinician no longer needs tion should be made is solely the clinician’s deci- to announce at recall, “It is not that bad,” or “We sion after considering case design and potential will watch it,” but instead can offer a dynamic Figure 1a. Preoperative photo. for trauma to the pulp from an extensive prep. solution the patient will want. When patients Painless, minimally invasive techniques are are informed about how much their appearance b simpler and efficient, protect the pulp, and are can be improved without shots, needles, or any more rewarding—if the time is taken to become pain, they will want their smiles improved and proficient in the finishing techniques. strengthened. The use of 4.5x magnification and As dental materials and adhesives advanced stronger porcelains and resin luting agents has during the last 3 decades, the prepless tech- expanded the patient base eligible for veneer nique has gained support.2,4 This shift toward placement using a noninvasive or minimally more conservative and painless techniques is invasive technique. due to a realization among clinicians that tradi- tional methods of veneer preparation result in A Brief Background many three quarters to seven eighths crowns, Interestingly, when we look back on the evo- not “veneers,”2,3 and that less tooth reduction lution of tooth preparation methods for the Figure 1b. Stone model showing the depth of the chip decreases the risk of disturbing or damaging the placement of veneers, we discover that the on the patient’s maxillary central incisor. pulp.6 Also, patients are aware that there are non-preparation (“no-prep”) or preparation-free less invasive techniques now available to them. (“prepless”) techniques were actually the orig- c With the advent of improved materials and inal methods for preparing teeth to receive adhesives, the understanding that tooth struc- veneers.2,3 In the mid-20th century, clinicians ture offers excellent support for bonded porce- were developing more conservative techniques lain, and the knowledge that enamel provides for preparation for caries4 that provided a foun- an outstanding surface for retention when the dation for no-prep techniques for veneers. proper principles of adhesion are used, this min- Several factors caused a shift in the dental imally invasive technique is an excellent treat- standard, from a preparation requiring signifi- ment option.6 cant tooth reduction, to a conservative prepara- tion.2,3,5 Restorative dentistry has historically CASE REPORT relied on preparations designed with resistance Diagnosis and Treatment Planning and retention in mind, and that is still the stan- Figure 1c. Retracted view; before contouring and A 35-year-old female, in excellent health, was dard in many restorative cases today. In prior bonding. referred to our office by a patient upon learning

DENTISTRYTODAY.COM • JUNE 2015 a b c

Figure 2a. After contouring and restoring the Figure 2b. Occlusal view, after contouring. Figure 2c. Our patient went home with no enamel defect with a bonded composite resin temporaries. restoration. 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 appear- ance 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 Figure 3. Dental rubber dam on lingual side of the Figure 4. Preparing the teeth for veneer placement. pull the trigger on anything that would require teeth. grinding my teeth down.” After having braces as a teenager,­ and years of bleaching in her 20s, she performed using the patient’s sensory system to edges, and somewhat flat surfaces with slight presented with a defect on tooth No. 9 that wors- alert of any sensitivity. No analgesics of any kind rounding on the mesial and distal incisal edges. ened over time, collecting superficial stains that were administered. A long ultrafine diamond After receiving the case back from the labo- made the defect even more apparent. (NeoDiamond 30 Micron­ Finishing Pointed ratory team, the patient was scheduled for the The patient saw her dentist regularly and Cone No. 3314.10VF [Microcopy]) was used to seating. (Only 1.5 hours was blocked off for the had a healthy dentition. She presented with a smooth the incisal edges, the upper right cen- placement appointment.) Prior to any surface balanced occlusion, healthy gingival tissue, and trals were shortened, and the patient’s mesial of preparation, veneers are first treated with a citric dentition capable of supporting veneers. the upper left central and the upper left lateral acid solution, then rinsed and dried thoroughly. When determining an aesthetic treatment were contoured to bring the arch into better The inside of the veneer is then coated with plan, there are multiple aspects to evaluate and alignment (Figures 2a and 2b). Magnification silane for 30 seconds, then excess can be gently consider. These include the expectations of the was used to avoid touching sensitive dentition blown off. Try-in is the opportunity to ensure patient, preferred shade, desired teeth shape and (ZEISS 4.5x magnification [ZEISS]). It should be the veneer fits properly, determine whether length, midline position, lip position and full- noted that restorations adjoining natural teeth any shade modification is necessary and verify ness, incisal edge position, occlusion, and the can be blended with the enamel at the gingi- the patient is satisfied with the appearance. extent and location of any tooth contouring,5 if val margin, making the porcelain restorations After the try-in is complete, place a thin layer any is required. indiscernible from the natural tooth.6 of Tenure S (DenMat) inside the veneer, gently The recommendation to the patient­ was a The labial defect on the maxillary left cen- blowing off the excess. To confirm fit and accep- minimally invasive solution that would address tral was restored with a composite resin (A2) tance, each veneer was carefully placed on the both aesthetics and function. It was proposed (such as Virtuoso Flowable [DenMat]) to allow patient’s teeth, one at a time, without adhesive. that 10 prepless veneers be done on her max- a smooth, clean, and flat surface. As noted in The fit was perfect, the patient liked the appear- illary teeth, from teeth Nos. 4 to 13 (second Figure 2c, her teeth were minimally altered, and ance of her new smile, and she wanted to pro- bicuspid to second bicuspid), with enamel con- the patient was allowed to go home without ceed with placement. touring limited to nonsensitive (enamel) tooth any temporaries. The patient was very pleased An unconventional and time-saving step, structure. Bleaching options, to be chosen and that there was an immediate improvement in which helps with postoperative cleanup, is to done at a later date, were presented for her low- appearance, and she later reported that she had apply a layer of dental dam/barrier material ers to avoid a noticeable postoperative shade dis- no postoperative pain/sensitivity problems. along the lingual surface of the teeth to receive crepancy between­­ her veneers and lower arch. A detailed vinyl polysiloxane (Precision­ [Den- the veneers. It is also recommended to apply a The patient was excited that this conserva- Mat]) impression was taken, using heavy body layer to the 2 teeth beyond the most distal teeth tive approach would still serve to strengthen, for the tray and light body for the wash on the to receive veneers (Figure 3). Brief light curing align, and further enhance her lip-line, while teeth. Several intraoral, facial, and close-up pho- was carried out for 2 to 3 seconds per tooth with protecting her existing dentition. She eagerly tos were taken before and after contouring. The a PAC light (Sapphire Supreme Plasma Arc consented to the treatment plan, as presented. impressions were sent to the lab for 10 lithium Curing Light [DenMat]) until the resin cement disilicate (IPS e.max [Ivoclar Vivadent]) veneers. reached a rubbery state. This is a critical time Clinical Protocol A detailed prescription was sent to the lab team, saver that allows for easy cleanup of bonding At the patient’s next visit, she chose shade requesting shade 020 with 50% translucency, material after placement. 020. Then, minimal enamel contouring was smooth surface texture, an incisal wrap, square When using the correct adhesives, porcelain

DENTISTRYTODAY.COM • JUNE 2015 a b c

Figure 5a. Tooth overflowing with bonding adhesive. Figure 5b. A Schure 349 Lumineer Instrument Figure 5c. Remove gingival ledge with an ultrafine foot- (DenMat) was used to remove excess cement without ball diamond (NeoDiamond 30 Micron Finishing Football scratching any porcelain. No. 3923VF [Microcopy]).

d e

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. veneers can be bonded to the following 5 sur- faces: 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 thor- oughly rinsed off and the teeth were thor- oughly dried. Next, a bonding agent (Tenure A and B [DenMat]) was applied to the etched surfaces and lightly air-thinned. This was fol- lowed by a resin liner bond enhancer (Tenure S); used to strengthen the bond and protect from contamination. Figure 6. Minimally invasive veneers are ideal for a variety of maladies. Bonding to enamel or porcelain creates a stronger bond than bonding to dentin. Also, the is applied is strongly recommended, as bubbles Football No. 3923VF [Microcopy]), with copious greater surface area from not reducing the teeth cause voids. If bubbles do appear, break them amounts of water and a light touch, were used to creates a more stable foundation for the adhe- with an explorer instrument and fill the voids blend the porcelain ledge on the lingual margin sive to create a tighter bond. The bond becomes with more composite. Applying excess material to the tooth (Figure 5c). This technique reduces secure and stable when the adhesive bond trans- ensures no air bubbles are trapped under the the possibility of gingival erosion by eliminat- forms from monomer to polymer (this only veneer, helping to obtain a stronger bond. Each ing any foreign body under the gingival mar- occurs after, at minimum, a 5-second cure to veneer was cured using a 9.0-mm curing tip fol- gin that could stimulate and exacerbate gum each tooth). Without the necessary surface area lowed by a final cure on both the labial and lin- recession (Figure 5d). A long ultrafine diamond and secured bond, the veneers would be seated gual of each tooth. was used to further contour the shoulder of the on an unstable surface and have a higher proba- The step that really differentiates this pain- porcelain to a feather-edge blending with the bility of future pop-offs. This is why preserving less porcelain veneer technique from the tradi- enamel at the gingival margin. as much of the natural (enamel) tooth structure tional veneer technique is the finishing. Excess Occlusal equilibrium was achieved to elim- as possible is highly recommended. resin cement was removed using a 12-fluted bur inate any eccentric influences. A 30-fluted bur With the teeth etched and the lithium disil- (FG No. 7902 12-blade Flame Carbide [Brasseler (FG No. 9903 30-blade Flame Carbide [Brasseler­ icate properly treated with silane, the veneers USA]) from around the margins. A Schure 349 USA]) was used to polish the veneers along the were ready to be seated. Starting at the incisal Lumineer Instrument (DenMat) was used to gingival margin, and then a Dialite (Brasseler edge and working upward in a back-and-forth remove cured cement on the labial surfaces, as USA) polishing cup and porcelain polishing motion, a liberal amount of composite lut- well as from the interproximal areas on both the paste were used to reglaze the porcelain, cre- ing cement (Ultra-Bond [DenMat])­ was slowly facial and lingual sides. This instrument is used ating a natural-looking sheen. The specially syringed onto the inside (concave surface) of because it does not scratch porcelain (Figure 5b). designed saw and sander instruments (CeriSaw each veneer, overfilling each one (Figure 5a). Then, an ultrafine American football-shaped and CeriSander­ [DenMat]) were used to open Carefully watching for bubbles as the composite diamond (NeoDiamond 30 Micron Finishing the easy-to-open interproximal contacts and

DENTISTRYTODAY.COM • JUNE 2015 a used to open any interproximal contacts that veneer cases that have been performed over were not opened at the initial visit. Dental floss many years—give great support and credibility was run through the interproximal surfaces to to no-prep to minimal-prep veneer procedures.7 ensure that all the contacts were smooth. Through the use of a minimally invasive procedure, the patient presented herein was CLOSING COMMENTS provided with a solution that restored her smile, The patient wanted to cover the chip on her addressed quality-of-life issues, and restored her front central and chose painless porcelain self-confidence to continue a successful career veneers because they did not require removal of centered on beauty and journalism. She was b any of her sensitive tooth structure. She did not extremely­ pleased with the final results of her have any extreme issues such as severe staining, treatment, especially after waiting many years overly crooked or missing teeth, or significant to find a solution that suited her (Figure 7). More gingival recession. Prior experience as well as than a year later, she still loves how natural her an initial laboratory wax-up assured us that teeth look, no longer worries about smiling or prepless veneers would adequately fulfill the taking photographs, and never has to worry patient’s needs and wishes. about bonding falling off her front tooth. “They It is best to determine the most conservative look amazing. I felt like I looked 5 to 10 years clinical treatment for your patient and then younger. If you do not have to grind down your select the optimal material and technician that teeth and get traditional veneers, I don’t know allow you to treat according with your preferred why you would do that!”F bonding modality.3,5 Moreover, carefully select References the laboratory team for the technical work to 1. Ibsen RL, Weinberg S. A conservative and painless approach ensure that they have the knowledge, skill, and to anterior and posterior esthetic restorative dentistry. Dent Today. 2006;25:118-121. the right materials to support the treatment 2. Cho GC, Donovan TE, Chee WW. Clinical experiences with modality that you have prescribed. It is import- bonded porcelain laminate veneers. J Calif Dent Assoc. 1998;26:121-127. ant to know that they are able to successfully 3. Kwasniewski J. Diagnosis and Placement of No-Prep Veneers create beautiful restorations over margin- and [DVD]. Newport Beach, CA: Glide­well Laboratories; 2008. 4. Malcmacher L. Back to the future with porcelain veneers. Dent shoulder-free preparations. Today. 2003;22:70-75. Remember, as with all dental procedures, 5. Principles of tooth preparation. In: Terry DA, Leinfelder­ KF, Geller W, et al. Aesthetic & Restorative Dentistry: Material it is important to do a thorough examination, Selection & Technique. Stillwater, MN: Everest Publishing c to present a full treatment plan, and to obtain Media; 2009:45,70. 6. Al-Zain A. No-Preparation Porcelain Veneers. Indianapolis, IN: written consent prior to the start of treatment. Indiana University School of Dentistry; 2009. dentistry.iu.edu/ It should be noted that, in this case, the initial files/8713/7597/9229/Non_Preparation_Veneers.pdf.­ Accessed March 10, 2015. exam and contouring appointment took less 7. Ibsen RL. Cuspid- and anterior-guided occlusion achieved with than an hour to complete, demonstrating that Cerinate porcelain withstands test of time. DentalTown. August 2003. dentaltown.com/images/dentaltown/magimages/ this veneer technique often allows the clinician aug03/aug03dtpg40.pdf. Accessed March 10, 2015. to save valuable chair time. As more dental professionals understand­ and learn a proper pain-free technique, they realize Dr. Ibsen, a graduate of the University of Southern Cali- fornia School of Dentistry, has dedicated his career to the that invasive preparations for veneers are often preservation of tooth structure in the practice of cosmetic unnecessary and can be traumatic to patients. dentistry. He now devotes his time to lecturing at dental Figures 7a to 7c. After contouring and final finishing. Clin­icians are also becoming more aware of the meetings, educating dentists about SmileSimplicity Pain- less Smile Improvement, and is still active in his private advantages of less reduction, the large variety of practice. He can be reached at via email at the address smooth rough edges (Figure 5e). These instru- adequate adhesives available, and the benefits [email protected] or by calling (805) 925-3271. ments do not harm or erode the porcelain but of using enamel as the foundation for bonding Disclosure: Dr. Ibsen was the founder and former CEO of simply remove the excess cement. veneers (Figure 6). Finally, as illustrated in this DenMat Corp and the developer of Rembrandt Toothpaste The patient was instructed to brush with article, patients are becoming increasingly aware and LUMINEERS. In 2007, Credit Suisse acquired DenMat. an electric toothbrush (Sonicare [Philips Oral of, and prefer, less invasive options. These facts— Now, Dr. Ibsen has no affiliation with the company and no financial connection with any of the products mentioned in Healthcare]) and a nonabrasive whitening tooth- combined with the tremendous number of suc- this article. He has received no compensation for writing paste. On the follow-up visit, the CeriSaw was cessful, noninvasive, and minimally invasive this article. He has an ownership interest in RLI Education.

DENTISTRYTODAY.COM • JUNE 2015