April 2010, Volume 6, Issue 4
Published by AEGIS Communications
Porcelain Laminate Veneer Therapy
Ultra-thin veneer options using a no-prep or partial-prep philosophy.
Dentistry is entering a new era in respect to porcelain laminate veneer therapy. Calamia’s article in 1983 was one of the first introducing porcelain veneers as we know them today.1 Since then, porcelain veneers have gone through significant changes from both a materials and technique aspect.
During the past 25 years, there has been a lot of discussion regarding the preparation techniques used for porcelain veneers. Calamia and other early pioneers looked at veneers as a noninvasive, additive process and worked primarily with a no-preparation concept. Early on it was found that a little enamel preparation could help to enhance the esthetic outcome and improve the marginal fit. Later, in the mid to late 1990s, pressed ceramic was introduced as a material option. Its excellent esthetics and strength and easier fabrication process paved the way for an industry shift away from stacked porcelain to the pressed product. However, the physical demands of proper pressed-ceramic fabrication required an increased amount of tooth reduction (0.8 to 1 mm compared to 0.5 mm for stacked porcelain) to make room for the required thickness of pressed ceramics. Porcelain veneer therapy with pressed ceramics became a more aggressive treatment.
Starting early this decade there began to be much debate over the ethics and advantages involved with the more aggressive pressed-ceramic preparation vs the more conservative stacked-porcelain preparation. Many well-known clinicians lined up on either side of this debate. Over time it began to appear that the more conservative-minded clinicians were more correct in their arguments. Friedman’s 1998 publication2 followed by others3-6 points to a very high clinical success rate for veneers when bonded to a mostly enamel surface. The pressed ceramics of the 1990s (which carried into the 2000s) required a preparation design that all but eliminated any enamel within the veneer preparation.
A new debate is now present in the world of porcelain veneer preparation design: preparation of the tooth vs no preparation at all.7 There is concern is that a no-preparation design will have the negative effects of compromised soft tissue health at the margin resulting from an over-contoured restoration, an unesthetic final result resulting from compromises required with no tooth reduction, and an inability to fabricate porcelain thin enough to be used in a “additive only” process. This debate has been fueled by many dentists observing clinically esthetic and functional failures of no-preparation veneers fabricated in a less than an esthetic manner and placed oftentimes by practitioners who have inadequate training or experience. These failures have led many cosmetic dental experts to believe that the no-preparation concept is a compromise. However, the argument could be made that many of these failures are due to the limited esthetic abilities of the porcelain that was used, the artistic ability of the ceramist or dentist, and/or the inexperience of the ceramist or dentist.
Many dentists have had excellent esthetic results using a no-preparation concept. Wells recently published several no-preparation cases that demonstrated excellent esthetic results.8 The no-preparation veneer concept can and does work. However, as with any procedure, it has its limitations. The dentist who wants to incorporate no-preparation veneers into his/her practice needs to understand the importance of proper case selection, material limitations, and have clinical experience with handling and finishing thin veneers. For many reasons, no-preparation veneers can be as challenging if not more so than conventionally prepared veneers.
Case selection is of upmost importance. Wells gives the following parameters of cases that have high success potential8:
- bicuspid extraction orthodontic cases.
- cases with short, worn teeth (assuming occlusion/bite forces are managed).
- misalignment cases in which one or more teeth are in a lingual position.
- cases in which teeth need more “presence” (big lips and small teeth).
- narrow maxillary incisors with diastema(s) or wide incisal embrasure form.
The following are presentations of case studies that demonstrate the esthetic potential of porcelain veneers created using a prepless philosophy. Additionally, a new pressed ceramic that has the ability to be fabricated to a minimal thickness of 0.3 mm to 0.4 mm will be discussed. This new material now provides a pressed ceramic for those cases appropriate for a no-preparation technique.
No-Preparation Case Studies
A 24-year-old woman presented 6 months after completing orthodontic treatment. The patient had a comfortable and balanced occlusion, excellent periodontal health, and no history of existing dental restorations on any of her anterior teeth. Her chief complaints included wanting whiter, bigger teeth and a fuller smile.
Clinically, her teeth had been orthodontically moved to an occlusally stable position and were aligned with no spaces (Figure 1). However, on closer inspection, the maxillary teeth were seen to be in a slight lingual version (Figure 2). An extraoral view shows that the patient’s upper lip was thin and appeared to lack hard tissue support (Figure 3).
From a case selection standpoint, this patient was an excellent candidate for veneers using a no-preparation concept. To confirm this, one of two techniques could be used. The first technique involves the use of a direct resin composite mock-up.9 A composite resin veneer could be temporarily fabricated on the teeth to be treated with the no-preparation porcelain veneer. The second technique requires the fabrication of a wax-up of the final desired result. A matrix of the wax-up is created; then, using a temporary acrylic or bis-acryl material, the wax-up is transferred onto the patient’s teeth.10 Either technique allows for the patient and the dentist to get an excellent visualization of the final result both from an esthetic and functional aspect.
In this case, the latter technique was used. Preoperative impressions were obtained along with a bite registration and sent to the ceramist for evaluation and fabrication of a wax-up. When the wax-up was returned, a matrix of the wax-up was created with a putty impression material.
The patient returned for an esthetic preview appointment. At this time orthodontic retractors were placed and the maxillary anterior teeth were dried. The putty matrix was loaded with a bis-acryl automix temporary material (Luxatemp®, DMG America, http://www.dmg-america.com) and set in the mouth for 4 minutes. After 4 minutes, the matrix was removed. Any excess flash was removed and the temporary material was polished. Now the patient and the dentist were able to get a preview of the esthetics and phonetics. At this time, the patient and the dentist agreed that the patient’s esthetic goals and phonetic needs could be accomplished and together they agreed to proceed with treatment.
The temporary material was completely removed from the teeth. The teeth were cleaned with a prophy cup and coarse-grit prophy paste. Final impressions were taken using a polyvinylsiloxane (PVS) impression material (Take 1® Advanced™, Kerr Corporation, http://www.kerrdental.com). The bite registration from the previous appointment was reused.
This information, along with preoperative photographs and written instructions, were sent back to the ceramist. The ceramist fabricated stacked porcelain veneers on teeth Nos. 4 through 12 using a highly esthetic stackable porcelain (Venus®, Heraeus, http://www.heraeus-dental-us.com). The clinician’s expectation was to receive porcelain veneers that were of minimal thickness (0.3 mm to 0.4 mm) and would slightly raise the value of the treated teeth.
On the patient’s return, the veneers were tried in and evaluated by the patient and the dentist. Once both agreed that their goals were met, the veneers were cemented into place using a light-cure only translucent shade resin cement (Vitique®, DMG America).
A 1-week postoperative photograph shows an excellent final result (Figure 4). The no-preparation veneers have filled out and added some needed bulk to the maxillary anterior teeth and eliminated the appearance of a generalized lingual version of the teeth (Figure 5). Also note in Figure 5 the excellent soft tissue health at the 1-week postoperative point. The veneers also will provide for more hard tissue support of the upper lip and help to create a full and broader smile (Figure 6).
A 30-year-old military officer presented with a chief complaint of having teeth that were too small. She was looking to achieve a bigger, broader, whiter smile. She specifically stated that she was only interested in a no-preparation option.
Figure 7 shows her preoperative condition. She had bicuspid extractions as part of orthodontic therapy. She had slight negative spacing in the buccal corridor. She had large, full lips that created the appearance of small teeth. Lastly, there was a slight lingual version of her maxillary anterior teeth (Figure 8). She fit many of the parameters stated by Wells as an ideal candidate for no-preparation veneers.8 Additionally, she had done extensive research on the Internet and specifically requested that her teeth not be prepared.
The patient was on a very tight time schedule based on her short military leave. This time frame did not allow for the time it would require to have the laboratory do a wax-up. In her case, a direct composite mock-up was done the same day as the consultation appointment. Using a composite resin (Venus® Diamond, Heraeus) teeth Nos. 6 through 11 were modified by adding temporary resin veneers. This gave the patient an opportunity to visualize a draft of what the final result would look like. It also provided an opportunity to see how much incisal length could be tolerated without effecting phonetics and function.
Once the temporary resin veneers were contoured and adjusted to the satisfaction of the patient and the dentist, a study model was created using an alginate substitute PVS material (AlgiNot™, Kerr). This study model was sent to the laboratory along with the final impressions.
The patient returned the next day. At the “preparation” appointment, the temporary resin veneers placed the day before were removed, all the needed photography was done, the teeth to be veneered were thoroughly cleaned and then PVS (Take One Advanced) final impressions were taken along with a bite registration. This information was sent to the laboratory along with the request to fabricate stacked porcelain (Venus) veneers on teeth Nos. 5 through 12. As the patient’s existing shade was very high in value and the patient was happy with the color of the teeth, the request to the ceramist was to make the final thin (0.3 mm thick) veneers highly transparent.
The patient returned in 1 week for the try-in/delivery of the final veneers. The patient and the dentist both evaluated the veneers with a transparent try-in paste. With mutual agreement on the esthetics and fit of the veneers, the patient agreed to have them cemented in place. Due to the patient’s limited time before having to report back to duty, the following are 2-day postoperative photographs. Figure 9 shows that even less than 48 hours after placement, the soft tissue had an excellent response to the veneers. A lateral view shows the benefits of an additive procedure to create teeth that appear larger, begin to help fill out the buccal corridor, and eliminates the retracted appearance of teeth that were in slight lingual version (Figure 10).
A 26-year-old professional model presented for a consultation to discuss options to improve her smile (Figure 11). The initial impression was that the patient had a very nice, natural-appearing smile. Upon further discussion with the patient she expressed that she felt her front teeth (maxillary centrals) were too prominent, her laterals were too small, and that she did not like the spaces (incisal embrasure) associated with her canines (Figure 12 and Figure 13).
To confirm that the patient’s concerns were correctly understood, and that her goals could be accomplished, a direct composite “wax-up” was done with resin at the consultation appointment. With this the author was able to verify that the patient’s concerns could be corrected with an additive process.
This case points out the significant benefit of the no-preparation concept. This patient had an attractive smile, and to prepare these teeth conventionally for veneers would be an ethically difficult decision for many dentists. However, if her goals could be accomplished with no harm to her existing dentition and these goals can be reached with an additive-only procedure, the ethical concerns for many would be minimized significantly.
Since the patient had beautiful, symmetrical centrals that were a bit prominent in her arch form and smile it was decided not to place veneers on them. However, the proportionately small and round laterals would benefit with the addition of volume and length. Then to achieve the shape she desired in her smile and smile line, it was decided to place veneers on both canines as well.
Stacked porcelain veneers (Venus) were fabricated for teeth Nos. 6, 7, 10, and 11. Figure 14 and Figure 15 show lateral views at a 2-week recall visit. Note the excellent soft tissue health, the ability to perfectly blend with the shade of the natural adjacent teeth, and that there is no appearance of excess bulk on the teeth restored.
Figure 16 shows the subtle but noticeable change to something more symmetrical, the emphasis on the centrals has been reduced, and a more mature smile with the addition of the four no-preparation veneers emerged. The final result is a natural-appearing smile (Figure 17).
Stacked Porcelain vs Pressed Ceramic
The previous cases demonstrated were completed using stacked porcelain. Stacked porcelain is routinely used in no-preparation veneer cases because it is possible for a talented, experienced ceramist to fabricate stacked porcelain to a minimal thickness of 0.3 mm. A majority of no-preparation cases will tolerate only the smallest addition of porcelain without looking too bulky.
Until recently, pressed ceramics’ minimal thickness was in the 0.7-mm to 0.8-mm range. The inability to fabricate pressed ceramic any thinner than this made it a difficult material to use successfully in no-preparation cases. New technology in pressed ceramic has brought to the dental market a material that is now able to provide a pressed ceramic option for no-preparation veneer cases. A lithium-disilicate material (e.max®, Ivoclar Vivadent, http://www.ivoclarvivadent.us) has demonstrated the ability to be pressed as 0.3 mm to 0.4 mm in thickness. Additionally, within the last year, this material has been brought to market in a high-translucency formulation that makes it ideal for use in “no-preparation” veneers.
The pressed version of the e.max material has excellent potential for use as an ultra-thin veneering material. There are many benefits of having the ability to create thin veneers in pressed ceramic. First of all, the pressed ceramic technique is an easier and faster process. Fabricating stacked porcelain veneers is an art form that takes years to learn and perfect. Pressed ceramics is an easier technique to learn. This allows for more laboratories and ceramists to be able to offer ultra-thin veneers. Pressed ceramics are also stronger than stacked ceramics. This has several benefits. There is less chance of fracture during the fabrication and delivery process. Additionally, the better physical properties may mean better longevity for the patients.
The following case study will demonstrate the potential of pressed ceramic veneers using a “no-preparation” concept of treatment.
A 24-year-old woman presented for a cosmetic consult. Her chief complaints were that she felt she had a gummy smile and that her teeth were short and uneven. Upon clinical examination, it was noted that there was excessive display of gingival tissue, the incisal edges of teeth Nos. 6 through 11 were uneven due to occlusion and minor acute trauma, there was negative space noted in the buccal corridor, and there was a slight lingual inclination of the central incisors (Figure 18). Aside from an unbalanced occlusion, the patient was in excellent dental health.
To achieve the patient’s goals, the following treatment plan was presented: occlusal equilibration; gingivectomy on teeth Nos. 6 through 11; and porcelain veneer therapy using a “no-preparation” concept on teeth Nos. 4 through 13. The patient agreed to the above treatment plan.
At the first appointment, upper and lower impressions and a bite registration were taken for fabrication of a Kois deprogrammer for facilitation of occlusal correction. After impressions were obtained, the maxillary anterior teeth were anesthetized. Teeth Nos. 6 through 11 were evaluated to confirm that a gingivectomy could be performed without violating biological width. Using a diode laser, the gingival levels were raised to decrease gingival display, increase tooth length, and create better soft tissue symmetry. The patient then returned for delivery of the Kois deprogrammer the following week. Then she returned once a week for 3 weeks as her occlusion was refined. Figure 19 shows the patient at her last equilibration appointment demonstrating the results of the gingivectomy. At this point, the patient was ready to proceed with the veneer therapy.
Study models were now obtained of the patient with her new gingival contours and balanced occlusion. These models were sent to the laboratory for wax-up for visualization of final restorations. The laboratory was informed that a “no-preparation” concept was desired and that these veneers were to be used to reestablish proper functional occlusion.
For the past year, the author has worked with Dental Arts Lab (Peoria, IL) on a concept called P2Veneers™. P2 stands for partial preparation. Experience over time with the “no-preparation” concept has led to the realization that in some of these veneer cases some preparation is required on a few teeth. But by calling this “partial preparation,” the hope is that dentists will grasp that oftentimes preparation can be limited to enameloplasty of only certain parts of specific teeth and not the entire tooth surface.
This case is an example of a partial preparation case. During the wax-up phase, the ceramist was able to identify a few areas of the patient’s teeth where the porcelain would be either too thin or over-contoured if minor contour changes were not made. He indicated on the study model and reinforced with a phone call the specific areas that required enamel reshaping.
Figure 20 and Figure 21 demonstrate that many times the reduction required can be accomplished with a sandpaper disc and small fine diamond. This recontouring was accomplished without the need for anesthetic. New impressions were obtained using a PVS impression material (Take One Advanced) and a new bite registration was sent to the laboratory. The porcelain used for these veneers was the high-translucency (HT) shade of e.max.
The patient returned 2 weeks later for the delivery appointment. The veneers were tried in with a clear try-in paste (NX3, Kerr Corporation) and evaluated for fit and esthetics. With the approval of the patient and the dentist, the veneers were cemented to place using a light-cure-only translucent composite resin cement (NX3).
When the patient returned for her postoperative evaluation, an excellent result can be seen. Figure 22 shows the patient’s new smile. The teeth were now even, symmetrical, and slightly whiter. The amount of gingival display was noticeably reduced and there was a filling of the buccal corridor creating the appearance of a bigger, wider smile. Figure 23 shows in a closer retracted view that there was excellent soft tissue health and that there was no excess bulk to the teeth. A full-face photograph shows that the new veneers helped to create a beautiful smile and a patient who was very happy with her smile transformation (Figure 24).
We are now starting to enter a new era in porcelain veneer therapy. It is an important step for cosmetic/elective dentistry. To be able to be truly minimally invasive if not non-invasive in our elective treatment options gives dentistry the opportunity to make significant changes in patients’ smiles and lives with minimal trauma to the patients’ teeth. Because tooth structure is sacred, if we do have treatment options that can minimize or eliminate the need for unnecessary removal of tooth structure, we are ethically bound to investigate that option with our patients.
Cases 1 through 3 were created by Americus Dental Lab in New York. Case 4 was fabricated by the Signature division of Dental Arts Lab in Illinois. The author would like to credit the ceramists from both laboratories for the excellent porcelain work demonstrated in this article.
The author has a financial interest in the P2Veneers™ concept.
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9. Wells DJ. “Durathin Live” Workshop. July 2009. Nashville, TN.
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About the Author
Gary M. Radz, DDS
Associate Clinical Professor
University of Colorado School of Dentistry
Cosmetic Dentistry of Colorado