a new perspective on minimally invasive veneer techniques

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A New Perspective on Minimally Invasive Veneer Techniques

Written by Peter Harnois, DDS

Thursday, 18 July 2013 08:29

Full-prep veneers remain the standard in our dental education, if not our practices. Not until the last decade have thin veneer

techniques been introduced to students as an appropriate treatment methodology, when indicated.

Today, our patients increas ing dental IQ is driving their demand for a les s invasive approach to aes thetic treatment. This article will

present a case report demons trating the latest generation of thin veneers (Lumineers [DenMat]). This clinical treatment approach

represents the opportunity for responsible aes thetics, while always ass ess ing the requirem ent for the removal of healthy tooth

structure. DenMats new approach and educational platform for Lumineers, called Thinnovation, is not just abou t no-preparation

dentistry, though we must always consider the concept of choosing the best possible approach for each patient, based on individual

needs and circumstances.

CASE REPORT

Diagnosis and Treatment Planning

A 28-year-old female patient, Ashley, presentedto our of fice. Shehad com pleted 3 years of orthognathic treatment with her oral

maxillofacial surgeon and her orthodontist. She specifically sought a dentist who offered no-prep style veneers. Her chief complaintwas her s mile o r, in her words, the lack of showing teeth when sm iling. In addition, she did not like the quality of the teeth/sm ile that

did show (Before Image and Figure 1).

BEFORE AFTER

Before Image.Pre-op smile

retracted, frontal view.

After Image.The final smile.

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Figure 1.Pre-op smile retracted,

frontal view.

The patient presented with a pos torthodontic removable upper Ess ix-style retainer, and with healthy periodontium and s table

occlusion, showing no temporomandibular joint disorder (TMD) symptoms or bruxing/clenching. Full dental records were performed

and a LUMISmile (DenMat) picture taken to produce a digital s mile m akeover. Her principal aes thetic issues included m ultiple

diastem as, peg lateral incis ors, and hyperplastic gingival tissues that covered the gingival one third of the maxillary (peg) lateral

incisors (teeth Nos. 7 and 10). Also evident was s tained, mottled, and hypocalcified enam el on all upper teeth.

At her ini tial appointment, it was apparent that she had already done he r homework. She had reques ted inform ation from her ora l

surgeon about the current landscape of porcelain veneer options and a lready knew about thin veneers, specifically Lumineers. She

had followed up by visiting DenMats patient Web site (lumineers.com) to learn more about what was possible with minimal-prep

veneer systems . She already knew what she w anted. This experience is increasing ly comm on. As a general dentist practicing

aesthetic dentis try for the past 31 years, I have found that the m ajority of new patients have som e idea of what they seek clinically.

Todays patients are more em powered with the knowledge available to them and often have gone beyond what theyve seen on

television or heard from friends to visit Web sites and educate themselves. Our role is to help them determ ine appropriate treatment

options and to outline the probable outcome based on the current state of their dentition. Giving patients all possible options, and

then letting them decide, has p roven to be a consis tently success ful beginning to case acceptance.

Ashleys firs t appointment was m ore focus ed on how her new smile could look, in term s of shapes and s hades, than i t was talking

about the difference between minimal- or no-prep veneers (such as Lumineers) and traditionally prepped veneers. She knew that

she wan ted an aesthetic solu tion that minimized the removal of her tooth structure. One of her first comments to me was, I dont

have that much tooth structure as it is, so I don t want my teeth made any smal ler!

As part of the aes thetic cons ult, LUMISmile photos were taken to provide a digital s mile makeover in les s than 30 minutes . (The

SNAP Digital Imaging system is another useful diagnostic tool that could be used here.) A comprehensive smile analysis was

conducted, including comple tion of a Smile Analysis Form by the patient. From this information, the patient communicated that she

did not like to smile due to her small, misshapen, and discolored teeth. After completing a full dental exam, smile analysis, and oral

cancer screening (which included the use of the VELscopeVx [DenMat]), we presented the patient with her LUMISmile be fore and

after digital images (Figures 2a and 2b).

Our patients responses at this stage are often emotional, and this patient was no different. The case proposal for 8 Lumineers for

teeth Nos. 5 to 12, with a pos t-treatment removable retainer/nightguard, was accepted.

Clinical Protocol

Treatment started in early December 2012, with a prophylaxis. A one-hour chairside whitening was done (Lum ibrite and Sapphire

light [Both by DenMat]), followed by one week of home whitening us ing a 35% carbamide peroxide gel (Lumibrite) with custom trays

(30 minutes per day for one week was pres cribed, and followed). Our patients teeth were whi tened from 2M1 to OM3/OM2, and theporcelain s hade the patient selected was OM2. (Note: Clinicians can use any effective whitening s ystem and technique of their

choosing . For example , with the EPIC laser technique [BIOLASE Technology], treatments can be performed in as little as 30

minutes.) Possible laser gingivoplasty was also discussed with the patient at this time, though she expressed hesitation with the

procedure so a final decision was postponed.

Figure 2a.Before. Patients before

image , which is sen t to DenMat

digitally.

Figure 2b.After. Patients LUMISmile

(DenMat) digi tal after, received in the

same consult appointment from

DenMat to give the patient an idea of

her eventual result.

Figure 3.Frontal retracted

contoured/prelaser.

Figure 4. Immediate postlaser.

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Figure 5a.Right lateral, postlaser

after one week of healing.

Figure 5b.Left lateral, postlaser at

one week.

One week after whitening and shade selection, enamel-contouring procedures were begun. Enamel contouring has long been

considered a som ewhat gray area in achieving the desired outcome sought by a patient. The problem has been that traditional prep

is well defined, but enamel contouring is not. There are no set principles of smile design . Beauty is in the eye of the beholder, and

there is no right or wrong. The new Thinnovation approach is based on the principles of smile design and utilizes minimally invasive

concepts of tooth preparation to achieve the desired res ult. For the first time, the Thinnovation concepts of enamel contouring strive to

define the proper principles o f contouring to achieve the aes thetic, natural lifelike res ult that the patient seeks from the doctor.

Initially, it is our job to obtain the neces sary information from the patient. We need to lis ten and photo document each persons

individual pre-op situation. LUMISmile allows the practitioner to show each patient an individual digital smile makeover and is a

tremendously successful visual starting point for discussing with the patient what is possible. In more advanced cases, live models,

intraoral mock-ups, and approved provisionals are tremendous diagnos tic tools that Thinnovation allows a doctor to employ. In this

patients case , enamel contouring was not only what she s ought from this dentis ts office, but a viable option for treatment utilizing

the following Thinnovation concepts of enamel contouring: correct size discrepancies, adjust occlusal plane cants, adjust midline

cants, adjust suprabulges and incisal bevel.

Understanding sm ile des ign concepts will di ctate what to contour. Any imperfection is m agnified if not contoured. In Ashleys case,

there were certain bulges and line angles that, if not properly contoured, would have looked thick, bulky, and unnatural in the end

result. Her natural teeth had a facial bulge to them that needed to be reduced to elongate her teeth and close the dias temas and

achieve the natural look she wanted. A very important concept for the doctor to grasp is that Lumineers is an additive cosmetic

procedure. Properly informing the patient that smoo thing the bumps off of her teeth to achieve a natural result made pe rfect sens e

to her. The fact that I could also inform he r that enamel contouring would not induce any biological harm to her teeth made her feel

even better about the prescribed treatment.

Figure 6.Frontal view (solid). Figure 7.Right lateral view (solid).

Figure 8.Left latera l view (sol id). Figure 9.Occlusa l view (soli d).

Figure 10.Frontal trans view

(transparent).

Figure 11.Finished frontal view

retracted.

After she signed the inform ed consen t form, we focus ed on 3 cl inica l objectives. First, an incisa l bevel would be created to al low for

design of the patients veneers with proper form and function with her existing occlus ion. The heights of contour on the facial aspect

would be reduced so all teeth would slope i n toward the incisal as pect from the facial heigh t of contour. Finally, all the line angles

would be reduced and rounded, and facial embrasures would be deepened where there was interproximal contact of teeth to allow

for well-defined line angles and a natural depth of field to the facial embrasures. All of this was accomplished without any patient

discom fort, local anesthetic, or temporization.

As mentioned, the patient was initia lly reluctant to trim tis sue with laser, so we contoured her enam el firs t and then s howed her wha t

a difference it would m ake if we could expose the natural tooth structure still under her hyperplas tic tissue. Also, I wanted to perform

an aesthetic crown lengthening (in general), since the patient showed her attached gingiva when she smiled. Once she saw and

understood that, we performed the las er gingivoplasty using a diode laser (SOL Diode Las er [DenMat]) at one W continuous wave

setting, uncovering the remain ing clinical crown of teeth Nos. 5 to 12. (Note: There are numerous other dental diode las ers su itable


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for this procedure s uch as Picasso Lite [AMD LASERS], EPIC 10 [BIOLASE Technology], SIROLaser Advance [Sirona Dental

Systems ] Odyss ey Navigator [Ivoclar Vivadent], and so on.) This created a more na tural result and a m ore symmetrical gingival

display in general (Figures 3 and 4). We let healing occur over one week (Figures 5a and 5b). Final impres sions were then taken

along with records and photos.

In preparation for Lumineers placement, 2 full-arch impressions were taken using a vinyl polysiloxane (VPS) impression material

(Splash! [DenMat]). In addition, a face-bow (Panadent), stick-bite, and a closed-tray bite registration were al so taken. Then, all was

sent to DenMats full-service dental lab in Ca lifornia. In addition, 8 post-contouring photos were taken and s ubmitted through an

online Web portal. An Ess ix .040 thickness removable retainer was fabricated for the patient to wear full-time until the placem ent of

her veneers.

Once the laboratory team received the materials from our office, the impressions were s canned to produce digital m odels forfabrication of the first set of digital des igns. Three days later, digitally designed previews were e-m ailed to m e for review. After the

design previews were altered, per m y instructions, an approved set of previews (Figures 6 to 10) were sent for final fabrication of the

veneers. These approved digital previews were made possible by implementing the previously discussed smile design concepts

and proper enamel contouring to achieve the desired lifelike aesthetic result the patient was seeking. The completed Lumineers

were sent 13 days later.

Placement Appointment

Lumineers were placed following the steps in The Doctors Guide to Lumineer Placement. The lab-etched Lumineers were treated

with porcelain conditioner and prime. The teeth were then polished with porcelain laminate polishing paste found in the Lumineers

Placement Kit (DenMat). Using Ul traBond (DenMat) try-in paste, I placed teeth Nos . 7 and 8 wi th the suprem e white shade and teeth

Nos. 9 and 10 w ith shade B-O. Our patient selected the suprem e white shade for her OM2 Cerinate veneers placement.

Her teeth were polished again with porcelain laminate polishing paste. The arch was isolated with Sapphire whitening system cheek

retractors and isola ted (Paint-On Dam [DenMat] placed on lingual as pect of teeth Nos . 4 to 13).

Figure 12.Right lateral view

retracted.

Figure 13.Left lateral view retracted.

Figure 14.Finished smile

nonretracted.

Teeth Nos. 5 to 12 were etched with 30% phosphoric acid, rins ed, and dried . Five coats of Tenure A and B (DenMat) self-cure

adhes ive were applied to the teeth and dried. Next, one coat of Tenure S was appli ed to both teeth and to the Lumineers , then

thinned with air.

The Lumineers were loaded and placed in sequence of teeth Nos. 8 and 9 using a Lumigrip and supreme white UltraBond. After

wiping off excess cement, teeth Nos. 7 and 10 were placed. Using a 2-mm tack-curing tip attached to a Sapphire curing light, teeth

Nos. 8 and 9 were spot-cured for one second. Teeth Nos. 6 and 11 were then placed. Teeth Nos. 7 and 10 were then tack-cured for

one second. Teeth Nos. 5 and 12 were placed. Teeth Nos. 5, 6, 11, and 12 were tack-cured for one second and remain ing material

was wiped off with brushes dipped in Tenure S. Final curing of 5 seconds facially and lingually was conducted with a 9-mm light-

curing tip.

Using a bur and finish ing system (des igned by DenMat for this restorative system), the remaining res in cement was removed. This

was accomplished using the mosquito diamond; 12 and 30 fluted carbides on the facial aspect; and the football-shaped diamond,

along with the 12 and 30 fluted carbides, on the L aspect. A finishing kit was used for final bite adjustment, and all contacts were

opened (Cerisaw [DenMat]) and smoothed (Cerisander [DenMat]). The final polish was completed with a polishing cup (Dialite

[Brasseler USA]) and porcelain laminate polishing paste. Full alginate impressions were also taken for the fabrication of a new

maxillary Essix .040 retainer/guard.

As the patien t experience is defin itive, her statem ent affords an appropriate conclusion: My sm ile looks natura l, but more importantly,it feels natural. My teeth dont look bu lky and m y bite feels no different than prior to having Lumineers placed. I am getting

complim ents left and right on how am azing my sm ile looks! (Figures 11 to 14, and After Image).

CLOSING COMMENTS

Minimally invasive Lumineers with a high level of natural aesthetics were s elected for this case, consistent with both expressed

patient objectives and clinical assessment. The goal was to deliver an aesthetic smile makeover while preserving the most tooth


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structure possible.

Digital design was used, as well as pretreatment patient imaging, which supports predictable results. Patient veneers are fabricated

as thin as 0.3 m m, therefore requiring m inima l reduction of healthy tooth structure. The current generation of leucite-reinforced

porcelain all ows for very thin (0.3 mm ) pressed veneers that are also strong (216 MPa). The manufacturer also provides a variety of

fabrication processes from pressed monochromatic to layered polychromatic restorations.

Its important to note that light enamel contouring was needed on this case in order to achieve naturally beautiful, lifelike results. The

distinction between no-preparation, minimal-preparation, and traditional full-preparation veneer techniques is often misunderstood

and miscommunicated. What makes a veneer restoration minimally invasive? The author suggests that minimally invasive applies

to any veneer prep technique as long as the least amount of tooth structure is being rem oved on that particular case or tooth while

still deli vering functional, aesthetic results.

It takes a m ultidiscipli nary approach to anterior aesthetics to ens ure that all tools at our disposal are be ing us ed to preserve natural

tooth structure while s till achieving the desired aes thetic results. In this pa rticular case, that multidis ciplinary approach included

orthognathic surgery, detailed treatment planning and risk assessment, soft-tissue recontouring, enamel contouring, and a

laboratory partner that delivered an ultra-thin set of aes thetic veneers.

Dr. Harnois practices general and cos metic dentistry in Hinsdale and C hicago, Ill. He graduated with honors from the University of

Illinois at Chicago College of Dentistry in 1982, where he then also served as an assistant clinical professor of Oral Diagnosis from

1983 to 1989. He is the p residen t of the Illinois Chap ter of the American Academy of Facial Esthetics (AAFE) and a mem ber of the

American Academy of Cosm etic Dentistry, the World Clin ical Laser Institute, the American Den tal Association , the Illino is State

Dental Society, and the Chicago Dental Society. He is al so a Fellow and faculty member of the AAFE. Dr. Harnois i s a nationally

recognized speaker who lectures for NuCalm; the AAFE on Botox and derm al fillers; and for DenMat on Lum ineers, Snap-On Smile,

and oral cancer de tection. He can be reached at [email protected].

Disclosure: Dr. Harnois is a nonpaid consultant for DenMat Holdings. He received no compensation for writing this article.

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