Custom designing a smile with minimally invasive veneers
by Dr. John Heimke
Patients today are very aware of
the social and intrinsic value of a
beautiful smile. While many may
use at-home whitening products
or whitening toothpastes to brighten
their smiles, others who need more
than over-the-counter solutions seek
a restorative approach to solve more
serious issues, including tooth discolorization,
chipped or crooked teeth,
diastemas and other abnormalities
affecting the aesthetics of their smile.
Most patients who seek restorative
care have done their homework and
are well-informed about restorative
dental procedures. Often, they express
concerns about any treatment that
requires removal of healthy tooth structure, and seek advice on alternative
types of procedures designed
to preserve as much tooth structure
as possible while providing a highly
aesthetic outcome.
When considering cosmetic treatment
for patients who have retained
most of their natural teeth, especially
young adults, it is of utmost importance
to preserve as much tooth
structure as possible. Although conventional
porcelain veneer treatment
approaches are still prescribed for
most patients receiving cosmetic care,
improvements in restorative materials
and conservative techniques offer
clinicians the possibility to deliver
highly aesthetic and long-lasting
outcomes using minimally invasive
or no-preparation veneers to aesthetically
restore a smile and even
straighten misaligned teeth.1–4
As aesthetic dentists, we are in a
true sense custom designers. Much
like architects, interior or fashion
designers, artists or plastic surgeons,
we create a design that reflects the
individual nature of our patients. The
objective is to capture the essence of
that patient, so it’s important to ask
questions such as: How do you live your
life? What are your primary interests?
What inspires you? All those personality
traits affect the oral design smile
process and correlate to tooth shapes
and arrangements chosen.5
Case report and treatment plan
A 32-year-old patient in good health
presented to the practice for consultation
(Fig. 1). His chief complaint was
the aesthetics of his smile—he was
concerned by the chipping occurring
on his maxillary central incisors
(Fig. 2), the discolorization of tooth #8
and the crowded teeth in the lower
anterior arch (Fig. 3). He wanted a
smile makeover to address these concerns
and a case outcome that would
give him a brighter, whiter, more
natural-looking smile.
A preliminary examination revealed
his teeth on both arches were natural.
Composite restorations on #8
and the midline of #8 and #9 were
deteriorating and discolored. His
lower anterior teeth displayed moderate
crowding on #22–#26, which was
contributing to the chipping of his two
central incisors. The patient’s narrow
jaw when smiling revealed deficient
buccal corridors from molars to
canines (Figs. 4 and 5), which affected
the aesthetics of his smile.6
Fig. 4
Fig. 5
The patient was assured that his
concerns could be addressed and
aesthetics restored by placing minimally
invasive veneers on teeth #4–#13
in the maxillary arch, which would
restore #8 and #9 and fill in the buccal
corridor to broaden his smile and
create a smile-lifting effect. To address
the overcrowding on #22–#26, veneers
would be placed on #21–#28 on the
mandibular arch, with the focus on
straightening and creating proper
tooth form on #22–#26 to eliminate
overcrowding and occluding interference
with his central incisors.
One of the most powerful tools dentists
can use to ensure case acceptance
is to provide patients with a visual of
the proposed case outcome. Using one
of the many 2D digital smile design
software programs on the market,
I uploaded measurements of the
patient’s mouth and a photograph of
him smiling into SmileFy calibrated
smile design software (Fig. 6). Selecting
tooth forms from the digital tooth
library, the blueprint of the patient’s proposed new smile was revealed
(Figs. 7 and 8) and he immediately
accepted the treatment plan.
At the second diagnostic record-taking
appointment, routine full-mouth
X-rays revealed no underlying
decay and the patient’s periodontium
was deemed healthy upon probing.
Evaluation of his TMJ was deemed
negative. A series of preoperative photos
was taken, along with a bite registration
and facebow transfer, which
were sent to the master ceramist—along with the preop photographs, a
30-second video showing the dynamics
of the patient’s face in motion,
a bite registration and impressions
(analog or digital IOS)—to create a 3D diagnostic waxup and putty matrix for
provisionalization. Note: It is imperative
that the interdisciplinary team of
restorative dentist and master dental
technician work together in real time,
using analog and digital technologies
to achieve predictable case success.
Preparation and provisionalization
Two weeks later, the patient returned
for a two-hour appointment to prepare
and provisionalize his maxillary
arch. The patient was retracted
(Optragate, Ivoclar) and anesthetized.
In any minimally invasive technique,
tooth preparation is one of the most
important elements of long-term
success, because of the bond value to enamel instead of dentin and to
provide the ceramist with the preparation
needed for the best aesthetic
result.7–10
To ensure proper emergence profile
of the minimally prepped veneers and
prevent over- or underpreparation,
the laboratory’s putty matrix that
replicates the diagnostic waxup is
used to create a facial reduction prep
guide that will allow removing a minimal
amount of tooth structure using
a depth-cutting diamond (Komet,
Figs. 9 and 10). The only maxillary
teeth in this case that required more
preparation were #8 and #9 because of
composite restorations in the midline
area and on the surface of #8 to allow masking of the discolored composite.
A centric occlusion bite was taken
(Futar D, Kettenbach Dental), and
stump shade photo taken with appropriate
shade tab. Then final impressions
were taken of the prepared
maxillary arch (Figs. 11 and 12) and
sent to the laboratory.
Fig. 9
Fig. 10
Fig. 11
Fig. 12
The prepared teeth in the maxillary
arch were spot-etched (Total Etch,
Ivoclar), a bonding agent applied
(Adhese, Ivoclar) and the putty matrix filled with self-curing provisional
material (LuxaTemp, Ivoclar, Fig. 13)
and inserted into the mouth. After
four minutes, the putty matrix was
removed and the provisionals ready
for refinement (Fig. 14). To make the
provisionals come alive, all excess
material was removed, tooth shapes
refined, margins adjusted and occlusion
verified. The patient approved the
shade and shape of the provisional
restorations and was instructed to
return a week later, when not numbed
from anesthesia, to ensure fit, function
and aesthetics met expectations.
Fig. 13
Fig. 14
A week later, the patient returned to
the practice and confirmed with the
dentist the fit, function and aesthetics
of the provisionals. Photographs,
a video and a final impression of the
provisionalized patient were taken for
communication with the laboratory
for delivery of the final restorations. In
collaboration with master dental ceramist
Peter Kouvaris (Peter Kouvaris
Dental Studio), it was determined that
shade OM2 Natural (Vita 3D Master)
would be used for the final restorations.
To provide the patient with
the desired strength and aesthetics as well as with a material that could
be pressed to the minimal thickness
some teeth in this case required, it
was decided that a lithium disilicate
material would be used (IPS E.max
Press, Ivoclar).
Final delivery
The patient returned three weeks
later for seating of the final maxillary
restorations. the patient was
retracted (Optragate) and the temporaries
were gently removed. Before final bonding, an aesthetic try-in
paste (Variolink Esthetic, Ivoclar) was
applied to selected veneers to verify
shade, then cleaned and dried. Then
the prepared teeth were acid-etched
and an adhesive applied (Adhese, Ivoclar)
and light-cured for 20 seconds.
Each veneer was cleaned (Ivoclean,
Ivoclar) and a primer applied (Monobond
Etch and Prime, Ivoclar). Luting
composite shade Light (Variolink
Esthetic) was applied to each veneer
and seated. A brush was used to
remove any excess material, then
each veneer was tacked and cured
(FlashLite Magna 4.0, DenMat). An
ultrafine ET diamond (Komet, Brasseler)
was used to clean the margins
and a separating strip (Komet) used
to clean the proximals of any material
and adjust occlusion. Rubber
polishing points (Ivoclar) were used
to fine-polish each restoration.
One week later, the mandibular
arch was prepared (Figs. 15 and 16)
and provisionalized. Teeth #23–#26
required more preparation to open the
distal contacts on #23 and the mesial
and distal contacts on #24 and #25, to
correct the moderate overcrowding
and create an optical illusion that the
teeth are in a natural position. Final
restorations were delivered three
weeks later and seated using the same
protocols (Figs. 17–19).
Fig. 15
Fig. 16
The patient was extremely pleased
with the case outcome (Figs. 20–22)
and wears a provided nightguard at
night for an added level of insurance
against damaging the restorations
during sleep.
Conclusion
With careful case selection and
knowledge of proper tooth preparation,
material selection and adhesive
protocols, patients can successfully
be restored using minimally invasive
veneers. This case demonstrates
that highly aesthetic outcomes can
be achieved to restore natural tooth
form and shape to broaden a patient’s
smile line and correct moderate
overcrowding.
Author credit
Special thanks to Oral Design member
and master ceramist Peter Kouvaris,
of Peter Kouvaris Dental Studio in New
York, for fabrication of the beautiful
porcelain veneers seen in this case.
References
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Dr. John Heimke, who has more than 30 years of experience in cosmetic and implant
dentistry, now practices in Cleveland. Heimke earned his DMD at Case Western
Reserve University School of Dental Medicine in Cleveland and an MPH from Emory
University in Atlanta, and completed an advanced education program in general
dentistry at Fort Benning, Georgia, while serving as a captain in the U.S. Army
medical department.
Heimke is a fellow of the Academy of General Dentistry and the Pierre Fauchard
Academy, and a member of the Oral Design International Foundation. A digital
smile design master instructor, he also lectures on cosmetic dentistry, digital/analog
dentistry workflows, full-arch
implants, marketing, and consults and case acceptance.