Non-prep veneers continue to be one of the biggest challenges in aesthetic veneering treatment because they demand a high degree of intensive diagnosis, optimal conditions, clear communication and dental technology of outstanding quality.
Though they have been around for 20 years and are well-established in the US and UK, the body of data in the literature is still relatively sparse, with a PubMed search using the keywords “non-prep veneer” yielding only 14 entries (searched December 8, 2013).
However, this type of treatment remains one of the gentlest and least invasive methods in cosmetic dentistry. Moreover, the shift towards older patients seeking such cosmetic treatment is increasing.
This clinical case study describes the use of non-prep veneers for a difficult aesthetic situation while achieving optimal aesthetic rehabilitation.
Case study
A 65-year-old patient, whom we have treated for a number of years, came to us after previously receiving a crown on tooth 22 with the request to have tooth 21 restored too. Her medical history did not reveal any particular abnormalities, she had good oral hygiene, no allergies, was a nonsmoker and was very compliant.
As can be seen in figure 1, both central incisors in the cervical third had enamel hypoplasia and vertical cracks in the enamel. At the same time, tooth 21 appeared shorter on the incisal edge than tooth 11 due to its palatally retruded position. A blackand- white image is useful here so that the surface texture becomes more obvious. Because the patient is an artist with a keen aesthetic eye, clear communication and pre-diagnosis were essential to avoid disappointment or overly high expectations.
What was interesting was that the patient only sought treatment of the maxillary teeth and was satisfied with the appearance of the mandibulary teeth and did not want any treatment of the latter. After clarification, consultation, and suggestions for treatment alternatives, the patient finally opted for two non-prep veneers on teeth 11 and 21.
The lip profile of the 65-year-old patient (fig 2) reveals a youthful appearance around the mouth, with healthy and bright teeth. The close-up colour image of the maxillary anterior situation (fig 3) illustrates the details of the shade changes in the cervical area and provides the dental technician with important information, while the lateral view provides important information about the lip support and phonetics (fig 4). The images on the screen were discussed with the patient, and it was clarified that it would not be possible to harmonise the width of the incisors using non-prep veneers because this would require tooth reduction, a process the patient declined. She was consequently aware that tooth 21 would remain wider than tooth 11 after the treatment.
Wax-up and try-in veneers
Based on the wax-ups, which were prepared to a high aesthetic level (master model, aesthetic wax-ups with different colours, anatomically ideal position, pronounced features adjusted to the wishes of the patient) and shown to the patient, the tryin veneers were prepared in shade A1 (Anaxdent, Germany) (fig 8) and adhered to the teeth with the try-in paste of the luting composite (Vitique, DMG). This facilitates optimal patient communication as the try-in veneers could now be ‘reviewed’ live and in full colour in the mouth so that both the patient and dentist could agree on the proposed treatment.
The patient was prompted to make ‘S’ sounds to ensure that the phonetics were not negatively impacted. After any adjustments, if necessary, the try in veneer should be shown to the patient. This should be documented photographically (lip at rest, mouth slightly opened, smiling, laughing) and attached to the records. An impression
was taken of the situation (fig 6) and this formed the clear and definite specification to enable the dental technician to prepare the veneers with “zero tolerance” regarding tooth length and shape. The standard procedure
for patients who receive veneer restorations is bleaching at least one week before attachment to ensure a base that is as light as possible to provide the best shade for the ceramic.
Veneer preparation
Aesthetic non-prep veneers in the anterior region place high demands on both dental technicians and materials. In our collaboration with Shahab Esfarjani, a master dental technician, who is a disciple of the Swiss Oral Design School of Willi Geller, coating a platinum foil with feldspar ceramic has become a proven technique. Along with the aesthetics, it must be mentioned here that from a materials science perspective the platinum foil does not store any heat and therefore does not have a negative effect on the ceramic. To achieve optimal aesthetic results, Shahab brought his equipment into the practice to prepare the veneer live and on-site. This guarantees optimal adjustment of the shade and brightness (value) to the adjacent teeth in agreement with the patient, who generally place high demands on aesthetic restorations (fig 7). The ceramic GC Initial MC (GC Germany) was used and was constructed on refractory dies (Cosmotech Vest, GC Germany).
Veneer placement
Cementation is critical for the success of a non-prep veneer restoration. Even if the technician does brilliant work, if
the dentist makes an error during the adhesive luting, the success will only be short lived. Staining, marginal gaps,
fractures or veneers that repeatedly fall off can occasionally lead to considerable alienation between patients and dentists.
In our practice we choose to use Vitique from DMG as our standard adhesive luting composite. It provides the option of guaranteeing the shade for adequate luting of the veneer by using try-in pastes with eight shades. At the same time it offers the dentist the option of working with both a lightcuring and dual-curing system, and the excess can be easily removed when cementing, thanks to the optimised gel phase.
After placement, the excess composite is carefully removed using a no12 scalpel, and the veneers are finished after placement with a finegrained diamond bur and polisher, and the occlusion and articulation are checked.
Figure 9 shows the harmonious incorporation of the veneer into the overall dentition, even with the imperfect anterior mandibulary teeth. The patient immediately indicated after the placement that she was absolutely satisfied, and the close-up photograph shows the harmonious relationship with the other teeth. The challenge here clearly lay in choosing the correct shade with regard to the differing optical phenomena due to the presence of a full-ceramic crown and the different thicknesses of the veneers. The live build-up on-site enabled the technician to accommodate the patient’s requests so that, even in this demanding case, the optimal result for the patient could be achieved.
Conclusion
Non-prep veneers are an optimal restorative option in aesthetic dentistry which should always be minimally invasive as much as possible. Optimal planning, perfect collaboration between dental technician and dentist, and clear communication with the patient are the prerequisites for long-term success and satisfaction for all parties involved.