Less Is More: Highly Aesthetic, Minimally Invasive Veneers by Dr. John Heimke

Categories: Cosmetic Dentistry;
Less Is More: Highly Aesthetic, Minimally Invasive Veneers 

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.

Minimally invasive veneers
Fig. 1
Minimally invasive veneers
Fig. 2
Minimally invasive veneers
Fig. 3


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


Minimally invasive veneers
Fig. 4
Minimally invasive veneers
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.

Minimally invasive veneers
Fig. 6
Minimally invasive veneers
Fig. 7
Minimally invasive veneers
Fig. 8


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.

Minimally invasive veneers
Fig. 9
Minimally invasive veneers
Fig. 10

Minimally invasive veneers
Fig. 11
Minimally invasive veneers
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.

Minimally invasive veneers
Fig. 13
Minimally invasive veneers
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).

Minimally invasive veneers
Fig. 15
Minimally invasive veneers
Fig. 16

Minimally invasive veneers
Fig. 17
Minimally invasive veneers
Fig. 18
Minimally invasive veneers
Fig.1 9


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.

Minimally invasive veneers
Fig. 20
Minimally invasive veneers
Fig. 21
Minimally invasive veneers
Fig. 22


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
1. Smielak B, Armata O, Bojar W. “A Prospective Comparative Analysis of the Survival Rates of Conventional Vs. No-Prep/ Minimally Invasive Veneers Over a Mean Period of 9 Years.” Clin Oral Invest 26, 3049–3059 (2022).
2. Calamia JR, Calamia CS. “Porcelain Laminate Veneers: Reasons for 26 Years of Success.” Dent Clin North Am 2007; 51(2):399–417.
3. Vanlioglu BA, Kulak-Özkan Y. (2014). “Minimally Invasive Veneers: Current State of the Art.” Clinical, Cosmetic and Investigational Dentistry, 6, 101–107.
4. Morita RK, Hayashida MF, Pupo YM, Berger G, Reggiani RD, Betiol EA. “Minimally Invasive Laminate Veneers: Clinical Aspects in Treatment Planning and Cementation Procedures.” Case Rep Dent. 2016; 2016:1839793.
5. Rambabu T, Gayatri C, Sajjan GS, Karteek Varma PV, Srikanth V. “Correlation Between Dentofacial Esthetics and Mental Temperament: A Clinical Photographic Analysis Using Visagism.” Contemp Clin Dent. 2018 Jan–Mar; 9(1):83–87.
6. Bhuvaneswaran M. “Principles of Smile Design.” J Conserv Dent. 2010 Oct; 13(4):22–32.
7. LeSage B. “Establishing a Classification System and Criteria for Veneer Preparations.” Compend Contin Educ Dent. 2013; 34(2):104–112. 114–115; quiz 116–117.
8. Gurel G, Morimoto S, Calamita MA, Coachman C, Sesma N. “Clinical Performance of Porcelain Laminate Veneers: Outcomes of the Aesthetic Preevaluative Temporary (APT) Technique.” Int J Periodontics Restorative Dent., Dec; 32(6):625–35.
9. Jing Gao, Jinxiu He, Lin Fan, Jiayi Lu, Haiyang Yu. “Accuracy of Reduction Depths of Tooth Preparation for Porcelain Laminate Veneers Assisted by Diª erent Tooth Preparation Guides: An In-Vitro Study. Journal of Prosthodontics, December 2021.
10. Sisler ZS. “Preparation Guides: 10 Steps to Maximize Success for Veneer Preparation.” Journal of Cosmetic Dentistry, Volume 35, Issue 4, 26–33.


Author Bio
Dr. Jay B. Reznick 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.

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