Author: Barry K. Freydberg, DDS "Most Distinguished Alumni Award" of the University of Illinois College of Dentistry, Fellow of the AGD, the International College of Dentists, and the International Academy for Dental-Facial Esthetics.
Article published in the journal Dentistry Today | June 2011
The case presented in this article demonstrates the use of no-prep veneers as the preferred minimally invasive option, and one that took into account all the best interests of patient. Please review the photographs closely. If you think that you would have done preparations in this case, please reconsider and know that there are many more situations for no-prep veneers than one might think.
Myths are often attached to new practices (using new techniques and materials) that replace those that have become unfounded when cycles change and new technology and new materials become available that totally, not gradually, alter the landscape and, therefore, the best practice of the day. Often, new practices scare professionals and others who don't want to make changes. So, old ideas are held in place by professional schools, professional practices, laboratory technicians, and journal articles that often continue to discuss "traditional preps" for veneers done by habit, experience, and convention.
Language about the new practice, often captured in slogans or stock phrases, is generated and then repeated. The use and power of such slogans are well-known in the arena of political campaigns: "no prep, no good." (Notice how this idea is "suspended" in language, and is therefore "held" in place.)
Some Background on Replacement Technology
My philosophy from day one has been and is: It is always desirable to preserve natural tooth structure for our patients, whenever it is possible.
— Such a benign-sounding word, but its meaning is anything but benign. Prep in this context means drilling or shaving, grinding down to a depth that leaves little behind, making the result irreversible.
The term "no-prep veneers" generally refers to very thin shells of porcelain that are designed to cover or replace enamel.
First, dental schools, in general, and most aesthetic teachers/gurus in particular, teach prepped veneers. They advocate reducing the labial of the tooth, rounding it off, removing the proximal line angles, shortening the incisal edge, and bonding to enamel and/or dentin. This is what many dental students are taught. Fortunately, in the author's opinion and that of others, this trend is gradually changing. At a recent meeting, a speaker recently noted that he no longer "tells students to drill as much as I used to." It's how we were taught, but the cycle of new technology and materials is responsible for a sea of change in our procedures. We now have materials and techniques available to us that eliminate the need to prep.
Second, dental laboratory technicians want more "room" to create their restorations. Instructions from the laboratory may dictate to the professional the amount of room necessary to create aesthetically pleasing porcelain veneers. Again, this is usually determined without the dental technician being able to personally and visually evaluate the patient with the doctor.
Third, habit and experience keep this idea for prepping (more often than not) perpetuated. Many dentists still believe in "remove and replace" dentistry. Some say there are times you have to prep, such as in a case of severe misalignment. This may be the case, but, with the new materials, you no longer have to prepare the tooth to the previous depth, and a shoulder or chamfer is no longer needed at the gumline unless the presence of caries or a previous fracture dictates it. Also, I have found that a supragingival margin with a feather edge (similar to a feather edge design that is used with gold) will not cause a periodontal reaction. Of course, orthodontics as an adjunct to veneers is always a good option for severe misalignment.
Myth — (Here's a core misperception referred to earlier) What are called "traditional preps" (notice the language here; "traditional" is very comforting when speaking of procedures) originally did not involve the amount of tooth preparation that is used now. It is a myth that the original version of the traditional veneer included such a preparation and that no-prep veneers are considered a "new" trend.
Again, "traditional" preps were originally no-preps. They were only changed later to include prepping because the veneers in use at that time were either found to be too thick or the tooth too prominent. Tooth surface was removed to compensate for the thickness so that veneers could be placed on large teeth, not just used exclusively on small or lingually positioned teeth or on dentitions with diastemata. In other words, the full-prep technique was developed to compensate for the weak porcelain available to dentists at the time and for limitations in the bonding materials, such as the ability to control or mask color. In fact, some of the current resistance to prepless veneers arises in part from the assumption that the limitations that existed at that time still exist. However, most of those limitations are no longer valid.
In the mid 1980s, when Cerinate Smile Design Studios introduced porcelain veneers, their motivation for that development was to enable restoration of anterior teeth with porcelain (bonded with a composite restorative material) without a preparation. That was the original "traditional" veneer! It essentially replaced direct bonding, which at the time, was the only alternative to preparing teeth to create better aesthetics.
Let's now look briefly at a case on a young girl, where I believe the use of traditional preparations in the process of the placement of porcelain veneers would have been unnecessary to achieve patient satisfaction.
Christine is a young patient who just had her orthodontic bands removed, and was sent to our office to "fix the 2 front bonded broken teeth with porcelain veneers" (Figures 1 and 2).
Figure 1. Composite resin "cosmetic bonding," as it presented after the patient's braces were removed
When we examined the arch, we noticed that teeth Nos. 7 through 10 were approximately 0.75 mm lingual to the arch, while the cuspids through the molars filled the buccal corridor nicely. This necessitated the use of 4 anterior veneers. In my belief system, I feel that patients like Christine are better served with prepless veneers. In situations like this, on young people, I offer no other plan.
Figure 2. The previous composite resin bonding "aesthetic" work was removed
We used Cerinate II (DenMat) porcelain, shade 030 with 50% translucency with incisal shading and bonded it with a neutrally-shaded composite resin cement (Ultra-Bond Plus [DenMat]).
Figure 3. Completed no-prep veneers (Lumineers [DenMat])
The 4 maxillary anteriors were aligned perfectly (Figure 3) and the patient was very pleased with her new smile (Figure 4). If I had veneered only the 2 maxillary centrals, I would have had to prepare them in order to align them with the lateral incisors.
Figure 4. Christine's completed smile
In the author's opinion, the case presented in this article demonstrates the use of no-prep veneers as the preferred minimally invasive option, and one that took into account all the best interests of our patient. Please review the photographs closely. If you think that you would have done preparations in this case, please reconsider and know that there are many more situations for no-prep veneers than one might think.
Dr. Freydberg, a full-time practitioner, is a 1968 graduate of the University of Illinois College of Dentistry and receiving their "Most Distinguished Alumni Award" in 2004. He is a Fellow of the AGD, the International College of Dentists, the American College of Dentists, and the International Academy for Dental-Facial Esthetics. He has lectured and published on the subject of computerization of the clinical and management aspects of the dental practice. He is also a consultant to the ADA Council on Dental Practice. Disclosure: Dr. Freydberg receives honoraria from DenMat to teach courses on no-prep veneers. He has no financial ties to any other products or companies mentioned in this article.