A new look at drill-free cosmetic dentistry
The notion of adding materials to teeth in order to change the way they look is nothing new to dentistry. Traditionally, teeth are prepared in some way or fashion in order to place and retain a restorative material — typically a filling, porcelain veneer or crown. Not only is tooth reduction generally necessary to restore lost or damaged natural enamel as a result of the ravages of tooth
decay or trauma, but it is also necessary to create room to place an aesthetic and functional “restoration.”The purpose of this article is to introduce and provide a clear understanding of an alternative cosmetic treatment option, the “no-prep” or “prepless veneer,” whereby no drilling is required to enhance a smile. It also endeavors to bring clarity and understanding to the numerous areas of confusion regarding this treatment modality. Most importantly, it examines the case selection process; when prepless dentistry will work and when it won't. As with almost all dental and medical procedures, there are risks, benefits and alternatives. It is with the help of a dental professional experienced in these advanced techniques, together with your own goals and understanding, that you can make decisions that are right for you.
No-Drilling: Reality Or Ridiculous?
“Prepless veneers” is a concept that elicits various reactions and opinions among dentists, ranging from absolute disbelief that they can facilitate effective restorations, to appreciation for these conservative and advanced works of art! This range of opinion about a novel approach to cosmetic dentistry is vast and with good reason. The concept of “additive only” restorations intuitively causes the experienced clinician reason for concern as visions of bulky, over-contoured teeth quickly come to mind. Unfortunately, some prepless techniques and products circulated heavily in the media have shown thick, bulky looking restorations, causing skepticism among some dentists and consumers alike.
And yet, despite these concerns, an undeniable trend is emerging among many esteemed cosmetic dentists to incorporate not only minimal prep, but also “no-prep” restorations into their compendium of viable treatment options and alternatives.
In recent years, new developments in techniques and materials have resulted in a fresh look at the aesthetic possibilities for the no-prep veneer option. Cases done by talented dentists and lab technicians have produced results which would meet the highest standards in cosmetic dentistry [Figures 1 and 2]. Part of the advanced level of training for prepless veneers includes the important aspect of proper case selection. Not every situation lends itself to a no-prep approach, but when it does, the results can be not only beautiful, but also stable and reversible!
Figures 1 and 2: Photographs illustrating a common problem improved dramatically with prepless porcelain veneers. Note that the original smile is attractive but it is improved with the new veneers.
Paradigms and Beliefs — A Shift
The promotion and endorsement of “prepless” veneers is predicated on the following paradigms and beliefs:
- It is not necessary to prepare a tooth to create a border (known in dental terms as a “margin”). Highly skilled dental technicians can design a custom-fit veneer that feathers into the tooth just short of the gumline.
- Aside from the other obvious benefits of prepless veneers, they are not placed under the gum tissue. This eliminates the risk of the restorations having a negative impact on the periodontal (gum tissue) health.
- In many cases it is possible to use an additive-only approach to create aesthetically pleasing and natural-looking restorations without reducing the underlying tooth structure.
- Consumers who are looking for a way to enhance their smiles are more likely to seek out and accept a no-prep approach with a highly-skilled dentist in situations in which they don't need aggressive enamel removal.
Potential Cases for No-Prep Veneers
Figures 3 and 4: Notice after treatment the increased length of the upper anterior (front) teeth along with space closure and how it makes a significant difference to the smile.
- There are a significant number of patients who have relatively small teeth for a variety of reasons:, e.g. external causes such as acid erosion; genetic factors resulting in naturally small teeth and in spacing between the teeth; discrepancies between jaw size and teeth size — to name a few. These instances all provide potential candidates for “prep-less” restorations [Figures 3 and 4].
- Orthodontic cases that involved the extraction of teeth to solve a crowding problem typically result in narrow arch forms with the teeth that sometimes tilt inwards.
- Short, worn teeth — creating a smile with more visible tooth length can sometimes “turn back the clock” for someone who has worn their teeth down by grinding.
- Narrow smiles — Many times, the teeth in the sides of the smile are positioned inward and do not show from a frontal view.
- Teeth that need to be more visually present, e.g. when big lips may overpower them, or the teeth are too small in relation to the overall smile.
- Teeth that are genetically misshapen; “Peg laterals” is a fairly common condition in which one or both of the teeth directly next to the two upper front teeth are very small and peg-shaped.
When No-Prep Veneers Won't Work — While no-prep veneers can make many positive changes, there are some situations that no-prep veneers can't correct. In cases that involve improper tooth position, large discrepancies in root position, poor bite relations or a poor facial profile, some form of orthodontic treatment will be required to mechanically move the teeth. If orthodontic treatment is declined, some amount of tooth preparation may be required to create the illusion of proper alignment. When veneers are used to “camouflage” improper tooth positions, it must be with an understanding of the degree of limitations and risks.
Not every smile can be enhanced with prepless veneers. Teeth that are already relatively large or positioned forward in the smile do not typically lend themselves to adding another layer of thickness. In these situations, careful decision-making in partnership with your dentist will be necessary to explore other options that might involve tooth preparation or orthodontics.
There is no substitute for an expert dentist's talent and expertise in the various cosmetic techniques. These skills — combined with a clear understanding of an individual's goals and determination of the clinical needs obtained by a thorough diagnostic evaluation — are critical to ensuring a successful and beautiful smile.
Test-Drive Your Smile: Another Benefit of Prepless Veneers
Committing to porcelain veneers can take a great deal of faith on the part of a patient because once the teeth are permanently reduced, there is no reversing the decision to have veneers designed. With no-prep veneers, the process is reversible (though removing them is not an easy task and best accomplished using a laser) and practically risk-free.
If a patient qualifies for prepless veneers, a highly-skilled dentist can artistically design hand-sculpted prototypes in order to allow both a preview and “test-drive” of a new smile. In this prototype phase, changes can easily be made to the tooth-colored materials and to capture them as a blueprint for the laboratory technician who fabricates the final veneers.
While this same approach can also be used for traditional veneers, the difference with no-prep veneers lies in the fact that the prototypes can be easily removed and the patient's original smile is unaltered.
A Preview of Coming Attractions
After a discussion about the goals and anticipated outcomes of the smile enhancement, detailed diagnostic records are gathered prior to beginning any dental restorations.
A comprehensive smile analysis is completed in order to compile information about the function and health of all the dental structures including the surrounding lips and facial features. Sometimes, a simple “mock up” can be made as a rough sketch in an effort to determine the feasibility of a prepless approach. The prototypes allow evaluation of the results in temporary materials before even making the final veneers. This is where an understanding of natural tooth shapes and contours allows an experienced cosmetic dentist to create the changes necessary for creating a natural looking smile.
The prototype stage allows individuals the exciting prospect of being involved in their smile design process. They can interact with their dentists providing feedback on shapes, sizes, and even colors of the new teeth. The prototypes can be test driven for several weeks while they are duplicated in the final porcelain veneers [Figures 5 and 6].
Once the laboratory technician has fabricated the custom porcelain restorations, the prototypes are removed and the final veneers are bonded directly to the enamel on the front surface of the teeth. The porcelain is then carefully contoured and polished to exactly mimic the natural teeth [Figure 7].
Figure 5: Photograph showing disproportionate tooth size, tooth discoloration and the black triangle between the front teeth.
Figure 6: Photograph showing the “test drive” prototypes to evaluate proposed changes with the prepless porcelain veneer approach before finalizing them.
Figure 7: Photograph showing the final prepless porcelain veneers.
All of the cases shown in this article were completed with absolutely no preparation of the teeth. Though additive-only techniques cannot be used in every case, prepless veneers should be considered for their benefits in cases where they may apply in whole or in part.
A prepless approach requires specific skills and training together with a keen sensitivity to natural tooth contours. Those who want to explore this as an option should consult with a dentist whose credentials and experience demonstrate an understanding of this technique-sensitive option.
More and more, dentistry, like medicine, is finding ways to be as conservative as possible while providing the best possible results. No-prep or prepless veneers are one way to improve and enhance smiles without the downside of drilling away healthy tooth enamel.
Questions to ask your dentist
- Am I a candidate for prepless or drill-free veneers?
- Can you create prototype veneers for me to test drive what my new smile will look like?
- How much will pr
Authored By: Dr. Dennis J. Wells
Reviewed By: Dr. Garry A. Rayant, Editor-in-Chief, Dear Doctor, Inc.