To prep or not to prep

Are non – prep veneers an option for the demanding dentist and their patients?

One of the hottest topics in dentistry today is that of ‘No Prep’ veneers. The interest in this technique is obviously consumer driven and the increased interest by clinicians is a direct result of their patients asking about it.

This interest is due to the fact that a major dental manufacturer went to the consumer and said: “You’ve got to have these”. Now the consumer, having read or seen marketing propaganda, comes to our office asking about treatment.

The whole concept of prepless or minimal prep veneers has been around for many years, but it has not been until recently that we have seen such widespread interest among clinicians. Many clinicians placing veneers today were taught that they must do relatively aggressive preparation to yield acceptable aesthetic results and so the ability to place aesthetic veneers without preparation is a relatively new concept for most clinicians, yet one that they must be familiar with.

This will be a huge paradigm shift for so many clinicians, like myself, that always had the mindset that if you are going to add something on the facial of the tooth, then you must remove something to make the room.

Like many clinicians, there was a pool of patients that I had either declined treatment because they would not let me prep their teeth, or that didn’t approach me because they were concerned about getting their teeth prepped. As I began looking more closely at this technique, I struggled with the fact that the non-prep veneer cases that I had seen – prior to really understanding how to make this work – all looked bulky, ugly and too opaque. I did not think that they were representative of the type of artistic dentistry that I wanted to provide. I realise now that those cases were a direct reflection of the lack of pre-planning and designing the smile, incorrect use of materials, and the quality of the ceramists used, not because they were necessarily minimal preparation.

I think as dentists practising in this new millennium, we need to look very closely at technique and concept of the prepless or minimal prep veneer and decide if this is something we can offer our patients that will provide a good aesthetic result coupled with a long-term prognosis. It’s important for the clinician to realise that there’s not just one certain brand of ceramic, or one certain manufacturer, or one laboratory that can do your prepless veneers. The prepless or minimal prep veneer is a technique, not a specific product. Any ceramic can be used and most great ceramists can give you great results.

Success is reliant on educating your ceramist to get involved in utilising the materials to do prepless or minimal prep veneers, and also the communication process in case selection and diagnosis. Many clinicians I have spoken with spend a lot of time in the smile design process and write a very detailed lab prescription when the treatment is a prepped veneer case; yet spend very little during this design process with a non-preparation veneer case.

The diagnostic process becomes even more important with these minimal preparation cases if you want to obtain predictable results. With the prepless veneer cases, I require more input from my ceramist to see if I can deliver a result that I can be proud of and that my patient is happy with. Many clinicians look at the prepless veneer as a ‘lesser’ veneer or cheaper veneer because it is not prepped. They use inferior labs or are not as concerned researching the best materials because of this. I think this is a huge mistake.

Some that I have spoken to even take alginate impressions as the master impression and pour the models up themselves and send them to the lab! When the case is returned with ill-fitting margins or compromised aesthetics, they use the prepless technique as an excuse for sub par restorations.

With these prepless or minimal prep cases, we need to have an intimate relationship with our ceramist and we have to design the case, just as we would if it was a traditional veneer case. The lab needs to give us input as to whether they can deliver acceptable results. I’ve had patients say: “I do not want my teeth prepped” and my response was: “I don’t know how aesthetic this is going to look; I think it’s going to look bulky or fake or it’s not going to be something that looks like the pictures in my reception room”.

I’ve taken impressions and sent them off to the ceramist despite the fact that I didn’t think it was going to look good just to get their input. The ceramist, after reviewing the case, calls me back and says: “I can’t do this. It’s going to be bulky and ugly and because this one tooth is flared, the entire case is going to be too far facial”. This is the type of relationship and input that is so important with these cases.

Although prepless veneers are not indicated for every case or even in the majority of the cases, it certainly should be a part of every clinician’s restorative armamentarium. It is a great option on young adults or teenagers with micro-dontia, post orthodontics. Working with the orthodontist to align teeth correctly can yield excellent results. Many of these veneers are only 0.2 mm thick, so they can look natural and not overly bulky.

Currently, I am using a leucite reinforced pressed ceramic for my prepless veneers (Emprethins), because I like the physical properties of this ceramic. The bottom line is to be educated and truly understand the indications and contraindications of this technique before attempting a case or dismissing it as not being possible.

Indications:

1) Colour change with uniform arch shade

2) Incisal edge wear

3) Collapsed buccal corridor

4) Small spaces or diastemas ‘Microdontia’

5) Limited tetracycline and flourosis cases

6) Direct ‘resin bonding’ or veneer replacement.

Contraindications:

1) Rotation or crowding

2) Buccal displaced teeth

3) Severely lingualized teeth

4) ‘Bell-shaped’ teeth

5) Severely discoloured teeth in relatively ideal arch position.

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David Hornbrook is speaking at The Dentistry Show at the NEC, Birmingham on 4 and 5 March 2011.

To register for your free place, visit http://www.thedentistryshow.co.uk/register-IDM4