Limited Orthodontic Pretreatment for Minimally Invasive Veneers
Achieve excellent esthetics while conserving natural tooth structure
Susan McMahon, DMD
Appearance and self-esteem have long been intertwined. An individual with a healthy self-esteem maintains a feeling of confidence and satisfaction about him or herself. Having a healthy, attractive smile can encourage self-esteem, inspiring confidence and a willingness to smile more. In addition, self-esteem is considered to play an important role in psychological adjustment and educational success.1 More and more young people are seeking out cosmetic dentistry in order to enhance their appearance. For patients with unattractive, crowded, or spaced teeth, cosmetic dentistry can offer a solution that is beneficial on many levels.
Cosmetic dentistry gives patients the opportunity to improve their confidence by acquiring a healthy and beautiful smile. When considering treatment options, conservation of tooth structure should be paramount, especially with younger patients. For the conservative restoration of unesthetic anterior teeth, porcelain veneers are steadily increasing in popularity among today's dental practitioners.
When treatment planning for veneers, if the teeth can be positioned into better alignment using orthodontics prior to preparation, then minimal preparation can be employed, saving a significant amount of tooth structure and ensuring that the entirety of the preparation will be in enamel. According to a review of the dental literature about porcelain veneers, if an optimally bonded restoration was achieved and the preparation was located completely in enamel, the maintenance of the esthetics in the medium- to long-term was excellent, patient satisfaction was high, and the presence of porcelain veneers had no adverse effects on gingival health among patients who maintained excellent oral hygiene.2
The conventional technique used to prepare rotated teeth for veneers involves removal of a significant portion of the tooth to allow room for the veneer material as well as to straighten the alignment. When conservation of tooth structure is the goal, it can be argued that using orthodontics to align rotated or crowded teeth prior to employing minimally invasive preparation techniques affords the best and healthiest treatment option. By remaining minimally invasive and preparing only the enamel for restoration, the success rate for veneers can be raised to 99% because the bond strength to enamel is significantly higher.3 When dentin is exposed, the tooth can flex 200% more than when in its usual state, causing unnecessary stress and potential fracture.3 The bond strength of veneers is higher when bonded to enamel than when bonded to dentin, and the ultimate objective of any dental treatment is to restore health and function, as well as esthetics, using the most conservative method possible.4 Other advantages of the minimally prepared veneer route include a reduced need for anesthesia, less pain/sensitivity, greater potential for reversal, and a higher level of acceptance among patients.4 Above all, the concept of maintaining as much natural tooth structure as possible is more biologically compatible than other options.
A 28-year-old female patient presented to the office with the chief complaint of wanting to improve the appearance of her smile, particularly her upper anterior teeth. Although her dentition was generally healthy and unrestored and her periodontium was healthy, several of her teeth were misshapen and chipped, and her maxillary central incisors were rotated mesially (Figure 1 through Figure 3).
Several treatment options were presented, including: 1) standalone orthodontic treatment, which was ruled out because even if the alignment was corrected, veneers were indicated to improve proportion and restore wear in order to meet the patient's esthetic expectations; 2) traditional veneer treatment of the upper anterior teeth with whitening treatment for the other teeth; and 3) limited orthodontic treatment to improve the alignment, followed by minimally prepared veneers for the upper anterior teeth with whitening treatment for the other teeth.
The patient selected option three. The goal of the orthodontics was to level, align, and rotate the teeth into a position that would require the least amount of tooth reduction while still achieving optimal results. Because the patient wanted to have all of the treatment completed in time to attend a wedding 6 months later, the treatment plan was designed to incorporate the use of a short-term orthodontic regimen (Six Month Smiles®). This method is fast because it is only concerned with straightening the anterior teeth,5 and patients like it because the clear brackets and tooth-colored wires make the treatment less noticeable. CONFIDEX, Six Month Smile's digital treatment planning service, provides a complete, predictable step-by-step plan. It includes a 3-dimensional simulation of the patient's teeth, which aids in visualization for both the dentist and patient from the beginning to the end of treatment. Furthermore, it offers digital bracket placement to facilitate accurate and precise bracket positioning. Using brackets and wires ensures patient compliance and predictable timing for the orthodontic portion of the treatment.
The patient underwent 4 months of orthodontic treatment (Figure 4 through Figure 6), during which time significant alignment was accomplished, and then the brackets were removed (Figure 7). Had the orthodontic treatment been extended, complete alignment could have been attained, but that was not necessary for this case. Following orthodontic treatment, the upper anterior central and lateral incisors were very conservatively prepared for lithium disilicate veneers (IPS e.max®, Ivoclar Vivadent) (Figure 8). The veneers were placed with a dual-cure cement (Variolink® Esthetic LC Light, Ivoclar Vivadent), and the other teeth received whitening treatment (Opalescence® Boost®, Ultradent). The postoperative photographs show a well-proportioned smile that met the patient's esthetic needs while being accomplished with very little removal of tooth structure (Figure 9 and Figure 10). The patient's confidence was improved, and the veneers have an excellent prognosis for long-term success.
About the Author
Susan McMahon, DMD
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Six Month Smiles
1. DiBiase AT, Sandler PJ. Malocclusion, orthodontics and bullying. Dent Update. 2001;28(9):464-466
2. Peumans M, Van Meerbeek B, Lambrechts P, et al. Porcelain veneers: a review of the literature. J Dent. 2000 Mar;28(3):163-177.
3. Gürel, G. Minimally Invasive Veneers. Dental Review News Website. https://www.dentalreview.news/dentistry/20-cosmetic-dental-surgery/1834-minimally-invasive-veneers. Published January 31, 2017. Accessed September 13, 2018.
4. Vanlıoğlu BA, Kulak-Özkan Y. Minimally invasive veneers: current state of the art. Clin Cosmet Investig Dent.
5. Total Orthodontics. The Pros and Cons of Six Month Smiles®. Total Orthodontics Website. http://www.totalorthodontics.co.uk/the-pros-and-cons-of-six-month-smiles. Accessed September 13, 2018.