Porcelain veneers have become a standard procedure in many American practices, even though this technique is still not routinely taught in most dental schools. For example, I had the opportunity to do the first set of porcelain veneers in the history of my dental school back in 1988, yet I have never spoken with another graduate since then who had that same opportunity. It is therefore left for most dentists to teach themselves how to successfully accomplish this technique.

This article will review what I have learned since that first nervous set of six veneers back in dental school.

Porcelain veneers are a great treatment modality for many patients, but should be considered as part of a differential diagnosis in which traditional orthodontics, direct bonding, esthetic recontouring and bleaching are considered as options.

While some clinicians advocate a no-prep approach to porcelain veneers, my experience has been that some type of preparation gives a more predictable esthetic result. The most common problems I have seen with no-prep veneers are overcontoured margins and bulkiness. These problems can make a case a failure and both doctor and patient unhappy.

On the other hand, no-prep veneers can work well in “additive” type esthetic cases. These would be cases where multiple diastema are present, the teeth are shorter than they used to be due to trauma or wear, and where there has been a loss of facial enamel volume, and some cases where the only goal is the “permanent bleaching” effect. A no-prep approach can also work well in bicuspid extraction cases when residual space remains between the anterior teeth.

I believe no-prep veneers are an area where we need to have effective, written informed consent with the patient about the different veneer options available to them. The sound of “no-prep, no shots, no temps” is definitely music to any patient’s ears, but you still need to talk with them about the downside of the no-prep veneers.

If the patient still wants to go forward with the no-prep veneers after explaining about the bulkier margins and the need for excellent oral hygiene habits on the part of the patient, you can go forward with no-prep with a good degree of confidence.

Also, be prepared to recontour the gingival margin if it feels too bulky to your explorer. I prefer the Brassier ET^® Carbide kit (Savannah, Ga.) and using the ultrafine grit in an electric handpiece to smooth off any “speed bumps” that may be present at the margin. To protect the gingival, you will need to use a cord packer to retract the tissue, or, if you prefer, a Zekrya instrument to protect the tissue to ensure the bur does not contact tissue. The cord packer I use to accomplish this has many bur marks on it, which is much more preferable to leaving those marks on the tissue itself.

Glidewell Laboratories is happy to provide a diagnostic service for no-prep, minimal prep and traditional veneers. Many dentists send in pre-op models of their patients to see if they are good candidates for no-prep veneers. Our technicians are able to study the models and advise you whether it would be a good no-prep veneer case. If they determine that a minimal prep approach is best, they will prep the study model for you and show you where to recontour the patient’s teeth for the best esthetic effect. This service can be done with or without a diagnostic wax-up. It is highly recommended that you use this design service for your first five or six no-prep veneer cases, or any case where you have questions about whether this approach is feasible.

Typically, I will still call it a no-prep case if all I have to do is recontour teeth with a sandpaper disc. Once I need to use a high-speed handpiece and a bur, it becomes a minimal prep or traditional prep veneer case.

As always, be careful during any veneer try-in (including no-prep) not to try to push the patient toward accepting veneers they are on the fence about. It has always seemed like you have definitely “married” most veneer patients, and you want to make sure they love their veneers before they are bonded to place. I do not look at no-prep veneers as “reversible” at all. I make sure patients are happy with the veneers before proceeding.

I have removed no-prep veneers without any damage to teeth before using my Waterless^® YSGG Laser from BIOLASE (Irvine, Calif.), but most dentists have not purchased this technology yet. I do not believe you can remove no-prep veneers bonded to enamel with a handpiece without doing some damage to the teeth. The only time I consider veneers reversible is while they are filled with try-in paste.

Part 1 of this discussion will cover no-prep veneers. Look for Part 2 on veneers seated using traditional prep techniques here.

I have always considered diagnostic wax-ups a critical part of the porcelain veneer process. A big reason why I always use diagnostic wax-ups is to give the patient an accurate idea of what their finished case could look like. In fact, I have always been suspicious of digital imaging programs because of the way they show patients what their smile could look like. Many of these systems have a smile library in which a smile is somewhat arbitrarily taken from the library and “pasted” over the patient’s existing smile. Unfortunately, this method of imaging doesn’t take the patient’s tooth position or hard or soft tissue architecture into account, and can show the patient an “after” scenario that is literally impossible to achieve.

The diagnostic wax-up also helps many patients make up their minds about treatment just by looking at the wax-up and comparing it to their existing smile. It is for this reason that I insist that all diagnostic wax-ups be fabricated from white stone models with white wax added for the veneers.

Yellow models and yellow wax just don’t elicit the same emotional response from patients when they view them, even though darker models and wax may make it easier for the dentist and technician to see certain details such as surface texture, etc. The bottom line is, if you are planning on showing the diagnostic wax-up to the patient or are going to let them take it home to show to their spouse, make sure your lab uses white models and white wax.

The diagnostic wax-up can also act as a financial screening tool. We charge $20 per tooth for this service, but we have the patient pay for it. So, for a typical 8-veneer case, the diagnostic wax-up would cost $160, and that amount is credited toward the overall case fee if the patient decides to have the treatment done. Years ago I would pay for the wax-up myself. However, many times I discovered that the patient wasn’t really that serious about having the treatment done.

After I became the owner of five or six wax-ups, the decision was made to have the patients pay for them. Any patient who balks at the $160 fee for the wax-up to see what their new smile could look like is probably not that serious about having the treatment done. This keeps you from wasting $160 on a wax-up you don’t need.

Seating veneers is typically the most difficult part of the procedure, especially compared with cementing PFM restorations. Most of this difficulty is due to the increased difficulty in working with a resin cement as opposed to a resin-reinforced glass ionomer (RRGI) cement for typical crown and bridge cases. Most dentists are comfortable “walking away” from cases where RRGIs are used.

For example, they will cement crowns on teeth #7, #8, #9 and #10 and then exit the operatory, leaving their RDAs to do all the cleanup of excess cement. If you walk away from bonding veneers, you will most likely bond all the anterior teeth together and spend the next two hours sawing through all the contacts, trying to make the teeth individual once again! As a result, the more cleanup you can do prior to curing the cement, the better the chance you won’t have to use burs and other potentially dangerous cleanup methods.

For color-stability purposes, only light-cured resin cements should be used when luting veneers. Dual-cure and self-cure resin cements are not as color-stable long-term as light-cure resin cements, and typically are not the best choices for under-porcelain veneers.

If the prep shade is within normal limits, I find I get the best results when using a translucent resin cement, such as Nexus^® Clear from Kerr (Orange, Calif.). I use just the base, not the catalyst, to ensure the cement will be as color-stable as possible. Another good choice is Variolink^® Veneer from Ivoclar Vivadent. I use the clear shade almost exclusively, which is also known as the medium-value shade.

The following is the step-by-step process of seating no-prep veneers.

The veneers are tried in one at a time without try-in paste to make it easier to evaluate the fit of the individual units. Once all the veneers have been tried in and the fit has been verified, the units can now be tried in together to check contacts. At this point, we typically will try in the restorations with a try-in cement (Appeal Translucent [Ivoclar Vivadent; Amherst, N.Y.]/medium value shade) to help them stay in place.

Also, once all the restorations are in place, we will give the patient a hand mirror so that they can take a look at the restorations as well. At this point, I have also printed up an 8 × 11-inch picture of their “before” shot so they can remember what they used to look like. Whether or not they have had temps, this before picture helps give the patient some perspective on where they started and where they are now.

The try-in paste is water-soluble, so it is very easy to rinse out of the internal aspects of the veneers and off the teeth. At this point, I like to clean the teeth with some fresh pre-mixed pumice (Pumice Preppies™ [Whip Mix Corp.; Louisville, Ky.]) and then apply some liquid Consepsis (Ultradent; South Jordan, Utah) and air-dry the teeth.