Written by: Drs. Brian Harris and Gregori M. Kurtzman
Introduction
Dissatisfaction with one’s smile aesthetics is a common problem affecting many patients. Oftentimes, these patients have healthy teeth and are just looking for a brighter color or a slightly different shape to their smile. It is important that we offer procedures that allow us to improve their smile while still being conservative with our approach.
Improving smile aesthetics can present challenges for the practitioner. These include obtaining the patient’s approval for the aesthetics prior to fabricating the veneers, delays in having the lab fabricate the veneers, and higher costs for ceramic restorations when lab fabricated. Another challenge can be understanding what the patient is looking for in terms of the size, shape, and color of their smile, especially when they have access to so many case examples on social media. Being able to give your patients a preview of their new smile can resolve many of these concerns. A clinical mockup aids in the patient being able to “test drive” the new smile and provide input before the actual veneers are fabricated. This ensures both the patient and practitioner are on the same page and the final result meets the patient’s expectations. Additionally, this lowers the practitioner’s stress level, as they are not dealing with a disappointed patient and do not have to try to correct changes expressed by the patient with the final result. Intraoral scanning and virtual designing aid in the process, permitting rapid design of the prosthetics by a service outside the practice, and the design file is returned to the practice shortly after file transmission to that service. This permits same-day appointment design, in-office fabrication, and veneer placement when 3D printing is utilized for the restorations.
Three-dimensional printing also eliminates the turnaround time commonly found when the veneers are fabricated at an outside lab. An outside design service can be utilized as mentioned should the practice not have the time to design the new smile in-office. This allows the practitioner and staff to treat other patients while that process is being performed. In-office 3D printing also reduces fabrication costs for the restorations, allowing a lower treatment fee to be charged, which may encourage more patients to move forward with aesthetic smile enhancement treatment. Once the design file is received from the design service, trained practice staff can print the restorations and finish them in preparation for intraoral placement by the practitioner. Should restoration design be done in-office, trained staff can perform those steps for final approval by the practitioner, thereby minimizing their time during the process and allowing them to treat other patients.
Reduced treatment costs for patients allow those who cannot afford treatment with ceramic veneers to achieve aesthetic smile enhancement. The advanced 3D-printed, ceramic-filled resins available allow for long-term restorations that will function for several years. Should a veneer fail (fracture), a new veneer can be quickly printed utilizing the virtual design from the original printed restorations. At a future date, should the patient’s finances improve, or they desire to convert to ceramic veneers, the virtual design can be sent to the lab to allow for the fabrication of ceramic veneers matching the aesthetics of the printed veneers.
Advances in 3D Printing and Aesthetic Smile Enhancement
Advancements in dental materials have led to the development of next-generation 3D printing resins with significantly increased ceramic filler content, enhancing both mechanical performance and clinical longevity. These highly filled hybrid ceramic resins have received FDA clearance for definitive prosthodontic applications, including full-contour crowns, inlays, onlays, and veneers. Crown HT resin (SprintRay), formulated with greater than 60% ceramic particulate by weight, demonstrates favorable optical properties due to its high translucency and is currently available in A1, A2, B1, and bleach shades. It is distributed in a premeasured capsule format compatible with the Midas printing system (SprintRay).
The increased viscosity of these heavily filled ceramic resins has posed processing challenges in conventional vat photopolymerization printing systems, resulting in suboptimal flow dynamics and inconsistent layer resolution. As a result, hardware innovations have emerged to overcome these limitations. The Midas 3D printer (SprintRay) incorporates proprietary Digital Press Stereolithography (DPS) technology, which is engineered to deliver precise, high-resolution output while accommodating the demands of viscous, ceramic filler-rich resins. The system’s patent-pending resin capsule system enables controlled extrusion and optimal resin replenishment throughout the print cycle, thereby resolving prior issues with flow and layer separation.
The Midas’s closed-loop, vacuum-sealed capsule delivery system enables high-throughput fabrication of definitive restorations with minimal operator intervention. The system supports rapid cycle times, allowing multiple units to be fabricated in under 10 minutes per capsule. Furthermore, Midas can process up to 3 capsules simultaneously, significantly enhancing workflow efficiency and enabling predictable same-day restorative protocols. This allows, in the case of veneers, fabrication of all the patient’s veneers in a single run of the Midas unit, reducing fabrication time, permitting single appointment smile enhancement.
Case Presentation
A 23-year-old female patient presented for a consultation to improve her smile. She indicated orthodontic treatment in the past. Further stating that she does not like the shape of her front teeth or the gaps between them, she points to teeth Nos. 5, 6, 11, and 12. Indicating that she was seeking a slightly brighter smile and had not seen any color improvement from professional whitening in the past, she was looking for a minimal or no-prep approach to improving her smile.
Examination noted diastema between teeth Nos. 5 and 6 and Nos. 11 and 12, with slight rotation of the maxillary lateral incisors (Nos. 7 and 10) facially, giving the appearance of slight tipping lingually of the central incisors (Figures 1 to 4). The patient’s dentition presented with no restoration or caries. A discussion was had with the patient on treatment options that would fulfill her expressed aesthetic goals and utilize a no-prep approach to smile rejuvenation. The recommended treatment was the fabrication of veneers to correct the diastemas, align the facial surfaces of the anterior teeth, and lighten the shade of the smile. As the patient has a wide smile, the veneers would need to be extended to the second maxillary premolars so that the shade of her smile is improved. As the patient expressed concern about treatment cost, she was informed that 3D-printed veneers could be fabricated as an alternative to ceramic veneers at about half the cost, in a single appointment, rather than involving an outside lab and the associated turnaround time. The patient agreed to the recommended treatment. It was suggested that a test-drive smile be created using flowable composite to allow her to evaluate what changes were possible before creating the final veneers. This would allow her input on any aesthetic changes she might desire.
The arches were scanned with an iTero scanner (Element Plus [Align Technology]) prior to any treatment (Figure 5). The arch was isolated with cotton rolls and the teeth dried with air. As the test drive smile is temporary, the teeth were not etched, nor was a bonding agent utilized. Additionally, as the patient would only wear the temporary smile for 24 hours to allow her to evaluate the change to her smile, the provisional would be fabricated as a single-piece unit locking interproximally to retain it during that short test drive period. Utilizing Herculite Ultra Flow composite (Kerr Corporation), a flowable composite in shade XL-1, resin was applied to teeth Nos. 4 to 13 incrementally to create the test drive smile (Figure 6). The patient was dismissed and scheduled for the next day to evaluate the smile and get her input on any changes she may desire. The 3D-printed veneers would be fabricated during that appointment, following any necessary modifications to the design, and then inserted.
The patient returned and expressed that she was happy with the smile aesthetics and no changes were necessary. The digital scan taken the prior day was transmitted to Da Vinci Dental Studios (West Hills, Calif), along with a digital scan of the test drive smile, to allow the designer to see what the patient desired for the new smile. The veneers were designed (Figures 7 and 8), and the files were sent back to the practice about 30 minutes later to allow in-office 3D printing. The practice staff imported the virtual design file into the SprintRay software, and a test veneer was printed for the central incisors to allow the patient to select a shade. No. 8 was printed in shade BLHT, and No. 9 was printed in shade B1HT. The shade test veneers were then tried in on Nos. 8 and 9 (Figure 9). The staff then, utilizing the software, created a nesting setup that was allowed in the Midas 3D printing unit (Figure 10). The veneers were then printed in Midas utilizing Crown HT resin in shade BL (Figure 11). Supports were removed from the veneers using a diamond bur in a high-speed handpiece following their removal from the Midas capsule. The individual veneers were finished and polished and ready for intraoral insertion (Figure 12). The time from seating the patient to reviewing the test drive smile and having the printed veneers ready for intraoral insertion was fewer than 2 hours, allowing treatment to be completed in a single appointment.
The 3D-printed veneers were tried in with water on the intaglio surfaces to verify seating together and that the interproximals did not hinder seating. The use of Variolink Esthetic Try-in pastes (Ivoclar) can be considered during try-in aesthetic restorations if desired. Minor modifications can be performed on the veneers’ interproximals should they not seat together. It was not required in this patient’s case. The veneers were tried in on the left side (Nos. 9 to 13) to verify seating together, demonstrating the size and shape prospective for the no-prep case to achieve the patient’s expressed aesthetic desires (Figure 13). The right-side veneers were then inserted (Nos. 4 to 8), verifying that all the veneers could be seated intraorally and did not require any interproximal adjustments to the printed veneers (Figure 14). The patient was shown a mirror for her to assess the new smile and approve the aesthetics before bonding them to the teeth. She indicated that she was happy with the aesthetics, and they achieved her goals.
The SprintRay Definitive Crown Cementation protocol was followed to insert the printed veneers. The intaglio surface of the veneers was air-abraded with aluminum oxide (50 µm) particles at 1 bar pressure. Ivoclean (Ivoclar) was applied to surfaces that will be bonded on the veneers, including the margins. After 20 seconds, the restorations were then rinsed with water, air-dried, and set aside. The teeth were isolated, and etching gel was applied to the teeth on the surfaces to be bonded. After 30 seconds, the etchant was rinsed off and air dried. Adhese Universal adhesive (Ivoclar) was then applied to the intaglio surface of the veneers and etched tooth surfaces and scrubbed in with a microbrush. After 20 seconds, air-thinning was applied to the intaglio surface of the veneers and teeth until an immobile layer was achieved. Light curing was not performed at this step. Variolink Esthetic DC (Ivoclar), a dual-cure resin cement for printed or ceramic restorations, was dispensed onto the intaglio surface of the veneers, and they were seated onto the teeth. The veneers were tack cured for 1 to 2 seconds to hold them in place. Excess cement was then cleaned at the margins with a microbrush dipped in Adhese Universal adhesive to remove all excess cement and make finishing easier. Liquid Strip (Ivoclar) was applied around the margins to prevent an oxygen-inhibited layer. This was then followed by light curing all the surfaces of the restoration for 10 seconds. The margins of the restorations were then polished to remove any residual cement. Occlusion was checked, and no adjustments were required (Figures 15 to 17). The patient was shown a mirror and indicated she was happy with the natural smile that was achieved, meeting her expressed goal for better aesthetics (Figure 18).
The patient returned a week later to review the clinical results and marginal adaptation of the 3D-printed veneers (Figures 19 and 20). She expressed high satisfaction with the results, indicating that her smile looked natural and that she had received numerous compliments from family and friends. The patient reported that she was smiling more now that she was no longer embarrassed by her smile.
Conclusion
Utilization of a test drive smile allows the patient to express what changes they wish for in the final smile enhancement and communicate that to the person doing the virtual design of the restorations. Advances in ceramic resins for 3D printing allow in-office fabrication of aesthetic, durable restorations. Additionally, 3D printing and virtual design allow same-appointment, in-office aesthetic smile enhancement, eliminating delays in treatment that occur when lab fabrication is used. Lower treatment costs, along with the potential for single appointment treatment, may increase patient acceptance of treatment.
Acknowledgment
The authors would like to thank Walter Orellana, aesthetic program director, and Franklin Orellana, CAD/CAM designer, at da Vinci Dental Studios for their assistance in virtually designing the veneers.
ABOUT THE AUTHORS
Dr. Harris is a practicing dentist at Harris Dental in Phoenix. With a passion for technology and cosmetic dentistry his process has transformed the smiles of patients from all over the world. He can be reached at [email protected].
Dr. Kurtzman is in private general dental practice in Silver Spring, Md, and a former assistant clinical professor at University of Maryland in the department of Restorative Dentistry and Endodontics and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, implant surgery, removable and fixed prosthetics, and periodontics. Dr. Kurtzman has published more than 900 articles globally and has written several ebooks and textbook chapters. He can be reached at [email protected].
Disclosures: Dr. Harris is a key opinion leader for SprintRay. Dr. Kurtzman received compensation from SprintRay for writing this article.
