Received: 7 September 2017 | Revised: 11 October 2017 | Accepted: 24 October 2017

DOI: 10.1111/jerd.12351

CLINICAL ARTICLE

Protocol for a new concept of no-prep ultrathin

ceramic veneers

Camillo D’Arcangelo1 | Mirco Vadini1 | Maurizio D’Amario2 |

Zaccheo Chiavaroli3 | Francesco De Angelis1

1
Unit of Restorative Dentistry, Department
of Oral Science, Nano and Biotechnology,
Abstract
“G. D’Annunzio” University of Chieti, Chieti,
Objectives: No-prep veneers, although ideally considered the best option because of tooth struc-
Italy
2
ture maximum preservation, have been frequently criticized for some potential limitations
Unit of Restorative Dentistry, Endodontics
and Oral Pathology, Department of Life, including esthetic outcomes and periodontal complications.
Health and Environmental Sciences, Dental
Clinical considerations: A new protocol to optimize no-prep veneers restorations is presented. A key
Clinic, University of L’Aquila, L’Aquila, Italy
3
point of the proposed technique is to identify optimal margins’ positions: margin is positioned in the
Private Practice, Pescara, Italy
point of maximum convexity of teeth, avoiding the over contouring of traditional no-prep veneers.
Correspondence
Conclusion: The procedure can be appreciated for the marginal accuracy and the resulting aes-
Prof. Camillo D’Arcangelo, Unit of
Restorative Dentistry, Department of Oral thetic stability. The case reports show that properly managed no-prep veneers can have
Science, Nano and Biotechnology, “G. biologically healthy and aesthetically pleasant tooth-restoration transitions and emergence profiles.
D’Annunzio” University of Chieti, Via dei
Vestini 31, 66100 Chieti, Italy. Clinical Significance
Email: [email protected]
High-quality no-prep veneers can be more challenging to realize than conventional veneers and
the success seems to depend on a combination of good case selection, margins’ position, sound
adhesive principles, clinical, and laboratory experience.

KEYWORDS
ceramic, dental adhesion, no-prep veneer

1 | INTRODUCTION managed. Some interesting papers focused on no-prep veneers case

selection process are available13–16; conversely clinical studies often do
Ceramic veneers are frequently presented as the major class of clinical con- not provide enough technical information on clinical and laboratory
servative modalities in aesthetic dentistry. 1,2
The so-called “no-prep” perspectives.
approaches have been described for more than 10 years in literature3–8 and In this article, a new protocol to optimize no-prep veneers restora-
ideologically reiterate the methodologies of 1980s, when veneers were tions (called CH NO-PREP VENEERS) is presented. A key point of the
introduced as conservative, additive restorative procedures for which slight proposed technique is to identify optimal margins’ positions: margin is
or no preparations were required. 9,10
Nevertheless, lack of clear-cut guide- positioned in the point of maximum convexity of teeth, avoiding the
lines for technical procedures and for case selection has often led to confu- over contouring of traditional no-prep veneers (Figure 1). Dental maxi-
sion and misunderstandings. 11
Frequently, no-prep veneers, although mum convexity works as a natural finishing line for veneer. In this way,
ideally considered the best option because of tooth structure maximum veneer cannot change dental profile after cementation.
preservation, were essentially criticized for some potential limitations
including esthetic outcomes and periodontal complications as a conse- 2 | CASE SELECTION
quence of overcontoured teeth that could alter the emergence profiles.11,12
Indeed, no-prep veneers could have biologically healthy and optically For patients who visually may be aspirants for no-prep veneers rehabil-
beautiful margins and emergence profiles if properly selected and itations, an additive-only wax-up should be prepared; a silicone matrix

J Esthet Restor Dent. 2017;1–7. wileyonlinelibrary.com/journal/jerd V

C 2017 Wiley Periodicals, Inc. | 1
2 | D’ARCANGELO ET AL.

of this wax-up is then produced and the final shape and position of
teeth should be subsequently verified in the patient’s mouth by filling
the matrix with an acrylic resin and placing it over the existing dentition

FIGURE 2 No-Prep direct intraoral resin mockup

to create an intraoral mock-up (Figure 2). Wax-up and mock-up are

essential to approve the final forms, or eventually to program small
adjustments for the final restoration. If an esthetically pleasant result
can be accomplished by additive procedures only, the case is one step
nearer to qualifying for very conservative veneers with no preparation.
If the mock-up results are esthetically pleasing, then phonetic and func-
tional evaluations should be undertaken.

3 | MARGINS INDIVIDUATION

After position, form, function, phonetics, and color evaluations, arches

impression are taken with silicon material (Hydrorise; Zhermack SpA,
Badia Polesine, Rovigo, Italy) and stone models (ResinRock IV; Whip
Mix Europe GmbH, Dortmund, Germany) are prepared. Stone models
should be used to determine which areas of the teeth are ideal to place
the finishing margins of the restorations. The upper model is placed on
a lab surveyor in order to mark the line of maximum convexity of each
tooth to be restored with a veneer (Figure 3A,B). This line is the border
line between buccal and cervical sides of frontal teeth; it is consistently
irregular because this transition line is not regular in nature.

3.1 | Laboratory Fabrication

As stated by Magne et al.,17 no-prep veneers require superior skills in
the laboratory: fabrication and handling of ultrathin veneers could be
particularly challenging. The major effort is to obtain a natural shape
without bulky margins and overhangs. With the proposed technique,
this task is made less demanding for the technician, because finishing
margins are exactly kept in the positions marked in the previous step
on the stone model (Figure 3C). It is enough that technicians use these
marked lines as margins and respect the natural emergency profile of
tooth for veneer shape.
There are two conventional porcelain options for making veneers.
An established technique that can yield lovely results is to stack feld-
spathic porcelain on either a platinum foil or refractory die. Advantages
include the ability to vary the opacity and chroma levels in different
parts of each individual restoration as needed. The main limitation to
these restorations is the very fragile nature of thin feldspathic veneers,
which can crack easily during fabrication and placement. Another tech-
nique is to fabricate pressed veneers using high-translucency lithium-
FIGURE 1 Illustration of margin positioning: red line corresponds
to the maximum convexity of teeth; blue line corresponds to disilicate ceramic material. This material can be pressed extremely
veneers restoration thinly, with high flexural strength that can reduce the delicate handling
D’ARCANGELO ET AL. | 3

F I G U R E 3 A,B, Model placed on lab surveyor to mark the blue line of maximum convexity of each tooth to be restored with a veneer; C,
laboratory diagnostic phase. The blue line, that is the transition line between buccal and cervical sides of frontal teeth, corresponds to the
finishing margin of the veneers; D, feldspathic porcelain veneers on die

necessary with feldspathic material. In the presented cases, after mak- Liechtenstein) on refractory die (Nori-Vest; Kuraray Noritake Dental
ing the impressions, a dental technician fabricated all veneers using Inc., Hattersheim am Main, Germany) (Figure 3D). Feldspathic veneers
feldspathic porcelain (IPS InLine; Ivoclar Vivadent AG, Schaan, are preferred to lithium-disilicate ceramic material as they can be fully
layered, which may lead to more natural aesthetics (Figures 4–6).

F4-F6
3.2 | Clinical Phases
After choosing the case for no-prep veneers rehabilitations (Figure 7)
and a dental technician fabricating the veneers using feldspathic porce-
lain (Figures 8 and 9), each veneer must be individually tried on dental

F I G U R E 4 Intraoral anterior view of teeth before treatment.

Diastemas and lateral conoids are evident and judged unpleasant
by the patient

FIGURE 6 Esthetical and gingival tissue integration around the

thin porcelain laminate veneers

FIGURE 7 Intraoral anterior view of teeth before treatment.

FIGURE 5 View of the thin porcelain laminate veneers ready for Preoperative view revealing nonuniform shape/position/color of
cementation maxillary anterior teeth
4 | D’ARCANGELO ET AL.

preset to 558C,19,20 put on the cementation surface of veneers, and

used as luting agent. Preheated composites are handled with preheated
metal tools, so as to maintain the temperatures reached by the compo-
sites as long as possible.
Then, the veneers are placed on the corresponding teeth, paying
attention to achieve full seating using finger pressure. Extreme care
must be given during this stage because thin margins are at risk of chip-
ping during handling and also because very often each veneer has a
single insertion path for the natural undercuts of no-prep teeth.17
A thin explorer is used to remove excess luting material extruded
from the veneers’ margins. The pressure on veneer is stopped when no
more excess of luting material extruded from the margins. Six to eight
seconds of light-polymerizing at the incisal edge ensure stabilization of
the veneer. Residual cement is removed under a stereomicroscope
(SOM 32; Karl Kaps GmbH & Co.KG) magnification with explorer, scal-
pel, and interproximal floss for interproximal side.
Oral and vestibular surfaces are subsequently light-polymerized in
two sessions of 40 seconds each (L.E. Demetron I; Sybron/Kerr). Then,
veneer margins are checked again under a stereomicroscope and using
a dental probe. Residual excess cement is further removed with a 15c
scalpel (#371716, Bard-Parker; Becton-Dickinson, Dr. Franklin Lakes,
NJ, USA). Diamond burs, polishing discs, or silicone polishers should
not be used to finish the veneers; interproximal floss should be pre-
ferred to polishing strips for interproximal sides. After that, static and
FIGURE 8 Feldspathic porcelain veneers on A, refractory and B,
dynamic occlusions are checked. The patient should be recalled after
primary dies
3–7 days for rechecking occlusion, proximal contact relationships, mar-
ginal integrity, and gingival margin health (Figures 11–14).
surfaces by clinician. In case of multiple restorations, they are tested on
teeth surfaces alternately and then all together to evaluate the congru- 4 | DISCUSSION F11-F14
ence of the proximal contacts. The dentist should assess in sequence:
the absence of friction between preparations and restorations; the When given the option, most patients choose the least amount of
accuracy of interproximal contact points; marginal fits; shapes, color tooth structure removal.21 The patients are highly motivated to have
18
and the overall esthetical integration. no dental reduction while achieving as many of his treatment goals as
Ceramics are treated with hydrofluoric acid at 9.6% for 90 sec- possible. Although this is definitely not a reversible procedure, the like-
onds, and then with an ultrasonic bath for 5 minutes in alcohol. After lihood of losing no tooth structure was still very attractive to the
this, a silane agent is applied for 30 seconds to the surface. Teeth are patient.15
treated for adhesion by application of 37% phosphoric acid on enamel No longer should be suggested to over-prepare teeth only for con-
for 15 seconds, rinsing with tap water for 15 seconds (Figure 10). The venience or lack of understanding of alternative treatments. Minimally
adhesive agent is brushed on the adhesive surface of veneers and teeth invasive dentistry should not be purely a simple responsibility, but a
and, to avoid inaccuracies of fit, it is not light-polymerized before resto- professional duty.11,22,23
ration placement. A microhybrid composite (Enamel Plus HRi; Mice- High-quality no-prep veneers are often more challenging to realize
rium, Avegno, Genova, Italy) is warmed up with the preheating device than conventional veneers. No-prep dentistry is not a simpler or

FIGURE 9 View of the thin porcelain laminate veneers

D’ARCANGELO ET AL. | 5

FIGURE 10 Etching step of the adhesive procedures. Each veneer must be individually luted on dental surface

quicker service, but rather a minimally invasive approach to smile paste.19,20 Some in vitro studies indicate a significant increase in con-
design that has a premium value to many patients. There are several version of commercially available resin composites with an increasing
attractive motivations for no-prep veneers’ rehabilitations. When tooth curing temperature, and an increase in both polymerization and conver-
reduction is totally eluded, anesthetic is not needed. The fact that no sion rates seen at maximum cure rate.28,29 As a result, more highly
tooth structure is removed means intermediate provisional restorations crosslinked polymer networking and improved mechanical and physical
are not required. Although accurate impressions are just as critical with properties (higher fracture toughness and strength, less wear) may be
minimal preparation techniques, the invasiveness and difficulty of the anticipated.29 The use of temperature to improve flowability avoids
impression technique are removed. With no preparation, there is a like- some of the possible problems associated with a flowable resin
lihood of retaining natural enamel, which increases bond strength and
the long-term integrity of the margins.15
With ultrathin veneers, thickness of the luting cement can have a
relevant influence on the stress distribution in the porcelain veneers. In
a finite element analysis, Magne et al.24 concluded that laminate
veneers that were too thin with a poor internal fit, resulted in higher
stresses at both the interface of the restoration and the surface. This
could lead to postbonding cracks in thin laminate veneers. Delivery of
thin porcelain shells on unprepared teeth is particularly challenging
because it calls for the use of very thin composite resins to prevent
bending forces during seating.14 When porcelain is prepared very thinly
to minimize the preparation of sound tooth structure, a good internal
fit has to be created.25 Using a resin composite cement, total control
on the seating of the restoration was created.
The satisfactory esthetical results for no-prep veneer restorations
of this article were achieved using a preheated light-cured composite
as luting agent.1,2,26,27 The necessary working time for positioning the
indirect restorations and removing the excess cement was conveniently
extended at the discretion of the clinician using a light-curing compos-
ite as luting agent, overcoming the relatively restricted working time
allowed by dual-cure cements. Warming resin-based restorative materi-
als prior to placement enhances composite adaptation to cavity walls FIGURE 11 Comparative (A) preoperative and (B) postoperative
by decreasing the viscosity of unpolymerized resin composite natural smile of the patient
6 | D’ARCANGELO ET AL.

FIGURE 12 Lateral views of natural smile of the patient with luted veneers

material, such as the ongoing release of unreacted monomer and less The CH NO-PREP VENEERS procedure can be appreciated for the
favorable physical characteristics.30 accuracy at the finishing line and the resulting marginal stability, which
To avoid compromising restorations’ marginal fit, no diamond burs, increases the durability and the predictability of prognosis.
polishing discs, or interproximal polishing strips were used to finish the
restorations. Residual cement was removed only with an explorer, scal- DIS CLOSUR E S TAT E MENT
pel, and floss, checking restorations’ margins under a stereomicroscope
The authors do not have any financial interest in the companies or
magnification.
products used in this article.
Through the clinician’s experience and knowledge, the appropriate
treatment plan can be selected based on the patient’s clinical situation
ORC ID
and demands, to give patients the best in function, longevity, and
esthetics.11,14,22 The philosophy of doing conservative dentistry is a Maurizio D’Amario http://orcid.org/0000-0003-3524-5756
noble goal but it should be noted that conservative does not mean lim-
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