Protocol for a new concept of no-prep ultrathin

ceramic veneers
Camillo D’Arcangelo | Mirco Vadini | Maurizio D’Amario |
Zaccheo Chiavaroli | Francesco De Angelis

JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY, 2017

 Introduction

• Ceramic veneers are frequently presented as the major class of clinical conservative
modalities in aesthetic dentistry.
• Frequently, no-prep veneers, although ideally considered the best option because of tooth
structure maximum preservation, were essentially criticized for some potential
limitations including esthetic outcomes and periodontal complications as a consequence
of over contoured teeth that could alter the emergence profiles
• In this article, a new protocol to optimize no-prep veneers restorations (called CH NO-
PREP VENEERS) is presented.
• A key point of the proposed technique is to identify optimal margins’
positions: margin is positioned in the point of maximum convexity of
teeth, avoiding the over contouring of traditional no-prep veneers
 Case Selection
• Diagnostic wax-up - An “additive-reductive
wax- up” is done where contour is added in wax
or removed from the stone models of the
patient’s existing dentition using the facial
photographs to orient the procedure.

• Mock-Up Evaluation of Additive-Only

Esthetic Outcome

• Functional and Phonetic Evaluation of Mock-

Up - If the mock-up results are esthetically
pleasing, then a phonetic evaluation should be
undertaken. After an evaluation of “f,” “v,” and
“s” sounds is completed, the overall form of the
teeth should be looked at.

MIN
 Case Selection
• Changing Brightness with Low-Preparation Veneers -
Low-preparation veneers are not a good choice when
attempting to brighten teeth.

• Path of Insertion -- If after evaluating for position, form,

function, phonetics, and color, the patient is still a
candidate for no- or minimal-preparation veneers, the path
of insertion and potential undercuts that may limit access
to the areas of the teeth requiring augmentation now needs
to be determined.
• If at this time there are no apparent undercuts, or they
can be solved with additive bonding to allow a path of
insertion, the patient is a candidate for “no-prep veneers.”
 Case Selection
When minimal tooth
reduction is done,
Anesthetic is either
there is less
not needed or it is
preparation time
• Minimal Preparation Philosophy - There are many and, thus, a shorter
used sparingly.
attractive reasons why the practitioner would want a appointment.
case to be minimal preparation.

• Illusions of Reversibility - The patient was highly more enamel

The fact that no or
motivated to have as little tooth reduction done as limited tooth
increases bond
possible while achieving as many of his treatment goals strength and the
structure is removed
long-term integrity of
as possible means intermediate
the margins. This
provisional
adds to the durability
restorations are not
and longevity of the
required.
restorations.
 Case Selection - Laboratory Perspectives

• From a laboratory perspective, ease of

fabrication is directly proportional to the
amount of tooth reduction achieved by the the more the tooth
dentist reduction, more the more material
space options available and
the easier the
• Minimal-preparation veneer porcelain can have fabrication of the
thicknesses as little as 0.1 mm in some areas restorations.
and over 1 mm thick on the same restoration
with more abrupt transitions from thin to thick
areas, requiring careful selection of ceramic
material to deal with the underlying color and
translucency levels of the preparations.
 Case Selection - Materials
• There are two traditional porcelain options
for making veneers.

The main limitation to

A long-standing these restorations is the
Advantages include the
technique that can yield very fragile nature of
ability to vary the
beautiful results is to thin feldspathic veneers,
opacity and chroma
stack feldspathic which can crack easily
levels in different parts
porcelain on either a during fabrication and
of each individual
platinum foil or refractory placement and exhibit a
restoration as needed.
die. low flexural strength in
the range of 85 MPa.
 Case Selection - Lab Fabrication

High-translucency, enamel-
Lithium disilicate was
The 400 MPa flexural like ingots were used in the
selected for this case
strength of this material also lost-wax pressing process,
because of its ability to be
decreases the risk of fracture which eliminated the need for
pressed into very thin
during insertion with the layering in the gingival third.
restorations; in this case, 0.2
complex path of insertion The incisal third was cut
mm in many areas of the
necessary with these very back slightly from the facial
facial portions of the
thin veneers. to allow layering of incisal
veneers.
effects
 Case Selection – The Ideal Patient

The ideal candidate for very conservative treatment is one with

a slightly underfilled buccal corridor;

slightly lingualized, small maxillary anterior teeth;

closed or almost closed contacts;

relatively even spacing of teeth;

no gingival recession with gingival tissue filling

interproximal areas

no severe discoloration.
 Margins Individuation
• After position, form, function, phonetics, and color evaluations,
arches impression are taken with silicon material and stone models
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.
 Laboratory Fabrication

• As stated by Magne et al., no-prep veneers require superior skills in the laboratory:
fabrication and handling of ultrathin veneers could be particularly challenging

• In the presented cases, after making the impressions, a dental technician fabricated all
veneers using feldspathic porcelain on refractory die. Feldspathic veneers are preferred to
lithium-disilicate ceramic material as they can be fully layered, which may lead to more
natural aesthetics.
 Clinical Phases
• Each veneer must be individually tried on dental surfaces
by clinician.

• The dentist should assess in sequence: the absence of

friction between preparations and restorations; the
accuracy of interproximal contact points; marginal fits;
shapes, color and the overall esthetical integration.
 Clinical Phases

• Ceramics are treated with

hydrofluoric acid at 9.6% for 90
seconds, and then with an
ultrasonic bath for 5 minutes in
alcohol. After this, a silane agent is
applied for 30 seconds to the
surface.
• Teeth are treated for adhesion by
application of 37% phosphoric
acid on enamel for 15 seconds,
rinsing with tap water for 15
seconds .
• The adhesive agent is brushed on the adhesive surface of veneers and teeth and, to
avoid inaccuracies of fit, it is not light-polymerized before restoration placement.
• A microhybrid composite is warmed up with the preheating device preset to 55
degree Celsius put on the cementation surface of veneers, and used as luting agent.
 Clinical Phases

• Then, the veneers are placed on the corresponding

teeth, paying attention to achieve full seating
using finger pressure.
• 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 magnification with explorer,
scalpel, and interproximal floss for interproximal
side.
 Clinical Phases

• Oral and vestibular surfaces are subsequently

light-polymerized in two sessions of 40 seconds
each .
• Residual excess cement is further removed with a
15c scalpel. Diamond burs, polishing discs, or
silicone polishers should not be used to finish the
veneers; interproximal floss should be preferred
to polishing strips for interproximal sides.
• After that, static and dynamic occlusions are
checked. The patient should be recalled after 3–7
days for rechecking occlusion, proximal contact
relationships, marginal integrity, and gingival
margin health.
 Discussion
• Minimally invasive dentistry should not be purely a simple responsibility, but a professional duty.

• 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. 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 post-bonding 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. When porcelain is prepared
very thinly to minimize the preparation of sound tooth structure, a good internal fit has to be created.
 Discussion
• Using a resin composite cement, total control on the seating of the restoration was created.
Warming resin-based restorative materials prior to placement enhances composite adaptation to
cavity walls by decreasing the viscosity of unpolymerized resin composite paste.

• Some in vitro studies indicate a significant increase in conversion of commercially available

resin composites with an increasing curing temperature, and an increase in both polymerization
and conversion rates seen at maximum cure rate.

• As a result, more highly crosslinked polymer networking and improved mechanical and
physical properties (higher fracture toughness and strength, less wear) may be anticipated.

• The use of temperature to improve flowability avoids some of the possible problems associated
with a flowable resin material, such as the ongoing release of unreacted monomer and less
favorable physical characteristics.
 Conclusion

• In conclusion, in the author’s opinion, the case presented in

this article demonstrates the use of no-prep veneers as the
preferred minimally invasive option, and one that took into
account all the best interests of our patient.

• The CH NO-PREP VENEERS procedure can be

appreciated for the accuracy at the finishing line and the
resulting marginal stability, which increases the durability
and the predictability of prognosis.