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The Effect of Various Preparation Designs on

the Survival of Porcelain Laminate Veneers

Article in The journal of adhesive dentistry October 2009

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Hamit Serdar Cotert Mine Dundar

Ege University Ege University
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 pyrig
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The Effect of Various Preparation Designs lica
tio
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on the Survival of Porcelain Laminate Veneers ss en c e fo r

H. Serdar terta/Mine Dndarb/Berran ztrka

Purpose: The aim of this clinical study was to observe the service duration of porcelain laminate veneers (PLVs) and
to estimate the influence of the categorical covariates such as location, tooth vitality, preparation depth, incisal, gingi-
val and proximal finishing lines, and peripheral tissue type on the survival rates of event-free and overall service dura-
tion.
Materials and Methods: A total of forty patients (26 women, 14 men; age range: 16 to 50) who had received 200
PLVs were evaluated in this study. Median follow-up time was 67.25 weeks with a range of 12 to 72 weeks. Fifteen of
the restored teeth were nonvital, while the remaining 185 were vital. Categorical covariates related to the restoration
design (localization, vitality, preparation depth, incisal, proximal, and gingival finishings, and surrounding tissue type)
were recorded in order to estimate their influence on the survival rates. Survival rates of the event-free and overall
service duration were calculated with the Kaplan-Meier analysis and Mantel log rank test.
Results: Twelve failures were observed. The most frequent failure type (11 units) was debonding of the restoration
from the abutment tooth. Nine of them were rebonded and the remaining 2 were remade with a different preparation
design. The last failure was observed as a coronal fracture at the cervical level. The overall survival rates were 99.5%,
99%, 97.5%, 94.9%, 94.4% and 93.8% at weeks 8, 9, 11, 15, 16, and 34, respectively, with a mean estimate of
68.45 weeks.
Conclusion: PLVs exhibited good clinical results with their conservative specifications and high survival rates. The
preparation and design specifications affect the service duration of PLVs.
Keywords: porcelain laminate veneers, survival rate, laminate preparation design.

J Adhes Dent 2009; 11: 405-411. Submitted for publication: 20.06.08; accepted for publication: 20.07.08.

P orcelain laminate veneer (PLV) restorations have

gained increasing popularity for esthetic improvement
of anterior teeth. PLVs have been reported to be durable
and conservative anterior restorations with superior es-
thetics.16,19,27-30 The treatment of discoloured, fractured,
worn, or congenitally malformed teeth, as well as esthetic
reshaping of anterior teeth and elimination of diastemas
once requiring full-coverage restorations are accom-
plished with the use of PLVs.27,29,35 The developments in
porcelain processing as well as improvements in adhesive
bonding systems have promoted the use of PLVs.32,38,42
Although retrospective observation methods have been
preferred in the studies on the survival rates of PLVs, there
are controversial reports due to diversities in study de-
signs, aims, and the obtained results.19,30 The varieties in
the PLV preparation designs might be an explanation for
these differences.
a Professor, Ege University, Faculty of Dentistry, Department of Prosthodontics,
Izmir, Turkey.
b
Dentist, Ege University, Faculty of Dentistry, Department of Prosthodontics,
Izmir, Turkey.
Correspondence: Prof. Dr. H. Serdar tert, Ege University, School of Dentistry,
Department of Prosthodontics, Bornova 35100-Izmir, Trkiye. Tel: +90-232-
3880327, Fax: +90-232-3880325. e-mail: cotert@gmail.com
Design principles and the tooth preparation methods
for PLVs were evaluated in several reports.2,3,5,7,10,17,22,26,
31,32,38 Although previous suggestions for tooth prepara-
tion were minimal or no tooth susbtance loss, recent stud-
ies have shown that this approach is uncommon in current
general dental practice.15,19,26,30 Nevertheless, most re-
searchers agree on the necessity of minimally invasive
preparation procedures.16,17,20,22,27,35 The recommended
preparation depth varies between 0.3 and 1.0 mm.
2,3,16,19,27,40,41 The most important reasons for this prepa-
ration recommendation are to avoid overcontour, maintain
an adequate material thickness for masking the dis-
coloured hard tooth tissues, and benefit from the better
bonding abilities of the restoration to prepared enamel
rather than unprepared enamel.8,20,23,39 Rather than the
intra-enamel preparation procedure advised in the re-
viewed literature, modern dentin bonding agents (DBAs)
may produce a reliable bond between the PLVs and the ex-
posed dentin surfaces.3,20,23,28-30,39 It was also reported
that it is important to prepare a clear cervical supragingi-
val chamfer in order to maintain a smooth finishing line
and diminish the marginal leakage.20,27,32,34,40 However, it
was shown in laboratory-based retrospective analyses of
dies for PLVs that more than half (55%) of the prepara-
tions performed by general practicioners had no clear
margin.26,38

Vol 11, No 5, 2009 405


tert et al
In the literature reviewed, proximal preparation design
was found classified into two main types as proximal
chamfer and proximal slice.2,41 The incisal edge prepa- replacement of existing restorations, the teeth were
ration was classified into four types as feathered incisal
edge, incisal bevel, overlapped incisal edge and in-
traenamel window.26,38 The relation between the prepa-
ration design and the strength of the PLV restoration was
evaluated in several in vitro studies.8,9,21,24,27,32,35
The clinical performance of the PLVs was also evalu-
ated in several retrospective follow-up studies. 1,6,10-
15,17,18,23,24,28,33,40-42 In these studies, restorations were
evaluated according to clinical parameters such as service
duration, debonding, fractures and chipping, esthetic per-
formance, marginal discoloration, and patient satisfaction.
Reports about the relation between the preparation de-
sign and the service longevity were rare in the reviewed lit-
erature.18,21
Based on the literature mentioned above, the aim of
this study was to evaluate the relation between the prepa-
ration design variables and the clinical service duration of
the PLVs. It was hypothesized that PLV preparation design
affected the longevity of the restorations.
MATERIALS AND METHODS
This study was performed with a total of 40 patients (age
range: 16 to 50 years), treated with 200 units of PLV
restorations at the Prosthodontics Clinics of Ege University,
School of Dentistry (Izmir, Turkey) between June 1999 and
June 2005. All PLVs were followed-up for 72 weeks. Some
patients received more than one restoration. Informed pa-
tient consent was obtained from all patients who partici-
pated in the study.
The success rate (a low prevalence of debonding, mi-
croleakage, fracture, and caries) for each response vari-
able was recorded at periodic control appointments, but
since the time required for the periodic controls differed
individually, these rates were considered as definitive
measures rather than estimations of population parame-
ters. The failure-time model, equivalent to the 95% confi-
dence interval, was estimated for the determination of
success rate at 72 weeks.
Patients with veneer indications such as diastema, dis-
coloration or poor restorations in their anterior teeth, lack-
ing active periodontal or pulpal disease, and having
adequate tooth structure and good oral hygiene were in-
cluded in the study, while patients with parafunctional
habits, large restorations, or excessive tooth wear were ex-
cluded. All PLV restorations included in the study were
completed by one experienced operator who followed a
meticulous clinical procedure, and the PLVs were fabri-
cated by one experienced dental technician. Design of the
restoration and the preparation were performed on the di-
agnostic casts for hard-to-predict situations, which were
poured with dental stone (Gilodur, Giulini Chemie; Lud-
wigshafen, Germany) into the preliminary impressions
which were made with an irreversible hydrocolloid impres-
sion material (CA 37, Cavex; Haarlem, The Netherlands)
and stock trays.
406
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Tooth Preparation and Impression Making rP
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After preoperative steps which included prophylaxis
lica and
Q ui
tipre-
pared with a Modular Veneer Preparation
on
teSet (MVS, Inten-
ot
n
ss e n c e by a
fo r
siv; Lugano, Switzerland) using an air turbine followed
red handpiece. Cervical marking was performed with the
bur #200S (Intensiv). Limited depth cutting to 0.3 mm was
done with bur #S4 (Intensiv). Labial and incisal reductions
were made with bur #101 (Intensiv), and all of the cham-
fers were finished with bur #4310S (Intensiv). To obtain
optimal gingival displacement, a retraction cord #00 (Ul-
trapack, Ultradent; Salt Lake City, UT, USA) soaked with he-
mostatic solution (20% ferric sulphate solution ViscoStat,
Ultradent) was used. Impressions were made with a
polyvinyl siloxane elastomeric material (Pentasoft Duo-Mix,
3M ESPE; Seefeld, Germany), mixed by an automatic mixer
(Pentamix, 3M ESPE) and put on individual trays. Master
casts were poured with a Type IV dental stone (Glastone
Dental Stone, Dentsply; Milford, DE, USA). Waxups were
made with white modelling wax (Pro-Art IPS Empress Wax,
Ivoclar Vivadent; Schaan, Liechtenstein) and tried in the
mouth. An irreversible hydrocolloid impression of the op-
posing dentition was made, and interocclusal registrations
were recorded.
Ceramic Surface Preparation
All PLVs were made of a heat-pressed ceramic material
(IPS Empress, Ivoclar Vivadent; batch no. E41431). The in-
ternal surfaces of the PLVs were sandblasted with 50-m
Al2O3 particles, etched for 40 s with 9.5 % hydrofluoric
acid (Ultraetch, Ultradent), rinsed, cleaned ultrasonically
first in detergent solution and then in distilled water by
using an ultrasonic cleaner (Sonorex; Bandelin, Germany),
dried, and silanized (Silane, Ultradent). An articulating
paper was used to establish appropriate occlusal morphol-
ogy and contacts. After the ceramic was glazed, an addi-
tional fitting was performed to harmonize the occlusion
and proximal contact areas, and the restorations were pol-
ished to their final forms.
Provisional restorations
Vacuum-formed transparent templates were made prior to
tooth preparation. The template was filled with a flowable
composite resin (Tetric Flow, Ivoclar Vivadent) and light
cured. Subsequently, the provisional restorations were ce-
mented with a eugenol-free temporary cement (Temp-Bond
NE, Cavex).
Intraoral evaluation and cementation
Provisional restorations and temporary cement remnants
were eliminated from prepared tooth surfaces. Teeth were
cleaned with nonaromatic pumice and rinsed. Moisture
control was established. Prepared surfaces were etched
with 37% orthophosphoric acid (Ultraetch, Ultradent) for
10 s, rinsed, and dried. A dentin bonding agent (Excite,
Ivoclar Vivadent; Schaan, Liechtenstein; batch #F50603)
was used before cementation when dentin was exposed.
The restorations were cemented with a dual-curing resin
cement (Variolink II, Ivoclar Vivadent, batch #E58415)
matching the color of the prepared teeth according to the
The Journal of Adhesive Dentistry

Fig 1 Clinical view at baseline for bilateral maxillary central and
lateral incisor PLVs.
Fig 2 Bilateral maxillary central and lateral incisor PLVs after 72
weeks.
manufacturers instructions. Excess cement was removed
after 10 s of preliminary light polymerization, and the
restorations were then completely light polymerized with
an energy density of 480 mW/cm2 (Optilux, Demetron;
Danbury, CT, USA) for at least 120 s from all aspects of
the tooth. The patients were instructed about the use of
their laminate veneers, ie, not to bite or tear hard food
substances, and were recalled 1 week later to assess the
oral hygiene and gingival response (Fig 1). All procedures
were carried out by one operator, and all PLVs were placed
by one operator.
Follow-up
A total of 40 patients who had received 200 PLVs were
evaluated in this study. Median follow-up time was 67.25
weeks with a range of 12 to 72 weeks. Fifteen of the re-
stored teeth were endodontically treated while the remain-
ing 185 were vital. Twenty-six of the patients were female
and 14 were male, with an age range of 16 to 50.
All restorations were re-examined clinically and radi-
ographically by two independent calibrated clinicians, who
came to a consensus agreement when necessary with re-
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Fig 3 Survival rates of the 200 PLVs.
gard to endodontic and periodontal changes through 6-
month periodic recalls (Fig 2). Periapical radiographs were
taken every 6 months, and re-examination data on the
contemporary status were recorded.
The variables evaluated in this study were: location
(maxillary or mandibular), preparation depth (with or with-
out dentinal exposure), incisal edge preparation type
(feathered or overlapped incisal edge), proximal finishing
line design (proximal chamfer or slice), gingival finishing
line location (supra- or subgingival), and finally, bordering
tissue type (marginal finishing line bordering on healthy
enamel or partially on enamel and dentin).
Statistical evaluation
The probability of survival of the PLV restorations for each
variable was determined by using the Kaplan-Meier sur-
vival estimation method (SPSS 11.0 for Windows; Chicago,
IL, USA).23 Survival rates of different groups of PLV restora-
tions were compared using the Mantel log-rank test.34 Any
kind of a clinical failure was recorded as an event. The
time interval from the initial placement to the failure was
recorded as event-free survival. The time interval
between the initial placement and the last follow-up exam-
ination was recorded as overall survival and also ana-
lyzed.
RESULTS
Among the 200 PLVs placed, a total of 12 failures were ob-
served. The most frequent failure type (11 units) was
debonding of the restoration from the abutment tooth.
Nine of them were rebonded and the other 2 PLVs were re-
made with a different preparation design. The last failure
observed was a coronal fracture at the cervical level. The
overall survival rates were 99.5%, 99%, 97.5%, 94.9%,
94.4% and 93.8% at weeks 8, 9, 11, 15, 16, and 34, re-
spectively, with a mean estimate of 68.45 weeks (Fig 3).
407
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Fig 4 Overall survival rates for the maxillary (1) and mandibular Fig 5 Overall survival rates for the vital (1) and nonvital (2) teeth.
(2) arches.

Fig 6 Overall survival rates for the preparation depths: enamel Fig 7 Overall survival rates for incisal finishing types: incisal over-
involved (1), dentin is exposed (2). lapping (1) and incisal bevel (2).

Fig 8 Overall survival rates for proximal finishing: proximal cham- Fig 9 Overall survival rates for gingival finishing: supragingival (1)
fer (1) and proximal slice (2). and subgingival (2).

408 The Journal of Adhesive Dentistry


The survival rate in the maxillary arch was 97.5% with a
mean estimate of 69.8 weeks, while it was 95% in the
mandible with a mean estimate of 65.6 weeks (Fig 4).
Mantel log-rank comparisons revealed that the difference
between the maxillary and mandibular restorations was
statistically significant (p < 0.05). The survival rate for vital
teeth was 94.8% with a mean estimate of 68.48 weeks,
while the rate of survival for nonvital teeth was 93.3% with
a mean estimate of 57.67 weeks (Fig 5). The effect of vital-
ity on the overall survival rate was insignificant (p > 0.05).
The survival rate of preparations on enamel was 93.2%
with a mean estimate of 67.58 weeks, but 95.7% with a
mean estimate of 69.4 weeks for preparations where
dentin was exposed (Fig 6). The effect of preparation
depth was found to be insignificant for the overall survival
rate (p > 0.05). The overall survival rate for incisal overlap-
ping was 97.8% with a mean estimate of 70.86 weeks,
whereas overall survival rate for incisal bevel type prepara-
tion was 84.7% with a mean estimate of 59.31 weeks (Fig
7). The effect of incisal finishing type was found to be sig-
nificant in favor of incisal overlapping (p < 0.05). The over-
all survival rate for proximal chamfer type of preparations
was 96.3% with a mean estimate of 70 weeks; in contrast,
proximal slice preparation type survival rate was 87.4%
with a mean estimate of 63.53 weeks (Fig 8). The effect of
proximal finishing type was found to be significant (p <
0.05) in favor of proximal chamfer. The overall survival
rate for supragingival preparation was 99.4% with a mean
estimate of 71.65 weeks, compared to just 63.3% with a
mean estimate of 43.3 weeks for the subgingival prepara-
tions (Fig 9). The effect of gingival finishing type was found
to be significant for the overall survival rate (p < 0.05). The
overall survival rate for intact enamel type of bordering tis-
sue was approximately 90.5% (Fig 10). The bordering tis-
sue type as unintersected enamel had a significant effect
on the overall survival rate (p < 0.05).
DISCUSSION
Design principles and tooth preparation methods for PLV
restorations have been described and evaluated in several
reports.16-19,31,38 A minimally invasive, conservative prepa-
ration procedure for PLV restorations was reported as nec-
essary by the majority of the authors.16-19,31,38 Therefore,
in our study, a minimally invasive tooth preparation ap-
proach was adopted for the individual preparation of the
teeth.
According to the results of the present study, maxillary
PLVs had a significantly higher survival rate than the
mandibular ones. This might be attributed to the fact that
maxillary anterior teeth have wider areas upon which the
PLVs can be cemented, while PLVs cemented on mandibu-
lar incisors cover less surface area, and therefore have
greater risk of failure after long-term use. No information
was found in the reviewed literature about the comparison
of the survival rates of maxillary and mandibular PLVs.
The effect of the tooth vitality on the overall survival
rate was found to be statistically insignificant in the pre-
sent study. In the reviewed literature, no information was
Vol 11, No 5, 2009
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Fig 10 Overall survival rates for bordering tissue type: intact
enamel (1) and enamel-dentin combination (2).
found about the comparison of the survival rates of PLVs
on vital vs endodontically treated teeth. However, in a
short-term clinical study on composite/porcelain veneer
survival rates that evaluated the effect of three prepara-
tion types, it was reported that the clinical failure risk for
composite veneers was higher (46%) than porcelain ve-
neers (0%) for nonvital teeth. The explanation given for
this difference was that nonvital teeth needed a shoulder-
type preparation for masking the discoloration of teeth,
and thus the survival rate increased for prepared teeth.
The differences between PLVs made on vital or nonvital
teeth were insignificant in our study, which was attributed
to the well-developed adhesive systems and the amount of
tooth structure involved in the preparation.29
Although the results of the present study showed that
the survival rate difference between the intra-enamel and
dentin-exposed PLVs was statistically insignificant, the role
of preparation depth on bonding capability of the restora-
tion to the tooth could not be confirmed in the present
study. The accumulated fatigue damage in restoration-
bearing dentin and enamel tissues may result in failures,
such as wedge-shaped defects, cracked teeth, and cervi-
cal fractures, especially in the regions of the dentoenamel
junction and the gingival third of the crowns, when the
maximum bite force generated by masticatory muscles
cannot be compensated by the neuromuscular sys-
tem.13,18 Occlusal forces increase microleakage and gap
formation at the cervical margin by the distortion of teeth
under functional load, and the retention of the PLV might
be at risk especially in situations where the dentin is ex-
posed. The reason for chipping/partial debonding in
preparations where dentinal exposure occurred in the pre-
sent study might be the distortion under uncompensated
functional load. Preparation depth was proposed to range
from 0.3 mm to 1 mm in various studies.16-19,38 Ferrari et
al17 reported that dentinal exposure is contraindicated, be-
cause resin composites bond better with enamel than with
dentin. Other authors found it unnecessary to avoid denti-
409

tert et al
nal exposure. 17,38,13,14 Kedici 25 reported that glass-
ionomer liners decrease the resin/dentin bond strength. It
has been reported that microleakage was common in PLV
restorations when the preparation margin was in dentin.
Even with the help of depth-guided burs, dentin is exposed
in elderly patients, and immediate dentin sealing with a
dentin bonding agent was proposed for prevention of bac-
terial invasion and hypersensitivity during interim treat-
ment and improved bond strength.9,34 In addition to the fit
of the restoration and location of preparation margins, a
luting composite resin with a high filler content is recom-
mended to minimize stresses occurring during polymeriza-
tion shrinkage. However, the viscosity of a high filler
content resin would require a careful luting procedure
while positioning the PLV restoration. When preparation,
impression, fabrication, cementation, and finishing steps
are performed carefully, marginal adaptation under scan-
ning electron microscopy was found to be excellent, and
no marginal gingival health problems were reported over 5
years.40 Loss of luting resin may create visible gaps, lead-
ing to marginal discoloration and caries recurrence.
Debonding appears to occur when 80% or more of the
tooth substrate is dentin and is highly unlikely when a min-
imum of 0.5 mm of enamel remains peripherally. Debond-
ing may also occur if there is contamination during the
luting process, regardless of the percentage of intact layer
of enamel. In the present study, service duration of the
PLV restorations with and without dentinal exposure were
compared, and the difference was found to be insignifi-
cant.
Incisal edge fracture toughness of PLVs with feathered
or overlapped incisal edges was compared with some in
vitro studies.8,23,33,37-41 There is no consensus on whether
the incisal edge of the tooth should be included in the
preparation for a PLV. Incisal edge overlapping was re-
ported to be necessary in all situations to enhance the
mechanical resistance of the veneer, even though this
type of preparation would involve the removal of a rela-
tively large volume of intact incisal tissue.39 Hahn et al23
examined the influence of the incisal preparation on the
loadability of the teeth restored with PLVs; they observed
lower fracture resistance values from the incisal overlap
group in comparison with the feathered incisal edge group.
Other authors have suggested incisal edge coverage only
when indicated by esthetic or occlusal requirements. For
example, in their retrospective clinical study, Nordbo et
al30 observed the 3-year clinical performance of PLVs
without incisal overlapping, finding that incisal chipping
occurred in 7 veneered teeth of 135 PLVs. Hui et al24 re-
ported that overlapping PLV design would transmit maxi-
mum stress to the veneer and increase the risk of
fracture. Castelnouvo et al8 compared the fracture load of
PLVs with 4 different preparations: (1) no incisal reduction,
(2) 2 mm reduction without palatal chamfer, (3) 1 mm in-
cisal reduction and 1 mm palatal chamfer height and (4) 4
mm incisal reduction and 1 mm palatal chamfer height.
They recorded the greatest fracture loads from groups 1
and 2, which were comparable to an unrestored control
group. On the other hand, Wall et al39 compared the frac-
ture resistances of PLVs bonded to teeth incisally reduced
410
pyrig
No Co
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t
0.0, 0.5, 1.0, and 2.0 mm, finding nofo significant
rP differ-
by N
ence between varying incisal edge reductions.uMagne
bli and
Q ui
cat
Douglas26 compared the stress distribution of 8 different
i n
te margins tooex-
palatal finish line designs varying from butt ot
n
se nc e
tended chamfers with a 2-dimensionalsfinite-element
fo r
model, reproducing a buccolingual cross section of an in-
cisor. The authors concluded that long chamfers extending
into the palatal concavity are unfavorable because thin ex-
tensions of ceramic are generated in an area of maximum
tensile stresses. Minichamfers or butted margins were rec-
ommended by those authors. According to the results of
the present study, overlapped incisal edge preparation
type had a significant positive effect on the overall survival
rate.
The proximal chamfer preparation type resulted in bet-
ter bonding capability to sound tooth substance, mainly
enamel, as well as maintenance of the natural proximal
contacts which enhanced the esthetic appearance, al-
though slice preparation to remove preexisting unesthetic
restorations did not significantly affect the bonding capa-
bility or esthetics.2,3
The tendency for increased bleeding on probing when
the PLV margin was placed subgingivally was comparable
to earlier reports.13,32 The effect of gingival finishing type
was significant for the overall survival rate, with supragin-
gival preparations increasing it. A supragingivally located
marginal finish is well tolerated by the periodontium, since
it does not interfere with the periodontal tissues or cause
any potential for inflammation, and permits the visual con-
trol of the veneer placement and polishing quality of the
finishing line. However, care must be taken to adapt the
PLV tight enough to make the the finishing line of the PLV
with the tooth margin invisible, to ensure good esthetics.
The bordering tissue type as intact enamel had a signif-
icant effect on overall survival rate. This finding is also in
accordance with earlier studies17,28,30 which reported that
intra-enamel window preparation resulted in higher bond
strength, although dentin bonding agents have also de-
monstrated reliable bonding. However, the prognosis of
the PLVs bordering on intact enamel and partially on
enamel and dentin were not assessed in previous studies;
the present study provided the information that the finish-
ing lines of the PLVs should always be located on the in-
tact and healthy enamel tissue where the tooth structure
allows.
CONCLUSIONS
The following conclusions can be drawn from this clinical
study:
Overlapped incisal edge had a significantly positive ef-
fect on the overall survival rate.
Supragingival preparation significantly positively ef-
fected the overall survival rate.
Intact enamel as the bordering tissue had a signifi-
cantly positive effect on the overall survival rate.
The proximal chamfer preparation type resulted in bet-
ter bonding capability to sound tooth substance.
The Journal of Adhesive Dentistry

ACKNOWLEDGEMENTS
The authors of the study would like to acknowledge dental technician-
ceramist Levent Kestaneci from Kurtulmus Dental Laboratory, Izmir,
Turkey, for preparing the porcelain laminate veneers.
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overlapping provided significantly improved clinical per-
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