porcelain veneers a review of the literature

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Review

Porcelain veneers: a review of the literature

M. Peumans*, B. Van Meerbeek, P. Lambrechts, G. Vanherle

Department of Operative Dentistry and Dental Materials, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery, Catholic University of Leuven,

Kapucijnenvoer 7, B-3000 Leuven, Belgium

Received 15 April 1999; received in revised form 25 June 1999; accepted 10 September 1999

Abstract

Objectives: Porcelain veneers are steadily increasing in popularity among today’s dental practitioners for conservative restoration of

unaesthetic anterior teeth. As with any new procedure, in vitro and in vivo investigations are required to assess the ultimate clinical efficacy

of these restorations. The current literature was therefore reviewed in search for the most important parameters determining the long-termsuccess of porcelain veneers.

Data sources: Laboratory studies focusing on parameters in prediction of the clinical efficacy of porcelain veneers such as the tooth

preparation for porcelain veneers, the selection and type of the adhesive system, the quality of marginal adaptation, the resistance against

microleakage, the periodontal response, and the aesthetic characteristics of the restorations have been reviewed. The clinical relevance of

these parameters was then determined by reviewing the results of short and medium to long-term in vivo studies involving porcelain veneers

performed during the last 10 years.

Conclusions: The adhesive porcelain veneer complex has been proven to be a very strong complex in vitro and in vivo. An optimal bonded

restoration was achieved especially if the preparation was located completely in enamel, if correct adhesive treatment procedures were

carried out and if a suitable luting composite was selected. The maintenance of aesthetics of porcelain veneers in the medium to long term

was excellent, patient satisfaction was high and porcelain veneers had no adverse effects on gingival health inpatients with an optimal oral

hygiene. Major shortcomings of the porcelain veneer system were described as a relatively large marginal discrepancy, and an insufficient

wear resistance of the luting composite. Although these shortcomings had no direct impact on the clinical success of porcelain veneers in the

medium term, their influence on the overall clinical performance in the long term is still unknown and therefore needs further study. 2000Elsevier Science Ltd. All rights reserved.

Keywords: Porcelain veneers; Adhesion; Clinical effectiveness; Laboratory performance; Literature review

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

1.1. The adhesion complex: tooth/luting composite/porcelain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

1.1.1. Tooth surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

1.1.2. Porcelain veneer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

1.1.3. Luting composite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

1.1.4. The adhesion complex: tooth/luting composite/porcelain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

1.2. Marginal adaptation of the porcelain veneer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1701.3. Microleakage at the tooth/luting composite/porcelain interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

1.4. Periodontal response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

1.5. Aesthetic characteristics of porcelain veneers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

2. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Journal of Dentistry 28 (2000) 163–177

Journal

of

Dentistry

0300-5712/00/$ - see front matter 2000 Elsevier Science Ltd. All rights reserved.

PII: S0300-5712(99) 00066-4

www.elsevier.com/locate/jdent

* Corresponding author. Tel.: 32-16-332432; fax: 32-16-332440.


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1. Introduction

The patients’ demand for treatment of unaesthetic

anterior teeth is steadily growing. Accordingly, several

treatment options have been proposed to restore the

aesthetic appearance of the dentition. For many years,

the most predictable and durable aesthetic correction of

anterior teeth has been achieved by the preparation of

full crowns. However, this approach is undoubtedly most

invasive with substantial removal of large amounts of

sound tooth substance and possible adverse effects on

adjacent pulp and periodontal tissues. The great progress

in bonding capability to both enamel and dentine made

with the introduction of multi-step total-etch adhesive

systems [1–3], along with the development of high-

performance and more universally applicable small-

particle hybrid resin composites has led to more conser-

vative restorative adhesive techniques to deal with

unaesthetic tooth appearance. Resin composite veneers

can be used to mask tooth discolorations and/or tocorrect unaesthetic tooth forms and/or positions.

However, such restorations still suffer from a limited

longevity, because resin composites remain susceptible

to discoloration, wear and marginal fractures, reducing

thereby the aesthetic result in the long term [4,5]. In

search for more durable aesthetics, porcelain veneers

have been introduced during the last decade. Glazed

porcelain veneers were proposed to be durable anterior

restorations with superior aesthetics. The idea of porce-

lain veneers is not a new one. In 1938, Dr Charles

Pincus [6] described a technique in which porcelain

veneers were retained by a denture adhesive during cine-matic filming. The fragile restorations had to be

removed after filming because no adhesive system

existed at that time to permanently attach them. Simon-

sen and Calamia [7] as well as Horn [8] reactivated the

interest in porcelain veneers by introducing special acid-

etching procedures that substantially improved the long-

term porcelain veneer retention. They demonstrated that

the bond strength of an hydrofluoric acid-etched and

silanated veneer to the luting resin composite is routi-

nely greater than the bond strength of the same luting

resin to the etched enamel surface [9]. From the moment

porcelain veneers could be adhesively luted, the clinical

and laboratory techniques have continued to be refined.As with any new procedure, in vitro studies are required

to analyse the different aspects of this new system, which

are important for clinical functioning. And finally, in vivo

studies are needed to assess the ultimate clinical efficacy of

these restorations. Therefore, laboratory studies focusing on

the most important parameters in prediction of the clinical

efficacy of porcelain veneers have been reviewed. The

clinical relevance of these parameters was then determined

by reviewing the results of short and medium to long-term in

vivo studies involving porcelain veneers performed during

the last 10 years.

1.1. The adhesion complex: tooth/luting composite/

porcelain

The porcelain veneer technique includes the bonding of a

thin porcelain laminate to the tooth surface using adhesive

techniques and a luting composite in order to change the

colour, form and/or position of anterior teeth. The success of

the porcelain veneer is greatly determined by the strengthand durability of the formed bond between the three differ-

ent components of the bonded veneer complex, as there are

the tooth surface, the luting composite and the porcelain

veneer.

1.1.1. Tooth surface

Concepts regarding the preparation of teeth for porcelain

veneers have changed over the past few years. Although

early concepts suggested minimal or no tooth preparation

[8,10–13], current beliefs support removal of varying

amounts of tooth structure [10,14–19].

Enamel reduction is required to improve the bondstrength of the resin composite to the tooth surface [20–

22]. Doing so, the aprismatic top surface of mature unpre-

pared enamel, which is known to offer only a minor reten-

tion capacity, is removed. In addition, care must be taken to

maintain the preparation completely in enamel to realise an

optimal bond with the porcelain veneer [23]. Although the

results of the newest generation dentin adhesive systems are

very promising, the bond strength of porcelain bonded to

enamel is still superior when compared with the bond

strength of porcelain bonded to dentin [24,25].

The vast majority of teeth receiving porcelain laminate

veneers should have some enamel removal, usually approxi-mately 0.5 mm, which allows for the minimal thickness of

porcelain. Christensen [26] states that 0.75 mm is the opti-

mum amount of enamel that should be removed. According

to Ferrari et al. [27], however, the extent and thickness of

enamel in the gingival area of anterior teeth does not permit

a reduction of 0.5 mm without encroaching upon the

dentine. In addition, Natress et al. [28] found that in case

of freehand preparation, the proximal and cervical enamel

was reduced more than 0.5 mm in the vast majority of cases

with exposure of dentine in most teeth.

If dentine is exposed, protection is recommended for the

period between preparation and cementation in order to

prevent post-operative sensitivity and bacterial invasion[29,30]. The temporary materials (resin composite or acrylic

resin) currently in use only partially seal the surface [31,32].

More effectively, the exposed dentine can be protected by

means of a primer, which is a hydrophilic reactive monomer

in an organic solvent [33,34]. The use of these primers or

desensitisers after preparation seems not to deteriorate adhe-

sion to dentine when the exposeddentine surface is adequately

re-treated at the final appointment prior to the actual cementa-

tion [35]. Paul and Schärer [36] even proposed the application

of the dentin bonding agent immediately after completion of

tooth preparation. This new dentin bonding agent application

M. Peumans et al. / Journal of Dentistry 28 (2000) 163– 177 164


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technique may prevent the development of bacterial leakage

and dentin sensitivity during the temporary phase, and the

technique is associated with improved bond strength in vitro.

If temporary resin veneers must be placed because of aesthetic

and/or phonetic reasons, it is indicated to use an eugenol

free temporary cement in order to maintain the original bond

strength [37]. Alternatively temporary veneers may be

constructed in composite, held in place by a small area of

etched enamel [14,17].

Regarding the incisal preparation, three basic types of

preparation have been described namely, the window or

intra-enamel preparation, the overlapped incisal edgepreparation and the feathered incisal preparation. Several

authors favoured the overlapped incisal preparation

[16,17,26]. With this type of incisal preparation, the

dental technician has more control on the aesthetic char-

acteristics of the incisal part of the porcelain veneer. In

addition, this preparation will make the restoration more

resistant to incisal fractures. Highton et al. [38]

confirmed this latter statement in vitro using a two-

dimensional photo-elastic stress analysis. This type of

preparation distributed the occlusal load over a wider

surface area and, consequently, reduced stress concen-

tration within the veneer. On the contrary, an in vitro

study by Hui et al. [39] and Gilde et al. [40] demon-strated that an overlap porcelain veneer design will

transmit maximum stress on the veneer and increases

the risk of cohesive fracture. A window design prepared

entirely into enamel withstood axial stress most favour-

ably in this investigation. They concluded that where

strength is an important requisite, the most conservative

type of veneer, namely the window preparation, was the

design of choice. However, in the clinical study of

Meijering et al. [41] no relation was seen between

survival and incisal preparation design (no incisal over-

lap versus incisal overlap) for both indirect resin

composite and porcelain veneers after 2.5 years of clin-

ical functioning. Further in vivo studies have to point

out if a similar result would be noticed in the long

term.

1.1.2. Porcelain veneer

Veneers are mainly fabricated from conventional low

fusing feldspathic porcelain. Two methods for fabrication

of these porcelain veneers have been described: the plati-

num foil technique [8,11,14,42] and the refractory die tech-

nique [14]. At present, the refractory die technique is

preferred to the platinum foil technique in most laboratories[43].

By etching the inner side of the porcelain veneer with

hydrofluoric acid and subsequently silanizing the etched

surface, the bond strength of a luting composite to the

etched porcelain surface has been measured to be higher

than the bond strength of a luting composite to etched

enamel and even exceeding the cohesive strength of the

porcelain itself [9,22,44–47]. Etching the inner side of the

porcelain veneer with hydrofluoric acid creates a retentive

etch pattern. SEM of the etched porcelain surface showed an

amorphous micro-structure with numerous porosities

[44,47–50] (Fig. 1). These micro-porosities increase the

surface area for bonding and lead to a micro-mechanicalinterlocking of the resin composite. Several factors like

the etching time, concentration of the etching liquid, fabri-

cation method of the porcelain restoration [7,44], and type

of porcelain [51,52] determine the micro-morphology of the

etch pattern and consequently the bond strength of the resin

composite to the etched porcelain.

In addition to micro-porosities, micro-cracks were

observed that grow when the etching time increases [49].

These cracks can act as sources of crack initiation and

slightly, although not significantly, decrease the flexural

strength of the etched porcelain. Weakening of the


Fig. 1. Field-emission SEM photomicrograph of a GC Cosmotech porcelain surface etched with 9.5% hydrofluoric acid (Porcelain Etch gel, Ultradent) for 60 s

and ultrasonically cleaned. The etched porcelain surface showed an amorphous micro-structure with numerous micro-porosities. (Bar 10 m;

Magnification 10 000 × ).


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porcelain by etching was also noted in other in vitro studies

[53,54].

Ultrasonic cleaning of etched porcelain in 95% alcohol,

acetone or distilled water is indicated to remove all residual

acid and dissolved debris from the surface. Inadequate

rinsing after etching the porcelain surface may leave re-

mineralised salts, which can be recognised as a white resi-

due or deposit [55]. Some authors [50,56] studied the etch

patterns of hydrofluoric acid on feldspathic porcelain with

SEM and concluded that the best surface, in terms of pene-trability, was obtained by immersion of the etched porcelain

in an ultrasonic bath. Aida et al. [57], however, observed no

significant differences in surface morphology and bond

strength between etched (5% GC Hydrofluoric Acid, GC

Corp., Tokyo, Japan) feldspathic porcelain with and without

ultrasonic cleaning.

Silanization of etched porcelain with a bi-functional

coupling agent provides a chemical link between the luting

resin composite and porcelain. A silane group at one end

chemically bonds to the hydrolysed silicon dioxide at the

ceramic surface, and a methacrylate group at the other end

copolymerises with the adhesive resin. Single-component

systems contain silane in alcohol or acetone and requireprior acidification of the ceramic surface with hydrofluoric

acid to activate the chemical reaction. With two-component

silane solutions, the silane is mixed with an aqueous acid

solution to hydrolyse the silane, so that it can react directly

with the ceramic surface. If not used within several hours,

silane will polymerise to an unreactive polysiloxane [58].

Several authors reported differences in bond strength depen-

dent on the silane treatment used [45,46,51,56]. In addition,

heating of the silane-coated porcelain to 100C resulted in a

bond strength twice as high than if no heating was used [52].

The bond strength of resin composite to a pre-treated

ceramic restoration has been described to be negatively

influenced by external factors like water sorption [52], ther-

mocycling [22,59], and fatigue [60]. Contamination of the

pre-treated surface with die stone [61], latex gloves [62],

saliva [46,59], silicone-based fit-checker paste [63,64], and

try-in paste [65] will also lower the bond strength. Several

cleaning methods were proposed to restore the original bond

strength. In case of contamination with saliva, re-etching the

inner side of the porcelain with 37% phosphoric acid

restored the bond strength [46,66]. Acetone cleaning, afterremoval of the try-in paste, produced a marked reduc-

tion in bond strength [61,65]. This cleaned surface had

to be silanated again to restore the original bond

strength [65]. A decreased bond strength due to contam-

ination with fit-checker paste was restored by re-etching

and silanizing the porcelain surface [64], whereas Sheth

et al. [63] reported that the original bond strength could

not be restored due to chemical contamination of the

porcelain surface.

1.1.3. Luting composite

For cementation of porcelain veneers a light-curing luting

composite is preferred [55]. A major advantage of light-curing is that it allows for a longer working time compared

with dual cure or chemically curing materials. This makes it

easier for the dentist to remove excess composite prior to

curing, and greatly shorten the finishing time required for

these restorations. In addition, their colour stability is super-

ior compared with the dual-cured or chemical-cured

systems. Nevertheless, it is important that there is enough

light transmittance throughout the porcelain veneer to poly-

merise the light-curing luting composite. The porcelain

veneer absorbs between 40–50% of the emitted light. The

thickness of the porcelain veneer is the primary factor


Fig. 2. The interface tooth/luting composite/porcelain of a bonded to tooth porcelain veneer shows the interdigitation of the luting composite into the etched-

and-silanized porcelain surface and the etched enamel surface. (Bar 25 m; Magnification 625× ) Center: Magnification of the luting composite (Opal

Luting Composite, 3M). At the luting composite/porcelain interface, the luting composite is diluted with unfilled resin (u) (Scotchbond Multi-Purpose, 3M).

The undiluted luting composite contains densely packed rounded filler particles of different sizes. (Bar 1 m; Magnification 5000 × ).


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Table 1

Descriptive statistics of clinical trials involving porcelain veneers (evaluation criteria*: color (1), surface texture (2), wear (3), marginal adaptation (4), marginal di

(8), post-operative sensitivity (9), gingiva response (10), patient satisfaction (11))

Author Number of veneers Number of patients Porcelain/adhesive-system Type of preparation Obser

Clyde and Gilmoure [42] 200 Not specified Chameleon(Terec)/Duo-cure

(Terec)

Feathered incisal edge

Incisal bevel

Palatal overlap

1 –30 m

Calamia [89] 115 17 Chameleon (Terec)/

Comspan Ultrabond

(Den-Mat)

No preparation

Slight incisal overlap

2–3 y

Jordan et al. [90] 80 12 Not specified/dual cure

(not specified)

Conventional

(no incisal overlap)

4 y

Rucker et al. [84] 44 16 Vitadur-N(Vita)/

Heliolink Dual cement

(Vivadent)

Incisal bevel 2 y

Feathered incisal edge

Christensen and Christensen

[91]

163 45 Cerinate (Den-Mat)/

Ultrabond (Den-Mat)

Feathered incisal egde 3 y

Nordbq et al. [85] 135 41 Ceramco (Ceramco Inc.)/

Porcelite LC (Kerr)

Conventional


3 y

Jäger et al. [86] 80 25 Mirage/Mirage

FLC Mirage Bond (FA

Mirage)

Palatal overlap 1–7 y

(10 ve

Strassler and Nathanson [83] 291 60 Cerinate (Den-Mat)/

Ultrabond (Den-Mat)

No preparation

Conventional


18 –42

Strassler and Weiner [92] 115 21 Cerinate (Den-Mat)/

Ultrabond (Den-Mat)

No preparation

Conventional


7–10 y

Walls [93] 54 12 Fiber reinforced porcelain

(not specified)/Heliolink

(Vivadent) Gluma (Bayer)

Special preparation for

worn teeth

5 y

Meijering [41] 56 Not specified Flexo-ceram (ElephantCeramics)/not specified Conventional(no incisal overlap) 2.5 y

Palatal overlap

Peumans et al. [87] 87 25 GC Cosmotech Porcelain/GC

Cosmotech Bonding Set

(GC) Scotchbond 2 (3M)

Palatal overlap 5–6 y

Kihn et al. [88] 59 12 Ceramco Colorlogic/

Ceramco Colorlogic Bonding

System

Conventional (no

incisal overlap)

Palatal overlap

48 mo


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Table 2

Results of clinical trials involving porcelain veneers

Author Retention Fracture rate (%) Excellent margins (%) Microleakage (%) Caries (%) Periodontal health Maint

Clyde and Gilmoure [42] 1 – – – Excellent (not specified) –

Calamia [89] 3 93 17 1 Acceptable 100

Jordan et al. [90] 3 83 – 0 Excellent 100

Rucker et al. [84] 0 100 – – Excellent (not specified) 100

Christensen and Christensen[91]

13 65 8 1 Slight gingival irritation 100

Nordbq et al. [85] 5 Not specified Negligible – – 100

Jäger et al. [86] 1 55 1 1 Excellent –

Strassler and Nathanson [83] 1.7 96 0 0 – 100

Strassler and Weiner [92] 7 88 14 1 – 100

Walls [93] 14 Not specified 28 – Excellent –

Meijering et al. [41] Not specified 98 22 0 Excellent 100

Peumans et al. [87] 1 14 25 2 Slight gingival irritation 100

Kihn et al. [88] 0 85 2 0–1 No gingival response 100


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determining the light transmittance available for polymer-

isation [67–73]. The colour and the opacity of the porcelain

would have less influence on the amount of absorbed light

[69,72,73]. Linden et al. [72] reported that the opacity of

porcelain became more important for facings with a thick-

ness of 0.7 mm or more. Consequently, the presence of a

porcelain veneer increases the setting time of the resin

composite used beneath the veneer [69–72]. O’Keefe et al.

[73] argued that it was necessary to double the recom-

mended exposure time.

In case of porcelain with a thickness of more than 0.7 mm

[72], light-cured resin composites do not reach their maxi-

mum hardness. A dual-cured luting composite, which

contains the initiation systems for both chemically and

light-cured composites, is advisable in these situations.

With these latter luting agents a stronger bond can be

obtained with the porcelain [68]. Also higher values of hard-

ness were reported for the dual-cure resin cements than for

the light-cured luting composites because of their higher

degree of polymerisation [72,74].Regarding the classification of luting composites, Albers

[55] ranked these luting composites following the classifi-

cation of resin composites for restorative purposes proposed

by Lutz and Phillips [75]. According to Inokoshi et al. [76],

it is difficult to classify the luting composites following

these criteria because their high content of small particles

requires that many of them would be classified as hybrid

resins or heavily filled resins. A classification of 14 dual-

cure luting composites was made according to their maxi-

mum filler size. This maximum filler size varied extremely

from less than 1 to 250 m. The predominant filler size for

all products was much smaller than the maximum filler size.The filler weight varied from 36 to 77%. No correlation was

observed between filler loading, maximum filler size and

consistency of these dual-cured luting composites, whereas

a strong correlation was found between the consistency and

the film thickness of the luting agents. This relation was

supported by the temperature dependence of the film thick-

ness reported for these dual-cure luting composites [77].

The great diversity in the currently available products

makes clear specification for luting composites urgently

needed.

1.1.4. The adhesion complex: tooth/luting composite/

porcelainThe adhesion complex porcelain/luting composite/tooth

was studied by Stacey [22]. He reported that a very strong

complex was obtained in vitro by luting the porcelain

veneer. The strength of the combined porcelain/luting

composite/enamel bond (63 MPa) was significantly higher

than the separate composite/etched enamel (31 MPa) and

luting composite/etched-and-silanized porcelain (33 MPa)

bond strengths. This assumes that a close apposition of the

enamel and the porcelain surface synergistically influences

the bond strength of the luting composite/enamel and luting

composite/porcelain bonds. In addition, Andreasen et al.

[78] and Stokes and Hood [79] noted that extracted incisors

restored with porcelain veneers were recovered to their

original strength. A laboratory investigation analysing

ultra-morphologically the adhesive interface of porcelain

veneers bonded to tooth structure confirmed the high reten-

tion of bonded porcelain veneers [50]: FE-SEM photo-

graphs showed a strong micro-mechanical interlocking of

the luting composite in the micro-retentive pits of the acid-

etched tooth surface at one side and in the etch pits of the

acid-etched porcelain surface at the other side (Fig. 2).

Magne and Douglas [80] also demonstrated that porcelain

veneers restore the mechanical behaviour and microstruc-

ture of the intact tooth in vitro even when they are bonded to

an extensive dentin surface using an optimised application

mode of dentine adhesives. Nevertheless, significant cyclic

temperature changes can induce the development of flaws in

porcelain veneers. A sufficient and even thickness of cera-

mic combined with a minimal thickness of luting composite

will provide the restoration with a favourable configuration

with regard to crack propensity, namely, a ceramic andluting composite thickness ratio above 3 [81]. This ratio

also appears to have a relevant influence on the stress distri-

bution in porcelain laminates. Restorations that are too thin,

combined with poor internal fit, resulted in higher stresses at

both the surface and interface of the restoration [82].

Ultimately, the clinical relevance of these in vitro results

must be determined in vivo. A review of clinical trials invol-

ving porcelain veneers, that were conducted during the last

10 years, is summarised in Table 1 with their respective

descriptive statistics (Table 1) and results (Table 2). These

in vivo results confirmed the strong bond between a porce-

lain veneer and the underlying tooth tissue as most short andmedium-term clinical studies reported a very low failure

rate (0–5%) due to loss of bonding and fracture [42,83–

88]. Somewhat higher failure rates were noted by Christen-

sen and Christensen [91], 13% after three years and by

Strassler and Weiner [92], 7% after 7–10 years. Walls

[93] also observed a high number of fractures and/or loss

of porcelain veneers (14%) after five years of clinical func-

tioning. Unfavourable occlusion and articulation seemed to

have been a determining factor for the high failure rate of

porcelain veneers as the latter restorations were placed

for aesthetic and functional reconstruction of fractured

and worn anterior teeth in patients with a history of

bruxism. The large exposed dentine surfaces to bebonded in these fractured and worn teeth (using a

third generation dentin adhesive) may also have contrib-

uted to the high failure rate.

Some authors [94,95] reported higher failure rates in vivo

when porcelain veneers were partly bonded to underlying

composite restorations. This bonding is based on delayed

resin-to-resin bonding, which may decrease the bond

strength of the porcelain veneer–tooth complex.

As a conclusion, in vitro and in vivo studies indicated that

porcelain veneers are strong and durable restorations in the

medium to long term when enough intact tooth tissue is left



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to bond the porcelain veneer and when occlusion and articu-

lation are not pathological.

1.2. Marginal adaptation of the porcelain veneer

For any cemented restoration the weak link is at the

restoration-cement– tooth interface. In porcelain veneers

the composite luting agent is the weak link in the system.

When used as a luting agent, the bulk of composite resin is

greatly reduced. However, there is still polymerisation

volumetric shrinkage in the amount of 2.6–5.7% [96],

which may create a marginal opening or loss of themarginal seal. The thermal expansion coefficient (TEC) is

also different from the tooth tissues and the porcelain.

Finally, composite resins may wear and the wear will be

greater in case of larger gap widths compared to smaller

ones [97]. In addition, in vitro studies have demonstrated

a dissolution of the resin matrix of composite resin in oral

fluids [98–100]. Therefore it is desirable to minimise the

composite component and maximise the porcelain compo-

nent by having as close an adaptation of the porcelain

veneer as possible.

Sorensen et al. [101] compared in vitro the marginal fit of

porcelain veneers fabricated by the two procedures

described above: the platinum foil technique and the refrac-tory die technique. They reported that the mean vertical

marginal discrepancy (for all positions combined) for plati-

num foil veneers (187 m) was significantly less than that

for veneers made with the refractory die technique

(242 m). The same observation was done by Sim and

Ibbetson [102] (60 versus 290 m) and Wall et al. [103]

(74 versus 132 m), although they reported smaller

marginal gap widths. This finding seems however incongru-

ous, considering that the platinum foil occupies 25 m. Lim

and Ironside [104] reported that divesting with aluminium

oxide abrasive may account for inadvertent abrasion of the

delicate inner porcelain surface and causes larger marginal

discrepancies (114 m with sandblasting versus 97 m

without sandblasting).

With the refractory die technique, the importance of

matching the thermal expansion coefficient between the

refractory die and the ceramic must be emphasised in

order to fabricate restorations with a significantly improved

marginal accuracy [105]. Intermixing of individual ceramic

and refractory products seems to be commonplace in many

laboratories with some combinations having different

thermal expansion coefficients [43].

For both fabrication techniques, the marginal openings atthe gingivo-proximal corners were two to four times larger

than at the mid-labial position [101,102,106]. This is prob-

ably the result of the shrinkage of porcelain towards the

region of greatest bulk (the centre) and the geometry of

the margins. Clinically this poorer fit at the gingivo-

proximal corners of the veneers would be further

compounded by the difficulty in access for finishing of the

luted veneers in these regions.

When luting porcelain veneers it is important that the

marginal discrepancies are completely filled with the luting

composite, in order to polish the cement layer to a smooth

margin. Harasani et al. [106] observed after finishing of the

veneers still a considerable amount of excess luting agent atthe veneer margins. Also Coyne and Wilson [107] reported

that only a small proportion of the margins of each porcelain

veneer was found to have an ideal marginal adaptation

microscopically. Hannig et al. [108] noted that especially

the cervical region seems to be a problematic area to achieve

perfect marginal adaptation.

Tay et al. [109] advised to remove the excess of non-

polymerised composite cement with a brush moistened

with bonding resin. This will reduce the dragging out

tendency of the resin out of the marginal gap and ensure a

smoother margin that is polishable.


Fig. 3. SEM photomicrograph of the cervical margin of a 5-year old porcelain veneer (P) showing a small marginal defect and a border of roughened porcelain

(arrows). (G, gingiva; C, luting composite) (Bar 250 m; Magnification 52 × ).


9/15

Finishing of the veneer margins corrects the inherent

marginal defects but results in removal of the glaze from

the porcelain [87] (Fig. 3). This will cause increased plaque

retention and gingival reaction on the one hand and wear of

the antagonistic elements on the other hand, unless the

porcelain can be polished to a smooth surface.

Some authors showed that polishing procedures can

produce a polished surface, which is equal to a glazed

porcelain surface [110–112]. While these polishing instru-

ments perform satisfactorily on flat accessible surfaces at

high speeds, none of them are well suited for finishing

crucial gingival or interproximal regions of a bondedveneer. Haywood et al. [113] evaluated finishing and

polishing in these crucial areas in vitro. According to

these authors, a finish equal or superior in smoothness to

glazed porcelain was achieved through the use of a series of

finishing grit diamonds (Micron Finishing System) followed

by a 30-fluted carbide bur and diamond polishing paste.

Other finishing combinations produced surface textures,

which were not as smooth as glazed porcelain. Polishing

under waterspray produced also a smoother surface for a

given diamond sequence than did dry polishing [114].

However, the effect of all these finishing procedures at

the cervical margins of the veneer with their difficult

accessibility for polishing instruments, must be evaluated

in vivo.Regarding the marginal adaptation of porcelain veneers

after several years of clinical functioning, most in vivo


Fig. 4. Field-emission SEM photomicrograph of the luting composite/etched enamel interface of a bonded to tooth porcelain veneer. At the most cervical

enamel area, the luting composite is bonded to aprismatic enamel. Atypically shaped prisms are present. (C, Luting composite; E, Enamel, u, unfilled resin)

(Bar 2 m; Magnification 5000 × ).

Fig. 5. Field-emission SEM photomicrograph of the luting composite/etched enamel interface of a bonded to tooth porcelain veneer at the area of prismatic

enamel. The enamel prismata are longitudinally sectioned. The perifery of the enamel prisms is preferentially dissolved forming macro-tags with a depth of

approximately 5 m (large arrows). Micro-tags are present between the hydroxyapatite crystals (small arrows). The macro-tags and micro-tags contribute to an

enormous increase in surface area for bonding. (C, Luting composite; E, Enamel) (Bar 2 m; Magnification 5000 × ).


10/15

studies reported a relatively high number of restorations

with an excellent marginal adaptation (65–98%)

[41,83,84,88–92], while only few clinical studies reported

that small marginal defects were frequently observed along

the entire outline of the porcelain veneer after five years of

functioning [86,87] (Table 2). SEM examination showed

that these small marginal defects were due to the wearing

out of the composite luting agent and loss of bonding

[86,87]. A similar phenomenon was reported as submargina-

tion in several in vivo studies of porcelain inlays [115–117].

Further research should be directed towards improve-

ment of marginal adaptation of the porcelain veneers.

Attention must be given to the laboratory procedure to

reduce the marginal gap width and to the finishing

procedure to diminish the excess of resin composite at the

margins. Finally more wear-resistant luting composites

should be developed.

1.3. Microleakage at the tooth/luting composite/porcelain

interface

The polymerisation shrinkage of the luting composite and

the difference in thermal expansion coefficient between the

luting composite and both the tooth and the porcelain veneer

causes stress at the tooth/luting composite/porcelain inter-

face. According to the theories by Feilzer et al. [118], there

is only a limited potential for relaxation of polymerisation

stress due to flow because the luting composite is bonded at

all sides in a narrow “gap” with only a limited area of

unbonded surface. Consequently, Feilzer et al. [119] found

that when the thickness of the resin composite is thinned

down, as in the case of a luting agent, the wall-to-wall

polymerisation shrinkage might be three times the normal

linear contraction of bulk resin composite. Residual poly-

merisation stress could then be expected to be even greater


Fig. 6. Field-emission SEM photomicrograph of the luting composite/etched dentine interface at the cervical third of a bonded to tooth porcelain veneer. The

dentine tubules (arrows) are longitudinally sectioned. The dark area represents the hybrid layer and the layer of unfilled adhesive resin (H). No loss of bonding

is observed in this area using a modern total etch dentine adhesive system (Scotchbond Multi-Purpose, 3M). (C, Luting composite; D, dentine) (Bar 10 m;

Magnification 1000 × ).

Fig. 7. The oblique sectioned dentine tubules at the luting composite/etched dentine interface are filled with resin tags (arrow). No loss of bonding is observed

in this area using a modern total etch dentine adhesive system (Scotchbond Multi-Purpose, 3M). (C, Luting composite; D, dentine; H, hybrid layer and layer of

unfilled adhesive resin) (Bar 5 m; Magnification 2000 × ).


11/15

than that reported for resin composite restorations. Due to

this contraction stress there exists a competition between the

adhesive forces of the two bonded interfaces: the porcelain/

luting composite interface and the luting composite/tooth

interface. The interface with the lowest adhesive forces

will fail namely the luting composite/tooth interface. Micro-

leakage will occur at this interface and may then lead to

staining, post-operative sensitivity and recurrent caries.

Microleakage at the luting composite/porcelain interface

was negligible [101,120,121]. At the interface luting

composite/tooth the microleakage was minimal when the

preparation margins were located completely in enamel

[101,120–123]. Only at the cervical margin, microleakage

was more pronounced. This would be due to the presence of

aprismatic enamel in the cervical region [50,124] (Figs. 4

and 5). Porcelain veneer preparations generally end in this

region of aprismatic enamel, which therefore may be largely

responsible for the poor marginal sealing reported at the

cervical margins of porcelain veneers in vitro [101,120–

123]. When the cervical preparation margin was located indentine, significantly greater microleakage was recorded at

the luting composite/tooth interface [125]. The use of a third

generation dentine bonding agent can reduce the occurrence

of microleakage according to several authors [120,125] in

contrast with the results obtained by Sim et al. [123],

who reported that none of the tested (third generation)

dentine bonding agents significantly reduced microleak-

age at the dentine margins. Dietschi et al. [126]

reported an obvious reduction in marginal leakage of

ceramic inlays when bonded to dentin using two

modern dentine adhesives, although the integrity of

the adhesive interface did not yet appear optimal indentine bonded ceramic restorations because bonding

failures occurred mainly between the hybrid layer and

the overlaying resin. In another in vitro study debonding

was never noticed along the luting composite/dentin

interface when a modern multi-step total-etch dentin

adhesive system was used [50] (Figs. 6 and 7). Magne

and Douglas [80] noticed in vitro that the method of

dentin adhesive application during placement of the

porcelain veneer had an influence on the quality of

the luting composite dentin/interface. Their scanning

electron microscope observations demonstrated that the

traditional application of a multi-step total etch dentin

adhesive (dentin adhesive applied when proceeding toluting the veneer) was associated with bonding failures

between the hybrid layer and the overlaying resin,

whereas unbroken and continuous interfaces were

obtained with a new method using the same dentin

adhesive (dentin adhesive applied to dentin and cured

before taking the impression of the veneer). However,

none of the modern adhesive systems appears yet to be

able to guarantee hermetically sealed restorations with

margins free of discoloration for a long time [25].

Another effective method to reduce microleakage is by

post-finishing sealing the margins of the veneer with a

bonding resin [125]. Further research is necessary to evalu-

ate the retention of the sealer.

In addition to the location of the preparation margins, the

type of luting composite determines the occurrence of

microleakage as the thermal expansion coefficient and the

amount of polymerisation shrinkage vary among the type of

resin composite. A high filler loading reduces the thermal

expansion coefficient and polymerisation shrinkage.

Because of these reasons, a luting composite with an opti-

mal filler loading is preferred to lute the porcelain veneers

[101,121,122,123]. However, the viscosity of such cements

is high and hence the positioning of the veneer during the

luting procedure may be delicate. The luting procedure with

these highly filled luting composites can be simplified by

using an ultrasonic insertion technique [127]. Clinical

confirmation of this method is however required.

Light-cured and dual-cured luting composites show a

similar leakage pattern at the luting composite/tooth inter-

face according to Zaimoglu et al. [122], whereas Jankowski

et al. [128] observed less microleakage when using dual-cured luting composites.

In clinical studies, microleakage was more frequently

observed when dentine was exposed during preparation

for porcelain veneers [89], even when a third generation

dentine adhesive system was used [87,93]. In other clinical

studies of porcelain veneers with complete intra-enamel

preparations, microleakage was reported less frequently

[83,85,88,91,92]. Finally, microleakage was rarely asso-

ciated with the presence of caries in vivo [41,83,86–92].

As a conclusion, microleakage can be minimised by

locating the preparation margins of the veneer in enamel

and by selecting a highly filled luting composite.

1.4. Periodontal response

Porcelain is considered as the most aesthetic and biocom-

patible material in dentistry with the ability to imitate sound

enamel. Several studies showed that porcelain retains

plaque less than other restorative materials or enamel

[129–132], that the plaque is removed more rapidly from

porcelain surfaces and/or that the bacterial plaque vitality on

these surfaces was smaller [133]. The low surface roughness

of the glazed porcelain may to a large part be responsible for

this phenomenon [134]. Based on these observations one

would expect no or even a positive reaction of the marginalgingival tissues towards porcelain veneers.

Several short-term [89,135] and medium-term

[88,93,136] clinical studies of porcelain veneers confirmed

this expectation. They reported no increase of even a

decrease in plaque accumulation on these restorations.

Kourkata et al. [135] even described a significant lower

bacterial plaque vitality immediately after placement of

the porcelain veneers. Peumans, however, observed a slight

increase in plaque retention at the cervical margins of 5-year

old porcelain veneers [137]. This slight increase was

explained by the increased surface roughness at the cervical



12/15

border of the restoration caused by removal of the glaze of

the porcelain during finishing with microfine finishing

diamonds (Fig. 3). In addition to this roughened cervical

border, the presence of small cervical marginal defects

can lead to an increased plaque retention [87].

Concerning the gingival response, most clinical studies

observed no change in gingival health at the restored teeth

[41,42,84,86,88–90,93,136] (Table 2). Only a few clinical

studies reported a slight gingival inflammation at the

restored teeth [91], especially in patients with a moderate

or bad oral hygiene [137].

According to Pippin et al. [136], the location of the cervi-

cal extension of the restoration in location to the gingival

margin also plays an important role in the reaction of the

gingival tissues. They reported that the gingival reaction

increased as the extension was located closer to or below

the gingival margin, however, the gingival reaction for

porcelain veneers was at the same location lower than for

the metal ceramic restorations.

In conclusion, no or a minimal periodontal response canbe expected at teeth restored with porcelain veneers. An

optimal oral hygiene of the patient and smoothly finished

margins are important factors to maintain an optimal period-

ontal health around the restored teeth.

1.5. Aesthetic characteristics of porcelain veneers

There is a general agreement among the practitioners that

porcelain veneers will continue to play a vital role in elec-

tive dental aesthetics. This places high demands on predict-

ability, especially with colour matching and maskingmethods. The final shade of the veneers depends not only

on the colour, opacity and thickness of the porcelain but also

on the colour of the underlying tooth and the colour and

thickness of the luting composite [138–143].

Colour matching of one discoloured tooth with a porce-

lain veneer to the surrounding natural teeth must be consid-

ered as most difficult. It is impossible to mask a strong

discoloration by a thin layer of porcelain (0.3–0.7 mm)

without making the restoration opaque and lifeless. Conse-

quently, the restored tooth will never have the same trans-

lucency as the surrounding natural teeth. [14,15,42,55,87].

Regarding the aesthetics (colour stability and surface

smoothness) of porcelain veneers after several years of clin-ical functioning, all clinical studies confirmed the mainte-

nance of aesthetics of porcelain veneers in the short term

and in the medium to long term (Table 2). In addition,

patient acceptance of porcelain veneers in these clinical

studies was high. The percentage of patients that were

completely satisfied with the porcelain veneers varied

from 80 to 100% (Table 2). Some studies even reported

an increase in patient satisfaction after several years

[91,144]. This increase was explained by the habituation

of the patients to the aesthetic improvement of their denti-

tion with porcelain veneers.

2. Conclusion

The adhesive porcelain veneer complex appeared to be a

very strong complex in vitro and in vivo. An optimal bond

was obtained if the preparation was located completely in

enamel, if correct surface treatment procedures were carried

out and if a suitable composite luting agent was selected.

However, from an aesthetic and periodontal point of view a

complete intra-enamel preparation cannot always be

realised. The quality of the restoration was inferior if

dentine was exposed to a large extent, as the current dentin

bonding agents are not yet able to prevent microleakage at

the dentin margins in the long term.

The periodontal response to porcelain veneers varied

from clinically acceptable to excellent. Regarding the

aesthetic properties of the porcelain veneers, these restora-

tions maintained their aesthetic characteristics in the

medium to long term and patient satisfaction was high.

The major shortcoming of porcelain veneers was the rela-

tively wide marginal discrepancy. At these marginal open-ings the luting composite was exposed to the oral

environment and the wear resistance of the composite luting

agents was not yet optimal.

Nevertheless, these shortcomings had no direct impact on

the success of porcelain veneers in the medium term,

however, their influence on the overall clinical performance

in the long term is still unknown.

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