J O U R N A L O F E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y110

Critical Appraisal

PORCELAIN VENEER OUTCOMES, PART II

Authors

Edward J. Swift Jr, DMD, MS*Mark J. Friedman, DDS†

Associate EditorEdward J. Swift Jr, DMD, MS

*Professor and chair, Department of Operative Dentistry, University of North Carolina, Chapel Hill, NC, USA†Private practice, Encino, CA, and clinical professor, University of Southern California School of Dentistry, Los Angeles,CA, USA

Etched porcelain veneers have now been used clinically for about 20 years. The profession wasoriginally very skeptical about bonding thin shells of a brittle ceramic material to teeth. However,

ceramic veneers have proved to be not only very esthetic but also extremely durable restorations. Thisarticle continues the Critical Appraisal from the previous issue of JERD and describes articles relatedto veneer longevity and clinical factors contributing to—or detracting from—longevity.

A PROSPECTIVE TEN-YEAR CLINICAL TRIAL OF PORCELAIN VENEERS

M. Peumans, J. De Munck, S. Fieuws, P. Lambrechts, G. Vanherle, B. Van MeerbeekJournal of Adhesive Dentistry 2004 (6:65–76)

ABSTRACT

Objective: The purpose of thisprospective clinical study was toevaluate the performance of porce-lain veneers after 5 and 10 years ofclinical service.

Materials and Methods: A singleexperienced clinician placed 87porcelain veneers in 25 patients in1990 and 1991. The teeth includedmaxillary central incisors to firstpremolars. As described in the5-year report of this study, prepara-tions included a chamfer margin,0.3 to 0.7 mm labial enamel reduc-

recurrent caries, pulp vitality, andpatient satisfaction. Marginal adap-tation was assessed further usingscanning electron microscopy toexamine epoxy replicas.

Results: Five years after placement,all 87 veneers remained in placeand had “perfect” color match andsurface smoothness. Four veneershad fractures, but only one of thoserequired repair. Ninety-nine percentof the veneers had clinically accept-able marginal adaptation, althoughjust 14% of the veneers had “per-fect” marginal adaptation at all

tion, and incisal edge coverage. Asingle laboratory technician fabri-cated the veneers using feldspathicporcelain on refractory dies. Inter-nal surfaces were etched with 5%hydrofluoric acid and silanated.Teeth were isolated with a rubberdam prior to veneer placement. Allveneers were bonded with a light-activated resin cement. Patientswere recalled at 5 to 6 years and at10 years after initial veneer place-ment. Two evaluators examinedeach veneer for retention, fractures,color match, surface roughness,marginal adaptation, leakage,

DOI 10.2310/6130.2006.00019

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margins. One had clinically unac-ceptable staining from leakage.Recurrent caries was present at theproximal margin of two veneers. Atthe 10-year evaluation, which had a93% recall rate, color match andsurface roughness remained opti-mal. Thirteen of 22 patients werevery satisfied with the estheticresult, whereas 7 complained ofminor esthetic problems. The frac-ture rate increased substantially, to34% at the 10-year recall. How-ever, only 11% of the fractureswere clinically unacceptable. Noneof the veneers had debonded, butthe percentage of veneers with“perfect” marginal adaptation haddeclined to only 4%. Leakage wasnow evident around two-thirds ofthe veneers, and eight restorationshad recurrent caries.

Conclusion: Porcelain veneers are areliable and effective means forconservative esthetic treatment of

Nevertheless, it is worth noting that the veneers were not com-pletely free of problems, either at 5 or 10 years after placement.Veneer problems are likely toincrease when, for example, appro-priate preparation guidelines arenot followed. The clinician who isconsidering veneers for a particularpatient should remember that theveneers will not last forever andwill almost certainly requirereplacement at some point.

SUGGESTED READING

Chen J-H, Shi C-X, Wang M, et al. Clinicalevaluation of 546 tetracycline-stainedteeth treated with porcelain laminateveneers. J Dent 2005;33:3–8.

Fradeani M. Six-year follow-up with Empressveneers. Int J Periodontics RestorativeDent 1998;18:216–25

Nordbo H, Rygh-Thoresen N, Henaug T. Clini-cal performance of porcelain laminateveneer restorations without incisal overlap-ping: 3-year results. J Dent 1994;22:342–5.

Walls AWG. The use of adhesively retained all-porcelain veneers during the managementof fractured and worn anterior teeth: part2. Clinical results after 5 years of follow-up. Br Dent J 1995;178:337–40.

anterior teeth in the long term.After 10 years of clinical service,esthetic results remained good,patient satisfaction was high, andthe retention rate was excellent.The number of irreparable fractureswas low. Appropriate preparationdesign, occlusion, and use of adhe-sive materials contribute to the ulti-mate outcome.

COMMENTARY

This study was somewhat limited in scope; fewer than 100 veneerswere evaluated, and all were pre-pared and bonded by a single clini-cian and fabricated by a singlelaboratory technician using a single ceramic material.

Certainly, the veneers were not perfect after 10 years of clinical service. However, most problemswere minor, and both the patientsand the clinician evaluators weresatisfied with the results.

DIRECT VERSUS INDIRECT VENEER RESTORATIONS FOR INTRINSIC DENTAL STAINS

J. Wakiaga, P. Brunton, N. Silikas, A.M. GlennyThe Cochrane Database of Systematic Reviews 2004 (1:CD004347)

ABSTRACT

Objective: The purpose of this studywas to examine the effectiveness ofindirect and direct veneer restora-tions, particularly with regard tolongevity and patient satisfaction.

Materials and Methods: Thisstudy evaluated the literature onrandomized clinical trials compar-

ing direct and indirect veneers onanterior teeth. The search strategyinvolved Medline and other data-bases and was followed by contact-ing authors to determine whetherany additional published or unpub-lished studies were available.

Relevant studies were assessed forfactors such as quality of random-

ization, outcome assessment, andcompleteness of recall evaluation.Data from the studies wereextracted by three independentreviewers using special forms.Authors were contacted for clarifi-cation and missing data. Studydetails such as dates, demograph-ics of the sample, and outcomeswere recorded.

C R I T I C A L A P P R A I S A L

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Results: The electronic searchesidentified 29 clinical trials and 1systematic review. Six of those werescreened as potentially relevant tothe review, but following a moredetailed screening, only one study(Meijering and colleagues, 1998)met all of the inclusion criteria. Inthe 2-year recall of that study, theoverall survival rates were 94% forporcelain, 90% for indirect com-posite, and 74% for direct compos-ite veneers. The survival rate washigher when the incisal edge wasreduced. Patient satisfaction rateswere 93% for porcelain, 82% forindirect composite, and 67% fordirect composite.

Conclusion: Very little reliable evi-dence compares the effectiveness ofindirect versus indirect veneers. Foran individual patient, the choicebetween the two options should

take into account patient preferenceand the clinician’s experience.

COMMENTARY

As this Cochrane review shows,there is very little scientific evidenceconcerning the longevity of porce-lain veneers compared with that of direct resin veneers. Only onerandomized clinical trial met theinclusion criteria of the review.That study did show greater techni-cal success and patient satisfactionfor the porcelain veneers butinvolved less than 200 restorationsat only 2.5 years after placement.

The most revealing aspect of thisCochrane review is that, as clini-cians, we cannot provide ourpatients with the highest level ofscientific evidence regarding veneerssimply because that evidence is notavailable. Certainly, one would

expect porcelain veneers to providelonger service and greater patientsatisfaction than direct veneers, and clinical experience supportsthis expectation. However, directveneers continue to have a place for some clinicians and patients.

SUGGESTED READING

Kreulen CM, Creugers NHJ, Meijering AC.Meta-analysis of anterior veneer restora-tions in clinical studies. J Dent 1998;26:345–53.

Meijering AC, Creugers NH, Roeters FJ, Mulder J. Survival of three types of veneerrestorations in a clinical trial: a 2.5-yearinterim evaluation. J Dent 1998;26:563–8.

Spear FM. Esthetic correction of anterior dentalmalalignment: conventional versus instant(restorative) orthodontics. J Esthet RestorDent 2004;16:149–62.

Reprint requests: Mark J. Friedman, DDS,Center for Dental Aesthetics, 16830 VenturaBlvd., Suite 258, Encino, CA 91436; e-mail:mfriedmandds@mac.com©2006 Blackwell Publishing, Inc.

THE BOTTOM LINE: PORCELAIN VENEER OUTCOMES

The most interesting issue that is revealed by these investigations is the significant variation in clinical suc-cess of bonded porcelain veneer restorations. Naturally, there are multiple clinical factors that will influencethe relative success and failure of any restorative dentistry technique. The ultrathin porcelain veneerrestoration is a particularly demanding procedure. It is reasonable to assume that all the investigators exer-cised great care to be as precise and consistent as possible.

In Part I, Shaini and colleagues found that the porcelain veneer restorations placed by one group of operatorsresulted in a nearly 50% failure rate at 6 years. Dumfahrt and Schäffer reported 90% success at 10 years.Peumans and colleagues reported similar success rates at 10 years, but 34% of the restorations in thisprospective study exhibited noticeable fractures and only 4% demonstrated “perfect” marginal adaptation.This evidence suggests that at least some porcelain veneer restorations are likely to require repair or replace-ment within a decade of service or even sooner. All the investigators attempted to ensure that the porcelainveneer restorations were bonded to an enamel substrate and reported less success when veneers were bondedto dentin or existing restorations. Friedman reported that catastrophic failures of porcelain veneer restora-tions were most common when the restorations were bonded to dentin. Debonding and leakage were not