Survival of Porcelain Laminate Veneers with Different

Degrees of Dentin Exposure: 2-year Clinical Results

Elif ztrka / kran Bolayb

Purpose: To evaluate the clinical performance of porcelain laminate veneers (PLVs) after 2 years.
Materials and Methods: Twenty-eight patients were treated with 125 PLVs. The experimental variables were
preparation design (incisal overlap [IO] and incisal bevel [IB]) and adhesion surface (enamel [E], enamel with
minimal dentin exposure [MDE], and enamel with severe dentin exposure (SDE)]. Marginal adaptation, marginal
discoloration, secondary caries, postoperative sensitivity, and patient satisfaction were assessed according
to the modified United States Public Health Service criteria. Each restoration was examined for fractures and
debonding. In addition, gingival tissue health by gingival plaque, bleeding, and recession was recorded. An experienced clinician evaluated the restorations at baseline and after 6, 12, and 24 months, and survival rates
evaluating relative and absolute failures were calculated (p = 0.05).
Results: Eleven (8.8%) veneers failed, and the overall cumulative survival rate was 91.2% after 2 years of followup. IB and IO preparation designs exhibited survival rates of 94% and 85.7%, respectively, but this difference
was not statistically significant (p > 0.05). PLVs bonded to SDE were more likely to fail than those bonded to E
and MDE (p < 0.05). There was no significant difference between the failure rate of PLVs bonded to E and those
bonded to MDE (p > 0.05).
Conclusions: PLVs have high survival rates when bonded to enamel only, as well as to enamel with minimal dentin exposure. However, extensive dentin exposure should be avoided during the preparation.
Keywords: porcelain laminate veneers, dentin exposure, preparation design.
J Adhes Dent 2014; 16: 481489.
doi: 10.3290/j.jad.a32828

he porcelain laminate veneer (PLV) technique, which

is one of the most popular esthetic treatment alternatives for anterior teeth to restore slight discolorations,
abrasions, fractures, malformations, and/or malpositions, bonds a thin porcelain laminate to the tooth
surface using dental adhesives and resin cements.23,26
One of the major advantages of the porcelain laminate
veneer technique is that it can be performed on a conservative preparation with a minimum of tooth reduction.39 However, there are some problems associated
with PLVs, such as debonding, fracture, or microleakage
from the margins of the restoration.29 Many factors can

Assistant Professor, Department of Restorative Dentistry, Faculty of Dentistry, Hacettepe University, Ankara, Turkey. Experimental design, clinical
applications, wrote the manuscript.

Professor, Department of Restorative Dentistry, Faculty of Dentistry,

Hacettepe University, Ankara, Turkey. Idea and hypothesis, follow-up examinations, proofread the manuscript.

Correspondence: Assistant Professor Elif ztrk, Hacettepe University, Faculty of

Dentistry, Department of Restorative Dentistry, Sihhiye-06100, Ankara, Turkey.
Tel: +90-312-305-2270, Fax: +90-312-311-3438. e-mail: dtelifoz@gmail.com

Vol 16, No 5, 2014

Submitted for publication: 05.03.14; accepted for publication: 19.09.14

influence the long-term success of porcelain laminate

veneers, such as structure of the adhesion surface,
preparation type and depth, type and thickness of the
porcelain, type of the resin cement and dental adhesive,
tooth morphology, as well as functional and parafunctional activities.22,26
Tooth preparation for PLVs is crucial for optimal function and esthetics; therefore, care should be taken to
completely perform this preparation in the enamel.16,22
In general, anterior tooth preparation requires a 0.3- to
0.7-mm facial reduction, depending on the location of the
crown, to imitate the natural contours of the tooth.28 This
anatomical preparation technique may enable tooth preparation within only enamel, because enamel thickness is
different in different zones of the tooth.
For PLV restorations, preparation design is classified
according to the type of incisal edge. The following two
preparation designs are frequently used: incisal bevel (IB)
and incisal overlap (IO) ending with a palatal chamfer. Both
techniques allow characterization of the incisal region and
better seating of PLVs.5 However, controversy exists over
which preparation design is the most suitable,5,35 and few
clinical studies have compared their efficacy.20
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Preparation performed completely in the enamel is

believed to maintain an optimal bond with PLV and decrease stress in the porcelain. Thus, preparation of PLVs
should be meticulously performed.16 In addition, the
preparation technique used impacts on the longevity of
the restoration, eg, high failure rates of PLVs have been
attributed to the exposure of dentin surfaces. However,
exposure of a considerable amount of dentin is inevitable during preparation, particularly in cervical and proximal areas, to compensate for slight malposition and/or
discoloration.21
Several medium-to-long-term clinical studies have evaluated the clinical performance of PLVs. One longitudinal
clinical study8 reported a low failure rate (0%7%) after 5
to 12 years, whereas others31,32,37 describe higher failure rates (14%33%). However, few clinical studies have
considered the performance of PLVs according to preparation depth7,14 or preparation design,2 when dentin is
exposed on the tooth surface. Therefore, in this study, we
assessed the medium-term clinical performance of PLVs,
using two preparation designs and a range of preparation
depths, causing different degrees of dentin exposure on
the tooth surface. The null hypotheses were as follows:
1. dentin exposure on the tooth surface does not affect
the clinical survival of PLVs, and 2. there is no difference
between IO and IB preparation designs in terms of the
clinical survival of PLVs.

MATERIALS AND METHODS

Study Design
The protocol of this clinical study was approved by the
Ethics Committee of Hacettepe University, Ankara, Turkey (FON 07/27-42). Informed consent was obtained
from each participant. Twenty-eight patients (5 men,
23 women) aged 18 to 51 years (average: 30 years)
were referred to the Department of Restorative Dentistry
at Hacettepe University with the main complaint of unesthetic anterior teeth. The patients received 125 PLVs
(29 in men, 96 in women) between May 2008 and May
2011.
The indications for treatment were as follows: severe intrinsic and/or extrinsic discoloration unrelieved by bleaching (46, 36.8%); minor to moderate noncarious structural
defects, and wear or fracture (6, 4.8%); diastema (4,
3.2%); slight malalignment (6, 4.8%); morphological disorders, such as peg-shaped maxillary lateral incisors, as
well as the presence of a canine tooth instead of a missing lateral tooth (23, 18.4%); existing unesthetic composite restorations of the anterior teeth (40, 32%). Nonvital
teeth (12, 9.6%) were not excluded from the study.
Inclusion criteria were as follows: all patients were
required to be at least 18 years old, able to read and
sign the informed consent document, physically and psychologically able to tolerate conventional restorative procedures, willing to return for follow-up examinations as
outlined by the investigators, and to have all maxillary
anterior teeth, no active periodontal or pulpal diseases,
and no systemic disorders. Patients with severe parafunc482

tional habits were excluded from the study. Initially, dental

calculus and extrinsic stains were cleaned from patients
teeth. Patients were instructed on improving their gingival
health and maintaining effective plaque control. However,
if their gingival health did not improve, they were excluded
from the study.
Diagnosis and Treatment Planning
Patients were treated with a minimum of one and a
maximum of nine veneers according to an evaluation.
Pre-operative photographs of each patient were taken to
evaluate the clinical appearance of their teeth. Before
preparation, impressions were taken from each patient
using a polyvinyl siloxane impression material in heavy
body (Virtual Putty, Ivoclar Vivadent; Schaan, Liechtenstein) to prepare diagnostic wax-up models. For each
patient, the wax-up models were duplicated, and cast
models were produced to prepare the vacuum sheets.
Final volume of the restorations was made with temporary flowable composite (Systemp.link, Ivoclar Vivadent)
using transparent, rigid, vacuum-shaped sheets (VacuFormerSystem, Cavex; Haarlem, The Netherlands).
Patients were able to preview the finished restoration
from the provisional restorations. Furthermore, the maximum conservative preparation was permitted. The same
sheet was kept during the treatment of each patient to
produce provisional restorations after preparation. This
technique was performed in accordance with the esthetic pre-evaluative temporary technique described by
Grel12 and Grel et al.13
Preparations were made after patient approval of a
mock-up, consisting of temporary composite restorations.
Before treatment with PLVs, gingival corrections (17 teeth
in four patients, 13.6%) were performed where necessary using a DELight Er:YAG laser (HOYA ConBio Laser;
Chicago, IL, USA) with low-fluence irradiation at 35 mJ
with 10 Hz.
Tooth Preparation
All preparations were performed over the provisional
composite restorations using a 2.5X binocular dental
loupe (Orascoptic, Kerr; Middleton, WI, USA) for minimal
preparations. The preparation surfaces were initially
colored with colored articulation papers. Facial surfaces
of the teeth were prepared by making depth-orientation
grooves (0.3 mm in depth) with a depth preparation diamond bur (Diatech, Coltne Whaledent; Altsttten, Switzerland). Facial reduction was continued with a tapered,
rounded-end diamond bur (Diatech) until the color was
removed from the facial surface. Facial preparation was
deepened further when necessary to overcome slight
malalignment or discoloration. Facial surfaces were reduced by 0.3 to 0.7 mm.
The incisal edge was included in each preparation to
maximize esthetics. Two different preparation designs
were used according to incisal finishing. IB preparations
were performed on 83 teeth (66%), whereas 42 teeth
(34%) were prepared with IO ending with a palatal chamfer. The reduction ranged from 1.5 to 2 mm on the incisal
edge.
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Table 1

Materials used in this study

Brand name

Type

Manufacturer

Composition

Lot No.

IPS e.max
Press

Lithium disilicate
glass-ceramic

Ivoclar Vivadent;
Schaan, Liechtenstein

SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, other oxides, color

oxides

M13076

Variolink Veneer

Light-curing resin
cement

Ivoclar Vivadent

Dimethacrylates, inorganic fillers, ytterbium trifluoride, catalysts and stabilizers, pigments

P38760

Total-Etch

Phosphoric acid

Ivoclar Vivadent

37% phosphoric acid

K27710

Porcelain
etchant

Hydrofluoric acid

Bisco; Schaumburg,
IL, USA

5% hydrofluoric acid

1000003009

Syntac Primer

Primer

Ivoclar Vivadent

Triethylene glycol dimethacrylate, polyethylene glycol

dimethacrylate, maleic acid, acetone

K16326

Syntac Adhesive

Adhesive

Ivoclar Vivadent

Polyethylene glycol dimethacrylate, glutaraldehyde

K30345

Heliobond

Bonding agent

Ivoclar Vivadent

Bis-GMA, triethylene glycol dimethacrylate, catalysts

and stabilizers

K30706

Monobond
Plus

Silane coupling
agent

Ivoclar Vivadent

Alcohol solution of silane methacrylate, phosphoric

acid methacrylate, sulfide methacrylate

K30207

All cervical margins were placed equi- or supragingivally

and were created with a shallow chamfer finish line 0.3
to 0.5 mm in preparation depth. Gingival finish lines were
cervically extended to half the interproximal area to hide
restoration margins up to the contact area.
All sharp edges and corners were smoothened with
an extra-coarse aluminum-oxide polishing disk (OptiDisc, Kerr; Orange, CA, USA) to reduce stress concentrations. Impressions were subsequently obtained
using a polyvinyl siloxane impression material (Virtual;
Putty and Light Body, Ivoclar Vivadent). Provisional veneers were made chairside using an autopolymerizing
temporary composite resin (Systemp.link, Ivoclar Vivadent). For fixation of the provisional veneers, enamel
was spot etched with 37% phosphoric acid (Total Etch,
Ivoclar Vivadent) for 30 s before application of the temporary composite resin.
After completing the preparations, the adhesion surfaces were gently air dried and meticulously evaluated by
the two experienced clinicians under 2.5X magnification
to categorize them as follows: intra-enamel only (E; 68 restorations, 54.4%), enamel with minimal dentin exposure
(MDE; 39 restorations, 31.2%), and enamel with severe
dentin exposure (SDE; 17 restorations, 13.6%).
PLVs were fabricated from a lithium-disilicate glass
ceramic (IPS e.max Press, Ivoclar Vivadent) with a lowfusing nano-fluorapatite glass-ceramic (IPS e.max Ceram,
Ivoclar Vivadent) for veneering and characterization of the
restorations using the layering technique according to the
manufacturers instructions.
Cementation Procedures
Table 1 presents the brand names, types, manufacturers, chemical compositions, and batch numbers of the
materials used in this study. Form, contour, marginal
Vol 16, No 5, 2014

adaptation, proximal contacts, and shade matching of

the restorations were clinically checked after removing
the provisional restorations and cleaning the teeth.
The color of the cement used was determined using
try-in pastes (Variolink Veneer Try-in Paste, Ivoclar Vivadent). All the veneers were adhesively cemented under
rubber-dam (Optra-Dam, Ivoclar Vivadent) isolation. The
bonding surface procedures for the tooth and porcelain
surfaces using light-cured resin cement (Variolink Veneer, Ivoclar Vivadent) are described in Table 2. After
these procedures, the PLV restoration was positioned,
and excess luting cement was removed with hand instruments and a brush. Before final curing, PLVs were
cervically pre-cured for 5 s to completely remove excess resin cement from the cervical and interproximal
areas using hand instruments and dental floss without
pressure. Final curing was performed according to the
manufacturers instructions for 40 s on each surface
(upper- and mid-buccal, cervical, mesial, distal, and
palatal) with a light-emitting diode polymerizing unit
(Bluephase LED, Ivoclar Vivadent, 1200 mW/cm 2).
Restoration margins were finished and further polished
with extra-fine diamond finishing burs (Diatech), polishing cups (Kerr HiLuster Plus, Kerr; Orange, CA, USA),
and interproximal polishing strips (Soft-Lex Finishing
Strips, 3M ESPE; Seefeld, Germany). Finally, the occlusion was checked in protrusive and lateral movements
of the mandible.
Follow-up
Patients were recalled after 1 week to recheck occlusion, proximal contacts, and gingival margins. This recall
was used as the baseline. The restorations were evaluated at baseline and after 6, 12, and 24 months by an
experienced clinician (not the clinician who performed
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Table 2 Surface conditioning protocols for the tooth

and porcelain
Surface Tooth surface
treatment

Porcelain inner
surface

Etching

Enamel: 37% H3PO4 for

30 s
Dentin: 37% H3PO4 for
15 s

5% HF for 60 s

Adhesive

(1) Syntac Primer for 15 s (1) Monobond S for 60 s

(2) Syntac Adhesive for 10 s (2) Heliobond for 10 s
(3) Heliobond for 10 s

H3PO4: phosphoric acid; HF: hydrofluoric acid.

the restoration) blinded to the objective of this study

according to the modified United States Public Health
Service (USPHS) criteria.3,4 The restorations were rated
according to the four USPHS scores of Alfa, Bravo, Charlie, and Delta. The restorations were visually inspected
with a dental mirror and probe. Digital photos were
taken before and after PLV placement and during followup sessions.
Statistical Analysis
A survival rate evaluating absolute failures according to
in situ criteria and success rates describing both relative (Bravo) and absolute (Charlie and/or Delta) failures
were determined. 11 Absolute failure was defined as
clinically unacceptable failures, such as loss, fracture,
and debonding of the PLV. A relative failure was defined
as minimal failures which were clinically acceptable in
that they allowed repair of the restoration or healing of
gingival tissues.
Survival was defined at three levels: survival of the
original restoration (Sr, endpoints: absolute failures);
functional survival (Sf, endpoints: relative failures); overall
survival (So, endpoints: both absolute and relative failures).19 The effects of the study parameters preparation
design and tooth tissue type on the different survival
levels were also analyzed.
Survival analyses were performed with the statistical
software program IBM SPSS Statistics for Windows (version 20.0; Armonk, NY, USA) (p = 0.05), using KaplanMeier and log-rank (Mantel-Cox) tests to obtain the cumulative survival rate in relation to observation time. A
restoration-related analysis using each restoration as a
statistical unit was used for the analysis.6

RESULTS
Twenty-eight patients were treated with 125 PLVs with a
2-year follow-up. All patients came for a follow-up evaluation after 1 week (baseline), 6, 12, and 24 months. No
patient was lost during this 2-year follow-up. The number of restorations evaluated at each of the follow-up
phases is summarized in Table 3.
484

Fig 1 Preoperative view of a patient with diastemata between

the four maxillary anterior teeth and lacking the maxillary left
lateral incisor.

One restoration (0.8%) in the IO-MDE group debonded

from the tooth without the PLV having any crack or fracture, and therefore it was re-bonded at 6 months. In the
same patient, gingivitis was detected on the gingival tissues of five other restorations. In total, eight restorations
(6.7%) in two patients were rated Bravo for gingival tissue
health at a 6-month recall. At a 12-month follow-up, one
score of Bravo (minimal ceramic cohesive fracture on the
incisal edge) and one of Delta (total tooth and ceramic
fracture) were recorded (Table 3). Marginal adaptation and
discoloration, as well as secondary caries and postoperative sensitivity, were rated Alfa during the 2-year follow-up
(Figs 1 to 3). As a consequence of the two absolute and
nine relative failures, the Sr, Sf, and So rates were 98.4%,
92.7%, and 91.2%, respectively (Fig 4).
The So rates for IO (85.7%) and IB (94%) preparations
were not significantly different (p > 0.05; Fig 5). However,
there were statistically significant differences between
the So rates of the restorations bonded to the three different tooth surfaces (E, MDE, and SDE; p < 0.05; Fig 6).
The So-E, So-MDE, and So-SDE were 94.1%, 97.4%, and
66.7% respectively. There were no significant differences
between So-E and So-MDE (p > 0.05), whereas So-SDE
was significantly lower than the other groups (p < 0.05).
The survival rates of PLVs after 2 years according to different parameters are presented in Table 4.

DISCUSSION
In the present study, we evaluated the clinical success
of PLVs of different preparation designs bonded to tooth
tissues prepared at different levels after 2 years. Longitudinal studies have some disadvantages, such as the
withdrawal of certain dental materials and loss of a proportion of patients over time. In this study, no patients
were lost to follow-up, and the materials used remain
available. Therefore, the results of this study were presented after a relatively short period.
The results of the present study suggest that PLVs are
favorable restorations, withstanding 2 years of clinical
service and demonstrating promising survival rates. The
survival rates determined in this study are comparable
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Table 3 Summary of the modified United States Public Health Service criteria and evaluation of porcelain laminate
veneers during follow-up
USPHS criteria

Score

Characteristics

Baseline

6 months

Marginal
adaptation

Alfa
Bravo
Charlie
Delta

Marginal
discoloration

12 months 24 months

Smooth margin
Minor voids/defects at margin
Obvious crevice at margin
Debonded

125
-

124
-

124
-

124
-

Alfa
Bravo
Charlie/Delta

No discoloration
Slight staining/acceptable
Large staining/unacceptable

125
-

124
-

124
-

124
-

Secondary
caries

Alfa
Bravo
Charlie
Delta

No caries
Caries at the margin
N/A
N/A

125
-

124
-

124
-

124
-

Postoperative
sensitivity

Alfa
Bravo
Charlie
Delta

No symptoms
Slight sensitivity
Moderate pain
Severe pain

125
-

124
-

124
-

124
-

Patient
satisfaction

Alfa
Bravo
Charlie/Delta

High
Moderate
Not satisfied

125
-

124
-

124
-

124
-

Fracture

Alfa
Bravo
Charlie
Delta

None
Small/acceptable
Moderate/unacceptable
Large/unacceptable

125
-

124
-

122
1
1

124
-

Retention

Alfa
Bravo
Charlie
Delta

None
N/A
N/A
De-bonded

125
-

124
1

124
-

124
-

Gingival
response

Alfa
Bravo
Charlie
Delta

Healthy
Calculus or gingivitis
Moderate pocketing and bleeding present
Severe periodontitis

125
-

116
8
-

124
-

124
-

N/A: not applicable.

Fig 2 Baseline view of the porcelain laminate veneers on

teeth 12, 11, 21, and 23 from the anterior (a) and the palatinal (b) region. The left maxillary canine tooth was reshaped like
a lateral incisor.

a
Vol 16, No 5, 2014

Fig 3 Two-year recall of the same patient as in Figs 1 and 2

with porcelain laminate veneers from the anterior (a) and the
palatinal (b) region. All restorations were scored Alfa.

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Survival Function

Survival Function
Survival
Function
0

1.0

0.8

0.8

Cum Survival

Cum Survival

Survival
Function
0

1.0

0.6

0.4

0.2

0.6

0.4

0.2

0.0

0.0
.00

5.00

10.00

15.00

20.00

25.00

.00

5.00

Time_So

20.00

25.00

Survival Function
Survival
Function
0

PREPARATION
DESIGN

1.0

IO
IB
IO-censored
IB-censored

0.8

Cum Survival

0.8

Cum Survival

15.00

Time_Sr

Survival Function
1.0

0.6

0.4

0.6

0.4

0.2

0.2

0.0

0.0

10.00

.00

5.00

10.00

15.00

20.00

25.00

Time_Sf

.00

5.00

10.00

15.00

20.00

25.00

Time_So

Fig 4 Kaplan-Meier cumulative survival curves for (a) overall

survival (So), (b) original restoration (Sr), and (c) functional
survival (Sf).

Fig 5 Kaplan-Meier overall survival curve for preparation design. IO: incisal overlap; IB and incisal bevel.

with those of other mid-term clinical studies, which report

So rates of 94%19 and 93.5%10 after 2.5 and 3 years, respectively. Therefore, the number of failures (two absolute
and nine relative) observed in this study can be considered relatively low. These low failure rates imply that the
clinical protocol employed and materials used are reliable.
However, long-term follow-up of an increased number of
restorations is necessary.
In this study, one debonded restoration and gingivitis on
the gingival margins of five other restorations occurred in a
patient who reported that she could not brush her teeth for
fear of her other restorations failing, as the debonded PLV
detached 1 week before recall. This failure may have been
caused by a mistake during the adhesive protocol. After
cleaning the inner surface of PLV and applying the adhesion protocols, it was rebonded and remained functional

until the end of the follow-up period. The other absolute

failure occurred in the form of a tooth fracture at the cervical
margin during preparation of the endodontic access cavity
on the palatal surface because of the loss of vitality. Subsequently, this tooth was restored with a post-core and full
crown. In one patient, a fracture was clinically acceptable;
after finishing and polishing the small fracture in the incisal
edge, the patient continued to use the restoration until the
end of the observation period (Figs 7a and 7b). The most
common failure was gingivitis, which scored Bravo. This
type of failure was observed to relate to patient behavior;
after periodontal treatment and patient education, the gingival tissues healed. Therefore, patients should be thoroughly evaluated before treatment to determine whether
they practice good oral hygiene. Otherwise, failure may
occur in the early post-treatment period.

486

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Survival Function
TOOTH TISSUE
E
MDE
SDE
E-censored
MDE-censored
SDE-censored

1.0

Parameter

Original
restoration
(Sr)

Functional
(Sf)

Overall
(So)

0.6

All

98.4%

92.7%

91.2%

0.4

Tooth
tissue

E
MDE
SDE

98.5%a
100%a
94.4%a

95.5%b
97.4%b
70.6%c

94.1%d
97.4%d
66.7%e

Preparation
design

IB
IO

98.8%f
97.6%f

95.1%g
87.8%g

94%h
85.7%h

0.8

Cum Survival

Table 4 Different survival levels according to the

tested parameters

0.2

0.0
.00

5.00

10.00

15.00

20.00

25.00

Time_So

*Same superscript letters show statistically homogeneous subgroups

within the same column and row (p > 0.05). Adhesion surface enamel:
E; enamel with minimal dentin exposure: MDE; enamel with severe

Fig 6 Kaplan-Meier overall survival curve for tooth tissue type.

Adhesion surface enamel: E; enamel with minimal dentin exposure: MDE; enamel with severe dentin exposure: SDE.

dentin exposure: SDE.

Fig 7a Porcelain veneer failure on the right maxillary lateral

incisor at a 12-month recall.

Fig 7b After finishing and polishing procedures on the incisal

edge of the lateral tooth, the patient continued to use the restoration.

Fractures are reportedly the most frequent cause of

the clinical failure of PLVs.11,25 The frequency of clinically
unacceptable fractures was variously reported to be 0%
by Magne et al,18 2% by Peumans et al,25 and 2.3% by
Guess and Stappert.22 In this study, two absolute failures
occurred (1.6%), which is consistent with the results of
other clinical follow-up studies.
Although early protocols suggested minimal or no tooth
preparation, current opinion supports enamel reduction
to remove the aprismatic enamel surface, which reportedly has a reduced retention capacity, and to improve the
strength of PLV bonding to the tooth surface.27 In addition, it was believed that preparation should be completely
performed in the enamel to maintain optimal bonding
with the PLV.28 However, dentin exposure is inevitable in
some cases depending on the degree of discoloration or
thickness of the enamel during preparation.21 Thus, the
primary objective of this study was to evaluate the survival
of PLVs after dentin exposure. However, the results support the rejection of the first null hypothesis that dentin
exposure on the prepared tooth surface does not affect
the clinical survival of PLVs.

Few clinical studies correlate dentin exposure with PLV

survival,13 and none identify an acceptable level for dentin
exposure. In this study, the degree of dentin exposure on
prepared and dried tooth surfaces was clinically classified
after preparation. When less than about 30% of the dentin
was observed on the cervical third of clinical crown, this
was classified as minimal dentin exposure. If the dentinenamel junction exceeded the cervical third of the crown
on the prepared surface, it was classified as severe dentin
exposure. However, quantitative methods are necessary
to accurately evaluate the proportion of dentin exposure
on the prepared surfaces.
In the literature, several studies that evaluate PLVs
both in vivo and in vitro report these restorations to be
extremely successful.27 Andreasen et al1 and Stokes
and Hood36 reported that extracted incisor teeth restored with PLVs exhibited their original strength in vitro.
Other studies6,9 reported that PLVs presented clinical
survival rates of approximately 96% to 98% over a longterm period. However, PLVs do not demonstrate 100%
success. In this study, the overall failure rate was 8.8%.
This failure rate was related to both substantial den-

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tin exposure on the tooth surface and inadequate oral

hygiene. Consistent with our results, the predisposing
factors for PLV failure reportedly include partial adhesion to surfaces with large regions of dentin exposure,
unfavorable occlusion, and the use of inappropriate materials and techniques.13,27
Four different types of preparation design have been
described for porcelain laminate veneers: window preparation, feathered incisal edge preparation, incisal bevel
preparation (butt joint or shoulder finishing line), and incisal overlap with a palatal chamfer.15,17,24,30,34,38 Incisal
bevel and incisal overlap with palatal chamfer preparation
designs have been proposed because they increase the
bonding surface area and provide better occlusal load
distribution as well as allow characterization of the incisal
region and better seating of the restoration.5,30 Therefore,
two different preparation designs with or without a palatal
chamfer were preferred for this study. However, there is
still no consensus regarding the use of a palatal extention
for the veneer preparation.38
In the present study, the preparation design was selected according to the occlusion of the patient. When
there was sufficient space between the maxilla and mandible, incisal overlap with a palatal chamfer was preferred
for better esthetic and better seating of the restoration.
In order to avoid the contacts between the incisal edge of
the lower anterior tooth and tooth-ceramic junction of the
maxillary restored tooth, incisal bevel preparation without
any palatal chamfer was selectively applied. Conflicting
evidence exists in the literature regarding optimal incisal
edge preparation. Some authors favor the IO preparation
design,2 whereas others observed no difference between
the different incisal preparations.33 In this study, there
was no statistically significant difference between IB and
IO groups (p > 0.05). Thus, the second null hypothesis
can be accepted.
The results of this study emphasize the importance
of preparation depth for the clinical success of PLVs.
Patients should be carefully examined, and the most accurate indication should be assessed for the success of a
PLV restoration. Preparation should also be meticulously
undertaken to reduce the risk of failure. Furthermore, the
vitality of the prepared tooth may influence the success
of the restoration. In this study, existing composite restorations were renewed when the necessary and carious
teeth were treated with composite resin restorations before treatment with PLVs. However, existing composite
restorations can affect the success of PLV restorations.
These factors should be considered in future studies.

CONCLUSIONS

y Preparation depth is an important factor for the success of PLVs. Minimal dentin exposure on the cervical
third of the prepared tooth surface may be insufficient
to influence the clinical success of restorations.
y Incisal preparation design does not affect PLV survival.

ACKNOWLEDGMENTS
This investigation was supported in part by Hacettepe University
Scientific Research Projects Coordination Unit (Project Number: 07
A 201 003). The authors would like to thank Dr. Altay Uludamar
and Dr. Merih Baykara for their contribution. The authors also acknowledge Mr. Ali Ylmaz for his work in fabricating the porcelain
laminate veneers.

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Clinical relevance: Avoiding extensive dentin exposure during preparation is the key factor for the
long-term success of PLVs. With restricted indications
and the careful application of clinical procedures,
porcelain laminate veneers are extremely reliable restorations.

489

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