Accepted Manuscript

Title: Title: Direct anterior composite veneers in vital and

non-vital teeth: a retrospective clinical evaluation

Author: Fábio Herrmann Coelho-de-Souza Daiana Silveira

Gonçalves Michele Peres Sales Maria Carolina Guilherme
Erhardt Marcos Britto Corrêa Niek J.M. Opdam Flávio
Fernando Demarco

PII: S0300-5712(15)30036-1
DOI: http://dx.doi.org/doi:10.1016/j.jdent.2015.08.011
Reference: JJOD 2516

To appear in: Journal of Dentistry

Received date: 2-7-2015

Revised date: 18-8-2015
Accepted date: 21-8-2015

Please cite this article as: Coelho-de-Souza Fábio Herrmann, Gonçalves Daiana
Silveira, Sales Michele Peres, Erhardt Maria Carolina Guilherme, Corrêa Marcos Britto,
Opdam Niek JM, Demarco Flávio Fernando.Title: Direct anterior composite veneers
in vital and non-vital teeth: a retrospective clinical evaluation.Journal of Dentistry
http://dx.doi.org/10.1016/j.jdent.2015.08.011

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
 Title: Direct anterior composite veneers in vital and non-vital teeth: a
retrospective clinical evaluation

Short title: Composite veneers in vital and non-vital teeth

Fábio Herrmann Coelho-de-Souzaa

Daiana Silveira Gonçalvesb
Michele Peres Salesb
Maria Carolina Guilherme Erhardta
Marcos Britto Corrêac
Niek J. M. Opdamd
Flávio Fernando Demarcoc

a
DDS; MSc; PhD
Department of Conservative Dentistry, Federal University of Rio Grande do Sul, RS,
Brazil.
b
DDS – private practitioner, RS, Brazil
c
DDS; PhD
Post-Graduate Program in Dentistry, Federal University of Pelotas, RS, Brazil.
d
DDS; PhD
Department of Restorative and Preventive Dentistry, Radboud University Nijmegen
Medical Centre, Nijmegen, The Netherlands.
Corresponding author:
Flávio Fernando Demarco
Address: Post-Graduate Program in Dentistry - Federal University of Pelotas – R.
Gonçalves Chaves, 457, 5th floor, Pelotas, RS, Brazil. CEP 96015-560
Phone/Fax: +55-53-32256741 r. 130
e-mail ffdemarco@gmail.com
Keywords: Clinical Trial; Longevity; Anterior Restorations, Dental Veneers, Non-vital
teeth.

Direct anterior composite veneers in vital and non-vital teeth: a

retrospective clinical evaluation
Abstract

Objectives: This retrospective, longitudinal clinical study investigated the performance

of direct veneers using different composites (microfilled x universal) in vital or non-
vital anterior teeth. Methods: Records from 86 patients were retrieved from a Dental
School clinic, comprising 196 direct veneers to be evaluated. The FDI criteria were used
to assess the clinical evaluation. The survival analysis was done using Kaplan-Meier
method and Log-Rank test. The multivariate Cox regression with shared frailty was
used to investigate the factors associated with failure. Results: A total of 196 veneers
were evaluated, with 39 failures. The mean time of service for the veneers was 3.5
years, with a general survival rate of 80.1%. In the qualitative evaluation of the
restorations, microfilled composite showed slighty better esthetics. The annual failure
rates (AFR) were 4.9% for veneers in vital teeth and 9.8% for non-vital teeth with
statistical significance (p = 0.009). For microfilled and universal veneers the respective
AFRs were 6.0% and 6.2% (p>0.05). Veneers made in non-vital teeth had a higher risk
of failure over time compared to those made in vital teeth (HR 2.78; 95% CI 1.02 –
7.56), but the type of material was not a significant factor (p=0.991). The main reason
for failure was fracture of the veneer. Conclusion: Direct composite veneers showed a
satisfactory clinical performance. Veneers performed in vital teeth showed a better
performance than those placed in non-vital teeth. No difference in the survival rate for
different composites was found, although microfilled composites showed a slightly
better esthetic appearance.

Clinical significance: Direct composite veneers show good results in esthetic dentistry
nowadays. Composite veneers in vital teeth have a lower risk of failure than those in
non-vital teeth.

Keywords: Clinical Trial; Longevity; Anterior Restorations, Dental Veneers, Non-vital

teeth.

INTRODUCTION

In the last decades there was a continuous evolution of composite resins,

adhesive systems and restorative techniques that contributed to a significant
improvement of esthetic dentistry1,2. The main advantages of composite restorations are
related to their adhesive properties, the minimal preparation size, the reinforcement of
remaining teeth and the esthetic appearance3,4.
 Many clinical situations such as tooth discoloration, extensive fractures,
misaligned teeth or dental caries lesions may cause an important impairement in esthetic
appearance and smile harmony, causing impact in the quality of life1,4. The use of direct
composite veneers may be an interesting option to recover the esthetic appearance of
damaged teeth4,5, especially because indirect techniques require more removal of sound
tooth structure and have a higher cost, due to the laboratory procedures involved6,7. In
fact, in a minimal invasive approach direct composite veneers seem to be the first
choice4. The esthetic appearance of endodontically treated anterior teeth is often
compromised by staining. Discoloured teeth can be treated with different restorative
approaches, including tooth bleaching, ceramic crowns, ceramic veneers and direct
composite veneers2,8. However, for endodontically treated teeth there is some
controversy in relation to the results obtained, especially when considering direct
composite veneers2,9,10.

A large number of studies have demonstrated long lasting good results for
composite restorations in posterior teeth11-13. A recent meta-analysis of prospective
studies on anterior composite restorations showed a median overall estimated survival
of 95% for class III and 90% for class IV, after 10 years14. Although the widespread
clinical use of composite resins for anterior teeth restorations, there is a lack of
scientific evidence regarding the longevity of direct composite veneers, especially when
placed in non-vital teeth3,6,10,15. So far, few studies have evaluated the performance of
direct composite veneers over a longer period of time3,5,15. Since esthetical appearance
is the main concern for veneers in anterior teeth, some professionals have recommended
the use of a composite resin with smaller filler size (microfilled or nanofilled
composites), in order to produce a smoother surface, resulting in a better esthetic
appearance16. However, there is a lack of clinical data supporting this assumption, and a
systematic review of in vitro studies was not able to show better surface smoothness
when comparing nanofill or submicron composites to mycrohybrid ones17.
Therefore, the aim of this retrospective longitudinal study was to investigate the
clinical behavior of direct veneers performed with different types of composite
(microfilled and universal) in vital and non-vital anterior teeth.
METHODS

2.1. Study characteristics, participants and design

The database with clinical records from the Operative Dentistry Clinic at the Federal
University of Rio Grande do Sul, School of Dentistry, Porto Alegre was used in the
present evaluation. From this database, all placed direct composite veneer restorations
were selected for this retrospective analysis. The study had the approval of the local
Ethics Committee (N. 21736) and the patients signed a written consent to participate in
the study.

Inclusion and exclusion criteria

All restorations that were placed either by final year undergraduate dental
students or by postgraduate students during Operative Dentistry courses (certificate
program) between January 1999 and January 2012 with minimum observation time of 6
months were selected from the files. Veneers were placed in vital or non-vital teeth,
using microfilled or universal hybrid composite resins, which are described in Table 1.
Patients were excluded when heavy smokers, when they had also received indirect
ceramic or composite veneers, had severe parafunctional habits or poor oral hygiene. In
total, 118 patients fulfilled the inclusion criteria and were invited by phone calls to
come to the Dental clinic for examination, of which 86 patients agreed to participate.
From the files, the type of the composite, the tooth vitatily (vital or non-vital) date of
placement, date of failure and reason for failure were collected.

Restorative procedures

The dentin-bonding agent used in all composite veneers was an etch-and-rinse 3-

step adhesive system (Scotchbond Multipurpose, 3M ESPE, St Paul, MN, USA). The
veneer restorations were placed using either a microfilled [Durafil VS (Heraeus Kulzer,
Hanau, Germany)] or a universal composite [Charisma (Heraeus Kulzer, Hanau,
Germany); 4Seasons (Ivoclar-Vivadent, Elwangen, Germany); Filtek Z350XT (3M
ESPE, St. Paul, MN, USA); Opallis (FGM, Joinville, SC, Brazil]. The applied materials
are shown in Table 1. Composite veneers were placed under rubber dam or retraction
cord with a multi-layer technique using different shades for dentin and enamel
reproduction and were light-cured using an LED polymerization unit. The restorations
were finished and polished in the same session using fine diamond burs and abrasive
discs (Sof-lex, 3M ESPE, St. Paul, MN, USA).
Evaluation procedures

The restorations were clinically evaluated between August and November 2013
by one trained and calibrated examiner using dental explorer and mirror, in accordance
with FDI criteria18, including several items on aesthetic, functional and biological
properties. The calibration procedures considered the analysis of some veneers twice,
randomly distributed, for Cohen’s Kappa calculation.

All scores 4 and 5 by FDI were considered as failure (restoarions requiring

repair –code 4- or replacement – code 5 – being considered clinically unacceptable,
Tables 3 and 4), with both codes being considered as failure for analysis. Whenever
necessary, a radiographic examination was done to evaluate the endodontic treatment by
another member of the clinical staff. Those patients who presented a treatment need
during clinical evaluation were referred for treatment. When restorations had failed
before the examination, date and reason for failure were recorded from the patient file.

Statistical analysis

The main outcome of this study was the survival of direct veneers. Additionally,
the associated factors with failures were investigated and the qualitative evaluation of
the restoration was also observed. Data were tabulated twice and statistical analysis was
carried out using the Stata 11.0 software package (StataCorp LP; College Station, TX,
USA). To report the frequency distribution for the evaluated criteria descriptive
statistics was used. Data were subjected to non-parametric statistical analysis by the
Mann-Whitney test (for qualitative analysis using FDI criteria). Survival curves were
obtained using the Kaplan-Meier method and Log-Rank test for comparison between
groups. There were multiple observations per patients in some cases (multiple
restorations). To account for that, multivariate Cox regression analysis with shared
frailty was used to verify the factors associated with failure. For survival analysis, data
was censored after 8 years of follow-up. Hazard Ratios and respective 95% Confidence
Intervals were determined. For all analyses a significance level of 5% was set.

RESULTS

The distribution of restorations according to the independent variables is shown in

Table 2. In total, 196 restorations were evaluated in 86 adult patients (mean age 44
years old), with an overall success rate of 80.1%. The majority of patients were females
(69.8%). 83.2% of veneers were placed in upper central incisors. Patients had from 1 up
to 8 restorations each (all veneers of the same patient were from the same follow-up
period). The follow-up time varied from 6 months up to 15 years with a mean
observation time of 3.5 years (95% CI: 3.02 – 3.83). Almost 80% of the evaluated
veneers were performed using universal composites and 73% of the restorations were
placed in vital teeth.

Qualitative analysis
In Table 3, the qualitative evaluation using FDI criteria for those restorations
still in situ are shown. In this evaluation, all restorations were considered acceptable,
but veneers in vital teeth had a better performance for the criteria fracture and retention
and color match while for surface luster a borderline significance was found. In Table 4,
the qualitative evaluation comparing veneers made with microfilled or universal
composites is shown. Even though almost all restorations could be classified as
clinically acceptable, especially in relation to the esthetic properties, microfilled veneers
had a significantly better performance than veneers made with universal composites
(p<0.001). Also, microfilled restorations had better marginal adaptation and patient’s
acceptance.

Survival analysis
In Figure 1, the Kaplan-Meier survival graph shows a better clinical
performance for composite veneers in vital teeth compared to non-vital teeth (log-rank:
p=0.005). There was no significant difference between survival curves for microfilled
and universal composites veneers (Figure 2) (log-rank: p=0.654).
In Table 5, the adjusted Cox Regression analyses showed that veneers performed
in non-vital teeth had a risk of failure of 2.78 times (1.02; 7.56) higher than those
veneers placed in vital teeth. The annual failure rate (AFR) for non-vital teeth was 9.8%
(95% CI: 5.9; 14.7) and for vital teeth was 4.9% (95% CI: 2.5; 9.2). Regarding the
restorative materials, when comparing microfilled and universal composites, there was
no significant difference between materials. The AFRs for microfilled veneers and
universal veneers were 6.0% (95% CI: 3.2; 10.5) and 6.2% (95% CI: 3.2; 10.5),
respectively.
The most common reason for failure was fracture of the restoration, occurring in
30 cases (15.3% out of the 19.9% of general failures).
Clinical images

Figures 3 and 4 show some examples of the investigated restorations. In Figures

3a and 3b, there are images of microfilled and universal veneers, which failed due to
fracture of the restorations. In Figures 4a and 4b, some examples of microfilled and
universal composites veneers with good clinical performance are shown.

DISCUSSION
This retrospective clinical study investigated the performance of veneers placed
by undergraduates and graduated dentists at a university clinic. A satisfying clinical
performance was observed for direct composite veneers, with an annual failure rate of
4.9% for vital and 9.8% for veneers on non-vital teeth after a mean observation of 3.5
years. The retrospective methodology was also used in other clinical studies3,15,19,20, and
collects data of restorations already placed, showing results that reflect more closely the
situation in real life clinical practice12,21,22. The present design included a clinical
evaluation by an independent observer like in some other retrospective analysys11,12,20,23,
which ensures the fact that at the end of the observation period, all restorations are
evaluated in an independent way, like in a prospective study. The independent observer
also enables the present qualitative analysis according to defined criteria which is absent
in those studies that rely on the judgement of the treating dentist21,24-26.

For a retrospective dataset, the multivariate character requires a multivariate

statistical method. For the survival analysis the Kaplan Meyer method is the gold
standard but the according Log-rank test has limitations in a multi-variate dataset as in
this study. Therefore the appropriate analysis for the survival of the veneers is a
multivariate Cox Regression. The shared frailty was applied in the present study and it
enables to compensate for the fact that more than one restoration could be present in the
same individuals, creating a cluster effect.

When comparing the present results with previous studies, the overall survival
rate observed in our study (80.1%) is less then in the studies by Frese et al (2013)3,
showing 84.6% of success in 5 years, and Gresnigt et al (2012)5, showing 87.5% of
success in 3.5 years. This may be explained by the fact that the present study evaluated
restorations performed by many operators including undergraduate students, which may
be a factor influencing the longevity of the restorations22. When evaluating anterior
restorations performed by final year dental students, Moura et al (2011)27 observed
considerably higher survival for class III than for class IV restorations (91.8% and
77.8%, respectively). The value found for class IV restorations is comparable to the
overall failure rate observed for the veneers in the present study. Further, the patients
included in the present survey were from Dental School attendants, which originate
from lower socioeconomic levels which is a factor associated with higher restoration
failure rates28.
Regarding the qualitative analysis, all kinds of failures were detected under FDI
evaluation process, considering all clinical criteria. The most frequent reason for failure
was related to fracture and retention (fracture of the veneer – 30 cases), followed by
recurrence of caries (7 cases). In the Frese et al (2013)3 study, more than 90% of the in
situ restorations were rated as clinically acceptable when using the FDI/USPHS criteria,
which was similar to the findings of our study. In a recent systematic review of anterior
composite restorations was observed that the main reason for restoration failure was
fracture of restorations, followed by esthetic reasons, 29 as detected in our study.
Even though vital and non-vital teeth presented good performance, there was
significant difference in relation to the survival rates, and the statistical analysis
demonstrated that the veneers made in non-vital teeth showed two times higher risk of
failure than veneers placed in vital teeth. The AFR for non-vital teeth (9.8%) was almost
double the AFR for vital teeth (4.9%). The lack of tooth vitality was considered as a
possible risk factor for posterior composite restorations22. A retrospective practice based
research on restorations performed in endodontically treated teeth showed that these
restorations could present a good clinical behavior, but the authors observed AFRs
higher than those expected for restorations in vital teeth10. Furthermore, in the
qualitative evaluation, vital teeth showed a better performance on the criteria fracture
and retention, color match, while a borderline significance was found for surface luster.
When the pulp is removed and endodontically therapy is carried out, there is a
significant removal of tooth structure and as a consequence lower resistance to fracture
in these teeth exist30. Moreover, endodontically treated front teeth often show
discolorations that may result in the patients wish for replacing a veneer restoration.
Also, bonding to tooth structure in endodontically treated teeth seems to be reduced
when compared to the adhesive procedures performed in vital teeth31.
Concerning the two types of composites evaluated (microfilled and universal),
both presented satisfying performance, with no significant differences in relation to the
survival rates. However, the veneers made with microfilled composite showed
statistically better surface lustre, lower marginal and surface staining, better color
match, anatomic form, better marginal adaptation and scored better on the patients’
view criterion. Microfilled composites have a better lustre and smoother surface32, also
when tooth brushing procedures were applied33. The differences in esthetic appearance
compared to the universal materials can be easily explained from the lower average
particle size for microfilled. In the present study, also 24 restorations were included in
the universal composite group made by Filtek Z350 xt, which is comparable to Filtek
Supreme outside South America. According to the nanofillers, also for this material a
high luster could be expected. However, due to the limited number of Z350 xt veneers
in the sample of this study, it was not possible to do a separate analysis on this material
and added it to the group universal composites, which is dominated by Hybrid materials
with an average particle size of 0.6 micron and higher. Moreover, a recent systematic
review of in vitro studies has not demonstrated any superiority of nanofilled or
submicronfilled composites compared to microhybrid composites, when evaluating
surface smoothness17. The better performance observed in the qualitative evaluation for
microfilled composites could be interesting for application in individuals with a high
esthetic demand or patients that easily have their teeth subject to staining. In a survey
among dentists in Southern Brazil (the same region where the present study was carried
out), only 26% of the dentists selected microfilled composite as the first choice for
anterior restorations, while microhybrid (universal) composites were the most selected
material16. A clinical trial evaluated after 41 months 96 direct microhybrid composite
veneers (Enamel Plus HFO and Miris2), according to modified USPHS criteria and this
resulted in a survival rate of 87.5%, with no statistically significant difference between
the two composites5.

Most of the failures found in our survey were related to the first years in service.
We could speculate that in a future analysis and follow-up of these veneers, the AFR
can change. In the present study, the general percentage of failures considering the
scores 4 and 5 of the FDI method was 19.9%, and most of them were fractures of the
veneer (15.3%)34. Restorations involving the incisal edge are subjected to masticatory
loads and parafunctions like grinding and nail-biting. Heintze, Rousson & Hickel
(2015)14 showed in their systematic review a higher risk of failure for the restorations
with the incisal edge involved (class IV against class III). Further, all restorations
considered failed in this survey were referred to the dental clinic for retreatment. For
those restorations classified with the score 4, a repair was performed and the
restorations remained in situ. However, for analysis such restorations were classified as
failures. Demarco et al. (2012)22 have pointed out that we should rediscuss this
classification, because the repaired restorations remain in function and therefore could
not be considered a complete failure. In fact those authors have observed in their review
that if the repaired restorations were not classified as failures, the annual failure rate for
posterior composite restoration could drop from 1.9 to 0.7. Thus, repairability is a factor
extending the survival for composite restorations and this should be taken into account
when evaluating results of clinical studies investigating restoration longevity.
Most studies on veneers report the results of porcelain veneers. Indirect
porcelain laminate veneers have a good survival rate, showing a survival of 90% after 3-
5 years service7,35,36. Clinical studies assessing the long-term direct composite veneers
are rare, especially including non-vital teeth34. This indicates the clinical relevance of
our study, which investigated situations often occurring in clinical practice. The
determination of risk factors that can impair the clinical performance of restorations in
daily practice is an ultimate goal for dentistry, in order to increase the longevity of
restorative procedures and reducing the costs of dental treatment37. Another important
aspect to highlight is related to the lack of important information provided from clinical
studies as reported in the systematic review29, which can impair the comparison of
different studies. Clinical studies should follow the guidelines for reporting different
study designs, which certainly would improve the quality of the published papers and
their transparency.38 In the present study we tried to follow these guidelines in order to
provide the most relevant information when describing our study.
CONCLUSION
Within the limitations of this current work, it is possible to conclude that:
- In general, the composite veneers evaluated showed a satisfactory clinical
performance and the survival rate was 80.1% after 3.5 years.
- Direct composite veneers performed in vital teeth showed a better performance
compared to those in non-vital teeth for color match, fracture and retention outcomes.
- Veneers in non-vital teeth have two times higher risk of failure than the veneers placed
in vital teeth.
- There was no difference in survival rate between veneers placed with microfilled or
universal composites. However, microfilled composite veneers showed a slightly better
performance for esthetic properties.

References
1. Sadowsky SJ. An overview of treatment considerations for esthetic
restorations: a review of the literature. The Journal of Prosthetic Dentistry 2006;
96: 433-442.

2. Meyenberg K. The ideal restoration of endodontically treated teeth - structural

and esthetic considerations: a review of the literature and clinical guidelines for
the restorative clinician. European Journal of Esthetic Dentistry 2013; 8: 238-
268.
3. Frese C, Schiller P, Staehle HJ, Wolff D. Contouring teeth and closing diastemas
with direct composite buildups: a 5-year follow-up. Journal of Dentistry 2013;
41: 979-985.
4. Prieto LT, Araujo CT, de Oliveira DC, de Azevedo Vaz SL, D'Arce
MB, Paulillo LA. Minimally invasive cosmetic dentistry: smile reconstruction
using direct resin bonding. General Dentistry 2014; 62:e28-3.
5. Gresnigt MM, Kalk W, Ozcan M. Randomized controlled split-mouth
clinical trial of direct laminate veneers with two micro-hybrid resin composites.
Journal of Dentistry 2012; 40:766-775.

6. Meijering AC, Creugers NH, Roeters FJ, Mulder J. Survival of three types of
veneer restorations in a clinical trial: a 2.5-year interim evaluation. Journal of
Dentistry 1998; 26:563-568.
7. Layton DM, Clarke M. A systematic review and meta-analysis of the survival of
non-feldspathic porcelain veneers over 5 and 10 years. International Jounal of
Prosthodontics 2013; 26:111-124.
8. Trushkowsky RD. Esthetic and functional consideration in restoring
endodontically treated teeth. Dental Clinics of North America 2011; 55: 403-
410.
9. Hu YH, Pang LC, Hsu CC, Lau YH. Fracture resistance of endodontically
treated anterior teeth restored with four post-and-core systems. Quintessence
International 2003; 34: 349-353.
10. Skupien JA, Opdam N, Winnen R, Bronkhorst E, Kreulen C, Pereira-Cenci
T, Huysmans MC. A practice-based study on the survival of restored
endodontically treated teeth. Journal of Endodontics 2013; 39:1335-1340.
11. Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, Loguércio AD, Moraes RR,
Bronkhorst EM, Opdam NJ, Demarco FF. 22-year clinical evaluation of the
performance of two posterior composites with different filler characteristics.
Dental Materials 2011; 27:955-963.
12. Van de Sande FH, Opdam NJ, Rodolpho PA, Correa MB, Demarco FF, Cenci
MS. Patient risk factors' influence on survival of posterior composites. Journal
of Dental Research 2013; 92(Suppl):78S-83S.
13. Opdam NJ, Van de Sande FH, Bronkhorst E, Cenci MS, Bottenberg P, Pallesen
U, Gaengler P, Lindberg A, Huysmans MC, Van Dijken JW. Longevity of
 posterior composite restorations: a systematic review and meta-analysis. Journal
of Dental Research 2014; 93: 943-949.
14. Heintse SD, Rousson V, Hickel R. Clinical effectiveness of anterior
restorations – a meta-analysis. Dental Materials 2015; 31: 481-495.

15. Alonso V, Caserio M. A clinical study of direct composite full-coverage crowns:

long-term results. Operative Dentistry 2012; 37: 432-441.
16. Demarco FF, Baldissera RA, Madruga FC, Simoes RC, Lund RG, Correa MB,
Cenci MS. Anterior composite restorations in clinical practice: findings from a
survey with general dental practitioners. Journal of Applied Oral Science
2013;21:497-504..
17. Kaizer MR, de Oliveira-Ogliari A, Cenci MS, Opdam NJ, Moraes RR. Do
nanofill or submicron composites show improved smoothness and gloss? A
systematic review of in vitro studies. Dental Materials 2014; 30:e41-78.
18. Hickel R, Peschke A, Tyas M, Mjör I, Bayne S, Peters M, Hiller KA,
Randall R, Vanherle G, Heintze SD. FDI World Dental Federation - clinical
criteria for the evaluation of direct and indirect restorations. Update and clinical
examples. The Journal of Adhesive Dentistry 2010; 12: 259-72.

19. Kubo S, Kawasaki A, Hayashi Y. Factors associated with the longevity of resin
composite restorations. Dental Materials 2011; 30:374-383.
20. Baldissera RA, Corrêa MB, Schuch HS, Collares K, Nascimento GG, Jardim
PS, Moraes RR, Opdam NJ, Demarco FF. Are there universal restorative
composites for anterior and posterior teeth? Journal of Dentistry 2013; 41:1027-
1035.

21. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. 12-year survival of
composite vs. amalgam restorations. Journal of Dental Research 2010; 89:1063-
1067.
22. Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJ. Longevity of
posterior composite restorations: not only a matter of materials. Dental
Materials 2012; 28:87-101.

23. Van de Sande FH, Da Rosa Rodolpho PA, Basso GR, Patias R, da Rosa QF,
Demarco FF, Opdam NJ, Cenci MS. 18-year survival of posterior composite
resin restorations with and without glass ionomer cement as base. Dental
Materials 2015; 31:669-675.
24. Pallesen U, Van Dijken JW, Halken J, Hallonsten AL, Höigaard R. Longevity of
posterior resin composite restorations in permanent teeth in Public Dental Health
Service: a prospective 8 years follow up. Journal of Dentistry 2013; 41:297-306.
25. Pallesen U, Van Dijken JW, Halken J, Hallonsten AL, Höigaard R. A
prospective 8-year follow-up of posterior resin composite restorations in
permanent teeth of children and adolescents in Public Dental Health Service:
reasons for replacement. Clinical Oral Investigations 2014; 18:819-827.
26. Kopperud SE, Tveit AB, Gaarden T, Sandvik L, Espelid I. Longevity of
posterior dental restorations and reasons for failure. European Journal of Oral
Science 2012; 120:539-548.
27. Moura FR, Romano AR, Lund RG, Piva E, Rodrigues Júnior SA, Demarco FF.
Three-year clinical performance of composite restorations placed by
undergraduate dental students. Brazilian Dental Journal 2011; 22:111-116.
 28. Correa MB, Peres MA, Peres KG, Horta BL, Barros AJ, Demarco FF. Do
socioeconomic determinants affect the quality of posterior dental restorations? A
multilevel approach. Journal of Dentistry 2013; 41:960-967.
29. Demarco FF, Collares K, Coelho-de-Souza FH, Correa MB, Cenci MS, Moraes
RR, Opdam N. Anterior composite restorations: a systematic review on long-
term survival and reasons for failure. Dental Materials 2014; 30:348-355. Doi:
10.1016/j.dental.2015.07.005.
30. Cauwels RG, Lassila LV, Martens LC, Vallittu PK, Verbeeck RM.
Fracture resistance of endodontically restored, weakened incisors. Dental
Traumatology 2014; 30:348-355.
31. Bitter K, Gläser C, Neumann K, Blunck U, Frankenberger R. Analysis of resin-
dentin interface morphology and bond strength evaluation of core materials for
one stage post-endodontic restorations. PLoS One 2014; 9:e86294.
32. Lu H, Roeder LB, Lei L, Powers JM. Effect of surface roughness on stain
resistance of dental resin composites. Journal of Esthetic and Restorative
Dentistry 2005; 17:102-108.
33. Turssi CP, de Magalhães CS, Serra MC, Rodrigues Júnior AL. Surface
roughness assessment of resin-based materials during brushing preceded by pH-
cycling simulations. Operative Dentistry 2001; 26:576-584.
34. Piovesan EM, Demarco FF, Cenci MS, Pereira-Cenci T. Survival rates of
endodontically treated teeth restored with fiber-reinforced custom posts and
cores: a 97-month study. International Jounal of Prosthodontics 2007; 20:633-
639.
35. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van
Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. The
Journal of Adhesive Dentistry 2004; 6:65–76.

36. Chen JH, Shi CX, Wang M, Zhao SJ, Wang H. Clinical evaluation of 546
tetracycline-stained teeth treated with porcelain laminate veneers. Journal of
Dentistry 2005; 33(1): 3-8.

37. Van de Sande FH, Collares K, Correa MB, Cenci MS, Demarco FF, Opdam
NJM. Restoration survival: revisiting patients’ risk factors through a systematic
review. Operative Dentistry 2015; doi: 10.2341/15-120-LIT.

38. Sarkis-Onofre R, Cenci MS, Demarco FF, Lynch CD, Fleming PS, Pereira-
Cenci T, Moher D. Use of guidelines to improve the quality and transparency of
reporting oral health research. Journal of Dentistry 2015; 43(4):397-404.

Table 1 – Characteristics of the composites evaluated

Composite Manufacturer Inorganic E- Inorganic Mean Clinical N

 filler modulus filler particle indication veneers
classification (GPa) percentage size
Durafil Heraeus Microfill 6.15 37.5 vl 0.04 Anterior 41
VS Kulzer µm teeth
Charisma Heraeus Microhybrid 14.06 59.4 vl 0.7 µm Universal 55
Kulzer
4Seasons Ivoclar Nanohybrid 9.05 76 wt 0.6 µm Universal 37
Z350 XT 3M/ESPE Nanofill 13.3 63.3vl 20- Universal 24
75nm
Opallis FGM Nanohybrid 9.1 58 vl 0.5 µm Universal 39
*Bicalho et al (2014)36; Baldissera et al (2013)20; Loomans et al (2008)37; Willems et al
(1992)38; Melo Junior et al (2011)39; Kim et al (2002)40.

Table 2 – Distribution of composite veneer restorations.

Independent variables n %
Sex
Male 26 30.2
Female 60 69.8
Total 86 100
Tooth type
Central incisor 88 44.9
Lateral incisor 82 41.8
Canine 26 13.3
Total 196 100
Follow-up time (years)
0.5 - 2 65 33.2
2 – 3.9 56 28.6
4 – 5.9 32 16.3
6 – 7.9 18 9.2
More than 8 125 12.7
 Total 196 100
Composite type
Microfilled 41 20.9
Universal 155 79.1
Total 196 100
Tooth Vitality
Vital 143 73.0
Non-vital 53 27.0
Total 196 100

Table 3 - Clinical evaluation of composite veneers: comparison between vital and non-vital teeth,
according to the FDI criteria:

Vital Teeth Non-vital Teeth Mann-Whitney

Restorations Restorations Restorations Restorations

scores* clinically scores clinically
p
acceptable acceptable
n (1/2/3/4/5) n (1/2/3/4/5)

Aesthetics Surface lustre 142 (95/43/4/0/0) 100% 45 (23/20/2/0/0) 100% 0.057

properties
Surface staining 142 (68/57/17/0/0) 100% 45(16/19/10/0/0) 100% 0.074

Marginal staining 142 (50/66/26/0/0) 100% 45 (10/26/9/0/0) 100% 0.198

Color match 142 (119/21/2/0/0) 100% 45 (29/13/3/0/0) 100% 0.004

Anatomic form 142 (88/43/11/0/0) 100% 45 (24/15/6/0/0) 100% 0.241

Functional Fracture and 143(105/14/8/12/4) 88.8% 53 (33/3/3/4/10) 73.6% 0.038

properties retention
Marginal 142 (57/76/8/0/1) 99.3% 45 (18/18/7/1/1) 95.6% 0.343
adaptation
Patient’s view 143 (116/21/5/0/1) 99.3% 46 (34/5/5/1/1) 95.7% 0.191

Biological Recurrence of 142 (133/2/1/6/0) 95.8% 45 (44/0/0/1/0) 97.8% 0.292

properties caries, erosion and
abfraction
 Postoperative 142 (135/4/1/2/0) 98.6% 45 (45/0/0/0/0) 100% 0.130
sensitivity

*For each evaluation criterion a score from 1 to 5 is given: 1-3 when the restoration is clinically
acceptable, while 4 and 5 designate failure (Kappa= 0.87).

Table 4- Clinical evaluation of composite veneers: comparison between the composite types (microfilled
and universal composites), according to the FDI criteria:
Microfill Universal Mann-Whitney
Restorations Restorations Restorations Restorations
scores* clinically scores clinically p
n (1/2/3/4/5) acceptable n (1/2/3/4/5) acceptable

Aesthetics Surface lustre 41 (41/0/0/0/0) 100% 146 (77/63/6/0/0) 100% 0.001

properties
Surface staining 41 (34/6/1/0/0) 100% 146 (50/70/26/0/0) 100% 0.001

Marginal staining 41 (23/15/3/0/0) 100% 146 (37/77/32/0/0) 100% 0.001

Color match 41 (39/2/0/0/0) 100% 146 (109/32/5/0/0) 100% 0.004

Anatomic form 41 (37/3/1/0/0) 100% 146 (75/55/16/0/0) 100% 0.001

Functional Fracture and 41 (33/0/3/4/1) 87.8% 155(105/17/8/12/13) 83.9% 0.150

properties retention
Marginal 41 (30/11/0/0/0) 100% 146 (45/83/15/1/2) 97.9% 0.001
adaptation
Patient’s view 41 (38/3/0/0/0) 100% 148 (112/23/10/1/2) 98.0% 0.014

Biological Recurrence of 41 (37/1/0/3/0) 92.7% 146 (140/1/1/4/0) 97.3% 0.156

properties caries, erosion and
abfraction
Postoperative 41 (41/0/0/0/0) 100% 146 (139/4/1/2/0) 98.6% 0.154
sensitivity
*For each evaluation criterion a score from 1 to 5 is given: 1-3 when the restoration is clinically
acceptable, while 4 and 5 designate failure (Kappa= 0.87).
Figure 1 – Kaplan-Meier survival curves for composite veneers in vital and non-vital teeth (log-
rank: p=0.005).
Figure 2 – Kaplan-Meier survival curves for microfilled and universal composites’ veneers (log-
rank: p=0.654).

Table 5 – Cox regression analysis with adjusted Hazard Ratio (HR) for independent variables
and failures of composite veneers.
Independent variables HRc 95% CI p-value
Sex (female vs male) 4.32 0.805 – 23.16 0.804
Tooth type (vs central incisors) 0.575
Lateral incisors 0.71 0.31 – 1.62
Canines 0.47 0.08 – 2.63
Material (universal vs microfilled) 1.07 0.23 – 5.08 0.933
Tooth vitality (non-vital vs vital) 2.78 1.02 – 7.56 0.045

A B

Figure 3 – Representative pictures of failed veneers: A- chip fracture of the veneer (score 4 –
repairable). B - bulk fracture of the veneer (score 5).
 A B

Figure 4 – Representative pictures of successful veneers: A- microfilled composite veneer after

09 years in the lateral incisor. B- composite veneers after 02 years in the central incisors.