Anterior Veneer Restorations – An Evidence-based

Minimal-Intervention Perspective
Edson Araujoa / Jorge Perdigãob

Purpose: The goals of this review are (1) to describe the evidence behind the use of ceramics vs composite resin
to restore teeth with anterior veneers using a minimally-invasive strategy; and (2) to discuss the choice of mater-
ials and techniques for anterior veneer restorations.
Overview: In recent years new adhesive restorative materials and techniques have been introduced in dentistry, in-
cluding nanofilled composite resins for direct restorations, new ceramic materials that combine esthetics and
strength, and polymer/ceramic materials for indirect restorations that are fabricated chairside using CAD/CAM
technology, allowing the dentist to design, mill, and cement the restoration in one session. In spite of the novelty
and new technology behind the introduction of new materials, the available evidence that backs some of these ma-
terials does not justify their use over similar materials or techniques that have been used by dentists for some
years. Notwithstanding the success of laminate veneers and the popularity of new materials and digital techniques,
the classical direct composite resin veneer is still very popular among clinicians and taught in dental schools and
continuing education courses. Direct composite resin veneers are usually more affordable than indirect veneers,
less invasive of the tooth structure, and easier to repair. Current composite resin materials can be finished to a
tooth-like appearance, but they are susceptible to alterations of the surface gloss and potential discoloration of the
composite resin. On the other hand, the preparation for indirect veneers is generally more invasive and the respec-
tive restorations are more difficult to repair. In addition, the esthetic outcome of bonded ceramic restorations still
depends on the clinical behavior of the dentin adhesive and resin luting cement used to bond the restoration to the
tooth structure.
Conclusions: The ultimate goals of any restorative treatment are to restore function and esthetics, prevent recur- r
rent caries lesions and bacterial leakage into the pulp space, save tooth structure, and promote the well-being of
our patients. The armamentarium of new dental materials for esthetic clinical procedures has increased exponen-
tially in the last few years. The use of different materials and techniques for anterior veneer restorations must be
based on sound evidence rather than on the marketing hype or testimonials.
Keywords: adhesion, ceramics, clinical, composite resin, MID, restorative materials, veneers.

J Adhes Dent 2021; 23: 91–110. Submitted for publication: 17.02.20; accepted for publication: 27.08.20
doi: 10.3290/j.jad.b1079529

I n 2012, the US population spent on the order of 1 billion

dollars on purely cosmetic dental procedures.95,181 The
global cosmetic dentistry market size was 18.79 billion
USD in 2018 and is expected to reach 32.73 billion USD by
2026.101
a Associate Professor, Department of Comprehensive Care, School of Dentistry,
Federal University of Santa Catarina, Florianópolis, SC, Brazil. Idea, clinical
cases, analysis of clinical differences between composite and ceramic veneers.
b Professor, Department of Restorative Sciences, Division of Operative Den-
tistry, University of Minnesota, Minneapolis, MN, USA. Literature review, wrote
the manuscript, proofread the manuscript, prepared specimens for SEM and
exposed respective micrographs, clinical case.
Correspondence: Jorge Perdigão, University of Minnesota School of Dentistry,
515 SE Delaware Street, 8-450 Moos Tower, Minneapolis, MN, USA.
Tel: +1-612-625-8486; e-mail: perdi001@umn.edu
Self-consciousness of physical attractiveness has reached
new levels with the advent of social media, resulting in a
growing demand for cosmetic procedures in dentistry and
other areas of health sciences. Patients’ demand for es-
thetic dental treatments have led to the introduction of
techniques aimed at reestablishing or enhancing the natu-
ral appearance of the human dentition, with special focus
on the anterior segment. Concomitantly, there has been a
shift in dental research over the last decades with empha-
sis on caries prevention. The etiology of dental caries is
now recognized as complex and multifactorial, in the same
category as cardiovascular diseases and diabetes, in which
many risk factors interact.69
The concept of minimally invasive dentistry (MID) has
evolved, supported by increased knowledge about the car- r
ies process and new adhesive restorative materials. Al-
though the MID philosophy is sometimes simplistically ac-

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Table 1 Selected physical properties of different materials1,8,14,16,36,44,55,60,84,92,98,113,157,172,176,193,208,210,212,213

Elastic modulus Flexural strength Fracture toughness

(GPa) (MPa) (MPa/m2)
Dentin 16–18 210 2.1–2.6
Enamel 55–100# 20 0.67–1.0##
Hybrid composite resins 11–20 100–180 1.0–1.8
Nanofilled composite resin 14–15 120–150 0.6–1.3
Feldspathic ceramics* 26–60 80–120 0.7–1.2
Leucite reinforced-ceramics* 62–68 105–150 1.3
Lithium-disilicate-reinforced ceramics* 90–103 306–480 1.9–3.6
Nano-particulate pre-polymerized composite resin 12–15 170–210 0.8–2
(Lava Ultimate, 3M Oral Care)
Polymer-infiltrated ceramic network (PICN) 27–37 125–180 1
Zirconia (3Y-TZP) 210 1050–1300 8–11
Cubic zirconia (also known as translucent zirconia) 210 450–650 4.8–6.9
Zirconia-reinforced lithium silicate 105–108 443–565 2.3–2.6
* Glass-CER; # increases with age; ## decreases with age.

knowledged as the restoration of small caries lesions while
avoiding the classical “extension for prevention” concept,
MID includes a broader application of a systematic respect
for the original tissue.63 Nevertheless, the term minimally
invasive dentistry has often been used associated with
major removal of tooth structure.17,133
With the introduction of the enamel acid-etch technique
with phosphoric acid in 195530 and the first bis-GMA-based
composite resin in 1962,28 dentistry entered a new era
characterized by the chairside use of direct tooth-colored
materials firmly adhered to the tooth structure, including
the restoration of anterior and posterior teeth to restore
caries lesions, build fractured teeth or simply to adjust the
esthetic appearance. With the evolution of composite resin
technology, direct anterior composite restorations, including
veneers, became an economical and visually pleasing solu-
tion compared to more complex restorations.42,115
Another acid-etch technique that proved crucial for the
adhesion of porcelain to the tooth structure was introduced
in 1983.32,190 Hydrofluoric acid (HF) was used to etch and
create microporosities on the porcelain surface. By combin-
ing the enamel acid-etch technique with the porcelain acid-
etch technique dentists were finally able to adhere porce-
lain veneers to enamel resulting in reliable and durable
restorations.
It has been often mentioned that direct composite ve-
neers are a more conservative option for some clinical
cases planned for porcelain veneers. Some patients treated
with porcelain veneers may be excellent candidates for less
invasive treatments, including bleaching and/or direct com-
posite veneers. These patients should be fully informed of
alternative treatments to porcelain veneers.41
The objectives of this clinical review article are to de-
scribe the evidence behind the use of ceramic vs compos-
ite resin to restore anterior teeth with veneers following a
minimally invasive concept and discuss the choice of ma-
terials and techniques for anterior veneer restorations.
CURRENT MATERIALS FOR
VENEER RESTORATIONS
Although ceramics and composite resins have some com-
mon clinical indications that depend on the clinical situa-
tion, they are materials with distinct physical properties
(Table 1). In this sense, it is of utmost importance that
the practitioner be aware of these differences so that he/
she is able to assess the distinct aspects related to the
clinical performance of the restoration including the pos-
sibility of future repairs or replacement. The final decision
as to which material is indicated for a clinical situation
must be pondered based on strong evidence rather than
on marketing claims. Manufacturers will quote bond
strengths and microleakage data of new dentin adhesives
and compressive or flexural strengths of composite resins
and ceramics to market their materials. Many other fac-
tors are more relevant and must be considered for each
individual case, including the number of teeth in the
mouth, the patient’s age, opposing dentition, the occlu-
sion, the periodontal status and the management of car-
ies risk factors.
Ceramics
The current ceramic materials are classified as follows:

92 The Journal of Adhesive Dentistry

 Araujo/Perdigao

a a

b b
Fig 1 SEM micrographs of Creation Fig 2 SEM micrographs of IPS e.max CAD Fig 3 TEM micrograph of sintered 3Y-TZP
(Jensen Dental) feldspathic glass-CER. (Ivoclar Vivadent) lithium-disilicate glass- (Lava Zirconia, 3M Oral Care) displaying the
Bar = 2 μm. Original magnification = CER. Bar = 1 μm. Original magnification zirconia crystals without any glass particles.
5000X. a. Fractured surface; b. intaglio = 20,000X. a. Fractured surface; b. intaglio Bar = 0.5 μm. Original magnification
surface after etching with 9.6% HF for 90 s surface after etching with 4.8% HF for 20 s. = 40,000X.
and rinsing with water for 120 s.

Glass-matrix ceramics (Glass-CER) Lithium-disilicate glass-CER is currently the most popular

According to Gracis et al,88 these are nonmetallic inorganic
ceramic materials that contain a glass phase.
Glass-CER have excellent properties, including esthetics,
biocompatibility, and chemical and wear resistance.7 Their
physical weaknesses include brittleness, relatively low ten-
sile and flexural strengths, insufficient fracture toughness,
and possible wear to the opposing dentition.46 Feldspathic
glass-CER, the original dental porcelain, was based on the
naturally occurring feldspar. It has been used for many
years primarily for anterior restorations, including jacket
crowns, veneers or laminates, and intra-coronal restor-
ations. Its optical properties made feldspathic glass-CER
the first choice for ceramic veneers for many years, being
currently used for veneering metal and zirconia structures.
The estimated 9-year survival of feldspathic porcelain ve-
neers is slightly lower than that of more recent glass-CER,
such as fluorapatite, leucite, or lithium-disilicate.141
Due to their improved physical properties, leucite-rein-
forced glass-CER and lithium-disilicate-reinforced glass-CER
have become more universally used than feldspathic ceram-
ics. Leucite-reinforced glass-CER has significantly lower flex-
ural strength than lithium-disilicate glass-CER.155 In addi-
tion, the clinical performance of lithium-disilicate glass-CER
is more successful than that of its leucite counterpart.22 In
spite of these differences, both materials become stronger
and more resistant to fracture once they are bonded with
adhesive and composite cement.25,155,205
ceramic material for laboratory-made veneers, inlays, on-
lays, and anterior crowns. For anterior veneers a minimum
thickness of 0.3 mm can be achieved when lithium-disili-
cate glass-CER is used with the press technique (IPS e.max
Press, Ivoclar Vivadent; Schaan, Liechtenstein), or 0.4 mm
when the CAD/CAM version is used (IPS e.max CAD), as
recommended by the respective manufacturer. For posterior
occlusal veneers, a thickness of 0.7-1.0 mm is recom-
mended.180 Clinical studies with lithium-disilicate glass-CER
anterior veneer restorations have resulted in excellent sur- r
vival rates.141 Lithium-disilicate glass-CER is also used for
single-unit crowns. A multi-center retrospective study on
single crowns with feather-edge preparation in posterior
teeth reported an overall survival probability of 97.93% up
to 12 years and an estimated mean survival of 11.5 years.
Out of the initial 627 crowns on 134 vital and 493 end-
odontically treated teeth in this study, 13 were classified as
failures.183 A 10-year evaluation of molar crowns made of
lithium-disilicate glass-CER in another study found a suc-
cess rate of 83.5%.166 The cumulative survival rate of an-
terior and posterior crowns was 97.4% at 5 years and
94.8% at 8 years, without any statistical difference between
anterior and posterior crowns.82 However, the use of lith-
ium-disilicate glass-CER for fixed partial dentures (FPDs or
bridges) has not been as successful. In fact, an in vitro
study recommended that lithium-disilicate should be used
as bridge material only up to the second premolar.97 In

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2011, the survival probability of 3-unit bridges made of
lithium-disilicate glass-CER was found to be 63% at 6 years
in 8 anterior and 10 posterior teeth.130 A clinical study re-
ported 69.8% success rate at 10 years for 3-unit bridges in
6 anterior and 30 posterior teeth.111
A more recent type of lithium silicate glass-CER is known
as zirconia-reinforced lithium-disilicate glass-CER (Vita Su-
prinity [Vita Zahnfabrik; Bad Säckingen, Germany] and Celtra
Duo [Dentsply Sirona; Konstanz, Germany]). It is basically a
material with lithium metasilicate crystallites and 10% dis-
persed zirconia grains, which do not seem to reinforce the
structure. The zirconia remains amorphous and aggregated
to the glassy matrix.170 Short-term clinical results have
been disappointing due to craze line fractures at 1 year.43
All glass-CER, including feldspathic (Fig 1) and lithium-
disilicate (Fig 2), can be etched with HF to create microre-
tentive features onto the intaglio surface for the adhesive
luting system. However, the HF concentration and etching
time are different for each glass-CER material as a result of
their different structures.147 Whereas feldspathic glass-CER
is usually etched with 9 to 10% HF for 90 s, the recommen-
dation for leucite-reinforced glass-CER is 5% HF for 60 s,
and for lithium-disilicate glass-CER is 5% HF for 20 s.67
The traditional clinical adhesive procedure for glass-CER
restorations includes etching the intaglio surface with HF,
rinsing with water for at least 60 s, drying thoroughly with
air, and applying a silane primer solution and/or dental ad-
hesive to the same intaglio surface. With the recent intro-
duction of universal adhesives, at least four dental manufac-
turers have incorporated silane into the composition of their
universal adhesive. By having the adhesive and the silane in
the same solution, the glass-CER adhesive procedure might
be less complex. However, the efficacy of the combined ad-
hesive/silane solution for luting glass-CER restorations is
controversial,109,114 as the silane is not stable when mixed
with the adhesive solution.53,206 In fact, the use of silanol
mixed with adhesive methacrylate monomers is contra-indi-
cated due to silanol deactivation.53 In addition, the acidic
pH of universal adhesives decreases the effectiveness of
the incorporated silane.206,209 For this reason, the applica-
tion of a separate silane solution, or silane freshly mixed
with the adhesive, is still recommended209 even for adhe-
sives that contain a silane in their composition.
Polycrystalline or oxide ceramics
Due to a phenomenon called “transformation toughen-
ing,”52 the material we know as zirconia or 3Y-TZP (3 mol%
yttria stabilized tetragonal zirconia polycrystal, Fig 3), is the
strongest tooth-colored material currently available
(Table 1) and the most durable tooth-colored material in
clinical practice.43 The use of monolithic 3Y-TZP for full-
coverage restorations in clinical practice has surpassed
that of porcelain-fused-to-metal restorations.
A new type of zirconia-based material known as translu-
cent zirconia has gained popularity recently. Translucent
zirconia contains less amount of alumina and more yttria
(5-9 mol%) than 3Y-TZP. The higher yttria content introduces
a higher percentage of the cubic zirconia phase at the ex-
94
pense of the tetragonal phase. For this reason, translucent
zirconia has also been known as cubic zirconia. There is,
however, a trade-off between fracture resistance and trans-
lucency of zirconia (Table 1).211 Increasing the yttria con-
tent enhances the translucency of yttria-stabilized zirconia
but lowers the strength of the material because of the re-
duced transformation toughening.88 Translucent zirconia is
therefore weaker and more brittle than the original opaque
3Y-TZP (Table 1).
Unfortunately, translucent zirconia is more opaque than
lithium-disilicate glass-CER. In addition, polycrystalline ce-
ramics do not contain glass.3 For this reason, zirconia res-
torations are not etchable with HF using conventional meth-
ods. In spite of being suggested by manufacturers and
dental laboratories, as well as advocated in published arti-
cles,91,119,140,194 polycrystalline ceramics are not indicated
for anterior veneer restorations.
Resin-matrix hybrid materials
With the rapid development of digital technology in restorative
dentistry, new materials for CAD/CAM have become avail-
able, including reinforced composite resins and hybrids of
composite resin and ceramics. Although some of these new
materials have been used for occlusal veneers,26,27, 56,105
their use for anterior veneers has not been fully studied.
i. Nanoceramic, or resin-based ceramics, or nano-
particulate pre-polymerized resin composite, or resin-based
composites for CAD/CAM196,203,208
These CAD/CAM materials are based on a pre-processed
composite resin.167,203 Several composite-based CAD/
CAM materials, including Cerasmart (GC; Tokyo, Japan),
Katana Avencia (Noritake Kuraray; Tokyo, Japan), KZR-CAD
HR (Yamakin; Osaka, Japan), Lava Ultimate (3M Oral Care;
St Paul, MN, USA), and Shofu Block HC (Kyoto, Japan)
contain nanofillers.120,208 According to the US Food and
Drug Administration (FDA), these materials are pre-cured
composite blocks for milling CAD/CAM indirect restor-
ations that belong in the “tooth shade resin material” cat-
egory.73-76 The intaglio surface of resin-based composites
for CAD/CAM is usually sandblasted to create microreten-
tive features. The application of a 10-MDP/silane solution
is recommended to increase bond strengths.208 However,
for some of the materials, sandblasting may damage the
intaglio surface.208
Most mechanical properties of this family of materials
are worse than those of glass-CER177 (Table 1). In addition,
some of these materials undergo degradation with aging in
water and thermal fatigue,177 as well as unacceptable color
changes when used for veneers in vitro.9 Their use for an-
terior veneer restorations has not been backed by clinical
evidence in spite of being recommended by several manu-
facturers. Some studies have also tested these materials
for occlusal and occluso-buccal veneers in posterior teeth.
The stress under occlusal and occlusal-buccal veneers in
premolars is substantially increased for Lava Ultimate (3M
Oral Care) compared to IPS e.max CAD (Ivoclar Vivadent)
x lithium-disilicate glass-CER.102
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 Araujo/Perdigao

a b c

d e f
Fig 4 SEM micrographs showing the evolution of composite resins. Bar = 1 μm; original magnification = 20,000X. a. Concise (3M), a
chemically cured paste-paste macrofilled composite resin; b. Durafill VS (Heraeus-Kulzer), a classical microfilled composite resin with particle
size of 0.04 μm with agglomerates of 5-20-μm-wide prepolymerized resin fillers; c. Herculite (Kerr), a classical hybrid composite resin with
average particle size ≈ 1 μm; d. Point 4 (Kerr), a microhybrid composite resin with average particle size of ≈ 0.4 μm; e. the original Filtek
Supreme (3M Oral Care) launched in 2002, a nanofilled composite resin with 0.02-μm nanoparticles and clusters of nanoparticles showing
the yellow translucent shade in this image; f. Filtek Supreme Ultra, shade A2 Body. This composite resin is also known as Filtek Supreme
XTE and Filtek Z350 XT.

ii. Polymer-infiltrated ceramic network (PICN) materials
Vita Enamic (Vita Zahnfabrik) is the most popular PICN ma-
terial. It is composed of a dual-network structure of poly-
mer-infiltrated ceramics. The organic part is UDMA and TEG-
DMA (14 wt%), while the inorganic part is a feldspathic
ceramic network (86 wt%).23,57,61 Similarly to glass-CER,
the intaglio of Vita Enamic must be etched with HF, specifi-
cally 5% for 30 s.185
Vita Enamic was developed to replace glass-CER mater- r Another shortcoming that has been reported for Vita Enamic
ials in some clinical indications, including crowns, inlays/
onlays, and occlusal veneers. Some physical properties,
such as elastic modulus (Table 1), may be more favorable
than the same properties for lithium-disilicate glass-CER.196
However, PICN veneers result in lower compression strength
and higher plastic deformation after one million thermal cy-y
cles compared to lithium-disilicate veneers.149 Furthermore,
the discoloration of Vita Enamic is more intense than that of
glass-CER materials.187 Regarding translucency, the PICN
material is more translucent than several other materials,
including the lithium-disilicate IPS e.max CAD, the nano-
particulate pre-polymerized resin composite Lava Ultimate,
and the hybrid composite resin Tetric Evo-Ceram (Ivoclar
Vivadent). Vita Enamic is slightly less translucent than the
nanofiled composite resin Filtek Supreme Plus/Supreme
XTE.13 There is no sound evidence to indicate PICN mater- r hybrid materials are not ideal for occlusal veneers.207
ials for anterior veneer restorations, in spite of being taught
in continuing education courses.The flexural strength and
hardness of Vita Enamic PICN material and Lava Ultimate
resin-based composite for CAD/CAM are substantial lower
than those of lithium-disilicate glass-CER.143,193 In addition,
the mechanical properties for both resin-matrix hybrid mater- r
ials decreases with thermal fatigue, whereas the physical
properties of lithium-disilicate glass-CER remain stable.193
is the lack of adhesion between the ceramic particles and
the polymeric matrix.179 Brushing does not significantly
change the gloss of lithium-disilicate, but causes significant
gloss decrease of Vita Enamic (27% reduction) and Lava
Ultimate (29% reduction).143 Concomitantly, there is a sig-
nificant increase in surface roughness after brushing for
both resin-matrix hybrid materials.143 Another study re-
ported that the surfaces of Vita Enamic become significantly
rougher than those of Lava Ultimate after toothbrushing.207
Regarding the use of both Lava Ultimate and Vita Enamic
for occlusal veneers in posterior teeth, an in vitro study con-
cluded that premolars restored with Lava Ultimate showed the
highest overall failure probability, while those restored with
IPS e.max CAD showed the lowest. Vita Enamic had higher
failure probability than IPS e.max CAD. Therefore, resin-matrix

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In summary, the available data fail to demonstrate that
the behavior of these resin-matrix hybrid materials sur-
passes that of lithium-disilicate glass-CER.
Composite Resins
The first commercial composite resin was Addent (3M) in
1964, a chemically-cured material that was based on the
bis-GMA resin molecule developed by Dr. Bowen in the early
1960s.28 Interestingly, since that time most changes in
composite resin technology have been focused on the filler
particle size and distribution (Fig 4) rather than on the resin
matrix, which is still based mostly on bis-GMA among other
methacrylate monomers.
In the mid to late 1980s chemically-cured (paste-paste)
macrofilled composites, with average filler particle size far
exceeding 1 μm (Fig 4a), were still taught in dental schools.
Some of the most popular materials were Concise (3M Oral
Care) (Fig 4a), Adaptic (Johnson & Johnson; New Bruns-
wick, NJ, USA), and Profile (S. S. White; Lakewood, NJ,
USA). Macrofilled composite resins were mechanically
strong but very difficult to finish to a smooth surface due to
filler size. In addition, they underwent surface wear and dis-
coloration very quickly.165 They have been discontinued ex-
cept for some areas of the world where access to new tech-
nology is difficult.
Current composite resin materials are classified accord-
ing to the filler particle size and/or clinical use.
a) Microfilled composite resins
Classical microfilled composite resins had 35% to 50% filler
by weight with 0.04 μm silica filler particles and prepolymer-
r physical properties of nanofilled and hybrid composite resins
ized resin fillers to compensate for their low filler content
(Fig 4b). Some of the popular materials were Durafill VS
(Heraeus Kulzer; Hanau, Germany), Heliosit (Ivoclar Viva-
dent) and Silux Plus (3M Oral Care). Because their particle
size was <100 nm (0.1 μm) they were the first true nano-
filled composites in dentistry. Microfilled composite resins
were very susceptible to chipping due to their low filler con-
tent. They became much less popular after the introduction
of sub-micron hybrid and nanofilled composites. Durafill VS
is still available after 30 years of continuous use, especially
because of its easy polish and high final gloss.
b) Hybrid composite resins
To overcome the inherent low flexural strength of microfilled
composite resins, dental manufacturers introduced a new
generation of hybrid composite resins with improved physi-
cal properties in the late 1970s and early 1980s (Table 1).
These new hybrid composite resins, such as Herculite
(Kerr; Orange, CA, USA) (Fig 4c) launched in 1984, had an
average filler particle size ≈ 1 μm and 70%-82% filler by
weight, which made them stronger than microfilled compos-
ites, but more difficult to obtain a smooth surface. Further
refinements in particle technology led to microhybrid com-
posite resins, such as Point 4 (Kerr) (Fig 4d), which had an
average particle size ≈ 0.4 μm. This reduction in average
filler particle size resulted in an improvement in polishability
white maintaining the strength of previous hybrid materials.
96
Overall, hybrid composite resins have excellent flexure
strength and fracture toughness even when compared to
glass-CER (Table 1). They have been used in dentistry for
over 30 years for anterior and posterior restorations, with
some changes in filler type and size. These materials have
been intensely studied over these years, both in vitro and
clinically.
c) Nanofilled composite resins
Nanofilled composite resins were introduced in 2002
(Fig 4e). Clinicians have reported the excellent polishability
of these materials and their inherent high gloss. However,
the surface roughness of the nanofilled composite Filtek
Supreme (3M Oral Care) is similar to that of the classical
microfilled composite Durafill VS (Heraeus-Kulzer) regard-
less of the polishing system.6,48 The nanofilled composite,
however, has higher final gloss than hybrid composites.6,48
Nanofilled composite resins are also appealing to clinicians
because of their easy sculptability compared to that of hy- y
brid composite resins.
As the name suggests, nanofilled composite resins are
based on nanotechnology (Fig 4e), a term that only applies
to particles up to 100 nm (0.1 μm) in diameter.145 The
third and current version of this nanofilled composite resin
is Filtek Supreme Ultra (also Filtek Supreme XTE and Filtek
Z350 XT in some countries), shown in Fig 4f. Its particles
are 20 nm in diameter clustered in wider units.
It should be pointed out that there is no clinical evidence
that nanofilled composite resins result in better overall clin-
ical behavior than hybrid composite resins.2,5,156 In fact,
are not too dissimilar (Table 1). In addition, hybrid compos-
ite resins result in a light propagation pattern similar to that
of the natural tooth structure, and better than that of nano-
filled composite resins.129 Therefore, one of the advantages
of current hybrid composite resins over nanofilled composite
resins is the excellent optical properties of the former.
Confusion is omnipresent on the denomination of the
categories of resin-based composite materials. The term
nanohybrid has been used by the dental industry to refer to
hybrid composite resins that contain some nanofiller parti-
cles in addition to prepolymerized resin clusters. There is
no clinical evidence that these so-called nanohybrid com-
posite resins are better clinically than the ‘older’ microhy-
brid materials.117 The so-called nanohybrid composite res-
ins are not nanofilled composite resins.38
Universal composite resins
This is a new generation of composite resins that includes
microfilled, nanofilled and hybrid composite resins.
Four major characteristics make them universal compos-
ites:
1. They are indicated for all direct restorative procedures
– class I to class VI direct restorations and direct ve-
neers.
2. Most of them follow the trend of simplification with
fewer shades and one translucency as a result of some
type of chameleon effect.
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 Araujo/Perdigao

3. They have an excellent polish retention.40 Fig 5 SEM micro-

4. These materials cost less than some of the most popu- graphs showing uni-
lar composite resins. versal composite
resins. Bar = 1 μm;
original magnifica-
These composite resins represent a simplified type of regu- tion = 20,000X.
lar-viscosity consistency material for which the stratification a. Harmonize (Kerr),
technique, ie, application of enamel, dentin and body a universal hybrid
shades, is not required, as most do not carry different composite with
translucencies. nanofiller clusters;
b. Filtek Universal a
Some universal composites contain nanofillers. Harmo-
(3M Oral Care), a
nize (Kerr), for example, includes clustered nanofillers, be-
universal nanofilled
sides glass particles (Fig 5a), which technically makes it a composite resin;
hybrid composite with a flexure strength of 115 MPa.40 Al- c. Omnichroma
though it polishes better than other current composite res- (Tokuyama), a uni-
ins,192 its potential for discoloration may be an issue.12 versal microfilled
Harmonize is considered less universal than many of the composite resin.
other new composite resins because it is available in 30
shades.The particle distribution of Filtek Universal (3M Oral
Care) falls into the definition of nanofilled composite
(Fig 5b). The fillers are similar to those of Filtek Supreme (a b
combination of a non-agglomerated/non-aggregated 20-nm
silica filler, a non-agglomerated/non-aggregated 4 to 11-nm
zirconia filler, an aggregated zirconia/silica cluster filler
[comprised of 20-nm silica and 4- to 11-nm zirconia parti-
cles], and an ytterbium trifluoride filler consisting of agglom-
erated 100nm particles [Filtek Universal Technical Product
Profile]). Filtek Universal is available in 8 regular shades, a
pink opaquer and an extra white shade. This new compos-
ite borrows two stress-relief monomers from the bulk-fill
composite resin by the same manufacturer. In spite of this c
technology, the wear resistance of Filtek Universal has
been classified as worse than Filtek Supreme Ultra.40
Omnichroma (Tokuyama; Tokyo, Japan) has 75%-80% filler
by weight with 100 nm-400 nm (0.1 μm-0.4 μm) spherical
particles reinforced with wide clusters of pre-polymerized par-r
ticles ranging from 4 μm to 20 μm (Fig 5c). It is available in TPH Spectra ST (Dentsply Sirona, six shades), and Clearfil
one shade only, with an additional opaque shade to replace Majesty ES-2 Premium (Kuraray Noritake, 10 shades).
dentin in class IV restorations Omnichroma has been shown
to have the best color adjustment potential when compared
with other composite resins with multiple shade options, in- RESTORATIVE TECHNIQUE
cluding Filtek Supreme Ultra (3M Oral Care).158 Evans66
showed that the shade difference between Omnichroma and The differences between composite resin and glass-CER
the tooth structure decreases as the tooth becomes materials under a clinician’s viewpoint are summarized in
brighter. This composite resin demonstrated the ability to Table 2. Composite resin materials have been developed
change shade as the surrounding tooth structure became specially for direct use, which means that they can be used
brighter, both visually and with the use of the colorimeter.66 in retentive areas, such as undercuts and areas of enamel
Omnichroma is technically a microfilled composite resin without full dentin support. In fact, adhesive procedures
that is considered truly a universal composite with a flexure result in reinforcement of enamel when dentin support is
strength of 100 MPa, very similar to that of Filtek Universal missing.19,139,142 For composite resin restorations there is
(101 MPa).40 The polish retention and wear resistant were basically no need for tooth preparation other than the re-
considered excellent.40 One of the shortcomings is that it is moval of carious tissue when deemed necessary.112,132,184
less radiopaque than all the other universal composites, Unlike composite resins, ceramic materials require a la-
which is typical of microfilled composites. For example, boratory phase or a chairside design and fabrication step,
while Omnichroma has a radiopacity of 158 (% Al equiva- which makes it necessary to perform additional steps dur- r
lency), the radiopacity of Harmonize (Kerr) is 269 and that ing the restorative sequence up to the luting procedure. As
of Filtek Universal (3M Oral Care) is 288.40 indirect restorations, ceramic materials can only be used
Other composite resins that fall into this category of uni- for non-retentive areas unless another material is used to
versal composites are Essentia Universal (GC, one shade), block the undercuts. In addition, it is mandatory to make

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Table 2 Differences between direct composite resin veneers and glass-CER veneers from a clinician’s perspective
Direct veneers
(composite resin)
Materials and Dental instruments are basic and not expensive
instruments needed
Number of 1 or 2 appointments
appointments
Technical complexity Clinician needs specific training and some artistic
awareness to be able to define and customize the
morphology of the restoration and combine
opacities to obtain the exact shade.
Who is responsible The dentist is solely responsible for the success of
for the esthetic and the treatment.
functional outcome?
Biological In many situations, the treatment is carried out
considerations without removal of tooth structure, which may
increase the durability of the restorations.
Adhesive interface Simple joint, adhesive layer “sandwiched” between
the tooth structure and the composite resin.
Translucency Composite resins are available in multiple
translucencies for the same shade (enamel, dentin
and body), plus opaquers, and special shades for
bleached teeth. The combinations of shades as
direct mock-up is an advantage.
How reversible is the Treatment is reversible for the cases in which there
treatment? was no removal of tooth structure.
Longevity In general, the esthetic longevity related to shade
and gloss stability is fair.
Need for periodical Need to be repolished periodically to increase the
maintenance longevity of the restoration, specifically shade and
gloss. With the newest composite resins, on
average once per year.
How difficult is to Repair is easy and quick using the same
repair restorations? restorative material, which provides a very good
esthetic outcome.
How easy is to Technically very easy, quick, with no need for
replace restorations? sophisticated materials. A Bard-Parker surgical
blade is recommended to remove thin layers of
residual composite resin. Some dentists use UV
light to be able to distinguish residual composite
resin from tooth structure.
98
Indirect veneers
(glass ceramics)
Requires complex materials, instruments and laboratory
techniques.
Clinicians need specialized bur kits, elastomeric
impression materials, special resins to fabricate
provisional restorations, dentin adhesive, composite
cement.
Usually require 3 appointments.
1. Clinical exam, study models, photography.
2. Tooth preparation, definitive impression, fabrication and
cementation of provisional restorations.
3. Try-in and cementation.
Clinician needs specific training and technical dexterity to
prepare teeth.
Must be familiar with the cementation technique and
respective materials.
Excellent communication with the dental technician is
paramount to the success of ceramic veneers
Although the dentist is still responsible for the overall
treatment, the fabrication of the restorations is carried out
by a dental technician.
Very rarely can the treatment be carried out without
preparation of the tooth structure. In some cases,
“no-prep” veneers may induce periodontal alterations.
Complex joint with two adhesive layers; one “sandwiched”
between the tooth structure and the composite cement,
while the second one is “sandwiched” between the
composite cement and the restoration intaglio.
Both the thickness and shade of the glass-CER affect its
translucency. Shade affects translucency parameter less
than thickness.18
The final shade also depends on the luting composite
cement.
In most cases, it is irreversible as a result of the tooth
preparation.
In general, the esthetic longevity related to shade and
gloss stability is excellent.
Esthetics is very durable, unless the luting cement or the
dentin adhesive undergo discoloration. The restoration
itself does not need esthetic maintenance.
Repair is not technically difficult, however cannot be
accomplished with the same material that the restoration
is made of. Therefore, the esthetic result may be
compromised.
The technique usually involves a dentin adhesive and a
composite resin. Etching glass-CER with hydrofluoric acid
(HF) improves substantially the bonding strength. HF must
be used cautiously in the mouth due to its corrosive effect.
The technique is more complex and time-consuming for
indirect veneers.
Because it uses specialized materials, it is more costly
than the technique used for direct veneers.
In most cases the restoration must be removed with a
diamond bur in high-speed under abundant water irrigation.
Some dentists recommend the use of specialized lasers
that interact with the composite cement layer.
The Journal of Adhesive Dentistry

the preparation non-retentive to enable the withdrawal of
the restoration.
Glass-CER restorations rely on dental adhesives and
resin-based luting cements to be retained in the respective
tooth preparation via simultaneous micromechanical attach-
ment to the ceramic and the tooth structure. The interface
or joint between a glass-CER restoration and the tooth sub-
strate is more complex that that formed between a direct
composite resin restoration and the tooth substrate
(Table 2). For a glass-CER restoration the interface includes
two adhesive layers, one applied over the restoration inta-
glio and the other one applied over the tooth structure, with
the composite cement in the middle. Therefore, reliable ad-
hesion is more crucial for the clinical success of ceramic
restorations than for direct composite restorations because
of the complexity of the respective adhesive joint. In addi-
tion, the composite cement shade has a significant effect
on both the ceramic opacity and the micromechanical prop-
erties of the composite cement.154
Composite cements were introduced with the objective
of bonding all-ceramic restorations.59 When glass-CER res-
torations are luted with dental adhesive and composite ce-
ment, they become mechanically stronger than restorations
cemented with other methods,195 especially when the inta-
glio is etched with HF.205
Regrettably, current resin-based dentin adhesive mater-
ials are unable to seal dentin margins effectively to provide
hermetic adhesive-dentin interfaces without in vitro and clin-
ical signs of microleakage.10,11,51,134,150,178
Consequently, one of the factors that is crucial for the
success of bonded glass-CER porcelain veneers is the loca-
tion of the cavo-surface margin in enamel,169 as the micro-
mechanical retention provided by acid-etched enamel is still
key for a successful and durable bond.11,80,134 Marginal
discoloration and interfacial gaps occur most often when
the margins of the porcelain veneer are located in dentin54
(Fig 6). As mentioned by these authors,54 “the weak link in
bonding veneers is considered to be the cement/dentin
bond”. The location of a veneer preparation into dentin ad-
versely affects survival rate.31,54 In addition, stresses at
the veneer cervical margin can lead to fracture, especially
when dentin is exposed.159
ANTERIOR VENEER RESTORATIONS
Direct Composite Resin Veneers
Dentists have treated patients with direct composite ve-
neers for almost 50 years. In 1973, Klaff and Ward115 re-
ported a clinical case of direct composite veneers to re-
shape two peg laterals. After etching enamel with 50%
phosphoric acid, the authors used an enamel adhesive
(Nuva-Seal, Dentsply Caulk; Milford, DE, USA) polymerized
with the respective ultraviolet curing light, and a chemically-
cured macrofilled composite resin (Adaptic, Johnson &
Johnson). The authors wrote that “these restorations were
placed without the use of anesthesia, without cutting tooth
structure, without impression procedures, without construc-
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Araujo/Perdigao
tion and cementation of temporary crowns, and without
time-consuming laboratory procedures”. This assessment is
in line with the current MID concept, which is remarkable
for clinicians practicing dentistry almost 50 years ago.
In 1981, Jordan et al107 elegantly described the use of
the acid-etch technique and a microfilled composite resin to
restore extensive fractures of anterior teeth and place di-
rect veneers on discolored teeth and teeth with enamel hy- y
poplasia.
In a survey conducted at the 1983 meeting of the Ameri-
can Academy of Esthetic Dentistry it was determined that
the one-appointment direct microfilled composite resin ve-
neer was the most popular type of veneer among clin-
icians,42 compared to preformed acrylic veneers and labo-
ratory-made microfilled composite veneers.
In 1991 Welbury conducted a clinical study in children
and adolescents with 289 direct composite veneers made
of a classical light-cured microfilled composite resin (Heli-
osit, Ivoclar Vivadent).202 The restorations were reviewed
after periods of up to 3 years. The median survival time
was 35.6 months with 14% of the veneers considered to
have failed. There was a small incidence of marginal stain-
ing, no deterioration in gingival health, and patient satisfac-
tion was high.
When direct composite veneers are executed following
strict anatomical principles, adequate enamel adhesion,
and balanced occlusal contacts, they can be durable and
highly appreciated by our patients.41 Depending on the spe-
cific clinical case, direct composite veneers may be placed
without any removal of tooth structure (Fig 7). Direct com-
posite veneers also allow dentists to modify tooth shape
using minimally-invasive procedures without the need for
more invasive full-coverage preparations (Fig 8). Patients
must be informed that when direct composite veneers are
placed in vital teeth, they result in a better clinical outcome
than when they are placed in non-vital teeth.45
Fig 6 Porcelain veneers after several
years of clinical use (patient did not recall
when these veneers were cemented). Mar-
ginal discoloration, recurrent caries lesion
on tooth 21 (9) and gaps due to deficient
bonding around dentin margins. The veneers
on teeth 21 (9) and 23 (11) have
already been repaired with composite resin.
99
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a b c

d e f
Fig 7 Direct composite resin veneers on the six maxillary anterior teeth to close diastemas and to improve the smile, as the central incisors
are not the dominant teeth in the smile. a. Pre-operative frontal view showing the compromised esthetics (hidden maxillary incisors) in rest
position. When the mouth is relaxed and slightly open, 3.5 mm of the incisal third of the maxillary central incisor should be visible in a young
individual.24 b. Pre-operative frontal view of patient’s smile showing multiple diastemata; c. Frontal view after direct composite resin veneers
on the six maxillary anterior teeth without any tooth preparation; d, e, f. Esthetic result at different angles.

a b c
Fig 8 Direct composite veneers to reshape the maxillary lateral incisors. a. Pre-operative frontal view depicting the unbalanced morphology
of the maxillary lateral incisors; b. isolation and positioning of a vinyl polysiloxane guide fabricated on the patient’s waxed-up stone model.
No tooth preparation was performed; c. final result after polishing.

A retrospective clinical study reported that direct com-
posite veneers result in satisfactory clinical performance.45
Another clinical study with two hybrid composite resins re-
ported a survival rate of 87.5% for a mean observation time
of 41.3 months.90 The type of composite may not be rele-
vant, although microfilled composites showed a slightly bet-
ter esthetic appearance.45
With the introduction of nanofilled composites, one of
the clinical details that clinicians have experienced is the
high gloss of the restorations after polishing. However, in
vitro studies do not support the idea that nanofilled com-
posite resins result in better surface smoothness (lower
roughness) than traditional hybrid composite resins after
different surface challenges.108
Porcelain Veneers
Anterior porcelain veneers (or laminates) have been used to
restore smiles for almost 90 years. Charles Pincus in
1938163 reported the use of ‘Hollywood veneers’ in movie
artists as removable snap-on porcelain veneers that cov- v
ered just the front of unpleasant teeth, or closed spaces
between teeth. In 1975, there was a crucial change in por-r
celain veneer technology. Alain Rochette173 published a
new technique to restore fractured teeth with ceramic frag-

100 The Journal of Adhesive Dentistry


a b
Fig 9 Porcelain veneer with lithium-disilicate glass-CER on a peg lateral. a. Pre-operative view of peg lateral incisor. Patient did not want to have
tooth restored with composite resin; b. image immediately after finalizing the tooth preparation for a glass-CER veneer. The preparation is strate-
gically located in the proximal, cervical and incisal areas. The buccal surface was left partially intact; c. after adhesive cementation and finishing.
ments. The enamel was etched with 40% phosphoric acid
for 90 s followed by bonding a porcelain fragment with Se-
vitron Cavity Seal (Amalgamated Dental Company), a self-
cured glycerol-phosphoric acid dimethacrylate (glycerol-phos-
phoric acid dimethacrylate was the first true self-etch
adhesive and is still currently used in a few dental adhe-
sives) developed by Oskar Hagger in 1949.116,191 The inta-
glio surface of the ceramic fragment was treated with a si-
lane solution for the first time.
In 1979, it was reported that HF creates porosities on
the dental porcelain surface by dissolving the glass
phase.103 In 1983, the application of HF on the porcelain
restoration intaglio surface prior to bonding to tooth struc-
ture was the milestone that forever transformed the reliabil-
ity and durability of dental porcelain restorations.32,190 As a
result of these pioneer techniques, bonded ceramic restor- r One specific brand name, Lumineers (Den-Mat Holdings LLC;
ations mimic the biomechanical properties and structural
integrity of the original tooth, resulting in excellent clinical
performance.21,80,162
The adhesively bonded ultra-thin esthetic glass-CER res-
toration may significantly reduce the risk of periodontal and
pulpal injury often associated with full coverage procedures
while offering excellent esthetics. However, the success of
glass-CER veneers depends on diverse factors, including
the operator experience,188 location of the cervical cavo-
surface angle (ie, enamel or dentin),21 the reduction
depth,153,159 the preparation design,99,182 the palatal con-
tact point position,197 parafunctional habits,54 and the ad-
hesives and composite cements used for the luting proced-
ure,93,152 among others.
Some crucially undesirable clinical situations are often
overlooked when planning glass-CER veneers:
1. Margins located in an existing composite restoration:
marginal defects and recurrent caries lesions often
occur when the margin of the veneer is located in an
existing composite restoration.159
2. Minimally-invasive preparations limited to enamel are
ideal regardless of the technique (Fig 9). Nonetheless,
a slight exposure of dentin is often unavoidable. In addi-
tion, the modification of tooth misalignment with glass-
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Araujo/Perdigao
c
CER veneers may result in dentin exposure, which is not
an ideal situation, as bonding to dentin is not as reli-
able as bonding to enamel.144 Extensive dentin expo-
sure on the labial surface, even when all margins are
located in enamel, reduces the survival rate of glass-
CER veneers,153 as enamel is the most predictable sub-
strate for lasting bonding.104
In the late 1980s, the most common preparation technique for
porcelain veneers was the so-called non-prep veneer.39 How-
ever, in 1991, it was reported that tooth preparation was pre-
ferred by most dentists, in spite of the generalized idea that
non-prep veneers were the best choice.39 It is still common for
potential patients to ask for non-preparation veneers when
they contact dental offices to inquire about porcelain veneers.
Lompoc, CA, USA), has been used by prospective patients as
a genericized trademark for no-preparation veneers.
The clinical evidence that glass-CER veneer restorations
perform significantly better than direct composite veneer
restorations in anterior teeth is not very strong.198,201 Sev-
eral clinical studies have nonetheless reported excellent
results up to 20 years for feldspathic and glass-CER ve-
neers.21,121-123,141 Multiple veneers in the same patient
resulted in the same outcome.123 Even when used to re-
store teeth with extensive damage, porcelain laminates re-
sult in high 5-year survival rates if bonded adequately to the
tooth structure.93
Porcelain veneers were originally prescribed to mask in-
trinsic tooth discolorations such as tetracycline staining.100
Albeit more conservative than preparations for full coverage
restorations, the preparations of tetracycline-stained teeth
had to provide enough labial clearance for the ceramic to
successfully mask the stain with the help of opaque com-
posite cements, resulting a monochromatic lifeless restor- r
ation. The same idea applies to teeth that underwent dis-
coloration. These clinical cases are very challenging, as
only the darkened tooth is usually restored (Fig 10).
The trend in esthetic smiles by design has also ex-
panded to CAD/CAM restorations. In addition to the conve-
101
Araujo/Perdigao
nience offered by digital systems, the overvaluation of aes-
thetic appearance has led to rapid smile transformations
both chromatically and morphologically. This trend has re-
sulted in questionable treatment plans that include multiple
veneer restorations in sound teeth or small posterior caries
lesions restored with CAD/CAM techniques. Articles pub-
lished in supposedly peer-reviewed journals have depicted
clinical cases treated with glass-CER veneers claiming to be
minimally invasive, including cases of “instant orthodon-
tics”, small enamel chipping of anterior teeth, and slight
enamel discoloration in young patients.78,79 For this rea-
son, it is important to highlight the opinion of one of the
pioneers in clinical studies with porcelain veneers, Dr. Mark
Friedman, who stated that “the economic incentives associ-
ated with the porcelain veneer ‘industry’ have spawned dis-
turbing trends, misleading information, and an unprece-
dented level of overtreatment in our profession”.78
LONGEVITY
The traditional approach to the restoration of small caries
lesions leads to a re-treatment cycle that includes exces-
sive tooth reduction, subsequent replacement of the restor- r
ation, and additional loss of tooth structure. This cycle is
irreversible and results in progressive loss of tooth struc-
ture and tooth loss in some cases.171,204 If we use a re-
storative material that does not require excessive tissue
removal, we will certainly provide greater protection and
longevity to our patients’ teeth. Also, if we consider repair-
r materials. When it comes to composite restorations, it is
ing or removing a restoration that has been deemed clini-
cally unacceptable, there is a difference between the two
materials. For porcelain restorations replacement or repair
is a more critical and time-consuming procedure, often end-
ing up in excision of more dental tissue compared to com-
posite resin restorations.
Despite being an easily understood concept, the term
longevity is very commonly associated with the durability or
time during which a restoration remains in the mouth pro-
viding function and esthetics. In this sense, a glass-CER
restoration is considered a material with greater longevity
because it undergoes fewer changes in gloss, texture and
even integrity over time compared to composite resin. How-
ever, if we consider the durability and preservation of tooth
structure rather than durability of the restoration, composite
resins provide more conservative restorative treatments.
Consequently, this more conservative approach with com-
posite resins may result in increased longevity of the tooth.
As mentioned before, several clinical studies have re-
ported excellent results up to 20 years for glass-CER ve-
neers, even when they are used to restore teeth with exten-
sive damage.21,93,121-123,141,169 After a mean period of
10 years of clinical service, in spite of a survival rate of
91.8%, fractures of the ceramic material were identified as
the primary cause of failure, whereas larger amount of ex-
posed dentin (more than 50%) was significantly associated
with technical and biological complications.169 For direct
composite veneers, the main reason for failure is also frac-
102
ture of the restoration.45 Surface roughness and marginal
discoloration were the other quality deficiencies observed in
a clinical study of composite veneers with two hybrid com-
posite resins up to 46-month observation period.90
One detail must be emphasized. The dentin adhesive
used to bond the direct composite veneer or the porcelain
veneer plays a very relevant role in the survival of the restor-
r
ations. Some dentin adhesives provide more reliably bonded
restorations than others.15,160,161 In general, two-step self-
etch adhesives and three-step etch-and rinse adhesives re-
sult in higher survival rates in direct restorations,144,160,161
as a result of the application of a hydrophobic bonding layer
with these two adhesive strategies.
REPAIR OR REPLACE?
The clinical longevity of any restoration repair depends on
many factors, including the extension of the fracture, the
location in the mouth, the isolation of the field during the
repair procedure, and the method used to create retention
for the repair material. It is important to diagnose and elim-
inate the cause of the fracture, for example, an occlusal
interference. It is up to the dentist to make the right choice
as to which restorative material is most appropriate for
each clinical situation.
Due to the compositional differences between glass-CER
and composite resin, it is important to understand that the
repair protocol is different for restorations with these two
common in dental offices to replace a restoration due to
the loss of gloss or increased marginal staining that may
occur on the surface or around the margins of the restor- r
ation. These situations would be easily solved with a simple
minimally-invasive procedure, such as re-polishing, to rees-
tablish a reasonable aesthetic appearance, thus avoiding
unnecessary replacements and consequently providing lon-
ger durability of the restorative treatment.64,65,127
Repair rather than total replacement of composite resin
restorations increases the survival of the original restor- r
ation,85,86 reducing the risk for pulp complications and treat-
ment costs.34,150 It must be highlighted that repair of restor-
r
ations that fail as a result of recurrent caries have a better
prognosis compared to repairs of fractured restorations.150
Research has shown that intra-oral sandblasting the ex-
isting composite resin with aluminum oxide particles is nec-
essary to provide strong micromechanical retention for the
repaired composite resin.77,174 The use of HF to repair
composite resin restorations is controversial. While HF has
been considered contra-indicated by some authors174 other
researchers have concluded that it depends on the compo-
sition of the composite resin used for the original restor- r
ation.128 In addition, 1% HF results in similar repair bond
strengths compared to 10% HF for both a nanofilled and a
hybrid composite resin,83 which is desirable because of the
increased toxicity of higher concentrations of HF. When clin-
icians are not aware of the composite resin used for the
original restoration, we recommend using intra-oral sand-
The Journal of Adhesive Dentistry
 Araujo/Perdigao

a b1 b2

Fig 10 Porcelain veneer on a discolored

tooth that had been traumatized in an
accident but no endodontic treatment was
required. Although dentin was exposed,
cervical margins were still located in enamel;
a. pre-operative view; b. preparation of
tooth 21 (9) with enamel still visible on the
labial surface; c. RelyX Veneer (3M Oral
Care) shade A1 try-in paste. Figure c2 de- c1 c2
picts the same view under polarized light;
d. RelyX Veneer (3M Oral Care) shade B0.5
try-in paste. Figure d2 depicts the same
view under polarized light; e. after
cementation with dental adhesive and
RelyX Veneer (3M Oral Care) shade B0.5
light-cured composite cement. Special
thanks to Dr. Dr. Luis Garbelotto, Dr. Claudia
Volpato, and dental technician Carlos
Maranguello. d1 d2

blasting with aluminum oxide particles to create microreten-
tion on the surface of the existing restoration, followed by a
dentin adhesive and a direct composite restoration.
With regard to glass-CER restorations, a potential fracture
usually involves a treatment that is more time-consuming
compared to a fracture in a composite restoration (Fig 11).
Repairing a glass CER restoration intra-orally may pose a
risk to the operator and the patient, as HF gel or an acidic
self-etch ceramic primer must be used to create micropo-
rosities on the existing glass-CER.58,72 The use of sand-
blasting with aluminum oxide particles to repair glass-CER
restorations results in significantly lower bond strengths
than etching with HF.136 Furthermore, sandblasting followed
by HF results in similar bond strengths compared to HF
alone.33,136 The bond strengths to lithium-disilicate glass-
CER are stable after thermal fatigue when the substrate is
etched with HF.151 Conversely, bond strengths decrease sig- g
nificantly with thermal fatigue when the glass-CER is sand-
blasted with aluminum oxide particles or with silica-coated
aluminum oxide particles.151 Replacements usually occur
due to fracture.169 Adhesive failure, recurrent caries lesions
around the margins, and clinical signs of marginal leakage
are also issues that dentists are aware of. In some clinical
situations small cracks develop in the ceramics a few days
after the luting procedure, which may be caused by internal
stresses at the adhesive interface.89 An infiltration tech-
nique of the crack with a filled adhesive has been shown to
be a potential treatment to mask the defect.127
GLOSS AND COLOR STABILITY
It is well established that composite resin restorations
become rougher with time after erosive and abrasive chal-
lenges in the oral environment.94 However, roughness and
gloss are not correlated.20 Toothbrushing increases sur-

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a b
c d
face roughness and decreases gloss for most composite
resins.49,110,138
Gloss is an important property for the aesthetic appear-
ance of restorations over time, especially in the anterior
sector. Gloss depends on the type of composite and the
polishing system used.35,175 Unlike most composite restor-
ations the gloss of glass-CER restorations remains stable
over the years. Compared to composite resin, the surface
of glass-CER materials undergoes little or no deterioration
over time after simulated toothbrushing and different loads
applied.94
Although it has been reported that nanofilled composites
have lower roughness values in vitro than other compos-
ites,131,138 a systematic review of in vitro studies deter-
mined that there is no evidence to support the choice for
nanofilled or submicron composites over traditional micro-
hybrid composites solely based on roughness.108
When there is a decrease in the gloss characteristics of
a composite resin restoration, it may be necessary to pro-
ceed with periodic maintenance for the restoration to con-
tinue reflecting light similar to dental enamel (Fig 12). The
time interval or periodicity for re-polishing depends on sev-
eral factors, such as type of composite resin (size and
shape of filler particles), patient’s habits, abrasiveness of
toothpaste, etc. An important factor to consider regarding
the loss of gloss in composite resin restorations is the
presence of saliva, since the loss of gloss is observed only
after air drying the surface of the restoration. Thus, it is dif-
ficult to notice the loss of gloss that occurs in the compos-
ites over time when saliva is in contact with the restoration.
Chromatic stability is also an important feature in aes-
thetic restorative procedures. In general, glass-CER have
excellent esthetics3,88 and do not change color over time.15
In some cases, especially only one tooth is veneered, the
104
Fig 11
toration. a. Pre-operative view of glass-CER
chipping on tooth 21 (9) involving the inci-
sal edge, mesial incisal angle and mesial
marginal ridge; b. after rubber-dam isola-
tion and sealing of cervical areas with Opal-
Dam light-curing resin (Ultradent; South
Jordan, UT, USA), the chipped surfaces
were etched with 9.6% HF for 60 s, rinsed
off with water for 2 min, and thoroughly air
dried. This image shows the application of
a silane coupling agent, which was left for
60 s and air dried; c. dentin adhesive was
applied to the chipped surfaces, gently air
dried for 10 s and light cured for 40 s.
A hybrid composite resin was inserted, light
cured and polished; d. final aspect of the
repaired glass-CER restoration.
color stability may be a disadvantage, as natural teeth will
undergo physiological discoloration while the color of the
r veneered tooth will remain more stable over time resulting
in a lighter restoration. However, we must keep in mind that
a composite composite cement is used as a luting agent for
r the veneer. The discoloration of the composite cement is a
major issue that may render the veneer less esthetic.135
As the color stability is also related to the maintenance
of gloss, composite resins, in turn, may change in color over
the years, as the loss of surface gloss and/or roughness
favors the impregnation of pigments into the surface of the
restoration. Again, periodic maintenance is important to re-
move surface staining and restore shine to the restoration.
r
DISCUSSION
The patients’ desire for extra white and perfectly aligned
teeth has been fueled by the new standard for attractive
smiles heavily disseminated through social media and non-
peer reviewed journals. In some regions of the world ultra-
thin porcelain veneers are generically known as contact
lenses and have become the only type of porcelain veneer
prescribed by dental professionals. Nonetheless, the term
“contact lens” veneer has been inaccurately associated
with ultra-thin veneers.146,148,189 The original terminology
for “contact lens” veneer related to the concept of camou-
f flaging the thin porcelain margin with the underlying tooth
structure,80,137 making the junction almost invisible.
Patients’ concerns regarding the appearance of their res-
torations are definitely a reason for intervention. However,
unwarranted removal and replacement of restorations with-
out signs of irreversible failure may be considered overtreat-
ment. This is especially problematic if the dentist decides
The Journal of Adhesive Dentistry

Fig 12
composite veneers on lateral incisors.
Periodic repolishing of direct composite
veneers improves shade and gloss.
a. Composite restoration of tooth 12 (7)
before (left) and after (right) periodic main-
tenance; b. composite restoration of tooth
22 (10) before (left) and after (right) peri-
odic maintenance.
a b
c d
that the restoration might look more esthetic if replaced,
without any clinical or radiographic signs of restoration fail-
ure. With every replacement, additional tooth structure
needs to be sacrificed to reshape the preparation, or to re-
move residual restorative materials that are not easily dis-
tinguished from enamel or dentin.29
In addition, the widespread concept of “instant orthodon-
tics”,96 which often includes aggressive preparation of mal-
positioned anterior teeth, has been advocated as an alterna-
tive esthetic treatment in patients for whom orthodontic
treatment is undoubtedly indicated. Aligning misaligned
healthy teeth with veneers has never been a minimally-inva-
sive procedure.106 Patients must be given the opportunity to
make informed decisions. The duty of nonmaleficence re-
quires obtaining proper informed consent after fully disclosing
longevity, risks and benefits, advantages and disadvantages
of the treatment without any type of financially-induced bias.
Our profession may be still behind when it comes to the
application of the MID philosophy to the use of anterior ve-
neers.47 As with other MID concepts, the minimally-invasive
glass-CER veneer has been misunderstood over the
years,62,71,104,124,126 as it has been sometimes used to il-
lustrate heavy reduction of tooth structure. In addition, full-
coverage restorations in anterior teeth have increased del-
eterious effects on the periodontal health and are more
susceptible to secondary caries lesions than glass-CER ve-
neers.164 According to the MID philosophy,63 direct com-
posite veneers are more likely to preserve the original tis-
sue. Glass-CER veneers may be a better choice for clinical
cases that involve removal of existing restorations and/or
cases that require incisal overlap with finish line into the
palatal/lingual surface. The issue of potential overtreat-
ment with new technologies deserves serious reflection.125
There are certainly many clinical cases in which procedures
Vol 23, No 2, 2021
Araujo/Perdigao
described above would be more conservative if a direct
composite resin was used. For example, as conservative as
they may apparently seem, the current concept of ‘contact
lens’ veneers is still an invasive treatment, because these
veneers need some kind of tooth preparation in the vast
majority of cases.68 In addition, every clinician is expected
to have the multidisciplinary knowledge to provide (or refer)
other more conservative options, such as orthodontics or
direct composite restorations, before deciding to perform
invasive restorative treatment. Orthodontics and direct com-
posite restorations may provide more esthetic and natural
results, besides their less invasive nature.
In spite of the novelty of recent CAD/CAM hybrid mater- r
ials, the ideal materials for direct and indirect anterior ve-
neers are still composite resin and glass-CER. One of the
best attributes of hybrid composite resins is that they have
a long track record of over 30 years. Furthermore, they have
excellent physical and optical properties that mimic tooth
structure. Nanofilled composite resins have very good phys-
ical properties, and are very easy to manipulate due to its
viscosity that leads to excellent sculptability. In addition,
they can be polished to a very glossy surface. The newest
family of universal composite resins was introduced very
recently, therefore clinical studies are scarce. In spite of
their recent introduction, some of them are based on mater- r
ials that have been in use for at least 18 years, which sug-
gests that their clinical behavior may not be very different
from their older counterparts. Durability of the color match
is still unknown because most universal composite resins
come in shades that are recommended to be used to
match multiple tooth shades without different translucen-
cies for the same shade. The stratification technique of
composite resins of different translucency to restore large
anterior tooth preparations may become obsolete soon, al-
105
Araujo/Perdigao
lowing all dentists to restore esthetically demanding clinical
cases using universal composite resins. It is apparent that
universal composite resins have simplified the clinical pro-
cedure for anterior esthetic restorations.
Some techniques and concepts introduced within the last
few years, allegedly less invasive, have been advertised in
dental meeting lectures and non-peer reviewed publica-
tions.47,96 However, many clinical techniques and concepts
introduced in the last few years in esthetic/adhesive den-
tistry are not based on sound clinical evidence.4,37,50,81,87,
168,186,199,200 Among these, we would highlight the percep-
tion that ceramic inlays result in better clinical outcomes
than indirect composite inlays;81 bulk-fill composite resin res-
torations are clinically better than incremental composite
restorations;200 self-etch adhesives cause less post-operative
sensitivity than etch-and rinse adhesives;168 glutaraldehyde-
based desensitizers are effective underneath restorations;37
MMP-inhibitors prolong the longevity of restorations,87 and so
forth.
When deciding which materials and techniques to use in
their patients, it is fundamentally important that dental pro-
fessionals recognize the difference between state-of-the art
and standard of care.70
CONCLUSION
The ultimate goals of any restorative treatment are to save
tooth structure, restore function and esthetics, prevent recur-
r ial, shade, and thickness on translucency. J Prosthet Dent 2014;112:
rent caries lesions and bacterial leakage into the pulp space,
promoting the well-being of our patients. The use of different
materials and techniques for anterior veneer restorations
must be based on sound evidence rather than on the market- t specular gloss and surface roughness of esthetic resin composites be-
ing hype or testimonials. In spite of the exponential increase
in the number of new dental materials for esthetic clinical
procedures in the last few years, composite resin materials
are still an excellent conservative option providing that pa-
tients are informed of the advantages and disadvantages.
ACKNOWLEDGMENTS
The authors do not have any financial interest in the companies
whose materials are included in this article.
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Clinical relevance: While composite resin and glass-
matrix ceramic materials are still an excellent choice
for anterior veneer restorations, direct composite
resin restorations are the most conservative option if
indicated for a specific clinical situation, provided that
the patients are informed of the advantages and dis-
advantages to enable them to make informed decisions.
The Journal of Adhesive Dentistry