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Main Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic

Laminate Veneers: A Systematic Review and Meta-Analysis of Survival and
Complication Rates

Article in The International Journal of Prosthodontics · January 2016

DOI: 10.11607/ijp4315

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 Main Clinical Outcomes of Feldspathic Porcelain and
Glass-Ceramic Laminate Veneers: A Systematic Review
and Meta-Analysis of Survival and Complication Rates
Susana Morimoto, DDS, MSD, PhD1/Rafael Borges Albanesi, DDS, MSD2/Newton Sesma, DDS, MSD, PhD3/
Carlos Martins Agra, DDS, MSD, PhD1/Mariana Minatel Braga, DDS, MSD, PhD4

Purpose: The aim of this study was to perform a systematic review and meta-analysis based
on clinical trials that evaluated the main outcomes of glass-ceramic and feldspathic porcelain
laminate veneers. Materials and Methods: A systematic search was carried out in Cochrane
and PubMed databases. From the selected studies, the survival rates for porcelain and glass-
ceramic veneers were extracted, as were complication rates of clinical outcomes: debonding,
fracture/chipping, secondary caries, endodontic problems, severe marginal discoloration, and
influence of incisal coverage and enamel/dentin preparation. The Cochran Q test and the I2
statistic were used to evaluate heterogeneity. Results: Out of the 899 articles initially identified,
13 were included for analysis. Metaregression analysis showed that the types of ceramics and
follow-up periods had no influence on failure rate. The estimated overall cumulative survival rate
was 89% (95% CI: 84% to 94%) in a median follow-up period of 9 years. The estimated survival
for glass-ceramic was 94% (95% CI: 87% to 100%), and for feldspathic porcelain veneers, 87%
(95% CI: 82% to 93%). The meta-analysis showed rates for the following events: debonding:
2% (95% CI: 1% to 4%); fracture/chipping: 4% (95% CI: 3% to 6%); secondary caries: 1% (95%
CI: 0% to 3%); severe marginal discoloration: 2% (95% CI: 1% to 10%); endodontic problems:
2% (95% CI: 1% to 3%); and incisal coverage odds ratio: 1.25 (95% CI: 0.33 to 4.73). It was not
possible to perform meta-analysis of the influence of enamel/dentin preparation on failure rates.
Conclusion: Glass-ceramic and porcelain laminate veneers have high survival rates. Fracture/
chipping was the most frequent complication, providing evidence that ceramic veneers are a safe
treatment option that preserve tooth structure. Int J Prosthodont 2016;38–49. doi: 10.11607/ijp4315

Interest in dental ceramics has been increasing,

driven by the demand for esthetic restorations and
the recent development of technologies and tech-
niques for their use in esthetic dentistry. The physical
properties of ceramics and bonding systems used for
laminate veneers have vastly improved, and this has
greatly increased the success rate of this treatment.
Nevertheless, some ceramic laminate veneer failures
continued to occur, leading to questioning of the
1Professor of Graduate Program, School of Dentistry, Ibirapuera University,
São Paulo, Brazil.
2Professor, Department of Dentistry, School of Dentistry,
University Santa Cecília, Santos, Brazil.
3Professor, Department of Prosthodontics, School of Dentistry,
University of São Paulo, São Paulo, Brazil.
4Professor, Department of Orthodontics and Pediatric Dentistry,
School of Dentistry, University of São Paulo, São Paulo, Brazil.
Correspondence to: Dr Newton Sesma, Prof. Lineu Prestes
avenue 2227, 05508-000 São Paulo, Brazil. Fax: 55-11-30917888.
Email: sesma@usp.br
©2016 by Quintessence Publishing Co Inc.
longevity of veneers. In view of the trend toward more
conservative preparations and the high dependence
on bonding procedures, primary studies have been
conducted to elucidate these questions.1–20
Dental ceramics have peculiarities with regard to
structure, properties, and manufacturing processes
that consequently affect their clinical indications.
Porcelains and glass-ceramics present a combination
of vitreous and crystalline phases and are frequent-
ly indicated for fabricating veneers because they
can be etched and they provide excellent esthetics.
Feldspathic porcelains, the first type of ceramic to be
used for dentistry, are available in powder (stratifica-
tion) or block (computer-aided design/computer-as-
sisted manufacture [CAD/CAM]) form. Glass ceramics
(fluorapatite, leucite or lithium-disilicate), commer-
cially available in the form of ingots (heat-pressed),
powder, or blocks, are also an excellent choice due to
their higher mechanical strength in comparison with
porcelains.13,21
For laminate veneers, there are two key principles
with the same degree of importance: esthetics and
bonding. The tooth-ceramic set becomes very strong

38 The International Journal of Prosthodontics

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after adhesive cementation because bonding rein-
forces the ceramic and restores the strength of the
tooth.8,11–13,20–25 Therefore, the differences in clinical
performance between porcelains and glass-ceramics
require elucidation.
Laboratory studies have sought results capable
of predicting complications and success of veneers,
important factors for isolating and detailing interfer-
ence at each step or with each material.22–25 However,
certain intraoral conditions cannot be reproduced in a
laboratory, as several clinical factors may interfere in
the success of restorations. The success of a clinical
procedure relies on indication, planning, clinical and
laboratory steps, and patients’ habits.8–13 With system-
atic reviews26–30 based on clinical follow-up studies, it
is possible to verify trends or associate them with an
event, material, or procedure that may be a factor in
ceramic laminate veneer failures.
Some of the problems that occur during the first year
are generally related to adhesive cementation failure,
which appears to occur most frequently in the first 6
months, after which the number of failures declines or
stabilizes at a low rate.3 Systematic reviews have ad-
dressed follow-up periods of up to 2 years,26–29 which
has contributed to the analysis of resin and ceramic
veneers26,30 as well as the success and complication/
failure rates of different ceramics.27–29 Information is
lacking on the clinical behavior of feldspathic porce-
lain and glass-ceramic veneers, and it is necessary to
conduct an extensive and detailed systematic review
of these different types of ceramics and their failures
and times of occurrence, which could generate inte-
grated scientific evidence.
The aim of this systematic review was to evaluate
the survival and complication rates of ceramic lami-
nate veneers.
Materials and Methods
Eligibility Criteria and Search Strategy
An electronic database search was performed in
advanced mode of the MEDLINE (PubMed) and
Cochrane databases up to April 6, 2014, and studies
related to ceramic laminate veneers from 1977 to 2014
were obtained. There were no limitations on language.
One study5 was translated from Chinese and included
in the analysis.
This review was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews
and Meta-Analysis (PRISMA) guidelines.31 To iden-
tify studies for this review, the population, interven-
tion, comparison, outcome, and study design (PICOS)
question was used to guide construction of the search
strategy: P = patients who received laminate veneers;
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Morimoto et al
I = ceramic veneers; C = (not applicable in the pres-
ent study); O = survival rate; S = randomized con-
trolled trials (RCTs) and cohort studies.
The final search strategy for the MEDLINE data-
base was: ((((ceramic*) OR porcelain*)) AND (((((fail-
ure) OR survival) OR success) OR clinical evaluation)
OR follow up)) AND ((veneer*) OR laminate*). For
Cochrane database, it was: ((laminate or veneer) and
(ceramic or porcelain) and (dental or tooth or teeth)
and (clinical and trial or clinical)).
Study Selection
Studies were selected by screening titles and ab-
stracts according to the following inclusion criteria:
(1) studies about ceramic laminate veneer and (2) hu-
man cohort studies (prospective and retrospective)
and RCTs. Articles with no abstract were included for
evaluation of their full texts.
Eligibility was based on full text assessment of the
studies included after screening; therefore, some ex-
clusion criteria were predetermined: (1) cavity prepa-
rations and/or clinical procedures without adequate
descriptions or with unusual descriptions (partial
veneer/fragments/unusual bonding procedures); (2)
case reports; (3) literature or systematic reviews,
protocols, interviews, or in vitro studies; (4) isolated
groups (tetracycline/bruxism); (5) not ceramic ve-
neer; (6) studies using the same sample6,13,15,18 (only
the most recent study was considered); (7) studies
without information on survival/success rate of ve-
neers and for which the rate was impossible to calcu-
late; and (8) studies with a dropout rate higher than
30%.
Data Collection Process
The literature review was conducted by two examiners
independently (RBA, SM). Interexaminer reproducibil-
ity was 0.8 (kappa), and a new calibration was per-
formed to resolve disagreements. Discrepancies and
doubts were settled by discussion and data checking.
When these were not resolved by consensus, a third
examiner (MMB) was consulted.
Qualitative Analysis
Quality assessment as described by Hayashi et al was
used (Table 1, items 1 to 24) in addition to another two
criteria (items 25 and 26) to evaluate the articles se-
lected.32 Studies with a positive response to each item
were marked with an X. At the end of the assessment,
a % value regarding quality items was calculated for
every study. Two calibrated reviewers carried out the
quality assessment.
Volume 29, Number 1, 2016 39
Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers
Table 1   Quality Assessment of Included Articles
1 Is the hypothesis/aim/objective of the study clearly
described?
2 Is the setting of the study or the source of the
subjects described?
3 Is the distribution of the study population by age or
gender described?
4 Are the inclusion criteria stated?
5 Are the exclusion criteria stated?
6 Are the treatments well described?
7 Are the main outcomes to be measured clearly described in
the introduction or methods section?
8 Is the sample size stated?
9 Was the sample size justified?
10 Was the concurrent control group used?
11 Was random allocation to treatment used?
12 Was the method of random allocation given?
13 Was blind assessment of the outcome carried out?
14 Was there more than one examiner for
outcome assessment?
15 Was examiner calibration carried out?
16 Are the statistical methods described?
17 Is the participation/follow-up rate stated?
18 Was the participation/follow-up rate greater than 80%?
19 Are nonparticipants/subjects lost to follow-up described?
20 Are the main findings of the study clearly described?
21 Are results stated in absolute numbers when feasible
(eg, 10/20, not 50%)?
22 Are confidence intervals given?
23 Are any important adverse events reported?
24 Are any conclusions stated?
25 Was this a prospective study?
26 Was ethical approval obtained?
Measures and Statistical Analysis
Descriptive and meta-analyses were performed using
random effects models based on survival rate data
obtained in the longest time of follow-up and the type
of ceramic used for the veneer. With regard to hetero-
geneity between studies, results of the Cochran Q test
(P < .001 was considered indicative of statistically sig-
nificant heterogeneity) and the I2 statistic were con-
sidered representative of the level of heterogeneity
(I2 > 50%).33 Summary estimates and 95% confidence
interval (CI) boundaries were assessed. The entire
meta-analysis was undertaken using R version 3.6-0
software (R Foundation for Statistical Computing).
Metaregression was performed on the time and
type of ceramic thresholds with the intention of clari-
fying sources of heterogeneity in the studies included
40 The International Journal of Prosthodontics
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and to determine whether the failures and complica-
tions occurred more often due to time of follow-up and
type of ceramic (P < .001). Subgroup analyses were
performed separating feldspathic porcelain and glass-
ceramic, and including studies that evaluated the sur-
vival rate for each material. This estimated survival
rate (Kaplan-Meier) and variance values were used for
meta-analysis. If the article did not present the vari-
ance (or standard error), it was calculated by analyzing
the number of failures and accounting for censorship
during the follow-up time. These data were searched
in the text or a count was taken on a Kaplan-Meier
graph. The Greenwood formula was used to calcu-
late the variance assuming that censorship occurred
uniformly over time, together with failures. The event
rate of clinical outcomes was also estimated: debond-
ing, fracture/chipping, secondary caries, endodontic
problems, severe marginal discoloration, influence of
incisal coverage, and enamel/dentin preparation. For
the severe marginal discoloration assessment, the
authors used different evaluation criteria (modified
UPSHS,5,8,9,11,12 CDA/ Ryge,2 and other proposed crite-
ria.10,17,18) In these cases, the worst criterion was cho-
sen for use in the present study.
Results
Study Selection
The search identified 899 articles. After evaluation
of titles and abstracts (inclusion phase), 167 studies
were considered for full-text review in the exclusion
stage. After exclusion, 13 full articles were kept for
quantitative and qualitative analysis. Fig 1 shows the
search results and all reasons for exclusions.
Quality of the Studies Included
The aim of the quality assessment of this study was
not to rank the studies included but to investigate
their methodologic quality level for statistical analysis
later. The percentage range of the studies included in
the quality assessment ranged from 42.3% to 92.3%
(Table 2).
Study Characteristics
Authors, year of publication, ceramic material, lan-
guage, period of inclusion, evaluation criteria, fol-
low-up period, country, setting/operators, sample
of patients/veneers, age, dropout rate, category of
evidence, outcomes (failure/survival rate, debond-
ing, fracture/chipping, severe discoloration, endodon-
tic problems, secondary caries, influence of incisal
coverage and enamel/dentin preparation), and type
 Morimoto et al

Table 2   Results of the Quality Assessment of the 13 Studies Included

Item assessed (according to Table 1)
Author 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 %*
Rinke et al19 X X X X X X X X X X X X X X X X X 65.4
Gurel et al14 X X X X X X X X X X X X X X X X X X 69.2
Layton and Walton16 X X X X X X X X X X X X X X X X X X X 73.1
Gresnigt et al11 X X X X X X X X X X X X X X X X X X X X X X 84.6
Beier et al2 X X X X X X X X X X X 42.3
Granell-Ruiz et al10 X X X X X X X X X X X X 46.1
Du et al5 X X X X X X X X X X X X X X 53.8
Cötert et al4 X X X X X X X X X X X X X X X X X X 69.2
Fradeani et al8 X X X X X X X X X X X X X X X 57.7
Smales and Etemadi20 X X X X X X X X X X X X X X X X X 65.4
Peumans et al17 X X X X X X X X X X X X X X X X X 65.4
Dumfahrt and Schäffer7 X X X X X X X X X X X X X X X X 61.5
Gresnigt et al12 X X X X X X X X X X X X X X X X X X X X X X X X 92.3
X = Yes
*% of questions answered yes.

of statistical analysis were evaluated to perform the

899 studies identified through
meta-analysis. Detailed information about the study database searching
design of the studies included is presented in Table 3.
Identification

PubMed (n = 878)
When necessary, data were extracted from a previous Cochrane (n = 21)
study by the same author.6,13,15,18
882 studies after 715 records excluded:
Survival Rate Analysis duplicates removed • 628 not ceramic veneer
PubMed (n = 877) • 29 review literature,
Thirteen studies were retained for the quantitative Cochrane (n = 5) protocols, guideline, or
analysis. Six of these studies,7,11,16,17,20 were conducted interview
Screening

with veneers fabricated only with feldspathic porce- • 58 in vitro

lain, and four,10,12,19 with glass-ceramic veneers. Three Kappa 0.8
studies2,8,14 had feldspathic porcelain and glass-ce- 154 records excluded:
ramic in their samples. • 19 unusual or inadequate
For metaregression, there was no association be- 167 full-text articles
clinical procedure or
tween survival rate and follow-up period (P = .11) or cavity preparations
assessed for
• 54 case report
Eligibility

type of ceramic (P = .29); therefore, subgroup meta- eligibility

• 39 review (literature or
analysis was possible. systematic), protocols,
At the survival rate threshold, the heterogeneity (I2) interview or in vitro study
presented for the 12 studies included (porcelain and • 2 isolated groups
• 2 studies containing same
glass-ceramic) showed a level of I2 = 95.7% (95% CI: sampling (study was the
84% to 94%) (P < .0001) (Fig 2). The heterogeneity 13 studies included most recent used)
for the subgroups porcelain and glass-ceramic was
Included

in qualitative and • 36 studies without survival

I2 = 79.2% (95% CI: 82% to 93%) (P = .0034) and I2 = quantitative rate of veneers or pos-
synthesis sibility of calculating it
94.9% (95% CI: 87% to 100%) (P < .0001), respectively (meta-analysis) • 2 dropout higher than 30%
(Figs 3 and 4).
The studies of Beier et al2 and Dumfahrt and
Fig 1   Flow diagram for selection of articles.
Schäffer7 contained the same type of porcelain sam-
ple; nevertheless, in the most recent study samples
of glass-ceramic veneers were added. Therefore, for
the total sample (Fig 2) the longest period of follow- Some authors, such as Granell-Ruiz et al10 and
up2 was considered, and for the subgroup analysis Smales and Etemadi,20 presented data separately for
of porcelains (Fig 3) Dumfahrt and Schäffer7 was veneers with and without incisal coverage, represent-
considered. ed in Figs 2 and 3 by letters a and b, respectively.

Volume 29, Number 1, 2016 41

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Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers

Table 3   Study Characteristics of 13 Studies Included

Author Year Material Language Country Inclusion period Evaluation criteria
Gürel et al14 2013 Feldspathic/glass-ceramic English Turkey 1997–2009 Proposal by author
Beier et al*2 2012 Feldspathic/glass-ceramic English Austria 1987–2009 CDA/Ryge
Fradeani et al8 2005 Feldspathic/glass-ceramic English Italy 1991–2002 Modified CDA/Ryge
Layton and Walton16 2012 Feldspathic porcelain English Australia 1990–2010 NS
Gresnigt et al11 2012 Feldspathic porcelain English NS 2007–2010 Modified USPHS
Du et al5 2009 Feldspathic porcelain Chinese China 1999–2007 Modified USPHS
Peumans et al17 2004 Feldspathic porcelain English Belgium 1990–1991 Proposal by author
Smales and Etemadi20 2004 Feldspathic porcelain English Australia 1989–1993 NS
Dumfahrt and Schäffer*7 2000 Feldspathic porcelain English Austria NS Modified CDA/Ryge

Gresnigt et al12 2013 Glass-ceramic English Netherlands 2008–2010 Modified USPHS

Rinke et al19 2013 Glass-ceramic English Germany 2002–2008 Modified USPHS
Granell-Ruiz et al10 2010 Glass-ceramic English Spain 1995–2003 NS

Cötert et al4 2009 Glass-ceramic English Turkey 1999–2005 NS

NS = not specified; op = operator; RC = Retrospective cohort; PC = Prospective cohort; * = same sample; = average; †
‡ = with incisal coverage; § = without incisal coverage.

Study Survival rate SE 95% CI W (random)

Gürel et al14 0.86 0.0300 0.86 [0.80; 0.92] 7.3%
Beier et al2 0.83 0.0160 0.83 [0.80; 0.86] 7.9%
Fradeani et al8 0.94 0.0286 0.94 [0.89; 1.00] 7.4%
Layton and Walton16 0.91 0.0200 0.91 [0.87; 0.95] 7.8%
Gresnigt et al11 0.95 0.0300 0.95 [0.89; 1.00] 7.3%
Du et al5 0.76 0.0500 0.76 [0.67; 0.86] 6.1%
Peumans et al17 0.64 0.0660 0.64 [0.51; 0.77] 5.1%
Samales and Etemadi20(a) 0.96 0.0410 0.96 [0.88; 1.04] 6.6%
Samales and Etemadi20(b) 0.86 0.0490 0.86 [0.76; 0.95] 6.2%
Gresnigt et al12 1.00 0.0010 1.00 [1.00; 1.00] 8.2%
Rinke et al19 0.95 0.0357 0.95 [0.88; 1.02] 7.0%
Granell-Ruiz et al10(a) 0.85 0.0200 0.85 [0.81; 0.89] 7.8%
Granell-Ruiz et al10(b) 0.94 0.0200 0.94 [0.90; 0.98] 7.8%
Cötert et al4 0.94 0.0200 0.94 [0.90; 0.98] 7.8%

Random effects model 0.89 [0.84; 0.94] 100%

Heterogeneity: I2 = 95.7%, tau2 = 0.0073, P < .0001
0 0.2 0.4 0.6 0.8 1.0

Fig 2   Forest plot of estimated overall cumulative survival rate for 12 included studies (porcelain + glass ceramic).
The random effects pooled is 89% (I2 = 95.7% [95% CI: 84% to 94%]) (P < .0001).
aWith incisal coverage.
bWithout incisal coverage.

The estimated overall cumulative survival rate for the
entire sample (porcelain + glass-ceramic: n = 2,848
veneers) of the studies included2,4,5,8,10,11,12,14,16,17,19,20
was 89% (95% CI: 84% to 94%). The median of the
maximum follow-up times of the studies included was
9 years (range: 1.4 to 20 years) (Fig 2).
In the porcelain group5,7,11,16,17,20 (n = 1,283 ve-
neers), the cumulative survival rate was 87% (95%CI:
82% to 93%). The median of the maximum follow-up
times of the studies included was 8 years (range: 1.7
to 20 years) (Fig 3). In the glass-ceramic group4,10,12,19
(n = 676 veneers), the cumulative survival rate was
94% (95% CI: 87% to 100%). The median of the maxi-
mum follow-up times of the studies included was 7
years (range: 1.4 to 11 years) (Fig 4).

42 The International Journal of Prosthodontics

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 Morimoto et al

Follow-up period Setting/operator (no) Age range (y) No. of patients Dropout (%) Study type No. of veneers Survival (%)
NS–12 y Private/1 23–73 66 0 RC 580 86
5,10,15 and 20 y University/2 44.4† 84 0 RC 318 82.9
NS–12 y Private/2 19–66 46 0 RC 182 94.4
1–21 y Private/1 15–73 155 19.35 PC 499 91
7 y–40 mo NS 19–70 20 0 PC 92 94.6
1–8 y University/NS 19–56 49 1.3 RC 310 76.3
5 and 10 y Private/1 19–69 25/22 12 PC 87/81 64
5–7 y Private/2 16– ≥ 51 50 0 RC 110 86
14–127 mo University/2 13–63 72/65 9.7 RC 205/191 95.8‡
85.5§
36 mo University/Private/NS 20–69 10 0 PC 23 100
6.2–84.7 mo Private/1 23–70 41/37 9.7 RC 130 95.1
3–11 y University/NS 18–74 70 0 RC 323 84.7‡
94§
12–72 wk University/NS 16–50 40 0 RC 200 93.8

Study Survival rate SE 95% CI W (random)

Layton and Walton15 0.91 0.020 0.91 [0.87; 0.95] 18.3%
Gresnigt et al11 0.95 0.030 0.95 [0.89; 1.00] 16.2%
Du et al5 0.76 0.050 0.76 [0.67; 0.86] 11.8%
Peumans et al17 0.64 0.066 0.64 [0.51; 0.77] 8.9%
Smales and Etemadi20(a) 0.96 0.041 0.96 [0.88; 1.04] 13.7%
Smales and Etemadi20(b) 0.86 0.049 0.86 [0.76; 0.95] 12.0%
Dumfahrt and Schäffer7 0.91 0.015 0.91 [0.88; 0.94] 19.2%

Random effects model 0.87 [0.82; 0.93] 100%

Heterogeneity: I2 = 79.2%, tau2 = 0.0034, P < .0001
0 0.2 0.4 0.6 0.8 1.0

Fig 3   Forest plot of estimated cumulative overall survival rate for a subgroup of 6 included studies (feldspathic porcelain).
The random effects pooled is 87% (I2 = 79.2% [95% CI: 82% to 93%]) (P < .0001).
aWith incisal coverage.
bWithout incisal coverage.

Study Survival rate SE 95% CI W (random)

Gresnigt et al12 1.00 0.0010 1.00 [1.00; 1.00] 22.0%
Rinke et al19 0.95 0.0357 0.95 [0.88; 1.02] 17.2%
Granell-Ruiz et al10(a) 0.85 0.0200 0.85 [0.81; 0.89] 20.3%
Granell-Ruiz et al10(b) 0.94 0.0200 0.94 [0.90; 0.98] 20.3%
Cötert et al4 0.94 0.0200 0.94 [0.90; 0.98] 20.3%

Random effects model 0.94 [0.87; 1.00] 100%

Heterogeneity: I2 = 79.2%, tau2 = 0.0034, P < .0001
0 0.2 0.4 0.6 0.8 1.0

Fig 4   Forest plot of estimated cumulative overall survival rate for a subgroup of 4 included studies (glass-ceramic). The random
effects pooled is 94% (I2 = 94.9% [95% CI: 82% to 93%]) (P < .0001).
aWith incisal coverage.
bWithout incisal coverage.

Volume 29, Number 1, 2016 43

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Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers

Study Events Total Proportion 95% CI W (random)

Gürel et al14 12 580 0.02 [0.01; 0.04] 11.6%
Beier et al2 3 318 0.01 [0.00; 0.03] 9.2%
Fradeani et al8 3 182 0.02 [0.00; 0.05] 9.2%
Layton and Walton16 1 499 0.00 [0.00; 0.01] 5.9%
Gresnigt et al11 1 92 0.01 [0.00; 0.06] 5.9%
Du et al5 4 310 0.01 [0.00; 0.03] 9.9%
Peumans et al17 0 81 0.00 [0.00; 0.04] 3.8%
Smales and Etemadi20 2 110 0.02 [0.00; 0.06] 8.0%
Gresnigt et al12 0 23 0.00 [0.00; 0.15] 3.8%
Rinke et al19 3 130 0.02 [0.00; 0.07] 9.1%
Granell-Ruiz et al10 29 323 0.09 [0.06; 0.13] 12.2%
Cötert et al4 11 200 0.06 [0.03; 0.10] 11.5%

Random effects model 2,848 0.02 [0.01; 0.04] 100%

Heterogeneity: I2 = 80.2%, tau2 = 0.8678, P < .0001
0 0.02 0.06 0.1 0.12

Fig 5   Forest plot of debonding outcomes for 12 included studies. The event rate was 2% (I2 = 80.2% [95% CI: 1% to 4%])
(P < .0001).

Study Events Total Proportion 95% CI W (random)

Gürel et al14 20 580 0.03 [0.02; 0.05] 11.7%
Beier et al2 16 318 0.05 [0.03; 0.08] 11.3%
Fradeani et al8 5 182 0.03 [0.01; 0.06] 8.2%
Layton and Walton16 4 499 0.01 [0.00; 0.02] 7.5%
Gresnigt et al11 4 92 0.04 [0.01; 0.11] 7.4%
Du et al5 19 310 0.06 [0.04; 0.09] 11.6%
Peumans et al17 11 81 0.14 [0.07; 0.23] 10.2%
Smales and Etemadi20 6 110 0.05 [0.02; 0.11] 8.7%
Gresnigt et al12 0 23 0.00 [0.00; 0.15] 1.8%
Rinke et al19 4 130 0.03 [0.01; 0.08] 7.5%
Granell-Ruiz et al10 13 323 0.04 [0.02; 0.07] 10.9%
Cötert et al4 1 200 0.00 [0.00; 0.03] 3.2%

Random effects model 2,848 0.04 [0.03; 0.06] 100%

Heterogeneity: I2 = 70.5%, tau2 = 0.309, P < .0001
0 0.05 0.10 0.15 0.20

Fig 6   Forest plot of subgroup fracture (dental and ceramic)/chipping outcome for 12 included studies. The event rate was 4%
(I2 = 70.5% [95% CI: 3% to 6%]) (P < .0001).

Subgroup Analysis outcomes in the meta-analysis, most often due to lack

The main clinical outcomes identified in this research
were: debonding, fracture/chipping, caries, endodon-
tic problems after cementation, severe marginal dis-
coloration, and the influence of incisal coverage and
enamel/dentin preparation. Not all the studies in-
cluded provided data and information about the main
outcomes found. Color match, marginal integrity, hy-
persensitivity, patient satisfaction, and other clinical
outcomes were identified in some of the studies in-
cluded; however, it was not possible to include these
of data and standardization of evaluation criteria.
The incidence of debonding for laminate veneers
was 2% (95% CI: 1% to 4%) and involved 12 stud-
ies2,4,5,8,10,11,12,14,16,17,19,20 with 69 total instances of
debonding among 2,848 veneers evaluated (Fig 5).
For fracture/chipping it was 4% (95% CI: 3% to 6%)
(n = 103 failures among 2,848 veneers evaluated) also
involving 12 studies2,4,5,8,10,11,12,14,16,17,19,20 (Fig 6), and
for secondary caries it was 1% (95% CI: 0% to 3%)
(29 cases of caries among 2,747 veneers) including
10 studies2,4,5,10,11,12,14,16,17,19 (Fig 7).

44 The International Journal of Prosthodontics

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 Morimoto et al

Study Events Total Proportion 95% CI W (random)

Gürel et al13 1 580 0.00 [0.00; 0.01] 9.3%
Beier et al2 1 318 0.00 [0.00; 0.02] 9.3%
Layton and Walton16 1 499 0.00 [0.00; 0.01] 9.3%
Gresnigt et al11 0 92 0.00 [0.00; 0.04] 6.6%
Du et al5 1 310 0.00 [0.00; 0.02] 9.3%
Peumans et al17 8 81 0.10 [0.04; 0.19] 14.3%
Gresnigt et al12 0 23 0.00 [0.00; 0.15] 6.5%
Rinke et al19 0 130 0.00 [0.00; 0.03] 6.6%
Granell-Ruiz et al10 10 323 0.03 [0.01; 0.06] 14.7%
Cötert et al4 7 200 0.04 [0.01; 0.07] 14.2%

Random effects model 2,556 0.01 [0.00; 0.03] 100%

Heterogeneity: I2 = 78.3%, tau2 = 1.448, P < .0001
0 0.05 0.1 0.15
Fig 7   Forest plot of subgroup with caries outcome (10 articles). The event rate was 1% (I2 = 78.3% [95% CI: 1% to 7%])
(P < .0001).

Study Events Total Proportion 95% CI W (random)

Beier et al2 0 298 0.00 [0.00; 0.01] 11.7%
Fradeani et al8 0 182 0.00 [0.00; 0.02] 11.7%
Gresnigt et al11 0 92 0.00 [0.00; 0.04] 11.7%
Du et al5 1 310 0.00 [0.00; 0.02] 14.7%
Peumans et al17 15 81 0.19 [0.11; 0.29] 19.1%
Gresnigt et al12 0 23 0.00 [0.00; 0.15] 11.6%
Granell-Ruiz et al10 127 323 0.39 [0.34; 0.45] 19.6%

Random effects model 1,309 0.02 [0.01; 0.10] 100%

Heterogeneity: I2 = 92.7%, tau2 = 2.922, P < .0001
0 0.1 0.2 0.3 0.4

Fig 8   Forest plot of subgroup with severe marginal discoloration outcome (7 articles). The event rate was 2% (I2 = 92.7%
[95% CI: 1% to 10%]) (P < .0001).

Study Events Total Proportion 95% CI W (random)

Gürel et al14 1 580 0.00 [0.00; 0.01] 8.0%
Beier et al2 8 298 0.03 [0.01; 0.05] 22.9%
Gresnigt et al11 0 92 0.00 [0.00; 0.04] 4.6%
Du et al5 1 310 0.00 [0.00; 0.02] 8.0%
Peumans et al17 3 81 0.04 [0.01; 0.10] 15.7%
Gresnigt et al12 0 23 0.00 [0.00; 0.15] 4.5%
Rinke et al19 2 130 0.02 [0.00; 0.05] 12.7%
Granell-Ruiz et al10 9 323 0.03 [0.01; 0.05] 23.6%

Random effects model 1,837 0.02 [0.01; 0.03] 100%

Heterogeneity: I2 = 47.2%, tau2 = 0.3443, P = .0663
0 0.02 0.06 0.1 0.12
Fig 9   Forest plot of subgroup with endodontic problems outcome (8 articles). The event rate was 3% (I2 = 47.2% [95% CI:
1% to 5%) (P < .0663).

The incidence of severe marginal discoloration was endodontic problems, including data from 8 stud-
2% (95% CI: 1% to 10%), including 7 studies2,5,8,10,11,12,17 ies2,5,10,11,12,14,17,19 (24 endodontic problems among
(143 failures among 1,309 veneers evaluated) (Fig 1,837 veneers) (Fig 9).
8). There was a 2% (95% CI: 1% to 3%) incidence of

Volume 29, Number 1, 2016 45

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Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers
Experimental Control
Study Events Total Events Total
Gürel et al13 24 261 18 319
Smales and Etemadi20 1 36 8 64
Granell-Ruiz et al10 11 199 2 124
Random effects model 496 507
Heterogeneity: I2 = 58.6%, tau2 = 0.673, P = .0893
Fig 10   Forest plot of subgroups without incisal coverage (control) compared with incisal coverage (experimental). The OR = 1.25 (95% CI: 0.33
to 4.73; I2 = 65.3%, P < .0562).
The incisal coverage odds ratio obtained in the
present study was 1.25 (95% CI: 0.33 to 4.73) including
data from 3 studies10,13,20 (36 failures in veneers with
incisal coverage out of 506 veneers, and 28 failures in
veneers without incisal coverage out of 507 veneers
evaluated) (Fig 10).
The influence of preparation depth (limited to
enamel or dentin) on failure rates could not be estab-
lished, since few articles4,7,14,19 compared this factor in
nonstandardized ways.
Discussion
Systematic reviews are essential to collate the results
reported in several studies, as they enable the best
clinical evidence to be pointed out to clinicians to sup-
port the decisions they make in their offices.31
With regard to other systematic reviews,26–29 a mini-
mum evaluation period was not an exclusion criterion
in this study. This was based on the clinical observa-
tion that some of the problems that occurred with ve-
neers during the first year were generally related to
adhesive cementation failure. These appeared to occur
most frequently in the first 6 months, and afterward
frequency declined or stabilized at low rates.3 In ad-
dition, the idea that there are often numerous survival
times within a clinical study led the present authors to
look for articles irrespective of the follow-up period.
However, the evaluation was based on the longest time
reported, since many articles did not report survival
and censorship in different time intervals, making it
impossible to evaluate survival in different times.
Another difference of the present study is that
it assessed data for two ceramic types (porcelain
and glass-ceramic). Although crystalline ceramics
(Procera, In Ceram, LAVA, etc), have been used for
laminate veneers, no longitudinal clinical study on
their use was found. Ceramics that contain a high
percentage of vitreous phase, such as the porcelain
and glass-ceramics, which can be acid etched and
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Odds ratio OR 95% CI W (random)
1.69 [0.90; 3.19] 49.2%
0.20 [0.02; 1.67] 20.8%
3.57 [0.78; 16.38] 30.0%
1.36 [0.40; 4.57] 100%
0.1 0.5 1 2 10
silanized, have the best bonding behavior.13,14,21,23 In
this systematic review, different ceramics, times, out-
comes, and failures were addressed extensively and in
detail. Thus, it generated scientific evidence and con-
tributed to a broad clinical perspective on the subject.
The quality assessment32 may serve as a good
delimitation or guide for the design of future clinical
studies, and presents important points and concepts
necessary for a valid study. The quality assessment of
the present study did not aim to rank the studies in-
cluded; the only intention was to investigate the level
of quality for later data interpretation and better un-
derstanding of these studies. Furthermore, the wide
range in percentage of the quality assessment, 42.3%
to 92.3%, suggests some source of heterogeneity
among the studies included (Table 2), and analysis
of the design of studies (Table 3) may help in under-
standing the differences among these studies.
The heterogeneity was investigated by means of
the Cochran Q test. In all cases with the exception of
endodontic problems (I2 = 47.2%) the I2 was higher
than 50%, showing the heterogeneity of the sample.
Nevertheless, a random effects model was also pre-
ferred for this outcome analysis due to the proxim-
ity of the I2 percentage to 50%. In fact, a high level
of heterogeneity was expected since all the articles
presented wide clinical and methodologic variations.
To assess possible sources of this heterogeneity, we
conducted visual inspection of the forest plot, metare-
gression, and subgroup analysis of the studies based
on thresholds of the follow-up periods and types of
ceramic.
Since metaregression discarded the hypothesis of
time and type of ceramic causing the heterogeneity,
subgroup analysis was also performed with distinct
feldspathic porcelain and the glass-ceramic veneer
groups. The random effects models were performed
in all analyses. This model assumes that different
studies are estimated differently, placing value on the
contribution of small studies and increasing the CI.33

On visual inspection of the forest plot of all studies
included (Fig 2), two articles5,17 seemed more indica-
tive of the high level of heterogeneity. According to
these studies, failures appeared to be related to the
inclusion and exclusion criteria and to the definitions
of survival and success, and this could have a direct
influence on heterogeneity. Layton16 reported a lack
of standardization of these criteria. Contributory fac-
tors for Du et al5 may have included number of opera-
tors and their level of graduation not being specified
by the university; more comprehensive inclusion cri-
teria; focus on the influence of systemic problems on
local dental issues, such as dental structural damage
(hypoplasia, severe tetracycline staining, occlusion
bruxism, anterior crossbite); and poor oral hygiene.
Peumans et al17 seem to have been strict about con-
sidering small bulk fractures clinically unacceptable
but reparable, which might have increased the fail-
ure rate. Other factors mentioned as possible expla-
nations for the high failure rate were the bond to a
dentin surface, presence of large composite filings
(composite fillings present in 70% of the porcelain ve-
neer sample), bonding to endodontically treated teeth,
and heavy mechanical loading during occlusion and
articulation.
The lack of standardization with regard to the
concepts makes it difficult to reach a better under-
standing of the outcome results. Differences among
authors about which occurrences were considered
failures may have changed the mean failure rate of
a given outcome. For example, chipping and fracture
concepts were often merged, and were sometimes
not considered failures if the patient agreed to having
a burnish or composite repair performed. The defini-
tion of survival and success should be very clear to
avoid divergences. A retrospective study by Rinke et
al19 presented distinct data as regards survival and
success rates. This lack of standardization of con-
cepts could be the cause of heterogeneity, in which
case some authors, such as Peumans et al,17 may have
been more strict about conceptualizing failures and
could have been out of tune with the group as a whole.
Another problem concerned the evaluation criteria
used in the studies, since some outcomes (ie, mar-
ginal integrity, color match, hypersensitivity, gingival
response) were not discussed in depth or investigat-
ed because data was insufficient for inclusion in the
meta-analysis.
Few studies provided information related to the
number of teeth that were endodontically treated be-
fore restorative treatment or the need for such treat-
ment after cementation of the ceramic veneer.2,4,5,10,14,19
Another item of information that was under-reported
in the studies concerned instructions with regard to
the care or maintenance of veneers after cementation.
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Morimoto et al
Of the studies included, only two4,11 provided informa-
tion on the use of occlusal splints and instructions to
patients not to bite or tear hard food after cementa-
tion. These recommendations could have had posi-
tive repercussions on the success rates of laminate
veneers but were not mentioned in the studies.
In the present study, the estimated overall cumula-
tive survival rate was 89% for ceramic veneers, 94%
for glass-ceramic veneers, and 87% for feldspathic
porcelain veneers, which is important evidence for
clinical practice. Although glass-ceramics have im-
proved mechanical properties compared to feldspath-
ic porcelains, Petridis et al in their systematic review
also reported that no statistically significant differ-
ence was detected between the complication rates
of feldspathic porcelain and glass-ceramic veneers.29
Pressable systems have higher strength and fracture
toughness than powder/liquid systems (porcelain)
due to less porosity and high concentration of crys-
tals.21 The present systematic review is in agreement
with Kreulen et al26 and Layton et al,27 who reported a
survival rate of over 90% to 95% in a period of 3 to 10
years for feldspathic porcelain, and with Layton and
Clarke,28 who reported a survival rate of over 90% in
5 years for etchable nonfeldspathic porcelain veneers.
In the analysis of outcomes, a low rate of complica-
tions was estimated in the present study: debonding
(2%), fracture/chipping (4%), caries (1%), severe mar-
ginal discoloration (2%), endodontic problems (2%),
and influence of incisal coverage (OR = 1.25). These
low rates could be due to conservative preparations
that preserve dental structure, particularly enamel.
The bond to enamel is superior to the bond to den-
tin, as it provides a decrease in microleakage, post-
cementation sensitivity, caries, debonding, fractures,
and discoloration.10,13 Secondary caries and marginal
discoloration are less common with laminate veneers
because all margins are in cleanable areas.14
In spite of Smales and Etemadi considering incisal
coverage a protective factor,20 two articles reported
incisal coverage as a risk factor for failures.10,14
The influence of preparation depth (limited to
enamel or dentin) on failure rates could not be es-
tablished, since few articles compared this factor in
a nonstandardized manner.4,7,14,19 One study reported
the hazard ratio,19 while another reported the number
of failures,7 and both agreed that laminate veneers
with preparation confined to enamel showed better
performance than preparation in dentin. Only Gürel
et al14 and Çotert4 specifically reported the survival
rates for preparation in enamel and in dentin. A meta-
analysis including only two studies with contradictory
results would bring poor evidence.
Ceramics with a vitreous phase, which allow bond-
ing, demand less dental preparation. The larger the
Volume 29, Number 1, 2016 47
Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers
amount of tooth preserved, the smaller will be the de-
flexion of the tooth,13 and this could explain the low
failure rates. The tooth-ceramic interface becomes
very strong after adhesive cementation, reinforcing
the ceramic and restoring the strength of the tooth.34
Another positive aspect observed in the present study
was the improvement in study design in recent re-
search; consequently only studies from 2000 to 2013
were included.
Based on the present review and previous system-
atic reviews, it may be observed that clinical evidence
is still lacking about the importance of enamel and
dentin preparation depth, the longevity of direct and
indirect laminate veneer restorations,30 fragments,
partial veneers, ultrathin (contact lens), and prepless
veneers.
Conclusions
The clinical implications of this systematic review are
that procedures used with laminate veneers are safe,
based on the high survival rate found for both por-
celains and glass-ceramics. The most frequent failure
found was fracture/chipping. There was no conclusive
evidence favoring enamel over dentin preparation or
vice versa.
With regard to research implications, more ran-
domized prospective clinical studies are needed, with
comparison of techniques, cavity preparations, and
materials; greater details about samples, link to cen-
sorship, and drop outs; acceptable and unacceptable
clinical failure data; and separate assessment of suc-
cess and survival rates.
Acknowledgments
The authors reported no conflicts of interest and no financial sup-
port for this study.
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Literature Abstract

Systemic Review of Dry Socket: Aetiology, Treatment, and Prevention

This systemic review evaluated 36 publications on the etiology, treatment, and prevention of dry socket infections, based on MEDLINE
database search between 2008 and 2013. The predisposing factors that were highlighted as significant included smoking, surgical trauma,
single tooth extractions, age, sex, medical history, systemic disorder, mandibular sites, amount of anesthesia use, operator experience,
difficulty of the surgery, previous surgical site infection, oral contraceptive use, menstrual cycle, and immediate postextraction socket
irrigation with saline. Current treatment options are generally directed toward palliative care of dry socket infections and include curettage
and irrigation of the surgical site and the use of alveogel, thermosetting gel of 2.5% prilocaine and 2.5% lidocaine, or eugenol on gauze
strips. These measures are considered effective in relieving acute pain episodes. New agents are also available that may accelerate
symptomatic pain relief or healing, such as plasma-rich growth factor (PRGF), low-level laser therapy, Salicept patch, and GECB (3%
guaiacol, 3% eugenol, 1.6% chlorobutanol) pastille. Ultimately, preventive measures should be stressed when risks factors are present as
part of the informed consent. Avoidance of smoking before and after surgery and other preventive measures such as chlorhexidine rinse or
gel can be effective in the reduction of dry socket incidence. Finally, the use of antibiotics, such as azithromycin, in patients with a history
of multiple dry sockets or immunocompromised states, can be considered.

Tarakji B, Saleh LA, Umair A, Azzeghaiby SN, Hanouneh S. J Clin Diagn Res 2015; 9:ZE10–13. References: 35. Reprints: Dr Bassel Tarakji,
Faculty, Department of Oral Maxillofacial Sciences, Al-Farabi College of Dentistry and Nursing, Riyadh, Kingdom of Saudi Arabia.
Email: denpol@yahoo.co.uk—Loke Weiqiang, Singapore

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