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

38 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Morimoto et al

after adhesive cementation because bonding rein- I = ceramic veneers; C = (not applicable in the pres-
forces the ceramic and restores the strength of the ent study); O = survival rate; S = randomized con-
tooth.8,11–13,20–25 Therefore, the differences in clinical trolled trials (RCTs) and cohort studies.
performance between porcelains and glass-ceramics The final search strategy for the MEDLINE data-
require elucidation. base was:  ((((ceramic*) OR porcelain*)) AND (((((fail-
Laboratory studies have sought results capable ure) OR survival) OR success) OR clinical evaluation)
of predicting complications and success of veneers, OR follow up)) AND ((veneer*) OR laminate*). For
important factors for isolating and detailing interfer- Cochrane database, it was: ((laminate or veneer) and
ence at each step or with each material.22–25 However, (ceramic or porcelain) and (dental or tooth or teeth)
certain intraoral conditions cannot be reproduced in a and (clinical and trial or clinical)).
laboratory, as several clinical factors may interfere in
the success of restorations. The success of a clinical Study Selection
procedure relies on indication, planning, clinical and
laboratory steps, and patients’ habits.8–13 With system- Studies were selected by screening titles and ab-
atic reviews26–30 based on clinical follow-up studies, it stracts according to the following inclusion criteria:
is possible to verify trends or associate them with an (1) studies about ceramic laminate veneer and (2) hu-
event, material, or procedure that may be a factor in man cohort studies (prospective and retrospective)
ceramic laminate veneer failures. and RCTs. Articles with no abstract were included for
Some of the problems that occur during the first year evaluation of their full texts.
are generally related to adhesive cementation failure, Eligibility was based on full text assessment of the
which appears to occur most frequently in the first 6 studies included after screening; therefore, some ex-
months, after which the number of failures declines or clusion criteria were predetermined: (1) cavity prepa-
stabilizes at a low rate.3 Systematic reviews have ad- rations and/or clinical procedures without adequate
dressed follow-up periods of up to 2 years,26–29 which descriptions or with unusual descriptions (partial
has contributed to the analysis of resin and ceramic veneer/fragments/unusual bonding procedures); (2)
veneers26,30 as well as the success and complication/ case reports; (3) literature or systematic reviews,
failure rates of different ceramics.27–29 Information is protocols, interviews, or in vitro studies; (4) isolated
lacking on the clinical behavior of feldspathic porce- groups (tetracycline/bruxism); (5) not ceramic ve-
lain and glass-ceramic veneers, and it is necessary to neer; (6) studies using the same sample6,13,15,18 (only
conduct an extensive and detailed systematic review the most recent study was considered); (7) studies
of these different types of ceramics and their failures without information on survival/success rate of ve-
and times of occurrence, which could generate inte- neers and for which the rate was impossible to calcu-
grated scientific evidence. late; and (8) studies with a dropout rate higher than
The aim of this systematic review was to evaluate 30%.
the survival and complication rates of ceramic lami-
nate veneers. Data Collection Process

Materials and Methods The literature review was conducted by two examiners
independently (RBA, SM). Interexaminer reproducibil-
Eligibility Criteria and Search Strategy ity was 0.8 (kappa), and a new calibration was per-
formed to resolve disagreements. Discrepancies and
An electronic database search was performed in doubts were settled by discussion and data checking.
advanced mode of the MEDLINE (PubMed) and When these were not resolved by consensus, a third
Cochrane databases up to April 6, 2014, and studies examiner (MMB) was consulted.
related to ceramic laminate veneers from 1977 to 2014
were obtained. There were no limitations on language. Qualitative Analysis
One study5 was translated from Chinese and included
in the analysis. Quality assessment as described by Hayashi et al was
This review was conducted in accordance with the used (Table 1, items 1 to 24) in addition to another two
Preferred Reporting Items for Systematic Reviews criteria (items 25 and 26) to evaluate the articles se-
and Meta-Analysis (PRISMA) guidelines.31 To iden- lected.32 Studies with a positive response to each item
tify studies for this review, the population, interven- were marked with an X. At the end of the assessment,
tion, comparison, outcome, and study design (PICOS) a % value regarding quality items was calculated for
question was used to guide construction of the search every study. Two calibrated reviewers carried out the
strategy: P = patients who received laminate veneers; quality assessment.

Volume 29, Number 1, 2016 39

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers

Table 1   Quality Assessment of Included Articles and to determine whether the failures and complica-
1 Is the hypothesis/aim/objective of the study clearly tions occurred more often due to time of follow-up and
described? type of ceramic (P < .001). Subgroup analyses were
2 Is the setting of the study or the source of the performed separating feldspathic porcelain and glass-
subjects described? ceramic, and including studies that evaluated the sur-
3 Is the distribution of the study population by age or vival rate for each material. This estimated survival
gender described?
rate (Kaplan-Meier) and variance values were used for
4 Are the inclusion criteria stated? meta-analysis. If the article did not present the vari-
5 Are the exclusion criteria stated? ance (or standard error), it was calculated by analyzing
6 Are the treatments well described? the number of failures and accounting for censorship
7 Are the main outcomes to be measured clearly described in during the follow-up time. These data were searched
the introduction or methods section? in the text or a count was taken on a Kaplan-Meier
8 Is the sample size stated? graph. The Greenwood formula was used to calcu-
9 Was the sample size justified?
late the variance assuming that censorship occurred
uniformly over time, together with failures. The event
10 Was the concurrent control group used?
rate of clinical outcomes was also estimated: debond-
11 Was random allocation to treatment used? ing, fracture/chipping, secondary caries, endodontic
12 Was the method of random allocation given? problems, severe marginal discoloration, influence of
13 Was blind assessment of the outcome carried out? incisal coverage, and enamel/dentin preparation. For
14 Was there more than one examiner for the severe marginal discoloration assessment, the
outcome assessment? authors used different evaluation criteria (modified
15 Was examiner calibration carried out? UPSHS,5,8,9,11,12 CDA/ Ryge,2 and other proposed crite-
16 Are the statistical methods described? ria.10,17,18) In these cases, the worst criterion was cho-
sen for use in the present study.
17 Is the participation/follow-up rate stated?
18 Was the participation/follow-up rate greater than 80%? Results
19 Are nonparticipants/subjects lost to follow-up described?
20 Are the main findings of the study clearly described? Study Selection
21 Are results stated in absolute numbers when feasible
(eg, 10/20, not 50%)? The search identified 899 articles. After evaluation
22 Are confidence intervals given? of titles and abstracts (inclusion phase), 167 studies
23 Are any important adverse events reported? were considered for full-text review in the exclusion
stage. After exclusion, 13 full articles were kept for
24 Are any conclusions stated?
quantitative and qualitative analysis. Fig 1 shows the
25 Was this a prospective study?
search results and all reasons for exclusions.
26 Was ethical approval obtained?
Quality of the Studies Included

Measures and Statistical Analysis The aim of the quality assessment of this study was
not to rank the studies included but to investigate
Descriptive and meta-analyses were performed using their methodologic quality level for statistical analysis
random effects models based on survival rate data later. The percentage range of the studies included in
obtained in the longest time of follow-up and the type the quality assessment ranged from 42.3% to 92.3%
of ceramic used for the veneer. With regard to hetero- (Table 2).
geneity between studies, results of the Cochran Q test
(P < .001 was considered indicative of statistically sig- Study Characteristics
nificant heterogeneity) and the I2 statistic were con-
sidered representative of the level of heterogeneity Authors, year of publication, ceramic material, lan-
(I2 > 50%).33 Summary estimates and 95% confidence guage, period of inclusion, evaluation criteria, fol-
interval (CI) boundaries were assessed. The entire low-up period, country, setting/operators, sample
meta-analysis was undertaken using R version 3.6-0 of patients/veneers, age, dropout rate, category of
software (R Foundation for Statistical Computing). evidence, outcomes (failure/survival rate, debond-
Metaregression was performed on the time and ing, fracture/chipping, severe discoloration, endodon-
type of ceramic thresholds with the intention of clari- tic problems, secondary caries, influence of incisal
fying sources of heterogeneity in the studies included coverage and enamel/dentin preparation), and type

40 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 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

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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 82% to 93%). The median of the maximum follow-up
entire sample (porcelain + glass-ceramic: n = 2,848 times of the studies included was 8 years (range: 1.7
veneers) of the studies included2,4,5,8,10,11,12,14,16,17,19,20 to 20 years) (Fig 3). In the glass-ceramic group4,10,12,19
was 89% (95% CI: 84% to 94%). The median of the (n = 676 veneers), the cumulative survival rate was
maximum follow-up times of the studies included was 94% (95% CI: 87% to 100%). The median of the maxi-
9 years (range: 1.4 to 20 years) (Fig 2). mum follow-up times of the studies included was 7
In the porcelain group5,7,11,16,17,20 (n = 1,283 ve- years (range: 1.4 to 11 years) (Fig 4).
neers), the cumulative survival rate was 87% (95%CI:

42 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 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

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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

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

44 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 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

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers

Experimental Control
Study Events Total Events Total Odds ratio OR 95% CI W (random)
Gürel et al13 24 261 18 319 1.69 [0.90; 3.19] 49.2%
Smales and Etemadi20 1 36 8 64 0.20 [0.02; 1.67] 20.8%
Granell-Ruiz et al10 11 199 2 124 3.57 [0.78; 16.38] 30.0%

Random effects model 496 507 1.36 [0.40; 4.57] 100%

Heterogeneity: I2 = 58.6%, tau2 = 0.673, P = .0893
0.1 0.5 1 2 10

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 silanized, have the best bonding behavior.13,14,21,23 In
present study was 1.25 (95% CI: 0.33 to 4.73) including this systematic review, different ceramics, times, out-
data from 3 studies10,13,20 (36 failures in veneers with comes, and failures were addressed extensively and in
incisal coverage out of 506 veneers, and 28 failures in detail. Thus, it generated scientific evidence and con-
veneers without incisal coverage out of 507 veneers tributed to a broad clinical perspective on the subject.
evaluated) (Fig 10). The quality assessment32 may serve as a good
The influence of preparation depth (limited to delimitation or guide for the design of future clinical
enamel or dentin) on failure rates could not be estab- studies, and presents important points and concepts
lished, since few articles4,7,14,19 compared this factor in necessary for a valid study. The quality assessment of
nonstandardized ways. the present study did not aim to rank the studies in-
cluded; the only intention was to investigate the level
Discussion of quality for later data interpretation and better un-
derstanding of these studies. Furthermore, the wide
Systematic reviews are essential to collate the results range in percentage of the quality assessment, 42.3%
reported in several studies, as they enable the best to 92.3%, suggests some source of heterogeneity
clinical evidence to be pointed out to clinicians to sup- among the studies included (Table 2), and analysis
port the decisions they make in their offices.31 of the design of studies (Table 3) may help in under-
With regard to other systematic reviews,26–29 a mini- standing the differences among these studies.
mum evaluation period was not an exclusion criterion The heterogeneity was investigated by means of
in this study. This was based on the clinical observa- the Cochran Q test. In all cases with the exception of
tion that some of the problems that occurred with ve- endodontic problems (I2 = 47.2%) the I2 was higher
neers during the first year were generally related to than 50%, showing the heterogeneity of the sample.
adhesive cementation failure. These appeared to occur Nevertheless, a random effects model was also pre-
most frequently in the first 6 months, and afterward ferred for this outcome analysis due to the proxim-
frequency declined or stabilized at low rates.3 In ad- ity of the I2 percentage to 50%. In fact, a high level
dition, the idea that there are often numerous survival of heterogeneity was expected since all the articles
times within a clinical study led the present authors to presented wide clinical and methodologic variations.
look for articles irrespective of the follow-up period. To assess possible sources of this heterogeneity, we
However, the evaluation was based on the longest time conducted visual inspection of the forest plot, metare-
reported, since many articles did not report survival gression, and subgroup analysis of the studies based
and censorship in different time intervals, making it on thresholds of the follow-up periods and types of
impossible to evaluate survival in different times. ceramic.
Another difference of the present study is that Since metaregression discarded the hypothesis of
it assessed data for two ceramic types (porcelain time and type of ceramic causing the heterogeneity,
and glass-ceramic). Although crystalline ceramics subgroup analysis was also performed with distinct
(Procera, In Ceram, LAVA, etc), have been used for feldspathic porcelain and the glass-ceramic veneer
laminate veneers, no longitudinal clinical study on groups. The random effects models were performed
their use was found. Ceramics that contain a high in all analyses. This model assumes that different
percentage of vitreous phase, such as the porcelain studies are estimated differently, placing value on the
and glass-ceramics, which can be acid etched and contribution of small studies and increasing the CI.33

46 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Morimoto et al

On visual inspection of the forest plot of all studies Of the studies included, only two4,11 provided informa-
included (Fig 2), two articles5,17 seemed more indica- tion on the use of occlusal splints and instructions to
tive of the high level of heterogeneity. According to patients not to bite or tear hard food after cementa-
these studies, failures appeared to be related to the tion. These recommendations could have had posi-
inclusion and exclusion criteria and to the definitions tive repercussions on the success rates of laminate
of survival and success, and this could have a direct veneers but were not mentioned in the studies.
influence on heterogeneity. Layton16 reported a lack In the present study, the estimated overall cumula-
of standardization of these criteria. Contributory fac- tive survival rate was 89% for ceramic veneers, 94%
tors for Du et al5 may have included number of opera- for glass-ceramic veneers, and 87% for feldspathic
tors and their level of graduation not being specified porcelain veneers, which is important evidence for
by the university; more comprehensive inclusion cri- clinical practice. Although glass-ceramics have im-
teria; focus on the influence of systemic problems on proved mechanical properties compared to feldspath-
local dental issues, such as dental structural damage ic porcelains, Petridis et al in their systematic review
(hypoplasia, severe tetracycline staining, occlusion also reported that no statistically significant differ-
bruxism, anterior crossbite); and poor oral hygiene. ence was detected between the complication rates
Peumans et al17 seem to have been strict about con- of feldspathic porcelain and glass-ceramic veneers.29
sidering small bulk fractures clinically unacceptable Pressable systems have higher strength and fracture
but reparable, which might have increased the fail- toughness than powder/liquid systems (porcelain)
ure rate. Other factors mentioned as possible expla- due to less porosity and high concentration of crys-
nations for the high failure rate were the bond to a tals.21 The present systematic review is in agreement
dentin surface, presence of large composite filings with Kreulen et al26 and Layton et al,27 who reported a
(composite fillings present in 70% of the porcelain ve- survival rate of over 90% to 95% in a period of 3 to 10
neer sample), bonding to endodontically treated teeth, years for feldspathic porcelain, and with Layton and
and heavy mechanical loading during occlusion and Clarke,28 who reported a survival rate of over 90% in
articulation. 5 years for etchable nonfeldspathic porcelain veneers.
The lack of standardization with regard to the In the analysis of outcomes, a low rate of complica-
concepts makes it difficult to reach a better under- tions was estimated in the present study: debonding
standing of the outcome results. Differences among (2%), fracture/chipping (4%), caries (1%), severe mar-
authors about which occurrences were considered ginal discoloration (2%), endodontic problems (2%),
failures may have changed the mean failure rate of and influence of incisal coverage (OR = 1.25). These
a given outcome. For example, chipping and fracture low rates could be due to conservative preparations
concepts were often merged, and were sometimes that preserve dental structure, particularly enamel.
not considered failures if the patient agreed to having The bond to enamel is superior to the bond to den-
a burnish or composite repair performed. The defini- tin, as it provides a decrease in microleakage, post-
tion of survival and success should be very clear to cementation sensitivity, caries, debonding, fractures,
avoid divergences. A retrospective study by Rinke et and discoloration.10,13 Secondary caries and marginal
al19 presented distinct data as regards survival and discoloration are less common with laminate veneers
success rates. This lack of standardization of con- because all margins are in cleanable areas.14
cepts could be the cause of heterogeneity, in which In spite of Smales and Etemadi considering incisal
case some authors, such as Peumans et al,17 may have coverage a protective factor,20 two articles reported
been more strict about conceptualizing failures and incisal coverage as a risk factor for failures.10,14
could have been out of tune with the group as a whole. The influence of preparation depth (limited to
Another problem concerned the evaluation criteria enamel or dentin) on failure rates could not be es-
used in the studies, since some outcomes (ie, mar- tablished, since few articles compared this factor in
ginal integrity, color match, hypersensitivity, gingival a nonstandardized manner.4,7,14,19 One study reported
response) were not discussed in depth or investigat- the hazard ratio,19 while another reported the number
ed because data was insufficient for inclusion in the of failures,7 and both agreed that laminate veneers
meta-analysis. with preparation confined to enamel showed better
Few studies provided information related to the performance than preparation in dentin. Only Gürel
number of teeth that were endodontically treated be- et al14 and Çotert4 specifically reported the survival
fore restorative treatment or the need for such treat- rates for preparation in enamel and in dentin. A meta-
ment after cementation of the ceramic veneer.2,4,5,10,14,19 analysis including only two studies with contradictory
Another item of information that was under-reported results would bring poor evidence.
in the studies concerned instructions with regard to Ceramics with a vitreous phase, which allow bond-
the care or maintenance of veneers after cementation. ing, demand less dental preparation. The larger the

Volume 29, Number 1, 2016 47

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers

amount of tooth preserved, the smaller will be the de-   6. Dumfahrt H. Porcelain laminate veneers. A retrospective evalu-
flexion of the tooth,13 and this could explain the low ation after 1 to 10 years of service: Part I--Clinical procedure.
Int J Prosthodont 1999;12:505–513.
failure rates. The tooth-ceramic interface becomes
 7. Dumfahrt H, Schäffer H. Porcelain laminate veneers. A ret-
very strong after adhesive cementation, reinforcing rospective evaluation after 1 to 10 years of service: Part II—
the ceramic and restoring the strength of the tooth.34 Clinical results. Int J Prosthodont 2000;13:9–18.
Another positive aspect observed in the present study   8. Fradeani M, Redemagni M, Corrado M. Porcelain laminate ve-
was the improvement in study design in recent re- neers: 6- to 12-year clinical evaluation—A retrospective study.
Int J Periodontics Restorative Dent 2005;25:8–17.
search; consequently only studies from 2000 to 2013
 9. Fradeani M. Six-year follow-up with Empress veneers. Int J
were included. Periodontics Restorative Dent 1998;18:216–225.
Based on the present review and previous system- 10. Granell-Ruiz M, Fons-Font A, Labaig-Rueda C, et al. A clini-
atic reviews, it may be observed that clinical evidence cal longitudinal study 323 porcelain laminate veneers. Period
is still lacking about the importance of enamel and of study from 3 to 11 years. Med Oral Patol Oral Cir Bucal
2010;15:e531–e537.
dentin preparation depth, the longevity of direct and
11. Gresnigt MM, Kalk W, Özcan M. Clinical longevity of ceramic
indirect laminate veneer restorations,30 fragments, laminate veneers bonded to teeth with and without existing
partial veneers, ultrathin (contact lens), and prepless composite restorations up to 40 months. Clin Oral Investig
veneers. 2013;17:823–832.
12. Gresnigt MM, Kalk W, Özcan M. Randomized clinical trial of
indirect resin composite and ceramic veneers: Up to 3-year
Conclusions
follow-up. J Adhes Dent 2013;15:181–190.
13. Gürel G, Morimoto S, Calamita MA, Coachman C, Sesma N.
The clinical implications of this systematic review are Clinical performance of porcelain laminate veneers: Outcomes
that procedures used with laminate veneers are safe, of the aesthetic pre-evaluative temporary (APT) technique. Int
based on the high survival rate found for both por- J Periodontics Restorative Dent 2012;32:625–635.
14. Gürel G, Sesma N, Calamita MA, Coachman C, Morimoto S.
celains and glass-ceramics. The most frequent failure
Influence of enamel preservation on failure rates of porce-
found was fracture/chipping. There was no conclusive lain laminate veneers. Int J Periodontics Restorative Dent
evidence favoring enamel over dentin preparation or 2013;33:31–39.
vice versa. 15. Layton D, Walton T. An up to 16-year prospective study of 304
With regard to research implications, more ran- porcelain veneers. Int J Prosthodont 2007;20:389–396.
16. Layton DM, Walton TR. The up to 21-year clinical outcome and
domized prospective clinical studies are needed, with
survival of feldspathic porcelain veneers: Accounting for clus-
comparison of techniques, cavity preparations, and tering. Int J Prosthodont 2012;25:604–612.
materials; greater details about samples, link to cen- 17. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G,
sorship, and drop outs; acceptable and unacceptable Van Meerbeek B. A prospective ten-year clinical trial of porce-
clinical failure data; and separate assessment of suc- lain veneers. J Adhes Dent 2004;6:65–76.
18. Peumans M, Van Meerbeek B, Lambrechts P, Vuylsteke-
cess and survival rates.
Wauters M, Vanherle G. Five-year clinical performance of por-
celain veneers. Quintessence Int 1998;29:211–221.
Acknowledgments 19. Rinke S, Lange K, Ziebolz D. Retrospective study of extensive
heat-pressed ceramic veneers after 36 months. J Esthet Restor
The authors reported no conflicts of interest and no financial sup- Dent 2013;25:42–52.
port for this study. 20. Smales RJ, Etemadi S. Long-term survival of porcelain laminate
venners using two preparation designs: A retrospective study.
Int J Prosthodont 2004;17:323–326.
References 21. McLaren EA, Whiteman YY. Ceramics: Rationale for material
selection. Compend Contin Educ Dent 2010;31:666–668, 670,
  1. Aristidis GA, Dimitra B. Five-year clinical performance of por- 672.
celain laminate veneers. Quintessence Int 2002;33:185–189. 22. Chaiyabutr Y, Phillips KM, Ma PS, Chitswe K. Comparison of
  2. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical perfor- load-fatigue testing of ceramic veneers with two different
mance of porcelain laminate veneers for up to 20 years. Int J preparation designs. Int J Prosthodont 2009;22:573–575.
Prosthodont 2012;25:79–85. 23. Gresnigt MM, Özcan M, Kalk W, Galhano G. Effect of static and
  3. Chen JH, Shi CX, Wang M, Zhao SJ, Wang H. Clinical evalu- cyclic loading on ceramic laminate veneers adhered to teeth
ation of 546 tetracycline-stained teeth treated with porcelain with and without aged composite restorations. J Adhes Dent
laminate veneers. J Dent 2005;33:3–8. 2011;13:569–577.
  4. Cötert HS, Dündar M, Oztürk B. The effect of various prepa- 24. Schmidt KK, Chiayabutr Y, Phillips KM, Kois JC. Influence of
ration designs on the survival of porcelain laminate veneers. preparation design and existing condition of tooth structure
J Adhes Dent 2009;11:405–411. on load to failure of ceramic laminate veneers. J Prosthet Dent
  5. Du RT, Li Y, Fan DN. A retrospective study on the long-term clin- 2011;105:374–382.
ical outcomes of 310 porcelain laminate veneers [in Chinese]. 25. D’Arcangelo C, De Angelis F, Vadini M, D’Amario M, Caputi S.
Zhonghua Kou Qiang Yi Xue Za Zhi 2009;44:343–346. Fracture resistance and deflection of pulpless anterior teeth
restored with composite or porcelain veneers. J Endod 2010;
36:153–156.

48 The International Journal of Prosthodontics

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Morimoto et al

26. Kreulen CM, Creugers NH, Meijering AC. Meta-analysis 30. Wakiaga J, Brunton P, Silikas N, Glenny AM. Direct versus in-
of anterior veneer restorations in clinical studies. J Dent direct veneer restorations for intrinsic dental stains. Cochrane
1998;26:345–353. Database Syst Rev 2004:CD004347.
27. Layton DM, Clarke M, Walton TR. A systematic review and 31. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group.
meta-analysis of the survival of feldspathic porcelain veneers Preferred reporting items for systematic reviews and meta-
over 5 and 10 years. Int J Prosthodont 2012;25:590–603. analyses: The PRISMA statement. Int J Surg 2010;8:336–341.
28. Layton DM, Clarke M. A systematic review and meta-analysis 32. Hayashi M, Wilson NH, Yeung CA, Worthington HV. Systematic
of the survival of non-feldspathic porcelain veneers over 5 and review of ceramic inlays. Clin Oral Investig 2003;7:8–19.
10 years. Int J Prosthodont 2013;26:111–124. 33. Higgins JP, Thompson SG. Quantifying heterogeneity in a me-
29. Petridis HP, Zekeridou A, Malliari M, Tortopidis D, Koidis P. ta-analysis. Stat Med 2002;15;21:1539–1558.
Survival of ceramic veneers made of different materials after 34. Cobankara FK, Unlu N, Cetin AR, Ozkan HB. The effect of dif-
a minimum follow-up period of five years: A systematic review ferent restoration techniques on the fracture resistance of
and meta-analysis. Eur J Esthet Dent 2012;7:138–152. endodontically-treated molars. Oper Dent 2008;33:526–533.

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: [email protected]—Loke Weiqiang, Singapore

Volume 29, Number 1, 2016 49

© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.