Randomized Clinical Trial of Indirect Resin Composite

and Ceramic Veneers: Up to 3-year Follow-up

Marco M.M. Gresnigta/Warner Kalkb/Mutlu Özcanc

Purpose: This randomized controlled split-mouth clinical trial evaluated the short-term survival rate of indirect
resin composite and ceramic laminate veneers.
Materials and Methods: A total of 10 patients (mean age: 48.6 years) received 46 indirect resin composite
(Estenia; n = 23) and ceramic laminate veneers (IPS Empress Esthetic; n = 23) on the maxillary anterior teeth.
Veneer preparations with incisal overlap were performed and existing resin composite restorations of good qual-
ity were not removed but conditioned using silica coating (CoJet) and silanization (ESPE-Sil). Enamel and dentin
were etched and rinsed; adhesive resin (ExciTE) was then applied. After cementation (Variolink Veneer), restora-
tions were evaluated at baseline and thereafter every 6 months for up to 3 years using modified USPHS criteria.
Results: Seventeen laminate veneers were bonded onto intact teeth and 29 on teeth having existing resin com-
posite restorations. In total, 3 failures were observed in the form of debonding (n = 1) and fracture (n = 2) in the
group of resin composite laminate veneers. No significant difference was observed between the survival rates
of composite and ceramic laminate veneers (Estenia: 87%, IPS Empress Esthetic: 100%; p > 0.05). The overall
survival rate was 93.5% (Kaplan-Meier). Of the 43 laminate veneers, minor voids and defects were observed in 6
of the composite and 3 of the ceramic veneers. Slight staining at the margins (n = 3) and slightly rough surfaces
were more frequently observed for the resin composite laminate veneers (n = 18) up to the final recall.
Conclusion: Early findings of this clinical trial on two veneer materials showed statistically similar survival rates.
Surface quality changes were more frequent in the composite veneer material.
Keywords: adhesion, ceramic, ceramic aging, composite aging, dental materials, indirect composite, laminate
veneers, randomized controlled clinical trial, silica coating, split mouth, surface conditioning.

J Adhes Dent 2013; 15: 10 pages. Submitted for publication: 2.07.12; accepted for publication: 10.07.12
doi: 10.3290/j.jad.a28883

I n restorative dentistry, laminate veneer restorations

are considered as minimally invasive treatment op-
tions. Their durability relies on the adhesive strength of
the resin luting cement to the veneering material and
the tooth surface. Laminate veneers are usually fabri-
cated from either particulate filled resin composites or
a
Researcher, Department of Fixed and Removable Prosthodontics, Center
for Dentistry and Oral Hygiene, University Medical Center Groningen, The
University of Groningen, Groningen, The Netherlands. Idea, hypothesis, ex-
perimental design, performed experiment, wrote manuscript.
b Professor Emeritus, Department of Fixed and Removable Prosthodontics,
Center for Dentistry and Oral Hygiene, University Medical Center Groningen,
The University of Groningen, Groningen, The Netherlands. Idea, experimental
design.
c Professor, University of Zürich, Dental Materials Unit, Center for Dental and
Oral Medicine, Clinic for Fixed and Removable Prosthodontics and Dental
Materials Science, Zürich, Switzerland. Idea, hypothesis, experimental de-
sign, proofread manuscript, consulted on statistical evaluation, contributed
substantially to discussion.
Correspondence: Dr. Marco Gresnigt, Department of Fixed and Removable
Prosthodontics, Center for Dentistry and Oral Hygiene, University Medical Cen-
ter Groningen, The University of Groningen, Antonius Deusinglaan 1, 9713 AV,
Groningen, The Netherlands. Tel: +31-50-363-2608, Fax: +31-50-363-2696.
e-mail: marcogresnigt@yahoo.com
ceramics. To date, little information is available in the
literature on the long-term survival rates of different
indirect laminate systems.30 Individual clinical studies
evaluated the survival of either only ceramics or only
resin composites as the laminate veneer material with-
out comparing their performance in the same mouth.
Therefore, the Cochrane Collaboration concluded that
there was no evidence that laminate material performs
better clinically.42
Ceramics are often referred to as the material of
choice, with favorable properties due to their higher frac-
ture resistance and color stability compared to resin com-
posites.10,31 Ceramic laminate veneers have been well
studied, with clinical studies reporting survival rates over
90% up to 4 to 10 years of follow-up.10,15,16,22,24,31,37
These clinical studies have shown that incidences of ab-
solute failures, resulting in complete loss of laminate
veneers, are low. However, survival rates were reported
to decrease from 92% at 5 years to 64% at 10 years when
relative failures are also taken into account as an out-
come measure.37 Among relative failures, minor fractures
of ceramics and marginal defects were reported as the
main reasons for failure.9,15,16,22,37 Relative failures are
considered defects in restorations that do not necessarily

doi: 10.3290/j.jad.a28883 1
Gresnigt et al
lead to replacement, but can be refurbished, repolished,
or repaired. On the other hand, clinical studies reporting
on indirect resin composite laminate veneers observed
susceptibility to both fracture and surface staining.30,43
From a financial perspective, indirect resin composite
laminates are a less expensive option than ceramics, and
from a biological point of view, resin-based materials wear
the antagonist enamel less than ceramics do, indicating
potential for this material.26
Modern particulate-filled resin composites for indirect
restorations are characterized by a filler:matrix ratio sig-
nificantly higher than that of the preceding generations
of such materials. One such indirect resin composite,
Estenia (Kuraray; Tokyo, Japan) contains up to 92 wt%
microfillers in a urethane tetramethacrylate (UTMA) resin
matrix, where 16 wt% of the microfillers have a grain size
of 0.02 μm and 76 wt% of the microfillers present a grain
size of 2 μm.28,40 The UTMA resin matrix in this particular
indirect composite contains four types of functional ure-
thane methacrylates, yielding a higher crosslink density of
the material.40 Although high filler content may increase
the optical properties, it can be anticipated that the ma-
terial may become more brittle.
Besides the inherent strength of the material itself,
durable adhesion of the luting cement to both the tooth
surface and the cementation surface of the restoration ma-
terial through surface conditioning methods is crucial, es-
pecially for bonded restorations such as laminate veneers.
Hydrofluoric acid (HF) etching followed by the application
of a silane coupling agent is a well-established method for
conditioning glassy matrix ceramics.1,2,4,36 For the condi-
tioning of polymeric materials, favorable results have also
been demonstrated using airborne particle abrasion with
alumina particles coated with silica followed by silaniza-
tion, as opposed to acid etching and silanization or using
alumina air abrasion and silanization only.3,21,25,34 Mono-
meric ends of the silane react with the methacrylate groups
of the adhesive resins by a free radical polymerization pro-
cess, increasing the wettability of the luting resin. From an
adhesion perspective, both ceramics and polymeric materi-
als are expected to deliver clinically satisfactory results.
The aging of dental materials in the hostile oral environ-
ment is almost unavoidable over time. Dental materials
are affected by stress, dynamic fatigue, and degradation
of the surface, which may in turn influence their physical,
mechanical, and optical properties. Exposure to food com-
ponents, acidic beverages, temperature changes,5 chew-
ing, saliva, and biofilm5,17 lead to degradation of resin
composite surfaces.32 Degraded composite surfaces may
show increased roughness, sometimes accompanied by
decreased microhardness and increased exposure of filler
particles or resin matrix swelling.19 Although dentists gen-
erally refrain from using resin materials due to aging of the
surface, in fact, ceramics may also show surface defor-
mations in an aqueous environment due to exposure to
the chemical solutions, water, and other fluids that may
damage the glaze layer.6,22 Consequently, this process
changes the surface hardness and surface properties,
promoting plaque accumulation and wear of antagonistic
structures, in addition to sometimes diminishing the es-
2 The Journal of Adhesive Dentistry
thetics, especially in the anterior region.18,25 Not only
the oral environment but also acidulated phosphate fluor-
ide present in professional fluoride applications in tooth-
pastes or in other forms at different concentrations have
been shown to etch dental ceramic surfaces.6
The objective of this randomized clinical trial was to
evaluate the clinical performance of laminate veneers
made of particulate filled composite or ceramic in a split-
mouth design. The null hypothesis tested was that both
laminate materials would function similarly in the clinical
situation.
MATERIAL AND METHODS
Study Design
The brand names, types, manufacturers, chemical com-
positions, and batch numbers of the materials used in
this study are listed in Table 1.
In order to avoid noticeable differences in case of dis-
tinct levels of discoloration, a modified split-mouth design
was employed where the central incisors and the sym-
metric other teeth received the same type of restoration.
Randomization was based on the paired teeth, and it was
performed by flipping a coin for the choice of material.
Inclusion and Exclusion Criteria
Between June 2008 and June 2010, a total of 10
patients from 20 to 69 years of age (7 female, 3
male, mean age: 48.6) received 46 indirect compos-
ite (n = 23) and ceramic laminate veneers (n = 23).
Patients recruited for this study were referred from
the Groningen University dental clinic and surrounding
local general practices. Before entering the trial, all
patients were provided with informed consent forms ap-
proved by the ethics committee of the University Medi-
cal Center Groningen review board (ABR number: NL
14837.042.06). Information was given to each patient
regarding the alternative treatment options. The inclu-
sion criteria were as follows: all subjects were required
to be at least 18 years old, be able to read and sign
the informed consent document, be physically and psy-
chologically able to tolerate conventional restorative
procedures, have no active periodontal or pulpal dis-
eases, have teeth with good restorations, and be willing
to return for follow-up examinations as outlined by the
investigators.
Existing composite restorations of good quality, pre-
senting no caries, ditching, or marginal staining were not
removed prior to tooth preparation. They were rated by
size: restorations covering more than half of the labial
surfaces were rated “large” and the others as “small”
restorations. Nonvital teeth were not excluded from the
study (Fig 1).
Tooth Preparation
Prior to treatment with laminate veneers, gingival correc-
tions or bleaching was performed. Alignment corrections
were made orthodontically, where necessary. Treatment
 Gresnigt et al

Table 1 Brand names, types, manufacturers, chemical compositions, and batch numbers of the materials used in
this study

Brand name Type Manufacturer Chemical composition Batch

number
IPS Empress Press Ceramic Ivoclar Vivadent; > 98% SiO2, BaO, Al2O3, CaO, CeO2, Na2O, K2O, B2O3, < 2% H18925
Esthetic Schaan, TiO2 and pigments
Liechtenstein

Estenia C&B Indirect Kuraray; Urethane tetramethacrylate (UTMA), aromatic dimethacrylate 00005A
Composite Tokyo, Japan (hydrophobic), aliphatic dimethacrylate (hydrophobic), alumina
microfiller, silanized glass filler, dl-camphorquinone, initiators,
accelerators, pigments, 92% colloidal silica spheres with 16
wt% superfine microfillers, grain size of 0.02 μm, and 76 wt%
microfillers, grain size of 2 μm

Variolink Veneer Photopolymerized Ivoclar Vivadent Urethane dimethacrylate, decamethylene dimethacrylate, inor- M51909
luting cement ganic fillers, ytterbium trifluoride, initiators, stabilizers, pigments

CoJet-Sand Sand 3M ESPE; Aluminium trioxide particles coated with silica, particle size: 433719
Seefeld, Germany 30 μm

ESPE-Sil Silane coupling 3M ESPE Ethyl alcohol, 3-methacryloxypropyltrimethoxysilane 189599

agent

Ceramic Etching Hydrofluoric acid Ivoclar Vivadent < 5% hydrofluoric acid M36138
Gel

Monobond S Silane coupling Ivoclar Vivadent 1% 3-methacryloxypropyltrimethoxysilane, ethanol-/water-based L15382

agent solution

ExciTE Bonding agent Ivoclar Vivadent Dimethacrylates, alcohol, phosphonic acid acrylate, HEMA, SiO2, N30084
initiators and stabilizers

Total-Etch Phosphoric acid Ivoclar Vivadent 37% phosphoric acid L13953

Assessed for eligibility Excluded due to not meeting inclusion criteria (n= 9)
(N= 19) r
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UIFSBQZ
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r
"DUJWF
PSUIPEPOUJD
UIFSBQZ
O


r
%JE
OPU
XBOU
UP
QBSUJDJQBUF
O


Allocated to intervention (n=10)

Allocation Received allocated intervention (n= 10)
Did not receive allocated intervention (n= O)

Lost to follow-up
Follow-up
n= 0
Fig 1 CONSORT flow chart present-
ing the inclusion/exclusion criteria
and the final characteristics of the Analyzed at each follow-up
Analysis
(npatients = 10, nteeth = 46)
patients recruited to participate in
this study.

planning was performed using digital photos and plaster
casts. For evaluation of the midline position, a facebow
was placed on the face perpendicular to the midline.
Shade was determined using different shade tabs under
standard conditions (6500 K, 8 light intensity, Longlife,
Aura; Stockholm, Sweden) in the dental laboratory. A
wax set-up was made on the plaster model using the
mock-up technique.23,29 The wax set-up was used to
communicate the correction of the form and position of
the teeth as well as to evaluate the expectations of the
patient. Only after the patient’s approval of the mock-up
were preparations made.
Magnifying loupes (4.2X) (Examvision; Rotterdam, The
Netherlands) and a microscope (3.4 to 21.3X) (Opmipico,
Zeiss; Sliedrecht, The Netherlands) were used for mini-
mal preparations. Ball-shaped diamond burs (ISO 001 514
023, Diatech; Altstätten, Switzerland) were used to mark
preparation depths through the set-up. The labial surfaces

doi: 10.3290/j.jad.a28883 3
Gresnigt et al
Table 2a Conditioning protocol of the tooth/restora-
tion
Sequence of conditioning
1 Cleaning the tooth/restoration surface with fluoride-free
pumice
2 Silica coating the existing composite restorations (5 s)
3 Acid etching enamel (30 s) and dentin (10–15 s)
(37% H3PO4)
4 Rinsing 30 s
5 Silane (ESPE-Sil) application on the existing restorations
(5 min)
6 Adhesive resin (ExciTE) application and air thinning
7 No photopolymerization
8 Bonding the laminate
were axially reduced by 0.3 to 0.5 mm. Tapered round-
ended diamond burs (ISO 199 514 018, Diatech) were
used for uniform preparations. An incisal overlap of 1 to
1.5 mm was prepared in all cases. In the cervical area, a
shallow chamfer finish line (0.5 mm) was created equi- or
supragingivally to maintain good periodontal health. A shal-
low chamfered marginal finish line extended interproximally
to hide the restoration margins up to the contact area.
All internal angles were smoothed to reduce stress
concentration. On the palatal aspect, a right-angled con-
tour (butt joint) between the incisal edge and the palatal
surface was achieved. Impressions were then made using
a polyether impression material (Impregum, 3M ESPE;
St Paul, MN, USA). Provisional veneers were made chair-
side using an auto-polymerized bis-acrylic resin (Structur
SC, Voco; Cuxhaven, Germany). For the fixation of the
provisional veneers, enamel was spot etched with 37%
phosphoric acid (Total Etch, Ivoclar Vivadent; Schaan,
Liechtenstein) for 30 s.
One dental technician made all laminate veneers. Leu-
cite-reinforced glass ceramic (IPS Empress Esthetic, Ivoclar
Vivadent) was processed according to the manufacturer’s
instructions using the IPS Empress layering and lost wax
technique. After wax-up, a cutback of 0.2 to 0.8 mm was
performed to allow layering of the veneering ceramic.
The indirect composite laminate veneers (Estenia C&B,
Kuraray; Tokyo, Japan) were fabricated using the layer-
ing technique following the manufacturer’s instructions.
They were heat- (100°C to 110°C for 15 min) and pho-
topolymerized (400 to 515 nm for 270 s) using a special
polymerization device (Heat-curing 110, Toesco-Yoshida;
Kawasaki-shi, Japan) according to the manufacturer’s rec-
ommendations.
Both ceramic and resin composite laminate veneers
were hand polished using diamond burs and silicone rub-
ber points (3044HP-30044HP Ceragloss, Edenta; St. Gal-
len, Switzerland).
4 The Journal of Adhesive Dentistry
Table 2b Conditioning and application protocol for the
ceramic laminate veneers
Sequence of conditioning and application
1 Hydrofluoric acid etching (1 min)
2 Rinsing with copious water (1 min)
3 Ultrasonic cleaning in distilled water (5 min)
4 Silane coupling agent application + let evaporate 1 min
5 Adhesive application (no photopolymerization)
6 Cement application on the cementation surface of the
laminate veneers
7 Placement of laminate veneer onto the tooth
8 Photopolymerization (3 s)
9 Removal of excess of cement
10 Glycerine gel application and photopolymerization at
buccal, oral, proximal sides (40 s each)
Cementation
The sequence of the adhesive procedures is summarized
in Tables 2a to 2c. Form, adaptation, and shade match of
the restorations were checked clinically. The color of the
cement to be used was determined using try-in pastes
(Variolink Veneer Try-in Paste, Ivoclar Vivadent).
After cleaning with 99% isopropanol, cementation sur-
faces of the laminates were etched with 4.9% hydrofluoric
acid (IPS Ceramic etching gel, Ivoclar Vivadent) for 1 min,
washed thoroughly for 1 min, and dried with oil-free com-
pressed air. Since etching with hydrofluoric acid leaves a
significant amount of crystalline debris precipitate at the cer-
amic surface,4 laminate veneers were ultrasonically cleaned
in distilled water for 5 min. Thereafter, the cementation
surfaces were silanized (Monobond S, Ivoclar Vivadent) for
1 min. After silanization, adhesive resin (ExciTE, Ivoclar Vi-
vadent) was applied and air thinned but not polymerized.
The intaglio of the indirect composite laminate veneers
was tribochemically silica coated (30-μm SiO2, CoJet-
Sand, 3M ESPE) using an intraoral air-abrasion device
(Dento-Prep, RØNVIG; Daugaard, Denmark) at a pressure
of 2.5  bar from a distance of approximately 10 mm for
20 s. They were then silanized with 3-methacryloxypro-
pyltrimethoxy silane coupling agent (MPS) (ESPE-Sil, 3M
ESPE) which was let sit for 5 min after application. After
silanization, adhesive resin (ExciTE, Ivoclar Vivadent) was
applied and air thinned but not polymerized.
All teeth to be veneered were isolated using a split
rubber-dam technique, where the interdental separation
between teeth is cut away and the rubber-dam clamps
are placed on the canines. Contour strips (Contour-Strip,
Ivoclar Vivadent) were placed with the help of interproxi-
mal wedges to perform a smooth restoration outline in
the cervical area. The prepared teeth were first cleaned
with fluoride-fee pumice (Pumice Flour, Dux; Utrecht, The
Netherlands) using a polishing brush (Polishing Brush,
Coltène/Whaledent; Altstätten, Switzerland).
 Gresnigt et al

Table 2c Conditioning and application protocol for the Table 3 List of modified United States Public Health
composite laminate veneers Service (USPHS) criteria used for the clinical evalua-
tion of the laminate veneers
Sequence of conditioning and application
Category Score Criterion
1 Silica coating cementation surface (20 s)

2 Gently blowing excess powder (30 s) Adaptation 0 Smooth margin

1 All margins closed, or possess minor
3 Silane coupling agent application + let evaporate 1 min voids or defects (enamel exposed)
2 Obvious crevice at margin, dentin or
4 Adhesive application (no photopolymerization) base exposed
3 Debonded from one end
4 Debonded from both ends
5 Cement application on the cementation surface of the
laminate veneers Color match 0 Very good color match
1 Good color match
6 Placement of veneer onto the tooth 2 Slight mismatch in color or shade
3 Obvious mismatch, outside the nor-
7 Photopolymerization (3 s) mal range
4 Gross mismatch
8 Removal of excess of cement
Marginal 0 No discoloration evident
9 Photopolymerization at buccal, oral, proximal sides discoloration 1 Slight staining, can be polished away
(40 s each) 2 Obvious staining, cannot be polished
away
3 Gross staining

Where composite restorations existed, they were silica Surface 0 Smooth surface
coated with the same parameters as described above. roughness 1 Slightly rough or pitted
2 Rough, cannot be refinished
Then, enamel and dentin were etched with 37% H3PO4 3 Surface deeply pitted, irregular grooves
(Total Etch, Ivoclar Vivadent) for 15 to 30 s. After rins-
ing for 30 s and air drying, an MPS silane (ESPE-Sil, 3M Fracture 0 No fracture
of restoration 1 Minor crack lines over restoration
ESPE) was applied on the existing composite restorations
2 Minor chipping of restoration
and let evaporate for 5 min. The adhesive resin (ExciTE, (1/4 of restoration)
Ivoclar Vivadent) was then applied on both the tooth and 3 Moderate chipping of restoration
the restoration surfaces with a microbrush for 15 s and (1/2 of restoration)
air thinned but not polymerized. 4 Severe chipping (3/4 restoration)
5 Debonding of restoration
Laminate veneers were cemented using a light-poly-
merizing luting cement (Variolink Veneer, Ivoclar Vivadent). Fracture 0 No fracture of tooth
Cement was applied to the inner surface of the laminates. of tooth 1 Minor crack lines in tooth
After placement, initially, they were photo-polymerized 2 Minor chipping of tooth (1/4 of crown)
3 Moderate chipping of tooth
with an LED curing light (Bluephase 20i, Ivoclar Vivadent) (1/2 of crown)
for only 3 s at the buccal surface to ensure stabilization of 4 Crown fracture near cementoenamel
the veneer. The light output was at least 800 mW/cm2 in junction
all applications. Gross excess cement at the margins was 5 Crown-root fracture (extraction)
removed immediately with the aid of brushes, scalers, Wear of 0 No wear
and dental floss (Oral-B; Rotterdam, The Netherlands). restoration 1 Wear
Application of glycerine gel (Liquid-Strip, Ivoclar Vivadent)
at the margins ensured oxygen inhibition during polymeriz- Wear of 0 No wear
antagonist 1 Wear of antagonist
ation. Buccal, oral, and proximal surfaces were further po-
lymerized for 40 s. After rinsing the glycerine gel, excess Caries 0 No evidence of caries continuous with
cement was removed with hand instruments and finish- the margin of the restoration
ing burs. Restoration margins were further polished with 1 Caries evident continuous with the
margin of the restoration
silicone polishers (Astropol FP, HP, Ivoclar Vivadent) and
interproximal polishing strips (Soft-Lex Finishing Strips, Postoperative 0 No symptoms
3M ESPE) at 7500 to 10,000 rpm under water. One clin- sensitivity 1 Slight sensitivity
ician (M.G.) placed all restorations. Finally, the occlusion 2 Moderate sensitivity
3 Severe pain
was checked in protrusive and lateral movements of the
mandible. The time spent for the restoration was also
recorded at the end of each session. blinded to the objective of this study. Caries, debond-
ing, chipping, and fracture were considered absolute
Evaluation failures. Patients were also questioned about post-
Restorations were evaluated at baseline and thereafter operative complaints. Both observers evaluated the
every 6 months by two calibrated observers who were restorations independently, according to the modified

doi: 10.3290/j.jad.a28883 5
Gresnigt et al
Survival Functions
100
80
Cumulative Survival
60
40
20
0 resin composite and ceramic laminate
0 10 20 30
Months
United States Public Health Service (USPHS) criteria
(Table 3). The restorations were visually inspected with
a dental mirror and probe. After data collection, in case
of discrepancies in scoring, restorations were evalu-
ated again, a consensus was reached, and this was
accepted as the final score. Patients were instructed to
call if any kind of failure occurred. Digital photos (1:1)
were made after placement of the veneers and during
follow-up sessions.
Statistical Analysis
Survival analyses were performed with the statistical
software program SPSS 13.0 (SPSS; Chicago, IL, USA),
using Kaplan-Meier and Log Rank (Mantel-Cox) tests to
obtain the overall survival rate in relation to observation
time. p-values less than 0.05 were considered to be sta-
tistically significant in all tests.
RESULTS
In total, five recalls were performed after baseline
measurements and no drop-out was experienced, so
that 46 indirect laminate veneers (Estenia: n = 23; IPS
Empress Esthetic: n = 23) were evaluated. The mean
observation time was 20.3 months, with a minimum ob-
servation period of 12 months (n = 46) and a maximum
of 36 months (n = 4). At the final follow-up, 27 of the
laminate veneers were observed for 12 months, 15 for
24 months, and 4 for 36 months. Of these 46 laminate
veneers, 17 of them were cemented onto intact teeth
and 29 onto teeth with existing resin composite restora-
tions. All existing composites were rated as small resto-
rations. The distribution of their locations in the maxilla
was as follows: 18 on central incisors, 18 on lateral
incisors, and 10 on canines.
6 The Journal of Adhesive Dentistry
Laminate Material
IPS Empress Esthetic
Estenia
IPS Empress Esthetic-
censored
Estenia-censored
Fig 2 Event-free survival rates of indirect
40 veneers based on material (Estenia:
87%, n = 23; events n = 3; IPS Empress
Esthetic: 100%, n = 23; events n = 0).
The average treatment time for each restoration was
noted to be approximately 120 min. Two patients re-
ceived occlusal splints after cementation.
As shown in Fig 2, the overall survival rate of the in-
direct composite laminate veneers (87%) and ceramic
veneers (100%) did not show statistically significant dif-
ferences (p > 0.05; Kaplan-Meier, Log Rank (Mantel-Cox),
Cl = 95%). The survival rates of the laminates bonded to
teeth and with (93.5%) and without (94.1%) existing resin
composite restorations also did not show significant dif-
ferences (p > 0.05; Kaplan-Meier, Log Rank (Mantel-Cox),
Cl = 95%). The overall survival rate was 93.5% (Kaplan-
Meier). Hazard ratios could not be calculated due to non-
significant differences between the groups.
A total of 3 absolute failures was observed in the group
of indirect resin composite veneers in the form of debond-
ing (n = 1) and fractures (n = 2). The debonding was a
complete adhesive failure between the tooth and the lut-
ing cement, which occurred 11 months after cementa-
tion. On the distal and cervical sides of the tooth (13),
there were small existing resin composite restorations.
The existing restoration in the cervical area, which was
bonded solely to dentin, remained attached to the cemen-
tation surface of the laminate restoration. After cleaning
the cementation surface, the debonded veneer was re-
cemented using the same adhesive protocol.
Both fractures occurred in the incisal area and were
cohesive failures in the indirect composite material. The
first fracture was experienced on tooth 11, which had a
small cervical existing composite restoration, 13 months
after cementation. The second laminate fracture was on
tooth 22, bonded to intact tooth structure with no existing
restorations, 11 months after cementation. All 3 failures
were experienced in laminate veneers bonded to vital
teeth. Representative failure types and observations are
presented in Fig 3.
 Gresnigt et al

Fig 3a Adhesively debonded composite laminate veneer from tooth 13. Note that Fig 3b Cohesive fracture failure (chipping) of
some resin cement was left bonded on the cementation surface of the laminate. the composite laminate veneer on tooth 11.
Tooth had small existing resin composites on the cervical area and distal side.

Fig 3c Cohesive fracture of the composite laminate veneer on Fig 3d Baseline frontal view of ceramic laminates on teeth
tooth 22 due to bruxism. Patient reported that he did not wear 11, 21, 13, 23 and composite laminates on teeth 12 and 22.
the splint provided. Note the similar glossy surfaces for both materials.

Fig 3e Rough surface and diminished gloss of the composite

laminate veneer on teeth 12 and 13 in comparison to the ce-
ramic veneer on tooth 11 at the 13-month follow-up.

Of the 43 laminate veneers, minor voids and defects
were observed in 6 of the composite and 3 of the cer-
amic veneers (adaptation, score 1). Slight staining at
the margins (n = 3, marginal discoloration, score 1) and
slightly rough surfaces (surface roughness, score 1)
were more frequently observed in the resin composite
laminate veneer group (n = 18) up to the final recall
(Table 4).
Secondary caries, endodontic complications, or wear of
the antagonist were not observed in any of the cases. In
total, 8 teeth showed postoperative sensitivity at baseline.
All postoperative sensitivities disappeared after 2 weeks.

doi: 10.3290/j.jad.a28883 7
Gresnigt et al

Table 4 Summary of USPHS evaluations at baseline time points, no direct comparison of their clinical perfor-
and final follow-up mance can be made. To the authors’ best knowledge,
this is the first randomized controlled clinical study
Criterion and Baseline Final Recall where materials of two different natures were compared
score in the same patient. Based on the non-significant differ-
Estenia IPS Estenia IPS ences in the clinical survival of the two materials, the
(n = 23) Empress (n = 20) Empress null hypothesis could be accepted. The interim results
Esthetic Esthetic presented here cover observations up to a maximum
(n = 23) (n = 23)
of 36 months. Overall, 93.5% of the laminate veneers
Adaptation 0 18 23 23 20 required no intervention by the final follow-up, which may
of restora- 1 6 – 6 3 be considered clinically acceptable. However, some of
tion 2 1 – – – the findings could provide insight into the long-term per-
3 – – – –
4 – – – – formance of the two materials tested.
The number of absolute failures was limited in this
Color 0 10 7 20 19 study, with one debonding and 2 cohesive fractures that
match 1 13 16 – 4 occurred only in the group of the composite laminate
2 – – – –
3 – – – – veneers. Early failures are commonly related to technical
4 – – – – failures and not as a consequence of fatigue. The com-
posite laminate veneers in which the 2 fractures were
Marginal 0 23 23 17 22 observed indicate that the adhesive strength of the ce-
discolor- 1 – – 3 1
ation 2 – – – – mentation interface was sufficient and exceeded that of
3 – – – – the cohesive strength of the particulate-filled composite.
Similar observations were made in an in vitro study,21
Surface 0 18 23 2 23 where cohesive fractures were the predominant failure
roughness 1 5 – 18 –
2 – – – – mode for the same indirect resin composite tested. In the
3 – – – – same study, the mean bond strength of the indirect com-
posite-restoration luting composite was higher than that
Fracture of 0 23 23 20 23 of ceramic-restoration luting composite cement where the
restoration 1 – – – –
2 – – – – latter presented mainly adhesive failures. Since no adhe-
3 – – – – sive failures were observed in the ceramic laminate group
4 – – – – in the current study, the results of that laboratory study21
5 – – – could not be confirmed.
Fracture of 0 23 23 20 23 In this study, the existing resin composites were not
tooth 1 _ _ – – removed, as every removal attempt would yield more tis-
2 _ _ – – sue loss. However, adhesion becomes complex in situa-
3 _ _ – – tions where the pre-existing composite restorations are
4 _ _ – –
5 _ _ – – next to enamel and dentin. These three substrates need
to be conditioned in three different fashions. Considering
Wear of 0 23 23 20 23 only 1 debonding incidence out of 46 laminate veneers
restoration 1 _ _ – – in this study, the adhesive protocol employed could be
Wear of 0 23 23 20 23 considered reliable. Certainly, the cross contamination
antagonist 1 _ _ – – due to different conditioning procedures might have im-
paired the adhesion,33 but the overall strength seems to
Caries 0 23 23 20 23
1 _ _ – –
be clinically sufficient. It should also be noted that the
existing restorations were all rated as small, indicating
Post- 0 17 21 20 23 that the majority of the substrate surface consisted of
operative 1 4 2 – – tooth substance. In a clinical study, where the size of the
sensitivity 2 2 _ – –
3 _ _ – –
restorations was not mentioned, ceramic laminate ve-
neers crossing existing composite restorations showed
lower longevity compared to those that did not, after 18
months of clinical service.24 However, no information
DISCUSSION was provided on whether any conditioning method was
employed on the existing composites. Karlsson et al24
This clinical trial compared the performance of partic- reported that 60% of the laminate veneers crossed over
ulate-filled composite and leucite-reinforced laminate an existing composite restoration. Although composite-
veneer materials in the same mouth. When patients are composite adhesion delivers promising results with the
treated at different times and places, or for financial same conditioning methods used here,3,21,34,35 further
reasons, finding the two types of materials in the same clinical observations are needed on the performance of
mouth is a common observation. In such cases, since the laminate veneers bonded to larger composite resto-
the laminate veneers are then usually made at different rations.

8 The Journal of Adhesive Dentistry


One of the two cohesive fractures was observed in
a patient with a history of bruxism who reported that
he did not use the splint he was given to wear at night,
and the reason for the other fracture could not be iden-
tified. The cohesive strength of not only composites
but also ceramics may be not enough for individuals
with parafunctional habits. In a review by Friedman,16
such patients were reported to be more prone to short-
term cohesive fractures in the ceramic. For this reason,
splints were indicated for such patients. The limited
number of fractures in the present study cannot confirm
the findings of this review.
While the fracture of laminate veneers could not be
attributed to one single cause only, adhesive debonding
failure with no remnants of cement left on the tooth sur-
face could be considered a consequence of insufficient
adhesion between the tooth and the resin cement. In the
debonded case, a small resin composite was present at
the cervical area and distal surfaces of the tooth. Thus,
the majority of the bonded substrate was the tooth sur-
face. On the other hand, the existing composite at the
cervical area was pulled out due to debonding. In this
study, a dual-polymerizing single-bottle adhesive resin
was used. In fact, such adhesives presented similar
results on both enamel and dentin.11,20 The existing
composite restoration in the cervical area was found
attached to the cementation surface of the composite
laminate. This could imply that the adhesive strength
of the composite-cement bond was stronger than the
dentin-cement bond. After cleaning the cementation sur-
face and reconditioning the laminate veneer according
to the adhesive protocol described, it was rebonded and
remained functional without any problems until the end
of the observation period.
Surface roughness, adaptation, and marginal staining
were the most frequent relative failures for the indirect
composite veneers. These kinds of changes were ex-
pected, but the intensity and speed of change was not
known, and therefore a modified split-mouth design was
employed in this clinical trial. In fact, in terms of color
match, resin composites presented better results than
did the ceramic laminate veneers. The surface roughness
was noticeable when the laminate surfaces were air dried
to remove the thin saliva film, in accordance with the
requirements for evaluations using USPHS criteria. The
increased surface roughness, however, was not always
accompanied by color change. Possibly for this reason,
none of the patients complained about the changes of
the surface and some even did not even notice them.
Refinishing and repolishing were not carried out on any of
the restorations.
In the dental community, surface degradation is con-
sidered a reason for replacing resin composite restora-
tions. Aging of the resin-based materials may lead to
leaching of the components, and swelling and degrada-
tion of the cross-linked resin matrix.8,41 Hydrolysis of
silane (Si-O-Si) at the filler/matrix interfaces may even-
tually lead to filler loss and increased surface rough-
ness.12,13,27 Since the laminate veneers are not placed
on the occlusal surfaces, the effect of application and
doi: 10.3290/j.jad.a28883
Gresnigt et al
polishing procedures are of more importance. In this
regard, high filler content and heat- and photopolymeriza-
tion processes in the particulate-filled composite tested
were expected to deliver better surface properties with
this material. In a recent study, surface characteriza-
tion of resin-based materials revealed the presence of
a principally resin matrix rather than the fillers on the
outer surface after polymerization.38 Among other aging
parameters, the biofilm effect with similar microbial com-
positions was found to age the direct resin composite
surfaces the most,39 possibly as a result of different
concentrations of positively-charged inorganic elements
on the composite surfaces.7 Although some surface deg-
radation could also be expected from ceramic materials
according to in vitro6,18,25 and clinical studies,9,24 the
leucite-based ceramic used in this study showed exclu-
sively smooth surfaces (surface roughness, score 0)
until the end of the observation period.
Minor voids and defects (6 out of 20 with Estenia and
3 out of 23 with IPS Empress Esthetic, USPHS criteria;
adaptation, score 1) and slight staining at the margins
were noted (3 out of 20 with Estenia and 1 out of 23 with
IPS Empress Esthetic, USPHS criteria; marginal discol-
oration, score 1) until the final recall. In other studies,
such defects were not only observed at the interface
between the laminate and the existing restorations, but
also at the tooth/laminate interfaces. Since the prep-
aration margins were extended to the proximal sites,
the margins at these areas were hidden and could not
be evaluated. Thus, minor voids, defects, and marginal
staining were mainly observed at the incisal or cervical
margins. In other studies, such adaptation defects were
reported to increase from 1.2% at 6 years to 7.9% after
12 years.14,37 The restorations from the present study
are being followed-up for a longer duration, both in terms
of absolute and relative failure.
CONCLUSIONS
Based on the interim results of this clinical study, the
following can be concluded:
When absolute failures are considered, the clinical
performance of the indirect resin composite and ceramic
laminate veneers tested showed no statistically signifi-
cant difference in survival rates up to 36 months. Surface
quality changes were more frequently observed in the
composite veneer material, which may require more main-
tenance over time.
ACKNOWLEDGMENTS
The authors acknowledge Mr. Stephan van der Made of the dental
laboratory Kwalident for his meticulous work in fabricating the indi-
rect resin composite and ceramic laminate veneers, as well as Dr.
Dick Prins, Dr. Hans van Pelt, and Dr. Henk Alting for evaluation of
the laminate veneers. We extend our gratitude to Ivoclar Vivadent,
Schaan, Liechtenstein and Kuraray, Tokyo, Japan for supplying
some of the materials used in this study.
9
Gresnigt et al
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The Journal of Adhesive Dentistry