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10.14219/jada.archive.1995.

0081
1995;126(11):1523-1529 JADA
DJ Pippin, JM Mixson and AP Soldan-Els
incisors: veneers vs. PFM crowns
Clinical evaluation of restored maxillary
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A R T I C L E 1
C L I N I C A L E V A L V A J I O N O F R E SI O R E D M A X I L L A DY I N C I SO R S:
V E N E E R S V S. PF M C R O WN S
DA V I D J . PI PPI N , D.D.S., M .S.; J A M E S M . M I X SO N , D.D.S., M .S.;
A N T O N P. SO L DA N -E L S, D.D.S.
T his cross-sectional study com-
pared the periodontal health and
clinical acceptab ility of max illary
incisors restored with porcelain
veneers vs. porcelain-f used-to-
metal crowns. T he authors eval-
uated 60 patients, a total of 1 20
restorations, in groups accord-
ing to the age of the restorations
( z ero to 60 months). M argins of
veneers were generally more
supragingival with less gingival
inf lammation. A ll veneers were
clinically acceptab le, while 5
percent of PF M s f ailed b ecause
of secondary caries.
G entists
historically
have used
porcelain-f used-to-metal
crowns
f or the esthetic restoration of max illary incisors. A lthough this type
of restoration has served us well, PF M preparations do have some
drawb ack s. F or ex ample, preparation f or PF M crowns is not conser-
vative of tooth structure. A lso, the margins of these restorations
of ten are placed b elow the gingival margin. Dentists have k nown
f or some time that such placement of restoration margins is detri-
mental to
gingival health.` 4 T his is true
regardless
of the material
used, although dif f erences ex ist f or various materials.4
Supragingival margin placement, b y contrast, of f ers greater ac-
cess f or plaq ue control and maintenance procedures and thus, re-
sults in f ewer deleterious ef f ects on gingival health.1 5 Despite the
clinical b enef its of supragingival placement, however, patients may
b alk at visib le margins on anterior teeth and may pref er sub gingi-
val placement.67
Porcelain laminate veneer restorations address some of the limi-
tations of PF M f ull coverage. F or ex ample, veneer restorations re-
q uire only conservative tooth preparation. V eneer margins can b e
b onded to enamel to increase retention and decrease microleak age.6
Supragingival or eq uigingival placement8 of the veneer margin may
allow a translucent b lending of the tooth and the restoration at the
margin of the veneer.6 Despite this f inal b enef it, however, K arlsson
and colleagues report that dentists continue to place a signif icant
proportion of veneer margins sub gingivally f or a variety of reasons.7
A necdotal reports suggest that the potential f or less intrusive mar-
gin placement when porcelain laminate veneers are used may lead
to advantages f or the periodontal tissues.69 A cceptance of porcelain
laminate veneers among practitioners is high, with 9 1 percent in a
recent survey rating veneers as an ethical choice f or esthetic
restorations.1 0
T his clinical study compares, f or the f irst time, parameters of
periodontal health, restoration integrity and esthetics b etween
PF M crowns and porcelain veneer restorations.
M A T E R I A L S A N D M E T HO DS
T his retrospective study is a cross-sectional survey of randomly se-
J A DA , V ol. 1 26, N ovemb er 1 9 9 5 1 523

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-C I N I C A L PO A C T I I C E
T A BL E I
lected volunteers f rom the pool
of active patients
at the
University
of M issouri-K ansas
C ity dental school. T he accep-
tance rate among those ask ed to
participate ex ceeded 9 0 percent.
A ll
participants signed an in-
f ormed consent f orm approved
b y the appropriate
I nstitutional
R eview Board.
T o q ualif y f or the study, par-
ticipants
had to have had the
same type of restoration-ye-
neers or PF M crowns-previ-
ously placed
on each of two
max illary incisors during a sin-
gle appointment
at the dental
school. A lthough
we pref erred
to evaluate restorations on cen-
tral incisors, we did occasionally
sub stitute restorations on lat-
eral incisors in the sample.
R estorations were placed b y
predoctoral dental students
under the direct supervision of
dental f aculty.
A ll PF M mar-
gins were b eveled shoulders.
L A BI A L L I N ,
PF M crowns were f ab ricated at
the school and veneers were
f ab ricated b y a local dental lab -
oratory.
We selected 60 patients
with
a total of 1 20 restorations to
participate
in the study.
Half
the sample had two porcelain
laminate veneer restorations
( G roup I ) and the others had
two PF M crowns ( G roup I I ).
G roup
I consisted of 1 3 men and
1 7 women ranging
in age
f rom
1 8 to 7 7 years, with an average
age of 3 6. G roup
I I was com-
posed of 1 5 men and 1 5 women,
ages 25 to 7 6 years, with an av-
erage age of 56.
T hese two groups
were then
f urther divided according to the
age of the restorations:
z ero to six months;
seven to 24 months;
25 to 60 months.
E ach sub group had 1 0 pa-
tients ( 20 restorations) assigned
to it.
We col-
lected a medi-
cal history
f or
each partici-
G QUA L . pant and ex -
~ ~ cluded anyone
T O O T R I who had con-
ditions or
hab its that
9 .53 * would ad-
3 4 .05 versely af f ect
gingival
1 .4 2
health ( such
as use of med-
_ 7 _ _ ications lik e
cyclosporine,
0.1 7 *
calcium chan-
0.60
nel b lock ers,
b irth control
pi' lls, estrogen
or phenytoin;
immune sys-
tem dysf unc-
tion; recent
anti-inf lam-
matory thera-
py;
chronic illness or inf ection;
diab etes; or tob acco use).
T o assess the periodontal
health and clinical adeq uacy
of
the restorations, three clini-
cians measured various clinical
parameters.
E x aminers col-
lected clinical measurements at
six sites per tooth ( distolab ial,
lab ial, mesiolab ial, distolingual,
lingual, mesiolingual). T he clin-
icians were calib rated, and they
ex amined approx imately
the
same numb er of patients
in
each sub group.
I nterrater
agreement ex ceeded 8 5 percent.
Periodontal measurements
included gingival crevicular
f luid f low, pock et depth mea-
surement, gingival b leeding
index 1 ' and the Quigley, Hemn
and T uresk y plaq ue index .' 1 2 T he
ex aminers measured gingival
crevicular f luid f low b y placing
a f ilter paper strip
1 millimeter
into the gingival sulcus f or 1 0
seconds and discarding it, then
1 524 J A DA . V ol. 1 26. N ovemb er 1 9 9 5
I N T E R -
M I D- I N T E R -~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
G ingival
c--re-viculanr
f lux id
V ex ieer 1 7 .25* 1 07 ' 1 6.4 0*
PF M A 3 5.9 1 22.4 8 4 5.62
V eneer- 2.28 1 .50 2.1 2
PF M 2.52 1 .67 2.4 8
V enaeer 0.4 l* 0.22 0Q3 9 *
PF M 0.63 0.25 0.7 7
V eneer ~ ~ ~ 0.9 3 0.8 2 1 L .8 9 *
PF M ~ ~ ~ ~ ~ 0.8 9 0.7 5 0.4 8
*Dif f erence b etween pairs is statistically signif icant, P< .001 .
t Dif f erence b etween pairs is statistically signif icant, P< .O 1 .
t Dif f erence b etween pairs is statistically signif icant, P< .05.
I N V E R -
PR O X I M A L
M I D-
irooirm
I N V E R -
PR O X I M A

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C L I N I C A L PR A C T I C E m
F igure 1 . M ean gingival crevicular f luid f low scores on the lab ial as-
pects of max illary incisors restored with veneer or PF M crowns.
M O
marginP2 mm ab ove the gingiva; M 1 , margin-c2 mm ab ove the gingiva;
M 2, margin even with the gingiva; M 3 , margin ex tends b eneath the
gingiva.
T A BL E 2
0
1
2
3
0.0
20.6
55.6
23 .8
0.0
1 0.0
27 .8
62.2
inserting a second, f resh strip
f or 3 0 seconds and immediately
measuring the gingival crevicu-
lar f luid in a Periotron 2000
( Pro-F low, I nc.). G C F scores
f rom z ero to 20 indicate relative
health, those 20 to 4 0 indicate
moderate gingivitis and scores
greater than 4 0 indicate overt
gingivitis.
C linicians used a UN C ( Hu-
F riedy) periodontal prob e
9 1 .1
1 .7
6.1
1 .1
1 .7
1 8 .3
3 1 .1
4 8 .9
graded in 1 -mm increments to
measure pock et depths.
T he ex aminers scored the
gingival b leeding index af ter
prob ing using 0 to indicate no
b leeding; 1 to indicate b leeding
at a single point; 2 to indicate a
line of b leeding; and 3 to indi-
cate prof use b leeding.
A f ter staining the teeth, the
clinicians rated the presence of
plaq ue on a scale of z ero
through f ive ( 0, no plaq ue and
5, ab undant plaq ue covering
two-thirds of the area or site).
F acial and lingual aspects were
considered separately since the
lingual aspect of the veneer
group consisted of virtually un-
restored tooth surf aces, particu-
larly at the gingival margin.
R estorative assessment in-
cluded the margin index of
Silness, which scores the mar-
gin position relative to the gin-
giva on a scale of z ero through
three. E x aminers scored caries
as present or ab sent. T hey as-
sessed margin integrity and the
restoration' s surf ace, color and
anatomic f orm according to the
modif ied R yge criteria f or clini-
cal assessment.' 3 O nly the lab ial
surf aces of each group were
compared f or these three
restorative index es. E ach pa-
tient also completed a survey
noting satisf action with esthet-
ics and comf ort of the restora-
tion.
We compared the parametric
data b etween the groups using
independent t-tests and com-
pared the ordinal data b etween
groups using K rusk al-Wallis
tests. T o evaluate the changes
across time within the two
groups b y sub group, we used
analysis of variance.
R E SUL T S
We evaluated a total of 1 20
restorations, 60 veneers and 60
PF M s. F or the veneers, the
mean time in service f or each
sub group was
- z ero to six months, 2.6
months;
-seven to 24 months, 1 3 .9
months;
-25 to 60 months, 4 1 .8 months.
F or PF M s, the mean time in
service f or each sub group was
-z ero to six months, 2.5
months;
J A DA , V ol. 1 26, N ovemb er 1 9 9 5 1 525

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C UL I N I C A L PR A C T I C E
F igure z . M ean gingival b leeodng I naex scores on tne lab ial aspects oT
max illary incisors restored with veneer or PF M crowns.
M O ,
marginx 2
mm ab ove the gingiva; M 1 , marginc2 mm ab ove the gingiva; M 2, mar-
gin even with the gingiva; M 3 , margin ex tends b eneath the gingiva.
-seven to 24 months, 1 5.9
months;
-25 to 60 months, 4 3 .2
months.
G C F increased as margins
were placed closer to and b elow
the gingiva ( F igure 1 ). T here
was a signif icant dif f erence b e-
tween the G C F scores of pa-
tients with veneers and those
with PF M s ( P< .001 , T ab le 1 ). A t
each margin index value, the
G C F scores f or the PF M s were
higher than the corresponding
values f or the veneers. T here
were no dif f erences b etween the
veneer and PF M groups related
to time and no pattern within
each group across time.
T he percentage of sites ex -
hib iting pock et depths greater
than 3 mm was low f or veneers
and PF M s ( T ab le 2). T he f re-
q uency of 4 -mm depths was 1
percent f or the lab ial surf ace of
veneers, 1 percent f or the lin-
gual surf aces of veneers, 4 per-
cent f or lab ial surf aces of PF M s
and 2 percent f or the lingual
surf aces of PF M s. T here was no
statistically signif icant dif f er-
ence b etween PF M sites com-
pared to corresponding veneer
sites. T here was no pattern re-
lated to time in service f or ve-
neers or PF M s.
G ingival b leeding index val-
ues increased as the margin
index scores increased, with the
highest values recorded f or sub -
gingival margin placement
( F igure 2). We noted signif icant
dif f erences f or gingival b leeding
b etween patients who had ve-
neers and those who had PF M s
( T ab le 1 ). A t each margin index
value, the scores f or the PF M s
were higher than the corre-
sponding values f or the veneers.
T here were no dif f erences b e-
tween groups f or gingival b leed-
ing index related to time and no
pattern within each group
across time.
G ingival crevicular f luid f low
and gingival b leeding index
scores f or the lab ial and lingual
aspects of veneers were not sig-
nif icantly dif f erent. T he PF M
lab ial and lingual scores, how-
ever, were signif icantly dif f er-
ent f or the G C F ( P< .01 ) and the
gingival b leeding index ( P< .01 ),
with lingual sites having higher
values.
Supragingival plaq ue scores
were generally low with no sta-
tistically signif icant dif f erences
on the f acial aspect ( T ab le 1 ).
A lthough dif f erences were sig-
nif icant on the lingual aspect,
these dif f erences could b e ex -
plained b y the f act that veneers
generally were not present on
this surf ace especially at the
gingival margin. T hus, on the
lingual surf ace, we were com-
paring unrestored tooth and the
PF M crown.
Scoring f or the margin index
showed that 56 percent of the
veneer margins on the lab ial
surf ace were placed at the gin-
giva and 21 percent were placed
ab ove the gingival margin,
while 28 percent of the PF M
margins on the lab ial surf ace
were placed at and 62 percent
were placed b elow the gingival
margin ( T ab le 2). L ingual ve-
neer margins generally were at
the incisal edge only, although
some veneers wrapped around
to the lingual interprox imally.
Placement of the PF M margins
on the lingual surf aces was sim-
ilar to that of the f acial sur-
f aces, with 3 1 percent placed at
and 4 9 percent placed b elow the
gingival margin. T here was no
change in the marginal index
values related to time in service
( sub groups) f or either type of
restoration.
E x aminers rated the q uality
of surf ace and color signif i-
cantly higher f or veneers than
PF M s ( P< .05) f or the z ero- to
six -month-old group ( 8 5 percent
ex cellent vs. 3 0 percent ex cel-
lent) and f or the 25- to 60-
month-old group ( 7 5 percent ex -
cellent vs. 3 5 percent ex cellent).
1 526 J A DA , V ol. 1 26, N ovemb er 1 9 9 5

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C L I N I C A L
PR A C T I C E I
F igure 3 . Percentage of participants who rated the appearance of their
restorations as "ex cellent."
T here was no dif f erence within
each group with the passage of
time.
T here were no dif f erences in
scores f or anatomic f orm b e-
tween groups f or each time peri-
od or within each group across
time. E x aminers did not detect
any f ractures in the veneer or
PF M group f or any time period.
M argin integrity was not sta-
tistically dif -
f erent b etween
veneers and
PF M s. O ne
Dr. Pippin I s an as-
sociate prof essor,
Department of
Periodontics, School
of Dentistry, Uni-
versity of M issouri-
K ansas C ity, 650 E .
25th St., K ansas
C ity, M o. 64 1 08 .
A ddres reprint re-
q uests to Dr. Pippin.
f tt_
Dr. M ix son I s an as-
sociate
prof essor,
Diagnostic Sciences,
School of Dentistry,
University of M is-
souri-K ansss C ity.
PF M , rated not acceptab le, had
z inc phosphate cement at the
margins that req uired removal.
A n additional three of the 60
PF M s ex amined had secondary
caries, eq ual to 5 percent of the
total. E x aminers did not detect
any caries on any of the restora-
tions in the veneer group.
Patients generally ex pressed
high satisf action with the ap-
pearance and comf ort of their
restorations, b oth veneers and
PF M s. N o signif icant dif f er-
ences were re-
ported in the
V comf ort of the
restorations;
1 _0most patients
rated the com-
f ort level of
Dr. Soidan-E ls I s an their restora-
associate prof essor.
tions as good
R estorative Den-
tistry, School of or ex cellent.
Dentistry, University A lthough there
of M lssouri-K ansas
C ity.
was no statisti-
cally signif icant dif f erence in
patient self -ratings concerning
the restorations' appearance,
there was a trend f or patients
with veneers to b e more highly
satisf ied than those with PF M s
over time ( F igure 3 ). F or ex am-
ple, at 25 to 60 months, 8 0 per-
cent of veneer patients rated
their appearance as ex cellent
compared with 4 0 percent of
patients with PF M s.
DI SC USSI O N
Studies show that sub gingival
placement of restoration mar-
gins adversely af f ects gingival
health.' 4 E x aminers of ten
noted clinical signs of gingivitis
during this study, especially
when margins were sub gingi-
val. A lthough they reported
variation among participants,
index es of inf lammation, gingi-
val crevicular f luid f low and
gingival b leeding index scores
sub stantiated this clinical ob -
servation. Because neither the
G C F nor the gingival b leeding
index scores increased over
time f or any given margin
index score, we assume that
the gingival inf lammation ap-
peared to estab lish itself early.
Higher scores were seen f or the
index es of inf lammation as the
margin index scores increased,
that is, as margin placement
moved closer to and b elow the
gingiva, there was more gin-
givitis.
Scores f or the clinical index es
were higher at each margin
index value f or PF M s than f or
veneers. Perhaps the PF M mar-
gin was more plaq ue retentive
due to margin adaptation, ce-
ment margin or gap siz e, or per-
haps the PF M margin harb ored
organisms that were more viru-
lent.1 4 N o correlation b etween
any of the index es and the
T uresk y plaq ue index was
J A DA , V ol. 1 26, N ovemb er 1 9 9 5 1 527

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-C L I N I C A L PR A C T I C E
f ound, in part b ecause this
index appears to have scored f or
plaq ue in the wrong area. T he
porcelain surf aces were rela-
tively f ree of plaq ue and
supragingival plaq ue scores
were correspondingly low. A
method of sampling or scoring
the margin area and its sub j a-
cent tooth surf ace may have
b een more usef ul.
T here was a notab le discrep-
ancy in the participants' ages
b etween the veneer group ( aver-
age age of 3 6 years) and the
PF M group ( average age of 56
years) in this study. T he ex am-
iners adhered to rigorous ex clu-
sion criteria f or any conf ound-
ing variab les that could have
adversely af f ected gingival
health. However, disparity in
age b etween groups is a limita-
tion of this study. A t our school,
the younger individuals tended
to have veneer coverage, while
older individuals may have had
greater need f or f ull coverage
b ecause of multiple restora-
tions, ex isting caries or previous
endodontic treatment.
T here was no evidence of gin-
gival recession f or veneers or
PF M s either clinically or when
the data were analyz ed b y sub -
group. When compared across
time, the margin index scores
showed no increase f or either
restoration.
Pock et depths generally were
shallow with a trend f or slightly
higher depths around PF M s.
O ur data did not indicate that
gingivitis necessarily led to per-
iodontal disease. O nly a very
small percentage of either type
of restoration ex hib ited pock et
depths greater than 3 mm and
no readings deeper than 4 mm
were recorded at any site. I t
may b e that periodontal disease
tak es longer to estab lish itself
than the 60-month limit of our
study or that our sample siz e
was not adeq uate to pick up the
small percentage of cases that
progress f rom gingivitis to peri-
odontal disease.
E x aminers rated veneers sig-
nif icantly higher than PF M s in
evaluating the q uality of sur-
f ace and color. T he higher
scores may b e attrib uted to sev-
eral f actors. Since veneers of ten
were placed f or esthetic rea-
sons, patients with veneers f re-
q uently had multiple veneers
Sub gingival placement of
the margins of restora-
tions adversely af f ects
gingival health, and ve-
neers have the potential
f or less intrusive place-
ment.
placed on their anterior teeth,
inf luencing a harmonious color
match. However, the presenta-
tion was not always simple. F or
the veneer group, 1 2 out of 3 0
sub j ects had f our or six anterior
teeth restored with veneers,
eight out of 3 0 sub j ects had
only teeth nos. 8 and 9 ve-
neered and 1 0 out of 3 0 had a
mix of veneers and PF M s. F or
the PF M group, six out of 3 0
sub j ects had f our or six anterior
teeth restored with PF M s, six
out of 3 0 had at least one other
PF M placed and 1 8 out of 3 0
had only teeth nos. 8 and 9 re-
stored. When PF M s or veneers
presented as two single restora-
tions in the anterior region,
there appeared to b e more dif f i-
culty in matching the color of
the porcelain to the adj acent
teeth. I n addition, veneers and
PF M s were f ab ricated at sepa-
rate lab oratories, which may
have inf luenced any dif f erences
in porcelain q uality. Surf ace
roughness of porcelain ap-
peared to b e caused b y inade-
q uate polishing f ollowing chair-
side adj ustments.
While there was no statisti-
cal dif f erence in margin integ-
rity b etween PF M s and veneers,
PF M margins appeared to b e
more susceptib le to secondary
decay ( 5 percent of the total ex -
amined). N o carious lesions
were recorded on teeth restored
with veneers.
G ender was evidently not a
f actor in this study. N o dif f er-
ences could b e attrib uted to
gender f or any index , and no
dif f erences ex isted over time as
related to gender.
C O N C L USI O N
T he trend f rom this study is
clear. Sub gingival placement of
the margins of restorations ad-
versely af f ects gingival health,
and veneers have the potential
f or less intrusive placement.
A dditionally, PF M s appear to
have increased deleterious ef -
f ects on the gingiva with higher
scores at each margin index
value compared with veneer
scores at the same margin index
value. PF M s may b e more sus-
ceptib le to secondary caries as
well. While there are clinical
situations that demand f ull-cov-
erage porcelain restorations,
this study suggests that when
teeth are restored f or esthetic
reasons, porcelain veneers are
the restoration of choice.
I ndeed, participants who had
veneer restorations in this
study tended to b ecome more
pleased with their appearance
as time passed, while PF M sub -
j ects b ecame less pleased.
Porcelain veneers appear to b e
clinically acceptab le, durab le
restorations f or max illary ante-
rior teeth. .
1 528 J A DA , V ol. 1 26, N ovemb er 1 9 9 5

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-C C I N I C A L PR A C I C E I
T his study was supported b y C hameleon
Dental Products. I nstruments were donated
b y Hu-F riedy.
1 . Silness J . Periodontal conditions in pa-
tients treated with dental b ridges. I I . T he in-
f luence of f ull and partial crowns on plaq ue
accumulation, development of gingivitis and
pock et f ormation. J Periodont R es 1 9 7 0;5: 21 9 -
24 .
2. Silness J . Periodontal conditions in pa-
tients treated with dental b ridges. I I I . T he re-
lationship b etween the location of the crown
margin and the periodontal condition. J
Periodont R es 1 9 7 0;5: 225-9 .
3 . V alderhaug J , Birk eland J M . Periodontal
conditions in patients 5 years f ollowing inser-
tion of f ix ed prostheses. J O ral R ehab il
1 9 7 6;3 : 23 7 -4 3 .
4 . L arato DC . E f f ect of cervical margins on
gingiva. J C alif Dent A ssoc 1 9 69 ;4 5: 1 9 -22.
5. R aetz k e P. [ R eaction of the marginal gin-
giva to contact with crown or veneering mate-
rials in sub j ects with ex cellent oral hygiene.]
Dtsch Z ahnarz tl Z 1 9 8 5;4 0: 1 206-8 ( E ng.
A b stract).
6. F riedman M J . T he enamel ceramic alter-
native: porcelain veneers vs. metal ceramic
crowns. J C alif Dent A ssoc 1 9 9 2;20( 8 ): 27 -3 3 .
7 . K arlsson S, L andahl I , Stegersj o G ,
M illeding P. A clinical evaluation of ceramic
laminate veneers. I nt J Prosthodont
1 9 9 2;5: 4 4 7 -51 .
8 . de R ouf f ignac M , de C ooman J . A esthetic
all-porcelain anterior restorations. Pract
Periodontics A esthet Dent 1 9 9 2;4 ( 8 ): 9 -1 3 .
9 . C utb irth ST . R estoration of max illary an-
terior teeth using porcelain j ack et crowns and
porcelain veneers. J E sthet Dent 1 9 9 2;4 ( 1 ): 1 -
5.
1 0. C hristensen G J . How ethical are es-
thetic dental procedures? J A DA 1 9 9 4 ;1 25( 1 1 ):
1 4 9 8 -502.
1 1 . M uhlemann HR . Psychological and
chemical mediators of gingival health. J Prev
Dent 1 9 7 7 ;4 ( 4 ): 6-1 7 .
1 2. T uresk y S, G ilmore N D, G lick man I .
R educed plaq ue f ormation b y the
chloromethyl analogue of victamine C . J
Periodontol 1 9 7 0;4 1 : 4 1 -3 .
1 3 . C alif ornia Dental A ssociation. Quality
evaluation f or dental care. G uidelines f or the
assessment of clinical q uality and prof es-
sional perf ormance. L os A ngeles: C alif ornia
Dental A ssociation; 1 9 7 7 .
1 4 . L ang N P, K iel R A , A nderhalden K .
C linical and microb iological ef f ects of sub gin-
gival restorations with overhanging or clini-
cally perf ect margins. J C lin Periodontol
1 9 8 3 ;1 0: 563 -7 8 .
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