Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19 (5):e426-32.

Bruxism and porcelain laminate veneers

Journal section: Clinical and Experimental Dentistry
Publication Types: Research

doi:10.4317/medoral.19097
http://dx.doi.org/doi:10.4317/medoral.19097

Influence of bruxism on survival of porcelain laminate veneers
Maria Granell-Ruíz 1, Rubén Agustín-Panadero 1, Antonio Fons-Font 2 , Juan-Luis Román-Rodríguez 1,
María-Fernanda Solá-Ruíz 3

DDS,PhD. Associate Profesor, Oclusion and Prosthodontics, Department of Stomatology, University of Valencia, Valencia,
Spain
2
DDS,PhD,MD. Professor of Oclusion and Prosthodontics, Department of Stomatology, University of Valencia, Valencia,
Spain
3
MF,DDS,PhD,MD. Adjunct Lecturer, Department of Stomatology, University of Valencia, Valencia, Spain
1

Correspondence:
Unidad de Prostodoncia y Oclusión
Edificio Clínica Odontológica
C\ Gascó Oliag, Nº 1
46010 Valencia Spain
maria.granell@uv.es

Received: 31/01/2013
Accepted: 19/05/2013

Granell-Ruíz M, Agustín-Panadero R, Fons-Font A, Román-Rodríguez
JL, Solá-Ruíz MF. Influence of bruxism on survival of porcelain laminate
veneers. Med Oral Patol Oral Cir Bucal. 2014 Sep 1;19 (5):e426-32.
http://www.medicinaoral.com/medoralfree01/v19i5/medoralv19i5p426.pdf

Article Number: 19097
http://www.medicinaoral.com/
© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
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Abstract

Objectives: This study aims to determine whether bruxism and the use of occlusal splints affect the survival of
porcelain laminate veneers in patients treated with this technique.
Material and Methods: Restorations were made in 70 patients, including 30 patients with some type of parafunctional habit. A total of 323 veneers were placed, 170 in patients with bruxism activity, and the remaining 153 in
patients without it. A clinical examination determined the presence or absence of ceramic failure (cracks, fractures and debonding) of the restorations; these incidents were analyzed for association with bruxism and the use
of splints.
Results: Analysis of the ceramic failures showed that of the 13 fractures and 29 debonding that were present in our
study, 8 fractures and 22 debonding were related to the presence of bruxism.
Conclusions: Porcelain laminate veneers are a predictable treatment option that provides excellent results, recognizing a higher risk of failure in patients with bruxism activity. The use of occlusal splints reduces the risk of
fractures.
Key words: Veneer, fracture, debonding, bruxism, occlusal splint.

Introduction

have proven to be one of the most successful techniques
used in Restorative Dentistry (1).
Porcelain laminate veneers represent a predictable restorative solution for anterior teeth due to their excellent
aesthetics as well as their durability and biocompatibility (2). These restorations constitute an alternative to

The veneer restoration technique was developed in the
mid nineteen-eighties in the United States, and later
spread throughout the world. Bonding these fragile porcelain laminae securely to natural teeth has been a challenge for our profession. Fortunately, these restorations
e426

the 323 restorations studied had been placed in 70 patients with a duration ranging from 3 to 11 years. where to date a large number of patients have been treated with porcelain laminate veneers in response to aesthetic demands. The clinical diagnosis was made by clinical inspection of teeth of the consequences of clenching or grinding activities were visible in the dentition and consistent with a bruxing habit.9. Material and Methods Three hundred twenty-three porcelain laminate veneers were placed during a period of eight years.3% (17) were male and 75.1% of the total. 238 were placed in the maxillary arch and 85 in the mandibular arch. We conducted a retrospective clinical study to review patients wearing porcelain laminate veneers. had to use occlusal splints (Hard acrylic). These criteria provided us with 3 patients groups for the study: A. Bruxism is generally recognized as non-functional jaw movements. Currently.7% (53) were female. replace old composite restorations. Restorations placed in patients presenting some type of bruxism activity should have a functional design.4%) were of simple design or window preparation. Liechtenstein) in order to standardize the results and eliminate any variables that could arise from the use of different ceramics.19 (5):e426-32.Med Oral Patol Oral Cir Bucal. with a mean age of 46 years (range 18 to 74). we checked occlusion properly.Patients with bruxism activity not using splints (they have it but they don´t use it). 124 (38. This study focussed on the relationship between the different ceramic failures and bruxism. This group included 15 patients (21. Of the maxillary restorations. Bruxism and porcelain laminate veneers full-coverage restorations since they require minimal tooth preparation. As with any technique. At the time of the study.6%) corresponded to those denominated ‘functional’ (with incisal overlap). This group included 40 patients. therefore. representing 57. 19 on canines and 4 on premolars. covering only the buccal surface (B) and 199 (61. and is defined as a forcible clenching or grinding of the teeth. Of the mandibular restorations. therefore information was collected on the presence or absence of bruxism activity and whether or not these patients had to use splints. These techniques have been used since 1985 at the Prosthodontics and Oclussion Teaching Unit of the University of Valencia.5) suggest that bruxism constitutes a contraindication to these bonded restorations. B. The occlusal splint is generally used to treat muscle hyperactivity. 82 on lateral incisors. The success rates may be increased if bruxism iscontrolled. This percentage is very similar to that obtained for metal-ceramic restorations in the same situation. it is therefore advisable to use these devices in patients with suspected bruxism following prosthodontic treatment with either full coverage crowns or with laminate veneers. all fabricated with IPS-Empress ceramic (Ivoclar®. and has long been regarded as a disorder requiring treatment (6).Patients with bruxism activity using splints properly. mask tooth discoloration (3). Magne et al. Some authors (4. We analyzed whether the presence of bruxims activity and the use of occlusal splints in our patients. all patients with it. affected the medium and long term survival of these treatments. 49 on canines and 10 on premolars. there by maintaining the dental structure. This group included 15 patients (21. Studies carried out by various authors (1013) show that these splints decrease bruxism activity generated during periods of stress.4%) with 81 veneers (28 conventional and 53 functional). Of the 323 veneers. porcelain laminate veneers are indicated for a wide range of situations and can be used to correct the shape and position of teeth. These patients were restored with 153 veneers (65 conventional design and 88 functional). the use of porcelain veneers requires medium and long term studies to confirm their indications (4. after placing the ceramic restorations. gnashing and grinding of the teeth (7). a nocturnal and / or diurnal splint is recommended as a preventive measure to reduce the risk of failure.Patients without bruxism. or a combination of both. According to the American Academy of Orofacial Pain. bracing. School of Medicine and Dentistry. especially in these patients (4. Thirty of the 70 patients presented bruxism activity.15-20). especially in situations where the patient has already lost some tooth structure and where these restorations provide the patient with a correct anterior and canine guidance (14). report that the success rate for the veneer is reduced to 60% in patients with bruxism activity (8). One hundred seventy veneers were bonded in patients with bruxism activity and 153 in patients without it. Therefore. Schaan. 2014 Sep 1. and to restore teeth following incisal abrasion and dental erosion. C. 24.9). bruxism is a diurnal or nocturnal parafunctional activity which includes clenching. 31 on lateral incisors. Regarding location. 15 complied with this requirement and 15 did not. e427 . close diastema. during maximum intercuspation and during mandibular excursive movements. 31 were located on central incisors. To this end we developed a data collection methodology to provide reliable results able to withstand the usual sta- tistical tests for these sample types and to be compared with results of other authors. covering the incisal edge and part of the palatal/lingual tooth surface (F). Of the patients studied. 97 were on central incisors.4%) with 89 veneers (31 conventional and 58 functional).

The Kaplan-Meier curves (Kaplan-Meier. the results were: Ceramic failures: The survival of restorations in terms of their structural integrity is the most important factor for both patients and professionals when deciding on this treatment option. The statistical analysis focused on: An initial descriptive analysis containing the frequencies and percentages for the categorical variables in the study. A Kaplan-Meier Survival Analysis was used to study survival. there were no significant differences between the type of restoration used (conventional or functional) and the presence of bruxism activity (p = 0. Twentytwo were found in patients with bruxism. without statistically significant differences (p = 0. although. and 7 in patients who did not (p = 0.19 (5):e426-32. Bruxism and porcelain laminate veneers Patients who were bruxers were provided with hard acrylic resin occlusal guards to protect the definitive restorations during bruxing episodes. The figure below illustrates the higher proportion of debonding in patients with bruxism versus those without it (Fig����������������������� . The figure below shows that a higher proportion of fractures were observed in patients with bruxism activity who did not use a splint (9%) than in those who used a splint properly (1%) (Fig. this was observed to be more frequent in patients with bruxism. Eight appeared in patients with bruxism.009) (Chi2). a clear link can be seen. the analysis was made in terms of the presence or absence of the three most important aspects: cracks. Two types of deterioration were considered: debonding and fracture. and only for dichotomous variables. Results During the evaluation period. and the remaining 5 in patients without it. 1 occurred in a patient who did use a splint. 4). ��������������������� 2). Debonding: A total of 29 debonded restorations were observed.511) (Chi2). This does not mean that some of the fractures found had not initiated as a crack. 12 appeared in patients using a splint and 10 in patients where splints were not used. Fractures: A total of 13 fractures were observed (4%). Regarding debonding. Table 1. which over time had developed into a fracture. Furthermore. indicating the probability that a restoration will remain in good condition over time.825) (Chi2).023) (Fisher). given that 5 fractures appeared in patients without bruxism versus 8 fractures that occurred in patients with it (p = 0. As a comparative test the log-rank test was used (Kaplan-Meier. in addition this deterioration was related to the presence or absence of bruxism. All of the patients were treated at the Prosthodontics and Occlusion Teaching Unit of the University of Valencia School of Medicine and Dentistry by a team that had followed the same method when placing the veneers. 1958). always provided that more than 5 cases were present in the contingency tables. the Fisher’s exact test was used. A bivariate analysis. and the remaining 7 in patients without it. Fractures: The estimated survival table showed that the mean survival times were similar between patients with and without bruxism. These analyses were performed using nonparametric statistical tests given the categorical nature of the variables. Debonding: Although the estimated survival table indicated that the mean survival times were similar between patients with and without bruxism.Med Oral Patol Oral Cir Bucal. covering all the statistical comparisons necessary to assess the relationship between fractures and debonding in patients with bruxism activity. 2014 Sep 1. By statistically relating ceramic failures with bruxism. in this study most patients with bruxism were fitted with functional restorations (F).151) (Chi2). are not statistically significant.519) (Fig. and the use of a splint by these patients. Presence of Nº Bruxism patients Nº veneers Fractures Debonding No 40 153 (65C-88F) 5 7 Yes (with splint) 15 89 (31C-58F) 1 12 Yes (without splint) 15 81 (28C-53F) 7 10 Total 70 323 13 29 e428 . Regarding design. 22 were produced in these patients (p = 0. a clear statistically significant difference can be seen between the two groups of patients (with and without bruxism activity). Of the 29 debonded veneers. since of these 8 fractures. On one hand we can see that fractures. corresponding to 9% of the sample. 1). Otherwise. the log-rank test confirmed that the survival curves were statistically equal (p = 0. ���������������������������������������������������� Cracks: At the time of the review no cracks were observed. in contrast. This analysis considered the time in years during which the restoration remained in good condition or the time until deterioration. 3). The Pearson c2 test was used to test the association or dependence between two categorical variables. statistically significant differences were found when examining the correct use of splints in patients with bruxism. Of the 22 debonded restorations in patients with bruxism.008) (Fig. Distribution of veneers restorations. the log-rank test confirmed statistically significant differences in the survival curves (p = 0. Therefore. 1958) clearly show the survival of the restorations. fractures and debonding (Table 1). Frequency of fractures and debonding. although more frequent in the presence of bruxism.

e429 . Percentage of veneers debonding and patients with bruxism. 2014 Sep 1.Med Oral Patol Oral Cir Bucal. Percentage of veneers fractures and use of splint.19 (5):e426-32. Fig. Bruxism and porcelain laminate veneers Fig. 2. 1.

15-20). Survival estimates according veneers fractures. Survival estimates according veneers debonding.Med Oral Patol Oral Cir Bucal. 4. 2014 Sep 1. e430 . Bruxism and porcelain laminate veneers Fig. Discussion given that certain intraoral conditions cannot be duplicated in the laboratory.19 (5):e426-32. intermittent and cyclical forces on biting. It has been shown that clinical studies are needed in order to evaluate the performance of restorative materials.9. 3. the consumption of To date many longitudinal clinical studies have investigated the performance of porcelain veneers (4. chewing or grinding. Fig. These situations include the application of multiple. bacteria-rich environment. the constant exposure to a moist.

Fradeani et al. Orofacial Pain.18) with in vivo studies report high rates of debonding in restorations due to the presence of composite reconstructions in teeth supporting this type of restoration. 2. Clinical observations of porcelain veneers: a three-year report. the use of splints reduces the failure rate of porcelain laminate veneers in patients with bruxism activity. Christensen RP. Clinical result after five years follow-up. American Academy of Orofacial Pain. J Orofac Pain. but more to the existence of a history of bruxism. Clark GT. In the present study it was observed that fractures occurred more frequently in patients with bruxism. Discussion of results With respect to ceramic failures. Chen W. Br Dent J. report three cases of debonding in one of their studies. we therefore consider that the debonding was not so much related to the use or otherwise of a splint. 2006. Fractures: We found 4% of fractures. In this study. while the remaining 10 were related to patients who did not use a splint. References 1. 5. data similar to those of Jordan et al.22). 2014 Sep 1. Hamburger HL. taking into account that these patients generally wear the splint only at night. a high proportion of which occurred in patients with bruxism. Thus. other authors indicate a much higher rate of fractures. Debonding: there was a notably high percentage of debonding in this study (9%).76:a126. Perroud R. 1975. Martínez-González A. for example Kinh et al. Fons-Font A. It was found that of the 22 debonded veneers in patients with bruxism. (23) 0%. arguing that the majority of their patients had a history of bruxism. 10.11:e297-302. 2005. Raigrodski AJ. Solberg WK. 8.19 (5):e426-32. Freire A. Int J Periodontics Restorative Dent. since the restoration is simply replaced. Solá-Ruiz MF. the probability of fracture being 8 times greater in patients who are required to use a splint but do not. Lobbezoo F. Conclusions 1. Visscher CM. Vanherle G. and Nordbø et al. (15) and Calamia (24) with 3%. 29 debondings (9. In vivo studies are therefore necessary to verify the acceptability of a laminate veneer as a definitive restorative treatment. Porcelain laminate veneer on a highly discoloured tooth: a case report.20:440-57.3:174-9.41:309-324. 1991. Christensen et al. 2. Longitudinal in vivo clinical studies are needed to evaluate the performance and predictability of restorative materials. 1998. Yoshida Y. Retrospective studies can provide a reliable picture of the clinical performance of materials and techniques. (5) 1%. 49-73. Van Meerbeeck B. J Oral Rehabil. It was found that.0%). and that they had used conventional feldspathic porcelain. Archegas LR. Rugh JD. A choice of ceramic for use in treatments with porcelain laminate veneers. Granell-Ruiz M.2:215-23. Controlled assessment of the efficacy of occlusal stabilization splints on sleep bruxism. 3. Clinical performance of novel-design porcelain veneers for the recovery of coronal volume and length. 2010. in the present study there were 13 fractures (4. Wicks DJ. Attanasio R. 2000. J Esthet Restor Dent. thus justifying the use of stronger porcelain. in vitro studies may have more impact.0%) and no cracks.23). Cracks: The fact that in this study no cracks appeared in the restorations may be due to the use of high-strength porcelain (IPS-Empress). the authors observed 12% cracks. Intraoral orthotic Therapy. The majority of clinical studies reviewed report a low incidence of fractures. Belser UC. J Esthet Dent. 4. as well as vigorous brushing.29:211-221. which has a lower fracture strength than high-strength feldspathic restorations. Quintessence Int. e431 . Hodges JS. ed. Some authors do not consider debonding as a failure. commenting that the debonding was most certainly due to an inappropriate adhesive technique. these were replaced. Okeson JP. A conservative approach for treating young adult patients with porcelain laminate veneers. diagnosis. Some authors (16. Magne et al. (8) in a clinical study used conventional feldspathic porcelain for the fabrication of the restorations. and it has been found that bruxism may be both diurnal and nocturnal (25). In these cases the adhesion is between resin and resin. Walls AWG. Guidelines for assessment. Magne P. 1995. Chicago: Quintessence Publish Co. Christensen GJ. The use of adhesively retained all-porcelain veneers during the management of fractured and worn anterior teeth: Part 2. Peumans M. these do not offer the same prognostic value or long-term predictability of this treatment as studies in vivo.178:337340.Med Oral Patol Oral Cir Bucal. and management. which reduces the bond strength between the porcelain veneer-tooth complexes. Lambrechts P.19:151-158. 1996. (9) reported 13% at 3 years and Walls (4) 14% at 5 years. (17) with 5%. 9. 1997. The probability of debonding is almost 3 times higher in patients with it. Bruxism and porcelain laminate veneers hot and cold liquids. and Peumans et al. J Can Dent Assoc. with no signs of internal damage or fracture. 7. they can sometimes become out of date due to the rapid and constant change in technology and materials. Med Oral Patol Oral Cir Bucal. Van Der Zaag J. and that not using a splint when required constitutes a risk factor for the presence of fractures. 6. The majority of authors do not consider small cracks in restorations as failures (5. but have no greater utility. since certain intraoral conditions cannot be reproduced in the laboratory. 12 were related to patients who used an occlusal splint. Nocturnal electromyographic evaluation of bruxism patients undergoing short term splint therapy. 11. Labaig-Rueda C. While numerous in vitro studies exist (21. 3. (19).20:223-238. Five-year clinical performance of porcelain veneers. 2008. the presence of fractures and debonding in porcelain laminate veneers increases considerably in patients with bruxism. However. Although longitudinal clinical studies of longer than 5 years certainly provide useful scientific data. Naeije M. Dent Clin North Am. p.

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