The International Journal of Periodontics & Restorative Dentistry

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 s87

Marginal Adaptation and Fracture Resistance of

Lithium Disilicate Laminate Veneers on
Teeth with Different Preparation Depths

Erhan Tuğcu, DDS, PhD1 Achieving good esthetics and reli-

Burçin Vanlıoğlu, DDS, PhD2 able results, especially with ceramic
Yasemin Kulak Özkan, DDS, PhD3 veneers, is one of the most challeng-
Yilmat Umut Aslan, DDS, PhD4 ing tasks dentists encounter. With
improvements in restorative ma-
terials and bonding techniques,
The purpose of this study was to evaluate the marginal adaptation and fracture minimally invasive dentistry has
load of ceramic laminate veneers on teeth with different preparation depths. become a field of great interest.
A total of 75 extracted intact human maxillary central incisors were prepared Ceramic laminate veneers are a
with three different preparation depths (P) and assigned to the following five
popular treatment choice to reha-
groups (n = 15): P1 (0.3-mm depth of preparation; preparation entirely in
enamel); P2 (0.5-mm depth of preparation; preparation in enamel and dentin bilitate the lost esthetic properties
complex); P3 (1-mm depth of preparation; preparation entirely in dentin); of malpositioned, discolored, trau-
P4 (no preparation, only surface roughening); and P5 (unrestored, intact teeth matized, fractured, or worn anterior
as control). A total of 60 lithium disilicate laminate veneers were fabricated. teeth.1 The role of the clinician is to
The marginal adaptation of the veneers was evaluated by light microscope choose the right preparation design
and scanning electron microscope after cementation with resin cement.
and restorative material to optimize
Finally, the veneers were loaded until fracture at a 90-degree angle to the
lingual surface of the tooth. Statistical analyses were performed using analysis marginal adaptation and fracture
of variance and Tukey multiple range test. There was a significant difference resistance for long-term success in
between the marginal gap value of the distocervical measurement points of P1 addition to esthetic needs. Since
and P2 and the distal measurement points of P3 and P4 (P = .33 and P = .017, laminate veneers are cemented by
respectively). The highest fracture resistance values were observed in the P5 a resin cement, they become an in-
group (mean: 389.55 ± 22 N) and the P2 group (mean: 322.86 ± 79.38 N), and
tegrated part of the tooth and face
the lowest values were observed in the P3 group (mean: 219.21 ± 60.74 N).
The marginal adaptation of the laminate veneer restorations was not related masticatory stress, thermal changes,
to the depth of preparation. Mean fracture resistance of laminate veneers with and the hydrolytic effect of water
0.5-mm preparation depth was greater than that of the 0.3-mm and 1-mm and other chemicals.2 Close prox-
preparation depth laminate veneers and those with no preparation. Int J imity between the ceramic material
Periodontics Restorative Dent 2018;38(suppl):s87–s95. doi: 10.11607/prd.2995 and the tooth protects the resin ce-
ment from excessive exposure to
the oral environment and prevents
disintegration of cement from caus-
1
Prosthodontist, Marmara University, Istanbul, Turkey. ing secondary decay, microleakage,
2
Associate Professor, Marmara University, Istanbul, Turkey. discoloration, and fracture.
3Professor, Marmara University, Istanbul, Turkey.

4Assistant Professor, Marmara University, Istanbul, Turkey. External marginal adaptation

can be defined as the vertical dis-
Correspondence to: Dr Erhan Tuğcu, Marmara Üniversitesi Başibüyük Sağlık Yerleşkesi, tance between the finishing line
Dişhekimliği Fakültesi, Başibüyük Yolu 9/3 34854 Başibüyük, Maltepe, Istanbul, Turkey.
of the preparation and the margin
Fax: +90216 421 02 91. Email: erhantugcu@hotmail.com
of the veneer. It can be measured
©2018 by Quintessence Publishing Co Inc. using different imaging methods,

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s88
Fig 1 Distribution of teeth.
including stereomicroscopy or scan-
ning electron microscopy. There is
no consensus in the literature on
the exact acceptable marginal gap
value for a fixed restoration. McLean
and von Franhoer reported that clin-
ically, it is difficult to detect a mar-
ginal gap of < 80 µm.3 The optimum
marginal gap value for modern ce-
ramic systems ranges between 7.5
and 206.3 µm in the literature.4 This
wide range may originate from dif-
ferences in adaptation determina-
tion methods, ceramic types, or test
parameters.4
Aside from esthetic rehabili-
tation, one of the most important
tasks of ceramic veneer restora-
tions is to rehabilitate function and
provide structural durability. Fried-
man5 reported that a ceramic ve-
neer provides not only suitable
esthetics but also reliable functional
strength. With the development of
new ceramic materials and bond-
ing technologies, the success rates
of ceramic laminate veneer resto-
rations seem to be increasing in
recent years.5 Long-term clinical
performance and success rates of
laminate veneer restorations are
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also affected by the preparation
design. The mechanical properties
of the restorative materials and the
restoration design can be evaluated
by mechanical tests. Variations in
test results can be related to differ-
ences in sample preparation or test
methods (eg, material type, material
thickness, thermal cycles, loading
conditions).6
Despite the increasing popu-
larity of ceramic veneers and resin
cementation procedures, the choice
of preparation depth is still a chal-
lenge to clinical success because of
its potential effects on marginal ad-
aptation and fracture resistance. It
remains controversial whether prep-
aration depth can affect fracture
resistance and marginal adaptation
of ceramic veneers or whether one
configuration of tooth preparation is
superior to another. Hence, the pur-
pose of this study was to evaluate
the marginal adaptation and frac-
ture resistance of ceramic veneers
on teeth with different preparation
depths. The null hypothesis was that
the preparation depth of ceramic
veneers would not affect marginal
adaptation and fracture resistance.
Materials and Methods
A total of 75 extracted, intact, di-
mensionally similar human maxillary
central incisors were selected. All
selected teeth were free of dental
caries or restorations. They were
cleaned by scaling and stored in dis-
tilled water at room temperature.
The teeth were divided into the
following five groups of 15 speci-
mens each:
• P1: 0.3-mm depth of
preparation; preparation
entirely in enamel
• P2: 0.5-mm depth of
preparation; preparation in
enamel and dentin complex
• P3: 1-mm depth of preparation;
preparation entirely in dentin
• P4: no preparation; only surface
roughening
• P5: unrestored, intact teeth as
control
The 75 maxillary central incisors
were mounted individually in acrylic
resin (Imicryl SC, Imicryl) (Fig 1) with
the long axis oriented parallel to the
center of the ring with the guidance
 s89

of a dental surveyor (KaVo EWL

Typ 990, KaVo Elektrotechnisches
Werk). Each tooth was suspended
in the middle of the ring by means
of 0.8-mm orthodontic wire (0.8 mm
round spring hard wire, Leowire)
that engaged the tooth at the the
cementoenamel junction (CEJ) and
rested on the edges of the ring.
The incisal reduction of the teeth a b
in the P1, P2, and P3 groups was
performed with a chamfer bur (Meis-
inger 880G, Hager & Meisinger),
and a straight cutting-edge finish-
ing line in the buccolingual direction
was obtained. The amount of incisal
reduction was calculated as 1.5 mm
with the help of the diameter of the
bur (Figs 2a and 2b). On the facial
surface, 0.3-mm (for P1), 0.5-mm
(for P2), and 1-mm (for P3) guide
c d
grooves were created using depth-
Fig 2 Preparation of teeth. (a) Determination of incisal reduction by diameter of bur.
guided burs (0.3 and 0.5 mm, FG (b) Incisal reduction. (c) Determination of buccal reduction by depth guided bur.
834, Horıco Dental). By the guidance (d) Buccal reduction.
of these grooves, preparations were
completed entirely in enamel for P1,
in enamel and dentin complex for
P2, and entirely in dentin for P3, with two coats of die spacer (Rem-E-Die resin bonding agent (Heliobond,
rounded line angles (Figs 2c and 2d). Removable Die Spacer, Ivoclar Viva- Ivoclar Vivadent) was applied with a
In all groups, on the facial side, dent) was applied 1 mm short of the brush and homogeneously sprayed
the cervical finish lines were prepared finishing lines of the preparations. with air for 5 seconds. The enamel
1 mm above the CEJ. Interproximal- The laminate veneers (IPS was etched for 30 seconds with
ly, preparations were extended to e.max, Ivoclar Vivadent) were adhe- 37% phosphoric acid (Total Etch,
include the contacts using diamond sively luted using Variolink Veneer Ivoclar Vivadent), and the teeth
burs and water coolant (Fig 3). composite resin cement (Ivoclar were rinsed with water and dried. A
An additional silicone impres- Vivadent) according to the manu- primer for dentinal adhesive (Syntac
sion material (Virtual, Ivoclar Viva- facturer’s recommendations. The Primer, Ivoclar Vivadent) was then
dent) was used for the impressions of veneers were etched with a 5% hy- applied, allowed to act for 15 sec-
prepared teeth. Custom acrylic trays drofluoric acid (IPS Empress etching onds, and dried. Dentinal adhesive
were used, and each tray allowed gel, Ivoclar Vivadent) for 20 seconds (Syntac Adhesive, Ivoclar Vivadent)
an impression of four specimens. and rinsed with water for 30 sec- was applied for 10 seconds and
Impressions were cast in vacuum onds. A silane agent (Monobond- dried. An unfilled resin bonding
mixed die stone (Elite Model Dental S, Ivoclar Vivadent) was applied agent (Heliobond, Ivoclar Vivadent)
Stone, Zhermack). Stone dies were to the etched surface and allowed was applied with a brush and air
recovered from impressions, and to dry for 60 seconds. An unfilled thinned. All the veneers were luted

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s90

tion was performed for 40 seconds

a 1.5 mm
b 1.5 mm
c 1.5 mm
Fig 3 Preparation groups. (a) P1. (b) P2. (c) P3.
with Variolink Veneer composite
resin cement. The ceramic veneers
were seated on the prepared teeth
with light finger pressure, excess
0.3 mm
0.5 mm
1 mm
cement was removed with an ex-
plorer, and an oxygen barrier was
applied to the margins (Liquid Strip,
Ivoclar Vivadent). Photopolymeriza-
for the facial and palatal margins
of each ceramic veneer. Margins
were finished with diamond finish-
ing burs.
The marginal adaptation of the
laminate to the tooth preparation
was evaluated at ×200 magnifica-
tion with a light microscope (Leica
Optic, Leica) at eight different loca-
tions (Figs 4 and 5). By calculating
the mean values of the measure-
ment areas in this manner, the total
mean of incisal, axial, and marginal
adaptation values were obtained.
The measurements are verified by
evaluation of a randomly selected
sample of each preparation group
on scanning electron microscope
(JEOL JSM-5910LV Scanning Elec-
tron Microscope, JEOL) (Fig 6).
The fracture loads were deter-
mined using a universal testing ma-
chine (AG-5 kNG, Shimadzu). The
load was applied at a 90-degree an-
gle to the lingual surface of the test
tooth. This orientation was standard-
ized with a mounting jig. The load
was consistently applied at 1 mm
from the incisal edge on the tooth-
restoration interface with a custom-
ized plunger (Fig 7). The plunger
was attached to the load cell, and
crosshead speed was 0.5 mm/min.
Failure modes were analyzed
after specimen testing for both ve-
neers (intact, fracture, bond failure
and fracture) and teeth (intact, coro-
nal fracture, cervical fracture, root
fracture).
Statistical analysis was per-
formed using SPSS for Windows,
version 11.0 with analysis of vari-
ance (ANOVA) and Tukey multiple
range test.

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Fig 4 (left) Marginal adaptation
measurement areas. (a) Buccal. (b) Palatal.
Fig 5 (right) Evaluation under light
microscope of the marginal adaptation
(×200 magnification).
b a
Fig 6 Evaluation under scanning electron
microscope of the marginal adaptation: (a)
×30 and (b) ×100.
Results
Marginal Adaptation
Mean values and standard devia-
tions of marginal gap measurements
are shown in Table 1. Statistical
analysis (one-way ANOVA) showed
that there were no significant differ-
ences in overall marginal gap values
within groups (P < .05). There were
significant differences at the dis-
tocervical and distal measurement
points (P = .37 and P = .10, respec-
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a b
Fig 7 (a) Customized plunger. (b) Application of the load from the palatal surface.
tively) Tukey test showed that there
was a significant difference between
the marginal gap value of the disto-
cervical measurement points of P1
and P2 and the distal measurement
points of P3 and P4 (P = .33 and
P = .017, respectively).
Fracture Load
Mean fracture load values and stan-
dard deviations are shown in Table
2. Statistical analysis showed that
s91
Tooth
Cement
Veneer
b
there were significant differences
in fracture load among the groups
(P < .05). Mean fracture resistance
was found to be highest in the
control group (389.55 N) and low-
est in the 1-mm preparation group
(219.20 N).
The failure modes of teeth and
veneers are shown in Table 3. The
failure modes showed that 10 ve-
neers of 15 fractured in the 0.3-mm
preparation group. Of these, 9 frac-
tures occurred on the incisal part
of the veneer and 1 on the labial
Volume 38, Supplement, 2018
s92

Table 1 Mean ± SD Adaptation Values by Group (μm)

P1 P2 P3 P4 P
Mesioincisal 47.33 ± 8.63 53.06 ± 18.78 58.47 ± 26.53 60.35 ± 17.06 .238
Mesial 56.70 ± 13.67 52.67 ± 17.51 57.73 ± 26.3 45.07 ± 9.84 .213
Mesiocervical 55.47 ± 13 65.42 ± 24.89 64.94 ± 26.56 53.99 ± 18.09 .314
Buccal 55.12 ± 13.07 72.13 ± 29.08 75.45 ± 32.13 69.01 ± 25.4 .162
Distocervical 51.34 ± 17.73 73.16 ± 20.52 66.98 ± 25.42 58.95 ± 20.35 .037
Distal 55.01 ± 15.80 67.12 ± 26.35 70.47 ± 20.92 48.13 ± 14.08 .01
Distoincisal 54.22 ± 21.29 54.38 ± 11.89 60.23 ± 23.31 49.73 ± 13.36 .435
Palatal 69.32 ± 23.70 87.40 ± 28.63 80.65 ± 22.76 80.29 ± 31.2 .329

Table 2 Mean ± SD Fracture Table 3 Failure Modes of the Teeth and Veneers
Load Values by Group Teeth (n) Veneers (n)
Group Fracture load (N) Intact Coronal Cervical Root Intact Fractured Fracture area
P1 287.84 ± 75.14 Incisal Labial Debonding
P2 322.86 ± 79.38 P1 11 – 3 1 5 10 9 1 1
P3 219.21 ± 60.74 P2 10 1 2 2 9 6 4 1 4
P4 276.26 ± 66.6 P3 11 1 3 1 13 2 0 2 12
P5 389.55 ± 73.22 P4 4 1 7 3 11 4 4 0 0
Total 299.14 ± 89.5 P5 – 2 7 6 – – – – –

surface. In the 0.5-mm preparation

group, 6 fractures occurred, 4 on the in-
cisal part and 1 on the labial surface. In
the 1 mm preparation group, 2 veneers
fractured labially. The group without
preparation showed 4 incisal fractures
(Fig 8).

Discussion

In the present study, no statistically

significant difference was in marginal
adaptation among preparation groups.
However, there was a statistically signif-
icant difference in fracture resistance.
Therefore, the null hypothesis was re-
jected for marginal adaptation and
Fig 8 Different fracture patterns of specimens. (a) Incisal veneer fracture (straight).
accepted for fracture resistance. Accu-
(b) Debonding. (c) Incisal veneer fracture (oblique). (d) Cervical tooth fracture. rate marginal adaptation of an indirect

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dental restoration has always been
important for periodontal health
because the cement filling the mar-
ginal gap is a weak restorative link.
The cement provides space for
bacteria in its porosities and can
be dissolved by oral fluids. A large
marginal gap between a restoration
and tooth preparation can result in
exposure of luting material to the
oral cavity. Because resin-based lut-
ing materials are vulnerable to water
resorption, polymerization shrink-
age, wear, and microleakage, these
materials can be a potential prob-
lem in the porcelain laminate ve-
neer–resin cement–tooth complex.7
Clinical investigations have re-
ported that marginal defects and
fractures are the main reasons for
laminate veneer failure.1,8 Thus, mar-
ginal adaptation and fracture resis-
tance were examined in the present
study. Although the ideal environ-
ment for the experimental study of
dental materials is the oral cavity,
clinical studies are time-consuming
and usually are not cost-effective.9
For a successful in vitro experiment,
the test conditions should closely
match the oral environment.10 Be-
cause of their unique characteristics
such as elasticity, strength, bond-
ing properties, and enamel thick-
ness that could affect results, human
teeth were used for this study.11
Methods for measuring the
marginal gap include four basic
categories: (1) direct view, (2) cross-
sectional, (3) impression technique,
and (4) explorer and visual examina-
tion. A researcher may use one or
more of these techniques to mea-
sure the marginal gap depending
on the specific factors to be stud-
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ied.12 In the present study, marginal
adaptations of veneer restorations
were analyzed directly by stereo
light microscope. Reported mar-
ginal gap values were lower than
those observed for conventional
porcelain veneers (50 to 195 µm).13
The values were consistent with
Aboushelib at al,14 who found that
pressable ceramic laminate veneers
produced higher marginal adapta-
tion and thinner cement film thick-
ness compared with machinable
ceramic veneers. Values reported in
the literature as acceptable marginal
adaptation show variations accord-
ing to the type of restoration and
the researcher. Taking this factor
into clinical consideration, a mar-
ginal gap of up to 145 μm could be
accepted.15–17 In the present study,
the marginal adaptation values are
found between 47.33 and 87.40 μm,
which is clinically acceptable.
According to Friedman,5 frac-
ture is responsible for the 67% total
failure rate recorded for ceramic ve-
neers over 15 years of clinical ser-
vice. Different preparation designs
seem to cause varied stress distri-
bution.18 Although developments
in dentin-bonding systems provide
strong resistance, the presence of
enamel still affects the bonding re-
sistance and provides stiffness and
rigidity. One of the main objectives
of this study was to evaluate the
fracture resistance of laminate ve-
neers fabricated with different prep-
aration depths.
There is no consensus on
whether the supporting structures in
which the specimens are embedded
have to provide resilience similar to
periodontal ligament (PDL) of natu-
s93
ral teeth. In this study, all the speci-
mens were embedded in the acrylic
resin without any material reproduc-
ing the PDL structure. Simulation of
the PDL was unnecessary because,
as Castelnuovo et al19 reported, the
load applied to the coronal portion
of the embedded tooth would not
have been decreased by fabrica-
tion of a softer structure between
the root and surrounding acrylic
resin. Because of the anatomical
variations of incisors, the specimens
were embedded in acrylic resin us-
ing a surveyor for standardization.
Orthodontic wires that fit the cervi-
cal portions of teeth were prepared
and used to control the long axis of
teeth at four surfaces.
Ferrari et al20 reported the thick-
ness of the enamel layer for anterior
teeth and showed that the central
incisors have 0.3 to 0.5 mm enamel
on the cervical part, 0.6 to 1.0 mm
enamel on the middle, and 1.0 to
2.1 mm on the incisal part.20 The
reduction in measurements of the
preparations in enamel and dentin
found in the present study parallels
this study. The quantity of incisal re-
duction is determined by consider-
ing the portion recommended for
esthetics as 1.5 to 2 mm in anterior
laminate veneer restorations.21
In some previous studies that
evaluated the fracture resistance
of laminate veneers, the fracture
loads were applied on the incisal
edge parallel to the long axis.22 But
in maxillary incisors, the chewing
forces are not applied from incisal
edge.19 Besides, the enhanced oc-
clusal forces produced by parafunc-
tion focus on the palatal side of the
maxillary incisors. The functional and
Volume 38, Supplement, 2018
s94
parafunctional forces push the lami-
nate veneer facially. For this reason,
the fracture test mechanism is set
for applying the load from palatal to
anterior.
The statistical analysis showed
a significant difference in fracture
loads among the groups. The frac-
ture resistance was highest in the
control group (mean 389.55 N) and
lowest in the 1-mm preparation
group (mean 219.20 N).
The evaluation of failure mode
indicated the different behaviors
of veneers during fracture. The
veneers of the 0.3-mm prepara-
tion group (preparation entirely in
enamel) showed 9 incisal fractures.
That result can be connected to the
thickness of the laminate veneer, as
the fracture lines showed a vertical
pattern on the connection of the
incisal and buccal surfaces. In the
0.5-mm preparation group (prepa-
ration in enamel-dentin complex), 4
incisal and 1 labial surface fractures
were seen. In the 1-mm prepara-
tion group (preparation entirely in
dentin), only 2 veneers fractured
labially. However, 12 debondings
occurred in this group. In the no-
prep group, 4 incisal fractures were
seen. This may be due to the thick-
ness of the laminate veneer and
the bonding ability of dentin. In the
thin fabricated veneers (P1 and P4),
despite the adhesive capacity of
the veneer with enamel, its limited
thickness leads to incisal fractures
at the area of load. In thick fabri-
cated veneer group (P3), the limited
bonding capacity of dentin caused
the veneers to show debondings
before reaching the fracture loads.
These results are consistent with
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the results of studies that report the
bonding ability of enamel is higher
than dentin.23,24 The fracture lines in
all groups showed an oblique direc-
tion, which is consistent with Magne
and Douglas.24
Conclusions
Within the limitations of this study,
it can be concluded that the overall
marginal adaptation of the laminate
veneer restorations was not related
with the preparation depth. There
was no difference in marginal adap-
tation among preparation groups.
The fracture resistance of laminate
veneers with 0.5-mm preparation
depth was greater than that of the
0.3-mm and 1-mm preparation
depth and no-prep laminate ve-
neers. In addition, a 0.5-mm prepa-
ration depth provides the optimum
veneer thickness and bonding abilty
for clinical use.
Acknowledgments
The authors reported no conflicts of interest
related to this study.
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