A Meta-Analysis of the Most Indicated Preparation

Design for Porcelain Laminate Veneers

Deisi Carneiro da Costaa / Margareth Coutinhob / Albert Schiaveto de Sousac /
Jussara Peixoto Ennesd

Purpose: To evaluate the fracture strength of three different types of tooth preparation design for ceramic ve-
neers and determine whether there is any correlation between the preparation performed and the type of failure
observed, by means of a meta-analysis of published in vitro studies.
Materials and Methods: Three databases were consulted to select the studies, considering previously estab-
lished inclusion and exclusion criteria. The data extracted were submitted to statistical analysis by means of the
software Review Manager 5.1, using the random effect statistical model with a confidence interval of 95%.
Results: The results showed a decrease in mean dental fracture strength of 76.53 N in teeth with feathered
incisal edge preparations, and 102.82 N for those with palatal chamfers when compared with nonprepared
teeth, whereas the preparation with a butt joint showed no significant difference compared to nonprepared teeth
(p = 0.37). Ceramic fractures occurred more frequently in the chamfer type than feathered incisal edge design.
Conclusion: The butt joint is the type of preparation that least affects the strength of the tooth and the chamfer
preparation type is more susceptible to ceramic fractures.
Keywords: meta-analysis, dental veneers, tooth preparation, dental porcelain, dental esthetics, porcelain lami-
nate veneer, survival rate.

J Adhes Dent 2013; 15: 215–220. Submitted for publication: 19.08.12; accepted for publication: 04.02.13
doi: 10.3290/j.jad.a29587

T he Glossary of Prosthodontic Terms, drawn up by

The Academy of Prosthodontics, defines porcelain
laminate veneers as thin ceramic restorations that re-
The esthetic properties and conservative preparation
of this technique, generally limited to the enamel,3 have
made it very popular both among patients and profession-
pair the vestibular face and part of the proximal surface als.25 The esthetic result provided by ceramic veneers
of teeth that demand esthetic interventions.32 This is guarantees high acceptability by patients26 and stability
a conservative treatment option3 for discolored, mis- in the medium- and long term25 is associated with the
aligned teeth with malformations, fractures or wear,2 correct indication and selection of cases.3
and provides esthetic and functional rehabilitation.18 There are three frequently used types of dental prep-
aration design for ceramic veneers, and these will be
discussed in this study (Fig  1). The feathered incisal
edge preparation is restricted to the vestibular region and
a Dentist, Residency Program in Multidisciplinary Care for the Critically Ill Pa- maintains the incisal edge partly in ceramic and partly
tient, University Hospital Maria Aparecida Pedrossian, Universidade Federal in enamel.28 In the butt joint and palatal chamfer prepa-
de Mato Grosso do Sul, Campo Grande, MS, Brazil. Experimental design,
performed the experiments, wrote the manuscript.
rations, there is incisal reduction, which allows charac-
b Professor, School of Dentistry “Prof. Albino Coimbra Filho”, Universidade
Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil. Contributed to
the scientific basis of the literature review and discussion, proofread the
manuscript.
c Professor, Center of Biological and Health Sciences, Universidade Federal de
Mato Grosso do Sul, Campo Grande, MS, Brazil. Orientation data analysis
and statistics.
d Professor, Center of Biological and Health Sciences, Universidade Federal de
Mato Grosso do Sul, Campo Grande, MS, Brazil. Idea, experimental design,
guidance, proofread the manuscript.
a b c
Correspondence: Deisi Carneiro da Costa, University Hospital Maria Aparecida
Pedrossian, Universidade Federal de Mato Grosso do Sul, Rua da Penha, 174
Fig 1 Schematic illustration of incisal preparation designs for
CEP 79.092-222 Campo Grande, MS, Brazil. Tel: +55-67-3386-6134. e-mail: porcelain laminate veneers: a) feathered incisal edge; b) butt
deisicar@hotmail.com joint; c) palatal chamfer (modified from Bona4).

Vol 15, No 3, 2013 215

Costa et al
Table 1 Relevance test: inclusion and exclusion criteria
Relevance Test
Inclusion criteria Exclusion criteria
y Published in the year 2000 y Resin composite veneer
or later y Dental anomalies
y English language y Clinical case reports
y In vitro studies y Preparation for complete
y Using natural central inci- crown
sors y Teeth with endodontic
y Providing fracture strength treatment
and/or frequency of fail- y Teeth with fractures
ures observed
terization of the incisal region and better seating of the
porcelain laminate veneer.28
Follow-up of the clinical performance of ceramic ve-
neers has shown that the estimated survival for teeth
with feathered incisal edge type of preparation is at least
80% at 1.5,10 7,29 and 1115 years in situ. The results of
survival rates for preparations with a butt joint are higher
than 92% in studies that varied from 1.5 to 7 years du-
ration.10,17,25,29 Results for the palatal chamfer design
showed a survival rate of over 84% in at least 5 years
of evaluation.14,15,17,19,25 The tooth preparation design,
cementation, and finishing procedures are determinants
of long-term success.11
Failure of ceramic veneers may be related to esthetic
dissatisfaction, periodontal problems, lack of bond, mi-
croleakage, tooth and ceramic fracture.19,25,29 Loss of
retention represents 12.5% and tooth fracture 6% of the
failures in a study with 16 years of follow-up,19 whereas
ceramic fracture showed a rate of 11% in a study with a
duration of 10 years.25
The aim of this study was to perform a meta-analysis
of in vitro studies conducted with ceramic veneers to com-
pare 1) the fracture strength of teeth without preparation
with teeth prepared with feathered incisal edge, butt joint,
and palatal chamfer types of preparations designs, and
2) the frequency of fracture of the ceramic veneers in the
different types of preparations.
MATERIAL AND METHODS
Method of Searching and Selecting Articles
Articles were located by means of electronic search
of Pubmed, Web of Science and Cochrane databases,
in the period from March to October 2011, using the
following keywords: laminate preparation design, por-
celain laminate veneers, veneer fracture load, veneer
preparation, overlap veneers, failure veneers and dental
veneers. The aim was to identify in vitro studies that
conducted fracture strength tests in teeth restored with
porcelain veneers and/or presented the frequency of
failures observed in at least two of the following types
of preparations: preparations of feathered incisal edge,
butt joint, or palatal chamfer with a control group (with-
out preparation). Only studies that used nonrestored
216
specimens were included. Thus, it would be possible
to compare the results obtained by comparison of the
preparation designs among themselves and also with
the control group.
Studies found in duplicate were visually detected and
discarded; relevant studies were identified by evaluation
of the titles and abstracts, then read in full and submit-
ted to the relevance test considering the inclusion and
exclusion criteria shown in Table 1, in order to meet the
objectives of this study.
After application of the relevance test, the selected
studies were again evaluated regarding the possibility
of extracting the data. Studies that provided values with
reference to fracture resistance in Newtons (N) or another
unit able to be converted into Newtons were kept.
Data Analysis
Review Manager software (RevMan, Version 5.1., The
Nordic Cochrane Center; Copenhagen, DK) was used
and comparisons were made of fracture strength and
frequency of root fracture, coronal fracture, and ceramic
fracture between each type of preparation design and
with the control group. Statistical analysis was devel-
oped using the random effect model, with a confidence
interval of 95%. The data relative to fracture strength
were processed in the form of continuous variables,
while the frequencies of failures were used as dichoto-
mous variables.
RESULTS
Results of Search for Articles
The search performed in the three databases, using the
seven keywords previously mentioned, resulted in 2347
articles being identified, of which 1254 remained after
exclusion of the studies found in duplicate. After read-
ing the titles and abstracts, 83 publications remained,
which were read in full and submitted to the relevance
test. At the end of this process, 8 studies that complied
with the relevance test were included: 5 presented re-
sults related to both fracture strength and frequency of
failures, 2 presented results related to fracture strength
only; 1 presented results only as regards frequency of
failures. Thus, 7 studies were included in the fracture
resistance comparisons, and 6 in the frequencies of
failures.
The selected studies enabled a large number of combi-
nations and comparisons of the results, depending on the
availability of data. The participation of each publication in
this meta-analysis is presented in Table 2. Five compari-
sons were made with regard to fracture strength, three
relating each preparation design to the control group, and
another two relating the feathered incisal edge to the pala-
tal chamfer type and the butt joint to the palatal chamfer
design. Each of these analyses was performed with four
publications, except the last, which involved only three.
For the frequency of root fracture analysis, it was possible
to compare each of the three preparation designs with
the control group. For the frequency of coronal fractures,
The Journal of Adhesive Dentistry
 Costa et al

Table 2 Studies included in the meta-analysis, type of analysis in which they were used, and number of iterations*

Study Preparation design Specimens per group Analysis criteria Total number of
iterations*
Akoglu et al (2011)2 Control group 15 Fracture strength 3
Butt joint Root fracture
Coronal fracture
Castelnuovo et al6 Control group 10 Fracture strength 13
Feathered incisal edge Root fracture
Butt joint Coronal fracture
Palatal chamfer Ceramic fracture
Adhesive failure
Chun et al8 Control group 10 Root fracture 1
Palatal chamfer
D‘Arcangelo et al11 Control group 15 Fracture strength 1
Butt joint
Hahm et al16 Control group 12 Fracture strength 5
Feathered incisal edge Root fracture
Palatal chamfer Coronal fracture
Ceramic fracture
Schmidt et al24 Butt joint 8 Fracture strength 3
Palatal chamfer Ceramic fracture
Adhesive failure
Stappert et al27 Control group 16 Fracture strength 11
Feathered incisal edge Root fracture
Butt joint Coronal fracture
Palatal chamfer Ceramic fracture
Zarone et al30 Control group 5 Fracture strength 2
Feathered incisal edge
Palatal chamfer
*Number of times each study was used in the different analysis criteria.

Fig 2 Results of comparison between specimens prepared with feathered incisal edge and teeth without preparation (control), with
regard to fracture strength.

only the feathered incisal edge and the butt joint design
were related to the control group. Ceramic fractures were
analyzed between the feathered incisal edge and palatal
chamfer preparations, as well as between the butt joint
and palatal chamfer preparations. With reference to the
frequency of each type of failure in ceramic restorations
or natural tooth structures, the comparisons were made
using each one of the three studies.
Results of the Interventions
The meta-analysis demonstrated that there was a signifi-
cant reduction in fracture strength when the teeth were
prepared with a feathered incisal edge (p < 0.00001)
and palatal chamfer (p = 0.01), with a mean reduction of
76.53 N and 102.82 N in the strength of the specimens
for the respective preparation designs when compared
with teeth without preparation, as may be observed in
Figs 2 and 3. In contrast, the butt joint preparation was
the only one that presented results without significant
differences with regard to fracture strength compared to
the teeth without preparation (p = 0.37, Fig 4). In the two
comparisons made between two different types of prepa-
ration designs, no significant differences were observed,
neither between the feathered incisal edge and palatal
chamfer (p = 0.24) nor between the butt joint and the
palatal chamfer preparation (p = 0.60).

Vol 15, No 3, 2013 217

Costa et al

Fig 3 Results of comparison between specimens prepared with palatal chamfer and teeth without preparation (control), with regard
to fracture strength.

Fig 4 Results of comparison between specimens prepared with butt joint and teeth without preparation (control), with regard to frac-
ture strength.

Fig 5 Results of comparison between specimens prepared with feathered incisal edge and those prepared with palatal chamfer,
with regard to frequency of ceramic fracture.

The frequency of fractures in the tooth root or crown, ob- DISCUSSION

served when the feathered incisal edge type of design was
used, did not differ significantly from the frequency found
in a nonprepared tooth (coronal fracture p = 0.84 and root
fracture p = 0.98). Similarly, when the tooth was prepared
with the butt joint, there was no significant difference in the
number of coronal fractures vs the tooth without preparation
(p = 0.66). Comparison between the control group and teeth
with butt joint and palatal chamfer preparations showed that
the preparation designs provide greater resistance to root
fractures (butt joint p = 0.04 and palatal chamfer p = 0.05).
Analysis of the frequency of ceramic fracture showed no
significant difference when teeth prepared with butt joint or
with palatal chamfer (p = 0.91) were compared. However,
the teeth with palatal chamfer showed a larger number of oc-
currences of fracture in the ceramic veneers than the teeth
with feathered incisal edge preparations (p = 0.003, Fig 5).
Different types of preparation designs for porcelain
veneers have been described and evaluated. The vary-
ing and sometimes contradictory results of the studies
did not allow a conclusion to be reached with regard to
the most adequate preparation design for this type of
esthetic solution. The use of reduced sample sizes is
frequently responsible for the low statistical power of
the tests used in studies.27,30
The random effect meta-analysis model was selected
because it avoids over appreciation of studies with a
larger sample size. In the general result, the weight
of each study is more balanced. It is the adequate
option when one has studies with methodological vari-
ations and that were conducted independently of one
another.5

218 The Journal of Adhesive Dentistry


The best manner of evaluating the performance of a
procedure is by means of clinical studies. To date, how-
ever, the number of longitudinal studies that have clinically
assessed the different types of preparations for veneers
is insufficient to enable a meta-analysis to be performed.
For this reason, only in vitro evaluations were included
in this study, even though it is not possible to reproduce
all the variables of the oral environment.14 The use of
extracted human teeth, for example, is a problem due to
the lack of standardization of size, shape, age, and quality
of specimens obtained.9,27,30 Nevertheless, natural teeth
are the best option for use in in vitro studies.31 The studies
used in this meta-analysis described the concern about se-
lecting teeth with similar dimensions, and without cracks or
apparent defects. During cavity preparation, enamel reduc-
tion was standardized by using a diamond bur with limited
cutting depth6 and/or silicone guides,20 as recommended.
On the facial surface, the reduction ranged from 0.3 to
0.5 mm and on the incisal edge from 1.5 to 3 mm.
In the in vitro studies used in this meta-analysis, the
strength test was performed by application of an increas-
ing static load. It is valid to point out that the mechanical
performance of a restoration in the oral environment will
not be determined only by its resistance to forces applied
on it.12,30 With the purpose of reducing the discrepancy
between the clinic and laboratory, the use of a cyclic
pattern of mechanical fatigue associated with thermal
cycling9 is recommended in in vitro studies.30 It would al-
low a more faithful reproduction of what occurs in the oral
environment.12 The thermal variations induced in the ther-
mocycling process may influence the clinical longevity of
the ceramic.1 These variations capable of causing cyclic
mechanical stress, intensified by the fact that the cement-
ing agent has a higher coefficient of thermal expansion
than ceramic.22 Half of the studies included in this meta-
analysis submitted the samples to thermocycling.2,9,12,30
The studies submitted to this meta-analysis used dif-
ferent angulations for the application of force during the
loading tests. Irrespective of the exact direction applied,
however, it is known that the palatal concavity is the
region where the stress forces are concentrated.21 The
closer the palatal margin of the preparation comes to the
palatal concavity, the higher is the probability of failure.
The risk of damage to the veneer is even greater when
there is a low ratio of the thickness of the ceramic to the
cementing material. The consequences of the difference
in the thermal expansion coefficients between the two
materials are greater.22 Therefore, when the tooth to be
restored presents or needs excessive incisal reduction,
preparing a palatal chamfer is not indicated. This avoids a
thin layer of ceramic close to the area of greatest stress11
and the low ceramic:cement ratio, although some studies
do not confirm this ratio in their results.9,17,31
A finite element analysis demonstrated that in the feath-
ered incisal edge, a concentration of stresses existed on
the incisal border close to the preparation margin, whereas
in the palatal chamfer preparation, the stress is distributed
throughout the entire surface of the preparation without
overload on the incisal margin.33 This meta-analysis re-
vealed that there was no significant difference between the
Vol 15, No 3, 2013
Costa et al
fracture strengths of the feathered incisal edge and palatal
chamfer types of preparation designs. Some clinical stud-
ies have also observed no difference in the clinical survival
of ceramic veneers prepared with or without incisal overlap-
ping.29 Nevertheless, more favorable results have been
reported for the preparation without incisal involvement.10
Some studies have found advantages in the mechani-
cal and adhesive properties of the palatal chamfer prepa-
ration over the butt joint preparation design.27 It has been
argued that the ceramic located in the area of the palatal
chamfer provides the veneer with stability in opposition
to the movements to which it is subjected on the vestibu-
lar surface during the application of force,8 and that the
layer of cement absorbs the stress from the region.33,34
Another justification of studies with more favorable results
for the palatal chamfer preparation design is that the pala-
tal extension, in addition to enlarging the bond surface,
also provides greater longitudinal exposure of the enamel
prisms, thus improving the bond quality.27 The present
study, however, observed no significant difference be-
tween the results of these two types of preparation de-
signs with regard to fracture strength or the frequency of
ceramic fractures.
Other studies have observed a greater frequency of
cracks in the ceramic which fills the area of the palatal
chamfer7,17,23 and have asked whether this would not be
the weak point of this type of preparation7 and whether it
could be influenced by the low ceramic layer:cement layer
ratio,22 previously described. The alternative presented
for avoiding these problems was to perform butt joint or
mini-chamfer preparation,30 keeping the preparation mar-
gin as far away as possible from the palatal concavity.21
This meta-analysis showed that the chamfer preparation
is more susceptible to fractures in the ceramic than the
feathered incisal edge preparation. Regarding the butt
joint preparation, there was no significant difference in
the frequency of failures in ceramic.
In this meta-analysis, studies with preparations per-
formed strictly in enamel were included. The concern
about performing minimal preparations without involving
dentin appears to be diminishing19 due to the great con-
fidence in the properties of contemporary adhesive sys-
tems. The influence of more invasive preparations on
the strength and retention of veneers has not yet been
well explained. Some authors have found no difference
between preparations restricted to enamel or involving
dentin,10 others have observed a greater frequency of
failures when dentin is involved.13,14
The preparation for veneers on teeth which already
have composite-resin restorations may be conservative
as well. There is no need to remove the material, but the
restoration must receive a suitable surface treatment, so
that resistance and adherence are not compromised.16,24
Specimens treated with a silica-coating system or etch-
and-rinse bonding system exhibited excellent results in in
vitro studies.16 No in vivo studies using a combination of
these two types of treatment have been found. The differ-
ence in methodology prohibits including these studies in
this meta-analysis. Only studies that used specimens free
from restorations were included.
219
Costa et al
While conducting this study, it was possible to observe
the variations in the methodologies adopted by each re-
searcher with regard to the characteristics of the prep-
aration designs, manner of fabricating the veneers, and
method of determining the fracture strength, which led to
limiting the number of studies included in this meta-analy-
sis. Moreover, the need was noted for randomized and
longitudinal clinical studies to evaluate the performance
of different preparations designs.
CONCLUSIONS
The results obtained by this meta-analysis allowed the
following conclusions:
y Preparations of the feathered incisal edge type and
those with palatal chamfer caused a reduction in the
strength of whole teeth;
y The fracture strength of teeth prepared with the butt
joint design did not differ significantly from nonpre-
pared teeth;
y The fracture strengths of teeth prepared with different
designs were similar to one another;
y The frequency of fractures in ceramic was greater in
veneers with the palatal chamfer preparation design
than with feathered incisal edge. Between the palatal
chamfer and butt joint preparation designs, no statis-
tical difference in ceramic fractures was observed.
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Clinical relevance: The butt joint preparation design
has little effect on the fracture strength of the tooth,
resulting in lower chances of failure occurring in
ceramic veneers. Fractures of veneer porcelain are
more frequent in the palatal chamfer preparation de-
sign than in the feathered incisal edge preparation.
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