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Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden
Review article
A R T I C L E I N F O A B S T R A C T
Article history: Background: There is no consensus on whether incisal coverage is a risk or a protective factor in
Received 29 December 2015 preparations for ceramic veneers.
Received in revised form 16 June 2016 Objective: The aim of this systematic review and meta-analysis was to evaluate the survival rates of
Accepted 17 June 2016
preparation designs for ceramic veneers with and without incisal coverage.
Methods: Primary clinical studies with the following characteristics were included: 1) studies related to
Keywords: ceramic laminate veneers and 2) prospective or retrospective studies conducted in humans. From the
Dental laminate
selected studies, the survival rates and failures rates for ceramic veneers were extracted according to
Dental veneers
Tooth preparation
preparation design, with or without incisal coverage. The Cochran Q test and the I2 statistic were used to
Esthetics evaluate heterogeneity. Metaregression, meta-analysis were performed.
Dental Two reviewers searched in the MEDLINE (Pubmed) and Cochrane Central Register of Controlled Trials
Ceramics (Central) electronic databases, from 1977 to June 5, 2016, without language restrictions.
Dental porcelain Results: Eight studies out of 1145 articles initially identified were included for risk of bias and systematic
Systematic review assessment. No study was identified for crystalline ceramic veneers. The estimated survival rate for
laminate veneers with incisal coverage was 88% and 91% for those without incisal coverage. Incisal
coverage presented an OR of 1.25.
Conclusions: Irrespective of the preparation designs, with or without incisal coverage, ceramic veneers
showed high survival rates. As regard implications for future clinical research studies, randomized
clinical studies are necessary to compare preparation designs with and without incisal coverage, and to
provide clear descriptions of these preparation designs.
ã 2016 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2016.06.004
0300-5712/ã 2016 Elsevier Ltd. All rights reserved.
2 R.B. Albanesi et al. / Journal of Dentistry 52 (2016) 1–7
A previous systematic review [26] that sought different (tetracycline/bruxism); 5) not a ceramic veneer; 6) studies
outcomes, found that the influence of incisal coverage showed containing the same sampling (only the most recent study was
divergence among publications, and did not allow for the clinical considered); 7) studies without survival/success rate of veneers
outcome and survival rate to be associated with the preparation and the impossibility of calculating this data; 8) dropout rate
design. Thus, for the present systematic review, the authors higher than 30%; 9) no description of incisal preparation design or
searched the scientific literature again to find articles that no number of each design.
contained tooth preparation descriptions, numbers of subjects,
and failures, that would allow inclusion of a larger number of 2.3. Data collection process
articles. With this in mind, the authors also sought to include
retrospective studies. Two calibrated reviewers (RBA, MNP) collected the data from
The data on preparation for ceramic laminate veneers, obtained the papers selected, and organized them in structured tables.
from randomized controlled trials (RTCs), have usually not shown Cohen’s Kappa values between examiners was 0.91, and a new
the consequences of incisal coverage separately, thereby making it calibration was performed to solve disagreements. Discrepancies
difficult to correlate the preparation design with clinical outcomes, and doubts were settled by discussion and data checking; however,
and the effectiveness of protecting the remaining tooth structure. when these were not resolved by consensus, a third examiner (SM)
There is a gap in this information [2,3,5–7,9,10,12,14,15,18–21,24] was consulted.
that justifies the elaboration of a systematic review about
preparation involving incisal coverage, in order to put forward 2.4. Analysis of risk of bias
scientific evidence. The aim of this systematic review was to
evaluate the survival rates of different preparations for ceramic Two calibrated examiners (RBA, MNP) used the Newcastle-
laminate veneers with and without incisal coverage, The null Ottawa Scale (NOS) [29] to assess the risk of bias in the studies
hypothesis was that the incisal coverage had no influence on the included. Any disagreement between the reviewers was resolved
survival rates of ceramic veneers. by a third author (SM). With the NOS, studies can be awarded a
maximum of one star for each numbered item within the Selection
2. Methods and Outcome categories. A maximum of two stars can be given for
the comparability category. Thus, the following topics were used:
2.1. Eligibility criteria and search strategy A) Selection—A1) the representativeness of the exposed individu-
als was considered when the study population included men and
This review was conducted in accordance with the PRISMA women, with a minimum age difference of 35 years between the
guideline [27] and registered at the PROSPERO (CRD42015016606). participants, A2) clear description of the exclusion criteria, with
The PICOS question (Population, Intervention, Comparison, Out- the non exposed group drawn from the same community as the
come, and Study design) was defined, where P = patients who exposed group, A3) ascertainment of the exposure factor by secure
received laminate veneers; I = ceramic veneers; C = (not applicable record, A4) demonstration that the outcome of interest was not
in the present study); O = survival rate; and S = RCTs and cohort present when the study started; B) Comparability—B1) two study
studies. The question focused on was: “In patients with ceramic control factors were used to measure the comparability between
laminate veneers, will the tooth preparation designs, with or groups (B10 —standardized protocol for tooth preparation and B100 —
without incisal coverage, have an influence on the survival rates of no more than 2 operators to perform the clinical procedures) and
these veneers?”. C) outcome—C1) assessment of the outcome must be made
An electronic database search in the advanced mode, was independently, by blind assessment, or by reference to secure
performed of the PubMed and Cochrane Central Register of records, C2) the follow-up period must be long enough for
Controlled Trials (1977-June 5, 2016). The references of articles outcomes to occur, in this case 3 years was considered, C3) subjects
included were checked manually. There were no limitations on lost during the follow-up period, unlikely to introduce bias, must
language. One study [28] was translated from Chinese and be fewer than 30%. Each study included could receive a maximum
analyzed. of 9 stars. Studies with !6 points were considered to have high
The final search strategy for the Medline database was: methodological quality, while a score <6 points indicated low
((((ceramic*) OR porcelain*)) AND (((((failure) OR survival) OR quality.
success) OR clinical evaluation) OR follow up)) AND ((veneer*) OR
laminate*), and for the Cochrane database, it was: ((laminate or 2.5. Study characteristics
veneer) and (ceramic or porcelain) and (dental or tooth or teeth) and
(clinical and trial or clinical)). In order to identify sources in heterogeneity of the outcome
between the studies selected according to Table 2, detailed
2.2. Study selection and eligibility criteria information about the way each study was conducted was
displayed to facilitate analysis.
Studies were selected by title and abstract for screening
according to these inclusion criteria: A—studies about ceramic 2.6. Measures and statistical analysis
laminate veneers and B—human cohort studies (prospective and
retrospective) and RCTs. Articles without abstracts were included Descriptive analysis and meta-analysis by using random effect
for evaluation of their full texts. Articles without abstracts, or with models were performed based on the estimated survival of
abstracts providing insufficient descriptions to enable decisions, preparation designs for ceramic laminate veneers, with and
were included for evaluation of the complete text. without incisal coverage. This estimated survival rate (Kaplan-
Eligibility was determined after evaluating the full texts Meier) and variance were used for meta-analysis. If the article did
according to the previously defined exclusion criteria: 1) cavity not present the variance (or standard error), the authors calculated
preparations and/or clinical procedures with no adequate or it by analyzing the number of failures and accounting for
unusual descriptions (partial veneer/fragments/unusual bonding censorship during the follow-up time. These data were searched
procedures); 2) case reports; 3) literature or systematic reviews, in the text, or a count was taken on a Kaplan-Meier graph. The
protocols, interviews, or in vitro studies; 4) isolated groups Greenwood formula was used to calculate the variance assuming
R.B. Albanesi et al. / Journal of Dentistry 52 (2016) 1–7 3
Fig. 1. Flow diagram with information from all of the phases of study selection based on PRISMA [27].
that censorship occurred uniformly over time, together with 3.3. Study characteristics
failures. The odds ratio (OR) was calculated for preparation
designs, with and without incisal coverage. The years of publication of the studies included ranged from
Cochran Q test was performed (p < 0.001, CI 95%) to evaluate 1987 to 2016. The information and characteristics of each study are
the heterogeneity among the studies, and the presence of provided in Table 2. Of the studies with the same sample [11,13,17],
heterogeneity was analyzed using the inconsistency test the most recent one was considered.
(I2 > 50%) [30]. All meta-analyses were undertaken using the
software program R package version 3.6-0 (R Foundation for 3.4. Measures and statistical analysis
Statistical Computing, Vienna, Austria).
Meta-regression was performed on the influence of the type of 3.4.1. Meta-regression and heterogeneity analysis
follow-up time on the survival rates intended to clarify sources of Meta-regression showed no association between survival rate
heterogeneity in the studies included. and follow-up time (p = 0.8007) (test of moderators-coefficient
2.3). Because meta-regression analysis for these thresholds
3. Results demonstrated no association with the survival rate, meta-analysis
was possible.
3.1. Study selection
3.5. Meta-analyses
The search strategies used yielded 1145 articles. After evaluat-
ing the titles and abstracts, and eliminating duplicates, 181 articles 3.5.1. Survival rate
were considered for full-text review. Finally, eight articles For the Group with incisal coverage (N = 1186), seven articles
[7,9,12,14,15,18,21,23] were included (Fig. 1) for quantitative (Figs. 2 were included, and the cumulative survival rate was 88% (95% CI:
and 3) and risk of bias analysis (Table 1). The flowchart diagram 80%–93%; I2 = 87,44%; p < 0.001) (Fig. 2–A).
shows the search results and all reasons for exclusions (Fig. 1). For the Group without incisal coverage (N = 188), two articles
were included, and the cumulative survival rate was 91% (95% CI:
3.2. Analysis of risk of bias 81%–97%; I2 = 72,13; p = 0.0582) (Fig. 2–B).
The purpose of the NOS of this study was to investigate the risk 3.6. Odds ratio (OR)
of bias of the articles. Assessment of the methodological quality of
each article is summarized in Table 1. Of the 8 studies selected, that Three articles were kept for the OR analysis of the Group with
met the inclusion criteria, only 1 (Fradeani et al., 2005) was incisal coverage preparation in comparison with the Group
considered to have high risk of bias, with NOS scores <6. without incisal coverage-preparation [9,12,21]. Incisal coverage
Otherwise, 7 studies (Magne et al., 2000; Peumans et al., 2004; presented an OR of 1.25 (95% CI: 0.33–4.73; I2 = 65.3%; p = 0.0562);
Smales & Etemadi, 2004; Granell-Ruiz et al., 2010; Layton & however, it was not statistically significant (36 failures in veneers
Walton, 2012; Gürel et al., 2013; Özturk & Bolay, 2014) had with incisal coverage out of 506 veneers, and 28 failures in veneers
relatively low risk of bias with NOS scores !6. without incisal coverage out of 507 out veneers evaluated) (Fig. 3).
4 R.B. Albanesi et al. / Journal of Dentistry 52 (2016) 1–7
Fig. 2. A: Forest plot of with-incisal-coverage group (estimated cumulative overall survival rate—seven included studies). B: Forest plot of without-incisal-coverage group
(estimated cumulative overall survival rate—two included studies).
Fig. 3. Odds ratio (OR) outcome for comparison of with- and without-incisal-coverage group- OR: 1.25 (95% CI: 0.33–4.73; I2 = 65.3%; p = 0.0562).
Table 1
Results of the risk of bias (NOS) of eight studies included.
A1 A2 A3 A4 B1 C1 C2 C3
Magne et al. (2000) * * * ** * * * 8
Peumans et al. (2004) * * * * ** * * * 9
Smales & Etemadi (2004) * * * * * * * 7
Fradeani et al. (2005) * * * * * 5
Granell-Ruiz et al. (2010) * * * * * * 6
Layton & Walton (2012) * * * ** * * 7
Gürel et al. (2013) * * * ** * * 7
Öztürk & Bolay (2014) * * * * ** * * * 9
R.B. Albanesi et al. / Journal of Dentistry 52 (2016) 1–7 5
Table 2
Study characteristics of eight studies included.
Author Year Material Idiom Country Inclusion Evaluation Follow Setting/ Age N Drop Study N Survival
period criteria up operator range patients out (%) veneers (%)
period (y)
Öztürk & 2014 Glass- English Turkey 2008– Modified USPHS 6 m- 2y University/ 18–51 28 0 PC 125 91,2
Bolay ceramic 2011 1op
(2014)
Gürel et al. 2013 Feldspathic/ English Turkey 1997– Proposal by ns-12y Private/ 23–73 66 0 RC 580 86
(2013) Glass 2009 author 1op
ceramic
Smales & 2004 Feldspathic English Australia 1989– Ns 5y-7y Private/ 16- 50 0 RC 110 95,8a
Etemadi porcelain 1993 2op ! 51 85,5b
(2004]
Granell-Ruiz 2009 Glass- English Spain 1999– Ns 3y-11y University/ 18–74 70 0 RC 323 84.7a
et al. (2010) ceramic 2005 ns op 94b
Layton & 2012 Feldspathic English Australia 1990– Walton’s six- 1y-21y Private/ 15–73 155 19.35 PC 499 91
Walton porcelain 2010 field 1op
(2012) Classification
Fradeani et al. 2005 Feldspathic/ English Italy 1991– Modified CDA/ ns-12y Private/ 19–66 46 0 RC 182 94.4
(2005) Glass- 2002 Ryge 2op
ceramic
Magne et al. 2000 Feldspathic English ns 1992– Proposal by 4,5 y ns/1 op 18–52 16 0 RC 48 85
(2000) porcelain 1996 author
Peumans 2004 Feldspathic English Belgium 1990– Proposal by 5y and Private/ 19–69 25/22 12 PC 87/81 64
et al. (2004) porcelain 1991 author 10y 1op
Legend: ns = not specified; y = year; m = month; w = week; N = Number; ns op = not specified operator; RC = Retrospective cohort; PC = Prospective cohort; * = same sample;
** = average.
a
With incisal coverage.
b
Without incisal coverage.
and for all-ceramic and metal-ceramic crowns, approximately 63% The clinical parameters for lengthening the incisal edge are
to 72% was removed. For a metal-ceramic crown, the amount of determined, based on occlusal and aesthetic factors. Professionals
tooth structure removed was 4.3 times greater than that removed should evaluate changes in shape, color, and the lack of harmony
for a porcelain laminate veneer (with facial surface preparation between teeth. Smile analysis helps whether determine if crown
only) and 2.4 times greater than that removed for a more extensive lengthening should be performed in the incisal or upward gingival
porcelain laminate veneer [8]. upward direction. In the majority of clinical cases, tooth volume
Some authors found better results with incisal covering [21], was re-established by repositioning the incisal edges in the incisal
while others did not [9,12]. The use of incisal ceramic coverage direction up to the point that aesthetics and function allowed.
with veneers has been suggested to enhance restoration survival, Therefore, in many instances, no additional tooth reduction
incisal-edge esthetics and adequate seating of the restoration. In occurred in this area when the mock-up and tooth preparation
addition, incisal coverage can diminish the occurrence of crack by means of the aesthetic pre-evaluative temporary method (APT)
lines and fractures on the palatal side, because it provides the allowed for an increase in the incisal edge on the mock-up, thus
restoration with a stronger bulk of porcelain [3,6,18,19,21]. On the resulting in a more conservative preparation [5,11,12].
other hand, incisal edge preparation was considered unnecessary As regards incisal coverage, no systematic review, up to now,
to ensure or improve restoration strength, as this thin palatal has determined its influence on the survival and failure rates of
extension tended to show more cracks. This occurred because the teeth restored with ceramic veneers. In previous systematic
fracture lines propagated due to repeated heavy mechanical reviews about ceramic veneers [4,24,25], only one systematic
loading, that eventually led to a large porcelain fracture in this review [22] included laboratory studies and addressed the
region [9,16,18]. However, there was no consensus about the most question of the most indicated preparation design. One literature
indicated preparation design, with or without incisal coverage, and review [20] attempted to explore the survival rates of veneers
the type of palatal design (butt joint or palatal chamfer) [2,3,5– based on different incisal preparation designs from both clinical
7,9,10,12,14–16,18–21]. At present, more conservative preparations and non-clinical studies.
should be advocated; however, covering the incisal third seemed to In this systematic review, the chance of failure (OR) was 1.25
be the approach most frequently used, in spite of not being the times higher for the veneers with incisal coverage; however, there
most conservative. In this review, seven studies (N = 1186 veneers) was no statistically significant difference between groups (95% CI:
were included and opted for incisal coverage preparation. Only two 0.33–4.73; I2 = 65.3%; p = 0.0562), and the variability could be
studies (N = 188 veneers) were chosen because they did not cover attributed to variations among the studies. Smales and Etemadi
the incisal edge (Fig. 2–A, Fig. 2–B). [21] considered incisal coverage a protective factor; on the other
It may seem nonsensical, but this occurred because when the hand, Granell-Ruiz et al. [9] and Gürel et al. [12] reported incisal
dentist considered the other clinical parameters, they had to coverage to be a risk factor for failures. Gürel et al. [12] affirmed
choose a method of incisal coverage although this was a less that the incisal coverage increased the chance of ceramic laminate
conservative approach. Therefore, dentists should try to determine veneer failure by 2.3 times.
the best decision-making, based on scientific evidence, according The survival rate was 88% for the group with incisal coverage
to the following clinical questions: 1) In cases in which it would be and 91% for the group without incisal coverage. There was no
possible to choose between two preparation designs, what would statistically significant difference between these groups. Thus, the
be the best option- to cover or not cover the incisal edge? and 2) If null hypothesis was confirmed.
incisal coverage is necessary, which clinical parameters are needed These data indicated that the preparation may not be the most
to lenghthen this incisal edge, and what would be the best type of important factor for the survival of veneers; therefore, if there are
palatal termination? no statistically significant differences, it is best not to overlap the
6 R.B. Albanesi et al. / Journal of Dentistry 52 (2016) 1–7
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