Dent Clin N Am 51 (2007) 399–417

Porcelain Laminate Veneers: Reasons

for 25 Years of Success
John R. Calamia, DMDa,*,
Christine S. Calamia, DDSb
a
Department of Cariology and Comprehensive Care, New York University College
of Dentistry, 345 East 24th Street, New York, NY 10010-4086, USA
b
Department of Biomaterials and Biomemetics, New York University College
of Dentistry, New York, NY

Since its introduction more than two decades ago [1,2], etched porcelain
veneer restoration has proved to be a durable and aesthetic modality of
treatment [3–6]. These past 25 years of success can be attributed to great at-
tention to detail in the following areas: (1) planning the case, (2) conserva-
tive (enamel saving) preparation of teeth, (3) proper selection of ceramics to
use, (4) proper selection of the materials and methods of cementation of
these restorations, (5) proper finishing and polishing of the restorations,
and (6) proper planning for the continuing maintenance of these restora-
tions. This article discusses failures that could occur if meticulous attention
is not given to such details. Failures that did occur structurally and aesthet-
ically warned individuals who were learning the procedure what to watch
for. Some concerns as to newer products and methods and their effect on
the continued success of this modality of treatment are also addressed.

Shade matching
Aesthetic shade matching and masking with thin porcelain veneer resto-
rations are arguably the most demanding facets of this procedure. The key
to success is understanding that the final color obtained is a combined me-
tamerism of the tooth, the resin cement selected, and the porcelain used for
the restoration.

* Corresponding author.
E-mail address: [email protected] (J.R. Calamia).

0011-8532/07/$ - see front matter Ó 2007 Published by Elsevier Inc.

doi:10.1016/j.cden.2007.03.008 dental.theclinics.com
400 CALAMIA & CALAMIA

The first part of the equationdthe underlying toothdcan play a crucial

role in the final appearance of the restoration. Imperfections should be
minimized, and existing restorations should be changed either before
preparation and impression making or at the time of insertion. The clini-
cian also may try to change the color of the teeth to be veneered (ie, tet-
racycline-stained case) with the use of modern bleaching techniques [7].
The final opacity, translucency, and distribution of color of the existing
tooth (the stump shade) should be communicated thoroughly to the tech-
nician by intraoral photographs, shade drawings, and custom shade
guides to allow the technician to plan the most important part of the
equation, the final restoration. Masking undesirable discolorations with-
out sacrificing natural translucency in the final restoration requires tech-
nical skills and experienced workmanship that can only be tapped if the
technician receives enough information about the case. Using contempo-
rary feldspathic porcelain (Omega900, Vident, Brea, CA; Finesse, Dents-
ply Prosthetic, York, PA; IPS, D.Sign, Ivoclar Vivadent, Amherst, NY)
and metal-free, high-strength restorations (IPS Empress, D.Sign, Ivoclar
Vivadent, Amherst, NY; OPC, Pentron Laboratories, Wallingford, CT),
which are developed specifically for bonded restorations, dental labora-
tory professionals are able to vary translucency and internal characteriza-
tions in the fabrication of aesthetic restorations. The technician’s
experience and ability are of vital importance to a successful case.
The last component of the equation is the luting cement. Under
normal circumstances, the cement is probably the least responsible for
the final result obtained, contributing less than 10% of the final color
of the restoration. There is an important contribution, however. Gener-
ally, the higher the filler content of cement, the more refractive and
opaque the final color of the restoration. If the laboratory technician in-
corporates a spacer on the die on which the veneer is fabricated, this im-
portant component of the process can be addressed. The resultant
increase in distance between the tooth and the veneer allows for increased
control of the restoration color with resin cement. The value and opacity
of the underlying cement are generally more important than the hue or
chroma selected [8]. It is the authors’ experience that thin viscosity,
highly filled resin cements cause fewer long-term problems with marginal
discoloration and air entrapment than do more viscous resin formula-
tions. Recent-generation resin cements (eg, Calibra, Dentsply Caulk, Mil-
ford, DE; Choice II, Bisco, Schaumburg, IL; Lutelt, Pentron Corp.,
Wallingford, CT; Variolink I and Appeal, Ivoclar Vivadent, Amherst,
NY; Ultra Bond Improved, Den-Mat Corp., Santa Monica, CA) can
be light cured or, if used with thick restorations such as inlays, onlays,
or crowns, dual cured with the addition of catalyst added to the base ce-
ment. It should be noted that once the dual-cure component is added, the
likelihood exists that the restoration may change slightly in color over
time because of the aromatic tertiary amine component of dual-cure
 PORCELAIN LAMINATE VENEERS 401

products [9–11]. Dual cure resin cement use should be limited to poste-
rior restorations outside the smile line.
In instances in which classes III and IV restorations that require replace-
ment are in contact with the veneer preparation, the authors also had success
with microhybrid restorative resins used as cements (ie, TPH Spectrum,
Dentsply Caulk, Milford, DE; Venus, Heraeus Kulzer, Armonk, NY; Point
4 Sybron/Kerr, Orange, CA). These resin cements are opaque enough that
they are also useful in masking stained teeth (ie, tetracycline-stained cases).
Clinicians should take care to properly provide a better contact angle of
these more highly viscose materials to the veneer. This is accomplished by
first applying a thin layer of a light-cured unfilled resin to the veneer and
then syringing the hybrid directly on the intaglio (ie, internal surface) of
the restoration. A composite instrument is used to flatten the hybrid over
the surface so that no air is trapped. The restoration should be seated slowly
and with pressure to ensure complete seating. Any excess resin cement is re-
moved with a microbrush soaked with unfilled resin. Finally, the veneer is
pushed into place one last time. Excess resin is left in place to ensure that
there are no voids at the margins. While slight finger pressure is applied,
the restoration is cured for at least 5 seconds with a standard halogen or
LED light, after which finger pressure is no longer needed and the curing
of the resin cement is continued for additional 40 seconds. These restorations
cannot be overcured, so more curing time is better than less curing time.

Marginal discoloration and loss of color stability

The least common problems associated with porcelain laminate veneers
are marginal discoloration and loss of color stability. These problems sel-
dom occur because (1) all margins are in cleansable areas often easily fin-
ished and polished at the time of cementation and (2) the glazed porcelain
surface, which is mostly impervious to extrinsic stain, also protects underly-
ing light-cured (more color stable) resin cement [10].
If a well-fitted restoration has been returned and a thin viscosity, but
highly filled, resin cement has been used with proper finishing and polishing
techniques, immediate marginal discoloration is rare, and little or no mar-
ginal discoloration is usually seen at long-term follow-up. However, ill-
fitting veneers, which expose inappropriate amounts of resin cement at their
margins, or well-fitting but poorly seated restorations caused by the use of
highly viscous cements often show a dark line stain at the margins
(Fig. 1). Only refinishing and repolishing can remove these dark lines. If
these lines are too deep, then a replacement restoration may be necessary.
To remove excess cement, the author uses a series of trimming diamonds
(ie, ET, Brasseler USA, Savannah, GA) in a 30-mm, 15-mm, and 8-mm se-
quence of finishing diamonds. (The Two-Striper MFS, another kit of dia-
mond finishing instruments by Premier Dental, Plymouth Meeting, PA,
comes in 40-mm, 20-mm, and 10-mm series.) This process is followed by
402 CALAMIA & CALAMIA

Fig. 1. Clinical view of discolored line that results from improper finishing or an undercon-
toured margin.

finishing and polishing with strips and disks (ie, Sof-Lex, 3M Espe, St. Paul,
MN) and then by porcelain diamond polishing paste applied with rubber
cups.

Breakdown in bonds
A possible cause of marginal discoloration and the loss of color stability
of the restoration is marginal leakage or a breakdown of the bond either be-
tween the cement and the tooth or between the cement and the veneer. This
discoloration starts as a dark line but eventually works its way under the res-
toration, with a resultant diffused discoloration that spreads from the in-
volved margin. This phenomenon was common with acrylic laminate
veneers as a result of the poor bond strength at the cement and acrylic ve-
neer interface. This separation is uncommon for porcelain veneers because
under normal circumstances, the bond to porcelain by the cement and the
bond of composite cement to tooth is more than acceptable to retain the ve-
neer over the long-term [12,13].
However, if the veneer is not properly etched or if the veneer and tooth
are in some way contaminated during the bonding process (ie, water or oil in
the air lines), it is possible to experience this problem or worsedthe com-
plete delamination of the veneer. This occurrence is rare, and it is usually
important to pay close attention to the porcelain, composite, and tooth in-
terfaces (Figs. 2 and 3). Organization of steps at the time of bonding usually
eliminates this concern. If a debonded but good-fitting restoration is recov-
ered, the tooth may be cleaned of all old composite using magnification. The
intaglio of the restoration intern can be delicately sandblasted and re-etched
using hydrofluoric acid and then cleaned, silanated, and recemented.

Air bubble entrapment

Air bubbles can become entrapped near the margin of the restoration,
which eventually becomes exposed. Food and other debris may be packed
 PORCELAIN LAMINATE VENEERS 403

Fig. 2. Delamination of tooth #24 is caused by poor cementation. Excess resin cement is also
present at the cervical margin of tooth #27 and is subgingival on teeth #23 through #25, causing
excessive gingival irritation.

into the small space between the restoration and the tooth. Although this is
a rare occurrence, the best treatment is first gaining proper access to this
void with a pointed diamond and thoroughly removing any food and debris
impaction. The porcelain can be etched with mild hydrofluoric acid and si-
lanated, the tooth can be etched with 37% phosphoric acid, and a new resin
cement can be introduced with a thin syringe tip or compule.
Leaking, old restorations or an uncovered surface of the veneered tooth
also may cause generalized discoloration. This possibility should be exam-
ined, and if it is found to be the cause of any discoloration, the restoration
should be removed and restored (Figs. 4 and 5). There has been some spec-
ulation that dual-cured or chemically cured composite resins used as ce-
ments for veneers eventually can discolor over time, with resultant change
of veneer color. Modern porcelain veneer cements are generally packaged
as base shades only and are light cured. Some of these cements can be
used in conjunction with the appropriate catalyst to be used as dual cements,

Fig. 3. It is evident from this debonded restoration that contamination occurred at the interface
between the cement and the tooth surface. Almost all of the cement is still attached to the
veneer.
404 CALAMIA & CALAMIA

Fig. 4. Improperly placed laminates are positioned too cervically, which is primarily caused by
little or no preparation of the teeth and no positive lock into place.

but they should have limited use on posterior restorations outside the smile
line.

Cohesive failure and repair

Another rare occurrence is the cohesive failure of either the tooth or the
porcelain. In the first instance, the fracture of the underlying tooth is usually
the result of poor judgment in selection of the tooth to be veneered. Vital
anterior teeth with large existing restorations on the mesial and distal sur-
faces might be better served with full-coverage porcelain restorations
bonded to the additional surface area of the crown preparation on dentin.
Nonvital anterior teeth that have at least one surface with large existing res-
toration and an average-to-large lingual access from root canal therapy
should be considered for post core and full-coverage porcelain crowns
(Figs. 6 and 7) [2,3].

Fig. 5. Leakage of a restoration on the mesiolingual surface of tooth #10 resulted in a discolor-
ation of its mesiofacial surface. Excess cement is also visible at the mesiocervical of tooth #6.
Poor axial inclination is also evident on teeth #9, 10, 11.
 PORCELAIN LAMINATE VENEERS 405

Fig. 6. Buccal view of fractured tooth with large access opening for root canal therapy and
a large mesiolingual class III restoration. Placement of an esthetic post and full coverage might
have been a better choice.

A more common problem is the cohesive failure of the porcelain itself,

which may occur during cementation as a result of a poor-fitting restoration,
a resin that is too thick (viscous), or a resin that has gone through some ini-
tial setting. The latter can result if the resin is left too long in ambient light
or unit light. Cohesive failure also may occur after cementation as the result
of poorly planned occlusion or traumatic injury. It is important to note that
these fractures, after cementation, occur almost exclusively within porcelain
and rarely extend to the junction of porcelain and cement. In the case of ve-
neer fractured at the time of placement, the restoration still may be placed
temporarily because of the usual intimate fit of the pieces. The patient is in-
formed of the problem and an appointment is made for removal of the frac-
tured veneer and creation of an impression for its final replacement. This
scenario has occurred twice in the authors’ experience, and in both instances
the patients did not see any aesthetic difference in the fractured restoration
compared with other restorations. To date, both patients have not elected to
have the fractured restorations replaced. One such case is 12 years old and

Fig. 7. It is interesting that the resulting fracture occurred totally within the tooth and the bond
between the veneer and the facial enamel remains intact.
406 CALAMIA & CALAMIA

the other is 8 years old. Since we began using high-strength porcelains, no

further fractures on placement have been experienced.
In the case of restorations that experience cohesive failure after cementa-
tion, repair may be attempted depending on the extent of the fracture. The
following steps are suggested to follow for this type of repair.
1. A rubber dam should be applied. Resin block-out materials, similar to
those used to protect gingival tissue during bleaching procedures, also
can be used if a small area is involved but control of the field is neces-
sary. At least cotton roll isolation and high-speed evacuation are
warranted.
2. Sandblasting of the area to be etched is suggested, generally with 50-mm
aluminum oxide particles. Roughening of the porcelain at the margin
with a coarse diamond may suffice.
3. Hydrofluoric acid is applied to the roughened porcelain surface (Fig. 8),
which is followed by the placement of phosphoric acid on exposed den-
tin and/or enamel.
4. After following the manufacturer’s directions on etch time, one should
rinse and dry the surface.
5. A suitable silane coupling agent is applied to the porcelain only (Fig. 9).
Premixed silanes generally have a short shelf life and should be used as
soon as possible. Silanes that come in two bottles that require mixing are
generally best. Silanes are transferred to the surface of the porcelain in
a chemical vehicle that dissipates on drying. Care should be used to en-
sure that the treated surface is dried properly. If the chemical vehicle is
still present (usually indicated by a wet appearance on the surface), it
could act as a separating medium and, rather than boost the bond
strength, cause delamination. It is important to follow manufacturer in-
structions exactly [14–16].

Fig. 8. Repair of the porcelain restoration is performed conservatively using an adhesive bond-
ing protocol. Here the porcelain has been roughened, and hydrofluoric acid was placed to etch
porcelain intraorally. Exposed tooth is etched with phosphoric acid.
 PORCELAIN LAMINATE VENEERS 407

Fig. 9. The acids are removed with a water spray and dried. A silane coupling agent is applied
and allowed to dry thoroughly. The properly etched and silanated surface is evident.

After the silane has been added and dried, an appropriate unfilled resin or
dentin bonding agent may be added to the porcelain/tooth interface and the
excess is blown off the surface to be repaired. This process prevents the pool-
ing of unfilled resin, which weakens the repair. This unfilled resin-covered
surface is then light cured for at least 20 seconds. Finally, a filled hybrid
or micro-filled composite is placed, appropriately contoured, and cured as
the repair material. It may be finished and polished to provide a smooth sur-
face (Fig. 10). In the short-term, it is difficult to delineate where the repair
material has been placed, but in the long-term, a new restoration eventually
may need to be considered.

Improper occlusion and its periodontal implications

Because most porcelain veneers are fabricated on the facial surface of
maxillary anterior teeth, occlusion is often not considered critical to the suc-
cess of these cases. On the contrary, occlusion is of vital importance, not

Fig. 10. An unfilled composite resin is applied, air thinned, and cured. This process is followed
by application of microhybrid composite resin for an aestheticdyet durabledrepair.
408 CALAMIA & CALAMIA

only in vertical occlusion but also in lateral and protrusive movements. Even
a slight lengthening of the maxillary anterior teeth over the incisal edge can
have severe consequences on the unrestored mandibular dentition because
of the difference in hardness between porcelain and the natural enamel.
This difference becomes even more critical in canine and first premolar oc-
clusion (Fig. 11). In some isolated cases, the author also has observed un-
usual gingival recession patterns in teeth that may have been inadvertently
brought into increased occlusal stress after lamination. If occlusion is not
properly planned into the final restorations, it likely will result in long-
term consequences. All cases should be articulated and checked carefully
before insertion, and final finishing and polishing should follow occlusal
equilibration followed by protective night guard appliances.

Discussion
The etched porcelain veneer has proved to be one of the most successful
modalities of treatment that modern dentistry has to offer. Difficulties with
this restoration have been relatively nonexistent over the past 25 years. The
problems that have arisen seem to involve matters of proper patient selec-
tion, attention to details in preparation and final placement, and material
and laboratory selection. The latest resin cements, bonding agents, and
high-strength ceramics have expanded the etched porcelain technology for
inlays, onlays, crowns, and simple bridges (Figs. 12–14).
With the advent of new dentin-bonding agents, ceramics that required
more room in preparation to allow for processing (ie, pressed ceramics),
and failure of many to take advantage of multidisciplinary cases incorpo-
rating orthodontics, oral surgery, and endodontics, however, the key con-
cept of the preservation of enamel somehow has gone by the wayside or
been considered less important. This may be a huge mistake. Deeper prep-
aration into dentin, a substrate that has a much lower modulus of

Fig. 11. Porcelain veneers on facial-incisal teeth #6 and #7 seem to be wearing the facial-incisal
of teeth #26 and #27. Restoration of the occluding mandibular teeth should have been consid-
ered in this case.
 PORCELAIN LAMINATE VENEERS 409

Fig. 12. In this tetracycline case, the existing composite bonding is removed and the teeth are
prepared for porcelain veneers and full-coverage porcelain crowns.

Fig. 13. Incisal/occlusal view of seated maxillary restorations. Note the natural arch form and
harmony of the definitive restorations.

Fig. 14. Postoperative facial view of the definitive all-ceramic veneer and crown restorations.
410 CALAMIA & CALAMIA

elasticity than porcelain, has provided a less rigid base or foundation for
restoration placement than enamel. This approach has resulted in reports
of much higher fracture rates than other previous enamel supported resto-
rations [17]. This disturbing trend has been further complicated by the use
of self-etch bonding agents that may show more long-term degradation of
the dentinal bond because of water permeations at the adhesive dentin in-
terphase [18–22].
Over the past 25 years, the etched porcelain-bonded restoration has dem-
onstrated four important criteria, in the opinion of the authors, in determin-
ing the ultimate success of this dental restorative system: (1) adequate
strength, hardness, and resistance to abrasion of porcelain exo-skin, which
protects the resin adhesive undercoating, (2) biocompatibility withdbut re-
sistance todthe oral environment of the total restoration, (3) ability to be
formed into the necessary shapes and colors while retaining the tooth’s
natural translucency, and (4) values for thermal conductivity and coefficient
of thermal expansion, similar to that of tooth structure, allowing long-term
adhesion of the restoration while still providing the feel of natural tooth
surface.
These important characteristics must place porcelain laminate veneers
among the most successful restorations that dentistry provides. This modal-
ity of treatment has been part of the curriculum in only a few dental schools
in North America, which has given rise to many privately owned institutes
being happy to fill this gap in modern education and providing what they
consider the proper techniques and philosophy of treatment using this res-
toration. It is our hope that all dental schools in North America will see
value in providing the proper training to their students.
The following case handled at New York University College of Dentistry
by a fourth-year student incorporated 20 all-porcelain restorations. The re-
sult was a revitalized smile of a young female executive (Figs. 15–18).

Fig. 15. Unattractive smile with leaking restoration and yellow teeth.
 PORCELAIN LAMINATE VENEERS 411

Fig. 16. Right lateral view.

Fig. 17. Direct frontal view.

Fig. 18. Left lateral view. Poor crown margin.

412 CALAMIA & CALAMIA

Fig. 19. Maxillary incisal/occlusal view.

Based on radiographs and an intraoral examination, it was clear that the

patient is at high risk for caries. All premolars had existing amalgam or
composite restorations. All incisors had large mesial and distal restorations.
Some of these restorations contained open margins. The patient’s main
complaint was that she would like all her teeth to be the same shade and
not cracked. She did feel that her teeth appeared too small (Figs. 19–21).
After exploring all possibilities, a treatment plan was decided on and agreed
to by the patient:
1) The premolar restorations would be restored with composite.
2) Tooth #10 had an existing porcelain fused to metal crown that, with
time, had caused gingival recession. It would be replaced with an all por-
celain crown.
3) Teeth #4–6, 11–13, 20–22, 27–29 would be restored with a feldspathic
porcelain (soft spar veneers).
4) Teeth #7–10 and 23–26 would be restored with (soft spare) porcelain
crowns to provide full coverage to incisors with large restorations of
endodontically treated teeth (Figs. 22–30).

Fig. 20. Mandibular incisal/occlusal view.

 PORCELAIN LAMINATE VENEERS 413

Fig. 21. NYU student prepares teeth while another student assists. In this way, two students
can share the knowledge of one large case.

Fig. 22. Prepared maxillary teeth.

Fig. 23. Finished restorations on working cast, direct facial view.

414 CALAMIA & CALAMIA

Fig. 24. Finished restorations on working cast, palatal view.

Fig. 25. Finished maxillary restorations, palatal view.

Fig. 26. Finished mandibular restorations, incisal view.

 PORCELAIN LAMINATE VENEERS 415

Fig. 27. Finished restorations, left lateral view.

Fig. 28. Finished restorations, direct view.

Fig. 29. Finished restorations, left lateral view.

416 CALAMIA & CALAMIA

Fig. 30. Improved smile.

All prepared teeth were etched with a 35% phosphoric acid, and prime
and bond bonding agent was applied. Softspar crowns and veneers were
treated with silane and cemented to teeth with Vario-link transparent base
resin cement. Pogo polishing cones were used to polish the final restorations.

Summary
Etched porcelain veneer technology has demonstrated long-term clinical
success. It has proved to be one of the most successful modalities of treat-
ment that modern dentistry has to offer. The relatively few difficulties that
have been encountered may be circumvented or eliminated if the practi-
tioner pays close attention to detail. Development of new products and ma-
terials is expected to bring longer term success. Modern-day restorations
offer great promise for the expanded use of the etched porcelain/resin-
bonded system for inlays, onlays, crowns, and simple bridges if the ability
of bonding to dentin is respected and further researched. Evidence based
principals need to determined and followed, like what has been done with
porcelain veneer bonding to enamel.

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