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International Journal of Recent Advances in Multidisciplinary Research

Vol. 03, Issue 02, pp.1232-1244, February, 2016

RESEARCH ARTICLE

NAME OF THE TITLE: MARGINAL DISCREPANCY IN CERAMIC LAMINATE VENEERS INFLUENCED

BY RESIN LUTING AGENTS- A SYSTEMATIC REVIEW AND META -ANALYSIS
1Ranganathan Hemalatha and 2,*Dhanraj Ganapathy
1Post
graduate trainee, Saveetha dental college, Chennai-77, India
2Professor and H.O.D, Department of prosthodontics, Saveetha Dental College, Chennai-77, India

ARTICLE INFO ABSTRACT

Article History:
nd
Received 02 November, 2015
Received in revised form
12th December, 2015
Accepted 28th January, 2016
Published online 29th February 2016
Keywords:
Ceramic laminate veneers,
Cervical marginal discrepancy,
Incisal marginal discrepancy,
Resin luting agents.
Statement of the Problem: The precise role of luting agents in inducing marginal discrepancy in
all ceramic laminate veneers is not clear and needs to be investigated further.
Aim:
 To evaluate the amount of marginal discrepancy induced by resin luting agents in all ceramic
laminate veneer restorations.
 To estimate the amount of marginal discrepancy present in the cervical and incisal portions of
ceramic laminate veneers.
Sources Used: An electronic search was conducted for scholarly articles about the primary
outcome, marginal discrepancy in ceramic laminate veneers, written in English or translated into
English listed with pubmed ,Cochrane library, ScienceDirect, Wiley online library,Google scholar
data bases,The Newyork Academy of Medicine Grey literature Report and Ingenta Connect till
July 31st 2015. The search methodology applied was a combination of MESH terms and suitable
keywords based on PICO formulated for the review.
Search Methodology: The database search yielded 543 articles out of which 530 articles were
discarded after reading the abstract. Full texts were obtained for the remaining 13 articles.6 articles
were selected based on the inclusion criteria and 7 articles were excluded. The finally selected 6
articles were subjected to data extraction. and statistical analysis.
Results: There is a significant difference in marginal discrepancy pre and post luting with resin
cements in all the studies (p<0.05) included. Meta analysis suggested marginal discrepancy is
significantly higher in incisal portions than the cervical portions of ceramic laminate veneers with
a marked effect size Z=3.5(p=0.004) in all the studies included.
Conclusion: Resin luting cements increases marginal discrepancy in ceramic laminate veneers and
incisal portions of ceramic laminate veneers exhibit more discrepancy than the cervical portions
and hence more vulnerable to microleakage.

INTRODUCTION Amongst these factors cementation procedures influence the

The marginal fit is one of the most important criteria for long
term success of all ceramic restorations (DellaBona et al.,
2008). Discrepancy in marginal fit facilitate microleakage,
salivary infiltration and seepage resulting in dissolution of
luting agent, thus increases the susceptibility for secondary
caries around abutments eventually leading to abutment and
restoration failure (Zaimog˘lu et al., 1992). Marginal
discrepancy also inflicts severe sensitivity due to the exposure
of exposed dentinal tubules. Also, marginal discrepancy results
in collection of plaque and food particles around the exposed
margins which subsequently initiates periodontal breakdown in
the abutment teeth. (Hekimoǧlu et al., 2004). Various factors
like type of finish lines, die spacing, choice of restorative
materials and cementation procedure influence this
phenomenon (Schmidt et al., 2011).
*Corresponding author: Dhanraj Ganapathy,
Professor and H.O.D, Department of prosthodontics, Saveetha Dental
College, Chennai-77, India.
marginal seating of all ceramic laminate veneer retainers
markedly. Among the luting agents, the resin bonded cements
possess a greater film thickness more than 25microns which
may interfere with complete marginal seating of the retainers
(Blatz et al., 2003). In addition to this the time interval between
the ceramic fabrication stages, sequence of firing,the bulk of
the material added for firing ,the core and veneering layer
mismatch, type of porcelain- high fusing, medium fusing and
low fusing ,play a role in influencing marginal discrepancy.
Laminate veneers being the most esthetic and biocompatible
restorative treatment option is a primary option in restoring
diastema spaces, esthetic restoration of discoloured teeth and
hypoplastic teeth (Spear et al., 2008). It is also conservative
method and also exhibits excellent compatibility with
periodontium. However, the major shortcoming of porcelain
veneer is the relatively wide marginal discrepancy. Marginal
discrepancy is observed irrespective of the various processing
techniques employed (Lawn et al., 2004).
This phenomenon is augumented by the use of luting agents
which have varying levels of film thickness.The resin luting
agents also have relatively high polymerisation shrinkage,low
International Journal of Recent Advances in Multidisciplinary Research
resistance to clinical wear and high coefficient of thermal
expansion.(Attin T et al 1995) which could potentially increase
marginal leakage. The ceramic veneers also exhibit varying
levels of adaptation over different surfaces of the teeth owing to
the convexity and biplanar reduction done in the tooth
preparation (Conrad HJ et al 2007). This bending of restoration
induces varying amounts of marginal discrepancy in the various
surfaces namely cervical, incisal and proximal and needs to be
further investigated in detail. Hence this systematic review was
formulated with the following aims and objectives:
AIM
 To evaluate the amount of marginal discrepancy induced by
resin luting agents in all ceramic laminate veneer
restorations.
 To estimate and evaluate the amount of marginal
discrepancy present in the cervical and incisal portions of
ceramic laminate veneers.
PICO ANALYSIS
P-Problem
Marginal discrepancy in all ceramic laminate veneers induced
by luting agents.
P-Population
Teeth undergoing restorative treatment with ceramic laminate
veneers.
I-Intervention
 Ceramic laminate veneers luted with resin luting agents.
 Observation of incisal margins in ceramic laminate veneers
for Marginal discrepancy
C-Comparison/control
(A)-Ceramic laminate veneers luted with resin modified Glass
ionomer cement
(B)-Observation of cervical margins in ceramic laminate
veneers for Marginal discrepancy.
O-Outcome
Primary outcome- marginal discrepancy in ceramic laminate
veneers.
 Horizontal marginal Discrepancy
 Vertical marginal Discrepancy
 Absolute marginal Discrepancy
Indirect primary outcome
The amount of microleakage present in cervical and incisal
margins.
Variables of interest
Influence of the following factors on marginal discrepancy
 Type of finish lines
1233
 Thickness of the die spacer
 Composition of ceramic processing materials
 Firing sequence of ceramic materials
 Core and veneer mismatch
 Dissolution of luting cements
 Abrasion of margins with brushing technique
 Gingival Porcelains
 The ceramic processing technique used
 Surface discolouration of veneers.
 Fracture of veneers.
MATERIALS AND METHODS
SOURCES USED:-
An electronic search was conducted for articles written in
English or translated into English listed with pubmed
,Cochranelibrary, ScienceDirect, Wiley online library,Google
scholar data bases,TheNewyork Academy of Medicine Grey
literature Report,Ingenta Connect till July 31st 2015 reporting
marginal discrepancy in ceramic laminate veneers.
PICO ANALYSIS
SEARCH METHODOLOGY
The search methodology applied was a combination of MESH
terms and suitable keywords.
POPULATION
Laminate veneers, Veneers, Porcelain laminate veneers,
Porcelain laminates, porcelain veneers, Partial veneers,
Feldspathic porcelain, Aluminous porcelain, Leucite porcelain,
Castable ceramics, Pressable ceramics, Machinable ceramics,
CAD CAM ceramics, Copymilling, Onlay, Resin bonded
veneers, Partial crowns, Ceramic veneers, Labial preparations,
Chamfer margin, Shoulder margin, Shoulder with bevel,
Esthetic restorations, Esthetic veneers, Resin veneers, Direct
veneers, Indirect veneers, Cemented veneers, Bonded veneers
INTERVENTION
Resin cements, Resin luting agents, Bis GMA cements,
UDGMA cements, TEGDMA cements, HEMA cements, Resin
based filling material, Pure resin cements, Dual curing resin
cements, Self adhesive resin cements, MDP resin cements,4
META cements, RelyXUnicem, Variolink, Calibra, Superbond,
Lutingcement, Self etching resin cement,Light cure resin
cement, Chemical cure resin cement, Acrylate resin cement,
Compomer,Composite cements, All ceramic luting cement,
Chemico mechanical cement, Fluoride releasing cement
COMPARISION/CONTROL
Glass ionomer cement, Polyalkenoate cement, Glass cements,
Resin modified glass ionomer, Conventional GIC,
Fluoroaluminosilicate cements, Polyacrylic acid cements,
Silicate glass powder, Hybrid ionomer cement, Tricure glass
ionomer cement, Metal reinforced GIC,Cermet, Linker,
GICFuji, Chemfil, Bio active galss, Detrey,Ketac –cem, Luting
cement, LutingGIC, Fluoride releasing cement, Chemical
bonding cement,Polyacrylic cement,Type 1 cement, Type 1
International Journal of Recent Advances in Multidisciplinary Research 1234

luting cement, Dual cure cement, Multi cure cement, Sandwich  Marginal discrepancy in porcelain fused metal restorations.
cement, Dentin conditioners, Dentin conditioning cement,  Marginal discrepancy with other partial veneer retainers.
Dentin cement  Marginal discrepancy with composite labial veneers.
 Porcelain repair systems creating marginal discrepancy.
OUTCOME  Gingival porcelains.
 Ceramic veneers over endodontically treated teeth.
Marginal fit, Marginal discrepancy, Marginal intergrity,
Marginal leakage, Marginal error, Marginal accuracy, Marginal
exposure, Misfit, Microleakage, Electrolytic corrosion, RESULTS
Marginal leak, Marginal gap, Gap, Healthy margin, Margin
misfit, Surface misfit, Marginmal alignment, Improper seating, The database search yielded 543 articles out of which 530
Finish line discrepancy, Shoulder discrepancy, Chamfer articles were discarded after reading the abstract. Full texts
discrepancy, Knife edge discrepancy, Feather edge discrepancy, were obtained for the remaining 13 articles.6 articles were
Restoration misfit, Cement exposure, Luting agent exposure, selected based on the inclusion criteria and 7 articles were
Dualcure, Cement removal, Subgingival margins, excluded. The finally selected 6 articles were subjected to data
Supragingival margins, Marginalcaries, Class V caries, extraction.The CEBM levels of evidence were affixed for the
Cervical caries, Cervical misfit, Proximal misfit, Incisal misfit, selected articles and the following information were extracted.
Incisal discrepancy, Proximal discrepancy ,Cervical
discrepancy, Cervical fracture, Rough margins, Improper Data extraction
luting, Cervical dentinal exposure, Cement space, Die spacer,
Marginal fracture, Marginal adaptation The data from the finally included studied were tabulated and
the following information were extracted.
SELECTION OF STUDIES
 Study design applied
The review process consist of two phases.In the first phase  Horizontal marginal discrepancy
titles and abstract of the search were initially screened for  Vertical marginal discrepancy.
relevance and the full text of relevant abstract were obtained  Absolute marginal discrepancy.
and accessed.The hand search of selected journals as well as  Types of finish lines used.
search of references in the selected studies were also done. The  Thickness of the die spacer.
articles that were obtained after first step of review process  Composition of ceramic processing materials.
using the following inclusion and exclusion criteria were  Core and veneer mismatch.
screened in second phase and relevant and suitable articles were  Type of luting cements.
isolated for further processing and data extraction.
 Method of measurement.
 Instruments for measurement.
INCLUSION CRITERIA
 Statistical tests.
The articles discussing the following parameters were included  Processing techniques used.
for the systematic review.  Incisal marginal discrepancy.
 Cervical marginal discrepancy.
 Randomized controlled trials reporting marginal
discrepancy in all ceramic laminate veneer retainers. Flow Chart For Search Stratergy
 Controlled in-vitro trials reporting marginal discrepancy
in all ceramic laminate veneer retainers.
 Experimental research reporting CAD/CAM processing
techniques for all ceramic laminate veneer retainers.
 Experimental research reporting heat processed
techniques for allceramic laminate veneer retainers.
 In vitro trials utilizing customized metal dies evaluating
marginal discrepancy.
 In vitro trials utilizing extracted human teeth evaluating
marginal discrepancy.
 Studies reporting marginal discrepancy following luting.
 Articles discussing slip casting and glass infiltration for
laminate veneers.

EXCLUSION CRITERIA

Articles and manuscripts discussing the following parameters

were excluded: TABLES Table 1: Shows the variables of interest in the
selected articles. The following information were extracted and
tabulated.
 Finite element analysis studies.
 Case reports and case series.
International Journal of Recent Advances in Multidisciplinary Research 1235

Table 11.Variables of interest and general information on selected articles

Horizontal Vertical Absolute Type of Type of

Technique Thickness of Instrument of
Name of the Author Study Design Method of Observation Marginal Marginal Marginal Finish Line Luting Stats Test
Used Die Spacer Measurement
Discrepancy Discrepancy Discrepancy Used Cement
Sno
1 Celik et all 2002 Experimental study Heat press Direct observation Not mentioned Not Mentioned Mentioned Not Mentioned Transmitting ANOVA
In vitro Transmitting light mentioned Chamfer mentioned light Duncans
microscope microscope multiple
range test
2 Ibarra et al 2006 Experimental study Heat press Direct observation Not mentioned Not Mentioned Mentioned Not Mentioned Light ANOVA
In vitro Light microscope mentioned Chamfer mentioned microscope student
Newman
kuels&Gemes
–Howel post
hoc
3 Hekimoglu.Cet al Experimental study Conventional Direct observation Not mentioned Not Mentioned Mentioned Not Mentioned Auto McNemar test
2004 In vitro Auto radiograph mentioned Chamfer mentioned radiograph
4 D’Arcangeloet al Prospective conventional Clinical Not mentioned Not Mentioned Not Not Mentioned Clinical Kpalanmier
2012 Observational observation mentioned Mentioned mentioned observation
Invivo study Alpha,Bravo,Charlie Alpha,Bravo,
Charlie
5 Stappert C.F et al Experimental study Heat press Optical microscope Not mentioned Not Mentioned Mentioned Mentioned Mentioned Optical Paired &
2007 In vitro mentioned Chamfer & microscope unpaired t test
shoulder Bonferoni
6 Aboushelib MN et Experimental study CAD/CAM Direct observation Mentioned Mentioned Mentioned Mentioned Mentioned Mentioned Stereo 1 way
al 2012 In vitro Heat press Stereo microscope Chamfer microscope analysis of
variance
International Journal of Recent Advances in Multidisciplinary Research 1236

Table 2. Characteristics Of Excluded Articles

Sn: AUTHOR NAME STUDY DESIGN CHARACTERISTICS OF EXCLUDED ARTICLES

1 A.N.Ozturk et al
2 GA Bonges et al
3 Fathemeh et al
4 Manoj shetty et al
5 Ritujha et al
6 Lim et al
7 Nadia et al
Experimental in vitro study
Experimental in vitro study
Experimental in vitro study
Experimental in vitro study
Experimental in vitro study
Experimental in vitro study
Experimental in vitro study
This article involved the study of microleakage of different cementation techniques in class 5 ceramic inlays
This article involved the study of marginal fit of 3 all ceramic full coverage crowns.
This article involved the study of microleakage and marginal adaptation of indirect composite veneer restorations.
This article involved the study of marginal gap and microleakage in CAD milled full veneer coverage zirconia copings
In this article quantitative assessment was not done only qualitative assessment was done.
Marginal discrepancy is induced by grit blasting technique and not by luting cement.
Marginal discrepancy was studied in complete veneer crowns.

Table 3. Extraction of Exisiting Data Regarding Marginal Discrepancy

Sn:no Author Year N-value Groups Method of Mean value for marginal discrepancy S.d Statistical test Inference
measurement employed
1 Celik et al 2002 42 3 Direct observation Art Glass Marginal Gap/Variolink High ANOVA No significant difference
Transmitting light viscosity Duncans between luting cements.
microscope Cervical-109µm multiple range Significant difference
Incisal -114 µm 39µm test present between
Proximal-123 µm 43µm P value ˂ 0.005 incisaland cervical
57µm margins.
Art Glass Marginal Gap/Variolink Ultra
Cervical-144 µm
Incisal -145 µm
Proximal-120 µm 95µm
100µm
Art Glass Marginal 17 µm
Discrepancy/Variolink High viscosity
Cervical-173 µm
Incisal -210 µm
Proximal-178 µm
50 µm
77 µm
129 µm

Art Glass Marginal 109 µm

Discrepancy/Variolink Ultra 94 µm
Cervical-177 µm 54 µm
Incisal -184 µm
Proximal-152 µm

Empress Grit blasted Marginal 55 µm

Gap/Variolink High viscosity 47 µm
Cervical-128 µm 40 µm
Incisal -146 µm
Proximal-110 µm

Continune…………….
International Journal of Recent Advances in Multidisciplinary Research 1237

Empress Grit blasted Marginal 29 µm

Gap/Variolink Ultra 66 µm
Cervical-111 µm 27 µm
Incisal -172 µm
Proximal-135 µm

Empress Grit blasted Marginal

Discrepancy/Variolink High viscosity
Cervical-191 µm
Incisal -218 µm 63 µm
Proximal-125 µm 69 µm
49 µm
Empress Grit blasted Marginal
Discrepancy/Variolink Ultra
Cervical-145 µm 41 µm
Incisal -233 µm 58 µm
Proximal-144 µm 39 µm

Empress Sodium Citrate Marginal

Gap/Variolink High viscosity
Cervical-108 µm
Incisal -182 µm 80 µm
Proximal-128 µm 254 µm
65 µm
Empress Sodium Citrate Marginal
Gap/Variolink Ultra
Cervical-105 µm
Incisal -163 µm
Proximal-114 µm 43 µm
68 µm
Empress Sodium Citrate Marginal 74 µm
Discrepancy/Variolink High viscosity
Cervical-190 µm
Incisal -392 µm
Proximal-216 µm

Empress Sodium Citrate Marginal 146 µm

Discrepancy/Variolink Ultra 175 µm
Cervical-189 µm 83 µm
Incisal -402 µm
Proximal-241 µm 48 µm
111 µm
99 µm

Continune……….
International Journal of Recent Advances in Multidisciplinary Research 1238

2 Ibarra et al 2006 36 4 Direct DENTIN VALUES ANOVA student Significant difference present
observation Excite/Variolink Newman between the cervical and
44.1% 26% kuels&Gemes – incisal portions of the ceramic
Light microscope Single bond/Unicem Howel post hoc laminate veneers.
55.5% 25% .α=0.05
Prompt/Unicem
54.7% 19%
Unicem
28.1% 20%

ENAMEL VALUES
Excite/Variolink
2.5% 1.5%
Single bond/Unicem
3.1% 2%
Prompt/Unicem
2.2% 1.5%
Unicem
20% 30%

3 Hekimoglu.C et al 2004 20 2 Direct Window type Not mentioned McNemar test Significant difference present
observation Cervical score P<0.01 between the cervical and
1 (12) incisal portions of the ceramic
Auto radiograph 0 (8) laminate veneers
Incisal score
Labial
1 (8)
0 (12)
Lingual
1 (0)
All interface score
1 (5)
0 (15)

Overlapped type
Cervical score
1 (13)
0 (7)
Incisal score
Labial
1 (2)
0 (9)
Lingual
1 (9)
All interface score
1 (4)
0 (16)
Continune……
International Journal of Recent Advances in Multidisciplinary Research 1239

4 D’Arcangelo et al 2012 119 1 Clinical Marginal adaptation Not mentioned Kaplan mier No significant changes present
prospective Alfa until 60 months
observation 0 day 119
Alpha,Bravo,Cha 36 months 119
rlie 48 months 119
60 months 111
72 months 101
84 months 96
Bravo
0 day 0
36 months 0
48 months 0
60 months 0
72 months 2
84 months 3
Charlie
0 day 0
36 months 0
48 months 0
60 months 0
72 months 0
84 months 0
5 Stappert C.F et al 2007 48 3 Direct Window type luted Not mentioned Paired & Significant difference present
observation 46.16 µm unpaired t test between immediate post luting
Incisal overlap type luted Bonferoni and aging of the ceramic
Optical 46.32 µm p˂0.036 laminate veneers.
microscope Complete veneer type luted
54.29 µm

Window type aged

47.61 µm
Incisal overlap type aged
50.69µm
Complete veneer type aged
63.12 µm

6 Aboushelib MN et al 2012 40 2 Stereo Pressable 1 way analysis of Significant difference present

microscope Incisal -308.45µm 95.3µm variance between the cervical and
Cervical-233.51 µm 66.5µm P,<0.5 incisal portions of the ceramic
Machinable laminate veneers
Incisal-831.7 µm 368.9µm
Cervical-509.9 µm 281.6µm
International Journal of Recent Advances in Multidisciplinary Research 1240

Table 4. Marginal discrepancy in cervical and incisal portions of the ceramic laminate veneers

Sn:no Author Study design Marginal Standard Marginal discrepancy Standard deviation Marginal Standard Statistics Inference
discrepancy deviation incisal discrepancy deviation
cervical Proximal

1 Celik et al Experimental Variolink High Variolink High Variolink High ANOVA No significant
2002 study In vitro viscosity viscosity viscosity Duncans multiple difference
Art glass 173µm Art glass 210 µm Art glass 178 µm range test between luting
Empress Grit Empress Grit blasted Empress Grit P value ˂ 0.005 cements.
blasted 50 µm 218 µm 77 µm blasted 129 µm Significant
191 µm Empress Sodium 125 µm difference present
Empress citrate Empress Sodium between the
Sodium citrate 392 µm citrate cervical and
190 µm 63 µm 69µm 216 µm 49 µm incisal portions of
Variolink Ultra the ceramic
Variolink Ultra Art glass Variolink Ultra laminate veneers
Art glass 184 µm Art glass
177 µm 146 µm Empress Grit blasted 175 µm 152 µm 83 µm
Empress Grit 233 µm Empress Grit
blasted Empress Sodium blasted
145 µm Citrate 144 µm
Empress 402 µm Empress Sodium
Sodium Citrate 109 µm 94 µm Citrate 54 µm
189 µm 241 µm

41 µm 58 µm 39 µm

48 µm 111 µm 99 µm
2 Aboushelib Experimental Pressable Pressable 1 way analysis of Significant
MN et al study In vitro 233.5 µm 308.4 µm variance difference present
2012 Machinable 66.5 µm Machinable 95.3 µm P,<0.5 between the
509.9 µm 831.7 µm cervical and
incisal portions of
281.6 µm the ceramic
368.9 µm laminate veneers
International Journal of Recent Advances in Multidisciplinary Research 1241

Table 5. Summation and assessment for homogenicity:

Sn: AUTHOR PRE LUTING POST LUTING LUTING AGENT THERMOCYCLING EXPRESSION OF OUTCOME MEASURE
1 Celik et al 2002 Mentioned Mentioned Variolink High viscosity Not mentioned Microns µm
Variolink Ultra
2 Ibarra et al 2006 Not mentioned Mentioned Excite/Variolink 5 & 55 degree Celsius for 2000 cycles Percentage %
Single bond/Unicem 20 sec dwell time
Prompt/Unicem
Unicem
3 Hekimoglu.C et al 2004 Not mentioned Mentioned 3M Scotch bond 5 & 55 degree Celsius for 4 hrs 60 sec Percentage %
dwell time
4 D’Arcangelo et al 2012 Not mentioned Mentioned Enamel plus HFO Not mentioned Percentage %
5 Stappert C.F et al 2007 Not mentioned Mentioned Variolink 2 High viscosity 5 & 55 degree Celsius 5500 cycles 60 Microns µm
sec dwell time
6 Aboushelib MN et al 2012 Not mentioned Mentioned Variolink 5 & 55 degree Celsius 15000 90 sec Microns µm
immersion time

Table 6. Meta analysis for incisal and cervical marginal discrepancy in ceramc laminate veneers
International Journal of Recent Advances in Multidisciplinary Research
Name of the author, study design, technique used for all
ceramic fabrication, method and gadget for measuring
marginal discrepancy, horizontal marginal discrepancy,
vertical marginal discrepancy, absolute marginal discrepancy,
type of luting cement, type of finish line, thickness of die
spacer, type of luting cements, instrument of measurement,
statistical tests, processing technique were extracted and
tabulated.
RESULTS
The following information were extracted and tabulated. Name
of the author, study design, technique used for all ceramic
fabrication, method and gadget for measuring marginal
discrepancy, horizontal marginal discrepancy, vertical
marginal discrepancy, absolute marginal discrepancy, type of
luting cement, type of finish line, thickness of die spacer, type
of luting cements, instrument of measurement, statistical tests,
processing technique were extracted and tabulated (Table 1,
Table 3, Table4) Six studies were included and seven studies
were excluded (Table 2) All the included invitro studies were
3b and one invivo study was 3a respectively as per CEBM
levels of evidence guidelines and data were summated for
assesing homogeneity (Table 5).For difference in marginal
discrepancy prior and after luting with resin cements ,a meta
analysis could not be performed because the data showed
significant heterogenicity with some studies not measuring the
pre post luting marginal discrepancy,qualitative measurements
instead of quantitative assesments were done in some
studies.Some reviewers have reported the overall
circumferential marginal discrepancy and categorization of
surfaces viz incisal, cervical and proximal was not
reported.Some authors have reported marginal discrepancy
immediate post luting and following aging accomplished
through thermocycling.Hence the data could not be categorized
into homogenous strata and a meta analysis could not be
initiated. However a quasi meta analysis was possible for the
assessment of marginal discrepancy in cervical and incisal
portions.The study by celik et al included three independent
variables effecting marginal discrepancy and every variable
was treated as a separate study and a meta analysis was
performed (Table 6). The effect size parameter for this meta
analysis was the difference between the means in cervical and
incisal portions respectively.The results showed an extreme
deviation toward the cervical group in the forrest plot. The
heterogenicity of variance was observed in the selected studies
Tau²=2715.30;Chi²=12.46,df=4(p=0.01);I²=68% and hence a
random effect model was choosen. The overall effect size was
z=3.51(p=.0004) and hence a very significant difference was
inferred between cervical and incisal marginal discrepancy in
ceramic laminate veneers.
DISCUSSION
The dental literature includes more detailed in vitro
investigations than in vivo studies with respect to marginal
discrepancy in ceramic laminate veneers. Many different
techniques have been used for determination of in vitro
microadaptation microleakage(Tjan AH et al 1989). These
techniques include the use of bacteria, compressed air,
chemical and radioactive tracers, electrochemical
investigations, scanning electron microscopy and the use of
1242
dye penetration studies.( Hekimoǧlu,et al 2004) . As far as the
ceramic processing techniques for veneers are concerned, the
heat pressing technique can be used for the fabrication of
copings as in Empress 2 lithium disilicateceramics.The heat
pressing technique is based on the lost wax principle
(Saraçoğlu et al 2004). Prefabricated ceramic ingots of
lithiumdisilicate ceramic are heated at high temperatures and
then pressed into the lost wax form of crown coping. The
coping is finished, over which layering of veneering ceramic is
done for the final prosthesis. (Abousheliba et al 2012)
Copy milling is another technique employed in all ceramic
fabrication .This technique is employed in celay system that is
commercially used.Here a resin wax pattern is fabricated over
the refractory die and laser scan is used which subsequently
transfers the scanned image and a ceramic core is
fabricated(Lim et al 1997).CAD/CAM processing technique
uses scanning design and milling process to customize and
shape the coping from industrially pre-fabricated ceramic
blocks(El Zohairy AA et al 2003).This technique offers a great
advantage over conventional ceramic processing techniques by
eliminating the clinical steps in impression making and
laboratory steps including cast pouring, articulation, die
sectioning, casting and subsequent layering, thus saving
enormous amount of time and manpower. According to
CAD/CAM milling technology, restorations with adequate
marginal adaptation may not necessarily demonstrate adequate
internal adaptation also reported that systems which depend on
optical impression experience problems with rounded edges
due to the scanning resolution and positive error, which
simulates peaks at the edges(Magne P et al 2010).
A thick cement film beneath the bonded veneer could interfere
with the mechanical integrity of the restoration, increase
polymerization pre-stresses, or influence final shade and
translucency of the restoration.( El-Badrawy W et al 2011).
Celik et al investigated the marginal intergrity of a composite
veneer, Artglass, in comparision to a ceramic veneer, IPS
Empress by using two different luting agents.No significant
differences were recorded between the marginal gap widths in
relation to different types of veneers or luting agents.However
,significantly higher marginal discrepancies were observed for
the incisal margins of IPS Empress veneers without grit
blasting.The use of a highly filled resin luting agent (Variolink
ultra) did not cause an increase in marginal gap widths of the
veneers.
D Archangelo et al studied the clinical performance of
laminate porcelain veneers bonded with a light-cured
composite. Thirty patients were restored with 119 porcelain
laminate veneers. The veneers were studied for an observation
time of 7 years. On the basis of the criteria used, most of the
veneers rated Alfa. After 7 years, the results of the clinical
investigation regarding marginal adaptation and marginal
discoloration revealed 2.5% and 4.2% Bravo ratings,
respectively, among the 119 initially placed veneers and the
authors concluded porcelain laminate veneers offer a
predictable and successful treatment modality giving a
maximum preservation of sound tooth. Stappert et al
investigated the influence of preparation design and mouth
motion fatigue on the marginal accuracy of press-ceramic
veneers bonded to human maxillary central incisors and
concluded Complete veneer preparation CVP demonstrated
International Journal of Recent Advances in Multidisciplinary Research
significantly higher marginal gap values than Window
preparation WP and Incisal overlap IOP, before and after
fatigue (P<0.004). No significant differences were found
between groups WP and IOP.
Hekimoglu.C et al investigated the microleakage
characteristics of laminate veneerswith different incisal edge
preparation. All veneers were fabricated according to the
manufacturer’s instructions with vacuum fired porcelain and
cemented with dual-cure resin cement. The autoradiographic
method was used for determination of microleakages. . In the
two preparation types the cervical microleakages were of
similar degree. The incisal microleakages in the overlapped
laminate veneers were greater than in the window type veneers.
The author concluded the window preparation type was more
effective in terms of prevention of microleakage at the incisal
margin than the overlapped type laminates. Aboushelib et al
evaluated the internal adaptation and marginal properties of
ceramic laminate veneers fabricated using pressable and
machinable CAD/CAM techniques.40 ceramic laminate
veneers were fabricated by either milling ceramic blocks using
a CAD/CAM system or press-on veneering using lost wax
technique . Dye penetration, internal cement film thickness,
and vertical and horizontal marginal gaps at the incisal and
cervical regions were measured .Pressable ceramic veneers
demonstrated significantly lower vertical and horizontal
marginal gaps at the cervical and incisal margins and lower
cement film thickness compared to machinable ceramic
veneers.
The authors concluded by saying Pressable ceramic laminate
veneers produced higher marginal adaptation, homogenous and
thinner cement film thickness, and improved resistance to
microleakage compared to machinable ceramics. Ibarra et al
evaluated the performance of self-adhesive, modified-resin
dental cement (Rely-X UniCem, 3M-ESPE) for the
cementation of ceramic veneer restorations without previous
conditioning of the tooth surface, and in combination with a
one-bottle adhesive and a self-etching adhesive.The authors
concluded the self-adhesive cement gave low leakage on
dentin .All the included studies were 3b,3a reportedly
according to CEBM levels of evidence For difference in
marginal discrepancy in laminate veneers prior and after luting
with resin cements ,a meta analysis could not be performed
because the data showed significant heterogenicity with some
studies not measuring the pre and post luting marginal
discrepancy,qualitative measurements instead of quantitative
assesments were done in some studies.and some reviewers
have reported the overall circumferntial marginal discrepancy
instead of categorizing surfaces viz incisal, cervical and
proximal. Thermocycling was done in few studies and not done
in some. Again varying periods of thermocycling were applied
by the various investigators.Hence the data could not be
categorized into homogenous strata and a meta analysis could
not be initiated.
However a meta analysis was possible for the assessment of
marginal discrepancy in cervical and incisalportions. The
investigation bycelik et al was a multifactorial study design
which included three independent variables effecting marginal
discrepancy and every variable was treated as a separate entity
and a meta analysis was performed.
1243
The effect size for this meta analysis was the difference
between the means in cervical and incisal portions
respectively. The results showed an extreme deviation toward
the cervical group in the forrest plot favouring the cervical
aspect with less marginal discrepancy in all the studies. A
statistically significant difference in marginal discrepancy in
incisal portions is observed than the cervical portions of the
ceramic laminate veneers in all the included studies in this
review. The various factors contributing to this factor may be,
excessive firing shrinkage of the porcelain in the incisal
portions, convexity of the tooth preparation, varying thickness
of the preparation,presence of voids during ceramic
addition,internal porosity due to incorporation of air,coefficient
of thermal mismatch between various layers of porcelain added
, dimensional change in the impression material and die system
used, could account for the variations between the cervical and
incisal marginal discrepancy.Further studies with controlled
variables and quantitative outcome measures will enable
further understanding and could be a scope for future research.
Conclusion
Resin luting cements increase the marginal discrepancy in the
ceramic veneers following luting. The incisal portion of
ceramic laminate veneer exhibited more marginal discrepancy
than the cervical portions, making the incisal surface more
vulnerable to restorative failure.
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