ORIGINAL RESEARCH Patient Satisfaction and Clinical ...

ORIGINAL RESEARCH

Patient Satisfaction and Clinical Evaluation of IPS Empress CAD versus ZLS Ceramic Laminate Veneers: A Randomized Controlled Clinical TrialOmnia MW El-Mesallamy1, Hayat IM EL-Banna2, Mohammed L Zamzam3, Jylan F El-Guindy4, Ahmed S Idris5

Ab s t r Ac t Aim and objective: To evaluate fracture resistance, patient satisfaction, and survival rate of IPS Empress CAD vs zirconia-reinforced lithium silicate ceramic (ZLS) laminate veneers.Materials and methods: Fifty-four ceramic laminate veneers were fabricated for maxillary anterior teeth. The patients were divided into three groups according to the material group I (control group) fabricated from IPS Empress CAD laminate veneers, group II (intervention group I) fabricated from glazed CELTRA DUO laminate veneers, and group III (intervention group II) fabricated from VITA SUPRINITY laminate veneers. Standardized the same preparation with butt joint design and chamfer finish line located supra gingival were performed for all the teeth. The fabrication of the veneers was performed using CAD\CAM (Ceramill motion) machine, with software (Exocad). The veneers surfaces were treated and silanated according to the manufacturer’s instruction of each ceramic and enamel surfaces were etched where total etch adhesive protocol was obeyed using dual cured amine free adhesive resin cement. Fracture resistance, patient satisfaction, and survival rate for all groups were evaluated according to United States Public Health Services (USPHS) criteria.Results: Fracture resistance, patient satisfaction, and survival rate were evaluated according to the criteria of USPHS and we found there is no significant difference as all groups scaled zero score.Conclusion: IPS Empress CAD, glazed CELTRA DUO, and VITA SUPRINITY laminate veneers revealed high successful clinical performance in terms of fracture resistance, patient satisfaction, and retention.Clinical significance: Zirconia-reinforced lithium silicate ceramics are recommended to be used for laminate veneers.Keywords: CELTRA DUO, Ceramic laminate veneers, Clinical performance, IPS Empress CAD, VITA SUPRINITY.World Journal of Dentistry (2021): 10.5005/jp-journals-10015-1813

In t r o d u c t I o n Because of their esthetic appearance, biocompatibility, and being a minimally invasive restoration; ceramic laminate veneers have become a very popular restoration.1

Several factors affect the long-term success of ceramic laminate veneers, such as preparation type and depth, the ceramic type and thickness, the adhesion surface area type (enamel or dentin), type of the resin cement used, tooth morphology, as well as functional and parafunctional activities.2

Fractures were reported to be the most prevalent type of failure for laminate veneers. Ceramic materials suffering from low ductility as an inherent problem and a major disadvantage that leads to crack formation that can be induced during laboratory adjustments or even during machining especially when used in thin restorations as laminate veneers. Also, stress concentrations at the adhesive interface caused by polymerization shrinkage of the luting composite may lead to fractures.3–5

It was found that the most frequent reason for failure (44.83%) in the case of glass-ceramics laminate veneers (feldspathic, leucite-based, and lithium silicate-based ceramics) was a fracture. Followed by cracks in the ceramic veneer (27.59%) in the second stage. Chipping and debonding occurred in 10% of all failure cases.6

CELTRA DUO is a new generation of glass-ceramic material enriched with approximately 10% zirconia by weight, which results in zirconia-reinforced lithium silicate ceramic (ZLS). The material has outstanding processing characteristics, including easy milling and polishing. After the milling process takes place, no additional

crystallization step is required.7 The flexural strength of the milled restoration is 210 MPa. After the glaze firing, the flexural strength is increased to 370 MPa.8

VITA SUPRINITY is a ZLS material with a zirconium dioxide content around 10 times that of traditional CAD/CAM glass-ceramic in combination with a, particularly fine-grained and homogeneous structure.9,10

The dental CAD/CAM applications of VITA SUPRINITY are a fabrication of inlays, onlays, partial crowns, veneers, anterior, posterior crowns, anterior and posterior single-tooth restorations on implant abutments with the following benefits:

1–3,5Faculty of Dentistry, Cairo University, Fixed Prosthodontics, Cairo, Egypt4Faculty of Dentistry, Cairo University, Fixed Prosthodontics, Cairo, Egypt; Faculty of Dentistry, Nahda University, Bani Sweif, EgyptCorresponding Author: Omnia MW El-Mesallamy, Faculty of Dentistry, Cairo University, Fixed Prosthodontics, Cairo, Egypt, Phone: +201006595375, e-mail: [email protected] to cite this article: El-Mesallamy OMW, EL-Banna HIM, Zamzam ML, et al. Patient Satisfaction and Clinical Evaluation of IPS Empress CAD versus ZLS Ceramic Laminate Veneers: A Randomized Controlled Clinical Trial. World J Dent 2021;12(3):183–188.Source of support: NilConflict of interest: None

© Jaypee Brothers Medical Publishers. 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Clinical Evaluation of Ceramic Laminate Veneers

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• High reliability due to zirconia-reinforced glass-ceramic matrix.• Optimized edge stability compared to lithium disilicate.• Simple processing thanks to good polishing characteristics and

high firing stability.• Brilliant esthetics based on integrated translucency, opalescence,

and fluorescence [9].A smooth surface of the ceramic restorations is a major

requirement for the patient’s comfort. It is also important for esthetic and biological considerations. Smooth surfaces can be obtained by polishing and glazing procedures.11

This study aimed to evaluate the patient satisfaction and clinical performance of IPS Empress CAD vs ZLS laminate veneers.

The null hypothesis of this study was that, for anterior teeth requiring conservative labial restoration, veneers constructed using Glazed ZLS (CELTRA DUO, VITA SUPRINITY) compared to IPS Empress CAD ceramics will provide better fracture resistance and patient satisfaction.

MAt e r I A l s A n d Me t h o d s This study was reviewed by the Ethics Committee of Scientific Research—Faculty of Dentistry—Cairo University, Cairo, Egypt and approved in July 2017 (approval no. 17710). Written informed consent was obtained from all patients who participated in the study under the approval of the ethics committee.

This study was registered on ClinicalTrials.gov (Identifier: NCT03129711).

This study was a double-blind randomized controlled clinical trial.

Patients selected for the study were between 20 years and 30 years, having no active pulpal or periodontal diseases, having teeth that were properly restored, and their chief complaint was to enhance their esthetic appearance. All treatment options were discussed with the patients. The treatment plan was then explained for each patient. Then, the informed consent was signed before the beginning of the clinical work. All participants had good oral hygiene. All participants were recruited during the time from September 2017 to November 2018 from the outpatient clinic of Fixed Prosthodontics Department, Faculty of Dentistry, Cairo University, Cairo, Egypt. Screenings of patients were carried out until the target number was reached. This study was completed by January 2020. Complete medical and dental history were obtained from all participants.

A prosthodontics colleague who was at arm’s length from the study was responsible for the generation of the random sequence of participant allocation. The process was completed electronically, using computer-based generation programs.

The candidate under supervision was responsible for all procedures, patient selection, preparation, shade selection, try in, and bonding.

A prosthodontics colleague allocated the participant patients into three groups by using computerized sequence generation.

Participants were allocated in three different groups by using computerized sequence generation (www.randomizer.org).

Participants were assigned to three groups:Group (I) control group (n = 18): included patients who received IPS Empress CAD laminate veneers with butt preparation design.Group (II) intervention group A (n = 18): included patients who received glazed CELTRA DUO laminate veneers with butt preparation design.

Group (III) intervention group B (n = 18): included patients who received VITA SUPRINITY laminate veneers with butt preparation design.

Double blinding (trial participants and outcome assessor), prosthodontics colleague assessors who were blinded about the aim of the study and participant’s allocation were responsible for assessing the outcomes of this study.

Preoperative photographs for each patient were taken using a 100 mm usm Canon macrolens mounted on a Canon 650D DSLR camera (Fig. 1). Two pairs of alginate impressions for upper and lower arches were taken and poured with type IV dental stone. One pair of impression was used for making diagnostic cast and the other for the study cast. The diagnostic casts were mounted on a semiadjustable articulator. Minimal veneer preparation was performed and diagnostic wax up was fabricated on diagnostic model to establish the appropriate tooth proportion, incisal edge positions, correction of minor tooth rotations and measuring the spaces in the hope of creating a more natural appearance.

Putty silicon was used to obtain an index for each patient using condensation silicon impression material. Each index was vertically cut to assess the amount of preparation of incisal and labial surfaces, respectively. Another putty silicon index was fabricated on the diagnostic wax-up model which was used later for temporization.

The labial reduction was started with horizontal orientation grooves using depth cutter wheels to accommodate veneers of equal thickness. The final depth of the preparation was marked and accentuated with a pencil. Then, the remaining island of the enamel was removed till the depth of original grooves to uniformly reduce the labial surface using a tapered diamond stone with around end of 0.5 mm diameter. The labial reduction was 0.3 mm at the cervical third and 0.5 mm at the middle and incisal thirds to ensure even preparation thickness. The preparation was carried out in two different planes following the contour of the labial surface. Then, the preparation was verified with the silicon index to check the amount of labial preparation. Vertical orientation grooves were done on the incisal edge of the tooth ensuring not to penetrate more than the diameter of the stone visually. The tapered stone with a round-end diamond stone was placed parallel to the incisal edge to remove the projection between grooves resulting in 1 mm butt joint incisal preparation. Teeth were finished and smoothed with 1 mm incisal reduction (butt joint preparation design). Then, each

Fig. 1: Intraoral frontal view


World Journal of Dentistry, Volume 12 Issue 3 (May–June 2021) 185

preparation was verified vertically with the silicone index to check the amount of incisal reduction. The cervical margin was created supragingivally along the free gingival margin. The margin of the preparation was ended by a chamfer finish line 0.5 mm diameter using a tapered diamond stone with a round end. Due to using the CAD-CAM system in all restorations, the interproximal preparation did not extend beyond the contact areas except in spacing cases. The preparation was done using a tapered diamond stone with a round end.

All sharp line angles were rounded using tapered round end diamond stone particularly at the junction of the incisal angle to both the labial and proximal surfaces (Fig. 2). Before proceeding with the following steps, a retraction cord was used to allow accurate impression making.

The final impression was taken using additional silicon in stock trays. A two-step impression technique was done.

The silicon index that was fabricated on the waxed-up cast was used for provisional restoration construction. The patient viewed the results of the provisional restoration and any modifications were discussed with the operator.

Master casts were poured with a type IV dental stone according to the manufacturer’s instruction, with respect to water/powder ratio and mixing time. Vacuum mixing was used for proper mixing to ensure the production of void-free casts. An extraoral scanner was used to scan the master cast. Using Exocad software, then the captured pictures were saved in the preparation folder. The software calculated a virtual model from the scanned pictures and an automatic margin finder was used for preparation margin detection (Fig. 3). The cement space was set by the software to be 80 μm. Using 5-axis milling machine the veneers were milled from IPS Empress CAD, CELTRA DUO, and VITA SUPRINITY blocks.

The restorations were cleaned for 3 minutes with an ultrasonic cleaner in a water bath to eliminate any remaining residue on the surface. Then, they were glazed at 820°C following the manufacturer’s instruction. Glazing was done after finishing smoothening the surface after slicing. The universal Celtra glazing paste was mixed with distilled water on a plastic slab, and then the mix was applied to the restorations with a brush to produce a uniform thickness.

VITA SUPRINITY ceramic laminates were fired in a short crystalization cycle for 30 minutes at 850°C according to the manufacturer’s instructions in a ceramic furnace. This process

imparts the glass-ceramic with its final strength and esthetic properties.

After veneers have been tried, they were cleaned with alcohol, rinsed with water, and then the following regime for preparing the fitting surface of the veneers was carried out. The fitting surface of the ceramic veneers was etched for 60 seconds in the case of IPS Empress veneers, for 30 seconds in the case of CELTRA DUO veneers, and 20 seconds in the case of VITA SUPRINITY veneers using 9.5% hydrofluoric acid. The veneers were rinsed with water for 20 seconds then dried with air by using a three-way syringe. Following this protocol, the veneer’s surfaces appeared clean and had a similar appearance to etched enamel. A single coat of the ceramic primer was then applied to the bonding surface of the veneers and left for 1 minute then air-dried.

For the preparation of the tooth for bonding, 37% phosphoric acid etchant was applied to the enamel for 30 seconds. And then rinsed and dried until enamel appeared frosty. Finally, surfaces were dried gently for 5 seconds. A fully saturated brush tip of single bond 2 was used to apply two coats of adhesive. Dual cured amine-free adhesive resin cement was applied to the tooth and fitting surfaces of the veneers using a mini brush. The veneers were placed to the teeth in position from the midline starting from the midline and moving laterally. Excess cement was removed using sharp explorer after 2 seconds of preliminary light polymerization and the veneers were then completely light polymerized for at least 60 seconds from each aspect of the tooth. A waxed dental floss was used interdentally for complete removal of excess cement in-between veneers, and articulating paper was used to check for any occlusal interference after complete curing (Fig. 4).

Patients were instructed to perform brushing and flossing regularly and to use non-abrasive fluoridated toothpaste. They were informed to avoid the excessive stresses, avoid bite on fingernails. The patients returned to the clinic after 1 week to permit a final examination of esthetics, phonetics, and occlusion. Follow-up sessions were done every 3 months for each patient using dental probe and operator vision to evaluate the fracture, patient satisfaction, and survival rate. Follow-up done according to United States Public Health Services (USPHS) grades (Table 1).

For statistical evaluation, the mean and standard deviation values were calculated for each group in each test. Data were analyzed using IBM SPSS advanced statistics (Statistical Package for Social Sciences), version 23 (SPSS Inc., Chicago, IL, USA). The frequency of fracture in the three groups was compared using

Fig. 2: Preparation after finishing Fig. 3: Designing of the laminate veneers



Fisher’s exact test. Survival rates were estimated using the Kaplan–Meier method for time to event. Differences between the survival curves of the three groups were assessed for statistical significance with the log-rank test. A p value ≤0.05 was considered statistically significant.

re s u lts Descriptive statistical analysis presented in Table 2.

According to USPHS criteria for fracture, patient satisfaction, and survival rate evaluation:

(a) Group I (IPS Empress), (b) Group II (CELTRA DUO glazed), (c) Group III (VITA SUPRINITY):

There was no statistically significant difference between (baseline), (after 3 months), (after 6 months), (after 9 months), and (after 12 months) where (p = 1).

Zero score was recorded for all the veneers at all the intervals of evaluation.

Relation between GroupsThere was no statistically significant difference between (group I) and (group II) and (group III), all groups showed zero scoring in all periods.

dI s c u s s I o n For restoration to be clinically successful, four distinct properties should be found: marginal adaptation, biocompatibility, esthetics, and mechanical strength.12

Fradeani et al.13 stated that in vitro and in vivo studies did not have the same value, as the studies of the clinical performance of ceramic veneers were limited, whereas several in vitro studies have been published.

In the present study, only anterior teeth showing no caries or restorations were included.

In the present study, preparation design for all teeth was with chamfer finish line labially, interproximal extension, and butt joint incisal configuration. The finish line was located supragingivally.14

Hahn et al.15 reported that butt-joint preparation presented better stress distribution to the tooth, directing all the forces toward the veneer itself. Butt joint incisal design allows the preservation of the peripheral enamel layer. This was inconsistent with Mirra and El-Mahalawy16 who studied fracture strength and microleakage of laminate veneers with different designs and found that the highest fracture load was noticed in teeth prepared with 2 mm incisal reduction without palatal extension.

In the present study, ceramic laminate veneers were fabricated from two different ceramics materials: IPS Empress CAD is a leucite glass-ceramic of the SiO2-Al2-O3-K2O material systems with leucite crystal ranging from 5 to 10 μm in size. The leucite crystals are responsible for increasing the material strength and inhibition of crack propagation, while the crystalline phase absorbs the fracture energy. Resistance and flexural strength of the material is improved due to the difference in the coefficient of thermal expansion between the glass phase and the crystalline phase, as well as the cooling process following the sintering phase (160 MPa).7

CELTRA DUO is a new generation of glass-ceramic material enriched with approximately 10% zirconia by weight, which results in ZLS. The material has a special fine-grained and homogeneous structure which provides excellent material quality and consistency, higher load capacity as well as long-term reliability. Additionally, the material has outstanding processing characteristics, including easy milling and polishing. After the milling process takes place, no additional crystallization step required.7 The flexural strength of the milled restoration is 210 MPa. After the glaze firing, the flexural strength is increased to 370 MPa.8

Also, ZLS (VITA SUPRINITY) is a glass-ceramic material enriched with a zirconium dioxide content around 10 times that of traditional CAD/CAM glass-ceramics. Zirconia is known for phase transformation of the tetragonal phase to the monoclinic phase with a volume increase that prevents crack propagation in combination with a particularly fine-grained and homogeneous structure leads to a high fracture strength of 420 MPa.9,10

Fracture ResultsFractures were reported to be the most common failure type for laminate veneers. Crack development in all-ceramic restorations was a result of several factors. Ceramic materials suffering from low ductility as an inherent problem and a major disadvantage that leads to crack formation that can be induced during laboratory adjustments or even during machining especially when used in thin restorations as laminate veneers. Also, stress concentrations at the adhesive interface caused by polymerization shrinkage of the luting composite may lead to fractures. In vivo strength degradation of

Table 1: Different outcomes and their measuring device and measuring unit

Outcome nameMeasuring device Measuring unit

Primary Fracture (USPHS)1 0 No fracture1 Minor cracks line over

the restoration2 Minor chipping of the

restoration (1/4)3 Moderate chipping of

the restoration (1/2)4 Sever chipping of the

restoration5 Complete fracture

Secondary Patient satisfaction

(USPHS) 0 Satisfied

1 Dissatisfied Survival rate (USPHS) 0 Retained

1 Debonded

Fig. 4: Postoperative intraoral occlusal view


World Journal of Dentistry, Volume 12 Issue 3 (May–June 2021) 187

ceramic restorations may occur in the oral environment as a result of masticatory and parafunctional forces of >200 N.

Depending on the chewed food and associated mastication force, many flaws of different magnitudes may occur. Also, adjustments of ceramic restorations by the technician or the clinician before or during their placement in the mouth may cause damage.17

In the present study, zero score was recorded for all veneers during all the follow-up sessions. Additionally, there was no statistically significant difference between the three groups.

Mirra and El-Mahalawy16 concluded that butt joint design with 2 mm incisal reduction showed the highest fracture resistance and least microleakage of laminate veneers with different designs.

Gresnigt et al.5 conducted a randomized controlled split-mouth clinical trial to evaluate the short-term survival rate of indirect resin composite and IPS Empress ceramic laminate veneers with no fractures in the ceramic veneers group which is in co-ordinance with the results of this study. Also, ZLS is a glass-ceramic material enriched with a zirconium dioxide content around ten times that of traditional CAD/CAM glass-ceramics. Zirconia is known for phase transformation of the tetragonal phase to the monoclinic phase with a volume increase that prevents crack propagation18 in combination with a particularly fine-grained and homogeneous structure leads to a high fracture strength of 370 MPa.19,20

Preis et al.20 conducted a study that had similar results to the present study where he found that marginal adaptation and fracture of ZLS crowns results in the range where no restrictions should be expected for clinical application. And, also Gomes et al.21 who found that crowns fabricated for implants from zirconia-reinforced lithium silicate materials have fracture load values and marginal fit within the acceptable limits.

Patient Satisfaction ResultsZero score was recorded for all the veneers at all the intervals of evaluation. Also, there was no statistically significant difference between the three groups which may be a result of the strict shade matching regimen and laboratory support. This comes in accordance with Abou-Steit et al. in 2019 who studied patient satisfaction according to VITA SUPRINITY vs (IPS e-max CAD) lithium disilicate all-ceramic crowns in esthetic zone using the modified USPHS criteria in a prospective controlled randomized clinical trial, and found that there was no statistically significant difference between the two groups.22

These results were in agreement with Nejatidanesh et al. in 2018 who conducted a study to compare the survival, modified California Dental Association (CDA) criteria, and periodontal parameters of laminate veneers made with Empress CAD and Emax CAD over 60 months and found that there was no significant difference in the patient satisfaction.23

Survival Rate ResultsZero score of retention was recorded for all veneers. Etching the ceramic surface with 9.5% HF increased the surface area and facilitated the penetration and retention of resin cement into the microretentions of the treated surface. the bonding process can be enhanced by the application of a silane coupling agent. These agents are capable of forming chemical bonds between the inorganic phase of the ceramic and the organic phase of the resin that will increase bonding strength to ceramic laminate veneers itself, thus improve the durability of the adhesive interface over time.24,25Ta

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Finally, the hypothesis was rejected as all materials were graded zero during all follow-up sessions, and no significance difference found between the three materials (IPS Empress CAD—CELTRA DUO and VITA SUPRINITY).

co n c lu s I o n Within the limitations of this study, the following conclusion could be drawn as follows:

Both IPS Empress CAD and ZLS laminate veneers revealed high successful clinical performance in terms of fracture resistance, patient satisfaction, and retention.

re co M M e n dAt I o n s Further randomized clinical studies should be implemented to evaluate the clinical survival rate of the ZLS laminate veneers and other restorations for more prolonged follow-up periods.

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laminate restoration based on different incisal preparation designs: an analysis. J Conserv Dent 2011;14(1):10. DOI: 10.4103/0972-0707.80723.

2. Ozturk E, Bolay S. Survival of porcelain laminate veneers with different degrees of dentin exposure: 2-year clinical results. J Adhes Dent 2014;16(5):481–489.

3. Morimoto S, Albanesi RB, Sesma N, et al. Main clinical outcomes of feldspathic porcelain and glass-ceramic laminate veneers: a systematic review and meta-analysis of survival and complication rates. Int J Prosthodon 2016;29(1):38–49. DOI: 10.11607/ijp.4315.

4. Obradović-Đuričić KB, Medić VB, Dodić SM, et al. Porcelain veneers-preparation design: a retrospective review. Hemijska Industrija 2014;68(2):179–192. DOI: 10.2298/HEMIND130323042O.

5. Gresnigt MM, Kalk W, Özcan M. Clinical longevity of ceramic laminate veneers bonded to teeth with and without existing composite restorations up to 40 months. Clin Oral Investigat 2013;17(3):823–832. DOI: 10.1007/s00784-012-0790-5.

6. Beier US, Kapferer I, Burtscher D, et al. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodon 2012;25(1):79–85.

7. Sannino G, Germano F, Arcuri L, et al. Cerec CAD/CAM chairside system. Oral Implantol 2014;7(3):57.

8. Rinke S, Pabel AK, Rödiger M, et al., Chairside fabrication of an all-ceramic partial crown using a zirconia-reinforced lithium silicate ceramic. Case reports in dentistry. 2016 Jan 1;2016.

9. Krüger S, Deubener J, Ritzberger C, et al. Nucleation kinetics of lithium metasilicate in ZrO2-bearing lithium disilicate glasses for dental application. Int J Appl Glass Sci 2013;4(1):9–19. DOI: 10.1111/ijag.12011.

10. Elsaka SE, Shaymaa E, Elnaghy AM. Mechanical properties of zirconia reinforced lithium silicate glass-ceramic. Dent Mat 2016;32(7): 908–914. DOI: 10.1016/j.dental.2016.03.013.

11. Flury S, Lussi A, Zimmerli B. Performance of different polishing techniques for direct CAD/CAM ceramic restorations. Operat Dentis 2010;35(4):470–481. DOI: 10.2341/09-373-L.

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14. Granell-Ruiz M, Fons-Font A, Labaig-Rueda C, et al. A clinical longitudinal study 323 porcelain laminate veneers. Period of study from 3 to 11 years. Popul 2010;3:12.

15. Hahn P, Gustav M, Hellwig E. An in vitro assessment of the strength of porcelain veneers dependent on tooth preparation. J Oral Rehabilitat 2000;27(12):1024–1029. DOI: 10.1046/j.1365-2842.2000. 00640.x.

16. Mirra A, El-Mahalawy S. Fracture strength and microleakage of laminate veneers. Cairo Dent J 2009;25:245–254.

17. Coldea A, Swain MV, Thiel N. In-vitro strength degradation of dental ceramics and novel PICN material by sharp indentation. J Mechan Behav Biomed Mater 2013;26:34–42. DOI: 10.1016/j.jmbbm.2013.05.004.

18. Manicone PF, Iommetti PR, Raffaelli L. An overview of zirconia ceramics: basic properties and clinical applications. J Dentis 2007;35(11):819–826. DOI: 10.1016/j.jdent.2007.07.008.

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20. Preis V, Behr M, Hahnel S, et al. Influence of cementation on in vitro performance, marginal adaptation and fracture resistance of CAD/CAM-fabricated ZLS molar crowns. Dental Mater 2015;31(11):1363–1369. DOI: 10.1016/j.dental.2015.08.154.

21. Gomes RS, Souza CM, Bergamo ET, et al. Misfit and fracture load of implant-supported monolithic crowns in zirconia-reinforced lithium silicate. J Appl Oral Sci 2017;25(3):282–289. DOI: 10.1590/1678-7757-2016-0233.

22. Abou-Steit S, ElGuindy J, Zaki A. Evaluation of patient satisfaction and shade matching of vita suprinity versus lithium disilicate (E-max) ceramic crowns in the esthetic zone: a randomized controlled clinical trial. F1000 Research 2019;8(371):371. DOI: 10.12688/f1000research.18337.1.

23. Nejatidanesh F, Savabi G, Amjadi M, et al. Five year clinical outcomes and survival of chairside CAD/CAM ceramic laminate veneers—a retrospective study. J Prosthodon Res 2018;62(4):462–467. DOI: 10.1016/j.jpor.2018.05.004.

24. Karagözoğlu İ, Toksavul S, Toman M. 3D quantification of clinical marginal and internal gap of porcelain laminate veneers with minimal and without tooth preparation and 2-year clinical evaluation. Quintessence Int 2016;47(6):461–471.

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