Failure of Tooth Structure

Continuing Caries

There is no doubt one of the most common reasons for the need to replace a restoration is failure to
eliminate the disease of caries in the first place. The term recurrent caries is the most usual reason
cited in the majority of surveys of replacement dentistry but it should really be used with caution.

If the original disciplines to control caries are not undertaken then it shpuld not surprise if further
lesions develop in relation to the margin between restoration and tooth structure. Obviously the
intimary of the union between the two is a weakness because of the potential for bacterial
microleakage into the gap.

However, there are a number of other factors that need to be understood and controlled. Tooth
structure can fail at the cavity margin adjacent to a restoration for a variety of reasons, including
leaving a margin under direct occlusal load or introducing microcracks in the enamel during cavity
preparation.


Failure of the enamel margin
Enamel is a brittle material with a very specific grain because it consists of serried rows of enamel
rods lying parallel to each other and at right angles to the surface of the crown. Ideally the cavity
margin in the enamel should lie at right angles to the surface.

Also the enamel rods can suffer microcracks during cavity preparation following use of an
eccentrically rotating bur.

Failure of the gingival enamel margin at the base of a proximal box may arise from poor placement of
the original restorative material, but is almost invariavly the result of continuing or reccurent caries.

Failure of the dentine margin
It is generally the gingival margin of the proximal box of restoration which is in dentine and detection
of a fault and subsequent repair may pose problems. Often the cause is an operator error such as
failure to adapt or condense the restorative material adequately at the margin. Also failure to develop
a good contact with the adjacent tooth may lead food impaction.

Root Surface caries is not specifically failure of a dentine margin although. It will often be
interproximal and easily confused with failure of the adjacent restoration margin.

Bulk loss of tooth structure
The strength of the crown of a tooth lies in maintenance of the circle of enamel around the full
circumference of the crown. Once the circle is broken by the preparation of a cavity on a proximal
surface for placement of a restoration the integritety of the cusp at risk.

Loss of an entire cusp is distressing for the patiet. It often arises through failure to take into account
the weakened nature of the remaining tooth structure in an extensively restored tooth and failure to
provide some form of protective restoration. It is also necessary to continually monitor changes to the
occlusal anatomy may result in a nonworking cusp eventually standing high and becoming subject to
lateral stress.

Split root
This occurs generally in the remaining root structure of a nonvital tooth which has been rstored with a
post crown. The post is essentially an intraradicular restoration which relies on the integrity of the root
to sustain it.
Diagnosis of split root is very difficult and almost invariably, terminal in the life of the tooth. When a
post crown becomes uncemented the remaining root must be carefully explored for signs of a split.

Loss of Vitality
There will need to be a modification to the treatment plan following loss of vitality whatever the
cause. There is likely to be a shift in the translucency colour of the remaining crown and some further
weakening following the enlargement of the root canal during root canal therapy.


Failure of Restorative Material
Failure of the margin of the material

Amalgam
Because the interface between the cavity and the restoration will seal itself as a result of
corossion of the amalgam, there will not often be a further caries lesion developing. In spite of the fact
that the average amalgam restoration looks less than ideal within a reasonably short period of time
after replacement, repair of the margins is not normally indicated.
Repolishing the occlusal surface to improve the margins will result in alteration to occlusal
anatomy and contact with the opposing tooth and is strictly contraindicated.
Composite resin
Composite resin has no resistance at all to renewed invasion of caries so failure, through loss of
adhesion at the margin, requres immediate attention. If the margin is left open on the occlusal surface,
plaque will be forced in to tje gap under the high hydraulic pressure generated by mastication and
caries will develop rapidly. right down to sound tooth structure so that it will be possible to generate a
new ion exchange adhesion layer with enamel or dentine.

Gold
Occasionally, gold will fail along a margin as a result of further wear on the occlusal surface,