CLINICAL FAILURES IN FIXED PARTIAL DENTURE

AND ITS MANAGEMENT

INTRODUCTION:
A complication has been defned as A secondary disease or
condition developing in the course of a primary disease or condition.
Although complications may be an indication that clinical failure has
occurred, this is typically not the case. It is also possible that
complications may refect substandard care. But once again this is
usually not true. Most of the time, complications are conditions that
occur during or after an appropriately performed fxed prosthodontic
treatment procedures.
An objective evaluation of an existing restoration is necessary
before coming to a conclusion that it is defective and requires either
replacement or repair.
What constitutes a failure?
Are failures absolute or are there degrees of failures?
There are of course minor failures, which are a matter of opinion
and could be possibly left without immediate repair or replacement, and
there are obvious failures where repair or replacement is essential to
avoid further damage to the dentition.
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Failure may occur at any time. Hence it is important to be aware of
obvious and subtle indications of prosthesis failure and have a working
knowledge of the procedure that are necessary to remember the
situation.
It is natural that dramatic mechanical failure such as fracture
attract attention, but it must be remembered that failures can be biologic
and esthetic in nature.
I. Biologic failure
II. Mechanical failure
III. Aesthetic failure
II. Mechanical Failure:
1. Loss of Retention:
This occur mainly due to leverage and unequal occlusal loads on
diferent parts of the bridge. Loose retainers cause rapid destruction of
the abutment tooth. Saliva and plaque and pumping action of loose
retainer are responsible for caries leading to rapid destruction of
abutment teeth.
Clinical Features:- Patient may be aware of looseness or sensitivity to
temperature or sweets. Also there may be a recurring bad taste or odour,
which must be diferentiated from similar symptoms caused by poor oral
hygiene or periodontal problems.
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Detection:-
- Sometimes the patient is aware of movement developing in the bridge.
- Diagnostic test is to examine the bridge carefully without drying the
teeth, pressing the bridge up and down (occlusocervically) and with a
curved explorer looking for small bubbles in the saliva at the
margins of the retainer.
- When more than 2 abutment teeth are involved in a prosthesis, it is
difcult or impossible to detect a single loose retainer.
Management:-
- If retainer becomes loose prosthesis must be removed so that the
abutment teeth can be evaluated.
- If the restoration can be dislodged from the prepared teeth without
damage and no caries is present, it is possible to recement the
prosthesis. Improper cementation procedures, such as contamination
with moisture or increased cement space may have caused the
problem.
- If the prosthesis reveals loss of adequate retention, teeth should be
modifed to improve the retention and resistance form. Additional
retention by cross pinning, grooves, boxes etc. Alternatively it may be
necessary to include additional abutment to increase overall retention
or change the design in some other way (i.e. use of full coverage
instead of partial coverage). In case of grossly destructed teeth, core
3
build up may be done to support the retainer or surgical exposure of
crown can also be done. After all this a new prosthesis is fabricated.
- Sometimes FPD come loose even when maximally retentive
preparation have been developed. This problem is caused by excessive
span length or heavy occlusal forces A RPD may be the only
satisfactory solution.
- It is better for teeth to have no cover than loose cover.
- Because there is usually less permanent damage or plaque is not
retained against the surface of preparation and the patient is
obviously aware of the problem and seeks treatment quickly.
2. Connector Failure/ Solder Joint Failure:
There are several points to watch if a breakdown of the solder joint
is to be avoided.
i) Adequate width and depth to resist occlusal stress
ii) A sufcient bulk of gold
Causes:-
- Connector failure can occur under occlusal load. When fracture
occurs pontic is placed in an cantilever relationship with the
retainer casting which may lead to excessive forces on abutment
teeth. Hence prosthesis should be removed and remade.
- A faw / inclusion in solder itself (porosity)
- Failure to bond to surface of metal
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- Joint not be sufciently large for the condition in which it is
placed.
- Improper fow of metal due to decreased width between joining
parts. Minimum width for solder to fow properly is 0.25mm.
Treatment:-
- Fracture connectors are difcult to detect in an abutment teeth
with no mobility. Wedges are placed beneath the connector to
separate the FPD components to confrm diagnosis. Occasionally
an inlay like dovetail preparation can be developed in metal to span
the fracture site and casting can be cemented to stabilize the
prosthesis.
- If this is not possible, and a remake cannot be rapidly
accomplished, the pontics should be removed by cutting through
the intact connectors. A temporary RPD can be inserted to
maintain the existing space and satisfy esthetic requirements.
- It is better whenever possible to join multiple unit bridges by solder
joint in the middle of pontics before porcelain is added. This gives
much larger surface area for the solder joint and it is also
strengthed by porcelain covering.
Efect of connector design on the fracture resistance of all ceramic FPD.
JDP 2002; 87
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- The results of this study showed that the occlusal embrasure can
be designed as sharp as is practical for the aesthetics of an all
ceramic 3 unit FPD; provided that the gingival embrasure has a
increased ratio of curvature to increase the fracture resistance.
3. Occlusal Wear and Perforation:
Heavy chewing forces, clenching or bruxism can produce accelerate
occlusal wear of a prosthesis.
Clinical Features:- Attrition of opposing teeth, polished facets on the
retainers/ pontics, gingival recession or infammation.
Causes:-
- Faulty preparation were occlusal clearance for metal is inadequate.
- Even with normal attrition, occlusal surfaces of posterior teeth
wear down substantially over a period of time.
- Gold crowns made with 0.5mm or so of gold occlusally may wear
through a period of 2-3 years.
- There perforations allow leakage and caries to occur which leads to
prosthesis failure.
Management:- If perforation is detected early, a gold or amalgam
restoration can be placed.
Other materials resin, composite and GIC
o If perforation is over amalgam core, leave it untreated and check it
periodically.
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o If metal surrounding perforation is extremely thin a new prosthesis
should be fabricated.
o If occlusal surfaces are covered with porcelain, wear of ceramic is not
a problem, instead the opposing natural teeth shows dramatic wear of
enamel. This problem is exacerbated by heavy chewing forces,
clenching or bruxism and often requires the restoration of abraded
teeth. The same occurs when porcelain opposes metallic restoration.
So, in mouths in which occlusal wear is anticipated, it is better to
place metal over occluding surfaces to minimize wear and maintain the
integrity of natural teeth.
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4) Tooth Fracture:
a) Coronal fracture:
Coronal tooth fracture can be dramatic, resulting in considerable
loss of tooth structure, or it can be minor with little signifcant damage.
Causes:-
- Caries of abutment teeth
- Excessive tooth preparation which may leave insufcient tooth
structure to resist occlusal forces.
- Preparation may have been composed mainly of restorative
material which was not retained in sound dentin with pins.
- Presence of interfering centric and eccentric occlusal contacts or
even heavy occlusal loads.
- Fracture can also occur when attempts to forcibly seat an
improperly ftting prosthesis/ unseat a cemented bridge
incorrectly.
Management:-
- If defect is small it is restored with amalgam, gold foil or resin to
provide additional years of service.
- If there is a question regarding the integrity of the remaining tooth
structure or restoration, a new prosthesis should be fabricated so
that it encompasses the fractured area.
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- Large coronal fracture around partial coverage retainers, then full
coverage restorations may be fabricated. Tooth may require
separate pin retained restoration to serve as core and provide
support and retention.
- If fracture causes exposure of pulp, endodontic treatment along
with post and core; abutment preparation should involve
placement of bevels to increase resistance form.
- Abutment tooth fracture under full coverage restoration usually
occur horizontally at the level of fnish line. This necessitates
removal of prosthesis. Endodontic treatment post and core
new prosthesis.
b) Root Fracture:-
Causes:- Most often due to trauma
- During endodontic treatment, forceful seating of post
- Attempts to fully seat an improperly ftting post
Fracture may not be immediately apparent and only become
detectable with time.
Root fracture are located well below the alveolar bone, so it must
be extracted and new prosthesis fabricated.
Occasionally fracture terminates at or just below the alveolar bone,
in such cases it may be possible to perform periodontal surgery, remove
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bone and expose the fracture site so that it can be encompassed by new
prosthesis.
c) Pontic fracture/ failure:-
Mechanical failure of the pontic may occur because of inadequate
strength. Thus an all porcelain occlusal pontic should never be used
unless the occlusion is favorable.
Similarly the gold framework must always be of adequate rigidity.
Even slight fexion will cause cementation failure or fracture of the
porcelain facing.
Probably one of the commonest cause of pontic failure is a faulty
occlusion particularly in lateral excursions, which was not corrected
when the bridge was placed.
An acrylic facing will wear and discolour quite rapidly. Tissue
contact of pontic extensive area of tissue contact is cited as major
cause of failure. Area of contact should be small and convex. Mesial,
distal, lingual and gingival embrasure should be wide open to allow easy
cleaning.
5) Porcelain Fracture:
Porcelain fracture occur with both metal ceramic an all ceramic
crown restoration. The majority of PFM fracture can be attributed to
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improper design characteristics of the metal framework or to problem
related to occlusion.
All ceramic restorations commonly fail because of defciencies in
tooth preparation or presence of heavy occlusal forces.
a) Metal-Ceramic Porcelain Failure:
Framework design:-
Sharp angles or extremely rough and irregular areas over the
veneering area serve as points of stress concentration that cause
crack propagation and ceramic fracture. Perforations in the metal can
also cause failure for same reason.
An overly thin metal casting does not adequately support porcelain, so
that fexure and porcelain fracture are allowed.
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Overbuilt porcelain unsupported by metal in PFM may fracture
because of cohesive failure within the porcelain.
In PFM restoration porcelain fracture result from framework design
that allows centric occlusal contact, on or immediately next to the
metal ceramic junction.
When angle between veneering surface and non-veneered aspect of
the casting is less than 90. These designs allow occlusal forces to
cause localized burnishing of metal and distortion, which leads to
premature porcelain fracture.
Occlusion:-
Heavy occlusal forces or habits such as clenching and bruxism
Centric or eccentric occlusal interferences can lead to failure, or
failure may also be due to uncorrected occlusal slides, which create
defective contact of opposing teeth with the prosthesis.
Metal Handling Procedures:-
Improper handling of alloy during casting, fnishing or application of
the porcelain can lead to metal contamination.
Bubbles may form at metal ceramic junction, when porcelain is
applied, creating stress or possibly cracks.
Severe contamination
Excessive oxide layer on metal, due to improper conditioning of base
metal alloys can lead to separation of porcelain from metal.
Preparation, Impression and Insertion:
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Preparation with slight undercut can cause binding of the
prosthesis as it is seated, which initiates crack in the prosthesis. This
may go unnoticed until premature postinsertion failure occurs.
An impression that is slightly distorted can lead to same problem.
Teeth with feather edge fnish line or impression which do not
record all fnish lines can lead to extension of metal beyond the actual
termination of tooth reduction. The thin metal may bind against the
tooth and initiate a crack in overlying porcelain.
Good preparation with defnite line and impression that record
proper detail are prerequisites to acceptable ceramics.
Metal and Porcelain Incompatibility:
In rare instances, an alloy and porcelain are found to be truly
incompatible, and successful bonding without loss of the veneer or
cracking is impossible.
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Repair of fractured metal ceramic restorations:-
Best method is fabrication of a new prosthesis
Resin materials are often used to rebuild the porcelain form in area
where fracture has occurred, adequate to good colour matching can
be achieved.
Drawback is lack of longevity and discolouration. Even light cure
composites can be used.
Retention of these materials is mainly due to mechanical interlocking
so if used in areas of heavy occlusal forces repair often fails shortly
after insertion.
If fracture is due to heavy occlusal forces the contact should be
avoided at the metal ceramic junction, and it should be at least
1.5mm away from the junction.
A more permanent repair is possible if adequate thickness of metal
available. Steps
- Removal of remaining porcelain
- Drill several pin hours (4-5) to depth of 2mm and make impression
- Creating pin retained metal casting 0.2 0.3mm thickness out of a
metal ceramic alloy to ft over exposed metal framework.
- Fusion of porcelain to the pin retained casting and establish
normal form
- Cementation of casting in position
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- If there is any risk of pontic area fexing, porcelain should be
carried on to the lingual side of the pontic to stifen them further.
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Sleeve Crown:-
When a considerable portion of porcelain is lost from labial/ incisal
surface of a retainer or pontic it is often possible to repair that replace
the entire unit. The porcelain facing is removed with some of the
underlying metal from the labial surface. Porcelain as well as metal are
removed from incisal third of the palatal surface. This is a simple
procedure when damaged unit is pontic, but when the damaged unit is a
retainer and underlying pulp has to be considered. Common mistake is
removal of too little porcelain and metal.
An impression is made of this and the two adjacent units. The
technician is then asked to make metal ceramic crown that will have 2
surfaces instead of usual four. This sleeve crown is then cemented in
usual way.
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If too little porcelain is removed from original unit, the new sleeve
crown will fll slightly bulky.
b) Porcelain Jacket Crown Failures:-
Since porcelain jacket crown have been in use for rarely a century,
considerable clinical experience related to their failure is available.
With good preparation considerable success has been achieved on
incisors, whereas fracture are more frequently observed when
restorations are placed on posterior teeth and on canines because of
occlusal force on these teeth.
Cause:- Quality of tooth preparation and magnitude of occlusal load are
the main factors that determine clinical success or failure. They are more
likely to fail in presence of heavy occlusal forces clenching/ bruxism.
Prevention:- Tooth preparation should be adequate but not excessive.
Tooth reduction must be designed to support the restoration since no
metal is present to provide support.
Management:-
- Short term repair can be done with GIC, resin and light cure
composites.
- Severely chipped all porcelain crowns must therefore be replaced by a
new crown.
- If an early failure occurs without any clinical/lab defects heavy
occlusal forces are likely to be present that exceed strength of
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restoration. Metal ceramics should be seriously considered for the
new restoration.
- If failure occurs after many years of service and optimal esthetics is
still required a new all-ceramic should be considered.
- If fracture is due to trauma it should be replaced by another all
ceramic restoration particularly when old restoration has served
successfully for sometime.
Types of Ceramic Fracture:-
a) Vertical Fracture:-
- Marginal area of jacket crown is often more closely adapted to
prepared tooth than other areas. If tapered fnish line is used,
restoration contacts the tooth on a sloping surface resulting in forces
that attempt to expand the restoration which are not well resisted by
porcelain, leading to vertical fracture.
- Sharp areas on tooth such as line angles and incisal angles produce
areas of high stress in restoration, leading to vertical fractures.
- A round preparation form that does not provides adequate resistance
to rotational forces can also cause vertical fracture.
b) Facial Cervical Fracture:
Often assumes a semilunar form (Half moon fracture), generally
occurs with a short tooth preparation. Inciso cervical length of the
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preparation should be 2/3
rd
to 3/4
th
that of the fnal restoration. When
opposing tooth contact is located incisally to prepared tooth, tipping
forces are more frequently developed, with the restoration having a
fulcrum on the cervically located incisal edges, leading to facial cervical
fracture.
Prevention:- Give 45 level
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c) Lingual Fracture:
Cause:-
- When occlusion is located cervically to the cingulum of the
preparation, when forces on the porcelain are more shear in nature
and not as well resisted.
- Inadequate lingual tooth reduction, in which <1mm of porcelain is
present.
- Exceptionally heavy occlusal forces.
6) Cementation Failure:
Causes:-
- Loosening of retainer due to inadequate mechanical retention as
strength of chemical adhesion, and cohesive strength of cement are
limited.
- Poor cementation technique:- Wrong choice of material, failure to
observe the manufacturers mixing instructions, use of old or
contaminated stock, inadequate P/L ratio. Insertion of prosthesis
when cement has set. Inadequate isolation weakens the bond. Where
full crowns are being employed, venting is usually inadequate.
- Resinous cements are considered to be the most retentive. But the
main drawback of resin cements being H2O percolation which leads to
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increased pressure in the interface acting as an hydraulic chamber,
which leads to failure.
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8) Design Failure:
a) Abutment preparation design:
i) Factors afecting dislodgement:-
Taper of preparation: Increased taper reduces ability of restoration to
resist occlusally directed forces and also lessens its ability to interfere
with arc of rotation as tipping forces act to unseat the restoration.
Taper/ angle between opposing walls determine the degree of
retention against axial unseating forces. A parallel preparation is
impractical as cement cannot extrude from the crown during
cementation leaving excessive thickness of cement occlusally and at
margins.
Once taper exceeds 30 or so failure through loss of retention
becomes common. Ideal taper for good retention is 7 with minimum
cement in between. However, it is not possible to achieve this taper
clinically without producing some undercuts/ damaging the adjacent
teeth.
Average taper for post preparation that have been shown to be
clinically in successful in a large number of cases is 10-20 approx.
Length of Preparation: Minimum cervico-incisal height is that which
allows the tooth structure to interfere with arc of rotation as tipping
forces attempts to cause rotation around a fulcrum located at the fnish
line on the opposite side of the tooth.
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In case of short teeth adequate height is achieved by extending
margin subgingivally or only alternative is to prepare tooth with less
taper.
Greater the length the more retentive. Minimum acceptable length
will depend on nature of occlusal forces, number of teeth and whether
the crown will be subjected to withdrawing forces from a FPD.
Relationship between length and taper is important:
Shorter clinical crowns require more parallel walls. If clinical crown
is assessed to be too short for adequate retention it must be built up with
a core (if there is sufcient occlusal clearance), or surgical crown
lengthening or retention achieved by pins/ grooves. Both have the
potential not only to resist loss of the crown in a direction other than
long axis but also reduces the angle of the path of insertion.
Circumferential Irregularities:
Circumference of teeth is usually irregular in form and when tooth
is uniformly reduced an irregular shape is formed which enhances ability
of restoration to resist both tipping and twisting forces.
When tooth encountered is round/ short/ over tapered
intentionally formed irregularities such as boxes, grooves may be used to
produce areas that interfere with dislodgement of restoration.
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Boxes are more efective than grooves and should be used when
sufcient tooth structure is present. Best location being the proximal
areas, where it adds resistance to faciolingual dislodging forces.
All partial veneers crown require use of boxes and grooves.
Occlusal irregularities:-
Aids in resistance to dislodging forces; fat reduction provides little
interference and unnecessarily reduces the length of preparation.
Irregular reduction according to occlusal plane produces an corrugated
sheet efect which enhances the rigidity of the retainer than one plane
reduction.
ii) Finish line requirements:-
Supragingival margins are more acceptable than subgingival as
they aid in proper oral hygiene maintenance. They also reduces pulpal
sensitivity as they are usually in enamel.
Margins should be smooth and even. Rough or irregular margins
reduces adaptation and increase plaque formation and gingival
infammation.
iii) Path of Insertion:-
Considered in 2 dimensions Faciolingual and mesiodistal
Faciolingual direction:- Faciolingual orientation can afect the esthetics
of metal ceramic or PV crowns. For metal ceramics the path of insertion
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should be roughly parallel to the long axis of the tooth. A facially inclined
path of insertion on a preparation for metal ceramic crown will leave the
faciolingual line angle too prominent, resulting in overcontouring of
restoration, opaque showing through or both.
For 3/4
th
crown on anterior teeth the path of insertion should be
parallel to the incisal half of the labial surface. If inclined more facially
short grooves and unnecessary display of gold will result.
Mesiodistal inclination:- It should parallel the contact areas of adjacent
teeth. If path is inclined mesially or distally the restoration will be held
up at the proximal contact areas and may be locked out. This is a
particular problem when restoring tilted teeth.
iv) Structural Durability:-
a) Occlusal Reduction:
- Minimum of 1.5mm for functional cusps and 1.0 mm for non-
functional cusps is needed
- Inadequate reduction leads to perforation and fracture of metal.
- One plane reuction may reduce the incisocervical length and
jeopardize the pup.
- Rigidity of metal is increased by following the contours of the
crown
b) Functional cusp bevel:
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Bevel should be given on the maxillary lingual cusp and
mandibular buccal cusp at an angle of 45 to provide space for adequate
bulk of metal in an area of heavy occlusal contact.
If crown is waxed and contoured to normal contour without a
bevel, casting will be extremely thin in area overlying the junction
between occlusal and axial reduction. To prevent thin casting from
fracture an attempt is made to wax the crown to optimal thickness in this
area. An overcontoured restoration will result leading to defective
occlusal contacts which can only be eliminated by reducing the opposing
teeth.
b) Inadequate bridge design:-
Designing bridges is difcult. It is neither a precise science nor a
creative form of art. It needs knowledge, experience and judgement,
which takes years to accumulate. Simple classifcation of failure
underprescribed and overprescribed bridges.
Underprescribed Bridges:- These include designs that are unstable or
have few abutment teeth e.g. cantilever bridge carrying pontics that
cover too long a span or a fxed movable bridge where again span is
too long or abutment teeth with too little support have been selected.
Another under design fault is too conservative in selecting retainer
e.g. Class II inlays for fxed-fxed bridges. Little can be done other
than removing and fabricating new prosthesis.
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Overprescribed bridges:- Cautions dentist will sometimes include
more abutment teeth than are necessary and fate usually dictates
that it is the unnecessary retainer which fails. E.g. 1
st
and 2
nd
premolar and 2
nd
molar included to replace 1
st
molar or use 3, 4, 5 on
either side to replace incisors in upper arch. If the large bridge unit
fails it is sometimes possible to section the bridge in the mouth and
remove the failed unit leaving the remainder of the bridge to continue
in function. The failed unit is remade as an individual restoration.
The retainers themselves may be overprescribed with complete crowns
being used where partial crowns or intracoronal retainers would have
been quite adequate or metal ceramic used where all metal crown
would have been sufcient.
ii) Marginal Defciencies:-
Positive ledge (overhang):-
It is an excess of crown material protruding beyond the margin of
preparation. These are more common with porcelain than any other
margins. However, it is often possible to correct them without otherwise
disturbing the restoration by grinding and polishing in situ.
Negative ledges:-
This is a defciency of crown material that leaves the margin of the
preparation exposed but with no major gaps between the crown and the
tooth. Again it is a fairly common fault, particularly with metal margins,
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but one that is difcult or impossible to correct at the try-in stage. It
often arises because the impression did not give a clear enough
indication of the margin of the preparation. The die was overtrimmed,
resulting in under extension of the retainer.
Provided the crown margin is supragingival or just at the gingival
margin, it is sometimes possible to adjust the tooth surface of the crown.
When the ledge is subgingival, and particularly there is localized gingival
infammation associated with it, it may still be possible to adjust the
ledge with pointed stone or bur, although this will cause gingival damage.
Sometimes it is necessary to remove the bridge and adjust the
tooth surface with/ without surgically raising the fap.
iii) Dowel design:-
If a dowel is used its extension into root must at least be equal the
length of the crown for optimum stress distribution and maximum
retention or the dowel should be 2/3
rd
the length of the root whichever is
greater.
A minimum of 4mm of gutta percha and more if possible should
remain to prevent dislodgement and subsequent leakage.
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Failures of Dowel and Possible Explanations:
Type of failure Explanation
Loss of post from
root canal
Post does not ft the walls of the canal or has too
much taper.
Post too short
Post not in canal but has been placed through a
perforation into the alveolar bone. This should be
suspected if there is any bleeding.
Radiographs taken from either side of the root will
show the post to be apparently in diferent positions.
Longitudinal or oblique fracture of root. This can be
confrmed by placing a probe in the post hole and
gently forcing the walls of the tooth apart. In this
situation blood can usually be seen in the crack. It
may be due to excessive force, as would be imparted
by a bridge abutment on a wedge-shaped post.
Fracture of post This usually occurs at the gingival margin.
In a cast post it may be due to the diameter being too
small, or the alloy too soft, or porosity in the casting,
or exceptional occlusal forces.
In a pre-formed post it may be due to corrosion, or
selection of a post which was too thin. Posts which do
not have sufcient resistance to stress will develop
metal fatigue.
Pain on
cementation of
post
Root has been split due to cement being partially set,
or mixed too thick. Screw posts which contact the
end of the post hole may also split the root.
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A poorly sealed root flling, lateral canal or
perforation may allow cement into the periodontal
membrane.
Loss of crown Core preparation too short or too conical in shape.
Fracture of crown Core too thick especially palatally.
A bonded crown should have been made instead of a
porcelain jacket crown. This would be indicated by
the presence of wear facets, very short clinical height
to the crown, or lack of space between the lingual
surface of the core and the occluding surface of the
opposing tooth.

MAINTENANCE:
Importance of high standard of maintenance i.e. by patient and
dentist cannot be overemphasized. It is to be hoped that any crown/
bridge placed will have a life expectancy of at least a decade and with
high level of maintenance, restoration are often seen surviving for 2-3
decades.
Following cementation patient should be instructed in particular
oral hygiene procedures necessary because of the restoration. For e.g. A
crown needs burnishing and fossing just as a sound tooth, but the
position of margin and particular need for care in cleaning should be
demonstrated to the patient. For a bridge, particular care has to be taken
of the proximal area between retainer and pontic. The patient will not be
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able to use a dental foss; the use of foss threader or superfoss should
be demonstrated.
In cases of high decay rate/ decreased salivary fow, dietary advice
should be given and use of fuoride rinses encouraged. Athletes and
patients with a tendency to brux should be provided with a suitable
guard appliance.
The patient should be asked to return for review if any symptoms
develop, mobility is felt or for some reason the restoration feels difcult
from when cemented.
REVIEW APPOINTMENTS:
Should be regularly made depending on caries rate and the standard
of oral hygiene.
Should be done every 6 months.
Restoration is examined with a sharp probe to detect if any defciency
is present, mobility of tooth determined.
Check occlusion
Periodontal evaluation, bleeding on probing, gingival recession, loss of
attachment indicate active disease and patient will need to be
encouraged in better cleaning.
Periodic radiography is essential for patients with high caries index.
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REFERENCES FROM JOURNAL:
1. Efect of connector design on the fracture resistance of all
ceramic FPD. JDP 2002; 87; 536.
Conclusion:-
1.The fracture resistance of 3 unit all ceramic FPDs was afected by
modifcation of the radii of curvature within the embrasure space.
2.For the connector design tested, the radii of curvature at the
gingival embrasure strongly afected the fracture resistance of all
ceramic FPDs. As the radius at the gingival embrasure increased
from 0.25 0.90 mm, the mean failure load increased by 140%.
3.The results of this study suggested that the occlusal embrasure
can be designed as sharp as is practical for the esthetics of an all
ceramic 3 unit FPD, provided that the gingival embrasure has a
increase radius of curvature.
2. Success rate and failures for FPD after 20 yrs of service. IJP
1999; 11(2):133.
Knowledge of the background factors and conditions that cause
FPD and crowns to become unserviceable should help dentists in their
prosthetic treatment planning. Furthermore, a more reliable prognosis
might be possible.
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This study reports the cumulative success rate of 140 FPD (at least
5 units after 20 yrs in service).
33
Conclusion:-
1.The cumulative success rate after 20 years in service was 65%.
2.The most frequent reason for the removal of a FPD were esthetic
and periodontal problem, as well as loss of retention.
3.There was no diference in failure rate between FPD with / without
a cantilever for the last 8 years of the 20 yr follow up period, even
though such a diference had been discovered for the preceding
follow-up.
4.The majority of the removed FPD had been replaced by a new fxed
restoration.
3. A survey of crown and FPD failures: length of service and reasons
for replacement: Length of service and reasons for replacement. JDP
1986; 56(4):416.
1) Mean length of service 8.3 yrs
2) Caries was the most common cause of failure, afecting 22% of units
failed
Mechanical problem 69.5%
Oral problem 28.5%
Resin veneer metal crowns provided the longest service and failed
most frequently because of worn/ lost veneers. Complete veneer life span
of 6.1 yrs fail because of caries or defective margins.
34
Ceramic metal life span 6.5 yrs. Failure because of porcelain fracture of
poor esthetics
35
Resin veneer metal crown longest service
PV crown
ceramic metal
No relationship between span of prosthesis and its length of service.
4. Clinically signifcant factors in dowel design. JDP 1984; 52:28.
- Tapered cast dowel and core displayed a higher failure rate than teeth
treated without intracoronal reinforcement.
- Parallel sided serrated dowel did not have failures caused by tooth
fracture, whereas failures of the tapered cast dowel and core required
extraction in approximately 1/3
rd
of the fractured teeth.
- Teeth that had a dowel length equal to or greater than crown length
had a success rate that exceeded 97%.
- The cast parallel sided serrated dowel and core and the parallel sided
serrated dowel with an amalgam or composite resin core recorded the
highest success rate.
Conclusion:
Well organized and efcient postoperative care is the chief
mechanism of success of FPD.
A restoration that is cemented forgotten and ignored is likely to fail
regardless of how skillfully it was designed and executed.
36
If possible the dentist should anticipate long term prognosis and
treatment needs of the patient and attempt to design the treatment plan
accordingly.
The patient must understand the limitations of fxed prosthodontic
treatment before the treatment begins.
Designing a bridge is difcult
It is neither a precise science nor a creative form of art
It needs knowledge, experience and judgment
which takes years to accumulate
BIBLIOGRAPHY:
1. Planning and Making Crown and Bridge Bernard GN Smith.
2. Inlays, Crowns and Bridges A Clinical Handbook. George F
Kantorowitz.
3. Modern Practice in FPD Johnston.
4. JPD 1984; 52:28.
5. JPD 2003; 90:31.
6. JPD 1995; 73:440.
7. BDJ 1984; 157:61.
8. JPD 1986; 50:416.
9. IJP 1999; 11:133.
10.JPD 2002; 87:536.
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