FAILURES IN FIXED PARTIAL DENTURES

CLASSIFICATION

Bennard G. N. Smith
1. Loss of retention 2. Mechanical failure of crowns or Fixed partial denture components a. Porcelain fracture b. Failure of solder joints c. Distortion d. Occlusal wear and perforation e. Lost facings 3. Changes in the abutment tooth a. Periodontal disease b. Problems with the pulp c. Caries d. Fracture of the prepared natural crown or root e. Movement of the tooth

4. Design failures a. Under-prescribed FPDs b. Over-prescribed FPDs 5. Inadequate clinical or laboratory technique a. Positive ledge b. Negative ledge c. Defect d. Poor shape and color 6. Occlusal problems

Presentation
Pain

Loss of retention
Inability to function Dissatisfaction with aesthetics Broken teeth or restoration Inflammatory swelling Bad taste Halitosis

Bleeding gums
Anxiety Symptom free

TYPES OF FAILURES IN FPD

I. Cementation failure II. Mechanical failure III. Gingival and periodontal breakdown IV. Caries V. Necrosis of pulp VI. Biomechanical failure VII.Esthetic failure

I. CEMENTATION FAILURE
Can be broadly divided into:

1. CEMENT FAILURE 2. RETENTION FAILURE 3. OCCLUSAL PROBLEMS 4. DISTORTION OF FPD

Causes of cement failure

1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Cement selection Old cement Prolonged mixing time Thin mix Cement setting prior to seating Inadequate isolation Incomplete removal of temporary cement Thick cement space Inclusion of cotton fibers Insufficient pressure

Selection of luting agent: The primary function of the luting agent is to provide a seal preventing marginal leakage and pulp irritation. The luting agent should not be used to provide significant retentive and resistive forces. An ideal luting agent would have the following properties: 1. Adequate working time 2. Adhere well to both tooth structure and metal surface 3. Provides a good seal 4. Non toxic to the pulp 5. Have adequate strength properties 6. Be compressible into thin layers 7. Have low viscosity and solubility 8. Exhibit good working time and setting properties

Cement failure
- Complete decementation
- Partial decementation

carious attack Patient feeling: movement of the bridge bad taste sensitivity Clinically: applying displacing pressure to the restoration will cause bubbles at the cervical margin

Management:
- Restoration must be removed
- Abutment should be evaluated - Recementation if abutments and restoration are

satisfactory or new restoration should be made

2. RETENTION FAILURE For a restoration to accomplish its purpose, it must stay in place on the tooth. The geometric configuration of the tooth preparation must place the cement in compression to provide the necessary retention and resistance.
CAUSES FOR RETENTION FAILURE 1) Excessive taper 2) Short clinical crowns 3) Mis-fit 4) Misalignment

Excessive taper : As a cast metal or ceramic restoration is placed on or in the preparation after the restoration has been fabricated in its final form, the axial walls of the preparation must taper slightly to permit the restoration to seat Theoretically, the more nearly parallel the opposing walls of the preparation are, the greater should be the retention. Recommendations for optimal axial wall taper of tooth preparations for cast restorations ranged from 10 to 12 degrees.

Short clinical crown : Cement creates a weak bond largely by mechanical interlocks between the inner surface of the restoration and the axial wall of the preparation. Therefore, the greater the surface area of the preparation the greater is its retention. The preparations on large teeth are more retentive than preparations on small teeth. A short, over-tapered or short clinical crown would be without retention as there would be many paths of removal. A shorter wall cannot afford this resistance. The walls of short preparations should have as little taper as possible.

Clinical conditions with excessive taper and short clinical crowns should be treated with :1. In case of excessive taper: a. Incorporation of proximal grooves. b. Additional retentive grooves (should be along with the path of insertion). c. Additional pins 2. In case of short crowns: a. Crown lengthening procedure b. Modification of supra-gingival margin to sub-gingival margin c. Additional retentive grooves and proximal box d. Incorporation of pins e. Addition of extra abutments

Misfit : The fit of casting can be defined best in terms of the misfit measured at various points between the casting surface and the tooth. The measurement of misfit at different locations and geometrically related to each other and defined as : 1. Internal gap 2. Marginal gap 3. Vertical marginal discrepancy 4. Horizontal marginal discrepancy 5. Over-extended margin 6. Under-extended margin

Causes for misfit : a. Defective casting b. Porcelain flowed inside the retainer c. Excessive oxide layer formation in inner side of the retainer (due to contaminated metal or repeated firing of porcelain) d. Tight contact points with abutment teeth e. Incorrect manipulation of luting agents f. Insufficient pressure during cementation procedure

Misalignment : it is more difficult to differentiate whether a FPD is not seating because of a faulty fit, or the alignment of the retainers relative to each other is incorrect. The only difference which may sometimes be apparent is that, in the case of misalignment the FPD will have some spring in it and tend to seat further on pressure due to the abutment teeth moving slightly, whereas in the case of a defective fit, the resistance felt will be solid.

Causes for misalignment a. Abutment displacement due to improper temporization. b. Distortion of wax pattern while sprueing and investing. c. Casting defects. d. Distortion of metal frameworks in porcelain firing. e. Porcelain flow inside the retainers. f. Misalignment of soldering points. g. Insufficient pressure in cementation. h. Thick cement film. i. Excessive metal or porcelain in tissue surface (ridge lap) of pontic prevents the proper seating of FPD and open margin (can be detected by observing the blanching of the tissue or patient may complain of pressure on the pontic region).

3. OCCLUSAL PROBLEMS Following the placement of a dental restoration, a patient might report discomfort ranging from a feeling of lameness to severe and constant pain. Sensitivity, in most cases, is due to pulp irritation from traumatic contact or greater leverages. When the occlusion has been adjusted, each type of discomfort may be relieved almost instantly and should disappear shortly.

Causes in occlusal problems 1. Immediate problems Occlusal interference Marginal ridges at different levels Supra eruption of the opposing tooth Parafunctional habits 2. Delayed problems Wearing of occlusal surface Loss of occlusal contacts Perforation of occlusal surface due to Porcelain Vs resin Porcelain Vs gold Food lodgment due to plunger cusp Fracture of facing due to defective occlusal contact Periodontal or gingival breakdown due to improper occlusal contacts Tenderness due to food lodgement

4. DISTORTION OF FPD The completed restoration should go into place without binding of its internal aspect against the occlusal surface or the axial walls of the tooth preparation. In other words, the best adaptation should be at the margins. If the indirect procedure is handled properly, there should be no noticeable difference between the fit of a restoration on the die and that in the mouth.

Causes of distortion: Casting defects- distorted margin, rough castings, banding of the FPD due to improper care taken during wax pattern making, investing and casting procedures. Bending of long span FPDs due to Thin crown, Soft metal, Heat treatment not being done, Porosity in the metal Distortion of the metal substructure during the porcelain firing

II MECHANICAL FAILURES

Classification of mechanical failure 1. Retainer failure 2. Pontic failure 3. Connector failure

1. RETAINER FAILURE
1) Perforation 2) Marginal discrepancy 3) Facing failure Fracture Wearing Discoloration

1) Perforation
Causes a) Insufficient occlusal reduction b) Insufficient occlusal material c) High points in opposing dentition (plunger cusp) d) Premature contacts e) Contaminated metal f) Porosity in metal work (subsurface, back pressure, suck back) g) Due to improper melting temperature h) Improper pattern position i) Improper sprue (too thin) j) Improper location k) Parafunctional habits

2) Marginal discrepancy
Causes a) Selection of margin b) Improper preparation and failure to establish the margin properly c) Failure to do gingival retraction prevents definite margin location and subsequently in impression d) Selection of the impression material i. Shrinkage in material (condensation silicon) ii. Distortion of material (alginate) e) Improper impression procedures f) Voids in the impression g) Variation in pressure application in wash technique h) Delayed pouring of die material i) Distortion of wax patterns at margins

j) Insufficient flow of metal k) Shrinkage of metal l) Nodules in margins and inner side of coping i. Due to inadequate vacuum during investing ii. Improper brushing technique iii. No surfactant m) Excessive sand blasting n) Distortion due to degassing procedure o) Open margins due to porcelain shrinkage (opaque porcelain) p) Thick mixing of luting agent q) Cement setting prior to seating r) Insufficient pressure application during cementation

3. Facing failure
Types of veneer failures a) Fracture b) Wearing of facing (resin veneers) c) Discoloration

Mechanical Failure
Porcelain failure
Full ceramic restorations:
Fracture indicate that full ceramic restoration is not suitable for the situation in regard to occlusal forces

Metal ceramic restorations: - Chipping: failure in porcelain buildup - Debonding: failure in the bond between metal and porcelain

Causes: - Technical failure in opaque layer application - Inadequate framework design - Placing porcelain margin at highly stressed areas - Thin metal framework for long span FPDs Management: - Small fractures can be repaired with composite kit - Large fractures: replace restoration avoiding the cause of failure

2. PONTIC FAILURE
Factors affecting selection and failure of pontics 1) Pontic space 2) Residual ridge contour 3) Biological consideration a. Ridge relation b. Dental plaque c. Gingival surface of pontic (Contact with mucosa) i. Mucosal contact ii. Non mucosal contact 4) Pontic ridge relationship 5) Pontic material 6) Biocompatibility 7) Occlusal forces 8) Metal substructure support

3. CONNECTOR FAILURE
The connector is that part of the FPD or splint that joins the individual components (retainers and pontics) together. Causes for connector failure Improper selection of connector Thin metal at the connector Incorrect selection of solder Solder gap narrow or wide Porosity Insufficient metal around Defective occlusal contacts over thin connectors

III GINGIVAL AND PERIODONTAL PROBLEMS

Margins are one of the most important and weakest links in the success of FPD restorations. One of the prime goals of restorative therapy is to establish a physiologic periodontal health. A successful prosthesis depends on a healthy periodontal environment and periodontal health depends on the continued integrity of the prosthodontic restoration. The margin is one of the components of the cast restoration most susceptible to failure, both biologically and mechanically. Most of the investigative proof shows that supragingival margins are kinder to the gingiva than are subgingival margins. However, practicality dictates that supragingival margins are not always usable

Failure to produce the margin of the preparation in the impression lead to reproducing the marginal integrity of the restoration. Using of gingival retraction technique in case of sub gingival preparation is mandatory. However, all displacement techniques have the potential damage gingiva, attachment apparatus and bone, especially if anatomic forms are weak or if disease is present. In healthy patients, properly used cord displacement or copper band methods have proved to be atraumatic.

IV CARIES

CAUSES
Iatrogenic (dentists role) Failure to identify caries Incomplete removal of caries Marginal discrepancy with subsequent plaque accumulation and microleakage Subgingival marginal placement in inaccessible areas or regions Burning of root dentin or cementum in electro surgical technique (leads to damage or rough surface and causes plaque retention) Over contouring of the cervical thirds of crowns or bridges prevents the physiologic too cleaning by tongue or muscles Thick cement space in margins leads to cement dissolution. Narrow embrasures (inaccessibility to maintain hygiene) Wide connector

Patient role Systemic factors Xerostomia Due to radiation therapy Drug induced Endocrine disorders Epilepsy (difficult to maintain the oral hygiene) Rheumatoid arthritis Local factors Improper brushing and flossing Dietary habits Failure to understand importance of oral hygiene.

Management
-Limited at margin: remove caries and restore -Extended under retainer: remove restoration, restore the teeth and reassess the need for new restoration

V PULP DEGENERATION

Pulp reactions to various procedures Each step in full crown preparation presents hazards, which may injure the pulp. In general, heat desiccation and / or chemical injury cause the insult. The result may be pulpitis or even necrosis. Among the many essential procedures that may cause pulp injury are: Tooth preparation: excessive heat generation, over preparation with less than 1mm of reaming dentin Impression making: irritation from the impression materials Pulp infection: from microbial infiltration due to poor oral health and faulty temporization and cementation.

VI BIOMECHANICAL FAILURE
Causes: - Failure in selection of right abutment - Lack of retention and resistance form - Incorrect design of FPD - Wrong material selection

VII. ESTHETIC FAILURES

REASONS FOR ESTHETIC FAILURE Failure to identify patient expectations regarding esthetics Improper shade selection Excessive metal thickness at incisal and cervical regions Thick opaque layer application Surface blistering (chalky appearance) Over glazing or too smooth a surface Metal exposure in connector, cervical and incisal regions (anteriors)

Failure to produce incisal and proximal translucency Improper contouring Failure to harmonize contra lateral tooth morphology Contour Color Position Angulation Dark space in cervical third due to improper pontic selection Discoloration of facing

Post and core failure

1- loss of retention - Short posts - Over tapered posts - No anti-rotation lock Management New post with adequate design

Post and core failure

2- lateral perforation of the root - Misalignment of root canal preparation - Thin root or over preparation Management - surgically by raising a flab and sealing the perforation - Extraction if access is dificult

Post and core failure

3- Root fracture - Over tapered posts - Short posts - Wide posts - Threaded posts Management Extraction

Removal of Crowns and FPDs

Attempts can be made to remove the prosthesis intact using crown removers caution *Sectioning of the prosthesis might be necessary if the retainers are firmly cemented

Before removing old restoration we should ask: - How long has this restoration been in place? - Why has it failed? - How can further failure be prevented?

Thats it!!