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Dr. Amar Bhochhibhoya, 2nd Batch, PG Resident, Dept. of Prosthodontics& Maxillofacial Prosthetics, PDCH
Contents : Introduction Terminologies Classifications of failure/complication Management Review of literatures Conclusion References
Introduction
A realistic approach to fixed prosthodontics is that total success or total failure is seldom achieved.
Between these extremes lies a large grey area of partial failures and partial successes.
Knowledge occur in
regarding fixed
the
complications and failures that can prosthodontics enhances the clinicians ability to complete a thorough diagnosis, develop treatment the most appropriate communicate plan,
realistic expectations to patients, and plan the time intervals needed for post-treatment care.
Merriam Websters Collegiate Dictionary. 10th ed. Springfield, MA: Merriam-Webster; 1993. p. 236.
Kenneth J. Anusavice. Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal ceramic fixed dental prostheses. Dental Materials 28(2012) 102-111
Success may be defined as the achievement planning expectations. of goals treatment and
Kenneth J. Anusavice. Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal ceramic fixed dental prostheses. Dental Materials 28(2012) 102-111
Survival
Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of the survival and
complication rates of all-ceramic and metal ceramic reconstructions after an observation period of at least 3 years. Part II: fixed dental prostheses. Clin Oral Implants Res 2007;18(Suppl. 3):
8696.
Restoration success is defined as the demonstrated ability of a restoration (including a prosthesis) to perform as expected.
Failure represents the inability of a restoration to perform as expected under typical clinical and patient conditions.
Kenneth J. Anusavice. Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal ceramic fixed dental prostheses. Dental Materials 28(2012) 102-111
Failure was defined as removal or complication requiring replacement for a FPD, or loss of an abutment.
fixed partial denture survival: Prostheses and abutments:J Prosthet Dent 1998;79:459-64.
Varieties of terminologies have crept into the and they dental have terminology
complicated our classification of success and failure of crown and bridge restorations.
Chadwick et al. suggested many factors that affect the survival of dental restorations:
the type of dentition; site of the restoration; reasons for placement; caries status; age, sex and socioeconomic characteristics of the patient; oral hygiene;
They
indicated
that
the
determination of failure is very problematic since there is no universally success restorations applied or standard of for dentists to determine the failure
Chadwick B, Treasure E, Dummer P, et al. Challenges with studies investigating longevity of dental restorations a critique of a systematic review. J Dent 2001;29:15561.
Hickel et al proposed three categories (esthetic, functional, and and biological) to to simplify a more clinical evaluation procedures encourage detailed analysis of failures.
Hickel R, Peschke A, Tyas M, et al. FDI World Dental Federation: clinical criteria for the evaluation of direct and indirect restorations. Update and clinical examples. J Adhes Dent 2010;12:25972.
Criteria for grading or classifying the type and severity of the failures are inadequate
There is the additional problem of reaching a common interpretation among investigators on the definition of failure
Biological
complications consisted
of caries, loss of pulp vitality, abutment tooth fracture and progression of periodontal disease.
Technical
complications consisted
of framework fracture, fracture or chipping of the veneering ceramic, marginal gap/discoloration, and loss of retention.
Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of the survival and complication rates of all-ceramic and metalceramic reconstructions after an observation period of at least 3 years. Part II: fixed
The lowest incidence of clinical complications was associated with all-ceramic crowns (8%).
Posts and cores (10%) and conventional single crowns (11%) had comparable clinical complications incidences.
Resin-bonded prostheses (26%) and conventional fixed partial dentures (27%) were found to have comparable clinical complications incidences.
When fixed partial denture studies were reviewed, the 3 most commonly reported complications were caries (18% of abutments), treatment need (11% for of endodontic
The 3 most common complications associated prostheses with were resin-bonded prosthesis
less than 15% of fixed partial dentures were removed or in need of replacement at 10 years
nearly one third were removed or in need of replacement at 15 years less than 5% of abutments were removed at 10 years
Mark S. Scurria, James D. Bader, and Daniel A. Shugars. Meta-analysis of fixed partial denture survival: Prostheses and abutments:J Prosthet Dent 1998;79:459-64.
Visual inspection (Discoloration around margins) Probing margins of restorations with a sharp explorer Radiographs for interproximal caries
Causes:
Defective margins (supragingival preferred over subgingival) Loose retainers that allow gross leakage to occur Incomplete removal of caries prior to restoration Poor design leading to food accumulation Change in the diet of patient
Management:
If carious lesion is small -conservative operative procedures , tooth preparation can be extended to eliminate the caries
An extensive lesion may require endodontic treatment. A grossly destroyed teeth by caries that cannot be restored must be extracted.
Pulp Degeneration:
Clinical features: - Postinsertion pulpal sensitivity in the abutment teeth that does not subside with time; intense pain or periapical
Causes:
Excess heat generation during preparation Excess tooth reduction Pin point exposure which may go unnoticed Occlusal trauma
Prevention:
Use of varnish or dentin bonding agent form an effective barrier and prevents underlying pulp from toxic effects of cement and core materials.
Management:
Endodontic intervention
A hole is drilled in the prosthesis through which the biomechanical preparation (BMP) is completed. The access cavity is restored Amalgam, Cast metal inlay
If the retainer come loose during access opening or if the porcelain fractures, then remaking of the prosthesis may be necessary.
Periodontal breakdowns:
Poor marginal adaptation Overcontouring of axial surfaces Large connectors that restrict cervical embrasures Pontics that contact too large an area on the edentulous ridge Prosthesis with rough surfaces which promote plaque accumulation
Management:
If less severe scaling and proper plaque control Increased severity surgical intervention (flap, graft) Correct occlusion
Poor prognosis of abutment teeth -- crown or bridge and the tooth may have to be removed
Occlusal Problems:
Clinical Features:
Large
tender
perforation,
periodontal ligament
Interfering centric and eccentric occlusal contacts can cause Excessive tooth mobility Irreversible pulpal damage Management:
Occlusal a
adjustment
combination of excessive
(traumatic occlusion on teeth previously weakened by periodontal disease or long term presence of occlusal interferences )
Irreversible In
MECHANICAL FAILURES:
Loss or retentions:
leverage
cementation
procedures
Saliva and plaque and pumping action of loose retainer are responsible for caries leading to rapid destruction of abutment teeth
Detection:Awareness of movement
Clinical examination:
unseat existing prosthesis by lifting the retainers up and down (occlusocervically) while they are held between the fingers
The occlusal motion causes fluids to be drawn under the casting and when it is reseated with a cervical force the fluid is expressed, producing bubbles as the air and liquid are simultaneously displaced.
Loss of adequate retention, preparation modified to improve the retention and resistance form (grooves, boxes etc.)
Include additional abutment to increase overall retention Change the design in some other way (i.e. use of full
Span length is excessive or occlusal forces heavy --- a removable partial denture
CONNECTOR FAILURE : Between an abutment retainer and a pontic or between two pontics
i) Adequate width and depth to resist occlusal stress ii) A sufficient bulk of material Cause: Internal porosity is the cast / soldered connectors Failure to bond to surface of metal Joint not be sufficiently large to resist occlusal forces Improper flow of metal due to decreased width between joining parts. Minimum width
Pontics
in
cantilevered
Management:
Prosthesis should be removed
and remade as soon as possible An inlay like dovetailed preparation can be developed in the metal to span the fracture site and a casting can be cemented to stabilize the prosthesis Pontics can be removed by cutting through the intact connectors and a temporary removable partial denture can
then be inserted to maintain the existing space and satisfy esthetic requirements.
Clinical Features: Attrition of opposing teeth, polished facets on the retainers/ pontics, gingival recession or inflammation Causes:
Faulty preparation/ inadequate occlusal clearance Even with normal attrition, occlusal surfaces of posterior teeth wear down substantially over a period of time There perforations allow leakage and caries to occur which leads to prosthesis failure.
Management:
Metal Wear
extremely thin --- new prosthesis wear of the opposing natural teeth. Occlusal wear anticipated -- metal over occluding surfaces (minimize wear and maintain the integrity of opposing teeth)
TOOTH FRACTURE:
Caries
Coronal fractures:
of abutment teeth tooth preparation Excessive
Use
of restorative material
of interfering
Attempting
Management:
Defect is small, restored with amalgam, or resin Questionable integrity of the remaining tooth structure or restoration-- fabricate a new prosthesis to encompasses the fractured area
Large
coronal
fracture
around full
partial coverage
coverage restorations
retainers--
Abutment tooth fracture under full coverage restoration usually occur horizontally at the level of finish line
Radicular fractures:
During endodontic treatment Forceful seating of post Attempts to fully seat an improperly fitting post
Root
fracture
well
below
the
Fracture terminates at or just below the alveolar bone -periodontal surgery, expose the fracture site encompassed by new prosthesis
Abrasion can result in loss of severe amounts of acrylic on acrylic veneer crowns and pontics.
Cause: Functional loadings or abrasive foods and habits. Tooth brush abrasion
Repair:
Replacing lost contours with acrylic resin/ composite resins Composites : More resistant to wear and
Maintain function and appearance longer than acrylic resin repairs
Porcelain Fracture:
Porcelain fractures occur with both metal ceramic and all ceramic crown restorations.
The majority of PFM fracture can be attributed to improper design characteristics of the metal framework or to problem related to occlusion.
All ceramic restorations commonly fail because of deficiencies in tooth preparation or presence of heavy occlusal forces.
Prevalence
of
ceramic
fractures ranged
between 5 to 10% over 10 years of use. The reasons for such failures are frequently repeated stresses and strains during chewing function or trauma
M. O ZCAN. Fracture reasons in ceramicfused-to-metal restorations. Journal of Oral Rehabilitation 2003 30; 265269
An
overly
thin does
castings adequately
Centric occlusal contact on, or immediately next to, the metal ceramic junction
Occlusions:
contamination due to
alloy surface
The occlusal forces attempt to rotate the restoration. A round preparation form that does not provide adequate resistance to rotational fracture forces can cause vertical
Short preparation -- forces applied at the incisal edge tip the restoration facially -cervical porcelain fracture
The incisocervical length of the preparation should be two thirds to three quarters that of the final restoration
Lingual fractures:
Semilunar lingual fractures are observed when the occlusion is located cervically to the cingulum of the preparation, where forces on the porcelain are more shear in nature and not well resisted
Twenty to 30% reduction in metal ceramic strength was found in a moist environment
Silicate bonds in the glassy ceramic matrix are susceptible to hydrolysis by environmental moisture in the presence of mechanical stress (Michalske and Freiman,1982) The most frequent reasons for ceramic failures are related to the cracks within the ceramic.
As the crack propagates through the material, the stress concentration is maintained at the crack tip until the crack moves completely through the material (Lamon & Evans, 1983).
Technical mistakes:
occasional
presence of pores
inside the ceramic could account for their weakness and eventual fracture at that site Cruickshank-Boyd, 1984)
Faulty design of the metal substructure, incompatible expansion substructure porcelain thermal between and thickness with coefficients the of metal excessive inadequate
(Oram &
ceramic,
metal support, technical flaws in the porcelain application, occlusal forces or trauma were also included as the failure reasons
Schneider
&
Avoidance of acute line angled preparations was advised as they enhance the formation of microcracks within the porcelain during the firing procedures (Burke, 1996)
It was reported that facings may crack, be fractured or damaged as a result of trauma, parafunctional occlusion or inadequate retention between the veneer and the metal (Farah & Craig, 1975).
Repair
Lack of longevity is the main drawback chemical occur resins because bonding either does metal the true not or current
between and
Porcelain veneer, Casting with a fused porcelain veneer, and Overlay metal-ceramic crown.
Porcelain Repair (Porcelain fused to metal crown ) With Composite (for optimal results: isolate with rubber dam) : A. Etch porcelain/metal surface with 4% hydrofluoric acid for 4 minutes. B. Rinse and dry thoroughly. C. Apply one coat of Porcelain Primer (Silane) to exposed porcelain. D. Light cure for 10 seconds.
E. Mix equal amounts of dual cure Opaquer Base & Catalyst. F. Apply thin layer on exposed metal surface to mask out metal shine-through. G. Light cure for 10 seconds. H. Use the composite of choice and light cure in small increments I. Proceed with finishing and polishing.
A more permanent repair is possible when adequate metal framework thickness is available.
Cementation Failure:
Causes:
inadequate mechanical retention (limited strength of chemical adhesion, and cohesive strength of cement)
Inadequate
Design Failure:
affecting 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 30 failure through loss of retention becomes common Ideal taper for good retention is 7 It is not possible to achieve this taper clinically without producing some undercuts/ damaging the adjacent teeth. Average taper that have been shown to be clinically successful in a large number of cases is approx.10-20
Length of Preparation:
Minimum
cervico-incisal
height -- allows the tooth structure to interfere with arc of rotation as tipping forces attempts to cause rotation
around a fulcrum located at the finish line on the opposite side of the tooth
Shorter
clinical crowns:
surgical crown lengthening margin subgingivally prepare tooth with less taper/ parallel walls
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
Occlusal irregularities:
Aids Flat
in resistance to
dislodging forces reduction provides little interference and unnecessarily reduces the length of preparation
Irregular
reduction
according to occlusal plane produces an corrugated sheet effect which enhances the rigidity of the retainer than one plane reduction
or irregular margins
Structural Durability:
Occlusal Reduction:
Minimum
Inadequate reduction leads to perforation and fracture of metal. One plane reduction may reduce the incisocervical length and jeopardize the pulp.
Underprescribed Bridges :
These
unstable or have few abutment teeth e.g. cantilever bridge carrying pontics that cover too long a span or abutment teeth with too little support
Another under design fault is too conservative in selecting retainer e.g. Class II inlays for fixed bridges
Little can be done other than removing and fabricating new prosthesis
Overprescribed bridges :
More abutment teeth than are necessary, e.g. 1st and 2nd premolar and 2nd molar included to replace 1st molar
Large bridge unit fails it is possible to section the bridge and remove the failed unit, the failed unit is remade as an individual restoration
Retainers may be overprescribed with complete crowns being used where partial crowns or intracoronal retainers would have been adequate
Marginal Deficiencies:
Excess of crown material protruding beyond the margin of preparation More common with porcelain
Negative ledges:
Deficiency of crown material that leaves the margin of the preparation exposed but with no major gaps between the crown and the tooth
common fault with metal margins Often arises because inadequate record of margin in the impression, over trimming of die resulting in under extension of the retainer
Supragingival
margin or just at
the gingival margin, possible to adjust the tooth surface of the crown
Subgingival
possible to adjust the ledge with pointed stone or bur, although this may cause gingival damage
Sometimes
it is necessary to
remove the bridge and adjust the tooth surface with/ without surgically raising the flap
ESTHETICS FAILURES:
Classification of Esthetic Errors:
Static prosthesis in dynamic mouth Inharmonious strength or weakness of dental composition compared to
background features. a. Weak mouth with strong face. b. Strong mouth with weak face.
Inadequate vertical space allocation Excessive vertical space allocation Excessive horizontal space allocation
Elevated occlusal plane Occlusal plane drops down posteriorly Asymmetrical occlusal plane
3. Unnatural lines
Reverse smiling line Unnatural axial inclination Cusp less posterior teeth Gradation errors Age-sex personality disharmony Vertical deviation Horizontal deviation Line conflict Midline error Imbalance of directions Artifact error Diastema error
4. Single-line errors
5. Imbalance
ESTHETICS FAILURES: Ceramic restorations more often fail esthetically than mechanically or biologically. Poor color match is the frequent reason for most of the remakes of the restorations
Causes: For unacceptable color match. 1) Inability to match the patients natural teeth with available porcelain colors
6. Incorrect form or a framework design that displays metal 7. As changes in the natural tooth over the years
8. Partial veneer resonations can be esthetically unacceptable because of over extension of the finish line facially. This displays excessive amount of metal 9. When thin incisors are prepared, the metallic color of the partial
coverage casting may be visible through the remaining tooth structure (grayness) 10. The marginal fit or cervical form of a prosthesis can promote plaque accumulation, causing gingival inflammation, which produces an unnatural
CONCLUSION: The first consideration when confronted with any failure or repair situation is to ascertain the suspected cause. Sometimes this is easy and
obvious. If there is a cause that is correctable it should be taken care of first. Care should be taken not to become involved in repairs that should have been remakes. Repairs are usually second best to the original in one or more ways.
Most failures are unique and present varying challenges to the dentist. Great satisfaction can be achieved in meeting a
References:
Bernard G N Smith, Leslie C Howe. Planning and making crowns and bridges.
Sailer I, Pjetursson BE, Zwahlen M, Hammerle CH. A systematic review of the survival and complication rates of all-ceramic and metalceramic
reconstructions after an observation period of at least 3 years. Part II: fixed dental prostheses.
Clin Oral Implants Res 2007;18(Suppl. 3): 86 96. R. Na Pa Nkangas, M. A. M. Salonen-kemppi
& A. M. Raustia. Longevity of fixed metal ceramic bridge prostheses: a clinical follow-up study. Journal of Oral Rehabilitation 2002 29; 140145
Merriam Collegiate
Websters Dictionary.
10th ed. Springfield, MA: Merriam-Webster; 1993. p. 236. M. O ZCAN. Fracture reasons in ceramicfused-to-metal restorations. Journal of Oral Rehabilitation 2003 30; 265269
Mark S. Scurria, James D. Bader, and Daniel A. Shugars. Meta-analysis of fixed partial denture survival: Prostheses and abutments:J Prosthet Dent 1998;79:459-64.
John Joy Manappallil. Classification system for conventional crown and fixed partial denture failures. J Prosthet Dent 2008;99:293-298
Kenneth J. Anusavice. Standardizing failure, success, and survival decisions in clinical studies of ceramic and metal ceramic fixed dental prostheses. Dental Materials 28(2012) 102-111 Chadwick B, Treasure E, Dummer P, et al. Challenges with studies investigating longevity of dental restorations a critique of a
systematic review. J Dent 2001;29:15561 Hickel R, Peschke A, Tyas M, et al. FDI World Dental Federation: clinical criteria for the evaluation of direct and indirect restorations. Update and clinical examples. J Adhes Dent 2010;12:25972. Heintze SD, Rousson V. Survival of zirconia- and metal-supported fixed
Charles J. complications
Goodacre. in
Clinical fixed
prosthodontics. J Prosthet Dent 2003;90:31-41. Sudhir Pawar. Failures of crown and fixed partial dentures -Aclinical survey. Int. Journal of Contemporary Dentistry. JANUARY, 2011, 2(1)
Thank
you..