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Journal of Oral Rehabilitation 2003 30; 265269

Review
Fracture reasons in ceramic-fused-to-metal restorations
M . O Z C A N Dentistry Faculty, Department of Prosthodontics, Marmara University, I_stanbul, Turkey

SUMMARY Ceramic-fused-to-metal restorations are region pose an aesthetic problem but when they are
widely used in dentistry with a high degree of in the posterior, chewing function could also be
general success. Fracture of the ceramic veneers as a affected. The published literature reveals that rea-
result of oral function or trauma is not an uncom- sons for failures cover a wide spectrum from iatro-
mon problem in clinical practice. Although fractures genic factors to laboratory mistakes or because of
of such restorations do not necessarily mean the factors related to the inherent structure of the
failure of the restoration, the renewal process is ceramics or simply to trauma.
both costly and time consuming and therefore KEYWORDS: fracture, ceramics
remains a clinical problem. Fractures in the anterior

restorations. Only a few studies in the literature have


Introduction
dealt with the survival rates of metalceramic restora-
Because of their excellent biocompatibility and superior tions.
aesthetic qualities, ceramic-fused-to-metal crowns and In a clinical follow-up study by Coornaert et al.
bridges are commonly applied in fixed prosthodontics. (1984), the prevalence of fractures in metalceramic
Despite the increased effort to improve the bond crowns was found to be approximately 5% over
strength between the ceramic and the metal substrate, 10 years of function. Strub, Stiffler and Scharer (1988)
on occasion, fractures of ceramic veneers still occur observed a failure rate of metalceramic restorations of
under clinical conditions. The reasons for such failures only between 1 and 3% over 5 years. Studies by
are frequently repeated stresses and strains during Karlsson (1986) revealed a 93% success rate for fixed
chewing function or trauma. Clinical studies indicated bridge restorations during a 10-year period, while
that the prevalence of ceramic fractures ranged Palmqvist and Swartz (1993) reported a 79% success
between 5 and 10% over 10 years of use (Coornaert, rate over an 1823-year period. The survival rates
Adrians & de Boever, 1984). obtained by Glantz et al. (1993) as a function of time
Ceramic fractures are serious and costly problems in between 1979 and 1994 indicated that most of the
dentistry. Moreover, they pose an aesthetic and func- debondings occurred over 15 years and almost all
tional dilemma both for the patient and the dentist. recorded dislodgements were observed within 5 years
Therefore the intent of this paper is to review the of placement. Subsequent clinical results from Hankin-
published literature on the reasons for fractures, son and Cappetta (1994) and Kelsey et al. (1995)
concentrating on the data obtained both from in vitro exhibited 24% failure rates after 2 years of function,
and in vivo studies. rising from 20 to 25% after 45 years because of con-
sistent repeating occlusal contacts.
In another clinical retrospective analysis, 1219 three-
Failure rates
unit fixed bridges and 1618 single crowns in the
Many patients are still in need of fixed restoration anterior region were evaluated between 1969 and
replacements as a result of some failures in those 1989 (Kerschbaum, Seth & Teeuwen, 1997). The results

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266 M . O Z C A N

of the study supported the superiority of metalceramic and fatigue, caused by cyclic loading such as mastica-
systems over acrylic-veneered crowns with 24% fail- tion, are considered important factors in the durability
ure rates after 2 years of function. Statistical analysis of metalceramic restorations. Yet, the effect of other
however, showed that after 10 years, 887% of the artificial environmental factors such as saliva or differ-
metalceramic crowns and 802% of the metalceramic ent kinds of drinks needs to be studied.
bridges were still in function. The most frequent reasons for ceramic failures are
Overall survival rate of metalceramic restorations related to the cracks within the ceramic. The minute
demonstrate a paradox in the different survival rate scratches present on the surfaces of nearly all materials
values in the literature. It is well recognized that many sometimes behave as sharp notches whose tips are as
factors are involved in the success rate assessments of narrow as the spacing between atoms in the materials.
fixed partial dentures limiting the longevity of the Thus, the stress concentration at the tips of these
restorations. minute scratches causes the stress to reach the theor-
etical strength of the material at relatively low average
stress. When the theoretical strength of the material is
Factors affecting failure
exceeded at the tip of the notch, the bond at the notch
Failure of the restorations is in fact a multifactorial tip breaks. As the crack propagates through the mater-
problem which could be related to a combination of ial, the stress concentration is maintained at the crack
different reasons. Optimization of the metalceramic tip until the crack moves completely through the
restorations requires knowledge of the failure phenom- material (Lamon & Evans, 1983). Long anterio-poster-
ena. Numerous studies over the years have focused on ior metal substructure also flexes under heavy or com-
reasons for failure. plex loading causing porcelain fracture (Reuter & Brose,
Mechanical failures of metalceramic systems are not 1984). The cracks existing within the ceramic are
surprising considering the vast differences in modulus important issues to be considered in the survival of
between the metal and ceramic materials. When feld- fixed partial dentures. Especially in long span bridges,
spathic dental porcelain is cooled, the leucite crystals crack propagation might then result in the catastroph-
contract more than the surrounding glass matrix ical failure of the restoration.
leading to the development of tangential compressive It was also noted that other reasons for the ceramic
stresses around the leucite particles as well as to fractures are technical mistakes during the preparation
microcracks within and around the crystals (Hasselman of the restorations and claimed that occasional presence
& Fulathy, 1966; MacKert, 1988; Anusavice & Zhang, of pores inside the ceramic could account for their
1998; Denry, Hollowey & Rosentiel, 1998). weakness and eventual fracture at that site (Oram &
Some studies attributed the reasons for failures to the Cruickshank-Boyd, 1984). The same results were also
environmental factors and particularly to the moisture. found by ilo (1988) who agreed that such mistakes
Twenty to 30% reduction in metalceramic strength markedly increase the failures.
was found in a moist environment (Sherill & OBrein, Further studies demonstrated the importance of
1974). Michalske and Freiman (1982) indicated that microcracks existing in the ceramic. Microcracks in cer-
silicate bonds in the glassy ceramic matrix are suscept- amic could also be caused by the condensation, melting,
ible to hydrolysis by environmental moisture in the and sintering process of the ceramics on metal because
presence of mechanical stress. The porcelain restoration of thermal coefficient differences (Yamamoto, 1989).
functions in a moist environment, which may allow Faulty design of the metal substructure, incompatible
static fatigue to cause the propagation of fractures along thermal coefficients of expansion between the metal
the microcracks resulting in failure of the restoration. substructure and ceramic, excessive porcelain thickness
The environment of the oral cavity was found to with inadequate metal support, technical flaws in the
aggravate the strength of dental ceramics. The silicon porcelain application, occlusal forces or trauma were
oxygen bond become weaker between the metal and also included as the failure reasons (Diaz-Arnold,
ceramic in the presence of moisture which abet failure Schneider & Aquilino, 1989). Because of the hetero-
in many ways primarily because of the water propaga- geneous nature of many dental materials, they are
tion at the crack tip (Dauskardt, Marshall & Ritchie, likely to contain defects or flaws in various amounts
1990). In the oral environment, the influence of water and sizes. Such flaws remain at fixed length unless

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FRACTURE REASONS IN CERAMIC RESTORATIONS 267

under load but then they become unstable and propa- preparation designs, voids in cement layers, and thick-
gate, catastrophically culminating in fracture. Small ness of the ceramic restorations were reported to affect
changes in microstructure or surface treatment can lead the fracture resistance as well (Tsai et al., 1998). One of
to drastic alterations in service life of fixed restorations the most popular test methods is mathematical model-
and repeated stresses and strains can cause slow crack ling in material research. Although such modelling has
growth and mechanical fatigue. Even a single load cycle some limitations and little is known on its applicability
can produce measurable cracking at the contact area to clinical situations, in a finite element analysis, it was
and damage accumulation during load cycling (Chad- found that the presence of a void in the ceramic
wick, Mason & Sharp, 1993; White et al., 1995). In structure did have a significant effect on the fracture
order to minimize the formation of microcracks a fairly (Abu-Hassan, Abu-Hammad & Harrison, 1998).
uniform thickness was recommended, which may Another reason for porcelain fracture was attributed
occur during the firing of the ceramic. Avoidance of to inadequate tooth preparation, which results in too
acute line angled preparations was advised as they little interocclusal space for the metal substructure and
enhance the formation of microcracks within the porcelain. It was concluded that the improper design of
porcelain during the firing procedures (Burke, 1996). the restoration for the occlusion is the major cause of
The results of these studies definitely favoured the failure (Creugers, Snoek & Kayser, 1992). The possible
requirement of technical skill and meticulous work in failure of ceramics was sometimes attributed to inade-
ceramic build-up. Clinical part of the process could quately registered occlusion, material type, spanning of
have been performed ideally however, when high level the restoration or inadequate marginal adaptation
of skill in ceramic build-up is not performed, the failure (Niedermeier et al., 1998). On the basis of this evidence,
of the restoration could be inevitable. The important clinicians should identify and address the reasons for
question is whether it would be possible to avoid any their failures in practice. When occlusion is not regis-
flaws during ceramic build-up. tered correctly and articulation is not checked properly,
Widerhorn (1968, 1974) stressed that during actual the premature contacts would act as stress bearing
masticatory conditions, restorations are subject to zones on the ceramics.
repeated loading over long periods, with superposed The fatigue failure is preceded by a combination of
tangential motion and further claimed that, especially crack initiation and crack propagation. Finally catastro-
in chemically active aqueous environments, this could phic failure occurs in the form of fracture. Llobell et al.
greatly exacerbate damage build-up. He stated that the (1992) described the reasons for intraoral ceramic
ceramic fracture process might be accelerated by the fracture as impact load, fatigue load, improper design,
environment. It was reported that facings may crack, be microdefects within the material, and added that
fractured or damaged as a result of trauma, parafunc- clinically, mastication, parafunction and intraoral
tional occlusion or inadequate retention between the occlusal forces create repetetive dynamic loading. It
veneer and the metal (Farah & Craig, 1975). In clinical was emphasized that fatigue is of considerable import-
practice however, the magnitude and direction of ance for metalceramic restorations which are subjec-
masticatory forces cannot be controlled. Studies that ted to small alternating forces during mastication.
involve forces from one direction can give the clinicians Amorphous materials like glasses or glassy materials
limited information which may not always be possible do not possess an ordered crystalline structure as do
to adapt real life. metals. Bertolotti (1997) described the reasons in detail
Mechanical fatigue of ceramics on the other hand, is why ceramic materials do not yield in the same manner
probably governed by several mechanisms which are as metals. Dislocations of a crystalline lattice do not
related to material properties including microstructure, exist in glassy materials and they have no mechanism
crack length and fracture thoughness, as well as to for yielding without fracture. Dislocations exist in crys-
applied stress intensity (Ban & Anusavice, 1990). Evans talline ceramic materials, but their mobility is severely
et al. (1990) indicated that every effort should be made limited. The energy required to do this is so large that
to minimize air entrapment between ceramic particles dislocations are essentially immobile in crystalline
as porosity does occur during ceramic application ceramic materials.
and can impair aesthetics as well as promote fracture. Stress direction is another contributory factor for
Properties of resin adhesives, cementation agents, failure as sometimes failure occurs at sites of relatively

2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 265269


268 M . O Z C A N

low local stress merely because there is a particularly the obviously substantial costs and the complex nature
large flaw oriented in a stress field which is ideal for of the restoration (Fan, 1991).
causing fractures. The possible sites from which failure The complexities of the oral environment and varied
may start were found to be highly unpredictable, since surface topography of dental restorations make it
this depends on flaw size and is related to the stress difficult to precisely define the magnitude and mode
distribution (White & Li, 1997). High biting forces, of stresses precipitating clinical fracture. The laboratory
destructive premature contacts and common beverages cannot reproduce intraoral variables and the complex-
with low pH ranges were reported to cause glass- ities of the oral environment. When the crowns are
containing dental restorations to break down (Anusavice cemented intraorally, factors other than inherent
& Zhang, 1998). Although these data appear to mechanical strength of the materials come into play.
document the importance of bite forces in failures, it Under continuous application of the mechanical envi-
is apparently not possible to quantify them during ronmental loads, progressive degradation may lead to
mastication. crack initiation and growth and ultimately to a cata-
The majority of the ceramic fractures were observed strophic failure of the restoration.
to occur during normal chewing function followed by Although failures of ceramic-fused-metal restorations
either trauma or some kinds of accidents being mostly in can be overcome by either some repair techniques or
the anterior region (Ozcan, 1999; Ozcan & Niedermeier, renewal of the restoration, it is beneficial to know the
2001). The findings of these studies clearly indicate that reasons for the failures, especially those because of
the reasons for ceramic failures might be also external iatrogenic or technical mistakes, which would help to
factors other than technical reasons in real life. increase the service time of such restorations.
Complications involving fixed partial dentures can
also occur during the pre-prosthetic preparation phase.
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2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 265269