Failures of Amalgam

Fracture of the Restoration

CAUSE
Too shallow cavity Too thick cavity liner Too thick cement base Inadequate cuspal reduction Thin Amalgam (over the cusp) Giving cavosurface bevel Sharp axio-pulpal line angle Sharp angles in occlusal outline form of Class II Stress Concentration (isthmus) Thin Amalgam

EFFECT

Failures of Amalgam
Fracture of the Restoration
CAUSE
Sloping gingival step Too narrow gingival step Insufficient Hg

EFFECT
No Resistance Form (isthmus)

Excess Hg
Undertrituration Moisture contamination (Zn having alloys)

Weak Amalgam

Delayed Expansion (flow over margins)

Failures of Amalgam
Fracture of the Restoration
CAUSE
Insufficient condensation pressure
Not squeezing out excess Hg Mix squeezed too dry Condensation of partially crystallized amalgam Overfilling Failure to warn patient not to chew on the restoration for first few hours Failure to support proximal part of the restoration while removing matrix band Early Strength Not High Enough Increased Residual Hg

EFFECT

Lack of Cohesion (amalgam weak) Thin Amalgam Over Margins

Failures of Amalgam
Fracture of the Tooth
CAUSE
Sharp angles in occlusal outline of Class II

EFFECT
Stress concentration

Excess removal of tooth structure

Enamel undermined and tooth weakened

Failures of Amalgam
Inadequate Retention
CAUSE
Absence of undercuts

EFFECT
No retention form

Dovetail with only one cornu

No resistance to dislodgement

Too thick liner that is lost subsequently

Lack of adaptation to cavity walls

Using large condensers initially

Undercuts and margins not filled - No retention

Failures of Amalgam
Marginal Leakage
CAUSE
Excess Sn (tin) in the alloy Overtrituration Excessive pestle pressure Failure to condense towards margins Using large condensers initially Carving from amalgam to tooth Excess amalgam left beyond cavosurface angles

EFFECT
Too much shrinkage Shrinkage on setting Slow setting with shrinkage Marginal gaps Deficient margins and undercuts Marginal defects and gaps Breaks away leaving deficient margins

Failures of Amalgam
Porous and Weak Amalgam
CAUSE
Increased 2 Phase (low Cu alloys) Irregularly shaped particles in the alloy Too less Hg

EFFECT
Weak phase Porosities and voids; less coherence of phases Same as above (Incomplete amalgamation; non-plastic) Increased residual Hg (Increased 2 Phase , decreased 1 Phase phases) Porosities & voids Decreased coherence (due to cracking of crystals) Porosities and voids Porosities and voids (increased residual Hg)

Too much Hg
Undertrituration Trituration beyond limits Delayed insertion after trituration Insertion of too large increments Decreased condensation pressure

Failures of Amalgam
Porous and Weak Amalgam
CAUSE
Moisture contamination Mix squeezed too dry Mix not squeezed (with high Hg:Alloy ratio) Condensation of partially crystallized amalgam Condensing with serrated pluggers with set amalgam in the serrations Overheating while polishing Burnishing set amalgam

EFFECT
Porous amalgam

Decreased coherence
Porosities and voids (increased residual Hg) Porous amalgam Old amalgam contaminates restoration and weakens it 'Burns' amalgam and releases H resulting in porosity Breaks up superficial crystalline structure releasing Hg causing porosity

Failures of Amalgam
Tarnish and Corrosion
CAUSE Alloy with excess 2 Phase EFFECT Has least resistance to corrosion

Fissures carved too deep

Failure to polish Contact with dissimilar metallic restoration

Food stagnation leading to tarnish and corrosion Rough surface causing crevicular corrosion
Galvanic corrosion

Failures of Amalgam
Gingivitis and Periodontitis
CAUSE No wedge used EFFECT Gross overhang; Contact area deficiency

Surface left high in bite

Failure to polish proximal surface Lack of proximal contact

High point causing periodontitis

Food stagnation resulting in gingivitis and periodonitis

Failures of Amalgam
Lack of Functional Efficiency
CAUSE Fissures carved too deep EFFECT

Underfilling
Failure to carve

Reduced masticatory efficiency Decreased masticatory efficiency (tooth anatomy not simulated)

Failures of Amalgam
Pain after Placing restoration
CAUSE
Failure to use liner and base Overfilling Moisture contamination Increased Hg: alloy ratio Failure to squeeze out excess Hg Inadequate condensation pressure Cavity preparation without water coolant

EFFECT
Thermal conduction High point causing periodontitis resulting in pain Delayed expansion with pressure on pulp Mercuroscopic expansion with pressure on pulp Mercuroscopic expansion (increased residual Hg)

Microscopic pulp exposure

Pulpitis resulting in pain

Failures of Amalgam
Tooth Discoloration
Sometimes, excess Hg within the restoration may seep through the dentinal tubules, discolor dentin and result in blackish or grayish staining of teeth.

Since enamel is semi- translucent, this discoloration is not inconspicuous.

Proportioning
most commonly carried out using volumetric dispensers or preproportioned capsules the advantages of the latter are: o that the dentist does not have to worry about getting the right ratio of alloy to mercury

(as this is prefixed by the manufacturer)

o that there is less danger of mercury spillage during the handling stages of amalgam placement unfortunately, the capsules are more expensive than buying the alloy powder in bulk

TRITURATION
adequate trituration is essential to ensure a plastic mix and thorough amalgamation trituration time needed is dependent upon both the type of alloy being used and the dispensing and mixing system

trituration times affect the dimensional changes that occur

when amalgam sets

CONDENSATION
most important demands on the condensation technique are: that as much excess mercury is removed as is possible that the final restoration will be non- porous that optimum marginal adaptation is achieved so as to prevent postoperative sensitivity important components in condensation are: the use of maximum force the use of suitably sized condensers in relation to cavity size the use of multiple and rapid thrusts the placement of small increments.

burnishing
more recent studies indicate that the overall effect of burnishing is to: increase surface hardness reduce porosity and decrease corrosion improve the marginal adaptation of the amalgam

Over filling, under filling, and over carving

if a cavity is overfilled and is not then carved back sufficiently to provide a smooth transition from the tooth surface to the restoration surface, a ledge will result

this ledge will eventually fracture, and give the appearance of marginal breakdown of the restoration

under filling or over carving can result in an acute amalgam margin angle that will give rise to marginal breakdown

Failures of Amalgam Restorations

Signs of Failures
Fracture Lines Marginal Ditching Proximal Overhangs Marginal Ridge Incompatibility Improper Proximal Contacts Recurrent Caries

Poor Anatomic Contours

Poor Occlusal Contact

Amalgam Blues

Amalgam Tattoo
accidental implantation of silver containing compounds into oral mucosal tissue occurs: removal of old amalgam broken pieces entering socket (tooth extraction) particles entering surgical wounds amalgam dust in oral fluids (abrasion areas)

Amalgam Tattoo
common sites: gingiva buccal mucosa alveolar mucosa

seen as grayish black pigmentation

Failures of g. i. c.
GlC sets within 6- 8 minutes from the start of mixing setting can be slowed when the cement is mixed on a cold slab this technique has an adverse effect on strength

conventional glass ionomer restorations are difficult to

manipulate as they are sensitive: to moisture imbibitions during the early setting reaction to desiccation as the materials begin to harden

Failures of g. i. c.
secondary or marginal caries most common failure of glass ionomer restorations 7 years median age of restoration failure for glass ionomer

Failures of composite resins

Undercured Composites
brighter light means deeper and faster curing of the composite many older lights are not bright enough to cure the full depth of a posterior composite filling can be solved by filling the tooth in thin increments and curing each increment thoroughly before placing the next increment

newer arc lights and laser curing units are so bright that they can cure to a greater depth quite quickly

Failures of composite resins

Undercured Composites
the tooth will remain sensitive for a very long time only solution for this problem is to remove the filling and replace it with a properly cured composite or an amalgam

Failures of composite resins

Shrinkage Stress
plastics tend to shrink when they transform from the liquid to the solid phase (similar to the way water tends to expand when frozen) microscopic shrinkage always happens

can cause the vertical walls of the preparation to be drawn together which can produce prolonged sensitivity to cold

Failures of composite resins

Shrinkage Stress
slicing a simple technique used to release the stress

the dentist cuts a vertical groove from the top of the filling to the floor of the preparation from mesial (front) to distal (back) through the filling this allows the cusps on either side to rebound relieving the stress
the groove is then refilled with composite and the filling is then as good as new

Failures of composite resins

Shrinkage Stress
the use of clear plastic matrix bands another way to avoid shrinkage away

from the walls of the prep

allows the curing light to be directed through the plastic from the side of the tooth

this would cause the composite to be drawn toward the cavity prep walls and eliminate the shrinkage away from them

Failures of composite resins

Shrinkage away from the Floor of the Cavity Preparation
composite tends to shrink toward the light since the light source is usually directed from the top of the tooth often causes the filling material to pull

away from the floor of the cavity preparation allowing a tiny void to form underneath the filling between the bottom of the filling and the tooth surface

Failures of composite resins

Shrinkage away from the Floor of the Cavity Preparation
the void eventually fills with fluid and can cause hydrostatic pressure in the dentinal tubules which leads to sensitivity to pressure on the filling

this is the most common reason for pain when

biting on a newly done composite filling only solution for this problem is to redo the filling

Failures of composite resins

Shrinkage away from the Floor of the Cavity Preparation
the dentist can often avoid this problem: o by placing the composite in increments that cover only part of the floor o by the use of a self curing glass ionomer

base used under the composite

Failures of composite resins

White line or halo around enamel margin (microfracture of marginal enamel)

Causes: 1. Traumatic contouring or finishing techniques 2. Inadequate etching and bonding of the area

Failures of composite resins

White line or halo around enamel margin (microfracture of marginal enamel)

Solution:
1. Re-etch, prime, and bond the area 2. Conservatively finishing techniques (light intermittent pressure)

Failures of composite resins

Voids

Causes:

1. Mixing of self cured composites 2. Spaces left between increments during insertion 3. Tacky composite pulling away from the preparation during insertion

Failures of composite resins

Voids

Potential Solutions: 1. More careful technique 2.Repair of marginal voids by preparing the area and re restoring

Failures of composite resins

Weak or missing proximal contact
Causes:

1. Inadequately contoured matrix band 2. Inadequate wedging, both preoperatively and during the composite insertion 3. Tacky composite pulling away from matrix contact area during insertion

Failures of composite resins

Weak or missing proximal contact

Solution: 1. Properly contour the matrix band 2.Have matrix in contact with adjacent tooth 3.Use firm insertion wedging technique

Failures of composite resins

Incorrect Shade
Cause:

1. Inappropriate operator lightning while selecting the shade 2. Selecting the shade after the tooth is dried 3. Shade tab not matching the actual composite shade 4. Wrong shade selected

Failures of composite resins

Incorrect Shade
Possible solutions:

1. Use natural light if possible 2. Select the shade before isolating the tooth 3. Preoperative place some of the selected shade on the tooth and cure (then remove) 4. Do not shine operating light directly on the area during shade selection