FAILURE OF RESTORATIONS

The restorative dentistry is provided with a wide range of materials to

choose from to restore any derangement of lesion in hard tooth substance.
These lesions include caries, erosion, attrition, traumatic fracture ,
discoloration as well as minor abnormalities in form, size alignment or
occlusion of teeth. In such cases, operative dentistry continues to be the
sole means for logical treatment.

Objectives of operative dentistry:

Operative dentistry comprises procedures whereby a preparation of
definite biomechanical and esthetic design features is provided in the
remaining hard tooth tissues to accommodate a restoration which is relied
upon to perform specific functions including:

I. Stop of the original insult of caries, erosion or attrition and

prevention of its recurrence. To achieve this goal:
 The preparation should have the correct outline form featuring
complete elimination of caries and retentive pits and fissures
establishing esthetic margins in sound smooth enamel which are
minimally (1/4 m) extending past the contacts.
 The restoration should be able to seal its interface with the
preparation hermetically to prevent marginal leakage, which
may cause recurrent caries, marginal discoloration and pulp
irritation. To achieve this purpose:
i. The restoration should be condensed against perfectly smooth, dry,
and clean enamel walls and margins.
ii.The restorative material must ideally wet and adhere to walls of the
preparation or properly condensed to effect maximum initial
adaptation to all walls of the preparation.
iii. The restoration should be free from dimensional changes on setting
and should not exhibit any differential dimensional change from
that of the tooth on thermal cycling.
iv. Restorative material should have adequate rigidity so that it does
not yield under force of mastication which will cause opening at the
margins.
v. The remaining tooth substance must be strong enough so that the
walls of the preparation do not open away from the restoration
when stressed under mastication force: overcutting should be
avoided.

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  Retention of bacterial plaque at the critical marginal areas of the
restorations should be inhibited. This necessitates elimination of
any retentive pits and fissures, marginal overhangs or crevices
and proper polishing of the restoration.

II. Restoration of comfortable and efficient mastication:

Lesions of hard tooth tissues may be detected and treated early, or
may be neglected until they inflict other influences such as dysfunction
because of pain, food impaction loss of normal interarch articulation and
lately disturbances in the tempromandibular joints.

Restoration of comfort and efficient mastication would mean

sedation of the pulp and dentin by elimination of caries and application of
necessary protective liners, bases or temporary restorations and finally
insertion of the permanent restoration which should be strong enough to
sustain the multiple forces of mastication without distortion, fractures, ear
or loss of smooth surface textures. This restoration should have the
normal harmonious occlusion without any prematurities. It must have
tight interproximal contacts of correct size form and location, and present
correct contours with deflective planes to avoid food impaction or
retention of bacterial plaque and to help massaging of the gingiva.

Teeth drifted because of loss of contact may need be moved slightly

back by immediate or slow separation before restoration of contact or
“plus contact”. The opposing plunger cusp must be ground down to
correct occlusion and smoothened.
The restorative material and procedures should be biocompatible
with dentin, pulp, gingival and periodontal tissues and should exert no
noxious effects either locally or systemically.

III. Restoration of esthetics:

The cosmetic appearance of the dentition depends on normal and
harmony of color, translucency, form surface texture and size of
individual teeth, their alignment in the dental arches and their occlusal
relationship during all jaw movements. These parameters must be strictly
observed and reproduced by the restoration.

Not only the restorative material but also the preparation itself
should be esthetic. Thus, cavity outlines should be very conservative and
run in even, smooth geometrical finishing lines parallel to corresponding
tooth surface or known land marks.

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Criteria of successful restoration:
In the light of the above-presented outline on objectives of operative
dentistry, the clinically successful restoration should satisfy such
objectives and should be durable, less costly and easy to do.

The criteria of a clinically successful restoration include:

1. Be an exact replica of the missing part of the tooth in size, form,
color, translucency and texture.
2. The margins of the restoration are flush with the tooth surface,
hermetically seal the preparation and remain free from any
recurrence of discoloration.
3. The restoration remains integral, securely retained in the
preparation and dimensionally stables.
4. The surrounding tissues are healthy and suffer no irritation.
5. The patient enjoys efficient and comfortable mastication and
occlusion. The restoration does not cause any discomfort on
thermal cycling, eating or drinking any food or drinks.

Success and failure of restorative work depends on many factors

which include:
1. The degree of involvement: The greater the derangement and the
longer the time it was neglected without treatment, the more
difficult it will be to achieve and maintain a success.
2. The skill of the operator including his working knowledge of the
demands for success visa-vis the nature of oral environment as well
as the properties and limitations of existing restorative materials
and techniques. The operator must have thorough knowledge of all
factors which will affect or get affected by his choice of material
(or combination of materials), plane of treatment and execution of
the restorative procedures.
3. The restorative materials and techniques employed: These should
always be of the certified modern quality products since a
restoration can never be better than the material from which it was
constructed

The situation:
The“ ideal of tall purpose” restorative is not yet developed
consequentgly, success and failure will depend largely upon.
1. The skill of the operator in selecting the most appropriate
restorative for each individual case.

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 2. His scientific knowledge and meticulous attention to details of
manipulation.
3. His ability to establish a cavity or foundation which complements
physical properties of the selected restorative. In other words,
success and of restorations is attributed to:
4. Misselection of the restorative material.
5. Wrong cavity preparation.
6. Faulty material manipulation.

I. Misjudgment in selection of the restorative:

Selection of the appropriate restorative, which meets most of the
demands of an individual case, is a pertinent factor for success of the
clinical restorations. This selection should be based on logical and
thorough analysis of al variables including properties of available
restoratives, the demands and limitations of the oral environment and the
past experience of the operator.

As an example, both amalgam and gold serve satisfactorily as

individual restorations but if both are used in the same mouth failure by
excessive tarnish and corrosion, possible patient discomfort due to
galvanic activities and shocks of pain may be inevitable. Similarly, the
use of permanent restorations for treatment of rampant caries is
considered to be inappropriate because failure by recurrent caries is
almost certain. Instead, caries should be thoroughly excavated and a
temporary restoration, preferably fluoride-emitting cement is placed until
after the period of acte involvement is over when the suitable permanent
restorative is made.

II. Cavity preparation:

The design of preparation furnishes the foundation in which the
restoration is established. It has a decided influence on the mechanical
integrity of both the tooth and restoration, the stability of the restoration,
the post restorative biological influences of the restoration on the dentin
and pulp and the health of the remaining tooth substance. It also has an
important effect on esthetics. More than 60% of failure may be due to
improper cavity preparation.

The stress response in both the tooth and restoration is largely a

function of the cavity design, which can convert a compressive force into
a destructive tensile or shear components; e.g., if inclined instead of
vertical floors were provided.

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 The cavity design should complement the physical properties of the
restorative employed and, consequently should incorporate essential
features, which are in accord with the properties of the particular
restorative.

III. Material manipulation:

Incorrect material manipulation is responsible for about 40% of
failure of clinical restorations. Manipulation of restoratives include
several procedures each of which involves known variables. Unless such
variables are sell controlled the physical properties of the final restoration
will be unfavorably affected. The effect may be more with certain
materials which are known to be more sensitive to manipulative variables.
Therefore, meticulous attention for details of material manipulation is
mandatory for obtaining of consistently successful restorations.

IV. The nature of oral environment:

It should be appreciated that oral environment present rigid
limitations and constitutes a challenge to the operative dentist because of
its destructive nature to restorations. Thus, access is very limited, the
demands are both multiple and intricate, the atmosphere is corrosive,
aqueous, full of microbes, multiple forces, wide ranges of temperatures
and pH fluctuations high staining propensity as well as other influences.

1. Accessibility:
Access to the operative field presents a difficult problem. The
operative dentist has to introduce his hands suction mechanisms and
instruments into a very limited area of the mouth which is very
constrained by the tongue, cheeks and teeth of the opposite arch. Under
these circumstances, he has to prepare designs of highly refined
engineering features and definitely directed walls, use instruments of high
cutting potentials and avoid any slight damage to hard or soft tooth
tissues.

2. The demands:
The need to replace missing enamel and dentin in a restorative
material and get exactly the same biomechanical and esthetic properties
of both tissues combined, regardless of bulk limitations is too difficult to
achieve because of the great differences in properties and variations in
architectural design.

3. The corrosive potentials:

The saliva with its salt content a good electrolyte. The warm
atmosphere activates any oxidation, reduction or sulfurization of metallic
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restorations specially those of non-homogenous structures as amalgam.
The accumulation of bacterial plaque at the gingival area of teeth causes
variations in concentration of electrolyte as compared with that at the
occlusal surface of restorations thus favoring concentration cell corrosion.
At the depth of a crevice e.g., at the restoration tooth interface, oxygen
tension will be different from that at the surface of restoration, and this
creates corrosion cells.

The presence of any dissimilarity in composition, surface condition,

stressing, pH, or metallic structure, forms galvanic cells and favors
corrosion.

4. The aqueous nature:

Saliva in the mouth creates problems for the restorative dentist who
has to work hard to eliminate it from the operative field through
application of rubber dam, use of suction and cotton rolls as well as to
seed up the condensation procedures because it adversely affect all
restorations.

Moisture contamination of amalgam causes an electrolytic corrosion

reaction which results in great loss of strength, delayed expansion and
excessive corrosion of the clinical restoration.

Moisture contamination of cements during their manipulation and

setting results in great loss of strength, increased solubility and loss of
translucency.

Resin restoratives will lose adaptation and retention to etched enamel

walls if moisture intervenes at the interface. Moreover, the clinical
restoration is subject to variable degrees of water sorption in the mouth,
which may cause discoloration or distortion.

Cavity liners, varnishes or cement bases require thoroughly dry

cavities in order to be satisfactorily applied and retained.

Saliva cause dissolution of some restorative materials, especially

cements which dissolves more in acidic pHs, e.g., at gingival areas where
bacterial plaque collects more and cause fermentation reactions and acid
production. This favors caries recurrence.

Of especial significance is the dissolution of luting cements under

cast restorations, which is a basic reason for caries recurrence under such

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restorations. Dissolution of cement restorations increases their surface
roughness at adversely affects their esthetic appearance.

5. Thermal changes:
Fluctuations in temperature are a common occurrence in the mouth.
Thermal cycling of restorations and tooth results in variable degrees of
differential expansion and contraction which can cause corresponding
degrees of marginal percolation and gross leakage depending on the
relative difference in coefficient of thermal expansion of the restorative
material from that for the enamel and dentin. It also induces residual
stresses which destroy any bond obtained between the tooth and
restoration.

Metallic restorations transmit thermal stimuli to the underlying dentin

and pulp which may cause discomfort or elicit pain response particularly
during the early period following insertion of restoration. Unless
installed, the pulp may be irritated.

Although thermal expansion is doubted to cause better peripheral seal,

yet contraction will surely bring about gross leakage.

6. The oral microbes:

Although the oral cavity contains many different types of bacteria, the
oral flora, yet the restorative dentist is specifically concerned of those
types, which are associated with the initiation or recurrence of caries.

In the presence of saliva, bacteria in dental plaque rapidly metabolize

and cause decalcification of enamel and initiation or recurrence of caries.
Consequently, factors, which favor retention of bacterial plaque, will
make caries recurrence more likely. Such factors include remaining pits
and fissures, the high surface energy of available restorative specially if
left without proper polishing, the presence of marginal overhangs or
crevices, open interproximal contacts, crowding and abnormal occlusal
relationship of teeth, in addition, to the main factor of poor oral hygiene.
Increased salivary viscosity and decreased salivary flow also favor
accumulation and retention of bacterial plaque.

The presence of bacteria under restorations was once thought to be a

potential cause for caries recurrence and recommendations were given of
the necessity to eliminate it by cavity sterilization prior to insertion of
restorations. This procedure, however, was discouraged because it was
found that bacteria under properly adapted restorations would either die

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or remain dormant. Moreover, available sterilizing agents are either non
effective and/or injurious to the pulp.

In the light of available information, the possibility for caries

recurrence remains to be a problem in the presence of bacterial plaque as
long as factors of its accumulation and retention exist.

7. Forces in the mouth:

Restorations are subject to mastication forces of multiple types
including the compressive, the tensile and shear, static and dynamic,
which occur in repetitive cycles. These biting forces vary in magnitude
from one individual to another and at different areas of the same mouth. It
ranges between 9-25 kg. (20-55P) at the incisor, 14-34 kg. (30-75P) at
cuspids, 23-46 kg (50-100P) at the bicuspid and 77 kg (170P) at the molar
areas.

These forces induce in the restoration and the tooth, stresses of

corresponding type and magnitude. As a result:
1. Both the tooth and the restoration may absorb the stresses
elastically without any unfavorable response.
2. The restoration may creep or deform if the forces are just sufficient
to induce that distortion, the warmth in the oral cavity enhances
this deformation.
3. The cavity walls may yield elastically allowing gross marginal
leakage if the stresses are within the elastic limits of the remaining
little thickness of the dentin walls associated with over cutting of
cavities.
4. The cavity walls may fracture if the stresses surpass the
corresponding strength of the stressed cavity wall.
5. The whole restoration may get dislodged out of the preparation if
the stresses surpass the retentive capacity of the preparation.
6. Portion, usually the auxiliary of the compound restoration may get
fractured if the stresses surpass both the retentive capacity of the
auxiliary preparation and the tensile or shear strength of the
restorative material, usually a brittle one.

The development of unfavorable stress response in the tooth and/or the

restoration constitutes a critical problem to the restorative dentist because:
1. The exact magnitude of mastication forces cannot be
predetermined, and therefore, the resulting stresses can never be
exactly predicted.

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 2. Most of the induced stresses are shear or tensile which are
deleterious to the brittle substances.
3. Most of the materials the operative dentist deals with are brittle and
have low tensile and still lower shear strength values.

To compensate, at least partly, for this inherent limitation, strict

engineering principles of resistance and retention should be meticulously
incorporated in the preparation. This may require additional sacrifice of
healthy hard tooth structure, embedding in the restoration or dentin of
certain metallic inserts to supplement retention and/or to reinforce the
restoration. If other words, the increase in the strength of the restoration is
done at the expense of the tooth.

Furthermore, the forces are repetitive in cycles, which may easily

initiate fatigue failure. The presence of any surface or structural
discontinuity will concentrate the stresses and initiate or propagate a
crack causing gross fracture.

Moreover, impact forces and induced impact stresses may easily cause
chip fracture of brittle materials especially at thin margins. Again impact
strength can similarly be improved at the expense of tooth substance
and/or the esthetic appearance of the restoration through provision for
more bulk of materials.

The surfaces of restorations are exposed to excessive wear in the

mouth. Materials which have low wear resistance will develop greater
surface roughness, and more significantly open interproximal contact.
These forces or loads induce in the restoration corresponding magnitudes
and types of stresses.
These stresses:
a. May surpass the retentive capacity of the preparation and cause
dislodgment of the whole restoration.
b. May surpass both the retentive capacity of the preparation and the
strength (force/area) of the restoration causing its fracture

FAILURE MANIFESTATIONS OF CONTEMPORARY

RESTORATIONS
FAILURE OF AMALGAM RESTORATIONS

1. Marginal degradation
Definition:
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 Marginal degradation, ditching, fracture or crevicing refers to
breakage of a thin edge of a restoration creating an irregular V-shaped
crevice.
Causes:
1) Depletion of support at margins:
 Amalgam is a brittle material with low tensile and shear strength so; it
must be supported by tooth structure.
 Lack of support may be due to: Excessive expansion resulted from:
- Under trituration
- Excess mercury.
- Moisture contamination.
- Age dependent changes in the microstructure.
a. Creep: Time dependent change in the form of amalgam under
constant loads and temperature.
N.B.: High copper amalgam shows lower creep values than
low copper amalgam.
b. Crevicular anodic corrosion: Crevice corrosion of amalgam
may be associated with marginal discrepancies and
development of dissimilar oxygen tension.
2) Insufficient bulk at margins:
 Strength of amalgam is essentially thickness dependent as it is a
brittle material with low tensile and shear strength.
 Lack of bulk may be due to:
1. Beveling of CSA.
2. Over carving.
3. Leaving thin marginal flashes.
3) Voids:
 Voids in amalgam produces a decrease in density and strength of
amalgam accelerating its fracture by stress concentration.
 Voids may be resulted from:
1. Inadequate condensation force.
2. Too dry amalgam mix.
3. Moisture contamination of zinc containing amalgam.
4. Corrosion.
4) Excess mercury:
 Excess mercury tends to lower the strength of amalgam.
 Excess mercury may be due to:
1. Wrong proportioning of alloy / mercury ratio.
2. Under trituration and squeezing.
3. Inadequate condensation force.
4. Burnishing of amalgam at margins.
Clinical picture:

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 All cavity margins are prone to ditching especially buccal end of
proximal marginal ridge because:
1. It is subjected to beveling.
2. Trapping of mercury.
3. Inadequate condensation.
 Isthmus outline especially buccal wall of lower first molars are more
common sites for marginal ditching so, this walls should be made in
the form of reverse curve to provide CSA 90.
Treatment:
 Protection against marginal fracture by:
1. Following biomechanical principles of cavity design.
2. Proper selection of the alloy.
3. Proper manipulation of the material.
 The actual treatment depends on the extent of ditching and presence
of other sorts of ditching:
1. Very small ditching : Resurfacing with plug finishing
bur.
2. Moderate ditching Repair with cermet cement or
amalgam, using adhesive amalgam bond.
3. Gross ditching : Total replacement of the restoration is
indicated.

2. Isthmus fracture
Definition:
 Isthmus: It is the narrowest junction between the principle portion
(occlusal) and the auxiliary portion (buccal, lingual or proximal).
 Isthmus fracture: A fracture of compound amalgam restoration at the
junction between the principle portion and the auxiliary portion of the
cavity.
Causes:
 It is a must to have a state of balance between the flexural stresses at
the isthmus area and the flexural strength of the amalgam at the same
area.
 So, the causes or factors attributed to isthmus fracture may be:
a) Factors that increase flexural stresses:
1. Incorrect resistance and inadequate retention.

2. Excessive occlusal forces.

3. Surface and structural discontinuities.

1. Incorrect resistance and inadequate retention:

 Masticatory forces may easily break compound restorations, which
are not adequately and independently retained.
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 So, the restoration should have adequate correct resistance in the form
of:
1. Flat pulpal floor and gingival floor perpendicular to the direction of
force.
2. Walls parallel to the direction of masticatory force.
3. CSA 90.
 The less effective the proximal retention the higher the tensile stresses
developed at the isthmus and the greater the tendency for isthmus
fracture.
 The forms of proximal retention may be:
1. Proximal axial grooves.
2. Increased condensation to increase density, adaptation and strength
of the restoration.
3. Using effective adhesive system.
 If the remaining amount of tooth structure is not enough to provide
sufficient retention for proximal portion, the following alternatives
may be done: →
1. Change to cast restorations as they have high tensile strength.
2. Use of suitable shaped and strong metallic inserts that are
embedded in the amalgam at the isthmus and parallel to the occlusal
plane.
Adhesive systems may be used to enhance the amalgam bond to both
the tooth and the metallic inserts.
The metallic inserts act to:
A. Increase anchorage.
B. Eliminate excessive flexural stresses.
C. Share in load carrying ability.
3. Use of threaded pins or amalgapins to supplement proximal
retention.
2. Excessive occlusal forces:
 As a result of:
i) Presence of premature contact due to:
A. Under carving of the marginal ridge.
B. Misplacement of marginal ridge.
C. Sudden biting on a hard object.
D. Presence of protruded or over erupted opposing plunger cusp.
ii) Biting on amalgam before sufficient setting.
3. Surface and structural discontinuities:
 As a result of:
i) Poor polishing leaving the surface rough and full of pits and
scratches.
ii) Over carving into deep grooves not only creates stresses, but also
weakens the restoration by decreasing its bulk.
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 iii) Presence of internal voids due to corrosionmoisture contamination,
too dry amalgam mix.Lack of forceful condensation.

b) Factors that decrease flexural strength:

1. Insufficient bulk of amalgam.
2. Excess mercury.
3. Structural discontinuities.
1. Insufficient bulk of the amalgam:
 Amalgam is a brittle material with low tensile and shear strength,
which needs bulk of at least 1.5-2 mm to have sufficient flexural
strength.
 Insufficient bulk may be due to: Over carving , and decreased cavity
depth.
2. Excess mercury:
 It lowers the strength of amalgam as it decreases the amount of ()
phase which provides the strength and increases (2 ) phase which is
the weakest phase.
3. Structural discontinuities:
 Due to: Corrosion, moisture contamination, dry mix, lack of
condensation forces.
Clinical picture:
 It starts as crack line propagates and widens with mastication force
then fracture occurs.
 Hypersensitivity with eating and drinking.
 Food impaction and recurrent caries.
 Periodontal irritation.
Complications:
 Recurrent caries.
 Tooth fracture.
 Periodontal irritation.
Treatment:
1. Search for the cause of fracture.
2. Improve resistance and retention forms.
3. Removal of any surface discontinuity.
4. Selective grinding of opposing plunger cusp.
5. Increase bulk of amalgam at the isthmus area by: Rounding, beveling
or saucering the axio-pulpal line angle and inclination of the axial wall.
6. Proper handling and manipulation of amalgam restoration.
7. Application of adhesive amalgam bond or metallic inserts.
 N.B. : Remake of amalgam is preferable than repair due to:
1. Repair will not allow correcting the cavity preparation.
2. Lack of bond between the old and new amalgam.
3. Corrosion between old and new amalgam.
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3. Tooth fracture
Definition:
 Fractured cusp or ridge under functional forces due to lack of support
and reinforcement.
Causes:
 Amalgam lacks sufficient tensile strength to support remaining tooth
substance and much less able to re-inforce weak cusps and ridges.
Treatment:
 Eliminate all undermined enamel as well as weak cusps and ridges.
 Preserve the integrity and continuity of the remaining tooth substance.
 Roundation of line angles.
 Ensure wide distribution of stresses.
 Reinforce weak cusps and ridges using inlays, onlays or full coverage.

4. Recurrent caries
Definition:
 Caries developed in a previously restored tooth.
Causes:
1) Incomplete elimination of the original lesion:
 Improper excavation of caries.
 Improper evaluation of the case for indirect pulp capping.
2) Improper outline form:
 Under extended:
Leaving defective and retentive pits and fissure.
Incomplete freeing of the contact.
Margins of the cavity will not be placed in self-cleansable areas.
Leaving undermined enamel .
 Over extended: The cavity margins will be placed in areas of stresses
3) Improper restoration of anatomy:
 Lack of adaptation due to: Marginal leakage, lack of condensation,
moisture contamination and the use of dry amalgam mix.
 Failure to restore anatomy, contact and contour leading to food
collection and recurrent caries .
 Improper finishing of restoration: due to over hanged margins,and
rough amalgam surface.
4) Retention and colonization of bacterial plaque:
 Remaining retentive pits and fissures.
 Unpolished rough restoration surface.
 Marginal over hangs.
 Open interproximal contact.

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 Presence of cracks or fracture , e.g. marginal ditching or isthmus
fracture.
 Bad oral hygiene.
Clinical picture:
 It is manifested as:
1. Caries extension : Under the restoration at the cavity floor.
2. Caries invitation : At margins which are defective.
Complications:
1. Pulpal irritation.
2. Periodontal irritation.
3. Displacement of restoration.
4. Tooth fracture.
Treatment:
 Prevention:
1. Adequate cavity extension.
2. Conservative treatment of non-carious pits and fissures by
enameloplasty, cavity walls slanting or sealing with GIC or adhesive
bond.
 Management:
1. Replacement of restoration, removal of caries, correction of cavity
design and proper manipulation of new restoration.
2. Marginal defects can be repaired with amalgam, bonded amalgam or
glass ionomer cermet cement.

5. Excessive discoloration
Definitions:
 Tarnish: Surface discoloration of amalgam with loss of its luster.
 Corrosion: Actual disintegration of the bulk of amalgam.
 Amalgam blues: The amalgam shown through enamel.
Causes:
i) Tarnish:
 Formation of a surface film of discoloring oxides and sulfides.
 This is enhanced by: Excess Hg, under trituration, improper
condensation, Lack of finishing, moisture contamination, and bad oral
hygiene.
ii) Corrosion:
1. Chemical corrosion: due to Lack of polishing and food stagnation
which may lead to halogenation and sulferization.
2. Electric corrosion: Setting of electromotive force between two
different electrodes of different electric potential through an
electrolyte.
This occurs between:
Two dissimilar metallic restorations,
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 A. Old and new similar metallic restoration.
B. Polished and unpolished areas of the same restoration.
C. The same restoration but heterogeneous in structure.
3. Concentration cell corrosion: It is a type of electric corrosion resulting
from accumulation of certain types of food on a site of restoration
making it different in its electric potential from other sites of
amalgam.
- It is increased with rough surfaced amalgam and bad oral hygiene.
c) Amalgam blues:
It is mainly due to:
 Thin or undermined enamel that shows dark blue discoloration of
amalgam.
 Penetration of metallic ions and corrosive products of amalgam
through the dentinal tubules.
Clinical picture:
1. Tarnish: Loss of surface luster.
2. Corrosion: Rough pitted amalgam surface.
3. Amalgam blues:: Dark bluish discoloration.
Treatment:
1. Tarnish requires re-polishing.
2. Corrosion may require removal of old restoration followed by
bleaching and correct replacement.

6. Post-restoration hypersensitivity

Causes:
 Hypersensitivity in a recently amalgam restored tooth may be
generated by stimulation of freshly exposed permeable virgin dentin
surface by: →
1. Galvanic: Stimuli generated on immediate contact with
opposing dissimilar metals.
2. Thermal: Thermal stresses conducted through large non-
isolated metallic restorations.
3. Chemical and osmotic: Stimuli by osmotic fluids that
penetrate through leakage, hairy crack or fracture in the
tooth or restoration.
4. Tactile: Pressure of premature contact.

Clinical picture:
 Pain occurring days or weeks after insertion of a restoration mostly
indicates microbial pulp involvement following frank or microscopic
exposure.

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 If it occurs on thermal stimulation and continues long after removal of
stimulus, it suggests pulp pathology after exposure.
 Pain on cold application indicates pulpitis.
 If it results from biting, it suggests periodontal involvement.
 Dull aching pain several days after insertion of restoration may be due
to delayed expansion of amalgam after moisture contamination of zinc
containing amalgam.
Treatment:
1. Prevention by dentin desensitization with cavity varnishes
liners/basses.
2. Inhibition of leakage.
3. Elimination of occlusal interference and pre-mature contacts.

7. Gingival and periodontal affections

Causes:
1. Gingival overhangs.
2. Thick subgingival margin of the restoration.
3. Ragged cavity margins.
4. Rough restoration margins.
5. Severing the epithelial attachment by overzealous preparation of
gingival or subgingival walls.
6. Improper selection of the matrix band and wedges.
7. Food impaction due to open contacts, wrong contouring,
disharmonies in height, size or contour of proximal marginal ridges,
or incorrect embrasures.
Clinical picture:
 Gingival and periodontal inflammation with increased bleeding
tendency.
 Discomfort.
 Tooth mobility.
Treatment:
 Defining and removal of the cause.

8. Dislodgment of restorations
Causes:
1. Inadequacy of the retention mechanism.
2. Fracture of the restoration.
3. Fracture of the tooth.
4. Recurrent caries.
Clinical picture:
 Totally dislodged restoration.
 It may show rocking.
Treatment:
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 Evaluation of the retention followed by replacing the restoration.

FAILURE OF CAST RESTORATIONS

 Clinical manifestations of cast restoration failures may be in the form
of:
1. Recurrent caries.
2. Dislodgment of restoration.
1. Recurrent caries
Causes:
1) Fitting discrepancies:
 Distortion of impression, dies or wax pattern.
 Incorrect compensation of casting shrinkage leading to under or over
sized restoration.
 Roughness of the fitting surface.
 Modifications by grinding.
2) Poor cement or cementation:
 High solubility.
 Low strength.
 Thick consistency.
 Moisture contamination.
 Using old mix starting setting.
3) Under extension of cavity outline:
 This may leave defective carious enamel or retentive pits and fissures.
 Improper placement of the cavity margins in area self-cleansable.
4) Stagnation of bacterial plaque:
 Due to lack of polish.
 Presence of marginal overhangs.
 Poor oral hygiene.
Treatment:
 Evaluation of the cause followed by remake of the restoration.

2. Dislodgment of restoration
Causes:
 This may be due to:
1. Inadequate mechanical retention due to over divergence of the cavity
walls.
2. Recurrent caries.
3. Poor cementation.
4. Excessive torque by occlusal interference.
5. Breaking of the cement interlocks by injudicious finishing or
premature loading of the restoration.
Treatment:
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 Evaluation of the cause and remake of the restoration if needed.

FAILURE OF GLASS IONOMER CEMENTS

 Failure of glass ionomer cements may be clinically manifested as:
1. Increased opacity or discoloration.
2. Loss or dislodgment of restorations.

1) Increased opacity or discoloration:

 It may be attributed to: Development of cracks and porosity as a result
of setting contraction stresses.
1. Dehydration with biodegradation by oral fluids.
2. Incorporation of air voids during mixing.
3. Inadequate amount of powder.
4. Injudicious finishing.
5. Poor oral hygiene.

2) Loss or dislodgment of restoration:

1. Moisture contamination during packing of restoration.
2. The use of incorrect consistency that results from wrong
powder/liquid ratio.
3. Premature setting that results in weak bonding and retention of the
restoration.

FAILURE OF COMPOSITE RESIN RESTORATIONS

1. Post-restorative tooth hypersensitivity

Causes:
 Dentin hypersensitivity is more frequently experienced with
composite particularly those in class 11 cavities and V cavities as a
result of:
1. Leakage, as has been explained
2. These dentin walls are usually not covered by cavity liners, difficult
for bonding and application of composite, bathed in fluids of low pH,
and are closer to the pulp.
3. Cusp deflection by polymerization shrinkage stresses.

Clinical picture:
 Hypersensitivity is characteristically manifested as: Sharp, transient,
and localizable sensation of exaggerated discomfort on drinking or
food chewing.
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 The response is evoked by non-noxious tactile, osmotic, thermal, or
evaporative low-intensity stimuli.
Treatment:
 Remake with proper bonding and adhesion to enamel and dentin.

2. Recurrent caries
Causes:
 Recurrent caries results from penetration and colonization of bacterial
plaque between the tooth and restorations as a result of:
1. Marginal leakage.
2. Polymerization shrinkage.
3. Rough restoration surface due to low wear resistance of the material.
Clinical picture and treatment:
 If catching discrepancies are identified in a composite restoration
caries recurrence must be expected, and the restoration must be
considered for replacement.
 Treatment involves replacement of the restoration after thorough
tracing and elimination of the carious lesion.

3. Cyto-toxic pulp reactions

Causes:
 Irreversible pulp reactions occur more frequently under composite
resin restorations that may be due to: Acid etching and material
compositional constituents, i.e. a chemical etiology.
1. Bacterial invasion associated with leakage, i.e. a bacterial etiology.
Clinical picture:
 This is accompanied by signs and symptoms of irreversible
inflammation.
 They do not occur immediately after placement of the fresh
restoration but they are rather clinically manifested later with aging,
parallel to the time-dependent increase in leakage.
 No such influences have been clinically reported with adequately
sealed composite restorations.
Treatment:
 The restoration must be removed and the tooth examined carefully for
caries recurrence and pulp involvement.

4. Discoloration
Causes:
1) Incorrect color determination:
 Due to poor illumination, use of a wrong light source, as well as
operator's eye problems.
 Good illumination by a neutral light source must be utilized.
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 Use of mocks of composite that are cured to unetched tooth surface
help determination of correct color.

2) Marginal discoloration:
1. Gross marginal leakage of environmental fluids and smoke stains.
2. Poor application of bonding systems.
3. Moisture contamination.
4. Excessive thinning out of margins, premature polishing or
overheating, may cause crevicing or pull of margins away from the
preparation with subsequent marginal discoloration.
5. Softening of composite due to hydrolytic instability, and degradation
increases their tendency to marginal discoloration especially at the
gingival margins where local acidity tends to increase.

3) Surface discoloration:
 It is largely a function of the surface roughness of the restoration.
 The rougher the surface the more dull it appears, and the greater is its
tendency to retain food and smoke stains and get discolored.
1. Low wear resistance.
2. Surface and subsurface porosity due to inadvertent polishing.
3. Voids trapped by injudicious mixing or application of composite.
4. Moisture contamination.
5. Soft spots due to air-inhibited polymerization may roughen and
soften the surface and thus accelerate discoloration.
6. Bio-degradation or gradual material breakdown by complex biologic
activities in the mouth including oral fluids, food constituents,
bacteria metabolic activities, and food chewing.

4) Bulk discoloration:
1. Chemical shift in peroxide-amine-cured resins on long exposure to
UV light.
2. Excessive porosity is a most common attribute for bulk discoloration
→ thus, trapped air voids with resulting "spongy spots" cause
unfavorable changes of optical characteristics.
3. Sorption of stain precursors in association with water sorption.

Prevention:
1. Elimination of all caries and undermined enamel.
2. Correct color determination with active decision-share of the patient.
3. Contaminants must be completely avoided.
4. Improving of oral hygiene and emphasis on routine check-up.
5. Standardization of the application technique.
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Treatment:
 It essentially depends on the extent of discoloration and generally
ranges between resurfacing and total replacement.
 Slight marginal discoloration, if not complicated by any caries
recurrence may be repaired in the same shade composite, employing
the AET following careful grinding down of the defective area of the
restoration and tooth.
 If careful examination reveals presence of caries, this should first be
eliminated and the restoration remade.
 Surface discoloration may be limited, and preferably eliminated by
proper polishing.
 If it is deep or involves the bulk of restoration total replacement or
veneering would be indicated.
 Veneers of adequate thickness may be required to mask the defect.
 Again, the discolored portion is uniformly cut with a suitable size
carbide round bur, the cut surface cleaned, washed, etched for
additional cleaning, bonded, and restored.

5. Dislodgment of restorations
Causes:
1. Deficient peripheral attachment to the tooth.
2. Excessive tipping functional or para-functional forces.
Treatment:
 Total replacement with re-assessment and improving the retention
mechanism.
 The use of glass-ionomer cavity liners/bases, incorporation of grooves
in dentin walls that are devoid of sufficiently thick enamel,
modification of the preparation and technique of application, and the
use of improved dentin adhesive systems must be considered.
 Occlusion must be adjusted, prematurities and interferences
eliminated and abnormal biting habits corrected.

6. Marginal chipping
Causes:
 Similar to other brittle restoratives, margins of composite resin
restorations especially those at stress-bearing areas are commonly
vulnerable to fracture with formation of marginal crevices.
 This may be due to:
1. Thinning out of these margins due to beveling of the underlying
cave-surface angle, over carving, inadvertent finishing and
inadequate curing weaken these margins and accelerate crevicing.

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2. Contamination of subgingival margins with tissue fluids inhibits
adequate polymerization and weakens the margins and increases their
tendency to breakage with formation of gingival crevices.

Treatment:
 Treatment involves repair of existing restoration employing the acid-
etch and bond technique.

7. Gross fracture

Causes:
 Composite is a brittle restorative with low flexure strength.
 Consequently, flexure fracture at the isthmus of compound
restorations is likely.
 Similar to amalgam, isthmus fracture may occur as a result of
unfavorable tipping in the balance between flexure strength of
composite and the flexure stresses developed at the isthmus area.

1) Excessive flexure stresses:

 may be induced as a result of:
1. Premature contact.
2. Sudden biting on a hard object
3. Inadequate retention of the auxiliary portion of compound
restorations.
4. Presence of structural or surface discontinuities in the form of
internal voids.

2) Low flexure strength:

 may result from:
1. Inadequate conversion.
2. Internal voids due to incremental condensation or air-inhibited
polymerization.
3. Moisture contamination.
4. Low filler content.
5. Material bio-degradation.

Treatment:
 Total replacement is usually preferable to repair of isthmus fractures,
at least to check for caries recurrence.

8. Biodegradation
Causes:

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 This refers to a process of gradual material break-down mediated by
specific oral environmental biologic activities.
 It includes disintegration and dissolution in saliva, as well as other
types of chemical/physical degradation such as wear and erosion
caused by food constituents, food chewing, and metabolic by-products
of plaque bacteria.
 It also includes discoloration, and fracture.
 Bio-degradation may significantly be accelerated with the increase in
available hydronium ions (H-), i.e., increase of acidity, e.g., at areas of
poor oral hygiene.
Complications:
 Degradation specifically results in:
1. Accelerated surface wear with opening of inter-proximal contact and
food impaction, loss of anatomy and occlusal relationship.
2. Marked loss in strength as a result of weakening of bonds and stress-
concentration by the cracks and porosity.
3. Increase in surface roughness and discoloration tendency.
Treatment:
 Replacement of the restoration.
 Efforts of all professionals in restorative dentistry have been centered
at improving of material and application techniques with hopes to
achieve effective control of leakage and wear.

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