Biologic

Failures

CLINICAL
FAILURES

Mechanical
Esthetic Failures
Failures
 CLINICAL FAILURES

Clinical failures can be divided into biologic failures, mechanical

failures and esthetic failures.

Biologic Failures:

Caries:
It is one of the most common failures encountered. This could
occur due to variety of causes. It is usually secondary caries that occurs
under the crowns or on the margins of the crowns. The extent of caries
may be minimal or sometimes it involves the pulp.
Causes of caries could be due to -
1. Caries prone mouth
2. Improper margin placement
3. Food lodgment in the proximal areas leading to periodontal breakdown
as well as cementation breakdown and resultant caries.
Caries can be detected using radiographs. If the extent of the
lesion is small it can be removed and filled with amalgam restoration. If
the pulpal involvement has occurred root canal treatment is carried out
and then the crown is replaced or if required a new crown is fabricated.
A through examination of the oral cavity and history of the patient
can avoid this problem. Patients with high caries susceptibility and-
patients with past history of developing carious lesions around
restorations, meticulous oral hygiene should be asked to maintain.
Adjunctive measures like fluoride containing dentifrice’s, flouridated mouth
rinses etc. can be used. Fluoride containing cements can be used for
cementing the restoration.

Pulpal degeneration:
Post insertion pulpal sensitivity on abutment teeth that does not
subside with time, intense pain or periapical abnormalities that is detected
radiographically. This may be due to deep caries, over reduction of the
tooth, use of non-biocompatible cements. The treatment is of root canal
treatment. This can be treated by opening an access through the crown
and after the treatment is over the access cavity and the crown cavity can
be restored using silver amalgam or composites. If the tooth structure is
not adequate and the carious destruction has weakened the tooth
structure cast post core restoration can be thought about.

Periodontal breakdown:
It is also one of the most common failure we come across. Variety
of reasons can be attributed for this:
1. Poor maintenance of oral hygiene by the patients
2. Improper crown fabrication
3. Already existing periodontal condition before prosthesis has been
cemented.
4. Any associated systemic conditions
It can produce extensive bone loss that in time results in the loss of
abutment. Less severe breakdown can be treated.

Aspects of the prosthesis that interfere with effective plaque control are:
1. Poor marginal adaptation
2. Overcontouring of axial surfaces
3. Excessively large connectors that restrict cervical embrasure spaces.
4. Improper pontic fabrication
5. Improperly finished and polished restoration.

Occlusal problems:
Interfering centric or eccentric occlusal contacts can cause
excessive tooth mobility. If this is detected early, the interference’s can be
eliminated, however if this persists it will weaken the tooth periodontally.
In some cases it can also cause pulpal damage. Neuromuscular
discomfort related to improper occlusion can result in prosthesis failure
since occlusal adjustments that are required to allow the mandible to be
properly positioned may cause perforation of the prosthesis or make it
unaesthetic. If anterior interferences are seen, the crown may fracture
Tooth perforation:
This is not one of the common failures seen because pin retained
restorations are not used often nowadays.

Mechanical Failures:

Loss of retention :
Prosthesis can come loose from an abutment tooth. This could be due to:
1. Cementation failure- open margins
2. Less retentive prosthesis- tooth preparations Connector failure
A connector between an abutment retainer and pontic or between pontics
can fracture under occlusal load. Failures are reported in both soldered
connectors as well as in cast connectors. This could be attributed to the
internal porosity that has weakened the metal. In soldered joints this could
be attributed to the improper soldering.

Occlusal wear:
Heavy chewing, clenching or bruxism can produce accelerated
occlusal wear of the prosthesis and resultant perforation and leading
sequalae. When occlusal surfaces are covered with ceramic wearing off
ceramic is not a problem, but the ceramic material may chip off. If it
opposes the natural tooth it wears of the enamel very fast. For this reason
if occlusal wear is anticipated metallic prosthesis is of choice.

Tooth fracture:
This is seen in partial coverage crowns as a result of thin
inadequately supported tooth structure and also the tooth becomes brittle
as the age advances. This is common in endodontically treated tooth,
excessive tooth reduction, excessive tooth reduction in a largely restored
tooth, presence of interfering centric or eccentric contacts. This can occur
while attempting forcibly to seat an improper fitting prosthesis or unseat a
cemented bridge. Root fractures are usually due to trauma. They also can
occur during Endo treatment, post core placement.
Porcelain fracture:
Porcelain fused to metal restorations is increasingly being used
nowadays. Ceramic fracture occurs both with the porcelain fused to metal
and in all ceramic restorations. The main causes for the fracture could be
1. Improper design of the framework
2. Occlusal problems
3. Inadequate preparation

Frame work design:

Sharp angles or extremely rough and irregular areas over the
veneering area serve as points of stress concentration that can cause
crack propagation and ceramic fractures. Perforations in the metal can
also cause failure. Very thin metal castings do not adequately support
porcelain so flexure can cause fracture. With facially veneered
restorations porcelain fracture results from a framework design that allows
centric occlusal contact on or immediately next to the metal to ceramic
junction. Also failures occur when the angle between the veneering
surface and the nonveneered aspect of the casting is less than 90 0

Metal handling procedures:

Improper handling of the alloy during casting finishing or
application of the porcelain can lead to metal contamination. Bubbles may
form at metal ceramic junction when porcelain is applied creating stress
and possible cracks. Separation of porcelain from the metal has also been
observed in cases of contamination. Excessive oxide formation on the
alloy surface can also cause separation of the porcelain from the metal.
Improper conditioning of the base metal alloy and certain gold-palladium
alloys most frequently causes this problem.

Preparation, impression, and insertion:

A tooth preparation with slight undercut can cause binding of the
prosthesis as it is seated which initiates crack in the porcelain. Tooth
prepared with no definite finish lines or impressions that do not record all
the finish lines can lead to an extension of metal beyond the actual
termination of tooth reduction. Because the technician will not be able to
visualize the finish lines the tin metal may bind against the tooth and
initiate a crack in the overlying ceramic.

Metal to ceramic incompatibility

In rare instances an alloy and ceramic are found to be truly

incompatible. However failures resulting from improper handling is

attributed to porcelain metal incompatibility.

Repair of fractured porcelain fused to metal restorations:

The best method is to re-fabricate the crown. However every time it
is not possible to do it. Resins are used to rebuild the porcelain-fractured
area. The main draw back is bonding, with the advent of newer bonding
agents this problem is solved to an extent. Another way of repairing is
porcelain veneers.

Esthetic Failures:
Ceramic restorations fail often esthetically than mechanically or
biologically.
1. Improper shade selection
2. Display of metal in cervical areas
3. Excessive metal display

Facings:
These are no longer used but if used if the tooth is not prepared
properly on the labial aspect display of the metallic shadow is common.