Lect: 20 ‫ محمد قاسم‬.

‫د‬

FAILURES IN CROWN AND BRIDGES

Every dentist would like to be able to answer the patient questions: how long will
the crown or bridge lost? Because crown and bridge are a custom-made device of a
daily use and perform their service in a hostile biological environment submerge in
water (saliva), and the failures more liable to occur. Failures can be grouped into 6
categories, with severity increasing from Class I to Class VI.

Class I: Cause of failure is correctable without replacing restoration.

Class II: Cause of failure is correctable without replacing restoration; however,

supporting tooth structure or foundation requires repair or reconstruction.

Class III: Failure requiring restoration replacement only. Supporting tooth

structure and/or foundation acceptable.

Class IV: Failure requiring restoration replacement in addition to repair or

reconstruction of supporting tooth structure and/or foundation.

Class V: Severe failure with loss of supporting tooth or inability to reconstruct

using original tooth support. Fixed prosthodontic replacement remains
possible through use of other or additional support for redesigned restoration.

Class VI: Severe failure with loss of supporting tooth or inability to reconstruct
using original tooth support. Conventional fixed prosthodontic replacement is not
possible.
Other classification of failures depending the cause: -

I - LOSS OF RETENTION:
A good diagnostic test for a loose retainer is to examine the bridge carefully without
drying the teeth, pressing the bridge up and down and looking for small bubbles in
the saliva at the margin of the retainers.
The possible causes of retention loss are:
1- Deformation of the metal cast on the abutment teeth.
2- Inadequate tooth preparation.

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3- Bad technique of cementation:
- Inadequate isolation. - Poor mixing or using improper ratio.
- Not removing any remnants that interfere with retention.
- Movement of the patient during cementation.
4- Solubility of the cement due to open margin or perforation in the bridge
5- Caries which cause leakage at the margin.
6- Over mach spacer materials on the die.
- When only one retainer become loose without a cement seal, plaque forms in the
space between the retainer and the abutment tooth and caries develops rapidly
across the whole of the dentine surface of the preparation.

II – MECHANICAL FAILURES OF CROWN AND BRIDGE COMPONENTS

Typical mechanical failures are:
1- Porcelain fracture. 2- Failure of solder joints. 3- Distortion
4- Occlusal wear and perforation. 5- Lost Facings.

1// Porcelain fracture.

At one-time pieces of porcelain fracturing off metal ceramic crowns, or the loss of
the entire facing due to failure of metal- ceramic bond.
1- Inadequate thickness of metal.
2- Excessive thickness of porcelain contributes to inadequate support predisposes to
eventual feature. This is often true in the cervical portion of a pontic.
3-The metal surfaces to be veneered not smooth and not free of surface pits or
irregularities will cause incomplete wetting by the porcelain slurry, leading to voids
at the porcelain metal interface that reduce bond strength and increase the possibility
of mechanical failure.
4- Sharp angles on the veneering area must be avoided, they produce increased
stress concentrations that could cause mechanical failure.
5- Excessive occlusal function or trauma.
7- Improper laboratory procedures.

All Porcelain Crown or Bridge Fracture.

Stresses are developed within porcelain jacket crowns as a result of contraction on
cooling after the firing cycle.
These stresses produce failure if the crown is subjected to sufficient force. These
stresses are concentrated around sharp internal angle of fit surface (so should be
rounded).
If the fracture is due to trauma, and particularly if the restoration had served
successfully for some time, it should be replaced by another all ceramic restoration.
If the failure occurs during normal function, the replacement should be metal
ceramic.

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2// Failure of solder joints :
Occasionally a solder joint that appears to be sound fails under occlusal
loading, this may be due to:
a) A flaw or inclusion in the solder itself.
b) Failure to bond to surface of the metal.
c) The solder joint not being sufficiently large for the conditions in which
it is placed.
A problem, particularly with metal-ceramic bridge work, is that too much
restriction of the solder connectors, buccally, gingivally and incisally can
lead to inadequate area of solder failure.
It is better to join multiple unit bridges by solder joints in the middle of
pontics before the porcelain is added, strengthened by porcelain covering.
There are no satisfactory intraoral repair methods, and it is not possible to
re solder (whole bridge has to be remade).
3// Distortion:
Distortion of all metal bridges may occur, for ex. hygienic pontics are
made too thin or if a bridge removed using too much force when this
happens the bridge has to be remade.
In metal ceramic bridges distortion of the framework can occur during
function, or as result of trauma. This is likely if the framework is too
small in cross section for the length of span and the material used.

4// Occlusal wear perforation:

a) Insufficient occlusal preparation lead to less thickness of the metal and
this may lead to perforation, which may occur in the finishing and
polishing.
b) Even with normal attrition, the occlusal surfaces of teeth wear down
substantially over a lifetime.
If perforation has been the result of normal wear and it is spotted before
caries has developed, it may be repaired with an appropriate restoration.

5// Lost Facings:

Laboratory made ceramic or acrylic facing, may be entirely lost. With
acrylic facing, wear and discoloration are also common.
The causes:
1. poor retention.
2. Heavy occlusion on the facing.
3. The facing is not protected by the metal completely.

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 III - Changes in the abutment tooth:
A\\ Periodontal Disease:
Periodontal disease may be generalized, or in a poorly designed made or
maintained restoration, its progress may be accelerated locally, If the loss of
periodontal attachment is diagnosed early enough, and the cause removed, no
further treatment is usually necessary.
However, if the disease has progressed to the point where the prognosis of the
tooth significantly reduced then the crown or bridge, or the tooth itself may have
to be removed.
Most the clinical and laboratory causes are:
1 - Position of the crown margin; subgingival margin may have better appearance
initially but will often have a degree of gingival inflammation which may lead to
more serious periodontal disease.
2- Thick margins with poor seating of the restoration and poor axial contour that
will ultimately cause periodontal problem.
3- Over margin which lead to a pressure on the gingiva.
4- Coarse or rough margins (not smooth).
5- Remnants of excessive cementing material.
B\\ Problems with the pulp: -
Great care is needed to prevent pulp injuries during fixed Prosthodontic
procedures, the main causes of injury are:
1- Temperature during tooth preparation.
2- Chemical irritation by dental material.
3- Microorganisms.
4- Recurrent caries.
5- More reduction of tooth structure without provisional restoration.
Every one of them can cause irreversible pulpits.

C\\ Fracture of the prepared natural crown or root:

Fractures of the tooth may occur as a result of:
1- Trauma.
2- Recurrent caries.
3- Removing the prosthesis intact with using large force.
4-Tooth structure is thin, especially with pulp less teeth ((so the post core is
necessary)).
D\\ Recurrent caries:
May be due to:
1-Over extension of the margin, will cause plaque formation and
periodontal problem due to resorption of the cement which close the space
between the cast-teeth.

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 2-Short casting will leave rough cementum or dentin which cause collection of
debris.
3- Open margin will allow the saliva and cariogenic organisms to enter between
the tooth and the restoration.
4- Wear of the cast will cause resorption of the cement, exposure of the tooth
surface which cause caries later on.
5- Looseness of one of the retainers.
6- Poor oral hygiene of the patient.
7- Using a wrong type of retainer.
Dental caries is the most common cause of failure of a cast restoration. It's
detection can by very difficult particularly with complete crown.
The caries is often detected only after irreversible pulp involvement had resulted.
Disease may rapidly progress to the point, where tooth loss or the fabrication of a
new prosthesis becomes inevitable.
The cause of the problem should be identified, dealt with before repair or
replacement is started.

• Design Failures:
A)) Abutment preparation
Inadequate crown preparation is a common cause of failures:
1- Taper of preparation when it exceeds 20˚ (ideal 5˚ – 10˚) failure through loss of
retention.
2- Improper path of insertion lead to the finished restoration can not be seated.
3- Insufficient reduction at the margin can result an over built crown produce a
plaque retention area at the margin.
4- The unrounded external angles of crown preparation lead to:
a- The stone die materials may not flow into the sharp angles of the impression
producing bubbles.
b- The sharp edges may be damaged at the wax up stage.
c- Investment material may not flow adequately into the wax pattern.
d- It may be difficult to remove entirely the investment material from sharp internal
angles without damaging the casting.
e- Cement will flow less readily around sharp angles increasing the likelihood of
unnecessary thick cement layer at the margins.

B)) Inadequate bridge Designs:

Designing bridges is difficult, it is neither a precise science nor a creative form of
art. It needs knowledge, experience judgment, which take years to accumulate.
Simple classification of these failures are:

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 1- Under-prescribed bridges.
These include designs that are unstable or have too few abutment teeth for ex: a
cantilever bridge carrying pontics that cover too long span, or a fixed-movable
bridge where again the span is too long, or where abutment teeth with too little
support has selected.

2 -Over-prescribed bridges:
The dentists sometimes include more abutment teeth than are necessary retainer
which fails:
* The 1st lower premolar might be included as well as the 2 nd premolar 2nd
molar in a bridge to replace the lower 1st molar, this is not necessary.
* Upper canines and both premolars on each side are replacing the four incisors.
As well as being destructive, or this gives rise to unnecessary practical
difficulties in making bridge.
The retainers themselves may be over prescribed with complete crowns being
used where partial crowns or intra-coronal retainers would have been quite
adequate, or metal-ceramic crowns might be used where all metal crowns would
have been sufficient.

• Inadequate clinical or laboratory technique.

It is helpfully to allocate problems in the construction of crowns and bridges to
one of three groups: Minor problems to be noted and monitored but where on
action is needed, the type of inadequacies that can be corrected in site, and those
that can not.

1- Marginal Deficiencies:
a- positive ledge (overhang): A positive ledge is an excess of crown material
protruding beyond the margin of the preparation. These are more common with
porcelain than any other margins. This easy to recognize and correct before the
crown cemented other-wise disturbing the restoration.

B-Negative ledge:
This is deficiency of crown material that leaves the margin of the preparation
exposed but with no major gaps between the crown and the teeth. It is a fairly
common fault, particularly with metal margins, but that is difficult or impossible
to correct at the try in stage.
causes:
1- The impression did not give a clear enough indication of the margin of the
preparation.
2- The die was over-trimmed, resulting in under-extension of the retainer.
3- The die is not separated.

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 Supragingival margin or just at the margin, it is possible to adjust the tooth
surface of the crown.
Subgingival margin can be adjusted with a pointed stone, although this will cause
gingival damage. However, the best solution is remade the restoration.

2- Marginal discrepancy
Fitness is the gap between the crown and preparation margins; there are four
possible causes of improper fitness:
1. The crown or retainer did not fit and the gap was present at try-in (faults during
waxing or impression taking).
2. The crown or retainer fitted at try-in but at the time of cementation the
hydrostatic pressure of the cement, particularly if the cement was beginning to
set, produced incomplete seating.
3. With a mobile bridge or splint abutment, the cement depressed the mobile tooth
in its socket more than the other abutment teeth, thus leaving the gap.
4. No gap was present at time of cementation but one developed following the loss
of cement at the margin and crevice has been created by a combination of
erosion, abrasion and possibly caries. For these cases, the choice is to remove the
bridge, restore the gap with a suitable restoration or leave it alone and observe it
periodically.

3 - Poor shape or color (esthetic problems):

1. A common mistake in preparing upper incisors for crowns is to remove
insufficient material from the buccal \ incisal third of the preparation. These
result in either a crown that is too thin, so that the opaque core material shows
through, or in a bulbous crown.
2. Insufficient thickness of porcelain.
3. Too much adjustment is done, the incisal shade of porcelain will be ground away
and the esthetic effect spoiled.
4. The stone should be held perpendicular to the junction otherwise the metal
particles may contaminate the porcelain.
5. Absent the embrasures will recognize the teeth as artificial
6. Excessive glazed anterior teeth will look unnatural.
7. Inaccurate shade selection.
Any problem in the waxing may create a problem on the final restoration such as:
1. When the wax pattern left of the die lead to distortion because stresses occur in
the wax as a result of the heating and manipulation of the wax during fabrication.
2. Wax pattern should be over sized slightly mesiodistally, finishing and polishing
without creating an open contact in the finished restoration.

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3. Most common error relating to axial contour is the creation of bulge or excessive
convexity leading to accumulation of food debris plaque causing gingival
inflammation, which is encouraged rather than prevented.
4. During the margin finishing, don’t approach the finishing line on the die with
sharp instrument that can remove die material causing the final restoration will
not fit on the prepared tooth. The margin is a critically area of any wax pattern.
5. Any roughness in the wax near the margin lead to plague, irritation and
inflammation of adjacent gingival tissues.

4. poor investing and casting procedures:

1. Vacuum mixing of investment materials highly recommended for obtaining
consistent results in casting with no surface defects, especially when phosphate
bonded investment is being used.
2. Cooling and reheating of the investment can cause casting inaccuracy, since
the refectory and binder will not revert to their original forms. Inadequate
expansion and cracking of the investment are typical results.
3. Excessive burn out temperature has led to increased surface roughness on this
casting.
4. Alloys from different manufacturers when they mixed even if they are similar
leading to defect in the casting. Over heated or otherwise abused alloys as well as
grinding and old restorations are best returned to the manufacturer as scarp rather
than reused.

5. Defects in the casting:

a- Nodules: bubbles of gas trapped between the wax pattern and the investment
produce nodules on the casting surface. When they are large or situated in a
margin, the restoration should be remade.
b- Fins: are caused by cracks in the investment that have been filled with molten
metal. These cracks can result from:
1. Weak mix of investment (high water \ powder ratio)
2. Excessive casting force.
3. Steam generated from the rapid heating.
4. Reheating invested pattern.
5. Improperly situated pattern (too close to the periphery of the casting ring).
6. Premature rough handling of the ring after investing
c- Incompleteness:
1- If an area of wax is too thin (less than 0.3 mm) incomplete casting may result
(veneering surface of a metal ceramic restoration).
2- Inadequate heating of the metal.
3- Incomplete wax elimination.
4- Excessive cooling (freezing) of the mold.
5- Insufficient casting force.
6- Not enough metal, or metal spillage.

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d- Voids or porosity: voids may be caused by debris trapped in the mold,
commonly a particle of the investment. A well waxed small sprue will help
prevent them. Porosity resulting from:
1. Solidification shrinkage occurs if the metal in the sprue solidifies before that in
the mold, as may happen when a sprue is too narrow, too long, or incorrectly
located or a large casting is made in absence a chill vent.
2. Gases may dissolve in the molten alloy during melting leave porosity defects.
3. Back pressure porosity may be caused by air pressure in the mold as the
molten metal enters.