CLINICAL FAILURES IN FIXED PARTIAL DENTURE

AND ITS MANAGEMENT

INTRODUCTION:

A complication has been defined as ‘A secondary disease or

condition developing in the course of a primary disease or condition’.

Although complications may be an indication that clinical failure has

occurred, this is typically not the case. It is also possible that

complications may reflect substandard care. But once again this is

usually not true. Most of the time, complications are conditions that

occur during or after an appropriately performed fixed prosthodontic

treatment procedures.

An objective evaluation of an existing restoration is necessary

before coming to a conclusion that it is defective and requires either

replacement or repair.

What constitutes a failure?

Are failures absolute or are there degrees of failures?

There are of course minor failures, which are a matter of opinion

and could be possibly left without immediate repair or replacement,

and there are obvious failures where repair or replacement is essential

to avoid further damage to the dentition.

Failure may occur at any time. Hence it is important to be aware

of obvious and subtle indications of prosthesis failure and have a

working knowledge of the procedures that are necessary to remember

the situation.

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 It is natural that dramatic mechanical failure such as fracture

attracts attention, but it must be remembered that failures can be

biologic and esthetic in nature.

I. Biologic failure

II. Mechanical failure

III. Aesthetic failure

I. BIOLOGIC FAILURE:

1. Caries:

It is the most common biologic failure. Caries may affect a bridge

in several ways, either directly at the margins of the retainer, or

indirectly by starting elsewhere on the tooth and spreading to the fit

surfaces of the casting or it may follow cementation failure.

Detection:

- Visual inspection (Discoloration around margins)

- Probing margins of restorations with a sharp explorer

- Radiographs for interproximal caries

Causes:

- Defective margins (supragingival preferred over subgingival)

- Loose retainers that allow gross leakage to occur

- Incomplete removal of caries prior to restoration

- Poor design leading to food accumulation

- Change in the diet of patient

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Prevention:

- Meticulous oral hygiene must be a routine procedure for patients

with a high caries index and particularly for those who have a

history of developing carious lesions around restorations.

- Fluoride containing dentifrices and mouthwashes

Management:

1) If carious lesion is small  conservative operative procedures

can be performed

- Good foil is the material of choice for marginal caries

- Amalgam is preferred over gold because of its long term

marginal seal and into areas of limited accessibility

- In aesthetic areas – Resin materials or GIC may be used.

2) If caries is on the proximal surfaces, prosthesis has to be removed

to gain access. If the lesion is small the preparation can be extended if

a large amalgam restoration may be required before fabrication of a

prosthesis.

2. Pulp Degeneration:

Clinical features: - Postinsertion pulpal sensitivity in the abutment

teeth that does not subside with time; intense pain or periapical

abnormality that are detected radiographically.

Causes:-

- Excess heat generation during preparation

- Excess tooth reduction
- Pin point exposure which may go unnoticed
- Occlusal trauma
- Cement involved

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Prevention: - Use of varnish or dentin bonding agent form an effective

barrier and prevents underlying pulp from toxic effects of cement and

core materials.

Management:-

- Access to the pulp requires a hole in the prosthesis through

which the necessary treatment is completed.

- Perforation created can be restored with gold foil or amalgam.

- If the retainer casting becomes loose or porcelain fracture occurs

during access cavity preparation  remake of prosthesis.

- During endodontic treatment an assessment should be made of

the quality and quantity of tooth structure remaining for support

and retention of restoration. If it is decreased reinforcement with

post and core may be required.

- Teeth that were satisfactorily root filled when the crown or

bridge were made may later give trouble. In such situations

apicectomy is the solution. Care must be taken not to shorten the

root of the abutment tooth more than absolutely necessary so that

maximum support for the bridge can be maintained.

Note: - Indirect pulp capping is not recommended as its failure may

jeopardize the existing prosthesis.

3. Periodontal Breakdown:

Clinical Features: - Gingival recession, furcation, pocket formation,

mobility of abutment.

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 This can be either a generalized periodontal breakdown of the

whole mouth which may be associated with the drifting of teeth or may

be localized to the bridge abutment.

Causes:-

- Inadequate instructions in prosthesis hygiene or its poor

implementation by the patient.

- Prosthesis that hinders good oral hygiene

o Poor marginal adaptation

o Overcontouring of axial surfaces

o Large connectors that restrict cervical embrasures

o Pontics that contact too large an area on the edentulous

ridge

o Prosthesis with rough surfaces which promote plaque

accumulation

- Traumatic occlusion

- Insufficient number of abutment selected

Prevention: - Proper oral hygiene instructions

Review appointments

Preparation design: - Proper axial contours  flat axial contour are

better than overcontouring as they are easy to maintain and avoid

plaque accumulation.

Treatment:-

- If less severe scaling and proper plaque control

- Increased severity – flap surgery, bone graft etc.

- Correct occlusion

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 - If prognosis of abutment teeth has decreased than the crown or

bridge and the tooth may have to be removed.

4. Occlusal Problems:

Clinical Features: - Large wear facets, mobility, tender on percussion,

open contacts, perforation, cusp fracture, tenderness of the

masticatory muscles involved. Radiographically-widened periodontal

ligament is seen.

Interfering centric or eccentric occlusal contact can cause

excessive tooth mobility. If this is detected early, the interferences can

be eliminated by occlusal adjustments without permanent damage.

However, traumatic occlusion on teeth previously weakened by

periodontal disease or long term presence of occlusal interferences on

teeth with normal bone support can lead to mobility which cannot be

reduced or eliminated through adjustment of the interfering area. The

prosthesis may have to be removed and teeth bilaterally braced with

RPD. Many a times it requires extraction of abutment teeth.

In patients with bruxism night guards or occlusal splints may be

given. A slightly flatter anterior ramp is preferred in clenchers than

ordinarily given.

Neuromuscular discomfort related to improper occlusion can

result in prosthesis failure, hence selective reshaping of defective

contacts and restoring or replacing teeth in more favorable position

should be done to accommodate occlusal forces.

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5. Tooth Perforations:

Pin holes or pins used in conjunction with pin retained

restorations can be improperly located and may perforate the tooth

laterally.

• If perforation is located occlusal to PDL – it is often possible

to extend the tooth preparation to cover the defect.

• If perforation extends into the PDL – perform periodontal

surgery to smooth off the projecting pin or place a restoration into

the perforated area.

• If area is not accessible – lead to extraction of tooth.

• Perforations may not be detected initially, becoming

apparent only after insertion of the prosthesis.

Endodontic treatment is required when pinholes or pins perforate

into pulp chamber.

II. Mechanical Failure:

1. Loss of Retention:

This occurs mainly due to leverage and unequal occlusal loads

on different parts of the bridge. Loose retainers cause rapid

destruction of the abutment tooth. Saliva and plaque and pumping

action of loose retainer are responsible for caries leading to rapid

destruction of abutment teeth.

Clinical Features: - Patient may be aware of looseness or sensitivity to

temperature or sweets. Also there may be a recurring bad taste or

odour, which must be differentiated from similar symptoms caused by

poor oral hygiene or periodontal problems.

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Detection:-

- Sometimes the patient is aware of movement developing in the

bridge.

- Diagnostic test is to examine the bridge carefully without drying

the teeth, pressing the bridge up and down (occlusocervically) and

with a curved explorer – looking for small bubbles in the saliva at

the margins of the retainer.

- When more than 2 abutment teeth are involved in prosthesis, it

is difficult or impossible to detect a single loose retainer.

Management:-

- If retainer becomes loose prosthesis must be removed so that

the abutment teeth can be evaluated.

- If the restoration can be dislodged from the prepared teeth

without damage and no caries is present, it is possible to recement

the prosthesis. Improper cementation procedures, such as

contamination with moisture or increased cement space may have

caused the problem.

- If the prosthesis reveals loss of adequate retention, teeth should

be modified to improve the retention and resistance form.

Additional retention by cross pinning, grooves, boxes etc.

Alternatively it may be necessary to include additional abutment to

increase overall retention or change the design in some other way

(i.e. use of full coverage instead of partial coverage). In case of

grossly destructed teeth, core build up may be done to support the

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 retainer or surgical exposure of crown can also be done. After all

this a new prosthesis is fabricated.

- Sometimes FPD come loose even when maximally retentive

preparation have been developed. This problem is caused by

excessive span length or heavy occlusal forces – A RPD may be the

only satisfactory solution.

- “It is better for teeth to have no cover than loose cover”.

- Because there is usually less permanent damage or plaque is not

retained against the surface of preparation and the patient is

obviously aware of the problem and seeks treatment quickly.

2. Connector Failure/ Solder Joint Failure:

There are several points to watch if a breakdown of the solder

joint is to be avoided.

i) Adequate width and depth to resist occlusal stress

ii) A sufficient bulk of gold

Causes:-

- Connector failure can occur under occlusal load. When fracture

occurs pontic is placed in an cantilever relationship with the

retainer casting which may lead to excessive forces on abutment

teeth. Hence prosthesis should be removed and remade.

- A flaw / inclusion in solder itself (porosity)

- Failure to bond to surface of metal

- Joint not be sufficiently large for the condition in which it is

placed.

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 - Improper flow of metal due to decreased width between joining

parts. Minimum width for solder to flow properly is 0.25mm.

Treatment:-

- Fracture connectors are difficult to detect in an abutment teeth

with no mobility. Wedges are placed beneath the connector to

separate the FPD components to confirm diagnosis. Occasionally

an inlay like dovetail preparation can be developed in metal to

span the fracture site and casting can be cemented to stabilize

the prosthesis.

- If this is not possible, and a remake cannot be rapidly

accomplished, the pontics should be removed by cutting through

the intact connectors. A temporary RPD can be inserted to

maintain the existing space and satisfy esthetic requirements.

- It is better whenever possible to join multiple unit bridges by

solder joint in the middle of pontics before porcelain is added.

This gives much larger surface area for the solder joint and it is

also strengthed by porcelain covering.

Effect of connector design on the fracture resistance of all ceramic

FPD. JDP 2002; 87

- The results of this study showed that the occlusal embrasure

can be designed as sharp as is practical for the aesthetics of an

all ceramic 3 unit FPD; provided that the gingival embrasure has

a increased ratio of curvature to increase the fracture resistance.

3. Occlusal Wear and Perforation:

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 Heavy chewing forces, clenching or bruxism can produce

accelerate occlusal wear of a prosthesis.

Clinical Features:- Attrition of opposing teeth, polished facets on the

retainers/ pontics, gingival recession or inflammation.

Causes:-

- Faulty preparation were occlusal clearance for metal is

inadequate.

- Even with normal attrition, occlusal surfaces of posterior teeth

wear down substantially over a period of time.

- Gold crowns made with 0.5mm or so of gold occlusally may wear

through a period of 2-3 years.

- There perforations allow leakage and caries to occur which leads

to prosthesis failure.

Management:- If perforation is detected early, a gold or amalgam

restoration can be placed.

Other materials – resin, composite and GIC

o If perforation is over amalgam core, leave it untreated and

check it periodically.

o If metal surrounding perforation is extremely thin a new

prosthesis should be fabricated.

o If occlusal surfaces are covered with porcelain, wear of

ceramic is not a problem, instead the opposing natural teeth shows

dramatic wear of enamel. This problem is exacerbated by heavy

chewing forces, clenching or bruxism and often requires the

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 restoration of abraded teeth. The same occurs when porcelain

opposes metallic restoration.

So, in mouths in which occlusal wear is anticipated, it is better to

place metal over occluding surfaces to minimize wear and maintain the

integrity of natural teeth.

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4) Tooth Fracture:

a) Coronal fracture:

Coronal tooth fracture can be dramatic, resulting in considerable

loss of tooth structure, or it can be minor with little significant damage.

Causes:-

- Caries of abutment teeth

- Excessive tooth preparation which may leave insufficient tooth

structure to resist occlusal forces.

- Preparation may have been composed mainly of restorative

material which was not retained in sound dentin with pins.

- Presence of interfering centric and eccentric occlusal contacts or

even heavy occlusal loads.

- Fracture can also occur when attempts to forcibly seat an

improperly fitting prosthesis/ unseat a cemented bridge

incorrectly.

Management:-

- If defect is small it is restored with amalgam, gold foil or resin to

provide additional years of service.

- If there is a question regarding the integrity of the remaining

tooth structure or restoration, a new prosthesis should be

fabricated so that it encompasses the fractured area.

- Large coronal fracture around partial coverage retainers, then

full coverage restorations may be fabricated. Tooth may require

separate pin retained restoration to serve as core and provide

support and retention.

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 - If fracture causes exposure of pulp, endodontic treatment along

with post and core; abutment preparation should involve

placement of bevels to increase resistance form.

- Abutment tooth fracture under full coverage restoration usually

occur horizontally at the level of finish line. This necessitates

removal of prosthesis. Endodontic treatment  post and core 

new prosthesis.

b) Root Fracture:-

Causes:- Most often due to trauma

- During endodontic treatment, forceful seating of post

- Attempts to fully seat an improperly fitting post

Fracture may not be immediately apparent and only become

detectable with time.

Root fracture are located well below the alveolar bone, so it must

be extracted and new prosthesis fabricated.

Occasionally fracture terminates at or just below the alveolar

bone, in such cases it may be possible to perform periodontal surgery,

remove bone and expose the fracture site so that it can be

encompassed by new prosthesis.

c) Pontic fracture/ failure:-

Mechanical failure of the pontic may occur because of

inadequate strength. Thus an all porcelain occlusal pontic should never

be used unless the occlusion is favorable.

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 Similarly the gold framework must always be of adequate

rigidity. Even slight flexion will cause cementation failure or fracture of

the porcelain facing.

Probably one of the commonest cause of pontic failure is a faulty

occlusion particularly in lateral excursions, which was not corrected

when the bridge was placed.

An acrylic facing will wear and discolour quite rapidly. Tissue

contact of pontic – extensive area of tissue contact is cited as major

cause of failure. Area of contact should be small and convex. Mesial,

distal, lingual and gingival embrasure should be wide open to allow

easy cleaning.

5) Porcelain Fracture:

Porcelain fracture occur with both metal ceramic an all ceramic

crown restoration. The majority of PFM fracture can be attributed to

improper design characteristics of the metal framework or to problem

related to occlusion.

All ceramic restorations commonly fail because of deficiencies in

tooth preparation or presence of heavy occlusal forces.

a) Metal-Ceramic Porcelain Failure:

Framework design:-

• Sharp angles or extremely rough and irregular areas over

the veneering area serve as points of stress concentration that

cause crack propagation and ceramic fracture. Perforations in the

metal can also cause failure for same reason.

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 • An overly thin metal casting does not adequately support

porcelain, so that flexure and porcelain fracture are allowed.

• Overbuilt porcelain unsupported by metal in PFM may

fracture because of cohesive failure within the porcelain.

• In PFM restoration porcelain fracture result from framework

design that allows centric occlusal contact, on or immediately next

to the metal ceramic junction.

• When angle between veneering surface and non-veneered

aspect of the casting is less than 90°. These designs allow occlusal

forces to cause localized burnishing of metal and distortion, which

leads to premature porcelain fracture.

Occlusion:-

• Heavy occlusal forces or habits such as clenching and

bruxism

• Centric or eccentric occlusal interferences can lead to

failure, or failure may also be due to uncorrected occlusal slides,

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 which create deflective contact of opposing teeth with the
prosthesis.
Metal Handling Procedures:-

• Improper handling of 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 or possibly cracks.

• Severe contamination

• Excessive oxide layer on metal, due to improper

conditioning of base metal alloys can lead to separation of porcelain

from metal.

Preparation, Impression and Insertion:

Preparation with slight undercut can cause binding of the

prosthesis as it is seated, which initiates crack in the prosthesis. This

may go unnoticed until premature postinsertion failure occurs.

An impression that is slightly distorted can lead to same

problem.

Teeth with feather edge finish line or impression which do not

record all finish lines can lead to extension of metal beyond the actual

termination of tooth reduction. The thin metal may bind against the

tooth and initiate a crack in overlying porcelain.

Good preparation with definite line and impression that record

proper detail are prerequisites to acceptable ceramics.

Metal and Porcelain Incompatibility:

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 In rare instances, an alloy and porcelain are found to be truly

incompatible, and successful bonding without loss of the veneer or

cracking is impossible.

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Repair of fractured metal ceramic restorations:-

• Best method is fabrication of a new prosthesis

• Resin materials are often used to rebuild the porcelain

form in area where fracture has occurred, adequate to good colour

matching can be achieved.

Drawback is lack of longevity and discolouration. Even light cure

composites can be used.

Retention of these materials is mainly due to mechanical

interlocking so if used in areas of heavy occlusal forces repair often

fails shortly after insertion.

• If fracture is due to heavy occlusal forces the contact

should be avoided at the metal ceramic junction, and it should be at

least 1.5mm away from the junction.

• A more permanent repair is possible if adequate thickness

of metal available. Steps –

- Removal of remaining porcelain

- Drill several pin hours (4-5) to depth of 2mm and make

impression

- Creating pin retained metal casting 0.2 – 0.3mm thickness out of

a metal ceramic alloy to fit over exposed metal framework.

- Fusion of porcelain to the pin retained casting and establish

normal form

- Cementation of casting in position

- If there is any risk of pontic area flexing, porcelain should be

carried on to the lingual side of the pontic to stiffen them further.

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Sleeve Crown:-

When a considerable portion of porcelain is lost from labial/

incisal surface of a retainer or pontic it is often possible to repair that

replace the entire unit. The porcelain facing is removed with some of

the underlying metal from the labial surface. Porcelain as well as metal

are removed from incisal third of the palatal surface. This is a simple

procedure when damaged unit is pontic, but when the damaged unit is

a retainer and underlying pulp has to be considered. Common mistake

is removal of too little porcelain and metal.

An impression is made of this and the two adjacent units. The

technician is then asked to make metal ceramic crown that will have 2

surfaces instead of usual four. This sleeve crown is then cemented in

usual way.

If too little porcelain is removed from original unit, the new

sleeve crown will fill slightly bulky.

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b) Porcelain Jacket Crown Failures:-

Since porcelain jacket crown have been in use for rarely a

century, considerable clinical experience related to their failure is

available.

With good preparation considerable success has been achieved

on incisors, whereas fracture are more frequently observed when

restorations are placed on posterior teeth and on canines because of

occlusal force on these teeth.

Cause:- Quality of tooth preparation and magnitude of occlusal load

are the main factors that determine clinical success or failure. They are

more likely to fail in presence of heavy occlusal forces clenching/

bruxism.

Prevention:- Tooth preparation should be adequate but not excessive.

Tooth reduction must be designed to support the restoration since no

metal is present to provide support.

Management:-

- Short term repair can be done with GIC, resin and light cure

composites.

- Severely chipped all porcelain crowns must therefore be

replaced by a new crown.

- If an early failure occurs without any clinical/lab defects heavy

occlusal forces are likely to be present that exceed strength of

restoration. Metal ceramics should be seriously considered for the

new restoration.

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 - If failure occurs after many years of service and optimal esthetics

is still required a new all-ceramic should be considered.

- If fracture is due to trauma it should be replaced by another all

ceramic restoration particularly when old restoration has served

successfully for sometime.

Types of Ceramic Fracture:-

a) Vertical Fracture:-

- Marginal area of jacket crown is often more closely adapted to

prepared tooth than other areas. If tapered finish line is used,

restoration contacts the tooth on a sloping surface resulting in

forces that attempt to expand the restoration which are not well

resisted by porcelain, leading to vertical fracture.

- Sharp areas on tooth such as line angles and incisal angles

produce areas of high stress in restoration, leading to vertical

fractures.

- A round preparation form that does not provides adequate

resistance to rotational forces can also cause vertical fracture.

b) Facial Cervical Fracture:

Often assumes a semilunar form (Half moon fracture), generally

occurs with a short tooth preparation. Inciso cervical length of the

preparation should be 2/3rd to 3/4th that of the final restoration. When

opposing tooth contact is located incisally to prepared tooth, tipping

forces are more frequently developed, with the restoration having a

fulcrum on the cervically located incisal edges, leading to facial

cervical fracture.

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Prevention:- Give 45° level

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c) Lingual Fracture:

Cause:-

- When occlusion is located cervically to the cingulum of the

preparation, when forces on the porcelain are more shear in nature

and not as well resisted.

- Inadequate lingual tooth reduction, in which <1mm of porcelain

is present.

- Exceptionally heavy occlusal forces.

6) Cementation Failure:

Causes:-

- Loosening of retainer due to inadequate mechanical retention as

strength of chemical adhesion, and cohesive strength of cement are

limited.

- Poor cementation technique:- Wrong choice of material, failure to

observe the manufacturers mixing instructions, use of old or

contaminated stock, inadequate P/L ratio. Insertion of prosthesis

when cement has set. Inadequate isolation weakens the bond.

Where full crowns are being employed, venting is usually

inadequate.

- Resinous cements are considered to be the most retentive. But

the main drawback of resin cements being H2O percolation which

leads to increased pressure in the interface acting as an hydraulic

chamber, which leads to failure.

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8) Design Failure:

a) Abutment preparation design:

i) Factors affecting dislodgement:-

Taper of preparation: Increased taper reduces ability of restoration to

resist occlusally directed forces and also lessens its ability to interfere

with arc of rotation as tipping forces act to unseat the restoration.

Taper/ angle between opposing walls determine the degree of

retention against axial unseating forces. A parallel preparation is

impractical as cement cannot extrude from the crown during

cementation leaving excessive thickness of cement occlusally and at

margins.

Once taper exceeds 30° or so failure through loss of retention

becomes common. Ideal taper for good retention is 7° with minimum

cement in between. However, it is not possible to achieve this taper

clinically without producing some undercuts/ damaging the adjacent

teeth.

Average taper for post preparation that have been shown to be

clinically in successful in a large number of cases is 10-20° approx.

Length of Preparation: Minimum cervico-incisal height is that which

allows the tooth structure to interfere with arc of rotation as tipping

forces attempts to cause rotation around a fulcrum located at the

finish line on the opposite side of the tooth.

In case of short teeth adequate height is achieved by extending

margin subgingivally or only alternative is to prepare tooth with less

taper.

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 Greater the length the more retentive. Minimum acceptable

length will depend on nature of occlusal forces, number of teeth and

whether the crown will be subjected to withdrawing forces from a FPD.

“Relationship between length and taper is important:”

Shorter clinical crowns require more parallel walls. If clinical

crown is assessed to be too short for adequate retention it must be

built up with a core (if there is sufficient occlusal clearance), or surgical

crown lengthening or retention achieved by pins/ grooves. Both have

the potential not only to resist loss of the crown in a direction other

than long axis but also reduces the angle of the path of insertion.

Circumferential Irregularities:

Circumference of teeth is usually irregular in form and when

tooth is uniformly reduced an irregular shape is formed which

enhances ability of restoration to resist both tipping and twisting

forces.

When tooth encountered is round/ short/ over tapered

intentionally formed irregularities such as boxes, grooves may be used

to produce areas that interfere with dislodgement of restoration.

Boxes are more effective than grooves and should be used when

sufficient tooth structure is present. Best location being the proximal

areas, where it adds resistance to faciolingual dislodging forces.

All partial veneers crown require use of boxes and grooves.

Occlusal irregularities:-

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 Aids in resistance to dislodging forces; flat reduction provides

little interference and unnecessarily reduces the length of preparation.

Irregular reduction according to occlusal plane produces an corrugated

sheet effect which enhances the rigidity of the retainer than one plane

reduction.

ii) Finish line requirements:-

Supragingival margins are more acceptable than subgingival as

they aid in proper oral hygiene maintenance. They also reduces pulpal

sensitivity as they are usually in enamel.

Margins should be smooth and even. Rough or irregular margins

reduces adaptation and increase plaque formation and gingival

inflammation.

iii) Path of Insertion:-

Considered in 2 dimensions – Faciolingual and mesiodistal

Faciolingual direction:- Faciolingual orientation can affect the esthetics

of metal ceramic or PV crowns. For metal ceramics the path of

insertion should be roughly parallel to the long axis of the tooth. A

facially inclined path of insertion on a preparation for metal ceramic

crown will leave the faciolingual line angle too prominent, resulting in

overcontouring of restoration, opaque showing through or both.

For 3/4th crown on anterior teeth the path of insertion should be

parallel to the incisal half of the labial surface. If inclined more facially

short grooves and unnecessary display of gold will result.

Mesiodistal inclination:- It should parallel the contact areas of adjacent

teeth. If path is inclined mesially or distally the restoration will be held

27
up at the proximal contact areas and may be locked out. This is a
particular problem when restoring tilted teeth.
iv) Structural Durability:-

a) Occlusal Reduction:

- Minimum of 1.5mm for functional cusps and 1.0 mm for non-

functional cusps is needed

- Inadequate reduction leads to perforation and fracture of metal.

- One plane reuction may reduce the incisocervical length and

jeopardize the pup.

- Rigidity of metal is increased by following the contours of the

crown

b) Functional cusp bevel:

Bevel should be given on the maxillary lingual cusp and

mandibular buccal cusp at an angle of 45° to provide space for

adequate bulk of metal in an area of heavy occlusal contact.

If crown is waxed and contoured to normal contour without a

bevel, casting will be extremely thin in area overlying the junction

between occlusal and axial reduction. To prevent thin casting from

fracture an attempt is made to wax the crown to optimal thickness in

this area. An overcontoured restoration will result leading to deflective

occlusal contacts which can only be eliminated by reducing the

opposing teeth.

b) Inadequate bridge design:-

Designing bridges is difficult. It is neither a precise science nor a

creative form of art. It needs knowledge, experience and judgement,

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which takes years to accumulate. Simple classification of failure 

underprescribed and overprescribed bridges.

• Underprescribed Bridges:- These include designs that are

unstable or have few abutment teeth e.g. cantilever bridge carrying

pontics that cover too long a span or a fixed movable bridge where

again span is too long or abutment teeth with too little support have

been selected. Another under design fault is too conservative in

selecting retainer e.g. Class II inlays for fixed-fixed bridges. Little

can be done other than removing and fabricating new prosthesis.

• Overprescribed bridges:- Cautions dentist will sometimes

include more abutment teeth than are necessary and fate usually

dictates that it is the unnecessary retainer which fails. E.g. 1 st and

2nd premolar and 2nd molar included to replace 1st molar or use 3, 4,

5 on either side to replace incisors in upper arch. If the large bridge

unit fails it is sometimes possible to section the bridge in the mouth

and remove the failed unit leaving the remainder of the bridge to

continue in function. The failed unit is remade as an individual

restoration.

The retainers themselves may be overprescribed with complete

crowns being used where partial crowns or intracoronal retainers

would have been quite adequate or metal ceramic used where all

metal crown would have been sufficient.

ii) Marginal Deficiencies:-

Positive ledge (overhang):-

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 It is an excess of crown material protruding beyond the margin of

preparation. These are more common with porcelain than any other

margins. However, it is often possible to correct them without

otherwise disturbing the restoration by grinding and polishing in situ.

Negative ledges:-

This is a deficiency of crown material that leaves the margin of

the preparation exposed but with no major gaps between the crown

and the tooth. Again it is a fairly common fault, particularly with metal

margins, but one that is difficult or impossible to correct at the try-in

stage. It often arises because the impression did not give a clear

enough indication of the margin of the preparation. The die was

overtrimmed, resulting in under extension of the retainer.

Provided the crown margin is supragingival or just at the gingival

margin, it is sometimes possible to adjust the tooth surface of the

crown. When the ledge is subgingival, and particularly there is

localized gingival inflammation associated with it, it may still be

possible to adjust the ledge with pointed stone or bur, although this

will cause gingival damage.

Sometimes it is necessary to remove the bridge and adjust the

tooth surface with/ without surgically raising the flap.

iii) Dowel design:-

If a dowel is used its extension into root must at least be equal

the length of the crown for optimum stress distribution and maximum

retention or the dowel should be 2/3rd the length of the root whichever

is greater.

30
 A minimum of 4mm of gutta percha and more if possible should

remain to prevent dislodgement and subsequent leakage.

31
Failures of Dowel and Possible Explanations:

Type of failure Explanation

Loss of post from Post does not fit the walls of the canal or has too
root canal much taper.

Post too short

Post not in canal but has been placed through a

perforation into the alveolar bone. This should be
suspected if there is any bleeding.

Radiographs taken from either side of the root will

show the post to be apparently in different
positions.

Longitudinal or oblique fracture of root. This can be

confirmed by placing a probe in the post hole and
gently forcing the walls of the tooth apart. In this
situation blood can usually be seen in the crack. It
may be due to excessive force, as would be
imparted by a bridge abutment on a wedge-shaped
post.
Fracture of post This usually occurs at the gingival margin.

In a cast post it may be due to the diameter being

too small, or the alloy too soft, or porosity in the
casting, or exceptional occlusal forces.

In a pre-formed post it may be due to corrosion, or

selection of a post which was too thin. Posts which
do not have sufficient resistance to stress will
develop metal fatigue.
Pain on Root has been split due to cement being partially
cementation of set, or mixed too thick. Screw posts which contact
post the end of the post hole may also split the root.

A poorly sealed root filling, lateral canal or

perforation may allow cement into the periodontal

32
 membrane.
Loss of crown Core preparation too short or too conical in shape.
Fracture of Core too thick especially palatally.
crown A bonded crown should have been made instead of
a porcelain jacket crown. This would be indicated by
the presence of wear facets, very short clinical
height to the crown, or lack of space between the
lingual surface of the core and the occluding
surface of the opposing tooth.

III) Esthetic Failure:

Ceramic restoration more often fail esthetically than

mechanically or biologically.

a) Colour Mismatch:

Main reason reported by dental laboratories is poor colour

match. This could be the result of:-

- Inability to match the patient’s natural teeth with available

porcelain colour

- Inadequate shade selection

- Due to metamerism

- Insufficient tooth reduction or failure to properly apply and fire

the porcelain may have created a restoration that does not

match the shade guide or surrounding teeth.

- Because incorrect form or framework design that displays metal

- In addition, natural teeth undergo colour changes that do not

occur in porcelain, so that an unacceptable colour match is

caused over the years.

33
 - The marginal fit or cervical form of a prosthesis can promote

plaque accumulation, causing gingival inflammation, which

produces an unnatural soft tissue colour or form that is

esthetically unacceptable.

Removing of Crown and Bridges:

• Before removal possible need for temporary crown must be

remembered and provision for this should be made.

• Important is to protect the airway as chances of inspiration

is more due to the small size of crown, bridge particularly inlays.

Alter chair position and make patient sit upright.

• Attempt to remove the prosthesis intact, if not possible

prosthesis is cut until the prepared tooth is exposed and then

removed.

• Preparing the slot lingually is advantageous as material

bulk on the lingual side is comparatively less and therefore easily

removed. As slot is on the lingual side the same prosthesis can be

used as a temporary crown.

• Usually facial slots work best for maxillary and mandibular

molars.

Removing Old Bridges:

Methods:-

1. Inertia forces

2. Reciprocal forces

3. Retainer division

34
 Some bridges are easy to remove and some can be most

difficult. Begin in securing the bridge by tying a long piece of dental

floss so that it cannot be swallowed.

The causes of failure have been discussed. If an old bridge has

come out, well and good, but some fail on one abutment and are held

firmly on the other. The cement may have softened if there has been

leakage but in other cases the cement can be remarkably strong after

20 to 30 years.

One retainer loose: If one retainer is loose it is important to support

that end of the bridge with firm finger pressure, otherwise the

dislodging force will slew the bridge and cause it to lock even tighter

on the firm retainer. It is even possible that damage could occur if the

force is misused in this way.

1. Inertia Forces:

a. Wire:

A loop of soft stainless steel wire or brass about 0.6 mm in diameter

may be threaded under the connectors and formed into a loop. A

bar or instrument handle can be passed through the loop and held

35
taught. A sharp tap with a light mallet such as a surgical hammer

(or a fire door hammer for glass windows) may dislodge the bridge.

If one retainer only should come loose, move the wire to the other

connector and support that loose end as just described.

b. Inertia bridge remover:-

The inertia bridge remover has a captive weight on the end of a rod

with an end stop. The other end has a hook or claw, often

interchangeable, but this is usually engaged under the connector. In

some bridges the claw may be engaged under a positive edge of a

retainer. The rod is held as near to the axial direction as possible

and a short blow is struck with a sliding action on the weight. When

removing a bridge from the upper jaw the patient’s head should be

steadied against the headrest by the DSA applying gentle pressure

with the palm of the hand against the forehead of the patient.

Support of the jaw when removing a lower bridge is more reassuring

for the patient as well as cushioning the action.

c. Chisel:-

36
 A straight chisel may be used to remove an inlay and also a full

veneer retainer by applying a gentle tap in the axial or near-axial

direction with a light hammer or weight. The chisel should not be

tungsten carbide tipped or it may become damaged. At first the

chisel should be so angled that, with a tap or two, it is made to cut

into the metal and then the angle is altered to be as near axial as

possible. Not only is this a useful method, as every surgery will have

a chisel, but it sometimes works where the inertia bridge remover is

difficult to apply, although the inertia bridge remover is usually the

most useful method.

2. Reciprocal forces:

a) Band-removing pliers: To use orthodontic band-

removing pliers, a hole is made in the top of the full veneer

crown, larger than the prong on the pliers, which rests on the

surface of the abutment. The claw or beak engages the cervical

margin and the handles are brought together.

37
 b) Inlay remover: An inlay remover is made of hard

tool steel similar to an engineer’s stud remover. A hole of

suitable size is drilled in the full veneer crown so that the threads

of the inlay remover engage in the metal. The end of the plug is

brought to bear on the occlusal surface of the abutment. Both of

these devices act reciprocally and no force is brought to bear on

the periodontium.

3. Division of the retainer:

38
 A burr cut can be made on the buccal or lingual surface of a full

veneer retainer. A chisel may be placed in the slot and twisted so as to

separate each part and break the cement lute, or the chisel may be

put in the groove so as to prize each part away from the tooth. This

method usually works well even with a stubborn bridge but the

problem is that the bridge will be spoilt for subsequent replacement or

even as a temporary bridge.

Thought should be given as to whether to divide on the buccal or

lingual. Gold is easier to bend than alloy with bonded porcelain and

such bulky retainers have even had to be divided on both buccal and

lingual to effect loosening.

Division of a connector: Sometimes it is indicated to divide a bridge

connector. In the illustration it may be desirable to extract the first

molar. The bridge could be divided at the conector between the pontic

and the molar. This leaves the first premolar covered and the pontic

continues to give aesthetics until the emergency is over.

39
 A diamond disc in a disc guard with water will do this rapidly. The

diamond should be confined to the peripheral part of the disc and then

it will not jam in the metal so easily.

Direct temporary bridge replacement: It may be worth taking an

alginate impression before starting to remove an old bridge that may

disintegrate and then a direct temporary bridge replacement in

autopolymerizing acrylic or epimine plastic may be readily produced.

Richwill crown removal: It is a green sticky tube which is softened in

hot water and placed over the crown. Patient is asked to bite and hold

for a few seconds. Then opening the mouth quickly leads to removal of

the crown.

MAINTENANCE:

Importance of high standard of maintenance i.e. by patient and

dentist cannot be overemphasized. It is to be hoped that any crown/

bridge placed will have a life expectancy of at least a decade and with

high level of maintenance, restoration are often seen surviving for 2-3

decades.

Following cementation patient should be instructed in particular

oral hygiene procedures necessary because of the restoration. For e.g.

A crown needs burnishing and flossing just as a sound tooth, but the

position of margin and particular need for care in cleaning should be

demonstrated to the patient. For a bridge, particular care has to be

taken of the proximal area between retainer and pontic. The patient

will not be able to use a dental floss; the use of floss threader or

superfloss should be demonstrated.

40
 In cases of high decay rate/ decreased salivary flow, dietary

advice should be given and use of fluoride rinses encouraged. Athletes

and patients with a tendency to brux should be provided with a

suitable guard appliance.

The patient should be asked to return for review if any symptoms

develop, mobility is felt or for some reason the restoration feels

difficult from when cemented.

REVIEW APPOINTMENTS:

• Should be regularly made depending on caries rate and the

standard of oral hygiene.

• Should be done every 6 months.

• Restoration is examined with a sharp probe to detect if any

deficiency is present, mobility of tooth determined.

• Check occlusion

• Periodontal evaluation, bleeding on probing, gingival

recession, loss of attachment indicate active disease and patient

will need to be encouraged in better cleaning.

• Periodic radiography is essential for patients with high

caries index.

41
REFERENCES FROM JOURNAL:

1. Effect of connector design on the fracture resistance of all

ceramic FPD. JDP 2002; 87; 536.

Conclusion:-

1. The fracture resistance of 3 unit all ceramic FPDs was affected by

modification of the radii of curvature within the embrasure

space.

2. For the connector design tested, the radii of curvature at the

gingival embrasure strongly affected the fracture resistance of

all ceramic FPDs. As the radius at the gingival embrasure

increased from 0.25 – 0.90 mm, the mean failure load increased

by 140%.

3. The results of this study suggested that the occlusal embrasure

can be designed as sharp as is practical for the esthetics of an all

ceramic 3 unit FPD, provided that the gingival embrasure has a

increase radius of curvature.

2. Success rate and failures for FPD after 20 yrs of service. IJP

1999; 11(2):133.

Knowledge of the background factors and conditions that cause

FPD and crowns to become unserviceable should help dentists in their

prosthetic treatment planning. Furthermore, a more reliable prognosis

might be possible.

This study reports the cumulative success rate of 140 FPD (at

least 5 units after 20 yrs in service).

42
Conclusion:-

1. The cumulative success rate after 20 years in service was 65%.

2. The most frequent reason for the removal of a FPD were esthetic

and periodontal problem, as well as loss of retention.

3. There was no difference in failure rate between FPD with /

without a cantilever for the last 8 years of the 20 yr follow up

period, even though such a difference had been discovered for

the preceding follow-up.

4. The majority of the removed FPD had been replaced by a new

fixed restoration.

3. A survey of crown and FPD failures: length of service and

reasons for replacement: Length of service and reasons for

replacement. JDP 1986; 56(4):416.

1) Mean length of service – 8.3 yrs

2) Caries was the most common cause of failure, affecting 22% of units

failed

Mechanical problem – 69.5%

Oral problem 28.5%

Resin veneer metal crowns provided the longest service and

failed most frequently because of worn/ lost veneers. Complete veneer

life span of 6.1 yrs fail because of caries or defective margins.

Ceramic metal life span 6.5 yrs. Failure because of porcelain fracture

of poor esthetics

43
Resin veneer metal crown – longest service

PV crown

ceramic metal

No relationship between span of prosthesis and its length of service.

4. Clinically significant factors in dowel design. JDP 1984;

52:28.

- Tapered cast dowel and core displayed a higher failure rate than

teeth treated without intracoronal reinforcement.

- Parallel sided serrated dowel did not have failures caused by

tooth fracture, whereas failures of the tapered cast dowel and core

required extraction in approximately 1/3rd of the fractured teeth.

- Teeth that had a dowel length equal to or greater than crown

length had a success rate that exceeded 97%.

- The cast parallel sided serrated dowel and core and the parallel

sided serrated dowel with an amalgam or composite resin core

recorded the highest success rate.

Conclusion:

Well organized and efficient postoperative care is the chief

mechanism of success of FPD.

A restoration that is cemented forgotten and ignored is likely to

fail regardless of how skillfully it was designed and executed.

44
 If possible the dentist should anticipate long term prognosis and

treatment needs of the patient and attempt to design the treatment

plan accordingly.

The patient must understand the limitations of fixed

prosthodontic treatment before the treatment begins.

“Designing a bridge is difficult

It is neither a precise science nor a creative form of art

It needs knowledge, experience and judgment

which takes years to accumulate”

BIBLIOGRAPHY:

1. Planning and Making Crown and Bridge – Bernard GN Smith.

2. Inlays, Crowns and Bridges – A Clinical Handbook. George F

Kantorowitz.

3. Modern Practice in FPD – Johnston.

4. JPD 1984; 52:28.

5. JPD 2003; 90:31.

6. JPD 1995; 73:440.

7. BDJ 1984; 157:61.

8. JPD 1986; 50:416.

9. IJP 1999; 11:133.

10. JPD 2002; 87:536.

45