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Clinical Study on the Reasons for and

Location of Failures of Metal-Ceramic
Restorations and Survival of Repairs

Article in The International journal of prosthodontics May 2002

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Mutlu zcan Wilhelm Niedermeier

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Clinical Study on the Reasons for ub

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and Location of Failures of tio
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Metal-Ceramic Restorations and ss e n c e
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Mutlu zcan, Dr Med Denta
Survival of Repairs Wilhelm Niedermeier, Prof Dr Med Dentb

Purpose: A recently introduced technique, the CoJet system, using SiOx (Al2O3 coated
with silisic acid), provides ultrafine mechanical retention by sandblasting, as well as a
chemicophysical bond between the metal/ceramic and the composite resin. This study
determined the reasons for and locations of failures of metal-ceramic restorations and
evaluated the survival of the intraoral silica-coating system used for the repair of failed
restorations. Materials and Methods: A total of 153 patients possessing 289 fractured
crowns were involved in this study; 255 of these fractures were on fixed partial dentures,
whereas 34 were on single crowns. The mean observation period was 34.6 months. The
materials used for the repair process were ESPE-Sil for silane; Visiogem, Sinfony, and
Dentacolor as opaquers; and Pertac II Aplitip, Sinfony, and Charisma as repairing
composite resins. Results: The majority of the failures (65%) occurred in the anterior
region. Sixty percent of the failures were observed at the labial, 27% at the buccal, 5% at
the incisal, and 8% at the occlusal regions. The fractures were mainly in the maxilla
(75%), predominantly at the labial surface. The overall cumulative survival rates of the
repairs (89%) showed that the first failures happened mostly from 1 week to 3 months
after the repair, without any difference between the composite resins. Conclusion: The
original failures happened mainly during chewing function or because of accidents,
iatrogenic factors, and surgical operations, whereas secondary failures after repair using
intraoral silica coating and composite resin were due to trauma, chewing function, or
lack of rubber dam application. Int J Prosthodont 2002;15:299302.

M etal-ceramic crowns and fixed partial dentures

(FPD) are common restorations used in fixed
prosthodontics, since they combine the high strength
properties of metal with the cosmetic appearance of
ceramic. Although fractures of such restorations do
not necessarily mean failure of the restoration, they
pose an esthetic and functional dilemma to both the
patient and the clinician. In clinical practice, such
failures may occur because of impact load, fatigue
load, improper design, microdefects in the ceramic,
aAssistant Professor and Lecturer, Department of Prosthodontics,
Dentistry Faculty, Marmara University, Istanbul, Turkey.
bProfessor and Head, Department of Prosthodontics, Medical and
Dental School, University of Cologne, Germany.
Reprint requests: Dr Mutlu zcan, University of Groningen, Faculty
of Medical Sciences, Oral Health Institute, Antonius Deusinglaan
1, 9713 AV Groningen, The Netherlands. Fax: + 31 50 3632696.
e-mail: mutluozcan@hotmail.com
This study was presented in part at the European Prosthodontic
Associations 24th Annual Congress, 2426 August 2000,
Groningen, The Netherlands.
inadequate metal support, poor abutment prepara-
tion, technical errors, incompatible thermal coeffi-
cients, or occlusal prematurity.16 These fractures
present a clinical problem and have created a de-
mand for the development of a simple, efficient in-
traoral repair method that does not necessitate the re-
moval and remake of the entire restoration.
The main reasons for an intraoral repair are to
avoid the substantial cost of interim prostheses and
laboratory work, to minimize the time required at the
clinic and laboratory, to avoid the possible propaga-
tion of cracks or crazing,7 to avoid the distortion (40
to 100 m)8 that might occur during removal and ad-
ditional firings of the restoration, to prevent accu-
mulation of microorganisms and plaque on the frac-
tured surface,9 and of course, to be conservative.
Various repair techniques have been suggested in the
literature, many of which are considered interim solu-
tions, but they are still preferable as it is important to
maintain an extensive restoration for even a few years
longer in the mouth.10,11 Of these systems, organosilane
coupling agents are not able to bond to metal surfaces

Volume 15, Number 3, 2002 299 The International Journal of Prosthodontics

 Failures and Repair Survival of Metal-Ceramic Restorations
as they do to porcelain.10 Hydroflouric acid and acidu-
lated phosphate fluoride facilitate micromechanical
retention, but these chemical agents are not applicable
to fractures where metal is exposed. Moreover, the
hazardous effects of hydrofluoric acid in vivo are well
recognized since it was found to be a harmful, irritat-
ing compound for soft tissue.11 Mechanical roughen-
ing with fine and coarse diamond burs is reported to
provoke crack initiation and propagation.12
A recently introduced air-abrasion technique (CoJet,
ESPE) based on tribochemical silica coating provides ul-
trafine mechanical retention by sandblasting, as well as
a chemicophysical bond between the composite resin
and the ceramic or metal alloy using a silane coupling
agent.1316 The working principle of CoJet is tribo-
chemical application of a silica layer by means of sand-
blasting. The surfaces are blasted with 30-m grain
size Al2O3 modified with silisic acid, CoJet-Sand, with
an intraoral sandblaster. The blasting pressure results in
the embedding of silica particles in the metal or ceramic
surface, rendering the surface chemically more reactive
to resin via silane. Superior bond strengths compared
to methods involving the use of silane with aluminum
oxide, hydrofluoric acid, or diamond roughening only
are achieved when this conservative approach is used.16
The purposes of this study were twofold, namely
to identify the reasons for and locations of failures of
metal-ceramic restorations, and to evaluate the sur-
vival of an intraoral silica-coating system used for the
repair of such failed restorations.
Materials and Methods
A total of 153 patients (83 women, 70 men) with a
mean age of 53 years (30 to 72 years old) possessing
289 fractured metal-ceramic restorations were in-
volved in this study; 255 of these ceramic fractures
were on FPDs, whereas 34 were on single crowns.
The clinical evaluation took place between July 1997
and May 2000. The follow-up examination stopped
in July 2000, with a minimum observation period of
2 months and a maximum of 40 months (mean 34.6
months). All the repairs were carried out by the same
operator at the Departments of Prosthetic Dentistry,
University of Cologne and University of Marmara,
Istanbul. The materials used for the repair process
were ESPE-Sil (ESPE) as silane; Visiogem (ESPE),
Sinfony (ESPE), and Dentacolor (Hereaus Kulzer) as
opaquers; and Pertac II Aplitip (ESPE), Sinfony, and
Charisma (Hereaus Kulzer) as repairing composite
resins.
The types of failures were observed in three cate-
gories: fracture in ceramic only (cohesive), fracture
with both ceramic and metal exposed (cohesive and
adhesive), or fracture with substantial metal exposure
The International Journal of Prosthodontics
zcan/Niedermeier
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(adhesive).17 Most of the repair casesNwere
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Clinical Repair Sequence cat
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After determining the appropriate color, the fracture
area was insulated with a rubber dam, and modifica-
tions were made in the rubber dam depending on the
position of the pontic, especially in extensive FPDs.
Protective eyeglasses and masks were used for both the
patient and the staff. Strong evacuation for CoJet-Sand
and saliva was required. Based on the optimal results
of pilot studies, air abrasion was employed with a
nozzle distance of 10 mm away from the surface at an
angle of 90 degrees for 13 seconds at 2.3-bar pres-
sure.18 The metal-ceramic surface was blasted with an
intraoral sandblasting device (Danville Engineering)
using silicated particles (CoJet-Sand, SiOx, 30 m).
The conditioned surfaces were silanized with ESPE-
Sil and allowed to dry (5 minutes) before the opaquer
was applied. No air drying was used because of pos-
sible water or oil contamination. Opaquer was then
dispensed, mixed using a plastic spatula, and painted
on the silanized surface to mask the underlying metal.
It was light cured from three different directions with
an Optilux 401 light-curing unit (Demetron Research).
The output of the light-curing unit was regularly
checked for sufficient intensity (Cure Riteo model
8000, EFOS).
Subsequently, repair resin was applied with incre-
mental buildup and light cured from three different
directions, strictly obeying the curing times advised
by the manufacturers. Following rubber dam removal,
centric and eccentric occlusal adjustments were per-
formed. Finishing and polishing, considered to have
potential effects on the quality of the repair resin, were
performed meticulously with diamond burs (Tc-b,
Intensiv) of 15- to 40-m grain size, carbide burs,
extra-fine diamond burs, or stones. The surfaces were
finally polished with a diamond gel or paste. The fail-
ure criteria for the study were chipping of the repair,
partial failure, which could be either adhesive or co-
hesive, or total failure.
Results
Original Failures
From the statements of the patients, it was found that
66% of the 289 failures happened during normal chew-
ing functions (nuts, chocolates with nuts, apple, ham-
burger, pizza, etc), 10% were due to accidents (roller
skating, motorcyle accident, or involved in a fight), 6%
happened during surgical operations when the oper-
ators placed the intubator in the mouth during general
300 Volume 15, Number 3, 2002
 zcan/Niedermeier Failures and Repair Survival of Metal-Ceramic Restorations

pyr
anesthesia, and 18% were due to iatrogenic factors No Failures
Table 1 Percent Distribution of 289 Ceramic
Co ig

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in Maxillary and Mandibular Regions
t fo
such as during occlusal adjustments, crown removal, r

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or endodontic treatment without crown removal.
Pu
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Aspect Maxilla Mandiblecat
The majority (65%) of the failures were observed ion
Labial 47 te 13 ot

n
in the anterior region, whereas 35% were in the pos-
terior region. Sixty percent of the failures occurred at
Buccal 22 ss e5n c e
fo r
Incisal 4 1
the labial, 27% at the buccal, 5% at the incisal, and Occlusal 2 6
8% at the occlusal regions. The fractures were mainly
in the maxilla (75%), predominantly at the labial sur-
face (Table 1). 100

Repairs
90
89%
Of the 289 repaired restorations, 22 (8%) were not
successful and required a second repair, 19 of which 80

were facings of FPDs and three of which were single
crowns. In six of these cases, rubber dam application
was not possible. In eight cases, damage was due to
a second trauma (sports, fight, roller skating, or mo-
torcycle accident), and eight cases fractured during
normal chewing function. Six of the restorations were
repaired for the third time. Some staining was ob-
served in 14 of the repairs in their third year, and these
were polished again. These patients were all heavy
smokers. The overall cumulative survival rate was
89% according to the Kaplan-Meier curve method.
The first failures happened mostly from 1 week to 3
months after repair (Fig 1).
Discussion
When a material has passed various preclinical lev-
els of physical and biologic tests, the ultimate test re-
mainsa clinical evaluation. This comprises ob-
serving the performance of the materials under
intraoral conditions. The repair of fractured porcelain
restorations or metal-ceramic bond failure is a chal-
lenging clinical situation, as there is little or no doc-
umentation on the clinical performance of such
restorations.
The complexities of the oral environment and var-
ied surface topography of dental restorations make it
difficult to precisely define the magnitude and mode
of stresses involved in clinical fracture. The laboratory
cannot accommodate intraoral variables and the com-
plexities of the oral environment. When crowns are
cemented intraorally, factors other than inherent me-
chanical strength of the materials come into play.
Under continuous application of mechanical envi-
ronmental loads, progressive degradation may lead to
crack initiation and growth, and ultimately to a cata-
strophic failure of the repaired restoration.17,19,20
In the clinical observations during this study, it
was realized that the reasons for the failures are im-
portant. The results of the study revealed that the
Survival (%)
70
60
50
0 10 20 30 40
Time (mo)
Fig 1 Kaplan-Meier cumulative survival plot.
great majority of the ceramic fractures occurred at the
buccal or labial surfaces of the restorations during
chewing. Patients who are at risk, such as those prac-
ticing physical contact sports, should not be involved,
or they should at least be warned of possible fracture.
The oral environment is also important for the dura-
bility of the repair materials. Water absorption may re-
duce the mechanical properties of resin-based materi-
als. Dimensional stability or creep properties are of
interest because restorations are used in load-bearing
areas, where relative deformation could occur under
a static or intermittent load. Clinical experience has also
shown that composite resins are subject to wear and un-
dergo other physical and chemical alterations.17 When
composite resins are used as esthetic anterior restora-
tions, these alterations lead to a decreasing esthetic ap-
pearance because of changes in surface gloss, color,
and loss of substance. Therefore, the surface gloss, ob-
tained using polishing procedures, must remain stable,
especially when the repair is in the anterior region.11
It is well known that fillers of the composite resins
are not stable under clinical conditions. Some glass
fillers are slightly water soluble. Roulet21 showed
changes in fillers after exposure to the oral environ-
ment over 1 year. Because of this fact, the choice of
a moderately filled resin would be important in an-
terior esthetics in clinical practice.22

Volume 15, Number 3, 2002 301 The International Journal of Prosthodontics

 Failures and Repair Survival of Metal-Ceramic Restorations
Oral habits of the patient are essential considerations
for the survival of repair resins. Expectations are ob-
viously reduced in a patient with poor oral hygiene be-
cause the resin composite does not provide a defence
against the effect of leakage and bacterial invasion.
From the clinical observations, it was also realized that
some patients who have high coffee, alcohol, or cig-
arette consumption should be considered risk patients
for discoloration of the repair. The average lifetime of
a repair with silica coating is often dependent on the
occlusal forces; therefore, occlusal adjustment should
be made meticulously. The adhesive technique re-
quires a perfectly isolated field. The use of a rubber
dam is mandatory during bonding procedures to pre-
vent contamination by debris or organic fluids.
The biggest advantage of the whole repair proce-
dure using intraoral silica coating is that it could be
carried out in the chair, which takes from 10 to 30
minutes, depending on the surface area of the frac-
tured veneer. Intraoral repair saves time and money
for both the patient and the clinician. However, care
should be exercised that FPDs that fulfill the funda-
mental requirements for an acceptable restoration are
the only candidates for intraoral repair.
At present, the minimum in vivo bond strength for
retention of an adhesive to a metal-ceramic restora-
tion in the oral environment is not known. Maximum
bite force capability of each patient and the presence
of surface damage may reduce the success rate. There
are, however, insufficient clinical data available at
this time to predict the clinical performance, which
also cannot be interpreted from in vitro studies.
Conclusions
1. The majority (65%) of the failures in metal-ce-
ramic restorations observed in this study were in
the anterior region, predominantly at the labial
surface and mainly in the maxilla (75%).
2. The reasons for the original failures varied from
chewing functions (66%) to iatrogenic factors
(18%), accidents (10%), or surgical operations (6%).
3. The outcome of this study revealed that intraoral
silica coating and silanization by means of the
CoJet system is a quick and promising option,
with an 89% success rate up to 3 years.
Acknowledgments
Special thanks are due to ESPE for their generous provision and
donation of the testing materials. The authors are grateful to Tero
Vahlberg for his assistance with statistical analysis.
The International Journal of Prosthodontics
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