FAILURE OF

RESTORATIONS
 The restorative dentist is provided with a
wide range of materials to choose from to
restore any derangement lesion in hard
tooth substance

These lesions include :-

Caries
Erosion
Attrition
Traumatic Fracture
Discoloration
As well as abnormalities in from , size or
occlusion .
 Success and failure of the restorative
work depends on many factors which
include :

Degree of involvement
Skill of the operator
Restorative materials and techniques
 LONGEVITY FACTORS
Risk Factors for Biomaterials Clinical Performance

(1) OPERATOR
Technical ability, Age, Eyesight (and magnification) , ...

(2) DESIGN
Smear Layer, Bevels, Outline Form, .

(3) MATERIALS
Composition, Product Age,...

(4) INTRAORAL LOCATION

Anterior-Posterior, Maxillary-Mandibular, Lingual-Facial,
Premolar-Molar, Tooth Flexure, ...

(5) PATIENT
F-History, Diet, Oral Hygiene IQ, Caries Risk, ...
SURVIVAL-FAILURE TERMINOLOGY
Survival = f (clinician, design, materials, site, patient factors)

100
Survival (5 yrs) = 92%
SURVIVAL (%)

75

50 CL50 = 10 years

25

5 10 15 20
TIME (Years)
 CLINICAL FAILURES
Rates and Mechanisms
100
Early
A
SURVIVAL (%)

Post-Operative
Amalgam
Sensitivity Problem with
75 B A Cross-sectional
FAILING RESTORATIONS

Caries B CR Studies
DISTRIBUTION OF

C
Bulk C Composite
50 Fracture

Your conclusions
Glass Ionomermay vary,
depending on when you
25 Middle observe a failure.
Late

Ceramic Inlays
5 10 15 20
TIME (Years)
 CLINICAL PRACTICE
(45%)(Efficacy) = Effectiveness
100
EFFICACY =
Clinical longevity from
SURVIVAL (%)

clinical research data.

75
EFFECTIVENESS =
Clinical longevity from
private practice data.
50
CL50 = 6 CL50 = 13

25

5 10 15 20
TIME (Years)
 REPLACEMENT RATES
versus LONGEVITY
100
Actual clinical failure.
Anticipation of future clinical failure.
SURVIVAL (%)

Replacement for minor changes.

75

???
50
Private Clinical
Practice Research
25

5 10 15 20
TIME (Years)
 POSTERIOR AMALGAMS
*2660 Class I and II amalgam restorations
100
SURVIVAL (%)

High copper, zinc-containing

75
High copper, no zinc

50 Low copper, zinc-containing

CL50 = 22 y

25
Low copper, no zinc

5 10 15 20
TIME (Years)
Letzel H, van 't Hof MA, Vrijhoef MM, Marshall GW Jr, Marshall SJ. A controlled clinical study of
amalgam restorations: survival, failures, and causes of failure. Dent Mater 1989;5:115-121.
Objectives of operative
dentistry
Operative dentistry compromises procedures to
:-
Stop the original insult of caries , erosion or
attrition and prevention of its recurrence
To achieve this goal :
Correct outline form
Hermetically seal the interface ( Rest / Tooth)
Retention of bacterial plaque should be
inhibited
 Restoration of comfortable and
efficient mastication :-
Sedation of the pulp and dentine by
elimination of caries and application
of necessary liners and bases .
Insertion of strong permanent
restoration which should have
normal harmonious occlusion
without any prematurities.

Restoration of aesthetics :-
Not only the restorative materials
but also the preparation it self
should be esthetic .
 Criteria of successful restoration :

Exact replica of the missing part of the tooth

( size , from , color , translucency and texture )
The margins of the restoration are flush with
the tooth surface , and hermetically seal the
preparation .
Dimensionally stable restoration .
Healthy surrounding tissue with no irritation .
Patient enjoys efficient and comfortable
mastication .
The nature of oral
environment
Accessibility
The demand
The corrosive potentials
The aqueous nature
Thermal changes
oral microbes
Forces in the mouth
 The clinical manifestations
of failure
Recurrent caries
Dislodgment of restoration
Marginal or isthmus fracture
Discoloration of tooth and / or
restoration
Patient discomfort
Gingival and periodontal affections
Pulp irritation
 I. Recurrent Caires

Usually at the margins , although it may

occur under cracked or broken
restorations.
Common causes :
In correct cavity preparation in terms of
underextension .
Margins of the proximal cavity cavities
are left within the contact area .
If undermined enamel is left at the
margin of the cavities .
Tooth Defects: caries

Primary Caries at Proximal Secondary Caries

Surface Caries progress into beneath amalgam
dentin. restorations.
Destruction of dentin leads
to change of tooth
translucency.
Cervical abrasion and
amalgam blue
 AF CR
Outline form Include fault Same
Include No- seal these
adjacnet areas
suspicious area
Pulpal depth Uniform 1.5 Removed fault
mm but not usually
uniform
Axial depth Uniform 0.2-0.5 Removed fault
mm inside DEJ but not usually
uniform
Cavosurface 90 degree 90 or greater
margin
 AF CR
Textured of smoother rough
prepared walls
Cutting burs diamonds
instrument
Primary Convergence None (rough
retention occlusally ness/bonding)
Secondary Grooves, slots, Bonding
retention locks, pins, (grooves for very
bonding large or root
surface
preparation
 AF CR
Resistance form Flat floors, Same for large
rounded restorations: no
angles, box special form for
shaped, floors- small-to-
perpendicular moderate size
to occlusal preparations
forces
Base 2 mm for Not needed
indications thermal
conductivity
(pulp
protection)
May need for
diffusion of toxic
resin monomers
Angle of Departure

= 90 degree

<90 degree >90 degree

Tooth fracture

Restoration
fracture
Undermined Enamel
II. Gross marginal leakage
An important attribute for the clinical
significance leakage in the causation
of recurrent caries has not been
established.
However , factors which increase
marginal leakage will increase the
likelihood for caries recurrence .
Thus , the wider the restoration - tooth
interface the more leaky restoration.
 The restorative materials can be rated on
the basis for their adaptation in the
following descending order :

Direct gold
Amalgam
G.I. Cement
Banded Composite
Silicate Cement
Cast restorations
Bonding

Enamel bonding > Dentin bonding

Enamel bonding = 20-35 Mpa
Dentin bonding = 15-25 MPa
Configuration Factor
C.L. Davidson (1984)
C-factor = bonded surface
unbonded surface
Polymerization shrinkage:
1-2%: dependent on type of CR
(filler/monomer ratio)
Indicate internal stress of resin
composite after polymerization
Usually C-factor < 8 MPa
Configuration Factor

Greater C-factor increased internal stress

Cavity configuration
C-FACTOR

BONDED WALLS
C= UNBONDED WALLS
Smooth surface
restoration

1 Bonded
C=
5 Unbonded

C-FACTOR 0.2
Two walled cavity

2 Bonded
C=
4 Unbonded

C-FACTOR 0.5
CAVITY CLASS IV
Three walled cavity

3 Bonded
C=
3 Unbonded

C-FACTOR 1
CAVITY CLASS III
Four walled cavity

4 Bonded
C=
2 Unbonded

C-FACTOR 2
CAVITY CLASS II
Five walled cavity

5 Bonded
C=
1 Unbonded

C-FACTOR 5
CAVITY CLASS V&I
C-Factor
Increasing C-Factor
increases the shrinkage
stress loading on the
tooth-resin interface
leading to de-bonding
C-Factor
Once failure occurs,
post insertion
sensitivity and
recurrent caries can
become a problem
III. stagnation of bacterial
plaque
Open inter proximal contact and food
impaction , marginal over hangs , poor
or neglected polishing of restorations
and poor oral hygiene habits .

Because of composite polymerization

contraction and greater differential therma
expansion as compared to tooth
substance , caries recurrence around
composite is not un common.
Factors which impair
adaptation in cast
restorations
Fitting inaccuracy of the casting
Excessive surface roughness
use of luting cement of inferior quality
wrong cementation techniques
Neglecting to burnish all thinned out
margins of the preparation
Premature finishing of the restoration
Preventive measures and
treatment
Correct cavity out line ( free from defective
and retentive enamel) . Also free from
contact with adjacent teeth .
Adequate control of manipulative variables .
Use of fluoride - emitting restoratives and
techniques .
Adequate control on the formation and
retention of of plaque .
IV. Marginal Ditching

It refers to chipping of a thin edge of

a restoration leaving a V- shaped
marginal crevice ( amalgam ,
composite , and cement rest )
Brittle materials as amalgam and
cements have low tensile strength
and depend on bulk for marginal
integrity .
 Causes
Inadequate bulk of material due to beveling
of cavo - surface angle , over carving or
leaving of thin marginal flash .
Depletion of support for the marginal areas
of the restoration :
A . Excessive expansion from under -
trituration of amalgam , excess Hg or
moisture contamination .
B . Creep
C . Crevice corrosion of amalgam
Lowered strength due to inadequate
condensation of amalgam .
 V. Gross isthmus fracture
This type of mechanical failure is almost
limited to compound amalgam restorations (
low tensile and shear strength )
It usually start as crack at the junction
between the principles and the auxiliary of
compound restoration .
The patient may seek treatment because of
felling of pain on taking cold or citrus fluid.
The integrity of compound amalgam
restoration is a balance between the
magnitude of the significant stress and the
tensile strength at the stressed area .
Factors which increase
tensile stress at the isthmus
Improper cavity design in terms of incorrect
and inadequate retention.
Presence of pre-mature contact due to
incorrect carving.
Presence of stress - concentrators as
increased roughness due to improper polish
, internal voids due to corrosion or lack of
adequate condensation and carving into
deep fissures.
Factors which lower the tensile
strength of amalgam
The tensile strength of amalgam restoration
may lowered by any manipulation which :-
A . Increase the amount of the weak tin-
mercury phase .
B . Impaired cohesion between the individual
phase of amalgam as well as between
successive increments.
C . Decreased density , such as poor
condensation leaving internal voids as well
as moisture contamination of certain alloys .
VI. Excessive Discoloration

Although this may a be a problem with tooth

colored restoratives , yet amalgam
restorations may cause unsightly discoloration
of the restored tooth if the undergoes
excessive corrosion .
Discoloration of tooth- colored restoratives ,
composite and cements , may initially related
to color selection or to an inherent weakness
of the material or poor techniques of
manipulation .
 Surface Discoloration
Composite and cements have heterogeneous
structure of a softer matrix binding harder
particles of cement powder or inorganic filler in
case of composite .
The two components wear at different rates
depending on their resistance .
This make maintenance of a perfectly surface
for clinical restorative materials a difficult
problem .
Marginal Discoloration

It is mostly due to impaired a adaptation

and marginal leakage of stains . Therefore ,
any factor which influence adaptation will
result in corresponding degree of marginal
discoloration , such as :
1 . Difference coefficient of thermal expansion
.
2 . Poor condensation techniques .
3 . Yielding of composite restoration.
4 . Setting contraction of cements .
Bulk Discoloration
It may be due to contamination of the
restorative during mixing , use of inferior
or expired product or it may be due to
chemical shift in peroxide amine .
Inclusion of air voids may inhibit the
polymerization and results in spongy spots
of composite restorations .
Water sorption by composite may lead to
sorption some stains and discoloration .
 To avoid discoloration of
clinical restorations :
1 . All Caries and stained tooth tissue must
be eliminated.
2 . Scientific techniques should be followed .
3 . Contamination must be completely
avoided.
4 . The importance of oral hygiene and
routine check-up.
ADA has indicated the
appropriateness of resin
composites for use as
Pit and fissure sealant
Preventive resins
Initial Class I, II lesions using modified
conservative tooth preparations
Moderate sized Class I and II
restorations
Class V restorations
ADA does not support the
use of composites in
Teeth with heavy occlusal stresses
Sites that cannot be isolated
Patients who are allergic or sensitive
to composite materials
Treatment of discoloration
Total removal of restoration .
Elimination of discolored tooth substance
and undermined enamel .
Application of cavity varnish under amalgam
.
Construction of a new restoration of good
quality product .
Also the effect of smoking on discoloration of
tooth colored rest .
VII. Adverse Effects on
Periodontium
Causes
Results
Causes Results
Overhanged margin Loss of periodontal
attachment
Food impaction
Margin of
restorations below
gum line Secondary caries
Over/under-contour Gingival inflammation
Loose contact of
restoration
Supraeruption,
malalignment
Edentulous area and
tooth shift
Operators:poor matrix
and wedge
Margin below CEJ
Dental materials: GI,
acid etching and
bonding Sloughed gingiva
VIII. Post - Restoration Pain And
Discomfort
It may be immediate or may occur several
weeks or months post restoratively .
The pain may be spontaneous or occur on
application of stimulus , thermal , electric ,
osmotic , mechanical and galvanic .
Pain occurring few hours after restoration
when the patient just bring the teeth in
contact be galvanic or may be due to
premature contact .
 White Lines
White lines indicate a failure to
control shrinkage stresses at the
tooth-restoration interface

When shrinkage stresses

exceed the bond strength, micro
gapping occurs
No white lines at the
margins?

What about white lines where

you cant see them
At the bottom of a proximal box
In the base of the restoration
Micro-gapping due to
composite shrinkage
A new patient
presented with hot,
Once desiccated, the
cold and pressure
de-bonding became
sensitivity
very apparent
associated with a
resin bonded
composite placed
less than a year
previously.
 Causes of possible pathological
responses of dental pulp related
to operative
Physical dentistry condensation, air
: occlusal interference,
blowing or dentin dehydration
Thermal: heat from cutting, insufficient pulpal
protection for metallic restoration
Electrochemical: galvanism
Chemical: toxicity of dental materials, acid
etching
Bacterial: toxin products
Traumatic stimuli: abrasion, attrition, erosion
dentin exposed
Operator: poor contour-contact, overhanged
margin, poor anatomy, damage of adjacent tooth
 Operative Procedures
1.Heat
2.Condensation
3.Dehydration
Brannstrom (1968): vigorous drying of dentin
(Cl V, human premolars) for 2 min mild
inflammation, frequently found loss of
odontoblasts followed by the formation of
reparative dentin
4.Iatrogenic:
mechanical pulpal exposure, pin placement
Class II tooth preparation: defects to adjacent
tooth
Injury to soft tissues: buccal mucosa, tongue
 If accurse on cold application it may
indicate the need for cement underlining
insulating base.
Cracked restoration will cause pain on
cold application or ingestion of citrus
drinks .
Pain occurring days or weeks after
restoration may indicate sever pulp
damage
Over extended of the gingival floor , may
cause gingival and periodontal damage .
Allergic Reactions to
Amalgam
Amalgam Tattoo
Adverse Effects of
Monomeric Resins
Dental Response to
Bacterial Invasion
Caries
Microleakage of restorations
Presence of Bacteria in Dentinal
Tubules

1500x
Ref: Chirnside IM, New Zeal Dent J 1958, 54, 173.
Dental Pulpal Response to
Bacteria
Positive correlation of presence of bacterial
beneath restorations and inflammation in
the underlying pulp
Bergenholtz (1982): dentin permeability to
noxious bacterial agents decrease with time
Smear layer may harbor bacteria. But,
evidence suggests that bacteria will grow
underneath a restoration only in the
presences of microleakage
Role of bacteria in dental
pulp reactions
Proteolytic enzymes: collagenase, protease
Active substances: toxin products
Stimulate lymphocytes, macrophages, plasma
cells, PMN leukocytes infiltration inflammation
Persistent inflammation leading to tissue
breakdown exudate pH change from alkaline
to acidic neutrophils disintegration
lysozymes, trypsin-like enzymes digestive
products pus
 VALUE OF EVIDENCE
TIME DEPENDENT CHANGES: Wear resistance, microleakage,
secondary caries, color change, micro-tensile bond strength, ..

4
PERFORMANCE

TIME