Failures In Amalgam Restorations

Presented by Arpita Pareek

4/4/2013 ARPITA PAREEK

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FAILURES OF DENTAL AMALGAM Dental amalgam is one of the most frequently used restorative materials for restoration of posterior teeth. In routine properly restored silver amalgam may not last for more than ten years. Early restored teeth appear excellent but gradually peculiar things begin to happen altering the technical details of the restoration. These may lead to fracture of restoration, tooth fracture, recurrent caries, discoloration, corrosion, loss of restoration and etc. The observed amalgam failures are most likely because of factors other than the material itself. The success of the amalgam restoration depends upon the control and attention to many variables.

 The different types of failure in an amalgam restoration are I. At visual level Secondary caries Marginal fracture Bulk fracture Tooth fracture Dimensional change II. At the microstructural level Corrosion and tarnish Stresses associated with masticatory forces III. Pain following amalgam restoration IV. Pulp and/or periodontal involvement

 Failures in an amalgam restoration can be studied in detail under two main headings: Failures due to faulty cavity preparation Failures due to poor matrix adaptation Failures due to faulty amalgam manipulation

I. Faulty Cavity Preparation Most clinical studies have concluded that improper cavity preparation leading to recurrence of caries and fracture is the greatest single factor responsible for failure. Healey and Philips (1949)40 evaluated 1521 defective amalgam restorations and reported that 56% of the failures were because of improper cavity preparation and 42% of the failures were because of faulty manipulation of amalgam. The different causes of failure that can occur at various steps while preparing a cavity for amalgam are as follows: Inadequate occlusal extension : On the occlusal surface the preparation should be extended to include all the susceptible pits and fissures while terminating the margins in areas that can be finished. b) Inadequate extension of the proximal box If the proximal box walls are not adequately extended into the embrasures they are not amenable to brushing & cleaning by mastication which predisposes to secondary caries c) Overextension of the cavity preparation walls: The ideal facio-lingual width of the cavity preparation for amalgam should be 1/4th the intercuspal distance. If the cavity preparation extends to half of the intercuspal distance, consideration should be given to capping of the cusps. If the cavity preparation extends to 2/3rds of the intercuspal distance cusp capping becomes mandatory. If the remaining cusps are not capped in large amalgam restorations, there are chances that the cusps can fracture. This is because amalgam restoration on acts as a wedge and tends to split the exposing cusps apart. During cusp capping amalgam should be present in a minimum thickness of 2 mm over functional cusps and minimum thickness of 1.5 mm over non-functional cusps to give it adequate strength.

 d)Amalgam cavity preparations should have a minimum depth of 1.5 mm to provide it bulk .Hence resistance to fracture. e) If pulpal floor of the cavity preparation flat but curved the restoration produces wedging effect thus increasing the chances of fracture of tooth. To assure strong junctions between amalgam and tooth regardless of its location, butt joints created particularly in those regions where occlusal stresses to be encountered. Cavosurface angle is acute there are chances of fracture of the tooth margins whereas if the cavosurface angle is obtuse the acute marginal amalgam is likely to collapse under occlusal stress. The cavity margins should be adequately finished to remove any unsupported enamel rods, which are susceptible to fracture leading to gap formation and subsequently secondary caries.

 g) Failure to round off the axio-pulpal line angle as well as internal line angles and point angles can lead to concentration of stresses and fracture of the tooth or restorative material. h) Occasionally, fracture may be seen at the isthmus portion of the proximo-occiusal restoration, which may be because of a very narrow isthmus or inadequate proximal retention form. i) Failure to diverge the mesial and distal walls of the occlusal cavity preparation. When the mesio-distal extension of the cavity is extensive it can cause fracture because of the undermining of the mesial and distal marginal ridge enamel. j) Retentive devices should be prepared entirely in dentin without undermining the enamel. k) Incomplete removal of carious tooth structure leads to failure of amalgam restoration. l) Flat pulpal floor should be provided around the excavation site of caries. If this is not possible at least three flat seats should be provided to resist the forces directed along long axis of the tooth m) Post operative pain can also be a routine failure. The dentist should use high speed rotary instruments, with intermittent cutting and adequate cooling of tooth structure thereby minimizing the post operative pain.

 II. Poor matrix adaptation

The areas and relationship of contacts, the anatomical design ofthe marginal ridges, the marginal continuity of the restoration all play important roles in assuring that the tissues of the periodontium will maintain a state of health. The matrix should be very stable after it has been applied. Instability of a matrix results in a distorted restoration, gross marginal excesses and an uncondensed soft amalgam. The cervical excesses can irritate the periodontium, gradually and progressively destroying the periodontum. Establishing a proper contacts and contours with the help of matrices are fundamental to the successful amalgam.

lll. Faulty amalgam manipulation It has been stated that more amalgam restorations fail because of poor manipulation than because of the use of poor alloys. Successful restoration can be relieved when variables are kept under strict control. The basic principle of all these manipulative procedures is to produce a well-prepared amalgam with the mercury content in the amalgam under control. a) Mercury alloy ratio A serious loss of strength occurs when the residual mercury is in excess of 55% in the restoration. The clinical result of excess residual mercury includes reduced crushing strength, increased flow and increased susceptibility to tarnish and corrosion It is preferable to use a minimal mercury technique with dispensers used for the correct proportioning. Mulling is a continuation of the trituration process and is done to assure that all alloy particles are duly coated with mercury. It can be done manually or mechanically. While doing it manually, moisture can be incorporated into the material if bare hands are used. Mechanically, mulling is done in the amalgamator Both under trituration and over trituration can lead to failures of amalgam restoration. Under trituration leads to soft powdery non-coherent mix whereas overtrituration may break the already forming matrix.

b) Condensation The rationale of condensation is to reduce residual mercury content, to ensure amalgam reach all parts of the preparation and to obtain a homogenous restoration devoid of voids. Freshly prepared amalgam has more desirable working properties. The effectiveness of removing residual mercury from the restoration is possible only if the amalgam is used within 4 minutes of trituration. If a larger cavity demands that the working time of the amalgam exceeds 3-4 minutes, the use of multiple mixes will allow the operator to handle plastic amalgam throughout the condensation procedure and ensure building a homogenous restoration. There are limits to the removal of mercury also. Certain amount of mercury is necessary to bind the mass together in a homogenous form. Elimination of mercury by excessive squeezing may induces a laminated effect and seriously reduces the strength of the restoration. The end result is similar to working with a partially crystallized or set amalgam. The critical reduction of mercury levels below 55% is however obtained during packing. Condensation can be carried out either manually or mechanically. Condensation should be done using the stepping process to drive away any voids from the restoration. Small increments should be design of the marginal

 ridges, the marginal continuity of the restoration all play important roles in assuring that the tissues of the periodontium will maintain a state of health Instability of a matrix results in a distorted restoration, gross marginal excesses and an uncondensed soft amalgam. The cervical excesses can irritate the periodontium, gradually and progressively destroying the periodontium. Establishing a proper contacts and contours with the help of matrices are fundamental to the successful amalgam. Condensation pressure used should be adequate. Contamination Contamination of the amalgam mix during trituration, mulling and condensation, by moisture weaken amalgam restoration especially with zinc containing alloy. There occurs delayed expansion, which could possibly result in marginal flaws, tarnish, pitting, corrosion and blistering etc. Expansion may also lead to pain.

 Finishing and polishing The amalgam should be finished gently. During finishing excess amalgam at the margins is dressed down to thin flakes or spur like overhangs, which can fracture from the restoration sooner or later, leaving susceptible crevices. Overcarving the restoration to create normal, deep anatomic features should be avoided. An over carved restoration will reduce the thickness of amalgam and increase chances of fracture. Amalgams that have a greater tendency for tarnish and corrosion do not retain surface polish for a long time. Failure to polish may accelerate corrosion because of surface irregularities. Also the restoration surface is rough promoting plaque accumulation and gingival irritation. When temperatures above 65C are generated, mercury s released from the amalgam leading to defective restoration.

 Post-operative pain This may occur following an amalgam restoration because of hyper occlusion lead to inflammation of the apical periodontium. Cracks in tooth: Such cracks cause pain during chewing because of expansion & contraction of tooth structure with every bite. Galvanism not only the adjacent/antagonist dissimilar metal restorations lead to galvanism, but in poorly condensed silver amalgam, variation in silver concentration at different areas of the same restoration, also leads to it. Delayed expansion is peculiar with zinc containing alloys Failure in the form of pain may occur if inadequate pulp protection is present. Amalgam is a good conductor of heat. If a base is not given, heat may be conducted to the pulp resulting in its damage. Varnish should be routinely applied under amalgam restorations. Failure to apply proper varnish layer can lead to continuous leakage around the restoration. This leakage may cause postoperative sensitivity and amalgam blues due to penetration of corrosion products into dentinal tubules. The restoration fracture may occur if the patient does not follow the instructions properly and bites on restoration before it sets.