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Failure in Fps
Failure in Fps
1 2 3 4
Fig. 3.-Loading in the centre of the beam causes flexure which has a
Fig. 1. -Four post-core designs subjected to loading. Design 2 was shown tendency to cause deformation at the abutment margins and places the
to be significantly more resistant to failure than the other designs. integrity of the cement seal at risk.
From Sorensen and Engelman." From Caputo and Standlee."
to fail than a tooth with no post. Optimal success rates a 60 degree bevel at the crown margin, or at the tooth-
were observed with long posts. core junction, was ineffective.
In a comparison of various post-core designs (Fig. l),
Sorensen and Engelman" found that teeth with cast Metal frameworks
tapered post-cores which were maximally adapted to the Fixed prosthodontic metal frameworks, as with any
root canal exhibited failure loads almost double those of metal beam, will flex when subjected to loading (Fig. 3).
the teeth with the other post-core designs. However, when Laboratory experimentsz0indicate that such flexure may
failure occurred, these teeth fractured and were unsal- cause deformation near the abutment margins and place
vagable whereas failure of teeth with parallel-sided posts great stresses on the sealing cement. This may ultimately
often involved less damage to tooth structure. lead to disruption of the cement layer and loss of cemen-
In a further study,I9 the same authors found that 1 mm tation. Consequently, metal frameworks must be
of coronal tooth structure above the crown margin (that sufficiently rigid to withstand such deformation.
is, encircling at least 1 mm of sound dentine) almost The flexure of a beam is proportional to the third power
doubled the fracture resistance (Fig. 2). On the other hand, of the beam span; therefore, limiting flexure becomes
increasingly more difficult as the space between abutment
teeth increases.z' There is, in these cases, an even greater
need for the selection of materials with adequate physical
properties (namely a high modulus of elasticity) and the
provision of a sufficient thickness of metal. The added
thickness is most needed in the direction of load applica-
tion, that is, occluso-gingivally.1. l 6
In ceramo-metal restorations deformation of the metal
can lead to debonding and fracture of the porcelain, hence
there is an added requirement for rigidity. Possibly of even
greater importance in the selection of a porcelain fused
to metal alloy is its ability to be effectively oxidized and
achieve optimum bonding of the porcelain veneering
material.
Fosterz2found that precious metal (that is, gold-based)
bridges had a significantly longer mean service life than
semi- or non-precious alloy bridges (10 years versus 3.9
years). The author felt that the unacceptably poor result
for semi- and non-precious alloys may be a reflection of
difficulties with bonding and incorrect oxidation encoun-
tered with these materials. Metal frameworks must also
be designed to avoid large unsupported sections of
porcelain which may otherwise f r a c t ~ r e . ~ , '
Fig. 2. -Encircling one millimetre of axial tooth Casting imperfections, porosity, poor or small solder
structure with the crown will significantly increase
the fracture resistance of the restored tooth.
joints and small connectors may all predispose to frac-
From Sorensen and Engelman." ture in a framework. Eighty-three per cent of fractures
Australian Dental Journal 1994;39:3. 153
the abutments, increased parallelism between abutments
and an increased thickness of metal to resist bending.
Reuter and Brose2found a higher incidence of failure with
long span bridges. Schwartz et a1.’ found that most long
span bridges had a markedly shorter than average life span
(8.6 years compared with 11.2 years for all bridges).
Interestingly, the exceptions to this were 6-unit bridges
from canine to canine which proved to have the longest
mean life span before failure (15.1 years). The results
reported by Walton et a1.* were similar.
Reuter and Brose2also found a significantly higher rate
Fig. 4.-A, Force applied outside the centre ofrotation ofabutments produces of failure with bridges that extended around the corner
a lifting force at the opposite end of the bridge. B, Force applied between
centres of rotation of abutments produces a seating force on both retainers. of the arch to include both anterior and posterior teeth.
From Jacobi R er aLZ4 Whereas 8.3 per cent of their posterior bridges failed, and
14.7 per cent of their anterior bridges failed, the authors
found 58.8 per cent of their combined anterior-posterior
in cantilevered bridges occur on the mesial of the most bridges became failures.
distal abutment toothy9hence this connector should be
strengthened routinely. Cantilever designs
An impact falling between the centres of rotation of the
Retainer selection abutment teeth in a fured prosthesis has the principal effect
It is recognized that the rigidity of an intact tube is much of seating the bridge rather than displacing it (Fig. 4).
greater than that of a tube which has been cut open. On the other hand, a force applied outside the centre of
Similarly, a full crown is much more resistant to defor- rotation of an abutment tooth will cause it to tilt and there
mation (and cement failure) than a three-quarter or partial will be a resulting force exerted on the distant retainer
crown. tending to lift it off the abutment tooth leading to early
Robertsz3 examined 1046 bridges made at Eastman failure. The importance of the fulcrum and its position
Dental Hospital between 1952 and 1964 to determine the relative to the site of load application is highlightea by
suitability or otherwise of different types of bridge the results of an experiment performed by Jacobi et aLZ4
retainers for various types of bridges. Although there have They observed that when the impacts fell between the
been a number of advances since this study was begun, centres of rotation of the abutments the retention time
the fundamental nature of crown and bridgework has not of the cemented bridges was more than 24 times greater
altered. The study is primarily concerned with matters than when they fell outside. In some situations longevity
of design, and the conclusions drawn regarding the rela- was increased 130 fold.
tive failure rates of various bridge designs or retainer types, Therefore, it would seem desirable in fixed bridge
when compared with one another, are still likely to be designs to minimize the application of loads outside the
valid. long axes of the abutment teeth wherever possible.
Robertsz3found that fill crowns were considerably more However cantilever bridges, by design, cannot avoid such
successful than three-quarter crowns as major retainers loads. Therefore, exceptionally good retention is needed
(that is, those retainers rigidly attached to a pontic). Inlays, for the retainer that is firthermost from the eccentric load.
pinlays and post-crowns had high failure rates. He In an epidemiological study of 274 fEed prostheses made
concluded that in bridges rigidly fixed at both ends, only 6 or 7 years earlier, Randow et a1.9compared three groups
full crowns should be used as retainers. In fixed-movable of bridges: bridges with a distal abutment tooth, bridges
designs a three-quarter crown might be adequate as the with a single cantilever pontic, and bridges with double
major retainer, although slightly less reliable. cantilever pontics. They found that the frequency of tech-
A minor retainer is defined as the one which is not nical failures (that is, fractures of prostheses, of abutments,
rigidly attached to a pontic in a stress-broken design (that and loss of retention) was directly related to the degree
is, the retainer incorporating the dovetail or slot). Roberts of cantilever extension. The rate of failures increased with
concluded that for use as minor retainers both full crowns time, and this increase was much more severe with
and three-quarter crowns were extremely successful. multiple cantilever pontics. These results were mirrored
MOD, Class I1 and Class I11 inlays could be considered by Karlsson’ who, after 14 years, found a failure rate of
for use, but are much less reliable. 12 per cent for bridges with an abutment at either end
as compared with 33 per cent in designs with cantilever
Long spans and complex designs pontics.
Failures are more likely to occur with long spans (more On the other hand, cantilevered fixed prostheses
than 5 or 6 units) and with complex designs. Nymen and compared favourably when compared with removable
Lindhe’ found that long spans and long cantilever designs partial dentures in a 5-year longitudinal study with two
were more prone to loss of retention. They stated that similar groups of patient^.'^ Although technical failures
in these cases there was a need for increased retention on occurred with 19 per cent of the bridges, most could be
154 Australian Dental Journal 1994;39:3.
Fig. 6 . -A stress-broken bridge design, utilizing shorter segments which
are not rigidly connected prevents the central abutment from acting as a
fulcrum.
Fig. 5.-An intermediate abutment tooth in a fully fixed design acts as a From Caputo and Standlee.”
fulcrum. Loads applied on one side cause lifting of the bridge retainer at
the opposite end.
From Caputo and Standlee.”
Foster” found a significant correlation between the life
span of failed bridges and the number of retainers in their
design: 7 years for bridges with one or two retainers as
easily recemented. However, in the removable partial compared with 4 years when three or more retainers were
denture group caries was six times more prevalent, and involved.
there was a pronounced deterioration in occlusal stability, Multi-abutment bridges are more prone to failure
in maxillary denture stability, and an increased soreness because the alignment of multiple tooth preparations is
of the anterior edentulous maxillary ridge. difficult and may result in excessive taper which will
Reichen-Graden and LangZ6 found no differences jeopardize retention, they are technically more difficult
between the rates of technical failures for conventional to fabricate and fit with accuracy (both for the technician
and cantilever bridges after 4 to 8 years. And Laurel1 et and the dentist), and because of the presence of pier
al., l6 in a study of 36 cross-arch prostheses with multiple abutments.
cantilevered pontics followed over 5 to 12 years, were able When more than two abutments are rigidly joined, the
to limit their failures to 8 per cent. In both of these studies, middle or pier abutment(s) will act as a fulcrum (Fig. 5).
there was a strict adherence to the principles of optimal The end result is frequently a loss of retention on the
retention, thick framework dimensions for rigidity and terminal abutment. The terminal abutments are report-
specific occlusal design criteria. edly the ones most prone to failure.’.’ A design more likely
to succeed is one which involves shorter segments that
Splinting and multiple abutments utilize non-rigid connectors in order to circumvent the
Fixed bridges present certain problems by virtue of the creation of a fulcrum (Fig. 6).
fact that more than one unit is involved. In these cases In view of all of the foregoing, it would seem prudent
the application of force to the restoration will involve the to refrain from rigidly splinting teeth wherever possible
transmission of forces indirectly to the various abutment and, when unavoidable, to ensure that the abutment teeth
teeth and supporting structures, with the direction of the offer exceptionally good retention.
original force being altered as it is transmitted. This in
turn will influence the resistance to displacement and ulti- Discussion
mate survival time of these restorations. Fixed prosthodontic treatment does not last a lifetime.
RobertsYz3 in comparisons between the failure rates of It represents a mechanical repair in a changing and
fixed, stress-broken and cantilever bridge designs, found demanding biological environment. The longevity of a
that designs which were fixed at both ends were much restoration is dependent on a great many factors including
more prone to loss of retention and failure. He concluded the type and design of the prosthesis, the degree of func-
that a bridge rigidly fixed at both ends places much higher tional and parafunctional loading, the structural integrity
demands on the retention provided by the abutment teeth and biological status of the supporting teeth and tissues,
than a bridge which is movable at one end. appropriate maintenance and home care, and the precision
Schwartz et aL7 found that a two-unit bridge with a with which the technical and clinical work has been carried
single abutment supporting a cantilever pontic lasted out.
longer on average than a two-unit prosthesis involving It is difficult to state, definitively, what might be consi-
two splinted abutments. The authors suggested that the dered a satisfactory lifetime for a fixed prosthesis.
‘temptation to use splinted retainers needlessly should be Practitioners must make their own assessment based upon
tempered by the knowledge of the added risk each abut- the information presented. In favourable circumstances,
ment brings to the prosthesis’. in a majority of cases, it would appear reasonable to expect
Australian Dental Journal 1994;39:3. 155
a well designed and constructed prosthesis to survive ten 11. Coornaert J, Adriaens P, De Boever J. Long-term clinical study of
porcelain-fused-to-gold restorations. J Prosthet Dent 1984;5 1:338-42.
years or more.
12. Sorensen JA, Martinoff JT. Clinically significant factors in dowel design.
J Prosthet Dent 1984;52:28-35.
Summary
13. Langer B, Stein SD, Wagenberg B. An evaluation of root resections.
Other than caries, the predominant reasons for failure A ten-year study. J Periodontol 1981;52:719-22.
are loss of retention, porcelain failure, and fracture of the 14. Landolt A, Lang NP. Results and failures with extension bridges -
bridge or abutment tooth. It is recommended that, a clinical and roentgenological follow-up study of free end bridges.
whenever possible, practitioners should: Schweiz Monatsschr Zahnmed 1988;98:239-44.
1. Maximize retention. 15. Randow K, Glantz PO. On cantilever loading of vital and non-vital
teeth. An experimental clinical study. Acta Odontol Scand
2. Maximize the strength of the metal framework. 1986;44:271-7.
3. Use only full crown retainers when rigidly joined 16. Laurel1 L, Lundgren D, Falk H, Hugoson A. Long-term prognosis of
to other parts of the prosthesis. extensive polyunit cantilevered fixed partial dentures. J Prosthet Dent
4. Minimize the use of splinted abutments. 1991;66:545-52.
17. Lewis R, Smith BGN. A clinical survey of failed post retained crowns.
5. Avoid short posts in non-vital teeth and thin or Br Dent J 1988;165:95-7.
weakened teeth.
18. Sorensen JA, Engelman MJ. Effect of post adaptation on fracture
6 . Beware of non-vital abutment teeth. resistance of endodontically treated teeth. J Prosthet Dent
7. Beware of load application outside the long axes of 1990;64:4 19-24.
abutment teeth and of cantilever designs. 19 Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of
endodontically treated teeth. J Prosthet Dent 1990;63:529-36.
8. Beware of long spans or complex designs.
20. Goldstein GR, Wesson A, Schweitzer K, Cutler B. Flexion charac-
9. Beware of patients with parafunction. teristics of four-unit futed partial denture frameworks using holographic
interferometry. J Prosthet Dent 1992;67:609-13.
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