University of Mosul

College of dentistry
Operative department

Failure in crown and bridge

26/10/2022

Submitted by
Othman malik burjes
List of contents

1- Introduction……………………………………………...2
2- Clinical manifestation of fixed partial denture failure…..3
3- Role of fixed partial denture failure……….…………….3
4- Three plane of fixed partial denture failure…...…………4
4.1 Esthetic failure……………………………………4
4.2 Mechanical failure………………………………..5
4.3 Biological failure…………………………………9
5- Avoiding fixed partial denture failure………………….12
4- Conclusion……………………..……………………….12

1
 1- Introduction

Fixed partial denture (FPD) is one of the most commonly used dental
solution for replacing missing teeth or restoring badly carious teeth
(dewan et al., 2022).
Poorly designed prosthesis (figure1) not only fails but also damages
the tooth and its supporting structures irreversibly. Poor patient selection
and improper execution of core buildup of tooth preparation, impression
taking and cementation leads to early complications and subsequent
failures in fixed dental prosthesis (Ijaz et al., 2022).
The margin of discrepancy results in the enhanced accumulation of
dental biofilm, microleakage, hypersensitivity, margin discoloration,
increased gingival crevicular fluid flow (GCF), recurrent caries, pulp
infection and, lastly, periodontal lesion and bone loss, which can lead also
to the failure of prosthetic treatment (Srimaneepong et al., 2022).

Fig1: Good marginal fit of the crown and a poor marginal fit leading to consequences

2
 .(Srimaneepong et al 2022)

2- Clinical manifestation of fixed partial denture failure

(prasad et al.,2013)
- Caries
- Need for endodontic treatment

- Loss of retention
- Esthetics failure

- Periodontal disease (gingivitis and periodontitis)

- Tooth fracture

- Prosthesis/porcelain fracture

3- Roles of fixed partial denture failure

3.1 technician role

Food impaction is one of the common causes of gingival and

periodontal diseases. It also leads to caries of the abutment and the
adjacent teeth leading to subsequent failure of the prostheses, Failure to
adhere to principles of crown contour, contact relation (form, type, and
position), margin placement, and pontic design often leads to food
impaction. Food impaction resulting from faulty constructed restoration
can be best avoided if suitable precautions are taken while designing the
prosthesis (nagarsekar et al., 2016)

3.2 operator role

Poor patient selection together with the sub-optimal clinical
execution of tooth core build-up, tooth preparation(s), impression taking,

3
jaw registration and cementation will increase the risk of early
restoration failure) Briggs et al., 2012).
Also ambiguity in communicating the desired shades for esthetic
restorations to the technician are the responsibility of the
clinician(Rosenstiel et al.,2006).

3.3 patient role

Postoperative dental care, including oral hygiene maintenance and
follow-up dental visits, is key to the long-term success of these
restorations.one of the commonest causes of failure of these FPDs is
plaque accumulation which can be the primary cause for caries and
periodontal disease. This can be attributed to poor at-home maintenance
and failure to visit the dentist for regular check-ups and
maintenance(Adawi et al.,2022).

4- Three plane of fixed partial denture failure (dewan et al.,

2022):

4.1 Esthetic failure factors

4.2 Mechanical failure factors
4.3 Biological failure factors

4.1 Esthetic failure factors

This cause of failure usually on the shoulders of Operator and

technician (figure 2), one of the objective in replacing missing tooth is
esthetic, definitely failure of this objective lead to failure of bridge
(Miettinen and millar, 2013).
- At the time of cementation: Bulky restoration, inadequate
anatomical form or shape, metal core visible (inadequate porcelain

4
thickness), over extend or under extend margin and shade mismatch
(zafar and Ghani, 2014).

.Fig 2: esthetic failure (Griffin, 2020)

- Delay esthetic failure: prosthetic discoloration and loss or

chipping of ceramic facing (detected by clinical examination). Either
redesigning or remaking of FDP are required or the use of a
conventional FDP is excluded (zafar and Ghani, 2014).

4.2 Mechanical failure factors

Loss of retention, decementation, fracture of bridge or connector
failure, coronal tooth fracture, occlusal wear of prosthesis or perforation
of the prosthesis and porcelain fracture are most common cause of
mechanical failure (Cha Chandranaik and Thippanna, 2017).

4.2.1 Looseness or dislodgment

Dental casting, because they are produced by many combinations

of technique, materials and technical skill, can exhibit great variation in
excellence and serviceability, excessive die spacer will end with loosely
fit crown and frequent dislodgment (Prashant et al., 2019).

Dislodgement of crowns was the most common mechanical

5
 failure reported. this is usually due to improper crown preparation and
heavy occlusal force This can be partially explained by the fact that
most of these restorations were found on posterior teeth which are
subjected to higher forces of mastication, thus having a higher chance
of dislodgement (Naz et al., 2020).

4.2.2 De-cementation

Superior marginal fit is an important characteristic for the success

and longevity of dental restorations. Marginal discrepancies of between
50 and 120 μm are considered clinically acceptable as regards longevity
of the restoration (Meirowitz et al., 2019).
Any excessive marginal discrepancy would increase the
susceptibility of cement dissolution at the area, which may promote
microleakage (cement dissolution) secondary caries, pulpal, and
periodontal complication (Taha et al., 2022).
Horizontal crown margin discrepancies were most associated with
the mesial site of the maxillary crowns, while vertical discrepancies
were commonly associated with the distal aspect of all crowns (Badar
et al., 2022).
Usually the cause of De-cementation is dislodgement stress, the
Modes of failure showed most of the cement remaining only in the
crown intaglio whereas other demonstrated cement adhesion to
both dentin and the intaglio surface, indicating cohesive failure of
the cement at separation (Lepe et al., 2021).
The cement layer is the weakest link of a prosthetic/tooth
assembly(figure3). therefore, cements with higher bond strengths are
preferred. In the oral environment, luting agents may dissolve and
erode, leaving a space in which plaque may accumulate and caries may

6
recur. Water-based cements mature after they have reached the defined
setting time. If they are allowed to mature free of contamination from
surrounding moisture and without loss of water, the cements increase in
strength and become more resistant to dissolution (Anusavice et al.,
2003).
While such a failure may result due to faulty cementation technique
or faulty fabrication, de-cementation of another wise perfect crown or
bridge usually occurs due to the use of sticky foods by the patient (Riaz
et al., 2018).

Fig3: De-cementation, (John, 2014).

4.2.3 fracture of bridge or connector failure

Several studies have demonstrated that the connector areas are

highly influential in failure and failure rate is relatively high in 3-unit
all-ceramic FPDs associated with the connector area (figure4).
Increasing the ceramic thickness especially in the connector areas and
selecting a ceramic material with a high modulus of elasticity are
methods of improving the load bearing capacity of FPDs.
The recommended connector dimensions in all-ceramic posterior
fixed partial dentures varied between 9 mm 2 to 16 mm2. Occluso-
gingival height of 4 mm has been suggested to reduce the failure
probability (Hamid et al., 2020).
7
 Fig4: connecter failure ( Bömicke, et al., 2016).

4.2.4 coronal tooth fracture

Fracture of abutment tooth/teeth is not uncommon in clinical practice,
which can be due to caries or during removal of definitive crowns or
provisional restorations. Loss of coronal tooth structure often precludes
the use of post and cores. (Mascarenhas et al., 2013).

Abutment teeth are subject to large

horizontal and torquing
forces during function, such as in
FPDs and removable partial
dentures, in which the abutment
teeth are at higher risk for
fracture
Abutment teeth are subject to large
horizontal and torquing
8
forces during function, such as in
FPDs and removable partial
dentures, in which the abutment
teeth are at higher risk for
fracture
other causes are subjecting to large horizontal and torquing forces
during function, such as in FPDs , in which the abutment teeth are at
higher risk for fracture (akman et al., 2011)

4.2.5 Porcelain fracture

several factors are involved in the higher chipping rates of ceramic
restorations, although additional studies are needed to clarify this
problem. Among the factors analyzed in laboratory studies were the
different coefficients of thermal expansion between the veneering
ceramic and the framework, the surface treatments of the framework
before the veneering procedure, the flexural strength of the veneering
ceramic and inadequate support of the veneering ceramic due to an
inadequate framework design and a lack of veneer thickness (Sailer et
al., 2018).
Another cause of fracture is inadequate occlusal reduction on
premolar and molar teeth. A minimum of 1.5-mm reduction is
recommended for metal-ceramic crowns in molar areas compared with
a thickness of 2.0 mm for most ceramic crowns (Anusavice et al.,
2003).

4.3 Biological failure factors (Kumar et al., 2021)

9
4.3.1 Caries
Caries can be detected by comprehensive probing of the margins of
the prosthesis and tooth surfaces with explorer or use of dental floss
interproximally the floss thread will get shredded and also the intraoral
periapical radiographs to view interproximal caries (Chandranaik and
Thippanna, 2017).
This suggests that patients with high risk caries who will be treated
with fixed partial dentures should take anti-caries measures such as
special diets and better oral care (Türker et al., 2019).

4.3.2 Periodontal disease

The primary etiologic factor of gingival inflammation is a plaque,
and by inadequate crown shape its accumulation can be facilitated. A
single crown can cause inflammation of the periodontal tissue, if the
hygienic principles have not been observed during its production. If the
finish line of the artificial crown disrupts the biologic width and is
placed in the connective tissue attachment area the inflammation may
occur (Bluma et al., 2016).

4.3.3 Occlusal problems

Zirconia experiences less and lithium disilicate experiences
equivalent occlusal wear as natural enamel. It is preferable to polish
zirconia and lithium disilicate after adjustment to make them wear
compatible with enamel. Veneering of zirconia and lithium disilicate
should be avoided in areas of occlusal contact to prevent enamel wear
(Lawson et al., 2014).
Other complication associated with occlusal problems is Fracture
of abutment tooth/teeth.The amount of tooth structure that remains after

10
endodontic therapy and post preparation appears to be of major
importance, as the residual dentin helps in incorporating a ferrule. the
presence of tooth structure coronal to the finish line enhanced fracture
resistance (Mascarenhas et al., 2013).

4.3.4 Gingival irritation

Hypersenstivity reactions remain the unprecedented complication
of metal alloys used in dentistry and are a diagnostic challenge for the
clinicians (figure 5).
Dental materials interact continuously with oral tissues and fluids.
They are subject to high temperature and pH variations in the oral
cavity, which leads to corrosion and leaching of byproducts inciting an
immunological response (Verma et al., 2021).

Fig5: linear gingival inflammation (Al-Abdaly et al.,2018)

4.3.5 Gingival recession

Various factors can affect the amount of recession, including the
tissue thickness (biotype), marginal accuracy of the interim crown and
amount of keratinized tissue. A thick biotype consists of more
connective tissue than a thin biotype and therefore is resistant to loss of
gingival height. Though the average loss of gingival height due to
retraction cord using may not seem to hold much of clinical
significance. with local, systemic and other contributing factors adding
up might lead to a questionable prognosis of the restoration (Kannan
11
 and Venugopalan, 2018).

4.3.6 Pulp and periapical health

One of the most common complications of fixed partial denture is
the need for endodontic treatment due to pulp insult either during or
after the fixed partial denture treatment (Johar, 2019).
Thermal injury to the pulp may occur in consequence to frictional
heat generated from high-speed rotary handpiece along with the type,
size and condition of the diamond bur, Usage of different chemical
materials throughout the treatment such as bis-acryl or acrylic resin for
provisional restoration, impression materials, temporary and permanent
cements can cause negative effect to the pulp (Kohli et al., 2022).

4.3.7 Root fracture

The loss of structural tooth

integrity associated with
endodontic access preparation is
reported as a possible
factor for the higher occurrence of
fractures in ETT [24].
Irrigation solutions have adverse
effects on the physical

12
properties of root canal dentin,
which might increase the
risk for root fractures [25–27].
Various obturation materials
and obturation techniques are
reported to have different
effects on fracture strengths of teeth
[12]. All of these
studies indicate that root canal
treatment has an effect on
the fracture strength of teeth.
The loss of structural tooth integrity associated with endodontic
access preparation is reported as a possible factor for the higher
occurrence of fractures. Irrigation solutions have adverse effects on the
physical properties of root canal dentin, which might increase the risk
for root fractures. Various obturation materials and obturation
techniques are reported to have different effects on fracture strengths of
teeth. this indicate that root canal treatment has an effect on the fracture
strength of teeth as an abutment in fixed partial denture (akman et al.,
2011)
5- Avoiding fixed partial denture failure
The replacement of crowns and bridges is a common procedure
for many dental practitioners. When correctly planned and executed,

13
 fixed prostheses will provide predictable function, aesthetics and value
for money. However, when done poorly, they are more likely to fail
prematurely and lead to irreversible damage to the teeth and supporting
structures beneath. Sound diagnosis, good assessment ,technical and
clinician skills are essential for successful fixed restorations.
Briggs, Peter & Ray-Chaudhuri, Arijit & Shah, Kewal. (2012).
Avoiding and managing the failure of conventional crowns and bridges.
Dental update. 39. 78-80, 82. 10.12968/denu.2012.39.2.78.

Conclusion

Although fixed partial denture in one of proper solution for

replacing missing teeth or protect teeth from further damage due to force
of mastication, hence , its complication may start from faulty diagnosis
and end with faulty prosthesis. However, failure in fixed partial denture
may be pre-cementation (aesthetic reasons) , immediately ( aesthetic and
mechanical reasons) or post-cementation (maintenance reasons).

Reference

 Adawi, H., Jain, S., Hakami, A. H., Mtwam, N. A., Koriri, A. Y., & Adawi,
14
 A. A. (2022). A Prospective Study to Assess Patients' Understanding and
Retention of Postoperative Instructions following a Fixed Partial Denture,
Using Different Information Delivery Techniques. European Journal of
Dentistry.
 Akman, Serhan & Akman, Melek & Eskitaşcıoğlu, Gürcan & Belli,
Sema.(2011).The use of endodontically treated and/or fiber post-retained
teeth as abutments for fixed partial dentures. Clinical oral
investigations. 16. 1485-91. 10.1007/s00784-011-0635-7.
 Al-Abdaly, M. , Qahas, A. , Honbos, A. and Alshehri, A. (2018).
Periodontal TissueStatus among Mental Retardation Patients with Fixed
Prosthodontic Appliances. International Journal of Clinical
Medicine, 9, 49-58.
 Anusavice, K.J., Shen, C. and Rawls, H.R. (2003).Phillips Science of Dental
Materials, 12th edition, Saunders, Philadelphia, 608-618.
 Bluma E, Vidzis A, Zigurs G. (2016). The influence of fixed prostheses on
periodontal health Stomatologija;18(4):112-21.
 Bömicke, W., Rues, S., Hlavacek, V., Rammelsberg, P., & Schmitter, M.
(2016).Fracture behavior of minimally invasive, posterior, and fixed
dental prostheses manufactured from monolithic zirconia. Journal of
Esthetic and Restorative Dentistry, 28(6), 367-381.
 Briggs, Peter & Ray-Chaudhuri, Arijit & Shah, Kewal. (2012). Avoiding and
managing the failure of conventional crowns and bridges. Dental
update. 39. 78-80, 82.
 Cha Chandranaik, M. B., & Thippanna, R. K. (2017). Fixed partial denture
failures:a clinical survey for evaluation of the factors
responsible. CODS Journal of Dentistry, 9(2), 41-45.
 Dewan, H., Haroon, T. M., Mogla, S., Gupta, A., Loganathan, J., Ahammed, A.
N.,& Kommuri, S. (2022). Assessment of Failure Rate of Fixed Partial
Dentures: A Clinical Study. Journal of pharmacy & bioallied sciences,
14(Suppl 1), S262–S263.
 Griffin, J. D. (2020). Durable, contemporary cementation of lithium-disilicate

15
 crowns and veneers. Compend Contin Educ Dent, 41(5).
 Hamid Kermanshah, Fariba Motevasselian, Saeedeh Alavi Kakhaki & Mutlu
Özcan.(2020). Effect of ceramic material type on the fracture load of
inlay-retained and full-coverage fixed dental prostheses, Biomaterial
Investigations in Dentistry, 7:1, 62-70.
 Ijaz M, Ibrahim S, Sharafat A, Younis S, Satti A, Rehman A. (2022). Frequency
of Esthetic and Periodontal Complications in Patients of metal Ceramic
Fixed Dental Prosthesis. J Bahria Uni Med Dental Coll ; 12(2):73-76.
 Johar AO.(2019). Incidence of Accidental Pulp Exposure During Tooth
Preparation by Undergraduate Students for Fixed Partial Dentures. J
Contemp Dent Pract ;20(2):258-262.
 John M.(2014). On the ferrule effect and the biomechanical stability of teeth
Restored with cores, posts, and crowns. European journal of
dentistry.8. 281-6.
 Kannan, A., & Venugopalan, S. (2018). A systematic review on the effect of use
Of impregnated retraction cords on gingiva. Journal of advanced
pharmaceutical technology & research, 11(5), 2121.
 Kohli, S., Bhatia, S., Al‐Haddad, A., Pulikkotil, S. J., & Jamayet, N. B. (2022).
Pulpal and periapical status of the vital teeth used as abutment for fixed
prosthesis—a systematic review and meta‐analysis . Journal of
Prosthodontics, 31(2), 102-114.
 Kumar A, Thakur R, Sharma P.(2021). Fixed partial denture failures: A review
Of classification. Adv Med Dent Scie Res; 9(5):82-85.
 Lawson, N. C., Janyavula, S., Syklawer, S., McLaren, E. A., & Burgess, J. O.
(2014). Wear of enamel opposing zirconia and lithium disilicate after
adjustment, polishing and glazing. Journal of dentistry, 42(12), 1586-
1591.
 Lepe, X., Streiff, K. R., & Johnson, G. H. (2021). Long-term retention of
Zirconia crowns cemented with current automixed cements. The
Journal of Prosthetic Dentistry, 125(5), 788-794.
 Mascarenhas K, Aras MA, Fernandes AS. (2013). Repair of fractured

16
 abutment teeth under pre-existing crowns: An alternative approach.
Indian J Dent Res;24:136-8.
 Meirowitz, A., Bitterman, Y., Levy, S., Mijiritsky, E., & Dolev, E. (2019). An in
vitro evaluation of marginal fit zirconia crowns fabricated by a CAD-
CAM dental laboratory and a milling center. BMC oral health, 19(1),
1-6.
 Miettinen, M., Millar, B. (2013). A review of the success and failure
characteristics of resin-bonded bridges. Br Dent J, 215, E3.
 Nagarsekar, A., Gaunkar, R., & Aras, M. (2016). Knowledge, attitude, and
Practice of dental professionals regarding the effect and management of
food impaction associated with fixed partial denture prostheses: A
survey. Journal of Indian Prosthodontic Society, 16(4), 372–379.
 Naz A, Musharraf H, Jawad A, Zia K, Kumar B, Lone MA.(2020). Assessment
of failure of prosthesis in fixed prosthodontics among patients reporting
to a teaching dental hospital of Karachi. J Pak Dent Assoc; 29(3):105-
109.
 Riaz W, Ayesha Aslam, Aziz S. (2018). Dental prosthesis; assessment of grades
of failures of conventional fixed dental prosthesis based on severity.
Professional Med J; 25(8):1261-1264.
 Rosenstiel, S.F., Land, M.F. and Fujimoto, J. (2006) Contemporary fixed
prosthodontics. 5th Edition, Mosby, St Louis; 445.
 Prasad, K., Bardia, A., & Prssad, A. (2013). CLINICAL FAILURES IN FIXED
PARTIAL DENTURES AND ITS MANAGEMENT. Guident, 6(5).
 Prashant Jadhav, M. D. S., Manish Kumar, M. D. S., Sayali Korde, M. D. S., &
Nilima Kadam, M. D. S. (2019). Evaluation of Casting Accuracy by
Axial Coverage Method of the Die Spacer 1 mm Short from the Finish
Line–An in Vitro Study.
 Sailer, I., Strasding, M., Valente, N. A., Zwahlen, M., Liu, S., & Pjetursson, B.
E. (2018). A systematic review of the survival and complication rates of
zirconia‐ceramic and metal‐ceramic multiple‐unit fixed dental
prostheses. Clinical oral implants research, 29, 184-198.

17
 Taha, F. A., Jasim, Z. M., & Husseien, H. A. (2022). Effect of cement-space
thickness on the marginal fitness of all zirconium oxide crowns—An in
vitro study. Journal of International Oral Health, 14(4), 382.
 Türker N, Özarslan M, Büyükkaplan UŞ, Özarslan MM.(2019). Radiographical
assessment of fixed partial denture abutment teeth. Med J SDU; 26(1):
1-7.
 Verma N, Srivastava A and Dubey PK.(2021). Hypersensitivity Reaction To
Nickel Based Metal Ceramic Prosthesis: A Case Report. J Adv Med
Dent Scie Res;9(4):17-19.
 Zafar, N., & Ghani, F. (2014). Common post-fitting complications in tooth-
Supported fixed-fixed design metal-ceramic fixed dental prostheses.
Pakistan Journal of Medical Sciences, 30(3), 619.

18