Failure in Fixed Prosthodontics Prof.

Jylan Elguindy

Failures in fixed prosthodontics

Failure meaning not to be satisfied by the result of your work , and as a
Prosthodontist should know the way for making a perfect restoration , one
should also know the reasons for failures and how to deal with as no
restoration has a life-time guarantee.
Major problems in fixed prosthodontics:
1- Improper case selection.
2- Faulty diagnosis and treatment planning.
3- Faulty clinical procedure.
4- Faulty laboratory procedure.
5- Improper care and maintenance.
Post insertion problems:
1- Pain and sensitivity to sweets.
2- Inability to function.
3- Dissatisfaction with esthetics.
4- Inflammatory swelling.
5- Bad taste and breath.
6- Broken teeth and /or restoration
7- Bleeding gum.
Classification of fixed prosthodontics:
1- Biological failures.
2- Mechanical failures.
3- Esthetics failures.
4- Maintenance failures.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

Biological failure:
1- Caries:
It is the most common type of failures .
Sign and symptoms:
1- Pain.
2- Loose retainer.
3- Bad taste and breath.
Detection:
Caries can be detected by radiographs to detect interproximal caries, or
clinically by using sharp explorer at the margins of tooth and restoration.
Types of careis:
a) At margin:
It is due to ill-fitting margins or short and open margins. It can be detected
by explorer.
b) Beneath restoration:
It is due to: incomplete removal of caries.
Loose retainer with microleakage.
c)Root caries:
It is associated with gingival recession and periodontal pocket with
decrease salivary secretion especially in old patients.
Treatment:
It depends on the size and location of the lesion.
-If small lesion and away from the margins , don”t follow blacks principles,
restored by cement.
-If large proximal lesion we have to follow blacks principles, and restored by
amalgam or composite and the restoration should be remake.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

-If extensive caries root canal treatment should be done, with post and core
and rebuild the tooth structure with restoration remake.
2- Pulp injury:
Cause :
 1- No coolant during preparation .
 2- Increase reduction with decrease dentin barrier.
 3- Un-noticed pulp exposure.
 4- Absence of temporary restoration.
 5- Using irritating cement .
 6- Caries.
Sign and symptoms:
 Post cementation senstivity.
 Intense pain.
 Periapical abnormalities.
Treatment:
-Root canal treatment and restoration remake.
-Root canal treatment can be done without restoration removal through
access which can be closed with using composite or amalgam.
3- Periodontal breakdown:
Causes:
1-Insufficient number of abutments.
2-Peridontaly affected abutment.
3-Bad oral hygiene.
4-Insufficient axial reduction.
5-Indefinite finish line.
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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

6-Improper tissue retraction.

7-Poor marginal adaptation.
8-Improper construction:
Which will prevent proper oral hygine measures
- Over or under contoured.
- Open contact.
- Large connector.
- Rough or over extended margins which restrict the cervical
embrasure.
- Large pontic.
Signs and symptoms:
1-Reddness , swelling and bleeding.
2-Periodontal pocket formation.
3-Bad odour and taste.
4-Pain on biting.
5-Periodontal abscess.
6-Mobility.
Treatment:
-Extensive bone loss will lead to loss of abutment tooth and attached
restoration.
-Less severe breakdown may be treated with perio-surgery causing
unacceptable relation between the restoration and soft tissue.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

4-Occlusal problems:
This is due to premature contact in centric and eccentric movements which
causing traumatic occlusion.
Primary occlusal trauma: occur in premature contact in healthy abutment
tooth and this can be eliminated without permanent damage.
Secondary occlusal trauma: occur in premature contact in periodontally
affected tooth causing mobility with increased bone loss and extraction.
Signs and symptoms:
1-Muscle pain and strain.
2-Pain on biting.
3-TMJ disorders.
4-Pulp damage.
Treatment:
Spot grinding should be done in centric and eccentric movement to
eliminate premature contact.
5-Tooth perforation:
Cause:
1- Improper preparation of pinholes.
Treatment:
-If lateral perforation occlusal to the periodontal ligaments, tooth
preparation should extend to cover the perforation.
-If lateral perforation into the periodontal ligaments , periodontal surgery
should be done and the perforation closed with MTA.
-If perforation in the pulp chamber, root canal treatment should be done.
-If perforation in bifurcation area , extraction .

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

2- Improper post drilling and insertion:

- If surgically accessible , it can be restored with MTA.
- If not accessible ,extraction should be done.

6-Abutment fracture:
A)Coronal fracture:
Causes:
1-Recurrent caries.
2-Over reduction.
3-Heavy occlusal forces.
4-In correct removal of cemented prosthesis.
Treatment:
a) In partial coverage restoration:
-If small fracture around the margins , it can be restored by gold foil or resin
cement.
-If large fracture , full coverage restoration should be done.
b) In full coverage restoration:
-Post and core should be done after root canal treatment.
B-Root fracture:
Causes:
1-Over widening of root canal.
2-Root caries.
3-Truma.
4-Type of post
Treatment:
-If the root fracture below the alveolar crest , extraction.
-If the root fracture just below the alveolar crest , periodontal surgery
should be done and the exposed site should be included in the new
restoration.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

7-Discomfort and sensitivity:

1- Excessive pressure on soft tissue.
2- Retention of food on the occlusal surface.
3- Torque on abutment:
improper soldering
no temporary restoration
v-shaped arch in missing centrals and laterals.
4- Allergic reaction:
Polyether impression materials
Ni-Cr alloys
5- Cervical hyper sensitivity:
Gingival recession
Short or open cervical margin
Cervical caries
Mechanical failure
Loose Retainer

The patient complains from:

- Sensitivity from hot, cold and sweet.
- Bad taste and smell at the site of Restoration.
- Movement in prosthesis.
How to detect looseness?
Loose Retainer will produce bubbles at the margins as air and fluids
are displaced.
Loose retainer may be due to:
 Improper case selection.
- The abutment teeth have mobility due to periodontal
problems.
- Torque, due to over loading on the abutment teeth, absence of
opposing teeth at one end of the prosthesis or patient with
abnormal types of occlusion.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

 Improper tooth preparation.

- Over Convergence of opposing axial wall.
- Over reduction.
- Short preparation.
- Short post canal preparation.
- Insufficient retentive grooves or pins in partial coverage
restoration.

 Improper Prosthesis design.

- Selection of partial coverage when complete coverage is
indicated.
- Insufficient number of abutment teeth in relation to the span
length.
 Improper prosthesis construction.
- Poorly fitted margins which lead to dissolution of luting
cement and looseness.
- Improper selection of casting alloys.
 Improper cementation technique.
- Using improper luting cement.
- Improper isolation and dryness of the abutment.
- Improper manipulation of luting cement.
- Unsteady pressure during setting of the cement.

A Study has showed that using a chamfer preparation produced

significantly smaller marginal gaps than could be achieved with shoulder
preparation although ,another study has found smaller marginal gaps with
shoulder preparation.

There is Study showed that Marginal discrepancy increased after

cementation and crowns luted with composite have 2-5 times smaller
marginal discrepancy than crowns which are cemented with zinc phosphate
cement.
Additionally, many studies found that a strong enhancement of the
breaking strength of adhesively luted all-ceramic crowns compared to non-
bonded crowns.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

Study found that there is no difference in Marginal discrepancy between

cell-ceramic crowns and porcelain fused to Metal crowns.

Prosthesis fracture

Joint fracture:
An improperly fabricated connector may fracture under functional
loading. Depending on the design and location of prosthesis.
The fracture may be in connectors between the retainers, or the
retainer and pontic.
The joint fracture may be due to;
- The presence of internal porosity that weaken the connector
- The use of improper solder alloy.
- Improper soldering technique.
- Strain hardening.

The patient may complain of varying degrees of pain. Extra force is

transmitted to the abutment teeth, and discomfort from overloading the
periodontal ligament may draw attention away from the location of actual
problem.

If the abutment teeth have good bone support and minimal mobility,
fractured connector can be very difficult to detect clinically. Wedge can
sometimes be positioned to separate the individual bridge components to
confirm the correct diagnosis.
Fractured porcelain veneer
Mechanical failure of a metal-ceramic restoration is not uncommon; it is
usually related to faults in frame-work design, improper laboratory
procedures, excessive occlusal function and Truma.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

All ceramic crown fracture

Fracture of all ceramic crowns may be due to

 Improper case selection, as in case of patient with occlusal problems.

- Patient with short clinical crown.
 Improper preparation.
- Short preparation
- Insufficient reduction
- Presence of sharp points or lines angles, which act as stress
concentration areas.
- Improper finish line preparation.
 Improper laboratory construction which is due to:

Esthetic failure classification:

• color matching errors:
1-Improper shade selection
2-Improper porcelain manipulation
3-Ground and unglazed porcelain
4-Failure to completely mask the metal color through the facing
5-Unnecessary display of metal with partial coverage
6-Darkening of thin tooth restored by Maryland Bridge
7-Use improper cement shade for cementing all-ceramic restoration
8-Improper use of metallic post in esthetic area
9-Type of ceramic
10-Umbrella effect
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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

• Esthetic – biological errors:

1-Improper marginal adaptation that lead to gingival inflammation.
2-Dark space in cervical third due to improper pontic selection (Anteriors).
3-Insufficient reduction.
• Smile design errors:
1-Mid-line deviation
2-Loss of Golden Proportion
3-High/low lip line effect on design
4-Incorrect Incisal Length selection
5-Zenith points importance
6-Tooth Surface Structure and Characterizations properties according to
patient age
7-Smile arc
8-If the gingiva recedes inter-proximally
9-The esthetic width
 color matching errors:
1-Improper shade selection:
Failure to identify patient expectations regarding esthetics.
Improper shade selection, wrong shade guide system.
Failure to transfer correctly the shade to dental laboratory.
2-Improper porcelain manipulation:
Improper condensation lead to voids which will lead to different color
shade.
Over glazing will lead to devitrification and loss of contour.
In hard machining it can cause chipping or cracks in porcelain which will
lead to porcelain fracture or accumulation if stains.
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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

3-Ground and unglazed porcelain:

During delivery checking of high occlusal contacts and grinding it will lead
to layer of porcelain that is rough and unglazed .
4-Failure to completely mask the metal color through the facing:
Metal exposure in connector, cervical and incisal regions.
Excessive metal thickness at incisal and cervical region.
Improper metal substructure framework design lead to porcelain chipping.
5-Unnecessary display of metal with partial coverage:
If metal exceeds the mesio-buccal or disto-buccal line angles of the
restoration.
6-Darkening of thin tooth restored by Maryland Bridge:
In thin tooth metal will affect the labial surface of natural teeth which will
lead to darkening of tooth due to natural tooth translucency
7-Use improper cement shade for cementing all-ceramic restoration:
Due to translucency of all ceramic crowns the luting cement can affect the
shade of the reflected light waves.

8-Improper use of metallic post in esthetic area:

Metallic when used in anterior tooth with thin gingival biotype can lead to
bluish discoloration in the gingival margin.
9-Type of ceramic:
The type of ceramics used can affect the esthetics of the restoration as if in
anterior restoration it is better if lithium disilicate used rather than zirconia
in terms of better translucency.
10-Umbrella effect:
"umbrella effect" characterized by gray marginal gingiva and dark
interdental papillae.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

upper lip, can cause this feature which indeed will significantly influence
the interaction of light with the teeth and their supporting tissues. So
incisal and middle thirds of the tooth will exhibit more light than cervical
third; in other words it is the shadow of the upper lip and it’s effect, so it
must be considered during shade taking.
 Esthetic – biological errors:
1-Improper marginal adaptation that lead to gingival inflammation:
Due to open margin which will lead to food debris and plaque accumulation
will lead to gingivitis or more apical margin placement will lead to gingival
blanching and subsequent gingiva recedes

2-Dark space in cervical third due to improper pontic selection (Anteriors):

In anterior bridges if sanitary pontic design was used it will lead to dark line
appearance due to gap between gingiva and pontic, so ovate or modified
ridge lap is used. Ovate pontic designs have decreased hygienic masseurs
which can lead to gingival inflammation.
In modified ridge lap it must be shaped to the gingival contour labially and
have passive pressure if not the pontic cervico-labially margin will make
shadow on the gingiva in that portion which will lead to improper gingiva
color over the pontic area.
3-Insufficient reduction:
Insufficient reduction in incisal third of the labial surface which will lead to
insufficient porcelain for metal masking or over contoured restoration
which will lead to subsequent gingivitis.
 Smile design errors:
1-Mid-line deviation:
There are two mid lines facial mid line and dental mid line.
The facial mid-line is located in the center of the face, perpendicular to the
interpupillary line.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

The dental mid-line as an imaginary vertical line that does not necessarily
coincide with the facial mid-line. The lingual papilla or the labial fraenum
may be used as a placement landmark. It divides the dental arch into two
equal halves.
The maxillary and mandibular mid-lines do not coincide necessarily but
they may coincide.
The mid-line between the facial mid-line and maxillary central incisors
should coincide whenever possible, but a deviation of 2mm. is also
acceptable.
The dental mid-line should be kept perpendicular to the pupillary or
horizontal lines, to prevent the illusion of asymmetry owing to an excessive
right or left shift of the dental mid-line.
2-Loss of Golden Proportion:
Golden Proportion: It is considered as the only mathematical tool for
determining dominance and proportion in the arrangement of the maxillary
teeth from the frontal view according to this rule, if the width of each
anterior tooth is approximately 60% of the size of its adjacent anterior
tooth then it is considered esthetically pleasing.
The contrast is created by their respective positions and the differences in
their mesiodistal widths, when observed from the facial aspect. The distal
surface of the lateral incisors is less visible, owing to their rotation in the
arch, whereas the most dominant anterior teeth in the dental arch, the
maxillary central incisors, can be seen in their full size. It is not the actual
size of the teeth, but the perceived size that these proportions were based
upon, when viewed from the anterior aspect.
3-High/low lip line effect on design:
Before any restorative procedure is initiated, the lip position should be
evaluated.By their display of gingiva, the lip lines can be classified in three
groups - high, medium and low.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

A low lip line covers the gingiva and a considerable portion of the anterior
teeth. In such cases, it is difficult to see the incisors when the lips are at
rest. In fact, when the patient speaks, these teeth can barely be seen.
In the cases with gingival asymmetry, the advantage of the low lip line is
that the gingival levels do not have to be altered, as they will not be seen
even in a strained smile.
A medium lip line applies to the lips where 1 -3 mm of the incisal edges of
the incisors are seen at rest. When in a full smile, the level of the upper lip
extends apically to a level where the tips of the papilla and a small portion
of the gingiva are displayed.is the most preferable.
The high lip line can be seen on a small percentage of the patients, where
more than 4-5 mm of the gingiva is exposed during a moderate smile.
In medium and high lip lines, if the gingival display is unpleasant, such as in
the case of the "gummy smile", or if gingival asymmetries are present, they
should be carefully altered by the means of ortho, perio, or orthognatic
surgery.
4-Incorrect Incisal Length selection:
The age and gender of the patient, along with the length and curvature of
the upper lip, will determine the length of the incisal edge.
Average anatomic crown length values for the maxillary central incisor
range from 10.4 to11.2 mm.
A central incisor that is not visible when the lips are at rest, but can be seen
when smiling, tends to render an older appearance to the dentition. A
young smile can be achieved when the upper front teeth are lengthened.
The dento-facial plane that is exhibited in youth is permanently changed,
and although it may vary from individual to individual, the degrading
process is unfortunately irreversible. This laxness first appears at
approximately the age of 30 to 40 years and continues to increase with
each passing year.
The lips and teeth have a different position and relation for each sound that
is made.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

While seated in an upright position, the patient is asked to produce the "M"
sound several times. When the lips relax, the dentist can observe the incisal
edge position of the lips at rest
The "E" sound is another important parameter when evaluating the length
of the teeth and the incisal line. The maxillary teeth should be displayed
halfway between the upper and lower lip lines while forming this sound.
5-Zenith points importance:
Zenith points are the most apical points of the clinical crowns; which are
the height of contour.
The zenith points are generally located just distal to a line drawn vertically
through the middle of each anterior tooth. The lateral incisors are one
exception to that rule, as their zenith points are placed more centrally or on
the mid-line of the tooth marginal.
In the case of diastema closure, if the zenith points are not moved mesially
from their originally existing positions, the finished porcelain laminate
veneers may give the perception of being mesially tilted. In addition, the
extreme distal positions of the gingival zeniths will result in an exaggerated
triangular form. To prevent these occurrences and to create an illusion of
bodily shifted central incisors towards the mid-line, the zenith points should
also be moved mesially.

6-Tooth Surface Structure and Characterizations properties according to

patient age:
The incisal edge, which may be slightly convex in shape initially, changes as
well. As a consequence of abrasion it may eventually become concave.
The cervical region, through gingival recession for example, also lead to an
appearance typical of a certain age.
Detail is most extensive in a young tooth

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

The labial surface at the first glance one sees horizontal depressions.
Vertical lines become visible with more careful observation, so that a
pattern of very fine, slightly displaced rectangles is seen.
The older the tooth becomes, the less prominent these structure become.
Enamel tears, abrasions, discoloration, incisal edge irregularities, bright
spots, and band-shaped shade variations are not the only characterizations
that must be evaluated.
Cervical erosions and fine lines that separate the clinical crown and the
root, which may result from simple aging or from oral hygiene procedures,
must also be evaluated.
7-Smile arc importance:
A pleasing smile is achieved when the angles of the mouth are parallel to
the bipupillary line and the occlusal plane, with the tips of the canines
barely touching the lower lip.
The visible maxillary teeth have a connecting or incisal line convex, caudal
and incisal that runs parallel to the upper margin of the lower lip.
8-If the gingiva recedes inter-proximally:
The gingiva usually recedes inter-proximally as well, it leaves the crown of
the tooth with a more triangular appearance. If these teeth are replaced by
a restoration having a square form, they will appear more unnatural. It is
expected that the form of the clinical crown correspond to the course of
the root.
9-The esthetic width:
As the supracrestal connective tissue attachment is resected during tooth
preparation.
So should the esthetic width be respected when designing the prosthetic
framework coronal border of the gingiva and the cervical margin of the
framework to provide adequate room for the application of specific
shoulder porcelain.

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 Failure in Fixed Prosthodontics Prof.Jylan Elguindy

• Maintenance failure:
A) The patient:
Oral hygiene measurements is of critical importance. The patient should
brush teeth normally and instructed how to use superdental floss.
B) The dentist:
Recall visits is important so any problem can be detected earlier and fixed
prosthesis should be evaluated after 3 months of delivery.
In general patients under normal conditions should have their oral cavity
checked every year for any oral disease.

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