Contents

Introduction Ways in which restorations fail Failure rates of common restorations Causes of failures Evaluation system for restorations Failures common to all restorations & causes Failures of specific restorations (A) Failures of amalgam restorations (B) Failures of pin retained restorations (C) Failures of glass ionomer restorations (!) Failures of composite restorations (E) Failures of inlays Conclusion "eferences

INTRODUCTION Failure may $e defined as the ina$ility to meet the desired outcome% &n specifications that have $een esta$lished $y national $ureau of standards and other institutions of standardi'ation and specifications( little chances e)ist of manufacturers selling inferior *uality restorative materials% +a,ority of restorative failures in dentistry can $e attri$uted to the hindrances of the operator himself% Everything done from the time of cavity preparation( until the restoration is polished has a definite affect on the success and failure of a restoration% Being critical a$out your wor- is good $ut $eing too critical a$out them aint so good either% It is salutary to replace a restoration that has $een condemned as ( only to produce a new restoration with ,ust as many( if not .more/ faults( When the mani-in turns into a real life person with fears( aspirations( and a small wet wriggling mouth( the difficulties $ecome compounded% Com$ined efforts of meticulously done wor-( and maintenance $y the patient is $ound to yield fruitful results.

Ways in which restorations fail

(Acc% to wilson & fu''i) Failure

0ew !isease Caries & 1ooth wear 2eriodontal disease 2ulpal pro$lems
3

1echnical Failure Fractured restoration +arginal $rea-down 1ooth fracture

1rauma

!efective contours Failure of retention

(ACC 1& 4E0!E"A5&0 & "&0I06 ) Failures of restorations can be characterized as. 5econdary caries +arginal deterioration 1ooth fractures 7oss of anatomy 7oss of aesthetics "estoration fractures

(Acc to mount et al)

Failure of tooth structure Failure of enamel margin Failure of dentin margin Bul- loss of tooth structure 5plit root 7oss of vitality Failure of restorative material failure of margins 8 or collapse of material 1otal loss of restoration

Failure rate of common restorations (Wilson( roulet( Fu''i) "estoration 1ype Amalgam "estoration !irect post composites 6IC restorations Cast gold inlays & onlays composite inlays onlays Ceramic inlays & onlays Anterior "estoration (III & I<) All 5tudies =: =%: > = #?%? = @%> = #= = :%# = ##%A
;

Annual Failure 9 5tudies 7ongitudi Cross :; yr nal studies sect studies =: =: # A%; =%: > =%: @%> ;%; > = #?%; = #?%? = @%> = 3%A =%@ @%> #%@ >%B = #= = ?%; = :%# =%B ? =%@ ##%A = ##%A #;

Cervical restorations (Class <)

= 3A

=%; :%3

= 3A

#%A @%>

rinci!le !roblems of indi"idual restoration Amalgam tooth Composites 6IC Inlays D Cervical overhang( +arginal deterioration Wear &f restoration( !iscoloration( 5econdary caries Bul- fracture !ue to low +echanical strength( (Ironically) 5econdary caries% fracture +arginal defects( +arginal !eterioration( 5econdary caries( Cigh incidence of $ul- &

Cast 6old D 1ooth "etention ceramic

+arginal & Bul- fracture( +arginal discoloration & degradation

Failures in #eneral occur due to $%

&aterial used A) Faulty production (Inferior 2roducts) wrong A)

O!erator Improper diagnosis &

treatment modality suggested B) C) Improper storing & handling( pac-aging Impurities incorporated
?

B) C)

lac- of -nowledge a$out use of restorative material 7ac- of s-ill

!) E)

1echni*ue sensitivity of material Inhi$itions of the material itself

!)

casual attitude & manipulative techni*ues

!atient
A) B) 0ot following post operative instructions & maintenance Improper &ral hygiene protocol c)deleterious ha$it

Any shortcomings occurring during following stages cause adverse effects to restoration &perative stage Candling storage & dispensing of material +anipulation stage Insertion stage Finishing & polishing 2ost Insertion & maintenance stage 2atient maintenance

Common Phenomenon Leading to Failure &icrolea'a(e !ef D .1he clinically indetecta$le passage of $acteria and $acterial products( fluids( molecules or ions from oral environment along various gaps present in cavity restoration interface/% 1hree 2ossi$le routes D #) 3) ;) Within or <IA smear layer BEW smear layer & cavity varnishEcement BEW varnishEcement & restoration A minimum of #= um space definitely e)ists $etween a restoration and tooth surface which is not clinically perceiva$le $ut large enough to allow ingress of $acteria and their products% 2roperties of restorative materials promoting microlea-age
@

&a)or contributors #)

$%

Coefficient of thermal e)pansion (C1E) change in length per unit length of material per degree change in temperature

+ore deviation of C1E &f material from C1E of tooth +aterial 1ooth Crown enamel !entin Amalgam Composite 6IC 2ure 6old Aluminous 2orcelain Inlay wa) 3) 2olymeri'ation shrin-age D 5een with resin restorations ( occurs when monomer chains are polymerised to form polymer chains 1his shrin-age pulls material away from walls of cavity 1ype Conventional Comp &rganic Comp +icrofilmed Cy$rid ;) 2roperty of adhesion Adhesion is attraction of molecules of two different su$stances to each other when $rought in close contact%
A

Cigher rate of microlea-age C1E () #= A 9) ##%? B%; 3@%= 3=%= 3@%= ##%= #?%= A%A ?==%=

<alue #%@ 3%=9 3%@ ;%@9 #%; #%@9 3%3 3%@9

Influenced $y D Wetting capa$ility 5urface energy 2resence of water & smear layer 5urface roughness etc%

Better adhesion F lesser gap F lesser +icrolea-age e%g 7eaving margins of inlay unfurnished e)poses cement more to lea-age +ore 7ea-age Improper isolation of composites 5urface contaminants Inade*uate $ond &inor contributors $ Creep Elasticity "esistance to fatigue 5olu$ility Role of smear layer $% 6enerally # 3 mm thic- consists of D Blood saliva( $acteria/s enamel & dentin particles smear layer may $e pushed to # @ um in tu$ules forming .5mear plugs/ 3 #) 3) 5chools of thought for smear plugs 2revent permea$ility of dentin $y $loc-age 5mear itself source of $acteria/s Best way D Fi)ing smear layer $y 3@9 tannic acid( polyacrylic acid #=9 2artial removal of layer 7eaves smear plug intact
:

+a-es sterile( inert( non to)ic synthetic smear layer% Secondary caries 1hese are caries around a restoration( also -nown as ."ecurrent caries/ Etiological Factors +arginal lea-age F around restoration When width of marginal defect is than @= um ris- is lower !itching of restoration +arginal fractures "ough restoration surface 2oor hygiene maintenance Improper cavity preparation &icrobiolo(y $% "esem$le pit & tissue caries type 5% +utans & lacto$acilli Found in increased num$er in secondary caries (Fonta na t al #>>A( #3) Fit'gerald et al (#>>?) stated role of ; ma,or organisms 5% +utans F ;@ 9 5% 5anguis F 3? 9 5 5alivarius F #?9 in samples &ther isolates( 5% gordonii 5% milleri 5% oralis 5% mitis Actinomyces found in ?A9 samples though in less num$ers% 5tudies D
B

I)

2imento et al (#>>@) ?: 5tudy on amalgam restoration (#?>: samples) ?:%#A9 non ditched surfaces @3%>?9 non ditched surfaces without caries @B%B3 F ditched with caries ?#%#B F ditched without caries

II)

Espelid and tveit (#>>#)#=

Classified secondary caries% 5# initial carious lesion characteri'ed $y discoloration only 53 lesions characteri'ed $y softness andEor cavitation on root surface 5; 7esions cavitation on root surface only% 5# :;%; 9( 53 @B%@9( 5; F B>%:9 didn/t specify status of occlusal caries +a,or (#>>B) ?? ;%B 9 5econdary caries with class I amalgam =%? 9 class I composite ?%; 9 6IC 3%; 9 unspecified Class II restorations Amalgam composite 6IC 6ingival >=9 :@9 A=%@ 9 *isto!atholo(y $% 2rocess D 2enetration of hydrogen ions -ey role in deminerali'ation
>

&cclusal @9 B9 #=9

&ther surf #=9 #@9 #=9

2enetration occurs along +icrospaces F capillary forces( diffusion difference in electrical potential $Ew tooth & restoration% !efects in restoration Fracture lines in tooth or restoration 5tudies show( Both wall and outer surface lesions A=9 &uter lesion and no wall lesion 3=9 Wall lesion and no outer lesion F ##%>9 Dia(nosis <isual and tactile method 1ransillumination Anterior portion of oral cavity "adiographs Especially $itewing Inhi$ition F incipient lesions 7atest 1uned Aperture computer topography (1act) &ffers ; dimensional images of synthesi'ed image slices( $y tuning num$er of pro,ections at angular disparity $Ew pro,ections Advantage D Can $e added to digital system without added costs% Loss of anatomy (Faulty contacts) I) 1oo $road a contact c($uccolingually or occlusogingivaly) Change in anatomy of co# and tooth increased degree of food impaction due to improper shunting of food II) 1oo narrow a contact

#=

Food impaction vertically( pla*ue accumulation% Inaccessi$ility to hygiene measures III) 7oose contact Continuity created $Ew co# & em$rasure leads to periodontal destruction & 5econdary caries I<) <) Contact too occlusally Contact too gingival increased !epth of occlusal F em$rasure Impingement of food <I) Contact placed too $uccally or lingually Flattened marginal ridge leads to fracture of restoration

Flattened restoration on e)pense of $uccal or lingual pro)imal wall !ecreased 5trength prone to fracture

Failures of s!ecific restorations

Failures of amal(am
Introduction 5ilver amalgam is indou$tly the most commonly used restorative material% It correctly used and compared with any other restorative material the advantages of silver amalgam always surpass the disadvantages% 1he average life span of an amalgam restoration is upto B #= yrs if manipulated correctly% 1hough failures occur% 1hey are mostly due to faulty cavity preparation or faulty manipulation% Cealy and 2hilips (#>?>) evaluated #@3# defected amalgam restorations and reported @A 9 Failures D !ue to improper cavity preparation ?3 9 Failures D !ue to faulty manipulation 1ypes of Amalgam Failures
##

At <isual 7evelD 5econdary caries +arginal fractures Buc- fractures 1ooth fractures !imensional change

At +icrostructural 7evel Corrosion and tarnish 5tresses associated with masticatory forces 2ain following restoration 2ulpal and periodontal involvement

Amalgam Failures Can Be Attri$uted 1o following Causes Failures due to faulty cavity preparation% Failures due to poor matri) adaptation% !ue to faulty amalgam manipulation% !ue to improper condensation% Failures due to contamination% Improper finishing and polishing procedures% 2ost operative pain% +icrolea-age of amalgam% 1arnish and corrosion "ole of creep "ole of faulty contacts Effects of $leaching%

#3

Faulty Ca"ity re!aration $ Improper cavity preparation leading to recurrence of caries and fracture of restorations is greatest single factor responsi$le for failures in amalgam% !ifferent causes that can occur at various steps while preparing cavities areD Inadequate occlusal extension:Inade*uate e)tensions into pits and fissures increases the chances of recurrent caries particularly in patients with high caries inde)% 1hus all suscepti$le pits and fissures should $e included while terminating margins in areas that can $e finished%

Inadequate extension of proximal box:Em$rasures if not involved ade*uately are not amnea$le to $rushing and cleaning% 1hese result in secondary caries affecting the life of the restoration% Cowever radical e)tension of the pro)imal $o) will wea-en the tooth structure leading to fracture of restoration% 5pecial attention in this category should $e given to lower $icuspid and distal em$rasures of ma)illary and mandi$ular # st molars where frail walls can $e formed easily% O"er e+tensions of ca"ity !re!ared walls$% &ne fourth of inter cuspal distance facio lingually is the ideal re*uirement for amalgam restoration to possess ade*uate strength for functioning% Caries Involvement #% #E?th of Facio lingual distance 3% G of facio lingual distance ;% 3E;rd of facio lingual distance 5uggested protocol 5imple preperation Considering cuspal capping Cuspal capping mandatory

#;

1his is $ecause amalgam acts as a wedge $etween the opposite cusps and tries to split them apart thic-ness of amalgam re*uired for capping D Functional cusps 3 mm 0on Functional cusps #%@mm If thic-ness re*uired is not provided fractures result inadverently% It has $een calculated that #%@mm of minimal amalgam $ul- is necessary to resist fractures It pulpal floor is not smooth or is curved the restoration causes a wedging effect and increases chances of tractor of tooth% Butt ,oints especially where occlusal stresses are to $e encountered are essential% 1hus the cavo surface angle has $een suggested to $e >= o or prefera$ly ##=o% Cavosurface angle +ore acute D +ore o$tuse D Fractures of tooth margins +arginal amalgam fracture under occlusal tresses% Cavity margins are to $e finished so as to remove unsupported enamel rods suscepti$le to fractures and resulting secondary caries failure to round off a)io pulpal line angle as well as internal line angles and point angles results in concentration of forces at these places resulting in fractures of the material or worse the tooth itself% By rounding a)io pulpal line angle increase $ul- of amalgam for strength is also o$tained% <ery narrow isthmus related to rest of the cavity preparation and co positioning of the isthmus and a)io pulpal line angle results in fracture of pro)imo occlusal restoration due vulnera$ility of these areas to $e the wea-est points of cavity preparation% 5uch phenomenon can also occur due to inade*uate pro)imal retention form% Hndermining of mesial and distal walls of preparations can result in fracture
#?

of mescal or distal marginal ridge due to these areas $eing unsupported% 1hus it is always advised to -eep mesial and distal walls straighter% 1he retentive element of the cavity should $e in dentine without undermining enamel so as to give proper support to the restoration or it lead to fractures% Incomplete caries removalD

Incomplete caries removalD Incomplete caries removal can lead to failures either $yD #% 3% FH"1CE" I0<&7<E+E01 A0! 2H72A7 I05H71% F"AC1H"E +A1E"IA7% If pulpal floor is not flat there will $e ina$ility of the restoration to resist forces directed along long a)is of tooth% 1his leads to stress concentration and as a result fracture of restoration% oor &atri+ ,da!tation $% 2roper matri) selection is mandatory for a pro)imal restoration to $e successful% A +inimal thic-ness of =%=; =%=@mm is re*uired for a matri) to $e $urnisha$le and allow condensation of amalgam without deformation% Also an e)tension of =%@ #mm $eyond cavo gingival line angle of cavity and similarly a$ove level of marginal ridge is re*uired for proper condensation of amalgam% 1he $and should also $e sta$le after application $ecause if not so it can lead to distorted restoration( gross marginal e)cess( uncondensed mass of amalgam( leading to failure% 1he use of a wedge is ,ustified and mandatory% Also( if $and width is too large it will lead to creations of an open contact or a contact too occlusally%
#@

&F

"E51&"A1I&0

!HE

1&

H05H22&"1E!

If Band width is less it will allow amalgam to escape and form an overhang resulting in tissue irritation & destruction or incorporation of amalgam in tissues% Faulty Amalgam +anipulationD &ercury - ,lloy Ratio $% 5erious loss of structure was reported when residual mercury is in an e)cess of @@9 in a restoration% Cigher mercury content used during mi)ing results in higher residual mercury which cannot $e effectively removed $y s*uee'ing or condensation% 1his high mercury results in D !ecrease in crushing strength% increase in flow and increased suscepti$ility to tarnish and corrosion % &ne should prefer minimal mercury techni*ue which gives proper mi)es with use of dispensers for correct proportioning or amalgamation% +ulling with $are hands causes incorporation of contaminants esp moisture into the mi) which is deleterious% esp in 'inc containing alloys% Cardened set amalgam if not removed from the mortars will act as points of wea-ness in the matri) of the mi)( rendering the restoration prone to failure as stress concentration occurs at these points% Hndertriturated and over triturated mi)es and their effectsD Hndertriturated &vertriturated +i) 5oft 2owdery( 0on coherent mass +ay $rea- already forming matri)

Effective removal of residual mercury is possi$le only within ? mins of triturating% "eplastiasing mi) $y adding mercury seriously decreases strength and rendering the restoration wea-% Im!ro!er Condensation $%

#A

Condensation is a very important step in amalgam restorative procedures as it reduces the residual mercury contents( and ensures amalgam reaches to all parts of preparation to o$tain a homogenous mi)% !ue to improper condensation if voids occur these serve as areas of least strength in the restoration very suscepti$le to fracture% 1hus proper condensation is a I5teppingJ motion to drive away anyvoids is advice%

Contamination$% By +oisture D Bare hand mulling leads to decreased strength esp in Kinc containing alloys +oisture contamination in oral cavity $y saliva and $loodD 7eads to delayed e)pansion( resulting in marginal flaws( tarnish( pitting corrosion and pain% .y &aterials $% Any impurities incorporated during the procedure% e%g% Bare hand manipulation of material to add impurities Hsing mi) -ept on unclean apparatus leads to incorporation of flaws into the matri) rendering the mi) wea- and suscepti$le to degradation% Improper carving( finishing & polishing Caries may recur in stagnation areas formed marginal gaps( e)cess of amalgam( or in crevices resulting from fracture of e)cess amalgam% 1he main carving should $e delayed until the surface offers resistance to instrumentation% 1he correct time is indicated $y a particular I5*uea-ingJ sound deviated from surface ICry of tinJ% 1he instruments used should $e sharp and proper otherwise defects can $e produced in the carvings occasionally e)cess amalgam at
#:

margins is dressed down to thin fla-es or I52H"J li-e overhangs which get 8ed away from restoration resulting in areas suscepti$le to secondary caries% A rough pitted and corroded surface leads to increased suscepti$ility for furnish and corrosion and increased failure rate% O"ercar"in( $% 7eads to decreased thic-ness of restoration with increased chances of fracture% Undercar"in( $% 7eads to production of high points causing increased forces on tooth resulting in post operative pain and potential source for fractures% When carving marginal ridges the instrument should $e directed into $ul- of restoration( otherwise the ridge amalgam remains relatively unsupported & may fracture%

olishin( $% 5hould not $e initiated less than 3? hrs after condensation and carving and should $e done ade*uately and sufficiently% If rough surfaces e)ist they act as sources of pla*ue adhesion and su$se*uent caries progression% 1hese spots also promote corrosion of the material% If polishing temperature increases more than A@9 mercury is released from amalgam leading to failure $y rendering the matri) wea-% Inadvertently this heat may also irritate the pulp and cause deleterious effects% &ar(inal de(radation /Ditchin(0 1he I!itchingJ around amalgam restorations misthought to $e due to amalgam contraction is mainly due to stressEcorrosion dependent defect occuring
#B

in areas su$,ected to occlusal loading% +agnitude of e)tent of ditching is directly related to creep properties so Increased Creep Role of Cree! $% Creep is a critical factor leading to fracture of restoration or teeth% e%g% 1he mere fact that incidence of fracture of lingual cusps in mandi$ular teeth and $uccal cusps in ma)illa e)plains the phenomenon of creep Cigh copper alloys have low creep rates and are thus more sta$le% +aterial Amalcap !ispersalloy 5y$ralloy type 7athecut Admi)ed 5pherical 9 CH A #3 ;= 9 Creep 3%@ =%3@ =%=@ Comp 5tr at 3? C"5(+pa) ?#= ??= @== Increased !itching

&ther Factors "esponsi$le for +arginal !eterioration D #% Improper +arginal preparation 2oorly supported enamel rods may fracture resulting in crevice formation% 3% ;% Improper Carving and finishing IFlashesJ around margins may fracture% E)cess +ercury E)cess mercury induces wea- gamma F 3 phase resulting in wea-er amalgam% ?% 7ow copper amalgams 7ow copper alloys have hiBgh corrosion rates( ma-ing margins porous and 8 prone% @% Amalgam E)pansion
#>

+aterial e)pands F 2rotrudes +argins unsupported% 2ost F operative pain Caused due to D Cyperocclusion due to undrcarving Crac-s in teeth 6alvanism !elayed e)pansion Kinc containing alloys on contamination with water%

+icrolea-age in amalgam D Amalgam when freshly condensed does not adapt closely to walls of prepared cavity% 6enerally a gap of #= #@ mm e)ists around a restoration and is ,ustified% 1hough amalgam later $ecomes a self sealing material $y virtue of products of corrosion% e%g% F !ifferent o)ides and chlorides( $ut if spherical particles of alloy are used or faulty manipulation done chances of increased +icrolea-age% Amalgam !lues" and #attoo" D 2enetration of amalgam products into dentinal tu$ules leads to very anaesthetic condition called IAmalgam BluesJ needing re restoration as desired $y the patient caused $y not adhering to proper lining systems% 2enetration of amalgam residuals during restoration in marginal gingiva and when not removed results in I1attooingJ attachment apparatus% Effects of $leaching D 1hese can also have deleterious effects on amalgam A 9 C3&3 6els F !o not alter surface te)ture #= #A9 car$amide 2ero)ide &n non polished surfaces causes corrosion and increases corrosion suscepti$ility on polished amalgams too%
3=

of gingiva which discolors the mucosa and irritates the

Caused due to active o)idation% Bleaching also 6reens the tooth F amalgam interface%

Failures of in Retained Restoration

Failures may occur in 1 areas $% #% Within "estoration 3% At Interface BEW 2in & "estorative +aterial ;% Within pin (2in Fracture) ?% At interface BEW pin & dentin (2in dentin separation) @% Within dentin (!entin Fracture) Within Restoration % !ue to D #% Improperly retained matri) 3% +ovement of matri) ;% Improper condensation ?% 2remature removal of matri) @% Cigh points in restoration 5olution D "epair or "e restoration 20 ,t in -Restoration Interface !ue to D Corrosion products at interface resulting in 8 of restoration 5olution D Hse of titanium pins or "e restoration 30 Within in / in 40 !ue to D Wrongs placement( leading to inadvertent force concentration on $ody of pin 5olution D "emoval of restoration & pin drilling another hole #%@ 3 mm away from original site "e "estoration

3#

50 ,t !in -Dentin Interface !ue to D 7oose pins that do not properly engage dentin( as hole si'e too large% 5olution D 2reparing pin hole for ne)t pin si'e or drilling hole at another site% 10 Within Dentin !ue to D 2reparation -ept rough on floor uneven direction of forces stress concentration dentin fracture 5olution D "educe to Cat surface & redrill pin hole ul!al dama(e or e+!osure6 biolo(ic s!ace in"asion #) Ceat generation while drilling 5olution D 2ulp capping with calcium hydro)ide( redrilling hole #%@ 3 mm away% As most of teeth receiving such restoration haveEhad e)tensive restorations Ecaries health of pulp already compromised 1CE"A2L% so ideal treatment is E0!&!&01IC

Failures of (lass ionomer cements%

Introduction D 6lass ionomers are one of the most versatile of the acid $ase cement and have many application( used as "estoratives( liners( $ases and luting cement% &utside profession used as $one cement( model material etc% With so( many uses and implications( criticisms are $ound to $e associated with the material% 1hough failures are to $e encountered $ut most of them still remain within confines of the operator only% !isadvantages of the material D M 5ensitivity to moisture at placement leads to e)pansion M 1echni*ue sensitive esp in powder D li*uid M 5uscepti$le to dehydration over time
33

M 7ess colour sta$le M 2oor a$rasion resistance M 2oor acid resistance M Average esthetics M 7ess strength thus contraindicated in stress $earing areas% M 7ess tensile strength than composite Failures of #ic can be "isualized as $% #) Fractures 3) !islodgment of restoration (By swelling !%1% hydration) ;) +icrolea-age ?) 6ic 5ensitivity @) 2orosities A) Colour insta$ility Failures can be attributed to followin( reasons. $% Altering powder li*uid ratio D Altering powder D li*uid F alteration of physical properties It more than "e*uired powder is incorporated physical properties are altered $y #% Increase in no% of voids & faults decrease in translucency 3% +ar-ed decrease in strength

Im!ro!er Dis!ensin( $% Bottle of powder it not sha-en and fluffed improper mi) with wea- matri)% occurs It li*uid left to lie on sla$ or pad ta-es up moisture and renders restoration wea-% 5o li*uid should $e dispensed immediately $efore mi)ing% ,lterin( mi+in( time6 wor'in( time $%
3;

up properly $efore

dispensing

Wor-ing time of 3 mins from completion of mi)ing can $e achieved with a mi)ing time of : #= secs% Decreased Mixing Time D 7eaves unreacted li*uid visi$le in cement Increased Mixing Time D Increased <iscosity( decreased Wor-ing 1ime By 3@ secs (;= secs +a)) +i)ing should $e complete any continuation of mi)ing will $egin to $rea- up newly formed polyacrylate chains & wea-en material% Improper 5torage D As 6ic is a water $ased material the lids should always $e replaced at earliest as there is increase in viscosity and deleterious effects on physical properties% Contamination D Hse of metal instruments for manipulation corrosion of metal surface F Incorporation into mi) Colour insta$ility !ecreases 5trength $y wea-ening matri) Contamination $y saliva( $lood( pellicle( pla*ue Improper or non removal of smear layer D Essential for formation of $ond with tooth surface% Failure to remove smear layer Adhesive 8 of restoration #= 9 2olyacrylic acid conditioning for #= #@ secs (A$oesh & 4en-ins #>B:) 1o dissolve smear layer% It left for more than 3= secs F !eminerali'ation of dentin% Another alternative( Fi)ing smear layer $y minerali'ing solution of 3@9 tannic acid or ferric chloride% Hnites smear layer to dentin and seals tu$ules% Improper tooth support D 6IC is a tooth supported material at least 3 ; mm of tooth structure re*uired% If placed at stress $earing areas li-e cups tips or marginal "idges "estoration li-ely to 8 !ue to 2oor 1ensile 5trength
3?

decrease in strength of 6IC

tooth interface $ond ( leads to adhesive fracture of restoration

2orosity D 5ome degree of 2orosity is inevita$le as two part material mi)ing%done +ain ha'ard with 2orosity Compressive strength 1ensile strength 2romotion of crac- propagation 2orosity Increased $y Improper dispensing Improper mi)ing 2orosity !ecreased $y +i)ing at low atmospheric pressure ;B 9 increase in strength achieved (0go et al( #>>:a) Hsing capsulated materials machine mi)ed% !ehydration D 6IC 2rone to dehydration( even varnishes seen not to provide significant results% 7eads to Crac- propagation 7eads to Bul- fractures "esin F modified (7ight F activated) least prone to dehydration% Cydration D 2rone to water upta-e during placement and first 3? hrs% 5welling of restoration !isplacement "e*uiring D "epolishing or replacement

#IC sensiti"ity $%
Caused $y dessication Attri$uted to washout and open margins from early saliva contamination% "emoval of smear layer $y conditioning followed $y early cement loss 2ermits access to $acteria to open tu$ules%
3@

5ol D A hydration period of 3 #= mins prior to restoration es post F op sensitivity% Improper Finishing D !ry finishing has deleterious effects% +arginal 7ea-age D Esp in cervical third of tooth prone to lea-age more% 1hough less critical than other materials% If occurs leads to 5econdary caries 2ulpal irritation

Failures of direct filling gold :Due to material Impurities in material added during production even small amounts of impurities in material have pronounced effects on mechanical properties e%g% =%39 lead ma-es gold $rittle and thus creation of a non uniform restoration% &ther Contaminants D Bismuth +ercury Impurities incorporated during procedures D #% Contaminated gases li-e 5&3 ( Ammonia and water vapours during annealing% 3% If flame used is not of +ethanol or Ethanol without additives contaminants are $ound to $e incorporated% ;% &verheating done during annealing leads to car$on contamination $y flame( tray or instrument ma-ing physical properties inferior% !ue to faulty procedures D A) Improper caries removal B) 7arge cavities D Ina$ility to ta-e masticatory stress( role of creep and thus leading to 8 of tooth though mallea$le and ductile% C) Contamination D A totally dry cavity is mandatory for cohesive condensation( contamination $y $lood( saliva etc lead to lac- of strength of !) Improper Annealing D Improper removal of surface contaminants cohesive form% &verheating ma-es gold stiller( difficult to condense and ductility%
3A

restoration%

 Contaminants may get incorporated $y over heating( use of faulty flame etc% 1emp $elow ;#@& (A==f) were inade*uate to attain optimum hardness of gold during annealing% Improper condensation D

It restoration not condensed in a proper I5teppingJ motion <&I!5 can $e incorporated decreasing cohesive form when in the $ul- % called I2itsJ

When on surface 2la*ue accumulation

1hese lead to Corrosion( marginal lea-age( secondary caries d%t% Cigh force concentration $y hand can damage tooth and insult pulp% Also high thermal conductivity of gold causes thermal insult to pulp( 6alvanism%

Failures of com!osite restorations

Composites have $ecome one of the most preferred esthetic restorations in modern times% But as they say %%%%%%%%%%%% IAll that loo-s gold is not gold( even these restorations have their own hindrances( failures that can be seen in a com!osite restoration are as follows $% !iscolorations esp at margins +arginal fractures "ecurrent Caries 6ross fractures of restorations 7ac- of contact maintenance
3:

2ost operative sensitivity 2ulpal irritation or damage +icrolea-age around composites

Failures caused by the followin( factors $% 7imitations of operator and processD Improper caries removal Faulty preparation Faulty handling( manipulation of material Improper isolation Contamination Improper Etching and $onding Inade*uate curing Bul- placements Improper finishing & polishing

Limitations of material composite: 2olymeri'ation shrin-age Wea- $ond strength when cavosurface margin in dentin Water sorption 2enetration in tissues to irritate pulp Inade*uate polymeri'ation in deep inter pro)imal areas

Incomplete caries e)cavation D If incomplete caries e)cavation is done( the left over caries hinders the $onding mechanism% As studies suggest that the wea-est $onding of composite is to carious tooth structure and early failures are to $e e)pected% Also if Kinc &)ide Eugenol is not removed fully in any case it hinders the methacrylate group of resins ma-ing the $onding wea-er %
3B

Incomplete etching or failure to remove residual acid from enamel tagsD 2roper concentration of etchant and etching time has to $e adhered to total etching time should not $e more than A= secs (;= A= 5ecs range)% 1hough #@ 5ecs etching sufficient for enamel( washing 3= ;= 5ecs (6els) #= #@ 5ecs (7i*uids) Avoid ; way syringe for drying F Contamination $y machine oils etc% "ole of e)it angles D >= degree Conservative !oesn/t e)pose ends of rods 5uperior seal Fdecreased +icrolea-age e)poses rods Concave e)it +ost retentive 7east conservative (used in cl I< cases) 4oining conve) e)it 7east practical clinically $ut illustrated rounded ends provide e)cellent e)its used for stiff composites provide e)cellent e)its used for stiff composites only 5em studies F >= e)it F 2oorest seal ?@ degree +ost common

Im!ro!er bondin( $%
Bonding agent is to $e applied gently and uniformly all around cavity walls% !ou$le Coats are to $e avoided as these lead to marginal lea-age non uniform $onding hinders the $ond strength to $onding agent% Also if one has to shift from microfilled resin to a layer of macrofilled( an unfilled $onding agent if not place wea-ens the $ond and causes fracture at that point% "ole of evaporation 7ac- of isolation
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Isolation is mandatory in a composite restoration ideally ru$$er dam should $e used( otherwise cotton rolls should $e -ept ready and changed evenly% Any contact with gingival fluid( saliva or $lood 2otential source of contamination reduces resin to resin $ond strength%

5ol F Etching and $onding to $e repeated% &ther contaminants D 1ouching the material with hands or fingers 2ic-ing material from tongue etc and placing $acHsing unclean instruments 1hese add impurities to the material rendering it wea- and less colour sta$le( changing shade characteristics% Always teflon coated instruments to $e used% Bul- placements +aterial is to $e cured in increaments and each increament should $e as small as possi$le as gaps may occur after shrin-age of material at tooth restoration interface% 1hese lead to post operative sensitivity( marginal lea-age & secondary caries% Also due to gaps and voids( material is rendered wea- and stress points F source of 8 Improper curing Curing if not done from all sides and for a stipulated period results in a restoration with mar-ed decreased strength and prone to marginal lea-age% If first curing is not done gingivally the material due to its property to shrin- towards source of light creates a gap $etween pulpal floor and $ul- of

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material in occlusal cavities and also leads to gap formation in gingival seat area in pro)imal restorations which are prone to lea-age/s and fractures%

Improper angle &2ath of light D As angle deviates from perpendicular( the penetration and intensity of light is afflicted & reduced% e%g% +arginal ridge of ad,acent tooth $loc-s light placed at an angle% &ptimum polymeri'ation occurs at depth of ,ust =%@ #mm owing to air inhi$ition at surface and difficulty of light penetration% 5tudy showedD : days after ?= sec curing cycle #mm deep composite F AB B?9 &ptimum hardness At 3 mm same composite F ?= A=9 At ;mm F only ;?9 Air Inhi$ition D &)ygen in air competes with polymeri'ation and inhi$its setting of resin% E)tent of surface inhi$ition is inversely related to filler loading% Hndercured layer can vary from @= @==mm or more( depending on reactivity of photoinitiator used % Hnfilled resins should $e cured( covered with air inhi$iting gel (&)yguard Commercial 2reparation ) 2etroleum ,elly glycerin & then recured 1his reduces air inhi$ition% Improper light intensityD &ptimum curing intensity F ?AB N 3=nm Blue light F ?==mvEcm3
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1hic-ness of resin D

Causes of decreased intensity D Age of $ul$ Increased Age F !ecreased Intensity <oltage <oltage drops decrease intensity 5terili'ation of curing tips reduces light transmission Filters to increase $lue light transmission degrades intensity% !istance of # mm from occlusal surface ideal increase in distance E)posure D +inimum e)posure of 3= ?= secs under continuous light is mandatory% Any deviations in lesser range results m partially cured( inferior restorations% 1emperature D 7ight cure composites cure less effectively if they are cold during application (Freshly ta-en out of refrigerator ) 1hey cure move rapidly & completely at room temp% Also most curing lamps produce heat which speeds curing process% Cowever e)cess heat $y undue application can result in pulpal irritation and inflammation% !ecreased intensity !ecreased strength

Curing distance D

Improper finishing & polishing D +eticulous finishing and polishing is to $e done( As all rough surfaces act as a nidus for microorganisms (2la*ue accumulation) 5pecial attention in interpro)imal area as sharp pro,ections F irritate & inflame gingiva $y impingement
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!ry 2olishing & Finishing is detrimental as it can open dentin margins at dentin F restoration interface% E)ception +icrofilled composites

Effect of num$er of flutes of finishing & polishing $ur F more the num$er of flutes lesser the damage 2ulp irritation or damage D It is difficult to differentiate the effect of components of composite resin itself( the trauma of cavity preparation( and se*uelae such as microlea-age at margins Cytoto)icity 5tudies 5tate D Cured polymeri'ed resin as far as possi$le causes minimum irritation% $ut incompletely cured resin $ecause of presence of uncured resins or surface active comple)es formed $Ew low molecular wt% components of light initiator systems% &ne potent component is Cema (Cydro)lethyl +ehacrylate ) an essential component of light cured composites( Cighly Cydrophillic Allergenic 5tudies show that it can transverse in tu$ules appear in pulp & Cause deleterious effects% Composite !iscoloration D Composite may undergo e)tensive surface staining intrinsic colour change or $oth% E)trinsic surface staining +a)% water sorption in first : #= days 5trong staining agents (1ea( Coffee( cola) penetrate to depth of ;%= @%= mm (+ount & Cume) 2ro$lems accentuate with wear and incomplete curing % Intrinsic discoloration
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5een in $oth chemically activated & light activated Chemically activated F 5u$stantial yellowing in # ; yrs due to o)idation of e)cess amine from initiator system <isi$le light cured systems D 7ighten in colour & $ecome more translucent during curing e further in 3? ?B hrs% $y decomposition of camphoro*uinone% !egradation in oral environment D Hnreacted methacrylate groups degrade more rapidly% +ay $e leached from resins Cydrolytic degradation of $arium & strontium 6lass fillers F 2ressure $uild up at resin Ffiller interface F crac- formation 1ype of composite used +icrofilled less suscepti$le to hydrolytic degradation Chemical attac- F Brea-down of silane coating Wea-ening of tiller resin $ond "apid thermal changes F Brea-down of silane coating In +icrofilled D Bond $Ew prepolymerised particles & +atri) F potential site for hydrolytic degradation failures% "ole of water sorption D 7imited amount may $e $eneficial +ore sorption F "estoration dimensionally unsta$le Aesthetically unpleasant +ore Water sorption F +ore Creep rate +icrofilled "esin F #%@ 3%= mgEcm3 Cy$rid & +acrofilled F =%A#%# mgEcm3

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Water sorption increases when Filler content less( resin content more reduced curing time F Increased Water sorption e%g 3@9 reduction in curing time 3fold increase in sorption F A fold increase in solu$ility 5eriously affects F !ura$ility & colour sta$ility% +icrolea-age of composites D Considera$le evidence Etching itself not a culprit of pulpal inflammation As acids get $uffered in dentin Cowever etching opens tu$ules ( allowing positive dentinal flow 5hould marginal lea-age occur & presence of partially or uncured monomers occurs F 2athway to pulp open% Adviced F not to etch dentin in vital teeth or a strong 6IC $ase completely covering all dentine $efore etching enamel walls% In vitro study (Caggesmon( +ason F 3==#) "esin +od 6IC Cas lesser +icrolea-age Bonding agents Flow a$le composites $y dunn/s test% (B) (C)

than (A)

+arginal !efects D
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#% 3% ;% ?%

5urface fracture of e)cess material Crevice formation C! itching( +arginal 2orosity or void (incorporation of air $Ew restoration & 1ooth during placement) Wear of restoration (2rogressive e)posure of a)ially directed cavity wall) "ole of type of composite used D +acrofilled F +ore of wearing type of defects Cy$rides F 1end to chip (Crevice formation) & wearing too +icrofilled F Chipping & 5urface fractures !ue to F Fracture toughness( tensile strength elastic modules( polymeri'ation shrin- coeff% of thermal contraction%

"ole of composite fatigue D Hnder certain loading conditions( composites $egin to tire( losing strength over a period of time% "esults in cohesive microcrac-s & e)ternal chipping% "ole of $leaching D "esults in colour insta$ility $y changing shade%

;A

#= #A9 car$amide pero)ide( may lead to slight deterioration $y statistically causing 5urface roughness & amount of parasites esp in microfilled & hy$rid resins result in increased pla*ue adhesion & staining 3@ ;@9 hydrogen pero)ide uniformly showed shear $ond & tensile $ond strength of all composites% ;:9 car$ide pero)ide or pastes c ;=9 C3&3 and 0a perorate( lead to microlea-age%

1hese concentrations after affecting marginal seal may penetrate to pulp and cause deleterious effects%

Failures of inlays
Important failures include D 5econdary caries 5urface discoloration +arginal fractures (Esp porcelain inlays) "estoration dislodgements +arginal lea-age 1ooth fractures

Failures caused due to (A) Faulty preparation D Angle of divergence of walls D Buccal and lingual walls divergence should $e at an angle $Ew @o & #= = If Angle O @o F "emaining structure under undue stresses during cementing & force loading in function If Angle P #=o F Compromised retention 7tructure of walls $% After inlay seated in mouth( maintenance of retention depends on 5trength and integrity of $oth lingual & $uccal walls%

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It is virtually impossi$le to gain strength and retention from opposite remaining cusp which is already wea- (E)tracoronal coverage) Improper +argins D ;= ?=o +arginal metal desira$le angle of #?= #@=o (Cavosurface angle) desira$le while cutting Cavosurface angle P #@=o F +etal too thin and weaO #?=o F +etal too $ul-y and difficult to $urnish 6ingival $evel of ;=o desira$le 0o mesial tilt of I051 F 1oo steep cutting +etal thin & wea0ot connecting & $lending with 5ec flares !istofacial & distolingual areas e)posed for cement dissolution% 5econdary flares D If not given results in pro)imal surfaces in F accessi$le to surface cleaning action F leading to pla*ue accumulation & periodontal pro$lems% 7uting cement dissolution% 7uting cements are prone to dissolution in oral environment +ore the gap in restoration tooth interface +ore cement e)posed +ore dissolution more marginal lea-age Also in pro)imal areas any e)cess cement remaining after cementation( unchec-ed Becomes an area of continuous periodontal irritation% 2ost insertion sensitivity D 5een c $oth 6IC and Kinc phosphate &ccurs mostly due to removal of smear layer Fi)ing of smear layer advised thus( 1hrough reinforced Koe has $een advised
;B

But tends to hydroly'e washings around margins more prone to lea-age &ar(inal lea'a(e 8 !ercolation 7ea-age occurs 1eeth su$,ected to alternative cooling and warming% !ue to F diff in coeff of thermal e)pansion of tooth and material% "esulting ingress & egress of fluids F percolation As a result $acteria/s can gain access & cause deleterious effects Another cause F increased taper F continuing loads F restoration gives away $y rotating on walls fractured thin metal margins% Considerations in !orcelain inlays D Bevels If given F 1hin sections of porcelain at cavosurface Cighly $rittle( prone to fracture

Fractures
A strain of only B #= mmEcm in dental porcelain is re*uired $efore it fractures +ost fractures start from inner surfaces esp at or near gingival margins Role of surface flaws $% 2orcelains are $rittle materials $ut not synonymous with wea-ness% Because of structure of 5i &3 $onds & a$sence of grain $oundaries( the vitreous matrices of porcelain have intrinsic strength% As material perfectly elastic F +easured strength strongly dependent on presence or a$sence of surface flaws%

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Fracture ro!a(ation $% Caused $y stress concentration at tip of surface Cow% &nce initiated ( the e)tension of crac- is ensured $y applied stresses & increasing stress concentration factor of growing crac-% E)posure to water strength of porcelain attri$uted to stress enhanced BEw glass & C3& occurs primarily at tips of such crac-s water reacts with glass F destruction of 5i & networ- Fhydro)yl ions attac- silo)ane $onds%

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CONCLUSION
As a wise man has saidQQ% In the wide arena of world failure and success are not accidents as we suppose $ut strict ,ustice of nature% If you do your wor- sincerely you are certain to get rewarded % A person who has not seen his or her wor- fail over the years is myopic( peripatetic( or simply very young% It is good to $e critical a$out wor- $ut $eing unfairly critical a$out wor- of others is not done for us we do not -now a$out the circumstances in which the restoration was done%

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R9F9R9NC97 A) B) C) !) E) F) 6) C) I) 4) 5tudervant F 1e)t$oo- of operative dentistry +ar'ov- F 1e)t$oo- of operative dentistry <imal si-r, F 1e)t$oo- of operative dentistry 1ooth coloured restorations F al$ers +ount 2reservation & restoration of tooth strvcture 7einfelders & 7emons F clinical restorative materials & techni*ues Advanced operative dentistry 2lc-ards +anual of dentistry 5-inners & 2hilips F dental material science 4"% of academy of dental materials 3= (>) 0ov 3==? 3=(#) 4an 3==? 3=(3) Fe$ 3==? 3=(;) +ar 3==? R) 4" of conservative dentistry : (;) 4ul F 5ep =? : (?) &ct F !ec =?s : (#) 4an F+ar =? Wilson( fu''i( <oli( vol II

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79&IN,R

FAILURES OF RESTORATIONS

$ 79&IN,R .: $ DR. 7*,NTUN &,;*OTR,

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