Bridge Failures

Technology in the hands of a skilled operator makes it possible

to do more work of an even higher quality. But in the hands of one
who has not mastered the skills of his or her profession, that
technology merely enables one to do tremendous damage.
- Herbert T. Shillingburg
Excellence in dental care is achieved through the dentists ability to
assess the patient, determine needs, design an appropriate treatment
plan and execute the plan with proficiency.

CLASSIFICATIONS

The causes of FPD failures were summarized as early as in 1920 when Tinker
wrote
Chief among the causes for such disappointing results has been:
First: Faulty, and in some cases, no attempt at diagnosis and prognosis.
Second: Failure to remove foci of infection in attention to treatment and care of the
investing tissues and mouth sanitation.
Third: Disregard for tooth form
Fourth: Absence of proper embrasures
Fifth: Inter proximal spaces
Sixth: Faulty occlusion and articulation



Other classification given by Bennard G. N. Smith

1. Loss of retention

2. Mechanical failure of crowns or bridge components
a. Porcelain fracture
b. Failure of solder joints
c. Distortion
d. Occlusal wear and perforation
e. Lost facings

3. Changes in the abutment tooth
a. Periodontal disease
b. Problems with the pulp
c. Caries
d. Fracture of the prepared natural crown or root
e. Movement of the tooth

4. Design failures
a. Under-prescribed FPDs
b. Over-prescribed FPDs

5. Inadequate clinical or laboratory technique
a. Positive ledge
b. Negative ledge
c. Defect
d. Poor shape and color

6. Occlusal problems






Failures of FPD

Failures of fixed partial dentures occur based on:
Patient complaints
Duration of time

Patient complaints
Pain
Sensitivity
Looseness of bridge
Pain in soft tissue (gingiva)
Esthetics
Fracture
Swelling
Speech
Mastication

Duration of time
Immediate
Delayed


TYPES OF BRIDGE FAILURES
I. Cementation failure
II. Mechanical failure
III. Gingival and periodontal breakdown
IV. Caries
V. Necrosis of pulp
VI. Esthetic failure

I. CEMENTATION FAILURE
Cement failure
Retention failure
Occlusal problems
Distortion of the bridge

Cement Failure
Cement selection
Old cement
Prolonged mixing time
Thin mix
Thick mix
Cement setting prior to seating
Inadequate isolation
Incomplete removal of temporary cement
Thick cement space
Inclusion of cotton fibers
Insufficient pressure while cementation

Cement Sel ection
FPD Multiretainers - GIC
Non Vital Teeth/Advanced Pulp Recession - ZINC PHOSPHATE
Temporary Cementation - ZINC OXIDE EUGENOL
Fixation of Facings- DIMETHACRYLATE COMPOSITES
Abutment with Minimal Dentin / Exposure - CALCIUM HYDRO
OXIDE + ZINC OXIDE EUGENOL

Thick Cement Space
Convergence below 6
Excessive application of die spacer
Thick cement mix
Grinding metal inside retainers
Cement setting prior to seating

How to Confirm Cement Failure
Pull the crown margin and see for movement of the crown

Crown margins which were subgingivally placed will be visible
when we pull the crown margin

Bubbles come out of the margin or through perforation of the crown
(if present) when the crown margin is pushed by applying pressure
occlusally


Retention failure
Excessive taper
Short clinical crown
Mis-fit
Mis-alignment

Retenti on
Retention prevents the removal of the restoration along the path of
insertion or the long axis of the tooth.

Resistance prevents dislodgement of the restoration by forces
directed in apical or oblique direction
Improving Retenti on
Additional retentive grooves/ proximal grooves.
Additional pins- drill the retainer & tooth .5 to .7 mm with round
bur in buccal & lingual aspects, cut the excessive length & smoothen
the area.
Crown lengthening
Sub gingival margins
Additional abutments


Excessi ve Taper
The relationship of one wall of preparation to the long axis of that
preparation is the inclination of that wall.
Sum of the inclination of two opposing walls give the taper of the
preparation.
Minimum 12 taper is necessary to ensure the absence of undercuts
& also the restoration is placed on the preparation after being
fabricated in final form.
Conscious effort to incorporate taper usually results in over tapered,
non retentive preparation.

Short Clini cal Crown
Cement creates a weak bond, largely by mechanical interlocks,
between the inner surface of the restoration & the axial wall of the
preparation. So, greater the surface area of preparation, greater wills
the retention.
A short, over tapered crown would have minimal ret ention because
the restoration can be removed along infinite paths.
Because the length of axial wall occlusal to finish line interferes
with the displacement, the length & inclination become important
factors.

Misfit
Causes
Expansion of metal substructure because of
-Improper water /powder ratio of investment
-Improper mixing time
-Improper burn out temperature
Distortion of the margins
Distortion of metal substructure
Metal bubbles in occlusal or margin regions because of
- Inadequate vacuum during investing
- Improper brush technique
- No surfactant
Porcelain inside retainer
Excessive oxide layer in inner side of retainer
Tight contact points
Thick cement space
Insufficient pressure during cementation
Misalignment
In case of misalignment the bridge will +ve spring in it & tend to
seat further on pressure due to abutment teeth moving slightly
In misfit the resistance felt is solid.
Causes
Abutment displacement due to improper temporization.
Distortion of wax pattern
Casting defects
Distortion of metal framework in porcelain firing.
Porcelain flow inside the retainers
Mal alignment of solder joints
Excessive metal or porcelain in tissue surface of pontic.
Remedy
If the bridge seats fully under pressure- leave it in place for 30 min
to 1 hr asking the patient to exert gentle pressure.
If it does not work, temporarily cement to one of the retainers for 1
to 2 days.
Then, the bridge is unsoldered, separate components tried. If they
seat, take location impression & resolder.
Occlusal problems
Problems in occlusion are basically
Immediate problems
1. Occlusal interferences
2. Marginal ridges at different levels
3. Supra eruption of opposing tooth
4. Para functional habits
Delayed problems
1. Wearing of occlusal surfaces
2. Loss of occlusal contacts
3. Cementation failure due to lateral forces
4. Periodontal and gingival breakdown
5. Tenderness
Torque
From a cusp extended too far bucally or lingually.
Pre mature contact on lateral excursion extremity.
Results in cementation failure.
Reduce bucco lingual width of occlusal surface
Indications
Mobility of teeth
Tenderness on mastication
Hyperemia of soft tissues
Sensitivity to heat, cold & sweet
Burnished metal in area of premature contact
Checking occlusion


Touch
Tin articulating paper
Occlusal indicator wax
Occlusion should be adjusted both in centric and eccentric
Distorti on
Distortion of wax patterns
Incomplete casting
Long span bridges
Wax Patterns
Removal from the die
Spruing stage
Investing stage because of the thick investment material.
I ncompl ete Casting
Too thin wax patterns
Incomplete wax elimination
Cool mold or melt
Insufficient metal

Long Span Bridges
Thin crown
Soft metal
Heat treatment not being done
Porosity in the metal
Distortion of margins.





MECHANICAL FAILURE
1. Retainer failure
2. Pontic failure
3. Connector failure
Retainer F ailure
Perforation
Insufficient occlusal reduction
High points in opposing dentition
Premature contacts
Soft metal
Porosity
Para functional habits
Marginal Discrepancy
The more accurately the restoration is adapted to tooth, the less
will be chances of cementation failure, recurrent caries or periodontal
disease. 50 to 100 discrepancy is acceptable.
Rough margins reduce adaptation
Open margins encourage entry of saliva and cariogenic organisms
Over extended margins cannot be adapted to converging convexity
of tooth at cervical margin
Causes
Selection of margin
Improper preparation
No gingival retraction
Improper selection of impression materi al
Distortion of wax patterns
Nodules at margin or inside casting
Thick cement
Prior setting of cement

F acing F ailure
Fracture
Too little retention
Spot contact at porcelain metal junction
Malocclusion
Microleakage.

Wearing



Deep bite
Acrylic veneering opposing porcelain teeth
Faulty brushing & flossing
Parafunctional habits

Discolorati on
Absorption of oral fluids
Absorption of artificial food colouring agents through the
microcracks or microleakage in metal & facing
Tarnish of underlying metal & facing

Ponti c failure
Requirements
F Fo or r m m & & s sh ha ap pe e o of f g gi i n ng gi i v va al l s su ur r f f a ac ce e m mu us st t n no ot t i i r r r r i i t t a at t e e r r e es si i d du ua al l r r i i d dg ge e
Design must incorporate mechanical principles for strength &
longevity
Esthetics
Residual Ridge Contour
Ideal - smooth, easy to clean
Irregular hyperplastic tissue (commonly because of an ill fitting rpd)
must be surgically removed
Severe bone resorption (particularly because of trauma) - surgical
ridge augmentation

Ridge Contact
Pressure free contact without blanching.
In esthetic zone, the pontic should contact on the labial/ buccal
aspect.
In mandibular posteriors hygienic pontic can be given.

Metal Sub Structure is compromised due to
Limited edentulous space in Occluso gingival direction due to supra
eruption of opposing tooth.
Limited space mesiodistally due to drifting of adjacent teeth
Framework must provide uniform thickness for porcelain- cut back
wax uniformly
Metal ceramic junction should be 1.5 mm away fr om junction.

GINGIVAL AND PERIODONTAL BREAKDOWN
- Margins placement
- Integrity of contacts and margins
- Occlusion

Reasons for gingival breakdown

Plaque retention
Improper design
Faulty margins
Incorrect occlusal anatomy
Over contoured retainer
Inadequate embrasure

Treatment options:
Give proper oral hygiene instructions
Remake the bridge

Reasons for periodontal breakdown:
General periodontal problems
Local periodontal problems like
- Poor bridge design
- Incorrect assessment of abutment strength
- Insufficient abutment selected
- Traumatic occlusion

Treatment options:
Remake the bridge

Supra Gingival Margins
Advantages
Can be easily finished
Easily cleanable
Impressions easily recordable
Easy evaluation at recall
Disadvantages
Esthetically inferior
Not indicated for short clinical crowns
Not indicated in case of root sensitivity
Sub Gingival Margi ns
I ndications
Esthetic demands
Caries removal
Existing sub gingival restorations
Crown lengthening.
Disadvantages
Difficult to prepare
Soft tissue prone to trauma
Causes gingival & periodontal pathosis
Difficult oral hygiene
Metal margins seen through gingival.




CARIES
Caries occouring on the margin of the retainer,
Caries affecting indirectly by starting elsewhere on the tooth and
spreading.
Caries due to cementation failure.
Reasons for caries:
Poor oral hygiene
Open margins
Faulty contacts
Treatment options:
Use conventional filling materials
Correction of crowns and bridges if possible
Remake the bridge

NECROSIS OF PULP


Can occour at three stages
- Prior to preparation

- During preparation

- After preparation
Reasons for pulp necrosis:
Increased occlusal trauma
Increased heat during preparation
No pulp protection

Other reasons for pulp necrosis:
Speed, size, and type of the rotating instrument
The amount of pressure used
Depth of remaining dentin
Vibration
Coolants
Desiccation
Chemical injury

T Tr r e ea at t m me en nt t o op pt t i i o on ns s: :
F Fo or r a an nt t e er r i i o or r t t e ee et t h h a ap pi i c ce ec ct t o om my y a an nd d r r e et t r r o og gr r a ad de e f f i i l l l l i i n ng g
F Fo or r p po os st t e er r i i o or r t t e ee et t h h e en nd do od do on nt t i i c c t t h he er r a ap py y
R Re em ma ak ke e t t h he e b br r i i d dg ge e

ESTHETIC FAILURES
Requi rements for Estheti c Restorations
Proper shade selection
Correct tooth preparation
Avoidance of grey margins
Prevention of metal exposure
Final impression


Reasons for Estheti c Failure
Failure to identify patient expectations regarding esthetics
Improper shade selection
Failure to transfer shade selection to laboratory
Excessive metal thickness at incisal and cervical regions
Over glaze or too much smooth surface
Metal exposure in connector, cervical, and incisal region
Dark space in cervical third due to improper pontic selection
(anteriors)
Failed to produce incisal and proximal translucency
Improper contouring
Failure to harmonize contra-lateral tooth morphology- contour,
colour, position, angulations
Discoloration of facing

Shade Sel ecti on
Walls and surroundings should be in neutral colour or blue
Never select under direct sunlight
Upright position of the patient
Use squint test
Teeth should be clean and unstained
Shade selection should be done before teeth preparation
Dont dry the tooth while selecting the shade
Canine is the darkest tooth
Premolars lighter shade than canine
Maxillary anteriors are missing, shade of the mandibular anteriors is
considered
In case of a non-vital tooth, cover it and select the shade of the
adjacent tooth.

Other Biologic bridge failure are

Fracture of tooth

Reasons for fracture:
Improper abutment selection
Wear of tooth
Increased occlusal forces

Treatment options:
Remake the bridge using more abutment teeth.


Temporo-mandibular joint problems



R Re ea as so on ns s f f o or r T TM MJ J p pr r o ob bl l e em ms s: :
I I m mp pr r o op pe er r o oc cc cl l u us sa al l s sc ch he em me e
T Tr r e ea at t m me en nt t o op pt t i i o on ns s: :
R Re em ma ak ke e t t h he e b br r i i d dg ge e u us si i n ng g p pr r o op pe er r o oc cc cl l u us sa al l s sc ch he em me e




Caries the frequent culprit

C Ca ar r i i e es s 3 38 8% %
P Pe er r i i a ap pi i c ca al l i i n nv vo ol l v ve em me en nt t 1 15 5% %
P Pe er r f f o or r a at t e ed d o oc cc cl l u us sa al l s su ur r f f a ac ce e 1 10 0% %
F Fr r a ac ct t u ur r e e p po os st t & &c co or r e e 8 8% %
D De ef f e ec ct t i i v ve e m ma ar r g gi i n ns s 8 8% %
F Fr r a ac ct t u ur r e e t t e ee et t h h 7 7% %
P Po or r c ce el l i i a an n f f a ai i l l u ur r e es s 8 8% %
J J P PD D, , V Vo ol l 7 78 8, , I I s ss su ue e 2 2, , p pg g 1 12 27 7- - 1 13 31 1, , A Au ug g 1 19 99 97 7














Conclusion

Failures most often occur because of violation of principles either
collectively or individually and for the most part are due to attempted
short-cuts or positive indifference and inexcusable ignorance on the
part of those concerned. Whatever said and done, at last it is only the
ability of a Prosthodontist which determines the success or failure of a
fixed partial denture.

























Bibliography

Shillingburg HT, Hobo S, Whitsett LD, Jacobe R, and Brackett SE:
Fundamentals of fixed prosthodontics, ed. 3, Chicago, 2001, Quintessence,
Inc.
Tylmans theory and practice of fixed Prosthodontics,8th edi,1989,William
F.P.Malone, David .L.Koth
Roberts DH: Fixed bridge prosthesis, ed. 1, Bristol, 1973, John Wright &
Sons.
Rosenstiel SF, Land MF and Fujimoto J: Contemporary fixed
prosthodontics, 2001, ed. 3, N.Delhi, Harcourt.
Longevity of fixed partial dentures,JPD,Vol 78,Issue 2,Pg 127-131,Aug
1997.
Failures related to crown and fixed partial dentures fabricated in Nigerian
dental school, Journal of contemporary dental practise, Vol 6, No 4,Nov
15,2005.
Clinical complications in fixed Prosthodontics, JPD,2003,90 Vol, pg 31-41





























A seminar on






Failures in fpd


Presented by
Dr.G.MANMOHAN,
Final year P.G Student,
Date: 12-07-08.
Signature of Prof & HOD









SIBAR INSTITUTE OF DENTAL SCIENCES
Guntur-522509