FAILURES OF DENTAL AMALGAM

a) Dental amalgam is one of the most frequently used

restorative materials for restoration of posterior
teeth. In routine properly restored silver amalgam may
not last for more than ten years.
b) Early restored teeth appear excellent but gradually
peculiar things begin to happen altering the technical
details of the restoration.
c) These may lead to fracture of’ restoration, tooth
fracture, recurrent caries, discoloration, corrosion,
loss of restoration and etc.
d) The observed amalgam failures are most likely
because of factors other than the material itself. The
success of the amalgam restoration depends upon the
control and attention to many variables.

The different types of failure in an amalgam restoration

are -

I. At visual level

1. Secondary caries
2. Marginal fracture
3. Bulk fracture
4. Tooth fracture
 5. Dimensional change

II. At the microstructural level

1. Corrosion and tarnish

2. Stresses associated with masticatory forces

III. Pain following amalgam restoration

IV. Pulp and/or periodontal involvement

Failures in an amalgam restoration can be studied in detail

under two main headings:

a) Failures due to faulty cavity preparation

b)Failures due to poor matrix adaptation
c) Failures due to faulty amalgam manipulation

I. Faulty Cavity Preparation

1) Most clinical studies have concluded that improper
cavity preparation leading to recurrence of caries and
fracture is the greatest single factor responsible for
failure.
2) Healey and Philips (1949)40 evaluated 1521 defective
amalgam restorations and reported that 56% of the
 failures were because of improper cavity preparation
and 42% of the failures were because of faulty
manipulation of amalgam.
3)The different causes of failure that can occur at
various steps while preparing a cavity for amalgam are
as follows:
a) Inadequate occlusal extension : On the occlusal
surface the preparation should be extended to include
all the susceptible pits and fissures while terminating
the margins in areas that can be finished.

b) Inadequate extension of the proximal box

If the proximal box walls are not adequately extended

into the embrasures they are not amenable to brushing
& cleaning by mastication which predisposes to
secondary caries

c) Overextension of the cavity preparation walls:

i. The ideal facio-lingual width of the cavity

preparation for amalgam should be 1/4th the
intercuspal distance.
ii. If the cavity preparation extends to half of the
intercuspal distance, consideration should be given to
capping of the cusps.
 iii. If the cavity preparation extends to 2/3rds of
the intercuspal distance cusp capping becomes
mandatory.
iv. If the remaining cusps are not capped in large
amalgam restorations, there are chances that the
cusps can fracture. This is because amalgam
restoration on acts as a wedge and tends to split the
exposing cusps apart.
v. During cusp capping amalgam should be present in
a minimum thickness of 2 mm over functional cusps and
minimum thickness of 1.5 mm over non-functional cusps
to give it adequate strength.

d)Amalgam cavity preparations should have a minimum

depth of 1.5 mm to provide it bulk .Hence resistance to
fracture.

e) If pulpal floor of the cavity preparation flat but

curved the restoration produces wedging effect thus
increasing the chances of fracture of tooth.

i. To assure strong junctions between amalgam and

tooth regardless of its location, butt joints created
particularly in those regions where occlusal stresses
to be encountered.
 ii. Cavosurface angle is acute there are chances of
fracture of the tooth margins whereas if the
cavosurface angle is obtuse the acute marginal
amalgam is likely to collapse under occlusal stress.
iii.The cavity margins should be adequately finished to
remove any unsupported enamel rods, which are
susceptible to fracture leading to gap formation and
subsequently secondary caries.

g) Failure to round off the axio-pulpal line angle as well as

internal line angles and point angles can lead to
concentration of stresses and fracture of the tooth or
restorative material.

h) Occasionally, fracture may be seen at the isthmus

portion of the proximo-occiusal restoration, which may
be because of a very narrow isthmus or inadequate
proximal retention form.

i) Failure to diverge the mesial and distal walls of the

occlusal cavity preparation. When the mesio-distal
extension of the cavity is extensive it can cause
fracture because of the undermining of the mesial and
distal marginal ridge enamel.
j) Retentive devices should be prepared entirely in dentin
without undermining the enamel.

k) Incomplete removal of carious tooth structure leads to

failure of amalgam restoration.

l) Flat pulpal floor should be provided around the

excavation site of caries. If this is not possible at least
three flat seats should be provided to resist the forces
directed along long axis of the tooth

m) Post operative pain can also be a routine failure. The

dentist should use high speed rotary instruments, with
intermittent cutting and adequate cooling of tooth
structure thereby minimizing the post operative pain.

II. Poor matrix adaptation

 i. The areas and relationship of contacts, the anatomical
design ofthe marginal ridges, the marginal continuity
of the restoration all play important roles in assuring
that the tissues of the periodontium will maintain a
state of health.
ii.The matrix should be very stable after it has been
applied. Instability of a matrix results in a distorted
restoration, gross marginal excesses and an
uncondensed soft amalgam.
iii. The cervical excesses can irritate the periodontium,
gradually and progressively destroying the
periodontum.
iv. Establishing a proper contacts and contours with the
help of matrices are fundamental to the successful
amalgam.

lll. Faulty amalgam manipulation

It has been stated that more amalgam restorations
fail because of poor
manipulation than
because of the use
of poor alloys.
 Successful restoration can be relieved when variables
are kept under strict control. The basic principle of all
these manipulative procedures is to produce a well-
prepared amalgam with the mercury content in the
amalgam under control.

a) Mercury alloy ratio

i. A serious loss of strength occurs when the residual

mercury is in excess of 55% in the restoration. The
clinical result of excess residual mercury includes
reduced crushing strength, increased flow and
increased susceptibility to tarnish and corrosion
ii. It is preferable to use a minimal mercury technique
with dispensers used for the correct proportioning.
iii. Mulling is a continuation of the trituration process and
is done to assure that all alloy particles are duly
coated with mercury. It can be done manually or
mechanically. While doing it manually, moisture can be
incorporated into the material if bare hands are used.
Mechanically, mulling is done in the amalgamator
iv. Both under trituration and over trituration can lead to
failures of amalgam restoration. Under trituration
 leads to soft powdery non-coherent mix whereas
overtrituration may break the already forming matrix.

b) Condensation
i. The rationale of condensation is to reduce residual
mercury content, to ensure amalgam reach all parts of
the preparation and to obtain a homogenous
restoration devoid of voids.
ii. Freshly prepared amalgam has more desirable working
properties. The effectiveness of removing residual
mercury from the restoration is possible only if the
amalgam is used within 4 minutes of trituration.
iii.If a larger cavity demands that the working time of
the amalgam exceeds 3-4 minutes, the use of multiple
mixes will allow the operator to handle plastic
amalgam throughout the condensation procedure and
ensure building a homogenous restoration.
iv. There are limits to the removal of mercury also.
Certain amount of mercury is necessary to bind the
mass together in a homogenous form. Elimination of
mercury by excessive squeezing may induces a
laminated effect and seriously reduces the strength
of the restoration. The end result is similar to
 working with a partially crystallized or set amalgam.
The critical reduction of mercury levels below 55% is
however obtained during packing.
v. Condensation can be carried out either manually or
mechanically. Condensation should be done using the
stepping process to drive away any voids from the
restoration.
Small increments should be design of the marginal
ridges, the marginal continuity of the restoration all
play important roles in assuring that the tissues of
the periodontium will maintain a state of health
vi. Instability of a matrix results in a distorted
restoration, gross marginal excesses and an
uncondensed soft amalgam.
The cervical excesses can irritate the periodontium,
gradually and progressively destroying the
periodontium.
vii. Establishing a proper contacts and contours with the
help of matrices are fundamental to the successful
amalgam.
viii.Condensation pressure used should be adequate.
 a) Contamination

Contamination of the amalgam mix during trituration,

mulling and condensation, by moisture weaken amalgam
restoration especially with zinc containing alloy. There
occurs delayed expansion, which could possibly result in
marginal flaws, tarnish, pitting, corrosion and blistering
etc. Expansion may also lead to pain.

b) Finishing and polishing

a.The amalgam should be finished gently.
b. During finishing excess amalgam at the margins is
dressed down to thin flakes or spur like overhangs, which
can fracture from the restoration sooner or later, leaving
susceptible crevices.
c. Overcarving the restoration to create normal, deep
anatomic features should be avoided. An over carved
restoration will reduce the thickness of amalgam and
increase chances of fracture.
d.Amalgams that have a greater tendency for tarnish and
corrosion do not retain surface polish for a long time.
e.Failure to polish may accelerate corrosion because of
surface irregularities. Also the restoration surface is
rough promoting plaque accumulation and gingival
irritation.
f. When temperatures above 65°C are generated, mercury s
released from the amalgam leading to defective
restoration.

a) Post-operative pain

a. This may occur following an amalgam restoration because

of hyper occlusion lead to inflammation of the apical
periodontium.
b. Cracks in tooth: Such cracks cause pain during chewing
because of expansion & contraction of tooth structure
with every bite.
c. Galvanism not only the adjacent/antagonist dissimilar
metal restorations lead to galvanism, but in poorly
condensed silver amalgam, variation in silver
 concentration at different areas of the same
restoration, also leads to it.
d.Delayed expansion is peculiar with zinc containing alloys
e.Failure in the form of pain may occur if inadequate pulp
protection is present. Amalgam is a good conductor of
heat. If a base is not given, heat may be conducted to
the pulp resulting in its damage.
f.Varnish should be routinely applied under amalgam
restorations. Failure to apply proper varnish layer can
lead to continuous leakage around the restoration. This
leakage may cause postoperative sensitivity and amalgam
blues due to penetration of corrosion products into
dentinal tubules.
g.The restoration fracture may occur if the patient does
not follow the instructions properly and bites on
restoration before it sets.