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Restoration failure

Why do we restore teeth?

1. Protect dentin-pulp organ
2. To stop carious process and prevent further caries spread
(endodontic treatment reduces the life span of the tooth)
3. To strengthen tooth and protect it from fracture
4. protect gingiva and investing tooth tissue (as in case of class V)
5. proper occlusal balance
6. restore esthetics
What determine restoration success?
1. Restore esthetics
ü Size
ü Form
ü Color translucency
ü Surface texture
2. Restores function (biological occlusion)
ü cusp anatomy: in centric and eccentric occlusion, and thus pre-
operative occlusion should be taken to check post-operative
occlusion
ü ridge height: to restore proper occlusion (cusp -> ridge
contact)
ü interproximal contact: to restore proper embrasure size to
prevent food impaction and to prevent mesial drifting of teeth
which occurs in case of open contact
ü physiologic contours: as not to be over or under
contoured
3. surface: should be
ü smooth and lustrous
ü free of cracks and fractures
ü free of porosities and voids
ü free of discolorations

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4. margins: should be
ü perfectly smoothed: to prevent plaque accumulation
ü free of discoloration: if present within the margin indicates
debonding, if outside indicates accumulation of stains (thus
etching should be done 1mm away from the cavity margin to
ensure proper bonding)
ü flush with the tooth
ü free of discrepancies and voids
ü free of overhangs
5. it should provide the following:
ü asymptomatic tooth
ü efficient mastication and balanced occlusion
ü long term maintenance of esthetics
ü long term maintenance of function
Causes of restoration failure:
1. iatrogenic:
- illness caused by medical examination or treatment,
which may be due to improper diagnosis or treatment
planning (pulp status)
- due to:
1) Improper diagnosis may be due to not knowing the
nature of pain whether it’s discomfort, pain associated with
stimulus or spontaneous, severe pain and the diagnosis of each
whether reversible or irreversible pulpitis
2) Mis-selection of restorative material
⇒ Caries risk assessment/eating habits: The teeth of patients
with high caries risk should be restored using glass ionomer
or even amalgam (bacteria can’t survive on it). However,
composite is contraindicated as bacteria can grow on it and
can break it down to obtain nutrients, also, the acidic
medium breaks the bond between composite chains, and
adhesive joint will dissolve by time forming a gap.

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⇒ Patients with occlusal stresses: these patients may suffer

from attrition, glass ionomer and ceramic restorations are
not preferred in this case
⇒ Material mechanical properties: wear resistance, surface
hardness and modulus of elasticity
⇒ Material esthetic properties
⇒ Wrong cavity design
⇒ Wrong material manipulation
⇒ Lack of follow up and early restoration repair
2. Lack of patient co-operation:
- Inconvenient operative and restorative procedure
- Incompliance for caries risk reduction programs
- Incompliance for abnormal occlusion habits correction
3. Oral environment factors:
- Difficult access to operative site
- Morphogenic, compositional and structural characteristics of
teeth
- Dynamic functional forces
- Microbial activity
- Biodegradation
- Thermal and pH fluctuations

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Types of failure:
1. Immediate (short term) failures: occurring within the first 24h
2. Delayed (long term) failures: occurring later than 24h (when
restoration becomes in function
Immediate failures:
1. Esthetic failure: failure to produce
⇒ Shade
⇒ Translucency
⇒ Form
⇒ Faulty material selection
2. Clinical manifestations:
⇒ Pain and sensitivity
⇒ Restoration fracture
⇒ Marginal problems (chipping and leakage)
⇒ Gingival and periodontal affection
Pain and sensitivity:
1. May be:
⇒ Severe, sharp
⇒ Spontaneous
⇒ +/- intensifies at night
- Causes:
⇒ - improper diagnosis (irreversible pulpitis)
⇒ - undetected exposure
⇒ - irreversible pulpitis due to procedural error
2. May be:
⇒ sharp, transient
⇒ related to osmotic changes, air blasts, tactile stimuli, thermal
stimuli
- causes:
⇒ procedural sensitivity (transient pulp hyperemia), will disappear
within 7 days
⇒ dentin sensitivity due to marginal defects or leaky restoration

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3. Pain after amalgam: amalgam marginal problems

(leaky amalgam/ditching):
⇒ faulty cavity preparation CSA
⇒ under trituration
⇒ inadequate condensation force
⇒ over carving
⇒ leaving the marginal flashes
⇒ post carving burnishing
4. Pain after composite: marginal problems (gap)
⇒ absence of finishing step: the burs cut by blade
that forms micro cracks thus if composite was
placed and cured without finishing of the cavity
-> gap due to polymerization shrinkage
⇒ insufficient bonding step
⇒ moisture contamination
⇒ improper layering technique (thick increments or bulk
placement)
5. May be:
⇒ discomfort
⇒ stimulated by temperature changes
⇒ decreases by time
- causes:
⇒ irritation due to procedural steps
⇒ soft tissue irritation
⇒ glass ionomer post-operative sting (not considered a failure)
NB. glass ionomer post-operative sting:
- the acid base reaction requires water especially in deep
cavities, so the cavity should be kept moist as to use the
superficial water and not that from dentinal tubules (to avoid
aspiration of dentinal tubules)
- in 85% of patient it declines and finally disappears by time
- if it persists or unbearable -> remake the restoration

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Restoration Fracture:
- it occurs due to premature contact at an early stage
- usually occurs with amalgam restoration due to not following the
instructions:
⇒ no biting or eating on the restoration before 1
hour, as in the first hour amalgam develops 50-
60% of its strength
⇒ no eating on the restoration side for 24 hours (so
no bilateral restoration)
- the probability of composite fracture within the first 24
hours is very low
So to sum up, short term failures are:
1. immediate esthetic failure (inability to produce shade
translucency-form-faulty material selection)
2. pain
3. restoration fracture
Delayed failures:
- Pain
1. Pain due to micro-leakage:
- Pain after asymptomatic restoration or discomfort
- Pain that doesn’t subside
- Pain that might increase by time
May be due to:
⇒ Insufficient curing: especially at the gingival
seat of class II restoration, due to improper
angulation of the light cure and thus there will
not be a sufficient peripheral seal
⇒ Bad oral hygiene: leads to plaque accumulation
⇒ Contamination by improper rubber dam application
⇒ Improper adaptation of restoration or no flowable composite
application in class II cavities -> gap formation at the corners
of the gingival seat

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2. Pain upon biting:

- Increases by time
- May proceed to periapical pain
May be due to:
⇒ Faulty occlusion production
⇒ Premature contact
And thus pre-operative occlusal records should be obtained to
return the patient’s occlusion to normal
NB. Sometime the patient may fell pain/discomfort after removal of
the high spot, even if there is no evidence of leakage or high spot?
- As we remove the high spot while the patient is in supine position
and we also check the occlusion in this position, where the
mandible is in the most retruded position and the patient closes
in centric relation. However, centric relation and centric occlusion
do not necessary coincide with each other and thus when the
patient closes in centric occlusion -> pain is felt
- So the high spot should be checked and then removed when the
patient’s position:
⇒ Supine (centric relation)
⇒ Upright (centric occlusion)
3. Pain that is characterized by:
- Discomfort or pain after composite that doesn’t subside
- Sometimes accompanying pain on biting
- Large cavities class II or MOD
May be due to:
⇒ After excavation and caries removal, only the buccal and
palatal walls remain connected by the base of the tooth, and
thus when composite shrinks:
ü Attracts the walls towards it -> cuspal deflection
especially in premolars -> tooth becomes stressed with
abnormal fluids movement
ü Gap formation due to breakage of adhesive joint
ü Breakage of cusps

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So, it is sometimes advised to reduce the cusps (1.5mm in non-

functional cusps and 1mm in functional cusps) and cover them by an
overlay
4. Pain with amalgam
- Starts after insertion by few days
May be due to:
⇒ Delayed setting expansion (zinc containing amalgam)
5. Periodontal pain
- Felt interproximal
- Gingival inflammation
May be due to:
⇒ Open contact
⇒ Fault proximal restoration contouring (overhangs), which
causes food impaction
6. Recurrent pain:
- With osmotic changes
- With temperature changes
Causes:
⇒ Caries development at restoration margins -> greyish
discoloration
⇒ Caries development or progression -> fracture of restoration
⇒ Caries progression -> tooth fracture due to undermining of
cusps
⇒ Food impaction
New caries development, occurs with amalgam or composite?
- It occurs with composite,
- Amalgam releases silver ions which have an antibacterial effect
and thus bacteria can’t grow on amalgam. However, the rough
surface of composite provides a good site for plaque accumulation
- Patient related factors (individual caries risk) remains the
dominant determinant of the secondary caries process

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- Fracture
1. Anterior composite restoration:
- Faulty preparation
- Improper bonding
- Improper diagnosis: as patient with edge to edge
bite or cross-bite which are contraindicated for
composite restoration
2. Bulk fracture of composite:
- High occlusal forces
- Absence of gingival seat as in deep class II (gingival
seat is crucial for longevity of restoration)
- Absence of gingival enamel which reduces the adhesion
quality (1st micro-leakage “pain” then fracture)
3. Amalgam:
- Bulk fracture:
⇒ Faulty occlusion (marginal ridge)
- Isthmus fracture:
⇒ Faulty cavity preparation design

4. Tooth fracture:
- Faulty cavity preparation
- Isolated cusps: as in MOD cavities or class II + buccal
extension of cusp -> no support, if there was sufficient cusp
structure left, composite may be used
to restore it, it not then it should be
covered
- Non-bonded restoration
- Improper bonding steps
- Improper occlusal check

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- Tooth cracks:
1. With amalgam: by time, change in anatomy and material will cause
an increase in the lateral forces and thus forms cracks in the
tooth
2. Faulty cavity preparation preparation (thin marginal ridges: if less
than 1.5mm enamel will carry the loads of amalgam -> cracks)
3. Non bonded restoration
4. Amalgam creep: permanent deformation under function ->
oxidation in alloys -> weakens the restoration
5. Delayed setting expansion
Solution of tooth cracks:
⇒ After removal of amalgam, check the amount of cracks:
ü If simple: enter with 329 size bur and include it with the
cavity to restore with composite
ü If extended + vertical root fracture: extraction of tooth
- Esthetic failure (composite restoration)
1. Surface discoloration: it should be re-finished and re-polished, if
the discoloration doesn’t disappear -> replace
2. Marginal discoloration
- Restoration dislodgment:
1. Unretentive cavity design as in case of amalgam
2. Faulty adhesion process as in case of composite or indirect
restoration
- TMJ problems:
1. Unilateral or bilateral pain upon mastication
2. Painful muscles of occlusion
3. Clicking sound
4. Abnormal habits (bruxism)
⇒ Due to restoration with interference. However, this is not felt
immediately by the patient due to adaptation of the muscles

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Factors affecting restoration longevity:

1. Number of surfaces involved
2. Restoration depth: as bonding will defer whether to enamel,
dentin or deep dentin
3. Material type and quality
4. Patient oral hygiene and risk assessment
5. Operator skill
Do restoration fail?
- Eventually, yes, all we do is to make it last longer
Biodegradation of composite
- Time dependent restoration
- Degradation due to interaction of restorative material with oral
conditions
- Factors:
1. Forces
2. Salivary environment
3. pH changes
4. temperature changes
- mechanism:
1. chemical
2. mechanical (wear)
3. combined
Chemical (corrosive wear):
- degradation of glass particles
- degradation of filler-matrix bond
- degradation of resinous matrix (ethanol- ketones- heat- esterase
bacterial enzymes), in bonding agent or restoration
NB. Silane is the first to degrade

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Mechanical wear:
1. 2-body wear
2. 3-body wear
how to overcome?
1. Low filler size
2. High filler load
3. Proper curing
Biodegradation for glass ionomer (wear)
- Sever wear occurs by time and thus may be considered as some
sort of provisional restoration (requires follow up)
1. Masticatory load + frictional forces = detachment of cement
at contact points
2. Water absorption = glass particle detachment
3. Changes in anatomy
4. Increase in surface roughness
5. Late marginal ditching due to bulk loss with retaining parts at
cavity restoration margins
Biodegradation for amalgam (creep):
1. Time dependent plastic deformation
2. Marginal ditching and fracture
3. Tarnish and corrosion -> surface discoloration

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