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Fracture reasons in ceramic-fused-to-metal restorations (Review)

Özcan, M.

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Journal of Oral Rehabilitation 2003 30; 265–269
Review
Fracture reasons in ceramic-fused-to-metal restorations
M . Ö Z C A N Dentistry Faculty, Department of Prosthodontics, Marmara University, I_stanbul, Turkey
SUMMARY Ceramic-fused-to-metal restorations are
widely used in dentistry with a high degree of
general success. Fracture of the ceramic veneers as a
result of oral function or trauma is not an uncom-
mon problem in clinical practice. Although fractures
of such restorations do not necessarily mean the
failure of the restoration, the renewal process is
both costly and time consuming and therefore
remains a clinical problem. Fractures in the anterior
Introduction
Because of their excellent biocompatibility and superior
aesthetic qualities, ceramic-fused-to-metal crowns and
bridges are commonly applied in fixed prosthodontics.
Despite the increased effort to improve the bond
strength between the ceramic and the metal substrate,
on occasion, fractures of ceramic veneers still occur
under clinical conditions. The reasons for such failures
are frequently repeated stresses and strains during
chewing function or trauma. Clinical studies indicated
that the prevalence of ceramic fractures ranged
between 5 and 10% over 10 years of use (Coornaert,
Adrians & de Boever, 1984).
Ceramic fractures are serious and costly problems in
dentistry. Moreover, they pose an aesthetic and func-
tional dilemma both for the patient and the dentist.
Therefore the intent of this paper is to review the
published literature on the reasons for fractures,
concentrating on the data obtained both from in vitro
and in vivo studies.
Failure rates
Many patients are still in need of fixed restoration
replacements as a result of some failures in those
ª 2003 Blackwell Publishing Ltd
region pose an aesthetic problem but when they are
in the posterior, chewing function could also be
affected. The published literature reveals that rea-
sons for failures cover a wide spectrum from iatro-
genic factors to laboratory mistakes or because of
factors related to the inherent structure of the
ceramics or simply to trauma.
KEYWORDS: fracture, ceramics
restorations. Only a few studies in the literature have
dealt with the survival rates of metal–ceramic restora-
tions.
In a clinical follow-up study by Coornaert et al.
(1984), the prevalence of fractures in metal–ceramic
crowns was found to be approximately 5% over
10 years of function. Strub, Stiffler and Schärer (1988)
observed a failure rate of metal–ceramic restorations of
only between 1 and 3% over 5 years. Studies by
Karlsson (1986) revealed a 93% success rate for fixed
bridge restorations during a 10-year period, while
Palmqvist and Swartz (1993) reported a 79% success
rate over an 18–23-year period. The survival rates
obtained by Glantz et al. (1993) as a function of time
between 1979 and 1994 indicated that most of the
debondings occurred over 15 years and almost all
recorded dislodgements were observed within 5 years
of placement. Subsequent clinical results from Hankin-
son and Cappetta (1994) and Kelsey et al. (1995)
exhibited 2–4% failure rates after 2 years of function,
rising from 20 to 25% after 4–5 years because of con-
sistent repeating occlusal contacts.
In another clinical retrospective analysis, 1219 three-
unit fixed bridges and 1618 single crowns in the
anterior region were evaluated between 1969 and
1989 (Kerschbaum, Seth & Teeuwen, 1997). The results
265
266 M . Ö Z C A N
of the study supported the superiority of metal–ceramic
systems over acrylic-veneered crowns with 2–4% fail-
ure rates after 2 years of function. Statistical analysis
however, showed that after 10 years, 88Æ7% of the
metal–ceramic crowns and 80Æ2% of the metal–ceramic
bridges were still in function.
Overall survival rate of metal–ceramic restorations
demonstrate a paradox in the different survival rate
values in the literature. It is well recognized that many
factors are involved in the success rate assessments of
fixed partial dentures limiting the longevity of the
restorations.
Factors affecting failure
Failure of the restorations is in fact a multifactorial
problem which could be related to a combination of
different reasons. Optimization of the metal–ceramic
restorations requires knowledge of the failure phenom-
ena. Numerous studies over the years have focused on
reasons for failure.
Mechanical failures of metal–ceramic systems are not
surprising considering the vast differences in modulus
between the metal and ceramic materials. When feld-
spathic dental porcelain is cooled, the leucite crystals
contract more than the surrounding glass matrix
leading to the development of tangential compressive
stresses around the leucite particles as well as to
microcracks within and around the crystals (Hasselman
& Fulathy, 1966; MacKert, 1988; Anusavice & Zhang,
1998; Denry, Hollowey & Rosentiel, 1998).
Some studies attributed the reasons for failures to the
environmental factors and particularly to the moisture.
Twenty to 30% reduction in metal–ceramic strength
was found in a moist environment (Sherill & O’Brein,
1974). Michalske and Freiman (1982) indicated that
silicate bonds in the glassy ceramic matrix are suscept-
ible to hydrolysis by environmental moisture in the
presence of mechanical stress. The porcelain restoration
functions in a moist environment, which may allow
static fatigue to cause the propagation of fractures along
the microcracks resulting in failure of the restoration.
The environment of the oral cavity was found to
aggravate the strength of dental ceramics. The silicon–
oxygen bond become weaker between the metal and
ceramic in the presence of moisture which abet failure
in many ways primarily because of the water propaga-
tion at the crack tip (Dauskardt, Marshall & Ritchie,
1990). In the oral environment, the influence of water
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 265–269
and fatigue, caused by cyclic loading such as mastica-
tion, are considered important factors in the durability
of metal–ceramic restorations. Yet, the effect of other
artificial environmental factors such as saliva or differ-
ent kinds of drinks needs to be studied.
The most frequent reasons for ceramic failures are
related to the cracks within the ceramic. The minute
scratches present on the surfaces of nearly all materials
sometimes behave as sharp notches whose tips are as
narrow as the spacing between atoms in the materials.
Thus, the stress concentration at the tips of these
minute scratches causes the stress to reach the theor-
etical strength of the material at relatively low average
stress. When the theoretical strength of the material is
exceeded at the tip of the notch, the bond at the notch
tip breaks. As the crack propagates through the mater-
ial, the stress concentration is maintained at the crack
tip until the crack moves completely through the
material (Lamon & Evans, 1983). Long anterio-poster-
ior metal substructure also flexes under heavy or com-
plex loading causing porcelain fracture (Reuter & Brose,
1984). The cracks existing within the ceramic are
important issues to be considered in the survival of
fixed partial dentures. Especially in long span bridges,
crack propagation might then result in the catastroph-
ical failure of the restoration.
It was also noted that other reasons for the ceramic
fractures are technical mistakes during the preparation
of the restorations and claimed that occasional presence
of pores inside the ceramic could account for their
weakness and eventual fracture at that site (Oram &
Cruickshank-Boyd, 1984). The same results were also
found by Øilo (1988) who agreed that such mistakes
markedly increase the failures.
Further studies demonstrated the importance of
microcracks existing in the ceramic. Microcracks in cer-
amic could also be caused by the condensation, melting,
and sintering process of the ceramics on metal because
of thermal coefficient differences (Yamamoto, 1989).
Faulty design of the metal substructure, incompatible
thermal coefficients of expansion between the metal
substructure and ceramic, excessive porcelain thickness
with inadequate metal support, technical flaws in the
porcelain application, occlusal forces or trauma were
also included as the failure reasons (Diaz-Arnold,
Schneider & Aquilino, 1989). Because of the hetero-
geneous nature of many dental materials, they are
likely to contain defects or flaws in various amounts
and sizes. Such flaws remain at fixed length unless
 FRACTURE REASONS IN CERAMIC RESTORATIONS
under load but then they become unstable and propa-
gate, catastrophically culminating in fracture. Small
changes in microstructure or surface treatment can lead
to drastic alterations in service life of fixed restorations
and repeated stresses and strains can cause slow crack
growth and mechanical fatigue. Even a single load cycle
can produce measurable cracking at the contact area
and damage accumulation during load cycling (Chad-
wick, Mason & Sharp, 1993; White et al., 1995). In
order to minimize the formation of microcracks a fairly
uniform thickness was recommended, which may
occur during the firing of the ceramic. Avoidance of
acute line angled preparations was advised as they
enhance the formation of microcracks within the
porcelain during the firing procedures (Burke, 1996).
The results of these studies definitely favoured the
requirement of technical skill and meticulous work in
ceramic build-up. Clinical part of the process could
have been performed ideally however, when high level
of skill in ceramic build-up is not performed, the failure
of the restoration could be inevitable. The important
question is whether it would be possible to avoid any
flaws during ceramic build-up.
Widerhorn (1968, 1974) stressed that during actual
masticatory conditions, restorations are subject to
repeated loading over long periods, with superposed
tangential motion and further claimed that, especially
in chemically active aqueous environments, this could
greatly exacerbate damage build-up. He stated that the
ceramic fracture process might be accelerated by the
environment. It was reported that facings may crack, be
fractured or damaged as a result of trauma, parafunc-
tional occlusion or inadequate retention between the
veneer and the metal (Farah & Craig, 1975). In clinical
practice however, the magnitude and direction of
masticatory forces cannot be controlled. Studies that
involve forces from one direction can give the clinicians
limited information which may not always be possible
to adapt real life.
Mechanical fatigue of ceramics on the other hand, is
probably governed by several mechanisms which are
related to material properties including microstructure,
crack length and fracture thoughness, as well as to
applied stress intensity (Ban & Anusavice, 1990). Evans
et al. (1990) indicated that every effort should be made
to minimize air entrapment between ceramic particles
as porosity does occur during ceramic application
and can impair aesthetics as well as promote fracture.
Properties of resin adhesives, cementation agents,
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 265–269
267
preparation designs, voids in cement layers, and thick-
ness of the ceramic restorations were reported to affect
the fracture resistance as well (Tsai et al., 1998). One of
the most popular test methods is mathematical model-
ling in material research. Although such modelling has
some limitations and little is known on its applicability
to clinical situations, in a finite element analysis, it was
found that the presence of a void in the ceramic
structure did have a significant effect on the fracture
(Abu-Hassan, Abu-Hammad & Harrison, 1998).
Another reason for porcelain fracture was attributed
to inadequate tooth preparation, which results in too
little interocclusal space for the metal substructure and
porcelain. It was concluded that the improper design of
the restoration for the occlusion is the major cause of
failure (Creugers, Snoek & Käyser, 1992). The possible
failure of ceramics was sometimes attributed to inade-
quately registered occlusion, material type, spanning of
the restoration or inadequate marginal adaptation
(Niedermeier et al., 1998). On the basis of this evidence,
clinicians should identify and address the reasons for
their failures in practice. When occlusion is not regis-
tered correctly and articulation is not checked properly,
the premature contacts would act as stress bearing
zones on the ceramics.
The fatigue failure is preceded by a combination of
crack initiation and crack propagation. Finally catastro-
phic failure occurs in the form of fracture. Llobell et al.
(1992) described the reasons for intraoral ceramic
fracture as impact load, fatigue load, improper design,
microdefects within the material, and added that
clinically, mastication, parafunction and intraoral
occlusal forces create repetetive dynamic loading. It
was emphasized that fatigue is of considerable import-
ance for metal–ceramic restorations which are subjec-
ted to small alternating forces during mastication.
Amorphous materials like glasses or glassy materials
do not possess an ordered crystalline structure as do
metals. Bertolotti (1997) described the reasons in detail
why ceramic materials do not yield in the same manner
as metals. Dislocations of a crystalline lattice do not
exist in glassy materials and they have no mechanism
for yielding without fracture. Dislocations exist in crys-
talline ceramic materials, but their mobility is severely
limited. The energy required to do this is so large that
dislocations are essentially immobile in crystalline
ceramic materials.
Stress direction is another contributory factor for
failure as sometimes failure occurs at sites of relatively
268 M . Ö Z C A N
low local stress merely because there is a particularly
large flaw oriented in a stress field which is ideal for
causing fractures. The possible sites from which failure
may start were found to be highly unpredictable, since
this depends on flaw size and is related to the stress
distribution (White & Li, 1997). High biting forces,
destructive premature contacts and common beverages
with low pH ranges were reported to cause glass-
containing dental restorations to break down (Anusavice
& Zhang, 1998). Although these data appear to
document the importance of bite forces in failures, it
is apparently not possible to quantify them during
mastication.
The majority of the ceramic fractures were observed
to occur during normal chewing function followed by
either trauma or some kinds of accidents being mostly in
the anterior region (Özcan, 1999; Özcan & Niedermeier,
2001). The findings of these studies clearly indicate that
the reasons for ceramic failures might be also external
factors other than technical reasons in real life.
Complications involving fixed partial dentures can
also occur during the pre-prosthetic preparation phase.
Raustia, Näpänkangas and Salonen (1998) noted that
the clinical skill of the dentist or dental student is
extremely important.
Conclusions
Fracture of porcelain is often considered an emergency
treatment and the restoration process can present a
difficult challenge to the dentist. Clinical studies indi-
cated that the prevalence of ceramic fractures ranged
between 5 and 10% over 10 years of use (Coornaert
et al., 1984). There is consistent epidemiological evi-
dence that mechanical failure of a dental prosthesis
occurs after a number of years of service. Therefore,
prosthodontic structures typically do not fail as a
consequence of a single episode of stress application,
but rather as the cumulative effect of a large number of
comparatively small loadings.
Because of the nature of the porcelain processing,
new porcelain cannot be added to an existing restor-
ation intraorally. The manual fabrication of metal
frameworks and the porcelain veneers is time consu-
ming and requires a high level of skill (Freilich et al.,
1998). It is an unpleasant experience for the patient and
arduous for the dentist to remove these restorations
from the mouth. Replacement of a failed restoration is
not necessarily the most practical solution because of
ª 2003 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 30; 265–269
the obviously substantial costs and the complex nature
of the restoration (Fan, 1991).
The complexities of the oral environment and varied
surface topography of dental restorations make it
difficult to precisely define the magnitude and mode
of stresses precipitating clinical fracture. The laboratory
cannot reproduce intraoral variables and the complex-
ities of the oral environment. When the crowns are
cemented intraorally, factors other than inherent
mechanical strength of the materials come into play.
Under continuous application of the mechanical envi-
ronmental loads, progressive degradation may lead to
crack initiation and growth and ultimately to a cata-
strophic failure of the restoration.
Although failures of ceramic-fused-metal restorations
can be overcome by either some repair techniques or
renewal of the restoration, it is beneficial to know the
reasons for the failures, especially those because of̀
iatrogenic or technical mistakes, which would help to
increase the service time of such restorations.
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Correspondence: Dr Mutlu Özcan, Faculty of Medical Sciences,
Department of Dentistry and Oral Hygiene, University of Groningen,
Antonius Densinglaan 1, 9713 AV, Groningen, The Netherlands.
E-mail: mutluozcan@hotmail.com