COMMON PROBLEMS

IN FIXED
PROSTHODONTICS
BY:
Jennifer Bantang
Ramarie Dickson
Gia Delpan
Jaliah Labay

Manifestations of
Failure

Pain
Inability to function
Dissatisfaction with esthetics
Broken teeth and/or restoration
Inflammatory swelling
Bad taste
Bad breath
Bleeding gums
Anxiety

Causes of Fixed Prosthesis

Failure

Improper case selection

Faulty diagnosis and
treatment plan
Inaccurate clinical or
laboratory procedures
Poor
patient
care
and
maintenance
following
insertion

Types of Bridge Failure

1. Cementation failure
2. Mechanical failure
3.Gingival
and
periodontal
breakdown
4. Caries
5. Necrosis of pulp
6. Biomechanical failure
7.Esthetic failure

1. CEMENTATION
FAILURE
Cementation failures can be
broadly divided into:
1.1
1.2
1.3
1.4

Cement Failure
Retention Failure
Occlusal Problems
Distortion of FPD

1.1 Cement Failure

Causes of cement failure
1)Cement selection
2) Old cement
3)Prolonged mixing time
4) Thin mix
5) Cement setting prior to seating

1.1 Cement Failure

Causes of cement failure
6) Inadequate isolation
7) Incomplete removal of
temporary cement
8) Thick cement space
9) Inclusion of cotton fibers
10) Insufficient pressure

Gingival Recession due to Excess

Cement Not Removed

1.2 RETENTION FAILURE

CAUSES FOR RETENTION
FAILURE
1)
2)
3)
4)

Excessive taper
Short clinical crowns
Mis-fit
Misalignment

Trouble shooting
In case of excessive taper:
a. Incorporation of proximal
grooves.
b. Additional retentive grooves
(should be along with the path of
insertion).
c. Additional pins

Trouble shooting
In case of short crowns:
a. Crown lengthening procedure
b. Modification of supra-gingival
margin to sub-gingival margin
c. Additional retentive grooves
and proximal box
d. Incorporation of pins
e. Addition of extra abutments

Misfits
Defined as:
1. Internal gap
2. Marginal gap
3. Vertical marginal discrepancy
4. Horizontal marginal discrepancy
5. Over-extended margin
6. Under-extended margin

Causes for misfit

a. Expansion of the metal
substructure
b. Improper water / powder ratio
c. Improper mixing time
d. Improper burnout temperature
e. Distortion of the margins
(towards the tooth surface)

Causes for misfit

f. Distortion of the metal
substructure
g. Metal bubbles in occlusal or
marginal regions
i. Inadequate vacuum during
investing
ii. Improper brush technique
iii. No surfactant

Causes for misfit

i. Excessive oxide layer formation
in inner side of the retainer (due
to contaminated metal or
repeated firing of porcelain)
j. Tight contact points
k. Thick cement space
l. Insufficient pressure during
cementation procedure

Under-extended Margins

Misalignment
Causes for misalignment
a. Abutment displacement due to
improper temporization.
b. Distortion of wax pattern while
sprueing and investing.
c. Casting defects.
d. Distortion of metal frameworks in
porcelain firing.
e. Porcelain flow inside the retainers.

Misalignment
Causes for misalignment
f. Misalignment of soldering
points.
g. Insufficient pressure in
cementation.
h. Thick cement film.

Misalignment
Causes for misalignment
i. Excessive metal or porcelain in
tissue surface (ridge lap) of pontic
prevents the proper seating of FPD
and open margin (can be detected
by observing the blanching of the
tissue or patient may complain of
pressure on the pontic region).

1.3 OCCLUSAL PROBLEMS

Causes in occlusal problems
1. Immediate problems
Occlusal interference
Marginal ridges at different levels
Supra eruption of the opposing
tooth
Parafunctional habits

1.3 OCCLUSAL PROBLEMS

Causes in occlusal problems
2. Delayed problems
Wearing of occlusal surface
Loss of occlusal contacts
Perforation of occlusal surface
due to
Porcelain Vs resin
Porcelain Vs gold

1.3 OCCLUSAL PROBLEMS

Causes in occlusal problems
Food lodgment due to plunger cusp
Fracture of facing due to defective
occlusal contact
Periodontal or gingival breakdown
due to improper occlusal contacts
Tenderness due to food lodgment

Occlusal Problems

1.4 DISTORTION OF FPD

Causes for failure in marginal
integrity:
1) Bending of FPD (wax patterns and
metal substructure)
In waxing stage
Removal from the die
Spruing stage
Investing stage (thick mix of
investment distort or displace the wax
pattern)

1.4 DISTORTION OF FPD

Causes for failure in marginal
integrity:
2) Incomplete casting
Wax patterns too thin
Incomplete wax elimination
Cold mold or melt
Inadequate metal

1.4 DISTORTION OF FPD

Causes for failure in marginal
integrity:
3) Rough casting
Improper finishing of wax pattern
Excess surfactant
Improper water powder ratio
Excessive burnout temperature
Improper devesting (direct hit on the
metal framework)

1.4 DISTORTION OF FPD

Causes for failure in marginal
integrity:
4) Bending of long span FPDs
Thin crown
Soft metal
Heat treatment not being done
Porosity in the metal
Distortion of the metal substructure
during the porcelain firing
Contaminated metal

2. MECHANICAL FAILURES

Classification of mechanical
failure
1. Retainer failure
2. Pontic failure
3. Connector failure

2.1 RETAINER FAILURE

1) Perforation
2) Marginal discrepancy
3) Facing failure Fracture
Wearing Discoloration

1) Perforation Causes
a) Insufficient occlusal reduction
b) Insufficient occlusal material
c) High points in opposing
dentition (plunger cusp)
d) Premature contacts
e) Contaminated metal

1) Perforation Causes
f) Porosity in metal work (subsurface,
back pressure, suck back)
g) Due to improper melting
temperature
h) Improper pattern position
i) Improper sprue (too thin)
j) Improper location
k) Parafunctional habits

2) Marginal discrepancy
Causes
a) Selection of margin
b) Improper preparation and failure
to establish the margin properly
c) Failure to do gingival retraction
prevents definite margin location
and subsequently in impression

2) Marginal discrepancy
Causes
d) Selection of the impression
material
i. Shrinkage in material (condensation
silicon)
ii. Distortion of material (alginate)
e) Improper impression procedures
f) Voids in the impression

2) Marginal discrepancy
Causes
g) Variation in pressure application in
wash technique
h) Delayed pouring of die material
i) Distortion of wax patterns at
margins
j) Insufficient flow of metal
k) Shrinkage of metal

2) Marginal discrepancy
Causes
l) Nodules in margins and inner side of
coping
i. Due to inadequate vacuum during
investing
ii. Improper brushing technique
iii. No surfactant
m) Excessive sand blasting
n) Distortion due to degassing procedure

2) Marginal discrepancy
Causes
o) Open margins due to porcelain
shrinkage (opaque porcelain)
p) Thick cement
q) Cement setting prior to seating
r) Insufficient pressure application
during cementation

Looseness due to Marginal

Discrepancy

3. Facing failure Types of veneer

failures

Types of veneer failure

a) Fracture
b) Wearing of facing (resin
veneers)
c) Discoloration

Causes for veneer fracture:

i. Too little retention (mechanical)
ii. Badly designed metal protection
iii. Deformation of the protecting metal
iv. Malocclusion
v. Micro-leakage between metal and
facing
vi. Improper curing or fusing technique
vii.Excessive oxide layer formation

Prosthesis Fracture

Cause of wearing of facing:

i. Improper curing or fusing

technique
ii. Deep bite (decreased overbite
in lower anteriors)
iii.Acrylic veneering opposing
porcelain teeth
iv. Faulty brushing techniques and
flossing
v. Parafunctional habits

Occlusal Wear on
Opposing Tooth

Causes of discoloration:
i. Absorption of oral fluids
ii. Absorption of artificial food colouring
agents through micro-cracks or
microleakage in metal and facing
interfaces
iii. Tarnish of underlying metal and facing
(greening of porcelain in silver alloys)
iv. Micro-cracks due to malocclusion

2.2 PONTIC FAILURE

Factors affecting selection and failure of
pontics
1) Pontic space
2) Residual ridge contour
3) Biological consideration
a. Ridge relation
b. Dental plaque
c. Gingival surface of pontic (Contact with
mucosa)
i. Mucosal contact
ii. Non mucosal contact

2.2 PONTIC FAILURE

Factors affecting selection and failure
of pontics
4)
5)
6)
7)
8)

Pontic ridge relationship

Pontic material
Biocompatibility
Occlusal forces
Metal substructure support

2.3 CONNECTOR FAILURE

Causes for connector failure
a. Improper selection of connector
b. Thin metal at the connector
c. Incorrect selection of solder
d. Solder gap narrow or wide
e. Porosity
f. Insufficient metal around
g. Defective occlusal contacts over thin
connectors

3.GINGIVAL AND PERIODONTAL

PROBLEMS

There are three locations in

which to prepare crown
margins:
1. Supragingival
2. At the crest of the gingiva
3. Subgingiva

SUPRAGINGIVAL
MARGINS
ADVANTAGES:
1. They can be easily finished
2. They are more easily cleaned
3. Impressions are more easily
made, with less potential for soft
tissue damage
4. Restorations can be easily
evaluated at recall appointments

SUPRAGINGIVAL
MARGINS
DISADVANTAGE:
1. Aesthetically not indicated for
anterior region
2. Metal can be seen
3. Not indicated in short clinical crowns
4. The proximal contacts extend to the
gingival crest
5. In case of root sensitivity

SUBGINGIVAL MARGINS
ADVANTAGES:
1. Aesthetic demands
2. Caries removal
3. To cover existing subgingival
restorations
4. To gain needed crown length
5. To provide more favourable
crown contour

SUBGINGIVAL MARGINS
DISADVANTAGES:
1. Difficult for preparation
2. Gingival management should be perfect
3. Prone for soft tissue trauma
4. More prone for gingival and periodontal
pathosis
5. Difficult to maintain oral hygiene
6. Metal margins can be seen thru the
gingiva

SOFT TISSUE PROBLEMS

1. GENERALIZED (Not due to
bridge)
2. LOCALISED (May be due to
bridge)

Causes for soft tissue problems

1. Over / under contouring

2. Narrow embrasures
3. Over / under extended crowns
4. Pressure of pontic over tissue
5. Loss of contact
6. Horizontal food impaction due to
plunger cusp in the opposing arch

Causes for soft tissue problems

7. Marginal ridges at different

levels
8. Wide occlusal table
9. Trauma from occlusion
10. Parafunctional habits
11. Acrylic facing in contact with
gingiva

Periodontal Breakdown

RESULTS OF IMPROPER CONTACT

AREAS

1. Cause displacement of teeth

bucally, lingually, mesially and
distally.
2. Exert a lifting force on the tooth
when placed too high occlusally.
3. Disturb the axial relation of the
teeth, resulting in trauma.
4. Cause rotation of the teeth.

RESULTS OF IMPROPER CONTACT

AREAS

5. Cause injury to the investing

structures by excessively opening
or closing the contact and
interproximal embrasures.
6. Disturb the coordination of the
inclined planes and cusps causing
deflective occlusal contacts.
7. Cause vertical or horizontal food
impaction.

OVER EXTENDED CROWN

The over extended crown usually encroaches
beyond the cut of the preparation on the tooth
and the excess beyond the margin of the
preparation is usually not in contact with the
tooth surface. This overhang impinges the
gingival tissue, irritates and often causes edema
and proliferation of the gingival tissue, destruction
of the marginal alveolar bone and ultimate loss of
the tooth. The overextension of the crown is
usually due to inaccurate technique and / or the
dentists desire to play safe by making it long
enough to cover the preparation or to extend
beneath the gingival margin.

Inflammation of Gingiva due to Over

Extended Margin of Crown

SHORT CROWN
The short crown fails to cover the cut
surface of the prepared tooth and often
does not extend below the gingival
margin. This uncovered ground tooth
surface is often sensitive to sweets and
to temperature changes and invites
development of caries and causes
gingival irritation. Also, it is usually due
to
inadequate
technique
and
a
willingness of the dentist to accept
impressions that are incomplete.

CROWN CONTOUR
The poorly contoured crown is one which
may have an excess contour that impinges
on the gingival tissue and deflects food
over and away from this tissue, thereby
depriving it of its normal stimulation; or it
may be under contoured and permit the
impaction of food into the gingival crevice,
thereby stripping the gingival tissue away
from the tooth. Either will cause irritation of
the surrounding tissue and may lead to the
loss of the tooth.

Inadequate Interdental and

Embrassure Space

4. CARIES
CAUSES

1. Iatrogenic (dentists role)

Failure to identify caries
Incomplete removal of caries
Rough abutment finishing
margins
Subgingival marginal placement
in inaccessible areas or regions

4. CARIES
CAUSES
1. Iatrogenic (dentists role)
Burning of root dentin or cementum
in electro surgical technique (leads
to damage or rough surface and
causes plaque retention)
Overhanging margins
Rough margins of crowns or bridges

4. CARIES
CAUSES
1.

Iatrogenic (dentists role)

Over contouring of the cervical
thirds of crowns or bridges
prevents the physiologic too
cleaning by tongue or muscles
Marginal discrepancy
Thick cement space in margins
leads to cement dissolution.

4. CARIES
CAUSES

1. Iatrogenic (dentists role)

Narrow embrasures
(inaccessibility to maintain
hygiene)
Wide connector
Failure to motivate or educate
the patient about oral hygiene

CAUSES
2. Patient role
Systemic factors
Xerostomia
Due to radiation therapy
Drug induced
Endocrine disorders
Epilepsy (difficult to maintain the
oral hygiene)

CAUSES
2. Patient role
Rheumatoid arthritis
Local factors
Improper brushing and flossing
Dietary habits
Failure to understand importance
of oral hygiene.

Carious Abutment

5. PULP DEGENERATION
CAUSES

Over heating
Over reduction
Minute pulp exposure
Inadequate protection
Recurrent caries

Pulp Injury

6. BIOMECHANICAL FAILURE

Failure to withstand constant

or increasing occlusal load
due to inadequate in crownroot ratio , pericemental
area, and number of
abutment tooth use

7. ESTHETIC FAILURES
Failure to identify patient
expectations regarding esthetics
Improper shade selection
Excessive metal thickness at
incisal and cervical regions
Thick opaque layer application
Surface blistering (chalky
appearance)

7. ESTHETIC FAILURES
Over glazing or too smooth a
surface
Metal exposure in connector,
cervical and incisal regions
Dark space in cervical third due to
improper pontic selection (anteriors)
Failure to produce incisal and
proximal translucency
Improper contouring

7. ESTHETIC FAILURES
Failure to harmonize contra
lateral tooth morphology
Contour
Color
Position
Angulation
Discoloration of facing

Incorrect Shade

Avoiding failures

Caution at the planning stage

Confirmation of diagnosis and
treatment
plan
for
inexperienced operator
Expertise of the technician
Treatment
of
preoperative
problems
Search for the primary cause

When the prognosis is

questionable ???

The methods used to facilitate

re-treatment are:
Use of temporary cement
Design
of
prosthesis
for
possible future addition
The placement of a rest seat
for possible future use

When the prognosis is

questionable ???

The methods used to facilitate

re-treatment are:
Specified undercut or guide
plane of a crown, even when
denture is not planned
Planning
and noting solder
joint placement
Recording of shades

When the prognosis is

questionable ???

The methods used to facilitate

re-treatment are:
Recording of cement used
Retention of working casts and
provisional restorations