14 Crown and bridge

failures and repairs

General considerations of success There are difficulties in defining

and failure and the value of survey failure
data
Looking at any crown, bridge or implant, it is
How long will it last? always possible to find some minor fault with the
fit or the appearance of some other aspect. In
This is a question which many patients ask when many cases it is a matter of degree. There is
a crown, bridge or implant is being discussed and nothing seriously wrong with the restoration,
a decision is being made between them or leaving only that one dentist, looking at another’s work,
the tooth without a crown or the space would have applied his or her skills in different
unrestored. ways – would have introduced a little more incisal
The honest answer is ‘I do not know’ but that translucence or placed the margin a little more
is not going to satisfy the patient. subgingivally or supragingivally, or finished it
There have been many surveys of crown, better. These variations in judgement are to be
bridge and implant success and failure; however, expected and need to be encouraged. If every
there are a number of major problems with these crown or bridge were standardized, there would
surveys. be no room for development and improvement.
Prospective surveys, following up restorations At the other extreme there are undisputed
from when they are placed, are usually of selected failures, for example, the fractured ceramic crown
and therefore biased samples – restorations made or the loose bridge where extensive caries has
in dental schools, or specific practices. Also, if it developed. Between these extremes lies a large
is known that the treatment is part of a survey, grey area of partial failures and partial successes.
extra care may be taken in the treatment, thus With these it is better to consider levels of
producing further bias. acceptability to patient and dentist (which may be
Retrospective surveys, looking at a cross- different) and to consider what needs to be done
section of restorations placed in different to improve matters.
locations – general or specialist practice or dental Because the prognosis for a crown, bridge or
hospitals – by a variety of dentists and by a variety implant cannot be guaranteed, potential failure
of techniques involve so many variables that it is should be regarded as a disadvantage and
difficult to analyse the results realistically. balanced against the advantages. It is not realistic
Retrospective surveys of failures are helpful to ignore the possibility of failure, and its finan-
when they look at the causes of failure and the time cial implications for patient and dentist must be
from the restoration being placed to its failure. recognised.
A reasonable way to record failures is as a For restorations which have only been available
percentage per year. For example, large surveys for a short time or where significant changes in
of bridges made in practice and elsewhere in design, materials or techniques have been made
different countries show that about 90% of it is not possible to give a reliable prognosis, only
bridges last at least 10 years. a best guess.

297
298 Crown and bridge failures and repairs

Many patients die with their restorations intact rate declines, with 60–70% of bridges still in place
and so these restorations, however long they at 15 years. There are not sufficient studies to
have been in place, have served their purpose and establish the number of years at which the
are successful. survival rate is 50%, in other words when there
Later in this chapter the causes of failure and is an even chance that the bridge will still be in
some solutions are described, together with some place. However, looking at the published survival
techniques for adjustment or repair. curves and extrapolating them, the figure is likely
to be between 30 and 40 years survival for small,
well-made conventional bridges.
One of the difficulties in interpreting these
How long do crowns and surveys is the fact that many of the bridges were
conventional bridges last? made a long time ago using techniques, materials
and concepts that are now regarded as out of
Most crowns and bridges do not wear out, date.
neither do the supporting teeth. Failure is the There is therefore no reliable, consistent figure
result of an isolated incident, a progressive which can be given to a patient when they ask:
disease process, or bad planning or execution in ‘How many years will the bridge last?’. It is often
the first place. Isolated incidents such as a blow necessary to give the patient a fairly detailed
cannot be predicted and may occur on the day explanation of why such a figure cannot be given
the restoration is fitted, in 40 years time or or to say something more vague such as (depend-
never. ing on the patient’s age, condition of the abutment
The prevention of caries and periodontal teeth, etc.): ‘A bridge made for you may have to
disease is largely under the control of the patient, be replaced with another bridge or an alternative
assisted and monitored by the dentist and hygien- prosthesis once (or twice) during a normal
ist. Some changes affecting caries and periodontal lifetime, at times that cannot be predicted’.
disease cannot be predicted. These include
dietary changes, drugs producing a dry mouth, the
onset of a general disease such as diabetes and
geriatric changes that may make cleaning difficult. How long do minimum-preparation
A number of long-term surveys of success and bridges last?
failure have produced results varying from very
low to high rates of failure. It is possible to calcu- These were introduced long after conventional
late from the published figures an average life bridges and so there has been less time for long-
expectancy of a bridge but this is the wrong term surveys. However, when they began to
statistic to use, and it should not be quoted to become popular two factors influenced the
patients. Some restorations are failures from the reviews of these bridges. First there was scepti-
day they are inserted, for example because they cism among many dentists about the likelihood of
do not fit properly, and some last for over 40 their success and this was reinforced by many
years with a range between. To quote an early failures while they were being developed.
‘average’ of 20 years is meaningless. This view still prevails among some traditionalists
In the more recent surveys more sophisticated but has almost disappeared with more modern
statistical methods have been used to describe dentists who have been trained and have devel-
survival rates of restorations. In addition, a oped for themselves policies of minimum inter-
number of factors affecting the survival rate have vention, maximum conservation and considerable
also been analysed, for example for bridges, the confidence in a range of bonding techniques and
design, the number of teeth being replaced, the materials for many applications in dentistry.
periodontal support for the abutment teeth and The second factor is that the time that
their vitality and factors to do with the patient minimum-preparation bridges started to become
such as age and gender. Some of the surveys popular and more reliable coincided with a fast
show a survival rate that remains high for the first growing emphasis on clinical audit and review, and
10 years or so with more than 90% of the bridges they were therefore prime candidates for well-
still in place at that time. After this, the survival designed prospective surveys of success and failure.
Crown and bridge failures and repairs 299

Many good but relatively short-term surveys Dealing with failures of implant fixtures and/or
and audits have been carried out and the results the prosthetic elements is a specialist subject
are very encouraging. It is now reasonable to say beyond the scope of this book. If a dentist finds
that a minimum-preparation bridge should be the evidence of failure in an implant, the patient
default option, rather than a conventional bridge, should be referred unless the dentist has had
when the circumstances are appropriate. specialist training. Preferably the referral should
be back to the dentist who placed the implant.

How long do porcelain veneers and

inlays last? How long have modern
restorations been available?
Porcelain veneers rarely fail by becoming de-
cemented unless this occurs soon after placement, The following approximate figures relate to the
indicating poor technique. More commonly porce- time when the various restorations first made a
lain fractures occur with or without loss of part of major impact on dentistry in the UK. They have
the veneer. These are normally vertical or oblique all been developed since then, producing contin-
fractures extending down from the incisal tip. ual improvement to a greater or lesser extent.
Fractures without loss can be monitored as they For example, conventional crowns and bridges
may not progress and the cement lute under the have been made for over 100 years but have
veneer, if intact, will protect the tooth from decay. improved significantly with new techniques and
Eventually the crack will stain and the veneer will materials in the last 30–40 years. However some,
usually need to be replaced. Small fractures to made with older materials and techniques, have
veneers can be repaired with composite. lasted for more than 50 years.
Removing failed veneers is difficult and is best These figures relate to the publication date of
done with a diamond bur, regularly stopping to the fourth edition of this book: 2007.
ensure that the enamel is not damaged. It is not
always possible to replace a failed veneer with • Metal–ceramic restorations about 40 years
another veneer if there is insufficient enamel • Modern ceramic crowns about 30 years
remaining. • Ceramic veneers about 20 years
Porcelain or composite inlays and onlays can • Minimum-preparation bridges:
fail by fracture, commonly across the narrowest – Fixed–fixed and cantilever
part of the occlusal lock, in which case repair is (Rochette 1975) about 25 years
not possible. Fracture may cause loss of part of – Fixed–movable and hybrid about 15 years
the cuspal coverage. Repair with composite may • Multiple implant retained restorations.
be possible. The Brannemark system was imported
The reason for failure of porcelain inlays or into the UK and USA in 1982 and it
veneers should always be investigated to ensure took about 5 years before a significant
that a design problem is not repeated. number of dentists were properly
trained in its use. Therefore the
substantial experience is about 20 years
How long do implants last? • Single tooth implants about 15 years

The early Swedish studies of highly controlled

groups of patients and treatment protocols
produced impressive results but are unlikely to be
A rough guide for advice to
reproduced in the less controlled environment of patients, to be modified by
‘high street’ general practice or specialist practice knowledge of the patient’s specific
elsewhere in the world. Dento-legal experience circumstances
shows that many failures do not get into survey
data, which are distorted towards suggesting a This guide is based on survey data where this is
higher than realistic success rate. reasonably robust, anecdotal evidence from
300 Crown and bridge failures and repairs

colleagues and the author’s personal experience. Conventional fixed–fixed bridges and
It is therefore not scientific and should not be splinted retainers
quoted in, for example, legal reports.
When only one retainer of a conventional bridge
Nevertheless, we feel it right to make an attempt,
becomes loose, this can be disastrous. Without a
however flawed, to help dentists to answer the
cement seal, plaque forms in the space between
question ‘How long will it last?’.
the retainer and the abutment tooth and caries
Provided that the patient fully understands the
develops rapidly across the whole of the dentine
likely effects of their own circumstances and that
surface of the preparation (Figure 14.2).
the following figures are very approximate with a
Sometimes the patient is aware of movement
wide range, it may be reasonable to give patients
developing in the bridge or experiences a bad
these figures. However, it is often better to
taste from debris being pumped in and out of the
estimate how many replacements will be necessary
space with intermittent pressure on the bridge. A
in the patient’s anticipated lifespan if everything else
good diagnostic test for a loose retainer is to
remains stable. In other words add lots of caveats
examine the bridge carefully without drying the
and estimate low rather than high. A patient whose
teeth, pressing the bridge up and down and
restoration lasts a few years longer than you
looking for small bubbles in the saliva at the
thought it would will be content but if it fails a few
margins of the retainers.
months beforehand they will be disgruntled.

Years Minimum-preparation bridges

• Ceramic veneers 8–10
• Individual anterior crowns 15–40 Loss of retention of one part of a fixed–fixed
• Individual posterior crowns 20–50 minimum-preparation bridge also occurs but,
• Small anterior conventional bridges 20–40 although caries does sometimes develop rapidly,
• Small posterior conventional bridges 20–50 because the surface of the tooth is enamel rather
• Large conventional bridges 10–30 than dentine, the development of caries is usually
• Minimum-preparation bridges slower than with a convential bridge. If one
– Cantilever 15–30 retainer does become loose, it is a matter of
– Fixed–fixed 10–15 urgency to remove at least that retainer, and
– Fixed–movable 10–20 usually the whole bridge. If a fixed–fixed
– Hybrid 10–20 minimum-preparation bridge becomes loose at
• Multiple implants one end but seems firmly attached at the other,
– Connected to each other 25+ one option is to cut off the loose retainer, leaving
– Connected to natural teeth 20+ the bridge as a cantilever.
• Single tooth implants 20+ Partial or complete loss of retention is the
commonest cause of failure of these bridges. It is
argued by some that if the bridge can be removed
without distorting it, cleaned, re-grit-blasted and
Causes of failure and some re-cemented without further treatment, it is not
solutions a true failure but only a partial failure. This is a
reasonable point of view, and when minimum-
Loss of retention preparation bridges are made, the patient should
be warned that re-cementation may be necessary
With the exception of post crowns, where failure as part of normal maintenance and should not
is usually due to inadequate post design or always be regarded as a disaster.
construction (Figure 14.1), loss of retention is not There is some evidence that minimum-prep-
a common cause of failure of individual crowns. aration bridges are retained for longer periods
However, because of the leverage forces on when they have been re-cemented. It is difficult
fixed–fixed bridges, one of the more common to imagine why this should be, other than perhaps
ways in which they fail is by one of the retainers the operator taking greater care the second time
becoming loose but the other remaining attached around. If a minimum-preparation bridge debonds
to the abutment tooth. soon after placement, this is often due to poor
Crown and bridge failures and repairs 301

Figure 14.1

The upper central incisor had a post-retained crown

but no diaphragm covering the root face. The tooth
has split longitudinally and the crown has fallen off. It
must now be extracted.

Figure 14.2

Carious abutment teeth (the upper right canine and

upper left first premolar) revealed by removing a bridge
that was still firmly attached to the sound central
incisors.

cementation technique and if re-cementation is the surface of the preparation, and the patient is
done with more care, the bridge is likely to last obviously aware of the problem and seeks treat-
for longer. Bridges that survive for many years ment quickly.
and then debond may well not last for as long a
second time.
There is now good evidence that fixed–fixed
Solutions for loss of retention
minimum-preparation bridges fail through loss of
retention more readily than cantilever (with one If there is no extensive damage to the prepara-
abutment tooth) and fixed–movable designs. This tion, it may be possible to re-cement the crown
is why these designs have been advocated earlier or bridge, provided that the cause can be identi-
in this book. It is very unusual for a minor fied and eliminated. It may be that a bridge was
retainer for a fixed–movable minimum-prepar- dislodged by a blow or that some problem during
ation bridge to lose its retention because there cementation was the cause. However, if the
are no significant forces to dislodge it. underlying reason is that the preparations are not
adequately retentive, they can sometimes be made
more retentive and the crown or bridge (or at
Other bridges least the unsatisfactory retainer) remade. A more
adhesive cement could be tried such as a chemi-
In the case of simple cantilever bridges with one cally active cement as used for minimum-prepara-
abutment tooth, or the major retainer of a three- tion bridges. It is always wise to re-check the
unit fixed–movable bridge, the loss of retention occlusion in case this contributed to the failure.
will result in the bridge falling out. The same is Alternatively it may be necessary to include
true if both ends of a fixed–fixed bridge become additional abutment teeth in a bridge to increase
loose. There is usually less permanent damage in the overall retention or to change the design in
these cases, since plaque is not retained against some other way.
302 Crown and bridge failures and repairs

Figure 14.3

Repairing porcelain facings.

a The porcelain of the lateral incisor facing has

chipped. The bridge is more than 10 years old.

b After polishing with pumice and water, a silane

coupling agent is painted over the surface, followed by
a resin bonding agent and light-cured composite.

c Polishing the composite.

d The finished result. This would have been better if

an opaquer had been used over the metal to stop the
‘shine through’.
Crown and bridge failures and repairs 303

e Fractured porcelain at the tip of a bridge retainer

that was 5 years old and otherwise satisfactory.

f An intra-oral grit-blasting machine.

g The fracture repaired with composite following grit-

blasting with alumina oxide particles and silane priming.

Mechanical failure of crowns or Porcelain fracture

bridge components At one time pieces of porcelain fracturing off
metal–ceramic restorations, or the loss of the
Typical mechanical failures are: entire facing due to failure of the metal–ceramic
bond, were relatively common. With modern
• Porcelain fracture materials and techniques this is much less
• Failure of connectors: solder and laser welded common; but when it does occur it is particularly
joints frustrating since, even though the damage may be
• Distortion slight, and can often be repaired with composite,
• Occlusal wear and perforation the repair is less satisfactory than the original
• Lost acrylic facings. porcelain (Figure 14.3). Even if the repair only
304 Crown and bridge failures and repairs

Figure 14.4

A laser welding machine.

lasts a few years before discolouring or wearing, A problem, particularly with metal–ceramic
it is a cost-effective way to extend the life of a bridges, is that soldered connectors should be
restoration. restricted from encroaching on the buccal side
To prevent this type of damage to too much to avoid metal showing, restricted
metal–ceramic bridges, the framework must be gingivally to provide access for cleaning, and
properly designed with an adequate thickness of restricted incisally to create the impression of
metal to avoid distortion, particularly with long- separate teeth. Too much restriction can lead to
span bridges. If there is any risk of the pontic area an inadequate area of solder and to failure.
flexing, the porcelain should be carried on to the It is better whenever possible to join multiple-
lingual side of pontics to stiffen them further. unit bridges by solder joints in the middle of
A ceramic crown or bridge that is fractured pontics before the porcelain is added. This gives
must be replaced. Sometimes the cause is a blow, a much larger surface area for the solder joint,
and then the choice of material can be regarded and it is also strengthened by the porcelain cover-
as fortunate: had a metal–ceramic material been ing. Ideally one-piece castings are preferred and
used it is more likely that the root of the tooth these are now more successful with modern
would have fractured. If the fracture is due to investment materials and casting techniques.
trauma, and particularly if the crown or bridge A failed solder joint is a disaster in a large
had served successfully for some time, it should metal–ceramic bridge, and often means that the
be replaced by means of another all-ceramic whole bridge has to be removed and remade.
restoration. However, if the failure occurs during Figure 9.4e shows a failed solder joint which was
normal function, shortly after the crown or too small. There are no satisfactory intra-oral
bridge is fitted, the implication is that the condi- repair methods, and it is not usually possible to
tions are not suitable for a ceramic restoration, remove the bridge to re-solder the joint without
and the replacement should be metal–ceramic. doing further damage.
Laser welded joints have been available for
less time than soldered joints, but it is likely that
Failure of connectors: soldered and laser they will be stronger. Figure 14.4 shows a laser
welded welding machine.

Solder joints. Occasionally a solder joint that

appears to be sound fails under occlusal loading.
Avoiding soldered or welded joints in the
This may be due to:
first place
• A flaw or inclusion in the solder itself The current, ideal laboratory technique is to
• Failure to bond to the surface of the metal produce both a working model with removable,
• The solder joint not being sufficiently large for trimmed dies to wax-up the separate components
the conditions in which it is placed. and a solid model to ensure that the components
Crown and bridge failures and repairs 305

Figure 14.5

a Sectioned and b unsectioned models of the same

preparation need to be used to verify the contact
points and confirm the fit of a crown.

are located together in an accurate relationship lifetime. Gold crowns made with 0.5 mm or so of
with good contact points (Figure 14.5). gold occlusally may wear through over a period of
two or three decades. If perforation has been the
result of normal wear and it is spotted before caries
Distortion has developed, it may be repaired with an appro-
priate restoration. Occasionally, particularly if the
Distortion of all-metal bridges may occur, for perforation is over an amalgam core, it is satisfac-
example, when wash-through pontics are made too tory simply to leave the perforation untreated and
thin or if a bridge is removed using too much force. check it periodically (see Figures 8.1b and 14.12d).
When this happens the bridge has to be remade. Occlusal perforations may also be made delib-
In metal–ceramic bridges distortion of the frame- erately for endodontic treatment or vitality
work can occur during function or as a result of testing (see Figure 10.2c).
trauma. This is likely if the framework is too small
in cross-section for the length of span and the
material used. Distortion of a metal–ceramic frame-
Lost acrylic facings
work invariably results in the loss of porcelain.
Old laboratory-made or acrylic facings may be
entirely lost, and wear and discoloration are also
Occlusal wear and perforation common (Figure 14.6). If the metal part of the
restoration is satisfactory then removing all or
Even with normal attrition, the occlusal surfaces of part of the facing, grit-blasting the metal and
posterior teeth wear down substantially over a repairing with composite is worth trying.
306 Crown and bridge failures and repairs

Figure 14.6

Badly worn acrylic facings.

The bridge has been present for many years and fits
well. It is worth replacing all or part of the
canine facing with composite.

Changes in the abutment tooth access cavity through the crown. There are of
course problems in the application of a rubber
dam with bridges, although these can usually be
Periodontal disease overcome by punching a large hole and applying
Periodontal disease may be generalized, or in a the rubber dam only to one tooth, stretching the
poorly designed, made or maintained restoration rubber over the connectors.
its progress may be accelerated locally. If the loss It is difficult to gain access to the pulp chamber
of periodontal attachment is diagnosed early and remove the coronal pulp completely without
enough and the cause removed, no further treat- enlarging the access cavity to a point where the
ment is usually necessary. However, if the disease remaining tooth preparation becomes too thin
has progressed to the point where the prognosis and weak to support the crown satisfactorily, or
of the tooth is significantly reduced then the where the (pin) retention of a core is damaged.
crown or bridge, or the tooth itself, may have to The crown may have been made with rather
be removed. different anatomy from the natural crown of the
With a bridge the original indication will still be tooth for aesthetic or occlusal reasons, so that
present, and so something will have to be done the angulation of the root is not immediately
to replace the missing teeth. It may be possible apparent. Provided that these problems can be
to make a larger bridge, or the abutment teeth overcome and a satisfactory root filling placed,
may be reduced and used as abutments for an the prognosis of the crown or bridge is only
over-denture. Teeth that have lost so much marginally reduced.
support that they are not suitable as bridge Teeth that were already satisfactorily root-
abutments are also not suitable either as filled when the crown or bridge was made may
abutments for conventional partial dentures. later give trouble. It may be possible to re-root-
Figure 14.7 shows how successful periodontal fill the tooth through the crown, but apicectomy
treatment and adjustment of bridge margins can is an alternative solution. Care must be taken not
be achieved. to shorten the root of an abutment tooth more
than is absolutely necessary so that the maximum
support for the bridge can be maintained.
Problems with the pulp
Unfortunately, despite taking the usual precau- Caries
tions during tooth preparation, abutment teeth
may become non-vital after a crown or bridge has Secondary caries occurring at the margins of
been cemented. It is usually reasonable to crowns or bridge retainers usually means that the
attempt endodontic treatment by making an patient has changed his or her diet, the standard
Crown and bridge failures and repairs 307

Figure 14.7

a An old bridge with defective margins and extensive

gingival inflammation.

b The same bridge after a periodontal flap has been

raised, the retainer margins adjusted by grinding and
polishing, and the flap then apically repositioned. The
gingival condition is now healthy.

of oral hygiene has lapsed or there is some inade- disease or relapsing orthodontic treatment, this
quacy in the restoration that is encouraging the must be remedied before the crown or bridge is
formation of plaque. The cause of the problem remade.
should be identified and dealt with before repair
or replacement is started.

Design failures
Fracture of the prepared natural crown
or root
Abutment preparation design
Fractures of the tooth occasionally occur as a The pitfalls of inadequate crown preparation
result of trauma, and sometimes even during design were described in Chapter 3, and are the
normal function, although the crown or bridge underlying cause of many of the problems listed
has been present for some time. With a bridge so far in this chapter.
abutment it is usually necessary to remove the
bridge, but occasionally the abutment tooth can
be dispensed with and the root removed surgi-
cally, the tissue surface of the retainer being Inadequate bridge design
repaired and converted into a pontic.
Designing bridges is difficult. It is neither a precise
science nor a creative art. It needs knowledge,
experience and judgement, which take years to
Movement of the tooth
accumulate. So it is not surprising that some
Occlusal trauma, periodontal disease or relapsing designs of bridge, even though well intentioned
orthodontic treatment may result in the crowned and conscientiously executed, fail. A simple classi-
tooth or bridge abutment becoming loose, drift- fication of these failures is as ‘under-prescribed’
ing, or both. When the cause is periodontal and ‘over-prescribed’ bridges.
308 Crown and bridge failures and repairs

Figure 14.8
A bad design.
The bridge is fixed–fixed and is firmly held by the
premolar retainer. The inlay in the canine is, however,
loose and caries has developed beneath it. Either the
design should have been fixed–movable with a mesial
movable connector or, if fixed–fixed, the retainer on
the canine should have covered all occluding surfaces
of the tooth and have been more retentive.

Under-prescribed bridges and one of the retainers fails, it is sometimes

possible to section the bridge in the mouth and
These include designs that are unstable or have
remove the failed unit, leaving the remainder of
too few abutment teeth – for example a
the bridge to continue in function. The failed unit
cantilever bridge carrying pontics that cover too
is remade as an individual restoration (Figure
long a span or a fixed–movable bridge where
14.9).
again the span is too long, or where abutment
The retainers themselves may be over-
teeth with too little support have been selected.
prescribed, with complete crowns being used
Another ‘under-design’ fault is to be too
where partial crowns or intracoronal retainers
conservative in selecting retainers, for example
would have been quite adequate; or metal–
intracoronal inlays for fixed–fixed bridges. With
ceramic crowns might be used where all-metal
these design faults little can be done other than
crowns would have been sufficient. When the
to remove the bridge and replace it with another
pulp dies in such a case, it is interesting to specu-
design (Figure 14.8).
late whether this might not have occurred with a
less drastic reduction of the crown of the natural
Over-prescribed bridges tooth.

Cautious dentists will sometimes include more

abutment teeth than are necessary, and fate
usually dictates that it is the unnecessary retainer
that fails. The first lower premolar might be Inadequate clinical or laboratory
included as well as the second premolar and technique
second molar in a bridge to replace the lower
first molar, no doubt so that there will be equal It is helpful to allocate problems in the construc-
numbers of roots each end of the bridge so as to tion of crowns and bridges to one of three
comply with the redundant ‘Ante’s Law’. This is groups:
not necessary.
Another example would be to use the upper • Minor problems to be noted and monitored
canines and both first premolars on each side in but where no other action is needed
replacing the four incisor teeth. As well as being • The type of inadequacies that can be corrected
destructive, this gives rise to unnecessary practi- in situ, and
cal difficulties in making the bridge and cleaning it. • Those that cannot.
This, in turn, reduces the chances of the bridge
being successful. This is often a matter of degree, and many of
When an unnecessarily large number of the following faults can fall into any of these
abutment teeth have been included in a bridge groups.
Crown and bridge failures and repairs 309

Figure 14.9
Overprescribed design.
a This four-unit bridge replaces only one central incisor.
The partial-crown retainer on the canine has become
loose. When the bridge was removed, the central and
lateral incisors were found to be sound and adequate
abutments, without the inclusion of the canine. Caries
has spread across the canine, and the pulp has died.

b and c Fortunately it was possible to remove the

bridge intact, and, after removing the canine retainer,
the remaining three units could be re-cemented. A
separate post crown was made for the canine tooth
following endodontic treatment.

Marginal deficiencies ible to correct at the try-in stage (Figure 6.26b).

It often arises because the impression did not give
a clear enough indication of the margin of the
Positive ledge (overhang) preparation and the die was over-trimmed, result-
A positive ledge is an excess of crown material ing in under-extension of the retainer (Figure
protruding beyond the margin of the preparation. 6.27).
Considering that this is a fairly easy fault to recog- Provided that the crown margin is supragingi-
nise and correct before the crown or bridge is val or just at the gingival margin, it is sometimes
fitted, it is surprising how frequently overhangs possible to adjust and polish the tooth surface.
are encountered (see Figure 6.26a). However, it When the ledge is subgingival, and particularly
is often possible to correct them without other- when there is localized gingival inflammation
wise disturbing the restoration. associated with it, it may still be possible to adjust
the ledge with a pointed stone or bur, although
this will cause gingival damage. However, it is
usually necessary to remove the crown or bridge.
Negative ledge
This is a deficiency of crown material that leaves
the margin of the preparation exposed but with Defect
no major gaps between the crown and the tooth.
Again it is a fairly common fault, particularly with A defect is a gap between the crown and prepa-
metal margins, but one that is difficult or imposs- ration margins. There are four possible causes:
310 Crown and bridge failures and repairs

Figure 14.10

Repair for a retainer margin.

a A small gap at the mesial margin of the upper canine

retainer on an otherwise very satisfactory bridge that
has been in place for several years. The gap was not
noticed at previous recall appointments, and although
it may now have become apparent through gingival
recession, it is more likely that the gap has been
enlarged by over-vigorous use of dental floss. The
patient demonstrated a faulty and damaging sawing
action, with floss running into the gap.

b The defect repaired with glass ionomer cement. The

patient has been shown gentler oral hygiene
techniques.

• The crown or retainer did not fit and the gap Poor shape or colour
was present at try-in
• The crown or retainer fitted at try-in, but at More can be done to adjust the shape of a crown
the time of cementation the hydrostatic or bridge in situ than to modify its colour,
pressure of the cement (particularly if the although occasionally surface stain on porcelain
cement was beginning to set) produced incom- can be removed and the porcelain polished. The
plete seating shape of metal–ceramic crowns or bridges can be
• With a mobile bridge or splint abutment, the adjusted if they are too bulky (and this is usually
cement depressed the mobile tooth in its the problem), provided that it is done slowly. At
socket more than the other abutment teeth, the first sign of the opaque layer of porcelain, the
thus leaving the gap adjustment is stopped.
• No gap was present at the time of cementa- Successful modifications can often be made to
tion, but one developed following the loss of open cramped embrasure spaces, reduce exces-
cement at the margin, and a crevice has been sive cervical bulbosity, shorten retainers and
created by a combination of erosion/abrasion pontics, and of course adjust the occluding
and possibly caries. surface. In all cases the adjusted surface, whether
it is metal or porcelain, should be polished.
In any of these cases, the choice is to remove the
bridge, restore the gap with a suitable restora-
tion, or leave it alone and observe it periodically.
Purists may say that all defective retainers Occlusal problems
should be removed and replaced. But this is not
always in the patient’s best interest, and the skilful As well as producing abutment tooth mobility,
application of marginal repairs may extend the life faults in the occlusion involve damage to the
of the restoration for many years (Figure14.10). retainers and pontics by wear and fracture.
Crown and bridge failures and repairs 311

Figure 14.11

a A set of instruments for polishing porcelain. These

are also available with contra-angle shanks for intra-oral
use.

b Scanning electron micrographs, at the same magnifi-

cation, of three areas of the same porcelain surface. Left:
the glazed surface showing some undulation and
occasional defects. Centre: the surface ground with a fine
porcelain grindstone. Right: the same surface re-
polished, after grinding, with the instruments shown in
a. The surface is smooth, without undulations, but with
some fine scratch marks and occasional residual defects.

The occlusion can change as a result of the • Adjusting or repairing the fault
extraction of other teeth, or their restoration, or • Replacing the crown or bridge.
through wear on the occlusal surface.
When action is necessary, it is clearly better to
extend the life of an otherwise successful crown
Techniques for adjustments, or bridge with the second option than replace
adaptations and repairs to crowns restorations too frequently. If there is any doubt,
or when adjustment or repair must be carried
and bridges out, the restoration must be kept under frequent
and careful review.
Assessing the seriousness of the
problem
In existing restorations there is not infrequently Adjustments by grinding and polishing
one or other of the faults listed above. A decision in situ
has to be made between:
In some situations the margins of crowns with
• Leaving it alone, if it is not causing any serious positive ledges can be satisfactorily adjusted. If the
harm margin is porcelain, specially designed porcelain
312 Crown and bridge failures and repairs

finishing instruments should be used. Alterna- visibility, and any necessary periodontal work or
tively, a heatless stone or diamond point can be endodontic surgery carried out at the same time
used, followed by polishing with successive grades (Figure 14.7).
of composite finishing burs and discs. These are
capable of giving a very good finish to non-porous
porcelain, which the patient can keep as clean as Repairs to porcelain
glazed porcelain (Figure 14.11). The contour of
porcelain restorations can be modified in situ Materials are available to repair or modify the
using the same instruments. shape of ceramic restorations in the mouth.
In the case of metal margins, a diamond stone These are basically composites with a separate
followed by green stones, tungsten carbide stones silane coupling agent to improve bonding. It is not
or metal and linen strips may be used. an acid-etch bond like the bond to enamel and is
Interdentally, a triangular-shaped diamond and an not strong, so the use of the material is limited
abrasive rubber instrument in a special recipro- to sites not exposed to large occlusal forces
cating handpiece designed specifically for remov- (Figure 14.3).
ing overhangs may be used. The margin should be An alternative and better solution is to use an
polished with prophylactic paste and a brush or intra-oral grit-blasting device if one is available.
rubber cup, and interdentally with finishing strips. This will produce a retentive surface on porcelain
to which bonding resin and composite can be
applied. In many cases the repair is strong enough
to be used on chipped or fractured incisal edges
Repairs in situ where there is sufficient porcelain to bond to
(Figure 14.3e, f and g).
Occlusal repairs
Occlusal defects in metal retainers can be
repaired with amalgam, which usually gives quite Repairs by removing or replacing
a satisfactory result. In ceramic or metal–ceramic parts of a bridge
restorations composite can be used, but the
repair may need to be redone periodically. Replacing lost facings
It is sometimes possible to replace a failed facing
on a bridge, usefully extending its life. But this is
Repairs at the margins
not worth attempting on individual crowns – it is
Although repairs are justified to extend the life of better to replace the whole crown.
an established crown or bridge, they should never When the porcelain is lost from a
be used to adapt the margins of a poorly fitting metal–ceramic unit and a composite repair is not
bridge on insertion. Secondary caries that is possible, there is often little choice but to remove
identified at an early stage or early abrasion/ the whole crown or bridge.
erosion lesions at crown margins can be repaired However, it is sometimes possible with retain-
using composite or glass ionomer cement. The ers or pontics to remove all the porcelain and re-
cause should be investigated and preventive prepare the metal part, producing enough
measures applied. clearance without damaging the strength of the
The cavity preparation at the margin must not metal. A new complete crown covering the skele-
be so deep that it endangers the strength of the ton of the old retainer or pontic can then be
preparation, although of course all caries must be accommodated. These are sometimes made in
removed. If there is poor access it may be better heat-cured acrylic, laboratory light-cured compos-
to remove part of the crown margin rather than ite or metal–ceramic material. They are known as
an excessive amount of tooth tissue. ‘sleeve crowns’. A metal–ceramic sleeve crown is
In some cases raising a full gingival flap may be shown in Figure 14.12a, b and c.
justified. Retainer margins can be adjusted and Before the routine use of metal–ceramic
restored under conditions of optimum access and materials, bridges were sometimes made with a
Crown and bridge failures and repairs 313

Figure 14.12

Techniques for repairing bridges.

a The porcelain on this bridge retainer has fractured.

It has all been removed and the tooth prepared for a
‘sleeve-crown’.

b The sleeve-crown with a metal lingual surface replac-

ing the original lingual porcelain. This could be bonded
with the resin bonding material used with minimum-
preparation bridges. The metal of the sleeve-crown
should be grit-blasted in the laboratory immediately
before bonding and the metal of the bridge could be
blasted with an intra-oral grit-blaster if one is available.
This would give a very retentive result.

c The sleeve-crown in place.

d A fractured traditional porcelain jacket crown, which

has been made over a gold coping as the canine
retainer for a bridge. Apart from this, and the hole
worn in the occlusal surface of the premolar partial
crown retainer, the bridge is still serving satisfactorily
after more than 20 years.

e The replacement ceramic crown cemented. Pictures

of the bridge illustrated in d and e were published in
the first edition of this book in 1986. By the 3rd edition
in 1996 the bridge with its replacement ceramic crown
was still in place. The bridge eventually had to be
removed for other reasons in 2002. It had been in
place for 37 years – showing that repairs of this sort
are well worthwhile.
314 Crown and bridge failures and repairs

Figure 14.13

Provision for the extension of a bridge (see text for

details).

metal framework and separate ceramic crowns such as that shown in Figure 13.6, it is possible
cemented to it. This design was known as ‘unit- to remove a failing abutment and fill the retainer
construction’. The individual ceramic crowns with composite. The bridge shown in Figure 13.6
often broke, since they were considerably was made with six abutment teeth but over the
reduced approximally to accommodate the years two abutment teeth developed untreatable
connector. However, a new ceramic or prefer- periodontal disease and were extracted. Despite
ably a metal–ceramic crown can easily be made this the bridge survived for more than 20 years
(Figure 14.12d and e). until the other abutment teeth deteriorated. The
patient had learnt and practised meticulous oral
hygiene methods.
Removing and/or replacing entire
sections of a bridge Extending bridges
Bridges are sometimes so designed that if a Provision is sometimes made to extend a bridge
doubtful abutment tooth becomes unsavable, it if further teeth are lost. Figure 14.13 shows a
can be removed with its associated section of the large bridge with a slot in the distal surface of the
bridge, leaving the remainder undisturbed. This is premolar retainer on the left of the picture so
one of the purposes of removable, telescopic that a further fixed–movable section can be added
crown-retained bridges and of dividing multiple- if the second premolar (which has a questionable
unit bridges into smaller sections. When part of periodontal prognosis) is lost. The slot is filled in
a bridge is removed, the remainder can the meantime by a small gold inlay.
sometimes be modified, perhaps by cutting a slot
for a movable joint and then replacing the lost
section.
Removing crowns and bridges
In removing any crown or bridge, and in particu-
Removing abutment teeth
lar posts and cores, it is often helpful to break up
Sometimes with large bridges, particularly those the cement by vibrating the restoration with an
made as bridge/splints for patients with advanced ultrasonic scaler. This works best with zinc
bone loss and following periodontal treatment, phosphate cement.
Crown and bridge failures and repairs 315

Figure 14.14

A selection of instruments for removing crowns,

bridges and posts.

From the left:

• a slide hammer remover with two alternative screw-

in tips: the tip is hooked into a crown margin or
under a bridge connector, and the weight slid down
the handle and tapped against the stop at the end;
• a spring-loaded slide hammer, also with replaceable
tips;
• a special heavy-duty instrument that is hooked under
crown margins and twisted to remove them;
• below: a turquoise-coloured adhesive polymer that is
softened in hot water and bitten upon by the patient.
The material is cooled with water and the patient is
asked to jerk the jaw open;
• above: this instrument is clamped beneath the crown
and the two screws (the heads visible here) are
screwed down on to the occlusal surfaces of adjacent
teeth, lifting the crown;
• two clamps that fit on to posts and cores, with a
screw that presses on to the shoulder of a post-
crown preparation and draws the post and core out
of the tooth.

Crowns cement, rather than tear the periodontal

membrane and extract the tooth. This should not
be attempted by the inexperienced!
Removing metal crowns There are several devices designed to remove
Complete and partial metal crowns can posts and cores intact and to remove broken
sometimes be removed intact by levering at the posts (Figure 14.14).
margins with a heavy-duty scaler such as a
Mitchell’s trimmer. Alternatively, a slide hammer
type of crown- or bridge-remover may be used, Removing ceramic crowns
or one of the other devices specially designed to
remove crowns; Figure 14.14 shows a selection. These cannot usually be removed intact, and should
If these techniques do not work, the crown will be cut off. A vertical groove is made with a diamond
have to be cut off (see under ‘Removing bur in the labial or buccal surface, just through to
metal–ceramic crowns’). the cement, and then the crown is split with a
suitable heavy-duty instrument (Figure 14.15).

Removing posts and cores

Removing metal–ceramic crowns
Unretentive posts can sometimes be removed by
gripping the core in extraction forceps and giving It is sometimes possible to remove metal–ceramic
it a series of sharp twists to fracture the brittle crowns intact by using one of the devices shown
316 Crown and bridge failures and repairs

Figure 14.15

Removing crowns and bridges.

a Removing a ceramic crown. A cut is made with a

diamond bur down the labial surface and across the
incisal edge. The crown can then be split with a suitable
heavy-duty instrument.

b Removing a metal–ceramic bridge by cutting through

the labial porcelain with a diamond bur.

c Then changing to a special metal-cutting (beaver) bur

to cut through the metal until the cement just shows.

d Springing open the retainer with a heavy-duty instru-

ment. It is sometimes necessary to continue the cut
round to the occlusal or lingual surface.
Crown and bridge failures and repairs 317

Figure 14.16

a Specialized equipment for removing crowns. The

pistol-shaped instrument is driven by compressed air
and vibrates one or other of the attachments against
the crown or bridge. The equipment is expensive and
is usually only available in specialist centres.

b The equipment being used clinically.

in Figure 14.14, but they are more rigid than gold possible to cut porcelain much more quickly than
crowns and the porcelain is liable to break, so metal, the metal on the buccal surface is usually
they usually have to be cut off. thinner than that on the palatal or lingual surface,
A groove is cut vertically from the gingival and visibility and access are far better buccally,
margin to the occlusal surface, preferably on the the groove is easier to make on the buccal side.
buccal side just through to the cement, and then
the crown is sprung open with a heavy instrument
such as a Mitchell’s trimmer or a heavy chisel,
breaking the cement lute. Sometimes the cut will Removing bridges
need to extend across the incisal or occlusal
surface (Figure 14.15b, c and d). There are three sets of circumstances:
Cast metal is best cut with a special solid
tungsten carbide bur with very fine cross-cuts • When the abutment teeth are to be extracted
(beaver bur). This is capable of cutting metal and so it does not matter if the preparations
without juddering or jamming, and there is less are damaged, the bridge will be removed in the
risk of the bur itself breaking than with a conven- most convenient way, often with a crown- and
tional tungsten carbide bur. Eye protection should bridge-remover. In some cases it may not be
always be worn by the patient, the dental nurse necessary to remove the bridge at all, for
and dentist, particularly when cutting metal. example with simple cantilever bridges with
Diamond burs cut cast metal slowly, but are one abutment tooth. In others it is quicker to
ideal for rapidly cutting porcelain, and so divide the bridge through a pontic or connec-
metal–ceramic units are best sectioned using tor and extract the abutment teeth individually
different burs for the two materials. Since it is with their retainers in place.
318 Crown and bridge failures and repairs

Figure 14.17

Removing a bridge with a soft brass wire loop.

The locking forceps are clipping the twisted ends of the

wire together to prevent the sharp ends damaging the
chin. The slide hammer (see Figure 14.14) is being used
in the wire loop rather than under the bridge pontic. This
is more controllable and effective and less dangerous.

• When it is the intention to retain the abutment membrane of the abutment teeth. The nature of
teeth – either to make a new bridge or to use the force is quite different to the slow tearing
them to support a partial denture or an over- applied in extracting teeth.
denture – it does not matter whether the Slide hammers are specially designed for the
bridge is damaged during its removal, but the purpose with replaceable tips to fit under retainer
preparations should be protected. The retain- margins, under pontics or into embrasure spaces
ers should be cut and the bridge carefully (Figure 14.14). Sometimes it is necessary to drill
removed with the bridge-remover. a hole in the palatal surface of the retainer or
• There are occasions when it would be helpful pontic and fit an attachment from the slide
to remove the bridge intact, modify or repair hammer into it.
it and then replace it, if only as a temporary Various other techniques can be used. Figure
measure. In this case neither the bridge nor the 14.16 shows a specialist air-driven appliance.
preparations should be damaged. Ultrasonic vibration with a scaler can loosen
crowns and bridges.
A good technique is to make a loop of soft wire
Removing bridges intact beneath the connector of the bridge and use a slide
hammer in the wire loop (Figure 14.17).
The slightly more flexible structure of all-metal Alternatively, if a slide hammer is not available, a
bridges and of minimum-preparation bridges heavy metal object is passed through the loops well
allows them to be removed intact rather more outside the mouth, and sharp blows applied to it
readily than metal–ceramic conventional bridges. with a mallet or other heavy instrument. This is a
However, all types can sometimes be removed by rather dramatic approach, and the patient needs to
sharp tapping, which fractures the cement lute have a phlegmatic personality and to be properly
without too much risk to the periodontal informed of what is proposed beforehand.