FAILURE OF AMALGAM RESTORATIONS

Introduction

Clinical failure is defined as a point at which the restoration is no longer serviceable

or at which time the restoration causes other severe risks if it is not replaced.

Clinical failure is defined as the condition when the restoration or the appliance is no
longer serviceable and may become harmful or risky if not changed.

For nearly 160 years dental amalgam has seen the most common and often used
material in restorative dentistry. The title of father of amalgam goes to Sir Regnault as he
worked extensively in 1818 by reducing the fusing temp of the alloys. The first form of
amalgam was silver mercury paste advocated by Traveau in 1826 in Paris. Later G V Black
carried out extensive studies and modification in amalgam until recently same composition
was followed. But now there is a change in the copper percentage to improve the physical
properties of amalgam. Major disadvantage of previous amalgam was strength, tarnish,
corrosion, creep etc.

The reasons for amalgam failures can be generally identified and avoided. These
failures commonly include retentive failure, marginal break down, fracture of the tooth or
restoration, post operative sensitivity, poor surface characteristics.

The materials are least often the source of problem, where as most of the failure are
attributed to the lack of attention in cavity preparation and handling of the materials.

About amalgam in Brief:

By dentition dental amalgam is an alloy of mercury with silver, tin, copper, and some
times zinc, mercury is liquid at room temperature. The mercury wets the particles of alloy to
produce a plastic mass. That is condensed into prepared cavity and allowed to set. The
setting amalgam is then smoothened and shaped to produce the final dental restoration.

It is essential that clinical characteristics of dental amalgam be well understood when

considering, use of material within the plan of patients treatment. Some characteristics make
amalgam most advantageous for the restoration of certain teeth, while other, characteristics
may result in early restoration failure. All the indication and contraindication for use of
amalgam must be considered when planning the treatment.

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 Composition of amalgam alloys generally effects their clinical characteristics.
Recently spherical high copper alloy are considered to give good results. A copper tin
compound is formed which either diminishes or eliminates the weak γ2 phase, which often
contribute to marginal failure.

Even the mechanical and physical properties of amalgam play an important role in
success of the restoration.

Clinically it is evident that amalgam can with stand compressive loading for better
than tensile. Compressive strength values for amalgam specimen and loading rates are
about 5 times greater than that of tensile value because of this thinner sections of amalgam.

Whether at margins or in the central restoration area have greater tendency to

fracture than thicker sections. These thin sections of amalgam behave as a brittle material
when subjected to high rates of loading induced during the masticatory forces.

Types of Failure in Amalgam Restoration:

1. Fracture

(i) Marginal fracture

(ii) Isthmus fracture

(iii) Bulk fracture

(iv) Tooth fracture

2. Secondary caries.

3. Post operative sensitivity and pain.

4. Dislodgment of the restoration.

5. Contribution to periodontal diseases.

6. Discoloration of the teeth.

7. Tarnish and corrosion.

8. Pulpal damage.

9. Plaque formation

10. Occlusal interference.

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11. Galvanism

12. Amalgam tattoo

Coming to the details of causes for failure of amalgam restorations:

A. Causes for Fracture of amalgam restoration:

Fracture of the amalgam restoration is one of the main failures seen. In amalgam
restoration the fracture can be marginal, isthmus, bulk or tooth fracture.

According to the study and reviews done by Ronald K. Harris which was published in
journal of operative dentistry 1992, 17, 243 he stated that material themselves are least of
the source of the problem, whereas most of the failure is due to lack of attention during
operating and manipulative procedure.

Few specific causes for the fracture of amalgam restoration:

1. Selection of the cases:

(a) Extenisive tooth loss and undermined enamel.

(b) Post endodontic restoration.

(c) Cases with poor retention / resistance

(d) Areas of high masticatory load where referred failure of amalgam restoration.

2. Selection of alloy.

3. Due to the improper cavity preparation.

(a) Over cutting.

(b) Under cutting.

(c) Poor retention and resistance

(d) Improper finishing of the cavity.

4. Due to physical properties of amalgam.

(a) Dimensional changes (Delayed expansion).

(b) Strength.

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 (c) Creep.

(d) Tarnish and Corrosion.

5. Improper manipulation of the alloy.

(a) Improper selection of the alloy.

(b) Improper powder, liquid ratio.

(c) Under trituration.

(d) Over trituration.

(e) Improper condensation.

(f) Improper carving

(i) Over caving.

(ii) Under carving.

(g) Improper finishing and polishing.

6. Due to improper matrix adaptation:

(a) Improper covering

(b) Excess thickness

(c) Improper wedging

(d) Premature matrix band removal

7. Due to contamination:

(a) Moisture

(b) Instrument indication

(c) Contamination during manipulation.

8. Oral environment

(a) Excess stress.

(b) Malposed teeth.

(c) Poor oral hygiene.

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9. Pin restoration

(a) Fracture of tooth.

(b) Improper placing.

(c) Improper adaptation.

I. Fracture due to the selection of the cases:

Selection of the cases is one of the factor contributed in the success of final
amalgam restoration.

(a) Extensive loss of tooth and undermined enamel:

In the cases of extensive loss of tooth structure prognosis of amalgam restoration is

very poor, as it is not possible to achieve an ideal form of the cavity. Even the undermined
enamel act as a week points, as it is not supported by underlying dentin. In these cases
stress concentration will lead to fracture of tooth or restoration.

(b) Post endodontic restoration:

As the tooth becomes non vital there is good chance of fracture of tooth or
restoration by concentration of masticatory stress. This is mainly due to the brittleness of non
vital tooth and in most of the cases of post endodontic treated teeth we can see extensive
loss of tooth structure.

(c) In the cases where retention and resistance that is not achievable the success of
amalgam is questionable in such cases. Other means of restoration is preferred to
overcome the failure of amalgam restoration.

(d) Areas of high masticatory loads where there is repeated failure of amalgam restoration
seen.

In the areas like cusp tips marginal ridges and also in cases of deep bite where there
is more stress concentration the success of the restoration becomes questionable.
Especially if the restoration involving the functional cusps i.e. buccal cusps in lower and
palatal of upper there is a good chance of fracture. As maximum load is taken by these
cusps, so in these cases cast restoration is preferred.

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(e) In cases of large and extensive contact area and in cases with spacing between the
teeth. In the cases of large contact area application of the matrix band is difficult and it is
difficult to achieve same contact area or a point in the amalgam restoration. In cases
where spacing either due to periodontal problem or natural spacing it will be difficult to
achieve nice proximal contact of the restoration. Manipulation of these cases will lead to
overhang of restoration and can lead or aggravate the gingival and periodontal problems.

II. Role of selection of alloy and mercury

It is the operation who causes the amalgam to be success or failure because the
choice of alloy is personal preference. Basic lathe cut without any additions or modification
are seldom used nowadays having given way to advanced modification in the alloys.

Amalgam can have ultimate compressive strength of 40000 psi to 75000 psi it
properly manipulated. These variations can be made by metallurgical modification in the
constituents, heat treatment, particle size and shape and surface texture.

The choice between zinc containing and zinc free alloy is controversial definitely zinc
containing alloys create problems. In presence of moisture all the same time amalgam not
containing zinc or any of its substitutes will tend to be less plastic and less workable and
more susceptible to oxidation. Non zinc containing alloys should be chosen in cases where it
is clinically impossible to eliminate moisture from the field of operation for e.g. Indium
containing alloys one same exception to this role as Indium performs same role as zinc in
addition to diminishing the V2 phase.

III. Due to improper cavity preparation:

(a) Over cutting of tooth structure by depth and surface area frequently compromises the
potential success of the silver amalgam restoration. These preparations may result in
failure through generalized weakening of remaining tooth structure. And also some
times if cavity out line is placed in the maximum stress bearing areas like cusp tips or
marginal ridges will lead to potential weakening of the tooth structure leading to
concentration of functional stress resulting in fracture of the tooth condition called
cracked tooth syndrome. This over cutting along with fracture can also precipitates
unnecessary pulpal irritation which can lead to irreversible changes.

(b) Under cutting of the cavity preparation also invites failure of the restoration through
insufficient removal of tooth structure. As amalgam requires bulk for sufficient strength

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 and due to decreased tensile property. There will be a very good chance for fracture if
used in thinner sections. Traditionally also it is accepted that the bulk is required for
amalgam restoration many silver amalgam restorations fail due to fracture at either
isthmus or at the junction between the occlusal and proximal portion of the restoration
because insufficient removal of dentin from pulpal axial or gingival walls.

It is also ideal to keep the depth of the restoration 0.5 mm into the dentin as it gives
sufficient bulk and also due to good resiliency of dentin as it gives a cushioning effect for
amalgam restoration.

(c) Due to poor resistance and retention form of the cavity resistance form may be defined
as that shape and placement of the cavity that best enables both the restoration and the
tooth to withstand the occlusal and masticatory forces. This form of the cavity plays an
important role in preparation of fracture of amalgam restoration. Fundamentals of
retention form are

(i) To utilize the box form with a flat floor which helps the tooth to resist occlusal
loading by virtue of being at right angle to the forces of mastication.

(ii) Restrict the extension of the walls to allow strong cusp and ridge areas to
remain with sufficient dentin support.

(iii) To provide enough thickness of restorative material to prevent its fracture under
load along with these all the line angles and point angles of the cavity is to be
rounded and walls are smoothened in order to prevent the stress concentration
which may contribute for fracture of tooth / restoration.

In cases of proximal boxes along with above points rounding of axiopulpal line
angles, bevelling of the gingival cavosurface in order to remove the unsupported enamel
rods which are directed apically increased and masticatory stress is transferred
perpendicular to the gingival seat and even distribution of forces is possible.

Retention form:

Is that form of cavity that permits the restoration to resist through tipping and lifting
forces. This form of the cavity mainly helps in preventing dislodgement of the restoration than
fracture. It will be discussed later with dislodgement of amalgam restoration.

(d) Due to improper convenience form finish of the cavity:

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 Convenience form is that form of the cavity that allows sufficient observation
accessibility and ease of operation in the final restoration of the cavity.

Improper convenience form might lead into insufficient condensation and void formation
which might affect the strength of the restoration leading to fracture.

IV. Fracture due to the physical properties of amalgam

The qualities of amalgam restoration are usually expressed in terms of properties of

the material. The quality of the amalgam restoration changes as its functions under oral
condition. The properties of amalgam which is responsible to qualify of the restoration can be
discussed under following headings.

(a) Dimensional changes:

The dimensional changes either expansion or contraction that results during the
hardening or setting of amalgam is one of the most important characteristic properties which
will affect the success of amalgam restoration.

In an early survey of the causes of failure of amalgam restorations 16.6% of large

group of defective restoration failed due to excessive expansion. There are several causes
for the expansion few of them are insufficient trifurcation and condensation and another is
delayed expansion brought about by contamination of zinc containing amalgam with
moisture during trifurcation and condensation. These properties will be discussed later when
we discussed the post operative pain and sensitivity in amalgam restoration.

(b) Strength:

A prime requisite for any restorative material is sufficient strength to resist fracture of
even a small area especially at the margin which promotes corrosion, secondary caries, and
subsequent restoration failure. A lack of adequate strength to resist the masticatory forces
has been recognized as one of the inherent weakness of amalgam restoration.

When a patient masticates, amalgam restoration is subjected to compressive, tensile

and shear stress since the tensile strength is poor compared to other two there is a good
chances of fracture. When used in thinner sections the tensile strength with both high and
low copper is between 40 to 70 mpa, whereas compressive strength of satisfactory amalgam

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should be at least 310 mpa. When manipulated properly most of amalgam will give
compressive strength in excess to the above given values.

Since amalgam is stronger in compression and much weaker in tension and shear
the prepared cavity should be designed so that the restoration will receive more compressive
force rather than tension or shear forces. A common example where tension fracture occurs
in the isthmus of compound restorations.

Another desirable feature of an amalgam restoration is that it should attain a high

compressive strength as quickly as possible since to reduce the possibility of fracture by
premature high contact stress by the patient between the final strength is reached.

Following methods can be accelerate the rate of altering strength

1. Reducing particle size.

2. Requalecity and smoothness of the particle shape and surface.

3. Increased trituration energy.

4. Increased condensation energy.

5. Homogenity heat treatment of powder alloy during manufacturing.

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Creep:

Creep of a dental amalgam is a slow progressive permanent deformation of set

amalgam which occurs under constant stress or incremental stress when an amalgam
specimen is placed under a constant load which is less than that needed to produce either
instantaneous plastic deformation or fracture. It slowly develops i.e. it exhibits creep. Creep
of amalgam is important in relation to maintain the shape of restoration of after setting it the
amalgam filling shows dynamic creep under chewing stress then the enamel surface. This
produces an opponent expansion of filling out of cavity. These thin margins will then fracture
on further stress producing a ditched amalgam.

Creep rate has been found to co-relate with marginal breakdown of traditional low
copper amalgams i.e. higher the creep, the greater the degree of marginal deterioration.

V. Due to improper manipulation of alloy

Failure of amalgam restoration due to manipulation of the materials can be

subdivided into 2 groups.

i) Fracture under control of manufacturer

a. Composition of the alloy.

b. Speed at which mercury will react with alloy.

c. Particle size and shape.

d. The form in which the alloy is supplied.

ii) Fracture under control of clinician

a. Selection of the alloy.

b. Mercury alloy ratio.

c. Trituration method and time.

d. Condensation technique.

e. Marginal integrity and anatomic characteristics.

f. The final finish.

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(A) Improper selection of alloy:

Proper selection of the alloy helps in the success of the restoration. High copper
spherical alloys are chosen over low copper because of better strength and lesser creep of
the material and it has also less corrosion properties.

(B) Improper trituration:

Under trituration – the property trifurcated amalgam mass will have shiny
appearance under trifurcated amalgam leads to granular mix, their by affecting the strength
of amalgam.

This leads to less working time for condensation and carrying leading to improper
condensation and carrying which intern affects the success of restoration.

(C) Improper condensation:

Delayed, prolonged or poor condensation of amalgam can adversely effect the

adaptation of the material. This will increases the chance of microleakage, secondary caries,
rough surface etc on proper condensation around 1- 1½ kgs of pressure is to be applied
immediately when the amalgam is placed into the cavity otherwise it might lead to void
formation and result in poor strength and fracture of the restoration.

(D) Over and under carving:

Over carving causes weakening of the material by reducing the bulk referred to resist
the masticatory stresses which in turn might lead to fracture of the restoration.

Under carving places the restoration and functional areas in conditions of

unnecessary stresses that may cause areas of stress concentration leading to the fracture of
the restoration. It might also causes the trauma from occlusion.

(E) Improper burnishing and finishing:

Burnishing is done to remove the excess mercury and proper adaptation of

restoration to the cavosurface margin over burnishing might remove excess mercury and
weaken the restoration. Improper burnishing might lead to improper marginal adaptability
and in turn.

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 Improper finishing will leave a rough surfaces which helps plaque adhesion and
leads to periodontal problems and lead to failure of restoration.

VI. Due to improper matrix adaptation:

Restoration of the prepared cavities with amalgam involving two or more surfaces
requires the use of matrix.

Matrix mainly serves the following functions.

a) Providing general contour of the restoration.

b) Substituting for the lost wall till amalgam sets.

i) Improper matrix adaptation is a common cause of failure of amalgam restoration.

Modification in shape of the tooth requires correct adaptation and modification in shape
of contour of the band. Matrix band adaptation should be tested with fine explorer so that
there is no gap in between the tooth and gingival cavosurface area, otherwise it might
lead to over hang of the restoration.

ii) Excess thickness the ideal thickness of band should be 0.05mm thick band might give
rigidity. They will lead to open contact which will cause food impaction. Thereby, causing
periodontal problems thus leading failure of restoration.

iii) Improper reinforcement and wedging

Many matrix needs reinforcement with impression compound, self cure acrylic to
prevent distortion of amalgam during condensation.

Matrix reinstrument improves desired anatomic form so improper reinstrument of

matrix might lead to improper condensation which in turn affect the strength and leads to
fracture amalgam restoratives.

Wedging is also an important step in proximal restoration which causes slight

separation of the tooth for easy placement of matrix band and also stabilizes it. This prevents
overhanging of the restoration for better finishing and good result of proximal restoration.

VII. Fracture due to contamination

a) Moisture: It includes saliva, blood and lubricant from the instrument. Most restorative
material are successful only if placed and finished in clean dry operating field.

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 Contamination seriously effects the setting and strength of amalgam leading to failure.
Rubber dam provides the optimum dry field for preparation of teeth to receive amalgam
and also helps in enhancing the physical properties.

It is seen that zinc containing low copper and high copper amalgams if contaminated
with moisture during trituration or condensation, a large expansion can take place the
expansion usually starts after 3-5 days and may continue for months reaching a value
greater than 400µm (4%) this type of expansion is known as delayed or secondary
expansion.

Delayed expansion is seen in zinc containing alloys. The effect is caused by reaction
of zinc with water. It has been clearly demonstrated that the contamination substance mainly
water and saliva.

VIII. Fracture due to pins used for retention.

a) Fracture of tooth / restoration: It is commonly seen as a simple cracking may develop

from placing of the pin to close to DEJ causing both enamel dentin fracture.

b) Pin position: Site of the pin placement is very critical in respect to possible perforation
of pulp chamber so placing the pins properly is important for the success of final
restoration.

c) Length of the pin: Pins provide retention but doesn’t give (or) enhance the strength of
the amalgam restoration. If the pin length exceeds 2mm, may weaker the whole
amalgam restoration leading to fracture of amalgam.

IX. Fracture due to oral environment

a) Excessive stress: Amalgams should not be placed in the mouth where large amount of
masticatory stress applied and where large amount of tooth structure is lost (or) in case
of developmental disorders of the teeth, which will fracture easily due to the brittleness.

b) Malposed teeth: In case of malposed teeth and malocclusion if the opposite cusp is
impinging on the restoration constantly will lead to the fracture of amalgam restoration.

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Post Operative Sensitivity or Pain

Post operative pain is one of the common clinical finding seen in some of the cases.
There may be many contributing factors but main cause discussed here is due to the
dimensional changes.

In an early survey shows dimensional changes are significantly contributed in failure

of amalgam restorations there are several causes for dimensional changes but most
common is insufficient treatment and condensation expansion due to zinc containing
amalgam with moisture during manipulation.

Delayed expansion is probably caused by internal pressure exerted by hydrogen gas

that is one of corrosion product between the zinc in amalgam and incorporated moisture.
Hydrogen is produced by electrolytic action involving zinc and water. This hydrogen does not
combine with amalgam but rather collects within the restoration which increases the internal
pressure. Pressure to high enough for amalgam to creep. This large expansion is seen in 4
or 5 days of condensation. This increased internal pressure due to expansion will cause post
operative pain and sensitivity.

One should also examine high point in the restoration which is also one of the main
causes for post operative pain. It can be examined by using articulating paper and these
symptoms will seen subside once high point is removed and tooth is relived from occlusion.

Dislodgment of the restoration

Dislodgment of the restoration is the second most failure seen next to fracture in all
amalgam restorations. This type of failure is also known as retentive failure. This is mainly
due to detective retention form of the cavity and the forces that try to displace or dislodge the
restoration.

Retention form is that form of the cavity that best permits the restoration to resist
displacement through tipping or lifting forces.

Retention of amalgam is mainly mechanical. It is obtained generally by giving the

undercuts grooves. Flaring of the wall will displace the restoration due to the masticatory
forces acting on it.

In the cases where it is not possible to achieve retention form bonded amalgam can
be tried but in case repeated failure it is ideal to go for cast restorations.

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Tarnish and Corrosion

Tarnish is a surface discoloration on a metal (or) even slight loss of alterations of the
surface finish.

Corrosion – is an actual deterioration of a metal by reaction with its environment.

Amalgam restorations often tarnish and corrode in the oral environment. The degree
of tarnish, corrosion and resulting discoloration appears to be dependent on the individual’s
oral environment and to certain amount to the particular alloy employed.

The tendency towards tarnish, although perhaps unaesthetic because of black silver
sulphide.

Mostly active corrosion of newly placed restoration occurs within the interface
between the tooth and the restoration. The space between the alloy and tooth permits micro-
leakage of electrolyte and leads to corrosion product. The build up of this corrosion product
gradually seals this space making dental amalgam a self sealing restoration.

The most common corrosion products found with traditional amalgam alloys are
oxides and chlorides of tin.

They are found at the tooth amalgam interface and penetrating into the bulk of the
old amalgam restoration. Thus the corrosion takes place.

The fractures Related Excessive Tarnish and Corrosion:

1. High residual mercury level can lead to increase in corrosion as a result of increase in γ2
phase.

2. Surface texture small scratches and exposed voids will develop concentration cells with
saliva as the electrolyte.

3. Galvanic action when two dissimilar metals come into contact.

4. Moisture contamination during condensation will cause air voids to develop and
corrosion to progress at taster rate.

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X. Pulpal Damage of Amalgam Restoration

Inadequate pulp protection might lead to pulp damage which might in turn lead to
pulp necrosis and failure of the restoration. As amalgam is a good conductor of heat in deep
cavities it is must to apply thermal insulating bases. In some of the cases even delayed
expansion also causes pressure on the pulp chamber and cause damage to the pulp.

XI. Galvanism

It is a small amount of current produced when two dissimilar metals come in contact,
where it might lead to failure of restoration.

Amalgam Tattoo

This is a macular and bluish gray or even black lesion usually seen in the buccal
mucosa gingiva or palate. Importantly they are found in the vicinity of teeth with large
amalgam restorations or crowned teeth that probably had amalgam restoration removed at
the time of tooth preparation for fabrication of crown.

This is most oftenly iatrogenic in origin mainly due to traumatically introducing flecks
by rotary instruments or some times metal particles may fall onto the extraction site and
during healing phase amalgam becomes embeded within the connective tissue while re-
epithelialisation is taking place.

Conclusion

If proper selection of cases, alloys and good cavity preparation is followed, failure of
amalgam restoration cause minimized or avoided.

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