Original Article

Braz J Oral Sci.

April | June 2013 - Volume 12, Number 2

Microleakage in combined amalgam/composite

resin restorations in MOD cavities
Kosmas Tolidis1, Christina Boutsiouki1, Paris Gerasimou1
1

Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Greece

Abstract
Aim: To compare marginal seal at tooth-material and material-material interfaces in the proximal
box in combined amalgam/composite resin restorations. Methods: Mesio-occlusal-distal (MOD)
cavities were prepared in 35 premolars and permanent molars with carbide bur. The distal
proximal box was restored with amalgam (Permite, SDI) until reaching the height of pulpal floor.
Dental tissues were etched with 37% acid and a bonding agent (Bond 1-SF, Pentron) was
applied and cured. Composite resin (Filtek Z250, 3M-ESPE) was placed in layers in the mesial
proximal box and occlusally, and light cured. Marginal adaptation was evaluated at the following
interfaces: amalgam-tooth (A), amalgam-composite resin (AC) and composite resin-tooth (C).
Microleakage was evaluated by means of methylene blue infiltration after 7-day water storage
and thermocycling regimen (1500 cycles). Microleakage was assessed as percentage depth of
horizontal dye penetration. Results: ANOVA showed statistically significant difference between
A-AC and A-C (p<0.01). No statistically significant difference was found between AC-C interfaces
(p>0.05). Mean microleakage values were A (73.529/28.71), AC (34.118/34.6) and C (40.435/
34.965), according to Tukeys test. Conclusions: Although the bonding mechanism between
amalgam and composite has not yet been completely explained, amalgam/composite resin
interface exhibited the lowest microleakage scores. Since amalgam/composite resin restorations
exhibited lower microleakage scores than composite resin on the cervical surface, combined
restorations can be considered as a biological and aesthetic alternative to conventional Class II
composite or amalgam restorations.
Keywords: combined restorations, amalgam-composite, microleakage, class II cavity, MOD
cavity.

Introduction

Received for publication: February 09, 2013

Accepted: May 22, 2013
Correspondence to:
Christina Boutsiouki
12 Kallidopoulou Str.
54642, Thessaloniki, Greece
Phone: +30 6945822764
Fax: +30 2310863631
E-mail: christinaboutsiouki@gmail.com
Braz J Oral Sci. 12(2):100-104

Secondary caries is still cause for composite resin restoration failure1. Teeth
restored using composite resins are especially prone to this phenomenon due to
stress generated within the tooth-restoration interface following resin contraction
during polymerization, known as polymerization shrinkage 2 . Should the
accumulated polymerization contraction stress result in tooth-composite adhesive
failure 3-4, bacterial aggregation at the disrupted tooth-restoration margin may
occur resulting in microleakage and later secondary caries. Furthermore, bonding
on the cervical surface of Class II composite restorations is complex. Despite the
favorable presence of cervical enamel, composite resin bonding on cervical surface
of proximal box usually takes place on aprismatic enamel or dentine. Bonding
onto aprismatic enamel is compromised by altered etching pattern 5 and dentin
bond is degraded, especially in permanent teeth 5-6 . Lower level of dentin

Microleakage in combined amalgam/composite resin restorations in MOD cavities

mineralization, challenging moisture control for application

of adhesive system, presence of tubular fluid and bonddegrading matrix-metalloproteinases hinder bonding to
dentin 5, making composite placement a technique-sensitive
procedure 7 . Thereby, both polymerization shrinkage and
quality of the bond seem to be responsible for the degradation
of marginal adaptation. Microleakage is strongly controlled
by marginal adaptation and is thought to be one of the major
disadvantages of resin composite restorations 8. Although
composite resins exhibit better initial marginal adaptation than
amalgam9, amalgam restorations rarely fail due to secondary
caries10. Amalgam surface corrosion and deposition of oxides
improve marginal auto-sealing over time 11. In contrast to
composite resins, amalgam is dimensionally stable.
The aim of the present study was to compare marginal
seal in tooth-material and material-material interfaces in the
proximal box in combined amalgam/composite resin
restorations via microleakage. The null hypothesis was that
there is no difference in microleakage values between any
of the tested interfaces.

Material and methods

A group of 35 freshly extracted maxillary and
mandibular premolars and permanent molars was collected
from a private dental office. Authorization was obtained from
the owner of the dental office and only teeth extracted for
orthodontic and periodontal reasons or impacted third molars
were included in the study, for ethical reasons.
Teeth free of caries and fractures were stored in saline
and not allowed to dry throughout the whole experiment.
Standard mesio-occlusal-distal (MOD) cavities were prepared
with carbide burs at high speed under air-water spray (depth
of 1 mm beneath dentinoenamel junction, buccolingual width
of 2.5 mm, mesiodistal width of cervical surface of proximal
box of 2 mm). All margins were placed on enamel and
proximal boxes were extended until 1 mm above cervix
(Figure 1). Bur was discarded after each preparation. Teeth
were solely mounted with no contact points. A 7 mm-wide
metallic matrix was used. Distal proximal box was restored
with amalgam (Permite; SDI Limited, Bayswater, Australia)
until reaching the height of pulpal floor.
Each increment was condensed with maximum hand
pressure, using the appropriate condenser size. Surface
mercury-rich amalgam layer was removed after condensation.
After 5 minutes, dental tissues and amalgam surface were
etched with 37% phosphoric acid (Ultra-Etch; Ultradent
Products Inc., South Jordan, UT, USA) and bonding agent
(Bond 1-SF; Pentron Clinical Technologies, Los Angeles CA,
USA) was applied on both and cured for 10 s according to
the manufacturers instructions. No additional preparation
was performed for the amalgam surface. Composite resin
(Filtek Z250; 3M-ESPE GmbH, Neuss, Germany) was inserted
in layers in mesial proximal box and was cured for 20 s each
layer. Subsequently, the occlusal surface was restored with
the same composite, covering both proximal boxes. Marginal
adaptation was evaluated at the following interfaces:

101

Fig. 1. Preparation of MOD cavity and its dimensions

amalgam-tooth (A), amalgam-composite resin (AC), composite

resin-tooth (C).
Teeth were kept in saline at room temperature (20oC)
for 1 week. All teeth were thermocycled for 1,500 cycles at
5o C 36o C 55o C 36o C with a dwell time of 15 s. These
temperatures were chosen in an effort to reproduce thermal
changes in the intraoral environment. Teeth were then covered
with nail varnish except for the restoration area and 1 mm
around it, in order to avoid false positive results via dye
penetration from another point rather than the restoration
margins. Following that, the teeth were immersed in 5%
aqueous solution of methylene blue for 24 h. After that they
were washed with saline and cut longitudinally by a
microtome (Figure 2). In order to assess the degree of
microleakage at the occlusal margin, photographs were taken
for each cut, under a stereomicroscope at 100x magnification.
Two specimens were excluded from the survey due to

Fig. 2. Microtome cut. The degree of dye penetration is evident at the interfaces:
amalgam-tooth (A), amalgam-composite resin (AC) and composite resin-tooth (C).
Braz J Oral Sci. 12(2):100-104

102

Microleakage in combined amalgam/composite resin restorations in MOD cavities

additional dye penetration through minor fractures.

Microleakage was assessed as percentage depth of horizontal
penetration (infiltration extent/cavity extension) (Table 1).
Descriptive statistics including means and standard
deviations were calculated for the microleakage analysis.
The obtained data were subjected to one-way analysis of
variance (ANOVA) and Tukey-Kramer multiple-comparison
test to determine significant differences among the three
interfaces. The level of significance was set at p =0.05.
All statistical analyses were performed using SPSS 12.0
(SPSS Inc., Chicago, IL, USA).

Results
Mean microleakage values, from higher to lower, were
as follows: A (73.529/28.71), C (40.435/34.965) and AC

(34.118/34.6). Statistically significant difference was observed

between A-AC and A-C (p<0.01), but no statistically
significant difference could be found between AC-C
interfaces (p>0.05).

Discussion
The first combined amalgam/composite case report was
published in 1982 and presented a mandibular premolar,
which was restored occlusally with composite resin in order
to mask the unaesthetic amalgam 12. Combined amalgam/
composite restorations have been investigated in the recent
literature in terms of bonding strength 13 or are suggested as
an alternative for amalgam repair without sacrificing healthy
tissues14 or as a means for increasing cusp fracture resistance14.
There are few studies on marginal seal14-18 and fewer still do

Table 1 - Microleakage exhibited as percentage % depth of horizontal penetration

(infiltration extent / cavity extension) in the interfaces examined.
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Braz J Oral Sci. 12(2):100-104

AMALGAM TOOTH
(A)
100
70
70
100
100
70
50
30
70
100
70
100
80
50
20
Excluded
70
50
100
70
50
70
Excluded
70
100
70
60
50
60
100
70
70
70
50
70

AMALGAM COMPOSITE
(AC)
80
50
30
0
10
40
40
10
30
100
30
0
70
0
0
Excluded
30
20
30
30
20
30
Excluded
30
100
30
30
10
30
40
30
30
30
20
30

COMPOSITE TOOTH
(C)
100
0
40
100
20
40
0
100
40
50
40
20
0
0
50
Excluded
40
0
80
30
60
40
Excluded
40
30
40
30
0
40
20
40
40
40
40
50

Microleakage in combined amalgam/composite resin restorations in MOD cavities

investigate microleakage at the amalgam/composite resin

interface 14,17-18. Franchi et al. (1994) 17 and Franchi et al.
(1999) 15 demonstrated that microleakage at the amalgam/
composite resin interface was in between amalgam/enamel
(higher) and composite resin/enamel (lower), results which
partially match our findings.
The present study showed that microleakage at the
materials interface was lower than microleakage around
amalgam or composite. However, contrary to the used
methodology, specimens in those studies were not
thermocycled, assuming that thermal loading may have an
effect on microleakage at amalgam/composite interface and
may explain the opposite findings.
In contrast, Cehreli et al. (2010) 14 demonstrated that
microleakage at the amalgam/composite resin interface was
higher than at the tooth interface, but dealt with old amalgam
as a substrate. It seems that use of fresh amalgam is favorable
in terms of sealing ability at the interface of an amalgam/
composite combined restoration. A similar study has been
performed with primary molars, reaching the same results for
amalgam/composite interface as in the conducted study 19 .
Kournetas et al. (2010)18 used a qualitative scale and concluded
that marginal adaptation in amalgam/composite resin interface
is comparable to composite/tooth with self-etch adhesive.
Type of materials tested, cavity preparation, type of dental
tissue, tooth age, amalgam condensation, amalgam surface
conditioning, amalgam and composite bonding procedures,
composite placement and polymeri-zation, use of oxidation
solution for amalgam, thermocycling and type of used dye,
all affect microleakage values and impose limitations for direct
comparisons between the published papers. Moreover, in vitro
microleakage does not necessarily predict in vivo restoration
failure due to secondary caries. Even though a threshold
marginal gap size for clinical failure of the restorations has
not been established20, restorations with marginal defects fail
more frequently 21 . In spite of these limiting aspects,
microleakage was chosen in this study because of its longterm report in the literature.
Concerning the present study, since teeth had no contact
points, a matrix system was used in order to condense
amalgam into the proximal box. Despite the fact that fresh
amalgam has high surface tension22, which affects negatively
the wettability of the surface, composite resin was inserted
after only 5 min in order to mimic clinical conditions. This
approach seems to be time saving and the use of a temporary
restoration over the placed amalgam is avoided. Composite
was applied in layers in order to control polymerization
shrinkage. Since high-copper amalgam was placed, no
oxidation solution was used, in order to comply with previous
studies. Higher microleakage values at the amalgam/tooth
interface, which are not confirmed by clinical experience10,
could be attributed to condensation technique and lack of
oxidation solution. In contrast, ideal presence of cervical
enamel for bonding and placement of the material in layers,
seem to be the reasons for lower microleakage at the
composite resin/tooth interface.
The use of amalgam in the cervical surface of proximal

103

boxes has been related to a good marginal seal 23. Adding

the advantageous time-dependent auto-sealing due to gradual
oxide deposition 11, amalgam is regarded as the material of
choice regarding optimum marginal behavior. This study
showed that the amalgam/composite resin interface performs
even better, concluding that despite the use of two completely
different materials, there is an excellent marginal seal. Since
the bonding mechanism is not fully understood 24, questions
arise regarding the irregularities of the amalgam surface, the
higher surface tension of fresh amalgam, the entrapment of
air, the presence of a hybrid surface or the proliferation of
the setting reaction, which could possibly affect marginal
integrity. However, even mechanical loading does not affect
marginal adaptation of the interface 18, eliminating the issue
of a possible failure of the interface due to occlusal forces. A
recent in vivo study on one-hundred posterior teeth,
demonstrated that combined restorations performed better
for contact, contour and retention than conventional
composite resin or amalgam restorations25.
Combined amalgam/composite restorations are not
thoroughly researched, as shown by the aforementioned
drawbacks, but in vitro microleakage results are convincing.
Lacking alternative conservative aesthetic restorative options,
which would improve the quality of the cervical area of Class
II restorations, and considering the research limitations,
combined amalgam/composite resin restorations can be
suggested. Combined restorations should be employed in
challenging clinical situations, particularly in cases of proximal
boxes with cervical margins located near the gingiva or
beneath the cementoenamel junction. Controlled clinical trials
involving the implementation of this technique should be
performed to determine its usefulness, durability and longevity.
The conclusion is that despite the fact that amalgam
and composite are two completely different materials their
interface exhibited the lowest microleakage values. Within
the limitations of an in vitro study, they can be combined in
Class II restorations.

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