C

ABSTRACT Dental amalgam has served as an excellent and versatile restorative material for many years, despite periods of controversy. The authors review its history, summarize the evidence in regard to its performance and offer predictions for the future of this material. For the present, amalgam should remain the material of choice for economical direct restoration of posterior teeth. When esthetic concerns are paramount, tooth-colored materials, placed meticulously, can provide an acceptable alternative.

AT THE NEW MILLENNIUM

If we were to believe the opinions of some experts of the last decade, dental amalgam would not survive as a restorative material into the 21st century.1-3 Various forces at work seemed to doom it to extinction. Among these forces were the development of more durable composite resins, concerns about mercury and the real and perceived advantages of bonding restorations to teeth. However, amalgam is still a widely used restorative material around the world. Although there is evidence of a decrease in its use in the United States, amalgams cost, durability and ease of manipulation have persuaded many dentists to continue to use it as their first choice for restoring posterior teeth. As recently as 1995, a survey reported that 76.3 percent of the dentists polled chose amalgam as their primary material for restoring teeth with Class II carious lesions, and 73 percent reported it as their first choice for restoring primary posterior teeth.4
THOMAS G. BERRY, D.D.S., M.A.; JAMES B. SUMMITT, D.D.S., M.S.; ALBERT K.H. CHUNG, D.D.S., PH.D.; JOHN W. OSBORNE, D.D.S., M.S.

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In 1959, Dr. Wilmer Eames recommended a 1:1 ratio of mercury to alloy, thus lowering the 8:5 ratio of mercury to alloy that others had been recommending.8 In 1962, a spherical particle dental alloy was introduced.9 This was followed in 1963 by a high-copper dispersion alloy system that proved to be superior to its low-copper predecessors.10 Although this performance was theorized to be the result of dispersion strengthening of the alloy, researchers discovered that the additional copper combined with the tin, creating a copper-tin phase that was less susceptible to corrosion than the tin-mercury (gamma 2) phase found in the low-copper alloys.11,12
DURABILITY OF AMALGAM RESTORATIONS

Figure 1. A large, complex, 48-year-old amalgam restoration is shown. Note that the restoration was repaired (replacing the distolingual cusp).

Figure 2. This 47-year-old amalgam restoration in the second premolar demonstrates the durability of amalgam. The conservative size of the restoration probably contributed to its longevity.
HISTORY OF AMALGAM

The history of amalgam is somewhat uncertain, but a silver paste was reportedly used in teeth as early as 659 A.D. in China.5 During the next several centuries, alchemists continued to mix mercury with alloys in the quest to make gold. Traveau used amalgam as a restorative material in France as early as 1826.6 In 1833, two other Frenchmenthe Crawcour brothersbrought it to the
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United States.5 In 1844, Westcott reported that 50 percent of all restorations placed in upstate New York were made of amalgam.7 Over the years, many metals have been combined with mercury, including platinum, palladium, gold, cadmium, zinc, antimony and bismuth. In 1895, G.V. Black published a formulation for dental amalgam that proved to provide acceptable clinical performance. This formulation remained essentially unchanged for almost 70 years.6

Recent research shows that amalgam restorations last longer than was previously thought (Figures 1 and 2). The older generation of low-copper amalgams (before 1963) did have a limited life span because they contained the gamma 2 phase that caused progressive weakening of the amalgam through corrosion.13 Several clinical studies have demonstrated that high-copper amalgams can provide satisfactory performance for more than 12 years (Figure 3).14-18 This appears to be true even for large restorations that replace cusps.19 In addition, high-copper amalgams do not appear to require polishing after placement, as was recommended for lowcopper amalgams to increase their longevity.20 Thorough daily brushing and flossing of a smooth, well-formed restoration slowly produces a surface finish

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similar to that of a polished restoration that has functioned for several years. However, even if not actually polished, the high-copper restoration should have a smooth surface after carving.
COMPOSITION OF AMALGAM ALLOY

Currently used alloys are composed of silver (40 to 70 percent), tin (12 to 30 percent) and copper (12 to 30 percent). They also may include indium (0 to 4 percent), palladium (0.5 percent) and zinc (up to 1 percent). The zinc improves the clinical performance of the amalgam.15,17,21,22 Although the role of zinc in enhancing clinical performance is not well-understood, it may be that the zinc inhibits corrosion.23 Although some researchers and clinicians believe that zinc causes delayed expansion of amalgam if contaminated with moisture, some research on high-copper amalgam indicates otherwise.24,25 Selection of a nonzinc alloy to avoid expansion of the amalgam is not indicated. The alloy is mixed with mercury (43 to 50.5 percent by weight) to form the amalgam. The amalgam may be supplied as lathe-cut irregular particles, small spheres or a combination of the two. Handling characteristics of the amalgam vary depending on formulation and particle size and shape. The clinical performance of various formulations and particle sizes and shapes does not differ significantly. Spherical alloys are less resistant to condensation, so it would seem that they should adapt easier to cavity walls. However, restorations made of spherical alloys exhibit greater

Figure 3. A 58-year-old Class II amalgam restoration is shown.

microleakage because of poorer adaptation to the cavity and/or shrinkage of the amalgam as it sets.26,27 Thorough lateral condensation during placement will help to overcome this problem.

ince resin bonding systems have

been shown to provide a better initial seal of cavity walls, their use is increasing while varnish use is diminishing.

CAVITY VARNISHES

Traditionally, copal resin varnish has been placed over cavity walls to seal the interface between the tooth and restoration, to minimize leakage of fluid along the interface between the amalgam and the cavity wall, and to seal the dentinal tubules.

Varnish, however, exhibits some breakdown in oral fluids, so its benefit may be relatively short-lived.28-31 Low-copper alloys may compensate partially for this dissolution of varnish by the gradual accumulation of corrosion products in the gaps at the interface.26,27,32 For highcopper amalgams, postinsertion corrosion is limited and takes more time to occur than it does for low-copper alloys, but it will eventually create a partial seal at the interface. Since resin bonding systems have been shown to provide a better initial seal of cavity walls and to inhibit microleakage at the interface,33,34 their use is increasing while varnish use is diminishing. Resin fissure sealants are often used in conjunction with amalgam restorations to reduce caries susceptibility.35 The use of varnish is contraindicated when amalgam is used with bonding resins or with resin sealants.
RECURRENT CARIES

Recurrent caries has often been associated with amalgam restorations. Some retrospective studies conducted in clinics and
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associate marginal discrepancies with caries, especially if the area is filled with soft debris and/or tends to mechanically trap an explorer tine. Although there is some correlation between gap width and recurrent caries,40,41 it is well-documented that a marginal discrepancy does not necessarily signal either recurrent caries or the likelihood of its occurrence, even when the interface is filled with debris.42-44 The diagnosis of recurrent caries is too often incorrect and results from relying on marginal ditching as a valid diagnostic criterion (Figure 4). Dental professionals should consider smoothing, refinishing and possibly repairing amalgam restorations before planning replacements. Dentists can lessen the incidence of recurrent caries by placing greater emphasis on preventive measures such as topical fluoride application and good oral hygiene, careful manipulation of the amalgam at placement, and placement of an unfilled resin to seal the restorations margins.35 A fluoride-releasing liner, such as glass ionomer, may also decrease the likelihood of secondary caries, although the fluoride release may be relatively short-term.45,46 Dentists also need a better approach to diagnosis than relying only on discoloration and the ability to insert an explorer tine into a marginal crevice. A diagnosis should involve many approaches, including an assessment of the patients caries risk.47
CAVITY PREPARATION DESIGN

Figure 4. Marginal ditching is evident in this restoration. Replacement was not indicated because no recurrent caries was present.

Figure 5. This disto-occlusal restoration in the second premolar involves only the proximal surface, the marginal ridge and fossa areas. The noncarious fissures were not included in the preparation.

private practices have indicated that as many as 50 percent of replacement amalgam restorations are in teeth diagnosed as having recurrent caries.36,37 However, this finding has not been substantiated by some long-term clinical studies reporting recurrent caries rates of less than 5 percent over 13- and 14-year periods.14,15,38 These studies indicate that recurrent caries is not a major problem in teeth restored with amalgam. Even the high rates of recur1550

rent caries reported in earlier studies may be partly the result of two factors. Kidd and colleagues39 have shown that demineralized tooth structure is left in many preparations at the time of restoration. Therefore, some of the recurrent caries could actually be residual carious lesions that have increased in size after the restoration is placed. A second factor may relate to the diagnosis of recurrent caries. Dentists have learned to

Improvements in materials and techniques for their placement have combined with preventive

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methods to alter the design of cavity preparations. Minimal intervention is the key to preserving tooth structure. Some authors advocate extending preparations only into fissures that are carious, rather than into all contiguous fissures, whether carious or not.48-52 Dentists can treat approximal carious lesions with proximal slot restorations without involving the occlusal surface except for the marginal ridge (Figure 5). The use of smaller burs to create preparations that involve the removal of only diseased and weakened enamel and dentin, combined with use of fissure sealants, allows preservation of more sound tooth structure than is possible with traditional techniques. A smalldiameter bur (for example, number 1/4 or 1/8) can be used to slightly open the fissures to be sealed to ensure access to sound enamel for etching and flow of a liquid resin to provide a seal. Studies have shown that smaller restorations last longer and that conservation of tooth structure leaves cusps more resistant to fracture.53,54 Osborne and Gale55 evaluated 196 amalgam restorations 13 to 14 years after insertion. They found that cavity width was the single most significant factor in clinical survival. The wider restorations showed greater marginal fracture and a higher rate of replacement than the narrow restorations. Amalgam type and tooth position were also factors, but of less significance than the dimensions of the restoration. Other benefits associated with the success of smaller preparations include reduced occlusal stress on the margins and preservation of tooth strength. These are convincing argu-

Figure 6. Three years after placement, this restoration in the first molar is still performing well. Retention is provided by bonding the restoration to the tooth.

ments for creating small preparations when conditions allow. In an in vitro study, Summit and colleagues56 found that Class II restorations need no

tudies have shown that

need more prominent proximal retention, such as distinct retention grooves extending from the gingival wall to the occlusal cavosurface margin.57,58 The amalgam must be condensed thoroughly into the retentive areas to provide adequate retention.
RETENTION OF LARGE RESTORATIONS

smaller restorations last longer and that conservation of tooth structure leaves cusps more resistant to fracture.

special retention form if the faciolingual width of the occlusal extension is as great as onefourth of the intercuspal distance. A narrower occlusal preparation may require placement of supplementary proximal retentive features for the proximal box portion of the preparation. Slot preparations

Retention of smaller amalgam restorations relies on undercuts in tooth structure and frictional resistance from the walls of the preparation. When much of the tooth has been destroyed by trauma or caries, additional retentive features must be created. Retentive pins have been used for decades. The technology has evolved from pins cemented into oversized pin channels in dentin59,60 or pins tapped into undersized pin channels in dentin61 to pins that are screwed into channels.62 While pins provide reliable retention and resistance to displacement, they require further invasion of the tooth. Pressure exerted during placement can cause crazing or
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fracture of surrounding tooth structure.63,64 Dentists can cut channels into strategic areas in the tooth to allow insertion of amalgam to create amalgapins.65 They provide good retention and resistance for the restoration, but also require removal of tooth structure in an already compromised tooth.65-67
AMALGAM BONDING

Within the last several years, bonding amalgam to the tooth structure has shown great promise. While the efficacy of bonding systems has not been tested over the long term, results of clinical studies reported two years after bonding have been quite favorable (Figure 6).68-70 As research continues, evidence is mounting that bonding provides truly effective retention for a significant number of years. If bonding proves successful over the long term, elaborate methods of mechanical retention can be eliminated, thus reducing the potential for further damage to tooth structure that occurs with pin placement or use of amalgapins. If mechanical retention is not needed, cavity preparation designs can allow more sound tooth structure to be preserved. While the bond strengths recorded in studies have varied, approximately 12 to 15 megapascals, or MPa, seem to be routinely achievable.71-73 Using a spherical amalgam in one study of bonded amalgams, Summitt and colleagues74 reported a mean bond strength of 27 MPa. The authors believed that this higher bond strength was achieved because the bonding material was refrigerated until immediately before its use.
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Bond strengths achieved with admixed alloys tend to be slightly lower than those achieved with spherical alloys.75 It has even been suggested that bonding provides some resistance to fracture of the cusps.76 However, the research findings are still mixed in regard to the degree to which bonding may reinforce the tooth. An early concern about bonding amalgam restorations was that the bond might undergo breakdown over time.77,78 As demonstrated in the clinical studies cited above,68-70 bond de-

t is important to continue monitor-

ing reports on the clinical studies currently under way to determine if the bond remains strong enough to retain the restoration.
terioration does not yet appear to be a problem. It is important to continue monitoring reports on the clinical studies currently under way to determine if the bond remains strong enough to retain the restoration. Another advantage of bonding is that it offers sealing properties that may play a role in minimizing postinsertion tooth sensitivity. Microleakage is further decreased by etching and placing an unfilled resin over amalgam margins. MertzFairhurst and colleagues35 com-

pared traditional amalgam restorations with composite resin restorations and with amalgam restorations with sealed margins. Their findingsreported at six years after placement, at nine years and at 10 yearsremained consistent through the 10th year, showing that sealed amalgam restorations had the fewest marginal discrepancies and the best survival rate of the three restoration types. One study compared postinsertion sensitivity of teeth with bonded amalgams with teeth with pin-retained amalgams.79 At baseline and six months, teeth with bonded amalgams were less sensitive than teeth with pin-retained amalgams. This difference in sensitivity was not present one year after insertion. This finding is possibly the result of corrosion products in nonbonded amalgam restorations filling the interface to a degree sufficient to decrease microleakage. Lower initial sensitivity, if found to be a routine outcome of bonding, may prove to be an advantage.
BIOCOMPATIBILITY AND TOXICITY OF DENTAL AMALGAM

Concerns about the health effects of amalgam must be approached from two aspects: effect on the patient in whom the material is placed and effect on the dentist and auxiliary staff members who are placing and removing restorations. Many untoward effects have been attributed to amalgam restorations and the mercury vapor that is released from them.80-82 Antiamalgam groups have claimed that amalgam is the cause of many health problems such as neurotoxicity, renal

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dysfunction, birth defects, reduced immunocompetence and compromised general health. Public concerns, often based on anecdotal reports that have been sensationalized in the media, have increased during the last decade to such an extent that many patients are requesting removal of their amalgam restorations and/or refusing to allow more amalgam to be placed in their mouths. Scientific studies have not found these concerns to be warranted. While it is well-known that mercury in certain forms (for example, organic and inorganic mercury, mercury vapor) and at high enough levels does produce toxic effects, research has yet to show that the minute amounts of mercury vapor escaping from amalgam restorations are in concentrations high enough to produce any detectable effect on the body.83 Claims of great health benefits from the removal of amalgam restorations in patients with neurological diseases such as multiple sclerosis are purely anecdotal. In fact, the blood mercury level of the patient spikes immediately after the amalgam is removed.84,85 If mercury is responsible for the patients neurological condition, it seems logical that he or she would exhibit an initial worsening of the condition rather than an immediate and dramatic improvement after removal. Other studies have found no substantiated evidence that patients with amalgam restorations have reduced kidney function, decreased immunocompetence, higher rates of birth defects or poorer general health.86-88 Although no one claims that amalgam restorations have a beneficial effect on patients general health, some studies actually offer evidence that patients with them exhibit better general health than patients without them.89 Dentists and dental auxiliary staff members generally have a higher mercury level than the population in general.90,91 However, dentists have a greater life expectancy than the general population and tend to die of the same diseases and conditions that affect others despite their prolonged increased exposure to mercury.92-94 Some studies have shown that the problems patients atgam, although rare, do occur99 and must be recognized.100,101 The hypersensitivity can be in response to any one or more of the various components of amalgam. Signs can include oral lesions such as eczematous reactions or lichenoid lesions.102 These problems usually can be relieved by removing restorations that are in contact with the lesion.103 Usually, it is not necessary to remove restorations not in the area of the lesion. Dental professionals should keep in mind that patients may also exhibit a sensitivity to other materials, such as composite resin.104
RECENTLY DEVELOPED METALLIC MATERIALS

esearch has yet to show that the

One amalgam substitute currently being tested is a consolidated silver alloy system developed at the National Institute of Standards and Technology.105 It uses a fluoroboric acid solution to keep the surface of the silver alloy particles clean. The alloy, in a spherical form, is condensed into a prepared cavity in a manner similar to that for placing compacted gold. One problem associated with insertion of this material is that the alloy strain hardens (that is, it becomes harder or more brittle as the metal is bent repeatedly or burnished), so it is difficult to compact it adequately to eliminate internal voids and to achieve good adaptation to the cavity without using excessive force. Research is ongoing to assess various formulations and compositions of this alloy to reduce the strainhardening phenomenon. Gallium alloys were examined in the 1950s and 1960s, but the lack of dimensional stability discouraged further inves1553

minute amounts of mercury vapor escaping from amalgam restorations are in concentrations high enough to produce any detectable effect on the body.
tribute to amalgam restorations are psychosomatic in nature and have been exacerbated greatly by information from the media or from a dentist.95-98 Unless new and compelling evidence is presented to the contrary, we believe that dentists cannot ethically tell patients that amalgam is a health hazard and that removal of restorations will benefit their health. We must note that true hypersensitivity reactions to amal-

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1997 (Maxwell H. Anderson, D.D.S., M.S., M.Ed., dental director, Washington Dental Service, Delta Dental, written and oral communication, May 21, 1998). Yet, amalgam continues to be the best bargain in the restorative armamentarium because of its durability and technique insensitivity. Amalgam will probably disappear eventually, but its disappearance will be brought about by a better and more esthetic material, rather than by concerns over health hazards. When it does disappear, it will have served dentistry and patients well for more than 160 years.
CONCLUSIONS

Dr. Berry is a professor and chair, Department of Restorative Dentistry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, Texas

Dr. Summitt is a professor and head, Division of Operative Dentistry, University of Texas Health Science Center at San Antonio.

Dr. Chung is a professor and chief, Restorative Dentistry Division, Faculty of Dentistry, National Yang-ming University, Taipei, Taiwan, Republic of China, and an adjunct professor,

Dr. Osborne is a professor and director of Clinical Research, Department of Restorative Dentistry, University of Colorado School of Dentistry, Denver.

tigation of these materireprint requests to als. The merDr. Berry. cury scare in the late 1980s and early 1990s revived manufacturers interest enough to market mercury-free metallic restorative materials. Although laboratory data indicated a potential clinical use106,107 (and one gallium alloy, Galloy [Southern Dental Ind.], received the Seal of Acceptance from the ADA, as well as acceptance by the Food and Drug Administration and the Scandinavian Institute of Dental Materials), several clinical studies have shown a high rate of fractured teeth, fractured restorations and even pulpal death.108,109 In May 1998, the Seal of Acceptance was withdrawn from Galloy for these reasons. Unless major changes are made in these materials, we believe that the potential for either the consolidated silver alloy or the gallium alloys to become a significant part of the dental restorative market is extremely limited.
78284-7890. Address

ments have been made Dentistry, University within the last of Texas Health Science Center at several years San Antonio. in their composition, techniques for placement and finishing, and/or agents for bonding them. The ultimate decision in regard to material selection should be based on several factors, including esthetic concerns of the patient, cost, functional demands on the restoration, tooth location, patient desires and time demands.
Department of Restorative

PREDICTIONS FOR THE FUTURE OF DENTAL AMALGAM

ALTERNATIVES TO AMALGAM

Many alternatives to amalgam are available, each with advantages and disadvantages. Most of these materials are not new, although significant improve1554

The prediction that amalgam would not last until the end of the 20th century is not proving to be accurate. Its unesthetic appearance, its inability to bond to the tooth, concerns about mercury and the versatility of other materials have not led to the elimination of this inexpensive and durable material. As other materials and techniques improve, the use of amalgam will likely continue to diminish, and it will eventually disappear from the scene. One report of dental insurance statistics shows a decline in use of amalgam for posterior direct restorations from 85 percent in 1988 to 58 percent in

Based on current evidence, we offer the following recommendations for dentists: dcontinue to use amalgam as the material of choice if esthetic results are not of overriding concern; dprepare the tooth as conservatively as possible, making access large enough only for removal of carious dentin and using resin sealants for noncarious fissures; duse amalgam bonding systems, but continue to monitor research reports for the longterm effectiveness of such systems; dwhen clinical research demonstrates that tooth-colored restorative materials are as economical and effective in the long term as dental amalgam, switch to the more esthetically pleasing materials. s
1. Wilson EG, Mandradjieff M, Brindock T. Controversies in posterior composite resin restorations. Dent Clin North Am 1990;34(1):27-44. 2. Leinfelder KF. After amalgam, what? Other materials fall short. JADA 1994;125(5):586-9.

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3. Simonsen RJ. Move over amalgamat last. Quintessence Int 1995;26(3):157. 4. Use survey1995. Clin Res Associates Newsletter 1995;19(10):4. 5. Ring ME. Dentistry, an illustrated history. New York: Abrams; 1985. 6. Anderson MH, McCoy RB. Dental amalgam: The state of the art and science. 3rd ed. Philadelphia: Saunders; 1993. 7. Westcott A. Report to the Onondongia Medical Society on metal paste (amalgam). Am J Dent Sci IV, 1st Ser, 1844:175-201. 8. Eames WB. Preparation and condensation of amalgam with low mercury alloy ratio. JADA 1959;58(4):78-83. 9. Demaree NC, Taylor DF. Properties of dental amalgam from spherical alloy particles. J Dent Res 1962;41:890-906. 10. Innes DBK, Youdelis WV. Dispersion strengthened amalgam. J Can Dent Assoc 1963;29:587-93. 11. Asgar K. Behavior of copper dispersion alloy (abstract 15). J Dent Res 1971;50(special issue):56. 12. Mahler DB. Micro-probe analysis of a dispersion amalgam (abstract 14). J Dent Res 1971;50(special issue):56. 13. Guthrom CE, Johnson LD, Lawless KR. Corrosion of dental amalgam and its phases. J Dent Res 1983:62:1372-81. 14. Osborne JW, Norman RD, Gale EN. A 14-year clinical assessment of 12 amalgam alloys. Quintessence Int 1991;22:857-64. 15. Osborne JW, Norman RD. 13-year clinical assessment of 10 amalgam alloys. Dent Mater 1990;6(3):189-94. 16. Mjr IA, Jokstad A, Qvist V. Longevity of posterior restorations. Int Dent J 1990;40(1):11-7. 17. Letzel H, vant Hof MA, Marshall GW, Marshall SJ. The influence of the amalgam alloy on the survival of amalgam restorations: a secondary analysis of multiple controlled clinical trials. J Dent Res 1997;76(1):1787-98. 18. Mahler DB. The high-copper dental amalgam alloys. J Dent Res 1997;76(1):53741. 19. Smales RJ. Longevity of cusp-covered amalgams: survivals after 15 years. Oper Dent 1991;16(1):17-20. 20. Mayhew RB, Schmeltzer LD, Pierson WP. Effect of polishing on the marginal integrity of high-copper amalgams. Oper Dent 1986;11(1):8-13. 21. Berry TG, Osborne JW. Effect of zinc in two non-gamma-2 amalgam systems. Dent Mater 1985;1(3):98-100. 22. Osborne JW, Berry TG. Zinc-containing high copper amalgams: a 3-year clinical evaluation. Am J Dent 1992;5(1):43-5. 23. Sarkar NK, Park JR. Mechanism of improved resistance of zinc-containing dental amalgams. J Dent Res 1988;67:1312-5. 24. Yamada T, Fusayama T. Effect of moisture contamination on high copper amalgam. J Dent Res 1981;60:716-23. 25. Osborne JW, Howell ML. Effects of water contamination on certain properties of high copper amalgams. Am J Dent 1994;7:337-41. 26. Mahler DB, Bryant RW. Microleakage of amalgam alloys: an update. JADA 1996;127:1351-6. 27. Mahler DB. The amalgam-tooth interface. Oper Dent 1996;21(6):230-6. 28. Sneed WD, Hembree JH Jr., Welsh EL. Effectiveness of three cavity varnishes in reducing leakage of a high-copper amalgam. Oper Dent 1984;9(1):32-4. 29. Powell GL, Daines DT. Solubility of cavity varnish: a study in vitro. Oper Dent 1987;12(2):48-52. 30. Fitchie JG, Reeves GW, Scarbrough AR, Hembree JH. Microleakage of a new cavity varnish with a high-copper spherical amalgam alloy. Oper Dent 1990;15(4):136-40. 31. Barber D, Lyell J, Massler M. Effectiveness of copal resin varnish under amalgam restorations. J Prosthet Dent 1964;14:533-6. 32. Bayne SC, Taylor DF. Dental materials. In: Sturdevant CM, Roberson TM, Heymann HO, Sturdevant JR, eds. The art and science of operative dentistry. 3rd ed. St. Louis: MosbyYear Book; 1995:224. 33. Cooley RL, Tseng E, Barkmeier WW. Dentinal bond strengths and microleakage of a 4-meta adhesive to amalgam and composite resin. Quintessence Int 1991;22:974-83. 34. Turner EW, St. Germain HA, Meiers JC. Microleakage of dentin-amalgam bonding agents. Am J Dent 1995;8(4):191-6. 35. Mertz-Fairhurst EJ, Curtis JW Jr., Ergle JW, Rueggeberg RA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. JADA 1998;129(1):55-66. 36. Klausner LH, Green TG, Charbeneau GT. Placement and replacement of amalgam restorations: a challenge for the profession. Oper Dent 1987;12(3):105-12. 37. Mjor IA. The reasons for replacement and the age of failed restorations in general dental practice. Acta Odontol Scand 1997;55(1):58-63. 38. Akerboom HB, Advokaat JG, Van Amerongen WE, Borgmeijer PJ. Long-term evaluation and rerestoration of amalgam restorations. Community Dent Oral Epidemiol 1993;21(1):45-8. 39. Kidd EA, Joyston-Bechal S, Smith MM. Staining of residual caries under freshlypacked amalgam restorations exposed to tea/chlorhexidine in vitro. Int Dent J 1990;40(4):219-24. 40. Hodges DJ, Mangum FI, Ward MT. Relationship between gap width and recurrent dental caries beneath occlusal margins of amalgam restorations. Community Dent Oral Epidemiol 1993;23:200-4. 41. Goldberg J, Tanzer J, Munster E, Amara J, Thai F, Birkhed D. Cross-sectional clinical evaluation of recurrent enamel caries, restoration of marginal integrity, and oral hygiene status. JADA 1981;102:635-41. 42. Solderholm KJ, Antonson DE, FischiSchweifer W. Correlation between marginal discrepancies at the amalgam tooth interface and recurrent caries. In: Anusavice KJ, ed. Proceedings: Quality evaluation of dental restorations: criteria for placement and replacement. Chicago: Quintessence Publishing; 1989:95-108. 43. Kidd EAM, OHara JW. The caries status of occlusal amalgam restorations with marginal defects. J Dent Res 1990;69:1275-7. 44. Elderton RJ, Mjor IA. Changing scene in cariology and operative dentistry. Int Dent J 1992;42(3):165-9. 45. Garcia-Godoy R, Jensen ME. Artificial recurrent caries in glass ionomer-lined amalgam restorations. Am J Dent 1990;3:89-93. 46. Olsen BT, Garcia-Godoy F, Marshall TD, Barnwell GM. Fluoride release from glass ionomer-lined amalgam restorations. Am J Dent 1989;2(3):89-91. 47. Osborne JW, Summitt JB. Amalgam removal (letter). J Dent Res 1998;77:340. 48. El-Mowafy OM. Fracture strength and fracture patterns of maxillary premolars with approximal slot cavities. Oper Dent 1993;18(4):160-6. 49. Schwartz RS, Summitt JB, Robbins JW. Fundamentals of operative dentistry: A contemporary approach. Chicago: Quintessence Publishing; 1996:252. 50. Caron GA, Murchison DF, Broom JC, Cohen RB. Resistance to fracture of teeth with various preparations for amalgam (abstract 208). J Dent Res 1994;73(special issue):127. 51. Summitt JB, Osborne JW. Initial preparations for amalgam restorations: extending the longevity of the tooth-restoration unit. JADA 1992;123:67-74. 52. Osborne JW, Summitt JB. Extension for preventionis it revelant today? Am J Dent (In press). 53. Berry TG, Laswell HR, Osborne JW, Gale EN. Width of isthmus and marginal failure of restorations of amalgam. Oper Dent 1981;65:55-8. 54. Blaser PK, Lund MR, Cochran MA, Potter RH. Effect of designs of Class 2 preparations on resistance of teeth to fracture. Oper Dent 1983;8(1):6-10. 55. Osborne JW, Gale EN. Relationship of restoration width, tooth position, and alloy to fracture of the margins of 13- to 14-year old amalgams. J Dent Res 1990;69(9):1599-1601. 56. Summitt JB, Osborne JW, Burgess JO, Howell ML. Effect of grooves on resistance form of Class 2 amalgams with wide occlusal preparations. Oper Dent 1993;18(2):42-7. 57. Sturdevant JR, Taylor DF, Leonard RH, Straka WF, Roberson TM, Wilder AD. Conservative preparation designs for Class II amalgam restorations. Dent Mater 1987;3(3):144-8. 58. Summitt JB, Osborne JW, Burgess JO. Effect of grooves on resistance/rentention form of Class 2 approximal slot amalgam restorations. Oper Dent 1993;18(5):209-13. 59. Markley MR. Pin reinforcement and retention of amalgam foundations. JADA 1958;56:675-9. 60. Markley MR. Pin-retained and pin-reinforced amalgam. JADA 1966;73:1295-1300. 61. Goldstein PM. 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