Endodontics

Restoring teeth that are endodontically treated

through existing crowns. Part iii: Material usage
and prevention of bacterial leakage
Glenn Trautmann, DMDVJames L. Gutmann, DDS^/Martha E. Nunn, DDS,
David E. Witherspoon, BDSc, MS^/Charles W. Berry, MS, PhDVGiancarlo G. Romero, DDS,
Objective: This study was undertaken to determine if any current materiais can prevent coronai ieal<age
in the restoration of endodontic access openings in permanently fixed crowns foiiowing nonsurgicai root
canal therapy. Method and materials: Sixty mandibuiar first moiars and 36 maxiiiary centrai incisors were
assigned into 1 of 8 compiete-coverage crown groups. Endodontic access openings were made through
the restorations and randomly placed in 1 of 5 access restorative modalities. A culture of Proteus vulgaris
was placed into the coronal reservoir of each assembly of a leakage assessment apparatus for 30 days.
Specimens were examined weekly, and turbidity was recorded. Results: Chi-square tests and Fisher's
exact test were used for statistical evaluation, A total of 5 1 % of specimens (41/80) demonstrated turbidity.
The findings did not indicate a statistically significant association between the materials used and the
presence of bacterial leakage. All-metal noble crowns demonstrated the lowest rate of turbidity (20%), and
all-porcelain crowns exhibited the highest rate of turbidity (70%) among posterior teeth. Anterior teeth
were more than 3.5 times as likely to exhibit bacterial leakage as posterior teeth. Conclusion: When challenged with bacteria, all materials allowed significant leakage. All-porcelain crowns demonstrated more
leakage than the other types of crowns. Anterior crowns leaked the most, regardless ot crown or restoration type. (Quintessence Int 2001:32:27-32)
Key words: amalgam, bacterial leakage, complete-coverage crown, glass-ionomer cement,
nonsurgicai root canal treatment, Proteus vulgaris, resin composite

CLINICAL RELEVANCE: Further evaluations are warranted for the identification of a leak-proof material and
placement technique to restore endodontic access cavities in complete-coverage crowns.

'Graduate Resident of Graduate Endodontios, Department of Restorative

Sciences, Baylor College of Dentistry, Texas A&M University System,
Health Science Center, Dallas, Texas,
^Professor and Director of Graduate Endodontics, Department of
Restorative Sciences, Baylor College of Dentistry, Texas A&M University
System, Health Science Center, Dallas, Texas,
^Assistant Professor, Department of Public Health Sciences, Baylor
College of Dentistry, Texas A&M University System, Health Science
Center, Dallas, Texas,
"Assistant Professor of Graduate Endodontics, Department of Restorative
Sciences, Baylor College of Dentistry, Texas A&M University System,
Health Science Center, Dallas, Texas,
^Professor of Biomdical Sciences, Baylor College of Dentistry, Texas A&M
University System, Health Science Center, Dallas, Texas,
Private Practice, Houston, Texas,
Reprint requests: Dr James L, Gutmann, Baylor College of Dentistry,
Graduate Endodontics (Room 335), 3302 Gaston Avenue, Dallas, Texas
75246. E-mail: jgutmann@tambcd.edu

Quintessence International

ore than 50% of all teeth with complete-coverage

crown restorations require nonsurgicai root
canal treatment (NSRCT).' This can he due to the
extensive effects of restorative procedures, the possible
leakage of bacteria and their by-products at imperfect
crown margins, or recurrent marginal caries that cannot always be detected clinically.'*
Following NSRCT on these teeth, the crowns are
not always replaced. The endodontic access openings
in teeth with preexisting complete-coverage crowns
are routinely restored with amalgam, resin composite,
or glass-ionomer cement, bonded or not bonded.
However, there is no evidence-based support for the
choice of material for the restoration and no data on
its clinical performance over time.' Material choice is
critical because coronal leakage of bacteria and their
by-products is an important factor in the failure of
nonsurgicai root canal treatment.'-^*^''^ The need for
re-treatment may arise from continued marginal leakage at the tooth-crown interface or the coronal
access-crown interface. Therefore, if the crown is
determined to be intact clinically at the interface with
the tooth and is to be retained, the integrity of the

27

 Trautmann et al

TABLE 1 Complete-coverage crown restoration

groups
Tooth type
Crown type

Anterior

Posterior

Total

Porcelain (Duceram*)-fused-tohigh-noble metal (Orion*)

Porcelain (Dceram*)-fused-tonoble metal (Lunar*)
All-metal, gold (Oro B-2*)
All-porcelain (Empress^)
All-metal, high noble (Orion*)
Total

10

10

20

10

10

20

10

10

10

10

20

10

10

30

50

80

*Degussa-Ney Dental.
'Empress (Ivoclar Nortii America).

interface between the endodontic access opening and

the crown material cannot be neglected.
The fact that bacterial contamination is the etiologic factor that will challenge the seal of the root
canal filling secondary to coronal leakage is well
known. Grossman," Seltzer,'' and Mortensen et al"'
indicated that the assessment of bacterial leakage is a
clinically reliable test. This resulted in further studies
that used bacterial species to assess the seal of rootfilled canals.8'13.17-23

The purpose of this study was to determine if any of

the dental materials in current clinical use has the
ability to prevent coronal leakage in restored
endodontic access openings in permanently fixed
crowns following NSRCT.
METHOD AND MATERIALS
Specimen preparation

A total of 60 extracted mandibular first molars and 36

extracted maxillary central incisors were used. Proximal and facial radiographs were made using size 2
Kodak Ultraspeed film (Eastman Kodak). Teeth were
evaluated to determine root curvature and canal morphology. Those exhibiting unusual anatomy, severe
curves, root caries, cervical defects, immature apices,
previous root canal therapy, and large coronal restorations were excluded from the study.
Gross tissue debris was removed carefully from the
teeth, which were then immersed in 10 mL of 5.25%
sodium hypochlorite (NaOCl) (Clorox) for a 5-minute
soak. The teeth were stored in distilled water containing dissolved thymol crystals (Sigma Chemical) and
allocated randomly to 1 of the 8 complete-coverage
restoration groups (Table 1).
28

Crowns were prepared as described by Rosenstiel et

al.^"* A high-speed handpiece with water spray and
fine-diamond cutting burs (Nos. 856, 850, 909, 368,
and 847, Brasseler) were used. The operator was calibrated for crown preparation, and the final preparations were evaluated by 2 prosthodontists.
The laboratory work for the crowns was performed
by a prosthodontist, who followed the manufacturer's
recommendations in the manipulation of the metals
and porcelain. Impressions of the crown preparations
were made with a polyvinyl siloxane impression material (Extrude, Kerr) with 12 teeth per plastic tray.
Crown castings were made with silky rock-ADA type
IV stone material (Resinrock, Whip Mix). Once die
spacer was placed uniformly throughout the die preparations, the crown forms were waxed with Gator Dip
Wax (Whip Mix), invested, and cast. The various materials were used in accordance with the manufacturer's
recommendations. All crowns were cemented permanently with Panavia 21 Dental Adhesive (J Morita),
and mixed according to the manufacturer's recommendations. The crowned teeth were left in an incubator at
37''C for 1 week.
After a 1-week incubation, straight-line endodontic
access openings were made with a high-speed handpiece
used with copious water spray and a combination of
Nos. 4 and 6 round diamond burs (Brasseler), transmetal, and safe-ended Endo Z burs (Dentsply Maillefer).
The openings followed the recommended outline form
for maxillary central incisors and mandibular molars.
The working length of the root canal was determined by
subtracting 1.0 mm from the point where a No. 10 Ktype file (LD Caulk) was observed at the apical foramen.
The canals were cleaned and shaped with a combination
of Orifice Shapers and ProFile NiTi rotary files of .04
and .06 taper (Dentsply-Tulsa Dental), while 5.25%
NaOCl was used as an irrigant. Once the instmmentafion was completed to the coronal or middle third of the
root, the canals were irrigated first with 5 mL of 5.25%
NaOCl for a period of 1 minute, then vWth 5 mL of 17%
R-ethylene diamine tetraacetic acid (REDTA) (Roth
Drug) for 2 minutes, and finally with 5 mL of 5.25%
NaOCl for 1 minute to remove the smear layer. Canals
were dried with paper points. Teeth from 8 completecoverage restoration groups (Table 1) were allocated randomly to 1 of 5 access restorative modalities (Table 2).
Sixteen teeth were allocated as positive or negative
controls:
1. Positive control group (intact crown): 5 posterior
teeth (1 of each crown type) and 3 anterior teeth (1
of each crown type)
2. Negative control group (unrestored accessed crown):
5 posterior teeth (1 of each crown type) and 3 anterior teeth (1 of each crown type)
Volume 32, Number 1 2001

Trautmann et al

TABLE 2 Restorative materials

Tooth/crown type
Restorative material

Anterior

Posterior

Total

10
10

16
16

10

16

10

16

10
50

16
80

Amalgam (Tytin FC*) and varnish

6
Amalgam (Tytin FC*) and bonding
6
agent (Panavia21ti
Light-cured resin (Prodigy*) and
6
bonding agent (Optibond Solo*)
Dual-cured resin (Corestore*) and
6
bonding agent (Optibond Solo*)
Glass-ionomer cement (Fuji IX GP > 6
Total
30

Crown line

*Kerr.
'J. Morita.
GO America.
Sterile TSB

Fig 1 (TSB) Trypticase soy broth. Leakage

apparatus.

Once restored, all teeth were placed in the incubator

at 37C, and the test apparatus was assembled for each.
Leakage assessment apparatus

The testing apparatus for this study was adapted from

the test assembly used in a previous study on bacterial
penetration,'' with certain modifications in the coronal tubing, to provide complete accessibility of the
microorganism to the full anatomic crown and all
restoration margins of the teeth (Fig 1). The coronal
portion of each tooth was sealed within the lumen
with cyanoacrylate cement, so that all restorative margins were exposed to the bacterial medium. A polyethylene tube of smaller diameter and 50 mm in length
was sealed with cyanoacrylate to the upper half of the
larger tube sleeve. A 0.01-mm orthodontic wire was
adjusted and twisted around the outer plastic sleeve
(approximately 3 mm above the apical edge), to maximize the integrity of the seal between the plastic sleeve
and the tooth root.
Bacterial leakage model

Following assembly in the testing apparatus, all teeth

were sterilized in ethylene oxide for 48 hours. After
sterilization was completed, the test assemblies were
degassed for 24 hours. The test organism, Proteus vulgaris (2.0 mL of 24-hour growth in trypticase soy
Quintessence International

broth [TSB]), was placed in the coronal reservoir of

each test assembly with a long-tipped Pasteur pipette.
An aseptic placement technique was used under a vacuum. The inoculated tooth-and-tubing assembly was
inserted into a presterilized test tube (17 x 100 mm)
containing 2 mL of sterile TSB. The test tube was
loosely covered with a plastic cap and briefly agitated
to remove air bubbles.
The TSB was incubated at 37C for 30 days and
observed weekly for turbidity, indicating microbial
penetration. The number of tubes exhibiting growth
was recorded. The microorganisms were inoculated
onto agar plates and observed for purity by gross
appearance and gram stained to determine contamination by species other than P vulgaris.
The inoculated TSB in the coronal reservoirs was
replaced every 7 days. After 30 days, the test assemblies were removed, rinsed with sterile saline, and subsequently exposed to 2% mthylne blue for 30 days.
Statistical evaluation

The outcomes of the bacterial leakage study were evaluated with a chi-square test to compare the influence
of (1) type of restoration, (2) type of crown, and (3)
type of tooth (anterior versus posterior) on the incidence of turbidity. For 1-tailed tests and where
expected cell counts were fewer than 5, Fisher's exact
tests were utilized.
29

 Trautmann et al

RESULTS

A total of 51% of specimens (41/80) demonstrated bacterial leakage. A cbi-square test of independence did not
indicate a statistically significant association between
the presence of turbidity (indicating bacterial leakage)
and tbe restorative materials used (P = 0.995). All materials leaked in at least 50% of tbe specimens: amalgam
and bonding agent (8/16); amalgam and varnish (8/16);
light-cured composite (8/16); glass-ionomer cement
(8/16); and dual-cured composite (9/16; 56%).
No statistically significant association between
crown type and bacterial leakage (as evidenced by the
presence of turbidity) was found (P = 0.149). Tbe
greatest incidence of bacterial leakage was observed
for all-porcelain crowns (14/20; 70%), wbile tbe lowest incidence of leakage was observed among all-metal
noble crowns (2/10; 20%). All otber crown types
exhibited a 50% incidence of turbidity (10/20 for both
types of porcelain-fused-to-metal crowns and 5/10 for
all-metal gold crowns).
To allow further investigation of possible associations between bacterial leakage and crown type, porcelain-type crowns were grouped togetber and compared
to all-metal crowns grouped togetber. Fisher's exact
test revealed some evidence tbat porcelain-type
crowns were more susceptible to bacterial leakage
tban were all-metal crowns (P = 0.077). Specifically, 7
of 20 all-metal crowns (35%) sbowed turbidity, while
34 of 60 porcelain-type crowns (57%) sbowed turbidity. The presence of turbidity among all-porcelain
crowns was then compared to the presence of turbidity
among all otber types of crowns in tbe study. Allporcelain crowns bad a significantly higher risk of turbidity; teeth witb all-porcelain crowns had an odds
ratio of 2.85 for tbe presence of turbidity compared to
teeth witb crowns tbat were not all-porcelain [P =
0.046 for 1-tailed Fisber's exact test).
A chi-square test of independence demonstrated a
statistically significant association (P = 0.009) between
tbe occurrence of turbidity and type of tootb; anterior
teetb demonstrated a greater frequency of bacterial
leakage (21/30; 70%) than did posterior teetb (20/50;
40%). Specifically, anterior teetb were 3.5 times as
likely to show signs of bacterial leakage than were
posterior teeth.
To investigate the difterence between anterior and
posterior teeth in the incidence of turbidity, tbe presence of turbidity among all-porcelain crowns was
compared to tbe presence of turbidity among porcelain-fused-to-metal crowns separately for anterior and
posterior teetb. Among anterior teeth, all-porcelain
crowns bad the same incidence of turbidity (7/10;
70%) as porcelain-fused-to-metal crowns (14/20;
70%). However, Fisher's exact test indicated tbat pos30

terior teeth with all-porcelain crowns exhibited a significantly greater incidence of bacterial leakage (7/10;
70%) than did posterior teeth with porcelain-fused-tometal crowns (6/20; 30%) (P = 0.045).
Teeth were examined for signs of turbidity at 1week intervals over a 4-week period during tbe course
of the study. Of tbe 41 teeth demonstrating bacterial
leakage during the study, tbe greatest proportion of
turbidity was observed after 1 week (17/41; 41%). Tbe
number exhibiting turbidity declined over tbe course
of tbe study, as 9 of 41 (22%) exbibited turbidity at
both weeks 2 and 3 and only 6 of 41 (15%) demonstrated bacterial leakage at tbe fourth week.
All positive controls showed no turbidity (0%), and
all negative controls show complete turbidity (100%).
DISCUSSION

Wben cballenged witb bacteria, all materials in tbis

study sbowed significant leakage (51%). Tbis finding
was comparable to that of previous studies.*'''*
Although tbe difterence was not statistically significant,
all-metal crowns leaked less than did crowns composed of porcelain. Anterior crowns leaked the most,
regardless of tbe type of crown or restoration used.
The purpose of tbis study was to determine if any of
tbe dental materials in current clinical use bas the ability to prevent marginal leakage of tbe restorations in the
endodontic access cavities of permanently fixed crowns.
Tbe results indicated that all materials will leak, and
none of tbe tested restorations prevented tbe penetration of mobile bacteria into tbe root canalfillingspace.
Proteus vulgaris is a highly motile microorganism
tbat grows easily and remains viable in a simple
medium for extended periods. Furtbermore, tbe size of
P vulgaris is comparable to tbat of other microorganisms tbat have been identified to be of significance in
periradicular lesions.^^ Pivteus vulgaris is comparable
by gram-stain to endodontic pathogens, wbicb makes
it an effective organism relevant for tbe bacterial leakage model. Because its efticacy bas been demonstrated
in prior studies, tbis microorganism was chosen for
measuring bacterial leakage.*"'*'^^'2'
Nonsurgical root canal tberapy must be regarded as
incomplete until a proper coronal restoration is
placed. Tbe final restoration is essential to establishing
a barrier between tbe periradicular tissues and the oral
cavity.'"- An unfavorable coronal restorative material
will disrupt the seal of tbe root canal, bringing about
contamination of an otherwise favorable NSRCT.^*
Furthermore, tbe tecbnical quality of coronal restorations has been identified as significant, and more
important tban tbe tecbnical quality of tbe root treatment, to apical periodontal health.^'-^i Tberefore,
Volume 32. Number 1, 2001

Trautmann et al

leakage is an ongoing process pertinent to all aspects

of endodontic and restorative treatment.
Since the original use of adhesive restorations by
Buonocore,^2 ^^g ^gg Qf bonding agents has enhanced
chemical adhesion by materials that lack such properties. Although the nature of the bond between resin
and amalgam is not clear, it is believed that adhesive
resin liners reduce leakage more effectively than do
cavity varnishes,"-^'' Varnishes are believed to have
poor sealing properties when applied to dentin,"'*' The
combination of amalgam and bonding agent is considered to control marginal leakage and produce retentive
bonds between dentin and amalgam."""'^''*'' This study
showed no statistically significant difference between
varnish and bonding agent in combination with amalgam in the prevention of coronal leakage along the
restored margins of the endodontic access opening.
The concept that volumetric changes in resin
materials will hinder the retention of the material to
the tooth has become antiquated with the improvement in performance over the 4 generations of bonding. This improvement is the result of a better understanding of the permeability of the dentin surface,*"
the effect within the dentin collagen complex,''^ and
the wettability of the dentin substrate,"" In spite of
these improvements, leakage studies have identified
resin composites as having questionable marginal
integrity that still presents gap defects as avenues of
bacterial leakage,*'*""' These data agree with previous
authors, in that significant bacterial leakage (50%) was
found when composite restorations were used,'*^'*'
The ease of use and delivery makes glass-ionomer
cement a material of choice among practitioners,'**'
Nevertheless, when exposed to leakage testing, it demonstrates not only significant leakage but also significant
shrinkage and material washout, properties that make it
a poor choice as a permanent restorative material,'"' This
study corroborates these findings from a leakage perspective; although the difference between groups was not
statistically significant, 56% of specimens restored with
glass-ionomer cement showed bacterial turbidity.
Another aspect of coronal leakage that is important
is the challenge, by bacteria, of the integrity of the cast
restoration's margins with the pulpal space. Bacterial
lipopolysaccharide molecules have been found beneath
cast crowns within 1 week,"*'"** Therefore, the integrity
of the crown margins must be considered as a factor
that may affect the root canal filling and ultimately the
periradicular tissues.
CONCLUSION

A bacterial model was used to evaluate leakage of

restored endodontic access openings in permanently
Quintessence International

fixed crowns that have undergone nonsurgical root

canal therapy. The following conclusions were
reached:
1, All restorative materials leaked. There was no statistically significant difference among materials,
2, All-metal crowns showed less leakage than did
porcelain-containing crowns; however, these differences were not statistically significant,
3, Anterior crowned teeth had significantly more
leakage than did posterior crowned teeth.
Further evaluation of these findings is warranted to
identify a leakproof restorative material and technique.
ACKNOWLEDGMENTS
The authors acknowledge the support of the following companies:
Degussa-Ney Dental for providing all necessary materials and metals; Ivoclar North America for providing all porcelain and materials;
and Kerr Mfg and GC America for providing all restorative materials.
This research was supported in part by the Intramural Grant of the
Baylor College of Dentistry, a member of the Texas A&M University
System, Health Science Center.

REFERENCES
1. Goldman M, Laosonthorn P, White RR. Microleakage-FuU
crowns and the dental pulp. J Endod 1992;18:473-475.
2. Tjan AH, Miller GD, Whang SB, Sarkissian R. The effect of
thermal stress on the marginal seal of cast gold full crowns.
J Am Dent Assoc 1980;100:48-51.
3. Larson TD, Jensen JR. Microleakage of composite resin and
amalgam core material under complete cast crowns. J
Prosthet Dent 1980;44:40-44.
4. Kawamura RM, Swartz ML, Phillips RW, Dykema RW,
Davis WH. Marginal seal of cast full crowns: An in vitro
study. Gen Dent 1983 ;31:282-284.
5. Gutmann JL, Dumsha TC, Lovdahl PE, Hovland EJ.
Problem Solving in Endodontics: Prevention, Identification,
and Management, ed 3. St Louis: Mosby, 1997
6. Cox CF, Keall CL, Keall HJ, Ostro E, Bergenholtz GF.
Biocompatibility of surface sealed dental materials against
exposed pulps. J Prosthet Dent 1987;57:l-8.
7 Madison S, Wilcox LR. An evaluation of coronal microleakage in endodontically treated teeth. Part III. In vivo study.
J Endod 1988;14:455-458.
8. Torabinejad M, Ung B, Kettering JD. In vitro bacterial penetration of coronally unsealed endodontically treated teeth.
J Endod 1990;16:566-569.
9. Saunders WP, Saunders EM. Assessment of leakage in the
restored pulp chamber of endodontically treated multirooted teeth. Int Endod J 1990;23:28-33.
10. Magura ME, Kafrawy AH, Brown CE Jr, Newton CW.
Human saliva coronal microleakage in obturated root
canals: An in vitro study, J Endod 1991;17:324-331.

31

 Trautmann et al

11. Wu M-K, Wessenk PR. Endodontic leakage studies reconsidered. Part I. Methodology, application and relevance, Inf
Endod J 1993;26:37-43,
12. Saunders WP, Saunders EM, Coronal leakage as a cause of
failure in root-canal therapy: A review, Endod Dent Traumatol 1994;10:105-108.
13. Behrend G, Cutler C, Gutmann J. An in vitro study of smear
layer removal and microbial leakage along root canal fillings, Int Endod J 1996;29:99-107
14. Grossman LI. A study of the temporary fillings as hermetic
sealing agents, J Denf Res 1939;18:67-71.
15. Seltzer S, The penetration of microorganisms between the
tooth and direct resin fillings, J Am Dent Assoc 1955;51:
560-566.
16. Mortensen DW, Boucher NE, Gunnar R, A method of testing for marginal leakage of dental restoration with bacteria,
J Dent Res 1965;44:58-63.
17 Krakow AA, de Stoppelaar JD, Gron P. In vivo study of
temporary filling materials used in endodontics in anterior
teeth. Oral Surg Oral Med Oral Pathol t977;43:615-620,
18. Goldman LB, Goldman M, Kronman JH, Letourneau JM.
Adaptation and porosity of poly-HEMA in a model system
using two microorganisms, ] Endod 1980;6:683-686,
19. Chailertvanitkul P, Saunders WP, MacKenzie D, Coronal
leakage of obturated root canals after long-term storage
using a polymicrobial marker, J Endod 1997;23:610-613,
20. Chailertvanitkul P, Saunders WP, Saunders EM, MacKenzie
D, An evaluation of microbial coronal leakage in the
restored pulp chamber of root canal treated multirooted
teeth, Int Endod J 1997;30:318-322,
21. Chailertvanitkul P, Saunders WP, MacKenzie D, Coronal
leakage in teeth root-filled with gutta-percha and two different sealers after long-term storage, Endod Dent Traumatol
1997;13:82-87
22. Barrieshi KM, Walton RE, Johnson WT, Drake DR. Coronal
leakage of mixed anaerobic bacteria after obturation and
post space preparation. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1997;84:310-314,
23. Alves J, Walton R, Drake D. Coronal leakage: Endotoxin
penetration from mixed bacterial communities through
obturated, post-prepared root canals. J Endod 1998;24:
587-591,
24. Rosenstiel S, Land M, Fujimoto J. Contemporary Fixed
Prosthodontics, ed 2. St Louis: Mosby-Year Book, 1995.
25. Holt JC, Krieg NR, Sneath PHA, Staley JT, Williams ST
Bergey's Manual of Determinative Bacteriology, ed 9,
Baltimore: Williams & Wilkins, 1993,
26. Keller DL, Peters DD, Setterstrom J, Bernier WE.
Microleakage of softened temporary restorations as determined by microorganism penetration. J Endod
1981;7:413-417
27 Williams S, Goldman M. Penetrability of the smeared layer
by a strain oi Proteus vulgaris. J Endod 1985;11:385-388,
28, Jeffrey IW, Saunders WP, An investigation into the bond
strength between a root canal sealer and root-filling points,
Int Endod J1987;20:217-222,
29. Swanson K, Madison S, An evaluation of coronal microleakage in endodontically treated teeth. Part I, Time periods, J Endod 1987;13:56-59,

32

30. Wilcox LR, Diaz-Arnold A. Coronal microleakage of permanent lingual access restorations in endodontically treated
anterior teeth, J Endod 1989; 15:584-587
31. Ray HA, Trope M, Periapical status of endodontically
treated teeth in relation to the technical quality of the root
filling and the coronal restoration. Int Endod J 1995;28:
12-18,
32. Buonocore M. A simple method of increasing the adhesion
of acrylic filling materials to enamel surfaces. J Dent Res
1955:34:849-853.
33. Varga J, Matsumura H, Masuhara E. Bonding of amalgam
filling to tooth cavity with adhesive resin. Dent Mater 1986;
5:158-164,
34. Ben-Amar A, Nordenberg D, Liberman R, Fisher J, Gorfil C.
The control of marginal microleakage in amalgam restorations using a denfin adhesive, A pilot study. Dent Mater
1987;3:94-96,
35. Staninec M, Holt M. Bonding of amalgam to tooth structure: Tensile adhesion and microleakage tests, J Prosthet
Dent 1988;59:397-402.
36. Pashley EL, Comer RW, Parry EE, Pashley DH, Amalgam
build ups: Shear bond strength and dental sealing properties, Oper Dent 1991;16:82-89.
37 Dippel H, Borggreven JMPH, Hoppenbrauers PMM. The
sealing capacity of intermediary materials. J Prosthet Dent
1987;58:166-169.
38, Ben-Amar A, Reduction of microleakage around new amalgam restorations. J Am Dent Assoc 1989;119:725-728.
39, Shimizu A, Ui T, Kawakami. Microleakage of amalgam
restoration with adhesive resin cement lining, glass ionomer
cement base fluoride treatment. Dent Mater 1987;6:64-69.
40, Yu XY, Wei G, Xu JW. Experimental use of bonding agent to
reduce marginal microleakage in amalgam restorations.
Quintessence Int 1987;18:783-787
41, Pashley D, Pashley E. Dentin permeability and restorative
dentistry: A status report for the American Journal of Dentistry, Am J Dent 1991;4:5-9.
42, Kanca J. Resin bonding to wet substrate, I. Bonding to
dentin. Quintessence Int 1992;23:39-41.
43, Eick JD, Robinson SJ, Chappell RP, Cobb CM, Spencer P
The dentin surface: Its inftuence on dentinal adhesion. Part
IL Quintessence Int 1993;24:571-582,
44, Mejare B, Mejre I, Edwardsson S, Acid etching and composite resin restorations, A culturing and histologie study on
bacterial penetration, Endod Dent Traumatol 1987;3:l-5.
45, Qvist V. Resin restorations: Leakage, bacteria, pulp. Endod
Dent Traumatol 1993;9:127-152.
46, Briseo-Marroquin B, Kremers L, Willerhausen ZD, Mucki
A, Microleakage of gold casting repairs with different materials as quantified by a helium gas system. Oper Dent
1995;20:197-203.
47 Coleman AJ, Macromolecular leakage beneath full cast
crowns. Part I. The diffusion of lipopolysaccharide and dextran, J Prosthet Dent 1995;74:187-197
48. Coleman AJ. Macromolecular leakage beneath full cast
crowns. Part II. The diffusion of lipopolysaccharide and
dextran, J Prosthet Dent 1996;75:86-92,

Volume 32, Number 1, 2001