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ABSTRACT
Background. The authors compared the clinical performance of complex amalgam restorations, replacing at A D A J least one cuspretained either mechanically with self-threading pins or bondedwith a filled, 4N C methacryloxyethyl trimelli- A U I N G E D U 3 RT tate anhydride, or 4-META, ICLE based resin designed for amalgam bonding. Methods. The authors placed 60 amalgam restorations (28 pin-retained and 32 bonded), each restoration replacing at least one cusp. They used self-threading stainless steel pins in the pin-retained group and a filled, 4-METAbased bonding resin in the bonded group. For both groups, the authors left in place any retention form remaining after removal of an old restoration but did not enhance it. Results. At four years, six restorations had failed. At five years, of the 40 restorations available for evaluation, three had failed, for a total of nine failed restorations; seven of those were pin-retained and two were bonded. Using the Fisher exact test to compare the groups at five years, the authors found no significant difference in failure rate, marginal adaptation, marginal discoloration, secondary caries, tooth sensitivity or tooth vitality. Conclusions. At five years, there was no difference in the performance of pinretained amalgam restorations and bonded amalgam restorations. This study will be continued for at least a sixth year. Clinical Implications. Bonding with a filled, 4-METAbased bonding resin appears to be a satisfactory method of retaining large amalgam restorations replacing cusps.
A
T

The performance of bonded vs. pinretained complex amalgam restorations

A five-year clinical evaluation
J.B. SUMMITT, D.D.S., M.S.; J.O. BURGESS, D.D.S., M.S.; T.G. BERRY, D.D.S., M.A.; J.W. ROBBINS, D.D.S., M.A.; J.W. OSBORNE, D.D.S., M.S.D.; C.W. HAVEMAN, D.D.S., M.S.

or years, dentists have used mechanical resistance features such as threaded pins,1,2 boxes,3 amalgapins4 and slots5 to provide retention and resistance for complex amalgam restorations replacing cusps.6 Although these mechanical features have served well, each comes with its associated risk.6,7 These risks could be avoided if these features could be replaced by noninvasive means of providing retention and resistance for The bonding of the restoration.8 amalgam In 1989, Parkell introduced a 4methacryloxyethyl trimellitate anhyrestorations appears to be dride, or 4-META, based amalgam bonding system to U.S. dentistry. Other a viable companies since have developed alternative to amalgam bonding systems or have mechanical altered existing products to allow their retention of use for amalgam bonding. Many in restorations. vitro studies have evaluated the adhesive and cavity-sealing capabilities of these materials.9-13 In amalgam bonding, the mechanism by which the bonding resin attaches to tooth structure is identical to the mechanism by which resin-based composite attaches to dentin and enamel. The attachment of the bonding resin to the amalgam, however, is quite different from that of bonding resin to resin-based composite. The amalgam-to-resin attachment is entirely mechanical rather than chemical. Unset amalgam is condensed into the bonding resin on the tooth surface before it polymer-

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izes, thus incorporating fingers of resin into the tooth or teeth requiring restoration that included amalgam at the interface.14 at least one proximal surface and replacement of The mechanical attachment of amalgam to the one or more cusps. Teeth to be restored had at bonding resin is enhanced by the incorporation of least one proximal contact and occluded with natfiller particles, either organic or inorganic, into the ural or restored teeth. We took preoperative apical resin.15-18 A probable reason for this improvement radiographs of all teeth restored in the study. in attachment is that the filled bonding resin is Sixty teeth (57 molars and three premolars) were more viscous during condensation of the amalgam, restored with amalgam in the study, 28 using pin and this provides improved penetration of bonding retention and 32 using the amalgam bonding resin into the amalgam for increased mechanical system. For each mouth requiring more than one retention. restoration, a coin toss determined which tooth or In vitro studies have demonstrated that the teeth received bonded restoration(s) and which resistance to a shearing load created by amalgam received pin-retained restoration(s). For a mouth bonding can be equal to or greater than resistance in which there was only one restoration, we also provided by mechanical features such as pins.15,19,20 used the coin toss to determine which type of Other studies have revealed that Amalgambond restoration would be done; then, in the next Plus (Parkell), with its polymethyl methapatient who needed only one restoration, the other crylate filler, provides one of the type would be done. strongest bonds of amalgam to tooth Patients read and signed the conIn vitro studies structure.15,17,18,20-22 sent form, which had been approved have demonstrated by the institutional review board of Several clinical studies of bonded that the resistance to the University of Texas Health Sciamalgam restorations have been a shearing load cre- ence Center at San Antonio. Patients reported. Mahler and colleagues23,24 reported no difference between bonded excluded from participation in the ated by amalgam and nonbonded Class II amalgam bonding can be equal study were those who could not tolrestorations in tooth sensitivity two erate the procedures, those who had to or greater than weeks after insertion or in marginal compromised immune systems or resistance provided by compromised salivary flow, and those fracture after one year23 or three mechanical features who stated they would not be availyears.24 Belcher and Stewart25 comsuch as pins. pared the clinical success of complex able for long-term recall. amalgam restorations retained with Five operators, all faculty mempins against that of restorations bers and experienced clinicians retained with Amalgambond Plus, both with and (J.B.S., J.O.B., T.G.B., J.W.R., J.W.O.), placed the without filler powder. At two years, all restorarestorations. One of the authors (J.O.B.) calitions in all three groups were retained with minbrated the operators to guidelines concerning imal sensitivity, good marginal adaptation and no resistance features and the use of the bonding recurrent caries. Staninec and colleagues26 system. The operators confirmed pulpal vitality reported two-year success of bonded amalgam preoperatively via electric pulp testing and restorations in primary teeth. An in vivo study by thermal testing. In each case, the clinician took a Smales and Wetherell27 evaluated 366 bonded preoperative radiograph to ensure that there was amalgam restorations using five bonding mateno radiographic evidence of pulpal pathosis. Operrials. Cuspal coverage was accomplished in 178 of ators used rubber dam isolation during tooth the 366 restorations. They reported a 98.6 percent preparation, amalgam placement and initial success rate at up to five years.27 carving of all restorations. We undertook a clinical study to compare the For both groups, any retention form remaining failure rates, marginal adaptation, marginal disafter removal of an old restoration was left intact coloration, secondary caries rates, sensitivity and but was not enhanced. For all restorations, tooth vitality of bonded and pin-retained complex enough occlusal tooth structure was missing or amalgam restorations. In this article, we report was removed to ensure at least 2 millimeters of the results after five years. amalgam thickness in all occlusal areas of the restorations. A total of 60 teeth were restored in SUBJECTS, MATERIALS AND METHODS the mouths of 28 patients. Patients selected for the study had a posterior The guideline for pin placement stated that one
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Figure 1. A bonded restoration in tooth no. 31 that had no mechanical resistance or retention features. A. Preoperative view. B. Preparation. C. Restoration immediately after completion with occlusal contacts marked and all excursive contacts removed. D. Occlusal view after five years.

vertical pin was used for each missing cusp, with a maximum of four vertical pins in any single restoration. Horizontal pins were placed at the operators discretion. We used TMS (Thread-Mate System, Coltne-Whaledent) Minim (0.024-inch diameter) vertical pins and Minikin (0.019-in. diameter) horizontal pins. The operators prepared pin channels with depth-limiting TMS pin channel drills to a depth of 2 mm for Minim pins and 1.5 mm for Minikin pins. They applied two coats of Copalite (Cooley & Cooley) varnish after preparing the pin channel, placed the pin, then placed a stainless steel matrix. The operators used no added mechanical retention form for the resin-bonded restoration group; instead, they used the Amalgambond Plus (Parkell) bonding system. The operator placed a stainless steel matrix before using any portion of the bonding system. The instructions for Amalgambond Plus state that it may be used either with or without incorporation of a polymethyl methacrylate filler powder called high-performance additive, or HPA, powder. In all bonded restorations in this study, operators used the HPA powder, following the manufacturers instructions to achieve extra retention. The Amal-

gambond Plus was refrigerated at a temperature of approximately 40 degrees until immediately before its use. The dentin activator (10 percent citric acid and 3 percent ferric chloride) was applied in accordance with manufacturers instructions (approximately 30 seconds to enamel and 10 seconds to dentin). The operator rinsed the prepared tooth surface with air/water spray and briefly dried it with air. The adhesive agent (containing hydroxyethyl methacrylate) was applied to all prepared surfaces, gently thinned with an airstream and left undisturbed for at least 30 seconds. Components of the resin adhesive (three drops of base, one scoop of HPA powder and one drop of catalyst) were mixed together while a spherical amalgam (Tytin, Kerr) was being triturated. The operator coated all walls of the preparation with the resin adhesive using a Kerr Applicator (Kerr) (Figure 1) to provide a thin coat of the material. The operators hand-condensed Tytin amalgam. For the pin-retained restorations, the operators inserted the amalgam and spread it over preparation floors so that increments of no more than 1 mm in vertical thickness were condensed. They used both vertical and horizontal condensation
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Figure 2. A pin-retained restoration in tooth no. 15. A. Preoperative view. B. Preparation after pin placement. C. Restoration immediately after completion. D. Restoration after five years.

strokes. In the restorations made with bonding resin, the operators inserted and condensed the amalgam against all walls within one minute from the start of the mixing of the Amalgambond Plus. After all walls were covered with amalgam, operators inserted additional increments of amalgam and condensed them using the same method as described for the pin-retained group. Amalgam was condensed to a vertical height approximately 1 mm in excess of the predicted occlusal extent of the restoration. The operator shaped the occlusal surface of each restoration with burnishers and carvers before removing the matrix. He then removed the matrix and carved the restoration to proper anatomical form. After removing the rubber dam, the operator adjusted the occlusion to provide contact in maximum intercuspation (centric occlusion) and to eliminate contact in eccentric mandibular excursions. He then smoothed the amalgam surface using wet flour pumice in a rubber cup in a low-speed handpiece running at low speed; burnishers also were used. Restorations were not polished. The operator took preoperative photographs of the preparation and of the restored tooth, both
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immediately after completion of the restoration and at each recall appointment. Figures 1 through 3 are representative photographs of teeth taken preoperatively of preparations, of restorations immediately after placement and of the same restorations at five years. One of the authors (J.O.B.) calibrated the evaluators in the use of an explorer to detect marginal discrepancies and in criteria and methods for determining tooth sensitivity, tooth vitality, marginal discoloration and secondary caries. Patients returned for a baseline evaluation as close to one week postoperatively as possible. We also recalled patients for evaluation at six months, one year, two years, three years, four years and five years after restoration. At each recall evaluation, the operators confirmed tooth vitality thermally and with an electric pulp tester, and they assessed tooth sensitivity thermally. In addition, they evaluated marginal integrity, marginal discoloration and secondary caries using modified Cvar/Ryge28 criteria (Table 1). The operator assessed sensitivity by using a cotton pellet or the tip of a cotton-tipped applicator, saturated with a thermal pulp tester. The cold stimulus was placed first on the facial sur-

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Figure 3. A bonded restoration in tooth no. 14. A. Preoperative view. B. Preparation, showing gingivally deep extension in mesial aspect. C. Restoration immediately after completion. D. Restoration after five years.

face of a nonrestored, noncarious tooth (control), then on the facial surface of each restored tooth. The patient rated the sensation in each restored tooth as the same as, more than or less than that in the control tooth.
RESULTS

Tables 2 and 3 (pages 929 and 930) display the results. Two bonded restorations of the 60 total did not meet selection criteria for the study and were excluded from consideration. Among the 28 total patients, two patients with three restorations between them (two pin-retained and one bonded) did not return for baseline evaluation and therefore were eliminated from the study. One patient with two restorations (one pinretained and one bonded) was lost from the study after baseline and before the six-month evaluation. One patient, who had one bonded restoration and one pin-retained restoration, was lost to the study after the six-month evaluation owing to a stroke. Another patient, who had a bonded restoration, did not return after the one-year recall. Three patients with a total of three bonded restorations and two pin-retained restorations were unavailable for the five-year recall because

they had moved away; at four years, all five of those restorations were performing satisfactorily. Of the remaining 46 restorations (23 bonded and 23 pin-retained), six (five pin-retained and one bonded) had failed before the five-year recall, leaving 40 restorations (18 pin-retained and 22 bonded) available for evaluation at five years. At the five-year recall, three more restorations (two pin-retained and one bonded) were found to have failed, for a total of nine failed restorations in the study. Restorations were classified as having failed when the restoration had to be replaced or required major repair, or when the tooth needed endodontic treatment or extraction. Failures fell into the following categories: dneed for endodontic therapytwo molars restored with pin-retained restorations required endodontic therapy, one after six months but before the one-year evaluation and one at the two-year evaluation; both were successfully restored after endodontic therapy; dsignificant tooth fracture adjacent to restorationthree molars restored with pin-retained restorations suffered significant fracture (one each at years one, three and four) but were restorable; one molar restored with a bonded
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TABLE 1

MODIFIED CVAR/RYGE CRITERIA* USED TO EVALUATE RESTORATIONS.

CRITERION Marginal Adaptation RATING Alfa () Bravo () DESCRIPTION Margins closed; explorer does not catch Crevice exists; explorer penetrates at interface and catches when moved from tooth surface to restoration surface and restoration to tooth; dentin not exposed Crevice evident, with dentin exposed No discoloration anywhere along the margin Discoloration is present but has not penetrated in a pulpal direction along the margin Discoloration has penetrated in a pulpal direction No caries present Caries present Less than or equal to that of control tooth More than that of control tooth Tooth vital Tooth nonvital; endodontic therapy required

Charlie (C) Marginal Discoloration Alfa () Bravo ()

Charlie (C) Alfa () Charlie (C) Tooth Sensitivity Alfa () Bravo () Tooth Vitality Alfa () Charlie (C)

Secondary Caries

* Based on information from Cvar and Ryge.28

restoration suffered significant fracture, including root fracture, at year five and was extracted; dsecondary cariesone molar restored with a bonded restoration had secondary caries (adjacent to the restoration) at year four, and two molars restored with pin-retained restorations had secondary caries (adjacent to the restorations) at year five; all carious teeth were restorable. We used the Fisher exact test to compare the failure rate of the two restoration groups, bonded and pin-retained. There was no significant difference in failure rate (P = .071) at five years. In addition, using the Fisher exact test, at five years, we found no significant difference between groups in marginal adaptation (P = .058), marginal discoloration (P = .066), secondary caries (P = .579), sensitivity (P = .500) or tooth vitality (P = .206). During the five years of the study, the only time at which there was a significant difference in tooth sensitivity was at six months (P = .013). Bonded restorations were performing as well
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as pin-retained restorations in all categories at five years.

DISCUSSION

Published results of clinical studies have shown bonded amalgam restorations to function well for periods up to two years.23-27,29 In these studies, researchers compared bonded amalgam restorations with mechanically retained amalgam restorations. The researchers reported that the bonded restorations were performing as well as the mechanically retained restorations. The restorations in our study yielded similar findings. This study involved replacement of at least one cusp with amalgam, and many of the restorations in the study replaced two or more cusps. These large restorations were exposed to more stress during function than simple Class I or Class II amalgam restorations, and there were more failed restorations in our study than in studies of smaller restorations. Several clinical investigations have demon-

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TABLE 2

RATINGS FOR PIN-RETAINED RESTORATIONS BY TIME OF SERVICE.

CRITERION Baseline Marginal Adaptation 26 NO. OF RESTORATIONS RECEIVING RATING AT EACH TIME POINT* 6 Months 25 1 Year 20 3 1 C Marginal Discoloration Secondary Caries Tooth Sensitivity Tooth Vitality 26 25 23 2 Years 17 5 1 C 22 3 Years 12 9 2 C 21 4 Years 10 10 3 C 17 3 26 25 23 22 21 20 5 Years 6 10 3 C 11 5 16 2 C 11 15 26 7 18 25 4 19 23 1 C 13 9 22 2 C 13 8 21 2 C 11 9 20 2 C 5 11 16 2 C

* : Alfa. : Bravo. C: Charlie. For descriptions, see Table 1. If a restoration was rated C, a failure, in a particular category, that rating was carried on to future ratings. If, however, the rating was before failure of the restoration for another reason or before loss of the patient to the study, the rating was not carried forward. When a C rating was assigned in one category during a periodic evaluation, none of the other categories was rated in that evaluation.

strated no difference in sensitivity between teeth restored with or without bonding.23-25,27,29,30 Other studies, however, have shown reduced thermal sensitivity when the amalgam restorations were bonded.31,32 One of these, reported by Davis and Overton,26 involved teeth that had had symptoms of incomplete tooth fracture before restoration. They found sensitivity to a cold-temperature stimulus (skin refrigerant) to be reduced in the bonded restorations at three and 12 months after placement, compared with baseline. In contrast, restorations that were based and not bonded demonstrated no reduction in thermal sensitivity. In another study, Hadi and colleagues32 compared amalgam restorations bonded with Amalgambond Plus to restorations in which a cavity varnish (Copaliner, Harry J. Bosworth) was used. They surveyed patients the day after restorations were placed and found significantly less sensitivity in the bonded group. In our study, we found no difference in sensitivity between bonded and nonbonded restorations at any point except at six months. The lack of a difference at baseline is similar to the results of the study by Davis and Overton.31 This absence of difference at baseline possibly could be the

result of recent mechanical trauma during tooth preparation that opened dentinal tubules, predisposing teeth with both bonded and nonbonded restorations to minor postoperative thermal sensitivity. At six months in our study, and at three and 12 months in the Davis and Overton study, teeth with bonded restorations exhibited less sensitivity than those with nonbonded restorations. This difference might have been caused by improved sealing of tubules provided by the resin adhesive and the elapsed time since restoration. Marginal discoloration is not a criterion for evaluation of amalgam restorations in most studies. We included it in this study because of the ability, in some areas, to see into the bonding resin. We made no attempt to discriminate staining at the amalgam-resin interface from that at the amalgam-enamel interface. This study will continue for at least a sixth year to gain additional information. It should be noted that several of the bonded restorations in this study had little or no mechanical retention form (Figure 1), yet none of them had dislodged. It is interesting that even though the bond strength provided by amalgam bonding agents for amalgam is lower than the bond strength pro929

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TABLE 3

RATINGS FOR BONDED RESTORATIONS BY TIME OF SERVICE.

CRITERION Baseline Marginal Adaptation 29 NO. OF RESTORATIONS RECEIVING RATING AT EACH TIME POINT* 6 Months 28 1 Year 27 2 Years 23 3 3 Years 20 6 4 Years 19 6 5 Years 15 6 1 C Marginal Discoloration Secondary Caries Tooth Sensitivity Tooth Vitality 29 28 27 26 26 24 1 29 28 27 26 26 25 1 C 18 11 29 18 10 28 11 16 27 11 15 26 15 11 26 18 7 25 20 1 21 1 C 10 11 21

* : Alfa. : Bravo. C: Charlie. For descriptions, see Table 1. If a restoration was rated C, a failure, in a particular category, that rating was carried on to future ratings. If, however, the rating was before failure of the restoration for another reason or before loss of the patient to the study, the rating was not carried forward. When a C rating was assigned in one category during a periodic evaluation, none of the other categories was rated in that evaluation.

vided by bonding agents for resin-based composite, it seems to be adequate even in very large restorations. This perhaps is because of the fact that amalgam does not exert a significant stress on the bonding mechanism as it sets, whereas resin-based compositebecause of polymerization shrinkagedoes.
CONCLUSIONS

the bonding of amalgam restorations appears to be a viable alternative to mechanical retention of restorations. s

The authors thanks go to Cheng H. Yuan, Ph.D., for statistical support for this study and to Parkell for providing partial funding for the study.

Amalgambond Plus, with HPA powder, is retaining complex amalgam restorations well at five years. In view of the results of this and other studies,
Dr. Summitt is a professor, Division of Operative Dentistry, Department of Restorative Dentistry, University of Texas Health Science Center at San Antonio, Dental School, Mail Code 7890, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900, e-mail summitt@ uthscsa.edu. Address reprint requests to Dr. Summitt.

1. Markley MR. Pin reinforcement and retention of amalgam foundations. JADA 1958;56:675-9. 2. Going RE. Pin retained amalgam. JADA 1966;73:619-24. 3. Birtcil RF, Venton EA. Extracoronal amalgam restorations utilizing available tooth structure for retention. J Prosthet

Dr. Burgess is a professor and chairman, Department of Operative Dentistry and Biomaterials, Louisiana State University Health Sciences Center, New Orleans.

Dr. Berry is a professor, Department of Restorative Dentistry, University of Colorado School of Dentistry, Denver.

Dr. Robbins is in private practice in San Antonio and is a clinical professor, Department of General Dentistry, University of Texas Health Science Center at San Antonio, Dental School, San Antonio.

Dr. Osborne is a professor and the director of clinical research, Department of Restorative Dentistry, University of Colorado School of Dentistry, Denver.

Dr. Haveman is an associate professor, Department of General Dentistry, University of Texas Health Science Center at San Antonio, Dental School, San Antonio.

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Dent 1976;35:171-8. 4. Shavell HM. The amalgapin technique for complex amalgam restorations. J Calif Dent Assoc 1980;8:44-55. 5. Outhwaite WC, Garman TA, Pashley DH. Pin vs. slot retention in extensive amalgam restorations. J Prosthet Dent 1979;41:396-400. 6. Robbins JW, Burgess JO, Summitt JB. Retention and resistance features for complex amalgam restorations. JADA 1989;118:437-42. 7. Webb EL, Straka WF, Phillips CL. Tooth crazing associated with threaded pins: a three-dimensional model. J Prosthet Dent 1989; 61:624-8. 8. Gwinnett AJ, Baratieri LN, Monteiro S. Jr., Ritter AV. Adhesive restorations with amalgam: guidelines for the clinician. Quintessence Int 1994;25(10):687-95. 9. Charlton DG, Moore BK, Swartz ML. In vitro evaluation of the use of resin liners to reduce microleakage and improve retention of amalgam resotrations. Oper Dent 1992;17:112-9. 10. Bagley A, Wakefield CW, Robbins JW. In vitro comparison of filled and unfilled universal bonding agents of amalgam to dentin. Oper Dent 1994;19:97-101. 11. Ben-Amar A, Liberman R, Rothkoff Z, Cardash HS. Long-term sealing properties of Amalgambond under amalgam restorations. Am J Dent 1994;7:141-3. 12. Winkler MM, Moore BK, Allen J, Rhodes B. Comparison of retentiveness of amalgam bonding agent types. Oper Dent 1997;22:200-8. 13. Winkler MM, Moore BK, Rhodes B, Swartz M. Microleakage and retention of bonded amalgam restorations. Am J Dent 2000;13:245-50. 14. Nakabayashi N, Watanabe A, Gendusa NJ. Dentin adhesion of modified 4-META/MMA-TBB resin: function of HEMA. Dent Mater 1992;8:259-64. 15. Imbery TA, Burgess JO, Batzer RC. Comparing the resistance of dentin bonding agents and pins in amalgam restorations. JADA 1995;126:753-9. 16. Bagley A, Wakefield CW, Robbins JW. In vitro comparison of filled and unfilled universal bonding agents of amalgam to dentin. Oper Dent 1994;19:97-101. 17. Diefenderfer KE, Reinhardt JW. Shear bond strengths of 10 adhesive resin/amalgam combinations. Oper Dent 1997;22:50-6. 18. Miller B, Chan DC, Cardenas HL, Summitt JB. Powder additive effect on shear bond strengths of bonded amalgam (abstract 1346). J

Dent Res 1998;77(special issue A):274. 19. Burgess JO, Alvarez A, Summitt JB. Fracture resistance of complex amalgam restorations. Oper Dent 1997;22:128-32. 20. Rosen AT, Hermesch CB, Summitt JB. Resistance of bonded complex amalgam restorations with and without pins (abstract 383). J Dent Res 1998;77 (special issue A):153. 21. Vargas MA, Denehy GE, Ratananakin T. Amalgam shear bond strength to dentin using different bonding agents. Oper Dent 1994;19:224-7. 22. Ramos JC, Perdigao J. Bond strengths and SEM morphology of dentin-amalgam adhesives. Am J Dent 1997;10:152-8. 23. Mahler DB, Engle JH, Simms LE, Terkla LG. One-year clinical evaluation of bonded amalgam restorations. JADA 1996;127:345-9. 24. Mahler DB, Engle JH. Clinical evaluation of amalgam bonding in Class I and II restorations. JADA 2000;131:43-9. 25. Belcher MA, Stewart GP. Two-year clinical evaluation of an amalgam adhesive. JADA 1997;128:309-14. 26. Staninec M, Marshall GW, Lowe A, Ruzickova T. Clinical research on bonded amalgam restorations, 1: SEM study of in vivo bonded amalgam restorations. Gen Dent 1997;45(4):356-62. 27. Smales RJ, Wetherell JD. Review of bonded amalgam restorations and assessment in a general practice over 5 years. Oper Dent 2000;25:374-81. 28. Cvar JF, Ryge G. Criteria for the clinical evaluation of dental restorative materials. San Francisco: U.S. Department of Health, Education, and Welfare, Public Health Service, National Institutes of Health, Bureau of Health Manpower Education, Division of Dental Health, Dental Health Center; 1971. 29. Kennington LB, Davis RD, Murchison DF, Langenderfer WR. Short-term clinical evaluation of post-operative sensitivity with bonded amalgams. Am J Dent 1998;11:177-80. 30. Browning WD, Johnson WW, Gregory PN. Clinical performance of bonded amalgam restorations at 42 months. JADA 2000;131:607-11. 31. Davis RD, Overton JD. Efficacy of bonded and nonbonded amalgam in the treatment of teeth with incomplete fractures. JADA 2000;131:469-78. 32. Hadi Z, Rosenstiel SF, Rashid RG. A comparison of post-treatment sensitivity using adhesive cavity liner vs conventional cavity varnish (abstract 1335). J Dent Res 1998;77(special issue A):272.

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