Microleakage : a review

Edwina A. M. Kidd, BDS, PhD, FDS RCS

Department of Conservative Dentistry, School of Dental Surgery, Royal Dental Hospital of London

ABSTRACT chemically bond to tooth substance to form a

Microleakage may be defined as the passage of perfect seal capable of withstanding the moist
bacteria, fluids, molecules or ions between a oral environment and its attendant temperature
cavity wall and the restorative material applied fluctuations.
to it.
Many techniques have been devised to test the IN VITRO DETECTION OF
cavity-sealing properties of restorations both in MICROLEAKAGE
vitro and in viva. These techniques include the
use of dyes, radioactive isotopes, air pressure, Many laboratory techniques have been developed
bacteria, neutron activation analysis, artificial to study marginal permeability at the interface
caries and scanning electron microscopy. Some between tooth and restoration. These include
form of thermal stressing has frequently been the use of dyes, radioactive isotopes, air pressure,
included in the experimental protocol. bacteria, neutron activation analysis and artificial
Research has shown that freshly packed caries techniques. The results of these studies
amalgam restorations leak but that this leakage emphasize that margins of restorations are not
tends to decrease as fillings age. Cavity varn- fixed, inert and impenetrable borders, but ‘dyna-
ishes and liners reduce initial leakage of the mic microcrevices which contain a busy traffE of
material. Many of the tooth-coloured restorative
ions and molecules’ (Myers, 1966).
materials in common use have been shown to
leak. Acrylic restorations appear particularly
susceptible to leakage after thermal stressing. Dyes and radioactive isotopes
There is some evidence that the newer composite The use of organic dyes as tracers is one of the
materials may form a good cavity seal. oldest but commonest methods of microleakage
detection. Early experiments were carried out in
glass tubes roughened to simulate the dental
INTRODUCTION tissue surface (Grossman, 1939; Massler and
Much attention has been focused on the problem Ostrovsky, 1954), but later work has involved
of microleakage in the past 25 years and it has the use of extracted human or bovine teeth. In
been implicated in a variety of conditions, includ- general, the method involved placing a restora-
ing recurrent caries, tooth discoloration under tion in an extracted tooth and immersing the
amalgams, hypersensitivity of restored teeth, specimen in the dye solution. After an interval
pulpal damage and a hastening of the breakdown of time the tooth was removed, washed,
of certain filling materials. Black (1936) empha- sectioned and examined to establish the extent
sized that filling materials should be adaptable to of penetration of the dye around the filling
cavity walls and free of dimensional changes once material.
placed in the oral environment. Today we are Radioactive salts (usually 4sCa) have been
still seeking a restorative material which will used extensively in a similar manner, but in
200 Journal of Dentistry, Vol. ~/NO. 5

these experiments autoradiographs were taken dentine shavings from the base of the cavity
of the cut surfaces of specimens to detect the cultured.
tracer (Armstrong and Simon, 1951). In both More recently, Mortensen et al. (1965) devel-
dye and isotope experiments results were quanti- oped a method of isolating the filled crown of a
fied by assigning numerals to defined depths of tooth from its root using a plastic tube sealed
penetration (Going et al., 1960). This somewhat with epoxy resin. Inoculated broth was placed
subjective method of quantification is one dis- over the crown and sterile broth in contact with
advantage of the technique (Going, 1972). In the root of the tooth. Microleakage was diag-
addition, Roydhouse (1968) has questioned nosed if the sterile broth turned cloudy.
whether the potential for microleakage demon- Unfortunately, all these bacterial tests have
strated by experiments carried out in vitro the disadvantage that results have been qualita-
was a reality in vivo where such factors as tive rather than quantitative. It might also be
pulpal hydrostatic pressure must be taken into argued that the microleakage detected is gross
account. if bacterial size be compared with that of the
hydrogen ion.
Air pressure
Air pressure was used in the detection of micro- Neutron activation analysis
leakage as early as 1912 when Harper con- Neutron activation analysis has been used by
structed Class II amalgam restorations in a steel Going et al. (1968) to study microleakage both
dye, delivered air under pressure to the floor of in vitro and in vivo. The restored teeth were
the cavity and examined the restorations under soaked in an aqueous solution of a non-
water. radioactive manganese salt. AI1 salts adhering to
A similar technique has been used in human the outside of the tooth were removed. Whole
teeth, air being delivered to the base of Class V teeth were then placed in the core of a nuclear
restorations via the pulp chamber. Acrylic reactor; the s*Mn was activated to 56Mn and the
(Fiasconaro and Sherman, 1952) and amalgam X-ray emission of %Mn formed during irradia-
(Pickard and Gayford, 1965) have been inves- tion was measured. The number of radioactive
tigated in this manner. The latter workers devel- counts was proportional to the uptake of Mn per
oped a reproducible method of measuring the tooth. Going (1972) pointed out that this method
degree of leakage around the periphery of restora- had the advantage that results could be quanti-
tions and were able to study microleakage over fied, but he also highlighted the limitations of
a period of time as examination of the specimen the technique. These were that teeth must be
did not necessitate its destruction. extracted for irradiation and analysis, the path
and depth of tracer penetration was not well
Bacteria defined unless serial sections were made (this
The use of bacteria in the study of microleakage would have been a safety hazard), experimental
would seem a more clinically orientated test than costs were high and a combined effort was
any mentioned so far. A microleakage experi- required from nuclear engineers and dentists. A
ment involving bacteria was developed as early further problem has been demonstrated by
as 1929 when Fraser tested cements and filling Meyer et al. (1974), who attempted to use the
materials to determine whether they would allow technique to compare microleakage around com-
bacteria to pass through or around them. Later posite resins and silicate cements. They noted
workers, investigating the marginal seal of acrylic that the presence of manganese, either in the
restorations (Rose et al., 1955; Seltzer, 1955), tooth or in the restorative material, caused
placed filed teeth in broth cultures. The fill- variability of the results, and they suggested
ing materials were subsequently removed and dysprosium as an alternative tracer.
Kidd: Microleakege 201

Artificial caries As has been pointed out by Going (1972), the

Artificial secondary caries-like lesions have been scanning electron microscope technique has a
produced in vitro using either bacterial cultures potential for the introduction of artefacts dur-
or a chemical system-the acidified gelatin gel ing specimen preparation. The use of a replica
technique. technique may overcome this problem, but the
In 1967 Ellis and Brown used a bacterial tech- results are still difficult to quantify and not
nique, developed some 5 years earlier by Brown related to diffusion and penetration, as are most
et al. (1962), to produce artificial caries at the microleakage experiments. At our present state
interface of the amalgam restoration and the of knowledge it is probably unwise to equate
tooth. Thus they linked the development of cari- cavity adaptation, as seen in the scanning micro-
ous lesions with microleakage, but they did not scope, with microleakage; more work is needed
describe the histological features of the lesions in this field.
that they produced. Thermal cycling
The acidified gelatin gel technique as developed
by Silverstone (1967) has been used by Rodda One of the essential physical properties of a den-
(1970), Hals and Nernaes (1971), Grieve (1973) tal filling material is that it should retain its
and Kidd (1975) to produce artificial lesions size and form after it is placed and contoured in
around restorations. The appearance of lesions in a tooth. As early as 1929 Fraser suggested the
polarized light has been described as consisting ofpossible importance of variations in tempera-
two parts: an ‘outer’ lesion and a ‘cavity wall’ ture on the marginal adaptation of restorative
lesion. The outer lesion showed the features of materials.
primary attack, while the cavity wall lesion In 1952 Nelsen et al. carried out some classic,
was formed by microleakage of ions from the and much quoted, experiments to study the
acidified gelatin gel into the restorationdental opening and closing of margins of restorations
tissue interface. which were subjected to temperature changes.
The use of an artificial caries system in the Extracted and filled teeth were immersed in iced
study of microleakage has the advantage that water, dried and viewed under a binocular micro-
microleakage may be linked directly with the scope. As the teeth were warmed in the fingers,
development of the artificial lesion. Quantifica- droplets of fluid were seen to exude from the
tion of results is possible where depth of lesion margins of the restorations. Amalgam, gold
penetration is chosen as a measurable parameter inlays, gold foil, silicate, gutta-percha, zinc oxide
(Kidd, 1975). Degree of demineralization may and eugenol and acrylic resin were all seen to
also be used but relies on subjective assessment leak in this manner. It was suggested that mar-
(Grieve, 1973). ginal percolation was caused by a difference in
the coefficient of thermal expansion between the
Scanning electron microscopy dental tissues and the restorative material and
The scanning microscope provides a means of by thermal expansion of fluids occupying the
direct visual observation of the adaptation of crevice between tooth and restoration.
restorative materials to cavity margins (Boyde Subsequently, many workers investigated the
and Knight, 1969). An attempt has been made to effects of temperature changes when carrying
correlate microleakage of radioactive isotopes out microleakage experiments. The transference
with fissure size between tooth and restoration as of specimens from hot to cold solutions became
seen in the scanning electron microscope (Lee known as ‘temperature cycling’. The technique
and Swartz, 1970). No direct correlation was has been combined with dye, isotope, air pres-
found, which led the authors to suggest that sure and bacterial studies. It has not yet
improved leakage tests were required. been reported in conjunction with neutron
202 Journal of Dentistry, Vol. ~/NO. 5

activation analysis and the artificial caries Attempts have therefore been made to carry
technique. out microleakage experiments in vivo and com-
The temperatures used in cycling procedures pare the results with comparable research in
have varied, with the majority of investigators vitro. Unfortunately, such comparisons have
using 4 “C combined with 60 ‘C, or 15 “C com- yielded conflicting results. Using a fluorescein
bined with 45 “C!. Nelsen et al. (1952) estimated dye method (Loiselle et al., 1969; Stuever et al.,
the limits of oral thermal tolerance to be 60 and 1971), microleakage in vivo was found to be less
4 ‘C, whereas a more recent study (Plant et al., than that in vitro. Results of isotope studies
1974) found that whilst subjects would sip hot (McCurdy et al., 1974) and artificial caries
coffee at 60 ‘C, they could drink it comfortably studies (Hals and Nernaes, 1971; Hals and
between 50 and 55 *C. Peterson et al. (1966) Simonsen, 1972) showed little difference
investigated the temperature at the surface of a between in vivo and in vitro results, whilst neu-
tooth when hot coffee (60 “C) and iced water tron activation analysis (Going et al., 1968)
(0 “C) were drunk alternately. Under normal found more leakage in vivo than in vitro.
drinking conditions the temperature at the tooth
surface ranged from 45 to 15 ‘C. It would thus
seem that the latter temperatures are more clini- MICROLEAKAGE AROUND
cally realistic than 60 and 0 “C. AMALGAM RESTORATIONS
The time of immersion of specimens in hot The cavity-sealing properties of amalgam have
and cold solutions has varied from a few seconds been extensively investigated. Experiments using
to several hours, with most investigators using isotopes, bacteria, air pressure, neutron activa-
30- or 60-second exposure times. The number of tion analysis and artificial caries techniques
temperature cycles employed has ranged from have all shown extensive microleakage around
1 to 2500. Peterson et al. (1966) reported greater the freshly packed amalgam restoration. How-
microleakage with an increased number of cycles ever, it should be noted that the majority of dye
when resin restorative materials were tested. experiments have failed to reveal leakage, even
Results of temperature cycling experiments after temperature cycling (Hirsch and Weinreb,
have almost invariably shown increased leakage 1958; Going et al., 1960; Parris and Kapsimalis,
after subjection of specimens to thermal treat- 1960; Kakar and Subramanian, 1963; Pinto and
ment. It is obvious that some form of thermal Buonocore, 1963). Only the fluorescent dye,
stressing should be incorporated in microleakage fluorescein, has been shown to penetrate the
work. interface between amalgam and tooth (Christen
and Mitchell, 1966; Loiselle et al., 1969).
When the freshly packed amalgam restoration
IN VIVO DETECTION OF was shown to leak research workers questioned
MICROLEAKAGE whether restorations present in the mouth for
Although some attempts have been made to age some time would also leak. In 1952 Nelsen et al.
restorations in uivo prior to their extraction noted marginal percolation from temperature
(Going et al., 1960; Phillips et al., 1961), remark- changes to be less in old amalgam than in freshly
ably few microleakage experiments have been packed restorations and suggested that this
carried out on living animals. The value of in might be due to the formation of corrosion pro-
vitro tests for microleakage has been questioned, ducts. This observation was further investigated
since such experiments eliminate the effect of by placing restorations in vivo and allowing these
pulpal hydrostatic pressure and plaque on the to age before the teeth were extracted. An iso-
restoration surface (Roydhouse, 1968; J_oiselle tope microleakage test demonstrated less micro-
et al., 1969). leakage in older restorations (Phillips et al.,
Kidd: Microleakage 203

1961). Subsequently, several workers artificially was probably due to a difference in their coeffici-
aged amalgam restorations in vitro using tap ents of thermal expansion.
water (Swartz and Phillips, 196 l), saliva (Stowell Comparatively few microleakage experiments
et al., 1962; Lye11 et al., 1964; Going and Sawin- have been carried out on the newer composite
ski, 1966) or sulphide solutions (Lye11 et al., materials, although the composite material
1964). Results again confirmed that there was Addent has been shown to form a good initial
less microleakage around the aged restorations. seal, with an increase in leakage after tempera-
Pickard and Gayford (1965) attributed this ture cycling (Going and Sawinski, 1966; Peter-
phenomenon to the formation of corrosion pro- son et al., 1966; Tani and Buonocore, 1969). Lee
ducts or organic accretions at the amalgam- and Swartz (1970) examined the marginal adapta-
dental tissue interface. Thus, the corrosion tion of composite resins in a scanning electron
property of the alloy, a property long deplored microscope study. This work incorporated an
by clinicians, may be responsible for its success isotope study to assess leakage together with
for long periods of clinical service. temperature cycling. Unfortunately, experiments
Once research workers had demonstrated the were carried out on very few specimens and it
poor sealing ability of the freshly packed amal- was difficult to draw meaningful results. How-
gam restoration it was logical to attempt to pre- ever, one composite, Adaptic, showed closer
vent this. In the past 25 years many workers have cavity adaptation and less isotope leakage than
shown that a cavity varnish applied both to the the other materials tested.
walls and floor of the cavity is effective in reduc- Brannstrdm and Nyborg (1971) placed com-
ing microleakage (Going and Massler, 1961; posite’ restorations in viva, and after a period of
Phillips et al., 1961; Swartz and Phillips, 1961; time extracted the teeth and examined them his-
1962; Barber et al., 1964; Dolven, 1966; Christen tologically for the presence of bacteria between
and Mitchell, 1966; Ellis and Brown, 1967; the restoration and the cavity walls. Bacteria
Grieve, 1.973). were found in this position, but it was reported
In addition, cavity liners containing fluoride that this leakage could be prevented by applica-
have also been shown to be beneficial (Soremark tion of a cavity liner prior to placement of the
et al., 1969; Grieve, 1973; Kidd, 1975). restoration. In contrast to these findings, artifi-
cial caries techniques have shown the composite
materials tested both in vivo and in vitro to allow
MICROLEAKAGE AROUND TOOTH- minimal microleakage (Hals and Kvinnsland,
COLOURED FILLING MATERIALS 1974; Kidd, 1975).
Silicate and acrylic resins have been extensively
investigated in microleakage experiments. Both
materials appear to allow leakage between the CONCLUSIONS
restoration and the cavity wall (Going et al., Microleakage has been extensively investigated
1960). Unfortunately, with acrylic materials it over the past 25 years. Many different methods
seemed that a good initial seal was rapidly des- of demonstrating the phenomenon have been
troyed after temperature cycling (Fiasconaro developed and applied to the restorative materi-
and Sherman, 1952; Seltzer, 1955; Hirsch and als in common use. Of the many microleakage
Weinreb, 1958; Going and Sawinski, 1966; Peter- tests available, artificial caries techniques would
son et al., 1966; Tani and Buonocore, 1969). The seem to be of particular clinical relevance since
marginal seal of silicate materials appears little they link microleakage with its consequence,
affected by temperature cycling (Going and lesion formation.
Sawinski, 1966; Tani and Buonocore, 1969). Results of extensive microleakage tests on
This difference in behaviour of the two materials amalgam restorations have shown that the freshly
204 Journal of Dentistry, Vol. ~/NO. 5

packed restoration leaks. As it has also been Ellis J. M. and Brown L. R. (1967) Application
shown that this leakage can be greatly reduced of an in vitro cariogenic technic to study the
by the use of a cavity varnish or liner, it would development of carious lesions around dental
obviously be wise to use these materials routinely restorations. J. Dent. Res. 46,403-408.
in caries-prone mouths. The development of new Fiasconaro J. and Sherman H. (1952) Sealing
properties of acrylics. NY. St. Dent. J. 18,
corrosion-resistant alloys may also necessitate
189-198.
the use of these varnishes.
Fraser C. J. (1929) A study of the efficacy of
Relatively few microleakage tests have been dental fillings. J. Dent. Res. 9, 507-517.
carried out on the newer composite materials, Going R. E. (1972) Microleakage around dental
but there is some evidence that they may form restorations: a summarizing review. J. Am.
a good cavity seal. Dent. Assoc. 84, 1349-1357.
Dental materials research would appear to be Going R. E. and Massler M. (1961) Influence of
in a particularly exciting phase. Products are cavity liners under amalgam restorations on
being developed which it is claimed will adhere penetration by radioactive isotopes. J. Prosthet.
to dental tissues physically or chemically. Micro- Dent. 11,298-312.
leakage experiments will obviously feature in the Going R. E., Massler M. and Dute H. L. (1960)
testing of these new materials. Marginal penetrations of dental restorations as
studied by crystal violet dye and Ir3r. J. Am.
Dent. Assoc. 61,285-300.
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