Dental Materials xxx (xxxx) xxx

Contents lists available at ScienceDirect

Dental Materials
journal homepage: www.elsevier.com/locate/dental

Effect of four different mono and multi-wave light-curing units on the

Knoop hardness of veneer resin composites
Thiago Silva Peres a, 1, Helena Letícia de Quirino Oliveira a, 2, Lilibeth Carola Leyton Mendoza a, 3,
Maria Tereza Hordones Ribeiro b, 4, Hugo Lemes Carlo c, 5, Richard Bengt Price d, 6,
Carlos José Soares c, *, 7
a
School of Dentistry, UFU – Universidade Federal de Uberlândia, Uberlaˆndia, MG, Brazil,
b
School of Dentistry, UFU – Universidade Federal de Uberlândia, MG, Brazil
c
Dentistry Department, School of Dentistry, UFU – Universidade Federal de Uberlândia, MG, Brazil
d
Dental Clinical Sciences Department and School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To evaluate the effect of mono and multi-wave light-curing units (LCUs) on the Knoop hardness of
Light exposure technique resin-based composites (RBC) that use different photoinitiators.
Light-curing unit Methods: Central incisor-shaped specimens 12 mm long, 9 mm wide, and 1.5 mm thick were made from 2 RBCs
Microhardness
that use different photoinitiators: Tetric N-Ceram (Ivoclar Vivadent) - and Vittra APS (FGM), both A2E shade.
Resin composite
They were light-cured with 4 different LCUs: two claimed to be multi-wave - VALO Grand (Ultradent) and
Emitter Now Duo (Schuster); and two were monowave - Radii Xpert (SDI) and Elipar DeepCure-L (3 M Oral Care)
using 2 different light exposure protocols: one 40 s exposure centered over the specimen; and two 20 s light
exposures that delivered light from two positions to better cover the entire tooth. 16 groups with 10 specimens in
each group were made. The Knoop hardness (KH, kg/mm2) was measured at the top and bottom of the specimen
in the center and at the cervical, incisal, mesial, and distal peripheral regions. The active tip diameters (mm) and
spectral radiant powers (mW/nm) of the LCUs were measured with and without the interposition of the RBC, as
well as the radiant exposure beam profiles (J/cm2) delivered to the top of the RBCs. The data was analyzed using
Three-way ANOVA and Tukey’s tests (α = 0.05).
Results: The VALO Grand (1029 mW) emitted twice the power of the Radii Xpert (500 mW). The KH values of VI
and TN resin composite specimens were significantly affected by the LCU used (p < .001), the measurement
location (p < .001), and the surface of the specimen (p < .001). LCUs with wider tip diameters produced greater
Knoop hardness values at the peripheries of the 12 mm of long, 9 mm wide specimens. In general, the VALO
Grand produced the highest KH values, followed by Elipar DeepCure-L, then by Radii Xpert. The Emitter Now
Duo LCU produced the lowest values. Exposing the veneers from two locations reduced the differences between
the LCUs and the effect of the measurement location. Only the VALO Grand could fully cover the composite
veneer with light when the two locations were used.
Significance: The light tip must cover the entire restoration to photocure the RBC beneath the light tip.

* Correspondence to: Federal University of Uberlândia, School of Dentistry, Avenida Pará, 1720, Bloco 4L, Anexo A, Sala 42, Campus Umuarama, Uberlândia, CEP
38400-902 Minas Gerais, Brazil.
E-mail address: [email protected] (C.J. Soares).
1
ORCID: 0000-0002-8988-2614
2
ORCID: 0000-0002-1916-8589
3
ORCID: 0000-0003-1608-4299
4
ORCID: 0000-0002-5126-7931
5
ORCID: 0000-0002-5111-7781
6
ORCID: 0000-0001-6479-1436
7
ORCID: 0000–0002-8830–605X

https://doi.org/10.1016/j.dental.2023.10.019
Received 28 April 2023; Accepted 20 October 2023
0109-5641/© 2023 Published by Elsevier Inc. on behalf of The Academy of Dental Materials.

Please cite this article as: Thiago Silva Peres et al., Dental Materials, https://doi.org/10.1016/j.dental.2023.10.019
T.S. Peres et al. Dental Materials xxx (xxxx) xxx

1. Introduction maxillary central incisor;.

2) There would be no difference in the Knoop hardness values across
Most restorative procedures now use resin-based composites (RBC) the specimens when using a single central 40 s exposure or two 20 s light
[1], and direct RBC veneers offer a conservative and esthetic treatment exposures from different locations that covered more of the RBC with
option that requires the removal of little tooth structure to treat caries, light.
restore fractured teeth, and improve the esthetics [2–4]. However, the
different brands of RBCs used to veneer teeth have different composi­ 2. Materials and methods
tions and often use a variety of photoinitiators that may require different
wavelengths to be photo-activated. Thus, they may require different 2.1. Study design
types of light-curing units (LCUs) to achieve adequate
photo-polymerization [5,6]. Two resin composites that were both a light EA2 shade were used.
Camphorquinone (CQ) is a commonly used photoinitiator, but it has According to their respective manufacturers, these RBCs use different
a yellow color, and the demand by patients for white teeth has meant photoinitiators. Four different LCUs were used in this study, two claimed
that some RBCs now use alternative photoinitiators either solely or in to be multi-wave, and two were monowave. The active tip diameter
combination with CQ [6,7] to reduce the yellowing effect of CQ. Some (mm) was measured with a digital caliper; the radiant power (mW),
manufacturers use 2,4,6-trimethylbenzoyldiphenylphosphine oxide, irradiance (mW/cm2), and emission spectrum (mW/cm2/nm) with and
commercially known as Lucirin® TPO, as the photoinitiator to reduce without resin composite veneer specimen between the light detector,
the yellow color of the final restoration [8]. However, these photo­ and the light transmission from the LCU through the resin composite
initiators have an absorption peak in the violet light region at around specimen were measured. Two light exposure protocols were tested; one
400 nm compared to CQ, which has its greatest absorption in the blue with the light tip over the center of the specimen, and the other used two
light region at approximately 470 nm [1,9]. Thus, using a multi-wave exposures from two locations to cover the specimen more fully. The
LCU to photoactivate RBCs that contain Lucirin® TPO should improve Knoop microhardness values (KH) at the top and bottom surfaces were
the polymerization of the RBC [9,10]. measured 24 h after photo-curing.
The power (mW), radiant exitance (mW/cm2), tip irradiance (mW/
cm2), emission spectrum (mW/cm2/nm), and the uniformity of the light 2.2. Specimen fabrication
beam profile are parameters used to characterize the LCU [11–13].
Many LCUs in the market claim to deliver equivalent irradiance values To produce the RBC specimens, a custom matrix was made using bio-
to other LCUs that cost more [14]. However, the LCUs that cost more CAD 3D software (Rhinoceros, Miami, FL, USA). This matrix simulated
generally deliver a higher power (mW) and have a wider tip diameter the Filtek™ Matrix system to make a restoration using a single direct
[11]. Since these LCUs can cover a larger area of the RBC, they may increment on the facial surface of the maxillary central incisor 12 mm
reduce the time spent photo-curing the restoration and thus save money. long from the incisal to the cervical, 9 mm wide from mesial to distal,
Using LCUs with a smaller tip diameter that does not cover the resto­ and 1.5 mm thick. Then the STL digital file was exported to slicing
ration could result in an inadequate amount of light received across the software (Chitubox, Shenzhen, China) and printed on a 3D printer
entire restoration, which could then negatively affect the outcome of the (Anycubic Photon Mono X, Shenzhen, China) using 3D Printing Ultra­
final restoration [15]. violet Sensitive black color resin (Anycubic, Shenzhen, China).
Maxillary central incisors have an incisal-cervical crown length Two RBCs that contain different photoinitiators were used. Vittra
ranging between 7.8 and 13.2 mm and a mesiodistal width of 7.5 – 10.1 APS (FGM, Joinville, SC, Brazil) uses CQ together with a proprietary
mm [16]. Most low-cost LCUs have an active tip diameter of 6–7 mm. Advanced Photoinitiator System, and Tetric N-Ceram (Ivoclar Vivadent,
This is done so that the lower-cost LCUs can deliver the same irradiance, Schaan, Liechtenstein) that uses a combination of Lucirin® TPO and CQ.
but they do not have to be as powerful as the higher-cost LCUs. In The information provided by the manufacturers about these RBCs is
contrast, most higher-cost LCUs usually have active tip diameters of 9 – summarized in Table 1. The samples were made in random order. First,
12 mm [14] and can cover more of the restoration. Consequently, a the matrix was positioned over a mylar strip that was 0.05 mm thick
direct RBC veneer made on maxillary central incisors can be larger than (TDV Dental, Pomerode, SC, Brazil), and a glass plate was filled in a
the active tip diameter of some low-cost LCUs on the market [11]. single increment of the resin composite. A second mylar strip was
A recent direct anterior restorative solution made by the 3 M™ pressed over the top surface of the resin composite. The LCU tip was
company is the Filtek™ Matrix. This system uses a digitally designed fixed 1.0 mm above the 1.5 mm thick RBC veneer specimen to mimic the
customized anterior matrix system to restore anterior teeth using direct effect of the plastic Filtek™ Matrix holder.
RBC veneers made with the plastic matrix attached to the tooth. This
protocol involves filling the RBC into the matrix and then light-cured the 2.3. Light exposure protocols
RBC for 20 s from the facial and 20 s from the lingual direction only [17].
However, the effect of the tip diameter is not mentioned, and a few Four different LCUs were used in their standard output modes; two
studies have already reported the impact of light tip diameter on the LCUs claimed to be multi-wave: VALO Grand (Ultradent Products, South
Knoop hardness of RBCs [6,15,18]. These studies showed that LCUs with Jordan, Utah, USA) and Emitter Now Duo (Schuster, Santa Maria, RS,
a smaller tip diameter produce a lower hardness and less Brazil); and two claimed to be monowave: Elipar DeepCure-L (3 M Oral
photo-polymerization at the margins of the RBC restoration [6,15,18]. Care, St Paul, MN, USA) and Radii Xpert (SDI, Bayswater, Victoria,
This reduced photo-curing at the margin of the RBC restoration may be Australia). The information about these LCUs is summarized in Table 2.
associated with more fractures, secondary caries, marginal leakage and The exposure time recommended by RBC manufacturers was at most 20
discoloration [18]. Since there is little evidence in the literature s for increments up to 2 mm thick. However, to deliver the same radiant
regarding the effect of using multiple light exposures on the hardness exposures to both RBCs, the following light-curing protocols were used:
across extensive RBC restorations, this study evaluated the impact of the
mono and multi-wave LCUs that have different tip diameters using a (1) a single light exposure of 40 s delivered over the center of the RBC
single 40 s exposure or two 20 s light exposures from two different lo­ specimen.
cations to cover the surface of the RBC to photo-activate RBCs that use (2) two 20 s light exposures (40 s in total), with the first light
alternative photoinitiators. The null hypotheses were: exposure positioned 3 mm from the center of specimens in the
1) The use of the LCUs that have different tip diameters would not cervical region and the second light exposure positioned 3 mm
influence the Knoop hardness of RBC specimens that were the size of a from the center of specimens in the incisal region.

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Table 1
Resin composites used in this study. Information was provided by the manufacturers.
Resin composites/ Manufacture Shade Organic matrix Photoinitiator system Filler W (%) Recommended light
activation time

Tetric N-Ceram (Ivoclar EA2 Bis-GMA, UDMA, Lucirin® TPO barium glass, barium glass, and aluminum, 80–81 ≥ 500 mW/cm2 – 20 s
Vivadent, Schaan, TEGDMA, highly disperse silica, mixed oxides, ≥ 1000 mW/cm2 – 10 s
Liechtenstein) prepolymers
VIT, Vittra APS EA2 UDMA, TEGDMA Camphorquinone and Zircon load, silica and pigments. 72–82 20 s
(FGM, Joinville, SC, Brazil) APS System*

Composition provided by manufacturers. Abbreviations: Bis-GMA, bisphenol A diglycidylmethacrylate; UDMA, urethane dimethacrylate; TEGDMA, triethyleneglycol
dimethacrylate; Lucirin® TPO* - photoinitiator dibenzoyl germanium derivative. APS system* - according to the manufacturer it is a proprietary ‘Advanced Poly­
merization System’.

Table 2
Description of light-curing units (LCUs).
LCU Serial Number LED LCU wavelength emission Battery/ mains Tip/light conductor Manufacture

VALO Grand C33856 multi-peak Battery Directly from the LED Ultradent Products, South Jordan, Utah, USA
Emitter Now Duo 04802346 single-peak Battery Directly from the LED Schuster, Santa Maria, RS, Brazil
Elipar DeepCure-L 932125 single-peak Battery Optical fiber/ black 3 M, St Paul, MN, USA
Radii Xpert 16536 single-peak Battery Directly from the LED SDI, Bayswater,
Victoria, Australia

After light exposure, the specimens were stored dry for 24 h at (37 ± 2.6. Knoop microhardness (KH)
1 ◦ C) in dark envelopes that blocked the ambient light.
The Knoop microhardness (KH, kg/mm2) at the top and bottom of
2.4. Characterization of LCUs and light transmission – Integrating sphere the 1.5 mm thick RBC specimens was measured after 24 h. The speci­
mens were positioned on the microhardness tester (Microhardness
A 12.5-inch integrating sphere (Labsphere, North Sutton, NH, USA) Tester FM-700, Future-Tech, Tokyo, Japan), and measurements were
connected to a fiber optic spectrometer (USB 4000, Ocean Insight, made 0.5 mm away from the margin of the RBC on each surface at five
Largo, FL, USA) was used to measure the total radiant power (mW), different positions (three measurements at each location: the center,
irradiance (mW/cm2), and spectrum (mW/cm2/nm) from the LCUs. The cervical, incisal, mesial, and distal) by applying a load of 100 kgf for 10
measurement system was calibrated before use. s. A total of 30 measurements were made, 15 at the top and 15 at the
Initially, the LCU was fixed over the entrance of the integrating bottom of each specimen.
sphere, and the total light outputs from the LCUs were measured. Then,
the matrix filled with RBC was fixed at the entrance to the integrating 2.7. Statistical analysis
sphere, and the tip of the LCU was positioned 1 mm above the RBC
specimen so that the light transmitted through the RBC veneer speci­ The KH data were analyzed for normal distribution and homosce­
mens could be measured. The transmitted light was measured using the dasticity using the Shapiro-Wilk and Levene’s tests. KH data were then
two light-curing protocols (light exposure for 40 s centered over the analyzed using 3-way ANOVA, with the repeated measurements being
center of the specimen, and two light exposures for 20 s each at the two the study factor of the LCU type (4 levels), the RBC (2 levels), the light-
different locations, for a total of 40 s curing protocol (2 levels), and the repeated measurement location on
the specimens (5 levels). Multiple comparisons were made using Tukey’s
2.5. Light transmission - Beam profiling post-hoc test. The ratios between top and bottom mean KH values were
calculated for all experimental groups and locations. All tests used a
The beam profiles of the LCUs were examined with the tip 1.0 mm significance level of α = 0.05, and all analyses were performed using
away from a holographic diffuser (60◦ holographic diffuser screen, Sigma Plot 12.5 (Systat Software Inc, San Jose, CA, USA).
Edmund Industrial Optics, Barrington, NJ, USA)). The image of the light
beam was viewed from the other side of the screen using a beam profile 3. Results
camera with a 50 mm focal length lens (SP928, Ophir-Spiricon, Logan,
UT, USA) with two blue filters (HOYA UV–VIS colored glass bandpass The radiant power and the emission spectra from the LCUs without
filter, Edmund Industrial Optics) to correct for the spectral response of the interposition of the specimen (control) are shown in Fig. 1, and
the camera. Spectrally flat reflective neutral density filters (Edmund through the 1.5 mm thick Vittra APS and Tetric N-Ceram made using
Optics) attenuated the light from the LCUs. The integration time was set both light activation protocols and are shown in Figs. 2 and 3.
to compare the beam profiles from all the LCUs so that the most powerful The main characteristics of the LCUs tested in this study are shown in
LCU did not saturate the camera. This setting allowed the beam profiles Fig. 1. and Table 3. Three LCUs emitted light that had a single wave­
from all the LCUs to be recorded on the same setting, and thus they could length peak: Elipar DeepCure-L (448 nm), Radii Xpert (452 nm), and
be compared. Emitter Now Duo (449 nm). In contrast, the VALO Grand emitted light
The diameter of the light tip and the power emitted from the LCU with multiple wavelength peaks at 396, 443, and 463 nm. Although the
were inserted into Beam Gage Professional 6.14.0.355 software (Ophir- Emitter Now Duo is described by its manufacturer as a multi-wave LCU,
Spiricon). and the calibrated data file was exported to OriginPro 2018 it only emitted a single peak (Fig. 1H). The radiant power curves of all
software (OriginLab, Northampton, MA, USA) to generate the calibrated LCUs transmitted through the resin composite veneer specimens are
two-dimensional beam profile images of the radiant exposures (J/cm2) shown in Fig. 3. Both RBCs blocked out most of the light, and the energy
delivered to the surface of the RBCs from the four LCUs. delivered through 1.5 mm of RBC was approximately 90% less than
what was delivered to the top surface. Very little violet light from the
VALO Grand passed through 1.5 mm of either RBC. The two light

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

Fig. 1. Radiant power during a 40 s exposure and emission spectrum from the LCUs without any RBC between the light tip and the detector. (A) Elipar DeepCure-L;
(B) Radii Xpert; (C) Radii Xpert; (D) Emitter Now Duo.

Fig. 2. Radiant power during a 40 s exposure and emission spectrum from the LCUs through the 1.5 mm thick Vittra APS and Tetric N-Ceram resin composite veneers
using both light-curing protocols. (A) Elipar DeepCure-L through Tetric-N Ceram; (B) Elipar DeepCure-L through Vittra APS; (C) Elipar Radii pert through Tetric-N
Ceram; (D) Elipar Radii Xpert through Vittra APS; (E) VALO Grand-L through Tetric-N Ceram; (F) VALO Grand through Vittra APS; (G) Emitter Now Duo through
Tetric-N Ceram; (H) Emitter Now Duo through Vittra APS.

exposure protocols tested in this study resulted in a similar amount of cervical for all LCUs. When the RBCs received two light exposures, the
energy transmitted through the center of the RBC specimens but not at ratio between the center top surface and the KH at the margin areas
the edges, where the overlapping exposures delivered more energy. reached values that were greater than 80%. This reduced the impact of
Tip diameter and beam profiles distribution at the tip of the LCUs the LCU and the effect of the results from the different locations on the
using both light activation protocols are shown in Fig. 4. The Valo Grand RBC veneers. Of note, Vittra APS reached the highest KH values and
had the greatest tip diameter (11.8 mm) and covered the greatest area of reducing the exposure time from 40 s to 20 s had a greater negative
the RBC with light when using one light exposure at the center. The effect on Tetric N-Ceram.
Emitter Now Duo and Radii Xpert did not fully cover the proximal and The distribution of the KH values from Vittra APS and Tetric N-
cervical areas, and they delivered less energy to these regions (Fig. 4). Ceram are plotted as box plot graphics in Figs. 5 and 6, respectively.
Using 2 light exposures from 2 locations improved the coverage area for Higher KH values at the center than the margins were achieved when
all LCUs, but only the VALO Grand completely covered the veneer. both RBCs received one single light exposure at the center of the spec­
The KH values of the Vittra APS and the Tetric N-Ceram specimens imen. However, using two 20 s light exposures resulted in similar values
light-cured using both exposure protocols and measured at different at the top and bottom surfaces in all regions of the restoration.
locations at the top and bottom surfaces are shown in Tables 4 and 5,
respectively. The KH values of Vittra and Tetric N-Ceram resin com­ 4. Discussion
posite specimens were significantly affected by the choice of LCU
(p < .001), by the location of the measurement (p < .001), and by the This study evaluated the effect of mono and multi-wave LCUs that
surface of the specimen (p < .001). In general, the VALO Grand pro­ had different tip diameters and light exposure protocols on the KH of
duced the highest KH values, followed by Elipar DeepCure-L, then by resin composites that use different photoinitiators. Since the KH at
Radii Xpert, and the Emitter Now Duo LCU produced the lowest values. different regions of resin composite veneer was affected by the tip
Using a single light exposure for 40 s resulted in lower KH values at the diameter of LCU when photoactivated by the different light exposure

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

Fig. 3. Emission spectrum (mW/cm2/nm) through 1.5 mm thick resin composite veneers of Vittra APS and Tetric N-Ceram using both light-curing protocols. (A)
Elipar DeepCure-L through Tetric-N Ceram using a single central light exposure protocol; (B) Elipar DeepCure-L through Tetric-N Ceram using two light exposures;
(C) Elipar DeepCure-L through Vittra APS using a single central light exposure protocol; (D) Elipar DeepCure-L through Vittra APS using two light exposures; (E)
Radii Xpert through Tetric-N Ceram using a single central light exposure protocol; (F) Radii Xpert through Tetric-N Ceram sing two light exposures; (G) Radii Xpert
through Vittra APS using a single central light exposure protocol (H) Radii Xpert through Vittra APS using two light exposures; (I) VALO Grand through Tetric-N
Ceram using a single central light exposure protocol; (J) VALO Grand through Tetric-N Ceram using two light exposures; (K) VALO Grand through Vittra APS
using a single central light exposure protocol (L) VALO Grand through Vittra APS using two light exposures; (M) Emitter Now Duo through Tetric-N Ceram using a
single central light exposure protocol; (N) Emitter Now Duo through Tetric-N Ceram sing two light exposures; (O) Emitter Now Duo through Vittra APS using a single
central light exposure protocol; (P) Emitter Now Duo through Vittra APS using two light exposures.

Table 3
Characteristics of the light-curing units (LCUs).
LCU Measured external tip diameter Measured effective tip diameter Calculated effective tip area Measured radiant power Irradiance (mw/
(mm) (mm) (mm2) (mW) cm2)

VALO Grand 15.0 11.8 109.3 1029 ± 6.7 939

Emitter Now 12.8 8.1 51.5 628 ± 16.8 1214
Duo
Elipar 9.7 9.0 63.6 831 ± 5.1 1304
DeepCure-L
Radii Xpert 12.1 7.8 47.7 500 ± 22.8 1032

protocols, the first null hypothesis was rejected. Unexpectedly, the different powers, irradiances, wavelength ranges, and tip diameters [5,
Emitter Now Duo could not be considered to be a multi-wave LCU. This 11]. LCUs with different technical characteristics can affect the Knoop
conclusion was confirmed by testing the light output from a second hardness and polymerization of RBCs [15,20–22]. In addition, the light
Emitter Now Duo that delivered the same light output. curing protocol and the techniques used to light activate the RBC are
The longevity of resin composite restorations depends on the linked with the skills of the operator, and they also determine the Knoop
adequate conversion of monomers into polymers [19,20]. The equip­ hardness of the RBC [23–25].
ment that is used to produce this conversion is the LCU, but many Resin composites are the main restorative choice in many situations
different kinds of LCU are available for the dentist to choose from [11, because they are a versatile material that can be bonded to the tooth
14]. These LCUs have different technical specifications: they deliver structure after only a conservative preparation, and RBCs have good

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

Fig. 4. Two-dimensional images of radiant exposure of the radiant exposures (J/cm2) delivered from the LCUs superimposed over across the resin composite veneer
specimen: Light tip diameters: VALO Grand 11.8 mm, Emitter Now Duo 8.1 mm, Elipar DeepCure-L 9 mm, and Radii Xpert 7.8 mm. Note the different areas covered
by the LCUs.

Table 4
Mean and standard deviation values of the Knoop hardness (N/mm2) measured at the center of the Vittra APS specimens when one 40 s light exposure and two 20 s
light exposures using different LCUs and the corresponding value (%) at the different locations (cervical, incisal, mesial and distal).
TOP

Location 1 light exposure (40 s) 2 light exposures (20 s)

Elipar Deep Cure Radii Xpert Now Duo VALO Grand Elipar Deep Cure Radii Xpert Now Duo VALO Grand

Center 66.7 ± 4.1 61.2 ± 5.3 60.3 ± 3.6 68.3 ± 4.3 61.4 ± 5.8 57.8 ± 3.8 54.2 ± 3.8 75.3 ± 4.8
Aa Ba Ba Ab Bb Cb Db Aa
89% 81% 80% 91% 82% 74% 72% 100%*
Cervical 50% 33% 42% 73% 73% 64% 61% 98%
Incisal 58% 38% 46% 82% 78% 61% 68% 95%
Mesial 70% 60% 70% 78% 68% 66% 58% 88%
Distal 78% 64% 58% 88% 68% 56% 54% 93%
BOTTOM
Location 1 light exposure (40 s) 2 light exposures (20 s)
Elipar Deep Cure Radii Xpert Now Duo VALO Grand Elipar Deep Cure Radii Xpert Now Duo VALO Grand
Center 58.6 ± 4.0 53.4 ± 5.8 48.0 ± 5.0 65.8 ± 4.5 53.0 ± 4.2 51.1 ± 4.1 46.8 ± 3.1 65.2 ± 3.7
Ba (88%) Ca (85%) Da (79%) Aa (97%) Bb (84%) Ba (94%) Ca (84%) Aa (87%)
78% 67% 64% 87% 70% 68% 62% 87%
Cervical 42% 29% 31% 60% 59% 54% 41% 78%
Incisal 52% 31% 31% 71% 63% 59% 40% 76%
Mesial 65% 50% 58% 75% 62% 50% 47% 76%
Distal 65% 53% 45% 74% 56% 49% 44% 74%

Different letters indicate significant difference – uppercase letters are used when comparing LCUs for each light exposure protocol, and lowercase letters are used for
comparing the light exposure protocol for each LCU; (%) at the center line indicates the ratio between top and bottom KH values measured at the center location. The
ratio % for all other location data were calculated comparing with maximum value (VALO Grand 2 light exposures for 20 s at the center/top – 75.3 ± 4.8 N/mm2).
* highlight the 100% value used for comparison with all other values.

esthetic properties. However, the various resin composites on the mar­ made from Barium glass, ytterbium trifluoride, mixed oxide, and co­
ket have different formulations and photoinitiators [3], which result in polymers with a smaller size of 40 – 3000 nm. Another factor that
different mechanical properties of the RBCs [26]. The resin composites influenced the KH in Tetric N-Ceram resin was the exposure time. Re­
evaluated in this study were chosen because they were known to have gions that received 20 s of light had lower KH values than those that
different compositions, as described in Table 1. As a result, Vittra APS received 40 s, indicating that the 10 s exposure time for LCUs with
and Tetric N-Ceram produced different KH values. In general, the region ≥ 1000 mW/cm2 (10 J/cm2) recommended for the manufacturer is
at the top in the center of the specimen had the highest KH for Vittra insufficient to achieve the best Knoop hardness for this material.
APS. Since both resin composites have a similar weight and volume of The four LCUs evaluated in this study are commercially available and
filler, this suggests that the difference in hardness occurs because these widely used, but they have different characteristics. The active tip di­
two composites have different filler compositions. Vittra APS has par­ ameters varied between four LCUs. The Radii Xpert and Emitter Now
ticles that are composed mainly of nanosphere of zirconia with a size Duo had the smallest tip diameter, 7.8 mm and 8.1, respectively, and the
average of 200 nm, this combination results in larger fillers that offer VALO Grand had the largest, 11.8 mm (Table 3). Thus, the emitting area
more resistance to indentation than the Tetric N-Ceram that has particles of the VALO Grand was 1.51 and 1.47 times greater than the Radii Xpert

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Table 5
Mean and standard deviation values of the Knoop hardness (N/mm2) measured at the center of the Tetric N-Ceram specimens when one 40 s light exposure and two
20 s light exposures using different LCUs and the corresponding value (%) at different locations (cervical, incisal, mesial and distal).
TOP

Location 1 light exposure (40 s) 2 light exposures (20 s)

Elipar Deep Cure Radii Xpert Now Duo VALO Grand Elipar Deep Cure Radii Xpert Now Duo VALO Grand

Center 58.9 ± 3.3 55.4 ± 3.3 46.6 ± 4.4 58.3 ± 4.1 54.5 ± 3.8 50.1 ± 4.5 44.1 ± 3.8 57.4 ± 3.6
Aa Ba Ca Aa Ba Cb Da Aa
100%* 94% 79% 99% 93% 85% 75% 97%
Cervical 61% 68% 44% 82% 83% 79% 72% 93%
Incisal 85% 82% 68% 94% 81% 77% 70% 88%
Mesial 73% 71% 54% 92% 85% 83% 72% 89%
Distal 78% 81% 67% 93% 84% 84% 69% 90%
BOTTOM
Location 1 light exposure (40 s) 2 light exposures (20 s)
Elipar Deep Cure Radii Xpert Now Duo VALO Grand Elipar Deep Cure Radii Xpert Now Duo VALO Grand
Center 56.0 ± 4.8 52.3 ± 4.2 48.2 ± 3.4 53.7 ± 4.9 47.2 ± 4.4 47.8 ± 4.5 45.0 ± 3.3 53.7 ± 4.2
Aa (95%) Ba (91%) Ca (103%) Ba (92%) Bb (87%) Bb (95%) Ba (102%) Aa (94%)
95% 85% 82% 91% 80% 81% 76% 91%
Cervical 60% 50% 38% 67% 67% 58% 68% 78%
Incisal 77% 62% 64% 75% 67% 64% 63% 79%
Mesial 68% 55% 52% 80% 70% 63% 63% 74%
Distal 74% 72% 65% 86% 71% 73% 63% 79%

Different letters indicate significant difference – uppercase letters are used when comparing LCUs for each light exposure protocol, and lowercase letters are used for
comparing the light exposure protocol for each LCU. (%) at the center line indicates the ratio between top and bottom KH values measured at the center location. The
ratio % for all other location data were calculated comparing with maximum value (Elipar Deep Cure 1 light exposure for 40 s at the center/top – 58.9 ± 3.3 N/mm2).
* highlight the 100% value used for comparison with all other values.

and Emitter Now Duo, respectively. Table 3 shows that the Valo Grand in the blue spectrum (400 – 500 nm) [27]. The results agree with other
(1029 ± 7 mW) emitted twice the power of the Radii Xpert (500 studies that do not show a difference between the mono and multi-wave
± 23 mW), but the radiant emittance from the VALO Grand was LCUs when photo-curing resin composites that contain the Lucirin® TPO
939 mW/cm2 compared to the Radii Xpert 1032 mW/cm2. This that is present in the Tetric N-Ceram [28,29]. The results suggest that the
apparent discrepancy occurred because the active diameter tip directly addition of violet light from the LCU should be evaluated with caution
influences the radiant emittance, and even small reductions in the active because the attenuation of the violet spectrum is so great, that the value
diameter tip have a sizeable positive effect on the radiant emittance. of adding violet light is limited to the surface of the RBC. So, although
This shows that it is possible to have an LCU that delivers a high irra­ the multi-wave LCU may have a high power or irradiance, much of the
diance (radiant emittance) but is actually less powerful than another light is wasted because it never reaches the bottom of the resin com­
LCU that delivers a lower irradiance (radiant emittance). As might be posite. In addition, the photons of violet light contain more energy than
anticipated, reducing the active tip diameter resulted in the lowest KH those in the blue region and thus will produce more unwanted heat in
values at the margins of resin composite veneer, especially when the the tooth and other oral tissues.
single localized light exposure for 40 s centered over the specimen was Light beam profiles have been reported to be a reliable method to
used. However, the increase in the tip diameter necessitates a more evaluate the distribution of radiant power that reaches the surface, and
powerful LED emitter and increases the price of the LCU [11]. Conse­ studies have already reported that there is a positive correlation be­
quently, dentists may purchase cheaper LCUs that deliver what appears tween the beam profile and the microhardness of the RBC [20]. In this
to be an acceptable irradiance, but which have a smaller tip diameter, study, it was possible to observe in Fig. 4 that the tip diameter did not
not realizing that the LCU may not be very powerful and that multiple cover the complete area of the restoration, especially in cervical-incisal
exposures are required with a smaller diameter tip LCU. The require­ dimension, which was 12 mm in length. The consequence of this size
ment to use multiple exposures may quickly negate any cost savings of discrepancy is contrary to the recommendations by 3 M [17], because
purchasing a low-cost LCU. However, while the reduced tip diameter one single localized central light-curing protocol from some LCUs does
does not mean they cannot be used, clinicians should still increase the not completely cover the entire restoration area. This study demon­
number of light exposures to fully cover the restoration with light for strated that all the margins had lower KH values than the center of the
40 s specimen at the top surface and especially at the bottom surface when
The wavelength peaks from the four LCUs are reported in Fig. 1. The this single facial exposure for 40 s was used. When the specimen was
emission peak from the VALO Grand in the violet spectrum delivered a photoactivated using a light exposure from two locations, the area
lower irradiance than the blue spectrum, and this violet light has lower covered by the tip of the LCU was greater, and the KN values were
penetration into the composite resin. Thus, the amount of violet that greater, but only the VALO Grand completely covered the veneer
reached the bottom of the specimen was much lower than the blue light. (Fig. 4). However, when using the Radii Xpert and Emitter Now Duo, the
Although the manufacturer of Emitter Now Duo indicated that it is a KH values in the mesial and distal region still did not achieve 80% of the
multi-wave LCU, the violet led in this LCU does not produce any peak in KH values compared to the central area on the bottom surface. These
the violet region of light, and this light was shown to be a mono-wave results suggest that despite changing the light-curing protocol, these two
LCU. The Emitter Now Duo results showed that, even when the RBCs LCUs should not be used if only two exposures are used because these
were exposed from two locations, lower KH values were achieved in the LCUs have an active diameter tip that is smaller than the 9 mm width of
margin location at the bottom surface of Vittra APS. The manufacturer of the maxillary central incisor. Instead, LCUs with a smaller diameter,
Vittra APS does not recommend any special LCU. According to the such as Emitter Now Duo or the Radii Xpert, will require more than two
manufacturer, the APS system combines different initiators with Cam­ light exposures to cover all the areas of the tooth.
phorquinone, which is supposed to help the composite resin achieve a Although the manufacturers of resin composites have different rec­
whiter result. However, these APS photoinitiators can only absorb light ommendations times for light-curing their materials, this study used 40 s

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

Fig. 5. Box plot distribution of KH values of the Vittra APS resin composite veneer specimens light-cured using both exposure protocols measured at five different
locations at the top and bottom surfaces.

delivered to the center of the specimen to evaluate the effects of deliv­ center of the tip of LCU and margins of the resin composite veneer. The
ering the same amount of energy to both resin composite restorations KH was measured because the hardness is an important parameter that
where the light was delivered for 20 s at two distinct regions of the reflects how well a resin composite is photo-cured. It has been suggested
restoration. This allowed a better comparison to determine if the light that this occurs when there is no more than a 20% difference between
exposure protocol affected the polymerization of the resin composite. the maximum hardness and the top and bottom of the resin composite
Additionally, to better evaluate the influence of the light exposure [30–35]. In this study, it was observed that the 20 s exposure protocol
protocol, the KH was measured at five different regions (center, mesial, from 2 locations produced higher KH values at the top and bottom at the
distal, and cervical), to represent the locations more distant from the margins of the specimens for both RBCs. Therefore, the second null

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

Fig. 6. Box plot distribution of KH values of The Tetric N-Ceram resin composite veneer specimens light-cured using both exposure protocols measured at five
different locations at the top and bottom faces.

hypothesis was rejected. recommended when photo-curing RBC. This will increase the KH values
This result suggests that unless the veneer is photo-activated from at at the margins of the RBC veneer, consequently improving the me­
least two locations so that all the margins receive direct light, the chanical properties of the resin composite. Of note, these results were
margins of the resin composite veneer will be weaker, have more frac­ obtained with the A2E shade of the composite resins and more com­
tures, staining, secondary caries, marginal leakage, and marginal posite resins that are more opaque may obtain even less favourable
discoloration in the restoration. These results have been reported in outcomes and require longer exposure times.
long-term clinical follow-up studies of anterior resin composite resto­
rations, where the main reason to change the restoration was for esthetic
reasons [4]. Therefore, delivering light from at least two locations is

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T.S. Peres et al. Dental Materials xxx (xxxx) xxx

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of Scientific and Technological Development – Grants 406840/2022–9; curing units on the polymerization of bulk fill resin-based composites. Dent Mater
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311001/2021-1; 422603/2021-0 and FAPEMIG (Foundation for [21] Al-Zain AO, Eckert GJ, Platt JA. The influence of distance on radiant exposure and
Research Support of the State of Minas Gerais) – Grants APQ-02105-18. degree of conversion using different light-emitting-diode curing units. Oper Dent
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[22] Pirmoradian M, Hooshmand T, Jafari-Semnani S, Fadavi F. Degree of conversion
Cell Biology Research Center from the Federal University of Uberlândia. and microhardness of bulk-fill dental composites polymerized by LED and QTH
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Declarations of Interest job.2019.12.004.
[23] Samaha S, Bhatt S, Finkelman M, Papathanasiou A, Perry R, Strassler H, Kugel G,
Garcia-Godoy F, Price R. Effect of instruction, light curing unit, and location in the
None. mouth on the energy delivered to simulated restorations. Am J Dent 2017;30(6):
All authors actively participated in the discussion of the manuscript 343–9.
[24] Bhatt S, Ayer CD, Price RB, Perry R. Effect of curing light and restoration location
findings, reviewed and approved the final version of this manuscript.
on energy delivered. Compend Contin Educ Dent 2015;36(3):208–10. 212, 214.
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