www.konkur.

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CHAPTER 6 Light Curing of Retorative Material 187

time20,78 and thus decrease the light output. he light output can
also be reduced due to the buildup of scale on the iberoptic light
probe after repeated autoclaving,79 after breakage or fracture at the
light tip,80,81 or due to the presence of cured composite resin or
debris on the light tip.80,82 All these factors can signiicantly decrease
the ability of the curing light to photocure the resin (Fig. 6.32).
hus it is important to use a dental radiometer to routinely measure
the output from the curing light. he value should be recorded,
as well as the condition of the curing light. Ideally, the value of
the light/tip combination should be recorded when the unit is
new and subsequent readings can be used to indicate the relative
performance of the curing light as a function of time.

Handheld “Dental Radiometer”

Examples of seven handheld dental radiometers that can be used
to monitor the output from dental curing lights are displayed in
Fig. 6.33A. hese radiometers usually have a bandpass ilter in
front of a silicon photodiode detector that converts the photons
received from the curing light into electrical current and, when
calibrated, into units of irradiance. However, the light is rarely
• Fig. 6.31 Images of good (top) and poor (bottom) beam proiles, super-
emitted uniformly across the entire light tip, and because the imposed on images of premolar and molar tooth preparations. Each image
entrance apertures on some dental radiometers are smaller than is normalized and scaled to 100% of its individual, maximum irradiance value.
the light tip (see Fig. 6.33B), most dental radiometers do not (From Rueggeberg FA, Giannini M, Arrais CAG, Price RBT: Light curing in
dentistry and clinical implications: a literature review, Braz Oral Res 31(suppl
1): e61, 2017. http://dx.doi.org/10.1590/1807-3107bor-2017.vol31.0061.
Licensed under CC BY 2.0, https://creativecommons.org/licenses/by/2.0/.)

A B C
• Fig. 6.32 Examples of damaged (A) and debris-contaminated light tips (B and C).

B
• Fig. 6.33 Image of seven commercial dental radiometers (A), and an example of the difference
between the 4.3-mm entrance aperture into the radiometer and the 10-mm tip of the curing light (B).
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188 C HA P T E R 6 Light Curing of Retorative Material

A B
• Fig. 6.34 A large diameter light tip (A) can cover an entire molar tooth, whereas smaller diameter light
tips (B) require multiple exposures to cover an entire the surface of a molar MOD restoration.

capture all the light from the light emitting tip.83 hus, depending
on where the light tip is positioned over the detector area, a region
of high or low irradiance may be measured. his limitation helps
to explain why several studies have reported that most dental
radiometers are inaccurate.83-86 In addition, because QTH, PAC,
or LED dental curing lights all deliver diferent emission spectra,
the type of bandpass ilter used within many dental radiometers
will afect the accuracy of the irradiance value reported.83,85 hus
the radiometer manufactured by the maker of the curing light
being tested should be the most accurate.

Practical Conideration for Light Curing

Dental Rein in the Mouth
Factor Afecting Light Delivery to the Target
Table 6.1 shows that when the irradiance delivered is multiplied • Fig. 6.35 Overlay graph indicating differences among three commer-
by the exposure time, the product describes the radiant exposure cial curing lights with respect to the power received using tip-to-target
(in J/cm2) delivered to the exposed surface of the resin. It has been distances from 0 to 10 mm.
recommended that a QTH curing light should deliver a minimum
irradiance of 400 mW/cm2 for 60 seconds to adequately polymerize
a 1.5- to 2-mm-thick increment of resin.87 It has also been recom- not cover the entire restoration area. Since there is increased interest
mended that most dental resins require a radiant exposure of in bulk illing and bulk curing of large restorations, this decrease
approximately 16 J/cm2 to adequately cure to a depth of 2 mm.88 in tip diameter is now of concern. With the dimensions of a
hus this threshold could be reached in 40 seconds if the curing mandibular molar being approximately 11.0 mm mesiodistally
light delivers an average irradiance of 400 mW/cm2 to the resin. and 10.5 mm buccolingually at the crown,95 the clinician who
However, diferent brands of resin require diferent exposure times, wishes to reduce time spent light curing restorations should use a
and the minimum radiant exposure may range from 6 to at least curing light with a tip that completely covers the entire restoration
24 J/cm2 to achieve an adequate level of polymerization in the surface. Otherwise, as seen in Fig. 6.34, even when using a resin
various shades and colors.89,90 intended for bulk illing, multiple, sequential, overlapping exposures
will be required to ensure that all areas of the restorative material
have received an adequate amount of light.21
Light Guide Tip Deign
As discussed previously, the design of the light tip can have a Ditance to Target
signiicant impact on the irradiance delivered to the restoration45,91
and can negatively afect the physical properties of the resin and Irradiance (radiant exitance) values stated by manufacturers are
its bond strength to the tooth.7,92-94 Twenty years ago, most light usually measured at the light tip end. Because the resin is usually
tips had a 10 to 13 mm tip diameter, but recently this has changed 2 to 8 mm away from the light tip, this value does not relect the
and many light tips are now only 6 to 8 mm in diameter. Although irradiance values that are received by the restoration. Fig. 6.35
a smaller diameter tip can increase irradiance, small light tips may displays how the efect of increasing the tip-to-target distance difers
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CHAPTER 6 Light Curing of Retorative Material 189

• Fig. 6.36 Examples of different types of plastic barriers placed over the curing light to
minimize contamination. Ideally, the plastic barrier should cover the entire unit instead of just
the light tip.

• Fig. 6.38 If the seam of the barrier crosses the light tip, light output
will be reduced.

• Fig. 6.37 The barrier should it snugly over the light tip and the seam
should be positioned so that it does not impede light output.

among various brands of dental curing lights. Depending on their

design, some curing lights deliver only 25% of the irradiance
measured at the tip when they are 8 mm away from the resin
surface.7,45,96-98 his decrease occurs because the design and the
optics of the light source and the light guide all afect the beam
divergence angle from the distal tip end of the light guide. Some • Fig. 6.39 Example of a curing light with air vents that should not be
of the light from a curing light is delivered as a collimated beam, covered by the protective barrier.
some is focused to a point, and some is immediately dispersed
laterally from the tip. hus curing lights do not act as a point
source and depending on the unit’s optical design, which sometimes
includes a lens, the efect of changes in the tip to target distance seam of a barrier traverses across the light tip and disrupts the
on the irradiance received does not obey the inverse square law. light beam.
Unfortunately, the design of these preformed plastic sheaths
that it over a curing light is not standardized and they may not
Infection Control be designed to optimize light transmission (Fig. 6.39). Some barriers
Although some iberoptic light guides can be autoclaved, the body can reduce the radiant exitance by up to 40%, and latex-based
of the curing light itself cannot. hus the use of infection control barriers should be avoided as they have been reported to negatively
barriers, such as the plastic barriers presented in Figs. 6.36 and afect resin polymerization.75,99-101 For this reason, the output from
6.37, that ideally should cover the entire curing light and light curing lights should be tested on the radiometer with the barrier
guides are recommended. he barrier should it snugly over the over the light tip. Clear, plastic food wrap stretched over the light
light tip and the sleeve seam should not impede the light output. tip in a single layer can also be an efective and inexpensive infection
Fig. 6.38 illustrates the detrimental efect that occurs when the control barrier that has minimal efect on light output.81,100,101
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190 C HA P T E R 6 Light Curing of Retorative Material

When using cold sterilizing techniques, only approved cleaning with temporary restorative material. he intrapulpal temperature
solutions should be used. Disinfectant sprays can erode the O-rings rise in the teeth, when using a LED curing light, was then measured.
used to stabilize light guides, and the residual luid can bake onto he radiant exposure was determined, and the resulting increase
the lens or relectors inside the light housing, thus decreasing the in intrapulpal temperature is shown in Fig. 6.40.
light output.102 herefore, if it can be detached, the light guide As the radiant exposure increased, there was a corresponding
should be removed from time to time and any lens, relector, and increase in intrapulpal temperature. However, only when the radiant
ilter inside the curing light should be checked to ensure that they, exposure levels approached 72 J/cm2 did some in vivo temperature
and both ends of the light guide, are clean and undamaged. values meet or exceed the 5.5°C increase threshold, and thus
potentially cause pulpal damage.103
Time-based proiles of in vivo temperature values inside the
Health-Related Iue pulp of upper bicuspid teeth exposed using the same curing light,
but with one tooth having an intact buccal enamel surface and
Intrapulpal Temperature Conideration another tooth having a Class V preparation with approximately
An in vivo study involving the direct application of heat from a 1-mm thickness of dentin remaining, are shown in Fig. 6.41.
soldering iron to the facial surfaces of intact rhesus monkey teeth Although both conditions demonstrate similar pulpal temperature
indicated that an increase in intrapulpal temperature of 5.5°C prior to the 30-second exposure, the rate and extent of temperature
resulted in pulpal necrosis in 15% of the teeth tested.103 his increase is much greater in the tooth with the Class V preparation
temperature value has been extrapolated to predict that similar than in the intact tooth. In addition, it takes longer for the pulpal
pulpal temperature increases when light curing may cause pulpal temperature to return to baseline levels at the end of the exposure.
necrosis to an already afected human dental pulp. Such evidence supports the concept that the potential for causing
As the radiant power output from curing lights has increased, temperature increase in pulpal tissue greatly increases as more
the potential for generating a damaging temperature increase in tooth structure is removed and there is less dentin overlying the
the pulp and oral tissues has also risen.6,68,104-108 his increase in pulpal tissues.110,111
temperature is related to the amount of energy delivered (the Where the pulp is at greater risk, such as in deep cavities with
product of irradiance delivered and exposure time) and the thermal little overlying dentin, consideration should be given to the choice
properties (conductivity and difusivity) of the tooth. Based on in of LCU and light exposure program. It has been recommended
vitro test results, it is suggested that curing lights that deliver an that the tooth should be air-cooled during light exposure112,113
irradiance greater than 1,200 mW/cm2 should be used for at most from the opposite side (Fig. 6.42) of the exposure. Alternatively,
15 seconds.108 a high-volume suction device can be used to cool the tooth by
However, this guideline has been questioned because recent pulling air across the coronal portion of the tooth.
human-based intrapulpal temperature studies have measured the Fig. 6.43 illustrates the in vivo cooling efect of the air spray
baseline temperature of anesthetized, healthy human pulp tissue.109 when it was applied 3 seconds prior to light exposure, and stopped
In that work, patients requiring extraction of bicuspids for orth- when the light was turned of.
odontic reasons volunteered as participants. Class I preparations Although the pulpal temperature starts to rise shortly after light
were made, which intentionally exposed the most coronal portion exposure, when air-cooled, the pulp temperature decreases both
of the buccal pulp horn. A sterile temperature probe was inserted during and after light exposure. Consequently, it may be possible
directly into the pulp chamber and remained in place during to use irradiance levels greater than 1200 mW/cm2 for longer than
temperature measurements, while the access opening was illed 15 seconds if appropriate cooling measures are used.

7
PULP TEMPERATURE INCREASE (°C)

6
5.5°C TEMPERATURE INCREASE SUGGESTED TO CAUSE PULPAL INJURY

4
60-s HIGH
10-s HIGH
5-s TURBO

3
y = 0.0622x + 0.2019
10-s LOW

2 R2 = 0.9982

0
0 10 20 30 40 50 60 70 80
2
APPLIED RADIANT EXPOSURE (J/cm )
• Fig. 6.40 Relationship between delivering known radiant exposures to the facial surfaces of intact,
upper bicuspid teeth and the resulting increase in human intrapulpal temperature rise when using a com-
mercial Polywave® LED-based curing light. Exposure duration and output mode selection noted vertically
for each group. N = 15 per test group. (Courtesy Dr. Cesar A.G. Arrais.)
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CHAPTER 6 Light Curing of Retorative Material 191

39.0

INTRAPULPAL TEMPERATURE (°C)

38.5
INTACT CLASS V
38.0

37.5

37.0

36.5

36.0

35.5
30-s exposure, “HIGH” setting
35.0
0 50 100 150 200 250 300
TIME (seconds)
• Fig. 6.41 Comparison of real-time temperature proiles inside the pulp of an intact bicuspid, and one
having a Class V preparation with approximately 1-mm of dentin remaining when exposed to the same
output time and curing mode from an LED-based curing light. (Courtesy Dr. Cesar A.G. Arrais.)

When light-curing gingival areas, as in Class V situations, the

gingival portions of veneers, and the margins of crowns, a portion
of light output also reaches soft tissue that is often not protected
by a rubber dam. Because of the translucent properties of the
poorly keratinized oral epithelium, light easily penetrates and is
absorbed by these tissues. his may result in a signiicant tissue
burn if some protection is not provided. Even when using a rubber
dam, the potential for elevated tissue temperatures may occur.114
Fig. 6.45 displays a tissue burn resulting from a 30-second direct
light exposure from a high-intensity LED curing light on the
attached gingiva of a pig. hus, especially when using contemporary
high-power curing lights, clinicians must keep in mind the potential
• Fig. 6.42 Directing an air syringe at the opposite surface being light- for causing both direct heat and radiant thermal damage to the
exposed will help to lower the in vivo intrapulpal temperature. (Courtesy
soft tissues and the dental pulp. Clinicians should closely monitor
Professor Marcelo Giannini.)
the position of the light tip and not arbitrarily increase the exposure
time in an attempt to ensure maximal polymerization without
using strategies to minimize thermal damage from the curing light.
Soft Tissue Damage One option is to place a small section of cotton gauze under the
Current literature has reported several cases of soft tissue burns dam to protect the gingiva (Fig. 6.46). Another is to carefully
that were caused by excessive heat either from a hot light curing position the light tip just over the resin and watch what you are
tip or from excessive amounts of light energy delivered to the oral doing when light curing so that the light tip does not wander over
tissues.114 Soft tissue damage to oral tissues arising from photocuring the lips or gingiva.
restorations can arise from two sources: heat developed by the
external housing of the curing light or from heat developed in The Optical “Blue Light Hazard”
tissues that are exposed to the high-intensity light. Often the light
guide of the curing light is used to retract the cheek or tongue. Dentists have a duty to protect both their patients and employees
For LED-based lights that contain the chip sets at the tip, heat from harm. here has been concern that blue light from high-power
generated by the chips is difused to the outer surface of the curing curing lights can place dental personnel at risk for ocular
light. In so doing, the surface temperature of areas on the curing damage.116-120 Although this hazard can be prevented by using
light body opposite to where the chips are emitting may become appropriate eye protection, these items are not universally used.121
hot and thus burn the soft tissues. Fig. 6.44 provides examples of his blue light hazard is related to the wavelength of light (Fig.
how the distal portions of light guides are used to retract the soft 6.47). he hazard mostly occurs between about 415 nm and 480 nm
tissue and illustrates the potential for causing soft tissue damage. and is greatest at 440 nm.122 his wavelength range is well within
However, the maximum acceptable external curing light temperature the emission spectra from all dental curing lights1 (Fig. 6.48). If
increases for curing lights is stipulated in the International Elec- eye protection is not used to eliminate the blue light, and instead
trotechnical Commission speciication, IEC 60601, that applies the operator looks directly at the curing light, even for just 1
to dental curing lights.115 hus, if the curing light has passed this second during the curing cycle before averting his or her eyes, it
speciication, the heat from the external housing of the unit should may only take as few as seven curing cycles to exceed the recom-
not be high enough to cause a burn. mended maximum daily exposure to blue light.116
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192 C HA P T E R 6 Light Curing of Retorative Material

38.0

INTRAPULPAL TEMPERATURE (°C)

37.5
INTACT AIR SPRAY
37.0
36.5
36.0
35.5
35.0 Air spray started 3-s
34.5 prior to light exposure

34.0
33.5
30-s exposure, “HIGH” setting
33.0
0 50 100 150 200 250 300
TIME (seconds)
• Fig. 6.43 Comparison of real-time, human pulpal temperature values between an intact facial surface,
with no air-cooling during exposure (blue proile), and when the lingual surface was air-cooled prior to
and all throughout the light exposure (orange proile). Air-cooling resulted in a 2°C pulp temperature
decrease. (Courtesy Dr. Cesar A.G. Arrais.)

A B

• Fig. 6.44 Curing light used to relect the tongue (A) and cheek
(B) to gain better access to the operative site, or resting on the lip
C
during light exposure (C).

Blue light is transmitted through the ocular media and absorbed is thought to accelerate age-related macular degeneration
by the retina. Although high levels of blue light can cause immediate (ARMD).123,124 Most countries follow international guidelines,
and irreversible retinal burning, there are also concerns that repeated, such as those from the International Commission on Non-Ionizing
chronic exposure to low levels of blue light will cause accelerated Radiation Protection (ICNIRP) and the American Conference of
retinal degeneration and chronic photochemical injury to the Governmental Industrial Hygienists (ACGIH), when determining
retinal-pigmented epithelium and choroid. his chronic exposure safe levels of exposure to blue light in all workplaces, not just
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CHAPTER 6 Light Curing of Retorative Material 193

• Fig. 6.45 Erythema resulting from exposure of pig gingiva to a high-

intensity LED curing light. (Reprinted from Maucoski C, Zarpellon DC, Dos
Santos FA, et al: Analysis of temperature increase in swine gingiva after
exposure to a Polywave® LED light curing unit, Dent Mater 33(11): 1266- • Fig. 6.47 Graphical depiction of the blue light hazard function related to
1273, 2017. With permission from The Academy of Dental Materials.) wavelength. The maximum hazard values occur between 415 and 480 nm.
(From Rueggeberg FA, Giannini M, Arrais CAG, Price RBT: Light curing in
dentistry and clinical implications: a literature review, Braz Oral Res 31(suppl
1): e61, 2017. http://dx.doi.org/10.1590/1807-3107bor-2017.vol31.0061.
Licensed under CC BY 2.0, https://creativecommons.org/licenses/by/2.0/.)

• Fig. 6.48 Superimposition of the wavelengths of light that cause the

blue light hazard (light blue area) and that of the emission spectrum from
a multiwave LED dental curing light (violet area). The blue light component
from dental curing light is within the hazard range. (From Rueggeberg FA,
Giannini M, Arrais CAG, Price RBT: Light curing in dentistry and clinical
implications: a literature review, Braz Oral Res 31(suppl 1): e61,
2017. http://dx.doi.org/10.1590/1807-3107bor-2017.vol31.0061. Licensed
B under CC BY 2.0, https://creativecommons.org/licenses/by/2.0/.)

• Fig. 6.46 Conventional positioning of a curing tip when exposing a

Class V preparation (A). Such a position can cause a tissue burn even Blue Light Blocking Protection
under the rubber dam. A small section of cotton gauze can be placed
Using appropriate ocular protection can completely prevent the blue
under the dam to protect the gingiva (B). (Courtesy Professor Marcelo
Giannini.)
light hazard and all LCU manufacturers supply and recommend the
use of protective blue-blocking orange shields to protect the eyes
from the bright blue light. hese orange plastic shields are usually
dental oices.122,123 It should also be noted that these maximum attached to the light tip and can be adjusted to provide eye protection
recommended exposure times have been developed for individuals to the operator. Other types of protective glasses and paddles are also
with normal photosensitivity. Patients or dental personnel who available in various sizes, thickness, and designs (Fig. 6.49).
have had cataract surgery or who are taking photosensitizing Most of the protective orange ilters used in dentistry are designed
medications will have a greater susceptibility for retinal damage.122,123 to reduce the risks of exposure to wavelengths of blue light between
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194 C HA P T E R 6 Light Curing of Retorative Material

A B
• Fig. 6.49 Various forms of “blue-blocker” eye protection.

A B
• Fig. 6.50 Depiction of spectral emission of a multiwave LED curing light (A) and how the blue-blocker
shield ilters harmful radiation while allowing light of longer wavelengths to pass (B).

420 and 500 nm. A schematic representation of how blue-blocking

ilters block the damaging radiation from curing lights is seen in
Fig. 6.50.
he best blue light iltering glasses (“orange blue-blockers”)
have been shown to reduce the transmission of light below 500 nm
by 99%.125 When such blue light iltering glasses are used, instead
of looking away from the bright blue light, the operator can safely
watch what he or she is doing when light curing; thus they can
keep the light tip directly over the resin they are trying to light
cure. However, not all brands of protective ilters are equally efective
and some protective ilters have been reported to be inadequate • Fig. 6.51 The position of the light tip can produce unwanted shadows
if they are used to protect the eye against a range of wavelengths and under-cured resin.
other than the intended range.125 hus it is important to use the
correct blue-blocking ilter for the curing light being used. Teaching How to Light Cure
Much of the research on dental resins has been conducted in a
Electromagnetic Rik From Curing Light laboratory setting, using a curing light held in a ixed position
here is some concern that the electrical circuitry in curing light that is very close to the resin surface. Although this method makes
can interact with implanted pacemakers.126 Although there is a the results more consistent, this is not a clinically relevant condition.
theoretical risk, the initial laboratory tests were performed under When light curing a restoration in the mouth both the dentist
conditions where the investigators used physiologic saline baths and the patient often move, and access to the posterior teeth is
and benchtop settings. Major companies are required to test for often limited. Unless the operator is very careful, the position of
this hazard before selling their curing lights, and there should be the light tip can drift away from the restoration, or unwanted
no risk if the curing light has been purchased from a reputable shadows may be produced that can have an adverse efect on the
manufacturer.127,128 here may be a risk when using untested budget amount of energy delivered to the restoration and the subsequent
curing lights. level of resin polymerization (Fig. 6.51).129,130
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CHAPTER 6 Light Curing of Retorative Material 195

It is known that the light-delivery technique used by the operator

can have a signiicant efect on the radiant exposure delivered to
the restorative material, especially when it is common practice not
to watch the position of the curing light tip over the restoration
when light curing. Not only can this practice negatively afect the
amount of energy delivered to the restoration, it can also result in
a tissue burn.6,114,130-133 he operator variability in how much light
is delivered can be reduced and the radiant exposure delivered to
restorations increased if the operator has been trained using a
device that shows, in real time, his or her ability to efectively
deliver light energy to a simulated restoration. Such a clinical
training simulator (MARC-Patient Simulator, BlueLight Analytics,
Halifax, Canada) is seen in Fig. 6.52.
Individualized hands-on training on how to perform light curing
of a restoration includes learning how to correctly position the
patient to improve access and how to position the light guide
throughout the light curing process.129,131,133-135 By providing
immediate feedback to the operator on how much irradiance and
energy is being delivered, together with instructor coaching on
how to avoid mistakes, the MARC-Patient Simulator has been
shown to be an efective method to teach how to light cure a restora-
tion. Examples of the real-time irradiance delivered to a speciic • Fig. 6.52 Light curing a simulated restoration using the MARC-Patient
restorative location by several operators during a 10-second exposure Simulator (BlueLight Analytics, Halifax, Canada).

• Fig. 6.53 Before and after images of irradiance

levels delivered by several operators to a speciic
intraoral location during a 10-second light expo-
sure, as monitored using the MARC-PS patient
simulator. The after image shows great improve-
ment in how consistently the light was delivered
throughout the exposures. The operators also
delivered more total energy after instruction.
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196 C HA P T E R 6 Light Curing of Retorative Material

and monitored using the MARC-PS patient simulator are seen in 12. Bhalla M, Patel D, Shashikiran ND, et al: Efect of light-emitting
Fig. 6.53. he after-image shows a great improvement in the diode and halogen light curing on the micro-hardness of dental
consistency in the irradiance that was delivered throughout the composite and resin-modiied glass ionomer cement: an in vitro
exposure. he operators also delivered a greater radiant exposure study. J Indian Soc Pedod Prev Dent 30:201–205, 2012.
13. Sigusch BW, Plaum T, Volpel A, et al: Resin-composite cytotoxic-
(amount of energy in J/cm2) after instruction, thereby increasing
ity varies with shade and irradiance. Dent Mater 28:312–319,
the potential for achieving the intended properties and the promising 2012.
in vitro results for the restorative material they are using. 14. Durner J, Obermaier J, Draenert M, et al: Correlation of the degree
of conversion with the amount of elutable substances in nano-hybrid
dental composites. Dent Mater 28:1146–1153, 2012.
General Recommendation When Uing 15. Salehi S, Gwinner F, Mitchell JC, et al: Cytotoxicity of resin
a Curing Light composites containing bioactive glass illers. Dent Mater 31:195–203,
2015.
As a general recommendation, users should be aware of the radiant 16. Soh MS, Yap AU: Inluence of curing modes on crosslink density
power output, active emitting tip dimensions, irradiance, efect of in polymer structures. J Dent 32:321–326, 2004.
17. Asmussen E, Peutzfeldt A: Inluence of pulse-delay curing on softening
distance on irradiance, and emission spectrum from the curing
of polymer structures. J Dent Res 80:570–573, 2001.
light they are using. heir light should be tested regularly to ensure 18. Benetti AR, Peutzfeldt A, Asmussen E, et al: Inluence of curing
that it is functioning according to the manufacturer’s speciications rate on softening in ethanol, degree of conversion, and wear of resin
and that the output has not changed signiicantly since purchase. composite. Am J Dent 24:115–118, 2011.
When light curing, clinicians should deliver suicient radiant 19. Craig RG: Chemistry, composition, and properties of composite
exposure at the correct wavelengths of light required by the resins. Dent Clin North Am 25:219–239, 1981.
photoinitiator used in the resin composite they are using. To 20. AlShaai MM, Harlow JE, Price HL, et al: Emission characteristics
maximize the radiant exposure delivered, the light tip should be and efect of battery drain in “budget” curing lights. Oper Dent
held both close to and perpendicular to the surface of the restoration. 41:397–408, 2016.
Operators should directly observe what they are doing throughout 21. Shimokawa CA, Turbino ML, Harlow JE, et al: Light output from
six battery operated dental curing lights. Mater Sci Eng C Mater
the entire light exposure, and to do so safely, they must also use
Biol Appl 69:1036–1042, 2016.
appropriate eye protection. Precautions should be taken to avoid 22. Stansbury JW: Curing dental resins and composites by photopoly-
causing an unacceptable temperature increase in the tooth and the merization. J Esthet Dent 12:300–308, 2000.
adjacent soft tissues.41,102,136 23. Neumann MG, Miranda WG, Jr, Schmitt CC, et al: Molar extinction
coeicients and the photon absorption eiciency of dental photoinitia-
tors and light curing units. J Dent 33:525–532, 2005.
Reference 24. Burtscher P: Ivocerin in comparison to camphorquinone. Ivoclar
Vivadent Report, No. 19, July, 2013: 2013.
1. Rueggeberg FA: State-of-the-art: dental photocuring–a review. Dent 25. Tirtha R, Fan PL, Dennison JB, et al: In vitro depth of cure of
Mater 27:39–52, 2011. photo-activated composites. J Dent Res 61:1184–1187, 1982.
2. Jandt KD, Mills RW: A brief history of LED photopolymerization. 26. Wilder AD, Jr, May KN, Jr, Bayne SC, et al: Seventeen-year clinical
Dent Mater 29:605–617, 2013. study of ultraviolet-cured posterior composite Class I and II restora-
3. Price RB, Ferracane JL, Shortall AC: Light-curing units: A review tions. J Esthet Dent 11:135–142, 1999.
of what we need to know. J Dent Res 94:1179–1186, 2015. 27. Musanje L, Darvell BW: Polymerization of resin composite restorative
4. Santini A, Turner S: General dental practitioners’ knowledge of materials: exposure reciprocity. Dent Mater 19:531–541, 2003.
polymerisation of resin-based composite restorations and light curing 28. Selig D, Haenel T, Hausnerova B, et al: Examining exposure reciproc-
unit technology. Br Dent J 211:E13, 2011. ity in a resin based composite using high irradiance levels and
5. Ferracane JL, Mitchem JC, Condon JR, et al: Wear and marginal real-time degree of conversion values. Dent Mater 31:583–593,
breakdown of composites with various degrees of cure. J Dent Res 2015.
76:1508–1516, 1997. 29. Leprince JG, Hadis M, Shortall AC, et al: Photoinitiator type and
6. Shortall A, El-Mahy W, Stewardson D, et al: Initial fracture resistance applicability of exposure reciprocity law in illed and unilled photoac-
and curing temperature rise of ten contemporary resin-based tive resins. Dent Mater 27:157–164, 2011.
composites with increasing radiant exposure. J Dent 41:455–463, 30. Hadis M, Leprince JG, Shortall AC, et al: High irradiance curing
2013. and anomalies of exposure reciprocity law in resin-based materials.
7. Xu X, Sandras DA, Burgess JO: Shear bond strength with increasing J Dent 39:549–557, 2011.
light-guide distance from dentin. J Esthet Restor Dent 18:19–27, 31. Wydra JW, Cramer NB, Stansbury JW, et al: he reciprocity law
discussion 28, 2006. concerning light dose relationships applied to BisGMA/TEGDMA
8. Vandewalle KS, Ferracane JL, Hilton TJ, et al: Efect of energy photopolymers: theoretical analysis and experimental characterization.
density on properties and marginal integrity of posterior resin Dent Mater 30:605–612, 2014.
composite restorations. Dent Mater 20:96–106, 2004. 32. Ruyter IE, Øysæd H: Conversion in diferent depths of ultraviolet
9. Purushothaman D, Kailasam V, Chitharanjan AB: Bisphenol A and visible light activated composite materials. Acta Odontol Scand
release from orthodontic adhesives and its correlation with the 40:179–192, 1982.
degree of conversion. Am J Orthod Dentofacial Orthop 147:29–36, 33. Harlow JE, Rueggeberg FA, Labrie D, et al: Transmission of violet
2015. and blue light through conventional (layered) and bulk cured
10. Nocca G, Iori A, Rossini C, et al: Efects of barriers on chemical resin-based composites. J Dent 53:44–50, 2016.
and biological properties of two dual resin cements. Eur J Oral Sci 34. Cook WD, Standish PM: Cure of resin based restorative materials.
123:208–214, 2015. II. White light photopolymerized resins. Aust Dent J 28:307–311,
11. El-Damanhoury HM, Gaintantzopoulou M: Efect of thermocycling, 1983.
degree of conversion, and cavity coniguration on the bonding 35. Chen YC, Ferracane JL, Prahl SA: A pilot study of a simple photon
efectiveness of all-in-one adhesives. Oper Dent 40:480–491, migration model for predicting depth of cure in dental composite.
2015. Dent Mater 21:1075–1086, 2005.
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CHAPTER 6 Light Curing of Retorative Material 197

36. dos Santos GB, Alto RV, Filho HR, et al: Light transmission on 58. Ilie N, Jelen E, Hickel R: Is the soft-start polymerisation concept
dental resin composites. Dent Mater 24:571–576, 2008. still relevant for modern curing units? Clin Oral Investig 15:21–29,
37. Price RB, Murphy DG, Dérand T: Light energy transmission through 2011.
cured resin composite and human dentin. Quintessence Int 31: 59. Dall’Magro E, Correr AB, Costa AR, et al: Efect of diferent
659–667, 2000. photoactivation techniques on the bond strength of a dental
38. Taira M, Suzuki H, Toyooka H, et al: Refractive index of inorganic composite. Braz Dent J 21:220–224, 2010.
illers in seven visible-light-cured dental composite resins. J Mater 60. Inoue K, Howashi G, Kanetou T, et al: Efect of light intensity on
Sci Lett 13:68–70, 1994. linear shrinkage of photo-activated composite resins during setting.
39. Shortall AC, Palin WM, Burtscher P: Refractive index mismatch J Oral Rehabil 32:22–27, 2005.
and monomer reactivity inluence composite curing depth. J Dent 61. van Dijken JW, Pallesen U: A 7-year randomized prospective study
Res 87:84–88, 2008. of a one-step self-etching adhesive in non-carious cervical lesions.
40. Price RB, Shortall AC, Palin WM: Contemporary issues in light he efect of curing modes and restorative material. J Dent 40:
curing. Oper Dent 39:4–14, 2014. 1060–1067, 2012.
41. Shortall AC, Price RB, MacKenzie L, et al: Guidelines for the 62. Harlow JE, Sullivan B, Shortall AC, et al: Characterizing the output
selection, use, and maintenance of LED light-curing units - Part settings of dental curing lights. J Dent 44:20–26, 2016.
II. Br Dent J 221:551–554, 2016. 63. Fujibayashi K, Shimaru K, Takahashi N, et al: Newly developed
42. Shortall AC, Price RB, MacKenzie L, et al: Guidelines for the curing unit using blue light-emitting diodes. Dent Jpn (Tokyo)
selection, use, and maintenance of LED light-curing units - Part 34:49–53, 1998.
1. Br Dent J 221:453–460, 2016. 64. Mills RW, Jandt KD, Ashworth SH: Dental composite depth of
43. Yaman BC, Efes BG, Dorter C, et al: he efects of halogen and cure with halogen and blue light emitting diode technology. Br
light-emitting diode light curing on the depth of cure and surface Dent J 186:388–391, 1999.
microhardness of composite resins. J Conserv Dent 14:136–139, 65. Hofmann N, Hugo B, Klaiber B: Efect of irradiation type (LED
2011. or QTH) on photo-activated composite shrinkage strain kinetics,
44. Curtis JW, Jr, Rueggeberg FA, Lee AJ: Curing eiciency of the temperature rise, and hardness. Eur J Oral Sci 110:471–479, 2002.
Turbo Tip. Gen Dent 43:428–433, 1995. 66. Weerakoon AT, Meyers IA, Symons AL, et al: Pulpal heat changes
45. Price RB, Derand T, Sedarous M, et al: Efect of distance on the with newly developed resin photopolymerisation systems. Aust
power density from two light guides. J Esthet Dent 12:320–327, Endod J 28:108–111, 2002.
2000. 67. Ozturk AN, Usumez A: Inluence of diferent light sources on
46. Busemann I, Lipke C, Schattenberg A, et al: Shortest exposure time microtensile bond strength and gap formation of resin cement under
possible with LED curing lights. Am J Dent 24:37–44, 2011. porcelain inlay restorations. J Oral Rehabil 31:905–910, 2004.
47. Burdick JA, Lovestead TM, Anseth KS: Kinetic chain lengths 68. Andreatta LM, Furuse AY, Prakki A, et al: Pulp chamber heating:
in highly cross-linked networks formed by the photoiniti- An in vitro study evaluating diferent light sources and resin composite
ated polymerization of divinyl monomers: A gel permeation layers. Braz Dent J 27:675–680, 2016.
chromatography investigation. Biomacromolecules 4:149–156, 69. Price RB, Labrie D, Rueggeberg FA, et al: Correlation between the
2003. beam proile from a curing light and the microhardness of four
48. Feng L, Carvalho R, Suh BI: Insuicient cure under the condition resins. Dent Mater 30:1345–1357, 2014.
of high irradiance and short irradiation time. Dent Mater 25:283–289, 70. Price RB, Labrie D, Rueggeberg FA, et al: Irradiance diferences in
2009. the violet (405 nm) and blue (460 nm) spectral ranges among
49. Lovell LG, Newman SM, Bowman CN: he efects of light intensity, dental light-curing units. J Esthet Restor Dent 22:363–377, 2010.
temperature, and comonomer composition on the polymerization 71. Issa Y, Watts DC, Boyd D, et al: Efect of curing light emission
behavior of dimethacrylate dental resins. J Dent Res 78:1469–1476, spectrum on the nanohardness and elastic modulus of two bulk-ill
1999. resin composites. Dent Mater 32:535–550, 2016.
50. Taubock TT, Feilzer AJ, Buchalla W, et al: Efect of modulated 72. Magalhaes Filho TR, Weig KM, Costa MF, et al: Efect of LED-LCU
photo-activation on polymerization shrinkage behavior of light irradiance distribution on mechanical properties of resin based
dental restorative resin composites. Eur J Oral Sci 122:293–302, materials. Mater Sci Eng C Mater Biol Appl 63:301–307, 2016.
2014. 73. ISO 10650 Dentistry-Powered polymerization activators. Geneva,
51. Randolph LD, Palin WM, Watts DC, et al: he efect of ultra-fast Switzerland: International Standards Organization: International
photopolymerisation of experimental composites on shrinkage stress, Standards Organization; 2015. p. 14.
network formation and pulpal temperature rise. Dent Mater 74. Coherent. White Paper: Novel Laser Power Sensor Improves Process
30:1280–1289, 2014. Control. https://http://www.coherent.com/?fuseaction=form.requi
52. Kanca J, 3rd, Suh BI: Pulse activation: reducing resin-based composite red&download=8992&title=PowerMax-Pro-White-Paper-Novel-
contraction stresses at the enamel cavosurface margins. Am J Dent Laser-Power-Sensor-Improves-Process-Control: Coherent; (Cited
12:107–112, 1999. 12 August 2016). 1-7.
53. Suh BI, Feng L, Wang Y, et al: he efect of the pulse-delay cure 75. Vandewalle KS, Roberts HW, Rueggeberg FA: Power distribution
technique on residual strain in composites. Compendium 20:4–12, across the face of diferent light guides and its efect on composite
1999. surface microhardness. J Esthet Restor Dent 20:108–117, discussion
54. Feng L, Suh BI: A mechanism on why slower polymerization of a 118, 2008.
dental composite produces lower contraction stress. J Biomed Mater 76. Michaud PL, Price RB, Labrie D, et al: Localised irradiance distribu-
Res B Appl Biomater 78:63–69, 2006. tion found in dental light curing units. J Dent 42:129–139, 2014.
55. Bouschlicher MR, Rueggeberg FA: Efect of ramped light intensity 77. Yearn JA: Factors afecting cure of visible light activated composites.
on polymerization force and conversion in a photoactivated com- Int Dent J 35:218–225, 1985.
posite. J Esthet Dent 12:328–339, 2000. 78. Friedman J: Variability of lamp characteristics in dental curing
56. Chye CH, Yap AU, Laim YC, et al: Post-gel polymerization shrinkage lights. J Esthet Dent 1:189–190, 1989.
associated with diferent light curing regimens. Oper Dent 79. Rueggeberg FA, Caughman WF, Comer RW: he efect of autoclaving
30:474–480, 2005. on energy transmission through light-curing tips. J Am Dent Assoc
57. Lopes LG, Franco EB, Pereira JC, et al: Efect of light-curing units 127:1183–1187, 1996.
and activation mode on polymerization shrinkage and shrinkage 80. Poulos JG, Styner DL: Curing lights: changes in intensity output
stress of composite resins. J Appl Oral Sci 16:35–42, 2008. with use over time. Gen Dent 45:70–73, 1997.
 www.konkur.in
198 C HA P T E R 6 Light Curing of Retorative Material

81. McAndrew R, Lynch CD, Pavli M, et al: he efect of disposable 105. Atai M, Motevasselian F: Temperature rise and degree of photopo-
infection control barriers and physical damage on the power output lymerization conversion of nanocomposites and conventional dental
of light curing units and light curing tips. Br Dent J 210:E12, composites. Clin Oral Investig 13:309–316, 2009.
2011. 106. Gomes M, DeVito-Moraes A, Francci C, et al: Temperature increase
82. Strydom C: Dental curing lights–maintenance of visible light curing at the light guide tip of 15 contemporary LED units and thermal
units. SADJ 57:227–233, 2002. variation at the pulpal loor of cavities: an infrared thermographic
83. Price RB, Labrie D, Kazmi S, et al: Intra- and inter-brand accuracy analysis. Oper Dent 38:324–333, 2013.
of four dental radiometers. Clin Oral Investig 16:707–717, 2012. 107. Mouhat M, Mercer J, Stangvaltaite L, et al: Light-curing units used
84. Leonard DL, Charlton DG, Hilton TJ: Efect of curing-tip diameter in dentistry: factors associated with heat development—potential
on the accuracy of dental radiometers. Oper Dent 24:31–37, 1999. risk for patients. Clin Oral Investig 1–10, 2016.
85. Roberts HW, Vandewalle KS, Berzins DW, et al: Accuracy of LED 108. Park SH, Roulet JF, Heintze SD: Parameters inluencing increase
and halogen radiometers using diferent light sources. J Esthet Restor in pulp chamber temperature with light-curing devices: curing lights
Dent 18:214–222, discussion 223-214, 2006. and pulpal low rates. Oper Dent 35:353–361, 2010.
86. Marovic D, Matic S, Kelic K, et al: Time dependent accuracy of 109. Runnacles P, Arrais CA, Pochapski MT, et al: Direct measurement
dental radiometers. Acta Clin Croat 52:173–180, 2013. of time-dependent anesthetized in vivo human pulp temperature.
87. Rueggeberg FA, Caughman WF, Curtis JW, Jr: Efect of light Dent Mater 31:53–59, 2015.
intensity and exposure duration on cure of resin composite. Oper 110. Kodonas K, Gogos C, Tziafas D: Efect of simulated pulpal
Dent 19:26–32, 1994. microcirculation on intrapulpal temperature changes following
88. Anusavice KJ, Phillips RW, Shen C, et al: Phillips’ science of dental application of heat on tooth surfaces. Int Endod J 42:247–252,
materials, ed 12, St. Louis, Mo., 2013, Elsevier/Saunders, p 290, 2009.
xiii. 571 p. 111. Flávio Henrique Baggio A, Gisele Kanda Peres B, Débora Alves
89. Calheiros FC, Daronch M, Rueggeberg FA, et al: Degree of conver- Nunes Leite L, et al: Efect of composite resin polymerization modes
sion and mechanical properties of a BisGMA:TEGDMA composite on temperature rise in human dentin of diferent thicknesses: an
as a function of the applied radiant exposure. J Biomed Mater Res in vitro study. Biomed Mater 1:140, 2006.
B Appl Biomater 84:503–509, 2008. 112. Onisor I, Asmussen E, Krejci I: Temperature rise during photo-
90. Fan PL, Schumacher RM, Azzolin K, et al: Curing-light intensity polymerization for onlay luting. Am J Dent 24:250–256, 2011.
and depth of cure of resin-based composites tested according to 113. Strassler HE: Successful light curing- not as easy as it looks. Oral
international standards. J Am Dent Assoc 133:429–434, 2002. Health 103:18–26, 2013.
91. Nitta K: Efect of light guide tip diameter of LED-light curing unit 114. Spranley TJ, Winkler M, Dagate J, et al: Curing light burns. Gen
on polymerization of light-cured composites. Dent Mater 21:217–223, Dent 60:e210–e214, 2012.
2005. 115. International Electrotechnical Commission: IEC 60601-1:2015
92. Leprince JG, Palin WM, Hadis MA, et al: Progress in dimethacrylate- SER Series. Medical electrical equipment. Geneva, Switzerland.
based dental composite technology and curing eiciency. Dent Mater 2015.
29:139–156, 2013. 116. Labrie D, Moe J, Price RB, et al: Evaluation of ocular hazards from
93. Shortall AC, Felix CJ, Watts DC: Robust spectrometer-based 4 types of curing lights. J Can Dent Assoc 77:b116, 2011.
methods for characterizing radiant exitance of dental LED light 117. McCusker N, Lee SM, Robinson S, et al: Light curing in orthodontics;
curing units. Dent Mater 31:339–350, 2015. should we be concerned? Dent Mater 29:e85–e90, 2013.
94. D’Alpino PH, Wang L, Rueggeberg FA, et al: Bond strength of 118. Bruzell Roll EM, Jacobsen N, Hensten-Pettersen A: Health hazards
resin-based restorations polymerized with diferent light-curing associated with curing light in the dental clinic. Clin Oral Investig
sources. J Adhes Dent 8:293–298, 2006. 8:113–117, 2004.
95. Ash MM, Nelson SJ, Ash MM: Dental anatomy, physiology, and 119. Price RB, Labrie D, Bruzell EM, et al: he dental curing light: A
occlusion, ed 8, Philadelphia, 2003, W.B. Saunders, p xiv. 523 p., potential health risk. J Occup Environ Hyg 13:639–646, 2016.
516 p. of col. plates p. 120. Stamatacos C, Harrison JL: he possible ocular hazards of LED
96. Price RB, Labrie D, Whalen JM, et al: Efect of distance on irradiance dental illumination applications. J Tenn Dent Assoc 93:25–29, quiz
and beam homogeneity from 4 light-emitting diode curing units. 30-21, 2013.
J Can Dent Assoc 77:b9, 2011. 121. Hill EE: Eye safety practices in U.S. dental school restorative clinics,
97. Corciolani G, Vichi A, Davidson CL, et al: he inluence of tip 2006. J Dent Educ 70:1294–1297, 2006.
geometry and distance on light-curing eicacy. Oper Dent 33:325–331, 122. American Conference of Governmental Industrial Hygienists
2008. (ACGIH): TLVs and BEIs Based on the Documentation for
98. Vandewalle KS, Roberts HW, Andrus JL, et al: Efect of light disper- hreshold Limit Values for Chemical Substances and Physical
sion of LED curing lights on resin composite polymerization. Agents and Biological Exposure Indices. ACGIH Cincinnati, Ohio,
J Esthet Restor Dent 17:244–254, discussion 254-245, 2005. 2015.
99. Coutinho M, Trevizam NC, Takayassu RN, et al: Distance and 123. International Commission on non-ionizing radiation protection:
protective barrier efects on the composite resin degree of conversion. Guidelines on limits of exposure to broad-band incoherent optical
Contemp Clin Dent 4:152–155, 2013. radiation (0.38 to 3 µm). Health Phys 73:539–554, 1997.
100. Scott BA, Felix CA, Price RB: Efect of disposable infection control 124. Ham WT, Jr, Rufolo JJ, Jr, Mueller HA, et al: Histologic analysis
barriers on light output from dental curing lights. J Can Dent Assoc of photochemical lesions produced in rhesus retina by short-wave-
70:105–110, 2004. length light. Invest Ophthalmol Vis Sci 17:1029–1035, 1978.
101. Sword RJ, Do UN, Chang JH, et al: Efect of curing light barriers 125. Bruzell EM, Johnsen B, Aalerud TN, et al: Evaluation of eye protec-
and light types on radiant exposure and composite conversion. tion ilters for use with dental curing and bleaching lamps. J Occup
J Esthet Restor Dent 28:29–42, 2016. Environ Hyg 4:432–439, 2007.
102. Strassler HE, Price RB: Understanding light curing, Part II. Delivering 126. Miller CS, Leonelli FM, Latham E: Selective interference with
predictable and successful restorations. Dent Today 1–8, quiz 9, 2014. pacemaker activity by electrical dental devices. Oral Surg Oral Med
103. Zach L, Cohen G: Pulp response to externally applied heat. Oral Oral Pathol Oral Radiol Endod 85:33–36, 1998.
Surg Oral Med Oral Pathol 19:515–530, 1965. 127. Elayi CS, Lusher S, Meeks Nyquist JL, et al: Interference between
104. Baroudi K, Silikas N, Watts DC: In vitro pulp chamber temperature dental electrical devices and pacemakers or deibrillators: results
rise from irradiation and exotherm of lowable composites. Int J from a prospective clinical study. J Am Dent Assoc 146:121–128,
Paediatr Dent 19:48–54, 2009. 2015.
 www.konkur.in
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128. Roedig JJ, Shah J, Elayi CS, et al: Interference of cardiac pacemaker 133. Federlin M, Price R: Improving light-curing instruction in dental
and implantable cardioverter-deibrillator activity during electronic school. J Dent Educ 77:764–772, 2013.
dental device use. J Am Dent Assoc 141:521–526, 2010. 134. Mutluay MM, Rueggeberg FA, Price RB: Efect of using proper
129. Price RB, McLeod ME, Felix CM: Quantifying light energy delivered light-curing techniques on energy delivered to a Class 1 restoration.
to a Class I restoration. J Can Dent Assoc 76:a23, 2010. Quintessence Int 45:549–556, 2014.
130. Konerding KL, Heyder M, Kranz S, et al: Study of energy transfer 135. Price RB, Strassler HE, Price HL, et al: he efectiveness of using
by diferent light curing units into a class III restoration as a function a patient simulator to teach light-curing skills. J Am Dent Assoc
of tilt angle and distance, using a MARC Patient Simulator (PS). 145:32–43, 2014.
Dent Mater 32:676–686, 2016. 136. Price RB: Light curing in dentistry. Dent Clin North Am 61:578–778,
131. Seth S, Lee CJ, Ayer CD: Efect of instruction on dental students’ 2017.
ability to light-cure a simulated restoration. J Can Dent Assoc
78:c123, 2012.
132. Price RB, Felix CM, Whalen JM: Factors afecting the energy
delivered to simulated class I and class v preparations. J Can Dent
Assoc 76:a94, 2010.
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200 C HA P T E R 7 Color and Shade Matching in Operative Dentitry

7
Color and Shade Matching in
Operative Dentistry
JOE C. ONTIVEROS, RADE D. PARAVINA

C
olor plays a critical role in the success or failure of esthetic he more numerous of the two photoreceptors are the rods, which
dental restorations. Shade matching is as much an art as are sensitive to low levels of light. he rods are primarily responsible
it is a science, and requires knowledge of color science for our peripheral vision and are unable to detect color. In low
principles and the implementation of adequate shade matching levels of light, rods help us see objects in gray scale; as the light
techniques. his chapter provides a working knowledge of the becomes brighter, the rods become inactive. On the other hand,
principles of color and perception relative to understanding the the cones operate in bright light and provide high acuity color
complex nature of tooth color and appearance. Shade matching vision. Both photoreceptors transform light into chemical energies
methods and tools for achieving predictable esthetic outcomes will that stimulate millions of nerve endings. he neural signals are
be discussed along with resources available for continued transported by the optic nerve to the brain, where color is inter-
improvement. preted. here are three types of cones in the retina that are sensitive
to diferent wavelengths of light: blue, green, and red. he blue
cones are most responsive to short wavelengths. he green and
Color and Perception red cones are most responsive to medium and longer wavelengths,
respectively, with some overlap.
The Color Triplet (Oberver Situation)
he human perception of color results from the interaction of Color Deiciency
three elements: light source, object, and observer (Fig. 7.1). Color vision deiciency is a weakness or absence in one or more
Because all three of these elements can be modiied, any change of the three types of cones. he most common color deiciency
in one element will afect the inal perception of color. he light in the population is an individual with a partial green defect known
source is a visible form of electromagnetic (EM) radiation that as deuteranomaly. Other deiciencies are protanomaly, which is caused
illuminates the object. When light strikes the object (tooth), a by a reduced sensitivity to red light, and tritanomaly, which is
proportion of the energy is absorbed, transmitted, or relected. Color someone lacking blue vision. Individuals with these color deiciencies
perception is dependent upon the subjective ability of the human still see color; however, their color vision is distorted (Fig. 7.2).
visual system to combine and interpret the physical interactions Color blind individuals lack all three types of cones; this condition
of light and object. he quantity of relected light reaching the is called monochromacy or achromatopsia. Color deiciency poses a
observer’s eyes stimulates a subjective sensation in the brain that challenge for the clinician when performing visual shade matching.
we experience as color. In other words, the perception of color Popular general tests to check color vision are the Ishihara Test
ultimately resides in the brain and not merely in the property of (Fig. 7.3) and the Farnsworth-Munsell Test.
the object. For this reason, color can be deined as a psychophysical
sensation provoked in the eye by the visible light and interpreted by Color Dimenion
the brain.
here are numerous systems and theories for arranging color in
Color Viion some orderly fashion (i.e., color spaces). he most popular system
for visual color matching in dentistry is based on the three-
Rods and Cones dimensional model devised by American artist Alfred H. Munsell
he human eye and brain, which enable color vision, form an in 1898.2 Munsell’s color system forms the basis for the classiication
amazing and complex system. he visual system of a person with of colored objects in the three dimensions: hue, value, and chroma.
normal color vision can identify millions of diferent colors.1,2 At It is important to grasp the concepts of hue, value, and chroma
the innermost retinal layer of the eye are two types of specialized to fully understand dental shade matching as described in this
neurons that function as photoreceptors, called rods and cones. chapter.

200
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CHAPTER 7 Color and Shade Matching in Operative Dentitry 201

Light source Object Observer

• Fig. 7.1 The color triplet (observer situation).

A B

C D
• Fig 7.2 A, Unaltered digital image, corresponding to normal color vision and after color deiciency
simulations. B, Protanomaly. C, Deuteranomaly. D, Tritanomaly. (The original image processed at http://
www.color-blindness.com/coblis-color-blindness-simulator/.)

Hue of gray. It is usually communicated in terms of lighter or darker.

his color dimension is the attribute by which an object is judged A tooth that appears lighter, or “brighter,” as a result of bleaching
to appear red, orange, yellow, green, blue, purple, etc. hese are would display an increase in value.
the “pure” colors found on a basic color wheel or a simple box of
crayons. hese hues, which appear on the visual spectrum, are Chroma
placed on a continuous, circular scale as seen in Fig. 7.4. Compared While hue enables the distinction and diferentiation among
to a standard, the hue of an object would be communicated in diferent colors, chroma is related to variation in strength of the
terms such as redder, yellower, greener, or bluer. same color. he further away from the achromatic vertical axis,
the higher the chroma (stronger, more intense). he closer the
Value color is to the achromatic (value) axis, the lower the chroma (paler,
he dimension of value refers to the lightness of a color. It is the weaker). Chroma is often described as more chromatic or less
achromatic vertical scale from black to white representing all shades chromatic. A tooth with a redder and/or yellower appearance at
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202 C HA P T E R 7 Color and Shade Matching in Operative Dentitry

A B
• Fig. 7.3 Ishihara Test. Observer should see number 74 (A) and number 42 (B). (Reproduced from
Ishihara’s Tests for Colour Blindness. Tokyo: Kanehara & Co., but tests for color blindness cannot be
conducted with this material. For accurate testing, the original plates should be used.)

the cervical region, as commonly seen on a canine, can be described

as more chromatic at that region. As the chroma increases, the
hue becomes more speciic.
Value
Hue Other Optical Propertie
When light waves strike the surface of an object, the change in
refractive index can cause waves to be relected, absorbed, or
transmitted by the material. he combination of light speed and
directional changes of the waves results in particular optical appear-
Chroma ances of teeth as described later in the chapter.

Translucency
Translucency is the degree to which an object scatters light upon
transmission, resulting in an appearance between complete opacity
and complete transparency. Complete opacity will obscure the
substrate beneath it by blocking the passage of light, while a
completely transparent object will transmit light without scattering
and will clearly show the substrate beneath it.

Iridescence
Iridescence is a rainbowlike efect caused by the difraction of light
that changes according to the angle from which it is viewed or
the angle of incidence of the light source. Iridescence occurs when
light is difracted from a thin layer that lies between two mediums
of diferent refractive index (e.g., air and water), as in a soap bubble
Munsell 1898 or a thin ilm of oil on water. Teeth do not display the property
of iridescence, which is often confused with opalescence.
• Fig 7.4 Munsell color system, with achromatic vertical value axis. Hues
(different colors) are arranged in a 360-degree circle. Chroma is repre- Opalescence
sented as the distance from the value axis—that is, the strength of the
same color increases as it departs from the value axis.
Opalescence is a milky iridescence that resembles the internal play
of colors of an opal. In a natural tooth, opalescence is caused by
light scattering between two phases of enamel that have diferent
indexes of refraction. Short wavelengths of light are relected display-
ing a blue hue, whereas longer light wavelengths, such as the
orange and red, are transmitted through the tooth.
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CHAPTER 7 Color and Shade Matching in Operative Dentitry 203

Gloss color-efect-designers-should-see/). When the opposite occurs, that

Gloss is an attribute of visual appearance that originates from the is, the perceived diference between the object’s color and its
geometrical distribution of light relected by surfaces.3 Particularly, surrounding is reduced, this is known as chromatic assimilation.
gloss is a term used to describe the relative amount of mirrorlike
(specular) relection from the surface of an object. Metals are usually Blending Efect
distinguished by stronger specular relection than that from other Clinically, the perceptual phenomenon of assimilation occurs when
materials, and smooth surfaces will appear glossier than rough ones. a restorative material (object) takes on the color of the tooth
(background/surround) and appears more similar combined than
Fluorescence when viewed in isolation. In the dental literature, this visual blending
Fluorescence is a form of luminescence, that is, a form of light of tooth and material is known as blending efect (BE).5,6 he
emission by a substance as the result of some external stimuli. blending effect is commonly (and incorrectly) referred to as
Following the excitation by light, usually ultraviolet (UV), a luo- “chameleon efect.”
rescent substance will reemit some of the absorbed energy in the
form of longer wavelengths. When the luminescence continues Complementary Afterimage
after the source of excitation has been removed, the “after-glow” Similar to contrast and assimilation efects, our eyes can adapt to
is referred to as phosphorescence. a recent visual experience and provoke illusionary perceptions of
color. When we stare at a solid color for approximately 30 seconds
or more, our photoreceptors become sensitized (retinal fatigue)
Surround Efect and Blending and can create illusionary images of the complementary color; this
Color not only is deined by its color dimensions and optical is known as complementary afterimage. If one concentrates on a
properties, but also depends on the surroundings in which the solid color red target, for example, the red cones gradually respond
object appears, the adaptation of our eyes, and our recent visual less strongly to that relected red signal. If one switches his or her
experience.3,4 gaze to a solid white target, now all colors are relected to the
retina and cones will send a strong green signal and a strong blue
Chromatic Induction signal, but a weak red signal. One will see a cyan color afterimage,
When two objects of the same color are surrounded by diferent cyan being the complementary color of red (see Fig. 7.5B).
colored backgrounds, an illusory sensation of color can be created
without direct stimulation of the corresponding cones. he two
objects can be the same color when viewed in isolation, but when Color and Appearance of Teeth and
each is combined with diferent surroundings, the objects can have
a perceived color diference in relation to each other. his is what Dental Material
color scientists call chromatic induction. Tooth Color and Appearance
Contrast and Assimilation How various relections and transmissions of light integrate to
Chromatic induction can generate either a contrast efect or an generate perceived colors in human teeth is a complex process that
assimilation efect. When the object’s color shifts toward the is not entirely understood. he polychromatic appearance of the
complementary color of its surroundings, this is known as simultane- tooth originates from the relative interactions of light signals and
ous color contrast (Fig. 7.5A) (http://www.andrewkelsall.com/ perceptions (Fig. 7.6).
he quantiication of tooth color has been reported in the past
by measuring the three regions of the tooth: cervical, middle, and
Simultaneous Color Contrast Complementary Afterimage incisal.7-9 Describing tooth regions can help understand how they
are related to overall tooth color and appearance. However, this
approach is not necessarily suicient to capture the polychromatic
and complex tooth appearance (Fig. 7.7).

Dentin
In general, the color of the tooth is not uniform. Dentin contributes
signiicantly to tooth color. his is particularly noticeable in the
cervical region, where only a thin layer of enamel exists. his
region is typically the most chromatic (Fig. 7.8), with the chroma
progressively decreasing through the middle to the incisal third,
A displaying hues ranging from yellow to red.7 Dentin is also the
primary source of tooth luorescence.10

B Enamel
In a healthy unworn tooth, the incisal third is typically all enamel.
• Fig. 7.5 A, Simultaneous color contrast. The two Xs appear to be of
different colors due to different backgrounds; however, when observed at
If the enamel were isolated from the dentin, it would appear primar-
their intersection at the middle base of the image it becomes obvious they ily achromatic like transparent or white frosted glass (Fig. 7.9).
are of the same color. B, Complementary afterimage. Stare for 30 seconds he translucency and value of the enamel can vary depending on
at the point where the four colors intersect; then switch gaze to the white many factors such as its thickness and age. hick enamel generally
target below the color images. Retinal fatigue results in the illusionary appears higher in value relative to thin enamel. High-value white
appearance of the complementary colors. patterns, or white spots, also may demonstrate hypomineralized
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204 C HA P T E R 7 Color and Shade Matching in Operative Dentitry

Specular & Diffuse Maximum

Reflection Transmission
(Translucency)

Incident White Light Diffuse

Transmission

Red Gingival Hue Direct Regular

Transmission

• Fig. 7.6 Complex interactions of light and tooth appearance.

• Fig. 7.9 Translucency of isolated enamel. (Courtesy Adam J. Mieleszko,

• Fig. 7.7 Polychromatic appearance of natural teeth. Notice the pro- CDT.)
gression of color from cervical to incisal on teeth #8 and #9—from chro-
matic to translucent, changes in hue and incisal opalescence.

• Fig. 7.10 The incisal halo: distinct line of opalescent relection at incisal
edge.
• Fig. 7.8 The exposed dentin showing accentuated chroma.

Color-Related Propertie of
regions within the enamel. For anterior teeth, the enamel gets Retorative Material
thinner toward the incisal and can appear gray to bluish against
the dark background of the oral cavity. Depending on the transmis- Restorative materials should display color and optical properties
sion or relection of light at the incisal edge, the incisal third may similar to those of dentin and enamel. In this section, we will
display an opalescent pattern with a distinct line of relection primarily focus on composite resin and ceramic dental materials
described as the incisal halo (Fig. 7.10). as they relate to color compatibility, stability, and interactions.
 www.konkur.in
CHAPTER 7 Color and Shade Matching in Operative Dentitry 205

Compatibility
When choosing dental materials such as composite resins or dental Color Matching Tool—Dental Shade Guide
ceramics for restorative procedures, the shade selection of the Dental Shade Guide
material will be dependent on the brand or system in use. Most
commonly a material is keyed to a commercially available shade he standard color matching tool used in dentistry for visual shade
guide. Shade guides will be further discussed under Color Matching matching is the dental shade guide. Dental shade guides are tab-
Tools. At other times, a restorative material may be labeled with based tools fabricated from ceramic, resin, or some other form of
a shade descriptor, such as “universal dentin” or names like “milky plastic or acrylic material. he shade tabs are typically arranged
white” or “pearl frost,” without any reference to a shade guide. In according to some dimension of color, but because of the complex
either case, a material will be most compatible with a tooth when polychromatic nature of natural teeth, a given shade guide system
it has shades that mimic both dentin and enamel. will only serve as a guide and not as an exact color matcher. While
dental shade guides exist for oral soft tissues and facial skin, the
Stability focus of this section will be on guides designed for shade matching
he color stability of dental materials is a signiicant concern for a tooth during the dental restorative procedure.
color and appearance in restorative dentistry. When comparing
composite resins and dental ceramics, resins are less color stable Commercial Shade Guide
after aging.11 Over time, resins are susceptible to extrinsic staining
from dietary exposures and intrinsic degradation of the inherent Ceramic Based
chemical components.12 Resins also can shift color upon curing. For direct restorative procedures, there are many shortcomings
Generally, microill composite resins become lighter and less associated with the use of a ceramic-based tooth shade guide for
translucent upon curing while microhybrid composite resins become dental shade matching, but it is the most logical starting point for
darker and more translucent.13 Ceramic materials, while more shade matching as most composite resins are keyed to a commercially
stable in service, can vary by batch and still undergo color shifts available ceramic-based system. he most popular of the ceramic-
upon iring and glazing.14 based commercial guides is the Vita classical A1-D4 shade guide
(VITA Zahnfabrik). his 16-tab shade guide can be arranged
Interactions according to the hue order (“A-D arrangement” [Fig. 7.12A]) or
An existing color diference between the restorative material and according to an apparent light to dark arrangement (“Value Scale”
the tooth can be lessened with favorable color interaction properties, [see Fig. 7.12B]).
such as layering and blending. Each tab has a number and a letter. According to the manu-
Layering is the essence of tooth anatomy as layers of enamel facturer, the letters represent one of the following hue groups:
and dentin of diferent thicknesses interact creating a polychromatic
appearance. Color of both enamel and dentin can change over A = Reddish-brown
time due to dietary habits or aging, respectively. Given that the B = Reddish-yellow
task is to mimic nature, layering is equally essential for creation C = Grey
of tooth colored restorations. D = Reddish-grey
A blending efect or color shift of a dental material, such as
composite resin or dental ceramic, toward the surrounding tooth he number next to the letter on the tab label represents the
color is a desirable property. his blending efect decreases the chroma and value within each of the A to D groups: 1 = lowest
color diference between the tooth-material interface giving the chroma, lightest, 4 = highest chroma, darkest. Within this system,
restoration a more lifelike and natural appearance. he blending shade B1 is the least chromatic and lightest of the reddish-yellow
efect is predominantly related to smaller restorations, surrounded shades, whereas B4 is the most chromatic and darkest of the
by hard dental tissues, such as composite restorations. It can reduce reddish-yellow shades. One way to use this shade guide is to observe
suboptimal shade matches due to operational error or lack of satisfac- the most chromatic portion of the patient’s tooth, usually the
tory match in the shade guide or restorative material. he veneers cervical region of the canine and select the best hue group. Next,
designed with “contact lens effect” margins before and after the best shade within that hue group should be selected based on
cementation are another example of blending efect (Fig. 7.11).15 the closest chroma number. A second way to use this shade guide

A B
• Fig. 7.11 A, Laminate veneers designed with “contact lens effect” margins. B, The blending effect of
indistinguishable translucent margins of laminate veneers.