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 İmtiyaz Sahibi / Publisher • Yaşar Hız
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Birinci Basım / First Edition • © HAZİRAN 2020

ISBN • 978-625-7884-59-4

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Academic Studies in
Health Sciences - II

Editor
Doç. Dr. Özgür SARI
 Chapter 27
NEW APPROACHES ON SOME NEUROPEPTIDES: KISSPEPTIN AND
NEUROPEPTIDE Y
Turan AKDAĞ.................................................................................................. 449

Chapter 28
POLYMERIZATION AND LIGHT CURING UNITS IN RESTORATIVE
DENTISTRY
Vahti KILIÇ...................................................................................................... 467
 Chapter 28

POLYMERIZATION AND LIGHT CURING UNITS

IN RESTORATIVE DENTISTRY

Vahti KILIÇ1

1  Assistant Professor; Department of Restorative Dentistry, Faculty of Dentistry, Firat University,

dt.vahtikilic@ gmail.com
 Academic Studies in Health Sciences - II 469

1. POLYMERIZATION
Polymerization is a chemical process where smaller molecules called
monomers are linked together to form large chains of molecules called
polymers. The functional groups of monomers possess carbon-carbon dou-
ble bonds (C=C). These double bonds have 2 pairs of electrons shared by
two carbon atoms. While C=C double bonds are the reactive part of the
monomer, other atoms and side groups can be linked to one or both of the
carbon atoms. The polymerization process basically involves four differ-
ent reactions. These are activation, initiation, propagation, and termination
reactions (1). In the activation step, free radicals that will initiate polym-
erization are released (2). In the initiation phase, free radicals activate the
monomer molecule by opening its unsaturated double bond so that it can
be linked to other monomers to form polymer chains. This process contin-
ues until there are no more free radicals left in the environment (3). During
the propagation stage, new monomers are added to the growing polymer
chain. Termination phase takes place when the reaction ends due to reasons
such as a decreased amount of monomers available (4). The sum of the mo-
lecular weights of a large number of monomers linked together by covalent
bonds in a polymer molecule gives the molecular weight of the polymer.
The more the carbon double bond conversion takes place, i.e., the
more monomers are added to the chain, the more successful the polymer-
ization is, and better physico-mechanical results are obtained. The unreact-
ed carbon double bonds may either be present as free radicals or added to
the polymer chain as pendant monomers (5). Adequate polymerization is
an important factor for a successful composite restoration because insuf-
ficient polymerization causes increased leakage in restorations, discolor-
ation of the composite, compromised mechanical characteristics due to de-
terioration of structural properties and decreased connection with the tooth
surface (6). Polymerization processes may involve different mechanisms.
Synthetic polymers are generally formed by either addition polymerization
or condensation polymerization of the monomers.

1.1. Polymerization Steps

• Initiation: The free radical required for the initiation of polymer-
ization is formed by the reaction of a chemical activator with heat or light.
This process is known as the activation stage. Resulting free radical then
binds to the carbon in the methyl methacrylate monomer, opens the double
bond, and provides the energy required for addition of other monomers to
this bond. Thus, by leaving the carbon atom in unstable state, it turns the
bond itself into a free radical. (7). Thereby, the chain of reactions begins.
470 Vahti KILIÇ

• Propagation: The unstable structure of the monomer molecule,

due to the opened double bond as a result of its reaction with the free
radical, also opens the double bond of the neighboring monomer mole-
cule. This process propagates continuously, causing the chain to grow. The
growth of polymer chains continues until exhaustion of the monomer units.
This process may also end up with the monomer going into a reaction with
any other material that has a free radical. Thus, this process continues until
all monomer molecules become a part of the polymer chain.
• Termination: The loss of reactivity of polymer molecules occurs
when the energy in the molecule is depleted. This either occurs directly
by the double bonds or by the exchange of hydrogen atoms from one en-
larged chain to another. Over time, as monomers are added to the chain,
the concentration of monomers will decrease and therefore, growth reac-
tions decrease and termination reactions increase. After the depletion of
the monomers in the environment, radicals cannot remain stable for a long
time, and lose their reactivity by interacting with water or other substances
such as oxygen and carbon dioxide in the air (8).
1.2. Polymerization Types
1.2.1. Addition Polymerization
This is a conversion process where multiple molecules of the same
structure are repeatedly added to the chain, without any change in their
chemical structure, to form a high molecular weight macromolecule with
the same chemical composition. Addition polymerization reactions always
occur with unsaturated molecules containing double bonds. Opening the
double bonds between two carbon atoms of a monomer molecule enables
its activation. In return, the monomer reacts with another monomer and
transfers its reactivity to another molecule. Then, the double bond in the
other molecule opens and this process is repeated for additional monomers.
Thus, a chain reaction begins (7). In theory, chain growth can continue
until all monomers are depleted. No change in the chemical composition
occurs during the addition polymerization. In other words, the structure of
the monomer is repeated over and over through the polymer.
Almost all composite resins used in dentistry involve addition polym-
erization. The addition polymerization may occur in three ways, depending
on the initiator in the monomer. Initiators can be cationic, anionic or radical
type. Examples are sodium and potassium for anionic initiators, and alumi-
num trichloride and tin dichloride for the cationic initiators. However, due
to the metabolic toxicity of these substances, radical polymerization is most
commonly used in dentistry. While ultraviolet light was previously used
for radical polymerization, visible light with wavelengths greater than 400
nm is currently used. For visible light, various amines with wavelengths of
 Academic Studies in Health Sciences - II 471

400-480 nm such as camphorquinone (a diketone) and reducing agents in-

cluding N,N-dimethylaminoethyl methacrylate, hydroxyethyl toluene and
hydroquinone are used. These radicals turn monomers into the reactive
state by interacting with the monomer molecules (7, 9). No by-products are
produced during the addition reactions. All monomers have the same mo-
lecular weight. In this process, unlike condensation polymerization, larger
size giant macromolecules are formed. There is only a difference in the
distribution of chemical bonds between the two processes (7).
1.2.2. Condensation Polymerization
It is a chemical reaction that proceeds with a similar mechanism, but
between more than one type of monomer species. Condensation polymer-
ization is a chemical reaction where structurally distinct or similar poly-
functional monomers join together, often losing small molecules. In con-
densation polymerization, the monomers are bifunctional and all become
reactive spontaneously. This reaction continues in a chain of sequential
reactions until a high-molecular weight polymer is formed. Such polymer-
izations are also known as “step polymerization” reactions (7).
In a condensation reaction, a small molecule such as water is released
as a byproduct and this represents a major difference from addition po-
lymerization. Today, condensation resins are not frequently used in dental
restorations or prosthetic applications. Polymerization processes may not
always give rise to polymers with all desired characteristics. Monomers
affect the physical and chemical properties of the polymers they form. In
particular, cross-linked polymers are materials that are physically more
stable with less water absorption and solubility. Thus, copolymerization
and cross-links are also important in a polymerization process (7).
-Copolymerization-
Copolymerization is a type of polymerization where different mono-
mers at various concentrations are added to the reaction medium to take
advantage of different chemical properties of monomers and a polymer
thus obtained is called a copolymer. The majority of composite resin ma-
terials used in dental practice are of this type. As copolymers add sever-
al characteristics to the resulting polymer, copolymerization is frequently
used for obtaining resins.
-Cross-Linking-
Monomers with reactive side chains are added to the structure which
consists of polymer molecules linked together in a chain. These added side
chains allow attachment of one chain to another. As a result, a three dimen-
sional, more physically stable structure is formed. Resulting cross-linked
polymers are stronger materials with less water absorption and solubility (7).
472 Vahti KILIÇ

1.3. Degree of Polymerization

In composite resins, the degree to which monomers convert into a
polymer or the rate of conversion of double carbon bonds (C=C) to single
carbon bonds (C-C) along the polymerization is referred to as the degree of
conversion or polymerization (10, 11). During polymerization of compos-
ite resins, conversion of all monomers into a polymer or a high degree of
polymerization is desired. As the degree of polymerization increases, the
amount of non-reacting residual monomers in the resin decreases and thus,
their physical properties are enhanced. An ideal composite resin should
produce low shrinkage while generating the highest degree of polymeriza-
tion (12, 13).
Not all double bonds of the monomers react in composite resins po-
lymerized by light. The rate of reacting double bonds varies between 55
and 80% (14, 15). The amount of residual monomers is affected by many
factors including composition and translucency of the resin, application
thickness, sample geometry, concentration of initiators activated by light,
light intensity and exposure, and environmental oxygen and temperature
(2, 16). Inadequate polymerization can lead to adverse effects of non-po-
lymerized toxic monomers on the pulp, defects in the restoration/tooth
bond as well as marginal leakage, postoperative sensitivity, discoloration,
erosion and secondary caries due to bonding failure (17). The degree of
polymerization has also been associated with hardness values, with lower
degree of polymerization causing less surface hardness, reduced wear re-
sistance and lower strength (18, 19).
1.4. Polymerization Methods
1.4.1. Chemical Polymerization
In the chemical polymerization method, materials are polymerized by
mixing a catalyst with a base substance. The chemical reaction between
benzoyl peroxide and a tertiary amine initiates chemical polymerization of
composite resins. The combination of these two materials (the paste with a
chemical activator and a paste with a chemical initiator) results in forma-
tion of free radicals. Benzoyl peroxide, the initiator activated by a tertiary
aromatic amine N, N-bis (2-hydroxyethyl)-p-toluidine is a component of
most of the chemically polymerized composites. The multi-step polymer-
ization process begins with the formation of benzoyl radicals that initiate
polymerization (20). Currently, the use of chemical polymerization is lim-
ited by low color stability of the components used, decreased mechanical
properties due to porosity resulting from mixing two components (21), in-
consistency of polymerization and insufficient time for using the material
for treatment purposes (22).
 Academic Studies in Health Sciences - II 473

1.4.2. Light Polymerization

This process is called photopolymerization. UV light was first used
for photopolymerization in 1972 but replaced by visible light due to harm-
ful biological effects of UV rays on both the patient and the dentist (1).
Light-activated polymerization is the most commonly used method for po-
lymerization of dental composites. Camphorquinone is the photoinitiator
in light-cured composites and it is sensitive to blue light at a wavelength
of 470 nm. The reactivity of camphorquinone is further enhanced by addi-
tion of various amine reducing agents. The concentrations of camphorqui-
none and amines in commercial composites vary between 0.2 and 1.2% by
weight (23). 1-phenyl-1,2-propanedione (PPD), a photoinitiator sensitive
to light with a wavelength close to 410 nm, and another photoinitator, Ivo-
cerin, have been recommended as alternatives.

Figure 1. Molecular structure of some photoinitiators

The major advantage of polymerization with visible light over chem-
ical polymerization is that the dentists can have control with the working
time. While there are no significant differences between light-cured and
chemically polymerized composite resins in the case of complete polym-
erization, photopolymerized composite resins have greater color stability
and lower rates of internal porosity (4).
1.4.3. Both Chemical and Light-Cure (Dual-Cure) Polymerization
The material used for this type of polymerization contains light-sensi-
tive activators as well as chemical catalysts. In this polymerization meth-
od, the rate of chemical polymerization is slow. Polymerization starts with
light and the process continues and terminates chemically (24). Dual-cured
composite resins are used in the case of deep cavities when there are con-
cerns about incomplete polymerization, applications of composites thicker
than 2 mm and aproximal areas that are difficult to reach.
1.5. Factors Affecting Polymerization
1.5.1 Material (Composite Resin)-Related Factors
• Type and amount of filler and other structures: While the light
applied has the highest intensity on the surface of the material, its intensity
474 Vahti KILIÇ

decreases due to scattering and reflections as it travels through the materi-

al. The type of monomer and filler, filler content and the refractive indices
of filler and polymer matrix may affect the ability of light to be transmitted
through the layers of resin (25).
• Shade of the composite resin: Since darker shades or opaque
composite resins absorb more light, they may require longer exposure time
for polymerization (26). However, opacity/translucency of the composite
resin was reported to have a greater effect on polymerization than its shade
(27).
• Thickness of the composite resin: Placement of composite resins
at a thickness of no more than 2 mm is recommended. When the composite
resin is placed as a thicker layer, the light applied on the top surface loses
its intensity as it approaches the bottom surface of the composite resin,
adversely affecting the properties and longevity of the material due to in-
complete polymerization (28). Therefore, a more uniform polymerization
is achieved with a composite resin thickness of 2 mm (29).
• Type of initiator: The composite resin should have a sufficient
concentration of initiator that responds to the wavelength of the light cur-
ing unit used for polymerization. Thus, a light curing unit that matches the
type of initiator contained in the material should be selected (30).
1.5.2. Effects of Dental Tissue and Cavity
Complete polymerization of the composite resin may not be achieved
especially in the aproximal areas as a result of absorption and scattering
of the light from the light curing unit while passing through the dental tis-
sues. Since the enamel tissue is translucent, the light transmission is much
better in the enamel than in the dentin tissue. For this reason, exposure
time is increased to complete polymerization of the restoration throughout
the dental tissue (31). The type, width and location of the cavity can affect
transmission and scattering of light and thus, are important for polymer-
ization (27).

1.5.3. Factors Related to the Light Curing Unit (LCU)

• Size of the light curing tip (Tip geometry): The LCUs currently
in use have tips of various diameters. In a LCU with a large diameter tip,
the distribution of light is greater than a LCU with a small diameter tip.
LCUs with a small diameter tip have a rather high light output intensity.
Therefore, the diameter of the light curing tip may affect the quality of
polymerization (32).
• Type of the LCU: Each LCU has a certain wavelength range, po-
lymerization efficiency and several advantages and disadvantages. There
 Academic Studies in Health Sciences - II 475

are studies showing variable results regarding the impact of the type of
LCU on polymerization (27).
• Light exposure time: Adequate polymerization of the composite
resins and bonding agents depends on the exposure time as well as the
LCU used. Light exposure time varies depending on the type of LCU and
the structure and color of the resin-based restorative material.
• Angulation of the light curing tip: When the light curing tip is
applied perpendicular to the surface of dental restoration, a circular area
with a high light intensity is formed. If the light curing tip is inclined, this
circular area assumes an elliptical shape and the light intensity reaching the
application area decreases (31).
• Distance between dental restoration and light curing tip: The
distance between the tip of the LCU and dental restoration is an important
factor affecting the polymerization. As increased distance between the light
curing tip and the composite resin surface will reduce the energy of light
and negatively affect the degree of polymerization (33). For all LCUs, as
the distance between the dental restoration and light curing tip increased,
the depth of cure and the degree of polymerization decrease (34, 35).
• Wavelength: It is the length of the electromagnetic wave emit-
ted by light. Composites are sensitive only to a limited wavelength. The
blue light energy between 400-500 nm activates the photoinitiator (cam-
phorquinone) in the composite resin.
• Power: It is the total amount of energy emitted by the LCU per
unit time. Power is expressed in milliwatts (mW) (36).
• Intensity: It is the power of light per unit area of the light applied
on and measured in mW/cm2 (36). Light intensity can be controlled by
increasing the output of the device or by reducing the diameter of the light
curing tip.

1.6. Photopolymerization Protocols

In recent years, various polymerization “protocols” were introduced
by manufacturers to increase the amount of polymerization, reduce in-
ternal stresses, maintain marginal integrity and decrease polymerization
shrinkage (37).
• Standard (continuous) polymerization: The light power, which
depends on the LCU used, remains constant at the same intensity from
the beginning to the end of polymerization and is applied continuously
throughout the process in different intervals such as 10, 20, 30 or 40 sec-
onds.
476 Vahti KILIÇ

• Soft-start polymerization: In the soft-start polymerization proto-

col, low light intensity is used initially and then increased gradually. This
allows for a slow rate of polymerization with formation of less free radicals
and extends the time for the composite to flow to the surface. Viscoelastic
phase of the composite is prolonged and shrinkage stress of the composite
resin can be controlled by slowing the hardening rate (38).
The soft-start protocol can be applied using four different regimens
including Step-cure polymerization, Ramped-curing, Exponential polym-
erization, Pulse delay polymerization and Oscillating polymerization. The
lamp units designed for application of the soft-start protocol automatically
generates low intensity light, which is followed by high intensity light.

2. LIGHT CURING UNITS

Composite materials polymerized with light have been introduced in
1970s (39). At the beginning, dental materials were polymerized using Ul-
traviolet (UV) light which was subsequently replaced by visible light due
to concerns that UV light might be harmful for both the patient and the
dentist (40). Currently, light curing units (LCUs) are used for initiating po-
lymerization reaction of composite resins (41). However, the mechanism
in the polymerization reaction using a LCU is mainly based on activation
of polymerization initiators found in the resin matrix to generate free rad-
icals and to achieve this, the wavelength of the light used must be close to
that of polymerization initiators (42). Polymerization with light activation
starts at electromagnetic wavelengths between 400 and 500 nm. The absor-
bance spectrum of camphorquinone, the most widely used photoinitiator,
is in this range and peaks at 470 nm.
Choosing a LCU may not be as simple as it seems because many fac-
tors such as the type of LCU, tip geometry of the curing unit and the light
intensity output significantly affect the polymerization of the material used
(43). Visible LCUs are used for polymerization of composite resins, res-
in-modified glass ionomers, polyacid-modified resin composites, fissure
sealants, binding agents, periodontal materials, adhesive agents and tem-
porary restorative materials (44). Owing to advances in the field of LCUs,
four visible curing lights, each functioning through a different system, are
available for use in dental practice (45, 46). These include:
1. Quartz-tungsten halogen (QTH) LCUs
2. Plasma-arc curing (PAC) LCUs
3. Argon-Ion Laser LCUs
4. Light Emitting Diode (LED) LCUs
 Academic Studies in Health Sciences - II 477

2.1. Quartz-Tungsten Halogen (QTH) LCUs

These LCUs developed in 1970s after UV systems are still in use. Also
known as conventional LCUs, these units use a halogen bulb with a tung-
sten filament as the LCU (47). QTH lamps produce light energy when the
tungsten filament is heated in a halogen gas such as iodine or bromine as
the electricity flows through it (48). These units produce visible blue light
at a wavelength ranging from 380 to 520 nm and emit light at an intensity
of 300-850 mW/cm2; they can polymerize composite resins up to a depth
of 2 mm in 40 seconds (49). Halogen LCUs are systems that irradiate blue
light needed for polymerization by absorbing white light and filtering out
the light at different wavelengths (47).
The most expensive component of halogen LCUs is the filter mecha-
nism. Excessive heat may be produced when these filters lose their prop-
erties and fail to filter the light and this may cause adverse effects on the
dental tissues (50). For this reason, light efficiency of these devices should
be checked and tested periodically. During the production of light by the
device, heat is released by the halogen lamp and shortens the lifespan of
the lamp. This heat generation requires a cooling fan which may be noisy.
If the power unit is shut down immediately after use due to noise, evapo-
rated tungsten atoms cannot return to the surface of the filament, resulting
in a short bulb life (51). Additionally, since the resulting heat leads to extra
energy requirement, it can lead to a reduction in both the light output and
the operating time of the device. The lifetime of the bulb is approximately
100 hours and the light output decreases with continuous use (24). Also,
it has been observed that many QTH LCUs fail to achieve the minimum
light intensity specified by the manufacturers. All of these shortcomings
may cause inadequate polymerization of the dental restoration (52). It was
reported that the QTH bulb converts 70% of electrical energy to heat and
only 10% produces visible light and only 0.5-2% of the energy input is
emitted as blue light (53, 54).
478 Vahti KILIÇ

Figure 2.A halogen LCU and its technical features (Hilux 250-Benlioğlu Dental
Ankara, TURKEY)
In order to eliminate the long curing time of conventional halogen
LCUs, high-power halogen LCUs have been developed which are less ex-
pensive than plasma arc curing light and argon lasers and provide faster
polymerization (55). These devices have a higher light intensity, which is
greater than 800-1000 mW/cm². Increased light intensity is achieved using
high-power lamps. Another method is to use turbo tips that collect the light
and concentrate it on a smaller area (56, 57). Although polymerization is
achieved in a shorter time due to increased power, there are also studies
reporting increased polymerization shrinkage forces of the composite (58).
The polymerization efficacy of QTH LCUs have been evaluated by
several studies in terms of polymerization depth and surface hardness. In
one study, the effects of a QTH and second-generation LEDs on the depth
of polymerization and surface hardness of three different composites were
assessed. Second-generation LEDs were found to achieve greater depth
of cure than the QTH in all composites but no difference was observed
between QTH and LEDs with respect to surface hardness in two compos-
ites (59). Another study compared the effectiveness of LED LCU (light
curing unit) and halogen LCU on the degree of conversion of 7 different
composite resins and LED LCU was found to have a superior effect on the
degree of conversion than halogen LCU in all study groups (60). In a study
by Ceballos et al., two composites were polymerized by LED and QTH
LCUs for 20 seconds and LED LCU was shown to have a better polymer-
ization efficacy than QTH LCU (61). In contrast to aforementioned data,
there are some studies reporting comparable or better results using QTH
LCUs (62, 63).
 Academic Studies in Health Sciences - II 479

Halogen light curing units are larger than other LCUs and the pro-
duction of blue light is more complex. Another drawback is that there is
a risk of blowing microorganisms into the mouth by the cooling fan (31,
61). New LCUs have been developed due to several disadvantages of QTH
curing lights such as excessive heat generation, lamp lifetime limited to
hours, difficulty of disinfecting the filters, deterioration of the reflector and
filters over time, noisy operation of the ventilating fan and reduced light
intensity (64).
2.2. Plasma Arc Curing (PAC) Lights
Plasma arc curing lights are LCUs that can deliver a considerably high
light intensity output (≈ 2400 mW/cm2). These units produce light from
hot plasma that forms between two tungsten electrodes that are surrounded
by xenon gas (38). The polymerization time of composite resins can be
shortened to a great extent owing to this high light power intensity (65).
PAC lights have a broader range of wavelengths (31). An exposure of 10
seconds from a PAC light is equivalent to 40 seconds from a halogen light
curing unit (24). Polymerization performed in 3 seconds with these LCUs
showed similar conversion rates with a polymerization using halogen
LCUs in 30-40 seconds (47). Currently, they are mostly used for bonding
orthodontic brackets and bands.
Plasma arc curing lights work at wavelengths between 370 nm and
450 nm or 430 nm and 500 nm (43). Thus, polymerization of systems with
both camphorquinone and photoinitiators other than camphorquinone can
be achieved. As with halogen light curing units, PAC units also have fil-
ters that filter out other lights and allow emission of blue light. Although
PAC units are more powerful LCUs than halogen LCUs, their use is not
recommended for polymerization of composites. The hardness values ob-
tained by polymerization with plasma arc curing lights have been shown
to be lower than LED and QTH devices (66). PAC units were reported to
cause more polymerization shrinkage of composite resins and increased
microleakage at enamel and dentin margins due to their high light intensity
(67, 68). In addition, excess heat released during the production of high
intensity light was reported to cause pulpal damage (38).
2.3. Argon-Ion Laser LCU
Argon lasers, one of the lasers available for use in dental practice,
have a wavelength range of 450-502 nm and are used for polymerization
of composite resins (38, 69). They require shorter exposure times for cur-
ing composite resins in comparison to conventional visible light curing
units (69). Since these devices do not emit infrared light waves, not much
heat is produced that can potentially harm tissues (38). Composite res-
ins polymerized using laser were reported to have better mechanical and
480 Vahti KILIÇ

physical properties, with a lower rate of residual monomers than conven-

tional LCUs (70, 71). No loss of energy occurs in these systems as seen in
halogen light curing units. These laser systems do not require a separate
filtration process.
Argon-ion laser LCUs produce a very narrow beam of light and work
at specific wavelengths in the range of 454-466 nm, 472-497 nm and 514
nm (43). A number of disadvantages have been reported including the fail-
ure to cure composites with photoinitiators other than camphorquinone due
to the narrow bandwidth of these systems, and their high cost (38). Addi-
tionally, the use of these units is limited because the device is large and not
portable and not regarded much practical for composite polymerization by
clinicians.
2.4. Light-Emitting Diode (LED) LCU
LED LCUs have been developed to address the shortcomings of hal-
ogen LCUs and overcome their disadvantages (63). These LCUs trans-
mit a visible blue light with a wavelength spectrum of 440-485 nm that
is sufficient for activation of camphorquinone, a polymerization initiator
contained in many composite resins (47, 72). No heat dissipation occurs
since the light is generated during the passage of electrons through gallium
nitride semiconductors in LED units and filtration is not required in these
systems because they emit light only at a specific wavelength (73). LED
light-curing units are portable systems with low power consumption and
operate quietly because they do not need a cooling fan (74). 95% of the
light generated can be used for polymerization, resulting in high energy
performance of the curing light. These devices produce light at a low volt-
age (1–4 volts) and therefore, are not dependent on the mains power (75).
Compared to halogen LCUs, these lamps have a long lifetime (≈ 10,000
hours) and no fluctuations are observed in the light intensity since the sys-
tem does not produce heat and contain a fan (76).
2.4.1. First-Generation LED LCUs
The first LED LCUs manufactured were experimental prototype
models that produced light at the correct wavelength and deliver a suffi-
cient number of photons required for the polymerizations of light-cured
resin-based dental materials (77). This first LED-based devices contained
arrays of many individual LED emitters (cans) (57). In fact, although these
LCUs had a low irradiant output power, they have attracted great attention
because they were cordless, lightweight devices that required low main-
tenance and the LED light could last for thousands of hours (51). Despite
their low light power, they could provide a comparable level of polymer-
ization with QTH LCUs by extending the polymerization time (78). How-
ever, since the first-generation LED lights had a narrow emission spectrum,
 Academic Studies in Health Sciences - II 481

they may not be fully absorbed by composite resins with polymerization

initiators sensitive to a different wavelength than that of camphorquinone
(79). In addition, first-generation LCUs introduced by manufacturers used
a large number of low-energy diodes (38) producing a light output of ap-
proximately 400 mw/cm2 (59) resulting in inadequate polymerization (80).
2.4.2. Second-Generation LED LCUs
Second-generation LED LCUs have been developed because first-gen-
eration had insufficient light output and required a long time for adequate
polymerization. Initially, thermal pads were developed that emitted smaller
and more efficient light, instead of LED cans as separate units (51). In this
way, new generation LED LCUs were manufactured using a smaller num-
ber of powerful diodes and had a broader wavelength spectrum between
430 nm and 490 nm. They produced an irradiance output of approximately
1000 mw/cm2 and allowed a short polymerization time with sufficient per-
formance (31, 81). A shorter polymerization time achieved by 2nd genera-
tion LED lights compared with QTH LCUs boosted the demand for these
LCUs. However, cooling fans or metal heat sinks were placed in some of
these devices to aid dissipation of heat because of potential overheating
and malfunction of the device due to higher light output (51).

Figure 3. Examples of second-generation LED LCUs (Elipar S10, Elipar Deep-

Cure-S -3M ESPE, MN, USA)
In a study investigating the effect of a halogen LCU and a LED cur-
ing light on the depth of polymerization and microhardness of 8 different
restorative materials, the LED device showed better performance than the
halogen lamp in both of the tested parameters (53). In another study, the
wear and microhardness of a composite resin cured with a halogen light
curing unit and LED LCU were compared and greater microhardness and
482 Vahti KILIÇ

less wear were reported with the LED LCU compared to the halogen LCU
(82). In a study by Antonson et al., 10 different LED light-curing units in-
cluding 1st and 2nd generation devices were compared with a halogen LCU
(Optilux 501) for depth of cure using the etch test and found that the greatest
depth of cure was achieved in samples cured with a LED LCU for 10 sec-
onds and 20 seconds. The authors also found that an exposure time of 20
seconds or longer provided a better depth of cure and a polymerization time
of 40 seconds was needed for optimal polymerization (83). In contrast to the
aforementioned studies, there are some studies in the literature that demon-
strated better results in certain parameters with halogen LCUs (62, 63).
2.4.3. Third-Generation LED LCUs
With the increased popularity of tooth whitening, the bright yellow
color of camphorquinone contained in the composite resin made shade se-
lection difficult after bleaching. New photoinitiators have been developed
both for this reason and to improve polymerization efficiency in parallel
with the advances in the formulation of the materials over time (57, 78).
The new 3rd generation (polyvawe, multiwave, multipeak LED LCUs)
LCUs can generate light at two or more wavelengths and activate pho-
toinitiators such as mono acyl phosphine oxide (Lucirin TPO), Ivocerin
or 1-Phenyl-1,2-Propanedione (PPD) which are found in the structure of
some composites (84). These LCUs produce both violet light with a short-
er wavelength and blue light with a longer wavelength (27). While violet
light activates photoinitiators that are sensitive to a light within the range
of 350-420 nm wavelength, blue light generally activates camphorquinone
which is sensitive to a wavelength of 468 nm (85, 86).

Figure 4. An example of a third-generation LCU and its technical features (Valo

Cordless – Ultradent, USA)
In these LCUs, the light emitting diodes generating light at diverse
wavelengths are arranged on different planes at the tip of the device, which
can hinder homogeneous polymerization of the resin-based composite
materials (87, 88). The type of photoinitiator found in the composite res-
in should be taken into account when using these devices. Using these
LCUs for composites containing only camphorquinone as the photoinitia-
 Academic Studies in Health Sciences - II 483

tor might adversely affect polymerization quality. In addition, if the prod-

uct range of the manufacturer consists of LCUs that emit light at a single
wavelength (as in the case of 3M products), the composites are manufac-
tured accordingly and there is no need to use 3rd generation LCUs for such
products (51).

CONCLUSION
A good polymerization of resin composites is essential to achieve
a long-lasting dental restoration with the desired mechanical properties.
LCUs used for the polymerization of resin-based composites which hold
an important place in restorative dentistry are among indispensable equip-
ment of a dental clinic. In this context, recognition of the polymerization
properties of the composite resins and the features of LCUs is crucial. An
important step in the polymerization involves choosing the right LCU and
using it for the intended purpose. With these considerations in mind, the
current study discussed polymerization, features of polymerization and
LCUs in detail.

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