Polymerization Lamps and Photocuring in

Orthodontics
Theodore Eliades
The purpose of this article is to review the fundamentals of photocuring with
various types of lamps in orthodontics. Information on the characteristics of
lamps, photopolymerization, from the perspective of both the material composite resin adhesive and source (lamp) are discussed, with reference to light
scattering, optimum filler size, extent of polymerization, and the degree of cure
of resins irradiated with different lamps. This discussion is followed by a review
of the clinically useful listing of properties of lamps and their application to
orthodontic bonding as these are reflected in 4 key properties of the material,
such as polymerization efficiency (degree of cure), mechanical properties (bond
strength), clinical performance (failure rate), and biological properties of blue
light. (Semin Orthod 2010;16:83-90.) 2010 Elsevier Inc. All rights reserved.

he development of various types of light

sources for use in polymerization has resulted in a multiplicity of factors taking an active
role in the polymerization kinetics of the polymeric material. The variation in intensity and
wavelength with selective filtering of undesired
wavelengths has also contributed to a multifaceted phenomenon in photo curing, which affects the properties of the resultant polymer.
This article will not place emphasis on reporting the performance of various types of lamps
through the typical bond strength protocols.
Such a tactic would have resulted in a dull repetition of data, which are often incoherent, and
in most cases clinically irrelevant. Because of the
lack of relevant evidence in the orthodontic published data, the fundamentals of light curing will
first be provided, as this encompasses both the
material (composite resin adhesive) and source
(lamp) perspectives. In the introductory text,
light scattering, optimum filler size, extent of
polymerization, and the degree of cure (DC) of
resins irradiated with different lamps will be re-

From the Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Greece.
Address correspondence to Theodore Eliades, DDS, MS, DrMed,
PhD, FIMMM, MRSC, MInstP, 57 Agnoston Hiroon, Nea Ionia
14231, Greece; Email: teliades@ath.forthnet.gr
2010 Elsevier Inc. All rights reserved.
1073-8746/10/1601-0$30.00/0
doi:10.1053/j.sodo.2009.12.008

viewed, whereas essentials of polymer reaction

and stages will be analyzed. This discussion will
be followed by a review of the clinically useful
listing of properties of lamps and their application to orthodontic bonding as these are reflected in 4 key properties of the material, such
as polymerization efficiency (DC), mechanical
properties (bond strength), clinical performance (failure rate), and biological properties
of blue light.

Light Intensity Variation in the

Material
When a light beam hits an orthodontic adhesive
surface, penetration of light into the relatively
thin layer of material depends on many factors
related to the light beam itself, the application
mode, and the material characteristics.
First, the distance of the source from the
surface and the path that the incident beam will
have to travel to reach the adhesive has a large
effect on the intensity of incident light.1 The
well cited Lambert Law in this field describes the
variation of intensity with distance as
I I0 ed
where I is the light intensity at distance d, I0 the
intensity departing from the source, and the
absorption coefficient of the medium.

Seminars in Orthodontics, Vol 16, No 1 (March), 2010: pp 83-90

83

84

T. Eliades

The published data include many studies

from the related field of restorative dentistry,
which deal with the effect of material composition on the light penetration and DC.2,3 In general, the translucency of the composite, which
allows for the penetration of light away from the
light source, increases with an increasing matching of the refractive indexes of the matrix and
fillers. The first term (matrix) relates to the
comonomer system of Bis-GMA/TEGDMA mixture, which is used to combine the favorable
features of both monomersthat is the increased molecular weight of bisphenyl-A diglycidyl dimethacrylate (Bis-GMA), which offers stability and a thicker consistency and the tetra
(ethylene glycol) dimethacrylate (TEGDMA),
which contributes to the larger DC because of its
decreased molecular weight and higher mobility. Varying the proportion of these constituents,
as well as other materials, such as amines, accelerators, inhibitors, and initiators, may slightly
affect the refractive index of the matrix, which
in methacrylate resins is about 1.5.4
Fillers, in contrast, which are contained in the
adhesive in a ratio of 0.6-0.7 (% wt) in the form
of silica particles and barium glasses, possess an
index of 1.55 at the wavelength of the photoinitiator.5 The evidence available in the field of
composite resins suggests that maximum light
scattering occurs at particle size equivalent of
half of the wavelength of the photo initiator of
the polymerization, which for camphoroquinone systems is 468 nm; hence, favorable filler
size is set to about 230 nm. However, the typical
picture of an adhesive includes a large size variation of the filler particles, which does not satisfy
the set values for size. Also, the distribution of
filler size in composites is designed to include
favorable size, in contrast to orthodontic adhesives where most filler systems are placed arbitrarily. The reflectance (r) of a composite material consisting of 2 different phases of indexes n1
and n2 is given by the equation:
r (n1 n2)2/(n1 n2)2
Thus, the deleterious effect of large index differences is well depicted.

Light and Polymerization Initiation

Having established the sources of variation of
light intensity of the incident light, we will now

proceed to the investigation of the phenomena

accompanying the exposure of the material to
light.
Almost all the light-cured adhesives employ
camphoroquinone as photoinitator of the polymerization. This molecule is contained in the
resinous phase at a concentration of 0.2%-1% of
the matrix, and shows a peak absorbance wavelength of 468 nm, which implies that increased
light intensity in other frequencies may not be
effective to excite the molecule into the excited
state that lasts for 0.05 ms.4 This is important in
choosing lamp source based on the peak intensity reported by the manufacturer; it is critical
that this peak should correspond to the absorbance wavelength of the photo initiator, namely
468 nm.
The formation of an exiplex (a short-lived
electronically excited molecule) because of the
excitation, which in turn acts as a recipient of an
electron, after a short process leads to the formation of a primary radical; it is this element
that reacts with the double bond and leads to
conversion of a double bond, essentially initiating polymerization.6
It may be interesting to note that because of
its yellowish tint and resultant undesirable
matching in uncured vs cured materials, camphoroquinone has been recently replaced in
some composite resins by 1-phenyl-1,2-propanedione
with a peak absorbance in the area of 390-410
nm, with preliminary promising results in the
properties of the polymer and color characteristics. It follows that potential replacement of camphoroquinone by 1-phenyl-1,2-propanedione will result in a necessity for altering the effective peak
wavelength of polymerization lamps due to the
shift of the required wavelength of the new material.7 However, studies looking at the effect of
mixing of these 2 initiator systems have shown a
synergistic action. The orthodontic adhesive systems are not expected to alter their initiator
systems because the main reason for moving to
this change, namely the change in color between
unpolymerized and cured material, is not of
orthodontic concern.
In concluding this introductory section, it
may be useful to note that the DC in light-cured
adhesives depends on all the factors analyzed
earlier in the text, that is, light irradiance reaching the adhesive, exposure time as more pho-

Lamps and Orthodontic Bonding

tons are given to the system at same I variance,

and thermal energy of the system.

Lamps and Degree of Cure of Adhesives

Light-cured orthodontic adhesives require a
light-curing source with sufficient intensity and
defined wavelength to initiate the polymerization reaction. Increased light intensity and curing time have been advocated for fast polymerization and high DC.8
Recently, various types of commercially available light-curing units have shown comparable
bond strength values to that produced by conventional halogen lights at shorter irradiation
times. The wide array of new light curing sources
includes plasma arc, laser, and light emitting
diode (LED) lights, which were integrated in the
profession to facilitate short irradiation times.
Plasma lamps present very high intensity compared with halogen lights (1600-2100 mW/cm2),
an effective spectrum of 450-500 nm, and a significantly higher cost, which nevertheless is
counterweighed by their increased lifespan of
5000 hours relative to 40-100 hours for halogen.
Orthodontic bonding with these light sources
can be achieved with only 6 seconds of irradiation for stainless steel brackets or 3 seconds for
ceramic brackets.9,10
Laser lights show an intensity of 700-1000
mW/cm2, with a monochromatic spectrum of
variable wavelength (454, 458, 466, 472, 477,
488, and 497 nm), are costly, but have an almost
infinite lifespan. Application of these light
sources to orthodontic bonding has shown that
5 second of irradiation, provided bond strength
values comparable to those found for halogen.11,12
LED light curing units yield a maximum intensity of 1100 mW/cm2, at a spectrum of 420600 nm, have cost comparable to that of conventional halogen lights and possess a nearly
infinite lifespan. The results of bond strength
studies show contradicting evidence on the performance of these lights, with most investigations demonstrating comparable bond strength
to halogen lights at same irradiation duration
and reduced strength when shorter time frames
are applied.13,14
Although a significant body of the relevant
published data deals with the variation of bond
strength as a function of the light-curing unit,

85

only few studies have focused on the effect of

different irradiation sources on the DC of the
resin phase. This factor may not be elucidated by
simple bond strength tests and is of paramount
importance because it modulates the mechanical, physical, and biological properties of the
resin adhesive.
The use of micro-MIR FTIR (micro multiple
internal reflection, Fourier transform infrared
spectroscopy) has been advocated as an appropriate analytical technique in quantifying the
carbon-carbon double bond (CC) conversion
of resin composites.15,16 Orthodontic bonding
involves adhesives firmly pressed between enamel
and a bracket base, leading to material layers of
no more than 250 m in thickness.17
As analyzed earlier, an important parameter
of curing units is the amount of light energy
emitted and the appropriate wavelength to efficiently excite the photoinitator. However, others
suggest that within the 490-450-nm wavelength
range, light intensity and exposure time are
more significant than light wavelength in determining DC4 since camphoroquinone exhibits a
broad absorption spectrum at this range. Curing
time has been directly associated with increased
conversion in a study comparing high and low
intensity halogen lights.18 Nevertheless, a LED
light with a lower intensity than a halogen light
has been shown to produce a greater depth of
cure,13 implying a rather complicated interaction pattern of light intensity, emitted wavelength, curing time, and extent of absorption by
the material.
Reduction of curing time when using high
intensity curing units has been initially advocated for restorative resin composites to reduce
chair side time. However, questions have been
raised on the efficacy of the high irradiance
emitted in a short time, especially by plasma-arc
sources, to achieve adequate polymerization. It
has been shown that composites cured by plasma-arc curing units for 7 seconds provided less
degree of cure (percentage of DC) compared
with halogen lights cured for 40 seconds,19 highlighting the critical role of the total emitted light
energy concept in the extent of photopolymerization. Also, the ranking of the total energy
emitted per unit area (J/cm2) calculated from
the intensity and suggested duration of irradiation did not match that of the percentage of
DC.8 Possibly, the size of the irradiation tip may

86

T. Eliades

affect the radiant flux density reaching the adhesive resin at the margins, and therefore the
resultant light scattering effects related to indepth curing. Although the distance of the tip
from the adhesive may not result in differences
in bond strength, the actual kinetics of the DC
and bond strength are unknown, and thus
changes in one variable may not be reflected in
variations in the other. In addition, the variation
of percentage of DC as a function of bond
strength has not been examined and it is possible that the latter is unaffected after a certain
percentage of DC is reached. The percentage of
DC is a material variable, largely unaffected by
environmental conditions, and not a derivative
of a constructed test, such as bond strength,
which involves many assumptions.20 Moreover,
bond strength is a poor indicator of percentage
of DC because of the interference of bracket
design, variation in load application, loading
rate, teeth storage and preparation, and testing
conditions, among other factors. In contrast,
percentage of DC has been shown to modulate
the mechanical properties of material21,22 as well
as the resistance to degradation and dissolution,23 a key property which cannot be explored
using bond strength tests.
The intensity and amount of light required
to reach the adhesive to initiate polymerization
has been a topic of extensive investigation. Previous research has proposed the concept of a
critical light transmittance and a threshold
light intensity with curing adhesives for ceramic
brackets24; the latter has to be attained in order
for the polymerization to be initiated. This result
is presumably because of the thin film nature of
the adhesive layer, which has a very high surfaceto-volume ratio. The dominance of surface properties over bulk adhesive properties is considered to favor the use of light-cured resins
because these systems are expected to possess
superior surface characteristics.25
In the broader adhesive materials published
data, high polymerization rates have been shown
to induce 2 undesirable effects. The first relates
to the development of high stresses because of
the polymerization shrinkage in the tooth cavity.
However, there is a lack of data on this issue for
orthodontic bonding, and it seems that this
should not constitute a concern because of the
relaxation of these stresses in the bracket-adhesive interface owing to the lack of margins and

cavity walls. The second pertains to the fact that

an exceedingly high light intensity, above 2000
mW/cm2 may cause material structural defects.
It has been suggested that very high rate of
excitation of radicals may induce such a high
polymerization rate that encapsulation of unreacted monomer may take place, leading to an
inhomogeneous material.4 This is due to the
development of prematurely terminated chains,
which do not get the required chain length and
are of insufficient cross linking. Although this
effect may not be reflected in the immediate
bond strength results of the adhesive, it is known
that inhomogeneously polymerized materials
are susceptible to dissolution and degradation
and present increased monomer leaching.

Lamps and Bond Strength

The consensus from ex vivo bond strength protocols on this topic is that there are no major
differences in mean strength values.26-32 However, the wide variation of irradiation durations,
adhesives, crosshead speeds, and experimental
conditions preclude the proper comparison of
evidence among studies. Moreover, the actual
clinical relevance of this test has been severely
criticized in the past for the scientific soundness,
especially at the transformation of force to pressure units. The reader is referred to the reviews
of Eliades and Brantley,20 and Fox et al,33 which
cite several deficiencies, weakness, and misconceptions in various stages of experimental configuration of conventional bond strength protocols.
Nonetheless, there are various steps, which if
adopted, can result in an increase in the reliability of these protocols. These include the preference of reporting force (N) as opposed to pressure (MPa) values. Work in this area has shown
that the stress distribution in the bracket base is
not homogeneous and thus the report of force
per surface is mistaken. Also, it is difficult to
estimate the effective surface area of bracket
base because of the mesh, as brackets with identical dimensions may have different areas depending on the mesh gauge. Moreover, comparisons of bond strength values with vaguely
defined threshold values, which derive from
over 3-decade long assumptions, should be
avoided.34 Despite the fact that most in vitro
studies have reported bond strength values,

Lamps and Orthodontic Bonding

which largely exceed the supposedly minimum

threshold set 30 years ago, clinical trials have
shown increased bond failure, which often
reaches 8%-10%. The validity of introducing a
minimum required bond strength has been criticized on the basis of: (a) lack of similarity between the materials, utilities, and treatment
mechanotherapeutical trends of the time of
proposition of this value relative to the ones
currently used; (b) absence of any consideration
for material aging patterns, which have been
found to induce potent degradation in adhesive
resins, such as the presence of esterases, which
cause enzymatic degradation of polymeric adhesives35; and (c) lack of simulation of masticatory
forces. Particularly, the process of comparison is
problematic because such a notion requires a
statistical test rather than arbitrarily reporting
differences between the observed mean and the
threshold proposed. An additional measure entails the inclusion of Weibull analysis, which can
be used to predict the survival of bond at specific
stress increments.36

Lamps and Bracket Failure Rates

To avoid the assumption of bond strength protocols, failure rate studies have been designed to
test the variable of retention of bonds throughout a set time, which ranges from 6 months to
entire treatment (18 months) duration. This
process provides direct clinical evidence and as
such is preferred over the conventional bond
strength tests wherever this is possible.
Although this type of study presents a major
advantage related to their profound clinical relevance, it does not provide an insight into the
cause or pattern of failure.37 Moreover, failure
rate protocols are very demanding from a set-up
perspective, since it is laborious, requires extended monitoring, and as such, it is difficult to
be applied in an ordinary practice setup. In
contrast, large clinical environments, such as
those found in educational institutions, carry
some unfavorable features, such as the intervention of multiple operators, the socio-economic
and dental status of patients seeking treatment
in institutions, variations in malocclusion classification, and resultant mechanotherapy, that is
use of interarch elastics, variety of archwires, etc.
These factors may introduce cross-effects from
various participant-related parameters, such as

87

habits, masticatory forces that vary with facial

type, and diet.
The results of the limited evidence available
from failure rate studies on this topic, including
the limited number of long-term trials on the
clinical performance of high-intensity LED, demonstrate that these lamps are incapable of reaching
the success rates observed for plasma lamps, implying that an increased irradiation should be
used.
Data on the failure rate of lamps report that
failure for the halogen lamp may be in the order
of 3%-5%, depending on the study with some
authors reporting higher rates38 and others
showing rates as low as 3.4%.39 This discrepancy
may be attributed to different irradiation times.
The overall failure rate recorded with the halogen unit was not significantly different from the
failure rate for the LED lamp. Higher bond
failure rates were most often found in the mandibular dental arch compared with the maxillary
and in the posterior segments (premolars) compared with the anterior. There are no clinical
studies in the published data evaluating the efficiency of LED lamps in orthodontic bonding.
Previous in vitro studies found that LED and
halogen lamps provided comparable shear bond
strength, when bonding orthodontic brackets
with equivalent polymerization time.39
The distribution of failures between the 2
dental arches has shown considerable variation.
Previous studies reported more failures in the
lower dental arch, whereas others found no statistically significant difference between failures
in the mandibular and maxillary arches.40-43
Others44 have noted more failures in the mandibular arch than in the maxillary arch. This
difference may be attributed to occlusal interferences between the brackets of the lower and the
upper dental arch during the first phase of orthodontic therapy, the gravity of the bolus of food,
and the presence of more initial crowding in the
lower dental arch especially in the anterior
segmentin most of the patients of this sample.
Regarding correlation between failure rate and
dental arch left or right side, previous studies
reported contradictory results.43 The variability
observed between these studies could be assigned to differences in mastication habits between patients, pressure during tooth brushing
between right- or left-handed patients, as well as
moisture control and handling of materials and

88

T. Eliades

bonding procedure between right- and lefthanded operators.

The finding reported by some studies on the
higher failure rate in premolars than in anterior
teeth has been attributed to higher masticatory
forces exerted on posterior teeth,45-47 access difficulties during bonding,48 and differences in
the morphology and structure of the superficial
enamel layer between posterior and anterior
teeth. Because some studies report more failures
in boys than in girls, it seems that individual
preferences, which are gender-specific and related to the character of the participants and the
attention to diet and care of appliances, may
have an effect on the outcome.

Lamps and the Biological Action of Blue

Light
Apart from the aforementioned cited performance variables of lamps, several reports have
focused on the potentially biologically hazardous effects of light sources on several tissues.
Blue light (wavelengths 380-500 nm) is commonly used to initiate polymerization activation
of dental resin composites of a variety of applications. Although initially blue light was characterized as relatively harmless, more recent studies have shown that it affects several aspects of
cell physiology. Particularly, it has been reported
that it disturbs mitochondrial function,49-54 thus
causing an oxidative stress leading to activation
of the stress-responsive pathways,55 oxidative
DNA damage,56 or even to the inhibition of
mitosis.57 The group of investigations cited earlier in the text has suggested that blue light
induces effects on the DNA integrity, cellular
mitosis, and mitochondrial status in various cell
types, through the generation of reactive oxygen
species. These investigations employed a variety
of mouse and human, normal and transformed
cell types, as well as a vast array of assays, which
extended from assessment of cell vitality to
markers of cells metabolism and oxidative status. This multiplicity of testing protocols has
resulted in a variety of effects described.
The result of the sole investigation adopting
the time exposures seen in an orthodontic routine bonding has shown that blue light did not
affect the viability of these cells, as no signs of
cytotoxicity were observed.58 In addition, there
was no immediate effect on the regulation of

proliferation, as until 24 hours after irradiation

there was no inhibition of DNA synthesis, a prerequisite for cell proliferation. For the long-term
effect, absolute cell counting was done as opposed to indirect assays, such as, for example,
the MTT assay, as the latter provides information not only on the cultures cell number but
also on the mitochondrial status of cells, the
latter known to be disturbed by blue light irradiation. One week after treatment, all types of
irradiation induced a significant inhibition of
cell proliferation compared with untreated cultures.
Several studies have shown the exposure to
blue light leads to the generation of reactive
oxygen species, proposing that these are responsible for the adverse biological effects of blue
light. However, in the study by Taoufik et al,58
the use of the potent antioxidant N acetyl-cysteine was unable to annul the inhibitory effect of
irradiation on cell proliferation. One possible
explanation for this may relate to the extracellular environment used in various studies.
It has been recently shown that blue light
suppresses mitochondrial activity in normal human epidermal keratinocytes and mouse Balb
fibroblasts only when cells are maintained in
culture medium during exposure and not in
phosphate-buffered saline.59 Accordingly, the effect of blue light in mitochondrial status and
reactive oxygen species production in different
environments requires further investigation. An
immediate cellular response to irradiation involves alteration of proliferation to provide time
for repair of the DNA damage before entering
into mitosis, thereby avoiding mutations and aneuploidy. Moreover, the results of DNA assay did
not suggest an intense DNA damage that would
activate intracellular pathways to inhibit proliferation, as no DNA breaks were identified.
In summary, the evidence on the biological
effects of blue light indicate an action that is
probably not an immediate reaction, confined
to long-term effects, and not mediated by oxidation mechanism or DNA damage. The array of
effects described suggests that high energy
sources such as plasma lamps should be used
with caution, especially when bonding mandibular tubes, where a close contact between the
tissue and the lamp tip occurs.

Lamps and Orthodontic Bonding

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