Comparison of temperature increase in the pulp chamber during

the polymerization of materials used for the direct fabrication

of provisional restorations
Konstantinos Michalakis, DDS, PhD,a Argiris Pissiotis, DDS, MS, PhD,b Hiroshi Hirayama, DDS,
DMD, MS,c Kiho Kang, DDS, DMD, MS,d and Nikolaos Kafantaris, DDS, PhDe
Tufts University, School of Dental Medicine, Boston, Mass; Aristotle University, Thessaloniki, Greece
Statement of problem. Polymerization of resin materials used for the fabrication of provisional restorations is
associated with an exothermic reaction. This temperature rise may present a serious biological problem, since it
can cause iatrogenic thermal trauma to the pulp.
Purpose. This in vitro study compared the temperature increase in the pulp chamber of a molar placed in
contact with different resins used for the direct fabrication of provisional restorations.
Material and methods. Polymethyl methacrylate (Jet), polyethyl methacrylate (Snap), polyvinylethyl meth-
acrylate (Trim), Bis-acrylic composite (Protemp II), and a VLP urethane dimethacrylate (Revotec LC) were
compared with respect to their exothermic reaction properties during polymerization. A mandibular molar pre-
pared for a complete coverage restoration was placed in an acrylic resin block. A thermal probe connected to a
digital thermometer was placed into the pulp chamber. Specimens were submerged in a water bath to simulate
intraoral conditions. The provisional resin materials tested were measured and mixed according to manufac-
turer’s instructions. The resin mixture was placed into a vacuum-formed acetate template and was then posi-
tioned on the prepared molar tooth. The temperature was recorded during polymerization at 30-second
intervals until it was evident that the peak temperature had been reached. Temperature increase was measured
(8C) for both the initial crown fabrication and the reline procedures. Data were analyzed with descriptive statis-
tics, 1-way analysis of variance, and Tukey Honestly Significant Difference tests (a=.05).
Results. One-way ANOVA revealed significant differences (F=57.010, P,.0001) in temperature rise for differ-
ent provisional resin materials. Mean temperature increase for the provisional crown fabrication ranged from
37.768C for the polyvinylethyl methacrylate to 39.408C for the polymethyl methacrylate. Mean temperature
rise for the reline procedures ranged from 36.808C for the polyvinylethyl methacrylate to 37.698C for the poly-
methyl methacrylate. All of the tested materials produced an exothermic chemical reaction.
Conclusions. Polymethyl methacrylate produced the higher exothermic reaction in both initial crown fabrica-
tion and reline procedures. Polyethyl methacrylate, polyvinylethyl methacrylate, and Bis-acrylic resins tested
were not significantly different from each other. (J Prosthet Dent 2006;96:418-23.)

CLINICAL IMPLICATIONS
Clinicians should be aware of increased temperature levels associated with the direct fabrication of
provisional restorations and take necessary precautions to minimize iatrogenic trauma to the pulp.

T he pulp can be subjected to lesions resulting from

caries or trauma. The latter can be iatrogenic, result-
ing from removal of previous restorations,1 tooth
a
Visiting Assistant Professor, Division of Graduate and Postgraduate
Prosthodontics, Tufts University, School of Dental Medicine; Clin-
ical Associate, Department of Fixed Prosthodontics, Aristotle
University; Private practice, Thessaloniki, Greece.
b
Associate Professor, Department of Removable Prosthodontics,
School of Dentistry, Aristotle University.
c
Professor, Director of Graduate and Postgraduate Prosthodontics,
Tufts University, School of Dental Medicine.
d
Associate Professor and Associate Director of Graduate and Post-
graduate Prosthodontics, Tufts University, School of Dental
Medicine.
e
Professor and Head, Department of Removable Prosthodontics,
School of Dentistry, Aristotle University.
preparation procedures,2,3 desiccation,4 or fabrication
of provisional restorations.5,6-10 Provisional restorations
are used between the initiation of the treatment and
placement of the definitive prostheses. Their purpose
is the stabilization of occlusion, protection of the teeth
and the periodontal tissues, function, esthetic enhance-
ment, and provision of diagnostic information.11-13
Treatment periods may be rather extensive due to ortho-
dontic, periodontic, and endodontic therapies or im-
plant placement.14,15 Evaluation of strategic teeth,
occlusal scheme, or alterations of a patient’s occlusal ver-
tical dimension are additional reasons for lengthy thera-
peutic periods.1
During the provisional restorative phase, the clinician
should strive to ensure that all the goals which should

418 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 96 NUMBER 6

MICHALAKIS ET AL
be fulfilled by an interim prosthesis are achieved. These
goals can be described as biologic, diagnostic, esthetic,
and mechanical. However, it should be noted that al-
though provisional restorations offer a wide range of
therapeutic objectives, their fabrication should be
done with care, since the materials used may be detri-
mental to the pulp if certain precautions are not taken.
The fabrication of treatment restorations with a direct
technique presents 2 major problems. The first problem
consists of the presence of free monomer, which can be
harmful to the pulp, especially when placed in direct
contact with open dentinal tubules.5 Secondly, most
of the materials used for provisional restoration in-
troduce a temperature rise during polymerization.6-10
This temperature rise may present a biological problem,
since a previous histologic animal study has demon-
strated that healthy pulps failed to recover from an in-
trapulpal temperature rise of 5.558C in 15% of the
situations. When the intrapulpal temperature increased
by 11.18C and 16.658C, 60% and 100% of the teeth, re-
spectively, lost vitality.16 Thus, it appears that a material
that does not produce an exothermic reaction should
be selected or certain precautions should be taken to
protect healthy pulpal tissue from losing vitality. The
purpose of this in vitro study was to compare the tem-
perature increase in the pulp chamber of a molar placed
in contact with different resins used for the direct fabri-
cation of provisional restorations.
MATERIAL AND METHODS
A polymethyl methacrylate (PMMA), a polyethyl
methacrylate (PEMA), a polyvinylethyl methacrylate
(PVEMA), a Bis-acrylic composite, and a visible-light-
polymerizing (VLP) urethane dimethacrylate were
compared with respect to their exothermic reaction
properties during polymerization (Table I). The mate-
rials included in the study were chosen because they
are widely used both in the United States and the
European Union.
A freshly extracted mandibular molar tooth was
stored in 1% chloramine solution (Sigma-Aldrich, St.
Louis, Mo) for 2 weeks. The tooth was then stabilized
with a minimal amount of sticky wax (Kemdent;
Purton, Swindon, UK) in a vertical position in a 4.5 3
2.5 3 0.4-mm box made of boxing wax (Hygenic
Corp, Akron, Ohio). Autopolymerizing acrylic resin
(ProBase; Ivoclar Vivadent, Schaan, Liechtenstein) was
then hand mixed and poured under vibration (No. 200
Vibrator; Buffalo Dental Mfg Co, Syosset, NY) in the
wax box, covering the root portion of the tooth. The
resin block was then placed in a pressure-polymerization
apparatus (Ivomat; Ivoclar Vivadent) for 15 minutes at
408C under 4 bar pressure. After complete polymeriza-
tion of the acrylic resin, an impression of the tooth and
the resin block was made using a custom tray made of
DECEMBER 2006
THE JOURNAL OF PROSTHETIC DENTISTRY
Table I. Resin materials included in study
Brand Material type Manufacturer Lot/batch no.
Jet Polymethyl Lang Dental, 1410-5063
methacrylate Wheeling, Ill
Snap Polyethyl Parkell Biomaterials, 46665
methacrylate Farmingdale, NY
Trim Polyvinylethyl Harry Bosworth, 04257
methacrylate Skokie, Ill
Protemp II Bis-acrylic 3M ESPE, Seefeld, 233479
composite Germany
Revotec LC VLP urethane GC Corp, Tokyo, Japan 509131
autopolymerizing PMMA (SR Ivolen; Ivoclar Vivadent)
and irreversible hydrocolloid material (Blueprint; Dents-
ply Caulk, Milford, Del). Type III stone (COECAL; GC
Europe, Leuven, Belgium) was mixed under vacuum
(Vacuum Power Mixer Plus; Whip Mix Corp, Louisville,
Ky) and the impression was poured under vibration (No.
200 Vibrator; Buffalo Dental Mfg Co). After setting of
the stone, an acetate template (Coping Material; Key-
stone, Cherry Hill, NJ) was fabricated using a thermal
vacuum-forming machine (Tray-Vac; Buffalo Dental).
Twenty-four hours later, the tooth was prepared for a
complete coverage restoration with a 10-degree axial
wall convergence17 and a 360-degree chamfer finish
line (Fig. 1). The reduction of the axial walls was 1.5
mm, and the occlusal reduction was 2.0 mm. The reduc-
tion was evaluated with the acetate vacuum-formed
template fabricated earlier.
The apical portion was removed to access the pulp
chamber from the apical side of the tooth, and the pulpal
tissues were removed. The pulp chamber was then
cleaned of all organic remnants using a 5.25% sodium
hypochlorite solution (Clorox Co, Oakland, Calif).18
A thermal probe connected to a digital precision ther-
mometer (BAT 8; Bailey Instruments Inc, Saddle
Brook, NJ) was placed through the root canal into the
pulp chamber, touching the roof of the chamber.9
Amalgam (Dispersalloy; Dentsply Caulk) was then con-
densed into the pulp chamber, surrounding and stabiliz-
ing the thermal probe in position (Fig. 2).19 Afterward,
the acrylic resin was replaced over the apical opening.
Amalgam condensation around the thermal probe per-
mitted the collection of readings from all directions,
since the amalgam is a good thermal conductor.20 All
thermal energy released from the exothermic reaction
of the acrylic resin polymerization was transmitted
from the occlusal and the axial walls to the thermal
probe, through the amalgam. A thin layer of petroleum
lubricant was applied to the acrylic resin block/prepared
tooth/engaged thermal probe assembly, which was
then placed in a water bath (Water Bath; Whip Mix
Corp, Louisville, Ky) containing distilled water at a tem-
perature of 368C. The assembly was then allowed to
419
THE JOURNAL OF PROSTHETIC DENTISTRY MICHALAKIS ET AL

Table II. Descriptive statistics for the temperature increase (8C) (n=10)
95% Confidence interval for mean
Mean SD SE Lower bound Upper bound Minimum Maximum

PMMA I 39.49 .81 .26 38.90 40.07 38.20 40.50

PMMA R 37.69 .25 .08 37.51 37.87 37.30 38.10
PEMA I 38.31 .43 .13 38.01 38.61 37.80 39.00
PEMA R 36.84 .27 .08 36.65 37.03 36.50 37.30
PVEMA I 37.76 .25 .08 37.58 37.94 37.40 38.20
PVEMA R 36.80 .16 .05 36.68 36.92 36.60 37.10
Bis I 37.77 .45 .14 37.44 38.09 37.10 38.60
Bis R 36.82 .17 .05 36.70 36.94 36.60 37.10
VLP I 38.83 .18 .06 38.70 38.96 38.50 39.10
VLP R 37.16 .34 .10 36.91 37.40 36.70 37.60
Total 37.75 .94 .09 37.56 37.93 36.50 40.50
I, Initial provisional crown fabrication; R, reline procedure.

Fig. 1. Molar prepared with 360-degree chamfer preparation. Fig. 2. Radiograph depicting thermal probe and amalgam
condensed into pulp chamber.

thermally equilibrate. The water bath was used to simu-
late intraoral conditions.21,22
The provisional resin materials tested were measured
and mixed according to the manufacturer’s instructions.
An electronic scale (Galaxy 110; Ohaus, Pine Brook,
NJ), with an accuracy of 60.0001 g, was used to weigh
the polymer of each resin material. A 1-mL syringe (BS-
01H2516; Terumo Europe NV, Leuven, Belgium) was
used for the measurement of the monomer. The Bis-
acrylic composite resin was dispensed from the cali-
brated syringe provided by the manufacturer, while
the VLP urethane dimethacrylate was used as provided
by the manufacturer. The vacuum-formed acetate tem-
plate was completely filled with the resin mixture and
then positioned on the prepared molar tooth. All excess
resin material was removed from the margins of the
tooth by the use of an explorer. The temperature was re-
corded during polymerization at 30-second intervals
until no further increase was noted.19 After complete
polymerization of the resin material, the template was
removed from the tooth, the provisional crown was
retrieved, and the intaglio surface was ground. The
assembly was cleaned of any resin residue, and a
new thin layer of petroleum lubricant was applied.
Afterwards, the assembly was placed in the water bath
to thermally equilibrate. A new resin mixture was mea-
sured and mixed, as previously described, and placed
into the provisional crown. The crown was then posi-
tioned onto the prepared molar, the excess was removed
from the margins, and the assembly was placed immedi-
ately in the water bath. The temperature was again re-
corded at 30-second intervals until no further evidence
of increase was noted.19
The procedure for the VLP urethane dimethacrylate
was the same as for the rest of the tested materials, except
that a light-emitting diode (LED) polymerizing unit
with a wavelength of 430 to 480 nm and a light intensity
of approximately 1000 mW/cm2 (Elipar FreeLight
2 LED; 3M ESPE, St. Paul, Minn) was used for the
polymerization of this material.23-29 The tip was held

420 VOLUME 96 NUMBER 6

MICHALAKIS ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. Box plots of temperature increase values (8C).

Table III. One-way ANOVA for intrapulpal temperature Table IV. Tukey HSD test for intrapulpal temperature
increase with different acrylic resins rise (8C) (n=10)
Sum of Mean Subset for alpha=.05
Temperature squares df square F P
Material 1 2 3 4 5 6
Between 74.55 9 8.28 57.01 ,.0001
PVEMA R 36.80
groups
BIS R 36.82
Within 13.08 90 .15
PEMA R 36.84
groups
VLP R 37.16 37.16
Total 87.63 99
PMMA R 37.69 37.69
PVEMA I 37.76 37.76
BIS I 37.77 37.77
at a 2-mm distance from the provisional crown surface, PEMA I 38.31 38.31
and a polymerizing time of 45 seconds was used for VLP I 38.83
each of the 5 surfaces. Ten provisional crowns were fab- PMMA I 39.49
ricated for each material and 10 specimens of each mate- Sig. .524 .072 1.000 .053 .084 1.000
rial for the reline measurements, providing a total of 100 Mean values for groups in homogeneous subsets are displayed.
temperature rise recordings.1 The room temperature I, Initial provisional crown fabrication; R, reline procedure.
was constantly 218C 6 18C. Descriptive statistics, 1-
way analysis of variance (ANOVA) (a=.05), and Tukey
Honestly Significant Difference (HSD) (a=.05) tests 39.408C for the PMMA. Mean temperature rise for
were used to determine statistically significant differ- the reline procedures ranged from 36.808C for the
ences in temperature rise for different provisional resin PVEMA to 37.698C for the PMMA. The Tukey HSD
materials. test revealed that PVEMA, Bis-acrylic, PMMA, and
VLP urethane dimethacrylate resins were not signifi-
cantly different when compared in the reline procedure
RESULTS
stage. However, the VLP urethane dimethacrylate was
The results of the descriptive statistics for the temper- significantly different (P,.0001) when compared to
ature increase values of the resin materials included in PVEMA and Bis-acrylic resins in the initial provisional
the study are depicted in Table II and Figure 3. The crown fabrication procedure. The PMMA was signifi-
1-way ANOVA revealed significant differences (F= cantly different (P,.0001) from the majority of the
57.010, P,.0001) in temperature rise for the provi- tested materials, but not from the VLP urethane dimeth-
sional resin materials tested (Table III). All of the tested acrylate. The reline temperature increase of the PMMA
materials produced an exothermic chemical reaction. resin was not statistically different from those of the
Mean temperature increase for the provisional crown PVEMA and Bis-acrylic resins in the initial provisional
fabrication ranged from 37.768C for the PVEMA to crown fabrication stage (Table IV).

DECEMBER 2006 421

THE JOURNAL OF PROSTHETIC DENTISTRY MICHALAKIS ET AL

DISCUSSION reaction. The present study demonstrated that the tem-

perature increase resulting from the polymerization pro-
This in vitro study demonstrated that PMMA resin
cess of the provisional resin materials ranged between
produced the highest exothermic reaction of all mate-
1.18C and 4.58C for the initial crown fabrication, and
rials tested. The maximum temperature recorded in
between 0.58C and 2.18C for the reline procedures.
this study was 40.508C, and the lowest was 36.508C.
According to Zach and Cohen,16 the intrapulpal
A previous study10 reported temperatures ranging
changes resulting from the temperature increase during
from 33.308C to 53.308C. However, the quantity of
polymerization of the materials will range from minimal
the provisional resin material used in that study was
to significant. The majority of the pulp tissues in their
much larger than that used for the fabrication of a pro-
study recovered. However, a number of properties
visional crown, since a polyvinyl mold, the approximate
should be considered when making a material selection,
size a maxillary molar size, was filled with the materials
one being the presence of a low exothermic reaction.
tested. Furthermore, that study was not performed in
Precautions that may minimize thermal trauma to teeth
a wet environment of 368C, and the light source was
include the use of molds other than vacuum-formed
kept away from the thermometer. Nevertheless, the pre-
templates, such as vinyl polysiloxane or irreversible hy-
sent study confirms the results of previous studies,8,10,19
drocolloid impressions, as demonstrated by Moulding
that PMMA demonstrates the largest temperature
and Teplitsky.19 According to that study, when autopo-
increase when compared to other provisional resin mate-
lymerizing resins are used in combination with molds
rials. Additionally, the results of the current study are
made from siloxane and irreversible hydrocolloid mate-
similar to those of Moulding and Teplitsky.19
rials, they present lower temperature rises because the
An interesting finding of the present study is that the
bulk of these materials can act as a heat sink and, thus,
temperature rise recorded with VLP urethane dimetha-
dissipate heat from the tooth. Additionally, the water
crylate is higher than that of PMMA, PVEMA, and Bis-
present in the irreversible hydrocolloid provides a cool-
acrylic resins. It has been previously reported that the
ing medium. Other safety measures include the repeated
heat release of these materials is less than that of other
removal and replacement of the template on the pre-
provisional resin materials.10 Yet, it seems that the
pared teeth and the use of air-water spray to minimize
polymerization of the VLP urethane dimethacrylate
the heat increase.
leads to a temperature rise which is the result of both
The present study has also demonstrated that the
the exothermic reaction process and the energy
intrapulpal temperature rise is always smaller during
absorbed during the irradiation.23-27 The temperature
reline procedures. This is probably due to the fact that
increase recorded during the reline procedure of the
a smaller volume of resin material is used for relining.
VLP urethane dimethacrylate was not different from
Since the temperature increase during relining is always
that of the other provisional resin materials tested,
smaller, it would be beneficial to fabricate the provi-
with the exception of the PMMA resin. It should be
sional restorations on a stone cast and then perform
mentioned, however, that the LED polymerizing unit
the reline procedures on the prepared teeth. These pre-
may have contributed to the temperature increase
cautions may help avoid iatrogenic trauma to the pulp.
observed during the polymerization of the VLP ure-
It should be noted that this is an in vitro study and,
thane dimethacrylate material. It is possible that the
therefore, has some limitations. These include the use
temperature increase would have been smaller if a con-
of amalgam in the pulp chamber and the use of acrylic
ventional halogen light had been used.28 Nevertheless,
resin to surround the prepared tooth. The use of a water
this requires further research since there is a study
bath was deemed necessary to simulate intraoral condi-
supporting the opposite finding.29
tions. Further in vivo animal studies are necessary to
Zach and Cohen16 demonstrated that a temperature
verify the results of this in vitro study.
increase of 2.38C produced minimal intrapulpal
changes. These were confined to the odontoblasts that
were next to the area of the thermal injury. When the CONCLUSIONS
intrapulpal temperature increased by 5.68C, a remark-
Within the limitations of this in vitro study, the
able pulpal response was noted, including destruction
following conclusions were drawn:
of most of the odontoblasts, displacement of nuclei
into the dentinal tubules, reduction of the thickness of 1. The PMMA resin produced a significantly higher
uncalcified predentin, denaturation of the matrix, and (P,.0001) exothermic reaction when compared to
destruction of Tomes! fibrils in the area of dentin imme- the rest of the materials included in this study. This
diately adjacent to the enamel that was touched by finding applied to both the initial crown fabrication
the instrument causing the thermal injury. However, and the reline procedures.
after 56 days, 85% of the teeth subjected to this 2. The PEMA, PVEMA, and Bis-acrylic resins were not
thermal trauma successfully overcame the inflammatory significantly different in terms of temperature rise

422 VOLUME 96 NUMBER 6

MICHALAKIS ET AL
for either the initial provisional crown fabrication
(P=.053) or the reline procedures (P=.0524).
3. The VLP urethane dimethacrylate produced a signif-
icantly higher (P,.0001) intrapulpal temperature
rise than that of PVEMA and Bis-acrylic resins in
the initial crown fabrication. However, no significant
difference in temperature rise was detected (P=.0524)
when the previously mentioned materials were com-
pared in the reline procedure.
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3, GREG. PALAMA STR.
THESSALONIKI 546 22
GREECE
FAX: 30 2310 272-228
E-MAIL: kmichalakis@the.forthnet.gr
0022-3913/$32.00
Copyright ! 2006 by The Editorial Council of The Journal of Prosthetic
Dentistry.
doi:10.1016/j.prosdent.2006.10.005
423