IRREVERSIBLE HYDROCOLLOIDS

INTRODUCTION

A dental impression material is used to make a mold that has the negative
dimensions of the surfaces of a patient’s oral structure. The purpose of the impression is the
formation of ‘positive’ model of the proper physical dimensions, shapes and spatial relationships
of these structures.

The accuracy of the model /cast depends on the accuracy of impression from
which it is made.

Requisites for impression materials

1. Accuracy: Impression material should be fluid enough to adopt to the oral tissues and record
fine details.

2. Adequate: Working time

3. Elasticity: impression material should be elastic so that it can be removed from undercut
areas without distortion.

4. Dimensional stability

5. Impression material should adhere to the tray

6. It should be non toxic and non irritant.

7. It should have acceptable taste and odour

8. Selling time should not be excessive to avoid fatigue to patient and operator

9. Impression material should be stable on storage over a period of time

10. It should be cheap

CLASSIFICATION

Classification of dental impression materials

Impression material


Rigid/ Elastic
Inelastic

Chemical reaction Thermal changes Chemical reaction Thermal changes

(Irreversible) (Reversible) (Irreversible) (Reversible)

Plaster of paris Compound Arginate Agar Hyrolloid

(Preliminary impression) Nonaueoud elastomers

Zinc Oxide Eugerol Wax Polysulfides

Polyethers
Condensation silicones
Addition silicones

The first elaster impression materials to be used were composed of colloid gels,
jelly like substances tat can be formed in the removed over the undercuts.

COLLOIDS

Derived from two greek words ’Kolla’ meaning glue and ‘oid’ meaning like. The
term was originally applied to substances that form solutions with properties that fall between
solution and suspension, the substances were originally studied and named by Thomas
Graham[1805-1869]

Colloid is defined as a state of matter in which the matter is dispersed through

out some medium called dispersion medium. Owing to the structure, constitutions and reaction
colloids are after classified as fourth state of matter known as Colloid state.
 Colloid solution exists somewhere between the extremers of very small
molecules in solution and the very large particles in suspension. Size of colloid particles range
from 1-200 nm. Types of colloid

Colloidal solution may be composed of combination of

Liquid / solid in air  aerosol

Liquid / gas in solid  Solidosol

Liquid / gas / solid in liquid  lysol

Metallic colloids are lysophobic and organic colloids are lyophilic. When
dispersion medium is water , colloid is called hydrocolloid.

The colloidal materials used for making impression are either agar or algi
dissolved in water- Hence the term hydrocolloid impression materials.

Hydrocolloid impression materials are classified as

1. Reversible eg. Agar

2. Irreversible eg. Alginate

Colloids may exist as either sol or gel . in sol state colloid is a viscous liquid

Gel is material of gelatin like consistency

SOL-Gel Transformation

Gelation is the process by which sol becomes gel. It occurs in two ways.

1. By Temperature changes

2. By chemical means
 1. By temperature changes:

Gelation is brought a reversible process. Eg. Agar. The fibrils are held together by secondary
molecular forces. So that they break at slightly elevated temperature and become
reestablished as the hydrocolloid cools to room temperature.

The temperature at which these chages occurs is Gelation temperature

The Gel is converted to sol when it is heated to a higher temperature which is

known as Liquification temperature.

The temperature lag between gelatin and liquification temperature is known a

hysterisis.

2. By chemical change

Conversion of sol to gel is brought about by chemical reaction, the fibrils this
formed are held together by primary bonds and are unaffected by temperature. Hence they are
called irreversible hydrocolloid eg. Alginate.

GENERAL CHARACTERISTIC OF GEL

Gel Strength

Gel can support considerable stress. Particularly sheer stress without flow,
provided the stress is applied rapidly. The stiffness and strength is directly related to
concentration of fibrile and fillers.

Dimesnsional effects

A major part of gel volume in hydrocolloid is made of water

Gel may lose water by

1. Evaporation - form the surface

2. Syneresis - Exudation o fluid on the surface

 The exudate is not pure water but may be alkaline or acid depending on the
composition of gel. Both these processes results in Shrinkage

Gel may absorb water if it is placed in water by a process imbibition. Causing the gel to swell

Both syneresis and imbibition should be avoided as former can cause shrinkage
ad latter expansion

Syneresis and imbibition

A great part of volume of gel is occupied by water. If water content is

reduced, gel will shrink and if it takes up water. It will expand or swell. These dimensional
changes are important in dentistry as any change in dimension of impression after it has
been move from the mouth is a source of error.

Syneresis is the process by which gel loses water from its surface by
evaporation. The exudate is not pure water, but either acid or alkali depending on the composition
of gel

Imbibition is the process by which gel lacking water absorbs it if it is placed in

contact with water. Gel appears to exhibit a memory in a way that is imbibes water and swells
only until the extent of lost water is restored.

Both syneresis and imbibition should be avoided as former can cause

shrinkage and latter expansion.

Alginate

Alginate was the first irreversible hydrolloid discovered and used. It’s still the most popular
impression material used for recording dentulous mouth.

Histological background

Alphons Poller, a Viennese physician in his ‘Short Introduction’ in 1924

published the first impression material which remained elastic even after setting. It was
based on agar-agar. This was further developed successfully by the dental firms which
acquired the patency.
 When the algae used for making agar-agar became scarce in USA during World
War II, research for a suitable substitute was carried out. The research was carried out on a
native brown algar called algin. Th algin was discovered by a chemist from Scotland at the end of
eighteenth century. The result of this research is what is now known as alginate. In England 40
years later, another chemist S William Wilding receiveda basic patency for use of algin as a
dental impression material.

Chemistry

The chief ingredient of irreversible hydrocolloids impression material is one

of the soluble alginates. Its generally a linear polymer of the sodium salt of anhydro beta –d-
mannuronic acid. Even though alginic acid is insoluble in water sodium, potassium and
ammonium salts of acid are soluble since the polar carboxyl groups are free to react. Sodium
, potassium and triethanolamine alginates are used as dental impression materials.

The alginate when mixe with water becomes a sol. Gelation occurs by a chemical
reaction. There are a number of methods for the production of this chemical change. The simplest
and the popular method is to react the soluble alginate with calcium sulphate to produce insoluble
calcium alginate gel. Gelation should take place in mouth; for that the reaction should be delayed
till the material is carried to the mouth. So a retarder which is another soluble salt is added. The
calcium sulphate will react with the retarder in preference to sodium alginate to form an insoluble
calcium salt. The reaction between calcium sulphate and sodium alginate is prevented as long as
any of the retarder is left. A number of soluble salts can be used. Sodiumtripolyphosphate and
tetrasodium pyrophosphate are the two most common salts used.

Calcium sulphate is the reactor and tro\isodiumphosphate is the retarder. Then

chemical reaction is as follows:

2Na3PO4 + 3 Ca(SO4)  Ca3(PO4)2 + 3 Na2SO4

When Trisodium phosphate is completely exhausted the calcium ions will

react with alginate to form calcium alginate.

KnAlg + n /2 CaSO4  n/2K2SO4 + Ca n/2Alg

 Various other additives are included to attain the desirable properties of
consistency, working time, setting time, elastic quality, strength and smooth and hard
surfaces on gypsum cast.

Ingredients and their functions

1. Any soluble salt of alginic acid - 15%

Reacts with calcium to give insoluble calcium

alginate gel.

2. Calcium sulphate dehydrate 16%

Reacts with alginate to form insoluble calcium

alginate. Source of calcium ions which cause
cross linkage of alginate chains.

3. Potassim sulphate,

Potassim titanium fluoride./silicate 3%

Top couteract the inhibitory effect of hydrolloid

on setting of gypsum and improves the surface
of stone model.

4. Diatomaceous earth 60%

1. increase the stiffness and strength of the gel

2. produce smooth texture

3. ensures a firm gel surface that is not tacky

4. increase the flexibility of set impression

5. Zinc oxide 40%

 It is used as filler. It influence physical properties
and setting time of the gel.

6. Sodium phosphate 20%

Acts as a retarder . Delays gelation by reacting

with calcium sulphate in preference to sol
alginate to form insoluble gel.

7. Glycol-small amount

To make powder dustless

8. Chemical indicators-small amount

Change colour with pH chnages from alkaline ot

neutral to indicate different stages in
manipulation

Violet – during spatulation

Pink - ready to load

White - ready for insertion into mouth

9. Wintergreen/peppermint-trace amount

to produce pleasant taste and give pleasant

odour

10. Disinfectants – small

to help in disinfection of viable organisms

The manufacturer can adjust the concentration of retarder to produce a

regular or fast set alginates.
Gel structure

Calcium ions replace the sodium ions o two adjacent molecules to produce
cross linking. The resultant gel structure can be envisioned as brush heap structure of
calcium alginate fibril network enclosing unreacted sodium alginate sol, excess water, filler
particles and reaction by products like calcium phosphate and sodium sulphate.

Packaging

1. Alginate is suppled as a poder i.e. packaged in bulk in a sealed screw top plastic container or
hermetically sealed metal can. A plastic scoop is provided for dispersing powder and a
cylinder for measuring water. This is by far the most popular method.

2. Preweighed packets constructed of plastic or metal foil. Packages increase storage life and
decrease moisture contamination.

Modified Alginates

1. Alginate can be purchased in the form of a sol containing water, but no source of calcium
ions. A reactor of plaster of paris is then added to the sol.

2. Two paste system: One with alginate sol and the other with calcium reactor. This can be
applied both as a tray and syringe material.

Shelf Life

Alginate impression material deteriorates rapidly at elevated temperatures

by depolimerisation of the alginate constituent. Materials stored for one month at 65
degree Celsius are unstable for use as they do not set at all or set too rapidly for any
practical use. Even an at 54 degree Celsius there’s evidence of deterioration.

The ADA specific number 18 for alginate impressions specify that storage
within original container for 1 week at 60 degree Celsius in a relative humidity of 100% the
compressive strength of the gel should not be less than 0.255Mpa.

Hondrum SO, Fernandez R Jr. Walter Reed Army Institute of Research,

Washington, D.C., USA, conducted a study on effects of long- term storage on properties of
alginate impression material. They exposed the material to various environmental conditions
for more than 78 months.

Results revealed increases in strength and working time and a decrease in

recovery from deformation at 30 to 50 months; strength and recovery then remained constant
past 6 years, whereas working time and creep compliance decreased. Only the most stressful
environmental conditions (heat and humidity) caused spontaneous failure of the material to set.
They concluded that, under most storage conditions, properties of the alginate material tested
remain within ADA specification limits well past manufacturer’s designated shelf life.

Manipulation

Alginate impression material are easy to use. Shake the container well
before use to get an even distribution of ingredients. The powder contains high
molecular weight substances like diatomaceous earth which settle down during storage.
Open the lid after some time so that the fumes settle down. The silaceous particle, are
similar to asbestos fibres that produce fibrinogenesis and carcinogenesis. So inhalation of
fumes should be avoided.

Although special plastic bowls and spatulas are available, generally, a flexible
rubber bowl and wide bladed stiff stainless stainless steel spatula is used. The bowl and
spatula should be clean Contamination during mixing le4ads to too rapid set, inadequate
fluidity or even rupture of the impression upon removal from mouth. Water-powder ratio
specified by the manufacturer should be strictly followed to ensure maximum gel strength and
elastic recovery. Usually the water powder ratio is 400ml water for 25gm powder.

The mixing time also affects strength of the gel structure. The strength of gel
structure. The strength of gel can be reduced as much as 50% if mix is not complete. Under
mixing can lead to grainy mix which leads to reduced tissue detail reproduction. Prolonged
mixing results in weakened gel structure as fibrils once formed will be broken up. This will
also lead to reduced working time.

Manual Technique

The Measured powder is sifted into premeasured water in a bowl.

Powder is incorporated into water by careful mixing with the metal spatula. A vigorous
figure 8 motion is best, with the mix being swiped against the sides of the bowl with
 intermittent rotation of the spatula to press out air bubbles. This promotes complete
dissolution. All the powder should be dissolved for residual powder will compromise the
properties.

A mixing time of 45 seconds to 1 minute is sufficient .

Mixing should result in a smooth creamy mix that does not drip off the
spatula, when it’s raised from the bowl.

Automated Technique

A variety of mechanical devices are available for spatulating the alginate

impression material. The required quantity of powder and water are dispensed in a bowl.
Spatulation is carried out until a smooth creamy mix of alginate is obtained. This results in
a superior mix than obtained manually.

Advantages: Convenience
Speed
Elimination of human variable.
Impression Technique

Select the tray with minimum of 3mm spacing between the tray flange and
tissue to ensure adequate thickness of impression material. Before seating, the material
should have developed sufficient body so that it does not flow out of the tray and choke
the patient. Tray should be perforated for better adhesion. If a plastic tray is used, tray
adhesive like sticky wax or methyl cellulose must be used. The disadvantage of using tray
adhesives is that it is difficult to clean the tray.

A study by Lim.P.F et al University of singapore in 1995 in which the surface

of the ireversible hydrocolloid impression material was smoothened out using a moistened
gloved finger prior to impression making resulted in fewer surface bubbles and voids than
impressions that were note smoothened out.

A study was conducted to test reaction between different gloves and

impression materials in common use by Baumann, M.A. of Cologne, Germany in 1995. Study
Concluded that impression materials can be mixed and handled with gloved hands without
affecting their setting time.
 The strength of alginate impression materials increases for the few minutes
after initial gelation. The strength of alginate doubles in the first 4 minutes after initial gelation.
The strength of alginate doubles in the first 4 minutes after initial gelation, after which there is
no appreciable changes. So the impression should not be removed for at least 2-3 minutes
afterf gelation has occurred. Any pressure on gel due removal of pression. The tray should be
removed with a sudden dislodging force. This sudden displacement ensures better elastic
recovery.

Control of Gelation Time

The gelation time is measured from the beginning of the mixing until
gelation occurs. It must allow sufficient time for the dentist to mix the material, load the tray
and place it in the patient’s mouth. Once gelation starts the impression must not be
disturbed because growing fibres will be fractured and impression would be sufficiently
weakened. Optimal gelation time is considered to be 3 – 4 minutes at a room temperature
of 200C.

ADA specification no:18 for alginate have described two types of alginate based
on gelation time.

1. Type I (fast setting) : gelation time not less than 60s but not more
than 120s (1 – 2 minutes)

2. Type II (normal setting) : gelation time between 2.5 -- 4 minutes

Gelation time is best regulated by the amount of retarder added during

manufacturing.

Another way the clinician can safely influence gelation time is to alter the
temperature of water used to mix the impression material. Increase in temperature leads
to a decrease in gelation time and vice versa. However using water cooler than 18 0C and
warmer than 540C is not recommended.

Altering the water – powder ratio will also alter gelation time but it is not
recommended as this will affect physical properties of set material.
Construction of the cast

Rinsing the impression: After the impression is removed from the mouth, it
is immediately rinsed under running water to remove oral fluid and debris from tissue
surface. If excess rinse water collects on impression surface rough stone surface will
result. If surface of impression is completely dry, the gel will adhere to the cast surface
upon removal. The surface of impression should be shiny with no visible water film or
droplets at the time cast is constructed .

Disinfecting the impression: Impression material can act as a vehicle for

transfer of bacteria and virus.

McNeill of Queens University, Northern Island in a study in a study in

1992 demonstrated that impression materials could act as a vehicle for transfer of
bacteria and virus. Rice.C.D et al, University of Missouri Kansas, demonstrated in their
study that commercial alginate impression materials are contaminated by viable
microorganisma.

Since the hydrocolloid impression material must be poured within a short time
after removal from the mouth, the disinfection procedures should be relatively rapid to prevent
dimensional change.

Methods of disinfection usually carried out are

1. Immersing the impression in a disinfectant

2. Spraying the disinfectant on to the impression

3. Using a disinfectant instead of water for mixing

4. Incorporating a disinfectant in the impression material.

The current protocol for disinfection as advised by the Center for Disease Control
and Prevention is the use of Household bleach (1-10) dilution), Iodophore or Synthetic phenol.
 The impression is rinsed, sprayed liberally with the disinfectant and wrapped in a
disinfectant soaked paper towel. This is then placed in a sealed plastic bag for 10 minutes before
being unwarapped, rinsed and poured.

An area of concern in using disinfectants was the dimensional stability of the

impression material due to its hydrophilic nature.

Tan HK, Hooper PM, Buttar IA, Wolfaardt JF, Department of Restrorative
Dentistry, University of Alberta, Edmonton, Canada conducted a study to show the effects of
disinfecting irreversible hydrocolloid impressions on the resultant gypsum casts. Results
indicated that disinfection treatment of alginate impressions with surface disinfectants did not
cause significant dimensional changes in the resultant stone casts from statistical and clinical
points of view.

Ramer MS, Gerhardt DE, McNally D., Department of Restorative Dentistry,

Baltimore College of Dental Surgery, conducted a study on accuracy of irreversible hydrocolloid
impression material mixed with disinfectant solutions. Results shoed that there was no statistical
difference in the accuracy of irreversible hydrocolloid impressions mixed with disinfectant
solutions.

Rueggeberg F.A. et al concluded in their study that spray disinfection of an

alginate impression did not cause dimensional difference of the poured stone cast when
compared with cast from water rinsed control.

Poulos JG, Antonoff LR. Division of Restorative and Prosthodontics, New York
University College f Dentistry, USA, studied about disinfection of impressions and methods and
effects on accuracy. They concluded that internal disinfection (replacing water with disinfectant
before impression taking) is the method of choice for alginate, since it allows immediate pouring
of the impression after removal from the oral cavity.

Tyler et al did a study to show the antiviral properties of alginate impression

material impregnated with dideyl dimethyl ammonium chloride. The material showed no clinically
acceptable effect against HSV I or II virus.

Disinfectant solutions usually used are

0.5% Soidum hypochlorite (10 minutes)

1:213 dilution iodophore (10 minutese)

2% Glutaraldehyde (20 minutes)

1:32 dilution phenyl phenol (20 minutes)

Pouring the case: The pouring of the cast should start from one end of arch.
Afterwards it is placed in a humidor while stone hardens. Stone cast or die should be kept in
contact with the impression preferably for 60 minutes or for a minimum of 30 minutes.

A new method for making casts from irreversible hydrocolloid impressions was
devised by Steas A. Department of Removable Prosthodontics, Aristotle University of
Thessaloniki, School of Dentistry, Greece. A proper dental stone mixed with an accelerator is
painted over the entire anatomic surface of the impression. A base is added only after the first
application of stone sets. This method protects against volume change of the irreversible
hydrocolloid impression material and distortion of the unsupported portions of the impression.

PROPERTIES

Toxicity:

Alginate is nontoxic.

Irritation:

Alginate is a nonirritant material with acceptable taste and odour.

Consistency and flow:

Alginate has smooth consistency and good flow.

Tissue detail reproduction:

Alginate reproduces lines with width less than 0.75mm.

Flexibility:

ADA Specification no: 18 for alginate permits a range of 10% to 20% at a stress
of 1000gm /cm2. Most alginate have a flexibility of typical value around 14%.

Elastic recovery:
Elastic recovery of alginate is 97.3%.

Permanent deformation:

ADA Specification no: 18 for alginate require less than 3% deformation when
alginate is compressed 10% for 30 seconds. Most alginate have a typical value around 1.5%.

Mixing time:

45 seconds for Type I and 1 minute for Type 2.

Setting time:

1 to 2 minutes for Type I and 2.5 to 4 minutes for Type 2.

Working time:

1 to 1.5 minutes for Type 1 and 2 minutes for Type 2.

Strength:

Current ADA Specification no: 18 for alginate impression requires a minimal

strength of 0.343MPA. Tear strength may vary from 300-700gm/cm 2 and compressive strength
5000-9000gm/cm2

Strength is affected by

1. Amount of water used: increase or decrease in amount of water weakens gel structure.

2. Quality of spatulation: under mixing or over mixing weakens the final set material.

3. Air bubbles or voids incorporated into the gel while mixing also reduce the strength.

Viscoelasticity:
 The freshly spatulated material has low viscosity which coupled with a degree of
pseudo plasticity classifies alginate as a mucostatic impression material. Hydrocolloids are strain
rate dependent. Thus the tear strength is increased when the impression is removed with a snap.

Accuracy:

The accuracy is dependent on the dimensional stability of the materials involved

and surface condition of both impression material and model. According to ADA Specification no:
18 for alginate the material must reproduce a line of 0.75mm width.

Another factor affecting surface reproducibility is p h changes occurring during

setting of impression material. Anastassiadou.V, Aristotle University, Greece, conclude in his
study that with alkaline pH values the reproducibility increases and the opposite was noted with
acidic values.

Most alginate impression are not capable of reproducing finer details. The
manufacturers have attempted to make material more accurate by increasing the concentration of
alginate. But this affects the dimensional stability of the material. For maximum accuracy; the
impression must be handled properly.

Dimensional stability:

Changes in dimension can be brought about by syneresis and imbibition.

Relaxation of internal stresses also causes distortion. One cause of production of such stress is
exertion of pressure during gelation. So tray should be held firmly under passive pressure.

Combined shrinkage after 1 hour is 0.44% and after 24 hours is 1.28%.

Douglass et al, University of Kentucky, College of Dentistry, in his study

concluded that when impressions are stored at high humidity, clinically acceptable orthodontic
retainers can be made from models poured as long as 72 hours after the impression is made.

Compatibility with gypsum:

Gypsum casts is not compatible with both type of hydrocolloid impression. To

ensure maximum surface hardness, two methods are usually employed:
(1) Immersing the impression in a solution containing an accelerator for setting of gypsum
products before pouring impression with gypsum. This acts by two ways (a) accelerates
setting of gypsum.

(b) Reacts with gel to produce a surface layer that reduces or prevent syneresis and
eliminate the retarding action of the gel.

Potassium sulphate, Zinc sulphate, manganese sulphate, potash alum etc are
chemcials usually used in hardening solutions. Most effective is 2% K2SO4 solution.

(2) Incorporating a plastic hardener or accelerator in the material by the manufacturer.

Potassium titanium fluoride is most commonly used hardening agent.

In general a hardening solution is not required unless specified by the manufacturer as most of
the commercially available alginates contain a hardener in them.

COMMON CAUSES OF DISTORTION

 Grainy material

Improper mixing

Prolonged mixing

Undeue gelation

Low water –power ratio

 Tearing

Inadequate bulk

Moisture contamination

 External bubble

Undue gelation
 Air incorporated during mixing

 Irregular shaped voids

Moisture or debris on tissues

 Rough or chalky stone model

Inadequate cleansing of impression

Excess water left in the specimen

Premature removals

Leaving model in impression too long

 Distortion

Impression not poured immediately

Movement of tray

Premature removal from mouth

Improper removal from mouth

ADVANTAGES

 Easy to manipulate

 Minimum equipment is required

 Low cost

 Elastic, so used in dentulous areas

 Accurate

 Comfortable for the patient

 Saliva does not affect accuracy

 Separating agent is not required

DISADVANTAGES

 Cannot be electroplated

 Cannot be corrected
 Poor dimensional stability

 Poor tear strength

RECENT DEVELOPMENTS

Siliconised alginate --- To counteract low tear strength two paste alginate
impression system was developed with incorporation of silicon-polymer component. But
dimensional stability is poor.

Dust free alginates - To reduce complication of inhaling silica particles while

fluffing, a dedusting agent, glycol, was incorporated into alginate impression material. The glycol
coated particles are denser and settle down early.

Chromatic alginate- Alginate impression material with a colouring agent

incorporated which changes in colour according to stages in manipulation.

Eg: Violet on mixing, pink while ready to load the tray and white upon gelation.

Agar- alginate combination impression – Double mixture technique. Agar is

injected on the surface and alginate is carried in a tray. Also called pick up impression.

As per Ohta. T., Nihon University, School of Dentistry, the stone cast prepared
by this method had better angle reproductivity than conventional one.

Heisler. W.H and Tjan.A.H. of Loam Linda University, School of Dentistry, in

their comparative study on the accuracy and bond strength or reversible and irreversible
hydrocolloids concluded that the combination system have better physical properties.

Hydro alginates is a combination of reversible and irreversible hydrocolloids

put together by Allard.Y and Viguie.G of Lyan in 1990. This is recommended as the material of
choice for impression of dentulous mouth to their reliability and ease of use.

CONCLUSION

Success of alginate hydrocolloid impression material since its emergence as

an alternative to reversible hydrocolloid was mainly due to four factors:
 East of manipulation

 It is comfortable for the patient and

 It is relatively inexpensive and

 Elaborate armamentarium is not needed.

But the facts like its dimensional instability, its incompatibility with gypsum and
availability of better alternatives like elastomers which produce better surface detail it as an
impression material.
REFERENCES

1. Philip’s Science of Dental Material- Anusavice

2. Applied Dental Materials – John.A. Anderson

3. Notes on Dental Materials – Combe

4. Restorative Dental Materials – Robert.G. Craig

5. History of dentistry – W. Hoffmann

6. Angle Orthodontics, 60(2) 1990

7. American journal of orthodontics, 97 (2) 1990 February

8. British dental journal, 179(4) 1995 August

9. European journal of oral science, 106(2) 1998 April

10. International Journal of Prosthodontics, 5(6) 1992 November

11. International Journal of Prosthodontics, 8(2) 1995 March

12. International Journal of Prosthodontics, 65(4) 1997 January

13. Journal of Prosthodontics Dentistry, 65(4) 1991 April

14. Journal of Prosthodontics Dentistry, 67(4) 1992 April

15. Journal of Prosthodontics Dentistry, 65(4) 1993 April

16. Journal of Prosthodontics Dentistry, 67(5) 1992 May

17. Journal of Prosthodontics Dentistry, 74(4) 1995 October

18. Journal of Prosthodontics Dentistry, 77(4) 1997 June

19. Journal of Prosthodontics Dentistry, 79(4) 1998 April