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Wear of dental materials: Clinical significance and laboratory wear simulation

methods -A review

Article  in  Dental Materials Journal · March 2019

DOI: 10.4012/dmj.2018-140

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 Dental Materials Journal 2019; : –

Review

Wear of dental materials: Clinical significance and laboratory wear simulation

methods —A review
Siegward D. HEINTZE1, Franz-Xaver REICHL2 and Reinhard HICKEL3

1
Research & Development, Ivoclar Vivadent AG, Preclinical Research, Schaan, Liechtenstein
2
Walther-Straub-Institute for Pharmacology and Toxicology, Ludwig-Maximilian-University, Munich, Germany
3
Department of Operative Dentistry and Periodontology, Ludwig-Maximilian-University, Munich, Germany
Corresponding author, Siegward D. HEINTZE; E-mail: siegward.heintze@ivoclarvivadent.com

This review focusses on tribological aspects of teeth during function, the clinical significance of wear, wear of natural teeth and
restorative materials and laboratory methods to simulate wear of restorative materials. Ceramic, metal alloy and amalgam show
low material wear, whereas resin-based materials demonstrate substantial wear in the long term. The clinical wear shows a high
variability with the patient factor accounts for about 50% of the variability. Wear as such seldomly compromises the function of the
stomatognath system or individual teeth and is in most cases an esthetic problem. Particles that are ingested due to attrition and
abrasion wear may pose a health risk to the patient, especially those from composite resin materials. However, systematic clinical
studies on that issue are not available. For laboratory research many wear simulation devices and methods have been developed but
only few are validated and have a moderate correlation with clinical wear.

Keywords: Wear methods, Composite, Ceramic, Clinical significance, Review

the oral cavity. It functions as a lubricant and diminishes

INTRODUCTION
Tribology in the oral cavity: factors and processes
Dental hard tissues (enamel) are subject to wear the
very moment when they erupt into the oral cavity or
when they get into contact with the antagonist tooth.
The same holds true for dental restorations, which are
subject to wear processes from the first moment they are
inserted into the oral cavity. Different wear mechanisms
can be distinguished and they refer to both teeth and
restorative materials: When teeth get into contact with
each other without a third medium between them, two-
body wear, or attrition, is caused1,2). Chewing on food
items or brushing teeth with a toothbrush and toothpaste
results in three-body wear, or abrasive wear. Buccal and
lingual tooth surfaces are mainly exposed to mechanical
oral hygiene procedures causing abrasive wear, while
the occlusal surfaces are mainly subject to both attrition
and abrasive wear. Another phenomenon is described
as adhesion wear and occurs when two solid surfaces
slide over one another under pressure. The high local
pressure causes the surface projections, or asperities,
to become plastically deformed and eventually they
are joined together. In the process, material may be
transferred from one tooth to the artificial surface or
enamel of the opposing tooth. Likewise, a similar transfer
of material may happen on the proximal surfaces of
adjacent teeth. Fatigue wear occurs when large portions
of dental hard tissues or restorative material chip off.
If this occurs on the cervical part of the tooth, the term
abfraction is used.
Saliva is an essential factor that influences wear in
Color figures can be viewed in the online issue, which is avail-
able at J-STAGE.
Received Apr 25, 2018: Accepted Jul 26, 2018
doi:10.4012/dmj.2018-140 JOI JST.JSTAGE/dmj/2018-140
wear by reducing friction. Mucopolysaccharides and
glycoproteins are the main lubricants in saliva. If acidic
substances and high occlusal loads occur together,
the wear rate may be accelerated dramatically. Such
substances can derive from acidic food items, from
gastric acid, or from sources outside the oral cavity, such
as factories that emit acidic substances in the air3-5).
The acidic attacks that cause loss of tooth substance
are summarized as erosive wear, but the term corrosive
wear would be more adequate here6).
All these processes occur in the biomechanical
stomatognathic system, where the teeth of the upper
jaw are fixed to the skull and the teeth of the lower
jaw are movable in three directions: to the lateral,
front and vertical, which gives them a high degree of
movement flexibility. The teeth get into contact with
each other during eating and chewing as well as during
other processes, such as swallowing, speaking and
yawning. Any other tooth contacts are attributed to
parafunctional or pathological actions or habits, namely
such as bruxism or thegosis7). Bruxism is the technical
term for teeth grinding without food and occurs mainly
unconsciously at night during short periods of 30 to 60 s
an hour8). Patients suffering from bruxism produce high
biting forces during the gnashing phases9). The maximum
biting forces, however, do not seem to be different from
those of non-bruxers10). In some patients, bruxism leads
to a hypertrophy of the masticatory muscles (e.g. M.
masseter) and to a considerable wear of the teeth, even
to the point where dentine becomes exposed. Equally,
restorative materials show more wear, fracture or
chipping in bruxers. The number of people that show
some level of bruxism has significantly increased
2 Dent Mater J 2019;
over the last three decades11). Based on several cross-
sectional studies, estimates assume that the prevalence
of bruxism in the industrialized countries is in the range
of 20%, with physiological stress factors being the most
important etiological factor12). Thegosis is the process of
sliding teeth into a lateral position and may derive from
the evolutionary genetic habit to sharpen teeth. Other
actions causing friction and wear on teeth are pipe-
smoking as well as chewing on pencils or toothpicks and
biting fingernails, etc.
The biomechanical process of mastication is very
complex and is controlled by trigger zones in the brain
stem and involves multiple feedback mechanisms, some
of which are located in the periodontal ligament13).
Mastication reduces the food bolus to a few cubic
millimeters, which facilitates swallowing and digestion.
The profile of the force curve corresponds to the positive
half of a sine curve and is therefore also called haversine
wave form14). The masticatory force depends on the
texture of the food as well as on the location where the
chewing occurs in the oral cavity. Higher pressure and
higher forces are exerted in the posterior region and
when grinding hard foodstuffs. However, biting forces
vary substantially between different individuals and
they decreases with age, with young adults having the
highest forces. The magnitude of the biting force is in
the range of 10 to 20 N in the initial biting phase and
increases to the range of 100 to 140 N in the molars
and 25 to 45 N in the incisors at the end of the chewing
cycle15). The entire cycle lasts for about 0.8 s whilst the
mean duration of occlusion is only about 0.4 to 0.6 s13,15).
The sliding distance is less than 1 mm with a speed of
0.25 to 0.5 mm/s16).
Direct antagonist tooth contact totals 15 to 20
min per day, depending on the eating frequencies and
habits and does not include the tooth contact during
swallowing, which, however, is only of a lower magnitude.
The mean chewing frequency is about 1.6 Hz (range
0.9–2.1 Hz) with about 300 strokes per meal17). If we
assume that 3 meals are eaten per day, an individual
carries out approximately 330,000 chewing cycles per
year. However, no systematic studies in large patient
samples have yet been carried out on the frequency of
chewing cycles. According to the literature, Europeans
chew about 400 kg of solid food on average per year18).
CLINICAL IMPORTANCE OF WEAR OF TEETH AND
RESTORATIVE MATERIALS
Wear of teeth is physiological and increases with age with
males showing significantly more wear than females19).
A systematic review revealed that the prevalence of
severe tooth wear in patients does not increase on a
linear scale from about 3% at the age of 20 to about 8%
at the age of 40 and to about 17% at the age of 7020).
It seems, though, that the prevalence of tooth wear in
the different age groups has increased over the last four
decades21). However, there is no consensus on the correct
tooth wear index or on the correct method to evaluate
tooth wear clinically22).
: –
Wear of natural or restored teeth can have mainly
three consequences: (1) esthetic effects that compromise
the appearance of the natural and restored teeth, (2) in
case of severe wear, irritation of the pulp with clinical
signs of hypersensitivity or pulpitis or even opening
of the pulp, and (3) functional effects that alter the
relationship between the tooth and antagonist and/
or tooth and adjacent tooth by promoting phenomena
like elongation of antagonists, movement of teeth or
reduction of vertical height with possible consequences
to the temporomandibular joint (TMJ). A clinical study
in the UK on 290 patients that were referred to a dental
clinic because of severe tooth wear revealed that esthetic
concerns were the most prevalent complaint (59%),
followed by tooth hypersensitivity (40%)23). Patients
who had lost molar tooth support showed significantly
more severe wear in the premolar and anterior region.
Furthermore, severe tooth wear was more than two
times more prevalent in males than in females23).
According to a clinical study on 1007 individuals in
southeast England, the percentage of excessive wear
in natural teeth varied between 3% and 9% of all tooth
surfaces according to different age groups24).
Wear particles derived from restorative materials
may have a biological and/or toxicological effect if
swallowed or inhaled. Components that can be released
from amalgams during the masticatory process include
copper, zinc and mercury. Based on clinical wear rates of
amalgam fillings, the average amount of dissolved zinc
and copper was found to be small even over a long period
of time25). Likewise, the amount of mercury released due
to abrasion seems to be relatively irrelevant clinically
—as measured in bruxist patients26). Wear of noble gold-
based dental alloys and ceramic materials is low and
these materials are regarded as being relatively inert,
even if some particles may be swallowed27,28). However,
alloys that contain nickel, chromium and beryllium
are considered to have a higher allergic and mutagenic
potential. With resin-based composites, there are
some concerns that, in addition to the leaching of (co)
monomers, micro- and nano-sized filler particles may be
worn, swallowed or inhaled and then be accumulated
in the tissues. These accumulations may be linked to
diseases of the liver, kidney, lung and intestine29-31). The
particle size of the dust grains created during grinding
and polishing of resin composite fillings with diamond
burs and rubber instrument is —depending on the
material— in the micrometer and submicrometer range
(between <100 nm and >15 µm), as shown in an in vivo
study, where 75% of the particles were smaller than 2.5
µm (Fig. 1)32). An efficient suction system, water spray
and protecting masks should be used during grinding and
polishing to prevent, or at least to reduce, the inhalation
of nano- and microsized composite dust. However, the
ingestion of the particles that are caused by wear cannot
be avoided.
Studies with radiolabeled 14C-(co)monomers
demonstrated high intestinal absorption33-35). Once
released, (co)monomers can diffuse into the pulp chamber
or they can be absorbed through the lungs by inhalation.
 Dent Mater J 2019;
Fig. 1 Transmission electron photomicrographs of
embedded composite dust of two different resin
composite materials (a and b).
Composite dust has a very wide size variation
ranging from a couple of nanometers to more than
15 µm. The large dust particles typically consisted
of filler particles embedded in resin, but very
frequently single nano-filler particles could be
observed (arrows )32). (Courtesy Van Landuyt and
by Dental Materials)
In this way, they reach the systemic circulation36,37),
where they are further metabolized38,39). Studies have
shown that cellular or liver microsomal degradation
of (co)monomers leads to the formation of the epoxy
compound 2,3-epoxymethacrylic acid38,40-52).
Composite particles may also be generated during
wear processes. Studies in rats that had been fed with
polystyrol particles of different sizes (50 nm —3 µm) have
shown that some parts of those particles accumulated
in the lymph nodes, Peyer patches and the liver53,54). If
all posterior teeth were restored with medium-sized
composite fillings, the mean maximum total material
loss and possible health burden due to ingestion would be
about 18 mm3 within five years of clinical service, based
on the data of clinical wear measurements of composite
fillings55). The wear data of this study suggest that there
is no self-limiting wear behavior of resin composite
restorations rather a steep increase of volumetric wear
after the fourth year of clinical service. However, little is
known about the systemic effects of ingested or inhaled
resin agglomerates and leached monomers etc. that
derived from composite restorations56).
As far as the biological consequences on the
stomatognathic system are concerned, there is evidence
that occlusal wear as such does in general not lead to the
dysfunction of the TMJ, to muscle pain or periodontal
disease57-62). Even severe loss of occlusal tooth substance
through wear is compatible with good oral health, as the
stomatognathic system is highly adaptive to changes. As
severe tooth wear in posterior teeth accelerates the wear
in anterior teeth, restoring worn posterior teeth protects
the anterior teeth from wear.
Based on the evidence available, it may be concluded
that wear as such is first and foremost seen as an
esthetical problem. Wear may nonetheless lead to the
premature failure and replacement of a restoration.
: – 3
WEAR BEHAVIOR OF NATURAL TEETH AND
DENTAL RESTORATIVE MATERIALS
Dental enamel is highly resistant to wear with a mean
annual vertical enamel loss rate of about 20–30 µm in
posterior teeth63-65). The wear rate of enamel is higher
during the first two years after coming into contact with
the opposing teeth (running-in phase) and decreases
thereafter. Furthermore, the surface hardness of enamel
and its depth of wear vary with age: lower hardness and
higher depth of wear were observed in older patients
compared with young or middle aged patients19). The
wear of enamel mainly results from microfracturing and
is characterized by delamination and microploughing. In
contrast, the wear of dentine is characterized by ductile
chip formation.
Artificial dental materials can be grouped into five
different categories: metal alloys, ceramics, amalgams,
composites and unfilled polymers. Clinical wear of
dental alloys and ceramic materials is low. A concern
was raised that the antagonist teeth may become
excessively abraded by ceramic materials that show a
high strength, E-modulus and/or surface hardness66).
However, this concern has been proven to be unfounded
in clinical trials with these materials67,68).
Resin composites show a particular wear pattern
because many characteristics associated with their
composition directly affect their wear resistance.
Composites consist of filler particles dispersed in a
brittle polymer. The fillers consist of glass particles such
as silicon oxide (quartz), barium aluminium silicate or
fillers that are manufactured from the matrix polymer by
grinding the matrix to small-sized/miniscule/nanoscale
particles, commonly referred to as pre-polymer fillers.
The polymers are produced from various monomers,
such as bisphenol-A-glycidyl methacrylate (Bis-GMA),
urethane dimethacrylate (UDMA), triethyleneglycol
dimethacrylate (TEGDMA) and other monomers. They
are polymerized with initiators that are sensitive to
visible light69). Ideally, the loading force is completely
transferred from the matrix to the filler particles. The
wear properties are affected by (1) the amount, size,
shape and hardness of the fillers, (2) the quality of the
bonding between fillers and polymer matrix and (3)
the three-dimensional polymerization dynamics of the
polymer70). The physical properties such as flexural
strength, fracture toughness, Vickers hardness, modulus
of elasticity, curing depth, etc. are defined by the
components used in the composition of the material69).
The physical properties in turn, may influence the
wear of the composite. In direct contact between resin
composite and antagonist, the wear pattern is mostly a
combination of attrition/abrasive wear and microfatigue.
The friction coefficient and the surface roughness are
determining factors for the wear rate of composites.
Thus, the size and volume of the fillers affect the wear
rate. A low modulus of elasticity leads to larger contact
areas and consequently to lower pressure.
Large filler particles, on the other hand, are
associated with high friction coefficients and lead to high
4 Dent Mater J 2019;
internal shear stress in the polymer matrix. The latter
in particular occurred in the early composites of the
eighties. These composites contained large fillers and
showed excessive wear in the posterior region, which
was clinically visible as loss of contour.
The composite technology has been continuously
optimized since then. While the composites of the late
nineties did not show the excessive wear of the early
generations anymore, their wear rate was still higher
than that of enamel. In a clinical trial on 35 posterior
resin restorations, the volumetric loss of the material
did not increase substantially during the first 3 years55).
After the third year of clinical service, however, there
was a non-linear increase of mean wear until the end of
the clinical study (5th year, Fig. 2)55,71). It can be assumed
that the wear of the resin composite restorations will have
further increased after the 5th year of clinical service,
which indicates that wear in many patients will not be
restricted to attrition wear but will extend to include
abrasive wear affecting the entire occlusal surface. Yet,
the variability was very high and the distribution was
uneven amongst the individuals in the above study :
the coefficient of variation was between 30% and 80%.
Similar levels of variability also occurred inthe clinical
trials of the Clinical Research Associates (CRA) [now:
Technologies in Restorative and Caries (TRAC)]. This
institute clinically evaluated many resin materials for
both direct and indirect Class II restorations and for
indirect crowns and fixed dental prostheses in the 90ties
of last century (1990s)65). In those trials, the restorations
were exclusively placed in the posterior regions, mostly
in molars. In total, 1484 posterior restorations were
placed and wear data of up to three years of clinical
service was collected on 25 different resin composite
materials as well as on one amalgam material and
enamel. The results of that study showed that the mean
coefficient of variation of the wear results within one
material was 53% which leads to the assumption that
53% of the variability is due to the influence of patient-
related factors (Fig. 3)65). Chewing and biting force,
Fig. 2 Mean volumetric wear in vivo (mm3) and standard
deviation of two composite materials (microhybrid
Z100, n=17; nanohybrid Filtek Supreme, n=18)
in relation to observation time (years) —based on
published data55,71).
: –
type and frequency of nutrition, parafunction, bruxism,
etc. may be patient factors affecting wear. Due to the
high variability, the wear results of 17 out of the 26
resin composite materials were in the same statistical
subgroup and were are statistically not significantly
different, if ANOVA with a post-hoc test to adjust for
multiple comparisons was applied65).
The CRA clinical wear data also showed that to
date no composite resin is as wear resistant as amalgam
or enamel65). The good wear resistance of amalgam
materials can be explained by the fact that surface
tension is partly compensated by plastic deformation.
During the wear process, an oxide layer is continuously
formed and removed.
Nevertheless, fillings with contemporary resin
composite materials do not fail because of wear but
mainly because of caries at the restorative margins or
material fractures72,73). Even a 30-year clinical trial
involving three resin composites demonstrated that
Fig. 3 Vertical wear in vivo after 2 years of clinical service
of 25 resin composite materials, amalgam (material
No. 29) and enamel (material No. 30).
Each dot represents the vertical wear of one
patient. Raw data by CR/TRAC, Provo/USA65).
Fig. 4 Two-surface resin composite restoration.
(A) Baseline, and (B) after 10 years of service.
Only by comparing both pictures, a minimal loss of
contour and hence material is visible.
Clinical pictures: Courtesy by A. Peschke, R&D,
Director of Clinical, Ivoclar Vivadent
 Dent Mater J 2019;
wear was not the primary cause of failure74). Occlusal
wear of resin composite restorations may be detected
clinically over time but it does not hamper the long-term
survival of the restoration (Fig. 4).
HOW TO MEASURE WEAR
Along with many other criteria, wear started to be
evaluated as part of the USPHS scoring system which
was introduced in early 1970s75). The evaluation,
however, is very subjective and wear cannot be accurately
assessed. Therefore, researchers modified the criteria
according to their needs, which led to many different
sets of modified USPHS criteria. Only in the last decade,
a group of renowned scientists have further developed
the USPHS criteria by systematically structuring them
using normative and subjective guidelines. However,
this group acknowledges that wear can only be precisely
quantified with the help of sophisticated equipment76,77).
Nowadays, mechanical or electro-optical sensors
are used to quantify clinical wear. Nonetheless, it is
necessary to take physical impressions. The quality
of the impression is therefore crucial for accurate
measurements. Systems that use optical technology
have advantages over mechanical sensors78,79). One
optical system in particular has been identified to
measure wear with an accuracy of 10 µm both in
clinical trials and in vitro80). To avoid fabricating
impressions and replicas, some researcher use intraoral
scanners for wear measurements. As these scanners,
however, are designed for the fabrication of CAD/CAM
ceramic or polymer restorations rather than for wear
measurements, they, and the software, are generally
not as user-friendly as laboratory scanners specifically
designed for wear measurements81,82). However, some
scanners provide sufficiently accurate results and
are comparable to systems that use replicas for wear
measurements.
LABORATORY METHODS TO TEST DENTAL
MATERIALS FOR WEAR
In 2001, the International Organization for
Standardization (ISO) published a technical specification
on “guidance on testing of wear”, describing 8 different
test methods of two- and/or three-body contact83) (see
Table 1). Another ISO technical specification covers the
wear caused by toothbrushing84). However, the usefulness
of this ISO standard is debatable as contemporary
restorative are very resistant to toothbrushing, which
has been shown both in vitro85,86) and in vivo87). The
advantage of these standards is that defined test
methods are described which can be performed and
reproduced with relatively easily accessible means
in laboratories. The specifications for test methods,
however, are the greatest common denominator between
the representatives of industry, authorities, and
universities, who work together in the standardization
committees. As a consequence, the ISO standard tests
and recommendations are not necessarily scientifically
: – 5
robust and often lack evidence for correlation between
test results and clinical phenomena. This fact may also
explain why the eight-wear test methods of the ISO
standard do not include a description of their advantages
and disadvantages. Furthermore, the specification does
not mention whether the methods have been validated
and whether the devices with which the methods have
been performed were qualified for that purpose. If you try
to retrieve this information from the original literature,
you may notice that hardly any of the methods described
in the relevant ISO technical specification followed the
guidelines established by FDA and that virtually none
of the wear-related components of these simulators had
been evaluated.
The different two- and three-body test methods
vary with regard to a number of aspects, such as
load, number of cycles, frequency of cycles, abrasive
medium, type of force actuator, sliding movement, etc.
(see Table 1). Qualification and validation, however,
are indispensable prerequisites for a test to become a
standard laboratory test88). The test equipment must
operate within acceptable and reproducible limits and
tolerances to generate reproducible results. A systematic
review showed that the wear rate results for the same
resin composite subjected to the same wear method and
using the same wear parameters varied between 30%
and 70%89).
A device that is used to test dental materials for
wear should have the following features:
- Force and force impulses should be reproducible
and adjustable in the range of 20 N to 150 N.
- A lateral movement of the stylus should be
integrated in the system to be able to test the
material for microfatigue.
- Continuous water change should also be
integrated to remove abraded particles from the
interface between stylus and material.
- All movements should be computer-controlled
and adjustable.
A qualified machine should use two axes of movement
(vertical and horizontal). At present, three commercially
available chewing simulators, the Willytec chewing
simulator89,90), the MTS chewing simulator14,91) and the
Bose ElectroForce 3330 Dental Wear Simulator (www.
bose-electroforce.com), fulfil these criteria. For the
latter machine, however, no studies on wear have been
published, only on fatigue of dental restorations92).
Furthermore, some institutes developed their own
systems, such as the OHSU machine93), the Alabama
machine94), the Zurich machine95), the Regensburg
simulator96) and the BIOMAT simulator97). More
recently, a complex system with six actuators has been
developed at the University of Bristol: the Dento-Munch
Robo-Simulator98). This simulator tries to mimic the
entire process of movements of the lower jaw by using a
Stewart platform.
As all simulators and wear methods follow different
approaches because they are based on different
operational and methodological concepts, the results
cannot be compared, even if efforts are made to use
6 Dent Mater J 2019; : –

Table 1 Two-/three-body wear methods and wear simulators

Simulator Correlation
ISO Number
Properties Method (Force Stylus Medium Movement Force with clinical References
TS83) of cycles
actuator) wear*
Proto-tec
OHSU poppy seeds/ impact
yes (electro- enamel 20 N 50,000 moderate 93)
abrasion PMMA beads +sliding
magnetic)
Abrasion
Alabama Alabama poly- impact
yes PMMA beads 75 N 400,000 weak 94, 114)
three body generalized (spring) acetal +sliding
ACTA
ACTA yes steel millet sliding 15 N 200,000 none 115)
(spring)
Proto-tec
OHSU poppy seeds/ impact
yes (electro- enamel 70 N 50,000 moderate 93)
attrition PMMA beads +sliding
magnetic)
Alabama Alabama poly- impact
yes PMMA beads 75 N 400,000 weak 94, 114)
localized (spring) acetal +sliding
Willytec
Ivoclar- (weights impact
Method driven by leucite +sliding
no water 80 N 120,000 weak 89)
(pin-on- engine) ceramic (short
block) Qualified excursion)
machine
Willytec
Munich- (weights
Sliding
Method driven by
no steatite water (long 50 N 50,000 weak 116)
(pin-on- engine)
excursion)
block) Qualified
machine
MTS
Attrition
(Servo-
Minnesota yes hydraulic) tooth water sliding 13.35 N 500,000 weak 14, 91)
Contact/
Qualified
two body
machine
Fatigue/ DIN
pin-on-disc 8–10
subsurface (pin-on- yes Al2O3 water sliding ? ? 83)
machine MPa
damage disc)
Zurich
water
simulator
+alcohol impact
Zurich yes CoCom enamel 49 N 1,200,000 weak 95, 117)
+toothbrush- (+sliding)
(electro-
ing
magnetic)
Freiburg
pin-on-disc
(pin-on- yes Al2O3 water sliding 8 MPa 40,000 ? 118)
machine
disc)
Newcastle pin-on-disc
yes steatite water sliding 15 N 10,000 ? 119, 120)
(pin-on-disc) machine
BIOMAT
cobalt- impact 20 MPa
BIOMAT no simulator water 4,000 ? 97, 121-123)
chrome +sliding (225 N)
(cam+weight)
enamel/
NBS
stainless rotation-
(pin-on- no weight water 10 MPa 127,500 ? 105, 124, 125)
steel/ sliding
disc)
sapphire

*Based on 65)
 Dent Mater J 2019;
Fig. 5 Agreement between laboratory wear methods
measured by relative ranks 1–9 (y-axis) in relation
to 9 restorative materials (x-axis)99).
similar wear parameters. This has been shown in a blind
round robin test, in which the test centers did not know
which materials they were testing. This test included 9
materials, which were assessed with 6 different methods
(ACTA, Alabama, Ivoclar, Munich, OHSU, Zurich)99).
The variability of the test results turned out to be very
large between the methods (Fig. 5)99).
The following factors that influence wear should be
controlled and standardized:
Surface roughness of specimen: The surface
roughness of the specimens prior to carrying out the
wear should be standardized although the influence
seems to be small in the long run100).
Number of specimens: The scattering of the results
expressed by the standard deviation determines
the number of specimens required to statistically
differentiate between materials. The variability of the
test results mainly reflects the quality of the wear testing
device. The more robust a device is constructed and the
more reliably test parameters, such as force, speed of
stylus, etc. can be reproduced, the lower the variability
will be89).
Loading force: Higher forces in general produce
more wear. However, the relationship does not seem to
be linear. There might be even a certain cut-off point at
which an increase in the loading force does no longer
result in an increase in wear89,101).
Type of stylus material: Enamel would be the
material of choice due to its physiological relevance.
However, it is not possible to standardize the composition
of a biological substrate and extracted teeth are in
short supply. The pressable leucite-reinforced ceramic
IPS Empress was tested as a suitable material for this
purpose and generated a similar wear rate as an enamel
stylus of the same shape102).
Size and shape of stylus: A pointed stylus produces
more wear than a ball-shaped stylus as a ball-shaped
stylus has a larger contact area between stylus and
material thus producing less fatigue stress on the
material90,103,104).
Sliding of stylus: Sliding is an essential component
of a wear testing method in order to subject the material
: – 7
to microfatigue105).
Descent/lifting speed of stylus: The speed with
which the stylus hits the surface of the specimen creates
a force impulse, which is different with varying speeds.
If weights are used to exert a force, then the force that
is generated on the material is the product of the weight
and the descent speed (F=m×a, N). Another variable is
the time during which the force is exerted i.e. the force
impulse is the product of the force and the time the force
is applied (F=F×t, Ns).
Lubricant: Lubricants, such as artificial saliva,
reduce the wear as they lower the friction coefficient.
A constant change of water removes the worn particles
from the interaction zone between stylus and material,
thus reducing the effect of the worn material, which,
otherwise, may act as an abrasive medium.
Number of cycles: The wear increases with increasing
number of cycles. Most in vitro wear test methods
demonstrate a running-in phase with a steep increase
in wear in the initial phase and a flattening of the curve
thereafter because of the increase in the area exposed to
the wear forces.
Abrasive medium: An intermediate medium may
reduce or increase the wear, compared with water106).
Furthermore, the composition and the type of the
abrasive medium affect the wear rate107,108).
The wear simulation should follow physical
principles: The wear simulation should imitate
tribological phenomena that occur in the mouth in a
standardized way109).
CORRELATION WITH CLINICAL WEAR
A wear method should not only be internally valid, which
means that the results for the same material tested at
two different points in time are similar. In addition,
the wear method should also be externally valid, and
correlate with in vivo findings. The raw data on clinical
wear of restorative materials was used to correlate the
clinical wear results with those of the most frequently
cited wear methods65). A moderate correlation was
found for OHSU (abrasion). Almost no correlation was
found for the ACTA method and a weak correlation for
the Alabama, Ivoclar, Munich and Zurich methods (see
Table 1). The combination of different methods did not
improve the correlation.
RATIONALE FOR WEAR SIMULATION
There are no regulatory requirements or international
standards with regard to testing dental restorative
materials for wear. Therefore, there is no official need
to test these materials for wear prior to their market
launch. However, if certain claims related to wear, e.g.
good wear resistance, are to be made, these claims should
be substantiated by adequate laboratory tests. Good
wear resistance of polymer materials in particular will
not only result in better esthetics but also in a possible
lower uptake/ingestion of worn particles and thus result
in better biocompatibility.
8 Dent Mater J 2019;
Fig. 6 Boxplots of pooled mean vertical loss of dental
restorative materials tested with the Ivoclar
method (see Table 1) (unpublished data based on
wear data generated at Ivoclar Vivadent with the
Ivoclar wear method between 2000 and 2015).
Most published studies focus on the wear of resin
composite materials rather than on the wear of ceramic
materials, alloys and polymer materials for denture
teeth89). A systematic review revealed a wide variation
with regard to experimental set-ups to test ceramic
materials for wear, variability of test results, and the lack
of correlation with clinical wear66). As ceramic materials
are very wear resistant and current products do not
seem to pose a clinical problem in terms of antagonist
enamel wear, there seems to be no urgent need for
conducting further comprehensive research and testing
on that score. Wear of denture teeth, on the other hand,
is still a clinical problem110,111) but rarely addressed with
laboratory research and testing112).
For resin composite materials, the clinical wear
data show that the patient factor contributes to a
much higher extent to the variability of wear than the
material itself. It is easy to find statistically significant
differences in the wear behavior of different materials
with standardized tests in the laboratory. But differences
between materials in the laboratory which cannot be
observed in clinical trials will always be found113).
Only glass ionomer cement derivates show a much
higher wear, which is in agreement with clinical studies
(Fig. 6). Figure 5 also shows that the wear results of most
resin composite materials lie within a narrow range
of 200 and 300 µm of vertical wear and probably will
not show any difference in clinical trials provided that
about 50% of the variability of wear can be attributed to
patient factors (see above).
Despite the weak correlation between in vitro and in
vivo findings, when new material concepts (systems or
technologies) are developed, the wear resistance should
be evaluated in the laboratory by reliable wear testing
methods before these materials are released for clinical
trials.
SUMMARY
The clinical significance of increased wear is mainly
due to the adverse effect on esthetic appearance and/
: –
or functional restrictions. Little is known about the
systemic effects of ingested or inhaled worn particles
that derive from resin composite restorations, which
have a much higher surface-volume-ratio than ceramic
materials. There is a need for studies to find out
more about the elimination pathways or possible
accumulations and the concomitant biological effects of
worn particles in the human body .
Wear can efficiently and accurately be measured
three-dimensionally with modern laser technology both
in vitro and in vivo restorations. The different laboratory
methods to test the wear rate of dental materials follow
different concepts and measure different phenomena.
Therefore, the results differ from one another. Most
of the laboratory methods to test the wear of dental
materials are not validated. Low reproducibility and
high variability of test results are the consequences.
Mimicking the entire masticatory cycle with all possible
movements of the lower jaw is not necessarily the best
approach. However, a machine that applies a force in
only one direction is also inadequate. Instead, the
device should have computer-controlled force actuators,
bi-axial motion and sufficient water exchange in the
test chamber. The device should be simple, robust and
efficient and require only low maintenance efforts.
Instead of enamel from extracted teeth, a pressable
or machinable ceramic material of low strength can be
standardized and is an adequate substitute as stylus
material. An indication of a valid wear simulation
concept is the fact that the wear of the composites can be
explained by the variation in their physical parameters,
thus making the method internally valid.
Contemporary composite materials using
polymethacrylate technology have less effect on wear
than patient-related variability in vivo. Clinical wear
studies have shown that inter-individual variability
is at least 50%, which outweighs the inter-material
variability observed in clinical wear trials. However, if
materials with new material concepts or properties are
to be brought to the market, laboratory wear testing is
indispensable.
CLINICAL RELEVANCE
Clinical wear of dental materials rarely results in oral
pathologies. Only few laboratory wear methods show a
moderate correlation to clinical wear.
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