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69]

Original Article

In Vitro Evaluation of the Wear of Primary Tooth Enamel against

Different Ceramic and Composite Resin Materials
A Bolaca, Y Erdoğan

Department of Pediatric Background: Although there are several studies on permanent tooth wear caused

Abstract
Dentistry, Faculty of
Dentistry, Pamukkale
by dental materials, studies concerning primary teeth are limited. Aim: To evaluate
University, Denizli, Turkey the wear of primary tooth enamel against different ceramic and composite resin
materials. Settings and Design: In vitro study. Materials and Methods: We
assessed five materials (n = 10 per group): monolithic zirconia (group Z), lithium
disilicate glass ceramic (group L), resin nanoceramic (group R), nanohybrid
composite resin (group C), and primary tooth enamel (group E). The mesiopalatal
cusps of primary maxillary second molars were used as antagonists. Wear tests were
performed in a dual‑axis chewing simulator, and the volume loss in the antagonist
tooth was evaluated using a laser scanner and three‑dimensional profiling system.
Statistical Analysis Used: Data were statistically analyzed using one‑way analysis
of variance with Tukey’s post hoc tests (P < 0.05). Results: The maximum
antagonist tooth wear was observed in group L (3.84 ± 0.7 mm3), followed
by groups C (3.68 ± 0.76 mm3), R (3.48 ± 0.71 mm3), Z (2.66 ± 0.65 mm3),
and E (1.66 ± 0.42 mm3). Volume loss was significantly lesser in group Z than in
groups L and C (P < 0.05), whereas there were no significant differences among
groups L, C, and R. Conclusion: Within the limitations of this in vitro study, our
findings suggest that zirconia should be used for full coronal coverage in primary
tooth restorations because it causes lesser antagonist tooth wear than does lithium
disilicate, resin nanoceramic, and nanohybrid composite resin.
Date of Acceptance:
09-Oct-2018 Keywords: Ceramic, composite resin, enamel, primary tooth, wear

Introduction effective restoration methods in pediatric dentistry since

T he treatment of severely decayed primary molars is
often a clinical challenge. Guidelines provided by
the American Association of Pediatric Dentistry[1] and
the British Society for Paediatric Dentistry[2] suggest that
decayed primary molar teeth should be restored with a
filling or a crown after the removal of carious tissue.
According to these guidelines, teeth with more than two
decayed surfaces, those with extensive caries involving
one or more surfaces,[2] and those with localized or
generalized developmental defects such as enamel
hypoplasia, amelogenesis imperfecta, and dentinogenesis
imperfecta should be restored with full coronal
coverage.[3] Stainless steel crowns (SSCs) are often the
first choice of restoration for primary teeth with major
hard tissue loss, and they have been one of the most
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their introduction by Humphrey in 1950.[4]
Despite advantages such as durability, longevity, and a
low rate of recurrent caries, SSCs do not meet the esthetic
demands of parents, patients, and pediatric dentists.[5] Peretz
and Ram[6] reported increased demands for tooth‑colored
restorations by both parents and children, while Zimmerman
et al.[7] stated that the most common parental concern was
esthetics, followed by cost, toxicity, and durability. At
present, pediatric dentists are using a variety of materials for
the esthetic restoration of primary teeth, with each having
Address for correspondence: Dr. A Bolaca,
Department of Pediatric Dentistry, Faculty of Dentistry, Pamukkale
University, Denizli, Turkey.
E‑mail: bolacaarif@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
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For reprints contact: reprints@medknow.com

DOI: 10.4103/njcp.njcp_358_18

How to cite this article: Bolaca A, Erdoğan Y. In Vitro evaluation of the

PMID: ******* wear of primary tooth enamel against different ceramic and composite
resin materials. Niger J Clin Pract 2019;22:313-9.

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Bolaca and Erdoğan: In vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials
advantages and disadvantages associated with technique,
function, and esthetics.[8] One option is open‑faced SSCs,
which are basically SSCs with a tooth‑colored resin‑filled
window on the facial surface; the window is created by
the removal of material with a high‑speed bur. While
open‑faced SSCs provide an esthetic option, the restoration
procedure requires more time and is complicated.[9]
Furthermore, these crowns do not provide optimal esthetics
because of poor gingival health, gingival bleeding, and
visibility of metal margins around the resin.[8‑10] Strip
crowns, another alternative, provide esthetic and natural
results,[11] although the procedure is time‑consuming and
technique‑sensitive.[10] Preveneered SSCs reduce chairside
time, and their appearance is not affected by gingival
bleeding and saliva.[9] However, facet fractures occur during
contouring and crimping,[12] occasionally necessitating
complete replacement of the restoration.[13]
Recently, prefabricated zirconia crowns were introduced
for primary anterior and posterior tooth restorations.
Zirconia, which is a crystalline dioxide of zirconium,
has mechanical properties similar to those of metals
and provides an optimal tooth‑like appearance.[14]
Zirconia ceramics have higher mechanical and fracture
strength and better chemical and volume stability than
do conventional dental ceramics, hence it is an ideal
material for the fabrication of anatomically contoured
crowns.[15] However, there are some disadvantages.
Because of their thickness, more aggressive tooth
preparation is required, which increases the risk of pulp
exposure. In contrast to SSCs, zirconia crowns cannot
be modified, and manufacturers recommend a passive
fit at the time of cementation. Furthermore, zirconia
crowns must be replaced if fractures occur, whereas
preveneered SSCs can provide full coronal coverage
even if the veneer chips or fractures.[5] With recent
developments in dental materials and computer‑aided
design (CAD)/computer‑aided manufacturing (CAM)
systems, esthetic restorations can be completed in a
single session. While esthetic CAD/CAM restorations
are widely used for the treatment of permanent teeth,
there are only a limited number of case reports involving
primary teeth.[16,17] Stines[16] used CAD/CAM systems for
the restoration of primary molars in pediatric patients and
stated that CAD/CAM restorations can be an effective
alternative to SSCs that provide superior esthetics, better
marginal adaptation, and parental satisfaction.
Tooth wear is a complex, multifactorial phenomenon
caused by the interaction of biological, mechanical, and
chemical factors. The amount of tooth wear may vary
according to individual factors such as the chewing
force, dietary habits, and the type of dental restoration.[18]
If dental materials have different wear properties when
314 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 3 ¦ March 2019
compared with those of natural teeth, they can affect the
wear rates for the opposing natural teeth.[19]
The wear properties of primary and permanent
teeth differ because of the differences in the enamel
hardness, enamel and dentin thicknesses, and biting
forces between children and adults.[4] Although there
are several studies on permanent tooth wear caused by
dental materials,[20‑25] studies involving primary teeth
are limited.[4,26‑28] Therefore, the aim of this study was
to evaluate the wear of primary tooth enamel against
different ceramic (monolithic zirconia, lithium disilicate
glass ceramic, resin nanoceramic) and composite
resin (nanohybrid resin) materials.
Materials and Methods
The protocol of this in vitro study was approved by
the Ethics Committee of the Faculty of Medicine,
Pamukkale University (No. 12; 16.05.16). We assessed
the following five materials [Table 1; n = 10 per
group]: monolithic zirconia (Zenostar® T; Wieland
Dental, Pforzheim, Germany; group Z), lithium
disilicate glass ceramic (IPS e.max CAD LT; Ivoclar
Vivadent, Schaan, Liechtenstein; group L), resin
nanoceramic (Lava Ultimate CAD/CAM Restorative;
3M ESPE, St. Paul, MN, USA; group R), nanohybrid
composite resin (CLEARFIL MAJESTY Posterior;
Kuraray Medical Inc., Okuyama, Japan; group C), and
primary tooth enamel (group E; control group).
For groups Z, L, and R, cylindrical samples with a
diameter of 11 mm and height of 13 mm were fabricated
using CEREC inLab MC X5 (Sirona Dental Systems
GmbH, Bensheim, Germany) system [Figure 1].
After the milling procedure, group Z samples were glazed
at 930°C in an Ivoclar P300 furnace (Ivoclar Vivadent)
according to the manufacturer’s instructions. For group C,
nanohybrid composite resin (CLEARFIL MAJESTY
Posterior) was obliquely placed as a 2‑mm‑thick layer in
a cylindrical mold with an 11‑mm diameter and a 13‑mm
height, and each layer was light‑cured with an LED
light polymerizing unit (Woodpecker; Guangxi, China)
for 20 s (1000 mW/cm2). After the samples were
removed from the mold, the upper and lower surfaces
and side walls of the samples were additionally cured for
20 s. Then, all the prepared samples were polished with
abrasive paper, polishing disks (Dia‑Finish L; Renfert,
Hilzingen, Germany), and brushes (Ziegenhaarbürste;
Renfert). All ceramic/resin samples were prepared and
polished by a single dental technician.
Group E included nearly flat lingual surfaces of
primary mandibular second molars, in accordance with
a previous study.[29] The mesiopalatal cusps of primary
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Bolaca and Erdoğan: In vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials
maxillary second molars that were naturally lost during
transition to permanent teeth were used as antagonists.
Teeth with excessive wear, fractures, caries, restorations,
and/or hypoplasia were excluded. The antagonist teeth
were stored in 0.04% thymol solution at 4°C until use.
The prepared samples were embedded in molds using an
acrylic resin [IMICRYL®, Konya, Turkey; Figure 2].
Wear tests were performed using a dual‑axis
chewing simulator (ModDental, MOY‑101; Esetron,
Ankara, Turkey). The restorative material samples were
placed in the upper sample holder and the antagonist
teeth were placed in the lower sample holder [Figure 3].
During the test, simultaneous thermal cycling with
distilled water was applied to reproduce temperature
changes in the oral cavity and for the removal of wear
particles from the contacting surfaces.[4,22] The parameters
were determined based on previously published studies
on primary teeth [Table 2].[4,26]
For measurement of the volume loss, the antagonist teeth
were scanned using a laser scanner (SD Mechatronik Laser
Scanner LAS‑20, Münich, Germany) before and after the
wear test. After scanning, the first and last image data were
Figure 1: Ceramic samples prepared for the evaluation of primary tooth
wear caused by different ceramic and composite resin materials
Figure 3: Chewing simulator (ModDental, MOY‑101; Esetron, Ankara,
Turkey) used for the evaluation of primary tooth wear caused by different
ceramic and composite resin materials
Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 3 ¦ March 2019
transferred to Geomagic Qualify 2012 (Geomagic Inc.,
Rock Hill, SC, USA), which provides three‑dimensional
images. The actual volume loss in the antagonistic teeth
was calculated by calculating the difference in the volume
before and after the wear test.[23]
Descriptive statics were calculated using SPSS
Ver. 23.0 (SPSS Inc., IBM Co., Somers, NY, USA).
Distribution normality and variance homogeneities were
determined using Shapiro–Wilk test. The statistical
significance of the mean difference in each parameter
was tested at a significance level of 5% using one‑way
analysis of variance (α = 0.05) with Tukey’s post hoc
tests (α = 0.05).
Results
Descriptive statistics for the volume of the antagonist
teeth (mm3) before and after the wear test and the volume
Figure 2: Preparation of antagonist and restorative material samples for
the evaluation of primary tooth wear caused by different ceramic and
composite resin materials
4.5 X-axis: Groups
4 Y-axis: Volume loss (mm3)
3.5
3
2.5
1.5
0.5
0
L R C Z E
Figure 4: Volume loss in the antagonist tooth caused by different ceramic
and composite resin materials, as assessed using wear tests (mm3).group L:
Lithium disilicate, group R: Resin nanoceramic, group C: Nanohybrid
composite resin, group Z: Monolithic zirconia, group E: Primary tooth
enamel
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Bolaca and Erdoğan: In vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials

Table 1: Composition and properties of the dental materials used in this study
Group Product Composition Particle size Fracture toughness Hardness
Z Zenostar® T Wieland Zirconium oxide (ZrO2 + HfO2 + Y2O3) ≥99% Yttrium 0.4 µm >5 MPa m1/2 1300 HV
Dental Profzeim, oxide (Y2O3) >4.5 to ≤6%
Germany Hafnium oxide (HfO2) ≤5%
Aluminum oxide + other oxides ≤1%
L IPS e.max CAD LT; SiO2 (57%‑80%), Li2O (11%‑19%), K2O (0%‑13%), 1.5 µm 2.25 MPa m1/2 5800 MPa
Ivoclar Vivadent, Schaan, P 2 O 5 (0%‑11%), ZrO 2 (0%‑8%), ZnO (0%‑8%),
Liechtenstein Al2O3 (0%‑5%), MgO (0%‑5%), coloring oxides (0%‑8%)
R LavaTM Ultimate CAD/ Silica particles 20 nm 2.02 MPa m1/2 1150 MPa
CAM Restorative; 3M Zirconia particles 4‑11 nm
ESPE, St. Paul, MN, USA
C CLEARFIL MAJESTY™ Organic matrix 0.02‑7.9 µm * *
Posterior; Kuraray Bis‑GMA, TEGDMA
Medical Inc., Okuyama,
Hydrophobic aromatic dimethacrylate
Japan
dl‑Camphorqui ‑ none
Inorganic particles
Silanated glass ceramic filler
Surface‑treated alumina microfiller
As per manufacturers’ information. Bis‑GMA=Bisphenol A‑diglycidyl methacrylate; TEGDMA=Triethylene glycol dimethacrylate. *Not
available

Table 2: Parameters for the wear test used to evaluate primary tooth wear caused by different ceramic and composite
resin materials
Test parameters Test parameters
Cold/hot bath temperature: 5°C/55°C Chewing force: 50 N
Vertical movement: 3 mm Number of cycles: 100,000
Horizontal movement: 2 mm Cycle frequency: 1.6 Hz
Rising speed: 30 mm/s
Descending speed: 30 mm/s

Table 3: Volume of the antagonist tooth before and after wear tests used to evaluate primary tooth wear caused by
different ceramic and composite resin materials
Group Volume of antagonist tooth Volume of antagonist tooth Volume loss in antagonist tooth after the wear test
before the wear test (mean±SD) after the wear test (mean±SD) Mean±SD Med (min‑max) P
L 25.19±2.33 21.35±2.06 3.84±0.7a 3.81 (2.7‑4.68) 0.0001*
R 24.23±1.68 20.75±1.50 3.48±0.7a.b 3.27 (2.24‑4.55) (F=18.988)
C 24.76±2.00 21.09±1.97 3.68±0.76a 3.7 (2.47‑4.86)
Z 25.25±1.79 22.59±1.26 2.66±0.65b 2.44 (1.99‑3.78)
E 22.48±1.64 20.82±1.54 1.66±0.42c 1.71 (1.07‑2.37)
SD=Standard deviation, med=Median; min‑max=Minimum and maximum; group L: Lithium disilicate; group R=Resin nanoceramic;
group C=Nanohybrid composite resin; group Z=Monolithic zirconia; group E=Primary tooth enamel. *Statistical significance

loss in the antagonist teeth in each group are shown in Discussion

Table 3 and Figure 4. Group L showed the maximum
amount of tooth wear (3.84 ± 0.7 mm3), followed by
groups C (3.68 ± 0.76 mm3), R (3.48 ± 0.71 mm3),
Z (2.66 ± 0.65 mm3), and E (1.66 ± 0.42 mm3), respectively.
Antagonist tooth wear was significantly lesser in group Z
than in groups L and C (P < 0.05), significantly higher
in group Z than in group E, and significantly lesser in
group E than in the other groups (P < 0.05). There were
no significant differences among groups L, R, and C.
Excessive wear of both the occlusal surfaces of teeth
and dental materials can cause functional and esthetic
problems, dentin hypersensitivity, temporomandibular
disorders because of loss of the vertical dimension,
overeruption of opposing teeth, and traumatic
occlusion.[30,31] Therefore, enamel wear caused by dental
materials is an important factor that should be considered
during material selection in clinical practice. Seghi
et al.[32] stated that dental restorative materials should not

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Bolaca and Erdoğan: In vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials
increase the wear rate for the opposing enamel surface
and should exhibit a wear rate similar to that for enamel.
Therefore, the aim of this study was to evaluate the wear
of primary tooth enamel against different ceramic and
composite resin materials and found that zirconia caused
the least amount of primary tooth wear.
Because in vivo wear studies are complicated and
time‑consuming, wear simulation devices and methods
have been developed. Because of several factors, there is
no in vitro system that can simulate the oral environment
completely.[33] However, chewing simulators provide the
same conditions for the material tested during a wear test
and can simulate simple movements such as grinding and
clenching. This helps in the comparison of wear properties
among different materials, and the mechanism underlying
the wear resistance of various materials can be assessed
at the preclinical stage using specific test variables.[22]
Because different studies have used different chewing
simulators and measuring systems, direct comparison of
their findings is difficult. Therefore, it is stated that the
best way to draw conclusions from single studies or in
the comparison of different investigations is to consider
the ranking of the tested materials within each study.[19]
It is preferred that chewing simulators simulate oral
environment as much as possible. Heintze[33] stated that
chewing simulators should generate clinically relevant
forces ranging from 20 to 120 N. In this study, we
used a chewing force of 50 N, which is the mean value
of the physiological biting forces in patients without
bruxism.[34] It has been reported that 240,000–250,000
chewing cycles in a chewing simulator clinically
correspond to the number of chewing cycles per year for
an individual.[21] However, it is stated that the amount of
wear increases with an increase in the number of cycles.[33]
Standardization of the enamel surface of a natural tooth
used as the antagonist in a wear test is controversial.[34]
Krejci et al.[35] reported that the nonstandardized enamel
cusp of a natural tooth is the most appropriate antagonist.
Because of standardization, the aprismatic enamel layer
is removed; therefore, a standardized cusp consists of
lower level of enamel. It is believed that aprismatic
enamel is more resistant to wear than prismatic enamel,
which probably explains why more wear is observed in
standardized antagonist cusps.[35] Kunzelmann et al.[36]
also stated that standardized and nonstandardized enamel
have different wear properties. Therefore, in this study, we
did not standardize the enamel surfaces of the antagonist
primary teeth. On the basis of the above findings and
previous studies[4,26] on the wear properties of primary
teeth, a chewing force of 50 N, 100,000 cycles, 3‑mm
vertical movement, and 2‑mm horizontal movement were
used in this study.
Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 3 ¦ March 2019
We found that volume loss in the antagonist teeth
was considerably greater with lithium disilicate glass
ceramic (group L) than with resin nanoceramic (group R),
nanohybrid composite resin (group C), monolithic
zirconia (group Z), and natural primary tooth enamel,
in the same order. The amount of wear in group Z
was significantly lesser than that in groups L and C.
However, there was no significant difference among
groups L, C, and R.
The wear of the tested material is influenced by several
factors such as hardness, contact geometry, surface
roughness, microstructural features, particle size, fracture
toughness, and environmental conditions.[20,31,37] Enamel
wear caused by different ceramics and composite resins
is also a multifactorial phenomenon.[20] Although it
is believed that increased hardness of the restorative
material causes greater wear of the antagonist tooth,[21]
it has been reported that zirconia, which has the highest
hardness value among ceramics, causes lesser antagonist
tooth wear than do other ceramics.[4,21,22] This can be
attributed to the superior physical and surface properties
of zirconia, including the hardness, bending strength,
fracture toughness, and density, which prevent surface
microfractures and maintain a smooth surface during
wear tests.[22] However, some researchers have reported
that zirconia causes more enamel wear than does glass
ceramic, feldspathic porcelain, and natural enamel.[29,38,39]
According to Oh et al.,[37] enamel wear caused by
ceramics is associated more with surface roughness,
microstructure, and fracture toughness of the ceramic as
well as environmental factors than with hardness values.
Fracture toughness of a material is a critical property. If
the restorative ceramic material does not have adequate
fracture toughness, chipping/fracture may occur on its
surface during the wear test, resulting in the formation
of sharp edges. Consequently, rough and porous surfaces
of restorative materials and broken particles increase the
wear rate for antagonists.[23,37] In this study, the amount
of primary tooth wear was maximum with lithium
disilicate, probably because this material has a low
fracture toughness value (2.25 MPa m1/2). Accordingly,
the rough surface of the material and broken glass
particles during the wear test may have increased the
amount of antagonist tooth wear. In contrast, zirconia,
which has a high fracture toughness value (>5 MPa m1/2),
could maintain a smooth surface more effectively than
lithium disilicate.
In general, the softer material wears faster than the
harder material when two materials are in contact with
each other.[24] This may explain why primary tooth
enamel (group E) caused the least amount of antagonist
tooth wear in our study. The use of composite resin for
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Bolaca and Erdoğan: In vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials
full coronal coverage in primary teeth is an alternative
method that satisfies the esthetic demands of patients and
parents.[28,40] Unlike that caused by ceramic, antagonist
tooth wear caused by composite resin is associated with
the hardness value of the resin.[24] Composite resin can
cause enamel wear because of the size, hardness, and
content of filler particles.[24,41] Although the hardness
of the nanohybrid composite resin used in our study
was lesser than that of the other restorative materials,
the composite resin caused more antagonist tooth wear
than did monolithic zirconia, resin nanoceramic, and
primary enamel. This can be explained by the contact
of the antagonist enamel with the rough surface of the
composite samples and the production of abrasive filler
particles (0.02–7.9 µm) during the wear test.
It is stated that the modulus of resilience affects the
surface roughness and wear of restorative materials
and the natural antagonists.[25] The resin nanoceramic
(Lava Ultimate CAD/CAM Restorative) used in this
study contains approximately 80% nanoceramic particles
in the organic resin matrix. The inorganic nanoceramic
part is composed of discrete silica nanoparticles (20 nm),
zirconia nanoparticles (4–11 nm), and zirconia–silica
nanoparticle clusters.[42] Resin‑matrix‑based materials
have a higher modulus of resilience than do ceramics.
They undergo elastic deformation by distributing the
stresses under the force. For this reason, these materials
tend to be less brittle and more flexible when compared
with ceramics.[43] Previous in vitro studies[44,45] showed that
resin nanoceramics caused lesser antagonist enamel wear
than did glass ceramics. In this study, resin nanoceramic
caused lesser antagonist enamel wear than did lithium
disilicate, although the difference was not statistically
significant. This was probably because the particle size in
the resin nanoceramic (4–11 nm and 20 nm) was smaller
than that in the lithium disilicate glass ceramic (1.5 µm).
In various in vitro studies, the wear properties of
antagonist enamel and dental materials have been
assessed using different chewing simulators. The results
of these studies showed that zirconia had high wear
resistance and caused antagonist enamel wear that was
comparable with or lesser than that caused by other
ceramics.[4,22,29] In our study, zirconia caused lesser
antagonist wear than did the other materials, probably
because of its superior physical properties and surface
features such as hardness, bending strength, fracture
toughness, and density, which enable the maintenance
of a smooth surface and prevent surface microfractures
during the wear test.[4,22] The rough surfaces of lithium
disilicate, resin nanoceramic, and composite resin, as
well as broken particles during the wear test may have
increased the amount of antagonist tooth wear.
318 Nigerian Journal of Clinical Practice ¦ Volume 22 ¦ Issue 3 ¦ March 2019
This study has the following limitations:
1. Test parameters used in this study differ from clinical
intraoral conditions
2. In addition, only two‑body wear was evaluated
3. Different results could be achieved with three‑body
wear tests.
Therefore, further studies with well‑simulated intraoral
conditions are necessary to further confirm our findings.
Conclusion
Within the limitations of this in vitro study, the findings
suggest that zirconia caused lesser wear of primary tooth
enamel than did lithium disilicate, resin nanoceramic, and
nanohybrid composite resin. Excessive wear of dental
materials and antagonist teeth can cause detrimental
effects on the biology, function, and esthetics of the
masticatory system. Our findings suggest that zirconia
should be preferred over other materials for the restoration
of primary teeth requiring full coronal coverage.
Acknowledgement
The authors would like to thank Editage
(www.editage.com) for English language editing.
Financial support and sponsorship
This research was supported by the Scientific Research
Projects Coordination Unit of Pamukkale University,
Denizli, Turkey (no. 2016/DİŞF001).
Conflicts of interest
There are no conflicts of interest.
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