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Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 313-319

In Vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials

Department of Pediatric Dentistry, Faculty of Dentistry, Pamukkale University, Denizli, Turkey

Date of Acceptance09-Oct-2018
Date of Web Publication6-Mar-2019

Correspondence Address:
Dr. A Bolaca
Department of Pediatric Dentistry, Faculty of Dentistry, Pamukkale University, Denizli
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_358_18

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Background: Although there are several studies on permanent tooth wear caused by dental materials, studies concerning primary teeth are limited. Aim: To evaluate 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.

Keywords: Ceramic, composite resin, enamel, primary tooth, wear

How to cite this article:
Bolaca A, Erdogan Y. In Vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials. Niger J Clin Pract 2019;22:313-9

How to cite this URL:
Bolaca A, Erdogan Y. In Vitro evaluation of the wear of primary tooth enamel against different ceramic and composite resin materials. Niger J Clin Pract [serial online] 2019 [cited 2019 May 21];22:313-9. Available from:

   Introduction Top

The 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 effective restoration methods in pediatric dentistry since 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 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],[9],[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 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],[21],[22],[23],[24],[25] studies involving primary teeth are limited.[4],[26],[27],[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 Top

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).
Table 1: Composition and properties of the dental materials used in this study

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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].
Figure 1: Ceramic samples prepared for the evaluation of primary tooth wear caused by different ceramic and composite resin materials

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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 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].
Figure 2: Preparation of antagonist and restorative material samples for the evaluation of primary tooth wear caused by different ceramic and composite resin materials

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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]
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

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Table 2: Parameters for the wear test used to evaluate primary tooth wear caused by different ceramic and composite resin materials

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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 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 Top

Descriptive statistics for the volume of the antagonist teeth (mm3) before and after the wear test and the volume loss in the antagonist teeth in each group are shown in [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.
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

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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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   Discussion Top

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 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.

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 m 1/2). 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 m 1/2), 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 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.

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 Top

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.


The authors would like to thank Editage ( 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).

Conflict of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3]


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