RESEARCH AND EDUCATION

Wear of resin teeth opposing zirconia

Jonathan Esquivel, DDS,a Nathaniel C. Lawson, DMD, PhD,b Edwin Kee, MCDT,c Karen Bruggers, DDS, MS,d and
Markus B. Blatz, DMD, PhDe

The placement of 4 or more ABSTRACT

implants has become a com-
Statement of problem. The use of dissimilar materials for opposing complete-mouth
mon procedure for restoring implant-supported prosthesis has become popular, especially when one arch is made from
an edentulous arch with fixed anatomical contour zirconia. However, the amount of wear zirconia causes on resin and other
1-3
dental prostheses. A tita- denture tooth materials is largely unknown.
nium bar supporting acrylic
Purpose. The purpose of this in vitro study was to determine the volumetric wear of 4 commercially
resin and denture teeth is available resin materials used for denture teeth in complete-arch implant-supported prostheses
the most prevalent prosthetic opposed by zirconia.
design for complete-arch
Material and methods. A total of 32 maxillary central incisor denture teeth were evaluated (n=8):
implant-supported prosthe-
3 4
double crosslinked polymethyl methacrylate (PMMA) (DCL), nanohybrid composite resin (PHO), and
ses. Box et al reported that computer-aided design and computer-aided manufacturing (CAD-CAM)-fabricated teeth made
the most common prosthetic from crosslinked PMMA (TEL) and acrylate polymer (ZCAD). Antagonist cone-shaped specimens
complication with metal- were milled from zirconia. Specimens were mounted in acrylic resin, polished to a flat surface by
acrylic resin complete-arch using 1200-grit SiC paper, and stored in water (37  C for 24 hours) before exposure in a custom
implant-supported prostheses dual-axis wear simulator for 200 000 cycles with a vertical load of 20 N, a horizontal slide of 2
was the wear of posterior mm, and a frequency of 1 Hz. Volumetric wear was measured by using a noncontact
profilometer and a superimposition software program. Data were analyzed with a 1-way analysis
denture teeth. Monolithic zir-
of variance (ANOVA) and the Tukey Honestly Significant Difference (HSD) post hoc test (a=.05).
conia complete-arch implant-
supported prostheses are Results. A statistically significant difference in volumetric wear was found between groups (P<.001),
another option for treating the with PHO (4.3 ±1.0 mm3)<TEL (11.9 ±2.0 mm3)<ZCAD (14.2 ±0.8)<DCL (17.3 ±1.0 mm3).
edentulous patient.5 Some of Conclusions. Denture teeth made from different materials demonstrate significantly different
the favorable biomechanical volumetric substance loss when subjected to occlusal wear by zirconia antagonists. Nanohybrid
properties of zirconia include composite resin denture teeth had the least amount of volumetric substance loss. (J Prosthet
Dent 2020;124:488-93)
its high fracture toughness (up
to 6 MPa$m ) and flexural
1/2

strength (up to 1200 MPa).6 A retrospective study of interocclusal space. The wear of such prostheses is not a
complete-arch zirconia implant-supported prostheses clinical concern because zirconia is a wear-resistant ma-
reported less than 1% of fractures in more than 2000 terial.7 However, Box et al4 reported that the most
5
prostheses. On account of its fracture resistance and common complication associated with monolithic zirco-
color, zirconia can be used for monolithic prostheses, nia complete-arch implant-supported prostheses was
which is especially helpful in patients with limited vertical wear of the opposing restorations.

a
Assistant Professor, Department of Prosthodontics, School of Dentistry, Louisiana State University, New Orleans, La.
b
Assistant Professor, Department of Clinical and Community Sciences, School of Dentistry, University of Alabama at Birmingham, Birmingham, Ala.
c
Associate Professor of Clinical Prosthodontics, School of Dentistry, Louisiana State University, New Orleans, La.
d
Assistant Professor and Department Chair, Department of Prosthodontics, School of Dentistry, Louisiana State University, New Orleans, La.
e
Professor of Restorative Dentistry, Chairman, Department of Preventive and Restorative Sciences and Assistant Dean for Digital Innovation and Professional Development,
University of Pennsylvania School of Dental Medicine, Philadelphia, Pa.

488 THE JOURNAL OF PROSTHETIC DENTISTRY

October 2020 489

implant-supported prostheses because of improved

Clinical Implications physical properties when compared with conventional
Proper selection of resin denture teeth to oppose PMMA.30,31 Although its abrasion wear resistance to
opposing zirconia has not been extensively studied, it is
zirconia complete-arch implant-supported
an essential factor in the long-term clinical behavior and
prostheses is essential to limit abrasion wear.
survival of these restorations.
The purpose of this in vitro study was to measure and
compare the volumetric wear of different artificial resin
Different materials may be used for complete-arch tooth materials opposed by zirconia. The null hypothesis
implant-supported prostheses in opposing arches. Even was that no difference in volumetric wear would be
though the survival of implants is not affected by the found among the materials tested.
number of arches restored,8 a patient restored with
implant-supported prostheses in both arches may expe-
MATERIAL AND METHODS
rience more mechanical complications than a patient
restored with an implant-supported prosthesis in a single Thirty-two maxillary central incisor denture teeth were
arch. Gonzales and Triplett9 reported complications with evaluated (n=8): DCL (Blueline DCL; Ivoclar Vivadent
layered zirconia complete-arch implant-supported pros- AG), PHO (SR Phonares II; Ivoclar Vivadent AG), TEL
theses that opposed similar layered zirconia complete- (Telio CAD; Ivoclar Vivadent AG), and ZCAD (ZCAD
arch implant-supported prostheses or a natural Temp Esthetic; Harvest Dental Products LLC.). Groups
dentition. When the same layered zirconia complete-arch DCL and PHO were prefabricated denture teeth, while
implant-supported prostheses were opposing metal- TEL and ZCAD were designed by using a computer-
acrylic resin complete-arch implant-supported prosthe- aided design and computer-aided manufacturing (CAD-
ses, all the complications occurred with the denture teeth CAM) software program (exocad Valletta 2.2; exocad
in the opposing arch.9 In a 1-year clinical report of 2 GmbH) and milled in a 5-axis milling unit (Tizian cut 5
patients with monolithic zirconia complete-arch implant- smart; Schutz Dental GmbH). The denture teeth speci-
supported prostheses opposing natural dentition or mens were mounted in the center of brass holders with
nanohybrid-composite resin teeth, Cardelli et al10 re- autopolymerizing acrylic resin (Coldpac; Yates Motloid)
ported that the wear of the nanohybrid-composite resin with the labial surfaces exposed. The specimens were
teeth was comparable with the wear of enamel opposing polished by using a series of SiC abrasive paper (320, 600,
a zirconia complete-arch implant-supported prostheses. and 1200 grit) (CarbiMet; Buehler) under water spray for
In addition, the nanohybrid composite resin teeth had 1 minute per paper and a rotational polishing device (No:
more wear than the opposing zirconia prostheses.10 233-0-1997; Buehler). The specimens were stored in
As wear of denture teeth is a concern for metal-acrylic distilled water at 37  C in an incubator for 24 hours.
resin complete-arch implant-supported prostheses and Antagonists were designed in a cone shape (Cerec
wear of the opposing prostheses is a concern for InLab 18.1; Dentsply Sirona) and milled from zirconia
monolithic zirconia implant-supported prostheses, the (Katana LT; Kuraray Noritake Dental Inc) in a 5-axis mill
effect of zirconia on the abrasion wear of opposing (inLab MC X5; Dentsply Sirona). The specimens were
denture teeth needs further evaluation. The wear of sintered in a furnace (inFire HTC Speed; Dentsply
zirconia has been studied extensively.7,11-13 When zir- Sirona) following the manufacturer’s recommended sin-
conia opposes natural tooth structures, it causes less tering schedule. The zirconia cusps were mounted in a
wear on enamel than feldspathic porcelain because of its custom dual-axis mastication simulator (Fig. 1). The test
small-particle grain size and a surface that remains device and parameters have been described in detail in a
smooth throughout the wear process, while feldspathic previous publication.32 A vertical load of 20 N and a
porcelain fractures and becomes rougher.7 When zirco- horizontal slide of 2 mm were applied for 200 000 cycles
nia opposes polymeric materials, it causes significantly at a frequency of 1 Hz. A 33% glycerin solution (Glyc-
more wear to composite resins than it does to erine; Sigma Aldrich) was used as a lubricant.
enamel.14,15 The abrasion wear resistance of different The specimens were scanned before and after wear
resin-based materials has been reported,16-22 with testing by using a noncontact 3D surface measurement
different testing protocols used to evaluate their resis- instrument (PROSCAN 2000; Scantron Industrial Prod-
tance to wear and on how these test conditions relate to ucts Ltd). A 4×4-mm area of the specimen was scanned
intraoral use.23-25 While wear behavior of different with a 20-mm resolution. The before and after scans were
antagonist and denture tooth materials has been tested, superimposed to determine volumetric material loss
data on the wear of denture teeth caused by zirconia (ProForm Software; Scantron Industrial Products Ltd).
are limited.26-29 Milled polymethyl methacrylate Representative specimens were examined by digital light
(PMMA) has become a preferred material for interim microscopy (VHX600; Keyence Corp). One-way analysis

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materials was rejected. PHO, a nanohybrid composite

resin material, demonstrated higher wear resistance to
the opposing zirconia cusps than the other groups. The
milled PMMA groups TEL and ZCAD had higher wear
resistance than group DCL, which had the least resis-
tance to wear.
Some of the differences in the performance of the
teeth may be because of their microstructure. The teeth in
group PHO are described as a nanohybrid composite
resin. More specifically, this material is composed of a
urethane dimethacrylate matrix reinforced with inorganic
fillers. The fillers in this nanohybrid composite resin
affect the wear resistance of the denture teeth. The
harder filler particles protect the softer resin matrix dur-
ing the wear process. Inspection of the worn surfaces of
Figure 1. Zirconia cusp mounted on screw for testing.
the PHO denture teeth revealed fine scratches traversing
in the same direction as the path of the zirconia antag-
Table 1. Mean ±standard deviation volumetric wear values of tested
onists (Fig. 3A). These scratches suggest that the denture
specimens
teeth underwent abrasive wear. In this mechanism of
Mean Volumetric
n Group Composition Wear (mm3) wear, irregularities on the surface of the zirconia antag-
8 DCL Crosslinked PMMA 17.3 ±1.0 onist, called asperities, plow through the softer denture
8 ZCAD Crosslinked acrylate polymer (CAD CAM) 14.3 ±0.8 tooth surface. The filler particles in the nanohybrid
8 TEL Crosslinked PMMA (CAD CAM) 11.9 ±2.0 composite resin were harder than the surrounding resin
8 PHO Nano-hybrid composite resin 4.3 ±1.0 matrix and, therefore, were not as easily abraded by the
Statistically significant differences found in volumetric wear among all groups (P<.05). asperities on the zirconia antagonist. Previous studies of
composite resins confirm the role of filler particles on
wear resistance.
of variance (ANOVA) and the Tukey Honestly Significant The denture teeth with unfilled polymer (TEL, ZCAD,
Difference (HSD) post hoc test were applied to analyze and DCL) had a wear scar that is slightly differently
the data (a=.05). shaped than the one in the PHO group (Fig. 3B-D). The
head of the wear scar (the area that was first impacted by
RESULTS the antagonist) was wider than the tail of the scar. This
wider area of first antagonist impact likely experienced
The volumetric wear of the 4 materials tested are pre-
fatigue wear. Fatigue wear occurs when microcracks form
sented in Table 1. The 1-way ANOVA indicates signifi-
below the surface of a material and eventually coalesce to
cant differences among materials (P<.001). The Tukey
free a small fragment of the material. Materials with a
post hoc analysis ordered materials into statistically
lower elastic modulus, such as unfilled resins, are sus-
distinct groups (average volumetric wear ±standard de-
ceptible to fatigue wear. The tail end of these wear scars
viation): PHO (4.3 ±1.0 mm3)<TEL (11.9 ±2.0 mm3)
demonstrates the scratches associated with abrasive wear
<ZCAD (14.2 ±0.8 mm3)<DCL (17.3 ±1.0 mm3).
occurring when the antagonist performed its horizontal
Three-dimensional images of the volumetric wear of
motion.21 Despite the differences in volumetric wear
the different materials are shown in Figure 2. In these
observed for the 3 unfilled polymers, no observable dif-
images, the head of the wear scar (first area of contact
ferences were found in the wear scar that would imply
between antagonist and specimen) is deeper than the tail
different mechanisms of wear were occurring. Addition-
of the wear scar for all materials. Figure 3 illustrates
ally, the manufacturers of these materials do not provide
digital light microscopy images of the wear patterns of
compositional information regarding their products that
groups. In these micrographs, the head of the wear scar
would explain the differences in measured volumetric
appears smooth, with an area of possible cracks at the
wear.
deepest portion of the head of the wear scar. The tail of
The wear of crosslinked PMMA and nanohybrid
the wear scar is composed of scratches running parallel to
composite resin denture teeth has been evaluated.16,20,28
the direction of travel of the zirconia antagonist.
The outcome of the present study in which the resin
composite material was more wear resistant than the
DISCUSSION
unfilled polymer materials is consistent with the out-
The null hypothesis that no significant differences would comes of earlier investigations. Ghazal and Kern19 re-
be found in volumetric wear between the denture teeth ported that composite resin denture teeth have better

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October 2020 491

Figure 2. Scan of representative specimens (20-mm resolution; ProForm software program; Scantron Industrial Products Ltd). A, Group PHO. B, Group
TEL. C, Group ZCAD. D, Group DCL. DCL, double crosslinked polymethyl methacrylate; PHO, nanohybrid composite resin; TEL, computer-aided design
and computer-aided manufactured from crosslinked PMMA; ZCAD, computer-aided design and computer-aided manufactured acrylate polymer.

wear resistance than acrylic resin teeth when opposing a clinical factors in vitro is challenging; however, the results of
steatite ceramic ball. Similar results were found in a study these studies can only serve as a guide because the applied
comparing conventional acrylic teeth, crosslinked acrylic in vitro test arrangement and parameters cannot fully
teeth, and composite resin teeth opposing a silicon nitride replicate the intraoral conditions. One advantage of the
ceramic ball.27 In contrast with the present study, Munshi current wear device is that the load was applied with a
et al16 reported that nanohybrid composite resin teeth nondampened load unlike the previous iteration of this
exhibited more wear than various types of PMMA den- wear device in which the load was dampened with a spring.
ture teeth.16 In their study, the different types of denture As there are no periodontal ligaments associated with
tooth materials were abraded against the same materials. opposing implant restorations, a nondampened load
This variation in testing methodology explains the should better replicate the clinical situation.
different results. A previous study29 reported that the type In the present study, a 2-body wear test was used to
of antagonist material had a significant effect on the wear evaluate the wear behavior of different resin materials for
properties of different denture teeth. A ceramic antagonist complete-arch prostheses opposing zirconia, simulating
discriminated better among different types of denture dissimilar materials for complete-arch implant-supported
teeth than metal or polymer antagonists. However, prostheses. A 33% glycerin solution served as a lubricant
studies with zirconia as an antagonist material in wear because of its similarity to saliva and to help wash away
tests of denture teeth are lacking. worn material particles.7 The concentration of glycerin
Intraoral wear is complex and related to both the was chosen to replicate the viscosity of stimulated saliva,
composition of denture teeth and the patient’s oral habits. acting as a boundary lubricant.7 The ability to control
A patient’s sex and intraoral clinical factors such as antag- intraoral factors that vary among patients makes in vitro
onist material, mechanical factors, neuromuscular force, 2-body wear testing a valid model to measure antagonist
intraoral pH, as well erosion and corrosion, have also been wear without involving an intermediate medium that
described as influencing parameters.18,23 Replicating these may influence the results.16,23,24

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Figure 3. Digital light microscopy of representative specimen (VHX600; Keyence). Original magnification ×15. A, Group PHO. B, Group TEL. C, Group
ZCAD. D, Group DCL. DCL, double crosslinked polymethyl methacrylate; PHO, nanohybrid composite resin; TEL, computer-aided design and computer-
aided manufactured from crosslinked PMMA; ZCAD, computer-aided design and computer-aided manufactured acrylate polymer.

The 200 000 cycles applied in this study represent abrasion wear resistance. This procedure could not be
approximately 9.6 months of clinical use.25 These types of avoided, however, because of the configuration of the
correlations of wear cycles and clinical service are based wear testing device. In general, in vitro studies can only
on correlating the volumetric loss with a reference assess limited parameters and may not be able to fully
restorative material in a laboratory device with clinical represent clinical reality and conditions. Some of these
wear measurements. Therefore, this estimation is likely parameters may include the effects of temperature and
flawed. A more useful observation is that the PHO teeth pH cycling on the wear behavior of the material.
had 3 to 4 times less wear than all other materials. However, limiting influencing parameters allows for a
Assuming a linear wear rate, these teeth would last 3 to 4 focused assessment of the materials and research
times longer than the others. An increased wear rate of question at hand. Further studies are suggested to better
denture teeth represents a clinical and financial disad- understand the behavior of materials exposed to func-
vantage, leading to an earlier remake. As denture teeth tion and abrasion wear. Such future studies should
wear more progressively, the patient will lose vertical incorporate simulated aging parameters such as tem-
dimension of occlusion (VDO). This loss of VDO may perature and pH cycling.
lead to mechanical failures such as the fracture of anterior
denture teeth, the prosthetic substructures, or functional CONCLUSIONS
and esthetic alterations.
Based on the findings of this in vitro study, the following
Limitations of the present study include that only 4
conclusions were drawn:
different resin materials were tested from the great
range of available materials. Furthermore, the creation 1. Denture teeth made from different materials
of a flat surface on the anterior teeth tested removed demonstrated significantly different volumetric
part of the outside enamel layer of the denture teeth in substance loss when subjected to occlusal wear by
groups PHO and DCL and may have altered their zirconia antagonists.

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2. Nanohybrid composite resin denture teeth had the 17. Kamonwanon P, Yodmongkol S, Chantarachindawong R, Thaweeboon S,
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wear of resin denture teeth with and without nanofillers. J Prosthet Dent
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Corresponding author:
supported monolithic zirconia posterior crowns in vivo: a systematic review.
J Prosthet Dent 2019;121:598-603. Dr Jonathan Esquivel
14. Pereira GKR, Dutra DM, Werner A, Prochnow C, Valandro LF, Kleverlaan CJ. Department of Prosthodontics
Effect of zirconia polycrystal and stainless steel on the wear of resin com- LSU School of Dentistry
posites, dentin and enamel. J Mech Behav Biomed Mater 2019;91:287-93. Box 2221100 Florida Avenue
15. Ludovichetti FS, Trindade FZ, Werner A, Kleverlaan CJ, Fonseca RG. Wear New Orleans, LA 70119
resistance and abrasiveness of CAD-CAM monolithic materials. J Prosthet Email: jesqu1@lsuhsc.edu
Dent 2018;120:318.e1-8.
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hybrid composite denture teeth. J Prosthodont 2017;26:224-9. https://doi.org/10.1016/j.prosdent.2019.11.004

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