Clinical evaluation of the association

between noncarious cervical lesions and

occlusal forces
Daniela Atili Brandini, DDS, PhD,a Carolina Lunardeli Trevisan, MS,b
Snia Regina Panzarini, DDS, PhD,c and Denise Pedrini, DDS, PhDd
School of Dentistry, So Paulo State University (UNESP),
Araatuba, Brazil

Statement of problem. Noncarious cervical lesions (NCCLs) are a frequent challenge in clinical dental practice, given
the variety of opinions regarding their etiology, diagnosis, and treatment.

Purpose. The purpose of this study was to assess the potential relationship between occlusal forces and the occur-
rence of NCCLs.

Material and methods. The participant population consisted of 111 volunteers (30 male and 81 female, mean age
23.6 years). General personal information was recorded, after which participants were examined for the presence and
location of NCCLs, gingival recession, fracture lines, dental and restoration fractures, presence and location of tooth
wear, type of occlusal guidance scheme for lateral mandibular movements, and existence of occlusal interference or
premature contacts. The participants were divided according to the presence or absence of NCCLs, and data were
statistically analyzed with the Independent t test, the Chi-square test, and the Fisher exact test (=.05).

Results. A significant association was found between the presence of NCCLs and age (P=.008), gingival recession
(P<.001), occlusal trauma (P<.001), presence (P<.001) and location of tooth wear, and group function as occlusal
guidance scheme in lateral excursive movements (P<.001).

Conclusions. A strong relationship between the presence of NCCLs and occlusal overload was found. (J Prosthet Dent
2012;108:298-303)

Clinical Implications
Knowledge of the characteristics and etiologic factors of NCCLs
assists dentists in selecting the appropriate treatment and improves
the prognosis. The strong relationship between NCCLs and occlu-
sal overload revealed by the results implies that the latter should be
investigated in patients presenting with NCCLs.

Noncarious cervical lesions (NC- an absence of caries.3,7,8 The appear- surface2,12,13 and have been observed
CLs) are a frequent challenge in clini- ance of NCCLs varies from shallow below the gingiva.14
cal dental practice, given the variety depressions with a large disk form Presently, NCCLs are considered
of opinions regarding their etiology, to broad, cone-shaped defects.9 to have a multifactorial etiology, and
diagnosis, and treatment. In many The cavity floor can be flat, smooth, various mechanisms such as abra-
patients NCCLs are the chief cause of bright, or sharply angled.10 NCCLs are sion, erosion, and abfraction can be
the dental sensitivity and discomfort predominantly found in premolars associated with their origin and pro-
that result from dentinal exposure.1-6 and molars, with decreasing occur- gression.7,8,10,16,17 Abrasion is defined
NCCLs are characterized by the rence in the anterior teeth.11 They are as the loss of dental tissue caused by
loss of cervical dental tissue but with most frequently located on the buccal mechanical wear, which commonly
a
Professor, Integrated Clinic, Department of Surgery and Integrated Clinic, School of Dentistry.
b
Postgraduate student, School of Dentistry.
c
Professor, Integrated Clinic, Department of Surgery and Integrated Clinic, School of Dentistry.
d
Professor, Integrated Clinic, Department of Surgery and Integrated Clinic, School of Dentistry.
The Journal of Prosthetic Dentistry Brandini et al
November 2012
results from incorrect tooth brushing
practices.18 Erosion is the loss of den-
tal tissue by means of chemical disso-
lution and is caused by gastric reflux
unrelated to caries3,13 or exogenous
factors such as excessive consump-
tion of acidic foods and beverages.1
Abfraction is the loss of dental tissue
caused by dental flexure, mainly oc-
clusal overload and/or eccentric oc-
clusal forces, in the cervical region.11,12
Studies have demonstrated that
occlusal trauma, defined as a tis-
sue alteration caused by masticatory
forces of a significant magnitude and
direction originating from malocclu-
sion and/or parafunctional habits, is
the primary etiological factor of NC-
CLs.2,3,14 Masticatory forces applied
outside the longitudinal dental axis
normally generate lateral forces that
are dissipated primarily in the cemen-
toenamel junction. Consequently,
the tooth is deformed, and discon-
nections between hydroxyapatite
crystals in the area of tension occur,
resulting in microruptures.1 The rup-
turing creates spaces filled with water
molecules that impede the formation
of new chemical connections be-
tween the crystals, thereby rendering
the crystalline structures vulnerable
to the chemical action and physical
forces generated by physiological or
mechanical processes.11 This region
is vulnerable to abrasives, erosive
agents, and occlusal overload be-
cause the enamel layer is thinner and
the connection between the enamel
and dentin is weaker because of the
smoothness of the enamel-dentin
junction and the absence of crystals.2
Knowledge of the characteristics
and etiologies of NCCLs is helpful in
selecting appropriate treatment and
improves the ability to make a prog-
nosis. However, it is important to ver-
ify the clinical relationship between
NCCLs and occlusal forces to create
a better understanding of the mecha-
nisms involved.
This study is based on the hypoth-
esis that occlusal overload is the pri-
mary cause of dental tissue loss in the
cervical region. The purpose of this
Brandini et al
Buccal
Lingual/Palatal
1 Division of occlusal surface of teeth in 5 parts on buccolingual axis.
study was to assess the potential rela-
tionship between occlusal forces and
the occurrence of NCCLs. The null hy-
pothesis tested was that the intensity
and direction of the occlusal forces
would not be affected significantly by
the presence of NCCLs.
MATERIAL AND METHODS
This cross-sectional study consist-
ed of a clinical survey of NCCLs and
occlusal forces. A convenience sample
was drawn from students, employ-
ees, and patients of the Department
of Integrated Clinic, UNESP. Before
the study began, all participants pro-
vided informed consent for the study
protocol, which was approved by the
Human Ethics Committee of the Ara-
atuba School of Dentistry (Process
FOA-2007/00814).
Of the 130 volunteers examined,
111 individuals (30 male, mean (SD) age
23.6 (3.00) years; and 81 female, mean
(SD) age 23.7 (4.39) years) participated
in the study. The selection of partici-
pants was based on the criteria of com-
plete dentition, not necessarily with the
presence of third molars, and absence
of caries or cervical restorations.
The clinical assessment consisted
of a form on which general personal
data were registered and a clinical
intraoral examination conducted by
1 calibrated dentist. To minimize dis-
crepancies in the interpretation of the
299
diagnoses, calibration was done by
comparing examinations of the same
participant by different examiners and
by having the examiner perform the
same examination at different times.
For the intraoral examination, a
sterile mirror, an explorer, and a mil-
limeter probe were used to detect the
presence and location of NCCLs and
tooth wear, the presence of dental/
restoration fracture, the enamel frac-
ture line, and gingival recession. The
loss of dental tissue near the cemen-
toenamel junction in the absence of
caries was considered as an NCCL.
For these variables, the control group
was represented by participants who
did not have an NCCL. To classify the
location of identified NCCLs, the oc-
clusal surface of the teeth with NCCLs
(171) was imaginarily divided into 5
parts on the buccolingual axis (Fig.
1). The incisal portion of the anterior
teeth was also considered.
Functional analysis of the occlusal
forces was conducted only in the 46
individuals with NCCLs. The presence
of premature contacts or dental inter-
ferences in the teeth with NCCLs was
verified with articulating paper (Ac-
cuFilm II, double side .0008; Parkell
Inc, Edgewood, NY) in centric occlu-
sion (CO), maximum intercuspation
(MI), right (RL) and left (LL) lateral
mandibular movement, and protru-
sion (P). Furthermore, the occlusal
guidance scheme for lateral mandibu-
300 Volume 108 Issue 5
lar movement (canine protective ar-
ticulation or group function) on the Table I. Baseline characteristics of participants and NCCL presence
right and left side was assessed. For
Without
these variables, the control group was
Characteristics NCCL NCCL Total P
represented by those teeth free of NC-
CLs in individuals with NCCLs.
Number of Participants 65 46 111
After the clinical examination, the
participants were divided into 2 groups Age (years)
according to the presence or absence Mean 22.78 24.97
of NCCLs: a control group (no NCCL SD 3.32 4.71 .008
presence) and a test group (NCCL Gender
presence). The data were analyzed by Female 50 31 81
using statistical software (SPSS, v16.0;
Male 15 15 30 .265
SPSS, Chicago, Ill) with the alpha
value for statistical significance set at P<.05 indicates significant difference.
.05. The analysis of group differences P values are for comparison between 2 groups. Independent t tests were used for
continuous variables and t test, 2, or Fisher exact test for appropriate categorical variables.
between test and control subjects was
performed with the Chi-square test for Table II. Teeth affected by NCCL and occurence of other dental problems
predominantly quantitative variables,
the Fisher exact test for categorical Without NCCL Total
variables, and Independent t tests for Characteristics NCCL (n) (n) (n) P
continuous variables.
Gingival recession
RESULTS No 2828 20 2848
Yes 106 151 257 .001
NCCLs were observed in 46 indi- Tooth wear
viduals (41.4%) in a population of No 1500 2 1502
111. Ages ranged from 19 years to
Yes 1432 169 1601 .001
38 years, with a mean (SD) age of
24.9 years (4.7) in the NCCL group Dental/Restoration fracture
and from 20 years to 41 years, with a No 2846 171 3017
mean (SD) age of 22.7 years (3.32) in Yes 86 0 86 .014
the control group. A significant asso- Fracture line
ciation was found between the pres- No 1847 64 1911
ence of NCCL and age (P=.008). Pro-
Yes 1087 107 1194 .001
portionally, NCCLs were significantly
more prevalent in men (50%) than in P<.05 indicates statistically significant result. P values are for comparison between 2 groups.
Independent t tests were used for continuous variables and t test, 2, or Fisher exact test
women (36.3%) (Table I). The data for appropriate categorical variables.
showed that NCCLs were more preva-
lent in the first maxillary premolars on tion in the middle third of the func- tric occlusion (34.5%) (P<.001), lateral
both sides, right 24 (23.1%) and left tional surfaces of buccal cusps (Fig. working side (46.8%) (P<.001), lateral
21 (20%), a tendency which was also 1, part 2), but it appeared predomi- nonworking side (14%) (P<.001), and
observed, although less pronounced, nantly in combination with other protrusion (8.2%) (P=.002) (Table V).
in the mandibular arch. parts of the occlusal table in the pos-
Of the 171 teeth with NCCLs, terior teeth (Table III). DISCUSSION
gingival recession was observed in The majority of the teeth affected
88.3% (P<.001), wear facets in 98.8% by NCCLs had group function guid- The null hypothesis that the pres-
(P<.001), and enamel fracture lines in ance for lateral mandibular move- ence of NCCLs would not be affected
62.6% (P<.001). None of the teeth with ment to the right (63.2%) and left side significantly by the intensity and direc-
NCCLs appeared to have dental or re- (54.4%) (P<.001) (Table IV). Compar- tion of the occlusal forces was reject-
storative material fractures (P=.014) ison between teeth with and without ed. The hypothesis that occlusal force
(Table II). NCCLs in the NCCL group revealed may be a cause of NCCL development
Tooth wear in the buccal cusps significant differences in the presence was investigated, and an analysis of
was observed in 65% of the NCCL of occlusal interference in maximum the prevalence and localization of
teeth. It sometimes appeared in isola- intercuspation (35.7%) (P<.001), cen- NCCLs, aimed at understanding and
The Journal of Prosthetic Dentistry Brandini et al
November 2012 301

Table III. Teeth affected by NCCL and tooth Table IV. Number of teeth with NCCL and occlusal
wear localization (Parts defined in Figure 1) guidance scheme for lateral mandibular movement

Tooth Wear Number (n) Percent (%) Without NCCL Total

Characteristics NCCL (n) (n) (n) P
Part 1 2 1.2
Part 2 11 6.4 Type guide to
Part 3 2 1.2 lateral movement
Part 4 8 4.7 Right side
Part 5 4 2.3 Canine guidance 678 63 741
Incisal 14 8.2 Group function 450 108 558 <.001
Part 1+2 58 33.9 Left side
Part 1+5 1 0.6 Canine guidance 742 78 820
Part 2+3 3 1.8 Group function 386 93 479 <.001
Part 2+4 4 2.3 P<.05 indicates statistically significant difference.
Part 2+5 2 1.2 P values are for comparison between 2 groups. Independent t tests were used for
continuous variables and 2 test for categorical variables.
Part 4+5 32 18.7
Part 1+2+4 8 4.7
Part 1+4+5 2 1.2
Part 1+2+4+5 13 7.6
TOTAL 171 100

Descriptive distribution of tooth wear in 5 schematic parts

of the teeth with NCCL, in number and percentage.

Table V. Teeth affected by NCCL and jaw position where

occlusal trauma occurred
Jaw Position and
Movement with Without NCCL Total
Occlusal Interference NCCL (n) (n) (n) P

Maximum intercuspation
No 1050 110 1160
Yes 75 61 136 <.001
Central occlusion
No 1039 112 1151
Yes 86 59 145 <.001
Lateral working side
No 1006 91 1097
Yes 119 80 199 <.001
Lateral nonworking side
No 1075 147 1222
Yes 50 24 74 <.001
Protrusion
No 1088 157 1245
Yes 37 14 51 .002

P<.05 indicates statistically significant difference.

P values are for comparison between 2 groups. Independent t tests were used for
continuous variables and 2 test for categorical variables.

Brandini et al
302
relating NCCLs with occlusion, was
performed.
In this study, NCCLs were present in
41.4% of the individuals. The prevalence
of NCCLs has been reported over a wide
range (2% to 90%).19 This wide variation
can be explained by the difficulty of as-
signing a single etiological mechanism
to NCCL and by the fact that different
studies have analyzed populations with
different characteristics.
Although not the cause of NCCLs,
age is an important factor because
it represents the cumulative effects
of NCCLs. Thus, age influences the
prevalence (number)1,20,21 and severity
(size)2,22 of these lesions. The mecha-
nism of abfraction and the higher fra-
gility of enamel with increasing age can
explain the greater occurrence of NC-
CLs in older populations.
It has been found that the maxil-
lary teeth are the most affected by
NCCLs,20,23,24 with the greatest num-
ber on the buccal surface,2,11-13 al-
though NCCLs can also be located
on the lingual surface.1 The high-
est concentrations of NCCLs were
found in the first premolars (21.6%),
which confirms findings in other
studies.1,2,4,5,23,25 This is probably be-
cause premolars possess less capac-
ity than canines to absorb the lateral
and oblique forces that occur dur-
ing clenching and lateral movement
guided by group function.26 When
the lateral movements are guided by
group function, an increased num-
ber of occlusal contacts between the
posterior teeth are made; these are
also subjected to greater force. This
makes the posterior teeth, and pre-
molars in particular, more susceptible
to dental tissue loss in the cervical re-
gion.1,5,9,13,17,27,28 Lateral movements of
the cusps caused by nonaxial loading
generate considerable stress on the
cervical enamel.29 This can explain the
positive association between the pres-
ence of NCCL and a group function
occlusal guidance scheme (in the man-
dibular lateral movement to the right
(63%) and to the left (54%) side).
The position of the teeth in the
arch also has an important effect on
The Journal of Prosthetic Dentistry
functional and parafunctional forc-
es.2,26 The first premolars are almost
perpendicular in the alveolar bone,
but the cusps of the premolars gener-
ate an inclined force in contact with
the antagonist teeth. This effect tends
to cause the cusps to incline towards
the buccal side during lateral mandib-
ular movements with teeth in contact,
thereby causing cervical stress and
contributing to the development of
abfractions.27 In finite element analy-
sis, it was observed that overloads
applied at an oblique angle produce
more cervical stress (185 MPa to 286
MPa) than axially applied loads (71
MPa to 83 MPa).9
The importance of occlusal over-
load for NCCL development can be
verified through the presence of frac-
ture lines in the enamel (62.6%) and
wear facets, confirming results in the
literature.6,11,13,17,24,25,27-30 Wear facets
are defined as wear resulting from
attrition or tooth to tooth contact
through functional or parafunctional
movements such as mastication or
bruxism. These can only occur on the
incisal, proximal, or occlusal surfaces
of the teeth unless an abnormal oc-
clusal relation exists or when the at-
trition is related to the aging of the in-
dividual.13 As shown by Takehara et al,31
the area of occlusal contact is directly
associated with the presence of NCCLs.
The authors demonstrated that 58.5%
of teeth with NCCLs have wear facets in
2 of the 5 parts of the occlusal surfaces
analyzed in this study (Fig. 1), and that
13.5% have wear facets in 3 or more of
the 5 parts. The wear facets found in
this study sometimes appeared to be
confined to the middle third of the func-
tional slopes of the buccal cusps (Fig. 1,
part 2) but were predominantly in com-
bination with other parts of the occlusal
facet in the posterior teeth.
The evaluation of functional oc-
clusion revealed that premature con-
tacts, such as in centric occlusion,
maximum intercuspation, and pro-
trusion, can occur in various positions
related to the presence of NCCLs. The
strong association between the pres-
ence of NCCLs and occlusal interfer-
Volume 108 Issue 5
ence22,24,25,29 confirms the theory that
in a less than ideal occlusion, traction
forces are generated that break the
chemical connections between hy-
droxyapatite crystals, thereby creat-
ing microruptures. As a result, dental
structures possess a limited capacity
to withstand these forces.30
However, Michael et al16 indicated
that the relation between NCCLs and
parafunctional habits cannot be mea-
sured by occlusal alterations because
the occlusal relationship can undergo
alterations over time and might not
show the actual situation; wear facets
can be caused by other factors such
as malocclusion, erosion, diet, and
attrition; and bruxism involves tooth
clenching and grinding, and although
clenching alone does not result in the
formation of wear facets, it still pro-
vokes tensile forces on teeth.
The primary etiological factors
causing gingival recession are per-
sonal oral hygiene and traumatic
habits, unfavorably positioned teeth,
high insertion of muscles and frenula,
bone dehiscence, periodontal dis-
ease, and iatrogenic factors, including
restorative and periodontal proce-
dures. Gingival recession was common
(88.3%) in teeth affected by NCCLs.8,25
Occlusal overload is a common etio-
logical factor of NCCLs and gingival
recession. This indicates that exposure
of the cementoenamel junction may
facilitate abrasion caused by tooth
brushing in the cervical region.32
A limitation of the study is that the
case-control study design falls in the
mid-level of the hierarchy of Evidence
Based Medicine. Future studies need
to distinguish the etiological factors
of NCCLs and whether occlusal over-
load preceded the loss of dental tissue
in the cervical region.
CONCLUSION
Although the etiology of NCCLs is
considered to be multifactorial, the
findings of this study indicate that the
direction and intensity of the forces
applied on teeth are important con-
tributors to the occurrence of NCCLs.
Brandini et al
November 2012
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Corresponding author:
Dr Daniela Atili Brandini
UNESP - Univ Estadual Paulista
School of Dentistry of Araatuba
Department of Surgery and Integrated Clinic
Rua Jos Bonifcio, 1193 Araatuba
So Paulo, 16015-050
BRAZIL
Fax: +55-18-3636-3332
E-mail: brandini@foa.unesp.br
Copyright 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.