J Clin Periodontol 2003; 30: 828–832 Copyright r Blackwell Munksgaard 2003

Printed in Denmark. All rights reserved

Neal Miller1, Jacques Penaud1,

Analysis of etiologic factors and Pascal Ambrosini1, Catherine
Bisson-Boutelliez1 and Serge
Briançon2
periodontal conditions involved 1
Department of Periodontology, Faculty of
Dentistry, University of Nancy, France;
2
Department of Epidemiology and Medical
with 309 abfractions Statistics, Hôpital Marin, Nancy, France

Miller N, Penaud J, Ambrosini P, Bisson-Boutelliez C, Briançon, S. Analysis of

etiologic factors and periodontal conditions involved with 309 abfractions. J Clin
Periodontol 2003; 30: 828–832. r Blackwell Munksgaard, 2003.

Abstract
Objectives: Non-carious cervical lesions (NCCL), also termed abfractions, have long
been thought to be produced by excessive brushing. Nearly 20 years ago an occlusal
etiology was proffered (Lee & Eagle 1984). Controversy still exists concerning these
two concepts. The present work was carried out to verify the occurrence of signs of
excessive brushing or occlusal disturbances associated with abfractions.
Material and methods: All first consultants were screened for the presence of
abfractions during one trimester. NCCL were found in 61 patients who consequently
received a thorough examination searching for clinical evidence of excessive brushing
or occlusal disturbances. The presence of plaque, calculus, periodontitis, or mobility
was also noted. Simple frequency and percentage were used to describe the occurrence
of different clinical signs in association with the presence of abfractions.
Results: Abfractions often exist in mouths presenting plaque (40.1%), calculus
(41.7%), or periodontitis (20.4%). Ulceration of the gingiva is a rare finding (1.6%).
However, subgingival apical limits were frequent (32.5%). NCCL coexist almost
systematically with occlusal wear facets (94.5%). Lack of canine disclusion (77.2%)
Keywords: abfractions; toothbrushing;
was also closely associated with the presence of abfractions. Conversely, mobility was occlusion; wear facets; gingival abrasion;
seldom found (1.9%). periodontitis
Conclusions: Clinical signs of excessive brushing were lacking, whereas signs of
occlusal disturbance were very consistent with the presence of abfractions. Accepted for publication 26 November 2002

Non-carious cervical lesions (NCCL) factors and concluded that none were alveolar bone determine the form and
are rarely described in the periodontal very convincing. Toubol (1984) had situation of the abfractions (Kuroe et al.
literature, perhaps because no direct link suggested the year before that occlusal 1999). Although this new theory elim-
between NCCL and periodontal lesions factors might be implied. That same inates objections concerning the former
has been demonstrated. Traditionally year Lee & Eagle (1984) published a hypothesis, many advocates of the
NCCL, also called abfractions, are paper affirming that tooth flexure caused toothbrushing explanation remain
thought to be produced by toothbrush- by occlusal loading could produce (Bergstrom & Eliasson 1988, Dyer
ing (Padbury & Ash 1974, Saxton & NCCL, which they termed abfractions. et al. 2000). The subject could seem
Cowell 1981, Klees 1980, Bergstrom & They demonstrated that when a tooth principally academic if it were not for
Eliasson 1988).Various explanations in- receives an occlusal force, a large the fact that NCCL, or abfractions, can
clude the effect of hard bristles (Meister quantity of stress will concentrate in be found on teeth presenting period-
et al. 1980), soft bristles (Dyer et al. the cervical area. Should a slightly ontitis. In such cases, informing patients
2000), and toothpaste (Radentz et al. oblique force be applied, a fulcrum is that their brushing is ‘‘excessive’’ could
1976). Other etiologic factors have been created near the cemento-enamel junc- be counterproductive, hindering period-
brought forward such as consumption of tion (Lee & Eagle 1996). This in turn ontal treatment instead of enhancing it.
acid-containing foods (vinegar, lemon) will cause a release of the mineral The following study was made to
(Fuller & Johnson, 1977) or regurgita- crystals contained in the enamel and compare the prevalence of clinical
tions (Steg et al. 1982). Miller & then in the dentine. Orientation of the manifestations due to excessive brush-
Penaud (1985) reviewed these putative forces and the position of the supporting ing versus those associated with flexure
 Abfractions and periodontal conditions 829

caused by occlusal forces, in the Table 1. Distribution of the sample according rotation (0.6%), and prematurities due
presence of abfractions. to sex and mean number of abfractions per to incisal edge bite (2.6%) or anterior
subject open bite (0.6%) were infrequent. Out-
Mean No. right bruxism concerned 10% of the
Materials and Methods teeth with abfractions. Mobility was a
Sex No. % NCCL
During a 3-month period, all first relatively rare finding affecting only
consultants were screened before being Men 146 47.25 5.6 1.9% of teeth presenting abfractions
oriented for treatment. Persons present- Women 163 52.75 4.7 (Table 3).
ing one or several abfractions were The types of lateral excursion seemed
further examined to establish a link to influence the type of NCCL found on
between either excessive brushing or Table 2. Morphologic characteristics and si- the teeth. Thus, group function would
occlusal factors. This examination in- tuation of the abfractions tend to produce more rounded shapes
cluded a search for occlusal wear facets, Characteristic Type % (po0.007), whereas balancing side
the presence or lack of canine disclu- prematurities would produce more
sion, cross bite, prognathism, balancing Edges Sharp 68.51 wedge-shaped lesions (po0.02). Ab-
side prematurities, rotated teeth, incisal Rounded 31.49 fractions from persons who brux usually
edge bite, anterior open bite, tongue Apical limits Supragingival 30.52 had supragingival limits (po0.03). Sub-
thrusting, and bruxism (evidenced by Juxtagingival 37.01 gingival limits were most often asso-
Subgingival 32.47
flat occlusal morphology). The presence ciated with wedge-shaped NCCL
of bacterial plaque and/or calculus in (po0.004).
the patient’s mouth and/or on the
abfractions, periodontitis, and tooth 48.8 years (range: 22–81 years). Wo-
mobility were also observed. Previous men were slightly more numerous Discussion
occlusal adjustments were noted. The (35 5 57.4%) than men (26 5 42.6%).
investigators meticulously recorded the A total of 309 NCCL were detected. The etiology of abfractions has been
types of NCCL (wedge shaped/sharp Men presented an average of 5.6 puzzling authors for over a century, if
edged or saucer form/rounded edged), abfractions (Table 1) and women 4.7; not more (Kirk 1887). The hard, po-
whether the limits were supra-, juxta- or the range was 1–14 per person. Most of lished surfaces of these lesions have
subgingival, and the presence or ab- the lesions (68.5%) were sharp edged brought many researchers to the con-
sence of gingival abrasion neighboring (wedge shaped) as opposed to rounded clusion that they were produced by
the lesion on the tooth. The presence or (saucer form) (31.5%) (Table 2). Con- excessive toothbrushing. Horizontal
absence of abrasion on acrylic facets of cerning the apical limits, the distribution brushing is often incriminated, but Pad-
dental crowns coronal to the abfractions was fairly equal with 30.5% being bury & Ash (1974) in a study comparing
was also noted. supragingival, 37.0% juxta gingival the effects of horizontal versus roll
Periodontitis was defined as the and 32.5% subgingival (Fig. 1). Abra- technique brushing demonstrated that
presence of periodontal pockets along sion of the surrounding gingiva was rare the roll technique caused much more
at least six teeth. Any tooth with visible with only five occasions (1.6%) being abrasion. Radentz et al. (1976) consid-
mobility was considered mobile. The discovered (Table 3). Two teeth were ered the brushing method as unimpor-
presence of plaque was recorded when crowned with acrylic facets attached to tant, as well as its frequency, the type of
abundant enough to be detected without gold. Neither of these facets presented brush or toothpaste. They found a
the use of disclosing solution or a abrasion. correlation between the first three teeth
periodontal probe (P&I 2 or 3) (Silness Most of the abfractions were spotless, brushed and the number of abfractions.
& Löe, 1963). Plaque was marked but a few (8 5 2.6%) were covered with To them the stiffness of the brush and
present when it was found on the buccal plaque or calculus (Table 4). However the concentration of dentifrice at the
surfaces of the teeth. No attempt was 40.1% of the teeth with abfractions were beginning of brushing was determinant.
made to detect its existence on the present in mouths that displayed visible More recent advocates of the brushing
proximal or lingual aspects of the teeth. plaque (score 2 or 3 of PlI) on the theory took an opposite stand and
Calculus was recorded when its pre- buccal aspect of one or more teeth. evidenced that soft brushes cause more
sence afforded easy detection. Negative 20.4% of the abfractions came from the abrasion than hard toothbrushes (Dyer
recording did not mean that no calculus mouths of persons affected by period- et al. 2000). Saxton & Cowell (1981)
was present, but simply that it was not ontitis (Table 3), and 41.7% from studied the effect of toothpastes with an
immediately noticeable and hence the mouths presenting calculus (Table 4). abrasion index of 20–120 on the rate of
patient’s mouth was fairly devoid of it. The most constant occurrence was mineralized tissue loss. They concluded
Simple frequency and percentage the presence of wear facets (94.5%) that the 1 m/week average deepening of
were used to describe the occurrence (Table 5). Quite commonly (77.0%) the lesions could not be explained by
of all these different parameters in the teeth with NCCL were part of dentitions the use of dentifrices and that the
presence of NCCL. w2 Ratios were used lacking canine disclusion. Group func- lesions were surely due to the brush.
when appropriate. tion concerned nearly three-quarters However, Brady & Woody (1977), after
(73.5%) of the teeth with NCCL, and studying the teeth of 200 dentists with a
balancing side prematurities were asso- scanning electron microscope (SEM),
Results ciated with one out of five (20.1%). stated that the form of most of the
In all, 61 persons presenting abfractions Relations with conditions such as prog- lesions could not be explained by tooth-
were examined. Their mean age was nathism (2.9%), cross bite (0.6%), brushing. This opinion was proffered
830 Miller et al.

a toothbrush, and not leave the slightest

scratch on the non-keratinized sulcular
epithelium, is not readily explained
(Fig. 1). To Braem et al. (1992) this
fact tends to lend credence to the
occlusal theory. On two occasions
acrylic facets were present coronal to
the NCCL, and in neither was there any
abrasion of this material indisputably
less resistant to abrasion than enamel or
dentine.
It seems that more elaborate scientific
material is progressively disproving the
excessive brushing theory. Bevenius et
al. (1993) documented six cases using
SEM replication and microendoscopy.
No correlation could be made between
brushing habits and the location and
severity of the lesions. However, opto-
electric recordings suggested a correla-
Fig. 1. Subgingival limit of an abfraction. No ulceration of the soft tissues is visible. tion between irregular lateral excursion
and the severity and location of NCCL.
Indeed, occlusion is becoming the prime
etiologic factor now reported in scien-
by Kirk (1887) at a time when tooth- arguments were the following facts: tific papers. Lee & Eagle (1984) were
brushing was not very widespread. In abfractions could be seen on the teeth perhaps not the first to imply that
his view, toothbrushing is not respon- of people who brush little or not at all; occlusion is associated with abfractions,
sible for abfractions. Among several abfractions sometimes had a vertical but it seems they were the first to
form even though the subjects brushed formulate a coherent hypothesis ex-
horizontally; an abfraction could exist plaining how occlusal forces could
Table 3. Periodontal conditions of teeth with between two intact teeth and even in produce such lesions. In the present
abfractions regions of difficult access with a tooth- work, among the 309 teeth with ob-
Characteristic % brush. servable NCCL, 77.0% were pertaining
In spite of evasive evidence for the to lack of canine disclusion, 73.5% to
Gingival abrasion 1.62 brushing theory, its proponents remain group function, and 20.1% to balancing
Periodontitis 20.39 numerous. Bergstrom & Eliasson side prematurities. The greatest occur-
Mobility 1.94 (1988), in a study of 250 subjects, find rence, though, was the wear facet that
no significant associations between coexisted with 94.5% of the abfractions.
abrasion and oral hygiene factors and Khan et al. (1999) found a 96%
Table 4. Hygiene conditions of teeth with yet still conclude that cervical abrasion association, and Mayhew et al. (1998)
abfractions is most likely related to toothbrushing. a 95% association. The slightly lower
Debris Situation % In the present study, 40.1% of the teeth percentage could be due to the fact that
with abfractions were found in the two patients had undergone occlusal
Plaque Buccal surfaces 59.87 mouths of persons with visible amounts adjustment and hence no longer pre-
Calculus Buccal surfaces 41.75 of plaque on the buccal aspects of their sented wear facets. It seems important
Plaque and On lesion 2.59 dentition, although only 2.6% actually though to stress the fact that grinding
calculus presented plaque on the hard tissue per se is not important in producing a
lesion itself. However, the case against flexure. In fact, a long contacting
excessive brushing was made with excursion surely displaces the fulcrum
Table 5. Occlusal characteristics of teeth with
abfractions
several other observations. One of these and provokes atypical lesions. The
was the very few instances where different strain patterns resulting from
Characteristic % gingival abrasion was found in associa- occlusal loading have been investigated
tion with abfractions. The difference in in vitro (Palamara et al. 2000). Progres-
Wear facets 94.50
hardness between the tooth and the sion of tissue loss has also been
Canine disclusion 22.98
Group function 73.46 gingiva would lead one to expect very investigated in vivo. Pintado et al.
Balancing interference 20.06 seriously ulcerated soft tissues, if indeed (2000), using digital and visualization
Edge bite 2.59 NCCL was due to toothbrushing. Even techniques at three intervals over a 14-
Open bite 0.65 more explicit is the fact that 32.5% of year time span, were able to establish a
Cross bite 0.65 the apical limits of the abfractions are very strong (r 5 0.98) and significant
Prognathism 2.91 subgingival. This type of limit is mostly (po0.0001) correlation between occlu-
Rotation 0.65 associated with sharp-edged abfractions sal and cervical volume loss. Experi-
Bruxism 10.03
(po0.004). That one could wear the mental models demonstrate that cuspal
Tongue thrusting 0.00
enamel and the dentine of a tooth using loading generates stress concentration in
 Abfractions and periodontal conditions 831

the cervical region and that it is highest tion during hygiene instruction for they occlusale a été avancée (Lee & Eagle 1984).
under buccal cusp loading. The accu- are often not zealous brushers and the Une controverse existe toujours en ce qui
mulation of this cervical stress does not form and hypersensitivity of these concerne ces deux concepts. Le but de l’étude
présente a été de vérifier l’apparition des signes
require grinding. lesions can be complicating factors.
d’un brossage excessif ou des perturbations
Only 10% of the teeth with abfrac- occlusales associées avec les abfractions. Tous
tions were associated with bruxism and les consultants ont été examinés pour la
a relatively rare finding was mobility Acknowledgement présence d’abfractions durant le premier tri-
(1.9%). This is quite logical, because to This work was supported by the Labor- mestre. NCCL ont été trouvés chez 61 patients
develop a fulcrum the teeth need to be atoire de Recherche Parodontale. qui ont ensuite reçu un examen complet afin de
stable. Teeth that loosen under occlusal vérifier la présence clinique de brossage
excessif ou de perturbations occlusales. La
loading at an early age are unable to présence de plaque dentaire, de tartre, de
form abfractions. Clenching and occlu- Zusammenfassung parodontite ou de mobilité ont également été
sal overloading are not synonymous notées. La fréquence et le pourcentage
Analyse der ätiologischen Faktoren und des
with trauma from occlusion. Thus, teeth parodontalen Status bei 309 Zähnen mit
ont été utilisés pour décrire l’apparition des
that present a widening of the period- différents signes cliniques en association avec
keilförmigen Defekten
ontal ligament space and other signs of la présence d’abfraction. Les abfractions ex-
Ziele: Man denkt seit langem, dass kariesfreie
istent souvent dans les bouches présentant de la
trauma usually do not present abfrac- zervikale Läsionen (NCCL), auch als keilför-
plaque dentaire (40.1%), du tartre (41.7%) ou la
tions (Horning et al. 2000). This infers mige Defekte bezeichnet, durch exzessives
parodontite (20.4%). L’ulcération de la gencive
that if teeth with NCCL are affected by Putzen produziert werden. Vor fast 20 Jahren
est une découverte rare (1.6%). Cependant, des
wurde auch eine okklusale Ätiologie vorges-
periodontitis, it is not complicated by limites apicales sous-gingivales étaient fré-
chlagen (Lee und Eagle, 1984). Es existiert
occlusal trauma but merely due to quentes (32.5%). NCCL coexistaient presque
immer noch die Kontroverse bezüglich dieser 2
bacterial mass. Indeed, 20.4% of the systématiquement avec les facettes occlusales
Konzepte. Die vorliegende Arbeit wurde aus-
d’usure (94.5%). Un manque de protection
teeth with abfractions came from geführt, um das Auftreten von Zeichen exzessi-
canine (77.2%) était aussi souvent associé à la
mouths with periodontitis and 40.1% ven Putzens oder okklusaler Störungen, die mit
présence des abfractions. Par contre la mobilité
came from mouths with visible amounts keilförmigen Defekten assoziiert sind, zu ver-
était rarement trouvée (1.9 %). Des signes
of plaque on the buccal surfaces. ifizieren.
cliniques de brossage excessif manquaient
Material und Methoden: Während eines Tri-
Periodontal therapy relies first and mesters wurden alle Erstkonsultationen hinsich-
tandis que des signes de perturbation occlusale
before all on plaque control. Informing étaient très souvent trouvés en présence d’ab-
tlich des Vorkommens von keilförmigen De-
patients that their abfractions could be fractions.
fekten gescreent. Es wurden 61 Patienten
due to excessive toothbrushing is coun- mit NCCLs gefunden. Bei ihnen erfolgte die
terproductive. Not only are these lesions klinische Untersuchung bezüglich der Merk-
not due to brushing, but also many are male für exzessives Putzen oder für okklusale References
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