NON CARIOUS

CERVICAL
LESIONS
(NCCLs)
Dr. Meena
NON CARIOUS
CERVICAL
LESIONS
(CERVICAL
WEAR)

“ The loss of the tooth

substance at the Cemento-
enamel junction”
- Mair 1992
 NCCLs not observed in the few studies
of ancient American skulls of
prehistoric & historic skeletal remains

Was there an
absence of lesions
in an environment
where there was
also no tooth brush Is it a life
abrasion and little
corrosion?????? style
disease???

JA Michel et al , Australian Dental Journal 2009 ; 54;2-8

  The noncarious loss of tooth structure
was first mentioned in the dental
literature by Dr. Hunter in 1728
(Non Carious Cervical Lesion : A Review ; Anil K Tomer Et Al ;IJJS Case
Reports And Review ; Feb 2016 , Vol 2 , Issue 9 ; 41-43)

 Many dental practitioners were very

curious about this non- carious lesions at
the cervix of the teeth , which they named
the –
“Mysterious non- carious cervical lesions”
“Wastings”
 In19th century the etiology of
tooth wear was unexplained
and the lesions were not
categorised.
 Overa period of time number of
theories regarding the etiologic
mechanisms have developed.
 • Looked at “wastings”
and concluded that
Miller brushing with coarse
1907 tooth powder was
the likely cause of
tooth wear.
 • Described the problematic etiology
of what he termed “erosion”
• He stated “ our information
regarding erosion is far from
complete & much time may
elapse before its investigation will
give satisfactory results”
• He identified 8 possible causes -
• Faults in the formation of teeth
• Friction from an abrasive tooth
powder

G V Black
• Action of an unknown acid
• Secretion from a diseased salivary
gland

1908 • Physiologic resorption , as with

deciduous teeth
• Acid associated with gouty diarethis
• Action of alkaline fluids on calcium
salts
• Action of enzymes released by
micro- organism
G V Black (1908 )

 After considering each

hypothesis in turn , finding fault
with all , he concluded that he
had no theory of his own to
offer .

(Ian wood et al ; Journal of Dentistry 36(2008) ;759-

766 )
 • Made the observation that in all cases of
cervical erosion , he noticed heavy wear
KRONFIELD facets on the articulating surfaces of teeth
1932

• Introduced the term

“ABFRACTION” for pathological
Grippo loss of dental hard tisues , caused
1991 by biomechanical forces.

• Suggested a modification of terminology

by replacing the term “erosion” with
Grippo “Corrosion” and by defining abrasion and
2004 attrition as “Friction”
 Most experts now agree that in :

“Each clinical form of NCCL-

multiple etiologic factors are
involved ,
one of them being prominent”.
Often

Abfractio Is it the
n Used as right
“Catch term to
all” term use?????

Is it the occlusal stresses which

start NCCLs ?????
 Association of Occlusal Loading
with NCCL Formation
 What we see:
 Patients in group function (GF) with higher
incidence of NCCLs versus canine disclusion
(CD).
 NCCLs found to coexist with wear facets,
altered tooth position, and parafunctional
habits
 Still, there is continued controversy in the
exact role of occlusal stress as THE FACTOR
in initiation and advancement of NCCLs.

Pecie et al, Am J Dent, Feb, 2011

 Recently

 With “Optical Coherence Tomography

(OCT)” , Wada et al reported -
 DENTIN DEMINERALIZATON promotes the
formation of NCCLs in the early stage
 Occlusal stresses contributes to
progression of lesion.

(Ahmed Mohammed El – Marakby et al , dentistry

2017,7:6)
 In 2017 with optical coherence tomography
applications in tooth wear diagnosis , it is
emerging that –
1. “ for Erosive tooth wear there is
existence of chemical aggresion , with strong
dimeralization of enamel and dentin”
2. “for Attrition lesions, there is
contribution of excessive force and friction
movements specific to bruxism”
3. “In Abfraction , OCT image revealed the
importance of the mechanical factor in
producing this form of tooth wear”
4. “ Abrasion may be considered
physiological according to patient’s age”
 Grippo et al suggested a schema of
pathodynamic mechanism of tooth surface
lesion under the “3 BIG- SPHERES”
which influences the NCCLs.

STRESS

FRICTION BIOCORROSION

(Grippo et al ; journal of esthetic and restorative dentistry , Vol 24;

No. 1 ,10-23, 2012)
(Grippo et al ; jornal of esthetic and restorative dentistry , Vol 24; No. 1 ,10-23, 2012)
 ETIOLOGIC MECHANISM OF
NCCLs: Etiologic Mechanism
NCCLs
Erosive mechanism / Chemical wear as a result of intrinsic , extrinsic or
corrosion chelators acts on plaque free tooth surfaces.
Factors – acidic beverages and foods , acidic medications ,
GERD , bolumia nervosa , occupational exposure to acids (
wine tasters )
Abrasion mechanism Physical wear as a result of mechanical process involving
(exogenous foreign objects .
friction ) Factors – abrasive tooth paste , improper tooth brushing
with a horizontal tech and excessive force , particularily
dietary habits
Abfraction Physical wear as a result of tensile / shear stress in CEJ
mechanism area provoking microfractures in enamel & dentin
/( stress) ( fatique wear).
Factors – parafunctions , bruxism , excessive functional
load , off axis force
Stress corrosion Tooth substance loss due to combination of acid & stress .
Acid in the area of stress concentration results either in
static stress corrosion or cyclic (fatique) stress
concentration

Ivo Krejci et al ; Noncarious cervical lesions - A clinical concept

based on the literature review. Part 1:Prevention; American journal of dentistry · February 2011
 PREVALENCE :

The data
reported in the There is
literature on dishomogen
the prevalence Most of the
eity in the Is it due to
of NCCLs studies have
investigated absence of
cover a wide not
range from population common
examined
( 11.4% – age, diagnostic
homogenous
62.2% ) with geographical criterion ?????
situations
prevalence area , life
increasing style ????
with age
 Life – style changes rising the risk of
NCCLs
 Increased consumption of acidic drinks
among youngsters
 Increase in number of older adults who
take prescription medicines – which
cause hyposalivation and xerostomia.

Warden .H Noble et al ; journal of Multidisiplinary Care;

Feb 2016 :1-6
 Hyposalivation

 Increases the acidity in the oral

cavity
 Softening the tooth surface
 Facilitating tooth loss

Warden .H Noble et al ; journal of Multidisiplinary Care;

Feb 2016 :1-6
Bader et al suggested :
3- areas of uncertainty regarding
NCCLs-

Classificatio Treatme
Cause
n nt
AFFECTED TEETH –
 Controversy regarding distribution of
NCCLs within dentition –
 Most common affected teeth –
Mandibular first premolar (34.2%) >
man second premolar
 Fewer other studies have reported
maxillary teeth to be more frequently
affected
 Variations noted in literature
 NCCLs are more common on the facial
aspects of teeth than lingual and
more common in the buccal segments
of the mouth than lingual aspects

( lan wood et al , journal of dentistry 36(2008) 759-

766 )
Reasons for paucity of lingual
Lesions-
 Weinberg and Jenkins stated that
there is 5x more saliva on the lingual
surface than in the vestibule.
 Lingual serous saliva has high flow
rate , buffering capacity from
bicarbonates .
 CLASSIFICATIO
N
 Classifying lesions according to etiology
was put forward by Levitch et al …
[ Lan Wood J. of dentistry 36 (2008) 759-766]
 They proposed that :
“An erosive lesion could be found on either
the lingual or facial aspect of the tooth, be
shallow, U-shaped or disc-like and would
have smooth angles and a smooth
surface”.
CLASSIFICATION.
..

 An abrasion lesion would be facially

located, wedge-shaped or grooved with
sharp angles and possibly a smooth or
scratched surface.

 A lesion associated with tooth flexure

would be found facially and would be
wedge-shaped or composed of overlapping
wedges, have sharp angles and a rough or
corrugated surface.
Classification of dental hard tissue
loss according to Eccles (1979) :

CLASS DESCRIPTION

CLASS I Superficial lesion, limited to the enamel

only

CLASS II Localized lesion, involvement of dentin in

less than 1/3
Generalized lesion, involvement of dentin
CLASS III in more than 1/3 –
A. Facial surfaces
B. Lingual and palatal surfaces
C. Incisal and occlusal surfaces
D. Severe multi-surface involvement

The anatomy of non-carious cervical lesions; C. Walter & E. Kress ; Clin Oral Invest
DOI 10.1007/s00784-013-0960-0
DRAWBACKS :

Most studies are limited to :

 lookingat factors associated with a
single aetiological mechanism”

 Failure to define criteria for lesions

 EROSION /
BIOCORROSION
 Aciderosion is the most important
factor in the development of NCCLs.
 Saliva keeps the oral environment in
the 7.0 pH range (neutral) due to its
ability to buffer acids .
 Individuals
with Xerostomia are
susceptible to acid erosion
 • Carbonated drink
• Acidic beverages including herbal
teas
• Acidic foods
EXTRIN • Citric lozenges
• Saliva substitutes
SIC • Recreational exposure to water in gas
chlorinated swimming pools
CAUSES • Occupational exposure to corrosive
agents such as battery acid fumes,
industrial aerosols , workers in
electroplating , metallurgical plant
,welders…….

• Bulimia
• Rumination or voluntary reflux
INTRINS phenomenon

IC • Subclinical regurgitation due to

chronic gastritis associated with
CAUSES alcoholism
• Xerostomia
• Mal -absorption syndrome
• GERD
 Checklist in Order to Unveil Etiological Factors for Erosions
(in part from Lussi & others;56 Lussi & Hellwig93)
 Take case history (medical and dental).
 Diagnose the severity and site-specific distribution.
 Record the dietary intake over four days and estimate the erosive
potential.
 Question the patient for specific factors that they may not be aware
of:-
1. Diet: Herbal teas, acidic candies, alcohol, sports drinks, effervescent Vitamin C tablets,
etc.
2. Gastric symptoms: Vomiting, acid taste in the mouth and gastric pain (especially when
awakening), stomach ache, any sign of anorexia nervosa.
3. Drugs: Alcohol, tranquilizer, anti-emetics, antihistamines, lemonade tablets. (Change of
acidic or saliva-reducing drugs is possible in consultation with the patient’s physician).
 Determine the flow rate and buffering capacity of saliva.
 Reveal the oral hygiene habits, abrasivity of toothpaste and
technique.
 Question the patient for occupational exposure to acidic
environments.
 Question the patient for X-ray therapy of the head and neck area.
 Assess further progression with silicone impressions, study models
and/or photographs.
 Interactions of the different factors
for the development of erosive
tooth wear

Buonocore Memorial Lecture Dental Erosion ; A Lussi • E Hellwig • C Ganss • T Jaeggi ; Operative Dentistry, 2009 ,34-3,
251-262
 The pH (less than 4.5) duration and
strength (buffer capacity) of the acid
challenge need to be considered.
 Ex. Compared to cola (phosphoric acid) ,
drinks containing citric acid with similar
pH
is more erosive as more buffering is
required
 Gastric acid with proteolytic enzymes
cause more damage to enamel and
dentin, also patients with gastric reflux
suffer from hypo salivation.
 Occupational exposure

Tooth surface Dental erosion rate

loss

Tuominen et al 1991 63.4%(exposure)

37.7% (nonexposure)

Suyama et al 2010 66.7% after 20 years of

work

Amin et al 2001 68.85% cervical lesions

91.8% with only loss of
enamel surface
characteristics

Rafael Aiello et al ; Braz Oral Res ( online ) :2015; 29(1);1-8

 Mechanism
 The action of strong acids cause the loss of
calcium (inorganic matter) from the tooth
surface, followed by softening of the top layer
of dentin and enamel.
 This softened layer becomes susceptible to
abrasive forces.
 The softened layer is between 0.2- 3µm thick
and is repeatedly removed by abrasive forces,
leading to permanent loss of tooth volume in
cervical areas.
Clinical Presentation
 Mandibular molars are the teeth most
commonly subject to erosion.
 Extrinsic acid damage the labial
surface of anterior teeth and occlusal
surface with severity decreasing
posteriorly.
 Intrinsic acid causes more damage
to lingual surfaces of the teeth.
However, the pattern of damage may be
modulated by the protective influence of
tongue which can force regurgitated
acid over the tongue, along the palate,
and into the buccal vestibule.
 Industrial or occupational erosion
lesions are found on the incisal one
third to one half of the labial surface
of incisor, industrial erosion lesions
don’t present commonly at the cervix.
 Thinning of enamel imparts an
unesthetic “yellowish” hue to
the teeth.

 Eroded teeth caused by intrinsic cause

have the appearance of having been
lightly prepared for full coverage
restoration with a chamfer margin.
Extrinsic factors produced
U-shaped or Dish shaped
but shallow , smooth edged
depression
 Abfraction means “To break
away”
A term copied from the latin language

ABFRACTIO
N
Grippo in 1991 was the first one
to describe the results of
biomechanical loading of forces leading
to pathological loss of enamel and
dentin and coined the term
“ABFRACTION”

“STRESS CORROSION”
is the other term suggested for this
process
CAUSES & THEORIES OF
ABFRACTION –
 Abfraction lesions associated with thin
structure of enamel rods with low pack
density of Hunter Schreger bands (HSB)
at the cervical area .
 Some studies suggest that
abfraction is due to flexure
in the cervical area of
tooth from the occlusal
compressive forces and
tensile forces leading to
microfractures of enamel
and dentin at the
hydroxyapatite level in
turn resulting in further
fatigue and deformity of
tooth structure.

Noncarious cervical lesions and abfractions A re-evaluation LUIS A. LITONJUA, JADA, Vol. 134, July 2003
 Bioengineering studies have
discovered the association between
wear at the cervical region and
occlusal stresses by employing finite
elemental analysis or photo elastic
methods.
 However clinical studies have not
provided enough evidence on the
relation between abfraction lesions
and occlusal stresses.
 Occlusal loading may not be the primary
factor in the formation of noncarious
cervical lesions.
 Some researchers believe that a non –
ideal bite leads to creation of stresses in
the cervical region of teeth.
 Several clinical trials found generators for
oblique loading such as altered tooth
position , group function as well as
parafunctional habits and bruxism to be
associated with NCCLs
Occlusal and Eccentric Loading :
 A theory that eccentric (flexing) and axial
(barreling) from occlusal forces can
contribute to NCCL formation.

Lee & Eakle, J Prosthet Dent, 1984

 Add note on clinical features
 Prevention
 Management
ABRASION
Defined as “wearing away of
dental hard tissues by
frictional forces”
 This can include wear caused by tooth
brushing , flossing , tongue action ,
abrasive foods , and rubbing from
opposing surfaces that are hard or
rough , such as unpolished porcelain
crowns.
 The effects of such actions are usually
more pronounced on dentin surfaces
than on enamel
 The role of abrasion has been
investigated in laboratory and clinical
studies
 Early clinical work suggested that –
 Orientation of tooth brush influenced
the wear of teeth
 Horizontal brushing causing two or
three times more wear compared to
vertical brushing.
 Prolonged contact time between
bristles and tooth surface reported
to increase this further
 Force and frequency applied to the
brush increase wear
The hypothesis of these early
studies reflected the understanding
at the time that cervical wear was
caused by abrasion
 Some studies suggest that tooth paste
has more relevance to abrasion than
does the tooth brush
 There was some suggestion that softer
brushes results in greater abrasion
than do harder brushes.

AGD 2016
Boston
 Abrasiveness of tooth paste combined
with brushing is responsible for loss of
tooth structure.
 Dentifrices that include whitening agents
or products promoted for their ability to
control tartar tend to be more abrasive
than other types.
 Any tooth paste with a relative dentin
abrasivity value of 250 or below can be
used safely on a daily basis for a life time

AGD 2016
Boston
 Cervical lesions thought to be
due to abrasive forces
generally :

 Have sharply defined margins

 Hard smooth surface that may
exhibit scratches.

Abrasive cervical lesions are not
always ‘wedge shaped defects’
 Others types seen are:
 SIMPLE FLAT FLOORED GROOVES
 C- SHAPED Defects in cross- section
with rounded floors.
 UNDERCUT DEFECTS with flat cervical
wall and a semicircular occlusal wall
 V – SHAPED GROOVES with oblique
walls that intersect axially

AGD 2016
Boston
 Abrasion is accelerated with acid
softening or dissolution
 A 6 – year longitudinal clinical study
reported that both consumption of
dietary acids and frequency of tooth
brushing correlated to increased wear.
 It has also been reported that a delay of
at least one hour before brushing , after
an acid challenge , can increase
resistance to tooth surfaces to abrasion.
 Minimal intervention dentistry: part 5. Ultra-conservative approach to the treatment of
erosive and abrasive lesions P. Colon*1 and A. Lussi2 rubbing ; BRITISH DENTAL JOURNAL
VOLUME 216 NO. 8 APR 25 2014
 Why cervical area is
unpredictable area for
adhesive resin
restorations????????
Cervical area are
MORPHOLOGICALLY AND
HISTOLOGICALLY -
different from the crown
and root portions of the
tooth
 ENAMEL DENTIN
• Enamel gradually • The orientation of
becomes thinner dentinal tubules in
• Enamel prism direction cervical region-
changes into a flattened • Their course has parallel
one in contrast to or oblique direction
scalloped arrangement • Only in depth of cavity ,
in crown enamel the tubules are
• Mechanical interlocking perpendicular
between enamel & • This configuration
dentin in the cervical represents a limit for the
area is weaker than in adhesion of composite
other regions of DEJ resin.
• Area of non-prismatic • Tubule density is low
enamel- this enamel • Sclerotic dentin
irregularly structured &
more resistant to
carious attack because it
is less soluble in acids
( explains why NCCLS is
more frequent than
caries in cervical area)
SCLEROTIC DENTIN :
 Bond strength in sclerotic dentin would
probably be sufficient to assure
retention , if bonding is performed with
phosphoric acid .
 Etching of enamel is to create additional
microechanical retention.
 The presence of bacteria on these
surfaces may justify the use of
antibacterial adhesives to disinfect the
substrate.
MANAGEMENT
OF NCCLs
 Management of NCCLs includes first
identifying the various etiologic factors ,
as more than two mechanism may be
involved in the etiology

Risk
assessment
of patient

Preventi
ve
therapy

Correcting
habits &
eliminating
possible
causes
RISK ASSESMENT :
 Comprehensive medical history
 Clinicians should question Patients regarding
their intake of acidic foods of beverages
including wine , sports and energy drinks
 Monitor frequency , duration , sequencing ,
mode of intake . Eg ; sipping & swishing a
drink is much more erosive than gulping the
beverages , as acidic beverage stays in
contact with the tooth surface for longer
periods
RISK FACTORS :

 Thereare many risk factors

involved in the erosive tooth –
wear process
 Biological
, behavioral and
chemical factors interact with
tooth surface.
BIOLOGICAL FACTORS :

Saliva
 Dilution
and clearance of an
erosive agent from the mouth
 Neutralizationand the buffering of
acids which slow down the rate of
enamel dissolution
Pellicle :
 The acquired pellicle act as a
diffusion barrier preventing direct
contact between the acids and the
tooth surface – reducing the
dissolution rate of dental hard
tissue.
CHEMICAL FACTORS :
 pH of acidic drinks and food stuffs , its buffering
capacity and calcium chelation properties
 The Ph value , calcium , phosphate and flouride
content of a drink determines the degree of
saturation with respect to tooth mineral , which
is the driving force for dissolution
 Citric acid are damaging to tooth structure.
 They have double action , the effect of hydrogen
ion and citrate anion , upto 32% of calcium in
saliva can be complexed by citrate reducing
supersaturation of saliva
Behavioral factors :

 Excessive consumption of acidic candies

 High intake of herbal teas
Recommendations for Patients at High Risk for Dental Erosion
(modified from Lussi & others;56 Zero & Lussi;68 Lussi &
Hellwig93)
1. Reduce acid exposure by reducing the frequency and contact
time of acids (main meals only).
2. Do not hold or swish acidic drinks in your mouth. Avoid
sipping these drinks.
3. Consider using modified acid beverages with no or reduced
erosive potential.
4. Avoid toothbrushing immediately after an erosive challenge
(vomiting, acidic diet). Instead, use a fluoride-containing
mouth rinse, a sodi- um bicarbonate (baking soda) solution,
milk or food, such as cheese or sugar-free yoghurt. If none of
the above is possible, rinse with water.
5. Use a soft toothbrush and low-abrasion fluoride-containing
toothpaste. High-abrasive toothpastes may remove the
pellicle.
6. Gently apply periodically concentrated topical fluoride
(slightly acidic formulations are preferable, as they form CaF2
at a higher rate). Use (tin-containing) fluoride mouthrinses.
7. After acid intake, stimulate saliva flow with chewing gum or
lozenges.
8. Use chewing gum to reduce postprandial reflux.
9. Refer patients or advise them to seek appropriate medical
attention (gastroenterologist and/or a psychologist) when
intrinsic causes of erosion are involved
 PREVENTIVE MEASURES
Erosion / Biocorrosion
 Fluoride mouth rinse and professionally
managed topical fluoride application
 Use of fluoride varnish & bonding agents can
protect teeth from acid attack – though long
term effect is limited
 Stannous fluoride is an important preventive
tool to protect the tooth surface from acid
challenge. It forms a thin layer of stannous
based complexes on the surface of enamel ,
protecting the surface from acid attack
 Recharge and remineralization of
demineralized tooth surface with CPP- ACP
PREVENTIVE MEASURES……

ABFRACTION :

 Determination of activity of abfraction

lesions can be done by using No 12
scalpel blade.
 Visual observation of the scratch will
give an indication of the rate of tooth
structure loss.
 Loss of scratch definition or loss of
scratch altogether signifies active tooth
structure loss
Monitoring of Abfraction lesions :

 When possible abfraction lesions are not causing

clinical consequences and/or they are only shallow in
depth ( less than 1mm)
 One may elect to simply monitor them at regular
intervals with standardized intraoral photographs and
study models.
 Don’t carry out Inappropriate occlusal adjustments-
increase risk of caries , occlusal tooth wear and dentin
hypersensitivity
 Occlusal splints to reduce nonaxial tooth loading may
be considered , though there is lack of evidence to
support its use.

( JA Micheal et al Australian Dental Jour 2009 ; 54: 2-8)

PREVENTIVE MEASURES :
Abrasion :
 Educating the patient technique of
correct tooth brushing
 Individual monitoring protocol by
assessing -

Severity of
present
lesions

Existing
etiological
Age
and risk
factors
PREVENTIVE MEASURES –
Abrasion …..

 Recommend use of soft brush

Low abrasion fluoridated
calcium containing tooth paste

 in case of soft enamel :

Sonic tooth brushes may lead to
significantly higher loss of
substance.
 Rapid progression – measurement
procedure at 6month intervals
 Most other cases – annually
 Progression can be assessed clinically
by measuring the width and the length
of the lesion with a graded probe, and
also by comparatively examining
photographs
 Preventive Measures –
To increase the salivary
flow

 Salivais important protective

factor through pellicle formation
and buffering capacity

 Use of sugar free chewing gum/

flouride containing or carbamide
containg gum to increases salivary
flow .
LOCAL PREVENTIVE
MEASURES
 Fluoride varnish
 Dentin sealing with resin based adhesives
 Some tested products are –
 “Seal and protect”- a self adhesive
, light curing , translucent sealing
material – produces hard coat , increasing
the resistance of cervical areas
 It is specially designed to protect exposed
dentin
 Calciumcontaining sodium
bicarbonate with fluoridated tooth
paste reported to harden enamel
surface by delivering minerals and
reduce surface roughness.
 CPP-ACP with fluoride – increased
concentration of bioavailable
calcium and phosphate ions.
RESTORATIV
E
TREATMENT
 Factors Situation Recommendation
Specific local Sclerotic dentin •Use of reliable adhesives (no difference
conditions between etch-and-rinse and self-etch
adhesives) or Fuji Bond LC + composites.
•Enamel beveling and etching is strongly
recommended.
•Removal of outer layer of dentin does not
improve efficiency in a predictable way.
Lesion Large, deep defects Reliable tested adhesives are recommended.
morphology –
Composite (hybrid or microfilled) used with
a layering technique.
Small, superficial Decision to restore: use of flowable
cavities composite or restorative composite.
Decision to monitor if etiological factors are
controlled, patient is kept under
surveillance and there are no esthetic
complaints or food impaction. A slow
progression of the lesion and no increased
resistance of the tooth when restoring the
lesion support this decision.30,90
Preventive measures and protection of the
area by fluoride varnishes or adhesive
coatings is recommended.
Hypersensitivity treatment.
Periodontal Gingival recession Indication for root coverage procedures.
involvement

American Journal of Dentistry, Vol. 24, No. 3, June, 2011 Noncarious cervical lesions:
 Factors Situation Recommendation

Location of Apical and coronal Root coverage procedures +

lesion to the CEJ restoration (glass-ionomer or
composite.
Coronal to the CEJ
Restoration alone.
Biomechanics High occlusal Composite combined with efficient
stress ,bruxism reliable adhesives.
parafunctions No difference between microfilled
and hybrid composites, based on
existing clinical investigations.
Age Younger For erosions occurring at younger
age, the decision to restore or not is
a function of defect size. Risk
management and surveillance of
patient + local preventive measures
could be sufficient.
Older
Lesions of older patients – restore
in the more complex context of
general treatment strategy (may
involve crowns, veneers, inlays ).

American Journal of Dentistry, Vol. 24, No. 3, June, 2011 Noncarious cervical lesions:
 Though a very common clinical
procedure, NCCLs also represent one
of least durable restoration
treatments, with concomitant
problems of:
i. Loss of retention
ii. Marginal excess (flash)
iii. Secondary caries lesion formation
iv. Discoloration
v. Decreased longevity
Is “wait and
see”
philosophy
OK?

Can be substantiated with slow

progression of lesion, high capacity
of self-defense with sclerotic dentin
production, lack of evidence for
tooth weakening, lack of dentinal
sensitivity, and esthetic concerns
Basic Guidelines for
Restorative Intervention:
 Esthetic desires of patient.
 Intractable dentin hypersensitivity.
 Depth >1mm as etiologies continue.
 Potential pulp exposure.
 Proximity of NCCL to RPD clasp location.
 Structural integrity of tooth threatened.

Lucci et al, Oper Dent, 2009

 Isolation

Challenges Options
with:
:
• Moisture control • Rubber dam
(gingival fluid and • Retraction cord
blood isolation
contamination) • Isolite system
• Access to
subgingival
margins.
• Absence of
peripheral enamel
walls
• Dentin
characteristics
 Recent advances in gingival tissue
displacement includes as follows:-
 Lasers
 Expasyl paste
 Gingitrac
 Magic foam cord
 Matrix impression system
 Mercocel
 RaceGel
 Magic foam cord
 Stayput.
 Newer gingival displacement methods can be
used to retract the gingiva in place of
conventional retraction.

Haripriya and Ajitha: Isolation techniques for restoring non-carious cervical lesions
Retraction Cord Placement

Don’t
Use only if
impregnate
tissue is
with
healthy and Use
HEMODENT
lesion no Ultrapack
! –Bond
more than #00 or
strength
slightly #000.
will be
subgingival
compromis
.
ed!
Shown to be as
effective in isolation as
rubber dam placement.
Preparation Considerations

 Bevelling of enamel is still indicated ,

as when sclerotic dentin is involved enamel
adhesion has to be predictable in order to
improve retention rate and marginal sealing

 Placement of retentive features (grooves)

in prep may create ‘mud flap’
phenomenon.

ADA Boston 2016

Should the Dentinal Surface be
prepared for Bonding? What Studies
Reveal :
 With sound dentin:-
 No benefit from roughening dentin.
 With etch and rinse (ER) and strong
self-etch (SE) DBAs, no additional
benefit from roughening.
 With mild SE and ultra-mild 1-step
SE, diamond bur roughening may
help.
 CHALLENGES :
Sclerotic Dentin

 Partial or total obliteration of dentinal

tubules with mineral crystals

 Presence of acid resistant

hypermineralized layer

1. Hinders formation of resin tags

2. Reduces thickness of hybrid
layer in the intertubular dentin
Changes in adhesive protocols :

 Phosphoric acid preatreatment when

using Self etch system
 Roughening of sclerotic dentin surface
with diamond bur
 Preconditioning of dentin with weak
acids , such as EDTA – 2 min
OR
Active EDTA application with microbrush-
30 sec
EDTA PRECONDITIONING

Produces shallow demineralization

of dentin

Inhibitory effect on matrix bound

endogenous Metalloproteinases
of demineralized dentin
Studies with Sclerotic Dentin:

 No predictable retention
improvement by modifying the
surface preparation.
 No difference between using ER
and SE DBAs.
 The condition of the peripheral
dentin is paramount to a
predictable seal.
Bonding effectiveness to
dentin by

 chemical vapor deposition

 Er,Cr:YSGG laser irradiation
 Silica coating
 Ozone treatment
 Aluminium oxide sandblasting

Didn’t show much evidence

 Restorative Options
 Options to consider :
1. Resin composite (RC) and dentin
bonding agent (DBA)
2. Resin-modified glass ionomer cement
(RMGIC)
3. RMGIC/RC as a ‘sandwich’ restoration

 New options :
1. Flowable composites
2. Bulk Fill Composites ( SDR )
Questions to answer
Is the clinical performance of
resin composite (RC) better
than resin modified glass
ionomer (RMGIC)?

Which resin composite is best

to use?

Which dentin bonding agent

system is best to use?
 Though RMGIC have been
treatment of choice in past:-
 Use of RC now shows best
performance.
 No difference between hybrid and
microfill.
 Flowable RC only for small, non-
sculpted preps.
 No particular indication for Ormocers,
Compomers, And Giomers.
Choice of adhesive system
has important role in
performance:-
 3-step etch & rinse and 2-step self-
etch have the best retention record.
 “Universal adhesives” containing
10- MDP with selective etch
appears favorable
Results from long term use is
required
S AUTHOR TITLE OF THE STUDY CONCLUSION
N.
1. Perdiga et “A New Universal Simplified The clinical retention
Adhesive: 18-Month Clinical of the multimode
al. Evaluation” adhesive at 18 months
(Operative does not depend on
Dentistry, 2014 ) the bonding strategy.
The only differences
between strategies
were found for the
parameter marginal
adaptation
2. Lawson et al. “Two-year clinical trial of a 24 month evaluation
(Journal of universal adhesive in total- of a universal
Dentistry -2015) etch and self-etch mode in adhesive indicates
non-carious cervical lesions” acceptable clinical
performance,
particularly in a total-
etch mode
3. Schroeder et “Influence of adhesive The adhesive strategy
strategy on clinical did not influence the
al. parameters in cervical POS and the retention
(Journal of
restorations: A systematic rates of CR in NCCLs
Dentistry -2017)
review and meta-analysis” in any of the follow-up
periods; but less
marginal discoloration
was found in ER
 ADA Boston 2016

Insertion Techniques :
 Challenges with enamel and dentin margins.
 To minimize polymerization shrinkage and
improve marginal adaptation, incremental
placement is recommended:-
 Gingival margin first (when no enamel there)
to reduce gingival margin gap when bonding
to enamel margin.
 Incremental placement with last one on
enamel margin.
 Sculpting prior to polymerization can reduce
stresses from finishing and polishing.
Finishing and Polishing :
 Use of 12-B blade for gingival
trimming.
Avoid rotary instruments on
cementum.
 ET (Esthetic Trimming) burs for axial
and proximal contours.
 Sequential polishing disks.
 Surface sealant.

ADA Boston 2016

Why Consider Combined
Periodontal and
Restorative
Intervention??????
 Gingival recession is often associated
with NCCLs.
 Soft tissue root coverage can improve
esthetics, decrease root sensitivity,
and prevent further recession.
 Ability to recreate the anatomic
position of the CEJ which may have
been lost during NCCL formation, and
the restored CEJ can be in harmony
with adjacent teeth.
 Withcervical restorations
gingival recession and /or
mucogingival defects may be
corrected by –
“Root coverage procedures”
Root coverage procedures :
 Free connective tissue grafts

 Non grafting procedures

 Rotational and coronally advanced flap
 Guided tissue regeneration
 Or a combination of these methods

Luis A Litonjua JADA ; vol 134 , July 2003 ; 845 – 850 ADA Boston 2016
 Among root coverage procedures –
Coronally advanced flap (CAF) with
connective tissue graft ( CTG)
technique is reported as gold standard
& does enhance the probability of
achieving complete root coverage.
( Buti J et al ; metaanlysis of root coverage procedures; j clin
Periodontal 2013;40; 372-386) ADA Boston 2016
 Many challenges confound
while restoring NCCLs
1. Margins of the restoration are located
on enamel and dentin/cementum –

This situation creates competition during

bonding composite resins-

Winner is bond to enamel , with risk of

microleakage in dentin/ cementum
border
2- Microscopic anatomy of cervical
region

I. Aprismatic enamel
II. Orientation of dentinal tubules

3- Sclerosis of dentin
4- Obtaining moisture control
5- Gaining access to subgingival
margins
Reasons For
Restoration
Failure
 Loss of retention ( may be due
to occlusal stress )
 Marginal defects / marginal
stains
 Discoloration ( early sign – prone
for failure ??)
 sensitivity
 Treatment for hypersensitive
noncarious cervical lesions :
 Sealing and restoration treatments are
effective overall in reducing NCCLs
hypersensitivity.
 The potassium nitrate dentifrice
reduced sensitivity with increasing
effectiveness through 6 months but not
to the degree offered by other
treatment.
Treatments for hypersensitive noncarious cervical lesions: Dr. Analia Veitz-
Keenan et al ; J Am Dent Assoc. 2013 May ; 144(5): 495–506.
 SUMMARY

 Clinicians are seeing an increasing

prevalence of noncarious cervical
lesions NCCLs
 Lesions most often seen on premolars
 While exact etiology of NCCLs is
unknown , it is generally accepted their
cause is multifactorial
 Early diagnosis , behavioral changes
and preventive strategies help in
reducing the severity and formation of
new NCCLs
 Chemical bonding potential of adhesives
REFERENCES –
 Non Carious Cervical Lesion : A Review ; Anil K Tomer Et Al ;IJJS Case Reports And

Review ; Feb 2016 , Vol 2 , Issue 9 ; 41-43

 Prevalence and risk factors of non-carious cervical lesions related to occupational

exposure to acid mists ; Aiello BOMFIM et al ; Braz. oral res. vol.29 no.1 São

Paulo  2015  Epub July 03, 2015

 Noncarious Cervical Lesions as Abfraction: Etiology, Diagnosis, and Treatment

Modalities of Lesions: A Review Article ; Ahmed Mohammed El-Marakby1,2, Fuad

Abdo Al-Sabri3*, Sahar A Alharbi4 , Shahad M Halawani4 and Mehaf T bin Yousef4 ;

El-Marakby et al., Dentistry 2017, 7:6 DOI: 10.4172/2161-1122.1000438

 Abfraction, abrasion, biocorrosion, and the enigma of noncarious cervical lesions: a

20-year perspective; Grippo JO, Simring M Coleman TA ; J Esthet Restor Dent.2012

Feb;24(1):10-23. doi: 10.1111/j.1708-8240.2011.00487.x. Epub 2011 Nov 17.

 Non-carious cervical lesions ; Levitch et al ; J. Dent 1994; 22: 195-207

 Non-carious cervical lesions and occlusion: a systematic review of clinical
studies ; Senna P1, Del Bel Cury A, Rösing C ; J Oral Rehabi 2012 Jun;39(6):450-
62. doi: 10.1111/j.1365-2842.2012.02290.x. Epub 2012 Mar 21.

 Dental Erosion in Gastroesophageal Reflux Disease ; Robert P. Barron , Robert P.

Carmichael et al ; Journal of the Canadian Dental Association; February 2003,
Vol. 69, No. 2

 Dental Erosion ; A Lussi et al ; operative dentistry , 2009 ; 34- 3 , 251-262

 Non carious cervical lesions. A review ; Giulio Menicucci , Dario Pittoni et al ;

Minerva stomatologica · January 2006 , 55 ; 13-57

 Noncarious cervical lesions and abfractions -A re-evaluation ; LUIS A. LITONJUA

et al ; July 2003Volume 134, Issue 7, Pages 845–850
DOI: https://doi.org/10.14219/jada.archive.2003.0282

 Non carious cervical lesions – a clinical concept based on the literature review ,
Part 1 – Prevention , Ivo Krejei et al , Americal journal of dentistry , Vol 24 . No
1, feb 2011 49- 56
 Non carious cervical lesions – a clinical concept based on the
literature review , Part 2 – Restoration , Ivo Krejei et al , Americal
journal of dentistry , Vol 24 . No3, JUNE 2011 183-192

 Restoration of Noncarious Cervical Lesions: When, Why, and How ;

Perez et al ; International Journal of Dentistry
Volume 2012 (2012), Article ID 687058, 8 pages ;
http://dx.doi.org/10.1155/2012/687058

 Minimal intervention dentistry: part 5. Ultra-conservative approach to

the treatment of erosive and abrasive lesions ; Colon P, Lussi A ; Br
Dent J. 2014 Apr;216(8):463-8. doi: 10.1038/sj.bdj.2014.328.

 Update on Managing Non-carious Cervical Lesions; Kevin M

Gurecklis , AGD Dental Pearls from the Masters and Fellows July 2016
KEY ARTICLES-
 Krejci , Franklin Garcia-Godoy et al ; Noncarious cervical lesions - A clinical
conceptbased on the literature review. Part 1:Prevention; Americal Journal of
Dentistry , Vol 24 ,No 1 ; feb 2011

 Giulio Menicucci , Dario Pittoni et al ; Non carious cervical lesions. A review ;

Minerva stomatologica · January 2006 , 55 ; 13-57

 Ahmed Mohammed El-Marakby1,2, Fuad Abdo Al-Sabri3*, Sahar A Alharbi4 , Shahad

M Halawani4 and Mehaf T bin Yousef4 ; Noncarious Cervical Lesions as Abfraction:
Etiology, Diagnosis, and Treatment Modalities of Lesions: A Review Article ; El-
Marakby et al., Dentistry 2017, 7:6 DOI: 10.4172/2161-1122.1000438

 Robert P. Barron , Robert P. Carmichael et al ; Dental Erosion in Gastroesophageal

Reflux Disease ; Journal of the Canadian Dental Association; February 2003, Vol. 69,
No. 2

 Krejci , Franklin Garcia-Godoy et al ; Noncarious cervical lesions (NCCL) - A clinical

concept based on the literature review. Part 2: Restoration , American Journal of
Dentistry, Vol. 24, No. 3, June, 2011