Journal of Oral Rehabilitation 2006 33; 17–25
Epidemiological evaluation of the multifactorial aetiology of
abfractions
O . B E R N H A R D T * , D . G E S C H †, C . S C H W A H N * , F . M A C K ‡, G . M E Y E R * , U . J O H N § &
T . K O C H E R ¶ *Department of Restorative Dentistry, †Department of Orthodontics, ‡Department of Prosthodontics, School of Dentistry,
§
Institute of Epidemiology and Social Medicine and ¶Unit of Periodontology, Department of Restorative Dentistry, School of Dentistry, University
of Greifswald, Greifswald, Germany
SUMMARY The purpose of this study was to determine
risk indicators for the aetiology of abfractions (cer-
vical wedge-shaped defects) on teeth using dental
and medical variables obtained in a population-
based sample of the cross-sectional epidemiological
‘Study of Health in Pomerania’ (SHIP). Medical
history, dental, and sociodemographic parameters
of 2707 representatively selected subjects 20–59 years
of age with more than four natural teeth were
checked for associations with the occurrence of
abfractions using a two-level logistic regression
model on a tooth and a subject level. The estimated
prevalence of developing abfractions generally
increased with age. The following independent
variables were associated with the occurrence of
abfractions: buccal recession of the gingiva, odds
ratio (OR) ¼ 6Æ7; occlusal wear facets of scores 1, 2 and
3, OR ¼ 1Æ5, 1Æ9, 1Æ9; tilted teeth, OR ¼ 1Æ4; inlays,
Introduction
Defects in the tooth’s cervical region are commonly
observed in daily practice. This usual non-carious
substance loss can lead to pronounced aesthetic limita-
tions and, in extreme cases, to tooth fractures (1).
Non-carious cervical defects occur in various forms
and to different extents. In addition to superficial
erosions, hollows, or notches, pronounced abfractions
or wedge-shaped defects manifest with a typical coronal
borderline to the intact enamel (2). Further identifying
characteristics of these defects include the unmistake-
able wedge shape when viewing the tooth laterally, and
the uniformly observed occurrence of abfractions
ª 2006 Blackwell Publishing Ltd
OR ¼ 1Æ6; toothbrushing behaviour, OR ¼ 1Æ9 to 2Æ0
(two and three times a day versus once a day). First
premolars had the highest estimated risk for devel-
oping abfractions, followed by the second premolars.
Maxillary and mandibular teeth behaved similarly in
terms of abfractions, with the exception of mandib-
ular canines, which had a much lower estimated risk
of incurring abfractions than did maxillary canines.
The results of this analysis indicated that abfractions
are associated with occlusal factors, like occlusal
wear, inlay restorations, altered tooth position and
tooth brushing behaviour. This study delivers further
evidence for a multifactorial aetiology of abfractions.
KEYWORDS: abfraction, non-carious cervical defect,
wedge-shaped defect, toothbrushing, epidemiology,
cross-sectional
Accepted for publication 13 April 2005
almost exclusively on the vestibular surfaces of the
teeth (3, 4).
The origin of abfractions is a very contentious issue
even today. Several theories explaining the origin of
cervical lesions are offered: abrasion of hard dental
tissue during toothbrushing, chemical erosion via
exogenous and endogenous acids, and occlusal loading
(4–8).
A relationship between brushing technique, brushing
force and the occurrence of cervical lesions has been
confirmed by various authors (5, 9).
Erosion in the cervical region can result from both
exogenous – e.g. excessive consumption of acidic food
and drink or occupational exposure to acidic vapours
17
18 O . B E R N H A R D T et al.
via inhaling – and endogenous factors, e.g. bulimia
nervosa (6, 8, 10).
Further, excessive occlusal loading of the teeth
because of dysfunction of the masticatory system,
malpositioned teeth and bruxism is thought to lead to
the formation of cervical lesions. According to this
theory, the tooth is elastically deformed, causing
disruption of the prismatic structure at the site of least
resistance, namely, the tooth cervix (4, 11).
Non-axial forces on occlusal and palatal guiding
surfaces of teeth in an acid environment may increase
the damage at the cervical margin. This effect is called
stress corrosion and is better known in the engineering
field (12). In a recent in vitro study 8% of the test teeth
developed abfraction-like lesions under stress and 10%
sulphuric acid. None of the control teeth, that where
placed in 10% sulphuric acid without occlusal loading
developed such lesions (13).
Some authors consider the aetiology of cervical
defects to be a multifactorial process in which not just
one or two but many of the processes mentioned above
are involved in the genesis of non-carious hard tooth
substance loss (14–17).
The purpose of this study was to investigate the
aetiology of non-carious cervical defects on teeth using
dental and medical findings obtained in an epidemio-
logical cross-sectional study.
Materials and methods
Sample structure
From the population-based cross-sectional ‘Study of
Health in Pomerania’ (SHIP), 2707 subjects aged
20–59 years (mean age 40Æ6
11Æ1 years) with more
than four natural teeth were chosen.
The SHIP is a population-based cross-sectional study
intended to systematically describe the prevalence of
and risk factors for diseases common in the population
of Pomerania in northern Germany. From 32 commu-
nities in the region, a random sample was drawn from
residence registries, stratified by gender and age. The
design of the study, recruiting of participants, and the
scope of this population-based cross-sectional health
survey was reported by John et al. (18). The gross
sample comprised 6267 subjects with an age range of
20–79 years. The response rate of the study was 68Æ8%.
Participants gave their written informed consent and
the study was approved by the local ethics committee.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25
The study consisted of four parts: a medical and a
clinical dental examination including the functional
analysis, an interview and a questionnaire.
In addition to a medical examination, the subjects
had undergone a clinical dental examination assessing
periodontal, orthodontic and cariologic data, and a
clinical functional analysis. Eight experienced, calibra-
ted dentists were the examiners. Training of the
examiners and consensus discussions were carried out
before the study started and took place twice a year
while the study was running. Fourteen dentate volun-
teers were re-examined for evaluating the reproduci-
bility of cervical defects and occlusal wear
measurements. Intra-examiner reliability showed a
range of Kappa values from 0Æ68 to 0Æ91 and inter-
examiner reliability varied from 0Æ53 to 0Æ74. For tooth-
guided dynamic occlusion measurements in these
14 volunteers, intra-examiner reliability had a range
of Kappa values from 0Æ62 to 0Æ88, and for inter-
examiner reliability from 0Æ58 to 0Æ79 (19).
Variables
Screening for risk factors for the occurrence of abfrac-
tions included the following clinical and anamnestic
data.
Abfractions Visible, vestibular defects located at the
cemento-enamel junction were evaluated. Defect edges
had to form sharp angles (as checked with the perio-
dontal probe PCP 11)*. The defects were recorded
without gradation of lesion depth or width. The wedge
shape had to be clearly discernable with a probe, even
apically. Carious, erosive, or hollowed areas of hard
substance loss were not counted as wedge shaped
defects. Fillings in the cervical region were considered
non-assessable in terms of abfractions.
In subjects with four or more natural teeth, all teeth
but the wisdom teeth were included in the analysis and
classified according the FDI numbering system.
Restorations Only those restorations were included in
which the cemento-enamel junction was assessable
(partial crowns, inlays, occlusal and approximal fill-
ings). All partial crowns, inlays and fillings located on
morphological occlusal surfaces were recorded inde-
pendent of their contact situation.
*HuFriedy, Chicago, IL, USA.
 MULTIFACTORIAL AETIOLOGY OF ABFRACTIONS
Tooth elongation Teeth were defined as elongated if they
protruded vertically beyond the occlusal plane, taking
the sagittal and transversal compensation curve into
consideration. If extensive tooth loss made it impossible
to locate the occlusal plane, the criterion ‘tooth elon-
gation’ could not be recorded and was considered not
applicable.
Tooth tilting Gap-adjacent and terminal teeth were
evaluated for tilting in line with the dental arch and
tilting towards the in- or outside of the arch.
Occlusal wear Abrasion and attrition facets were regis-
tered if found on occlusal surfaces, incisal edges, or cusp
apices.
Occlusal dental hard-substance loss was recorded
according to the method of Hugoson et al. (20) using the
following gradation:
no or minimal (doubtful) enamel loss
enamel loss/dentine spots
loss up to one-third of the crown with
obviously exposed dentine areas
loss over one-third of the crown
Facets in restorations were recorded separately for
all restored occlusal surfaces (fillings, inlays, partial
crowns) and coded as present/absent.
Recession of the gingiva Exposed portions of the buccal
root surface were registered as gingival recession if the
gingiva was located more than 1 mm below the
cemento-enamel junction.
Dynamic occlusion Tooth contacts were registered during
physiological, tooth-guided mandibular movement in
the regular dynamic occlusal zone.
Definition of the dynamic occlusal zone:
1 Tooth-guided lateral movement of the mandible
3 mm to the right and 3 mm to the left of habitual
contact position.
2 Tooth-guided protrusion movement of the mandible
up to incisal edge contact of the maxillary and
mandibular incisors, if this involved a distance of no
more than 5 mm.
Bruxism In the dental interview, the following ques-
tions were asked about bruxism:
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25
19
Do you grind your teeth?
Do you clench your teeth?
If yes, sometimes, often, or always?
Both questions were combined in one variable in the
statistical analysis.
Frequency of toothbrushing The following answers were
possible to the question about toothbrushing frequency:
1 Three or more times a day.
2 Usually twice a day
3 Once a day or less.
Fruit juice The intake of fruit juices was also asked in
the interview, with possible answers being daily intake,
several times a week, once a week, several times a
month, once a month, or never.
Age and gender These two variables were taken from the
medical interview.
0
1 Statistical procedures
2
As tooth-related factors were to be tested in the risk
3 analysis for the occurrence of abfractions, the patient-
related file was transformed into a tooth-related
file. The advantage of this tooth-related file format
consists in the ability to directly assign tooth-related
characteristics to the occurrence of cervical abfractions
(21).
Special software for the statistical analysis of corre-
lated data (SUDAAN 7.5.3)† was used to take into
consideration the dependence among the teeth of a
person.
All factors assumed to influence abfractions were
simultaneously examined for associations in a multi-
variable analysis; interactions between factors were also
considered. This method delivers associations for all
investigated variables with the dependent variable
‘abfraction’.
These associations are expressed as odds ratios, e.g. a
1:1 ratio implies no increased estimated risk. In the
model, variables become potential risk factors if the
determined odds ratio clearly exceeds 1. Values
between 0Æ9 and 1Æ1 yield no effect, values between
1Æ2 and 2Æ5 indicate a weak association between factor
and disease/event, and the association is considered
strong at values over 2Æ5 (22).
†
Research Triangle Institute, Research Triangle Park, NC, USA.
20 O . B E R N H A R D T et al.

Table 1. Sample structure, frequency of subject-related variables Out of all subjects, 23Æ9% reported sometimes
(n ¼ 2707) clenching or grinding their teeth and 8Æ3% reported
doing this often. 7Æ4 % of the subjects reported brushing
Frequency total
their teeth three or more times a day and 14Æ7%
Variable n % brushed their teeth once a day or less. 24Æ7% of all
Age groups (years)
subjects exhibited one to four abfractions; 6Æ7% had
20–24 264 9Æ8 more than four defects.
25–29 321 11Æ3 Table 2 displays the tooth-related characteristics of
30–34 370 13Æ7 the groups. 5Æ3% of all teeth included in the examina-
35–39 375 13Æ9 tion exhibited abfractions. Premolars were the tooth
40–44 355 13Æ1
type most frequently affected by abfractions.
45–49 352 13Æ0
50–54 319 11Æ8 26Æ9% of all teeth showed protrusion contacts, and
55–59 351 13Æ0 teeth with laterotrusion contacts to the left or right
Gender
Male 1267 46Æ8 Table 2. Sample structure, frequency of tooth-related variables
Female 1440 53Æ2
Bruxism
Frequency
Never 1836 67Æ8
within teeth
Sometimes 646 23Æ9
Frequency with abfrac-
Often or always 225 8Æ3
total tions
Tooth brushing
Once a day 398 14Æ7 Variable n % n %
Two times a day 2110 77Æ9
‡ Three times a day 199 7Æ4 Teeth
Fruit juice Central incisor 8971 16Æ6 261 9Æ2
Daily 1040 38Æ5 Lateral incisor 8951 16Æ5 269 9Æ4
Several times a week 775 28Æ7 Canine 8912 16Æ4 389 13Æ7
Once a week 229 8Æ5 First premolar 7619 14Æ1 878 30Æ8
Several times a month 236 8Æ7 Second premolar 7055 13Æ0 569 20Æ0
Once a month 149 5Æ5 First molar 5667 10Æ5 384 13Æ5
Never 278 10Æ1 Second molar 7029 13Æ0 99 3Æ5
Abfractions Upper Jaw 25 347 46Æ8 1294 45Æ4
0 1852 68Æ4 Lower Jaw 28 857 53Æ2 1555 54Æ6
1–4 670 24Æ7 Site
>4 281 6Æ7 Left 26 599 49Æ1 1366 47Æ9
Right 27 605 50Æ9 1483 52Æ1
Dynamic occlusion
Only those factors demonstrating a significant associ- Protrusion 14 096 26Æ9 570 20Æ6
ation – corresponding to the preset level – to the Laterotrusion to the left 10 050 20Æ5 658 23Æ9
Laterotrusion to the right 10 492 20Æ1 538 19Æ5
presence of abfractions remained in the definitive
Restoration
model. A P-value of 0Æ1 was set as the acceptance level Sound 33 510 61Æ8 1604 56Æ3
for inclusion in the model. All calculations were Partial crown 180 0Æ3 14 0Æ5
performed with the software programs SPSS 11Æ0‡ and Filling 19 627 36Æ2 1130 39Æ7
SUDAAN 7Æ5Æ3.† Inlay 8874 1Æ6 101 3Æ5
Recession 13 529 25Æ0 2198 77Æ0
Facets
Results Degree 0 16 776 30Æ9 672 23Æ6
Degree 1 25 557 47Æ1 1350 47Æ4
Table 1 contains the frequencies of the general charac- Degree 2 11 125 20Æ5 779 27Æ3
teristics of the subjects examined. A somewhat greater Degree 3 746 1Æ4 48 1Æ7
number of female subjects fulfilled the inclusion criteria Facets in restorations 6595 12Æ2 473 16Æ6
Tooth tilting 1557 2Æ9 130 4Æ6
for the risk analysis. The male:female ratio was 1:1Æ1.
Tooth elongation 1248 2Æ3 99 3Æ5
‡
SPSS Inc., Chicago, IL, USA. Number of teeth ¼ 54 204, number of abfractions: 2849 (5Æ3%).

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25

 MULTIFACTORIAL AETIOLOGY OF ABFRACTIONS 21

were each found at a rate of about 20%. Within teeth Table 3. Odds ratios of significant variables for abfractions
with abfractions, only the number of laterotrusion
contacts to the left was slightly higher. Odds CI 95% CI 95%
Variable ratio lower value upper value P-value
Of teeth with abfractions, only a slight difference
according to side was discernable. 52Æ1% of abfractions Age groups (years) <0Æ001
were found on the right half of the mouth and 47Æ9% 20–24*
25–29 1Æ49 0Æ84 2Æ64 ns
on the left.
30–34 2Æ14 1Æ39 3Æ55 <0Æ01
Almost 38% of the teeth had restorations, but only a 35–39 2Æ12 1Æ27 3Æ53 <0Æ01
small percentage of these were cast. Within the group 40–44 2Æ71 1Æ66 4Æ42 <0Æ001
with abfractions, the percentage frequency of teeth 45–49 2Æ31 1Æ40 3Æ82 0Æ001
with inlays was over twice that found for the total 50–54 3Æ05 1Æ83 5Æ10 <0Æ001
55–59 3Æ37 2Æ03 5Æ59 <0Æ001
group.
Gender <0Æ001
25% of all teeth and 77% of teeth with abfractions
Male*
showed recessions on the buccal aspect. Female 1Æ01 0Æ84 1Æ21 ns
31% of all teeth and 23Æ6% of teeth with abfractions Facets <0Æ001
had neither occlusal nor incisal facets. Compared with Degree 0*
the group of all teeth, the group with abfractions had a Degree 1 1Æ45 1Æ26 1Æ66 <0Æ001
Degree 2 1Æ87 1Æ55 1Æ24 <0Æ001
higher proportion of teeth with second- and third-
Degree 3 1Æ91 1Æ16 2Æ13 <0Æ01
degree occlusal facets and facets in restorations. In Facets in restorations 1Æ16 1Æ01 1Æ34 0Æ04
addition, teeth with abfractions also exhibited a higher Tooth tilting 1Æ44 1Æ13 1Æ84 <0Æ01
percentage of elongations and tilting. Restoration <0Æ01
Table 3 presents the significant odds ratios with 95% Sound*
Partial crown 1Æ37 0Æ65 2Æ85 ns
confidence intervals and significance levels of general
Filling 0Æ98 0Æ85 1Æ13 ns
and tooth-related variables which were associated with
Inlay 1Æ60 1Æ14 2Æ11 <0Æ001
abfractions. The coefficient of determination (R2) of the Toothbrushing <0Æ001
model was 8%. Once a day*
The odds ratio for developing abfractions generally Two times a day 1Æ87 1Æ36 2Æ56 <0Æ001
increased with age (except among 45- to 49-yr-olds). ‡ Three times a day 2Æ07 1Æ32 3Æ24 <0Æ001
Bruxism <0Æ001
Gender-specific differences were not significant. This
Sometimes 1Æ21 1Æ00 1Æ49 0Æ05
was also true for the parameters of dynamic occlusion, Often or always 1Æ16 0Æ82 1Æ54 ns
the comparison of right and left mouth halves, and the Buccal recession 6Æ69 5Æ66 7Æ92 <0Æ001
intake of fruit juices (P > 0Æ1).
*Reference group.
Recessions constitute a high odds ratio for abfrac-
CI, confidence interval; ns, not significant.
tions, as also indicated by the prevalences (Table 2).
Occlusal facets of scores 1 to 3 showed a significant
effect on the formation of abfractions. A dose-response abfractions as the teeth of subjects who brushed once a
effect was evident for scores 2 and 3. Occlusal facets in day or less.
restorations also proved significant, but the odds ratio of Although bruxism was significant for abfractions, the
1Æ2 cannot yet be considered an effect (22). effect was slight. Frequent bruxism was not significant.
Tilted teeth exhibited a 1Æ4-fold higher odds ratio for Figure 1 depicts the odds ratios of abfraction genesis
developing abfractions. by tooth type, including all variables examined. The
Whereas fillings and partial crowns demonstrated no maxillary canine was chosen as the reference tooth
significant relationship, inlays were significantly asso- (odds ratio ¼ 1). Mandibular premolars had the highest
ciated with abfractions. odds ratio for developing wedge shaped defects, fol-
Of the subject-related factors applied to the tooth- lowed by the maxillary premolars. Maxillary and
related analysis, toothbrushing behaviour was found to mandibular teeth behave similarly in terms of abfrac-
have a marked correlation with abfractions. The teeth tions, with the exception of mandibular canines, which
of subjects who brushed two or three times a day have a much lower odds ratio of incurring abfractions
were at about twice the estimated risk of developing than do maxillary canines.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25

22 O . B E R N H A R D T et al.
Fig. 1. Odds ratios for abfractions of the different teeth (interactions of the upper and lower jaw), reference: upper canine
(odds ratio ¼ 1).
By including the examiners in the model, signifi-
cance levels or odds ratios of the independent variables
were only slightly altered.
Discussion
The data in the literature on the prevalence of non-
carious cervical lesions are highly discrepant and are
determined by defect criteria of the morphology. For
instance, reviews report prevalences of 5% to 85%
(23, 24). This high variance pinpoints the difficulty of
defining what constitutes a non-carious cervical lesion.
Due to the selection criteria (assessability of the vestib-
ular cervical region), the prevalences listed are not
representative for the assessment of tooth loss, extent of
restorative/prosthetic work, etc, and serve only to
describe the subjects in terms of abfractions.
Clinical subdivision of cervical lesions into erosions
and abfractions has been suggested and conducted by
several authors (1, 23, 25). The criteria common to all
were the typical wedge shape and sharply delimited
borders. Prevalences of non-carious cervical defects
found according to these criteria are rather comparable.
For instance, Lussi et al. (1) reported an average of 3
abfractions in 19Æ1% of a group of 26- to 30-yr-old
subjects and in 47Æ2% of a group of 46- to 50-yr-olds.
Dawid et el. (25) examined 4367 German soldiers with
average ages of 21Æ4 to 42Æ6 years and found 8% to
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25
9Æ9% of soldiers not under stress to have abfractions,
and 46Æ8% to 53Æ6% of soldiers under stress (pilots) to
have them.
In our study, 24Æ7% of all subjects exhibited 1 to 4
abfractions and 6Æ7% had more than 4.
Other studies substantiate our finding that the
number of defects per individual increases with age
(26, 27). Larsson (26) detected twice the number of
defects in the 41- to 55-yr-old group compared to the
26- to 40-yr-old group. Hong et al. (27) described an
increase in abfraction frequency after age 20, culmin-
ating at 96Æ3% in the 51- to 66-yr-old age group.
In studies with subjects grouped into several age
categories, Bergström and Lavstedt (28), and Bergström
and Eliasson (29) also showed that the number of
cervical defects increase with age.
It is difficult to construct an index appropriate for a
subject-related risk analysis due to the secondary
masking of abfractions by cervical fillings and crowns.
Therefore, only subjects with more than 4 teeth
without cervical restorations were included in the
analysis.
Today, it is generally accepted that multivariable
analyses are preferable to bivariate analyses when
screening for risk factors. Multivariable models permit
better monitoring of confounding (30, 31).
It is furthermore known that aggregate and non-
aggregate analysis may result in different outcomes
 MULTIFACTORIAL AETIOLOGY OF ABFRACTIONS
(32). The problem of aggregation and the loss of the
tooth-to-tooth relation was avoided by using adequate
software which takes the clustered structure of the
investigated units into consideration (33).
Risk indicators for abfractions were identified with a
two-level logistic regression analysis. With this method,
all plausible and potential risk factors were tested in the
model (34).
The parameters recorded in our study made it
possible to determine several co- and risk indicators
which support the hypotheses that toothbrushing and a
high occlusal load play a role in the aetiology of
abfractions.
The parameter ‘intake of fruit juices’, which could
support the acid-erosion theory, did not show signifi-
cance. The question about the intake of fruit juices does
not cover the variety of acid diets, but was thought to
be highly selective for acid-erosion. Because of the
limitation of the question, this result cannot be gener-
alized. Several studies have shown that the frequent
intake of acidic drinks is a predictor for the develop-
ment of non-carious cervical defects (35, 36). However,
in these studies also superficial erosions and hollows
were included. Lussi and Schaffner (35) distinguished
in their longitudinal study on progression rate and risk
factors of non-carious cervical defects between erosions
and wedge-shaped defects. The consumption of dietary
acids was significantly associated only to erosion but
not to wedge-shaped defects. In this respect our
findings confirm their results since in the present study
only cervical defects with sharp wedge-shaped angles
were included.
As with most chronic diseases, the regression model
confirmed the decisive role of age as a co-factor for
abfractions. From age group to age group, a dose–
response effect was found, which substantiates the
existence of a strong association between these two
factors (22).
Recessions are associated with the genesis of abfrac-
tions and must be seen as co-factors. 77% of all defects
exhibited recessions, and they also showed a high odds
ratio in the regression model. Volk et al. (5) described
the formation of a recession as a prerequisite for the
development of abfractions; however, defects bordered
by enamel alone have been described without reces-
sions (37).
The increased odds ratios given occlusal facets, inlays,
and tilted teeth may be evidence of a correlation
between occlusal factors and abfractions.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25
23
Occlusal facets are by definition a consequence of
stressing the hard dental tissues, primarily via abrasion
and attrition of the teeth (2, 15, 38).
In various studies, high correlations between higher-
grade occlusal facets and reported bruxism have been
documented (39–41). However, a combination of
mechanical and chemical factors is also assumed in
the origin of occlusal facets (2, 42, 43). Bruxism
therefore cannot be considered the sole cause of
occlusal facets.
The study by Schiller et al. (44) on correlations
between occlusal facets and pathological findings in the
masticatory system of young adults showed – in
addition to chronically more highly stressed masticatory
muscles, especially the M. masseter, M. pterygoideus
lateralis and medialis – that cervical defects are associ-
ated with occlusal facets.
In addition to the increased odds ratios for abfractions
posed by occlusal facets, this investigation found only a
very weak direct association with bruxism. However,
the determination of parafunctions in a brief screening
is not unproblematic (45).
In the German soldiers examined by Dawid et al. (25)
in two categories (high and low stress potential), it was
observed that abfractions occurred five times as fre-
quently in the stressed group as in the relatively non-
stressed control group.
The increased estimated risk of abfractions in tilted
teeth can be explained by the altered occlusal contact
situation and the consequently altered force vectors
(46). Braem et al. (47) found evidence of such
phenomena in patients.
Of the occlusally restored teeth in this study, those
with inlays exhibited increased estimated risk of devel-
oping abfractions. Partial crowns comprised only a
small percentage of the restorations, and the estimated
risk was not increased in teeth restored with composite
or amalgam.
There is a paucity of data in the literature on the
correlation between cervical defects and dental resto-
rations. The results obtained by Rees (48) show a
correlation between cervical defects and occlusal amal-
gam fillings. The author assumes that with increasing
filling size, the extent of the cervical defects also
increases because of weakening of the tooth. The idea
that a cast restoration versus amalgam or composite
filling materials has a greater influence on potential
changes in tooth contacts is still considered a hypothe-
sis, but provides a plausible explanation for the
24 O . B E R N H A R D T et al.
phenomenon found. Recently, experimental studies
have provided evidence for the flexural stress theory
via altered occlusal forces (46, 48).
Indicators for a correlation between toothbrushing
technique and the formation of abfractions are the
frequency of toothbrushing and mouth side.
Although this study recorded the frequency of
toothbrushing only through a short screening ques-
tion, we found it to be correlated with abfractions.
Although it is not clear if this association is caused by
the toothbrush alone or is based on the abrasive effect
of toothpaste, earlier epidemiological studies also
found correlations between heightened oral hygiene
awareness and abfractions (28). Sangnes and Gjermo
(9) found that those subjects who brushed more than
twice a day showed a high frequency of wedge-shaped
lesions. In addition, Poynter and Wright (49) observed
abfractions significantly more often in patients with
good oral hygiene. Addy and Hunter (50) assumed
that the toothbrush alone has no or little effect on
enamel and dentine. They argued that the kind of
toothpaste in combination with an erosive challenge is
the crucial influence for the development of erosive
lesions.
In the present study, no side-dependence of abfrac-
tions was found. Neither the prevalence of wedge
shaped defects nor the regression model displayed a
dominance of the left side of the mouth. The theory
behind this observation is a higher brushing force
exerted by right-handed persons on the teeth of the left
side of the mouth (5, 51, 52).
In conclusion the results of this risk analysis – based
on a population-based subject group – indicated that
abfractions are associated with occlusal factors, like
occlusal wear, inlay restorations, altered tooth position
and tooth brushing behaviour. Abfractions are already
detectable in young adults, and the estimated risk of
developing such defects increases with age. Maxillary
and mandibular first and second premolars are most
frequently affected by abfractions.
Acknowledgments
This study is part of the Community Medicine
Research net (CMR) of the University of Greifswald,
Germany, which is funded by the Federal Ministry of
Education and Research (grant no. ZZ9603), the
Ministry of Cultural Affairs as well as the Social
Ministry of the Federal State of Mecklenburg – West
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 17–25
Pomerania. This paper was supported by a fellowship
from the Alfried Krupp von Bohlen and Halbach-
Foundation, Germany.
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Correspondence: Dr Olaf Bernhardt, Department of Restorative
Dentistry, School of Dentistry, University of Greifswald, Rotgerberstr.
8, 17487 Greifswald, Germany.
E-mail: obernhar@uni-greifswald.de