Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2013; 58: 306–314

doi: 10.1111/adj.12084

Non-carious cervical lesions: influence of morphology and

load type on biomechanical behaviour of maxillary incisors
PV Soares,* PCF Santos-Filho,† CJ Soares,† VLG Faria,* MF Naves,* JA Michael,‡
JA Kaidonis,‡ S Ranjitkar,‡ GC Townsend‡
*Nucleus of Extension, Research and Teaching of NCCL, Operative Dentistry and Dental Materials Department, School of Dentistry, Federal
University of Uberlandia, Brazil.
†Operative Dentistry and Dental Materials Department, School of Dentistry, Federal University of Uberlandia, Brazil.
‡School of Dentistry, The University of Adelaide, South Australia.

ABSTRACT
Background: The aim of this study was to measure the effect of simulating two different loads on maxillary incisors dis-
playing eight morphological types of non-carious cervical lesions, unrestored and restored with an adhesive restoration,
by quantifying the stress distributions generated using finite element analysis.
Methods: Virtual models of maxillary incisors were generated using the CAD software (RhinoCeros). After composing
virtual dental and supporting structures with and without non-carious cervical lesions, each model was meshed using a
control mesh device (ANSYS Finite Element Analysis Software). All of the virtual models were subjected to two load
types, oblique load and vertical load, to simulate occlusal forces of 100 N each. Comparisons were made between simu-
lated teeth with non-carious cervical lesions, with and without composite resin restorations, and a simulated sound
tooth. Data summarizing the stress distributions were obtained in MPa using von Mises criteria.
Results: Oblique loading on simulated non-carious cervical lesions resulted in greater stress concentration compared with
vertical loading, and non-carious cervical lesions with acute angles displayed higher stress concentrations at the depth of
the lesion. Restoring the lesions with an adhesive restoration, such as composite resin, appeared to overcome this stress
concentration.
Conclusions: Restoring NCCLs with adhesive restorative materials, such as a nanohybrid composite resin, appears to
recover the biomechanical behaviour similar to sound teeth.
Keywords: Biomechanical behaviour, composite resin, finite element analysis, non-carious cervical lesion, teeth.
Abbreviations and acronyms: FEA = finite element analysis; GIC = glass ionomer cement; NCCLs = non-carious cervical lesions.
(Accepted for publication 7 November 2012.)

abrasion have been implicated definitely.5 In addition,

INTRODUCTION
Non-carious cervical lesions (NCCLs) are formed by
loss of tooth structure in the cervical third of the
crown and root surface that is unrelated to dental car-
ies.1,2 It is generally accepted that the lesions are not
generated by a single factor but result from a combi-
nation of factors.1,3,4 Among the factors proposed to
be related to the formation and progression of NCCLs
are: biocorrosion (chemical, biochemical and electro-
chemical degradation) caused by intrinsic and extrin-
sic acids; friction (wear) caused by traumatic
brushing; and possibly stresses (abfraction) caused by
parafunction, traumatic occlusion and load applica-
tion.4 It is most probable that not all of these factors
are involved in any particular case, but more likely
only a small number. So far, erosion and toothbrush
306
reports of NCCLs developing on teeth that did not
have an opposing tooth for many decades add to the
controversy surrounding the aetiology of these
lesions.6 NCCLs are usually diagnosed based on a
detailed history, visual inspection and tactile examina-
tion.1 It has been proposed that a major factor con-
tributing to the progression of NCCLs is a high level
of loading associated with occlusal forces.7,8 Two
types of loading on maxillary incisors have been
described,8 one being an oblique type (due to oblique
or inclined contact with the lingual surface) and the
second a vertical load (along the long axis of the
tooth, applied via the incisal edge).
Several studies have examined the characteristics of
NCCLs, such as which teeth show greater involve-
ment and the extent of damage, through subjective
© 2013 Australian Dental Association

observations and also using scanning electron micros-
copy.5,9,10 Michael et al.11 proposed a classification
for NCCLs based on their morphological appearance,
following an analysis of more than 15 000 extracted
anterior teeth. These researchers catalogued and
defined eight different morphological types of NCCLs
in anterior teeth.
The selection of appropriate direct restorative mate-
rials for NCCLs involves consideration of aesthetics,
presence of dentinal hypersensitivity and the amount
and state of remaining tooth structure. Restorative
materials, such as glass ionomer cement, resin-modi-
fied glass ionomer, flowable composites, and micro
and nanohybrid composite resins, may be used to
restore NCCLs.1,12 Finite element analysis (FEA) has
been shown to be a useful method for measuring
stress distributions in teeth and restorations in
response to various loads, and it is possible to model
the responses of different dental tissues to load appli-
cation, taking account of their biological proper-
ties.3,8,13,14
We hypothesize that the biomechanical behaviour
of maxillary central incisors will differ depending on
the morphology of the NCCL present on the tooth,
the presence of a composite resin restoration, and the
type of load applied. Therefore, our objective was to
simulate the influence of an adhesive restoration, such
as a nanohybrid composite resin, and two types of
load application (oblique and vertical) on maxillary
incisors with eight different NCCL morphologies, by
analysing the stress distribution patterns using the
finite element method.
MATERIALS AND METHODS
Two-dimensional elastic linear analysis was per-
formed using anatomically based geometric represen-
tations for the dentine, pulp, enamel, periodontal
ligament, cortical bone and trabecular bone.15 We
simulated eight NCCL morphologies: concave (CO),
three types of irregular form (IR1, IR2 and IR3),
notched (NO), two types of shallow form (SH1 and
SH2), wedged-shape (WS) and also a sound model
(SO), according to the classification system of
Michael et al.11 (Fig. 1).
Fig. 1 2D-finite element models representing NCCL morphologies: SO = sound, CO = concave, IR1 = irregular (with acute internal angles), IR2 = irregular
(with rounded internal angles), IR3 = irregular (with acute and rounded internal angles), NO = notched, SH1 and SH2 = shallow and WS = wedge-shaped.
© 2013 Australian Dental Association
Biomechanical behaviour of NCCLs
The external and internal contours of enamel, den-
tine, pulp, periodontal ligament space, cortical and
trabecular bone were generated by CAD Software
(RhinoCeros 3D, McNeel, USA) based on the anatom-
ical geometry of the maxillary central incisor. These
contours were made by point and line association
using a polyline module of CAD software. The areas
corresponding to each structure were created using
the biomechanical analysis software ANSYS 12.0
(ANSYS Inc., Houston, USA). With this software, the
following steps were performed: the pre-process step
(area definition, mechanical properties insertion,
boundary conditions and mesh creation of each struc-
ture), process step (data calculation) and post-process
step (results analysis by stress distribution criteria).
The data obtained were exported to ANSYS 12.0
using the IGES format. Areas corresponding to each
structure were meshed with controlled and connected
elements. The meshing process involved division of
the system to be studied into a set of small discrete
elements defined by nodes. The number of elements
generated varied depending on the different geome-
tries that were meshed, so that the final model accu-
rately represented the original geometry. The
isoparametric elements of eight nodes with three
degrees of freedom per node (plane 183) were used
according to the mechanical properties of each struc-
ture (Fig. 2). The values for mechanical properties
were obtained by means of a literature review and are
listed in Table 1. For this initial analysis, all of the
dental structures and the restorative material in the
models were considered to be homogeneous and iso-
tropic, displaying linear elastic properties.
The nanohybrid composite resin restorations were
simulated in all models16 (Fig. 3). The restorations
were bonded by mesh connection with dentine and
enamel, simulating an adhesive hybrid layer (Fig. 3).
The step of establishing boundary conditions consisted
of developing a displacement/restriction model with
load application. Model displacement of all nodes on
the lateral surface and base of the cortical bone were
constrained (Fig. 2). Two load types were applied on
the nodes: vertical load (VL) and oblique load (OL),
simulating occlusal forces on the palatal surface of an
incisor during clenching (in maximum intercuspation)
307
PV Soares et al.

(a) (b) (c) (d)

(e) (f) (g) = displacement restriction

Oblique Load - 100N Vertical Load - 100N

Fig. 2 Model generation and boundary conditions. (a) Outlines in CAD software; (b) Outlines in FEA software; (c) Areas of each dental and support
structure; (d) Meshes of each area; (e) Oblique load region; (f) Vertical load region and (g) Displacement restriction lines.

Table 1. Mechanical properties of dental hard tissues, In the dual centre morphologies (IR1, IR2, IR3 and
supporting periodontal tissues and a nanohybrid SH2), there was more stress concentration in the cer-
composite resin material used to perform linear elas- vical centre of the NCCL. The lesions IR1 and WS
tic FEA models had stress levels above 100.0 MPa. Lesions CO, IR2,
IR3 showed high stress levels above 40.0 MPa. The
Structure Elasticity modulus Poisson Reference
(MPa) ratio lesion SH2 presented a stress level of 25.8 MPa
(Fig. 7).
Enamel 46800 0.30 16
Dentine 18600 0.31 14
The VL model was associated with lower levels of
Pulp 2 0.45 14 stress concentration than the OL model (Fig. 8).
Periodontal ligament 68.9 0.45 14 NCCLs with a single centre and rounded angles, i.e.
Cortical bone 13700 0.30 14
Trabecular bone 1370 0.30 14
NO, CO and SH1, showed higher stress concentra-
Composite resin 16600 0.24 16 tions at the outer regions of the lesions. Lesions with
a dual centre had higher stress concentrations at the
cervical centre of the lesion. Lesions CO and WS had
and on the incisal edge during an incising movement.8 stress levels higher than 40.0 MPa and the lesion IR1
The value of each load was 100 N. The VL was presented stress levels above 30.0 MPa. Lesions IR2
applied down through the incisal edge, parallel to the and IR3 showed maximum stress between 10.0 and
longitudinal axis of the tooth; the OL was applied to 20.0 MPa. The lesions SH2 and SH1 showed maxi-
the palatal cingulum at 130 degrees to the longitudi- mum stress below 10.0 MPa, close to the values for
nal axis (Fig. 2). The stress distribution analyses were the SO model (Fig. 9).
recorded using the criteria of von Mises, measured in The simulated nanohybrid composite resin restora-
MPa. Five points were chosen for each NCCL, tion promoted stress dissipation in the NCCL region
according to morphology type, for analysis of specific in models with OL (Figs. 10 and 11) and VL (Figs. 12
regions (Fig. 4). and 13) similar to the behaviour of the SO model.
There was no difference in the stress distribution pat-
terns of restored NCCLs. The restored models pre-
RESULTS
sented low stress levels in the cervical regions, with
Rounded angle lesions (CO, NO, SH1, SH2, IR2) average stress values of approximately 4.0 MPa and
showed less stress concentration than acute angle 5.5 MPa for OL and VL, respectively (Figs. 11 and
lesions (IR1, IR3, WS). The OL increased the stress 13).
concentration in the cervical area, in the deep dentine
and next to pulp, while the VL promoted lower levels
DISCUSSION
of stress in the supporting structures, with more stress
concentration in the incisal enamel (Fig. 5). Our hypothesis was retained; i.e. load types, presence
For OL, points that represented the deep areas of of a nanohybrid composite resin restoration, and the
the lesion showed the highest indices of stress concen- different morphologies of NCCLs were found to be
tration (Fig. 6). NCCLs with deep and acute angles major factors that influenced the stress distribution
had the highest stress concentration (IR1, WS, IR3). pattern of maxillary incisors, when compared to
308 © 2013 Australian Dental Association
 Biomechanical behaviour of NCCLs

(a) (b) (c)

COR IR1R IR2R IR3R

NOR SH1R SH2R WSR

Fig. 3 Composite restorations in an NCCL. (a) Composite resin area; (b) Mesh of restoration and (c) Interface composite/enamel/dentine.

(a) (b) (c)

5
4
3
5
2 5
1

4
4 3
1 1
2
2 3

Fig. 4 Specific points chosen for quantitative analysis of different NCCL morphologies. (a) SO model analysis; (b) IR1, IR2, IR3 and SH2 analysis; (c)
CO, NO, SH1 and WS analysis.

MPa
0
1.6
3.2
4.8
6.4
8
8.8
10.4
12
13.6
SO/OL 15.2
16
17.6
19.2
20.8
22.4
24
24.8
26.4
28
29.6
31.2
32
33.6
35.2
36.8
SO/VL 38.4
40

Fig. 5 Stress distribution by von Mises criteria (MPa) of sound (SO) model with two load types (OL and VL). Complete models and magnification of
cervical regions are shown.
© 2013 Australian Dental Association 309
PV Soares et al.

OBLIQUE LOAD

MPa
0
1.6
3.2
CO IR1
4.8
6.4
8
8.8
10.4
12
13.6
15.2
IR2 IR3 16
17.6
19.2
20.8
22.4
24
24.8
26.4
NO SH1 28
29.6
31.2
32
33.6
35.2
36.8
38.4
SH2 WS 40

Fig. 6 Von Mises stress distribution of different NCCL morphologies with oblique load. Complete models and magnification of cervical regions are
shown.

Oblique Load
110 is 48.7 MPa.17 These values are much higher than the
100 stress values modelled in this study and, therefore, our
SO
90 modelled values are unlikely to be sufficient to cause
Von Mises Stress (MPa)

CO
80
IR1
catastrophic damage to dental tissues.
70
IR2
The VL induced high levels of stress concentration
60
IR3
in the incisal enamel and the apical aspect of the root.
50
NO In this case, the stress concentration occurs in the inci-
40
SH1 sal region because of the greater enamel thickness.
30
SH2 The high elasticity modulus (Table 1) of enamel
20
WS favours high stress concentration into its structure.
10
These models enabled estimates of stress concentra-
0
1 2 3 4 5
tion deep in the NCCLs; however, they did not allow
Fig. 7 Stress concentration at five specific points of NCCLs with obli-
aetiological factors to be assessed.
que load. When NCCLs were present, those models simulat-
ing an OL showed higher stress concentration com-
pared with VL. This behaviour is due to the direction
sound teeth. The applied loads were chosen because of the force that promotes bending of the tooth crown
they simulated two types of occlusal forces, one on because the load is inclined at 130 degrees to the long
the palatal cingulum that simulated a clenching activ- axis of the tooth. The VL was applied to the incisal
ity in intercuspal occlusion and the other on the inci- edge, and this favoured a lower dissipation of the
sal edge that simulated a biting action.8 stresses within the tooth structure because the enamel
The ultimate tensile strength value of cervical is thicker in this region and the resultant force is sub-
enamel in a perpendicular direction, measured experi- stantially parallel to the tooth long axis with the point
mentally by microtensile tests, is approximately of load application being remote from the lesion. It is
11.5 MPa; the corresponding value for superficial important to note that the simulated oblique forces
dentine is 61.6 MPa and the value for middle dentine applied in this study tended to produce compressive
310 © 2013 Australian Dental Association
 Biomechanical behaviour of NCCLs

VERTICAL LOAD

MPa
0
1.6
3.2
CO IR1 4.8
6.4
8
8.8
10.4
12
13.6
15.2
16
IR2 IR3
17.6
19.2
20.8
22.4
24
24.8
26.4
SH1 28
NO 29.6
31.2
32
33.6
35.2
36.8
38.4
SH2 WS 40

Fig. 8 Von Mises stress distribution of different NCCL morphologies with oblique load. Complete models and magnification of cervical regions are
shown.

stresses on the labial surfaces of the incisor and tensile Vertical Load
60
stresses on their palatal surfaces. However, it is still
unclear how concentrated compressive forces can 50
SO
Von Mises Stress (MPa)

cause the breakdown of dental hard tissues, especially CO

at the levels simulated. 40 IR1
SH models favoured more stress dissipation, inde- IR2
pendent of load type. It was noted that the NO 30
IR3
model presented the lowest levels of stress concentra- NO
20
tion to OL and VL, probably due to the configura- SH1
tion of its concave form. On the other hand, NCCLs 10 SH2
with acute angles had more stress accumulation in WS
the lesion’s centre due to the acute angles promoting 0
1 2 3 4 5
smaller areas for stress dissipation. This behaviour
was found at stress point 3: 108.56 MPa for WS and Fig. 9 Stress concentration at five specific points of NCCLs with verti-
cal load.
stress point 4: 109.6 MPa for IR1 (Fig. 7). This fact
was more apparent when these lesions received OL.
It is possible that the areas of stress concentration probably because this represented the fulcrum upon
observed within each morphological type of NCCL loading. WS lesions showed a concentration of stress
represent areas of susceptibility to further breakdown at the base of the lesion. However, it should be
but further studies are required to clarify this noted that the role of stress in the aetiology of
hypothesis.18 NCCLs with a single centre and NCCLs is still controversial and yet to be fully sup-
rounded angles (NO, CO and SH1) showed higher ported.1,5,19 The aforementioned theory would need
stress concentration within the outer areas of the to be supported by appropriately designed ex vivo
NCCL walls with vertical loading. In the dual centre laboratory and clinical studies of NCCL progression.
morphologies (IR1, IR2, IR3 and SH2) there was This finite element study only demonstrated the
more stress concentration in the cervical centre of major areas of high stress concentration and quanti-
the NCCL for both oblique and vertical loading, fied the effect of morphology on this process.
© 2013 Australian Dental Association 311
PV Soares et al.

MPa
OBLIQUE LOAD 0
1.6
3.2
4.8
6.4
8

COR IR1R 8.8

10.4
12
13.6
15.2
16
17.6
IR2R IR3R
19.2
20.8
22.4
24
24.8
26.4
28
NOR SH1R
29.6
31.2
32
33.6
35.2
36.8
SH2R WSR 38.4
40

Fig. 10 Von Mises stress distribution of different NCCL morphologies restored with composite resin with oblique load. Complete models and magnifica-
tion of cervical regions are shown.

Oblique Load resin-modified GIC are also commonly used to restore

7
NCCLs,23 but clinical studies show shorter longevity
Von Mises Stress (MPa)

6 COR
IR1R
5 GIC has also been considered to possess inadequate
IR2R
4 material and bond strengths in NCCLs when the
3
IR3R
NOR
2 SH1R
1 SH2R
0 WSR
1 2 3 4 5
Fig. 11 Stress concentration at five specific points of restored NCCLs
with oblique load.
Our finding of reduction in stress concentration in
NCCLs after placement of a simulated adhesive dental
material, i.e. a nanohybrid composite resin, provides
some support for its use in restoring these lesions.
Composite resin has been shown to provide good clin-
ical outcomes for longevity, aesthetics, adhesion and
biomechanical properties for various types of
cavities.12,20–22 Glass ionomer cement (GIC) and
312
for these materials compared with composite resin.22
lesions are subjected to high tensile stresses.24 Future
studies investigating stress concentration in NCCLs
using different types of adhesive materials could assist
clinicians in choosing the appropriate restorative
material. However, other issues, including ease of
access to the cavity (for light-curing purposes), mois-
ture control problems and need for fluoride release,
will need to be considered in making that decision.
Although, based on our findings, some clinicians
may consider rounding of the internal angles of
NCCLs with diamond burs rather than restoring
them. We believe that removal of sound tooth struc-
ture in the deeper parts of NCCLs would increase the
chances of pulpal irritation or mechanical pulp expo-
sure, outweighing the benefits associated with this
type of management. This approach is also contrary
to the philosophy of minimally invasive dentistry. In
© 2013 Australian Dental Association
 Biomechanical behaviour of NCCLs

MPa
VERTICAL LOAD
0
1.6
3.2
4.8
6.4
8
COR IR1R 8.8
10.4
12
13.6
15.2
16
17.6
IR2R IR3R 19.2
20.8
22.4
24
24.8
26.4
28
NOR SH1R
29.6
31.2
32
33.6
35.2
36.8
SH2R WSR
38.4
40

Fig. 12 Von Mises stress distribution of different NCCL morphologies restored with composite resin with vertical load. Complete models and magnifica-
tion of cervical regions are shown.

Vertical Load
7 of NCCLs. Also, we have performed a linear analysis,
6 COR assuming that the dental tissues display isotropic
Von Mises Stress (MPa)

IR1R properties, which is a simplification of the real situa-

5
IR2R tion. Further studies are being performed associating
4 orthotropic properties, shrinkage stresses and 3D
IR3R
3 geometry on stress concentrations in NCCLs. Future
NOR
2
FEA analyses and experimental studies incorporating
SH1R
strain gauge analysis, microscopic analyses, experi-
1 SH2R
mental fracture tests for different restorative materials
0 WSR and longitudinal clinical studies, will further serve to
1 2 3 4 5
elucidate the behaviour of NCCLs and add to the
Fig. 13 Stress concentration at five specific points in restored NCCLs
with vertical load. findings of the present study.

our opinion, the use of an adhesive restorative mate-

rial, when indicated, is a more practical and non-inva-
sive treatment of choice, since the results of this paper
prove that biomechanically the tooth affected by
NCCL when restored behaves as sound teeth.
Some important limitations of this research should
be acknowledged. This study analysed only the influ-
ence of morphology types and direction of loads on
stress concentration within existing NCCLs, not the
role of stress as an aetiological factor in the initiation
© 2013 Australian Dental Association
CONCLUSIONS
Within the limits of this study, we can conclude that
in maxillary incisors oblique loading results in greater
stress concentration compared with vertical loading
within existing NCCLs, and those NCCLs with acute
angles display the highest stress concentrations at the
depth of the lesion. Restoring NCCLs with adhesive
restorative materials, such as a nanohybrid composite
resin, appears to overcome this stress concentration
313
PV Soares et al.
whether the internal angles of the lesions are rounded
or not.
ACKNOWLEDGEMENTS
This study was supported by a grant (SAU022/12 –
FAPEMIG-Brazil) from the Minas Gerais Research
Foundation.
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Address for correspondence:
Paulo Vinıcius Soares, DDS, MS, PhD
Av Para 1720 Campus Umuarama
Uberlandia 38400-000
Federal University of Uberlandia
Minas Gerais
Brazil
Email: paulovsoares@yahoo.com.br
© 2013 Australian Dental Association