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Abfractions and Attachment Loss in Teeth With Premature Contacts in

Centric Relation: Clinical Observations

Article  in  Journal of Periodontology · December 2009

DOI: 10.1902/jop.2009.090149 · Source: PubMed

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J Periodontol • December 2009

Abfractions and Attachment Loss in

Teeth With Premature Contacts in
Centric Relation: Clinical Observations
Elio Reyes,* Charles Hildebolt,† Eric Langenwalter,‡ and Douglas Miley§

Background: It has been suggested that eccentric occlusal

forces may be an etiologic factor for abfraction lesions. It has
also been suggested that traumatic occlusal forces may have
a damaging effect on the periodontal tissues. The purpose of
this study was to determine whether associations were present
between premature contacts in centric relation (PCCR), clini-
cal attachment loss, and abfraction lesions.

I
t has been suggested that traumatic
Methods: Forty-six subjects were examined. Within sub- occlusal forces may be a risk factor
jects, the mean attachment loss was determined for teeth for periodontal disease and attach-
with and without PCCR and for teeth with and without abfrac- ment loss.1,2 Although it is well recog-
tions. In addition, teeth with PCCR (experimental group) nized that the primary etiologic agent
were matched with contralateral teeth without PCCR (control responsible for periodontal diseases is
group). Comparisons between groups were made with the the inflammatory response elicited by
Wilcoxon signed rank test, Wilcoxon rank sums test, and the bacteria in the dental biofilm,3,4 other
Spearman r correlation coefficient. factors such as age, genetics, smoking,
Results: The results demonstrated that attachment loss in- medications, hormonal changes, and poor
creased with age. Within subjects, teeth with abfraction lesions nutrition are thought to increase the risk,
had significantly more buccal attachment loss than teeth with- severity, and speed of development of
out abfraction lesions (P <0.01). The majority of abfractions periodontal diseases.5 However, there
and PCCR occurred in premolars. The presence of PCCR had is no consensus regarding the effect of
no influence on the appearance of an abfraction lesion or in- occlusal forces on the periodontium.
creased attachment loss. Similarly, subjects who exhibited Prospective studies on the effect of oc-
abfractions had similar attachment loss as those subjects clusal forces on the progression of peri-
without abfraction lesions. odontitis are not ethically acceptable in
Conclusions: Within the same patient, teeth with abfrac- humans;2,6 however, there have been
tions presented more attachment loss than those without some clinical studies7-11 for which as-
abfractions. However, associations were not demonstrated sociations between occlusal discrep-
between PCCR and the presence of abfractions or increased ancies and periodontal destruction were
attachment loss. Future studies are needed to improve the reported, particularly in response to
knowledge regarding interactions among occlusal factors, at- treatment. Other studies12,13 found no
tachment loss, and abfractions. J Periodontol 2009;80:1955- association.
1962. Excessive occlusal forces have also
been associated with tooth flexure, caus-
KEY WORDS
ing mechanical microfractures and tooth
Dental esthetics; dental occlusion; diagnosis; gingival substance loss at the cervical area pre-
recession; malocclusion; risk factors. senting a characteristic pattern of dental
substance loss at the cemento-enamel
junction (CEJ).14,15 These lesions result
* Department of Periodontics, School of Dental Medicine, Southern Illinois University,
Alton, IL. from the impact of tensile stress from
† Mallinckrodt Institute of Radiology, School of Medicine, Washington University in Saint mastication and maloclussion on affected
Louis, St. Louis, MO.
‡ Department of Information Technology, School of Dental Medicine, Southern Illinois teeth and are typically present as v-shaped
University.
§ Graduate Periodontics, Center of Advanced Dental Education, Saint Louis University,
wedges with sharp contours.16 From a
St. Louis, MO. biomechanical standpoint, loading forces

doi: 10.1902/jop.2009.090149

1955
Abfractions, Attachment Loss, and Premature Contacts in Centric Relation
acting at the cervical level may cause the failure of the
enamel prisms and result in a pathologic loss of tooth
structure termed abfraction.15 It is likely that abfrac-
tion lesions, combined with chemical erosion, may
decrease the wear resistance of the cervical hard
tissues to mechanical abrasion from toothbrushing,
resulting in additional loss of tooth structure.17-19
These lesions are different from those caused by a car-
ious lesion and are termed non-carious cervical le-
sions (NCCLs). The prevalence of NCCLs may be
as high as 85%; however, their etiology remains un-
clear.20
Premature contacts in centric relation (PCCR) oc-
cur when the jaw closes into a physiologic position
and is deviated to a functional position where maxi-
mum tooth contact occurs. This movement can be
reproduced by manipulating the mandible to its
most posterior and superior position and bringing it
to its first contact with the maxilla, thus locating the
PCCR.21 A centric-relation/centric-occlusion slide
occurs as the prematurely contacting surfaces slide
past each other and the teeth move to maximum inter-
cuspation. Such a slide causes eccentric forces to be
transmitted through the tooth to the cervical area and
periodontal tissues and could eventually result in the
formation of NCCLs, localized attachment loss, or
both.14,22-24 The purpose of this study was to deter-
mine the extent to which associations exist between
PCCR and abfraction lesions and clinical attachment
loss.
MATERIALS AND METHODS
This study was approved by the Southern Illinois Uni-
versity Edwardsville Institutional Review Board, and
written informed consent was obtained from each en-
rolled subject. From October 2004 to December
2005, patients presenting to the School of Dental
Medicine at Southern Illinois University for compre-
hensive dental care and dental students in their senior
year were invited to participate if they met the inclu-
sion criteria. Individuals included in the study were
‡18 years of age, dentate with 10 pairs of opposing
teeth, and had a current, full-mouth radiographic se-
ries. Exclusion criteria included occlusal equilibration
and periodontal therapy other than routine prophy-
laxis in the 2 years prior to the study, removable par-
tial dentures, and/or a history of orthodontic therapy.
Further, pregnant patients or those classified accord-
ing to the American Society of Anesthesiology25 as
risk class III or higher were excluded.
The evaluation included a screening appointment
and a thorough dental, occlusal, and periodontal ex-
amination. All teeth in each patient’s mouth were
evaluated. Third molars were excluded because most
subjects did not have four fully erupted third molars.
Information regarding occlusion and temporo-
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Volume 80 • Number 12
mandibular joint pathology was collected, including
history, load testing, occlusal habits, bruxism auscul-
tation, and palpation. Periodontal measurements
were performed using a Williams probei on the facial
aspect of each tooth. Tissue height was considered to
be the distance from the gingival margin to the CEJ as
detected with the probe; this number was recorded as
positive if the gingival margin was coronal to the CEJ
and negative if the gingival margin was apical to the
CEJ. Tissue height was recorded as zero when the gin-
gival margin was at the same level as the CEJ. The at-
tachment level was determined by subtracting the
tissue height from the probing depth. If the CEJ could
not be located, the clinician (ER) used the best judg-
ment in estimating its location using landmarks on the
tooth (such as restoration margins or change in color
or texture between enamel and cementum). All cervi-
cal lesions deemed to be of non-carious origin were
termed abfractions. Abfractions were detected,¶ and
their location and shape were documented. Special
attention was placed on differentiating the shape of
the NCCLs to include only abfraction-type lesions ap-
pearing as a sharp, wedge-shaped loss of dental struc-
ture16 and further differentiating them from abrasive
or erosive lesions that may appear more rounded
and wider20 (Fig. 1). Lesions that clinically appeared
to be from abrasive or erosive etiology were excluded.
Each patient was bimanually manipulated into cen-
tric relation as described by Dawson.21 In short, the
tips of the thumbs were placed on the chin, stabilizing
the mandible and preventing tooth contact. The angle
of the mandible was cradled between the last two
fingers, with the rest of the fingers together on the in-
ferior border creating an upward force, thus position-
ing the condyles in their most superior position. The
centric-relation hinge position was confirmed by the
absence of tension or tenderness in either joint after
load testing by increasing the pressure from light to
very firm.26,27 After the manipulation by the first exam-
iner (ER), the results were confirmed by a second ex-
aminer (EL), who was masked to the periodontal
findings. Patients who could not be accurately manip-
ulated at the first attempt were deprogrammed by us-
ing a smooth, flat, anterior bite plane (wood tongue
blades) to completely separate all posterior tooth con-
tact for 10 minutes, allowing the lateral pterygoid mus-
cle to release any hypercontraction.26,27 PCCR were
detected and confirmed with the use of double-sided
red/black occlusal marking film# and recorded. Laptop
computers and a wireless network were used to enter
data into an encrypted, password-protected database.
Clinical attachment loss (facial aspect), PCCR, and
abfractions were determined for 46 subjects. Teeth
i Hu-Friedy, Chicago, IL.
¶ EXD 11-12 Explorer, Hu-Friedy.
# Accufilm II, Parkell, Edgewood, NY.
J Periodontol • December 2009
Figure 1.
Diagram illustrating different patterns of cervical dental structure loss. A) Abfraction lesion:
sharp, wedge-shaped loss of dental structure. B) Abrasion lesion: wide, rounded, dish-shaped
loss of dental structure. C) Erosion: wide, flat, rounded loss of dental structure.
with PCCR were matched with contralateral teeth
without premature contacts and served as controls.
To the greatest possible extent, molars, premolars,
canines, and incisors were matched with the same
teeth from the contralateral side. If the same contralat-
eral tooth could not be used, an equivalent tooth of the
same type was used. When a contralateral tooth of the
same type could not be used, the pair was excluded.
Using sites or teeth as the unit of measurement
for statistical analyses would violate the assumption
of independence required for statistical testing; there-
fore, the unit of analysis was the subject. Within sub-
jects, mean attachment loss was determined for
teeth with and without PCCR and for teeth with and
without abfractions. The resulting data distributions
were tested for normality with the Shapiro-Wilk W test
and were non-normal (Shapiro-Wilk W test; P <0.05).
The non-normal distributions were mostly attributable
to the inclusion of students who were young and had
little or no attachment loss. For this same reason, dis-
tributions for age were also non-normal (Shapiro-Wilk
W test P <0.05). Therefore, central tendencies were in-
dicated with medians and ranges, and comparisons
between groups were made with the Wilcoxon signed
rank test, Wilcoxon rank sums test, and Spearman r
correlation coefficient. Alpha for all statistical testing
was set at 0.05.
RESULTS
A summary of the results for the different comparisons
is outlined in Figure 2. Forty-six subjects participated
in the study providing a total sample of 1,174 teeth. Of
the subjects, 32 were female with an age range of 23 to
82 years. Of the 46 subjects, two (ages 45 and 82
Reyes, Hildebolt, Langenwalter, Miley
years) did not have PCCR. The remain-
ing 44 subjects had teeth both with and
without PCCR (median: two; range: one
to nine; median age: 45 years; range: 23
to 78 years). The majority of the prema-
ture contacts occurred in premolars
(49.1%; 58/118) and primarily first pre-
molars (29.6%; 35/118), followed by
first and second molars (21.1%; 25/
118) and second premolars (19.5%;
23/118) (Table 1).
Attachment loss was not a common
finding in the present sample. Of the
1,174 teeth studied, 80% had <2 mm
attachment loss. The median attach-
ment loss per subject for teeth with
and without PCCR was 1.00 mm (range:
0.00 to 6.00 mm) and 0.89 mm (range:
0.00 to 4.29 mm), respectively. The
median difference was -0.03 mm
(range: -3.42 to 1.00 mm; Wilcoxon
signed rank test; P = 0.07; Fig. 3A). At-
tachment loss was associated with age (Spearman
r = 0.50; P <0.01), but neither attachment loss
(Spearman r = -0.03; P = 0.85) nor age (Spearman
r = -0.22; P = 0.15) was associated with the number
of PCCR.
Twenty-three (median age = 45 years [range: 23 to
82 years]) of the 46 subjects did not have abfractions
and had a median attachment loss of 0.70 mm (range:
0.04 to 4.32 mm). The 23 subjects with abfractions
(median age = 48 years [range: 23 to 78 years], had
a median attachment loss of 1.15 mm (range: 0.00
to 3.29 mm). The differences in ages and attachment
loss between these two groups were not significant
(Wilcoxon rank sums test; P = 0.68 and 0.30, respec-
tively). For these subjects who had abfractions, the
median number of abfractions per subject was five
(range: one to 14), and for these teeth, the median at-
tachment loss was 2.00 mm (range: 0.00 to 5.00 mm).
For these 23 subjects, the median attachment
loss on teeth without abfractions was 0.95 mm
(range: 0.00 to 3.18 mm). The median difference
was -0.67 mm (range: -2.46 to 0.13 mm; Wilcoxon
signed rank test; P <0.01; Fig. 3B). For the 23 sub-
jects with abfractions, age and attachment loss were
correlated (Spearman r = 0.56, P <0.01), but neither
attachment loss (Spearman r = 0.13; P = 0.55) nor
age (Spearman r = 0.37; P = 0.08) was associated
with the number of teeth with abfractions. Of all the
teeth with abfractions in both arches, 45.6% were
premolars (57/125). The teeth with the most abfrac-
tions were first premolars 29.6% (37/125) followed
by canines 16.8% (21/125) (Table 1).
There were only seven subjects presenting both
PCCR and abfractions. The attachment level was
1957
Abfractions, Attachment Loss, and Premature Contacts in Centric Relation Volume 80 • Number 12

Figure 2.
Outline of group comparisons. CR- = absence of PCCR; CR+ = presence of PCCR; AB- = absence of an abfraction lesion; AB+ = presence of an abfraction
lesion; AB & CR+ = presence of an abfraction lesion and PCCR on the same tooth; m#CR = median number of PCCR; m#AB = median number of teeth with
abfractions; mAL = median attachment loss; NS = not statistically significant (P >0.05).

Table 1.
Frequency Distribution of Teeth With Abfractions (AB) and PCCR (CR)

2nd M 1st M 2nd P 1st P Can Lat Cen Total

CR AB CR AB CR AB CR AB CR AB CR AB CR AB CR AB

Maxillary
Right 4 4 5 4 6 5 6 8 2 2 0 2 0 3 23 28
Left 7 1 8 8 4 7 14 13 2 9 1 3 0 2 36 43
Total 11 5 13 12 10 12 20 21 4 11 1 5 0 5
Mandibular
Left 9 0 6 2 6 2 11 8 2 5 0 4 0 4 34 25
Right 5 0 6 3 7 6 4 8 3 5 0 3 0 4 25 29
Total 14 0 12 5 13 8 15 16 5 10 0 7 0 8

Total 25 5 25 17 23 20 35 37 9 21 1 12 0 13 118 125

M = molars; P = premolars; Can = canines; Lat = laterals; Cen = centrals.

similar in teeth without PCCR or abfractions, teeth with
only abfractions, teeth with only PCCR, and teeth with
both abfractions and PCCR. Of the six possible com-
parisons of attachment loss for these teeth, none of
the differences were significant (Wilcoxon signed rank
test; P >0.31; Fig. 4).
For 43 of 46 subjects, it was possible to match
a tooth with PCCR with a tooth on the opposite side
that did not have PCCR. The median attachment loss
for teeth with or without PCCR was 1.00 mm (range:
0.00 to 6.00 mm and 0.00 to 5.50 mm, respectively).
The median difference between these two matched
values was 0.00 mm (range: -2.00 to 2.00 mm;
Wilcoxon signed rank test; P = 0.74). Attachment loss
for teeth with and without PCCR was correlated with
age (Spearman r = 0.41; P <0.01), and the two sets
of attachment-loss measurements were correlated
with each other (Spearman r = 0.83; P <0.01).
The median number of abfractions for teeth with
and without PCCR was zero (range: 0.0 to 1.0), and
the median difference was zero (range: -1.0 to 0.5;
Wilcoxon signed rank test; P = 0.27). The number of

1958
J Periodontol • December 2009
Figure 3.
A) Box plots of attachment loss for teeth with and without PCCR for 44 subjects. B) Box plots of attachment loss for teeth with and without abfractions for
23 subjects with abfractions.
Figure 4.
Box plots of attachment loss for teeth with and without PCCR (CR) and
with and without abfractions (AB) for seven subjects.
abfractions for teeth with and without PCCR was not
correlated with age (Spearman r = 0.27, P = 0.08
and Spearman r = 0.18, P = 0.25, respectively), but
the numbers of abfractions on the two sets of teeth
were correlated with each other (Spearman r = 0.71;
P <0.01).
DISCUSSION
The data from this cross-sectional sample were ana-
lyzed for associations between PCCR and the pres-
ence of clinical attachment loss and abfraction
lesions. First, teeth with occlusal interferences were
analyzed within the whole mouth; second, a subsam-
ple of teeth with occlusal prematurities was compared
to corresponding teeth on the contralateral side.
The sample included individuals seeking dental
care and dental students who were considered to have
high dental intelligence quotients. This may have in-
Reyes, Hildebolt, Langenwalter, Miley
troduced a bias related to gingival and periodontal
health. In addition, the ages of the dental students were
below the median age for the sample; nevertheless,
the sample consisted of 46 patients between the ages
of 23 to 82 years with a median age of 45 years that
coincided with the mean age.
In a longitudinal study,1 patients were followed for
28 years, and changes in attachment level were eval-
uated in an adult population. The authors reported
that increased age, smoking, and tooth mobility were
the factors most closely associated with attachment
loss. Unfortunately, occlusion was not specifically
evaluated in that study. In the present study, a trend
for increased attachment loss with increased age
was observed, regardless of the presence or absence
of PCCR.
It has been reported that age is the only statistically
significant variable in comparisons of patients with
and without occlusal discrepancies, with older pa-
tients having fewer occlusal discrepancies.11,28 Older
subjects may have eliminated the PCCR by attrition of
contact points over time, loss of teeth, or tooth move-
ment due to occlusion or periodontal disease. The
present study had a similar finding: PCCR were more
common in younger subjects; nonetheless, this trend
was not statistically significant. Furthermore, when
analyzing the effect of age on attachment loss in
the presence or absence of PCCR, there was a statisti-
cally significant increase in attachment loss with age
at the patient level; however, when age was controlled
in the model, PCCR had no significant effect on attach-
ment loss.
A coincidental centric relation and centric occlu-
sion is a rare finding. A study reporting the occlusal
and periodontal condition of 66 adults found a dis-
crepancy in almost 80% of the patients.29 In the pres-
ent study, only two subjects (4.4%) had coincidental
1959
Abfractions, Attachment Loss, and Premature Contacts in Centric Relation
centric relation and centric occlusion. At the tooth
level, 10.0% of teeth presented with centric-relation
prematurities. The majority of these contacts oc-
curred in premolars, more specifically first premolars.
This is in agreement with another report29 in which
first premolars had a greater frequency of PCCR.
A study12 investigating the association of occlusal
trauma and periodontitis in maxillary first molars
from patients with occlusal disharmonies showed no
difference in the periodontal parameters related to
teeth with or without occlusal discrepancies. Simi-
larly, another report29 found that teeth with centric,
non-functional and protrusive contacts had no signif-
icant differences in probing depths compared to
other teeth. The present study had similar findings re-
garding the effect of occlusal disharmonies on the
periodontium; nearly 80% of the teeth with PCCR
presented with <2 mm of attachment loss. This was
almost identical to the attachment loss on teeth with-
out PCCR.
In an attempt to determine the association between
signs of trauma from occlusion and the severity of
periodontitis, PCCR and other occlusal discrepancies
were analyzed in 32 patients.13 No association was
found among probing depths, attachment loss, or
bone height between teeth with normal or abnormal
occlusal contacts. However, the authors observed
that teeth with occlusal trauma had less bone support,
which was more noticeable as attachment loss in-
creased and suggested that trauma from occlusion
was positively related to the loss of support in patients
with moderate-to-advanced chronic periodontitis. In
the present study, teeth with PCCR were identified
and matched with contralateral teeth without cen-
tric-relation prematurities. Using the patients as their
own controls allowed the use of paired comparisons.
Special attention was placed on matching the controls
to the contralateral tooth of the same type to minimize
any effects of different occlusal schemes, tooth posi-
tion, or any other patient factors. The present findings
agree with those of an earlier study13 showing that the
mean attachment loss was not significantly different
between teeth with or without centric-relation con-
tacts. However, the study13 did not find an increase
in attachment loss on teeth with occlusal trauma. A
possible explanation for this is that subjects in the
earlier study13 had more severe periodontal condi-
tions. In the present study, half of the teeth had no at-
tachment loss, and 80% presented with <2 mm
attachment loss. The low level of attachment loss in
the current sample may have masked any effect of
centric-relation prematurities.
A wide range on the prevalence of NCCLs was
reported.20 In a study with a fairly large sample
(10,827 extracted teeth), the prevalence was 18%.30
In this study, an attempt was made to include only
1960
Volume 80 • Number 12
those NCCLs appearing as abfraction lesions. The
term abfraction implies an occlusal component; such
lesions are considered to be more wedge shaped
and less rounded,16 which is not the appearance asso-
ciated with lesions from an abrasion or erosion;20
however, because NCCLs may be the result of a com-
bination of several factors,31-33 identifying the lesions
based on their appearance is not completely objec-
tive. In the present study, half of the patients had at
least one abfraction lesion, and at the tooth level,
10% of the teeth presented abfractions. Various au-
thors17,34 analyzed the prevalence of NCCLs in dental
students and determined associations of NCCLs with
occlusal pathology and increased age. In one of the
reports,17 almost 50% of the students had at least
one NCCL and a pattern of occurrence similar to the
present study. Even though older patients had a ten-
dency for having more abfractions in this study, the
correlation with age was not statistically significant.
In addition, only 1.8% of the teeth had simultaneously
occurring abfractions and PCCR.
The present study did not account for wear facets.
Wear facets may be an indicator of occlusal trauma;35
nevertheless, no strong correlation has been found
between occlusal wear and NCCLs.36 In the present
study, after evaluating teeth with PCCR and their con-
trols, it was clear that the majority of teeth had no
abfractions regardless of the occlusal pattern, dem-
onstrating no significant difference in the presence
of abfractions between teeth with or without PCCR.
A study37 investigating the relationship between
PCCR and other occlusal discrepancies in teeth with
and without NCCLs found a statistically significant
correlation between the prevalence of NCCLs and
premature occlusal contacts. The present study found
the same distribution for NCCLs and PCCR at the
tooth level (first premolars); however, no correlation
was found between NCCLs and PCCR. This difference
may be explained by the way the data were analyzed.
In the previous study,37 multiple teeth from all pa-
tients were treated as the unit of measurement. This
artificially inflated the sample size and increased the
likelihood of finding a significant result. In the present
study, mean attachment loss per subject was deter-
mined for teeth with and without PCCR and for teeth
with and without abfractions, with the unit of analysis
being the subject.
To analyze the etiologic factors for NCCLs, it is im-
portant to consider the abrasive effects of toothbrush-
ing on the dental structures. A cross-sectional study23
found that teeth with abfractions often exist in mouths
presenting with plaque and calculus, whereas the oc-
currence of gingival ulceration is rare. This confirmed
observations from another study16 in which no evi-
dence was found that toothbrushing was an etiologic
factor for abfraction lesions. In the statistical analyses
J Periodontol • December 2009
of the present study, plaque scores, brushing tech-
nique, and gingival trauma were not accounted for.
In general, the patients presented good overall oral
hygiene and, although the effect of oral hygiene mea-
sures cannot be ruled out, only narrow, sharp, wedge-
shaped cervical lesions were recorded as abfractions:
lesions were not counted that resembled abrasions or
erosions (typically, abrasions present as broad smooth
lesions with well defined margins, and erosion presents
as shallower, dish-shaped, rough lesions with less de-
fined margins).16,20,24 From the present observations,
it is not possible to identify the etiologic factors that
cause abfractions. It is clear that abfraction lesions
are associated with buccal attachment loss; however,
the order of appearance between the two cannot be de-
termined; that is, it is possible that an abfraction lesion
leads to buccal attachment loss, and it is also possible
that buccal attachment loss makes the tooth surface
more susceptible to abrasion or abfraction.
Bimanual manipulation was used in this study to
locate the PCCR. The reliability of accurately iden-
tifying PCCR through patient manipulation may be
questioned; however, bimanual manipulation is con-
sidered a reliable and consistent technique to position
the mandible in centric relation and, hence, accu-
rately locate any PCCR.21,26,27 Moreover, compared
to more complex methods for positioning the mandi-
ble in centric relation, the clinical differences appear
to be insignificant.38 It is recognized that a temporo-
mandibular disorder may prevent an accurate manip-
ulation into centric-relation position. Load test during
bimanual manipulation may be painful in the presence
of a temporomandibular disorder,26,27 however, an
assessment of temporomandibular disorder was out
of the scope of this study; nevertheless, none of the pa-
tients reported any symptoms that could lead to sus-
pecting any temporomandibular joint pathology.
The findings from the present study should be inter-
preted with caution. One of the major limitations of
this study is that it is cross-sectional. Collecting data
from a single point in time does not allow for an as-
sessment of disease activity or progression. More-
over, the sample size may not allow a complete
analysis of the effects of occlusion, particularly when
considering that only a small number of subjects pre-
sented with both PCCR and abfractions.
CONCLUSIONS
The results demonstrate that clinical attachment loss
significantly increased with age regardless of the pres-
ence or absence of abfraction lesions or PCCR. In pa-
tients with abfractions, greater attachment loss was
observed in the teeth that had abfraction lesions,
and the difference in attachment loss between teeth
with or without abfractions was statistically signifi-
cant. Most of the abfractions occurred in premolars,
Reyes, Hildebolt, Langenwalter, Miley
mostly in first premolars. Even though patients with
abfraction lesions were slightly older, the differences
in age and attachment loss between patients with or
without abfractions were not significant. Most of the
PCCR occurred in premolars, mostly in first premo-
lars; however, neither attachment loss nor age was as-
sociated with the presence of PCCR contacts.
This study did not find an association between
PCCR and the presence of abfractions or attachment
loss. Future studies are needed to improve the knowl-
edge regarding interactions between occlusal factors,
attachment loss, and abfractions.
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this study.
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Correspondence: Dr. Elio Reyes, Department of Periodon-
tics, School of Dental Medicine, Southern Illinois Univer-
sity, 2800 College Ave., Bldg. 285, Alton, IL 62002. Fax:
618/474-7124; e-mail: ereyesr@siue.edu.
Submitted March 17, 2009; accepted for publication July
16, 2009.