TOWNSEND, GRISWOLD, AND VERMILYEA
non-precious dental castinp alloys. J Oral Rehabil 73325.
1980.
‘0 Prttersen, .2. H., and Jacobsen, N.: Nickel corrosion of
non-precious casting alloys and cytotoxic rlfect of nickel jr!
: ziro. J Biomed Eng 2:419. 1978.
?I hioffa. J. P.. Guckerq. A. D.. Okawa, M. ‘I‘.. md Lilly, G. I<.:
:\n evaluation of non-precious alloys for use with porcelain
veneers. Part 11. Industry safety and biocompatibility. .J
PROSTHEI. DEIZ.T 30~432. 1973.
‘7
L.. Sarkar. K. K.. and Greener, E. Ii.: In N(V) corrosion resistanw
of new dental alloys. Biomarer Mrd Devices Artif Organs
l:l?l, 1973
?i ,Idrian, J. (I., and Huget, F;. F.: ‘l’tssue responsr to haw-mrtal
tlrnial allow Milit bled 141:748. 1077
Possible role of tensile stress in the etiology of
cervical erosive lesions of teeth
William C. Lee, D.D.S., M.A.,* and W. Stephan
IInivrrsity of California, School of Dentistry. San Francisco,
N oncarious loss of tooth structure in the human
dentition can be classified into the three categories of
abrasion, attrition, and erosion. Abrasion is the loss of
tooth substance through mechanical means such as
toothbrushing. Attrition is the loss of structure caused
by wear in functional and parafunctional modes, and
includes normal mastication and bruxism. Erosion is
the loss of tooth structure by chemical or idiopathic
processes. Chemical erosions are generally caused by
acids from dietary sources, the environment, and the
stomach. Idiopathic erosions are usually found in the
cervical surfaces of teeth. This article will address the
etiology of the idiopathic cervical erosions.
Idiopathic cervical lesions are frequently confused
with acid erosions and toothbrush abrasions. This is
due in part to the variable morphology of the lesions
and the lack of understanding of the etiology of the
different lesions. A number of investigators have exam-
ined the erosive effects of acids from dietary and
environmental sources on tooth structure, and some
have suggested that erosion may be related to the citrate
content of saliva. l-5Subsequent studies 6-Rthat attempted
to correlate citrate and citric acid content in the oral
environment with the occurrence of erosive lesions in
teeth have resulted in some confusion in distinguishing
*Ix~:~urcr. Department oi Resmrative Ikntistry.
** ‘Antant Professor. Department of Restornti\c I)cntistr\
374
14. Mofla, J. P., Jenkins, W. A., and Hamilton, J, C.: Five-year
clinical evaluation of two base-metal alloys. J Dent Res
60(Special issue A):405, 1981.
75. German, R. M. Wright. D. C., and Gallant, R. F: In vitro
tarnish measurements on fixed prosthodontic allovs. J PROS-
THET DENT 47599, 1987.
26. Tuccillo, J. J., and Nielsen. J. P.: Observations of onset of
sulfide tarnish on gold base alloys. J PROSTHET DENT 25629,
19’1
Eakle, D.D.S.**
Calif.
acid erosions, from idiopathic cervical erosions. Acid
erosions show tooth structure loss over a wide area with
no sharp line angles while idiopathic cervical erosions
are generally wedge-shaped defects limited to the
cervical area of teeth. Studies by Shulman and Robin-
son’ showed no correlation between citrate content and
occurrence of erosions in human beings. Furthermore,
the studies do not explain how citric acid content in the
oral fluid can affect one tooth but not the tooth next to
it. A number of studies cite toothbrush abrasion as the
possible cause of cervical erosions.‘0-12 While some
cervical lesions may be produced by abrasion from the
brush and dentifrice, others cannot be explained ade-
quately by this process alone. Some lesions probably
can be attributed to both cervical erosion and abra-
sion.
A number of other possible etiologic factors have
been suggested. Mannerberg’j looked at salivary fac-
tors in erosion and suggested that a high mucin content
prevented the precipitation of calcium phosphate that
repairs minor acid injuries to the enamel. Rost and
Brodie’” suggested that cervical erosions might be
caused by abrasion from hyperactive oral soft tissues.
ROLE OF OCCLUSAL STRESS
Observations of wedge-shaped cervical lesions may
indicate that occlusal stress on teeth is the major factor
that initiates these lesions. For lack of better terminol-
ogy, we will call the lesions cervical erosions to
SEPTEMBER 1984 VOLUME 52 NUMBER 3
TENSILE STRESS AND CERVICAL LESIONS

Fig. 1. Lateral forces create cervical regions of tension and compression, as indicated by
arrows. The magnified section depicts disruption of chemical bonds between enamel
rods. Small molecules enter between hydroxyapatite crystals and prevent reestablish-
ment of bonds to make crystals more susceptible to breakage and chemical dissolu-
tion.

Fig. 2. Proximal view shows teeth functioning along a contact plane. Based on
principles of leverage, magnitude of tensile stress on tooth is function of distance
between applied force and fulcrum, as indicated by arrows. Faciai view shows morphol-
ogy of lesion dictated by contact plane. The further applied force is from fulcrum, the
greater the region of defect on same side of tooth. Two separate occlusal forces can create
two occlusal line angles in cervical lesion.

distinguish them from smooth rounded acid erosions.
Studies have shown that eccentric loads applied to the
occlusal surfaces of teeth generate stresses that are
concentrated in the cervical regions.‘5-‘7 Our hypothesis
is that the primary etiologic factor in cervical erosion is
the tensile stress caused by mastication and malocclu-
sion, and that the local milieu plays a secondary role in
dissolution of the tooth structure to create the lesion.
Types of stress
The masticatory system during function places three
types of stress on teeth: compressive, tensile, and
THE JOURNAL OF PROSTHETIC DENTISTRY
shearing stress. Compressive stress is the resistance
against compression, tensile stress is the resistance
against stretch or elongation, and shearing stress repre-
sents the resistance against twisting or sliding.
Physical properties of tooth structure
The physical properties of teeth have been me&ured
extensively and appear to vary considerably among
individuals, from tooth to tooth in the same individual,
and even within different locations on the same tooth.1s
However, certain physical characteristics can be gener-
alized. Among these is that dentin appears to be
375

Fig. 3. Stone casts show large wedge-shaped cervical
lesion on mandibular first premolar. Adjacent teeth
are minimally affected. Occlusal line angle of premo-
lar lesion is skewed to correspond to contact plane
with lateral incisor.
substantially stronger than enamel in tension.” “I The
high resiliency of dentin enables it to withstand greater
deformation without fracture. Enamel moves as a rigid
unit, while dentin deforms elastically beneath it.
Enamel is made up of three components: a mineral
component that comprises the enamel rods, an organic
matrix, and water either free or bound. With the
electron microscope, enamel rods can be seen to be
composed of minute crystallites that are about 40 nm in
diameter.” Enamel, although rather hard, is also
brittle and can tolerate only a small amount of defor-
mation before it fractures. Its ability to withstand stress
depends significantly on the direction of force with
respect to the orientation of enamel rods.‘* For exam-
ple, enamel’s ability to withstand forces that pull the
enamel rods from each other (that is, tension) appears
to be rather weak. In a study on the frictional behavior
and surface failure of enamel, Powers et al.22observed
that tensile cracks occurred around enamel rods and
through the interprismatic substance. It is a well
known fact that surface microcracks seriously weaken
brittle materials.
Compressive and tensile stress
When occlusion is ideal, the masticatory forces
during function are directed primarily along the long
axis of the tooth, the forces are dissipated, and minimal
distortion of the dentinal and enamel hydroxyapatite
crystals results. When occlusion is not ideal, significant
lateral forces are generated, which can cause bending of
the tooth and create two types of stress on tooth
structure (Fig. 1). The first is a compressive stress that
is located primarily on the side toward which the tooth
is being bent. The second type of stress is a tensile force
that acts on the side away from the direction of
376
LEE AND EAKLE
Fig. 4. Cervical lesions on upper left second premolar
and lower left first premolar each show two distinct
line angulations on occlusal edge of lesions. Occlusal
line angles of lesions on upper canine, premolar, and
molar all show different angulations.
bending. For example, if a lingually directed occlusal
force is applied on a lower premolar, the lingual
portion of the tooth would be compressed while the
buccal portion would be stretched. The region under
the greatest tensile stress is that closest to the fulcrum,
while the regions of greatest compressive stress are the
ncclusal contacts, the fulcrum, and the apex of the root.
Because both dentin and enamel have high compressive
strength, little or no disruption of the crystalline
structure results from compression. However, the abil-
ity of tooth structure to withstand tension is limited.
The tensile force that acts on the tooth may cause
disruption of chemical bonds between the hydroxyapa-
tite crystals.
MECHANISM FOR FORMATION OF
LESIONS
In their study of the enamel surface, Arends et al.”
found that small spaces that are filled with water and
proteinlike organic material exist between discontinu-
ous crystallites. Liquids and small ions probably can
pass through these spaces.
As bonds are broken between crystals, additional
spaces could be created where small molecules, such as
those of water, may penetrate, The action of these
small molecules may prevent the reestablishment of
chemical bonds between crystalline structures. Subse-
quent tensile stress of sufficient magnitude would tend
to propagate cracks once they are initiated. If this
hypothesis is correct, the disrupted crystalline structure
SEPTEMBER 1984 VOLUME 52 NUMBER 3
TENSILE STRESS AND CERVICAL LESIONS
Fig. 5. Lower left first premolar has wear facets near
tip of buccal cusp. Facets show two distinct directions
of occlusal forces acting on tooth that correspond to
two distinct line angulations on occlusal edge of
cervical lesion.
that results would be more susceptible to chemical
dissolution and breakage from physical forces such as
friction from brushing, compression, and shearing
during mastication and bruxism.
Characteristics of a lesion created by tensile
stress
A lesion created as a result of tensile stress should
possesscertain characteristics. First, the lesion should
be at or near the fulcrum. Second, the region of greatest
tensile stress concentration would be a wedge-shaped
volume at the fulcrum, which is the typical morphology
of cervical erosive lesions. Local factors would tend to
modify the shape of the lesion, but the overall patterns
should be wedge-shaped with sharp line angles. Third,
the direction of the lateral force that generates the
tensile stress would determine the location of the lesion.
For example, if there are two directions of lateral force
acting on the same tooth, the created lesion would be a
combination of two lesions generated by each of the two
forces; that is, the morphology of the lesion would be
overlapping of two wedge-shaped volumes. Fourth, the
size of the lesion would be directly related to the
magnitude and frequency of application of the tensile
force. For a given lateral force, the further the lesion is
from the fulcrum, the greater is the tensile force
generated and therefore the greater the region of tooth
structure disruption near the fulcrum (Fig. 2). Occlusal
contact is seldom a single point. Instead, opposing teeth
function with each other over a surface area. Conse-
quently, the force imposed on a tooth is distributed
along the contact plane. The force on any point in the
plane of contact is a fixed distance from the fulcrum
and is different from any other point within the plane.
Occlusal forces on the tooth further from the fulcrum
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 6. Upper right and lower right first molars each
show two separate wedge-shaped cervical lesions on
facial surface. Two lesions on same tooth correspond
to tensile stresses that fulcrum at a point around two
roots to leave undisturbed area between.
create greater tensile stress on the tooth structure near
the fulcrum. If it is assumed that the amount of tensile
force needed to break the chemical bonds that hold the
hydroxyapatite crystals together is constant in the same
tooth, then the further the lateral force is from the
fulcrum, the greater is the tensile force that affects the
tooth structure near the fulcrum and therefore the
larger the region of disruption. As a result of this effect,
lesions of cervical erosion would possessline angles that
are dictates of the surface of contact. It is presumed that
shearing forces are generated also, and these may play
an important but lesser role than tensile stress in the
development of cervical lesions.
PATIENT REPORTS
Three representative cases chosen from more than
100 whom we examined are presented to illustrate the
characteristics of cervical erosions.
Patient No. 1
The patient was a 32-year-old man with a Class III
malocclusion. The cervical erosion on the lower left first
premolar had several points worth noting (Fig. 3). First, the
lesion was rather large and the factor(s) that caused the lesion
did not seem to affect the adjacent teeth, although there was a
smaller lesion on the second premolar. It seems unlikely that
the lesion was caused by mechanical means such as brushing.
Likewise, factors such as citric acid should not affect only one
tooth and leave the adjacent ones intact. Second, the occlusal
line angle of the lesion was skewed with respect to the long
axis of the tooth. Articulation of the teeth showed contact only
between the premolar and the upper lateral incisor. The
upper canine was out of occlusion completely. The surface of
contact was at the mesial incline of the buccal cusp of the
premolar. The occlusal surface contact and the occlusal line
angle of the lesion occurred at the same angle, which
377

Fig. 7. A, Facial view of molar shows production of
two separate cervical lesions as tensile stressesproduce
fulcruming about each of two buccal roots. B, Proximal
view of molars in function demonstrates production of
cervical lesion in region of tooth under tensile
stress.
appeared to be consistent with the theory that tensile force
was the primary factor in the etiology of the lesion.
Patient No. 2
.A M-year-old man with a Class II malocclusion presented
with cervical erosive lesions in a number of teeth. The lesions
of interest were those of the upper left second premolar and
the lower left first premolar (Fig. 4). Unlike Patient No. 1,
the lesions on these teeth had two distinct line angulations on
the occlusal edge of the lesions. It is unlikely that brushing or
acid alone caused such unusual defects. However, the shape
was consistent with the concept that tensile stresses from two
directions were responsible for the lesions. In effect, the
lesions represented two wedge-shaped defects on the same
tooth. The wear facets on the lower premolar were clearly
visible near the tip of the buccal cusp (Fig. 5) and showed two
distinct directions of occlusal forces acting on the tooth.
F’urthermore, the lesions on the upper first and second
premolars and the first molar all showed different angula-
tions, a fact explainable by the tensile stress concept.
Patient No. 3
A 4.5year-old woman presented with numerous wear
facets on her teeth, which indicated problems of bruxism.
Seven substantial cervical erosive lesions and several small
ones were located on the cervical buccal regions of the
posterior teeth. Of particular interest were the lesions on the
upper right first molar and the lower right first molar (Fig.
6). The lesions consisted of two distinct and separate wedge-
shaped defects that appeared to occur only in the molar teeth
with the highest incidence among first molars. These unusual
dual defectscan also be explained by the tensile stresstheory.
Each of the lesions on the same tooth correspond to the
fuicruming effect of the roots of the tooth (Fig. 7). For the
upper molar, the defects would be causedby the tensile stress
created as a result of the fulcrum points that correspond to the
two buccal roots, Because there is no fulcrum between th’e
378
LEE AND EAKLE
buccal roots, the tooth structure was undisturbed or disturbed
to a lesser extent. Consequently, two separate lesions were
created. The lower molar lesions extended well beneath the
gingiva where toothbrush bristles would not easily reach.
DISCUSSION
A number of hypotheses have been proposed to
explain the etiology of cervical erosive lesions. These
include mechanical abrasions such as brushing, chemi-
cal dissolution by acids, intrinsic weakness of tooth
structure in the cervical surface, and traumatic occlu-
sion. Neither the abrasion nor the chemical dissolution
hypothesis accounts for the frequently localized effect
of cervical erosions. It is difficult to explain how these
processescan often cause a lesion on one tooth and not
the adjacent tooth. Neither hypothesis can explain the
varied morphology and location of the lesions in the
patients described. At present, there is no evidence that
intrinsic weakness existed in the region where the
lesions developed. Brady and Woodyz3 suggested that
occlusal stress and collagen/apatite interaction in den-
tin may explain the development of angular lesions.
However, no satisfactory mechanism has been pro-
posed that explains how traumatic occlusion and
bruxism can produce cervical erosions.
Although tensile stress is proposed as the initiating
factor in the etiology of cervical erosions, multiple
factors affect the developmental process. Some of these
factors are abrasion from toothbrushing, acids in oral
fluid, the presence of fluoride in teeth and oral fluid,
the presence of adjacent teeth that affect bending of the
tooth under tensile stress, and the alignment and
anatomy of teeth.
The contributory role of toothbrush abrasion is
likely to vary depending on the lesion. Tooth structure
that has been disrupted by tensile stress may be
susceptible to frictional wear, but only where accessi-
ble. This is not to imply that toothbrush abrasion
cannot produce similar cervical lesions, but it cannot
explain the varied morphology and location of all
wedge-shaped cervical lesions. Certain lesions, such as
those in upper anterior teeth of older patients, may
indeed be abrasive in origin.
The presence of plaque may contribute to the acidity
of oral fluid. Acidity, whether from plaque, diet,
stomach, or other sources, may have a significant
contributory role in the dissolution of tooth substance,
particularily that which has been disrupted by tensile
stress.
The presence of fluoride in teeth and in oral fluid
may affect the development of cervical erosions by
decreasing the solubility of tooth structure and thus
slowing the development of the lesions after the inter-
prismatic bonds are broken. In that regard, it would be
interesting to examine the prevalence and rate of
SEPTEMBER 1984 VOLUME 52 NUMBER 3
TENSILE STRESS AND CERVICAL LESIONS
progression of cervical erosions in fluoridated and
nonfluoridated populations. The effectiveness of topical
fluoride treatments on cervical erosions has been exam-
ined, In a 5-month study, Xhonga et a1.24found that the
topical applications of 33.33% sodium fluoride had no
effect on the rate of progression of cervical erosions.
However, they did not consider their results to be
conclusive and suggested a longer term study. In
another study conducted over 1 year, Xhonga and
Sognnaes25used fluorides and sealants to treat cervical
erosions and observed only a minimal amount of
protection.
Because of the morphology of occlusal surfaces
(buccal and lingual inclined planes and fossae) most
forces generated during functional and parafunctional
jaw movements are directed along the long axis of teeth
or in a buccolingual direction. The presence of adjacent
teeth can help to direct forces buccolingually. When
third molars are absent, second molars do not develop
erosions on their distal surfaces because the major
forces are directed axially or buccolingually; and the
adjacent first molar prohibits mesial bending of the
tooth, which would be necessary to generate tensile
stresses on the distal surface.
The alignment and anatomy of a tooth may play a
significant role in determining how susceptible it is to
tensile stress. Furthermore, they may dictate where the
maximum stress concentrates on a tooth. In the upper
molars, cervical erosions usually develop in the mesio-
buccal regions. Perhaps the lingual cusp, because it is
more to the mesial portion of the tooth, concentrates the
stress mesially. Traumatic occlusion in itself may not
generate a significant tensile stress. Depending on the
direction of the applied force and the alignment and
anatomy of a tooth, occlusal trauma may produce
mainly compressive stress and thus require a greater
force than would tensile stress to cause the disruption of
tooth structure.
In lateral movements of the mandible, the canines
play a significant protective function in disclusion of
the posterior teeth. In dentitions that lack canine
disclusion, lateral forces are transmitted to the posteri-
or teeth, which may lead to the development of cervical
erosions in teeth that are under tensile stress. In
bruxism where canine disclusion eventually may be
lost, the potential for the development of cervical
erosions exists. Indeed, reports seem to indicate that
there is a high frequency of cervical lesions in patients
who brux.26,27The relationship of canine disclusion to
the prevalence of cervical erosions remains to be
examined.
The tensile stress-induced cervical erosion theory
provides a feasible explanation for a puzzling phenom-
enon. In a study of 10,000 extracted teeth, Sognnaes et
a1.28reported an 18% incidence of cervical lesions. Even
THE JOURNAL OF PROSTHETIC DENTISTRY
if only a fraction of these teeth requires treatment,
cervical lesions still would constitute a significant
problem economically. To the present time, treatment
of these lesions has been largely empirical. With the
tensile stress concept, a rational approach to treatment
of cervical erosions could be planned and tested.
SUMMARY
A tensile stress hypothesis for the etiology of idio-
pathic cervical erosions of human teeth is presented. It
is proposed that when occlusion is not ideal, lateral
forces cause the teeth to bend. The tensile stresses
created during bending disrupt the chemical bonds of
the crystalline structures of enamel and dentin. Small
molecules may enter between the crystals and prevent
the reestablishment of the chemical bonds. As a result,
the disrupted tooth structure is more susceptible to loss
through dissolution and abrasion and results in the
development of the typically wedge-shaped lesions.
Patients with lesions typical of hundreds examined by
the authors were presented to illustrate the concept.
The possible consequences of the proposed hypothesis
were discussed. The hypothetical conclusions made in
this article will be tested by experimentation.
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2. Stafne, E. C., and Lovestedt, S. A.: Dissolution of tooth
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Thresher, R. W., and S&to, G. E.. The stress analysis of
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Gingival tissue response to rotary curettage
Fred W. Kamansky, D.D.S.,* Thomas R. Tempel, D.D.S., M.S.Ed.,** and
Arthur C. Post, D.D.S., M.Ed.***
Walter Reed Army Medical Center, Washington, D.C.
T he management of gingival tissues during subgingi-
val preparation of teeth for fixed prostheses varies in
the technique used and the degree of effectiveness.
High-frequency electrosurgery and lateral gingival
tissue displacement achieved with a variety of chemi-
cally treated retraction cords are now the most common
methods for tissue management of prepared teeth.
One approach to gingival tissue management during
fixed prosthodontic procedures is rotary gingival curet-
tage. This technique? uses a specially designed rotary
diamond instrument to remove a portion of the inner
epithelial lining of the gingival sulcus during the
I‘hr opinions or assertions herein are the private views of the authors
,ind are not to be construed as official or as reflecting the views of
~hc I.~.$. Departments of the Army, Naby. or Defense.
Subrnittrd in partial fulfillment of the requirements of the Fixed
i’rosthodontirs Rrsidenc) Program. Walter Reed .4rmy Medical
(:entrr, Washington. D.C
“! Zrxnmander (DC:) USN; Prosthodontirs Dept.. Branch Dental
(:linic NDC, N.4S North Island. San Diego. C.4.
**Colone!, DC. LrSA, 1.1 S. Army Hospital, \C’orzburg. West
t Germany.
*‘*Formerly, Colonel. DC, USA; Augsburg, West Germany; pres-
cntly, Colonel, DC, 17% (retired).
fInqrah,+m. R. Perconal communication. 1978
380
LEE AND EAKLE
23. Brady, J. M., and Woody, R. D.: Scanning microscopy of
cervical erosion. J Am Dent Assoc 94:726, 1977.
24. Xhonga, F. A., Wolcott, R. B., and Sognnaes, R. F.: Clinical
measurements of dental erosion progress. J Am Dent Assoc
84:577. 1972.
2s Xhonga, F A., and Sognnaes, R. F.: Dental erosion: Progress
of erosion measured clinically after various fluoride applica-
tions J Am Dent Assoc 87:1223, 1973.
16 Xhonga, F. :I.. Bruxism and irs effect on the teeth. J Oral
Rehabil 4~65. 1977
27. Xhonga, F. A, and Van Herle, A.: The influence of hyperthy-
roldism on dental erosions. Oral Surg 36~349, 1973.
28 Sognnaes. R. F., Wolcott, R. B., and Xhonga, F. A.: Erosion-
hke patterns occurring in association with other dental condi-
twn$. J Am Dent Assoc 84:571, 1972.
placement of the finish line on tooth preparations.
Tupac and Neacy’ conducted a study on dogs to
compare cord gingival displacement with the rotary
gingitage technique. They found no significant differ-
ence clinically or histologically between the two meth-
ods.
Amsterdam* suggested the use of rotary curettage in
conjunction with the preparation of teeth for fixed
prostheses. However, he observed that the rotating
diamond instrument provided questionable tactile
guidance while locating the position of the rotary
instrument in the gingival sulcus during the proce-
dure.
The rate of healing of the gingival tissues after a
surgical curettage procedure is relevant to the rotary
curettage technique. Moskow3 reported that complete
coverage of the debrided tissue with epithelium was
seen within 7 days after gingival curettage on dogs.
Blass and Lite4 found microscopically that complete
healing was seen within 10 days after curettage on a
healthy patient.
Although complete healing of the gingiva can be
predicted after rotary curettage, the human clinical
application of the procedure could have collateral
factors that affect the ultimate clinical response. The
SEPTEMBER 1984 VOLUME 52 NUMBER 3