Correlation of noncarious cervical lesion size and occlusal wear in a single

adult over a 14-year time span

Maria R. Pintado, MPH,a Ralph DeLong, DDS, MS, PhD,b Ching-Chang Ko, DDS, MS, PhD,c
Ronald L. Sakaguchi, DDS, MS, PhD,d and William H. Douglas, BDS, MS, PhDb
University of Minnesota, Minneapolis, Minn., and Oregon Health Sciences University, Portland, Ore.
Statement of problem. Noncarious cervical lesions are described as having a multifactorial cause, with
occlusal trauma and toothbrush abrasion frequently mentioned as major factors. Finite element modeling
studies have demonstrated a relocalization of occlusal stresses to the cervical area due to flexure of the
crown. This may cause microcracking, especially under tensile stresses, that will lead to a loss of enamel
and dentin in the cervical region. Clinical confirmation of an occlusal cause for noncarious cervical lesions
has been difficult to obtain.
Purpose. This study investigated whether occlusal wear was correlated with an increase in the size of
noncarious cervical lesions.
Material and methods. Loss of contour at occlusal and cervical sites on 3 teeth of a single individual
was measured using digital and visualization techniques at 3 time intervals over a 14-year time span. The
1983 baseline casts and 1991, 1994, and 1997 clinical impressions of a single adult patient with existing
noncarious cervical lesions were replicated in epoxy. Surfaces of all replicas were digitized with a contact
digitizing system. Sequential digitized surfaces were fit together and analyzed using AnSur-NT surface
analysis software. Clinical losses of surface contour by volume and depth of the left mandibular first molar
and first and second premolars were recorded.
Results. Nine measurements of cervical volume loss (range 0.9 to 11.5 mm3) and 9 corresponding mea-
surements of occlusal volume loss (range 0.39 to 7.79 mm3) were made. The correlation between
occlusal and cervical volume loss was strong (r2=0.98) and significant (P<.0001).
Conclusion. For the single adult patient in this study, there was a direct correlation between occlusal
wear and the growth of noncarious cervical lesions. (J Prosthet Dent 2000;84:436-43.)

CLINICAL IMPLICATIONS
The results of this study support a relationship between occlusal wear and noncarious
cervical volume loss for 3 teeth in a single individual. Should future studies support
this result, it could have a profound influence on diagnosis and treatment of noncar-
ious cervical lesions. If the occlusal function theory is correct, it might be possible to pro-
vide diagnostic criteria that determine susceptibility to noncarious cervical lesions,
and prevention could be as simple as an enamelplasty. Treatment of existing lesions
might also require enamelplasty to reduce stress and a judicious choice of restorative
materials that can better accommodate cervical stress.

The substance of this report was presented as a poster at the 1999

IADR/AADR annual meeting in Vancouver, Canada. (Pintado MR,
Sakaguchi RL, DeLong R, Ko CC, Douglas WH. Abfraction and
occlusal wear: a correlation. J Dent Res 1999;78:161, no. 447.)
Supported by the Minnesota Dental Research Center for Biomaterials
and Biomechanics, University of Minnesota.
aAssociate Professor, Minnesota Dental Research Center for
Biomaterials and Biomechanics, Department of Oral Science,
University of Minnesota.
bProfessor, Minnesota Dental Research Center for Biomaterials and
Biomechanics, Department of Oral Science, University of
Minnesota.
cAssistant Professor, Minnesota Dental Research Center for
Biomaterials and Biomechanics, Department of Oral Science,
University of Minnesota.
dProfessor, Department of Biomaterials and Biomechanics, Oregon
Health Sciences University.
T he cause of the noncarious cervical lesion is a
source of considerable controversy in the dental clinical
community. Bader et al1 concluded that the cause of
the noncarious cervical lesion was multifactorial and
that several mechanisms may be associated with the ini-
tiation and progression of these lesions. Contending
theories ascribe the cervical loss of contour to either
(a) toothbrush abrasion or (b) microcracking resulting
from crown flexure during occlusal function. The reso-
lution of this problem is of interest in the general area
of oral biomechanics; however, it also has practical
implications in clinical dentistry. The reason for this lies
in determining the optimal properties of the dental
materials used to restore the Class V cervical lesion.

436 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 84 NUMBER 4

PINTADO ET AL
Should such materials have their maximal properties
engineered to resist toothbrush abrasion, to resist
repeated flexure and microcracking, or both? Also,
knowing the cause of noncarious cervical lesions pro-
vides the possibility of early diagnosis and prevention.
Careful clinical observations have provided mounting
evidence in favor of the occlusal function theory. Lee
and Eakle2,3 noted an anatomic relationship between
occlusal wear facets and cervical lesions on the same
tooth. Ott and Proschel’s4 clinical study found a sig-
nificant relationship between working occlusal con-
tacts and the wedge-shaped defects in posterior teeth.
Heymann et al5 also found a relationship between the
loss of cervical restorations and the presence of a trau-
matic occlusion, which is expected to cause more cus-
pal flexure. Grippo6 recognized the need for an
additional category of noncarious cervical lesions to
distinguish these lesions from lesions whose cause may be
abrasion or erosion. He introduced the term abfraction.
Finite element modeling and other studies of tooth
biomechanics recently dispelled the notion that the
cervical area of the tooth is a low stress area.7 Coronal
stress trajectories originating at the point of occlusal
contact can reconcentrate in the cervical area of the
tooth.7 Furthermore, this observation is supported
clinically by the placement of strain gages on the buc-
cal surfaces of teeth and the use of a bite force trans-
ducer to construct stress-strain curves for the tooth
crown in situ. These studies showed that buccolingual
flexure of the crown occurs clinically and that the
point of maximum flexure is in the cervical area.
Clinical observations by Heymann et al5 and Lee
and Eakle3 noted that occlusal force and lateral excur-
sion are the chief etiologic agents of the noncarious
cervical lesion. Based on this observation, the occlusal
function theory states that the volumetric loss of tooth
structure in the noncarious cervical lesion is a function
of the occlusal force (F) and lateral excursion (L) over
which that force is applied. An expression for the rela-
tionship between occlusal force and lateral excursion
can be derived from the equation for work performed
on a body (W):
W=f•d
where f is the force applied to the body and d is the
distance through which the body moves. Substituting
occlusal force for f and lateral excursion for d, the work
performed on a tooth (Wt) is expressed as:
Wt = F • L
Assuming a simple linear relationship, the occlusal
function theory for noncervical lesions can be
expressed by the equation:
Vc = C • F • L = C • W
OCTOBER 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
where Vc is the cervical volume loss and C is a con-
stant. This equation implies that the cervical volume
loss is directly proportional to the occlusal work per-
formed on the tooth (occlusal function):
Vc ∝ Wt = F • L
Evidence from studies of tooth biomechanics sup-
ports the plausibility of the occlusal function theory as
the pathogenesis of noncarious cervical lesions, but
direct, quantitative clinical evidence has been difficult to
obtain. The major obstacles are accurate measurements
of the volumetric loss of cervical lesions and direct mea-
surements of the occlusal force and the excursive path.
Three-dimensional digital techniques exist that enable
accurate quantification of the volumetric loss of tooth
structure.8-12 Direct measurement of the occlusal force
and the excursive path length are difficult to measure at
any point in time and nearly impossible to measure over
an extended time period. A possible solution is to mea-
sure these parameters indirectly through occlusal wear,
which can be measured very accurately using the 3-
dimensional measurement techniques. Occlusal wear is
a complex phenomenon that is influenced by occlusal
force, lateral excursion, and material properties such as
the yield hardness (H). The relationship between these
parameters is expressed by the equation:
V/L = K • F/H
where V is the volumetric loss that occurs while the
teeth are in contact over the distance L, F is the
occlusal force, and K is a constant referred to as the
wear coefficient.9 It is reasonable to assume that the
material properties of enamel are the same in the pos-
terior region of the same mouth and are relatively sta-
ble with time. This leaves the simpler concept that
occlusal wear, as measured by volume loss, is propor-
tional to the occlusal force times the lateral excursion:
V0 ∝ F • L
where V0 is defined to be the occlusal volume loss.
Thus, measuring the volume loss on the occlusal sur-
face provides an indirect measure of the total amount
of force applied to the tooth and where it was applied
to the tooth during the measurement time interval.
Comparing the occlusal wear equation with the
occlusal function theory equation yields a relationship
between cervical volume loss and occlusal volume loss:
Vc ∝ F • L ∝ V0
The purpose of this study was to investigate the
occlusal function theory prediction that there is a cor-
relation between the growth of a noncarious cervical
lesion and the occlusal force applied to that tooth over
the excursive path. The growth of the cervical lesion
was measured by volume loss in the lesion, and the
437
THE JOURNAL OF PROSTHETIC DENTISTRY
effect of occlusal force and lateral excursion was mea-
sured indirectly by the volume loss on the occlusal sur-
face. The hypothesis was that there is a significant
positive correlation between the 2 volume measure-
ments. If this hypothesis proves to be true, it will help
clarify the cause of noncarious cervical lesions.
MATERIAL AND METHODS
This preliminary study reports the results for a single
male adult who was under the age of 30 at the start of
the study and who had documented noncarious cervical
lesions that were observed over a 14-year time interval.
The subject grew up in a community with fluoridated
water, had excellent periodontal health and oral
hygiene, used no specific toothpaste, brushed primarily
with electric toothbrushes, had no unusual dietary
habits, was restoration free, and had minor orthodontic
treatment to correct the alignment of the anterior teeth.
The subject stated that he bruxed and clenched, but he
did not report any muscle pain or discomfort.
Full maxillary and mandibular arch die stone models
from the subject were used as the 1983 Baseline.
Articulation of the casts revealed a Class III malocclu-
sion (group function) on the right and a Class I
canine-guided occlusion on the left. Quadrant replicas
were made from the stone models using a vinyl poly-
siloxane impression material (Express, 3M, St Paul,
Minn.), supported in quadrant metal trays and poured
with epoxy die material (Epoxy-Die, Ivoclar, Schaan,
Liechtenstein). These epoxy replicas were digitized by
using a null-point contact stylus system, as described
previously.8,10 A customized tungsten carbide stylus
with a spherical tip (55 µm radius) was used to digitize
the replicas. The digitizer’s software corrected the mea-
sured data for the stylus thickness. The precision and
accuracy of this profiling system (digitized data plus
computer alignment) were determined by following a
method similar to that suggested by Hewlett et al.13
The upper hemisphere of a grade 5 precision ball
bearing with a diameter of 4.000 mm was digitized
and then compared with a mathematically generated
data set for the ball bearing. For each x,y coordinate
point in the digitized data set, the z-difference between
the corresponding point in the mathematical data set
was calculated. Precision and accuracy were calculated
as a function of surface angle (0% is defined to be hor-
izontal). Precision is defined as the root mean squared
difference per point (RMS/pt), and accuracy is
defined as the mean magnitude of this difference. The
mean accuracy and precision for surface angles from 0 to
60 degrees are 5 ± 2 µm and 3 ± 2 µm, respectively.11
Differences are typically less than 10 µm.
All replicas were digitized with a series of profiles.
Each profile was separated by 100 µm, and within each
profile the surface was digitized in 50-µm steps.
Approximately 25,000 points represented the facial
438
PINTADO ET AL
and occlusal surfaces of each tooth, or about 75,000
points for each replica.
Sequential clinical impressions of the same teeth of
the subject were made with vinyl polysiloxane impres-
sion material (Express, 3M) supported in quadrant
metal trays and poured with epoxy in 1991 (8 years),
1994 (11 years), and 1997 (14 years). These replicas
were digitized by using the same method described for
the baseline.
The digital data were processed by using AnSur-NT
software (Regents, University of Minnesota, Minneapolis,
Minn.). Color contour maps and 3-dimensional numeric
comparisons were produced of the “before” and “after”
noncarious cervical lesions and occlusal surfaces.
AnSur-NT software uses state-of-the-art techniques
and 6 degrees of freedom to fit the “before” and
“after” surfaces. The 2 numerical data sets for the before
and after replicas are rendered on the computer monitor
as gray-scaled surfaces for easy visualization. Each sur-
face is constructed from triangular surface areas that
use the data set points as vertices.
On one of the rendered images, an area was outlined
in which little surface change was expected. The 2 sur-
faces were fit to each other by minimizing the distance
between the 2 data sets in the outlined area. The distance
was calculated as the z-difference between points with the
same x,y coordinates. For each x,y,z point in the outlined
area in the before data set, the z value for the corre-
sponding x,y coordinates in the after data set was calcu-
lated by identifying the triangular surface that contained
the x,y coordinates, then calculating the z value using lin-
ear interpolation.
The quality of the fit was measured by the RMS/pt
of the 2 z values. The RMS/pt is used to calculate
errors for all measured values. After the surfaces were
fit, the differences between the 2 surfaces were high-
lighted by a contour map superimposed on one of the
surfaces. Areas of difference highlighted by the con-
tour map were outlined. Examining the individual
profiles was used to refine the border of an area.
Descriptive parameters, such as volume loss, surface
area, maximum depth, and mean depth, were calculat-
ed for areas of interest.
AnSur-NT software was used to measure surface
changes for both the noncarious cervical lesions and
the occlusal wear. The descriptive parameters for com-
paring the noncarious cervical lesion and the occlusal
wear facets on the mandibular left premolars and
molar were volume loss (mm3), mean loss of depth
(microns), and anatomic location of the morphologic
change. Volume loss was calculated by using Simpson’s
rule14 to integrate the z-differences over the region
defined by area border. The error in the volume calcu-
lation is estimated as the RMS/pt times the projected
surface area in the XY plane, plus a calculation error,
for the Simpson’s method. Mean loss of depth is the
VOLUME 84 NUMBER 4
PINTADO ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Noncarious cervical lesions on mandibular left first and second premolars and first
molar, at 1983-Baseline; 1991-8 years; 1994-11 years; and 1997-14 years. Noncarious
lesions are wedge-shaped with sharp line angles.

Table I. Noncarious cervical loss

1991 (8 y) 1994 (11 y) 1997 (14 y)

Volume loss Mean depth Volume loss Mean depth Volume loss Mean depth
Tooth (mm3) (µm) (mm3) (µm) (mm3) (µm)

First premolar 0.90 252 0.96 266 1.64 330

Second premolar 1.39 287 1.63 303 2.72 415
First molar 4.62 390 8.18 557 11.50 772

average of the z-differences over the area defined by
the border and is reported with the standard deviation.
The correlation coefficient (r) was calculated for the
paired occlusal and cervical volume loss data to deter-
mine whether a relationship exists and, if a relationship
does exist, the direction of the relationship. The null
hypothesis tested was that there is no relationship
between the volume loss of the cervical lesions and the
volume loss of occlusal wear for the same tooth (r = 0).
The hypothesis was tested at the 5% level of signifi-
cance with the JMP 3.0 statistical software (SAS
Institute, Cary, N.C.).
RESULTS
The increase in size of the noncarious cervical lesions
for each of the successive years is depicted in the gray-
scaled images in Figure 1. The loss represented on each
of these gray-scaled images by volume and mean depth
is presented in Table I. An example of the corresponding
loss because of occlusal wear is presented in gray-scale
contours in Figure 2 for the first premolar. Table II pre-
sents the occlusal volume loss and mean depth.
Typical fitted profiles through the noncarious cervi-
cal lesions for the baseline and the 14-year interval are
shown in Figure 3, where the location of the profile is
indicated by the vertical line on the buccal face. The
correlation between the volume loss for cervical and
occlusal lesions is based on 9 measurements, 3 teeth
(mandibular left first and second premolars and molar)
at 3 time periods (8, 11, and 14 years) (Fig. 4). The
correlation coefficient was calculated for the noncari-
ous cervical lesion volume loss and occlusal wear vol-
ume loss. A strong correlation (r2=0.98) was found,
which was significant (P<.0001). A line of best fit,

OCTOBER 2000 439

THE JOURNAL OF PROSTHETIC DENTISTRY PINTADO ET AL

Fig. 2. Occlusal surface of mandibular left first premolar shows 2 wear facets on mesial (blue)
and distal (pink) inclines of buccal cusp at baseline, 8 years, and 11 years that have merged
into 1 wear facet at 14 years.

Table II. Occlusal wear

1991 (8 y) 1994 (11 y) 1997 (14 y)

Volume loss Mean depth Volume loss Mean depth Volume loss Mean depth
Tooth (mm3) (µm) (mm3) (µm) (mm3) (µm)

First premolar 0.40 72 0.68 99 1.18 146

Second premolar 0.94 79 1.77 137 1.89 123
First molar 3.69 115 4.98 184 7.79 231

according to the least-squares criteria, yielded the
equation:
Cervical volume loss = –0.18 + 1.5 × occlusal volume loss
DISCUSSION
The volumetric measurements in Tables I and II
show a significant correlation (r2=0.98; P<.0001)
between tooth-matched occlusal wear and the noncar-
ious cervical loss. For the single subject in this study,
the null hypothesis was rejected, and the hypothesis
that there is a significant positive correlation between
the 2 volume measurements was accepted. Concurrent
with the acceptance of the hypothesis was the accep-
tance of the implied relationship between the volume
loss of the cervical lesion (Vc), occlusal force (F), and
lateral excursion (L):
Vc ∝ F • L
The high correlation found in our study supports
the clinical observations of Heymann et al5 and Lee
and Eakle,3 who noted that occlusal force and lateral

440 VOLUME 84 NUMBER 4

PINTADO ET AL THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 3. Gray-scaled computer images of noncarious cervical lesions on buccal surfaces of 2

premolars and molar (A, C, E, and G). Corresponding cross-sectional profiles at location of
vertical line (B, D, F, and H) show extent of loss of tooth structure in buccolingual plane at
14 years (red line) compared with baseline (green line).

OCTOBER 2000 441

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 4. Correlation graph (r2=0.98; P<.0001). Equation for
line determined by least-squares best fit to data is as follows:
Cervical volume loss = –0.18 + 1.5 × occlusal volume loss.
excursion were the chief etiologic agents of the non-
carious cervical lesion.
A line of best fit to the correlated data indicates
that, for the subject, 1.0 mm3 of occlusal wear was asso-
ciated with 1.5 mm3 of cervical loss during the 14
years of observation. The difference in occlusal and
cervical volume losses was expected because of the dif-
ferent material properties involved. Occlusal vol-
ume loss is mostly removal of enamel, and cervical
volume loss is mostly removal of dentin. The line of best
fit does not pass through the origin, which intuitively is
expected. From the equation of the line, a cervical vol-
ume loss of zero occurs at an occlusal volume loss of
0.12 mm3.
If the primary etiologic factor of the noncarious cer-
vical lesion is the breakdown of the enamel structure
by occlusal function, as proposed by Lee and Eakle,3
then there must be a period when force is applied but
no lesion is visible. This is the time of crack initiation
and crack growth. Extracting backward, the subject in
our study had little occlusal wear (0.12 mm3) before
the predicted onset of the cervical lesion. Clinically, it
is common to find teeth with substantial occlusal wear
and without noncarious cervical lesions. One possible
explanation for this apparent contradiction comes
from fracture mechanics. Cyclic forces present in the
mouth imply that fracture most likely occurs through
fatigue. Fatigue is viewed as a 3-stage process: crack
initiation, crack propagation, and material failure.15
If preexisting defects exist in the material, then the
crack initiation period is drastically reduced or even
eliminated, which reduces the life of the material. It is
442
PINTADO ET AL
possible that the subject in this study had preexisting
defects in his cervical enamel that made it susceptible
to fracture. Individuals without these defects may
require substantially longer time before cervical enam-
el fracture occurs. These individuals would be expect-
ed to have larger occlusal wear facets. Unfortunately,
this theory cannot be verified for the subject in our
study because details of the surface structure of the
cervical enamel before the initiation of occlusal wear
are not known. This is a question for future investiga-
tions.
A second possibility for the discrepancy in occlusal
wear between individuals and the initiation of cervical
lesions is the location of the wear. It has been demon-
strated clinically through the use of strain gauges that
the location of the force application on the occlusal
surface affects the strains measured on the buccal surface
of the tooth. Sakaguchi16 showed a similar effect using
finite element analysis. Thus, wear in different loca-
tions on the occlusal surface will produce different
stress distributions within the tooth. Some of these
distributions are likely to be more favorable to the
production of cervical lesions than others. The mor-
phologic details in Figure 2 illustrate the heavy buccal
inclination of the occlusal wear on the first premolar of
the test subject. The location of the wear is consonant
with lateral forces proposed by Heymann et al5 and
Lee and Eakle3 for buccal cervical loss.
The subject in this study exhibited unilateral canine-
guided occlusion at baseline, which evolved to bilateral
group function by the end of this continuing 14-year
study. This development was seen in the early loss of
canine height and the progressive loss of cuspal height
in the first and second premolars. Cervical loss was
detected only on the buccal surfaces of the maxillary
and mandibular posterior teeth on the side of the initial
group function. As the contralateral side develops into
full group function through occlusal wear of the
canines and premolars, it will be interesting to observe
whether cervical loss develops on that side as well.
The dynamics of the opposing dentition also affect the
stress distribution within a tooth; however, to a large
extent, this is taken into account by the volumetric mea-
surement of wear. The proposed proportionality for cer-
vical volume loss (Vc ∝ F • L) implies a connection
between occlusal force (F) and lateral excursion (L).
There are an infinite number of combinations of the
2 that will yield the same volume loss of material.
Consider the extremes of a large occlusal force with small
lateral excursion and small occlusal force with large lateral
excursion. Both could produce the same cervical volume
loss even though the stress distributions in the tooth
would be different. The larger excursive path of the
smaller force could allow that force to be applied at a
location that produces larger buccal flexure. This can be
likened to a teeter-totter, where large or a small individu-
VOLUME 84 NUMBER 4
PINTADO ET AL
als can lift the same weight by locating themselves at dif-
ferent distances from the fulcrum. Viewed differently, the
amount of cervical loss may be influenced by the degree
of lateral excursive contacts for a given occlusal force.
Thus, a canine-guided occlusion with minimum posteri-
or occlusal contact during lateral excursion would be
expected to have few, if any, noncarious cervical lesions. A
group function occlusal scheme, which has larger excur-
sive contacts, would be expected to be more susceptible
to loss of cervical tooth structure.
The lateral excursion (L) in the equations refers to
the total lateral excursive movement over the measure-
ment interval. Total movement is the individual later-
al excursion times the number of masticatory cycles
(n). Thus, identical occlusal forces and identical later-
al excursive movements can produce different volume
losses because of different numbers of occlusal con-
tacts (for example, different n values).
The matching profiles in Figure 3 illustrate the
progress of the cervical loss in the buccolingual plane.
In this case study, the premolar noncarious cervical
lesions first appeared as saucer-shaped depressions that
became more angular with the passage of time and, in
the case of the second premolar, became almost box-
like (Fig. 3, D). A different and more unfavorable
morphology emerged for the molar (Fig. 3, F and H).
The lesion first appeared as a wedge shape that has
been maintained throughout the life of the lesion. The
point of deepest invagination (Fig. 3, G and H) con-
tinued to deepen, threatening exposure of the buccal
canals. It is interesting that the 3 teeth in this study,
which exist in the same environment, have different
shapes in cross section.
Although the results of our study support the
occlusal function cause of the noncarious cervical
lesion, the details (including the extent, distribution,
and morphology) are specific to the test subject of this
study. The proposed relationship between cervical vol-
ume loss, occlusal volume loss, and the interrelationship
of occlusal force and lateral excursion fits with clinical
observations and with mechanisms reported by other
authors. Further clinical testing is required, however,
before these concepts can be accepted as fact.
CONCLUSIONS
Within the limitations of this study of the preexist-
ing noncarious cervical lesions on 3 teeth in a single
subject, the following conclusions were drawn:
1. There was a strong correlation between occlusal
OCTOBER 2000
THE JOURNAL OF PROSTHETIC DENTISTRY
wear and cervical loss on the same tooth; this correla-
tion was highly significant (P<.0001).
2. Cervical volume loss was directly proportional to
the occlusal force times the total lateral excursive
movement.
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Reprint requests to:
MARIA R. PINTADO, MPH
MINNEAPOLIS DENTAL RESEARCH CENTER FOR BIOMATERIALS
AND BIOMECHANICS
16-212 MOOS TOWER
515 DELAWARE ST SE
MINNEAPOLIS, MN 55455
FAX: (612)626-1484
E-MAIL: pinta001@tc.umn.edu
Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/2000/$12.00 + 0. 10/1/109477
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