REVISÃO | REVIEW

Abfraction lesions reviewed: current concepts

Uma revisão sobre lesões de abfração: conceitos atuais

Adriana de Fátima Vasconcelos PEREIRA1

Isis Andréa Venturini Pola POIATE2
Edgard POIATE JUNIOR2
Walter Gomes MIRANDA JUNIOR2

ABSTRACT
Non-carious cervical lesions are characterized by structural loss near the cementoenamel junction, without the presence of caries. A
number of theories have arisen to explain the etiology of such lesions, although the real causes remain obscure, as is reflected by the
contradictory terminology used in the literature. In addition to describing acidic and abrasive processes documented as etiological factors,
attention is given to the role of mechanical stress from occlusal load, which is the most accepted theory for the development of abfraction
lesions. Considering that tensile stress leads to the failure of restorations in the cervical region and that this is a fruitful area for future
research, the present study has highlighted diagnosis, prognosis and the criteria for treatment.
Indexing terms: finite element analysis; tooth abrasion; tooth cervix.

RESUMO
As lesões cervicais não cariosas são caracterizadas pela perda de estrutura próxima à junção cemento-esmalte sem a presença de cárie.
Algumas teorias têm surgido para tentar explicar a etiologia dessas lesões, embora as causas verdadeiras permaneçam obscura devido
à terminologia contraditória na literatura. Apesar dos processos abrasivos e erosivos serem apontados como fatores etiológicos, atenção
é dada ao papel da força biomecânica das cargas oclusais que é a teoria mais aceita para o desenvolvimento das lesões de abfração.
Ao considerar que falhas de restauração podem ocorrer por tensões de tração e que constituem área promissora para pesquisas futuras,
o presente trabalho demonstra os conceitos atuais sobre diagnóstico, prognóstico e critérios para o tratamento.
Termos de indexação: análise de elemento finito; abrasão dentária; colo do dente.

INTRODUCTION to penetrate and render these crystals more susceptible to

chemical attack and further mechanical deterioration5. In
this case, it has been termed abfraction6. This is a condition
Non-carious cervical lesions are often observed on the observed on the buccal surface at the cementoenamel
buccal surfaces of teeth, but seldom on lingual and rarely on junction of teeth, with prevalence ranging from 27 to 85%7.
proximal surfaces. They are more frequent on incisors, canines It is described as the clinical entity characterized by loss of
and premolars and more prevalent in the maxilla than in the hard tissues caused mainly by a non-functional distribution
mandible1. These lesions vary from shallow grooves to broad of occlusal loads6.
dished-out lesions or large wedge-shaped defects with sharp When a tooth is hyperoccluded, the masticatory
internal and external line angles2. They have been attributed forces are transmitted preferentially to this tooth, which in
to three factors (abrasion, attrition and erosion) acting turn transfers this energy to the cervical region8,9. Lateral
independently or together3. Moreover, it has been related that force produces compressive stress on the side towards
tensile stresses resulting from occlusal overload may be involved which the tooth bends and tensile stress on the other side5.
in the development of non-carious cervical lesions4,5. The stresses create microfractures in the enamel or dentine
It has been suggested that lateral forces can create adjacent to the gingival region. These fractures propagate in a
tensile stress that disrupts hydroxyapatite crystals in the direction perpendicular to the long axis of the tooth leading
enamel, allowing small molecules, such as those of water to a localized defect around the cementoenamel junction9,10.

1
Universidade Federal do Maranhão, Centro de Ciências Biológicas e da Saúde, Departamento de Odontologia II. Av. dos Portugueses, s/n, Departamento
de Odontologia II, Bacanga, 65000-000, São Luis, MA, Brasil. Correspondence to: AFV PEREIRA (adrivasconcelos@yahoo.com).
2
Universidade de São Paulo. São Paulo, SP, Brasil.

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A.F.V. PEREIRA et al.

Occlusal forces increase microleakage and gap are actually due to eccentrically applied occlusal forces, such
formation at the cement/dentinal margin11. Continual occlusal as those produced during bruxing3,5,6,21. This can be explained
loading produces displacements and stresses under the buccal because in normal mastication, occlusal forces are loaded
cervical enamel and dentin, increasing crack initiation and along the long axis of the tooth. Thus, force dissipates, and
encouraging loss of restoration12. This occurrence can require the distortion of enamel and the dentinal crystal is minimal10.
restorative treatment in most patients and it sometimes leads Nevertheless, when occlusal loading is not ideal, lateral forces
to hypersensitivity or further degradation of hard tooth may be generated causing the tooth to flex22.
tissues10. Thus, the selection of restorative materials represents The side towards which the tooth is bending
a critical factor for successful restoration13 due to the position experiences compression, while the side opposite to the
of these lesions, which makes it difficult to provide a long- direction of force is placed under tension5. Since the tooth
lasting restoration14. substance is capable of resisting great compression, no
While the role of occlusal forces in the etiology disruption of enamel or dentine would usually occur on
of abfraction lesions has been widely discussed4-6,15,16, many this side, but tensile forces may cause disruption of the
materials and techniques have been tried in an attempt bonds between hydroxyapatite crystals, leading to cracks in
to obtain the best clinical performance14. The following the enamel and eventual loss of enamel and the underlying
materials are indicated for restoring cervical lesions: glass- dentine5,6.
ionomer cements, resin-modified glass-ionomer cements, Grippo6 has suggested that abfraction is the basic
polyacid-modified resin-based composites (compomers) cause of all non-carious cervical lesions. There is some
and composites resins17-19. However, clinical studies have evidence supporting the tooth flexure theory: presence of
shown repeatedly that restorations of abfraction lesions have class V non-carious lesions in some teeth but adjacent teeth
inadequate retention rates, with a higher percentage of failure (not subjected to lateral forces) are unaffected22,23; the lesions
in the cervical area20. progress around restorations that remain intact3 and under
Considering that mechanical stress is accepted as a the margins of complete crowns23; the lesions are rarely
cause of restoration failures, the present study has emphasized seen on the lingual aspect of mandibular teeth22; the major
the contemporary concepts in diagnosis, prognosis and incidence is in patients who are bruxists24 and lesions may
treatment measures of abfraction lesions. be subgingival3. However, other studies have proposed a
combination of occlusal stress, parafunction, abrasion, and
Development of abfraction lesions erosion in the development of lesions, leading to a conclusion
Bruxism may be the primary cause of angled notches that the progression of abfraction may be multifactorial5,16.
at the cementoenamel junction. It was postulated that tooth The cervical fulcrum area of a tooth might be
flexure from tensile stress led to cervical wear4. It has been subject to unique stress, torque, and moments resulting from
hypothesized that the primary etiological factor in wedge- occlusal function, bruxing, and parafunctional activity15.
shaped cervical erosions was the impact of tensile stress Nevertheless, it is important to know how periodontal status
from mastication and malocclusion. The wear is created by is involved to the development of cervical lesions. Alveolar
a combination of bending and barreling deformations that bone loss changes the position of the fulcrum of bending
cause alternating tensile and compressive stresses, which lead moment causing more apically placed lesions21. Indeed, loss
to weakening of the enamel and dentin5. A new category - of periodontal support leading to a high degree of tooth
abfraction – was introduced into the classification of non- mobility may conversely be a protective factor, rather than
carious cervical lesions to refer to the type of pathologic flexing at the cementoenamel junction25. Generally, mobile
loss of hard tissue at the cementoenamel junction caused by teeth are not as frequently affected as non-mobile teeth.
biomechanical loading forces that result in enamel and dentin It may be that the mobility of the tooth dissipates the
flexure at a location away from the loading. The term is used stress23.
to distinguish it from erosion and abrasion6. Researches and clinicians are paying increased
The tooth flexure theory postulates that the attention to noncarious cervical lesions. This interest has
biomechanical effects of occlusal loading are the main factors resulted in a substantial number of contributions to the
that initiate the formation of non-carious cervical lesions6. dental literature as regards abfraction lesions, with the aim of
Many of these cervical defects that were thought to be determining the etiological factors, characteristics, therapeutic
extrinsic factors acting directly upon the surface of the tooth measures and prognosis (Table 1).

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 Abfraction lesions

Table 1. Studies comparing abfraction with cervical wear. The continual occlusal loading produces
displacements and stresses under the buccal cervical enamel
and dentine, increasing crack initiation and favoring loss of
the restoration12,28. In this case the stress concentration caused
by the cervical lesion would facilitate further tooth structure
deterioration23. It is well known that if the dentin and adhesive
interface is exposed to the oral cavity, marginal discolorations,
poor marginal adaptation and subsequent loss of retention of
the restoration are frequent clinical findings33.
Considering that mechanical stress is accepted as a
cause of restoration failures in the cervical region, the restoration
materials used include those that adhere to tooth substance,
such as glass-ionomers, or resin composites retained by the use
of dentin bonding agents22. With regard to current adhesive
systems, they interact with the enamel/dentin substrate using two
different strategies, either removing the smear layer (etch-and-
rinse technique) or maintaining it as the substrate for bonding
(self-etch technique). The classification relies on the number
of the steps constituting the system34. Restoration is generally
indicated to prevent propagation of the lesion and support the
use of composite materials that bond and have an elastic modulus
that allows elastoplastic deformation23. However, problems with
obtaining and maintaining a good seal between the restoration
and tooth at the margin have been found to be a primary reason
for failure of Class V resin-based composite restorations3,34.
The retention rate for restorations with a lower elastic
modulus may be significantly better than a material with a
higher elastic modulus26. Moreover, it seems that these flexible
intermediate layers provide stress relief while the composite
material is undergoing polymerization shrinkage, when
compared with a restorative material which resists forces and
Treatment decision: restorative technique and materials may dislodge the restoration by flexing with the tooth13,18.
The treatment will be ineffective in the long term Microfilled composites, which demonstrate greater
should any predisposing factors not be brought under elasticity than hybrid composites, may be appropriate if
control3,22. Thus, to improve this situation and develop a esthetics is a concern. With this type of resin, much of the
better understanding of the cervical lesion, which is obviously transferred energy is absorbed by the restoration rather than
relevant to the clinical treatment, it is highly desirable to transmitted to the dentin-restoration interface9,19,26. However,
analyze the stress distribution in teeth10. no significant difference was found in the parameters of
Since abfraction lesions implicate enamel and dentine retention, recurrent caries, staining or color match in a study
margins, class V non-carious cervical lesions represent a comparing glass ionomers and composites, but there was
challenge to the dental profession due to their position, greater surface roughness in glass ionomer restorations22.
which make it difficult to provide a long-lasting restoration14. Glass ionomer materials have been found to perform
It is well known that enamel and dentine respond differently significantly better than composites35-37, possibly due to their
to masticatory stresses. Although these tissues are intended greater resilience allowing the material to flex with the tooth,
to support each other, they can react to occlusal forces which is not possible with the more rigid composite materials.
independently. Dentine has shown low compressive and high Resin-based glass ionomer cements may be of value, because
tensile stresses at the cementoenamel junction while enamel they generally produce a more acceptable esthetic result than
has demonstrated a reverse trend32. conventional glass ionomer material22.

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A.F.V. PEREIRA et al.

It is also important to report that restoring affected and second premolars31. Moreover, such lesions are more
teeth improves the maintenance of patients’ oral hygiene; frequently found on the buccal or lingual surfaces due to the
decreases thermal sensitivity; prevents pulpal involvement direction of occlusal or incisal loads, angling and asymmetry
and improves esthetics and strengthens the teeth. Since of the tooth buccal-lingual plane, and its relationship with the
abfraction lesions are caused by biomechanical forces, supporting alveolar bone43.
occlusal adjustments and elimination of parafunctional habits Previous clinical investigations have provided a great
are required to decrease the prevalence and slow the progress deal of evidence supporting the role of occlusal force in the
of established lesions23,27. etiology of non-carious cervical lesions. They have pointed
out a relationship between the loss of cervical fillings and the
Finite element analysis presence of traumatic occlusal contacts26. Bruxing, clenching
In an attempt to reproduce the phenomenon of and other parafunctional habits lead to the magnitude of
stress distribution in teeth and their anatomic support cervical stress and would increase non-carious cervical lesions
structures, a variety of methodologies have been used. With formation45. Such clinical observations are in agreement with
photoelasticity methodology is possible to determine sites of the results and substantiate the role of occlusal force in the
stress concentration but it does not quantify nor define the etiology of these lesions5,16,22. Furthermore, wear facets, a sign
stress type (compression or tensile), and it is also difficult to of stressful occlusion, are present on teeth with non-carious
build objects with more than one physical property38. A variety cervical lesions, providing support for occlusal forces and
of other methods has been used to analyze the distribution flexure as casual factors45.
of stress generated in the tooth and its adjacent structures, Abfraction is the basic cause of all non-carious
yet, new technologies inevitably encounter some difficulties, cervical lesions6. However, other studies proposed a
which make them vulnerable to criticism39. multifactorial etiology with a combination of occlusal stress,
The Finite Element method is the most appropriate parafunction, abrasion, and erosion in the development and
and important tool for evaluating the stress distribution in progression of lesions5,16,27. This can be explained, because
the cervical region. Because it is capable of analyzing stresses when occlusal loading is not ideal, lateral forces may be
quantitatively and conducting parametric studies, each generated causing the tooth to flex22 producing compressive
factor, such as physical and mechanical conditions, which is stress on the side towards which the tooth bends and tensile
represented mathematically, can be rapidly modified and the stress on the other side5.
stress distribution can be investigated in two-dimensional Since abfraction lesions implicate enamel and dentine
(2D) or three-dimensional (3D) models41. margins, class V non-carious cervical lesions represent a
The occurrence of non-carious cervical lesions is challenge to the dental profession due to their position, which
very common on anterior and premolar teeth because they makes it difficult to provide a long-lasting restoration14 and
are of a smaller size42. Such lesions are more frequently because it is well known that enamel and dentin respond
found on the buccal or lingual surfaces due to the direction differently to masticatory stresses32.
of occlusal or incisal loads, the angling and asymmetry of Mechanical stress is accepted as a cause of restoration
the tooth buccal-lingual plane, and its relationship with the failures in the cervical region, and therefore, the materials
supporting alveolar bone40-41. used for restoring the lesions include those that adhere to
In premolar teeth, one can expect to find tensile tooth substance. Nevertheless, close attention must be paid to
stresses in the cervical region on the buccal surface. Oblique occlusal adjustments during clinical and restorative treatments
traumatic loading on the palatal cusp of the maxillary second of non-carious cervical lesions and occlusal splints should
premolar produces dental flexion in the buccal direction, be used in order to avoid further progression of abfraction
resulting in tensile stress on the enamel in the cervical region. lesions22. As mentioned previously, the treatment will be
A variety of studies5,10,26,44 have demonstrated that this is the ineffective in the long term, should any predisposing factors
main cause of rupture of the union between enamel crystals. not be brought under control3,22. This approach would thus
include prevention and treatment of the resultant lesion28.
Based on this information, the most significant
DISCUSSION consideration in the restoration of an abfraction lesion is the
correction of possible prematurities before restoring the tooth9.
To do so, an accurate diagnosis is required and evidence-based
The occurrence of non-carious cervical lesions is treatment for loss of dental tissue should consider restoration
very common on anterior and premolar teeth because they and the choice of material27. Composite resin restorations offer
are of a smaller size43, particularly the first premolars30,31 a more permanent solution because of the acid-etch technique

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 Abfraction lesions

and the chemical attachment to the tooth structure through There is a significant correlation between these lesions
dentinal bonding systems23, in particular microfill composite and the cause of failure of the class V restorations.
resins9. Glass ionomers are effective for treating non-carious However, further research is required to confirm the
cervical lesions because of their potential to release fluoride9. cause and determine whether preventive and therapeutic
In general, composites resins and glass ionomer are indicated measures would decrease the prevalence and progression
for non-carious cervical lesions and offer the most esthetic and of abfraction lesions.
long-lasting solution46.

Collaborators
CONCLUSION
A.F.V.PEREIRA, I.A.V.P. POIATE and E.
Within the limitations of this report, the following POIATE JUNIOR participated in the conception, writing
conclusion must be taken into consideration. Occlusal and corrections of the article. W.G.MIRANDA JUNIOR
forces are predictors of the presence of abfraction lesions. participated in the conception and corrections of the article.

12. Rees JS. The role of cuspal flexure in the development of abfraction
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