CONTENTS

Introduction
Attrition
Abrasion
Erosion
Abfraction
Treatment
Materials used for restoration
Enamel hypoplasia
Enamel hypocalcification
Dentin hypocalcification
Discolouration
Malformation
Amelogenesis imperfecta
Dentinigenesis Imperfecta
Trauma
Conclusion

Introduction
Tooth structure loss cannot be blamed entirely on caries.Many non carious destructive
process that are etiology to loss of tooth structure includes
attrition,abrasion,abfraction,erosion,tion and enamel hypoplasia, dentin hypoplasia.
Amongst these attrition,abrasion,erosion and abfraction are the commonest ones .
Miller was amongst the first to associate these etiologic factors to the presence of non
carious lesions
Not necessarily any of the etiology can be isolated, but two or more may act together to
initiate and promote the development of the lesions.
Non carious cervical lesions, depending upon their etiological factors, present a variable
morphology ranging from shallow grooves to broad dished out lesions to large notched or
wedge shaped defects. floor of the lesions may be flat ,rounded or sharp angled. Rounded
lesions are less frequently encountered than angular ones.
The reported prevalence of non carious lesion regardless of form and etiology is shown to
vary from 5-85%.Both prevalence and severity are known to increase with age.

Non carious lesions

Tooth loss or surface loss due to a disease process other than dental caries

Attrition
Loss of tooth structure occurring as a result of frictional contact between opposing teeth

Etiology
Tobacco chewing
Malocclusion
Bruxism
Age
A certain amount of physiological attrition is normal,However accelerated attrition
should be noted including the location of significant wear facet
Significant attrition of teeth is often indicative of a meaningful chronic occlusal habits
like bruxism.

TREATMENT
Pulpally involved teeth should be extracted , or undergo endodontic therapy,
according to and future in stomatognathic system.
Para functional habits notably bruxism should be controlled with use of splints .
Myofunctional , TMJ or any other symptoms need to be identified and resolved.
Exposed sensitive dentinal areas should be protected and actual carious lesions
obliterated.
Lost tooth structure should be restored with metallic restorations.

Abrasion

Definition
An abnormal wearing away of substance or structure by a mechanical process, habit or
abrasive substance
Etiology
Vigorous brushing.
Use of hard tooth brush.
Improper brushing technique.
Abrasive dentifrices.
Ill fitting clasps.
Use of tooth picks
Abrasion may defect one or more teeth or the entire dentition
Any surface of the tooth may be affected but the most commonly affected site is the
cervical region
Clinical Features
Usually V shaped.
Sharp and well defined margins.
Lesion are more wider than deep.
Canine and premolars are the most affected.

More on left side for right handed individuals and vice versa.
Location is mostly gingival portion of the facial aspect of the tooth.
Cervical lesions due to abrasive forces have sharply defined margins and has smooth
surface with burnished appearance.
Occasionally the surface may exhibit scratches.
Hypersensitivity is intermittent in character.
In slowly progressing lesions reparative dentin formation occurs over a period of time
making them asymptomatic. Lesions may show varying depths like
Shallow:0.1-0.5mm
Deep: more than 0.5 mm but no pulpal involment.
Exposure: Pulp is exposed.
Location
Abrasion lesions are usually generalised and most commonly seen to damage facial
surface of maxillary teeth.
Lingual surface are rarely affected.
Lesions are generally located on canines through molars with premolars exhibiting the
highest frequency.

TREATMENT
Diagnose the cause of the lesion and eliminate it.
Knowing the causative factors replace the iatrogenic dental work.
If the habit cannot be broken restorative treatment to be done with an objective to
prevent further destruction.
Abrasive at non occluding tooth surfaces should be critically evaluated for need for
restoring them.
If the lesions are multiple shallow no need to restore them.
If the lesion is wedge shaped and exceeds 0.5 mm into dentin it should be restored .
If the involved teeth sensitive preferable to desensitize exposed before restorative
treatment is started.

Erosion

Definition
The dissolution of tooth structure subsequent to chemical attack of either endogenous or
exogenous ,or combined chemico mechanical action.
Etiology
Depending on the source of chemicals
Intrinsic
Gastrointestinal ulcer
Hiatus hernia
alcoholism
Anorexia nervosa
Bulimia nervosa
Pregnancy
Morning sickness
Extrinsic
Citrus fruit
Fruit juice
Carbonated drink
Pickle foods
Intrinsic type of erosion is mostly seen on the lingual surface of anterior teeth
especially maxillary teeth because of the accumulation of vomitus on the dorsum of
the tongue first reaches and is in prolonged contact with these surfaces

Diseases because of lack of oxygen or faulty metabolism, which result in excessive

formation and elimination of acid sodium phosphate /acid calcium phosphate from
the labial and buccal mucous glands also cause erosion.
This type of erosion usually is confined to the labial surface and buccal surface of
teeth
Here the entire dentition is involved
A large number of studies have been carried out to determine the effect of beverage
on erosion
These studies suggested that several factors influence the degree of erosion like
A large number of studies have been carried out to determine the effect of beverage
on erosion
These studies suggested that several factors influence the degree of erosion like

1. Manner in which the fluid is consumed

2. Tooth surface that comes in contact with the fluid
3. Duration of contact
4. pH buffering effect and content of calcium and phosphate in the drink.
5. Swallowing habits.
6. Access to saliva
7. Soft tissue movement
Morphology
Erosion lesions are most often seen as buccal shallow saucer shaped excavations or
depressions present in the enamel/dentin but with no sharp angles and less well
defined margins
At times lesions may even be grooved wedge shaped or irregular
Hypersensitivity may be marked in rapid forms or in lesions in which dentin is
exposed with no underlying tubular calcification.

According to Mannenberg-1961
Two erosive Phases are seen
1. Manifest Erosion
Which I actively occurring and appears in micrographs as a hollowed out pitted
surface resembling honey comb. the pits characterize ends of enamel prisms that have
been dissolved below the level of inter prismatic matrix.
2. Latent Erosion
It is an inactive stage and here the prisms are much less obvious. Manifest erosions is
more common then latent erosions and is seen more frequently in females and young
individuals.
TREATMENT
Complete analysis of diet, occlusion, habits, chronic vomiting and environmental
factors.Observe the rate of lesions progress and choose the restorative procedures.
Tooth colored materials capable of chemico physical bonding to tooth structure is the
material of choice.
ABFRACTION
Definition
This is the pathological loss of tooth substance due to biomechanical loading forces that
results in flexure & ultimate fatigue of enamel & dentine at a location away from loading.
Many authors termed these lesion as Idiopathic Cervical Lesions
Etiology
Excessive occlusal forces
Para functional habits
Bruxism
Clenching

Mechanism For Abfraction Lesion Formation

Dentin is substantially stronger than enamel in counteracting tensile stress.
The high resiliency and elasticity of dentin enables it to withstand greater deformation
with out fracture.
Enamel as a rigid unit is brittle and liable to fracture even with small deformation loads.
Hypothesis
The tensile or compressive strain gradually produce micro fractures in the thinnest
region of enamel at the CEJ.
Such factor predisposes enamel to loss when subjected to
tooth brush abrasion/erosion .

Characteristics of Abfraction lesion

The lesion will me at or near the cervical region
Its typical morphology is wedge shaped lesion with sharp line angles and is the area
of great tensile stress concentration
Local factors like abrasion acid erosion may modify the shape of the lesion but the
over all pattern remain wedge shaped
The direction of lateral forces may determine the location of the lesion.
The size of the lesion is determined by the magnitude and frequency of applied tensile
force.

Treatment Of Non Carious Lesions

Case History
The first and foremost step in the treatment of non carious lesion is a careful
consideration of the etiology and progression of the condition. Without the
determination of the causative factors the treatment rendered is bound to fail. For this
a detailed case history should be taken comprising of the following aspects
Dietary habits
Gastric disturbances
Acidic mouth taste
Drugs
Radiotherapy
Salivary gland dysfunction
Work related exposure to the acid environment
Para functional habits
Oral hygiene method etc
Preventive aspects of the treatment
Removal of the etiological factors is an important step in preventive treatment.
It cannot undo damage already done but surely can prevent development of fresh
lesions and arrest progression of the old ones
General preventive measures
Since systemic diseases contribute to the formation of non carious lesion, they should be
managed wisely the management includes.
1. Regulation of diet
2. Exercise
3. Fresh air
4. Massage
5. Administration of sodium bicarbonate(0.75-2gms)thrice daily
6. Plenty of plain water should be drunk.

Local Preventive Measures

Use of soft tooth brush, low abrasive tooth paste, vertical brushing technique, less
force during brushing etc.
Correction or avoidance of ill fitting metal clasps or dentures
In case of bruxism,use inter dental splints at night and treat the cause
Correction of malocclusion
Regulate frequency of consumption of acid foods and bevarages
Do not swish acid beverages
Do not brush immediately after the consumption of acid beverages.
Management of sensitivity
Patient with non carious cervical lesions also commonly complaints of dentin
sensitivity to both physical (cold, airblow, scratches)and hyper osmotic (glucose
solution) stimulations. This should be simultaneously treated by using desensitizing
tooth paste, burnishing dentin with fluorides and other agents or layering with
bonding agents etc.
Restorative aspects of treatments
A restoration in a non carious lesion is indicated after considering the following factors
1.Structural integrity of teeth: If the notched or affected area is very deep, strength of
the teeth at the cervical area is decreased. Placement of a boned restoration is indicated to
restore the lost strength.
2.Pulp Protection: When the lesion is quite deep so as to endanger the vitality of the
pulp a restoration is carried out.
3.Sensitivity:When sensitivity continues to exist
despite use of desensitizing agents, lesion should be filled
4.Esthetics:If the notched area is in an esthetically critical position the patient may want
the restoration
to be done with a tooth colored restorative material
5.Gingival Health:If the lesion irritates the gingiva leading to ulceration or gingivitis the
lesion should be considered for restoration.

6.Caries:If caries supervences the lesion it should be restored unless it is

incipant/superficial and can be treated by preventive measures alone.
7.Presence of removable partial denture:If the locaton of the lesion interferes with the
desigh of removable partial denture,restoration is indicated.
Materials
Non carious lesion may be restored with any of the permanent restorative material
presently available.
Amalgam ,cast, gold, inlay & ceramic inlay are no longer preferred as they require
some amount of cavity preparation.
Currently composite resin & glass ionomer cement are more popular because they are
adhesive & do not require any extensive cavity preparation.
Composite resins
Advantage
Superior esthetic.
Excellent polishing.
High bond strength.
Good abrasion resistance
Disadvantage
Technique sensitivity.
Polymerization shrinkage may open marginal gaps
Glass ionomer cement
Advantage
Adhesion to tooth structure.
Fluoride release.
Biocompatibility
co-efficient of thermal expansion similar to tooth structure
Disadvantage
Less esthetic than composite.
Brittleness.
Sensitive to moisture contamination

Sandwich Technique
Restoration with combined GIC and composite is known as sandwich technique or
laminate technique
This offers advantage of both restorative materials
GIC serves as the dentin replacement and provides chemical adhesion to the under
lying tooth structure
Whereas composite provides control of contours and esthetics.
Endodontic treatment
When tooth loss is extensive resulting in pulpal involvement, endodontic treatment is
necessary followed by post placement full coverage restoration in form of crown.
PERIODONTAL THERAPY
Is required when non-carious cervical lesions are associated with gingival recession
and mucogingival defects.
This consist of root coverage procedures using free gingival grafts or connective
tissue grafts .
Root coverage procedures using non grafting procedures like rotational and coronally
advanced flaps or guided tissue regeneration
Localized Non hereditary Enamel Hypoplasia
Enamel hypoplasia is reduction in thickness of enamel.
Lesions range from isolated pits to widespread linear defects , depressions ,loss of
segment in the enamel
TREATMENT
Selective odontotomy
Vital bleaching
Laminated tooth coloured resins or ceramic veneers

Discolouration
Two main types
Extrinsic due to calculus , smoking
Intrinsic due to enamel hypoplasia , dentin hypoplasia ,tetracycline , changes in pulp
root canal system due to pulp necrosis, internal resorption
Amelogenesis Imperfecta
Genetically determined abnormality in the formative stage of enamel unassociated with
evidence of biochemical or systemic diseases.

Symptoms
Thin enamel
Open contact
Small teeth
Delay in eruption
Enamel is glassy
Enamel look wrinkled
Occlusal wear
Treatment
Selective odontotomy
Full veneering

Dentinogenesis Imperfecta
Genetic disease affecting the formation and/or maturation of dentin matrix in the absence
of systemic or biochemical changes.

Clinical features
Colour vary from grey, brown, yellow brown to violet. Exhibits translucent hue. Crowns
are over contoured. Roots are short and slender. Dentin is devoid of tubules.
Dentin contains a lot of interglobular dentin. Root canal space is obliterated.
Treatment
Selective odontotomy
Permanent full veneering

Conclusion
Non carious lesion continue to be a matter of great concern especially so as more and
more teeth are being retained into the older age.
Adequate preventive and/or restorative measures need to be instituted to attain high
levels of success
Also in non carious lesion a minimum amount of instrumentation should be carried
out.
Though most of the retention is a function of the chemical bonding, additional
undercuts will do no harm but definitely add to mechanical retention yet being
conservative.

BIBLIOGRAPHY
Text book of operative dentistry

Vimal K Sikri

Sturdevant's textbook of operative dentistry

Operative dentistry

MA Marzouk