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This landmark article by Dr. John O. Grippo presents a revised classification of noncarious cervical lesions (NCCLs), particularly abfractions, rooted in biomechanical and histological evidence. It challenges older assumptions that such lesions are primarily caused by toothbrush abrasion or chemical erosion. Instead, the article proposes a more comprehensive model that accounts for multifactorial etiologies—especially occlusally induced stress leading to enamel and dentin flexure. This new classification system aims to guide clinicians in more accurate diagnosis, targeted treatment, and effective prevention of NCCLs.
Understanding Noncarious Cervical Lesions
NCCLs refer to the loss of tooth structure near the cementoenamel junction (CEJ) that is not related to bacterial decay. Historically, they were often misattributed solely to aggressive brushing or acidic diets. However, these lesions frequently present in patients without such habits and often affect isolated teeth in a pattern inconsistent with uniform wear.
Grippo’s research refines the definition of abfractions as lesions caused primarily by tensile and compressive forces from occlusal loading, particularly lateral or non-axial forces. These stresses lead to flexural fatigue at the cervical area, ultimately resulting in microfracture and loss of enamel and dentin.
The Biomechanical Model of Abfraction
The article offers a detailed explanation of how occlusal stress leads to tooth flexure. When occlusal forces are applied in lateral directions—especially in the absence of proper anterior guidance or when posterior teeth contact during excursions—the cervical areas experience concentration of tensile and compressive forces. Over time, these stresses weaken the enamel rods and underlying dentin, causing structural breakdown.
This biomechanical theory is supported by finite element analysis, which shows stress concentration at the cervical margin during occlusal loading. Importantly, abfractions are often wedge-shaped and occur in teeth with heavy occlusal wear, TMJ dysfunction, or bruxism—further supporting the mechanical origin.
New Classification System for NCCLs
Grippo introduces a multidimensional classification system for NCCLs, recognizing that most lesions result from overlapping etiologies. The system includes four primary categories:
- Abfraction: Biomechanical loading-induced lesions from occlusal stress.
- Abrasion: Mechanical wear from external forces such as tooth brushing or objects.
- Erosion: Chemical dissolution by intrinsic (e.g., reflux) or extrinsic (e.g., citrus) acids.
- Attrition: Tooth-to-tooth mechanical wear from occlusion or parafunction.
This integrated model allows clinicians to assign a multifactorial diagnosis—for example, a lesion may be classified as “abfraction + erosion” to reflect the combined effects of stress and acid exposure.
Diagnosis and Clinical Implications
Proper diagnosis begins with a comprehensive evaluation: occlusal analysis, diet history, parafunctional habits, and clinical photography. Lesions caused by abfraction are often found on the facial surfaces of premolars or canines, are sharp or angular in shape, and are often unilateral depending on the occlusal scheme.
The article encourages clinicians to look beyond the surface and recognize the systemic contributors. Simply restoring lesions with resin without managing occlusion or parafunction may lead to repeated failure, sensitivity, or lesion recurrence.
Treatment and Prevention Strategies
Grippo advocates a conservative and interdisciplinary approach. In early cases, no restoration may be needed—occlusal adjustments, splint therapy, and behavior modification can halt progression. In cases requiring restoration, bonded resin or glass ionomer may be used, but only after addressing underlying stressors.
Prevention includes managing occlusal interferences, restoring anterior guidance, addressing acid exposure, and educating patients on proper brushing technique and parafunctional control. The ultimate goal is to restore the tooth’s biologic balance and protect it from continued stress and breakdown.
Key Clinical Takeaways
- Abfractions are biomechanically driven NCCLs caused by stress concentration from occlusal loading.
- NCCLs are multifactorial and should be classified using a system that includes abfraction, abrasion, erosion, and attrition.
- Accurate diagnosis requires evaluating occlusion, joint health, diet, brushing habits, and systemic health.
- Treatment should prioritize managing occlusal forces and underlying behaviors—not just restoring tooth structure.
- Restoring biologic occlusion and anterior guidance can reduce stress at the cervical margins.
- Prevention is key: splints, occlusal refinement, dietary counseling, and soft brushing all play a role.
This article reframes how clinicians understand and manage cervical lesions. By embracing a broader, biologically grounded model of diagnosis and treatment, practitioners can improve outcomes and protect patients from unnecessary interventions and long-term damage.
Read the full article here.