MANAGEMENT

OF NON CARIOUS LESIONS

DR. Omar Abdelaziz
Lecturer of Operative Dentistry
 Classification of non carious tooth defects
Attrition
Abrasion
Demastication
Erosion
Abfraction
Trauma & fracture
Non carious tooth tissue loss is defined as surface
loss due to a disease process other than dental
caries.

Although decay is the usual cause of tooth

destruction necessitating operative procedures , it
has been estimated that 25% of tooth destruction
does not originate from a carious process .
CONSEQUENCES OF PATHOLOGICAL
TOOTH WEAR:

• Exposure of dentine on buccal or lingual surfaces

normally covered by enamel.

• Notched cervical surface.

• Exposure of dentine on incisal or occlusal surfaces -

further erosion often results in preferential loss of
dentine to produce a Cupped surface.

• Restorations (which do not erode) are left projecting

above the tooth Surface.
CONSEQUENCES OF PATHOLOGICAL
TOOTH WEAR:
CONSEQUENCES OF PATHOLOGICAL
TOOTH WEAR:

• Exposure of reparative dentine or pulp.

• wear producing sensitivity

• Pulpits and loss of vitality attributable to tooth wear.

• Wear in one arch more than in the other.

• Inability to make contact between worn incisal or

occlusal surfaces in any excursion of the mandible.

• Reduction in length of the incisor teeth so that length

is out of proportion to width.
 ATTRITION
Physico-mechanical wear process of the tooth substance
or restoration as a result of direct frictional forces due to
tooth to tooth contacts during functional or parafunctional
movements of mandible(Pathologic condition).

It is an age dependent , physiologic continuous process.

ATTRITION
 Clinical presentation
Site
 Occur at the occluding surfaces(inscisal or occlusal surface).
 It also include the proximal surface wear at the contact area because
of the physiologic tooth movement.
 May occur at labial or lingual surfaces as in cross bite .

Appearance
 Attrition is seen as loss, flattening, faceting (facets), saucering at the
occluding surfaces or ,at reverse cusping of the occluding surfaces or
elements (palatal cusps of upper premolars and molars and facial cusps
of lower posterior teeth).
 Shiny facets on amalgam contacts
Facets: flat surface with a circumscribed and well-defined border.
Reverse cusp: in severe cases and it is in the place of the cusp tip and the
inclined planes, leading to loss of the vertical dimension of the teeth.
palatal cusps of upper premolars and molars and facial cusps of lower
posterior teeth.
 Sometimes there may be presence of peripheral, ragged, sharp enamel
edges .
 The degree of wear in both arches is normally equal.
 The presence of hypertrophic masseter is indication of impact of Para
functional habits such as bruxism and clenching which accelerate the
attrition.
COMPLICATIONS ASSOCIATED WITH
ATTRITION PROCESS:

• Tooth sensitivity will occur due to dentin exposure to

the oral environments.

• Pulpal & periapical affection due to the presence of

abnormal physiological forces and stresses.

• Tearing of the periodontal ligaments.

• Micro-cracks (crazing) and liability for stagnation of

irritating substrates on the created flat or concave
areas of exposed dentin with discomfort and pain
Attrition can predispose to the following :-

A) Proximal surface attrition (proximal surface facets)

Results from surface tooth structure loss and flattening,resulting
inwidening of the proximal contact areas.
Surface area proximally increases in dimension , which is
susceptible to decay.
Mesiodistal dimension of the teeth is decreased, leading to
drifting , with the possibility of overall reduction in the dental
arch.
B) Occluding surface attrition ( OCCLUSAL WEAR)
▪ It is the loss ,flattening of the occluding elements.
▪ It leads to loss of vertical dimension of the tooth .
 If the LOSS IS SEVERE & accomplished in a relatively short time:-

-there would be no chance for the alveolar bone to erupt occlusally to

compensate for the occlusal tooth loss, & therefore the vertical loss
might be imparted to the face

-Leading to overclosure during mandibular functional movements &

strain areas on stomato-gnathic system.
 if the loss occurs over a long period-
- the alveolar bone can grow occlusally, bringing the teeth to their original
occlusal termination.
i.e vertical dimension loss will be confined to teeth but not imparted to
face.
-Deficient masticatory capabilities

-Cheek biting : vertical overlap between the working inclined planes will be
lost, which will cause surrounding cheek, lip, tongue to be fed between the
teeth.

-Decay: because the underlying dentin will be exposed & thereby becomes
more susceptible to decay.
 TMJ problems by the over closure situation (will overstretch the
joint ligaments ).

 Severe occluding surface attrition → predominantly horizontal

masticatory movement of the mandible→ extreme strain on the
muscles of stomatognathic system .

 When surface attrition is SLOWER & compensated by, intrapulpal

deposition of secondary & tertiary dentin, then there will be no pulpal
exposure.

 At other times, the attrition is faster than the intrapulpal dentine

deposition, leading to direct pulpal exposure.
TREATMENT MODALITIES:
 Line of treatment according to the complications may be: -

▪ Treatment of hypersensitivity

▪ Direct occlusal correction through a mounted diagnostic casts and

correction can be made with selective grinding.

▪ Soft vinyl night mouth guards.

 Abrasion
 Abnormal tooth surface and structure loss resulting from multiple direct friction
forces between the teeth and the external object.
 Contacting teeth components in the presence of an abrasive material.

 It’s a pathological condition may be diffuse or localized

Site
 It occurs most frequently on the cervical neck of the teeth.
 Incisal Surface as in pipe smokers or by improper use of bobby pins.

 The labial or buccal surfaces and lingual surfaces( in case of poorly fitted

clasps and artificial dentures ) .

 Proximal surface as in tooth pick or interdental brushes and floss.
Abrasion
 Causes of abrasion
 Traumatic occlusion .
 Improper brushing technique .
 Occupational (Habits such as holding pins in between the teeth .)
 Tobacco chewing /tobacco pipe .
 Vigorous use of tooth picks between the adjacent teeth.

Iatrogenic causes as
 Dentures with porcelain teeth opposing natural teeth.
 Extremely rough occluding surface of the restoration its increase abrasive action

 ill fitting dentures and clasps ,producing a constant wear of the affected surfaces .
 The clinical signs and symptoms of an abrasion are :

The abrasive lesion may be linear in outline.

The peripheries of the lesion are angularly demarcated from
the adjacent tooth surface.
The surface of the lesion is extremely smooth and polish.
Probing or stimulating (hot, cold, sweet) can elicit pain.
Depression abrasion (pipe smoker): latero-anterior portion
of the arch.
 Hypersensitivity
may be intermittent in character appearing and
disappearing at occasional or frequently repeated periods .
N.B
brushing technique, frequency of brushing, time spent on
brushing , force applied, type of material stiffness and
end rounding of tooth brush bristles, tuft design of the
brush, flexibility and length of tooth brush grip,
abrasiveness, pH and amount of dentifrice used affect on
the rate of abrasion.
 Tooth brush abrasion results in a
horizontal cervical notches on the buccal
surfaces of exposed radicular cementum
and dentin .

Notching in right central incisor caused

by improper use of bobby pins .
 DEMASTICATION

Wearing away of tooth substance during the mastication it

is by the abrasiveness of the-individual food.

Demastication is normally a physiological process affecting

the occlusal and incisal surfaces.

Demastication is combination of abrasion and attrition.

DEMASTICATION
 EROSION
 Irreversibleloss of dental hard tissue by a chemical process that does
not involve bacteria
 Loss of surface tooth structure by chemical action in the continued
presence of demineralizing agents(acids).
 It is one of the most predominant oral pathologic changes .
 There is no convincing etiology ,and multiple factors have been
theorized for its pathogenesis:
Mechanical factors:
The action of the muscles of lips and cheeks , and of tooth brush
against affected surfaces .
EROSION
 CAUSES OF EROSION
Extrinsic factors
Intrinsic factors
Idiopathic factors
EXTRINSIC CAUSES OF EROSION
 Habitual consumption of highly acidic, low pH
carbonated drinks, sports drinks or concentrated
fruit juices
 Alcopops, fruit flavoured alcoholic beverages and
strong ciders
 Causing a wide shallow lesion effecting the labial
and palatal surfaces of the upper teeth
 EXTRINSIC CAUSES OF EROSION
 Swishing or holding drinks in the mouth
 Modern packaging has also been blamed, tetra
pack, plastic bottles and cans – directional flow
onto teeth
 Can extend from the labial and palatal lesions of
the upper teeth to all surfaces of all teeth
 Chemical factors :
Ingested acids : citric acids (lemon and citrus fruits )
esp. if use in large amounts , can precipitate or initiate
erosive lesion

Secreted acids : the acidity of crevicular fluid has been

correlated to cervical erosion
(Bodecker CF. Local acidity: a cause of dental
erosion-abrasion.Ann Dent 1945)
 Acid fumes : acid vapours from nitric acid and sulphuric acids, acting
in the mouths of workers in the factories ,where these acids are
largely used or manufactured ( Miller)

 Refused acids : as a result of chronic , frequent regurgitation ,the

stomach’s hydrochloric acid can hit the teeth at specific locations
( atypical pattern of erosion affecting buccal surfaces of lower
posterior teeth)

▪ The latter defective surfaces are associated with gastro esophageal

reflux .(GERD)
CLINICAL PRESENTATION
• Extensive loss of buccal and
occlusal tooth structure
• Raised amalgam restoratins .

• Occlusal view of maxillary dentition

exhibiting concave dentin depressions
surrounded by elevated rims of enamel
 Multiple cupped out depressions
corresponding to the cusp tips

Extensive loss of enamel and dentin on

the Buccal surface of maxillary
bicuspids. ( pt had sucked chronically
on tamarinds )
 Palatal surfaces of maxillary dentition
in which the exposed dentin exhibits a
concave surface and a peripheral white
line of enamel

Perimylosis (decalcification of the teeth caused by exposure to gastric

acid in patients with chronic vomiting, as may occur in anorexia or
bulimia)
• Loss of lingual enamel and dentin due to acid
regurgitation aggravated by circular movements of
tongue.
• Associated with stress reflux syndrome
A similar appearance is found in patients with eating disorders-
Anorexia ( is an eating disorder characterized by immoderate food restriction and
irrational fear of gaining weight, as well as a distorted body self-perception)
Bulimia nervosa (is an eating disorder characterized by consuming a large amount of
food in a short amount of time followed by an attempt to rid oneself of the food
consumed , typically by vomiting)
Rumination ( a chronic condition characterized by effortless regurgitation of most
meals following consumption) have all been closely associated with dental erosion
 Chronic alcoholism produces a similar pattern of erosion, although usually more
generalized.

( ND Robb and BGN Smith, Anorexia and bulimia nervosa (the eating
disorders): conditions of interest to the dental practitioner, J Dent (1996)
 It has been reported that any food substance with a critical pH
value of less than 5.5 can become a corrodent and demineralize
the teeth.
( Stephan RM, JADA 1940) ,( Gray JA, J Dent Res
1962) , (Zero DT. Cariology. Dent Clin North Am 1999)

 Holding ,swilling or retaining acidic drinks and foods in the

mouth prolongs the acid exposure on the teeth increasing the
risk of erosion .
(Mossazzez R ,Smith BGN,Barlett DW,Oral Ph and drinking
habit during the ingestion of carbonated drink in a group of
adolescents with dental erosion ,J Dent 2000)
TREATMENT MODALITIES:
A) Conservative approach:

i. Surface hardening:

▪ application of 10% stannous fluoride for 30 seconds

▪ Sodium fluoride paste will aid also in surface hardening and

reduce tooth sensitivity.

ii. Remineralization:

▪ to prevent destruction of enamel and dentin

▪ Dentifrices and solutions containing calcium fluoride traces

phosphates are capable of causing surface changes.
TREATMENT MODALITIES:
A) Conservative approach:

iii. Prevention and care of periodontal tissues

▪ Relief of traumatic occlusion.

▪ Proper selection and use of tooth brush

iv. Desensitization to decrease hypersensitivity by:

▪ Paste which contains equal parts of sodium fluoride and

kaoline in glycerin base

▪ Siloxane ester which contain 10% strontium chloride

and 1.5% formaline
TREATMENT MODALITIES:

B) Restorative approach:
• Indicated in large lesions
• Metallic and non metallic restorations depending
on the location and the extent of eroded area.
• No need for protective base because of the
limited depth.
• Dentin should be painted with varnish to
decrease postoperative hypersensitivity.
CLASSIFICATION OF EROSION

A) Extrinsic
Environmental factors
Dietary factors
Medication

B) Intrinsic
 Abfraction

Some authors explain the formation of cervical, wedge

shaped defect by the heavy force in eccentric occlusion
resulting in flexuring (elastic bending) of the tooth.

When the tooth is loaded in long axis ,the forces are

dissipated with minimal stress on enamel and dentin .

If the direction of force changes laterally ,teeth are flexed

towards both the sides .
ABFRACTION
Changes in stress pattern continuously in the same area ▪

compresssive tensile
(esp. ,underneath the enamel)reaches to the fatigue limit.

rupture of chemical bond between hydroxyapetite

crystals is termed as Abfractures . (Grippo JO,1991: Levitch
LC , Bader JD, Heymann HO ,1994 )

This occurs most commonly in the cervical regions of the 

tooth where the flexure may lead to breaking away of
extremely thin enamel rods ,as well as microfractures of
cementum and dentin .
RESTORATION
when clinical consequences (e.g. dentin
hypersensitivity ) have developed or likely to be
developed .

Aesthetics demands are a concern .

Tyas recommended the RMGIC should be the first
preference
(Tyas MJ,the class V lesion –aetiology ,restoration,Aust. Dental
Journal.1995)

In esthetically demanding cases,

RMGIC/GIC liner laminated with resin composite.

Vandelwalle and Vigil ( Gen Dent 1997)

Recommended the use of microfilled resin composite(low
modulus of elasticity ) as it will flex with tooth and not
compromise retention .
TRAUMA & FRACTURE :
TRAUMA & FRACTURE :
1. Definition:

 Loss of tooth structure due to trauma.

1. Etiology of trauma:

 Trauma is commonly caused be the following:

• Falls

• Sports or athletics.

• Blows from foreign bodies

• Fights.

• Car or bicycle accidents

• Injuries during convulsive seizures (e.g. epilepsy)

• Battered child syndrome (the most difficult and yet the most
important to diagnose)
TYPES OF FRACTURE CAN BE:
a) Enamel fracture:

the best solution would be enamel recontouring, smoothing

the edges and peripheries of the defect, may be sufficient

treatment in most cases.

b) Enamel and dentin fracture without pulpal

involvement treated by either tooth fracture
reattachment or composite restorations:
TOOTH FRACTURE REATTACHMENT TECHNIQUES:
TOOTH FRACTURE REATTACHMENT TECHNIQUES:
RESTORATION WITH COMPOSITE RESIN:
THANK YOU