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DIncau2012-ToothWear.PDF
archives of oral biology 57 (2012) 214–229
Available online at www.sciencedirect.com
journal homepage: http://www.elsevier.com/locate/aob
Review
Human tooth wear in the past and the present: Tribological
mechanisms, scoring systems, dental and skeletal
compensations
Emmanuel d’Incau a,b,*, Christine Couture b, Bruno Maureille b
a
Université Bordeaux Segalen, Faculté d’Odontologie, 16-20 cours de la Marne, 33082 Bordeaux Cedex, France
Université Bordeaux, UMR 5199 PACEA, ‘‘Anthropologie des Populations Passées et Présentes’’, Université Bordeaux 1, Avenue des Facultés,
33405 Talence Cedex, France
b
article info
abstract
Article history:
This review of human tooth wear describes the fundamental mechanisms underlying this
Accepted 24 August 2011
process. Using the tribological approach they can be systematised and this in turn aids our
Keywords:
physiological as it was related to their food and their technologies. In these populations, it
understanding of them. In past populations wear was ubiquitous, intense, abrasive and
Human tooth wear
affected the proximal surfaces, and the occlusal surfaces which modified the occlusal plane
Tribology
profoundly. To categorise this wear many different classification systems are used, from
Dental anthropology
which we can determine diet, cultural changes and the age at death of individuals. They also
Scoring systems
illustrate the evolution of certain functional dental and skeletal compensations in the
Compensations
masticatory apparatus such as continuous dental eruption, mesial drift of the arches
and incisor lingual tipping which can then be monitored. These physiological adaptations
related mainly to function and ontogenesis can also be found in present-day populations
where wear is moderate, although they are much less obtrusive. Apart from certain
pathological cases associated with a specific parafunction, iatrogenic tooth brushing or
an eating disorder and encouraged by an acid environment, they are the result of a
physiological process that should not be halted. To ensure this, it is essential to prevent
lesions related to tooth wear, to detect them early and establish a reliable diagnosis. Types of
tooth wear that had remained unchanged since the origin of humanity have undergone
profound changes in a very short space of time. Today’s tribochemical pathological model
has replaced the abrasive physiological model of the past.
# 2011 Elsevier Ltd. All rights reserved.
Contents
1.
2.
Introduction . . . . . . . . . . . . . . . . . . .
Fundamental wear mechanisms . . .
2.1. Abrasive wear . . . . . . . . . . . .
2.1.1. Two-body abrasion . .
2.1.2. Three-body abrasion.
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215
215
215
215
217
* Corresponding author at: Université Bordeaux Segalen, Faculté d’Odontologie, 16-20 cours de la Marne, 33082 Bordeaux Cedex, France.
Tel.: +33 557 107 957.
E-mail address: [email protected] (E. d’Incau).
0003–9969/$ – see front matter # 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.archoralbio.2011.08.021
215
archives of oral biology 57 (2012) 214–229
3.
4.
5.
1.
2.2. Adhesive wear . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Fatigue wear . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Corrosive wear. . . . . . . . . . . . . . . . . . . . . . . .
Scoring systems. . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1. Qualitative and quantitative classifications .
3.2. Qualitative and chronological classifications
Dental and skeletal compensations . . . . . . . . . . . .
4.1. Continuous eruption . . . . . . . . . . . . . . . . . . .
4.2. Mesial drift . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3. Incisor lingual tipping . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.
Introduction
Wear is deterioration as a result of use. Tooth wear has existed
since the beginning of humanity and in all civilisations. It
occurred systematically and intensively in past populations,
but is considered a physiological process. However, this notion
is often unclear as nowadays, although the process is less well
developed, it is sometimes pathological in nature. In addition,
it depends on many complex mechanisms, synchronous or
sequential, synergetic or additive which can also often mask
its true origin. With the aim of improving the diagnosis of
tooth wear and for a better understanding of its various
manifestations, in this review we first present the fundamental mechanisms of wear and their consequences, both in past
populations and in contemporary industrialised populations.
The second part looks at the categorisation of wear and
choosing the most appropriate of the scoring systems used in
odontology and dental anthropology according to origin,
location and the populations studied. The last part covers
dental and skeletal compensation mechanisms and explains
how the masticatory apparatus adapts as wear progresses in
order to maintain a functional occlusion throughout our
lifetime.
2.
Fundamental wear mechanisms
In dentistry, wear is a generic term commonly used to describe
phenomena of attrition (proximal and occlusal inter-dental
friction), abrasion (friction with the intervention of particles)
and erosion (chemical dissolution). Although this longstanding terminology introduced by Hunter1 is the one that is
normally used, it does not entirely take into account the reality
and variety of the physical and chemical mechanisms
involved. In addition, it suggests that these three phenomena
act independently, whereas in fact it is more often the case
that they interact together, which makes diagnosis all the
more difficult.2 Another approach is to use terminology
borrowed from the science and technology of tribology (from
the Greek tribein, meaning to rub) which covers the study of
friction, wear and lubrication.3–5 To facilitate diagnosis of the
different forms of wear of dental tissues and restorative
materials, the oral cavity can be likened to a tribological
system made up of four elements6:
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219
219
220
220
220
221
221
221
222
223
223
225
225
- a solid body represented by a tooth, which may or may not be
restored,
- a counter body usually represented by a solid (opposing
tooth, tongue, soft tissue, object, etc.) less frequently by a
liquid, a gas or a combination of these different elements,
- there may be an interfacial element represented by a solid
(particles in the food bolus, in toothpaste, etc.), a liquid
which lubricates to varying degrees (saliva), less frequently a
gas or a combination of these different elements,
- an environment, usually represented by air.
Within this tribological system, four basic wear mechanisms can be described.6 Their occurrence depends on many
different parameters and enables us to qualify the behaviour
of the dental tissue and the restorative materials. These may
be (1) flexible or rigid depending on their capacity to deform
reversibly, (2) hard or soft depending on their capacity for
irreversible plastic deformation, (3) brittle or ductile depending on their capacity to resist crack propagation, and act as a
shock-or energy-absorber.
2.1.
Abrasive wear
Abrasive wear is the most common type of wear.6 At the
microscopic scale, no surface is entirely smooth. When there
is contact between different materials it is through asperities
which act as abrasive particles. Depending on the microroughness of these materials a number of microcontacts are
made and define the real surface area, which is in fact much
smaller than the maximal theoretical surface area. In addition,
even though the overall pressure exerted between different
materials may be low, the pressure developed locally at each
microcontact is sometimes so great during displacement that
it may lead to deformation or to rupture. Depending on the
number of materials in contact, tribology distinguishes two
types of abrasive wear: two-body abrasion and three-body
abrasion.3–6
2.1.1.
Two-body abrasion
This type of abrasion (from the Latin verb abradere, to abrade)
is the friction between two solid bodies in movement where
the surfaces are in direct contact. Tribology distinguishes four
models of two-body abrasion, determined according to the
angle of attack and the geometry of the asperities, the friction
coefficient, the speed of the displacement, the pressure, the
216
archives of oral biology 57 (2012) 214–229
distance and the differential hardness between the two
surfaces in contact.7,8
When two surfaces have very different levels of hardness,
microasperities on the harder surface move across the softer
surface with a microploughing mechanism. At microscopic
level, a prow is formed ahead of the abrading particle and
material is continuously displaced sideways to form ridges
adjacent to the groove produced. With repeated passes, many
grooves are formed parallel to the direction of displacement of
the abrasive asperities. The proximity of the grooves eventually weakens the more ductile material which deforms locally
and matter is removed with a microfatigue mechanism.6
When two brittle surfaces have a similar, high level of
hardness (metals hardened to a high degree, dental ceramics),
the microasperities on the harder surface cut the more ductile
surface cleanly, with no plastic deformation, using a microcutting mechanism. The shape and volume of the groove that
is formed correspond exactly to the volume of material
displaced. If in addition these two surfaces are subjected to
high pressure, some surface asperities may become detached
by a microcracking mechanism. Small cracks then form along
a main groove, they propagate then nucleate within the
material, and blocks may then become detached.6 With
repeated passes, all the surface asperities are subjected to
one or more of these models and become dissociated so that
the cumulative effect of these microscopic losses results in
macroscopic wear.
Note that if a third solid moving body is often interposed
between two surfaces, then each wears separately with a twobody abrasion mechanism. If the body is removed, the contact
surfaces do not correspond.3
Within the oral cavity, two-body abrasion is often called
attrition (from the Latin attritio, friction), which could lead to
confusion because attrition is not a tribological process in its
own right. As it occurs at sites of direct contact between
surfaces it will have contributions from the two-body
processes of abrasion, adhesive wear or fatigue wear9 (see
Sections 2.2 and 2.3 below). This is a gradual phenomenon
which is mainly the result of physiological or pathological
proximal and occlusal inter-dental friction.
In terms of proximal contact, this type of wear is linked
mainly to masticatory forces and their cumulative effect. Two
simultaneous factors are responsible.10 The first is a relative
lateral movement which leads to friction across adjacent
teeth. It occurs along a plane perpendicular to the line linking
their contact points and it is due to the visco-elasticity of the
periodontal ligament. The second factor is a posterior-anterior
movement which distributes the mesial component of the
occlusal forces across the entire dental arch, pushing the distal
tooth onto the mesial tooth. If the curve of Spee is absent or
decreased, and this is associated with considerable occlusal
wear, this movement is significantly intensified.11 To these
two factors should be added the axial depressibility of the
periodontal ligament when a tooth is subjected to occlusal
pressure. Its value can reach 28 mm.12
In past populations, interproximal wear started in childhood and was often heavy in adults.13 There was generally a
difference between the very worn mesial surfaces, which were
strongly concave, and the distal surfaces which remained
convex (Fig. 1). According to Gaspard14 this has to be
Fig. 1 – Interproximal two-body abrasion linked to
masticatory forces and their cumulative effects observed
in a Nubian adult individual (Mirgissa sample, 1890–1580
BC housed in Pessac, Gironde, France). Mesial surfaces are
often concave whilst distal remained convex.
considered in relation to the form of the masticatory cycle.
For Kubein and Krüger15 this uneven wear represents a
difference in oscillation speed between the two teeth in
contact, with the mesial tooth oscillating at a higher frequency
than the distal tooth.
Another form of two-body abrasion which is independent
of mastication is also described at interproximal level.
Originally described by Siffre16 in two molars of the Neandertal
La Quina H5, it has the aspect of a fairly regular groove, usually
located on or close to the neck of the posterior teeth (Fig. 2). Its
origin is interpreted in different ways in the literature,17 but is
usually attributed to the frequent passage of a solid body like a
tooth-pick between the teeth (made of bone, horn or plant
material).16–22 The reason for this action would be therapeutic,
palliative or idiopathic. Less frequently, these grooves which
are found exclusively in human fossil taxons17 are located at
the level of the anterior teeth.23 Their presence in modern-day
individuals, on the other hand, has not been much reported in
the literature.24 Note that this type of wear may also result
from a three-body abrasion when mineral particles penetrate
between the tooth and the solid moving body. It appears to
increase the speed of wear and to produce deeper scratches.22
At the occlusal level, physiological two-body abrasive wear
can theoretically occur since there is evidence of fleeting and
inconsistent inter-dental contacts during swallowing and
mastication.25 However, a longitudinal study by Kaidonis
et al.26 in a sample of Australian aborigines contradicts this
idea. These authors show that the definition of facets typical of
two-body abrasion is not constant over time despite the
continual influence of abrasive particles in the food. Thus the
occurrence of this type of facet could be linked with frequent
grinding episodes, independent of any masticatory action.
When two-body abrasion predominates, it is characterised
by well-defined, smooth, shiny wear facets at sharp angles.
The cusps and the free edges of the incisors are flat. When the
dentine is exposed, it is at the same level as the enamel, with
no margin.3,9 Whether they are located on dental tissue,
restorative material or on both at the same time, the facets
come together, they match up and remain in close contact
archives of oral biology 57 (2012) 214–229
217
stated that most mammals, including Man, deliberately
sharpen their teeth to use them as a weapon and to make
them more efficient during mastication. This genetically
determined ancestral behaviour is an indication of the
aggressiveness in every individual which manifests itself
during episodes of stress. In this case, two-body abrasion wear
facets are formed which are independent of mastication.34 For
Murray and Sanson35 this theory was proposed on the basis of
various different points but is based on suppositions rather
than facts.
Lastly, we should note that extra-masticatory two-body
abrasion can sometimes follow certain rituals or certain tasks
regularly carried out by past populations36 but in modern
populations too.24 It gives rise to cuts, notches or chips, which
may be vestibular, incisal or occlusal.
2.1.2.
Three-body abrasion
Three-body abrasion is the displacement of two bodies, one
across the other, with the interposition of abrasive particles
which constitute the third body. In odontology and dental
anthropology it is often called abrasion. In general it is
associated with the size, the shape and the hardness of the
interstitial particles. In tribology two types of three-body
abrasion are distinguished, according to the proximity of the
moving solid bodies3,37:
Fig. 2 – (A) Environmental scanning electron microscope
(ESEM) micrograph of interproximal groove on the mesial
facet of a second lower right molar belonging to the
neandertal dental remains from the Rochelot cave (SaintAmant-de-Bonnieure, Charente, France). (B) Microwear
detail of the same groove as A at higher magnification
showing parallel striations on the enamel.
during the small excursive mandibular movements.3,9 This
characteristic is fundamental when diagnosing this wear
mechanism, especially in patients presenting with a parafunction during awake or sleep bruxism.27,28
It should be noted, however, that the presence of major
wear should not systematically assume a diagnosis of this last
pathology,29 characterised by a grinding and/or involuntary
and stereotypical clenching of the teeth, as some young
individuals with confirmed sleep bruxism do not show major
tooth wear.30
If the surfaces do not correspond exactly one with another
or if there is a difference in the degree of wear between two
opposing dental arches, then one or several other wear
mechanisms prevail or exist in addition and should be looked
for.31 It may be acid dissolution in the dental tissue (erosion in
the odontological sense) or three-body abrasion caused by the
abrasive load of food in the exposed dentinal areas.3,9
Differential diagnosis is often difficult. If possible, it can be
refined by microscopic examination of the facets which can
reveal parallel striations when two-body abrasive wear
predominates.32
According to Every33 and his theory of ‘‘thegosis’’ (from the
Greek thego, to sharpen, to hone), another form of occlusal
two-body abrasion can be considered as physiological. Every
- when the two bodies are distant, the abrasive particles are
free to move and they act like a slurry across all surfaces.
Only a small proportion of particles (10%) are responsible for
the three-body abrasion.8 The surfaces of the two bodies do
not correspond as they are not in direct contact,
- when the two bodies are sufficiently close together, the
abrasive particles are gradually trapped between the surface
of one or both bodies and are no longer in suspension. They
are then carried away by the two bodies in movement
causing specific types of grooves and striations, especially
when the surfaces of these bodies are rough. Surfaces
subjected to this type of wear sometimes do correspond one
with another as the particles become an integral part of the
bodies.
In the oral cavity, three-body abrasion can be generalised
and/or localised. When it is generalised, it is associated mainly
with the abrasive load of the food bolus, which affects all tooth
surfaces during mastication. During this function, there are
two phases that succeed one another and which correspond to
the tribological model.3,37 Their occurrence depends on the
proximity of the opposing teeth and the dilaceration of the
food bolus.
In the first crushing phase, the particles contained in the
bolus are free to move around and preferentially abrase nonocclusal contact areas. On the vestibular and lingual surfaces
where there is no bacterial plaque, friction by the tongue and
the soft tissues also contributes to developing this wear. It is
particularly visible in restorative materials like glass-ionomers or composites where abrasion of the matrices exposes
the loads which eventually become dissociated.3,37
During the second sliding phase, the teeth come closer and
closer together as the food bolus is shredded and the abrasive
218
archives of oral biology 57 (2012) 214–229
particles are gradually dragged in then trapped between their
surfaces. They then form temporary and haphazardly arranged microscopic gouges, furrows, pits and scratches which
when studied for microwear provide a great deal of information for the paleoanthropologist38 and the odontologist39 as
their depth, length and width are characteristic of specific
masticatory cycles and masticated foods (Fig. 3).40 The rougher
the dental tissue or restorative material, the more the particles
have a tendency to become incorporated into the surface
microgrooves. During this rapid and uneven masticatory
phase, inter-dental connections are established around the
occlusal contact areas. At the same time, the particles trapped
between the teeth cause a three-body abrasion in the occlusal
areas without contact.3,37 Contacts persist during the swallowing phase and even afterwards, during self-cleaning
movements of the teeth and the oral cavity. The cumulative
effect of these mechanisms is to produce enamel surfaces that
are blunted and smooth, with rounded edges.3 When the
dentine is exposed, its softness combined with its organic
content produces differential wear with the enamel.41 There is
then a margin separating these two tissues as the dentine
surfaces wear more quickly.3,9,37 They become concave in
shape and orangey brown in colour. Making a differential
diagnosis between this and corrosive occlusal lesions is
Fig. 3 – (A) SEM micrograph of occlusal surface of a first
upper left molar in a medieval adult individual (Sains-enGohelle, Pas-de-Calais, France, 7–15th centuries).
E = enamel, D = dentine. Top left is an area with a
predominance of pits (1) and top right is an area with
predominance of scratches (2). (B) Stereomicroscopy (50T)
of the same molar as A in an other area showing on the
left scratches (2) on the enamel. E = enamel, D = dentine.
sometimes difficult (see Section 2.4 below); if possible, the
diagnosis can be refined by microscopic examination of the
surfaces which reveals a smear layer obstructing the tubuli
when the wear is abrasive in origin.32
In ancient populations, three-body abrasion was associated mainly with mastication, sometimes called ‘‘demastication’’.
It was ubiquitous, intense and progressed rapidly.42–44 In these
populations it involved opposing teeth and food that was not
necessarily abrasive in itself but which contained particles
that were harder than the dental tissue (phytoliths, quartz,
amorphous silica).45,46 Cusp morphology is gradually altered
by a macroscopic process which exposes wear facets on the
enamel then the dentine in the form of points and islets that
gradually coalesce.47,48 When individuals remain dentate and
well balanced functionally, the topography of the occlusal
plane can take on different forms, depending on diet and
morphological factors such as the shape and size of the dental
arch and the type of occlusion.49 Traditionally, three forms are
described. (1) Helicoidal, which is the most common in France,
from the Neolithic to the Bronze Age50 and from the GalloRoman period to the Middle Ages.51 In Europe, it is also often
found from the Middle Palaeolithic until the present day.52,53
The total abrasion surface, normally the mandibular, takes the
form of a double helicoid54 in which the location of the worn
flat surface depends on the progress of the occlusal wear.55
When the large blade, oriented ad vestibulum, includes on each
side the two premolars, the first molar (M1) and the mesial half
of the second molar (M2), then the small blade, oriented ad
linguam, includes the distal half of M2 and the third molar (M3),
with the pitch of the helicoid oriented ad planum and located in
the middle of M2 (Fig. 4). This particular topography results
from masticating food that requires considerable muscular
force56 and a particular masticatory cycle.57–59 Alongside these
main factors, the differential wear associated with the
chronology of tooth eruption60,61 and the original orientation
of the molars58,59 are also relevant, as is the relative width of
the dental arches58,62–64 and the lesser tissue resistance in
M1.65,66 (2) the second form is the horizontal ad planum form
with the flattening of the sagittal (Spee) and frontal (Wilson)
compensation curves. This form characterises the occlusal
Fig. 4 – Helicoidal occlusal plane in a medieval adult
individual (Sains-en-Gohelle, Pas-de-Calais, France, 7–
15th centuries). The topography that develops with wear
results from masticating food that requires considerable
muscular force and a particular masticatory cycle.
archives of oral biology 57 (2012) 214–229
plane of the hunter-gatherers whilst in prehistoric agriculturalists the Wilson curves (ad vestibulum wear) were usually
inverted as occlusal wear progressed.67 In the Bronze Age,
Maytié50 estimates this at 1.4% in France compared with 95.5%
for helicoidal wear. Curiously, Gisclard and Lavergne68 found
this form more often than helicoidal wear in certain sites in
Languedoc. (3) the third form is the ad vestibulum form
characterised by a high level of abrasion of the cusp supports
for all the mandibular molars. This may be the result of the
evolution of helicoidal wear if there is a ‘‘severe attrition
syndrome’’64 but when it is generalised across the dental arch,
it is an atypical form. Maytié50 evaluates it at 3% in France,
from the Neolithic to the Bronze Age.
In today’s industrialised populations, three-body abrasive
wear, although it is limited, is physiological wear when viewed
in correlation with ageing and individual diets. It gives rise to
wear facets where the surface area increases with age.69 In the
incisors, these surface areas are associated with proclusion/
retroclusion movements. Meanwhile, the other teeth are
associated with lateroclusion/medioclusion movements. In
the premolars and molars, two types of facet coexist: working
facets and non-working facets, both of which are functional.69
They form during the different masticatory cycles and in turn
they guide these cycles.29,57,70–72
When it is localised, generally at the cervico-vestibular
level, three-body abrasion is basically associated with tooth
brushing.73 The abrasive particles in the toothpaste are the
third body, interposed between the brush and the teeth. In
some pathological cases accentuated by acid attack, the
dentine in the roots is exposed to varying degrees and there is
heavy wear in cases of iatrogenic brushing. In these cases,
extended lesions or notches form around the exposed root
dentine.24 There is often associated hypersensitivity.73
2.2.
Adhesive wear
This wear mechanism is associated mainly with metals and
polymers and can occur when two bodies subjected to strong
pressure slide one against the other.3,6 From a tribological
point of view, the surface asperities that come into contact
undergo plastic deformation and can come together locally, as
happens in cold welding. In such cases varying amounts of
material are transferred from one surface to the other,
depending on the distance separating the materials, their
properties, their roughness, the pressure, the temperature or
the environment.6 This mass of transferred material may
break up as the movements increase but not necessarily along
the original line of fusion. If it is interposed between the two
bodies, a three-body abrasion begins.3,6
In the oral cavity, this type of wear can theoretically occur.
Indeed, two-body friction tests in vitro reveal a transfer of
material onto the enamel or an analogue, from restorative
materials such as amalgam,74 gold75 and some composite
materials under great pressure.76 Other results show that this
type of wear can also occur between two poly(methyl
methacrylate) surfaces.77 In the oral cavity, however, adhesive
wear is limited, thanks to the lubricating action of saliva,
which reduces the friction coefficient. In addition, three-body
abrasion caused by the food bolus tends to remove the layer of
displaced material.3
2.3.
219
Fatigue wear
When one surface under high pressure slides over another, a
compression zone is created ahead of the movement whilst a
tension zone is created behind. These deformations which
concern the surface molecules can propagate in the subsurface of brittle materials causing ruptures to the intermolecular bonds.6 Depending on the nature of the materials,
micro-cracks may then be initiated around the damaged subsurface zone and propagate as the cycles are repeated. When
propagation reaches the surface, fairly large fragments of
material can become detached and interposed between the
two surfaces in contact giving rise to three-body abrasion.6
Generally, surface delamination is the result of interactions
between abrasion, adhesion and fatigue mechanisms.
In the oral cavity, fatigue wear can occur on certain enamel
occlusal contact surfaces subjected to considerable pressure,
besides during mastication.78 The high mineral content of this
tissue means that it is harder than dentine but its high
modulus of elasticity and its low tensile strength make it
brittle. In Man, it is organised prismatically, and this controls
microcrack propagation79,80 which is least at occlusal level
where the prisms are perpendicular to the surface and
mineralisation is at a maximum.41,81 When microcracks
initiate in the enamel they cause delamination first of the
interprismatic substance and then of the prisms82 but they are
unable to propagate into the dentine because of the enameldentine junction which disperses the stresses.83
For some authors, the formation of sub-vertical grooves at
proximal level, which are frequently found in Neandertals,84–
87
is initiated by these microcracks (Fig. 5). The strength of
axial88 and/or lateral85 forces in combination with a particular
orientation of the Hunter-Schreger bands86 and an acid
environment84 then amplify this mechanism to form veritable
semi-circular radial grooves. Other authors87 consider that the
high frequency of these grooves on both anterior and posterior
teeth showing little occlusal wear and no micro-cracks tends
to invalidate these different sequential hypotheses.
In addition, the notion of fatigue is also central to the
theory that tooth flexion initiates surface fragmentation in
Fig. 5 – ESEM micrograph of sub-vertical grooves (white
arrows) on the distal facet of a first upper left premolar
belonging to the neandertal dental remains from the
Rochelot cave (Saint-Amant-de-Bonnieure, Charente,
France).
220
archives of oral biology 57 (2012) 214–229
cervical enamel (abfraction).89–91 Although various clinical
and theoretical arguments have been put forward to justify
this indirectly, a causal relationship nevertheless remains
speculative.92,93 Indeed, no non-carious cervical lesion of this
type has been evidenced in past populations94,95 and contemporary individuals with bruxism have no more abfraction
lesions than others.96
2.4.
Corrosive wear
Strictly speaking, tooth surface loss caused by chemical or
electrochemical action is termed corrosion.91 As far as
terminology is concerned, it is often called erosion in dentistry
(from the Latin verb erodere, to eat away). This may cause
confusion with the tribological use of this term which is
defined as the progressive loss of material from a solid surface
due to mechanical interaction between that surface and a
fluid, a multicomponent fluid, impinging liquid or solid
particles.91 Tribochemical wear is caused when chemicals
(acid, chelating agent) weaken the inter-molecular bonds of
the surface and therefore potentiate the other mechanical
wear process.9,97 This situation can be particularly critical in
cases of sleep bruxism where two-body abrasion following
episodes of teeth clenching and/or grinding is often accompanied by intrabuccal acidity linked with gastroesophageal
reflux disease (GERD).98 Three-body abrasion linked with
iatrogenic tooth brushing can also significantly aggravate
occlusal and cervical lesions in an acid environment as surface
molecules are driven away, only for the newly exposed surface
to be immediately attacked by the corrosive environment.3,73
A diagnosis of corrosive wear is essentially based on the
presence of concave cup-shaped zones, with rounded surfaces.3,9,37,78 In the enamel, demineralisation of the prisms
and the interprismatic substance forms a characteristic
‘‘honeycomb’’ structure whilst dissolution of the aprismatic
enamel is more irregular.99 The lesions are smooth and
polished, without perikymata and with no variations in shade.
In the dentine, the peritubular zones are affected before the
intertubular zones, which enlarges the tubuli.99 There is no
deep-seated acid diffusion so that, in contrast to caries, the
demineralised surface only concerns a thickness which is
generally less than 100 mm. Concerning occlusion, the contact
surfaces of opposing teeth do not correspond and restorations
are generally not damaged, apart from glass-ionomers.100
When the dentine is affected, differential diagnosis with
three-body abrasion lesions is based on the location and the
depth/width ratio of the cup-shaped areas of wear.101 This
ratio is greater than 0.25 and increases as the corrosive wear
progresses, whereas it is less than 0.25 and varies little as the
abrasive wear progresses if the nature of the food remains
constant.94 Whenever possible, diagnosis can be refined using
scanning electron microscopy (SEM). The absence of smear
layer on the tubuli suggests chemical origin rather than
mechanical.94
In past populations, corrosive wear is reported only rarely.
It is described, however, in a molar of a Homo habilis (OH 16, ca.
1 750 000) who fed on unripe fruit102 and also in a pre-contact
sample of New Zealand Maori94 eating food that had been
fermented.32 For some authors103,104 the origin of the lingual
surface attrition of the maxillary teeth (LSAMAT) first
described by Turner and Machado105 in a sample from Brazil
(4200–3000 BP) is partly corrosive as it is associated with acid
regurgitations. For others106–108 these particular lesions are
not corrosive in origin and instead are linked with the
consumption of abrasive food, like manioc.
In present-day industrialised populations, there is an
increasing prevalence of corrosion resulting from food habits,
especially in young individuals.109,110 The corrosive agents
involved here are acids of extrinsic and/or intrinsic origin,
from non-bacterial sources. The main extrinsic sources are
chemical environmental factors111 or they are to be found in
food.112 These consist mainly of sodas, acid fruits, premix
alcoholic drinks aimed at adolescents (alcopops), energy
drinks, fruit juices, wine, etc., where the extreme acidity is
rarely indicated. Some medical sources (ascorbic acid,
acetylsalicylic acid) and some mouthwashes are also offenders.110 The main intrinsic sources are regurgitations, GERD
and vomiting, whether spontaneous (chronic alcoholism) or
induced (anorexia-bulimia).110 Finally, note that saliva plays
an essential role in modulating corrosive wear, thanks to its
buffer effect associated mainly with the presence of phosphate and bicarbonate ions which can compensate when pH
values drop to so-called critical levels, i.e. pH of around 5.5.110
In addition, it forms a protective protein film and has the
ability to remineralise, which limits deleterious effects
although without being able to prevent them.2
3.
Scoring systems
Scoring systems for occlusal and interproximal wear can be
qualitative and/or quantitative. Surface examination is carried
out directly on teeth, photographs, drawings, replicas or
computer reconstructions.113 It can be visual or done with
analogue and/or digital instruments. Scoring assesses tissue
loss from an organ of which the primitive volume is unknown,
and so dividing tooth wear into successive levels is a
subjective process and varies with different authors. Nevertheless, it forms the basis of a vast number of classifications
which can be used under certain conditions to determine food
habits, paleodemography (age at death class) and the state of
health of past populations. If some classifications are more
frequently used113,114 the main problem with different wear
indices is that different populations cannot be directly
compared. In some cases, classifications can also be used to
follow the clinical evolution of wear, to carry out epidemiological studies, to establish links with certain pathologies or
compensations of the masticatory apparatus, in specific
classes of the current population.
3.1.
Qualitative and quantitative classifications
Qualitative and quantitative classifications generally differ
according to the field of study. In Odontology they can be used
to code corrosive and abrasive wear. Almost all classifications
used to determine the former type of wear derive from those of
Eccles115 and Smith and Knight.116 They take into account the
severity and the site of the erosion. However, they lack any
standardisation and it is difficult to reconcile both clinical and
experimental imperatives.117 To overcome these limitations,
archives of oral biology 57 (2012) 214–229
Bartlett et al.117 propose a Basic Erosive Wear Examination
(BEWE) where the vestibular, occlusal and lingual faces of all
the teeth, except the wisdom teeth, are examined for lesions.
These are then classified according to one of four degrees of
severity and the highest value in each sextant is used. The sum
of these values then defines the degree of severity of the
lesions due to acid attack and recommendations can then be
formulated for the patient’s subsequent care.
Classifications used to categorise abrasive wear mainly
take into account the enamel facets, recording the mandibular
kinematics of present-day populations which often show
limited wear.29,118,119 They can also be used for assessing the
severity and progression of occlusal tooth wear.120
Anthropological classifications, first instigated by Broca,121
are usually used for ancient populations, characterised by
rapid and intense occlusal wear. They are unable to make clear
distinctions between the first stages of enamel wear and are
most often based on the amount of exposed dentine. Whilst
some authors13 have used the Broca scale,121 others have
taken it as a basis for proposing scales of 4–7 stages.52
Currently, these classifications are only used for rapid coding
of occlusal wear and they are often adjusted according to the
populations being studied. With Murphy47 a more elaborate
system of measurement emerged. With an 8-point scale and
many subdivisions, there were 25 levels with which to code
wear across the entire dentition, irrespective of age. This
classification was used for a long time and inspired Brothwell122 but it was rather cumbersome and nowadays Scott’s
system123 tends to be preferred when coding wear of molars in
past populations.114 This system is based on the amount of
enamel that has disappeared rather than the amount of
exposed dentine. In this way not only the intensity of tooth
wear can be studied, but also the speed at which it occurred,
and these two factors make it possible to study inter- and
intra-population variability. When coding other teeth, Smith’s
system67 is preferred.114 As well as the rate of wear, the angle
of the occlusal surfaces of the molars is determined. This
system is one of several classifications42,124 to associate
different criteria such as the surface area of exposed dentine,
the morphology and orientation of wear surfaces which as
well as making isotopic or carious analyses possible can also
be used to study food habits and technology in past
populations. In these same populations, interproximal wear
can sometimes be assessed even though it is difficult to code
when the teeth are in place on their bone base. One method is
to determine the reduction in length of a segment of worn arch
and compare this value with values from segments without
wear.10,13,125,126 Another possibility is to measure the width of
the proximal wear facet at the occlusal level and compare it
with the occlusal127 or proximal wear,128 but the relation
between these variables is only partial. Whilst interproximal
attrition is associated mainly with the intensity and frequency
of the masticatory forces, occlusal wear is influenced in
addition by the abrasive properties of the food.10
3.2.
Qualitative and chronological classifications
As soon as the chronological variability of tooth eruption was
better understood, some authors established ratios for the
relative differences in tooth wear in the same dental
221
arch.42,48,122,129–133 According to age, different tables were
drawn up for the progress of wear in the dental arch, with the
grading of abrasion according to date of tooth eruption being
particularly remarkable in M1, M2 and M3. Indeed, the
majority of authors were in agreement over the fact that
abrasion of the M1 was greater than that of the M2, which was
in turn greater than that of the M3.123,131 This can be explained
by the chronology of eruption, especially for M1 and M2 which
demonstrate little variation between populations, whereas the
eruption of M3 is more variable. Next, on the basis of the
decreasing gradient of wear from M1 to M3, different
chronological classifications were created to estimate the
age at death of individuals from past populations. However,
even though wear is increasing significantly with age in
today’s industrialised populations, care should still be taken
when considering the age/tooth wear relationship especially
in past populations. Wear varies significantly between different groups depending on their food and food preparation
habits, especially since the first ‘‘food revolution’’ which
occurred at the transition from the hunter-gatherer lifestyle to
a food producer lifestyle,67,134,135 but also since the second
much more recent ‘‘food revolution’’, characterised by the
consumption of food that is soft and not very abrasive.42,136
Even though there is a strong relationship between these two
variables, in individuals in the same population, the same
generation and with the same food habits, the speed of
abrasion is not constant over time. It varies according to
tissues,41 sex and occlusal function,137 craniofacial morphology138 and oro-facial musculature.139–142
4.
Dental and skeletal compensations
The advance of occlusal and proximal wear modifies the
distribution of occlusal stresses. This in turn leads to a change
in the position of the teeth and a remodelling of the bone and
cementum structures across the three spatial planes.128 These
compensatory mechanisms by the masticatory apparatus are
universal143 as they can be found in past populations, but also
in modern industrialised populations, although in a more
discrete form.144 When the occlusion remains functional, the
teeth undergo three types of migration (1) passive eruption at
all levels (2) mesial drift at the posterior level and (3) lingual
tipping at the anterior level, it therefore evolves physiologically with ontogenesis and the development of the wear. This
pattern can be profoundly modified when there is edentation,
carious and/or periodontal diseases (Fig. 6).
4.1.
Continuous eruption
The idea that human teeth undergo continuous eruption
throughout life was first proposed by Gottlieb145 then developed further by other authors13,146–148 although the actual
biological mechanisms involved had not been completely
understood or documented. Murphy149 was the first to
compare two samples from aboriginal Australians with and
without wear and showed that this eruption was linked
mainly to bone apposition in the alveoli (for 2/3) and
cementum along the roots (for 1/3). He quantified it (4 mm
in the sample with wear) and showed that it was not
222
archives of oral biology 57 (2012) 214–229
more apically, at the level of the cementum.167 When the
roots are exposed, we may also suspect bone atrophy or
bone loss as a result of periodontal inflammation.
Differential diagnosis can be refined by observing the
aspect and the destruction of the interproximal bone
septum. In health, it is smooth and forms convex to flat
surfaces faciolingually.168 In disease, the cortex is
resorbed, and the surface becomes roughened.152,163 The
nutrient canals, which are normally small, become
enlarged and can easily be seen. As resorption of the
cortex continues, the underlying trabecular pattern of the
cancellous bone is exposed.168
Fig. 6 – Profoundly modified occlusion with edentation and
periodontal diseases in a medieval adult individual (Sainsen-Gohelle, France, 7–15th centuries). Note that upper left
molars have overerupted into open space.
associated systematically with major tooth wear. Thus
according to the kinetics of occlusal wear and the way the
phenomenon is expressed, three situations are possible.150
(1) When occlusal wear is heavy and progresses faster than
the compensating tooth eruption, the anatomical and
clinical crown heights decrease significantly. The occlusal
vertical dimension (OVD) also decreases149,151,152 whereas
when at rest, interocclusal space (IS) increases.150 This
situation occurs when wear is at an advanced stage and it
is mainly to the detriment of the dentine, which is less
resistant than the enamel.153,154 In the pulp chamber,
reactional dentine sometimes forms too slowly and cannot
prevent pulp effraction. Bacteria then spread to cause a
chronic periapical inflammation often associated with
severe bone lesions.36,155,156
(2) When occlusal wear is heavy but is compensated by
continuous eruption of the teeth, OVD and IS do not vary
significantly.150 This situation has been demonstrated
extensively from direct craniometric, radiological and/or
histological measurements on various ancient samples
from American Indians157 (Knoll, 5000–4000 BC),
Nubians158 (1890–1580 BC), Romano-British153,159,160 (100–
400 AD), Anglo-Saxons153,161 (700–900 AD), medieval
individuals from Britain,153 Finland154,162 and Scotland,163
Australian aborigines164 and pre-industrial revolution
Irish.165 In terms of radiological observations, the distance
between the upper edge of the inferior dental canal (IDC), a
fixed reference point,166 and the occlusal surface (OS) of the
mandibular premolars and molars where wear occurs is
constant whereas the distance between IDC and the
cemento-enamel junction (CEJ) in these same teeth
increases. In addition, the distance between IDC and the
alveolar crest (AC) remains constant or increases slightly
when bone apposition is concomitant with tooth eruption.
In this latter case, promoted when wear progresses
rapidly,164 the distance between CEJ and AC remains
constant, whereas it increases when eruption concerns the
teeth only.149,157 In periodontal terms, this continuous
eruption leads to the epithelial attachment being relocated
Lastly, note that continuous eruption of teeth to
compensate for occlusal wear is also found in contemporary individuals with heavy occlusal wear.169 Here again,
although the height of the teeth decreases in anatomical
terms, clinically speaking their height does not vary
significantly.
(3) When occlusal wear is moderate and posterior dental
stability is maintained, the OVD increases slightly throughout life151,170–174 and IS decreases or remains constant.150
This increase is suggestive of continuous eruption of the
mandibular incisors which lead to a slight posterior
mandibular rotation.172 This usually occurs during the
third decade of life.172–174 In a British sample of determined
age at death and with only moderate wear (Spitalfields,
east London) Whittaker et al.171 estimated that in 40 years
the molars erupted 2.8 mm whilst the apex migrated
coronally only 2.2 mm. This means that in one year, these
teeth erupted 0.07 mm and that in 40 years 0.6 mm of
cementum was deposited at the apex.
Finally, note that this eruption to compensate for occlusal
wear can also be found in the deciduous dentition175 and that
it is not exclusive to the Homo genus having also been
described in Pongo, Gorilla, and Pan genus.176
4.2.
Mesial drift
The origin of physiological mesial drift of the posterior teeth
has not been completely determined, but the role of the
transseptal and supracrestal fibre systems is often mentioned.177 It leads to a remodelling of the bone178 and
cementum179 with distal apposition in areas of tension and
resorption mesially in areas of compression. When heavy
interproximal wear accompanies this drift, the length of the
dental arches decreases significantly. This link has been
repeatedly demonstrated and quantified in past populations.10,13,57,125,126,155,157,158,180,181 Studying 9 mandibles from
Australian aborigines, Begg13 estimated that this reduction
was about 10 mm, after eruption of the third molars. In a
sample of native American Indians from New York state (10–
19th centuries) Fishman181 found a similar value, however
Murphy126 assessed it at less than half this in samples from
Australian aborigines. This mesial drift is also found in
present-day populations, at adolescence and in young adults,
then it decreases with ontogenesis.182–185 It brings about a
reduction in the size of the dental arches of between 2 and
2.5 mm despite the absence of interproximal wear. According
archives of oral biology 57 (2012) 214–229
to Begg13 and his ‘‘attritional occlusion’’ model, this absence of
wear is responsible for the gradual development of malocclusions in present-day populations. Also, the growing frequency
of dental crowding and third molar impaction or non-eruption
is linked with a diet of soft foods. Some authors share these
views186–190 although others are less sure191–193 and believe
that the lack of space responsible for malocclusions is due to a
reduction in masticatory strength, which leads in turn, by
mechanomorphosis, to a reduction in the basal bone of the
arches. The larger size of teeth that were not worn would have
no influence. On the other hand, the high frequency of
overcrowding found in an ancient sedentary population from
the Copper Age (Roaix, France) tends to go against this idea,
supporting instead a genetic origin.194
4.3.
Incisor lingual tipping
In addition to continuous eruption and mesial drift of the
posterior teeth, there is a third movement, lingual tipping,
which can affect the anterior mandibular and/or maxillary
teeth with wear and age. This change in axial inclination,
which has not been extensively described in the literature,
was first observed by Selmer-Olsen195 in a Norwegian sample,
then confirmed by metric and cephalometric studies also on
ancient samples.157,158,180,196–200 Depending on the arch under
consideration, different situations occur: whilst Seddon198 and
Hasund180 could detect no change in the axis of worn central
mandibular incisors respectively in Romano-British (Poundbury, 4–5th centuries) and medieval Norwegian samples,
Hylander157 demonstrated significant lingual tipping of the
central maxillary and mandibular incisors in a cephalometric
study of American Indian skulls (Knoll, 5000–4000 BC). He also
showed that the amount of inclination associated with wear
was greater in the maxillary incisors. These same observations were made by Varrela199 in a medieval Swedish sample,
by Kaifu200 in different prehistoric Japanese samples (Jomon,
5000–300 BC; Yayoi, 300 BC–AD 300), in medieval (Kamukura,
AD 1333), premodern (Edo, 1600–1868 AD) or recent (1868 AD–
1926 AD) samples and also by d’Incau and Rouas158 in a Nubian
sample (1890–1580 BC). On the other hand, Fishman181 and
also Mohlin et al.187 found no significant inclination change in
the maxillary incisors in samples of native Americans from
New York state (10–19th centuries) and medieval Swedish
samples respectively. Despite these divergences, most
authors157,180,195,200 nevertheless believe that this lingual
tipping ensures that the proximal spaces caused by tooth
wear are closed and also ensures that contact is maintained
between adjacent teeth. In terms of mechanics, two tipping
movements are theoretically possible201: in the first, the centre
of rotation is more apical than the centre of resistance of the
tooth. It is effective, but requires a considerable amount of
energy. In the second, the centre of rotation is at the centre of
resistance of the tooth. This is more economical and requires
only a horizontal force at the level of the dental crown. It
draws the apex towards the exterior and the free edge towards
the interior. For some authors125,157,195 this force originates in
an imbalance between the action of the tongue and the lips,
with the lips predominating. In modern-day populations
where teeth undergo limited wear, a very slight anteroposterior movement of the maxillary incisors has been
223
demonstrated by Fosberg172 in a longitudinal study over 10
years and by Crétot173 in a study of 723 individuals grouped by
age class (15–22 years, 23–42 years, 43–80 years) and according
to dento-facial morphology. Sarnäs and Solow174 on the other
hand, in a 5-year study, observed no significant change.
Krogstad and Dahl139 compared dento-facial morphology
between a group of Norwegians with considerable tooth wear
and a control group with limited or no wear. They demonstrated a verticalisation of the incisors in the first group. These
results have been confirmed by other studies.140–142 Lastly, we
note that lingual tipping of the central incisors associated with
tooth wear has also been observed in some great apes176 and
has been demonstrated indirectly in certain Hominid fossils,
i.e. Australopithecus robustus202 and Neandertals.203
5.
Summary
In past populations tooth wear was ubiquitous, intense and
progressed rapidly. It affected the occlusal surfaces with a
three-body abrasion mechanism and profoundly changed the
occlusal plane which, in the absence of edentation, usually
took the shape of a double helicoid. The proximal surfaces,
subjected to two-body abrasion, were also affected. In these
same populations, by applying a scoring system for wear,
diet and cultural change can be determined as well as the
age at death of individuals. It is also possible to illustrate
and monitor the evolution of certain dental and skeletal
functional compensations in the masticatory apparatus:
continuous eruption, mesial drift of the posterior teeth,
incisor lingual tipping, especially of the maxillary teeth.
These compensations, along with other factors, i.e. anterior
mandibular rotation,199 condylar growth,157,204 a reduction
in overbite205 and in overjet,205,206 are responsible for the
genesis of the edge-to-edge bite (labiodontia) from an
occlusion that was originally scissor bite (psalidontia)
(Fig. 7).13,62,143,149,155,157,200,204–207 These universal adaptations
have also been described in certain present-day individuals
with heavy tooth wear140 and to a lesser extent in elderly
people who have kept their teeth and remain balanced
functionally,173 however, they do not always result in the
formation of an edge-to-edge bite.139 Certain factors, such as
the initial mesio-distal relation between the first mandibular
molar and the first maxillary molar, seem to be determinant as
despite the progress of tooth wear, a scissor bite persists in
some dental class 2 prehistoric individuals.205 These observations must also be compared with the fact that food has
become more refined over time as have the associated
technologies (use of chopsticks in Asia, and the fork in
Europe) and this means that such physiological and ontogenic
occlusal evolution is now virtually impossible.208,209 On the
other hand, in present-day industrialised populations overbite
persists and when the force involved in eruption is not limited
by the work involved in biting this sometimes leads to
supraclusion of the incisors.210 To this is added a growing
prevalence of eating disorders (anorexia-bulimia), problems
associated with consuming food and drinks that are too acid
(soda), with awake or sleep bruxism, especially in the young.
Types of tooth wear that had remained unchanged since the
origin of humanity have undergone profound changes in a
224
archives of oral biology 57 (2012) 214–229
Fig. 7 – Wear-related changes in dento-alveolar complex observed in a medieval adolescent individual with developing
dentition (left) and an adult individual with extensive wear (right) (Sains-en-Gohelle, France, 7–15th centuries). Note
continuous eruption, changes in incisor inclination and modification in anterior occlusion. Initial scissor bite during
childhood is modified through edge-to-edge bite in adults with advanced wear.
archives of oral biology 57 (2012) 214–229
very short space of time. Today’s tribochemical pathological
model has replaced the abrasive physiological model of the
past.
Acknowledgements
We are grateful to Pr. P. Semal (IRSNB, Bruxelles), J. Cillys
(Laboratoire de microscopie électronique IRSNB) for ESEM
micrographs (Figs. 2 and 5) and to Y. Lefrais (IRAMAT-CRP2A,
Pessac) for SEM micrograph and stereomicroscopy (Fig. 3). For
providing access to Mirgissa archaeological sample, we thank
P. Courtaud (UMR PACEA/5199, Talence) and for the Sains-enGohelle sample, C. Beauval (SARL ArchéoSphère, Bordeaux).
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
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