Indian J Stomatol 2011;2(4):245-48

2010;1(1):1-5

Interproximal Enamel Reduction in Comprehensive Orthodontic Treatment: A Review

3
Sandhya Jadhav1, Shilpa Vattipelli2, Mani Pavitra

Abstract
Interproximal enamel reduction (IER) technique is a means of gaining space as a part of comprehensive orthodontic treatment.
Following a careful literature review the article discusses interproximal enamel reduction techniques. The history, indications,
contraindications, advantages, disadvantages and precautions of interproximal enamel reduction are also discussed.
Interproximal enamel reduction technique when used correctly for the right cases can serve as an effective way to gain space
during orthodontic treatment. If the technique is utilized correctly there is no evidence that it is in any way deleterious to the
dental hard tissues or soft tissues.

Keywords: Interproximal enamel reduction, proximal stripping, recontouring.

Introduction polishing and topical application of fluoride.

Interproximal enamel reduction is a clinical procedure
involving the reduction, anatomic recontouring and protec-
tion of proximal enamel surfaces of permanent teeth (Peck
and Peck 1972).1 The aim of this reduction is to create
space for orthodontic treatment and to give teeth a suitable
shape whenever problems of shape or size require attent-
ion. In the literature, this clinical act is normally referred to
as “stripping,” although other names can be found, such as
“slicing”, “Hollywood trim”, “selective grinding”, “mesi-
odistal reduction”, “reapproximation”, “interproximal
wear” and “coronoplastia”. The use of this procedure has
increased in recent years with the desire of the orthod-
ontists to treat variety of malocclusions with less of extra-
ctions to provide space to correct minor malocclusions.
Orthodontists have also turned to proximal stripping to
help them stabilize the occlusions that have been produced
by their therapy and help retreat any relapse that may have
occurred after this therapy.
IER is a critical procedure. Therefore, planning and execu-
tion need to be carefully assessed. This treatment should be
considered as an exact reduction of interproximal enamel
and not just as a simple method to solve problems.
Review of literature
Interproximal dental stripping has been used by orthodo-
ntists for many years. It was initially used to gain space
when correcting mandibular incisor crowding or to prevent
such crowding.
Ballard2 in 1944, suggested stripping of the interproximal
surfaces, mainly from the anterior segment, when a lack of
balance is present. Begg3 published his study of Stone Age
man's dentition, in 1954 where he referred to the shortening
of the dental arch over time, which occurred through inter-
proximal abrasion. Although the degree of shortening of
the dental arch found by Begg was contested, the existence
of this natural reduction led to the publication and develo-
pment of the technique for interproximal enamel redu-
ction.
In 1956, Hudson4 advocated the use of medium and fine
metallic strips for mesiodistal reduction followed by final
1
Reader, 2PG Student, Deptt. of Orthodontics and Dentofacial Orthopaedics, Panineeya Mahavidyalaya Institute of Dental Sciences and
Research Centre, Hyderabad, 3Sr. Lecturer, Sri Sai College of Dental Sciences, Vikarabad, India.
Correspondence: Dr. Sandhya Jadhav, email: drsandhyaortho@yahoo.co.in
In 1958, Bolton5 published his seminal study titled “Disha-
rmony in tooth size and its relation to the analysis and
treatment of malocclusion.” This study, together with
Ballard's study, supported the need, to use interproximal
stripping to correct problems of dental imbalance.
In 1969, Kelsten6 stated that only after alignment could
stripping be simply and accurately achieved.
That same year, Rogers and Wagner7 described an in-vitro
study that used teeth extracted for orthodontic reasons
which were subjected to stripping and polishing. It was
found that if the extracted teeth were treated with fluoride
after stripping, they offered greater resistance to acid
attacks, mainly in the 48 to 96 hours after the procedure.
This scientifically justified the importance, already high-
lighted by Hudson, of topical fluoride application after
stripping and polishing.
In 1971, Paskow8 published an article that advocated the
use of mechanical methods of IER. In 1973, Shillingbourg
and Grace9 wrote an article entitled “Thickness of enamel
and dentin”, which was an important study on enamel and
dentin thickness. The results of this study later served as
the scientific basis for work on stripping and allowed the
amount of enamel that could be safely removed from each
dental face to be accurately determined.
In the 70s, Peck and Peck1,10 published articles on crowding
of the mandibular incisors and presented the Peck index.
They advised stripping whenever the mesiodistal dime-
nsion of the mandibular incisors did not fall within accep-
table figures calculable from their index. They claimed that
anything in excess would constitute predisposition towa-
rds crowding.
In 1980, Tuverson11 published “Anterior interocclusal rela-
tions: Part 1”, which presented a highly detailed descript-
ion of the stripping technique using a back angle and
abrasive disks.
In 1981, Doris, Bernard and Kuftinec12 concluded that one
of the strongest determining factors for dental crowding is
the dimension of teeth in the arch.
In 1981, Betteridge13 presented the results of stripping on
the anterior and inferior segment after 1 year without

245

Figure 1: IER using abrasive strip
Figure 3: IER using air-rotor with diamond point
retention. She observed some relapse, but concluded that
esthetics were clearly acceptable, after observation by a
panel of three dentists, three orthodontists and three non-
dentists.
In 1985, Sheridan14 published his article “Air-rotorstri-
pping” and in 1987, “Air-rotor stripping update.”15 These
articles totally revolutionized the technique and aims of
interproximal enamel reduction. He recommended:
1. Use of a turbine with carbide drill, instead of diamond
disks and strips.
2. Stripping on buccal sectors; in other words, distally on
canines or mesially on the second molars on both arches.
This achieves greater space and allows the preservation of
incisors.
3. Use of stripping procedures to achieve space (upto 8 mm
per arch) for the correction of moderate dentomaxillary
disharmony, without recourse to extraction or excessive
expansion.
In 1986, Zachrisson16 proposed a new direction for strip-
ping: improvement of the shape of the teeth, mainly for
incisors and reduction of the black triangular space above
the papilla.
Indications
The IER technique has evolved over the years; it was first
used only for stripping mandibular incisors, with the aim of
preventing and correcting crowding. Areas of application
have continued to grow:
1. Tooth size discrepancy: Ballard in 1944, found a left-
right tooth discrepancy in one or more pairs of teeth, in
his study of 500 cases. These discrepancies, if not
corrected, could be responsible for rotations and
slipped contacts. He advocated careful stripping of the
proximal surfaces of the anterior teeth.2
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Indian J Stomatol 2011;2(4):245-48
2010;1(1):1-5
Figure 2: IER using abrasive disc
2. Inter-arch size discrepancies: Kesling in 1945 stresses
the importance of a favorable inter arch tooth-size
relationship for the establishment of a stable occlu-
sion.17
3. Tooth shape and dental esthetics: Stripping can and
should be used for the reshaping of enamel on some
teeth, thus contributing to an improved finishing of
orthodontic treatment and dental esthetics. Peck and
Peck (1972) indicate that a substantial relationship
exists between mandibular incisor shape and the
presence and absence of mandibular incisor crowd-
ing.10 Apparently, well aligned mandibular central and
lateral incisors have a remarkably distinct crown
shape.
4. Macrodontia size discrepancies: Though this in itself
is not an indication for proximal stripping, but in cases
where teeth are crowded and larger than normal
(macrodontia), proximal stripping should be consider-
ed.
5. Crowding of mandibular incisors: Stripping was first
used to obtain space for the correction and prevention
of crowding.4
6. To enhance retention and stability: Proximal stripping
may enhance retention and stability in a number of
ways. In cases, where there are tooth material-arch
length discrepancies not only is it necessary to reduce
these discrepancies so that the teeth are aligned
properly but also, so that the teeth will remain stable
after orthodontic therapy and retention has been
completed. Begg and Kesling have stressed the need
to remove these discrepancies to allow the teeth to be
placed in positions of stability.18
7. To simulate stone-age man's proximal attrition: Begg
and Kesling (1977) believed that attritional occlusion

is of great benefit to man, and that proximal stripping
simulates this if carried out regularly throughout life.18
8. Normalization of gingival contour and elimination of
triangular spaces above the papilla, thus greatly
improving esthetics and smile.
9. Moderate dentomaxillary disharmony: This is a prim-
ary area of application for interproximal enamel
reduction in the technique developed by Sheridan in
1985 and 1987, which allowed space to be obtained
for the correction of moderate dental crowding; up to 8
mm per arch could be achieved without the need for
extraction or excessive expansion.14,15
10. Reduced expansion and premolar extraction.
11. Camouflage of Class II and III malocclusions: The use
of mandibular stripping can be beneficial in camoufl-
aging slight to moderate Class III conditions and
overjet. In orthodontic treatment to camouflage Class
II with the extraction of two maxillary pre- molars,
correcting the crowding and inclination of the man-
dibular incisors with stripping is an ideal solution.
12. Correction of the Curve of Spee: For the correction of
an exaggerated Curve of Spee, it is necessary to create
a few millimeters of space in the arch. This can be
achieved through moderate stripping.
Contraindications
There are several contraindications for the approximation
technique:
1. Severe crowding (more than 8 mm per arch): With
application of IER, it would be hazardous to carry out
orthodontic correction. There would be risk of excess-
ive loss of enamel and all of the ensuing consequ-
ences.
2. Poor oral hygiene and/or poor periodontal environm-
ent: IER should not be used when there is active
periodontal disease or poor oral hygiene.
3. Small teeth and hypersensitivity to cold: Stripping
should not be used in these situations, as the risk of the
appearance of or an increase in dental sensitivity is
great.
4. Susceptibility to decay or multiple restorations: There
is a risk of causing imbalance in unstable oral situat-
ions, although the stripping of restorations, instead of
enamel surfaces, is an option to consider.
5. Shape of teeth: Stripping should not be carried out on
“square” teeth, that is teeth with straight proximal
surfaces and wide bases, as these shapes produce
broad contact surfaces, and could potentially cause
food impaction and reduced interseptal bone.
Treatment planning
A complete set of radiographs and models is needed. From
the x-rays, the clinician can determine:
 The convexity of each proximal surface
 The thickness of enamel on each tooth
 The size of fillings
 The disposition of the roots
If the tooth is rotated, the contour will not be shown
accurately on the x-ray, and the model must also be used.
The orthodontist must decide how much enamel can be
removed from each tooth surface, allowing for a minimum
convexity to form the contact point, a sufficient amount of
Indian J Stomatol 2011;2(4):245-48
2010;1(1):1-5
enamel and avoidance of root contact. The amount of
possible reduction from each surface (usually between 0.2
mm and 1.0mm) is then recorded in tenths of millimetres.
If the total amount of possible reduction in each quadrant is
less than the amount of space needed, then another treat-
ment method must be chosen. If the total is greater than the
space needed, then the amounts on the chart are revised
downward until the totals are equal.
The second and third molars and the distal surfaces of the
first molars should not be stripped, if possible, to preserve
anchorage. Ceramic crowns will often have to be replaced
if they are ground.
When a tooth is rotated, the anatomic proximal surface
should be reduced rather than the contact area.
Steps involved in IER:
1. Separation: This involves separating the teeth to be
reduced by the use of separators to make the area of
reduction more accessible.
2. Reduction: The enamel is reduced with the help of
appropriate abrasive strip (Figure 1), diamond cutting
discs ( Figure 2) or burs (Figure 3).
3. Recontouring: After the reduction the teeth are care-
fully reshaped to recreate the original contact conto-
urs.
4. Polishing: The tooth surface is polished to reduce the
surface enamel roughness.
5. Protection: The teeth reduced are fluoridated as the
outer protective fluoridated enamel layer is lost.
How much of enamel can be reduced?
There are no studies that indicate how much of enamel is
needed for adequate protection of tooth against carious,
thermal or chemical damage. The variation in the thickness
of enamel suggests that there is no protective advantage in
preserving thick enamel interproximally, when comparati-
ve thin enamel occurs naturally on labial, buccal and
lingual surface.
John Sheridan suggests that if 50% of inter proximal
enamel was removed, 6.4mm of space could be generated
from 8 buccal contacts (0.8mm/contact) and 2.5mm of
space could be created from 5 anterior contacts (0.5mm/
contact).15 So a cumulative gain of 8.9mm of space within
the arch is feasible.
The thickness of interproximal enamel can be estimated by
projecting a line from the cervical line vertically to the
occlusal or incisal plane. Dentin is projected in a straight
line from cervical line or in a line that tapers slightly
towards the pulp.
Techniques for enamel reduction
There are various methods recommended by various
authors for IER. Some of them are:
 Hudson used lightning steel strips of 0.10- 0.12 mm.
He followed it by finishing abrasive strips to remove
the roughness.4
 Paskow begins stripping with wide metal abrasive
polishing strips to gain proximal access followed by
coarse abrasive metal disc and then single- sided
diamond disc. He used a small diamond stone bur to
round off the sharp edges8 and finally rubber abrasive
disc to polish all surfaces.
 Peck and Peck recommended use of double sided
abrasive steel strip for gross reduction when less than
247

0.2 mm per surface of enamel has to be reduced and a
safe sided steel abrasive disc on slow speed straight
hand piece for reduction beyond 0.2 mm per surface.
Finishing is done with cutterfish strips.10
 Zachrisson used a thin flexible diamond disc for gross
reduction, steel strips for contouring, finishing and
polishing surface for surface smoothness.16
 John Sheridan advocated air- rotor stripping by use of
699L small tapered crosscut fissure carbide bur with
an extended cutting area. Finishing is done by
polishing with carbide finishing burs, finishing diam-
onds, polishing disc of hand held finishing strips.14
Protection of soft tissues
Sheridan advised use of 0.20 inch brass wire to be placed
gingivally between teeth to be reduced. This wire also
additionally serves as an indicator for reduction of enamel.
Rubber dam can be used to isolate the working area and
protect the rest of the tissues.14
Advantages
The space obtained can be continuously monitored to adju-
st it to the space needed to achieve the treatment goals.
1. Overexpansion of the dental arch is avoided.
2. Extraction of teeth is greatly reduced.
3. The need for excessive tooth movement, as well as the
possible loss of bone and of root cementum, is reduced
due to the fact that the iatrogenic potential is conside-
red less, than with extraction.
4. Treatment time is reduced.
5. The quality of treatment is significantly improved in
patients with crowding and contraindications for
extraction, as in the case of closed bites.
6. Esthetics are improved, as is the final health of the
gingival papilla, which adapts better to a reduction of
interdental space than to the space left by extraction.
7. Treatment of adults with slight or moderate crowding
is possible, without the need for extraction.
8. Greater post treatment stability is possible.
Disadvantage
It is a time-consuming treatment.
Precautions
1. Always carry out IER with new instruments.
2. Carefully protect soft tissues.
3. Proximal stripping should not be carried out until
dental rotation has been corrected, so that it can be
done at the correct contact areas.
4. Stripping should be carried out sequentially.
5. Stripped areas should be paralleled.
6. The stripped areas are carefully polished.
7. Stripped areas should be fluoridated following polis-
hing, as this procedure removes fluoride rich caries
resistant enamel.
248
Indian J Stomatol 2011;2(4):245-48
2010;1(1):1-5
8. Only individuals having low caries index should be
selected.
Conclusion
IER is a critical procedure. Therefore, planning and execu-
tion need to be carefully assessed. This treatment should be
considered as an exact reduction of inter- proximal enamel
and not just as a simple method to solve problems. Inte-
rproximal enamel reduction technique when used correctly
for the right cases can serve as an effective way to gain
space during orthodontic treatment. If the technique is
utilized correctly there is no evidence that it is in any way
deleterious to the dental hard tissues or soft tissues.
References
1. Peck H, Peck S. An index for assessing tooth shape deviatio-
ns as applied to the mandibular incisors. Am J Orthod 1972;
61:384-01.
2. Ballard ML. Asymmetry in tooth size: A factor in the etiol-
ogy, diagnosis, and treatment of malocclusion. Angle
Orthod 1944;14:67-71.
3. Begg PR. Stone Age man's dentition. Am J Orthod 1954;40
:298-12,373-83,462-75,517-31.
4. Hudson AL. A study of the effects of mesio-distal reduction
of mandibular anterior teeth. Am J Orthod 1956;42:615-24.
5. Bolton WA. Disharmony in tooth size and its relation to the
analysis and treatment of malocclusion. Angle Orthod
1958;28:113-30.
6. Kelsten LB. A technique for realignment and stripping of
crowded lower incisors. J Pract Orthod 1969;3:82-84.
7. Rogers GA, Wagner MJ. Protection of stripped enamel surf-
aces with topical fluoride applications. Am J Orthod 1969;
56:551-59.
8. Paskow H. Self-alignment following interproximal strippi-
ng. Am J Orthod 1970;58:240-49.
9. Shillingbourg HT, Grace CS. Thickness of enamel and de-
ntin. J So Calif Dent Assoc 1993;41:33-54.
10. Peck H, Peck S. Crown dimensions and mandibular incisor
alignment. Angle Orthod 1972;42:148-53.
11. Tuverson DL. Anterior interocclusal relations: Part I. Am J
Orthod 1980;78:361-70.
12. Doris JM, Bernard BW, Kuftinec MM. A biometric study of
tooth size and dental crowding. Am J Orthod 1981;79:326-
36.
13. Betteridge MA. The effects of interdental stripping on labial
segments evaluated one year out of retention. Br J Orthod
1981;8:193-97.
14. Sheridan JJ. Air-rotor stripping. J Clin Orthod 1985;19:43-
59.
15. Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1987;
21:781-87.
16. Zachrisson BU. Zachrisson on excellence in finishing- Part
2. J Clin Orthod 1986;20:536-56.
17. Kesling HD. The philosophy of the Tooth Positioning
Appliance. Am J Orthod 1945;31:297-04.
18. Begg PR, Kesling PC. Begg orthodontic theory and techn-
ique, 3rd edn. Philadelphia: W.B. Saunder,1977.