ORIGINAL ARTICLE

Pattern of maxillary and mandibular

proximal enamel thickness at the contact area
of the permanent dentition from first molar
to first molar
Rachel Sarig,a Alexander D. Vardimon,b Celine Sussan,c Lea Benny,d Ofer Sarne,d Israel Hershkovitz,e
and Nir Shpackf
Tel Aviv, Israel

Introduction: Proximal enamel thickness (PET) at the mesial and distal contact areas of the complete permanent
dentition has not been previously reported. Anatomic investigation of PET is essential for interproximal reduction
treatment. Our objectives were to measure the PETs of the complete maxillary and mandibular dentitions at the
contact areas, to compare the PETs of adjacent teeth, and to evaluate the vertical position of each contact area.
Methods: We evaluated 720 extracted teeth; of these, 109 intact teeth were selected. The mesial and distal con-
tact areas were demarcated, and each tooth was embedded in transparent epoxy resin. Blocks were prepared so
that the 2 demarcated contact areas were exposed, and 6 measurements were taken and statistically analyzed.
Results: Both jaws showed the same PET pattern characterized by 5 features: PET increased progressively
from incisor (0.63 mm) to first molar (1.48 mm). Per tooth, mesial and distal PET did not differ. Total maxillary
(26.86 mm) and mandibular (24.52 mm) PETs were similar. Paired PETs at the interproximal interface were
similar, with the exception of the lateral incisor-canine interfaces. From incisor to first molar, the contact area
becomes located farther gingivally. Conclusions: The existing guideline of maximal 0.5-mm interproximal
reduction per 2 adjacent teeth should be kept in the anterior region and could be increased to 1 mm in the
posterior region, when an equal amount is removed. (Am J Orthod Dentofacial Orthop 2015;147:435-44)

From Tel Aviv University, Tel Aviv, Israel.
a
Lecturer, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine; Dan David Center for Human Evolution and Bio-
history, the Steinhardt Museum of Natural History and National Research Center.
b
Professor, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine.
c
Formerly, resident, Department of Orthodontics, the Maurice and Gabriela Gold-
schleger School of Dental Medicine.
d
Instructor, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine.
e
Professsor, Department of Anatomy and Anthropology, the Sackler Faculty of
Medicine; Dan David Center for Human Evolution and Biohistory, the Steinhardt
Museum of Natural History and National Research Center.
f
Chair, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine.
Rachel Sarig and Alexander D. Vardimon are joint first authors and contributed
equally to this work.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of interest and none were reported.
Based on a thesis submitted by Celine Sussan in partial fulfillment of the require-
ments for a master in orthodontics degree at Tel Aviv University.
Partially supported by a research grant from Align Technology, San Jose, Calif.
Address correspondence to: Rachel Sarig, Department of Orthodontics, the
Maurice and Gabriela Goldschleger School of Dental Medicine, Department of
Anatomy and Anthropology, Sackler School of Medicine, Faculty of Medicine,
Tel Aviv University, Tel Aviv 69978, Israel; e-mail, sarigrac@post.tau.ac.il.
Submitted, March 2014; revised and accepted, November 2014.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.11.026
D
ental crowding is a common characteristic of
malocclusion, defined as a discrepancy between
tooth size and arch length.1 Although crowding
may occur in the anterior or posterior region of each
arch, adults are most likely to have crowding in the
mandibular anterior region.2 Late anterior crowding is
considered to be a normal physiologic phenomenon in
which a developmental reduction in arch length causes
increased crowding.3
As oral esthetic demands become more exacting,
resolving dental crowding has become a common
complaint, especially among adult patients. Furthermore,
this condition makes it difficult to maintain oral hygiene
and gingival health.4 Also, it may compromise the
esthetics and functionality of prosthetic rehabilitation.
In orthodontics, the patient-driven trend demanding
faster treatment, with minor interventions, has margin-
alized extraction-based therapy to use in only severe
malocclusions. The technique of removing tooth mate-
rial by reducing the thickness of interproximal enamel
has come into use when the amount of space required
to resolve an orthodontic problem is not extreme. This
435
436
is commonly referred to as “interproximal reduction.”
The principle of interproximal reduction is to partially
reduce the enamel layer and consequently the mesiodis-
tal tooth size without affecting the dentin. This tech-
nique was first described by Ballard5 in 1944 and was
primarily dedicated to the treatment of mild or moderate
crowding. It is based on the natural phenomenon of
physiologic interproximal wear and allows the fitting
of the dental units to the arches. The major advantage
of interproximal reduction is that a precise amount of
space is created to unravel the crowding, as opposed
to tooth extraction, which often results in more space
than required to resolve the dental crowding.
Incomplete enamel removal raises 2 major questions:
what is the minimal enamel layer necessary after inter-
proximal reduction to protect the dentin layer, and
how much enamel thickness is available in different
dental units? Regarding the former, in a long-term
study, 10 years after interproximal reduction to the
mandibular incisors, the treated teeth demonstrated no
increases in sensitivity or in the distance between the
roots.6 However, there are no reports comparing the
sensitivity of varying thicknesses of residual layers of
enamel after interproximal reduction. There are, howev-
er, 4 indirect indicators that suggest that even a thin
layer of enamel can provide adequate protection of the
underlying tissues: (1) the enamel thickness adjacent
to the cementoenamel junction of the labial crown sur-
face of the maxillary anterior teeth is normally about
13 mm7,8; (2) occlusal attrition is frequently associated
with exposure of the dentin layer with no evidence of
sensitivity; (3) dentinal reaction to enamel reduction is
characterized by occluded dentinal tubules; and (4)
additional dentinal reaction is in the form of buildup
of secondary dentin.9
Interproximal reduction was developed further by
Sheridan.10 Several studies have reported on proximal
enamel thickness (PET) on posterior11-14 and anterior
dentitions.7,15-17 Macha et al11 and Fernandes et al12
suggested a strong right-left symmetry for the same
contralateral teeth, but their analyses were based only
on the maxillary first and second premolars. Right-left
symmetry from incisors to premolars was also found
by Vellini-Ferreira et al.18 Stroud et al15 suggested,
based on bitewing measurements, that PET increases to-
ward the distal aspect in the mandibular posterior denti-
tion except for the second premolar, with no sex
dimorphism.
Currently, orthodontic interproximal reduction is
limited to 0.5 mm per interproximal region, about
0.25 mm from each of the 2 teeth.4,5,10 The technique is
based on removing enamel from the proximal wall
starting at the contact area. The principle of orthodontic
April 2015  Vol 147  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Sarig et al
interproximal reduction for the intact dentition should
follow 3 guidelines: leaving a thin layer of enamel,
removing more enamel from teeth with greater PET,
and performing selective reduction at the 2 contact
areas between paired adjacent teeth. “Selective
reduction” refers to greater reduction at the contact
area with greater PET. However, these guidelines cannot
be implemented precisely because of lack of data.
To make up for these deficiencies, the objectives of
this study were to map the PET of the complete maxillary
and mandibular dentitions at the contact areas, to
compare the PET of 2 adjacent contact areas (ie, the
distal contact area of the anterior tooth and the mesial
contact area of the adjacent posterior tooth), and to
evaluate each contact area in relation to the vertical
dimension of the crown. Four null hypotheses were
postulated in this study: (1) the PETs are similar per
arch between teeth and between sides (mesial vs distal),
(2) maxillary and mandibular PETs share a similar
pattern, (3) adjacent contact areas of paired teeth have
the same amount of PET, and (4) the contact area is
located in all teeth at the same distance from the cemen-
toenamel junction or the occlusal plane.
MATERIAL AND METHODS
We obtained 720 extracted permanent teeth from the
Department of Maxillofacial Surgery at Tel Aviv Univer-
sity in Israel. Upon examination using a Toolmakers
microscope (Mitutoyo, Tokyo, Japan), we excluded 611
because of peripheral preparations, proximal restora-
tions, or extensive proximal loss (ie, interproximal wear
facet spread buccolingually to the edges of the proximal
wall), or impaired proximal walls during extraction
(proximal wall scratched or damaged). Therefore, 109
(59 maxillary, 50 mandibular) intact teeth were included
in the study (Fig 1); 48 (44%) of these teeth were derived
from male subjects and 61 (56%) from female subjects.
All were of white ethnicity. The mean age of the subjects
was 34.3 6 10.3 years, with a range from 12 to 59 years.
The teeth, which were stored in 8% formaldehyde
(Bio Lab, Jerusalem, Israel), were rinsed in water (3 hours)
and dehydrated in ascending ethanol concentrations
(40%, 70%, 95%, and 100%) every 2 hours, and then
placed in Xylen (Bio Lab) for an additional 2 hours.
Each tooth was then classified according to type, jaw,
and side, and the mesial and distal contact areas were
demarcated with red and blue markers, respectively.
The identification of the contact area was based on dif-
ferential brightness of the enamel during wear. That is,
the proximal facet in the contact area may appear as a
polished surface or a bright plain area,19 according to
the method described by Sarig et al.20
Sarig et al 437

Fig 1. The 109 teeth used in the study divided by type and jaw. Central incisor, I1; lateral incisor, I2;
canine, C; first premolar, P1; second premolar, P2; first molar, M1.

Fig 2. Schematic drawing illustrating the sectioning process. A, Block before sectioning. The block
was bisected parallel but 2 mm away from the contact area plane, producing 2 unequal portions. B,
The portion including the 2 demarcated contact areas was then trimmed to the point where the mesial
contact area (red) was exposed (red arrows, exposed surface). C, Trimming was continued until the
distal contact area (blue) was also exposed, and the exposed surface was then polished (red arrows,
exposed surface).

Each tooth was positioned vertically in a 20-mL vial
with the long axis parallel to the long axis of the vial using
molding paste at the bottom of the vial. Subsequently,
each tooth was embedded in transparent epoxy resin
(Polysciences, Warrington, Pa). After curing, the block
was sectioned. Since the purpose was to measure the
enamel on a plane where the 2 contact areas were present,
the sectioning was carried out in 2 steps (Fig 2). First, us-
ing an apparatus for microstructural analysis (Isomet low
speed saw; Buehler, Lake Bluff, Ill), each tooth was bi-
sected parallel to but 2 mm away from the contact area
plane, producing 2 unequal portions (Fig 2, A and B).

American Journal of Orthodontics and Dentofacial Orthopedics April 2015  Vol 147  Issue 4
438 Sarig et al

Second, the portion including the 2 demarcated contact

areas was then trimmed (Single Wheel Orthodontic Model
Trimmers; Wehmer, Lombard, Ill) up to the point where
both the mesial and distal contact areas were part of
the exposed surface (Fig 2, C). The exposed surface was
then polished (Ecomet, variable speed grinder-polisher;
Buehler) using P320 and P120 waterproof abrasive paper
(WS flex 18-G; Hermes Schliefmittel, Hamburg,
Germany). Six measurements were made on each tooth
with the Toolmakers microscope with a closed camera
and a monitor (Koyo Electronics Industries, Tokyo Japan)
at 10-times magnification. The measurements included
the following (Fig 3).
1. Mesial proximal enamel thickness (PETM), the
distance from the midmesial contact area to the
dentinoenamel junction (measured on a line
parallel to the long axis of the tooth passing through
the contact area).
2. Distal proximal enamel thickness (PETD), the
distance from the middistal contact area to the
dentinoenamel junction (measured on a line parallel
to the long axis of the tooth passing through the
contact area).
3. Mesial contact area to occlusal plane (CAM-OP), the
distance from the midmesial contact area to the
occlusal highest point on the mesial side (measured
on a line parallel to the long axis of the tooth pass-
ing through the contact area).
4. Mesial contact area to the cementoenamel junction
(CAM-CEJ), the distance from the midmesial contact
area to the mesial cementoenamel junction
(measured on a line parallel to the long axis of the
tooth passing through the contact area).
5. Distal contact area to occlusal plane (CAD-OP), the
distance from the middistal contact area to the
occlusal highest point on the distal side (measured Fig 3. A, Longitudinal cross section of a molar through
the mesial (red arrow) and distal (blue arrow) contact
on a line parallel to the long axis of the tooth pass-
areas. B, Schematic illustration of the 6 measurements:
ing through the contact area). proximal enamel thickness mesial (PETM), proximal
6. Distal contact area to cementoenamel junction enamel thickness distal (PETD), contact area (CA) to
(CAD-CEJ), the distance from the middistal contact occlusal plane (OP) on the mesial (CAM-OP) and distal
area to the distal cementoenamel junction (CAD-OP) sides, CA to cementoenamel junction (CEJ)
(measured on a line parallel to the long axis of the on the mesial (CAM-CEJ) and distal (CAD-CEJ) sides.
tooth passing through the contact area).
intratester and intertester tests were 0.93 and 0.91,
Statistical analysis respectively. Statistical analysis was carried out with
The intraclass correlation coefficient was calculated SPSS software (version 18.0; SPSS, Chicago, Ill). Data
to determine the intratester and intertester reliabilities analysis was carried out using t test analysis and 1-
of the measurements (repeated measurements of 10 way analysis of variance with post hoc analysis (Tukey
teeth). Intratester reliability was assessed by 1 investi- B). The level of significance was set at P \0.05. No
gator (C.S.), and intertester reliability involved 2 testers significant difference was found between the sexes
(C.S., R.S.). The testers were unaware of each other's re- regarding PET (the lowest nonsignificant P value was
sults. The intraclass correlation coefficient values for the in the maxillary canine, P 5 0.329, on the distal side);

April 2015  Vol 147  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Sarig et al 439

Table. Proximal enamel thickness (PET) in the mesial (PETM ) and distal (PETD ) sides according to tooth type and jaw
Comparison of tooth types

Tooth PETM (mm) PETD (mm) PETM vs PETD (P value) PETM (Tukey B) PETD (Tukey B)
Maxilla
I1 0.81 6 0.06 0.81 6 0.27 0.998 I1, I2, s M1, P1, I1, I2, C s P1, P2, M1
C, P1 s P2 P #0.01
P #0.01
I2 0.76 6 0.14 0.86 6 0.28 0.206
C 1.10 6 0.21 1.11 6 0.26 0.747
P1 1.13 6 0.15 1.25 6 0.37 0.593
P2 1.41 6 0.27 1.36 6 0.30 0.652
M1 1.35 6 0.29 1.48 6 0.17 0.137
Mandible
I1 and I2 0.64 6 0.19 0.60 6 0.18 0.581 I1, I2 s C s P1, P2 I1, I2 s C, P1, P2, M1
P1 s M1 P #0.01
P #0.01
C 0.97 6 0.21 1.30 6 0.61 0.133
P1 1.16 6 0.13 1.05 6 0.24 0.227
P2 1.23 6 0.10 1.30 6 0.20 0.305
M1 1.37 6 0.12 1.40 6 0.20 0.720

I1, Central incisor; I2, lateral incisor; C, canine; P1, first premolar; P2, second premolar; M1, first molar.

therefore, the teeth of both sexes were used in all statis-
tical analyses.
RESULTS
Categorizing the contact area of the maxillary denti-
tion according to PET greater than or less than 1 mm, we
found that the central and lateral incisors demonstrated
PETs of less than 1 mm on both the mesial and distal con-
tact areas, and that the canine, the first and second pre-
molars, and the first molar had PET greater than 1 mm on
both the mesial and distal contact areas. The mesial PETs
for the canine and the first premolar were significantly
less than those of the second premolar (P \0.01). PET
of the second premolar did not statistically differ from
that of the first molar. Additionally, the second premolar
had the greatest PET (1.41 6 0.27 mm) at the mesial con-
tact area (Table). As for the distal side, PETs of the lateral
incisor and the canine differed significantly from those of
the first and second premolars and the first molar
(P \0.01) (Table).
Dividing the mandibular dentition as above, we
found that the lateral incisor on both the mesial and
distal contact areas and the canine on the mesial side
demonstrated PETs less than 1 mm. All other teeth
(canine on the distal side, first and second premolars
and first molar on the mesial and distal contact areas)
showed PETs greater than 1 mm. At the mesial contact
area, the PET of each tooth type differed from the
others, resulting in 4 significantly different groups: in-
cisors, canines, premolars, and first molars. A gradual
increase in mesial PET was seen from the incisors to
the molars. Posteriorly, only the first premolar exhibited
significantly reduced enamel compared with the first
molar (P\0.01). On the distal contact area, a significant
difference in PET was found between the incisors and
the canines, premolars, and first molars (Table).
In relation to both jaws, only the incisor group
showed a significant difference between the jaws, pre-
senting greater PET in the maxilla.
The interproximal interface of neighboring teeth
comprises 2 opposing proximal walls of the 2 adjacent
teeth, ie, the distal proximal wall of the anterior tooth
and the mesial proximal wall of the posterior tooth. In
the maxilla, the sum of the 2 PETs ranged from
1.57 mm between the central and lateral incisors to
2.71 mm between the second premolar and the first
molar. In the mandible, the sum ranged from 1.23 mm
between the right and left lateral incisors to 2.67 mm be-
tween first premolar and the first molar. A difference be-
tween paired adjacent PETs was found only between the
lateral incisor and the canine for both the maxillary arch
(P 5 0.039) and the mandibular arch (P\0.001). In both
cases, the mesial PET of the canine was significantly
greater than the distal PET of the lateral incisor (Fig 4).
For the vertical positions of the contact areas, the
greatest distances of CA-OP were on the distal side of
the canine in the maxillary (4.5 mm) and mandibular
(3 mm) arches. The smallest CA-OP values were found
on the mesial side of the maxillary first premolar
(2 mm) and the mesial side of the mandibular lateral
incisor (1.5 mm). The distances of CA-CEJ were the
greatest on the mesial side of the central incisors in
the maxillary (5.2 mm) and mandibular (6.2 mm) arches,

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440 Sarig et al

A
Maxilla
3.5

proximal enamel thickness (mm)

2.5
*
2

1.5 Distal tooth

Mesial tooth
1

0.5

0
I1-I2 I2-C C-P1 P1-P2 P2-M1
*p<0.05 paired adjacent teeth

B Mandible
3.5
proximal enamel thickness (mm)

2.5

2 *
Distal tooth
1.5
Mesial tooth
1

0.5

0
I1-I2 I2-C C-P1 P1-P2 P2-M1
paired adjacent teeth
*p<0.05

Fig 4. Comparison of PETs of adjacent paired teeth: A, maxillary dental arch; B, mandibular dental arch.

and the lowest were on the distal sides of the first premo- the study sample was based on our study and previous
lar in the maxillary (3.4 mm) and mandibular (3.4 mm) studies that found no sexual dimorphism in PET.17,23,24
arches (Fig 5). Generally, the contact area was located The PETs of the anterior teeth in both jaws differed
closer to the cementoenamel junction in the posterior significantly from the rest of the teeth. This diversity by
than in the anterior dentition (Fig 5). type of tooth occurred on both the mesial and distal sides.
Thus, the null hypothesis that PET in all teeth is uniform
DISCUSSION was rejected. On the other hand, this study confirmed the
Although the age range of the sample was 12 to null hypothesis that mesial and distal PETs for an individ-
59 years, there was a lack of influence of age on enamel ual tooth were similar. This does not agree with previous
thickness, since enamel formation of the permanent studies.11,12,15 However, this might be explained by the
dentition up to the first molar is completed by the age differences in the methodologies used. In our study, the
of 3.0 to 3.3 years.21 However, reductions in enamel enamel thickness was measured directly histologically at
thickness take place especially after the age of 50.22 the mesial and distal contact areas, whereas Macha
For this reason, 95% of the teeth in our sample were et al11 and Fernandes et al12 investigated only the greatest
below this age limit (mean age, 34.3 6 10.3 years). thickness of enamel, and Stroud et al15 investigated this
Moreover, teeth with severe proximal wear were radiographically.
excluded from the study; since normal wear was taken Maxillary incisors and canines were found to have
into account, this suggests that our data were skewed significantly thinner enamel than premolars and molars.
to the thin range of PET. The merging of both sexes in In the mandible, only the incisors had significantly

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Sarig et al 441

Fig 5. The vertical position of the contact area was defined by the distances of contact area to cemen-
toenamel junction (CAM-CEJ, CAD-CEJ) and contact area to the occlusal plane (CAM-OP, CAD-OP) for
each tooth in A, the maxillary dental arch; and B, the mandibular dental arch. m, Mesial; d, distal.

thinner contact area enamel than did the rest of the arch.
In both jaws, no differences were found between the
molar and the premolar groups. Only between the maxil-
lary and mandibular incisors was a significant interarch
difference in PET found.
The study confirmed the null hypothesis that the PETs
of adjacent teeth are essentially equal, with the exception
of the lateral incisor-canine interface in both arches. This
suggests that when planning interproximal reduction, it
is safe to apply a technique to remove an equal amount
of enamel from the adjacent proximal walls of both teeth.
In the lateral incisor-canine interfaces of both arches,
more enamel can be removed from the mesial proximal
surface of the canine, since it is significantly greater
than the distal PET of the lateral incisor.
A further aspect to consider is the maximal amount
of interproximal reduction between adjacent teeth
that can be performed. Given a normal distribution of
interproximal enamel thicknesses, 68.27% and 95.45%
of PET measurements lie within 1 or 2 SDs from the
mean, respectively (3 sigma rule). Therefore, without an
individualized enamel thickness analysis, the limit of
interproximal reduction should be planned based on
the equation of mean PET of 62 SD. Consequently, if
equal amounts of enamel are removed from adjacent
teeth in the anterior region of both dental arches, it is rec-
ommended that a maximum of 0.5 mm of interproximal
reduction be performed. In the posterior region (canine
to first molar), 1 mm of proximal enamel can be removed.
Our findings do not support the null hypothesis that
the vertical distances between the contact areas to the
cementoenamel junction or to the occlusal plane in all
teeth are identical. We found that a progressive migra-
tion of the contact areas in an apical direction from
anterior to posterior occurred. That is, the contact areas
were closer to the incisal edge in the anterior teeth and

American Journal of Orthodontics and Dentofacial Orthopedics April 2015  Vol 147  Issue 4
442
closer to the proximal midcrown in the posterior teeth.
This finding is consistent with our previous study.25
The location of the contact area is associated with the
location of interdental crestal bone,26 periodontal
breakdown of the interproximal gingival col,27 inter-
dental black triangles,28 and malaligned teeth.29
The vertical position of the contact area provides a
guideline for interproximal reduction procedures. This
should be performed at the contact area to accomplish
interproximal clearance between 2 adjacent teeth.
Accordingly, it should be carried out on the occlusal third
of the proximal walls of anterior teeth and midcoronally
on posterior teeth, ideally at a vertical distance of 5 mm
from the base of the contact area to the alveolar crestal
height.30 Furthermore, it has been suggested that
enlarging the 2 contact areas by interproximal reduction,
creating a flat proximal surface, might reduce the relapse
potential compared with a pointed interproximal inter-
face, which is prone to produce overlapped teeth.
Such a regimen is particularly recommended for anterior
teeth.31
The null hypothesis regarding the maxillary vs
mandibular PET relationship is supported by our find-
ings. Both jaws showed the same pattern of PET, with
minor deviations. This similarity is related to 4 character-
istics. First, the PET of anterior teeth was not found to
exceed 1 mm, and that of posterior teeth was between
1.10 and 1.48 mm. Consequently, PET increased pro-
gressively along the dental arch from the central incisor
to the first molar in both arches.
Second, the sums of mean enamel thicknesses of the
maxillary and mandibular hemiarches (from the mesial
side of the central incisor to the distal side of the first
molar) were not found to be significantly different
(13.43 mm in the maxilla, 12.26 mm in the mandible).
This suggests that when performing interproximal
reduction of 50% in each hemiarch, a space almost equal
to the extraction of 1 premolar becomes available.
Third, the adjacent enamel surfaces comprising a
contact area were found to be similar, with the exception
of the lateral incisor-canine interproximal interface,
where the distal PET of the lateral incisor was signifi-
cantly less than the mesial PET of the canine.
Fourth, the vertical location of the contact area was
found to be more occlusal in the anterior teeth and
farther gingivally in the posterior teeth.
The PET similarity in these 4 characteristics suggests
that when no Bolton discrepancy is present, the same
amount of interproximal enamel should be removed in
a patient with an Angle Class I relationship. However, a
patient with a Bolton discrepancy, an Angle Class II
malocclusion, or an Angle Class III malocclusion might
require dissimilar amounts of interproximal reduction.
April 2015  Vol 147  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Sarig et al
Three strategies should be considered when planning
interproximal reduction to correct an arch length defi-
ciency: (1) anterior interproximal reduction (incisor re-
gion), (2) posterior interproximal reduction (canine,
premolars, first molar), (3) full interproximal reduction
(both anterior and posterior regions).
Anterior interproximal reduction should be consid-
ered for oversized incisors (especially maxillary central
incisors or mandibular lateral incisors). Anterior inter-
proximal reduction should be taken into account in
the case of left-right incisors' size asymmetry,
triangle-shaped incisors (shovel shaped), and black tri-
angles. According to this study, maximal space gains
of 3.24 mm in the maxillay arch and 2.48 mm in the
mandibular arch are available when 50% of the enamel
thickness is preserved. Our findings demonstrate that
the greatest contact areas to cementoenamel distance
are on the mesial side of the central incisors in both
the maxillary (5.2 mm) and mandibular (6.2 mm) arches.
This suggests that performing anterior interproximal
reduction to further displace the contact area gingivally
may prevent or counteract black triangles.
Posterior interproximal reduction should be consid-
ered if anterior proportions are normal and no triangular
teeth or black triangles are present. Posterior interprox-
imal reduction is applicable for mild, moderate, and
severe crowding, especially with proximal restorations.
According to our study, maximal space gains of
10.19 mm in the maxillay arch and 9.78 mm in the
mandibular arch are available when 50% of the enamel
thickness is preserved.
Using both anterior and posterior interproximal re-
ductions should be considered for patients with moder-
ate and severe arch length deficiency when anterior
interproximal reduction is favorable but is not sufficient
to unravel the crowding. According to our study,
maximal total space gains of 13.43 mm in the maxillay
arch and 12.26 mm in the mandibular arch are available
when 50% of the enamel thickness is preserved.
Although it is beyond the scope of this study, enamel
reduction should be considered in the context of its
impact on sensitivity and tooth morphology. Zachrisson
et al6 demonstrated that 10 years after interproximal
reduction in mandibular anterior teeth, no sensitivity
was found in 59 of 61 patients, and there was no in-
crease in caries susceptibility.32 However, temporary
sensitivity might appear immediately after interproximal
reduction and should be treated with fluoride varnish,
fluoride mouth rinse, and fluoride gel.33,34
Morphologic changes after interproximal reduction
are related to changes in tooth size and shape of the
proximal contact area. Diminished tooth size due to
interproximal reduction is beneficial in attempting to
Sarig et al
replace a lateral incisor with a canine,35 but disadvanta-
geous for already slender teeth such as mandibular inci-
sors.17 Changing the contact point to a contact area
between 2 adjacent teeth is beneficial in reducing black
triangles,30 especially maxillary central incisors.36 Thus,
interproximal reduction may be apt in addressing ortho-
dontic issues for patients with triangle-shaped teeth.36
It has also been reported that root proximity causes
an improvement in the interdental papilla.37,38 Root
proximity can occur after interproximal reduction, and
authors investigating any detrimental effects of this
did not conclude that this was the case.6 Interproximal
alveolar bone crest and interdental papilla can be
restored after interproximal reduction procedures
because of more apical migration of the contact
area.30 This occurs because of the reestablishment of
the biologic distances.30
CONCLUSIONS
PET is characterized by the following.
1. Similar PET patterns between the 2 dental arches.
2. PETs of anterior teeth did not exceed 1 mm, and
those of posterior teeth was between 1.1 and
1.5 mm.
3. The sums of mean enamel thicknesses from the right
distal PET of the first molar to the left distal PET of
the first molar were 26.86 mm in the maxilla and
24.52 mm in the mandible.
4. The 2 PETs of intra-arch paired adjacent teeth are
similar, with the exception of the lateral incisor-
canine interproximal interface in both arches, where
the distal PET of the lateral incisor is significantly
less than the mesial PET of the canine.
5. The vertical location of the contact area is more
occlusal in the anterior teeth and farther gingivally
in the posterior teeth.
ACKNOWLEDGMENTS
We thank the following for their significant contribu-
tions: Ilana Gelernter, Department of Statistics; Ana
Bahar, Department of Anatomy and Anthropology;
and Michael Blum and Moshe Davidovitch, Department
of Orthodontics, all at Tel Aviv University.
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