SYSTEMATIC REVIEW

Proximal enamel thickness of the

permanent teeth: A systematic review
and meta-analysis
Vignesh Kailasam,a Hita Rangarajan,a Harshini Nivetha Easwaran,b and M. S. Muthub,c
Chennai, India, and Ajman, United Arab Emirates

Introduction: This systematic review aimed to identify, evaluate, and provide a synthesis of the available liter-
ature on the proximal enamel thickness (PET) of permanent teeth. Methods: The eligibility criteria were studies
that assessed the PET of the permanent teeth. A search of studies in Medline (via PubMed), the Cochrane Li-
brary, Scopus, Web of Science, Embase, and Lilacs databases that measured PET was conducted until August
31, 2020. Two reviewers independently selected the studies, extracted the data, and assessed the risk of bias for
systematic reviews involving cross-sectional studies. The quality of evidence was assessed using the Grading of
Recommendations, Assessment, Development, and Evaluations approach. PET data generated from the
systematic review were summarized by random-effects inverse-generic meta-analysis. Results: From 1388
potentially eligible studies, 11 were considered for systematic review and meta-analysis. The measurement
of PET was done with radiographs, microscopes, microtomographs, or profilometers. In total, 4019 mesial
and distal surfaces involving 2118 teeth were assessed. All included studies showed low to moderate risk of
bias, whereas GRADE revealed that the level of evidence was low. Greater mesial and distal enamel
thickness was observed for the premolars and molars, whereas it was least for the mandibular central
incisors. The least difference of 0.02 mm (95% confidence interval [CI], 0.07 to 0.11 and 0.06 to 0.09,
respectively) between mesial and distal sides was observed for the maxillary and mandibular second molars,
whereas the maximum difference of 0.12 mm (95% CI, 0.07-0.17 and 0.07-0.16, respectively) was observed
for the maxillary central incisors and maxillary first premolars. The meta-analysis indicated a moderate level
of heterogeneity (I2 of 45%). The funnel plot revealed minimal publication bias. Conclusions: The summary ef-
fect of the meta-analysis revealed that the thickness of the enamel on the distal aspect was greater than on the
mesial aspect by an average of 0.10 mm (95% CI, 0.09-0.12). This finding would be of relevance to all disciplines
of dentistry and especially for the clinician planning interproximal reduction, a procedure that is routinely done for
clear aligner therapy. (Am J Orthod Dentofacial Orthop 2021;-:---)

E
namel stripping, also known as interproximal
reduction (IPR) or reproximation, is an attractive
alternative to tooth extraction in patients with
a
Department of Orthodontics, Sri Ramachandra Faculty of Dental Sciences, Sri
Ramachandra Institute of Higher Education and Research, Chennai, India.
b
Centre for Early Childhood Caries Research (CECCRe), Department of Pediatric
and Preventive Dentistry, Sri Ramachandra Faculty of Dental Sciences, Sri Ram-
achandra Institute of Higher Education and Research, Chennai, India.
c
Adjunct Research Associate, Centre of Medical and Bio-Allied Health Sciences
Research, Ajman University, Ajman, United Arab Emirates.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Registration: The proposal was registered on the International Prospective
Register of Systematic Reviews (PROSPERO, 180647).
Address correspondence to: Vignesh Kailasam, Department of Orthodontics, Sri
Ramachandra Faculty of Dental Sciences, Sri Ramachandra Institute of Higher
Education and Research, Chennai, India 600116; e-mail, Vignesh.k@
sriramachandra.edu.in.
Submitted, October 2020; revised and accepted, May 2021.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2021.05.007
mild-moderate crowding because it allows the trans-
verse arch dimensions and anterior tooth inclinations
to be maintained.1,2 It is based on the natural phenom-
enon of physiological interproximal wear and allows for
fitting the dental units to the arches. In this procedure,
partial reduction of the enamel layer is carried out, re-
sulting in the reduction of the mesiodistal tooth size
so that a precise amount of space is created to allow
the crowding to unravel. Therefore, this procedure is
preferred to tooth extraction, which often results in
more space than required to resolve dental crowding.3
The principle of IPR should follow 3 guidelines: leave a
thin layer of enamel, remove more enamel from teeth
with greater proximal enamel thickness (PET), and
perform selective reduction at the 2 contact areas be-
tween paired adjacent teeth.3
Several studies have reported on the PET of poste-
rior4-6 and anterior teeth,1,7-9 with various conclusions.
Gillings and Buonocore7 reported that enamel on the
1
2 Kailasam et al

distal surface was slightly thicker than on the mesial sur-

Table I. Inclusion and exclusion criteria
face. However, Sarig et al3 reported that for the maxillary
second premolars, mandibular incisors, and mandibular Inclusion criteria Exclusion criteria
first premolars, the mesial enamel was thicker than the Studies on human participants in Studies that assessed the
distal enamel, with Stroud et al1 suggesting that PET in- whom the PET of permanent teeth PETs of primary teeth
was measured
creases toward the distal aspect in the mandibular pos-
English language studies Studies that assessed the
terior dentition, with the exception of the second PETs of stone age
premolar. dentition
PET would be a significant parameter in caries sus- Studies that evaluated PET by Review articles, systematic
ceptibility, progress, and tooth sensitivity. Moreover, microscopy, profilometry, or reviews, and letters to the
radiography were included. Other editor or author
PET is an important aspect of tooth preparation in the
assessment methods, such as
field of pediatric dentistry and prosthetics for crowns ultrasonic imaging, flat plane
and bridges. Although PET has not been extensively radiography, x-ray computed
studied from these aspects, variations in PET would tomography, and cone-beam
have clinically significant ramifications in treatment computed tomography was also
considered
planning in these areas. Given the irreversible effects
of enamel removal and a wide variation in the published
data on PET, pooled data from the available literature
could provide more solid conclusions. Table II. Search key words
Search term MeSH terms
Objectives Enamel “dental enamel”[MeSH Terms] OR (“dental”[All
This study aimed to summarize the proximal enamel Fields] AND “enamel”[All Fields]) OR “dental
enamel”[All Fields] OR “enamel”[All Fields] OR
thickness of the permanent dentition from the incisors to
“enamels”[All Fields] OR “enamel's”[All Fields] OR
the second molars through a systematic review of the “enameled”[All Fields] OR “enameling”[All Fields]
literature. The review question in population, interven- OR “enamelling”[All Fields]
tion, control, and outcomes format was “are there any Thickness “thick”[All Fields] OR “thickness”[All Fields] OR
differences in enamel thickness between the mesial “thicknesses”[All Fields]
Width “width”[All Fields] OR “widths”[All Fields]
and distal surfaces in permanent teeth?”
Mesial “mesial”[All Fields] OR “mesialization”[All Fields] OR
“mesialized”[All Fields] OR “mesially”[All Fields]
MATERIAL AND METHODS Distal “distal”[All Fields] OR “distalization”[All Fields] OR
Protocol and registration “distalize”[All Fields] OR “distalized”[All Fields] OR
“distalizer”[All Fields] OR “distalizers”[All Fields]
This systematic review was conducted and reported OR “distalizes”[All Fields] OR “distalizing”[All
in accordance with the PRISMA guidelines (Preferred Fields] OR “distally”[All Fields] OR “distals”[All
Reporting Items for Systematic Reviews and Meta- Fields]
Proximal “proximal”[All Fields] OR “proximalization”[All
Analyses).10 The proposal was registered on the Interna- Fields] OR “proximalize”[All Fields] OR
tional Prospective Register of Systematic Reviews “proximalized”[All Fields] OR “proximalizes”[All
(PROSPERO, 180647). Fields] OR “proximalizing”[All Fields] OR
“proximally”[All Fields] OR “proximals”[All Fields]
Eligibility criteria Permanent “dentition, permanent”[MeSH Terms] OR
dentition (“dentition”[All Fields] AND “permanent”[All
Inclusion and exclusion criteria were specified before Fields]) OR “permanent dentition”[All Fields] OR
the study (Table I). The main outcome was the measure- (“permanent”[All Fields] AND “dentition”[All
ment of the mesial and distal enamel thicknesses of the Fields])
permanent teeth.
Science, Scopus, Embase, and Cochrane electronic data-
Information sources, search strategy bases (Table II).
Electronic searches in Medline (via PubMed), the Co-
chrane Library, Web of Science, Scopus, Embase, and Li- Study records
lacs were conducted until August 31, 2020. Search terms The selection of the studies consisted of 2 phases.
were based on both Medical Subject Headings (MeSH) Initial screening of articles identified in the databases
and free text with combinations and were prepared for searched involved independent screening of titles and
Medline via PubMed and adapted for Lilacs, Web of abstracts by 2 reviewers (V.K., H.R.) on the basis of the

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Kailasam et al
research question and against the inclusion and exclu-
sion criteria. In articles in which the title and abstract
failed to provide sufficient information, the full text
was reviewed to assess for relevance. In the second
phase, full-text articles were then retrieved from these
potentially eligible studies. To ensure that no relevant
studies were missed, the reference lists of the remaining
articles were hand-searched. Articles identified by this
process were added to the pool of full-text articles to
be evaluated. Any discrepancies with regard to the eligi-
bility of an article were resolved by discussion with the
third reviewer (M.S.M.) when necessary. This pool was
then assessed for eligibility for both quantitative and
qualitative reviews.
Data items and collection
The data extraction of the included articles was per-
formed independently and in duplicate by 2 authors
(V.K., H.N.E.). A predetermined and standardized table
was used for data extraction. The predefined data to
be extracted were title, authors, authors’ institutional
affiliation, study type, age, gender, population, sample
size, assessment technique, teeth assessed, mesial
enamel thickness, distal enamel thickness, section as-
sessed, and P value.
Outcome
The outcome for which the data will be sought would
be the distal and mesial enamel thickness from which the
difference would be obtained.
Risk of bias and quality assessment
The risk of bias was assessed using the risk of bias in
nonrandomized studies of interventions for systematic
reviews involving cross-sectional studies.11 The
following domains were evaluated: (1) confounding
bias, (2) selection bias, (3) bias due to deviation of in-
tended interventions, (4) missing data, (5) measurement
of outcomes, (6) bias in the selection of reported result.
The bias in the classification of interventions was
referred to as not applicable.
Two reviewers (H.R., H.N.E.) assessed all included
studies independently. Disagreements were resolved
through discussion and consensus, or the decision of
the third reviewer (V.K.) was taken whenever necessary.
Data synthesis
The studies were grouped on the basis of the data as-
sessed. For each article that met the validity criteria, data
were extracted and compiled into a table of evidence.
Analysis was prepared according to the Cochrane Hand-
book for Systematic Reviews.12 Data were analyzed in
American Journal of Orthodontics and Dentofacial Orthopedics
3
Revman 5.3.13 The continuous data were presented as
mean difference and 95% confidence interval [CI]. An
inverse variance method of pooling the data with a
random-effects model was used for the meta-analysis.
Heterogeneity of the included studies was also assessed
on the basis of the individual tooth and by the assess-
ment technique used. Heterogeneity was assessed with
the Cochrane Q test along with I2 statistics, which ranged
from 0% to 100%. An I2 index \25% is indicative of low
heterogeneity, between 25% and 75% represents
average heterogeneity, and more than 75% would indi-
cate considerable heterogeneity.14
Meta biases and confidence in cumulative evidence
Publication bias and selective reporting, if any, would
be assessed. Publication bias would be assessed through
a funnel plot. The quality of evidence was assessed using
the Grading of Recommendations, Assessment, Devel-
opment, and Evaluations approach.15
RESULTS
Study selection and characteristics
Searches of databases retrieved 2535 records, from
which 1147 duplicates were removed, leaving 1388
unique records. The titles and abstracts of these records
were screened by 2 independent reviewers (V.K., H.R.).
One thousand three hundred and seventy-four were re-
jected on the basis of the exclusion criteria, resulting in
14 articles whose full texts were assessed for eligibility.
Of these 14 articles, 11 studies provided sufficient data
for quantitative assessment (Fig 1).
All included studies were cross-sectional and pub-
lished between 1998 and 2020. The studies had a sample
size ranging from 32 to 402. Five studies mentioned the
age range (from 12 to 60 years) of the patients from
whom the samples were assessed.1,3,4,16,17 Most studies
assessed the PET tooth wise and did not differentiate
on the basis of gender. However, 1 study17 assessed
the PET on the basis of tooth and gender but proceeded
to combine gender data because no differences in PET
between genders were observed. Of the 11 studies, 3
assessed premolars only4,5,18; 1 assessed canines
only19; 2 assessed incisors only9,17; 1 assessed premolars
and molars1; 1 assessed incisors, canines, and premo-
lars20; and 3 assessed incisors, canines, premolars, and
molars.16,20,21 The measurement of PET was done with
either bite-wing1 or intraoral periapical radiographs,9,17
microscopes,3,4,21 profilometer5,18,20 or microcomputed
tomography.16,19 For the purpose of meta-analysis, the
weighted mean and standard deviation for each study
and the individual tooth were calculated using a stan-
dard mathematical formula. The maximum difference
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4 Kailasam et al

Identification Records identified through database searching

PubMed (n=1037), Lilacs (n=362), Web of Science (n=171),
Cochrane (n=0), Scopus (n=523), Embase (442)

Screening Records after removal of duplicates

(n=1388)

Records screened Records excluded

(n=1388) (n=1009)

Eligibility
Full-text articles Full-text articles excluded,
assessed for eligibility with reasons (n=3)
(n=14)
1. Ang et al – mesial and
distal thickness not
measured
Studies included in
quantitative synthesis 2. Atsu et al – facial and
Included (n=11) lingual enamel measured not
mesial and distal thickness

3. Kaaouara et al – IPR done

prior to measurements

Fig 1. Flowchart of the identification and selection process.

in PET for the maxillary teeth was observed in the ca-
nines. Shillingburg and Grace21 reported the mesial
and distal enamel thicknesses to be 1.42 6 0.26 mm
and 1.67 6 0.30 mm, respectively, resulting in a differ-
ence of 0.25 mm. The second premolars exhibited the
maximum difference in the mandibular arch.21
The mesial and distal enamel thicknesses were
1.38 6 0.23 mm and 1.8 6 0.46 mm, respectively, re-
sulting in a difference of 0.42 mm. Most of the studies
reported that the enamel was thicker in the distal than
in the mesial aspect (Table III).
Risk of bias
The risk of bias was assessed using the risk of bias in
nonrandomized studies of interventions for systematic
reviews involving cross-sectional studies11 (Table IV).
The risk of bias was assessed over 7 parameters. The
overall risk of bias for the included studies was assessed
to be low to moderate. The quality of evidence was as-
sessed using the Grading of Recommendations, Assess-
ment, Development, and Evaluations approach,12
which revealed a low level of evidence. (Fig 2).
Because .10 articles were included, a publication bias
assessment using the funnel plot was done. The funnel
plot showed minimal publication bias (Fig 3).
Results of individual studies, meta-analysis, and
additional analyses, tooth wise assessment:
incisors
Five studies assessed maxillary central and lateral in-
cisors.3,16,17,20,21 One thousand and twenty-eight mesial
and distal aspects were assessed. For the maxillary cen-
tral incisors, the distal enamel thickness ranged from
0.81 to 1.1 mm, whereas the mesial enamel thickness
ranged from 0.81 to 0.98 mm. For the maxillary lateral
incisors, the distal enamel thickness ranged from
0.73 mm to 1.02 mm, whereas the mesial enamel thick-
ness ranged from 0.72 to 0.93 mm. The meta-analysis
revealed that the enamel was thicker on the distal aspect
by 0.12 mm (95% CI, 0.07-0.17) for the central incisors,
whereas it was 0.11 mm (95% CI, 0.08-0.13) for the
lateral incisors. Five studies assessed mandibular inci-
sors.3,9,16,20,21 Eight hundred and sixty-three mesial
and distal aspects were assessed. The distal enamel
thickness ranged from 0.60 to 0.88 mm, whereas the
mesial enamel thickness ranged from 0.64 to 0.76 mm.
The mandibular central and lateral incisors were assessed
by Hall et al,9 Bian et al,16 and Ferreira et al,20 whereas
Sarig et al3 and Shillingburg and Grace21 combined the
data from the central and lateral incisors. The meta-
analysis revealed that the enamel was thicker on the

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 Table III. Summary of study characteristics
American Journal of Orthodontics and Dentofacial Orthopedics

Kailasam et al
Author/y/ Investigation Mesial enamel Distal enamel
No. reference Journal name Study type Population Age, y Sex Sample size used Section assessed Teeth assessed thickness thickness P
1 Stroud et al/ Angle Cross-sectional Caucasian 20 to 39 59 male and 98 Radiograph Maximum Md first premolars 0.99 6 0.21 1.07 6 0.23 0.001
1998/1 Orthodontist 39 female (bitewing) mesiodistal
diameter of
the tooth
Md second premolar 1.19 6 0.21 1.22 6 0.22 0.11
Md first molars 1.28 6 0.23 1.40 6 0.25 \0.001
Md second molars 1.29 6 0.20 1.48 6 0.26 \0.001
2 Harris and Arch Oral Biol Cross-sectional American 13-17 y Pooled, no 115 Radiograph Maximum Mx central incisor right 0.90 6 0.12 1.06 6 0.15 \0.0 01
Hicks/ Caucasoid difference (IOPA) thickness
1998/17 noted
Mx central incisor left 0.91 6 0.11 1.05 6 0.14 \0.001
Mx lateral incisor right 0.91 6 0.12 1.01 6 0.12 \0.001
Mx lateral incisor left 0.91 6 0.11 1.02 6 0.14 \0.001
3 Hall et al/ J Am Dent Cross-sectional African NR 40 male and 80 Radiograph Contact point Md right central 0.72 6 0.10 0.77 6 0.11 \0.0001
2007/9 Assoc American and 40 female (IOPA)
(JADA) White
Md left central incisor 0.71 6 0.10 0.77 6 0.11 \0.0001
Md right lateral 0.79 6 0.11 0.95 6 0.13 \0.0001
Md left lateral incisor 0.81 6 0.11 0.96 6 0.14 \0.0001
4 Macha Braz Oral Res Cross-sectional White adult 19-31 NR 40 Microscope The central Mx premolar right 1.22 6 0.17 1.28 6 0.19 0.0759
et al/ area that
1998/4 encompassed
the greater
crown width
and the thicker
enamel portion
Mx premolar left 1.22 6 0.18 1.39 6 0.17 0.09851
5 Fernandes Braz Oral Res Cross-sectional NR NR NR 40 Microscope The central Md second premolar 1.16 6 0.17 1.24 6 0.12 0.24
et al/ area that right
2011/5 encompassed
the greater
crown width
and the thicker
enamel portion
Md second premolar 1.03 6 0.22 1.10 6 0.21 0.33
left
6 Munhoz et al/ Braz J Oral Sci Cross-sectional NR NR NR 40 Profilometer Contact area Mx premolar right 1.22 6 0.17 1.28 6 0.19 0.001
2012/18
1.22 6 0.18 1.39 6 0.17
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Mx premolar left 0.001

7 Vellini-Ferreira Braz J Oral Sci Cross-sectional NR NR NR 302 Profilometer Tooth long Mx central incisors 0.854 6 0.174 1.015 6 0.173 \0.001
et al/2012/20 axis and
contact surfaces
coincided with
the cutting
plane of the disc
Mx lateral incisors 0.860 6 0.129 1.002 6 0.176 \0.001
Mx canines 1.027 6 0.126 1.220 6 0.145 \0.001
Mx first premolars 1.220 6 0.173 1.266 6 0.187 0.001
Mx second premolars 1.101 6 0.176 1.155 6 0.149 \0.001
Md central incisors 0.675 6 0.144 0.872 6 0.276 \0.001
Md lateral incisors 0.734 6 0.139 0.879 6 0.158 \0.001

5
 Table III. Continued
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6
Author/y/ Investigation Mesial enamel Distal enamel
No. reference Journal name Study type Population Age, y Sex Sample size used Section assessed Teeth assessed thickness thickness P
Md canines 0.781 6 0.106 1.014 6 0.118 \0.001
Md first premolars 1.051 6 0.166 1.266 6 0.187 \0.001
Md second premolars 1.376 6 0.198 1.450 6 0.172 \0.001
8 Sarig et al/ Am J Orthod Cross-sectional NR 12 to 59 48 male, 109 Microscope Contact area Mx central incisors 0.81 6 0.06 0.81 6 0.27 0.998
2015/3 Dentofacial 61 female
Orthop
Mx lateral incisors 0.76 6 0.14 0.86 6 0.28 0.206
Mx canines 1.10 6 0.21 1.11 6 0.26 0.747
Mx first premolars 1.13 1 0.15 1.25 1 0.37 0.593
Mx second premolars 1.41 6 0.27 1.36 6 0.30 0.652
Mx molars 1.35 6 0.29 1.48 6 0.17 0.237
Md central incisors 0.64 6 0.19 0.60 6 0.18 0.581
and lateral incisors
Md canines 0.97 6 0.21 1.30 6 0.61 0.133
Md first premolars 1.16 6 0.13 1.05 6 0.24 0.227
Md second premolar 1.23 6 0.10 1.30 6 0.20 0.305
Md molars 1.37 6 0.12 1.40 6 0.20 0.72
9 Akli et al/ Am J Orthod Cross-sectional NR NR NR 32 Microcomputed 1.5 mm Mx canines 0.856 0.861 0.430
2020/19 Dentofacial tomography incisally and
Orthop 1.5 mm
gingivally from
each of the
American Journal of Orthodontics and Dentofacial Orthopedics

2 reference
slices
10 Shillinburg Journal-Southern Cross-sectional Assumed to be NR NR 159 Microscope 9 sections Mx central incisors 0.98 6 0.11 1.1 6 0.31 NR
and California Caucasian, small
Grace/ Dental percentage of
1973/21 Association African American
and American
Indian
Mx lateral incisors 0.93 6 0.35 0.97 6 0.39 NR
Mx canines 1.42 6 0.26 1.67 6 0.3 NR
Mx first premolars 1.48 6 0.2 1.54 6 0.11 NR
Mx second premolars 1.27 6 0.22 1.21 6 0.28 NR
Mx first molars 1.34 6 0.09 1.41 6 0.1 NR
Mx second molars 1.27 6 0.15 1.3 6 0.17 NR
Md incisors 0.76 6 0.24 0.87 6 0.12 NR
Md canines 1.28 6 0.1 1.24 6 0.24 NR
Md first premolars 1.41 6 0.15 1.51 6 0.19 NR
Md second premolars 1.38 6 0.23 1.8 6 0.46 NR
Md first molars 1.46 6 0.12 1.47 6 0.09 NR
Md second molars 1.44 0.13 1.46 6 0.14 NR
11 Bian et al/ Chinese Journal Cross-sectional Beijing residents, 12 to 60 y; 85 women 182 Microcomputed Contact area Mx central incisor 0.80 6 0.21 0.81 6 0.17 NR
2014/16 of Stomatology Han nationality mean and tomography
(39.5 6 10.6) 97 men
0.72 6 0.12 0.73 6 0.24

Kailasam et al
Mx lateral incisors NR
Mx canines 1.06 6 0.18 1.12 6 0.16 NR
Mx first premolars 1.19 6 0.13 1.24 6 0.26 NR
Mx second premolars 1.2 6 0.21 1.25 6 0.15 NR
Mx first molars 1.37 6 0.23 1.46 6 0.25 NR
Mx second molars 1.42 6 0.18 1.43 6 0.13 NR
 Kailasam et al 7

distal aspect by 0.09 mm (95% CI, 0.03-0.015) for the

mandibular incisors. The studies used different methods
P

to assess the thickness, with Harris et al17 and Hall et al9

NR
NR
NR
NR
NR
NR
NR
using radiographs, Ferreira et al20 using profilometers,
Mesial enamel Distal enamel

0.63 6 0.16
0.66 6 0.14
1.16 6 0.21

1.21 6 0.18
1.42 6 0.20
1.41 6 0.16
thickness

Bian et al16 using microcomputed tomographs,

and Sarig et al3 and Shillingburg and Grace21 using
microscopes.
0.65 6 0.19
0.64 6 0.22
1.07 6 0.25

1.40 6 0.14
1.41 6 0.23
1.15 6 0.2
thickness

Canines
Five studies assessed the maxillary canines,3,16,19-21
whereas 4 studies3,16,20,21 assessed the mandibular
Md second premolars
Teeth assessed
Md central incisors

Md first premolars
Md lateral incisors

Md second molars

canines. Mesial and distal aspects of 174 maxillary ca-

Md first molars

nines and 95 mandibular canines were assessed. For

Md canines

the maxillary canines, the distal enamel thickness ranged

from 0.86 to 1.67 mm, whereas the mesial enamel thick-
ness ranged from 0.86 to 1.42 mm. For the mandibular
Section assessed

canines, the distal enamel thickness ranged from 1.01 to

1.3 mm, whereas the mesial enamel thickness ranged
from 0.78 to 1.28 mm. The meta-analysis revealed
that the enamel was thicker on the distal aspects of
the maxillary canines by 0.11 mm (95% CI, 0.01-0.20).
Investigation

The enamel was thicker on the distal aspect of the

used

mandibular canines by 0.11 mm. (95% CI, 0.04 to

0.27). The 5 studies used different methods to assess
the thickness, with Ferreira et al20 using profilometers,
Sample size

Sarig et al3 and Shillingburg and Grace21 using micro-

scopes, and Akli et al19 and Bian et al16 using microcom-
puted tomography.
Sex

Premolars
Six studies assessed maxillary first premo-
lars,3,4,16,18,20,21 whereas 4 studies assessed maxillary
Age, y

IOPA, intraoral periapical; Mx, Maxillary; Md, Mandibular; NR, not reported.

second premolars.3,16,20,21 Mesial and distal aspects of

297 first premolars and 158-second premolars were as-
sessed. For the maxillary first premolars, the distal enamel
Population

thickness ranged from 1.25 to 1.54 mm, whereas the

mesial enamel thickness ranged from 1.13 to 1.48 mm.
For the maxillary second premolars, the distal enamel
thickness ranged from 1.16 to 1.36 mm, whereas the
mesial enamel thickness ranged from 1.1 to 1.41 mm.
Study type

The meta-analysis revealed that the enamel was thicker

on the distal aspect by 0.12 mm (95% CI, 0.07-0.16) for
the first premolars, whereas it was 0.04 mm (95% CI,
Journal name

0.02 to 0.10) for the second premolars. Mesial and distal

aspects of 339 mandibular first premolars and 414
Table III. Continued

mandibular second premolars were assessed. For the

mandibular first premolars, the distal enamel thickness
ranged from 1.05 to 1.51 mm, whereas the mesial enamel
Author/y/
reference

thickness ranged from 0.99 to 1.41 mm. For the mandib-

ular second premolars, the distal enamel thickness ranged
from 1.21 to 1.80 mm, whereas the mesial enamel thick-
No.

ness ranged from 1.15 to 1.38 mm. The meta-analysis

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8 Kailasam et al

Table IV. Risk of bias assessment

Bian Macha Fernandez Munhoz Harris Hall Shillinburg Ferriera Stroud
Outcome Domain et al et al et al et al Akli et al and Hicks et al and Grace Sarig et al et al et al
Preintervention Bias due to Low Moderate Low Moderate Moderate Low Low Low Low Moderate Low
confounding
Participant Low Low Moderate Low Low Low Low Low Low Low Low
selection
Intervention Bias in NA NA NA NA NA NA NA NA NA NA NA
classification of
intervention
Bias due to NA NA NA NA NA NA NA NA NA NA NA
deviation of
intended
interventions
Missing data Low Low Low Low Low Low Low Low Low Low Low
Postintervention Measurement Low Low Low Low Low Low Low Low Low Low Low
of outcomes
Selection of Low Low Low Low Low Low Low Low Low Low Low
reported result

NA, not applicable.

Fig 2. GRADE approach indicating a low level of evidence.

revealed that the enamel was thicker on the distal aspect
by 0.09 mm (95% CI, 0.01 to 0.19) for the first premo-
lars, whereas it was 0.06 mm (95% CI, 0.02-0.10) for the
second premolars. The mandibular first premolars were
assessed by Ferreira et al,20 Sarig et al,3 Shillingburg and
Grace,21 Bian et al,16 and Stroud et al,1 whereas the sec-
ond premolars were assessed by Ferreira et al,20 Sarig
et al,3 Shillingburg and Grace,21 Bian et al16 and Fer-
nandes et al5; Ferreira et al20 and Munhoz et al19 used
profilometers; Sarig et al3 Shillingburg and Grace,21 and
Macha et al4 used microscopes; Sarig et al3 used radio-
graphs; and Bian et al16 used microcomputed tomography
to assess the thickness.
Molars
The maxillary first molars were assessed by 3
studies,1,16,21 the second molars by 2 studies,16,21 the
mandibular first molars by 4 studies,1,3,16,21 and the

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Kailasam et al
Fig 3. Funnel plot showing minimal publication bias.
second molars were assessed by 2 studies.16,21 Seventy-
six mesial and distal aspects of the maxillary first molars,
52 mesial and distal aspects of the second molars, 271
mesial and distal aspects of the mandibular first molars,
and 66 mesial and distal aspects of the second molar
were assessed. For the maxillary first molars, the distal
enamel thickness was 1.41-1.48 mm, whereas the mesial
enamel thickness ranged from 1.34 to 1.37 mm. The
distal enamel was thicker by 0.08 mm (95% CI, 0.02-
0.14). For the maxillary second molars, the distal enamel
thickness was 1.3-1.43 mm, whereas the mesial enamel
thickness ranged from 1.27 to 1.42 mm. The distal
enamel was thicker by 0.02 mm (95% CI, 0.07 to
0.11). For the mandibular first molars, the distal enamel
thickness was 1.4-1.47 mm, whereas the mesial enamel
thickness ranged from 1.28-1.46 mm. The meta-analysis
revealed that the enamel was thicker on the distal aspect
by 0.05 mm (95% CI, 0.01 to 0.12). For the mandibular
second molars, the distal enamel thickness was 1.41-
1.46 mm, whereas the mesial enamel thickness ranged
from 1.41 to 1.44 mm. The meta-analysis revealed
that the enamel was thicker on the distal aspect by
0.02 mm (95% CI, 0.06 to 0.09). Although Sarig
et al3 and Shillingburg and Grace21 used microscopes,
Stroud et al1 used radiographs, and Bian et al16 used mi-
crocomputed tomography to assess the proximal
enamel.
DISCUSSION
This systematic review aimed to summarize the PET
of the permanent dentition from the incisors to the
second molars. The included studies were categorized
as showing low to moderate risk. The quality was vari-
able, and it was clear that there is a need for better-
designed studies.
The meta-analysis was performed tooth wise by
obtaining the appropriate data from the 11
American Journal of Orthodontics and Dentofacial Orthopedics
9
studies.1,3-5,9,16-21 In total, 4019 mesial and distal
surfaces involving 2118 teeth were assessed (Fig 4 and
Supplementary Fig 1). The distal enamel was thicker
than the mesial by an average of 0.10 mm. (from 0.09
to 0.12). The least difference of 0.02 mm was observed
for the maxillary and mandibular second molars, and a
maximum difference of 0.12 mm was observed in the
maxillary central incisors and maxillary first premolars.
There was considerable heterogeneity in the included
studies, particularly the tooth being assessed, the crown
section analyzed, and the assessment technique. There-
fore the findings of the overall meta-analysis should be
interpreted with caution, and there was a definite need
for subgroup analysis. The subgroups considered were
tooth wise, assessment technique, and contact area
(Supplementary Fig 1-3). Subgroups were based on the
exact reference point at which enamel thickness was
being measured (other than the contact area or point)
was not possible given the small number of studies
with similar reference points. However, the data in the
subgroup analysis did not differ from the outcome of
the meta-analysis of the 11 included studies.
The differences in mesial and distal enamel thick-
nesses have been explained by Stroud et al1 as being
because of differential wear patterns.1 Low level of
mesial force is necessary to produce interstitial
wear.22,23 This explanation is reinforced by the fact
that the least difference was observed in the premolars.
It would be expected that premolars are extracted mostly
from adolescents (for orthodontic treatment) and there-
fore experience minimal wear.
Right and left sides, sexual dimorphism, age, and race
are expected to be parameters affecting enamel thick-
ness. A strong right-left symmetry for the same contra-
lateral teeth has been noted.4,5,9,20 There was no sexual
dimorphism in enamel thickness.9,24,25 Furthermore,
Stroud et al1 demonstrated that the sexual dimorphism
in posterior tooth size was due to dentin thickness rather
than enamel thickness. Munhoz et al18 and Fernandes
et al5 used tooth banks, which do not provide informa-
tion on the age range, gender, or race of the donors. Age
and mastication would have more impact on the reduc-
tion in occlusal wear than would proximal thickness.18
Because enamel formation of the permanent dentition
up to the first molar is completed by the age of 3.0-
3.3 years,26 and reductions in enamel thickness occur
especially after the age of 50,27 this parameter would
not create a considerable difference in the interpretation
of the results. Moreover, teeth with severe proximal wear
were excluded from all studies.
Earlier studies on the thickness of enamel were
measured by typical histologic crown cross-section.
This method is the most accurate and reliable with
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10
Fig 4. Meta-analysis of 11 studies.
many applications, but it needs to destroy the tooth tis-
sue. The second includes nondestructive methods, such
as x-ray film measurement, ultrasonic measurement,
computed tomography measurement, etc.16 Conven-
tional and digital intraoral radiographs, as well as
computed tomography, are considered good diagnostic
adjuncts for the clinical assessments of the tooth crown
and proximal enamel measurements.17,28 The articles in
this systematic review used radiographs,1,9,17 micro-
scopes,3,4,16 profilometers,5,18,20 and microcomputed
tomography.19,21 Conventional computed tomography
studies were conspicuous by their absence. This could
be due to the fact that conventional computed tomog-
raphy, although having high image resolution, results
in the production of a blurred image if the limits of
enamel thickness are smaller than 1.1 mm.28
There was a lack of standardization of both the
different assessment tools and of the different enamel
slices. Enamel measurements by microcomputed tomog-
raphy are highly accurate and reliable.29 Enamel thick-
ness studies that use radiographs need to be viewed
with circumspection because there was a general overes-
timation of measurements made from the radiographs,
as well as a large variability in error.30 This was partially
evident with the assessment technique-based meta-
analysis, which revealed that greater differences between
mesial and distal enamel were observed when assessed
with profilometers and radiographs, and the least differ-
ence in thickness being observed with microcomputed
tomography.
The point at which enamel thickness was being
measured was variable. A few studies measured the
enamel thickness at the mesial and distal contact
areas,1,3,9 whereas others measured the greatest thick-
ness of enamel.4,5,17,18 Akli et al19 measured the enamel
thickness at the widest mesiodistal slice and 2 mm inci-
sally and 4 mm gingival to this reference slice. Shilling-
burg and Grace21 measured it at 9 regions. For the
purpose of this systematic review, the maximum
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Kailasam et al
thickness measurements from the data of Shillingburg
and Grace21 were taken.
As pointed out by Hall et al9 before deciding how
much enamel to remove, clinicians need to know the to-
tal thickness of enamel present on a tooth's surface. The
main finding of this systematic review and meta-
analysis, which was the greater thickness of enamel on
the distal aspect, would influence almost all clinical
branches of dentistry. In orthodontics, this would be
applicable in the planning of IPR, which is routinely
done in clear aligner therapy and to avoid tooth extrac-
tion. Currently, the orthodontic IPR is limited to 0.5 mm
per interproximal region, about 0.25 mm from each of
the 2 involved teeth.31-33
Enamel reduction is common with clear aligner ther-
apy and is preplanned. The operator can choose the
interproximal areas to gain space and the amount of
enamel to be removed.34 The dedicated software plan-
ning the IPR is capable of virtually separating the teeth,
enlarging and rotating them for better visualization.34 It
would thus be clinically prudent to plan the quantum of
IPR such that there would be a greater reduction on the
distal aspect.
In restorative and preventive dentistry, although the
amount of enamel required to protect against caries or
sensitivity is unknown,1 it would be expected that
greater thickness of enamel would require greater time
for the caries lesion to reach the dentin and the pulp.35
If caries lesions can be detected when they are limited
to just the enamel, especially less than half of the
enamel, noninvasive treatment, such as frequent fluo-
ride application maintenance visits, can be performed
to stop the progression of the caries lesion, thereby pre-
venting a Class II restoration that may potentially subject
the tooth to a lifetime of treatment.36
The new paradigm of operative conservatism, some-
times referred to as minimally invasive dentistry, incor-
porates the dental science of detecting, diagnosing,
intercepting, and treating dental caries at the
Kailasam et al
microscopic level.37 Therefore, arguments can be made
for asymmetric tooth preparation in the field of pediatric
dentistry for crowns and prosthetics for bridge prepara-
tion, which would be directly related to the greater distal
enamel thickness. Although the pulp space shows great
variations in terms of shapes, sizes, and configura-
tions,38 the mesial pulp horn is higher in most molars.
The increase in enamel thickness on the distal aspect
would relate to pulp space, and crown symmetry would
require further research. PET would also be expected to
play a significant role in esthetic dentistry because
enamel thickness would have a bearing on the natural
color of the tooth, which varies from light yellow to
grayish (bluish) white and is better extrapolated through
the Munsell system, namely, hue, value, and chroma.39
Finally, from the standpoint of occlusion, greater func-
tional load on the more posterior teeth causes the
enamel to become thicker from the premolar toward
the molar.1 Because distal enamel thickness was greater,
the question of the distal aspect of the tooth encoun-
tering greater functional load warrants investigation.
With the distal movement of posteriors as a planned
mechanism of correction, the space creation should be
planned such that this greater distal enamel thickness
is maintained to ensure the occlusal load during masti-
cation is maintained.
Other potential areas of interest would be how these
various thicknesses affect the shapes of proximal contact
areas, a subject which has been addressed three-
dimensionally in a proposed classification of contacts
called OXIS,40 location of the contact area, which is asso-
ciated with the location of interdental crestal bone, peri-
odontal breakdown of the interproximal gingival col,
interdental black triangles, malaligned teeth, and ortho-
dontic movement and stability.
With nonextraction treatment using IPR as a method
of gaining space becoming popular, it is evident the
contemporary orthodontist should have greater clinical
information on IPR and enamel thickness. It is desirable
to design better studies with a methodology that could
estimate the enamel thickness accurately. A comparison
of the thickness of the same tooth using different tech-
niques like computed microtomography, microscopy,
histology, etc to assess the most accurate technique
would be useful. Furthermore, the enamel width
differing at various sections of the clinical crown, studies
with 3-dimensional data would provide more informa-
tion for planning IPR.
Limitations
English language studies were included, and 6 data-
bases were searched. Studies that map the enamel
American Journal of Orthodontics and Dentofacial Orthopedics
11
thickness with sections measured at different areas of
the crown, that is, the enamel thicknesses at the occlusal,
middle, and cervical thirds, which have been proven to
be different, are required to provide more concrete infor-
mation to the clinician. The enamel mineral content also
differs at different depths and may play a role along with
thickness. Three-dimensional assessments are more
accurate, but there is only limited data, and hence
this systematic review was limited to 2-dimensional
measurements.
CONCLUSIONS
The present systematic review and meta-analysis
suggest that the thickness of the enamel on the distal
aspect was greater than that on the mesial. The least dif-
ference was observed for the maxillary second premolars,
and a maximum difference was observed in the mandib-
ular canines. The summary effect of the meta-analysis
revealed that the thickness of the enamel on the distal
aspect was greater than that on the mesial by an average
of 0.10 mm (from 0.09 to 0.12).
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2021.05.007.
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Kailasam et al 12.e1

Supplementary Fig 1. Tooth wise meta-analysis.

American Journal of Orthodontics and Dentofacial Orthopedics - 2021  Vol -  Issue -

12.e2 Kailasam et al

Supplementary Fig 1. (continued).

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Kailasam et al 12.e3

Supplementary Fig 2. Assessment technique based on meta-analysis.

Supplementary Fig 3. Tooth section based on meta-analysis.

American Journal of Orthodontics and Dentofacial Orthopedics - 2021  Vol -  Issue -