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. NO PART OF THIS ARTICLE MAY BE

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Int erpr o ximal Enamel Reduction

Martinho L. R. Moreno Pinheiro, DMD1
Aim: To describe in detail the stripping technique, or interproximal enamel reduction. Material and Methods: Following a careful literature review, this article discusses the interproximal enamel reduction techniques currently available and presents two clinical cases. The
indications, contraindications, advantages, disadvantages, and precautions of interproximal
enamel reduction are discussed. Results and Conclusion: Orthodontists can effectively use
interproximal enamel reduction techniques in many aspects of clinical practice. There is no
evidence that, when utilized correctly and in selected clinical situations, interproximal
enamel reduction causes harm to the dental hard tissues or soft tissues. World J Orthod
2002;3:223232.

In 1944, Ballard4 recommended a careful stripping of the interproximal surfaces, mainly from the
anterior segment, when a lack of balance is present.
In 1954, Begg5 published his study of Stone Age
mans dentition, where he referred to the shortening
of the dental arch over time, which occurred through
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 development of the technique for interproximal
enamel reduction.
In 1956, Hudson6 stated that mesiodistal reduction of the mandibular incisors is only occasionally
referred to in the literature, and listed just three previous articles with direct reference to the mesiodistal
reduction of mandibular incisors. In his study, Hudson stated that stripping should be carried out with
medium and fine metallic strips, followed by final
polishing and topical application of fluoride (to the
authors knowledge, this is the first description of a
stripping technique). He stated that it was possible
to gain 3 mm of space between mandibular canines,
and presented an enamel thickness table for incisor
and mandibular canine contact points.
In 1958, Bolton 7 published his seminal study
titled Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. This
study, together with Ballards study, supported the
need, in dental dimension discrepancy problems, to
use interproximal stripping to correct problems of
dental balance.

nterproximal enamel reduction (IER) is understood

to be the clinical act of removing part of the dental
enamel from the interproximal contact area. 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 attention. In
the literature, this clinical act is normally referred to as
stripping, although other names can be found, such
as slandering, slicing, Hollywood trim, selective
grinding, mesiodistal reduction, reapproximation,
interproximal wear, and coronoplastia.13
IER is a critical procedure. Therefore, planning
and execution 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.

HISTOR Y OF INTERPROXIMAL
ENAMEL REDUCTION
Interproximal dental stripping has been used by
orthodontists for many years.2,3 It was initially used
to gain space when correcting mandibular incisor
crowding or to prevent such crowding.
1Private

Practice of Orthodontics, Portalegre, Portugal.

REPRINT REQUESTS/CORRESPONDENCE
Dr Martinho Pinheiro, Av. Pio XII n2 r/c DTO, 7300-073 Portalegre, Portugal. E-mail: martinhopinheiro@hotmail.com

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In 1969, Kelsten 8 recommended the use of

mechanical means to carry out stripping and recommended prior alignment of teeth. He posited that
only after alignment could stripping be simply and
accurately achieved. That same year, Rogers and
Wagner9 described an in vitro study that used teeth
extracted for orthodontic reasons. These extracted
teeth 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 impor tance, already highlighted by
Hudson,6 of topical fluoride application after stripping and polishing.
In 1971, Paskow10 published an article that recommended the use of mechanical methods of IER.
In 1973, Shillingbourg and Grace11 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.
Also in the 70s, Peck and Peck published articles12,13 on crowding of the mandibular incisors and
presented the Peck index. They advised stripping
whenever the mesiodistal dimension of the
mandibular incisors did not fall within acceptable figures calculable from their index. They claimed that
anything in excess would constitute predisposition
toward crowding.
In 1980, Tuverson14 published Anterior interocclusal relations: Part 1, which presented a highly
detailed description of the stripping technique using
a back angle and abrasive disks. In 1981, Doris,
Bernard, and Kuftinec15 concluded that one of the
strongest determining factors for dental crowding is
the dimension of teeth in the arch. In 1981, Betteridge16 presented the results of stripping on the
anterior and inferior segment after 1 year without
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, Sheridan published his article Air-rotor
stripping 17 and, in 1987, Air-rotor stripping
update.18 These articles totally revolutionized the
technique and aims of interproximal enamel reduction. He recommended:

on both arches. This achieves greater space and

allows the preservation of incisors.
3. Use of stripping procedures to achieve space (up
to 8 mm per arch) for the correction of moderate
dentomaxillary disharmony, without recourse to
extraction or excessive expansion.
In 1986, Zachrisson19 proposed a new direction
for stripping: 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. In 1944, Ballard recommended careful stripping of the proximal surfaces
of the anterior teeth when there was imbalance.4
2. Crowding of mandibular incisors. Stripping was
first used6 to obtain space for the correction and
prevention of crowding.
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.19
4. Normalization of gingival contour and elimination
of triangular spaces above the papilla, thus
greatly improving esthetics and smile.19,20
5. Moderate dentomaxillary disharmony. This is a primary 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.17,18
6. Reduced expansion and premolar extraction.
7. Camouflage of Class II and III malocclusions. The
use of mandibular stripping can be beneficial in
camouflaging slight to moderate Class III conditions and overjet. In orthodontic treatment to camouflage Class II with the extraction of two maxillary
premolars, correcting the crowding and inclination
of the mandibular incisors with stripping is an
ideal solution.
8. 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.

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
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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
excessive loss of enamel and all of the ensuing
consequences.
2. Poor oral hygiene and/or poor periodontal environment. IER should not be used when there is
active periodontal disease or lack of dental stability. Although little scientific evidence exists linking
IER and increased dental mobility, it is prudent to
avoid this technique in these situations. In addition, IER should not be used when there is poor
oral hygiene; the orthodontist could be held
responsible for all subsequent iatrogenic activity.
Vanarsdall has called attention to the potential
deleterious consequences.20
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 situations, 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 teethteeth with straight proximal surfaces and wide basesas these shapes produce
broad contact surfaces, and could potentially cause
food impaction and reduced interseptal bone.

Fig 1 Holding device with metallic strips

used for the manual method of IER.

Mechanical method
This technique greatly reduces working time. The
tools for its use mainly consist of disks for handpieces or contra-angles8,10,14,19 (Fig 2a), high-speed
handpieces,17 and mechanical files for contra-angle
heads with shuttle movement (Figs 2b and 2c)
A new generation of perforated disks was recently
tested by Zhong and colleagues24 (Fig 3). In Zurich,
van Waes and Matter have developed an orthostrips system (Intensiv; GAC International, York, PA,
USA) of flexible strips for contra-angle shuttle heads
composed of four small metallic strips of decreasing
grain size (Fig 4).

Techniques
Initially, stripping was done as described by Hudson,6
with metallic strips (Fig 5). Hand disk contra-angles
were introduced later, and are recommended by a
number of authors8,14,19,23 (Fig 6).
In 1985, Sheridan17 advised the use of carbide
fissure drills for turbines, cutting from a horizontal
position and parallel to a 0.022-inch wire, called an
indicator wire, which was previously positioned at
the gingival margin (Fig 7). For the shaping and finishing of the tooth, Sheridan recommended a finegrain diamond drill.18
Other authors have recommended very fine diamond drills, used vertically, which facilitate the shaping movement and reduce the risk of causing the formation of steps (Fig 8).
Zhong and colleagues 24 have concluded that
stripping executed with perforated disks, followed by
polishing with fine and ultra-fine Sof-Lex disks (3MUnitek, St Paul, MN, USA), proved to be efficient and
provided good results in final polishing (Fig 9).

MATERIAL AND METHODS

Correct IER is composed of four stages: reduction,
reshaping, polishing, and protection of the enamel.
There are two main techniques for IER, depending on
whether manual or mechanical methods are used.

Manual method
This method consists of metallic strips, impregnated
with abrasive metal oxides, and numerous holding
devices (Fig 1). This method was first described in the
literature by Hudson.6 The technique is seldom used for
three reasons: (1) it is time consuming; (2) there is technical difficulty in working on posterior teeth; and (3) it
causes much deeper grooves on the abraded enamel
than those caused by mechanical instrumentation.22,23
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Fig 2 Tools for the mechanical method of IER. (a) Disks for handpieces, (b,c) mechanical files for contra-angle
heads with shuttle movement.

Fig 3

Perforated disks for IER.

Fig 4 The ortho-strips system

developed by van Maes and Matter.
(a) Metallic strips of decreasing grain
size for (b) contra-angle shuttle head.

Fig 5 (Left) Manual stripping with

small metallic strips.
Fig 6

(RIght) Stripping with disks.

Fig 7 (a) Indicator wire and (b) the

Sheridan stripping technique.

Fig 8 Stripping technique with a

very fine diamond drill, used vertically.

Fig 9 (a) Stripping with perforated disks, followed by (b) polishing with
Sof-Lex disks.

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Pinheiro

Fig 10 (a) Ortho-strips system technique and (b) its adaptation to the
shape and convexity of the tooth.

The four metallic strips in the van Waes and Matter

ortho-strips system, with grains between 15 and 90
m for cutting and polishing, can be adapted to a 36position shuttle head with oscillation movement of 0.8
mm. They have the advantage of being flexible and
adapt well to the shape and convexity of the tooth,
especially at the contour of cervical area (Fig 10).
Files for use with shuttle heads are available in several different grains (15 to 125 m) for cutting and polishing, They are also practical for shaping teeth (Fig 11).

Fig 11
heads.

Files for use with shuttle

However, this also necessitates the prior measurement of the space opened up by the elastic (or
spring) for optimal reduction (Fig 13c).
Using one or more of the techniques previously
described, IER and polishing are then carried out on
the mesial surface of the last tooth to be stripped
and on the distal surface of the penultimate tooth.
The space obtained is measured with the instrument recommended by Sheridan25,26 or with calibrated wires, as recommended by Philippe27 (Figs
14a and 14b). Anchorage of the posterior teeth is
then prepared, which can be done with stops (Fig
14c), bends in the arch, or through the prior fitting of
palatal and lingual bars.
Distalization should be carried out tooth by tooth
to avoid any loss of space.18 The archwire should
slide freely in the brackets, so round steel arches are
recommended (Fig 15a). Brackets with a ball hook
can also be used, which allows the fitting of a metallic ligature to the bracket and force application at
that point (Fig 15b).
At the end of each stripping and polishing session, a topical application of fluoride should be performed6,9,17,23,28 (Fig 16). Initially, Sheridan recommended the use of sealants,29 but he later withdrew
these recommendations because remineralization
might spontaneously occur.22
When distalization of the tooth is finished, the
whole process is repeated in the next contiguous
space (Fig 17). When the stripping and distalization
stages are complete, a nickel-titanium or thermoactive arch is placed, followed by alignment of the
anterior teeth.
Figures 18 and 19 illustrate, with pre- and posttreatment photographs, the results achieved with
proper IER technique in two patients with Class I
malocclusion and moderate crowding.

Treatment sequence
The following treatment steps are described in more
detail below.
1. Complete treatment planning, with accurate
measurement of study casts.
2. Ensure that no contraindications to IER exist.
3. Place orthodontic appliances and correct rotation.
4. Place elastic or spring separators.
5. Carefully do the IER (carried out sequentially).
6. Shape and polish the stripped surface.
7. Measure and control the obtained space.
8. Check posterior anchorage.
9. Reduce friction and perform the progressive distalization.
10. Apply fluoride.
11. Align anterior teeth.
12. Retain properly to maintain optimal results.
For sound practice of this technique, the first step
should be to plan the treatment and accurately measure, on the study casts, the amount of space
required18 for the desired correction (Fig 12). No contraindications to stripping should exist for the patient.
A few days before stripping, separators are placed
in position (Fig 13a) or, as Sheridan18 recommends,
a spring is placed (Fig 13b) to separate each tooth at
the contact area. This has the advantage of allowing
stripping to be carried out individually on each tooth.

Advantages of IER
The following are the main advantages of the IER
technique:
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Fig 12 Measurement of the teeth

on the cast.

Fig 13 A few days before stripping (a) separators are placed in position or (b) spring is used to separate teeth, and
(c) measurement of the space is obtained with the spring or separator.

Fig 14 (a) Calibrated wires, as recommended by Julien Philippe. (b) Instrument recommended by Sheridan (Raintree Essix, Metairie, LA, USA). (c) Anchorage of the posterior teeth with stops.

Fig 15 (a) Distalization elastic placed on bracket and (b) distalization elastic
placed on a ball hook.

Fig 17

Treatment progress.

228

Fig 16 Fluoride ready for topical

application.

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Pinheiro

Fig 18 Young adult female patient with Class I malocclusion and moderate crowding, treated with IER. (a to e)
Pretreatment and (f to j) posttreatment.

The space obtained can be continuously monitored

to adjust it to the space needed to achieve the
treatment goals.
Overexpansion of the dental arch is avoided.
Extraction of teeth is greatly reduced.
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 considered less than with extraction.
Treatment time is reduced.

The quality of treatment is significantly improved in

patients with crowding and contraindications for
extraction, as in the case of closed bites.
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.
Treatment of adults with slight or moderate crowding is possible, without the need for extraction.
Greater posttreatment stability is possible.

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Fig 19 Young adult male patient with a Class I malocclusion and moderate crowding, treated with IER. (a to e) Pretreatment and (f to j) posttreatment.

Disadvantages of IER

Does stripping increase the risk of decay?

Does stripping cause periodontal damage?
How much enamel can be stripped?

It is a time-consuming treatment.

A perusal of the literature offers some answers.

Radlanski and colleagues30,31 demonstrated that
even with thorough polishing it was impossible to
totally remove grooves left by stripping and that after
1 year, such grooves are still microscopically visible
at the contact point, where there is natural abrasion.
They also found that even after careful cleaning,

RESER VATIONS OR POTENTIAL

IATROGENIC SEQUELAE
In 1956, Hudson already questioned whether IER
could have adverse consequences on oral health. It
is legitimate that some issues arise:
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ADMONITIONS

including flossing, bacterial plaque was evident.

They concluded, however, that no study has demonstrated that this roughness suggested predisposition
to decay. In 1980, Boese,32 in a 9-year retrospective
study, concluded that it was not possible to find
adverse effects. Zachrisson,19 in 1986, considered
polishing and treatment of the stripped surface
unnecessary. In 1990, Crane and Sheridan,33 in a
retrospective study conducted on patients who had
been subjected to stripping between 1985 and
1988, found 4.6% of new caries lesions on stripped
areas and 4.1% of new caries lesions on unstripped
areas. This difference was statistically insignificant.
In 1991, El-Mangoury et al,28 in an in vivo study, concluded that the roughness produced by stripping
does not increase propensity to decay, and that after
9 months, the natural remineralization of the
stripped area is complete. However, the application
of fluoride is advised. In 1991, Joseph et al23 recommended a mixed technique of polishing with strips
and treatment with 37% phosphoric acid. This provided an excellent polish, which was then followed
by topical application of fluoride. It can be concluded
from these studies that stripping itself is not a factor
that enhances the decay process.
In addition, the preponderance of evidence suggests that stripping does not predispose patients to
periodontal deterioration. In 1980, Boese,32 in a 9year retrospective study carried out on patients subjected to stripping and fiberotomy, concluded that
there was no significant reduction of the osseous
crest in these patients. Sadowsky and BeGole,34 in a
study conducted in 1981 comparing a group of
patients that received orthodontic treatment during
adolescence with a control group, concluded that this
treatment did not have any effect on long-term periodontal health. In 1981, rtun et al35 concluded that
the approximation of roots through orthodontic treatment did not predispose patients to faster periodontal
destruction. In 1990, Crain and Sheridan,33 in a study
on premolars and molars in patients subjected to
stripping, found no alterations of the osseous crest
when comparing stripped areas to non-stripped areas.
Finally, several authors have conducted studies
on the thickness of dental enamel (Fig 20, see WJO
website at www.quintpub.com).6,11,36 On the basis of
these studies, several possibilities regarding the
amount of enamel that can be stripped were
described, but it is now widely accepted that 50% of
existing enamel is the maximum amount that can be
stripped without causing risk to dental and periodontal health.17 In most situations, this corresponds to a
maximum of 0.5 mm per dental surface or, in other
words, 1 mm33,37 per mesial contact area of second
molars to the distal of the canines.

Always carry out IER with new instruments.

Carefully protect soft tissues.
Never carry out IER until dental rotation has been
corrected, so that it can be done at the correct contact areas.
In cases of Class I malocclusions, without tooth size
discrepancy, always carry out IER on both arches.
Take into consideration that IER on anterior teeth
may detract from their esthetic appearance.
When using IER in adolescents, consider extraction
of third molars, since many clinicians feel that they
could cause new crowding and need for additional
treatment.

KEY POINTS
Carry out stripping sequentially.
Limit stripping to 0.5 mm per contact surface or, in
other words, 1 mm per mesial contact area of second molars to the distal of the canines.
Measure space accurately.
Parallel stripped contact areas.
Shape dental surfaces to their original configuration, without abraded grooves.
Carefully polish the stripped surface.
Topically apply fluoride after stripping.
Reduce, as much as possible, inadvertent loss of
space obtained, by using anchorage on posterior
teeth and reducing friction through the use of
round arch and metallic ligatures.

CONCLUSION
It has been shown that orthodontists can effectively
use the IER technique in many aspects of their practices. There is no evidence that IER conducted within
recognized limits and in appropriate situations
causes harm to teeth or gingiva.

REFERENCES
1.

2.
3.
4.

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lorthodontie de ladulte (prmiere partie). Rev Orthop Dento
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Ritto AK. Remodelao Dentria Interproximal. Revista de
Sade Oral 1997;2:107118.
Ritto AK. Remodelao Dentria Interproximal. Revista de
Sade Oral 1998;3:3344.
Ballard ML. Asymmetry in tooth size: A factor in the etiology,
diagnosis, and treatment of malocclusion. Angle Orthod
1944;14:6771.

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232

VOLUME 3, NUMBER 3, 2002

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WEB ONLY

Average
Total

Mesial Distal

Tooth
5.00
5.83
6.58

Least

Mesial Distal

Total

Mesial

mm

0.544
0.650
0.763

0.522
0.683
0.900

5.88
6.50
8.53

0.88
1.05
1.11

Distal

mm
0.70
0.98
1.80

4.40
4.95
5.27

0.37
0.47
0.38

0.36
0.50
0.55

Hudsons enamel thickness table.6

Maxillary
Mandibular
Fig 20b

Total

mm

Central incisor
Lateral incisor
Canine
Fig 20a

Greatest

Central
Incisor

Lateral
incisor

Canine

0.85
0.75

0.91
0.77

1.19
0.88

1.31
1.16

0.96 0.80
0.75 0.77

First
premolar
M

1.48 1.54
1.41 1.51

Second
premolar
M

1.27 1.21
1.38 1.80

First
molar
M

1.34 1.41
1.46 1.47

Shillingbourgs and Graces enamel thickness table; contact point values selected by Didier Fillion.11,22

Fig 20c Stoud, English, and Buschangs enamel

thickness table.38
1.29
M2

1.48
1.28

M1

1.41
1.18
1.22

PM2

Mesial
Distal

0.98

PM1

1.07
0.8

0.9

1.0

1.1

1.2

1.3

1.4

1.5

1.6