Stripping.prof.dr.maher fouda

By
SamehhamedGhadirragheb
Under supervision of
Prof. Dr. Maher fouda
INTERPROXIMAL REDUCTION
(STRIPPING)

• Creation of space to facilitate tooth movement is one of the basic
principles of orthodontics.
• This can be achieved through extraction, expansion or IPR(Stripping).
• Stripping is a clinical procedure involving the reduction, anatomic
recontouring and protection of proximal enamel surfaces of permanent
teeth.
• Inter-proximal reduction also known as: slenderizing, enamel reduction
or selective reduction, slicing, Hollywood trim, selective grinding,
mesiodistal reduction, reapproximation, interproximal wear and
coronoplastia.
• With appropriate case selection and correct technique, stripping offers
the ability to safely obtain sufficient space for tooth movement without
the need for extractions and without compromising the health and
shape of slenderized teeth.

 The aim of this reduction is to create space for
orthodontic treatment to correct minor
malocclusions with less of extraction.
 To give teeth a suitable shape whenever
problems of shape or size require attention.

Prior to IPR,
teeth slightly overlap
During IPR
Following IPR,
the patient has a more aesthetically
pleasing smile and an improved bite.

 Historically, it was believed that decreasing the space between the roots
of teeth was detrimental to the periodontium.
 After a thorough review of the literature, it is apparent that there is no
negative or positive effect when teeth become closer due to
slenderization.
 Investigators studying horizontal and vertical bony defects on posterior
teeth found no evidence supporting the viewpoint that narrow spaces
between roots were risk factors for periodontal disease.
 Other investigators found that teeth could function even when the roots
were touching and sharing a periodontal ligament.
 According to Fillión, even if slenderization is performed on already
aligned teeth and the interdental septum thickness is reduced as a
result, the periodontal state is improved.
 If <0.3 mm or less enamel is removed per tooth surface during
slenderization, no effects are noticeable on the periodontal ligament
either radio graphically or clinically.

1.When space requirement is minimal (2.5-
3.0 mm).
Severe crowding not indicated for IPR
2.macrodontia size discrepancy
in cases where teeth are crowded and larger than normal ,
proximal stripping can be considered.

3- inter-arch size discrepancies :
Kesling in 1945 stresses the importance of a favorable inter arch tooth
Size relationship for establishment of stable occlusion

4- Tooth shape and dental esthetics:
Stripping can be used for the reshaping of enamel on
some teeth, thus contributing to an improved finishing of
orthodontic treatment and dental esthetics.
canines were positioned to replace the
congenitally missing maxillary lateral
incisors.
Cosmetic reshaping of the maxillary
canines and esthetic bonding were
completed.

5.Crowding in primary dentition
Van Der Linden suggests that dentists can prevent
crowding, or improve conditions for the alignment of
anterior teeth by taking advantage of the leeway space in
selective stripping of some temporary teeth. But,
primarily, orthodontists use stripping on permanent teeth.
A- The crown of the temporary canine is stripped mesially in
order to create space for alignment of the anterior teeth

B-The crown of the first temporary molar is
stripped mesially to facilitate eruption of
permanent canine into its correct position.
C- The mesial surface of the crown of the
second temporary molar is stripped to ease
eruption of the first bicuspid.
D-The width of the second temporary
molar is more or less equal to the width of
the second bicuspid.

6- Crowding of mandibular
incisors:
stripping was first used to obtain space for the
correction and prevention of crowding

7- To be performed on temporary tooth
to improve occlusion :
Interproximal stripping is about to be performed on this temporary tooth to
improve occlusion.

8-Normalization of gingival contour and
elemination of triangular spaces above
the papilla (dark triangles)
thus greatly improving esthetics and smile .

9. Multiple Tooth Rotations
In patients with multiple rotations, slenderization can provide wider interproximal
contact facets that make relapse less likely.
Many orthodontists purposely flatten out contacts in the lower anterior regions in
the belief that relapse can be prevented or at least minimized due to the
proximation of the flat contacts.

10- 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 IPR.
11.To enhance retention and stability.

12.Class I arch-length discrepancies with
orthognathic proﬁles.
13. Camouflage of Class II and III malocclusion:
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 extraction of two
maxillary premolars, correcting the crowding and inclination
of the mandibular incisors with stripping is an ideal solution.
tendency Class III molar
relationship.
Class II molar relationship.

Bolton tooth-size discrepancies.
In many cases, patients present with some type of tooth size
discrepancy, described by Bolton: the Cuspid-to-Cuspid Bolton Index
(maxillary or mandibular – 6 teeth) or the first Molar-to-first-Molar
Bolton Index (maxillary or mandibular – 12 teeth).
Bolton determined that the relation between the upper and lower molar-
to-molar tooth size is 91.3 ± 1.91

Cuspid-to-Cuspid Bolton Index (6 teeth).
If the patient presents with Bolton discrepancies, it is necessary
to compensate for this discrepancy with IPR of the dental arch in
order to achieve a good occlusion.
If teeth are too small, space should be opened, and build-ups
should be performed

Patient with a Bolton tooth-size discrepancy. The
patient has congenitally missing maxillary lateral
incisors
The missing maxillary lateral incisors were
replaced with a Maryland acid etched bridge,
and lower incisor interproximal enamel
reduction was performed

1- Sever crowding ( more than 8 mm per arch
2- Poor oral hygiene and /or poor periodontal environment
3- Small teeth and hypersensitivity to cold
4- Susceptibility to decay or multiple restorations
5- severely rotated teeth for which access to the proper
contact area is not accessible (in cases like this, it is
recommended to either make room using the separation
technique or wait until crowding in the area of the tooth is
resolved and space is created).
6. Shape of teeth:
stripping should not be carried out on square teeth(rectangular-shaped teeth),
that is teeth With straight proximal surfaces and wide bases, as the shapes
produce broad contact surfaces, and could potentially cause food impaction
and reduced interseptal bone.

1. Overexpansion of the dental arch is avoided.
2. Extraction of teeth is greatly reduced
3. The need for excessive tooth movement, as well as the possible
loss of bone and of root cementum, is reduced due to the fact that
the iatrogenic potential is considered less, than with extraction.
4. Treatment time is reduced.
5. The quality of treatment is significantly improved in patients
with crowding and contraindications for extraction, as in the
case of closed bites.
6. Esthetics are improved, as is the final health of the gingival
papilla, which adapts better to a reduction of interdental space
than to the space left by extraction.
7. Treatment of adults with slight or moderate crowding is
possible, without the need for extraction.
8. Greater post treatment stability is possible.

1. Techniques which do not emphasize
conservativeness, along with operator error, can
result in enamel damage or over-reduction.
2. Contours of teeth can easily be destroyed, after
which a restorative procedure is required.
3. Performing slenderization with instruments with
which the operator can lose control of the
procedure, such as ARS (air rotor stripping), is not
recommended.
4. This can result in spacing that requires
subsequent orthodontic treatment for closure

High-speed spinning diamond disks easily slice teeth, as the
disk takes its own path while spinning, and are not
recommended. To control the reduction of tooth structure, a
low-speed, high torque hand piece should be used.
Improper contour visible on radiographs, accompanied by incomplete space
closure on same patient.

Tooth shape and
enamel thickness

 The enamel thickness around teeth is similar in incisors, cuspids, molars,
and premolars.
 Enamel thickness in premolars can be well over 1
mm
 The enamel is slightly thicker in the contact point, and gradually
decreases in thickness toward the cementoenamel junction.
 The enamel is slightly thinner in distal than in mesial surfaces. In
upper cuspids and lower second bicuspids, these differences are
greater.
 There is no relation between dental size and enamel thickness;
therefore, macrodontic teeth should not be stripped more than
microdontic teeth are (although aesthetically it is better to carry out the
slenderizing on macrodontic teeth)

Three main dental shapes:
rectangular, triangular,barrel-shaped
teeth
 Dental shape is of great importance in orthodontics.
 A rectangular shape allows a wide and stable contact point, without visible
spaces.
 It do not show any “black triangles”, and slenderization is usually not favorable
as too much tooth reduction is required to gain sufficient space in the dental
arch
 Barrel-shaped teeth have a reduced contact point in the middle with
apparent separations at the incisal level.

It is possible to carry out slenderization and re aproximation, or incisal
reconstructions
Barrel-shaped teeth and visible incisal
spaces
Slenderization and reapproximation
as a solution for visible incisal spaces

 A triangular shape allows a reduced occlusal or incisal contact point.
 Patients who present with triangular teeth sometimes present with “black
gingival triangles” due to increase the distance between the bone crest and the
contact point.
 “Black gingival triangles” are not always the result of an enlarged distance
between the contact point and the bone crest.

A “black gingival triangle” can appear as a consequence of a bracket
malpositioning with respect to inclination
Black gingival triangle following
bracket malpositioning
Triangular and barrel-shaped teeth often require slenderizing
or cosmetic restoration to improve the aesthetics after
orthodontic treatment

Dental shape does not have any influence on enamel
thickness, so it is not possible to vary the amount of
slenderization depending on dental shape.
Rectangular, triangular, and “barrel-shaped”
teeth with different thicknesses of enamel layer

How much
enamel can be
reduced?

The orthodontist must decide how much enamel can be
removed from each tooth surface, allowing for a minimum convexity to
form the contact point, a
sufficente amount of enamel and avoidance of root
contact.
It is generally recommended to remove only approximately half of the
enamel thickness on any surface being reduced.
I
A number of authors state that the amount of enamel reduction depends
on the shape of the tooth, with triangular teeth allowing a greater
reduction. However, studies reveal that there is no relationship between
dental shape and enamel thickness.

Jhon Sheridan suggests that if 50% of inter-proximal enamel
was removed , 6.4mm of space could be generated from 8 buccal posterior
contacts (0.8mm/contact) and 2.5mm of space could be created from 5
anterior contacts (0.5mm/contact) so the total space gained 8.9mm within the
arch.

Thickness Gauges/Leaf Gauges
 These gauges are readily available and very useful when
documenting the amount of tooth structure reduced.
 It is difficult to measure thicknesses in tenths of millimeters,
and the leafs allow for accurate measurements.

Factors that must
be considered

1. Degree of physiologic abrasion present (contact
tips or facets)
Normal evolution increase the contact area into a contact surface

2. whether or not the patient has already undergone
orthodontic stripping , and the presence of over-
dimensioned crowns or fillings.
Over-dimentioned restorations

3. When performing stripping on incisors and
cuspids, Asymmetries should be compensated
for and midlines centered
Slenderizing from cuspid to cuspid must improve
the midline and dental symmetry

4. In the case of bicuspids and molars, the cusps
should remain intercuspated.
Slenderizing of the posterior teeth must
improve the occlusion

5. Slenderizing should be carried out such that the vertex of
the interdental papilla and the contact point remain in the
same perpendicular line to the occlusal (vertical) plane.
Otherwise, the teeth will look as if they are incorrectly
inclined
The vertex of the dental papilla and the contact
point must be in the same vertical line
The teeth appear to have a faulty
inclination

6. The interproximal contact point remains at a distance of 4.5–5 mm From
the Upper border of the bone crest.
The bone crest height is determined by probing and radiographic
examination.

 No. Enamel is the material that makes up the outer shell of our teeth. It
does not contain any nerves and so no discomfort is felt.
 As only a very thin layer of enamel is removed, no anaesthetic is required.
You may, however, feel a strange pulling/pushing pressure during the
procedure.

The removal of the enamel generally causes no discomfort for most patients
because there are no nerve endings in the outer layer of the tooth.

DOES STRIPPING
INCREASE THE
SUSCEPTIBILITY OF
TEETH TO CARIES AND
PERIODONTALDISEASE?

 Plaque can collect more readily on teeth, that have undergone
interproximal reduction, if the tooth surface is not smoothed and
polished by the orthodontist afterwards.

 Accidentally introduced proximal steps during grinding have been also
claimed to cause future cavities.
 It is likely that in clinical conditions remineralization from regular fluoride
intake, and the natural interproximal enamel abrasion will restore the affected
surfaces in the long term.
 The authors observed no signs of gingival recession or thinning of the labial
gingiva in 93% of the patients.
 There is no reduction of mesio-distal bone widths between the roots in the
mandibular anterior region.

 Sheridan advised use of 0.20 inch brass wire to be placed
gingivally between teeth to be reduced.
 This wire also additionally serves as an indicator for
reduction of enamel.
 Rubber dam can be used to isolate the working area and
protect the rest of the tissues.

Interdental tissues protected using a wooden wedge.

GPS Separator
Disc guard
Rubber dam
wedge
Cheek & lip retractor

The ABC’s of IPR
with a straight nose cone hand-piece & diamond disc
Avoid the tongue, lips, & cheeks
Brace yourself with a finger rest
Check for fully-broken contact

A: Avoid the tongue, lips, & cheeks:
Protect the patient’s soft tissues with a mirror & cheek
retractor .
B: Brace yourself with a finger rest :
Use a finger/thumb rest to stabilize the
hand-piece & align the disc
Line up the handpiece with the contact area
C: Check for fully-broken contact
Use the hand-piece to blanch the gums

1. Always carry out IER with new instruments.
2. Carefully protect soft tissues.
3. Proximal stripping should not be carried out until dental rotation has been
corrected, so that it can be done at the correct contact areas.
4. Stripping should be carried out sequentially.
5. Stripped areas should be paralleled
6. The stripped areas are carefully polished.
7. Stripped areas should be fluoridated following polis-hing, as this
procedure removes fluoride rich cariesresistant enamel.
8. Only individuals having low caries index should be selected.
9. Avoid placing contact areas sub-gingivally

 Deciding which teeth to stripping is very important. It is recommended to
perform Bolton analyses on all cases to determine whether the anterior or
posterior teeth need stripping.
 In cases presenting with minor isolated crowding, such as a case with Class I
molar and canine, stripping should be performed in the segment of the dental
arch where the crowding exists.

A complete set of radiographs and models is needed. From the x-
rays, the clinician can determine:
 The convexity of each proximal surface.
 The thickness of enamel on each tooth.
 The size of fillings.
 The disposition of the roots.
If the tooth is rotated, the contour will not be shown
accurately on the x-ray, and the model must also be
used.

The thickness of inter-proximal enamel can be estimated by projecting a line from
the cervical line vertically to the occlusal or incisal plane.
Dentin is projected in a straight line from cervical line or a line that tapers slightly
towards the pulp.
Proximal enamel extension limited by lines parallel to the tooth’s long axis
(mesial: L1-L2 and distal: L3-L4).

• Initial model
• Progress model. IPR was required
mesial and distal to the upper second
bicuspid to achieve a better Class I
relationship. Not enough stripping was
done leading to dental intrusion of the
bicuspid.
• lab set-up to determine where IPR
might be required.

• Re-creating the dimensions of the lab setup
Intra-orally prior to taking impression.
• The amount to be removed is highlighted in
red, and the width dimension exported and
sent as a reproximation form to the doctor.
• Needle-tipped diamond bur with copious irrigation
to effeciently re-contour inter-proximal surfaces.

 The second and third molars and the distal surfaces of the first
molars should not be stripped, if possible, to preserve anchorage.
 Ceramic crowns will often have to be replaced if they are ground.
 When a tooth is rotated, the anatomic proximal surface should be
reduced rather than the contact area.

Stripping Goals
• Smooth parallel lines without sub-gingival
ledges is the goal
The outmost important goal when performing Stripping is to
do no harm! Remove enamel only on teeth that can tolerate
Stripping.
After Stripping, restore tooth contours to the original form as
much as possible.
Other goals include finishing teeth after Stripping to a nice
polished finish using finishing disks or strips. Care should
also be taken to replace the contact point between teeth in
the correct anatomical location.

1- Stainless Steel Strips and Manual Disk Hand
Tool
Manual Disk Hand Tool.
Stainless steel strip and strip
holder

Abrasive strips are available in either single or
double-sided coatings, and come in three grades of
coarseness (fine, medium, and coarse)
 Strips are useful for re-contouring teeth that have
already been reduced. They are also helpful when
slenderizing on apprehensive patients, especially at
the first visit

2- Diamond Disks (High Torque)
• Disks come in varying grits and sizes, similar to strips;
coarse, medium, and fine.
• They are manufactured to withstand the low speeds
delivered with a high torque motor.

3- Burs
When using a high-speed air turbine, to keep the bur spinning
fast enough to cut you must use high rpms, which decreases
the dentist’s ability to be conservative and to avoid gouging of
enamel and over-reduction.

4- ARS (Air Rotor stripping) Burs
and Diamond Disks
use air-powered high-speed motors that rotate as
fast as 200,000 rpm, and slow-speed motors that
rotate at either 20,000 rpm or 5,000 rpm. Air rotor
is difficult to get a controlled degree of cutting
power.

5- OS Discs (Oscillating segments)
 The segment disc is to be used in the oscillating komet
contra-angle OS30.
 It is possible to use the instruments in an air motor.
OS1M.000.140

 The disc has to be inserted from occlusal or
vestibular and guided down through the contact point
in a slow but continuous movement.
Apply sufficient spray coolant.

6- ERS (Electric Rotor stripping)
Burs and Diamond Disks
 Using high-torque, low-speed motors with low
speeds and high-torque cutting power that you
control, safety and accuracy are now achievable.
 ERS makes possible control of the amount of
tooth stripping.
 The SPEE Electric Motor comes complete with foot-
pedal, digital torque and speed control for easy
operation.
 You can also use this motor for all your hygiene
appointments, thus minimizing the need for
additional equipment.

1. Separation: This involves separating the teeth to be reduced by
the use of separators to make the area of reduction more
accessible.

2. Reduction: The enamel is reduced with the help of appropriate
abrasive strip ,diamond cutting discs or burs.

3. Recontouring: After the reduction the teeth are carefully reshaped
to recreate the original contact contours.

4. Polishing: The tooth surface is polished to reduce the surface
enamel roughness.
Polishing of treated surfaces by means of fine
sand discs.

5. Protection: The teeth reduced are fluoridated as the outer
protective fluoridated enamel layer is lost.
Application is very easy! A small amount of air may be used to
dry the tooth surface. A little brush is used to apply the tooth
colored varnish to the teeth and at the gum line. The
varnish begins to set on contact with the teeth. It is safe for all
ages. Fluoride varnish will last at least 4 hours after
application. Patients are instructed to not brush for a certain
amount of time after application and avoid hot and/or sticky
foods

Techniques for
enamel reduction

There are various methods recommended by various
authors for IER. Some of them :
• Hudson used lightning steel strips of 0.10- 0.12 mm. he
followed it by finshing abrasive strips to remove the roughness.

• Paskow, begins stripping with wide metal abrasive polishing strips to
gain proximal access followed by coarse abrasive metal disc and then
single-sided diamond disc .
He used a small diamond stone bur to round off the sharp edges and
finally rubber abrasive disc to polish all surfaces.

• Peck and peck recommended use of double sided
abrasive steel strip for gross reduction when less than 0.2 mm per surface
of enamel has to be reduced and a safe sided steel abrasive disc on slow
speed straight handpiece for reduction beyond 0.2 mm per surface.
Finshing is done with cutterfish strips.

• Zachrisson used a thin flexible diamond disc for gross reduction, steel strip
for contouring, finishing and polishing surface for surface smoothness.
• John Sheridan advocated air-motor striping by use of 699L small tapered
crosscut fissure carbide bur with an extended cutting area. Finishing is done by
polishing with carbide finishing burs, finishing diamond, polishing disc of hand
held finishing strips.

Demonstration of interproximal enamel reduction
method
(frontal view)
(A) Initial enamel amount removed
by a handheld abrasive strip.
Interdental tissues protected using
a wooden wedge.
(B) Main interproximal removal
carried out by single sided
diamond disks. Note
the air syringe used for necessary
cooling.
(C) Polishing of treated surfaces
by means of fine sand discs.
(D) Final outcome

Demonstration of interproximal enamel reduction method
(Occlusal view)
(E) Further alignment improvement
Is achieved.
(F) End of treatment, bonded lingual
retainer in place.

A-C, Boy (age, 13 years) with Class I bimaxillary crowding at the start of treatment;
D- E, stripping of all teeth mesial to the first molars; F-H, 5 years after treatment, with
gold-coated .030-in lingual retainer bonded to both canines. Note the optimal tooth
shapes and intact interdental and marginal gingival conditions

14-year-old boy with Class I moderate bimaxillary crowding at start of treatment.
Marked stripping from second premolar to second premolar was performed in both
dental arches. Bonded 3-3 retainer was used for 8 years and then removed. Intraoral
photographs: C, 11years posttreatment and D, 15 years posttreatment show good
stability with only minor incisor irregularity. E, Radiograph at 15 years posttreatment
shows normal interdental bony structures with no evidence of pathology.

Stripping.prof.dr.maher fouda

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