Download Proximal Stripping and the Apprehension to Implement

Review Article
DOI: 10.17354/cr/2016/228
Proximal Stripping and the Apprehension to
Implement it in Contemporary Orthodontics: A
Review
V Aniruddh Yashwant1, Balamani Arayambath2
Senior Lecturer, Department of Orthodontics & Dentofacial Orthopaedics, Indira Gandhi Institute of Dental Sciences, MGMCRI Campus, Sri Balaji
Vidyapeeth University, Puducherry, India, 2Professor & Head, Department of Orthodontics & Dentofacial Orthopaedics, Mahatma Gandhi Post-graduate
Institute of Dental Sciences, Puducherry, India
1
Interproximal reduction, referring to the reduction of tooth structure in the proximal surfaces of anteriors or posteriors as required by
the clinical scenario, has most often intrigued the orthodontist and the general dentist in particular in implementing it in contemporary
orthodontics on a regular basis. The reduction of tooth structure as likelihood for the development of dental caries proximally, when the
patient is undergoing orthodontic therapy, can in itself be a subject of debate between the conservative general dentists and the orthodontist.
With recent treatment options for minimal space requirements in aligning teeth and others such as clear aligner therapy which involve the use
of proximal stripping, this review aims to present the current concepts in interproximal reduction and its questionable role as an etiological
factor in the development of caries.
Keywords: Contemporary orthodontics, Interproximal stripping, Proximal caries
INTRODUCTION
Proximal stripping is also known as interproximal enamel
reduction, interdental stripping, enamel approximation, or
slenderizing.1,2 Ballard was one of the first persons to have
used proximal stripping to reduce tooth material excess.3
Over the decades, comprehensive orthodontic treatment
has emphasized the importance of achieving ideal
occlusion, functional efficiency, and an esthetically
pleasing profile. In conventional orthodontic treatment,
methods of gaining space for the correction of malocclusion
include expansion of the arch, extraction of teeth as
required, distalization of molars, uprighting of molars,
derotation of posteriors, and proximal stripping. The
choice of treatment depends on the amount of crowding,
soft tissue profile, and patient’s age. Begg’s philosophy has
shown that Australian aborigines did not have crowding
which was attributed to proximal wear of teeth surfaces.
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This has generated interest in clinicians to use proximal
stripping in contemporary orthodontics.4 The paradigm
shift in treatment modalities in the present era, such as
importance for soft tissue profile and the demand for
esthetic appliances such as clear aligner therapy, has put
forth proximal stripping as a viable treatment modality.
Interproximal enamel reduction is not carried out as a
sole dental treatment but is most often combined with
orthodontic fixed appliance therapy.5 Several renowned
clinicians such as Hudson,6 Paskow,7 Peck and Peck,2
Sheridan,8,9 and Zachrisson10 have used proximal stripping
to achieve ideal treatment results.
Indications
Comprehensive orthodontic treatment involves the use
of proximal stripping as an adjunct procedure to obtain
ideal occlusion. The reduction in the tooth structure
mesiodistally is done so as to achieve esthetic alignment of
the teeth, establishment of ideal Bolton ’s ratio, offer stability
for alignment of teeth in the long term, malocclusions
which require minimal space for correction (3-4 mm), for
spontaneous correction of crowding in mixed dentition and
for the correction of black triangles which develop after
orthodontic treatment.5,11-21 In the current scenario, proximal
stripping serves as a useful adjunct treatment modality for
both general practitioners as well as orthodontists when
non-extraction treatment is desired.
Corresponding Author:
Dr. V Aniruddh Yashwant, Department of Orthodontics & Dentofacial Orthopaedics, Indira Gandhi Institute of Dental Sciences, MGMCRI Campus,
Sri Balaji Vidyapeeth University, Puducherry, India. E-mail: [email protected]
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Yashwant and Arayambath: Proximal Stripping in Contemporary Orthodontics
Procedure
The space required for treatment and the site for proximal
stripping should be determined using Bolton’s discrepancy
index.22 In proximal stripping, up to 50% of interproximal
enamel can be removed. The appropriate amount should be
0.5 mm for each tooth in the anterior region, whereas up to
0.75 mm of the proximal surface can be removed for posterior
teeth.19,20 Before performing proximal stripping, the leveling
and aligning phase of orthodontic treatment should have
been completed. Rotation of teeth or vertical discrepancies
should be corrected so as to check if proper occlusion can
be achieved with proximal stripping. 10 A thin brass or
steel wire or a wedge should be placed interproximally
to protect the interdental papillae.23 Careful consideration
should be given to the thickness of enamel while performing
proximal stripping as it varies between different teeth and no
relationship exists between size and shape of the tooth and
the enamel thickness.20 The armamentarium that is used for
proximal stripping is diamond-coated disks, fine tungstencarbide or diamond burs or handheld/motor-driven abrasive
metal strips (Figure 1). The discs or strips should be placed
below the contact points and then drawn up to the occlusal
surface.24 If the stripping armamentarium is motor driven
as in Sheridan’s air-rotor slenderizing technique,16 adequate
water cooling should be ensured. Burs with safety-tipped
non-cutting areas should be used to prevent furrows of the
proximal walls, which can occur when using conventional
burs. The amount of enamel removed can be measured using
gauges made from round orthodontic wire or metal strips
with thickness from 0.012” to 0.040” or a digital caliper.
After the proximal stripping procedure is completed and the
amount of tooth structure removed matches that of the space
requirement for correction of malocclusion, contouring of
the teeth back to its normal morphology is essential. The
contact point should be restored, and the surface should
be made smooth using polishing paste and Sof-lex: 3M
ESPE (Figure 2). Few authors have suggested the use of
phosphoric acid (chemical stripping) for attaining better
surface recontouring.25,26
Once surface recontouring is done, surface treatment with
fluorides can be done to the stripped proximal surfaces
if necessary. This includes application of 85% stannous
fluoride for 4 min, fluoride mouth rinses for 45 days, the
use of 0.05% sodium fluoride mouthwash once daily or
use of 1.23% professionally applied acidulated phosphate
fluoride gel for 4 min, casein phosphopeptide-amorphous
calcium phosphate tooth mousse.21,27-29
CONTRA INDICATIONS AND COMPLICATIONS
The clinical conditions and malocclusions wherein
proximal stripping are contraindicated are poor oral
IJSS Case Reports & Reviews | May 2016 | Vol 2 | Issue 12
Figure 1: Diamond-coated disks (a), fine diamond burs (b), abrasive metal
strips (c)
Figure 2: Sof-lex disks: 3M ESPE
hygiene, crowding of teeth more than 8 mm per arch,
enamel hypoplasia, hypersensitivity, multiple restorations,
rectangular shaped anteriors, round premolars, and young
patients with large pulp chambers.30,31 Complications due
to proximal stripping arise due to incorrect technique
and inappropriate treatment plan. When it is used as an
alternative to extraction treatment in borderline cases, it is
important for the clinician to understand that overzealous
stripping may cause hypersensitivity, irreversible pulp
damage, increased incidence of caries, and periodontal
disease.32,33
PROXIMAL STRIPPING AND CARIES
SUSCEPTIBILITY - A REVIEW OF LITERATURE
Ever since the introduction of proximal stripping as an
adjunct treatment in fixed orthodontic therapy, there have
been many contradictory reports on the role of proximal
stripping as an iatrogenic etiology for the development of
caries. In many countries, wherein general dentists practice
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Yashwant and Arayambath: Proximal Stripping in Contemporary Orthodontics
orthodontics, there has been apprehension to perform
proximal stripping as a routine procedure. This has led to
various studies being done to produce a definite answer
to the question “does proximal stripping cause increased
susceptibility to caries?” It is a common perception that tooth
surface irregularities can promote plaque accumulation and
cause irreversible damage such as caries and periodontal
breakdown. There are few controlled studies done with
short follow-up periods, which have tried to find the
relationship between proximal stripping and susceptibility
to caries and periodontal breakdown.34-37 These studies
have shown there is no difference between unaltered and
stripped enamel surfaces. Zachrisson developed a technique
for proximal stripping using a perforated diamond-coated
disk (<30 µ grain size) with adequate air and water cooling
followed by polishing with fine and ultrafine Sof-lex (3M
ESPE) disks.34 Scanning electron microscope studies by
Zhong et al.38,39 and long-term studies by Zachrisson et al.,30,40
which evaluated this technique confirmed that proximal
stripping when done with Zachrisson’s technique, does not
predispose the enamel surface to caries.
There does exist a difference in the views of general dentists
as compared to orthodontists regarding the proximal
stripping procedure. In the current scenario, general
dentists are increasingly performing proximal stripping in
orthodontic therapy using clear aligners. Recent studies have
shown that general dentists are more conservative in their
approach and tend to use ideal polishing procedures and
topical fluoride application as compared to orthodontists.
General dentists are not comfortable with using proximal
stripping as a routine procedure. Orthodontists have
extensively researched on proximal stripping and its effects
over the years. It has been shown that fluoride application
on stripped tooth surface has minimal benefits in preventing
caries in patients exposed to sources of fluoride such as tooth
and fluoridated water. This can be one of the reasons as to
why orthodontists are less likely to apply topical fluoride for
the stripped surfaces.35,41 Enamel roughness due to proximal
stripping is one of the factors which has been evaluated
extensively in various in vitro and in vivo studies.42-45 A
recent systematic review evaluated the evidence in relation
to enamel roughness and caries susceptibility of patients
treated with interproximal stripping. It was concluded
that the incidence of caries on tooth surfaces treated with
proximal stripping was statistically equivalent to that of
intact surfaces.46
CONCLUSION
The current era in orthodontics is evidence based. Any
apprehension in treatment modality can be laid off with
sufficient evidence from clinical studies and systematic
reviews. With treatment modalities such as clear aligner
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therapy which demand the use of proximal stripping, the
need to ascertain the fact that proximal stripping does not
increase the susceptibility to caries is important. This review
shows that current scientific literature does not support
the role of proximal stripping in causing dental caries, but
further studies are needed to establish a standard protocol
for proximal stripping procedure.
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How to cite this article: Yashwant VA, Arayambath B. Proximal Stripping and
the Apprehension to Implement it in Contemporary Orthodontics: A Review.
IJSS Case Reports & Reviews 2016;2(12):18-21.
Source of Support: Nil, Conflict of Interest: None declared.
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