ORIGINAL ARTICLE

Dental health assessed more than 10 years

after interproximal enamel reduction of
mandibular anterior teeth
Björn U. Zachrisson,a Lise Nyøygaard,b and Karim Mobarakc
Oslo, Norway

Introduction: We investigated whether interdental enamel reduction using fine diamond disks with air
cooling, followed by polishing, leads to iatrogenic damage or reduced interradicular distances. Methods: Our
subjects were 61 consecutive patients who had received mesiodistal enamel reduction of all 6 mandibular
anterior teeth more than 10 years previously. Dental caries, bleeding on probing, probing depths, and gingival
recessions were assessed with standard techniques. Incisor irregularities and tooth width/thickness ratios
were measured on models, and the patients were asked about any increased tooth sensitivity. The reference
group comprised 16 students. Results: No new caries lesions were detected. Three mature adults had some
minor labial gingival recessions. There was no evidence of root pathology. The distance between the roots
of the mandibular incisors was statistically significantly greater in the patients who had received stripping
than in those who had not; 59 of 61 patients reported no increased sensitivity to temperature variations. The
overall irregularity index at follow-up was only 0.67 (SD, 0.64). Conclusions: Interdental enamel reduction
according to this protocol did not result in iatrogenic damage. Dental caries, gingival problems, or alveolar
bone loss did not increase, and the distances between the roots of the teeth in the mandibular anterior region
were not reduced. The overall incisor irregularity at the follow-up examination was small. (Am J Orthod
Dentofacial Orthop 2007;131:162-9)

R
eduction of tooth size by grinding interproxi- dental caries or periodontal pathology. Some clinicians
mal surfaces (interdental stripping) is a com- also expressed concern that roots might come too close
mon procedure in orthodontics, and several after extensive enamel reduction,12 and that the thin
techniques are used.1 Hand-held or motor-driven abra- interdental alveolar bone septa could lead to accelerated
sive strips and handpiece-mounted diamond-coated attachment loss and other signs of periodontal tissue
disks or tungsten carbide or diamond burs are the most breakdown.
common.1-6 Some of these techniques can cause deep Few controlled studies have examined the relation-
furrows and scratches that cannot be removed by ship between interdental stripping and caries suscepti-
polishing.2,3,6-9 These surface irregularities could pro- bility, periodontal tissue complications, and increased
mote the adherence of plaque bacteria and induce sensitivity of intentionally ground teeth,2,4,7,11,13-15 and
iatrogenic damage, such as dental caries, gingival most studies had relatively short follow-up periods. Our
inflammation, periodontal tissue breakdown, gingival aim in this study was to use detailed clinical and
recession, and increased sensitivity of the recontoured radiographic methods to observe the long-term out-
teeth to hot and cold temperatures.10,11 The finer the comes (more than 10 years posttreatment) in a large
grain size used for removing enamel, the easier and less group of patients who had received marked interdental
time-consuming the subsequent polishing.8,9 So far, stripping in the mandibular anterior region with a
however, no evidence has demonstrated that the rough- careful technique using fine diamond disks with air-
ness produced by stripping is a predisposing factor for cooling during their orthodontic treatments.

a
MATERIAL AND METHODS
Professor, Department of Orthodontics, University of Oslo, Oslo, Norway.
b
Orthodontist, Public Dental Health Service, Ostfold, Fredrikstad, Norway.
Subjects and grinding technique
c
Private practice, Oslo, Norway. The material for this study was collected from the
Reprint requests to: Björn U. Zachrisson, Department of Orthodontics, Uni-
versity of Oslo, PO Box 1109 Blindern, 0317 Oslo, Norway; e-mail, private practice of the senior author (B.U.Z.). The
[email protected]. experimental sample included all patients in a consec-
Submitted, September 2006. utive series of 87 who had had stripping of all 6 teeth
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists. in the mandibular anterior region at least 10 years
doi:10.1016/j.ajodo.2006.10.001 previously. These patients were contacted by mail or
162

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American Journal of Orthodontics and Dentofacial Orthopedics Zachrisson, Nyøygaard, and Mobarak 163
Volume 131, Number 2

some patients, only 61 of the 87 subjects (70.1%)

appeared for the clinical follow-up examinations. Eigh-
teen patients could not be traced or had moved to other
parts of Norway, 5 lived abroad, and 3 had died. The
group examined consisted of 36 women and 25 men,
with a mean age of 34 years, ranging from 22 to 68
years. The mean posttreatment observation time was
12.5 years (SD, 2.9). The retention appliance used in
the mandibular anterior region in 42 patients was the
second-generation bonded 3-3 retainer,17 with a
3-stranded .032-in spiral wire (#709-060, 3M Unitek,
Monrovia, Calif) bonded to the canines only. In 16
patients, a .0215-in 5-stranded wire (Penta-One #4998
Fig 1. Separator and air cooling during stripping with 211, Masel, Bristol, Pa) had been bonded to all 6
modified Tuverson technique, using fine safe-sided anterior teeth (321-123 retainer). Three patients re-
diamond disks in 4-handed approach. ceived no bonded mandibular retainer. At the follow-up
examinations, the bonded retainers had been lost or
telephone and were invited to participate in a follow-up removed in 15 patients (13 with 3-3 retainers, 2 with
study. All had been treated by the same clinician 321-123 retainers) from 1 to 9 years earlier.
(B.U.Z.), using maxillary and mandibular fixed edge- The reference group consisted of 16 dental or
wise appliances (.018 ⫻ .025-in attachment slots). Care postgraduate students in orthodontics at the University
was taken to prevent proclination of the mandibular of Oslo. It included 7 men and 9 women, with a mean
incisors if they were in front of the A-pogonion plane at age of 30 years. Three reference participants had
the start of treatment and to maintain normal (24-26 received orthodontic treatment but not interdental strip-
mm) intercanine widths and mandibular arch forms. ping.
Mesiodistal enamel reduction was performed according
to the method of Tuverson16 with fine (#911 HH and Clinical examinations and measurements
HV, Komet, Gebr. Brasseler, Lemgo, Germany) or All examinations and measurements were per-
medium grit (Horico Superdiaflex-C #W 356 C-220 formed by one dentist (L.N.). The examination con-
and 357 C-220, Hopf, Ringleb & Co., Berlin, Germany) sisted of 1 session when 2 intraoral radiographs of the
and safe-sided 0.1-mm diamond disks at medium speed mandibular incisors were taken by using a standardized
(about 30,000 rpm) in a contra-angle (blue ring) KaVo paralleling technique. Caries diagnosis was made with
(D-7950 Biberach, Germany) handpiece. A 4-handed 3 methods: traditional explorer catch, radiographic
approach was used, with careful air-cooling during the examination (and comparison with pretreatment radio-
grinding (Fig 1). The interproximal corners were graphs), and transillumination with a Microlux unit
rounded by using round or triangular (# 8833, Komet) (AdDent, Danbury, Conn). Clinical photography and
diamond burs. inquiry about increased tooth sensitivity to hot and cold
As a general rule, stripping was performed at the temperatures were also part of the examination. Prob-
beginning of treatment after initial leveling of the ing pocket depths and bleeding on probing were regis-
mandibular teeth for 1 or 2 months. Improved access to tered according to standard techniques.18 Alginate im-
the interproximal surfaces on crowded teeth was aided pressions were taken of the mandibular dental arches
by an Elliott anterior straight separator (S/S #1854-184, and poured in plaster for measurements of incisor
Benco Dental, Wilkes-Barre, Pa) (Fig 1). Polishing crowding and assessment of tooth shape in comparison
after stripping with the diamond disks was done with with models taken of all patients at debonding. The
fine sand and cuttle ¾-inch disks (E. C. Moore, Dear- irregularity index according to Little19 and the mesio-
born, Mich). Topical fluoride agents were not applied to distal/faciolingual (MD/FL) index according to Peck
the ground tooth surfaces, but all patients were rou- and Peck20 were measured by using a digital caliper
tinely instructed to use dilute (0.05%) sodium fluoride (Jocal One-Hand Caliper, CE Johansson Gage, White
mouthrinses once daily. If increased sensitivity devel- Plains, NY).
oped after the stripping procedure, the patients were
instructed to rinse with fluoride twice daily for 1 to 2 Radiograhic measurements
weeks. The mesiodistal dimensions of the interdental bone
Because of difficulties in locating and contacting septa between the roots of the mandibular incisors in

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164 Zachrisson, Nyøygaard, and Mobarak American Journal of Orthodontics and Dentofacial Orthopedics
February 2007

Fig 2. A-C, 27-year-old woman with Class I bimaxillary crowding at start of treatment; D, after stripping
in anterior region; E, at end of treatment with direct-bonded 321-123 retainer; and F-H, 10 years after
appliance removal. Lingual retainer remained intact without bond failure (E, F). Gingival conditions are
normal with intact interdental and labial gingivae (G). Widths and heights of interdental alveolar bone on
radiographs are also normal, and lamina dura structures are evident around roots (H).

the experimental and reference groups were measured Statistical analysis and method errors
directly on the radiographs to the nearest 0.1 mm with Statistical analyses were performed with SPSS for
a calibrated magnifying glass (⫻ 8) marked at every 0.1 Windows (SPSS, Chicago, Ill). A t test for independent
mm. Measurements were made at 3 locations: (1) 2 mm
samples was used to examine differences between
below the most incisal part of the alveolar bone crest,
radiographic measurements in both groups.
(2) between the root apices of 2 neighboring incisors,
Radiographs and plaster casts of 25 patients were
and (3) the midpoint between the first and the second
measured twice after randomization. The measure-
measurements. These regions of the roots will be
ment errors were calculated according to Dahlberg’s
referred to as coronal (C), apical (A), and midpoint (M)
formula22 and the reliability coefficient according to
locations, respectively.
Any vertical bone loss was measured from the Houston.23 Systematic errors were assessed by a paired
cementoenamel junction (CEJ) to the alveolar bone t test at the 10% level.22
crest (BC). The most coronal level where the periodon- The measurement errors for horizontal bone widths
tal space still retained its normal width was considered varied from 0.12 to 0.18 at C, from 0.22 to 0.33 at M,
the alveolar crest.21 Because the normal CEJ to bone and from 0.22 to 0.36 mm at A. The measurement
distance varies about 1 to 2 mm,5 only vertical mea- errors varied between 0.20 and 0.43 mm for the CEJ to
surements greater than 2 mm were considered true bone BC distance and from 0.10 to 0.19 mm for the MD/FL
loss on the radiographs. index.

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American Journal of Orthodontics and Dentofacial Orthopedics Zachrisson, Nyøygaard, and Mobarak 165
Volume 131, Number 2

Fig 3. A, 31-year-old woman with Class III malocclusion and mandibular incisor crowding at start
of treatment; B, marked anterior and posterior stripping was performed after 1 month of leveling;
C-E, long-term result 12 years after treatment with bonded 3-3 retainer. D, Note normal gingival
architecture at follow-up examination; E, radiographs show normal height and width of interdental
alveolar bone, with apparent lamina dura outlines around roots.

RESULTS ported no increased sensitivity to temperature varia-

These clinical follow-up examinations generally tions. One patient had generally sensitive teeth, and 1
showed healthy dentitions with excellent occlusion, complained about increased sensitivity of the mandib-
little if any signs of iatrogenic effects, and normal ular incisors. There were no radiographic signs of
periodontal conditions with intact gingival papillae periapical complications in any patient.
between all teeth in the mandibular anterior region. The horizontal distances between the roots of the 4
Figures 2 through 5 show the clinical and radiographic incisors at the C, M, and A locations in both groups are
outcomes of 4 patients. shown in Table I. The mesiodistal bone measurement
No new caries lesions were found in the patients of was statistically significantly larger between the lateral
the experimental group on the intraoral radiographs and central incisors in patients who had received
taken at the follow-up examinations or in the clinical stripping than in those who had not. This was true on
examinations with explorer catch or transillumination. the right side for all 3 locations along the root and on
Fifty-seven of the 61 participants in the experimen- the left side for M and A (Table I). The differences in
tal group had no evident signs of gingival retraction on bone thickness between the central incisors in the 2
the labial surfaces of their mandibular incisors (Figs 2, groups (Table I) were not statistically significant.
G; 3, D; 4, G; and 5, C). Only 3 older subjects (ages, 50, The vertical CEJ-CB measurements in both groups
58, and 64 years) had gingival recessions on the are shown in Table II. The mean measurements in both
photographs and plaster models, with mean retractions groups were less than 2 mm in all areas studied, and the
on the 6 mandibular anterior teeth of 0.33, 0.85, and standard deviations were similar in the 2 groups.
1.37 mm, respectively. These recessions had not Mandibular incisor crowding of the patients in the
changed significantly from pretreatment and posttreat- experimental group is shown in Table III. The overall
ment to the follow-up examinations. A younger woman irregularity index score was only 0.67 (SD, 0.64). Even
(age, 30 years) had a 1.4-mm recession on a central patients who no longer had bonded retainers in place
incisors at all 3 examinations. A pregnant participant had a minimal irregularity score of 1.06 (S, 0.92). The
had generalized gingival hyperplasia, and another sub- difference between patients with bonded 321-123 re-
ject had red and swollen gingiva in the central incisor tainers (mean, 0.61) and those with 3-3 retainers (mean,
region. 0.54) was not statistically significant.
Fifty-nine patients in the experimental group re- The MD/FL index values for the 6 mandibular

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166 Zachrisson, Nyøygaard, and Mobarak American Journal of Orthodontics and Dentofacial Orthopedics
February 2007

Fig 4. A-C, 13-year-old boy with Class II deep overbite malocclusion, bilateral scissors bite, and
bimaxillary crowding at start of treatment; note constricted mandibular arch form with lingually
inclined premolars (C). D and E, condition at end of treatment with upright premolars and bonded
3-3 retainer; retainer came loose after 11 years and was not rebonded. F, Clinical situation 2 years
later (13 years after treatment) shows good stability and G, normal gingival conditions in mandibular
anterior region. H, Radiographs at 11 years posttreatment with retainer still in place show normal
interdental bony structures.

anterior teeth are shown in Table IV. The values for the followed by polishing with fine sand and cuttle disks.
incisors are somewhat smaller than the standards of These instruments probably caused some scratches and
Peck and Peck20 for central (88-92) and lateral incisors furrows in the enamel surfaces2-4,7,15 that might have
(90-95). facilitated plaque accumulation.7 However, remineral-
ization from saliva15,24 or normal interproximal abra-
DISCUSSION sion of enamel in the contact areas25,26 apparently had
Our results demonstrate that, after careful inter- restored the affected surfaces adequately so that no
proximal enamel reduction procedures in the mandib- caries lesions were observed at the long-term examina-
ular anterior region, the long-term outcomes can be tion. Recent SEM studies by Zhong et al8,9 showed that
healthy dentitions with intact periodontal soft-tissue our present technique10 with a perforated diamond-
contours (Figs 2-5). The finding that the reproximated coated disk with less than 30-␮m grain size for inter-
tooth surfaces are no more susceptible to caries and proximal enamel reduction will further minimize the
periodontal disease than unaltered surfaces confirms furrows from grinding, and subsequent polishing with
observations after air-rotor stripping by Crain and fine and ultrafine Sof-Lex XT disks might produce
Sheridan14 and Jarjoura et al.11 tooth surfaces that are as smooth as or smoother than
Our stripping technique, more than 10 years ago, untreated enamel.8,9 On the other hand, Arman et al27
used fine- and medium-grit ultrathin diamond disks, recently claimed that, compared with intact enamel of

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American Journal of Orthodontics and Dentofacial Orthopedics Zachrisson, Nyøygaard, and Mobarak 167
Volume 131, Number 2

Fig 5. A and B, 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, 11 years
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.

Table I. Mean horizontal distance (in mm) between roots at 3 locations

Experimental group Reference group

Location C M A C M A

Right lateral to central incisor 0.97 (0.44) 1.51 (0.80) 1.96 (1.10) 0.68* (0.24) 0.98† (0.43) 1.50† (0.61)
Right central to left central incisor 1.04 (0.39) 1.43 (0.62) 2.28 (0.97) 1.03 (0.57) 1.34 (0.85) 2.09 (1.06)
Left central to lateral incisor 1.06 (0.48) 1.54 (0.76) 1.98 (1.06) 0.89 (0.37) 1.10‡ (0.63) 1.37† (0.70)

SD in parentheses.
*P ⬍.001; †P ⬍.01; ‡P ⬍.05.

Table II. Mean CEJ-alveolar crest vertical distance (in mm) along mesial and distal surfaces of mandibular incisors
Experimental group Reference group

Mesial Distal Mesial Distal

Right lateral incisor 1.14 (0.88) 1.22 (1.01) 0.70 (0.60) 1.05 (0.60)
Right central incisor 1.53 (1.04) 1.30 (0.78) 1.24 (0.84) 0.76 (0.59)
Left central incisor 1.35 (1.01) 1.18 (0.85) 1.06 (0.79) 1.02 (0.67)
Left lateral incisor 1.27 (0.89) 1.14 (1.07) 1.15 (0.82) 0.77 (0.58)

SD in parentheses.

permanent and deciduous teeth, a stripping disk fol- ies29 on grinding of teeth showed that extensive grind-
lowed by fine Sof-Lex disks produced significantly ing of enamel, even to the extent that dentin is exposed,
rougher surfaces with grooves and furrows. can be done safely, if adequate water and air cooling
The amount of enamel removed in these patients are used and the prepared surfaces are smooth and
depended on the actual morphology of their incisors self-cleansing. For stripping purposes, water cooling is
(Figs 2-5). Previous short-term28 and long-term stud- unnecessarily messy, but all teeth that were stripped in

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168 Zachrisson, Nyøygaard, and Mobarak American Journal of Orthodontics and Dentofacial Orthopedics
February 2007

Table III.Mean long-term mandibular incisor irregular- incisor roots are probably closer together in most un-
ity in 61 patients who had received interproximal treated persons with mild to moderate incisor crowding
stripping ⬎10 years previously than they are after careful stripping and proper leveling
n Mean SD
and uprighting of the teeth in orthodontic patients.
It is controversial whether roots that come too close
All patients 61 0.67 0.77 to one another might predispose to future periodontal
3-3 retainer 30 0.54 0.64 tissue breakdown. Vermylen et al34 recently described
321-123 retainer 16 0.61 0.79
No retainer 15 1.06 0.92 a 2-digit classification for root proximity, based on
severity and location along the root. They defined root
Patients received retainer bonded to either canines only (3-3 retainer)
proximity as 0.8 mm or less bone or interdental tissue
or all 6 anterior teeth (321-123 retainer). No retainer refers to patients
whose bonded retainers had been removed or lost (from 1 to 9 years between 2 adjacent roots on intraoral radiographs. Root
previously). proximity was scored in 3 subdivisions: severity 1,
0.5-0.8 mm: small amount of cancellous bone between
Table IV. Mean MD/FL index values of mandibular adjacent roots; severity 2, 0.3-0.5 mm: only cortical
anterior teeth in 61 patients who had received inter- bone and connective tissue attachment are present; and
proximal stripping severity 3, less than 0.3 mm: only connective tissue
attachment is present. In a group of patients with
Mean SD
advanced periodontal disease, they found root proxim-
Right canine 81.6 5.8 ity to be a risk marker for periodontal disease.35 A risk
Right lateral incisor 84.7 6.03 marker indicates that root proximity is associated with
Right central incisor 81.3 6.84 increased probability of disease, but not necessarily a
Left central incisor 80.6 6.18
causal factor. One explanation might be that periodon-
Left lateral incisor 85.8 6.64
Left canine 83.1 5.51 tal treatment (scaling, root planning, surgical access)
might be incomplete at sites with severe root proximity.
On the other hand, neither Trosello and Gianelly,36
in a sample of postorthodontic patients at least 2 years
this study were carefully air-cooled during the grinding
after treatment, nor Årtun et al,37 examining patients 16
in a 4-handed approach (Fig 1). The careful cooling
years or more after orthodontic treatment, found any
procedure might at least in part explain why increased
significant relationship between root proximity in the
sensitivity to temperature variations was not a problem
incisor region and periodontal tissue breakdown in this
in our experimental group.
In addition to the commonly quoted advantages area. However, the situation could be different in older
of interproximal enamel reduction, such as increas- age groups when some patients show evidence of
ing the amount of available space in the mandibular advanced periodontal tissue destruction. Root proxim-
anterior area, providing broader contact point areas ity is most frequently found between the maxillary
and thereby greater contact stability,13,16,30 and the second and first molars, and between the mandibular
positive correlation between increased overbite with incisors. These are exactly the teeth that are most
increased amount of stripping,16,31 there is also an susceptible to bone loss and tooth loss.38,39
obvious esthetic advantage of stripping in that it will The irregularity index in this experimental sample
prevent or reduce interdental gingival retraction—ie, was remarkably small (Table II). The mean score for all
the development of black triangles between the incisors patients was 0.67, which is well below what is consid-
after resolution of anterior crowding.32 Intact gingival ered clinically satisfactory. Little19 and Little et al40,41
papillae are noticeable in all patients in Figures 2-5. considered irregularity index scores greater than 3.5 to
Provision of adequate connector areas in the incisor be clinically unsatisfactory. Even in patients whose
region to allow optimal gingival papillae fill in is, of retainers had been lost or removed several years before
course, particularly important when treating adult orth- the final examination (Table II), the mean score was
odontic patients.33 only 1.06 (SD, 0.92); this is comparable with the
An important and interesting observation in this end-of-treatment result in other stability studies after
study was that the horizontal distances between the fixed-appliance therapy.19,41,42 The explanation for the
mandibular incisor roots were the same or greater than excellent stability might in part be because no canine-
the corresponding distances in the reference subjects to-canine expansion or mandibular-incisor proclination
who had not received mesiodistal enamel reduction had been performed in our study. Forty-six patients still
(Table I). The explanation could be that the mandibular had their retainers in place, apparently without delete-

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American Journal of Orthodontics and Dentofacial Orthopedics Zachrisson, Nyøygaard, and Mobarak 169
Volume 131, Number 2

rious side effects with regard to caries or harmful 22. Dahlberg G. Statistical methods for medical and biological
periodontal tissue sequelae.40 students. New York: Interscience Publications; 1940.
23. Houston WJB. The analysis of error in orthodontic measure-
ments. Am J Orthod 1983;83:383-90.
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