Interproximal Enamel Reduction (stripping)

1. Supervised by :
Prof. Dr. Maher A. Fouda
prepared by: Dr. Abdullah H. Bayazed

2. Introduction:
Inter-proximal reduction is the removal of a small amount of
enamel from between the teeth to reduce their width.
Inter-proximal reduction (also known as slenderizing, stripping,
enamel reduction, reproximation and selective reduction)

3. Aim of reduction :
The aim of this reduction is to create space for ideal tooth
alignment during orthodontic treatment and to give teeth a
suitable shape whenever problems of shape or size
require attention.
Prior to interproximal reduction,
teeth slightly overlap
During interproximal reduction Following interproximal reduction,
the patient has a more aesthetically-
pleasing smile and an improved
bite.

4. Indication
1- Crowding/relapse of crowding:
Sheridan, points out, orthodontists can use stripping to
correct crowding of 4 to 8 mm.
Severe crowding not indicated for IPR Mild crowding indicated for IPR

5. 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 foralignment of the anterior teeth;

6. b-The crown of the first temporary molar is
stripped mesially to create conditions that will
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.

7. 2- inter-arch size discrepancies :
Kesling in 1945 stresses the importance of a
favorable inter arch tooth Size relationship for
establishment of stable occlusion.

8. 3- 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.

9. 4- Macrodontia size discrepancies :
in cases where teeth are crowded and larger than normal ,
proximal stripping can be considered.

10. 5- Crowding of mandibular incisors:
stripping was first used to obtain space for the correction
and prevention of crowding.

11. 6- To be performed on temporary tooth to improve
occlusion. :
Interproximal stripping is about to be performed on this temporary
tooth to improve occlusion.

12. 7-Normalization of gingival contour and elemination of
triangular spaces above the papilla (dark triangular)
thus greatly improving esthetics and smile .

13. 8- 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. See case report 5
Class II molar relationship. (See
case report 9)

14. 9- 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 stripping.

15. 10. 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.



16. Contraindication
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).

17. 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 inter-
septal bone.
rectangular-shaped teeth

18. Tooth shape and enamel thickness
According to Bennett and McLaughlin, three main dental
shapes: rectangular, triangular, and barrel shaped teeth.
Studies reveal that there is no relationship between dental
shape and enamel thickness.
Rectangular
Triangular
Barrel

19. Rectangular-shaped teeth 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.
Triangular and barrel-shaped teeth often require
slenderizing or cosmetic restoration to improve the
aesthetics after orthodontic treatment.
Barrel-shaped teeth and
visible incisal spaces
Triangular-shaped teeth and
Black gingival triangle
Rectangular-shaped teeth

20. Treatment planning
A complete set of radiographs and model are nedded.
From the x-ray, 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.

21. 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 slightelly towards the pulp.
Proximal enamel extension limited by lines parallel
to the tooth’s long axis (mesial: L1-L2 and distal: L3-L4).

22. If the tooth is rotated, the contour will not be shown
accurately on the x-ray, and the model must also be
used.

23. • 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.

24. • Re-creating the dimensions of the lab set-
up 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.

25. • Diamond disk with disk guard to protect the
soft tissue.
• Mouth mirror to protect the tongue. Disk is
spinning labially towards the mirror at very low
RPMs.
• Smooth parallel lines without sub-gingival
ledges is the goal.

26. Perforated diamond strips in three thicknesses
(Yellow=extra fine, Red=fine, Blue=medium).
Extra tight contacts can be effectively opened
by first starting with the yellow and working up
to the blue.
Thickness gauge to verify the amount removed
in 1/10th mm increments.
Using diamond strips to round out line angles
and create natural-looking dental anatomy.

27. 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.

28. How much enamel can be reduced?
There are no studies indicate how much of enamel is
needed for adequate protection of tooth against carious,
thermal or chemical damage.
The variation in the thickness of enamel suggests that
there is no protective advantage in preserving thick enamel
inter-proximally, when comparative thin enamel occurs
naturally on labial, buccal and lingual surface.

29. 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.

30. Steiner states that for each millimeter of protrusion, the
discrepancy is reduced by 2 mm. Torque enlargement
without protrusion permits a gain of 1 mm per 5° of
radicular palatal torque enlargement.

31. Clinical procedure
Clinical procedure involving enamel reduction, anatomic
re-countouring and protection of proximal enamel
surface of permanent teeth .

32. Steps Involved In Inter-proximal Reduction
1- Separation: this involves separating the teeth to be
reduced by the use of separators to make the area of
reduction more accessible.

33. 2- Reduction: the enamel is reduced with the help of
appropriate abrasive strip, diamond cutting discs or burs.

34. 3- Re-contouring: after the reduction the teeth are
carefully reshaped to re-create the original contours.

35. 4- Polishing: The tooth surface is polished to reduce the
surface enamel roughness.
Enamel surface after reduction Same surface after polishing
With Sof Lex Discs

36. 5- Protection: The teeth that 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 gumline. 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.

37. 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.

38. • Paskow, begins stripping with wide metal abrasive
polishing strips to gain proximal access followed by coars
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.

39. • 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.

40. • Zachrisson used a thin flexible diamond disc for gross
reduction, steel strip for contouring, finshing and polishing
surface for surface smoothness.

41. • John Sheridan advocated air-rotor striping by use of
699L small tapered crosscut fissure carbide bur with an
extended cutting area. Finshing is done by polishing
with carbide finshing burss,,finshing diamond, polshing
disc of hand held finshing strips.
Occlusal Approach customized carbide bur Lateral Approach

42. Protection of soft tissues
Sheriden advised use of 0.20 inch brass wire to be placed
gingivally between teeth to be reduced. This wire also
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.
GPS Separator
Disc guard
wedgeRubber dam
Cheek & lip retractor

43. 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

44. A: Avoid the tongue, lips, & cheeks:
Protect the patient’s soft tissues with a mirror & cheek
retractor .

45. B: Brace yourself with a finger rest :
Use a finger/thumb rest to stabilize the hand-piece &
align the disc

46. B: Brace yourself with a finger rest:
Line up the handpiece with the contact area

47. C: Check for fully-broken contact
Use the hand-piece to blanch the gums

48. Precautions
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 area .
4. Stripping should be carried out sequentially.
5. Stripped areas should be paralleled.
6. The stripped areas carefully polished.
7. The stripped areas should be flouridated following
polishing.
8. Avoid placing contact areas sub-gingivally .

49. instruments

50. There are 3 methods to reduce teeth inter-proximally:
1-Abrasive Strips
•Hand held & Motor driven.
•available in either single- or double sided coatings.
•Come in three grades of coarseness (fine, medium, and
coarse).
•Use for anterior teeth .
•Use for minor tooth reduction.
•Useful for re-contouring teeth.
•Less aggressive removal of enamel .
•Thickness : 0.010 mm & 0.012 mm

51. Flex-View TM Interproximal Strips
perforated stainless steel strips allow optimal visibility and minimise
clogging. They also for easy access for interproximal stripping and
finishing. All strips are single-sided and autoclavable

52. Interproximal Serrated Strips:
Use these interproximal serrated strips for ease in opening up
bonded proximal contacts prior to reduction with diamond strips.

53. Diamond Interproximal Strips - Autoclavable
Reduce interproximal enamel. These very thin strips
(0.08mm / 0.003”) are made of electrolytically bonded
diamonds on a vibro cushion base.

54. Tooth Stripper Kit : The hand-held Tooth Stripper provides a
more precisely controlled method of reducing enamel at
interproximals, unlike powered instruments which often
remove more enamel than desired.

56. 2- Abrasive Discs
• Usually for anterior teeth
• Removes more enamel than abrasive strips.
• Risk of cutting lip and gingiva .
• Must finish with abrasive strips .
• Risk excessive enamel reduction .
• Use a disc guard to protect the patient .

57. Diamond Discs
Use Diamond discs for both separating and
contouring. Available single and double-sided.
Designed for use with a straight handpiece
only.

58. Flexible Serrated Diamond Discs
Used for anterior inter-proximal stripping. Available in two
sizes and are double sided. For use with a straight hand-
piece only, and can be used with disc guards.

59. Disc Guard, Adapter and E-Type Hand-piece
For use with a straight hand-piece, Disc Guards have
visual access windows for safety, and are available in two
sizes. The Adapter allows discs to attach to a straight
hand-piece.

60. Flex-ViewTM Snap-On Finishing Discs
For interproximal stripping . Also used for contouring and
shaping of embrasure areas. note: when using a friction grip
mandrel, a slow speed hand-piece (not to exceed 30,000rpms)
must be used. Thickness of disc 0.10mm.

61. Flex-ViewTM Curved Disc
• Used in anterior inter-proximal stripping.
• Straight handpiece only.
• Thickness of disc 0.10mm.

62. Flexible Solid Honeycomb
Designed for intermediate contouring and inter-proximal
stripping.

63. Flex-ViewTM Mesh Discs
For interproximal stripping and ultra-fine contouring/shaping
Straight handpiece only

64. Incisal Contouring
• For shaping and contouring

65. Plaster Disc
Great for sectioning teeth from plaster model for diagnostic
wax ups. Replaces the use of a coping saw. Not
recommended for intra-oral use.

66. 3-Air Rotor Stripping.
• Tungsten carbide or diamond burs.
• High speed hand-piece.

67. Safe-Tipped Air-Rotor Stripping (STARSTM) Burs :
The STARS series of burs has been developed to assure the
precision reduction of interproximal enamel while drastically
reducing the possibility of excessive bur-induced grooves.

68. Kit includes:
• A sterilisable 10 piece bur block , four safe-tipped cross-cut carbide
fissure burs (O/No 9001-699ST)
• Two medium-particle size (100 microns) Safe-tipped finishing
diamond burs (O/No 9001-5MDST)
• Two fine-particle size (30 microns) Safe-tipped finishing diamond
burs (O/No 9001-5FDST)
• Two anterior fine needle diamond burs Non safe tipped. For anterior
interproximal stripping. Open field not necessary. Head size 1.6mm,
length 5mm (O/No 9001-55000).

69. Incremental Thickness Gauge
Six stainless steel gauges for measuring inter-proximal
spaces. A set consists of the following thicknesses:
0.25mm, 0.5mm, 0.1mm, 0.2mm, 0.3mm, and 0.4mm.

73. The Sheridan Interdental Space Measuring Gauge:
The gauge consists of a series of cylinders, of progressively
increasing diameters, which can measure natural or created
interdental space from 0.75 to 3.0mm in increments of
.25mm.

74. Manual Instruments:
Enamel hand stripper:
KIT INCLUDES:
• 1 Stainless Steel Enamel Hand Stripper
• Abrasive Strips Sample Pack
ADDITIONAL STRIPS AVAILABLE:
• Single sided strips- package of 10 pcs.
• Double sided strips- package of 10 pcs.
STRIPS AVAILABLE IN:
• Fine, Medium and Coarse
WIDTHS AVAILABLE:
• 4mm, 6mm, 8mm

75. CONTOURING KIT
Removes interproximal tooth mass to produce additional
intra-arch space.
May also be used for opening contact points, re-contouring
or removing overhanging fillings.

76. MINI STRIPPER:
• Small and easy to handle.
• Complete with 16 refill strips (single side only).
ADDITIONAL STRIPS AVAILABLE:
Serrated strips- package of 10 pcs.
Steel strips- package of 10 pcs.
Diamond strips- package of 10 pcs.

77. Cello Stripper
The Cello Stripper Holder accepts 2 sizes of steel abrasive
strips- 2mm and 3mm.
KIT CONTAINS:
•Stainless Steel Strip Holder
•Sample Package of 10 Abrasive Strips
(2mm or 3mm width, single-sided or double-sided)

78. Manual Microcut
Manual handling saw blade strip for removing
excesses of any type of filling materials from the
interproximal areas without breaking the contact point
relation due its thickness of only 0,05mm;

79. Manual stripping, the equipment used (ETM
Corporation, Glendora, California, USA).

80. MASTERING INTERPROXIMAL STRIPPING : WITH INNOVATION
IN SLENDERIZATION

84. Hand-piece Driven Instruments
C-SAW Inter-proximal Reduction System:
Advantages:
• Single-sided files provide greater control
• 2 different file types & 4 different file grades provide more
precise reduction and finishing
• GPS Clamp opens contact area for ease of file entrance and
prevents injury to soft tissue .

85. Features
• A low-speed, high torque reciprocating hand-piece for
controlled reduction
• Slenderizing reciprocal files: _ Stainless steel with a
diamond coating _ Color coded for easy identification
• System is totally autoclavable.

86. Targeted ASR

88. Defined Reduction
Defined follow-up contouring.
Final Polishing

90. Remin+TM Gel
For enamel remineralisation after tooth whitening,
interproximal stripping, occlusal equilibration and
decalcification. Shown to be effective in enamel
remineralisation process of decalcified teeth.
Comes in a 120ml (4oz) squeeze bottle.

91. Case reports

92. Case 1.
• Woman (age, 31 years) with mild Class II malocclusion
and mandibular crowding at the start of treatment;

93. • Interproximal enamel reduction on all teeth mesial to
the first molars.

94. • 6 years after completion of orthodontic treatment with lingual
retainer bonded to 6 anterior teeth. Note the inter-proximal
caries lesions (grade 1) on the maxillary left first and second
premolars (arrows). There is also a small caries lesion (grade 1) on
the mesial aspect of the maxillary second premolar.

95. Case 2.
Boy (age, 13 years) with Class I bimaxillary crowding
at the start of treatment;

96. • D and E, after stripping in the anterior and posterior
regions (note the improved tooth morphology, particularly of
all 4 first premolars);

97. F-H, 4 years after appliance removal, gingival conditions
are normal with intact interdental and labial gingivae.

98. Case 3.
A-C, Boy (age, 13 years) with Class I bimaxillary crowding at
the start of treatment;

99. D and E, stripping of all teeth mesial to the first molars;

100. 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.
at the start of treatment

101. • This 30-year-old woman had
extremely large central incisors with
overlapping maxillary and mandibular
teeth.
• An occlusal view showing the overlapping
central incisors.
• Cosmetic contouring was first
performed on the maxillary central
incisors and mandibular anterior.
Case 4

102. • After contouring the mandibular anterior
teeth, they were polished with an
impregnated aluminum oxide wheel
(Cosmetic Contouring Kit, Shofu, Menlo
Park, CA).
• Next, the maxillary laterals were bonded
with composite resin and contoured and
finished with ET carbide finishing burs
(Brasseler).
• Better tooth proportion and straighter
appearing teeth can be seen here before the
final polishing.

103. Final result shows a straighter arc
with more proportional teeth.
Pretreatment view of the smile. Post-treatment view showing
better harmony with the smile.

104. Case 5
A. Patient with minimal overbite and overjet, tendency toward Class
III molar relationship, minimal upper crowding, and moderate lower
crowding (continued on next page).

105. • Appraising arch form after leveling, alignment, and space management.
Because lower incisors need to be retracted distally and upper incisors
placed over them to establish optimum overbite and overjet, anterior ARS is
also indicated.
• Initial ARS sites in lower arch (arrows); separators placed to gain
space for additional ARS.

106. • Proper buccal inter-cuspation and
acceptable incisal relationships after
treatment.
• Lower crowding resolved without
lateral or anterior expansion.

107. case 6.
A, Patient with triangular crown morphology. Reducing
black triangle by changing point contact (B) to a broader
surface (C) by interproximal reduction. Orthodontic space
closure and soft tissue filling the gingival embrasure.
A

108. Reduction of black triangle with inter-proximal reduction. A,
Point contact with black triangle present between central
incisors. B, Inter-proximal reduction with medium diamond
strip. C, Post-treatment. Complete fill of soft tissue in gingival
embrasure by closing space and creating a broader contact
that is closer to the alveolar crest.
A
B
C

109. Case 7
Female patient (27 years of age ) with Class I bimaxillary
crowding at start (a-c).

110. (d,e) After stripping in anterior and posterior regions of
both the maxillary and mandibular tooth. (f) during
orthodontic treatment.

111. At the end of therapy with six unit bonded lingual retainers in
both dental arches (g-i)

112. Case 8
Female (31 year Old) patient with Class III malocclusion
and mandibular incisor crowding.

113. marked anterior and posterior stripping was done after 1
month of leveling.
final result

114. The radiograhs Show normal height and width of the interdental
alveolar bone, with apparent lamina dura oulines around roots.
long term result 12 years later

115. Case 9.
A 13.11 years old female presented with a Class II Division I
malocclusion. Facially, the patient appeared symmetrical, with
normal lip competence, with a slightly cconcave profile and a
retruded chin.

116. Pre treatment upper and lower intra-oral view.

117. Combi pull headgear.
Initial arch wire . Application of an anterior bite plate

118. Application of Class II elastic on rectangular posted archwires.

119. Interproximal enamel reduction of lower incisors.

120. Finishing stage improving intercuspation

121. Post treatment facial photographs after 18 months
of orthodontic treatment.

122. Post-treatment intraoral photographs

123. The powerful combination of reprox and nickel titanium
gave us this result in less than three months treatment time.
CASE 10

124. You can see how perfectly a diamond disk fits
between the teeth. This is an ideal instrument
for reprox. You simply disk through the contact
point, making sure to go all the way down to
the gingiva. Then polish with a finishing bur
and a polishing strip.
Here is the net result. You can see the
amount of enamel removed is quite small,
but it creates enough space to alleviate
the crowding. More reprox can be
preformed at subsequent appointments as
needed.

125. This picture shows the incredible flexibility of
nickel titanium arch wires. Even with severe
rotations we were able to get complete
bracket engagement by using nickel
titanium 6 arch wires.
The strength and flexibility of nickel titanium coupled with reprox
allowed for this dramatic progress in less than three months.

126. an example of a case finished within 6 months leaving
the teeth with uneven stripped edges.

127. THANK YOU
HAVE A NICE DAY
‫م‬ ‫المكالء‬/‫حضرموت‬/‫اليمن‬