A P P L I E D R E S E A R C H

A Pilot Investigation of
Enamel Reduction Procedures
• P. Emile Rossouw, BSc, BChD, BChD (Hons), MChD (Ortho), PhD, FRCD(C) •
• Andrew Tortorella, BSc, DDS •

A b s t r a c t
Objective: To test and describe the use of various combinations of mechanical and chemical techniques for enamel
reduction to obtain a smooth surface.
Methods: Bovine teeth (2 surfaces on each of 32 teeth) were used. The teeth were mounted in blocks of dental plaster,
which were then mounted in a vise. The mesiodistal enamel contact areas were reduced by various combinations
of mechanical and chemical aids. The mesiodistal width of each tooth was measured with a digital caliper after
initial reduction of the enamel surface and again after polishing. The teeth were subsequently prepared and
mounted for scanning electron microscopy.
Results: All combinations yielded statistically significant enamel reduction ( p < 0.05). The use of acid stripping in conjunc-
tion with mechanical procedures produced especially smooth enamel surfaces.
Conclusions: Steps must be taken to ensure that a smooth enamel surface remains after enamel reduction and polishing.
It is recommended that conventional enamel etchants be added to the polishing procedure. Enamel reduction can
increase available space, but the quantity of enamel that can be removed without adverse consequences should be
carefully evaluated.

MeSH Key Words: dental enamel/surgery; malocclusion/surgery; orthodontics, corrective/methods

© J Can Dent Assoc 2003; 69(6):384–8

This article has been peer reviewed.

nterproximal enamel reduction is a technique with

I
tooth was mechanically removed, and the teeth were
tremendous flexibility. It can be used as a stand-alone mounted in blocks of dental plaster to simulate a dental
procedure to contour a tooth surface or as an adjunct arch. The blocks were then mounted in a vise for stability,
procedure during other restorative, prosthodontic and and the mesiodistal enamel contact areas were subjected to
orthodontic treatments. reduction by combinations of mechanical and chemical aids
The purpose of this pilot project was to test and describe (Table 1).
the use of various combinations of mechanical and chemi- The mechanical techniques included removal of the
cal techniques for enamel reduction to obtain a smooth enamel by Midwest high-speed and low-speed hand-
enamel surface and to evaluate the residual smoothness of pieces (Midwest Dental Products Corp. Des Plaines,
the enamel of bovine teeth after application of these differ- Illinois) equipped with 16-blade tungsten carbide burs
ent methods. (Brasseler, Savannah, Georgia), superfine needle diamond
burs (Brasseler), diamond disks (Brasseler) and diamond
Materials and Methods Lightning strips (Moyco Union Broach, York,
Bovine teeth were used for this study. They are readily Pennsylvania). The stripped enamel surfaces were polished
available, and bovine enamel is an acceptable substitute for with 3M Sof-Lex extra-thin polishing disks attached to
human enamel in research projects,1,2 because histochemi- mandrels (3M Dental Products, St. Paul, Minnesota) and
cally all mammalian teeth appear essentially similar.3 In the 3M Sof-Lex finishing strips (coarse and medium aluminum
present study, the mesial and distal surfaces of 32 bovine oxide, as well as fine and superfine) (3M Dental Products)
teeth were used (total of 64 surfaces). The pulp of each in combination with various enamel acid etching solutions

384 June 2003, Vol. 69, No. 6 Journal of the Canadian Dental Association
 A Pilot Investigation of Enamel Reduction Procedures

Table 1 Results of interproximal enamel reduction (mean ± standard deviation of 9 measurements

for each method)
Method Enamel loss after Enamel loss after Enamel reduction by
initial reduction (mm) (IR) polishing (mm) (P) polishing only (mm) (P – IR)
TB + D 0.17 ± 0.02 0.38 ± 0.08 0.21 ± 0.06
TB + S 0.44 ± 0.06 0.54 ± 0.01 0.10 ± 0.06
TB + D + Ph 0.03 ± 0.04 0.07 ± 0.03 0.04 ± 0.02
TB + D+M 0.51 ± 0.04 0.64 ± 0.05 0.13 ± 0.03
TB + D + Pr 0.55 ± 0.05 0.64 ± 0.02 0.09 ± 0.06
TB + S + Ph 0.44 ± 0.09 0.67 ± 0.03 0.23 ± 0.06
TB + S+M 0.29 ± 0.06 0.42 ± 0.03 0.13 ± 0.08
TB + S + Pr 0.17 ± 0.06 0.16 ± 0.09 –0.01 ± 0.06
DS + D 0.19 ± 0.12 0.24 ± 0.06 0.06 ± 0.07
DS + S 0.15 ± 0.04 0.14 ± 0.09 –0.01 ± 0.09
DS + D + Ph 0.22 ± 0.11 0.27 ± 0.07 0.05 ± 0.18
DS + D+M 0.08 ± 0.08 0.19 ± 0.05 0.11 ± 0.07
DS + D + Pr 0.17 ± 0.15 0.33 ± 0.16 0.16 ± 0.03
DS + S + Ph 0.22 ± 0.02 0.26 ± 0.02 0.04 ± 0.02
DS + S+M 0.08 ± 0.01 0.17 ± 0.06 0.09 ± 0.07
DS + S + Pr 0.08 ± 0.03 0.14 ± 0.02 0.06 ± 0.01
DB + D 0.39 ± 0.04 0.53 ± 0.03 0.14 ± 0.03
DB + S 0.24 ± 0.12 0.38 ± 0.12 0.13 ± 0.01
DB + D + Ph 0.28 ± 0.11 0.38 ± 0.08 0.10 ± 0.05
DB + D+M 0.28 ± 0.09 0.49 ± 0.04 0.21 ± 0.12
DB + D + Pr 0.09 ± 0.12 0.02 ± 0.07 –0.07 ± 0.05
DB + S + Ph 0.34 ± 0.11 0.45 ± 0.11 0.11 ± 0.09
DB + S+M 0.37 ± 0.04 0.40 ± 0.05 0.03 ± 0.01
DB + S + Pr 0.39 ± 0.04 0.59 ± 0.06 0.20 ± 0.02
DD + D 0.22 ± 0.06 0.34 ± 0.08 0.12 ± 0.07
DD + S 0.16 ± 0.06 0.22 ± 0.05 0.05 ± 0.05
DD + D + Ph 0.23 ± 0.03 0.39 ± 0.01 0.16 ± 0.03
DD + D+M 0.01 ± 0.12 0.14 ± 0.03 0.13 ± 0.11
DD + D + Pr 0.43 ± 0.07 0.62 ± 0.08 0.19 ± 0.04
DD + S + Ph 0.56 ± 0.09 0.74 ± 0.09 0.18 ± 0.16
DD + S+M 0.36 ± 0.09 0.43 ± 0.03 0.07 ± 0.07
DD + S + Pr 0.28 ± 0.12 0.43 ± 0.01 0.15 ± 0.12
TB = tungsten carbide bur, D = 3M polishing disks, S = 3M polishing strips, Ph = 35% phosphoric acid, M = 10% maleic acid, Pr = Prema enamel
microabrasion kit, DS = diamond (Lightning) strip, DB = diamond bur, DD = diamond disk.

in some of the groups. The chemical etching products were specially sharpened to a knife-edged point to make accurate
the Transbond XT etching gel delivery system containing measurement possible (Fig. 1).
35% phosphoric acid (3M Dental Products), Scotchbond The average mesiodistal width before enamel reduction
Multi-Purpose etchant containing 10% maleic acid (3M and after polishing was determined and used for statistical
Dental Products) and the Prema enamel microabrasion kit analysis. The teeth were immersed in 100% ethanol for
containing an abrasive powder in a water-soluble gel 1 week after the stripping procedures and then allowed
combined with a mild concentration of hydrochloric acid to air dry to remove all moisture. The teeth were then
(Premier Dental Products, King of Prussia, Pennsylvania). individually mounted on aluminum scanning electron
The enamel surfaces were rinsed with distilled water for microscopy (SEM) stubs and coated with 3 nm of platinum
60 seconds after the application of the acid compounds. in a Polaron E 5100 SEM coating unit (Quorum
Three measurements of the mesiodistal width of each Technologies, East Sussex, England). The samples were
tooth were obtained before each method of enamel reduc- then viewed with a scanning electron microscope (Hitachi
tion. A total of 32 methods of enamel reduction were S-2500, Mito City, Japan) at an operating voltage of 10 kV.
completed, with 9 repetitions of each method, for a total of Images were photographed at 100× and 500× magnifica-
288 observations. The measurements were obtained with a tion for descriptive purposes.
digital caliper (Mitutoyo Corporation, Kawasaki, Japan), Statistical analyses included descriptive statistics and
calibrated to 0.01 mm, after initial reduction of the enamel Duncan’s multiple range test. The level of significance was
surface and again after polishing. The caliper tips were set at p < 0.05.

Journal of the Canadian Dental Association June 2003, Vol. 69, No. 6 385
Rossouw, Tortorella

that is commonly applied during

orthodontic treatment. Better align-
ment and better occlusion of the teeth,
as well as simplification of long-term
maintenance of tooth alignment, have
been reported.4–8
In the study reported here, bovine
enamel surfaces were subjected to
conservative reduction with a variety of
Figure 1: Digital calipers indicating mea- orthodontic grinding and finishing
surement to 0.01 mm. techniques and materials, the amount
of enamel removed was measured, and
the enamel surfaces were evaluated by
Figure 2a: Bovine tooth after enamel
reduction with a 16-blade tungsten carbide
SEM. Even when the teeth were
bur plus 3M polishing disks. polished with the finest finishing strips,
it was impossible to produce an enamel
surface free of the furrows caused
during initial abrasion by coarse reduc-
tion procedures. This phenomenon has
also been recognized by researchers
using human enamel.9–11 The furrows
caused by mechanical reduction may
enhance the predisposition for plaque
retention.12–14 The use of dental floss
apparently cannot prevent plaque accu-
mulation at the bottom of furrows cut
into the approximal enamel in this
way.10 A vicious cycle is thus estab-
lished, with subsequent risk of decalci-
Figure 2b: Bovine tooth after enamel Figure 2c: Bovine tooth after enamel fication, gingivitis, caries or some
reduction with a 16-blade tungsten carbide reduction with a 16-blade tungsten carbide
bur plus 3M polishing disks plus 10% bur plus 3M polishing disks plus Prema combination of these problems.15 The
maleic acid. enamel microabrasion kit. grinding-down of enamel by diamond-
coated disks, burs or finishing strips
Results remains the subject of controversy. Although injuries to the
The differences in enamel surface after the initial reduc- enamel surface caused by grinding instruments can predis-
tion and after polishing are presented in Table 1. There pose the patient to caries and periodontal disease,12–14
were no significant differences among the groups (Duncan’s interdental reduction is not yet considered by orthodontists
multiple-range text, p > 0.05). However, there was a statis- as a problem. Development of a technique that yields a
tically significant difference between the initial and final smooth enamel surface after enamel reduction is recom-
enamel measurements (p < 0.05) for all procedures, which mended to prevent iatrogenic lesions.
indicates that all of the techniques removed enamel from It is common to reshape the approximal contacts in the
these bovine teeth. anterior region to solve crowding problems4–8,16,17 and to
Examples of the results of the various procedures, stabilize the dental arch.18 This approach to treatment
including acid polishing, are shown in Figs. 2 and 3. These seems to have originated from the finding that aboriginal
SEM images revealed that the use of acids in polishing the and prehistoric humans usually exhibited not only
enamel after initial stripping resulted in a smoother surface. occlusal19,20 but also approximal19,21 wear of the dentition.
In particular, maleic and phosphoric acids (Figs. 2b, 3b The perceived impossibility of artificially producing
and 3c) yielded equivalent smoothness, whereas the use of highly polished surfaces has resulted in a preference to
the Prema enamel microabrasion kit reduced surface rough- avoid reduction and accept slight crowding as a natural
ness but left visible furrows (Figs. 2c and 3d). phenomenon.22 Nonetheless, there is a need for this
procedure in clinical practice, as reduction is rapidly
Discussion becoming a common procedure for the treatment of
Interproximal enamel reduction, also known as inter- minor discrepancies in arch length. The reduction proce-
dental stripping or slenderizing, is a well-known technique dure is usually limited to the lower anterior dental
386 June 2003, Vol. 69, No. 6 Journal of the Canadian Dental Association
 A Pilot Investigation of Enamel Reduction Procedures

apparently confirmed by Carstensen.24

Phosphoric acid concentrations greater
than about 27% produce monocal-
cium phosphate monohydrate, where-
as concentrations less than about 27%
yield dicalcium phosphate dihydrate.25
The former is readily soluble and
would be completely washed away in
the clinical situation, whereas the latter
is less soluble. This seems to be a disad-
vantage in providing a retentive surface
for resin bonding following applica-
tion of low-concentration acids.
Figure 3a: Bovine tooth after enamel Figure 3b: Bovine tooth after enamel
reduction with a diamond disk plus 3M reduction with a diamond disk plus 3M
Conversely, the overall loss of superfi-
polishing disks. polishing disks plus 35% phosphoric acid. cial enamel, which is especially rich in
fluoride,26 is probably less after etching
with 2% or 5% phosphoric acid than
with a 40% solution.27–30 Also, the
depth of acid penetration into the
deeper enamel layers seems to be less at
low acid concentrations.31 Therefore,
using low-concentration acids could
diminish the risk of decalcification in
the enamel regions around orthodontic
attachments. For this reason acid strip-
ping or polishing in the present study
was performed with low-concentration
acids.
Figure 3c: Bovine tooth after enamel
Light microscopic studies have
Figure 3d: Bovine tooth after enamel
reduction with a diamond disk plus 3M reduction with a diamond disk plus 3M shown that an enamel surface
polishing disks plus 10% maleic acid. polishing disks plus Prema enamel stripped by abrasive means cannot be
microabrasion kit. highly polished.22 Hence, acid strip-
ping was tested in the present study,
segment, where caries seldom develop. However, it has and SEM was used to determine the differences between
recently been proposed that such therapy be extended to acid and non-acid polishing (Fig. 2 and 3). In addition,
the premolar and molar regions5 to gain space along the it is known that artificially roughened enamel is less resis-
dental arch. This method might allow for just as much tant to penetration of a lactate buffer32 and that fluoride
space as can be achieved by the extraction of premolars. treatment must be applied for a lengthy period after
The in vitro study presented here confirms that enamel stripping.9,33
can be successfully removed by a variety of methods
Conclusions
(Table 1). Because the results of Radlanski and others10
Interproximal enamel reduction is an important auxil-
indicate that reduction leads to plaque accumulation, iary orthodontic treatment. However, the clinician must
careful evaluation is needed to determine whether take steps to ensure that a smooth enamel surface remains
potential damage to multiple approximal tooth surfaces after the polishing procedures described in this article, to
by enamel reduction is preferable to extraction and other ensure that the negative effects of abrasive stripping are
space-gaining procedures. The SEM images obtained in eliminated. It is recommended that conventional enamel
the present study clearly show roughening of the enamel etchants, as used in orthodontic practice, be added to the
surfaces if left unpolished (Figs. 2 and 3). polishing procedure during the reduction technique. A
The etching pattern of enamel appears to play a part in rubber dam may be used when any acidic products are
the bond strength of dental resins. However, Denys and included as part of the polishing procedure to prevent
Retief23 stated that it is impossible to define an etched further irritation of the gingiva. However, this is a minor
enamel surface as retentive to dental resins only on the basis consideration, as similar acids are typically used in bonding
of distribution of the etching patterns, an observation of brackets.

Journal of the Canadian Dental Association June 2003, Vol. 69, No. 6 387
Rossouw, Tortorella

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Correspondence to: Dr. P. Emile Rossouw, Professor and Clinic
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The authors have no declared financial interests in any company
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