A scanning electron microscopy comparison of enamel

polishing methods after air-rotor stripping

Cesare Piacentini, DMD, DDS," and Giuseppe Sfondrini, DMD, DDS ~

Pavia, Italy
In the last few years, orthodontic literature has shown particular interest in the interproximal enamel
reduction technique described as stripping or slenderizing. Most researchers have shown, by
scanning electron microscopy (SEM) studies, the difficulties encountered while attempting to
remove coarse abrasions left after stripping with the first instrument. The objective of this SEM
study was to compare the different polishing methods proposed in the literature and to assess the
efficiency of our own procedure. For this purpose, 48 healthy human teeth (premolars and molars)
were used after removal for orthodontic or periodontal reasons. The teeth were divided into eight
groups of six teeth each (two molars and four premolars), and mounted on a typodont to simulate a
clinical situation. Each group underwent stripping according to one of the following techniques:
16-blade tungsten carbide bur and fine and ultrafine diamond burs; coarse diamond bur and fine
and ultrafine diamond burs; coarse diamond disk and Sof-Lex disks (Dental products/3M, St. Paul,
Minn.); 16-blade tungsten carbide bur and phosphoric acid on finishing strip; and 8-straight blade
tungsten carbide diamond bur and Sof-Lex disks. The SEM investigations demonstrated that it is
not possible to eliminate, with normal polishing and cleaning methods, the furrows left on the
enamel both by the diamond burs and the diamond disks and the 16-blade tungsten carbide burs.
Mechanical and chemical stripping as well did not prove to be effective. By contrast, with the use
of a 8-straight blade tungsten carbide bur followed by Sof-Lex disks for polishing the enamel, it
is possible to obtain well-polished surfaces that many times appear smoother than the intact or
untreated enamel. (AM J ORTHOD DENTOFACORTHOP 1996;109:57-63.)

I n recent years, almost all orthodontic specialists have increasingly focused their interest on
nonextraction therapy, a-7
Among the existing therapeutic methods to increase the maxillary and mandibular length, stripping or slenderizing is with no doubt the most
popular. Such therapeutic procedures have been
carefully tested and progressively improved and
several researchers have been interested in the
orthodontic aspect of this subject, as well as in the
cariogenic and periodontal implications associated
with this procedure.
In 1985 Sheridan s introduced a stripping technique called the "ARS technique" that recommended: (1) positioning of a 0.20 wire in the
interdental space to prevent damaging the papilla
during stripping; (2) accomplishing enamel removal
by means of a 16-blade tungsten carbide bur (699
L). Such reduction of the interproximal enamel
could reach the 50% of the total, with an increase
of each arch length of approximately 6.4 mm; the

~Researcher of Oral and

bHead of Department of
Copyright 1996 by the
0889-5406/96/$5.00 + 0

Dental Research Institute.

Orthodontics.
American Association of Orthodontists.
8/1/59560

stripping was only to be performed on the first

molars and premolars. The reduction could reach
8.9 mm if the space obtainable by reducing the
enamel in the anterior segments was also calculated; (3) following the first enamel reduction finish
the area with finishing burs, disks, and polishing
finishing strips; and (4) applying topical fluoride
solutions after treatment to prevent the formation
of secondary caries where the enamel had been
removed.
In 1987 the same author 9 presented a revision
of his technique introducing some modifications
and suggesting the following: (1) aligning of the
dental elements; (2) opening the interproximal
area by introducing a thick elastic separator in the
contact point or using compressed coil springs; (3)
positioning a 0.20 wire to prevent nicking the papilla and making the initial enamel reduction with
a 16-blade tungsten carbide bur. The enamel surfaces could be reduced by 1 to 1.5 mm in thickness
(calculating the amount of enamel removed from
the mesial and distal aspects of the tooth) by
working from posterior to anterior; and (4) polishing the abraded area with a stiletto-shaped ultrafine finishing diamond to give the contact point
the optimum anatomic features.
57

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Piacentini and Sfondrini

In 1989 Sheridan 1 considered the possibility of

applying a resin composite to the stripped enamel
surface for sealing the furrows.
Scanning electron microscopic (SEM) observations of the interface between sealant and enamel
surface after treatment with 16-blade tungsten carbide bur showed that the resin adhered strongly to
the enamel. The treated surface, covered with the
sealant, appeared smooth. The author inferred that
possible secondary caries could be reduced.
In 1990, Crain and Sheridan 11did not find, from
a statistical point of view, any relationship between
interdental stripping (performed from 2 to 5 years
earlier) and caries susceptibility or periodontal
disease.
Another author has shown interest in this subject. Radlanski in his 1988 investigations~2 reported, through SEM investigations, the physiologic presence of abrasion areas on the interproximal enamel of healthy human teeth. In that area 30
to 40 ~m deep roughness was observed. According
to the author this roughness could be attributed to
masticatory forces or to bruxism phenomena. In
additional research, the same author 13 reported on
the interproximal surface of human teeth that underwent stripping with coarse and fine diamond
burs, followed by fine and ultrafine finishing strips
at SEM level. Radlanski emphasized the extreme
difficulty involved in polishing the enamel, especially when eliminating the furrows left by the first
bur. The author reported that, in general, the
ridges and edges of the stripped areas evaluated
after 12 weeks in vivo were more rounded compared with the samples stripped under in vitro
conditions.
According to the author, the structure of the
areas where interproximal reduction was performed could favor adherence and, consequently,
bacterial colonizations, with an increased risk of
secondary caries.
In later research Radlanski 14 reported the interproximal enamel structure at SEM level a year
after stripping. He confirmed that it was impossible
to polish those surfaces despite the careful use of
fine and ultrafine strips, but he also observed the
low incidence of caries in treated areas.
In 1982 Brudevold et al. 4 reported that the
iodide permeability of abraded bovine enamel increased after short exposure to an acid buffer and
decreased after short exposure to a mineralizing
solution. The rapid rate of initial phase of intraoral
mineralization, according to the authors, 1~reveals a

American Journal of Orthodontics and Dentofacial Orthopedics

January 1996

powerful mechanism for protecting the dentition

against demineralization.
In 1991 Nagwa H. E1-Mangoury et al. 15 perf o r m e d SEM research and concluded that the
enamel interproximal reduction in the posterior
segments did not expose the teeth to pathologic
caries and that a spontaneous remineralization of
the tissue followed after approximately a 9-month
period of demineralization.
Joseph et al. 16 proposed a mechanical stripping
procedure, combined with the chemical action of
37% phosphoric acid. This procedure, according to
the authors, produced enamel surfaces that encouraged "self-healing" on the basis of demineralization enhanced by the application of
fluoridating/remineralizing solutions.
Leclerc 17 carried out a complete analysis, using
the SEM to investigate existing stripping procedures. The author proposed using a diamond disk,
followed by a diamond bur, a 16- and 30-blade
tungsten carbide bur and a polishing paste.
Given the current interest in the subject and in
light of recent literature, it seemed of value to carry
out a morphological evaluation with the SEM of
enamel surfaces resulting from the application of
the most widely used stripping procedures proposed by various authors. The results obtained by
means of these techniques were then compared
with those obtained by using our personal procedures.
MATERIALS AND METHODS

Forty-eight healthy human teeth (permanent premolars and molars), extracted for orthodontic and periodontal reasons from patients aged under 40 years, were used.
The samples were stored in 70% ethanol for no
longer than 3 days and subdivided into eight groups of
two molars and four premolars each. The teeth were
mounted in typodonts, to be treated with the different
stripping procedures and to simulate clinical conditions.
To have comparable operative conditions, a single arch
was used for each type of procedure to be assessed. The
interproximal stripping was performed according to the
following methods:
Method 1: 16-blade tungsten carbide bur (Komet
H284) and polishing by means of fine (Komet 862EF)
and ultrafine (Komet 862UF) diamond burs (Komet burs
made by Brasseler, Lemgo, West Germany);
Method 2: coarse diamond bur (Komet 859) and
polishing by means of fine and ultrafine diamond burs;
Method 3: diamond disk (Komet 919) and polishing
by means of medium, fine and ultrafine 3M Sof-Lexdisks
(Dental products/3M, St. Paul, Minn.);
Method 4: tungsten carbide bur (Komet H28) and

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Piacentini a n d Sfondrini

59

Fig. 1. Enamel structure after stripping with 16-blade tungsten

carbide bur. (Magnification x372.)

Fig. 3. Enamel structure after stripping with coarse diamond

disk. (Magnification x372.)

Fig. 2. Enamel surface after treatment with coarse diamond

bur. (Magnification x372.)

Fig. 4. Enamel surface after mechanical and chemical stripping. (Magnification x372.)

polishing by means of medium, fine and ultrafine Sof-Lex

disks;
Method 5: coarse diamond bur and polishing by
means of medium, fine and ultrafine Sof-Lex disks;
Method 6: 16-blade tungsten carbide bur (Komet
H284) and 20 passages of a medium and fine 3M finishing strip with phosphoric acid 37% gel on the surface
(Phosphoric acid, jelly type, from "Concise Orthodontic
Bonding System" Dental products 73M, St. Paul, Minn.);
and
Method 7:ET9 8-straight blade tungsten carbide bur
(Komet-E.T. Carbide Set 4159 according to Dr. Ronald
Goldstein, and polishing by means of fine and ultrafine
Sof-Lex disks.
All teeth were dehydrated and gold coated for SEM
observation.

OBSERVATIONS

The photomicrographs were divided into two

groups. The first group (Figs. 1 to 5) shows the
enamel surface after the first stripping, and the
second group (Figs. 7 to 14) shows the enamel
morphologic features after polishing and the results
of the different methods examined. The number on
the lower left of the photograph refers to the
method examined.
Fig. 1 shows the enamel structure after stripping with a 16-blade tungsten carbide bur. Furrows
that are the result of the passage of the bur are
visible: they appear irregular and are uniformly
distributed on the enamel surface.

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Piacentini and Sfondrini

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January 1996

m i ~ b ~

Fig. 5. Enamel structure after stripping with a 8-blade tungsten carbide bur. (Magnification 372.)

Fig. 6. Intact enamel surface. (Magnification x 372.)

Fig. 7. Enamel surface after stripping according to method 1.

(Magnification x 1010.)

-~

--I

Fig. 8. Enamel surface after stripping according to method 2.

(Magnification 1010.)

Fig. 9. Enamel surface after stripping according to method 3.

(Magnification x 1010,)

Fig. 2 shows the enamel surface after treatment

by means of a coarse diamond bur. The surface
appears crossed by deep and irregular furrows that
form hills and valleys.
The enamel structure after stripping with a
coarse diamond disk shows gross furrowing due to
the use of a diamond disk. The furrows are regularly and uniformly distributed over the entire
treated area (Fig. 3).
Fig. 4 refers to the enamel surface after mechanical (16-blade tungsten carbide bur) and
chemical (finishing strips and phosphoric acid)
stripping.
The grooves that are the result of the passage of
the bur have almost completely disappeared, and
the heads of the enamel prisms can be seen on the
surface.

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Fig. 10. Enamel surface after stripping according to method 4.

(Magnification x 1010.)

Fig. 11. Enamel surface after stripping according to method 5.

(Magnification x 1010.)

Fig. 5 shows the different structure of the area

between the Untreated enamel (top) and the area
stripped with an 8-straight blade tungsten carbide
bur (bottom). The surface appears finely rough and
grooves or furrows cannot be seen.
Fig. 6 shows the untreated enamel surface. A
comparison with the previous images can be useful.
Fig. 7 shows the enamel surface after stripping
with tungsten carbide bur and polishing, using fine
and ultrafine diamond burs (method 1). Furrows
can be seen crossing the surface at different depths.
After stripping with a coarse diamond bur and
polishing with fine and ultrafine diamond burs
(method 2), the enamel appears crossed by deep
furrows, which alter its morphologic features
(Fig. 8).

Piacentini and Sfondrini

61

Fig. 12. Enamel surface after stripping according to method 6.

(Magnification x 1010.)

Fig. 13. Enamel surface after stripping according to method 7.

(Magnification x 1010.)

Fig. 14. Higher magnification of enamel surface after stripping

according to method 7. (Magnification x2840.)

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Piacentini and Sfondrini

After treatment according to method 3 (coarse

diamond disk and polishing with Sof-Lex), the
surface appears smooth, although the furrows left
by the diamond disk can still be seen (Fig. 9).
Tungsten carbide bur stripping and polishing
with Sof-Lex disks produce a finely rough surface
where the furrows left by the first bur are still
visible (method 4 and Fig. 10). Also in Fig. 11
(method 5) the surface is crossed by deep furrows
despite the polishing with Sof-Lex disks.
Mechanical-chemical stripping (method 6) partially alters the inorganic component of the enamel
and the classical etch pattern is discernible (Fig.
12).
Fig. 13 refers to the final result of stripping,
using an 8-straight blade tungsten carbide bur and
polishing with Sof-Lex (method 7). The enamel
surface appears crossed by fine furrowing alternating with well-polished areas. At higher level magnification the furrows reveal themselves as fine and
shallow (Fig. 14).
CONCLUSIONS

The morphologic analysis of the surfaces shows

that the results obtained with the use of the different stripping methods proposed by the literature
are comparable among themselves. All the different morphologic pictures, in fact, reveal the presence of furrowing and roughness, despite the use of
careful polishing techniques.
Therefore we can assume that polishing enamel
after stripping to make it appear somewhat similar
to the normal tissue before treatment is extremely
difficult. This is essentially due to the difficulties,
emphasized in the literature, when trying to eliminate furrowing and roughness left by the first bur.
These abrasive areas might favor the adherence of
bacterial plaque and offered little resistance to
breakdown.IS
Joseph et al. x6 propose a combined mechanical
and chemical technique. However, the result is an
etched adamantine surface that, in our opinion, is
susceptible to decalcification, despite the application of calcifying/fluoridating solutions as suggested
by the authors. We believe that such a method may
be risky because of rapid plaque accumulation on
the enamel surface, which may result in greater
exposure to carious agents. The clinician is unable
to check whether the patients use calcifying/fluoridating solutions.
We did not examine the procedure proposed by
Leclerc because its clinical application seems to be
very complicated. Given the high number of bur

American Journal of Orthodontics and Dentofacial Orthopedics

January 1996

passages and the numerous burs required, the

clinician might lose control of the quantity of the
enamel removed or might be tempted to eliminate
some steps of the procedure with negative effects
on the final result.
The morphologic analysis of our findings shows
that satisfactory results may be achieved with a
tungsten carbide bur as the first bur and polishing
with Sof-Lex disks. Nevertheless, the best results
were obtained with a method that uses the following: (1) 8-straight blade tungsten carbide bur for
the first stripping, (2) fine Sof-Lex disk for first
polishing, and (3) ultrafine Sof-Lex disk for final
polishing. This method seems to be simple and
clinically expedient as it involves only three steps.
The 8-straight blade tungsten carbide bur allows a
very precise first stripping and leaves very fine
furrows, as it was made for polishing resin composite fillings. This fine roughness can then be easily
removed with Sof-Lex disks.
In conclusion, given the current emphasis on
nonextraction treatment in orthodontics today,
stripping is a technique that can increase space but
it must be performed after a careful evaluation of
the quantity of enamel that can be nonpathologically removed. It must accomplish this reduction
with the best possible finishing of the interproximal
enamel surface and meet the biologic requirements
of the oral cavity.
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1986;89:95-112.
2. Betteridge MA. The effects of interdental stripping on the
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3. Brudevold F, Tehrani A, Bakhos Y. Intraoral mineralization
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analysis and treatment of malocclusion. Angle Orthod 1958;
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Reprint requests to:
Dr. Cesare Piacentini
Istituto di Discipline Odontostomatologiche
Policlinico S. Matteo
Piazzale Golgi 2
27100 PAVIA
ITALY