Interproximal Enamel Reduction: A Cross Sectional Study of Moroccan Orthodontists

Abstract

The aim of our study is to provide an overview of the methods, knowledge and frequency of interproximal enamel reduction of Moroccan orthodontists. We conducted a descriptive cross-sectional study among a sample of 118 orthodontists, using descriptive questionnaire survey of dentists practicing orthodontics in Morocco. 96% of orthodontists asked reported being familiar with stripping, with a predominance of doctors with a university degree in orthodontics. The clinical criteria on which practitioners based their decision to perform stripping were the need for space, enamel thickness, oral hygiene assessment, tooth position and the presence of proximal caries. As for the main indications for stripping: 87% of practitioners used this method to close black triangles, 85% used it to create space, 73% used it to correct a DDD, and 72% used it to resolve overlap problems. 35% used it to improve occlusion and 34% used it to treat dental rotations. Stripping burs are the most commonly used instrument for stripping, with 82% of dentists using them, followed by discs (79%). In our sample, Moroccan orthodontists have good knowledge of the methods, indications, and limitations of stripping. However, it is also evident that they do not systematically follow the guidelines established by the international community regarding the equipment and operating techniques associated with IPR. This highlights a potential gap between local practices and international standards, suggesting the need for ongoing updating and harmonization of clinical protocols with international recommendations.

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Sair, S. , El Benna, S. and Ousehal, L. (2024) Interproximal Enamel Reduction: A Cross Sectional Study of Moroccan Orthodontists. Open Access Library Journal, 11, 1-14. doi: 10.4236/oalib.1111854.

1. Introduction

The major objective of orthodontics is to improve both aesthetics and oral functionality, in order to move teeth into a more optimal position. This involves a careful assessment of various aspects of the patient’s face, such as profile and smile, in addition to case-specific aesthetic considerations [1]. Modern orthodontics is based on a wide range of techniques, some more recent than others, all with the common aim of establishing or restoring a stable, functional and aesthetically pleasing occlusion.

To achieve harmony between the dental arches, correct alignment of contact points and optimal occlusion, the orthodontist is faced with lack of space. Three options are available: transverse or sagittal expansion of the arches, tooth extractions [2] or the interproximal reduction of the enamel. These techniques can be combined or used individually.

The choice can only be made following a detailed clinical, radiographic and cephalometric analysis, including a calculation of the patient’s space assessment.

From this analytical approach, two therapeutic options can be considered: to extract or not to extract. The conservative choice remains reversible, unlike extractions, which are irreversible [3].

As a therapeutic option, proximal enamel reduction or stripping can become an alternative to dental extractions, provided that the dento-maxillary disharmony (DMD) is less than 8mm, the morphology of the teeth lends itself to it (triangular crowns are the most favorable), and oral hygiene is in order.

Interproximal enamel reduction or stripping (IPR) is defined as the reduction of proximal tooth enamel thickness to correct minor crowding [2].

In 1944, Ballard et al. [4] recommended reduction of the proximal surfaces of the mandibular anterior segment to correct a lack of harmony in tooth size. A few years later, Hudson et al. [5] described in detail a stripping technique using metal bands, followed by preventive measures of polishing and fluoride. Peck and Peck et al. [6] observed that well-aligned mandibular incisors had significantly lower mesio-distal and vestibulo-lingual indices than upper incisors, and recommended proximal grinding to correct dento-dental disharmony.

Orthodontics has evolved considerably in recent years. And to best meet our patients’ needs, dentists have become enthusiastic about university or continuing orthodontic training courses that include the data needed to perform orthodontic stripping.

The aim of this work is to provide an overview of the methods and frequency of stripping among Moroccan orthodontists.

2. Materiel and Methods

This is a cross-sectional study, using descriptive questionnaire survey of dentists practicing orthodontics in Morocco. This survey was carried out over a period of eleven weeks.

The study population consisted of a randomly selected group of Moroccan orthodontists.

2.1. Sample Description

Of the 118 dentists contacted, only 100 correctly completed the questionnaire.

2.1.1. Inclusion Criteria

  • Dentists’ specialists in orthodontics after residency;

  • Dentists’ specialists in orthodontics after obtaining a Moroccan or foreign university degree;

  • Dentists practicing orthodontics following private training in Morocco or abroad;

  • Practitioners in both the private and public sectors.

2.1.2. Exclusion Criteria

  • Orthodontists practicing outside Morocco;

  • Dentists not practicing orthodontics;

  • Dentists who refused to take part in the survey.

2.2. Data Processing

2.2.1. Survey Support

We began with an introduction to present and explain the aim of the study.

We made it clear that all responses would remain confidential, thus guaranteeing the anonymity of the participants. In fact, we did not ask for any information on the identity of the respondents.

The questionnaire is made up of 22 multichotomies closed questions, with single and multiple-choice answers.

The questionnaire was divided into four parts:

1) General information about participants;

2) Knowledge and practice of stripping;

3) Attitudes and opinions about stripping;

4) Personal experiences of stripping.

2.2.2. Data Entry and Statistical Analysis

Data was entered into an Excel spreadsheet and analyzed using Jamovi V1.6.15 software.

The first step was to describe the study population, summarizing quantitative variables as means with standard deviations, and qualitative variables as percentages.

Secondly, a univariate analysis was carried out to explore a possible association between doctors’ knowledge and practices according to their characteristics, while stratifying according to the gender variable.

The tests used were mainly the Chi2 test. In the event of non-compliance with the conditions of application, Fisher’s exact test was used.

A significance level of less than 0.05 was used to conclude that the difference was statistically significant.

3. Results

As part of our survey, 118 questionnaires were submitted to dentists practicing orthodontics in Morocco. However, 18 questionnaires were excluded due to non-return or incomplete responses. Thus, our study was based on information collected from 100 participants, equivalent to a response rate of 84.75%.

1) Sample characteristics:

- Participation in our survey showed a gender split among practitioners, with 67 women and 33 men (Table 1).

- 39% of the dentists in our sample practiced orthodontics following a university degree in orthodontics, while 35% had national specialty diploma.

- The sample is characterized by the predominance of experienced orthodontists, 65% of them having more than 5 years’ experience to their credit.

- As for the orthodontic techniques used, all the dentists in our sample used vestibular orthodontics, 54% used aligners, while only 9% opted for the lingual technique.

2) Individual stripping experience:

- 32% of the dentists in the sample surveyed said they only informed their patients of the possibility of stripping occasionally, 25% informed them most of the time, and 23% said they always informed their patients of the possibility of stripping (Table 1).

- 91% of participants said they were open to integrating new alternative techniques (Table 1).

- 95% of dentists thought that stripping should be discussed further (Table 1).

Table 1. Individual stripping experience.

Count

Percentage

Frequency of information about the possibility of stripping

Always

24

24.0

Most of the time

25

25.0

Occasionally

32

32.0

Rarely

12

12.0

Never

7

7.0

Use of new alternative techniques

Yes

91

91.0

No

9

9.0

Stripping should be further discussed

Yes

95

95.0

No

5

5.0

3) Correlation between gender, years of practice and type of degree with stripping practices:

The study showed that orthodontists with a university degree were the most familiar.

Statistical comparison according to gender, years of practice and type of degree showed no significant difference.

Our study revealed that female specialists who had been practicing for more than 10 years were the most prone to use stripping frequently.

However, no statistically significant difference was observed in this comparison (Table 2).

Table 2. Statistical comparison of stripping frequency by years of practice and type of diploma, stratified by gender.

Frequently

Count (%)

Sometimes

Count (%)

Rarely

Count (%)

p-value

Female

Years of practice

0.251

<10

8 (20.0)

25 (62.5)

7 (17.5)

≥10

10 (38.5)

12 (46.2)

4 (15.4)

Type of diploma

0.328

Specialists

10 (43.5)

10 (43.5)

3 (13.0)

Private training courses

4 (18.2)

14 (63.6)

4 (18.2)

University diploma

4 (18.2)

14 (63.6)

4 (18.2)

Male

Years of practice

0.445

<10

4 (33.3)

8 (66.7)

0 (0.0)

≥10

8 (38.1)

10 (47.6)

3 (14.3)

Type of diploma

0.876

Specialists

4 (33.3)

6 (50.0)

2 (16.7)

Private training courses

2 (50.0)

2 (50.0)

0 (0.0)

University diploma

6 (35.3)

10 (58.8)

1 (5.9)

Our survey on the criteria used by participants to perform orthodontic stripping revealed the following results:

- Female, specialist dentists with more than ten years’ practice reported assessing the amount of space required before stripping (Table 3).

- Enamel thickness was the criteria most taken into account by specialist orthodontists and those practicing for less than 10 years (Table 3).

- The presence of proximal caries was rated higher by female orthodontists with more than ten years’ practice and by male orthodontists with a university degree (Table 3).

- The position of teeth on the arch was more of a clinical decision criterion for female specialists with less than 10 years’ practice (Table 3).

No statistically significant difference was observed between the years of practice or type of degree for either sex of dentist, with the exception of oral hygiene, which was rated higher by female specialists than by those with training or university degrees (96% versus 59% for the others, p = 0.004) (Table 3).

No significant association between the criteria evaluated and years of practice or type of diploma was noted in men (Table 3).

- Female dental specialists with less than 10 years’ practice considered oral hygiene as a clinical decision criterion (Table 3).

Table 3. Clinical decision criteria for the use of stripping according to years of practice and type of diploma in males and females.

Years of practice

Type of diploma

<10

Count (%)

≥10

Count (%)

p-value

University diploma

Count (%)

Private course training

Count (%)

Specialist

Count (%)

p-value

Necessary space

Male

Yes

10 (83.0)

20 (95.0)

0.538

17 (100)

4 (100)

9 (75.0)

0.073

No

2 (17.0)

1 (5.0)

0 (0.0)

0 (0.0)

3 (25.0)

Female

Yes

37 (93.0)

26 (100)

0.3

20 (95.0)

20 (91.0)

23 (100)

0.4

No

3 (8.0)

0 (0.0)

1 (5.0)

2 (9.0)

0 (0.0)

Email thickness

Male

Yes

10 (83.0)

13 (62.0)

0.259

10 (59.0)

3 (75.0)

10 (83.0)

0.438

No

2 (17.0)

8 (38.0)

7 (41.0)

1 (25.0)

2 (17.0)

Female

Yes

34 (83.3)

20 (77.0)

0.546

19 (86.0)

16 (73.0)

19 (83.0)

0.549

No

7 (17.0)

6 (23.0)

3 (14.0)

6 (27.0)

4 (17.0)

Presence of proximal caries

Male

Yes

8 (67.0)

10 (48.0)

0.469

11 (65.0)

1 (25.0)

6 (50.0)

0.332

No

4 (33.0)

11 (52.0)

6 (35.0)

3 (75.0)

6 (50.0)

Female

Yes

11 (27.0)

13 (50.0)

0.07

8 (36.0)

6 (27.0)

10 (43.0)

0.595

No

30 (73.0)

13 (50.0)

14 (64.0)

16 (73.0)

13 (57.0)

Tooth position on the arch

Male

Yes

7 (58.0)

13 (62.0)

1.00

11 (65.0)

1 (25.0)

8 (67.0)

0.410

No

5 (42.0)

8 (38.0)

6 (35.0)

3 (75.0)

4 (33.0)

Female

Yes

20 (49.0)

15 (58.0)

0.617

12 (55.0)

9 (39.0)

14 (61.0)

0.422

No

21 (51.0)

11 (42.0)

10 (45.0)

13 (59.0)

9 (39.0)

Oral hygiene

Male

Yes

8 (67.0)

15 (71.0)

1.0

12 (71.0)

2 (50.0)

9 (75.0)

0.750

No

4 (33.0)

6 (29.0)

5 (29.0)

2 (50.0)

3 (25.0)

Female

Yes

29 (71.0)

19 (73.0)

1.0

13 (59.0)

13 (59.0)

22 (96.0)

0.004*

No

12 (29.0)

7 (27.0)

9 (41.0)

9 (41.0)

1 (4.0)

Regarding the main indications for stripping, our study showed that:

Statistical comparison based on gender, years of practice and type of degree showed no significant difference, except for the correction of a DDD, which reported a significant difference in the comparison between lengths of practice in men (Table 4).

Table 4. Main indications for stripping according to years of practice and type of diploma in males and females.

Years of practice

Type of diploma

<10

Count (%)

≥10

Count (%)

p-value

University diploma

Private course training

Count (%)

Specialist

Count (%)

p-value

Treating tooth rotations

Male

Yes

4 (33.0)

7 (33.0)

1.0

4 (24.0)

2 (50.0)

5 (42.0)

0.504

No

8 (67.0)

14 (67.0)

13 (76.0)

2 (50.0)

7 (58.0)

Female

Yes

13 (32.0)

10 (38.0)

0.308

5 (23.0)

10 (45.0)

8 (35.0)

0.308

No

28 (68.0)

16 (62.0)

17 (77.0)

12 (55.0)

15 (65.0)

Creating space for tooth alignment

Male

Yes

11 (92.0)

19 (90.0)

1.0

16 (94.0)

4 (100)

10 (83.0)

0.701

No

1 (8.0)

2 (10.0)

1 (6.0)

0 (0.0)

2 (17.0)

Female

Yes

33 (80.0)

22 (85.0)

0.753

20 (91.0)

19 (86.0)

16 (70.0)

0.202

No

8 (20.0)

4 (15.0)

2 (9.0)

3 (14.0)

7 (30.0)

Solving overlap problems

Male

Yes

7 (58.0)

16 (76.0)

0.433

12 (71.0)

2 (50.0)

9 (75.0)

0.750

No

5 (42.0)

5 (24.0)

5 (29.0)

2 (50.0)

3 (25.0)

Female

Yes

28 (68.0)

21 (81.0)

0.397

17 (77.0)

15 (68.0)

17 (74.0)

0.837

No

13 (32.0)

5 (19.0)

5 (23.0)

7 (32.0)

6 (26.0)

Improving occlusion

Male

Yes

4 (33.0)

9 (43.0)

0.719

7 (41.0)

1 (25.0)

5 (42.0)

1.0

No

8 (67.0)

12 (57.0)

10 (59.0)

3 (75.0)

7 (58.0)

Female

Yes

11 (27.0)

11 (42.0)

0.286

8 (36.0)

4 (18.0)

10 (43.0)

0.203

No

30 (73.0)

15 (58.0)

14 (64.0)

18 (82.0)

13 (57.0)

Correcting dento-dental disharmony (DDD)

Male

Yes

4 (33.0)

16 (76.0)

0.027*

8 (47.0)

2 (50.0)

10 (83.0)

0.108

No

8 (67.0)

5 (24.0)

9 (53.0)

2 (50.0)

2 (17.0)

Female

Yes

30 (73.0)

23 (88.0)

0.217

18 (82.0)

14 (64.0)

21 (91.0)

0.077

No

11 (27.0)

3 (12.0)

4 (18.0)

8 (36.0)

2 (9.0)

Closing black triangles

Male

Yes

8 (67.0)

20 (95.0)

0.047

15 (88.0)

3 (75.0)

10 (83.0)

0.811

No

4 (33.0)

1 (5.0)

2 (12.0)

1 (25.0)

2 (17.0)

Female

Yes

35 (85.0)

24 (92.0)

0.469

20 (91.0)

17 (77.0)

22 (96.0)

0.155

No

6 (15.0)

2 (8.0)

2 (9.0)

5 (23.0)

1 (4.0)

The main instruments used revealed the following results:

Statistical comparison according to gender, years of practice and type of degree showed no significant difference, with the exception of two specific cases: the use of stripping strips among women according to type of degree (P = 0.009) and the use of stripping discs among male dentists according to type of degree (P = 0.032) and years of practice (P = 0.027).

More experienced practitioners tend to use discs more frequently (Table 5).

Table 5. Main instruments used according to years of practice and type of diploma in males and females.

Years of practice

Type of diploma

<10

Count (%)

≥10

Count (%)

p-value

University diploma

Count (%)

Private course training

Count (%)

Specialist

Count (%)

p-value

Stripping burs

Male

Yes

11 (92.0)

17 (81.0)

0.630

15 (88.0)

3 (75.0)

10 (83.0)

0.811

No

1 (8.0)

4 (19.0)

2 (12.0)

1 (25.0)

2 (17.0)

Female

Yes

32 (78.0)

22 (85.0)

0.752

16 (73.0)

19 (86.0)

19 (83.0)

0.549

No

9 (22.0)

4 (15.0)

6 (27.0)

3 (14.0)

4 (17.0)

Stripping bands

Male

Yes

7 (58.0)

18 (86.0)

0.106

13 (76.0)

2 (50.0)

10 (83.0)

0.452

No

5 (42.0)

3 (14.0)

4 (24.0)

2 (50.0)

2 (17.0)

Female

Yes

31 (76.0)

23 (88.0)

0.225

19 (86.0)

13 (59.0)

22 (96.0)

0.009*

No

10 (24.0)

3 (12.0)

3 (14.0)

9 (41.0)

1 (4.0)

Stripping discs

Male

Yes

1 (8.0)

10 (48.0)

0.027*

9 (53.0)

1 (25.0)

1 (8.0)

0.032*

No

11 (92.0)

11 (52.0)

8 (47.0)

3 (75.0)

11 (92.0)

Female

Yes

9 (22.0)

6 (23.0)

1.0

8 (36.0)

5 (23.0)

2 (9.0)

0.082

No

32 (78.0)

20 (77.0)

14 (64.0)

17 (77.0)

21 (91.0)

In terms of the methods used to assess enamel reduction, our study revealed the following results:

Our study revealed no significant differences according to years of practice or type of degree obtained, with the exception of the use of stripping gauges, which was more frequent in male doctors with a length of practice of 10 years or more (62% vs. 17%, p = 0.027) (Table 6).

- Tooth sensitivity after stripping was observed by orthodontists, especially specialists and dentists with less than 10 years’ practice.

- Gingival irritation was observed by dentists with more than 10 years’ practice, and also by orthodontists.

- Sensitivity during stripping was mainly observed in female university graduates and male specialists.

- The development of proximal caries was mainly reported by female orthodontic-trained doctors, and by male university-educated dentists.

- Statistical comparison according to gender, length of practice and type of degree showed no significant difference, except for gingival irritation, where the comparison was similar for male practitioners (P = 0.005) (Table 7).

Table 6. Methods for assessing the value of enamel reduction according to years of practice and type of diploma in males and females.

Years of practice

Type of diploma

<10

Count (%)

≥10

Count (%)

p-value

University diploma

Count (%)

Private course training

Count (%)

Specialist

Count (%)

p-value

Visually

Male

Yes

8 (67.0)

12 (57.0)

0.719

9 (53.0)

3 (75.0)

8 (67.0)

0.689

No

4 (33.0)

9 (43.0)

8 (47.0)

1 (25.0)

4 (33.0)

Female

Yes

26 (63.0)

14 (54.0)

0.456

16 (73.0)

12 (55.0)

12 (52.0)

0.347

No

15 (37.0)

12 (46.0)

6 (27.0)

10 (45.0)

11 (48.0)

Stripping gauges

Male

Yes

2 (17.0)

13 (62.0)

0.027*

7 (41.0)

1 (25.0)

7 (58.0)

0.554

No

10 (83.0)

8 (38.0)

10 (59.0)

3 (75.0)

5 (42.0)

Female

Yes

13 (32.0)

13 (50.0)

0.198

6 (27.0)

7 (32.0)

13 (57.0)

0.105

No

28 (68.0)

13 (50.0)

16 (73.0)

15 (68.0)

10 (43.0)

Burs diameter

Male

Yes

5 (42.0)

4 (19.0)

0.230

5 (29.0)

1 (25.0)

3 (25.0)

1.00

No

7 (58.0)

17 (81.0)

12 (71.0)

3 (75.0)

9 (75.0)

Female

Yes

10 (24.0)

11 (42.0)

0.177

6 (27.0)

9 (41.0)

6 (26.0)

0.575

No

31 (76.0)

15 (58.0)

16 (73.0)

13 (59.0)

17 (24.0)

Table 7. Undesirable effects of stripping according to years of practice and type of diploma in males and females.

Years of practice

Type of diploma

<10

Count (%)

≥10

Count (%)

p-value

University diploma

Count (%)

Private course training

Count (%)

Specialist

Count (%)

p-value

Tooth sensitivity after stripping

Male

Yes

6 (50.0)

7 (33.0)

0.465

6 (35.0)

3 (75.0)

4 (33.0)

0.410

No

6 (50.0)

14 (67.0)

11 (65.0)

1 (25.0)

8 (67.0)

Female

Yes

15 (37.0

7 (27.0)

0.439

7 (32.0)

5 (23.0)

10 (43.0)

0.357

No

26 (63.0)

19 (73.0)

15 (68.0)

17 (77.0)

13 (57.0)

Gum irritation

Male

Yes

0 (0.0)

10 (48.0)

0.005*

5 (29.0)

1 (25.0)

4 (33.0)

1.00

No

12 (100)

11 (52.0)

12 (71.0)

3 (75.0)

8 (67.0)

Female

Yes

14 (34.0)

6 (23.0)

0.417

6 (27.0)

6 (27.0)

8 (35.0)

0.842

No

27 (66.0)

20 (77.0)

16 (73.0)

16 (73.0)

15 (65.0)

Increased sensitivity during stripping

Male

Yes

5 (42.0)

7 (33.0)

0.716

5 (29.0)

0 (0.0)

7 (58.0)

0.068

No

7 (58.0)

14 (67.0)

12 (71.0)

4 (100)

5 (42.0)

Female

Yes

10 (24.0)

3 (12.0)

0.225

5 (23.0)

4 (18.0)

4 (17.0)

0.929

No

31 (76.0)

23 (88.0)

17 (77.0)

18 (82.0)

19 (83.0)

Development of proximal caries

Male

Yes

2 (17.0)

3 (14.0)

1.00

3 (18.0)

1 (25.0)

1 (8.0)

0.660

No

10 (83.0)

18 (86.0)

14 (82.0)

3 (75.0)

11 (92.0)

Female

Yes

4 (10.0)

3 (12.0)

1.00

2 (9.0)

5 (23.0)

0 (0.0)

0.027

No

37 (90.0)

23 (88.0)

20 (91.0)

17 (77.0)

23 (100)

None

Male

Yes

1 (8.0)

1 (5.0)

1.00

2 (12.0)

0 (0.0)

0 (0.0)

0.614

No

11 (92.0)

20 (95.0)

15 (88.0)

4 (100)

12 (100)

Female

Yes

7 (17.0)

8 (31.0)

0.235

4 (18

6 (27.0)

5 (22.0)

0.820

No

34 (83.0)

18 (69.0)

18 (82.0)

16 (73.0)

18 (78.0)

4. Discussion

Stripping or interproximal tooth reduction (IPR) is a common orthodontic procedure. Its main purpose is to create the space needed to correct dental crowding. Other indications proposed in the literature include the correction of inter-dental black triangles linked to gingival defects, the correction of DDD, or as part of orthodontic finishing for better stabilization of the dental alignment obtained.

This is a descriptive cross-sectional study, the first of its kind carried out among Moroccan orthodontists. The literature search for similar studies revealed two studies by Donovan J. [7] in Ireland, who carried out a similar survey of orthodontists and patients, and Barcoma [8] in Italy, who compared the opinions of orthodontists with those of general dentists regarding stripping. Other published studies focused mainly on stripping techniques [9], the consequences of stripping on proximal enamel, gingival health [10] or predisposition to proximal carious lesions [11] [12].

The aim of this work is to describe practitioners’ knowledge of stripping in orthodontics and their technical preferences, as well as the methods used to carry it out.

Our main findings on stripping showed that 96% of practitioners are familiar with stripping, with only 14% saying they rarely use it. 93% of practitioners chose the space required in the arches to correct malocclusions as the main clinical requirement for stripping.

The main indications for stripping in orthodontics are crowding [2] [13], when the lack of space in the dental arch is 4 to 8 mm [4], the DDD [4] [14] [15], followed by normalization of gingival contours and elimination of black triangles [9] [10].

In our sample, lack of space and black triangles come in first place, with rates of 85% and 87% respectively.

We found that 33% of the orthodontists included used a retro alveolar radiography and 60% of practitioners did not use gauges to assess the amount of stripping, preferring visual assessment.

The use of radiographic images to determine the exact amount of enamel, although recommended by various authors [16] [17], may not be feasible for routine clinical application.

In his study of 105 Irish orthodontists, Joey Donovan [7] noted that 98% of orthodontists used stripping, including 59% who used aligners, and 33% who used the pre-adjusted Edgewise technique. Manual stripping was used by 37% of Irish orthodontists. Here again, and in line with our study, correction of crowding and closure of black triangles are the main indications for stripping.

Statistical comparison of our results according to gender, years of practice and type of degree showed that only oral hygiene as a clinical decision criterion for stripping was given greater consideration by specialist who had completed a university residency program.

One of the main concerns regarding IPR is the possible increase in caries risk due to plaque accumulation on rough enamel surfaces. Based on Elvi Barcoma et al. [8], IPR is a minimally invasive procedure with little risk of interproximal caries development, according to the majority of general dentists and orthodontists. On the other hand, general dentists were more likely than orthodontists to apply topical fluoride and perform post-IPR polishing (P < 0.0001).

A retrospective investigation examined a sample of 61 cases who had received IPR on all six mandibular anterior teeth at least 10 years previously [11]. The results confirmed that there was no increased susceptibility to caries on treated enamel surfaces. This was studied again, but with a shorter follow-up period, in patients who had received an IPR only four to six years earlier [18]. Of the 278 surfaces reduced in this study, only seven showed new carious lesions (2.5%), and of the 84 untreated (control) surfaces, two showed new carious lesions (2.4%).

According to Danesh et al. [19], IPR treated and polished enamel in general showed a reduced surface roughness compared to untreated enamel before IPR. Proper polishing of IPR-treated surfaces is thus advisable irrespective of the IPR procedure used, to minimize caries susceptibility.

Koretsi et al. [20], conclude that because of the variety of studies, it was challenging to reach evidence-based conclusions on enamel roughness following IPR. On the other hand, caries occurrence on tooth surfaces that had previously received IPR treatment was statistically equal to that of intact surfaces. Furthermore, it is anticipated that there will be a statistically equal number of carious lesions on treated and untreated teeth, suggesting that interproximal enamel reduction does not raise the risk of caries on treated teeth.

Many patients have a difference in tooth size that can influence treatment goals and outcomes. Freeman et al. [21] found that 30.6% of orthodontic patients had a significant difference in anterior tooth size.

Mesiodistal enamel reduction is performed by either manual or mechanical methods.

Metal strips may be more suitable than discs for rotated teeth. Diamond discs must be used correctly so as not to leave undercuts on the enamel or come into contact with the patient’s soft tissues. When using burs, it is advisable to square the tips so that they do not leave grooves. Burs also tend to produce a rough finish on the enamel surface [12].

A significant difference was noted with the use of stripping bands among practitioners who had a residency program using them more than their university-qualified or privately-trained colleagues. Stripping discs were used significantly more by practitioners with over 10 years’ experience and by dentists with a university degree.

Stripping gauges are used significantly more by experienced orthodontists than by young ones. One might have thought the opposite, that younger practitioners should be more cautious about the amount of stripping, and that only gauges provide an objective assessment of the amount of enamel reduced.

Orthodontists should proceed with caution when considering the disadvantages of IPR.

First, sensitivity could develop following IPR as a result of the reduced enamel. Second, excessive space may result from over stripping brought on by negligent pre-treatment planning. Inadequate planning may also have an impact on overbite, overjet, posterior intercuspation, and appearance. However, because of the grooves that remain on the enamel surface following reduction, it is thought that more plaque is retained [22].

In terms of the risks associated with periodontal diseases, it is acknowledged that IPR won’t increase bone loss in the absence of gingival inflammation. On the other hand, when inflammation was present with nearly approximated roots, bone loss progressed more quickly. IPR is therefore not recommended for patients who have poor oral hygiene.

5. Conclusions

We can conclude that Moroccan orthodontists are well informed about the methods, indications and limitations of stripping in orthodontics.

However, despite this undeniable mastery, a significant discrepancy was observed between local practices and established international standards with regard to the choice of material and techniques for stripping.

We noted differences in protocol and instruments used between the orthodontists included in our sample. Our aim is to ensure safe stripping practice for our patients, while preserving their dental and periodontal health in the long term. This requires a precise and careful approach to minimize the risks associated with this orthodontic technique.

Conflicts of Interest

The authors declare no conflicts of interest.

Conflicts of Interest

The authors declare no conflicts of interest.

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