Scanning electron microscope

A SCANNING ELECTRON MICROSCOPE
COMPARISON OF
RE-PROXIMATED ENAMEL SURFACES
AFTER VARIOUS
STRIPPING AND POLISHING METHODS
- AN IN VITRO STUDY
www.indiandentalacademy.comwww.indiandentalacademy.com

INTRODUCTION
Indications
Correction of tooth-shape deviations
Eliminate tooth size discrepancies
(Bolton discrepancy problems).
Gain space for correction of moderate
crowding.
Eliminates the need for lower
retention.

Various methods
Hand-held or motor-driven abrasive
strips - creates patient discomfort and
the risk of cutting gingival tissue
Hand piece-mounted abrasive discs
-tissue injury and inadequate
contouring
Air-rotor stripping

Air-rotor stripping in this study is done
with:
Tungsten carbide
16-bladed TC bur (Sheridan)
8-bladed TC bur (paicentini)
Diamond burs
Surface characteristics of the stripped
enamel surface is compared with SEM

Stripping procedures removes caries-
resistant, fluoride-rich layer of surface
enamel
Protection of stripped surface can be done
by
Finishing the cut enamel with different
grades of polishing disc or burs
Sealant application
Fluoride varnishes or rinses.

Polishing after enamel stripping can be done
using
Carbide finishing burs
Hand held diamond coated finishing strips
Fine garnet discs
Sof-Lex discs and
Extra fine and ultra fine diamond burs.
Sof-Lex discs and diamond burs were used
in our study to compare the surface
characteristics of the stripped and polished
enamel. www.indiandentalacademy.comwww.indiandentalacademy.com

The sealants ideally suited for proximal
stripped surfaces are the pit and fissure
sealants
In this study resin-based light-cured
sealant is used for sealing proximally
stripped etched and non-etched
surfaces and the sealed surface is
compared with stripped and polished,
and unaltered enamel

Part I – Stripping procedures
To study and compare the surface
characteristics of the stripped enamel
produced by 16-Bladed TC bur, 8-bladed
TC bur and coarse diamond burs using
SEM.
AIMS AND OBJECTIVES

Part II – Polishing procedures
characteristics of stripped enamel by 16-
bladed, 8-bladed and coarse diamond
burs followed by polishing with fine
diamond burs using SEM.
characteristics of stripped enamel by 16-
bladed and coarse diamond burs followed
by polishing with Sof-Lex discs using
SEM. www.indiandentalacademy.comwww.indiandentalacademy.com

characteristics of stripped and polished
enamel between Sof-Lex discs and fine
diamond burs using SEM.
The objective of the part II of the study
is to compare the various polishing
methods and identify the method,
which is most efficient.

Part III – Sealing procedures
To study and compare using SEM the
enamel sealant bond between etched and
non etched stripped surfaces, produced by
16-balded TC burs, 8-Bladed TC burs or
coarse diamond bur and sealed.
To study and compare using SEM the
smoothness between the sealed surfaces,
stripped and polished surfaces by various
methods and unaltered enamel.

Thus, this study is primarily aimed to
suggest the appropriate procedure of
stripping, polishing or sealing that
produces an ideal and smooth enamel
surface.

REVIEW OF LITRATURE
Pus M.D et al (1980) in a study
demonstrated that diamond instruments
were unacceptable for enamel stripping.
Even fine diamond burs according to them
produce coarse scratches and gave a
deeply marred surface.
John J. Sheridan (1985) introduced a
stripping technique called the "ARS
technique“. Enamel removal is
accomplishing by means of a 16-blade
tungsten carbide bur (699 L).
Proximal stripping

John J. Sheridan (1987) presented a
revision of his technique introducing some
modifications like aligning of the dental
elements and opening the interproximal
area before stripping
John J. Sheridan et al (1989) applied
sealants to the stripped surfaces and
concluded that the use of ARS and sealant
helps the patient by preventing
interproximal decay and is advantageous
to the clinician in saving chair side time
needed to finish stripped surfaces.www.indiandentalacademy.comwww.indiandentalacademy.com

Cesare Piacentini, and Giuseppa Sfondrini
(1996) have done an SEM study to
compare the different polishing methods
and to assess the efficiency of them. They
concluded that the use of 8-straight blade
tungsten carbide bur followed by Sof-Lex
disks for polishing the enamel, obtains
well-polished surfaces that many times
appear smoother than the intact or
untreated enamel.

Bravo M. et al (1996) have done a study
where comparison was carried out to assess
the effectiveness of visible light cure fluoride
sealant Vs fluoride varnish in a 24 month
clinical trial. The percent effectiveness was
greater in sealed molars than in varnished
molars.
Rossouw PE et al (2003) have done a study
with the use of various combinations of
mechanical and chemical techniques for
enamel reduction and concluded that acid
stripping in conjunction with mechanical
procedures produced especially smooth
enamel surfaces.

Brudevold, F.; Tehrani, A; Bakhos, Y. (1982)
reported that smooth surface enamel
abrasion initially causes rapid
demineralization followed by
remineralization.
Radlanski et al (1988) reported on the inter-
proximal surface of human teeth that
underwent stripping with coarse and fine
diamond burs, followed by fine and ultra-fine
finishing strips at SEM level and concluded
that based on scanning electron
micrographs, presumed a possible carious
effect of ARS.
Cariogenic implications

Radlanski et al (1989) have done a follow-up
study where the observation period includes
two to three years after treatment during
which stripping was performed without
further polishing and concluded that "Even
though plaque accumulation would be
expected, the SEM analysis revealed no
incidence of caries in the artificially produced
furrows”.
Crain and Sheridan (1990) and El-Mangoury
et al (1991) have done investigations on
posterior air-rotor stripping and concluded
that "Posterior interproximal enamel
reduction does not appear to expose the
enamel to pathological changes that could
lead to caries, but to a period of
demineralization, followed by
remineralization."

Hanachi, F (1992) working with iodide ion
penetration technology, concluded that
stripped enamel surfaces have more
potential for remineralization (hardening)
than unaltered controls.
David A. Twesme et al. (1994) have done a
study to evaluate the effects of air-rotor
stripping on the susceptibility of human
enamel to demineralization using an in
vitro caries model. Their results suggest
that air-rotor stripping significantly
increases the susceptibility of proximal
enamel surfaces to demineralization. As a
result, the clinician should use caution in
the application of this technique until the
long-term effects on caries susceptibility

MATERIALS AND METHODS
58 healthy human upper permanent
premolars
Stored in 70% ethanol

Mounted in typhodonts in a well-aligned
arch setup
Air-rotor pressure -- 1.8 to 2.2 Kg/cm²www.indiandentalacademy.comwww.indiandentalacademy.com

Procedure of Air rotor stripping

PART I - STRIPPING
Group Number
of
teeth
Stripping
Group I 4 16- Blade Tungsten carbide
bur (Komet H 23L)
Group II 4 8-Straight blade tungsten
carbide bur (Komet H 135)
Group III 4 Coarse diamond bur (Komet
859)

8 – TC BUR
COARSE
DIAMOND BUR
16 – TC BUR

Polishing

PART II - POLISHING
Group Numb
er of
teeth
Initial
stripping
Finishing or
polishing
Group
IV
8 16 – TC
Coarse
diamond
Extra fine (komet
862EF) and ultra fine
(komet 862UF) flame
shaped diamond burs.
Group
V
12 16 – TC
8 – TC
Coarse
diamond
Medium, fine and
superfine 3M Sof–
Lex disks

ULTRA-FINE
DIAMOND
EXTRA-FINE
DIAMOND
BUR
SOF-LEX
DISCS
POLISHING DEVICES

Sealant
Ecthing – 20 seconds
Sealant – 20 seconds

16 - TC16 - TC
PART III
Group Numb
er of
teeth
Initial
stripping
Pit and fissure
fluoride releasing
light cure
(Embrace)
Part III
WE
Group VI
12 8 – TC
Coarse
diamond
Sealant without
etching
Part III E
Group VII
12 8 – TC
Coarse
diamond
Sealant with
etching

SEM examination
Dehydration
25 per cent ethanol, 10 min.
100 per cent ethanol, 3 X 5 min.

HOT AIR OVEN --
50˚c for 10 min
Specimen mounting
Platinum coater

DISPLAY UNIT
SCANNING ELECTRON
MICROSCOPE

Observations
Part I
Stripping with 16- bladed tungsten carbide bur
16 -TC 16 -TC 16 -TC
16 -TC 16 -TC 16 -TC
Furrows are irregular and uniformly distributed
on the stripped enamel surface ( waterfall on glass
appearance).

8-TC 8-TC8-TC
8-TC 8-TC8-TC
Enamel surface appears finely rough. Grooves or
furrows cannot be seen.

COARSE
DIAMOND
COARSE
DIAMOND
COARSE
DIAMOND
COARSE
DIAMOND
COARSE
DIAMOND
COARSE
DIAMOND
Stripping with Coarse diamond bur
Deep and irregular furrows are seen that forms
hills and valleys (blizzard appearance).www.indiandentalacademy.comwww.indiandentalacademy.com

16-TC 8-TC COARSE
DIAMOND
16-TC 8-TC COARSE
DIAMOND
Comparison after stripping with 16- bladed
tungsten carbide bur, 8- bladed tungsten carbide
bur and coarse diamond bur.
8- TC bur is finely rough but smoother when
compared 16 – TC and coarse diamond bur

16-TC + Diamond 16-TC + Diamond 16-TC + Diamond
16-TC + Diamond16-TC + Diamond 16-TC + Diamond
Part II
and polishing with extra-fine and ultra-fine
diamond burs.
Furrows are seen crossing the surface at
different depths.

16-TC + Sof Lex
16-TC + Sof Lex
16-TC + Sof Lex
16-TC + Sof Lex
16-TC + Sof Lex
16-TC + Sof Lex
Stripping with 16- TC and polishing with medium,
fine and super-fine Sof-Lex discs.
Finely rough surface where the furrows left by the
first bur (16- bladed TC bur) are still visiblewww.indiandentalacademy.comwww.indiandentalacademy.com

8-TC + Sof Lex 8-TC + Sof Lex
8-TC + Sof Lex8-TC + Sof Lex
8-TC + Sof Lex
8-TC + Sof Lex
Stripping with 8- and polishing with medium, fine
and super fine Sof-Lex discs
Fine furrowing alternating with well polished areaswww.indiandentalacademy.comwww.indiandentalacademy.com

Coarse diamond
+ diamond
Coarse diamond
+ diamond
Coarse diamond
+ diamond
Coarse diamond
+ diamond
Coarse diamond
+ diamond
Coarse diamond
+ diamond
Stripping with coarse diamond bur and polished
with extra-fine and ultra-fine diamond burs.
Deep furrows are seenwww.indiandentalacademy.comwww.indiandentalacademy.com

Coarse diamond + Sof LexCoarse diamond + Sof Lex Coarse diamond + Sof Lex
Coarse diamond + Sof Lex Coarse diamond + Sof LexCoarse diamond + Sof Lex
Stripping with coarse diamond bur and polished
with medium, fine and super-fine Sof-Lex disks.
Deep furrows crossing the polished enamel surface.www.indiandentalacademy.comwww.indiandentalacademy.com

16 -TC 16-TC + Diamond 16-TC + Sof Lex
16 -TC 16-TC + Diamond 16-TC + Sof Lex
Comparison of enamel surface stripped with 16-
TC, and polished with fine diamond or Sof-Lex
discs.
Furrows formed with 16 – TC are left even after
polishing. When compared Sof-Lex discs are more
efficient than fine diamond burs.

8-TC
8-TC 8-TC + Sof Lex
8-TC + Sof Lex
Comparison of enamel surface stripped with 8-
TC and polishing by means of medium, fine and
ultra-fine 3M Sof-Lex discs.
The enamel surface appears crossed by fine
furrowing alternating with well polished areas.

Coarse diamond
+ diamond
Coarse diamond
+ Sof Lex
COARSE DIAMOND
COARSE DIAMOND
Coarse diamond
+ diamond
Coarse diamond
+ Sof Lex
Fig 12
Comparison of enamel surface stripped by coarse
diamond bur, and polished with fine diamond or
Sof-Lex discs.
Deep and irregular furrows formed as a result of
stripping with the initial bur (coarse diamond
bur) are only slightly reduced

16-TC + Diamond 16-TC + Sof Lex 8-TC + Sof Lex Coarse diamond
+ diamond
Coarse diamond
+ Sof Lex
16-TC + Diamond 16-TC + Sof Lex 8-TC + Sof Lex Coarse diamond
+ diamond
Coarse diamond
+ Sof Lex
Stripping produced by 8- bladed tungsten carbide
bur and polishing by Sof-Lex discs produces
surface which is well polished when compared to
other methods

16 - TC
16 - TC
16 - TC16 - TC
16 - TC 16 - TC
E
S
EEE
EE S
S
S
S
S
S
PART III
Enamel sealant interface after stripping with 16-
bladed tungsten carbide bur and sealant
application without acid etching.
Sealant did not adhere to the stripped proximal
enamel surface

8 - TC
8 - TC
8 - TC
8 - TC 8 - TC
8 - TC
E S
EE E
EE
S
S
S
S
S
bladed tungsten carbide bur and sealant
application without acid etching.
enamel surface

Coarse diamond Coarse diamond
Coarse diamondCoarse diamond
Coarse diamond
Coarse diamond
E E E
E E
E
S S S
S S
S
Enamel sealant interface after stripping with
Coarse diamond bur and sealant application
without acid etching.
enamel surface

16 - TC 8 - TC Coarse diamond
16 - TC 8 - TC Coarse diamond
SSS
S
S
S
E E E
E E E
Comparison of the enamel sealant bond between
enamel surfaces stripped by various burs and
sealed without acid etching.
Sealant did not adhere to the proximal enamel
of surfaces that were not etched, regardless of
the type of bur used for initial stripping.

16 - TC
16 - TC
16 - TC
16 - TC 16 - TC
16 - TC
E E E
E E E
S
S
SS
S
S
Tungsten carbide bur and sealant application
after acid etching of the stripped surface.
Sealant has adhered to the stripped proximal
enamel surface

8 - TC8 - TC
8 - TC 8 - TC 8 - TC
8 - TC
E
EEE
EE
S
S
S
S
S
S
Tungsten carbide bur and sealant application
after acid etching of the stripped surface.
enamel surface

Coarse diamond
Coarse diamond
Coarse diamondCoarse diamond
Coarse diamond Coarse diamond
E
EE
EE
E
S SS
S S
S
Enamel sealant interface after stripping with
coarse diamond bur and sealant application after
acid etching of the stripped surface.
enamel surface

16 - TC 8 - TC Coarse diamond Unaltered enamel
16 - TC 8 - TC Coarse diamond Unaltered enamel
E
E
EE
E
E
E
E
S
SSS
SSS
S
Comparison of enamel sealant bond between
stripped surfaces sealed with acid etching and
unaltered enamel surface sealed with acid etching
Sealant resins applied to mechanically
roughened surfaces produce adhesive patterns
similar to that observed between unaltered
enamel and the sealant.

Sealant surface
Sealant surface
8-TC + Sof Lex Unaltered enamel
8-TC + Sof Lex Unaltered enamel
Comparison of the surface of the sealed proximal
surface after stripping with that of the smoothest
enamel surface produced after stripping and
polishing and unaltered enamel
Both the polished surface and sealed surfaces are
as smooth as unaltered enamel

Discussion
The disadvantageous effect of stripping is that
it is not possible to produce an enamel surface
free of furrows, which are 10 to 25 µm in depth.
To prevent inter-dental caries the stripped
enamel surface must be smooth without any
grooves. This can be achieved by either
polishing the stripped surface or by applying
sealant over the stripped surface. Thus, an in-
vitro Scanning electron microscopic evaluation
of the stripped, stripped and polished, and
stripped and sealed surface was conducted to
study the enamel surface.

In Part I of this study the surface characteristics
of the enamel surfaces stripped with 16-bladed
tungsten carbide bur, 8-bladed tungsten carbide
bur and coarse diamond bur are compared.
It is seen that the surface produced by 8- bladed
tungsten carbide bur is smoother as the surface
it produces is only a finely rough, as compared to
the surfaces produced by 16 – bladed tungsten
carbide bur. The difference in smoothness
encountered in the present study could be
attributed to the design and configuration
between 8 and 16 bladed TC burs. The diamond
bur showed the roughest surface with deep
grooves and furrows.www.indiandentalacademy.comwww.indiandentalacademy.com

Due to ready availability and popularity of Sof-Lex
discs and diamond burs we incorporated them in
Part II of our study to compare the surface
characteristics of stripped and polished enamel. 8-
bladed tungsten carbide bur is itself a finishing
bur and hence the surfaces stripped with this bur
are polished only with Sof-Lex discs and diamond
polishing burs were not used.
It can be observed that stripping with 8- bladed
tungsten carbide bur and polishing by Sof-Lex
disks produces surface which is well polished
when compared to other polishing methods. The
use of 8-TC bur for initial stripping allowed a very
precise first stripping and left only surface
roughness with very fine furrows. This was easily
removed with the use of Sof-Lex discs.

In Part III of the study comparison of the enamel
sealant bond between etched and non-etched
stripped and sealed surfaces are compared.
Comparison is also done for surface smoothness
between sealed, polished and unaltered enamel.
It is observed that the mechanically roughened
surfaces do not have sufficient retentive capacity to
make etching unnecessary. When SEM
photomicrographs of surfaces of the best-polished
enamel in Part II of the study (8- bladed TC
followed by polishing with Sof-Lex discs) is
compared with unaltered and sealant surfaces it
could be observed that both the polished and
sealed surfaces were as smooth as the unaltered
enamel.

There are two ways to protect the stripped
surface. One is by stripping with an instrument,
which produces minimal grooves and surface
roughness, so that on polishing these can be
removed.
The best results were obtained with a method
using 8-straight blade tungsten carbide bur for
first stripping followed by polishing with medium,
fine and super-fine Sof-Lex discs. The advantage
of this procedure was that a permanently
polished surface, which is as good as unaltered
enamel, could be achieved without adding sealant
to the armamentarium.www.indiandentalacademy.comwww.indiandentalacademy.com

The second technique was to apply a sealant after
etching. It was advantageous to the clinician in the
sense that chair-side time could be saved which
was needed to finish stripped surfaces with a
series of abrasives. The technique is faster but
raises questions as how long the sealant lasts and
what condition the enamel would be in once the
sealant has dissipated. Improper application of the
sealant (applied as a bulky layer instead of a thin
layer) leads to plaque accumulation, pocket
formation in the undercut formed after closure of
the stripped space and limits the space available
for decrowding.

The study can be further improved by
evaluating the procedure in an in-vivo
situation. Long term studies on the
caries susceptibility, fluoride uptake,
and efficacy of the sealant can provide
an insight into the benefits and ill
effects of proximal stripping.

Summary and conclusion
The SEM photomicrographs are observed and the
following conclusions were drawn in each part of
this study:
The surfaces produced by stripping with TC
burs are smoother than those produced by the
use of coarse diamond burs. Within the TC burs
8-TC bur produces a smoother surface compared
to 16-TC burs.
Sof-Lex discs are more efficient than fine
diamond burs in polishing the stripped enamel
surface and, the surfaces polished with Sof-Lex
discs after initial stripping with 8-TC bur are
found to have a surface smoothness equal to that
of unaltered enamel.www.indiandentalacademy.comwww.indiandentalacademy.com

Mechanically roughened surfaces do not have
sufficient retentive capacity to make etching un-
necessary. Sealed proximal surfaces were as
smooth as unaltered enamel.
We infer from this study that best results
would be obtained if initial stripping is done with
8-TC bur, followed by polishing with medium, fine
and super-fine Sof-Lex discs. The other choice is
to strip the enamel surface by TC or diamond bur
followed by sealant application. If diamond burs
are used for stripping due to non-availability of TC
burs then a smooth surface can be obtained if a
pit and fissure sealant is used for sealing after
etching of the stripped surface. Both the above
techniques produce surfaces that are comparable
to unaltered enamel.

In conclusion, given the current
emphasis on non-extraction treatment
in orthodontics today, stripping is a
technique that can increase space but
must be performed with the best
possible finishing of the inter-proximal
enamel surface and meets the biological
requirements of the oral cavity.

THANK YOU

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