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Abstract Introduction Metallic and elastomeric ligatures are widely used in orthodontics to secure the archwire within the bracket slots, but elastomeric ligatures have traditionally been associated with increased microbial colonization, which could adversely affect periodontal health. Aim This systematic review compares the periodontal effects of elastomeric and steel ligatures used for orthodontic fixed appliances. Methods Unrestricted literature search of 7 databases (MEDLINE, Scopus, Web of Science, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Virtual Health Library) up to July 2023 were performed for randomized / non-randomized clinical studies on humans comparing the two ligation methods during fixed-appliance therapy. After duplicate study selection, data extraction, and risk-of-bias assessment with the Risk of Bias (RoB) 2 or the Risk Of Bias In Non-randomized Studies - of Interventions (ROBINS-I) tool, random-effects meta-analyses of Mean Differences (MD) or Standardized Mean Differences (SMD) and their 95% confidence intervals (CIs) were carried out, followed by assessment of certainty of existing evidence with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. Results A total of 11 studies (3 randomized / 8 non-randomized) with 354 patients (mean age 14.7 years and 42% male) were included. No statistically significant differences were seen for plaque index (5 studies; SMD = 0.48; 95% CI = -0.03 to 1.00; P = 0.07), gingival index (2 studies; MD = 0.01; 95% CI = -0.14 to 0.16; P = 0.89), probing pocket depth (2 studies; MD = 0; 95% CI = -0.17 to 0.16; P = 0.97), or Streptococcus mutans counts (4 studies; SMD = 0.40; 95% CI=-0.41 to 1.20; P = 0.21). Elastomeric ligatures were associated with moderately increased total bacterial load (3 studies; SMD = 0.43; 95% CI = 0.10 to 0.76; P = 0.03). Confidence in these estimates was low in all instances due to the inclusion of non-randomized studies with high risk of bias. Conclusions Existing low quality evidence indicates that ligature method does not seem to influence the periodontal health during fixed treatment, even if elastomeric ligatures are associated with a moderate increase of bacterial load. Registration PROSPERO (CRD42023444383)

Abstract Background The aim of the present study was to investigate qualitatively and quantitatively the elution of substances from polyester-urethane (Invisalign™) aligners and resin composite attachments (Tetric EvoFlow) in vivo. Methods Patients (n = 11) treated with the aligners and attachments (16 per patient, without other composite restorations) for an average of 20 months, who were planned for attachment removed were enrolled in the study. Patients were instructed to rinse with 50 mL of distilled water upon entry and the rinsing solution was collected (before removal). Then, the attachments were removed with low-speed tungsten carbide burs for adhesive residue removal, a thorough water rinsing was performed immediately after the grinding process to discard grinding particle residues, and subsequently, after a second water-rinsing the solution was collected for analysis (after removal). The rinsing solutions were analyzed for targeted (LC-MS/MS: Bis-GMA, DCDMA, UDMA, BPA) and untargeted (LC-HRMS: screening of leached species and their degradation products) compounds. Results Targeted analysis revealed a significant reduction in BPA after attachment removal (4 times lower). Bis-GMA, DCDMA, UDMA were below the detection limit before removal but were all detectable after removal with Bis-GMA and UDMA at quantifiable levels. Untargeted analysis reviled the presence of mono-methacrylate transformation products of Bis-GMA (Bis-GMA-M1) and UDMA (UDMA-M1), UDMA without methacrylate moieties (UDMA-M2), and 4-(dimethylamino) benzoic acid (DMAB), the degradation product of the photo-initiator ethyl-4-(dimethylamino) benzoate (EDMAB), all after attachment removal. Several amino acids and endogenous metabolites were also found both before and after removal. Conclusions Elevated levels of BPA were traced instantaneously in patients treated with Invisalign™ and flowable resin composite attachments for the testing period. BPA was reduced after attachment removal, but residual monomers and resin degradation products were found after removal. Alternative resin formulations and attachment materials may be utilized to reduce eluents.

Abstract Objectives Three-dimensional (3D) printing technology is an emerging manufacturing process for many orthodontic appliances, and the aim of this study was to evaluate the mechanical properties of resin-based materials as alternatives for the in-house preparation of orthodontic brackets. Material and Methods Two types of 3D printed resins used for temporary (T) and permanent (P) crown fabrication were included in this study. Ten blocks from each resin were manufactured by a 3D printer and, after embedding them in acrylic resin, the samples were subjected to metallographic grinding and polishing, followed by instrumented indentation testing (IIT). Martens hardness (HM), indentation modulus (E IT), and elastic index (η IT) were determined with a Vickers indenter recording force-indentation depth curves from each specimen. After calculating descriptive statistics, differences between material types were investigated with Wilcoxon rank sum test accounting for clustering of measurements within specimens at alpha = 5%. Results No statistically significant differences in the mechanical properties of the two tested materials were seen: HM: median 279 N/mm2 (interquartile range [IQR] 275–287 N/mm2) for T and median 279 N/mm2 (IQR 270–285 N/mm2) for P (P value = 0.63); E IT: median 5548 MPa (IQR 5425–5834 MPa) for T and median 5644 (IQR 5420–5850 MPa) for P (P value = 0.84); η IT: median 47.1% (46.0–47.7%) for T and median 46.0% (IQR 45.4–47.8%) for P (P value = 0.24). Conclusions Under the limitations of this study, it may be concluded that the mechanical properties of the two 3D printed resins tested are equal, and thus, no differences in their clinical performance are expected.

Abstract Objectives Adults with fixed orthodontic appliances are increasing nowadays. Compared with adolescents, adults present biological differences that might influence treatment duration. Therefore, the aim of the study was to compare duration of treatment with fixed appliances between adults and adolescents. Materials and methods Eight databases were searched up to September 2019 for randomized and non-randomized clinical studies comparing treatment duration with fixed appliances in adolescents and adult patients. After duplicate study selection, data extraction, and risk of bias assessment with the Cochrane ROBINS-I tool, random effects meta-analyses of mean differences (MD) and their 95% confidence intervals (CIs) were performed, followed by assessment of the quality of evidence with GRADE. Results A total of 11 unique studies (one prospective and 10 retrospective non-randomized) with 2969 adolescents and 1380 adult patients were finally included. Meta-analysis of 7 studies found no significant difference in the duration of comprehensive treatment with fixed appliances (MD = − 0.8 month; 95% CI = − 4.2 to 2.6 months; P = 0.65; I 2 = 92%) between adults and adolescents. Similarly, both distalization of upper first molars with skeletal anchorage for class II correction and the retraction of canines into the premolar extraction spaces lasted similarly long among adults and adolescents. On the other hand, alignment of palatally displaced canines lasted considerably longer in adults compared to adolescents (1 study; MD = 3.8 months; 95% CI = 1.4 to 6.2 months; P = 0.002). The quality of evidence for the meta-analysis was low due to the inclusion of non-randomized studies with considerable risk of bias. Conclusions While existing evidence does not indicate a difference in the overall duration of treatment with fixed appliances between adults and adolescents, the alignment of palatally displaced canines lasted significantly longer in adults. However, our confidence in these estimates is low due to the risk of bias in the included studies. Trial registration PROSPERO: ( CRD42019148169 )

Abstract Background The aim of the current systematic review was to compare the radiologic effects of functional appliance Class II treatment compared to no treatment on the temporomandibular joint and its components. Methods Nine databases were searched up to June 2019 for randomized or prospective non-randomized clinical trials comparing Class II patients treated with functional appliances to untreated patients. After duplicate study selection, data extraction, and risk of bias assessment with the Cochrane tool and the ROBINS-I tool, random effects meta-analyses of mean differences (MDs) and their 95% confidence intervals (CIs) were performed, followed by the assessment of the quality of evidence with GRADE. Results A total of 11 papers on 8 unique trials with 377 patients (39.8% male; average age 10.3 years) were finally included. Limited evidence indicated that compared to untreated growing patients functional appliance treatment was associated with increased condylar width (2 studies; MD 1.1 mm; 95% CI 0.1 to 2.2 mm; very low evidence quality), decreased anterior joint space (2 studies; MD − 0.7 mm; 95% CI − 0.5 to − 0.9 mm; very low evidence quality), increased superior joint space (2 studies; MD 0.7 mm; 95% CI 0.5 to 1.0 mm; very low evidence quality), increased posterior joint space (2 studies; MD 1.0 mm; 95% CI 0.9 to 1.2 mm; very low evidence quality), and vertical displacement of the glenoid fossa (2 studies; MD 0.4 mm; 95% CI 0.1 to 0.7 mm; very low evidence quality). The main limitations affecting the validity of the present findings were the inclusion of non-randomized studies with methodological issues, imprecision due to limited samples of the included studies, and inconsistencies among studies. Conclusions Currently existing evidence from controlled clinical studies on humans indicates that functional appliance treatment is associated with positional and skeletal alterations of the temporomandibular joint in the short term compared to untreated controls. However, the clinical relevance of these changes remains unclear, while the quality of existing evidence is low due to methodological issues of existing studies. Review registration PROSPERO, CRD42018109271

Abstract Background The aim of the current systematic review was to compare the clinical effects of bone-borne or hybrid tooth-bone-borne rapid maxillary expansion (RME) with conventional tooth-borne RME in the treatment of maxillary deficiency. Methods Nine databases were searched up to September 2018 for randomized clinical trials comparing bone-borne or hybrid tooth-bone-borne RME to conventional tooth-borne RME in patients of any age or sex. After duplicate study selection, data extraction, and risk of bias assessment with the Cochrane tool, random effects meta-analyses of mean differences (MD) and their 95% confidence intervals (CIs) were performed, followed by assessment of the quality of evidence with GRADE. Results A total of 12 papers on 6 unique trials with 264 patients (42.4% male; average age 12.3 years) were finally included. Limited evidence indicated that bone-borne RME was associated with greater suture opening at the first molar post-retention (1 trial; MD 2.0 mm; 95% CI 1.4 to 2.6 mm; moderate evidence quality) compared to tooth-borne RME, while no significant differences could be found regarding tooth inclination, nasal cavity width, and root resorption (very low to low evidence quality). Hybrid tooth-bone-borne RME was associated with less buccal tipping of the first premolar (2 trials; MD − 4.0°; 95% CI − 0.9 to − 7.1°; moderate evidence quality) and lower nasal airway resistance post-retention (1 trial; MD − 0.2 Pa s/cm3; 95% CI − 0.4 to 0 Pa s/cm3; moderate evidence quality) compared to tooth-borne RME, while no significant difference could be found regarding skeletal maxillary width, molar inclination, and analgesic use (low to moderate evidence quality). The main limitations affecting the validity of the present findings were (a) imprecision due to the inclusion of few trials with limited sample sizes that precluded robust detection of existing differences and (b) methodological issues of the included trials that could lead to bias. Conclusions Limited evidence from randomized trials indicates that bone-borne or hybrid tooth-bone-borne RME might present advantages in terms of increased sutural opening, reduced tooth tipping, and lower nasal airway resistance compared to conventional tooth-borne RME. However, the limited number of existing studies and issues in their conduct or reporting preclude the drawing of definite conclusions. Review registration PROSPERO (CRD42017079107).

Abstract Background Fixed orthodontic appliances might be associated with intraoral adverse effects on enamel, due to plaque accumulation and their colonization by oral microbes. At the same time, the demand for esthetic alternatives to orthodontic treatment, like thermoplastic aligners, is growing. However, thermoplastic aligners may behave differently intraorally than fixed appliances in terms of bacterial colonization and biofilm formation. Therefore, the aim of this prospective cohort study was to assess the salivary prevalence of the cariogenic bacteria Streptococcus mutans, Lactobacillus acidophilus, and Streptococcus sanguinis among adolescents treated orthodontically with thermoplastic aligners or fixed appliances. Methods Thirty adolescent patients (17 girls/13 boys; mean age 13.8 years old) were assigned to treatment with either (i) self-ligating fixed appliances with nickel-titanium archwires or (ii) aligners constructed from clear transparent polyethylenterephthalat-glycol copolyester (PET-G) thermoplastic sheets. Whole stimulated saliva was collected from each patient at three time points: at baseline (before bonding and initiation of orthodontic therapy or before insertion of the thermoplastic aligners), after 2 weeks, and after 1 month. A simplified plaque index, a simplified gingival index, and the decayed, missing, and filled teeth (DMFT) index were assessed from the clinical examination of the patients. Microbiological analysis of salivary bacteria was performed by quantitative polymerase chain reaction, followed by descriptive and inferential statistics at the 5% level. Results Although patients treated with aligners had significantly lower plaque and gingivitis scores throughout treatment compared to patients treated with fixed appliances, no significant difference could be found between the S. mutans counts of the two groups at any time through treatment (P > 0.05). On the other hand, patients treated with aligners had significantly lower salivary S. sanguinis counts at all time points than patients treated with fixed appliances (P

Abstract Background The purpose of the study is to investigate the effect of the bonding procedure on the mechanical properties of human enamel. Methods A total of 20 extracted human premolars were included in this study, with the half of each tooth acting as its own internal control. Embedded and horizontally cut specimens were prepared, and two bucco-orally zones were separated. The first enamel zone of each tooth remained untreated. The opposing zone was subjected to simulated bonding and debonding, including etching with 37% phosphoric acid, bonding with primer and flowable composite resin, and subsequent removal of the composite with an adhesive removal bur. The properties tested were (a) elemental composition by energy-dispersive X-ray analysis, (b) mechanical properties of specimens by instrumented indentation testing (Martens hardness, elastic modulus, and elastic index), (c) enamel morphology by low-vacuum scanning electron microscopy, and (d) molecular composition by Raman microspectroscopy. Statistical analysis was performed by one-way mixed-effects analysis of variance at a = 0.05. Results No significant differences could be found in the mechanical properties (Martens hardness, elastic modulus, and elastic index) and elemental composition of intact and treated enamel, with the possible exception of Si traces, which were found only in the latter. Raman analysis revealed no differences between the two surface states while shallow grooves and parallel lines were found on the surface of treated enamel by SEM analysis. Conclusions Under the limitations of the conditions of the study, there were no mechanical properties’ alterations on enamel subjected to orthodontic bonding.

Abstract Background Torque of the maxillary incisors is crucial to occlusal relationship and esthetics and can be influenced by many factors. The aim of this study was to assess the relative influence of the material of the orthodontic appliance (adhesive, bracket, ligature, and wire) on tooth displacements and developed stresses/strains after torque application. Methods A three-dimensional upper right central incisor with its periodontal ligament (PDL) and alveolus was modeled. A 0.018-in. slot discovery® (Dentaurum, Ispringen, Germany) bracket with a rectangular 0.018 x 0.025-in. wire was generated. The orthodontic appliance varied in the material of its components: adhesive (composite resin or resin-modified glass ionomer cement), bracket (titanium, steel, or ceramic), wire (beta-titanium or steel), and ligature (elastomeric or steel). A total of 24 models were generated, and a palatal root torque of 5° was applied. Afterwards, crown and apex displacement, strains in the PDL, and stresses in the bracket were calculated and analyzed. Results The labial crown displacement and the palatal root displacement of the tooth were mainly influenced by the material of the wire (up to 150% variation), followed by the material of the bracket (up to 19% variation). The magnitude of strains developed in the PDL was primarily influenced by the material of the wire (up to 127% variation), followed by the material of the bracket (up to 30% variation) and the ligature (up to 13% variation). Finally, stresses developed at the bracket were mainly influenced by the material of the wire (up to 118% variation) and the bracket (up to 59% variation). Conclusions The material properties of the orthodontic appliance and all its components should be considered during torque application. However, these in silico results need to be validated in vivo before they can be clinically extrapolated.

Abstract Background The aim of this study was to compare the torque efficacy of square and rectangular wires in 0.018- and 0.022-in. conventionally ligated brackets. Methods Brackets of the same prescription were evaluated in both slot dimensions. Identical acrylic resin models of the maxilla were bonded with the brackets and mounted on the Orthodontic Measurement and Simulation System. Ten 0.018 × 0.018 in., 0.018 × 0.022 in., and 0.018 × 0.025 in. stainless steel wires were evaluated in the 0.018-in. brackets and ten 0.019 × 0.019 in., 0.019 × 0.025 in., and 0.019 × 0.026 in. stainless steel wires were evaluated in the 0.022-in. brackets. A 15° buccal root torque was gradually applied to the right central incisor bracket, and the moments were recorded at this position. One-way ANOVA was applied for both bracket slot sizes along with post hoc analysis for the various archwire sizes. Results The mean measured moments varied between 10.78 and 30.60 Nmm among the assessed wire-and-bracket combinations. Both square and rectangular archwires in the 0.018-in. bracket system exerted statistically significantly higher moments in comparison with their counterparts in the 0.022-in. bracket system. Rectangular archwires exerted statistically significantly higher moments than square archwires, both for the 0.018- and the 0.022-in. bracket system. Conclusions Rectangular archwires seem to be more efficient in torque exertion, especially in 0.018-in. brackets.