Impact of Clear Aligners on Oral Health and Oral Microbiome During Orthodontic Treatment

Comprehensive Analysis of Orthodontic Treatment Effects on the Oral Microbiome, Metabolome, and Associated Health Indicators

INTRODUCTION AND AIMS

Effects of orthodontic treatments on oral health, particularly on the microbiome and metabolome, are not well understood, and this study aims to clarify these influences using multi-omics approaches.

METHODS

We used 16SrRNA sequencing to analyze oral microbiota and untargeted metabolomics for metabolic profiling, comparing clear aligners (CAs) and fixed appliances (FAs) in healthy and unhealthy oral environments.

RESULTS

We found CAs significantly improve oral health markers-including reduced plaque accumulation, enamel demineralization, microbiome alpha diversity, and microbial heterogeneity, especially in unhealthy oral environments. Orthodontic treatment type and overall oral health status significantly altered the oral microbiota structure and metabolite composition. Notably, the effect of orthodontic methods was more pronounced on metabolome than on microbiome. There's a strong link between changes in oral microbiome, health status, and hygiene habits. For example, Prevotella and Treponema were linked to poor oral health indicators, whereas Rothia, Granulicatella, and Streptococcus were associated with good oral hygiene indicators. Machine learning analysis identified 13 key metabolites, including cholylarginine, alpha-CEHC glucuronide, 2-hydroxypentanoic acid, Cer (d17:1/6 keto-PGF1alpha), and LysoPE (15:0/0:0), which were associated with inflammatory responses and served as predictive markers for poor oral health. These metabolites were closely correlated with specific microbial species enriched in oral environment, including Rothia, Prevotella, and Anaeroglobus, suggesting their potential as biomarkers for oral health monitoring. KEGG enrichment revealed differential metabolites were significantly enriched in alkaloid biosynthesis pathways, particularly map01064, which is crucial for polyamine synthesis related to bacterial activities.

CONCLUSION

CAs significantly improve oral health markers, particularly affecting the metabolome more than the microbiome, with key metabolites and microbial species serving as potential biomarkers for oral health monitoring.

CLINICAL RELEVANCE

This study provides comprehensive insights into interactions among orthodontic treatments, oral health status, microbial, and metabolic dynamics, offering foundation for developing personalized strategies in oral health management and orthodontic care.

Aligners as a Therapeutic Approach in Impacted Canine Treatment: A Systematic Review

Background/Objectives: The growing demand for esthetic, less painful, and more comfortable orthodontic treatment has led to increasing use of aligner systems. Initially used for less complicated malocclusions, aligners are now being incorporated into complex treatment plans, including cases involving impacted teeth. While aligners are a popular alternative to traditional fixed appliances, they still have limitations. This study aims to evaluate the effectiveness of aligner-based orthodontic treatment in patients with impacted or significantly ectopic canines. Methods: This study was conducted in accordance with the PRISMA guidelines. The search terms used were as follows: 'Clear Aligner' OR 'Invisalign' AND 'Impacted Canine' OR 'Impacted Tooth' OR 'Ectopic Tooth' OR 'Ectopic Canine.' A total of 1101 records were identified, of which 170 articles underwent screening. Fifteen articles were assessed for eligibility, and ultimately six case reports and one three-dimensional finite element analysis (FEA) study were included for both quantitative and qualitative synthesis. Results: According to the studies, additional appliances are often required to achieve favorable outcomes when treating impacted canines with aligner systems. Temporary anchorage devices (TADs) were used in 5 out of 9 reported cases for canine traction into the dental arch. In three cases, TADs were combined with sectional wires implemented as cantilevers. Elastics were used in 6 out of 9 cases for traction to the opposite arch, and in 5 out of 9 cases as interarch elastics attached to the aligners. Interarch elastics were applied in various ways, either directly to the aligners or to primary canines using hidden buttons inside pontics or dovetail hooks. Elastics were also anchored to the lower arch with class II, class III, or cross-arch (criss-cross) mechanics. Conclusions: This review highlights the promising potential of aligner systems in the treatment of impacted canines. However, additional auxiliaries, such as TADs, sectional wires, or elastics remain nearly essential for initial canine traction. Aligner systems offer versatile treatment options, and the possibility of reduced treatment time represents a valuable area for future research.

Changes in subgingival microflora in patients with fixed orthodontic appliances

INTRODUCTION

Fixed orthodontic therapy is often accompanied by accumulation of plaque around the orthodontic brackets, which increases the number of periodontopathogenic bacteria.

OBJECTIVE

The objective of this study was to determine the changes in the subgingival microflora that occurred six months after the placement of a fixed orthodontic appliance.

METHODS

The study included 30 patients aged 13 to 35 years, in whom samples of subgingival plaque were taken before and six months after the start of fixed orthodontic therapy from the disto-buccal subgingival space of the left upper (U1) and lower central incisors (L1), mesio-buccal subgingival space of left upper (U6) and lower (L6) first molars. Material samples were tested for the presence of the following bacteria: Tannarela forsythia, Treponema denticola, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Prevotella intermedia, Prevotella nigrescens and Eikenella corrodens, using the PCR method.

RESULTS

A significant increase of patients with presence of bacteria especially in the molar region was found: Tannarela forsythia (U6 T1 10%-T2 80%, L6 T1 16.67%-T2 80%), Porphyromonas gingivalis (U6 T1 60%-T2 90%, L6 T1 60%-T2 83.33%), Prevotella intermedia (U6 T1 23.33%-T2 73.33%, L6 T1 26.67%-T2 76.67%), Prevotella nigrescens (U6 T1 16.67%-T2 63.33%, L6 T1 23.33%-T2 73.33%) and Eikenella corrodens (U6 T1 26.67%-T2 63.33%, L6 T1 23.33%-T2 73.33%) six months after the placement of the fixed orthodontic appliance.

CONCLUSION

In the initial phase of fixed orthodontic therapy, an increase in the number of patients with periodontopathogenic bacteria Tannarela forsythia, Treponema denticola, Porphyromonas gingivalis, Prevotella intermedia, Prevotella nigrescens and Eikenella corrodens was observed.

Exploring the impact of orthodontic appliances on the oral microbiome and inflammatory parameters

BACKGROUND

The symbiotic relationship between the oral microbiome and the host immune system is a prerequisite of oral health. Disruptions to this system can be associated with the development of diseases like dental caries. Introducing orthodontic treatments, such as aligners and fixed appliances, might impact this microbial ecosystem. This study evaluated potential changes in salivary microbiome and the level of inflammatory marker myeloid-related protein 8/14 in patients undergoing orthodontic treatment with aligners or fixed appliances.

METHODS

Forty-eight patients were divided into two groups for treatment with fixed appliances or clear aligners. Unstimulated saliva samples were collected at baseline, three, and six months for microbiome analysis via 16 S rRNA sequencing and MRP-8/14 level measurement using ELISA.

RESULTS

Among 503 identified microbial species, no significant changes were noted in overall microbiome. A considerable increase of caries-relevant species could not be observed either. MRP-8/14 levels remained unchanged across treatments, indicating no alterations in the inflammatory level.

CONCLUSION

Orthodontic treatment with fixed or removable appliances does not significantly alter the salivary microbiome or influence inflammation, suggesting that these interventions are unlikely to affect oral health negatively.

Protraction of a mandibular second molar into the adjacent atrophic first-molar extraction site with ridge-split technique through clear aligners: A case report

This case report describes the successful orthodontic management of a 25-year-old female patient presenting with Class II Division 2 malocclusion, moderate maxillary anterior crowding, and a missing mandibular left first molar. Treatment plan involved extraction of two maxillary first premolars to address crowding and protraction of two mandibular left molars, combined with the strategic use of mini-implants for precise tooth movement control. Ridge-split surgery was adopted to manage alveolar ridge resorption in the edentulous area. This procedure was essential for widening the narrow alveolar ridge, thereby reducing resistance and facilitating the mesial movement of two mandibular left molars. Lingual and labial biomechanics, including linguoincisal elastics and a cantilever system, were utilized to optimize torque control and molar protraction. Clear aligners were employed throughout the treatment phases, navigating challenges such as the closure of extraction spaces and achieving stable buccal interdigitation. The treatment spanned 4 years, using a total of 175 aligners. The initial phase required 66 aligners to close maxillary extraction spaces and the mandibular edentulous space, followed by 52 aligners in the first refinement and 57 aligners in the second refinement phase. Posttreatment evaluations demonstrated successful alignment of dental arches, correction of malocclusion, and enhancement of facial aesthetics. This case highlights the efficacy of integrated orthodontic techniques in achieving comprehensive functional and aesthetic outcomes in complex orthodontic cases.

The Use of Clear Aligners for Orthognathic Surgery: A Systematic Review

PURPOSE

Clear aligners, known for their esthetic appeal, are now increasingly utilized in orthognathic surgery treatment, offering preoperative and postoperative benefits. This systematic review aims to answer the research question: Are clear aligners as effective as traditional fixed appliances in achieving dental and skeletal changes, improving oral health, and enhancing patient-reported satisfaction in patients requiring orthognathic surgery?

METHODS

We conducted a systematic review following a predefined protocol. We searched databases including MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane's CENTRAL from inception until September 2024, with no language or date restrictions. Studies were included based on the Population, Intervention, Comparison, and Outcome (PICO) criteria, focusing on patients requiring orthognathic surgery (Population), the use of clear aligners (Intervention), compared with traditional fixed appliances (Comparison), and outcomes related to dental and skeletal changes, oral health, and patient satisfaction (Outcome). Inclusion criteria were clinical studies addressing the PICO question, while exclusion criteria were studies not involving human subjects or unrelated to orthognathic surgery with clear aligners. The risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) and Cochrane Risk of Bias 2.0 (ROB.02) tools. Data extraction included publication year, study design, participant demographics, malocclusion type, surgical procedures, aligner specifications, treatment protocols, aligner utilization stages, treatment durations, and evaluated outcomes.

RESULTS

Our comprehensive search identified 765 studies, supplemented by 12 from manual searching. After screening, 34 studies underwent full-text review, and 16 clinical studies (375 patients) were included in the qualitative review: 2 randomized clinical trial, 2 prospective, and 12 retrospective studies. Four studies using presurgical aligners reported an increase in the incisor mandibular plane angle by 3 to 15° for Class III cases, while 2 studies on postsurgical aligners noted similar decompensatory movements, such as a change in incisor mandibular plane angle exceeding 10°. The remaining 7 studies used aligners before and after surgery and sometimes during surgery to create surgical splints. Comparative results between aligners and fixed appliances indicated no significant differences in dental and skeletal changes. Aligners had higher patient satisfaction scores (3 to 5 points higher on a 10-point scale) and better periodontal health outcomes. The Peer Assessment Rating score reductions were similar (60% for aligners vs 69% for fixed appliances). Overall, clear aligners may provide similar effectiveness to fixed appliances in orthognathic surgery while enhancing periodontal health and patient satisfaction. However, due to the low quality of evidence, these findings should be interpreted cautiously, warranting further investigation.

CONCLUSION

Based on the limited evidence available in our study, clear aligners may provide outcomes similar to those of fixed appliances in orthognathic surgery. They might also offer additional benefits in terms of periodontal health and patient satisfaction. However, it is important to interpret these findings with caution due to the limited quantity and quality of the studies. Further comparative research with rigorous methodology is necessary to confirm these initial observations and support clinical decision-making.

Expert consensus on the clinical strategies for orthodontic treatment with clear aligners

Clear aligner treatment is a novel technique in current orthodontic practice. Distinct from traditional fixed orthodontic appliances, clear aligners have different material features and biomechanical characteristics and treatment efficiencies, presenting new clinical challenges. Therefore, a comprehensive and systematic description of the key clinical aspects of clear aligner treatment is essential to enhance treatment efficacy and facilitate the advancement and wide adoption of this new technique. This expert consensus discusses case selection and grading of treatment difficulty, principle of clear aligner therapy, clinical procedures and potential complications, which are crucial to the clinical success of clear aligner treatment.

[Clinical efficacy of clear aligner treatment for pathologically migrated teeth in the anterior region of patients with severe periodontitis]

OBJECTIVE

To evaluate the clinical efficacy of clear aligner therapy in patients with severe periodontitis accompanied by pathological tooth displacement in the anterior region.

METHODS

This retrospective study analyzed patients diagnosed with severe periodontitis and pathological displacement in the anterior region, who visited both the Periodontics and Orthodontics Departments at Peking University School and Hospital of Stomatology between 2019 and 2022. A total of 26 eligible cases were included in this study. All the patients underwent regular periodontal maintenance throughout the treatment process, and clear aligners were used for orthodontic treatment. Intraoral scans were analyzed by dedicated software to measure and compare occlusal distribution and proximal contact scores before and after orthodontic treatment. Periodontal clinical indicators were assessed at three key time points: before periodontal treatment (T0), before orthodontic treatment (T1), and after orthodontic treatment (T2). All the cases were treated with clear aligner.

RESULTS

A total of 217 pathologically displaced anterior teeth from 26 patients were analyzed. Among these, 105 teeth exhibited periodontal pockets [probing depth (PD) ≥5 mm] before periodontal treatment. After clear aligner therapy, the occlusal score improved significantly from 10.35±8.61 to 23.62±9.73 (P < 0.001), and the proximal contact score increased from 13.62±4.73 to 31.62±10.37 (P < 0.001). The median PD decreased significantly from 3.33 mm [interquartile range (IQR)=0.92] at T0 to 2.50 mm (IQR=0.67, P < 0.001) at T1 and remained stable at 2.50 mm (IQR=0.50) after treatment (T2). A significant reduction in PD was observed between T0 and T2 (P < 0.001), but no significant difference was found between T1 and T2 (P=0.948).

CONCLUSION

Clear aligner therapy demonstrates favorable clinical efficacy in patients with severe periodontitis and pathological anterior tooth displacement. It effectively improves occlusal distribution and proximal contact while maintaining periodontal health in these patients. However, further large-scale prospective controlled studies are needed to verify its long-term clinical outcomes.

Orthodontic Treatment with Fixed Appliances Versus Aligners: An Experimental Study of Periodontal Aspects

Objective: This study aimed to compare the effects of orthodontic treatment on the same patients using aligners (upper arch) versus traditional fixed appliances (lower arch) on oral hygiene and periodontal health. Materials and Methods: A total of 90 patients, all treated by the same orthodontist and with an average age of 26 years, were included in the study. The research focused on factors predisposing patients to periodontitis, as well as plaque and tartar accumulation. Statistical analysis was performed using the paired-samples Student's t-test, with values of p < 0.05 deemed statistically significant. Results: Patients treated with fixed orthodontic appliances generally showed increased plaque accumulation (+10% PI) and a decline in periodontal health compared to those treated with aligners (40% presented a high level of S.Mutans and Lactobacilli). In patients who did not maintain proper oral hygiene, the initial conditions of the upper arch remained stable, while the lower arch exhibited significant deterioration, with increased plaque buildup and greater tissue inflammation. Conclusions: The findings emphasize the critical role of individual oral hygiene practices during orthodontic treatment in preserving periodontal health. Aligners appear to be more favorable in protecting periodontal tissues, improving plaque control, and reducing gingival inflammation. Various supplementary approaches for plaque management and microbial colonization in saliva should be implemented based on the type of orthodontic appliance used.

Impact of clear aligners on gingivitis incidence and prevention strategies in adolescents and adults: a prospective observational study

OBJECTIVE

This study aims to analyze the differences in gingivitis incidence among adolescents and adults using clear aligners for orthodontic correction and to evaluate the effectiveness of prevention strategies on orthodontic outcomes.

METHODS

This observational study included 120 patients undergoing clear aligner orthodontic treatment from June 2018 to September 2023. Participants were divided into an adolescent group (66 cases) and an adult group (54 cases), each further split into a study group and a control group. The control group patients maintained their daily lifestyle throughout the study period. The study group received personalized oral hygiene education and guidance on self-oral care techniques at each follow-up visit. Routine periodontal treatment and personalized oral hygiene education were provided, and the incidence of gingivitis was evaluated six months post-treatment. Statistical methods, including chi-square tests for categorical data, t-tests for continuous variables, and two-way ANOVA for group comparisons, were employed to ensure the robustness of the results.

RESULTS

The incidence of gingivitis was significantly higher in the adolescent group compared to the adult group (P < 0.05). Specifically, within the adolescent group, the study group exhibited a higher gingival index (GI) than the control group (P < 0.05), while the difference in the adult group was not significant.

CONCLUSION

During clear aligner orthodontic treatment, adolescents are more prone to developing gingivitis than adults. Additionally, basic periodontal therapy, as opposed to verbal oral health education alone, can moderately reduce the incidence of gingivitis in clear aligner patients during treatment.

Anti-caries effect of a novel elastic silicone appliance material incorporating sodium fluoride

Introduction

This study developed an elastic silicone appliance material incorporating sodium fluoride (NaF) and evaluated its mechanical properties, biocompatibility, antibacterial effects, and remineralization potential.

Methods

Silicone components A and B were combined with varying concentrations of NaF (0.5, 1, 1.5, 2, and 2.5%), thoroughly mixed, and transferred into molds. After drying and curing, the resulting orthodontic appliance was retrieved from the mold and underwent finishing processes, followed by the assessment of its mechanical properties, cytotoxicity, and antibacterial impact. Additionally, the impact of this novel silicone appliance material on salivary biofilm's activity and acid production was evaluated in samples from children with severe early childhood caries (S-ECC). The hardness of demineralized and remineralized bovine enamel was measured.

Results

Incorporating NaF (0.5, 1, and 1.5%) resulted in no cytotoxic effects, with cell viability >85%. The fluoride release rate initially increased over 14 days, followed by a gradual decline, maintaining a steady release for approximately 28 days. Incorporating 1.5% NaF preserved the mechanical properties and exhibited specific antibacterial properties that inhibited the growth, biofilm formation, and acid production activity of Streptococcus mutans (S. mutans) and saliva biofilms from S-ECC children. Furthermore, all concentrations of the samples helped improve enamel hardness loss.

Discussion

The novel silicone appliance material incorporating NaF exhibited antibacterial, fluoride releasing, and enamel remineralization properties while maintaining its physical and chemical integrity without cytotoxic effects.

The microbiome alterations of supragingival plaque among adolescents using clear aligners: a metagenomic sequencing analysis

BACKGROUND

White spot lesions (WSLs) may develop in adolescents undergoing clear aligner (CA) therapy with poor oral hygiene. The specific effects of CAs on the microbial composition and functional characteristics of supragingival plaques remain unclear. The present study investigated the shift in the supragingival microbial community induced by CAs in adolescents through metagenomic technology.

METHODS

Fifteen adolescents (12-15 years old) with Invisalign appliances were recruited. Supragingival plaque specimens were obtained twice, before treatment (T1) and three months after treatment (T2). All the bacterial plaque specimens were analyzed for microbial communities and functions using metagenomic analyses.

RESULTS

A total of 2,840,242,722 reads disclosed 180 phyla, 3,975 genera, and 16,497 microbiome species. During the first three months, the microbial community was relatively stable. The genus level revealed a higher relative abundance of Capnocytophaga, Neisseria, and Arachnia in the T2 period. Furthermore, the functional analysis suggested that the relative abundances of folate biosynthesis, biotin metabolism and biofilm formation-vibrio cholerae were increased in the T2 period compared to the T1 period. Finally, virulence factor analysis demonstrated that the relative abundance of genes associated with type IV pili (VF0082) and polar flagella (VF0473) was higher in the T2 period than in the T1 period.

CONCLUSION

In adolescents undergoing CA therapy with poor plaque control, caries progresses quickly within three months and noticeable WSLs develop on the tooth surface. Although the microbial community remained relatively steady and CA therapy did not cause significant changes in the overall functional gene composition in the first three months, virulence factors, including type IV pili and flagella, were more abundant and actively contributed to microorganism adhesion and biofilm formation.

Changes in the Oral Microbiota with the Use of Aligners vs. Braces: A Systematic Review

Background: Orthodontic treatments have evolved significantly, with clear aligners becoming increasingly popular due to their aesthetic appeal and ease of use. This study systematically reviewed the impact of clear aligners in the changes in the oral microbiota compared to traditional fixed appliances. Methods: Following PRISMA guidelines, a systematic review was conducted using two databases such as Scopus, Web of Science, and the PubMed search engine. The studies included were those published between 2010 and 2023, involving adults over 18 years using clear aligners and fixed appliances. The data on oral microbiota changes were extracted and analyzed. Results: The review included eight studies, highlighting the differences in microbial changes associated with clear aligners versus fixed appliances. Clear aligners were associated with fewer detrimental changes in the oral microbiota, potentially due to their removable nature allowing for better hygiene. Fixed appliances showed a tendency to harbor more pathogenic bacteria, which is likely due to their difficulty to clean. Conclusions: Clear aligners may offer a better alternative to fixed appliances in terms of maintaining a healthier oral microbiota. Their design and ease of hygiene contribute to less accumulation of pathogenic bacteria, showing a more positive impact on maintaining a balanced oral microbiota when compared to fixed appliances.

Biofilm formation of Streptococcus mutans, Streptococcus sanguinis, Staphylococcus epidermidis, Staphylococcus aureus, Lactobacillus casei, and Candida Albicans on 5 thermoform and 3D printed orthodontic clear aligner and retainer materials at 3 time points: an in vitro study

INTRODUCTION

Orthodontic clear aligners and retainers have numerous advantages that is making them ever increasingly popular. However, they might, similar to any other oral appliance, contribute to biofilm formation and finally dental caries or white spot lesions or gingival inflammations. The literature on biofilm formation on orthodontic clear appliances is very scarce and limited to a few microorganisms and materials. Therefore, this experimental study evaluated the biofilm formation on 5 thermoformed and 3D printed CAD/CAM orthodontic retainers in 3 intervals.

METHODS

In this in vitro study, 345 specimens (270 test discs and 45 negative controls) were created from fabricated retainers. Retainers included a 3D printed CAD/CAM material (Detax) and four thermoformed retainers [Erkodent (polyethylene terephthalate glycol [PETG]); EasyVac (polyethylene); DB (polyester based on terephthalic acid); and Clear Tech]. They were all 1 mm thick, and all completely fabricated, i.e., heated or printed. The discs were placed in 96-well plates. Microorganisms were cultured on 270 discs for 24 h (90 discs), 72 h (90 other discs), and 5 days or 120 h (90 other discs). Biofilm formation of the strains and negative controls was measured using the microtiter plate assay by ELISA reading. The microbes' ability to produce biofilm was categorized based on the comparison of average optical density (OD) of tests versus a cut-off point OD (ODc) calculated as the average of the OD of corresponding negative controls plus 3× its standard deviation: non-biofilm former [OD ≤ ODc], weak biofilm former [ODc < OD ≤ (2 × ODc)], moderate biofilm former [(2 × ODc) < OD ≤ (4 × ODc)], and strong biofilm former [(4 × ODc) < OD]. These were also converted to ranked scores between zero (no biofilm) and 3. The difference between ODs with control ODs were calculated. These were analyzed using 3-way ANOVA, 2-way ANOVA, and Tukey tests (α = 0.05, α = 0.008).

RESULTS

The 3-way ANOVA showed that the overall difference among the ΔODs of 5 retainers (all microorganisms and all intervals combined, n = 270) was not significant (F = 1.860, P = 0.119). Nevertheless, the difference among 3 intervals (F = 31.607, P = 0.0000) and the difference among the 6 microorganisms (F = 24.044, P = 0.0000) were significant. According to the Tukey test, the differences between the 1st interval with either of the other two intervals was significant (both P values = 0.000). There were significant differences between Candida albicans with all other organisms (all 5 P values = 0.0000). All other pairwise comparisons were insignificant (all 10 P values ≥ 0.1). After taking the averages of the 3 intervals, the order of the biofilm generation for different materials were as follows: Detax (average score: 1.56), Easyvac (1.67), Erkodent (1.78), Clear Tech (1.83), BD (2.28).

CONCLUSIONS

As far as these 6 microorganisms are of concern, there might not be a significant overall difference among the clear retainer materials tested in this study. A significant overall increase was observed between the first and third days, which later did not significantly increase more until day 5. The Candida albicans biofilm was more intense than the tested 5 bacteria, which themselves showed rather similar growth patterns to each other.

The oral microbiota and periodontal health in orthodontic patients

The oral microbiota develops within the first 2 years of childhood and becomes distinct from the parents by 4 years-of-age. The oral microbiota plays an important role in the overall health/symbiosis of the individual. Deviations from the state of symbiosis leads to dysbiosis and an increased risk of pathogenicity. Deviations can occur not only from daily life activities but also from orthodontic interventions. Orthodontic appliances are formed from a variety of biomaterials. Once inserted, they serve as a breeding ground for microbial attachment, not only from new surface areas and crevices but also from material physicochemical interactions different than in the symbiotic state. Individuals undergoing orthodontic treatment show, compared with untreated people, qualitative and quantitative differences in activity within the oral microbiota, induced by increased retention of supra- and subgingival microbial plaque throughout the treatment period. These changes are at the root of the main undesirable effects, such as gingivitis, white spot lesions (WSL), and more severe caries lesions. Notably, the oral microbiota profile in the first weeks of orthodontic intervention might be a valuable indicator to predict and identify higher-risk individuals with respect to periodontal health and caries risk within an otherwise healthy population. Antimicrobial coatings have been used to dissuade microbes from adhering to the biomaterial; however, they disrupt the host microbiota, and several bacterial strains have become resistant. Smart biomaterials that can reduce the antimicrobial load preventing microbial adhesion to orthodontic appliances have shown promising results, but their complexity has kept many solutions from reaching the clinic. 3D printing technology provides opportunities for complex chemical syntheses to be performed uniformly, reducing the cost of producing smart biomaterials giving hope that they may reach the clinic in the near future. The purpose of this review is to emphasize the importance of the oral microbiota during orthodontic therapy and to use innovative technologies to better maintain its healthy balance during surgical procedures.

Microbial Changes in the Periodontal Environment Due to Orthodontic Appliances: A Review

Orthodontic appliances significantly influence the microbiological dynamics within the oral cavity, transforming symbiotic relationships into dysbiotic states that can lead to periodontal diseases. This review synthesizes current findings on how orthodontic treatments, particularly fixed and removable appliances, foster niches for bacterial accumulation and complicate oral hygiene maintenance. Advanced culture-independent methods were employed to identify shifts toward anaerobic and pathogenic bacteria, with fixed appliances showing a more pronounced impact compared to clear aligners. The study underscores the importance of meticulous oral hygiene practices and routine dental monitoring to manage these microbial shifts effectively. By highlighting the relationship between appliance type, surface characteristics, treatment duration, and microbial changes, this review aims to enhance dental professionals' understanding of periodontal risks associated with orthodontic appliances and strategies to mitigate these risks. The findings are intended to guide clinicians in optimizing orthodontic care to prevent plaque-associated diseases, ensuring better periodontal health outcomes for patients undergoing orthodontic treatment.

Clear Aligners in the Growing Patient: A Systematic Review

Mixed dentition represents a critical phase in the oral development of pediatric patients, characterized by the simultaneous presence of primary and permanent teeth. This article proposes a comprehensive systematic review of the application of aligners as an innovative methodology in managing mixed dentition. The primary objective is to explore the efficacy, safety, and acceptability of this emerging orthodontic technology in the evolving age group. This systematic review focuses on randomized controlled trials, cohorts, and observational studies investigating the use of aligners in patients with mixed dentition. Clinical, radiographic, and psychosocial parameters will be considered to assess the overall impact of aligner therapy in this critical phase of dental development. An in-depth analysis of such data aims to provide a comprehensive overview of the potential of this technology in pediatric orthodontics. Expected outcomes may contribute to outlining practical guidelines and targeted therapeutic strategies for orthodontists involved in managing mixed dentition. Furthermore, this article aims to identify gaps in the current research and suggest future directions for studies exploring the use of transparent aligners in patients with mixed dentition, thereby contributing to the ongoing evolution of evidence-based orthodontic practices.

Digital orthodontic setup and clear aligners system for treating adult patients with periodontitis: a descriptive case report

This case report describes the treatment of an adult female patient with a history of periodontitis (Stage 3 -Grade B) and presenting significant crowding in both maxillary and mandibular arches. After periodontal stabilization, the patient underwent orthodontic treatment with clear aligners (CAT) for less than one year. CAT provided an effective quantitative and qualitative control of the forces applied to resolve the malocclusion. This case report provides a detailed description of the clinical strategy and features associated with the clear aligners system which were considered ideal tools for treating periodontal patients during the decisional workflow. The orthodontic treatment goals have been successfully achieved considering functional, periodontal, and aesthetic expectations. Several characteristics of clear aligners could support the recurrence of this orthodontic system for treating patients with a history of periodontitis or at risk of periodontal damage.

Orthodontic Practitioners' Knowledge and Education Demand on Clear Aligner Therapy

OBJECTIVES

Clear aligner therapy (CAT) has been gaining popularity amongst the orthodontic community. No systematic course on CAT has been reported to date. The objectives of this study were to determine practitioners' knowledge and to offer insights for future tailored courses on CAT.

METHODS

An online questionnaire was distributed. The questionnaire comprised personal background information, predictability of tooth movement through CAT, and CAT knowledge that practitioners demanded to learn. Four senior expert orthodontists' answers to the predictability of tooth movement through CAT were averaged to be a standard reference. Descriptive statistics, 1-way analysis of variance (ANOVA), principal component analysis, Student t test, and multivariate logistics regression analysis were performed with significance set at P < .05.

RESULTS

In total, 190 practitioners participated in this study. As compared to the standard reference, participants overestimated the predictability of difficult-to-be-achived tooth movements (eg, molar mesialisation; P < .0001). Strategy of managing troubleshooting cases and extraction cases ranked the highest CAT knowledge that participants requested to learn. Practice type, number of completed CAT cases, number of undergoing CAT cases, years of practice, education background, and time of using CAT were the influencing factors of the questions regarding the predictability of tooth movement through CAT and CAT knowledge that were demanded to be learned.

CONCLUSIONS

The predictability of difficult-to-be-achieved tooth movement through CAT is often overestimated by practitioners with limited clinical experience. Tailored education on CAT, especially managing troubleshooting cases and extraction cases, should be designed for all practitioners.