Attachments for the Orthodontic Aligner Treatment-State of the Art-A Comprehensive Systematic Review

Accuracy Evaluation of Indirect Bonding Techniques for Clear Aligner Attachments Using 3D-Printed Models: An In Silico and Physical Model-Based Study

An inaccurate bonding procedure of the attachments related to clear aligner systems could influence the predictability of tooth movement The aim of this study was to compare the positioning reliability of horizontal and vertical orthodontic clear aligner attachments.

MATERIALS AND METHODS

A total of 70 horizontal and 70 vertical orthodontic clear aligner attachments were bonded to five upper and five lower experimental anatomically based acrylic resin models with 14 clinical crowns each. The experimental anatomically based acrylic resin models were randomly distributed to the following study groups: Group A-horizontal orthodontic clear aligner attachments (n = 70) (HORIZONTAL) and Group B-vertical orthodontic clear aligner attachments (n = 70) (VERTICAL). Afterward, the orthodontic clear aligner attachments were digitally planned using orthodontic planning software, and orthodontic templates were manufactured by thermoforming on 3D-printed models in trilayer glycol-modified polyethylene terephthalate. Both horizontal and vertical orthodontic clear aligner attachments were put through an intra-oral scan to obtain a postoperative digital image, and PAPver, PCPver, PMVver, AUver, Alver, PPMhor, PPDhor, PMVhor, AMhor and ADhor cephalometric parameters were analyzed using a t-test or a non-parametric Mann-Whitney-Wilcoxon test.

RESULTS

The results showed that all cephalometric parameters showed statistically significant differences (p < 0.05) between the accuracy of the indirect bonding technique for horizontal and vertical orthodontic clear aligner attachments, except for the PAPver (p = 0.6079) and PMVhor (p = 0.5001) cephalometric parameters.

CONCLUSIONS

The vertical orthodontic clear aligner attachments are more accurate than the horizontal orthodontic clear aligner attachments through the indirect bonding technique.

Mechanical Behaviour of Orthodontic Auxiliary Photopolymerisable Resins in Simulated Oral Conditions: An In Vitro Study

BACKGROUND

The widespread adoption of clear aligners in orthodontic practice has driven the development of biomechanical devices to improve treatment efficiency. The mechanical properties of these materials play a critical role in determining their clinical performance and efficacy. This study investigates the Young's modulus of Clear-Blokker® (Scheu Dental), a photopolymerisable resin used for the attachment of clear aligner, and evaluates its mechanical behaviour under different curing times (5 s and 10 s) and environmental conditions (dry storage and immersion in artificial saliva at 37 °C).

METHODS

Forty-eight cylindrical specimens were prepared and subjected to quasistatic compression tests after 14 days. A multi-factorial analysis of variance (ANOVA) at a significance level of 5% was performed to compare the variances.

RESULTS

The results showed that samples immersed in artificial saliva had significantly reduced Young's moduli compared to samples stored in dry conditions (p = 0.0213), while no significant difference was observed between curing times.

CONCLUSIONS

The results suggest that Clear-Blokker® has mechanical properties comparable to those of clear aligner materials, making it suitable as a biomechanical aid for orthodontic treatment. However, further clinical studies are required to confirm its long-term efficacy in the oral environment.

Evaluation of the effect of attachments on torque control of palatally positioned maxillary lateral teeth with clear aligners: Finite element analysis

Objective

The effect of different attachment positions on torque control during the labialization of maxillary lateral incisors with clear aligners was evaluated using finite element analysis.

Methods

Anatomical data acquired through cone-beam computed tomography, combined with the design of 0.625-mm-thick aligners and horizontal attachments, were integrated into the software. Six distinct simulations were generated: (1) attachment-free, (2) labial attachment placed gingivally, (3) labial attachment placed mid-crown, (4) labial attachment placed incisally, (5) palatal attachment, and (6) attachment placed labially and palatally. The evaluation was performed using a default aligner activation of 0.25 mm.

Results

The crown of the lateral incisor demonstrated labial movement, while the root exhibited palatal movement in all models. Group 6 showed the lowest crown and root displacements on both axes, whereas the attachment-free group exhibited the greatest crown movement. The aligner experienced maximum deformation at the incisal edge, with deformation progressively decreasing towards the gingival region. Group 6 demonstrated the least deformation of all groups. The Von Mises stresses in the periodontal ligament (PDL) were most pronounced at the gingival level, with higher values on the palatal side than on the labial side.

Conclusions

The use of attachments, particularly the combination of labial and palatal attachments, enables a more precise labialization process, helping to reduce tipping. Increasing crown movement of the lateral incisor elevates stress within the PDL, with the highest stress observed in the palatal region at the gingival level.

Effects of curing lights on polymerization shrinkage of composite attachments in clear aligner treatment: A microcomputed tomography study

INTRODUCTION

This study aimed to investigate the polymerization shrinkage of composite attachments and changes in attachment templates during bonding in clear aligner treatments.

METHODS

A total of 24 extracted teeth were divided into 4 groups, and plaster models were digitized. Attachment templates were produced with beveled attachments on premolars and rectangular attachments on molars. Polymerizations used a halogen curing light (800 milliwatts per square centimeter [mW/cm2] for 20 seconds) and light-emitting diode (LED) curing light in 3 modes (1000 mW/cm2 for 20 seconds, 1000 mW/cm2 for 10 seconds, and 3200 mW/cm2 for 3 seconds). The curing distance was 5 mm, and temperature changes were recorded with a thermal camera. Microcomputed tomography scanning measured volumetric and linear attachments before and after polymerization. Statistical analyses employed a 1-way analysis of variance with Bonferroni corrected Tukey post-hoc for multiple comparisons and the Kruskal-Wallis test for temperature change.

RESULTS

Significant differences (P <0.001) were found in temperature among curing lights. The highest temperature was in the LED unit-extra mode, and the lowest was in the halogen curing unit. The LED unit for 20 seconds caused the highest temperature change. A significant difference (P = 0.048) in occlusal attachment length was found between the LED unit for 20 seconds and the LED unit-extra mode. Polymerization resulted in increased attachment template thickness across all groups, with significant changes noted in the halogen unit, LED unit for 20 seconds, and LED unit-extra mode.

CONCLUSIONS

Temperature generated during polymerization varied between halogen and LED curing lights. Significant differences were found in attachment length at the occlusal level and template thickness postpolymerization. Preferences in attachment bonding protocols may affect the clinical precision of clear aligner treatments.

The biomechanical effects of clear aligner trimline designs and extensions on orthodontic tooth movement: a systematic review

BACKGROUND

Clear aligner treatment (CAT) has emerged as an effective alternative to conventional multibracket systems in orthodontics. The trimline design and extension of aligners may significantly influence their biomechanical performance and tooth movement efficacy.

AIM

To systematically review the biomechanical effects of different aligner trimline designs and extensions on orthodontic tooth movement.

METHODS

A systematic search was conducted across PubMed, Scopus, Embase, ProQuest Dissertations & Theses Global, and Google Scholar for studies published between January 2000 and August 2024. The review included any types of empirical research focusing on the influence of trimline of orthodontic aligners on tooth movement efficacy conducted between January 2000 and August 2024. The Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool was used for quality assessment.

RESULTS

Twelve studies met the inclusion criteria, all assessed as having low to moderate risk of bias. Aligner trimline design significantly influenced orthodontic tooth movement efficacy through two primary mechanisms: enhanced force delivery and increased aligner retention. Aligners with straight and extended margins generally exerted higher forces and moments compared to scalloped or shorter designs. This resulted in greater tooth displacement for certain movements, particularly intrusion, translation, tipping, and root torquing. Extended trimlines also demonstrated superior retention. However, the effects varied depending on the type of tooth movement.

CONCLUSION

Aligner trimline designs and extensions can significantly influence biomechanical performance and tooth movement efficacy in CAT. Straight extended trimlines generally demonstrate superior force delivery and retention, leading to more predictable clinical outcomes. This could reduce the need for revisions, thereby decreasing overall treatment time and increasing patient satisfaction. However, further research is needed to investigate the interactions between aligner trimline designs and other factors to develop evidence-based guidelines for their optimal combination in various clinical scenarios.

Bonding positional accuracy of attachments and marginal adaptation of in-house aligners - A quality improvement laboratory study

OBJECTIVES

To evaluate the 3D accuracy of attachment positioning and the adaptation of aligners to attachments using in-house templates made with either polyethylene terephthalate glycol (PETG) or ethylene-vinyl acetate (EVA) and either pressure or vacuum thermoforming machines.

MATERIALS AND METHODS

Overall, 140 test specimens were resin-printed. Templates for the attachment bonding were made with 1-mm EVA or 0.5-mm PETG laminates. Orthodontic aligners were manufactured with 0.75-mm PETG. The thermoplastification process was carried out using either vacuum or pressure machines. The positional differences between the virtual and bonded attachments were assessed in the X, Y and Z coordinates. The marginal adaptation between the aligners and the attachments was measured.

RESULTS

Minor inaccuracies in the positioning of the attachments were observed in all combinations of thermoforming machines and plastic laminates used to fabricate the templates, mainly in the superior-inferior (Z) dimension. PETG performed better than EVA in the anterior region (p < .05). No association was found between thermoplastification machines and the accuracy of the positioning of the attachments (p > .05). While small misadaptations between the aligners and the attachments were observed, the EVA templates performed better than the PETG templates.

CONCLUSIONS

The inaccuracy of the attachment positioning and the misadaptation of the aligners to the attachments were slight. The vacuum and pressure thermoplastification machines showed no difference in attachment positioning accuracy. The PETG template was better than the EVA template in the anterior region, but the EVA attachments presented a better adaptation to the aligners than the PETG attachments.

Effect of attachment configuration and trim line design on the force system of orthodontic aligners: A finite element study on the upper central incisor

OBJECTIVES

To use the finite element method (FEM) to investigate the effect of various attachment configurations and trimming line designs of orthodontic aligners on their biomechanical performance.

METHOD

A 3D upper jaw model was imported into 3D design software. The upper right central incisor tooth (Tooth 11) was made mobile, and its periodontal ligament (PDL) and bone structures were designed. Aligners were modelled with three distinct attachment configurations: No attachment, rectangular horizontal, rectangular vertical, and two trimming line designs; scalloped and straight extended, with a homogeneous thickness of 0.6 mm. These models were then imported into an FE software. Simulations were conducted for three different movements, including facial translation, distalization, and extrusion.

RESULTS

Forces were recorded at 1.3-2.6 N during facial translation, 1.4-5.9 N in distalization, and 0.0-2.0 N in extrusion. The straight extended trimming line consistently generated higher forces than the scalloped design. Attachments had no significant impact on force components during facial translation but were more effective in distalization and extrusion. The combination of a straight extended trimming line with horizontal attachments exhibited the least stresses at the apical third during distalization, and the highest stresses during extrusion, suggesting superior retention.

CONCLUSIONS

Rectangular attachments offer limited benefits in facial translation, but horizontal rectangular attachments can intensify load in distalization and are crucial for force generation in extrusion. Horizontal attachments are preferred over vertical options. Additionally, the straight extended trim line enhances control of tooth movement and can replace attachments in certain cases.

CLINICAL RELEVANCE

These findings provide biomechanical evidence and an optimal protocol to guide clinical practice in planning diverse teeth movements. The emphasis is on the influence of attachment utilization and the specific design of aligner trimming lines to enhance control over tooth movement.

Seeking orderness out of the orderless movements: an up-to-date review of the biomechanics in clear aligners

INTRODUCTION

Although with increasing popularity due to aesthetic appeal and comfort, clear aligners (CAs) are facing challenges in efficacy and predictability. Advancement in the underlying biomechanical field is crucial to addressing these challenges. This paper endeavors to provide a comprehensive framework for understanding the biomechanics of CA and enlightening biomechanics-based improvements on treatment strategies.

METHODS

A thorough review of the English-language literature accessible through PubMed and Google Scholar, without any publication year restrictions, was undertaken to unravel the biomechanical aspects of CA.

RESULTS

This review presented an up-to-date understanding of aligner biomechanics arranged by the framework of the material-dependent mechanical characteristics of CA, the geometric characteristics-dependent force transmission of the CA system, methods for studying the biomechanics of CA, and the biomechanical analyses for different types of tooth movement.

CONCLUSIONS

Biomechanics should be the fundamental concern for concepts, methods and adjuncts attempting to enhance the accuracy and predictability of tooth movement induced by CA. Improvement on material properties and alteration of geometric design of CA are two main approaches to develop biomechanically optimized force system. Exploration of real-world force sensing and monitoring system would make substantial progresses in aligner biomechanics.

Finite element analysis of the mechanical behavior of 3D printed orthodontic attachments used in aligner treatment

The composite attachment loss during orthodontic clear aligner therapy is an adverse event that commonly happens in clinical practice and can affect the overall outcome and length of treatment. The aim of our research is to provide a basis for the further study of an innovative digital protocol and application method for orthodontic aligner attachments. Two 3D models were designed, one based on the proposed protocol and the other on the conventional method for aligner attachment application. Four attachment shapes were used to identify the maximum values for the von Mises equivalent stresses, the maximum displacements values and the areas in which these values were recorded through FEM analysis. The results of the mechanical simulation show lower values of von Mises stress recorded in the 3D printed attachments assemblies, independent of their shape, when simulated under the same boundary and load conditions. The trapezoidal prism shaped 3D printed model has a 3.7 times smaller displacement value (0.088 [mm]) compared to the adhesive resin model (0.326 [mm]). In conclusion, the proposed protocol for aligner attachments and the introduction of innovative materials is a promising method of solving conventional attachment problems in current orthodontic treatments.