Preparation and characterization of thermoplastic materials for invisible orthodontics

Validation of a double-semicircular notched configuration for mechanical testing of orthodontic thermoplastic aligner materials

The potential of using specimens with a double-semicircular-notched configuration for performing tensile tests of orthodontic thermoplastic aligner materials was explored. Unnotched and double-semicircular-notched specimens were loaded in tension using a universal testing machine to determine their tensile strength, while finite element analysis (FEA) and digital image correlation (DIC) were used to estimate stress and strain, respectively. The shape did affect the tensile strength, demonstrating the importance of unifying the form of the specimen. During the elastic phase under tension, double-semicircular-notched specimens showed similar behavior to unnotched specimens. However, great variance was observed in the strain patterns of the unnotched specimens, which exhibited greater chance of end-failure, while the strain patterns of the double-semicircular-notched specimens showed uniformity. Considerable agreement between the theoretical (FEA) and practical models (DIC) further confirmed the validity of the double-semicircular-notched models.

A comparative study on tensile strength of various thermoplastic polymers sheets following thermoforming on a pre-treatment and post-treatment maxillary model of a patient: an in vitro study

OBJECTIVES

Thermoplastic polymers show alteration in their mechanical properties after thermoforming on a dental model. The purpose of this in-vitro study was to evaluate the tensile strength of different thermoplastic polymer sheets thermoformed on a pre-treatment (moderate crowding) and post-treatment (well-aligned) maxillary model of a patient.

MATERIALS AND METHODS

Forty maxillary models (Twenty Pre-treatment & twenty Post-treatment of uniform dimension) were made by duplicating them using alginate Hydrogum 5 (Zhermack). Samples were then divided into eight groups of 5 samples each. The thermoplastic sheets Imprelon® (Scheu-Dent), AVAC R® (Jaypee), Placa Crystal® (BioART), EZ-VAC® (3A Medes)-1.0 mm thick were thermoformed on these models respectively. The sample was retrieved using ceramic bur mounted on a straight hand-piece and subjected for testing using TINIUS Olsen 10ST micro universal testing machine and recorded.

RESULTS

There was no statistically significant difference (P > .05) in tensile strength of thermoformed thermoplastic polymer sheets between pre-treatment and post-treatment maxillary model. Tensile strength of EZ-VAC (3A Medes) showed higher variation between pre-treatment and post-treatment maxillary model though it was found to be statistically insignificant (P > .05). Significant difference (P < .05) was seen between groups when they were compared separately among pre-treatment and post-treatment models.

CONCLUSION

Placa Crystal (BioART) among the pre-treatment group, EZ - VAC (3A Medes) among the post-treatment group, showed highest tensile strength.

CLINICAL RELEVANCE

Results of the study highlights the necessity to test materials in conditions which stands in accordance with the clinical scenario to a considerable extent and also emphasizes the need for further study in aligner.

Thermoplastic clear dental aligners under cyclic compression loading: A mechanical performance analysis using acoustic emission technique

The objective of this work is to analyse the performance of clear aligners made of thermoplastic materials. Within this framework, the damage evolution stages and damage states of the aligners at different cycles of the compressive loading are evaluated using the Acoustic Emission (AE) technique. Three different clear aligner systems were prepared: thermoformed PET-g (polyethylene terephthalate glycol) and PU (polyurethane), and additively manufactured PU. Cyclic compression tests are performed to simulate 22500 swallows. The mechanical results show that the energy absorbed by the thermoformed PET-g aligner remains stable around 4 Nmm throughout the test. Although the PU-based aligners show a higher energy absorption of about 7 Nmm during the initial phase of the cyclic loading, this gradually decreases after 12500 cycles. The time-domain based, and frequency-based parameters of the stress wave acoustic signals generated by the aligners under compression loading are used to identify the damage evolution stages. The machine learning-based AE results reveal the initiation and termination of the different damage states in the aligners and the frequency-based results distinguish the different damage sources. Finally, the microscopy results validated the damage occurrences in the aligners identified by the AE results. The mechanical test results indicate that the thermoformed PET-g has the potential to match the performance and requirements of the dentistry of the popular Invisalign (additively manufactured PU). The AE results have the potential to identify at which cycles the aligners may start losing their functionality.

Assessment of wear characteristics, longevity and stiffness of Essix-type retainers

OBJECTIVE

To compare four commercially available Essix-type retainers in terms of longevity, wear characteristics, stiffness and their range of rigidity.

MATERIALS AND METHODS

An in vitro study was conducted at Queen Mary University of London. Four groups of thermoplastic materials were included: Duran (PETG), Essix C + (Polypropylene), Vivera and Zendura (Polyurethane). A working typodont was fabricated to evaluate surface wear characteristics using a wear machine with a customized jig. Retainers were measured for tensile test, and water absorption was measured at five different time points up to 6 months after initial immersion in two different physical states and two different solutions. Hydrolytic degradation was also evaluated using FTIR spectroscopy.

RESULTS

Essix C + was the most flexible retainer with Vivera the stiffest material. Zendura and Essix C + had the most surface wear (413 μm ± 80 and 652 μm ± 12, respectively) with absorption rates of up to 15 wt% in artificial saliva occurring with Zendura. Only Essix C + displayed signs of degradation following water absorption.

CONCLUSIONS

All materials had characteristic levels of flexibility and were susceptible to water absorption. Duran 1.5 mm performed similarly to Vivera in relation to stiffness and wear properties. While Zendura and Vivera have similar chemical structures, they exhibited differences concerning wear resistance and water absorption. Further clinical research evaluating the clinical relevance of these laboratory findings is required.

CLINICAL RELEVANCE

Characteristic patterns of wear and rigidity of four commercially available Essix-type retainers were observed. This information should help in the tailoring of retainer material on a case-by-case basis considering treatment-related factors and patient characteristics including parafunctional habits.

Degree of cure of orthodontic composite attachments underneath aligners

The aim of this study was to assess the percentage degree of cure (DC%) of 2-mm-thick resin composite attachments used for aligner treatment. Three types of aligner - two thermoformed aligners (Clear Aligner [CLA], polyethylene terephthalate glycol modified; and Invisalign [INV], polyester urethane) and a three-dimensional-printed aligner (Graphy TC-85DAC [GRP], an acrylate-methacrylate copolymer) - were selected, along with two universal resin composites (3M Filtek Universal [FTU] and Charisma Topaz ONE [CTO]). Samples of each composite were placed under each aligner, and the degree of cure of each composite was evaluated on the top (facing the aligner) and the bottom (facing the substrate) attachment surfaces after curing. Five specimens were used per combination of aligner and composite, and an additional group of composites irradiated without aligners served as the control. The DC% measurements were performed using attenuated total reflection Fourier transform infrared (ATR-FTIR) spectroscopy. The DC% across the aligners were (median values) 33.8%-44.8% for CLA, 33.6%-40.8% for INV, 32.8%-40.6% for GRP, and 40.0%-51.7% for the control group. The DC% values of the attachments cured under any aligner were significantly lower than that of the corresponding control, with the values recorded on the top surfaces being 6% higher than those on the bottom surfaces after adjusting for aligner group and composite type.

Chemical-Physical Characterization of PET-G-Based Material for Orthodontic Use: Preliminary Evaluation of micro-Raman Analysis

OBJECTIVES

 Orthodontic treatment with clear thermoplastic aligners is in great demand by patients especially for aesthetics. Any alterations in the chemical composition of the thermoplastic material for aligners, subjected to the oral environment and exposure to various commonly used substances, could influence the desired orthodontic movement decreasing the predictability of the treatment. The objective of this study was to determine the chemical-physical characterization by micro-Raman spectroscopy of a thermoplastic material based on polyethylene terephthalate glycol (PET-G) used for the manufacture of Lineo aligners (Micerium Lab, Avegno, Italy) subjected to different staining beverages and cleaning agents.

MATERIALS AND METHODS

 Twenty-two thermoformed PET-G samples were immersed to various substances of daily use for 10 and 15 days (coffee, tea, Coca-Cola, red wine, colloidal silver disinfectant, nicotine, artificial saliva, cigarette smoke, and different combinations of saliva with some of the previous solutions). Subsequently, the chemical-physical characterization was investigated by micro-Raman spectroscopy.

RESULTS

 The analysis of the spectra acquired for all the specimens showed no difference in the exposure to the different solvents at 10 and 15 days. Furthermore, having ascertained the heterogeneous surface morphology of the PET-G material due to thermoforming, various deposits were present on all the samples whose consistency and concentration depended on the substance used.

CONCLUSION

 The spectroscopic investigations have provided a precise and detailed analysis of the qualitative and structural data of the PET-G material under examination. No significant structural modifications of the thermoplastic polymer were found after immersion in different solutions in the exposure times adopted.

The effect of enhanced structure in the posterior segment of clear aligners during anterior retraction: a three-dimensional finite element and experimental model analysis

BACKGROUND

Mesial tipping of posterior teeth occurs frequently during space closure with clear aligners (CAs). In this study, we proposed a new modification of CA by localized thickening of the aligner to form the enhanced structure and investigate its biomechanical effect during anterior retraction.

METHODS

Two methods were employed in this study. First, a finite element (FE) model was constructed, which included alveolar bone, the first premolars extracted maxillary dentition, periodontal ligaments (PDL), attachments and aligners. The second method involved an experimental model-a measuring device using multi-axis transducers and vacuum thermoforming aligners. Two groups were formed: (1) The control group used common CAs and (2) the enhanced structure group used partially thickened CAs.

RESULTS

FE model revealed that the enhanced structure improved the biomechanics during anterior retraction. Specifically, the second premolar, which had a smaller PDL area, experienced a smaller protraction force and moment, making it less likely to tip mesially. In the same vein, the molars could resist movement due to their larger PDL area even though they were applied larger forces. The resultant force of the posterior tooth was closer to the center of resistance, reducing the tipping moment. The canine was applied a larger retraction force and moment, resulting in sufficient retraction of anterior teeth. The experimental model demonstrated a similar trend in force variation as the FE model.

CONCLUSIONS

Enhanced structure allowed force distribution more in accordance with optimal principles of biomechanics during the extraction space closure while permitting less mesial tipping and anchorage loss of posterior teeth and better retraction of anterior teeth. Thus, enhanced structure alleviated the roller coaster effect associated with extraction cases and offered a new possibility for anchorage reinforcement in clear aligner therapy.

Comparative assessment of orthodontic clear aligner versus fixed appliance for anterior retraction: a finite element study

BACKGROUND

The aim of this study is to conduct a comparative evaluation of different designs of clear aligners and examine the disparities between clear aligners and fixed appliances.

METHODS

3D digital models were created, consisting of a maxillary dentition without first premolars, maxilla, periodontal ligaments, attachments, micro-implant, 3D printed lingual retractor, brackets, archwire and clear aligner. The study involved the creation of five design models for clear aligner maxillary anterior internal retraction and one design model for fixed appliance maxillary anterior internal retraction, which were subsequently subjected to finite element analysis. These design models included: (1) Model C0 Control, (2) Model C1 Posterior Micro-implant, (3) Model C2 Anterior Micro-implant, (4) Model C3 Palatal Plate, (5) Model C4 Lingual Retractor, and (6) Model F0 Fixed Appliance.

RESULTS

In the clear aligner models, a consistent pattern of tooth movement was observed. Notably, among all tested models, the modified clear aligner Model C3 exhibited the smallest differences in sagittal displacement of the crown-root of the central incisor, vertical displacement of the central incisor, sagittal displacement of the second premolar and second molar, as well as vertical displacement of posterior teeth. However, distinct variations in tooth movement trends were observed between the clear aligner models and the fixed appliance model. Furthermore, compared to the fixed appliance model, significant increases in tooth displacement were achieved with the use of clear aligner models.

CONCLUSIONS

In the clear aligner models, the movement trend of the teeth remained consistent, but there were variations in the amount of tooth displacement. Overall, the Model C3 exhibited better torque control and provided greater protection for posterior anchorage teeth compared to the other four clear aligner models. On the other hand, the fixed appliance model provides superior anterior torque control and better protection of the posterior anchorage teeth compared to clear aligner models. The clear aligner approach and the fixed appliance approach still exhibit a disparity; nevertheless, this study offers a developmental direction and establishes a theoretical foundation for future non-invasive, aesthetically pleasing, comfortable, and efficient modalities of clear aligner treatment.

Mechanical properties of materials for 3D printed orthodontic retainers

AIM

The purpose of this study was to compare the mechanical properties of materials used for orthodontic retainers made by direct 3D printing and thermoforming.

The tooth movement efficiency of different orthodontic thermoplastics for clear aligners: study protocol for a randomized controlled clinical trial

INTRODUCTION

With regard to the esthetics and comfort of orthodontic treatment, the requirement for removable clear aligners (CAs) is increasing. Unlike conventional fixed orthodontic appliances, CAs were made of thermoplastic film by thermoforming on the personalized dental models. The construction of orthodontic thermoplastic is a critical factor for orthodontic tooth movement (OTM). Polyethylene terephthalate glycol-modified (PETG) and thermoplastic polyurethane (TPU) are the most commonly orthodontic thermoplastics; however, the evidence of the differences between different orthodontic thermoplastic are limited to vitro environment and the evidence in vivo environment is not available. Therefore, this trial aims to provide reliable evidence for orthodontists' personalized treatment plans whether the two most commonly used orthodontic thermoplastics of PETG and TPU have differences in the efficiency of OTM.

METHODS AND ANALYSIS

This randomized controlled clinical study will recruit 44 orthodontic patients for orthodontic treatment. All the subjects will be randomized into two groups (PETG and TPU, n = 22 for each group). In the first stage (M0 to M1), clear aligners will be made of two orthodontic thermoplastics and move the maxillary first or second premolars 2 mm. In the second stage, patients will take the standard orthodontic treatments. The primary outcome will be the efficiency of clear aligners made of different materials on the digital models. The secondary outcome will be the efficiency of clear aligners made of different materials on the cone-beam computed tomography (CBCT). The efficiency will be calculated through the superimposition of the digital models and CBCT.

DISCUSSION

The results from this trial will serve as evidence for orthodontists and manufacturers and clarify whether the difference in orthodontic thermoplastics significantly impacts the efficiency of OTM.

TRIAL REGISTRATION NUMBER

ChiCTR2300070980. Registered on 27 April 2023. https://www.chictr.org.cn/showproj.html?proj=186253.

Effect of oral exposure on chemical, physical, mechanical, and morphologic properties of clear orthodontic aligners

INTRODUCTION

The dental industry is heavily committed to developing more esthetic solutions for orthodontic treatments. Invisalign is a system of transparent orthodontic aligners introduced as an alternative to conventional orthodontic fittings with brackets and metal wires. This study aimed to assess the chemical, physical, mechanical and morphologic changes in these polymeric aligners after exposure to the oral environment.

METHODS

Twenty-four Invisalign orthodontic aligners were equally divided into 2 groups: an in vivo aged group in which patients used aligners for 14 days and the reference group, unexposed to the oral environment. Different experimental techniques were used to study the chemical structure, the color changes and translucency, the density and subsequent volume of the aligners, mechanical properties, surface roughness, morphology and elemental composition. The data were subjected to several statistical analyses.

RESULTS

Clear orthodontic aligners exhibit chemical stability but undergo a statistically significant optical change in color and translucency. There was a gradual increase in the water absorption rate and the dimensional variation of the polymer, indicating a strong correlation among these factors. The mechanical properties of the polymer showed a statistically significant decrease in its elastic modulus and hardness. There was a slight tendency toward increased surface roughness of the material, but no statistical differences were found between reference and aged groups. The surface morphology of the used aligners demonstrates microcracks, distortions and biofilm formation.

CONCLUSION

Intraoral aging adversely affected the physical, mechanical, and morphologic properties of the Invisalign appliance.

Development of an antibacterial polypropylene/polyurethane composite membrane for invisible orthodontics application

In virtue of the advantages, such as aesthetics, designability, convenient removal, and comfortable experience, invisible orthodontics (IO) have been widely recognized and accepted by the public. However, most of the membranes currently used for IO only meet the requirement of shape retention. Other vital functions, like antibacterial and antifouling activities, are neglected. Herein, antibacterial composite membranes (ACMs) containing polypropylene (PP), thermoplastic polyurethane (TPU) and poly (hexamethylene guanidine) hydrochloride-sodium stearate (PHMG-SS) were facilely manufactured through the hot-pressing membrane forming technology. ACMs were conferred with favorable transparency (∼70% in the visible light range) and excellent antibacterial ability. Experiment results demonstrated that bactericidal rates of ACMs against Staphylococcus aureus, Escherichia coli and Streptococcus mutans were larger than 99.99%. Noticeably, the amount of protein adhered on the surface of ACMs was only 28.1 μg/cm², showing ideal antifouling performance. Collectively, the mutifunctional ACMs in the study are expected to be prominent alternatives for existing IO.

Comparison of translucency, thickness, and gap width of thermoformed and 3D-printed clear aligners using micro-CT and spectrophotometer

The present study compared the thickness and gap width of thermoformed and 3D-printed clear aligners (CAs) using micro-computed tomography (micro-CT) and evaluated their translucency using spectrophotometer. Four groups of CAs were tested: thermoformed with polyethylene terephthalate glycol (TS) or copolyester-elastomer combination (TM), and 3D-printed TC-85 cleaned with alcohol (PA) or with centrifuge (PC). CIELab coordinates were measured (n = 10) to evaluate translucency. CAs (n = 10) were fitted onto respective models and micro-CT was performed to evaluate the thickness and gap width. Thickness and gap width were measured for different tooth type and location in sagittal sections on all sides. The PC group showed significantly higher translucency than the PA group, which was similar to the TS and TM groups (p < 0.01). After the manufacturing process, thickness reduction was observed in the thermoformed groups, whereas thickness increase was observed in the 3D printed-groups. The TM group showed the least gap width amongst the groups (p < 0.01). Thermoformed and 3D-printed CAs had significantly varied thicknesses and regions of best fit depending on the tooth type and location. Differences in the translucency and thickness of the 3D-printed CAs were observed depending on the cleaning methods.

Resistance of PETG Materials on Thermocycling and Brushing

The aim was to assess the impact of thermocycling and brushing on the surface roughness and mass of PETG material-the most commonly used for orthodontic retainers. A total of 96 specimens were exposed to thermocycling and brushing with three different kinds of toothbrushes depending on the number and thickness of the bristles. Surface roughness and mass were evaluated three times: initially, after thermocycling, and after brushing. In all four brands, both thermocycling and brushing increased surface roughness significantly (p < 0.001), with Biolon having the lowest and Track A having the highest. In terms of brushing, only Biolon samples showed statistically significant increased roughness after brushing with all three types of brushes, in comparison to Erkodur A1, where differences were not statistically significant. Thermocycling increased the mass of all samples, but a statistically significant difference was found only in Biolon (p = 0.0203), while after brushing, decreased mass was found in all specimens, statistically significant only in Essix C+ (CS 1560: p = 0.016). PETG material showed instability when exposed to external influences- thermocycling produced an increase in roughness and mass, and brushing mostly caused an increase in roughness and decrease in mass. Erkodur A1 demonstrated the greatest stability, whereas Biolon demonstrated the lowest.

Effectiveness and predictability of treatment with clear orthodontic aligners: A scoping review

INTRODUCTION

In an ideal clinical setting, orthodontic therapy with clear aligners (CA) should improve the patients' initial malocclusion and must guarantee equivalence between the results predicted and those obtained clinically to be considered an effective treatment. Therefore, this scoping review aimed to identify the orthodontic literature concerning the effectiveness and predictability of CA treatments.

METHODS

A systematic computerized search was performed in 3 databases: PubMed, Scopus, and Embase. Inclusion criteria selected observational and clinical studies performed in at least 10 adult orthodontic patients, whose results of CA treatment's effectiveness and/or predictability were assessed.

RESULTS

The 3 database computerized searches resulted in 1,553 articles, and 169 full texts were considered potentially relevant. After applying the eligibility criteria, 33 studies were included. Most studies (76%) were designed as cohort studies and have been published in the last 5 years (79%). The majority included only non-extraction treatments (73%), and 79% reported results achieved with the Invisalign® system. The most predictable movement was the buccolingual tipping, while the least predictable movements were rotation, intrusion, and extrusion. Aligner treatment was effective for mild to moderate crowding resolution, and the success of overbite correction still seems to be limited.

CONCLUSIONS

The studies have demonstrated improvement of initial malocclusion through CA treatments. Still, predictability degree is overestimated and does not accurately reflect the occlusion immediately at the end of treatment. In future studies, there should be an effort to broaden the utilization of alternative aligner systems beyond Invisalign® and broadly disseminate their outcomes to strengthen clear aligners evidence base.

Topographical and Optical Characteristics of Thermoplastic Dental Appliances Materials Related to Water Sorption

Clear thermoplastic materials have increased in popularity in the dental field due to their various applications, combination of excellent aesthetics, and good biomechanical behavior, but they may be influenced by different environmental conditions. The purpose of the present study was to assess the topographical and optical characteristics of thermoplastic dental appliances materials relative to water sorption. PET-G polyester thermoplastic materials were evaluated in this study. Related to water uptake and desiccation stages, surface roughness was analyzed, and three-dimensional AFM profiles were generated for nano-roughness measurements. Optical CIE L*a*b* coordinates were recorded and parameters like translucency (TP), contrast ratio for the opacity (CR), and opalescence (OP) were derived. Levels of color changes were achieved. Statistical analyses were performed. Water uptake significantly increases the specific weight of the materials, and after desiccation, the mass decreases. Roughness increased after water immersion as well. Regression coefficients indicated a positive correlation between TP and a* and between OP and b*. Studied PET-G materials have a different behavior to water exposure, but for all their specific weight, they increased significantly within the first 12 h. It is accompanied by an increase in the roughness values, even if they continue to be kept below the critical mean surface roughness. On nano-level, 3D images show an increase in inhomogeneity in the network structure of particles. Slight color changes were registered.

Evaluation of Mechanical Properties of Different Thermoplastic Orthodontic Retainer Materials after Thermoforming and Thermocycling

While the durability of thermoplastic aligners has been the subject of numerous studies, the durability of thermoplastic retainers has received significantly less attention. Patients are often advised to wear their thermoplastic retainers indefinitely, so the durability of the materials used in their fabrication is crucial to determining whether they are worth the cost. Limited studies have evaluated the properties of thermoplastic retainer materials and the effects of thermocycling on their mechanical properties. Thus, this study aimed to examine six thermoplastic retainer materials after thermoforming with and without thermocycling. The materials' flexural modulus, hardness, and surface roughness values were measured after thermoforming (Group 1) and after thermoforming with subsequent thermocycling for 10,000 cycles (Group 2). After thermoforming, there was a significant difference in flexural modulus and hardness values between most of the materials. However, their surface roughness was not significantly different (p < 0.05). After thermocycling, the flexural modulus and hardness increased significantly for most tested materials (p < 0.05) compared to Group 1. Concerning the surface roughness, only two materials showed significantly higher values after thermocycling than Group 1. Thus, all the mechanical properties of the evaluated materials differed after thermoforming, except the surface roughness. Moreover, while thermocycling made the materials stiffer and harder in general, it also made some of them rougher.

Color stability of aligner materials on exposure to indigenous food products: An in-vitro study

Background

In the recent day, there has been an exponential growth in the usage of clear aligners for orthodontic treatment. As with any removable appliance, the compliance of patients to remove it during ingestion of food is, at times, poor. Thus, the stability of the clear aligner to be "clear" becomes questionable. This in-vitro study examined how the clear aligners changed colour on exposure to various indigenous food products used in everyday life.

Methods

Aligners from 5 different companies (K Line, Clearbite Aligners, The Aligner Company, iAligners and MaxDent CA Digital) were exposed for 12 hours and 24 hours to various indigenous substances (tea, green tea, coffee, turmeric, saffron and Kashmiri red chili powder) and a control solution (distilled water) in-vitro. The color change was assessed with the help of VITA Easyshade compact colorimeter based on Commission Internationale de I'Eclairage L*a*b* color system. Values were then modified to NBS units for clinical relevance.

Results

The hue of the transparent aligners was noticed to change in a statistically meaningful way when exposed to turmeric, saffron, Kashmiri red chili powder and coffee in decreasing order and mild color change in tea and green tea at both 12 hours and 24 hours intervals.

Conclusion

Aligners are prone to color change when exposed to indigenous foods that contain staining properties.

Advances in orthodontic clear aligner materials

Rapid technological improvements in biomaterials, computer-aided design (CAD) and manufacturing (CAM) have endorsed clear aligner therapy (CAT) as a mainstay of orthodontic treatment, and the materials employed for aligner fabrication play an all-important role in determining the clinical performance of clear aligners. This narrative review has attempted to comprehensively encompass the entire gamut of materials currently used for the fabrication of clear aligners and elucidate their characteristics that are crucial in determining their performance in an oral environment. Historical developments and current protocols in aligner fabrication, features of contemporary bioactive materials, and emerging trends related to CAT are discussed. Advances in aligner material chemistry and engineering possess the potential to bring about radical transformations in the therapeutic applications of CAT; in the absence of which, clear aligners would continue to underperform clinically, due to their inherent biomechanical constraints. Finally, while innovations in aligner materials such as shape memory polymers, direct three-dimensional (3D) printed clear aligners and bioactive materials combined with clear aligner materials are essential to further advance the applications of CAT; increased awareness of environmental responsibilities among aligner manufacturers, aligner prescribing clinicians and aligner users is essential for better alignment of our climate change goals towards a sustainable planet.

Stress Relaxation Properties of Five Orthodontic Aligner Materials: A 14-Day In-Vitro Study

We aimed to investigate the stress relaxation properties of five different thermoplastic aligner materials subjected to 14 days of constant deflection. Five different thermoplastic aligner materials were selected, whose elastic properties varied: F22 Evoflex, F22 Aligner, Durasoft, Erkoloc-Pro and Duran. The static properties of these materials—in particular, stiffness, stress–strain curve and yield stress—were measured with a three-point bending test. For all the tests that were performed, a minimum of three samples per material were tested. The yield load, yield strength, deformation and particularly the stiffness of each material were found to be similar in the single-layer samples, while the double-layer samples showed far lower stiffness values and were similar one to another. F22 Evoflex and Erkoloc-Pro maintained the highest percentages of stress, 39.2% and 36.9%, respectively, during the 15-day period. Duran and Durasoft obtained the lowest final stress values, 0.5 MPa and 0.4 MPa, respectively, and the lowest percentage of normalized stress, 4.6% and 3.9%, respectively, during the 15-day period. All the materials that we tested showed a rapidity of stress decay during the first few hours of application, before reaching a plateau phase. The F22 Evoflex material showed the greatest level of final stress, with relatively constant stress release during the entire 15-day period. Further research after in vivo aging is necessary in order to study the real aligners’ behavior during orthodontic treatment.

A full-field DIC analysis of the mechanical-deformation behavior of polyethylene terephthalate glycol (PET-G) aligners

OBJECTIVES

The aim was to investigate the full-field mechanical-deformation behavior of clear aligners made by polyethylene terephthalate glycol (PET-G) subjected to cyclic compression tests.

METHODS

Digital Image Correlation (DIC) (Chu et al., 1985; Schreier et al., 2009), a contactless full-field measurement technique, and Optical Microscope (OM) analysis were applied to study two PET-G aligners thermoformed from discs of a thickness of 0.75 mm and 0.88 mm. The clear aligners were placed on dental shape resin casts and were subjected to cyclic compression up to 13000 load cycles from 0 to 50 N at room temperature. The chosen number of load cycles simulates the average load history to which an aligner is subjected for one week. Local displacements and strains were measured for each test at 2, 6, 10, 20, 1000, 5000 and 13000 loading cycles.

RESULTS

Both aligners showed greater displacements in the early stages of loading, more pronounced for the 0.88 mm one. Local displacement and strain maps are derived both along the load direction and to the transverse one (never done from other researchers). Load-displacement cyclic curves allowed to evaluate the evolution of the stored energy and the stiffness during the test. The OM analyses showed significant morphological variations on the aligners' surface, such as wear and tear, high depressions and cracks, especially for the 0.75 mm specimen.

SIGNIFICANCE

Full-field analysis allowed to understand the mechanical behavior of device with complex geometry and complex load distribution, like invisible aligners. The knowledge of the stiffness and the direction of the total displacement helps the orthodontist to implement the best strategy to improve the patient's comfort and the treatment time.

Effects of various cleaning agents on polypropylene and copolyester thermoplastic orthodontic retainer materials

Objectives

This study aimed to evaluate and compare the effects of four cleaning agents on the flexural modulus and light transmittance properties of polypropylene and copolyester thermoplastic retainer materials after long-term exposure.

Methods

A total of 120 pieces of standardized copolyester and polypropylene retainer materials were tested after being thermoformed. They were divided equally into six subgroups: as-received, artificial saliva, chlorhexidine, alcohol-based and alcohol-free mouthwashes, and Retainer Brite®. The pieces were subjected to a cleaning process involving 15 minute immersion three times weekly for 3 months. The flexural modulus and light transmittance were then measured for all specimens with three point bending tests and spectrophotometry, respectively. One-way ANOVA and independent samples t-test were applied to compare the means, and Tukey's post hoc test was used in cases of significant differences. The threshold for significance was 0.05.

Results

For each retainer type, the statistical results revealed that the flexural modulus values of the copolyester retainer material significantly differed from those of polypropylene material under chlorhexidine mouthwash, alcohol-based mouthwash, and Retainer Brite® conditions. Copolyester and polypropylene showed significant differences in light transmittance under all conditions. No significant difference in flexural modulus values was observed among conditions, whereas significant differences in light transmittance were observed between alcohol-based mouthwash and the other conditions for copolyester material.

Conclusions

According to our results, any cleaning agent can be safely used for both materials without affecting the elastic modulus. However, alcohol-based mouthwash decreases the light transmittance of copolyester retainer material.

Color Stability, Chemico-Physical and Optical Features of the Most Common PETG and PU Based Orthodontic Aligners for Clear Aligner Therapy

It is difficult to find research papers collecting comparative results about characterization studies of clear aligners. Therefore, the aim of this paper is to provide the first comparative analysis of most commercial clear aligners, in terms of their stability towards intra-oral staining agents, their physicochemical and optical properties, as well as their water absorption behavior. Five types of aligners, characterized by different techniques, are considered: Erkodur, Essix Plastic, Ghost Aligner, Zendura, and Invisalign. The obtained results show that clear aligners are made up of PETG, semi rigid PU, and a mixture of PU and PETG, with different degrees of crystallinity which affect the transparency of each aligner. In particular, the PETG-based materials reveal the highest value of short-range order and the highest properties in terms of transparency in the visible range. After 14 days of immersion into red wine and coffee, PETG and PU-based aligners reveal a perceivable change in color (NBS values from 1.5 to 3), corresponding to a loss of transparency due to the deposition of impurities on the surface. These results are particularly marked for Invisalign, showing changes towards other colors (NBS up to 35), probably due to the thermoforming process which led to the formation of a wrinkled surface entrapping the impurities.

Effect of Water-Based Disinfectants or Air-Drying on Dimensional Changes in a Thermoplastic Orthodontic Aligner

The polymer structure of thermoplastic materials currently used to make aligners is altered by the oral conditions and this negatively affects their capacity to move teeth. This study aimed to compare different options for storing aligners when not in use by superimposing successive 3D images to identify which storage method least affects material shape and weight. Fifty PET-G aligners, produced using the CA Digital method, were divided into four groups (1A, 1B, 1C, and 2D) and were stored for 18 h a day in artificial saliva at 37 °C. Then, to mimic their storage conditions when not in use, aligners in group 1A were immersed for the remaining 8 hours a day in bicarbonate solution, those in group 1B in chlorhexidine solution, those in group 1C in distilled water, and those in group 2D were stored dry. The samples were scanned at the baseline (before the immersion cycles began) and again two weeks later. The digital scans were superimposed and the median deformation, its variability, and weight differences were recorded for each group. Statistical analysis showed aligner deformation (expansion) in all three groups stored in wet conditions, with a statistically significant difference between groups 1A and 1C. Aligners in group 2D shrank slightly, and to a significantly greater degree with respect to group 1C. Variability in the degree of deformation was similar among the three groups stored in wet conditions, but significantly greater in group 2D. Weight gains were recorded in all four groups, the smallest in group 2D and the largest in group 1A. Storing aligners in dry conditions promoted lower deformation in the material, involving a slight shrinkage, whereas wet storage conditions caused an expansion of the aligner, especially when distilled water is used.

Thermal and mechanical characterization of thermoplastic orthodontic aligners discs after molding process

Polymeric aesthetic aligners were introduced in orthodontics as an innovative alternative to fixed appliances, however, their compositions and the thermal molding process may influence the biomechanical characteristics of these aligners. In this study four different clear aligner brands were used, ACE 035 Essix, C + Essix, Crystal 0.75 and Crystal 1.0, whose aim was to identify the thermal-processing influence on the mechanical and physicochemical properties of these materials, and to suggest a orthodontic sequence of wear for these appliances to achieve more effective treatment results. For the tensile tests the sample size calculation was based on probability distributions from the F test. The effect size used was 0.3, type 1 error of 0.05. Statistical Yield strength and Young's Modulus results were evaluated using the Shapiro-Wilk test. The groups were compared using the parametric test of analysis of variance, with Tukey post-test. Differences were statistically considered at the p < 0.05. The Infrared spectroscopy analysis showed no changes in the samples' chemical structure after thermal-processing. However, in the polypropylene aligner, differences were verified in the region attributed to the crystalline phase. Differential Scanning Calorimetry analysis for the same sample showed a crystallinity fraction decrease due to relaxation between polymer chains after molding. In the tensile tests evaluated, the tensile strength and 'Young's modulus presented higher values for aligners containing 100% polyethylene terephthalate glycol. Performing an analogy exercise of the properties of orthodontic wires used in conventional fixed appliances and, relating them to orthodontic plastics, aligners composed of different materials and/or thicknesses could be used in increasing sequence in terms of the modulus of elasticity, starting with C+, which has a lower elastic modulus value, using the ACE 035 as an intermediate and finishing with the Crystal 0.75 and 1.0, providing the desired stiffness to the aligners for the final phase.

SEM characterization and ageing analysis on two generation of invisible aligners

Background

The purpose of the in vitro study is to investigate and compare the morphological features and the chemical stability in weight of two different polyurethane-based blends, Smart Track (LD30) and Exceed30 (EX30), used for orthodontic aligners manufacture before and after the oral usage.

Methods

Twenty orthodontic aligners were randomly selected: 10 LD30 and 10 EX30, each group was divided in two subgroups, never used and intra-orally aged. By the employment of a Stereomicroscope, a section of 5 × 5 mm was cut from the buccal surface of the incisal region of each aligner. All samples were subjected to Scanning Electron Microscopy and Ageing tests in different solutions to simulate the hostility of the oral environment. The statistical method used was t-test.

Results

At SEM images, LD30 appears more homogeneous in texture respect to EX30. However, after clinical usage, both materials show significant structural alterations: findings have been supported by higher magnifications at SEM, by which it is clearly to observe many superficial cracks cross through the polymer structures of LD30U, absent in never used samples. LD30U surface becomes also smoother due to the disappearance of most of the conglomerates, but at the same time also rougher while EX30U shows a greater irregularity and porosity in which large and deep cracks are also highlighted. Although these changes occur persistently, in the aging tests no significant weight loss from both materials has been found, confirming the initial hypothesis of a good chemical stability and safety of both polyurethane mixtures even in conditions of severe hostility.

Conclusion

LD30 is the expression of the technological evolution of EX30, this is made evident above all by its morphological architecture, more homogeneous and defined but also by the chemical stability that can be appreciated even in evident critic situations.

Force Distribution of a Novel Core-Reinforced Multilayered Mandibular Advancement Device

A mandibular advancement device (MAD) is a commonly used treatment modality for patients with mild-to-moderate obstructive sleep apnea. Although MADs have excellent therapeutic efficacy, dental side effects were observed with long-term use of MADs. The aim of this study was to analyze the force distribution on the entire dentition according to the materials and design of the MADs. Three types of MADs were applied: model 1 (single layer of polyethylene terephthalate glycol (PETG)), model 2 (double layer of PETG + thermoplastic polyurethane (TPU)), and model 3 (core-reinforced multilayer). In the maxilla, regardless of the model, the incisors showed the lowest force distribution. In most tooth positions, the force distribution was lower in models 2 and 3 than in model 1. In the mandible, the mandibular second molar showed a significantly lower force in all models. The mandibular incisors, canines, and molars showed the highest force values in model 1 and the lowest values in model 3. Depending on the material and design of the device, the biomechanical effect on the dentition varies, and the core-reinforced multilayered MAD can reduce the force delivered to the dentition more effectively than the conventional single- or double-layer devices.

Orthodontic Aligner Incorporating Eucommia ulmoides Exerts Low Continuous Force: In Vitro Study

The aim of this study was to investigate the orthodontic force exerted by thermoplastic orthodontic appliances incorporating Eucommiaulmoides in terms of usefulness as the aligner-type orthodontic device. Erkodur, Essix C+^®, Eucommia elastomer, and edgewise brackets were used (n = 3, each; thickness = 1.0 mm, each). The orthodontic force on the upper right incisor was measured every 24 h for two weeks using a custom-made measuring device. The force of the Eucommia elastomer (4.25 ± 0.274 N) and multi bracket system (5.32 ± 0.338 N) did not change from the beginning to the end (p > 0.01). The orthodontic force exerted by the Eucommia elastomer was lower than that of the multi-bracket orthodontic appliance from the beginning to the end. The force of Erkodur significantly decreased from the beginning to 24 h (6.47 ± 1.40 N) and 48 h (3.30 ± 0.536 N) (p < 0.01). The force of Essix C+^® significantly decreased from the beginning (13.2 ± 0.845 N) to 24 h (8.77 ± 0.231 N) (p < 0.01). The thermoplastic orthodontic appliance made of Eucommia elastomer continuously exerted a constant orthodontic force for two weeks under water immersion conditions. The orthodontic force of Eucommia elastomer was found to be similar to the orthodontic force exerted by the multi-bracket orthodontic appliance with 0.019 × 0.025 in nickel–titanium wire. These results suggest that the Eucommia elastomer has possibly become one of the more useful materials to form thermoplastic orthodontic appliance exerting low continues orthodontic force.

Surface Quality Evaluation of Removable Thermoplastic Dental Appliances Related to Staining Beverages and Cleaning Agents

(1) Background: Thermoplastic materials are not inert and subject to changes in the oral environment, which affect their surface quality. Color stability and topographic characteristics of clear thermoplastic appliances are critical considerations. The study aimed to evaluate the optical changes and surface topography of different thermoplastic materials related to staining beverages and cleaning agents. (2) Methods: Thermoplastic polyethylene terephthalate glycol (PET-G) material specimens were selected for the study: S (Duran, Scheu-Dental GmbH, Iserlohn, Germany), D (Biolon, Dreve Dentamid GmbH, Unna, Germany), and B (Crystal, Bio Art Dental Equipment, Sao Carlos, Brazil). Four different media were involved for immersion: coffee (C) and black tea (T) at 55 °C, Coca-Cola (K) at 5 °C, and distilled water (W) at 22 °C. As for cleaning, chemical options and mechanical brushing were selected (P-powder, T-tablets, and X-brushing). Color changes, and mean surface roughness were measured at 24 h, 48 h, and after 7 days. Statistical analysis was performed. After the testing period, atomic force microscopy (AFM) analyses and SEM images were registered in order to characterize the surface topography. (3) Results: Quantitative color change evaluations revealed a slight change in color after 24 h and an extremely marked change after 48 h, respective 7 days. Mean roughness values are kept below the clinically acceptable limit of 0.20 µm for all samples. Related to mean nanoroughness values Sa, and 3D evaluations of the surface quality, Biolon samples have demonstrated the most constant behavior, while Crystal samples are visibly influenced by water immersion. Related to the cleaning method, the topography of Duran samples was influenced by mechanical brushing. (4) Conclusions: Nanoscale investigations provided high accuracy and more realistic surface quality examinations of the examined samples compared to profilometry. Both SEM and AFM should be used for a more detailed description of the surface topography.

Influence of constant strain on the elasticity of thermoplastic orthodontic materials

The aim of this study was to identify a physical property suitable for evaluating the orthodontic force by analyzing the physical properties of thermoplastic materials. Four thermoplastic materials were used: Essix A+^® Plastic (EA), DURAN^® (DU), Erkodur (ER), and Essix C+^® Plastic (EC). Finite element analysis (FEA), a water absorption test, constant strain loading test, X-ray diffraction (XRD) and Fourier transformation infrared spectroscopy analysis were conducted. FEA found a significant correlation between the elastic modulus and the orthodontic force. The water absorption of EC was significantly smaller than the other materials. EC showed no elastic modulus change. The XRD pattern indicated that EC was a crystalline polymer. FEA of thermoplastics showed that the elastic modulus is suitable for the evaluation of orthodontic force. The crystalline thermoplastic EC demonstrated a stable elastic modulus even under strain in a wet environment, suggesting the advantage of its use as an orthodontic aligner material.

Thermoplastic Disks Used for Commercial Orthodontic Aligners: Complete Physicochemical and Mechanical Characterization

Invisible orthodontic aligners (IOAs) have been introduced in the orthodontic field as an innovative alternative for fixed brackets, in relation to their ability to be easily inserted/removed from the oral cavity without affecting the chewing ability and the aesthetic of the patients. The paper provides a complete physicochemical and mechanical characterization of thermoplastic materials in the form of disks used for commercial IOAs. A wide palette of specific techniques is considered, from tensile tests and dynamic-mechanical analysis, to X-Ray diffraction (XRD), differential scanning calorimetry (DSC), Fourier transformation infrared spectroscopy (FTIR-ATR) analyses and water absorption tests. The disks are investigated before and after immersion into staining beverages (red wine, coffee, nicotine and artificial saliva), in terms of colour variations, transparency, and microscopic surface modifications by means of colorimetry, UV-VIS absorbance and scanning electron microscopy (SEM). Among all the samples, polyurethane (PU) exhibited the highest crystallinity and the highest values of mechanical and thermal resistance, while the poly(ethylene terephthalate)-glycol (PETG) samples presented better transparency and less ability to absorb water. Moreover, red wine and coffee give noticeable colour variations after 14 days of immersion, together with a slight reduction of transparency.

ATR-FTIR Analysis and One-Week Stress Relaxation of Four Orthodontic Aligner Materials

The aim of this study was to estimate possible differences in the chemical composition and relaxation of orthodontic aligner materials. Four commercially available thermoplastic materials CAM (Scheu-Dental, Iserlohn, Germany), COP (Essix, Dentsply Raintree Essix Sarasota,FL, USA), DUR (Great Lakes Dental Technologies, Tonawanda, NY) and ERK (Erkodent Erich Kopp, Pfalzgrafenweiler Germany) were included in this study. Rectangular strips from each material were prepared according to the manufacturer's instructions and subjected to attenuated total reflection-Fourier transform infrared (ATR-FTIR) spectroscopy and stress relaxation characterization. The reduction in applied stress (RAS) after one week was estimated and statistically analyzed by one-way ANOVA at the 0.05 level of significance. All specimens were subjected to optical microscopy before and after stress relaxation testing under transmittance polarized illumination. ATR-FTIR microscopy revealed that all materials are made of polyethylene terephthalate glycol (PETG) while no significant differences were identified in RAS values among materials tested, which ranged from 6%-10% (p ≥ 0.05). All samples illustrated the developments of shear bands during relaxation testing according to optical microscopy findings. The tested materials illustrated similar chemical composition and relaxation behavior and thus no differences in their clinical efficacy are anticipated.

Thickness of orthodontic clear aligners after thermoforming and after 10 days of intraoral exposure: a prospective clinical study

Background

Clear aligners (CA) are among the most chosen orthodontic therapies for patients who require an invisible treatment. Previous studies showed that the thermoforming process and the complexity of the intraoral environment might alter the properties of these devices. The aim of the current prospective clinical study was to assess the thickness changes of the CA after 10 days of intraoral use. The secondary aim was to assess the reproducibility of the thermoforming process, in terms of aligner thickness.

Materials and methods

CA from 18 consecutive patients (13 women, 5 men, mean age 28.8 ± 9.6 years) were investigated. Before intraoral exposure (T0), the thickness of the unused CA was measured at different occlusal points on a 3D model with a dedicated software (Geomagic Qualify 2013; 3D Systems, Rock Hill, SC, USA). Two CA configurations were studied: passive maxillary aligner (P—no tooth movement; no shape for attachments) and active maxillary aligner (A—tooth movement; shape for attachments and divot). The used aligners were returned after 10 days (T1) and the thickness measurements were repeated. A Student’s t test for paired data (T1 vs. T0) was applied to compare the thicknesses of used and unused devices (significance level after Bonferroni correction for multiple comparison was set at p < 0.0014). Furthermore, to study the reproducibility of the thermoforming process, P and A aligners were thermoformed twice, and the thicknesses of the two unused thermoformed devices were compared by means of Student’s t test for paired data (significance level after Bonferroni correction for multiple comparison was set at p < 0.0014) and Dahlberg’s error.

Results

The thermoforming process showed good reproducibility for both aligner configurations, with a maximum Dahlberg’s error of 0.13 mm. After intraoral use, the thickness of P showed some statistically significant, but not clinically relevant, thickness changes as compared to the unused aligners, while A did not show any significant changes.

Conclusion

Considering the thickness changes, the thermoforming process is reliable both with active and passive aligner configurations. Also, the CA examined show good thickness stability after physiological intraoral ageing in a population of healthy adults.

Mechanical Characterization of Thermoplastic Aligner Materials: Recommendations for Test Parameter Standardization

Background

Understanding of the different mechanical properties of thermoplastic materials is essential for a successful aligner treatment and further developments. However, data of previous material testing studies are scarcely comparable. Aim of the current study was to evaluate the different test parameters to lay the foundations for guidelines for future, more standardized three-point-bending aligner material tests.

Materials and Methods

Several parameters concerning the specimen preparation and experimental three-point-bending setup were varied. The specimens were collected from polyethylene terephthalate glycol (PET-G) Duran® foils with different thicknesses. Both raw foils and foils thermoformed using different geometrical forms were investigated. The three-point-bending tests were performed using span lengths of 8 and 16 mm and variable deflection ranges between 0.1 and 0.2 mm. The influence of water storage on the bending forces was studied using unloaded and loaded specimens. Experimental results were validated using a beam cantilever mathematical model.

Results

Local macroscopic cracks after long-term loading could be avoided by keeping the deflections within a thickness-dependent individual range. The mathematical calculations confirmed that these individual deflection ranges lead to local stresses between 14 and 18 MPa. Constantly loaded specimens immersed for 24 hours in water showed a decrease of the bending force by 50%. This reduction was much smaller for the unloaded specimens (14%).

Conclusion

During clinical aligner therapy, very small bending deflections are combined with small distances between the tooth surface regions supporting the aligner. In vitro aligner material testing by three-point bending should consider these geometrical aspects, while keeping the material stresses in a range between 14 and 18 MPa to avoid local microcracks. Considering these aspects, thickness-dependent deflections were established for three-point bending of the PET-G specimen for a span length of 8 mm. We recommend the application of these test parameters in future aligner material studies to achieve valid and comparable test results.

Efficacy of self-designed intraoral appliances in prevention of cheek, lip and tongue bite after local anesthesia administration in pediatric patients

BACKGROUND

The occurrence of self-inflicted soft tissue injuries following administration of local anesthesia in pediatric patients who have received dental treatment has been reported. Aim: To evaluate the attitudes and knowledge regarding cheek, lip, and tongue bite post administration of local anesthesia among dental practitioners in Saudi Arabia. Additionally, the efficacies of three types of intraoral appliances on the prevention of self-harm were evaluated in pediatric patients.

MATERIAL AND METHODS

A total of 301 practitioners were provided with a questionnaire consisting of 9 items. In addition, three types of intraoral appliances made of polyethylene terephthalate were designed as follows: design 1 (consisted of an anterior extension with numerous perforations); design 2 (had a buccal flap extension); and design 3 (comprised of serrated borders). The appliances were placed in the oral cavities of 45 children (age, 3-15 years) immediately after the completion of the dental procedure. The patient was asked to retain the appliance for 3 h. After 24 h, both parents and children were required to respond to a checklist to evaluate the effectiveness the appliances.

RESULTS

Almost half of the dental practitioners had never encountered self-inflicted soft tissue injury in children after local anesthesia administration. About 60% of the dentists were of the opinion that provision of adequate instructions after treatment could prevent the occurrence of lip, cheek, and tongue biting. Furthermore, among the three appliances used, design 1 was most well accepted.

CONCLUSIONS

Intraoral appliances used in this study may be considered for use to prevent self-inflicted soft tissue trauma in children following administration of local anesthesia. Key words:Cheek biting, lip biting, intraoral appliance, local anesthesia.

Effects of thermoforming on the physical and mechanical properties of thermoplastic materials for transparent orthodontic aligners

Objective

The aim of this systematic multiscale analysis was to evaluate the effects of thermoforming on the physical and mechanical properties of thermoplastic materials used to fabricate transparent orthodontic aligners (TOAs).

Methods

Specimens were fabricated using four types of thermoplastic materials with different thicknesses under a thermal vacuum. Transparency, water absorption and solubility, surface hardness, and the results of three-point bending and tensile tests were evaluated before and after thermoforming. Data were analyzed using one-way analysis of variance and Student's t-test.

Results

After thermoforming, the transparency of Duran and Essix A+ decreased, while the water absorption ability of all materials; the water solubility of Duran, Essix A+, and Essix ACE; and the surface hardness of Duran and Essix A+ increased. The flexure modulus for the 0.5-mm-thick Duran, Essix A+, and eCligner specimens increased, whereas that for the 0.75-/1.0-mm-thick Duran and eClginer specimens decreased. In addition, the elastic modulus increased for the 0.5-mm-thick Essix A+ specimens and decreased for the 0.75-mm-thick Duran and Essix ACE and the 1.0-mm-thick Essix ACE specimens.

Conclusions

Our findings suggest that the physical and mechanical properties of thermoplastic materials used for the fabrication of TOAs should be evaluated after thermoforming in order to characterize their properties for clinical application.

Mechanical properties of "two generations" of teeth aligners: Change analysis during oral permanence

Aim of this in vitro study was to analyze structural properties of two different polymeric orthodontic aligners, Exceed30 (EX30) and Smart Track (LD30), before and after use. Forty patterns of aligners were randomly selected: 20 LD30 and 20 EX30, worn intra-orally for 14±3 days, 22 h/day. From each aligner, 10 specimens were prepared from buccal surfaces of the incisor region by the cutting of samples 5×5 mm under a stereomicroscope. All samples were subjected to Fourier transform infrared spectroscopy, micro-Raman spectroscopy, X-ray diffraction, tensile and indentation strength test. LD30 appeared more homogeneous, with a crystalline fraction lower than EX30 and exhibited a higher elastic behavior and a lower tendency to warp after use than EX30. LD30 demonstrated better adaptability to the dental arch and greater consistency of application of orthodontic forces than produced with EX30. However, both materials showed structural modifications that resulted in increased sample hardness and hyper-plasticity.

Long-term effects of seven cleaning methods on light transmittance, surface roughness, and flexural modulus of polyurethane retainer material

OBJECTIVES

To evaluate the long-term effects of seven different cleaning methods on light transmittance, surface roughness, and flexural modulus of a polyurethane retainer material.

MATERIALS AND METHODS

Polyurethane retainer specimens (Vivera®, Align Technology Inc) (70 specimens, n = 10 per method, 50.8 mm × 12.7 mm × 1.0 mm) were exposed to seven cleaning methods twice a week for 6 months. Before treatment and after 6 months, light transmittance, surface roughness, and flexural modulus of the specimens were quantified. Qualitative assessment of randomly selected specimens from each solution was performed at baseline and after 6 months using a scanning electron microscope. Statistical analyses were performed at the .05 significance level.

RESULTS

Of the three test variables, light transmittance through the specimens was the only one that changed significantly from baseline to 6 months for all cleaning solutions, with all of them causing a decrease. However, except for 0.6% sodium hypochlorite showing a change in surface roughness values and 2.5% vinegar and toothbrushing showing an increase in flexural modulus, none of the other four cleaning methods resulted in significant changes in surface roughness or flexural modulus values for the polyurethane specimens between baseline and after 6 months.

CONCLUSIONS

Of the seven cleaning methods, Invisalign® cleaning crystals, Polident®, and Listerine® showed the least amount of change in light transmittance values for the polyurethane specimens over 6 months, and they had no effect on surface roughness and flexural modulus values.

[Current situation and prospect for orthodontic thermoplastic materials]

Aesthetic and comfortable transparent retainers and clear plastic appliances are becoming increasingly popular, and their components, especially thermoplastic materials, are gradually attracting widespread interest. Orthodontic thermoplastic materials are versatile polymers, and thus their properties, such as force delivery, force relaxation, and aging properties have been comprehensively studied. Meanwhile, blending modification technology has been applied for the acquisition of novel materials with enhanced characteristics. In this paper, we review the types and properties of thermoplastic materials, the development process they undergo, factors that influence their properties, and some development prospects.

Colour stabilities of three types of orthodontic clear aligners exposed to staining agents

The aim of this study was to evaluate and compare the colour stabilities of three types of orthodontic clear aligners exposed to staining agents in vitro. Sixty clear orthodontic aligners produced by three manufacturers (Invisalign, Angelalign, and Smartee) were immersed in three staining solutions (coffee, black tea, and red wine) and one control solution (distilled water). After 12-h and 7-day immersions, the aligners were washed in an ultrasonic cleaner and measured with a colourimeter. The colour changes (ΔE*) were calculated on the basis of the Commission Internationale de I'Eclairage L*a*b* colour system (CIE L*a*b*), and the results were then converted into National Bureau of Standards (NBS) units. Fourier transformation infrared (FT-IR) spectroscopy and scanning electron microscopy (SEM) were conducted to observe the molecular and morphologic alterations to the aligner surfaces, respectively. The three types of aligners exhibited slight colour changes after 12 h of staining, with the exception of the Invisalign aligners stained with coffee. The Invisalign aligners exhibited significantly higher ΔE* values (ranging from 0.30 to 27.81) than those of the Angelalign and Smartee aligners (ΔE* values ranging from 0.33 to 1.89 and 0.32 to 1.61, respectively, P<0.05). FT-IR analysis confirmed that the polymer-based structure of aligners did not exhibit significant chemical differences before and after the immersions. The SEM results revealed different surface alterations to the three types of aligner materials after the 7-day staining. The three types of aesthetic orthodontic appliances exhibited colour stability after the 12-h immersion, with the exception of the Invisalign aligners stained by coffee. The Invisalign aligners were more prone than the Angelalign and Smartee aligners to pigmentation. Aligner materials may be improved by considering aesthetic colour stability properties.

Stress relaxation properties of four orthodontic aligner materials: A 24-hour in vitro study

OBJECTIVE

To investigate the stress release properties of four thermoplastic materials used to make orthodontic aligners when subjected to 24 consecutive hours of deflection.

MATERIALS AND METHODS

Four types of aligner materials (two single and two double layered) were selected. After initial yield strength testing to characterize the materials, each sample was subjected to a constant load for 24 hours in a moist, temperature-regulated environment, and the stress release over time was measured. The test was performed three times on each type of material.

RESULTS

All polymers analyzed released a significant amount of stress during the 24-hour period. Stress release was greater during the first 8 hours, reaching a plateau that generally remained constant. The single-layer materials, F22 Aligner polyurethane (Sweden & Martina, Due Carrare, Padova, Italy) and Duran polyethylene terephthalate glycol-modified (SCHEU, Iserlohn, Germany), exhibited the greatest values for both absolute stress and stress decay speed. The double-layer materials, Erkoloc-Pro (Erkodent, Pfalzgrafenweiler, Germany) and Durasoft (SCHEU), exhibited very constant stress release, but at absolute values up to four times lower than the single-layer samples tested.

CONCLUSIONS

Orthodontic aligner performance is strongly influenced by the material of their construction. Stress release, which may exceed 50% of the initial stress value in the early hours of wear, may cause significant changes in the behavior of the polymers at 24 hours from the application of orthodontic loads, which may influence programmed tooth movement.

Optical properties of orthodontic aligners--spectrophotometry analysis of three types before and after aging

Background

The aim was to assess and compare absorbance and transmittance values of three types of clear orthodontic aligners before and after two cycles of in vitro aging.

Methods

Nine samples of orthodontic aligners from three different manufacturers (Invisalign, Align Technology, Santa Clara, CA, USA; All-In, Micerium, Avegno, GE, Italy; F22 Aligner, Sweden & Martina, Due Carrare, PD, Italy) were selected, and each sample was subjected to spectrophotometry analysis of both its transmittance and absorbance a total of 27 times. Samples were subsequently aged in vitro at a constant temperature in artificial saliva supplemented with food colouring for two cycles of 14 days each. The spectrophotometry protocol was then repeated, and the resulting data were analysed and compared by means of ANOVA (p < 0.05).

Results

All types of aligners tested yielded lower transmittance and higher absorbance values after aging, but the difference was not significant in any case. That being said, the F22 aligners were found to be most transparent, both before and after aging, followed by Invisalign and All-In, and these differences were statistically significant.

Conclusions

Commercial aligners possess significantly different optical, and therefore aesthetic, properties, both as delivered and following aging.

Efficacy of three hygienic protocols in reducing biofilm adherence to removable thermoplastic appliance

OBJECTIVES

To examine the ability of a removable thermoplastic appliance (RTA) to adsorb hygienic solutions and inhibit bacterial growth and to examine the efficacy of three hygiene protocols in reducing bacterial biofilm adherence to RTA.

MATERIALS AND METHODS

Solution adsorption and bacterial growth inhibition were examined in vitro using paper vs RTA discs. Subsequently, 11 patients treated with RTA (mean age, 29.1 ± 4.7 years) were assigned into a sequence of three hygiene protocols: regular RTA brushing (baseline), immersion RTAs in chlorhexidine mouthwash (CHX), and using a vibrating bath with cleaning solution (VBC). For each patient, 12 upper RTAs were examined (2 baseline RTAs, 5 CHX RTAs, and 5 VBC RTAs), for a total of 132 RTAs. All RTAs were stained with gentian violet, and biofilm presence was measured using a photodensitometer.

RESULTS

The RTA discs did not adsorb CHX or cleaning solution. The later agent did not show antibacterial features. Baseline RTAs showed significant biofilm adherence (P < .001) on the posterior palatal side of the aligner and on the anterior incisal edge. CHX and VBC hygienic protocols significantly (P < .001) reduced baseline biofilm adherence by 16% and 50%, respectively. Hygienic improvement was maintained over 140 days when CHX and VBC were used. However, VBC was three times more efficient than CHX.

CONCLUSIONS

This study highly recommends the use of a VBC protocol. Biofilm deposits on the RTA, especially on incisal edges and attachment dimples, could lead to inadequate tooth/RTA and attachment/RTA overlap and consequently impair tooth alignment.