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

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.

Clinical expression of programmed maxillary buccal expansion and buccolingual crown inclination with Invisalign EX30 and SmartTrack aligners and the effect of 1-week vs. 2-week aligner change regimes: A retrospective cohort study

Objective

: This retrospective cohort study aimed to assess and compare the accuracy of 3 different Invisalign® treatment regimens in terms of variations of aligner change frequency and type of aligner material in achieving maxillary dental buccal expansion.

Methods

: Altogether, 120 adult patients whose treatment involved maxillary dental expansion with Invisalign® were included. The patients were divided into 3 groups, with each group comprising 40 patients as follows: SmartTrack® 1-week changes (ST1), SmartTrack® 2-week changes (ST2), and EX30® 2-week changes (EX2). The groups were assessed by comparing actual changes achieved with those prescribed by ClinCheck®. The rates of clinically significant inaccuracies (CSI) observed for buccal expansion (≥ 0.5 mm) and buccolingual inclination (≥ 2°) during expansion were then determined.

Results

: In terms of expansion, the ST1 group demonstrated the highest CSI rate at all tooth levels, whereas the ST2 group had the lowest rate of CSI and the lowest mean inaccuracy for each tooth level. In terms of buccolingual inclination, the ST1 group had the highest CSI rate across all tooth levels, whereas the EX2 group had the lowest CSI rate at all tooth levels except for the canine level where the ST2 group had the lowest CSI rate. A tendency toward overexpression of buccal crown inclination, and underexpression of buccal expansion was observed at all tooth levels.

Conclusions

: Two-week aligner change regimens offer improved accuracy compared with 1-week aligner changes. SmartTrack® 2-week changes were the most accurate for buccal expansion, whereas EX30® 2-week changes were the most accurate for buccolingual inclination.

Accuracy of Invisalign® aligners in adult patients: a retrospective study of angular tooth movements

OBJECTIVE

This retrospective study aimed to assess the predictability of Invisalign® aligners regarding rotational, mesio-distal and buccal-lingual tip movements.

METHODS

Two materials were included in the analysis - EX30, used until 2013; and SmartTrack, in current use. The study comprised 56 adult patients treated with Invisalign Comprehensive. Data sample were assessed on three sets of digital models; model 1 - initial, model 2 - predicted, and model 3 - achieved. Sixty reference points were marked in each dental arch, and two reference planes assisted the superimposition. The degree of rotation, mesio-distal and buccal-lingual tip was obtained via trigonometric calculations, through a previously published validated method. The accuracy of outcomes was compared according to the types of tooth movement and teeth groups,and the influence of predetermined variables on movement accuracy was also investigated.

RESULTS

Rotation and mesio-distal tip did not present any significant difference when comparing EX30 and SmartTrack groups. Only buccal-lingual tip presented a significant difference, incisor and canine groups treated with EX30 aligners presented an increase in accuracy (p= 0.007 and p = 0.007, respectively). For each additional degree planned for rotation movements, there was an increase of 0.35° in the discrepancy, and an increase of 0.40° and 0.41° for mesio-distal and buccal-lingual tip, respectively. EX30 and SmartTrack discrepancies were compared by multilevel linear regression.

CONCLUSION

EX30 aligners reached higher accuracy for buccal-lingual tip in anterior teeth. However, for rotation and mesio-distal tip, SmartTrack and EX30 are similarly accurate. The total amount of planned movement has a significant impact on accuracy rates, with a decrease in accuracy for every additional degree.

Comparative evaluation of physical and mechanical properties of clear aligners - a systematic review

INTRODUCTION

The clinical effectiveness of clear aligners depends on the material properties both physical and mechanical. The purpose of this systematic review is to evaluate the physical and mechanical properties of different clear aligner materials and changes in the same during and after intra-oral use.

METHODS

Search was done in five electronic databases: Pubmed, Embase, Scopus, Web of Science and Ovid individually by two reviewers. In vivo, Ex vivo and In vitro studies that evaluated the physical and mechanical properties of clear aligner materials were selected. The risk of bias assessment was performed using a modified Cochrane risk of bias tool.

RESULTS

From the 24 articles selected, 19 evaluated a single physical property and 23 articles evaluated a single mechanical property of clear aligner materials. All domains in the risk of bias assessment showed low risk of bias except for 'blinding of outcome' which was unclear in almost all the selected studies. Properties such as hardness, optical properties, stiffness, and yield strength were found to be different for different clear aligner materials and were found to change with thermoforming, with intra-oral aging, and in simulated intraoral conditions. Due to heterogenicity in the parameters used to assess physical or mechanical properties a meta-analysis could not be done.

CONCLUSIONS

Properties like hardness, color, stiffness, stress relaxation and creep behavior were different for various clear aligner materials and were found to deteriorate with thermoforming and intra-oral aging. Polyurethane-based materials have a higher level of hardness and stiffness but exhibit increased creep and stress relaxation properties.

PROSPERO REGISTRATION NUMBER

CRD42021269597.

Treatment Efficiency of Maxillary and Mandibular Orovestibular Tooth Expansion and Compression Movements with the Invisalign® System in Adolescents and Adults

OBJECTIVES

Aligners are an effective and esthetic orthodontic treatment option for permanent and mixed dentition. There are only a few studies dealing with the effectiveness of orovestibular tooth movement using aligners and applying adequate examination methods. In the present retrospective study, the aligner efficiency of orovestibular movements for the entire dentition was systematically evaluated using 3D superimposition, taking into account the influence of jaw, tooth type and Invisalign® system.

METHODS

Group 1 (n = 18 adults, Invisalign®) and Group 2 (n = 17 adolescents, Invisalign® Teen) were treated with Invisalign® Ex30 aligner material and Invisalign® specific auxiliary means. In this non-interventional retrospective study, pre- and post-treatment maxillary and mandibular plaster cast models were scanned and superimposed with ClinChecks® via Surface-Surface Matching Algorithm on unmoved teeth providing stable references. Effectivity of planned versus clinically realized movements was evaluated for each tooth. Statistics were performed with a t-test and Bonferroni-Holm correction (α = 0.05).

RESULTS

Orovestibular movement efficiency was excellent without statistical significance regarding jaw, tooth type or Invisalign® system. Mandibular translational tooth movements were highly effective, and outstanding for premolars (91-98%). Maxillary translational tooth movements were successful for incisors and premolars, but less effective for canines and molars. Almost all teeth were moderately or very effectively corrected by crown tipping, performing better for mandibular (70-92%) than maxillary (22-31%) canines as much as for adolescent upper front teeth (81-85%) and lower canines (92%).

CONCLUSIONS

Aligners are able to effectively implement translational orovestibular movements, supported by tilting the crowns for even more efficient implementation of the movements. This phenomenon was observed in our studies for all teeth in both jaws, regardless of the Invisalign® system used. Treatment planning should nevertheless take into account the individual patient parameters with regard to the movements to be performed in order to make the aligner therapy as successful as possible in terms of realizing the desired therapeutic goal.

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.

Effects of intraoral aging on mechanical properties of directly printed aligners vs. thermoformed aligners: an in vivo prospective investigation

OBJECTIVE

The objective of this study was to examine the impact of intraoral aging on the mechanical properties of directly printed aligners (DPA) compared to thermoformed aligners (TA).

MATERIALS AND METHODS

This prospective in vivo experiment included three types of aligners: DPAs (group DP) fabricated from Tera Harz TC-85 DAC resin (Graphy, Korea), TA (group INV) made from a polyurethane-based polymer (Align Technology, Inc., CA, USA), and TA (group DUR) made from polyethylene glycol terephthalate based polymer (Scheu-Dental, Germany). Each group was categorized into retrieved (Clin) and unused aligners (Ctr). Thirty patients (10 per group) wore the aligners for 7 days, thereby generating the retrieved samples. Thirty unused aligners were employed as control samples. The following mechanical properties were determined: Martens Hardness (HM), indentation modulus (EIT), elastic index (ηIT), and indentation relaxation (RIT). Intergroup comparisons were conducted using ANOVA/Kruskal-Wallis test. Comparisons between retrieved and control samples were done using Wilcoxon-Mann-Whitney-U/Student's t-test/Welch's test.

RESULTS

Statistically significant differences between the groups were found for both control and used samples (P < .001). Pairwise comparisons also revealed significant differences between the samples. The mechanical properties did not differ significantly between unused and retrieved INV- and DUR-aligners, whereas for DP-aligners significant differences for ηIT and RIT were found following intraoral service (P-values .012 and .002, respectively).

CONCLUSIONS

Group DUR showed generally more favorable mechanical properties compared to DP and INV. The much higher RIT and EIT in DP aligners suggest their higher rigidity and force decay, which could compromise their clinical efficacy.

In vitro analysis of the influence of the thermocycling and the applied force on orthodontic clear aligners

The mechanical properties of polyurethane dental aligners have been studied in an oral environment at 37°C and subjected to thermal cycling between 5°C and 55°C for long periods of time at different mechanical stresses. The aim is to determine the efficacy of the orthodontic aligner at different stress levels, the effect of thermal cycling with therapy time on tooth position correction. Sixty aligners with the same design were studied applying tensions of 0, 3 and 30 N and determining the deformation at different times from 1 to 760 h. Half of these aligners were subjected to stresses submerged in artificial saliva at 37°C and the other half were subjected to thermal cycles between 2°C and 55°C in salivary medium. Deformation was determined using a high-resolution stereo magnifier and ImageJ image analysis software. Water adsorption by the polyurethane was determined at the different test times. The results showed that in the unloaded aligners there is no appreciable deformation, but with thermal cycling there is a light shrinkage of the aligner due to the semi-crystallization process (ordering of polymeric chains) of the polyurethane. When applying loads of 3 and 30 N, creep curves with constant deformation transition zones can be seen. The transition zones decrease as the applied mechanical load increases. In addition, the significant effect of thermal cycling on the reduction of the transition zone of the aligners has been demonstrated. The transition zones are optimal for dental correction as constant stresses are exerted for tooth movement. The effect of thermal cycling shortens the constant deformation zone and reduces tooth alignment time. It was observed that the absorption of water in the aligner is constant after 1 h of immersion and does not exceed 0.4% by weight of absorbed water.

Orthodontic Aligners: Current Perspectives for the Modern Orthodontic Office

Orthodontic aligners are changing the practice of orthodontics. This system of orthodontic appliances is becoming the mainstay appliance of choice for orthodontic offices in many countries. Patient preferences and lifestyle needs have made this appliance the primary choice when seeking care. In the early days, appliances lacked the efficiency and effectiveness of traditional bracket-wire systems, but modern systems are now able to handle a more comprehensive orthodontic caseload. Current systems provide newer biomechanical strategies and artificial intelligence-driven tooth movements for better outcomes. These improvements now mean that an orthodontist can be better prepared to manage a larger number of orthodontic malocclusions. This paper aims to discuss some of the evolution of orthodontic aligners and to describe to orthodontists the fundamentals of aligner therapy. In addition, it will provide an evidence-based outcome to the existing treatment outcomes in the current literature.

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

The demand for clear aligners has risen over the past decade because they satisfy patients' desire for less noticeable and more comfortable orthodontic appliances. Because clear aligners are increasingly used in orthodontics, there is a big push to learn more about the physiologic and microbial changes that occur during treatment. The present work highlighted further links between clear aligners and changes in oral health and the oral microbiome and provided plaque control methods for clear aligner trays. Existing literature revealed that clear aligners have no significant influence on the structure of the oral microbiome during orthodontic therapy. Clear aligner treatment demonstrated promising results in terms of controlling plaque index, gingival health, and the prevalence of white spot lesions. Nevertheless, grooves, ridges, microcracks, and abrasions on the aligner surface would provide a prime environment for bacterial adherence and the development of plaque biofilms. A combination of mechanical and chemical methods seems to be a successful approach for removing plaque biofilm from aligners whilst also preventing pigment adsorption.

The incidence and severity of open gingival embrasures in adults treated with clear aligners and fixed appliances: a retrospective cohort study

BACKGROUND

To evaluate the incidence and severity of open gingival embrasures (OGEs) in adult patients treated with clear aligners and fixed appliances.

METHODS

Two hundred non-extraction adult subjects with less than 5 mm of crowding (mean age, 24.6 ± 3.8 years) were enrolled in this retrospective study. The subjects were divided into the clear aligner (n = 100) and fixed appliance group (n = 100). The intraoral photographs were utilized to determine the incidence of OGEs in the upper arch between maxillary central incisors, as well as the lower arch between mandibular central incisors. Crown overlap, crown shape, posttreatment root angulation, the distance from the interproximal contact point (ICP) to the alveolar bone crest (ABC) after treatment and interproximal enamel reduction (IPR) were determined in the two groups.

RESULTS

The incidence of OGEs between maxillary and mandibular central incisors after orthodontic treatment was 35.0% and 38.0% in the clear aligner group, respectively, significantly higher than that (18.0% and 24.0%) in the fixed appliance group (P < 0.05). The average area of an OGE after clear aligner treatment was larger both in the maxilla (0.16 ± 0.12mm²) and mandible (0.21 ± 0.24mm²) compared with that (0.05 ± 0.03mm² and 0.05 ± 0.06mm²) after fixed appliance treatment (P < 0.05). No difference was found regarding pretreatment crown overlap, crown shape, treatment duration, posttreatment root angulation, amount and distribution of IPR and the distance from ICP to ABC.

CONCLUSIONS

The incidence and severity of OGEs were higher in adults treated with clear aligners. Clinicians should be aware of the risk of OGEs during treatment with clear aligners.

Effect of thermomechanical aging of orthodontic aligners on force and torque generation: An in vitro study

The aim of the study is to investigate the effects of artificial aging by thermocycling and mechanical loading on force/torque delivery by thermoplastic orthodontic aligners. Ten thermoformed aligners, made of Zendura™ thermoplastic polyurethane sheets, were aged over two weeks in deionized water by thermocycling alone (n = 5) and by both thermocycling and mechanical loading (n = 5). The force/torque generated on upper second premolar (Tooth 25) of a plastic model was measured before aging (as control), and after 2, 4, 6, 10, and 14 days of aging, using a biomechanical set-up. Before aging, the extrusion-intrusion forces were in the range of 2.4-3.0 N, the oro-vestibular forces were 1.8-2.0 N, and the torques on mesio-distal rotation were 13.6-40.0 Nmm. Pure thermocycling had no significant effect on the force decay of the aligners. However, there was a significant decrease in force/torque after 2 days of aging for both thermocycling and mechanical loading aging group, which is no longer significant over 14 days of aging. In conclusion, artificial aging of aligners in deionized water with both thermocycling and mechanical loading results in a significant decrease in force/torque generation. However, mechanical loading of aligners has a greater impact than pure thermocycling.

The Effect of 10% Carbamide Peroxide Dental Bleaching on the Physical Properties of Invisalign Aligners: An In Vitro Study

The high aesthetic demands of patients have increased their requests to align their teeth using clear aligners, including Invisalign. Patients also want to have their teeth whitened for the same purpose; the use of Invisalign as a bleaching tray at night has been reported in few studies. However, whether 10% carbamide peroxide affects the physical properties of Invisalign is unknown. Therefore, the objective of this study was to evaluate the effect of 10% carbamide peroxide on the physical properties of Invisalign when used as a bleaching tray at night. Twenty-two unused Invisalign aligners (Santa Clara, CA, USA) were used to prepare 144 specimens to test their tensile strength, hardness, surface roughness, and translucency. The specimens were divided into four groups: a testing group at baseline (TG1), a testing group after application of bleaching material at 37 °C for 2 weeks (TG2), a control group at baseline (CG1), and a control group after immersion in distilled water at 37 °C for 2 weeks (CG2). Statistical analysis was conducted using a paired t-test, Wilcoxon signed rank test, independent samples t-test, and Mann-Whitney test to compare samples in CG2 to CG1, TG2 to TG1, and TG2 to CG2. Statistical analysis showed no statistically significant difference between the groups for all physical properties, except for hardness (p-value < 0.001) and surface roughness (p-value = 0.007 and p-value < 0.001 for the internal and external surface roughness, respectively), which revealed a reduction in hardness values (from 4.43 ± 0.86 N/mm² to 2.2 ± 0.29 N/mm²) and an increase in surface roughness (from 1.6 ± 0.32 Ra to 1.93 ± 0.28 Ra and from 0.58 ± 0.12 Ra to 0.68 ± 0.13 Ra for the internal and external surface roughness, respectively) after 2 weeks of dental bleaching. Results showed that Invisalign can be used for dental bleaching without excessive distortion or degradation of the aligner material. However, future clinical trials are required to further assess the feasibility of using Invisalign for dental bleaching.

Force decay of polyethylene terephthalate glycol aligner materials during simulation of typical clinical loading/unloading scenarios

BACKGROUND

This in vitro study investigated the effect of three distinct daily loading/unloading cycles on force delivery during orthodontic aligner therapy. The cycles were applied for 7 days and were designed to reflect typical clinical aligner application scenarios.

MATERIALS AND METHODS

Flat polyethylene terephthalate glycol (PET-G) specimens (Duran®, Scheu Dental, Iserlohn, Germany) with thicknesses ranging between 0.4 and 0.75 mm were tested in a three-point-bending testing machine. Measurements comprised loading/unloading intervals of 12 h/12 h, 18 h/6 h, and 23 h/1 h, and specimens were exposed to bidistilled water during loading to simulate intraoral conditions.

RESULTS

A very large decay in force for the PET‑G specimens could already be observed after the first loading period, with significantly different residual force values of 24, 20, and 21% recorded for the 12 h/12 h, 18 h/6 h, and 23 h/1 h loading/unloading modes, respectively (Mann-Whitney U test, p < 0.01). In addition, further decays in force from the first to the last loading period at day 7 of 13.5% (12 h/12 h), 9.7% (18 h/6 h), and 8.4% (23 h/1 h) differed significantly among the three distinct loading modes (Mann-Whitney U test, p < 0.01).

CONCLUSION

Although the initial material stiffness of PET‑G is relatively high, the transmission of excessive forces is attenuated by the high material-related force decay already within a few hours after intraoral insertion.

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.

A spectroscopic study on orthodontic aligners: First evidence of secondary microplastic detachment after seven days of artificial saliva exposure

Clear orthodontic aligners have recently seen increasing popularity. The thermoplastic materials present several advantages, even if it is known that all plastic products can be subjected to environmental and mechanical degradation, leading to the release of microplastics (MPs). Their ingestion could cause oxidative stress and inflammatory lesions. This study aims to evaluate the potential detachment of MPs by clear aligners due to mechanical friction simulated with a 7-day protocol in artificial saliva. The study was performed on orthodontic clear aligners from different manufacturers: Alleo (AL); FlexiLigner (FL); F22 Aligner (F22); Invisalign® (INV); Lineo (LIN); Arc Angel (ARC), and Ortobel Aligner (OR). For each group, two aligners were immersed in artificial saliva for 7 days and stirred for 5 h/day, simulating the physiological teeth mechanical friction. After 7 days, the artificial saliva was filtered; then, filters were analyzed by Raman Microspectroscopy (RMS) and Scanning Electron Microscopy (SEM), respectively to chemically identify the polymeric matrix and to measure the number and size of the detected MPs. RMS spectra revealed that AL, FL, LIN, ARC, and OR aligners were composed by polyethylene terephthalate, while F22 and INV ones by polyurethane. SEM analysis showed that the highest number of MPs was found in ARC and the lowest in INV (p < 0.05). As regards MPs' size, no statistically significant difference was found among groups, with most MPs ranging from 5 to 20 μm. Noteworthy, a highly significant correlation (p < 0.0001) was highlighted between the distribution of MPs size and the different typologies of aligners. This in vitro study highlighted for the first time the detachment of MPs from clear aligners due to mechanical friction. This evidence may represent a great concern in the clinical practice since it could impact human general health.

The effect of clear aligners on speech: a systematic review

OBJECTIVE

To assess the effect of clear aligners on the speech of patients undergoing orthodontic therapy through a systematic review of the literature. Search methods and selection criteria: The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) CRD42021278694. An electronic search of the Scopus, Embase, Pubmed, and Web of Science databases was done for papers published between January 2000 till September 2021. Studies that evaluated speech difficulties in patients undergoing orthodontic treatment with clear aligners using objective and subjective analyses were included. The evaluated primary outcome was speech difficulties. Secondary outcomes were time to adaptation and recovery from speech difficulties. Study quality was assessed based on the Cochrane Handbook for Systematic Reviews of Interventions Handbook guidelines and ROBINS-I tool.

RESULTS

Two hundred and eighty-three articles were screened to identify seven studies (n = 332 patients) that assessed speech difficulty with aligners, of which two were randomized trials. Meta-analysis was not performed due to the heterogeneity in the study designs. Five studies compared speech difficulty with aligners to fixed appliances. Two studies showed a moderate risk of bias and five studies had a serious risk of bias. Level of evidence was downgraded to low due to the methodological insufficiencies and risk of bias in the studies. All seven studies reported that aligners could influence the clarity and delivery of speech, similar to fixed appliances. Various phonemes were affected including /s/,/z/,/zh/,/sh/,/th/,/ch/ on wearing aligners. Errors in articulation of consonants and sibilants were noted with lisping and speech impairment. These speech difficulties were temporary and most patients recovered in 7-14 days while few patients took 30-60 days to recover.

CONCLUSION

The likelihood of speech difficulties appears high with clear aligners. However, patients adapt quickly and speech returns to normal. The results of this review must be interpreted with caution and more well-designed randomized trials examining long-term effects of aligners on speech are indicated.

CLINICAL SIGNIFICANCE

Orthodontists should counsel patients opting for clear aligner treatment of the potential transient speech difficulties.

REGISTRATION

The protocol for this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) CRD42021278694.

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.

Comparative mechanical testing for different orthodontic aligner materials over time - in vitro study

Background

The purpose of the present study is to mechanically evaluate and compare the forces over 12 hours on different orthodontic aligners manufactured by Polyethylene terephthalate glycol (PETG).

Material and Methods

Twelve orthodontic aligner specimens will be produced by a thermoforming laboratory vacuum machine. All specimens will be divided into two equal groups, group A representing Duran (Scheu Dental GmbH, Iserlohn, Germany) and group B representing Erkodur (Erkodent, Pfalzgrafenweiler, Germany). These specimens will be fabricated via CAD/CAM technology by scanning a Frasaco model (Henry Schein Dental, Gallin, Germany) using D 800 (3Shape, Copenhagen, Denmark) and printed via a Varseo S machine using Varseo ModelWax material (BEGO, Bremen, Germany). Group A specimens are manufactured by a Twinster thermoforming machine (Scheu Dental GmbH, Iserlohn, Germany) while group B is produced using Erkoform thermoforming machine (Erkodent, Pfalzgrafenweiler, Germany). Afterwards, a tooth will be removed from the printed model and replaced by an ivory tooth (Henry Schein Dental, Gallin, Germany) to apply forces at a predicted measured centre of resistance. The universal testing machine Z010 (ZwickRoell, Ulm, Germany) will be used for mechanical testing with 0.3 mm displacement over 12 hours. Statistical analysis was performed using Sigmaplot 13.0 (Systat Software GmbH, Erkrath, Germany). Behaviours over time were analysed using R2-regression analysis (SPSS 26.0, IBM SPSS Statistics, Armonk, USA).

Results

There is no statistically significant difference in the maximum force between both groups (p=0.071). The mechanical testing over 12 hours showed cubic properties.

Conclusions

The PETG material has no influence on the produced mechanical forces regardless of the manufacturing company. The forces over time showed no tendency towards a lower boundary of force.

Key words:Mechanical testing, CAD/CAM, orthodontics, thermoplastic aligner materials.

Adaptational changes in clear aligner fit with time

OBJECTIVES

To analyze adaptational changes in clear aligner fit after intraoral usage at different sets of time.

MATERIALS AND METHODS

Eight Invisalign appliances (Align Technology, San Jose, California, USA) were collected after intraoral usage. Acrylic imprints of the lower incisor region were constructed for each appliance at T0 (unused appliance). Two appliances were then used intra-orally for each of the following defined periods of time: 3 days, 7 days, 10 days, or 15 days. Used aligners were adapted on its T0 imprint and both were sectioned buccolingually from the distal surfaces of each incisor at the attachment area. Eight surfaces were collected for each set of time (n = 32 surfaces). Microphotographs of obtained sections and micrometric measurements of aligner fit were recorded at five different levels using scanning electron microscopy (SEM). Mean values of the fit changes (gap width) and group comparisons were statistically analyzed using analysis of variance and Tukey's post hoc tests. Significance level was set at P < .05.

RESULTS

Highly significant differences in aligner fit were found at the different time points assessed (P < .001) with the least mean gap width at 15 days (176 ± 98 μm) and the highest at 7 days (269 ± 145 μm). Significant differences in aligner fit at different attachment levels were also found (P < .01) with the least mean gap width at the middle of the labial surface of the attachment (187 ± 118 μm).

CONCLUSIONS

The 15-day period of intraoral aligner wear might still be recommended as it showed the best adaptation and least gap width between the aligner and the attachment.

Efficacy of various multi-layers of orthodontic clear aligners: a simulated study

BACKGROUND

In the invisible orthodontic treatment, composite thermoforming film materials have become the focus of orthodontic clear aligners. The orthodontic efficacy of clear aligners which consisted of multi-layers materials remains unclear. This study aims to evaluate the biomechanical effects of various multi-layers of clear aligners on en-mass retraction of maxillary anterior teeth.

METHODS

A patient-specific 3D non-linear finite element model numerical analysis was constructed to simulate the en-mass retraction of maxillary anterior teeth with clear aligner after extraction of the first premolars. Four kinds of multi-layers clear aligners with different proportion of film materials were simulated. The biomechanical responses of four different clear aligners on invisible orthodontics were calculated. The tooth displacement in all directions, the hydrostatic pressure of periodontal ligament, the orthodontic deformation of clear aligner, and the stress distribution of alveolar bone were compared and investigated.

RESULTS

In all experimental models, the maximum equivalent deformation of alveolar bone, the vector displacement of tooth and the compressive/tensile stress of periodontal ligament decreased with the increase of soft layer thickness. The elastic strain of clear aligners also decreased with the increase of the ratio of soft/hard layers.

CONCLUSIONS

The multi-layers clear aligner is better than the single-layer clear aligner in tooth movement, stress distribution of periodontal ligament and mechanical loading of alveolar bone, especially when the ratio of soft layer to hard layer is more than 50%. Moreover, the side effects of the multi-layers clear aligner are significantly less than those of the single-layer one.

Performance of Rigid and Soft Transfer Templates Using Viscous and Fluid Resin-Based Composites in the Attachment Bonding Process of Clear Aligners

Objectives

The study aims at assessing the accuracy of the process of attachment bonding in aligner treatments. The analysis leads to the error estimation in the faithful reproduction of master model attachments using two types of transfer templates and two light-curing resin-based composites usually used in orthodontics.

Methods

The authors have used two transfer templates made of two different materials. The first, named Leone-biocompatible thermoforming material hard/soft, has a lower Young's modulus and is labelled as soft, while the other, named Leone-biocompatible thermoforming material, is marked as rigid. The resin-based composites possess different mechanical and rheological properties. Specifically, Transbond™ XT Light Cure Paste Adhesive, 3M has a higher viscosity than the TetricEvoflow, Ivoclar Vivadent, a flowable nanohybrid composite. The authors attempt to estimate the performance ranking between the four possible couples obtained by combining the two light-curing resin-based composites and transfer templates. Each combination was repeated in six models and compared with twelve master models, resulting in 36 total samples. A 3-D laser scanner is used to generate a digital model of each model. The comparison between digital models is the base for a comparative assessment in terms of relative and absolute error. The relative error is estimated using scalar performance indicators ranging from 0 to 1, where 1 indicates the optimum matching. The absolute error estimated from the mean square error between the coordinates of each digital model yields the reproduction accuracy in micrometer. Furthermore, the authors attempted to assess the error distribution by evaluating the point-by-point difference between the digital models.

Results

This analysis aims at localizing the sources of error in the considered models. The use of Transbond™ XT Light Cure Paste Adhesive, 3M with a rigid transfer template is always associated with significant accuracy and minor dispersion. However, in a few instances, using the soft template or the flowable resin-based composite can lead to bad performances. Significance. The data processing bestowed the following performance ranking from the first with lower reproduction error to the last characterized by the worst performance: (1) attachments bonding with rigid template and Transbond™ XT Light Cure Paste Adhesive, 3M, (2) attachments bonding with soft template and Transbond™ XT Light Cure Paste Adhesive, 3M, (3) attachments bonding with rigid template and TetricEvoflow, Ivoclar Vivadent, and (4) attachments bonding with soft template and TetricEvoflow, Ivoclar Vivadent.

Biomechanics of clear aligners: hidden truths & first principles

Over the past two decades clear aligner-based treatment has received remarkableattention from the orthodontic profession and more so from general practitioners.Different companies have emerged using vigorous advertisement to promote theirproducts mainly to patients and clinicians through social media. A variety of concepts,methods, and adjuncts have been introduced to enhance the efficacy andeffectiveness of clear aligners. However, the accuracy of tooth movement (vspredicted) with aligners still hovers around 50%. Fixed appliances fare much better onaccuracy and predictability of treatment. Why is there a discrepancy betweenexpected and actual outcomes? This paper utilizes 'first principles' and the existingevidence to unravel some of the key drawbacks of aligner-based therapy. Severalshortcomings in the biomechanical properties of aligner material (thermoplastics) thataffect clinical performance are discussed. Based on the first principles of alignerbiomechanics, this paper provides clinical insights for improving predictability and effectiveness of aligner therapy.

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.

Comparison of 2 Invisalign tray generations using the Peer Assessment Rating index

INTRODUCTION

This study aimed to establish if there is a significant difference in effectiveness between 2 generations of Invisalign trays in terms of Peer Assessment Rating (PAR) score reduction for finished patients from a graduate orthodontic clinic.

METHODS

Forty-five pretreatment and posttreatment patients treated with the previous Invisalign material and 49 pretreatment and posttreatment patients treated with SmartTrack material were scored using the Peer Assessment Rating (PAR) index. Both groups were controlled for initial weighted PAR score, age, gender, and treatment time. The 2 generations were compared in regard to absolute reduction, percent reduction, and great improvement in PAR score.

RESULTS

The mean absolute reduction in weighted PAR score between the groups was not statistically significant (P = 0.526). The mean percent reduction in weighted PAR score between the groups was not statistically significant (P = 0.210). The proportion of great improvement between the groups was not significant (P = 0.526). Only 6 of the 8 components of occlusion had enough variation to be modeled. An absolute reduction in unweighted PAR score was not significantly different between the groups for maxillary anterior alignment, overjet, or mandibular anterior alignment (P = 0.996, 1.000, and 0.114, respectively). Percent reduction in unweighted PAR score was not significantly different between the 2 groups for an anteroposterior, overbite, or transverse (P = 1.000, 1.000, and 1.000, respectively) relationships.

CONCLUSIONS

Our study indicates that both generations of Invisalign aligners improved the malocclusion to a similar degree according to the PAR index. Patient-centric benefits of SmartTrack aligner should also be considered by the provider.

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.

Micro computed tomography evaluation of Invisalign aligner thickness homogeneity

OBJECTIVES

To measure the thickness homogeneity of Invisalign (Align Technology Inc, San José, Calif) aligners with micro-computed tomography (micro-CT) scans.

MATERIALS AND METHODS

Starting from micro-CT scanning of 20 different aligners, multiplanar reconstructions were obtained. An orthodontist blinded about the study measured aligner thickness in different regions (molar, canine, incisor) and in different sites (gingival-buccal, buccal, occlusal, lingual, and gingival-lingual). To assess various thicknesses in different aligner sites and regions, the sample was stratified into subgroups and linear regression analysis was performed.

RESULTS

Descriptive analysis showed that mean thickness of aligners in the incisor region ranged from 0.582 mm to 0.639 mm, in the canine region from 0.569 mm to 0.644 mm, and in the molar region from 0.566 mm to 0.634 mm. Student's t-tests showed no significant differences in the aligner thickness of different regions when data were stratified by different sites. Student's t-tests showed significant differences in thickness homogeneity for the molar region when the data were stratified by tooth (mean difference = 0.068 mm; 95% confidence interval, 0.009-0.126 mm; P = .024).

CONCLUSIONS

Invisalign aligner thickness is characterized by small differences. The only significant difference was revealed in the molar region where thickness of the gingival-lingual edge is significantly thinner than that measured at the occlusal aspect. From a clinical perspective, the results of the present study could be considered to explain the reduced predictability of several orthodontic tooth movements in the molar region.

ATR-FTIR Analysis of Orthodontic Invisalign® Aligners Subjected to Various In Vitro Aging Treatments

Clear and removable tooth aligners for orthodontics treatments have become an increasingly popular alternative to fixed appliances. Even if protocols suggest removing aligners before eating or drinking, most patients retain them when they drink beverages. Alterations in the material during the daily use could determine a reduction in the application forces, affecting the desired orthodontic movement; the knowledge of how this material reacts when subjected to different aging processes is mandatory to establish the predictability of the orthodontic treatment. According to this, the aim of the present study was to assess a new objective approach, coupling spectroscopic and chemometric tools, to evaluate the changes occurring in Invisalign^® aligners, the most widely used brand, exposed in vitro to coffee, tea, Coca Cola^® and UV radiation for 24 and 48 h. In particular, ATR-FTIR spectroscopy was utilized to characterize, at the molecular level, the chemical and color modifications in the surfaces of the appliances; the obtained data were submitted to PCA and one-way ANOVA and Tukey's multiple comparison test. Moreover, a colorimetry analysis was carried out to evaluate any changes in color and transparency. Coffee and tea samples displayed the major color changes between the tested groups. The differences highlighted in the spectral features of coffee, tea and UV-treated samples were mainly ascribable to color and transparency changes, because the chemical properties remained unaltered.

Evaluation of masticatory muscle response to clear aligner therapy using ambulatory electromyographic recording

INTRODUCTION

Patients undergoing clear aligner therapy (CAT) report muscle tenderness and produce wear facets on their aligner trays. However, little is known about the masticatory muscle response to clear aligners. Here, we measured the activity of the masseter during CAT using ambulatory electromyography. We also explored whether psychological traits modulate the masticatory muscle response to CAT.

METHODS

Using portable data loggers, we recorded the electromyographic (EMG) activity in the right masseter muscle of 17 healthy adults without temporomandibular disorder (16 females, 1 male; mean age ± standard deviation, 35.3 ± 17.6 years) commencing treatment with CAT over 4 weeks, under the following conditions: week 1 without aligners (baseline), week 2 with a passive aligner (dummy), week 3 with their first active aligner (active1), and week 4 with their second active aligner (active2). We used a mixed-effect model to test differences in EMG activity over the 4-weeks and a general linear model to test the effect of psychological traits on EMG activity.

RESULTS

The EMG activity of the masseter increased significantly with aligners compared with baseline. The largest relative increase in EMG activity was seen during the dummy (152%; P <0.001) and active1 (155%; P <0.001) stages. During active2, the activity of the masseter decreased significantly toward baseline levels. Participants' trait anxiety was positively associated with increases in EMG activity (P = 0.027).

CONCLUSIONS

CAT is associated with a transient increase in masticatory muscle activity, possibly because of an increase in wake-time parafunctional tooth clenching. Temporomandibular disorder-free patients adapt well to CAT as the masticatory muscle activity decreases toward baseline levels after 2 weeks.

Behaviour of Human Oral Epithelial Cells Grown on Invisalign® SmartTrack® Material

Invisalign aligners have been widely used to correct malocclusions, but their effect on oral cells is poorly known. Previous research evaluated the impact of aligners’ eluates on various cells, but the cell behavior in direct contact with aligners is not yet studied. In the present study, we seeded oral epithelial cells (cell line Ca9-22) directly on Invisalign SmartTrack material. This material is composed of polyurethane and co-polyester and exhibit better mechanical characteristics compared to the predecessor. Cell morphology and behavior were investigated by scanning electron microscopy and an optical cell moves analyzer. The effect of aligners on cell proliferation/viability was assessed by cell-counting kit (CCK)-8 and 3,4,5-dimethylthiazol-2-yl-2,5-diphenyl tetrazolium bromide (MTT) assay and live/dead staining. The expression of inflammatory markers and proteins involved in epithelial barrier function was measured by qPCR. Cells formed cluster-like structures on aligners. The proliferation/viability of cells growing on aligners was significantly lower (p < 0.05) compared to those growing on tissue culture plastic (TCP). Live/dead staining revealed a rare occurrence of dead cells on aligners. The gene expression level of all inflammatory markers in cells grown on aligners’ surfaces was significantly increased (p < 0.05) compared to cells grown on TCP after two days. Gene expression levels of the proteins involved in barrier function significantly increased (p < 0.05) on aligners’ surfaces after two and seven days of culture. Aligners’ material exhibits no cytotoxic effect on oral epithelial cells, but alters their behavior and the expression of proteins involved in the inflammatory response, and barrier function. The clinical relevance of these effects has still to be established.

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.

Changes in mechanical properties, surface morphology, structure, and composition of Invisalign material in the oral environment

INTRODUCTION

The mechanical properties of Invisalign material have rarely been explored because of the inaccessibility of the patent-protected raw material. The purpose of this study was to systematically evaluate the Invisalign thermoformed aligner material before and after clinical application, including mechanical properties, surface morphology, internal structure, and chemical composition changes.

METHODS

Twenty sets of "as-received" (0-week) and retrieved (2-week; worn for 2 weeks, 20 ± 2 hours per day) Invisalign aligners were randomly collected from 4 different patients. Tensile tests, stress relaxation, and creep tests were carried out with a dynamic mechanical analyzer to characterize the changes in the mechanical properties of this material, Fourier transform infrared spectroscopy was used to capture the molecular changes on the surface of these aligners, scanning electron microscopy and transmission electron microscopy were used to observe the changes in surface morphology and internal structure, and scanning transmission electron microscopy-energy dispersive x-ray analysis was used to detect any changes in the chemical composition of this material before and after clinical application.

RESULTS

The elastic modulus of 0-week and 2-week samples were 842 ± 63 MPa and 806 ± 19 MPa, respectively, with no significant difference. In addition, the relative stress after stress relaxation of 2 hours was 19.89 ± 2.25% and 15.91 ± 6.04% for 0-week and 2-week groups, respectively, with no significant difference. Scanning electron microscopy observations showed voids and signs of delamination on the surface of the 2-week samples, and scanning transmission electron microscopy-energy dispersive x-ray analysis indicated the possible release of trace elements during clinical use, such as aluminum. Results of Fourier transform infrared spectroscopy analysis, and transmission electron microscopy observations were quite stable, indicating that the molecular structure on the surface and the internal structure of this material were relatively stable under the oral environment.

CONCLUSIONS

The surface morphology showed some defects after the clinical use of 2 weeks; however, there was no significant difference in mechanical properties. Trace elements may release out during clinical use and may pose a specific danger to allergic patients.

Mechanical Properties of Thermoplastic Polymers for Aligner Manufacturing: In Vitro Study

The use of metal-free thermoplastic materials plays a key role in the orthodontic digital workflow due to the increasing demand for clear aligner treatments. Three thermoplastic polymers commonly used to fabricate clear aligners, namely Duran^®, Biolon^® and Zendura^®, were investigated to evaluate the effect of thermoforming (T.), storage in artificial saliva (S.A.S.) and their combination on their mechanical properties. Elastic modulus and yield stress of the specimens were characterized. Each material was characterized for each condition through tensile tests (ISO527-1). The results showed that thermoforming does not lead to a significant decrease in yield stress, except for Zendura^® that showed about a 30% decrease. An increase of the elastic modulus of Duran^® and Zendura^®, instead, was observed after thermoforming. The same increase was noticed for the yield stress of Duran^®. For S.A.S. specimens, the elastic modulus generally decreases compared to supplier condition (A.S.) and simply thermoformed material. A decrease of yield stress, instead, is significant for Zendura^®. The results demonstrated that the impact of the operating conditions on the mechanical properties can vary according to the specific polymer. To design reliable and effective orthodontic treatments, the materials should be selected after their mechanical properties are characterized in the simulated intraoral environment.

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.