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17 June 2020

Enamel demineralization during orthodontic treatment: clear aligners vs fixed appliance therapy.

Davide Elsido


In the latest issue (May 2020) of the American Journal of Orthodontics and Dentofacial Orthopedics a randomized clinical trial was published evaluating  the relationship between clear aligner (CA) therapy and the development of white spot lesions and compare it with orthodontic fixed appliance (FA) therapy.

Demineralization of the enamel surface adjacent to orthodontic appliances, which manifests initially as white spot lesions (WSLs), is an unsightly, important, and prevalent side effect of orthodontic treatment, which compromises the results of such treatment.
The prevention, diagnosis, and treatment of WSLs are crucial to minimize tooth decay and tooth discoloration, which could compromise the esthetics of the smile. In recent years, an increasing number of young and adult patients have sought orthodontic treatment with clear thermoplastic aligners (CAs) as a more esthetic and comfortable alternative to fixed orthodontic appliances (FAs). The increased popularity and use of CAs has raised the question if CAs are effective in controlling the orthodontic movement in nongrowing subjects. Therefore, several studies were conducted in the past decades to evaluate the validity of CA therapy and determine its boundaries. To evaluate the proficiency of CAs, all aspects of orthodontic therapy should be investigated including the adverse effects imposed on oral health, such as pain and discomfort, root resorption, periodontal health integrity, and enamel demineralization with the subsequent formation of WSLs. Although CA therapy has been cited as a safe, esthetic, and comfortable orthodontic procedure for adult patients, only few trials were focused on its side effects and implications on oral health. Although the general assumption is that these appliances are hygienic by design, this hypothesis needs to be questioned and investigated with proper methodology to provide high-quality evidence defining the pros and cons of CAs. The increase in the number of newly developed WSLs was significant in both groups.

The incidence of WSLs in the FA group, however, was higher than that of the CA group.  In addition, more mineral loss was seen in the FA group compared with the CA group. By contrast, lesion area was significantly larger in the CA group compared with the FA group. In the study, the incidence of new WSLs and the significant increase in the surface area of WSLs during the CA therapy could be explained by the effect of CA on limiting the flow of saliva, negating saliva's natural cleansing, buffering, and remineralizing properties. In addition, the large area of the WSLs in the CA group is mostly attributed to the use of attachments, which usually cover a considerable area of tooth surfaces.
Therefore, special care is needed during their bonding, and patients need to be instructed on how to properly keep them clean. However, further investigation is needed to evaluate the effect of size, shape, and location of the attachments on enamel decalcification because one could anticipate that attachments with angular sharp edges might cause more food entrapment than smooth circular ones. The findings of this study emphasize the falsehood of the claims that CA therapy is completely safe and does not have implications on oral health. The practice of “Do-It-Yourself” orthodontics has gained popularity on such false claims because orthodontic therapy with CAs can be performed without professional evaluation and monitoring by dentists and/or orthodontists.

As conclusion, Orthodontic treatment with Cas and FAs caused enamel demineralization. The CA group developed larger but shallower white spot lesions, whereas the FA group developed more new lesions with greater severity, but the were smaller in area. More plaque accumulation was found in the FA group compared with the CA group.


For additional information:  Enamel demineralization during clear aligner orthodontic treatment compared with fixed appliance therapy, evaluated with quantitative light-induced fluorescence: A randomized clinical trial.

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