This interesting new paper provides us with initial information on the environmental impact of fixed appliances and aligners. This is particularly relevant because the increasing use of plastics and the release of greenhouse gases are of concern.

A team from Nijmegen, Holland, did the study, and the European Journal of Orthodontics published the paper.

Environmental impact of orthodontic treatment: a simplified fast-track comparative life-cycle impact assessment of self-ligating metal brackets and clear aligners.

Maria Johanna Jacoba Heezen et al

EJO advance access. https://doi.org/10.1093/ejo/cjag025

What did they ask?

The aim of this study was to

“Develop an estimate overview of the environmental impact of self-ligating metal brackets treatment compared with clear aligner treatment”

What did they do?

They carried out an analysis based on the treatment of four cases: two were non-extraction and two involved extractions. Each case was treated with either clear aligners or fixed appliances. The team obtained these cases from an experienced orthodontist in both fixed appliance and aligner care.

They obtained information on all environmental aspects of providing this treatment, and from this they constructed environmental indicators. These were

• Carbon footprint, expressed per kilogram of carbon dioxide equivalent. 
• Cumulative Energy Demand. This measures the total energy consumption throughout the life cycle of a treatment.
• ReCiPe 2016. This is a widely used method for evaluating the environmental impact of processes.

The data they used were provided by the manufacturers of the fixed appliances (Damon) and the clear aligners (Spark). They then combined this with data from the individual treated cases. This included the amount of materials, the materials’ life cycle, the impact of transport, and, most importantly, the multiple stages of clear aligner treatment.

What did they find?

They produced a large volume of complex data. I do not have the space to cover all of this in this post. However, the key findings were;

1. The carbon footprint for clear aligner treatment ranged from 20.6 to 24.7 kg of CO₂, while fixed appliance treatment was 0.22 kg CO₂.
2. The CED was in favour of fixed appliance treatment and showed greater energy waste with aligner treatment.
3. Fixed appliances created a lower environmental burden.

Their overall conclusions were:

“Within the limitations of a small sample size and simplified model, fixed appliance treatment showed a lower environmental impact than clear aligners.”

What did I think?

This was a very interesting yet complex paper to interpret. Importantly, the authors noted that the results are exploratory and that more research is certainly needed.

Nevertheless, the findings were logical. For example, there are many stages to aligner treatment. These include: 

• multiple 3D printed models
• thermoforming
• trimming and polishing
• the individual plastic wrapping and 
• international shipping

This is compounded by discarding the aligner after a week or two of wear. This process is repeated 30 to 40 times per patient. It was interesting to note that the author estimated that aligner therapy up to 2020 had already generated approximately 1,875 tonnes of plastic waste. This is certainly concerning.

In contrast, fixed appliances use comparatively small quantities of material and generate far less waste.

The authors made several suggestions to change this situation: 

• The use of recyclable polymers
• Biodegradable materials
• Direct 3D printing aligners
• An improved disposal programme

Final thoughts?

This paper addresses a very serious question that is relevant to us all. While the authors have made several assumptions that may overestimate the impact of aligners, there is a degree of logic to their conclusions. This area requires considerably more detailed investigation. I hope to see this team and others continue working on this over the next few years. We need to become more environmentally aware.

Until then, perhaps we need to consider the environment and sustainability when prescribing different types of treatment. This may influence our and our patients’ treatment choices.

       

Comments

• In reply to Ross Hobson. Hi Ross – Check out our recycling ... by Maddy Goodman
• Kevin, I'm not being dismissive of this study, and everyone ... by Barry Winnick
• PS as plastics indefinitely recyclable (like metal) why do ... by Ross Hobson
• What about recycling ? From looking into this All plastics ... by Ross Hobson

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The study was done by a team based in Erciyes University, Turkey. The European Journal of Orthodontics published the paper. 

The impact of different rapid palatal expansion appliances on sleep, nasal airway resistance, and dentoskeletal/dentoalveolar characteristics: a prospective, randomized controlled trial.

Sertan Soylu et al

EJO On line. https://doi.org/10.1093/ejo/cjag030

What did they ask?

They did this study to 

“Evaluate and compare the effects of different RPE appliance designs on sleep-related breathing, nasal airway resistance, and dental-skeletal outcomes in post-pubertal adolescents with maxillary constriction.”

What did they do?

They carried out a randomised controlled trial with 3 arms with a 1:1:1 allocation.  The PICO was

Participants

Orthodontic patients aged 14 to 17 years in the post-pubertal growth stage. They had mouth breathing, which was confirmed through a comprehensive ENT examination. They had skeletal maxillary constriction of between 4 and 10 mm transverse deficiency with unilateral or bilateral posterior crossbites. 

Intervention one. 

This was a full-coverage RPE appliance which covered all the buccal, palatal, and occlusal surfaces of the maxillary teeth. (FCRPE)

Intervention two.

A similar RPE appliance , however, the upper incisors and canines were not included in the appliance. (MMRPE)

Intervention three.

A MARPE appliance fixed with two palatally placed mini screws. (MARPE).

Outcomes

These included;

• Respiratory polygraphy
• Rhinomanometry
• Sleep questionnaires
• PA radiographs
• Digital models

They took measurements before treatment and approximately three months after treatment.

They used a pre-prepared randomisation scheme and conducted an adequate sample size calculation. I was unclear about their method of concealment. 

They carried out a relevant univariate statistical analysis.

They compared the active treatment groups with an untreated control group. This group comprised healthy people from the same age group who attended the department. However, little additional detail about this group was provided.

What did they find?

45 patients entered the study. At the end of treatment, forty-three completed the study. Fifteen participants were enrolled in the control group, and all 15 had data collected at the second data collection.

They produced a large amount of data, and I’m going to focus on AHI, oxygen desaturation and sleepiness scale.

There were no differences between the groups at the start of treatment. Importantly, the control group had lower AHI and fewer oxygen desaturations.

I have tried to interpret the large amount of data they included by focusing on the end-of-treatment values. This is a simple yet relevant method for analysing large data sets in a study such as this. I have included data on AHI, De SPO2 and the Epworth Sleepiness Scale (ESS).

The statistical analysis revealed the following:

• The control group had significantly lower AHI values and De SP02 index.
• When they looked at the data for the RPE groups, they showed decreases in AHI and De SPO2 across all groups. Importantly, there was no change in the control group.
• Although AHI values decreased in the MMRPE group, the effect was not as pronounced as in the MARPE group.
• There were no significant differences in EES scores between the groups.

Their overall conclusion was

“RPE decreases AHI. This approaches the values of individuals in the control group.”

What did I think?

This was another small-scale randomised controlled trial exploring an important question. The authors noted that since the participants were post-pubertal, facial growth likely had minimal impact. Therefore, any observed changes could probably be attributed to the expansion itself. However, factors like BMI and hormonal changes during late puberty might influence tissue remodelling around the airway. This highlights the need for an untreated control group to draw more definitive conclusions. Additionally, the follow-up period was quite short.

It’s worth mentioning that the AHI values in this study for all the groups suggest mild obstructive sleep apnea, and the EES scores indicate normal levels.

We should also remember that polysomnography is considered the gold standard for sleep assessment. In this case, the authors used respiratory polygraphy, which is more practical but generally less sensitive than PSG. Still, it offers reasonable validity for measuring AHI, though it’s a bit of a compromise.

The study also found that MARPE was the most effective method of expansion, adding to the evidence supporting the use of miniscrews in expansion devices.

It was encouraging to see that the authors avoided making exaggerated claims about expansion treatment. Overall, this study is much better than the retrospective, convenience-based studies often promoted by some “airway” orthodontists.

We’re gradually making progress in exploring this important area of research.

       

Comments

• I enjoyed reading this post Professor. I think the authors ... by James Patrick Murphy DMD
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• Interesting post as always, sir! Kudos to the researchers out ... by Chad Carter

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Before I continue with my discussion of this paper, I would like to point out that I did not post over the last two weeks because I was on a fantastic holiday in the Isle of Skye in Scotland. In addition to giving me a break, the internet access was rather poor where we were staying, in a remote part of the island. 

The authors of this paper noted that digital dentistry is significantly affecting our treatment methods. When these are combined with Artificial Intelligence, there are enormous opportunities to deliver our care. 

A team from China and Malaysia did this study. The journal PLOS ONE published the paper. 

Randomized controlled trial comparing AI assisted digital and conventional orthodontics: Superior PAR reduction and occlusal outcomes

Xie Xiaoting et al

PLOS One. https://doi.org/10.1371/journal.pone.0347499

What did they ask? 

They wanted to

“Compare AI-assisted digital orthodontics with conventional fixed appliance therapy using percentage reduction in the PASS score as a primary endpoint.” 

What did they do? 

They conducted a single-centre, parallel-group, randomised controlled trial. The PICO was 

Participants 

140 orthodontic patients with class I malocclusion 

Intervention. 

This was an AI-assisted digital workflow. It comprised a suite of AI-assisted tools embedded within 3D planning software and the Dental Monitoring platform. These tools use machine learning algorithms to automate tooth segmentation, landmark identification, arch form estimation, and preliminary tooth movement simulations. The outputs were then used to inform treatment planning. However, all final diagnostic interpretations and movement prescriptions were determined by the treating orthodontists. 

They manufactured custom brackets chair-side using 3D printing. 

When treating patients, remote monitoring with Dental Monitoring was used. This detected issues such as bracket failure, wire displacement, plaque accumulation, or soft tissue irritation. If threshold-based alerts were triggered, clinicians reviewed the images and arranged earlier clinical visits where necessary. 

Control 

This group of patients was treated with conventional orthodontics. Panoramic radiographs and lateral cephalograms were used for diagnosis and treatment planning, and all patients were treated with 0.022-inch-slot pre-adjusted edgewise appliances. Follow-up appointments were scheduled at four-week intervals. 

A team of board-certified orthodontists, each with at least five years of clinical experience, carried out the treatment. 

Outcome 

The primary outcome was the percentage reduction in the Peer Assessment Rating (PAR) from baseline to treatment completion. 

They conducted a clear sample size calculation, which indicated that 140 participants were needed to take part in the study. 

They used a pre-prepared randomisation sequence with block randomisation and concealed the allocation using sequentially numbered, sealed envelopes. These were prepared by a research assistant not involved in participant recruitment or assessment. The envelopes were opened by a treating clinician only after all baseline measurements had been completed. It was not possible to blind patients or operators to the group allocation, but data were analysed blind. 

Finally, they carried out appropriate univariate and multivariate analyses. 

What did they find? 

140 patients were randomised in a one-to-one ratio to the interventions. All participants received their allocated intervention and completed treatment. 

At the start of treatment, there were no major differences between the two groups. 

When PAR scores were examined, they decreased in both groups, with a lower post-treatment score in the digital and AI group. The mean final PAR score for the AI group was 4.88 points, with a standard deviation of 4.45. For the conventional group, the mean was 7.81, with a standard deviation of 0.7. This resulted in a mean difference of -2.93 (95 CI -3.13 to -2.73). These differences were statistically significant. 

Another way to interpret PAR scores is to consider a 70% reduction a “great change” in score. The proportion of participants achieving this was 82.9% in the AI group and 50% in the conventional group. 

The final step in the statistical analysis was a regression analysis aimed at identifying independent predictors of improvement in PAR scores. The most significant factor was treatment modality, followed by patient age and baseline PAS scores. 

Their overall conclusions were 

“The AI-assisted digital orthodontic workflow produced statistically significant and clinically interpretable short-term improvements in PAR scores compared with fixed appliances. These benefits likely reflect the combined influence of high-precision imaging, customised appliance fabrication, and AI-supported monitoring. They cannot be attributed to AI alone.”

The authors made an important point. The intervention was not limited to AI. In fact, they tested improved imaging, appliance customisation, remote monitoring and workflow integration simultaneously. 

What did I think? 

It is not often that I come across a very well executed and well written publication. This was the case with this study, which was published in a very good open access journal. The study team followed a standardised and clear randomised trial methodology, and the trial was carried out very well. 

Their findings were interesting, showing a difference between the two interventions. As usual, we need to consider whether these are clinically significant. When I looked at the raw PAR scores and the differences in finish between the two groups, the differences were only in the region of 2-3 PAR points. These are not clinically significant, even though they were statistically significant. 

However, it was interesting to see that a much greater proportion of cases treated with AI-assisted mechanics were classified as greatly improved. As a result, their conclusions are fairly robust. 

The study team highlighted some shortcomings in their study. Firstly, they noted that the treatment was assessed at the end of active treatment. I thought this was entirely reasonable and reflected common practice in occlusal index studies. They also noted that it was a single-centre study. While this may reduce generalisability, it still provides us with very useful information. 

When I consider the findings of this study, however, I cannot help but feel that I would have liked to see some information on the overall duration of treatment. As I am sure this would influence the final treatment outcomes. It would also provide us with very useful information on whether AI-assisted treatment was of shorter duration. The study team pointed this out and suggested that larger-scale studies be conducted. This study is an excellent starting point for planning future studies.

I think that we should all look forward to further studies in this interesting area, as it is very likely to influence the future of orthodontic treatment. 

       

Comments

• and here an interesting one from the past… Artificial ... by Ross Hobson
• use of computers for ortho planning is not new; Chris ... by Ross Hobson

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A team from South Africa, the USA and South Korea wrote the paper. The AJO-DDO published the paper.

Orthodontic perspective on treatment recommendations for missing maxillary incisors: A contemporary guideline

Mark Wertheimer, Lauren Kim, Jae Park

Am J Orthod Dentofacial Orthop 2026;169:559-67 https://doi.org/10.1016/j.ajodo.2025.12.003

What did they ask?

They wrote this paper to provide information on 

“The treatment considerations for treatment selection, complications and evidence-based guidelines for the management of missing anterior teeth”.

What did they do?

They condensed the available evidence on options for replacing missing maxillary incisors.  Importantly, this was a “traditional” non-systematic review.

What did they find?

Firstly, they suggested that the options for this problem were canine substitution to close the space, bridges, autotransplantation and implants. They then discussed these options in more detail, with an emphasis on how facial growth affects treatment success.

Growth and implants 

We all know that we are experts in facial growth. However, we need to remember that facial growth doesn’t simply cease in the late teens. It continues at a much slower rate throughout adulthood. As a result, compared with an ankylosed implant, the vertical and horizontal movement of the teeth and the alveolus increases the risk of implant submergence. This is referred to as implant infraposition and is a considerable problem because its correction can be difficult. 

Some may argue that growth potential can be determined using hand-wrist radiographs and cervical vertebral maturation; however, these methods have been shown to be comparatively inaccurate for the individual patient. As a result, no definitive criteria or diagnostic methods exist to indicate when dental alveolar changes have ceased. 

The authors of this paper noted that systematic reviews have shown that nearly half of patients with implants develop an infraposition. As a result, we should carefully consider the appropriate timing for implant placement or look for alternatives.

Alternative Treatment Options 

One of these is of bridges. There is, of course, reluctance to prepare unblemished teeth as abutments for a fixed bridge. As a result, this form of treatment is not popular. 

The other alternative is, of course, orthodontic space closure. They pointed out that we have to consider the whole malocclusion when planning this treatment, but importantly, the use of temporary anchorage devices may make this an option in many cases. 

It goes without saying that one consequence of replacing a missing lateral incisor with a canine is that treatment is necessary to ensure the canine resembles the lateral incisor. This may be rather complex, but it should be within the skill set of most dentists and certainly of specialists.  

This also depends on the canines’ morphology, size, and colour. Another concept to consider is whether group function, rather than canine guidance, is acceptable. Importantly, there is no evidence supporting a preference for either option. 

There are, of course, other issues, such as symmetry, when one lateral incisor is missing. Finally, we need to consider whether there is an age at which we can safely placed an implant in the anterior region without adverse effects. I felt that they suggested there was no definitive answer to this question because the craniofacial complex continues to adapt. 

Key takeaways

At the end of their discussions, they identified several key takeaways for us to bear in mind. 

“Growth and development will continue well into the third decade, and there are no reliable methods to determine when dental alveolar development ceases. Importantly, the reported incidence of IIP is between 50% and 75%, and it is very prevalent when implants are placed during the second and third decades. As a result, treatment methods that promote stable and aesthetic outcomes should be recommended”. 

What did I think?

This was an interesting overview of a relatively complex clinical problem. They wrote a clear paper and outlined several concepts very well. I think it is still important to point out that these guidelines are not necessarily based on high levels of evidence. We also need to remember that guidelines are not mandatory.

However, in the absence of high-level research, when we consider the concept of evidence-based care, this information is, arguably, useful. This paper achieves its aim of encouraging discussion.

Some may feel the content of this review is rather obvious, and we are well aware of the decisions we need to take and the factors that influence them. Nevertheless, I can’t help feeling that if these concepts are obvious, why do so many patients end up with implant infraposition in the anterior maxillary arch? 

My only concern with this paper is that I wish the authors had been a little more definitive in their conclusions and had made a recommendation on which option was best: space opening or space closure. After reading this paper several times, I felt that the decision still remained mine. This may have been their intention, but it does nothing to diminish my poor tolerance of uncertainty.

Now that you have read this blog post.

My plea for funds to support this blog is going very well. Your donations have almost reached my target for funds to keep going for another year.

This is my last appeal to help me cover the blog’s running expenses for the upcoming year. The funds will cover web hosting, software upgrades, email lists and general running costs. This also means that I do not have to seek funding from advertising and lack of independence for my posts.

I believe that if every reader contributes a small amount, I can cover the yearly running costs. Your help will be much appreciated.

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Comments

• A decision should be made after consulting the orthodontist, ... by Medhat ALY
• Great insights on improving oral health with orthodontic care. ... by Bettagere Orthodontics
• Just my personal opinion, canine substitution might be a long ... by Jason Chua
• I think Ross and Jack sum it up best, depends on many factors ... by Anand Srinivasa
• I didn't see much discussion on what the molar relationship ... by Ronald Eugene Austin
• Plus 2 more...

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In this study, they examined the effect of sequencing slow rapid maxillary expansion (SRME) and adenotonsillectomy (TA) in paediatric obstructive sleep apnoea. A team from Australia and Hungary conducted the study. The Journal of Clinical Medicine published the paper.

Maxillary Arch Expansion and Adenotonsillectomy in Prepubertal Children Diagnosed with Paediatric Obstructive Sleep Apnoea: An Interventional Study

Derek Mahony Niroj Bhattarai and Peter Petocz

Journal of Clinical Medicine. On line https://doi.org/10.3390/jcm15082981

The paper is open access so anyone can read it.  The Journal of Clinical Medicine is listed as a predatory journal on the Predatory Journals website. 

What did they ask?

They did this study to ask the following question. 

” What are the combined effects of adenotonsillectomy and maxillary arch expansion in pre-pubertal children with OSA, and is there an effect of the sequence of treatment? 

What did they do? 

This was a retrospective cohort study using a subsample of patients from a larger cohort that I have previously posted about. 

They selected 80 sets of patient records from an original sample of 3,671 children aged 7-9 years who underwent polysomnography at their first orthodontic consultation, representing 2% of the original sample.

The main inclusion criteria were the availability of complete PSG records at three times:

• Baseline (pre-treatment)
• After the first intervention
• After both interventions

They had to complete slow rapid maxillary expansion and adenotonsillectomy, regardless of the sequence. 

They had no history of prior orthodontic treatment or diagnosed sleep disordered breathing at baseline. 

Exclusion criteria were incomplete records and the absence of level one hospital-based PSGs. 

They then divided this sub-sample into two groups. This was “based on a treatment sequence that was determined by the patient and parental preference and logistical factors rather than randomisation”. As a result, they suggested this reflected the “real world” of decision making.

Group one was designated TA first, comprising patients who underwent tonsillectomy as the initial intervention, followed by SRME. 

The second group had SRME as the initial intervention. This was due to delays in accessing publicly funded ENT appointments or waiting periods for private insurance cover. 

They collected demographic details, cephalometric classifications, and BEARS questionnaire scores greater than 5, indicating an SDB risk. 

Accredited sleep laboraties did the polysomnography measurements.

The primary outcome for this study was the respiratory disturbance index (RDI). This is the average number of apnoeas, hypopnoeas, and respiratory effort-related arousals per hour of sleep. 

Statistical analysis was based on a repeated-measures analysis of variance over time. The authors did explain the method clearly, and I couldn’t really work out the statistical plan.

What did they find? 

The mean age of the participants was 8.3 years, and 43% were male. At the start of treatment, the mean RDI was 18.99, indicating moderate severity.

At the start of treatment, there were no differences between the groups in most measured variables; however, there was a marked difference in BMI. The TA first group had 87% of the sample classified as overweight or obese, whereas the SRME group had 45% of participants in this classification. This is important because it represents a marked imbalance between the groups. 

I have extracted some of the data into this table. This illustrates the RDI for the combined BMI groups. I also calculated the 95% confidence intervals for this data.

When you look at the 95% confidence intervals, you can see that they overlap for the interventions’ effects. This means that the effects may not be statistically significant. Furthermore, they do not overlap at the start of treatment.

I looked closely at their statistical analysis, and the tables outlining it were rather brief, which made it difficult to interpret the findings.

They also presented a table showing RDI reduction. However, I felt we could be more focused in this blog post by simply comparing the values between the two groups.

The conclusions were 

“Both TA and SRMA significantly improved the RDI in pre-pubertal children with OSA and maxillary constriction. The greatest benefit was seen when these were combined. The SRMA first, followed by TA, was somewhat more effective by about 1.5 events per hour overall.” 

What did I think?

This study used the Respiratory Distress Index (RDI). I was unfamiliar with the RDI and sought further information on this measure. The RDI is similar to the Apnoea-Hypoxia Index (AHI) but includes Respiratory Effort-Related Arousals (RERAs). This makes it useful for assessing milder forms of sleep-disordered breathing. It is highly sensitive to treatment and, importantly, more sensitive than the AHI.

The RDI values can be classified as

• Normal: RDI < 1 event per hour.
• Mild OSA: RDI between 1 and 5 events per hour.
• Moderate OSA: RDI between 5 and 10 events per hour.
• Severe OSA: RDI > 10 events per hour. 

Problems with the study

Importantly, we may need to consider the accuracy of diagnosing sleep disorders from a single night’s readings. A systematic review has examined this and concluded that this variation may lead to misdiagnosis in single-night studies. We need to consider this when we interpret the results of this study, which used a single-night recording.

Bias

There is also considerable risk of further selection bias in the study, given that the authors analysed only 80 sets of records from a total sample of 3971 (2%). This risk is further compounded by the inclusion criteria, which require completion of treatment and full records. As a result, the study is at risk of being biased towards favourable outcomes.

When I looked at the data they presented, it was clear that the groups were unbalanced for BMI at the start of treatment. It appears that the clinicians had a preference for TA in obese children, which could lead to selection bias in the study. Furthermore, the treatment allocation order was determined by delays in access to ENT care. It appears that if a patient’s ENT treatment was delayed, they received SRME. This design is subject to systematic confounding, and we must account for differences between the groups. For example, they may be children from low socioeconomic groups.

Control group and effect size

In addition, there was no untreated control group. This is crucial for this form of study because the CHAT study estimated that 50% of 5- to 9-year-old children with OSA who were randomised to watchful waiting achieved OSA remission, as defined by PSG findings, after 7 months.

When we look at a paper, it is important to consider the differences in effect sizes. Even a cursory examination shows that there is limited difference between the two intervention sequences. I also could not really understand the statistics they used because of a lack of data, particularly the p-values. They also presented the percentage change in RDI as an outcome. It is more important to look at the group differences.

It is also relevant to point out that they did the in 9 private orthodontic practices with an interest in airway treatment. As a result, the findings may not be relevant to the general population.

We must also consider whether Dr Mahoney has an undeclared conflict of interest, given that he is the CEO of a company that operates several orthodontic practices specialising in “airway-focused” care.

Final comments

I may be criticised for being so blunt about a study. However, I felt it was necessary to point out the deficiencies in this paper.  This study provides very low-level evidence. However, its data may be used for planning randomised trials in this important area.

Now that you have read this blog post.

Last year, I requested donations to support my blog, and thankfully, I received an overwhelming response. With your help, I was able to raise sufficient funds to keep my blog going for another year. 

Now, I’m seeking your support again to help me cover the blog’s running expenses for the upcoming year. The funds will cover web hosting, software upgrades, email lists and general running costs. 

I believe that if every reader contributes a small amount, I can cover the yearly running costs. Your help will be much appreciated.

To make a donation, just use the form below. You can use the set-amount buttons or the free-field button to enter other amounts.

Then the easiest way to pay is to tap the Apple Pay button. If you want to use another payment method, click the “next” button and enter your details. This will take you to credit cards, PayPal, and other payment methods.

       

Comments

• In reply to Prof Dave Singh. Craniofacial orthodontists are ... by Rany Bous
• Prof, Thanks for your erudite analysis which is so valuable to ... by Geoffrey Wexler
• There is a small randomized clinical trial conducted to address ... by Steve Marshall
• I was surprised to read that you were “unfamiliar with the ... by Prof Dave Singh
• In reply to Trevor Baret. I wonder if I did not make myself ... by Kevin O'Brien
• i have never before seen a study being accused of bias because ... by Trevor Baret

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We are all familiar with the use of clear aligners in adults; however, new research is now being published on their effectiveness in adolescent patients. 

The authors of this study pointed out that little is known about the effectiveness of treating Class II malocclusion with clear aligners. This study should add to our knowledge. 

A team from Adelaide, Australia, did this study. The American Journal of Orthodontics published the paper.  It is open access.

Efficacy of Class II correction with clear aligner therapy and intermaxillary elastics in adolescent patients: A retrospective study

Maurice Meade, Bariah Rans and Tony Weir

AJO-DDO advanced access:  https://doi.org/10.1016/j.ajodo.2026.02.014

What did they ask? 

They did this study to 

“Assess the changes in overjet and the intermaxillary sagittal first permanent molar relationship in adolescent patients after treatment with an initial set of Invisalign aligners and Class II elastics.” 

What did they do? 

They obtained the sample for this study from the Australian Aligner Research Database. This database contains data on approximately 17,500 patients treated by 18 experienced orthodontists. 

I have previously done blog posts about papers from this study team that use this database. It certainly seems to be a valuable source of information. 

The inclusion criteria for patients to take part in this study were that they were under 18 years old with a Class II malocclusion, defined by the molar relationship. The orthodontists treated them with Invisalign only. They had to have full records.  

The source of information was the STL models. They obtained the files for (1) pre-treatment, (2) planned movements, and (3) achieved outcomes after wear of the initial aligners.

The primary outcome measures were overjet and intermaxillary sagittal relationship. 

They conducted a sample size calculation, which indicated they needed 64 patients. However, they decided to base their sample size on eligibility for inclusion in this study. As a result, they included information on 199 participants. 

They performed standard univariate analyses to examine their data. 

What did they find? 

They included 199 patients in their final sample. 65.8% of these were female, and the mean age of the sample was 13.66 years. 

I have extracted the mean and 95% CI data for overjet and first molar (FPM) variables (mm) into this table.

At the end of treatment, 45.2% had an overjet greater than 4.1 mm. Importantly, only 33.6% of the planned overjet reduction was achieved. Interestingly, 31% of patients showed an increase in overjet, despite a planned reduction.

The greater the pre-treatment overjet, the larger the discrepancy between the planned and achieved changes. When assessing sagittal change, the overall accuracy of the planned sagittal change was 45.9%.  

The final conclusions were 

“Almost half of the participants had an overjet greater than 4.1 mm at the end of the initial series of aligners. Importantly, 31% showed an increase in overjet despite a reduction in overjet being planned.”

What did I think? 

Regular readers of this blog will know that over several years, we have made a plea for increased research into the effectiveness of clear aligners. Ideally, this should be done with prospective cohort studies or randomised trials. Unfortunately, investigations of this nature are lacking. As a result, we have to rely on retrospective studies for information. 

This team has conducted extensive research and published numerous papers using the Australian aligner database. This is a large database and appears to be a good source of information, albeit retrospective. When we consider the nature of this research, we must assume there is some selection bias in the sample; however, we do not know its direction. This is, to a degree, offset by the fact that the database is large and that all orthodontists are obliged to include their patients treated with clear aligners in it. 

As a result, I think we can conclude that this is the best information we have on the use of clear aligners. 

The results of this study are similar to those reported in previous papers by this group. It appears that there is a disparity between planned and achieved tooth movements with clear aligners. In this respect, the results suggest that aligners used in this way are not an effective method of class 2 correction. It certainly appears that functional appliances achieve better results. However, we also need to remember that there is a relatively high discontinuation rate with removable functional appliances. Unfortunately, there does not seem to be information on the discontinuation rate in this sample of patients. Therefore, this information is lacking. 

Final thoughts. 

I used and studied removable functional appliances for many years during my clinical practice. The results of this study would not persuade me to switch this group of patients to clear aligner treatment. However, some people may be excellent operators with better results than those reported in this paper. It would be good to hear their comments on this paper. 

Now that you have read this blog post.

Last year, I requested donations to support my blog, and thankfully, I received an overwhelming response. With your help, I was able to raise sufficient funds to keep my blog going for another year. 

Now, I’m seeking your support again to help me cover the blog’s running expenses for the upcoming year. The funds will cover web hosting, software upgrades, email lists and general running costs. 

I believe that if every reader contributes a small amount, I can cover the yearly running costs. Your help will be much appreciated.

To make a donation, just use the form below. You can use the set-amount buttons or the free-field button to enter other amounts.

Then the easiest way to pay is to tap the Apple Pay button. If you want to use another payment method, click the “next” button and enter your details. This will take you to credit cards, PayPal, and other payment methods.

       

Comments

• Interesting study, unsurprising findings, but a waste of time ... by Vishnu Raj
• In reply to Kevin O'Brien. Thank you, Kevin. I agree that ... by Tommaso Castroflorio
• In reply to Kevin O'Brien. Thanks for your comment. I am not ... by Vicki Vlaskalic
• Kevin, Thanks for posting this study. As you and others here ... by Art Sonneborn
• In reply to vicki vlaskalic. Thanks for declaring your ... by Kevin O'Brien
• Plus 5 more...

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This new pilot study looked at the effects of dental arch constriction on SDB. I found the results interesting. They provide an argument against some of the nonsense circulating about the effects of orthodontics.

A team from Canada, did this study. The Angle Orthodontist published the paper. 

Effects of simulated arch constriction on upper airway function during sleep

Da In Kim; Manuel O. Lagravère; Fernanda Almeida; Benjamin T. Pliska

Angle Orthodontist: On line. DOI: 10.2319/051925-396.1

What did they ask? 

The aim of this study was 

“To characterise the presence of functional changes of the airway with level three polysomnography while using an appliance simulating airway constriction” 

What did they do? 

They conducted a single-blind, prospective, randomised crossover study in healthy adults. 

The PIC0 was 

Participants 

Healthy adults were recruited from the student and staff population of the Faculty of Dentistry. 

They had standardised demographic and anthropometric data collected and orthodontic records. This included a lateral cephalogram and an intraoral scan of the dentition. 

Intervention

This was a vacuum-formed retainer designed to constrict the arches. Constriction was simulated by adding a 5 mm thickness to the lingual and palatal aspects of all the teeth in both upper and lower arches. This resulted in a 1cm constriction overall.

Control 

A vacuum-formed retainer. 

Outcomes. 

The primary outcomes were Respiratory Events Index (ROI) This was derived from data obtained from a portable sleep monitor at home. 

Other outcomes were oxygen desaturation index (ODI), SpO2 measured with a pulse oximeter. The Epworth Sleepiness Scale and morphological data. 

Each participant underwent three sleep studies. The initial study was conducted at baseline, before any appliances were fitted. Patients were then randomly assigned by computer-generated randomisation to an intervention sequence arm, and they wore either the control appliance or the constricting appliance for six days. After this period, a second home sleep study was conducted. 

The participants then crossed over and used the other appliance for another six days. This was followed by a third sleep study. 

They analysed their data with a relevant univariate statistical test. 

They conducted a sample size calculation for a pilot study, which suggested they needed 12 participants per group. As a result, they attempted to recruit 24 participants, with an additional 11 to account for potential dropouts. 

What did they find? 

They recruited 35 healthy participants with an average age of 28.5 years for the study. By the end of the study, 34 participants had completed all required data collection. When analysing their data, there were no statistically significant differences in REI at any stage of the study. 

Similarly, when they examined ODI, they did not find any statistically or clinically significant differences. There did not find any differences in the Epworth sleepiness scores. 

The overall conclusion was 

“Simulated severe constriction of the dental arches does not affect respiratory function during sleep as measured by at-home polysomnography.” 

What did I think? 

This was a good, ambitious study that employed quite novel techniques. They used an interesting and relevant method to simulate dental arch constriction. We might think that this does not fully represent the gradual arch constriction that can occur with “retractive orthodontics”. Nevertheless, I believe this was a reasonable approach.

I have considered whether the rather sudden constriction might have influenced the results. I cannot help feeling that rapid constriction would have a greater impact than a slow constriction resulting from any orthodontic treatment. This is because the airway is given sufficient time to adapt to the constriction. However, I am not an expert on this matter, and my thoughts are purely conjecture.

We also need to acknowledge that this study is a pilot with a relatively small sample size; however, given the small effect sizes detected, we would argue that they are unlikely to change substantially with a larger sample. Still, I would prefer to see a larger study before drawing any firm conclusions.

The authors also mention that they relied on participants’ cooperation and did not measure the duration of appliance wear. This factor could, of course, influence the results. 

Final thoughts. 

We need to consider whether we can generalise these findings to real-world clinical care. I believe they offer some evidence that the constriction of arches does not impact breathing.

Nonetheless, we should interpret the results of this study with caution, but they provide useful preliminary data to guide further research and enhance our understanding of this important issue. 

Now that you have read this blog post.

Last year, I requested donations to support my blog, and thankfully, I received an overwhelming response. With your help, I was able to raise sufficient funds to keep my blog going for another year. 

Now, I’m seeking your support again to help me cover the blog’s running expenses for the upcoming year. The funds will cover web hosting, software upgrades, email lists and general running costs. 

I believe that if every reader contributes a small amount, I can cover the yearly running costs. Your help will be much appreciated.

To make a donation, just use the form below. You can use the set-amount buttons or the free-field button to enter other amounts.

Then the easiest way to pay is to tap the Apple Pay button. If you want to use another payment method, click the “next” button and enter your details. This will take you to credit cards, PayPal, and other payment methods.

       

Comments

• It is 3PM on the west coast of the US and so far ... by John L. McDonald

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A team from Wuhan, China did this review. Sleep and Breathing published their paper.

The effect of rapid maxillary expansion on children with obstructive sleep apnea: a systematic review and meta-analysis

Yu et al. 

Sleep and Breathing, Advance access. DOI: https://doi.org/10.1007/s11325-026-03606-1

What did they ask? 

“The primary object of this systematic review was to evaluate the efficacy of RME in treating pediatric OSA.”

What did they do? 

They did a systematic review using standardised methodology.  

The PICO was 

Population. 

Children with maxillary transverse deficiency who are diagnosed with OSA via overnight PSG 

Intervention. 

Treatment with rapid maxillary expansion appliances. 

Comparison 

Baseline pre-RME treatment or Watchful waiting. 

Outcome. 

Respiratory Outcomes and Radiological Outcomes 

Study Design 

They included cohort studies, cross sectional, retrospective studies, case controlled studies with a comparison or control group, and randomised controlled trials.

They carried out an electronic search, followed by identification of studies, filtering of studies, data extraction, risk of bias assessment and outcome assessment.

The primary outcome was the apnea-hypopnea index (AHI). Secondary outcomes were, sleep efficiency, peripheral capillary oxygen saturation and other patient-related outcomes

They conducted a meta-analysis using a random-effects model. 

They assessed the risk of bias in all studies using the Risk of Bias in Non-Randomised Studies (ROBINS-I) tool. This was not relevant for the randomised trials they found. Finally, they appraised the quality of evidence with the GRADE tool. 

What did they find? 

After filtering the studies, they identified 14 suitable for data analysis. Seven of these were before-and-after studies. Five were non-randomised controlled trials, and three were randomised controlled trials. 

When they performed their risk of bias analysis and found that ten studies had a serious risk of bias. They assessed four studies as having a moderate risk of bias. 

Ten studies examined changes in AHI within 6 months after completing RME (mean difference: -4.04, 95% CI: -6.39 to -1.7, p = 0.0007). Heterogeneity was 93%. 

Seven studies examined changes within 12 months of the intervention. These showed that the mean difference was -6.15 (95% CI, -11.66 to -0.64), p = 0.03. Heterogeneity was 97%. 

They reported significant improvements in most of their other outcome measures. 

The discussion was insightful because they noted a significant reduction in the apnea-hypopnea index at both 6- and 12-month follow-up. However, they highlighted that the RME did not consistently bring AHI values below 1 to normal levels. 

They also highlighted that heterogeneity was very high. This diminishes confidence in their findings. Significantly, the quality of the evidence, as assessed by GRADE, was rated low or very low. They further noted that the number of high-quality RCTs was very limited, with many studies having small sample sizes and methodological flaws. Consequently, we need to be cautious when interpreting the results. 

Their final conclusion was: 

“These findings indicate that RME can effectively enhance the transverse width of the maxilla and improve polysomnographic parameters in pediatric patients with OSA.” 

I took this from their abstract, as it is likely to be more widely read than the paper itself. 

What did I think? 

A relatively well-known team conducted this review. They followed standard systematic review methodology. When I read the abstract, I thought that this review could significantly contribute to our knowledge because of its very positive conclusion. However, upon reading the paper, I concluded that this was an excellent example of an abstract that does not necessarily reflect the quality of the research and content of the paper. We must remember that the overall quality of the evidence was rated low or very low.

Systematic reviews can be quite challenging to interpret due to the vast amount of information they contain. However, I have several main concerns with this review. 

Firstly, they merely reported the results before and after treatment for the studies they included. They did not compare any changes to an untreated control group. As a result, it is impossible to conclude that the RME influenced AHI. This is because the results do not account for the possible effects of growth. For example, in the classic CHAT study, they found that “46% of children in a watchful wait group had some resolution of polysomnographic abnormalities.” I am not endorsing watchful waiting based on this study; I am simply highlighting that AHI can reduce spontaneously.

Secondly, they identified several included studies as being at high risk of bias. As a result, they stated that the strength of evidence was very low. Furthermore, most of these studies were cohort and retrospective studies. Again, this further diminishes the strength of evidence.  

Finally, the heterogeneity in the meta-analysis was very high. They removed outlier studies to reduce heterogeneity; however, they did not publish the meta-analysis results after this removal. I have contacted the authors to clarify the situation, but I have not received a reply. 

Final comments. 

Over the past six months, I have been accused of being overly critical of several studies concerning orthodontics and breathing disorders. I would like to emphasise that I genuinely want to see strong evidence demonstrating that we can improve the health of this group of children with a disorder that may lead to long-term problems.

However, I have critically appraised these studies and found that many lack robust methodology and do not meaningfully address the questions we have about orthodontics and breathing disorders. I am sorry to say that this is yet another study that fails to illuminate this complex issue. 

       

Comments

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The study team tested a modified open exposure technique that they have used for over 40 years (GOPEX). This involved, instead of surgical packing, applying glass ionomer cement to the canine. The glass ionomer remains on the tooth until it has spontaneously erupted above the gingiva. This certainly seems to be a better method than the one I used when I practised, where we placed a periodontal dressing over the open exposure and removed it after 10 days. Unfortunately, it tended to detach, and the tooth happily covered up again.

The well-known trial team from Gothenburg, Sweden, conducted this study. The European Journal of Orthodontics published the paper. Since it is open access, anyone can read it. 

Glass ionomer open exposure and closed exposure of palatally displaced canines: a randomised controlled trial comparing postoperative pain perception and complications

Anna Dahlén et al

EJO Advance access: https://doi.org/10.1093/ejo/cjag011

What did they ask? 

They did this study too.

“Compare glass ionomer open exposure (GOPEX) with closed exposure (CE) in terms of patient-reported outcomes, surgical duration, and complications.” 

What did they do? 

They did a single-centre randomised controlled trial with a one-to-one allocation of two parallel groups. The PICO was:

Participants 

Children and adolescents under 18 years old with a palatally displaced canine were referred for treatment between March 2017 and April 2024. The main inclusion criteria were that they had a unilateral PDC and were planned for surgical exposure and orthodontic treatment. Importantly, the canine had to be positioned within sectors 2-5 on the panoramic radiograph. 

Intervention one. 

GOPEX. This was an open exposure in which glass ionomer cement was applied to the cusp tip of the exposed PDC. 

Intervention two. 

The paediatric dentist exposed the tooth, and then bonded an eyelet and chain with light-cured composite. They then sutured the flap back to its original position. 

Outcomes 

The study reported on several outcomes. The primary outcome was the amount of pain recorded by the patients. They also included information on the children’s fear of their procedure, as well as the duration of surgery and any complications. 

They used a pre-prepared randomisation scheme. Allocation concealment was stored securely at the clinic and was not accessible to the recruiting orthodontists. The allocation was carried out after obtaining the patients’ written consent. 

One of three experienced paediatric dentists performed the surgical procedures. 

They did a clear sample size calculation. Based on the amount of pain the patients could report. This revealed that 40 patients per group were required. They increased the target sample to 92 participants to compensate for dropouts. 

They conducted relevant multivariate and univariate statistical tests, and clearly outlined them in their paper. 

What did they find? 

They randomised 92 patients to the interventions: 43 to the GOPEX group and 40 to the closed exposure group. All of these patients completed the study.

During the first fourteen post-operative days, there were no significant differences between the groups in pain levels; however, after seven days of cooperation, pain scores were substantially higher in the GOPEX group than in the CE group. There were no differences in the percentage of pain-free patients, analgesic use, or chewing difficulty. 

Their overall conclusions were: 

“The GOPEX group had more pain in the first post-operative week, but no difference was seen in pain scores or any other outcome measures over the whole 14-day post-operative period.” 

What did I think? 

This was a very well-executed and well-presented trial and publication. They followed the CONSORT guidelines in their write-up; all aspects of a good trial were achieved. This is a high-quality research paper. 

When I reviewed their results, I found them to be clinically useful. Importantly, they found no difference between the two interventions in any of the outcomes they assessed. This provides us with valuable information we can share with our patients when they choose their preferred treatment.

However, while this information is useful, I could not find any details in this paper about the relative success rates of the two interventions. I contacted the authors to ask when this information will be available. They told me they are writing a paper on this and hope to publish it in early 2027. Once they have published this research, we will have the information needed to make clinical decisions with our patients. 

       

Comments

• Dr.Michael Weber April. 1. 2026 In my practice I prefered the ... by Dr.Michael Weber
• Thank you for sharing this nice comparison. I have a question ... by Nagwan Elfadil
• An interesting study. I found that often, in the closed ... by Danny Radnzic
• Man, impacted canines are the bane of modern ortho! Always good ... by Chad Carter

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A team from Mansoura, Egypt conducted this research. The angle orthodontist published the paper. 

Dento-facial changes and oral health-related quality of life assessment in management of anterior crossbite in mixed dentition: a randomized clinical trial.

Asmaa S. Salem et al

Angle Orthodontist On line advance access. DOI: 10.2319/020325-109.1

What did they ask?

The authors did this study to

“Evaluate the dental-facial changes and the improvement in oral health-related quality of life between clear aligners and inclined plane appliances for managing anterior functional crossbite in the mixed dentition.” 

What did they do? 

They conducted a single-centre, randomised clinical trial with a parallel design, allocating participants in a 1:1 ratio. The PICO was: 

Participants 

24 children aged 8 to 12 years who had an anterior functional crossbite involving more than two teeth 

Intervention one. 

In-house clear aligners. They asked the patients to wear their aligners for 22 hours a day and change the aligner every 10 days. 

Intervention 2. 

A removable inclined plane which fitted the lower arch. This was made of transparent sulfur-cured acrylic resin, which was applied to a PETG sheet. The operator saw the patients every two weeks, and the operator relieved the inclined plane. After the completed treatment, they asked the patients to wear their appliance for a further four weeks. 

Outcomes 

The primary outcomes were cephalometric measurements; however, they based their standard sample size calculation on the upper incisor to SN angle, and I’ve assumed that this is the primary outcome. Secondary outcomes were oral health-related quality of life, and they measured this using the CPQ 8-10 questionnaire. 

The team performed a clear sample size calculation that suggested they needed 12 patients per group. 

The same postgraduate student treated all the patients at a single centre.

They used a pre-prepared randomisation sequence, and the allocation was performed by drawing a card from a box containing 24 cards, with 12 cards assigned to each group. It was not possible to treat the patients blindly; however, all data was analysed blind. 

They analysed the data using univariate statistics to evaluate any differences between the groups. 

What did they find? 

24 of the patients completed the trial. I could not find any information about whether they corrected all the crossbites, but I assume that this was the case. 

At the start of treatment, there were no differences between the two groups. 

They then supplied a large amount of cephalometric data with multiple comparisons. As you know, I find this kind of data presentation rather confusing and unclear. This is especially due to the risk of false positives when measuring many related variables and performing simple statistical tests. 

As a result, I have just concentrated on the straightforward outcomes of upper incisor and lower incisor angulation.

When they looked at U1-SN. In the clear aligner group, after treatment, the upper incisor position was 114.44mm (6.03).  Whereas for the inclined plane appliance, this was 108.1 mm (4.31). The mean change in this measurement was 11.65mm (3.95) for the clear aligner and 6.73mm (2.94) for the inclined plane group.  This difference was statistically significant.

When they evaluated the L1-NB (mm). For the clear aligner group, the mean was 4.01mm (1.73), and for the inclined plane group, it was 3.93mm (2.34). When they evaluated the change in this measurement, this was 0.77mm (1.42) for the clear aligner and -2.03mm (2.21) for the inclined plane group. This was statistically significant.

Finally, there were no differences in the oral health-related quality of life measurement between the groups; however, both groups showed an increase in this measurement, indicating an improvement in oral health-related quality of life for all participants.

The final conclusions were;

“The clear aligner group experienced more proclination of the upper incisors, whereas the inclined plane group showed that upper incisor proclination and lower incisor retrusion resulted in the correction of the anterior crossbite”.

What did I think?

Firstly, I thought it was positive to see more studies exploring the effectiveness of clear aligners. Importantly, this study demonstrated that clear aligners are an effective treatment for anterior cross-bite with a functional shift. However, it was also notable that there were no significant differences in the final treatment outcomes between the clear aligners and the simpler inclined plane appliance. This finding is important because, as the authors suggested, the inclined plane appliance offers a cheaper alternative to using clear aligners. 

When I examined the design of the two interventions before reading this paper, I expected to see different cooperation rates, as the inclined plane seems to be a much more challenging device for participants to tolerate. It was interesting that this was not the case, as there were no significant differences in cooperation rates between participants in either group.

In summary, this was another well-conducted small study on the effectiveness of clear aligners. This leads us to the conclusion that this study provides important information that may guide our patients’ decisions when they are giving consent for treatment.

       

Comments

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• Thankyou Kevin for the review of the well conducted project ... by Vicki Vlaskalic
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