Orthodontic treatment is delivered in increasingly diverse clinical and digital environments, yet outcomes continue to depend on patients' understanding, adherence, and timely responses to complications. This World Federation of Orthodontists Global Guidance provides the first internationally oriented, consensus-based framework for orthodontic patient instructions and emergency protocols. An expert panel of orthodontists from 13 countries across 6 continents used a multi-stage, blinded consensus process and external review to synthesize evidence, clinical experience, and best practice. The document sets global standards and recommendations across key domains: risk communication and informed consent; oral hygiene and appliance care; triage and management of emergencies, urgencies, and minor events; peri‑procedural counselling for minor and orthognathic surgery; retention and long-term monitoring; and the ethical integration of tele-orthodontics and artificial intelligence. Core principles emphasize health literacy-sensitive, culturally adaptable, and ethically grounded communication, supported by digital tools without replacing clinician oversight. The guidance is intended for orthodontists, trainees, and dental teams worldwide, and offers a basis for professional organizations, regulators, and academic institutions to develop locally adapted protocols, curricula, and quality indicators. By standardizing key elements of patient-facing communication and emergency management, this World Federation of Orthodontists initiative aims to reduce preventable complications, enhance patient safety, and catalyze global audit and research into orthodontic communication and patient-centered outcomes.
BACKGROUND:Orthodontic practice is being reshaped by digital workflows, artificial intelligence (AI), shifting patient expectations, global communication platforms, and complex models of care delivery. Future competence, therefore, should not be defined by appliance proficiency alone. METHODS:A group of experienced orthodontic educators from various academic settings worldwide was convened to identify, regroup, and harmonize competencies they considered essential for future orthodontic practice. Independent submissions were analyzed thematically and consolidated into ten domains after several rounds of group interactions. RESULTS:Ten competency domains were identified: ethics and professionalism; communication and patient-centered care; digital and AI fluency; research literacy; individualized and minimally invasive care; clinical excellence and biomechanics; biological foundations; interdisciplinary care; leadership and global responsibility; and adaptability, innovation, and lifelong learning. No formal validation of these proposed competency domains is implied. CONCLUSIONS:The ten proposed competency domains are intended to foster constructive discussion within the orthodontic academic community.
BACKGROUND:Clear aligner therapy has expanded substantially in mixed dentition, yet the boundaries of clinical predictability across indications, movement types, and growth stages remain incompletely defined. The aim of this review was to synthesize evidence on clear aligner therapy in mixed dentition, describe indication-specific performance patterns, and identify evidence gaps that limit clinical confidence. METHODS:This scoping review was reported in accordance with PRISMA-ScR. PubMed/MEDLINE, Embase, and Scopus were systematically searched for studies published from 2000 to 2025. Additional records were identified through Google Scholar and reference list searching. Randomized controlled trials, prospective and retrospective cohorts, and cross-sectional studies were eligible. Data were charted and synthesized descriptively. RESULTS:Fifty-nine studies were included (8 randomized controlled trials, 11 prospective cohorts, 38 retrospective cohorts, 2 cross-sectional), most involving children aged 7 to 12 years. Achieved transverse dentoalveolar expansion with clear aligners was lower than planned, particularly posteriorly and at gingival levels. Comparative studies suggested greater posterior and palatal changes with rapid maxillary expansion. Mandibular advancement aligners were associated with Class II sagittal improvement, with responses varying by skeletal maturity and dentoskeletal pattern. Evidence for incisor correction, molar movement, vertical outcomes, airway, oral health, patient-reported outcomes, and smile esthetics remained limited. CONCLUSIONS:Clear aligners in mixed dentition demonstrate indication-dependent predictability influenced by movement type, anatomical region, and growth stage. Clinical confidence remains limited by retrospective evidence, heterogeneous outcome measures, and insufficient standardized reporting of post-treatment stability.
BACKGROUND:Biological maturation varies substantially among children of the same chronological age, which may affect growth-based orthodontic decisions. METHODS:In this cross-sectional study, 120 patients aged 8 to 16 years were evaluated using routine orthodontic diagnostic records. Chronological age was compared with dental age estimated using the Nolla and Demirjian methods, and skeletal maturation was assessed using cervical vertebral maturation stages (CVMS). Associations with sex, BMI, BMI-for-age z-score, and menarcheal status in females were examined. RESULTS:Both dental methods systematically overestimated chronological age. Mean discrepancies were +0.59 years for the Nolla method (95% CI: 0.39-0.79; Cohen's dz = 0.52) and +1.09 years for the Demirjian method (95% CI: 0.87-1.31; Cohen's dz = 0.89) (both P < 0.001). Female participants exhibited a higher proportion of pubertal and postpubertal CVMS than males (Cramer's V = 0.41; P < 0.001), although sex differences in dental age discrepancies were small (Cohen's d ≤ 0.14). BMI and BMI-for-age z-scores were positively correlated with dental age discrepancies (ρ = 0.27-0.31) and CVMS stage (ρ = 0.35-0.36) (all P ≤ 0.003), indicating small-to-moderate associations. Menarcheal status was not significantly associated with CVMS (P = 0.727) or dental age discrepancies (P > 0.05). CONCLUSIONS:Chronological age alone provides an incomplete estimate of biological maturation. Dental age estimation and CVM assessment offer complementary but nonequivalent information, and their interpretation should consider sex and basic anthropometric context.
BACKGROUND:Anatomical variability of the mandibular retromolar space (MRS) plays a decisive role in planning mandibular molar distalization; however, available evidence remains fragmented across heterogeneous tomographic studies. OBJECTIVE:To synthesize current evidence derived from computed tomography (CT) and cone-beam computed tomography (CBCT) regarding morphometric factors influencing MRS and their implications for orthodontic distalization. METHODS:A systematic search was conducted in MEDLINE, LILACS, Scopus, Web of Science, and Google Scholar in accordance with PRISMA guidelines. Observational studies evaluating MRS using CT or CBCT in adult populations were included. Data extraction focused on skeletal classification, vertical facial pattern, sex, age, and third-molar status. Methodological quality was assessed using the Joanna Briggs Institute critical appraisal tools. RESULTS:Fourteen studies met the inclusion criteria, comprising samples from China, South Korea, Egypt, Turkey, India, Japan, and Taiwan, with a mean age of 25.8 years. A skeletal Class III pattern consistently exhibited the greatest MRS, followed by Class I and Class II. Normodivergent individuals demonstrated larger MRS values compared with hyperdivergent or hypodivergent patients. Third-molar position and angulation, rather than mere presence, were identified as key determinants of the effective distalization limit. Sex-related differences were inconsistent across studies, and the influence of age varied. The internal (lingual) cortical plate emerged as the principal anatomical boundary restricting mandibular molar distalization. CONCLUSIONS:Mandibular retromolar space is strongly influenced by skeletal classification, vertical growth pattern, and third-molar morphology. Pre-treatment CBCT assessment is essential to identify anatomical constraints, prevent cortical interference, and optimize individualized orthodontic biomechanics. Future multicenter studies employing standardized CBCT protocols are needed to enhance the clinical applicability of these findings across diverse populations.
OBJECTIVE:Understanding the chief complaints of patients is essential for effective communication and successful orthodontic treatment. Although previous studies have often used structured questionnaires, few have applied data-driven methods to unstructured free-text responses. Furthermore, how these complaints from distinct semantic structures based on molar classifications remains underexplored. This study aimed to examine these structural differences using correspondence and co-occurrence network analyses. MATERIALS AND METHODS:Patients who visited an academic dental hospital for an initial orthodontic evaluation between April 2011 and March 2024 were included. Data on chief complaints (free text), sex, age, skeletal classification, and molar classification were obtained from standardized diagnostic records. Chief complaints were analyzed structurally, retaining nouns and adjectives. We extracted the 60 most frequently used terms, followed by correspondence and co-occurrence network analyses. RESULTS:In total, 2568 (35.4% male) patients were included. Their mean age was 22.0 years (range: 7-74 years). Anterior esthetic concerns were the most frequently reported chief complaints across all patients. However, correspondence and network analyses revealed distinct structural patterns according to molar classification. Class I patients mainly cited esthetic reasons. Class II patients were characterized by morphological and symptomatic concerns and referrals. Class III patients presented interrelated skeletal, functional, and psychological concerns, often involving an awareness of surgical necessity and mentions of being pointed out by others. CONCLUSIONS:Although esthetic dissatisfaction is common, distinct complaint patterns exist based on molar classification. Recognizing these semantic structures facilitates shared decision-making and provides a foundation for developing patient-centered PROMs in orthodontic practice.
Background Extra-alveolar anchorage sites, particularly the infrazygomatic crest (IZC) and the mandibular buccal shelf (MBS), are increasingly used for orthodontic anchorage. Although cone-beam computed tomography (CBCT) is widely employed to evaluate these regions, the available evidence shows substantial methodological heterogeneity. Objective To map the CBCT-based evidence on the morphological characteristics of the infrazygomatic crest and mandibular buccal shelf as extra-alveolar anchorage sites for orthodontic miniscrews. Methods A scoping review was conducted following PRISMA-ScR guidelines. Searches were conducted in PubMed, Scopus, and the Cochrane Library through June 2025. Observational studies reporting CBCT-based anatomical measurements of the IZC and/or MBS were included and charted descriptively. Results Of the 58 initially identified records, 13 studies were finally included. Considerable heterogeneity was observed in CBCT acquisition protocols, measurement approaches, anatomical reference points, and studied populations, limiting direct comparability across studies. Conclusions Current CBCT-based evidence on the morphology of extra-alveolar anchorage sites is highly heterogeneous. This scoping review provides a structured overview of the existing literature on the IZC and MBS and underscores the need for greater standardization of morphological measurement protocols.
BACKGROUND:Orthodontic finishing is a preference-sensitive decision point in which patients and clinicians may place different emphasis on satisfaction and clinician-defined finishing standards. This study compared patient and orthodontic clinician perspectives on treatment completion, focusing on how satisfaction is weighted relative to occlusal perfection. METHODS:A cross-sectional study used two online surveys (adult patients and orthodontic clinicians) with five-point Likert items. Ordinal responses were compared using Mann-Whitney U tests; selected contrasts were dichotomized (agree 4-5 vs. 1-3) and tested using Fisher's exact tests with odds ratios. Within-clinician paired comparisons used Wilcoxon signed-rank tests. Free-text responses were translated and grouped into clinically interpretable categories. RESULTS:In total, 100 patient and 23 clinician questionnaires were analyzed. Patients tended to disagree with stopping treatment when satisfied if bite/alignment remained imperfect (mean 2.37, SD 1.39; 21.6% agree 4-5), whereas clinicians tended to endorse satisfaction having equal weight to occlusal perfection (mean 3.91, SD 0.95; 69.6% agree 4-5), with a significant distributional difference (p = 4.25 × 10⁻⁶). Clinicians were more likely than patients to endorse the satisfaction-weighted stance when dichotomized (OR 8.27; p = 2.23 × 10⁻⁵). Clinicians also showed a principle-practice tension, endorsing "equal weight" more strongly than comfort ending earlier (paired p = 0.000918). Qualitative responses most often defined success as straightness and improved appearance; burdens centered on time/appointments, with cost a common barrier. CONCLUSIONS:Patients and clinicians differed in how satisfaction-guided treatment completion was viewed and applied. Explicit finishing discussions about residual discrepancies, marginal gains, and time/burden trade-offs may support clearer shared decision-making at treatment completion.
Background To evaluate the dentin hypersensitivity (DH) after interproximal enamel reduction (IPR) in patients undergoing clear aligner (CA) treatment after using diode laser versus sodium fluoride. The secondary aim was to assess the gingival status in the three groups during treatment. Methods This double-blinded randomized controlled clinical trial included patients with permanent dentition, aged between 15 and 35 years, good oral and general health, to be treated with CAs and IPR. Exclusion criteria were history of DH, enamel defects, cervical caries, periodontal disease, or pregnancy. 45 patients were randomly assigned to three groups: Group A (acidulated sodium fluoride gel: 0.33% sodium fluoride), Group B (diode laser: Soft Touch, 810 nm, 0.5 W), and Group C (control, no treatment). The response to air stimuli and the gingival indices were recorded before (T0), and after IPR (T1), one week (T2), one month (T3), and three months post-treatment (T4). DH was assessed using a visual analog scale by a blinded operator while gingival health was evaluated using Silness and Löe Plaque and Gingival Index. Results All groups showed an increase in DH immediately after IPR compared to baseline, which subsequently decreased at T2, T3, and T4. The laser group exhibited a statistically significant reduction in DH, with rapid improvement at T1 and sustained benefits over time. The Gingival Index showed the most pronounced improvements in the laser group. Moreover, the Plaque Index was reduced in all groups. Conclusions The application of a diode laser after IPR during CA treatment significantly reduced DH without adversely affecting gingival health.
BACKGROUND:Maxillary transverse deficiency limits the choice of safe and stable palatal miniscrew sites. Cone-beam CT (CBCT) mapping of the posterior palatal supra-alveolar insertion site (PPSAIS) may support bicortical/tricortical anchorage planning. OBJECTIVE:To quantify bone height available for tricortical and posterior bicortical insertion in patients with maxillary atresia using CBCT. METHODS:In this observational cross-sectional study, 90 full-head CBCT scans (ages 14-40 years; equal sexes) with maxillary atresia were analyzed. Palatal bone height was measured at paramedian bicortical sites (anterior: second premolars; posterior: first molars) and at PPSAIS trajectories (45°-60°) on both sides using 3D Slicer/NNT. Intra-observer reliability was tested with ICC. Spearman correlations assessed the relationship between insertion angle and tricortical height. RESULTS:Tricortical PPSAIS heights exceeded bicortical values: means 5.6 mm (right) and 5.8 mm (left). Anterior bicortical heights averaged 3.5 mm; posterior bicortical heights were lowest (2.7-2.8 mm). No significant sex differences were observed for tricortical height. Spearman correlations between insertion angle and tricortical height were weak and non-significant (ρ = 0.12-0.25; all P > 0.05). Comparisons across age groups (14-19, 20-29, 30-40 years) showed no significant differences in transverse discrepancy or bone height at any site (all P > 0.05), indicating stability of palatal anatomy across this age range. Intra-observer reliability was good (ICC = 0.90). CONCLUSIONS:In maxillary atresia, the posterior palatal supra-alveolar region provides sufficient bone for tricortical miniscrew trajectories largely independent of modest angle variation and with no clinically relevant age-related differences in bone height. CBCT-guided planning should prioritize PPSAIS when stable skeletal anchorage is required for expansion.
BACKGROUND:This study aimed to evaluate the changes in the oral microbiome surrounding zinc oxide nanoparticle (NP)-coated orthodontic mini-implants using whole-genome metagenomic sequencing and to compare the microbial colonization and clinical stability with uncoated orthodontic mini-implants. METHODS:A randomized split-mouth trial was conducted on 12 orthodontic patients requiring bilateral skeletal anchorage in the maxillary arch. Each patient received one zinc oxide NP-coated mini-implant and one uncoated implant. The implants were coated using radiofrequency magnetron sputtering. Peri mini-implant crevicular fluid samples were collected at 1 week (T1), 4 weeks (T2), and 3 months (T3) postinsertion, and the pooled sample at each time point was subjected to whole-genome shotgun metagenomic sequencing. Taxonomic and functional profiles were analyzed using Kraken and MEGAN6, with diversity indices calculated via the VEGAN R package. Stability was assessed using a 4-point semiquantitative mobility scoring. RESULTS:Alpha diversity indices (Shannon and Chao1) showed no comparable differences between coated and uncoated mini-implants at any time point. Descriptive analysis of pooled metagenomic samples showed lower relative abundance or absence of peri‑implant pathogens, including Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Parvimonas micra, around coated implants. Functional gene analysis revealed reduced expression of bacterial motility, chemotaxis, and ribosomal pathways in the coated group. All mini-implants remained clinically successful during follow-up. Mobility scores were significantly lower at 1 month (P = 0.04), but not at 3 months (P = 0.102). CONCLUSIONS:Within the constraints of pooled metagenomic analysis, zinc oxide NP-coated mini-implants were associated with a lower relative abundance of selected peri‑implant pathogens and differences in functional pathway profiles compared with uncoated implants. Overall microbial diversity did not differ significantly between groups. Both implant types remained clinically stable, although coated implants showed reduced early mobility at 1 month. These findings should be interpreted as exploratory, and further validation through patient-level metagenomic studies is warranted.
Background To evaluate the cytotoxicity of direct 3D-printed aligners fabricated from Tera Harz TC-85DAC resin (TC) compared with conventional thermoformed aligners, and to investigate the effect of different post curing durations on TC cytotoxicity. Materials and methods Human gingival fibroblasts (HGFs) were exposed to eluates from TC and three thermoformed aligners (Essix ACE, Duran, Invisalign). TC aligners were postcured for 14, 20, and 40 minutes (TC80, TC100, TC200). Cell viability was assessed using the CCK-8 assay at 1, 3, 5, and 7 days, and cell migration was evaluated using a scratch wound healing assay at 24 and 48 hours. Statistical analysis was performed using ANOVA with Tukey’s post hoc test. Results Cell viability was significantly reduced in the TC group compared with thermoformed aligners at days 3, 5, and 7. Cell migration was also significantly impaired in the TC group at 48 hours. Among TC subgroups, day-7 viability was significantly lower in TC80 compared with TC100 and TC200, whereas no significant differences in migration were observed among curing times. Conclusions TC aligners significantly reduced cell viability over the 7-day incubation period compared to control and conventional thermoformed aligners. The cell migration was also significantly reduced in the TC group at 48 hours. Under-curing significantly decreased cell viability, whereas extending the post curing time beyond the manufacturer’s recommendation did not result in additional improvement. Furthermore, the amount of cell migration across varying post curing durations was not different at both 24 and 48 hours.
Permanent maxillary canine agenesis is a rare condition caused by genetic, epigenetic, or environmental factors affecting tooth development. It results in malocclusion and adverse physiological changes. We present our orthodontic diagnosis, treatment challenges, and successful outcomes of a case involving a 10-year-old male with Class II/0 malocclusion, mild class III skeletal pattern, anterior crossbite, left mandibular lateral displacement malocclusion, right dental-skeletal crossbite, mild transitional bilateral posterior open bite, moderate lower anterior crowding, mild maxillary spacing, and genetic polymorphisms in MSX1 and PAX9; bilateral permanent maxillary canine agenesis, molar taurodontism, and bilateral mesioangular mandibular permanent second molar impactions. Presumptive mild-to-moderate hypolordosis and phase 2 left adolescent idiopathic scoliosis were also identified. Treatment involved widening the maxilla, replacing maxillary canines with bicuspids, second bicuspid extraction and closing spaces in the mandible, and deimpacting second mandibular molars. Spine follow-up showed indirect effects on head posture. Class I occlusion with normal overjet and overbite was achieved. Cervical spine correction occurred spontaneously years later. The spatiotemporal effects of MSX1 and PAX9 polymorphisms on the patient’s phenotype led us to apply age-related orthodontic transverse and sagittal treatment strategies to avoid dental replacements and correct dental relationships and molar impactions. This approach also contributed to adolescent idiopathic scoliosis (AIS) self-correction in adolescence and long-term stability in adulthood.
BACKGROUND:In animal studies we have shown that the inflammatory response and rate of tooth movement triggered by orthodontic force reach a saturation point beyond which increased force produces no additional response. In addition, our previous clinical study found that adolescents and adults have different inflammatory response, tooth movement rates, and pain with increasing orthodontic forces. Based on these findings, our goal in this study was two-fold. First, to determine if there is a saturation point for the inflammatory response and tooth movement rates in orthodontics patients. Second, to determine if age impacts the saturation point. METHODS:We conducted a non-randomized, single-center, single-blinded clinical study on two groups of healthy subjects who required first premolar extraction and canine retraction to correct their malocclusion. Adolescents (11-14 years old) and adults (21-45 years old) of both sexes were recruited and randomized within their age group (n = 4 per force) to receive one of the following four magnitudes of force during canine retraction: 50, 100, 150, and 200 cN Gingival crevicular fluid (GCF) from the distolabial crevice of the canine was collected to assay inflammatory marker levels before treatment and one day after beginning retraction. IL-1β, CCL2, and RANKL proteins were quantified using a slide-based protein array assay. Study models were used to assess canine retraction after 28 days of force application. Differences within and between treatment groups were assessed statistically. RESULTS:We found that inflammatory cytokine levels and the rate of tooth movement reached its maximum at 100 cN or 150 cN for adults and adolescents respectively. Adolescents had lower cytokine levels at lower magnitude forces than adults, but the levels increased at higher magnitude forces, with adults reaching saturation sooner than adolescents. The rate of canine movement in 28 days was not significantly different between adolescents and adults at any force level. However, the rate was higher in adolescents for all force groups. CONCLUSIONS:As in our animal studies, humans demonstrate a saturation point for inflammatory responses and the rate of tooth movement to orthodontic force. Adults reached saturation of the biological response earlier, while younger patients had a higher saturation point. This study has important clinical significance as it may guide orthodontists toward optimizing orthodontic forces and treatment duration, while reducing the risk of pathology arising from excessive forces.
BACKGROUND:External root resorption (ERR) and external cervical resorption (ECR) are common orthodontic complications with prognostic impact. Early, accurate detection helps prevent irreversible damage. OBJECTIVES:Our objective is to synthesize diagnostic accuracy of artificial intelligence (AI) for ERR/ECR on orthodontic imaging and compare performance by imaging modality and model architecture. METHODS:Data Sources: Web of Science, PubMed, Scopus, Embase, IEEE Xplore, and Cochrane Library (through September 9, 2025). STUDY SELECTION:Original human or ex-vivo imaging studies of AI models for ERR/ECR with extractable accuracy data. DATA EXTRACTION AND SYNTHESIS:Two reviewers independently extracted TP/FP/TN/FN. Pooled sensitivity/specificity and HSROC were estimated via a bivariate random-effects model; risk of bias with QUADAS-2; PROSPERO: CRD420251103690. RESULTS:Five studies (1089 images) met criteria. Pooled sensitivity was 90.7% (95% CI, 85.6-94.1) and specificity 91.8% (95% CI, 86.0-95.3). CBCT-based models outperformed panoramic models, and transformer/hybrid architectures showed slightly higher accuracy than CNNs, though subgroup power was limited. Heterogeneity was moderate (I² ≈ 55-61%), plausibly related to variable diagnostic thresholds, mixed tooth types, and differing reference standards (orthodontists/endodontists/radiologists). LIMITATIONS:Small evidence base (n = 5), small geographically limited datasets, and absence of true external validation restrict generalizability. With <10 studies, formal publication-bias testing was not feasible. CONCLUSIONS AND RELEVANCE:AI shows high accuracy for ERR/ECR, particularly with CBCT and transformer/hybrid models, yet moderate heterogeneity and limited generalizability warrant cautious interpretation. AI should augment, not replace, clinician judgment within explainable, standardized workflows. Priorities include open multicenter annotated datasets, harmonized thresholds/protocols, and external validation to enable reliable clinical adoption.
