Objectives: Precise estimation of the treatment duration and selection of proper appliances have always been a challenge clinically due to individual variables such as growth, compliance, and complexity of the case. At present, advances in artificial intelligence (AI) provide opportunities for improvement in diagnostic precision by integrating clinical and imaging data. This research assessed the development and validation of an ensemble learning-based AI model that could estimate with accuracy the duration of orthodontic treatment by integrating cephalometric measurements with standardized photographic data for the determination of appliance type between fixed appliances and clear aligners. Material and Methods: We conducted a retrospective observational research study using anonymized data of 450 orthodontic patients aged between 12 and 35 years. Each record included pre-treatment lateral cephalograms, intraoral and extraoral photographs, appliance type, and treatment duration. The dataset was further divided into two parts – an 80% training set and a 20% testing set – in a random manner. Four models have been trained and compared: Support vector machines, decision trees, convolutional neural networks, and ensemble (hybrid fusion of cephalometric and photographic features). Predictive performance was assessed for accuracy, precision, recall, F1 score, and area under the receiver operating characteristic (AUC-ROC). Model predictions were compared with expert consensus using Cohen’s κ statistic and Bland–Altman analysis. Results: The ensemble model performed best, with an accuracy of 89%, precision of 90%, recall of 88%, F1 score of 0.89, and AUC-ROC of 0.92. For treatment duration, the mean absolute error was 1.5 months (95% confidence interval: 1.2–1.8), which reflects about 7–8% deviation from the average clinical duration of 20.7 ± 4.9 months. Model–expert agreement was highly reliable (κ = 0.86), demonstrating clinically acceptable error margins. Conclusion: An ensemble AI model that integrates cephalometric and photographic features reliably predicts the duration of orthodontic treatment and appliance type, and perhaps in the future, an adjunctive tool for evidence-based treatment planning.
The use of photography has been incorporated into orthodontic practices since the early days of the specialty. Despite the absence of a universal standard, the most commonly used intraoral images are the following 5 photographic shots (frontal, buccal right and left, and maxillary and mandibular occlusal views). Interestingly, these intraoral photographs do not include the evaluation of the mandibular arch with the same detail as the maxillary arch. Therefore, the purpose of this article is to discuss the inclusion of another photograph in the series of five intraoral photographs, based on the arguments presented here. The incorporation of a frontal intraoral photograph taken with a semi-open mouth does not generate additional time or financial cost to orthodontists, but it enriches the photographic records, adding valuable information from the mandibular arch, such as the anatomy and leveling of the incisors, the real depth of the Curve of Spee, and the torque of the posterior teeth.
This paper highlights the critical role of digital workflows and decision flows in interdisciplinary dental treatment planning, emphasizing their integration into clinical practice. By incorporating tools such as intraoral scanning, cone-beam computed tomography, virtual model setups, and structured decision flows, digital workflows enhance precision, improve communication, and facilitate collaboration among orthodontic, periodontal, and prosthodontic specialties. Two clinical cases illustrate these benefits: the first involves an implant-first approach, where virtual setups guided implant placement and provided stable anchorage to address lower anterior crowding. The second case demonstrates full-mouth reconstruction, utilizing virtual simulations to evaluate treatment feasibility, guide space redistribution, and coordinate implant and prosthetic planning. These examples emphasize how digital workflows and structured decision flows enable seamless collaboration and achieve precise, patient-centered outcomes.
Objectives: Attachments are composite structures that help clear aligners (CAs) move teeth and must be removed at the end of treatment. Made from various composites, they are sometimes replaced during therapy. This study evaluates enamel damage after removing attachments made from three different composites, aiming to determine whether the type of resin affects the extent of damage caused by rotary instruments. Material and Methods: This in vitro study used 30 extracted teeth, divided into three groups: A (packable composite), B (flowable composite), and C (orthodontic composite). Before bonding (T0), each tooth was duplicated in epoxy resin. Attachments were applied using a consistent protocol, then removed with a tungsten carbide bur. After removal (T1), teeth were finished with sandpaper discs and polished with pumice paste. Impressions were taken to create resin replicas. Enamel damage was assessed using scanning electron microscopy (SEM), and a modified enamel damage index (EDI) was applied. Data were analyzed with a Chi-square test ( p < 0.05). Results: Groups A (packable composite) and C (orthodontic composite) showed a significant difference in enamel damage ( p = 0.0235) at T1. However, there were no significant differences between Group B (flowable composite) and the other groups ( p > 0.05). Conclusion: Attachment removal causes enamel damage, with greater damage observed in the packable composite group compared to the orthodontic composite group. Group A (packable composite) shows a heterogeneous distribution, with a prevalence of EDI 2 (60%) and lower proportions of EDI 1 and EDI 3 (20% each). In Group B (flowable composite), EDI 1 predominates (60%), followed by EDI 2 (40%). Finally, Group C (orthodontic composite) is characterized almost exclusively by EDI 1 values (80%), with a residual proportion of EDI 2 (20%). These results suggest that the type of composite used for attachments influences enamel surface integrity during removal.
Objectives: This experimental study analyzed the influence of attachment designs on the insertion and removal force of orthodontic clear aligners (CA). Material and Methods: Eleven CA (0.63 mm thickness) were manufactured with rectangle, beveled, distal slice, round wedge, pyramidal, and half-moon attachment shapes. The attachments were included in dental units 11, 12, 13, and 16, and absence of attachments in the control group. Analyses of the deformation stress (-) and expansion (+) of the CA were recorded six times using a strain gage during appliance insertion and removal. Descriptive analyses were calculated for all the study variables, followed by the analysis of variance test for repeated measures (significance level of 0.05). Results: Despite no attachments, CA still had low expansion (2.730; Standard deviation [SD] = 0.327) alteration. Rectangle horizontal scale in the dental unit 16 had the highest strain (−13.869; SD = 1.198 µm/m), similar to the half-moon type (−13.009; SD = 2.399 µm/m) in dental unit 11. CA with a beveled horizontal scale in dental unit 16 had a higher expansion threshold (5.337; SD = 0.453 µm/m) than the beveled low-profile horizontal scale in dental unit 12 (1.046; SD = 1.010 µm/m). Conclusion: Attachments significantly influence this behavior, with certain designs, such as the half-moon and rectangular types, producing higher stress and expansion values. The control group showed minimal strain, confirming the attachments’ role in guiding force distribution. These findings highlight the importance of attachment design in optimizing aligner performance and treatment effectiveness.
Objectives: To evaluate the effect of 10% Trigona sp. propolis gel on osteoclasts, osteoblasts, and RANKL expression during bone remodeling around temporary anchorage devices. Material and Methods: Thirty male rabbits were randomly divided into six groups (n = 5/group), comprising control and treatment groups observed on days 3, 7, and 14 after TAD placement. The treatment group received topical 10% Trigona sp. propolis gel twice daily (0.5 g per application) around the TAD site. Osteoblasts and osteoclasts were quantified histologically using hematoxylin-eosin staining, and RANKL expression was measured using ELISA. Data were analyzed using independent t-tests and linear regression ( p < 0.05). Results: Propolis treatment significantly reduced osteoclast counts and increased osteoblast numbers at all observation points ( p < 0.05). On day 14, osteoclasts were reduced to 0.80 ± 1.10, while osteoblasts increased to 296.00 ± 24.17 ( p = 0.001). Linear regression analysis revealed strong correlations between treatment duration and both osteoblast (R 2 = 0.935) and osteoclast (R 2 = 0.859) counts. Although RANKL expression showed no significant difference on day 14 ( p = 0.421), it declined over time (R 2 = 0.530, p = 0.001), indicating time-dependent modulation. Conclusion: These findings indicate that 10% Trigona sp. propolis gel has the potential to enhance peri-implant bone remodeling and biological healing responses around TADs, suggestsing its potential as a local adjunctive agent in orthodontic applications.
Objectives: A digital model can be used to evaluate periodic tooth movement during treatment with fixed orthodontic appliances to obtain functional and esthetic outcomes, avoid unnecessary movements, and to decrease the treatment time, expenses, and side effects. Assessment of orthodontic tooth movement depends on the presence of a stable structure, this study aimed to compare two digital superimposition methods, i.e., the 3 rd rugae method versus the anterior palatal vault method, to suggest a stable reference area and to find a simple, efficient, and precise way to evaluate orthodontic tooth movement. Material and Methods: Maxillary digital scans of 93 patients were obtained at the beginning of treatment (T0), and at 6 months (T1) after the start of active treatment. To assess the tooth movement from T0 to T1, following reference areas were selected on the T0 model: (a) area A: a small area of the palate including the medial two-thirds of the third rugae and the area 5 mm dorsal to them (b) area B: almost the whole palate including all rugae delineated by a line 5 mm from all the gingival margins and spreading posteriorly back until the middle of the 1st permanent molar. Superimposition was done in two steps to get more precise results, which allowed calculation of movement in all three planes of space. Results: Paired t -tests revealed that there were no statistically significant differences in the means of linear tooth movements and rotation of both the superimposition methods. The Pearson correlation coefficients of both methods revealed that the r values of all the variables were very high. Bland-Altman plots revealed no significant differences between the two methods for both the linear and rotational measurements Conclusion: Both methods showed comparable accuracy and reliability for three-dimensional digital maxillary superimposition and represent reliable reference areas.
Objectives: The clinical displacement of mini-implants can compromise anchorage during en-masse anterior retraction. This study evaluated whether bisphosphonate-coated mini-implants reduce displacement and enhance retraction efficiency compared to uncoated implants. Material and Methods: This was a split-mouth, randomized controlled clinical trial involving 30 patients requiring maximum anchorage following premolar extraction. Patients were randomly assigned to receive either bisphosphonate-coated or uncoated mini-implants in the maxillary arch. Cone beam computed tomography superimposition was used to assess implant displacement in the X (bucco-palatal), Y (mesio-distal), and Z (vertical) axes. Retraction space closure was measured using three-dimensional digital models at 3 and 6 months. Results: Miniscrew displacement was significantly lower in the bisphosphonate-coated group in the mesio-distal (Y) direction ( p < 0.05). The coated group also showed a significantly greater rate of space closure at both 3 and 6 months ( p < 0.05). Conclusion: Bisphosphonate coating reduces mini-implant displacement and may enhance the rate of anterior retraction when used in maximum anchorage cases.
Objectives: Diabetes is a metabolic disease that can be diagnosed by persistent high blood sugar levels. This study examines the relationship between serum level of insulin-like growth factor 1 (IGF-1) and the maturation stage of the middle phalanx of the third finger (MP3) and determines the highest levels of serum IGF-1 throughout different phases of skeletal maturity. Material and Methods: The study included 80 patients with type 1 diabetes mellitus (T1DM), 40 boys and 40 girls. Radiographs of MP3 and blood samples were obtained from these individuals. The MP3 radiographs were staged using the Rajagopal and Kansal method. A comparative analysis was conducted to evaluate the serum levels of IGF-1 in various phases of skeletal development. Results: The levels of IGF-1 at the time of maximum pubertal growth were significantly elevated ( p ≤ 0.001) compared with the levels observed at the onset of pubertal development and post-pubertal phase. The median IGF-1 levels throughout the pubertal phases were found to be significantly different. Conclusion: Serum IGF levels can serve as a supplementary means to enhance the timing of orthodontic therapy in individuals with T1DM along with other methods of skeletal maturity assessment.
Objectives: This study aimed to assess the clinical accuracy of digital treatment planning by comparing arch width measurements at pre-treatment (T0), planned with ClinCheck ® software (TC), and achieved at the first refinement stage (T1) in clear aligner (CA)-treated patients with and without extractions. Material and Methods: This retrospective single-center study included 26 patients treated with CAs, divided into non-extraction ( n = 13) and extraction ( n = 13) groups. Arch width measurements were performed in the maxilla at the canine (3–3), second premolar (5–5), and first molar (6–6) regions at T0, TC, and T1. Planned expansion (TC–T0), achieved expansion (T1–T0), and the discrepancy between planned and achieved values (T1–TC) were calculated. Clinical accuracy was expressed as the ratio of achieved to planned expansion. Intra-observer reliability was assessed using the intra-class correlation coefficient (ICC). Statistical analyses were performed using paired t -tests or Wilcoxon tests ( p < 0.05). Results: Intra-observer reliability was high for all measurements (ICC >0.866). In the non-extraction group, mean planned and achieved expansions were 1.23 mm and 0.94 mm, respectively, corresponding to a clinical accuracy of 66.67%. Significant increases were observed between T0 and T1 at all measurement sites ( p < 0.05). In the extraction group, the mean planned expansion was 1.53 mm, whereas the achieved expansion was limited to 0.34 mm, resulting in a clinical accuracy of 38.92%. Planned expansions were not achieved at any measurement point, and TC–T1 differences were statistically significant ( p < 0.05). Conclusion: Digital treatment plans with CAs show acceptable clinical accuracy in non-extraction cases, whereas accuracy is substantially reduced in extraction treatments. Therefore, greater caution is required when planning expansion in extraction cases.
Clear aligners are becoming increasingly popular, especially among adults. Aligner companies typically recommend changing aligners weekly to improve treatment efficiency and shorten treatment time. However, there are currently a limited number of high-quality clinical studies addressing this topic. To investigate this further, a comprehensive search was conducted using electronic databases, including Medline, PubMed, Web of Science, and Scopus, for studies comparing different change intervals. Of 1,104 records screened, 15 studies met the criteria. Most compared 7-day with 14-day wear. Some studies showed slightly better accuracy with 14-day changes for selected movements but usually below clinical thresholds, while others found no significant differences in accuracy or overall treatment quality. In extraction cases, overall outcomes were similar across 7-, 10-, and 14-day protocols. Overall, weekly change protocol appears acceptable for simpler movements and early evidence suggests that it may be feasible and promising even in extraction cases, but more high-quality data are needed.
Objectives: The aim of the study is to compare the accuracy of the orthodontic treatment outcome in predicted and achieved results using clear aligners. Material and Methods: The study involved 20 adult participants aged 18–35, with an average age of 22 years. Materials used included a lateral cephalogram, orthopantomogram (OPG), Addition silicone impression material, Duran thermoplastic material, Open Technology Lab scanner, Autolign software, Phrozen Sonic Mini 4k 3D Printer, Biostar Thermoforming Machine, Geomagic Software Control X 2020, and Orthokal plaster. The study recorded the impression of both arches and created a 3D virtual model using Autolign software. The virtual model was segmented using Autolign software to define individual teeth, and a treatment plan was stimulated. The aligner was constructed using Duran thermoplastic material and thermoformed using a Biostar thermoforming machine. The predicted and achieved models were superimposed in Geomagic Software Control X 2020 (Version 1.1) using the first molars as reference points to check the accuracy. Results: A statistically significant difference was seen in the accuracy of the orthodontic treatment outcomes in the maxilla and mandible, with a percentage mean of 70.42% and 66.35%, respectively. There was a statistically significant difference in the gap distance (which signifies the linear measurement between the predicted and achieved Models) of the inter-canine width between the maxilla and mandible. There was a statistically highly significant difference seen between the predicted and achieved vertical and horizontal changes in relation to the tooth type (i.e., Central incisor, Lateral incisor, Canine, etc.). Conclusion: The study found that clear aligner treatment was highly accurate in predicting and achieving orthodontic treatment outcomes, with a mean accuracy of 68.38%. The maxilla had the overall highest accuracy, where no significant differences were found between predicted and achieved results. The study also found that mandibular arch width was more predictable than the maxillary arch. Patient compliance was a significant factor in achieving predicted tooth positions.
Objectives: Orthodontic tooth movement (OTM) involves bone remodeling influenced by mechanical forces and inflammation. Matrix metalloproteinases 8 (MMP-8) serves as a key biomarker of periodontal response. This study aims to evaluate and compare periodontal status and salivary MMP-8 levels during OTM in individuals with healthy and compromised periodontium. Material and Methods: This pilot study included 24 orthodontic patients (18–30 years), divided into healthy and compromised periodontium groups. The sample was convenience-based. Periodontal parameters (bleeding on probing, probing pocket depth, clinical attachment level (CAL)) were assessed at baseline, 3, 6, and 9 months. Salivary MMP-8 levels were measured using enzyme-linked immunosorbent assays at baseline and after alignment. Cone-beam computed tomography (CBCT) was used to evaluate alveolar bone levels in compromised patients at baseline and 9 months. Results: Both groups showed improvement in clinical periodontal parameters over time. MMP-8 levels increased significantly in both groups during early treatment. In the compromised group, CBCT demonstrated a small but statistically significant increase in alveolar bone loss over the study period. The intergroup difference in MMP-8 change approached but did not reach statistical significance. Conclusion: Within the limitations of a small convenience-based sample and short-term follow-up, OTM following periodontal stabilization was associated with improvement in clinical periodontal parameters in both groups. However, the observed increase in alveolar bone loss among periodontally compromised patients should be interpreted with caution, and definitive conclusions regarding the safety or equivalence of the treatment cannot be established without long-term follow-up.
Objectives: The objectives of the study are to evaluate root resorption using three-dimensional reconstruction and quantify the effects of risk factors. Material and Methods: This retrospective study included 50 Class I extraction patients (27 fixed appliances and 23 clear aligners). Pre- and post-treatment cone-beam computed tomography and model/oral scans were used for 3D reconstruction of teeth and alveolar bone. Root resorption and tooth displacement were measured; potential risk factors, including appliance type, tooth position, and magnitude/type of movement, were analyzed. Results: The incidence and extent of root resorption were significantly lower in the clear aligner group (31.88%, 0.55 ± 0.07 mm) compared with the fixed appliance group (46.30%, 1.02 ± 0.09 mm). Among all tooth positions, lateral incisors demonstrated the highest incidence and greatest severity both in the clear aligner group (39.13%, 0.64 ± 0.13 mm) and the fixed appliance group (55.56%, 1.15 ± 0.16 mm). A strong positive correlation was observed between the incidence and extent of root resorption in both groups ( p < 0.001). Regional volumetric loss appeared to be associated with both the magnitude and type of tooth movement. For example, in the fixed appliance group, each 1 mm of root intrusion was associated with an average cervical-third resorption of 1.393 mm 3 in tooth 13 ( p = 0.023). Conclusion: Root resorption was associated with appliance type, tooth position, and tooth movement. Clear aligners were associated with more favorable root health outcomes in this retrospective study. Lateral incisors exhibited the highest incidence and extent of root resorption in anterior teeth. Root resorption was associated with both vertical intrusion and changes in torque.
Objectives: The objective of this study was to assess the clear aligner thickness and gap width after thermoforming process among three different materials. Material and Methods: Three different aligner materials, each comprising nine samples, were adapted to standardized three-dimensional-printed dental casts. High-resolution micro-computed tomography was employed to evaluate each sample. Two-dimensional (2D) quantitative analysis was conducted to assess aligner thickness and gap width. The analysis focused on the influence of three independent variables: tooth type (central incisor, canine, and molar), 2D reference point location, and aligner material. Statistical analysis was performed using analysis of variance followed by Tukey’s post hoc test for multiple comparisons. Results: Tooth type, dental region, and aligner material significantly influenced both gap width and aligner thickness. Among the materials tested, polyurethane (PU) exhibited the greatest variations in both parameters. In contrast, polyethylene terephthalate glycol (PET-G) and multilayer PU (MLPU) showed no statistically significant differences in either gap width or aligner thickness. Conclusion: PU demonstrated the highest variability in gap width and aligner thickness, indicating less precise adaptation and greater gap formation compared to PET-G and MLPU.
Objectives: The objective of the study was to evaluate the effect of topical application of 10% Trigona sp. propolis gel on temporal changes in transforming growth factor-beta (TGF-β) levels during peri-implant soft-tissue healing around temporary anchorage devices (TADs). Material and Methods: This in vivo experimental study involved 18 male New Zealand White rabbits randomly allocated into two groups: A control group receiving TAD placement only and a treatment group receiving device placement with topical application of 10% Trigona sp. propolis gel. Serum TGF-β levels were measured on days 3, 7, and 14 following device placement using an enzyme-linked immunosorbent assay. Intragroup comparisons were analyzed using repeated-measures analysis of variance followed by post hoc tests, while between-group comparisons were performed using independent samples t -tests. Data are presented as mean ± standard deviation. Results: Repeated-measures analysis demonstrated a significant effect of time on TGF-β levels within each group ( p < 0.05). In both groups, mean TGF-β levels increased from day 3 to day 7 and subsequently decreased from day 7 to day 14. At all observation time points, the topical propolis group exhibited significantly higher TGF-β levels compared with the control group ( p < 0.05). Post hoc analysis revealed significant differences between specific observation intervals, with the greatest differences observed during the transition from the proliferative to the remodeling phase. Conclusion: Topical application of 10% Trigona sp. propolis gel modulated the temporal expression of TGF-β during peri-implant soft-tissue healing around TADs. Within the limitations of an animal model, topical propolis may serve as a biologically active adjunct to support peri-implant soft-tissue healing. Further clinical studies are required to confirm its potential applicability in orthodontic practice.
Objectives: The aim of the study is to evaluate skeletal maturation using salivary dehydroepiandrosterone sulfate (DHEA-S) levels and their correlation with existing skeletal maturity indicators represented by 4 cervical vertebrae growth stages. Material and Methods: Based on cervical vertebral maturation index (CVMI) growth, 48 samples were split into four groups with ages ranging from 9 to 16 years. Using the passive drooling approach, saliva was collected at a consistent 10 am and placed in marked, sterile plastic centrifuging tubes. These tubes were then immediately frozen at −4°C in a home freezer. Before the DHEA level was determined, samples were centrifuged for 5 min at 5000 rpm. 3 mL of the centrifuged supernatant was then transferred to storage containers and kept at −80 C. Before the assessment, all samples were brought to room temperature. Results: Analysis of variance test was applied to compare the DHEA-S levels among the CVMI stages. DHEA-S levels in the group were found to be 12.03 ± 0.87 nmol/mL for CVMI 2, 15.12 ± 1.33 nmol/mL for CVMI 3, 18.9 ± 0.81 nmol/mL for CVMI 4, and CVMI5 to be 22.11 ± 3.17 nmol/mL. Mean DHEA-S levels were higher in CVMI stage 5, followed by stage 4, stage 3, and stage 2. Conclusion: In the present study, salivary DHEA-S levels and cervical maturational stages demonstrated the potential utility of salivary DHEA-S as a prospective marker of skeletal maturation to pinpoint the pubertal growth spurt.
Objectives: Myofunctional appliances stimulate mandibular growth in Class II malocclusion with a retrognathic mandible. The twin-block appliance is favored over other appliances for comfort and it can advance the mandible in a single-step or two-step protocol. Although many studies have been conducted comparing the effects of single-step and two-step advancement in the twin block, its biochemical impacts remain unclear. This study compares salivary alkaline phosphatase (ALP) (a bone-turnover marker) during single-step versus two-step twin-block therapy in growing Class II patients to compare treatment-related skeletal remodeling differences biologically. Material and Methods: This study involved 40 Class II patients aged 10–14 years with overjet >7 mm. Patients were randomly divided into two groups: Group 1 including twin block with single-step advancement ( n = 20) and Group 2 including twin block with two-step advancement ( n = 20). Salivary ALP was measured at baseline and monthly for 6 months (M0–M6). Skeletal changes were assessed through pre-treatment and post-treatment lateral cephalograms. Results: In Group 1, ALP showed a gradual rise from 837 IU/L (M0) to a peak of 876 IU/L (M3) then fell to 847 IU/L (M6). Group 2 increased from 862 IU/L to 919 IU/L (M4), declining to 880 IU/L (M6). Both groups ended with higher ALP than baseline. Comparison of skeletal and dental parameters between both the groups showed a significant difference in Sella Nasion A point angle (SNB), A point Nasion B point angle (ANB), total mandibular length, and lower incisor proclination. Conclusion: These findings indicate that while the two-step protocol resulted in a slightly stronger and more sustained ALP response, the differences were not sufficient to demonstrate statistical superiority over the one-step protocol within the observed sample. Overall, the pattern of skeletal and dental outcomes indicates that the two-step advancement protocol delivers greater skeletal correction while producing fewer dentoalveolar changes than the single-step approach.
Objectives: Fixed orthodontic appliances create retentive niches that favor plaque accumulation and may alter salivary chemistry, increasing demineralization risk. This study compared early changes in unstimulated salivary pH among patients treated with self-ligation (SL), elastomeric modules (EM), and stainless-steel ligation (SS). Material and Methods: In this three-arm, randomized clinical trial, patients were allocated (1:1:1) to SL, EM or SS. Unstimulated whole saliva was collected at baseline, 4 weeks, and 8 weeks under standardized conditions. Salivary pH was measured with a calibrated digital pH meter. The primary outcome was the mean salivary pH at 4 and 8 weeks. Between-group differences were assessed by one-way analysis of variance with post hoc testing; pairwise mean differences, 95% confidence intervals and Cohen’s d effect sizes were reported. Results: At 4 weeks, EM showed a marked reduction in pH (5.96 ± 0.65) compared with SS (7.12 ± 0.12) and SL (7.05 ± 0.16), with large effect sizes (Cohen’s d ≈ 2.3–2.5). These differences persisted at 8 weeks, while SL and SS did not differ meaningfully. Conclusion: Elastomeric ligatures were associated with a substantial early decrease in salivary pH compared with SS and self-ligating systems. Clinicians should consider this increased early acidogenic challenge when treating patients at high caries risk and intensify preventive measures for patients using EM.
