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OBJECTIVE: The aim of this study was to evaluate gingival tissue adaption induced by orthodontic tooth movement, in terms of clinical crown height (i.e., attachment loss), and thickness of the keratinized gingiva at the margin level. METHODS: Pre- and post-treatment intraoral models/scans of 100 orthodontically treated patients (50 treated with clear aligners and 50 treated with fixed appliance) were acquired. Models were digitally scanned. Each couple of pre- and post-treatment scans were superimposed using the Compare© software (Medit spa, Seoul, Republic of Korea) taking the same reference landmarks in all cases, that were the palatal rugae for the upper arch, and the labial median frenulum for the lower arch. Only teeth that had undergone vestibulo-palatal (or vice versa) movement, greater than 1 mm were included in the analyses. The change from pre-treatment to post-treatment, in the clinical crown height and thickness of the keratinized gingiva at the margin level were digitally measured and compared between the two groups. Statistical analysis included paired t-tests, and unpaired t-tests with significance set at p<0.05. RESULTS: There was a statistically significant change in clinical crown height and gingival thickness in both groups. However, a clinically relevant attachment loss was found only within the fixed appliance group. Whereas, regarding the change in gingival thickness, there was no clinically relevant changes between the two groups. CONCLUSIONS: Orthodontic tooth movement with fixed appliance is associated to a clinically relevant attachment loss. Clear aligners seem to be associated with a more discrete attachment loss than the one observed with fixed appliances. CLINICAL RELEVANCE: Orthodontists should pay attention and monitoring the clinical crown height (i.e., attachment loss) during orthodontic movement, mostly when using fixed appliances.

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Key Clinical Message: Amelogenesis imperfecta (AI) is a rare developmental anomaly characterized by poorly developed or absent tooth enamel, which complicates orthodontic treatment due to weak enamel-bracket bond strength. This case report presents a successful management of AI using fixed orthodontic appliances and prosthodontic rehabilitation. Abstract: Amelogenesis imperfecta (AI) causes enamel defects, complicating oral hygiene, reducing masticatory function and lowering self-esteem. This case report details an 18-year-old female with AI who underwent fixed orthodontic treatment followed by prosthodontic rehabilitation. The multidisciplinary approach restored function and aesthetics, significantly improving her quality of life.

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Objective: To evaluate tooth displacement and periodontal stress generated by the dual action vertical intra-arch technique (DAVIT) for open-bite correction using three-dimensional finite element analysis. Methods: A three-dimensional model of the maxilla was created by modeling the cortical bone, cancellous bone, periodontal ligament, and teeth from the second molar to the central incisor of a hemiarch. All orthodontic devices were designed using specific software to reproduce their morpho-dimensional characteristics, and their physical properties were determined using Young's modulus and Poisson's coefficient of each material. A linear static simulation was performed to analyze the tooth displacements (mm) and maximum stresses (Mpa) induced in the periodontal ligament by the posterior intrusion and anterior extrusion forces generated by the DAVIT. Results: The first and second molars showed the greatest intrusion, whereas the canines and lateral incisors showed the greatest extrusion displacement. A neutral zone of displacement corresponding to the fulcrum of occlusal plane rotation was observed in the premolar region. Buccal tipping of the molars and lingual tipping of the anterior teeth occurred with intrusion and extrusion, respectively. Posterior intrusion generated compressive stress at the apex of the buccal roots and furcation of the molars, while anterior extrusion generated tensile stress at the apex and apical third of the palatal root surface of the incisors and canines. Conclusions: DAVIT mechanics produced a set of beneficial effects for open-bite correction, including molar intrusion, extrusion and palatal tipping of the anterior teeth, and occlusal plane rotation with posterior teeth uprighting.

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Background: This longitudinal prospective study aimed to assess orthodontic patients' immune system response to metal ion release in saliva. Methods: Thirty adult patients (18-35 years) were equally divided into three groups: groups at the end (G1) and beginning (G2) of multibracket appliances (MBA) treatment and a non-treated control group (G3). Participants were evaluated at four timepoints within 21 days, with saliva samples being analyzed for metal ion concentrations and blood for the lymphocyte transformation test (LTT). Results: There were no significant differences between groups or timepoints for saliva. LTT analyses revealed hypersensitivity in one-third of all patients and 50% of G2 for nickel, with three developing sensitizations after MBA insertion. All nickel-sensitized patients exhibited varying elevated saliva nickel concentrations. The most nickel-sensitized patients had low ion saliva loads. In borderline nickel-sensitization cases, saliva ion concentrations were up to 20 times higher than the reference. Hypersensitivity to palladium, gold, and mercury was also observed. Conclusions: These findings indicate that increased MBA ion release was not inherently linked to the immune response (Type-IV sensitization), as reactions occurred even with ion levels below thresholds. This underlines the need for a comprehensive evaluation of the immune response to metal ion release in orthodontic patients.

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OBJECTIVES: To evaluate the 3D accuracy of attachment positioning and the adaptation of aligners to attachments using in-house templates made with either polyethylene terephthalate glycol (PETG) or ethylene-vinyl acetate (EVA) and either pressure or vacuum thermoforming machines. MATERIALS AND METHODS: Overall, 140 test specimens were resin-printed. Templates for the attachment bonding were made with 1-mm EVA or 0.5-mm PETG laminates. Orthodontic aligners were manufactured with 0.75-mm PETG. The thermoplastification process was carried out using either vacuum or pressure machines. The positional differences between the virtual and bonded attachments were assessed in the X, Y and Z coordinates. The marginal adaptation between the aligners and the attachments was measured. RESULTS: Minor inaccuracies in the positioning of the attachments were observed in all combinations of thermoforming machines and plastic laminates used to fabricate the templates, mainly in the superior-inferior (Z) dimension. PETG performed better than EVA in the anterior region (p < .05). No association was found between thermoplastification machines and the accuracy of the positioning of the attachments (p > .05). While small misadaptations between the aligners and the attachments were observed, the EVA templates performed better than the PETG templates. CONCLUSIONS: The inaccuracy of the attachment positioning and the misadaptation of the aligners to the attachments were slight. The vacuum and pressure thermoplastification machines showed no difference in attachment positioning accuracy. The PETG template was better than the EVA template in the anterior region, but the EVA attachments presented a better adaptation to the aligners than the PETG attachments.

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The oral microbial flora may be significantly altered by orthodontic therapy and the use of fixed orthodontic brackets. Most orthodontic research has focused on cariogenic pathogens, while some evidence has demonstrated an increase in many known periodontal pathogens. However, little is known about the prevalence of the Gram-negative periodontal pathogen Selenomonas noxia (SN) among these patients. Using an existing saliva biorepository, n = 208 samples from adult and pediatric orthodontic and non-orthodontic patients were identified and screened for the presence of SN using qPCR and validated primers. In the pediatric study sample (n = 89), 36% tested positive for the presence of SN, with orthodontic patients comprising more SN-positive samples (87.5%) than SN-negative samples (78.9%), p = 0.0271. In the adult study sample (n = 119), SN was found in 28.6%, with orthodontic patients comprising 58.8% of positive samples and only 28.2% of negative samples (p < 0.0001). These data demonstrated that both pediatric and adult orthodontic patients exhibited higher prevalence of SN compared with age-matched non-orthodontic controls. As this microorganism is associated not only with periodontal disease but also long-term health issues such as obesity, more research is needed regarding the factors that increase the prevalence of this microbe.

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OBJECTIVE: To develop a novel mandibular advancement device (MAD) with high comfort, good compliance, and bidirectional fine-tuning capability for patients with obstructive sleep apnea hypopnea syndrome (OSAHS), and to evaluate the therapeutic efficacy of the new MAD. METHODS: The MAD, featuring upper and lower dental splints with a fine-tuning mechanism for mandibular adjustment, incorporates improved design elements such as partial dental coverage, shortened baffles, and memory resin lining. The novel MAD was used to treat 30 OSAHS patients in the study, comparing pre- and post-treatment scores on the Epworth Sleepiness Scale (ESS), the Apnea-Hypopnea Index (AHI), and the lowest oxygen saturation (LSO2). RESULTS: The novel MAD reduced size and side effects, enhancing comfort. All patients complied well, using it for an average of 95% over 30 days and ≥ 5 h nightly. After treatment, significant improvements were observed in ESS, AHI, and LSO2 (P < 0.05). CONCLUSIONS: This novel bidirectional adjustable MAD provides high comfort and compliance, improving treatment precision. It is an effective choice for mild to moderate OSAHS patients and an alternative for those intolerant to CPAP or averse to surgery.

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OBJECTIVE: Current standardized in vitro bending experiments for orthodontic archwires cannot capture friction conditions and load sequencing during multi-bracket treatment. This means that clinically relevant forces exerted by superelastic wires cannot be predicted. To address these limitations, this study explored a novel test protocol that estimates clinical load range. METHODS: The correction of a labially displaced maxillary incisor was simulated using an in vitro model with three lingual brackets. Deflection force levels derived from four different protocols were designed to explore the impact of friction and wire load history. These force levels were compared in nickel-titanium (NiTi) archwires with three commonly used diameters. The unloading path varied between protocols, with single or multiple sequences and different load orders and initial conditions. RESULTS: Deflection forces from the new protocol, employing multiple continuous load/unload cycles (CCincr), consistently exceeded those from the conventional protocol using a single continuous unloading path (CUdecr). Mean differences in plateau force ranged from 0.54 N (Ø 0.014" wire) to 1.19 N (Ø 0.016" wire). The CCinr protocol also provided average force range estimates of 0.47 N (Ø 0.012" wire), 0.89 N (Ø 0.014" wire), and 1.15 N (Ø 0.016" wire). SIGNIFICANCE: Clinical orientation towards CUdecr carries a high risk of excessive therapeutic forces because clinical loading situations caused by friction and load history are underestimated. Physiological tooth mobility using NiTi wires contributes decisively to the therapeutic load situation. Therefore, only short unloading sequences starting from the maximum deflection in the load history, as in CCincr, are clinically meaningful.

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Gingival enlargement is a common clinical sign in the gingival diseases associated with orthodontic treatment. Its biological mechanisms are not completely understood; nevertheless, the biochemical changes associated with these inflammatory and overgrowth processes could alter the post-translational protein modifications occurring in various locations within the mouth. Here, changes in the profiles of the carbonylated and phosphorylated proteins in saliva were examined in donors with gingival enlargement (seven men and seven women) and healthy donors (six men and eight women). The sociodemographic characteristics of both groups did not present significant differences. Carbonylation was measured by a quantitative immunoassay (Dot Blot), whereas the profiles of the phosphorylated proteins were visualized by SDS-PAGE with quercetin staining. Some phosphopeptides were also identified using a typical LC-MS-MS approach. Our results showed that gingival enlargement induced a significant increase in oxidative damage in salivary proteins. While a significant reduction in phosphorylation was observed at the stain level in SDS-PAGE, there was a slight increase in the number of phosphorylated proteins identified by MS in samples with gingival enlargement.

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Although rare, oral manifestations of hypersensitivity reactions in orthodontic patients pose a significant clinical challenge due to their heterogeneous presentations, and can cause discomfort and pain, possibly impacting patients' quality of life and orthodontic treatment duration and outcomes. This comprehensive review aimed to elucidate the oral, perioral, and systemic manifestations of hypersensitivity reactions in orthodontic subjects, focusing on patients with fixed appliances, removable appliances, and clear aligners, and detailing their epidemiology, macroscopic and microscopic features, allergy testing, clinical implications, and specific management strategies. Oral and extra-oral manifestations of (immediate and delayed) hypersensitivity reactions occur rarely and are due to the release of metal and non-metal ions from orthodontic appliances. They typically present as erythema, erosive-ulcerative lesions, and gingival hyperplasia, with histopathological findings showing inflammatory infiltrates. Nickel is a significant allergen, and diagnostic tests like patch tests are essential for managing these reactions. Likely due to prolonged contact with oral tissues, fixed orthodontic appliances pose a higher risk compared to removable appliances and clear aligners. Early identification and removal of allergenic materials, combined with effective treatments, can resolve symptoms and prevent recurrence. Keeping dental and medical records updated and knowing family and personal medical histories helps clinicians choose appropriate materials and counsel patients about potential risks. Proper patient education, regular monitoring, and using hypoallergenic materials are key strategies for managing these reactions.

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OBJECTIVES: To synthesise the dentoalveolar, periodontal and skeletal changes that occur when using maxillary expansion techniques assisted by temporary anchorage devices compared to conventional protocols. METHODS: Five databases and grey literature were consulted, up to December 2023, focusing on intervention designs and excluding other type of studies. The quality assessment was conducted by using the adaptation for orthodontics of the CONSORT statement, the guidelines for reporting non-randomised studies, the RoB-2 tool, and the ROBINS-I tool. A descriptive summary and meta-analysis using RevMan 5.4 were performed. RESULTS: Nine clinical trials were included (n=377 patients, mean age 13.2±0.6) with a diagnosis of transverse maxillary deficiency. The analysed studies showed qualitative dentoalveolar and periodontal changes after expansion, which were greater on the maxillary first premolars in tooth-borne appliances. Meta-analyses for some effects were included from two studies (n=64); patients who used tooth-borne appliances had greater effects of buccal intercoronal width between the premolars with statistically significant differences (Std Mean difference 2.34; 95% CI: 0.04-4.65 p=0.05). Conversely, those patients who used bone-borne or hybrid appliances had greater effects of buccal intercoronal width between molars with statistically significant differences (Std Mean difference -0.64; 95% CI: -1.38-0.10; p=0.09). CONCLUSIONS: According to the studies analysed, all measurements increased in the intervention groups after expansion. Quantitative analyses show different findings at dentoalveolar level when tooth-borne, bone-borne or hybrid appliances are considered. Nevertheless, the results should be taken with caution due to the heterogeneity of the studies. The protocol was registered at PROSPERO (CRD42021283170), with no funding to report.

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Background: Traditional working procedures requires a lot of clinical processes and processing time. Methods: The orthodontic metal appliances were made by applying oral scanners, digital images, computer-aided design and computer-aided manufacturing (CAD-CAM) printers. Results: The computer digital technology simplified the manufacturing process for dental appliances and shorten the duration for clinical operation and technical processing. Conclusions: The technique described in this paper can guarantee the accuracy of orthodontic appliances and bring revolution the field. Clinical significance: The CAD-CAM technology provides a fully digital workflow for manufacturing metal orthodontic appliances, which saves a considerable amount of labor and material costs, and significantly reduces heavy metal pollution in the working environment of dental technicians.

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White spot lesions (WSLs) refer to localized areas of hypo-mineralization limited to the enamel of the teeth surface, which is noticeable clinically to the naked eye on drying of the teeth. During fixed orthodontic treatment, it is very hard for the patient to maintain excellent oral hygiene as the brackets, bands, wires, elastics, and other appliances and attachments worn intra-orally provide a platform for food retention, plaque formation, and then colonization by acidogenic bacteria like Streptococcus mutans and Lactobacillus. This review aims to elaborate and focus on etiology, pathophysiology, diagnosis, treatment aspect, and future scope for research about the WSLs occurring due to fixed orthodontic treatment.

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We demonstrate pre-epiglottic baton plate as non-invasive treatment modality for initial airway management in newborns with Pierre Robin Sequence. A case example illustrates management of upper airway obstruction and feeding using digital technology to facilitate customization. Laryngoscope, 2024.

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Aim Balanced function of the orofacial muscles is important for normal occlusion and dentition; however, patients with malocclusion often present with myofunctional disorder (MFD). Myofunctional therapy (MFT) has received much attention as a method for reducing MFD. Moreover, prefabricated functional appliances (PFAs) have been developed as a method to eliminate abnormal muscle pressure and guide the tongue into the correct position. However, PFAs have disadvantages, such as poor intraoral retention, limited usage time due to discomfort and poor patient compliance, and changes in the axis of the mandibular anterior teeth. Therefore, this study aimed to develop a new custom-made splint-type orthodontic appliance with CAD/CAM technology. Moreover, we evaluated the characteristics of the appliance and conducted functional tests to determine the effects of the appliance on the orofacial muscles and the discomfort associated with its use. Materials and methods Twenty-five volunteers (nine females and 16 males; mean age 28.4 ± 3.4 years) with normal swallowing function were included in the study. Lip-closing strength (LCS), electromyogram during swallowing, oxygen saturation, and pulse rate were measured and compared when the appliance was not worn and when it was worn. In addition, tongue habits were evaluated, and the maximum tongue pressure was measured when the appliance was not worn. The subjects were asked to answer a questionnaire using a numerical rating scale (NRS) regarding discomfort when wearing the appliance. The evaluation items were swallowing difficulty, speaking difficulty, and breathlessness, which were rated on an 11-point scale ranging from 0 to 10. Statistical tests were conducted using IBM SPSS version 28.0.1 (IBM, Armonk, NY, USA) with the Shapiro-Wilk and Levene's test, followed by the Wilcoxon signed rank sum test. The significance level was set at α = 0.05. The measurement error for each measurement item was evaluated using an intraclass correlation coefficient. Results A new custom-made splint-type orthodontic appliance was fabricated for each subject. The fit and retention of the appliance in the mouth were good when fitted, and a comparison of the functional test measurements of 25 subjects with and without the appliance showed that the LCS decreased significantly (p<0.05) before and after wearing the appliance. However, no statistically significant differences were found for the other items. The Mann-Whitney U test regarding the effects of sex, previous orthodontic treatment, or MFT, and oral habits did not statistically significantly influence the effects of wearing the device. In the NRS results, "difficulty swallowing" was observed in half of the subjects, "difficulty breathing" was rarely observed, and "difficulty speaking" was observed in all subjects. Conclusions A novel custom-made splint-type orthodontic appliance was designed and fabricated using digital workflow and 3D printing technology. This appliance was designed to correct oral habits and was made from a new material classified as a class II medical appliance according to the international harmonized classification.

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Ankylosis of the temporomandibular joint (TMJ) is associated with restricted mandibular movements, with deviation to the affected side. The management of TMJ ankylosis involves surgery to mitigate the effects of ankylosis, and adjunctive appliance therapy to supplement the results achieved through surgery. Several appliances have been used to help maintain jaw mobility postsurgery, but have been rarely documented in the literature. Our systematic review aimed to examine the clinical outcomes of various appliances for TMJ ankylosis management. A comprehensive electronic search of the literature was performed in July 2022 to identify eligible articles that had tested the use of orthodontic or physiotherapy appliances for the management of TMJ ankylosis. In total, 13 publications were included in the narrative synthesis. Both generic and custom-made appliances were used, with overall findings suggesting that using these appliances improved mouth opening and reduced chances of re-ankylosis. In this review no universally accepted appliance was found to be utilized, and the criteria used for appliance selection were unclear. The field of research in developing appliances for the treatment of TMJ ankylosis is open to advancement, and this review will help guide future research in this area.

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The purpose of orthodontic therapy is to correct malocclusion and produce a stable outcome that endures over time. Long-term stability can be difficult to achieve, and many patients relapse after treatment, particularly in instances of open bite relapse (OBR). This systematic review aimed to analyze different types of management strategies for OBR and conduct a meta-analysis to find the best method of dealing with relapse. A comprehensive search was carried out across six major online databases using relevant keywords pertaining to our study, including "open bite relapse," "orthodontic retention," "orthodontic surgery," "orthodontic appliance," "orthodontic management," "orthodontic treatment," "orofacial myofunctional therapy (OMT)," "skeletal anchorage," and "treatment follow-up period." Eleven studies were selected after the application of relevant inclusion and exclusion strategies. The mean follow-up period of treatment for the studies ranged from six months to 4.5 years. Of all the management strategies assessed, OMT was found to be the least effective for OBR management. Surgical management modalities, such as mandibular repositioning and molar intrusion using skeletal anchorage, in conjunction with the usage of orthodontic appliances, were found to be noticeably effective, especially in the cases of participants who were <18 years of age. However, when utilized on a singular basis, either of them was found to be lacking the desired effect. The overall odds ratio (OR) of 0.48 (0.37, 0.64) and risk ratio (RR) of 0.62 (0.51, 0.74) were obtained after the meta-analysis of the different interventions for OBR, indicating statistical significance. There were only 11 studies included in the study, so it's possible that not all management strategies for OBR were fully understood. The limited number of studies may also have affected the generalizability of the findings. Although statistical differences were obtained to a certain degree, more clinical trials are needed to assess the effect of such surgical modalities as a viable management tool for OBR, since these represent a significant limiting factor in terms of the overall cost of the treatment placed upon the patient. Prior to the start of the research, registration was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The research protocol was created to meet the goals and was properly filed with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023401991).

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Background: The aim was to assess three-dimensionally mandibular and maxillary changes in growing Class II patients treated with removable functional appliances followed by fixed appliances. Methods: Twenty-four Class II patients (age range: 9 to 14, mean: 12.1 ± 1.1 years) treated with removable functional appliances followed by fixed appliances (functional appliance group-FAG) were retrospectively selected and compared to an age-matched control group (CG) treated with fixed appliances only. To be included in the study, pre- and post-treatment CBCT scans had to be available. The CBCTs were used to analyze, in 3D, the changes following treatment and growth. Results: Before treatment, overjet (FAG: 9 mm ± 2.8 (mean ± standard deviation); CG: 4 mm ± 1.7), ANB (FAG: 5.7° ± 2.0; CG: 3.2° ± 1.4), and effective mandibular length (FAG: 113.0 mm ± 4.1; CG: 116.6 mm ± 5.9) were statistically significantly different between the two groups. After treatment, overjet (FAG: -6.8 mm ± 2.8; CG: -1.8 mm ± 1.8) and effective mandibular length (FAG: 6.3 mm ± 2.6; CG: 3.9 mm ± 2.6) statistically significantly changed. There was a significant difference in the treatment effect between the FAG and the CG in overjet, ANB, and effective mandibular length. Conclusions: The results indicate that functional appliances are effective in correcting Class II malocclusions. The growth modification in the FAG resulted in an increase in mandibular length. Yet, the final length of the mandible in the FAG was smaller when compared to the CG.

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AIM: The aim of this study is to evaluate the discolouration resistance of attachments made of composites having different physical properties, filler ratios and viscosity through the simulated environment and conditions. MATERIALS AND METHODS: Seventy-two extracted human teeth were aligned to simulate upper and lower dental arches. The attachments were prepared according to the guides determined by ClearCorrect. Three different composite groups were used for attachments preparation: Aligner Connect, G-Aenial Universal Injectable, and Tetric Prime and Tetric Evoflow combination. Dental models and aligners were kept in artificial saliva throughout the experiment of 96 weeks. The aligners were also subjected to 2308 thermal cycles and insertion and removing procedures 840 times for each period of 12 weeks. Afterwards, the models were kept in coffee and red wine solutions. Colour measurements were made with Vita Easy Shade 4.0 at 12th, 24th, 48th and 96th simulated weeks. RESULTS: No significant difference in discolouration was observed during thermal cycle application of 12th and 24th week experimental periods. In the later periods, discolouration was observed in the composite materials, and G-Aenial Universal Injectable was less coloured than the other samples. The composite samples were more coloured in proportion to their residence time. The G-Aenial Universal Injectable was more affected by wine solution, and Tetric Prime and Tetric Evoflow combination were more affected by coffee solution. CONCLUSIONS: Viscosity, resin matrix content and nature of inorganic filler particles of the composite materials significantly affect the colour changing properties of them due to the long-term ageing and exposure to colouring agents.

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BACKGROUND AND OBJECTIVES: Different expedited aligner wear protocols are currently in practice. This review was undertaken to systematically appraise the available evidence on the comparative efficacy of orthodontic tooth movement (OTM) across the different wear protocols. SEARCH METHODS: Two assessors conducted comprehensive searches of electronic databases, including MEDLINE (via PubMed), Scopus, Embase, Web of Science, Google Scholar, Directory of Open Access Journals, Cochrane Library, OpenGrey, and Clinical Trial Registry, till 18 February 2024. Titles and abstracts were independently screened. SELECTION CRITERIA: Prospective or retrospective studies comparing expedited wear protocols with the conventional 14-day protocol were included. DATA COLLECTION AND ANALYSIS: A pre-piloted data extraction form was used. Risk of bias (RoB) assessment employed the Cochrane RoB 2.0 tool for randomized-controlled trials (RCTs) and the Newcastle-Ottawa scale for non-RCTs. The quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation Pro tool. RESULTS: Six studies, including 3 RCTs and 3 non-RCTs, were selected from 9076 records. Four studies (two RCTs and two retrospective cohort) found no statistically significant difference (P > 0.05) in the OTM efficacy between expedited and conventional protocols. Two studies (one RCT and one prospective cohort) found greater efficacy (P < 0.05) with the 14-day protocol, with the RCT reporting greater efficacy for certain movements, such as maxillary posterior intrusion, maxillary posterior distal tipping and buccal torquing, and mandibular posterior intrusion and extrusion. One RCT reported statistically insignificant difference (P > 0.05) in pain perception between the 10-day and 14-day protocols. Two studies demonstrated low RoB, two moderate, and two high RoB. The evidence level was very-low for OTM efficacy and high for pain perception. Meta-analysis was precluded due to significant heterogeneity among the studies. CONCLUSIONS: Within the limitations of the study, the 7-day, 10-day, and 14-day protocols did not show any significant difference in OTM efficacy, except for certain movements that exhibited superior outcomes with the 14-day wear. Hence, a 'hybrid aligner-wear protocol', based on clinical judgement, might serve a better alternative in complex situations. REGISTRATION: PROSPERO CRD42021288179.

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