Introduction

Orthodontics as a speciality has seen a journey from full arch stainless steel banding to high-precision brackets where teeth are programmed to a predetermined position. Digital technology is transforming the theoretical aspect of design and manufacturing into clinical fruition today. Breakthroughs have been accomplished in varied fields, such as; (1) 3D printing, 3D assisted diagnosis and treatment planning (2) Biomaterials, nanotechnology, biomimetics in (3) Patient education, practice management, and post-graduate orthodontic education (4) E-health, tele-orthodontics and (5) Marketing and Social media utility.

The last decade specifically has witnessed steadfast advancement in the field of 3D technology with a noteworthy emphasis on dual modalities; (1) 3D-assisted diagnosis and management, and (2) computer aided design (CAD) and computer aided manufacturing (CAM). The primary purpose of incorporating 3D applications into orthodontic practices is to aid the practitioner with a better understanding of the craniofacial complex and provide a seamless interface for efficient fabrication of chair-side appliances based on this improved understanding. This could entail, but not limited to, fabrication of customised brackets, printing retainers, fabricate surgical splints, or sequential planning of orthodontic treatment in a 3-dimensional milieu.

In the pursuit of epitomising efficiency and decreasing untoward effects, smart brackets that have a micro-electromechanical system with encapsulated microelectric chips that can control applied forces and moments have been developed. In addition, sophisticated algorithms have successfully created precise archwire bending using robots with an accuracy of 0.1 mm. ^, Likewise, a persistent effort has been made to improve bracket characteristics and adhesive properties (via biomimetic adhesives, Geckel brackets) in order to increase therapeutic efficiency, such as; optimising tooth movement, monitoring force-moment components, miniaturising bracket profile, and decreasing or eliminating untoward effects of orthodontic treatment. ^{, ,}

Patient education and compliance plays a vibrant role in the success of orthodontic treatment. Observance of orthodontic treatment appropriate diet, enforcement of positive hygiene-related behaviour and adherence form an indispensable part of the orthodontic treatment experience. The psychological behaviour change models (for e.g. Behaviour Change wheel, BCW) have shown the most influential way of enforcing oral health amongst all the behaviour change techniques (BCT). In the modern-day context, technology (i.e. mobile phone apps to improve brushing via reminders,sending personalised treatment information, and monitoring treatment via thermal sensors) is poised to conceivably deliver interventions that can not only be suitable for a patient’s capability (C), but also can increase the usage opportunity (O), and enhance motivation (M) in a cost-effective manner to adapt to a particular behaviour (B), thus fulfilling the basic tenet of COM-B model.

Nanotechnology has instituted a profound influence in practically all the expanses of clinical orthodontics, such as, archwires, adhesives, elastomeric ligatures, and brackets. Nanoparticles are aimed at; (1) minimising archwires frictional effects via nanocoating of inorganic fullerene-like nanoparticles of tungsten disulfide (IF-WS2), (2) improving mechanical properties and increasing fracture resistance of adhesives by incorporating nanofillers to the tune of 0.005 – 0.01 µm, (3) equipping elastomeric ligatures with anticariogenic and anti-inflammatory properties by nanocoating, ^, (4) improving the shape memory effect of clear polymer archwires with thermal or photosensitive nanoparticles, ^, and (5) improving the osseointegration of temporary anchorage devices with biocompatible nanotubular coatings. ^, Newer biomaterials such as bioactive glass (BAG), Niobium pentoxide have been introduced to potentially prevent enamel demineralization and formation of white spot lesions. ^,

With the entire clinical terrain witnessing a conceptual and technology driven metamorphosis, Post-graduate orthodontic education and training has also braced itself to train orthodontists of the future. Noteworthy, incorporations in teaching protocols include-(1) Simulators such as haptic-enhanced virtual reality (VR) simulation to develop orthodontic dexterity skills ; (2) augmented reality (AR) by overlaying computer-generated virtual content over real structures ; and (3) development of patient like robots and virtual reality dental training systems (VRDTS) ^, to create an immersive and interactive virtual dental teaching environment such that the trainee can be better equipped with patient experiences and management skills prior to seeing actual patients.

The delivery of orthodontic care to remotely located patients via information technology is also gaining momentum as it facilitates consultation, transference of electronic records, supervision of treatment, and remote monitoring of the patient in real time. Are the teleconsultation, electronic record sharing, and remote orthodontic care operating under the legal framework and regulations such as Health Insurance Portability and Accountability Act (HIPAA), and personal data protection act globally? And how safe is the internet-based consultation and treatment in the light of ‘online data theft’? Is the demographic information collected by the online direct to consumer (DTC) orthodontic treatment provider companies compliant with international data transfer regulations. ^, These questions demand credible answers as we evolve.

Marketing of practices and commercial marketing by orthodontic manufacturers are two important domains that have reorganized themselves with the advent of social media. The promotion of orthodontic practices and products have indeed taken a new-fangled leap. Technology has empowered both the provider and the consumer to move from the bygone era of disseminating and accquiring information via billboards, direct mail, newspaper, radio, pamphlets to a more advanced, quicker, and broader mode of market penetrability by efficient usage of sleek information technology tools

How far have the aforementioned advancements found applicability, and what are the limitations that have precluded their envisioned development? This scoping review aims at providing an overview of the existing technological developments, as reported in orthodontic literature. The authors have made an attempt to (1) map the broad outcomes, (2) quantify the utilization of the technology, and (3) collate the range of study designs and methodologies that have been implemented. The purpose of this review is also to develop plausible core outcome sets for future studies so that the transference of technology in a clinical setting is a seamless process.

Materials and method

A scoping review of literature was carried out by following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. The development of a study protocol was primarily based to address the main research question and study’s eligibility criteria ( Table 1 ). The scoping review was performed on Medline, CINAHL Plus, Embase, Pubmed, and Google scholar to assimilate the studies on recent advancements in orthodontics. The various search terminologies used are presented in the ( Table 2 ). The literature search was limited to English language only with publication dating back to ten years from the time of this review (January, 2009 to September, 2019). The search was limited to ten years as Meline T describes the time-period for search of ‘contemporary studies’ can be limited to ten years in order to maintain relevancy. Titles and abstracts were screened to satisfy the scoping review eligibility criteria.

The fundamental research question, ‘Recent advancements in orthodontics’ was further sub-categorised into five domains, as enumerated below;

• (1)

  Recent advancements in orthodontic 3D applications including 3D printing, diagnosis and management .

• (2)

  Recent advancements in orthodontic biomaterials, nanotechnology, biomimetics, battery-driven devices .

• (3)

  Recent advancements in orthodontic patient education, orthodontic training, and orthodontics practice management .

• (4)

  Recent advancements in orthodontic E-health protocols, tele-orthodontics, teleconsultations etc .

• (5)

  Recent advancements in orthodontic marketing and social media influences .

Data extraction was charted according to “PICO” guidelines with collected information that included the first author and year of publication, study design, number of participants, intervention, comparison, outcome (primary and secondary), a method of measurement, and an outcome domain.

Additionally, each domains’ outcomes were categorized into the following outcome area using the modified method described by Sinha et al. and Tsichlaki et al.

• (1)

  Morphological features or surface characteristics.

• (2)

  Physical and chemical characteristics.

• (3)

  Functional and emotional status, perceptibility, and sustainability.

• (4)

  Health resource information and utilization.

• (5)

  Biocompatibility including toxicity.

Results

The initial database and additional search resulted in 1245 records, of which 65 potentially relevant articles were retrieved in full. 42 studies met the selection criteria following screening and were included in the scoping review with the results of the search depicted in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart ( Fig. 1 ).

Preferred reporting items for systematic reviews and meta-analyses flow chart.

The studies included in the review are shown in Table 3 , and excluded studies with reasons are enumerated in Table 4 . 3 D application including 3D printing, diagnosis and management has the largest share with 49%, followed by 27% share by orthodontic marketing and social media influence, and 20% by biomaterials, nanotechnology, biomimetrics, and battery-driven devices. The least represented were; patient education, orthodontic training, and orthodontic practice management (4%), and E-health, tele-orthodontics, tele-consultations (0%) ( Fig. 2 ).

Table 3

Studies selected for scoping review.

Sr. No	Author/Year	Study design	Participant	Intervention	Comparison	Outcome Primary/Secondary	Method of measurement	Outcome Domain
1.	Loflin/ 2019	Case-control	12 cases study models	3D-sterioltihography printed models	traditional orthodontic plaster models	Clinical acceptability of 3D models	American Board of Orthodontics Cast-Radiograph Evaluation grading system	Morphological features
2.	Camardella/2017	Case-control	30 pairs of study models	Polyjet and stereolithography printer models	regular base models	Accuracy of printed models	Digital linear measurements	Morphological features
3.	Cole/2019 /	Case-control	27 retainers divided into three groups	3D-printed (CAD/CAM) ultraviolet (UV)-sensitive PMMA retainers	conventional vacuum-formed retainers	Clinical acceptability of 3D printed retainers	Digital linear measurements	Morphological features
4.	Favero, 2017	Case-control	36 models stereolithography-based 3D printer and Forty-eight models with 4 3D printers	3D-sterioltihography printed models	4 commercially available 3D printers	Accuracy of printed models	Superimposition analysis	Morphological features and surface characteristics
5.	Kim, 2018	case-control	5 models stereolithography based printed using 4 types of 3D printer	3D-sterioltihography printed models	4 commercially available 3D printers	precision and trueness of dental models	American Board of Orthodontics’ increments for grading plaster models	Morphological features and surface characteristics
6.	Ye, 2019	case-control	10 dental models	3D- printed splints on offset 3D dental models	3D-printed splints on no-offset 3D dental models	precision of 3D-printed splints	3-dimensional (3D) euclidean distances	Morphological features surface characteristics
7.	Ledingham/2016	case-control	30 models 3D printed	calcium sulfate hemihydrate and liquid inkjet ceramic based models	Three groups with different treatment; heat and Epsom salt	Mechanical property ( compressive strength), and precision	universal testing machine and laboratory digital scale	Morphological features
8.	Guzman, 2019 ,	case-control	ten sets of pre-treatment models into 20 models of numerus malocclusion	3D printed models	conventional (manual) and virtual set-ups	dimensional accuracy of digital setup model construction.	Digital linear measurements	morphological features and surface characteristics
9.	Scott, 2019	case control	15 cases plaster models	automated assessment of digital orthodontic models	Hand grading of 3D printed models	dimensional accuracy	American Board of Orthodontics cast-radiograph evaluation (ABO CRE) system	Morphological features or surface characteristics
10.	Jacox, 2019	qualitative study	24 privately practising orthodontists	observed and expected developments in digital dentistry	early, middle, and late adopters	barriers, incentives, and influence on practice	semistructured qualitative interviews	Practice management
11.	Hazeveld, 2014	case-control	12 mandibular and maxillary models of 6 patients	Plaster models	digital light processing, jetted photopolymer, and 3-dimensional printing models	dimensional accuracy, reproducibility	electronic digital caliper linear measurments	Morphological features or surface characteristics
12.	Kim, 2018	case-control	5 maxillary plaster models	digital bracket position	intended bracket position	Accuracy of bracket positions CAD/CAM indirect bonding system	3-dimensional program	Morphological features
13.	Bazina, 2018	retrospective study	31 subjects (21 ± 8 years)	Dolphin 3D voxel-based superimposition	2 open-source programs	precision and reliability	absolute closest point color map	Morphological features,
14.	Talaat, 2017	Retrospective	20 orthodontic cases	3D landmark-based superimposition of digital dental models	surface-based superimposition utilizing two commonly used softwares.	validity and reliability of three-dimensional (3D) digital dental models	superimpostion best fit method	Morphological features, surface characteristics
15.	Ganzer, 2017	case control study	16 cases study model	algorithm based analysis	Raw matching, fine matching, and deformation analysis.	validity and reliability of three-dimensional (3D) digital dental models	superimpostion best fit method	Morphological features, surface characteristics
16.	Morris/2019	case-control	10 typodonts	3D digital dental models generated from direct monitoring (DM) smart phone application	iTero Element intraoral scanner	Accuracy of 3D dimensional (3D) digital dental models	American Board of Orthodontics (ABO) objective grading system	Morphological features and surface characteristics
17.	Choi/2012	Retrospective study	30 patients	3-dimensional (3D) superimposition method of digital models	Superimposition on cephalograms	Validity of palatal superimposition of 3D dimensional (3D) digital dental models	3D models superimposition using palatal references	Morphological features and surface characteristics
18.	Tanikawa/2019	Cross-sectional	130 subjects	Three-dimensional morphometry assessment of	Three different age groups	The effects of age on facial morphology at rest and during smiling	Principal component analysis (PCA)	Morphological features and surface characteristics
19.	Talaat/2015	Retrospective	20 patients (12.3 ± 1.9 years)	New non-invasive 3D orthodontic tooth movement software	Spiral CT machine scan	Reliability of dental-arch measurements obtained from 3D laser-scanned models	Superimpostion best fit method	Morphological features and surface characteristics
20.	Brown/2018	Quantitative	30 patients	3-dimensional printed dental models from digital intraoral impressions	3-dimensional printed dental models from alginate impressions	Accuracy of the 3D printed dental models	Linear measurements using didtal calipers and 3D software	Morphological features and surface characteristics
21.	Manfred/ 2013	Quantitative	50 human teeth	4 novel bioactive glass (BAG) adhesives	Traditional resin adhesive	Changes in enamel microhardness	Knoop microhardness testing	Physical characteristics
22.	Altmann/2017	Quantitative	Ninety-six crowns of bovine incisors	3 Niobium pentoxide phosphate invert glass (PIG-Nb) adhesives	Adhesive without PIG-Nb	Shear Bond Strength, Surface composition and Ph changes	Knoop microhardness testing, Scanning Electron Microscopy (SEM) Energy Dispersive X-Ray Spectroscopy (EDS)	Physical and chemical characteristics
23.	Kloukos/2015	Qualtitative and quantitative	20 orthodontic patients	Bisphenol-A (BPA) release in tap water mouth rinse and simulated deionised water/ethanol rinse		BPA analysis	Gas chromatography–mass spectrometry	chemical characteristics
24.	Illadi/2017	Quantitative	5/material (for mechanical properties and curing efficiency) 10/material (for water storage test)	UEDMA/TEGDMA flowable composite and PCDMA/UEDMA/TEGDMA composite	BisGMA adhesive	Degree of conversion, mechanical properties water storage effect, pull-out strength	Universal hardness-testing machine, Vickers indenter	Physical characteristics
25.	Uysal/2009	Quantitative	60 human maxillary premolar teeth	Nano-composite and nono-inomer composite	conventional light-cure orthodontic bonding adhesive	shear bond strength, failure site location	Adhesive remnant index, Universal testing machine	Physical characteristics
26.	Hammad/2016	Quantitative	Ninety-six premolars	Silica dioxide (SiO2) nanofillers	4 different bonding systems	shear bond strength (SBS), failure of orthodontic brackets	Adhesive remnant index, Universal testing machine	Physical characteristics
27.	Blocher/ 2015	Quantitative	16 bovine incisors	microsilver or nanosilver particles in orthodontic primer	primer without microsilver or nanosilver particles	shear bond strength (SBS) and bracket/adhesive failure	Adhesive remnant index, Universal testing machine	Physical characteristics
28.	Subramani/2016	Quantitative	3 sample groups with 24-well plate	carbon nanotube-coated orthodontic titanium mini screw implants	uncoated titanium miniscrew implants	proliferation, differentiation, and matrix mineralization	Scanning electron microscope, assay	Surface characteristics Biocompatibility, cellular response
29.	Oyonarte/	Qualitative and quantitative	35 rats	low-intensity pulsed ultrasound (LIPUS) stimulation on condylar growth	Untreated condyle	condylar cartilage histology and histomorphometry	Light microscopy	Histology and cellular response
30.	Henzel/2014	Qualitative	131 twitter posts	orthodontic-related posts on Twitter	None	Patients perceptions and treatment experiences	description analysis	Perceptibility
31.	Chan/2017	Qualitative	548 twitter posts screened, 321 included	Orthodontic-related (morphological, psychological) posts on Twitter	None	psychological and/or psychosocial impact of bullying	Thematic analysis	Morphological feature, Functional and emotional status, perceptibility
32.	Tuncer/2015	Cross-sectional	491 patients (274 female, and 217 male 14-–22 yrs) and 399 parents (245 female, 154 male)	Orthodontic treatment decision by patients and parents	None	Patients perceptions and treatment expectations, and media influence	Questionnaire survey	Perceptibility
33.	Al-Silwadi/2015	Prospective Randomised controlled trial	30 participants ( 15.50 yrs, male and female), 30 participants ( 15.50 yrs, male and female)	YouTube video with information having dentition care and fixed appliances during treatment	standard verbal information	Patient perception and audiovisual information influence	Questionnaire survey	Patient perception and knowledge
34.	Knosel/2011	Cross-sectional	30 videos	YouTube orthodontic related videos	None	information value, intention, source, and bias of videos	Questionnaire	Health resource information and patient perception
35.	Lena/2018	Cross-sectiona	32 videos	YouTube orthodontic related videos	None	Audio-visual information quality on lingual orthodontic treatment	video information and quality index (VIQI)	Health resource information and patient perception
36.	Nelson/2015	Cross sectional	189 Orthodontists and 188 patients/parents	Use of social media in orthodontic practices	None	orthodontic patient and practitioner use of and preferences for social media, and potential benefit	Questionnaire Survey	patient and practioners perception
37.	Livas/2013	Qualitative	25 webpages	Internet Data quality regarding pain experienced by orthodontic patients	Text book information	Accuracy and readability	Flesch Reading Ease Score (FRES	Health resource information
38.	Henzell/2013	Cross–sectional	130 participants (17.2 yrs., 52.3 % females)	treatment experiences and attitudes through Internet-based social media websites	None	Patients perceptions, and treatment experience	Questionnaire Survey	Health resource information and patient perception
39.	Leone/2018	Prospective	42 patients (14-–34 yrs, 20 males, 22 females)	Text message reminders	no text message reminder	Compliance assessment, and facilitators	Study model assessment	Patient perception
40.	Noll/ 2017	Cross-sectional	3784 tweets	Invisalign patient experience	Braces patient experience	Orthodontic patient experience	Naïve Bayes classifiers	Patient perception
41.	Al-Moghrabi/2017	Cross-sectional	827 tweets	Orthodontic retainers posts	None	Orthodontic patient experience, barriers and facilitators to wear retainer	Thematic content analysis	Patient perception
42.	Zotti/2019	RCT	60 patients ( 16-–19 yrs)	Follow-up supported byWhatsApp chat group	Follow up with no WhatsApp chat group	Compliance, follow-up attendance	linear measurements on study models,	Perceptibility, patient education

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