The last decade in orthodontics: A scoping review of the hits, misses and the near misses!

Abstract

The past decade (2009-19) has seen orthodontics incorporate many new infusions into its fold. This scoping review analyzes published orthodontic literaure in five different domains:(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. and (5) Recent advancements in orthodontic marketing and social media influences. A total of 1245 records were searched,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. The review found studies pertaining to morphological features or surface characteristics with respect to 3D applications (3D printing, diagnosis and management)as the most represented outcome assessment (49%).Orthodontic Marketing & Influence of Social Media (27%) and Biomaterials,Nano-Technology,Biomimetics and battery Driven devices have also been considerably reported (20%) in the past decade. More scientific data needs to be gathered in the field of Patient education, E-health, tele-orthodontics, and protection of patient confidentiality. The authors present COS (Core Outcome Sets)that could be a road map for evaluating currently employed developments as well as testing new ones in future.

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.

Table 1
Scoping review selection criteria.
Inclusion criteria Exclusion criteria
All types of studies including randomised controlled trials (RCTs), controlled clinical trials (CCTs), cohort studies, retrospective studies, and case-control studies on the five subcategories as enumerated in the text. Case reports and studies with less than five participants or sample
Any types of comparison with conventional mode of orthodontic treatment, method or approach. Personal opinion, descriptive paper, letter to editor or interviews
All types of reported outcomes (primary and secondary) Technique article (focus on design description), Proof of concept

Table 2
Table depicting the search terminologies employed for the scoping review.
S/N Database Search Term 1 (Main search term) Search Term 2 Search Term 3 Not relevant
S1 (2009–2019, full text, English)

  • MEDLINE

  • CINAHL Plus

  • EMBASE

  • PubMed

  • Google Scholar

*3D application orthodontics* AND 3D printing* AND *Laser printing*
  • 1.

    letter to editors

  • 2.

    Systematic review and Meta-analyses

  • 3.

    Technique article (focus on design description)

  • 4.

    Opinion article, and interview.

OR OR
*Stereolithography* *Inkjet printing*
OR OR OR
*Diagnosis management * *Image rendering*
OR
*Orthodontic
3D design*
OR *rapid prototyping*
*3D model*
OR
OR OR *Toxicity test*
*Virtual design orthodontics* *acquisition*
OR
*CAD models*
OR
OR *CAM models*
*Feasibility* OR
OR *3D computer supported design*
*Reliability *
S2 *Biomaterials Orthodontics* *Bisphenol A-free monomers* *Mussel-mimetic polymers*
OR
OR
*Biomimetic adhesives* OR
*Gecko adhesion*
OR
*NanoRobotics*
OR
*Battery driven* OR
OR
*Smart brackets* *Geckel brackets*
OR
*Nanocomposites* OR
OR
Nanaoparticle implants* *Sensor chip brackets*
OR
OR
*Microsensor*
OR
*Self-healing materials* *NanoHollow wires*
OR OR
*Nanoenamel Remineralization agents* *Fullerene-Graphite based nanowires*
OR OR
*Nanoelectromechanical systems* *Shape-memory polymers*
OR
OR
*Biomedical* *NanoLIPUS*
OR
*Antibacterial Nanoparticles*
*Nanotechnology orthodontics*
OR
*Biomimetics orthodontics*
OR
*Feasibility*
OR
*Reliability
S3 *E-health orthodontics* *Electronic record * Legal regulations
OR OR
OR
*Teledentistry-
Orthodontics*
*Clinical decision* Acceptability
OR OR
Applicability
OR
Health Insurance Portability and Accountability Act (HIPAA)
OR
*Support system* Family Educational Rights and
Privacy Act (FERPA)
OR
*Patient education*
OR
OR Protected Health Information (PHI)
OR *Remote care*
OR
OR Health Information Technology for Economic and Clinical Health Act (HITECH Act).
*Teleconsultation-orthodontics* *Distance care*
OR
*Electronic medical record (EMR) *
OR
*Electronic Health Record (EHR) *
OR OR
*Feasibility*
OR *Electronic Health Care (EHC) *
*Reliability *
S4 *Marketing orthodontics* *Twitter*
*Smile direct*
OR
*Promotion*
OR OR
OR *Facebook* *Advertising*
OR
*Wikis*
OR
OR *Blogs*
OR
*Vlogs *
OR
*Social media orthodontics* *Google * *Apps*
OR
OR *LinkedIn*
*Youtube* OR
OR *Email*
OR
*Practise websites*
*do-it-yourself* *Instagram*
OR
*direct-to-consumer (DTC) *
OR
*Feasibility*
OR
*Reliability *
S5 *Patient Education orthodontics* *Softwares*
OR
*technology enhanced learning*
*ELearning*
OR
OR
OR *Haptic technology*
OR
*semantic web*
OR
*Practise management orthodontics* *Reality Dental Training System* *flexible learning platform (FLP) *
OR OR OR
*Education and practise management * *Orthodontics
Personal Learning Environments (PLEs)*
*Wikis*
OR
OR OR *Blogs*
*Orthodontics training* *Personalised treatment information* OR
*Vlogs*
OR
*toothbrushing reminders* OR
OR
OR *mobile phone-based reminders* *Apps*
*Orthodontics continuing development education*
OR
*Feasibility*
OR
*Reliability *

S1 (search 1), recent advancements in orthodontics in 3D application including 3D printing, diagnosis and management; S2 (search 2), recent advancements in orthodontics in biomaterials, nanotechnology, biomimetics, battery-driven devices. S3 (search 3), recent advancements in orthodontics in E-health, teledentistry-orthodontics, teleconsultation; S4 (search 4), recent advancements in orthodontics in orthodontics marketing and social media influence; S5 (search 5), recent advancements in orthodontics in patient education, orthodontics training, and orthodontics practise management.

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 ).

Figure 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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Jan 9, 2020 | Posted by in Orthodontics | Comments Off on The last decade in orthodontics: A scoping review of the hits, misses and the near misses!
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