eCommons@AKU

Department of Surgery Department of Surgery

July 2019

Application of new biomedical materials in

orthodontic appliances
Hafiz Taha Mahmood
Aga Khan University, [email protected]

Adeel Tahir Kamal

Aga Khan University, [email protected]

Bushra Khan
Aga Khan University, [email protected]

Mubassar Fida
Aga Khan University, [email protected]

Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg

Recommended Citation
Mahmood, H., Kamal, A., Khan, B., Fida, M. (2019). Application of new biomedical materials in orthodontic appliances. Journal of the
College of Physicians and Surgeons Pakistan, 29(7), 654-657.
Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/782
REVIEW ARTICLE

Application of New Biomedical Materials in

Orthodontic Appliances
Hafiz Taha Mahmood1, Adeel Tahir Kamal1, Bushra Nazeer Khan2 and Mubassar Fida1

ABSTRACT
This review article describes the application and characteristics of certain biomedical materials in orthodontic appliances.
The elastic recoil of shape memory polymers, determination of the forces and moments experienced by the brackets and
eventually by the tooth, reduction in treatment time by employing self-healing smart brackets and decreased enamel lost
during debonding due to usage of biomimetic adhesives such as dihydroxyphenylalanine (DOPA) is discussed. Increased
plaque retention and microbial attachment around brackets and teeth is of profound concern and by utilisation of
hydrophobic properties of self-cleaning materials, this can be reduced significantly. Implantation of bioresorbable
temporary anchorage devices, which resorb once their purpose is accomplished and increasing the concentration of
fluoride in the oral environment to counter the deleterious consequences of orthodontic treatment such as white spot
lesions and caries, are also discussed briefly.

Key Words: Biomedical engineering, Orthodontic appliances, Biodegradable materials.

INTRODUCTION played a vital role in the development of many materials

The importance of a well-coordinated interaction of ortho- that are being used in orthodontic practices today.3
dontists with biomedical engineers for the production of Technological advances have helped develop complete
many customised orthodontic appliances has been under- orthodontic solutions such as Suresmile, Invisalign and
appreciated. Usually, the biomedical engineers, hired by Incognito systems.4,5 Each of these offer crucial benefits
many orthodontic appliance manufacturing companies, to the patient and to the clinician and have been refined
develop the appliances, overlooking the day-to-day through close communication and interaction with the
clinical difficulties faced by the orthodontists in their busy orthodontists to reach exemplary finesse.
practices. On the other hand, not many general dentists The aim of this review is to describe the current trends
choose or pursue their career in biomedical engineering and innovations of biomedical materials and their
as well. In addition, an absence of collaboration of implications in orthodontic science. The list of new
orthodontists with biomedical engineers in their research biomedical materials is fairly extensive and we cannot
endeavours leads to a significant vacuum in the discuss all the innovations related to the orthodontic
innovation of biomedical materials in the orthodontic science. Hence, only the materials that could overcome
science.1 day-to-day clinical problems are discussed.
Numerous appliances and materials are introduced in Shape-memory polymers (SMPs): Polymers continue
the market and yet they fail to influence orthodontic to be an important component of a variety of materials
practices. The innovation should address a critical used in orthodontics, let alone dentistry. Their wide
clinical concern; for example, a material that has easy clinical application has proved to be most useful in
handling characteristics and shortens chair side time or several circumstances.
one that significantly improves the quality of treatment
The metallic color of orthodontic appliances such as
by addressing important variables such as treatment
brackets and archwires has always been a great
duration and cost.2 Moreover, a material which can help
concern in adolescents and adult orthodontic patients.
reduce errors in treatment will be widely accepted by
Means to make appliances more esthetic have led to the
the orthodontic community. Clinician's experience has employment of ceramic, plastic or polycarbonate
1 Department of Surgery, Aga Khan University Hospital, brackets and Teflon coated archwires for esthetically
Karachi, Pakistan concerned patients.6
2 Department of Orthodontics, Altamash Institute of Dental SMPs, as the name suggests, are the polymers that attain
Medicine, Karachi, Pakistan
their original shape when deformed due to the appli-
Correspondence: Dr. Mubassar Fida, Department of Surgery, cation of a recovery trigger in the form of either light,
Section of Dentistry, Aga Khan University Hospital, Karachi, heat, electrical or magnetic fields, infrared radiation, or
Pakistan immersion in water.7 Due to interatomic robust and
E-mail: [email protected] directional bonds, SMPs can remember its original
Received: September 05, 2018; Revised: December 18, 2018; shape and return back to it, in turn having a dual shape
Accepted: December 19, 2018 capability.

654 Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (7): 654-657
Application of new biomedical materials in orthodontic appliances

SMPs have numerous inherent advantages, such as place which leads the monomer out into the air; as a
transparent nature, easy working, low density, reduced consequence of which, space created by fracture is
cost, and acceptable appearance.8 In addition, SMPs polymerised and filled.12 This would result in minimising
have a considerable shape returning force for the damage of the brackets and archwires and
approximately 3 months.9 They were introduced in simultaneously leads to an overall reduction in treatment
orthodontic treatment for initial alignment and levelling of duration. However, multiple trials and approval from
esthetically concerned patients.10 SMPs consists of hard different organisations such as Current Good Manu-
and soft segments and have gained increased popularity facturing Practice (CGMP) is required for these
among many clinicians due to their glass transition materials to be used in routine orthodontic practice.
temperature, which is near the body temperature.11 Biomimetic adhesives: The bonding of the brackets to
These polymers have increased utility in the correction the tooth surface requires enamel preconditioning which
of malaligned and severely rotated teeth. leads to alteration in the enamel thickness and color.
Brackets with force moment sensors: When a two- The durability and firmness of the bond between enamel
couple system or an indeterminate force system is surface and bracket base depends on adhesive
employed using orthodontic appliances, the amount of material, preparation of tooth surface and brackets base
forces and moments cannot be measured or appro- retention.12 Zachrisson et al. reported that sandblasting
priately determined. This drawback and with the also increases the bond strength to gold, porcelain and
frequent utilisation of two-couple system in orthodontics, amalgam,18 but all these manoeuvre would result in
researchers are constantly looking for modalities or enamel damage and loss.
devices that can measure these forces and moments In the past, different types of materials were introduced
first in vitro and later on, in vivo. Hence, there will be which are closely related to the nature's pattern and has
adequate utilisation of forces for effective orthodontic led to the creation of a separate division of biomimetic
tooth movement and minimal consequences on oral materials. Their essence can be appreciated by
health.12 However, in vitro assessment has certain breaking the word into "bio", meaning life and "mimetic"
limitations, because, by all means, we cannot provide which means imitating.12
the exact environment imitating the oral apparatus.
Geckos, a kind of lizard, use the concept of "contact
According to the pertinent literature survey, many splitting" to balance their weight while they are upside
in vitro,13,14 and later in vivo15 systems have been down. This kind of adhesion goes well with dry
introduced in the past to precisely measure forces and surroundings. The example of mussel is fascinating for
moments. In the last decade, Lapatki et al. introduced a
the researchers as it provides adhesion in wet
smart bracket having stress sensor system implanted in
environment. In this way, Geckel was introduced which
the bracket base for the evaluation of three dimensional
is a mixture of adhesive components of Geckos and
forces and moments experienced by the bracket and
mussels and performs well in both dry and wet
then eventually by the tooth.15 However, none of the
surroundings.12
systems have yet been tested and used in the oral
environment; and further research in this regard is The application of biomimetic adhesives in orthodontic
essential. science is by utilising the brackets with bases covered
with L-3,4-dihydroxyphenylalanine (DOPA). DOPA is an
Self-healing materials: The development of smart
important glue protein of mussels and provides sufficient
synthetic materials, which show prompt reactions to
bond strength with the enamel surface.19 Hence, enamel
environmental behaviours, have been an interesting
conditioning before bonding would not be required and
innovation because of their unusual biomimetic
less structural changes to enamel would be needed.
properties.12 Motivated by nature, researchers have
developed some smart materials which have self- Self-cleaning materials: The plaque accumulation
healing properties, capable of healing the damage and around brackets and tooth surfaces causes significant
applicable during drug delivery, tissue and organ damage to the periodontium and subsequently leads to
repairing and shape memory functions.16 Over the past deleterious effects such as gingivitis, bone loss and
few decades, hydrogels have been introduced, which white spot lesions. The introduction of such materials,
display unusual bio-mimicking properties. Researchers which could easily flush away the organic and inorganic
demonstrated some cross-linked hydrogels which show substances from the calcified surfaces and brackets
self-healing properties.17 would play a tremendous role in orthodontic material
Self-healing materials for orthodontic applications can application.12
include polymer brackets and archwires. Wire and bracket Over time, research has helped develop several bio-
breakages can be minimised by incorporating nano- logical micro and nano-structures which have beneficial
sized bubbles filled with auto-polymerised monomer. properties.20 A good example is the lotus leaf, which
When a bracket breaks, shattering of the bubbles take grows in water. This is the only natural plant which is

Journal of the College of Physicians and Surgeons Pakistan 2019, Vol. 29 (7): 654-657 655
Hafiz Taha Mahmood, Adeel Tahir Kamal, Bushra Nazeer Khan and Mubassar Fida

extremely hydrophobic in nature and stays clean in dirty Furthermore, a study using CO2 lasers and fluoride
water environment.20,21 Following the example of lotus varnishes has also been conducted demonstrating the
leaf, self-cleaning materials have been introduced which effect of laser therapy on the solubility of enamel.36
show hydrophobic qualities. Introduction of titanium Bonding materials such as compomers and resin-
oxide nano-coating on the surface of aircrafts to modified glass ionomer cements (RMGICs) have been
increase the safety and durability also provides the self- shown to reduce the incidence of caries development
cleaning effect.12 but still require additional trials before they are widely
used due to questionable bond strengths. 32,37
In orthodontic materials, the photo-catalytic behaviour of
titanium oxide with ultraviolet light is the centre of The conversion of hydroxyapatite to fluorapatite crystals
recognition in current time.22 The surface of nickel contributes to the anti-cariogenicity imparted by fluoride.
titanium archwire alloy has been changed to crystalline In addition, high quantities of fluoride in plaque is bac-
rutile by treating the alloy surface with titanium oxide film tericidal and further prevents enamel breakdown. Casein
electrolytically and then with heat.12 Here a question Phosphopeptide-Amorphous Calcium Phosphate (CPP-
arises, "Would this surface alteration of nickel titanium ACP) maintains the level of phosphate and calcium in
archwire result in significant change in the biomechanical the plaque, therefore, it prevents the discharge of these
properties of the alloy?" A question which is yet to be elements and further encourages remineralisation.32,38
answered and a grey area which requires further Methods to maintain high concentrations of fluoride in
research. the oral cavity in orthodontic patients has also included
slow releasing devices, chewing gums and elastomers.
Biodegradable or bioresorbable miniimplants: The
Each of these has shown increased amounts of fluoride
concept of biodegradable implants was introduced in
in the oral cavity. However, incorporation of fluoride has
the 1980's after extensive research for orthopedic resulted in significant alteration in the mechanical
purposes.23 The use of these materials was popularised properties of these materials.32,39-41 Multiple trials need
due to the drawbacks of metallic fixation such as to be undertaken to establish standard guidelines for the
cosmetic deformity, palpability or wound dehiscence.24 usage of fluoride for each orthodontic patient so that
Initially, fixation plates and screws were fabricated from deleterious and iatrogenic effects such as development
polylactic and polyglycolic acid (PLA/PGA).25,26 These of white spot lesions can be minimised.
materials have the ability to break down into simpler
Recommendations: Smart biocompatible materials,
compounds that can easily be excreted from the body.
adhesives, brackets and archwires will soon become the
This makes them a valuable prospect for temporary
part of the routine orthodontic armamentarium due to
anchorage devices used in orthodontic treatment. By
continuing in vitro trials. New advances and tech-
altering the PLA/PGA ratio, we can change the de-
nologies of biomedical engineering and predominantly
gradation, excretion rate and biomechanical properties the use of nanotechnology for material construction and
of these implants.24 manufacture are being used for headway in material
The hesitation in widely adopting bioresorbable materials sciences. The application of tissue engineering principles
is the delayed resorption time.27 Several authors28-30 for dental, skeletal and soft tissues, and development of
have reported the time between 2-5 years for complete nanostructured and biomimetic materials should be
resorption of different materials. These polymer prominent areas of forthcoming research. Orthodontic
materials are overcoming the possibility of developing faculties in research-oriented institutions need to
inflammatory response, infection and loosening of approach faculty in biomedical engineering or bio-
conventional temporary anchorage devices, but there is engineering departments and point out the opportunities
still a need to ensure safe elimination of the byproducts that are available for collaboration and advances in both
from the body.26 Perhaps, continued research will help in areas.
developing new materials that can be used and excreted
from the body safely. CONCLUSION
Fluoride releasing materials: The potential of ortho- This review has discussed the biomedical materials,
dontic appliances to promote plaque accumulation their current trends, orthodontic implications and future
orthodontic perspectives. For customisation of ortho-
and initiate the cariogenic process has led numerous
dontic appliances, the interaction between orthodontists
innovations to tackle this complication.31 The application
and biomedical engineers is of profound importance to
of fluoride varnishes before bonding and monthly appli-
serve the patients in a better way with least undesirable
cation has shown reduced incidence of demineralisation.32,33
complications of the armamentarium.
New materials, which are easy to apply such as titanium
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