The use of attachments in aligner treatment: Analyzing the "innovation" of expanding the use of acid etching-mediated bonding of composites to enamel and its consequences.

Orthodontic treatment with sequential aligners has seen a considerable surge in the last decades, and is currently used to treat malocclusions of varying severity. To enhance tooth movement and broaden the spectrum of malocclusions that can be treated with aligners, composite resin attachments are routinely bonded with the acid-etch technique on multiple teeth, a process known to impose irreversible alterations of the enamel structure, color, gloss, and roughness. Additionally, this clinical setting introduces a unique scenario of different materials applied in a manner that involves the development of friction and attrition between the attachment and the softer aligner material, all performing in the harsh conditions of the oral environment, which impact the aging of these materials. The latter may give rise to alterations of the aligners and the composite attachments and potential intraoral release of Bisphenol A, a known endocrine disrupting agent. Furthermore, at the final stages of contemporary aligner treatment, the removal of multiple, sometimes bulky, composite attachments with a volume and surface far greater than the remnant adhesive after debonding of brackets, through grinding that might be associated with pulmonary effects for the patient or staff. Because of the extensive enamel involvement in bonding, the release of factors from the attachment-aligner complex during service, the aging of these entities in the oral environment, and the laborious debonding/composite grinding process coupled with the hazardous nature of aerosol produced during the removal of these bulky specimens, appropriate risk management considerations should be applied and an effort to confine the application of multiple composite specimens bonded to enamel to the absolutely necessary should be pursued.