The clinical use of computer aided designed/computer aided manufactured titanium nitride coated implant abutments: Surgical and prosthetic considerations-A case series.

OBJECTIVE: To describe the clinical use of nitride-coated titanium CAD/CAM implant abutments in the maxillary esthetic zone in two patients with high esthetic and functional demands and, to highlight the advantages of nitride-coated milled titanium abutments when compared to stock/custom titanium, one-piece monolithic zirconia, and hybrid metal-zirconia implant abutments. CLINICAL CONSIDERATIONS: Due to the inherent mechanical and esthetic clinical challenges, single implant-supported reconstructions in the maxillary esthetic zone are a complex restorative treatment. While CAD/CAM technology has been suggested to enhance and ease implant abutment design and manufacturing, implant abutment material selection remains as a critical decision affecting restoration's long-term clinical outcomes. To date, considering the esthetic disadvantages of conventional titanium implant abutments, the mechanical limitations of one-piece zirconia abutments and the manufacturing time and costs associated with hybrid metal-zirconia abutments, no abutment material can be considered "ideal" for all clinical scenarios. Due to their biocompatibility, biomechanical characteristics (hardness and wear resistance), optical properties (yellow color), and peri-implant soft tissue esthetic integration, the use of CAD/CAM titanium nitride-coated implant abutments has been suggested as a predictable implant abutment material in mechanically challenging but esthetically demanding clinical situations, as the maxillary esthetic zone. CONCLUSIONS: Two patients requiring a combined tooth-implant restorative treatment in the maxillary esthetic zone were treated using CAD/CAM nitride coated titanium implant abutments. The principal advantages of TiN coated abutments include comparable clinical outcomes to stock abutments, optimal biocompatibility, adequate fracture, wear, and corrosion resistance, reduced bacterial adhesion, and excellent esthetic integration with adjacent soft tissues. CLINICAL SIGNIFICANCE: Clinical reports and short term mechanical, biological and esthetic clinical outcomes indicate that CAD/CAM nitride coated titanium implant abutments can represent a predictable restorative alternative to stock/custom and metal/zirconia implant abutments and be considered a clinical relevant option in mechanically challenging but esthetically demanding situations, as often found in the maxillary esthetic zone.

Demirjian and Cameriere methods for age estimation in a Spanish sample of 1386 living subjects.

Currently, human identification is a challenge. Migration due to war, economic crisis or other factors is frequent. The wisdom teeth are the last teeth to initiate and complete development therefore, are fundamental for determining the legal age of majority in different countries. The aim of the study is to determine the validity of two methods based on mineralisation of the third molar to predict the ages of majority of individuals in a Spanish population. Orthopantomographies of 636 men and 750 women (mean age, 16.5 years) were analysed. The Demirjian and Cameriere methods were used, and each tooth was assigned a value according to the degree of mineralisation and maturation. The level of significance used in the analyses was 5% (α = 0.05), with a power of 96.2%. The predictive ability of the Demirjian method to determine 18 years of age in the lower wisdom teeth 93%, respectively. The Cameriere method has a predictive capacity of 88%. There are no statistically significant differences between men and women. Stage H and a cut-off point of 0.08 were the guiding values for determining the age of majority of the study population. For other proposed age ranges (14 and 16 years), both methods were useful in determining the actual age of individuals, with the Demirjian method having a sensitivity of 97.5% with and Cameriere having a predictive capacity of 95%. Both methods can be used with high reliability to determine the age of individuals where reliable documentation is unavailable. Stage H with the Demirjian method and a cut-off point of 0.08 with the Cameriere method can determine the age of majority of the Spanish population. The combination of the two methods does not substantially increase predictive ability.

Surgical approach combining implantoplasty and reconstructive therapy with locally delivered antibiotic in the treatment of peri-implantitis: A prospective clinical case series.

BACKGROUND: Nonsurgical treatment, resective surgery, reconstructive surgery, or combined approaches have been proposed for the treatment of peri-implantitis, with variable results. PURPOSE: To evaluate the 1-year clinical and radiographic outcomes following combined resective and reconstructive surgical treatment with topical piperacillin/tazobactam antibiotic in the management of peri-implantitis. MATERIAL AND METHODS: Forty-three patients diagnosed with peri-implantitis were included. Surgical treatment consisted of implantoplasty of the supra-crestal component of the defect, the application of a topical antibiotic solution over the implant surface, and subsequent reconstruction of the intra-osseous component of the peri-implant defect. The primary outcome was disease resolution, defined as the absence of bleeding on probing (BoP) and/or suppuration on probing (SoP), a peri-implant pocket probing depth (PPD) ≤5 mm, and no bone loss >0.5 mm 1 year after surgery. Secondary outcomes included changes in BoP, PPD, SoP, and peri-implant marginal bone levels. One implant per patient was included in the analysis. RESULTS: The treatment success rate of the 43 dental implants included in the study was 86% at 1 year after surgery. Mean PPD and BoP decreased from 6.41 ± 2.11 mm and 100% at baseline to 3.19 ± 0.99 mm (p < 0.001) and 14% (p < 0.001) at 1 year, respectively. SoP was significantly reduced from 48.8% at baseline to 0% 1 year after surgery (p < 0.001). Radiographically, a mean defect fill of 2.64 ± 1.59 mm was recorded (p < 0.001). CONCLUSIONS: The combination of a resective and reconstructive surgical approach together with locally delivered antibiotic achieved a high disease resolution rate after 1 year of follow-up and constitutes a viable option for the management of peri-implantitis.

Clinical outcomes of lingual fully customized vs labial straight wire systems : Assessment based on American Board of Orthodontics criteria.

PURPOSE: To evaluate orthodontic treatment outcome in patients treated with a lingual appliance (Incognito™ Appliance System, 3M Unitek, Monrovia, CA, USA) versus patients treated with a labial appliance (Victory series™, 3M Unitek, Monrovia, CA, USA). METHODS: A total of 72 patients were retrospectively analyzed. The complexity of each case was evaluated using the American Board of Orthodontics (ABO) Discrepancy Index (DI), and orthodontic clinical outcomes were evaluated using the ABO Objective Grading System (cast-radiograph evaluation: C­R Eval). RESULTS: The mean total ABO C­R Eval score was 16 ± 9.1 in the labial appliance group and 12.7 ± 5.4 in lingual appliance group (p = 0.152). The mean total ABO-DI scores were 16.3 ± 7.3 and 15.4 ± 6.6 in the labial and lingual appliance groups, respectively (p = 0.445). A significant correlation was observed between the total DI and total C­R Eval scores. CONCLUSIONS: In this particular study and in the hands of two experienced orthodontists, no differences in the finishing quality of orthodontic treatments using the lingual technique or the buccal appliance technique were found. However, further prospective studies with larger sample sizes are necessary in order to generalize these results.

Does Non-Surgical Periodontal Treatment Improve Glycemic Control? A Comprehensive Review of Meta-Analyses.

AIM: Periodontal treatment is reported to be associated with an improved periodontal condition in diabetic patients. Therefore, a comprehensive review of meta-analyses was conducted to evaluate whether periodontal treatment can improve glycemic control in patients with type 2 diabetes. MATERIALS AND METHODS: The search on electronic databases included PubMed-Medline, Cochrane Library, Scopus, and LILACS databases. The methodological quality of the systematic reviews was evaluated using AMSTAR, and primary studies were performed in accordance with PRISMA guidelines. The weighted mean difference (WMD) was calculated, nested in a random-effects model with corresponding Z scores, p-values, and 95% confidence intervals. RESULTS: A total of 11 meta-analyses were included, and a meta-analysis of 11 primary studies comprising a total of 1341 participants was carried out. All the studies evaluated glycosylated hemoglobin (Hb1Ac), and 6 of the 11 publications evaluated fasting plasma glucose (FPG). The AMSTAR scores ranged between 9 and 11, with a median of 10.3. Statistically significant reductions were observed in HbA1c values [-0.32% (3.5 mmol/ mol); 95%CI: -0.50 to -0.15] and FPG values (-11.59 mg/dl; 95%CI: -15.16 to -8.01). CONCLUSION: The review of currently available clinical studies concludes that periodontal treatment is associated with improved glycemic control in patients with type 2 diabetes. New guidelines, including periodontal treatment as a routine public health measure to improve glycemic control in diabetic patients, would be of great value.

Clinical efficacy of xenogeneic and allogeneic 3D matrix in the management of gingival recession: a systematic review and meta-analysis.

OBJECTIVE: A systematic review and meta-analysis was thus conducted to answer the following focused question based on PICO strategy: Is there any 3D matrix biomaterial used for root coverage of human Miller class I and II defects equivalent with the connective tissue graft in localized defects of at least 2 mm and 3 mm? MATERIAL AND METHODS: The search on electronic database included MEDLINE, Cochrane Central Register of Controlled Trials, Clinical Trials.gov, Web of Science, and New Zealand/Australian Clinical Trials. Only randomized clinical trials (RCTs) that compared connective tissue graft (CTG) with at least one 3D matrix alone for root coverage in Class I and II Miller localized defects of at least 2 mm, with at least 6 months follow-up, were included in this systematic review. RESULTS: A total of 14 studies were included for meta-analysis (12 compared CTG with acellular dermal matrix allograft and 2 compared CTG with Xenogenic Collagen Matrix). Relative root coverage showed no significant difference among the materials, for either 2 or 3 mm minimal recessions. For keratinized tissue width, on 2 mm recessions, CTG showed superiority above other biomaterials, but on 3 mm recessions, it seemed to have the same results. The percentage of recessions with complete root coverage for both 2 and 3 mm recessions showed similar results for all biomaterials. CONCLUSIONS: With their limits, the present data concluded that CTG, acellular dermal matrix allograft, and xenogenic collagen matrix provided similar results for root coverage. CLINICAL RELEVANCE: To know if there is a 3D matrix with equivalent predictable results for root coverage, that we could avoid the morbidity of the connective tissue graft for these cases.

Evaluation of the maxillary midline, curve of the upper lip, smile line and tooth shape: a prospective study of 140 Caucasian patients.

BACKGROUND: A number of reference patterns such as the interincisal line, curve of the upper lip, width of the smile or shape of the teeth have been studied in different populations. Determining the frequency of different smile aesthetic parameters in a European Caucasian population and exploring possible gender differences is important in order to obtain predictable treatment outcomes. METHODS: Photographs were obtained under resting and forced smiling conditions in 140 individuals (70 males and 70 females) with a mean age of 20.1 ± 4.3 years. Different variables were recorded, including the position of the maxillary interincisal midline in relation to the facial midline, the arc and width of the smile, and the shape of the teeth. The data were processed using the SPSS version 15.0 statistical package, with application of the chi-squared test and a confidence level of 95%. The statistical power was 80%, and the level of significance 5% (α = 0.05). RESULTS: A total of 94.3% of the sample presented a maxillary interincisal midline coinciding with the facial midline, and 80% had a consonant smile line. The curve of the upper lip was upwards in 47.1% of the cases, followed by a straight curve in 41.4%. Most of the subjects (84.3%) presented a medium smile line with tooth exposure to the second premolar (61.4%). There were no significant differences between males and females. CONCLUSIONS: The integration of aesthetic criteria is needed in order to guarantee satisfactory and predictable dental treatment outcomes. There were no statistically significant differences between males and females. The maxillary interincisal midline coincided with the facial midline, with a consonant smile arc and a medium smile line, upward lip curve and oval tooth shape.

Combined Near-Infrarred Light Transillumination and Direct Digital Radiography Increases Diagnostic In Approximal Caries.

The objective of this study was to evaluate the clinical ability of Near-Infrared Light-Transillumination (NILT) for approximal dentinal caries detection and to compare with direct digital-radiography (DDR), as well as to determine whether the combination of both techniques improves the diagnostic capacity of the lesions. From 88 patients (over 18 years), 138 posterior teeth (76 molars and 62 premolars), that had approximal caries reached into dentine determined by DDR, were included. Lesion extension and DDR images were scored as follows: D0 = sound surface, D1/D2 = caries restricted to the outer/inner-half of the enamel, and D3/4 = caries restricted to the outer/inner-half of the dentin. Opening of the approximal surface using 0.5 mm-in-diameter diamond-bar was used as gold-standard. The lesion extension was then determined by the following criteria: no dentinal caries (D0/1/2) or dentinal caries (D3/4). Seventy-one lesions were D3 and 67 lesions were D4. Sensitivities of overall/D3/D4 were 98.0/95.7/100.0 (NILT) and 100/100/100 (DDR), respectively. Correlations with gold-standard were 0.92 (NILT) and 0.42 (DDR), respectively. The correlation increased to 0.97 (p = 0.045) on combining NILT and DDR. There was no difference in sensitivity between the methods (p > 0.05); but was differences in the correlation (p < 0.01). It can be concluded that NILT showed sensitivity similar to that of DDR and higher correlation than DDR for approximal dentinal caries detection. Accordingly, it may be used to monitor the progression of caries without exposing the patient to ionizing radiation, this being of particular interest in growing patients and in pregnant women. In this respect, NILT can be an effective diagnostic tool adjunctive to bitewing radiographs in detecting approximal dentinal caries. The combination of NILT and DDR represents an increase in the diagnosis of approximal lesions The proposed diagnostic protocol comprises visual examination, followed by NILT and DDR only if the former technique detects approximal caries.

Effectiveness of lingual versus labial fixed appliances in adults according to the Peer Assessment Rating index.

INTRODUCTION: The purpose of this study was to compare the effectiveness of lingual treatment and labial fixed appliances in the treatment of adult orthodontic patients. METHODS: We conducted a retrospective study of 72 patients. The Peer Assessment Rating (PAR) index was measured at the start (T0) and end (T1) of treatment. Significant differences between treatment means were determined by means of analysis of variancewith the Bonferroni correction or with the use of Fisher exact test. RESULTS: The lingual group had a mean pretreatment age of 28.6 ± 6.7 years, and the labial group had a pretreatment age of 26.6 ± 9.5 years. This difference was statistically not significant. The mean pre- and posttreatment PAR scores in the labial group were 22.9 ± 6.2 and 2.1 ± 2.3, respectively, and the mean pre- and posttreatment PAR scores in the lingual group were 26.5 ± 8.3 and 2.3 ± 2.5. There were no significant differences between the treatment groups. CONCLUSIONS: Lingual and labial appliances produced similar reductions in PAR scores. There was no difference in the posttreatment PAR scores between the lingual and labial treatment groups. Further studies involving larger sample sizes and longer follow-up periods are required to confirm the results obtained.

Revisiting the Maxillary Teeth in 384 Subjects Reveals A Deviation From the Classical Aesthetic Dimensions.

Dental esthetics need to be defined from the scientific perspective in order to obtain predictable treatment outcomes and avoid the effects of subjectivisms on the part of the dental profesional. It can be deduced that the ideal dimensions in the maxillary anterior sector are difficult to establish. Therefore, the primary purpose of this study was to define the dimensions of the maxillary anterior teeth and the relationships between them. In addition, an analysis was made to reinvestigate whether they complied with the Golden proportion, the RED (Recurrent Esthetic Dental) proportion and the Golden percentage. A total of 2304 tooth corresponding to 384 subjects were evaluated. The central incisor presented a mean width of 8.58 mm and a height of 9.35 mm, while the lateral incisor presented a width of 6.69 mm and a height of 7.75 mm. The mean width of the canine was 7.69 mm, with a height of 8.68 mm. The teeth revisited in this study did not comply with the ideal dimensions in the anterior maxillary sector as established by the Golden proportion, Golden percentage and RED. The information obtained from this study can be clinically applied to restore the dimensions during periodontal surgery, restorative dentistry and prosthetic rehabilitation.

Comparison of peri-implant soft tissues in submerged versus transmucosal healing: A split mouth prospective immunohistochemical study.

OBJECTIVE: The present split-mouth prospective study involves an immunohistochemical evaluation of peri-implant soft tissue healing after the osseointegration period, comparing submerged and transmucosal approaches using two-piece implant systems. The null hypothesis was that both surgical procedures elicit a similar immune response of the peri-implant soft tissues. DESIGN: Thirty-one healthy patients were included in this study, in which two implants were placed in the right and left maxillary pre-molar regions. A total of 62 dental implants were analyzed, establishing a control side with 31 submerged implants, and a study side with 31 exposed implants bearing healing abutments. After a three-month healing period, a soft tissue biopsy was collected and prepared for immunohistochemical analysis of the proportions of different lymphocyte subpopulations. RESULTS: The comparative analysis between the submerged and transmucosal approaches failed to identify statistically significant differences in CD19+ B cells, CD4+ T cells, CD8+ T cells, CD25+ T cells or γd T cells. However, significant differences in NK lymphocytes (p = 0.012) were recorded with the submerged surgical procedure. CONCLUSIONS: Peri-implant soft tissue immune response with submerged or transmucosal healing protocols demonstrated comparable outcomes after the osseointegration period. There is sufficient evidence that the null hypothesis of no difference cannot be rejected. To the best of our knowledge, this is the first study of its kind. Further research is therefore needed to further clarify the role of these lymphocyte subpopulations in peri-implant soft tissues.

Histopathological comparison of healing after maxillary sinus augmentation using xenograft mixed with autogenous bone versus allograft mixed with autogenous bone.

OBJECTIVE: To compare the clinical and histologic outcomes of two different grafting materials (allograft and xenograft) when combined with autogenous bone and covered with a collagen membrane for sinus augmentation. MATERIAL AND METHODS: A parallel case series of fourteen patients in need of a unilateral sinus augmentation was evaluated in this study. Seven patients received a graft composed by autologous cortical bone (ACB) and anorganic bovine bone in a ratio of 1:1; the other seven patients received ACB mixed with an allograft in the same ratio. Bone biopsies were obtained 6 months after sinus augmentation at the time of implant placement. Comparative histomorphometrical, histopathological, and immunohistochemical analyses were conducted and statistically analyzed. RESULTS: After 12 months of functional loading, all implants in both groups were clinical and radiographically successful. Histomorphometrically, although the initial bone formation was not significantly different between groups (new mineralized tissue: 41.03(12.87)% vs. 34.50(13.18)%, p = .620; allograft vs. xenograft groups), the graft resorbed faster in the allograft group (remnant graft particles: 9.83[7.77]% vs. 21.71[17.88]%; p = .026; allograft vs. xenograft groups). Non-mineralized tissue did not statistically differ either (49.00[14.32]% vs. 43.79[19.90]%; p = .710; allograft vs. xenograft groups). The histologic analyses revealed higher cellular content, four times more osteoid lines, and higher vascularization in the xenograft group. Musashi-1 (mesenchymal stromal cell marker) was also more intensively expressed in the xenograft group (p = .019). CONCLUSIONS: Both composite grafts generate adequate substratum to receive dental implants after healing. Compared with the xenograft composite, allograft composite shows faster turnover and a quicker decrease in biological action after 6 months.

Are there differences in treatment effects between labial and lingual fixed orthodontic appliances? A systematic review and meta-analysis.

BACKGROUND: An evaluation is made of possible differences in treatment effects between labial and lingual fixed appliances. METHODS: A comprehensive search was made of the PubMed-Medline, Cochrane Library and LILACS databases, with an additional manual search covering the period up until April 2017. There were no restrictions in terms of year of publication or language. Agreement between the authors was quantified by the Cohen kappa statistic. A random-effect model was applied to calculate weighted mean differences with 95% confidence intervals. RESULTS: A total of 249 patients corresponding to four eligible studies were included in the systematic review. Among the six angles and distances entered in the meta-analysis, a tendency was observed in lingual appliances to increase the interincisal angle (95% CI -0.80-8.99; p = 0.101) and reduce the angle between the major axis of upper central incisor and the sellar-nasion plane - though statistical significance was not reached (95% CI -5.75-0.32; p = 0.079). CONCLUSION: The results obtained indicate that treatment with lingual appliances favors incisor tipping by exerting lingual crown torque, but there are no differences in cephalometric values between labial and lingual fixed appliances. Because of the small number of included studies, the results of this meta-analysis should be interpreted with caution. Future research should focus on the generation of a consensus document allowing selection of the type of orthodontic approach not only conditioned to the esthetic requirements of the patient but also considering the characteristics of the malocclusion. On the other hand, standardized international guidelines are lacking; the measurements of angles and distances therefore have to be unified with a view to future investigations.

Caries diagnosis using light fluorescence devices in comparison with traditional visual and tactile evaluation: a prospective study in 152 patients.

The objective of the study was to evaluate the in vivo effectiveness of two fluorescence techniques (DIAGNOdent and VistaProof) and of visual and tactile evaluation in the diagnosis of occlusal caries in permanent teeth. A total of 302 teeth (molars and premolars) from 152 patients were studied. The occlusal surfaces were cleaned using pumice mixed with water, followed by application of the diagnostic methods according to the instructions of the manufacturer, and of the visual and tactile methods according to the recommendations. The true extent of the lesions was determined by fissurotomy. The sensitivity and specificity of visual diagnosis were 79 and 72 %, respectively, versus 53 and 98 % in the case of tactile diagnosis. Teeth with caries lesions exhibited significantly higher DIAGNOdent and VistaProof scores than those without caries. Using the optimum cutoff point of 23.5 obtained in our study for DIAGNOdent, sensitivity and specificity were found to be 92.4 and 92.7 %, respectively, while values of 88.1 and 95.1 % were obtained with a cutoff point of 28.5. Sensitivity in the case of the VistaProof system varied between 92.9 % (cutoff point 1.05) and 85.3 % (cutoff point 1.3), with respective specificity values of 95.8 and 88.6 %. The areas under the curve were 0.756, 0.759, 0.954 and 0.965 for the visual and tactile methods and for DIAGNOdent and VistaProof, respectively. The fluorescence-based techniques showed greater internal and external validity than the visual and tactile methods in diagnosing occlusal caries in permanent teeth. VistaProof is the best method for diagnosing caries in its early stages.

Accuracy of the estimation of dental age in comparison with chronological age in a Spanish sample of 2641 living subjects using the Demirjian and Nolla methods.

Age estimation is an important procedure in forensic medicine and is carried out for a number of reasons. For living persons, age estimation is performed in order to assess whether a child has attained the age of criminal responsibility, in scenarios involving rape, kidnapping or marriage, in premature births, adoption procedures, illegal immigration, pediatric endocrine diseases and orthodontic malocclusion, as well as in circumstances in which the birth certificate is not available or the records are suspect. According to data from the UNHCR (United Nations High Commissioner for Refugees), the number of people seeking refugee status continued to increase in the last years, driven by the wars in Syria and Iraq, as well as by conflict and instability in Afghanistan, Eritrea and elsewhere. The objective of this study is to compare the accuracy of estimating dental age versus chronological age using the Nolla and Demirjian methods in a Spanish population. A final sample of 2641 panoramic X-rays corresponding to Spanish patients (1322 males and 1319 females) between 7-21 years of age was analyzed. Dental age was assessed using the Nolla and Demirjian methods, establishing comparisons with mean chronological age based on the Student t-test for paired samples, followed by the generation of a linear regression model. Both methods showed slight discrepancy between dental and chronological age. On examining the reproducibility of the Nolla and Demirjian methods, technical errors of 0.84% and 0.62%, respectively, were observed. On average, the Nolla method was found to estimate an age 0.213years younger than the chronological age, while the Demirjian method estimated an age 0.853years older than the chronological age. Linear combination of the mean Nolla and Demirjian estimates increased the predictive capacity to 99.2%. In conclusion the Nolla and Demirjian methods were found to be accurate in estimating chronological age from dental age in a Spanish population. The error was found to be greater in males than in females, and involved an over-estimation of age with the Demirjian method and under-estimation of age with the Nolla method. Combination of the Nolla and Demirjian methods for estimating chronological age from dental age affords a predictive capacity of over 99%, and is fast and easy to perform, and inexpensive.

Adverse effects of lingual and buccal orthodontic techniques: A systematic review and meta-analysis.

INTRODUCTION: The aim of this systematic review was to assess the prevalence of adverse effects associated with lingual and buccal fixed orthodontic techniques. METHODS: Two authors searched the PubMed, EMBASE, Cochrane Library, and LILACS databases up to October 2014. Agreement between the authors was quantified by the Cohen kappa statistic. The following variables were analyzed: pain, caries, eating and speech difficulties, and oral hygiene. The Newcastle-Ottawa scale was used to assess risk of bias in nonrandomized studies, and the Cochrane Collaboration's tool for assessing risk of bias was used for randomized controlled trials. RESULTS: Eight articles were included in this systematic review. Meta-analysis showed a statistically greater risk of pain of the tongue (odds ratio [OR], 28.32; 95% confidence interval [95% CI], 8.60-93.28; P <0.001), cheeks (OR, 0.087; 95% CI, 0.036-0.213; P <0.0010), and lips (OR, 0.13; 95% CI, 0.04-0.39; P <0.001), as well as for the variables of speech difficulties (OR, 9.39; 95% CI, 3.78-23.33; P <0.001) and oral hygiene (OR, 3.49; 95% CI, 1.02-11.95; P = 0.047) with lingual orthodontics. However, no statistical difference was found with respect to eating difficulties (OR, 3.74; 95% CI, 0.86-16.28; P = 0.079) and caries (OR, 1.15; 95% CI, 0.17-7.69; P = 0.814 [Streptococcus mutans] and OR, 0.67; 95% CI, 0.20-2.23; P = 0.515 [Lactobacillus]). CONCLUSIONS: This systematic review suggests that patients wearing lingual appliances have more pain, speech difficulties, and problems in maintaining adequate oral hygiene, although no differences for eating and caries risk were identified. Further prospective studies involving larger sample sizes and longer follow-up periods are needed to confirm these results.