Comparison of acceptability of orthodontic appliances in children in mixed dentition treated with removable acrylic appliances and Invisalign first: a cross-sectional study

Abstract

Purpose

This study aimed to compare the acceptability of removable acrylic appliances (RA) and Invisalign First (IF) clear aligners (Aligntech, USA) among children undergoing orthodontic treatment during the mixed dentition period, considering the severity of malocclusions.

Methods

A total of 40 patients, aged 6 to 13 years, were recruited for the study. Malocclusion severity was evaluated using the Index of Orthodontic Treatment Need-Dental Health Component (IOTN-DHC). Patients completed the "Acceptance of Orthodontic Appliance Scale (AOAS)" via a face-to-face Google survey. To assess the reliability of the AOAS, the survey was resent to five patients after three months for a second response, and reliability analysis was conducted. Additionally, inter-rater reliability was evaluated by having all patients independently assessed by a second researcher. Data were analyzed using SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA), with statistical significance set at p < 0.05.

Results

Although no significant difference was found in IOTN-DHC scores, the IF group demonstrated significantly higher AOAS scores compared to the RA group (p = 0.014). Survey responses revealed noticeable distinctions between groups regarding speaking discomfort, preference for orthodontic appliances, and facial appearance comfort. A negative correlation (r = -0.477, p = 0.034) was observed between malocclusion severity and appliance acceptance.

Clinical significance

This study underscores the significant superiority and advantage of IF over RA among pediatric orthodontic patients during the mixed dentition period.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-024-05059-y.

Introduction

Removable acrylic appliances (RA) are often favored for treating malocclusions in children primarily due to their cost-effectiveness [1]. However, the effectiveness, ultimate success or failure of the treatment hinges significantly on patient compliance and acceptance of the appliances. Despite their economic advantages, clinical findings show that pediatric patients have difficulty adjusting to these appliances due to their size and unfixed positioning inside the mouth, excessive tactile stimulation, pressure on mucous membranes, soft tissue tension, restricted tongue movement, and challenges in swallowing, breathing, and speaking, along with aesthetic concerns that can adversely impact both compliance and acceptance [2]. Also, determining the need for orthodontic treatment emerges as a critical factor influencing the acceptability of these appliances. Previous research has suggested a correlation between the Index of Orthodontic Treatment Need-Dental Health Component (IOTN-DHC) values and patient cooperation. Patients with lower IOTN-DHC values exhibit decreased cooperation with removable appliances, while those with severe malocclusions demonstrate varying levels of cooperation [3]. These findings highlight the importance of early identification of treatment needs, serving as a valuable guide in selecting the appropriate type of orthodontic appliance during the diagnostic stage.

Clear aligner treatment represents a contemporary advancement in orthodontics that has rapidly garnered global popularity. This surge in preference can be attributed partly to extensive company advertising and the allure of ‘invisible’ orthodontics perceived by patients. As a removable and transparent orthodontic appliance, clear aligners have gained acclaim for their aesthetic appeal and effectiveness in addressing mild to moderate malocclusions. Notably, clear aligners, a prevalent choice in adult orthodontics, have expanded their utility to cater to pediatric patients through innovations as “Invisalign First”. Tailored for growing jaws and erupting teeth, Invisalign First comprises a set of clear aligners designed to gently guide teeth and jaws into their correct positions, and aligners also require compliance to the treatment.

No matter which treatment system is used, the viability of an appliances is highly dependent to its capacity to be adapted by patients and to be comfortable for consistent usage. If a device doesn’t facilitate rapid adaptation and comfortable wear, patients are less likely to comply, leading to not achieving desired results and prolonged treatment duration. Therefore, evaluating the acceptability of an appliance is crucial for ensuring compliance and ultimately treatment success. Recent investigations have explored the effects of fixed orthodontic treatment and Invisalign on adult patients [4], and assessed the acceptability of Invisalign and twin block systems in class 2 patients [5]. Although studies have evaluated the acceptability of removable appliances based on general self-efficacy scales and orthodontic treatment need indicators [6], there is a notable absence of research examining how the acceptability of different treatment modalities is influenced by the severity of malocclusion and the need for orthodontic treatment in pediatric patients. This study seeks to address this gap by comparing the acceptability of removable orthodontic appliances and the Invisalign First system, both utilized during the mixed dentition period, with a particular emphasis on considering the severity of malocclusions. Therefore, the aim of this study is to compare the acceptability of removable acrylic appliances (RA) and Invisalign First (IF) clear aligners among pediatric patients, while assessing how malocclusion severity influences appliance acceptance and compliance.

Material and methods

Study design and participants

This study evaluated 40 patients aged between 6 and 13, with 20 patients treated with a removable appliance RA and 20 patients treated with IF. Patients were randomly selected through a manual process from the pool of eligible participants at each clinic to minimize selection bias. To ensure geographic diversity, patients were equally recruited from two private dental clinics located on the European and Asian sides of Istanbul, Turkey.

Following the withdrawal of one IF patient from the Asian-side clinic, the final sample size consisted of 20 patients per clinic. Both clinics maintained an equal distribution: 10 patients using RA and 10 using IF. This ensured balanced representation of both treatment modalities across the study.

Sample size determination

A power analysis was conducted to determine the required sample size for this study, based on an assumed 70% success rate in both the standard and experimental treatment groups. It was aimed to achieve 80% confidence that a two-sided 90% confidence interval would exclude differences greater than 50% between the groups. Consequently, a total of 30 patients (n=15 per group) were required to attain this level of statistical confidence.

Ethical considerations

The study adhered to the principles outlined in the Declaration of Helsinki, and ethical approval was obtained from the Istanbul Gelisim University Ethics Committee (protocol #2023-08). Informed consent was obtained from the parents of all participating children.

Inclusion and exclusion criteria

The inclusion criteria comprised children aged between 6 and 13, who were systemically healthy and diagnosed with orthodontic malocclusion. In mixed dentition, appliances were primarily used to address crowding, maxillary and mandibular narrowness, and crossbite.

Participants were required to have no prior orthodontic treatment and to have completed either RA or IF treatment. The exclusion criteria included children with mental or physical disabilities, as well as those with periodontal disease.

One patient, a 13-year-old female from the IF group with a history of psychological disorder, was excluded from the study to mitigate potential bias. Two weeks following the completion of the survey, she informed her physician of her desire to withdraw from the study. Consequently, the final study sample consisted of 40 volunteer participants.

Types of appliances used

This study included patients with orthodontic conditions such as crowding, narrow arches, and crossbite, but who did not require mandibular functional advancement (e.g., twinblock appliances or MA precision cuts in IF). The doctor presented two appliances, outlining their respective advantages, disadvantages, and costs. The final choice of appliance, whether RA or IF, was made collaboratively between the parent and patient.

For the RA group

In the RA group, Hawley appliances with components like expansion screws and/or Z springs was used. These appliances were selected to address issues such as dental arch expansion, minor crossbites, and crowding. Patients were instructed to wear their appliances or clear aligners throughout the day, except during meals, to ensure effective treatment outcomes.

For the IF group

In the IF group, aligners was utilized to manage similar orthodontic issues, focusing on the alignment of teeth and correction of mild to moderate malocclusions. Aligners were chosen for their ability to provide a more aesthetic and comfortable alternative to traditional appliances, with the treatment plan tailored to the specific needs of each patient. Patients were advised to wear the aligners throughout the day and night, except when eating or drinking, to achieve optimal results.

Treating dentists

Two treating dentists were involved in this study: a 10-year clinically experienced pediatric dentist (EEK) and a 10-year clinically experienced orthodontist (GDG). Both clinicians specialize in orthodontic treatment during the mixed dentition period and have extensive experience in treating children on a daily basis. Despite their different specialties, both clinicians have worked closely together for 2 years as assistant professors in the orthodontics and pediatric dentistry department at the same institution. During this time, they collaborated on cases involving early orthodontic treatment, particularly in mixed dentition, ensuring a consistent and complementary approach to patient care. This collaboration ensured that both the pediatric and orthodontic perspectives were integrated into the treatment protocols, which were applied uniformly across the two clinics in this study. Their combined expertise and unified approach to treating mixed dentition period patients strengthen the consistency and reliability of the treatment outcomes in this study.

Study procedure and evaluation

Participants were provided detailed explanations of all procedures, and written consent forms were obtained from their parents before the study commenced. The severity of malocclusion was assessed by the treating dentists (EEK & GDG) using the Index of Orthodontic Treatment Need-Dental Health Component (IOTN-DHC) based on patient records.

Following the assessment, participants completed the "Acceptance of Orthodontic Appliance Scale" (AOAS) via a Google survey form, which collected demographic data and treatment experiences. The AOAS consisted of 5 questions related to demographic data and 10 questions regarding treatment experiences. Participants were accompanied by their parent while responding to the questionnaire.

The survey utilized a 6-point Likert scale for the 10 treatment-related questions (Supplementary Information Table S1), with each response accompanied by a corresponding facial expression to enhance comprehension as developed by Naseri et al. [6] The patients filled out the questionnaires during their control visits after their orthodontic treatment had been completed. This timing was chosen to ensure that the patients had experienced the full impact of the treatment before providing their feedback. To assess reliability, the same questionnaire was administered to five randomly selected patients three months after they first responded to the survey. The results indicated an 88% consistency between the two time points, demonstrating strong stability in patients’ self-reports over time. At the time of the second administration, no new aligner had been delivered, nor had there been any activation of the expansion screw. Although the Turkish version of the "Acceptance of Orthodontic Appliance Scale" has not been specifically validated in the Turkish population, the original scale developed by Naseri et al. has established scientific validity. We selected this questionnaire for its robustness and adapted it for our study by incorporating internationally recognized WhatsApp emojis. These emojis were included to facilitate understanding and engagement for our 6-13 year-old patient demographic, ensuring comprehensibility and accessibility without compromising the questionnaire’s original intent and structure. We opted not to use overly long or complex questionnaires due to the young age of our participants.

All patients’ IOTN-DHC assessments were independently evaluated by a second researcher to assess inter-rater reliability. The IOTN-DHC, developed by Brook and Shaw [7], records various occlusal features of malocclusion and rates the individual’s need for treatment based on the most prominent occlusal feature. The evaluation criteria are as follows:

• Grade 1: Individuals who do not require treatment

• Grade 2: Individuals with minimal treatment needs

• Grade 3: Individuals with borderline treatment needs

• Grades 4 and 5: Indicate individuals with a high need for treatment.

Statistical analysis

Data analysis was conducted using SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means and standard deviations, were employed for data summarization. To control for potential confounding factors such as age and gender, multivariate linear regression analysis was performed. For normally distributed variables, one-way analysis of variance (ANOVA) was applied, followed by pairwise comparisons without the use of post-hoc tests. Binary group comparisons were conducted using independent t-tests. The relationships between variables were assessed using Spearman’s rank correlation test for non-parametric data. The significance level was set at p < 0.05 to establish statistical significance.

Results

Distribution of RA and IF groups by age and sex was showed on Table 1. In the RA group (mean age: 9.90 ± 2.183 years), the mean IOTN-DHC score indicated moderate variability in orthodontic treatment need (3.30 ± 1.252), and the AOAS score suggested varied acceptance of orthodontic appliances (39.70 ± 9.370). For the IF group (mean age: 10.22 ± 1.563 years), the mean IOTN-DHS score reflected moderate variability in treatment need (3.44 ± 1.130), and the AOAS score indicated consistently high acceptance (45.22 ± 3.598). Statistical analyses revealed no significant difference in IOTN-DHC scores between RA and IF groups (p = 0.795). However, a notable difference was found in AOAS scores, with the IF group exhibiting a significantly higher mean score compared to the RA group (p = 0.014). Multivariate linear regression analysis revealed that the effects of age and gender on AOAS score were not statistically significant (p =0.547, p =0.662 respectively). However, the ‘groups’ variable exhibited a significant impact indicating a statistically significant association with AOAS score (p =0.037) (Table 2).

Table 1.

Distribution of RA and IF groups by age and sex

		Total		RA group		IF group		p
Age		10.05 ± 1.87		9.90 ± 2.18		10.22 ± 1.56		0.0281
Sex	Male	12	30%	6	30%	6	30%	p >0.052
	Female	28	70%	14	70%	14	70%

¹One Way Analysis of Variance

² Chi Square test

Table 2.

Mean, standard deviation, upper and lower bounds within 95% confidence interval, minimum, maximum values of IOTN-DHS score and AOAS scores and comparison by groups

Independent Samples t-test *p >0.05; **p=0.014

Upon conducting multivariate logistic regression analysis, it was found that neither age (p = 0.547) nor gender (p = 0.662) had statistically significant effects on AOAS score. However, the variable ‘groups’ demonstrated a notable impact (Coefficient = 7.1, SE = 3.1, Beta = 0.3, t = 2.28), indicating a statistically significant association with AOAS score (p = 0.037)

The intraclass correlation coefficient for the subset of patients who were asked to re-answer the survey after a three-month interval was found to be 0.88. This value indicates the level of agreement between patients’ initial responses and their responses upon re-administration of the survey, providing insight into the consistency of their ratings of orthodontic appliance acceptability over time. Survey responses highlighted distinctions between the groups. In terms of speaking discomfort, 70% of the IF group reported no issues, while only 40% in the RA group shared this sentiment. Additionally, liking orthodontic appliances showed a significant contrast, with 60% of the IF group expressing a high liking level (30% very much, %30 too much), compared to only 20% in the RA group (10% very much, 10% too much). Assessing facial appearance comfort, 70% of the IF group reported no issues, contrasting with 40% in the RA group (Table 3).

Table 3.

Survey responses

Questions.		Score 5 Doesn’t hurt all	Score 4 Hurts a bit	Score 3 Hurts a little	Score 2 Hurts	Score 1 Hurts too much	Score 0 Completely hurts
1. Speaking during using orthodontic appliance	RA	40%	30%	30%	0	0	0
	IF	70%	10%	10%	10%	0	0
2. Swallowing saliva during using orthodontic appliance	RA	60%	30%	0	0	10%	0
	IF	90%	10%	0	0	0	0
3. Oral and dental appearance during using orthodontic appliance	RA	40%	30%	0	0	0	30%
	IF	70%	30%	0	0	0	0
4. Facial appearance during using orthodontic appliance	RA	40%	20%	10%	0	0	30%
	IF	70%	20%	10%	0	0	0
5. Routine oral hygiene during orthodontic treatment	RA	80%	20%	0	0	0	0
	IF	70%	30%	0	0	0	0
6. Doing daily activities during using orthodontic appliance	RA	20%	30%	30%	10%	0	10%
	IF	70%	20%	10%	0	0	0
7. Sleeping during using orthodontic appliance	RA	50%	30%	10%	0	10%	0
	IF	80%	20%	0	0	0	0
8. Level of using orthodontic appliance	RA	70%	0	10%	20%	0	0
	IF	90%	0	10%	0	0	0
9. Level of liking orthodontic appliance	RA	10%	10%	50%	0	0	30%
	IF	30%	30%	20%	10%	0	10%
10. Level of liking to complete orthodontic treatment	RA	80%	10%	0	10%	0	0
	IF	70%	20%	0	10%		0

A correlation analysis was conducted to examine the relationship between IOTN-DHC and AOAS scores. The Pearson correlation coefficient revealed a moderate, negative correlation (r = -0.477, p = 0.034), indicating that as orthodontic treatment need severity increases, acceptance of orthodontic appliances tends to decrease. This relationship was statistically significant (p < 0.05) and consistent with the negative correlation coefficient presented in Table 4. Inter-rater reliability for IOTN-DHC measurements between the two researchers was high, with an intraclass correlation coefficient of 0.80.

Table 4.

Correlation between IOTN-DHS scores and AOAS scores

	IOTN-DHS score	AOAS score
IOTN-DHS Score	1	-0.477a
		(0.034)
AOAS Score	-0.477a	1
	(0.034)

^aCorrelation is significant at the 0.05 level (two-tailed)

Discussion

The age range of 6 to 13 years, encompassing both early and late mixed dentition phases, was specifically chosen due to its critical role in dental development, as both primary and permanent teeth coexist, facilitating timely orthodontic interventions. Traditionally, orthodontic treatment has been postponed until the full eruption of permanent teeth, based on the assumption that corrections are more effective in a fully developed dentition. However, contemporary advancements in orthodontics underscore the substantial benefits of early intervention during the mixed dentition period [8]. Procedures such as arch expansion, when appropriately timed, can create sufficient space for the eruption of permanent teeth, thus preventing the development of more severe malocclusions. Early treatment has also been shown to reduce, or even eliminate, the need for comprehensive orthodontic procedures in the permanent dentition phase. For example, 42% of patients treated during the early mixed dentition phase did not require a second phase of treatment, while 82% of early-treated patients avoided the need for tooth extractions in the permanent dentition [9]. Although it is important to explain the importance of this period to patients and ensure their compliance with the treatment, this study is also meaningful in terms of evaluating the factors arising from appliance designs and affecting the success of treatment. This study evaluates the acceptability of two apparatus systems used in this very important period by patients and therfore, this research is a timely and necessary study that adds to our understanding of orthodontic concerns.

The study utilized a 10-item questionnaire developed by Naseri et al. [6] to evaluate the acceptance levels of removable orthodontic appliances among children. This questionnaire allowed children to express their experiences, both positive and negative, by selecting the most appropriate response, supported by the use of emojis. The reliability of this questionnaire was confirmed by resending it to a randomly selected group of five patients, demonstrating good consistency with an ICC value indicating strong reliability.

While the severity of malocclusions, as evaluated by the IOTN-DHC, did not show significant differences between groups, the IF group exhibited notably higher scores on the AOAS compared to the RA group (p = 0.014). This suggests a heightened level of satisfaction and comfort with IF among pediatric patients during the mixed dentition period. Understanding the influence of malocclusion severity on appliance acceptability is pivotal for estimating treatment outcomes and developing strategies to sustain patient motivation throughout the treatment process. The present findings reveal a negative correlation between malocclusion severity and appliance acceptance, suggesting that patients with more severe malocclusions may struggle with adaptation and compliance, particularly when treatment duration is extended.

Although previous studies showed that children tend to prefer clear aligners over traditional removable appliances, citing reasons such as greater comfort and aesthetic appeal [4], beyond the children’s preferences, parents also play a critical role in treatment decisions, particularly concerning cost. While clear aligners are often more expensive than traditional removable appliances, many parents may weigh the potential benefits, such as increased compliance and reduced treatment time, against the higher cost. This balance between cost, comfort, and long-term outcomes is an important consideration in orthodontic treatment planning, making patient and parental preferences integral to the decision-making process. Additionally, parents’ behavior in motivating the patients regarding treatment. Brumini et al. [10] highlighted the potential impact of increased parental agreement and motivation for treatment on enhancing cooperation among preadolescents. Morever, independent of the choices made by children and parents, dental professionals must uphold ethical standards, prioritizing the patient’s well-being by making treatment decisions grounded in the best available research and clinical expertise. The appeal of Invisalign First is undeniable, favored by patients for its superior aesthetics and comfort, and by clinicians for its simplicity, safety, and accessibility, requiring minimal training to implement. In the present study, the physician gave information to the patient and parents about two different systems and the patient’s acceptability of the device was evaluated purely to illuminate the patient’s objective implications about the appliance choice and treatment outcome.

Naseri et al. [6] investigated 10 to 12-year-old patients to explore the correlation between the application of the general self-efficacy scale, the severity of malocclusion, and the acceptance of removable orthodontic appliances. They utilized a removable orthodontic appliance featuring a midline screw, a labial bow, and Adams or Delta clasps on posterior teeth. Unlike the present study, their findings did not reveal a significant correlation between IOTN and AOAS scores. In addition, it’s worth noting that the present study group comprised children younger than those in Naseri et al.’s study [6]. This age difference could potentially influence the relationship between malocclusion severity and appliance acceptance. Younger children may have lower tolerance for longer treatment durations associated with more severe malocclusions, leading to decreased acceptance. Therefore, the age of the patient, combined with the severity of the malocclusion, should be considered when planning orthodontic treatments, as it could affect both compliance and treatment success. Clinically, these findings suggest the need for more customized approaches in treatment planning. For patients with severe malocclusions, clinicians might consider offering additional support, such as regular check-ins, adjustments to appliance fit, or providing more comfortable alternatives like aligners. This patient-centered approach could help improve appliance acceptance, even in cases where malocclusion severity is high, ultimately leading to better treatment outcomes.

Torsello et al. [11] aimed to analyze the factors affecting patients’ compliance with orthodontic treatments, including the wearing of removable devices or clear aligners. It was showed that compliance is influenced by patient-related factors such as age, personality traits, the importance of personal appearance, and self-perception of malocclusion. Notably, pre-pubertal patients often exhibit external motivation for treatment, while adolescents and young adults demonstrate more intrinsic motivation. This underscores the importance of considering age-related factors in assessing treatment outcomes and patient satisfaction.

Dianiskova et al.’s study [12] compared elastodontic appliances and clear aligners in terms of patient and parental satisfaction following treatment during mixed dentition. According to parental reporting, treatment with elastodontic appliances was perceived as significantly more painful compared to clear aligner therapy, although this discrepancy was not confirmed by the patients themselves. Both parents and patients reported that elastodontic appliances were significantly more challenging to wear than clear aligners. Despite these challenges, the present study findings align with the notion of differing patient experiences with different orthodontic appliances. In the present survey responses, more than half of the IF group expressed a high liking level compared to the RA group. Examining comfort related to facial appearance, a majority of participants in the IF group reported no discomfort, whereas this figure was lower among participants in the RA group. Specifically, a higher acceptance score in the IF group compared to the RA group was observed. This suggests that while patient-reported difficulties may vary between appliance types, overall acceptance levels may be influenced by factors beyond perceived discomfort, such as; aesthetics, convenience, and treatment duration.

The findings from Zybutz et al.’s study [5] comparing patient experiences with Invisalign Teen and Twinblock appliances emphasized the importance of patient comfort and adaptability to orthodontic treatment. Notably, a higher percentage of patients using the Twinblock appliance reported visual intimidation and embarrassment compared to those using Invisalign Teen. Additionally, challenges with inserting the Twinblock appliance and increased soreness were reported, along with a higher proportion requiring extra appointments for appliance breakage. However, both groups experienced initial difficulties with speech, drooling, and soreness, which improved over time. These results are consistent with previous research highlighting the impact of appliance design and comfort on patient compliance and treatment outcomes. Proffit et al. [13] emphasized the importance of orthodontic appliances that do not interfere with occlusion or hygiene and are capable of withstanding masticatory forces while being firmly retained. While removable appliances offer advantages in terms of simplicity and differential tooth movement, challenges related to patient adaptation and compliance remain significant.

A very recent study explored publicly available Instagram posts related to clear aligner therapy, categorizing them into three groups: before, during, and after treatment. The study found that 90% of posts before treatment were positive. However, during treatment, the sentiment shifted, with 54.8% of posts being negative compared to 45.2% positive. Post-treatment posts predominantly reflected positive sentiments (60%) regarding treatment outcomes and the patient-clinician relationship, though negative feedback was noted concerning treatment duration, cost, and distrust towards the dentist. Although the mean age of the patients in this social media study is unknown, the present study findings indicate high satisfaction among pediatric patients following clear aligner treatment [14].

While the present study offers valuable insights into the acceptability of orthodontic appliances among pediatric patients, it is crucial to acknowledge several limitations. One notable limitation is the relatively small sample size, which may restrict the generalizability of the findings. Additionally, the study only elicited responses from children themselves, without incorporating input from their parents. Further research with larger sample sizes is warranted to validate the observed relationships and explore additional factors influencing patient experiences, such as socioeconomic status, cultural differences, or specific orthodontic conditions. Although the importance of these variables was acknowledged, specific data on the cultural or socioeconomic backgrounds of the patients were not collected. However, both clinics involved in the study were private, in an area where people with similar socioeconomic income live. Additionally, all patients paid for their orthodontic treatment out-of-pocket, with no insurance contributions. This payment structure suggests that the socioeconomic status of the participants was likely in the medium to high range, potentially minimizing the influence of lower income levels on appliance acceptance. Future research should address this gap by stratifying data based on cultural and socioeconomic variables or conducting subgroup analyses to identify any disparities or unique trends that could provide a more comprehensive understanding of appliance acceptance. Additionally, the present study focused on short-term outcomes, and future research could benefit from longitudinal studies to assess the long-term effects of appliance acceptability on treatment outcomes and patient satisfaction. Another limitation is that the Turkish version of the "Acceptance of Orthodontic Appliance Scale" used in the present study has not been specifically validated in the Turkish population. However, this questionnaire was selected for its established scientific validity, as developed by Naseri et al., to facilitate understanding and engagement of young patient demographic, that incorporated internationally recognized WhatsApp emojis.

In conclusion, this study provides valuable insights into the acceptability of orthodontic appliances among pediatric patients undergoing treatment with RA or IF clear aligners. Despite no significant difference found in the severity of malocclusion between the two groups, the present results demonstrate a significant preference for IF over RA in terms of appliance acceptance. Notable distinctions were observed in patient-reported outcomes, including speaking discomfort, liking for orthodontic appliances, and facial appearance comfort, with the IF group exhibiting higher levels of satisfaction. Furthermore, the negative correlation between malocclusion severity and appliance acceptance underscores the importance of considering patient preferences and comfort levels in orthodontic treatment planning. Based on the results of the study, due to compliance tends to drop in more complex cases and adherence with RA is generally lower compared to Invisalign First IF, it would be more prudent for clinicians to recommend IF in challenging cases, despite the higher costs, to optimize treatment outcomes.

Abbreviations

RA

Removable acrylic orthodontic appliances

IF

Invisalign First

IOTN-DHC

Orthodontic Treatment Need-Dental Health Component

AOAS

Acceptance of Orthodontic Appliance Scale

Authors’ contributions

EEK and GDG contributed to the study design, measurement, and evaluation. EEK analyzed the data and drafted the manuscript. GDG revised the paper. All authors approved the final version for publication.

Funding

No grant/ funding was received for this study.

Data availability

The raw data is available upon request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study adhered to the principles outlined in the Declaration of Helsinki, and ethical approval was obtained from the Istanbul Gelisim University Ethics Committee (protocol #2023-08). Informed consent was obtained from the parents of all participating children.

Consent for publication

Consent for publication is not applicable.

Competing interests

The authors declare no competing interests.