© September 2024 | IJIRT | Volume 11 Issue 4 | ISSN: 2349-6002

Clear Aligners with Not-So-Clear Disposal

DR. MAMTA BISHNOI1, DR. KAMAL BAJAJ2, DR. SIDDHARTH MEHTA3
1 rd
3 Year Post Graduate, Department of Orthodontics and Dentofacial Orthopaedic, Mahatma
Gandhi Dental College and Hospital, Jaipur
2
HOD and Professor, Department of Orthodontics and Dentofacial Orthopaedics, Mahatma Gandhi
Dental College and Hospital, Jaipur
3
Professor, Department of Orthodontics and Dentofacial Orthopaedics, Mahatma Gandhi Dental
College and Hospital, Jaipur

Abstract—This study investigates orthodontists' awareness As the popularity of Clear Aligners grows, so does the
of clear aligner material's effect on the environment and need to manage their disposal effectively. This study
disposal of plastic waste generated from Clear Aligner aims to evaluate the knowledge, attitudes, and
Therapy (CAT) in India. Methods: An electronic
practices regarding Clear Aligner waste and to
questionnaire was distributed online to gather information
encourage proper disposal methods among clinicians
about the materials used in Clear Aligners, their
properties, environmental impact, and disposal practices. and patients. By understanding current practices and
Results: Orthodontists are generally aware of the material challenges, we hope to find ways to reduce the
properties of Clear Aligners, but many lack clear environmental impact of Clear Aligners.
guidelines on proper waste disposal and its environmental
effects. Conclusions: There is a need for strict disposal II. MATERIALS AND METHODS
guidelines for Clear Aligner waste, making it more
environmentally friendly. This is a cross-sectional study involving Orthodontists
and general practitioners. The questionnaire was
Index Terms—Biomedical, Clear Aligner, Environment
initially developed digitally and validated by a group
safety, Plastic material, Waste disposal.
of orthodontists before distribution. It included 20
I. INTRODUCTION questions—19 closed-ended and 1 open-ended.

Clear Aligners have transformed orthodontic Questionnaire

treatment, offering a discreet and flexible alternative Ques 1: Why are Clear Aligners trending nowadays?
to traditional braces. These aligners are primarily Your answer:
made of plastics like PET, PETG, and TPU1. The • Convenient to the patient
characteristics of materials used for aligner trays are • Convenient to Dentist
Transparency, flexibility, elasticity, durability with Ques 2: Why do patients prefer Clear Aligners over
optimum strength, and thermal stability. The conventional braces? Your answer:
thermoplastic materials used in clear aligners are • Convenience
amenable to modern manufacturing techniques, • Esthetics
including 3D printing and thermoforming. This • Accuracy of treatment
adaptability allows for precise customization and rapid Ques 3: Which material is used in Clear Aligner
production, facilitating tailored treatment plans. While Fabrication? Your answer:
the performance characteristics of clear aligners are • Thermoplastic
beneficial, a notable drawback is their non- • Silicon Polymers
biodegradable nature. Materials like PET and TPU can • Biodegradable Plastic
persist in the environment for extended periods, • Not sure
raising concerns about waste management and its
environmental impact, as orthodontic treatment using
clear aligners becomes more prevalent.

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Ques 4: How are Clear Aligners manufactured? • Special solution recommended by the
• Thermoforming manufacturer
• CAD-CAM • This is not required as there is no Bisphenol on
• Curing Clear Aligner trays
• Not sure • Not sure
Ques 5: Do you think DIY Aligners generate more Ques 13: Should Aligners be returned to the
waste? Your answer: Orthodontist after completion of treatment for
• Yes disposal?
• No • Yes
Ques 6: Does the duration of the regime (14 days/7 • No
days/alternate days) of Clear Aligner Treatment have Ques 14: Do Clear Aligners cause air pollution?
an effect on waste generated? Your answer: • Yes
• Yes • No
• No • Not sure
• Not sure Ques 15: What kind of waste do post-treatment CA set
Ques 7: Have any patients ever questioned Clear trays come under?
Aligner material and shown any concern about its • Biomedical waste
disposal? Your answer: • Simple plastic (single-use)
• Yes • Biodegradable waste
• No • Not sure
Ques 8: Do Clear Aligners imbibe saliva in the Oral Ques 16: What do you think is the correct method of
Cavity? Your answer: CA waste disposal?
• Yes • Incineration
• No • General municipal waste after treatment
Ques 9: Which population should be educated in • BMW
controlling Aligner waste generated? Your answer: • Not sure
• Biomedical waste collection agencies Ques 17: Have you ever heard of 4R? Which R is
• Orthodontists applicable in CA treatment?
• Patient • No
• Manufacturing companies • Yes, reuse
Ques 10: What percentage of world post-consumption • Yes, reduce
plastic waste is mechanically recycled? Your • Yes, recycle
answer: • Yes, recover
• <10% Ques 18: On 1 July, single-use plastic was banned in
• <1% India. Do you think this law applies to CA
• <25% Treatment also?
• Not sure • Yes
Ques 11: How many years does it take for the complete • No
degradation of plastic? Your answer: • Not sure
• <100 Ques 19: Should the government allocate a portion of
• 450-600 the budget to establish and support efficient
• >1000 biomedical waste management?
• Not sure • Yes
Ques 12: How can patients avoid traces of bisphenol • No
on Clear Aligners? Ques 20: What do you suggest for clear aligner waste
• Treatment at home with water only management and Aligner material to be more
environmentally friendly

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III. RESULTS Table lV: Association of DIY Aligners and waste

generated.
Data was collected and entered into a computer using Frequency Percentage
a coding system, and proofed for entry errors. Data
NO 11 25.6
obtained was compiled on an MS Office Excel Sheet
YES 32 74.4
(v 2019, Microsoft Redmond Campus, Redmond,
Washington, United States). Data was subjected to TOTAL 43 100
statistical analysis using Statistical Package for Social
Sciences (SPSS v 26.0, IBM). Descriptive statistics 62.8 % replied that the duration of the regime of Clear
like frequencies and percentages for categorical data, Aligner Treatment affects the amount of waste
have been depicted. On receiving 43 responses, the generated. (Table V)
results were as 97.7 % replied that convenience to
patients and esthetics is the reason for Clear Aligners Table V: Effect of duration of regime on amount of
trending nowadays. (Table l) waste generated.
Frequency Percentage
Table l: Clear Aligners trends NO 8 18.6
Frequency Percentage NOT SURE 8 18.6
Convenient to Dentist 1 2.3 YES 27 62.8
Convenient to Patient 42 97.7 TOTAL 43 100
TOTAL 43 100
81.4% replied that their patients never asked about the
95.3 % replied correctly that the thermoplastic material used for aligners, nor were concerned about
material is used to manufacture Clear Aligner trays. its disposal. (Table Vl)
(Table ll)
Table Vl: Patient questioning about aligner material
Table ll: Material used in Clear Aligner Fabrication. and disposal.
Frequency Percentage Frequency Percentage
Thermoplastic 41 95.3 NO 35 81.4
Silicon polymer 2 4.7 YES 8 18.6
Biodegradable plastic 0 0 TOTAL 43 100
Not sure 0 0
TOTAL 43 100 69.8% responded that Clear Aligners do imbibe saliva
from the Oral Cavity. (Table Vll)
93% replied thermoforming is used for Aligner
manufacturing. (Table lll) Table Vll: Clear Aligners trays imbibing saliva in
the Oral Cavity
Table lll: Clear Aligners manufacturing technique. Frequency Percentage
Frequency Percentage NO 13 30.2
Thermoforming 40 93 YES 30 69.8
CAD-CAM 2 4.7 TOTAL 43 100
Curing 0 0
Not sure 1 2.3 25.6% responded correctly to the percentage of the
world's post-consumption plastic waste that is
TOTAL 43 100
mechanically Recycled. (Table Vlll)
77.4 % think that Do It Yourself (DIY) aligners
generate more waste than clear aligners prescribed by
Orthodontists. (Table lV)

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Table Vlll: Percentage of the world's post- Table Xll: Air pollution by clear aligners
consumption plastic waste that is mechanically Frequency Percentage
Recycled NO 13 30.2
Frequency Percentage NOT SURE 12 27.9
<1 8 18.6 YES 18 41.9
<10 11 25.6 TOTAL 43 100
<25 2 4.7
Not sure 22 51.2 93 % replied correctly that post-treatment Aligners
TOTAL 43 100 come under Biomedical Waste. (Table Xlll)

39.5% replied correctly to years to take for complete Table Xlll: Consideration of clear aligners as BMW
degradation of plastic. (Table lX) Frequency Percentage
Biodegradable waste 0 0
Table lX: Years for complete degradation of plastic. BMW 40 93
Frequency Percentage Not sure 1 2.3
<100 yrs 3 7 Simple plastic 2 4.7
>1000 yrs 17 39.5 TOTAL 43 100
450-600 yrs 12 27.9
Not sure 11 25.6 16.3 % replied correctly that out of 4R, only Reduce is
TOTAL 43 100 applicable in CA waste management. (Table XlV)

88.4 % think aligners should be returned to The Table XlV: Application of 4R in CAT
Orthodontist after completion of treatment for proper Frequency Percentage
disposal. (Table X)
NO 10 23.3
Yes, Recover 6 14
Table X: Returning aligners to Orthodontist
Yes, Reuse 1 2.3
Frequency Percentage
Yes, Recycle 19 44.2
NO 5 11.6
Yes, Reduce 7 16.3
YES 38 88.4
TOTAL 43 100
TOTAL 43 100

When asked about Which population should be

9.3% replied correctly that by treatment with water,
educated in controlling the most of Aligner waste
patients can avoid traces of Bis-phenol on Clear
generated, we received results that showed awareness
Aligners. (Table Xl)
must be among all. (Table XV)
Table Xl: Removal of traces of Bis-phenol
Table XV: Awareness to the population about waste
Frequency Percentage
disposal.
Not sure 21 48.8
Frequency Percentage
By special solution 7 16.3
BMW Collection 10 23.3
This is not required 11 25.6
Agencies
Treatment at home 4 9.3
Manufacturing 10 23.3
TOTAL 43 100
companies
Orthodontists 8 18.6
41.9% replied that Clear Aligner does cause Air
Patients 15 34.9
pollution. (Table Xll)
Total 43 100

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On 1 July 2022, single-use plastic was banned in India. Clear aligner trays used in orthodontics are primarily
46.5% think this law doesn’t apply to clear aligners. made from specialized thermoplastic materials, each
(Table XVl) exhibiting distinct characteristics that contribute to
their efficacy and usability. The most common
Table XVl: Single-use plastic ban application to materials include polyethylene terephthalate (PET),
CAT. glycol-modified polyethylene terephthalate (PETG),
Frequency Percentage and thermoplastic polyurethane (TPU). The material
NO 20 46.5 properties of clear aligners—transparency, flexibility,
NOT SURE 11 25.6 elasticity, durability, thermal stability, and
YES 12 27.9 biocompatibility—make them a highly suitable option
TOTAL 43 100 for adult patients seeking orthodontic correction.
These characteristics not only address aesthetic
97.7% do think that the government should allocate concerns but also facilitate effective and comfortable
a portion of the budget to establish and support orthodontic treatment, ultimately contributing to
efficient Biomedical Waste Management. (Table enhanced patient compliance and satisfaction.
XVll) Clinically, conditions that could be addressed with a
single nickel-titanium archwire often require multiple
Table XVll: Government budget allocation for BMW aligners. While these materials provide a cosmetic
Frequency Percentage advantage, they also raise environmental concerns due
NO 1 2.3 to their non-biodegradable nature. Clear Aligners are
YES 42 97.7 challenging to recycle through standard municipal
programs.
TOTAL 43 100

The current state of clear aligner waste management

IV. DISCUSSION
highlights a complex interplay of practices and
challenges faced by orthodontic professionals and
Over the past decade, there has been a significant
patients alike. Ambiguous disposal guidelines
escalation in the demand for Clear Aligner Therapy
frequently lead to difficulties, resulting in a significant
(CAT). This trend can be largely attributed to an
number of aligner trays being discarded in household
increasing number of adult patients who favor
waste and ultimately deposited in landfills, thereby
aesthetic alternatives for orthodontic correction over
contributing to long-term environmental degradation.
conventional metal braces. Furthermore, CAT has
Furthermore, the waste footprint is exacerbated by
recently gained traction in the pediatric demographic
packaging materials such as plastic pouches and
for the treatment of malocclusions, reflecting a
protective cases. This study aimed to assess the
broader application of this technology.
knowledge, attitudes, and practices of professionals
involved in Clear Aligner Treatment (CAT), yielding
The surge in popularity of CAT is also linked to
several critical findings. A substantial 97.7% of
aggressive marketing strategies employed by clear
respondents identified aesthetics and convenience as
aligner companies. These strategies encompass direct-
the primary motivations for adults choosing CAT.
to-consumer advertising and targeted social media
Additionally, 95.3% of practitioners were aware of the
campaigns, which effectively enhance public
specific materials used in aligner trays, and 93% were
awareness of aesthetic orthodontic solutions,
familiar with the thermoforming process utilized in
particularly among adult populations. Such
their manufacture. Notably, 74.4% of participants
promotional efforts have contributed to a paradigm
believed that do-it-yourself (DIY) aligners produce
shift in orthodontic treatment preferences, positioning
greater plastic waste compared to professionally
clear aligners as a viable and appealing option for a
administered options, underscoring the necessity for
diverse range of patients seeking orthodontic
professional oversight in orthodontic treatment. The
intervention.
transition from a two-week to a one-week or even
alternate-day aligner change regimen has further

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exacerbated plastic waste, with 62.8% of respondents public to foster sustainable practices within the field of
indicating that the frequency of aligner changes orthodontics.
significantly impacts waste generation. Alarmingly,
81.4% of patients expressed indifference towards the Manufacturers are increasingly working on aligners
materials used in aligner trays and their disposal, that are easier to recycle or naturally degrade.
highlighting a critical need for enhanced education Manufacturers should prioritize developing more
regarding the environmental implications of aligner efficient plastic alternatives and refining recycling
waste. Moreover, 69.8% of practitioners processes. Developing biopolymers and
acknowledged that aligner trays absorb saliva during biodegradable thermoplastics that can offer promising
use, potentially altering their properties and alternatives while maintaining the mechanical
categorizing them as biomedical waste; 72.1% further integrity and aesthetic qualities required for clear
believed that post-treatment aligners should also be aligners. Mechanical recycling, which involves
classified as biomedical waste. A significant 88.4% of turning post-consumed disinfected plastic into
respondents recommended returning aligners to granules for reuse, can be one promising approach.
orthodontic offices for appropriate disposal, given that Looking ahead, sustainability must be a key focus in
patients may lack the necessary knowledge to handle orthodontic innovation.
biomedical waste responsibly. Despite the established
fact that plastics can take approximately 1,000 years to In the US, clinics and programs like Terra-Cycle
fully degrade, only 39.5% of practitioners accurately encourage patients to return their aligners for
recognized this timeframe. 9% of post-consumer recycling. Similar initiatives could benefit the Indian
plastic waste is mechanically recycled globally, and a subcontinent.
mere 25.6% of practitioners were aware of this
statistic. The presence of Bisphenol in aligner trays The judicious application of biomechanical principles
and its potential leaching into the oral cavity remains in clear aligner therapy enhances the efficacy of
a controversial topic, with only 9.3% correctly noting orthodontic treatment by ensuring precise control over
that an initial immersion in water at 37°C for 24 hours tooth movement, optimizing patient comfort, and
can assist in removing traces of this compound. minimizing complications. By integrating knowledge
Additionally, 41.9% agreed that incinerating plastic of force systems, tooth movement mechanisms,
aligners releases harmful gases that contribute to air anchorage strategies, material properties, and patient
pollution. Only 16.3% identified "Reduce" as the dynamics, orthodontic professionals can develop
pertinent principle from the 4Rs of waste individualized treatment plans that leverage the unique
management, indicating a pressing need for improved advantages of clear aligners while adhering to
practices aimed at minimizing waste. Regarding established biomechanical standards. This
India’s ban on single-use plastics instituted on July 1, comprehensive approach is critical for achieving
2022, 46.5% of respondents believed this regulation successful clinical outcomes while simultaneously
does not extend to aligners; nonetheless, an minimizing the generation of unwanted plastic waste.
overwhelming 97.7% advocated for government
investment in effective biomedical waste CONCLUSION
management. To enhance clear aligner waste
management, recommendations include the Addressing the challenges of clear aligner waste
development of biodegradable and eco-friendly management requires a multi-faceted approach
materials, the establishment of systems for returning involving innovation, education, and collaboration
aligners to the clinicians post-treatment, the within the orthodontic industry. By integrating
exploration of recycling options following biomechanical principles with effective waste
disinfection, the prohibition of DIY aligners, and management strategies, orthodontic practitioners can
public education campaigns focusing on the optimize treatment efficacy and enhance patient
implications of biomedical waste. Addressing these satisfaction, all while addressing the environmental
challenges necessitates a concerted effort among impact associated with the disposal of clear aligners
orthodontic professionals, regulatory bodies, and the and their packaging. This dual focus not only fosters

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sustainable practices within the field of orthodontics biocompatibility. Am J Orthod Dentofacial

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