Clinical Red Flags in Orthodontic Treatment: An Umbrella Review of Risk Indicators and Iatrogenic Complications

Clinical Red Flags in Orthodontic Treatment: An Umbrella Review of Risk Indicators and Iatrogenic Complications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Clinical Red Flags in Orthodontic Treatment: An Umbrella Review of Risk Indicators and Iatrogenic Complications Maen Mahfouz, Eman Alzaben This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9670282/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Within contemporary orthodontic practice, the term "clinical red flags" denotes warning signs of impending treatment-related complications that necessitate prompt clinical intervention. This umbrella review synthesizes evidence derived from existing systematic reviews to evaluate the identification and management of such red flags during active orthodontic treatment. Methods A systematic search of open-access electronic databases—specifically PubMed/MEDLINE, DOAJ (Directory of Open Access Journals), Google Scholar, and SpringerOpen—was conducted for the period spanning January 1, 2000 to December 31, 2025, to identify systematic reviews and meta-analyses addressing orthodontic red flags. Grey literature, conference abstracts, dissertations, and unpublished studies were not systematically searched. Quality appraisal was adopted from source reviews, which employed validated instruments including AMSTAR-2, ROBIS, ROBINS-I, and RoB2. No formal overlap analysis (e.g., corrected covered area) was performed. Results Seven systematic reviews and meta-analyses satisfied the predefined inclusion criteria. Convergent evidence across multiple reviews indicates that heavy orthodontic forces, intrusion mechanics, and prolonged treatment duration are consistently associated with an elevated risk of orthodontically induced inflammatory root resorption (OIIRR). One systematic review suggested that a two- to three-month treatment pause may attenuate total root resorption, although this finding has not been corroborated by subsequent investigations. Evidence comparing clear aligners with fixed appliances remains conflicting: one CBCT-based meta-analysis identified no statistically significant difference between modalities (mean difference 0.19 mm; p = 0.28), with mean resorption below 1 mm in both groups; conversely, an umbrella review reported small differences favoring aligners (0.62–0.65 mm), albeit with variable methodological quality across the included reviews. Structured management protocols addressing progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession, and patient non-compliance are presented as an expert-informed clinical synthesis. Conclusions Heavy forces, intrusion mechanics, and extended treatment duration are consistently associated with increased OIIRR risk. Evidence comparing aligners and fixed appliances is conflicting. Structured red flag protocols offer a systematic framework that may enhance patient safety. High-quality randomized controlled trials are urgently required to resolve outstanding uncertainties. Dentistry Orthodontic red flags root resorption patient compliance iatrogenic complications umbrella review Introduction In contemporary orthodontic practice, the traffic light analogy (red, yellow, green) serves as a heuristic to signal treatment-related complications requiring clinical attention, force modulation, compliance intervention, or treatment termination. The term "red flag" is employed pragmatically throughout this review to denote warning signs of potential iatrogenic complications that mandate reassessment or clinical intervention. This terminology is derived from established clinical risk management frameworks and is adapted here to the specific context of orthodontic treatment. These clinical red flags encompass progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession or fenestration, and patient non-compliance with safety-critical instructions (e.g., elastic wear, headgear use, appointment attendance). External apical root resorption (EARR) constitutes one of the most frequently reported iatrogenic sequelae of orthodontic tooth movement. Nevertheless, the literature currently lacks robust and unequivocal scientific evidence regarding the clinical and biological factors that precipitate EARR [ 1 ]. Root resorption has been characterized as the most unfortunate complication of orthodontic treatment [ 2 ]. Given the proliferation of systematic reviews addressing orthodontic complications, an umbrella review—also termed a review of systematic reviews—is timely to synthesize higher-level evidence and furnish clinicians with a consolidated, evidence-informed framework for recognizing and managing clinical red flags [ 2 , 3 , 4 ]. Objectives Primary Objectives : To synthesize evidence from extant systematic reviews concerning risk factors for and management of orthodontically induced root resorption. To identify and categorize clinical red flags that necessitate intervention during active orthodontic treatment. To provide evidence-informed management protocols for each identified red flag category. Secondary Objective : To delineate research gaps requiring future investigation. Conceptual Framework This umbrella review focuses specifically on clinical red flags that emerge during active orthodontic treatment —that is, warning signs of complications that require prompt clinical response. Björk's structural signs for mandibular growth prediction are presented separately as historical and conceptual background; they do not form part of the umbrella review evidence synthesis. Methods Study Design This investigation constitutes an umbrella review (synonymous with review of systematic reviews or overview of reviews). Umbrella reviews synthesize evidence from existing systematic reviews and meta-analyses to provide a comprehensive, high-level overview of a clinical topic [ 3 , 4 ]. This methodological approach is particularly appropriate when multiple systematic reviews addressing the same or related questions are available [ 4 ]. This umbrella review was not registered with PROSPERO. Eligibility Criteria Inclusion Criteria : Study designs : Systematic reviews, meta-analyses, and umbrella reviews. Population : Patients undergoing orthodontic treatment with full permanent dentition (excluding third molars). Intervention : Fixed appliances (conventional or self-ligating brackets), clear aligners, or removable appliances. Outcomes : Root resorption, iatrogenic complications (including loss of arch length, posterior open bite, asymmetric space closure, and gingival recession), and patient non-compliance. Comparators : Alternative treatment modalities (aligners versus fixed appliances; self-ligating versus conventional brackets) where applicable. Exclusion Criteria : Primary studies (i.e., those not published as systematic reviews or meta-analyses). Non-English publications where translation was unavailable. Animal studies or in vitro investigations. Narrative reviews lacking systematic methodology. Search Strategy and Databases Databases searched (open access) : PubMed/MEDLINE (free access via the United States National Library of Medicine). DOAJ (Directory of Open Access Journals). Google Scholar (open access articles; limitations acknowledged in Section 2.8). SpringerOpen (open access journals). Databases NOT accessed (subscription required) : EMBASE (no institutional subscription available). Scopus (no institutional subscription available). Web of Science (no institutional subscription available). Cochrane CENTRAL (Cochrane Central Register of Controlled Trials; limited access). Grey literature : Grey literature, conference abstracts, dissertations, and unpublished studies were not systematically searched. Preprints were excluded. Search details : Search period: January 1, 2000 to December 31, 2025. Last search executed: December 31, 2025. Language restriction: English. Search terms (Boolean operators applied to PubMed and Google Scholar) : Search Component Search Terms Review type ("systematic review"[Title/Abstract] OR "meta-analysis"[Title/Abstract] OR "umbrella review"[Title/Abstract] OR "overview"[Title/Abstract] OR "review of reviews"[Title/Abstract]) Orthodontic treatment ("orthodontic "[Title/Abstract] OR "aligner "[Title/Abstract] OR "clear aligner "[Title/Abstract] OR "fixed appliance "[Title/Abstract]) Root resorption ("root resorption"[Title/Abstract] OR "EARR"[Title/Abstract] OR "OIIRR"[Title/Abstract] OR "apical resorption"[Title/Abstract]) Complications ("iatrogenic"[Title/Abstract] OR "complication "[Title/Abstract] OR "adverse effect "[Title/Abstract] OR "red flag*"[Title/Abstract]) Compliance ("compliance"[Title/Abstract] OR "non-compliance"[Title/Abstract] OR "patient behavior*"[Title/Abstract]) Study Selection Two independent reviewers (MM and EA) screened titles and abstracts against the predefined eligibility criteria. Disagreements were resolved through discussion and consensus between the two reviewers, without recourse to a third-party arbitrator. Full-text systematic reviews were retrieved for all potentially eligible studies. For this umbrella review , only systematic reviews and meta-analyses were included . Primary studies were not extracted or analyzed directly; all quantitative findings are reported as synthesized in the source reviews. Data Extraction Data were extracted from included systematic reviews and meta-analyses using a standardized form capturing the following elements: reference (author, year, journal), type of review (systematic review, meta-analysis, umbrella review, or overview), number of primary studies included, key findings, risk of bias assessment (as reported by the source review), and overall quality rating (as reported by the source review). Historical and Conceptual Background: Björk's Structural Signs Important note : This section on Björk's structural signs is not derived from systematic review evidence and does not form part of the umbrella review synthesis . It is included solely as historical and conceptual background for clinicians unfamiliar with this classic orthodontic concept. The evidence base consists of longitudinal implant studies (n > 300) conducted by Björk and colleagues between 1955 and 1984 [ 5 , 6 ]. Historical Background Professor Arne Björk and Dr. Vibeke Skieller conducted landmark longitudinal implant studies at the Royal Dental College in Copenhagen, placing metallic pins in the jaws of growing children to track mandibular growth rotation [ 5 , 6 ]. Björk suggested that conventional best-fit superimposition methods may introduce significant interpretive errors [ 6 ]. On the basis of these findings, Björk and Skieller developed the "structural technique" for superimposing serial cephalograms, which reduces errors inherent in conventional methods [ 6 ]. The Structural Signs Structural Sign Forward Rotation (Horizontal Grower) Backward Rotation (Vertical Grower) Condylar head inclination Posteriorly inclined Anteriorly inclined Antegonial notch depth Shallow or absent Deep Symphysis inclination Posteriorly inclined Anteriorly inclined Intermandibular angle Small Large Source: Björk & Skieller, 1972, 1984 [ 5 , 6 ] Clinical Application Forward rotation (horizontal growth pattern) : Tends to develop or deepen anterior deep bite; prognostically favorable for Class II correction as mandibular growth compensates. Backward rotation (vertical growth pattern) : Tends to develop or exacerbate anterior open bite; vertical dimension control during treatment is challenging, and relapse risk following open bite closure is elevated. Quality Assessment Quality assessment was adopted directly from the source systematic reviews; no additional quality appraisal was performed beyond that reported in the source reviews. The instruments employed in the source reviews included AMSTAR-2, ROBIS, ROBINS-I, and RoB2. Methodological Limitations of This Umbrella Review The following methodological limitations are explicitly acknowledged : No PROSPERO registration : The review protocol was not prospectively registered. Database access limitations : Systematic searches of subscription-based databases (EMBASE, Scopus, Web of Science, Cochrane CENTRAL) could not be performed due to lack of institutional access. This constitutes a significant limitation; the review should not be interpreted as exhaustive. Google Scholar limitations : Google Scholar was used despite its well-recognized limitations for systematic searching, including lack of reproducibility, variable coverage across disciplines, and absence of Boolean operator precision. The first 200 relevant results per search string were reviewed to mitigate these constraints. Grey literature exclusion : Conference abstracts, dissertations, preprints, and unpublished studies were not systematically searched. Language bias : The review was restricted to English-language publications. No overlap analysis : No formal overlap analysis (e.g., corrected covered area) was performed to quantify duplication of primary studies across the included systematic reviews. No GRADE assessment : No de novo certainty assessment (e.g., GRADE) was performed. Quality of source reviews : The included systematic reviews ranged from critically low to high methodological quality [ 2 , 10 , 11 , 12 ]. Evidence Synthesis A narrative synthesis was performed, organized thematically into three domains: (1) root resorption risk factors and management, (2) clinical red flags and corresponding management protocols, and (3) research gaps and future directions. Results Included Systematic Reviews and Meta-Analyses Seven systematic reviews and meta-analyses satisfied the eligibility criteria and were included in this umbrella review: Table 1: Included Systematic Reviews and Meta-Analyses Reference Type Primary Studies Included Focus Quality (as reported) Weltman et al. (2010) [7] Systematic review 13 OIIRR risk factors Methodological differences prevented quantitative pooling Yassir et al. (2021) [2] Overview of SRs 28 SRs OIIRR evidence synthesis 71.5% moderate-to-high quality on AMSTAR-2 Villaman-Santacruz et al. (2022) [8] SR with MA Multiple EARR by technique Low certainty evidence Sameshima & Iglesias-Linares (2021) [1] Position paper (SR-based) N/A EARR risk factors Moderate quality Yassir et al. (2022) [9] Overview of SRs Multiple CAT effectiveness Moderate quality Kreuter et al. (2025) [10] CBCT-based MA 5 Aligners vs. fixed Moderate-to-high ROB Selvaraj et al. (2025) [11] Umbrella review 8 SRs Aligners vs. fixed Critically low to high (varied) Abbreviations: SR, systematic review; MA, meta-analysis; CAT, clear aligner therapy; ROB, risk of bias; OIIRR, orthodontically induced inflammatory root resorption; EARR, external apical root resorption. Note: Baneshi et al. (2025) [12] was screened but not included in the primary synthesis because root resorption was a secondary outcome only; it is discussed in the narrative synthesis where relevant. Synthesis of Findings: Root Resorption Key Findings from Included Systematic Reviews Weltman et al. (2010) [7] concluded: Comprehensive orthodontic treatment increases both the incidence and severity of root resorption. Heavy orthodontic forces are consistently associated with increased OIIRR risk. OIIRR is unaffected by archwire sequencing, bracket prescription (e.g., conventional versus self-ligating), or bracket type. Previous dental trauma and tooth morphology are unlikely causative factors. One systematic review suggested that a two- to three-month treatment pause may decrease total root resorption; this finding has not been confirmed by subsequent reviews. Yassir et al. (2021) [2] concluded: The incidence and severity of OIIRR increase with fixed appliance therapy, particularly in the context of heavy forces, intrusion mechanics, torquing movements, prolonged treatment duration, and extraction-based treatment protocols. Evidence regarding most other treatment- and patient-related factors was insufficient. The precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood. Following precautionary measures, pausing treatment and implementing regular monitoring benefit patients with OIIRR. Villaman-Santacruz et al. (2022) [8] concluded: Evidence suggests that EARR induced by orthodontic treatment is similar irrespective of the technique employed. Endodontically treated teeth exhibit less EARR associated with orthodontic treatment compared to vital teeth. These conclusions should be interpreted with caution owing to the low certainty of the available evidence. Sameshima & Iglesias-Linares (2021) [1] identified risk factors: Patient-related factors: Genetic predisposition, tooth anatomy (e.g., pipette-shaped or conical roots), demographic characteristics, malocclusion type, previous endodontic treatment, medical history, and short root anomaly. Treatment-related factors: Biomechanical force characteristics, appliance type, adjunctive therapies to accelerate tooth movement, early treatment, maxillary expansion, tooth extractions, treatment duration, and magnitude of apical displacement. Aligners versus Fixed Appliances: Evidence from Multiple Reviews Table 2: Comparison of Reviews Examining Aligners versus Fixed Appliances Review Finding on Root Resorption Quality Notes Kreuter et al. (2025) [10] No significant difference (MD 0.19 mm; p = 0.28); mean resorption <1 mm in both groups Moderate-to-high ROB CBCT-based meta-analysis Selvaraj et al. (2025) [11] Significant difference (0.62–0.65 mm favoring aligners) Critically low to high (varied) Umbrella review of 8 SRs Yassir et al. (2022) [9] Lower root resorption risk with CAT Moderate quality Overview of SRs Overall interpretation across reviews: Mean differences between treatment modalities were generally small, with the primary CBCT-based meta-analysis reporting mean resorption below 1 mm in both groups [10]; the umbrella review reported differences of 0.62–0.65 mm favoring aligners [11]. Individual primary studies within the included reviews may report larger absolute resorption values in specific high-risk patient subsets. The clinical significance of these small differences remains debatable. Critically, the precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood [2]. Root Resorption Risk Factors: Summary Table 3: Root Resorption Risk Factors with Agreement Across Reviews Risk Factor Category Specific Factors Agreement Across Reviews Biomechanical factors Heavy forces Consistent across two reviews [2,7] Intrusion mechanics Reported in one review [2] Torquing movements Reported in one review [2] Prolonged treatment duration Consistent across two reviews [2,7] Extractions Reported in one review [2] Large apical displacement Reported in one review [2] Patient-related factors Genetic predisposition Reported in one review [1] Tooth anatomy (pipette-shaped, conical) Reported in one review [1] Previous dental trauma Reported in one review with limitations [7] Short root anomaly Reported in one review [1] Previous endodontic treatment (protective) Reported in one review with low certainty [8] Clinical Red Flags: Identification and Management Protocols Important note on clinical protocols: The management protocols presented in Sections 4.3.1–4.3.6 constitute an expert-informed clinical synthesis derived from available evidence integrated with widely accepted orthodontic principles. They should not be interpreted as formal, evidence-based clinical practice guidelines. Where evidence from systematic reviews exists, it is cited; where evidence is limited, this is explicitly noted as "clinical consensus." Red Flag #1: Progressive Root Resorption (EARR) Table 4: Root Resorption Severity Classification and Management Severity Criteria Action Timeline Evidence Base Yellow (caution) Mild (<2 mm loss) Monitor; continue with light forces Radiographic re-evaluation at 6–12 months Consistent across two reviews [2,7] Orange (moderate) 2–4 mm loss, stable Reduce force magnitude; avoid intrusion and torque mechanics Recheck at 3–4 months Reported in position paper [1] Red (severe) >4 mm loss or rapid progression Remove active forces; place passive archwire; consider early debonding Immediate (within 48 hours) Consistent across two reviews [2,7] Long-term management: Permanent bonded retention; avoidance of future orthodontic treatment on affected teeth; annual radiographic follow-up. Evidence note: Weltman et al. (2010) [7] suggested that a two- to three-month pause in active treatment may attenuate total root resorption; this finding has not been confirmed by subsequent reviews. Red Flag #2: Loss of Arch Length / Increased Lower Incisor Crowding Table 5: Management of Arch Length Loss (Clinical Consensus) Action Details Immediate Discontinue Class II elastics; verify integrity of lingual arch or Nance appliance Short-term Open coil spring (6–9 mm) positioned between molars and incisors if space loss is <3 mm Severe Consider temporary anchorage device (TAD) for distalization if space loss exceeds 3 mm Prevention Employ lower lingual holding arch for growing patients undergoing Class II treatment exceeding 6 months Red Flag #3: Iatrogenic Posterior Open Bite Table 6: Management of Iatrogenic Open Bite (Clinical Consensus) Timeframe Prognosis Management 6 months Poor (≈40% relapse risk) Consider orthognathic surgery consultation Red Flag #4: Asymmetric Space Closure Table 7: Management of Asymmetric Space Closure (Clinical Consensus) Action Details Immediate Discontinue all elastics; inspect for broken brackets, displaced bands, or twisted archwires Short-term Apply power chain to the slower-closing side only until midline is centered Persistent Use transpalatal arch (TPA) with stop on the faster-closing side; consider unilateral TAD Prevention Provide written elastic wear diagrams; advise patients that sleeping on one side may induce asymmetry Red Flag #5: Gingival Recession or Fenestration Table 8: Management of Gingival Recession Severity Action Evidence Base Mild Discontinue buccal/labial root torque; replace heavy archwire with light passive wire (0.012–0.014 NiTi) Clinical consensus Moderate Move tooth palatally/lingually back into alveolar housing using light force (≈25 g) via closed coil spring from palatal TAD Clinical consensus Severe (<2 mm attached gingiva + visible root) Stop active orthodontic forces; debond if feasible; refer to periodontist for connective tissue graft (wait 3 months after force removal before grafting) Reported in review [13] Risk factors: Thin gingival biotype (approximately 4.2-fold increased risk), proclination exceeding 15° from baseline, and history of periodontal disease [13]. Red Flag #6: Patient Non-Compliance with Safety Risks Table 9: Management of Non-Compliance (Clinical Consensus) Occurrence Action First Document findings; re-instruct patient (and parent/guardian if minor); schedule follow-up in 2–4 weeks Second Convene emergency patient–parent conference; establish written behavioral contract; simplify mechanics (remove elastics, place passive archwire); implement 4-week probation with weekly appointments Third (or no improvement) Debond appliances; deliver passive retainers; provide written discharge letter with transfer recommendations Warning signs requiring heightened vigilance: Elastics found stockpiled (unopened or hidden); two or more consecutive missed appointments; repeated bracket fractures (particularly on anterior teeth); generalized bleeding on probing, heavy plaque accumulation, or visible calculus. Discussion Summary of Principal Findings This umbrella review synthesizes evidence from seven systematic reviews and meta-analyses addressing clinical red flags in orthodontic treatment: 1. Heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk. Convergent evidence across multiple systematic reviews [2,7] identifies these factors as modifiable risk determinants. One systematic review suggested that a two- to three-month treatment pause may reduce total root resorption; however, this finding awaits confirmation by subsequent investigations [7]. 2. The precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood. Yassir et al. (2021) [2] concluded that, although orthodontic treatment clearly contributes biologically to root resorption, the specific predictors, biomechanical interactions, and susceptibility factors are not fully characterized. Sameshima and Iglesias-Linares (2021) [1] similarly observed that "no robust and unequivocal scientific evidence is yet available." 3. Evidence comparing clear aligners with fixed appliances is conflicting. A CBCT-based meta-analysis identified no statistically significant difference between modalities (p = 0.28), with mean resorption below 1 mm in both groups [10]. An umbrella review reported small differences favoring aligners (0.62–0.65 mm), albeit with variable methodological quality across included reviews [11]. An overview of systematic reviews found lower root resorption risk associated with clear aligner therapy [9]. 4. Structured red flag protocols offer a systematic framework that may enhance patient safety. Although direct outcome studies validating these protocols are lacking, the precautionary principle—supported by Yassir et al. (2021) [2] and Sameshima & Iglesias-Linares (2021) [1]—justifies structured monitoring and protocolized intervention. Comparison of Findings Across Included Reviews Table 10: Agreement Across Included Systematic Reviews Topic Agreement Level Reviews Agreeing Notes Heavy forces associated with increased OIIRR risk High 2/2 reviews [2,7] Consistent finding across systematic reviews Two- to three-month rest period suggested Single review 1/1 [7] Not yet confirmed by subsequent reviews OIIRR unaffected by bracket type (conventional vs. self-ligating) Single review 1/1 [7] Not contradicted in the literature Aligners vs. fixed appliances Low Mixed [9,10,11] Conflicting findings across reviews Genetic factors contribute to OIIRR risk Single review 1/1 [1] Supported by SR-based position paper Clinical Implications Recommendation Evidence Base Employ light forces, particularly during incisor intrusion Consistent across two reviews [2,7] Consider a two- to three-month treatment pause if progressive resorption is detected Single review [7]; not yet confirmed Monitor high-risk patients (those with genetic predisposition, unfavorable root morphology, or prolonged treatment duration) Reported in position paper [1] Interpret OIIRR evidence cautiously owing to low-to-moderate evidence quality and conflicting findings Consistent across reviews [2,10,11] Limitations Umbrella Review Limitations No PROSPERO registration: The review protocol was not prospectively registered. Database access limitations: Subscription-based databases (EMBASE, Scopus, Web of Science, Cochrane CENTRAL) could not be searched due to lack of institutional access. This constitutes a significant limitation; the review should not be interpreted as exhaustive. Google Scholar limitations: Google Scholar was used despite its recognized limitations for systematic searching, including lack of reproducibility, variable coverage, and absent Boolean operator precision. The first 200 results per search string were reviewed. Grey literature exclusion: Conference abstracts, dissertations, preprints, and unpublished studies were not systematically searched. Language bias: The review was restricted to English-language publications. No overlap analysis: No formal overlap analysis (e.g., corrected covered area) was performed to quantify primary study duplication across included systematic reviews. No GRADE assessment: No de novo certainty assessment was performed. Quality of source reviews: Included reviews ranged from critically low to high methodological quality [2,10,11,12]. Evidence Base Limitations Low-to-moderate evidence quality: Yassir et al. (2021) [2] noted "a limited number of high-quality studies" addressing OIIRR. Conflicting findings: Discrepancies between meta-analyses [10,11] reflect substantial underlying uncertainty. High statistical heterogeneity: The CBCT-based meta-analysis reported very high heterogeneity (I² = 98.5%) [10]. Incompletely understood causal relationships: The precise causal relationships between orthodontic biomechanics and OIIRR severity remain incompletely understood [2]. Clinical Protocols Disclaimer The clinical management protocols presented in Sections 4.3.1–4.3.6 constitute expert-informed syntheses intended for educational purposes. They should not be interpreted as formal clinical practice guidelines. These protocols are derived from available evidence integrated with widely accepted orthodontic principles. Where evidence is limited, this is explicitly noted as "clinical consensus." Formal guideline development would require a systematic review of primary studies with GRADE certainty assessment, which was not performed in this umbrella review. Research Gaps and Future Directions Gap Identified Recommended Future Research Priority Conflicting evidence on aligner versus fixed appliance OIIRR High-quality RCTs employing standardized CBCT protocols and low risk of bias High [2,12] Incompletely understood causal relationships Prospective studies controlling for confounding variables (genetic, biomechanical, demographic) High [2] Effectiveness of two- to three-month treatment pause RCTs directly comparing immediate continuation versus paused treatment Moderate Validity of clinical consensus protocols Prospective cohort studies examining protocol effectiveness and safety outcomes Moderate Emerging Concepts Requiring Future Validation A preliminary behavioral classification framework has been proposed in the literature, identifying five orthodontic patient categories—Idealists, Inconsistents, Skeptics, Strugglers, and Unpredictables—based on treatment demand, trust in the orthodontist, compliance, and treatment response [14]. This framework derives from a single cross-sectional study (n = 100) employing subjective clinician assessment and has not undergone external validation. It is included here as an emerging concept for future research, not as established evidence. External validation in larger, multicenter samples is required before clinical implementation can be recommended. Conclusions Key Conclusions 1. Heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk. Consistent evidence across systematic reviews [2,7] identifies these as modifiable risk factors. One systematic review suggested that a two- to three-month treatment pause may be beneficial; this finding awaits confirmation by subsequent reviews [7]. 2. The precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood. Yassir et al. (2021) [2] concluded that, while orthodontic treatment clearly contributes biologically to root resorption, the specific predictors, biomechanical interactions, and susceptibility factors are not fully characterized. 3. Evidence comparing aligners with fixed appliances is conflicting and of variable methodological quality. A CBCT-based meta-analysis found no statistically significant difference between modalities [10]; an umbrella review reported small differences favoring aligners, albeit with variable quality across included reviews [11]. 4. Structured red flag protocols offer a systematic framework that may enhance patient safety. Although direct outcome studies validating these protocols are lacking, the precautionary principle supported by the literature [1,2] justifies structured monitoring and protocolized intervention. Recommendations for Clinical Practice Recommendation Evidence Base Employ light forces, particularly during incisor intrusion Consistent across two reviews [2,7] Consider a two- to three-month treatment pause if progressive root resorption is detected Single review [7]; not yet confirmed Monitor high-risk patients (genetic predisposition, unfavorable root morphology, prolonged treatment duration) Reported in position paper [1] Interpret OIIRR evidence cautiously owing to low-to-moderate quality and conflicting findings Consistent across reviews [2,10,11] Final Statement Clinical red flags in orthodontic treatment—progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession, and patient non-compliance—mandate systematic recognition and protocolized management. This umbrella review of seven systematic reviews confirms that heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk. Evidence comparing aligners with fixed appliances remains conflicting. Structured red flag protocols provide a systematic framework that may enhance patient safety. Future high-quality randomized controlled trials employing standardized protocols and low risk of bias are urgently required to definitively resolve outstanding questions. References Sameshima GT, Iglesias-Linares A (2021) Orthodontic root resorption. J World Federation Orthodontists 10(4):135–143 Yassir YA, McIntyre GT, Bearn DR (2021) Orthodontic treatment and root resorption: an overview of systematic reviews. Eur J Orthod 43(4):442–456 Fusar-Poli P, Radua J (2018) Ten simple rules for conducting umbrella reviews. 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Dent Med Probl 59(3):437–450 Yassir YA, Nabbat SA, McIntyre GT, Bearn DR (2022) Clinical effectiveness of clear aligner treatment compared to fixed appliance treatment: an overview of systematic reviews. Clin Oral Invest 26(3):2353–2370 Kreuter P et al (2025) Root resorption caused by aligners, self-ligating appliances, and conventional fixed appliances: a CBCT-based meta-analysis. BMC Oral Health 25:1259 Selvaraj M et al (2025) Orthodontically induced external apical root resorption with clear aligners compared to fixed appliance treatment: An umbrella review. Journal of Oral Biology and Craniofacial Research. PMID: 40621584 Baneshi M, O'Malley L, El-Angbawi A, Thiruvenkatachari B (2025) Effectiveness of clear orthodontic aligners in correcting malocclusions: A systematic review and meta-analysis. J Evid Based Dent Pract 25(1):102081 Parashos P (2023) Endodontic-orthodontic interactions: a review and treatment recommendations. Aust Dent J 68(Suppl 1):S66–S81 Savio S, Sreenivasagan S, Balasubramaniam A (2025) A Behavioral Classification Framework for Orthodontic Patients: Understanding Demand, Compliance, Trust, and Treatment Response. J Neonatal Surg. ;14 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9670282","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":637659483,"identity":"b4cc6d5b-8e5f-41bc-ae40-93f47b9f8053","order_by":0,"name":"Maen Mahfouz","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIie2Qz0rDQBCHZxnYXEZzzZL6DpFAT9K+SkLAU/FSEMRCC4XkEvTqk+wLLKQX0avQS6KQsz0I9eb0D5XSBOtNZD+W2WGZj93fAlgsfxFHTCACIG7legGCKHmj0zYFdwpuFELAYKXIVuW72ypcPdhc2og7xbQsR72O6z8X5fv1xVXfwfrmY9DrSMDq9eVQ8YzIgqhISN0lzvnD0+WQUHbnZzrhh8kwHBwqAYrUiydIwSNK/yQ1cY4k50pz5Th+uzLeV4ZKj39SzL4iFtq0Kpwl9aJiRirHruIscW5k6As9I4nNWdwsq9VydNt3SdQe/1ic3Ztq8an5xJlWbw1KM0jreuz4CrH8zbTFYrH8d74AvOhQot3tM+4AAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-9669-9984","institution":"Private Orthodontic Practice , Ramallah, Palestine.","correspondingAuthor":true,"prefix":"","firstName":"Maen","middleName":"","lastName":"Mahfouz","suffix":""},{"id":637659560,"identity":"0b7a1199-02ab-47ea-bd5c-69892264de85","order_by":1,"name":"Eman Alzaben","email":"","orcid":"https://orcid.org/0009-0000-2829-6833","institution":"Private Dental Clinic, Jerusalem","correspondingAuthor":false,"prefix":"","firstName":"Eman","middleName":"","lastName":"Alzaben","suffix":""}],"badges":[],"createdAt":"2026-05-10 13:06:24","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9670282/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9670282/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109057068,"identity":"63b85724-732f-47e8-b012-e6b831e7b096","added_by":"auto","created_at":"2026-05-12 07:46:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":431494,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9670282/v1/138504b5-39a5-4353-852f-4cd2909f9212.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eClinical Red Flags in Orthodontic Treatment: An Umbrella Review of Risk Indicators and Iatrogenic Complications\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIn contemporary orthodontic practice, the traffic light analogy (red, yellow, green) serves as a heuristic to signal treatment-related complications requiring clinical attention, force modulation, compliance intervention, or treatment termination. The term \"red flag\" is employed pragmatically throughout this review to denote warning signs of potential iatrogenic complications that mandate reassessment or clinical intervention. This terminology is derived from established clinical risk management frameworks and is adapted here to the specific context of orthodontic treatment.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThese clinical red flags encompass progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession or fenestration, and patient non-compliance with safety-critical instructions (e.g., elastic wear, headgear use, appointment attendance).\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eExternal apical root resorption (EARR) constitutes one of the most frequently reported iatrogenic sequelae of orthodontic tooth movement. Nevertheless, the literature currently lacks robust and unequivocal scientific evidence regarding the clinical and biological factors that precipitate EARR\u003c/span\u003e [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRoot resorption has been characterized as the most unfortunate complication of orthodontic treatment\u003c/span\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGiven the proliferation of systematic reviews addressing orthodontic complications, an umbrella review\u0026mdash;also termed a review of systematic reviews\u0026mdash;is timely to synthesize higher-level evidence and furnish clinicians with a consolidated, evidence-informed framework for recognizing and managing clinical red flags\u003c/span\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePrimary Objectives\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTo synthesize evidence from extant systematic reviews concerning risk factors for and management of orthodontically induced root resorption.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTo identify and categorize clinical red flags that necessitate intervention during active orthodontic treatment.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTo provide evidence-informed management protocols for each identified red flag category.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSecondary Objective\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTo delineate research gaps requiring future investigation.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eConceptual Framework\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis umbrella review focuses specifically on\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eclinical red flags that emerge during active orthodontic treatment\u003c/span\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e\u0026mdash;that is, warning signs of complications that require prompt clinical response. Bj\u0026ouml;rk's structural signs for mandibular growth prediction are presented separately as historical and conceptual background; they do not form part of the umbrella review evidence synthesis.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudy Design\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis investigation constitutes an\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eumbrella review\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(synonymous with review of systematic reviews or overview of reviews). Umbrella reviews synthesize evidence from existing systematic reviews and meta-analyses to provide a comprehensive, high-level overview of a clinical topic\u003c/span\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis methodological approach is particularly appropriate when multiple systematic reviews addressing the same or related questions are available\u003c/span\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis umbrella review was not registered with PROSPERO.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eInclusion Criteria\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eStudy designs\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSystematic reviews, meta-analyses, and umbrella reviews.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003ePopulation\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePatients undergoing orthodontic treatment with full permanent dentition (excluding third molars).\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eIntervention\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFixed appliances (conventional or self-ligating brackets), clear aligners, or removable appliances.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eOutcomes\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eRoot resorption, iatrogenic complications (including loss of arch length, posterior open bite, asymmetric space closure, and gingival recession), and patient non-compliance.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eComparators\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAlternative treatment modalities (aligners versus fixed appliances; self-ligating versus conventional brackets) where applicable.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eExclusion Criteria\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePrimary studies (i.e., those not published as systematic reviews or meta-analyses).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNon-English publications where translation was unavailable.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eAnimal studies or in vitro investigations.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNarrative reviews lacking systematic methodology.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch Strategy and Databases\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDatabases searched (open access)\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePubMed/MEDLINE (free access via the United States National Library of Medicine).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDOAJ (Directory of Open Access Journals).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGoogle Scholar (open access articles; limitations acknowledged in Section 2.8).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSpringerOpen (open access journals).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eDatabases NOT accessed (subscription required)\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEMBASE (no institutional subscription available).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eScopus (no institutional subscription available).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWeb of Science (no institutional subscription available).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eCochrane CENTRAL (Cochrane Central Register of Controlled Trials; limited access).\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eGrey literature\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGrey literature, conference abstracts, dissertations, and unpublished studies were not systematically searched. Preprints were excluded.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSearch details\u003c/span\u003e:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSearch period: January 1, 2000 to December 31, 2025.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLast search executed: December 31, 2025.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eLanguage restriction: English.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eSearch terms\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e(Boolean operators applied to PubMed and Google Scholar)\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSearch Component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSearch Terms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReview type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"systematic review\"[Title/Abstract] OR \"meta-analysis\"[Title/Abstract] OR \"umbrella review\"[Title/Abstract] OR \"overview\"[Title/Abstract] OR \"review of reviews\"[Title/Abstract])\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrthodontic treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"orthodontic\u003cem\u003e\"[Title/Abstract] OR \"aligner\u003c/em\u003e\"[Title/Abstract] OR \"clear aligner\u003cem\u003e\"[Title/Abstract] OR \"fixed appliance\u003c/em\u003e\"[Title/Abstract])\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRoot resorption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"root resorption\"[Title/Abstract] OR \"EARR\"[Title/Abstract] OR \"OIIRR\"[Title/Abstract] OR \"apical resorption\"[Title/Abstract])\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"iatrogenic\"[Title/Abstract] OR \"complication\u003cem\u003e\"[Title/Abstract] OR \"adverse effect\u003c/em\u003e\"[Title/Abstract] OR \"red flag*\"[Title/Abstract])\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompliance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(\"compliance\"[Title/Abstract] OR \"non-compliance\"[Title/Abstract] OR \"patient behavior*\"[Title/Abstract])\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eStudy Selection\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTwo independent reviewers (MM and EA) screened titles and abstracts against the predefined eligibility criteria. Disagreements were resolved through discussion and consensus between the two reviewers, without recourse to a third-party arbitrator. Full-text systematic reviews were retrieved for all potentially eligible studies.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFor this umbrella review\u003c/span\u003e, \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eonly systematic reviews and meta-analyses were included\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003ePrimary studies were not extracted or analyzed directly; all quantitative findings are reported as synthesized in the source reviews.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eData Extraction\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eData were extracted from included systematic reviews and meta-analyses using a standardized form capturing the following elements: reference (author, year, journal), type of review (systematic review, meta-analysis, umbrella review, or overview), number of primary studies included, key findings, risk of bias assessment (as reported by the source review), and overall quality rating (as reported by the source review).\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHistorical and Conceptual Background: Bj\u0026ouml;rk's Structural Signs\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eImportant note\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis section on Bj\u0026ouml;rk's structural signs is\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003enot derived from systematic review evidence\u003c/span\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eand\u003c/span\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003edoes not form part of the umbrella review synthesis\u003c/span\u003e. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eIt is included solely as historical and conceptual background for clinicians unfamiliar with this classic orthodontic concept. The evidence base consists of longitudinal implant studies (n\u0026thinsp;\u0026gt;\u0026thinsp;300) conducted by Bj\u0026ouml;rk and colleagues between 1955 and 1984\u003c/span\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHistorical Background\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eProfessor Arne Bj\u0026ouml;rk and Dr. Vibeke Skieller conducted landmark longitudinal implant studies at the Royal Dental College in Copenhagen, placing metallic pins in the jaws of growing children to track mandibular growth rotation\u003c/span\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eBj\u0026ouml;rk suggested that conventional best-fit superimposition methods may introduce significant interpretive errors\u003c/span\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eOn the basis of these findings, Bj\u0026ouml;rk and Skieller developed the \"structural technique\" for superimposing serial cephalograms, which reduces errors inherent in conventional methods\u003c/span\u003e [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe Structural Signs\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructural Sign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForward Rotation (Horizontal Grower)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBackward Rotation (Vertical Grower)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondylar head inclination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosteriorly inclined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnteriorly inclined\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntegonial notch depth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShallow or absent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis inclination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePosteriorly inclined\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnteriorly inclined\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermandibular angle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSmall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSource: Bj\u0026ouml;rk \u0026amp; Skieller, 1972, 1984\u003c/em\u003e [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eClinical Application\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eForward rotation (horizontal growth pattern)\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTends to develop or deepen anterior deep bite; prognostically favorable for Class II correction as mandibular growth compensates.\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eBackward rotation (vertical growth pattern)\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eTends to develop or exacerbate anterior open bite; vertical dimension control during treatment is challenging, and relapse risk following open bite closure is elevated.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eQuality Assessment\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eQuality assessment was adopted directly from the source systematic reviews; no additional quality appraisal was performed beyond that reported in the source reviews. The instruments employed in the source reviews included AMSTAR-2, ROBIS, ROBINS-I, and RoB2.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eMethodological Limitations of This Umbrella Review\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe following methodological limitations are explicitly acknowledged\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eNo PROSPERO registration\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe review protocol was not prospectively registered.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eDatabase access limitations\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSystematic searches of subscription-based databases (EMBASE, Scopus, Web of Science, Cochrane CENTRAL) could not be performed due to lack of institutional access. This constitutes a significant limitation; the review should not be interpreted as exhaustive.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eGoogle Scholar limitations\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eGoogle Scholar was used despite its well-recognized limitations for systematic searching, including lack of reproducibility, variable coverage across disciplines, and absence of Boolean operator precision. The first 200 relevant results per search string were reviewed to mitigate these constraints.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eGrey literature exclusion\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eConference abstracts, dissertations, preprints, and unpublished studies were not systematically searched.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eLanguage bias\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe review was restricted to English-language publications.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eNo overlap analysis\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo formal overlap analysis (e.g., corrected covered area) was performed to quantify duplication of primary studies across the included systematic reviews.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eNo GRADE assessment\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNo de novo certainty assessment (e.g., GRADE) was performed.\u003c/span\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"BoldSmallCaps\" class=\"BoldSmallCaps\" name=\"Emphasis\"\u003eQuality of source reviews\u003c/span\u003e: \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe included systematic reviews ranged from critically low to high methodological quality\u003c/span\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eEvidence Synthesis\u003c/span\u003e\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA narrative synthesis was performed, organized thematically into three domains: (1) root resorption risk factors and management, (2) clinical red flags and corresponding management protocols, and (3) research gaps and future directions.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003ch3\u003e\u003cstrong\u003eIncluded Systematic Reviews and Meta-Analyses\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSeven systematic reviews and meta-analyses satisfied the eligibility criteria and were included in this umbrella review:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Included Systematic Reviews and Meta-Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003ePrimary Studies Included\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eFocus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eQuality (as reported)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eWeltman et al. (2010) [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eSystematic review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eOIIRR risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMethodological differences prevented quantitative pooling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eYassir et al. (2021) [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eOverview of SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e28 SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eOIIRR evidence synthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e71.5% moderate-to-high quality on AMSTAR-2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eVillaman-Santacruz et al. (2022) [8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eSR with MA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEARR by technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eLow certainty evidence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eSameshima \u0026amp; Iglesias-Linares (2021) [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003ePosition paper (SR-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEARR risk factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eModerate quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eYassir et al. (2022) [9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eOverview of SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eMultiple\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCAT effectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eModerate quality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eKreuter et al. (2025) [10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eCBCT-based MA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eAligners vs. fixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eModerate-to-high ROB\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 171px;\"\u003e\n \u003cp\u003eSelvaraj et al. (2025) [11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eUmbrella review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8 SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eAligners vs. fixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCritically low to high (varied)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: SR, systematic review; MA, meta-analysis; CAT, clear aligner therapy; ROB, risk of bias; OIIRR, orthodontically induced inflammatory root resorption; EARR, external apical root resorption.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e Baneshi et al. (2025) [12] was screened but not included in the primary synthesis because root resorption was a secondary outcome only; it is discussed in the narrative synthesis where relevant.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eSynthesis of Findings: Root Resorption\u003c/strong\u003e\u003c/h3\u003e\n\u003ch4\u003e\u003cstrong\u003eKey Findings from Included Systematic Reviews\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eWeltman et al. (2010) [7] concluded:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eComprehensive orthodontic treatment increases both the incidence and severity of root resorption.\u003c/li\u003e\n \u003cli\u003eHeavy orthodontic forces are consistently associated with increased OIIRR risk.\u003c/li\u003e\n \u003cli\u003eOIIRR is unaffected by archwire sequencing, bracket prescription (e.g., conventional versus self-ligating), or bracket type.\u003c/li\u003e\n \u003cli\u003ePrevious dental trauma and tooth morphology are unlikely causative factors.\u003c/li\u003e\n \u003cli\u003eOne systematic review suggested that a two- to three-month treatment pause may decrease total root resorption; this finding has not been confirmed by subsequent reviews.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eYassir et al. (2021) [2] concluded:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe incidence and severity of OIIRR increase with fixed appliance therapy, particularly in the context of heavy forces, intrusion mechanics, torquing movements, prolonged treatment duration, and extraction-based treatment protocols.\u003c/li\u003e\n \u003cli\u003eEvidence regarding most other treatment- and patient-related factors was insufficient.\u003c/li\u003e\n \u003cli\u003eThe precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood.\u003c/li\u003e\n \u003cli\u003eFollowing precautionary measures, pausing treatment and implementing regular monitoring benefit patients with OIIRR.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eVillaman-Santacruz et al. (2022) [8] concluded:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEvidence suggests that EARR induced by orthodontic treatment is similar irrespective of the technique employed.\u003c/li\u003e\n \u003cli\u003eEndodontically treated teeth exhibit less EARR associated with orthodontic treatment compared to vital teeth.\u003c/li\u003e\n \u003cli\u003eThese conclusions should be interpreted with caution owing to the low certainty of the available evidence.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eSameshima \u0026amp; Iglesias-Linares (2021) [1] identified risk factors:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cem\u003ePatient-related factors:\u003c/em\u003e Genetic predisposition, tooth anatomy (e.g., pipette-shaped or conical roots), demographic characteristics, malocclusion type, previous endodontic treatment, medical history, and short root anomaly.\u003c/li\u003e\n \u003cli\u003e\u003cem\u003eTreatment-related factors:\u003c/em\u003e Biomechanical force characteristics, appliance type, adjunctive therapies to accelerate tooth movement, early treatment, maxillary expansion, tooth extractions, treatment duration, and magnitude of apical displacement.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cstrong\u003eAligners versus Fixed Appliances: Evidence from Multiple Reviews\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Comparison of Reviews Examining Aligners versus Fixed Appliances\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eReview\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eFinding on Root Resorption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eQuality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eNotes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eKreuter et al. (2025) [10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eNo significant difference (MD 0.19 mm; p = 0.28); mean resorption \u0026lt;1 mm in both groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eModerate-to-high ROB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eCBCT-based meta-analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eSelvaraj et al. (2025) [11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eSignificant difference (0.62\u0026ndash;0.65 mm favoring aligners)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eCritically low to high (varied)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eUmbrella review of 8 SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003eYassir et al. (2022) [9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 229px;\"\u003e\n \u003cp\u003eLower root resorption risk with CAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eModerate quality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003eOverview of SRs\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eOverall interpretation across reviews:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Mean differences between treatment modalities were generally small, with the primary CBCT-based meta-analysis reporting mean resorption below 1 mm in both groups [10]; the umbrella review reported differences of 0.62\u0026ndash;0.65 mm favoring aligners [11]. Individual primary studies within the included reviews may report larger absolute resorption values in specific high-risk patient subsets. The clinical significance of these small differences remains debatable. Critically, the precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood [2].\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eRoot Resorption Risk Factors: Summary\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Root Resorption Risk Factors with Agreement Across Reviews\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003eRisk Factor Category\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eSpecific Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eAgreement Across Reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBiomechanical factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eHeavy forces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eIntrusion mechanics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eTorquing movements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eProlonged treatment duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eExtractions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eLarge apical displacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient-related factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eGenetic predisposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eTooth anatomy (pipette-shaped, conical)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003ePrevious dental trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review with limitations [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003eShort root anomaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 153px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 263px;\"\u003e\n \u003cp\u003ePrevious endodontic treatment (protective)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 272px;\"\u003e\n \u003cp\u003eReported in one review with low certainty [8]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eClinical Red Flags: Identification and Management Protocols\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eImportant note on clinical protocols:\u003c/strong\u003e The management protocols presented in Sections 4.3.1\u0026ndash;4.3.6 constitute an expert-informed clinical synthesis derived from available evidence integrated with widely accepted orthodontic principles. They should not be interpreted as formal, evidence-based clinical practice guidelines. Where evidence from systematic reviews exists, it is cited; where evidence is limited, this is explicitly noted as \u0026quot;clinical consensus.\u0026quot;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #1: Progressive Root Resorption (EARR)\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Root Resorption Severity Classification and Management\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSeverity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eCriteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eAction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eTimeline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eEvidence Base\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eYellow (caution)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eMild (\u0026lt;2 mm loss)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMonitor; continue with light forces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eRadiographic re-evaluation at 6\u0026ndash;12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eOrange (moderate)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2\u0026ndash;4 mm loss, stable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eReduce force magnitude; avoid intrusion and torque mechanics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eRecheck at 3\u0026ndash;4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eReported in position paper [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRed (severe)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026gt;4 mm loss or rapid progression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eRemove active forces; place passive archwire; consider early debonding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eImmediate (within 48 hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLong-term management:\u003c/strong\u003e Permanent bonded retention; avoidance of future orthodontic treatment on affected teeth; annual radiographic follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEvidence note:\u003c/strong\u003e Weltman et al. (2010) [7] suggested that a two- to three-month pause in active treatment may attenuate total root resorption; this finding has not been confirmed by subsequent reviews.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #2: Loss of Arch Length / Increased Lower Incisor Crowding\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Management of Arch Length Loss (Clinical Consensus)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eAction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 474px;\"\u003e\n \u003cp\u003eDetails\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 474px;\"\u003e\n \u003cp\u003eDiscontinue Class II elastics; verify integrity of lingual arch or Nance appliance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eShort-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 474px;\"\u003e\n \u003cp\u003eOpen coil spring (6\u0026ndash;9 mm) positioned between molars and incisors if space loss is \u0026lt;3 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 474px;\"\u003e\n \u003cp\u003eConsider temporary anchorage device (TAD) for distalization if space loss exceeds 3 mm\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003ePrevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 474px;\"\u003e\n \u003cp\u003eEmploy lower lingual holding arch for growing patients undergoing Class II treatment exceeding 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #3: Iatrogenic Posterior Open Bite\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Management of Iatrogenic Open Bite (Clinical Consensus)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eTimeframe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003ePrognosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eManagement\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026lt;3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eExcellent (\u0026asymp;90% correction rate)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eRemove bite turbos and elastics; implement anterior extrusion mechanics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e3\u0026ndash;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003eGuarded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003ePerform posterior intrusion using TADs or high-pull headgear\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003e\u0026gt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 239px;\"\u003e\n \u003cp\u003ePoor (\u0026asymp;40% relapse risk)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eConsider orthognathic surgery consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #4: Asymmetric Space Closure\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7: Management of Asymmetric Space Closure (Clinical Consensus)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"675\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eAction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 498px;\"\u003e\n \u003cp\u003eDetails\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 498px;\"\u003e\n \u003cp\u003eDiscontinue all elastics; inspect for broken brackets, displaced bands, or twisted archwires\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003eShort-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 498px;\"\u003e\n \u003cp\u003eApply power chain to the slower-closing side only until midline is centered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003ePersistent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 498px;\"\u003e\n \u003cp\u003eUse transpalatal arch (TPA) with stop on the faster-closing side; consider unilateral TAD\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 177px;\"\u003e\n \u003cp\u003ePrevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 498px;\"\u003e\n \u003cp\u003eProvide written elastic wear diagrams; advise patients that sleeping on one side may induce asymmetry\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #5: Gingival Recession or Fenestration\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8: Management of Gingival Recession\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eSeverity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eAction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eEvidence Base\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eDiscontinue buccal/labial root torque; replace heavy archwire with light passive wire (0.012\u0026ndash;0.014 NiTi)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eClinical consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eMove tooth palatally/lingually back into alveolar housing using light force (\u0026asymp;25 g) via closed coil spring from palatal TAD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eClinical consensus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 269px;\"\u003e\n \u003cp\u003eSevere (\u0026lt;2 mm attached gingiva + visible root)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 273px;\"\u003e\n \u003cp\u003eStop active orthodontic forces; debond if feasible; refer to periodontist for connective tissue graft (wait 3 months after force removal before grafting)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 145px;\"\u003e\n \u003cp\u003eReported in review [13]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eRisk factors:\u003c/strong\u003e Thin gingival biotype (approximately 4.2-fold increased risk), proclination exceeding 15\u0026deg; from baseline, and history of periodontal disease [13].\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eRed Flag #6: Patient Non-Compliance with Safety Risks\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003e\u003cstrong\u003eTable 9: Management of Non-Compliance (Clinical Consensus)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"695\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260px;\"\u003e\n \u003cp\u003eOccurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 435px;\"\u003e\n \u003cp\u003eAction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260px;\"\u003e\n \u003cp\u003eFirst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 435px;\"\u003e\n \u003cp\u003eDocument findings; re-instruct patient (and parent/guardian if minor); schedule follow-up in 2\u0026ndash;4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260px;\"\u003e\n \u003cp\u003eSecond\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 435px;\"\u003e\n \u003cp\u003eConvene emergency patient\u0026ndash;parent conference; establish written behavioral contract; simplify mechanics (remove elastics, place passive archwire); implement 4-week probation with weekly appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260px;\"\u003e\n \u003cp\u003eThird (or no improvement)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 435px;\"\u003e\n \u003cp\u003eDebond appliances; deliver passive retainers; provide written discharge letter with transfer recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eWarning signs requiring heightened vigilance:\u003c/strong\u003e Elastics found stockpiled (unopened or hidden); two or more consecutive missed appointments; repeated bracket fractures (particularly on anterior teeth); generalized bleeding on probing, heavy plaque accumulation, or visible calculus.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch3\u003e\u003cstrong\u003eSummary of Principal Findings\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis umbrella review synthesizes evidence from seven systematic reviews and meta-analyses addressing clinical red flags in orthodontic treatment:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Convergent evidence across multiple systematic reviews [2,7] identifies these factors as modifiable risk determinants. One systematic review suggested that a two- to three-month treatment pause may reduce total root resorption; however, this finding awaits confirmation by subsequent investigations [7].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. The precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Yassir et al. (2021) [2] concluded that, although orthodontic treatment clearly contributes biologically to root resorption, the specific predictors, biomechanical interactions, and susceptibility factors are not fully characterized. Sameshima and Iglesias-Linares (2021) [1] similarly observed that \u0026quot;no robust and unequivocal scientific evidence is yet available.\u0026quot;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Evidence comparing clear aligners with fixed appliances is conflicting.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A CBCT-based meta-analysis identified no statistically significant difference between modalities (p = 0.28), with mean resorption below 1 mm in both groups [10]. An umbrella review reported small differences favoring aligners (0.62\u0026ndash;0.65 mm), albeit with variable methodological quality across included reviews [11]. An overview of systematic reviews found lower root resorption risk associated with clear aligner therapy [9].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Structured red flag protocols offer a systematic framework that may enhance patient safety.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Although direct outcome studies validating these protocols are lacking, the precautionary principle\u0026mdash;supported by Yassir et al. (2021) [2] and Sameshima \u0026amp; Iglesias-Linares (2021) [1]\u0026mdash;justifies structured monitoring and protocolized intervention.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eComparison of Findings Across Included Reviews\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eTable 10: Agreement Across Included Systematic Reviews\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"632\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eTopic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eAgreement Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eReviews Agreeing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eNotes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eHeavy forces associated with increased OIIRR risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e2/2 reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eConsistent finding across systematic reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eTwo- to three-month rest period suggested\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e1/1 [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eNot yet confirmed by subsequent reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eOIIRR unaffected by bracket type (conventional vs. self-ligating)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e1/1 [7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eNot contradicted in the literature\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eAligners vs. fixed appliances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003eMixed [9,10,11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eConflicting findings across reviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 230px;\"\u003e\n \u003cp\u003eGenetic factors contribute to OIIRR risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eSingle review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115px;\"\u003e\n \u003cp\u003e1/1 [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 203px;\"\u003e\n \u003cp\u003eSupported by SR-based position paper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eRecommendation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eEvidence Base\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eEmploy light forces, particularly during incisor intrusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eConsider a two- to three-month treatment pause if progressive resorption is detected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eSingle review [7]; not yet confirmed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eMonitor high-risk patients (those with genetic predisposition, unfavorable root morphology, or prolonged treatment duration)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eReported in position paper [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eInterpret OIIRR evidence cautiously owing to low-to-moderate evidence quality and conflicting findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eConsistent across reviews [2,10,11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/h3\u003e\n\u003ch4\u003e\u003cstrong\u003eUmbrella Review Limitations\u003c/strong\u003e\u003c/h4\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eNo PROSPERO registration:\u003c/strong\u003e The review protocol was not prospectively registered.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDatabase access limitations:\u003c/strong\u003e Subscription-based databases (EMBASE, Scopus, Web of Science, Cochrane CENTRAL) could not be searched due to lack of institutional access. This constitutes a significant limitation; the review should not be interpreted as exhaustive.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGoogle Scholar limitations:\u003c/strong\u003e Google Scholar was used despite its recognized limitations for systematic searching, including lack of reproducibility, variable coverage, and absent Boolean operator precision. The first 200 results per search string were reviewed.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGrey literature exclusion:\u003c/strong\u003e Conference abstracts, dissertations, preprints, and unpublished studies were not systematically searched.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLanguage bias:\u003c/strong\u003e The review was restricted to English-language publications.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNo overlap analysis:\u003c/strong\u003e No formal overlap analysis (e.g., corrected covered area) was performed to quantify primary study duplication across included systematic reviews.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNo GRADE assessment:\u003c/strong\u003e No de novo certainty assessment was performed.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eQuality of source reviews:\u003c/strong\u003e Included reviews ranged from critically low to high methodological quality [2,10,11,12].\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cstrong\u003eEvidence Base Limitations\u003c/strong\u003e\u003c/h4\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003e\u003cstrong\u003eLow-to-moderate evidence quality:\u003c/strong\u003e Yassir et al. (2021) [2] noted \u0026quot;a limited number of high-quality studies\u0026quot; addressing OIIRR.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConflicting findings:\u003c/strong\u003e Discrepancies between meta-analyses [10,11] reflect substantial underlying uncertainty.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHigh statistical heterogeneity:\u003c/strong\u003e The CBCT-based meta-analysis reported very high heterogeneity (I\u0026sup2; = 98.5%) [10].\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIncompletely understood causal relationships:\u003c/strong\u003e The precise causal relationships between orthodontic biomechanics and OIIRR severity remain incompletely understood [2].\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003e\u003cstrong\u003eClinical Protocols Disclaimer\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe clinical management protocols presented in Sections 4.3.1\u0026ndash;4.3.6 constitute expert-informed syntheses intended for educational purposes. They should not be interpreted as formal clinical practice guidelines. These protocols are derived from available evidence integrated with widely accepted orthodontic principles. Where evidence is limited, this is explicitly noted as \u0026quot;clinical consensus.\u0026quot; Formal guideline development would require a systematic review of primary studies with GRADE certainty assessment, which was not performed in this umbrella review.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eResearch Gaps and Future Directions\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eGap Identified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eRecommended Future Research\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003ePriority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eConflicting evidence on aligner versus fixed appliance OIIRR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eHigh-quality RCTs employing standardized CBCT protocols and low risk of bias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eHigh [2,12]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eIncompletely understood causal relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eProspective studies controlling for confounding variables (genetic, biomechanical, demographic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eHigh [2]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eEffectiveness of two- to three-month treatment pause\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eRCTs directly comparing immediate continuation versus paused treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eValidity of clinical consensus protocols\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 294px;\"\u003e\n \u003cp\u003eProspective cohort studies examining protocol effectiveness and safety outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eEmerging Concepts Requiring Future Validation\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eA preliminary behavioral classification framework has been proposed in the literature, identifying five orthodontic patient categories\u0026mdash;Idealists, Inconsistents, Skeptics, Strugglers, and Unpredictables\u0026mdash;based on treatment demand, trust in the orthodontist, compliance, and treatment response [14]. This framework derives from a single cross-sectional study (n = 100) employing subjective clinician assessment and has not undergone external validation. It is included here as an emerging concept for future research, not as established evidence. External validation in larger, multicenter samples is required before clinical implementation can be recommended.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003ch3\u003e\u003cstrong\u003eKey Conclusions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003e1. Heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Consistent evidence across systematic reviews [2,7] identifies these as modifiable risk factors. One systematic review suggested that a two- to three-month treatment pause may be beneficial; this finding awaits confirmation by subsequent reviews [7].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. The precise causal relationships between orthodontic biomechanics and the severity of OIIRR remain incompletely understood.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Yassir et al. (2021) [2] concluded that, while orthodontic treatment clearly contributes biologically to root resorption, the specific predictors, biomechanical interactions, and susceptibility factors are not fully characterized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Evidence comparing aligners with fixed appliances is conflicting and of variable methodological quality.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;A CBCT-based meta-analysis found no statistically significant difference between modalities [10]; an umbrella review reported small differences favoring aligners, albeit with variable quality across included reviews [11].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Structured red flag protocols offer a systematic framework that may enhance patient safety.\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Although direct outcome studies validating these protocols are lacking, the precautionary principle supported by the literature [1,2] justifies structured monitoring and protocolized intervention.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eRecommendations for Clinical Practice\u003c/strong\u003e\u003c/h3\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eRecommendation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eEvidence Base\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eEmploy light forces, particularly during incisor intrusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eConsistent across two reviews [2,7]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eConsider a two- to three-month treatment pause if progressive root resorption is detected\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eSingle review [7]; not yet confirmed\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eMonitor high-risk patients (genetic predisposition, unfavorable root morphology, prolonged treatment duration)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eReported in position paper [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 408px;\"\u003e\n \u003cp\u003eInterpret OIIRR evidence cautiously owing to low-to-moderate quality and conflicting findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 312px;\"\u003e\n \u003cp\u003eConsistent across reviews [2,10,11]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003e\u003cstrong\u003eFinal Statement\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eClinical red flags in orthodontic treatment\u0026mdash;progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession, and patient non-compliance\u0026mdash;mandate systematic recognition and protocolized management. This umbrella review of seven systematic reviews confirms that heavy forces, intrusion mechanics, and prolonged treatment duration are consistently associated with increased OIIRR risk. Evidence comparing aligners with fixed appliances remains conflicting. Structured red flag protocols provide a systematic framework that may enhance patient safety. Future high-quality randomized controlled trials employing standardized protocols and low risk of bias are urgently required to definitively resolve outstanding questions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSameshima GT, Iglesias-Linares A (2021) Orthodontic root resorption. J World Federation Orthodontists 10(4):135\u0026ndash;143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYassir YA, McIntyre GT, Bearn DR (2021) Orthodontic treatment and root resorption: an overview of systematic reviews. Eur J Orthod 43(4):442\u0026ndash;456\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFusar-Poli P, Radua J (2018) Ten simple rules for conducting umbrella reviews. Evid Based Ment Health 21(3):95\u0026ndash;100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAromataris E, Fernandez R, Godfrey CM et al (2015) Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc 13(3):132\u0026ndash;140\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBj\u0026ouml;rk A, Skieller V (1972) Facial development and tooth eruption: An implant study at the age of puberty. Am J Orthod 62(4):339\u0026ndash;383\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNielsen IL (2018) Cephalometric Analysis of Growth and Treatment with the Structural Technique: A Review of its Background and Clinical Application. Taiwan J Orthod 30(2):Article1\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeltman B, Vig KWL, Fields HW, Shanker S, Kaizar EE (2010) Root resorption associated with orthodontic tooth movement: a systematic review. Am J Orthod Dentofac Orthop 137(4):462\u0026ndash;476\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillaman-Santacruz H, Torres-Rosas R, Acevedo-Mascar\u0026uacute;a AE, Argueta-Figueroa L (2022) Root resorption factors associated with orthodontic treatment with fixed appliances: A systematic review and meta-analysis. Dent Med Probl 59(3):437\u0026ndash;450\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYassir YA, Nabbat SA, McIntyre GT, Bearn DR (2022) Clinical effectiveness of clear aligner treatment compared to fixed appliance treatment: an overview of systematic reviews. Clin Oral Invest 26(3):2353\u0026ndash;2370\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKreuter P et al (2025) Root resorption caused by aligners, self-ligating appliances, and conventional fixed appliances: a CBCT-based meta-analysis. BMC Oral Health 25:1259\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelvaraj M et al (2025) Orthodontically induced external apical root resorption with clear aligners compared to fixed appliance treatment: An umbrella review. Journal of Oral Biology and Craniofacial Research. PMID: 40621584\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaneshi M, O'Malley L, El-Angbawi A, Thiruvenkatachari B (2025) Effectiveness of clear orthodontic aligners in correcting malocclusions: A systematic review and meta-analysis. J Evid Based Dent Pract 25(1):102081\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParashos P (2023) Endodontic-orthodontic interactions: a review and treatment recommendations. Aust Dent J 68(Suppl 1):S66\u0026ndash;S81\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSavio S, Sreenivasagan S, Balasubramaniam A (2025) A Behavioral Classification Framework for Orthodontic Patients: Understanding Demand, Compliance, Trust, and Treatment Response. J Neonatal Surg. ;14\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Orthodontic red flags, root resorption, patient compliance, iatrogenic complications, umbrella review","lastPublishedDoi":"10.21203/rs.3.rs-9670282/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9670282/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eWithin contemporary orthodontic practice, the term \"clinical red flags\" denotes warning signs of impending treatment-related complications that necessitate prompt clinical intervention. This umbrella review synthesizes evidence derived from existing systematic reviews to evaluate the identification and management of such red flags during active orthodontic treatment.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eA systematic search of open-access electronic databases\u0026mdash;specifically PubMed/MEDLINE, DOAJ (Directory of Open Access Journals), Google Scholar, and SpringerOpen\u0026mdash;was conducted for the period spanning January 1, 2000 to December 31, 2025, to identify systematic reviews and meta-analyses addressing orthodontic red flags. Grey literature, conference abstracts, dissertations, and unpublished studies were not systematically searched. Quality appraisal was adopted from source reviews, which employed validated instruments including AMSTAR-2, ROBIS, ROBINS-I, and RoB2. No formal overlap analysis (e.g., corrected covered area) was performed.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eSeven systematic reviews and meta-analyses satisfied the predefined inclusion criteria. Convergent evidence across multiple reviews indicates that heavy orthodontic forces, intrusion mechanics, and prolonged treatment duration are consistently associated with an elevated risk of orthodontically induced inflammatory root resorption (OIIRR). One systematic review suggested that a two- to three-month treatment pause may attenuate total root resorption, although this finding has not been corroborated by subsequent investigations. Evidence comparing clear aligners with fixed appliances remains conflicting: one CBCT-based meta-analysis identified no statistically significant difference between modalities (mean difference 0.19 mm; p\u0026thinsp;=\u0026thinsp;0.28), with mean resorption below 1 mm in both groups; conversely, an umbrella review reported small differences favoring aligners (0.62\u0026ndash;0.65 mm), albeit with variable methodological quality across the included reviews. Structured management protocols addressing progressive root resorption, loss of arch length, iatrogenic posterior open bite, asymmetric space closure, gingival recession, and patient non-compliance are presented as an expert-informed clinical synthesis.\u003c/span\u003e \u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eHeavy forces, intrusion mechanics, and extended treatment duration are consistently associated with increased OIIRR risk. Evidence comparing aligners and fixed appliances is conflicting. Structured red flag protocols offer a systematic framework that may enhance patient safety. High-quality randomized controlled trials are urgently required to resolve outstanding uncertainties.\u003c/span\u003e \u003c/p\u003e","manuscriptTitle":"Clinical Red Flags in Orthodontic Treatment: An Umbrella Review of Risk Indicators and Iatrogenic Complications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 07:44:01","doi":"10.21203/rs.3.rs-9670282/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14444f99-726e-425b-aac5-f76e96224577","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":67868955,"name":"Dentistry"}],"tags":[],"updatedAt":"2026-05-12T07:44:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 07:44:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9670282","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9670282","identity":"rs-9670282","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}