DOI: 10.12688/f1000research.189954.1 ISSN: 2046-1402

Combined At-Home Dental Bleaching and Clear Aligner Therapy Using a New Self-Cure Bulk-Fill Composite: Clinical Insights and a Systematic Review on Attachment Loss

Rim Bourgi, Louis Hardan, Anh Tuan Dang, Alaa Charif, Grace Ellen S. Dey, Carlos Enrique Cuevas-Suárez, Mohammed Mzedawee, Naji Kharouf, Youssef Haïkel
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Background The rising demand for dental aesthetics has driven interest in combining orthodontic treatments with tooth whitening. Clear aligners offer a removable, aesthetic alternative that can serve as dual-purpose devices, simultaneously guiding tooth movement and acting as trays for bleaching agents. However, their clinical effectiveness heavily depends on aligner retention and attachment stability. Objective This study evaluated the clinical applicability and efficacy of at-home dental bleaching during clear aligner therapy utilizing a novel self-cure bulk-fill composite for attachments. Additionally, a systematic review was conducted to evaluate attachment loss during clear aligner therapy, providing critical context on factors influencing aligner retention and bleaching uniformity. Methods A 32-year-old female patient undergoing clear aligner treatment received nightly at-home bleaching with 16% carbamide peroxide (Pola Night, SDI, Victoria, Australia) for 14 days. Digital intraoral scanning was used to plan tooth movement, and composite attachments were fabricated using a novel self-cure bulk-fill composite (Stela Automix, SDI). Standardized photographs (Smile Lite MDP2, Smile Line, St-Imier, Switzerland) documented baseline and post-treatment shades. Patient comfort, gingival health, and aesthetic outcomes were recorded. Concurrently, a systematic review following PRISMA guidelines was conducted across PubMed, Web of Science, Scopus, Embase, and Scielo for clinical studies published up to March 24, 2026, reporting on attachment loss and associated risk factors. Risk of bias was assessed using the ROBINS-I tool. Results The combined protocol achieved a noticeable shade improvement from baseline A2 to post-treatment B1, with minimal tooth sensitivity and no gingival irritation. The clear aligners effectively delivered the whitening agent uniformly, including around the attachments. No attachment loss occurred during treatment, and the patient reported high satisfaction. From 186 identified records, 2 clinical studies met the inclusion criteria for the systematic review. These studies identified reduced wear time, frequent aligner removal, and specific tooth locations as key risk factors for attachment loss, which may compromise aligner seating and retention. Conclusions Combining at-home bleaching with clear aligner therapy using Stela Automix attachments demonstrated excellent clinical viability, uniform whitening, and stable attachment retention. While the systematic review highlights that factors like reduced wear time and frequent removal increase the risk of attachment loss, the novel bulk-fill composite remained stable throughout the dual protocol. Further long-term clinical trials are warranted to confirm these findings.

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