Biocompatibility and Safety of Orthodontic Clear Aligners and Thermoplastic Retainers: A Systematic In Vitro Review (2015–2025)

Background: Clear aligners have become a common alternative to fixed appliances for tooth movement, and thermoplastic retainers hold the outcome. The prolonged intraoral contact of these devices has made the materials a focus of biocompatibility research. Objectives: This paper aims to summarize laboratory evidence on the biocompatibility of clear aligners and thermoplastic retainers. Materials included thermoformed polyethylene terephthalate glycol-modified (PETG), multilayer polyurethane, and directly printed resins. Primary outcomes were cytotoxicity, endocrine activity, and chemical or particle release. Methods: We systematically searched PubMed, the Cochrane Library, and Google Scholar through 31 May 2025, and we followed the PRISMA 2020 statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). We applied predefined eligibility criteria. Two reviewers screened records and extracted data in duplicate, including study design, extraction conditions, surface-area-to-volume ratio (SA/V), cell models, endpoints, and analytical sensitivity as the limit of detection (LOD) and limit of quantification (LOQ). We assessed the risk of bias across seven domains and graded certainty by outcome. We did not register a protocol prospectively. Results: Seventeen studies met the inclusion criteria. Materials spanned multilayer polyurethanes (SmartTrack, Clarity), PETG sheets (Essix ACE, Duran), and directly printed resins (Graphy TC-85DAC); a subset tested zinc-oxide (ZnO) nanoparticle coatings. Typical extractions immersed 0.1–1 g of material in cell-culture medium or artificial saliva at 37 °C for 24 h to 30 days. Cell viability usually remained ≥80%. Mild cytotoxicity (about 60–70% viability) appeared with harsher extractions, extended soaks, or an inadequate post-curing of printed parts. The estrogen-sensitive proliferation assay (E-Screen) returned negative results. In saliva-like media, bisphenol A (BPA) and related leachables were undetectable or in the low ng/mL range. In printed resins, urethane dimethacrylate (UDMA) sometimes appeared in water extracts, and amounts varied with curing quality. Evidence for chemical leaching and endocrine outcomes is sparse. We found no eligible in vitro study that quantified particle or microplastic release while also measuring a biological endpoint; we discuss particle findings from mechanical wear simulations only as the external context. Limitations: The evidence base is limited to in vitro studies. Many reports incompletely described extraction ratios and processing parameters. Risk of bias and certainty: Most studies used appropriate cell models and controls, but the reporting of surface-area-to-volume ratios, LOD/LOQ, and detailed post-processing parameters was often incomplete. Sample sizes were small, and dynamic wear or enzymatic conditions were uncommon. The overall risk of bias was moderate, and the certainty of evidence was low to moderate due to heterogeneity and in vitro indirectness. Conclusions: Under standard laboratory conditions, clear aligners and thermoplastic retainers show a favorable biocompatibility profile. For printed resins, outcomes depend mainly on processing quality, especially thorough washing and appropriate light-curing parameters. To improve comparability and support clinical translation, we recommend harmonized test protocols, transparent reporting, interlaboratory ring trials, and targeted clinical biomonitoring.