Enamel Surface Alterations and Residual Composite After Removal of Clear Aligner Attachments: A Systematic Review

This systematic review assessed enamel surface alterations and residual composite following clear aligner attachment removal, focusing on how removal techniques, instrument type, operator experience, and magnification influence enamel loss and composite remnants. Methods: A comprehensive search of PubMed, Scopus, Embase, Web of Science, and the Cochrane Library was conducted up to October 2025. In vitro, ex vivo, and clinical studies assessing enamel loss, residual composite, surface roughness, or removal time were included. Data extraction followed PRISMA 2020 guidelines, and risk of bias was evaluated using the modified JBI checklist. Due to heterogeneity across studies, a narrative synthesis was performed. Results: Of 583 screened records, three in vitro/ex vivo studies met the criteria. Enamel loss ranged from about 15 µm to over 50 µm, varying with the instrument used and operator visibility. Residual composite covered 20–40% of the surface. Sequential use of tungsten carbide burs followed by silicone polishers under magnification provided the best balance between enamel preservation and composite removal. Fiberglass burs produced smoother surfaces but caused greater enamel reduction. One-step systems (OneGloss, Enhance, SM104) offered low surface roughness and reduced removal time. Magnification ≥2.5× consistently improved precision and reduced composite remnants. Differ-ences in study designs and outcome measures prevented meta-analysis. Overall methodological quality was acceptable. Conclusions: Clear aligner attachment removal leads to measurable enamel loss and composite remnants. Technique selection and visualization aids significantly influence outcomes. Sequential carbide–silicone polishing under magnification appears to opti-mize enamel preservation and procedural control.