Comparative effectiveness of manual and powered toothbrush types in patients with fixed orthodontic appliances: a systematic review and network meta-analysis

Background Fixed orthodontic appliances promote plaque retention and increase the risk of gingival inflammation and enamel demineralization. Evidence comparing toothbrush designs in this population remains limited. Objective To compare nine manual and powered toothbrush types for plaque, gingival inflammation and bleeding in patients with fixed orthodontic appliances using network meta-analysis. Methods PubMed/MEDLINE, Scopus, Web of Science and CENTRAL were searched through 31 March 2026 for randomized controlled trials. Nine treatment nodes were defined by mechanism of action and head design. Outcomes were synthesized as standardized mean differences (plaque, bleeding) or mean differences (gingival index) using frequentist random-effects models at ≤2 weeks, 4–6 weeks (primary), 8–12 weeks and ≥6 months. Inconsistency was assessed locally and globally. Risk of bias was evaluated with RoB 2, sensitivity analyses were conducted, and certainty of primary-window estimates was assessed with CINeMA. The review was not prospectively registered. Results Eighteen trials (986 participants randomized; 947 analysed) comprising nine treatment nodes were included. At 4–6 weeks, neither oscillating–rotating nor sonic powered brushes differed from conventional manual brushes for gingival inflammation or bleeding. Oscillating–rotating brushing reduced plaque in the primary analysis (SMD −0.98, 95% CI −1.74 to −0.21), but this finding was not robust to sensitivity analyses excluding smartphone-assisted interventions, trials with implausible dispersions, or trials at high risk of bias. Prediction intervals included no difference for all powered comparisons at 4–6 and 8–12 weeks. Significant global inconsistency occurred for plaque and bleeding (both p < 0.001), but not gingival inflammation ( p = 0.36). Conclusions Powered toothbrushes did not demonstrate superiority over conventional manual brushing for plaque, gingival inflammation or bleeding in patients with fixed orthodontic appliances. Findings favoring specific designs were based on limited and methodologically uncertain evidence, while some trials confounded toothbrush technology with co-interventions. Certainty was very low throughout; therefore, the findings indicate an absence of demonstrated superiority rather than equivalence. Well-powered head-to-head trials controlling oral hygiene instruction and adjunctive measures are needed.