Review Article

Clear Aligner: Effectiveness, Limitations and Considerations

Pimsiri Kanpittaya1, Chidsanu Changsiripun1, Tanan Jaruprakorn1, Ruangrat Komolpis1,

Somsak Chengprapakorn1, Vudhibhong Laoamata1, Preeya Suwanwitid1
Department of Orthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
1

Abstract
Clear aligner has been an alternative appliance in orthodontic treatment to conventional fixed appliances
in adult and teen patients. There are advantages in terms of hygiene, comfort and esthetics, however, clinician
expertise and patient compliance are critical for satisfactory treatment results. Lower incisor intrusion, mandibular
arch expansion and upper molar distalization are the predictable movements with clear aligner while extrusion and
rotation are the movements that require auxiliaries and additional technique to reach the designated position. To achieve
the best treatment results, clinicians must consider movement limitations, considerations and recommendations for
clear aligner therapy.

Keywords : Clear aligner, Effectiveness, Fixed appliance, Orthodontic treatment

Received Date: Dec 2, 2020 Revised Date: Jan 8, 2021 Accepted Date: Mar 19, 2021
doi: 10.14456/jdat.2021.25

Correspondence to :
Preeya Suwanwitid, Department of Orthodontics, Faculty of Dentistry, Chulalongkorn University, Henri-Dunant Road, Wangmai, Pathumwan,
Bangkok 10330 Thailand. Email : [email protected] Tel: 02-2188930 Fax: 02-2188953

Introduction
Increasing demand for adult orthodontic treatment to create tooth movement. However, each clear aligner
has resulted in clear aligners gaining popularity as a treatment needed to be manually set up to achieve tooth movement
option. Clear aligners offer a better experience in terms of until Invisalign was launched in 1998 (System for incrementally
hygiene, comfort, esthetics, number of visits and duration moving teeth with clear aligner. Santa Clara, California Align
compared with conventional fixed appliances.1 Thus, Technology; 1998) using computer-aided design (CAD) and
clinicians consider them as an alternative to conventional a computer-aided manufacturing (CAM) process known
fixed appliances. as stereolithography to produce the appliances.
Clear aligner was first used in orthodontics as a Initially, clear aligner could only be used to correct
tooth positioner by Kesling2 in 1946. In 1993, Sheridan3 simple malocclusions.4 However, as the company invested
suggested using a clear aligner with interproximal reduction in research and development, the limitations of Invisalign

Kanpittaya et al., 2021 231

have been reduced by company innovations such as Clear aligner biomechanics
material innovation, various types of attachments, and The mechanism of tooth movement using a clear
the amount of movement per aligner, as well as clinicians aligner is classified into two systems.5 There is the shape
gaining expertise in using the appliance. driven system (displacement system), where the shape
This review summarizes the effectiveness of clear of the plastic aligner is changed incrementally into each
aligners for different types of tooth movement and the upcoming stage of tooth alignment to move each tooth
clinical limitations of the appliance. into the designated position (Fig. 1).

Figure 1 Shape driven system: tooth displacement as changing of aligner’s shape

Each tooth is moved based on the plastic aligner’s This system allows for more complicated movement,
shape. This system can only control simple movements, such as root movement. Biomechanically, aligners produce
such as tipping or slight rotation. There is also the force a pushing force from the plastic to the tooth surfaces or
driven system, in which the aligner’s plastic is shaped attachments. In contrast, conventional fixed appliances
using digital treatment plan software in which the clinician generate a pulling force by ligating the wire and brackets
can set the parameters of tooth movement by the aligner using an elastomeric ring. The predictability of movement
combined with other attachments to apply force to the with two armamentariums is different because of dissimilar
tooth (Fig. 2a., 2b.). force application concept. Aligners cannot generate a pulling
force because they disengage from the tooth. Tipping and
intrusion are the most easily accomplished movements
for clear aligners.6
Plastic is not as rigid as metal wires and brackets
so that the aligner may distort when placed on malaligned
teeth. Moreover, the plastic edge of the aligner cannot
deliver force at the gingival level.6 In contrast, force is
always applied directly on the occlusal part resulting in
intrusion, which is an undesirable movement. Attachments
and other auxiliaries are recommended to make specific
movements possible. (Fig. 2b.)
Figure 2 Force driven system : (a) movement from force application:
Effectiveness of tooth movement
Plastic indentation create force (arrow) to torque root
lingually, (b) Force driven system: movement from force Intrusion/Extrusion
application: Tooth extrusion from force (arrow) applied Movement in the vertical plane is challenging
on attachment surface when using clear aligners. Kravitz et al.7 reported a 41 %

232 J DENT ASSOC THAI VOL.71 NO.4 October - December 2021

accuracy for anterior intrusion and 30 % for extrusion. the amount of change required in treatment planning was
Khosravi et al.8 demonstrated good deep bite management lower compared to the maxilla.
with Invisalign appliances; however, the result occurred Crossbite elastics may be used to obtain a better
predominantly due to incisor proclination and relative transverse tooth relationship. Overcorrection of maxillary
intrusion, not true intrusion. In contrast, an open bite was arch expansion is recommended to be prescribed into the
successfully treated using incisor extrusion with attachments digital plan for predictable bodily movement, especially
and posterior intrusion.8 in the posterior region.11 Moreover, appropriate attachments
A subsequent study9 reported a higher accuracy for buccal root torque is important for bodily movement
for lower incisors intrusion at 73 %. The improved results control during arch expansion.
could be from a new aligner material called SmartTrack Rotation
(available after 2013) that the manufacturer claims to Tooth rotation is another challenging movement
give a more gentle and constant force, together with the for clear aligners. Studies demonstrated low accuracy when
routine incorporation of overcorrection in the clinicians’ derotating canines and premolars, 36 % and 40 % respectively,
digital treatment plan.8 which had round clinical crowns, while higher accuracy
To improve the accuracy of vertical movement, the was found at the incisors.13,14 Interproximal reduction, proper
use of horizontal attachments on premolars for retention, attachment design and staging (amount of movement per
bite ramps, or vertical elastics, is recommended. Besides, aligner) improve rotation accuracy since tooth movement
additional aligners or overbite overcorrection should be with clear aligner requires sufficient tooth surface area
used to achieve accurate results.10 to engage with and enough space with an optimum rate
Arch expansion of movement to achieve the predicted rotation.13,15 In
Two studies demonstrated that maxillary arch contrast, in poor compliant patients, attachments in an
expansion using clear aligners occurred via tooth tipping unfitted aligner may create a counter moment which leads
rather than bodily movement11,12 with the lowest bodily to rotation in the opposite direction. That is the reason why
expansion efficiency found on the maxillary first molar a study showed poor compliance caused a lower mean
(37 %).12 The amount of transverse change decreased from accuracy of premolar derotation in tooth surface with
anterior to posterior due to multiple factors, such as cortical attachment rather than without attachment.13 However
bone thickness, soft tissue resistance, masticating force, attachment selection is a clinician-based decision. For
and root anatomy. Moreover, the mechanical efficiency canine derotation, the accuracy of movement is significantly
of the force delivered from an aligner decreases from the reduced for rotation greater than 15°.13 Proper staging
anterior to posterior region, which might be another concern for premolar derotation is <1.5° per aligner.7
for effective expansion.12 Molar distalization
In the mandible, the accuracy of overall arch ex- Molar distalization, translational movement, with
pansion is 88 %.11 The highest accuracy of bodily movement clear aligners is predictable. Simon et al. reported 87 %
measurement at the gingival level was found at the accuracy for molar distalization of >1.5 mm on upper molars
premolar and the lowest at the canine. There was no without using Class II elastics for anchorage.13 The accuracy of
statistical difference between the digital plan prediction molar distalization was similar in the attachment-supported
and the clinical outcome, which indicated that transverse group compared with the no attachment group.13 These
movement in the mandibular region with clear aligner was findings agreed with those of another study. Using Class II
predictable.11 However, the authors suggested that the elastics and attachments, upper first molars could be
mandible achieved higher accuracy for expansion because distalized 2.25 mm without tipping.16 Class II elastics were

Kanpittaya et al., 2021 233

recommended as anchorage preservation during distalization ments were not achieved due to anchorage loss. Anchorage
to prevent anterior tooth proclination. Rectangular and tooth preparation was recommended to reach the anticipated
vertical attachments were needed on the buccal surface tooth movement. Distal crown tipping of the first molars
of distalizing molars to create moment resisting undesirable with attachments should be prescribed to maintain the
tipping movements.17 normal angulation and bodily tooth movement.18 Power
Molar distalization is a common strategy to ridges, attachments, and greater labial crown torque should
correct Class II malocclusion without extraction in an adult be planned in aligner fabrication software to obtain the
whose further growth is not anticipated. When using this optimal clinical incisal torque at the end.
protocol in hyperdivergent patients, the vertical dimension The study showed no significant difference in
must be controlled to prevent increasing the lower facial alignment, marginal ridges, occlusal relations, overjet,
height, which may cause mandibular clockwise rotation interproximal contacts, and root angulation in the final
and worsen the desired result. Clear aligner is an effective result in an extraction case compared with conventional
appliance for molar distalization in hyperdivergent patients fixed appliances.19 Although significant differences were
because there is no significant crown tipping and no significant found at the occlusal contacts and buccolingual inclination
change in vertical facial height.16 between systems, these were not clinically meaningful.
Premolar extraction site closure Moreover, good root angulation was well managed with
In first premolar extraction cases using clear aligners, the appropriate attachments. The overall results indicated
tooth movement predictability of upper first molars and that with good control, clear aligner is as effective as fixed
upper central incisors were studied. At the maxillary first appliances to treat class I extraction cases.19
molars, greater mesial tipping, mesial translation, and intrusion The effectiveness of clear aligner and recom-
were found than predicted.18 However, at the central incisors, mendation for each type of tooth movements are
less retraction, greater lingual crown torque, and extrusion summarized in Table 1.
were found than predicted.18 The predicted tooth move-

Table 1 Clear aligner effectiveness and recommendations

Movement accuracy Recommendations
Intrusion7-10 - 73% lower incisors intrusion - SmartTrack material
- Overcorrection
Extrusion7-10 - 30% incisor extrusion - Extrusion attachment
Arch expansion 11,12
- 37% bodily buccal expansion for maxil- - Preset for sufficient buccal root torque
lary first molar - Overcorrection
- Crossbite elastics
- 88% overall mandibular arch expansion
Rotation4,13-15 - 40% premolar rotation - Interproximal reduction
- 36% canine rotation - Attachments
- Staging with derotation <1.5° per aligner
- Total rotation <15°

234 J DENT ASSOC THAI VOL.71 NO.4 October - December 2021

Table 1 Clear aligner effectiveness and recommendations (cont.)
Movement accuracy Recommendations
Molar distalization11,13,16,17 - 87% upper molar distalization - Vertical rectangular attachment on
distalized molar with Class II elastics
Premolar extraction site closure18,19 - No significant difference in alignment, - Preset with distal tipping of upper first
marginal ridges, occlusal relations, overjet, molars
interproximal contacts, and root angulation - Power ridges, attachment, and greater
compared with braces. labial crown torque for incisors
- Significant difference in occlusal contacts
and buccolingual inclination compared
with braces.

Treatment duration anterior interferences due to inadequate anterior intrusion,

Treatment with clear aligners occurs more rapidly posterior teeth intrusion from aligner thickness19, inadequate
compared to treatment with fixed appliances.20,21 Additional anterior lingual root torque during anterior retraction, crown
aligners can be prescribed for finishing and detailing the tipping during posterior teeth expansion or speedy arch
treatment results. Patients who choose clear aligners did length reduction. Adequate crown torque and anterior
so based on esthetics and a shorter treatment time. Many intrusion can help prevent a posterior open bite. Posterior
patients rejected extended treatment time to complete vertical elastic or reducing aligner wearing time can simply
difficult tooth movement.21 In addition to total treatment correct the issue. Tooth movement in a clear aligner is
duration, clear aligner treatment time is shorter compared limited only inside the plastic frame, if there is not enough
with fixed appliances in the number of visits, the number of space for alignment or if the tooth is moving slower than
emergency visits, chairtime per visit, and total chairtime.22 the aligner’s shape, the tooth will be intruded. Therefore,
However malocclusion improvement from fixed appliances is proper staging of tooth movement and space preparation
better than clear aligner as shown with PAR index (quantitative can prevent a posterior open bite from concurrent movement
index to assess an orthodontic outcome).21 Pretreatment of the tooth and the aligner.
PAR score of fixed appliances is higher than of clear aligners
while post-treatment score is lower which represents the Conclusion
ability of fixed appliances in achieving better clinical results. Clear aligner has gained popularity as a treatment
Considerations option for adult treatment. The studies showed the
Clear aligner is an effective alternative for orthodontic effectiveness of clear aligner for distalization of upper
treatment. Because it is a removable appliance, patient molar, expansion of lower molar and intrusion of lower
compliance (proper placement and removal, adequate incisor. Limitation of movement stated on incisor extrusion,
wearing time) is a crucial factor to achieve the designed canine derotation, bodily expansion of upper molar and
tooth movement. Alteration of tooth morphology, such as premolar derotation. Effectiveness and limitation were
tooth fracture or new restorations, will result in unfitted affected by the quality of the aligner material, clinician
aligners thus re-scanning or PVS impression is required. expertise, clinician-technician communication, the attitude
Posterior open bite is a common side effect of clear aligner and cooperation of the patient. All of the considerations
therapy which is caused by multiple factors that include are important in achieving successful clinical results.

Kanpittaya et al., 2021 235

 References
1. Miller KB, McGorray SP, Womack R, Quintero JC, Perelmuter M, torque, premolar derotation and molar distalization. BMC Oral
Gibson J, et al. A comparison of treatment impacts between Invisalign Health 2014;14:68.
aligner and fixed appliance therapy during the first week of treatment. 14. Nguyen C, Chen J. Three-Dimensional Superimposition Tool; In:
Am J Orthod Dentofacial Orthop 2007;131(3):302 e1-9. Tuncay O, editor. The Invisalign System. 1st ed. New Malden:
2. Kesling HD. Coordinating the predetermined pattern and tooth Quintessence Publishing; 2006. p. 121-32.
positioner with conventional treatment. Am J Orthod Oral Surg 15. Kravitz ND, Kusnoto B, Agran B, Viana G. Influence of attachments
1946;32:285-93. and interproximal reduction on the accuracy of canine rotation
3. Sheridan JJ, LeDoux W, McMinn R. Essix retainers: fabrication and with Invisalign. A prospective clinical study. Angle Orthod 2008;
supervision for permanent retention. J Clin Orthod 1993;27(1):37-45. 78(4):682-7.
4. Chang MJ CC, Chang CY, Lin JSY, Chang CH, Roberts WE. Introduction 16. Ravera S, Castroflorio T, Garino F, Daher S, Cugliari G, Deregibus
to Invisalign® Smart Technology: Attachments Design, and Recall- A. Maxillary molar distalization with aligners in adult patients: a
Checks. J Digital Orthod 2019;54:80-95. multicenter retrospective study. Prog Orthod 2016;17:12.
5. Tamer I, Oztas E, Marsan G. Orthodontic Treatment with Clear 17. Paquette D. Extraction Treatment with Invisalign; In: Tuncay O,
Aligners and The Scientific Reality Behind Their Marketing: A Literature editor. The Invisalign System. 1st ed. New Malden: Quintessence
Review. Turk J Orthod 2019;32(4):241-6. Publishing; 2006. p. 195-205.
6. Brezniak N. The clear plastic appliance: a biomechanical point 18. Dai FF, Xu TM, Shu G. Comparison of achieved and predicted
of view. Angle Orthod 2008;78(2):381-2. tooth movement of maxillary first molars and central incisors:
7. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well First premolar extraction treatment with Invisalign. Angle Orthod
does Invisalign work? A prospective clinical study evaluating the 2019;89(5):679-87.
efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial 19. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign
Orthop 2009;135(1):27-35. appliance in extraction cases using the ABO model grading system:
8. Khosravi R, Cohanim B, Hujoel P, Daher S, Neal M, Liu W, et al. a multicenter randomized controlled trial. Int J Clin Exp Med 2015;
Management of overbite with the Invisalign appliance. Am J Orthod 8(5):8276-82.
Dentofacial Orthop 2017;151(4):691-9 e2. 20. Lanteri V, Farronato G, Lanteri C, Caravita R, Cossellu G. The
9. Glassick A, Joel Gluck A, Kotteman W, Messersmith M. ALIGNER efficacy of orthodontic treatments for anterior crowding with Invisalign
CORNER. J Clin Orthod 2017; 51(4):233-9. compared with fixed appliances using the Peer Assessment Rating
10. Krieger E, Seiferth J, Saric I, Jung BA, Wehrbein H. Accuracy of Index. Quintesence Int 2018;49(7):581-7.
Invisalign(R) treatments in the anterior tooth region. First results. 21. Gu J, Tang JS, Skulski B, Fields HW, Jr., Beck FM, Firestone AR,
J Orofac Orthop 2011;72(2):141-9. et al. Evaluation of Invisalign treatment effectiveness and efficiency
11. Houle JP, Piedade L, Todescan R, Jr., Pinheiro FH. The predictability compared with conventional fixed appliances using the Peer As-
of transverse changes with Invisalign. Angle Orthod 2017;87(1):19-24. sessment Rating index. Am J Orthod Dentofacial Orthop 2017;
12. Zhou N, Guo J. Efficiency of upper arch expansion with the 151(2):259-66.
Invisalign system. Angle Orthod 2020;90(1):23-30. 22. Buschang PH, Shaw SG, Ross M, Crosby D, Campbell PM.
13. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C. Treatment Comparative time efficiency of aligner therapy and conventional
outcome and efficacy of an aligner technique--regarding incisor edgewise braces. Angle Orthod 2013.

236 J DENT ASSOC THAI VOL.71 NO.4 October - December 2021