ORIGINAL ARTICLE

A cone-beam computed tomographic

study evaluating the efficacy of incisor
movement with clear aligners: Assessment
of incisor pure tipping, controlled tipping,
translation, and torque
Ting Jiang,a Yu-Nan Jiang,b Feng-Ting Chu,c Pei-Jun Lu,c and Guo-Hua Tangc
Shanghai, China

Introduction: This retrospective clinical study aimed to evaluate the efficacy of different types of incisor
movements with clear aligners in the sagittal plane. Methods: Pretreatment and posttreatment cone-beam
computed tomography (CBCT) scans were collected from 69 patients who underwent nonextraction
treatment with clear aligners (Invisalign; Align Technology, San Jose, Calif). Integrated 3-dimensional models
of the virtual incisor position (ClinCheck; Align Technology) and the posttreatment incisor position (from
posttreatment CBCT scans) were superimposed over the pretreatment position (from pretreatment CBCT
scans) using Mimics software (Materialise, Leuven, Belgium). On the basis of the location of the rotation
center, incisors showing pure tipping (.10
), controlled tipping (.10
), translation (.1 mm), or torque (.10
)
movements were selected. Efficacy was determined by comparing the predicted and achieved incisor
movement, and differences with efficacy were analyzed using Kruskal-Wallis and Shapiro-Wilk tests
(a 5 0.05). Results: In measurements for 231 incisors, the mean efficacy of incisor movements in the sagittal
plane was 55.58%. The most and least predictable movements were pure tipping (72.48%) and torque (35.21%),
respectively. Labial root movement was significantly more predictable than lingual root movement, and labial
movement of the mandibular incisors was significantly easier than that of the maxillary incisors. The type of tooth
movement achieved was different from the type designed. Conclusions: The efficacy of incisor movement in the
sagittal plane using clear aligners varies with designed movement type, and labial root movement appears to be
more accurate than the lingual root movement. The biomechanics of clear aligners remains to be further eluci-
dated to achieve more predictable treatment results. (Am J Orthod Dentofacial Orthop 2021;159:635-43)

a
Department of Orthodontics, Shanghai Ninth People's Hospital, College of Sto-
matology, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
b
Department of Stomatology, Tong Ren Hospital, Shanghai Jiao Tong University
School of Medicine, Shanghai, China.
c
Department of Orthodontics, Shanghai Ninth People's Hospital, College of Sto-
matology, Shanghai Jiao Tong University School of Medicine; National Clinical
Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology &
Shanghai Research Institute of Stomatology, Shanghai, China.
Ting Jiang and Yu-Nan Jiang are joint first authors and contributed equally to
this work.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
This work was supported by the Natural Science Foundation of Shanghai, China
(19ZR1429600).
Address correspondence to: Guo-Hua Tang, Department of Orthodontics,
Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao
Tong University School of Medicine, No. 639, Zhizaoju Rd, Shanghai 200011,
China; e-mail, drtanggh@163.com.
Submitted, July 2019; revised and accepted, November 2019.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.11.025
T
he clear aligner system, which contains a series of
removable polyurethane appliances, has been
widely used in clinical practice as an esthetic and
more comfortable alternative to fixed orthodontic
appliances. For example, Invisalign was used to treat
over 300,000 orthodontic patients with a variety of
malocclusions in its first decade,1 and over 6 million as
of today.
Although the consumer demand and the professional
use of clear aligners continue to grow, questions
regarding the efficacy of this system still remain. Accord-
ing to the manufacturer, clear aligners could effectively
achieve major tooth movement, including premolar der-
otation up to 50
and root movement of the maxillary
central incisors up to 4 mm. Despite the advocated effi-
ciency of the treatment, its clinical potency still
remains debatable; opponents pointed out its significant

635
636
limitations when treating complex malocclusions,
whereas advocates remained convinced by the patients
with successful outcomes.
To achieve the desired goals, patients treated with
clear aligners require either a midcourse correction or
case refinement. Align Technology reported that 20%-
30% of patients might require additional aligners,
whereas many clinical orthodontists reported a propor-
tion of 70%-80%.2 Accurately assessed efficacy
of tooth movement could help design the amount of
movement before treatment and reduce the frequency
of refinements.
A substantial body of studies has concentrated on the
efficacy of tooth movement on clear aligners. Kravitz
et al3 evaluated the accuracy of anterior tooth move-
ment and concluded that maxillary incisor lingual crown
tipping (53.1%) was significantly more accurate than
labial crown tipping (37.6%). Castroflorio et al4 exam-
ined 12 maxillary incisors in Invisalign patients needing
lingual root torque and found that when a torque
correction of about 10
was required, torque loss was
negligible. Simon et al5 reported the mean accuracy
for maxillary incisor torque was 42% and concluded
that no differences were observed if the torque (.10
)
was supported with a horizontal ellipsoid attachment
or with a power ridge. These results varied considerably
from each other, and the reason might be related to the
absence of root information and unclear definitions of
tooth movements.
Incisor movements in the sagittal direction can be
classified into 4 types according to the position of the
rotation center: pure tipping, controlled tipping, trans-
lation, and torque.6 These 4 types of movements are
supported by completely different extents of root con-
trol. However, limited published data have assessed the
differences and evaluated the efficacy of these 4 types
of incisor movements.
Consequently, this retrospective study aimed to
evaluate the efficacy of these 4 types of incisor move-
ments by clear aligner treatment with additional root
information from integrated 3-dimensional (3D) digital
models and determine whether any inputs could be
derived from the differences between efficacy. The pre-
dicted amount of tooth movement was compared with
the achieved amount after treatment, and the amount
was calculated by measuring the area of the root move-
ments.
MATERIAL AND METHODS
Patients treated with Invisalign (Align Technology,
San Jose, Calif) between January 2016 and December
2018 at the Department of Orthodontics, Shanghai
Ninth People's Hospital were selected. The following
May 2021  Vol 159  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al
inclusion criteria were used: (1) age $20 years; (2) the
presence of crowding that could be harmonized using
conservative space-gaining measures such as protrusion,
proclination, expansion, and interproximal enamel
reduction; (3) completed treatment with the whole
active stages of the first serial of aligners. Availability
of 1 CBCT scan each from before and after the treat-
ment; (4) no auxiliary device such as segmental wire
and elastics was used on incisors; and (5) CBCT voxel
size ranging from 0.20 mm to 0.30 mm.
The following parameters represented exclusion
criteria: (1) unclear CBCT images of teeth and jaws and
(2) presence of alveolar cleft or other bone defects.
Both CBCT scans (pretreatment and posttreatment)
were collected and evaluated. The use of the data was
approved by the ethics committee of the Shanghai Ninth
People's Hospital (SH9H-2018-T63-1).
Three-dimensional models of jaws (from both pre-
and post-CBCT scans) and each incisor (from the post-
CBCT scan) were reconstructed using Mimics software
(version 19.0; Materialise, Leuven, Belgium) and im-
ported into 3-Matic software (Materialise) to perform
surface-based superimposition. The 3D models of the
initial dentition (pre-D) and the virtual setup dentition
were obtained from ClinCheck (Invisalign; Align Tech-
nology) and imported into the 3-Matic program.
Surface characteristic-based automated registration
of pre-CBCT jaws and pre-D was performed using the
crowns as areas of optimal overlap. Subsequently, each
individually segmented incisors were registered to corre-
sponding pre-D and virtual setup dentition crowns.
Finally, the pretreatment integrated model and virtual-
treatment model were completed, which included accu-
rate crowns determined by ClinCheck models and roots
and pre-CBCT jaws positions derived from CBCT imag-
ing. The posttreatment integrated models, including
post-CBCT jaws and incisors derived by post-CBCT
scans, did not require any superimposition (Fig 1).
To analyze incisor positions in the same space coor-
dinates, we superimposed both integrated models (pre-
treatment integrated model and posttreatment
integrated models) on the basis of skeletal marks (eg,
anterior nasal ridge), and then global registration was
performed with an iterative closest point algorithm.
Because the virtual and the pretreatment incisor posi-
tions were automatically superimposed in ClinCheck,
the 3 incisor positions were finally matched to the
same spatial coordinates.
The alveolar bone height (ABH) was represented by
the distance between the midpoint of the mesiodistal
alveolar ridge crest (pre-C) and apex (pre-R), as the
root length (RL) was represented between the apex
(pre-R) and the midpoint of the mesiodistal
Jiang et al 637

Fig 1. Construction of preintegrated and postintegrated models and the virtual-treat model. 3D models
of each incisor were reconstructed separately by threshold segmentation performed on post-CBCT
scans. The crown of each segmented CBCT incisor was superimposed onto the corresponding crown
of the initial dentition (pre-D); Registration of the pre-CBCT jaws (pre-J) and pre-D was preformed using
the crowns as areas of optimal overlap, and finally, the pretreatment integrated model (pre-IM) was con-
structed. The crown of each segmented CBCT incisor was superimposed onto the virtual dentition (vir-
D), after which the virtual-treat model (vir-M) was completed. The postintegrated model (post-IM) was
composed of post-CBCT jaws and post-CBCT incisors, which did not require any registration.

cementoenamel junction (Fig 2, A). To ensure the uni-
versality of the results, teeth with short roots and those
in which the alveolar bone had absorbed more than a
third of RL were excluded.7
A reference coordinate system was set up using 3-
Matic software, and the following reference points
were used: pre represents the pretreatment position, vir
represents the virtual position, post represents the post-
treatment position (Fig 2, B): (1) pre/vir/post-R: the root
apex point; (2) pre-M: the most prominent point of the
lingual protuberance; (3) pre/vir/post-I: midpoint of
the incisal edge; (4) pre/vir/post-RI: the line from
point-R to point-I, which was defined as the axis of the
incisor; (5) pre/vir/post-C: the point of the alveolar ridge
crest that was on line-RI and was of the same length as
ABH from point-R; (6) pre/vir/post-Cs: center of resis-
tance, the point on line-RI that was half the length of
the ABH from point-R6; (7) sagittal plane: the plane
covering the points pre-R, pre-M, and pretreatment
midpoint of the incisal edge; (8) vir/post-RI’: the
projection of the incisor axis (vir/post-RI) in the sagittal
plane; (9) vir/post-RC: the line from point-R to point-C
with length the same as ABH; (10) vir/post-RC’: the pro-
jection of vir/post-RC in the sagittal plane, of which the
length was usually shorter than ABH; (11) center of rota-
tion (Ctr): the intersection point of pre-RI and vir-RI.’ In a
right-handed coordinate system, pre-R was defined as
the coordinate origin, pre-RI was defined as the y-axis,
and the line in the sagittal plane perpendicular to the
y-axis from the origin was defined as the x-axis.
The angle (a) formed by vir-RI0 and y-axis and the
distance (d) between pre-Cs and virtual center of resis-
tance (vir-Cs) was recorded. To ensure that measure-
ments were limited to the sagittal direction, the length
of vir/post-RC0 was corrected as follows: on the basis
of the vir/post-Cs, the points vir/post-C0 and vir/post-
R0 were marked on vir/post-RI’ with the length between
these 2 points the same as ABH.
On the basis of the location of Ctr, 4 types of tooth
movement were identified as follows (Fig 3, A): (1)

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5
638 Jiang et al

Fig 2. Measurement of ABH, RL, and establishment of the incisor coordinate system: A, the ABH was
represented by the distance between the midpoint of the mesiodistal alveolar ridge crest (pre-C) and
apex (pre-R); the RL was represented by the maximum linear length between pre-R and the midpoint
of the mesiodistal cementoenamel junction (pre-CEJ); B, the midpoint of the incisal edge was defined
as pre-I. In the right-handed coordinate system, the pre-R was defined as the coordinate origin, the pre-
RI (line composed of pre-R and pre-I) was defined as the y-axis, and the line in the sagittal plane
perpendicular to the y-axis from the origin was defined as the x-axis. Black indicates pretreatment po-
sition; red indicates the posttreatment position; and blue indicates the virtual position.

pure tipping: a .10
, a movement in which Ctr was
within 2 mm from pre-Cs; (2) controlled tipping:
a .10
, a movement in which Ctr was within 2 mm
from pre-R; (3) translation: d .1 mm, a movement in
which Ctr was more than 6 times the length of the
ABH from pre-Cs; and (4) torque: a .10
, a movement
in which Ctr was within 2 mm of the midpoint of the
incisal edge.
Considering the relationship between pre-Cs and vir-
Cs, we defined the direction of root movement as follows
(Fig 3, B): if vir-Cs was on the labial side of pre-Cs, the
direction was recorded as labial; otherwise, the direction
was recorded as lingual.
Tooth movement efficacy was calculated by
measuring the area of the root movement in the sagittal
plane. The accuracy of each tooth movement
was determined by the following equation: percentage
of accuracy 5 post-S/vir-S 3 100% (post-S, the
area composed of the pre-root and post-root; vir-
S, the area composed the pre-root and virtual root)
(Fig 4).
Statistical analysis
All statistical analyses were performed with SAS soft-
ware (version 8.02; SAS Institute Inc, Cary, NC). The
differences between the 4 types of tooth movement
were compared using the Wilcoxon test. The differences
between labial vs lingual and maxilla vs mandible were
analyzed by the Shapiro-Wilk test. The significance level
was set at P 5 0.05.
RESULTS
Sixty-nine patients (44 female and 25 male) aged be-
tween 20 and 41 years (mean age, 28.5 6 5.7 years) were
collected. The mean number of maxillary and mandib-
ular aligners per treatment was 45.0 6 7.5 and
41.9 6 9.3, respectively. According to our criteria, 231
teeth out of 552 maxillary and mandibular incisors
were included in the present study. The average RL
and ABH of incisors are listed in Table I. The average
predicted amount of change for each type of movement
was as follows: 13.28
for pure tipping, 13.75
for
controlled tipping, 12.91
for torque, and 1.69 mm for
translation.
The overall efficacy of Invisalign for all incisor move-
ments in the sagittal plane was 55.58%. The highest ac-
curacy was achieved during pure tipping (72.48%),
followed by controlled tipping (65.24%) and translation
(49.50%), and the lowest accuracy was during torque
(35.21%). There were significant differences among

May 2021  Vol 159  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al 639

Fig 3. Definitions of different movements and the definition of directions: A, based on the distance be-
tween the Ctr and pre-R or pre-Cs or midpoint of the incisal edge (pre-I). The definitions for the 4 types
of tooth movements were as follows: (a) pure tipping: a movement in which Ctr was within 2 mm from
pre-Cs; (b) controlled tipping: a movement in which Ctr was within 2 mm from pre-R; (c) translation: a
movement in which Ctr was more than 6 times the length of the ABH from pre-Cs; and (d) torque: a
movement in which Ctr was within 2 mm of pre-I; B, considering the relationship between pre-Cs
and the vir-Cs, the direction of root movement was recorded as either labial (red, vir-Cs was on the
labial side of pre-Cs) or otherwise lingual (green).

Fig 4. Measurements of tooth movement efficacy: A, vir-S, the area composed of the pretreatment root
(black) and predicted virtual root (blue); B post-S, the area composed the pretreatment root (black) and
posttreatment root (red); C, the efficacy of tooth movement was calculated by the following equation:
percentage of accuracy 5 post-S/vir-S 3 100%.

the 4 types of movements (P \0.05), and all movements
had large standard deviations (Table II).
When analyzing differences in efficacy between
different tooth types, only translation showed a signifi-
cant difference in efficacy between the maxillary and
mandibular incisors (P 5 0.0013). When comparing
the difference between maxillary and mandibular arches,
only translation movement of the maxillary incisors
showed statistically less efficacy than that of the
mandibular incisors (Table II).

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5
640 Jiang et al

Table I. Average RL and ABH of the incisors Table III. Efficacy of root sagittal movement by tooth
type
RL ABH
Labial Lingual
Standard Standard
Tooth (n) Mean deviation Mean deviation Standard Standard
Maxillary central 12.57 0.96 9.79 0.76 Tooth type Mean N deviation Mean n deviation
(58) Maxillary 57.40 32 19.43 44.43 26 15.62
Maxillary lateral 12.73 1.03 10.03 1.12 central*
(57) Maxillary 54.74 28 19.16 46.36 29 20.05
Mandibular central 12.15 0.93 9.79 0.96 lateral
(57) Mandibular 70.16 29 15.13 50.37 28 17.01
Mandibular lateral 12.46 1.15 10.06 1.07 central*
(59) Mandibular 68.95 32 14.77 48.81 27 16.41
Note. Values are in mm. lateral*
Total* 62.90 121 18.33 47.53 110 17.33

Note. Values are percentages.

When analyzing the difference between labial and
lingual groups, labial root movement was significantly
more predictable than lingual root movement
(Table III). In contrast, the efficacy of labiolingual
movement for maxillary incisors was 51.03%, which
was significantly lower than that for mandibular inci-
sors (60.01%) (P 5 0.001). More specifically, the
efficacy of labial movement for the maxillary incisors
was 56.16%, which was significantly lower than that
for the mandibular incisors (69.52%). However, there
was no significant difference in lingual movement
between the maxillary and mandibular incisors
(P 5 0.1756).
In addition to the differences in efficacy, the type of
movement achieved was also likely different than the
type designed (Fig 5). When incisors were designed to
undergo pure tipping or torque, they actually kept the
same mode of movement. When incisors were designed
to perform controlled tipping, around 65% of teeth un-
derwent controlled tipping, whereas about 35% showed
pure tipping. When incisors were designed for labial
translation, 67.3% of teeth followed the same type of
movement, and when they were designed for lingual
translation, only 20.0% of teeth finally followed.
*Significant difference in efficacy between labial and lingual move-
ment, P \0.05.
DISCUSSION
Although clear aligners seem to meet all the criteria
that an ideal system should have, some of their biome-
chanical limits have not yet been overcome.8 One of
the major challenges is controlling root movement,
including the labiolingual inclination of incisors. The
virtual setup in clear aligner software displays only the
changes of crowns rather than roots, and it does not
accurately reflect the patients’ final occlusion.9 The
overall tooth movement accuracy on the basis of the pre-
treatment and posttreatment superposition on the
crowns was reported to be 59%.5 When integrated 3D
digital models with crown and root were evaluated, it
was found that clear aligners moved tooth by tilting mo-
tion, and crowns but not roots of anterior teeth could be
moved to designated positions.10 The efficacy of tooth
movement by clear aligner treatment varied largely on
different types of tooth and the mode of movement de-
signed. The most effective movement was molar distal-
ization (87%), and the least accurate movement was

Table II. Efficacy of PTP, CTP, TSL, and TQ

PTP CTP TSLy TQ

Tooth Mean n SD Mean n SD Mean n SD Mean n SD

Maxillary central 65.40 13 17.26 64.78 16 12.02 43.21 16 11.59 31.83 13 9.07
Maxillary lateral 69.10 14 11.40 62.70 15 13.93 39.86 10 14.58 31.70 18 8.68
Mandibular central 77.17 15 15.70 66.67 13 13.97 57.95 14 11.74 40.62 15 10.45
Mandibular lateral 77.42 14 14.06 66.81 17 13.35 54.73 15 9.32 37.20 13 8.49
Total* 72.48 56 15.24 65.24 61 13.08 49.50 55 13.55 35.21 59 9.76

Note. Values are percentages.

PTP, pure tipping; CTP, controlled tipping; TSL, translation; TQ, torque; SD, standard deviation.
*Significant difference in efficacy between different types of movements, P\0.05; ySignificant difference in efficacy between different tooth types,
P \0.05.

May 2021  Vol 159  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al 641

Fig 5. Sketch illustrating changes in types of movement. The pre-, post-, and virtual incisor positions
were superimposed to illustrate the predicted and achieved types of movement in either labial or lingual
direction. The percentage represents the proportion of different modes in each type of movement. For
example, when incisors were designed to undergo pure tipping, 100% of the teeth showed the pure
tipping movement. When incisors were designed for labial controlled tipping, 65.6% of them underwent
controlled tipping.

extrusion (29.6%).3,5 Possibly, changes in the labiolin-
gual inclination of incisors could derive from different
extents of root control, such as pure tipping, controlled
tipping, translation, or torque. Thus, the specific way
that how incisors move should first be determined before
any efficacy of tooth movement was evaluated.
A theoretical way to determine the mode of tooth
movement is to consider the ratio between the moment
created when a force is applied to the crown of a tooth
and the counterbalancing moment generated by a
couple with the appliance. With regard to clear aligners,
the force delivery mechanism can be more complicated.
For instance, torque movement requires a tipping force
evoked by reversible deformation of the aligner near
the gingival margin and the resulting force in the oppo-
site direction produced by the movement of the tooth
against the inner opposite surface of the appliance
near the incisor edge.11 Although a rigid connection be-
tween the tooth and a force-torque sensor could help to
record forces and moments, changes in periodontal lig-
aments and alveolar bones can hardly be simulated,
which might impair the reliability of the results from
in vitro experiments.11,12
Another way to define types of tooth movements is
by identifying the rotation center, such as the method
used in the present study. A few articles are available
dealing with torque movement with clear aligners.5,11-15
Among them, some described torque as the angulation
of teeth in labiolingual dimensions, whereas others
evaluated torque movement on virtual superimposition
software of the manufacturer. In our present study,
only these incisors whose designed movement met the
typical characteristics of either pure tipping, controlled
tipping, translation, or torque were selected for further
evaluation.
Treatment efficacy is usually determined by quanti-
tative measurements for the predicted and achieved
movements, such as the angulation for tipping and dis-
tance for translation. However, it might not be specific
enough and sometimes was even misunderstanding.
The highest accuracy of molar distalization ever reported
was 108.7%, which could not be achieved by aligner
treatment only.5 Similarly, more than one third of inci-
sors designed to undergo controlled tipping showed
pure tipping with larger angulation changes (Fig 5).
The efficacy will be more than 100% if only angulation

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5
642
is measured. In addition, previous studies using a surface
matching algorithm on the models might ignore the
anchorage loss, which would overstate the efficacy of
the tooth movement achieved.3,5,10 In the present study,
preintegrated and postintegrated 3D digital models with
crowns and roots were superimposed using the jaws as
areas of optimal overlap. Tooth movement efficacy
was calculated by measuring the area of the root move-
ments, and the results would be more specific and
reasonable.
The overall efficacy of incisor movement in our pre-
sent study was 55.58%, which was comparable with
the previous reports.3,5 When the types of tooth move-
ment were taken into consideration, the most accurate
tooth movement was pure tipping (72.48%), followed
by controlled tipping and translation, whereas the least
accurate was torque (35.21%) (Table II). Not a surprising
result because the more the root moves, the more diffi-
cult it will be achieved. This finding suggested that clear
aligners share the same biomechanical principle of tooth
movement as the other orthodontic appliances. Never-
theless, the material properties of clear aligners might
probably be responsible for their inability to apply root
control. The gingival margin of the aligner is elastic,
and it would have difficulty in applying forces in this re-
gion.11 To overcome this weakness, Invisalign advocates
using power ridges. Although power ridges on maxillary
incisors generate more moments than attachments
in vitro, measurement of incisor torque before and after
the aligner treatment showed that power ridges achieved
similar mean accuracy as attachments.5,12 Hahn et al11
concluded that aligners tend to lift up during torquing,
which would not have a close fit of the incisor edge in the
appliance with the tooth. In this way, the force couple
produced by aligners could not be sufficient enough
and consequently lead to a lower efficacy of the move-
ment. In addition, the distortion of the appliance could
cause unintended intrusion of the tooth, which is the
so-called watermelon seed effect.16 These results sug-
gested that even minor toque movements might justify
overcorrection.
The efficacy of labiolingual root movement with clear
aligners has drawn great interest, as clinicians pay more
attention to the alveolar bone and periodontal tissue
during orthodontic treatment. Our results showed that
labial root movement was significantly more accurate
than the lingual root movement (Table III). This finding
suggests that when incisors are designed to move labi-
ally, the boundary of the alveolar bone must be taken
into account. In contrast, when incisors are designed
to move lingually, more overcorrection might be neces-
sary. Pan et al17 reported that alveolar bone defects ap-
peared significantly more often on the labial side
May 2021  Vol 159  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al
(99.98%) than the lingual side (0.02%). When roots
were designed to move labially, the resistance on the
labial side would reduce, which might be the reason
why the labial movement was more accurate.
In comparison with maxillary incisors, mandibular in-
cisors were more likely to move labially, and there might
be 3 reasons for this: first, more dehiscence was found in
the mandible than maxilla, which resulted in less resis-
tance18; second, the coronal area of mandibular roots
was less than that of maxillary roots, and the movements
might occur even with minor force; third, the lingual
margin of mandibular aligner was usually longer than
the labial side, which made the force application point
on the lingual side more closed to the resistance center
of the tooth and may result in a more achievable labial
root control. These data suggest that clear aligners can
achieve greater accuracy in alleviating mandibular ante-
rior crowding with the labial expansion than maxillary.
However, clinicians should consider the thickness of
mandibular alveolar bone, which was reported only
0.2-0.6 mm.19
In addition to the insufficient efficacy, our present
results showed that the type of movements achieved
was also unpredictable, especially for controlled tipping
and translation movement (Fig 5). For example, when
incisors were designed for lingual translation, four fifths
of them actually underwent tipping. This finding sug-
gested that additional lingual root torque might be
needed to achieve lingual translation for anterior retrac-
tion. In contrast, when the labial alveolar bone was
compromised, the labial translation movement should
be carefully designed because quite a majority of incisors
(67.3%) would finally undergo this type of movement.
Similarly, when incisors were designed for lingual
controlled tipping, pure tipping would occur for 36.1%
of the incisors; this results in the labial movement of
the roots, which increases the risk of fenestration. These
results indicated that attention to both efficacy and type
of tooth movement should be addressed during clear
aligner treatment.
The present study aimed to evaluate the treatment
efficacy of pure tipping, controlled tipping, translation,
and torque movements of incisors using clear aligners,
whereas movements in other directions were not as-
sayed. Because the efficacy of tooth movements could
be influenced by the severity of initial irregularity, the
impact of malocclusion complexity should be required
in further investigation. In addition, the use of adjuncts
such as power ridge, attachments, and intermaxillary
elastics was not considered in the present study; how-
ever, they were frequently applied in treatment with
clear aligners. A relatively low number of participants
might also reduce the reliability of these results.
Jiang et al
Despite the difficulty in considering all the above fac-
tors in 1 clinical study, it might be possible to interpret
the impact of a single factor by a well-designed pro-
spective study, such as the difference between transla-
tion and controlled tipping designed for incisor
retraction in patients undergoing extraction. Finally,
different types of clear aligners other than the Invisa-
lign could be studied to determine the more appro-
priate removable thermoplastic systems for different
dental malocclusions.
CONCLUSIONS
This study established a reliable method to evaluate
the treatment accuracy of clear aligner on incisor move-
ment specific for pure tipping, controlled tipping, trans-
lation, and torque by using integrated 3D models from
CBCT scanning. The following conclusions were made
on the basis of the findings:
1. The mean accuracy of incisor movements in the
sagittal direction with Invisalign was 55.58%. The
most predictable tooth movement was pure tipping,
whereas the least predictable movement was torque.
2. Lingual root movement was significantly more diffi-
cult to be accomplished than labial root movement.
3. Labial movement of mandibular roots was signifi-
cantly more achievable than that of maxillary roots.
4. The type of tooth movement achieved might be
different from the type of tooth movement
designed, especially for controlled tipping and
translation.
These results indicate that both the efficacy and the
type of movement achieved were less predictable under
orthodontic treatment with clear aligners. Clinicians
should fully recognize its limitations and commit them-
selves to provide sufficient care for their patients.
AUTHOR CREDIT STATEMENT
Guo-Hua Tang designed the study. Feng-Ting Chu
and Pei-Jun Lu collected the data. Yu-Nan Jiang
performed the statistical analysis. Ting Jiang and Guo-
Hua Tang carried out the study and drafted the manu-
script. All authors read and approved the final manuscript.
REFERENCES
1. Kuncio D, Maganzini A, Shelton C, Freeman K. Invisalign and
traditional orthodontic treatment postretention outcomes
compared using the American Board of Orthodontics objective
grading system. Angle Orthod 2007;77:864-9.
American Journal of Orthodontics and Dentofacial Orthopedics
643
2. Sheridan JJ. The readers’ corner. 2. What percentage of your pa-
tients are being treated with Invisalign appliances? J Clin Orthod
2004;38:544-5.
3. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does
Invisalign work? A prospective clinical study evaluating the effi-
cacy of tooth movement with Invisalign. Am J Orthod Dentofacial
Orthop 2009;135:27-35.
4. Castroflorio T, Garino F, Lazzaro A, Debernardi C. Upper-incisor
root control with Invisalign appliances. J Clin Orthod 2013;47:
346-51: quiz 387.
5. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C. Treatment
outcome and efficacy of an aligner technique–regarding incisor
torque, premolar derotation and molar distalization. BMC Oral
Health 2014;14:68.
6. Proffit W, Fields H Jr, Sarver D. Contemporary Orthodontics. 5th
ed. Amsterdam, the Netherlands: Elsevier; 2012.
7. Kim SY, Lim SH, Gang SN, Kim HJ. Crown and root lengths of in-
cisors, canines, and premolars measured by cone-beam computed
tomography in patients with malocclusions. Korean J Orthod
2013;43:271-8.
8. Schupp W, Haubrich J, Neumann I. Class II correction with the In-
visalign system. J Clin Orthod 2010;44:28-35.
9. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM. Predicted
and actual end-of-treatment occlusion produced with aligner
therapy. Angle Orthod 2015;85:723-7.
10. Zhang XJ, He L, Guo HM, Tian J, Bai YX, Li S. Integrated three-
dimensional digital assessment of accuracy of anterior tooth
movement using clear aligners. Korean J Orthod 2015;45:
275-81.
11. Hahn W, Zapf A, Dathe H, Fialka-Fricke J, Fricke-Zech S, Gruber R,
et al. Torquing an upper central incisor with aligners–acting forces
and biomechanical principles. Eur J Orthod 2010;32:607-13.
12. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C. Forces and
moments generated by removable thermoplastic aligners: incisor
torque, premolar derotation, and molar distalization. Am J Orthod
Dentofacial Orthop 2014;145:728-36.
13. Gr€unheid T, Loh C, Larson BE. How accurate is Invisalign in non-
extraction cases? Are predicted tooth positions achieved? Angle
Orthod 2017;87:809-15.
14. Huanca Ghislanzoni LT, Lineberger M, Cevidanes LH, Mapelli A,
Sforza C, McNamara JA Jr. Evaluation of tip and torque on virtual
study models: a validation study. Prog Orthod 2013;14:19.
15. Tepedino M, Paoloni V, Cozza P, Chimenti C. Movement of ante-
rior teeth using clear aligners: a three-dimensional, retrospective
evaluation. Prog Orthod 2018;19:9.
16. Brezniak N. The clear plastic appliance: a biomechanical point of
view. Angle Orthod 2008;78:381-2.
17. Pan HY, Yang H, Zhang R, Yang YM, Wang H, Hu T, et al. Use of
cone-beam computed tomography to evaluate the prevalence of
root fenestration in a Chinese subpopulation. Int Endod J 2014;
47:10-9.
18. Enhos S, Uysal T, Yagci A, Veli _I, Ucar FI, Ozer T. Dehiscence and
fenestration in patients with different vertical growth patterns as-
sessed with cone-beam computed tomography. Angle Orthod
2012;82:868-74.
19. Foosiri P, Mahatumarat K, Panmekiate S. Relationship between
mandibular symphysis dimensions and mandibular anterior alve-
olar bone thickness as assessed with cone-beam computed tomog-
raphy. Dental Press J Orthod 2018;23:54-62.
May 2021  Vol 159  Issue 5