Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62:(1 Suppl): 58–62

doi: 10.1111/adj.12480

Clear aligners in orthodontic treatment

T Weir*,†
*Private Practice in Corinda, Brisbane, Australia.
†Clinical Consultant in Invisalign Australia, Sydney, NSW.

ABSTRACT
Since the introduction of the Tooth Positioner (TP Orthodontics) in 1944, removable appliances analogous to clear align-
ers have been employed for mild to moderate orthodontic tooth movements. Clear aligner therapy has been a part of
orthodontic practice for decades, but has, particularly since the introduction of Invisalign appliances (Align Technology)
in 1998, become an increasingly common addition to the orthodontic armamentarium. An internet search reveals at least
27 different clear aligner products currently on offer for orthodontic treatment. The present paper will highlight the
increasing popularity of clear aligner appliances, as well as the clinical scope and the limitations of aligner therapy in gen-
eral. Further, the paper will outline the differences between the various types of clear aligner products currently available.
Keywords: clear aligners, orthodontics.
Abbreviations and acronyms: CAT = Clear Aligner Therapy; MTM = Minor Tooth Movement; CAD CAM = Computer Aided Design
and Manufacture; 3D = 3 Dimensional.

aligner treatment to cover movements otherwise con-

INTRODUCTION
With the recent increase in adults seeking orthodontic
treatment, there has been a corresponding increase in
demand for appliances that are both more aesthetic and
more comfortable than conventional fixed appliances.1
As with fixed appliance systems, the term Clear
Aligner Therapy (CAT) embraces a wide range of appli-
ances with differing modes of action, methods of con-
struction, and applicability to various malocclusion
treatments. All share the use of clear thermoformed
plastic aligners that cover many or all of the teeth, but
from that common point, there are major and signifi-
cant differences which affect the ability of any given
system to treat a wide range of orthodontic problems.
CAT was initially introduced to treat minor irregu-
larities of tooth position only. Some aligner systems
remain deliberately and explicitly limited to the correc-
tion of minor positional irregularities whilst others also
claim to target complex malocclusions. Published clini-
cal evidence supporting such claims is either lacking or,
for the most part, well short of high-level scientific evi-
dence. Nevertheless many CAT systems are marketed
directly to the public, and some (Crystal Braces, Smile
Care Club) do not even require the intervention of any
dental practitioner at any stage in the process.
Some CAT systems incorporate the use of bonded
resin attachments on teeth to increase the scope of
58
sidered difficult or impossible for CAT to achieve.
CAT is particularly prone to rapid technological
changes impacting on aligner materials, appliance
design and manufacture. This feature has been noted,1
to make scientific assessment of CAT efficacy difficult
due to the speed of evolution of the various CAT sys-
tems when compared with the lead time involved in
the collection of data related to past treatments, and
the time to analyse and publish study results. There-
fore, all too commonly the CA product being tested,
analysed, and reported upon is no longer the same as
the CA product in current use.
In addition, it has been noted 2 that published
studies which compare fixed appliances with CAT
are subject to numerous flaws, including poor
methodology (63% of studies had a high risk of
bias), absence of control groups, proper blinding pro-
cedures or sample randomisation procedures. Sample
sizes were generally small and similar criticisms could
be fairly directed at published studies on CAT in
general.
In 2012, Robert Keim, the editor of the Journal of
Clinical Orthodontics nominated two major advances
in the previous 15 years in orthodontics, those of tem-
porary anchorage devices and Invisalign. It was fur-
ther said that: “Invisalign has offered patients a viable
alternative to fixed braces” and that “today,
© 2017 Australian Dental Association

practically any malocclusion can be successfully trea-
ted using this or similar technologies”. 3
HISTORY
While the formal introduction of clear aligners to the
orthodontic armamentarium has been considered to
date back to the 1998 FDA approval for Align Tech-
nology to employ Invisalign for orthodontic use, the
technology has clearly been employed, in modified
forms, at least as far back as the Tooth Positioner by
Dr Harold Kesling in 1946.
CAT is a natural extension of the use of tooth posi-
tioners, an appliance first introduced by TP
Orthodontics in 1945,4 and also spring aligners for
tooth alignment that have been employed by
orthodontists for many decades. These ideas were fur-
ther developed by Nahoum5 Ponitz,6 McNamara,7
Sheridan 8 and Truax,9 before being combined
recently with advances in transparent thermoplastic
materials and computer technology (CAD-CAM,
stereolithography and tooth-movement simulation
software). This has resulted in clear aligner (CA)
products being made increasingly available and effec-
tive for tooth alignment in a variety of malocclusions.
VARIETY
An internet search for “clear aligners” will generate a
list of brands from numerous companies, all of which
broadly fall under the umbrella of “Clear Aligners”.
A Google search in late 2015 revealed approximately
27 different CA products on offer. These can be
broadly grouped into the following categories:
Minor tooth movement (MTM) with limited clinical
applicability
Positioned as a cheaper, faster alternative to compre-
hensive orthodontic treatment, this category includes
products such as Originator, Simpli 5, MTM Clear
Aligner, and Clearguide System.
Direct to Consumer Alternatives
“At home” treatment for the patient with a dental pro-
fessional possibly offering remote oversight. Positioned
as a “convenient and 50% cheaper” solution, this cate-
gory includes Crystal Braces and Smile Care Club.
These products are not yet available in Australia.
Make Your Own Aligners
3D treatment planning software, integrated with
scanners and 3D printers, enables full in-house or labo-
ratory fabrication. Available products include Orches-
trate, 3 Shape and Suresmile.
© 2017 Australian Dental Association
Clear aligners in orthodontic treatment
Complex, Comprehensive Systems:
Incorporating 3D CAD CAM tooth movements, a
computerised 3D interactive treatment planning and
appliance design, bonded resin attachments and possi-
bly additional features, designed for more complex,
comprehensive tooth movements, improved control of
tooth position in all planes of space, these products
include Invisalign, ClearCorrect, ClearPath, eCligner,
K Line and Orthocaps.
The most complex CAT appliance currently available
is Invisalign – which offers the utility of both scan or
impression submission, a doctor-adjustable (to a high
degree of detail) computerised treatment plan and
appliance design, computerised 3D model manipulation
to a high level of precision, and pressure-formed tooth-
borne aligners which are accompanied by a wide range
of specifically computer-analysed and designed attach-
ment types, anterior bite ramps and precision cuts and
button cut-outs for the ease of incorporation of the
wear of elastics in treatment, and power arms and
power ridges for improved axial root control and tor-
que control, respectively. Pressure points are also built
into the aligners to assist with more difficult uprighting
and tooth-intrusion movements.
The Align Corporate Fact Sheet Q2 2015 reveals
the following statistics for Invisalign appliances:
Invisalign cases shipped 3.2 million
Aligners manufactured 199 million
Invisalign-trained doctors 98,860
Active Invisalign doctors 45,580
ClearCorrect, founded in 2006, received FDA
approval in 2009 and aligners have been available in
the United States ever since. ClearCorrect was intro-
duced into Australia via Osseodent in 2015. Unlike
Invisalign, which has no significant gingival coverage,
ClearCorrect aligners are trimmed to overlap the
attached gingiva, a method which is claimed to pro-
vide improved aligner retention,10 although it does
therefore require more gingival detail in the impres-
sion or scan. ClearCorrect aligners incorporate CAD-
CAM generated, precision bonded resin attachments,
although these are limited to one shape only at pre-
sent.
Features similar to those of ClearCorrect can be
found in ClearPath, eCligner, K line and Orthocaps
SCOPE AND LIMITATION
CAT offers certain advantages over traditional fixed
appliance orthodontic treatments. These include fewer
clinical emergencies and improved aesthetics, comfort,
and oral hygiene, periodontal health, and lack of soft
tissue irritation.,2 11
Emergencies: There are few emergencies in CAT.
Lost or damaged aligners can be replaced usually
59
T Weir

within 2 weeks while the patient keeps wearing the Buschang et al. further noted that, as a general rule,
previous aligner. CAT aligns and levels arches. The intrusion of ante-
Aesthetics: Patients who request CAT have been rior teeth and control of posterior buccolingual incli-
shown to have aesthetic concerns as a primary motive.12 nation is relatively predictable. The extrusion of
Comfort: The pain and discomfort of CAT in the anterior teeth, rotations of rounded teeth and anterior
first week of treatment has been compared with that buccolingual inclination improvement are more prob-
of fixed appliances. In addition, the aesthetics, remov- lematic. A preliminary study by Castroflorio et al. 15
ability and small size of Invisalign aligners resulted in on the predictability of small amounts of anterior
superior functional and psychosocial differences com- tooth buccolingual inclination change using Invisalign
pared with fixed appliances, as well as significantly appliances reported a high degree of accuracy,
reduced pain. 13 although the study had several significant flaws in
Periodontal health: CAT has been recommended for sample selection and methodology. Again however,
consideration in treatment planning adult orthodontic the number, quality and heterogeneity of studies make
patients at risk of periodontitis. Over a 12-month results difficult to interpret. 2
study period, CAT was found to be associated with The table below has been constructed using a syn-
increased periodontal status and decreased levels of thesis of reported data from two of the larger aligner
periodontopathic bacteria when compared with treat- manufacturing companies, Align Technology and
ment by fixed buccal orthodontic appliances.14 ClearCorrect. Align Technology is the manufacturer
Of less certainty is the advantage of CAT over fixed of Invisalign appliances, which have been used to treat
appliances related to treatment efficiency. A study by the largest number of patients to date (in excess of 3
Buschang et al. in 2015 2 on efficiency, confirmed the million) of any clear aligner product. ClearCorrect
advantages of minimal to no patient emergencies and has been used in the treatment of over 80,000
reduced chairside time with CAT, although clinician orthodontic cases.
time in considering the treatment plan via ClinCheck
was a counterbalance in considerations of practice TOOTH MOVEMENT PREDICTABILITY WITH
efficiency, which clearly is also related to the experi- ALIGNERS ALONE
ence of the treating doctor. Predictable Moderate Difficult
A systematic review of the literature by Buschang
et al. in 2014 showed that CAT is recommended for Crowding or spacing Up to 6mm 6-8mm >8mm
per arch
the treatment of simple malocclusions. Midline discrepancy Up to 2mm 2-3mm >3mm
CAT need not be based on aligners alone, particu- Central incisor rotation Up to 40° 40-50° >50°
larly for malocclusions of increasing complexity. Lateral incisor rotation Up to 30° 30-40° >40°
Canine and premolar Up to 45° 45-55° >55°
More difficult movements, inter-arch changes, and rotation
anchorage management requires the use of additional Molar rotation Up to 20° 20-30° >30°
orthodontic techniques. As the complexity of required Anterior extrusion per arch Up to 2.5mm 2.5-3mm >3mm
Anterior intrusion per arch Up to 0.5mm 0.5-1mm >1mm
movements increases, attachments or altered aligner Posterior intrusion per arch Up to 0.5mm 0.5-1mm >1mm
geometries (such as pressure points, bite ramps and Posterior extrusion per arch 0mm 0.5mm >0.5mm
Power Ridges for lingual root torque) become increas- Expansion per quadrant Up to 2mm 2-3mm >3mm
Anteroposterior correction Up to 2mm 2-4mm >4mm
ingly necessary to provide better three-dimensional Incisor lingual root torque 0-10° 10-15° >15°
control of tooth movements and improved treatment Posterior tooth lingual 0-5° 5-10° >10°
outcomes. Other treatment features that are capable root torque
Posterior tooth distal 0-2mm 2-4mm >4mm
of being incorporated into more sophisticated aligner movement (maxilla)
systems, which are also employed by fixed appliances Posterior tooth mesial 0-1mm 1-2mm >2mm
include the use of intermaxillary elastics, interproxi- movement
mal reduction, temporary anchorage devices, lingual
buttons, power arms and fixed expanders.
CAT DIFFERENCES
CAT LIMITATIONS
CAT Material
As noted by Buschang et al.,2 clinicians planning to
employ CAT have to rely primarily on weak forms of Parameters that influence the biomechanical character-
published evidence (expert opinions and low-level istics of aligners include the properties of the material,
poorly designed scientific studies) or otherwise their the thickness of the material, and the fitting accuracy
own clinical experience. There are few published of the aligner to the teeth and any attachments. 16
investigations which focus on the predictability of Clear aligners may be made in a series which
orthodontic tooth movement with CAT. 2 relies on the progressive alteration of aligner shape
60 © 2017 Australian Dental Association

using one aligner material. However, in alternative
systems, different aligner materials may be used in a
sequential series, or in a repeating cycle of differing
materials.
CAT Forming Methods
Some clear aligners are vacuum formed, and some
are pressure formed. Nahoum17 draws a distinction
between vacuum-formed and pressure-formed appli-
ances. While both methods use air pressure to form
the appliances, vacuum forming involves pressures of
3-14 psi, while pressure forming involved pressures of
up to 100psi. Up to a limit, the detail of the inner, fit-
ting surface of the aligner, and hence the intimacy of
fit and improved ability to grip and generate forces to
a tooth or attachment surface is dependent upon air
pressure. Higher pressures therefore tend to equate
with improved force generation and higher precision.17
CAT Initial Data Recruitment
CAT can be based on the submission stone models, or
impressions (usually polyvinyl siloxane but not exclu-
sively) by the treating clinician to a laboratory which
allows the appliances may be manufactured via the
use of 3D scanning technology. The models produced
from the varying sources can be, in turn, manipulated
into the various treatment stages via manual adjust-
ment or by CAD-CAM technology. Some products
are available to the clinician to manufacture in-house
via 3D printing, while others are made in, and
shipped from, a central laboratory. The more accurate
the model on which the clear aligners are to be made,
the more precise are the subsequent tooth movements.
CAT Tooth Retention Strategies
Some aligner systems involve tooth and gingival cov-
erage (Clear Correct, K-line, Originator, Prestige) and
it is claimed that this provides superior appliance
retention,10 while others are entirely tooth borne. For
both of these systems, attachments (composite resin
shapes bonded to teeth) may be employed to enhance
aligner retention and to allow more complex move-
ments to be performed. While gingival coverage by
aligner materials may have periodontal implications,
purely tooth-borne appliances require bonded attach-
ments simply to aid retention of the appliance.
CAT and the Use of Bonded Attachments, and
Altered Aligner Geometries
Bonded resin attachments are a feature of some aligner
systems. The attachments have been introduced to
retain the appliances on the teeth and to extend the
© 2017 Australian Dental Association
Clear aligners in orthodontic treatment
ability of CA to perform movements that otherwise fall
outside those which are routinely predictable.18 Poorly
predicted movements include the extrusion of teeth;
rotation of round teeth (when viewed from the occlu-
sal) such as small upper lateral incisors, canines and
premolars); aligner retention when clinical crowns are
short or lack sufficient undercuts and to improve the
ability of aligners to intrude teeth by the use of adjacent
or more distant teeth for anchorage; and control of
mesio-distal root tip. Aligner systems which lack the
ability to incorporate bonded attachments can only
generate limited tooth movement.
In 2014, Simon et al. in a retrospective study, anal-
ysed premolar rotations of 10u, and concluded that
attachment use and the amount of movement per aligner
significantly influenced treatment predictability.16
Altered aligner geometries include the use of pres-
sure points within the aligner to deliver forces
instead of bonded resin attachments, the use of
Power Ridges for lingual root torque, and the incor-
poration of bite ramps. Since 2010, Align Technol-
ogy has produced a series of improved attachment
designs, pressure points, Power Ridges, bite ramps
and other altered aligner geometries which have
increased the effectiveness of force delivery by the
Invisalign appliances. Generally, these improvements
have yet to be replicated in any other commercially
available CAT system.
Factors Clinicians Should Use To Assess a CAT
System
Whether the aligners need to cover the gingiva is a
question awaiting a definitive answer. Gingival cover-
age is important to improve aligner retention in the
absence of tooth-borne attachments, but is potentially
less hygienic and requires greater impression/scan
detail.
Variable material stiffness or thickness: Are all the
aligners in a CAT system made out of the same mate-
rial or is material variability important to move teeth?
Should the aligners be made using a stone model, an
impression or an intraoral scan? Intraoral scans are the
most accurate for aligner manufacture and fit. 19–22
Is the model on which the aligner is made manipu-
lated by hand in a laboratory or via CAD- CAM soft-
ware? Hand manipulation (Originator - TP
Orthodontics) clearly offers much less precision, espe-
cially for small incremental movements necessary with
current aligner materials.
Are aligners manufactured using vacuum- or pres-
sure-forming? Pressure-forming is generally associated
with superior aligner fit.
Does the treating doctor have access to a three-
dimensional model of the treated case for confirma-
tion of the accuracy of the data and the proposed
61
T Weir
treatment plan, modification of the proposed treat-
ment plan, and final approval of data and plan prior
to manufacture?
Can the treating doctor interact with the manufac-
turer to alter tooth movements and treatment plans
on-line directly or via a technician or at all?
What is the number and frequency of impressions
or scans required to manufacture the entire initial
aligner treatment sequence intended to treat the
malocclusion to the desired outcome?
Is there a limit to number of aligners manufactured
for a case? Products which limit the complexity of the
malocclusion potentially able to be treated do so pri-
marily via restricting the number of aligners manufac-
tured for a specific case.
Are there other limits to case complexity able to be
treated by the aligner product, according to the manu-
facturer?
Does the aligner product use integrated bonded
attachments, specific aligner geometry alterations
(pressure points, power ridges, bite ramps, elastic cut-
outs etc)? The more sophisticated the range of the
available aligner auxiliaries, the more complex the
movement that can be treated with confidence.
CONCLUSIONS
There is a wide range of options from which a clini-
cian can choose if CAT is the desired treatment appli-
ance. The differences between these appliances are
profound which makes the choice of a specific appli-
ance a critical decision determined by the severity of
the malocclusion, the ability of the doctor to influence
the final outcome, the speed and utility of the clinical
treatment, and appliance aesthetics and comfort. The
primary features of CAT systems in general have been
highlighted to allow clinicians to make an initial
assessment of any system for potential clinical utility.
It falls outside the scope of this article to discuss the
laboratory fees and other clinical costs (for example
chair time) that may be associated with specific sys-
tems. Similarly, in depth specific analyses of individual
CAT systems or comparisons between specific systems
are not included in this article.
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Address for correspondence:
Tony Weir BDSc (Qld)
1st Class Hons MDS Ortho (Adelaide)
667 Oxley Rd Corinda 4075
Email: tonyweir@bigpond.com
© 2017 Australian Dental Association