ORIGINAL ARTICLE

Variables affecting orthodontic tooth movement

with clear aligners
Justin R. Chisari,a Susan P. McGorray,b Madhu Nair,c and Timothy T. Wheelerd
West Palm Beach and Gainesville, Fla

Introduction: In this study, we examined the impacts of age, sex, root length, bone levels, and bone quality on
orthodontic tooth movement. Methods: Clear aligners were programmed to move 1 central incisor 1 mm over the
course of 8 weeks. Thirty subjects, ages 19 to 64, were enrolled, and measurements were made on digital
models (percentage of tooth movement goal achieved). Morphometric features and bone quality were assessed
with cone-beam computed tomography. Data from this study were combined with data from 2 similar studies to
increase the power for some analyses. Results: The mean percentage of tooth movement goal achieved was
57% overall. Linear regression modeling indicated a cubic relationship between age and tooth movement, with a
decreasing rate of movement from ages 18 to 35 years, a slightly increasing rate from ages 35 to 50, and a
decreasing rate from ages 50 to 70. The final decreasing trend was not apparent for women. As would be ex-
pected, the correlation was significant between the percentage of the goal achieved and the cone-beam
computed tomography superimposed linear measures of tooth movement. A significant negative correlation
was found between tooth movement and the measurement apex to the center of rotation, but bone quality, as
measured by fractal dimension, was not correlated with movement. Conclusions: The relationship between
age and tooth movement is complex and might differ for male and female patients. Limited correlations with
cone-beam computed tomography morphology and rate of tooth movement were detected. (Am J Orthod
Dentofacial Orthop 2014;145:S82-91)

T
he use of clear aligners to produce orthodontic
tooth movement (OTM) provides an opportunity
to measure incremental movement and investigate
factors that might affect the rate of movement. The
broad principles of OTM are based largely on bone and
tissue remodeling, specifically the resorption and depo-
sition of alveolar bone as force is applied. The biology of
OTM has proven to be an extremely complex process
involving an array of coordinated biochemical reactions,
including critical cell signaling pathways and a wide
range of cellular differentiation, leading to bone remod-
eling.1 As the science of bone biology continues to
evolve, several theories of OTM have surfaced. The
a
b
Private practice, West Palm Beach, Fla.
Assistant professor, Department of Biostatistics, University of Florida,
Gainesville.
c
Chairman and professor, Department of Oral & Maxillofacial Diagnostic
Sciences, University of Florida, Gainesville.
d
Professor, Department of Orthodontics, University of Florida, Gainesville.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Supported by Align Technology, San Jose, Calif, and the Southern Association of
Orthodontists.
Address correspondence to: Susan P. McGorray, Department of Biostatistics, Box
117450, Gainesville, FL 32611; e-mail, spmcg@ufl.edu.
Submitted, June 2012; revised and accepted, October 2013.
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.10.022
S82
pressure-tension theory has emerged as the most
popular concept behind the movement of teeth.
Bone remodeling involves an intricate arrangement
of coordinated cellular activity leading to bone resorp-
tion performed by osteoclasts, followed by bone forma-
tion carried out by osteoblasts.2 Dolce and Holliday3
have reported that although the precise biologic
response to orthodontic force has not been identified,
several hypotheses regarding the mechanisms by which
osteoblasts and osteocytes sense this initial mechanical
stimulus have been proposed, including strain-
sensitive ion channels, shear stress receptors, integrin
activation, and cytoskeleton reorganization. Three
phases of tooth movement have been described in the
literature: initial phase, lag phase, and secondary
phase.4,5 The secondary stage accounts for most of the
tooth movement, and teeth during this period move at
a faster, more continuous pace.6
The magnitude and direction of force placed on teeth
during OTM, in addition to the length of time these
forces are in place, also play critical roles in how teeth
move. Forces applied to teeth cause various types of
tooth movement depending on the location of the center
of resistance of that tooth and the direction in which the
force is applied. It is understood that the center of resis-
tance for a given tooth changes based on tooth size,
Chisari et al
number of roots, and amount of tooth root that is
submerged in bone.
Variability among patients can affect OTM. Factors
including age, sex, root length, bone levels, bone
density, medications, and certain systemic conditions
can have inhibitory, synergistic, or additive effects on
OTM.7 The majority of literature on the effects of age
on OTM has been completed using animal models.
Bridges et al8 reported that a significantly greater
amount and rate of tooth movement occurred in
younger rats compared with their older counterparts in
all 3 phases of tooth movement. Similar findings of
the effects of increasing age on the rate and amount
of tooth movement have been reported by Misawa-
Kageyama et al9 and Harris.10 There has also been
some indication that whereas there is a delay in the onset
of tooth movement in adult rats, once the secondary
phase of tooth movement is reached, the movement
becomes equally efficient among the 2 age groups.11
The effect of age on OTM clearly exists and is likely
due in part to a decreased biologic response. Although
there is individual variability from patient to patient, a
direct difference in OTM between the sexes has not
been shown in the literature.
Medications with pharmacologic effects can impact
the cells targeted in OTM. Some of these medication
classes include bisphosphonates, estrogens, NSAIDS
and other analgesics, corticosteroids, calcium regulators,
and supplements.7,12,13 There is little human
experimental data on the effects of medications on
OTM and limited information from animal models.
However, knowing the biochemical action of these
medications has led to concerns regarding how they
can affect orthodontic treatment.13 Any medication
that interferes with or alters bone biology might impact
the rate of tooth movement.
Systemic factors or nutritional deficiencies affecting
bone metabolism have also been found to alter OTM.
Specifically, diseases of bone can have a significant
impact on the rate of tooth movement as well. Reduced
or complete lack of osteoclast function can lead to a
condition known as osteopetrosis, characterized by
sclerosis of the skeleton and inhibited tooth movement
and eruption. On the other hand, in Paget's disease,
uncontrollable bone turnover occurs because of the
overactivity of osteoclasts.14 Since OTM stimulates an
inflammatory process in the periodontal ligament and
surrounding tissues, it is thought that any chronic
inflammatory disease such as thyroiditis, asthma, and
even allergies can affect the movement of teeth.15
Other variables that might be of significance in OTM
are root length, bone levels, and the density or quality of
bone. Age-related decreases in bone turnover as well as a
American Journal of Orthodontics and Dentofacial Orthopedics
S83
relatively higher level of bone density have been
documented.8,13 Alveolar bone levels, on average,
decrease over time, impacting OTM by changing the
center of resistance. The center of resistance of a tooth
is largely influenced by its surroundings, particularly in
regard to root morphology, bone levels, and bone
quality.16 Thus, patients with alveolar bone loss or
abnormally long roots will have centers of resistance
farther from the point of force application (more
apically). Alternatively, the more the root tapers, the
more the center of resistance moves coronally.17
Clear aligners with sequentially programmed
movement provide an excellent model for investigating
tooth movement. A single tooth can be isolated, and
frequent measurements made with polyvinyl siloxane
or digital impressions provide incremental information
regarding the pattern of movement. For example,
McGorray et al18 characterized the weekly pattern of
tooth movement using this model over 8 weeks, along
with subsequent relapse. Kravitz et al19 compared actual
tooth movement with aligners with predicted movement
over the course of treatment. Aligner treatment is now a
commonly prescribed modality for OTM in adolescents
and adults, and a better understanding of the pattern
of movement and factors that influence movement
could lead to more efficient treatment.
The purposes of this study were to better characterize
the pattern of tooth movement with clear aligners with
programmed movement over 8 weeks and to examine
the influence of age, sex, root length, morphometric
measurements, and bone quality on the rate of OTM.
MATERIAL AND METHODS
The design for this study was similar to 2 previous
studies that investigated specific aspects of tooth move-
ment with clear aligners.18,20 Approval was obtained
from the University of Florida Institutional Review
Board for the Protection of Human Subjects. This
project was a prospective single-center clinical trial
involving subjects of 2 age groups with minor incisor
malalignments, who were otherwise healthy and would
be undergoing orthodontic treatment. The first group
included 7 men and 8 women between the ages of 18
and 35 years, inclusive. The second group consisted of
5 men and 10 women 50 years of age and older.
Throughout this article, this study will be called Study
3. Study 1 investigated the role of relaxin in tooth move-
ment and relapse, and has been previously described.18
No difference in tooth movement was detected when
comparing those who received relaxin injections with
those who received placebo injections; thus, data from
both groups in this study were combined, yielding a
sample size of 37 subjects. Cone-beam computed
April 2014
Vol 145
Issue 4
Supplement 1
S84
tomography (CBCT) imaging was not performed in
Study 1. Study 2 was similarly designed but included
CBCT imaging and examined the role of aligner material
fatigue in tooth movement.20 Subjects in this study
received a new aligner every week rather than every 2
weeks as in Study 1. No difference was detected in total
tooth movement when comparing the weekly aligner
and the biweekly aligner groups. For studies 1 and 2,
the biweekly tooth movement goal was 0.50 mm, for a
total 8-week goal of 2 mm. Study 3 was designed to
broaden the age range and to be used in conjunction
with the previous studies to examine the role of age
and other factors in tooth movement. In the 3 studies
combined, the total number of subjects was 82. All
subjects were in good health and had acceptable maloc-
clusions as defined in the inclusion criteria, which have
been described in a previous study.18
Once a subject was accepted into the trial, the right or
left maxillary central incisor was selected as the target
tooth. The selection was based on the target tooth's
not being blocked out by the adjacent teeth to allow a
total anteroposterior movement of 1 mm. Tooth move-
ment was accomplished using a series of 4 maxillary
aligners (Invisalign; Align Technology, San Jose, Calif),
each programmed in increments of 0.25 mm of anterior
movement of the central incisor being studied, as
described above. Aligners were collected every 2 weeks
from each subject, and new aligners were dispensed.
The study termination visit and final time point for
data collection was at week 8. Polyvinyl siloxane impres-
sions were taken weekly and sent to Align Technology
for scanning to create 3-dimensional models. Tooth
movement measurements from baseline through week
8 were made from each scanned model using Tooth-
Measure proprietary software (Align Technology).
CBCT measurements and fractal analysis were
completed using a combination of software including
InVivo (Anatomage, San Jose, Calif), ImageJ (National
Institutes of Health, Bethesda, MD), and Tact Work-
bench (Wake Forest University, Winston-Salem, NC).
The following are definitions of the measurements
used in the CBCT superimposition analysis. D U1 (x)
refers to the distance between lines drawn through the
midpoint of the incisal edges of the superimposed target
tooth perpendicular to the anteroposterior axis (the
plane of prescribed tooth movement). D U1 (s) is the
length of the line connecting the midpoint of the incisal
edges of the superimposed target tooth. D Apex refers to
the length of a line connecting the change in apex of the
superimposed target tooth. Rotation angle is the angle
created by the intersection of lines drawn from the
midpoint of the incisal edge to the apex of the target
tooth. The apex of this angle is considered the center
April 2014
Vol 145
Issue 4
Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chisari et al
of rotation. Tooth length refers to the distance from
the midpoint of the incisal edge to the apex of the target
tooth from the initial computed tomography image.
Crown length is the portion of the tooth length that is
coronal to the bone. Bone to C-rot is the section of tooth
length between the center of rotation and a line con-
necting the most coronal aspect of the faciolingual
crestal bone. These variables are illustrated in Figure 1.
All study subjects were instructed to wear the aligner
appliance full time. They were allowed to remove the appli-
ance when eating, drinking, or brushing their teeth. Their
medication and medical histories were taken initially. Each
subject recorded aligner wear time in a diary format. At the
conclusion of the study, the participants were routinely
treated orthodontically with clear aligners.
To determine subject eligibility, 2 visits were
required. The first visit was designed to identify potential
subjects with malocclusions needing minor incisor
alignment of at least the maxillary incisors. Those with
medical conditions or intraoral problems, including
significant periodontal disease, chronic daily use of
any nonsteroidal or anti-inflammatory medication,
current smokers, or history of significant cardiac disease,
uncontrolled hypertension, bleeding disorders, or renal
disease, were also excluded. Subjects who were deter-
mined to be eligible based on these procedures
proceeded to the next visit.
The screening visit was designed to finalize the
subject's eligibility and collect initial records. The
following procedures were performed at this visit:
impressions were taken with polyvinyl siloxane for prep-
aration of the Invisalign appliances, impressions were
sent to Align Technology after confirmation of
eligibility, and intraoral and extraoral photographs and
CBCT imaging were done. For women, a negative urine
pregnancy test immediately before this procedure was
required. After the investigator (T.T.W.) reviewed all sub-
ject information to confirm eligibility, the subjects were
enrolled into the study and assigned a unique number.
At the first study visit (week 0), the first aligner was
delivered to each subject. The acceptable visit window
for weeks 1 through 8 was 6 1 day, and all 30 treatment
subjects successfully satisfied this requirement.
During the study visits of weeks 1 through 8, the
following procedures were performed: intraoral clinical
examination, maxillary occlusal and frontal photo-
graphs, and polyvinyl siloxane impressions. In addition,
during the study visits of weeks 2, 4, and 6, the aligner
(used during the previous 2 weeks) and the wear diary
were collected, and the next aligner and diary were
dispensed. At the study termination visit, week 8, the
same procedures were performed, and CBCT imaging
of the maxilla took place.
Chisari et al
Fig 1. Superimposed CBCT measurements. Blue is
initial tooth position, and red is final tooth position (figure
from thesis of Carl Drake; Gainesville: University of Flor-
ida; 2010).
Weekly anteroposterior movement of the target
tooth was recorded with polyvinyl siloxane impressions.
These impressions were sent to Align Technology, and
digital models were created so that OTM could be
measured using Align Technology's ToothMeasure
software. The digitized model fabricated each week
was superimposed on the baseline digital model, taken
at week 0, according to the best fit of unmoved teeth,
particularly the posterior dentition. The most central
portion on the facial surface of the clinical crown of
the target tooth, referred to as the centroid, was deter-
mined, and subsequent tooth movements in all dimen-
sions were measured from this point at each study visit.
The same investigator (J.R.C.) measured the digital
models for all 30 subjects.
CBCT scans of each subject were performed at the
screening visit and at the study termination visit
(week 8). Using the InVivo software, the images were
superimposed on each other and registered at the
curvature of the palate in addition to other stable
maxillary structures. Measurements recorded from
these superimpositions are shown in Figure 1. A fractal
dimension score was calculated for each subject,
representing the quality of the bone.21 Higher fractal
dimensions correspond to greater morphologic
complexity of the bone.
Weekly wear time was calculated for each subject,
with mean, median, and standard deviation of weekly
wear time used to characterize each participant's wear
patterns.
American Journal of Orthodontics and Dentofacial Orthopedics
S85
Statistical analysis
Orthodontic tooth movement was quantified using
descriptive statistics for the digital model analysis.
Chi-square tests of equality of proportions and analysis
of variance (ANOVA) were used to compare subject char-
acteristics and results over the 3 studies. To standardize
the studies, the primary outcome was the percentage of
tooth movement goal achieved over 8 weeks. Spearman
correlation coefficients were estimated to examine the
relationship between that outcome variable and age,
morphometric measurements, and compliance. Median
weekly hours of wear were used to represent compliance
during the study, and this would not be overly influ-
enced by a week of limited wear or excessive wear and
would better represent typical weekly compliance. Linear
regression modeling was used to examine the relation-
ship between the percentage of tooth movement goal
achieved and multiple covariates. Based on the R2 value
(percentage of variability in the outcome explained by
the model), the best 1, 2, 3, and so on variable models
were determined. Model building was concluded when
additional variables did not significantly improve the
previous model. Potential interactions between covari-
ates and the influence of outliers were also examined.
A P value less than 0.05 was considered statistically
significant, and analyses were performed using SAS
software (version 9.1.3; SAS Institute, Cary, NC) and R
software (version 2.15; R Foundation for Statistical
Computing, Vienna, Austria).
RESULTS
The demographic characteristics of the subjects for
the 3 studies can be found in Table I. No significant
differences were detected when comparing the studies
for sex, race, compliance, and percentage of tooth
movement goal achieved. Tooth movement goal and
age were not compared because they differed in the
designs of the studies. The pattern of tooth movement
over 8 weeks is shown in Figure 2. Most tooth movement
occurred in the first week of the 2-week wear cycle.
Table II presents summary statistics and group com-
parisons for the demographic variables and planned
biweekly tooth movement. The percentage of the goal
achieved did not differ significantly by sex or race.
Although it was not statistically significant (P 5 0.06),
subjects with a smaller goal had a higher mean percent-
age of goal achieved, 62%, compared with 54% for those
with a planned movement of .50 mm. There was no sig-
nificant correlation with age, according to the Pearson
correlation coefficient estimate of 0.021 (P 5 0.90).
However, examining this correlation separately for men
and women, different patterns were suggested, with
April 2014
Vol 145
Issue 4
Supplement 1
S86 Chisari et al

Table I. Demographic characteristics and descriptive statistics

Study 1 (n 5 37) Study 2 (n 5 15) Study 3 (n 5 30) Total (n 5 82) P value
Sex, female (%) 70 60 60 65 0.63*
Race (%)
White 76 54 77 72 0.32*
Black 13 13 10 12
Other 11 33 13 16
y
Tooth movement 2-week goal
0.25 mm (%) 0 0 100 37
0.50 mm (%) 100 100 0 64
y
Age (y), median 27.1 23.1 43.5 27.9
Mean (SD) 26.7 (5.1) 25.1 (4.9) 40.7 (15.5) 31.5 (12.3)
Range 18.6-40.5 20.0-35.0 19.0-68.0 18.6-68.0
Compliance, median hours/wk (n 5 34) (n 5 15) (n 5 30) (n 5 79) 0.13z
Mean (SD) 138 (24) 144 (14) 147 (8) 142 (18)
Range 28-162 104-157 128-160 27-162
% goal achieved, median 59.0 58.0 68.0 61.8 0.17z
Mean (SD) 53.2 (16.2) 55.4 (15.0) 61.6 (20.0) 56.9 (17.7)
Range 11.0-77.5 17.5-73.0 11.0-93.0 11.0-93.0

*Chi-square test of equality of proportions; ynot tested because of different study designs; zANOVA.

Fig 2. Mean percentage of tooth movement goal achieved for the 3 studies. Solid line indicates tooth
movement goal (assuming linear movement) over the 8 weeks.

the women having a positive correlation coefficient esti-
mate, 0.09 (P 5 0.52), whereas the men had a negative
correlation coefficient estimate, 0.23 (P 5 0.25). We
also did not detect a significant correlation between
compliance (measured by median weekly hours worn)
and percentage of goal achieved, with the Pearson cor-
relation coefficient estimate of 0.06 (P 5 0.59). This
relationship is displayed in Figure 3.
Summary statistics for the CBCT measurements and
their correlations with percentage of goal achieved are
given in Table III. High correlation would be expected
between percentage of goal achieved and DU1(x),
DU1(s), and rotation angle, since these should corre-
spond well with the model-based tooth movement per-
centage of goal achieved measurement. Significant
correlations were not noted for most morphometric
measures. A negative correlation with percentage of
goal achieved was identified for the apex to center of
rotation measurement; this is illustrated in Figure 4.
Linear regression modeling was used to examine the
relationship between percentage of tooth movement
goal achieved and covariates. Covariates considered for

April 2014
Vol 145
Issue 4
Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chisari et al S87

Table II. Descriptive statistics and comparisons of

demographic variables and planned treatment goals
Variable n Mean SD Range P value *
Sex
Male 29 54.4 16.1 17.5-80.0 0.35
Female 53 58.2 18.5 11.0-93.0
Race
White 59 58.0 16.1 11.0-93.0 0.37
Black 10 58.4 19.4 24.0-85.3
Other 13 50.5 22.8 15.0-77.5
Goal
0.25 mm 30 61.6 20.0 11.0-93.0 0.06
0.50 mm 52 54.1 15.8 11.0-77.5

*Two-sample t test or ANOVA.

inclusion in the model included age, age2, race, study

biweekly goal (0.25 or 0.50 mm), compliance, and study
number (1, 2, or 3). Sequentially, we determined the best
models consisting of 1 to 5 variables. When 2 or more
Fig 3. Correlation between compliance (median weekly
variables were selected for a model, a potential interac-
hours wear) and percentage of tooth movement goal
tion between these variables was also considered for achieved. Circles indicate observed data, solid line repre-
inclusion in the model. This is appropriate if the sents best linear fit (Pearson correlation coefficient
combined impact of the 2 variables differs from what estimate 5 0.06; P 5 0.59), and dotted line indicates
would be expected from their individual contributions best linear fit with outlier removed (Pearson correlation
(ie, synergy or antagonism). Age and age2 were included coefficient estimate 5 0.12; P 5 0.28).
to have more flexibility to identify the relationship
between age and tooth movement. The best 1-variable
to 0.25 mm. In studies 1 and 2, where each set of aligners
model consisted of the biweekly goal (R2 5 0.042). The
was programmed for 0.5 mm of tooth movement, only
best 2-variable model included age and age2 (R2 5
54% of the tooth movement was achieved; slightly
0.084). The best 3-variable model included age, age2,
more, 62%, was achieved with the smaller 0.25-mm
and their interaction (ie, age3) (R2 5 0.14). No additional
goal. As mentioned earlier, the magnitude and direction
variables significantly improved the model. The fitted
of force placed on teeth during OTM, in addition to the
models and the actual data points are displayed in
length of time these forces are in place, can play critical
Figure 5. Because this model includes intercept, age,
roles in how teeth move.
age2, and age3, it is considered a cubic age model. The
The use of aligners has increased in both the adoles-
overall cubic age model suggests that tooth movement
cent and young adult populations and among older
slows from ages 18 through 35 years, increases slightly
adults seeking orthodontic treatment in recent years,
until approximately age 50, and then declines. We also
raising concerns regarding the efficiency of tooth move-
fit this model separately for men and women. Model fit
ment, particularly in the older population. Conventional
statistics and parameter estimates are provided in
thinking and clinical experience from several studies has
Table IV, and the predicted tooth movements for men
led to the belief that the rate of tooth movement
and women are also illustrated in Figure 5. The decline
decreases with age.8-10 Additional factors, including
in tooth movement after the age of 50 is not apparent
sex, root length, bone levels, and bone density, can
in the model, with only the data from women.
have various affects on tooth movement as well.7 Our
results suggest that the relationship between age and
DISCUSSION
tooth movement is complex and can differ depending
The combined data indicate that despite having on sex. Regression modeling supports an overall cubic
aligners programmed to move 1 central incisor 1 mm relationship between OTM and age, represented by an
labially (0.25 mm per aligner), on average only 57% of s-shaped curve. Further exploratory analysis showed a
that movement was achieved. This discrepancy might quadratic (u-shaped) relationship for women and a
be due to several reasons. It has been postulated that a more linear relationship for men. These trends might
greater percentage of tooth movement would occur if be the consequence of decreased quality of bone (oste-
the prescription in each aligner was decreased from 0.5 oporosis) typically seen in older women. However, data

American Journal of Orthodontics and Dentofacial Orthopedics April 2014
Vol 145
Issue 4
Supplement 1
S88 Chisari et al

tooth movement increased, these measurements

Table III. Descriptive statistics for CBCT measure-
increased in both the CBCT superimposition and the
ments and Spearman correlation coefficient estimates
digital model analysis. The DU1(s) and rotation angle
of specified variables with percentages of tooth move-
difference between studies 2 and 3 implies more uncon-
ment goal achieved (n 5 45)
trolled tipping in Study 2, likely because of the higher
Spearman programmed tooth movement in that study. There was
correlation a significant negative correlation for the measurement
with
Variable Study Mean SD Min Max % goal apex to the center of rotation, indicating that as tooth
D U1 (x) 2 1.56 0.38 0.80 2.02 0.90* movement increased, the apex to the center of rotation
3 0.85 0.37 0.22 1.96 0.69* measurement decreased. This could be the result of
Total 1.09 0.50 0.22 2.02 0.37* root resorption, but it was more likely due to decreased
D U1 (s) 2 1.63 0.40 0.80 2.09 0.86* alveolar bone levels.22,23
3 1.17 0.49 0.34 2.32 0.56*
Total 1.33 0.51 0.34 2.32 0.44*
Other authors have examined the efficiency of tooth
D Apex 2 0.73 0.26 1.32 0.39 0.72* movement with aligners. Kravitz et al19 examined
3 0.41 0.14 0.67 0.09 0.21 pretreatment and posttreatment locations for 37
Total 0.52 0.24 1.32 0.09 0.09 subjects, with 401 teeth. They considered all types of
Rotation angle 2 5.31 1.32 2.70 7.50 0.86* movement and the complete treatment period (means
3 4.08 1.63 1.60 8.90 0.59*
Total 4.49 1.63 1.60 8.90 0.47*
of 10 maxillary and 12 mandibular aligners per treat-
Tooth length 2 24.87 2.02 21.67 30.32 0.42 ment). Overall, the mean accuracy of tooth movement
3 22.84 2.09 17.90 26.90 0.08 was 41%. It was expected that this would be lower
Total 23.52 2.26 17.90 30.32 0.17 than our observed 57% because the study was signifi-
Crown length 2 12.27 0.74 10.84 13.27 0.17 cantly longer and involved multiple types of movement
3 11.51 0.93 9.82 13.79 0.07
Total 11.76 0.94 9.82 13.79 0.07
and multiple teeth per subject. Bollen et al24 quantified
Root length 2 12.60 1.74 10.56 17.74 0.40 tooth movement with aligners by assessing the ability to
3 11.33 1.87 6.44 14.95 0.12 complete treatment (25-35 sequential aligners). Of 51
Total 11.76 1.90 6.44 17.74 0.16 subjects, only 15 (29%) completed their initial series.
Crown/root ratio 2 0.99 0.12 0.71 1.23 0.12 This suggests that tooth movement is less than optimal
3 1.05 0.22 0.75 1.78 0.13
Total 1.03 0.19 0.71 1.78 0.12
and illustrates the potential usefulness of understanding
Bone to C-rot 2 5.14 1.25 2.89 7.70 0.10 factors that affect tooth movement.
3 5.64 2.24 1.90 10.19 0.13 Factors related to tooth movement via archwires and
Total 5.47 1.96 1.90 10.18 0.15 brackets were examined by Dudic et al.25 Thirty subjects,
Apex to C-rot 2 7.46 2.01 4.59 12.82 0.18 ranging in age from 11 to 43 years, participated;
3 5.70 1.57 1.18 9.26 0.27
Total 6.29 1.90 1.18 12.82 0.35*
younger subjects (age 15 and younger) appeared to
Bone C-rot/ 2 0.41 0.11 0.25 0.63 0.08 have more tooth movement that those 16 years and
apex C-rot older. Multiple teeth per subject were studied, and cor-
3 0.49 0.16 0.20 0.87 0.19 relations within subjects were not adequately accounted
Total 0.46 0.14 0.20 0.87 0.24 for, making the results difficult to interpret. No relation-
Fractal dimension 2 1.71 0.20 1.37 2.00 0.25
3 2.11 0.05 1.99 2.21 0.00
ship was detected between sex or tooth location and
Total 1.98 0.23 1.37 2.21 0.13 amount of movement.
Compliance with the treatment plan is a key
*Significant, P \0.05.
element in achieving tooth movement with aligners,
and we were surprised that our measure of compliance
from studies 2 and 3 showed no statistical correlation was not related to the percentage of tooth movement
between age and fractal dimension, a bone complexity goal achieved. The use of diaries to obtain time of
and quality indicator. Caution must be used in interpret- wear requires accurate and truthful recording by the
ing the fractal dimension analysis, and additional infor- participants. The subjects in these studies appeared
mation such as bone mass or structural properties of the to be highly motivated, and their compliance level
bone might be needed to truly assess bone quality.21 was uniformly high, with the exception of 1 outlier.
Hormone replacement therapy can also play a role in Similar compliance rates have been reported in a
the differing patterns. similar study.19 Compliance might play a role in tooth
Of the many CBCT and digital model measurements movement in less motivated patients, but because of
examined, significant positive correlations were noted the uniformity of our sample, we were unable to
with DU1 (x), DU1(s), and rotation angle. That is, as detect this.

April 2014
Vol 145
Issue 4
Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chisari et al
Fig 4. Correlation between tooth movement and apex to the center of rotation measurement. Dots repre-
sent observed data, and line indicates best linear fit (Pearson correlation coefficient estimate 5 0.35;
P 5 0.0184).
Fig 5. Cubic age model representing age vs the amount
of tooth movement for the 3 data sets. Solid line, overall
cubic model; dotted line, model using only data from
women; dashed line, model using only data from men;
solid squares, observed data for men; open circles,
observed data for women.
We were fortunate to be able to combine data from 3
studies to investigate factors associated with tooth
movement. Each of the component studies was designed
to address a specific question regarding aligners, and the
American Journal of Orthodontics and Dentofacial Orthopedics
S89
similar designs, patient populations, and outcome
measures allowed the combined data to provide a suffi-
cient sample size to address our larger question. Care
was taken in combining data, with separate comparisons
of subject characteristics in the 3 studies and acknowl-
edgment and testing (in our regression modeling) for
the impact of unidentified study-specific components
that could have affected tooth movement. No unidenti-
fied study-specific components were detected.
The advantages of using the aligner model for tooth
movement include ease of patient wear and patient
recruitment, reliable outcome measures, and the benefit
of a human model. Of particular interest is the ability to
measure tooth movement on an incremental time scale.
In all 3 substudies, stair-step movement was observed,
with most movement occurring during the first week
of the 2-week aligner time period. We have previously
investigated whether this was due to a lack of contin-
uous force caused by aligner fatigue, but we did not
find this to be the case.20 Wear time appeared to be
uniform throughout the 8-week study. It would be of
interest to further characterize the movement over the
2-week period with more frequent measurements. As a
consequence of not achieving biweekly tooth movement
goals, accuracy decreased, resulting in poorer aligner fit
over time. This can result in revised treatment planning
and longer treatment times.
There are several limiting factors associated with
studying tooth movement with this model. Patient
April 2014
Vol 145
Issue 4
Supplement 1
S90
Table IV. Linear regression model fit and parameter estimates (parameter estimates and P values)
Model R2
Overall fit (P value) Intercept
Overall 0.20 0.0006 252.9 (\0.0001)
Women 0.20 0.0116 145.7 (0.18)
Men 0.24 0.07 235.7 (0.0041)
compliance is the single most important factor contrib-
uting to the amount of tooth movement seen. Unfortu-
nately, even recording wear time on a daily basis has
limited value. Clinical experience has suggested that a
more continuous force enhances tooth movement.
Removing the aligners for eating and brushing results
in an interrupted force. Another factor, addressed by
other studies, is the loss of anchorage of adjacent teeth
during tooth movement. Whereas only 1 target tooth
was programmed for tooth movement, movement of
adjacent teeth is expected and can falsely minimize the
amount of tooth movement of the target tooth. Polyvi-
nyl siloxane impressions can have inaccuracies because
of operator error or subject movement. Lastly, the use
of aligners to produce tooth movement might be consid-
ered a limitation because it is not a perfect system for
producing tooth movement.
The ability to make an accurate prediction regarding
how teeth will move when a force is applied has long
been a challenge for orthodontists. Contributing to
this factor is the large degree of variability of OTM
seen among patients of the same age group, not to
mention those across age groups. Different types of
tooth movement, combined with varying biologic
responses, make prediction difficult. Although there
will always be variability in patients, our results suggest
that there are general trends in tooth movement for
different age groups, and that these might differ for
male and female subjects.
CONCLUSIONS
In this single-center prospective clinical trial, we
examined the variables affecting tooth movement using
a clear aligner model. When all 3 data sets were
combined, the mean percentage of tooth movement
achieved compared with the tooth movement goal was
57%. The results of regression modeling suggest an
overall cubic relationship between OTM and age, repre-
sented by an s-shaped curve. Further exploratory
analysis revealed a quadratic (u-shaped) relationship
for women, indicating an increase in tooth movement
in younger and older women, and a more linear
April 2014
Vol 145
Issue 4
Supplement 1 American Journal of Orthodontics and Dentofacial Orthopedics
Chisari et al
Variables in the model
Age Age2 Age3
16.23 (\0.0001) 0.41 (\0.0001) 0.0033 (0.0001)
15.49 (0.59) 0.079 (0.80) 0.0001 (0.98)
9.92 (0.0229) 0.37 (0.0234) 0.0030 (0.0232)
relationship for men, with decreased movement at older
ages. Significant positive correlations were found be-
tween CBCT superimposition measurements and digital
model measurements of the percentage of goal achieved
for the DU1 (x), DU1(s), and rotation angle variables,
whereas a significant negative correlation was seen
with the percentage of goal achieved and the apex to
center of rotation measurement.
REFERENCES
1. Masella RS, Meister M. Current concepts in the biology of ortho-
dontic tooth movement. Am J Orthod Dentofacial Orthop 2006;
129:458-68.
2. Proff P, Romer P. The molecular mechanism behind bone remod-
eling: a review. Clin Oral Investig 2009;13:355-62.
3. Dolce C, Holliday LS. Toward molecular orthodontics. In: Riolo ML,
Avery JK, editors. Essentials for orthodontic practice. Ann Arbor
and Grand Haven, Mich: EFOP Press; 2003.
4. Kohno, Matsumoto Y, Kanno Z, Warita H, Soma K. Experimental
tooth movement under light orthodontic forces: rates of tooth
movement and changes of the periodontium. J Orthod 2002;29:
129-35.
5. Krishnan V, Davidovich Z. Cellular, molecular, and tissue-level
reactions to orthodontic force. Am J Orthod Dentofacial Orthop
2006;129:469.e1-32.
6. Iwasaki LR, Haack JE, Nickel JC, Morton J. Human tooth move-
ment in response to continuous stress of low magnitude. Am J
Orthod Dentofacial Orthop 2000;117:175-83.
7. Krishnan V, Davidovitch Z. The effect of drugs on orthodontic
tooth movement. Orthod Craniofac Res 2006;9:163-71.
8. Bridges T, King GJ, Mohammed A. The effect of age on tooth
movement and mineral density in the alveolar tissues of the rat.
Am J Orthod Dentofacial Orthop 1988;93:245-8.
9. Misawa-Kageyama Y, Kageyama T, Moriyama K, Kurihara S,
Yagasaki H, Deguchi T, et al. Histomorphometric study on the
effects of age on orthodontic tooth movement and alveolar
bone turnover in rats. Eur J Oral Sci 2007;115:124-30.
10. Harris EF. Effects of patient age and sex on treatment: correction
of Class II malocclusion with the Begg technique. Angle Orthod
2001;71:433-41.
11. Ren Y, Maltha J, Van't Hof MA, Kuijpers-Jagtman A. Age effect on
orthodontic tooth movement in rats. J Dent Res 2003;82:38-42.
12. Rinchuse DJ, Rinchuse DJ, Sosovicka MF, Robison JM, Pendleton R.
Orthodontic treatment of patients using bisphosphonates: a report
of 2 cases. Am J Orthod Dentofacial Orthop 2007;131:321-6.
13. Bartzela T, T€urp JC, Motschall E, Maltha JC. Medication effects on
the rate of orthodontic tooth movement: a systematic literature
review. Am J Orthod Dentofacial Orthop 2009;135:16-26.
Chisari et al
14. Helfrich M. Osteoclast diseases and dental abnormalities. Arch Oral
Biol 2005;50:115-22.
15. Davidovitch Z, Krishnan V. Role of basic biological sciences in clin-
ical orthodontics: a case series. Am J Orthod Dentofacial Orthop
2009;135:222-31.
16. Proffit WR. Biologic basis of orthodontic therapy; mechanical prin-
ciples of orthodontic force control. In: Proffit WR, Fields HW,
Sarver DM, editors. Contemporary orthodontics. 4th ed. St Louis:
Mosby; 2007.
17. Choy K, Pae E, Park Y, Kim K, Burstone CJ. Effect of root
and bone morphology on the stress distribution in the peri-
odontal ligament. Am J Orthod Dentofacial Orthop 2000;
117:98-105.
18. McGorray SP, Dolce C, Kramer S, Stewart D, Wheeler TT. A
randomized, placebo-controlled clinical trial on the effects of
recombinant human relaxin on tooth movement and short-
term stability. Am J Orthod Dentofacial Orthop 2012;141:
196-203.
19. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does
Invisalign work? A prospective clinical study evaluating the
American Journal of Orthodontics and Dentofacial Orthopedics
S91
efficacy of tooth movement with Invisalign. Am J Orthod Dentofa-
cial Orthop 2009;125:27-35.
20. Drake CT, McGorray SP, Dolce C, Nair M, Wheeler TT. Orthodontic
tooth movement with clear aligners. ISRN Dent 2012 [Epub 2012
Aug 14].
21. Hua Y, Nackaerts O, Duyck J, Maes F, Jacobs R. Bone quality
assessment based on cone beam computed tomography imaging.
Clin Oral Implants Res 2009;20:767-71.
22. Liang S, Hosur KB, Domon H, Hajishengallis G. Periodontal inflamma-
tion and bone loss in aged mice. J Periodontal Res 2010;45:574-80.
23. Renvert S, Persson RE, Persson GR. A history of frequent dental
care reduces the risk of tooth loss but not periodontitis in older
subjects. Swed Dent J 2011;35:69-75.
24. Bollen AM, Huang G, King G, Hujoel P, Ma T. Activation time and
material stiffness of sequential removable orthodontic appliances.
Part 1: ability to complete treatment. Am J Orthod Dentofacial
Orthop 2003;124:496-501.
25. Dudic A, Giannopoulou C, Kiliaridis S. Factors related to the rate of
orthodontically induced tooth movement. Am J Orthod Dentofa-
cial Orthop 2013;143:616-21.
April 2014
Vol 145
Issue 4
Supplement 1