Received: 29 November 2022 | Revised: 2 July 2024 | Accepted: 7 August 2024

DOI: 10.1111/ocr.12846

RESEARCH ARTICLE

Accuracy of clear aligners in the orthodontic rotational

movement using different attachment configurations

Gianluigi Fiorillo1 | Alessandra Campobasso2 | Silvia Croce1 | Umar Hussain3 |

Giovanni Battista2 | Eleonora Lo Muzio4 | Gualtiero Mandelli1 | Alessandro Ambrosi1 |
Giorgio Gastaldi1

1
Dental School, San Raffaele Vita-­Salute
University of Milan, Milan, Italy Abstract
Objective: To evaluate the accuracy of dental rotational movements using clear align-
2
Department of Clinical and Experimental
Medicine, University of Foggia, Foggia,
Italy
ers with different attachment configurations.
3
Department of Orthodontics, Saidu Materials and Methods: This retrospective study analysed 212 teeth from 89
College of Dentistry, Swat, Pakistan patients undergoing Invisalign treatment. Digital models were analysed after the
4
Department of Translational Medicine
virtual treatment plan (ST1) and after the first treatment phase (ET1) to evaluate
and for Romagna, University of Ferrara,
Ferrara, Italy the effective clinical rotational movement. The rotational movements of incisors,
canines, and bicuspids were measured using data from the Clincheck Movements
Correspondence
Alessandra Campobasso, Department Table. ST1 and ET1 were compared to determine the actual rotational movement
of Clinical and Experimental Medicine,
achieved (ST1-­E T1). The presence or absence of attachments (rectangular or op-
University of Foggia, Clinica Odontoiatrica
Via Rovelli 50, 71122, Foggia, Italy. timized) on teeth was analysed. The accuracy of rotational movements among
Email: [email protected]
attachment types was compared using the Kruskal-­Wallis test. Multiple linear re-
gressions were conducted with accuracy as the dependent variable and tooth type,
gender, and age as predictors.
Results: Optimized attachments had the highest median accuracy (70%), followed
by rectangular (65%), and without attachment (63%), with no significant differences
(p = .5). There were no significant differences across age groups, genders, or tooth
types. Baseline accuracy was 68.62% (95% CI: 56.03–81.20, p < .001). Age was a sig-
nificant predictor (estimate = −0.30, 95% CI: −0.58 – −0.03, p = .032), indicating de-
creased accuracy with increasing age. The model's R 2 was 0.046, with an adjusted R 2
of 0.003, indicating minimal variance explained.
Conclusion: The addition of attachment configurations to clear aligners improves ro-
tational accuracy, but not significantly. Further advancements in these configurations
are needed to enhance the performance of the aligners.

KEYWORDS
attachment, clear aligner, rotation

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2024 The Author(s). Orthodontics & Craniofacial Research published by John Wiley & Sons Ltd.

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wileyonlinelibrary.com/journal/ocr Orthod Craniofac Res. 2024;27:996–1003.
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FIORILLO et al. 997

1 | I NTRO D U C TI O N hypothesis is that no differences exist between the expected and

obtained rotation achievable by CAT.
In recent years, an increasing number of patients have been seeking
orthodontic treatment,1,2 and clear aligner Therapy (CAT) has be-
come a key part of routine clinical practice.3,4 2 | M ATE R I A L S A N D M E TH O DS
CAT represents a viable alternative to traditional fixed therapy,
such as vestibular or lingual braces, due to the use of comfortable, 2.1 | Study design, participants, and settings
removable clear appliances with a low aesthetic impact.5,6
These characteristics have made CAT popular among orthodon- A total sample of 998 adult patients who received Invisalign® (Align
7,8
tic patients, particularly adults. Technology, Santa Clara, CA, USA) aligner treatment was retro-
Additionally, three-­dimensional (3D) treatment planning soft- spectively enrolled. The sample was obtained from a single experi-
ware enables clinicians to virtually pre-­visualize treatment out- enced orthodontist at the section of Orthodontics, Department of
comes, also representing a motivational tool for patients.7 Dentistry, University of San Raffaele (Italy). All the procedures of
With the Clincheck® which is the dedicated software of Align tech- this research adhered to the Declaration of Helsinki, and informed
nology, clinicians can simulate dental movements until achieving the consent was obtained from all patients. The minimum sample size
final occlusion, allowing them to stage the sequence of tooth displace- was 45 patients (15 in each group) calculated through openepi soft-
ments and predict the therapy duration using Invisalign® aligners.7 ware (https://​w ww.​opene​pi.​com/​Sampl​eSize/​​SSMean.​htm) at 80%
1,9
Over the years, as reported in literature, several improve- power, 95% confidence level using mean accuracy (%) of 72.8 ± 23.6
ments have been introduced in the Invisalign® system, including the with optimized attachment and 48.1 ± 23.4 with conventional rota-
change in the aligner material (form Exceed30® to SmartTrack®), tion attachment from previous similar study.18 However, for normal-
advances in aligner design (SmartForce® Aligner Activation), and ity assumption, we have taken all available 89 cases.
the update of Clincheck® software version (Invisalign®G8 with its All patients met the following inclusion criteria: (1) treatment
SmartStage technology). plan simulation using Clincheck® G8 software version; (2) age be-
However, despite technological advances, several critical issues tween 18 and 70 years old, without gender restrictions; (3) per-
still remain regarding the actual reliability of CAT in expressing all manent dentition, without agenesis (except for third molars) or
10–12
predicted orthodontic movements, including rotation. supernumerary teeth; (4) tooth rotation between 4° and 65° on the
In fact, each aligner is shaped with a predetermined mismatch initial model; (5) 2° of planned rotation per stage; (6) a minimum of
between dental and aligner surfaces, which gradually moves the tar- 14 aligners, without midcourse correction or additional aligners; (7)
get teeth towards the correct position.7,13–15 good compliance.
Therefore, one factor that could influence the efficiency of CAT The main exclusion criteria were as follows: (1) treatment plan
is the tooth shape because it could affect the fit between aligners simulation using Clincheck G6 and G7 software versions; (2) severe
and teeth.16 Although anterior teeth can be successfully rotated maxillary contraction, extractive or surgical cases; (3) anomalies of
using CAT,1 the available literature has reported that the rotation of dental crowns; (4) unerupted teeth; (5) ankylosis and primary erup-
round-­shaped teeth is the most unpredictable movement to correct tion defect; (6) periodontal diseases; (7) missing teeth or implants or
with CAT.10,17–19 The absence of interproximal undercuts in these prosthetics; (8) more than 2° of planned rotation per stage; (9) aux-
tooth types could induce an incorrect force distribution, leading to a iliaries for rotation correction (such as buttons, elastic chain, etc.).
loss of fit of the aligner on the tooth surfaces.16,20 Although Kravitz According to the eligibility criteria, the final sample consisted
21 22
et al. and Simon et al. reported that the least predictable move- of 89 adult patients, including 35 males and 54 females (mean age
ment is premolar rotation, Lombardo et al.17 suggested that the least 30.90 ± 12.59 years old).
accurate movement is the rotation of mandibular canines. For each patient, initial digital casts were acquired with a TRIOS 3
Considering the limitations of CAT for canine and premolar ro- (3Shape, Copenhagen, Denmark) colour intraoral scanner, and these
tational movement, Papadimitriou et al.1 suggested the use of addi- pre-­treatment scans were sent to Align Technology for Clincheck®
tional attachments for these types of movements. planning.
Composite attachments are bonded to the dental crowns to in- For each treated arch, two digital models were obtained from
crease the aligner's retention and facilitate dental movements.18 Clincheck®: (1) virtual models of Clincheck planning, with the rota-
Although several authors have demonstrated that the use of tion simulated by the software; (2) virtual clinical models after the
auxiliaries (such as attachments) significantly enhances the reliability first phase of aligners or before the refinement phase.
and predictability of planned movements using aligners,17,23,24 con-
trasting results were reported for rotational movements, 21,22,25 as
confirmed by a recent review by Nucera et al. 25 2.2 | Digital measurements
Therefore, the aim of the present study was to evaluate the
accuracy of dental rotational movements with Invisalign® aligners For each maxillary and mandibular model, the amount of rotation
using different attachment configurations, comparing the planned was examined for different teeth, including central and lateral inci-
Clincheck simulation with the achieved clinical outcomes. The null sors, canines, first and second bicuspids.
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998 FIORILLO et al.

These angular measurements were obtained from the Clincheck An accuracy value of 0% indicates that no rotation has occurred
Tooth Movement Table, which is a software application developed after the first phase of aligners, while an accuracy value of 100%
by Align Technology to perform an automatic analysis report, which indicates no residual rotation.
showed quantitative measurements for the simulated and effective
rotations, avoiding any inaccuracy due to the manual detection of
landmarks. 2.3 | Statistical analysis
Using an automatic algorithm, the ClinCheck software calculates
the degree of rotation of clinical crowns by comparing the initial po- Data analysis was done in R software 4.3.3 (Vienna, Austria). Due
sition of each tooth with its simulated final position after the first to skewed data, non-­parametric tests were run. Median and in-
aligner stage. terquartile ranges were calculated for the accuracy of rotational
After performing the virtual treatment simulation, ClinCheck movements. Comparison was done for the accuracy of rotational
uses common reference points on the teeth to superimpose the ini- movements among various configurations of the attachments using
tial scan with the simulated model, ensuring that all scans are aligned the Kruskal–Wallis test. Analysis was stratified by gender, age group,
within a consistent spatial reference coordinate system. and tooth types. Multiple linear regressions were run using the accu-
The algorithm then calculates the degree of rotation for each racy of rotational movements as the dependent variable, while tooth
tooth, from the initial positions (from the pre-­treatment scan) to the type, gender, and age were predictors. The level of significance was
simulated final positions (planned by the virtual simulation). set at p ≤ .05.
After the first stage of aligners, the pre-­refinement scan is also
aligned with both the initial scan and the simulated final model. The
differences between the effective clinical rotations and the simu- 3 | R E S U LT S
lated virtual movements are automatically analysed, determining
any remaining degrees of rotation required for each tooth. The mean age of the participants was 30.90 ± 12.59 years. Among
Finally, 212 dental elements were analysed in the present study females (n = 156, 73.58%), the rotated teeth were more than males
(83 for the maxillary arch and 129 for the mandibular one). (n = 56, 26.42%). The most commonly rotated tooth was the lower ca-
Based on these angular measurements, the models with the sim- nine (n = 40, 18.87%), followed by the lower incisor (n = 37, 17.45%).
ulated rotation and the pre-­refinement models were compared in Rotations were more common in the lower arch (n = 129, 60.85%)
order to evaluate: (Table 1). The outcome data (accuracy of Invisalign) was skewed, as
shown by the histogram (Figure 1) and Shapiro–Wilk test (p < .01), so
• ST1 (simulated T1): the amount of rotational movement planned non-­parametric tests were applied.
by Clincheck® software to reach the ideal position. It was ex- The highest median accuracy of rotational movement was for op-
pressed in degree (°). timized attachments (median [IQR] = 70 [49, 81]), followed by rectan-
• ET1 (effective T1): the amount of rotational movement (°) that the gular attachments (median [IQR] = 65 [41, 82]), and least for without
tooth has yet to perform to reach the ideal position, after the first attachment (median [IQR] = 63 [39, 81]); however, the difference was
phase of aligners or before the refinement. not statistically significant (p = .5) (Table 2).
• ST1-­E T1 (actual rotational movement), namely the difference
between ST1 and ET1 which indicated the amount of rotational
TA B L E 1 Distribution of rotated teeth among genders, tooth
movement actually obtained in the first treatment phase or be- types, and arches.
fore refinement.
Rotated teeth,
Variable Characteristic n (%)
For each measurement, the absence or presence of attachments
on teeth was then analysed, considering different combinations of Gender Female 156 (73.58)

attachments: Male 56 (26.42)

Tooth type Lower 1st premolar 26 (12.26)
1. No attachments (50 teeth). Lower 2nd premolar 26 (12.26)
2. Optimized attachments, automatically positioned on the buccal Lower canine 40 (18.87)
crown surface of the rotated teeth (96 teeth). Lower incisor 37 (17.45)
3. Vertical rectangular attachments, manually positioned on the Upper 1st premolar 10 (4.72)
buccal crown surface of the rotated teeth (66 teeth).
Upper canine 28 (13.21)
Upper central incisor 15 (7.08)
The overall accuracy for individual teeth and attachments was
Upper lateral incisor 30 (14.15)
calculated in percentages (%) as follows:
Arch Lower 129 (60.85)
ST1 − ET1
Accuracy = ∙ 100 Upper 83 (39.15)
ST1
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FIORILLO et al. 999

Accuracy of orthodontic rotational movement using different as indicated by their p-­values greater than 0.05. Age was a signif-
attachment configuration was not significant in all age groups and icant predictor with an estimate of −0.30 (95% CI: −0.58 – −0.03,
both in males and females (Figure 2; Table 3). Similarly, no signif- p = .032), suggesting a slight decrease in accuracy with increasing
icant difference was found for accuracy of orthodontic rotational age. The overall model had an R 2 of 0.046 and an adjusted R 2 of
movement using different attachment configurations for all teeth 0.003, indicating that the predictors explained only a small fraction
(Table 4). of the variance in rotational movement accuracy (Table 5).
The intercept estimate indicates a baseline median accuracy of
rotational movement of 68.62 (95% CI: 56.03–81.20, p < .001). Most
predictors, including specific teeth and gender, did not show statis- 4 | DISCUSSION
tically significant associations with rotational movement accuracy,
According to Andrews, rotation is the fourth key to normal occlu-
sion, referring to the position of a tooth turned along its long axis in
mesial or distal direction. 26 Although an ideal occlusion was achieved
when no dental rotations were recorded within the arch, 27 the clini-
cal expression of rotation movement using CAT is still a controversial
topic, as reported in a recent review of Koletsi et al.10
Therefore, the objective of the present study was to determine
the efficacy of Invisalign® for rotational movements after an initial
series of aligners, using different types of attachments.
Clinically, this should be useful to minimize the need for addi-
tional aligners suggesting the use of different attachment geom-
etries to improve the clinical achievement of the planned tooth
F I G U R E 1 Distribution of outcome data. movement. 27

TA B L E 2 Comparison of overall
No attachment, Optimized, Rectangular,
accuracy among attachments.
Characteristic N = 50 N = 96 N = 66 p-­valuea

Median (IQR) 63 (39, 81) 70 (49, 81) 65 (41, 82) .5

a
Kruskal–Wallis test.

F I G U R E 2 Accuracy of various attachments stratified by age groups.

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1000 FIORILLO et al.

TA B L E 3 Comparison of accuracy
Characteristic No attachment Optimized Rectangular p-­valuea
among attachments in both genders.
Male 73 (44, 87) 73 (49, 80) 70 (46, 86) >.9
Female 58 (39, 78) 69 (48, 81) 63 (40, 76) .3
a
Kruskal–Wallis test.

TA B L E 4 Comparison of accuracy
Type of attachment
among attachments for individual teeth.
Characteristic n No attachment Optimized Rectangular p-­valuea

Lower 1st premolar

Median (IQR) 26 24 (24, 24) 77 (55, 82) 66 (40, 72) .2
Lower 2nd premolar
Median (IQR) 26 90 (73, 91) 68 (38, 85) 59 (38, 74) .4
Lower canine
Median (IQR) 40 63 (61, 65) 67 (48, 81) 80 (58, 91) .4
Lower incisor
Median (IQR) 37 55 (42, 85) 72 (54, 79) 37 (26, 54) .5
Upper 1st premolar
Median (IQR) 10 34 (34, 34) 83 (64, 91) 45 (45, 55) .3
Upper canine
Median (IQR) 28 48 (35, 62) 75 (57, 80) 49 (43, 73) .2
Upper central incisor
Median (IQR) 15 73 (53, 80) 59 (53, 60) 83 (83, 83) .3
Upper lateral incisor
Median (IQR) 30 52 (34, 72) 58 (40, 73) 69 (40, 85) .6
a
Kruskal–Wallis test.

TA B L E 5 Regression analysis for

Predictors [Reference category] Estimates 95% CI p-­value
accuracy with respect to tooth type,
(Intercept) 68.62 56.03 to 81.20 <.001 gender and age.
Teeth [lower 2nd premolar] 1.54 −12.05 to 15.14 .82
Teeth [lower canine] 7.2 −5.15 to 19.54 .25
Teeth [lower incisor] −1.65 −14.18 to 10.89 .79
Teeth [upper 1st premolar] −6.12 −24.33 to 12.09 .51
Teeth [upper canine] 1.57 −11.75 to 14.90 .82
Teeth [upper central incisor] 4.92 −10.96 to 20.80 .54
Teeth [upper lateral incisor] 1.04 −12.22 to 14.30 .88
Gender [male] 3.65 −4.12 to 11.42 .35
Age −0.3 −0.58 to −0.03 .03
R2/R2-­adjusted 0.046/0.003

Rotation of teeth with rounded anatomies, such as bicuspids and vectors resulting from tangential forces applied during the rotation
molars, has been reported to be particularly challenging with plastic of rounded crowns crosses at a short distance from the centre of
aligners without specialized attachments that enhance biomechan- resistance, resulting in weaker rotational moments. 29 Composite
28
ical capabilities. The difficulties associated with rounded crown attachments with properly oriented active surfaces can overcome
morphologies are due to three main factors. 29 First, in rounded these issues by reconfiguring force vectors, increasing inter-­vector
crown configurations, the tangential forces produced during aligner-­ distance, and blocking the slipping effect, leading to stronger and
based tooth rotation, combined with a low coefficient of friction be- more effective rotational moments. 29 Additionally, unintended in-
tween the two surfaces, cause a slipping effect between the aligner trusion during rotational tooth movement has been observed.30
29
and the tooth. Second, the line of action of the normal force In a study using finite element analysis,31 researchers found that
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FIORILLO et al. 1001

aligner-­based rotation of an upper canine without attachments the amount of total rotation movement, 22 the staging16,22,37 and the
caused not only a lag of nearly 3 degrees compared to the corre- interproximal reduction (IPR), 21 although Kravitz et al. 21 and Karras
sponding aligner stage but also significant intrusive forces, 3.5 times et al.18 reported that IPR did not significantly affect the rotational
greater than with attachments. Appropriate attachment design has accuracy.
been reported to mitigate this effect by orienting the active surface Other factors that might affect the results reported in literature
31
to reduce intrusive forces and promote extrusive tendencies. are the different superimposition methods among studies and also
However, although some articles suggested that use of attach- the inability to measure the patients' compliance. 27
17
ments could increase the effectiveness of rotational movement, a Further studies should be suggested to evaluate the influence
recent review by Nucera et al. 25 reported conflicting results about of interproximal reduction on rotation movements and to compare
the ability of attachments to improve dental rotation control. different aligner materials.
In the present study, the highest overall accuracy was reported Another important aspect shown in this study is the lack of sig-
with optimized attachments (70%), followed by rectangular ones nificance in the accuracy among the various tooth types using differ-
(65%), and when no attachments were used (63%). However, no ent attachment configurations. Although it has been suggested that
significant differences were found among these percentages, sug- round-­shaped crowns and tapered, longer crowns are associated
gesting the uncertain clinical efficacy of the attachments in the im- with more or less difficulty in achieving rotational movement, respec-
provement of rotational movements. tively,16 the present findings did not find any relationship between
21
When assessing canine rotational movement, Kravitz et al. the tooth shape and the accuracy. This agrees with the contrasting
suggested that the use of attachments did not significantly improve findings reported in the literature, where there is no consensus on
the accuracy of canine rotation with the Invisalign system, 21 which the type of tooth that shows the most favourable clinical response
is consistent with the current findings. However, in this previous to rotational movement, considering that some studies have shown
study, 21 the most common attachment shape was vertical-­ellipsoid, better results for premolars.17 Even if in the meta-­analysis of Koletsi
while in the present study optimized and rectangular attachments et al.10 the maxillary canines demonstrated the lowest percentage
were analysed. accuracy for rotational tooth movement (47.9%), while mandibular
Similar results were also reported by Simon et al. 22 who found incisors presented the highest percentage accuracy for predicted
no significant differences of premolar rotation between groups with rotational movement (70.7%), in their conclusions, the authors high-
22 18
optimized or without attachments, as well as Karras et al. who lighted the high level of heterogeneity identified among the included
reported that conventional attachments are as efficient as optimized studies.10
attachments in the rotations of canines and premolars. In the present study, the median accuracy of rotational move-
Partially in line with these results, another study of Simon ment was of 68.62%, which is higher compared to 41% reported by
et al. 32 reported enhanced results in premolar rotation using op- Kravitz et al.37 using Invisalign® EX30 aligners, of 61.5% by Lombardo
timized attachments automatically placed by the software, com- et al.17 using F22 aligners, and of 50% reported by Haouili.38
pared to patients in which no attachment was used. Although in Additionally, in the present study, the accuracy of rotational
the present study no statistical significance was found, the use movement using different attachment configurations was not sig-
of optimized attachments was associated with the highest mean nificant between males and females and in all age groups. However,
accuracy (70%). a slight decrease in accuracy was reported with increasing age, and
According to the previous literature21,22 and in line to the present this may be due to the different mechanisms of bone remodelling in
outcomes, Momtaz33 also reported no statistically significant differ- orthodontic tooth movement in the adults.39
ences in bicuspid rotation between groups with or without attach-
ments, using in-­office aligners. However, the author33 found that
the group with a rectangular attachment had the highest overall ob- 5 | LI M ITATI O N S
servable rotational correction. It is important to notice that this pre-
vious study considered in-­office systems to produce aligners, which Limitations of this retrospective study include the inability to ac-
are not as sophisticated as those used by Align technology.34,35 count for certain variables, such as patient compliance, initial tip of
A possible explanation for the present findings was reported by the rotated teeth, presence or absence of space mesial and distal to
Papadopoulou et al.,36 who demonstrated a substantial reduction to rotated teeth, and the dimension of the clinical crowns, which could
50% of the applied force over time when Invisalign aligners were have affected the present results.
used with attachments.
Additionally, as shown by Koletsi et al.,10 although various types
of attachment have been suggested as potential prognostic factors 6 | CO N C LU S I O N S
for better efficacy of rotational tooth movement, this does not nec-
essarily translate into an identified clinical effect. The aim of this study was to investigate accuracy in rotational move-
This aspect should be explained considering that several fac- ments with CAT. Taken together, the measurements obtained from
tors seem to influence the rotation efficacy with CAT,10 including the retrospective observational study suggest that:
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1002 FIORILLO et al.

• There is no difference between optimized and rectangular attach- ORCID

ments for improving the accuracy of rotational movement. Alessandra Campobasso https://orcid.
• Although the addition of attachments increases accuracy, this in- org/0000-0003-4726-8816
crease is not significant. Giovanni Battista https://orcid.org/0000-0003-3543-686X
• The overall median accuracy for rotational movement was
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