| |

Received: 12 May 2019    Revised: 25 July 2019    Accepted: 4 August 2019

DOI: 10.1111/jicd.12455

REVIEW ARTICLE
Effectiveness of invisible aligners

Assessment of the effectiveness of invisible aligners compared

with conventional appliance in aesthetic and functional
orthodontic treatment: A systematic review

Matheus Melo Pithon1,2  | Felipe Carvalho Souza Baião1 | Letícia Iandeyara Dantas de

Andrade Sant´ Anna1,2 | Luiz Renato Paranhos3 | Lucianne Cople Maia2

1
Departament of Health I, Southwest Bahia
State University UESB, Jequié, Bahia, Brazil Abstract
2
Department of Pediatric Dentistry and To seek scientific evidence to support the effectiveness of invisible aligners, in the aes‐
Orthodontics, School of Dentistry, Federal
thetic and functional aspects, compared with that of conventional braces. An electronic
University of Rio de Janeiro, Rio de Janeiro,
Rio de Janeiro, Brazil search was performed with a complementary grey literature search for in vivo research.
3
Department of Social and Preventive No language restrictions were applied. Scopus, PubMed, Web of Science, Cochrane,
Dentistry, School of Dentistry, Federal
University of Uberlândia, Universidade
ClinicalTrials and GreyLiterature databases were used. Studies were first selected by
Federal de Uberlândia, Uberlândia, Minas title and abstract; those potentially eligible were read in full. Non‐randomized studies
Gerais, Brazil
were assessed for risk of bias using the tools Methodological Index for Non‐randomized
Correspondence Studies (MINORS) and Cochrane Collaboration Common Scheme for Bias as a function
Matheus Melo Pithon, Av. Otávio Santos,
395, sala 705, Centro Odontomédico Dr.
of the presence of randomization. The search found 559 studies, of which 55 were po‐
Altamirando da Costa Lima, Bairro Recreio, tentially eligible. A total of 4 articles were included in this systematic literature review:
CEP 45020‐750 – Vitória da Conquista –
Bahia, Brazil.
three non‐randomized controlled studies and one randomized controlled study, three
Email: matheuspithon@gmail.com with low risk of bias (RoB) and one with moderate RoB. Three studies showed time of
correction of dental crowding shorter or equal to that of the control group and only
one study showed less time of correction using conventional braces. Invisible align‐
ers were deficient with respect to anterior/posterior and vertical corrections compared
with fixed orthodontic appliances. Invisible aligners are effective in promoting dental
alignment, but present clinical limitations in relation to the conventional system.

KEYWORDS
aligners, malocclusion, effectiveness, esthetics, orthodontic appliance

1 |  1I NTRO D U C TI O N
Considerations of aesthetics are an important factor in patients’
choice of treatment. Orthodontics has experienced advances with
regard to this theme given that many patients prefer to hide the
metal braces and, consequently, seek the use of aesthetic orthodon‐
tic appliances (with the use of clear brackets), lingual appliances and
thermoplastic aligners.1,2
In 1945, Kesling introduced the use of removable, flexible ortho‐
dontic appliances so that minimal movements could be performed after
fixed orthodontic therapy.3 The use of removable, thermoplastic align‐
ers has become an alternative to conventional fixed dental appliances
by means of gradual, sequential and consecutive dental reposition.4
The use of aligners is suitable for low to moderate degrees of
crowding (1‐6 mm), for medium to moderate spaces (1‐6 mm) and for
recurrence after fixed orthodontic therapy.5 Their main advantages

J Invest Clin Dent. 2019;00:e12455. wileyonlinelibrary.com/journal/jicd © 2019 John Wiley & Sons Australia, Ltd  |  1 of 8
https://doi.org/10.1111/jicd.12455
 |
2 of 8       PITHON et al.
are the possibility of removal during meals, improved conditions for
oral hygiene, reduction in the pain level experienced by patients, and
the possibility of viewing the end of treatment with the use of com‐
puter software.6,7
Disadvantages related to the use of invisible aligners include lim‐
ited control over root movement, limited intermaxillary correction,
little or no control by the operator, as well as dependence on their
full‐time use by the patient, with the appliance being removed only
for eating and sanitation.8 The objective of this systematic review
is to find scientific evidence to solve the controversy on the effec‐
tiveness of outcomes obtained with treatment with invisible aligners
compared with those obtained with conventional braces.
The present systematic review aims to respond to the follow‐
ing guiding question: Is there scientific evidence to support the ef‐
fectiveness of invisible aligners in the correction of aesthetic and
functional aspects compared with that of conventional braces (labial
positioning) in orthodontic treatment?
2 |  M ATE R I A L S A N D M E TH O DS
The Preferred Reporting Items for Systematic Reviews and Meta‐
Analysis (PRISMA) statement checklist13 was used for conducting
and reporting this review.
Before data collection, the project was sent for approval to the
research ethics committee and approved under ordinance number
17333113.1.0000.0055.
2.1 | Protocol and registration
This systematic review was registered in the international database
PROSPERO and conducted in accordance with PRISMA and the
Center for Reviews and Dissemination (University of York) statements.
2.2 | Eligibility criteria
The following inclusion criteria were adopted for this review: con‐
trolled clinical trials conducted with orthodontic patients (P) under
treatment with removable, thermoplastic appliances (I), compared
with conventional fixed orthodontic appliance (C) in order to iden‐
tify the effectiveness in correcting aesthetic and functional aspects
related to malocclusions (O).
The initial selection was performed based on the reading and
analysis of the titles and abstracts of the articles found to evaluate
the correct framework according to the study proposal. Studies of
patients under treatment with systemic medication, patients with
syndromic disorders, using in vitro analysis, case reports, conference
proceedings and editorial letters were excluded from the this review.
In the cases where the title and/or abstract did not provide suf‐
ficient information, or where the abstract was not available, articles
were downloaded and analyzed in full in order to decide on their
eligibility. Articles found in more than 1 database were accounted
only once.
In the cases where additional data were needed, the authors
were contacted by email to clarify the doubts related to eligibility.
2.3 | Information sources, search strategy and
study selection
A systematic search was conducted to identify relevant clinical
trials, without limitation of language or year of publication, in the
following databases: Scopus, PubMed, Web of Science, Cochrane,
ClinicalTrials and OpenGrey. A manual search was also performed on
references of the articles found to identify possible items not listed
in the electronic search.
The search strategy was adapted according to each database
using the following Medical Subject Heading (MeSH) terms: “ortho‐
dontics”, “malocclusion”, “tooth crowding”, “orthodontic treatment”,
“orthodontic patients”, “aligners”, “orthodontic appliances” and “or‐
thodontic brackets”; and the following keywords: “Invisalign”, “clear
aligners”, “invisible appliances”, “orthodontic aligners” and “removable
thermoplastic appliance”. The search details are presented in Table 1.
2.4 | Data items and collection
2 researchers (FCSB and LIDAS) conducted the selection of articles
independently and the results were compared to avoid any possible
discrepancies during data collection. In the event of disagreement
between the two examiners regarding the inclusion or exclusion of
any study, a 3rd examiner (LMP) was consulted until consensus be‐
tween the parties was reached.
2.5 | Risk of bias/quality assessment in
individual studies
For the quality assessment and risk of bias of the non‐randomized
studies included in this review, the score of the Methodological
Index for Non‐randomized Studies (MINORS)9 was used, with an
ideal score of 24 points for comparative studies. The following key
items were used in the assessment: a stated aim of the study, in‐
clusion of consecutive patients, prospective collection of data,
end‐point appropriate for the study aim, unbiased evaluation of end‐
points, follow‐up period appropriate to the major end‐point, loss of
follow up not exceeding 5%, prospective calculation of sample size, a
control group presenting the gold standard intervention, contempo‐
rary groups, baseline equivalence of groups, and statistical analyses
adapted to the study design. Quality assessment of studies was con‐
sidered as follows: high, 19‐24 points; moderate, 13‐18 points; low,
7‐12 points; and very low, below 7 points.
The randomized study included in this review was assessed using
the tool Cochrane Collaboration Common Scheme for Bias: selec‐
tion, performance, detection, attrition and reporting.10
Selection bias consists of the systematic difference between
baseline characteristics of the groups that are compared. It com‐
prises the domains sequence generation and allocation concealment.
Performance bias consists of the systematic differences between
PITHON et al. |
      3 of 8

TA B L E 1   Search strategy in electronic databases

Database Search Result Selected

Scopus (orthodontics OR malocclusion OR tooth crowding OR orthodontic treatment OR orthodontic pa‐ 17 11

tients) AND (invisalign OR aligners OR clear aligners OR invisible appliances OR orthodontic align‐
ers OR removable thermoplastic aligners) AND (orthodontic appliances OR orthodontic brackets)
Web of Science TS = (orthodontic applianc* OR orthodontic brack*) AND TS = (invisalign OR clear align* OR invisible 334 28
applianc* OR orthodontic align* OR removable thermoplastic applianc*) AND TS = (orthodontic*
OR malocclusion OR tooth crowding OR orthodontic treatment OR orthodontic patient*)
PubMed ((((((((((“orthodontics” [MeSH Terms] OR “malocclusion” [MeSH Terms]) OR “malocclusion” [MeSH 138 11
Terms]) OR (orthodontic [All Fields] AND “therapeutics” [MeSH Terms])) OR (orthodontic [All
Fields] AND “patients” [MeSH Terms])) OR orthodontics [Title/Abstract]) OR malocclusion [Title/
Abstract]) OR tooth crowding [Title/Abstract]) OR orthodontic treatment [Title/Abstract]) OR or‐
thodontic patients [Title/Abstract]) AND (((((invisalign [Title/Abstract] OR aligners [Title/Abstract])
OR clear aligners [Title/Abstract]) OR invisible appliances [Title/Abstract]) OR orthodontic aligners
[Title/Abstract]) OR (removable [All Fields] AND thermoplastic [All Fields] AND aligners [Title/
Abstract]))) AND (((“orthodontic appliances” [MeSH Terms] OR “orthodontic brackets” [MeSH
Terms]) OR orthodontic appliances [Title/Abstract]) OR orthodontic brackets [Title/Abstract])
Cochrane (orthodontics OR malocclusion OR tooth crowding OR orthodontic treatment OR orthodontic pa‐ 12 5
Library tients) AND (invisalign OR aligners OR clear aligners OR invisible appliances OR orthodontic align‐
ers OR removable thermoplastic aligners) AND (orthodontic appliances OR orthodontic brackets)
in Title, Abstract, Keywords
ClinicalTrials (orthodontics OR malocclusion OR tooth crowding OR orthodontic OR orthodontic patients) AND 56 0
(invisalign OR aligners OR invisible appliances OR orthodontic aligners OR removable thermoplas‐
tic aligners) AND (orthodontic appliances OR orthodontic brackets
OpenGrey (orthodontics OR malocclusion OR tooth crowding OR orthodontic OR orthodontic patients) AND 2 0
(invisalign OR aligners OR invisible appliances OR orthodontic aligners OR removable thermoplas‐
tic aligners) AND (orthodontic appliances OR orthodontic brackets)

groups in the care that is provided, or in exposure to factors other

than the interventions of interest. It comprises the domains blinding
of participants and personal and other potential threats to valid‐
ity. Detection bias consists of the systematic differences between
groups in how outcomes are determined. It comprises the domains
blinding of outcome assessment and other potential threats to va‐
lidity. Attrition bias consists of the systematic differences between
groups in withdrawals from a study. It comprises the domain incom‐
plete outcome data. Reporting bias consists of the systematic differ‐
ences between reported and unreported findings. It comprises the
domain selective outcome reporting. The articles included in this re‐
view were evaluated according to the Cochrane Collaboration's tool
for assessing risk of bias of the Cochrane Handbook for Systematic
Reviews of Interventions (version 5.1.0). Quality assessment of
studies for each domain was considered as follows: low risk; high
risk; and unclear risk, when there was not sufficient information for
proper assessment.
3.2 | Quality assessment
Of the non‐randomized studies included and assessed accord‐
ing to MINORS, one article was considered of high methodologi‐
cal quality11 and two articles were considered of moderate quality
(Table 2).4,12 In these studies, the unfulfilled key items presenting
bias were inclusion of consecutive patients,4,12 prospective data
collection and prospective calculation of sample size,4,12 and loss of
follow up not exceeding 5%.4,12 In addition, there was deficiency in
contemporaneousness wherein the treatment occurs in each group,
namely study groups were not contemporary.4,11,12
The only randomized controlled study was considered of low
risk of bias13 by the Cochrane Collaboration's tool, with all do‐
mains adequately fulfilled (random sequence generation, alloca‐
tion concealment, blinding of participants and personnel, blinding
of outcome assessment, incomplete outcome data, selective re‐
porting and other bias), including blinding of outcome assessors
and statisticians to the groups assessed.

3 | R E S U LT S
3.1 | Study selection and characteristics
From the searches conducted in the electronic databases, 559 arti‐
cles were found, of which 55 met the inclusion criteria and were con‐
sidered as potentially eligible. After reading in full, 45 works were
excluded and four articles were finally included in this systematic
literature review, as shown in the flowchart (Figure 1).
3.3 | Data collection and description of
included studies
Table 3 shows a summary of the authors, years of publication,
number of participants, mean age, inclusion criteria of consecutive
patients, type of aligner and treatment protocol, comparison with
conventional fixed orthodontic appliance, assessment method, out‐
comes and conclusions of the author(s).
 |
4 of 8       PITHON et al.
The studies included in the review were conducted between
2005 and 2016 4,11-13 and presented sample sizes ranging 96‐182
participants. The mean age of participants varied between 15 and
33 years; only one study did not mention the age of participants.13
All studies used the Invisalign system as the invisible aligner.
With respect to the treatment protocol for Invisalign, one study
recommended its use 24 hours, 7 days a week, for 2 weeks,14 one
study recommended its use 24 hours, 7 days a week, for 2‐3 weeks;
and two studies did not mention use recommendations, suggest‐
ing that the manufacturer's recommendations were followed.
Comparison with the fixed orthodontic appliance was performed in
11
four studies; one of these used it as a self‐ligating appliance
4,12,14
the other studies used it as a tip‐edgewise appliance.
Regarding the duration of treatment, two studies reported
shorter treatment time for the group with Invisalign compared with
that for the group with fixed orthodontic appliance,4,12 one study
11
reported the same treatment time for both groups, and one study
reported shorter treatment time for the group with fixed orthodon‐
tic appliance.14
F I G U R E 1   Study flowchart
Three studies used dental plaster casts, cephalometric radio‐
graphs and the objective grading system (OGS) 4,12,14 scores to as‐
sess the protocols, whereas one study used only plaster casts and
cephalometric radiographs.11
With regard to the results obtained, differences were found for
anterior/posterior corrections. Djeu et al4 claimed that aligners are
deficient in this regard, whereas a randomized controlled trial coun‐
teracts stating that they are effective. Although the Invisalign sys‐
tem is effective in teeth alignment,11 higher recurrence of crowding
4,12
is observed after the use of this treatment protocol compared with
that of conventional fixed orthodontic appliances.12
and The outcomes of the randomized controlled clinical trial when
assessing the discrepancy index showed no significant statistical
difference between the two groups. With respect to the OGS
scores, buccolingual inclination of teeth was worse in the group
with the Invisalign system than in the group with fixed appli‐
ance.13 Both the fixed orthodontic appliance and the Invisalign sys‐
tem succeeded according to OGS scores for correction of class I
malocclusion.14
PITHON et al. |
      5 of 8

4 | D I S CU S S I O N

Total

20
13

14
4.1 | Summary of evidence

Adequate
statistical
analyses
Nowadays, aesthetics and discretion are major concerns of patients
undergoing orthodontic treatment15; therefore, manufacturers are

1
Baseline constantly supplying the market with new types of appliances, such

lence of
equiva‐ as aesthetic sapphire braces, lingual fixed braces and, more recently,

groups
clear aligners.1 The effectiveness of these appliances compared

2
with that of labial fixed orthodontic ones has been questioned.13
Contemporary

According to Li et al, Invisalign OGS scores for occlusal contacts and

buccolingual inclination were not as good as those for braces.13 This
groups

systematic review seeks scientific evidence to support the effective‐

ness of invisible aligners compared with that of conventional braces,
1

1
because knowledge on their capabilities and limitations is essential
control
equate
An ad‐

group

for orthodontists.
To this end, a systematic search was conducted in the afore‐
1

mentioned electronic databases. As a result, three non‐randomized

the study size
calculation of
Prospective

controlled studies were found, one of high and two of moderate

methodological quality according to the MINORS tool, and one ran‐
domized controlled study was found and classified as of low risk of
2

bias according to the Cochrane Collaboration's tool.

follow up
less than

The studies that compared clear aligners with fixed orthodontic

Loss to

appliances and used the OGS reported lower scores for the group
5%

with the first protocol in the categories buccolingual inclination and

occlusal contact.13 This occurred because fixed appliances can be
propriate to
period ap‐
Follow‐up

the aim of
TA B L E 2   Methodological rating Methodological Index for Non‐randomized Studies (MINORS)

the study

adjusted vertically within the 0.5‐mm limits to intrude or extrude a

Items are scored as follows: 0, not reported; 1, reported but inadequate; or 2, reported and adequate.

tooth when necessary,15,16 whereas these types of movements are

difficult to be performed with invisible aligners, resulting in diffi‐
0

culty to achieve adequate occlusal contacts.13 Djeu et al4 notes that

of the study
assessment

lack of occlusal contact after treatment with aligners occurs due to

end‐point
Unbiased

the coating of teeth by the aligners, impairing settling of occlusion.

Some studies in the literature corroborate this fact: Kravitz et al22
2

17
and Kravitz et al state that the vertical movement of the teeth is
appropriate to

more difficult to be achieved with Invisalign, considering that the

the aim of the
End‐points

mean anterior intrusion movement is 41%.17

Occlusal relations and overjet were considered insufficient with
study

the use of invisible aligners by a study included in this systematic re‐

2

view4 as well as by other studies18,19; however, Li et al13 reported that

collection of
Prospective

anterior/posterior correction in the group with Invisalign seemed to

be as adequate as that in the group with fixed appliance, and the
data

authors explain that this was possible because, in their study, the
0

extraction space was used to adjust the overjet.

Inclusion

Clinically, dental alignment is one of the most important is‐

secutive
patients
of con‐

sues during orthodontic treatment, in addition to being one of

the main reasons patients seek treatment. The study by Li et al,13
0

as well as other studies included in this review, 4,11 describe that

clearly
stated

Invisalign succeeded in aligning and leveling. However, attainment

aim
A

of tooth movement consists of the movement of the crown, not

MINORS score

in the movement of the roots.11 Kuncio et al12 compared dental

Kuncio et al

Pavoni et al
Djeu et al

changes in orthodontic treatment postretention outcomes and

(2005)

(2007)

(2011)
Author

found that patients using the Invisalign system presented greater

deterioration in dental alignment than patients treated with fixed
TA B L E 3   Data extraction
|

Participants Invisible aligner

Author Comparison with Assessment
6 of 8      

(year) Total Mean age Inclusion criteria Type Intervention fixed appliance method Outcome Conclusion

Djeu et al 96 Control: — Invisalign Duration of (298‐804F, TP Plaster Models Control: buccolingual Inclination: According to the OGS,
(2005) Control: 48 23.7 y treatment: Orthodontics) Lateral 2.81 Invisalign does not treat
Aligner: 48 Aligner: Control: 1.7 y cephalometric Occlusal contact: 5.64 malocclusions as well as the
33.6 y Aligner: 1.4 y Evaluation for Occlusal Relationship: 5.50 fixed appliance. Invisalign
Objective Grading Overjet: 3.56 was especially deficient in
System (OGS) (P < .05) correcting large anter‐
Invisalign: LaPorte, Ind oposterior discrepancies
Inclination buccolingual: 4.19 and occlusal contacts. Its
Occlusal contact: 10.46 strengths are its ability
Occlusal relationship: 7.71 to close gaps and correct
Overjet: 6.21 previous rotations
(P < .05)
Kuncio et al 22 Control: — Invisalign Duration of Tip‐edge fixed Plaster models Control: There was more recurrence
(2007) Control: 11 (10 26.79 y treatment: appliances Lateral Total alignment: in the Invisalign group. In
F/1 M); Invisalign: Control: 3.8 y; cephalometric After treatment: 8.36 the postretention period
Invisalign: 11 33.97 y Aligner: 2.7 y Evaluation for OGS Postretention: 9.73 in 2 groups or total and
(10F/1 M) Invisalign: mandibular alignment were
Total alignment: worse
Post‐treatment: 5.91
Postretention: 8.81
Li et al 182 — >18 y Invisalign 24 h/d 3M brackets Models of plaster Control: The OGS score of the group
(2015) Control: 76 (45 Extraction 7 d a week for (Gemini brand, and cephalomet‐ Buccolingual inclination: 5.85 Invisalign for occlusal con‐
F/27 M); To consent to 2 wk 3M Unitek, ric radiographs Occlusal contact: 3.90 (P < .001) tact and buccolingual slope
Invisalign: 76 participate Duration of Monrovia, CA, evaluated OGS Invisalign: was worse than the group
(45 F/27 M) Good quality of treatment: USA) Buccolingual inclination: 3.55 with fixed appliance. Both
study models Control: 22 mo Occlusal contact: 1.88 (P < .001) devices have succeeded
and radiographs Aligner: 31.5 mo according to OGS score in
the correction of malocclu‐
sion class I
Pavoni et al 96 (21 F/19 M) Control: Class I Invisalign 22 h/d; 7 d Self‐ligating Dental casts, Control (P < .05): Invisalign had success with
(2011) Control: 20 (9 15 y malocclusion; a week for brackets Time orthopantomog‐ Intercanine distance: 3.15 mm; straightening arches by
F/11 M); 6 mo Mild crowding 2‐3 wk. 3 (AO American raphy, lateral First inter premolar widths: rotating the teeth and by
Alinhador: 20 Aligner: (4.4 ± 0.8 mm); Duration of Orthodontics cephalograms. 3.40 mm (lingual), 2.45 mm (cusp); leveling arches. It can eas‐
(12 F/8 M) 18 y Permanent treatment: Products). Second inter premolar widths: ily tip crowns but cannot
4 mo dentition; Control: 1.8 y 2.50 mm (lingual), 2.15 mm (cusp) tip roots. No statistically
Vertebral Aligner: 1.8 y Invisalign (P < .05): significant differences
maturation; Second inter premolar fossa point: between the 2 groups are
No previous 0.45 mm; evident when there are
orthodontic Intermolar width at fossa: 0.50 mm relatively aligned roots
treatment
PITHON et al.
PITHON et al.
orthodontic appliances; namely this group presented greater
recurrence.
Incorrect rotations in canines and premolars have been 1 of the
complaints of orthodontists who used the Invisalign system, because
there is often need for corrections or completion of treatment with a
fixed appliance.20 In the studies included in this systematic review, it
was verified that, due to the difficulty in the rotation of these units,
orthodontists should consider the incorrect rotations immediately
after the achievement of the most predictable movements, namely
the use of resin accessories, interproximal reduction, overcorrection
or adjuvants to assist in the reduction of rotating movements are rec‐
ommended.21 In the literature, there are searches for devices, associ‐
ated with invisible aligners, to improve traction of canines. Kravitz et
al, 22 using three different methods for canine traction—canines with
accessories (AO), interproximal reduction only (IO) and control group
(N)—found low rotation correction in the AO group; however, the re‐
sults demonstrate that the labial fixed attachment, centrally located
and with vertical ellipsoid attachments, showed better rotation than
that of the control group without attachment and interproximal re‐
duction. Furthermore, it should be considered that, at some point,
the time of traction with the aligner will cease, and the overcorrection
will not improve the correction of tooth rotation. 22
One study reported shorter treatment time for the group with
fixed orthodontic appliance compared with that for the group with
invisible aligners,14 whereas one study reported the same treatment
time for both groups, but final occlusion was not ideal.11 According
4 12
to Djeu et al and Kuncio et al, duration of treatment using aligners
(1.4 years and 2.7 years) was shorter than that of treatment using
fixed orthodontic appliances (1.7 years and 3.08 years); however,
despite the faster results, the final occlusion is not ideal, with better
outcomes being achieved in prolonged treatment or with the use of
complementary treatment of different types.4
The literature has presented discussions on the advantages and
disadvantages of clear aligners, as well as on their capabilities and lim‐
itations. This system is one of the most sought by patients because of
their aesthetics and comfort compared with other types of treatments.
Nevertheless, this system presents limitations in relation to correction
of malocclusion, because, as discussed in this systematic review, align‐
ers are deficient in some aspects, such as increase of teeth inclination
after use; lack of control of tooth movement that reflects in their de‐
ficiency to rotate roots, considering that in these cases there is need
for overcorrection, interproximal accessories or reduction; in addition
to being little successful in promoting dental occlusion and performing
intrusion and extrusion of teeth. Also, their use is dependent on the
cooperation of patients in using them for the recommended period. In
contrast, this system has succeeded in correcting mild crowding and
overbite, and it may be a good option in cases where there was little
recurrence of a past orthodontic treatment.
4.2 | Limitations
The only randomized study verified that the Invisalign sys‐
tem showed OGS scores similar to those of fixed orthodontic
|
      7 of 8
appliances, with lower scores only for occlusal contact and bucco‐
lingual inclination. This system was also successful in treating class
I malocclusion in cases of extraction. The authors suggest that, due
to the limited experience of the orthodontists with the Invisalign
system, this point might have been a limitation to their study.13
Therefore, it is necessary that orthodontists acquire more knowl‐
edge and clinical experience with this system for future compari‐
sons, as well as it being essential to conduct further double‐blind
randomized controlled clinical trials to provide strong scientific
evidence for comparison.
4.3 | Conclusion
Based on the evidence found and analyzed, the following conclu‐
sions can be drawn about the use of clear aligners:
a. they are effective in correcting dental crowding;
b. there are present limitations regarding the intrusion and extrusion
of teeth, not promoting proper occlusal contact;
c. with the Invisalign system, higher recurrence of crowding is ob‐
served compared with that of conventional fixed orthodontic
appliances;
d. there is little difference in treatment duration compared with that
of braces.
ORCID
Matheus Melo Pithon  https://orcid.org/0000-0002-8418-4139
REFERENCES
1. Boyd RL. Esthetic orthodontic treatment using the invisalign ap‐
pliance for moderate to complex malocclusions. J Dent Educ.
2008;72(8):948‐967.
2. Shalish M, Cooper‐Kazaz R, Ivgi I, et al. Adult patients' adjustabil‐
ity to orthodontic appliances. Part I: a comparison between Labial,
Lingual, and Invisalign. Eur J Orthod. 2012;34(6):724‐730.
3. Kesling HD. The philosophy of the tooth positioning appliance. Am
J Orthod Oral Surg. 1945;31:297‐304.
4. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign
and traditional orthodontic treatment compared with the
American Board of Orthodontics objective grading system. Am J
Orthod Dentofacial Orthop. 2005;128(3):292‐298; discussion 8.
5. McNamara JA, Brudon WL, Kokich VG, eds. Orthodontics and dento-
facial orthopedics. Ann Arbour, MI: Needham Press; 2001.
6. Miller KB, McGorray SP, Womack R, et al. A comparison of treat‐
ment impacts between Invisalign aligner and fixed appliance ther‐
apy during the first week of treatment. Am J Orthod Dentofacial
Orthop. 2007;131(3):302.e1‐e9.
7. Schaefer I, Braumann B. Halitosis, oral health and quality of life
during treatment with Invisalign((R)) and the effect of a low‐dose
chlorhexidine solution. J Orofac Orthop. 2010;71(6):430‐441.
8. Phan X, Ling PH. Clinical limitations of Invisalign. J Can Dent Assoc.
2007;73(3):263‐266.
9. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi
J. Methodological index for non‐randomized studies (minors):
development and validation of a new instrument. ANZ J Surg.
2003;73(9):712‐716.
 |
8 of 8       PITHON et al.
10. Higgins JPT, Green S.Cochrane Handbook for systematic reviews
of interventions. Version 5.1.0 [updated March 2011]2011 August
2016. Available from http://handb​ook.cochr​ane.org/
11. Pavoni C, Lione R, Lagana G, Cozza P. Self‐ligating versus
Invisalign: analysis of dento‐alveolar effects. Ann Stomatol (Roma).
2011;2(1–2):23‐27.
12. Kuncio D, Maganzini A, Shelton C, Freeman K. Invisalign and tra‐
ditional orthodontic treatment postretention outcomes compared
using the American Board of Orthodontics objective grading sys‐
tem. Angle Orthod. 2007;77(5):864‐869.
13. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign appli‐
ance in extraction cases using the the ABO model grading sys‐
tem: a multicenter randomized controlled trial. Int J Clin Exp Med.
2015;8(5):8276‐8282.
14. Wu C‐C, Chang Y‐P, Wang J‐J, et al. Dietary administration of
Gynura bicolor (Roxb. Willd.) DC water extract enhances immune
response and survival rate against Vibrio alginolyticus and white
spot syndrome virus in white shrimp Litopeneaus vannamei. Fish
Shellfish Immunol. 2015;42(1):25‐33.
15. Vlaskalic V, Boyd RL. Clinical evolution of the Invisalign appliance. J
Calif Dent Assoc. 2002;30(10):769‐776.
16. Wong BH. Invisalign A to Z. Am J Orthod Dentofacial Orthop.
2002;121(5):540‐541.
17. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does
Invisalign work? A prospective clinical study evaluating the efficacy
of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop.
2009;135(1):27‐35.
18. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables affect‐
ing orthodontic tooth movement with clear aligners. Am J Orthod
Dentofacial Orthop. 2014;145(4 Suppl):S82‐91.
19. Prescott TM, Miller R. Interview with align technology execu‐
tives. Interview by David L Turpin. Am J Orthod Dentofacial Orthop.
2002;122(2):19A‐20A.
20. Sheridan JJ. The Readers' Corner. 2. What percentage of your pa‐
tients are being treated with Invisalign appliances? J Clin Orthod.
2004;38(10):544‐545.
21. Inc. AT. The Invisalign Reference Guide. Santa Clara, CA: Invisalign;2002.
22. Kravitz ND, Kusnoto B, Agran B, Viana G. Influence of attach‐
ments and interproximal reduction on the accuracy of canine ro‐
tation with Invisalign. A prospective clinical study. Angle Orthod.
2008;78(4):682‐687.
How to cite this article: Pithon MM, Baião FCS, Sant´ Anna
LIDA, Paranhos LR, Cople Maia L. Assessment of the
effectiveness of invisible aligners compared with
conventional appliance in aesthetic and functional
orthodontic treatment: A systematic review. J Invest Clin
Dent. 2019;e12455. https​://doi.org/10.1111/jicd.12455​