Improving the predictability of clear

aligners
Steven Jay Bowman

Once limitations of clear aligner treatments were identified, conceptualizing

techniques to improve the predictability in producing desired results was the
next logical step. The present communication offers a variety of concepts
methods to enhance the efficiency and effectiveness of clear aligners. (Semin
Orthod 2017; 23:65–75.) & 2017 Elsevier Inc. All rights reserved.

I like predictability because I know what I’m

getting into.
—Actress Katherine Heigl
Addressing limitations of clear aligner
treatment
The advent of using a series of clear aligners
came at the turn of the 21st century, despite the
basis for this concept originating over 55 years
earlier.1 Although, the original fanfare of plastic
aligners equitably replacing traditional metal
braces quickly tarnished as early adopters
became painfully aware of limitations of the
concept.2–9 Some practitioners vacated, some
vacillated, and others simply dug-in to doggedly
invent ways to improve this innovation. Patients
desire “braceless” correction of their smiles10 and
thus far, the efforts to give them what they want
has led to continual advances and increasing
number of applications and adjuncts for aligners
in orthodontics.11–23
Compliance, consequences, and quality of
life with clear aligners
If treatment with aligners was to be seen as
completely successful, it was not enough to
occasionally straighten some teeth just in the
Kalamazoo Orthodontics, Portage, MI; Adjunct Associate
Professor, Saint Louis University, Saint Louis, MO; Instructor,
The University of Michigan, Ann Arbor, MI; Assistant Clinical
Professor, Case Western Reserve University, Cleveland, OH; Visiting
Clinical Lecturer, Seton Hill University, Greensburg, PA
Address correspondence to S. Jay Bowman, DMD, MSD,
Kalamazoo Orthodontics, 1314 West Milham Ave, Portage, MI.
E-mail: info@kalamazooorthodontics.com
& 2017 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2016.10.005
esthetic zone. Predictable, consistent, and com-
pleted results without adverse effects were
requirements. First and foremost was a justified
concern for patient compliance in wearing
removable devices during the course of possibly
years of treatment. As Buzz Behrents cautioned,
compliance is the single most important factor in
treatment success.
Cooperation in wearing aligners differs from
that of fixed braces in that wires and brackets
cannot be taken off and disregarded by the
patient, so the treatment might proceed toward
at least “straighter” teeth. In contrast, if aligners
are not worn as prescribed, the patient receives
no result. Consequently, an alternative track for
the non-compliant patient must be a part of
informed consent.
The introduction of so-called Compliance
Indicators for the Invisaligns (Align Technology,
San Jose, CA) product was evaluated during testing
of their Teen product (targeted for the audience
with the highest concerns for adherence to wear).
The soluble, color-fading dots were found to rea-
sonably demonstrate if patients had been con-
sistently wearing their aligners.24 If used as a
“policing” device, however, much like embedded
timers in headgears or functional appliances, their
effectiveness in actually eliciting cooperation is still
in question.24 More importantly, compliance by
orthodontic patients with either braces or plastic is,
on average, favorable and comparable.25 Non-
compliant patients likely suffer consequences of
prolonged or compromised results no matter the
treatment method chosen.
In terms of adverse effects, although there are
still concerns for decalcification, gingivitis, root
resorption, etc., with either fixed braces or
removable aligners, the oral hygiene advantage
for removable appliances is significant; however,
the trade-off is the risk of patients failing to

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 65–75 65

66 Bowman
re-insert their aligners after eating and brushing.
All in all, it was not surprising that the quality-of-
life satisfaction of teen aligner patients was found
to be quite high.25
Aligner tracking
A common concern running consistently
throughout the history of aligner treatments has
been that of teeth not following the predicted or
desired movement. This is despite the fact that the
forces and moments produced with plastic are
comparable to those generated with fixed braces.26
For instance, Chisari et al.13 found that just 57% of
the tooth movement programmed for a single
incisor was actually realized in a period of an 8-
week investigation. In addition, researchers from
the University of Illinois11 reported only a 41%
mean accuracy of predicted tooth movement. The
reasons for these frustrations are multi-factorial
and require a variety of responses to resolve. For
example, specific teeth oft times do not remain
seated within the confines of the plastic aligner
trays as treatment progresses. This may produce an
air gap between tooth and plastic termed “lag” or
“tracking error.” Strategies to reduce “tracking
errors” will be described below.
Rohit Sachdeva has described the process of
orthodontic finishing as “reducing the errors that
have accumulated during treatment.” These
errors can crop up quickly during the sequence
of aligners, resulting in a loss of tracking and
treatment “running off the rails.” These errors
may include those of diagnosis and treatment
planning, but with aligners these accrue at the
outset. They include issues with impression tak-
ing, laboratory scanning of those impressions,
tolerances in the creation of laboratory models
(poured or printed), tolerances in the process of
the molding of plastic over said models, limi-
tations of the plastic materials themselves, and, of
course, inconsistent compliance.
Much like issues in manufacturing of metal
wires and braces, there are tolerances permitted
in fabrication that may limit the accuracy of tooth
movement. The same situation occurs in molding
plastic trays, especially when “simulated/pre-
dicted tooth movements” are involved. In addi-
tion, thin plastic may mold around the undercuts
and interproximal spaces between teeth but
might provide insufficient force to achieve the
desired tooth movement. The flexibility of the
material and its conformation from the incisal
edge to the gingival margin of individual teeth,
combined with the necessary duration of forces
applied to specific teeth, can be problematic. It
seems there must be a compromise between
heavier forces from thicker or less pliable plastic
versus thinner or more resilient materials.27,28 In
any event, some tooth movements (extrusion,
torque, and rotations) especially for certain teeth
(maxillary laterals and cuspids) have been clearly
demonstrated to be less predictable and require
extra attention.1–3,11–13,29–32 These types of con-
cerns led directly to the creation of bonded
composite attachments with the intent to
increase the surface area for plastic aligners to
“grip” onto teeth.
More importantly, the design of the sequence
and velocity of the movement of teeth during
treatment requires the greatest consideration.
Sequential or simultaneous tooth movement
plans are desirable in different situations. Simply
expecting teeth to move from start to a finished
occlusion without a specific plan in-between for
how these teeth will overcome obstacles (i.e.,
collisions, contact points, occlusal and muscular
forces, insufficient force, or contacts from the
plastic) is unrealistic at best.9
One of the earliest adjuncts to help seat aligner
trays, attempt to maintain “tracking,” and increase
occlusal forces to elicit tooth movement was the
introduction of aligner “chewies” (Chewies Aligner
Tray Seaters, Dentsply Raintree Essix, York,
PA).15,19 These plastic “cotton rolls” are prescribed
for patients to use at least the first few days after
changing to each new pair of aligners. Like the
concept of a tooth positioner, the patient places
the device in a site where teeth are not tracking (i.
e., a visible “air” gap is seen between the occlusal or
incisal of a tooth and the aligner). The patient then
bites and holds onto the chewies repeatedly, over a
few minutes of time daily, with their aligners in
place.15,19 The intent is to help seat the aligner on
the teeth that are not tracking, slightly intrude the
teeth adjacent to a tooth in question, and the
added perturbations may help to accelerate the
remodeling in that site to stimulate the tooth to
move as prescribed.
Lack of space
Crowded dentitions offer only two options for
resolution: create more space (expand) or
 Clear aligners
reduce tooth mass (IPR or extraction). Expan-
sion implies either development or growth of
new bone in the buccal alveolus. This may
potentially position teeth into less stable locations
due to change in equilibrium in the facial mus-
culature and an associated potential loss of bone
as teeth are pushed beyond the envelope of the
alveolus. Certainly, some modicum of expansion
appears to be tolerable or at least “retainable.”
Unfortunately, aligners tend to expand a most
unstable site: the mandibular intercanine
dimension.33 IPR to reduce the dimensions of
teeth to provide for their accommodation within
the arch perimeter is useful, but should be
limited in scope. Extractions are a time-tested,
evidence-based approach to resolving significant
arch length discrepancies; however, the results
with aligners have been unpredictable. These
more complex cases often benefit from adjuncts
such as elastics, miniscrew anchorage, or even the
use of sectional fixed braces.16,34–43
In the simplest terms, if there is insufficient
space for a tooth to move, it would not. To
prescribe the unraveling of anterior crowding
with aligners seems such a simple procedure.
Without the creation of space, the “binding”
collisions or contacts between irregular incisors
will prevent movement. As noted earlier, the
options to solve this are obvious and they can be
combined (mild expansion þ mild IPR; extrac-
tion þ IPR).
Selecting IPR from the outset makes little
sense, unless the original discrepancy is quite
minor. That leaves the application of some
degree of expansion (labially and laterally).
Expansion to resolve minor crowding may be as
simple as prescribing the opening of “visible”
space (40.2 mm) between specified teeth. Then
reasonable amounts of IPR could be performed
more safely. Some perform this structural
reduction chairside with “lightning strips or
disks.” Others provide abrasive strips to patients
with prescribed directions to “floss” the strips
between contact points to create small amounts
of space. Once space is achieved, then more
predictable correction of rotations and labiolin-
gual discrepancies can be accomplished. Any
small residual space that remains can be easily
closed with the aligners as treatment progresses.
If extractions are chosen, then an entirely
different group of concerns must be addressed
from control of anchorage, torque (root
67
rotation), tipping (bodily movement), and ensur-
ing interproximal contacts are created at the
end.35–38,44,45 The application of intramaxillary
or intramandibular elastics to miniscrews,41–43
intermaxillary elastics, and the increase in size
and type of composite attachments may be
needed to increase predictability.16
Predictable sequencing of space closure or
pushing individual teeth into alignment for any
of the previous scenarios may be best handled in
small segments of tooth movement.16,20,23 In
other words, to control anchorage in small
increments, teeth adjacent to a specific tooth that
is out of position are prescribed to be held in
place (no movement) until the irregular one is
moved to place and so on. This detailed
sequencing of small parts of a treatment plan are
intended to reducing tracking errors that are
sometimes experienced during simultaneous
movements of large numbers of teeth.
Rotations
It seems quite obvious that attempting to rotate
some teeth with plastic is unlikely to occur due to
their anatomy.7 For example, expecting to
reliably rotate a “round” premolar seems futile
unless a “handle” is placed on it to increase its
profile asymmetrically. Molded composite
attachments46,47 have increased the predict-
ability of rotational control to some degree.48,49
But, the simple application of a prominent
handle, of even a specific engineered design,
cannot be depended upon without accompany-
ing proper treatment planning.
The most unpredictable teeth to achieve
rotation for in the esthetic zone are the maxillary
laterals and cuspids11; despite the use of
seemingly enormous attachments. Rotating
these teeth appears to require the most
attention to detailed treatment sequencing.15
Consider the typical position of a maxillary
lateral incisor often accompanying a Class II
Division 2 malocclusion. Simply prescribing that
this tooth be “straight” at the end of aligner
treatment is absurd. Space must first be created
or this tooth will simply not move. This may be
accomplished by “expansion” laterally, but also
arch perimeter may be increased as lingual root
torque is applied to often “rabbited” central
incisors. Once visible space is open, then any
68 Bowman

Figure 1. Ineffectual movement of a crowded and rotated central incisor due to insufficient space. Additional
space must be created by either IPR and/or expanding to open visible space on either side of the affected tooth;
otherwise, no movement is possible. Once space is created, a rotational couple is necessary to produce the desired
change. Holding or preventing movement of the teeth adjacent to the rotated tooth in question (by staging in the
setup) and using accent pliers to place indents on opposite sides of the plastic (The Vertical pliers, Clear
Collection, Hu-Friedy, Chicago, IL) may enhance the intended biomechanical effect.15,50

desired IPR can be provided, but no rotation of
the incisor can be started until there is room.
The shape, size, and the position of the lateral
incisor between two larger neighboring teeth
preclude much contact with plastic. This is fur-
ther compromised if there is a desire to extrude
the lateral and/or intrude the central incisors.
There is simply insufficient retention of plastic
stretched over the blade-shaped lateral. Con-
sequently, a variety of attachments have been
designed and modified for use on laterals with
varying degrees of success.48 Unless combined
with the prerequisite creation of space, the
dimensions or design of an attachment are
pointless. In fact, the iatrogenic effect of
applying these forces without space can actually
produce more intrusion, squeezing the tooth
apically; thereby, increasing tracking error.
More predictable has been the introduction of
adjunctive forces from orthodontic elastics as
described below.
Expecting a tooth to be rotated into an ideal
prescribed position, using flexible plastic (with
inherent errors or limits in tolerances), without
asking for “over-rotation” also seems dubious. For
instance, it is probably necessary to prescribe
21–31 of “over-rotation” to ever be able to simply
reach “ideal.” Besides, over-correction has been a
time-tested tenet in orthodontics.
Another option is to use detailing pliers (The
Vertical, Clear Collection, Hu-Friedy, Chicago,
IL)15,50 to produce indentations into the plastic
to create accented rotational couples (Fig. 1).
Finally, just because the tooth was moved to the
desired spot does not guarantee it will remain.
For instance, it may be advisable to consider an
Edward’s supracrestal fiberotomy for significantly
rotated teeth that you do not want to return to
their original position (i.e., lateral incisors in
Class II Division 2).
Torque and root angulation
Control of root movement with aligners has been
an unfailingly constant concern.7,51,52 Rotation of
roots (torque), bodily tooth movement, and root
paralleling have been deemed to be limitations of
applying relatively “loose” forces with plastic.
Fixed braces have the advantage of a more
intimate junction between the forces generated
by the deformation of wires bound in brackets
bonded directly to the teeth.
Plastic aligners, despite often covering the
majority of surface area of teeth, still do not have
the same connection; therefore, the crown of the
tooth may slip away from the plastic. Accordingly,
to alter the angle of roots (moving them some
distance through bone) is much more difficult
than simple crown tipping. Complicate this with
the flexibility of plastic, including the differential
in resilience and force levels from the gingival
margin to the occlusal of the aligners, and cre-
ating rotational couples for roots become diffi-
cult. If simultaneous movements of crown
rotation, intrusion, extrusion, and unresolved
crowding are added to the mix, predictability can
be problematic.
The application of torque, specifically for
maxillary anterior teeth, was identified early in
aligner history as unpredictable.12,32,53 As a result,
most changes noted in the angle of incisors
occurred due to “flaring,” “rounding-out the arch,”
 Clear aligners 69

using The Horizontal pliers (Clear Collection,

Figure 2. Torque ridge indentations to increase the
force applied to the crown to enhance a rotational
couple with intent to change the angulation of a tooth.
These ridges can be prescribed in some commercial
appliances such as Invisaligns or added using The
Horizontal pliers (Clear Collection, Hu-Friedy, Chi-
cago, IL).15,50
or facial tipping as crowding was resolved using
expansive pushing forces. Unintended excess
overjet or bimaxillary protrusion may result. For
example, the Class II Division 2 malocclusion seems
an easy fix if you simply tip the upper central
incisors labially. Unfortunately, the resulting overjet
accompanying a straighter “social six” is not exactly
what most patients have in mind.
The addition of so-called “torque ridges” to
enhance forces for lingual root torque (limiting
labial crown tipping) was first evaluated during
the Invisalign Teen Research project.25 These
ridges were added to the plastic at the gingival
margin on the labial and at the incisal edge of the
lingual to generate a rotational couple to tip
roots palatally (and vice versa if labial root torque
was desired). These ridges can also be added
individually anywhere along the aligner tray
Hu-Friedy, Chicago, IL )(Fig. 2).15,50
Results from the Teen Study25 demonstrated
that the predicted actual degrees of torque
produced were reasonably achieved (Fig. 3).
But, due to the flexibility of plastic and the
inherent difficulty in moving roots through bone,
prescribing over-correction of torque is sug-
gested in order to just achieve the intended
angulation. In addition, caution is warranted as
these additional forces may tend to push the
plastic incisally and increase tracking error.52
Keeping the trays seated onto the incisor crowns
using some programmed intrusion may improve
the response. Finally, do not ignore the
unintended posterior effects from anterior
torque. Loss of posterior anchorage seen with
mesial tipping and intrusion of the mesial
marginal ridge of molars may be attendant to
anterior torque expression.16
What is so important about anterior torque?
More attention than ever is being paid to proper
coupling of upper and lower anterior teeth as the
population of adult orthodontic patients has
increased. The development of crowding, coin-
cident with deep overbites, is often associated
with “upright incisors” (obtuse interincisal angle)
and the constricted envelope of anterior func-
tion. The long-term consequence may be sub-
stantial loss of tooth structure from a
combination of functional and dysfunctional
wear. Mix-in any unidentified Bolton tooth-size
discrepancies (e.g., small maxillary lateral inci-
sors), acidic diet, or gastrointestinal reflex dis-
ease, and the damage to teeth can be dramatic.
Consequently, it may not be simply enough to
line up the front teeth in short order to only

Figure 3. During the Invisalign Teen Study,25 torque ridge indentations were added to aligner trays with the intent
to affect a rotation couple to improve the predictability of producing desired angulation of upper incisors.
Although the “torque” amounts reasonably matched the planned “setups,” prescribing over-correction of this root
movement may be required in order to achieve intended goals.
70
Figure 4. The American Board of Orthodontics
determined that the most common error noted in
case reports failing the ABO examination were
inappropriate buccolingual inclination or torque of
posterior teeth.54 Attention to detail is critical in all
aspects of preparing virtual set-ups (e.g., adding buccal
root torque).
satisfy patient’s esthetic requests. Informed
consent begs proper diagnosis and treatment
planning to address possible functional concerns.
Addressing root angulation or torque is not
limited to only anterior teeth. The American
Board of Orthodontics described that the most
common error found in case reports that failed
their examination was, in fact, insufficient pos-
terior buccolingual inclination (posterior tor-
que),54,55 a concern shared in other reports.56–59
Unless the angle of posterior teeth is specifically
addressed in the virtual setup, an excessive curve
of Wilson, prominent palatal cusps of uppers,
improper posterior intercuspation with inap-
propriate posterior overjet may result (Fig. 4).57
Marshall et al.56 advised, “For proper occlusion,
there should be no significant difference
between the heights of the buccal and lingual
cusps of molars and premolars.”
Attention to detail in setups by evaluating the
posterior teeth from the lingual view can assist in
correcting these errors. In addition, increasing
posterior collisions during the completion of
treatments can significantly reduce the iatrogenic
creation of posterior open bites from “passive
posterior intrusion” that can occur
by simply wearing plastic trays long-term.60 Recent
changes in some proprietary software have
permitted orthodontists to specifically address
these issues with their own individual
manipulation of tooth movement in virtual setups.
Extrusion
Asking for extrusion where occlusal surfaces of
teeth are “capped” with plastic (without
Bowman
substantial undercuts for retention) is unrealistic.
At 29.6% effectiveness, extrusion was reported to
be the least accurate tooth movement with
aligners.11 Without some type of retention, the
plastic will simply slip occlusally or incisally,
leaving the tooth behind; resulting in a loss of
aligner contact often termed “aligner lag.” These
teeth are not lagging behind; they had no chance
to be moved. Once again, the knee-jerk reaction
was to increase the size and shape of composite
attachments to attempt to urge teeth occlusally
with bigger handles for the plastic to grip
onto.46,47,61 In situations where extrusion was still
not seen, the concept of aligners itself was
blamed for the “lag” without thinking through
the limitations and finding solutions.
If the intent is to extrude an incisor, then
certainly adequate retention of the plastic is
required to produce the extrusive force. We
cannot expect a blade-shaped tooth to track
occlusally as if magically attracted to plastic above
it. But, is just a more prominent attachment
simply enough?
Tight interproximal contacts or significant
collisions (even without overlap or crowding) can
stop extrusion; therefore, adequate space must
be produced prior to attempting extrusion. This
is especially important when considering the
shape of teeth adjacent to one that is to be
“pulled-up.” Incisors or canines are often nar-
rower gingivally and taper to a wider dimension
incisally. In those instances, extrusion is an
obvious non-starter without space creation.
Finally, the application of root tip or torque
along with labiolingual positioning also play
intimate roles in extrusion. Sequential tooth
movement to achieve the desired vertical change
is much more complex than simply communi-
cating “an order” with a lab tech to just pull the
tooth occlusally.
Adjunctive forces
The addition of adjunctive forces to enhance
clear aligners is not a new idea.6 For example, the
application of orthodontic elastics to enhance or
facilitate various biomechanics was the earliest
and most obvious addition. But, attempting to
improve aligner “tracking” and reduce the so-
called “lag” for certain teeth has been the most
perpetual dilemma affecting predictable results.
Much like using intermaxillary elastics with
 Clear aligners 71

Figure 5. Preparing bootstrap biomechanics.15,62 Tear Drop pliers are used to cut notches in mesial and distal
embrasures of the aligner plastic. Hole Punch pliers clear the aligner plastic to allow the addition of a bonded
button. Orthodontic elastics are stretched from the button to the teardrop notches or, alternatively, to another
button bonded on the opposite side of the tooth. (Clear Collection pliers, Hu-Friedy, Chicago, IL).

braces to increase intercuspation when produc-
ing a solid final occlusion, a combination of
bonded buttons and elastics can also be used with
clear aligners. In these scenarios, buttons bonded
on the buccal surfaces of posterior teeth can be
used to apply “triangle, box, or up-and-down”
elastics to seat teeth into the aligners and into the
final occlusion prescribed in the setup.15,62
Therefore, the application of orthodontic elas-
tics that are connected to the aligner plastic,
bonded buttons on teeth, or to miniscrew
anchors have increased the variety of achievable
movements possible.
Bootstrapping for predictability
The predictability of single tooth extrusion and/
or rotation can be enhanced using orthodontic
elastics in a so-called “bootstrap” arrangement.63
Bootstrap mechanics involve placing bonded
buttons at the gingival margin on the facial,
lingual, or both surfaces of a tooth that is
lagging.15,62 An orthodontic elastic is then
stretched across the occlusal surface of the seated
clear aligner to attach to buttons and/or notches
cut into the tray on opposite sides. The gingival
margin of the aligner plastic must be relieved to
avoid the buttons so as to permit the tray to seat
fully (Figs. 5 and 6).
Intrusion of a segment of teeth can also be
supported using elastics supported by miniscrew
anchorage. The possibilities include applying the
orthodontic elastics or chain from buccal and/or
palatal elastics to buttons bonded to teeth (while
relieving plastic from the trays to avoid those
attachments).15,62 As an example, bonded but-
tons can be placed at the gingival margin of all
incisors (for a patient with a deep overbite) or of
molars (for hypererupted posteriors). Ortho-
dontic elastics from those buttons are stretched
to miniscrews inserted interradicularly apical to
the teeth to be intruded.15
Posterior intrusion to enhance the closure of
anterior open bites is another option with elastics
and miniscrews. Sequential intrusion of posterior
teeth combined with some extrusion of anterior
72 Bowman

Figure 6. Bootstrap mechanics15,62 to forcibly erupt “lagging” teeth using orthodontic elastics. Adult female with
Class II Division 2 malocclusion, deep overbite, crowding, rotations, and uneven maxillary anterior teeth. Initially,
Invisaligns treatment featured angulated, horizontal beveled attachments bonded to the facial of the lateral
incisors.48 After limited improvement noted in the overbite, torque of central incisors, and extrusion/rotation of
the lateral incisors, a bootstrap setup was created at “refinement.” Clear buttons were bonded at gingival margin on
the facial and metal buttons on the lingual of both upper laterals. Plastic was relieved from the aligners to
accommodate those buttons using The Hole Punch pliers.62 Orthodontic elastics were stretched from the lingual
to the palatal buttons across the seated plastic aligners. The virtual setup featured arch expansion with visible space
created adjacent to the laterals, forced extrusion of the laterals, intrusion and torque for central incisors, intrusion
of lower anterior teeth, and over-rotation for the lateral incisors.15

teeth to increase the curve of Spee22,23 can be
reinforced with bootstrap elastics. In this sce-
nario, elastics are stretched across the occlusal of
seated aligners from miniscrews to buttons,
notches in trays, or to another miniscrew in bone
on the other side of the alveolus.15
Skeletal discrepancies
Addressing skeletal discrepancies were originally
seen to be an anathema to be avoided with
aligners.3,4 Only limited changes in over or
underjet were attempted with aligners, while
expecting little if any anteroposterior correc-
tion.64,65 Later, maxillary posterior distalization
was attempted, but without consideration of
anchorage concerns. This led to the application
of intermaxillary Class II elastics to make-shift
notches cut into the plastic trays, then to buttons
bonded to the trays, and finally to buttons
directly bonded to the teeth (or some combi-
nation of those options).20 Once elastics were
found to improve the chance of orthodontic
movement for Class IIs, then employing
sequential molar distalization supported by
elastics20 was a logical strategy that has proven
successful with aligners.66 Currently, elastics on
aligners have found their way into correcting
Class IIs, IIIs, and open bites; especially for
growing individuals.
Other options for improving the predictability
of skeletal correction have included “pre-cursor”
adjuncts used prior to beginning clear aligners.
These have included the use of the Carrière arm
(Carrière Distalizer, Ortho Organizers, Henry
Schein, Melville, NY) to hold Class II elastics to
distalize posterior segments14,67,68 or typical,
stand-alone distalizers, such as the Pendulum or
Distal Jet. Any of these devices may be supple-
mented with miniscrew anchorage to avoid
reciprocal adverse effects.
For example, the Horseshoe Jet (Specialty
Labs, Atlanta, GA), is a laboratory modification of
the Distal Jet (American Orthodontics, Sheboy-
gan, WI), supported by miniscrews. These
appliances are used to produce molar distaliza-
tion14,69–72 prior to initiating clear aligner
treatment. After posterior teeth are moved into a
Class I occlusion, clear aligners are prescribed to
hold the molars in place while the remaining
anterior teeth are retracted; just as they would be
with fixed braces. This retraction is often sup-
ported with Class II elastics or even Class I
intramaxillary elastics from miniscrews to reduce
the possibility of anchorage loss.14,50,71
Finally, the introduction of a variety of
methods intended to accelerate the rate of tooth
movement have arisen in recent years. For
example, the use of a device to produce micro-
vibrations or perturbations (AcceleDent,
 Clear aligners
OrthoAccel, Bellaire, TX) with the intent of
stimulating tooth movement has been anecdo-
tally described to reduce treatment time with
clear aligners, warranting further research.16,43,73
Predicting the future of clear aligners
Technology has continued to improve clear
aligner treatments since their inception.
Replacing impressions with increasingly more
accurate intraoral scanners, 3D printing instead
of plaster models, individual tooth movement
and staging in virtual setups, and improvements
in aligner materials and attachments are all
examples of recent advancements. Simulta-
neously, general practitioners with limited
training are providing more “social six” treat-
ments (disregarding the fit and function of
teeth) and nearly every orthodontic lab (in or out
of the orthodontist’s practice) is offering some
type of clear plastic product. Can all options
(specialist or general dentist; scanner with
computer setup versus bench model setup)
provide equal or similar results? Clearly, aligner
treatments are here to stay, but are we all equally
trained to serve the best interests of our patients
using these devices or are some depending upon
lab techs to provide the diagnosis and prescribe
the treatment plan? All practitioners simply need
to be as honest with ourselves as we are with those
that choose to have us treat them.
References
1. Kesling HD. The philosophy of tooth positioning appli-
ance. Am J Orthod. 1945;31:297–304.
2. Javidi H, Graham E. Clear aligners for orthodontic
treatment?Evid Based Dent 2015;16(4):111. http://dx.
doi.org/10.1038/sj.ebd.6401133.
3. Clements KM, Bollen AM, Huang G, King G, Hujoel P, Ma
T. Activation time and material stiffness of sequential
removable orthodontic appliances. Part 2: dental
improvements. Am J Orthod Dentofacial Orthop. 2003;124:
502–508.
4. Djeu G, Shelton C, Maganzini A. Outcome assessment of
Invisalign and traditional orthodontic treatment com-
pared with the American Board of Orthodontics objective
grading system. Am J Orthod Dentofacial Orthop. 2005;128:
292–298.
5. Phan X, Ling PH. Clinical limitations of Invisalign. J Can
Dent Assoc. 2007;73(3):263–266. Available at: www.cda-adc.
ca/jcda/vol-73/issue-3/263.html.
6. Tuncay O. The Invisalign System. Quintessence Publishing,
London 2007[ISBN 1850971277].
73
7. Rossini G, Parrini S, Castroflorio T, Deregibus A,
Debernardi CL. Efficacy of clear aligners in controlling
orthodontic tooth movement: a systematic review. Angle
Orthod. 2015;85(5):881–889. http://dx.doi.org/10.2319/
061614-436.1 [Epub 2014 Nov 20].
8. Lagravère MO, Flores-Mir C. The treatment effects of
Invisalign orthodontic aligners: a systematic review. J Am
Dent Assoc. 2005;136(12):1724–1729.
9. Buschang PH, Ross M, Shaw SG, Crosby D, Campbell PM.
Predicted and actual end-of-treatment occlusion pro-
duced with aligner therapy. Angle Orthod. 2015;85
(5):723–727. http://dx.doi.org/10.2319/043014-311.1
[Epub 2014 Nov 5].
10. Walton DK, Fields HW, Johnston WM, Rosenstiel SF,
Firestone AR, Christensen JC. Orthodontic appliance
preferences of children and adolescents. Am J Orthod
Dentofacial Orthop. 2010;138(6):698. http://dx.doi.org/
10.1016/j.ajodo.2010.06.012.
11. 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;135:27–35.
12. Krieger E, Seiferth J, Marinello I, et al. Invisaligns
treatment in the anterior region: were the predicted
tooth movements achieved?J Orofac Orthop 2012;73
(5):365–376[Epub 2012 Aug 11].
13. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables
affecting orthodontic tooth movement with clear align-
ers. Am J Orthod Dentofacial Orthop. 2014;145(suppl 4):
S82–S91. http://dx.doi.org/10.1016/ajodo2013.10.
022.57.
14. Bowman SJ, Celenza F, Sparaga J, Papadopoulos MA,
Ojima K, Lin JC. Creative adjuncts for clear aligners: part
1: class II treatments. J Clin Orthod. 2015;49(2):83–94.
15. Bowman SJ, Celenza F, Sparaga J, Papadopoulos MA,
Ojima K, Lin JC. Creative adjuncts for clear aligners: part
2: intrusion, rotation, and extrusion. J Clin Orthod. 2015;49
(3):162–174.
16. Bowman SJ, Celenza F, Sparaga J, Papadopoulos MA,
Ojima K, Lin JC. Creative adjuncts for clear aligners: part
3: extraction and interdisciplinary treatment. J Clin
Orthod. 2015;49(4):249–262.
17. Lin JC, Tsai SJ, Liou EJ, Bowman SJ. Treatment of
challenging malocclusions with Invisalign and miniscrew
anchorage. J Clin Orthod. 2014;48(1):23–36.
18. Giancotti A, Germano F, Muzzi F, Greco M. A miniscrew-
supported intrusion auxiliary for open-bite treatment
with Invisalign. J Clin Orthod. 2014;48(6):348–358.
19. Tuncay O. Clinical reports & techniques. Fall. 2005;6(2):1.
20. Daher S. Dr. Sam Daher’s techniques for Class II correction with
Invisalign and elastics.Align Technology, Inc.; 2011. Avail-
able at: https://s3.amazonaws.com/learn-invisalign/
docs/06840000000GHgmAAG.pdf. cited 2015 Accessed
Jan 29, 2015.
21. Paquette D. Temporary Anchorage Devices in Combination
With Aligners 2009. Available at: http://www.aligntechin
stitute.com/files/ATEArchive/pdf/ate_110609.pdf.
22. Boyd R How successful is Invisalign for treatment of
anterior open bite and deep overbite? American Association
of Orthodontists Annual Session, 2013 Philadelphia, PA.
Available at: https://www.aaoinfo.org/system/files/
media/documents/Boyd,%20Robert%20–%20Treat
74 Bowman
ment%20of%20Deep%20and%20Open%20bite%20with
%20Clear%20Aligners.pdf.
23. Dayan, W Techniques for posterior intrusion in the
correction of anterior open bite with Invisalign. Techni-
ques White Paper 2011 Available at: http://www.alignte
chinstitute.com/files/openbite/Dayan%20Techniques%
20White%20Paper.pdf.
24. Tuncay O, Bowman SJ, Amy B, Nicozisis J. Effectiveness of
clear aligner compliance indicator. J Clin Orthod. 2009;43
(4):263–268.
25. Tuncay O, Bowman SJ, Amy B, Nicozisis J. Aligner
treatment in the teenage patient. J Clin Orthod. 2013;47
(2):115–119.
26. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C.
Forces and moments generated by removable thermo-
plastic aligners: incisor torque, premolar derotation, and
molar distalization. Am J Orthod Dentofacial Orthop. 2014;145
(6):728–736. http://dx.doi.org/10.1016/j.ajodo.2014.03.
015.
27. Duong T, Kuo E. Finishing with invisalign. Prog Orthod.
2006;7(1):44–55.
28. 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 treat-
ment. Am J Orthod Dentofacial Orthop. 2003;124:496–501.
29. Kamatovic M. A retrospective evaluation of the effectiveness of
the Invisalign appliance using the PAR and irregularity indices
[dissertation]. Toronto (Ont.): University of Toronto;
2004.
30. Gomez JP, Peña FM, Martínez V, Giraldo DC, Cardona CI.
Initial force systems during bodily tooth movement with
plastic aligners and composite attachments: a three-
dimensional finite element analysis. Angle Orthod.
2015;85(3):454–460. http://dx.doi.org/10.2319/050714-
330.1[Epub 2014 Sep 2].
31. Dasy H, Dasy A, Asatrian G, Rózsa N, Lee H, Kwak JH.
Effects of variable attachment shapes and aligner material
on aligner retention. Angle Orthod. 2015;85(6):934–940.
http://dx.doi.org/10.2319/091014-637.1.
32. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C.
Treatment outcome and efficacy of an aligner technique
—regarding incisor torque, premolar derotation and
molar distalization. BMC Oral Health. 2014;14:68. http:
//dx.doi.org/10.1186/1472-6831-14-68.
33. Grünheid T, Gaalaas S, Hamdan H, Larson BE. Effect of
clear aligner therapy on the buccolingual inclination of
mandibular canines and the intercanine distance. Angle
Orthod. 2016;86(1):10–16. http://dx.doi.org/10.2319/
012615-59.1 [Epub 2015 May 22].
34. Boyd RL. Esthetic orthodontic treatment using the
Invisalign appliance for moderate to complex malocclu-
sions. J Dent Ed. 2008;72:948–967.
35. Hönn M, Göz G. A premolar extraction case using the
Invisalign system. J Orofac Orthop. 2006;67:385–394.
36. Miller RJ, Doung TT, Derakhshan M. Lower incisor
extraction treatment with the invisalign system. J Clin
Orthod. 2002;36:95–102.
37. Womack WR. Four-premolar extraction treatment with
Invisalign. J Clin Orthod. 2006;40:493–500.
38. Giancotti A, Greco M, Mampieri G. Extraction treatment
using Invisalign technique. Prog Orthod. 2006;7:32–43.
39. Uribe F, CutreraA, Nanda R. A segmented appliance for
space closure followed by Invisalign and fixed appliances.
Orthod (Chic). 2011;12:386–395.
40. Samoto H, Vlaskalic V. A customized staging procedure to
improve the predictability of space closure with sequen-
tial aligners. J Clin Orthod. 2014;48(6):359–367.
41. Nak-Chun Choi, Park Young-Chel, Jo Yong-Min, Lee Kee-
Joon. Combined use of miniscrews and clear appliances for
the treatment of bialveolar protrusion without conventional
brackets. Am J Orthod Dentofacial Orthop. 2009;135(5):671–681.
http://dx.doi.org/10.1016/j.ajodo.2006.12.025.
42. Park YC, Chu JH, Choi YJ, Choi NC. Extraction space
closure with vacuum-formed splints and miniscrew
anchorage. J Clin Orthod. 2005;39:76–79.
43. Ojima K, Dan C, Nishiyama R, Ohtsuka S, Schupp W.
Accelerated extraction treatment with Invisalign. J Clin
Orthod. 2014;48(8):487–499.
44. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign
appliance in extraction cases using the the ABO model
grading system: a multicenter randomized controlled
trial. Int J Clin Exp Med. 2015;8(5):8276–8282[eCollection
2015].
45. Baldwin DK, King G, Ramsay DS, Huang G, Bollen AM.
Activation time and material stiffness of sequential
removable orthodontic appliances. Part 3: premolar
extraction patients. Am J Orthod Dentofacial Orthop.
2008;133(6):837–845 http://dx.doi.org/10.1016/j.
ajodo.2006.06.025.
46. Kuo E, Duong T, Invisalign attachments: Materials. In:
Tuncay O, ed. The Invisalign System. London: Quintes-
sence Publishing; 2007:91–98.
47. Boyd RL, Vlaskalic V. Three-dimensional diagnosis and
orthodontic treatment of complex malocclusion with the
Invisalign appliance. Semin Orthod. 2001;7:274–293.
48. Nicozisis JL. Tripping the plastic fantastic. Orthod Products
2013:28–34.
49. Humber P. Rotating canines using the Invisalign system.
Aesthetic Dentistry Today. 2013;7(1):30–34.
50. Bowman SJ. Clear collection instruments for clear aligner
treatments. Orthod Practice US. 2015;6(3):74–78.
51. Zhang XJ, He L, Guo HM, Tian J, Bai Y, Li S. Integrated
three-dimensional digital assessment of accuracy of
anterior movement using clear aligners. Korean J Orthod.
2015;45(6):275–281. http://dx.doi.org/10.4041/
kjod.2015.45.6.275[Epub 2015 Nov 20].
52. Hahn W, Zapf A, Dathe H, et al. Torquing an upper central
incisor with aligners—acting forces and biomechanical
principles. Eur J Orthod. 2010;32(6):607–613. http://dx.doi.
org/10.1093/ejo/cjq007[Epub 2010 May 12].
53. Castroflorio T, Garino F, Lazzaro A, Debernardi C.
Upper-incisor root control with Invisalign appliances.
J Clin Orthod. 2013;47:346–351.
54. American Board of Orthodontics. Why case reports do
not pass the ABO Phase III clinical examination. Am J
Orthod. 1996;110:559–560.
55. Bowman SJ. Addressing concerns for finished cases: the
development of the Butterfly Bracket System. Part I. J Ind
Orthod Soc. 2003;36:73–75.
56. Marshall S, Dawson D, Southard KA, Lee AN, Casko JS,
Southard TE. Transverse molar movements during
growth. Am J Orthod Dentofacial Orthop. 2003;124:615–624.
 Clear aligners
57. McLaughlin RP, Bennett JC, Trevisi H. Systemized Ortho-
dontic Treatment Mechanics. St. Louis: Mosby; 2001.
58. Yang-Powers LC, Sadowsky C, Rosenstein S, BeGole EA.
Treatment outcome in a graduate orthodontic clinic
using the American Board of Orthodontics grading
system. Am J Orthod Dentofacial Orthop. 2002;122:451–455.
59. Sondhi A An analysis of orthodontic prescriptions: their
strengths and weaknesses. Lecture, AAO Annual Session,
Honolulu, May 6, 2003.
60. Schupp W, Haubrich J, Neumann I. Treatment of
anterior open bite with the Invisalign system. J Clin
Orthod. 2010;44:501–507.
61. Boyd RL. Complex orthodontic treatment using a new
protocol for the Invisalign appliance. J Clin Orthod.
2007;42:525–547.
62. Bowman SJ. Clear collection instruments for clear aligner
treatment: part 2. Orthod Practice US. 2015;6(4):48–52.
63. Giancotti A, Ronchin M. Pre-restorative treatment with
the Invisalign system. J Clin Orthod. 2006;40:679–682.
64. Fischer K. Invisalign treatment of dental Class II
malocclusions without auxiliaries. J Clin Orthod. 2010;44:
665–672.
65. Schupp W, Haubrich J, Neumann I. Class II correction
with the Invisalign system. J Clin Orthod. 2010;44:28–35.
66. Klein BM. A cephalometric study of adult mild Class II
nonextraction treatment with the Invisalign System.Master’s
Thesis. St. Louis: Saint Louis University—Center for
Advanced Dental Education; 2013.
75
67. Sandifer CL, English JD, Colville CD, Gallerno RL,
Akyalcin S. Treatment effects of the Carrière distalizer
using lingual arch and full fixed appliances. J World Fed
Orthod. 2014;3:e49–e54.
68. Colville CD. Carrière distalizer and Invisalign combo for
Class II treatment. Invisalign Insights 2012. Available at:
http://www.aligntechinstitute.com/RealStories/Docu
ments/newsletter_OR_2012-09.pdf.
69. Bowman SJ, Thinking outside the box with miniscrews. In:
McNamara JA Jr, Ribbens KA, eds. Microimplants as
Temporary Anchorage in Orthodontics, 45. Ann Arbor:
Craniofacial Growth Series, The University of Michigan;
2008:327–390
70. Ludwig B, Baumgaertel S, Bowman SJ. Mini-Implants in
Orthodontics: Innovative Anchorage Concepts. Chicago: Quin-
tessence; 2008.
71. Bowman SJ, Settling the score with Class IIs using
miniscrews. In: Kim KB, ed. Temporary Skeletal Anchorage
Devices—A Guide to Design and Evidence-Based Solutions.
New York: Springer; 2014.
72. Bowman SJ, The evolution of the Horseshoe Jet. In:
Papadopoulos MS, ed. Skeletal Anchorage in Orthodontic
Treatment of Class II Malocclusion: Contemporary Applications
of Orthodontic Implants, Miniscrew Implants and Miniplates.
St. Louis: Mosby Elsevier; 2015.
73. Schupp W, Haubrich J, Ojima K, Boisserele W, Morton J.
Aligner Orthodontics: Diagnosis, Treatment Planning, Ortho-
dontic and Orthopedic Treatment. London: Quintessence
publishing; 2015.