Original Article

Predicted overbite and overjet changes with the Invisalign appliance:

a validation study

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023

Maurice J. Meadea; Haylea Blundellb; Tony Weirc

ABSTRACT
Objectives: To investigate whether the predicted changes in overbite (OB) and overjet (OJ) in Align
Technology’s (Santa Jose, Calif) digital treatment plan for the prescribed course of treatment with the
Invisalign appliance were consistent with those same changes in OB and OJ measured with the
Geomagic Control X (Geomagic US, Research, Triangle Park, NC) metrology software system.
Materials and Methods: Geomagic Control X software was used to determine OB and OJ differ-
ences between the pretreatment and predicted outcome. STL files for patients satisfying inclusion
criteria and undergoing nonextraction orthodontic treatment with the Invisalign appliance. The dif-
ferences were compared, using the Bland-Altman analysis, to the corresponding data provided
by Align Technology’s digital treatment-planning interface, ClinCheck.
Results: Data regarding 76 adult patients who satisfied strict inclusion criteria were assessed.
The Shapiro-Wilks test indicated normality (P . .05). The Bland-Altman analysis showed high
levels of agreement between the two measurements, with a bias range of 0.131 to 0.111 for
OB and 0.393 to 0.03 for OJ recorded.
Conclusions: Clinicians and researchers can be confident that measurement data provided by
Invisalign’s ClinCheck digital treatment-planning facility concerning OB and OJ changes from the
initial to the predicted treatment outcome are valid. (Angle Orthod. 0000;00:000–000.)
KEY WORDS: Clear aligner therapy; Invisalign; Metrology; Overbite; Overjet; Validation

INTRODUCTION Align Technology uses an online facility called Clin-

Clear aligner therapy (CAT) is commonly used to
address malocclusion, with the Invisalign (Align Tech-
nology, San Jose, Calif) appliance being among the
most frequently prescribed CAT appliances globally.1–4
One of the proposed advantages of CAT is the use of
three-dimensional (3D) technology for treatment plan-
ning and the manufacture of aligners.5
a
Associate Professor, PR Begg Chair in Orthodontics, Adelaide
Dental School, University of Adelaide, Adelaide, Australia.
b
Associate Professor, La Trobe Rural Health School, La
Trobe University, Bendigo, Victoria, Australia.
c
Honorary Clinical Senior Lecturer, Orthodontic Unit, Adelaide
Dental School, The University of Adelaide, Adelaide, Australia.
Corresponding author: Dr Maurice J. Meade, Associate
Professor and PR Begg Chair in Orthodontics Orthodontic Unit,
Adelaide Dental School, Level 10, Adelaide Health and Medical
Sciences Building Corner of North Terrace and, George St,
Adelaide SA 5000, Australia
(e-mail: maurice.meade@adelaide.edu.au)
Accepted: July 2023. Submitted: April 2023.
Published online: September 1, 2023
Ó 0000 by The EH Angle Education and Research Foundation, Inc.
Check that enables the orthodontist to modify tooth
position and plan treatment procedures virtually, such
as interproximal reduction, until an acceptable digital
treatment plan (DTP) is finalized.5 An additional fea-
ture is the ability to view the predicted outcome from
the finalized DTP. Also, Align Technology provides
supplementary treatment information, including the ini-
tial and predicted overbite (OB) and overjet (OJ) mea-
surement values, via the facility.
3D metrology is a commonly used tool to assess treat-
ment changes associated with orthodontic therapy.6
Among the most commonly used metrology software sys-
tems is Geomagic Control X software (Geomagic US,
Research, Triangle Park, NC). It has been used in several
investigations to compare changes in malocclusion traits
between the initial pretreatment occlusal state, the pre-
dicted occlusal outcome, and the actual treatment out-
comes with the Invisalign appliance.7–12 In addition, it has
been shown to be accurate in the measurement of linear
tooth movements on digital scans and changes in some
tooth movements associated with digital superimpositions
and is considered to be a “gold standard” in metrology-
associated research.13,14

DOI: 10.2319/041323-269.1 1 Angle Orthodontist, Vol 00, No 00, 0000

2 MEADE, BLUNDELL, WEIR
Information regarding the accuracy of numerical treat-
ment information provided by CAT provider DTP interface
facilities is limited in the literature. Recent studies, how-
ever, have indicated that some values provided by Align
Technology may be incorrect.15,16 A recent investigation,
for example, established that Align’s mesiodistal tooth size
measurements, and the Bolton analysis derived from it,
was subject to systematic error and did not match two
other gold standards.15 In addition, Smith et al.16 noted
that the angular measurements supplied in the ClinCheck
Tooth Movement Table were not consistently supported
by independent metrological analysis. Relevant data, how-
ever, regarding OB and OJ measurements are lacking.
Knowledge in this regard can aid orthodontists in
determining the accuracy of information provided by
ClinCheck. It can also enable researchers to determine
whether data provided by Align Technology regarding
OB and OJ changes can be used in future relevant stud-
ies. If the pertinent information provided by Align Tech-
nology has been validated against accepted metrology
software-derived values, researchers may be able to
reduce the time-consuming and expensive metrological
processes for some studies, and clinicians may feel
more confident in basing treatment planning and case
analysis upon this readily available data source.
The aim of the investigation, therefore, was to deter-
mine whether the predicted changes in OB and OJ in
Align’s DTP for the prescribed course of treatment with
the Invisalign appliance were consistent with those same
changes in OB and OJ measured with the Geomagic
metrology software system.
MATERIALS AND METHODS
Ethical approval was granted by the University of Ade-
laide for this retrospective study using de-identified data of
orthodontic patients treated with the Invisalign appliance
between 2014 and 2022. The digital models were from a
database curated by a single practitioner (Dr. Weir) and
comprise of a total of 12,000 patients treated with the Invis-
align appliance by 14 experienced specialist orthodontists.
All patients signed informed consent forms to indicate their
consent to orthodontic treatment and for their data to be
used for research purposes before treatment commenced.
The de-identified digital models of 76 patients to be
used for evaluation of changes between the initial and
predicted OB and OJ in the current study corre-
sponded to the sample evaluated in a recent study
investigating the predictability of anterior open bite
treatment with Invisalign.17 Strict inclusion/exclusion
criteria were applied for patient inclusion in the study.
Inclusion Criteria
• Aged 18 years or older before commencing ortho-
dontic treatment
Angle Orthodontist, Vol 00, No 00, 0000
Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023
Figure 1. Horizontal reference plane showing the palatal interproxi-
mal papilla between the upper first and second molars and the mid-
point of the superior margin of the incisive papilla.
• Nonextraction orthodontic treatment with the Invisalign
appliance only
• Completion of an initial phase of dual-arch Invisalign
therapy consisting of at least 14 aligners
• Apparent open bite associated with one or more
central incisors in the maxilla according to clinical
images
• Prescribed anterior open bite reduction in the
ClinCheck DTP
• Began treatment using SmartTrack aligner material
no earlier than January 2014
• Availability of the initial, predicted, and end of initial
sequence of aligner digital models
Exclusion Criteria
• Uncaptured teeth in the intraoral scanning process
• Combined CAT/orthognathic surgery patients
• Patients requiring restorative intervention during
treatment
• Medical conditions altering tooth movement or bone
metabolism
Data regarding patient gender and age were recorded
in a Microsoft (Redmond, Wash) Excel spreadsheet. Ini-
tial and predicted OB and OJ measurement values pro-
vided by the DTP in ClinCheck information tables were
also documented. The corresponding Geomagic mea-
surements were obtained by the creation of a horizontal
reference plane via the palatal interproximal papilla
between the upper first and second molars and the mid-
point of the superior margin of the incisive papilla.7,17 This
was used to align the .STL files of each patient at the ini-
tial and predicted time points (Figure 1). The initial and
predicted digital models were aligned to this reference
plane. Figure 2a shows the midpoint of the incisal edge
OVERBITE AND OVERJET CHANGES WITH INVISALIGN 3

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023

Figure 2. (a) Midpoint of the upper left central incisor incisal edge as measurement point for overjet and overbite. (b) Lower arch point defined
as the midpoint between the midpoints of the lower left central incisor and the lower left lateral incisor incisal edges for overjet and overbite
measurements.

Figure 3. Linear measurement (in millimeters) of overjet (Y plane) and overbite (Z plane) between the midpoint of the upper left central incisor
incisal edge and the midpoint of the vector between the lower left central incisor and the lower left lateral incisor.

of the upper left central incisor. Figure 2b indicates the
vector determined by the midpoint of the incisal edges of
the lower left central incisor and the lower left lateral inci-
sor. The horizontal and vertical linear distance between
the upper left central incisor midpoint and the vector mid-
point were used to measure the OJ and the depth of OB
(Figure 3) for the initial and predicted digital models.
Intra- and interexaminer scores for the Geomagic mea-
surements were excellent.17
Statistical Analysis
Statistical analyses were computed via R (version
4.0; R Core Team, Vienna, Austria) and SPSS (ver-
sion 25; IBM Corp, Armonk, NY) and were presented
in tabular, graphic, and text formats. As points of refer-
ence and centers of rotation used by ClinCheck were
not defined in a manner allowing reproduction with
metrology software, direct comparisons at the initial (I)
and predicted (P) time points were not possible.
Therefore, the difference (I P) for each method was
compared. The Bland-Altman analysis was used to
determine agreement between the differences of each
method using the bland R package.18,19 The Shapiro-
Wilks test was used to test for normality.
RESULTS
The data of 53 females and 23 males, with a mean
age of 35.17 years at the start of treatment, were
available for evaluation.
Table 1 outlines the summary statistics for the initial
and predicted OB and OJ measurements evaluated
via the Geomagic metrology software and the corre-
sponding measurements provided by ClinCheck. The
mean (SD) predicted OB measurement provided by

Table 1. Initial and Predicted OB and OJ Measurementsa

Geo CC
Mean (SD) 95% CI Mean (SD) 95% CI
Initial OB 1.48 (1.09) 1.73, 1.23 1.48 (1.16) 1.75, 1.22
Predicted OB 1.66 (0.81) 1.42, 1.82 1.61 (0.92) 1.40, 1.82
Initial OJ 4.12 (1.87) 3.70, 4.55 3.5 (1.92) 3.06, 3.94
Predicted OJ 3.11 (0.87) 2.91, 3.31 2.3 (078) 2.12, 2.48
a
CI indicates confidence interval; CC, ClinCheck; Geo, Geomagic; OB, overbite; OJ, overjet; and SD, standard deviation.

Angle Orthodontist, Vol 00, No 00, 0000

4 MEADE, BLUNDELL, WEIR

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023

Figure 4. Bland-Altman plot comparing the difference between Geomagic and ClinCheck initial and predicted overbite differences. CC indi-
cates ClinCheck Geo, Geomagic; I, initial; LOA, level of agreement; OB, overbite; and P, predicted.

Geomagic was 1.66 (0.81) mm compared with the
mean (SD) predicted OB measurement provided by
ClinCheck of 1.61 (0.92) mm.
The Bland-Altman plots of the changes in OB and OJ
are displayed in Figures 4 and 5, respectively. The
dashed lines represent the summary Bland-Altman statis-
tical data, namely, (1) bias, (2) upper limit of agreement,
and (3) lower limit of agreement. The dotted lines repre-
sent confidence intervals for the summary statistics, and
the blue solid line represents a regression line measuring
any proportional bias. If the regression slope is signifi-
cantly different from zero, it may indicate proportional bias.
For OB, there was no proportional bias, and the
sample bias was very close to zero, indicating the two
methods were similar on average. Most of the points
fell between the lower and upper limits of agreement
or within their respective confidence bands.
For OJ, there may have been some proportional
bias. However, the 95% confidence interval for the
regression slope contained zero, indicating the slope
was not significantly different from zero; therefore,
there was no proportional bias. The sample bias was
0.181. However, the confidence interval contained
zero; hence, no significant bias was present. Most of
the points fell between the lower and upper limits of
agreement or within their respective confidence bands.
Checking Assumptions
The validity of confidence intervals depended on the
normality of the measure involved. This assumption
was checked for the differences involved using normal
quantile plots and a Shapiro-Wilks test (Figures 6 and
7). The OB plot and P value confirmed its normality,
and although the OJ data showed some deviation
from normal, the P value was ..05, indicating no seri-
ous problem with normality.
DISCUSSION
The global popularity of the Invisalign appliance and
the widespread use of Geomagic metrology software in
CAT studies highlighted the relevance of the present

Figure 5. Bland-Altman plot comparing the difference between Geomagic and ClinCheck initial and predicted overjet differences. CC indicates
ClinCheck Geo, Geomagic; I, initial; LOA, level of agreement; OB, overbite; and P, predicted.

Angle Orthodontist, Vol 00, No 00, 0000

OVERBITE AND OVERJET CHANGES WITH INVISALIGN
Figure 6. Normal quantile plot of overbite measure difference.
study. The findings indicated that the differences in the
initial and predicted OB and OJ values provided by
Invisalign’s ClinCheck software facility were consistent
with the corresponding differences from the Geomagic
metrology software.
A sample of patients with reduced OB or anterior
open bite was chosen for the study presented here,
as one of the proposed strengths of CAT over fixed
appliance therapy is its effectiveness in deepening a
reduced OB anteriorly.20 Exact agreement with the
specific numbers involved was not sought in the pre-
sent study, as it was uncertain how Align Technology
measures OB and OJ. However, consistency in the
changes of both traits between initial and predicted
Figure 7. Normal quantile plot of overjet measure difference.
5
Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023
measurements via ClinCheck and Geomagic were
accepted as validation of the numerical data provided
by Align Technology. Since recent studies have indi-
cated problems with some measurements provided by
Align regarding mesiodistal tooth size measurements
and mesiodistal tooth uprighting, it was encouraging
that the present study indicated acceptability of the
data regarding OB and OJ changes provided by
ClinCheck.15,16
The findings suggested that the algorithms used by
Align Technology for their OJ- and, particularly, OB-
related data were similar to that observed via the
methodology used with the Geomagic software in the
present study. Further investigation and information
Angle Orthodontist, Vol 00, No 00, 0000
6 MEADE, BLUNDELL, WEIR
from Align Technology, however, are required to con-
firm this. The data from this investigation, neverthe-
less, can provide orthodontists with reassurance
regarding the accuracy of the numerical information
related to OB and OJ changes provided by Clin-
Check. It will also enable researchers to use these
data in future studies, thus facilitating the reduction
of time-consuming and expensive metrological pro-
cesses in some investigations.
A limitation of the present study was that the find-
ings may not be applicable to patients with an initial
presentation of very deep OB. Also, the study did not
validate additional numerical data provided in the Clin-
Check facility. A strength of the investigation was the
excellent intra- and interexaminer reliability in the
Geomagic measurements. An additional strength was
the use of the Bland-Altman analysis to compare the
two methodologies for changes in OB and OJ mea-
surements. The analysis provided a rigorous, visual,
easy-to-interpret estimation of the agreement or reli-
ability between two measurements of the same object
and is superior to the use of correlation coefficients
and t tests in this regard.21,22
Further investigation, however, is necessary to
determine why two points fell outside the lower and
upper limits of agreement for OB and three points fell
outside the lower and upper limits of agreement for
OJ. Future research is also required to determine the
accuracy and validity of the additional numerical data
provided by Align Technology’s ClinCheck facility and
the numerical data by other companies’ DTP interface
facilities.
CONCLUSIONS
• The predicted changes in OB and OJ during treat-
ment with the Invisalign appliance as reported by
Align Technology are consistent with the changes in
OB and OJ reported by direct measurement using
the gold standard Geomagic metrology software
system.
• Clinicians and researchers can be confident that mea-
surement data provided by Invisalign’s ClinCheck dig-
ital treatment-planning facility concerning OB and OJ
changes from the initial to the predicted treatment out-
come are valid.
• Further research is required to determine the
validity of additional numerical data provided by
Invisalign’s ClinCheck facility and the numerical
data provided by other CAT providers’ DTP inter-
face facilities.
ACKNOWLEDGMENTS
The authors acknowledge the support provided by the
Australian Society of Orthodontists Foundation for Research
Angle Orthodontist, Vol 00, No 00, 0000
and Education and the University of Adelaide Kwok Paul
Lee bequest. The funding bodies did not have any role in the
study design, collection, analysis, interpretation, or writing of
the manuscript.
REFERENCES
1. Meade MJ, Weir T. A survey of orthodontic clear aligner
Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023
practices among orthodontists. Am J Orthod Dentofacial
Orthop. 2022;162:e302–e311.
2. Abu-Arqub S, Ahmida A, Da Cunha Godoy L, Kuo CL,
Upadhyay M, Yadav S. Insight into clear aligner therapy pro-
tocols and preferences among members of the American
Association of Orthodontists in the United States and Can-
ada. Angle Orthod. 2023;93:417–426.
3. Meade MJ, Dreyer CW. A content analysis of orthodontic
treatment information contained within the websites of
general dental practices. J Consum Health Internet. 2022;
26:396–409.
4. Arun M, Usman Q, Johal A. Orthodontic treatment modali-
ties: a qualitative assessment of Internet information. J
Orthod. 2017;44:82–89.
5. Meade MJ, Ng E, Weir T. Digital treatment planning and
clear aligner therapy: a retrospective cohort study [published
online ahead of print April 1, 2023]. J Orthod. doi:10.1177/
14653125231166015
6. Weir T. The application of 3D metrology software in the
quantitative and qualitative assessment of aligner treatment
outcomes. Austral Orthod J. 2021;37:100–108.
7. Blundell HL, Weir T, Kerr B, Freer E. Predictability of over-
bite control with the Invisalign appliance. Am J Orthod Den-
tofacial Orthop. 2021;160:725–731.
8. Bowman E, Bowman P, Weir T, Dreyer C, Meade MJ.
Occlusal contacts and treatment with the Invisalign® appli-
ance: a retrospective analysis of predicted versus achieved
outcomes. Angle Orthod. 2023;93:275–281.
9. Goh S, Dreyer C, Weir T. The predictability of the mandibu-
lar curve of Spee leveling with the Invisalign appliance. Am
J Orthod Dentofacial Orthop. 2022;162:193–200.
10. Houle JP, Piedade L, Todescan R Jr, Pinheiro FH. The pre-
dictability of transverse changes with Invisalign. Angle
Orthod. 2017;87:19–24.
11. Maree A, Kerr B, Weir T, Freer E. Clinical expression of
programmed rotation and uprighting of bilateral winged
maxillary central incisors with the Invisalign appliance: a
retrospective study. Am J Orthod Dentofacial Orthop.
2022;161:74–83.
12. Bowman E, Bowman P, Weir T, Dreyer CW, Meade MJ.
Evaluation of the predicted vs. achieved occlusal out-
comes with the Invisalign® appliance: a retrospective
investigation of adult patients. Int Orthod. 2023;21:
100746.
13. Adel SM, Vaid NR, El-Harouni N, Kassem H, Zaher AR. Digital
model superimpositions: are different software algorithms
equally accurate in quantifying linear tooth movements? BMC
Oral Health. 2022;22:1–2.
14. Adel SM, Vaid NR, El-Harouni N, Kassem H, Zaher AR. Tip,
torque & rotations: how accurately do digital superimposition
software packages quantify tooth movement? Prog Orthod.
2022;23:8.
OVERBITE AND OVERJET CHANGES WITH INVISALIGN
15. Shailendran A, Weir T, Freer E, Kerr B. Accuracy and reliability
of tooth widths and Bolton ratios measured by ClinCheck Pro.
Am J Orthod Dentofacial Orthop. 2022;161:65–73.
16. Smith JM, Weir T, Kaang A, Farella M. Predictability of lower
incisor tip using clear aligner therapy. Prog Orthod. 2022;
23:37.
17. Blundell H, Weir T, Byrne G. Predictability of anterior
open bite treatment with Invisalign®. Am J Orthod Dento-
facial Orthop, In press. https://doi.org/10.1016/j.ajodo.
2023.04.017
18. Bland JM, Altman D. Statistical methods for assessing
agreement between two methods of clinical measurement.
Lancet. 1986;327:307–310.
7
19. Datta D. blandr: a Bland-Altman Method Comparison pack-
age for R. (Zenodo. https://doi.org/10.5281/zenodo.824514,
https://github.com/deepankardatta/blandr, 2017). Accessed
April 2, 2023.
20. Harris K, Ojima K, Dan C, et al. Evaluation of open bite closure
using clear aligners: a retrospective study. Prog Orthod. 2020;
21:1–9.
21. Donatelli RE, Lee SJ. How to report reliability in orthodontic
research: Part 1. Am J Orthod Dentofacial Orthop. 2013;144:
Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/doi/10.2319/041323-269.1/3254393/10.2319_041323-269.1.pdf by Mexico user on 10 September 2023
156–161.
22. Donatelli RE, Park JA, Alghamdi YM, Pandis N, Lee SJ.
Assessment of reliability in orthodontic literature: a meta-
epidemiological study. Angle Orthod. 2022;92:409–414.
Angle Orthodontist, Vol 00, No 00, 0000