International Orthodontics 2023; 21: 100750

Websites:
www.em-consulte.com
www.sciencedirect.com

Systematic Review
Is maxillary arch expansion with Invisalign®
efficient and predictable? A systematic
review

Mathilde Bouchant 1,2, Aline Saade 3, Marwan El Helou 1,2

Available online: 27 March 2023 1. Université de Clermont Auvergne, CROC, 63000 Clermont-Ferrand, France
2. Service d'odontologie, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
3. Private Practice, Abu Dhabi, United Arab Emirates

Correspondence:
Marwan El Helou, Université de Clermont Auvergne, CROC, 49, boulevard François-
Mitterrand, 63000 Clermont-Ferrand, France.
marwan.el.helou@hotmail.com

Keywords Summary
Invisalign®
Clear aligners Background > The main objective of this review is to assess the effectiveness and predictability of
Transverse expansion the transverse expansion movement performed by Invisalign®. The secondary objectives are to
Effectiveness determine whether the expansion is of a dentoalveolar or skeletal nature, and to locate the areas
Predictability of expansion on the dental arch.
Methods > Two investigators used the PubMed database to search for articles related to the
subject. After using a research equation, specific inclusion and exclusion criteria were applied and
the final selection of articles was done after being read in full. The ROBINS-I tool for non-
randomized studies was applied to assess risk of bias in the results of each included study.
Results > After reading the articles in full, 12 articles were included. Regarding effectiveness, most
studies showed an increase in all measured interdental distances, with a maximum expansion at
the premolar level. As for predictability, significant differences were found between post-treat-
ment models and Clincheck® models, making it generally weak. Concerning the nature and areas
of expansion, increase of arch width was due to buccal tipping of the crowns following a
decreasing gradient from anterior to posterior.
Conclusions > Invisalign® treatment is effective in achieving a maxillary transverse expansion.
However, this expansion is mainly dentoalveolar, with a facial crown tipping of the posterior teeth.
Clincheck® software tends to overestimate the expansion movement when compared to the
clinical outcome, therefore the predictability of movement is low.

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https://doi.org/10.1016/j.ortho.2023.100750
© 2023 CEO. Published by Elsevier Masson SAS. All rights reserved.
M. Bouchant, A. Saade, M. El Helou

Systematic Review
Introduction TABLE I
A posterior crossbite occurs when the buccal cusps of the maxil- Eligibility criteria
lary posterior teeth engage with the pits of the mandibular
posterior teeth [1]. Depending on the aetiology and the age of Inclusion criteria Exclusion criteria
the patient, treatment of this malocclusion consists of a den- Clinical prospective or retrospective Observational studies
toalveolar and/or skeletal expansion [2]. studies on humans
In recent years, orthodontics has witnessed a significant shift of Articles published during the last 15 In vitro studies
adult treatments from conventional fixed brackets to clear years
aligners. One example is Invisalign® with its Clincheck® plan- Written in French or English Pre-clinical studies
ning software that allow individual tooth movement planning.
Treating the transverse dimension in Case reports
Patients are given a set of aligners, to be changed every other orthodontics
week, and worn 22 hours a day. Tooth movement and retention
Involving patients of all ages treated Patients treated with
of aligners are allowed by composite resin attachments bonded with clear aligners fixed appliances, stripping
to the buccal surfaces [3]. A study showed that more adult and/or extractions
patients are turning to aligner treatment because they consider
it more aesthetic than conventional brackets and more comfort-
able than lingual orthodontics [4].
The first systematic review aiming to study treatment effects of
aligners was published in 2005. However, it could not draw any
conclusions regarding the effectiveness of the Invisalign® sys- Information sources and selection process
tem on tooth movement [5]. Since then, many studies investi- The studies included in this review were selected by two inves-
gated the capacity of clear aligners to achieve various dental tigators from the PubMed electronic database between June
movements such as distalisation, intrusion, extrusion, levelling 2022 and January 2023.
the curve of Spee, aligning the teeth and rotational control [6]. The following search equation was used in the PubMed search
Only a few were interested to study the transverse expansion of bar:
the arches. As a matter of fact, a recent systematic review "Invisalign'' AND (Transverse OR Expansion OR Expand* OR Arch).
investigated the accuracy and efficiency of dental movements The two investigators searched separately for articles on
with Invisalign®, one of the studied variables was the transver- PubMed with the equation cited above, read the title and then
sal movement in mild and severe crowding cases but the the abstract. They were not blinded to the location of the study,
measurements of intercanine distance and faciolingual inclina- names of the authors or results obtained. Articles that met the
tion were only made in the mandibular arch. No information eligibility criteria were then read in full after which the final
was mentioned about the ability of the system to correct pos- selection was established by discussion between both
terior crossbite with upper arch expansion [7]. To our knowl- investigators.
edge, no literature review has summarized the current After reading the selected studies in full, the following data
knowledge on the upper transverse expansion allowed by Invis- were extracted and tabulated as follows:

study title;
align® aligners. The main objective of this review is to assess

author(s) and year of publication;
the effectiveness and predictability of the transverse expansion

study design;
movement performed by clear aligners. The secondary objec-

results including measurement of expansion distances, effec-
tives are to determine whether the expansion is of a dentoal-
veolar or skeletal nature, and to locate the areas of expansion on tiveness, and predictability;

conclusions of authors.
the dental arch.

Reporting bias assessment

For each study, The ROBINS-I tool for non-randomized studies
Methods was applied to assess risk of bias [9].
Protocol
To meet the objectives mentioned above, a literature review Results
was carried out following the PRISMA protocol [8]. Study selection
During the first stage, 16 studies were identified from their
titles. After reading the abstracts, two studies were excluded
Eligibility criteria because one was a case report [10], and the other was written in
The inclusion and exclusion criteria are found in table I. Chinese. After reading the full articles, two additional studies

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International Orthodontics 2023; 21: 100750
Figure 1
Flowchart
were excluded. The first did not meet the objectives mentioned
above [11], and the second only dealt with the periodontal
consequences of expansion [12]. Finally, 12 articles [13–24]
were included in this review. The flowchart is shown in figure 1.
Studies characteristics
The included studies were conducted between 2016 and 2021 at
universities. Two studies were prospective [18,24], and the rest
were retrospective [13–17,19–23]. All studies were carried out
on patients with permanent dentition treated with Invisalign®
but two were on Invisalign First® in the mixed dentition [13,24].
Evaluation methods
Comparison using digital models
In all the included studies, the authors compared different
digital models:

pre-treatment model: maxillary arch model before the Invis-
align® treatment;

Clincheck® model: final clinical situation model planned by
the Clincheck® software;
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Systematic Review

post-treatment model: actual clinical situation model obtained
after treatment.
Pre- and post-treatment models were obtained with the iTero®
intraoral scanner for 6 studies, by digital conversion of a plaster
model for two studies and were not specified for one study.
Linear and angular measurements were then taken to be com-
pared between the different models.
The palatal rugae served as a reference for superimposing the
models. Interdental distances in studies made on permanent
dentitions were measured as explained in table II and figure 2.
As for the study by Levrini et al. on Invisalign First®, the
interdental distances of deciduous canines, deciduous molars
and first permanent molars were measured at the level of the
buccal and mesiobuccal cusps, and at the level of the gingival
collars [13].
The faciolingual inclination of first permanent molars was mea-
sured in 6 studies, to differentiate bodily movement from crown
tipping.
M. Bouchant, A. Saade, M. El Helou

Systematic Review
TABLE II
Interdental measurements and reference points.

Measured distances Reference points

ICD = intercanine distance Between the cusp tips of 13 and 23

IPMD = interpremolar distance Between the buccal or palatal cusps
Between the mesiopalatal or distobuccal cusps of
IMD = intermolar distance first molar (M1)
Between the mesiobuccal or distobuccal cusps of
the second molar (M2)
IDDG = interdental distance at the level of Between the gingival collars of canines, premolars,
the gingival collars first and second molars

Figure 2
Maxillary digital models with presentation of measured linear transverse measurements (Lione et al. [18]). Interdental distances at
canines (A); first premolars (B); second premolars (C); MB cusps of M1 (D); DB cusps of M1 (E); MB cusps of M2 (F); DB cusps of M2
(G). Interdental distances at the level of the gingival collar of M1 (H) and M2 (G)

CBCT comparison files to assess changes in the alveolar ridges and transverse move-
In Zhou and Guo's study [19], the authors used pre- and post- ment of the first molar following expansion. The initial torque of the
treatment CBCTs, oriented in a standardized fashion, to compare first molar was measured using root vector analysis. Measurements
them. Linear and angular measurements were performed on both were taken on a cut at M1 level as shown in figure 3.

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Systematic Review
Figure 3
CBCT sections with presentation of the linear and angular measurements taken (Zhou and Guo [19]). BBW: Width of the maxilla at the
most concave points of the buccal basal bone, close to the apices of the first molars; BCPW: width of the maxilla at the level of the
most convex points of the alveolar bone; PACW: distance between the palatal alveolar ridges; BACW: distance between buccal alveolar
ridges; BAW: intermolar distances between buccal root apices; PAW: intermolar distances between the palatal apices of the roots;
PCTW: intermolar distances between the palatal cusps; BCTW: intermolar distances between the buccal cusps; HLA: inclination of the
first molar relative to the palatal plane; UPAW: distance separating the palatal apex from the midsagittal plane

Arch Form evaluation
In the study by Deregibus et al. [20], the shapes of the maxillary
arch, before and after treatment, were superimposed in the
transverse plane (figure 4).
To assess shape change, the authors defined a coronal emer-
gence point for each tooth using GOM Inspect® software.
In occlusal view:

the origin of the coordinates was the contact point between
the central incisors;

the x-axis, defined in the transverse direction, was a straight
line parallel to the line connecting the proximal contact points
between the second premolars and the first molars;

the y-axis was defined in the antero-posterior direction.

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M. Bouchant, A. Saade, M. El Helou

Systematic Review
Figure 4
Representation of the maxillary arch shapes obtained after positioning the coronal emergence points: arch shape at the beginning
(T0) and the end of the treatment (T1) (Deregibus et al. [20])

Summary
Effectiveness models. In permanent dentition, six studies evaluated the effec-
The effectiveness of aligners was assessed by comparing the tiveness of transparent aligners, and two studies in mixed
cross-sectional measures of the pre- and post-treatment dentition. The results are shown in table III.

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Systematic Review
TABLE III
Effectiveness of clear aligners according to the included studies

Study Expansion Tipping Bone width

Morales- Burruezo et al. Increase in all measured interdental distances. Not specified Not specified
[16] Maximum expansion at the IPMD level.
Minimum expansion at the ICD and IM2D
levels
Vidal- Bernárdez Greatest change was at the gingival level of Not specified A CBCT was not made for
et al. [21] premolars (IDDG) ethical reasons
Least change was at the cuspid level of these
same teeth (IPMD and ICD).
(P < 0.00005)
Cretella Lombardo Increase in the transverse dimension at the level Not specified Not specified
et al. [22] of the canine and the first
deciduous molar widths P < 0.038
Lione et al. [24] The greatest increase of maxillary width was Not specified Not specified
detected at the level of the upper first deciduous
molars, followed by the second deciduous
molars and by the deciduous canine. Upper first
molars showed
a greater expansion in the intermolar mesial
width due to a rotation that occurs
around its palatal root (P < 0.001).
Lione et al. [18] Increase in all measured interdental distances Increase in buccal crown tipping for all teeth Not specified
except for the IM2D. except for the second molars.
Maximum expansion at the IPMD level. Increase from the canines to the second
premolars, then a decrease in expansion
posteriorly.
Zhou et Guo [19] Increase in all measured interdental distances. Increase in buccal crown tipping for the Increase in the distance
Maximum expansion at the IPMD level. molars. between the vestibular and
palatal ridges.
No modification at the level
of the
basal bone.

Deregibus et al. [20] Increase in all measured interdental distances. Not specified Not specified
Maximum expansion at the IPMD level.
Levrini et al. [13] Increase in all maxillary interdental distances. Not specified Not specified
Increase in the intermolar angle.
Maximum expansion values for the first
and second deciduous molars.

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M. Bouchant, A. Saade, M. El Helou

Systematic Review
Predictability permanent dentition, nine studies evaluated the predictabil-
The predictability of aligners was evaluated by comparing the ity of Invisalign® clear aligners. The results are shown in
final Clincheck® model and the post-treatment model. In table IV.

TABLE IV
Predictability of clear aligners according to the included studies

Study Predictability of transverse movement (%) Comparison between final Clincheck® model and post
treatment models

Solano-Mendoza et al. [14] Weak. Statistically significant differences found between

interdental transverse
measures.

Vidal-Bernárdez et al. [21] At the gingival and cuspid level, the predictability for All the changes produced were statistically significant
canines was 87.71%, (P-value < 0.00005)
first premolars a result of 84.03%, for second premolars
84.28% and for first molars
87.35%
Tien et al. [23] At the maxilla: 72.2% canines, 78.9% first premolars, Large variability was noted in the accuracy of expansion
81.1% second premolars, 63.5% first molars, and 41.5% with both underexpansion and overexpansion observed
second for all
molars. teeth (excluding second molars)

Riede et al. [15] 45% with the Smartrack® Not found.

material.
Morales-Burruezo et al. [16] 74.8% for canines, 80.3% for first premolars, 81% for Not specified.
second premolars, 79.1% for first molars, 65.2% for
second
molars.
Houle et al. [17] 72.8% Found between all transverse measurements at the
Invisalign® became less precise maxilla.
the more we move posteriorly.
Lione et al. [18] Weak for maxillary canines. Found for intercanine distance
and canine inclination.

Zhou et Guo [19] Not specified Found between all cross- sectional measurements.
Difference between planned and achieved expansion
increases the more we move
posteriorly.

Deregibus et al. [20] Not specified Differences were found in the

canines' measures but were not
clinically important.

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Systematic Review
TABLE V
Nature of expansion and expansion areas according to the collected data

Study Findings

Morales-Burruezo et al. Expansion with aligners were more effective in the premolar area, and less effective in the canine and second molar
[16] areas.

Lione et al. [18] Expansion rate shows a progressive reduction in the canine, premolar and posterior regions, with a greater increase in
the premolars.
Invisalign® could increase the arch width by increasing the crown
tipping of the maxillary teeth following the same decreasing gradient from anterior to posterior as for that of the
interdental distances.

Deregibus et al. Invisalign® Class II treatment leads to an increase in arch width in

[20] molars and premolars.

Houle et al. [17] Greater buccal tipping movement than planned.

Zhou et Guo [19] Invisalign® system could increase the arch width by tipping the posterior teeth.

Riede et al. [15] Rapid palatal expansion prior to Invisalign® should be considered in
patients with a large transverse shift.

Nature and expansion areas
The expansion that was achieved had a dentoalveolar nature.
The maximum tipping of teeth occurred in the premolar area,
while the minimum tipping occurred at the second molar. The
results are presented in table V.
Risk of bias in studies
As all the studies included in this analysis were non-randomized,
the ROBINS-I tool was used to assess their methodological
quality [9]. Two studies were considered to have a low risk
of bias, which made them comparable to well-performed ran-
domized trials, they also happen to be prospective clinical
studies [18,24]. Most of the studies had a moderate risk of bias
[13–15,17,19–23], and only one study had a serious risk of bias
[16]. The results are presented in table VI.
Discussion
Research quality and selection process
Investigators favoured the PubMed database to search for
articles. To limit selection bias, the research was carried out
by two separate operators.
All the included articles in this study were non-randomized
studies (NRS). To determine the risk of bias, we used the
ROBINS-I tool to assess the quality of evidence [9]. This method

TABLE VI
Assessment of risk of bias for expansion outcome using the ROBINS-I Tool

Article reference 13 14 15 16 17 18 19 20 21 22 23 24

Bias due to confounding L L M L L L M M M M M L

Bias in selection of participants into the study M L M M M L M M L L L L

Bias in classification of interventions L L M M M L M L M M L L

Bias due to deviations from intended interventions M L L S L L L M M M M L

Bias due to missing data M M M M L L L M M M L L

Bias in measurement of outcomes L M M S L L M L L M L L

Bias in selection of the reported result L L L L L L L M L M M L

Overall risk of bias M M M S M L M M M M M L

L: low risk; M: moderate risk; S: serious risk of bias; C: critical risk; N: no information.

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M. Bouchant, A. Saade, M. El Helou
revealed that most of the included articles presented a moder-
ate risk of bias, indicating that each study is methodologically
sound for an NRS but cannot be compared to a well-performed
randomized trial. The study by Morales-Burruezo et al. [16] was
rated as having a critical risk of bias and is therefore too
problematic to provide any trustworthy evidence about expan-
sion with Invisalign®. In fact, the authors used intermaxillary
elastics to potentiate the expansion of aligners, which was
considered a methodological bias.
Evaluation methods
The evaluation of the effectiveness and predictability of aligners
in the studies included in this review was conducted by com-
paring digital models that utilized palatal rugae as reference
points. With regards to interdental distances, most studies mea-
sured the transverse distance at the level of the dental cusps and
gingival collars. However, Morales-Burruezo et al. [16] found
gingival measurements unreliable because during Clincheck®
planning, technicians tend to remove the gingiva from the
digital model before the software calculates all the parameters
and protocols, and then randomly reposition it during the final
steps.
Effectiveness
One of the main goals of our review was to evaluate the efficacy
of clear aligners in achieving transverse expansion movement.
The systematic review by Ke et al. carried out in 2018 compared
the effectiveness of clear aligners with conventional fixed treat-
ments. They concluded that both types of devices were effective
in the treatment of malocclusions, but that fixed braces were
more effective when it comes to transverse expansion [25].
However, more studies were necessary because the aligners'
technique was constantly evolving in terms of materials, soft-
ware, and auxiliary devices. In the review by Papadimitriou
et al., the authors conclude that there are no clear evidence-
based recommendations on the indications for the system of
clear aligners, except for the treatment of mild to moderate
malocclusions, in adult patients whose growth has stopped [26].
In addition, a recent study by Haouili et al. found that the
accuracy of movement with Invisalign has improved over the
years, even though the mean accuracy was estimated to be
around 50% [27].
However, treatment with aligners offers significant advantages
in terms of aesthetics, comfort, and hygiene for patients. Fur-
thermore, aligners can be an alternative for patients who refuse
conventional brackets. Additionally, the use of digital models
provides significant advantages in terms of ease of storage,
durability, and transfer [28].
Permanent dentition
In permanent dentition, significant increases were observed in
all intercanine, interpremolar, and inter first molar distances
following treatment with clear aligners. Regarding the perma-
nent second molar, Morales-Burruezo et al. [16] reported a
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Systematic Review
significant post-treatment expansion, while Lione et al. [18]
did not observe any significant changes.
Several factors may have influenced the effectiveness of clear
aligners and introduced biases in the included studies. In six of
the studies conducted in permanent dentition, all patients were
over 18 years old, which eliminated the possibility of any
residual intermaxillary suture growth. However, in the study
by Riede et al. [15], some of the patients included were ado-
lescents, and growth may have contributed to further expan-
sion, potentially affecting the results.
Another important factor to consider is the use of intermaxillary
crossbite elastics, which was included in some of the studies,
such as the one by Morales-Burruezo et al. [16]. The use of these
elastics may have overestimated the expansion achieved with
clear aligners, potentially affecting the results of these studies.
The experience of the practitioner may also have played a role in
the effectiveness of clear aligners. It is possible that practitioners
with extensive experience in using the Invisalign® system may
have planned for overcorrections from the beginning of the
treatment or utilized expansion auxiliaries to enhance its effec-
tiveness. This may have influenced the outcomes observed in
the included studies.
Mixed dentition
In mixed dentition, only two studies were included in this
review. In fact, the Invisalign First® system was launched by
Align Technology very recently, in 2018, so very few studies
have been carried out on the subject.
Levrini et al. found that Invisalign First® was effective in achiev-
ing transverse expansion in cases of mild crowding or limited
maxillary transverse deficit, with a significant increase observed
in all interdental distances, including deciduous canines, decid-
uous molars, and first permanent molars after treatment [13].
However, it is important to note that the average age of the
patients included in this study was 9 years old, which means
that the growth potential at the level of the intermaxillary
suture may have contributed to an overestimation of the align-
ers' effectiveness.
Further studies are needed, especially randomized controlled
clinical trials, comparing Invisalign First® aligners to conven-
tional transverse expansion orthopaedic appliances. Indeed, if
these aligners allow skeletal expansion, it would be necessary
to determine to what extent they could stimulate intermaxillary
suture growth and be used instead of rapid palatal expanders.
Predictability
The second main objective of our review was to assess the
predictability of transverse tooth movement achieved with clear
aligners. Many orthodontists report that 70 to 80% of their
patients require midcourse refinements during treatment,
and in some cases, they need to bond fixed brackets to finish
the case, which is unfavourable for both the patient and the
practitioner. This increases the treatment and chair time,
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requires removal of the Invisalign® system and results in an
outcome different from what was initially presented to the
patient on Clincheck® [11].
In the articles included in this review, predictability was defined
as the percentage of predicted expansion achieved:
Achieved expansion
Predictability ¼ Predicted 100
expansion
Predicted expansion
In four studies [14,16,17,19], there were significant differences
between the results planned on Clincheck® while in three
studies [15,18,20], there were no significant differences.
Results differed regarding the maxillary canines. Riede et al.
[15] found this to be the most predictable area, unlike Lione
et al. [18] and Deregibus et al. [20].
According to Lione et al., particular attention should be given to
the maxillary canines, as a greater amount of change is usually
expected at the anterior level of the arch, in order to obtain
alignment, levelling, and space closure, hence an overcorrection
should be expected [18]. Riede et al. [15] as well as Zhou and
Ghuo [19] found a negative correlation between planned
expansion quantities and bodily expansion: the larger the
planned movement, the less predictable it was.
Furthermore, Castroflori et al. explained that the predictability of
orthodontic tooth movement with Invisalign was limited by
biomechanical factors such as the shape of the attachments
and auxiliaries used during treatment. In addition, the authors
pointed out the importance of the practitioner's expertise and in
particular the understanding of the limitations of the Invisa-
lign® technique to achieve successful treatment outcomes [29].
Systematic Review

the thickness of the alveolar bone, which increases from
anterior to posterior, creating greater resistance to expansion;

a higher masticatory load in the posterior sectors;

greater resistance of the soft tissues of the cheeks in the
posterior region.
The nature of the transverse expansion allowed by transparent
aligners was purely dentoalveolar. The only study that quanti-
fied expansion at the skeletal level found no significant differ-
ence in cross-sectional basal bone measurements. However, an
increase in buccal and palatal interridge distances was observed.
This dentoalveolar expansion was achieved through buccal tip-
ping of the crowns.
To promote body translation movement rather than tipping
movement, Zhou and Guo [19] proposed incorporating palatal
crown torque to the expansion movement. Lione et al. [18] also
included this torque, but they still observed buccal tipping of all
teeth.
Zhou and Guo [19] suggested that practitioners should therefore
decrease the magnitude of expansion for each aligner and add a
compensating torque.
Conclusions
Despite the limitations of the included studies, the following
conclusions can be drawn from the available evidence:

Invisalign® aligners are supposed to be effective in achieving
maxillary transverse expansion;

the expansion obtained is mainly dentoalveolar, with posterior
teeth exhibiting crown tipping;

due to its weak predictability, the Clincheck® software tends

Nature and location of expansion to overestimate the expansion;

The studies included in this review found that the effectiveness
the expansion follows a decreasing gradient moving from

of expansion decreased from the anterior to the posterior anterior to posterior segments and is more noticeable in
region, with a greater increase in the premolar area. Lione premolar areas;
et al. [18] suggested that this was due to the premolars being
more prospective studies and randomized controlled clinical

located on a straight line, resulting in a greater tendency to
expand.
Some possible explanations for the decreased effectiveness of
expansion from the anterior to the posterior region, as sug-
gested in [17,18], are:

the anatomy of the roots of molars, which are more numerous
and voluminous, making their movement more challenging;
trials are necessary to confirm these findings.
Contribution: Mathilde Bouchant: research and writing of the manuscript,
Aline Saade: revised critically the manuscript and participated in
assessment of bias (ROBINS-I tool) and Marwan El Helou: supervisor and
senior author.
Disclosure of interest: The authors declare that they have no competing
interest.

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tome 21 > n82 > Juin 2023