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
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
Addressing limitations of clear aligner years of treatment. As Buzz Behrents cautioned,
treatment compliance is the single most important factor in
treatment success.
The advent of using a series of clear aligners
Cooperation in wearing aligners differs from
came at the turn of the 21st century, despite the
that of fixed braces in that wires and brackets
basis for this concept originating over 55 years
cannot be taken off and disregarded by the
earlier.1 Although, the original fanfare of plastic
patient, so the treatment might proceed toward
aligners equitably replacing traditional metal
at least “straighter” teeth. In contrast, if aligners
braces quickly tarnished as early adopters
are not worn as prescribed, the patient receives
became painfully aware of limitations of the
no result. Consequently, an alternative track for
concept.2–9 Some practitioners vacated, some
the non-compliant patient must be a part of
vacillated, and others simply dug-in to doggedly
informed consent.
invent ways to improve this innovation. Patients
The introduction of so-called Compliance
desire “braceless” correction of their smiles10 and
Indicators for the Invisaligns (Align Technology,
thus far, the efforts to give them what they want
San Jose, CA) product was evaluated during testing
has led to continual advances and increasing
of their Teen product (targeted for the audience
number of applications and adjuncts for aligners
with the highest concerns for adherence to wear).
in orthodontics.11–23
The soluble, color-fading dots were found to rea-
sonably demonstrate if patients had been con-
Compliance, consequences, and quality of sistently wearing their aligners.24 If used as a
life with clear aligners “policing” device, however, much like embedded
timers in headgears or functional appliances, their
If treatment with aligners was to be seen as
effectiveness in actually eliciting cooperation is still
completely successful, it was not enough to
in question.24 More importantly, compliance by
occasionally straighten some teeth just in the
orthodontic patients with either braces or plastic is,
on average, favorable and comparable.25 Non-
Kalamazoo Orthodontics, Portage, MI; Adjunct Associate
compliant patients likely suffer consequences of
Professor, Saint Louis University, Saint Louis, MO; Instructor,
The University of Michigan, Ann Arbor, MI; Assistant Clinical prolonged or compromised results no matter the
Professor, Case Western Reserve University, Cleveland, OH; Visiting treatment method chosen.
Clinical Lecturer, Seton Hill University, Greensburg, PA In terms of adverse effects, although there are
Address correspondence to S. Jay Bowman, DMD, MSD, still concerns for decalcification, gingivitis, root
Kalamazoo Orthodontics, 1314 West Milham Ave, Portage, MI.
E-mail: info@kalamazooorthodontics.com
resorption, etc., with either fixed braces or
removable aligners, the oral hygiene advantage
& 2017 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 for removable appliances is significant; however,
http://dx.doi.org/10.1053/j.sodo.2016.10.005 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. material and its conformation from the incisal
All in all, it was not surprising that the quality-of- edge to the gingival margin of individual teeth,
life satisfaction of teen aligner patients was found combined with the necessary duration of forces
to be quite high.25 applied to specific teeth, can be problematic. It
seems there must be a compromise between
heavier forces from thicker or less pliable plastic
Aligner tracking
versus thinner or more resilient materials.27,28 In
A common concern running consistently any event, some tooth movements (extrusion,
throughout the history of aligner treatments has torque, and rotations) especially for certain teeth
been that of teeth not following the predicted or (maxillary laterals and cuspids) have been clearly
desired movement. This is despite the fact that the demonstrated to be less predictable and require
forces and moments produced with plastic are extra attention.1–3,11–13,29–32 These types of con-
comparable to those generated with fixed braces.26 cerns led directly to the creation of bonded
For instance, Chisari et al.13 found that just 57% of composite attachments with the intent to
the tooth movement programmed for a single increase the surface area for plastic aligners to
incisor was actually realized in a period of an 8- “grip” onto teeth.
week investigation. In addition, researchers from More importantly, the design of the sequence
the University of Illinois11 reported only a 41% and velocity of the movement of teeth during
mean accuracy of predicted tooth movement. The treatment requires the greatest consideration.
reasons for these frustrations are multi-factorial Sequential or simultaneous tooth movement
and require a variety of responses to resolve. For plans are desirable in different situations. Simply
example, specific teeth oft times do not remain expecting teeth to move from start to a finished
seated within the confines of the plastic aligner occlusion without a specific plan in-between for
trays as treatment progresses. This may produce an how these teeth will overcome obstacles (i.e.,
air gap between tooth and plastic termed “lag” or collisions, contact points, occlusal and muscular
“tracking error.” Strategies to reduce “tracking forces, insufficient force, or contacts from the
errors” will be described below. plastic) is unrealistic at best.9
Rohit Sachdeva has described the process of One of the earliest adjuncts to help seat aligner
orthodontic finishing as “reducing the errors that trays, attempt to maintain “tracking,” and increase
have accumulated during treatment.” These occlusal forces to elicit tooth movement was the
errors can crop up quickly during the sequence introduction of aligner “chewies” (Chewies Aligner
of aligners, resulting in a loss of tracking and Tray Seaters, Dentsply Raintree Essix, York,
treatment “running off the rails.” These errors PA).15,19 These plastic “cotton rolls” are prescribed
may include those of diagnosis and treatment for patients to use at least the first few days after
planning, but with aligners these accrue at the changing to each new pair of aligners. Like the
outset. They include issues with impression tak- concept of a tooth positioner, the patient places
ing, laboratory scanning of those impressions, the device in a site where teeth are not tracking (i.
tolerances in the creation of laboratory models e., a visible “air” gap is seen between the occlusal or
(poured or printed), tolerances in the process of incisal of a tooth and the aligner). The patient then
the molding of plastic over said models, limi- bites and holds onto the chewies repeatedly, over a
tations of the plastic materials themselves, and, of few minutes of time daily, with their aligners in
course, inconsistent compliance. place.15,19 The intent is to help seat the aligner on
Much like issues in manufacturing of metal the teeth that are not tracking, slightly intrude the
wires and braces, there are tolerances permitted teeth adjacent to a tooth in question, and the
in fabrication that may limit the accuracy of tooth added perturbations may help to accelerate the
movement. The same situation occurs in molding remodeling in that site to stimulate the tooth to
plastic trays, especially when “simulated/pre- move as prescribed.
dicted tooth movements” are involved. In addi-
tion, thin plastic may mold around the undercuts
Lack of space
and interproximal spaces between teeth but
might provide insufficient force to achieve the Crowded dentitions offer only two options for
desired tooth movement. The flexibility of the resolution: create more space (expand) or
 Clear aligners 67

reduce tooth mass (IPR or extraction). Expan- rotation), tipping (bodily movement), and ensur-
sion implies either development or growth of ing interproximal contacts are created at the
new bone in the buccal alveolus. This may end.35–38,44,45 The application of intramaxillary
potentially position teeth into less stable locations or intramandibular elastics to miniscrews,41–43
due to change in equilibrium in the facial mus- intermaxillary elastics, and the increase in size
culature and an associated potential loss of bone and type of composite attachments may be
as teeth are pushed beyond the envelope of the needed to increase predictability.16
alveolus. Certainly, some modicum of expansion Predictable sequencing of space closure or
appears to be tolerable or at least “retainable.” pushing individual teeth into alignment for any
Unfortunately, aligners tend to expand a most of the previous scenarios may be best handled in
unstable site: the mandibular intercanine small segments of tooth movement.16,20,23 In
dimension.33 IPR to reduce the dimensions of other words, to control anchorage in small
teeth to provide for their accommodation within increments, teeth adjacent to a specific tooth that
the arch perimeter is useful, but should be is out of position are prescribed to be held in
limited in scope. Extractions are a time-tested, place (no movement) until the irregular one is
evidence-based approach to resolving significant moved to place and so on. This detailed
arch length discrepancies; however, the results sequencing of small parts of a treatment plan are
with aligners have been unpredictable. These intended to reducing tracking errors that are
more complex cases often benefit from adjuncts sometimes experienced during simultaneous
such as elastics, miniscrew anchorage, or even the movements of large numbers of teeth.
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
Rotations
prescribe the unraveling of anterior crowding
with aligners seems such a simple procedure. It seems quite obvious that attempting to rotate
Without the creation of space, the “binding” some teeth with plastic is unlikely to occur due to
collisions or contacts between irregular incisors their anatomy.7 For example, expecting to
will prevent movement. As noted earlier, the reliably rotate a “round” premolar seems futile
options to solve this are obvious and they can be unless a “handle” is placed on it to increase its
combined (mild expansion þ mild IPR; extrac- profile asymmetrically. Molded composite
tion þ IPR). attachments46,47 have increased the predict-
Selecting IPR from the outset makes little ability of rotational control to some degree.48,49
sense, unless the original discrepancy is quite But, the simple application of a prominent
minor. That leaves the application of some handle, of even a specific engineered design,
degree of expansion (labially and laterally). cannot be depended upon without accompany-
Expansion to resolve minor crowding may be as ing proper treatment planning.
simple as prescribing the opening of “visible” The most unpredictable teeth to achieve
space (40.2 mm) between specified teeth. Then rotation for in the esthetic zone are the maxillary
reasonable amounts of IPR could be performed laterals and cuspids11; despite the use of
more safely. Some perform this structural seemingly enormous attachments. Rotating
reduction chairside with “lightning strips or these teeth appears to require the most
disks.” Others provide abrasive strips to patients attention to detailed treatment sequencing.15
with prescribed directions to “floss” the strips Consider the typical position of a maxillary
between contact points to create small amounts lateral incisor often accompanying a Class II
of space. Once space is achieved, then more Division 2 malocclusion. Simply prescribing that
predictable correction of rotations and labiolin- this tooth be “straight” at the end of aligner
gual discrepancies can be accomplished. Any treatment is absurd. Space must first be created
small residual space that remains can be easily or this tooth will simply not move. This may be
closed with the aligners as treatment progresses. accomplished by “expansion” laterally, but also
If extractions are chosen, then an entirely arch perimeter may be increased as lingual root
different group of concerns must be addressed torque is applied to often “rabbited” central
from control of anchorage, torque (root 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 Edward’s supracrestal fiberotomy for significantly
the incisor can be started until there is room. rotated teeth that you do not want to return to
The shape, size, and the position of the lateral their original position (i.e., lateral incisors in
incisor between two larger neighboring teeth Class II Division 2).
preclude much contact with plastic. This is fur-
ther compromised if there is a desire to extrude
Torque and root angulation
the lateral and/or intrude the central incisors.
There is simply insufficient retention of plastic Control of root movement with aligners has been
stretched over the blade-shaped lateral. Con- an unfailingly constant concern.7,51,52 Rotation of
sequently, a variety of attachments have been roots (torque), bodily tooth movement, and root
designed and modified for use on laterals with paralleling have been deemed to be limitations of
varying degrees of success.48 Unless combined applying relatively “loose” forces with plastic.
with the prerequisite creation of space, the Fixed braces have the advantage of a more
dimensions or design of an attachment are intimate junction between the forces generated
pointless. In fact, the iatrogenic effect of by the deformation of wires bound in brackets
applying these forces without space can actually bonded directly to the teeth.
produce more intrusion, squeezing the tooth Plastic aligners, despite often covering the
apically; thereby, increasing tracking error. majority of surface area of teeth, still do not have
More predictable has been the introduction of the same connection; therefore, the crown of the
adjunctive forces from orthodontic elastics as tooth may slip away from the plastic. Accordingly,
described below. to alter the angle of roots (moving them some
Expecting a tooth to be rotated into an ideal distance through bone) is much more difficult
prescribed position, using flexible plastic (with than simple crown tipping. Complicate this with
inherent errors or limits in tolerances), without the flexibility of plastic, including the differential
asking for “over-rotation” also seems dubious. For in resilience and force levels from the gingival
instance, it is probably necessary to prescribe margin to the occlusal of the aligners, and cre-
21–31 of “over-rotation” to ever be able to simply ating rotational couples for roots become diffi-
reach “ideal.” Besides, over-correction has been a cult. If simultaneous movements of crown
time-tested tenet in orthodontics. rotation, intrusion, extrusion, and unresolved
Another option is to use detailing pliers (The crowding are added to the mix, predictability can
Vertical, Clear Collection, Hu-Friedy, Chicago, be problematic.
IL)15,50 to produce indentations into the plastic The application of torque, specifically for
to create accented rotational couples (Fig. 1). maxillary anterior teeth, was identified early in
Finally, just because the tooth was moved to the aligner history as unpredictable.12,32,53 As a result,
desired spot does not guarantee it will remain. most changes noted in the angle of incisors
For instance, it may be advisable to consider an occurred due to “flaring,” “rounding-out the arch,”
 Clear aligners 69

using The Horizontal pliers (Clear Collection,

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
Figure 2. Torque ridge indentations to increase the plastic incisally and increase tracking error.52
force applied to the crown to enhance a rotational Keeping the trays seated onto the incisor crowns
couple with intent to change the angulation of a tooth. using some programmed intrusion may improve
These ridges can be prescribed in some commercial the response. Finally, do not ignore the
appliances such as Invisaligns or added using The
unintended posterior effects from anterior
Horizontal pliers (Clear Collection, Hu-Friedy, Chi-
cago, IL).15,50 torque. Loss of posterior anchorage seen with
mesial tipping and intrusion of the mesial
marginal ridge of molars may be attendant to
or facial tipping as crowding was resolved using anterior torque expression.16
expansive pushing forces. Unintended excess What is so important about anterior torque?
overjet or bimaxillary protrusion may result. For More attention than ever is being paid to proper
example, the Class II Division 2 malocclusion seems coupling of upper and lower anterior teeth as the
an easy fix if you simply tip the upper central population of adult orthodontic patients has
incisors labially. Unfortunately, the resulting overjet increased. The development of crowding, coin-
accompanying a straighter “social six” is not exactly cident with deep overbites, is often associated
what most patients have in mind. with “upright incisors” (obtuse interincisal angle)
The addition of so-called “torque ridges” to and the constricted envelope of anterior func-
enhance forces for lingual root torque (limiting tion. The long-term consequence may be sub-
labial crown tipping) was first evaluated during stantial loss of tooth structure from a
the Invisalign Teen Research project.25 These combination of functional and dysfunctional
ridges were added to the plastic at the gingival wear. Mix-in any unidentified Bolton tooth-size
margin on the labial and at the incisal edge of the discrepancies (e.g., small maxillary lateral inci-
lingual to generate a rotational couple to tip sors), acidic diet, or gastrointestinal reflex dis-
roots palatally (and vice versa if labial root torque ease, and the damage to teeth can be dramatic.
was desired). These ridges can also be added Consequently, it may not be simply enough to
individually anywhere along the aligner tray 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 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
Figure 4. The American Board of Orthodontics to be moved. Once again, the knee-jerk reaction
determined that the most common error noted in was to increase the size and shape of composite
case reports failing the ABO examination were attachments to attempt to urge teeth occlusally
inappropriate buccolingual inclination or torque of with bigger handles for the plastic to grip
posterior teeth.54 Attention to detail is critical in all onto.46,47,61 In situations where extrusion was still
aspects of preparing virtual set-ups (e.g., adding buccal
root torque). not seen, the concept of aligners itself was
blamed for the “lag” without thinking through
the limitations and finding solutions.
satisfy patient’s esthetic requests. Informed If the intent is to extrude an incisor, then
consent begs proper diagnosis and treatment certainly adequate retention of the plastic is
planning to address possible functional concerns. required to produce the extrusive force. We
Addressing root angulation or torque is not cannot expect a blade-shaped tooth to track
limited to only anterior teeth. The American occlusally as if magically attracted to plastic above
Board of Orthodontics described that the most it. But, is just a more prominent attachment
common error found in case reports that failed simply enough?
their examination was, in fact, insufficient pos- Tight interproximal contacts or significant
terior buccolingual inclination (posterior tor- collisions (even without overlap or crowding) can
que),54,55 a concern shared in other reports.56–59 stop extrusion; therefore, adequate space must
Unless the angle of posterior teeth is specifically be produced prior to attempting extrusion. This
addressed in the virtual setup, an excessive curve is especially important when considering the
of Wilson, prominent palatal cusps of uppers, shape of teeth adjacent to one that is to be
improper posterior intercuspation with inap- “pulled-up.” Incisors or canines are often nar-
propriate posterior overjet may result (Fig. 4).57 rower gingivally and taper to a wider dimension
Marshall et al.56 advised, “For proper occlusion, incisally. In those instances, extrusion is an
there should be no significant difference obvious non-starter without space creation.
between the heights of the buccal and lingual Finally, the application of root tip or torque
cusps of molars and premolars.” along with labiolingual positioning also play
Attention to detail in setups by evaluating the intimate roles in extrusion. Sequential tooth
posterior teeth from the lingual view can assist in movement to achieve the desired vertical change
correcting these errors. In addition, increasing is much more complex than simply communi-
posterior collisions during the completion of cating “an order” with a lab tech to just pull the
treatments can significantly reduce the iatrogenic tooth occlusally.
creation of posterior open bites from “passive
posterior intrusion” that can occur
Adjunctive forces
by simply wearing plastic trays long-term.60 Recent
changes in some proprietary software have The addition of adjunctive forces to enhance
permitted orthodontists to specifically address clear aligners is not a new idea.6 For example, the
these issues with their own individual application of orthodontic elastics to enhance or
manipulation of tooth movement in virtual setups. facilitate various biomechanics was the earliest
and most obvious addition. But, attempting to
improve aligner “tracking” and reduce the so-
Extrusion
called “lag” for certain teeth has been the most
Asking for extrusion where occlusal surfaces of perpetual dilemma affecting predictable results.
teeth are “capped” with plastic (without 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- stretched across the occlusal surface of the seated
ing a solid final occlusion, a combination of clear aligner to attach to buttons and/or notches
bonded buttons and elastics can also be used with cut into the tray on opposite sides. The gingival
clear aligners. In these scenarios, buttons bonded margin of the aligner plastic must be relieved to
on the buccal surfaces of posterior teeth can be avoid the buttons so as to permit the tray to seat
used to apply “triangle, box, or up-and-down” fully (Figs. 5 and 6).
elastics to seat teeth into the aligners and into the Intrusion of a segment of teeth can also be
final occlusion prescribed in the setup.15,62 supported using elastics supported by miniscrew
Therefore, the application of orthodontic elas- anchorage. The possibilities include applying the
tics that are connected to the aligner plastic, orthodontic elastics or chain from buccal and/or
bonded buttons on teeth, or to miniscrew palatal elastics to buttons bonded to teeth (while
anchors have increased the variety of achievable relieving plastic from the trays to avoid those
movements possible. 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
Bootstrapping for predictability
molars (for hypererupted posteriors). Ortho-
The predictability of single tooth extrusion and/ dontic elastics from those buttons are stretched
or rotation can be enhanced using orthodontic to miniscrews inserted interradicularly apical to
elastics in a so-called “bootstrap” arrangement.63 the teeth to be intruded.15
Bootstrap mechanics involve placing bonded Posterior intrusion to enhance the closure of
buttons at the gingival margin on the facial, anterior open bites is another option with elastics
lingual, or both surfaces of a tooth that is and miniscrews. Sequential intrusion of posterior
lagging.15,62 An orthodontic elastic is then 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 Other options for improving the predictability
reinforced with bootstrap elastics. In this sce- of skeletal correction have included “pre-cursor”
nario, elastics are stretched across the occlusal of adjuncts used prior to beginning clear aligners.
seated aligners from miniscrews to buttons, These have included the use of the Carrière arm
notches in trays, or to another miniscrew in bone (Carrière Distalizer, Ortho Organizers, Henry
on the other side of the alveolus.15 Schein, Melville, NY) to hold Class II elastics to
distalize posterior segments14,67,68 or typical,
stand-alone distalizers, such as the Pendulum or
Skeletal discrepancies
Distal Jet. Any of these devices may be supple-
Addressing skeletal discrepancies were originally mented with miniscrew anchorage to avoid
seen to be an anathema to be avoided with reciprocal adverse effects.
aligners.3,4 Only limited changes in over or For example, the Horseshoe Jet (Specialty
underjet were attempted with aligners, while Labs, Atlanta, GA), is a laboratory modification of
expecting little if any anteroposterior correc- the Distal Jet (American Orthodontics, Sheboy-
tion.64,65 Later, maxillary posterior distalization gan, WI), supported by miniscrews. These
was attempted, but without consideration of appliances are used to produce molar distaliza-
anchorage concerns. This led to the application tion14,69–72 prior to initiating clear aligner
of intermaxillary Class II elastics to make-shift treatment. After posterior teeth are moved into a
notches cut into the plastic trays, then to buttons Class I occlusion, clear aligners are prescribed to
bonded to the trays, and finally to buttons hold the molars in place while the remaining
directly bonded to the teeth (or some combi- anterior teeth are retracted; just as they would be
nation of those options).20 Once elastics were with fixed braces. This retraction is often sup-
found to improve the chance of orthodontic ported with Class II elastics or even Class I
movement for Class IIs, then employing intramaxillary elastics from miniscrews to reduce
sequential molar distalization supported by the possibility of anchorage loss.14,50,71
elastics20 was a logical strategy that has proven Finally, the introduction of a variety of
successful with aligners.66 Currently, elastics on methods intended to accelerate the rate of tooth
aligners have found their way into correcting movement have arisen in recent years. For
Class IIs, IIIs, and open bites; especially for example, the use of a device to produce micro-
growing individuals. vibrations or perturbations (AcceleDent,
 Clear aligners 73

OrthoAccel, Bellaire, TX) with the intent of 7. Rossini G, Parrini S, Castroflorio T, Deregibus A,
Debernardi CL. Efficacy of clear aligners in controlling
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