Lombardo et al.

Progress in Orthodontics (2017) 18:35

DOI 10.1186/s40510-017-0190-0

RESEARCH Open Access

Predictability of orthodontic movement

with orthodontic aligners: a retrospective
study
Luca Lombardo1, Angela Arreghini1* , Fabio Ramina1, Luis T. Huanca Ghislanzoni2 and Giuseppe Siciliani1

Abstract
Background: The aim of this study was to evaluate the predictability of F22 aligners (Sweden & Martina, Due
Carrare, Italy) in guiding teeth into the positions planned using digital orthodontic setup.
Methods: Sixteen adult patients (6 males and 10 females, mean age 28 years 7 months) were selected, and a total
of 345 teeth were analysed. Pre-treatment, ideal post-treatment—as planned on digital setup—and real post-
treatment models were analysed using VAM software (Vectra, Canfield Scientific, Fairfield, NJ, USA). Prescribed and
real rotation, mesiodistal tip and vestibulolingual tip were calculated for each tooth and, subsequently, analysed by
tooth type (right and left upper and lower incisors, canines, premolars and molars) to identify the mean error and
accuracy of each type of movement achieved with the aligner with respect to those planned using the setup.
Results: The mean predictability of movements achieved using F22 aligners was 73.6%. Mesiodistal tipping showed the
most predictability, at 82.5% with respect to the ideal; this was followed by vestibulolingual tipping (72.9%) and finally
rotation (66.8%). In particular, mesiodistal tip on the upper molars and lower premolars were achieved with the most
predictability (93.4 and 96.7%, respectively), while rotation on the lower canines was the least efficaciously achieved (54.2%).
Conclusions: Without the use of auxiliaries, orthodontic aligners are unable to achieve programmed movement with 100%
predictability. In particular, although tipping movements were efficaciously achieved, especially at the molars and
premolars, rotation of the lower canines was an extremely unpredictable movement.
Keywords: F22 aligner, Orthodontic movement, Movement accuracy, Predictability

Background simple malocclusion cases such as slight crowding or

Since orthodontic aligners were launched on the market, minor space closure [4]. Over time, however, the range
they have been in growing demand among patients, of malocclusion cases that can be treated by means of
especially adults, thanks to their aesthetic properties and invisible aligners has widened. Clinical research has de-
clinical efficacy [1]. veloped aligner-based solutions for even complex cases
Although the idea of using consecutive clear thermo- involving major rotation of the premolars, upper incisor
plastic appliances to align the teeth was first introduced torque, distalisation and/or extractive space closure [5].
by Kesling in 1946 [2], it was not until Align Technology That being said, there is as yet no consensus as to the
(Santa Clara, CA, USA) launched the Invisalign system predictability of aligner treatment in such large movements;
in 1998 that such appliances were prescribed on a large although the aesthetic impact of aligners has been empha-
scale, thanks to their introduction of CAD/CAM tech- sised [6], few studies have yet been set up to investigate the
nology into Orthodontics [3]. At first, aligners were mar- effective capacity of aligners to achieve complex movements
keted as an alternative to traditional fixed appliances in [7]. Indeed, the majority of articles published on aligner or-
thodontics have been case reports or series, reports on the
use of a particular system, and expert opinions [3, 8, 9].
* Correspondence: angela_arreghini@yahoo.com
1
Postgraduate School of Orthodontics, University of Ferrara, Via Fossato di
Furthermore, studies have concentrated on the market leader,
Mortara, 44100 Ferrara, Italy Invisalign, even though many other competing systems have
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 2 of 12

been developed since Align Technology’s patent expired. day, excepting mealtimes and oral hygiene procedures.
These alternative aligner systems differ from Invisalign in Aligners were replaced every 14 days.
terms of construction material [10], production process, mar- Pre-treatment, ideal post-treatment (according to setup)
gin finishing and STL model precision, but perhaps the most and real post-treatment digital models of the upper and
influential difference is the professionals charged with execut- lower jaws of each patient were analysed. Pre-treatment
ing treatment planning and setup (IT specialists, dental tech- and post-treatment models were acquired using a Trios
nicians or professional orthodontists) [11]. intraoral scanner (3Shape, Copenhagen, Denmark), and
As regards treatment outcomes, Align Technology re- setups were constructed using Orthoanalyzer software
ports that roughly 20–30% of Invisalign patients require (3Shape, Copenhagen, Denmark).
mid-course correction or post-alignment finishing in
order to achieve the results prescribed on the setup [12].
This figure, however, contrasts with that reported by or- Measurement of digital models
thodontists, who indicate that the number of patients Digital models pertaining to each patient were analysed in
who require some unplanned correction or even re- .stl format by a single operator using VAM software (Vectra,
course to fixed orthodontics, is closer to 70–80% [1, 13]. Canfield Scientific, Fairfield, NJ, USA). This enabled the
In fact, Kravitz [14] reported that Invisalign aligners had a identification of anatomical reference points, planes and
mean accuracy of 41% in terms of achieving planned out- axes on the digital models, required, in turn, for calculation
comes, with the most predictable movement being lingual of the angulation, inclination and vestibular prominence of
contraction (47.1%), and the least predictable, extrusion each tooth, as well as linear and angular measurements, for
(29.6%). In a systematic review of the literature, Rossini and example, the intra-arch diameters [16]. Measurement was
Castroflorio confirmed that the most problematic move- based on a method originally involving the identification of
ment for Invisalign was extrusion, followed by rotation [15]. a total of 60 reference points per model (excluding second
However, these authors also emphasised the paucity of molars). However, in this case, we also included the second
reliable literature on the subject, and the aim of this molars in the digital measurements, thereby expanding the
study was therefore to compare planned and achieved number of reference points to 100 per model (Fig. 1).
tipping and rotation in patients using F22 aligners Once the 100 reference points had been marked, their
(Sweden & Martina, Due Carrare, Italy) in order to pro- three-dimensional coordinates were extrapolated and
vide data on their effective clinical predictability. exported, first into a .txt file, and then onto a dedicated
spreadsheet provided with the software. This spreadsheet
enabled extrapolation of the mesiodistal and vestibulo-
Methods lingual tip and rotation (Figs. 2, 3, and 4) of each tooth
Sample selection with respect to a 3D Cartesian grid based on the occlu-
Sixteen adult Caucasian patients (6 males and 10 females, of sal reference plane, which was obtained by means of the
mean age 28 years and 7 months) treated by means of F22 following points: (Fig. 5):
aligners at the University of Ferrara Postgraduate School of
Orthodontics Clinic were retrospectively selected. Inclusion
Reference points at the mediovestibular cusps of
and exclusion criteria are reported in Table 1. Treatment teeth 16 in the maxilla and 46 in the mandible
staging, i.e. the maximum movement planned for each
Reference points at the mediovestibular cusps of
aligner, had been 2° rotation, 2.5° vestibulolingual and mesio- teeth 26 in the maxilla and 36 in the mandible
distal tip, and 0.2-mm linear displacement. No auxiliaries of
The centroid of all occlusal points of the FACC (the
any kind had been used (intermaxillary elastics, buttons, facial axis of the clinical crown) of teeth 15, 14, 12,
chains), although the use of F22 system Grip Points (attach- 11, 21, 22, 24 and 25 in the maxilla and 35, 34, 32,
ments) and anterior and/or posterior stripping was allowed. 31, 41, 42, 44 and 45 in the mandible; canines were
Patients were instructed to wear their aligners for 22 h per excluded from this calculation as their occlusal

Table 1 Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria
• Adult subjects > 18 years with permanent dentition • Systemic pathologies
• Complete dentition, or with 4 missing teeth at the • Ongoing pharmacological treatment able to influence
most (third molars excluded) orthodontic movement (e.g. prostaglandin inhibitors,
• No supernumerary teeth biphosphonates)
• No tooth shape anomalies • Active periodontal disease
• No dental rotation > 35° • Treatments requiring extraction space closure
• No diastems > 5 mm
• Crowding < 5 mm per arch
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 3 of 12

Fig. 1 Positioning of the 100 reference points per arch (Upper jaw)

FACC point is generally outside the occlusal plane ∣prescription ∣ ¼ ∣ideal posttreatment−pretreatment∣
identified by the other teeth.

One month after the 96 arches had been analysed, the

analysis was repeated on 16 randomly selected digital
The absolute value of the imprecision, i.e. the
models (8 upper and 8 lower arches). Dahlberg’s D was difference between ideal and real post-treatment
calculated in order to quantify the measurement error, measurements, to identify the difference between
and Student’s t test for paired data to identify any sys- the actual post-treatment position of each tooth and
tematic error. the programmed movement:

Analysis of mean imprecision

∣imprecision ∣ ¼ ∣ideal posttreatment−real posttreatment∣
The following calculations were made for each type of
movement of each tooth in each patient: Absolute values were used for the prescription and impre-
cision parameters, as the direction of movement (clockwise

The absolute value of the prescription, i.e. the vs. anticlockwise rotation, and lingual vs. vestibular or mesial
difference between ideal post-treatment and vs. distal for the tip) was not taken into consideration. Pre-
pre-treatment measurements, to identify the total scription and imprecision values were grouped into eight
programmed movement: categories (upper and lower incisors, canines, premolars and
molars) and according to the three types of movement
(mesiodistal tip, vestibulolingual tip and rotation).
The different types of tooth (incisors, canines, premolars
and molars) were analysed separately because of the differ-
ent anatomy of the crown and the root (both in shape and
length), which inevitably results in a different response to
the application of orthodontic forces, in particular, in the

Fig. 2 Vestibulolingual tipping: labiolingual inclination of the FACC Fig. 3 Mesiodistal tipping: mesiodistal inclination of the FACC with
with respect to the occlusal plane of reference respect to the occlusal plane of reference
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 4 of 12

The Kolmogorov-Smirnov statistical test was used to

determine the non-normal distribution of the mean im-
precision, using the median as a measure of central ten-
dency and the interquartile interval as an expression of
its distribution. The Kruskal-Wallis H test (p < 0.05) was
applied in cases of an imprecision of tooth/movement
combination whose mean was different to the others.

Analysis of movement accuracy

The following formula was used to quantify the accuracy
of each movement for each tooth type with respect to
the prescription:
Fig. 4 Rotation: the angle between the mesiodistal axis of the tooth
and plane y real posttreatment−initial pretreatment
movement accuracy ¼
ideal posttreatment−initial pretreatment

treatment with aligners. In addition, the upper jaw teeth Thus, an index of the accuracy of each movement was
were divided from the mandibular ones, due to the differ- obtained: the closer the value to 1, the more precise the
ent type and compactness of the bone, which can greatly dental movement achieved by the aligner series (100% of
influence the orthodontic movement. the prescription). The mean accuracy index, standard de-
Movements with a prescription of less than 2° were ex- viation and mean standard error were calculated for each
cluded from the analysis. This sensitivity threshold was type of movement in each tooth category, and Student’s t
determined from the mean intra-operator error pertain- test for single samples (p < 0.05) was applied in cases in
ing to measurements made using the VAM software, which the predictability of any type of movement/tooth
which has been previously published in the study valid- was significantly different to 1, i.e. significantly lower than
ating the method [16]. 100% of the prescription. Finally, F ANOVA (p < 0.05) and
Thus a database containing measurements of 345 Bonferroni’s post hoc tests were applied if there was a sta-
teeth, subdivided into the following types, was obtained: tistically significant difference in the predictability among
the different types of tooth movement.

57 upper incisors

29 upper canines Results

53 upper premolars Measurement method analysis confirmed that there were

37 upper molars no systematic measurement errors in any of the mesiodis-

64 lower incisors tal tip, vestibulolingual tip or rotation values (Table 2).

30 lower canines Table 3 shows the absolute values for the mean prescrip-

52 lower premolars tion and mean imprecision of each movement of each

23 lower molars tooth, alongside the median, relative interquartile and stat-
istical significance. In the upper arch, the least precise
movement in terms of absolute values was incisor rotation
(imprecision, 5.0° ± 5.3°), while the most precise move-
ment was vestibulolingual tipping of the canines (impreci-
sion, 2.5° ± 1.5°). In the lower arch, on the other hand, the
least precision was recorded for premolar rotation (impre-
cision, 5.4° ± 5.8°), while the most precise movement was
vestibulolingual tipping of the molars (imprecision,
1.3° ± 0.9°). In the upper arch, there was no statistically
significant difference in imprecision between the different
types of tooth movements, whereas in the lower arch the
canines showed a significantly greater error in terms of
rotation of the canines (6.9° ± 5.4°) with respect to the
incisors (3.4° ± 2.5°) and molars (2.0° ± 1.8°). Likewise, the
lower molar rotation imprecision was significantly more
precise than the lower incisor rotation.
Table 4 shows the mean accuracy, its standard deviation
Fig. 5 Occlusal plane of reference
and standard error, and the statistical significance calculated
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 5 of 12

Table 2 Method analysis

Arch Parameter Vestibulolingual tip Mesiodistal tip Rotation
D Dahlberg Systematic D Dahlberg Systematic D Dahlberg Systematic
error p level error p level error p level
Upper arch 11 0.300 NS 0.390 NS 0.525 NS
12 0.298 NS 0.979 NS 0.500 NS
13 0.782 NS 0.656 NS 0.957 NS
14 0.437 NS 0.783 NS 1.132 NS
15 0.674 NS 0.814 NS 1.162 NS
16 0.497 NS 0.081 NS 1.290 NS
17 0.686 NS 1.014 NS 0.964 NS
21 0.075 NS 0.274 NS 1.174 NS
22 0.785 NS 0.292 NS 0.788 NS
23 0.753 NS 0.433 NS 1.081 NS
24 0.539 NS 1.159 NS 0.883 NS
25 0.636 NS 0.715 NS 2.135 NS
26 0.579 NS 0.097 NS 1.214 NS
27 0.358 NS 1.254 NS 1.616 NS
Mean 0.528 0.639 1.102
Lower arch 31 0.658 NS 0.348 NS 0.551 NS
32 0.474 NS 0.536 NS 0.773 NS
33 0.445 NS 0.593 NS 0.926 NS
34 0.882 NS 0.581 NS 0.965 NS
35 0.334 NS 0.100 NS 0.800 NS
36 1.119 NS 1.510 NS 1.314 NS
37 0.954 NS 1.110 NS 1.527 NS
41 0.338 NS 0.351 NS 0.540 NS
42 0.810 NS 0.673 NS 1.275 NS
43 0.423 NS 0.752 NS 1.233 NS
44 0.877 NS 0.856 NS 1.305 NS
45 0.824 NS 0.653 NS 1.432 NS
46 1.131 NS 0.932 NS 1.389 NS
47 0.960 NS 1.262 NS 1.468 NS
Mean 0.731 0.733 1.107
NS not significant

for each type of tooth and tooth movement. In the upper Table 5 compares the mean accuracy among all tooth/
arch, the inferential statistical analysis performed showed movement combinations. This comparison revealed only
that neither the mesiodistal tip on the canines, premolars one statistically significant difference. In other words, there
and molars, nor the rotation of the molars were significantly was no greater precision statistically demonstrable in terms
different from 1 (p < 0.05), chosen as the reference value to of one tooth movement with respect to another, with the
indicate 100% achievement of the planned movement. That exception of the lower incisors, whose rotation accuracy
being said, all other tooth movements displayed a (0.40) was significantly lower than that of the lower premo-
predictability that was significantly lower than 100%. lars (0.87).
In contrast, in the lower arch, mesiodistal tipping and
rotation of the canines and rotation of the incisors Discussion
were significantly less accurate than 100%, while all It is a common experience among clinicians that some tooth
other tooth movements achieved were not statistically movements can be achieved more easily than others with
different from the target movement. aligners. However, the precise degree to which the achieved
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 6 of 12

Table 3 Mean prescription and mean imprecision values

N Mean prescription(°) SD Mean imprecision(°) SD Median IQR Significance.
Upper arch
VL tip Incisors 57 9.2 6.7 4.5 4.0 3.4 − 0.6 NS
Canines 29 5.1 3.2 2.5 1.5 2.3 0.8 NS
Premolars 53 5.1 3.4 3.1 2.6 2.1 − 0.5 NS
Molars 37 3.9 1.4 2.9 2.2 2.5 0.3 NS
MD tip Incisors 57 6.4 4.5 3.2 2.6 2.5 − 0.1 NS
Canines 29 4.7 2.8 2.8 2.2 2.6 0.4 NS
Premolars 53 4.6 3.3 3.6 2.3 3.9 1.6 NS
Molars 37 4.5 1.6 3.4 2.3 3.4 1.1 NS
Rot. Incisors 57 10.8 9.3 5.0 5.3 3.7 − 1.6 NS
Canines 29 6.5 4.6 4.3 2.8 3.6 0.8 NS
Premolars 53 7.0 6.7 3.5 3.1 2.9 − 0.2 NS
Molars 37 7.2 4.8 4.8 4.6 4.4 − 0.2 NS
Lower arch
VL tip Incisors 64 5.9 2.1 2.9 2.6 2.3 − 0.3 NS
Canines 30 7.2 5.0 3.5 2.8 3.1 0.3 NS
Premolars 52 6.2 4.1 3.2 2.2 2.9 0.7 NS
Molars 23 3.9 1.7 1.3 .9 1.9 1.0 NS
MD tip Incisors 64 4.2 1.5 2.7 1.9 2.2 0.3 NS
Canines 30 4.8 2.0 3.3 2.2 2.9 0.6 NS
Premolars 52 5.4 4.7 3.4 2.6 3.1 0.5 NS
Molars 23 6.3 3.7 4.3 3.0 3.5 0.5 NS
Rot. Incisors 64 7.2 4.4 3.4 2.5 2.8 0.3 *
Canines 30 12.4 10.0 6.9 5.4 5.5 0.1 *
Premolars 52 7.3 6.0 5.4 5.8 3.7 − 2.1 NS
Molars 23 4.6 2.8 2.0 1.8 1.4 − 0.4 *
VL tip vestibulolingual tip, MD tip mesiodistal tip, Rot. rotation, SD standard deviation, IQR interquartile range, NS not significant
*p < 0.05

movements differ from the ideal movements planned using and any teeth used as anchorage may be subject to reaction-
digital setups is difficult to quantify experimentally. First and ary displacement [20].
foremost, it is necessary to identify stable structures within The method of tooth position measurement proposed by
the oral cavity that can be used as reference points for Huanca [16], on the other hand, is based on the occlusal
superimposition of digital images. Among these, the palatine plane as a point of reference. Calculated as the plane pass-
folds are the most frequently chosen [17], even though ing through the mesiovestibular cusps of the first molars
several studies have shown that their position and/or dimen- and the centroid of the FACC of all of the other teeth, with
sions may vary in certain clinical conditions [18]. Further- the exception of canines, the occlusal plane is a reference
more, palatal structures may only be used as reference that enables the measurement error due to tooth move-
points in the upper jaw. This is one of the reasons why ment during orthodontic treatment to be minimised. More-
superimposition on stable teeth has been selected as the over, it is applicable to both arches in all individuals, and
method of choice for evaluating the accuracy of Invisalign allows evaluation of orthodontic movement of all teeth,
by several authors [14, 19, 20]. However, that method may both anterior and posterior. What is more, the reliability of
only be used in cases in which orthodontic treatment in- this method has been demonstrated for tooth movements
volves the displacement of only some teeth; moreover, even greater than 2°, at which it displays no measurement or
if this is the case, collateral effects on the position of other systematic error.
teeth cannot be ruled out. Indeed, intrusion may occur due Using this method, we demonstrate that the mean accuracy
to the masticatory forces exerted when wearing aligners, of orthodontic movement provided by the F22 aligner is
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 7 of 12

Table 4 Accuracy of movements achieved

N Mean accuracy Standard deviation Mean standard error Significance
Upper arch
VL tip incisors 28 0.65 0.34 0.064714 *
VL tip canines 16 0.54 0.57 0.143044 *
VL tip premolars 32 0.70 0.81 0.142849 *
VL tip molars 16 0.52 0.53 0.133131 *
MD tip incisors 36 0.77 0.58 0.096078 *
MD tip canines 16 0.78 0.50 0.125380 NS
MD tip premolars 27 0.71 0.78 0.150417 NS
MD tip molars 22 0.98 0.98 0.217782 NS
Rot. incisors 45 0.61 0.29 0.042538 *
Rot. canines 25 0.62 0.66 0.131114 *
Rot. premolars 29 0.54 0.54 0.100854 *
Rot. molars 18 0.78 0.61 0.144458 NS
Lower arch
VL tip incisors 35 0.86 0.65 0.109173 NS
VL tip canines 15 0.66 0.55 0.142351 *
VL tip premolars 29 0.90 0.82 0.151409 NS
VL tip molars 7 0.86 0.51 0.191882 NS
MD tip incisors 31 0.88 0.86 0.154196 NS
MD tip canines 18 0.87 0.82 0.193936 NS
MD tip premolars 33 0.97 0.97 0.168750 NS
MD tip molars 17 0.62 0.82 0.199778 NS
Rot. incisors 51 0.67 0.57 0.080357 *
Rot. canines 25 0.54 0.74 0.147841 *
Rot. premolars 36 0.83 1.38 0.229989 NS
Rot. molars 14 0.85 0.67 0.180257 NS
VL tip vestibulolingual tip, MD tip mesiodistal tip, Rot. rotation, NS not significant
*p < 0.05

73.6%, considering all movements in both anterior and pos- Rotation

terior teeth, while it falls to 70.6% if only the anterior teeth Rotation movements, especially of rounded teeth like the
are considered. Although derived from a different method- canines and premolars, are notoriously difficult to achieve
ology, these figures appear to compare favourably with the 56 with aligners. Indeed, one prospective study [19] con-
and 41% predictability achieved by Invisalign for anterior ducted on 53 canines in 31 subjects found a mean canine
teeth reported by Nguyen and Cheng [21], and Kravitz et al. rotation accuracy of 36%. Greater canine rotation accuracy
[14], respectively. can be achieved with interproximal reduction (IPR), but
We found that the most accurate movement achieved by this only provides an accuracy of 43%, albeit with a lower
F22 was mesiodistal tipping, whose mean accuracy was standard deviation (SD = 22.6%). Another study [14]
82.5% (SD = 77.4) overall, and 96.7% at the lower premolars found a rotation accuracy of 32% at the upper canines and
(SD = 96.9), closely followed by the upper molars (93.4%, even less at the lower canines (29%), as compared to the
SD = 72.6) and lower incisors (87.7%, SD = 85.9%). Less upper central (55%) and lower lateral incisors (52%).
precise movements were found to be vestibulolingual Moreover, there is an even further significant reduction in
tipping of the upper molars (52.5%, SD = 53.3) and upper the accuracy of upper canine rotation at rotations of
canines (54.0%, SD = 57.2%) and rotation of the upper greater than 15° (19%; SD = 14.1%; P < .05).
premolars (54.0%, SD = 54.3) and lower canines (54.2%, Our data confirm that among the lower teeth canine
SD = 73.9) (Table 6, Fig. 6). movement is the least accurate. That being said, our
Table 5 Accuracy among tooth/movement combinations
Group/arch Group/arch Vestibulolingual tip Mesiodistal tip Rotation
Difference between Standard error Significance Difference between Standard error Significance Difference between Standard Significance
means means means error
Incisors— Incisors—lower arch − .06361 .11235 NS − .23697 .13106 NS − .13364 .11270 NS
upper arch
Canines—upper arch − .18249 .13887 NS .02068 .16072 NS − .24391 .13745 NS
Canines—lower arch − .07897 .14178 NS − .22471 .15442 NS − .27064 .13745 NS
Premolars—upper arch − .19907 .11467 NS − .18541 .13618 NS − .18593 .13121 NS
Premolars—lower arch − .18289 .11740 NS − .28056 .12891 NS − .4711025* .12321 .005
Molars—upper arch − .10530 .13887 NS − .36883 .14475 NS − .13254 .15367 NS
Molars—lower arch .05389 .18725 NS − .22751 .15741 NS − .11360 .16863 NS
Incisors— Incisors—upper arch .06361 .11235 NS .23697 .13106 NS .13364 .11270 NS
lower arch
Canines—upper arch − .11888 .13372 NS .25765 .16466 NS − .11027 .13453 NS
Lombardo et al. Progress in Orthodontics (2017) 18:35

Canines—lower arch − .01537 .13675 NS .01227 .15851 NS − .13700 .13453 NS

Premolars—upper arch − .13546 .10838 NS .05156 .14081 NS − .05229 .12815 NS
Premolars—lower arch − .11928 .11127 NS − .04359 .13379 NS − .33746 .11995 NS
Molars—upper arch − .04170 .13372 NS − .13186 .14912 NS .00110 .15107 NS
Molars—lower arch .11749 .18347 NS .00946 .16143 NS .02004 .16626 NS
Canines— Incisors—upper arch .18249 .13887 NS − .02068 .16072 NS .24391 .13745 NS
upper arch
Incisors—lower arch .11888 .13372 NS − .25765 .16466 NS .11027 .13453 NS
Canines—lower arch .10351 .15926 NS − .24539 .18379 NS − .02673 .15585 NS
Premolars—upper arch − .01658 .13568 NS − .20609 .16876 NS .05798 .15038 NS
Premolars—lower arch − .00040 .13800 NS − .30124 .16295 NS − .22719 .14345 NS
Molars—upper arch .07718 .15667 NS − .38951 .17575 NS .11137 .17033 NS
Molars—lower arch .23637 .20080 NS − .24819 .18632 NS .13031 .18394 NS
Canines— Incisors—upper arch .07897 .14178 NS .22471 .15442 NS .27064 .13745 NS
lower arch
Incisors—lower arch .01537 .13675 NS − .01227 .15851 NS .13700 .13453 NS
Canines—upper arch − .10351 .15926 NS .24539 .18379 NS .02673 .15585 NS
Premolars—upper arch − .12010 .13866 NS .03929 .16277 NS .08471 .15038 NS
Premolars—lower arch − .10391 .14093 NS − .05585 .15674 NS − .20046 .14345 NS
Molars—upper arch − .02633 .15926 NS − .14412 .17001 NS .13810 .17033 NS
Molars—lower arch .13286 .20283 NS − .00280 .18091 NS .15704 .18394 NS
Premolars— Incisors—upper arch .19907 .11467 NS .18541 .13618 NS .18593 .13121 NS
upper arch
Incisors—lower arch .13546 .10838 NS − .05156 .14081 NS .05229 .12815 NS
Canines—upper arch .01658 .13568 NS .20609 .16876 NS − .05798 .15038 NS
Page 8 of 12
Table 5 Accuracy among tooth/movement combinations (Continued)
Group/arch Group/arch Vestibulolingual tip Mesiodistal tip Rotation
Difference between Standard error Significance Difference between Standard error Significance Difference between Standard Significance
means means means error
Canines—lower arch .12010 .13866 NS − .03929 .16277 NS − .08471 .15038 NS
Premolars—lower arch .01618 .11361 NS − .09515 .13881 NS − .28517 .13749 NS
Molars—upper arch .09377 .13568 NS − .18342 .15363 NS .05338 .16534 NS
Molars—lower arch .25296 .18490 NS − .04210 .16562 NS .07233 .17932 NS
Premolars— Incisors—upper arch .18289 .11740 NS .28056 .12891 NS .4711025* .12321 .005
lower arch
Incisors—lower arch .11928 .11127 NS .04359 .13379 NS .33746 .11995 NS
Canines—upper arch .00040 .13800 NS .30124 .16295 NS .22719 .14345 NS
Canines—lower arch .10391 .14093 NS .05585 .15674 NS .20046 .14345 NS
Premolars—upper arch − .01618 .11361 NS .09515 .13881 NS .28517 .13749 NS
Lombardo et al. Progress in Orthodontics (2017) 18:35

Molars—upper arch .07758 .13800 NS − .08827 .14723 NS .33856 .15907 NS

Molars—lower arch .23677 .18660 NS .05305 .15969 NS .35750 .17356 NS
Molars— Incisors—upper arch .10530 .13887 NS .36883 .14475 NS .13254 .15367 NS
upper arch
Incisors—lower arch .04170 .13372 NS .13186 .14912 NS − .00110 .15107 NS
Canines—upper arch − .07718 .15667 NS .38951 .17575 NS − .11137 .17033 NS
Canines—lower arch .02633 .15926 NS .14412 .17001 NS − .13810 .17033 NS
Premolars—upper arch − .09377 .13568 NS .18342 .15363 NS − .05338 .16534 NS
Premolars—lower arch − .07758 .13800 NS .08827 .14723 NS − .33856 .15907 NS
Molars—lower arch .15919 .20080 NS .14132 .17273 NS .01894 .19636 NS
Molars— Incisors—upper arch − .05389 .18725 NS .22751 .15741 NS .11360 .16863 NS
lower arch
Incisors—lower arch − .11749 .18347 NS − .00946 .16143 NS − .02004 .16626 NS
Canines—upper arch − .23637 .20080 NS .24819 .18632 NS − .13031 .18394 NS
Canines—lower arch − .13286 .20283 NS .00280 .18091 NS − .15704 .18394 NS
Premolars—upper arch − .25296 .18490 NS .04210 .16562 NS − .07233 .17932 NS
Premolars—lower arch − .23677 .18660 NS − .05305 .15969 NS − .35750 .17356 NS
Molars—upper arch − .15919 .20080 NS − .14132 .17273 NS − .01894 .19636 NS
NS not significant
*p < 0.05
Page 9 of 12
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 10 of 12

Table 6 Mean (%) accuracy of tooth movements achieved using F22

Vestibulolingual tip Mesiodistal tip Rotation
Tooth Mean (%) n SD Mean (%) n SD Mean (%) n SD
Upper incisors 64.5 28 34.2 76.7 36 57.6 61.5 45 28.5
Upper canines 54.0 16 57.2 78.3 16 50.2 62.3 25 65.6
Upper premolars 69.6 32 80.8 70.6 27 78.2 54.0 29 54.3
Upper molars 52.5 16 53.3 93.4 22 72.6 78 18 61.3
Lower incisors 86.1 35 64.6 87.7 31 85.9 67 51 57.4
Lower canines 66.4 15 55.1 86.7 18 82.3 54.2 25 73.9
Lower premolars 90.4 29 81.5 96.7 33 96.9 82.7 36 138
Lower molars 86.2 7 50.8 61.8 17 82.4 85.4 14 67.4
Total 71.2 178 59.7 81.5 200 75.8 68.1 243 68.3

predictability percentage was higher than that reported in central and lateral incisors); Nguyen and Cheng [21] too
the literature for other aligner systems (54.2%, SD = 73.9). confirm this finding, reporting a mean incisor rotation of
Furthermore, the F22 aligners achieved an accuracy index 60%. This parallels our figure of 61.5% (SD = 28.5%), but
not significantly different from 1, i.e. 100% of the pre- with F22 aligners, we found that the best rotation accuracy
scribed movement, for rotation of the upper molars (0.78, was achieved at the lower molars (85.4%, SD = 67.4) and
SD = 0.61), lower premolars (0.83, SD = 1.27) and lower lower premolars (82.7%, SD = 138)—teeth that were not
molars (0.85, SD = 0.67). considered in Kravitz’s analysis—albeit with a high standard
That being said, comparison of all movements achieved deviation.
by F22 in all tooth categories shows that, with respect to
the prescription, the mean rotation of the upper incisors Mesiodistal and vestibulolingual tipping
appeared significantly more accurate than the mean rota- Kravitz’s 2009 study [14] repeated a mean accuracy of 41%
tion of the lower premolars. This is in line with several for mesiodistal tipping, which was most accurate at both
literature reports on other aligner systems, for example the upper (43%) and lower (49%) lateral incisors; mesio-
Djeu et al.’s Invisalign study [22], in which they noted that distal tipping of the upper (35%) and lower (27%) canines
one of the strengths of the system was the ability to correct and the upper central incisors (39%) was the least accur-
the rotation of anterior teeth and level the incisor margins. ate. Our F22 results are in line with these findings, in that
Kravitz [14] also showed that the greatest rotation accuracy the least predictable movements achieved in the anterior
is achieved at the upper incisors (mean accuracy 48.8% for sector were the upper canines and incisors, although once

Fig. 6 Accuracy of planned movements by tooth type

Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 11 of 12

again, our accuracy scores were markedly higher. Indeed, we evaluated outcomes achieved by the F22 Grip Points
the mesiodistal tip achieved at neither the upper canines (attachments) and stripping alone. It is conceivable that in
(0.78, SD = 0.5), nor the upper premolars (0.7, SD = 0.78), the hands of an experienced orthodontist, with a full array
upper molars (0.93, SD = 1.02), lower incisors (0.88, of auxiliaries at their disposal, the accuracy percentages
SD = 0.86), lower canines (0.87, SD = 0.82), lower premo- we revealed could be further improved upon.
lars (0.97, SD = 0.97) or lower molars (0.62, SD = 0.82)
was significantly different from 1, considered full achieve-
Conclusions
ment of the outcomes predicted by the setup. As regards
Our analysis of the predictability of orthodontic move-
vestibulolingual tipping, on the other hand, neither the
ments that can be achieved using F22 aligners, without
lower incisors (0.86, SD = 0.64), nor the lower premolars
auxiliaries, enables us to state that
(0.9, SD = 0.81) or lower molars (0.86, SD = 0.5) exhibited
an accuracy index not significantly different from 1.

The mean accuracy of rotation, mesiodistal tipping
The orthodontic movement is a multifactorial issue.
and vestibulolingual tipping was 70.6% in the
There are many parameters that can affect the ability to
anterior sector and 73.6% across both full arches.
reach the goal planned in the setup. The crown anatomy,

Mesiodistal tipping was the most predictable
the root length and bone density were taken in consider-
movement, reaching a mean accuracy of 82.5%;
ation in this study dividing the sample into different groups
vestibulolingual tipping and rotation reached 72.9
by dental typology. Other parameters like sex and age of
and 66.8% of the prescribed movement, respectively.
the patient could also influence the response to the aligners’

The least predictable movement was rotation of the
application, as suggested by literature [23]. In addition, the
lower canines (54.2%), while the most predictable
characteristics of the material, thickness, alignment proto-
movements were mesiodistal tipping of the upper molars
col application and staging may affect the efficiency of the
and lower premolars (respectively 93.4 and 96.7%).
orthodontic movement. All these parameters will need to

The mean rotation error was significantly greater at the
be thoroughly investigated in future research.
lower canines than at the lower incisors and molars.
There were several limitations to this study. First and fore-

In the upper arch, mesiodistal tipping of the canines,
most, it would have benefitted from a larger sample. Only 16
premolars and molars displayed a very high accuracy
patients remained after the selection process, giving a poten-
index, not significantly different from 1. This was
tial 448 teeth to be analysed. However, once movements of
also true of vestibulolingual tipping of the molars.
prescription lower than 2° were excluded, this number fell to

In the lower arch, the accuracy index was not
346. Second point, as this is a retrospective study, the cases
significantly different from 1 for mesiodistal tipping
with complete records are more likely to be those that com-
of all teeth, vestibulolingual tipping of the incisors,
pleted treatment, rather than truly representative of those
premolars and molars, and rotation of the premolars
who started treatment with aligners. This could overestimate
and molars.
the effectiveness of the treatment.

There were no significant differences in the accuracy
Furthermore, we analysed only three types of tooth
index between tooth movements, with the exception
movement: rotation, mesiodistal tipping and vestibulolin-
of upper incisor rotation, which was significantly
gual tipping; as digital models rather than radiographs were
lower to that achieved at the lower premolars.
used for measurements, there was no information regard-

Further research on the topic using such a precise
ing root position from which to derive torque values.
and reproducible means of model superimposition
Nevertheless, the method of measurement we used, with
and measurement is required and should involve
the aid of VAM software, did enable us to analyse both an-
larger samples in order to shed light on the potential
terior and posterior teeth, relying as it did on an “average”
benefits and drawbacks of aligner systems.
occlusal plane, passing through the centroids of the FACC
points of all teeth (except for the canines) as a reference. In-
Authors’ contributions
deed, this plane is only minimally affected by the tooth FR analysed the dataset. AA recruited and treated the patients. LHG
movements achieved during treatment. That being said, the developed the analytical method. LL designed the study. GS supervised the
occlusal plane cannot be considered entirely stable and, research. All authors read and approved the final manuscript.
moreover, it is difficult to compare the results of this type
of analysis with those in the literature, which derive from Ethics approval and consent to participate
superimpositions of the palatine folds and posterior teeth. The study was performed in accordance with the Declaration of Helsinki.
It is a retrospective analysis, and the protocol was approved by the Chairman
Finally, it is worth noting that the study design did not of Postgraduate School of Orthodontics, University of Ferrara.
enable us to explore the full potential of F22 aligner treat-
ment. Indeed, complex movements are usually aided by Competing interests
the use of auxiliaries such as elastics or chains, whereas The authors declare that they have no competing interests.
Lombardo et al. Progress in Orthodontics (2017) 18:35 Page 12 of 12

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Author details
1
Postgraduate School of Orthodontics, University of Ferrara, Via Fossato di
Mortara, 44100 Ferrara, Italy. 2Department of Biomedical Sciences and Health,
University of Milan, Milan, Italy.

Received: 9 August 2017 Accepted: 18 September 2017

References
1. Sheridan JJ. The Readers’ Corner 2: what percentage of your patients are
being treated with Invisalign appliances? J Clin Orthod. 2004;38:544–5.
2. Kesling HD. Coordinating the predetermined pattern and tooth positioner
with conventional treatment. Am J Orthod Oral Surg. 1946;32:285–93.
3. Kuo E, Miller RJ. Automated custom-manufacturing technology in
orthodontics. Am J Orthod Dentofac Orthop. 2003;123:578–81.
4. Joffe L. Invisalign: early experiences. J Orthod. 2003;30:348–52.
5. 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 Dentofac Orthop. 2008;133:837–45.
6. Lombardo L, Arreghini A, Maccarrone R, Bianchi A, Scalia S, Siciliani G.
Optical properties of orthodontic aligners—spectrophotometry analysis of
three types before and after aging. Prog Orthod. 2015;16:41.
7. Zheng M, Liu R, Ni Z, Yu Z. Efficiency, effectiveness and treatment stability
of clear aligners: a systematic review and meta-analysis. Orthod Craniofac
Res. 2017;26
8. Wong BH. Invisalign A to Z. 5, May 2002. Am J Orthod Dentofac Orthop.
2002;121:540–1.
9. Boyd RL. Complex orthodontic treatment using a new protocol for the
Invisalign appliance. J Clin Orthod. 2007;41:525–47.
10. Lombardo L, Martines E, Mazzanti V, Arreghini A, Mollica F, Siciliani G. Stress
relaxation properties of four orthodontic aligner materials: a 24-hour in vitro
study. Angle Orthod. 2017;87:11–8.
11. Guarneri MP, Lombardo L, Gracco A, Siciliani G. The state of the art of clean
aligner technique [in Italian]. Bologna, Italy: Martina Editor. 2013:15–24.
12. Align Technology, Inc. The Invisalign reference guide. Santa Clara, Calif; 2002.
13. Boyd RL. Increasing the predictability of quality results with Invisalign.
Proceedings of the Illinois Society of Orthodontists; Oak Brook; March 7, 2005.
14. 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 Dentofac Orthop. 2009;135:27–35.
15. 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):881–9.
16. Huanca Ghislanzoni LT, Lineberger M, Cevidanes LH, Mapelli A, Sforza C,
McNamara JA Jr. Evaluation of tip and torque on virtual study models: a
validation study. Prog Orthod. 2013;26:14–9.
17. Miller RJ, Kuo E, Choi W. Validation of Align Technology’s Treat III digital
model superimposition tool and its case application. Orthod Craniofac Res.
2003;6(Suppl 1):143–9.
18. Ali B, Shaikh A, Fida M. Stability of palatal rugae as a forensic marker in
orthodontically treated cases. J Forensic Sci. 2016;61:1351–5.
19. Kravitz ND, Kusnoto B, Agran B, Viana G. Influence of attachments and
interproximal reduction on the accuracy of canine rotation with Invisalign.
A prospective clinical study. Angle Orthod. 2008;78:682–7.
20. 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.
21. Nguyen CV, Chen J. (Chapter 14) in: O.C. Tuncay (Ed.) The Invisalign system.
New Malden: Quintessence Publishing Company, Ltd; 2006. p. 12–32.
22. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and
traditional orthodontic treatment compared with the American Board of
Orthodontics objective grading system. Am J Orthod Dentofac Orthop.
2005;128:292–8.
23. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables affecting orthodontic
tooth movement with clear aligners. Am J Orthod Dentofac Orthop. 2014;
145(4 Suppl):S82–91.