Journal of the World Federation of Orthodontists 13 (2024) 57–64

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Journal of the World Federation of Orthodontists

journal homepage: www.jwfo.org

Review Article

Aligner biomechanics: Where we are now and where

we are heading for
Tommaso Castroflorio a,∗, Simone Parrini b, Gabriele Rossini a,c
a
Board Director, Clear Aligner Academy Italia, Turin, Italy
b
Research Assistant, Department of Orthodontics, Dental School, University of Turin, Turin, Italy
c
Private Practice, Milan, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Aligner orthodontics has gained significant popularity as an alternative to traditional braces because of
Received 16 November 2023 its aesthetic appeal and comfort. The biomechanical principles that underlie aligner orthodontics play a
Accepted 7 December 2023
crucial role in achieving successful outcomes.
Available online 15 January 2024
The biomechanics of aligner orthodontics revolve around controlled force application, tooth movement,
Keywords: and tissue response.
Aligner deformation Efficient biomechanics in aligner orthodontics involves consideration of attachment design and opti-
Clear aligners mized force systems. Attachments are tooth-colored shapes bonded to teeth, aiding in torque, rotation,
Composite attachments and extrusion movements. Optimized force systems ensure that forces are directed along the desired
Orthodontic biomechanics movement path, reducing unnecessary strain on surrounding tissues.
Understanding and manipulating the biomechanics of aligner orthodontics is essential for orthodon-
tists to achieve optimal treatment outcomes. This approach requires careful treatment planning, consider-
ing the mechanics required for each patient’s specific malocclusion. As aligner orthodontics continues to
evolve, advances in material science and treatment planning software contribute to refining biomechani-
cal strategies, enhancing treatment efficiency, and expanding the scope of cases that can be successfully
treated with aligners.
© 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.

1. Introduction In the last century, orthodontics was mostly a matter of metals

and predefined prescriptions. In recent decades, the introduction
We currently live in the “Plastic Age” with a total consumption of clear aligners has drawn orthodontists’ attention to thermoplas-
of about 182 million tons of polymers per year. Of this, polypropy- tic materials, potential applications, and personalized prescriptions.
lene is 24% to 25% and all polyethylene is about 40%. The human In clear aligner therapy (CAT), each aligner is made for a specific
race has always progressed by using raw materials. Growth from stage of orthodontic tooth movement (OTM) of a specific patient.
the Stone Age to Plastics Age has been very rapid. Use of plastics Aligners are comfortable, less visible, and more aesthetically pleas-
within the last century, and, in particular, after World War II, has ing than fixed buccal appliances. They can be removed for eating
increased exponentially [1]. and oral hygiene, which reduces the occurrence of emergencies.
Despite these advantages, which mean that clear aligners are in-
creasingly in demand by patients in our beauty-conscious society,
there has always been much debate about the effectiveness and ef-
Funding: The authors have not declared a specific grant for this research from ficiency of this appliance in controlling OTM. For example, ques-
any funding agency in the public, commercial, or not-for-profit sectors.
tions have been raised about the extent to which the aligners can
Competing interests: Authors have completed and submitted the ICMJE Form for
disclosure of potential conflicts of interest. Drs. Castroflorio and Parrini received fees
control extrusion, rotation, and body movement.
and honorarium for lectures and presentations by Align Technology Inc. in the past While the predictability of clear aligner treatment is controver-
36 months without any effect on the present manuscript. Dr. Rossini has no conflict sial and reported by Haouili et al. [2] to be around 50%, it should
of interest to be declared. be noted that 74% of randomly selected cases from the same pa-
Provenance and peer review: Commissioned; Internally peer reviewed
∗
tient sample would pass the American Board of Orthodontics grad-
Corresponding author: Department of Orthodontics, Clear Aligner Academy
Italia, Turin, Italy
ing score. And this percentage is not far from the 79% success
E-mail address: tommaso.castrofl[email protected] (T. Castroflorio). rate showed in the February 2022 American Board of Orthodontics

2212-4438/$ – see front matter © 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ejwf.2023.12.005
58 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64

examination report, where fixed appliance treatments were pre-

dominantly reported [3]. Furthermore, in a recent research paper,
Grünheid et al. [4] analyzed the differences between predicted and
achieved tooth positions and found statistically significant differ-
ences for all teeth except the maxillary lateral incisors, canines, and
first premolars. In general, the anterior teeth were more occlusally
positioned than predicted, the rotation of the rounded teeth was
incomplete, and the movement of the posterior teeth was not fully
achieved in all dimensions. However, apart from the excessive buc-
cal crown torque of the maxillary second molars after treatment,
these differences were not large enough to be clinically relevant.
Compared to what was possible a few years ago, when the rec-
ommendation was to treat only simple malocclusions with align-
Fig. 1. Example of conventional rectangular and vertical attachments.
ers, the growing base of general knowledge about the control of
OTM has allowed the application of this technique in more com-
plex cases [5–9]. These results were possible with orthodontists
who began to consider the virtual setup not only to visualize the
moving teeth but also as a tool to develop the correct biomechan-
ics and thus began to transfer known concepts in this field.
Tooth movement with aligners is more complex than with fixed
appliances. In the last 20 years, we have learned that attachments
are necessary to increase the interaction between the aligner and
teeth and that the orientation of the active surfaces was enough
to design the proper force system. This approach was supported
and strongly encouraged by the manufacturing companies, which
released new versions and features based on internal and unaf-
fordable studies. However, in the last 6 to 7 years several indepen-
dent clinical and finite element method (FEM) studies supported
Fig. 2. Example of conventional rectangular and horizontal attachments.
the clinical feeling that in many cases the moment of force and
moment of couple are not provided by the attachment at all, and
when the moment of couple exists on the attachment itself, nu- shape and volume of attachments, Mantovani et al. [21] concluded
merous interferences between the aligner and crown exist which that the use of bulk-filled resins for the fabrication of attachments
will degrade the intended force system [10]. Therefore, this narra- improves dimensional stability compared with low-viscosity resins,
tive review about aligner biomechanics has been designed to an- which exhibit higher polymerization shrinkage. In another in vitro
swer the following research/clinical question: Whether OTM con- study Gazzani et al. [22] demonstrated that, from a materialis-
trol of bodily movement, anterior extrusion and rotations with tic point of view, conventional nanocomposite resins showed bet-
aligner is a question of attachment shape and/or dimension and/or ter mechanical behavior and therefore seem to be the best choice
position? for the production of attachments. The use of translucent compos-
ites generally provides adequate aesthetic acceptance and stain re-
2. Attachments characteristics sistance as long as an adequate bonding technique is performed,
avoiding voids (bubbles) in the attachment surface and excessive
Considering the state of the art of thermoformed aligners, the residue (flash) on the tooth surface [23].
use of aligners without attachments is something like orthodontics, Attachments can be classified as:
but it is not orthodontics. Attachments are not only useful to guide
1. Conventional attachments (rectangular, beveled, ellipsoidal,
the teeth in a certain direction, but also to control the anchorage,
semi-spherical with predefined dimensions),
depending on the type of orthodontic movement planned. The use
2. Optimized attachments (shape, dimension, and position based
of attachments is crucial for effective treatment: through clinical
on tooth anatomy and requested movement).
studies (see, e.g., Ravera et al. [11], Garino et al. [12], Groody et al.
[7], D’Antò et al. [13]) as well as finite element studies (see, e.g., Conventional attachments (Figs. 1 and 2) can be positioned by
Cortona et al. [14], Rossini et al. [15], Yang et al. [16]) have shown the orthodontist on any tooth (always considering the extension of
the importance of using attachments to improve root control. In in the clinical crown) and can be oriented in any direction. Rectangu-
vitro studies, Simon et al. [17] and Rossini et al. [18] showed that lar attachments are the most commonly used conventional attach-
load transfer from aligners to teeth is limited without the use of ments.
attachments. Optimized attachments (Fig. 3) are positioned by technicians
It is important to keep in mind that attachments do not ac- and the orthodontist cannot change their position, dimension, or
tively generate forces, but passively “get in the way” of the aligner orientation. This type of attachment was originally introduced to
plastic, which elastically deforms because of the mismatch between create specific force systems to control canine and premolar rota-
the position of the tooth and the aligner material, thus generating tion.
the force vector that subsequently acts on the tooth [19]. As they The orientation of the surface on which the aligner is intended
are necessary auxiliary elements for the aligner systems, their in- to push to create the designed force system and thus generate or-
tegrity, and shape must be maintained during treatment to ensure thodontic forces in response to the particular pattern of mismatch
functional validity and to not compromise the efficiency of move- between the aligner and the tooth is crucial in planning treatment
ment and fit of the aligner [20,21]. While D’Antò et al. [20] have mechanics. The attachment design should consider specific areas
shown that the viscosity of the composite has no influence on the (active surfaces) that contact the aligner material with predeter-
 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64 59

Fig. 3. Example of optimized attachments, serving as anchorage attachments for the intrusion of lower incisors on the canine, root tipping control on the first bicuspid, and
extrusion attachment on the second bicuspid.

Fig. 4. Active surfaces are highlighted in blue on the optimized attachments. These areas are the ones on which the aligner is pushing only once.

mined force magnitudes, creating the desired force vectors and re- signs are desirable because of their better biomechanical capabil-
sulting in tooth movements. The “active” surfaces can and should ities but lead to increased aligner retention (with subsequent pa-
be determined with thoughtful biomechanical intent and in accor- tient discomfort) and negative aesthetic perception, especially in
dance with the clinical goals (Fig. 4). While the magnitude of the high-profile configurations in the anterior region. Eye-tracking data
force is related to the mismatch between aligner, attachment, and show that an increase in attachment size in aesthetic areas led to
tooth structure, the direction of the force is related to the inclina- an increase in total fixation duration [26] nullifying the “invisibil-
tion of the active surface. The principles of mechanics state that ity” of clear aligners.
the direction of the normal component of the contact force (the
vector acting on the active surface of the attachment in this case)
3. Open bite
is always perpendicular to this surface [19].
Once the geometry of the attachment has been defined, a
Attachments play a pivotal role in open bite cases, serving as
proper location should be identified. Based on the premise that the
indispensable tools to overcome specific challenges associated with
magnitude of a moment is proportional to the perpendicular dis-
this malocclusion. In these scenarios, the strategic placement of at-
tance between the line of action and the center of resistance, it is
tachments, whether conventional or optimized, is crucial for or-
essential to determine this distance in the three spatial planes for a
chestrating the desired force systems required to address the com-
complete understanding of the effect of aligner-based orthodontic
plexities of open bite correction. The design of attachments must
forces applied at a given moment. Once this correlation is clearly
align with biomechanical intent and clinical goals, considering the
established and quantified, a much clearer picture emerges of the
unique requirements of each case. Several studies confirm the effi-
effectiveness of the expected rotational moments and the possibil-
ciency of clear aligners in treating open bite malocclusions [27–29].
ity of avoiding undesirable events such as bucco-lingual and mesio-
All the authors included attachments in their setups, agreeing that
distal tilts and intrusions [19]. Several FEM studies demonstrated
these are mandatory auxiliaries for this type of correction.
the effects of different attachments location on the same OTM.
Analyzing the role of attachments in incisor extrusion, which
Rossini et al. [15] demonstrated that the presence of rectangular
is crucial for open bite correction, Karras et al. [30] observed that
horizontal attachments on the buccal or palatal surface of upper
the differences between optimized and conventional attachments
incisors was found to produce the most efficient force system in
on incisor extrusion accuracy were negligible. A recent randomized
incisors extrusion. Comparing the effects of different attachment
controlled trial by Groody et al. [7], added evidence to these re-
locations on maxillary second molar requiring intrusion, Fan et al.
sults, stating that conventional rectangular horizontal attachments
[24] showed that combining buccal and palatal rectangular hori-
are better than optimized ones in controlling the extrusion of max-
zontal attachments produced the best efficiency.
illary lateral incisors. These results align with older in-silico studies
The size of the attachment is important because of its mechani-
by Savignano et al. [31] and Rossini et al. [15]. Both studies adopted
cal and aesthetic effects. Small configurations are desirable because
the finite element analysis technique to analyze the biomechanics
they are less conspicuous. However, as size decreases, so does the
of upper incisor extrusion. Results of Savignano et al. [31] showed
ability to generate predictable forces because the active surface
that the best-performing attachment for single incisor extrusion
area becomes smaller. Ferlias et al. [25] reported that rectangular
was the palatal horizontal one, obtaining an almost bodily move-
vertical attachment performs best in premolar rotation when com-
ment; the authors stated that the reason for this is connected to
pared with smaller attachments. In contrast, larger attachment de-
the position of the attachment surface being on the line of force
60 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64

control their rotation: attachments are necessary but current de-

signs do not seem to work effectively.
Inefficiencies in premolar rotation with rectangular attachments
were also reported in the FEM study by Cortona et al. [14], in
which a comparison between different numbers of rectangular
attachments was performed. The authors observed that rotation
without an attachment led to a displacement on the contralat-
eral side of the arch, which was greater than the obtained rota-
tion of the desired tooth. Furthermore, despite the inefficiencies,
the authors concluded that attachments are mandatory to rotate
premolars. Regarding molar rotation, Lione et al. [33,34] reported
that aligners with attachments can efficiently rotate molars, in both
children and adults, especially if a combined movement of distal
rotation and expansion is performed.
Concerning the attachments’ role in the rotation of anterior
teeth, the available evidence is limited. The recent paper from Xie
et al. [35] stated that attachment type is not one of the factors in-
fluencing anterior tooth rotation. Furthermore, their results high-
Fig. 5. Aligner deformation during the first second of insertion while extruding up- lighted that the difference between predicted and achieved rota-
per incisors with rectangular horizontal attachments on the buccal side. Rectangular tional movements was different among anterior teeth, with max-
and vertical attachments are applied on posterior teeth to reinforce anchorage
illary lateral incisors presenting the lowest accuracy, followed by
mandibular incisors and canines. Castroflorio et al. [32], showed
that optimized attachments provide the best results in controlling
passing through the center of resistance of the tooth. The study
lower canines’ rotation indicating that these attachments should be
by Rossini et al. [15] obtained partially different results, analyz-
applied to improve clinical outcomes.
ing the extrusion movement on the four upper incisors simulta-
This evidence is partially supported by Karras et al. [30], since
neously. In their study, both palatal and buccal horizontal attach-
their study did not analyze incisor rotation but highlighted the low
ments performed equally in terms of working surfaces, while the
efficiency in canine rotation. Therefore, considering the available
optimized attachments setup showed the same surface activation
evidence, while optimized attachments work well on the lower ca-
as the configuration without any anterior attachment. However,
nines, vertical and rectangular attachments are mandatory tools for
the initial tooth displacement was observed to be the same for all
rotating other teeth, placing them also on adjacent teeth, and re-
configurations (Fig. 5), leading to the need for further investiga-
ducing aligner activation to less than 1° per aligner to optimize the
tions on the topic. The application of posterior attachments in open
system.
bite cases, given all the previously cited evidence, is nondebatable
and mandatory (Fig. 6). Observing the entire body of evidence, we
5. Bodily movement
think it is reasonable to state that the recommended attachments
setup for open bite treatment is to apply attachments to each up-
First premolar extraction cases are the best to explain the differ-
per tooth, with horizontal attachments being the ones of choice on
ences in terms of force system expression between the virtual de-
upper incisors.
sign and clinical reality in controlling bodily movements. The chal-
lenge represented by the closure of extraction spaces in the mid-
4. Tooth rotation dle of dental arches is very helpful in understanding the aligner-
attachment-tooth interaction. From the early case reports on these
Attachments also play a pivotal role in addressing the challenges kind of treatments, Ojima et al. [36] highlighted that when extrac-
of tooth rotation during orthodontic treatment. In the context of tion spaces are closed with aligners, a roller-coaster effect is of-
tooth rotation, the size, shape, and orientation of attachments be- ten caused by sagging of the plastic around the extraction sites
come critical considerations in planning effective force systems. and that this effect can be prevented by using Class II elastics to
The 2021 study by Karras et al. [30] recognized that the most trou- enhance intermaxillary anchorage. Furthermore, the use of vertical
blesome teeth to rotate with aligners are canines and premolars. rectangular attachments was suggested on teeth housing the elas-
Simon et al. [17] in 2014 were the first research group to address tics anchor buttons.
premolar rotation efficiency, analyzing the effects of attachments, Unless reciprocal space closure is desired, anchorage reinforce-
staging, and the overall amount of movement on rotation accu- ment is a necessity [37]. Considering the complexity of extraction
racy. The authors reported cutoff values for both overall rotation biomechanics with clear aligners, any treatment plan will require
movement (15°) and single aligner staging (1.5°) that significantly carefully customized staging, as described by Samoto and Vlaskalic
influenced performance. Ferlias et al. [25] confirmed the results [38], accurate attachment selection, and anterior and posterior an-
from Simon et al. [17], emphasizing the importance of attachment chorage reinforcement.
size, particularly in premolar derotation, highlighting the need for Aligner materials have a certain elasticity: this means that when
predictable forces. The findings suggest that rectangular attach- we try to close the extraction space, the aligner compresses the
ments may be the best choice to optimize biomechanical capabili- dental arch with a molar-mesial tilt and a bite deepening of the in-
ties, even if they result in increased aligner retention and potential cisors (roller-coaster effect) [39] (Fig. 7). In particular, the intrusion
side effects. In a recent study, Castroflorio et al. [32] reported that and mesial tilt of molars are more pronounced in the mandibu-
for the rotation of upper canines neither optimized attachments lar arch than in the maxillary arch [16]. Dai et al. [40], analyz-
nor conventional attachments are working properly, losing 0.4° of ing the data of extraction cases treated with aligners, showed that
movement per every prescribed 1°. Similar results were obtained first molar anchorage control and central incisor retraction were
for premolars since optimized attachments offer no advantage to not fully achieved as predicted and that these differences became
 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64 61

Fig. 6. A clinical example of the possibilities offered by aligners in treating dentoalveolar open bite patients.

words creating a reversed Curve of Spee on both arches in the vir-

tual setup.

6. Class II non extraction treatment

The non extraction treatment of Class II malocclusion is another

example of desired bodily movement with CAT. The development
of CAT, allows the clinician to obtain a distal movement of the up-
pers without the use of bulky appliances like extraoral tractions
[42,43].
Fig. 7. When the aligner is squeezing the arch to close an extraction space the re- Recent literature [17,44] assessed that maxillary molar distaliza-
sult is always a roller-coaster effect. tion was one of the most predictable movements with CAT. More
recent studies performed by Ravera et al. [11] and Garino et al.
[12] confirmed the possibility of achieving anteroposterior correc-
larger increasing the incisors’ retraction. From the regression equa- tion ranging from 2.5 mm to 3 mm, with the recommendation to
tion, even if the first molar were set stable, it would move mesially use attachments on all teeth from the canine to the second molar.
by 2.8 mm. The effects of attachments on maxillary molar anchor- Gomez et al. [19] in their study, analyzed the behavior of an up-
age control were also investigated and the G6-optimized attach- per canine during a distal movement. They highlighted that when
ment (Align Technology Inc., San José, CA, USA) showed similar an upper canine is distalized without any attachment, distal tip-
control in first molar angulation and mesiodistal translation as did ping is the result. When an attachment is placed on the canine,
3- and 5-mm horizontal rectangular attachments. the interaction between aligner and attachment generates a bodily
Recent studies showed that mesial tipping and mesiolingual ro- movement of the canine. Similar results were obtained in another
tation of mandibular first molars occurred in patients with four finite element analysis conducted by Comba et al. [9].
premolar extractions with CAT, resulting in loss of anchorage of However, the journey toward correcting Class II malocclusion
mandibular molars and buccal open bite. Therefore, the design of with clear aligners presents some challenges. One of the primary
an additional distal tipping of the molars called an aligner anchor- concerns in upper distalization is the potential loss of anterior an-
age preparation, can prevent the loss of anchorage of the posterior chorage, leading to uncontrolled proclination of anterior teeth and
teeth. Yang et al. [16], working with finite element model, demon- an increase in overjet (Fig. 9A). To counteract these side effects, the
strated that the use of Class II elastics determines a greater mesial use of Class II elastics is recommended (Figs. 9B and 10). Nonethe-
tipping and reduce the intrusion of lower molars. Furthermore, less, from a patient’s perspective, the use of interarch elastics can
aligner anchorage preparation was effective in preventing mesial be perceived as cumbersome, potentially interfering with smile
and lingual tipping of the mandibular molars, with the distal and aesthetics during orthodontic treatment. Patient selection should
lingual cut-out for elastic anchor buttons being more effective than be performed carefully considering the request of compliance with
the mesial cut-out mode. For each aligner stage (0.25 mm), an- aligners and elastics.
chorage preparation of 1.7° should be designed to produce bodily In response to these challenges, the integration of temporary
protraction of mandibular molars with distal and lingual cutouts, anchorage devices (TADs) has been explored to enhance the effec-
whereas anchorage preparation of 2° is suggested for maximal an- tiveness of CAT. Recent studies have demonstrated the efficacy of a
chorage patients. “hybrid approach,” combining clear aligners with TADs to address
Recently Liu et al. [41] demonstrated that mechanical compen- Class II malocclusion [45,46]. This approach aims to reduce side
sation through overcorrection of the target position in four pre- effects associated with upper distalization, offering a more con-
molar extraction cases should be designed based on bimaxillary trolled and predictable treatment outcome. The synergy between
control deficiencies, and retention compensation by adding specific clear aligners and TADs represents a promising combination in the
attachments should also be considered according to the overcorrec- ongoing evolution of orthodontic treatments.
tions (Fig. 8A,B and C). They recommended the use of conventional
rectangular horizontal attachments on upper and lower molars and 7. And then?
rectangular and vertical attachments on upper and lower premo-
lars and canines, and the design of teeth extrusion in the middle of The body of evidence demonstrates the importance of attach-
the dental arches and the intrusion of teeth in the ends, in other ments in controlling orthodontic movement, but they also high-
62 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64

Fig. 8. Clinical aspects before (A), during (B), and after (C) an extraction treatment with aligners. Burning anchorage in the lower arch will result in mesal and lingual tilting
of lower second premolar. In this case the correct final position was recovered with a new set of aligners, buttons, and vertical elastics.

Fig. 9. Aligner deformation while distalizing the second molar and anchoring the interarch Class II elastic on a button applied on the buccal surface of the upper canine (A).
Aligner deformation while distalizing the second molar and anchoring the Class II elastic on a hook placed on the upper first bicuspid (B). The B configuration shows an
aligner performing better considering the treatment plan.

Fig. 10. A clinical example of Class II nonextraction treatment performed with attachments, aligners, and Class II elastics.
 T. Castroflorio et al / Journal of the World Federation of Orthodontists 13 (2024) 57–64 63

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