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Predictability of Rotational Tooth Movement with Clear Aligners
and Its Determining Factors: Exploratory Systematic Review
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Predictibilidad del movimiento rotacional dental con
alineadores transparentes y sus factores determinantes:
Revisión sistemática exploratoria
ABSTRACT
Introduction:
Clear aligners have become a widely used therapeutic alternative in orthodontics
due to their aesthetic and comfort advantages. However, despite advances in
thermoplastic materials, three-dimensional digital planning, and attachment
design, certain tooth movements continue to present biomechanical limitations.
Among these, tooth rotation is recognized as one of the least predictable
movements, especially in teeth with unfavorable crown and root morphology, such
as canines and premolars.
Objective:
To analyze the available scientic evidence on the predictability of rotational tooth
movement in patients treated with clear aligners and to identify the main factors
that inuence the accuracy of this movement.
Methods:
An exploratory systematic review was conducted following the PRISMA guidelines.
Searches were performed in the PubMed and ScienceDirect databases in English
and Spanish, using combinations of MeSH terms and keywords related to clear
aligners and tooth rotations.
Original, fully accessible studies published between January 2020 and October
2025 that evaluated the clinical accuracy of rotational movements with aligners
were included. Case reports, previous reviews, and studies that included combined
treatments with xed appliances, miniscrews, or orthognathic surgery were
excluded.
Results:
After the selection process, 10 studies were included for qualitative analysis. The
evidence showed that the predictability of rotational movement with clear aligners
is variable, with values ranging approximately from 28% to 70%, depending on the
tooth type, the magnitude of rotation, and the treatment design.
Incisors showed greater accuracy compared to canines, premolars, and molars,
with rotations greater than 10–15° being the least predictable. Factors such as the
conguration and type of attachments, treatment staging, the number of aligners,
patient compliance, and dental morphology signicantly inuenced the clinical
outcomes.
Ramos, H.N., Munive, A. Predictability of Rotational Tooth Movement with Clear Aligners and Its Determining Factors: Exploratory Systematic Review. Odontología Vital, 2 (45) 18-26.
https://doi.org/10.59334/ROV.v2i45.742
Article info
Recibido 2025-12-17
Revisado 2026-03-25
Aceptado 2026-05-22
Keywords:
clear aligners
tooth rotation
orthodontic movement
biomechanics
predictability.
a. DDS, Orthodontics and Dentofacial
Orthopedics Resident, Universidad
b. DDS, Professor of Orthodontics
and Dentofacial Orthopedics,
Universidad
Ramos, H.N. a Munive, A. b
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Conclusions:
Tooth rotation remains one of the least predictable movements in clear aligner therapy. Despite technological advances, the
effectiveness of rotational control depends on multiple biomechanical, biological, and digital planning factors. Individualized
planning, appropriate use of attachments, and the programming of progressive movements can improve the clinical
expression of movement, although the need for renements remains frequent.
Introduction
In recent years, clear aligners have
revolutionized orthodontic practice by offering
an aesthetic, comfortable, and removable
alternative to conventional xed appliances.
Their popularity has increased due to advances
in digital design, thermoplastic materials,
and three-dimensional planning techniques,
enabling the treatment of a wide range of
malocclusions with increasingly predictable
outcomes (Haouili et al., 2020). However,
despite technological progress, certain types of
tooth movement continue to pose signicant
biomechanical challenges for aligners
(Naoum & Lee, 2025). Among the most difcult
movements to control are tooth rotations,
particularly in teeth with rounded morphology,
such as canines and premolars.
These movements require proper control of
frictional forces, effective coupling between
the aligner and the tooth surface, and the use
of auxiliary attachments to enhance force
transmission (Aminian et al., 2024). Several
studies have evaluated the overall accuracy
of clear aligners by comparing planned versus
clinically achieved movements.
Haouili et al. (2020) reported that while aligners
are highly effective for movements such as
tipping, their accuracy decreases considerably
in more complex movements such as rotation
and root torque. This variability has driven the
need to optimize attachment design and rene
clinical protocols to improve biomechanical
performance.
Studies such as those by D’Antò et al. (2024) and
Castroorio et al. (2023) have demonstrated that
the predictability of these movements varies
considerably, with accuracy decreasing when
rotations exceed 15 degrees.
Similarly, a recent review by Benedetti et al.
(2025) showed that, despite advances in digital
design and attachment congurations, the
clinical effectiveness of rotational movements
remains highly variable across studies.
Recent literature has explored different
strategies to optimize rotational control. Fiorillo
et al. (2024) evaluated various attachment
congurations, reporting greater accuracy when
optimized attachments were combined with
shorter aligner sequences.
Likewise, studies by Medeiros et al. (2024) and
Bilello et al. (2022) have shown that clinical
outcomes still differ from digitally planned
movements, suggesting that individual
biomechanical response and patient adherence
remain key determinants of treatment efcacy.
Therefore, the aim of this article is to conduct
an exploratory systematic review on the
predictability of rotational tooth movement
with clear aligners and to identify the factors
inuencing its accuracy.
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Materials and Methods
This study was conducted as an exploratory
systematic review following PRISMA guidelines
to ensure a transparent, reproducible, and
structured process.
The research question was formulated
according to the PICO format (Table 1): What is
the predictability of rotational tooth movement
in patients treated with clear aligners, and which
factors inuence the accuracy of the achieved
movement?
Table 1. Description of the PICO format
ELEMENT DESCRIPTION
P (Population) Patients treated with clear aligners.
I (Intervention) Use of clear aligners for the control of tooth rotations.
C (Comparison) Digitally planned movements vs. clinically achieved movements.
O (Outcome) Predictability and accuracy of rotational tooth movement.
Searches were conducted in English and Spanish
in the PubMed and ScienceDirect databases
using a combination of MeSH terms and
keywords related to clear aligners and tooth
rotation, combined with Boolean operators (AND,
OR) (Table 2). The search was limited to full-text
articles published between January 2020 and
October 2025.
Table 2. Bibliographic Search Strategy
Source Search Query
ScienceDirect
(“clear aligner” OR Invisalign OR ClearCorrect) AND (“tooth rotation” OR “rotational movement”)
AND
(efcacy OR accuracy OR predictability)
Pubmed
((“clear aligner” OR “clear aligners” OR “invisible aligner*” OR “transparent aligner*” OR “thermoformed
aligner*” OR Invisalign OR ClearCorrect OR Spark) AND (“tooth rotation” OR “rotational movement” OR
“rotational control” OR “tooth movement” OR “tooth alignment”)
AND
(“efcacy” OR “accuracy” OR “effectiveness” OR “predictability” OR “treatment outcome” OR “clinical
performance”))
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Eligibility Criteria
Inclusion criteria:
• Original studies (clinical trials, prospective or
retrospective studies)
• Publications between 2020 and 2025
• Human studies
• Articles in English or Spanish
• Studies evaluating the predictability,
accuracy, or efcacy of rotational
movements with clear aligners
Exclusion criteria:
• Case reports
• Literature reviews, systematic reviews, or
meta-analyses
• In vitro or animal studies
• Studies involving combined treatments
(xed appliances, miniscrews, or
orthognathic surgery)
• Articles without full-text access
Selection Process
Identied articles underwent a multi-stage
selection process. First, duplicate records were
removed. Then, a screening by title and abstract
was conducted, excluding studies that did not
meet the established criteria. Finally, potentially
relevant studies were assessed in full text to
conrm eligibility.
The selection process is presented using a
PRISMA ow diagram (Figure 1).
Case reports (n=49) Combined treatments with
fixed appliances, mini-implants (TADs), or
orthognathic surgery (n = 10)
Records not available (n = 24)
IdentificationScreeningIncluded
Records removed before screening: Duplicate
records removed
(n = 7) Records removed for other reasons (n = 4)
Records meeting inclusion
criteria (n = 103)
Records available in full text
(n = 20)
Did not answer the PICO question (n = 10)
Articles assessed for eligibility
(n = 20)
Articles included in the review
(n = 10)
Records identified from:
PubMed (n = 57)
ScienceDirect (n = 57)
Identification of studies through databases and registers
Figure 1. PRISMA Flow Diagram for the Selection of Studies on Dental Rotations with Clear Aligners
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Table 3. Characteristics of the Included Studies
Author (year) Title Study design Sample Intervention Main results Inuencing
factors
Haouili et al.
(2020)
The predictability
of orthodontic
tooth movements
through clear
aligner among
rst-premolar
extraction patients:
a multivariate
analysis.
Prospective
study
Patients with
premolar
extractions
Invisalign
aligners
(SmartTrack,
attachments)
Rotations showed
low predictability
(~46%); tipping was
more accurate.
Magnitude >15°,
attachments,
staging,
compliance.
Naoum & Lee
(2025)
The predictability
of tooth movement
with clear aligner
systems.
Narrative
review
Not
applicable Clear aligners
Variable
predictability
(<30%–85%);
rotation and
extrusion were less
predictable.
Attachments,
staging, 20–22
h/day wear,
auxiliaries.
Desai et al.
(2025)
Estimation of
centers of rotation
of the maxillary
incisors during
nonextraction
space closure
using the Invisalign
appliance.
Clinical study
Non-
extraction
patients
Invisalign
aligners
Low efciency
(~33%); tipping
more predictable;
poorer root control.
Aligner
biomechanics,
tooth
morphology,
complexity.
Due to the heterogeneity of the included
studies, no formal risk-of-bias assessment using
standardized tools was performed. However,
aspects such as study design, sample size,
measurement methods, and consistency of
results were considered during the qualitative
analysis to enable a critical interpretation of the
available evidence.
Results
For this exploratory systematic review on
the effectiveness of rotational control with
clear aligners, a comprehensive search was
conducted in PubMed (n = 57) and ScienceDirect
(n = 57), yielding a total of 114 records.
After removing 7 duplicate records and 4
records excluded for other reasons (e.g.,
incomplete articles), 103 studies met the initial
inclusion criteria. During the screening phase, 49
case reports and 10 studies involving combined
treatments with xed appliances, miniscrews,
or orthognathic surgery were excluded.
Consequently, 44 articles advanced to the full-
text assessment stage, of which 24 could not be
retrieved due to lack of access.
Finally, 20 articles were evaluated in full text
to conrm eligibility, with 10 excluded for not
addressing the PICO question. As a result, 10
studies were selected for qualitative analysis
and discussion (Figure 1).
A descriptive table summarizing the main
characteristics of the included studies was
developed, allowing a clear and comparative
visualization of their objectives, methodologies,
and key ndings (Table 3).
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D’Antò et al.
(2024)
Predictability of
tooth rotations in
patients treated
with clear aligners.
Clinical study Patients with
aligners Clear aligners
Moderate
predictability
(~65–68%);
incomplete
rotations.
Tooth type,
rotation
magnitude,
attachments.
Castroorio
et al. (2023)
Predictability of
orthodontic tooth
movement with
aligners: Effect of
treatment design.
Prospective
study
Patients
treated with
Invisalign
Invisalign
aligners
Moderate accuracy;
rotation and torque
less predictable.
Treatment
design,
staging, dental
morphology.
Fiorillo et al.
(2024)
Accuracy of
clear aligners in
the orthodontic
rotational
movement
using different
attachment
congurations.
Clinical study
Patients with
different
attachments
Aligners with
different
attachments
Moderate accuracy;
100% rotation not
achieved.
Type of
attachment,
rotation
magnitude,
biomechanics.
Medeiros et
al. (2024)
Accuracy of
Invisalign® aligners
in adult patients: a
retrospective study
of angular tooth
movements.
Retrospective
study
Adult
patients
Invisalign
aligners
Discrepancy
between planned
and achieved;
lower accuracy in
posterior teeth.
Dental
morphology,
planning,
adherence.
Bilell o et al.
(2022)
Accuracy
evaluation of
orthodontic
movements
with aligners:
A prospective
observational
study.
Prospective
study
Patients with
aligners Clear aligners
Accuracy ~50–60%;
rotations less
predictable.
Type of
movement,
usage,
magnitude,
anchorage.
D’Antò et al.
(2022)
Evaluation of
Tooth Movement
Accuracy with
Aligners: A
Prospective Study.
Prospective
study
Patients with
aligners Clear aligners
Simple movements
more accurate;
limited rotations.
Attachments,
staging,
compliance.
Alwa et al.
(2023)
A new method
assessing
predicted
and achieved
mandibular tooth
movement in
adults treated
with clear aligners
using CBCT and
individual crown
superimposition.
Clinical study
with CBCT
Adult
patients
Aligners +
CBCT analysis
Accuracy ~50%;
rotations less
predictable.
Type of
movement,
morphology,
anchorage,
compliance.
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Discussion
Recent evidence demonstrates that tooth
rotation remains one of the least predictable
movements in clear aligner therapy, with
reported values ranging between 28% and 70%,
depending on tooth type, movement magnitude,
and treatment design. Studies by Haouili et al.
(2020), D’Antò et al. (2024), Fiorillo et al. (2024),
and Medeiros et al. (2024) consistently indicate
that canines, premolars, and molars exhibit the
lowest rotational accuracy, particularly when
movements exceed 10–15°.
Despite technological advances, rotational
predictability rarely exceeds 60–70%,
often necessitating clinical renements,
overcorrections, or auxiliary approaches
(Haouili et al., 2020). Among the factors
inuencing movement accuracy, tooth type
plays a fundamental role. Incisors show greater
agreement between planned and achieved
movements, whereas canines and premolars
present greater difculty, likely due to their more
rounded crown morphology, which limits aligner
coupling (D’Antò et al., 2024; Medeiros et al.,
2024). Additionally, the magnitude of rotation
directly affects predictability, with a signicant
decrease observed when rotations exceed 15°
(D’Antò et al., 2024; Bilello et al., 2022).
Regarding technical factors, attachment
conguration and treatment design directly
inuence rotational control. The use of optimized
or rectangular attachments improves force
transmission, although it does not fully overcome
biomechanical limitations (Fiorillo et al., 2024;
Haouili et al., 2020).
Variables such as staging, number of aligners,
and progressive distribution of movements
have also been shown to be critical in clinical
expression (Castroorio et al., 2023; Alwa et
al., 2023). Short, sequential movement staging
appears to enhance accuracy compared to
large movements performed in a single step.
Patient-related factors also inuence treatment
predictability. Compliance with aligner wear,
age, and individual biological characteristics
such as bone density and periodontal condition
can affect the response to tooth movement
(Haouili et al., 2020; Medeiros et al., 2024). In
particular, adherence to the recommended
wear time of 20–22 hours per day is associated
with improved clinical outcomes.
From a biomechanical perspective, tooth
rotation with aligners is challenging due to the
difculty in generating pure rotational moments.
The tendency of the aligner to slip over convex
tooth surfaces and the concentration of forces
at the crown level favor tipping movements
rather than controlled rotations, limiting
effectiveness in complex movements (Aminian
et al., 2024). This explains why limitations persist
despite improvements in materials and digital
planning.
The use of three-dimensional evaluation
methods, such as digital model superimposition
or cone-beam computed tomography (CBCT),
has enabled more precise quantication of
discrepancies between planned and achieved
movements. Studies such as Alwa et al. (2023)
report accuracy values of approximately
50–60%, conrming that rotations and
extrusions remain among the least predictable
movements.
Overall, the evidence suggests that rotational
predictability depends not on a single factor but
on the interaction of biomechanical, biological,
and digital planning variables. This complexity
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References:
Alwa, A. A., Hannam, A. G., Yen, E. H., & Zou, B. (2023). A new method
assessing predicted and achieved mandibular tooth movement in adults treated with clear aligners using
CBCT and individual crown superimposition. Scientic Reports, 13, 4084. https://doi.org/10.1038/s41598-
023-31339-8
highlights the need for individualized treatment
planning, appropriate attachment use, and
complementary strategies to optimize clinical
outcomes (Haouili et al., 2020; D’Antò et al.,
2024; Castroorio et al., 2023; Fiorillo et al., 2024;
Medeiros et al., 2024; Bilello et al., 2022; Alwa et
al., 2023).
Key limitations of the included studies include
sample heterogeneity, lack of standardized
measurement methods, and small sample
sizes. Additionally, limited differentiation among
commercial systems restricts the generalizability
of ndings to broader clinical practice.
Future research should focus on developing
standardized evaluation protocols and
comparing different materials, aligner designs,
and attachment congurations under controlled
clinical conditions to improve the predictability
and efciency of rotational movements.
Conclusion
The analyzed evidence indicates that the
predictability of rotational tooth movement
with clear aligners remains variable, with better
outcomes observed in smaller rotations and in
teeth with more favorable morphology.
Despite advances in materials, attachment
design, and digital planning, biomechanical
limitations affecting movement accuracy persist.
The effectiveness of rotational control depends
on the interaction of multiple factors, including
tooth type, movement magnitude, treatment
design, and patient compliance. In this context,
individualized planning, appropriate use of
attachments, and progressive movement
staging are essential to optimize clinical
outcomes.
Nevertheless, the need for renements remains
frequent, highlighting that tooth rotation
continues to represent a challenge in clear
aligner therapy. Further clinical studies with
standardized methodologies are required to
improve the prediction and efciency of this type
of movement and to strengthen the available
evidence.
Authors contribution statement:
Conceptualization and design: HNRS, AMM
Literature review: HNRS
Methodology and validation: HNRS, AMM
Formal analysis: HNRS
Research and data collection: HNRS
Resources: HNRS
Data analysis and interpretation: HNRS, AMM
Drafting: HNRS
Writing, revision, and editing: HNRS, AMM
Supervision: AMM
Project management: HNRS
Funding:
This study was funded with the authors’ own
resources.
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Esta obra esta bajo una Licencia Creative Commons Atribución 4.0 Internacional (CC BY 4.0)
Derechos de autor ©2026 Ramos, H.N., Munive, A.
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