Accepted: 9 April 2024

DOI: 10.1111/ocr.12796

RESEARCH ARTICLE

Biomechanics of clear aligner therapy: Assessing the influence

of tooth position and flat trimline height in translational
movements

Flavio Traversa1 | Philippe Chavanne1 | James Mah2

1
Orthodontic Business Unit, Institut
Straumann AG, Basel, Switzerland Abstract
Objective: The present clear aligner therapy (CAT) research focuses on isolating and
2
School of Dental Medicine, University of
Nevada, Las Vegas, Nevada, USA
reporting the biomechanical performance for three separate teeth, three translational
Correspondence movements and two flat trimlines at different heights. By identifying key patterns,
Flavio Traversa, Institut Straumann
AG, Peter Merian-­Weg 12, Basel 4052,
the research seeks to inform the development of improved aligner designs, ultimately
Switzerland. enhancing the effectiveness of clinical orthodontic treatments.
Email: [email protected]
Materials and Methods: In an in vitro setting using the Orthodontic Force Simulator
(OFS), the biomechanical response of 30 aligners was investigated on three differ-
ent teeth of a straight symmetric maxillary dentition (central incisor, canine and first
molar). Each tooth was tested under two flat trimline conditions (trimmed at gingival
margin, TL0; extended 2.0 mm below, TL2) and for three types of translational move-
ments (palatal translation, mesial translation and intrusion). Forces and moments were
reported at the centre of resistance for each displaced tooth as well as the two neigh-
bouring teeth, evaluating a total of 18 distinct scenarios.
Results: Findings indicate significant variability in the biomechanical responses based
on tooth location in the arch, trimline height and movement performed. For pala-
tal translations, the palatal force required to perform the movement was observed
highest in molar cases, followed by canine and incisor cases, with a notable differ-
ence in the distribution of side effects, indicating a strong influence of tooth anatomy
and position in the arch. Similarly, in mesial translations and intrusions molars expe-
rienced greater forces and moments than the corresponding movements applied on
canines and incisors, but uniquely dispersed for each configuration tested. Regarding
the shape of the aligner, TL2 consistently showed improved control over orthodontic
movements compared to TL0. Neighbouring teeth frequently displayed compensa-
tory reactions up to about half of the intensity observed on the tooth being moved,
with notable variations from case to case.
Conclusions: This research supports fundamental factors impacting CAT:
• Characteristic patterns in the direction and intensity of forces and moments are
associated with each of the three translational movements tested.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 Institut Straumann AG. Orthodontics & Craniofacial Research published by John Wiley & Sons Ltd.

Orthod Craniofac Res. 2024;00:1–11.  wileyonlinelibrary.com/journal/ocr | 1

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2 TRAVERSA et al.

• Tooth anatomy and arch location significantly influence the biomechanical per-
formance of aligners, with an observed trend for molars to display higher forces
and moments over canines and incisors, but distributed differently.
• The height of a flat trimline, specifically TL2, shows enhanced control over ortho-
dontic movements.
• Additional findings revealed a compensatory activity of neighbouring teeth,
which varies based on tooth region and movement type. It potentially could influ-
ence CAT outcomes negatively and merits attention in future investigations.
These results support a tailored CAT method that improves aligner design for better
force application. This method needs to be used alongside, and confirmed by, clinical
knowledge. Future research should extend these findings to a wider range of clinical
conditions for greater applicability in the day-­to-­day orthodontic practice.

KEYWORDS
aligner biomechanics, bodily movement, flat trimline, orthodontic force simulator, scalloped
trimline

1 | I NTRO D U C TI O N suggests that augmenting the material at the trimline enhances

insertion forces, improving aligner retention and potentially
Clear aligner therapy (CAT) has emerged as an aesthetic alternative the overall biomechanical performance.15 Our prior research
to traditional braces, appreciated for its aesthetic appeal and patient focused on two trimline designs, a scalloped trimline and a flat
comfort. Recent literature underscores that the efficacy of CAT in trimline 2.0 mm below the gingival margin. 8 Our findings showed
executing precisely planned movements, especially in severe cases, that when subjecting the central incisor to buccopalatal transla-
remains an area of focus.1–3 As the understanding of CAT biome- tions, the flat aligner group displayed higher translational force
chanics deepens, so does the need to refine treatment protocols and and tipping moment compared to its scalloped counterpart. The
appliance designs to enhance clinical outcomes. moment-­to-­force ratio was lower for flat trimlines, showing better
The biomechanics underlying CAT have been the subject of translational control. Additionally, research combining in vitro and
extensive research, especially concerning the translation of single FEA tests has highlighted the influence of trimline on the loca-
teeth. In vivo studies have revealed that simple movements, such tion and magnitude of pressure between aligners and teeth.16,17
as pure translations, often result in a combination of translation There, aligners featuring an extended flat trimline yielded the
and unintended crown torque, with insufficient root control.4,5 highest forces and pressures over scalloped designs. However, a
In vitro investigations have further supported these findings, high- few questions appeared: Is the increased force due to the trimline
lighting that upper incisors predominantly move through tipping shape, specifically the added interproximal material present in flat
motion. 6–8 designs, or is it related to the overall trimline offset? How does the
Introducing a new set of assumptions from continuum mechan- performance vary in distinct locations of the upper arch, and by
ics, Finite Element Analysis (FEA) studies reinforced that tipping, applying diverse translational movements?
rather than the sought-­after translation, contributes to the ineffi- In the present study, we attempt to uncover valuable insights
ciencies observed in CAT.9–11 Further, a body of FEA research is fo- for designing more efficient aligners and refining CAT planning
cusing on remodelling the periodontal ligament past the initial phase by investigating aligner groups created by varying the following
of aligner insertion.12,13 These studies reported that desired root variables:
movements are unachieved, even when ample time for adjustment
was provided, except for translational movements performed with • Two distinct trimlines—a flat trimline passing through the gingival
attachments. This planned to achieve movement gap, combined with margin and the same trimline extended 2.0 mm below the first.
the lack of a universally agreed optimal force for tooth movement,14 • Three teeth, namely the central incisor 11, the canine 13 and the
underscores CAT's challenges in its most simple use cases as well as first molar 16, have been selected to capture variability in biome-
the need for fundamental research. chanical responses across the arch.
The aligner trimline has been identified as a potential factor • We focus on palatal translation, mesial translation and intrusion
influencing CAT's biomechanical performance. Early research to cover diverse translational cases that aligners might face.
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TRAVERSA et al. 3

We hypothesize that these factors play a significant role in the 2.2 | Aligner designs
forces and moments expressed during orthodontic movements.
The production of aligners for this study largely mirrored the meth-
odology detailed in our prior research.8 Aligners were created
2 | M ATE R I A L S A N D M E TH O DS through a multi-­step process:

2.1 | Orthodontic Force Simulator (OFS) setup • The OFS dentition was digitalized using a scanner (Virtuo Vivo,
Straumann, Basel, Switzerland), followed by a series of digital ma-
The OFS (Institut Straumann, Basel, Switzerland) is an in vitro nipulations (Spaceclaim 2022 R2, Ansys, Canonsburg, USA). After
instrument designed for clear aligner testing able to measure a final scaling of +0.8% to account for 3D-­printing inaccuracies and
three-­dimensional forces and moments (mesiodistal force Fmd, buc- thermoforming shrinkage,18 six identical models were 3D-­printed
copalatal force Fbp, intrusive-­extrusive force Fie, mesiodistal mo- (Object260 with VeroWhite resin, Stratasys, Rehovot, Israel).
ment Mmd, buccopalatal moment Mbp and rotational moment Mr) at • Each model thermoformed five aligners (Drufomat, Dreve, Unna,
the centre of eesistance (CoR) for up to 14 independent teeth. In Germany) using 0.762 mm thick ClearQuartz material (Straumann,
this study, we employed the OFS consistently with our previous Basel, Switzerland). To minimize model damage during removal,
work. 8 Aqualease75 (Mann, Macungie, USA) was applied to the models
The scope of the present study was broadened to include more before thermoforming.
teeth. Beyond the upper right central incisor tested previously, we • The 30 produced aligners were divided into two designs for laser
updated the device to also manipulate the upper right canine and the trimming (Laser Aligner Cutter, DMU, Salzburg, Austria): one with a
upper right molar. The dentition, inclusive of the established CoRs, flat trimline passing through the lowest point of the gingival margin
is depicted in Figure 1A. Each tooth was individually subjected to of each tooth, and another extending 2 mm below it, aiming for
specific translational movements applied at its CoR. To accommo- precise gingival margin tracing and smooth tooth transitions.
date different testing configurations, additional support arms were • Finally, aligners were rinsed and two aligners per group were
introduced. For example, Figure 1B illustrates the configuration imaged using a camera (iPhone12, Apple, Cupertino, USA). One
necessary for the central incisor 11 to move. Regardless of the con- aligner per group was also imaged at a closer distance using a dig-
figuration, 13 teeth were maintained in a static position, with the ital microscope (VHX-­7000, Keyence, Mechelen, Belgium). The
selected tooth connected to the hexapod. resulting images are provided separately as Figures S1 and S2.
For a comprehensive understanding of the OFS and its de-
tailed methodology, readers are encouraged to refer to our earlier Notably, the distinction in this study lies in the introduction of
8
publication. the two trimline designs, while aligning with previous methodologies

F I G U R E 1 The digital dentition used as reference and its physical counterpart mounted on the Orthodontic Force Simulator (OFS) for
testing. (A) The digital model of the upper dentition incorporates teeth up to the second molars, complemented by the gingival structure.
Central incisor 11, canine 13 and first molar 16 are highlighted in white. A centre of resistance (CoR) is represented as a reference coordinate
system for each tooth. Colour-­coded arrows indicate anatomical directions: red for mesiodistal, green for buccopalatal and blue for the long
axis. (B) A top-­down OFS view with the right central incisor assigned for movement. A TL2 aligner is fitted onto the upper dentition. The
metallic plate of the OFS is equipped with 14 force/torque sensors (one, not in use, is visible above the ‘1.1’ mark on the aligner as a rounded
surface with four holes). The remaining sensors are equipped with 13 arms made of white ceramic, each culminating in teeth crowns. Lastly,
incisor 11 is assigned to a separate sensor and in turn fixed to the hexapod. The moving platform of the hexapod is visible as the metallic disc
beneath the base plate.
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4 TRAVERSA et al.

for aligner production. Further details on the fabrication process can 5. The tested aligner was removed, the software stopped and the
8
be found in the earlier publication. procedure was repeated for the remaining 14 aligners in the se-
lected case.

2.3 | Case definition A controlled temperature of 23.0 ± 2.0°C was maintained

throughout testing. A recovery of 30 minutes was ensured before
All aligners previously constructed, although presenting different testing a new case involving the same aligners.
trimlines, were built to look and behave identical to a retainer since
they were based on a straight dentition with no tooth misalignments.
Thus, to activate an aligner into one of the three selected move- 2.5 | Data analysis
ments, the OFS introduced a temporary 0.3 mm misalignment on the
tooth CoR in the direction opposite to the desired movement. For Analysis for each case began with the raw data set, encompassing
example, to investigate palatal translation of an incisor, it was initially 18 channels containing forces and moments (Fmd, Fbp, Fie, Mmd, Mbp
displaced buccally instead. and Mr ) gathered before. The initial 0.7 seconds of each measure-
The selection of cases was motivated by a comprehensive ap- ment, representing the time needed for the hexapod to move, was
proach to understanding aligner biomechanics. By examining three excluded. For each measurement and channel, a median was calcu-
distinct teeth, we aimed to capture the variability across the den- lated from the raw data, serving as the primary measurement. This
tal arch. Further, by considering three types of movements—palatal method was applied consistently across all 15 aligners for a specific
translation, mesial translation and intrusion—we attempted to en- case.
compass the distinct challenges aligners might face in clinical appli- A signal-­to-­n oise ratio (SNR) was introduced, aimed at com-
cations. The inclusion of two trimline heights for each combination paring the magnitude of the expected outcome to the largest and
was designed to elucidate the potential biomechanical implications undesired side effect for the moved tooth. For palatal translations,
of trimline design. the primary outcome is Fbp and the significant unwanted side ef-
Building on the three highlighted variables, this study analysed a fect is Mbp, so the SNR was calculated as Fbp ∕ Mbp. Similarly, for
total of 18 distinct cases, reported in Table 1A. Each case stands for mesial translations, the SNR was Fmd ∕ Mmd. Intrusion cases pre-
a unique set of conditions designed to investigate the interactions of sented a unique challenge due to two large side effects: Fbp and
aligner-­tooth biomechanical dynamics. Mbp. Consequently, two SNRs were reported: Fie ∕ Fbp and Fie ∕ Mbp.
By including SNR in the previously created 18 forces and moments
channels, the channel total resulted in either 19 or 20 channels.
2.4 | Test protocol At this point, every channel totalled 45 measurements. For case
In-­11-­TL2, three anomalous measurements from one single aligner
To simulate the biomechanical effects of tooth movement using were identified and excluded.
clear aligners, the OFS was employed for each case tested in the Descriptive statistics, specifically mean and standard deviation,
following sequence: were then calculated for each metric. For the SNR values, the me-
dian was instead reported since data distribution highly deviated
1. Aligners were prepared with artificial saliva (Biotène Oralbalance from normality for intrusion cases. Resulting descriptive statistics
Moisturizing Gel, Haleon Group, Weybridge, Surrey, UK) to were reported in three tables, grouped by tooth movement. To en-
mimic the oral cavity. The OFS software was configured to hance readability, a graphical representation was introduced, show-
perform the selected movement, and sensors were initialized casing teeth models in 2D views featuring CoRs and coloured arrows
to zero. (linear for forces and rotational for moments) representing forces
2. Aligners were manually inserted front to back, using thumbs, onto and moments.
the OFS dentition in air environment.
3. The OFS began logging Fmd, Fbp, Fie, Mmd, Mbp and Mr for the se-
lected tooth and the two neighbouring teeth at 25 ms intervals. 2.6 | Statistical analysis
An initial baseline measurement of 5.0 s, not reported in our re-
sults, established the starting point. All sensors were zeroed for Statistical analysis was conducted using Welch's ANOVAs in Minitab
1.0 s, ensuring subsequent measurements would only capture ef- 20.2 (Minitab, State College, US), selected after observing hetero-
fects from the induced movement and ignore the initial aligner scedasticity in our preliminary data and insights from prior studies,
response as a retainer. indicating violations of the equal variance assumption. We analysed
4. The target tooth was displaced to its desired position for 5.0 s, then the factors Tooth (levels: 11, 13, 16) and Trimline (levels: TL0, TL2)
reverted to its initial position for another 5.0 s. This sequence was on both expected and unintended responses. Expected outcomes
repeated three times per aligner, yielding three measurements. were determined by the force needed to perform the requested
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TRAVERSA et al. 5

TA B L E 1 (A) Summary of cases tested, and (B) statistics performed.

A. All cases tested, combining different movements, teeth and trimlines B. Welch's ANOVAs performed for selected groups

Trimline ANOVA
Short case name Tooth moved design Case group Response Factor name

pT-­11-­TL0 Central incisor 11 TL0 Palatal Translation Expected response: Tooth ANOVA1
Cases (pT-­) Buccopalatal force Fbp Trimline ANOVA2
pT-­11-­TL2 Central incisor 11 TL2
pT-­13-­TL0 Canine 13 TL0
pT-­13-­TL2 Canine 13 TL2 Largest secondary response: Tooth ANOVA3
pT-­16-­TL0 First Molar 16 TL0 Buccopalatal moment Mbp Trimline ANOVA4

pT-­16-­TL2 First Molar 16 TL2

mT-­11-­TL0 Central incisor 11 TL0 Mesial Translation Expected response: Tooth ANOVA5
Cases (mT-­) Mesiodistal force Fmd Trimline ANOVA6
mT-­11-­TL2 Central incisor 11 TL2
mT-­13-­TL0 Canine 13 TL0
mT-­13-­TL2 Canine 13 TL2 Largest secondary response: Tooth ANOVA7
mT-­16-­TL0 First Molar 16 TL0 Mesiodistal moment Mmd Trimline ANOVA8

mT-­16-­TL2 First Molar 16 TL2

In-­11-­TL0 Central incisor 11 TL0 Intrusion Cases (In-­) Expected response: Tooth ANOVA9
In-­11-­TL2 Central incisor 11 TL2 Intrusive-­extrusive force Fie Trimline ANOVA10

In-­13-­TL0 Canine 13 TL0 Secondary response 1: Tooth ANOVA11

In-­13-­TL2 Canine 13 TL2 Buccopalatal force Fbp Trimline ANOVA12

In-­16-­TL0 First Molar 16 TL0 Secondary response 2: Tooth ANOVA13

In-­16-­TL2 First Molar 16 TL2 Buccopalatal moment Mbp Trimline ANOVA14

tooth movement, while unintended outcomes were identified from is calculated as Fmd ∕ Mmd. Table 4 displays the six intrusion cases.
preliminary OFS tests as significant unintended forces or moments. Differently from previous tables, here two SNRs are provided, cal-
For intrusion cases, two unintended responses were selected due culated as Fie ∕ Fbp and Fie ∕ Mbp.
to their similarly pronounced magnitudes. A total of 14 Welch's Table 5 presents the statistical analysis. Through multiple one-­
ANOVAs (seven for each of the factors: Tooth and Trimline) were way Welch's ANOVA, with tooth position and trimline design as
performed and summarized in Table 1A. factors, significant differences in means were identified. Post hoc
Given that two or three ANOVAs were conducted on the same Games-­Howell tests further discerned which groups had significant
response, we applied Bonferroni correction to control for Type I differences, except for ANOVA14 that displayed no significance.
error rate, adjusting the significance level from 0.05 to 0.025 or
0.016, respectively. Upon identifying significant main effects,
Games-­H owell post hoc tests, detailed in Table 1B, were con- 4 | DISCUSSION
ducted to pinpoint which specific levels of the factors (e.g. dif-
ferent teeth or trimlines) had significantly different means for the This study focused on how tooth position and variations in flat
response variables. trimline influence CAT. Results revealed that these factors im-
pact aligner biomechanics, demonstrating characteristic patterns
of forces and moments across 18 different combinations of teeth,
3 | R E S U LT S trimlines and movements. The following discussion will dissect
these findings, examining each orthodontic movement individually.
Table 2 showcases outcomes for palatal translation cases, combin-
ing different tooth positions and trimline designs. The table displays
reports both qualitatively and quantitatively forces and moments 4.1 | Palatal translation
for each tooth moved as well as the neighbouring teeth. The pro-
vided SNR ratio Fbp ∕ Mbp serves as an indicator for the quality of Palatal translation cases showcased a consistent palatal force (Fbp ) in
the expressed movement. Table 3 results for mesial translation cases the range of p5.67–p11.00 N, and palatal tipping moment (Mbp) in the
are presented similarly to palatal translation cases. Here the SNR range of p8.25–p16.89 Ncm, with significant differences captured
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6 TRAVERSA et al.

TA B L E 2 This table presents six palatal translation cases alternating tooth position and trimline design.

Case pT-11-TL0 pT-11-TL2 pT-13-TL0 pT-13-TL2 pT- 16-TL0 pT-16-TL2

b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b
Occlusal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m
p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p

Frontal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m

Sagial View b← →p b← →p b← →p b← →p b← →p b← →p

Tooth 12 11 21 12 11 21 14 13 12 14 13 12 17 16 15 17 16 15
m0.10 d0.52 d0.15 m0.85 d0.87 d0.04 m 1.11 m0.21 d0.26 m1.29 m0.20 d0.31 m2.20 d0.39 m0.08 m2.69 d0.22 d0.41
(0.40) (0.21) (0.35) (0.22) (0.17) (0.13) (0.39) (0.31) (0.26) (0.31) (0.30) (0.42) (0.57) (0.41) (0.40) (0.61) (0.33) (0.46)
b0.79 p5.67 b2.85 b1.10 p7.68 b4.67 b3.44 p7.50 b1.12 b3.38 p8.21 b1.69 b3.97 p9.75 b5.07 b5.13 p11.00 b5.29
(0.36) (0.50) (0.93) (0.41) (1.12) (0.51) (0.29) (0.61) (0.45) (0.49) (0.84) (0.57) (0.73) (1.17) (0.70) (0.89) (1.32) (0.46)
i0.08 i0.84 i0.53 e0.15 i0.06 e0.13 e0.65 e2.15 e0.09 e0.29 e2.97 e0.04 e0.63 e2.04 i0.34 e0.35 e2.43 e0.18
(0.13) (0.49) (0.26) (0.14) (0.64) (0.29) (0.56) (0.66) (0.17) (0.28) (0.76) (0.28) (0.53) (1.11) (0.56) (0.44) (1.08) (0.62)
m0.15 d0.31 m0.18 m1.30 d0.98 d0.47 m1.46 m3.34 d0.26 m1.90 m3.77 d0.23 m3.17 d1.10 m0.16 m3.80 d0.07 d0.22
(0.52) (0.51) (0.81) (0.26) (0.42) (0.45) (0.67) (0.54) (0.39) (0.50) (0.42) (0.47) (0.63) (0.77) (0.43) (0.91) (0.88) (0.49)
b1.02 p12.26 b4.54 b1.21 p16.89 b8.16 b4.18 p8.25 b1.88 b4.05 p8.19 b2.69 b5.34 p12.83 b6.46 b6.75 p13.66 b6.71
(0.49) (1.09) (1.33) (0.59) (2.35) (0.87) (0.35) (0.48) (0.72) (0.65) (0.73) (0.89) (1.28) (1.73) (1.27) (1.34) (1.50) (0.59)
cc0.08 c0.81 c1.55 cc0.32 c1.51 c2.23 cc0.33 c1.38 c0.26 cc0.27 c1.82 c0.35 cc1.50 c0.71 c0.69 cc2.49 c0.55 c0.31
(0.08) (0.26) (0.37) (0.09) (0.28) (0.27) (0.29) (0.20) (0.17) (0.21) (0.28) (0.27) (0.57) (0.42) (0.44) (0.90) (0.40) (0.18)
SNR =
- 0.46 - - 0.46 - - 0.90 - - 0.99 - - 0.76 - - 0.80 -

Note: Visual qualitative directions of forces and moments are depicted in the upper quadrants with coloured arrows: arrows from a brown point, the
CoR, indicate forces, and arrows revolving around the CoR signify moments. Quantitative data for these forces and moments follow, as means with
standard deviations in parentheses, using the same colour scheme. The ‘m’ and ‘d’ signs in Fmd represent a mesial or distal translational force, leading
to mesiodistal bodily movements; ‘b’ and ‘p’ in Fbp denote a buccal or palatal force, leading to a pure buccopalatal translation; for Fie, ‘i’ and ‘e’ signify
intrusive or extrusive forces; mesiodistal moment Mmd and buccopalatal moment Mbp use the same directional indicators of Fmd and Fbp, respectively;
while ‘c’ and ‘cc’ in M_r depict clockwise and counterclockwise rotations around the vertical axis. Light blue cells indicate the expected response and
light orange cells highlight the largest secondary response. Finally, the SNR for the moved tooth is reported in the last row as median.

TA B L E 3 This table presents six mesial translation cases alternating tooth position and trimline design.

Case
mT-11-TL0 mT-11-TL2 mT-13-TL0 mT-13-TL2 mT-16-TL0 mT-16-TL2

b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b
Occlusal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m
p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p

Frontal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m

Sagittal View b← →p b← →p b← →p b← →p b← →p b← →p

Tooth 12 11 21 12 11 21 14 13 12 14 13 12 17 16 15 17 16 15
d0.88 m6.93 m1.39 d2.62 m9.24 m1.31 d1.50 m8.43 d1.83 d2.85 m10.04 d1.65 d3.77 m9.98 d4.47 d8.52 m16.97 d5.65
(1.06) (0.80) (0.23) (0.75) (0.78) (0.19) (0.64) (1.00) (0.41) (0.29) (0.70) (0.26) (1.25) (1.43) (0.81) (0.96) (1.21) (0.41)
b0.65 p0.33 p2.13 b1.66 p0.25 p1.61 b1.62 b0.14 p1.42 b0.12 b1.51 p1.42 b0.64 p0.08 p1.12 b1.81 p0.49 p0.89
(0.57) (0.23) (0.45) (0.42) (0.35) (0.25) (0.58) (0.62) (0.21) (0.38) (0.38) (0.32) (0.27) (0.27) (0.34) (0.44) (0.35) (0.28)
i0.27 e0.05 e0.64 i0.75 e0.50 e0.40 e1.46 i3.22 i0.39 e0.71 i3.21 i0.05 i0.13 i0.95 i0.41 i1.29 e2.93 e1.30
(0.49) (0.45) (0.18) (0.24) (0.48) (0.24) (0.46) (0.45) (0.33) (0.28) (0.35) (0.23) (0.22) (0.36) (0.34) (0.30) (1.02) (0.60)
d1.19 m19.13 m3.29 d3.95 m25.77 m3.19 d2.54 m18.77 d2.57 d4.34 m22.00 d1.88 d5.20 m19.93 d5.21 d12.40 m27.33 d5.93
(1.48) (2.50) (0.59) (1.13) (2.38) (0.46) (0.97) (2.31) (0.60) (0.47) (1.83) (0.39) (1.77) (2.56) (1.00) (1.21) (1.95) (0.52)
b1.05 b0.16 p2.28 b2.92 b0.10 p1.52 b2.01 p6.63 p1.46 b0.26 p6.49 p1.35 b2.17 b1.93 b0.01 b4.82 b6.58 b0.60
(1.10) (0.56) (0.67) (0.76) (0.71) (0.29) (0.67) (0.62) (0.24) (0.40) (0.80) (0.52) (0.69) (0.38) (0.44) (0.98) (0.74) (0.46)
cc0.21 c4.59 c1.35 c0.08 c6.34 c1.21 c0.85 c3.20 c0.72 c1.13 c4.10 c0.32 c0.27 c2.80 c0.29 c1.79 c2.80 c0.14
(0.12) (0.66) (0.26) (0.07) (0.62) (0.18) (0.22) (0.58) (0.17) (0.18) (0.51) (0.11) (0.30) (0.43) (0.16) (0.43) (0.49) (0.27)

- 0.36 - - 0.36 - - 0.45 - - 0.46 - - 0.50 - - 0.62 -

Note: Visual qualitative directions of forces and moments are depicted in the upper quadrants with coloured arrows: arrows from a brown point,
the CoR, indicate forces, and arrows revolving around the CoR signify moments. Quantitative data for these forces and moments follow, using the
same colour scheme: ‘m’ and ‘d’ signs in Fmd represent a mesial or distal translational force, leading to mesiodistal bodily movements; ‘b’ and ‘p’ in Fbp
denote a buccal or palatal force, leading to a pure buccopalatal translation; for Fie, ‘i’ and ‘e’ signify intrusive or extrusive forces; mesiodistal moment
Mmd and buccopalatal moment Mbp use the same directional indicators of Fmd and Fbp, respectively; while ‘c’ and ‘cc’ in M_r depict clockwise and
counterclockwise rotations around the vertical axis. Values are shown as means with standard deviations in parentheses. Light blue cells indicate the
expected response and light orange cells highlight the largest secondary response. Finally, the SNR for the moved tooth is reported in the last row as
median.
 |

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TRAVERSA et al. 7

TA B L E 4 This table presents six palatal translation cases alternating tooth position and trimline design.

Case In-11-TL0 In-11-TL2 In-13-TL0 In-13-TL2 In-16-TL0 In-16-TL2

b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b b↑ ↑b
Occlusal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m
p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p p↓ ↓p

Frontal View d← →m← →d d← →m← →d d← →m d ← →m d ← →m d ← →m

Sagittal View b← →p b← →p b← →p b← →p b← →p b← →p

Tooth 12 11 21 12 11 21 14 13 12 14 13 12 17 16 15 17 16 15
d0.30 m0.37 m0.53 d0.05 m0.68 m0.96 m0.74 d0.28 d0.28 m0.37 d0.41 d0.06 m1.58 m1.32 d1.02 m3.30 m1.94 d2.09
(0.28) (0.18) (0.12) (0.32) (0.24) (0.42) (0.25) (0.30) (0.18) (0.35) (0.32) (0.39) (0.31) (0.27) (0.44) (0.76) (0.39) (0.37)
p0.53 p1.81 p0.42 p1.34 p2.35 p0.68 p0.50 p1.88 p0.11 p0.57 p1.46 p0.72 b0.78 p2.37 b0.62 b1.70 p3.00 b0.15
(0.32) (0.29) (0.20) (0.37) (0.74) (0.26) (0.19) (0.25) (0.18) (0.26) (0.91) (0.47) (0.22) (0.30) (0.20) (0.40) (0.48) (0.30)
e0.03 i3.32 e0.41 i0.01 i5.46 e1.03 e1.62 i4.39 e0.35 e1.63 i5.80 e0.47 e2.87 i5.80 e1.84 e4.58 i9.50 e2.94
(0.33) (0.55) (0.17) (0.43) (1.58) (0.61) (0.41) (0.96) (0.38) (0.62) (1.57) (0.49) (0.34) (1.20) (0.47) (1.33) (2.38) (1.14)
d0.40 m1.27 m1.38 d0.12 m1.76 m2.52 m1.11 d0.54 d0.31 m0.65 d0.97 d0.05 m1.93 m2.17 d0.88 m4.40 m1.80 d1.94
(0.40) (0.57) (0.32) (0.61) (0.70) (1.03) (0.36) (0.64) (0.23) (0.53) (0.67) (0.42) (0.39) (0.74) (0.47) (0.84) (0.79) (0.38)
p0.62 p3.58 p0.26 p1.90 p4.23 p0.33 p0.65 p2.85 b0.06 p0.68 p2.37 p0.80 b1.38 p2.84 b1.45 b2.71 p3.33 b0.81
(0.44) (0.66) (0.29) (0.50) (1.37) (0.51) (0.30) (0.34) (0.34) (0.30) (1.59) (0.77) (0.51) (0.47) (0.34) (1.01) (0.67) (0.50)
cc0.01 c0.43 c0.71 cc0.25 c0.49 c1.06 cc0.03 cc0.14 cc0.02 c0.12 cc0.40 c0.03 cc0.68 c0.55 cc0.12 cc1.75 c0.12 cc0.02
(0.04) (0.14) (0.21) (0.10) (0.23) (0.44) (0.12) (0.15) (0.07) (0.19) (0.21) (0.13) (0.18) (0.28) (0.14) (0.67) (0.40) (0.29)

- 1.82 - - 2.34 - - 2.38 - - 3.63 - - 2.55 - - 3.12 -

- 0.95 - - 1.27 - - 1.56 - - 2.10 - - 2.03 - - 2.90 -

Note: Visual qualitative directions of forces and moments are depicted in the upper quadrants with coloured arrows: arrows from a brown point,
the CoR, indicate forces, and arrows revolving around the CoR signify moments. Quantitative data for these forces and moments follow, using the
same colour scheme: ‘m’ and ‘d’ signs in Fmd represent a mesial or distal translational force, leading to mesiodistal bodily movements; ‘b’ and ‘p’ in Fbp
denote a buccal or palatal force, leading to a pure buccopalatal translation; for Fie, ‘i’ and ‘e’ signify intrusive or extrusive forces; mesiodistal moment
Mmd and buccopalatal moment Mbp use the same directional indicators of Fmd and Fbp, respectively; while ‘c’ and ‘cc’ in M_r depict clockwise and
counterclockwise rotations around the vertical axis. Values are shown as means with standard deviations in parentheses. Light blue cells indicate the
expected response and light orange cells highlight the two main secondary responses. Finally, SNR1 and SNR2 for the moved tooth are reported in
the last row as median.

across tooth location (ANOVA1, P < .001) and trimline height 4.2 | Palatal translation: comparison with
(ANOVA2, P < .001). Following up with post hoc, Games-­Howell previous research
tests (P ≤ .001) exposed that molar cases exhibited the highest Fbp ,
followed by the canine cases, and incisor cases. This hierarchy of Similar in vitro research performed 0.2 mm palatal translations on
force magnitudes could be attributed to the inherent structural and the central incisor and on the canine, with the main differences in
positional differences of teeth, with molars having a crown size that the method being a different anatomy of the arch, the teeth included
could be simplified to a rectangular cross-­section, potentially allow- and the use of scalloped aligners made of Taglus material.7 There,
ing for greater force application compared to a smaller and triangular resulting Fbp and Mbp were observed highest on the canine, and the
shaped one for the canine or incisor. Additionally, this disparity could SNR, retrospectively calculated from the results provided, was the
be due to a significant thinning of aligners observed in the frontal lowest again on the canine. This disparity in results clashes with
region compared to the posterior,19 calling for a reevaluation of the present results, highlighting how variations in study design such as
large body of FEA literature where aligners are modelled with a con- dentition, aligner design, and test method can significantly influence
stant thickness. outcomes.
In terms of undesired responses, the buccopalatal moment (Mbp) Current findings resonate with our earlier observations, where
was pronounced in a different succession than for Fbp, being mostly a 0.3 mm palatal translation of the upper central incisor was per-
pronounced in incisor cases, followed by molar cases and finally by formed on the OFS.8 There, aligners featuring a 2 mm flat trimline
canine cases (ANOVA3, P < .001; Games-­Howell test, P ≤ .001). The displayed an Fbp of 7.51 N, an Mbp of 15.94 Ncm and an SNR of 0.47.
trimline significantly influenced Mbp in the same fashion as Fbp did This is strikingly similar to the current findings for the same con-
(ANOVA4, P < .001; Games-­Howell test, P < .001). Overall, canine figuration (pT-­11-­TL2), strengthening the reproducibility of the test
cases displayed the lowest Mbp values as well as being the only tooth protocol and of the OFS in capturing aligner performance. In con-
additionally expressing a mild extrusive force (Fie). By relating Fbp to trast, in the earlier study8 the scalloped trimline resulted in an Fbp
Mbp, the significance of the SNR becomes evident, with the most of p4.93 N, Mbp of p10.64 Ncm, and SNR of 0.46, suggesting that
predictable palatal translation resulting for canine cases (0.90 for pT-­ a scalloped trimline can deliver lowered forces and moments com-
13-­TL2 and 0.99 for pT-­13-­TL2), followed by molar cases and incisor pared to a 0 mm flat trimline tested in the current study. Both current
cases. and previous findings collectively highlight that the trimline design
 | 8

TA B L E 5 Results of the statistical analysis. Significant ANOVAs (ANOVA1-­13) were followed up by post hoc tests.

One-­way Welch's ANOVA Post hoc Games-­Howell test

Difference of Mean difference [N 95% CI [N or Adjusted

Case group Response Factor Name F-­value P-­value levels or Ncm] Ncm] P-­value

Palatal translation cases Buccopalatal force (Fbp) Tooth ANOVA1 175.62 <.001** 13–11 p1.18 (p0.79, p1.57) <.001*
(pT-­) 16–11 p3.70 (p3.22, p4.18) <.001*
16–13 p2.52 (p2.12, p2.92) <.001*
Trimline ANOVA2 37.70 <.001** TL2–TL0 p1.32 (p0.88, p1.77) <.001*
Buccopalatal moment (Mbp) Tooth ANOVA3 523.88 <.001** 13–11 b6.35 (b5.59, b7.11) <.001*
16–11 b1.33 (b0.48, b2.17) .001*
16–13 p5.02 (p5.47, p4.58) <.001*
Trimline ANOVA4 20.54 <.001** TL2–TL0 p1.80 (p2.58, p1.02) <.001*
Mesial translation cases Mesiodistal force (Fmd) Tooth ANOVA5 84.48 <.001** 13–11 m1.15 (m1.61, m0.70) <.001*
(mT-­) 16–11 m5.39 (m6.40, m4.39) <.001*
16–13 m4.24 (m5.22, m3.25) <.001*
Trimline ANOVA6 113.40 <.001** TL2–TL0 m3.64 (m4.31, m2.96) <.001*
Mesiodistal moment (Mmd) Tooth ANOVA7 21.07 <.001** 13–11 d2.07 (d0.84, d3.29) <.001*
16–11 m1.17 (m2.67, d0.32) .154
16–13 m3.24 (m4.5, m1.97) <.001*
Trimline ANOVA8 290.09 <.001** TL2–TL0 m5.76 (m6.43, m5.09) <.001*
Intrusion cases (In-­) Intrusive-­extrusive force (Fie) Tooth ANOVA9 51.35 <.001*** 13–11 i0.75 (i1.29, i0.20) .004*
16–11 i3.30 (i4.07, i2.53) <.001*
16–13 i2.55 (i3.31, i1.80) <.001*
Trimline ANOVA10 90.04 <.001*** TL2–TL0 i2.45 (i2.96, i1.94) <.001*
Buccopalatal force (Fbp) Tooth ANOVA11 66.64 <.001*** 13–11 b0.40 (b0.63, b0.17) <.001*
16–11 p0.61 (p0.41, p0.81) <.001*
16–13 p1.01 (p0.80, p1.23) <.001*
Trimline ANOVA12 7.31 .008*** TL2–TL0 p0.24 (p0.07, p0.42) .008*
Buccopalatal moment (Mbp) Tooth ANOVA13 29.70 <.001*** 13–11 b1.29 (b0.88, b1.69) <.001*
16–11 b0.81 (b0.49, b1.13) <.001*
16–13 p0.48 (p0.81, p0.15) .002*
Trimline ANOVA14 2.09 .150 — — — —

Note: Responses and factors are the same for both ANOVA and Games-­Howell tests. Cells in light blue represent the expected force response for a particular case, whereas those in light orange highlight
the most significant undesired responses. Asterisks denote statistical significance: *P < .050, **P < .025, **P< .016, after Bonferroni correction for multiple comparisons.
TRAVERSA et al.

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TRAVERSA et al. 9

widely affects forces and moments achieved in palatal translation be more complex. Additionally, an FEA study22 showed that adding a
of the incisor, while unwanted tipping moments remains a constant modified lever arm with elastics could effectively counter the align-
challenge in all of them. er's distal Mmd during molar mesialization and unlocking root tipping.
Seeking to solve recurring issues of buccopalatal movements, a However, this approach requires elastics, significant aligner modi-
body of research has recently appeared introducing local aligner al- fications, and the potential impact of metallic parts on the gingival
11,20
terations. These modifications, combined with the variabilities in tissue.
anatomy, trimline design, and study methodologies, highlight com-
plexities in formulating uniform guidelines for effective CAT plan-
ning, as well as suggesting a simple approach to overcome issues 4.5 | Intrusion cases
encountered in buccopalatal translations.
In intrusion cases, aligners typically exert an intrusive Fie between
i3.32 and i9.50 N, with side effects Fbp (p1.46 to p3.00 N) and Mbp
4.3 | Palatal translation: neighbouring teeth (p2.37 to p4.23 Ncm). The first molar manifested the highest Fie ,
followed by the canine (ANOVA9, P < .001; Games-­H owell tests
Looking at neighbouring teeth, our findings indicate a compensatory P ≤ .004). The side effect Fbp was the lowest on the canine, followed
dynamic. For central incisor cases, incisor 21 steps in to absorb a by the incisor (ANOVA11, P < .001; Games-­H owell tests, P < .001).
significant portion of Fbp and Mbp in the opposite direction. The lat- For the second undesired outcome Mmd, the order changed to low-
eral 12 shows minimal involvement, possibly due to reduced aligner est on the canine, followed by the molar (ANOVA13, P < .001;
contact. Similarly, in canine cases, premolar 14 takes on a compensa- Games-­H owell tests, P ≤ .002). SNRs indicated the worst perfor-
tory role, reflecting nearly half of the forces and moments directed mance in In-­11-­TL0 case (SNR1 = 1.82, SNR2 = 0.95), while the
at the canine, revealing a potential correlation between crown size best results for SNR1 were found in In-­13-­TL2 (SNR1 = 3.63), and
of neighbouring teeth and the response observed. In molar cases, SNR2 was found in In-­16-­TL2 (SNR2 = 2.90). These unwanted re-
adjacent 15 and 17 display a more symmetrical distribution. Here, sults accentuate the challenge of achieving pure vertical intrusion
forces are above 5 N, high enough to hint at a trigger for bone re- movements precisely, especially in TL0 cases and incisor cases. Fie
modelling. In the future, more research aiming at counteracting side was significantly affected by the trimline, with TL2 scoring higher
effects is needed, particularly when multiple teeth movements are force values by i2.45 N than TL0 (ANOVA10, P < .001; Games-­
planned simultaneously. Howell test, P < .001). The trimline interaction with the two side
effects was instead not detected (Mbp, ANOVA14, P = .150) or
significantly present but with a low power only (Fbp, ANOVA12,
4.4 | Mesial translation cases P = .008; Games-­H owell test, P = .008, TL2–TL0 = p0.24 N). The
combination of these trends suggests an elevated biomechanical
In mesial translation cases, Fmd ranged from m6.93 to m16.97 N performance for TL2 over TL0 while keeping side effects in a simi-
and an Mmd from m19.13 to m27.33 Ncm. The Fmd magnitude dis- lar range.
played significant differences following the same teeth order as Neighbouring teeth, particularly in canine and molar cases, exhib-
palatal translations: molar, canine and incisor (ANOVA5, P < .001; ited compensatory extrusion, which in a clinical setting could again
Games-­H owell tests, P < .001). Neighbouring teeth often showed lead to misfitting aligners and unnecessary bone remodelling. This
unpredictable responses to mesial translations, except for a com- could be further exacerbated in a scenario where multiple nearby
mon mild distal Fmd and Mmd opposite to the moved tooth. The trim- teeth are planned to be intruded together, as highlighted by clinical
line influenced significantly both Fmd and Mmd, with TL2 scoring studies. 23,24 This emphasizes the need for research on intrusions to
higher values (ANOVA6 and ANOVA8, P < .001; Games-­H owell mitigate side effects, possibly exploring structural reinforcements,
tests, P < .001). The unwanted Mmd was found less pronounced in attachments, bite ramps and incorporating occlusal forces.
the canine (ANOVA7, P < .001; Games-­H owell tests, 13–11 and
16–13 levels, P < .001). SNRs emphasized this divergence further,
displaying a rising trend from 0.36 for incisor cases to 0.62 for 4.6 | More on trimline
the molar case with TL2. Compared to palatal translations, mesial
translations exhibited overall lower SNRs, up to around 50% for Trimline significantly affects clear aligner performance, with TL2
canine cases, potentially leading to a decrease in tooth movement recommended for better control and efficacy in CAT, especially for
predictability. Additionally, mesial translations were complicated incisor movements. TL2 appears to provide superior control over
by the expression of a mild Mr. side effects, possibly due to increased aligner material in contact-
Introducing attachments could potentially reduce the observed ing the tooth, which can enhance force application.16 However,
21
side effects, but their effectiveness remains mixed. One study in cases of severe proclination, gingival recession, abfraction and
found that attachments on molars did not significantly improve me- black triangles, a common clinical practice is to reduce the trimline
siodistal translations, suggesting their role in aligner therapy might extension to ease aligner removal and reduce extreme retention,
 |

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10 TRAVERSA et al.

potentially reducing CAT effectiveness and predictability. Reducing 1. Aligner response varies significantly depending on the tooth's
movement rates could be an alternative strategy, delivering gentler anatomy and position within the dental arch, necessitating
forces for extensive mesialization or distalization, balancing effi- custom aligner designs depending on the tooth moved.
ciency, patient comfort and treatment outcome. 2. Trimline design significantly impacts aligner performance, with
higher trimlines (TL2) providing enhanced control, especially for
incisors.
4.7 | Contrast of the three different movements 3. The three tested translations display characteristic biomechanical
responses, specific to the applied movement direction.
The study applied forces to aligners, moving them from a relaxed 4. A compensatory response is observed on neighbouring teeth,
state to a deformed position. This creates areas of tension and com- opposite to the planned movement. Overcoming this interaction
pression within the aligner, due to its spring-­like viscoelastic behav- is crucial for designing aligners that minimize unintended tooth
iour, characteristic of the three-­layered thermoplastic material used. movements.
Depending on the direction of the applied movement, the location 5. The intensity of aligner forces should be balanced between pa-
of the movement application and the anatomy of the dental arch tient comfort and successful initiation of tooth movement. Given
results could change dramatically.7,25 Our findings indicate the high- the variation between in vitro and in vivo forces, achieving opti-
est forces occur during mesial translations, with palatal translations mal CAT results requires a harmonious blend of empirical clinical
and intrusions following, suggesting a reconsideration of the typi- practice and biomechanical theory.
cal uniform staging protocol. A force-­controlled treatment protocol, 6. Study limitations, including its in vitro nature, the number of
adjusting movement rates, trimline heights and aligner shapes could movements and teeth reported, movements limited to one tooth,
enhance treatment efficacy and reduce the need for revisions. While and the exclusion of various clinical factors such as the periodon-
this study suggests biomechanical factors like root number and peri- tal ligament, suggest areas for further research. Future studies
odontal health affect performance, patient comfort and outcome should aim to include multiple teeth movements, teeth, dentitions
optimization need clinical validation. and aligner systems, to enhance the applicability of the findings in
clinical scenarios.

4.8 | Study limitations AU T H O R C O N T R I B U T I O N S

The authors confirm contribution to the paper as follows: Study
This study's limitations point to the need for further research, par- conception and design: Flavio Traversa, Philippe Chavanne, James
ticularly due to its in vitro design, which does not fully replicate the Mah. Data collection: Flavio Traversa. Analysis and interpretation of
complex in vivo conditions. The lack of a periodontal ligament over- results: Flavio Traversa, Philippe Chavanne, James Mah. Draft manu-
emphasizes the magnitude of forces and moments measured, as the script preparation: Flavio Traversa. All authors reviewed the results
presence of the ligament allows for tooth repositioning between and approved the final version of the manuscript.
their original position and the one dictated by the aligner, likely re-
ducing the aligner force delivered by a large factor. Variables, such DATA AVA I L A B I L I T Y S TAT E M E N T
as patient age, oral health, dental crowding and the presence of Research data are not shared.
implants, were not studied. Additionally, the focus on a single tooth
misalignment using one material type and two trimline designs, E T H I C A L A P P R OVA L
without including attachments or elastics, limits the applicability of This study, evaluating the biomechanics of clear aligner therapy
the results. The large 0.3 mm movement applied and cooler testing using an in vitro test device, required no ethical approval as it did not
conditions may have led to unnaturally high force measurements involve human or animal subjects, adhering strictly to all applicable
compared to real orthodontic settings, where smaller movements research integrity and ethical standards.
occur in the warmer oral environment. The omission of aligner ma-
terial's stress relaxation, which lowers force over time, suggests a ORCID
need for protocols that more closely mimic oral conditions, con- Flavio Traversa https://orcid.org/0009-0006-2468-6301
sidering different temperatures, humidities, and aligner types to
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