ORIGINAL ARTICLE

Activation time and material stiffness of

sequential removable orthodontic appliances.
Part 3: Premolar extraction patients
Danilee K. Baldwin,a Greg King,b Douglas S. Ramsay,c Greg Huang,d and Anne-Marie Bollene
Seattle, Wash

Introduction: The purpose of this study was to describe the movement of teeth adjacent to premolar
extraction spaces during space closure with aligner appliances and then fixed appliances. Methods: The
sample included 24 subjects from a larger study investigating an aligner system. All subjects had at least 1
premolar extracted as part of treatment. Dental casts and panoramic radiographs were measured for tooth
tipping adjacent to extraction spaces at 3 treatment points: T0, initial; T2, end of aligners; and T3, end of fixed
appliances. Chart records were reviewed for information about time in treatment. Results: Treatment with
aligners resulted in significant tipping of the teeth adjacent to premolar extraction sites. When followed by
fixed appliances, these teeth were significantly uprighted. Aligner treatment followed by treatment with fixed
appliances took an average of 40 months. Conclusions: In premolar extraction patients treated with aligners,
dental tipping occurs but can be corrected with fixed appliances. This dual modality treatment might require
more time than treatment with fixed appliances alone. (Am J Orthod Dentofacial Orthop 2008;133:837-45)

T
he importance of evaluating the mesiodistal
inclination of teeth is a widely accepted concept
in orthodontics. A goal of orthodontic treatment
is to establish good root parallelism. Function, esthet-
ics, and stability have all been cited as reasons for
achieving proper tooth inclinations.1,2 Controlling tooth
inclination is especially important during closure of
extraction sites because the crowns of adjacent teeth
can easily tip into these spaces.
Although control of tip and torque during the
closure of extraction spaces is important to achieve an
optimal result, it can sometimes be difficult to accom-
plish. In general, fixed appliances have an advantage
over removable appliances in this respect because of
their ability to create an effective couple. In contrast,
removable appliances typically generate forces that
lead to dental tipping. Although removable, it is feasi-
From the University of Washington, Seattle.
a
Formerly resident, Department of Orthodontics; currently private practice,
Seattle, Wash.
b
Professor and chair, Department of Orthodontics.
c
ble that systems such as Invisalign (Align Technolo-
gies, Santa Clara, Calif) and OrthoClear (San Fran-
cisco, Calif) can create couples that effectively control
tip and torque, because their bonded attachments and
aligners cover the entire crown.
The idea of a removable appliance to incrementally
move teeth is not new.3-8 Yet, it was not until Align
Technologies developed the Invisalign system in 1997
that this type of treatment became more widely used.9
Invisalign is an “invisible” method of orthodontic
treatment that uses a series of computer-generated,
clear, removable trays—“aligners”—to move teeth.
OrthoClear, released in 2005, uses a similar technol-
ogy. In addition to esthetics, these systems offer other
advantages for patients over conventional fixed appli-
ances: ease of use, comfort, simplicity of care, and
better oral hygiene.10
Although the literature on Invisalign is increasing,
most past articles have been descriptions of the system
and case reports,11-16 with only a few clinical trials.17,18
Information on the success of premolar extraction

d
Professor and chair, Department of Dental Public Health Sciences. treatment with aligner appliances is limited. Studies
Associate professor, Department of Orthodontics.
e
Professor, Department of Orthodontics.
that have included patients treated with premolar ex-
Funded by Align Technologies, NIH/NIDCR, and the University of Washing- tractions focused more on the ability to finish these
ton Orthodontic Alumni Association. patients with aligners or the amount of space closure
Reprint requests to: Anne-Marie Bollen, Department of Orthodontics, Box
357446, University of Washington, Seattle, WA 98195; e-mail, mine@u.
compared with incisor extractions.16-18 To date, no
washington.edu. study has specifically examined the ability of aligner
Submitted, April 2006; revised and accepted, June 2006. appliances to control dental tipping into premolar
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists. extraction sites during space closure.
doi:10.1016/j.ajodo.2006.06.025 We analyzed a subset of records collected during a
837
838 Baldwin et al
randomized clinical trial, with the primary purpose of
describing tooth movement adjacent to premolar ex-
traction spaces with aligner appliances. For subjects
who had subsequent treatment with conventional fixed
appliances, those records were evaluated to assess
whether the tipping was corrected. Specifically, do
teeth adjacent to extraction sites tip during space
closure with aligners, and, if so, can this be corrected
with fixed appliances? A secondary goal of the study
was to measure the time required for dual modality
treatment (aligners followed by fixed appliances).
MATERIAL AND METHODS
The sample consisted of a subset of subjects who
took part in a randomized clinical trial of the Invisalign
system. The sample and the protocol for the original
study were previously described.17 Briefly, the subjects
were adults with any malocclusion not requiring or-
thognathic surgery and no active caries or periodontal
disease. The subjects were stratified into more or less
severe malocclusion (based on the peer assessment
rating [PAR] score) and extraction or nonextraction
treatment. Of the 51 original subjects, 24 had at least 1
premolar extracted and participated in this study. The
subjects were randomly assigned to 1 of 4 treatment
protocols. The treatment protocols differed in tray
stiffness, either soft or hard, and frequency of change,
either 1 week or 2 weeks. The soft aligners were
one-tenth as stiff as the commercially available mate-
rial. The hard aligners were twice as stiff as the
commercially available material. All aligners were
manufactured to provide approximately 0.25 mm of
tooth movement per aligner and were designed to fully
correct each subject’s malocclusion. Ovoid- or rectan-
gular-shaped attachments were placed as designed by
Align Technologies. The subjects wore their first series
of aligners until either the series was completed or they
could not progress to the next aligner. Subjects who
could not complete their initial series of aligners were
considered “failed” according to the original protocol.
They were given 4 options at the time of failure:
continue with the aligners but switch to a different
stiffness or change schedule; “backtrack,” which re-
quired returning to a previous well-fitting aligner in the
series and working back up again; “reboot,” requiring
new impressions and starting over with a new series of
aligners from that point forward; or switch to fixed
appliances.
The subjects (n ⫽ 24) had at least 1 premolar
extracted, and their mean age was 32.8 years (range,
18-54 years). There were 18 women and 6 men. The
average ages were 29.4 years for the women and 42.7
for the men. The subjects started with a mean number
American Journal of Orthodontics and Dentofacial Orthopedics
June 2008
of 30 teeth (range, 25-32), with the mode being 28 (the
most frequent number). Initial PAR scores (US weight-
ings) ranged from 19 to 45 (mean, 30).
The 24 subjects had a total of 65 premolar extrac-
tions. Most subjects had 2 premolars extracted (40%),
followed by 4 premolars (30%), 3 premolars (17%),
and 1 premolar (13%). Maxillary first premolars were
the most commonly extracted teeth. The stratification
and random assignment of subjects to either hard or soft
aligner material and either the 1- or 2-week change
schedule resulted in a fairly even distribution among
the 4 treatment protocols. However, because of the
variable number of premolar extraction sites in sub-
jects, when analyzed by extraction sites, more extrac-
tion sites were assigned to the hard/1-week protocol (24
extraction sites, or 37% of the total of 65). This was
followed by soft/1-week (28%), soft/2-week (18%),
and hard/2-week (17%). Nearly as many extraction
sites started with soft aligners as with hard, and almost
twice as many started with a 1-week rather than a
2-week change schedule.
Dental casts and panoramic radiographs of the
subjects were analyzed for tooth tipping around the
extraction spaces. Chart records were reviewed for
information about time in treatment.
Dental casts and panoramic radiographs for each
subject were collected at up to 3 treatment points: T0,
initial; T2, end of aligners; and (if appropriate) T3, end
of fixed appliances. All impressions for dental casts
were taken at the University of Washington and sent to
the same laboratory for pour up and trim. All pan-
oramic radiographs were taken on the same machine
(Orthophos, Siemens, Benstein, Germany).
A method described by Ciambotti et al19 was used
to indicate the angulation of teeth adjacent to extraction
spaces. By using light-curable Triad custom impression
tray material (Dentsply International, York, Pa), occlu-
sal acrylic caps were fabricated for every tooth adjacent
to an extraction site on the initial model for each
subject. Before curing, a 1-in piece of .032-in orthodon-
tic wire was inserted into the acrylic cap parallel to the
long axis of the tooth (Fig 1). A panoramic radiograph
taken at the same time in treatment was used as an aid
in determining each tooth’s long axis. Exact correlation
with the long axis was not crucial, however, because
the main outcome was the difference in tooth angula-
tion with treatment progress, not the absolute angula-
tion.
Occlusal acrylic caps were placed on models for
each time point and photographed (Fig 1). Models were
placed on a table 2 feet away from a second table where
a digital camera (S-2, Fuji, Tokyo, Japan) with a lens
(AF Micro, Nikon, Melville, NY) was mounted. Mod-
American Journal of Orthodontics and Dentofacial Orthopedics Baldwin et al 839
Volume 133, Number 6

Fig 1. Occlusal acrylic caps fabricated for the teeth adjacent to each extraction site on the initial
models were photographed, transferred to the next treatment models, and photographed. NIH
image was used to measure I, the interdental angle at each treatment point. These models are from
the same patient assigned to the hard, 1-week condition, and they illustrate how tooth angulation
was measured on the initial model (T0; I angle, ⫺12.5°) to when aligner treatment ceased (T2; I
angle, 12.1°), and that the tipping was corrected with fixed appliances (T3; I angle, ⫺3.4°). 0°
represents parallel teeth, and angle I indicates how far from parallel the teeth are. When teeth
converge, the angle is positive. When teeth diverge, the angle is negative.

els were placed on the edge of the table with the

extraction space directly in front of the camera. The
tangent to the arch at the extraction site was oriented
parallel to the side of the table and perpendicular to the
camera lens. Digital images of each extraction site at
the different treatment points with the occlusal caps in
place were downloaded onto a computer and analyzed
using National Institutes of Health software (NIH
Image, Bethesda, Md, http://rsb.info.nih.gov/nih-image/).
With the NIH image, the angle between the wires on
the acrylic caps adjacent to each extraction space
(interdental angle) was measured at each treatment Fig 2. Angles measured on panoramic x-rays: I, inter-
point. dental angle; M, mesial angle; D, distal angle.
Five patients (17 extraction sites) were randomly
selected and remeasured 2 weeks after the original data
collection. Intraexaminer variability of interdental-an- labeled and measured (in the same manner as the
gle measurements (root mean square error, 1.4°) was models) (Fig 2).
considered acceptable. The principal investigator (D.B.) and 2 dentists who
To demarcate tooth angulation adjacent to extrac- were blind to the purpose of the study measured the
tion spaces, panoramic radiographs were scanned into a radiographs. The interexaminer variability was consid-
computer and imported into Photoshop (Microsoft, ered acceptable (root mean square error, 3.1°). An
Redmond, Wash), and lines were digitally drawn rep- average of the 3 values for each angle was used for
resenting the long axis of the adjacent teeth. Reference statistical analysis.
lines were also drawn connecting the lowest points of Five subjects (17 extraction sites) were randomly
the orbital rims and along the left and right mandibular selected, and the panoramic radiographs were remea-
borders. These images were then imported into NIH sured 2 weeks after the original measurement to assess
image for measurement. The angle made between the intraexaminer reliability. Intraexaminer variability of
tooth lines on the scanned panoramic radiographs was interdental-angle measurements for the panoramic ra-
840 Baldwin et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2008

Table I. Mean tipping after aligner treatment and fixed appliance therapy

Range

N Mean SD Min Max P value*

After aligner treatment

X-ray 19 17.2 7 2.7 29.5 ⬍0.0001
Model 21 17.3 7.8 1.6 28.2 ⬍0.0001
After fixed appliances
X-ray 12 –15.5 5.3 –22.4 –3.3 ⬍0.0001
Model 8 –15.5 8 –24.4 –5.6 0.001

Min, minimum; Max, maximum.

*P value associated with the 1 sample t test testing for a significant (non-zero) average change in interdental angle.

Table II. Mean tipping in maxillary and mandibular arches during aligner treatment

Range

N Mean SD Min Max P value*

Maxilla
X-ray 12 –12.9 6.6 –22.1 –1 ⬍0.0001
Model 8 –11.8 9.4 –24.4 1.7 0.0094
Mandible
X-ray 8 –19.4 10.1 –35.1 –3.6 0.001
Model 6 –17.6 7.9 –27.6 –7 0.0029

Min, minimum; Max, maximum.

*P value associated with the 1 sample t test testing for a significant (non-zero) average change in interdental angle.

diographs was considered acceptable (root mean square
error, 1.2°).
Aligner treatment start and end dates, and fixed
appliance therapy start and end dates, were collected
from subjects’ chart notes.
STATISTICAL ANALYSIS
The change in interdental angle— or tipping—from
1 treatment point to the next was calculated. For each
extraction site, the measured T0 interdental angle was
subtracted from the T2 interdental angle to determine
the amount of tipping during aligner treatment. Simi-
larly, the T3 interdental angle minus the T2 interdental
angle gave the tipping during fixed appliance therapy
after aligner treatment. Because many extraction sites
in the same subject were not independent, and because
the same extraction site in 1 subject at different
treatment points also was not independent, an average
value of change in interdental angle (for each subject)
was calculated. Therefore, the sample size was 24
subjects and not 65 extraction sites.
Descriptive statistics were generated with Excel
(version 10, Microsoft). SAS software (version 9.1,
SAS, Cary, NC) was used to analyze data for statistical
significance. R (version 2.1, http://www.r-project.org/)
was used to create plots.
One-sample t tests were used to determine overall
trends in tipping around the premolar extraction sites
and their significance. A paired t test was used to
determine whether there were differences in tipping in
the maxilla vs the mandible. Data for subjects assigned
initially to the same tray material or change schedule or
of the same tooth type were pooled, and the mean
amounts and directions of tipping were compared.
Two-sample t tests were used to determine whether
stiffness of material, aligner change schedule, or type of
tooth extracted had a statistically significant impact on
the tipping of teeth.
A Pearson correlation coefficient was calculated to
evaluate correspondence between measurements of tip-
ping on the models vs measurements from the x-rays.
RESULTS
The mean change in radiographic interdental angle
from T2 to T0 was 17.2° (P ⬍0.0001; n ⫽ 19). The
mean change measured on the models was 17.3° (P
⬍0.0001; n ⫽ 21). The mean radiographic tipping from
T3 to T2 was ⫺15.5° (P ⬍0.0001; n ⫽ 12). The mean
average change in model interdental angle was ⫺15.5°
(P ⫽0.001; n ⫽ 8) (Table I).
A trend for more tipping during aligner treatment
and fixed appliance therapy was noted in the mandible
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
Table III. Mean tipping in maxillary and mandibular arches during fixed appliance therapy
N Mean
Maxilla
X-ray 19 16.3
Model 20 15.9
Mandible
X-ray 10 21.5
Model 12 20.8
Min, minimum; Max, maximum.
*P value associated with the 1 sample t test testing for a significant (non-zero) average change in interdental angle.
compared with the maxilla (Tables II and III). During
aligner treatment, the average changes in interdental
angle as measured radiographically were 21.5° (P ⫽
0.0001; n ⫽ 10) in the mandible and 16.3° (P ⫽
⬍0.0001; n ⫽ 19) in the maxilla. On the models, the
average changes were 20.8° (P ⫽ ⬍0.0001; n ⫽ 12) in
the mandible and 15.9° (P ⫽ ⬍0.0001; n ⫽ 20) in the
maxilla.
Similarly, during fixed appliance therapy, the aver-
age change in interdental angle as measured radio-
graphically was greater in the mandible at ⫺19.4° (P ⫽
0.001; n ⫽ 8) compared with the maxilla at ⫺12.9° (P
⫽ ⬍0.0001; n ⫽ 12). This was also the case on the
models, with mean average changes in interdental angle
of ⫺17.6° (P ⫽ 0.0029; n ⫽ 6) in the mandible and
⫺11.8° (P ⫽ 0.0094; n ⫽ 8) in the maxilla. Overall, the
5° to 6° greater tipping of the mandibular teeth com-
pared with the maxillary teeth was not significant, as
indicated by a paired t test on subjects with extractions
in both jaws.
Comparisons of soft vs hard tray and the 1-week vs
the 2-week change schedule showed no obvious differ-
ences in interdental angle change. The average change
was similar for both hard and soft aligners (2-sample t
test, P ⬎0.05). It was also similar across different
replacement schedules (2-sample t test, P ⬎0.05). The
statistical power of these comparisons was small be-
cause of small sample sizes, and the variability between
subjects was larger than any differences between
groups.
When data were stratified by premolar extraction
site, there was more tipping of teeth adjacent to the
second premolar extraction sites than the first premolar
sites. However, this difference was not significant (P
⬎0.05).
There was a moderate association between radio-
graphic and model measurements of tipping during
aligner treatment (r ⫽ 0.61). Correlation of measure-
ment methods for the time period of fixed appliance
Baldwin et al 841
Range
SD Min Max P value*
6.6 2.7 27.2 ⬍0.0001
8.1 –3.1 29.9 ⬍0.0001
10.7 9.4 35.6 0.0001
7.9 9.3 32 ⬍0.0001
therapy was not significant (r ⫽ 0.03), primarily due to
the small sample size.
In accordance with the original study protocol, the
subjects continued with their assigned aligners and
change schedules until they completed the initial series
of aligners or until failure. No subject in this premolar
extraction study completed the initial series of aligners.
The average time in the initial series of aligners before
failure was 7 months (range, 1-17 months). At initial
failure, 50% were switched to a different aligner
stiffness or change schedule, 25% were “backtracked,”
12.5% went to full fixed appliance therapy, and 12.5%
were “rebooted.”
Eventually, 50% of the subjects had to be “reboo-
ted” at some point during the aligners, and most were
switched to a hard/2-week protocol. Only 1 of the 24
subjects ultimately completed treatment with aligners.
Nineteen went on to fixed appliances, and 4 were lost to
follow-up. Fixed appliance therapy was provided by 2
board-certified orthodontists (G.K. and G.H., both full-
time orthodontic faculty) in the faculty practice at the
University of Washington. The average total time in
aligners for the 24 subjects was 16.6 months (range,
6-28 months). At the time of data analysis for this
study, 13 of the 19 subjects who went on to fixed
appliances had finished treatment (1 transferred in
midtreatment, and 5 are still in fixed appliance therapy).
Average treatment times for the 13 subjects completing
treatment were 16.9 months in aligners (range, 6-28
months) and 23.2 months in fixed appliances (range,
11-42 months). The average total treatment time for
dual modality therapy was 40 months (range, 23-68
months) (Table IV).
Time in fixed appliance therapy was unrelated to
the number of premolars extracted, the initial PAR
score, the amount of time in aligners, or the tipping of
the teeth adjacent to the extraction site after aligner
treatment.
842 Baldwin et al
Table IV. Treatment progression, sample descriptors, and length of treatment
Aligner Finished with
treatment aligners
Subjects (n) 24 1 4
Initial PAR score 30.2 (19–45) 33
(range)
Premolars extracted (n) 2.7 (mode ⫽ 2) 1 3.5 (mode ⫽ 4)
Months in initial 7.1 (1–17) 14
aligner series (range)
Months in aligners total 16.6 (6–28) 25
(range)
Months in fixed N/A N/A
appliances (range)
Total treatment time N/A 25 aligners only
(range)
DISCUSSION
In this study, treatment with aligners in premolar
extraction patients was associated with increased tip-
ping of the teeth adjacent to the extraction sites. This
tipping could be corrected with fixed appliances. Al-
though dental tipping previously has been associated
with removable appliances, we originally postulated
that aligner systems, with bonded attachments and trays
that cover the entire crown, could create couples and
therefore control tip and torque.20
It is reasonable to ask whether dental tipping into
extraction spaces is a concern, especially when it can be
corrected. Some techniques, such as the Begg,21,22
incorporate dental tipping as an intended part of treat-
ment. However, rotation of a tooth around its center of
resistance places maximum periodontal stress in the
regions of the alveolar crest on 1 side and the root apex
on the other side.20 This can, in turn, lead to resorption
in these areas.23 If dental tipping occurs with extraction
space closure and then again in the uprighting of teeth,
there might be increased risks of loss in bone heights in
these areas and root resorption of the tipped teeth.23-28
Accordingly, translatory tooth movement might have
less deleterious periodontal effects, because it tends to
distribute loading more evenly and along a greater area
of root surface, resulting in less tissue damage.26,29
However, a few studies in which tipping in untreated
premolar extraction subjects was followed in the long
term suggest that the dangers of uncontrolled tipping
have been unduly emphasized.30,31 However, in these
studies, the extractions were in adolescents whose
subsequent growth and eruption along with lack of
preexisting bone loss or root resorption might not
represent adults who have extractions, as in our study.
Moreover, the forces accompanying dental drift were
undoubtedly lower than those in orthodontic treatment.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2008
Recommended to finish with fixed appliances n ⫽ 23
Chose not to Moved Finished fixed
continue mid-treatment Still in treatment appliances
1 5 13
35.5 (21–43) 25 24.6 (19–32) 30.9 (19–45)
1 2.4 (mode ⫽ 2) 2.9 (mode ⫽ 2)
7.3 (3–11) 17 4.4 (2–7) 6.8 (1–13)
17 (13–19) 17 13.8 (6–22) 16.9 (6–28)
N/A N/A 46⫹ (40–55) to 23.2 (11–42)
date
N/A N/A ⬃60⫹ (52–68) 40.1 (23–68)
Because of distortion in panoramic radiographs, the
methodology used to measure dental tipping might be
questioned.32 Although the American Board of Orth-
odontics currently uses panoramic radiographs to assess
root parallelism in evaluating board-candidate cases,33
several studies have shown that the panoramic radio-
graph is unsuitable for the assessment of mesiodistal
tooth angulation,34,35 or at least should be approached
with caution.36 Conversely, other studies concluded
that angular measurements obtained from panoramic
radiographs are predictable and satisfactory for most
clinical purposes.37,38 In our study, all radiographs
were taken on the same machine, by the same techni-
cians, and on nongrowing subjects. Thus, any distortion
due to machine type, technique, or growth should be
fairly consistent from 1 radiograph to the next in the
same subject. We measured the change in angle from 1
time point to another, not the actual value of an angle at
1 time point. Because any discrepancy between radio-
graphic image angles and true tooth angles would be
the same for each radiograph, it should have little effect
on the changes measured in this study. Additionally,
another method of measuring dental tipping (dental
models) produced the same conclusions and similar
results for magnitude and direction.
Although this study clearly showed that teeth adjacent
to premolar extraction sites experienced dental tipping
with aligners, our results do not exclude the possibility
that aligners can produce bodily movement and might be
of use in premolar extraction patients. Perhaps the attach-
ment sizes and shapes used on our subjects were not the
most effective for this type of movement. After this study
(2000-2002), others have been evaluating various designs
and sizes of attachments, although these findings have yet
to be published.39 Another issue might have been the time
each aligner in a series was worn. Perhaps this should be
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6
longer for premolar extraction patients. In our study, 2
weeks was the most common change schedule during
aligner treatment. Currently, however, OrthoClear recom-
mends changing it aligners every 3 weeks.40 Additionally,
some type of reinforcement at the extraction sites, such as
a pontic or thicker tray material, as has been suggested,
could have prevented or decreased the dental tipping.16
Although not statistically significant, the data sug-
gest a trend for greater tipping in the mandible around
premolar extraction spaces compared with the maxilla.
Although literature comparing dental tipping in the
maxilla vs the mandible in extraction patients is lack-
ing, 1 study, which looked at the long-term changes in
untreated first premolar extraction patients, found the
same trend.30 Differences in bone density between the
maxilla and the mandible could explain this discrep-
ancy in dental tipping. Because bone in the maxilla is
less dense than in the mandible, it is conceivable that
there was less resistance around the roots of the
maxillary teeth adjacent to an extraction site, and,
therefore, they were more amenable to bodily move-
ment by the aligner.41
In addition, there was an indication that greater tipping
occurs around second premolar extraction sites than first
premolar extraction sites. Unfortunately, little was found
in the literature about this topic. Crossman and Reed,42
however, studied the long-term results of patients who had
premolar extractions treated by removable appliances.
They found that second premolar extraction sites in the
maxilla had more unsatisfactory contacts, in terms of axial
inclination and rotation of the adjacent teeth, than first
premolar extraction sites. The proportion of unsatisfactory
contacts in the mandible, however, was equal between
first and second premolar extraction sites. Second premo-
lar extraction sites are bound by a molar and a premolar,
whereas first premolar extraction sites are bound by a
premolar and a canine, suggesting that the moment-to-
force ratio applied to the teeth by an aligner produces
more tipping in molars because they are larger than
premolars and canines.
Our data did not show differences between aligner
treatment with hard and soft trays or 1-week and
2-week change schedules. This finding might be due in
part to the limited time (on average) that the subjects
remained in their initial groups and because, after
failure in their initial protocol, most went to the
hard/2-week protocol. In addition, the small sample
sizes of each group did not provide enough power to
detect differences. These subjects did not use aligners
of the same stiffness as those currently commercially
used by Invisalign and OrthoClear. However, premolar
extraction patients treated with the commercially avail-
Baldwin et al 843
able aligners might have similar dental tipping, since
they are between the soft and hard aligners we used.
The average treatment time for subjects who finished
combined treatment of aligners and fixed appliances was
40 months. Because some are still in treatment at the time
of writing, the actual average treatment time for this group
will ultimately be longer than 40 months. Treatment time
appears unrelated to initial difficulty, number of premolars
extracted, time spent in aligners, or amount of tipping after
aligner treatment. Several factors, however, that were not
investigated might have had an impact on the time in fixed
appliances: amount of time from extraction to treatment
with fixed appliances and the amount of space left to
close. After an average of 15 months in aligners, most
subjects who went on to fixed appliances still had extrac-
tion spaces to close. Several studies indicated that teeth
move faster into recent rather than healed extraction
sites.43,44 Amler et al45 suggested that healing is nearly
complete about 100 days after extraction. The minimum
time in aligners before fixed appliances for our subjects
was 6 months, and the maximum was 28 months. The
increased time in fixed appliances leading to longer
overall treatment time might have been due to the diffi-
culty of moving teeth into healed extraction sites.
A search of the literature showed that treatment
time for premolar extraction patients treated with fixed
appliances generally is about 20 to 30 months.46-49
Although the original study was not designed to com-
pare total treatment time of dual modality therapy vs
fixed appliance therapy alone, our results suggest that
aligner treatment followed by conventional fixed appli-
ances might not be quicker than fixed appliances alone
for premolar extraction patients.
There were several limitations to this study. As
mentioned before, the attachments used during aligner
treatment were not the same design or size that Invis-
align and OrthoClear now recommend. Generaliza-
tions, therefore, cannot be drawn directly from this
study to their current products. The sample size of this
study was small because of its retrospective nature and
the limited records that fit the inclusion criteria. Thus,
the statistical power to detect differences was reduced.
Additionally, there was no control or comparison
group; therefore, it is difficult to draw conclusions on
how aligner therapy alone compares with fixed appli-
ances alone, or with a combination of aligners and fixed
appliances. Finally, it is possible that some tipping was
built into the aligner treatment, which would have
uprighted the teeth during later stages (as with the Begg
technique). However, we could not detect this. Future
research should focus on some of these issues.
844 Baldwin et al
CONCLUSIONS
In premolar extraction patients, we concluded the
following.
1. With the described protocol, aligner treatment is
associated with tipping of teeth adjacent to extraction
sites, but fixed appliances can correct this tipping.
2. Treatment of premolar extraction patients with
aligners first, followed by fixed appliances, might
not be faster than fixed treatment alone and actually
could be longer.
3. There is a trend for greater tipping of mandibular teeth
into the extraction space and around second premolar
extraction sites during treatment with aligners.
4. Use of hard aligners vs soft aligners or changing
them weekly vs every other week did not make a
difference in the amount of dental tipping around
the extraction spaces.
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