Treatment Effectiveness of Clear Aligners in Correcting Complicated and Severe Malocclusion Cases Compared to Fixed Orthodontic Appliances: A Systematic Review

Abstract

This systematic review aimed to critically assess the available evidence regarding the effectiveness and efficiency of clear aligners in the comprehensive treatment of complex cases accompanied by premolars extraction. An electronic literature search by two reviewers was independently done on 27 February 2023 in the following databases without time and language limitations: Pubmed®, Scoups®, Google Scholar, Cochrane Library database, Web of Science™, and Proquest Database Open. Randomized controlled trials (RCTs) of any type, non-randomized clinical trials (CCT), cohort studies, and prospective, retrospective, and cross-sectional studies were reviewed. The risk of bias in included studies was assessed using the Risk of Bias (RoB 2.0) tool for randomized trials and the Risk of Bias in Non-randomized Studies (ROBINS-I) tool for non-randomized studies. After carefully searching the literature, six trials were included in this systematic review, three RCTs, two retrospective cohort studies, and one CCT. Two hundred eighty-three patients were included (186 females, 97 males). Three studies found that there were no differences between the clear aligners and fixed appliances when evaluations were done using the American Board of Orthodontists Objective Grading System (ABO-OGS) or the Peer Assessment Rating (PAR) index. Two studies found that there were some differences between predicted and achieved tooth movements when clear aligners were used in premolars extraction cases. Based on the included studies, the duration of treatment was shorter with fixed appliances than the clear aligners when applied to orthodontic extraction cases. Both clear aligners and fixed appliances were found effective in the orthodontic treatment of premolar extraction-based cases. Fixed appliances have the advantage of achieving better buccolingual inclination and occlusal contacts in a shorter treatment duration. Treatment with clear aligners might be associated with differences between predicted and achieved tooth movements. Therefore, the characteristics of these techniques should be considered when making a treatment decision.

Keywords: clear aligners; clinical effectiveness; crowding of teeth; effectiveness; invisalign; orthodontic; premolar extraction; systematic review.

Figure 1. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram of the reviewing process.

Figure 2. Risk of bias summary: the review authors' judgments about each item of the risk of bias for the randomized controlled trial studies

Red circle - high risk of bias; yellow circle - some concerns; green circle - low risk of bias Domains: D1: Bias arising from the randomization process; D2: Bias due to deviations from the intended intervention; D3: Bias due to missing outcome data; D4: Bias in measurement of the outcome; D5: Bias in the selection of the reported result.

Figure 3. Risk of bias summary: the review authors' judgments about each item's risk of bias for the non-randomized controlled trials

Red circle - serious risk of bias; yellow circle - moderate risk of bias; green circle - low risk of bias. Domains: D1: Bias due to confounding; D2: Bias due to selection of participants; D3: Bias in the classification of interventions; D4: Bias due to deviations from intended interventions; D5: Bias due to missing data; D6: Bias in measurement of outcomes; D7: Bias in selection of the reported result.

Figure 4. Risk of bias graph for the randomized controlled trials: the review authors' judgments about each item's risk of bias, presented as percentages across all the studies included

Figure 5. Risk of bias graph for the non-randomized controlled trials: the review authors' judgments about each item's risk of bias, presented as percentages across all the studies included