Original Article

Effects of variable attachment shapes and aligner material on

aligner retention
Hiltrud Dasya; Andreas Dasya; Greg Asatrianb; Noémi Rózsac; Hao-Fu Leed; Jin Hee Kwake

ABSTRACT
Objective: To evaluate the retention of four types of aligners on a dental arch with various attachments.

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Materials and Methods: For this study, three casts were manufactured, two of which contained
attachments (ellipsoid and beveled), and one without any attachments to serve as a control. Four
types of aligners were thermoformed: Clear-Aligner (CA)-soft, CA-medium, and CA-hard, with
various thicknesses, and Essix ACE. Measurements of vertical displacement force during aligner
removal were performed with the Gabo Qualimeter Eplexor. Means and standard deviations were
next compared between different aligner thicknesses and attachment shapes.
Results: CA-soft, CA-medium, and CA-hard did not present a significant increase in retention,
except when used in the presence of attachments. Additionally, CA-medium and CA-hard required
significantly more force for removal. Essix ACE demonstrated a significant decrease in retention
when used with ellipsoid attachments. The force value for Essix ACE removal from the cast with
beveled attachments was comparable to that of CA-medium. Forces for aligner removal from the
model without attachments showed a linear trend. Essix ACE did not show a continuous increase
in retention for each model. Overall, ellipsoid attachments did not present a significant change in
retention. In contrast, beveled attachments improved retention.
Conclusions: Ellipsoid attachments had no significant influence on the force required for aligner
removal and hence on aligner retention. Essix ACE showed significantly less retention than CA-
hard on the models with attachments. Furthermore, beveled attachments were observed to
increase retention significantly, compared with ellipsoid attachments and when using no
attachments. (Angle Orthod. 2015;85:934–940.)
KEY WORDS: Aligner therapy; Retention; Attachment shapes; Thermoplastic appliances

INTRODUCTION materials, thermoplastic appliances have evolved over

the past 10 years and can now be used for full
Thermoplastic appliances have an extensive history
orthodontic treatment.1
in orthodontics. As a result of new technology and
Numerous companies have developed aligners with
various features. For example, Invisalign (Align Tech-
a
Postgraduate Student, Section of Orthodontics, School of
Dentistry, University of California, Los Angeles, Calif.
nology, San Jose, Calif) uses identical aligner material
b
Dental Student, School of Dentistry, University of California, throughout treatment and a scalloped margin design.
Los Angeles, Calif. Clear-Aligner (Scheu Dental, Iserlohn, Germany)
c
Associate Professor, Department for Paediatric Dentistry offers aligners in three different thicknesses (0.5 mm,
and Orthodontics, Faculty for Dentistry, Semmelweis University, 0.625 mm, and 0.75 mm) for each stage in treat-
Budapest, Hungary.
ment.2
d
Instructor, Section of Orthodontics, School of Dentistry,
University of California, Los Angeles, Calif. Furthermore, different attachment shapes have
e
Assistant Professor, Section of Orthodontics, School of been designed (CA Power Grip,2 Invisalign attach-
Dentistry, University of California, Los Angeles, Calif. ments3) to enhance retention and facilitate complex
Corresponding author: Dr Jin Hee Kwak, Assistant Professor, movements such as rotation.4 The variations between
Section of Orthodontics, School of Dentistry, University of
different aligners (such as lab fabrication vs online
California, Los Angeles, Los Angeles, CA 90095
(e-mail: [email protected]) order of aligners, or digital versus manual setups)
enable providers to select their preferred techniques.
Accepted: January 2015. Submitted: September 2014.
Published Online: February 26, 2015 In order to make an informed decision, the orthodontist
G 2015 by The EH Angle Education and Research Foundation, requires awareness about aligner properties. Howev-
Inc. er, research on aligners is limited and additional

Angle Orthodontist, Vol 85, No 6, 2015 934 DOI: 10.2319/091014-637.1

VARIABLES IN ALIGNER RETENTION 935

Figure 1. Stone model with ellipsoid attachments, which were added

to both premolars. Attachment shapes inspired by Invisalign

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attachments.

assessment of scientific features is not well investi-

gated. Figure 2. Attachment dimensions. Ellipsoid attachments were
Retention remains an unquantified variable in aligner oriented vertically and measured 3 mm in height, 2 mm in width,
and 1mm in depth. Rectangular beveled attachments were oriented
use. Aligners require flexibility for insertion and re-
horizontally, and were 2 mm high, 3 mm wide, and 0.25 mm deep
moval, but need rigidity to exert the force necessary for toward the incisal edge and 1.25 mm deep toward the
orthodontic tooth movement. Clinicians and aligner gingival margin.
companies attempt to increase an aligner’s retention
by using thicker material and retention attachments, orthodontic plastic fabrication. Essix ACE is one of the
and extending the margin of the aligner over the thermoforming plastics from this company used for
gingiva. To date, there is no evidence as to which orthodontic aligners. Testing up-to-date plastic materi-
aligner design and material provides optimal retention als aims at being a clinically relevant study providing
when combined with different attachment shapes.5–7 information for orthodontists currently using—or con-
This study analyzes how aligner materials from sidering—aligner therapy.
various companies influence retention in combination
with two different attachment shapes. It is commonly MATERIALS AND METHODS
said that softer material and rounder attachments
provide less retention than more rigid material and Three precision polyvinyl siloxane impressions
edgy attachments, but no data have yet been (Bisico, Bielefelder Dentalsilicone GmbH & Co KG,
published to prove this. The numerical results from Bielefeld, Germany) of a human upper jaw with mild
this study can be used to create guidelines for misalignment and missing third molars were taken and
optimized future aligner therapy. Thus, orthodontists poured in die stone. Two casts were modified by the
using aligner therapy will have a broader understand- addition of plastic attachments on all premolars
ing of the numerous aligner materials and attachments (Figure 1). In this study we used attachments closely
being offered by so many different companies. This will related to the attachments termed “conventional
give them the chance to use materials and attach- attachments” by Invisalign.8 Two types of conventional
ments wisely according to the needs of each case. In attachments with the following dimensions were
this study, two of the major aligner companies were applied (Figure 2):
compared. Scheu Dental is a German family-owned
1. ellipsoid attachments (height: 3 mm, width: 2 mm,
company with expertise in thermoforming machines
depth: 1 mm)
and aligner materials that has been producing lab
2. rectangular attachments, which were beveled to-
products for aligner fabrication for three generations.
ward the incisal edge (height: 2 mm, width: 3 mm,
The Biostar thermoforming machine by Scheu Dental
depth: 0.25 mm incisally and 1.25 mm gingivally).
was used in this study. The company’s own system for
aligner therapy is called Clear-Aligner and consists of The third cast contained no attachments and served
three aligners for each setup. Each aligner is made of as a control. The models were then duplicated and
the same material but varies in thickness (CA-soft, recreated using a nonabrasive, hard plastic material
-medium, -hard). These three CA aligners were (Figure 3). Premolars containing attachments were
examined in the present experiment. For comparison substituted with their metal equivalents. Four different
with a different material type, Essix ACE, aligners were types of aligners were thermoformed over each of the
also included in the study. Dentsply Raintree Essix is three models using a Biostar vacuum thermoforming
an American company with decades of experience in machine (Scheu Dental): Clear-Aligner (CA)-soft

Angle Orthodontist, Vol 85, No 6, 2015

936 H. DASY, A. DASY, ASATRIAN, RÓZSA, LEE, KWAK

To avoid deviations, special emphasis was put on

accurate aligner and model fabrication. Aligners were
thermoformed as per manufacturing code to avoid
overheating and inconsistency during each process.
All listed material thicknesses refer to the thickness
prior to thermoforming. After thermoforming, all aligner
thicknesses were remeasured to ensure homogeneity.
Aligner thickness was decreased after thermoforming
(0.017 mm–0.022 mm); however, this change was
consistent and universally observed, thus suggesting
minimal fabrication error. All aligners were trimmed
along the border of the model base to create an

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unvarying reference.
Casts were modified by drilling holes into a
reproducible location of the cast. One 6-mm diameter
hole was made through the center of the cast base for
fixation of the cast inside the measuring device and
secured by a tight screw. The placement was
determined by the intersection of a line along the
palatal suture and one leading through the occlusal
Figure 3. Duplicated model of cold-curing dental resin (Palapress- holes using a laser level (Figure 4). Two additional
vario, Heraeus Kulzer, Hanau, Germany) in a Biostar Thermoforming holes (3 mm in diameter, 5 mm in depth) were also
Machine (Scheu Dental).
drilled into the occlusal surfaces of the first molars at
the edge of the mesiolingual cusp and the central
(0.5 mm), CA-medium (0.625 mm), CA-hard fissure. These depressions allowed for the placement
(0.75 mm), and Essix ACE (0.76 mm). of a metallic stop attached to a steel rope. Both of
Three types of CA foils were selected to test the ropes lead from inside the molar, through the
different thicknesses of the same material type. Essix thermoformed aligner, and into the measuring ma-
ACE is similar in thickness to CA-hard, but has a chine, which delivered a vertical pulling force on the
different material composition. CA is made of glycol- rope. The stop on the end of the rope did not interfere
modified polyethylene terephthalate designed by with the hole perimeters, avoiding friction which could
Scheu Dental. Alternatively, Essix ACE is a copolymer affect the trials. Nor did it interfere with the anatomy of
of polyethylene terephthalate from Dentsply Raintree the tooth, which allowed the aligner to cover the teeth
Essix, York, Pennsylvania. in its original, thermoformed shape.

Figure 4. Reproducible locations of holes on the model base (6 mm in diameter) and the occlusal surfaces (3 mm in diameter and 5 mm in depth)
of the first molars. The central mounting hole was used for fixation of the model in the Gabo Qualimeter Eplexor (GQE). The location was
determined with one median line through the location of the palatal raphe intersecting with a line through the mesiolingual cusps of the first
molars. The molar holes provided room for the stops of two steel ropes that passed through the aligner into the bolting apparatus on the GQE.

Angle Orthodontist, Vol 85, No 6, 2015

VARIABLES IN ALIGNER RETENTION 937

to move upward in steps of approximately 10 seconds.

The highest force that dislodged the aligner from the
dental arch was used to calculate an average force for
each of the four aligners.
Three key aspects influencing aligner retention were
measured in this study: (1) whether ellipsoid or
beveled attachments improve retention; (2) whether
increased material thickness or different material
composition increases retention; and (3) a cross
comparison between different aligners (CA-soft, CA-
medium, CA-hard, ACE) and attachments (none,
ellipsoid, beveled).

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RESULTS
Effect of Attachment on Aligner Retention
First, the effectiveness of ellipsoid versus beveled
attachments on aligner retention was compared with
control having no attachment (Figure 6A–C). Vertical
displacement force was measured in Newtons for each
aligner material. The first group of four columns shows
vertical displacement forces for CA-soft, -medium, and
-hard and Essix ACE from the model, which contained
Figure 5. Model inside the GABO Qualimeter Eplexor (GQE). no attachments (Figure 6A). The second group illus-
Aligner attached via steel ropes running straight from the first molars trates the vertical displacement force of each aligner
through the aligner to the bolting apparatus. The upward displace-
while being removed from the model with ellipsoid
ment force was measured in 10-second intervals until the aligner was
removed from the model. attachments on all premolars (Figure 6B). The third
group demonstrates removal from the cast containing
Measurements were made while removing the beveled attachments (Figure 6C). When no attach-
aligner from the dental arch using a Gabo Qualimeter ment was used, a significant and linear trend was
Explexor (GQE; Testanlagen GmbH, Ahlden, Ger- observed. The first four columns in the illustrated chart
many). To avoid shearing forces during aligner increased from CA-soft toward Essix ACE continuous-
removal, a bolting apparatus was manufactured to ly. This linear pattern reappears for all CA aligner
allow the steel ropes to connect perpendicularly from materials in the second and third group of columns.
the teeth to the apparatus. However, a distinct drop in aligner retention was
The minimum force needed to remove aligners from registered with Essix ACE when either ellipsoid or
the cast was measured using the same cast with a new beveled attachments were implemented (second and
aligner for each of the four test runs. Vertical third group of columns).
displacement force was applied perpendicularly on When comparing overall retention of each material
the steel rope, leaving the cast in an unchanged on the cast containing ellipsoid attachments with the
position (Figure 5). The force applied during aligner control group, no significant increase was seen
removal was registered, while the machine continued (Figure 6A,B). The expected increase compared with

Figure 6. Quantification of variable aligner material on retention. (A) Vertical displacement forces (Newtons) of each aligner material during
removal from the control cast containing no attachments. (B) Vertical displacement forces of each aligner material during removal from the cast
containing ellipsoid attachments. (C) Vertical displacement forces of each aligner material during removal from the cast containing beveled
attachments. Each column represents one of the tested aligner materials (CA soft, medium, hard; Essix ACE).

Angle Orthodontist, Vol 85, No 6, 2015

938 H. DASY, A. DASY, ASATRIAN, RÓZSA, LEE, KWAK

Figure 7. Quantification of variable attachments on retention. (A) CA soft aligner removal from three different casts containing either no
attachments, ellipsoid, or beveled attachments. (B) CA medium aligner removal from three different casts containing either no attachments,
ellipsoid, or beveled attachments (C) CA hard aligner removal from three different casts containing either no attachments, ellipsoid, or beveled
attachments (D) Essix ACE aligner removal from three different casts containing either no attachments, ellipsoid, or beveled attachments.

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control in retention was observed only for the cast Using beveled attachments, CA-medium showed a
containing beveled attachments (Figure 6A–C). 90% increase in retention. Finally, with ellipsoid
In summary, the casts containing ellipsoid attach- attachments, CA-medium had a 23% increase in
ments did not significantly increase retention. Addi- retention. CA-medium did not differ significantly from
tionally, Essix ACE aligners did not demonstrate a CA-hard in any of the groups.
linear behavior similar to that of CA aligners. When comparing CA-hard and Essix ACE, Essix
ACE demonstrated increases in retention without
Effect of Aligner Material on Retention attachments. There were no significant differences in
1. material thickness retention when comparing each of these two materials’
retention on the casts with ellipsoid attachments
2. material composition
(Figure 7C,D).
As a second part of our study, we compared each An unexpected, yet interesting finding from a cross
aligner’s retention during removal from the casts. Two comparison was the force required for Essix Ace
components were analyzed. First, material thickness aligner removal from a cast with ellipsoid attachments
was compared using CA-soft, CA-medium, and CA- (Figure 7D, center column). It required less force than
hard. Second, Essix ACE and CA-hard were compared the amount needed to remove the CA-hard aligner
for material composition analysis. from a cast without any attachments (Figure 7C, first
When CA-soft was removed from each cast, a column).
gradual increase in retention was observed; however,
this was not statistically significant (Figure 7A). A DISCUSSION
statistically significant increase of 60.12% was ob-
served when the CA-medium aligner was removed Our investigation provided evidence that disproves
from the cast with beveled attachments (Figure 7B). the dogma that attachments enhance aligner retention
CA-hard also demonstrated a significant increase in under any circumstance. Our findings suggest that
retention (65.28%) during removal from the cast with only certain attachments increase retention when used
beveled attachments (Figure 7C). with increased aligner thickness or a certain material.
In our material composition analysis, CA-hard and The following will elaborate on each of the investigated
Essix ACE showed contrasting results. Essix ACE categories.
demonstrated an 80.63% decrease in retention be-
tween the cast with no attachments and the cast with Effect of Attachment on Aligner Retention
ellipsoid attachments. This was not observed during We observed that attachment shapes affect reten-
any other material testing of this study (Figure 7D). tion, especially in combination with harder material.
Additionally, there was a significant increase in CA-medium and CA-hard show that a greater
retention between the cast containing ellipsoid attach-
amount of force was required to remove an aligner
ments and the cast with beveled attachments
from a cast containing beveled attachments, compared
(57.90%).
with a model having either ellipsoid attachments or no
attachments (Figure 6). The results obtained from
Further Observations and Trends
comparing retention on the cast with no attachments
A significant increase in retention was observed for to the cast with ellipsoid attachments show no
CA-medium compared with CA-soft throughout all significant difference between CA-soft, CA-medium,
groups (Figure 7A–C). CA-medium demonstrated or CA-hard (Figure 6A,B). Essix ACE demonstrated a
a 36% increase in retention without any attachments. significant decrease in retention here. This suggests

Angle Orthodontist, Vol 85, No 6, 2015

VARIABLES IN ALIGNER RETENTION 939

that ellipsoid attachments do not increase aligner and measuring device impede drawing one conclusion
retention significantly under all circumstances. for aligner retention from the listed findings.
The small sample size in this study inherited a
Effect of Aligner Material on Retention limited perspective that needs to be widened in future
studies. Since our study revealed the significance of
The linear increase in retention, when comparing CA-
material composition on aligner retention, additional
soft, CA-medium, and CA-hard, suggests that retention
trials should be conducted to compare different
varies based on material thickness (Figure 6A–C). In
material types of the same thickness to determine
contrast, Essix ACE demonstrated decreased retention
which material component contributes to increased
compared with CA-hard when removed from the cast
retention. Future clinical studies should include the
with ellipsoid attachments, as well as the cast with
effect of body temperature, saliva, and patient comfort
beveled attachments (Figure 6B,C). Since CA-hard and
on aligner retention.

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Essix ACE have approximately the same thickness but
Aligner friction is also influenced by the thermoform-
different compositions, this suggests that retention
ing process, according to Hahn et al.9 This can be
depends on material composition and does not
avoided in the future by using modern three-dimen-
necessarily correlate with material thickness. This is
sional printing technology, which enables various
in line with the Hahn et al. findings.9
thicknesses to exist within one aligner: a thicker portion
Also, when analyzing the results of Essix ACE, we
for teeth that do not require movement and a thinner,
found that a significant decrease in force during aligner
more flexible portion for misaligned or crowded teeth
removal from the cast with ellipsoid attachments
that do.
suggests that attachment types have different effects
on different materials. Therefore, the effect of attach-
CONCLUSIONS
ments correlates with the material of each individual
aligner. N Ellipsoid attachments showed no significant effect on
retention in the aligner used in this study.
Further Observations and Trends N Essix ACE showed statistically significant less re-
The similar values in retention between CA-medium tention on models with attachments compared with
without attachments and CA-soft with beveled attach- CA-hard having similar thickness.
ments suggest that the use of CA-soft with beveled N The use of beveled attachments increased retention
attachments can be replaced with CA-medium with no significantly.
attachments in order to create the same amount of
retention. ACKNOWLEDGMENTS
Numerous investigators have reported additional
This work was supported by the University of Applied Science,
factors that can influence aligner retention, including PHWT (private Hochschule für Wirtschaft und Technik) in
attachment placement, marginal design of aligners, Diepholz, Germany. The authors thank Professor Dr Jons
and clinical crown size.5–7 The evidence and the Kersten and Professor Dr Carsten Bye for their support. Special
results from this study provide guidance for selecting thanks goes to Thomas Schröder for his engineering expertise.
an aligner from a wide selection of brands and The authors would also like to thank Heather Householter for
editing advice and Dr. Philip Matthew Nisco as well as Dr Martin
materials. When using an aligner system that provides Martz for professional consultation in the field of aligner therapy.
in-office fabrication, one must take into consideration
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Angle Orthodontist, Vol 85, No 6, 2015