Open Access Original Article

The Effects of Different Attachment Types and

Positions on Rotation Movement in Clear Aligner
Review began 07/25/2024
Treatments: A Finite Element Analysis
Review ended 08/02/2024
Published 08/06/2024 Erkan Sultanoğlu 1, Hakan Gürcan Gürel 1, Muzaffer Gülyurt 1

© Copyright 2024
Sultanoğlu et al. This is an open access 1. Orthodontics and Dentofacial Orthopedics, Biruni University, Istanbul, TUR
article distributed under the terms of the
Creative Commons Attribution License CC-
Corresponding author: Erkan Sultanoğlu, [email protected]
BY 4.0., which permits unrestricted use,
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source are credited.
Abstract
DOI: 10.7759/cureus.66273
Aim
Rotation of the mandibular premolars during aligner treatment is a difficult movement to achieve
accurately. The purpose of this study is to compare the effects of different attachment types and positions
used in clear aligner treatments on the rotation movement and retention of clear aligners in the rotated first
premolar teeth. The study also addressed the stress values in periodontal ligaments (PDLs) with finite
element analysis.

Materials and methods

For purposes of this research, we created a mandibular tooth model and modeled the premolar tooth with a
30° rotation. Twelve separate groups were created by attaching horizontal rectangular, vertical rectangular,
ellipsoid, and semi-ellipsoid attachments to the premolar tooth in buccal, lingual, and combined buccal and
lingual ways. A model without attachments was created to be used as the control group. An activation
movement of 0.25 mm was applied to the first premolar tooth in all 12 models. The study evaluated clear
aligner displacement, von Misses stress on the PDL, and tooth displacements using the finite element stress
analysis method.

Results
It was found that the group with horizontal rectangular attachments placed on both the buccal and lingual
sides had the highest stress value in the PDL (0.1971 MPa) and the highest displacement in the tooth (0.1267
mm). Conversely, the group with semi-ellipsoid attachments placed both buccally and lingually had the
least displacement movement in clear aligners (0.1441 mm).

Conclusion
The results indicate that groups with attachments provided better retention than groups without
attachments. Models with horizontal, rectangular attachments showed significantly more tooth
displacement compared to other models. Horizontal rectangular attachments placed buccally and lingually
combined to provide tooth movement in rotated mandibular first premolars can be recommended for
clinical use.

Categories: Dentistry
Keywords: finite element analysis, rotation, mandibular premolar, attachment, clear aligner

Introduction
To improve the control of tooth movements with clear aligners, researchers have attempted to regulate force
transmission patterns and design new innovations [1]. To achieve complex movements, particularly
rotations, composite attachments must be used on the teeth [2,3]. Attachments can increase the retention of
clear aligners, control the direction of applied force, and enable specific tooth movements. In cases where
extrusion, rotation correction, and root movements are required, attachments positioned automatically by
computer-aided software are used. The recesses in the clear appliances, which create pressure points, are
positioned in the areas of the root that require torque [4]. Attachments are created by applying a composite
material to the teeth, using guide clear aligners to create spaces at the beginning of the treatment.
Attachments are typically classified into three types: rectangular, beveled, and ellipsoid [5].

The rectangular attachment has a width of 2 mm, a height of 3-4-5 mm, and a thickness of 0.5-1 mm. When
placed horizontally on the tooth, it can cause vertical movement. This type of attachment is preferred for
tooth extrusion movement. Structurally, the attachment prevents slippage between the plaque and the
tooth. When placed vertically on the tooth surface, it facilitates mesiodistal movements and makes it
particularly beneficial for closing long gaps. The beveled attachment has a width of 3-4-5 mm, a height of 2

How to cite this article

Sultanoğlu E, Gürel H, Gülyurt M (August 06, 2024) The Effects of Different Attachment Types and Positions on Rotation Movement in Clear
Aligner Treatments: A Finite Element Analysis. Cureus 16(8): e66273. DOI 10.7759/cureus.66273
 mm, and a thickness of 0.25-1.25 mm. Inclined attachments are necessary for tooth extrusion. Ellipsoid
attachments measure 3 mm in height, 2 mm in width, and 0.75-1 mm in thickness. Incisors are used in pairs
to rotate canines and premolar teeth or for root movement. When used independently, they should provide
control over rotation [6]. However, research on aligners is limited, and further evaluation of their scientific
properties is necessary [7].

To achieve rotational movement in teeth, it is essential to create space between them through expansion
and interproximal reduction. Attachments designed for this purpose are recommended, especially for the
round surfaces of canine and premolar teeth. Rotating round teeth is particularly challenging and requires
careful consideration [8,9].

Finite element analysis (FEA) is a reliable and convenient method for evaluating stress around bones and
implants. This analysis provides baseline data for new clinical methods and determines their potential
effects. FEA generates computational data that reveals the behavior of new materials or techniques under
simulated clinical conditions [10]. To the authors’ knowledge, no previous FEA study has evaluated the
effects of attachment types and positions in clear aligner treatments for correcting mandibular first premolar
tooth rotations. The null hypothesis was that attachment types and positions have no effect on tooth
movement, clear aligner retention, or stresses in the periodontal ligament (PDL).

Materials And Methods

The mandibular bone model used in the study was created by modeling cortical bone, trabecular bone, teeth,
and PDL. A 25-year-old male individual’s tomography was taken with a section thickness of 0.1 mm, and the
resulting data was reconstructed. The individual’s mandibular bones and teeth were healthy. This
reconstructed data was then transferred to 3D Slicer software in DICOM (.dcm) format. The computed
tomography data in DICOM format was segmented in 3D Slicer software based on appropriate Hounsfield
values and converted into a three-dimensional model. The resulting model was exported in STL format and
imported into the Ansys SpaceClaim software, where a model of the mandibular bone was created.

Similar to FEA studies [9] in the literature, to create a 2 mm thick cortical bone model, a 2 mm offset was
applied to the mandibular bone model. Trabecular bones were obtained by referencing the inner surfaces of
the three-dimensional cortical bone with an adjusted thickness. PDL that was 0.25 mm thick was modeled
using the outer surface of the teeth as a reference. The prepared models were placed in the correct
coordinates in 3D space using Ansys SpaceClaim software, and the modeling process was completed.

Modeling attachments and clear aligners and creating working models

Attachments included a semi-ellipsoid attachment with a width of 2 mm, a height of 3 mm, and a thickness
of 1 mm at the center; a vertical rectangular attachment with a width of 2 mm, a height of 3 mm, and a
thickness of 1 mm; a horizontal rectangular attachment with a width of 3 mm, a height of 2 mm, and a
thickness of 1 mm; and an ellipsoid attachment with a width of 2 mm, a height of 3 mm, and a thickness of 1
mm. The study employed four different attachments, each with specific dimensions and shapes, modeled
using Ansys SpaceClaim software (Figure 1a-1d, Table 1).

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 FIGURE 1: (a-d) Attachment shapes compared in the study
(a) Semi-ellipsoid attachment. (b) Vertical rectangular attachment. (c) Horizontal rectangular attachment. (d)
Ellipsoid attachment.

Group Attachment shape Attachment placement

Group 01 (control group) -

Group 02 Semi ellipsoid Buccal

Group 03 Vertical rectangular Buccal

Group 04 Horizontal rectangular Buccal

Group 05 Ellipsoid Buccal

Group 06 Semi ellipsoid Lingual

Group 07 Vertical rectangular Lingual

Group 08 Horizontal rectangular Lingual

Group 09 Ellipsoid Lingual

Group 10 Semi ellipsoid Buccal + lingual

Group 11 Vertical rectangular Buccal + lingual

Group 12 Horizontal rectangular Buccal + lingual

Group 13 Ellipsoid Buccal + lingual

TABLE 1: Attachment shape and placement of the groups compared in the study

After repositioning the attachments, which were originally placed on the middle third of the mandibular first
premolar tooth, both buccal and lingual 0.5 mm-thick clear plaques were modeled in Ansys SpaceClaim
software to fit the attachments (Figure 2).

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 FIGURE 2: Picture of the model with the clear aligner used in the study

Obtaining Mathematical Models

Mathematical models were created by dividing geometric models into small, simple pieces called meshes.
After completing the modeling process in Ansys SpaceClaim software, the models were mathematically
created using Ansys Workbench software and prepared for analysis.

To perform the analyses, the mathematical models prepared in the Ansys Workbench software were
transferred to the LS-DYNA solver. This program is primarily used for explicit solutions and also has an
implicit solver that is also used for static problems.

Material Definitions

The analyzed model was defined numerically using linear material properties, including elastic modulus and
Poisson’s ratio (Table 2).

Material Elastic module (MPa) Poisson’s ratio

Cortical bone 13,700 0.26

Trabecular bone 1,370 0.3

Dentin 18,600 0.3

PDL 0.667 0.45

Composite attachment 12,500 0.36

Aligner 528 0.36

TABLE 2: Physical properties of the substances modeled in the study

PDL, periodontal ligament

Loading Scenarios and Boundary Conditions

In all models, a total activation force of 0.25 mm was applied to the buccal and lingual regions of the clear
aligner on the first premolar tooth. Force was applied counterclockwise. This force represented a
displacement of 0.125 mm from each surface. The models were fixed by restricting all degrees of freedom at
the nodal points in the region of the bone, preventing movement in all three axes. The model includes all
parts. The boundary condition was applied to ensure symmetry in the Y-Z plane, perpendicular to the X-axis.
Thirteen nonlinear static analyses were performed on 13 models under specified force and boundary
conditions.

Table 3 provides quantitative information for the 13 models created, including the combined systems and
connection status between parts. To obtain accurate results when analyzing mathematical models, it is

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 essential to define the surface relationships of the model’s parts in the analysis program. For all models,
nonlinear friction contacts a coefficient of µ = 0.2 as defined on the aligner-tooth and aligner-attachment
interfaces.

Model Total number of nodes Total number of elements

Model 1 278,913 1,017,593

Model 2 280,915 1,024,468

Model 3 282,970 1,032,612

Model 4 283,295 1,033,275

Model 5 281,938 1,029,034

Model 6 279,784 1,020,124

Model 7 282,089 1,029,183

Model 8 283,016 1,032,448

Model 9 281,187 1,025,824

Model 10 284,293 1,036,566

Model 11 288,051 1,051,371

Model 12 285,580 1,040,676

Model 13 284,352 1,037,342

TABLE 3: Total element and node number of analysis models

The study defines the bonded type of contact among other contacting components. This approach assumes
that the parts operate with full correlation during their movement.

Results
Table 4 shows tooth displacements, clear aligner displacements, and von Mises stress values occurring in
PDL for the groups compared in the study. The von Mises stress distribution and the values of transversal,
sagittal, and vertical displacement distributions of the selected nodes on the created models were obtained.
The X-axis indicates the direction of the transverse displacement, the Y-axis indicates the direction of the
sagittal displacement, and the Z-axis indicates the direction of the vertical displacement. The displacements
and stresses obtained in the analysis are represented visually on a color scale within specified limits. The
regions exhibiting the highest von Mises stress levels and movement are indicated in red, while those
exhibiting the lowest levels are indicated in blue. The images of displacement amounts are evaluated
separately in the sagittal, transversal, and vertical directions. The red areas indicate displacements in the
direction of the specified axis, the blue areas indicate displacements in the opposite direction of the
specified axis, and the green or yellow areas indicate the lowest amount of displacement in the direction of
the specified axis. In this study, displacement amounts were expressed in millimeters (mm), and stress
values were expressed in newtons per square meter (MPa) (Figures 3-6).

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 (1) PDL von Mises stress (2) Aligner total displacement (3) Tooth total displacement
Group
(MPa) (mm) (mm)

Group 01 (control
0.1166 0.2014 0.07043
group)

Group 02 0.1587 0.2016 0.09547

Group 03 0.1528 0.1995 0.09092

Group 04 0.1789 0.2128 0.1115

Group 05 0.1644 0.2008 0.09856

Group 06 0.1267 0.1821 0.0936

Group 07 0.1197 0.1814 0.07283

Group 08 0.138 0.1767 0.1012

Group 09 0.1232 0.1759 0.07531

Group 10 0.1877 0.1441 0.1184

Group 11 0.1749 0.1614 0.1109

Group 12 0.1971 0.1562 0.1267

Group 13 0.1689 0.1657 0.1042

TABLE 4: Tooth total displacement, aligner total displacement, and von Mises stress values
occurring in PDL for the groups compared in the study
PDL, periodontal ligament

FIGURE 3: Example representations of model elements in color maps

(a) Rotated premolar. (b) Clear aligner. (c) PDL.

PDL, periodontal ligament

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 FIGURE 4: Displacement distance of a rotated premolar

FIGURE 5: Displacement distances of clear aligners

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 FIGURE 6: von Mises stress values on the PDL
PDL, periodontal ligament

The highest tooth displacement for the mandibular first premolar was observed in Group 12 (0.1267 mm),
and the lowest was seen in Group 1 (0.07043 mm). The total tooth displacement is generally higher in
models with buccal-lingual attachments than in other models: Group 10 (0.1184 mm), Group 11 (0.1109
mm), Group 12 (0.1267 mm), and Group 13 (0.1042 mm) (Figure 4). The displacement of the clear aligner was
highest in Group 4 (0.2128 mm) and lowest in Group 12 (0.1562 mm). The aligner total displacement is
higher in the control group and in general in models with buccal attachment placement than in other
models: Group 1 (0.2014 mm), Group 2 (0.2016 mm), Group 3 (0.1995 mm), Group 4 (0.2128 mm), and Group
5 (0.2008 mm) (Figure 5). The highest von Misses stress in PDL was observed in Group 12 (0.1971 MPa),
while the lowest was detected in Group 1 (0.1166 MPa). Stress values occurring in PDL were generally
observed to be lower in models with lingual attachments than in other models. Group 6 (0.1267 MPa), Group
7 (0.1197 MPa), Group 8 (0.1380 MPa), and Group 9 (0.1232 MPa) (Figure 6).

Discussion
The findings of the present study have led to the rejection of the null hypothesis. The study found that the
shape and position of attachments used in clear aligner treatments have varying effects on tooth
displacements, clear aligner displacements, and von Mises stresses in PDL. Although clear aligners are
becoming more popular, there is often a discrepancy between the planned orthodontic movements in the
virtual installation and the actual results [11]. Chisari et al. [12] reported that in clear aligner treatments, the
movement of a single incisor tooth was 57% of the expected amount. In these treatments, movement was
adjusted via software [13]. Auxiliary elements, such as power arms, elastics, and buttons, can also be used
[14]. Factors such as the physical properties of the aligners and their production methods [13] and the
position of the aligner relative to the gum [15] are not thought to significantly affect the outcome of the
treatment due to the phasing of tooth movement.

The extant literature contains a variety of opinions regarding the degree of tooth movement activation in
clear aligner treatments [16-21]. In a study, treatment plans were created in such a way that the activation
amount in each plate would be 0.5 mm in clear aligner treatments, and it was reported that the stress on the
teeth decreased rapidly. They explained the time-dependent stress reduction as the tooth moving away from
the aligner [16]. Houle et al. [17]. suggested that a displacement amount of 0.25 mm per aligner should be
applied in clear aligner treatments. Jiang et al. [18] indicated that the activation range for each aligner
should be between 0.15 and 0.25 mm. They noted that an activation amount of 0.25 mm represents the
maximum achievable tooth displacement, given the elasticity and thickness of the clear aligner materials. In
this study, a total activation of 0.25 mm was applied from the active surfaces of the buccal and lingual
regions of the clear aligner on the mandibular first premolar tooth in all models, resulting in a 0.125 mm
displacement from each surface.

It was widely acknowledged that correcting rotational movement with clear aligners represents a
particularly challenging task in the case of tapered teeth. Research indicates that clear aligner treatments
without attachments result in less tooth displacement due to tipping forces on the teeth. In contrast,
treatments with composite attachments increase the rotation force in clear aligner treatments [19,20]. The
use of composite attachments in both vertical and horizontal shapes during clear aligner treatments has
been shown to increase tooth displacement [21]. Studies have determined that clear aligners with ellipsoid

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 and rectangular attachments result in more successful tooth displacement [16]. It has further been suggested
that attachments can enhance the effectiveness of derotation movement and improve retention by creating
undercuts for the clear aligner [20-22]. In this study, it was observed that tooth displacement was greater in
models with attachment placement. It was also observed that lingual and buccal attachment designs, when
used together, allowed greater tooth displacement than those attachments that were placed only lingually or
buccally. The results suggest that the placement of attachments affects the retention of clear aligners.

Evaluation of the displacement of clear aligners

Movement values occurring in clear aligners are valuable for examining their retention. In our study, the
highest displacements in clear aligners were observed in models with buccally placed attachments (Groups
2, 3, 4, and 5), and these values were close to the control group (0.2014 mm). Our study did not determine a
clear order in the mobility of clear aligners based on attachment shapes. Since no similar study comparing
attachment types was found in the literature, we could not discuss our results. Dasy et al. [7] evaluated the
retention of clear aligners with ellipsoid and inclined rectangular attachments placed in the buccal area in
their study. They further investigated the effects of aligner thicknesses and attachment shapes on clear
aligner retention. According to the report [7], ellipsoid attachments did not have a significant effect on
retention, whereas beveled attachments had a significant effect. It was observed that the group with the
ellipsoid attachment had higher aligner displacement than the vertical rectangular attachment group and
lower aligner displacement than the horizontal rectangular group when the attachment groups in the buccal
area were examined. Unfortunately, we could not make a full comparison as we did not use an inclined
attachment in our study.

Evaluation of von Misses stress distribution in the PDL

This research examined the stresses on PDLs and found that the models with buccal and lingual attachments
had the highest stress values when the buccal-lingual combined attachment was used. The highest stress
values for buccally and lingually placed attachments were observed in horizontal rectangular, ellipsoid,
semi-ellipsoid, and vertical rectangular shapes, respectively. In models with buccal and lingual attachments,
the order of attachment placement was a horizontal rectangle, semi-ellipsoid, vertical rectangle, and
ellipsoid. The stress values in the control group without attachments were lower than in all models.
Therefore, the model with the horizontal rectangular attachment placed in Group 12 (0.1971 MPa) had the
highest stress value.

The model with a vertical rectangular attachment in Group 7 exhibited the lowest stress value (0.1197 MPa)
compared to the other models. The observed stress values (0.1971 MPa and 0.1197 MPa) are within the range
that can cause alteration of the PDL, leading to bone remodeling [23,24]. Cortana et al. [25] conducted a
study to evaluate tooth displacements and deformation in the PDL of mandibular second premolars with
different rotations, both with and without vertical rectangular attachments. They found that tooth
displacement was significantly greater in groups with attachments compared to those without and that
higher stresses occurred in the PDLs of teeth with attachments and higher rotation.

Evaluation of displacement numbers of teeth

The highest amounts were observed in the buccal-lingual, buccal, and lingual groups, respectively. In terms
of rotation movement, models with all attachments provided more tooth displacement than the control
group. The group with the highest total tooth displacement was Group 12, where the horizontal rectangular
attachment was placed on the buccal and lingual surfaces (0.1267 mm). The study found that the attachment
placed on the vertical rectangular lingual in Group 7 resulted in the lowest tooth displacement (0.07283
mm). When evaluating attachment shapes individually, buccally placed attachments resulted in greater
tooth displacement compared to lingually placed designs. Savignano et al. [21] observed that ellipsoid
attachments were more successful in achieving transversal and sagittal tooth displacements. In this study,
we compared the displacement amounts of the model with an ellipsoid attachment and the model with a
horizontal rectangular attachment. The results showed that the displacement amount of the model (Group 2)
with ellipsoid attachment was lower. This difference can be attributed to the evaluation of different tooth
displacements. Elkholy et al. [22] found that rotation movement was more successful in premolar teeth with
ellipsoid attachments than in teeth without attachments. Similarly, our study determined that the first
premolar tooth moved more in the model with ellipsoid attachment than in the model without attachment.
Due to the limited number of studies evaluating the effect of attachment shapes and positions on the
stresses on the teeth, aligner displacement, and PDL, we were unable to make a detailed comparison of our
results.

Limitations of the study

FEA models generally assume linear, elastic, and homogeneous models. However, the fact that the
mandibular bone structure is not homogeneous and has anisotropic properties causes different stress
distributions and intensities. Additionally, this study is the product of a controlled virtual simulation and
cannot describe situations where naturally varying and multidirectional stresses are present in the oral
cavity [26-28].

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 Conclusions
Considering the study’s limitations, it can be suggested that using attachments in clear aligner treatments
positively influences tooth displacement and aligner retention. Evidence indicates that combining
attachments on both buccal and lingual surfaces is more effective for rotating a tooth than using
attachments on a single surface. However, placing attachments on two surfaces increased stress values in
the PDL, although this did not exceed biological limits. Further advanced, comprehensive, and clinical
studies are needed on this topic.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Erkan Sultanoğlu, Hakan Gürcan Gürel, Muzaffer Gülyurt

Acquisition, analysis, or interpretation of data: Erkan Sultanoğlu, Hakan Gürcan Gürel, Muzaffer
Gülyurt

Drafting of the manuscript: Erkan Sultanoğlu, Hakan Gürcan Gürel, Muzaffer Gülyurt

Critical review of the manuscript for important intellectual content: Erkan Sultanoğlu, Hakan Gürcan
Gürel, Muzaffer Gülyurt

Supervision: Erkan Sultanoğlu, Hakan Gürcan Gürel, Muzaffer Gülyurt

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All
authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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2024 Sultanoğlu et al. Cureus 16(8): e66273. DOI 10.7759/cureus.66273 11 of 11