Non-Cochrane · intervention · PM41440338
External Apical Root Resorption Following Orthodontic Treatment with Clear Aligners Versus Fixed Appliances: A Systematic Review and Meta-Analysis.
Darvizeh Atanaz, González Sánchez José Antonio, Doria Jaureguizar Guillermo, et al. · Dentistry journal · 2025 · PubMed · doi:10.3390/dj13120580
Findings
23 findings
| Population | ||||
|---|---|---|---|---|
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Maxillary central incisor (MxC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Maxillary central incisor (MxC); abstract-reported value | MD -0.64 [-0.90, -0.38] GRADE not reported Studies not reported |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Sensitivity analysis excluding two high risk of bias studies (Metcalf 2016, Wang 2017) | MD -0.47 [-0.76, -0.18] GRADE not reported 7 studies |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Maxillary lateral incisor (MxL), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Maxillary lateral incisor (MxL) | MD -0.44 [-0.77, -0.11] GRADE not reported 6 studies · 321 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Follow-up 12 to 24 months · Follow-up 12-24 months | MD -0.69 [-0.76, -0.62] GRADE not reported 5 studies · 318 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), Mandibular central incisor (MdC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Mandibular central incisor (MdC) | SMD -0.33 [-0.56, -0.10] GRADE not reported 4 studies · 299 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Mandibular central incisor (MdC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Mandibular central incisor (MdC); abstract-reported value | MD -0.26 [-0.43, -0.09] GRADE not reported Studies not reported |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Follow-up under 12 months · Follow-up <12 months | MD -0.08 [-0.42, 0.26] GRADE not reported 1 study · 39 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), Mandibular lateral incisor (MdL), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Mandibular lateral incisor (MdL) | SMD -0.53 [-1.25, 0.20] GRADE not reported 4 studies · 298 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Maxillary central incisor (MxC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Maxillary central incisor (MxC) | MD -2.13 [-3.35, -0.91] GRADE not reported 7 studies · 399 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), Maxillary central incisor (MxC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Maxillary central incisor (MxC) | SMD -0.54 [-0.79, -0.28] GRADE not reported 7 studies · 399 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Mandibular lateral incisor (MdL), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Mandibular lateral incisor (MdL) | MD -1.91 [-4.45, 0.63] GRADE not reported 4 studies · 298 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), Mandibular central incisor (MdC), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Mandibular central incisor (MdC) | MD -1.14 [-1.94, -0.33] GRADE not reported 4 studies · 299 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Sensitivity analysis excluding two high risk of bias studies and Toyokawa-Sperandio 2021 (6-month follow-up, intraoral radiographs) | MD -0.55 [-0.85, -0.25] GRADE not reported 6 studies · 340 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Follow-up under 12 months · Radiographic technique: intraoral radiograph (IOR) | MD -0.08 [-0.42, 0.26] GRADE not reported 1 study · 39 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), all incisor types combined in tooth-type subgroup analysis, patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Overall total across tooth-type subgroups | SMD -0.49 [-0.67, -0.30] GRADE not reported 1317 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Mean follow-up about 22 months (range 6 to 43.7) | MD -0.54 [-0.76, -0.33] Low Downgraded: risk of bias, inconsistency 9 studies · 495 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Radiographic technique: CBCT | MD -0.62 [-0.81, -0.43] GRADE not reported 8 studies · 456 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), Maxillary lateral incisor (MxL), patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Maxillary lateral incisor (MxL) | SMD -0.51 [-0.89, -0.14] GRADE not reported 6 studies · 321 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (%), all incisors, patient as unit Mean follow-up about 22 months (range 6 to 43.7) | SMD -0.46 [-0.75, -0.16] Low Downgraded: risk of bias, inconsistency 7 studies · 399 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisor types combined in tooth-type subgroup analysis, patient as unit Mean follow-up about 22 months (range 6 to 43.7) · Overall total across tooth-type subgroups | MD -1.19 [-1.65, -0.74] GRADE not reported 1317 participants |
| Patients with malocclusion undergoing orthodontic treatment | Clear aligners | Fixed orthodontic appliances | EARR (mm), all incisors, patient as unit Follow-up over 24 months · Follow-up >24 months | MD -0.45 [-1.07, 0.16] GRADE not reported 3 studies · 138 participants |
| Patients with malocclusion treated with tooth extraction | Clear aligners | Fixed orthodontic appliances | EARR, extraction versus non-extraction cases Mean follow-up about 22 months (range 6 to 43.7) · Extraction cases versus non-extraction cases (planned subgroup) | Subgroup analysis by tooth extraction could not be performed; only Al-Gumaei et al. reported extraction cases separately; no statement possible due to lack of evidence No studies found 0 studies |
| Patients with malocclusion undergoing orthodontic treatment; by age and gender | Clear aligners | Fixed orthodontic appliances | EARR by patient age and gender Age and gender subgroups | Subgroup analysis accounting for age and gender could not be performed due to lack of individual data in the included studies. No studies found 0 studies |
Included primary studies 10
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Almagrami 2023 A quantitative three-dimensional comparative study of alveolar bone changes and apical root resorption between clear aligners and fixed… PMID:36843193 | 2023 | 1 other review | not stated | not extracted yet |
| Chen 2023 Changes of maxillary central incisor and alveolar bone in Class II Division 2 nonextraction treatment with a fixed appliance or clear… PMID:37079283 | 2023 | 1 other review | not stated | not extracted yet |
| Eissa 2018 Evaluation of root length following treatment with clear aligners and two different fixed orthodontic appliances. A pilot study. PMID:29963506 | 2018 | 1 other review | not stated | not extracted yet |
| Jyotirmay 2021 Comparison of Apical Root Resorption in Patients Treated with Fixed Orthodontic Appliance and Clear Aligners: A Cone-beam Computed… PMID:34615781 | 2021 | 1 other review | not stated | not extracted yet |
| Li 2020 Prevalence and severity of apical root resorption during orthodontic treatment with clear aligners and fixed appliances: a cone beam… PMID:31903505 | 2020 | 1 other review | not stated | not extracted yet |
| Al-Gumaei 2025 Three-dimensional comparative analysis of upper central incisors external apical root resorption/ incisive canal changes in first premolar… PMID:39982527 | 2025 | this review only | not stated | not extracted yet |
| Metcalf 2016 matched by author and year (probable) | NR | this review only | not stated | not extracted yet |
| Toyokawa-Sperandio 2021 External apical root resorption 6 months after initiation of orthodontic treatment: A randomized clinical trial comparing fixed appliances… PMID:34556587 | 2021 | this review only | not stated | not extracted yet |
| Wang 2017 [A retrospective study on incisor root resorption in patients treated with bracketless invisible appliance and straight wire appliance]. PMID:28474083 | 2017 | this review only | not stated | not extracted yet |
| Yi 2018 External apical root resorption in non-extraction cases after clear aligner therapy or fixed orthodontic treatment. PMID:30895094 | 2018 | this review only | not stated | not extracted yet |
Overlap with other reviews
Reviews that include the same primary studies are not independent evidence. Shared counts match studies by PMID, DOI or NCT, and otherwise by author and year (a probable match). Only the non-Cochrane dental reviews have study lists, so overlap with Cochrane reviews is not counted yet.
| Review | Shared studies | Jaccard |
|---|---|---|
| CBCT-Based Assessment of External Apical Root Resorption in Clear Aligner Versus Fixed Orthodontic Therapy: A Systematic Review and… (2026) | 5 | 0.45 |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Patients with malocclusion in need of orthodontic treatment, regardless of age or gender | Orthodontic patients; 286 CA and 289 FA patients (n=575); mean age about 16 to 25 years |
| Intervention | Clear aligners | Clear aligners, mostly Invisalign (n=286 patients) |
| Comparison | Fixed orthodontic appliances | Fixed appliances (n=289 patients) |
| Outcomes | EARR in the vertical dimension, in mm or % of baseline root length | EARR in mm (9 studies) and % (7 studies) at maxillary and mandibular central and lateral incisors |
| Study designs | RCTs, prospective and retrospective cohort studies with at least 6 months of observation and at least 10 patients per group | 10 studies: 1 RCT, 2 prospective cohort, 7 retrospective |
| Timing | At least 6 months from start of treatment | Mean follow-up 22.7 months (CA) and 22.5 months (FA); range 6 to 43.7 months |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | No | No | yes |
| 7List of excluded studies with reasonscritical | Yes | Yes | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Yes | NRSI: Yes · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: No | NRSI: No · RCT: Yes | no |
| 12Impact of risk of bias on the pooled results | Yes | Yes | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | Yes | Yes | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Low | Low | yes |