Non-Cochrane · intervention · PM42782998
Clinical Outcomes of Sequential Distalization with Clear Aligners: A Systematic Review and Meta-Analysis.
Baxmann Martin, Zsoldos Márton, Kárpáti Krisztina · Dentistry journal · 2026 · PubMed · doi:10.3390/dj14090611
Findings
Population Adolescents or adults undergoing sequential distalization
10 findings
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary second-molar distal tipping | MEAN 5.77 [-6.84, 18.38] Very low Downgraded: risk of bias, imprecision, inconsistency 3 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary first-molar distalization | MEAN 1.72 [1.02, 2.42] Very low Downgraded: risk of bias, inconsistency 7 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Mandibular first-molar distalization | MEAN 1.87 [-0.32, 4.06] Very low Downgraded: risk of bias, imprecision, inconsistency, indirectness 3 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Mandibular second-molar distalization | MEAN 1.96 [-2.06, 5.97] Very low Downgraded: risk of bias, imprecision, inconsistency, indirectness 2 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary first-molar distalization Participant-level estimates only; sensitivity analysis | MEAN 2.07 [1.04, 3.10] GRADE not reported Studies not reported |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary first-molar distal tipping | MEAN 5.33 [1.37, 9.30] Very low Downgraded: risk of bias, imprecision, inconsistency 4 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary first-molar intrusion | MEAN 0.58 [0.05, 1.10] Very low Downgraded: risk of bias, imprecision, inconsistency 3 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary second-molar distalization Participant-level estimates only; sensitivity analysis | MEAN 1.96 [0.64, 3.28] GRADE not reported Studies not reported |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary second-molar distalization | MEAN 1.76 [1.12, 2.40] Very low Downgraded: risk of bias, inconsistency 6 studies |
| Sequential distalization with clear aligners | No comparator (single-group pooled mean) | Maxillary second-molar intrusion | MEAN 0.67 [-1.14, 2.48] Very low Downgraded: risk of bias, imprecision, inconsistency 2 studies |
Included primary studies 28
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Al-Tayar 2023 Impact of molar teeth distalization by clear aligners on temporomandibular joint: a three-dimensional study. PMID:37455279 | 2023 | this review only | not stated | not extracted yet |
| Al-Worafi 2024a Impact of molar teeth distalization by clear aligners on maxillary alveolar bone thickness and root resorption: a three‑dimensional study. PMID:38355506 | 2024 | this review only | not stated | not extracted yet |
| Al-Worafi 2024b Effect of maxillary molars distalization using clear aligners and fixed orthodontic appliances on the positional and dimensional… PMID:39538283 | 2024 | this review only | not stated | not extracted yet |
| Balboni 2023 Vertical effects of distalization protocol with Clear aligners in Class II patients: a prospective study. PMID:37162331 | 2023 | this review only | not stated | not extracted yet |
| Caruso 2019 Impact of molar teeth distalization with clear aligners on occlusal vertical dimension: a retrospective study. PMID:31409348 | 2019 | this review only | not stated | not extracted yet |
| D'Anto 2023 Predictability of Maxillary Molar Distalization and Derotation with Clear Aligners: A Prospective Study. PMID:36833638 | 2023 | this review only | not stated | not extracted yet |
| Elfouly 2023 Does maxillary sinus proximity affect molar root resorption during distalization using Invisalign? a CBCT study. PMID:37990186 | 2023 | this review only | not stated | not extracted yet |
| Elfouly 2024 Tip, torque and rotation of maxillary molars during distalization using Invisalign: a CBCT study. PMID:39009996 | 2024 | this review only | not stated | not extracted yet |
| Hatami 2026 Treatment outcomes of Class II subdivision with clear aligners: A retrospective study. PMID:41182199 | 2026 | this review only | not stated | not extracted yet |
| Keilig 2024 Accuracy of Digital Orthodontic Treatment Planning: Assessing Aligner-Directed Tooth Movements and Exploring Inherent Intramaxillary Side… PMID:38673571 | 2024 | this review only | not stated | not extracted yet |
| Lin 2023 Treatment of class II malocclusion with Invisalign®: A pilot study using digital model-integrated maxillofacial cone beam computed… PMID:36643222 | 2023 | this review only | not stated | not extracted yet |
| Lione 2022 Effects of pendulum appliance versus clear aligners in the vertical dimension during Class II malocclusion treatment: a randomized… PMID:36217134 | 2022 | this review only | not stated | not extracted yet |
| Liu 2024 Miniscrew anchorage versus Class II elastics for maxillary arch distalization using clear aligners. PMID:39229948 | 2024 | this review only | not stated | not extracted yet |
| Liu 2025 Maxillary molar distalization with invisalign in adult patients: a preliminary study using iTero-created digital models. PMID:40702438 | 2025 | this review only | not stated | not extracted yet |
| Loberto 2023 Anchorage Loss Evaluation during Maxillary Molars Distalization Performed by Clear Aligners: A Retrospective Study on 3D Digital Casts DOI:10.3390/app13063646 | 2023 | this review only | not stated | not extracted yet |
| Maksyukov 2026 Evaluation of the effectiveness of maxillary molar distalization using clear aligners in combination with micro-implants: a randomized… DOI:10.17816/dent702551 | 2026 | this review only | not stated | not extracted yet |
| Mamani 2024 Effectiveness of Clear Aligners on Sequential Maxillary Molar Distalization: Discrepancy between Treatment Goal and Outcome. PMID:39064256 | 2024 | this review only | not stated | not extracted yet |
| Miao 2023 Influence of maxillary molar distalization with clear aligners on three-dimensional direction: molar distal movement, intrusion, distal… PMID:38151662 | 2023 | this review only | not stated | not extracted yet |
| Qiang 2025 Accuracy of maxillary molar distalization with clear aligners in three-dimension: a retrospective study based on CBCT superimposition. PMID:39964527 | 2025 | this review only | not stated | not extracted yet |
| Ravera 2016 Maxillary molar distalization with aligners in adult patients: a multicenter retrospective study. PMID:27041551 | 2016 | this review only | not stated | not extracted yet |
| Rongo 2022 Class II Malocclusion in Adult Patients: What Are the Effects of the Intermaxillary Elastics with Clear Aligners? A Retrospective Single… PMID:36555949 | 2022 | this review only | not stated | not extracted yet |
| Saif 2026 Molar distalization and stability following maxillary anterior teeth alignment with class II elastics and a 10-day aligner protocol. PMID:41775797 | 2026 | this review only | not stated | not extracted yet |
| Shen 2026 Maxillary molar distalization with clear aligner therapy and infrazygomatic temporary skeletal anchorage devices. PMID:41105056 | 2026 | this review only | not stated | not extracted yet |
| Simon 2014 Treatment outcome and efficacy of an aligner technique--regarding incisor torque, premolar derotation and molar distalization. PMID:24923279 | 2014 | this review only | not stated | not extracted yet |
| Wang 2024 Comparison of treatment effects between clear aligners and fixed appliances in patients treated with miniscrew-assisted molar distalization. PMID:38733349 | 2024 | this review only | not stated | not extracted yet |
| Wu 2021 Efficacy of mandibular molar distalization by clear aligner treatment. PMID:34911842 | 2021 | this review only | not stated | not extracted yet |
| Yurdakul 2024 Evaluating anchorage loss in upper incisors during distalization of maxillary posterior teeth using clear aligners in adult patients: A… PMID:38533599 | 2024 | this review only | not stated | not extracted yet |
| Zhao 2026 Soft tissue and dentoskeletal changes associated with mandibular molar distalization using clear aligner therapy: a retrospective… PMID:41974799 | 2026 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Adolescents or adults undergoing sequential distalization with clear aligners for Class II or selected Class III malocclusions | Adolescents and adults, mostly Class II (including Class II subdivision), few selected Class III or mandibular crowding; samples of 7 to 46 participants (n=28 studies) |
| Intervention | Sequential distalization using any commercially available clear aligner system, with or without adjunctive biomechanics (TADs, Class II elastics, attachments) | Sequential maxillary molar distalization with clear aligners (mostly Invisalign), with Class II elastics, miniscrews/TADs or no auxiliary anchorage; mandibular molar distalization (V-pattern) in few studies |
| Comparison | Alternative distalization protocols, different anchorage strategies, different aligner systems, fixed appliances, or no comparator | Mostly no comparator (single-group); comparators in some studies: fixed appliances (n=2), pendulum appliance (n=1), Class II elastics vs miniscrew/micro-implant anchorage (n=2), 33% vs 50% sequencing (n=1), staging/anchorage strategies (n=1), with vs without auxiliaries (n=1) |
| Outcomes | Primary: amount of posterior tooth distalization. Secondary: anchorage preservation, movement predictability, vertical changes, treatment duration, root resorption, periodontal outcomes, treatment stability, adverse events, patient-reported outcomes | Pooled: maxillary first/second molar distalization, distal tipping and intrusion; mandibular first/second molar distalization. Narrative: predictability/accuracy, anchorage loss, torque/rotation, root resorption, alveolar bone, TMJ, treatment duration, refinements, stability, soft tissue |
| Study designs | RCTs, prospective and retrospective cohort studies, comparative clinical studies, observational clinical studies | 3 RCTs, 3 nonrandomized comparative studies, 22 uncontrolled single-group clinical studies (n=28) |
| Timing | Not specified | Post-distalization, post-treatment and planned-versus-achieved assessments; distalization phase about 4 to 11 months, comprehensive treatment about 33 to 34 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 | Yes | Partial Yes | no |
| 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 | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | Yes | Yes | yes |
| 8Included studies described in detail | Partial Yes | Yes | no |
| 9Risk of bias assessed satisfactorilycritical | NRSI: Partial Yes · RCT: Yes | RCT: Yes · NRSI: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: No | NRSI: Yes · RCT: N/A | no |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | Yes | No | no |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Low | Low | yes |