Improving the predictability of rotational correction with clear aligners: Evidence gaps, biomechanical principles, and clinical strategies

Clear aligner therapy (CAT) has evolved from an aesthetic modality into a widely used orthodontic treatment system capable of addressing increasingly complex malocclusions. Improvements in thermoplastic materials, digital planning, staging protocols, and attachment design have broadened the scope of treatment; however, rotational correction remains one of the least predictable tooth movements. The expression of derotation is influenced by tooth morphology, rotational direction, magnitude of correction, available space, staging velocity, attachment geometry, wear compliance, and unintended three-dimensional side effects. Yet much of the available evidence continues to evaluate rotation as a single endpoint, thereby limiting the clinical utility of reported predictability estimates. This narrative review synthesises clinical, systematic-review, and biomechanical evidence on rotational correction with clear aligners, emphasising movement-specific determinants, evidence limitations, and practical management strategies. The available literature suggests that derotation may be more predictable when treatment planning accounts for tooth-specific anatomy, movement magnitude and direction, space availability, staging strategy, attachment design, and treatment compliance. For severe or resistant rotations, adjunctive or hybrid mechanics may be considered when adequate expression cannot be achieved with aligner-only mechanics. Overall, a movement-specific and biomechanics-informed approach may help improve the clinical management of rotational correction, although further prospective evidence is needed to establish the relative contribution of individual treatment variables.