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A comparison of SureSmileTM, InsigniaTM, and InvisalignTM, in treating non-extraction cases of mild to moderate crowding: a prospective clinical trial

Edward Kim
Edward Kim
, 
Niloufar Sherf
Niloufar Sherf
, 
Manish Lamichane
Manish Lamichane
, 
Sam Levine
Sam Levine
, 
Veerasathpurush Allareddy
Veerasathpurush Allareddy
, 
Yianni Ellenikiotis
Yianni Ellenikiotis
, 
George K. Koch
George K. Koch
 and 
Mohamed I. Masoud
Mohamed I. Masoud
   | Sep 29, 2022
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Published Online: Sep 29, 2022
Page range: 290 - 306
Received: Sep 01, 2021
Accepted: Jun 01, 2022
DOI: https://doi.org/10.2478/aoj-2022-0026
© 2022 Edward Kim et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1.

Sample superimposition (X-axis: Transverse, Y-axis: Sagittal, Z-axis: Vertical).
Sample superimposition (X-axis: Transverse, Y-axis: Sagittal, Z-axis: Vertical).

Gender and Treatment Group Crosstabulation for arches used for objective grading scores.

Treatment group
Insignia Invisalign SureSmile Total
Sex
    Male
        Count 20 10 22 52
        % within Female Gender 38.5% 19.2% 42.3% 100.0%
        % within Treatment Group 58.8% 23.8% 44.0% 41.3%
        % of Total 15.9% 7.9% 17.5% 41.3%
    Female
        Count 14 32 28 74
        % within Female Gender 18.9% 43.2% 37.8% 100.0%
        % within Treatment Group 41.2% 76.2% 56.0% 58.7%
        % of Total 11.1% 25.4% 22.2% 58.7%
Total
    Count 34 42 50 126
    % within Female Gender 27.0% 33.3% 39.7% 100.0%
    % within Treatment Group 100.0% 100.0% 100.0% 100.0%
    % of Total 27.0% 33.3% 39.7% 100.0%

Lower and upper arch age distribution (years).

Treatment group Mean Median SD
Lower arch
Insignia 13.9 14 1.4
Invisalign 29.1 28 10.2
SureSmile 16.5 14 7.5
Upper arch
Insignia 14 14 1.4
Invisalign 29.1 28 10.2
SureSmile 16.5 14 7.5

Mann-Whitney Test comparing the Invisalign outcomes between the two offices. Only landmarks with significant differences included. Remaining non significant landmarks in supplementary table C.

Landmark Mann-Whitney U Wilcoxon W Z p-value
Upper left canine cusp x_Actual_Goal 39 105 -2.564 0.01
Upper right first premolar B cusp z_Actual_Goal 23 68 -2.774 0.006
Lower left first molar DB cusp y_Actual_Goal 33 99 -2.846 0.004
Lower right first premolar DMR y_Actual_Goal 36 102 -2.566 0.01
Lower right second premolar DMR y_Actual_Goal 27 93 -3.128 0.002
Lower left second premolar DMR z_Actual_Goal 39 105 -2.564 0.01

Lower and upper arch inital crowding/spacing (positive value indicates crowding in mm).

Treatment group Mean crowding (mm) Median SD
Lower arch
Insignia 2.0188 2.25 1.0742
Invisalign 2.8318 2.83 1.99914
SureSmile 2.207 1.92 1.47366
Upper arch
Insignia 2.4261 2.415 1.73217
Invisalign 2.7546 2.5 1.60262
SureSmile 2.7359 2.42 1.54442

Intermolar and intercanine mean target width and SD by intervention.

System Mean target intercanine width (mm ) Target intercanine width standard deviation Mean target inter molar width at first molars (mm) Target intermolar width standard deviation
Insignia 27.53 1.06 54.92 2.21
Invisalign 25.39 1.696 51.12 3.41
Suresmile 26.34 1.18 52.33 2.53

Objective Grading Score (OGS) descriptive statistics for each treatment category.

Treatment Group Alignment/Rotations Marginal Ridges Buccolingual Inclination Total OGS Score Age
Insignia
    Mean 2.56 .91 1.56 5.03 14
    Std. Deviation 1.260 1.026 1.673 1.800 1.393
    Percentile: 50 2.00 1.00 1.00 4.50 14.00
Invisalign
    Mean 3.26 .38 2.21 5.83 30.48
    Std. Deviation 1.499 .795 1.920 2.626 13.74
    Percentile: 50 3.00 .00 2.00 6.00 25.00
SureSmile
    Mean 1.98 .66 2.40 5.02 16.16
    Std. Deviation 1.059 .895 2.157 2.386 7.536
    Percentile: 50 2.00 .00 2.00 5.00 14.00

Ranges of mean difference between predicted and actual loctions of Anterior & Posterior Landmarks.

Transverse difference (X) Sagittal difference (Y) Vertical difference (Z)
Insignia
Upper Anterior 0.27–0.48 mm 0.42–0.81 mm 0.33–0.57 mm
Upper Posterior 0.47–1.27 mm 1.15–2.22 mm 0.26–0.61 mm
Lower Anterior 0.31–0.50 mm 0.28–0.43 mm 0.36–0.57 mm
Lower Posterior 0.40–1.01 mm 0.40–0.81 mm 0.27–0.57 mm
Suresmile
Upper Anterior 0.21–0.56 mm 0.32–0.68 mm 0.33–0.63 mm
Upper Posterior 0.30–0.84 mm 0.28–0.63 mm 0.31–0.62 mm
Lower Anterior 0.16–0.44 mm 0.30–0.46 mm 0.29–0.47 mm
Lower Posterior 0.30–0.80 mm 0.40–0.70 mm 0.28–0.58 mm
Invisalign
Upper Anterior 0.23–0.45 mm 0.32–0.45 mm 0.31–0.60 mm
Upper Posterior 0.26–0.50 mm 0.18–0.41 mm 0.17–0.48 mm
Lower Anterior 0.13–0.37 mm 0.29–0.52 mm 0.34–0.51 mm
Lower Posterior 0.28–1.0 mm 0.47–0.83 mm 0.18–0.46 mm

Multiple pair-wise comparisons of mean differences betwee the predicted and actual location of each landmark.

Landmark Reference system Comparison system Mean difference Std. error P value
Upper right first molar DB cusp x_Actual_Goal Insignia Invisalign 0.709 0.174 0.000
SureSmile 0.449 0.175 0.037
Upper right first molar DMR x_Actual_Goal Insignia Invisalign 0.892 0.170 0.000
SureSmile 0.435 0.171 0.039
Upper right first molar MMR x_Actual_Goal Insignia Invisalign 0.666 0.156 0.000
SureSmile 0.521 0.157 0.004
Upper right second premolar B cusp x_Actual_Goal Insignia Invisalign 0.536 0.135 0.001
SureSmile 0.359 0.136 0.031
Upper right second premolar DMR x_Actual_Goal Insignia Invisalign 0.738 0.160 0.000
SureSmile 0.650 0.161 0.000
Upper right second premolar MMR x_Actual_Goal Insignia Invisalign 0.504 0.121 0.000
SureSmile 0.413 0.122 0.003
Upper left first molar DB cusp x_Actual_Goal Insignia Invisalign 0.512 0.157 0.005
SureSmile 0.257 0.158 0.326
Upper left first molar DMR x_Actual_Goal Insignia Invisalign 0.526 0.157 0.004
SureSmile 0.294 0.158 0.203
Upper right first molar DB cusp y_Actual_Goal Insignia Invisalign 1.825 0.214 0.000
SureSmile 1.788 0.215 0.000
Upper right first molar MB cusp y_Actual_Goal Insignia Invisalign 1.660 0.206 0.000
SureSmile 1.650 0.207 0.000
Upper right first molar DMR y_Actual_Goal Insignia Invisalign 1.665 0.204 0.000
SureSmile 1.612 0.206 0.000
Upper right first molar MMR y_Actual_Goal Insignia Invisalign 1.770 0.194 0.000
SureSmile 1.736 0.196 0.000
Upper right second premolar B cusp y_Actual_Goal Insignia Invisalign 1.534 0.195 0.000
SureSmile 1.346 0.197 0.000
Upper right second premolar DMR y_Actual_Goal Insignia Invisalign 1.429 0.179 0.000
SureSmile 1.399 0.180 0.000
Upper right second premolar MMR y_Actual_Goal Insignia Invisalign 1.364 0.178 0.000
SureSmile 1.359 0.179 0.000
Upper right first premolar B cusp y_Actual_Goal Insignia Invisalign 1.103 0.210 0.000
SureSmile 0.906 0.208 0.000
Upper right first premolar DMR y_Actual_Goal Insignia Invisalign 1.114 0.168 0.000
SureSmile 1.011 0.166 0.000
Upper right first premolar MMR y_Actual_Goal Insignia Invisalign 1.064 0.153 0.000
SureSmile 0.978 0.151 0.000
Upper right canine disto-incisal y_Actual_Goal Insignia Invisalign 0.668 0.143 0.000
SureSmile 0.591 0.144 0.000
Upper left canine disto-incisal y_Actual_Goal Insignia Invisalign 0.691 0.134 0.000
SureSmile 0.545 0.135 0.000
Upper left first premolar B cusp y_Actual_Goal Insignia Invisalign 1.185 0.189 0.000
SureSmile 0.953 0.187 0.000
Upper left first premolar MMR y_Actual_Goal Insignia Invisalign 0.875 0.146 0.000
SureSmile 0.749 0.144 0.000
Upper left first premolar DMR y_Actual_Goal Insignia Invisalign 1.005 0.149 0.000
SureSmile 0.891 0.147 0.000
Upper left second premolar B cusp y_Actual_Goal Insignia Invisalign 1.391 0.184 0.000
SureSmile 1.243 0.185 0.000
Upper left second premolar MMR y_Actual_Goal Insignia Invisalign 1.320 0.150 0.000
SureSmile 1.260 0.151 0.000
Upper left second premolar DMR y_Actual_Goal Insignia Invisalign 1.238 0.167 0.000
SureSmile 1.232 0.168 0.000
Upper left first molar MB cusp y_Actual_Goal Insignia Invisalign 1.535 0.197 0.000
SureSmile 1.418 0.198 0.000
Upper left first molar DB cusp y_Actual_Goal Insignia Invisalign 1.843 0.208 0.000
SureSmile 1.804 0.209 0.000
Upper left first molar MMR y_Actual_Goal Insignia Invisalign 1.578 0.176 0.000
SureSmile 1.442 0.177 0.000
Upper left first molar DMR y_Actual_Goal Insignia Invisalign 1.543 0.173 0.000
SureSmile 1.526 0.174 0.000
Upper right lateral incisor CEJ actual_goal Suresmile Insignia 0.556 0.214 0.034
Invisalign 0.831 0.189 0
Upper right central incisor CEJ actual_goal Suresmile Insignia 0.958 0.255 0.001
Invisalign 0.746 0.226 0.005
Upper left central incisor CEJ actual_goal Suresmile Insignia 0.895 0.239 0.001
Invisalign 0.804 0.212 0.001
Upper left lateral incisor CEJ actual_goal Suresmile Insignia 0.471 0.22 0.108
Invisalign 0.645 0.195 0.005
Lower left first molar MB cusp x_Actual_Goal Insignia Invisalign 0.339 0.162 0.122
SureSmile 0.570 0.164 0.003
Lower right second premolar B cusp x_Actual_Goal Insignia Invisalign 0.701 0.142 0.000
SureSmile 0.469 0.143 0.005

Lower and upper arch gender distribution.

Treatment group Female lower arches Male lower arches Total
Lower arches
Insignia (all from office 1) 6 11 17
Invisalign (11 from office 1, 17 from office 2) 22 6 28
SureSmile (all from office 2) 16 11 27
Total 44 28 72
Upper arches
Insignia (all from office 1) 6 12 18
Invisalign (11 from office 1, 17 from office 2) 22 6 28
SureSmile (all from office 2) 16 11 27
Total 44 29 73

Multivariable Linear Regression Analysis for (A) Alignment/Rotations Objective grading score, (B) Marginal ridge Objective grading score, (C) Buccolingual Inclination Objective Grading Score, and (D) Combined Intra-arch Objective Grading Score.

Unstandardized Coefficients Standardized Coefficients 95.0% Confidence Interval for B
Model B Std. error Beta t p-value Lower bound Upper bound
(A) Alignment/Rotations Objective grading scorea
(Constant) 1.998 0.328 6.087 <0.001* 1.348 2.648
Invisalignb 1.291 0.326 0.444 3.963 <0.001* 0.646 1.936
Insigniab 0.57 0.289 0.185 1.97 0.051 -0.003 1.143
Female Gender -0.06 0.249 -0.021 -0.24 0.811 -0.552 0.433
Age 0 0.013 -0.001 -0.01 0.992 -0.026 0.025
Crowding 0.007 0.073 0.008 0.098 0.922 -0.138 0.153
(B) Marginal ridge Objective grading score
(Constant) 0.461 0.229 2.013 0.046* 0.008 0.914
Invisalignb -0.464 0.227 -0.239 -2.04 0.044* -0.914 -0.014
Insigniab 0.257 0.202 0.125 1.271 0.206 -0.143 0.656
Female Gender -0.186 0.173 -0.1 -1.07 0.287 -0.529 0.158
Age 0.014 0.009 0.18 1.58 0.117 -0.004 0.032
Crowding 0.031 0.051 0.054 0.606 0.546 -0.07 0.133
(C) Buccolingual Inclination Objective Grading Score
(Constant) 2.826 0.498 5.677 0.000* 1.84 3.811
Invisalignb 0.277 0.494 0.066 0.561 0.576 -0.701 1.255
Insigniab -0.891 0.439 -0.201 -2.03 0.045* -1.76 -0.022
Female Gender 0.177 0.377 0.044 0.47 0.639 -0.569 0.923
Age -0.036 0.019 -0.213 -1.842 0.068 -0.074 0.003
Crowding 0.023 0.111 0.018 0.202 0.84 -0.198 0.243
(D) Combined Intra-arch Objective Grading Score
(Constant) 5.314 0.601 8.848 0 4.125 6.503
Invisalignb 1.121 0.593 0.226 1.889 0.061 -0.054 2.295
Insigniab -0.047 0.527 -0.009 -0.089 0.93 -1.09 0.997
Female Gender -0.05 0.452 -0.011 -0.111 0.912 -0.946 0.846
Age -0.024 0.024 -0.118 -1.012 0.314 -0.07 0.023
Crowding 0.05 0.134 0.034 0.371 0.712 -0.215 0.315

List of dental landmarks used in the study on each type of tooth.

Tooth type Landmark 1 Landmark 2 Landmark 3 Landmark 4
Right First Molar Distobuccal Cusp Tip Mesiobuccal Cusp Tip Distal Marginal Ridge Mesial Marginal Ridge
Right Second Premolar Buccal Cusp Tip Distal Marginal Ridge Mesial Marginal Ridge
Right First Premolar Buccal Cusp Tip Distal Marginal Ridge Mesial Marginal Ridge
Right Canine Buccal Cusp Tip Mesial-incisal Point Distal-incisal Point
Right Lateral Incisor Distal-incisal Point Mesial-incisal Point Labial CEJ
Right Central Incisor Distal-incisal Point Mesial-incisal Point Labial CEJ
Left Central Incisor Mesial-incisal Point Distal-incisal Point Labial CEJ
Left Lateral Incisor Mesial-incisal Point Distal-incisal Point Labial CEJ
Left Canine Buccal Cusp Tip Mesial-incisal Point Distal-incisal Point
Left First Premolar Buccal Cusp Tip Mesial Marginal Ridge Distal Marginal Ridge
Left Second Premolar Buccal Cusp Tip Mesial Marginal Ridge Distal Marginal Ridge
Left First Molar Mesiobuccal Cusp Tip Distobuccal Cusp Tip Mesial Marginal Ridge Distal Marginal Ridge

Mean and SD of observation period in months for each intervention.

System Mean to observation period (months) Observation period standard deviation (months)
Insignia 12.5 1
Invisalign 8.4 2.9
Suresmile 11.5 3.1
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