Introduction: Clear aligners, introduced in the 1990s with the Invisalign® system, have transformed orthodontics by providing an esthetic and comfortable alternative to fixed appliances. However, questions remain regarding their effectiveness and predictability in achieving different tooth movements and specifically tooth rotation. This systematic review aimed to critically evaluate the efficiency of aligners in controlling rotational movements and to identify the factors influencing their predictability. Materials and Methods: A systematic review was conducted following the PRISMA guidelines. Electronic searches were performed in PubMed, Cochrane Library, and ScienceDirect using a PICOS-based strategy. Methodological quality and risk of bias were assessed using standardized tools (AMSTAR 2, NHLBI/NIH). Results: Studies published between 2014 and 2024 were included. After screening, 14 studies met the eligibility criteria, including prospective and retrospective cohort studies, and systematic reviews. The review revealed that accuracy of tooth rotation is moderate (≈37–60%), it can be improved with attachments and interproximal reduction, but decreases with large or rapidly staged movements. Despite some progress, rotational control remains a key clinical limitation requiring cautious planning and monitoring. Conclusion: Rotations with clear aligners are poorly predictable, particularly for canines and premolars due to limited aligner grip on rounded crowns which often requires the use of auxiliaries and overcorrection strategies. Future high-quality randomized clinical trials and standardized protocols are necessary to strengthen the evidence and improve clinical outcomes.