Clear Aligner Therapy

By Catherine M. Fascilla, D.D.S.

Advertising campaigns are promoting a new concept in clear aligner therapy and their message is resonating with the public as patients are beginning to ask, is it for me doc? Let’s take a look...

Clear aligners are orthodontic devices that are a nearly invisible plastic form of dental braces used to move teeth. Unlike traditional dental braces, they are removable. A series of aligners are created from one impression of the mouth. Each aligner in the series is pro-grammed to incrementally exert a precise amount of pressure to specific teeth. Each aligner is worn for one to two weeks and for twenty-two hours a day. Treatment is very effective for mild to moderate crowding and spacing (1-6 mm) where there are no jaw size discrepancies. It is not recommended for children as successful treatment relies completely on patient compli-ance. It is often used to treat relapses after fixed orthodontic treatment.

While Invisalign created clear aligner therapy as we know it today, it all started in 1945 when an American orthodontist named Harold D. Kesling invented a removable custom de-signed appliance that looked and functioned like a mouth guard. The “tooth positioner” as it was known was the first non-metal removable device used in conjunction with traditional braces to speed up the process of straightening teeth. But it wasn’t until the 1990’s that clear aligners really took off. In 1993, another American orthodontist, John Sheridan devised the Es-six retainer which is still in use today. It was truly the first clear aligner system. Essix is an acronym for S-Six or “Sheridan’s Simple System for Stabilizing the Social Six” (the six front teeth). This system was and still is used to correct minor misalignment of the front teeth.

Two Stanford University students, Zia Chishti and Kelsey Wirth invented Invisalign in 1997. It was the world’s first complete clear aligner system. Chishti was a graduate student in his early twenties going through orthodontic treatment himself when he conceived the idea of using the clear retainers for the entire orthodontic process instead of the metal wires and brackets. Recruiting fellow graduate students to intensively research CAD modeling and 3D printing, the necessary programming needed to manufacture these “ incremental retainers” was perfected and Align Technology was founded. It is the company that produces Invisalign and it received a patent for its unique ability to replicate these clear aligners producing more than three using computer-aided models taken from one impression. They were granted FDA approval to manufacture Invisalign in 1998 and had acquired well over $100 million in venture capital funding. Orthodontists were initially skeptical about Invisalign especially since none of the founders or partners of Align Technology had any orthodontic expertise. By the year 2000, 75% of orthodontists in the U.S. were trained in Invisalign and a massive TV campaign was launched aimed at adults seeking discreet orthodontic treatment. Soon afterwards the founders offered training to general dentists.

For several years Align Technology had no competition. They were constantly innovat-ing and designing better aspects to their product and protecting those innovations with hun-dreds of patents. Despite all of the intellectual property owned by Align, it did not stop other companies from trying to enter the market. The early 2000’s were marked with a number of lawsuits that were filed against companies who encroached on Align’s patents.

Fast forward to 2020, the newest trend in clear aligner therapy is direct to consumer orthodontics. There are over thirty such companies in the U.S. market today, including Smile Direct Club, Candid Co, Byte, Sure Smile and Aligner Co. These companies offer treatment at a markedly reduced rate. While some of the larger brands, such as Smile Direct and Candid Co, have retail locations in NY where appointments can be made for evaluation and 3D scans; most offer these services with the submission of a selfie and a mail-in self-taken dental impres-sion. Most of these companies advertise that your treatment will be evaluated and overseen by a licensed orthodontist or dentist and that treatment is faster than conventional braces. Aligners are shipped directly to the consumer. Upon completion, most companies provide a retainer for an additional fee. Some of these companies offer free bleaching with the aligners.

Smile Direct Club is offering something new and unique and that is Nighttime Clear Aligner therapy. The aligners are worn for ten continuous hours at night with treatment time being longer than their conventional aligner therapy. For example, Smile Direct advertises that a 6 month case would take 10 months to complete.

As an Invisalign provider for about fourteen years, I can vouch for the fact that In-visalign is a high quality tried and true product and Align Technology is a great company to partner with. This technology company continually invests in improving its products by re-searching and developing better medical grade plastics, enhancing its software and providing quality continuing education for its providers, to ensure the best outcomes for their patients.

A couple of years ago, after many years of being approached by several Invisalign competitors, I decided to try another product that was offered by a very reputable dental com-pany that I had done business with for a long time. They presented me with a product that would provide clear aligner therapy to my patients whom Invisalign was financially out of reach. The problem with Invisalign at the time was the high lab cost with respect to simpler easier cases. This new company promised to provide treatment for half the cost and half the time us-ing impressions that my dental assistant could take. I was excited about the possibility of of-fering a cost effective solution to my patients seeking treatment for minor misalignment. Unfor-tunately, the experience was a big disappointment as over a year was spent with their aligners on what was clearly a very simple case only having to finish the case with Invisalign. The valu-able lesson I gained from this experience is that you get what you pay for.

I am confident that some degree of success can be achieved from these companies for some or most people. But patients are different and dentists and orthodontists develop the relationships with their patients to tailor treatment to their specific needs. Some patients re-quire more in office observation during treatment as some of the movements don’t happen as predicted. I question how closely these remote doctors will follow a particular case to provide the patient with great rather than mediocre results. Time and competition has brought down the cost of Invisalign but it will still cost you more than the direct to consumer companies. Ul-timately the value of closer treatment monitoring, better quality and efficiency of plastic and your doctor as a partner, does substantiate that difference.

The other company that I had tried a couple of years ago will be phasing out its original product in March of 2020. It has merged with another company and will provide a different product under a new name. Only time will tell if any of these new companies will succeed in satisfying the market for clear braces. By my estimation it is too soon to know, but for now I am certain that Invisalign is available and guaranteed to finish the case!

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