May 02, 2022

What do I know about clear aligner treatment?

Clear aligner treatment has been used in various forms since 1945.  Following the development of Invisalign there has been a remarkable increase in aligner treatment. Aligners are used increasingly by providers of varying experience levels. Furthermore, there maybe a perception that they are easy to use. This might be a strength from a marketing perspective but could perhaps also be the undoing of these systems? Finally, there are significant developments and the introduction of new treatment methods nearly every year, which makes research difficult.

As a result, it is perhaps no surprise that there is little research done into the effectiveness of aligners. Indeed, in about 2003, Bill Shaw and I met with Invisalign to discuss carrying out trials. They were not keen on the level of research that we wanted to do, but they gave us some nice bottles of Californian red wine for our time.

What do I think?

Many years have passed since that meeting. So, I thought I would set out the main points of my understanding of CAT from the literature that I have reviewed in my past blog posts and some personal comments.

Summary

In summary, the research that has been published suggests that clear aligner treatment is effective for treating minor malocclusions. However,  I cannot help thinking that fixed appliances are still the most effective treatment method for most cases. Nevetheless, hybrid approaches also exist in some instances, particularly where aligners may struggle to deal with more complex tooth movements predictably.

A bit of retrospection

My final comments are my own perception of looking at completed aligner cases on social media, KOL posts, and aligner company websites. While some operators show excellent cases, others are not so good and don’t look as though they are finished properly.

UK orthodontics 40 years ago was not high quality because most treatments were provided with simple removable appliances that tipped teeth. I am not sure that aligner results are dramatically different. If I quote a catchphrase from an aligner KOL. “I can’t do that with braces” I agree; “I can often do a better job with braces”.

Finally, perhaps, an “untidy finish” is the trade-off for invisible appliances? Or am I just a cynical retired ivory tower Professor? Let’s have a heated discussion.

 

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Have your say!

  1. Hi Kevin
    i use and teach aligners with IAS Academy – so declaring an interest

    I remember an IADR meeting in USA (Washington, around 2000 IIRC) and there were dozens on abstracts /presentations on aligners by a well known company, by most of the US orthodontic teaching institutes…. basically the overall message was ‘good at minor movements in selected cases’…….BUT as far as i can recall none/ very few of these abstracts made it to publication.
    Cynical moi?

    So as both a user and teacher, I have seen the predictive software improve and various other developments in design of attachmenst, auxiliaries, materials.
    On the software front,you cannot just take the first proposal, many need modification and adjusting. When you listen to an experienced aligner user, you will hear that they are significantly adjusting the first software iteration. This is where the inexperienced ortho provider gets into problems, either they “dont know, what they don’t know” and IMHO that is usually due to poor teaching by the chosen provider OR they have not subscribed for access to the full software to be able to see /adjust the outcome to what is actually achievable.

    my own use of aligners is now in selected ‘minor’ cases (non extraction / IPR/expansion) with little significant tooth movements OR i use a more conventional appliance lingual/buccal/Inman to get the gross movements quick then detail and finish with aligners. When i use aligners alone i feel i just don’t get the finish that i can with fixed, not this may be due to lack of skill etc with aligners on my part, but i know number of others who have the same issues. Maybe we just have higher expectations/standards?

    In my experience the area of weakness for aligners are
    rotations over 20-25 degrees
    bodily movement esp extraction cases
    intrusion/extrusion

    I find in practice that aligners are often a patient driven choice and in the correct cases that is fine, but (as ever) it comes back to case selection and the appropriate appliance: The Right person, using The Right technique/appliance, for The Right patient”

    • Hi Ross, yes you are correct. The right person using the appliance for the right patient is the key. There is nothing wrong with a compromise treatment, as long as both the operator and patient are aware of the compromise.

  2. Dear Kevin
    Thank you for opening up the debate.

    With any new system there is a steep learning curve. The most experienced and able aligner orthodontists are now achieving excellent results. The mechanics and treatment philosophies are very different to conventional fixed as it is a pushing appliance.
    It requires one to study how it all works and to look at and plan carefully your plans and learn from those more experienced than you.

    I agree sectional fixed and tads are needed to augment the appliance in certain situations. However there are some things aligners are better at such as anterior open bites and I think they can control
    arch form well. Severe Class II correction can be a challenge.
    Some of the results I see are truly stunning but Rome was not built in a day and I think people need to invest time and hours of study to achieve the better and more predictable results.

    • Hi Maria, thanks for the comments. I agree with you about the experience of the operator. However, I have also seen some of the most experienced operators, even KOLs show poorly finished aligner cases. The learning curve appears to be steep and I would really like to see some of the more experienced operators present their cases in a study. Even a prospective cohort would be nice.

  3. Kevin, I agree with your conclusions and agree that a heated discussion is needed. An accelerant (and perhaps Acceledent) onto the fire.

    Someone in my neighbourhood claims that they can do everything fixed appliances can do and more with CAT’s. It appears that marketing and exaggeration have triumphed over results and science.

    Old fashioned beliefs that teeth respond to force applied by wires, that cause pressure in the PDL and result in tooth movement, are consigned to the analogue scrap heap of orthodontics by cgi, where we no longer need to measure what we believe we see.

    Cartoons of tooth movement take precedence over bio-mechanics. We just need to determine whether we are the Coyote or the Roadrunner.

    • Thanks, I have certainly seen many presentations of the moving cartoons! But not real tooth movement,

      • And IMHO this is probably the core problem for some who want to use CAT. They think that the computer will design the treatment plan for them. It will not! There is no magical A.I. in the background.
        This is simply CAD-CAM Orthodontics – the treating doctor can utilize the support of technology to plan and manufacture the orthodontic appliance. But even the best computer-guided appliance will not be able to express unrealistic treatment plans.
        What can go wrong when instead of biomechanics, you trust biomagical vision and try to apply it to the patient?
        I can imagine that someone can ask to create a simulation, a cartoon as you call it, where surgical Class III is turning miraculously into ideal Class I without surgery. But then it’s a no-brainer (should be, but is it?) that this will result in a failure.

        Also, just a thought – let’s define “the real tooth movement”. What does it mean? Which tooth movements are not real? And why CAT would not be able to perform these? I’m not trying to be negative here at all, but rather want to better understand this topic.

        Nonetheless, very interesting discussion.

  4. Saw 3 aligner patients today – which makes it obvious I am not a ‘fan-boy’. 1 very simple one worked fine and fast. The other 2 were fairly simple but needed mid course corrections. By the time I set these up online, remove and place attachments I have spent as much time as bandup/deband and have a far, far greater lab fee to do simple ortho to a worse level than fixed appliances.
    It reminds of of self-directed learning – the kids tell the (professional) teacher what they want to learn – that worked well. So patients telling the orthodontist what appliances they should have to align their teeth and improve their occlusion has to be a good idea!

  5. Clear aligners are just another orthodontic tool that practitioners can choose to train with and deliver treatment with. Every tool has strengths and weaknesses. For example, one weakness of braces that is very often overlooked- many patients simply refuse to wear them or cannot wear them due to allergy or needing regular head MRIs. So aligners open up the possibility of treatment for more people. Of course they are biomechanically different to braces, but different does not always mean worse, difference can be a strength also. For example, they make treating mild to moderate anterior open bites much simpler.
    As an orthodontist who had clear aligners as part of their university training (more emphasis on fixed appliances) I needed to work very hard to understand aligners after graduating. Now I would say the majority of orthodontic treatment can be successful with aligners with the right patient cooperation, planning and persistence. Of course there are some cases that are better suited to fixed appliances (or a combination of fixed and aligners) due to either personality or biomechanics, but equally I now look at some cases (both teeth wise and personality wise) and say they are better treated with clear aligners than braces. Better suited to fixed appliances does not necessarily equate to impossible with clear aligners. Patients just need to accept that if their case is complex and they choose aligners they choose a longer treatment.
    And anyone who thinks the Clincheck is what is planned to happen to the teeth needs to consider the modality more. It is a plastic biomechanics plan, not predicted tooth movements. Just as a reverse curve wire is not where you want the teeth to end up.

    • Love it Amanda!

    • I was sceptical at first, but now I can say that even difficult cases can be succesfully treated with invisalign. Actually treatment time is in average 6 Months shorter. I used to apply Tads and Bollard anchors frequently, but nowadays I treat these cases with invisalign. Much more convenient for the patiënt.
      Aligners are also very useful in cases with tongue thrust and open bites not to mention cases with extraction of a lower incisor. The results are stunning. Even torque differences can be treated. But I am happy to say that headgears, activators and Herbstappliances are also on the scène in my practice ;). The appliance need to fit the patiënt. In other words the tool is of secundary importance.

  6. Even within many KOLs, there is currently a dearth of well treated complex cases that they are able to show, commensurate with comprehensive pre and post treatment records. The cases without full records do not count. As it is too easy to show partial or incomplete records which mask the cases shortcomings, “selection for projection”.

    This becomes especially so in the case of extraction patients. Many of the cases posted by even KOLs charging for courses have shortcomings that would be deal breakers for me. Perhaps they got the roots parallel with a special technique, attachment, or through case selection. However, the first molars are now in 2mm openbite. I personally don’t want to be treating a clear aligner extraction case that has a 2mm first molar openbite and is towards the end of treatment. The reply might be, “Well the case is not finished”. They are KOLs supposedly treating hundreds of these extraction cases. Why do they not have full records on well finished cases to show? We all know that they are already likely showing the top 10% of their cases. This makes me wonder that the other 90% look like.

    I am thinking of another recent case posted online, that did have full records for all time points. A welcome exception there. To give credit, final roots were parallel and I did not see an openbite. However, rotations were everywhere, the lower anteriors were still not aligned, and even the maxillary central incisors were off from each other in vertical alignment. The claim may have again been “well there is still finishing work”. However, why did they then remove attachments? It’s hard to believe that canine and incisor rotations will be take care of without attachments, not to mention incisor verticals. I do believe that I was staring at a poorly finished clear aligner case, treated by a KOL. Again, when we see a KOLs cases, we have to remember we are seeing the best that they have got.

    The overall point being not to trash KOLs. The real point is that at least some of the KOLs teaching courses, are not able to bring many complex courses to a satisfactory finish. That tells me several things. The first is that orthodontists are being encouraged to do things, with clear aligner treatment that is perhaps doomed from the start. Even those behind the podium encouraging us do do certain things are not able to do it themselves. At least, if we look closely at their cases, they are not doing it to standards that most of us walking out of our offices. “Well the patient was happy”, is not a scientific standard and can mean almost anything.

    The second is that we really do now need to pay attention to what research is out there on the limits of clear aligner treatment. There are things that it just won’t do or just won’t do efficiently in a reasonable time frame. We need to respect those boundaries.

    The third is that we really do need to pay attention to where we get our information from. If we uncover a person, KOL, corporation, or Facebook group presenting information that is inaccurate, misleading, or sometimes even harmful, we need to avoid that information source completely.

  7. Hi Kevin, and other commentators,
    I have used and taught Invisalign in a university environment for several years. It is a reasonable approach to smaller corrections. In the past, I have selected 5 cases completed by pre-doctoral students for each of several years and looked to see if, in my subjective opinion, the chief complaint was addressed in a satisfactory fashion. These cases were assigned to pre-doctoral students because they were in our guidelines (non-growing, dental not skeletal issues etc.) and the first series of aligners would be completed in 20 trays (two week protocol) or 30 trays (one week protocol). With a few exceptions the chief complaint (generally crowding, sometimes spacing or rotated teeth) was fully addressed. So much for case selection and outcome.
    I would like to raise a few issues. I would expect to do a second series of aligners on practically every case. Trays are to be worn for 22h/day and 7 days a week. Our own research indicated that wearing the aligners fewer hours daily resulted in less movement. Additionally, I assume that Align has some guidelines about movement per tray that are based on this ideal wear and some ‘standard’ mouth. Neither of them is true for any patient. Ergo, a second set of aligners. I generally ask for over-correction on larger rotations and intrusion/extrusion. I generally have ‘fussed’ with my arch wires too.
    But now I would like to ask about what the proper outcome should be. I know that I have held patients in appliances for a pair of months or longer to make some final finishing adjustments. I shudder to think about the sum of years that adds up to in orthodontics. However, when I ask my patients about whether they would like additional aligners, for example to improve some rotations, they may or may not want to ‘perfect’ that alignment.
    I assure you that I do not practice, teach or condone substandard orthodontics. However, some patients are not as concerned as for example, the ABO, about perfection. And it is paternalistic to continue to perfection against the informed decision of the patient where there is no health related reason to insist that they continue to ‘take their medicine’.
    So, if I were to do the study, I would be sure to use the PAR index to measure outcome and improvement (I believe your were one of the instructors that weekend in Manchester) and I would have several measures of patient satisfaction and oral health related quality of life during the full course of treatment. If I were an engaging researcher I might look to find dyads where the second observer could comment on process and outcome as well.
    If this has seemed like a defense of aligners I would like to be clear (ha!) that, in my opinion, both conventional and aligner therapy can and will remain part of modern orthodontics. There are a great number of situations where conventional appliances are an obvious choice. I would not get rid of my brackets and arch wires unless I were also willing to send some patients down the street to the colleague who still has them.

    • Hi Alan, it is nice to hear from you and I hope that you are well. Yes, I was one of the instructors on that PAR course and I think that it was close to the dawn of time! I agree with your idea of a study using patient measures as well as some of our own. It would be great if someone would do this. It is not difficult.

  8. Our perception of aligner cases outcomes is relative. Relative to the amount of Californian wine drunk.

  9. This will not be a popular comment; but unfortunately, many practitioners (including, sadly, some trained orthodontists) produce less than stellar results with fixed appliances. Their CAT patients look just as good as the rest.

  10. Dear Kevin, Dear Colleagues,
    For sure there is a discrepancy between the advanced, rapid pace of developments in the field of clear aligner orthodontic therapy and the status of relevant scientific documentation.
    Last year Ted Eliades and I published the book “Eliades T, Athanasiou AE. Orthodontic Aligner Treatment: A Review of Materials, Clinical Management, and Evidence. New York: Thieme, 2021. [ISBN 3132411493, 9783132411494]”.
    This publication reviews the subject from clinical, technical, materials, and treatment outcome perspectives, emphasizing on the principles and evidence of aligner treatment. It also includes a clinical manual, case
    presentations, and tips on various applications of aligner treatment in adolescents and adults to be
    used by the reader. As such, it serves as a reference source of the aligner technique with many different
    systems. It also includes the most recent guidelines on clinical management with aligners and presents
    the evidence in a variety of fields. This extends from material properties, to assessment of treatment
    outcome, to forces generated with aligners. This book also provides a detailed list of case planning
    with aligner systems for a wide spectrum of malocclusions.
    We were privileged to include in the book chapters prepared by experts in the field, with great clinical experience and evidence-based scientific background.
    Maybe some of the readers of this block find the book useful.
    With best regards,
    Athanasios E. Athanasiou

  11. Dear all,
    If we suppose that the aligners were and are mainly promoted to compensate the lack of aesthetic using conventional fixed appliances (metallic or ceramic brackets); well, the solution to the list of issues mentioned above could be completely customized lingual orthodontics combining 100% invisibility , efficiency and predictive treatment outcome.
    Best regards,
    Magali Mujagic
    Paris France

  12. I agree with much of the above. When I explain the good wear needed and the reduced predictability of the result compared to fixed appliances many of my patients choose fixed. I call it the ‘hassle factor’ and the constant in/out for eating/drinking is not compatible with many people’s lifestyle.

    I also think the Invisalign model of more discount the more cases you do is not ideal, it encourages clinicians to use it more than they might if there was equity between systems, this model does not apply to most other appliances we use.

  13. Hi Kevin – thanks for the forum.
    Disclosure, speak for Align since before Align was Align, never held shares.
    Thoughts to your conclusions below –
    – The overall accuracy of treatment relative to predictions is only 50%: Still asking what does this mean? Nothing : treatment outcome was not measured, expression of tooth movement compared to that programmed was. Very different variables and FYI – we will never reach 100% expression of activation in any mechanical system, least of all analogue appliances with moving/ undefined final targets! My lengthy comments on this finding in your blog July 2020
    – We don’t know how effective aligners are at correcting Class II problems: Same as fixed. If there is a definitive study, may I have the references so we may simulate design with aligners?
    – The standard of treatment with Invisalign for mild malocclusions is high: for some yes, for some clinicians, no. Same as fixed?
    – Invisalign treatment takes longer than braces: here you quote a study with a high risk of bias. Also 1.3 cf 1.7 years is longer, is it a clinically acceptable difference? Does this difference negate or bolster benefits of aligner systems, considering retention protocols?Hmm
    – We still don’t know if Invisalign Mandibular advancement is effective: Yep. We still debate all kinds of functional appliance efficacy
    – With clear aligner therapy, most tooth movements may not be predictable except for minor horizontal tooth movement.: “predictable” is possibly an incorrect use of term. Computer Programmed Aligner tooth movement is arguably more predictable than fixed appliance tooth movement (This is not the same as saying every computer programmed aligner tooth movement expresses to a high degree). Depends what you are referring to. Most clinicians quoting or measuring “predictability” are referring to the difference between programmed movement and clinically expressed movement. This deficit, alas, cannot be measured using most analog fixed mechanics. Imagine for a moment it was possible – would we measure that each bracket position, each initial wire bend, each bracket slot express to 100% of “targeted” / “planned” position? Never! Impossible ,and likely has a larger deficit than digitally programmed aligner movements.
    – We don’t know if aligners result in less root resorption than fixed braces: yep, anyone have some case reports/ research to share? Think I have seen 1 from Brezniak of previously traumatized tooth with severe resorption. We should know more.
    – Patients don’t like multiple attachments- they don’t like brackets or bills either! Attachments are getting smaller and hopefully smarter; need controlled external studies on efficacy of attachment designs. Issue is that “active” / “optimized” attachments work in unison with aligner force systems so just adding or subtracting an attachment in isolation will not give us the answers. SDC has aligners without attachments……..
    – There is not much evidence to support the 7-day aligner change protocol: I was there when 14 days was developed, no science there except paradigm of 1mm month for bodily tooth movement. Every patient is different and we don’t all change wires at the same intervals. No 1 fit all recipe in orthodontics. I think it is important to remember, after reading comments, that plastic, even smart ones…degrade over time (as well as compliance with weeks old aligner), maintaining a longer wear time is not analogous to maintaining a CuNiTi wire for longer period and changing aligners weekly does not increase speed of movement, assuming same compliance. Time is decreased. Interesting to read some biologic tooth movement studies looking at value, or not, of lag phase.
    – May clear aligners be harmful to the Worlds environment?- great topic. We should be looking at this and raising with aligner companies, we care!
    – I don’t understand why some orthodontists post pictures of themselves with piles of aligner boxes.: Me neither
    – Why do people look at their ClinChecks by the swimming pool or in lectures?: Because we can (poolside), that’s just rude (in lectures)!
    – Why does everyone appear to be a top 1% provider?: Wish I was. Just hope they still pay attention to programming and evaluating mechanics and final position, not just relishing in the volume discount (as alluded to above).

    Enjoyed reading the comments, hope this encourages research and questioning of the highest quality. 🙂

  14. The way I see it, aligners fill a gap in the orthodontic armamentarium which is useful to address (mostly) patients’ and orthodontists’ needs. there are certain movements that aligners struggle to achieve and finishing can be painstaking. Truth is if we consider our treatment aims as being patient-centred rather than operator centred, a number of patients do feel that aligner treatment would fit their lifestlyle better, and as mentioned in previous posts our definition of successful treatment and a patients’ definition differs considerably. They are a tool which I use in around 15-20% of my cases these days, and have had reasonable success. I have also found it a great way to treat case together with my GDP colleagues. They’re not all perfect but realistically nor are my fixed cases. But in general patients are content with a couple of drop outs inevitably for compliance reasons. As the tech improves and hopefully my skillset does as well I believe I will be using them more but I’m still miles away from comprehending how they can be used for all cases that walk through your door.

  15. I would wish to share my opinion on the blog.

    For disclosure I lead on education of aligners at a teaching hospital, I am not a KOL and have no financial interest in aligner companies. I enjoy the blog Kevin and consider it a staple of anyone’s orthodontic diet. I have learned and clinically used aligners for 7 years (I am a top 99% provider).

    I will reply to the key topics mentioned in the blog, not for the sake of disagreement, but to highlight the lack of reliable and reproducible evidence has left uncertainty on the matter, which enforces a decision on the clinician’s opinion, more so than on their powers of deduction from research. The phrase I will direct readers to is what I believe Carl Sagan stated, “absence of evidence is not evidence of absence” and dismissing of an item lacking of evidence as “impatience with ambiguity”.

    1. Accuracy of aligners: Aligner research assessing accuracy varies, from 50% Haoulli 2019 to 86% Bileilo 2022. There is a significant range in accuracy. The main challenge is with the method of assessment. The studies above, and most accuracy studies, base the assessment on a superimposition of the outcome simulator with the actual tooth position at the end of the series of aligners. The issue here is the outcome simulation is considered to be where the aligner should move the teeth to, rather than what the outcome simulator actually represents, which is (a visual representation) the force delivery to the teeth. The reason why (I think) this method is prevalent in aligner studies is the ease of assessment for research. There is still a value to this research as it aids users in planning overcorrection, for example Al-Bahaa’s 2021 study showed 50% intrusion accuracy, and I now plan 200% correction. However a more meaningful assessment would be ABO / PAR. For which there are few studies with varying outcomes. In Ke’s 2019 systematic review “no statistically significant difference in CAT and fixed appliances with the ABO and PAR, however as commented by Yassir in his 2022 review, although no difference was found in Ke’s paper, the none statistically significant difference of 8 points on the ABO scale may be of clinical significance. We must bear in mind we do not assess direct fixed appliances of their ‘accuracy’, and our evaluation of appliances has been based on occlusal outcomes (mainly), which appears unknown at the moment in terms of reliability with CAT.

    2. Class 2 cases: Indeed we don’t know how effective they are. This is a sore topic as myself and Professor Martyn Cobourne applied for funding to investigate this very question 2 years ago, after some initial enthusiasm we were not approved for funding of the research from Align technology. I therefore relent to the lowest form of research, but major component of evidence based practice – clinical experience. Having treated a number of patients with the Invisalign’s Mandibular advancement appliance I had a (small) number of successes, (enough to poke Martyn into writing a research protocol). I continue to offer the appliance as an alternative to the Twinblock, a decision unsupported by research in both directions.

    3. CAT treatment duration. Eric Lin’s study found a 4.8 month difference in favour of fixed appliances, however the fixed appliance group took on average 1.3 years for non-extraction mild crowding (less than 4mm), a long time for what appears to be a straight forward cohort, and questions the reproducibility of the study. These finding were at odds with other research, Ke’s systematic review found for mild-moderate cases of CAT were 6 months shorter in duration. Other components of treatment should also enter the conversation of time, such as the number of appointments, breakages and chairside time, Zheng’s 2017 systematic review showed 4 less appointments with CAT, 1 less emergency and less chairside time by 7 minutes, however this systematic review was from 2017 (several decades in aligner research years) and based on cross sectional studies, leaving the question of duration both in terms of time and appointments uncertain

    4. Low predictability of movements apart from mild horizontal movements. It is interesting how a ‘predictability’ statistic is interpreted. Clinically it is as important (or even more important) to have the standard deviation of the predictability present, which unfortunately is not routine in studies. For example if intrusion of an incisor was 50% predictable with a standard deviation of the mean of 2%, I would be able to use this information to ‘predictably’ achieve 50% of my planned movements, or overcorrect with a degree of predictability.

    5. Root resorption. I consider this topic less important as I would expect some root resorption for any orthodontic appliance due to the physiology of orthodontic tooth movement. A direct comparison is challenging to perform as for a true comparison CAT and fixed appliances needs the roots of teeth the same distance in both appliances, and achieving such accuracy (I feel) is currently not possible with either appliance, and this topic will remain uncertain.

    To conclude with a statement of the current situation regarding evidence and CAT by the exhaustive work from Yassir Yassir and David Bernie in their 2022 systematic review as to why a meta-analysis is not possible; “Due to the lack of primary data, standardized treatment protocols, differences in interventions, clinical and methodological heterogeneity across the studies, further meta-analysis was not feasible”.

    I do wish to congratulate the authors who have contributed to CAT research, although the above may appear critical, their efforts and work is adding to a growing body, and research questions are becoming increasingly refined to produce more meaningful answers, and I am optimistic that the answers to your questions Kevin will materialise as the aligner years pass.

  16. Interesting debate, I’m looking forward to see a serious study talking about the stability 15 years after finishing Aligners.
    The Right person, the right design and a high level of compromise is the key to success.

  17. What could the utility of aligners be for patients with fibromyalgia or sensory issues (autism), who are likely to experienced increased pain and sensory disturbance with braces? As a complex patient, I am (skeptically and critically) considering Invisalign because it may simply be the treatment I can reasonably tolerate.

  18. Thanks a lot for such deep, thought-provoking analysis, Farooq. You have nicely put research data under an adequate set of eyes. Your comments with our colleagues before have been an eye-opener for those like me who have limited experience using clear aligners. I would like to emphasize how difficult it is to agree on a defined set of variables to reflect an adequate result. Some have already acknowledged that patient-oriented outcomes are a must be considered. Criticizing a final occlusal result without having the whole story behind the set of shared decisions that applied to the case is short-sighted. Personally, I treat my patient to a reasonable outcome “area”. Then I get my patient (including the minor if it applies) involved in the decision process over what I can still do to get closer to ideal. At the end of the day, the patient decides what is good, adequate, reasonable, ideal, etc., from their perspective. If, before the orthodontic treatment is started, I find that what the patient wants is a result that I am uncomfortable with, I do not treat. Instead, I suggest the patient search for another provider that will treat the patient as they want. As the patient has the right to decide who provides the elective orthodontic treatment, I, as a provider, also have the right to decide who not to treat. Clear aligners, fixed appliances, etc., are tools to move the teeth. All have strengths and weaknesses as we also have.

  19. Hello everyone,
    I believe Aligners aren’t alternative to conventional braces regardless of how well they are made and planned for because at the end of the day they require 💯 percent compliance to achieve minimal results whereas braces will still deliver good results with minimal compliance.

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