Aligners: More regulation or just a consumer product?

After the French dentist Pierre Fauchard, who is credited with inventing modern orthodontics, first published his pioneering book in 1728 on dental treatments, in which he explained how to use a Bandeau device, a horseshoeshaped piece of iron that helped expand the palate, people figured out that they could improve facial anatomy and the position of the teeth and consequently improve chewing, posture and ultimately facial aesthetics, by applying mechanical forces to teeth. This made it something desirable and, to a certain extent, a consumer product.

There are so many different ways to do this nowadays, so much has been discussed, analysed and proved to be true, and by the same token, we all have come to understand that many things that we were doing in the past no longer make sense. I am certain that we have all seen historic images of external devices applying mechanical forces that look like something out of a Tim Burton movie. It is strange to think that in the past people would be open to use of such dramatic orthodontic devices in order to achieve a better smile.

We have come a long way just in the past 20 years. I graduated in 1998, and I never really got into orthodontics as a practitioner, but very early on understood its importance in my clinic. I am proud to say that I have been working alongside a fantastic orthodontist since the very beginning, for almost 20 years now. Back in the day, we used classic brackets with elastics, and I always paid a lot of attention to how much art, planning and strategic thinking went into diagnosing each case. Early on, in 2003, we acquired a digital panoramic radiography unit that could also take cephalometric radiographs to enable proper cephalometric planning. The investments in appropriate technologies have not stopped since. As an implant surgeon and prosthodontist, I had the right team and tools to head bravely into the new century. I am very happy to say that, with solid foundations in science and clinical evidence and the right mentors, for over 20 years we have been doing interdisciplinary case management and pre-surgical orthodontic treatment, combining orthodontics and implant treatment in complex cases, to then finally restore a case to perfect occlusion when necessary. Little did I know back then that this would be the right way to do things 20 years later and ubiquitously accepted.

Today, thanks to concepts such as digital smile design (DSD) and special software and 3D printers, we can very easily understand where we need to take the dentition with orthodontic movements prior to minimally invasive treatment with veneers, just as an example. Back then, this required quite a lot of thinking and a very hands-on approach. I feel I have acquired knowledge as the founder and clinical director of an interdisciplinary clinic to talk about orthodontics and aligners.

I very clearly remember the excitement when we discovered the Damon system, which used self-ligating brackets that were gentler on teeth and soft tissue and that required a lot less force to move teeth with much higher efficiency and in fewer appointments. Dr Alessandra Curto, head orthodontist at the practice, took a course on the system and we immediately implemented the system at the White Clinic. Despite the cost of the system, we quickly understood the implicit benefits of having a system that was faster, required less management and was ultimately more comfortable for our patients. Obviously, we passed on that extra cost to the patient, and yes, it was a harder sell back then; Portugal was and still is, after all, the second or third poorest economy in the European Union, but our ethos has always been nothing but the best for our patients. It is important to say that we have absolutely no commercial relationship with Damon system and never have had. I just always believe good things deserve a mention. We still use this system today and have done some amazing cases over the years that we believe could still not be done with aligners, although the things we can do with aligners is increasingly improving. It is important to say that my team and I have always practised Slow Dentistry and spend on average 2.5 hours planning each case prior to starting therapy and follow the No Half Smiles treatment philosophy, which I created in 2006. This philosophy basically means that we never treat just one arch, or perform partial dentistry, leaving untreated teeth in the oral cavity. The aim is to always restore the whole mouth to health, function and, if so desired, aesthetics. Patients with few problems have fast treatment times and little work is necessary, and those with major issues need a lot more work, time, patience and care and their treatment ends up costing a lot more too. No matter what, we always focus on establishing good occlusion and biology, as aesthetics can usually only be achieved after these parameters have been set. It is also worth mentioning that the White Clinic has never had investors or shareholders, is not part of a dental service organisation (DSO), or had never worked with an insurance company. We also have never sold courses or distributed dental products. Why am I saying this? Well because we can focus all our time and our resources on investing in technology, training and doing the right thing always. I am not saying that these are wrong, just that we prefer to focus on the patient and on what truly matters, doing extraordinary dentistry every day and updating knowledge and technology as it comes into existence, so we are always ahead of the game, offering our patients the best there is to offer in any given year.

When in 2005 we were introduced to clear aligners from Align Technology, I was truly blown away. I mean 3D printing was unheard of in real life; it was a thing of sci-fi. I love exciting new technologies that offer more and are better for our patients. Remember, in 2005 there was no social media and no real way of seeing what the world was saying about anything. We started using aligners immediately, and I can tell you that it was not an easy sell to patients, mostly because of the cost. Notwithstanding, we pushed on, and I recall that sales represented about 5% in the first year. Few dentists in Portugal were using clear aligners, and it was really difficult to gain credibility for this modality, as there were no social benchmarks.

I think that dentists who take more time to plan cases, use CBCT and intra-oral scanning technology, and carefully integrate orthodontics with periodontics and restorative dentistry start any case with a DSD study, in order to understand whether the tooth ratio is ideal for the patient’s face. This is also something most aligner companies overlook, focusing only on straightening the arch and bringing the occlusion ideally to a Class I occlusion, often overlooking the fact that the teeth might be too small for the patient’s mouth. I have seen this happen so many times. Treatment seems to be going well, but at the end of such a long journey, the patient is unhappy with the results, because he or she does not really understand that the problem involved the shape and size of the teeth too and not just misalignment. This should not be happening in 2022. We have the tools and resources to understand all of this, before we even touch the patient’s anatomy.

Would it not make more sense to let the patient know prior to initiating a long orthodontic treatment that at the end of the procedure he or she might need to undergo some crown lengthening and/or veneers? People have a right to know before they decide to proceed with alignment that they will have to incur extra costs and undergo more therapy to achieve the desired results. This is all possible with digital software and can be outsourced just like the aligners. I believe that groundbreaking technologies such as those employed by DSD, deserve all the respect and recognition, as these promote and enable the ideal of designing the smile prior to treatment, and this is critical to understanding what is necessary throughout the entire treatment (I have no commercial relationship with DSD–I am just a fan). We were doing it long before the technology existed; it just took a lot longer. Many dentists were doing this, but now, more can do it. It appears, however, that way too many dentists are too cheap or too lazy to invest time and money or, even worse, are scared that the extra costs will scare patients away.

I believe that the reason this happens in the first place is that the largest clear aligner companies in the world seem to be focused on profit and take very little responsibility for quality control regarding the final use of their product. It is very easy for them to say that it is the dentists’ responsibility at the end of the day to do the right thing. They are right, but not all dentists have the right training, tools or mindset. We need more quality control to benefit the patient.

Rewarding dentists on volume of sales and not quality of outcome creates an environment for absolute corruption of care in my opinion. Some dentists might not like what I have to say, but I am sure that the patient, who is the real consumer at the end of the day, would prefer to know the facts. I believe soon the interface will be more public facing and patients will have access to this information. Times are changing; we must change with them. The technology that was invented back in the nineties using 3D printing and stereolithographic technology and software to straighten teeth was absolutely incredible. It is now available ubiquitously around the world, many companies providing what appears to be the same thing.

I personally will always prefer to work with companies that can integrate CBCT data with intra-oral scan data, we are already using such systems that have a higher degree of monitoring of treatment planning. I would also love to see them offering rewards on the quality of outcome, based on the final CBCT and intra oral scans sent back, comparing the results with the treatment planning. I do not think that exists yet, but I have heard that some companies are working on this, and that is the way it should be done! Unfortunately, I have come to understand, after 24 years in dentistry and having lectured in more than 54 countries around the globe, that owing to global economics not every dentist can place ethics at the centre of their treatment all the time. They often lack the resources to do the right thing and are trapped in the past. It is the obligation of large companies to ensure some oversight in the technology to make sure that the patient, who is the real consumer, receives nothing but the best. Hopefully artificial intelligence will mitigate these concerns in the future, and I am certain that we are all heading in the same direction: great volume of sales and extraordinary quality of care.