This post is about case selection and some of the issues that can arise when working with clear aligners.
Challenges during treatment
Across 16 countries, we see a worrying trend. More and more dentists are approaching us in the middle of a course of treatment with clear aligners that they have started themselves. They ask for help with treatments that don't follow the digital plan they see on the computer screen. During the course of treatment, they have often already had their treatments corrected with 1 or more sets of additional aligners. Still, they are far from the desired treatment result.
Many express that they can't understand why they are not getting the results that were shown in their digital online planning tool. In many of these cases, we have to inform that it is because the patient has a skeletal deviation that is so severe that it is not possible to treat the patient with clear aligners (or fixed appliances alone), as surgery is required.
When surgery is the solution
When a dentist is confronted with the need for such a major correction to a treatment plan that surgery entails, it naturally causes a lot of frustration. Especially if the dentist has been treating a patient for years and now has to inform the patient that there is no way around surgery. Because once you've started orthodontic treatment, it's not always possible to go back to square one. You should be aware of this every time you start treatment with clear aligners. Even those treatments where you have received professional help with the treatment plan, as patient compliance and patient biology are unknown factors that can influence clinical outcomes during treatment.
Clear aligners are not magic
Clear aligners are not a product that should be used by all general dentists. They CAN be used by nearly any dentist with the right help. But there is essentially no difference in the diagnostic and treatment planning requirements whether you use fixed appliances or clear aligners. This is basically why it is worth considering who should perform the treatment planning and the optimisation of the digital setup.
The big challenge is that aligner manufacturers' software can make everything look amazing on a computer screen. In our experience, this often confuses the dentists who are looking at the plans. After all, it looks tempting when you can see how an extreme class III patient with 20 aligners and a little IPR in the mandibular front can be corrected to a class I. But clear aligners are not magic. No matter how amazing the treatment plan looks on the computer screen, it needs to be realized in practice. This is where the responsibility of the treating dentist comes in.
Think about the realism
It is the responsibility of the treating dentist to determine whether or not the digital plan can be realized. The examples mentioned in this blog post may sound extreme. It's just our experience that many colleagues start such treatments without thinking about the realism of the digital plan. When they are later confronted with the fact that it's their responsibility and not the aligner manufacturers', most start to get nervous about the consequences.
And that's a shame.
Because it often causes the affected dentists to refrain from treating patients with clear aligners afterwards. This means that many patients who could benefit from orthodontic or orthodontic-prosthetic treatment are not offered optimal treatment. Which is not optimal either.
In our view, it's all about avoiding the extremes and seeking help to solve tasks that are outside your area of expertise. That way, dentists experience clinical success while patients receive better treatment.
The clinical reality
Over the past week, we've seen several cases where dentists have contacted us in frustration and asked for help. The problem is that they have come a long way in their treatments and are now starting to realize that there is a growing gap between the digital setup and the clinical reality. We see open bites, collapsed bites, large discrepancies between the upper and lower jaw, jaws that seem to fit together worse and worse as the patient progresses in treatment.
Responsibility of Aligner manufacturers
Had our expert dentists or orthodontists had the opportunity to perform case selection BEFORE treatment had started, we would have been able to warn that the skeletal or dental conditions required fixed appliances and typically orthognathic surgery.
Aligner manufacturers cannot and will not provide this information. Because it takes highly specialized orthodontic knowledge and lots of experience to be able to see this.
Referring in an orderly manner
When these situations arise, our only option as consulting dentists and orthodontists is to help the dentist find an orthodontist who can take over the treatment. Ideally, the orthodontist supports the dentist in a way that the patient still has a reasonable experience. In most cases, there has been a clear indication for treatment from the start of clear aligner treatment. The treatment just couldn't be completed with clear aligners. From here, it's up to the orthodontist to bring the patient to the finish line.
If a patient has a skeletal deviation, it is rarely possible to achieve a Class I molar and canine relationship without surgery or highly complex orthodontics. In some cases, where patients' initial bite is in balance with muscles and joints, satisfactory treatment results can be achieved without surgery. However, this requires the person planning the treatment to have a thorough knowledge of functional occlusion and orthodontics, as well as plenty of clinical experience.
When we first started treating patients with clear aligners in 2008, no one could help us. Because no one had experience with clear aligners. We had a lot of orthodontic knowledge and training. But it was knowledge that was 100% related to fixed appliances. Since several of our patients needed minor corrections before restorative treatment and because our clinic was very far from any orthodontist, we performed a lot of orthodontics with braces and wires ourselves. We were very conscious about which patients we started treating. Just as we were very clear with our patients that if something didn't go as planned, the patient would be referred directly to an orthodontist who would take over the treatment. No matter how annoying it was for the patient to have to drive a long way for this.
Clear aligners - limitations
By 2008, it was obvious that clear aligners had a lot of limitations in their ability to move teeth, and the aligner manufacturers were open about this. This created a natural limitation in our case selection proces.
As we developed our knowledge, the aligner systems evolved as well.
The responsibility lies with the practitioner
In 2023, the situation is completely different than when we started. Aligner systems have evolved significantly and allow the practitioner to move the roots far more advanced than ever before. Provided the practitioner knows how. Because the technicians, or the artificial intelligence that designs treatment setups, have a very limited knowledge of what can be done. They also don't necessarily know how to get from a to b and rarely take into account the need for anchorage. There IS a reason why it takes 3-4 years to become an orthodontist.
In order for aligner manufacturers to keep production costs at a reasonable level and to avoid direct product liability, they don't have orthodontists designing the setups that the dental practices receive.
No difference between clear aligners and fixed appliances
Clear aligners - regardless of brand - are a piece of orthodontic equipment on par with brackets and wires, removable appliances or similar. Treatment planning with clear aligners is therefore in no way different from treatment planning with fixed appliances. It is the sole responsibility of the practitioner - and not the aligner manufacturers - to design realistic, safe and predictable treatment plans. Just as it is the practitioner's responsibility to figure out how to work around the problems that can arise during treatment when the teeth don't follow the plan designed on the computer.
The more you know, the more you know you don't know.
Once you've made a mistake, admitted that you've made a clinical error and figured out why you failed, you've gained new knowledge that's hard to forget. Every dentist has had such experiences. We're not proud to talk about our mistakes. But it's the way to gain experience and become better.
The challenge with clear aligner treatments is that mistakes are often very costly. Either financially, because the treatment requires many more hours of chair time than expected. Or biologically, because patients are mistreated and end up in situations that have potentially damaged their biology. It's the latter part that is challenging and far more problematic than when we make a restorative error on a single tooth or two. It doesn't help that many of the patients treated with clear aligners are often younger patients with initially healthy biological conditions.
Fortunately, most dentists are aware of the potential risks associated with orthodontic patient treatment. They are very humble about their own abilities and want to become more proficient theoretically before embarking on treating patients with clear aligners.
External expert support
Today, there are also a lot of options for case selection, diagnostics, orthodontic treatment planning, ortho-restorative treatment planning, digital smile design in combination with orthodontic planning, optimization of digital setups, clinical support, etc.
Tips for case selection
In the courses we run for dentists, we often encounter the desire to learn a few simple tips on how to perform case selection safely, quickly and predictably. The truth is that it takes experience from between 500-1000 orthodontic treatments to understand all the factors needed to perform a reliable case selection. This is also one of the reasons why orthodontic training involves going through a huge number of cases. Both your own and others'.
Free remote case selection
That's also why we offer free case selection to our regular customers. If you use Invisalign, ClearCorrect, Spark or SureSmile and want to try it out, follow this link.
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Jesper Hatt DDS
Phone: +41 78 268 0078
AlignerService helps dentists create realistic, safe and predictable treatment plans with clear aligners.
Currently, we help approximately 1500 dental practices in 16 different countries.