Most aligner complications are decided before treatment even starts
- Jesper Hatt DDS
- 5 days ago
- 5 min read
Most aligner complications are explained as technical problems.Tracking issues. Refinements. Compliance. Biology.
This post takes a different starting point.
It looks at aligner treatment from the decision side - not the treatment side - and examines why many of the problems clinicians struggle with were predictable long before the first aligner was delivered.
Based on recurring clinical observations, this article explores where aligner cases actually begin to go wrong, why common “solutions” rarely fix the underlying issue, and what experienced dentists tend to underestimate when cases are started under everyday clinical pressure.
If you already treat aligner patients, this is not about learning new techniques.It’s about rethinking when, why, and under what conditions aligner treatment should begin in the first place.
Aligner Complications Start With Decisions, Not Aligners
Most aligner treatments don’t fail because aligners “don’t work.”They fail because the wrong decisions were made before the first aligner was ever delivered.
That statement tends to make experienced clinicians uncomfortable. Not because it’s provocative - but because, deep down, most of us recognize it from our own cases.
When things go wrong in aligner treatment, we usually describe it as something that happened during treatment: tracking issues, poor compliance, refinements piling up, biological surprises, or patients losing motivation. But in practice, those problems are rarely spontaneous. They are predictable. And often, they are already baked into the case from day one.
An observation from practice
If you look honestly at your most frustrating aligner cases - the ones that consumed disproportionate time, energy, and chairside discussion - there is often a moment early on where you knew this case was not straightforward.
You may not have articulated it clearly.
You may not have documented it.
You may not even have said it out loud.
But you felt it.
The patient expectations were vague.
The biology was uncertain.
The movements were ambitious.
The compliance assumptions were optimistic.
Yet the case was started anyway.
Not because the diagnosis was wrong.
Not because the aligners were inadequate.
But because the decision to start was made without fully acknowledging the risk profile of the case.
The clinical reality we don’t like to discuss
Most aligner complications fall into a few recurring categories:
Wrong cases
Not “impossible” cases - but cases where aligners were chosen despite clear warning signs. Complex movements combined with compromised anchorage, periodontal limitations, or unrealistic timelines.
Overlooked biology
Reduced periodontal support, altered bone metabolism, parafunction, or age-related response differences that were noted - but not weighted heavily enough in the treatment decision.
Compliance assumptions
Patients assessed as “motivated” based on conversation rather than behavior. Wear time, attachment care, and aligner handling assumed rather than stress-tested mentally.
Unclear treatment goals
Cases started without a sharply defined endpoint. Was this about alignment, occlusion, esthetics, or compromise? When goals are vague, refinements multiply.
Workflow pressure
Busy clinics, full schedules, and the silent push to keep production moving. Starting a case becomes easier than stopping to ask whether it should be started now - or at all.
None of these issues originate mid-treatment. They exist before the first scan is uploaded.
The false solutions we reach for
When aligner cases start drifting off course, the instinctive response is almost always the same: add more.
More support.
More revisions.
More software tweaks.
More time.
We schedule longer appointments.
We contact the aligner company more frequently.
We redesign attachments.We request new treatment plans.
These actions feel productive. They give the impression of control. But they rarely address the root cause. They manage symptoms, not decisions.
More support does not change a case that should never have been started.
More refinements do not fix unclear objectives.
More software does not compensate for ignored biology.
More time does not solve misjudged compliance.
In many cases, these “solutions” only prolong the inevitable: a compromised outcome that costs far more than it should - clinically and emotionally.
Where the real problem sits
The core issue is not aligner mechanics.
It is not digital planning.
It is not patient education.
The real problem is the absence of a structured way to evaluate risk before treatment starts.
Most clinicians rely on experience, intuition, and pattern recognition. These are valuable - but they are also inconsistent. They fluctuate with stress, workload, confidence, and context.
Without a structured pre-treatment risk assessment, critical decisions are postponed until the case is already underway. At that point, every correction becomes more expensive - financially, biologically, and psychologically.
When decisions are taken too late, they feel like complications.
When they are taken early, they are simply good judgment.
Responsibility is uncomfortable - but unavoidable
Aligner companies don’t start cases.
Software doesn’t start cases.
Patients don’t start cases.
Dentists do.
That responsibility doesn’t disappear just because aligner treatment feels more “automated” or “supported” than traditional orthodontics. If anything, the ease of starting cases increases the importance of knowing when not to start.
The uncomfortable truth is that many aligner problems are not accidents. They are foreseeable outcomes of underweighted risk.
A question worth sitting with
Why do we spend so much time discussing how to treat aligner cases and so little time discussing whether they should be treated this way, right now, or at all?
Why is risk something we handle reactively, instead of explicitly, before the first aligner is delivered?
These are not questions about technique.
They are questions about decision-making.
And once you start looking at aligner treatment through that lens, something shifts.
You stop asking how to fix cases that are drifting.You start asking why aligner complications were allowed to develop in the first place.
Not every complication can be prevented.But far more aligner complications are predictable than we like to admit.
And that realization has little to do with aligners themselves - and everything to do with the decisions made before the first one is ever worn.
If these questions resonate, the next post will go one step further and focus on what can actually be done before treatment starts to avoid many of these problems.
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No promises.
Just observations, decisions, and clinical reality.
Kind regards
Jesper Hatt DDS
P: +41 78 268 00 78
AlignerService
We are dentists helping dentists create realistic, safe and predictable treatment plans with clear aligners.
Currently more than1500 dental practices in 19 different countries use our service on a regular basis. We offer expert guidance in the following clear aligner systems: Invisalign, SureSmile, ClearCorrect, TrioClear, Angel Aligners and Spark.
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