Part 1: Overview of the aligner market – Where is the future and why general practitioners should get involved

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Clear aligners were introduced in the United States, where they were born at the end of the 1990s by the company Align Technology^© (Santa Clara, CA, USA), which then gave life to the Invisalign® system. Since then, the interest and the diffusion of this therapeutic alternative to the classic multi-bracket orthodontic therapy have increased exponentially. The commercial proposals regarding aligners include many different brands all over the world.

Clear aligner treatment has evolved mainly over the last 15 years through new technologies and materials to widen the range of tooth movements. It can be provided by both orthodontists and general dentists. Several differences in treatment plan and management, as well as training and expertise between orthodontists and general dentists performing Clear Aligner treatments are being surveyed.

Efficiency of clear aligner system

Clear aligners do not seem to be the same and consistent differences can be observed between different brands.

The concepts of “efficacy and efficiency” in clinical orthodontics are used interchangeably to describe “achieving the desired results without wasting time for the orthodontist and the patient”. In the field of invisible aligners, efficacy and efficiency is expressed even better through the ability of these devices to perform more or less complex dental movements in a predictable way as much as traditional fixed appliances with equally stable results. 

Besides understanding the strengths and weaknesses of clear aligners compared to fixed appliances, clinicians need to know the limitations of clear aligner therapy and be able to think outside the box in treatment planning, adding a further level of complexity.

Clear aligner therapy poses many challenges to clinicians compared to conventional orthodontic treatment with brackets and archwires. While orthodontic manufacturers have introduced clear plastic brackets, tooth-coloured ceramic brackets and archwires, lingual brackets, and clear aligners to provide better aesthetics, these appliances often come with reduced efficiency.

Therefore, it is critical that orthodontists and general dentists who provide orthodontic treatment are aware of the characteristics and treatment mechanics of new modalities.

Advantages of clear aligners     

The treatment with Clear aligners may be indicated to plan and visualise the treatment outcomes before starting the multidisciplinary treatment. See Table 1 for acceptance rates  in adults and teens.

Due to the major request of invisible orthodontic treatment even in younger patients with a greater awareness of oral health, younger patients are increasingly involved in CA treatment in the last years. The main advantages of this treatment are better aesthetics with higher patient acceptance and a general better quality of life.

Patients	Percentage	Treated by
Adults	97%	Orthodontist and General Dentist
Teens	27%	Orthodontist and General Dentist

Information gained about clear aligners

According to a study conducted by Park et al (JCO 2021), it’s been estimated that as many as 45% of all general dentist offer Clear aligner therapy (Table 2). Clearly, private practice and dental education are out of sync.   

Table 2: Study on dental education in the area of clear aligner therapy.   

While the number of general dentist offering orthodontic treatment has grown significantly, the quality of their orthodontic care has been controversial. Dental schools offer limited training in orthodontic diagnosis and treatment; while many general dentists acquire orthodontic knowledge from CE (continuing education) courses, it is questionable whether these courses offer sufficient training to provide comprehensive orthodontic treatment.

In dental schools, among the instructors who did teach clear aligner therapy to dental students, more than 90% agreed that their students needed more continuing education (CE) after graduation to be competent with clear aligners.

According to a study by d’Apuzzo et al (2019), Clear Aligner system providers gained their information about clear aligners, according to the following weightage: Private courses (68%); academic seminars (49%); congress lectures (42%) and book chapters or papers (35%). 

Orthodontists learned more about clear aligner during academic seminars 53% vs 35% of general dentists, whereas general dentists attended more private courses (Table 3). Patients requiring a treatment with clear aligners were mainly females (74%) with an age between 18 and 45 years. 

Type of Learning	Orthodontist	General Dentist
Private Courses	65%	78%
Academic Seminars	53%	35%
Congress Lectures	44%	35%
Book Chapters or Papers	37%	27%

Future of Aligners

According to a survey conducted by d’Apuzzo et al (2019) (Table 4):

• 69% Clinicians who reported not using clear aligners declared the intention to begin using them in the near future.
• 79% of dentist who are using clear aligner in their practice, most of them are Orthodontists. 
• 45% Orthodontists not using clear aligners considered the outcomes with this type of treatment limited compared to conventional fixed appliances. 
• 40% of general dentists were not using clear aligners because of their poor experience.

Table 4: Comparison between Orthodontist and General Dentist for reasons not using clear aligners.

Marketing of clear aligners system  

The increase in primary care dentists who are providing their own orthodontic care has caused orthodontic specialists to change their marketing strategy. Recently, a paradigm shift in marketing has occurred from dentist-based referrals to direct-to-consumer advertising (Table 5).

Patient’s reasons for requesting clear aligner treatment	Percentage
Information by advertising and directly asking for clear aligner	73%
Information through the office marketing	31%
Word of mouth from friend or family member	40%
Suggestion by the doctor	50%

Orthodontists are now choosing to advertise to patients directly, rather than solicit primary care dentists to refer patients when they deem ready. In essence, primary care dentists have forced the orthodontist’s proverbial hand to become independent. The reach of this independence will likely extend well beyond current direct-to-consumer methods to orthodontists soon owning pediatric and general dental offices in the future

A high percentage of patients wearing clear aligners seemed to have previously received information about this type of treatment by advertising on social media and network. A lower percentage received suggestions from the doctor himself, or from word of mouth of friend or family member, and in a little percentage through the office marketing.

Recent studies have underlined the increased relevance of marketing and social media in our working activities. Orthodontists and patients routinely get access to social media and practice websites that are indeed becoming effective marketing and positive communication tool in the orthodontic practice and patient experience. The patient’s knowledge about the clear aligner treatment was mainly provided by information from external media advertising.

References

• d’Apuzzo et al. Clear aligner treatment: different perspectives between orthodontists and general dentists. Progress in Orthodontics (2019) 20:10
• Graber, Vanarsdall- Orthodontic Current Principles and Techniques (6^th edition)
• Park et al, Aligner Corner, JCO 2021 
• Putrino, A et al, Clear Aligners: Between Evolution and Efficiency—A Scoping Review. Int. J. Environ. Res. Public Health 2021, 18, 2870.
• Vaid NR. The emperor’s new clothes, APOS Trends in Orthodontics • Volume 9 • Issue 1 • January-March 2019