Outsourcing your Orthodontics; the Invisalign Generation

Contemporary Orthodontics & Dentofacial Orthopedics

James R. Waters, DDS, MSD, PA

Board Certified Treatment for Children, Teens and Adults  

Outsourcing your Orthodontics; the Invisalign Generation

Consumers today have been bombarded by advertising efforts to align their teeth with “invisible trays” or “invisible aligner trays”, first by corporate advertising but later by their own general dentists and friends.  In fact now, even the specialists have been squeezed to the point that many have just given in to consumers’ desires and now offer extensive treatment with clear aligners knowing that the overall occlusion cannot be fully corrected.

As a practitioner for 19 years and a Board certified Specialist who was training when Invisalign was first introduced, I have been witness to the evolving marketing from correcting minor alignment, to partially correcting the front teeth to now correcting adolescent crowding and severe malocclusions.  The initial introduction was created for specialists to correct minor relapse or alignment when the roots were already in good position with the idea that the Orthodontist is trained well enough to know the limitations and to realize when function would be compromised. 

Within a short time, the General dentists sued the manufacturer and the settlement allowed the General dentists to begin using Invisalign without the extensive base of knowledge or experience that a specialist has earned.  Within the next 10 years, every dental office that needed to supplement their income began offering these trays until the specialist realized that if they did not “embrace” these trays, then the majority of adult patients would pursue treatment elsewhere even if the education and experience level was very low.

Today, I would argue due widespread failures and relapse seen with clear aligners, dentists are trying to increase their profit base by offering trays to teens.  Of course with compliance paramount for any movement and with patients still growing (altering the relationship of the teeth during treatment), we can only expect more failures.   I am particular amused (and disappointed) to see recent graduates with only a couple of years experience, yet to finish even 100 cases, claim they can do anything with aligners from teens up to adults; then leaving the care of the patients up to whatever the technicians in India provided and whatever forces the trays from Mexico can exhibit.  When it doesn’t work, they either blame the patient for a lack of compliance, or they claim “that has never happened” and then place real braces to “finish”.

And if the consumer attempts an honest research of the systems, they again get bombarded by a deluge of self-described experts and company-provided/biased “articles” blocking any real critique on search engines.  These companies spend millions to keep their products in favorable light online where there is no standard of truth and no ethics.  I would wager that Invisalign alone or it’s “top providers” own at least the first 5 pages of Google at any one time.

“These companies spend millions to keep their products in favorable light online where there is no standard of truth and no ethics …. Invisalign alone or it’s “top providers” own at least the first 5 pages of Google at any one time.”

So what exactly is the process for aligner trays and how can so many non-specialist dentists offer it if they don’t have extensive knowledge in orthodontics?  Simple, clear aligner providers exist by outsourcing the treatment from the digitizing of the impressions and teeth to the movement of the teeth digitally, to the fabrication of the treatment models and finally the fabrication of the trays. Then, to add to the mix, most have their limited trained assistants with little to no formal training, place and monitor the trays from appointment to appointment.  It has become common to even hand out months of trays to the patient with instruction to just change them out to tighter trays every 2 to 3 weeks without any supervision.

“clear aligner providers exist by outsourcing the treatment from digitalizing of the impressions and teeth to the movement of the teeth digitally, to the fabrication of the treatment models and finally the fabrication of the trays …..  most have their limited trained assistants with little to no formal training, place and monitor the trays from appointment to appointment”

How long will it be before there are scanning kiosks in the malls and mail-order treatment with more outrageous claims?  Probably not long.  So is this a service to the public?  Is this what to expect for the future?  I would say no to both and so would most true Board Certified Specialists.  Do I compete with dentists and other orthodontists that provide and even push aligners looking to pad their bottom line?  Yes, but I maintain that as a specialist, I should only treat to the highest standard.  It is not my place or the philosophy of any specialist to offer less than the best functional and esthetic correction and it is malpractice to knowingly introduce functional problems at the expense of lining up the “front six”.  I have seen many of the parents of some of my patients with atrocious and iatrogenic (doctor introduced) malocclusions that are only missed because the dentist who provided the “correction” did not critique his own work and no one else sees the patient’s teeth unless they change to a new dentist.  I would wager that if every patient “treated” with aligners switched to a good dentist and asked about their bite, a large majority of them would be shocked at the assessments.

“It is malpractice to knowingly introduce functional problems at the expense of lining up the “front six … I would wager that if every patient “treated” with aligners switched to a good dentist and asked about their bite, a large majority of them would be shocked at the assessment.”

So is it wrong to only partially correct alignment if there is no functional malocclusion present or introduced? Not necessarily and many adults are just looking for a little alignment but they should receive realistic expectations including limitations and possible problems after a partial or incomplete alignment such as a shift in the occlusion, premature contacts, an openbite due to incomplete alignment and settling, and even possible joint discomfort.  Aligners are simply unable to move the teeth the same as fixed braces and perspective patients need to know when limited treatment is acceptable and when it is contraindicated (this is of course where it becomes more important to seek advice of a certified and ethical Orthodontic specialist). 

“Is there an alternative that isn’t made in India or Mexico, leaving control to the orthodontist at every level?”

There is (although there is still limitations even with a better aligner system since the trays have to be loose enough to be removed and changed out by the patient); Orchestrate is the only clear aligner system made by and for Specialists only.  It has the same technology where the teeth are scanned with a 3-D laser and digitized.  But instead of sending the file to India and having the trays fabricated in Mexico, Orchestrate allows the Orthodontist himself/herself to move the teeth digitally in all dimensions, fabricate models with a 3-D printer and make clear trays as they are needed, all on-site under the control of the Specialist.  Tray materials can be changed based on the needs (more flexible trays v. stiffer trays), and even partial trays can be used in conjunction with fixed braces where more force is needed (once the more difficult movement is made, the bracket can be removed and the remaining treatment completed with trays.  It is fully customizable and controlled on-site by your well trained specialist.      

“Orchestrate is the only clear aligner system made by and for Specialists only …. Orchestrate allows the Orthodontist himself/herself to move the teeth digitally in all dimensions, fabricate models with a 3-D printer and make clear trays as they are needed, all on-site under the control of the Specialist”

 

In my practice, I offer Orchestrate but I educate the patients before offering such and I do not recommend removable aligner trays for a growing adolescent.  I also offer the same treatment with clear braces which is usually half the fee and half the time estimate so the patient knows all the facts.  In the long run, I would rather lose patients to aligner providers than treat patients with sub-par outcomes that are bound to relapse or create functional problems following alignment.   Unfortunately this may not be the common philosophy and once treated poorly, many cases cannot be recovered once damage is done (at least without significant effort and cost).

So when looking for treatment, consumers must consider the education and reputation of the provider, they need to understand the difference between a general dentist and a specialist Orthodontist, and they need to be able to discern between what they may want to hear and what they may actually need.  Consumers should ask questions about education levels, they should be wary of marketing materials not endorsed by the American Association of Orthodontists or the American Board of Orthodontics and they should ask for the limitations and risks of aligner treatment versus fixed braces.  Finally, consumers should use common sense when considering treatment with removable aligners; clearly if they really worked in most cases, we simply would not still use braces and specialists would not need 3 years of advanced, post-doctorate residencies to move teeth.    

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35^th street and MoPac.

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics.  Dr. Waters and his wife of 19 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com.

Central Austin

1814 W. 35^th Street

Austin, TX 78703

(512) 451-6457

 

Steiner Ranch

4302 N. Quinlan Park

Austin, TX 78732

(512) 266-8585

 Bracesaustin.com