Wednesday, July 11, 2018

(In)Accuracy of Invisalign spotlighted in recent study.

New Study Continues to Confirm Invisalign Inferior despite Claims by Advertisers and Dentists

Once again, the most recent study published in the American Journal of Orthodontics & Dentofacial Orthopedics ( confirms Invisalign along with the other clear aligner systems are inferior to braces and lead to insufficient movements, inability to correct teeth, inaccurate predictions and excessive relapse after the partial corrections (see excerpts of the article below).
In recent years, researchers have used several methods including the American Board of Orthodontics objective grading system, Peer Assessment Rating scores, and other objective occlusal criteria to assess the quality of Invisalign treatment.1-12  The most notable conclusions were that Invisalign is not as effective as fixed appliances [Braces] for expansion,6 it seems to cause more relapse,5 and it is not very effective in controlling buccolingual inclination,4,10,11 occlusal contacts,4,10,11 occlusal relationships,4,11 overjet,4 and overbite.7
It should also be noted that results of this study are based on hand-picked cases that were deemed successful but still had to be refined due to failures in movement and inability to achieve predicted results.  In other words, these were patients that wore aligners, were compliant with wearing the aligners AND were chosen as good candidates with minimal movements by expert Orthodontists and they still failed.
 “All achieved rotations were significantly smaller than the predicted ones by different amounts.”
“ …the achieved rotations and vertical movements were significantly different than predicted.”
In fact, many studies published in the dental Journals have repeated similar results from different samples rating the success of aligners v. braces and all have found that aligners are simply inferior to braces (see the list of references at the end of this blog).  The real question is when can aligners be used for acceptable outcomes even if they cannot perform as well as braces.
Unfortunately due to advertising, poor public education (if not outright being misled by so-called professionals) and patients’ overall preference to clear aligners over braces, many patients are being offered a treatment that simply will not work.  There will always be improvements in alignment that are noticeable, but when do we as doctors draw the line on what is success versus what is improved but ultimately a failure?

And who is the public going to go to for advice when the professionals have simply given up trying to overcome the false advertising and just give in to offer what the patients demand?
Recently the head of Orthodontics at a prominent New York Dental School outright suggested in a letter to the American Journal of Orthodontics that Orthodontists need to just lower their standards and give the patients what they want even though we know the failure rate and relapse rate are high and the predictability is poor even with mild cases!  His reasoning was that we will be out of business if we do not just give them what they want.  This is an educator that has given up on educating.  No different than a principal at a school telling teachers not to teach algebra, chemistry or physics because parents feel they will never use them (and they are hard subjects for the kids) and kids/parents have been complaining.  Is that the school you want your kids enrolled; or the principal you want running it?
So I ask the same questions I have every time a study confirms the inferiority of Invisalign (and ever since I stopped using Invisalign 15 years ago when it was clear results were poor); What is the future of Orthodontics?  Are we only about the front six teeth or are we there to improve the function and the bite?  What responsibility do we have as dental specialists to provide care that improves function of the teeth and jaw and what liability do we have for providing a “service” that actually does harm to the bite even if the front six teeth look straight-ish?

Does the public in whole really just want a short-cut even though it may harm their teeth/jaw/ability to chew?

The public seems to have forgotten that Orthodontics is a specialty in the first place; why it takes two to three years AFTER becoming a dentist to be proficient enough to actually practice as an Orthodontist.  From experience over the last 22 years in practice, I can say there are far too many un-ethical professionals out selling a product they KNOW is inferior under false pretenses and solely for profit without concern of “do no harm”.  I worry about doctors that will push an inferior product on patients, products that can harm patients over time, instead of offering what they KNOW is best (and usually FAR superior); makes me wonder what else they will do for profit.


“I worry about doctors that will push an inferior product on patients, products that can harm patients over time, instead of offering what they KNOW is best (and usually FAR superior); makes me wonder what else they will do for profit.”

There is far too much money in advertising pumped into social media and TV by Invisalign to counter with a simple blog by this humble practitioner.  For now, it is up to the public to wade through the noise and seek out good advice.  If you are looking for a good Orthodontist you can trust, I suggest reading my earlier blog on selecting a family orthodontist.

A full view of the article may be seen at :
Accuracy of clear aligners: A retrospective study of patients who needed refinement
Orfeas Charalampakis,a Anna Iliadi,b Hiroshi Ueno,a Donald R. Oliver,a and Ki Beom Kima
St Louis, Mo, and Athens, Greece
(ajodo, July 2018)


Further information and studies concerning Invisalign can be found listed in several of my other Blogs including, “Braces are Better … and here’s why.” and “Does Invisalign really work as advertised?”.


1 Bollen, A.M., Huang, G., King, G., Hujoel, P., Ma, T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 1: ability to complete treatment. Am J Orthod Dentofacial Orthop. 2003;124:496–501.Google Scholar
2 Clements, K.M., Bollen, A.M., Huang, G., King, G., Hujoel, P., Ma, T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 2: dental improvements. Am J Orthod Dentofacial Orthop. 2003;124:502–508.
3 Baldwin, D.K., King, G., Ramsay, D.S., Huang, G., Bollen, A.M. Activation time and material stiffness of sequential removable orthodontic appliances. Part 3: premolar extraction patients. Am J Orthod Dentofacial Orthop. 2008;133:837–845.
4 Djeu, G., Shelton, C., Maganzini, A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop. 2005;128:292–298.
5 Kuncio, D., Maganzini, A., Shelton, C., Freeman, K. Invisalign and traditional orthodontic treatment postretention outcomes compared using the American Board of Orthodontics objective grading system. Angle Orthod. 2007;77:864–869.
6 Pavoni, C., Lione, R., Lagana, G., Cozza, P. Self-ligating versus Invisalign: analysis of dento-alveolar effects. Ann Stomatol (Roma). 2011;2:23–27.
7 Krieger, E., Seiferth, J., Marinello, I., Jung, B.A., Wriedt, S., Jacobs, C. et al, Invisalign® treatment in the anterior region: were the predicted tooth movements achieved?. J Orofac Orthop. 2012;73:365–376.
8 Krieger, E., Seiferth, J., Saric, I., Jung, B.A., Wehrbein, H. Accuracy of Invisalign® treatments in the anterior tooth region. First results. J Orofac Orthop. 2011;72:141–149.
9 Kassas, W., Al-Jewair, T., Preston, C.B., Tabbaa, S. Assessment of Invisalign treatment outcomes using the ABO Model Grading System. J World Fed Orthod. 2013;2:e61–e64.
10 Li, W., Wang, S., Zhang, Y. The effectiveness of the Invisalign appliance in extraction cases using the ABO model grading system: a multicenter randomized controlled trial. Int J Clin Exp Med. 2015;8:8276–8282.
11 Buschang, P.H., Ross, M., Shaw, S.G., Crosby, D., Campbell, P.M. Predicted and actual end-of-treatment occlusion produced with aligner therapy. Angle Orthod. 2015;85:723–727.
12 Grunheid, T., Gaalaas, S., Hamdan, H., Larson, B.E. Effect of clear aligner therapy on the buccolingual inclination of mandibular canines and the intercanine distance. Angle Orthod. 2016;86:10–16.
13 Chisari, J.R., McGorray, S.P., Nair, M., Wheeler, T.T. Variables affecting orthodontic tooth movement with clear aligners. Am J Orthod Dentofacial Orthop. 2014;145:S82–S91.
14 Drake, C.T., McGorray, S.P., Dolce, C., Nair, M., Wheeler, T.T. Orthodontic tooth movement with clear aligners. ISRN Dent. 2012;2012:657973.
15 Kravitz, N.D., Kusnoto, B., Agran, B., Viana, G. Influence of attachments and interproximal reduction on the accuracy of canine rotation with Invisalign. a prospective clinical study. Angle Orthod. 2008;78:682–687.
16 Kravitz, N.D., Kusnoto, B., BeGole, E., Obrez, A., Agran, B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135:27–35.
17 Simon, M., Keilig, L., Schwarze, J., Jung, B.A., Bourauel, C. Treatment outcome and efficacy of an aligner technique—regarding incisor torque, premolar derotation and molar distalization. BMC Oral Health. 2014;14:68.
18 Rossini, G., Parrini, S., Castroflorio, T., Deregibus, A., Debernardi, C.L. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85:881–889.
19 Simon, M., Keilig, L., Schwarze, J., Jung, B.A., Bourauel, C. Forces and moments generated by removable thermoplastic aligners: incisor torque, premolar derotation, and molar distalization. Am J Orthod Dentofacial Orthop. 2014;145:728–736.

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 35th street and MoPac.
Dr. Waters with his family on vacation in Oregon.

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 and is a Diplomate of the American Board of Orthodontics and member of the College of Diplomates of the ABO.  Dr. Waters and his wife of 22 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 
Contemporary Orthodontics of Austin, Central Austin, TX
Steiner Ranch Orthodontics, Steiner Ranch (West Austin)




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