Wednesday, July 18, 2018

Orchestrate 3D v. Invisalign; which is better?

Why is Orchestrate 3D a better Aligner System than Invisalign?

Some 20 years ago, digital technology advanced to the point that lasers could scan your teeth and create a digital image to be manipulated by computer software and Invisalign was born. 
A patient being scanned with a laser scanning wand; note the digital image of the dental arch on the monitor.  Scanners like this can capture an entire dentition in a matter of minutes.
Certainly the pioneer of the clear aligner process, today Invisalign (Align Technologies) is not the only game in town (though they certainly would have the pubic believe this and they have purchased other start-ups to stomp out competition).  In fact there more than two dozen companies and labs now offering clear aligners and more join the field every year due to lax standards and essentially no regulation.
The question for prospective patients today is which system is the best for you and your family?
Set of Clear Aligners formed from 3D models following laser scan of teeth.
To answer this question, one must understand the process of traditional Orthodontics a bit more in detail. 
When you discuss braces, I bet you never ask “What brand of bracket do you use?” to your Orthodontist.  Why? Because you are paying for the Orthodontist and his/her expertise, not the brand of material that is used.  How the Orthodontist gets the job done is up to them and their training/experience.  Just like if you have a crown made, you don’t ask “What brand crown?” or “which lab will you be using?” 
As you would expect, there are many different brands of every dental supply we use as Orthodontists; different slot sizes, different metals, different wires, etc.  Some may even be better for one patient over another for whatever reason and based on experience.  A good Orthodontist would never handicap themselves as disciples of only one technique or one system.


And a good Orthodontist bases treatment on their understanding of bio-physics, not on the materials alone.  If one system is incapable or less efficient of movements needed, they will choose another system or appliance.  For instance, forces are being generated using some teeth as anchorage so that other teeth can be moved.  Some movements require tipping, others rotations or moments; opposing forces must be recognized and either countered or harnessed.  It becomes a very complex system as every force will have an equal and opposite force.  This is true whether we use aligners, braces or simple rubber bands.  
Newton’s 3rd Law
The old adage is that a good Orthodontist (using traditional braces) can fix teeth with a paper-clip which might be over-simplified but points out that it is the doctor, and not the material, that corrects the malocclusion and restores the function and the overall smile. 
“[with traditional braces] it is the doctor, and not the material, that corrects the malocclusion and restores the function and the overall smile.”
When aligner trays are used instead of traditional braces, the ability of the doctor to make changes to aligners mid-treatment and throughout the course of treatment is very important since all trays are pre-fabricated in almost all systems including Invisalign; in other words when certain trays fail to move a particular tooth or there is an unexpected force that opens the bite, future trays will be unable to make the correction.  The more failures along the way, the poorer the correction and the higher risk of leaving new malocclusions such as openbites, interferences, crossbites and incomplete uprighting of teeth.  In MANY cases, poor aligner performance from Invisalign introduces malocclusions previously not present at the initiation of treatment (see my blogs listing recent studies on Invisalign).
This is even more troubling when Invisalign “doctors” leave oversight to relatively under-educated assistants.  Invisalign would have you concentrate on their materials and technology but they neglect to educate the public on the role of the doctor (or lack of) as if the doctor has no role.  In fact they would prefer no doctor involvement which is why they have invested in aligners being marketed direct through TV commercials and kiosks in some malls.  In some sense there really is NO reason to go to a doctor for such incomplete care. 
But Invisalign cannot ignore biology.  Treatment without considering bone physiology, the inflammatory process or developmental processes is treatment in the dark.  Moving teeth though irregular bone in a functioning, living system that undergoes modification and changes throughout treatment (and thereafter depending on how we leave the bite or occlusion) takes a complete knowledge of that system and an ability to make changes along the way.  This is absolutely ignored by many who sell “aligner alignments”.


It is also clear in the literature (and confirmed regularly from my own 22 years of experience) that the jaw shifts as the teeth are moved throughout treatment (almost always in adults); some shifts will be predictable but some can be a surprise.  The relationship between upper and lower teeth can and will change significantly from the start to the end of treatment requiring modifications of the treatment plan along the way (continuous re-scanning if aligners are used).  Consider a perfectly good doorway after its foundation settles or moves.  After the shift, the door is identical, the jamb is the same.  But the door no longer opens.  It doesn’t fit because of the shift. 
Note the settled foundation and now off-set door.  No damage was done to the door but it no longer functions due to the shifting of the foundation.
The same thing happens to differing degrees when the jaw shifts during orthodontic treatment and a good Orthodontist will identify the shift, adjust his/her course of treatment and modify the force systems and even appliances being used to counter the shift.  Invisalign limits the Orthodontist’s ability to adjust for these changes.

What is Orchestrate 3D?  How is it better than Invisalign?
Orchestrate 3D is an aligner system used only by certified Orthodontists; it uses clear aligner trays the same as Invisalign and the other higher-end products but changes to the teeth (the angles and movements) can be performed completely by the treating Orthodontist.  Cases can also be reviewed by other certified Orthodontists at the beginning of treatment to gain from experience of other specialists. 
With Orchestrate 3D, teeth are scanned the same way as Invisalign but the raw image (.stl file) is sent to the Orthodontist directly and he/she makes all of the actual movements and attachments in-house on high power proprietary software owned by the Orthodontist and not a 3rd party.  Then models based on those changes can either be made in-house with a 3D printer or sent to a lab for printing based on the Orthodontist’s changes made in the software.
Another great difference between Orchestrate 3D and other aligner systems like Invisalign is that with Orchestrate 3D, the Orthodontist uses the models he/she created to make the aligner trays in-house; that means he/she can use different strength materials based on the movement of the teeth/compliance/fit of the teeth.  If rotations are too great, more pliable material can be used.  If there is a stubborn tooth, a thicker material can be used just for that movement or a new tray can be fabricated until the tooth moves. 
Finally, a huge advantage that I like about Orchestrate3D is that as the Orthodontist, I own the file start to finish; I don’t have to pay a third party company every time new trays are made or when changes in the dentition/jaw relationship warrant a new scan.  For very Orthodontist, this makes more difficult cases less costly and the Orthodontist more likely to re-scan as needed instead of just leaving some teeth unmoved.  I can limit myself to printing 5 to 6 trays in advance so that I can easily make digital changes for future trays in more severely rotated cases including placement of buttons on stubborn teeth mid-treatment.  This prevents the temptation of moving forward based on a previous jaw position or a previous scan when surfaces of teeth may have been initially hidden from rotations. 
In other words, Orchestrate3D is much closer to regular braces than Invisalign when used by a competent and experienced Orthodontist.  Most importantly, this assures you are paying more for the Orthodontist and not just for the material and lab techs to move the teeth.
“Orchestrate3D … assures you are paying more for the Orthodontist and not just for material and lab techs to move the teeth”
With other aligners like Invisalign, most of the time, you are paying for a technician to scan your teeth (the laser actually does the scanning), advertising for a corporate product independent of any doctor, royalties on the software that interprets the data and builds a digital image of your teeth (something a high school kid can do these days), and an unknown and likely uneducated third-world Country “technician”  to digitally re-set the teeth with a mouse into what they think looks and fits good.  Then to top it off, a relatively un-educated dental assistant approves the digital bite with a yes/no, and sets of trays are fabricated somewhere (again, usually in a third-world Country) and packaged in a clever container to present to you (again many times by the assistants) when it arrives back via UPS. 
You may ask (like I used to before speaking with so many colleagues) why a Dentist or even a real Orthodontist would leave there profession up to private companies, lab techs and third world technicians?  The answer is simple and I will be direct: Profit and ease of treatment (for the doctor).  The following are real responses I have gotten from dentists and Orthodontists and consultants/sponsored speakers at dental conferences:
“Why refer to a specialist when I can just send it to a lab like a crown?”
“Why go two to three years (after you are already a dentist) to learn about Orthodontics when you can just send the patient to have a scan and your completely done?” 
“Why place braces and take the time to see the patient every month and why worry about repairs and emergencies when they can give something that can simply be removed if it hurts?”
“Why figure out the physics and continue to evaluate each patient at each visit when you can receive all of the mail-order trays at one time and just give them all out or 4 at a time?”
“Why provide excellent care if the patient does not demand it?” (This was actually alluded by the head of Orthodontics in a New York Dental School!)
If you think there are higher motives than these, you are mistaken.


So can Orchestrate3D clear aligners be used with success?
The answer is yes in certain cases.  The following are general guidelines for proper Aligner Treatment:
  1. Proper examination and records.  No treatment should be planned without first obtaining a standard set of orthodontic records including photos (face, teeth and smile), a panograph X-ray and a side view or Cephalometric X-Ray.  There should be an in-person examination of the teeth and jaw BY THE DOCTOR so that function and joints may be assessed and the overall health of the gums and teeth are evaluated.  If there is bone loss or any other concerns/disease, then further records/consultation with other doctors may be needed.
  2. Proper Case Selection. Aligners are able to make certain movements on teeth but unable to move others; for instance a canine cannot be uprighted by aligners and teeth cannot be pushed into the bone adequately with aligners.  Also, some mal-occlusions are more due to discrepancies in jaw size, shifting of the jaws or more severe interferences; aligners are not able to correct significant overjet, deepbites or openbites with any stability. 
  3. Realize and acknowledge that there is almost no case that cannot be treated faster and to a better result with traditional braces.  Aligners are great only because they are relatively un-noticeable.  But aligners CANNOT move teeth as predictably, as far, as precise or as fast as braces.  If someone tells you otherwise, they are misleading you and you should question their motives.  There is nothing wrong with using aligners as long as you are informed and willing to accept the results.  Aligners will align front teeth and give you a better smile but be realistic in your expectations. 
  4. If aligners are prescribed without an option of braces, ask if it is the best treatment.  Ask if there are certain aspects that may not treat as well as braces.  If a dentist or Orthodontist flat out tells you it is a bad idea, you should heed that warning.  I personally won’t treat cases with aligners if they cannot make enough improvement in the smile, if they will risk significant malocclusions, if they will lead to certain relapse or if compliance is predictably going to be poor.  It is malpractice to offer something that we know will do harm.  That is not to say someone won’t sell you what you are asking for somewhere (usually down the street in my case), but don’t expect less risks from the same products especially from something like Invisalign that is made the same for everyone (less doctor-specific).
  5. Follow all instructions and DEMAND you see the doctor at every visit.  Ask questions as to the progress and if something doesn’t feel correct, make sure you bring it up with the Orthodontist before the end of treatment.   You ae indeed paying for the doctor, not the plastic or the assistant.
  6. Finish your prescribed course of treatment.  After speaking with dentists and Orthodontists over the last 20 years it has become clear that a significant portion of patients simply fade away and discontinue treatment on their own, I would wager it is @25%.  That is an amazing number but I assure readers that if they ask around they will see this is not inaccurate or exaggerated.
  7. Demand at least some occlusion on all back teeth at the end.  There may be less of a correction but the front teeth should look good and the back teeth should at least touch after treatment.  If not, YOU ARE NOT DONE!  Don’t allow any office to dismiss you without contact on your back teeth.
  8. Wear retainers.  Aligners relapse more often (much of this is due to poor treatment and/or poor case selection).  Aligner cases should expect to wear nighttime retainers indefinitely.
What are potential problems with poor Aligner treatment?
First of all, you can damage the roots of teeth and leave a bite that damages the edges of your teeth.  Over time this can lead to chronic jaw pain, multiple restorations and even loss of teeth.  You can EASILY leave teeth worse off than when you began even if they look straight.  I repeat, EASILY.  Pushing teeth outside of their natural arch form will lead to recession (gums falling away from the teeth and exposing the roots), relapse and/or sensitivity.
Will the dentist tell you if the treatment was a failure?  Some will I know because I see patients referred after failure of aligners, but many (especially those who are treating without adequate knowledge or morals) will not and patients are left with chronic problems and sometimes chronic pain that Orthodontists now won’t touch.  If you question your correction and bite after treatment, see another Orthodontist and ask for an evaluation; these are generally free and can either give you peace of mind or inform you if there is indeed a problem.
It is up to patients to ask the right questions, interview prospective doctors and filter through the direct advertising that bombards the public regularly in search of more dollars.  Remember Orthodontics is about your smile but equally about your function and dental health for the future.  And remember what you are paying for and what questions to ask BEFORE entering into treatment with anyone.

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. 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.  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 

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