Orthodontics with clear aligners – a fringe therapy just a few years ago, is now en vogue. But what criteria do you apply to choosing the right provider?

MALL: If you are just looking at the production of the aligners themselves, there are only a few differences. They are all ultimately produced by the same principle. What is important is the service and the price structure. That's where the differences are quite profound. I personally need a contact in my workflow who I get on with and with whom I can communicate directly, who can react in real time to my concerns and can immediately implement them. That’s what ClearCorrect offers. Anything else means that the workflow is delayed and that means extra costs for the patient. If the cost structure and service are not right, I can produce the aligner in my own lab as I used to.

MÜLLER: I see it the same way. We have included clear aligner treatment in our treatment options for a very long time now. In the beginning, we worked with different labs and smaller suppliers. In the last two and a half years we have been using Invisalign, CA Aligners and the ClearCorrect concept, which hardly anyone in Germany knew anything about until it was taken over by Straumann...

... but now it is one of the leading suppliers. What is the concept behind its success?

MÜLLER: Straumann didn’t just push ClearCorrect with marketing instruments alone, but put their faith in science, service and support. Before they started they involved dentists and orthodontists in the optimization process. The idea of buying straight teeth in an aligner shop without a dental review or consultation was never on the cards with the ClearCorrect concept. And that’s something we should welcome.

My opinion after two and a half years: We get the treatment set-ups really quickly, the material is fantastic, it is made of 0.76 mm polyurethane, has high retention capacity and is resistant to discoloration.

KOMISCHKE: And the price-performance profile is especially good. That’s really important in my practice in the countryside. The treatment cannot cost too much but it has to do what it promises. If one of these two aspects does not hold up, that spreads like wildfire, especially in rural areas. That’s why I made sure that I didn’t choose the most expensive or the cheapest supplier.

Figs 1a to 1f: Treatment of a unilateral crossbite on the left with a slight distal bite with 20 pairs of aligners

(Figures: Komischke)

To what extent does the aligner treatment change your practice routine?

KOMISCHKE: It makes a nice contrast to conventional dentistry. Patients are certainly willing to put their hands in their pockets for their new smile. There is also no other dental field where the patient has to take on so much responsibility of their own. And that goes down well with patients. The patients change their aligners themselves. And they also have the option every now and then not to wear the aligners and to add the time onto the end of the treatment.

MALL: Of course that has its risks. Anyone who “cheats” with the aligners has to take on board the risk that the treatment will not advance as expected.

Unfortunately, patients like to blame the dentist for that.

What do you advise?

MALL: Carry out regular checkups, about every four weeks. Generally, patients have a vested interest because they are paying for the treatment themselves.

Discussing the treatment in detail with the patient should also help. What should the focus be?

WOLLITZ: First and foremost, the recommendation on how long to wear the transparent aligners. It has to be at least 22 hours a day. We also advise them that they may have temporary pressure and temperature sensitivity, temporary changes in their speech and more discoloration because there is less saliva flowing under the aligners. We also talk about the bonding attachments – what ClearCorrect calls “engagers” – and interproximal stripping and the development of temporary gaps during treatment. Basically, we advise aligner patients to have their teeth professionally cleaned at short and regular intervals.

KOMISCHKE: Costs, data protection and treatment consent – you need to watch out for these three points when explaining the treatment to patients. I advise all patients that the success of the treatment depends on regularly wearing the aligners and show them the anticipated result in the treatment set-up. Like Dr. Wollitz, I explain to every patient what engagers are and what interproximal stripping is all about before they sign the treatment consent.

MÜLLER: Many aligner patients get the wrong idea about the treatment time and are surprised how long the whole thing takes. We inform them before the treatment starts that there may potentially be delays, maybe because of another scan or a revision. In the practice we switch the aligners in the evening so that the patients don’t have to go to work with the fresh aligner.

So what is the average treatment time?

MALL: The treatment time depends on how extensive the correction is and how long the patient wears the aligner. As Dr. Wollitz explained, it should be 22 hours a day but at least 19 hours. After consultation with the treatment provider, the aligners are generally changed every 14 days. That can vary from one patient to another. Especially when they are starting the treatment, you have to make it clear to patients that not everything works as it is mapped out on the drawing board. Often you need to adjust planning during treatment – especially if there is more complex movement – and counteract in time.

If the teeth do not move in the right direction it may be necessary to use brackets. So, for example, you start with aligners and continue the treatment with fixed braces or vice versa. The treatment options are immense.

Figs 2a to 2f: Case study: Open bite, crowding in upper and lower jaw, treatment duration 1.5 years, 15 aligners, 11 engagers, interproximal stripping 1.5 mm, after revision a further ten aligners and five engagers

(Figures: Wollitz)

Development of clear aligners:

How many aligners are needed on average for slight crowding?

MÜLLER: Simple crowding and the like can be treated with ten to twelve aligners. Our cases tend to be more complex and need more aligners. This is why I chose a ClearCorrect package with unlimited treatment options for five years.

Could you be more specific? Are there special options available?

MÜLLER: Yes, there are the “Flex” and “Unlimited” price options. Treatment providers can submit cases free-of-charge and with no obligation and when case planning is approved they select one of the price options. With Flex you pay for the case planning and for all aligners required once. The Unlimited price covers all necessary aligners including revisions and replacements for five years. Retainers are also included with up to two sets every six months in this period.

So that means you can provide as much treatment as you want for five years?

MÜLLER: That’s right. Unlimited is perfect for my range of treatments.

My main indications are: 

• functional situations
• compromised mandibular joints where we have to make more space and
• resolving vertical defects.

We also address crowding where necessary. Sometimes we extract a tooth in the esthetic zone and the gap is closed with aligner treatment. We also carry out aligner treatment before implantation to optimize a situation where there is a gap or to eliminate asymmetry. The options are enormous. We have a few wide-ranging cases but some are also minor.

KOMISCHKE: We mainly treat crowding followed by diastema. But I also like to use aligners to rectify functional problems such as premature contacts or forced bite.

WOLLITZ: In our practice too, the main indications are crowding in the front of the upper and lower jaw.

What does the orthodontist or oral surgeon say?

MALL: The main indications were already set out in the statement from the German Society for orthodontics (DGKFO) published back in 2010 which included moderate anterior crowding and diastema as well as anterior protrusion and retrusion. I also see clear aligners as indicated for very expanded complementary treatments, such as finishing after fixed brace treatment. It’s the opportunities for mixing that make it especially interesting and attractive.

What about aligner treatments for implant patients?

KOMISCHKE: That works very well because you can exclude the implanted teeth completely from the movement.

WOLLITZ: However, you may later on need a new prosthetic restoration, especially in the anterior region.

MALL: There are also advantages in per-interproximal treatment: Molars can be straightened with clear aligners and gaps in the teeth can be opened further to make enough space for an implant or to be able to place it in a gap so that it is aligned. I also use implants in a targeted way – or use existing implants as anchors for orthodontic aligner treatment so that the arch can be more effectively or more quickly shaped.

When do you opt for the controversial interproximal stripping?

MÜLLER: Interproximal stripping is indicated whenever there is not enough space in the anterior arch. That happens, for example, if teeth have to be turned. Other measures usually take a very long time and are very complicated. I don’t have a problem with doing it “lovingly” and polishing nicely. But sometimes we are too careful, remove too little enamel and then there isn’t enough space to move the teeth as planned. That is one of the main reasons for delayed treatment success.

KOMISCHKE: For outcomes that are as lasting as possible, you should always do interproximal stripping if there is crowding or rotation. If you only work with expansion and protrusion, recurrence is often per-programmed. Without interproximal stripping, I agree with Dr. Müller, it would take much longer to rectify the crowding and rotation. To drag an aligner treatment on artificially like that is only going frustrate the treatment provider and the patient.

Talking of dragging things on: How do you explain the costs to the patient?

MÜLLER: In most of my cases the costs are between 3,500 and 4,000 Euros. The material and laboratory costs amount to a maximum of 1,695 Euros, at least in complex cases. Then there is the dentist’s fee too. Generally speaking, even private health insurances do not cover the treatment. I send the link for treatment set-up in the hope that the reviewer is able to open it. But that is often not the case.

It’s a pity because the clear aligner treatment plans are actually much more detailed than conventional orthodontics. We show every precise step through to a successful treatment outcome.

WOLLITZ: I have been luckier than that. If orthodontic treatment is indicated and not purely esthetic, the private health insurances cover the costs more often than not. It depends on the justification given by the treatment provider. Above all, it is often true that the aligner treatment is much cheaper than fixed braces.

So what is the dentist’s fee?

KOMISCHKE: I basically make sure that the treatment provider earns at least as much as the aligner manufacturer.

MALL: Treatment complexity and treatment time are the key considerations. In adolescents and young adults the costs are comparable with fixed brace treatment measures but they can be lower at times.

But more popular?

MALL: Definitely Clear aligners have become a real alternative to arch wire braces if they are properly indicated.

The advantages cannot be denied.

• The number of appointments is reduced freeing up valuable chairside time.
• We don’t need as many checkups.
• The number of complications is reduced compared to arch wire braces.
• Decay, enamel abrasions caused by brace contact, periodontal lesions and gum irritation, as often seen in multibracket braces hardly ever occur.
• Patients also have the opportunity for optimal oral hygiene.

How many aligner treatments does your practice carry out?

MALL: We treat about 120 patients a year.

And your fellow dentists?

MÜLLER: We have about twelve new aligner cases per quarter; we are currently treating 120 aligner patients.

KOMISCHKE: In some months we have ten new cases, while in others the number is much lower. It averages out at five a month.

WOLLITZ: That’s similar to us, we have between three and five new aligner patients per month but we do then keep these patients. Our new aligner patients regularly attend to have their teeth professionally cleaned, for recall appointments and are then open for further treatments after the aligner treatment, such as bleaching, filling treatment and veneers.

Do you need orthodontic know-how to be able to offer aligner treatment as a dentist?  

MÜLLER: Definitely for complex cases! You simply have to get to grips with the subject. Straumann supports the users with webinars, courses and exact instructions. The workflow itself is self-explanatory based on the scans of the situation.

KOMISCHKE: I was lucky enough to be able to do lots of fixed orthodontic treatments before I started with clear aligner treatments. You certainly do have to have a certain level of understanding as to how teeth move. What works and what doesn’t work? It’s important that you start with the easy cases.

Such as?

KOMISCHKE: I recommend that newcomers start by treating slight crowding in the lower jaw. Almost every colleague has a case like this among his patients. Alternatively, dental assistants are often up for aligner treatment. If that works well, word gets around quickly. It is of course possible to monitor these patients very closely.

There are also great courses such as those offered by POS (Progressive Orthodontic Seminars). 

MALL: The advantage is, of course, that the counterpart technician from the ClearCorrect portal sitting at the screen plans the case with the patient documents you have created and with your own specifications. ClearCorrect - where necessary - advises interproximal stripping as standard as well as the application of attachments, the engagers mentioned before, which increase the force on the teeth, primarily for rotation movements. Anyone not wanting this option informs ClearCorrect in the form. The responsibility for the treatment is, however, clearly always with the treatment provider. We often, for instance, correct the treatment plan. Ultimately the technician does not have any patient contact. The treatment set-up, an interactive 3D preview of the treatment, is definitely helpful for newcomers and it can also be sent on to the patient for demonstration purposes. It contains the anticipated final outcome and the progress at every step including recommended procedures, such as interproximal stripping and bonding attachments.

WOLLITZ: The ClearCorrect concept is also almost self-explanatory as I see it. In the support center, you are guided step-by-step, from explaining the procedure to patients to the wearing schedule, from scanning through to accepting or rejecting the treatment schedule. The treatment provider informs the technician what he does not like about the set-up. Basic orthodontic knowledge is, of course, the prerequisite for referring complex cases to the orthodontist.

Fig 3a to 3f: Treatment of upper and lower jaw crowding, treatment time one year, 27 aligners, no revision, neither enamel reduction nor engagers

(Figures: Wollitz)

Can a crossbite, open bite or deep bite be treated with aligners?

MÜLLER: Yes, as I see it, the orthodontic understanding of a dentist is sufficient. Ultimately, the change in vertical dimensions by grinding and reconstruction is part of our practice routine. Anyone working with partial crows and the like must have sufficient orthodontic know-how when carrying out deep bite aligner therapy.

KOMISCHKE: It does need aids such as buttons and elastics. It can become complex. I advise beginners against it.

WOLLITZ: We discuss deep bite and crossbite indications in advance with the orthodontist. If the case is complex, we refer it.

Dr. Mall, aligner treatment for deep bite, yes or no? What do you say as an orthodontist?

MALL: A true deep bite and open bite are among the supreme disciplines of orthodontic treatment and are often associated with high rates of recurrence. In light of the increased therapeutic input – involving extra equipment, intermaxillary elastics to close the bite – it is worth considering carefully on a case-by-case basis if it isn’t initially better to start with a fixed brace.

Let’s move on to CMD prevention and using aligner therapy to avoid invasive restorations. Is that an option for you?

MÜLLER: Of course, we’ve been doing that for years. In the past we addressed CMD problems with long-term orthodontic treatments.

Nowadays we can achieve the same results with a six-month aligner treatment, in difficult cases the appropriate reconstructions are required.

KOMISCHKE: We have many patients with impaired occlusion, such as buccal non-occlusions and crossbites of individual teeth. If they are not treated, CMD is inevitable. The case study (fig. 1a to 1f:) shows the clinical outcome.

MALL: Because we are working with a “living object”, it is important to keep checking progress if you are carrying out CDM prophylaxis with aligners. For this reason, no patient can expect that everything is going to stay exactly the same after an “active” treatment as was achieved in one result.

What other aligner treatment options can you see?

KOMISCHKE: We have a 28-year-old bruxism impatient who grinds his teeth all day. No guard had been able to stand up to the force of his bite and his teeth were already showing signs of significant abrasion. Since the patient has been wearing upper and lower aligners acting as retainers; this has brought significant relief and has reduced his bruxism. The aligners on the market now can last almost a year with daily wear and tear. There are other interesting options in periodontitis treatment. You can down-regulate the strength of the aligners and so bring spread out teeth back into position after periodontitis treatment and stabilize them in the long term.

WOLLITZ: Aligner treatment also opens up new opportunities in the field of per-prosthetic correction, depending on the case.

(Figures: Mall)

ClearCorrect workflow:

For which indications do you actually refer a patient to an orthodontist?

WOLLITZ: Complex cases: a significant open bite, pronounced cross bite, jaw repositioning, uprighting and larger scale per-prosthetic orthodontic treatments. 

KOMISCHKE: We don’t do early treatments or orthodontic treatments covered by the health insurance ourselves. I do treat anything not included in the orthodontic indication groups (the German system to classify treatment covered by the health insurance) myself.

Does an intercollegial exchange take place?

KOMISCHKE: I work with a very friendly orthodontist who has enough to do so he does not begrudge me my aligner patients.

Do orthodontists criticize dentists for gaining a foothold in orthodontics?

KOMISCHKE: Some certainly do. But I do treat many cases that are not interesting for an orthodontist because they are not challenging enough.

It’s more a matter of being able to help some patients rather than building up a completely new group of patients who only receive orthodontic treatment.

MÜLLER: Of course it’s competition. There’s no question about it. But the aligner treatments we carry out could be associated with extensive planning at many orthodontic practices. Because in Germany orthodontic treatment is a terrain especially for children and adolescents who I currently always refer to the orthodontic practice. Carrying out aligner treatments in children and adolescents is taboo in my practice. We leave that to the experts. Orthodontic treatment of adults is easier.

Dr. Mall, as a person “affected” by this, do you accept that dentists are gaining a foothold in the orthodontic business?

MALL: Yes, of course. But it is actually a question of competition. Orthodontists generally live off referrals and therefore actually want to be set apart.

So there is jealousy?

MALL: Essentially, yes. I personally see the matter as slightly more differentiated: On the one hand, I think it is good that dentists are brave enough to try something that is more or less new and are expanding their treatment horizons and the range of treatments they offer. Dentists are taking simple treatments off the orthodontists’ hands and so are basically giving them the space they need and sharpening their own understanding of orthodontics.

Dentists develop an “eye” for more complex cases that they then refer to specialists. On the other hand, there is the risk that a colleague will bite off more than they can chew and because they lack sufficient knowledge may “mess up” a case. The patient ends up with the “specialist” in the end who then has to persuade the patient to carry on the treatment. This was why I would urge dentists not to experiment but to make use of the hands-on courses on offer.

The patient can take photos of their teeth conveniently at home on their smart phone and artificial intelligence assesses the intraoral situation – this is all made possible by the DenToGo-App. I. To what extent does this mobile orthodontic remote solution support patient compliance?

MÜLLER: The approach certainly has massive potential. The majority of my patients still, however, reject the additional tool because most of them are older.

But we mustn’t underestimate what is available to us there – and not just for orthodontics. DenToGo makes diagnosis much easier. A scan is all you need; the AI easily detects decay, plaque or gum infections and how the teeth are aligned.

As I see it, it is only a matter of time until we scan the oral situation and then have a documented analysis within seconds.

The interview was conducted by Anne Barfuß, editor of Medizin, Zahnmedizin in the Deutscher Ärzteverlag. 

First publication:  DEUTSCHER ÄRZTEVERLAG, DENTAL MAGAZIN, 2020;38(4), pages 16-25.