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Professional News Articles : : ON PRACTICE MANAGEMENT by Janyce Hamilton : To Invisalign or not to Invisalign? That is the question

To Invisalign or not to Invisalign? That is the question

June 05, 2007

After hearing the third commercial for Invisalign in as many days on my car radio, I started thinking about it. I wondered if they really work as well as the old “railroad tracks” I had to endure in junior high. My older brother was smarmy from the first day I got them on, because he didn't need braces. “Tin grin,” “metal mouth”—I heard it all. The torture I endured as he made fun of my awkward smile, pimply face and everything else!  

When my own brood reaches junior high, what will the mainstream orthodontia look like?

Will it be something like Invisalign, or is this just another fad?
I decided to pose questions like these to Lou Shuman, DDS, vice president, Strategic Clinical Relations, Align Technology Inc., Santa Clara, CA.

The interview

Janyce Hamilton (JH): How was the Invisalign product invented?

Dr. Lou Shuman (LS): The company was founded in 1997 by two Stanford graduate students who realized the benefit of applying advanced 3-D computer imaging graphics to the field of orthodontics. One of the students had worn braces and noticed the impact of wearing—or not wearing—his removable retainer.

In September 1998, Align received FDA clearance to market Invisalign to the general public, and began commercial sales of Invisalign in July 1999. In September 2000 Align launched its first national advertising campaign directly to consumers and started 10,000 patients in treatment with Invisalign.

Since inception, more than 530,000 patients have entered Invisalign treatment and more than 23 million unique Invisalign aligners have been manufactured.

JH: How does it work?

LS: Invisalign consists of a series of removable, plastic, nearly invisible orthodontic aligners that let patients straighten their teeth without braces. An Invisalign-certified doctor submits patient records and a treatment plan to Align. Align then uses proprietary 3-D treatment planning software to create a customized ClinCheck, which is a stage-by-stage virtual treatment plan in “movie format.” Once the doctor approves the ClinCheck, the patient's entire series of Invisalign aligners are manufactured.

Because it does not rely on the use of metal or ceramic brackets and wires, Invisalign significantly reduces the limitations associated with traditional braces, including patient concerns about aesthetics and discomfort. Statistics show that with experience, doctors can use Invisalign to treat a vast majority of patients who want a better smile.

JH: What challenges did the product encounter early on, and how were those dealt with?

LS: The orthodontic industry is often slow to change, due in large part to the length of time it takes to really see the efficacy and long-term benefits of a new product, technique or treatment option. So there was normal, healthy skepticism about the Invisalign system. Align addressed that by working closely with universities and leading educators to test and demonstrate what Invisalign treatment could accomplish—and what its limitations were. But more than that, doctors began to embrace Invisalign based on their own experiences and results with the Invisalign system.

There was also some concern from the orthodontic community about Align's consumer advertising—Align was the first company to market an orthodontic appliance directly to potential patients. Most of these concerns subsided as doctors started to see an increase in new patients as a result of the advertising.

JH: What's the biggest patient resistance to the product? And dentists' resistance?

LS: There is very little patient resistance to Invisalign treatment. In fact, patients very often walk into their doctor's office and request Invisalign. Any hesitation is typically related to the perceived complexity of their case—“will Invisalign really work for me? Will it straighten MY teeth?”

As for dentists' resistance. . . there is the typical concern regarding the outcome they can expect from a new product or technique—but with more than 530,000 cases treated, that is less and less of a factor. GPs are also sometimes concerned about case identification and the skill sets necessary to treat patients with Invisalign—particularly if they haven't been doing orthodontics in their practice. But we're working to alleviate those concerns through our clinical education and support programs, and with products that make case selection easier, such as the recently launched ClinAdvisor.

JH: What's the fee range for average/typical treatment?

LS: Fees are set by the treating doctor, but the national average ranges between $3,500 and $5,500 for full Invisalign treatment.

JH: How much cheaper is Invisalign than regular orthodontics (if it's cheaper)?

LS: I don't think many doctors price Invisalign at a lower cost than traditional bracket therapy. Doctors see the cost savings in terms of better profit margins—fewer appointments, no emergency appointments, less overall chair time and less doctor chair time, increased referrals from happy patients, etc.

JH:  Is there a trend toward colors or something else fun in Invisalign appliances, or can you name celebrity clients?

LS: Not really. The appeal of Invisalign treatment is that it's inconspicuous—we haven't had requests for colored aligners or anything else that would make them more noticeable.  And that's one of the reasons why celebrities and other people in high-profile positions like Invisalign—it's a treatment solution that allows them to improve their smile without calling attention to their treatment. We do have celebrities in treatment, but due to patient confidentiality we can't share any names.

JH:  Are they worn at night?

LS: Yes, Invisalign aligners should be worn 24 hours a day—patients remove them to eat, drink, brush and floss.

JH: Do they help snoring?

LS: Invisalign is not indicated as a device to help alleviate snoring, and we don't have any data that indicates that it might help.

 JH:  Do they irritate gingivae, and if so, how will the dentist handle it?

LS: Due to our precision manufacturing and robotic trimming of aligners at the gingival line, a rough edge appears only on rare occasions. When it does, the doctor or dental assistant can smooth the edge with an acrylic burr or with crown and bridge scissors.

JH:  Do bacteria and food get trapped underneath, causing extra staining and decay/erosion?

LS: Aligners are not worn during eating and drinking, so there is minimal opportunity for food to get trapped. Patients typically brush and floss before re-inserting their aligners after meals, snacks, etc. In fact, a study from the University of Florida found that periodontal health improved during Invisalign treatment.

JH:  What's the average treatment length?

LS: Based on average number of aligners manufactured per case, less than one year.

JH: After treatment is completed, is the retainer used the same type that is worn by patients with traditional braces, or is it a special clear Invisalign type? And is a retainer permanent or for a few years?

LS: As is the case with all orthodontic treatment, retention is for life. Any type of retention can be used—the appliance is usually determined by the type of case. But we find that Invisalign patients become accustomed to a clear, removable appliance and prefer to continue with that style of retention when at all possible.

JH: If Invisalign isn't cheaper but just more “invisible,” why would someone pick it over clear bonded bracketed braces?

LS: I don't think this is a price-related decision for most patients, especially since so many Invisalign providers price Invisalign treatment and clear/traditional bracket therapy very comparably. Most patients choose Invisalign because it's clear, barely noticeable, easy to keep clean and convenient. The fact that Invisalign is removable is a huge benefit to patients who are concerned about maintaining good hygiene and who want the option of removing their aligners for an important presentation, a big date, to have a cup of coffee or a glass of wine. Invisalign fits their lifestyle.

JH: Let's talk controversy. Why do more orthodontists reject Invisalign products vs. general practitioners?

LS: Orthodontists have been previously trained in orthodontic techniques that they have used for quite some time. So when they approach an Invisalign case, they have multiple options in how to treat the case. With many GPs, Invisalign is the only orthodontic technique they have decided to use in their practice, taking the necessary educational courses to provide this service to their patients.

JH: Is it true that there's just certain complex cases that are not treatable with Invisalign? Explain.

LS: Yes. At this time, Invisalign is not recommended for cases with no posterior teeth present or mixed dentition cases.

JH: Do some patients drool excessively at night wearing Invisalign?

LS: Since a new device is inserted into a patient's mouth, a patient may experience increased or diminished salivation.

JH: Are there different Invisalign systems? Why?

LS: There are only two Invisalign options available to the practitioner. The decision on which option to be used is based on the complexity of the case. Invisalign Express was developed as a lower-cost solution for very simple crowding and spacing cases—those that can be treated with 10 stages of aligners or fewer.

JH: Some people complain their really crooked teeth get “loose” during Invisalign treatment and it alarms them. Does this happen with regular braces too, and does it resolve on its own?

LS: Yes it does happen with all orthodontic techniques, and with cases that are treated with sound periodontal health, it resolves on its own as well. When force is applied to a tooth, the reaction will be to create mobility in order for that tooth to ultimately be moved to its ideal location. Once that occurs, the tooth will stabilize and return to its nonmobile state. 

JH: Is speech affected while wearing Invisalign?

LS: There may be a day or two of adjustment at the beginning of treatment, but patients adjust very quickly. Most patients report few or no problems with speech or pronunciation.

JH: Do some patients ever have trouble getting the aligners off themselves because they are so snug they almost bond to the teeth with suction?

LS: Occasionally this happens—particularly when the patient switches to a new aligner. The doctor or dental staff can show the patient their preferred tip or trick for removing an aligner when there is an especially snug fit.

JH: Do Invisalign-ers who use tobacco and drink coffee get yellowed Invisalign appliances? Can these be bleached?

LS: Patients remove their Invisalign aligners to drink, eat, etc., so discoloration due to coffee or other beverages isn't a factor. We have not heard any reports of patients smoking while wearing their aligners.

JH: Do you really have to wear them full time?

LS: Patients are advised to wear their Invisalign aligners 24 hours per day, removing them only to eat, drink and brush/floss.

JH:  How has business been over the last 5 years?

LS: Align has experienced strong growth and increased case submissions, particularly from GPs.

JH: Are there any published patient/dentist satisfaction surveys on the product and if so, please summarize their findings.

LS: According to Align-sponsored patient surveys, 87 percent of patients are Extremely Satisfied or Very Satisfied with their Invisalign treatment.

JH: What is your business trend projection for Invisalign and are there new products/services on the horizon we should look for?

LS: There is a tremendous untapped potential market for Invisalign treatment, and Align is working to capture it by providing innovative, excellent products for customers. For our GP customers specifically, that means developing products in the near future that increase treatment predictability, that are less labor intensive and reduce chair time, and that require less orthodontic training for GPs.

Invisalign is a fascinating product, and I'd test it out, but these teeth are straight. To confirm that the system does work, I wanted to talk to dentists in the area. James L. Derrico, DDS, of Lisle, told me they work at about the same speed and cost as brackets-and-bands ortho. “I've got patients 17 to 73 using Invisalign. It gives general practitioners the option to offer orthodontics without four years of additional college—a good thing, and a bad thing.” In fact, he only needed to take a two-day intensive course for certification. “I was overwhelmed, but the sales rep worked closely with me for the first four to six months, and after about 15 cases, I became really comfortable doing them.”

The aligners saved one of Dr. Derrico's patients a little bit of money who came to him for six veneers and instead left with Invisaligners (he also throws in a free whitening at the end of treatment).

“I also like how Invisalign can invisibly work on changing the position of just one tooth, while traditional braces would involve all the teeth and be noticeable just to do that one tooth.”

According to Dr. Derrico, he knows orthodontists who offer Invisalign as well as traditional orthodontics “because they want to be cutting-edge” and have them on-hand if patients walk in and ask for something not noticeable.

“By offering this option, my patients who like me as their general dentist are happier, my practice is more visible, I've got a great way to increase my income, and greater satisfaction because you can do more as a dental practice,” he said.

Most importantly, teenagers wearing “invisible” aligners will be teased for one less reason.

I do know someone whose teeth twist like tree roots. The front ones look like they are crossing their legs. He would love to be a guinea pig for an Extreme Dental Makeover. My brother thinks they'd have to open up a new resin-production facility for the series of aligners it would take.

Janyce Hamilton is a Chicagoland freelance dental writer and editor. Send suggestions for topics to be covered, or any comments on this column, to review@cds.org.

Copyright 2007, Chicago Dental Society