August, 2005
Invisalign: The Bracketless Alternative for Comprehensive Orthodontic Treatment
This is the first article in a series of papers detailing with the use of Invisalign® in complicated, comprehensive treatment.
Dr. David Paquette
By now most, if not all, of us are familiar with Invisalign® treatment. As I lecture around the world, I am surprised by the extent of apprehension and misunderstanding surrounding the latest tool in the orthodontist’s armamentarium.
First, I must emphasize that Invisalign® is a technique, not a treatment. Invisalign utilizes a series of custom made plastic aligners pressing directly on the teeth rather than a series of wires pressing against brackets to transfer pressure to the teeth. The biomechanical principals remain the same; the applied biomechanics are simply a little different. In other words, as far as the teeth are concerned, aligners work the same way braces do.
It is my opinion that the treatment plan for a patient should be independent of the appliance used to achieve that goal. In other words, my treatment goals remain the same whether the patient chooses Invisalign® or fixed appliances. It is my responsibility as the treating orthodontist to give the patient realistic risks and benefits for each of their alternatives, and now, as with the typical choice some patients have between extraction and non-extraction treatment, my patients have the choice between Invisalign and fixed appliances. Yes there are some problems that I would prefer to treat with fixed rather than Invisalign but there are other problems that I would prefer to treat with Invisalign rather than fixed. Ultimately I leave the decision up to the patient as long as they understand and accept the shortcomings involved with that choice.
Invisalign as a treatment technique is still in a very dynamic state of development. Although they have both moved on to other pursuits and are no longer involved with Align Technology, two non-dentists, Kelsey Wirth and Zia Chasti, started the company in 1997. Fortunately for us they were not biased by experience nor deterred by naysayers. Rather they had similar experiences as former orthodontic patients. They managed to raise funds and, with the help of a handful of forward thinking orthodontists, create a workable device that was introduced to the public in 1999 with a lot of marketing and fan fare. The brash approach to publicity, marketing directly to the public and the more or less in-your-face attitude toward traditional orthodontics accomplished two things. It created a huge public awareness and demand while at the same time alienating many of the orthodontists in the United States and Canada who were skeptical of the claims and disliked the direct-to-public marketing campaigns. In addition, many orthodontists are vocally upset about the extent of involvement general dentists have attained in utilizing this treatment technique with the active help and educational courses provided by Align Technology. Despite these early missteps, it is orthodontists who must ultimately have the greatest knowledge and level of capability with Invisalign if we are to continue to provide the public with the highest level of orthodontic care possible and be perceived as the experts in our field.
…it is orthodontists who must ultimately have the greatest knowledge and level of capability with Invisalign.
As technology has advanced, orthodontics has changed almost as dramatically as aviation has over the last 100 years. Take for example the skills required to fly an airplane…orthodontics with standard edgewise fixed appliances can be compared to the early aviators or a contemporary weekend private pilot flying by Visual Flight References (VFR)…it takes lots of training to learn how to fly a little way, look out the window and check where you are, compare it to the map and move on to your next check point in the flight. The pilot is very busy making corrections to stay on the intended course of flight. Likewise, the orthodontist using standard edgewise appliances has spent years in training to develop the skills necessary to plan treatment and then stays very busy because they must see their patient every few weeks to monitor movement and make adjustments to the wires to maintain progress along the intended course of treatment.
Orthodontics with “straight wire” appliances is similar to the more accomplished private pilot flying with some form of autopilot…he or she uses additional technology to simplify routines, but still must look out the window and verify their whereabouts, compare it to the chart and move on to the next check point in the flight. The pilot is not quite as busy and flight can be smoother and shorter. Similarly, the orthodontist takes advantage of the fact that many of the typical bends that were previously placed into the wires are now built in to the brackets. This also allows them to utilize the newer high technology alloy wires available to make treatment faster and more comfortable, with fewer visits and fewer required adjustments.
…to the casual observer, the computer is flying the plane while the pilot is reading the paper.
Invisalign orthodontics is like the commercial airline pilot flying an Airbus…to the casual observer, the computer is flying the plane while the pilot is reading the paper and seems to do nothing. That is because instrument rated commercial airline pilot uses all their training and experience to make certain that EVERYTHING has been evaluated and prepared prior to the flight ever leaving the ground. The pilot appears to be relaxing, but in fact everyone knows that pilot has a much greater appreciation of what is happening and what will happen during the flight than a VFR rated private pilot can ever hope to have. To my way of thinking, orthodontists learning the skills needed to get great results with Invisalign are working on their orthodontic “instrument rating.” It would appear to the uninformed that the Invisalign software is doing all the treatment when in fact it is the orthodontist who must prescribe every movement and attachment throughout the course of treatment before the first aligner is ever delivered. When you gain that level of understanding it is generally smooth sailing for both the orthodontist and the patient, but it all starts with preparation.
Early adopters were told that only simple problems could be treated effectively and patients had to fit the company’s criteria for acceptance. Unfortunately, along with this, the erroneous perception was created that Invisalign in fact involved a treatment plan developed for each patient by some sophisticated software program overseen by knowledgeable orthodontists at the company and at the same time conventional wisdom said that most patients simply could not be treated, or if they could it was most certainly a compromise. The result was that most orthodontists chose not to recommend Invisalign as a treatment alternative and the handful that did essentially became pioneers. These original few are referred to as the Alpha group, because we were obviously the first to try this new technique… with mixed results. Some quit, some persevered and most sat on the sidelines and observed, occasionally treating a patient who absolutely demanded Invisalign as their only treatment choice…for them it was treatment with Invisalign or no treatment at all.
My first patient was one of the obstinate early patients who refused to believe that it would not work for her…she was my wife. Thanks to her I became fully immersed in this new technology because failure was not an option. I learned much from that first patient, and continue to learn every day. Even with several hundred thousand patients around the world now successfully treated with Invisalign, this technique is still evolving. Virtually any malocclusion now can be treated with quality results and the scope of capabilities continues to grow every day. In the series of articles to follow I will share with you some of my insights, both good and bad, gained in the treatment of more than 450 patients with Invisalign over the last 6 years.
Contributed by:
Dr. David Paquette
Dr. Paquette graduated from UNC School of Dentistry in 1979 with a doctorate of Dental Surgery. He received a Master’s degree in Pediatric Dentistry from UNC in 1983. His Master’s thesis won a national research award that same year. He is board certified by the American Board of Orthodontics and the American Board of Pediatric Dentistry. He served as consultant in Pediatric Dentistry for the United States Air Force in Europe and Asia until 1987. In January of 1990 he received his Master’s degree and specialty certificate from St. Louis University. Since 1990 he has been in private practice in Charlotte, NC. Dr. Paquette won the coveted Milo Helman Award in 1991 with his Master’s thesis and has since gone on to achieve numerous, prestigious honors in the field of Dentistry and Orthodontics. In addition, Dr. Paquette has carried out several Academic appointments within St. Louis University, Carolinas Medical Center and UNC School of Dentistry. He has published numerous articles in many different industry publications and is a frequent speaker both in the United States and Worldwide, teaching Orthodontists current techniques as well as practice management skills. Dr. Paquette is passionate about advancing the art and science of Orthodontics. He enjoys spending time with his lovely wife Jenny and their four girls and when time permits he likes running, scuba diving, water and snow skiing, snow boarding and being an instrument-rated private pilot.
