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I have the privilege of working in a craniofacial hospital as a member of an inter-disciplinary dental specialty team including a prosthodontist, oral surgeons, pediatric dentists, and we have fellows and hospital dental residents who rotate through each week. I arrived one morning greeted by a nervous dental resident who said she was relieved to see me because she really needs to speak with me. She explained that she was moon-lighting doing dentistry in private practice and needed help to look over an Invisalign™ case that wasn’t working.

She said it was her fifth case, a 16-year-old boy with a difficult mother who is quite upset.   He wore the first series of aligners and it didn’t work, and she really had to make it right with her refinement so the family doesn’t become more upset and she needed the help of an orthodontic specialist.

She had the ClinCheck™ on the computer screen ready for me to assess (A Clincheck™ is a simulation of the virtual movements the teeth will make after each tray is worn. The patient can therefore have a projection of what their teeth will look like at the end of treatment. Invisalign™ provides this software to communicate with their technicians in Costa Rica. As orthodontists, we review the exact movement of each tooth in detail and in relation with their neighbour and communicate back and forth with the technicians explaining the exact biomechanical tooth movement necessary and that is biologically possible).

Technology like Invisalign™ have simplified the ability for non-specialist dentists to provide orthodontic care to patients. Moving teeth through bone can be simple, however moving them “properly” through bone in the right three dimensional position so they can effectively and esthetically relate to their neighouring teeth with a resultant bite that is not uncomfortable, can be challenging. Anyone can virtually ‘manipulate’ the movement of teeth in an Invisalign video. For predictable and proper tooth movement, what is required is the rendering of a proper diagnosis of the case with a realistic and effective treatment plan. That’s where the question arises, “who should be doing your Invisalign™ treatment?” Shouldn’t it be an orthodontic specialist with advanced training and expertise in moving teeth and who does it day in, day out, all day long?

If general dentists are offering orthodontic treatment, are they giving patients the option of seeing a specialist? We often are asked the question if patients are “qualified” for Invisalign™. The question that patients should be asking is if their dentist is “qualified” to be performing Invisalign™. Invisalign™ or other clear aligner systems are not a commodity but they result in different outcomes between different providers. Invisalign™ is just a vehicle for the orthodontist to take a patient through their journey, just like braces, with the goal of a beautiful smile and functional bite.

 

Questions patients should ask their dentist prior to proceeding with orthodontic treatment with them include:

1) Are you an orthodontic specialist and is this what you do all day, every day?

2) Have you completed an advanced full time 2-3 year orthodontic residency training program?

3) If no to the above questions, what makes you qualified to be moving my teeth and are you confident you can provide the same level of care as a specialist?

4) Did an orthodontic specialist treat your smile or your children’s smile?

5) Do you develop your own treatment plans or do you rely on a specialist or outside company to do so?

6) Are you just getting my teeth straight or are you paying attention to how my bite will fit together after treatment or the specific details of my smile?

7) How many cases similar to mine have you treated in your career and can you show me before and after photographs?

8) What will you do if something goes wrong?

 

Unfortunately, sometimes dentists and their staff may falsify themselves as orthodontists. To determine if the person treating you really is an orthodontist, you can ask them which advanced specialty training program they have attended, or if they successfully passed the royal college of dentists specialty training exam. You can also get a hint if they are doing cleanings, fillings, crowns, and other common general dental procedures. If they have a one-stop shop for treatment, they are likely not orthodontic specialists. In fact, many dentists lower their Invisalign™ fees, using Invisalign™ as a loss leader to give them ability to charge patients for regular cleanings, check-ups and other procedures.

Here is an example of a case treated by a general dentist doing Invialign™ which had to be retreated by an orthodontic specialist, and the final result achieved.

 

 

When I reviewed the dental residents Clincheck, I saw a lot of problems. My first question was, do you have photos? She pulled out unhelpful out-of-focus photographs which had been taken on her cell phone. My next question was if she had a panorex and lateral cephalogram? She had a full mouth series of x-rays, no panorex, no lateral cephalogram because the dental office where she was working doesn’t have the machine to take these diagnostic orthodontic x-rays.

I went through the Clincheck video and saw explained to her the issues she was facing. I first ask asked her why the case was finished with a posterior open bite and no anterior coupling. Her answer was, “Well why would they leave the case finished like that?” I tried to gently explained to her that she’s the one who is responsible for treating the case and the technician is responsible for following her instructions. Then I asked her why the teeth are not straight. She told me they were, and then I pointed out the angulation was off and the torque wasn’t right on several teeth and the alignment was not even ideal. I told her it would be helpful to see a lateral cephalogram as the incisors look significantly proclined and appear to need retraction, and that this case may require the extraction of four premolar teeth.

She was disconcerted with my answers and recommendation to her and said that she thinks it’s best for the patient to be referred to another general dentist who does Invsialign™ to keep things simple for the patient. The oral surgeon and pediatric dentist who were in the room and witnessed the interaction, both came to me and said that she will figure it out herself after she specializes. She later thanked me for the help and admitted that since she was doing her residency, she appreciated the value in patients seeing dental specialists for their care.

Where I practice in Toronto, there are hundreds of dentists providing Invisalign™, and some who treat hundreds of cases each year. These patients often have to spend more money, and have to undergo the burden of additional orthodontic treatment so they can “get it right” by a certified specialist. And sometimes, what has been done is irreversible. When it comes to orthodontic treatment, it is truly a “buyer beware” jungle out there. Invisalign™ and other clear aligner systems are wonderful alternatives to traditional braces that we as orthodontists can offer patients. But don’t be fooled. It’s not like buying a shirt or shoes. The person who is treating you is what is critical to achieve a successful esthetic and functional outcome that can last you a lifetime.

— James Noble