Making a Case for Adult Orthodontics With Clear Aligner Therapy Provided by the General Dentist

Patients today are being marketed to on a daily basis for a variety of direct-to-consumer oral health-related products that exclude dentists' expertise and guidance. Occlusal guards, whitening products, sleep dental appliances, clear aligners, and desensitizing agents are among the more prevalent ones. When dentists do not offer these services, and sometimes even when they do, patients may still elect to pursue direct-to-consumer dentistry. As such, dental professionals must be able to educate their patients regarding what types of cases are acceptable to treat without specialty knowledge or care and, when appropriate, offer them services involving the products they want.

In the United States only 35% of adults have well-aligned mandibular incisors.¹ With more than 258 million adults over the age of 18 living in the United States and 75% of them having class I malocclusions, it is not surprising that the direct-to-consumer approach for clear aligner treatment has gained so much momentum.² Clear aligners are a viable alternative to traditional orthodontics to treat some malocclusions,³ and they provide patients the opportunity to remain in their dentist's office where the dentist can plan, monitor, refer when necessary, and execute treatment, all while in a comfortable and familiar environment. Patients treated with clear aligners have been shown to have a better periodontal outcome and greater satisfaction during orthodontic treatment than patients treated with fixed orthodontic appliances.⁴

Often when providers refer a patient for specialty care, the patient may ask if the dentist can perform the treatment right there in the office, where the patient feels comfortable and has built a trusting relationship with the dentist. Although this may be flattering to providers and give them a feeling of validation, they know they lack the armamentarium to provide the treatment. However, this may be an opportunity to, when appropriate, offer patients what they want while expanding the practice. Case selection is imperative and can be the catalyst in the provider's success.

When preparing to start treatment of the adult dentition with clear aligners, clinicians must first consider the patient's chief complaint. Based on what the patient describes, the clinician can determine whether or not the patient's expectations are reasonable and if the clinician will be able to provide them a service that they will be happy with and the clinician will be comfortable providing. Reaching the end of a case and realizing that the patient's wishes are not congruent with what the clinician is able to accomplish is an unenviable position for providers to find themselves in.

Radiographic and periodontal evaluation by a trained dentist is necessary to determine if the patient is a candidate for any orthodontic procedure, including clear aligners. Once risk is evaluated, a treatment plan can be generated, consent obtained, and services rendered. When a clinician's patient is treated in another general practice office for services he or she provides, it can be a humbling experience. It is important for dentists to have conversations with their patients about the types of cases they are willing to treat. Although clear aligners can be used to treat moderate to severe malocclusions, these cases are often more challenging and should be approached with caution.⁵

The following cases were treated in the author's office using OraFit^™ clear aligners (OraPharma, hcp.myorafit.com). OraFit features Zendura^™ FLX flexible plastic, which is marketed to deliver a slow, consistent pressure to aid in patient comfort during orthodontic movement.

A 42-year-old female patient, who was classified as American Society of Anesthesiologists (ASA) II but otherwise healthy, presented to the author's practice for esthetic and functional improvement of her dentition. Her medical history was remarkable only for past hypercholesteremia and hypertension. Upon presentation her chief complaint was excess spacing of both her maxillary and mandibular dentitions despite having previous comprehensive orthodontic treatment and fixed retention. The patient's molar relationship was class I. She had recently undergone treatment in her maxillary arch, which motivated her to seek further treatment. In the previous year she had her maxillary left second premolar (tooth No. 13) extracted and a bone-level implant placed and restored, and she was now ready to undergo orthodontic treatment (Figure 1 and Figure 2).

The patient was seen for a records appointment where a series of intraoral and extraoral photographs were taken. Using an intraoral scanner (CEREC^® Omnicam, Dentsply Sirona, dentsplysirona.com), maxillary, mandibular, and bite registration digital impressions were captured and then converted to STL files. Both the photographs and the digital impressions were uploaded through the OraPortal (OraPharma) (Figure 3).

Similar to a traditional prescription for treatment or any other clear aligner submission application, the OraPortal is the OraFit proprietary treatment planning application. It allows the provider to submit, treatment plan, and communicate to the OraFit team the patient's chief complaint, classification and diagnostic information, the provider's treatment goals, and the instructions for the case. For the present case, it was communicated that tooth No. 13 was an implant restoration and, therefore, should not have any pressure applied on it during treatment.

Upon receiving all the necessary information, the OraFit team generated a treatment plan via the OraPortal. This digital plan shows the stepwise treatment steps and the movements that are to be accomplished throughout each step (Figure 4).

After being reviewed for accuracy, the plan was submitted to the patient for approval to commence treatment. Consent for treatment and financial arrangements were made with the patient, and the case was accepted and ordered through the OraPortal. For this case, six resin engagers were needed, and no interproximal reduction was required.

Nine sequential trays of OraFit Zendura FLX plastic aligners, as well as a template for engagers, were delivered to the clinician and inspected. In the author's experience, Zendura FLX has shown to be a very discreet clear aligner material that resists staining. At the delivery appointment, engagers were placed on teeth Nos. 4, 8 through 10, 20, and 29 using the engager template with a combination of flowable and condensable resins using traditional etching and bonding techniques. An existing fixed retainer between teeth Nos. 8 and 9 was removed, and tray sets 1 through 3 were provided to the patient with instructions on wear times and home care. In this case wear time was established at 2-week intervals at 23 hours per day.

The patient returned after 6 weeks, and trays 4 through 6 were provided. At this appointment the patient was given the opportunity to ask any questions, the engagers were inspected, and compliance was observed. Wear time for these appliances was maintained at the 2-week, 23-hour-per-day intervals previously established, and the patient was rescheduled for 6 weeks.

Upon evaluation of the patient at the next visit, it was observed that treatment was continuing without any complications. Remaining trays 7 through 9 were provided, and the patient was rescheduled and instructed to continue as previously directed.

At final check, the case was evaluated for completion and the patient was asked to rate her level of satisfaction. If she had provided any negative feedback, a revision would have been requested. Such a revision would be requested by the treating doctor via the OraPortal, with a set of new impressions and bite registration with instructions to the OraFit team on what was being requested. Examples of needs for revisions may include incomplete movements, poorly adapted aligners due to noncompliance, and refinement modifications toward the end of the case. In this case, however, the patient was satisfied and the retainer was ordered. Prior to delivery of the retainer, the engagers were removed with a fine finishing diamond, and the teeth were polished. Wear time for the retainer was established at 23 hours per day for 90 days, and a minimum of 6 hours daily indefinitely.

This case represents a situation in which the patient became motivated to correct minor esthetic concerns after investing in her dental implant. Had the patient been more open to multidisciplinary care initially, the implant site might have been better optimized. As it was, the results, despite being relatively subtle, were to the clinician's and patient's satisfaction (Figure 5 and Figure 6).

A healthy, ASA I 18-year-old female patient presented to the author's practice with a noncontributory medical history. She had class I malocclusion. Her chief complaint was the mandibular anterior crowding that was evident when she smiled (Figure 7).

As in Case 1, the patient was seen for evaluation, records, treatment plan presentation, and case acceptance. In this case the number of steps was 11, and 10 engagers were required. Six-week intervals for office visits again were established and adhered to, and the protocols for wear times were consistent with Case 1. Results were measured to include the patient's chief complaint and satisfaction with the treatment outcome, as well as the author's satisfaction with spacing, occlusion, and alignment. The patient was happy with the outcome.

In this case, the patient's malocclusion likely would have eventually led to some level of compromise of her gingival health. The treatment provided allowed for an esthetic result that also would enable the patient to more easily care for her oral hygiene (Figure 8 and Figure 9).

Case selection is one of the most critical aspects when considering providing clear aligner treatment. Not only is it important for clinicians to know what to do when complications arise, but it is equally important to know how to avoid them. Being able to provide services with predictable results in a manner that is pleasing to patients and profitable for the dental practice is crucial to success.

Many patients trust their dentist and dental office and prefer to be treated by them whenever possible. Class I malocclusions represent the majority of malocclusions, and clear aligners are a desirable alternative to traditional orthodontics for adults seeking treatment. Class I malocclusions also are usually the easiest and most predictable cases to treat. Such cases may present opportunities for general practitioners to expand their service offering while giving their patients what they want-a more healthy, functional, and esthetic result achieved in a relatively convenient manner.

There are many different options in the clear aligner space. Factors for providers to consider when selecting their aligner of choice include simplicity, cost, customer service, patient comfort, and aligner material appearance before and after aging. In the author's experience, OraFit offers an effective product in Zendura FLX. OraFit aligners are backed by the OraPharma customer service team, providing clinicians a simple process to deliver a positive experience to their patients and the flexibility to treat cases they may have previously referred out of their office.

This article was commercially supported by Bausch.

James P. Bennett, DDS
Past Guest Faculty, Case Western Reserve University School of Dental Medicine, Cleveland, Ohio; Private Practice, Westlake, Ohio