Invisalign: technique rather than a product

[MCOMarkhamOrthodontist]

Invisalign is a brand name that is very much misunderstood by the general public in terms of how it works, who is "in charge" of the tooth movement, and how one product can have such varying costs.

I was invited to the Canadian Invisalign Insider's Meeting last week, with attendance limited to the top Invisalign doctors across the country. One of the most interesting points, along with some amazing treatments using TADs, elastics, and surgery, was one that I have long tried to describe, but was not able to simplify into a short sentence. It came to me last week during one of the seminars.

"Invisalign should be viewed as a technique of moving teeth, not as a product. " Not all doctors using Invisalign are the same. For example, I can wear LeBron James' headband and jersey, or play soccer with David Beckham's shoes, but neither of those is going to let me dunk a basketball like LBJ or put the ball in the corner of the net like Becks. In fact, even with these products, without training and work, I will never develop the technique, expertise, and skill of these individuals.

As described on other parts of this forum, it is the orthodontist who is treating you, with their diagnosis and treatment plan, that make the difference in your care, not the type of brace. Hopefully Invisalign can be seen in the same light in the future .

[myhollywoodsmile]

I agree, which is why I get so scared on my blog when people just email me to ask the "cheapest" Invisalign doctor I know.

[MCOMarkhamOrthodontist]

I understand both sides. Obviously potential Invisalign candidates would like to save as much money as possible, especially during this economic time. While Align does a great job marketing, they simplify the process to make it seem automated and uniform for any treating doctor. There have been multiple threads about cost of providers, whether to see an orthodontist or dentist, etc.

It would be nice to see this thread as a sticky for visitors to this site who are interested in Invisalign .

[Teresuzza]

I have to agree. Unfortunately, I went on the advice of a colleague and didn't do enough research. She sold me on the product and not the technique. Had I known then what I know now, I would have come to your office Dr. Tam (I live in the GTA). I will be moving on to refinements now but I still have the unneasy feeling that I should have gone to someone who knew more about moving teeth and how Invisalign could facilitate that. I'm not sure about the price I got because I didn't really shop around so price was not a factor.

I would recommend to Invisalign that they allow the patient to change doctors mid-treatment.

I will hopefully get to where I'm supposed to be - i.e., with a beautiful smile - after refinements.

[MCOMarkhamOrthodontist]

Patients are allowed to change doctors mid-treatment, just as someone with braces may switch. However, remember that the contract is one between you and the doctor, not you and Align Tech. Align can facilitate the transfer of your file to another orthodontist, but you will have to reach any financial agreements with your existing and new doctor on your own.

When patients transfer in with braces, it is often necessary to replace them in order to continue. With Invisalign, it is likely necessary to take a new impression to "reboot".

Of note, if Invisalign were simply a product and not a technique, it wouldn't be necessary to have regular visits to monitor treatment. Unfortunately, experienced Invisalign providers only make up a small percentage of those certified. This will change drastically with the new proficiency requirements.

Thanks for the kind words and good luck .

[mommamorin]

great analogy. I wish I had known prior to my picking the provider that it was he who was doing all the work so to speak. My old dentist does it and his girls now have the most perfect teeth I've ever seen. I went to this other dentist because he was 1700 cheaper. oh well... lesson learned...the hard way.

[MCOMarkhamOrthodontist]

I know that this board highly favours orthodontists for treatment, as in general, it should, for standard orthodontic treatment with braces.

Invisalign is a completely different story. GPs as well as orthodontists have to understand this technique well in order for it to work. I can tell this board first hand, after having recently attended a meeting of over 40 orthodontists, that being an orthodontist does mean knowing how to move teeth properly with Invisalign. The advantage in this situation is that they can always do fixed brackets for you if the Invisalign doesn't work out...

As I see patients who have had failed Invisalign treatment from orthodontists/GPs, read this board and others, talk to other Invisalign providers, and continue to learn more about Invisalign myself, it cannot be emphasized enough that orthodontic proficiency does not equal Inviaslign proficiency. Remember, Invisalign is a technique, not a product .

[myhollywoodsmile]

So, Dr Tam are you saying that when it comes to Invisalign it doesn't really matter whether you choose an orthodontist or a dentist as long as they are experienced in Invisalign? Or do you still think (as regards Invisalign only) that an orthodontist is a better choice? I get a lot of emails on my blog asking me this so would be very interested in your views.

[MCOMarkhamOrthodontist]

So, Dr Tam are you saying that when it comes to Invisalign it doesn't really matter whether you choose an orthodontist or a dentist as long as they are experienced in Invisalign? Or do you still think (as regards Invisalign only) that an orthodontist is a better choice? I get a lot of emails on my blog asking me this so would be very interested in your views.

Great question. I'm going to qualify this answer as saying that this my personal opinion, rather than based upon some kind of study.

I feel that Invisalign experience is important. It is difficult, however, to determine experience level in some cases, since certain providers may only treat patients who need minor tooth alignment, while others are working with extractions, elastics, open bites, surgery, etc. Both doctors could be "experienced" in the number of cases, yet treat a very different group of patients.

That being said, if all else is equal between the GP and specialist (whether new or well-versed with Invisalign), the orthodontists generally look at the occlusion and alignment in a more detailed manner, and have other methods of moving the teeth should certain teeth require auxiliaries.

[myhollywoodsmile]

Thanks Dr Tam, great answer! I hadn't considered the aspect about the complexity of cases treated in relation to experience. Very interesting point.

[liccledevil83]

That is interesting to know. I was very much under the impression my orthodontist just sent my impressions and xrays off to invisalign and they decided on what was to be done. I had assumed there was only one way of doing things regardless of the orthodontist. So (out of interest) If i saw a different professional is it possible my teeth would be moved in a different way and have different results?

[MCOMarkhamOrthodontist]

That is interesting to know. I was very much under the impression my orthodontist just sent my impressions and xrays off to invisalign and they decided on what was to be done. I had assumed there was only one way of doing things regardless of the orthodontist. So (out of interest) If i saw a different professional is it possible my teeth would be moved in a different way and have different results?

In many cases, the doctors do send off all the materials and Invisalign decides what is to be done. This is usually done by inexperienced doctors and patients often end up with poor Invisalign results since Invisalign doesn't use doctors to figure out how to move the teeth. They employee animation technicians who move the teeth to straighten them, but without regard for biology, physics, or orthodontics!

Invisalign is just another way to fix bites and straighten teeth. You still need an orthodontist or dentist to know how to diagnose, plan, and treat you. Therefore, just as with braces, your treatment would vary from doctor to doctor.

[Stephanie]

this is a great post and all the reason why to shop around for a good doctor

[chaudi]

"They employee animation technicians who move the teeth to straighten them, but without regard for biology, physics, or orthodontics!"

sorry i find that hard to believe.

I believe that is reviewed by a teem of orthodontist who have years of data and a computer to help decide the movements to use with invisalgn. In otherwords, some has had my exact same problem and they now after years of trail and error what will be the results. Obviously a computer plays a big part. However you maybe right when it comes to extractions and more complex case.

should mention i only had 8 on top and 16 on the bottom.

[MCOMarkhamOrthodontist]

I have been fortunate enough to have an inside look at the tech plant in Costa Rica, met my technicians, team leader, and supervising dentist, not an orthodontist. I am unable to reveal too many details of the trip, since I signed a confidentiality agreement to be allowed access to the site.

Most cases are not reviewed by a dentist at all, unless the tech has any questions. The training for a tech is on how to use the software. There are several basic steps, but they involve use of software, not biology or physics. Don't get me wrong... they are extremely hard-working and nice people, but without orthodontic training.

The software is not "intelligent" enough to detect movements that will not occur in the mouth. If it were so, there would not be so many clinical training sessions required for Invisalign providers. There would also be no variation on the ClinChecks I receive when my dedicated technician is on holidays. They would be uniform and not require revisions. However, this is not the case. I simply need to run the simulation to know that someone else has done the ClinCheck simulation, meaning there is significant human input. Still, with my own tech, I send several revisions to determine exactly how I would like to move the teeth.

View Invisalign as an appliance just like braces or an expander. There may be a day when Invisalign as a company can automate treatment without an orthodontist, but that day is not yet here, and probably will not be for several years to come.

[mommamorin]

very interesting Dr. Tam, it must have been an exciting experience for you as an orthodontist.
So the tech plant is in Costa Rica? that is interesting too.....
thanks for the info

[leevshan]

Thank you Dr. Tam...
Wow, this is very interesting...

After a doctor got his Invisalign Certificate, isn't he then 'qualified' ?
I thought at Align Tech, they are being monitored by the Invisalign founder, as the founder may know what can be treated and what can't with Invisalign, before they approve and make the aligners.

Don't you actually have to meet certain requirements to get Invisalign Certificate? Say, you have to get a Master degree in orthodontics, or perform/display a satisfactory understanding in tooth movement, etc to Invisalign representatives?

If a general dentist also can get Invisalign Certificate, I think it's rather scary, as they're not trained with tooth movement,etc as orthos are. And if should Invisalign treatment failed, it will have negative perception on Invisalign, I think.

[MCOMarkhamOrthodontist]

The founders of Invisalign were two MBA students from Stanford, not orthodontists. Align is a public company traded on the NYSE. Their job is to drive the share price up, unfortunately.

Any dentist can get "Invisalign Certification". This certification is simply a one day course in what materials you need to send to Align, and how to use the tooth simulator program. There is no instruction at moving teeth. Therefore, despite being and orthodontist or dentist, this is a poor marker of Invisalign knowledge and experience.

Invisalign treatment doesn't fail. Treatments do not come out properly due to poor planning by the doctor or due to poor patient compliance. When was the last time an orthodontist blamed a brace for failed treatment? Due to these issues, Align has implemented "proficiency requirements", but these simply show a doctor's volume of Invisalign patients rather than skill.

Momma, it was a great experience in Costa Rica and I'm looking forward to go back at some point as well. To get an inside look at the company was great. It reinforces the notion that the Invisalign is a technique, not a product . I made a blog post about this a while back:
Markham Centre Orthodontics: Your Markham Orthodontist and Richmond Hill Braces at Work and At Play: Toronto Invisalign Braces Specialist Provides Trip Report from Costa Rica Study Club

[dhodgson21]

Dr Tam,

I have been an invisalign patient for almost a year and have about 6-9months left. I have had no problems thusfar and things seem to be going well with the treatment. However, a few weeks ago, I had to pick up and move out of state. Now, I am forced to transfer the treatment to another doctor. I saw the post above regarding the transfer and had a few more questions. Are there professional guidelines for how much of my initial upfront-payment should be transferred to the new doctor? If my previous doctor absolutely refuses to give up anything, what are my options at that point(which is where I am at right now)? In the accounting world, which is my profession, revenue sits on the doctors books as a prepaid until the service obligation is performed and thus earned. The initial payment can be amoritized to revenue as it is earned over the service or treatment period. I would think the unearned portion should be transferred to the new doctor, but that is just from the accounting viewpoint. What are the professional guidelines from your perspective?


Dave

[MCOMarkhamOrthodontist]

I decided to put together this video to help potential Invisalign patients understand why Invisalign should be viewed as a technique not a product... Hope it helps!

YouTube - What Can Toronto Invisalign Correct?

[rapidfire7]

Patients are allowed to change doctors mid-treatment, just as someone with braces may switch. However, remember that the contract is one between you and the doctor, not you and Align Tech. Align can facilitate the transfer of your file to another orthodontist, but you will have to reach any financial agreements with your existing and new doctor on your own.

When patients transfer in with braces, it is often necessary to replace them in order to continue. With Invisalign, it is likely necessary to take a new impression to "reboot".

Of note, if Invisalign were simply a product and not a technique, it wouldn't be necessary to have regular visits to monitor treatment. Unfortunately, experienced Invisalign providers only make up a small percentage of those certified. This will change drastically with the new proficiency requirements.

Thanks for the kind words and good luck .

Thanks for that information. As I mentioned some things are not going too well with my current provider and I am considering moving to someone else if possible. I have paid for all my trays up to this point so I don't have any further financial obligations. I am aware I would have to pay consultation fees and the like to my new provider but my question is if I have already paid for a course of Invisalign treatment would I have to pay any additional costs to align if I switched providers and needed a new impression "reboot" (As you say) with my new provider? Would this just be considered a mid course correction and be included in what I have already paid?

[MCOMarkhamOrthodontist]

I have paid for all my trays up to this point so I don't have any further financial obligations. I am aware I would have to pay consultation fees and the like to my new provider but my question is if I have already paid for a course of Invisalign treatment would I have to pay any additional costs to align

Your lab fee for Invisalign is a contract between Align and your doctor. Your contract with your doctor is for orthodontic treatment using Invisalign, and not one with Align. Align allows for a certain number of mid-course correction and refinement per patient, but your contract with your doctor may not include them.

There are no fees for you to pay Align to transfer doctors. However, you may have to pay your current doc a records transfer fee, and you may have varying success in receiving some of your payment back if treatment is indeed not complete. Furthermore, you have paid for Invisalign treatment with your current doc, not with any new potential doctor. If you see an new doctor, they will have to be compensated for their time and expertise in the management of your malocclusion.

This emphasizes the importance viewing Invisalign as a technique, rather than as a product, as well as the need to choose an experienced orthodontist who has shown proven successes with Invisalign, rather than basing treatment decisions on cost alone. Good luck!

[rapidfire7]

This emphasizes the importance viewing Invisalign as a technique, rather than as a product, as well as the need to choose an experienced orthodontist who has shown proven successes with Invisalign, rather than basing treatment decisions on cost alone. Good luck!

Thanks for that information. It seems quite complicated to change providers but I am going to get an opinion atleast from someone else as to how my treatment is going as I don't have any faith with my current provider.

I feel really unhappy and conned as I really wanted to get Invisalign treatment with an experienced orthodontist and not a dentist but I found it very difficult to determine who was what on the UK invislalign website. It doesn't say what they are unlike the Australian Invisalign site! When I looked closer at my providers website it still didn't say if he was a dentist or an orthodontist. When I asked him at my consultation if he was a dentist or an orthodontist he told me 'Orthodontist' and I had no reason to think otherwise at the time. Later after having suspicions and conducting further research I now know for a fact that he is just a costmetic dentist! I even checked with the British Orthodontic Society!

Other things are just adding up how dodgy this guy is. There are lots of complaints over the internet regarding the Q Clinic and how unhappy those who have been treated there are. If you type 'Q clinic complaints' into google it's disturbing. Also he has apparently completed 2000 cases (Twice as many as anyone else in the world) yet he has no before/after pictures. The price he is offering was incredibly low compared to others places I looked into and the treatment time is a lot less than others I got quotes from. He told me initally that my treatment would take 8-10 months which has since turned out to be 6 where as the first guy I went to see said 14-16 months! How can there be such a discrepency?

How can you trust a guy who has blatantly lied to your face about his qualications?

[Stellina]

In my case, I am very happy with my results so far.. I have to confess I didn't do so much of a research and after the first consultation with a Cosmetic dentist that apparently is quite famous around UK (I didn't know this..!) I made up my mind and decide to go for it as he seemed very professional and had been working with Invisalign for more than 6 years.. I don't have many regular check ups but that works for me as I am working full time and sometimes it is difficult to go and make time to go their office.. and also he is a very busy man and the appointments usually don't last more than 15min. So far so good as I said, I am in the middle of the treatment, it costed me a bit less than what I am reading here and they have all my confidence.. And I agree that Invisalign is a technique more than a product, as if it is not supervised by a good professional it can go very wrong...

[mal]

id say pick a great orthodontist who offers invisalign. dont just pick and orthodontist because of invisalign.

look at their previous work and how much experience they have as well as any other extra qualifications and things of that nature. research them online and see if people have left any comments on them, positive or negative.

pick a great orthodontist first. then pick the course of treatment (invisalign or fixed braces) second.

[MCOMarkhamOrthodontist]

id say pick a great orthodontist who offers invisalign. dont just pick and orthodontist because of invisalign.

look at their previous work and how much experience they have as well as any other extra qualifications and things of that nature. research them online and see if people have left any comments on them, positive or negative.

pick a great orthodontist first. then pick the course of treatment (invisalign or fixed braces) second.

I just returned from giving 3 lectures for Align Technology teaching doctors how to move teeth using Invisalign. While I would agree with the general line of choosing an orthodontist and choosing the right treatment plan first, there are some amazing orthodontists who used fixed braces who may not have the same experience level with Invisalign, and vice versa.

As an orthodontist, I feel the best way of approaching patients is to describe the types of changes we would like to see with orthodontic treatment, and then describe the methods by which we can achieve these changes. Sometimes the problems will be corrected with Invisalign, sometimes using Invisalign with a combo of fixed buttons/braces/elastics, and other times fixed orthodontics may be the best option. Of course, each doctor will be able to correct varying levels of malocclusions with aligners depending on their expertise with Invisalign, as we are working with a technique, not a product .

[MCOMarkhamOrthodontist]

Just returned from Las Vegas attending the Invisalign Summit for Orthodontists with my team. I heard one line in a presentation that I thought was fantastic. It has to do with how a video simulation that makes your teeth look good means virtually nothing.

The line is "the teeth didn't see the video". In other words, they will only move where they have been asked to move by the doctor. The proper use of IPR, attachments, auxiliaries such as button/elastics/partial braces, and order of movements is required to get the teeth to move where the orthodontist has asked them to move. As a simple example, if a tooth is shown to extrude 2mm in the video, there will be certain things the doctor has to do to get it to move properly. The tooth doesn't know where it is supposed to move...

Hope this helps further drive the point home about Invisalign as a technique rather than a product.

[Jensen]

An orthodont told me that Invisalign can move teeth with up to 3-4 mm. I wonder:
1. Why only 3-4 mm. Is it not possible to wear Invisalign some longer time and so move the teeth as much as needed?
2. You say the Invisaling can extrude a tooth with 2 mm. What about a 3mm extrusion which I guess is achieved with attachments? Is there a maximum for how much a tooth can be extruded and what is this maximum?