5 Clear Advantages of Aligners by Dr. Jonathan Nicozisis

Categories: Orthodontics;
Orthotown Magazine 

The ministry of a silly orthodontic appliance

by Dr. Jonathan Nicozisis

In their early history in orthodontics, aligners were the Rodney Dangerfield of orthodontic appliances: They got no respect, because of their perceived limited clinical applicability.

Echoes of this perspective persist today, with detractors eschewing aligners and challenging their legitimacy. Often, research findings assign a percentage of predictability to create science that best quantifies how what we see on a computer screen is expressed clinically. More so, profound statements and conclusions are made after treatment with a single series of aligners, as if a single activation of fixed appliances always does the trick. Detractors run through the halls of orthodontic social media proclaiming these headlines as scientific proof and insinuating that anyone who uses aligners with their patients must be practicing with subpar standards.

Perhaps this is out of fear and loathing of the general perception created by aligners that orthodontics is easy to do and anyone can do it. Perhaps it is the corporate influence from aligner companies that is the proverbial “tail that wags the dog,” and orthodontists don’t like feeling like a canine. But after nearly a quarter-century, aligners’ impact and penetration are undeniable.

Much like the bloke in the Monty Python skit “Ministry of Silly Walks” who wishes to apply for a government grant to help him develop his silly walk, doctors in private practice and academia no longer feel silly for investing in manufacturing equipment for in-house aligners, or applying for grants to investigate this “silly” appliance to help legitimize their teaching position or attempt to stay relevant in their twilight years. (Why does academia not innovate, leaving a void for others to do so? But I digress; that’s another discussion for another time.)

At the 2018 AAO, orthodontic silliness was at its fervent peak when many vendors, 3D-printer companies and software solutions for tooth movement all clamored for attention. Why was that? Patient demand? Practice and clinical efficiencies? Both? Or was it simply the notion that many patents had finally expired and they wanted in on the silliness?

While some orthodontists may still consider aligners silly, what’s not silly are some efficient qualities aligners offer that are unparalleled by traditional fixed appliances. I have been tasked for this article with discussing my top five aligner efficiencies.

1. Aligners are the ultimate of a continuous force system.

Aligners are a customized appliance whose force system is continuous to the end of each set of aligners, whereas traditional braces (customized or stock) need frequent adjustments to reset or recharge force systems with new wires, springs, power chains or other activations. More so, aligners have the better ability to isolate movements during treatment to best move desired teeth—and more importantly, not to move certain teeth—during different times of treatment.

Aligners are also a self-contained force system, with deliberate and precise movements lacking the orthodontic entropy of unwanted or undesirable side effects often experienced with fixed appliances. Think of multiloop edgewise archwire (MEAW) mechanics to alter and upright teeth along the occlusal planes to help close an anterior open bite malocclusion: Vertical elastic auxiliaries are needed in the anterior to transfer the intrusive forces to the posterior dentition. If elastics are not worn with MEAW wires, the uncontained force system allows the movement to be expressed at both the anterior and posterior ends of the wire and the open bite worsens quickly. In this sense, fixed appliances are not limited nor limiting with their activations.

With aligner MEAW mechanics, intrusive forces are limiting with each stage and limited to the posterior dentition, with nary an undesirable side effect on the anterior teeth worsening the open bite despite not using anterior vertical elastics. So being both a continuous force system without the need to be recharged within each series of aligners, and a limiting and limited force system within each aligner, makes aligners superlative in efficiency when compared with fixed appliances.

2. Aligner companies are most efficient at driving public awareness about orthodontics.

While I love and support the AAO, and always will, it is a simple fact that aligner companies spend the most on marketing each year to make crooked teeth top of mind for adults and teens. How we as orthodontists decide to engage this public awareness—to make it our own, to our great benefit—and educate people on the need for a doctor-directed exam, diagnosis and treatment is up to us. Each month, I consistently experience the benefit of new exams being driven to my office via these marketing campaigns, leading to conversion of new starts. I am grateful for these marketing campaigns, which increase my accounts receivable each month! As of now, bracket companies do not do this for our practices, but I’m hopeful this will change.

3.Deep-bite treatments can be done without the need to bond artificial bite openers. (See Case Study 1)

Everything works and, as we know, there are many different approaches to treat a single case. One of the efficiencies I have enjoyed with aligners is treating dentoalveolar deep-bite cases with virtual bite ramps whose position changes to optimize their effects as treatment progresses. There is no need to physically bond anything to the teeth that may be uncomfortable for adults or create an emergency visit from bond failure.

Furthermore, aligners create an efficiency by allowing an orthodontist to start both arches simultaneously, without the need to bond anything to create clearance for lower fixed appliances. Finally, virtual bite ramps have been shown to increase the efficacy of intruding lower anterior teeth, which is advantageous when leveling the lower curve of Spee.

Case Study 1
Sixteen months of treatment in seven office visits (including the initial exam and placing retainers). Virtual bite ramps were used to help level lower curve of Spee, facilitating intrusion of lower incisors that tracked according to planned treatment, as demonstrated by progress tracking software.


Nicozisis_Clear Aligners
Nicozisis_Clear Aligners
Nicozisis_Clear Aligners
Nicozisis_Clear Aligners

Nicozisis_Clear Aligners
Nicozisis_Clear Aligners

4. More patients can be treated using less human labor.

Any good business learns how to do more with less. In today’s labor environment, aligner efficiency is something never envisioned nor appreciated with the advent of aligner therapy years ago.

Twenty-two years ago, when I started practice, we had five full-time-equivalent chairside assistants, working 5½ days a week and starting around 180 new starts a year. Fast-forward to today: Working 4½ days a week with 3½ full-time-equivalent chairside assistants, I am able to start about 450 new cases a year with plenty of schedule capacity to spare for new exams.

With aligner therapy, it is well accepted that the time a patient spends in the dental chair is greatly reduced, as is the number of actual office visits needed to complete treatment. For example, if you start 400 new cases a year and with aligners can see each patient for five to seven fewer appointments to complete treatment, that translates into 2,000–2,800 fewer appointments that need to be scheduled in a year. Of course, these effects on scheduling compound the following year. The net result, ultimately, is increased schedule capacity for new exams (or perhaps time off).

These practice management efficiency qualities are hard to match with fixed appliances. Some consider this a marketing gimmick, but working fewer hours each month while producing more with less staff is a legitimate consequence of aligner orthodontics—and exactly what my work-family life balance has benefited from. Patients also benefit, because they may like you but don’t want to come to your office with any great frequency to complete their treatment.

5. Aligners are second to none at controlling lower incisal position. (See Case Study 2)

My favorite unrivaled efficiency is the total ability to control lower incisor positioning during all types of movements. Whether it is using Class 2 elastics, resolving moderate to severe crowding, or leveling the lower curve of Spee, the ability to move, not move or limit the movement of lower incisors to prevent excessive flaring is something no amount of cinching or tiebacks of wires can do with the same amount of efficacy and efficiency.

Case Study 2
Records demonstrating control of lower incisors: 32 months progress records of all phases of treatment with aligners and a fixed palatal expander. Lower aligners were only used to resolve severe crowding while controlling the lower incisor angle.


Nicozisis Clear Aligners
Nicozisis Clear Aligners
Nicozisis Clear Aligners

Nicozisis Clear Aligners
Nicozisis Clear Aligners
Nicozisis Clear Aligners


These facets of efficiency are only five of many that I have grown to appreciate. Such attributes have my subconscious orthodontic alter ego whispering into my ear, “I can’t do that with braces …” as I review progress and final records of my cases, as well as think about the practice management impact that aligners have had in my 22-year career.

Early in my career, I was undistracted by others’ doubts of aligners’ correctness; rather, I have been most efficient when I decisively apply my orthodontic acumen to this appliance once thought of as silly I have always tried to share my experiences with colleagues via lectures, publications, online interaction in orthodontic social media groups, and a comprehensive online course I co-founded that has educated more than 3,500 orthodontists, residents and faculty globally on aligner orthodontics. Somewhere along this path, I have been labeled with the scarlet letters of “KOL,” so please take everything you just read with grain of pumice sand—because it would be silly not to.

Author Bio
Jonathan Nicozisi
Dr. Jonathan Nicozisis completed his dental education at the University of Pennsylvania before attending Temple University for his orthodontic residency. During his training, he also completed an externship at the Lancaster Cleft Palate Clinic in Lancaster, Pennsylvania, where he was involved with the care of patients with craniofacial syndromes.

Nicozisis is a member of the Angle Society and an Align Technology faculty member. As part of Align Technology’s clinical research network, he has helped conduct research and development of new improvements. He has given more than 400 lectures globally on advanced techniques with the Invisalign system and is the co-founder of The Aligner Intensive Fellowship course.

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