READERS’ FORUM
Letters to the editor*
Invisalign material studies
I read with interest the comments in Editor’s Choice in
the November issue of the AJO-DO regarding the 2-part
article on activation time and stiffness of removable appli-
ances (Bollen A-M, Huang G, King G, Hujoel P, Ma T.
Activation time and material stiffness of sequential remov-
able orthodontic appliances. Part 1: Ability to complete
treatment. Am J Orthod Dentofacial Orthop 2003;124:496-
501; and Clements KM, Bollen A-M, Huang G, King G,
Hujoel P, Ma T. Activation time and material stiffness of
sequential removable orthodontic appliances. Part 2: Dental
improvements. Am J Orthod Dentofacial Orthop 2003;124:
502-8). I read both parts of the article as well, but I feel as if
I read an entirely different pair of articles.
First, you should know that I am on Align Technology’s
Academic Advisory Board and am involved with research
with the company. Those who know me can attest that I speak
my mind and that my ethical standards are high and can’t be
bought by any company. I have no financial stake in Align,
and my only interest is in the improvement of an orthodontic
appliance and its methods for treating patients. My involve-
ment with Align has allowed me to learn what the appliance
can and cannot do; more importantly, it has allowed me to
give the company input from my research and clinical
practice on how to improve the appliance for use in patients.
A statement in the second paragraph of the Editor’s
Choice comment, “Although the materials tested in this
long-term study differ from those currently used by Invis-
align,” is of utmost importance to the conclusions of the
article and how they are applied to our current clinical
practice. This article was on research and development of
materials under consideration by the company to determine
their effectiveness. Instead of just sending their product
directly to market, Align conducted a clinical trial to look at
outcomes on complicated premolar extraction cases. As a
result of this trial, these materials are not used, and premolar
extraction cases remain difficult to treat.
Unfortunately, many orthodontic products are sent to
market without sufficient clinical trials, and, as a result,
practitioners are often frustrated by the differences between
the promises or claims and the outcomes. I can clearly
remember ceramic brackets hitting the market and all the
initial problems that occurred. Many of those problems would
have been avoided by good clinical research.
Because the article in question reports research of materials
not offered commercially by Align, the statements in the last
paragraph of the Editor’s Choice piece are invalid and mislead-
ing. The materials reported have no relationship to what is
currently being used with the Invisalign appliance. It is like
comparing a prototype computer from the 1970s with what is
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
American Journal of Orthodontics and Dentofacial Orthopedics /March 2004
available today. If one had used a 1970s computer for complex
mathematical equations, one might have concluded that there
were too many difficulties associated with the process; then,
what would we have today? Research and development are
crucial to overcoming the obstacles. But research must be
viewed in the context of its intended scope or objectives and in
its historical place in the development of a product.
Having said that, I will give you some unsolicited opinions
concerning treatment with the Invisalign appliance to date. It is
not for every patient, and the technique is not easy. One must
learn how to work with the appliance, just as with any other
orthodontic appliance. The Invisalign appliance is good for
incisor alignment, anterior and posterior crossbites, opening
deep bites, controlling anterior open bites or shallow overbites,
and controlling periodontally involved patients. At this time, I
generally do not use it for my private patients for premolar
extractions, extrusions, and uprighting tipped teeth. There are, of
course, exceptions, and that is why I say “generally.”
One needs to understand that Invisalign is only an
appliance, and the technique for working with it is continually
being developed and honed. Refinement, adjustment at each
appointment, and rebooting are all part of the technique, and
all depend on the orthodontist’s skill—just as with a patient in
any fixed appliance. I can’t think of a patient that I treated
with any technique who did not need the knowledge of an
orthodontist to complete. Invisalign is no different.
We will submit several articles over the next few months,
but one of the most interesting findings from our clinical trial
involved the periodontal tissues. As part of the trial, we mea-
sured the response of the periodontal tissues with the papillary
bleeding and pocket depth scores and found that these measures
improved during treatment—not just after treatment as they do
with fixed appliances. This is only 1 of several findings that we
hope will be of interest to the orthodontic community.
Timothy T. Wheeler, DMD, PhD
Gainesville, Fla
0889-5406/$30.00
doi:10.1016/j.ajodo.2004.01.010
Enhanced learning through ARS
I read with great interest the recent editorial (Turpin DL.
Enhance learning with an audience response system. Am J
Orthod Dentofacial Orthop 2003;124:607) on enhancing
learning with an audience response system. This system
certainly has great potential for boosting the active (learning)
involvement at meetings and CME for any scientific gather-
ing. Quantum leaps in information technology have already
created the inexpensive practicability of its use for large
audiences, and it is thoughtful of you to write an editorial on
this system, with supporting data from the PCSO meeting,
where it proved to be so successful.
Having seen somewhat similar techniques used in
some TV debates, I had often fancied something like this
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