Research Article
Volume 2: 1-4
Journal of Dental Research and Reports
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
ISSN: 2632-0649
Teleorthodontic treatment with clear aligners: An analysis
of outcome in treatment supervised by general practitioners
versus orthodontic specialists
Marc B Ackerman1,2*
1American Teledentistry Association, Wellesley Hills, Massachusetts, USA
2Department of Developmental Biology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
Abstract
e objective of this study was to assess the clinical eectiveness of teleorthodontic treatment with clear aligners on maxillary and mandibular incisor alignment utilizing
the SmileDirectClub® teleorthodontic platform, to objectively measure dierences in clinical eectiveness between treatment supervised by general practitioners
versus orthodontic specialists and to subjectively consider patient satisfaction after the teleorthodontic delivery of clear aligner treatment and the relationship between
satisfaction and whom the treatment was provided by. A sample of 50 patients determined by inclusion and exclusion criteria were randomly selected from an initial
sample of 200 patients. e pre and posttreatment maxillary and mandibular arch stereolithography (STL) les taken from the iTero digital scans were imported into
computer software for measurement. Point to point millimetric measurement of crowding or spacing was measured from the distal of one maxillary or mandibular
lateral incisor to the distal of the opposite lateral incisor on the pre and posttreatment models. Lastly, the subjective measure of patient satisfaction was tabulated
for each patient. General linear models found treatment eectiveness to achieve statistical signicance in the multivariate tests conducted. ere was no statistically
signicant dierence between treatment supervised by general practitioners versus orthodontic specialists. Lastly, Fisher’s exact test determined that there was no
signicant association between satisfaction and who the respondent was treated by.
*Correspondence to: Marc B Ackerman, American Teledentistry Association,
9 Roberts Road, Wellesley Hills, MA, USA, Tel: 1-781-304-4409; E-mail:
admin@americanteledentistry.org
Key words: teledentistry, teleorthodontics, orthodontic treatment, clear aligners,
incisor alignment, orthodontic specialist, general practitioner
Received: May 02, 2019; Accepted: May 13, 2019; Published: May 16, 2019
Introduction
Technologic advancements in the delivery of clinical orthodontic
care have lowered practice overhead, shortened treatment time, and
placed less of a burden on the orthodontist. Most orthodontic practices
can see far more patients per day than ever before. However, in a
recent survey of orthodontists no participant was “too busy” to treat
all persons requesting appointments [1]. Two leading factors that
have created excess capacity in the contemporary orthodontic delivery
model are the high cost of treatment and the burden of a signicant
amount of time away from work or other activities for the patient.
Telemedicine has been employed in various forms for over two
decades. Low acuity (non-serious health problem) patients have been
successfully treated via telemedicine for such medical conditions as
sinusitis and urinary tract infections (UTI). A study found that the
fraction of patients with any follow up for sinusitis or UTIs was the
same between telemedicine and in oce visits [2]. is measure is a
very good proxy for misdiagnosis or treatment failure. Teledentistry
has also been shown to be very safe and eective for low acuity dental
patients [3]. A systematic review examined the accuracy of detecting
tooth decay from photographs versus direct visual inspection of the
patient and found comparable results between both modalities [4]. e
accuracy of direct examination versus teledental examination in the
diagnosis of dental pathology in older adults in nursing homes, a higher
acuity group of patients, has also been investigated. It was found that
teledentistry exams had excellent diagnostic accuracy and were much
quicker than face-to-face exams, 12 minutes versus 20 minutes [5]. A
randomized controlled trial evaluating teledentistry for screening new
patient orthodontic referrals found that teledentistry was a valid system
for positively identifying appropriate new patient orthodontic referrals
[6]. ere is ample evidence in the scientic literature that conrms the
clinical eectiveness of teledentistry and how it increases access to care
for the patient [7-9].
Over 60 percent (1,972) of the counties in the United States do not
have an orthodontist’s oce [10]. e new teleorthodontic delivery
model of clear aligner treatment [11] has the potential to bridge the gap
in this access to care divide. Patients who for many dierent reasons
had been previously denied access to orthodontic care, now have a
viable option for addressing anterior tooth alignment issues and obtain
a detectable improvement in their social smile (Figure 1). ere has
been a great deal of confusion about the denition of teleorthodontics
which has unfortunately negatively inuenced orthodontists, state
dental boards, and the lay public [11]. Teleorthodontics is the delivery
of health information and orthodontic care across distances using
information technology and telecommunications. Teleorthodontics
encompasses diagnosis, treatment, monitoring and prevention,
continuing education of providers and consumers, and research.
Do-it-yourself orthodontics has been used synonymously with both
teleorthodontics treatment with clear aligners [12]. When in fact, do-it-
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 2-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
yourself orthodontics refers to a patient’s self-directed eorts to move
teeth without the supervision of a doctor.
A recent systematic review examined the clinical eectiveness
of in-oce orthodontic treatment with clear aligners provided by
orthodontic specialists [13]. It found that Invisalign® (Santa Clara,
CA) aligners can safely straighten dental arches in terms of aligning
the incisor teeth. ere are several studies in the literature that have
investigated [14,15], the dierences in approach to treatment planning
and usage of the Invisalign system between general practitioners and
orthodontic specialists. However, there have been no studies assessing
the clinical eectiveness of teleorthodontic treatment with clear
aligners. Consequently, there are no studies that have examined the
clinical eectiveness of this teleorthodontic modality with treatment
supervised by general practitioners versus orthodontic specialists.
e aim of this study was threefold:
• to objectively assess the clinical eectiveness of teleorthodontic
treatment with clear aligners on maxillary and mandibular incisor
alignment utilizing the SmileDirectClub® teleorthodontic platform.
• to objectively measure dierences in clinical eectiveness between
treatment supervised by general practitioners versus orthodontic
specialists.
• to subjectively consider patient satisfaction aer the teleorthodontic
treatment with clear aligners and the relationship between
satisfaction and whom the treatment was provided by.
Materials and methods
New England Independent Review Board (NEIRB, Needham, MA)
determined that this research activity (WO-6634) was exempt from
IRB approval under the category of research involving the collection
or study of existing data, documents, records, pathological specimens,
or diagnostic specimens, if the investigator records the information in
such a manner that subjects cannot be identied, directly or through
identiers linked to the subjects. A sample of 200 patients that had been
treated with the SmileDirectClub (Nashville, TN) teleorthodontic
platform from the practices of endorsed local providers (at least 5 years
of experience with Invisalign treatment) who were either general
practitioners or orthodontic specialists was available for study. Patients
had consented to the use of their de-identied records prior to their
treatment by the treating general practitioner or orthodontic specialist.
At the end of treatment, each patient was asked whether or not they
were satised with the treatment rendered in the form of a yes/no
question. e preliminary sample of 200 patients was subjected to the
following inclusion and exclusion criteria:
Inclusion criteria
• Male or Female
• Age 18-45
• Orthodontic problems of anterior tooth crowding no greater than 6
mm and anterior tooth spacing no greater than 6 mm
• Pre and Posttreatment digital photographs and iTero® (San Jose,
CA) intraoral digital scans
Exclusion criteria
1. Missing photographs or intraoral digital scans
2. Poor quality of patient records (photographs and digital tooth
scans)
3. Did not answer the subjective question of “Are you satised with
treatment (Y or N)?”
Aer application of the inclusion/exclusion criteria, 127 patients
were eligible for the study. A power analysis (set at 80%, p < 0.05) was
used to determine the nal sample size. It was concluded that a sample
of 50 patients would have sucient power to detect a meaningful
dierence between groups. Aer randomization of the 127 patients
using Research Randomizer soware [16], a nal sample of 50 patients
was selected.
Pre-treatment intraoral clinical photographs of each patient were
visually reviewed in order to assign their maxillary and mandibular
arches to a group by type-crowding or spacing. Maxillary or mandibular
arches that did not have treatment were not measured. e pre and
posttreatment maxillary and mandibular arch stereolithography (STL)
les taken from the iTero digital scans were imported into Autodesk
MeshmixerTM soware (San Rafael, CA) for measurement [17]. Figure
2 illustrates a study patient from the crowding group. is example
shows point to point millimetric measurement of crowding from the
distal of one lower lateral incisor to the distal of the opposite lateral
incisor on the pre and posttreatment models. ose arches in the
spacing group were measured by the same method. Posttreatment
intraoral clinical photographs of each study patient were visually
reviewed and compared with the treatment outcome seen on the
digital model. Lastly, the subjective measure of patient satisfaction was
tabulated for each patient.
Results and discussion
Table 1 presents the measures of central tendency and variability
associated with the continuous measures of interest included within
this study. Mean and median values were generally found to be very
similar, suggesting normality. Table 2 presents the sample sizes and
A
B
Figure 1. The average study patient who underwent doctor-directed at home clear aligner
treatment. Most consumers who elect to undergo doctor-directed clear aligner treatment are
seeking a detectable improvement in anterior tooth display. A. Pretreatment photograph. B.
Posttreatment photograph.
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 3-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
categorized as either general practitioner or orthodontic specialist,
with type categorized as either crowding or spacing. e GLMs
incorporated as predictors, only who the respondent was treated by
and type. ese reduced models were run originally as the sample size
of 50 respondents meant that the addition of further predictors such
as age or gender would have a substantially greater negative impact
on statistical power as compared with studies incorporating a larger
sample size, thereby resulting in a greater likelihood of Type II error
(the erroneous nding of non-signicance).
e rst GLM conducted, focused upon maxillary treatment,
found only treatment eectiveness to achieve statistical signicance in
the multivariate tests conducted, F (1,37) = 105.39, p < 0.001, partial
eta-squared = .74, observed power = 1.00. Statistical signicance was
not indicated with respect to the interaction between treatment and
who the respondent was treated by, F (1, 37) = 2.98, p > .05, partial
eta-squared = .07, observed power = .39, treatment and maxillary type,
F(1, 37) = .39, p > .05, partial eta-squared = .01, observed power = .09,
or treatment by who the respondent was treated by maxillary type, F(1,
37) = .01, p > .05, partial eta-squared < .01, observed power = .05. With
respect to the tests of between-subjects eects, statistical signicance
was not indicated with regard to who the respondent was treated by,
F(1, 37) = 3.10, p > .05, partial eta-squared = .08, observed power =
.40, maxillary type, F(1, 37) = .57, p > .05, partial eta-squared = .02,
observed power = .11, or the interaction between who the respondent
was treated by maxillary type, F(1, 37) = .01, p > .05, partial eta-squared
< .00, observed power = .05.
e second GLM conducted focused upon mandibular treatment.
is analysis also found only treatment eectiveness to achieve
statistical signicance in the multivariate tests conducted, F (1, 36)
= 42.38, p < .001, partial eta-squared = .54, observed power = 1.00.
Statistical signicance was not indicated with respect to the interaction
between treatment and who the respondent was treated by, F (1, 36) =
Figure 2. Measurement method. A. Pretreatment digital model created from a stereolithography (STL) le derived from an iTeroTM intraoral scan and imported into the Autodesk
MeshmixerTM software. B. The occlusal view of the pretreatment digital model with point to point measurement across the 4 mandibular incisors. C. Posttreatment digital model. D. The
occlusal view of the posttreatment digital model demonstrating resolution of mandibular incisor crowding.
Measure Mean Median SD Range Min Max
Age 30.04 30.00 5.86 24.00 18.00 42.00
Maxillary T0 (mm) 2.73 2.28 1.66 5.00 1.00 6.00
MaxillaryT1 (mm) .08 .00 .26 1.14 .00 1.14
Mandibular T0 (mm) 2.43 1.83 1.56 5.45 .55 6.00
Mandibular T1 (mm) .20 .00 .41 1.68 .00 1.68
Months in Treatment 5.54 5.50 .86 5.00 3.00 8.00
Table 1. Descriptive Statistics: Continuous Measures
Measure N %
Gender
Female 32 64%
Male 18 36%
Treatment
GP 30 60%
Ortho 20 40%
Maxillary Type
Crowding 24 58.54%
Spacing 17 41.46%
Mandibular Type
Crowding 35 87.50%
Spacing 5 12.50%
Satisfaction
No 4 8%
Yes 46 92%
Table 2. Descriptive Statistics: Categorical Measures
frequencies of response with respect to the categorical measures of
interest included within this study.
A series of general linear models (GLMs) using SPSS soware
(IBM, Armonk, NY) were conducted in order to examine treatment
eectiveness measured in millimetres and the impact of who the
respondent was treated by. Who the respondent was treated by was
Ackerman MB (2019) Teleorthodontic treatment with clear aligners: An analysis of outcome in treatment supervised by general practitioners versus orthodontic
specialists
Volume 2: 4-4
J Dent Res Rep, 2019 doi: 10.15761/JDRR.1000114
.78, p > .05, partial eta-squared = .02, observed power = .14, treatment
and mandibular type, F(1, 36) = 2.24, p > .05, partial eta-squared = .06,
observed power = .31, or treatment by who the respondent was treated
by mandibular type, F(1, 36) = 1.95, p > .05, partial eta-squared = .05,
observed power = .28. With respect to the tests of between-subjects
eects, statistical signicance was not indicated with regard to who the
respondent was treated by, F(1, 36) = .63, p > .05, partial eta-squared
= .02, observed power = .12, mandibular type, F(1, 36) = .54, p > .05,
partial eta-squared = .02, observed power = .11, or the interaction
between who the respondent was treated by mandibular type, F(1, 36)
= 1.02, p > .05, partial eta-squared = .03, observed power = .17. Fisher’s
exact test was conducted to determine whether there was a signicant
association between satisfaction and who the respondent was treated
by. No signicant association was indicated, p > .05.
Today, the goal of all orthodontic treatment is the enhancement
of a patient’s smile thereby increasing their opportunities for
education, employment, and even marriage [17,18]. rough the
use of information technology and the digital health record, dentists
are able to utilize teledentistry to diagnose, treatment plan, render
treatment and monitor the treatment progress of patients. Access to
in oce orthodontic treatment with clear aligners for anterior tooth
alignment problems has been cost prohibitive for a large segment of
the population. As well, this same population group does not have the
luxury to take time away from work or childcare to visit a traditional
orthodontic oce for treatment.
e teleorthodontic treatment modality examined in this
study costs 40% less for the patient than the cost of similar in oce
orthodontic treatment. is has signicantly increased access to care
since its introduction nearly 5 years ago. e results of the study suggest
that both general practitioners and orthodontic specialists are equally
successful at rendering clinically eective teleorthodontic treatment.
From an access to care standpoint, this means that the amount of
competent dental professionals who can supervise teleorthodontic
treatment is exponentially larger and over the next 5 years those
patients in geographic areas that do not have orthodontic oces can
receive treatment. Although teleorthodontics is in its infancy, the speed
with which technology has been improving would indicate that it is
only a matter of time before a greater breadth of orthodontic problems
will be able to be treated with this modality.
Conclusion
Study data suggest that teleorthodontic treatment with clear aligners
is clinically eective in the correction of maxillary and mandibular
incisor alignment problems (crowding or spacing) less than 6 mm.
ere appears to be no dierence in clinical eectiveness between
teleorthodontic treatment with clear aligners supervised by general
practitioners versus orthodontic specialists. Patient satisfaction aer
teleorthodontic treatment with clear aligners seems to be unrelated
to who provided the treatment, general practitioner or orthodontic
specialist.
Conict of Interests
e author declares that there is no conict of interest regarding
the publication of this paper.
Acknowledgements
e author would like to thank Dr. David Kremelberg, DK Statistical
Consulting, Inc. for his help with statistical analysis. is project was
entirely sponsored by the American Teledentistry Association and all
costs related to IRB approval and statistical consulting were paid for by
the American Teledentistry Association. e Author has no conict
of interests.
References
1. Keim RG, Gottlieb EL, Vogels DS, Vogels PB (2015) 2015 JCO orthodontic practice
study: Part 1 trends. J Clin Orthod 49: 625-639. [Crossref]
2. Mehrotra A, Paone S, Martich GD, Albert SM, Shevchik GJ (2013) A comparison of
care at e-visits and physician oce visits for sinusitis and urinary tract infection. JAMA
Intern Med 173: 72-74. [Crossref]
3. Namakian M, Subar P, Glassman P, Quade R, Harrington M (2012) In-Person versus
“virtual” dental examination: Congruence between decision-making modalities. J Calif
Dent Assoc 40: 587-95. [Crossref]
4. Meurer MI, Caery LJ, Bradford NK, Smith AC (2015) Accuracy of dental images
for the diagnosis of dental caries and enamel defects in children and adolescents: A
systematic review. J Telemed Telecare 2: 449-458. [Crossref]
5. Queyroux A, Saricassapian B, Herzog D, Muller K, Herafa I, et al. (2017) Accuracy
of teledentistry for diagnosis dental pathology using direct examination as a gold
standard: Results of teledent study of older adults living in nursing homes. J Am Med
Dir Assoc 18: 528-532. [Crossref]
6. Mandall NA, O’Brien KD, Brady J, Worthington HV, Harvey L (2005) Teledentistry
for screening new patient orthodontic referrals. Part 1: A randomized controlled trial.
Br Dent J 199: 659-662. [Crossref]
7. Irving M, Stewart R, Spallek H, Blinkhorn A (2018) Using teledentistry in clinical
practice, an enabler to improve access to oral health care: a qualitative systematic
review. J Telemed Telecare 24: 129-146. [Crossref]
8. Estai M, Kanagasingam Y, Tennant M, Bunt S (2018) A systematic review of the
research evidence for the benets of teledentistry. J Telemed Telecare 24: 147-156.
[Crossref]
9. Daniel SJ, Kumar S (2014) Teledentistry: a key component in access to care. J Evid
Based Dent Pract 14 Suppl: 201-208. [Crossref]
10. National Plan and Provider Enumeration System (NPPES). Research report.
Washington, D.C.: U.S. Department of Health and Human Services Centers for
Medicare and Medicaid Services; 2017.
11. Kravitz ND, Burris B, Butler D, Dabney CW (2016) Teledentistry, do-it-yourself
orthodontics and remote treatment monitoring. J Clin Orthod 50: 718-726. [Crossref]
12. American Association of Orthodontists Consumer Alert. Retrieved on December 10,
2018. Available from: http://www.marketwired.com/press-release/consumer-alert-
risks-involved-with-do-it-yourself-teeth-straightening-products-1988020.htm.
13. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D (2018) Clinical eectiveness
of Invisalign® orthodontic treatment: a systematic review. Prog Orthod 19: 37.
[Crossref]
14. Vicens J, Russo A (2010) Comparative use of Invisalign by orthodontists and general
practitioners. Angle Orthod 80: 425-434. [Crossref]
15. Best AD, Shro B, Carrico CK, Lindauer SJ (2017) Treatment management between
orthodontists and general practitioners performing clear aligner therapy. Angle Orthod
87: 432-439. [Crossref]
16. Urbaniak GC, Plous S. Research Randomizer computer software (Version 4.0).
Available from: http://www.randomizer.org
17. Ackerman MB. Enhancement Orthodontics: Theory and Practice. Ames: Blackwell
Publishing; 2007.
18. Ackerman M, Burris B. Straighter: The Rules of Orthodontics. Orlando: Ackerman &
Burris Publishing; 2018.
Copyright: ©2019 Ackerman MB. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
