How to Avoid Clear Aligner Attachment Disorder

Look closely, put on your loops and say, all right, this attachment's not doing great, the aligner's not tracking over it, but it could be because there's a ton of flash or a clunk of it's missing, or sometimes bad composite, and it looks okay at the beginning, but as you take the tray on and off our tray multiple times a day, it starts to wear, so now the tray doesn't deliver the force of the right vector. Welcome to the Phil Klein Dental Podcast. In today's episode, we're focusing on one of the most critical and often overlooked elements of clear aligner therapy, and that is clear aligner attachments. But before we dive into the technical details, we'll step back and compare the pros and cons of clear aligner therapy versus traditional orthodontics. We'll hear from our expert, Dr. Farod Hakim, on how to communicate with the patient so that they say yes to clear aligner therapy. From there, we'll zoom in on clear aligner attachments. those small but powerful composite additions that are bonded to the teeth that can make or break treatment success. We'll also talk through common pain points in aligner therapy, including issues with attachments failing or aligners not tracking properly. And we'll also explore the use of a high-quality composite resin designed specifically for fabricating attachments using the clear aligner template. So if you've ever dealt with aligners that don't seat, patients who fall behind in treatment, or cases that just aren't tracking as planned, we've got some troubleshooting tips you won't want to miss. Our guest today is Dr. Farouk Hakim. He has maintained a private practice for over 30 years, is a sought-after key opinion leader and speaker, and is a highly respected consultant for new product evaluation and development. He's also a frequent contributor on VivaLearning.com. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Hakim, it's a pleasure to have you on the show. Phil, it's great to be here. I love our conversations every year. Yeah, it seems like time is going by so fast because we do these like once a year. But when I see my schedule and I see Dr. Hakim is on the schedule here, it's like, did a year go by? It's just that scary. So to begin this podcast, tell us, Dr. Hakim, a little bit about the history of clear aligners. When did it start? And how did it become so predominant in orthodontic treatment today? If you go back to 1998, the ortho world was kind of turned on its ear. That is when the FDA approved the first clear aligner system, which is Invisalign. By the following year in 99, the first few cases were sold to market and docs were up and running. Before you knew it, orthodontists and GPs alike were starting to do clear aligners and it very quickly gained traction. And what's really interesting is, and I did a little research on this, clear aligners... I don't know if they were clear, but aligners through removable appliances actually started in 1945 by a dentist. And of course, it wasn't a mass produced item. He made successive removable appliances. And when you think about it, it took a little over 50 years for a company to take advantage of this concept. And that was aligned technology. So it's quite a story. And it's amazing how dentists of the past thought of these things. and thought out of the box. And actually within their means, they created these devices to help move teeth without wires. Very, very interesting. So what's the prevalence of clear aligners in dentistry, specifically the GP office? Yeah, like we were talking about, if we look at the 2019 study or report, it looks like in the range of 50% of GPs are using clear aligners for treatment. They're doing... Ortho in their office and nearly half of them were using clear aligners, either completely or in combination with traditional ortho wires and brackets. That's six years ago. I know that it's only growing. And the proof of that is that as of 2024, the estimation was that there was $8.4 billion is what made up the clear aligner market. And we know it's only going to grow because the median estimate is that it's going to be a $25 billion market by 33. So this is exploding everywhere, globally, not just the US. So when you say $25 billion market, are you talking about the services rendered to the patient or the manufacturer's sales to the dental professionals? I think that's related to the opportunity for the manufacturers, how big that market is, how many cases they sell to all the deliveries. Yeah. So the information that I got before this podcast episode was that approximately 52% of GPs provide ortho treatment. So 48% don't provide ortho treatment at all. And of those 52%, like you said, 45% or a little more than 45% are actually using clear aligners. So basically half the GPs that are offering orthodontic treatment are using clear aligners as their solution. And I assume if the case is very complex, They just obviously would refer to an orthodontist that would eventually go to wire, I would assume, right? Correct. And this is like anything else that people learn initially. Early on, the folks that label themselves early adopters that behave that way tiptoed into the waters. Many people, this is when it first came out, were kind of hands off and said, yeah, I don't want to tread onto my... orthodontist turf. I wasn't trained for this. As there was more education, more information released, as people started to see, okay, a colleague down the hall is starting to do it, people let down their guard a little bit, especially when generalists have an orthodontic ally, somebody that can help them a little bit and give them the reassurance. And fast forward 20 years later, like you said, a big volume of people are doing this. And it's only going to grow. I think it belongs in most every contemporary practice for a number of reasons. Yeah. Now, do you think one of those reasons is that it can lead to conservative, minimally invasive dentistry by moving the teeth first and then doing the cosmetic work later versus an extreme contrast to that being in the past where teeth were massively drilled down and overprepared in order to obviate the need for minor orthodontic treatment? A hundred percent. That's what every generalist that does cases involving more than single tooth restorative dentistry can attest to is when we historically told an adult that maybe had ortho as a youngster and remembers they didn't love it, having wires and headgear, what have you, or maybe never had it. So their teeth are not even remotely in the condition that you'd like them to be or the position you'd like them to be. When we recommend or even insist on ortho before we did any prosthetic work, a very small percentage would say yes. They're busy with their lives, social aspects, the stigma, not wanting to see railroad tracks on their teeth. And so I was lucky if I get 10% of my patients that I would say, hey, your case will really go a lot better. Get them to accept it and go see an orthodontist. When suddenly they're able to do it in the office they're used to coming to in a way that's cosmetically not as offensive. These are clear liners. You know, you have to look close and you see people wearing them. They're very acceptable. They can take them out to eat. They don't have spinach stuck between their braces. They can brush and floss and keep things healthy. Suddenly now, I would say when I recommend it strictly for the sake of pre-prosthetic ortho, I'm having somewhere in the neighborhood of 60% say yes when they really see the value. So a tremendous jump there. In addition to often patients are doing this, whether it's preceding cosmetic dentistry or that is the cosmetics, maybe a little bleaching and the aligner therapy, they're getting their dessert and it's easy for them to see the benefit of that. I'm able to articulate the vegetables they're getting as well with it, meaning when your teeth. in better position, you can keep them cleaner, leads to better long-term perio health, better wear, and then talk about the whole systemic link to whole body health and perio health as we age. So there's just so many win-wins. It's easy conversations to have with patients. Let's talk about the pros and cons. And there's a lot of pros. You covered some of those, but give us the real compelling reasons why GPs that are not... involved with clear aligner therapy. And it doesn't have to be with align technology. There's other options that they can go with. Yeah, from the practice perspective, it's obviously a production source, an income source. And when it's an income source that actually makes your patients healthier, improve self-esteem, they like their cosmetics, then it's really a win-win, not to mention the health benefits. You know, more appropriately guided occlusion, better teeth setups. less drilling if we are doing restorative work after the fact, better perio health. So those are the wins. You can make money, you can make people healthier. And that's one of, that's probably the primary reason a lot of people are doing dentistry is they have to make a living at it. And also they want to improve people's lives. So that's an obvious pro. When you can do it without the treatment time being extensive or offensive in the sense of what they look like while they're in braces versus clear liners, then It's an easy choice for patients. I'm going to read a few of the things that I picked up just by reading some articles before this episode. Number one, aesthetics. That's a big advantage. Removability, so they could take it out and floss and maintain their brushing habits and they can eat without them. Comfort is another one. Fewer office visits, which you mentioned. Also, another big one is digital planning. using obviously 3D imaging, and that makes for more predictable movement and patient visualization of the outcome. So digital planning is a big one. And then this was interesting, shorter treatment for mild cases. Do you find that as well? 100%. Every time I do a, whatever it is, a mild case, a moderate case, or an extensive case, I have a great relationship with that orthodontist. I will send them photos and models. And I say, by the way, this patient's doing clear liners. Tell me how long it would take you to treat this. What estimate would you give the patient? Almost every single time, inevitably, the number of aligners and the time span that I have on my screen looking at me when I have the proposal from whatever clear aligner system I'm using winds up being shorter than what my orthodontist quotes as the time he or she would need to do the case. So I definitely see them going faster. 100% we see better gingival health, periodontal health during the course of treatment. Gums were notoriously angry and more so with younger kids that didn't have the hygiene when the person was wearing braces. We see some of the best perio health while they're going through the treatment, while they're using clear aligners. Yeah, and I think orthodontists themselves, the specialists, many of them are probably half their cases are clear aligners at this point. So let's talk about the cons. Here's some of the stuff I came up with. Comment on it if you would, Dr. Hakim. uh patient compliance is required now you're looking at 20 20 to 22 hours per day of wearing this stuff right and and you know somebody goes to a business meeting or they're on a zoom call and they by the time they they eat and they brush now they're down to 15 hours which makes a difference in in the results so that's a that's an issue whereas if you're wired up with braces you know you don't have to worry about compliance um cost it can be more expensive than traditional braces depending on the case and the provider You could lose an aligner, and that could really knock you back because then you got to go in and get a replacement. Speech disruption, there's a lisp, at least in the beginning, that you may have to get used to. And then, of course, the attachments may be visible. What are your comments on some of those cons? I'll work my way backwards. When you get into the cosmetic appearance, for example, visible attachments, we are still doing treatment. It's not treatment. with an absolutely invisible aligner that feels like you're not wearing anything. So at the end of the day, a patient is going to get often some stuff on their teeth attachments, but we're going to talk about later. To that, I don't think of that as a con because the relation to the counter side to that is your other option if you're doing ortho is metal brackets. So it's always aesthetically less offensive for that. So I don't think of that as a con necessarily. Although put yourself in a patient's shoes, they're coming to get clear aligners unless they're already educated on it. They're thinking this is invisible. This is the best thing to slice bread. That's where it comes to our verbiage and how well we communicate, setting them up for success, saying this is going to look pretty darn good, but you will notice X, Y, and Z. And trust us, it's coming off at the end. You're going to be good to go at that point. As far as compliance, yes, that's where case selection and honesty, proper informed consent is very critical. Because like you said, it's got to be north of 20 hours. The one benefit is since more adults are doing that, of course, there are kids and teens systems in play. But since more adults are doing it, they're paying for it out of their own pocket. It's one of the things that helps. It's often them making a choice rather than parents saying, you must wear this, you must wear your headgear, things like that. And so most people are pretty compliant, pretty honest with them. When they're not, they know they're not moving at the pace or things go sideways. So I'm typically not too concerned about that because I front load the information appropriately. set expectations appropriately. That's one of the things that's not in our control. Speech, I found almost everybody sounds the same because a patient's ears are very close to their mouth. They might feel a little different resonance. They might feel like they're different, but rarely do I see people lisping. And I assure them, even from the moment the aligners on the first time when they're getting their training, that you sound perfectly fine. You're going to be able to get on a phone call, get on a sales meeting and do what you want without it really being an interruption. And there's a very quick learning inside the mouth. So when you are trying to present the option to the patient of using clear aligners, what do you find the most successful approach, that communication, when you're planning the case out? Yeah, so that's very case dependent. When, you know, being a generalist and doing quite a bit of restorative work, when the promotion of the case forward has to do with getting the teeth. in a better place getting the trees in the forest better space so that it leads to more conservative better lasting dentistry then that's the primary driver and conversations about preserving more of your natural enamel and dentin not needing root canals better root alignment which will help with hygiene never mind that your final ceramics or composites are going to look better that's an obvious lead-in for somebody that's not doing it as a precursor to restorative Then it comes down to the aesthetics and the health benefits. All the stuff we talked about, better gingival health, perio health, better hygiene maintenance, less restorative necessary in the long run, better balance and wear and tear on your teeth. Yeah. And I think what you said earlier, to try to get an adult to do ortho back in the day was very challenging because of obvious reasons. But today, not only is it more aesthetic with clear aligner therapy, but also it's more accepted. Adult orthodontics is not something that is just an odd thing that why would someone over 30 have orthodontics? But of course, once you talk to the patient about the benefits and now having the opportunity to use clear aligners, it's a much easier sell. Now, with all that, there are some pain points from the standpoint of a clinician. So let's talk about the pain points specifically related to the attachments that have to be placed on these teeth in order to get the proper movement and so forth. yeah absolutely so when we when we can take the variables of the equation the variables what we talked about before patient compliance that's something that we can speak to and encourage but can't force happen then the rest of it comes down to the practitioner the system how we deliver it and that i think those things have that i can break them up into basically three categories how well the treatment design is which has a little bit to do with the system you're using who's on the other end whether it's technicians consulting orthodontists And of course, all of them have quite a bit of AI and big data working from these zillions of cases have been done. So how good the case is set up? Is it realistic? Next is IPR. A lot of these cases have to go through some, not a lot, some have to go through some slenderization. And being precise with IPR, not removing enough enamel or removing too much, which hopefully doesn't happen, can mean that the software is counting on X amount of space and you prepare less of that space. That's under our control. That could be a great topic for another day. to give the ability for the aligners that deliver the right vectors of force attachments from paramount so we can move a tooth just in one planar movement by changing that series of aligners but as soon as you have to grab it and move that tooth into x y and z axis you have to intrude or extrude a number of complex planar movements then these handlebars that we put on teeth what we call attachments are critical to the case moving smoothly and efficiently And while it seems simple, you know, a little slam dunk of a little composite bond into a tooth, precision is very important. And anybody that does any of this research using finite element analysis to see how a well-adapted attachment that looks exactly like the software intended it to be versus one that doesn't look good, which could mean voids, extra flash, having the attachment come off. All those things are major pain points. And that's what the doctors most frequently complain about is, hey, my case is not tracking is the word we use. It's not where it should be at aligner 10, for example. And if we take compliance out of the equation, often it's that the tray or the aligner is not fitting over the attachment appropriately for a number of reasons. And attachments can be problematic. So what's the major flaw that you see in the clinical? fabrication, chair side fabrication of these attachments on the teeth. What is the dentist doing that would lead to more problems with these attachments? I'm going to say that the mode of operation should be to continually look to perfect your attachment technique because people have a wide range of practices on how they deliver them. Sometimes the doctor themselves is doing it. Sometimes it's offloaded to auxiliaries. That means nothing. The auxiliary could be better than the doctor doing it. But the scrutiny involved in placing them, the precision. So you can imagine if I just sloppily load an entire template, 14 attachments with inappropriate material that's running out of the tray, try to keep every tooth on the upper or lower arch dry at the same time, try to condition or etch the teeth correctly, put adhesive, not have lips or cheeks collapse, shove it in there, not have it be over or under loaded. You can see all the things that go wrong. It would be the equivalent of you trying to do eight fillings all at once rather than taking care of each of them, creating contact correctly and such. So technique, materials, staging can lead to better outcomes or poor outcomes. And that's the protocol that each practice has to figure out how it works best in their hands and learn from when things don't go well. Look closely, put on your loops and say, all right, this attachment is not doing great. The aligner is not tracking over it, but it could be because there's a ton of flash. or clunk of it's missing or sometimes bad composite and it looks okay at the beginning but as you take the tray on and off our tray multiple times a day it starts to wear so now the tray doesn't deliver the force of the right vector yeah we're going to talk about the materials in a second but before we get to that as far as the technique with the attachments do you recommend doing a certain like a maximum number of teeth at a time when you have a full mouth to take care of Absolutely. These treatment plans, as we said, can be lucrative. Everybody's got a range of pricing. Usually the biggest appointment is not that intense. It's appointment one when you do the IPR and mostly deliver the attachments. Sometimes they're staged later attachments. But I usually allow 45 minutes an hour max to do that, and I can get a full mouth attached up. After that, once every six weeks, eight weeks, ten weeks, depending on the number of aligners you give, very easy. So it's worthwhile. to spend a little bit more time rather than trying to do the shotgun approach. What I'll tell people is just start to manipulate your patient, put your hands in their mouth, pull cheeks aside, see how active their cheeks and tongues are, look at the screen and see how many attachments you're putting on and how far back they are. I typically will say, even if you have an entire quadrant where every tooth is getting an attachment, don't try to do more than six or seven, a quadrant's worth at a time. Sometimes you have a stubborn molar in the back where the cheek collapses and you think you need all hands on deck. And let's say you're bonding it to something that's not as easy to bond to, a zirconia crown, which has a whole bunch of challenges, a silica-based crown. Sometimes I divide and conquer and only do one or two teeth at a time. Or I get creative with different auxiliary retraction techniques using something like a dry shield or an isolate or an obturgate, things that will help me free up my hands so I'm not pulling on soft tissue. And then I'll load the tray very precisely, condition a few teeth at a time. The extra 10 or 15 minutes far saves having to redo cases and having cases drag up once a month on end after the treatment supposedly should have been done. You mentioned the wear and tear on the actual material because obviously the patient is taking the tray out when they eat. They're taking the tray out and putting it back in when they brush and floss. And this is going on for months during their entire course of the tooth movement. Tell us about the materials. What are we looking for? We need to get good adhesion, right? And we also need a strong composite that could withstand that kind of wear. So what are you looking for? Absolutely. So composites were originally developed in dentistry to serve our needs. When you look at early generations, later generations, when the universals came along, where there were more all-purpose composites. So we had composites that we used for bonding and fillings, crowns, restorations. It's final definitive restorations. each of them with a particular makeup. Nobody invented a composite, said, I'm going to invent this one niche product for just attachments. So people would experiment between body composites because they felt like they could butter them in like cream cheese and load an attachment template more precisely. And they said, well, I know this is more filled. That's why it's a body composite, a sculpting composite. So don't wear less. But you could get voids and it was hard to not underfill or overfill. Other people would say it's very easy for me to fill a bucket. I'll use a full bowl attached composite and fill in the resin bubbles. But those would sometimes run out, not have the right viscosity. And so that's where more recently a company like Voco has come to the rescue. They've worked between their different composite lines. And they're a company that's really dedicated to creating unique composites that I use a lot of in my practice. They've come up with a particular composite that's the best of both worlds. They call it Aligner Flow LC. So we developed a composite that has the right flow characteristics, allows you to easily fill a bubble quickly, be very controlled with the syringe so you don't overfill or underfill, voids or flash, and it won't flow out. So you can set that tray on its side. Attachments are going in every direction. Gravity is not going to pull it out. You can turn your attention to the tooth, condition the tooth, bring that template back in, and you just have less issues, less cleanup, less delaminations. Now when we take the attachment material out of the equation and look at the adhesion itself, the step we do on the teeth. thing is it's very easy to bond in enamel and the majority of time we're bonding to enamel. So any adhesive system that you have in your practice works well. Folks are very keen on using universal adhesive systems. I wind up using the Futurabon U from Boco. It's a flexible material that you can selectively etch or total etch or use their self etching primer. The nice thing is we're asking these attachments to stay on for four months, eight months, a year and a half maybe. It's not like a filling that you hope. It's going to be there for 12 years, 15 years. And so even if you use a slightly less aggressive bond strength, the sheer bond strength to enamel, you can use it in self-etching mode, eliminate the phosphoric acid step, and generally it'll stay on. People that want to wear their belt with their suspenders, they can total etch with phosphoric acid and even get a more tenacious bond to that. So the bonding to natural enamel becomes very simple. Yeah. Now, do you like to stay within the same system? when it comes to the actual manufacturer, when you're using an adhesive with the body composite? I like it for this reason. Any composite, this GMABIS composite will work with any reputable adhesive. So sometimes people say, I swear by brand X for my adhesive. That's why I already inventory my office. But I like the idea of using something like a liner flow LC. It's universal in that it will stick to any other acceptable adhesive out there. Other people say, well, give me some of the benefits of... other adhesives. For example, in the universal world, like Futurabond Universal, they also have additional primers. They have silane-based primers and 10MDP primers. So if you use that adhesive, you know that you have the bonding capability built in when the attachment happens to be planned for a tooth that has a feldspathic porcelain, a silica-based porcelain, Emax, for example, which is very prevalent these days. They also have that 10MDP primer for when you're bonding to zirconia. There's some additional steps you have to do. But now you don't have to buy dedicated separate primers. That's where it's really useful. Are you finding when you talk, when you teach, I mean, I know you lecture a lot and you pack a room and you have, you know, hundreds of people that raise their hand, ask questions. What are you finding amongst the clinicians out there as far as the failures? What are the weak points? Is it the adhesion where the whole attachment pops off? Or are the attachments not being replicated properly based on the template so the vectors are off? As a 20,000-foot level, most of the people that are frustrated by this will not get that nuance. What they'll say is, I love this when it goes well, but I hate it when my case doesn't track. And the profit margins erode because I told them it would be eight months. Now I'm ordering more aligners, more treatment. It's month 12, month 13, month 15. They hate that. But then if I say, okay, now let's break that down and see why it didn't track. Then sometimes... we can get down to the nitty-gritty, which is the attachments. And we can look at those and say, look at this up close. We have a ton of flash. That means that this aligner never seats completely and the forces aren't going in the right direction. That's one of the variables under your control. The variable is strictly patient compliance. That comes with talking and education. So when it doesn't track according to plan, which could be the fault of the clinician based on what we just talked about, what is the next step to get it? So they're two months behind. They're not where they should be. What do they need to do now? What should they be evaluating to get back on track? Yeah, if the deviance from tracking is small and slowly growing, what they should do is look at their attachments again. If there's lots of flash around them, simply get the right burr, finishing burr, and clean up the flash. If it's so far off where the template is not going to engage it, then it comes down to taking a progress scan or impression. sending it back to the company and saying, hey, we're at a liner seven, and it doesn't even come close to seating. Sometimes within your own template bubbles, you can replace an attachment if you realize a gross flaw. If it's simple, and this comes with experience, you can say, I can rescue this. I just need to redo this attachment. Or I can rescue this because the patient showed up after eight weeks, and I just see two of their attachments are missing. Let me review my bonding protocol. But the biggest microscopic challenge is when people say, hey, Felsbathic porcelain, silica-based porcelain has been around forever. I know I have what I need in my toolbox. I know I need a little bit stronger etch like hydrofluoric acid, silane. I can figure out how to get my attachments to stay on those. What people have trouble with is zirconia bonding and with more and more zirconia crowns around, not just back teeth. Now we have highly translucent zirconia, it's more aesthetic. So it's becoming very commonplace for the mouth, in the front of the mouth, more than 90% of the crowns ordered now from labs or zirconia, some variation of zirconia. Well, we all know the zirconia bonding takes an additional step. We're always thinking about it from the intaglio of cementing a crown, but the same challenge is there on the outside. In a wet environment where saliva contaminates that. So that series of decontamination steps is very critical. And I don't know if you want me to get into that detail now. I certainly covered it quite a bit in the webinar that I did that's on Viva. And it's a great resource for people to go and listen to. Yeah, absolutely. Well, yeah, we're running out of time here. done an amazing job covering the material in an audio presentation that we're doing in this podcast. But I do recommend to our audience to check out Dr. Hakim’s webinar. And the title of that webinar is Aligner Attachments Perfected. Stop stressing and stop guessing. And to listen to all of Dr. Hakim’s Viva Learning content, just go to vivalearning.com, type in Hakim, H-A-K-I-M, in the search bar. There's a lot of really good stuff. that he presents in both webinar and podcast format. Any last thoughts, Dr. Hakeem, before we wrap it up? Yeah, thanks, Phil. I would just end with saying that, yeah, visit the webinar. A lot of the answers that weren't answered will be answered there. And I firmly believe that in any progressive practice, clear aligners, if you're not doing it, they belong there. They're a great service for your patients. And then certainly niche products like Aligner Flow LC just reduce some of the pain points, makes things more predictable. Dr. Hakim, thank you so much for your insight. Great discussion. And we look forward to having you on future programs. Great talking to you, Phil. Bye now.