Aligner Treatment in the Teenage Patient: A Guide for Orthodontists

Key takeaways on clear aligner treatment for teenagers

• The article highlights the advantages of using clear aligners for teenagers, emphasizing factors such as improved compliance, reduced chair time, enhanced oral health, dietary flexibility, and high patient satisfaction. 

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• It underlines the importance of a thorough candidacy assessment, considering age, developmental factors, and treatable cases, including Class II and III malocclusions.

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• The evaluation of teenage patients involves a comprehensive examination, assessing compliance, and educating them about treatment expectations. The treatment planning process utilizes digital impressions, 3D simulations, and a case management platform, ensuring precision and efficiency. 

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• Special considerations for teenagers include tailoring treatment to dynamic dentition changes, adherence to guidelines for attachments and elastics, and expectations for potential refinements. 

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• The article also underscores the need for effective communication to manage adolescent expectations and discusses positive outcomes from research and case studies, supporting the consideration of aligner therapy for the primary orthodontic patient base.

2. Benefits of using aligners on teen patients

In this age of social media and public visibility, teenagers are increasingly looking for an aesthetic smile without impeding their social lives. Clear aligners for teenagers are an optimal treatment modality that offers several benefits:

2.1 Compliance

Aligners are essentially plastic trays that are less visible to the eyes as compared to traditional braces. Clear aligners present a more socially acceptable option for teenagers, encouraging more compliance towards the treatment. 

2.2 Average chair time

The average chair time during clear aligner treatment is greatly reduced when compared to traditional braces. The appointments are hassle-free with studies reporting that treating teenagers with clear aligners is “easy” or “very easy”. The chair time was reported to be 3.5 minutes for the doctor and 10.5 minutes for the staff (1). 

2.3 Oral health

Clear aligner treatment for patients reported a plaque index reduction of an average 15.1% in the maxilla and 16.6% in the mandible. All other teeth exhibited only a minimal (<1mm) band of plaque. Overall the plaque and gingival indices showed better oral conditions than orthodontic patients wearing fixed appliances (1) . 

2.4 Fewer dietary restrictions

Studies reported that a significant number of teen patients either infrequently or never restricted their dietary choices. Since clear aligners are removable, teens experience minimal changes in their diet making it an easier option. 

2.5 Patient Satisfaction

Of the patients assessed for overall quality of life at the three-month check-up, approximately 70% had seldom or never encountered discomfort associated with the aligners, while around 80% had infrequently or never resorted to the use of pain relievers. As the course of treatment advanced, patients consistently reported a diminishing occurrence of discomfort and fewer associated concerns reporting high patient satisfaction (2). 

3. Candidacy assessment

3.1 Age and development factors

Skeletal and dental developmental factors are essential factors that need to be assessed to ensure that the treatment aligns with the overall growth. All permanent or secondary molars should be fully erupted. Clear aligners can be used for teens who have some erupting dentition. 

3.2 Treatable cases

A clinical and radiographic examination is essential to assess whether a malocclusion can be effectively treated with clear aligners. Clear aligner treatments are effective for malocclusion with mild to moderate crowding. Complex cases with clear aligners can be treated with the help of auxiliaries, such as attachments and TADS (3).  Evaluation of malocclusion and subsequent treatment planning is an essential part of clear aligner treatment for teens. 

4. Teenager patient evaluation

4.1 Comprehensive examination

A comprehensive dental and radiographic examination should be carried out before deciding on the appropriate treatment plan. Lateral cephalogram and hand-wrist X-rays can be used to assess a patient's skeletal maturity. OPGs help in assessing the status of erupting succedaneous teeth while treatment planning. 

4.2 Patient compliance and lifestyle

Evaluating a teenager's ability to comply with the treatment plan is essential since clear aligner therapy requires good patient compliance. Assess their responsibility in wearing aligners for the recommended duration, attending regular check-ups, and following oral hygiene instructions and accordingly motivate the patient to wear aligners for the required 22 hours (4). 

4.3 Educate and set expectations

Communicate effectively with the teenager and their parents or guardians. Provide clear information about the expected duration of treatment, potential challenges and the importance of compliance. Setting realistic expectations ensures a collaborative approach to treatment success. 

5. Treatment planning

5.1 Digital impressions and scanning

Treatment planning for aligner therapy for teenagers starts with precise digital impressions and scans of the patient's dentition using intraoral scanners (5). 

5.2 3D treatment simulation

After acquiring digital impressions a virtual model of the patient's dentition is created that allows orthodontists to meticulously plan tooth movement. 

5.3 Aligner fabrication process

Clear aligners are fabricated using computer-aided design (CAD) and computer-aided manufacturing (CAM) technologies.

5.4 Number of aligners and treatment duration

The total number of aligners and the wear cycle (one or two weeks) are customized based on the complexity of a case and what the prescribing physician wants. 

5.5 Case management platform

The aligner case management platform serves as the central hub for organizing patient data, treatment plans and aligner fabrication details.

5.6 On-demand clinical support

An essential cornerstone of aligner therapy is on-demand clinical support provided by the aligner provider company.

6.1 Compliance and Responsibility

Clear aligner therapy for teenagers includes understanding the dynamic changes that occur in their dentition and planning the aligner treatment around that. Ensuring that this particular age group understands the importance of wearing the aligners for a maximum amount of time is essential. Teenagers require special attention, the right amount of education and motivation to ensure the right course of treatment is followed. 

6.2 Treatment Guidelines

IPR

Generally, IPR for younger patients is avoided unless absolutely necessary. Even then, IPR should fall within certain limits (not more than 0.3 mm per contact area). If space is required, aim for arch expansion rather than IPR. 

Attachments

Attachments can be planned and placed on deciduous teeth if required. In partially erupted teeth, only place attachments if two-thirds of the crown is visible in the oral cavity. Furthermore, attachments should be planned at least on the primary canine and permanent first molar if arch expansion is the objective. 

Planning for erupting teeth 

In case the eruption of deciduous teeth is expected, clear aligner trays should be modified by the addition of an eruption space within the tray itself. This will provide the erupting teeth with more occlusal freedom. 

Elastics

Class II and Class III elastics can be used in clear aligner teen cases as and when required. While precision cuts for elastics can be made on primary teeth, button cutouts and the placement of buttons on them should be avoided. . 

Rate of tooth movement

Teenagers undergo faster bone remodelling and accelerated tooth movement as compared to adults. The treatment plan should factor in this and be modified accordingly. Usually, a one week wear cycle is preferred for teen cases. 

Bite jump 

Bite jump should be planned and corrected in cases of Class II malocclusion with a retrognathic mandible. Class II elastics can be used to achieve a virtual bite jump while ensuring the absence of premature contact in the anterior zone towards the end of the treatment. 

Refinements 

Due to expected dynamic dentoalveolar changes in teenagers, an increased number of refinement trays can be expected. Treatment plans may have to be modified to accommodate the growth potential and patterns of both the jaws. 

6.3 Managing adolescent expectations

Managing expectations is a crucial part of orthodontic therapy, especially concerning adolescents and teenagers. An open communication should be maintained between the practitioner, the patient and parents. Practitioners should highlight the importance of wearing aligners consistently, emphasising the need to stick to the recommended wearing schedule to avoid unnecessary delays. 

Any potential problems and challenges should also be discussed. The patient should be made aware that they might experience initial discomfort and encouraged to reach out if it becomes bothersome. 

7. Research and case studies

A 2013 study conducted with 62 patients compared patient satisfaction and oral health while recording plaque, gingival-bleeding, and decalcification scores, using plaque and gingival bleeding indices adopted from a study by the University of Florida. The study reported that the teenagers who stayed enrolled in the study had no difficulty in compliance and were satisfied with their aligner treatment, indicating a potential opportunity to treat young patients who might not otherwise accept orthodontic care. In addition, the results showed favourable consequences for periodontal health compared to fixed-appliance treatment (1).

Another 2023 multicenter clinical study examined the oral health-related quality of life and oral hygiene in adolescents before and during aligner therapy. The study was conducted with 40 subjects with the mean age being 14.6 years. It reported that they  show statistically significant limitations during the initial year of treatment with aligners. 

As the treatment progressed, there was an observable improvement in psychosocial well-being along with a notable enhancement in oral hygiene practices at home without any clinical evidence supporting an increase in dental plaque accumulation. Given these considerations, coupled with the growing demand for orthodontic treatment in this age group, opting for aligner therapy as a discreet orthodontic appliance should be contemplated for the primary orthodontic patient base (6).