Dental News - “By combining aligners with temporary anchorage devices, clinicians can take this tool to the next level”

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“By combining aligners with temporary anchorage devices, clinicians can take this tool to the next level”

Dr Skaner Ellouze enjoys working with his patients and sharing his knowledge. (Image: Skander Ellouze)

An internationally recognised orthodontist, teacher, researcher and author, Dr Skander Ellouze is renowned as a global authority on aligners, passive self-ligation, lingual orthodontics and skeletal anchorage systems. He enjoys working with patients as much as sharing his knowledge and experience with his peers, and he takes a holistic approach to patient care. During the fifth European Aligner Society (EAS) congress, held in Valencia in Spain, Dr Ellouze generously gave of his time in an interview with Dental Tribune International after presenting his paper to talk about when aligners are the optimal modality choice and why.

What are the factors, if any, that influence your choice between aligners and fixed appliances in orthodontic treatment?
Biomechanics, treatment efficacy and efficiency remain the most important factors for me in choosing between these modalities. Aligners used alone still have limitations related to the mechanics of the system itself. By combining aligners with temporary anchorage devices, clinicians can take this tool to the next level. Our treatment goals are not negotiable and should never depend on the appliance: tools follow; they don’t precede. To surpass these limits while remaining minimally invasive and improving the patient experience, orthodontists need to be familiar with all the protocols available. Only then can they advance their aligner treatments and master all kinds of malocclusions and complex cases.

In about half of my cases, aligners and fixed appliances are equally effective. In those cases, the patient’s preference is king—and most patients today want aligners.

Have you encountered situations where aligners demonstrate clear biomechanical superiority over fixed appliances?
Definitely! I will give you three examples. Firstly, aligners are superior in all situations where intrusion is needed, whether anterior or posterior. I’ve also treated cases with anterior or posterior extrusion, and the results have been incredible. The limitations of aligners are being overcome a little bit more every day. Secondly, at the recent EAS congress, I had the pleasure of sharing cases presenting severe gingival recession and explained that, compared with fixed appliances, aligners help me to minimise unwanted effects and prevent further pushing the roots out of the bone during the initial phases of the treatment. Thirdly, aligners can also be more effective in achieving asymmetrical expansion.

Are there specific orthodontic challenges where aligners consistently outperform fixed appliances?
I believe there are. I will give you just two examples. In the case of anterior open bite cases, aligners offer advantages owing to their ability to apply targeted forces to individual teeth. It is possible to use auxiliaries to address underlying causes of the open bite and encourage proper alignment. I am so happy to be able to avoid using fixed appliances with the children I treat. Children and especially teenagers may be apprehensive about wearing fixed appliances, being concerned about their appearance wearing these fixed appliances. Aligners are more discreet, helping children feel less self-conscious. They are removable, making it easier to maintain good oral hygiene and thus reducing the incidence of caries and periodontal disease. The ability to remove them for eating and special occasions enhances patients’ satisfaction and increases compliance. I would even say that for these reasons compliance with children is better than with many adults.

Do factors like the length of treatment, patient compliance and treatment cost influence your choice between aligners and fixed appliances?
Very often, yes. When both modalities will be equally effective, aligners allow shorter treatment time owing to their ability to apply controlled forces and their flexibility in tooth movement. However, if aligner treatment exceeds a certain threshold, typically 12 to 15 months, the orthodontist may recommend fixed appliances, whether labial or lingual, for more precise control over tooth movement.

Compliance is crucial for the success of orthodontic treatment. Aligners require consistent wearing for optimal results, typically 20–22 hours a day. Some patients find aligners more comfortable and thus easier to comply with, whereas others struggle with wearing them consistently. Fixed appliances require minimal patient compliance.

In your paper during the EAS congress, you mentioned a patient with sleep apnoea and expressed a preference for aligners over fixed appliances for addressing breathing issues. Dr Pinter during her presentation, discussed using maxillary expansion to treat snoring. Have you noticed an increase in patient awareness or referrals from general dental practitioners seeking assistance with breathing issues?
Absolutely. The patient you are referring to underwent orthognathic surgery. Thus, the improvement was immediate and obvious.

In my courses, I generally recommend that clinicians purchase a CBCT device or secure access to one, establish an airway protocol in their practices, and educate other dental professionals and patients and their parents in the case of paediatric patients on the benefits of using aligners.

Although the evidence is still minimal, if we think about our clinical findings from treating maxillary transverse deficiencies or retrognathic mandibles—there being a significant mandibular response in growing patients—or surgical mandibular advancement in adults, it’s clear that those findings support a strong relation between these treatments and the improvement of patients’ breathing problems.

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