Editorials Orthodontic Science and Practice – Edition 54

Key insights from the global aligner market: the industry’s view

Change is not easy to accept, especially when it takes us out of our comfort zone. But fortunately for some and unfortunately for others, that’s what aligners are doing.
The January issue of the American Journal of Clinical Orthodontics was devoted to complex cases treated with removable aligners. In his column, editor Robert Keim1 points out that conventional brackets will become obsolete in the next 10 to 15 years, and that today any case can be treated with aligners.

And what is the vision of the companies?

According to a Fortune Business Insights report2 published in February 2021, the global market size for clear aligners was $2.41 billion in 2020. The global impact of COVID-19 was unprecedented and surprising, with aligners witnessing a negative impact on demand in all regions amid the pandemic. The global market showed a lower growth of 4.4% in 2020 compared to the average year-on-year growth during the period 2017 to 2019. The market is projected to grow from $2.85 billion in 2021 and $10.04 billion in 2028 at a CAGR (compound annual growth rate) of 19.7% during the period 2021 to 2028.

In April 2019, US pharmacy chain CVS Health collaborated with SmileDirectClub, a direct-to-consumer business, to expand the population’s access to transparent aligner therapy. As a result, the launch of SmileShops by SmileDirectClub is planned at several CVS pharmacy locations. This, according to the report, will further drive the global market for these aligners.

The global market is experiencing significant levels of activity in the form of acquisitions, partnerships, training of new professionals, and technological developments. In recent years, major dental product companies have entered this lucrative market through acquisitions and new product launches. For example, Straumann acquired ClearCorrect LLC in 2017, while Dentsply Sirona acquired OraMetrix in 2018.

The companies are focusing on developing new products and enhancing current product offerings through a strong focus on R&D (research and development). There is an ongoing effort to make products more comfortable, hygienic, and bring improvements in 3D modeling software to design these products based on specific patient needs. The major “players” in this market are also increasing awareness of the product benefits among orthodontists and general practitioners through training. In 2018, according to a research article published by Progress in Orthodontics, about 45.0% of U.S. general dentists providing orthodontic treatment offered clear aligners versus only 19.0% who provided brackets.

Aligners have also driven the growth in the number of orthodontic procedures. In the United States, the number of patients using braces has increased from about 0.8 million in 1994 to about 4 million in 2018.

According to data published by Align Technology, Inc. in 2018, about 60% of the world’s population suffers from malocclusion problems, and about 300 million people could benefit from orthodontic treatment. Globally, between 10 to 12 million people seek orthodontic treatment each year, but the penetration of aligners is significantly low. These products are used to treat only 15 to 17% of orthodontic cases annually in North America and 6 to 7% of cases outside North America. This insufficient penetration offers a significant opportunity for global market expansion.

Despite the growing adoption of aligners worldwide, there are some strong limiting factors that are responsible for restraining the market. Many companies operating on a direct-to-consumer business model have emerged in the recent landscape. And, the cost of direct-to-consumer products is considerably lower than the model followed by the major market participants. The cost of the clear aligner in the direct-to-consumer system ranges in the range of $1,800 to $4,000, while the cost of treatment with these products from companies like Align can be in the range of $3,000 to $8,000. SmileDirectClub, generated $750.4 million in terms of revenue in 2019. This refers to a 77.3% increase over 2018. This is an excellent example of the growing demand for direct-to-consumer products, which can negatively impact the market.

Based on region, the global market can be segmented into North America, Europe, Asia-Pacific, and the rest of the world. The market in North America was valued at USD 1.41 billion in 2020 and is expected to continue to dominate the global market during the forecast period. Some of the critical factors contributing to the dominance of the region include the presence of large companies in the region, such as Align, along with growing investments.

The competitive landscape of the global market reflects a consolidated market with the dominance of a single company, Align. Other market participants with significant presence in the global market include 3M, Institut Straumann AG, 3Shape A/S, Dentsply Sirona and Henry Schein, Inc. These companies are expected to increase their market share during the forecast period.

Usually, we orthodontists have the habit of evaluating things based on our own vision, which is often small and biased. When we read a report like this, we realize how big and billion-dollar the orthodontic market is. The use of aligners has grown a lot in the last few years and will continue to grow more and more. There are many interests at stake, and unfortunately they are not always under the control of orthodontists. And what does this show us? That we should increasingly support and strengthen our institutions, such as the Brazilian Association of Orthodontics (ABOR) and the World Federation of Orthodontists (WFO), so that they can try to regulate the orthodontic market. This will allow us to have a specialty that is good for the population, but also successful for orthodontists.

1-Keim, RG. Complex treatment with Clear Aligners. The Editor’s Corner. J Clin Orthod. 2021;55(1):9.

2- Clear Aligners Market Size, Share & COVID-19 Impact Analysis, By Patient Age Group (Teenager, and Adults), By End-User (Hospitals, and Dental & Orthodontic Clinics), and Regional Forecast, 2021-2028. Fortune Business Insights. Available at: https://www.fortunebusinessinsights.com/industry-reports/clear-aligners-market-101377.

Prof. Dr. Alexandre Moro
Scientific Director

Prof. Dr. Alexandre Moro
Scientific Director

Where is orthodontics heading in 2021?

In past years I’ve asked this same question in this column and answered it based on the scientific program of the American Orthodontic Association congresses that took place in Chicago, Honolulu, Philadelphia, New Orleans, San Francisco, Orlando, San Diego and Washington.

We will repeat it now with the schedule for the 2021 congress, which in the same way as the 2020 congress took place virtually, only a little more enhanced.

It was a 3-day congress, from June 25 to 27, with 4 concurrent virtual rooms. Two were for the general lectures, one for the practice management, and another for the company speakers. The lectures, for the most part, lasted between 25 and 45 minutes.

After evaluating the schedule, I divided the presentations into 20 different subjects. The ones that were most covered and the number of presentations were: Removable Aligners with 25, 15 of which were about Invisalign; Office Administration with 20; Digital Orthodontics with 12; Orthognathic Surgery with 7; Class III Treatment with 6 presentations.

Few lectures took place on: Biomechanics; Laser; Sleep Apnea; Impacted Teeth; Computed Tomography. Some topics continue to lose their relevance and had no presentations: Self ligating brackets, Root resorption, Lingual Orthodontics.

We could say that this was the congress of aligners and office management. The subject of in-house aligners is gaining strength and seems to be a trend. As for administration, technology is also in fashion with the increase of virtual consultations and remote monitoring of treatments, thanks to the COVID 19 Pandemic.

The number of Brazilian speakers was 7 this year. Our representatives were: Daniela Garib, Jorge Faber, Lucia Cevidanes, Eustáquio Araujo, Flavia Artese, Weber Ursi, and Marcio Almeida. This is an excellent number, considering that the virtual programming required a reduction in the schedule. This shows the prestige of Brazilian Orthodontics.

A fact that called my attention was the small participation of Brazilian orthodontists in the audience. This was proven in conversations with colleagues who usually attend the American congress, and also observing the comments on social networks. What could be the explanations for this? The high cost of registration: 490 dollars; or the fact that people are already tired of attending lectures online?

And what are the conclusions after this evaluation of the event?

Time goes by, the tools for treatment change, and always the American orthodontist is more and more concerned with office management and marketing. The office is a business that must be well managed. Aligners are here to stay and there is no regression, only progress, both in the quality of the treatments and in the way they are made and delivered to the patient.

Prof. Dr. Alexandre Moro
Scientific Director

Editorial – Digital Notebook Dentistry in Science

Prof. Dr. Mauricio Accorsi

Scientific Director DDS-BR

Dental fair play

An appeaser is someone who feeds a crocodile hoping to be the last to be devoured. Winston Churchill

The balance of the last Olympic Games in Tokyo is very positive for the Brazilian delegation and represents the best result in history, even in the midst of the extremely delicate pandemic moment we are living. Naturally, this brings some reflections and valuable lessons. The first of them is that it is always possible to overcome, especially in the midst of adversity, if our goals are indeed worthy, such as representing our country well, in a great battle that ends up being fought much more internally than with the opponents. Sport brings us great lessons, such as the well-known concept of “fair play¹,” which means to play fair, to have a sporting spirit. We had countless good examples of winners with “good blood”, such as our fairy, skater Rayssa Leal, gymnast Rebeca Andrade, canoeist Isaquias Queiroz, among many others.

In dentistry, we could translate “fair play” as “professional ethics”, and then our performance starts to play an enormous role in life in society, in that an ethical behavior means not only complying with the rules of the game so as not to harm the competitors, more precisely our professional colleagues; but mainly, in the sense of acting in a way that exalts the moral principles and values that define dentistry as a health profession. Unfortunately, the reality is something much more astonishing and worrisome. In 2022 I’ll be 30 years graduated, and I have the impression that we are going through the period of the biggest ethical crisis in Brazilian dentistry in the last decades, where many times the enemy lives next door.

In sports, the influence of multimillionaire marketing and the pressure of the media strongly influence the athletes to obtain better results, making many of them think of victory as something to be obtained at any cost, resorting to illicit means such as doping, genetic manipulation, among others, thus breaking the fundamental principles of fair play.

In dentistry, the pressure comes largely from social networks and also from some manufacturers, usually publicly traded mega-corporations that want to sell their products at any cost, and for this they use extremely predatory approaches, absolutely unethical and often illegal. In a country where part of the institutions are biased and those who should protect and regulate the professional practice end up covering up reprehensible behavior, we can only try to understand where this insatiable lust for power, fame, and money comes from, at least as a legacy for the next generations.

And so we return to Japan, a country I have had the opportunity to visit three times, and to which I will return for another thirty, God willing. This explicit and notorious admiration comes not only from the spectacular cuisine, or the technological innovations, many of which we could observe in real time during the Olympics, but mainly from the extremely high quality of life the Japanese enjoy, a result of the essence of their millennial culture which is the spirit of collectivity, something that naturally explains this priceless quality of life. Honor is something the Japanese take very seriously and do not give up. Offenders greatly embarrass their families and their peers, and many times the only way to save oneself from the eternal fire of dishonor is to open one’s own belly, by means of Seppuku².

This code of social ethics, this spirit of collectivity is something that is breathed in Japan and represents a great example to be followed, especially by us, Brazilians, where the “rule” is exactly the opposite, that is, individualism pure and simple. Our never-ending woes can be very well defined by the maxim: “little flour, first pot of corn”. Professionally, this “pure and simple individualism” can be translated by a mercenary behavior, typical of those who do not know the meaning of altruism and the value of honor. Many times, the wolf in sheep’s clothing acts as a false prophet, deceiving his peers through supposedly virtuous behavior, while at the same time acting in the shadows, manipulating the people around him, in order to sell himself for a few coins.

Contrary to what we think, we do not really live in this “glamorous world” of social networks, even though they are fun and, in a way, useful for us. Our daily encounter with reality happens every day, more precisely every night, when we lay our head on the pillow and are alone and relentlessly confronted by our conscience. However, we don’t need to keep a Katana ready in case we slip up, because men of good character also make mistakes, and make many mistakes. The path to redemption begins by admitting our own mistakes, always drawing the best lessons from each event that happens in our lives, sharing these lessons with everyone.
To leave a better future for our younger colleagues, our children, and society, we need to learn the value of good example, and to do this we need to spend more time in the real world and less in the “outside world”, where all the limelight, vanity, and endless pressure are.

To keep our conscience in peace, we need to carefully evaluate our choices, because what is good for us individually is not always good for the group, for the profession, and for society. Professional success and financial return are absolutely legitimate and should be sought, but not at any cost, not through treacherous and insensitive pragmatism, and certainly not through cowardly omission. Unfortunately, to speak the truth in Brazil, based on facts and common sense is to become a victim of public scrutiny, but it is the troublemakers, as opposed to the appeasers, who represent the last line of resistance to the total deconstruction that is being carried out in our profession, and purely because of spurious financial interests. Winston Churchill³, the greatest hero of the 20th Century, is the one who brings us the great lesson of life: “never give in, never give in, never, never, never, never – in anything, great or small, significant or trivial – never give in, except to the convictions of honor and common sense. Never yield to force; never yield to the seemingly oppressive power of the enemy.”

Speaking of men of honor, in the last edition we mentioned the Americans Henry Naoum and John Sheridan, and in this edition we have chosen the great professor Sebastião Interlandi, who was the first full professor of the Department of Orthodontics and Pediatric Dentistry at FOUSP, and who created, in 1966, the first post-graduation course in orthodontics in Brazil. He was a master student of the iconic Professor Charles Tweed, at Saint Louis University, USA, and the great mentor of generations of Brazilian orthodontists, who received the first teachings of the specialty at “Fazenda Arco de Canto”, in Bragança Paulista, in the interior of the state of São Paulo. Very creative, he innovated in the fields of diagnosis, with emphasis on the “I-Line”, and mechanics, with the Interlandi Headgear. He published books with his students in mind, but with his heart close to his less fortunate patients, the ones with “feet on the ground”, as he likes to refer to the brilliant Professor Solange de Mongelle Fantini, one of his disciples and also his wife, with whom he shared his life for decades until his departure for the higher plane in 2019.

Professor Interlandi cultivated with equal enthusiasm the love for letters, being the author of poems of unique sensibility. Bold, he chose aviation to take to the skies, in search of a clearer and deeper look at his existence and, thus, positively influenced the lives of many and, without a doubt, he deserves this simple tribute from us.

[1] Fair play is an English expression that means to act loyally, to play in a way that does not deliberately harm one’s opponent.

[2] As part of the Bushido code of honor, Seppuku was a common practice among samurai, who considered their life as a surrender to the honor of dying gloriously, rejecting to fall into the hands of their enemies, or as a form of death penalty in the face of dishonor for a crime, misdemeanor, or for any other reason that defamed them.

[3] In a speech given on October 29, 1941, to the students of Harrow School, in London, in the middle of World War II.

Dr. Mauricio Accorsi
Scientific Director – DDS Booklet – Digital Dentistry in Science

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