Virginia Commonwealth University

VCU Scholars Compass

Theses and Dissertations Graduate School

2022

Clear Aligner Therapy in the Mixed Dentition: Indications and

Practitioner Perspectives
Nicholas M. Lynch
Virginia Commonwealth University

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 Clear Aligner Therapy in the Mixed Dentition: Indications and Practitioner Perspectives

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science
in Dentistry at Virginia Commonwealth University.

By
Nicholas M. Lynch, DDS
Bachelor of Arts in Biology & Spanish, 2015
Doctor of Dental Surgery, 2020

Thesis advisor: Bhavna Shroff, DDS, M Dent Sci, MPA

Department of Orthodontics

Virginia Commonwealth University

Richmond, Virginia
May 2022
 ii

Acknowledgements

Funding for this study was provided by the Southern Association of Orthodontists,

Virginia Commonwealth University, and the National Center for Research Resources (award

number UL1TR002649).

I would also like to personally thank my entire thesis committee, including Dr. Bhavna

Shroff, Dr. Caroline Carrico, Dr. Steven Lindauer, and Dr. Vincent Sawicki. Special thanks go to

Dr. Shroff as my thesis advisor for her high standards, unerring diligence, and constant guidance.

Additionally, I greatly appreciate Morgan Sabol’s assistance with data collection.

 iii

Table of Contents

Acknowledgements ......................................................................................................................... ii
Table of Contents ........................................................................................................................... iii
List of Tables ................................................................................................................................. iv
List of Figures ................................................................................................................................. v
Abstract .......................................................................................................................................... vi
Introduction ..................................................................................................................................... 1
Materials & Methods ...................................................................................................................... 4
Results ............................................................................................................................................. 7
Discussion ..................................................................................................................................... 19
Conclusion .................................................................................................................................... 29
References ..................................................................................................................................... 30
Appendix ....................................................................................................................................... 34
 iv

List of Tables

Table 1: Respondent and Practice Demographics .......................................................................... 8

Table 2: Self-Reported Clear Aligner Utilization ......................................................................... 10
Table 3: Association Between Use of Clear Aligners in the Mixed Dentition (CAMD)
and Respondent and Practice Characteristics ................................................................. 11
Table 4: Clinical Indications for Treatment with Clear Aligners and Fixed Appliances ............. 12
Table 5: Clinical Indications for Treatment with Clear Aligners by Level of Clear
Aligner Use for Mixed Dentition Cases ......................................................................... 14
 v

List of Figures

Figure 1: CAMD Use by AAO Constituency ................................................................................. 9

Figure 2: Phase I Indications According to Appliance Type ........................................................ 13
Figure 3: Phase I Indications for CAMD According to Level of Use .......................................... 15
Figure 4: Perceived Compliance and Oral Hygiene with CAMD Usage ..................................... 16
Figure 5: Perceived Compliance and Oral Hygiene for CAMD According to
Level of Clear Aligner Usage ........................................................................................ 17
Figure 6: Anticipated Change in Future CAMD Usage................................................................ 18
 Abstract

CLEAR ALIGNER THERAPY IN THE MIXED DENTITION: INDICATIONS AND

PRACTITIONER PERSPECTIVES
By: Nicholas M. Lynch, DDS
A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science
in Dentistry at Virginia Commonwealth University.
Virginia Commonwealth University, May 2022
Thesis Advisor: Bhavna Shroff, DDS, M Dent Sci, MPA
Department of Orthodontics

Introduction: This study evaluated current trends and perspectives among orthodontists
regarding clear aligner therapy in the mixed dentition (CAMD), including insights into perceived
indications, compliance, oral hygiene, and other factors.
Methods: An original, 22-item survey was mailed to both a randomized, nationally
representative sample of practicing orthodontic specialists (n = 800) and to a specific,
randomized sub-sample of high-aligner-prescribing orthodontists (n = 200). Questions assessed
respondents’ demographic information, experience with clear aligner therapy, and perceived
advantages/disadvantages of CAMD compared to fixed appliance therapy (FA). Responses were
compared using McNemar’s chi-squared and paired t-tests to assess CAMD versus FA.
Results: 1,000 orthodontists were surveyed, and 181 (18.1%) responded during a 12-week
period. Respondents were primarily solo private practice orthodontists. None of the demographic
factors showed significant associations with CAMD use. CAMD use was less common than
mixed dentition FA, but the majority of respondents predicted an increase in their future CAMD
use (57.9%). Among respondents utilizing CAMD, the percentage of mixed dentition cases
treated with clear aligners was significantly less than the overall percentage of clear aligner cases
(23.7% vs 43.8%, P < 0.0001). Significantly fewer respondents considered skeletal expansion,
growth modification, sagittal correction, and habit cessation to be feasible indications for CAMD
compared to FA (P < 0.0001). Perceived compliance was similar for CAMD and FA (P =
0.5841), but perceived oral hygiene was significantly better with CAMD (P < 0.0001).
Conclusions: CAMD is emerging as an increasingly appealing treatment modality for children.
The majority of surveyed orthodontists reported limited indications for CAMD compared to
fixed appliances, but they perceived noticeable benefits for oral hygiene with CAMD.
 Introduction

Clear aligners have now been used for adult orthodontic treatment for decades, and their

popularity drastically increased after Align Technology released its “Invisalign” clear aligner

product in 1997.1 Initially, clear aligners were regarded as an option for treating mild or

moderate malocclusions, but their applications have expanded along with new generations of

software algorithms and plastic materials.2,3 Numerous studies have subsequently explored

practitioners’ uses of clear aligner therapy for different treatment goals, case types, and case

difficulty levels in adults with permanent dentition.4–9

Align introduced clear aligner therapy in the mixed dentition in 2008 with the release of

their “Invisalign Teen” product.1 The hallmark of this product was the inclusion of “eruption

compensation wells” in the aligners that allowed for the eruption of permanent teeth by using

algorithms to predict the size and shape of teeth.1,10,11 However, this was mostly limited to mild

malocclusions in the late mixed dentition, and the software required that numerous adult teeth

already be present in order for the trays to perform more predictably.1,12,13

In 2019, Align Technology released its “Invisalign First” product, which included

numerous new features: improved eruption compensation wells for canines, premolars, and

incisors; terminal molar tabs; scalable attachments; pre-programmed arch expansion staging

patterns; and other ClinCheck software changes, such as automatically maintaining primary tooth

1
spacing.1 These revisions to both the software and the physical design of the trays were all

intended to make aligner therapy more feasible in the mixed dentition by appropriately managing

tooth exfoliation and eruption. Indeed, many preliminary studies and case reports have indicated

that providers are interested in exploring the potential applications for mixed dentition aligner

treatment, such as for anterior crossbite correction, eruption guidance, and other common early

interventions.14–17

Orthodontists need to carefully weigh the possible advantages and disadvantages of

utilizing clear aligners in the mixed dentition compared to fixed appliances. For example, some

studies have shown better periodontal outcomes in child patients with aligners versus fixed

appliances due to improved oral hygiene.18,19 Additionally, compared to fixed appliances, these

young patients might also experience less pain with aligner therapy.20 Another study found that

patients experienced less difficulty eating and chewing with clear aligners than with fixed

appliances.21,22 In terms of quality of life, a recent study found that aligners might offer easier

adaptation to the appliance, fewer missed school days, and increased self-perception of

attractiveness during treatment.21 Finally, from both patient management and practice

management standpoints, some studies have shown that aligner treatment might involve fewer

appointments, fewer emergency visits, less chair time, and even reduced treatment time.6,7

Nevertheless, there is still a lack of high-level evidence on the effectiveness of clear

aligners in children with mixed dentition, specifically when used for an early interceptive phase

of treatment prior to comprehensive orthodontics in the permanent dentition. Additionally, some

orthodontists have traditionally avoided clear aligner therapy in children due to presumed poor

compliance.10,23,24 However, given the possible benefits of this treatment modality, further

investigation is warranted. Therefore, this study sought to assess orthodontists’ current

2
preferences and perceived indications for aligners in the mixed dentition using an original

survey. In this way, we can elucidate current trends among orthodontists, giving insight into the

indications and exploring concerns over compliance. With this information, orthodontists can

better evaluate the advantages and disadvantages of aligner therapy in the mixed dentition and

re-assess their attitudes toward this treatment modality. Most importantly, this could potentially

prompt orthodontists to provide a new treatment option to young and growing patients with

beneficial effects on their oral health and wellbeing.

At present, there are few published studies regarding the use of clear aligner therapy in

the mixed dentition (CAMD). This study sought to assess differences in orthodontists’

experiences with clear aligner therapy versus fixed appliance therapy (FA) in the mixed

dentition. Thus, all of the following aims were addressed: to quantitatively determine the

frequency with which orthodontists prescribe CAMD; to qualitatively assess treatment

indications for prescribing CAMD; and to qualitatively determine orthodontists’ subjective

perceptions of both compliance and oral hygiene with CAMD. The null hypothesis was that there

would be no difference in reported prescribing frequency, indications, perceived compliance, or

perceived hygiene between CAMD and FA.

3
 Materials & Methods

Materials:

Approval to conduct this study was granted by the Virginia Commonwealth University

Institutional Review Board (No. HM 20021335).

An original 22-question survey was sent via VCU Mail Services to both a randomized,

nationally representative sample of practicing orthodontic specialists (n = 800) and to a specific,

randomized sub-sample of high-aligner-prescribing orthodontists (n = 200). Thus, a total of

1,000 surveys were mailed. After six weeks, a second round of surveys was sent by mail to those

providers who did not respond to the initial mailing. All practitioners were identified using either

the American Association of Orthodontists (AAO) online database or Align Technology’s

Invisalign provider website. The primary sample was made to be geographically proportionate

using a ZIP code randomization strategy to select practitioners from different ZIP codes on a

weighted population basis by state. The secondary sample was also geographically proportionate

by ZIP code and state, but only included orthodontists with the “Diamond Plus” designation on

the Invisalign provider website. These two samples were intentionally designed to ensure

sufficient survey participation of orthodontists with experience using clear aligners in the mixed

dentition. Exclusion criteria included retired orthodontists, orthodontic students/residents, and

any other non-orthodontic dental practitioners, such as general dentists or other dental specialists.

4
 The survey questions were designed to acquire information on respondent demographics,

current indications for clear aligner therapy in the mixed dentition, and respondents’ preferences

toward clear aligner therapy in the mixed dentition. Demographic questions assessed

employment situation, practice geographical setting, years in practice, and experience with clear

aligner treatment. Respondents were asked to report their practice statistics regarding the amount

of aligner treatment versus fixed appliance treatment, the amount of Phase I treatment they

perform, and their perceived indications for clear aligner therapy in the mixed dentition.

Respondents’ attitudes toward clear aligner therapy in the mixed dentition were also assessed,

including questions on perceived compliance, perceived oral hygiene, and future trends. The

complete survey document is included in the Appendix.

Data Collection:

All survey responses were collected by VCU Mail Services and de-identified prior to

receipt by the research team. All study data from paper survey responses were then catalogued

electronically and managed using REDCap electronic data capture tools hosted at Virginia

Commonwealth University.25,26 No personal identifying information was included in the results.

Statistical Analysis:

Survey responses were summarized using descriptive statistics, including counts and

percentages for categorical variables and means with standard deviations for continuous

variables. Respondents were categorized based on their self-reported use of clear aligners in the

mixed dentition (CAMD). Respondents who reported that 0% of their cases in the mixed

dentition were treated with clear aligners were categorized as “No Use”; those who reported 1-

5
49% of their cases were treated with clear aligners were categorized as “Low Use”; and those

with 50% or more were categorized as “High Use.”

Paired t-tests were used to test for differences in clear aligner use for mixed dentition

cases as compared to the overall practice rate. Associations between CAMD use and provider

demographics (including practice type, practice setting, AAO constituency, years in practice, and

time using clear aligners) were compared using chi-squared and Fisher’s exact tests as

appropriate. Selections for the clinical indications for treatment were compared for fixed

appliances versus clear aligners with McNemar’s chi-squared test, and indications for clear

aligners were compared based on CAMD use categories with chi-squared tests. Perceived

compliance and oral hygiene ratings were compared between clear aligners and fixed appliances

with paired t-tests and among the categories of CAMD use with ANOVA. Post hoc pairwise

comparisons were adjusted using Tukey’s adjustment. Significance level was preset at P = 0.05.

SAS EG v.8.2 (SAS Institute, Cary, NC) was used for all analyses.

6
 Results

A total of 181 surveys were returned, with 149 responses from the primary sample

(82.3%) and 32 responses from the secondary sample (17.7%). Thus, the overall response rate

was 18.1%, the primary sample response rate was 18.6%, and the secondary sample response

rate was 16.0%. The majority of respondents were solo private orthodontic practitioners (n =

136, 76%). Most respondents practiced in a suburban or urban setting (74%). There was a

roughly proportional distribution of respondents across the various AAO constituencies and a

normal distribution in terms of years in practice. Only 8% of respondents reported using clear

aligners for less than 5 years, whereas 92% had at least 5 years of experience and 43% had over

15 years of experience. A complete summary of respondent characteristics is provided in Table

1. When correlating these demographic factors to the level of CAMD use, AAO constituency

was the only category demonstrating statistical significance (P = 0.0282), with increased CAMD

usage in the Pacific Coast and Great Lakes constituencies (See Figure 1).

7
Table 1: Respondent and Practice Demographics

n %
Practice Type
Solo private orthodontic practice 136 76%
Group private orthodontic practice 36 20%
Corporate orthodontic practice 3 2%
Academic institution 3 2%
Practice Setting
Rural 3 2%
Small town 44 25%
Large town / Suburban 103 58%
Urban / Metropolitan 29 16%
AAO Constituency
Northeastern 26 15%
Middle Atlantic 27 15%
Southern 31 17%
Midwestern 25 14%
Great Lakes 12 7%
Southwestern 15 8%
Rocky Mountain 11 6%
Pacific Coast 32 18%
Years in Practice
< 5 years 9 5%
5 - 10 years 27 15%
11 - 20 years 42 23%
21 - 30 years 54 30%
31 - 40 years 35 20%
> 40 years 12 7%
Time Using Clear Aligners
< 5 years 14 8%
5 - 10 years 45 25%
11 - 15 years 43 24%
> 15 years 77 43%

8
Figure 1: CAMD Use by AAO Constituency

CAMD Use by AAO Constituency

100%

75% 78%
80%
63%
58% 55%
60% 52%

40% 36%
27%

20%

0%
Northeastern Middle Southern Midwestern Great Lakes Southwestern Rocky Pacific Coast
Atlantic Mountain

On average, respondents reported that 31% (SD = 24.8) of their cases were treated with

clear aligners and 69% (SD = 24.7) were treated with fixed appliances. They also reported that

about 21% (SD = 12.8) of their total cases involved Phase 1 or early treatment in the mixed

dentition. The average percentage of mixed dentition cases treated with clear aligners was

reported to be 13.6% (SD = 24.5%), versus 85.4% (SD = 25.6%) that were treated with fixed

appliances. Among the respondents who reported treating patients in the mixed dentition with

clear aligners, the average percentage of CAMD was significantly less than their average overall

use of clear aligners in their practice (23.7% vs 43.8%, P < 0.0001). A summary is provided in

Table 2.

9
Table 2: Self-Reported Clear Aligner Utilization

Mean SD
What percentage of your overall practice consists of clear aligner cases? 31.3% 24.8
What percentage of your overall practice consists of fixed appliance cases? 68.8% 24.7
In a typical year, what percentage of your total cases involve some form of
Phase I or early treatment in the mixed dentition? 21.2% 12.8
When treating children in the mixed dentition, what percentage of your cases
consists of clear aligners? 13.6% 24.5
When treating children in the mixed dentition, what percentage of your cases
consists of fixed appliances? 85.4% 25.6
On a scale of 1 to 10 (with 1 being highly unfavorable and 10 being highly
favorable), what is your current attitude toward the use of clear aligner therapy
for children with mixed dentition? 5.0 3.4
On a scale of 1 to 10 (with 1 being highly unlikely and 10 being highly likely),
what is the likelihood that you will prescribe clear aligner therapy for children
with mixed dentition in the future? 5.3 3.6
Percentage of Clear Aligners (among those who use clear aligners in the mixed
dentition) Mean SD
Overall Percentage of Clear Aligners 43.8% 24.1
Percentage of Clear Aligners in the Mixed Dentition 23.7% 28.4
Paired Difference (P < 0.0001) 20.2% 21.2

Respondents were categorized into three groups based on their level of CAMD use: no

use (0% of cases), low use (1-49% of cases), and high use (50% or more of cases). These

categories were not significantly associated with any of the respondent or practice demographics.

Among these three categories, there was also no difference in the average percentage of cases

that included some form of early mixed dentition treatment (P = 0.5091). A summary is provided

in Table 3.

10
Table 3: Association Between Use of Clear Aligners in the Mixed Dentition (CAMD) and
Respondent and Practice Characteristics

No Use Low Use High Use

(n = 75) (n = 76) (n = 25) P-value
Practice Type (n, %) 0.3043
Solo private orthodontic practice 60, 45% 54, 40% 20, 15%
Group private orthodontic practice 12, 33% 21, 58% 3, 8%
Corporate orthodontic practice 1, 33% 1, 33% 1, 33%
Practice Setting (n, %) 0.1495
Rural/Small town 21, 46% 19, 41% 6, 13%
Large town/Suburban 47, 46% 42, 41% 13, 13%
Urban/Metropolitan 5, 19% 15, 58% 6, 23%
AAO Constituency (n, %) 0.1927
Northeastern 11, 44% 11, 44% 3, 12%
Middle Atlantic 9, 35% 13, 50% 4, 15%
Southern 14, 45% 14, 45% 3, 10%
Midwestern 11, 46% 10, 42% 3, 13%
Great Lakes 3, 27% 7, 64% 1, 9%
Southwestern 11, 73% 3, 20% 1, 7%
Rocky Mountain 7, 64% 2, 18% 2, 18%
Pacific Coast 7, 23% 16, 52% 8, 26%
Years in Practice (n, %) 0.9929
< 5 years 3, 33% 5, 56% 1, 11%
5 - 10 years 11, 42% 12, 46% 3, 12%
11 - 20 years 18, 45% 16, 40% 6, 15%
21 - 30 years 22, 41% 24, 44% 8, 15%
31 - 40 years 15, 45% 14, 42% 4, 12%
> 40 years 4, 33% 5, 42% 3, 25%
Time Using Clear Aligners (n, %) 0.1536
< 5 years 8, 57% 4, 29% 2, 14%
5 - 10 years 21, 49% 19, 44% 3, 7%
11 - 15 years 17, 43% 20, 50% 3, 8%
> 15 years 27, 35% 33, 43% 17, 22%

Percentage of Cases in the

Mixed Dentition (Mean, SD) 20.4%, 2.09 21.1%, 1.46 23.8%, 2.57 0.5091

11
 Respondents were asked to select all of the clinical orthodontic scenarios and indications

for which they felt it could be appropriate to utilize clear aligner therapy and/or fixed appliance

therapy (see survey questions #15-16). Respondents were significantly more likely to select fixed

appliances than clear aligners for all of the clinical indications except for spacing/diastemas

(57% vs 58%, P = 0.7815). There were significantly more respondents who stated that there were

no clinical indications for CAMD (15%), compared to those who selected no clinical indications

for mixed dentition FA (1%) (P < 0.0001). The largest difference was seen for skeletal

expansion, which was considered an indication for mixed dentition FA by 83% of respondents,

compared to only 7% with CAMD (P < 0.0001). A complete summary of the clinical indications

are given in Table 4.

Table 4: Clinical Indications for Treatment with Clear Aligners and Fixed Appliances

Indications Fixed Appliances Clear Aligners P-value

Crowding* 123 (68%) 95 (53%) 0.0006
Spacing/Diastemas 102 (57%) 104 (58%) 0.7815
Dentoalveolar Expansion* 126 (70%) 85 (47%) <0.0001
Skeletal Expansion* 149 (83%) 12 (7%) <0.0001
Eruption Guidance* 111 (62%) 60 (33%) <0.0001
Space Maintenance* 137 (76%) 70 (39%) <0.0001
Anterior Crossbite and/or Shift* 153 (85%) 107 (59%) <0.0001
Deep Bite Correction* 96 (53%) 58 (32%) <0.0001
Open Bite Correction* 105 (58%) 78 (43%) 0.0016
Sagittal Correction* 104 (58%) 43 (24%) <0.0001
Growth Modification* 116 (64%) 40 (22%) <0.0001
Habit Cessation * 143 (79%) 30 (17%) <0.0001
Esthetics and Psychosocial Reasons* 145 (81%) 121 (67%) 0.0023
None* 1 (1%) 27 (15%) <0.0001

*Indicates statistically significant differences with McNemar’s Chi-squared test

12
Figure 2: Phase I Indications According to Appliance Type

Phase I Indications According to Appliance Type

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Crowding* 68%
53%

Spacing/Diastemas 57%
58%

Dentoalveolar Expansion* 70%

47%

Skeletal Expansion* 83%

7%

Eruption Guidance* 62%

33%

Space Maintenance * 76%

39%

Anterior Crossbite and/or Shift* 85%

59%

Deep Bite Correction* 53%

32%

Open Bite Correction* 58%

43%

Sagittal Correction* 58%

24%

Growth Modification* 64%

22%

Habit Cessation * 79%

17%

Esthetics and Psychosocial Reasons* 81%

67%

None* 1%
15%

Other 9%
4%

Fixed Appliances Clear Aligners

Indications for clear aligners were also significantly associated with the level of CAMD

use for all clinical indications presented in the survey (Table 5, Figure 3). Respondents in the

high-use group reported the greatest frequency and variety of CAMD usage, with statistically

significant differences for all indications (P < 0.0001). The no-use group reported significantly

13
fewer perceived indications by a large margin compared to both the low-use and high-use

groups. For example, all of the respondents in the high-use group selected crowding as an

indication for CAMD, compared to only 66% and 24% of respondents in the low-use and no-use

groups, respectively (P < 0.0001). Among the no-use group, 33% answered that there were no

feasible clinical indications for CAMD compared to only 1% in the low-use group and 0% in the

high-use group (P < 0.0001).

Table 5: Clinical Indications for Treatment with Clear Aligners by Level of Clear Aligner Use
for Mixed Dentition Cases

No Use Low Use High Use

Indications (n = 75) (n = 76) (n = 25) P-value*
Crowding* 24% 66% 100% <0.0001
Spacing/Diastemas* 33% 71% 92% <0.0001
Dentoalveolar Expansion* 20% 60% 92% <0.0001
Skeletal Expansion 3% 6% 20% 0.0109
Eruption Guidance* 11% 42% 76% <0.0001
Space Maintenance * 20% 47% 72% <0.0001
Anterior Crossbite and/or Shift* 28% 81% 92% <0.0001
Deep Bite Correction* 12% 34% 88% <0.0001
Open Bite Correction* 17% 55% 88% <0.0001
Sagittal Correction* 7% 27% 68% <0.0001
Growth Modification* 9% 26% 52% <0.0001
Habit Cessation * 9% 17% 40% 0.0017
Esthetics and Psychosocial Reasons* 45% 79% 100% <0.0001
None* 33% 1% 0% <0.0001

*P-value from Chi-squared test

14
Figure 3: Phase I Indications for CAMD According to Level of Use

Phase I Indications for CAMD According to Level of Use

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

24%
Crowding 66%
100%

33%
Spacing/Diastemas 71%
92%

20%
Dentoalveolar Expansion 60%
92%

3%
Skeletal Expansion 6%
20%

11%
Eruption Guidance 42%
76%

20%
Space Maintenance 47%
72%

28%
Anterior Crossbite and/or Shift 81%
92%

12%
Deep Bite Correction 34%
88%

17%
Open Bite Correction 55%
88%

7%
Sagittal Correction 27%
68%

9%
Growth Modification 26%
52%

9%
Habit Cessation 17%
40%

45%
Esthetics and Psychosocial Reasons 79%
100%

33%
None 1%
0%

No use Low use High use

The average perceived compliance with mixed dentition fixed appliances was not

significantly different from that of clear aligners (7.8 vs 7.7, P- = 0.5841). However, perceived

oral hygiene was rated significantly higher on average for clear aligners than with fixed

appliances (8.1 vs 6.1, P < 0.0001). See Figure 4.

15
Figure 4: Perceived Compliance and Oral Hygiene with CAMD Usage

Perceived Compliance and Oral Hygiene for Treatment in Mixed Dentition Among
Respondents who Treat with Clear Aligners
10

9
8.1
7.7 7.8
8

7
6.1
6

0
Clear Aligners Fixed Appliances Clear Aligners Fixed Appliances
Compliance (P = 0.5841) Hygiene (P <0.0001)

The ratings of perceived compliance were also significantly associated with the amount

of CAMD use (P < 0.0001). Respondents in the high-use group rated compliance with clear

aligners to be on average 8.6 out of 10, which was significantly higher than the low-use group

(7.3, P = 0.0046) and the no-use group (5.2, P < 0.0001). Perceived compliance for the low-use

group was also significantly higher than the no-use group (P = 0.0008). Perceived hygiene

showed only a marginally significant association with CAMD use (P = 0.0584). Respondents in

the high-use group rated perceived hygiene to be on average 8.5 out of 10, which was not

significantly different from the low-use group average of 8.0 (P = 0.1646) nor the no-use group

average of 7.5 (P = 0.0684).

16
Figure 5: Perceived Compliance and Oral Hygiene for CAMD According to Level of Clear
Aligner Usage

Perceived Compliance and Oral Hygiene with CAMD

According to Clear Aligner Usage
10.0

9.0 8.6 8.5

8.0
8.0 7.5
7.3
7.0

6.0
5.2
5.0

4.0

3.0

2.0

1.0

0.0
Compliance Oral Hygiene
(P < 0.0001) (P = 0.0584)

High use Low use No use

When asked about their anticipated use of CAMD in the next 5 years, 18% of

respondents (n = 32) indicated a significant increase in use and 40% (n = 71) indicated a

moderate increase. Only 2 respondents indicated an anticipated decrease in CAMD use. As

shown in Figure 6, anticipated change was significantly associated with the current use of

CAMD (P < 0.0001). Respondents in the high-use and low-use groups were more likely to

indicate moderate or significant increases in CAMD (80% and 78%, respectively) compared to

only 30% in the no-use group. Respondents in the no-use group were most likely to either predict

17
no change (41%) or that they could not predict (24%). Overall, the answers from all respondents

indicated a collective future increase in CAMD usage, with the minority of respondents

predicting no change in their level of CAMD use, and only very few respondents predicting a

decrease in their level of CAMD use.

Figure 6: Anticipated Change in Future CAMD Usage

18
 Discussion

This study assessed current preferences among orthodontists regarding clear aligner

therapy in the mixed dentition (CAMD), including insights into respondent demographics,

practice statistics, indications, compliance, oral hygiene, and various patient factors related to

appliance selection. Based on previous studies assessing dental professional response rates to

mailed paper surveys, the achieved response rate of 18.1% is acceptable.27,28 As such, the data

give a representative picture of the current state of CAMD use among U.S. orthodontists.

It is important to note that our sample comprises two different subgroups: one is

nationally representative and generalizable, while the other specifically targeted high-aligner-

using practitioners. This was done intentionally to ensure that the survey data included enough

responses from orthodontists who have experience with a sufficiently large volume of CAMD in

order to provide meaningful responses on their observations of this treatment modality (instead

of simply receiving an inordinate number of responses from those who do not use CAMD and

thus might have less input to offer regarding its effectiveness). To account for this, the aggregate

data was analyzed using the following group breakdown: “No Use”, “Low Use”, and “High

Use.” Given that there were 32 respondents included in the secondary sample that was identified

via the Invisalign database, these respondents roughly constitute the high-use group (n = 25). By

contrast, the remaining orthodontists in the low-use and no-use groups can be considered more

19
representative of the average orthodontist. As such, the way that the data were analyzed allows

for comparison of responses from typical orthodontists against the responses from orthodontists

who self-reported a significantly higher level of clear aligner usage. Thus, in this way, we sought

to reduce bias in the results and demonstrate how CAMD trends differ in relation to respondent

usage levels

Despite this two-pronged approach to the survey strategy, the respondent demographic

data still appear to exhibit fairly typical AAO orthodontist demographic characteristics. The vast

majority of respondents were solo private practitioners (76%), and 20% were in a group private

practice. This agrees well with the 2018 AAO membership data showing that 93% of member

orthodontists belonged to either a solo or group private orthodontic practice owned by a dental

practitioner. The majority of respondents practiced in suburban settings (58%), which also

agrees somewhat well with the AAO data showing that 43% of member orthodontists practice in

suburban areas.29 The number of years in practice followed a normal distribution, with a plurality

(30%) indicating that they had been practicing for 21-30 years; this was similar to the median of

19 years in practice found in the 2019 JCO Orthodontic Practice Study.30 AAO constituencies

also appeared to have a relatively proportional distribution of respondents in agreement with the

constituencies’ respective populations, as well as being comparable to the same JCO survey.30

Additionally, across all groups, the high overall percentage of respondents with several years of

experience using clear aligners further demonstrates that this sample of respondents represents

valid candidates to offer information about their experiences using clear aligner therapy. Taken

together, these comparisons of demographic and practice data indicate that the sample in this

study is acceptably representative of US orthodontists.

20
 As a general summary, our data indicate that orthodontists still predominantly use fixed

appliances more often than clear aligners, both for their overall cases (mean 68.8%, median

75%) and for mixed dentition cases (mean 85.4%, median 98%). This is somewhat similar to a

2019 published survey of orthodontic practice data which found that aligners comprised only

15% of average total cases started.31 The somewhat large difference between the mean and

median values can be explained by two factors: a small number of outlier respondents with very

high aligner usage, and the tendency for respondents to give simple round-number responses

(such as 75% vs 25%, and 50% vs 50%). Even among the respondents who reported performing

any CAMD treatment (excluding non-users), CAMD usage was still significantly less than

overall aligner usage (43.8% vs 23.7%, P < 0.0001). If anything, given that the combined sample

specifically included a high-use group, the numbers in this study might even represent an

overestimate of the level of CAMD usage in the overall orthodontist population. The average

percentage of total cases that involve some form of mixed dentition or Phase I treatment was

21.2%; this appears to roughly agree with another Phase I-related survey study which found that,

on average, 9.5% of active orthodontic patients were aged 6-8 and 26.6% were aged 8-11.32

The advantages and disadvantages of Phase I treatment have been investigated

extensively in the literature. Some practitioners consider many types of mixed dentition

orthodontic treatment to be unnecessary or to be a form of over-treatment. In fact, Gianelly

asserted that nearly all treatment goals are achievable with single-phase treatment in the late

mixed dentition for over 90% of patients.33 Therefore, it is a valid question to ask whether or not

increased CAMD use might merely represent Phase I treatments that are either too early or

unnecessary. However, our data indicate that those respondents with the highest level of CAMD

use do not perform a significantly greater overall amount of mixed dentition treatment than those

21
in the low-use and no-use groups in this survey (respectively, 23.8% vs. 21.1% and 20.4%; P =

0.5091). These values are similar to those of another survey study which showed that

orthodontists reported treating 15% of their patients with two phases in 2020, and 20% in an

earlier 2002 version of the same survey.34 In sum, the anecdotal notion of an association between

more frequent CAMD treatment and overall Phase I treatment frequency is not supported by

these data. Instead, this would seem to indicate that the average practitioner still relies on their

diagnosis and perception of treatment needs when deciding whether or not to intervene early.

Regarding the specific indications for Phase I orthodontic intervention, there is arguably

still debate in the literature regarding which specific conditions require early treatment. In fact,

scientific reviews have concluded that early interceptive orthodontic treatment (particularly when

performed in two phases) rarely offers improved outcomes over single-phase orthodontic

treatment performed in the permanent dentition; furthermore, even when early treatment is

effective, the benefits often do not outweigh the additional cost and burden to the patient, family,

and provider.35,36 Nonetheless, this survey included a variety of potential indications for early

treatment to broadly assess how and when respondents prefer to intervene.

Sagittal correction was among the least commonly selected indications for mixed

dentition treatment with aligners, despite being an objective that many practitioners prefer to

address earlier in treatment (such as through the use of various Class II correction appliances).

However, this is arguably not surprising, given that there is significant evidence showing that

early Class II correction is generally not indicated. Specifically, early Class II correction as part

of a two-phase treatment is typically more relapse-prone, more costly, more time-consuming,

and no more successful than single-phase treatment later in life.37,38 On a related note, it is often

claimed that early sagittal correction is nonetheless beneficial with regard to overjet reduction

22
protecting against trauma to prominent upper incisors. However, research has also cast doubt on

this purported benefit, showing that early orthodontic treatment did not reduce the incidence of

incisor trauma, despite decreased overjet.39

The presence of an anterior crossbite and/or shift was most frequently rated as an

appropriate mixed dentition treatment indication, both for CAMD and FA. This agrees well with

another study on orthodontic treatment timing, where anterior crossbite was the most frequently

selected indication for early mixed dentition orthodontic treatment.32 A recent cases series also

advocated for CAMD therapy as an esthetic and comfortable strategy for treating mixed

dentition anterior crossbites, citing the benefit of aligner thickness for vertical bite clearance.40

While anterior crossbite was the most frequently selected indication overall, when

analyzing responses by level of aligner use, the presence of crowding was the most frequently

selected indication among the high-use group. Interestingly, crowding has been rated as one of

the most common indications for which orthodontists prescribe clear aligners in the permanent

dentition.34 However, it is debatable whether or not this indication is warranted in the early

mixed dentition. In particular, Gianelly argued that early treatment of crowding is not necessary

in the mixed dentition.33,41 Tied with crowding as a highly rated indication were esthetics and

psychosocial concerns; even across all levels of aligners, respondents frequently agreed that, not

only is this an appropriate situation to initiate early treatment, but also that CAMD therapy

would be well-suited to address it. This agrees with the findings of another study comparing

quality of life in adolescent patients treated with aligners versus those treated with fixed

appliances; the aligner patients reported greater comfort and faster adaptation to treatment,

missed less school, and had greater feelings of attractiveness and self-confidence.21 All of these

23
purported benefits would likely contribute to any esthetic and/or psychosocial benefits of

orthodontic treatment.

One concept that is commonly discussed in connection with clear aligners for children is

that of transverse maxillary arch development. Importantly, a considerable amount of scientific

evidence indicates that maxillary expansion for the resolution of posterior crossbites, especially

when any occlusal shifts are present, is often more beneficial and more successful at earlier

ages.42 Among all of the potential indications included in this survey, maxillary skeletal

expansion was deemed the least appropriate indication for CAMD, with only 7% of overall

respondents selecting it. This agrees with conventional orthodontic wisdom that some form of

fixed appliance (whether a rapid maxillary expander, quad helix, or other related appliances) are

necessary to achieve true skeletal expansion at the mid-palatal suture. Indeed, studies on

attempted maxillary expansion with clear aligner therapy in adults have demonstrated inaccurate

virtual predictions and overestimated amounts of bodily movement, with primarily buccal

tipping of posterior teeth occurring instead.43–46 Clinical research on the use of clear aligners for

maxillary expansion in mixed dentition patients is still limited. Two recent studies claim that

CAMD is effective for treating mild maxillary transverse deficiencies, with one even claiming

that clear aligners might be a feasible substitute for traditional fixed maxillary expanders.

However, the expansion noted in these studies was only mild (ranging from approximately 1 to 3

mm), largely due to mesial-out rotations of upper molars, and likely only dentoalveolar in nature

(given the lack of CBCT data to provide evidence of true skeletal expansion).47,48

Overall, more respondents selected FA more often that CAMD as an appropriate choice

for every single indication listed. This suggests that FA therapy is generally still perceived as the

most suitable appliance for all early treatment indications. Additionally, for all indications

24
surveyed, there were statistically significant differences between the no-use, low-use, and high-

use groups. There was a clear pattern, with significantly fewer respondents selecting any given

indication as an appropriate situation to use CAMD therapy when comparing the low-use and

high-use groups. Very few respondents from the no-use group rated any indications as

appropriate for CAMD. This seems to demonstrate that there is no consensus among respondents

on CAMD indications, and that the perceived appropriateness of CAMD therapy is closely tied

to the respondents’ respective levels of clear aligner usage.

Compliance is arguably even more important to clear aligner therapy than fixed appliance

therapy, since removable appliances can only work when worn. As such, concerns over poor

compliance are often cited as a challenge with CAMD therapy, with children being considered

less dependable wearers than adolescent or adult patients. Attempts to increase and measure

aligner compliance in younger patients, such as built-in compliance indicators, demonstrate just

how important this aspect is to orthodontists.24 Several studies in the literature have found that

increasing age was negatively correlated with daily wear time, with younger patients wearing

various removable appliances for a greater amount of time per day.49,50 More specifically, a

recent study found that poor cooperation with aligner treatment was most common among

teenage (14-17 years old) and young adult (20-29 years old) patients, whereas there was

significantly better cooperation in child patients (less than 12 years old).23 Similarly, this study

found that there was no overall difference in perceived compliance between CAMD and mixed

dentition FA, which would indicate that aligner cooperation might be acceptably high among

young patients. However, when compliance ratings were compared between the respondent

groups based on level of aligner use, the results clearly showed that compliance ratings

positively correlated with the frequency of aligner therapy. The direction of this relationship is

25
unclear, though, as it cannot be determined whether high-aligner-prescribing orthodontists

prescribe more aligners because they have high compliance, or if they achieve increased

compliance because of their greater experience with aligners. Alternatively, it is also possible

that the ratings of higher compliance among the respondents in the high-use group merely

represent an overall positive bias in favor of aligner treatment. Conversely, it can likely be

inferred that the significantly lower level of perceived compliance in the no-use group is an

important factor in their appliance selection.

During any type of orthodontic treatment, adequate oral hygiene is essential for

maintaining oral health, and fixed appliances present physical obstacles to proper brushing and

flossing. As such, some practitioners assert that removable clear aligners permit superior oral

hygiene, and this notion appears to be supported by several studies. One prospective clinical trial

in adults found that clear aligners were associated with improved periodontal status compared to

fixed appliances, including decreases in plaque, gingival inflammation, bleeding on probing,

probing depths, and periodontal pathogen levels.51 A subsequent study with patients ranging in

age from 11 to 62 years found similarly improved gingival health in clear aligner patients

compared to fixed appliance patients.18 More specific to adolescent patients, another clinical trial

involving patients aged 10-18 years also found decreased plaque scores, decreased bleeding on

probing, and decreased probing depths in clear aligner patients versus fixed appliance patients.19

On a broader level, both a recent systematic review and a recent meta-analysis also found

improved periodontal health with decreases in periodontal indices for clear aligner patients

compared to fixed appliance patients; however, both studies cautioned that the current level of

evidence is only of moderate quality due to heterogeneity and risk of bias, thereby necessitating

future RCTs of higher quality.52,53 Overall, the respondents in the present study appeared to agree

26
that young patients tend to have superior perceived oral hygiene with clear aligner therapy. Thus,

it may be beneficial for orthodontists to consider utilizing CAMD instead of FA with child

patients for whom they anticipate oral hygiene difficulties.

When asked about their intentions to increase, maintain, or decrease their current level of

CAMD usage, the vast majority of respondents predicted either a significant or moderate

increase (see Figure 6). Granted, this predicted increase was much more frequent among current

CAMD users, especially the high-use group. Therefore, it is reasonable to assume that any future

growth in this treatment modality will likely be attributable to those who already use CAMD or

have a favorable opinion regarding its applications. However, even though the majority of

respondents in the no-use group expected no change, many of them still stated that they expected

either a significant or moderate increase in their CAMD usage. Thus, there still appears to be

much appeal to at least try this modality, even among current non-users. As previously

mentioned, possible benefits of CAMD such as improved oral hygiene are likely factors that are

prompting providers to consider this appliance. With that being said, future clinical studies will

be needed to assess the efficacy of CAMD more closely.

Open-ended feedback from the final question of the survey generated highly varied and

subjective answers, but several similar comments seemed to represent certain trends. These

comments focused on controversial indications, compliance, hygiene, the necessity of early

treatment, and financial factors. Many respondents endorsed negative views of what they called

“Phase I” treatment, arguing that it often represents unnecessary treatment that is performed

primarily due to the pressure felt by practitioners to produce. Furthermore, some respondents

insisted that aligner companies’ marketing aggravates these pressures. However, the results of

this study do not seem to confirm this worry; instead, it appears that early mixed dentition

27
treatment rates are low overall and similar between no-, low-, and high-use groups. Several

respondents specifically mentioned skeletal expansion, which is a widely accepted Phase I

indication; they stated that they do not believe it is possible with clear aligners. Therefore, they

reported either avoiding clear aligners entirely, or using a fixed maxillary expander prior to or

concurrent with aligner therapy. The results of this study confirm that this anecdotal view is

widely shared among respondents, with very few respondents selecting skeletal expansion as an

appropriate indication for CAMD therapy. Regarding compliance, the comments fit into two

opposing categories: half of the compliance-related responses argued that compliance will

always be the biggest barrier to CAMD success, while the other half reported surprisingly

successful compliance levels. Some respondents even claimed that they observe better

compliance in younger children than in teenagers and adults. It was clear that respondents’ early

experiences with aligner compliance impacted whether or not they continued to utilize CAMD

with confidence. Finally, while several open responses asserted that they will categorically avoid

ever using aligners in the mixed dentition, a greater number of open responses expressed

enthusiasm & satisfaction with the results of their mixed dentition clear aligner therapy. In sum,

it is clear that this treatment modality is still relatively new and that there is a large variation in

the extent to which orthodontists are willing to utilize it.

28
 Conclusion

Overall, the results of this survey study indicate that clear aligner therapy is emerging as an

increasingly popular orthodontic treatment modality for children in the mixed dentition.

Specifically, the following main conclusions were elucidated:

 CAMD usage is still significantly less than both mixed dentition FA and adult clear

aligners, but it is predicted to grow.

 The majority of respondents perceived CAMD to be less suitable than FA for skeletal

expansion, growth modification, sagittal correction, and habit cessation.

 Perceived compliance is similar between CAMD and FA.

 Perceived oral hygiene is superior with CAMD compared to FA.

 Respondents with high CAMD use do not report a greater amount of early mixed

dentition treatment than the average orthodontist, but they do report significantly greater

indications, oral hygiene, compliance, and predicted future usage with respect to CAMD.

29
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33
 Appendix

Survey document .......................................................................................................................... 34

34
 Survey

Clear Aligner Therapy in the Mixed Dentition: Indications and Practitioner Preferences

You are invited to participate in a research study investigating the current practitioner
preferences and perceived indications for aligners in the mixed dentition. All responses are
anonymous, and no personal identifiers will be collected. Your participation in this study is
voluntary. You may stop answering questions at any point and withdraw from the study. The
survey should take 5 – 10 minutes to complete. If you elect to participate, please read and
follow the instructions before, and throughout, the survey.
We thank you for your willingness to participate in this study.

Should you have any further questions, you may contact the research team at:

Bhavna Shroff Nicholas M. Lynch

VCU School of Dentistry VCU School of Dentistry
520 N. 12th St. 520 N. 12th St.
Richmond, VA 23298 Richmond, VA 23298
[email protected] [email protected]
(804) 828-9326 (804) 828-0843

1
This survey contains questions about your attitudes and experiences regarding clear aligner
therapy for patients in the mixed dentition. For the purposes of this study, we ask that you answer
all questions based on your current perceptions of this specific clinical modality, regardless of
whether or not you personally have provided this type of treatment. For any questions regarding
terminology, please refer to the following working definitions:

 Phase I treatment = interceptive orthodontic treatment for child patients in the mixed
dentition (e.g., correction of anterior or posterior crossbites, growth modification, space
maintenance, etc.)
 Clear aligner therapy = any type of clear thermoplastic used in a series to perform
orthodontic tooth movement; not limited to any particular company, brand, or product
 Fixed appliances = refers to the bands, brackets, and wires used as part of the standard
edgewise straight-wire technique
o Can be considered to include other traditional appliances or orthopedic devices,
such as headgear, palatal expanders, habit appliances, etc.
 Permanent dentition = characterized by the presence of only permanent teeth, but not
necessarily all permanent teeth; no primary teeth present
 Mixed dentition = characterized by the presence of both permanent and primary teeth

Please select one answer for each question, unless otherwise instructed. For paired questions
involving percentages, your summed answers should add up to 100 percent. Thank you for your
participation.

1. Which of the following best describes your practice situation?

Private solo orthodontic practice

Private group orthodontic practice

Corporate orthodontic practice

Academic institution

2
2. Which of the following best describes the geographical setting of your practice?
Rural

Small town

Large town / Suburban

Urban / Metropolitan

3. In which region of the United States do you practice (based on AAO districts)?

Northeastern
Middle Atlantic
Southern
Midwestern
Great Lakes
Southwestern
Rocky Mountain
Pacific Coast
Southern

4. How many years have you been practicing as an orthodontist?

< 5 years 21 – 30 years

5 – 10 years 31 – 40 years

11 – 20 years > 40 years

5. How long have you been using clear aligners in your practice?

< 5 years 11 – 15 years

5 – 10 years > 15 years 3
6. Please indicate your current Invisalign provider level:

Bronze Platinum

Bronze Plus Platinum Plus

Silver Diamond

Silver Plus Diamond Plus

Gold Not applicable

Gold Plus

***For questions #7 and #8, your answers should combine to equal 100%.

7. What percentage of your overall practice consists of fixed appliance cases?

____________ %

8. What percentage of your overall practice consists of clear aligner cases?

____________ %

***For questions #9 and #10, your answers should combine to equal 100%.

9. When treating children in the mixed dentition, what percentage of your cases consists
of fixed appliances?

____________ %

10. When treating children in the mixed dentition, what percentage of your cases consists
of clear aligners?

____________ %
4
11. In a typical year, what percentage of your total cases involve some form of Phase I or
early treatment in the mixed dentition? (Does NOT need to add up to 100% with another
answer)

____________ %

12. On a scale of 1 to 10 (with 1 being highly unfavorable and 10 being highly favorable),
what is your current attitude toward the use of clear aligner therapy for children with
mixed dentition?

1 2 3 4 5 6 7 8 9 10
Unfavorable Favorable

13. On a scale of 1 to 10 (with 1 being highly unlikely and 10 being highly likely), what is the
likelihood that you will prescribe clear aligner therapy for children with mixed dentition
in the future?

1 2 3 4 5 6 7 8 9 10
Unlikely Likely

14. How do you anticipate your use of clear aligners in the mixed dentition will change over
the next five years?

Significant increase

Moderate increase

No change

Moderate decrease

Significant decrease

Cannot predict / Have not yet formed an opinion

5
Not applicable
15. For which of the following clinical scenarios or indications do you feel it could be
appropriate to prescribe fixed appliances for interceptive Phase I therapy in the mixed
dentition [select all that apply]:

Crowding Deep bite correction

Spacing/diastemas Open bite correction

Dentoalveolar expansion Sagittal correction

Skeletal expansion Growth modification

Eruption guidance Habit cessation

Space maintenance Esthetics & psychosocial reasons

Anterior crossbite and/or shift None

Other: _____________________________________________________

16. For which of the following clinical scenarios or indications do you feel it could be
appropriate to prescribe clear aligners for interceptive Phase I therapy in the mixed
dentition [select all that apply]:

Crowding Deep bite correction

Spacing/diastemas Open bite correction

Dentoalveolar expansion Sagittal correction

Skeletal expansion Growth modification

Eruption guidance Habit cessation

Space maintenance Esthetics & psychosocial reasons

Anterior crossbite and/or shift None

Other: _____________________________________________________

6
 17. Aside from the specific clinical indications assessed in Questions #15, which of the
following additional reasons explains your rationale for selecting fixed appliances over
clear aligners for children in the mixed dentition? [Select all that apply]

Poor compliance with clear aligners (lost/broken trays, lack of wear, etc.)

Poor oral hygiene with clear aligners

Patient esthetic preferences (O-tie colors, bracket shapes, etc.)

Patient social reasons/peer pressure

Appliance biomechanics (modifications, adaptability, etc.)

Environmental concerns (recycling)

None/Not applicable

Other: _____________________________________________________

18. Aside from the specific clinical indications assessed in Questions #16, which of the following
additional reasons explain your rationale for selecting clear aligner therapy over fixed
appliances for children in the mixed dentition? [Select all that apply]

Poor compliance with fixed appliances (broken brackets, poor elastic wear, etc.)

Poor oral hygiene with fixed appliances

Patient esthetic preferences (clear trays, colored attachments, stickers, etc.)

Patient social reasons/peer pressure

Appliance biomechanics (modifications, adaptability, etc.)

Environmental concerns (recycling)

None/Not applicable

Other: _____________________________________________________

7
19. If you currently prescribe fixed appliances in the mixed dentition, or have prescribed them
previously, how would you rate the overall compliance of these child patients on a scale of
1 to 10? (With “1” being a total lack of compliance and “10” being perfect compliance)

1 2 3 4 5 6 7 8 9 10 N/A
Non-compliant Compliant

20. If you currently prescribe clear aligner therapy in the mixed dentition, or have prescribed it
previously, how would you rate the overall compliance of these child patients on a scale of
1 to 10? (With “1” being a total lack of compliance and “10” being perfect compliance)

1 2 3 4 5 6 7 8 9 10 N/A
Non-compliant Compliant

21. If you currently prescribe fixed appliances in the mixed dentition, or have prescribed them
previously, how would you rate the overall oral hygiene of these child patients on a scale of
1 to 10? (With “1” being to a total lack of oral hygiene and “10” being perfect oral hygiene

1 2 3 4 5 6 7 8 9 10 N/A
Poor OH Excellent OH

22. If you currently prescribe clear aligner therapy in the mixed dentition, or have prescribed it
previously, how would you rate the overall oral hygiene of these child patients on a scale of
1 to 10? (With “1” being to a total lack of oral hygiene and “10” being perfect oral hygiene)

1 2 3 4 5 6 7 8 9 10 N/A
Poor OH Excellent OH

8
23. Comments:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________