Summary: Over the past two decades, aligners have transformed from a niche treatment into a core component of orthodontic care, driven by advancements in materials, technology, and treatment planning. As the industry continues to evolve with innovations like AI, 3D-printed attachments, and in-house aligner production, orthodontists face new opportunities and challenges in delivering effective, customized care.

Key Takeaways:

  • The increasing number of aligner manufacturers has given orthodontists greater flexibility in treatment selection, enhancing customization and efficiency.
  • Advancements in treatment planning software and AI are improving case predictability, but concerns remain about AI’s role in clinical decision-making.
  • In-house aligner production is gaining traction, offering orthodontists more control over costs and case outcomes, particularly in interdisciplinary treatments.

Over the past two decades, aligners have evolved significantly, moving from a niche treatment option to a staple in orthodontic practices. In 2025, the landscape is more competitive, innovative, and accessible than ever, offering orthodontists unprecedented opportunities and challenges.

The evolution of aligner technology

Since 2019, when the aligner market expanded, aligner technology has advanced significantly, providing orthodontists with greater control, efficiency, and predictability in treatment. Orthodontists now have access to advanced materials with varying properties, including multi-layered plastics and options ranging from rigid to flexible. Attachments have also evolved to improve control and efficiency.

“Now that we have multiple players in the game, we, as doctor-consumers, have choices—something we never really had before,” says Christian Groth, DDS, MS, of TDR Orthodontics, a Smile Doctors practice, with locations in the Detroit metro area. “We now have a situation where we can pick the system that we think works best and even have multiple systems in an office if we choose.”

For Groth, the introduction of 3D printed attachments has been a game changer. These attachments now mean the physical aligner can better match the treatment plan he worked up. “We’re actually going to get attachments on the teeth that truly reflect what we have on the computer. I think we’ve completely undervalued and haven’t really considered it because we didn’t have anything else. We just accepted the attachments we’ve had—and they’re not accurate.

“And maybe this is why some of these movements were less effective with aligners—they weren’t engaging an attachment that was accurately placed. If you think about how an attachment works, the pushing surface may not actually be the pushing surface. If your attachment is not put in the right spot, if it’s a little high, a little low, or it’s skewed in its shape, that aligner could be pushing in a totally different spot than we expected it to. And now you look back and say, well maybe my lack of control is due to an inaccurate attachment; and if we now have a really good attachment, does aligner therapy get that much more efficient? I don’t have the answer to that because we don’t have any research on it yet; but theoretically, it works.”

Trim line innovations are also changing the efficiency of treatment. As Melissa Shotell, DMD, MS, points out, aligner companies are offering straight, semi-scalloped, or scalloped trim lines, which can affect the rigidity and retention of the aligner. Now she says, “[Orthodontists] can select what [they] want according to the demands of the case.”

Aligners for complex cases

For years, aligners were considered an option primarily for mild to moderate orthodontic cases, while traditional braces were the go-to for more complex movements. However, advancements in aligner technology, combined with improved treatment planning platforms, have expanded the scope of cases that can be effectively and efficiently treated with aligners, giving clinicians the tools to treat a growing number of adult patients who prefer to avoid brackets.

“I love complex cases,” says Groth. “I don’t think there’s a case where I can’t figure out how to treat with aligners. For some cases, will the end result be the same as braces? No, probably not. But if we have a patient who’s refusing to have braces, and aligners are the only thing that they’re going to consider, I think something is better than nothing. And as long as [the patient] knows what we can do and can’t do, and as long as we have informed consent and they understand what the limitations are, I’m ok with compromised treatment.”

Erin Fraundorf, DMD, MS, owner of BOCA Orthodontic + Whitening Studio in Ladue, Mo, whose practice is primarily aligner-based, responds “absolutely” when asked if she treats complex cases with aligners. However, there are some challenging movements, like a severely rotated premolar, where she prefers a hybrid approach—engaging buttons, a power chain, or brackets to complete the movement more quickly, then turning to aligners for fine-tuning.

A hybrid approach also works well for noncompliant teen patients in the suburban Stafford, Va, office of Bob Kumra, DDS. Kumra uses braces for the heavy lifting in the first phase of treatment, then switches to aligners for finishing and fine-tuning the case—as long as the patient has kept up their hygiene during the braces phase. But in his downtown Washington, DC, location, which focuses on adults, his patients prefer aligners. As he puts it, “You need to learn how to be really good at moving teeth with aligners, otherwise, the adult patient isn’t going to want to do much treatment.”

Treatment planning advancements

Treatment planning software has evolved alongside aligners. For Groth and Shotell, the most impactful advancements are the communication tools.

Consumers have multiple options when it comes to orthodontic treatment. They can seek treatment from a general dentist or an orthodontist. Many patients don’t know the difference, which means when they sit in an orthodontist’s chair, the orthodontist often steps into the role of salesperson, explaining the unique value they offer. Visuals can be a powerful tool here.

“We are equal parts medical providers and salespeople,” says Groth. Given this, he appreciates that software platforms include exam room tools to assist in case presentations, such as treatment outcome simulations. “Having those tools and the ability to show things in real time is great.”

Meanwhile, Shotell, who shares a practice with her husband, a prosthodontist, values how the treatment planning platforms she uses enhance communication in interdisciplinary cases.

“I absolutely believe that having this aligner software technology enhances communication, with either specialists or a referring general dentist, because you can show them your anticipated outcome,” she says. “You can sit with them, especially if they need to do restorative treatment, and discuss, in advance, whether your planned treatment is going to give them the tooth positioning they need. I find it invaluable when I’m doing interdisciplinary care.”

Artificial intelligence

Artificial intelligence (AI) is finding its way into orthodontic treatment planning, but its reliability remains a concern. As Shotell points out, not all aligner companies fully disclose how much they use AI, for example in setups.

“I think we’ve all received setups where we question whether a technician looked at them or if they were strictly set up by AI,” she says. “And while I see companies wanting to move towards AI, I’ve yet to see AI technology in the clear aligner space that can replicate what I can do in treatment planning and setups.”

Groth agrees that AI can’t replicate an orthodontist’s experience but remains optimistic that it can enhance practitioners’ skills. “I think we’re still diving in and figuring out how this gets integrated into orthodontic care, but it’s going to make us better,” he says. “I think people get scared that AI is going to cut out the orthodontist, but it’s just going to make our lives more efficient, getting us to that result on the computer more quickly. It’s exciting, but we still don’t know exactly what it’s going to look like. It’s this ever-evolving game.”

Where AI has shown its greatest immediate value is in remote monitoring. Shotell sees it as a game-changer in patient management. “From my experience working with the AI with DentalMonitoring, I can say that AI picks up things that are very difficult to catch with the eye.”

An early adopter of remote monitoring, Shotell says she’s fascinated by AI’s capabilities. She has reviewed scans to assess how AI determines whether an aligner is seated and to compare its findings with her own judgment.

“It was fascinating. I’d see an unseated aligner in a scan, and even if I was examining the patient in person with a mouth mirror, I would have had difficulty seeing it,” she says.

Patient engagement tools

Many orthodontists, like Shotell and Groth, are integrating aligners with remote monitoring in their practices. Groth uses the technology with 100% of his aligner patients. Both appreciate the wealth of data these platforms provide, the continuous connection to patients, and the added convenience—all while making chair time more productive for the practice. However, Fraundorf and Kumra prefer regular in-person check-ins with their patients.

Fraundorf’s boutique-style practice follows a concierge approach. As she explains, she spends significant time upfront getting to know her patients, their lifestyles, and their treatment goals. She also dedicates significant time to patient education early on to prepare them for any issues. If an issue arises, she simply asks patients to send a text or picture to the practice. “We make it very easy for them to reach out,” she says.

Like Fraundorf, Kumra prioritizes patient connection and ensures that patients recognize the value of seeking treatment from an orthodontist specifically. “The last thing I want is for a patient to feel that I can be outsourced,” he says about his decision to not use remote monitoring. “I want to really connect with patients and have them in the office, where I can provide that human touch and personal care.”

In-house aligner production

In recent years, the rise of in-house aligner production has given orthodontists greater control over treatment planning, costs, and efficiency. This is particularly true for Shotell’s interdisciplinary cases. Often, the orthodontic component of a prosthodontic case is relatively short but cost prohibitive for the patient. She needed a cost-effective solution for cases requiring just 10 aligners to prepare patients for prosthodontic treatment. That’s where in-house aligner production came in.

This workflow allows her to customize aligner solutions that cater to her needs as a clinician and those of her patients. Today, she has found a balance. She uses commercial labs for larger cases, while her in-house lab—equipped with over a dozen 3D printers serving both the practice’s orthodontic and prosthodontic work—handles smaller cases and those she wants more control over, including complex cases with multiple stages.

READ MORE: Cost Savings and Control Drive In-Office 3D Printing

“Sometimes, I just need complete control over a case,” says Shotell. “One of the biggest challenges with laboratories is the setup process. You may go back and forth three, four times—especially if you’re doing interdisciplinary care. Sometimes you’re putting the teeth into a position the lab technician isn’t comfortable putting them in.” She cites the example of leaving a patient with an open bite because she needs to create restorative space. “It’s really hard to communicate that to a lab technician, and even when you do, you don’t always get back the result you want.”

Groth and Kumra have also adopted in-house 3D printing. Groth was an early adopter of 3D printing technology, starting with one printer and going on to found Motor City Lab Works, now an independent company, with John Dumas, DDS, in 2014. Although Kumra’s lab is small, with three 3D printers and two full-time technicians, he, like Groth, recently began experimenting with direct-print 3D aligners.

Groth and Kumra are cautiously optimistic about advancements in 3D printing and their impact on in-house aligner production. As Groth puts it, “It’s going to reinvent the aligner game as we continue learning what we can and can’t do with 3D printing of aligners.”

The road ahead

In the last 25 years, aligners have evolved into a cornerstone of modern orthodontic treatment, offering flexibility for clinicians and patients alike while continuing to push boundaries. This treatment modality has created new opportunities for care. Patients who never would have considered braces are now enthusiastic about orthodontics because of aligners.

Innovations will continue, and discussions will arise regarding the environmental impact of clear aligner therapy, specifically as it relates to plastic waste and microplastics. Companies are actively exploring and introducing greener solutions. This will be yet another factor shaping the evolution of aligner therapy in the orthodontic practice in the years to come. OP

Photo: ID 132179516 @ Edward Olive | Dreamstime.com

Alison Werner is the chief editor of Orthodontic Products.