Expand podcast: In-office aligners - should the driver build the car?

This transcript has been reviewed by AI and may contain inaccuracies.

Daniel Ramos: Welcome to episode 8 of the Expand podcast. Today, I’ll be speaking to Dr. Pedro Costa Monteiro about in-office aligners and the value of clear aligner companies. Pedro is an experienced orthodontist and has a wealth of insight to share with us. Let’s get started.

Welcome to the Expand podcast, a DSD podcast about ortho insights. Today’s topic: in-office aligners—should the driver build the car? This is something I’d love to discuss with my friend and colleague, Pedro Costa Monteiro, joining me here for the second time. Even though Pedro, like me, isn’t a frequent user of in-office aligners, we’re both out there, right, Pedro? Going to congresses, hearing what colleagues are saying, really understanding what’s out there. I think this will be an interesting discussion with you. Thanks so much for being here, Pedro—welcome.

Pedro Costa Monteiro: Well, first of all, thank you for inviting me one more time. It’s always a great pleasure to share the stage with you and discuss such a special topic. I did my homework on this topic, and I’ll obviously share some ideas with you, give my opinion. It’s quite interesting to see how fast things are changing around orthodontics, because, come on, ten years ago, it would have been unbelievable to think we’d be here talking about aligners in this way. And probably in five or six years, we’ll say, “Hey, do you remember the time when we used companies?”

It’s happening so quickly. It’s difficult to keep up with such a high level of information, given the amount of things being introduced every day. It’s hard for us to fully understand it all. As you said, I’m not an in-office user. We have some printers, and we’re doing some tests, but for now, I’m still dealing with the companies. We’ll discuss this topic more deeply throughout the podcast, but to start, here’s what I see. If you’re a big player and you’re doing thousands of cases, which, for example, in my country doesn’t exist because, in Portugal, we have very small offices and don’t do a large number of aligners. But if you are a big player with thousands of cases, maybe you’re already there, and maybe, by the end of the year, your invoices are smaller. I think that’s one of the reasons there are so many of them, but for a small office or a small player, I think it’s still a big investment—not only in the system but also in time and in staff to help with it.

Daniel Ramos: Yeah, to set the tone here, the idea is to help those listening understand the advantages and disadvantages of each system. In this analogy, “should the driver build the car” essentially means: should the orthodontist handle everything in the clinic and not delegate to a company to manufacture the aligners or use third-party software? More and more, we’re seeing key figures, important doctors—speakers like Kenji, for example—

Pedro Costa Monteiro: Yes, I’ve been following him.

Daniel Ramos: When Kenji starts doing something, I think the minimum we should do is pay attention.

Pedro Costa Monteiro: Yes, at the very least.

Daniel Ramos: I saw him at the last two congresses, and you were there at one, in Hamburg at the TPAO, which was an amazing event, and the other in Valencia at the European Aligner Society Congress. I think he wasn’t in Valencia, I might be mistaken, but in Hamburg, the last time—it was incredible how he presented, with so many images; it looked easy, right? It makes sense because we control everything. But we already discussed the benefits of AI and data collection in the last episode you were on with me. Here’s the topic: between a company and an in-office system, in your opinion, do you think a clinic can compete with companies?

Pedro Costa Monteiro: Okay, let me go back a bit and give you two examples. I had the chance to visit the facilities of Invisalign and also Angel Aligner. So, I saw both facilities, and what’s incredible is that I wasn’t expecting so much technology around the facility. I was really amazed by the number of workers—or rather, the lack of them—because I was expecting more. A lot of things are done through artificial intelligence and robotic technology, which for sure brings a lot to the table.

Also, as you mentioned, I follow Kenji. He’s an outstanding orthodontist, and more than that, he’s always ten steps ahead. What I saw in his latest posts is really important because it’s something I’ve been at least studying and trying to understand. They’re working hard on the plastics, with this concept of “shape memory,” which is almost like what we have with our NiTi wires. They’re changing the types of plastics they’re using. This is something we need to take note of and understand—will this be the future or not?

Another very important topic related to in-office aligners is that they’re reducing the number of attachments. I saw cases being done without attachments, and I’m seeing this in some companies as well. This is something we need to understand—will it work or not? Another thing I saw with Kenji is that they already have some in-office robotic technology to help with the detailing process of the aligner because otherwise, you need a technician to cut and prepare the aligners. I don’t think, as of today, it’s the best system. It’s impossible, in my opinion, to compete with the big companies.

But on the other hand, in Brazil, you have a lot of options, and in Portugal, we have some too. If we forget the three or four big companies in the market, and look at the smaller companies, for example, I know a small Portuguese company that’s succeeding with a few thousand aligners—not millions, but some thousands. What they have is a very small facility with printers, two or three technicians, and one or two CAD designers. So, this isn’t much more than an in-office aligner system. So, again, if you have a big clinic with, say, ten chairs, why can’t you have your own in-office system? Why can’t you have your own technician or a robotic system to handle your aligners?

To be honest, for me, for my concept, for my way of working, it will not work. I’m not going to invest time and money in that because I have a very small company. I have what I call a “gourmet clinic,” so my patients aren’t so focused on money.

Pedro Costa Monteiro:
"For my concept, for my way of working, it will not work. Because I have a very small company, I have what I call a gourmet clinic, so my patients are not so focused on money. I can charge them and get the best appliance in the market, in my opinion. So this is my way of being. But let's imagine I have a DSO with 10, 15, or 50 clinics—why not have my own system? This could probably be the future. This is, in an easy way, how I see it."

Daniel Ramos:
"Hello, Daniel here, just taking a quick break from this podcast interview to tell you about the DSD Aligners Course. I host a live-stream course where I teach dentists how to treat all their orthodontic cases with aligners, from simple to complex, with clinically validated and science-based protocols. Whether you’re an established Invisalign or clear aligner provider, an orthodontist, or a general dentist just starting out, this course curriculum covers the common challenges with proven systems. To get an idea of what the course is about, you can access a taster class free of charge on the webpage linked in the notes of this episode. Be sure to check it out, and I hope to see you at one of these upcoming courses. Now back to the episode."

Daniel Ramos:
"I agree because I was trying to outline all the steps we need to go through until the moment we deliver the aligners to the patient. You probably know this process much better than me because you visited two major companies and saw a lot of this technology. Now, remove that technology and put it inside your clinic. To invest in this kind of technology, you’d either need to be like Kiyo or need to invest a lot of money. And every year, you’d probably need to upgrade because things are changing fast. So for a doctor who is listening now and thinking, 'I don’t know what to do. It’s expensive for me to use a company, but they’re offering me the software so I can plan and make my own aligners,' they need to know the software is just one part of the process, right Pedro?"

Pedro Costa Monteiro:
"Yes, and software is only part of it. I know this because I work with a company and we use many different software programs, always training our team to stay updated. Software gets frequent updates, with new features and tools that we need to learn, and this requires a lot of time. So for orthodontists who are considering moving to in-office aligners, let’s imagine the process step-by-step, starting from the moment a patient comes into your clinic and accepts the treatment. What happens next?"

Daniel Ramos:
"Good point. So, basically, as all orthodontists would do, you start by diagnosing, right? Then, you collect the data—scans, photos, everything needed. Then, you have to send that data to any program that you buy. With an in-office system, you’ll need software to create the initial position and then the desired final position for the teeth. After that, you have to set up the staging plan and decide the attachment placements and force system to achieve that final position. It sounds easy, but in reality, it’s a complex process."

Pedro Costa Monteiro:
"Exactly. And it looks easy to us because in big companies, there’s a CAD designer working behind the scenes doing all this. When I visited, I got to see the CAD designers in action at both brands’ offices. And it was unbelievable. I stayed there for a day and saw how long it takes to design a case. For an experienced CAD designer, it takes about 10 to 15 minutes to create a case. For a beginner, even someone with special knowledge and daily instruction, it can take an hour. Imagine being in your office, using a new software for the first time, setting up the initial and final positions, staging, and biomechanics. It could easily take you four hours."

Daniel Ramos:
"Right, four hours at least. So, with that in mind, why not delegate this task?"

Pedro Costa Monteiro:
"It’s like this: every day, I have lunch at home, and I have two options. I can cook for myself, or I can call Uber Eats. For me, time is precious. I’d rather spend 15 dollars on Uber Eats and have good food than spend 30 minutes cooking and another 30 minutes eating. That’s one hour out of my day, and an hour of my time is valuable. It’s the same with aligners—you can make them in-office, but then you’re doing it every day, repeatedly. Yes, you can choose the best ingredients or the best materials, but doing it yourself every time isn’t necessarily more comfortable or efficient."

Daniel Ramos:
"And if you think about these big companies, they’re investing billions in technology and knowledge to give us the best treatment plans, reducing the amount of aligners and increasing precision. So why not trust them?"

Pedro Costa Monteiro:
"It’s a tough decision to make, but for me, this is how I see it. It all comes down to how you want to invest your time because you mentioned just one part of the process—designing and planning in the software. After that, you have to print the aligners, cut each one, separate, polish, and prepare them. I’m not saying it’s a bad solution; it can work. But if you look at examples like Kenji’s setup, I think that’s Graphy, right?"

Daniel Ramos:
"Yes, Graphy."

Pedro Costa Monteiro:
"Graphy—it's like managing an in-office big company. It’s hard for me to consider that route, but if I ran a DSO, I might think differently. It’s similar to how large hospitals or clinics often have their own labs. So why not have your own aligner lab? And there’s another topic Kenji brought up that I think we should discuss because it ties into this whole issue. One of the positive points about doing in-office aligners is pollution reduction. You only produce the aligners you actually need, so you don’t end up wasting hundreds of aligners that might never be used. That’s a big issue for all of us—companies produce a lot of plastic that’s difficult to recycle. Reducing that waste could be a huge advantage for in-office aligners."

Daniel Ramos:
"I completely agree. Kenji made an important point because we’re putting a lot of plastic out there. Like you, I’ve been pushing the companies on this. Why can’t they print just batches and wait for quality control before continuing? If we need to adjust, we can do a refinement without unnecessary waste. What Kenji is doing helps everyone understand that he plans the case in stages and doesn’t produce everything at once."

Daniel Ramos:
"Impossible. Then there's the software, of course, and if we look at the three big companies, come on—they aren’t that different. The software systems are basically copying each other, so if you know how to work with one, you’ll adapt pretty easily to another. They’re always launching new features, but be very careful with this. I’m quite focused on the stock market, and we know that when stocks are going down, companies tend to launch everything they can to push stocks back up. So, be careful when you see a new feature; try to see if there's actual science behind it or if it’s just clinical cases. We see this every day. We understand that it’s business and they need to launch something, but be cautious, as we're dealing with health and patients. Don’t apply something to your patients if you don’t believe it’s orthodontically sound. Be careful about that."

Pedro Costa Monteiro:
"But obviously, the more features we have, the more possibilities we get, and ultimately, our treatments will be better. So, for me, having more features is important. One thing I’ve learned, at least from working with two different companies, is that I appreciate a company that allows or at least listens to your ideas. For example, if I’d like to change the design of the attachments, I like a company that says, 'Okay, we’ll do it for you. Try it, and if it works, great. If not, we’re here to help.' Being an early adopter, I like to try new things. So, for me, it’s important to have a strong relationship with the CAD designers and the staff. I think we need to work as part of a team, almost like a family, to achieve the best outcomes because, otherwise, it’s difficult to go it alone. Together, we achieve more, and that’s something I try to foster with the companies I work with."

Daniel Ramos:
"Right. And we need to be careful with the marketing around every company. I’m not talking about any one company in particular; it’s true for all of them. And I think both of us enjoy marketing, so we know how to use it effectively, but we have to do it honestly—with the doctors and, ultimately, with the patients, who are the most important reason we’re here."

Pedro Costa Monteiro:
"Exactly. You make a good point, and I’ve heard the same from colleagues who switch from one company to another because they feel like they’re not being listened to. They say it’s hard to communicate, and it takes a long time to get responses. So, if you’re listening, it’s crucial to investigate this and talk to colleagues to understand what they like and don’t like. Check if you’re going to get the kind of support you need."

Daniel Ramos:
"And then there’s the branding, of course. Our patients come to us, and if we offer a well-known aligner system with a solid brand, they’re already familiar with it. It’s easier to sell than a system they’ve never heard of. Otherwise, they might feel suspicious and ask, 'Why are you using this system and not the best one?'"

Pedro Costa Monteiro:
"I can share my experience on that, if you’d like. About nine months ago, I changed to a new company, and when patients came in, I’d tell them, 'I changed brands. I’m using a new one because of this or that reason.' And they’d just say, 'Doctor, we trust you. If you say this is the one, then we’ll go with this one.' They didn’t care about the brand. And this isn’t just my experience; I’ve spoken to other friends using different brands, and they all say the same thing. The most important factor is the orthodontist. If the patient has a good relationship with you and you’re honest with them, they’ll trust your judgment. At the end of the day, they want to straighten their teeth, achieve good aesthetics, and have a nice functional outcome."

Daniel Ramos:
"Yes, and that’s a key takeaway for colleagues listening, especially those who may not have as much experience. Many brands will try to push you by saying, 'We have this feature' or 'Our plastic is better.' Don’t worry about that. Be honest, focus on diagnosis and treatment planning, and you’ll succeed with any brand."

Pedro Costa Monteiro:
"Absolutely. Building that trust with your patients, where they say, 'I trust you, Pedro; whatever you say, I’ll go with,' is something we work hard for. Maybe one day, we can do a podcast just about building patient trust because it’s something I could talk about for hours. For me, it’s all about investing energy and time in that first appointment. My first appointment is a big one. I do everything I can, all the exams, and I charge for it—an expensive first appointment. This is something I’ve really pushed for here in Iberia because in Portugal and Spain, a lot of very good orthodontists still offer the first appointment for free. I don’t believe in that approach. If you go to any other type of doctor, whether it’s a pediatrician, oncologist, or any specialist, you pay for that diagnosis, even if they don’t do any treatment. We’re part of the medical profession, so we need to charge for our expertise. But with that fee, we should give patients everything we can in that first appointment."

Daniel Ramos:
"And this is where AI can really help us. You know better than me, with all the features DSD offers—extraoral and intraoral scanners, live simulations, mockups, and more—you have amazing technology to give the patient the best experience possible. I learned this approach from you and Christian. You’re really the best at creating that exceptional first appointment experience."

Pedro Costa Monteiro:
"Thank you. That trust—when patients tell us, 'I trust you'—is incredible. But to get there, like you said, we need to invest time and energy. So, for anyone considering which aligner system to use, if you have a system that saves you time and offers speed, quality, reliable materials, and good customer support, then you start connecting the dots and figuring out if it’s the right system for you."

Daniel Ramos:
"And as you mentioned, we don’t really have a serious paper comparing all the systems and saying which one is best because this is a competitive field. Companies are publishing their own research, so we’re not only relying on science to answer these questions. In the end, the most important thing is that human connection, having someone there to answer your questions and solve your problems. When a patient is complaining or needs something, you want to be able to respond to them effectively. So, we have a lot of arguments today, Pedro, to justify using a company system. I really liked your point about the software. They’re very similar now, so it can come down to a personal decision on which one you prefer. The technology itself is pretty comparable across the major companies. We probably have three that are in a different league."

Pedro Costa Monteiro:
"Yes, and if you want to know which ones, you can message me or ask Daniel later! But the options are there, and this competition is actually good. One company pushes the other, like with iPhone and Galaxy. One brings out a bigger camera, and the other follows, and it goes back and forth. This competition drives improvements, and that benefits us as orthodontists and ultimately the patient."

Daniel Ramos:
"Exactly. My final thought here on the in-office vs. company debate is that, personally, I choose to use a top company. Even though it may be more expensive, in the end, it’s cheaper because of the experience, the time saved, the quality of materials, and the improved patient experience. I’ve tried in-office aligners, smaller brands, and major companies, and I settled on one of the top three for this complete package."

Pedro Costa Monteiro:
"I completely agree. Beyond just the features, these three companies offer things we don’t have with in-office setups. If you want buttons on the aligner, CBCT integration with your STL, or specialized attachments for elastics or mandibular advancement, it's challenging to do this in-office. I see the current in-office systems as similar to the old setups we did in the past with our S6 appliances for minor crowding. When you see cases like Kenji’s, where he’s doing extractions without attachments and with shape-memory plastic, it’s impressive, but he’s Kenji. There’s really no one else doing it on that level. While I think in-office will continue to grow, to be honest, it’s not for me. I’ll be out of the system by then."

Daniel Ramos:
"Pedro, it was a pleasure to have you here. Amazing energy and insights, as always. I’m sure everyone listening enjoyed this, and I’m so happy to have you here."

Pedro Costa Monteiro:
"Thank you so much. And thank you, everyone, for supporting us, for being with us on social media. I’m so happy to be part of this project and look forward to seeing you soon. Now that we’re closer geographically, I’m sure we’ll be seeing each other more."

Daniel Ramos:
"Thank you, my friend. Thank you to everyone for listening to the podcast, and see you soon. Bye-bye."

Pedro Costa Monteiro:
"Bye-bye, see you!"

Daniel Ramos:
"Thank you for listening! This episode concludes Season 1 of the Expand podcast. It’s been my pleasure to bring orthodontic insights with a selection of high-profile and interesting guests. If you enjoyed listening, you’ll be pleased to know we’re bringing out a second season with more guests and exciting topics. Stay tuned!"