Abstract
It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence. —William Kingdon Clifford
1
In the rapidly expanding Indian clear aligner landscape, this maxim is especially relevant because enthusiasm, marketing, and patient demand must never outrun evidence, training, and ethical oversight. Clear aligner therapy (CAT) has rapidly transformed the landscape of contemporary orthodontics. The Indian clear aligner market was valued at approximately $96 million in 2022 and is projected to grow at a compound annual growth rate exceeding 34%, potentially crossing $1.3 billion by 2031.2, 3 Amidst this enthusiasm, however, an important question emerges: are we expanding aligner therapy responsibly or merely commercially?
CAT offers genuine clinical advantages—esthetics, removability, and better patient-reported quality of life compared with fixed appliances—and for appropriately selected cases, systematic reviews confirm outcomes comparable to conventional treatment.4, 5 The evidence for CAT, while growing, must be interpreted with care. Overall tooth movement predictability ranges between 55% and 72%, with rotational movements of maxillary canines as low as 48% accuracy.6, 7 Vertical control and torque remain challenging, and a landmark 2023 overview of systematic reviews rated the overall evidence as low to moderate in quality. 5
High-quality randomized controlled trials with long-term follow-up beyond 2 years remain scarce, and much of the existing literature pertains to a single commercial system, with comparatively limited independent data on the numerous domestic and international brands now available in India. Despite these caveats, technological progress is real and meaningful. Advances in thermoplastic materials, attachment design, and artificial intelligence-assisted digital treatment planning have improved predictability across successive aligner generations. The problem, as this editorial argues, lies not in the technology itself, but in the conditions under which it is too often deployed.
India’s orthodontic landscape adds layers of complexity. The malocclusion profile of Indian patients, with a higher prevalence of skeletal discrepancies and bimaxillary proclination—means many presenting cases are not ideal candidates for aligner-only treatment. 7 Yet commercial pressure and patient demand may incentivize practitioners to attempt aligner treatment in cases better served by fixed appliances or combined approaches. Aligners in India are increasingly prescribed by general dental practitioners with minimal formal training in orthodontics, a phenomenon driven by commercial certification programs offered by aligner manufacturers that cannot substitute for specialist education. More troublingly, direct-to-consumer (DTC) aligner models have entered the Indian market, bypassing clinical examination, radiographic assessment, and professional oversight entirely—a model whose global embodiment, SmileDirectClub, collapsed in 2023, leaving millions of patients without recourse. 10
The ethical imperatives are clear. Every patient deserves a comprehensive clinical and radiographic evaluation before commencing CAT, honest counseling about its limitations and the real possibility of refinement, and regular in-person monitoring throughout treatment. 10 Commercial certification is not a substitute for specialist training. We call upon the Indian Orthodontic Society and the National Dental Commission to develop evidence-based guidelines for aligner case selection and prescriber competency, to pursue regulatory oversight of DTC models, and to embed digital orthodontics formally within postgraduate curricula. The research community must similarly prioritize India-specific outcome data.
Aligner therapy is a genuinely valuable tool when used with clinical rigor and appropriate case selection.4, 11 It is equally capable of harm when deployed without professional oversight.9, 12 The challenge before us is not to resist innovation, but to ensure that innovation remains accountable to evidence, competence, and patient welfare. That is the standard our patients deserve, and the standard to which our society must hold the profession.