For a glimpse of the future of orthodontics, consider a peek inside Motor City Lab Works, a Birmingham, Michigan, office filled with 3D printers and other equipment that create custom retainers and clear plastic aligners.
In the laboratory, technicians use digital imaging and printers that spray resins to not just straighten people's teeth, but also potentially save patients thousands of dollars and the discomfort of metal braces.
"This is like the Terminator coming out of the metal," lab co-owner Christian Groth said, describing how one of the big printers works. "You know when the Terminator came out of the liquid? This is kind of what this printer is like. You've got this liquid resin and the model is rising out of it."
In the science fiction film, it took seconds for the liquid-like substance to take solid form. In real life, it takes minutes and hours to make orthodontic models.
Still, dentists and orthodontists say it is only a matter of time before even more sophisticated technology makes it possible to make plastic appliances during patients' appointments and for entrepreneurs, such as those behind SmileDirectClub, to sell more do-it-yourself treatments.
The advances already are setting off some big legal – and medical – clashes.
The broader question in the medical community – not just among dentists and orthodontists – is what limits, if any, should be put on entrepreneurs as innovations give patients treatment options that eliminate face-to-face visits with licensed professionals.
"One of the struggles that we are having in this field right now is getting both sides of the story," Groth said. "The two sides of the story are the SmileDirectClub side and the other side is the orthodontists and dentists."
The dental industry has been transformed in the past 20 years by computers that can design a sequence of clear aligners – plastic appliances that fit over the teeth and nudge them into place – to replace metal wires and brackets.
Moreover, 3D printer technology, which has helped create the molds for the aligners, has become more sophisticated and affordable, giving rise to companies such as SmileDirectClub – started in Detroit by two entrepreneurs who grew up in Michigan – that sell the aligners directly to patients.
SmileDirectClub emphasizes convenience and cost, calling its service "the secret to affordable braces for your teen" and saying that it "eliminates the middlemen who mark up the cost and cuts out all those unnecessary monthly office visits."
SmileDirectClub says that braces can run US$5,000 (RM19,561) and more, but with the company's aligners, children 12 and older can have their smiles transformed for US$1,850 (RM7,237).
With the click of a mouse, SmileDirectClub customers can set up a free, 30-minute appointment to book a scan of their mouth at a shop and order a kit to make their own teeth moulds to mail back to get "a digital rendering of how great your new smile will look following treatment."
But, Kevin Dillard, general counsel for the St Louis-based American Association of Orthodontists, argues that orthodontists are essential and that self-treatment, such as that offered by SmileDirectClub, can in the long run, do more harm – and cost more – than good.
"If what they mean by bypassing the middleman is taking the specialist or the professional out of the treatment plan process or follow-up process, that's a bad thing," Dillard said. "These people are specialists who make sure the teeth and jaw fit together properly."
Last April, the association, which represents more than 19,000 orthodontists around the world, filed complaints with boards and attorneys general in 36 states, raising concerns about whether SmileDirectClub was improperly providing medical treatment.
SmileDirectClub said in an email to the Detroit Free Press that it works with a network of more than 225 licensed dentists and orthodontists.
"It has been and will continue to be our primary mission to provide customers a more convenient and affordable option for straightening their teeth than what is offered by traditional orthodontics," the company said. "SmileDirectClub's teledentistry model provides greater access to care for thousands of customers who, without cost-effective invisible aligners and convenient remote care, would not otherwise have access to a viable teeth-straightening option."
It also said it is "a target of a well-funded lobbying and public relations effort" to shut down "pioneers of innovative, affordable teledentistry services," and "to date, not one dental board has taken any adverse action against SmileDirectClub or any of its affiliated state-licensed dentists or orthodontists."
Dillard countered that the orthodontists' association is a nonprofit organization, while SmileDirectClub is a privately held company backed by deep-pocketed investors, and it remains to be seen what actions states will take.
The idea of using braces to straighten teeth dates back thousands of years, the evidence of which comes from archaeologists who report finding ancient mummies with what appear to be metal bands around their teeth.
Modern orthodontics took root in the 18th and 19 centuries, and by the late 1990s, two Stanford University business students – Zia Chishti and Kelsey Wirth – found they could use 3D computer imaging to make clear plastic aligners to replace wires and brackets.
Chishti and Wirth had been orthodontic patients but were not orthodontists.
They took their innovation to market, forming the now-public San Jose, California-based company Align Technology. The company sold the clear plastic appliances, which they called Invisalign, to dental and orthodontic practices.
Groth, whose father is a dentist, said he was his dad's first Invisalign patient.
"This is moving teeth with plastic," Groth said of the aligners. "Before that, it was impossible to take a digital model, sequentially move the teeth on the computer and take it into the real world and make physical models."
In recent years, Groth and other orthodontists have realised that they can invest in their own labs to affordably make their own appliances for patients and even have a small business manufacturing them for other practices.
Makers of 3D printers see dental offices as an opportunity to sell their products.
And entrepreneurs have figured out that they can now sell appliances directly to patients by mail, offering customers a lower-cost alternative to traditional treatment that cuts the expense of visiting an orthodontist.
They say that if you can buy contact lenses and eyeglasses online, you should be able to buy orthodontia.
Alex Fenkell, who had braces, and Jordan Katzman met at age 13 at summer camp. They started a company in 2014 to, as they put it, "democratise orthodontics" by selling aligners directly to patients.
Initially, they called their company SmileCareClub, and later renamed it SmileDirectClub and moved it to Nashville.
The privately held company is backed by Camelot Venture Group, a private investment group that also has invested in 1-800 Contacts, and enterprises owned by Detroit businessman Dan Gilbert, including Quicken Loans, Fathead and the Cleveland Cavaliers.
In 2016, SmileDirectClub sold Align Technology a 17% stake in the company for US$46.7mil (RM182.53mil) and agreed to have Align manufacture its clear aligners. The next year, SmileDirectClub sold Align Technology another 2% for US$12.8mil (RM50.03mil).
Align Technology said in an email that it "values its relationships with its doctor customers and with industry organizations" and that the American Association of Orthodontists' complaints are an issue for SmileDirectClub to address.
The direct-to-consumer concept has set the stage for legal showdowns in several states.
In Michigan, the Michigan Dental Association published an, "MDA Probes SmileDirectClub," in August that raised questions about "out-of-state companies performing orthodontia-type services through mail-ordered, self-administered impression kits and retainers."
The report said "this method of providing diagnosis and treatment raises numerous legal and patient safety concerns." It added that the association sent a letter to SmileDirectClub asking it to respond "to questions to determine whether it is complying with Michigan law," and that the company responded but "refused to identify Michigan dentists involved."
The next month, SmileDirectClub filed a lawsuit in U.S. District Court for the Western District of Michigan. The company accused the MDA of libel and said it "recklessly impugned the competence and maligned the reputation of SmileDirectClub."
It also filed a lawsuit in US District Court in the Southern District of New York against orthodontists and practices in New York and New Jersey that posted YouTube videos warning that there were risks of using the company's products.
"The MDA article is the latest in a series of anti-consumer activities aimed at limiting access to affordable aligner treatment," the company said. "SmileDirectClub's web-based teledentistry platform and SmileCheck system are both innovative and disruptive by nature, and the affordable and accessible tenets of the company's business model challenge the business interests of more traditional orthodontic delivery models."
The MDA took the issue to the American Dental Association.
In November, the ADA, which is based in Chicago and has more than 160,000 members, said it "strongly discourages" the practice of do-it-yourself orthodontics because of the potential for patient harm. Moreover, leaders in the organisation criticised direct marketing campaigns encouraging people to "manage their own orthodontic treatment."
Dillard, who represents the American Association of Orthodontists, said he fears SmileDirectClub may be trying to use lawsuits to chill any discussion or warnings about whether the company's process may pose any risks to patients.
In addition to the enticing advertising, dentists and orthodontists fear that the availability of do-it-yourself videos is playing a role in convincing people to try to treat themselves.
In 2016, online reports of a digital design student in New Jersey using a 3D printer to make his own set of orthodontic aligners for less than US$60 (RM234) – similar to ones that cost thousands of dollars – went viral.
The student, Amos Dudley, published on his blog how he did it. He said he was unhappy with his crooked teeth and wasn't smiling, so he did some research on orthodontic alignment, took a mould of his teeth, and used 3D imaging and a 3D printer to make his own dental appliances.
"As far as I know, I'm the first person to have tried DIY-ing plastic aligners," he wrote, after wearing them for 16 weeks. "They're much more comfortable than braces, and fit my teeth quite well. I was pleased to find, when I put the first one on, that it only seemed to put any noticeable pressure on the teeth that I planned to move – a success!"
He also posted a warning: Don't ask me to make you braces. I'm not an orthodontist.
Still, orthodontists fear Dudley's experiment, and others like it, will encourage more self-treatment.
Last year, the American Association of Orthodontists said that nearly 13% of its members had patients that tried do-it-yourself teeth straightening, and some of those attempts caused irreparable damage.
"Moving teeth is best done under the direct supervision of an orthodontist after an in-person assessment, including complete diagnostic records," said DeWayne McCamish, who was then president of the association. "It's really a shame when someone comes in after attempting DIY orthodontic treatment and we determine that the damage they've done to their teeth is so extensive that teeth cannot be saved."
The group warned that using Internet videos and websites to practice medicine "could result in the permanent loss of teeth, which may result in expensive and lifelong dental problems," and pointed out "orthodontists receive two to three years of specialised education beyond dental school."
SmileDirectClub makes the case that more remote treatment – what it called telehealth – is coming.
"The telehealth model provides access to health services for millions of customers who need them but wouldn't otherwise have the funds or time to receive them," it said in an email. "Telehealth connects qualified health care providers with underserved patients affordably and conveniently."
Motor City Lab Works opened in 2014 as a separate business from Groth's TDR Orthodontics practice.
"We got into it by necessity," Groth said of the lab. "We moved our workflow fully digital and we were doing so much business with outside labs it made sense for us to bring it in-house and there wasn't a low cost option for our colleagues, so we decided that we can do this."
The five-employee laboratory takes digital images of patients' mouths and turns them into virtual 3D models that can be adjusted to create a series of moulds in three different 3D printers that will be used to create orthodontia to move their teeth and fix their bites.
Groth said the lab – which is a small part of a four-office, six-orthodontist practice – allows the partners to offer more products to their patients at a quicker pace. It also gives their patients more options to customize orthodontia, sports mouth guards for example, in their school colours.
The lab now supplies about 225 other offices and last year had revenue of about US$600,000 (RM2.34mil).
Groth said it is difficult to predict what will happen in the profession's future.
It's likely, he said, that as technology improves, more orthodontists will invest in digital printers.
It's also likely that entrepreneurs will try to find ways to offer orthodontia directly to patients.
"You've got a lot of do-it-yourself aligners – and there's going to be more," he said. "There have been thousands of people who have gone through it and are happy with the results. They also have lots of people who have gone through it and are unhappy with the results." — Detroit Free Press/Tribune News Service