From Italy, the signs of the demand boom for invisible aligners in Europe

Problems of malocclusion for two out of three Italians

Almost two out of three Italian adults affirm to have dental malocclusion or misalignment problems. The demand for clear aligners in dental clinics is already booming.

This is demonstrated by an extensive market study carried out by Key-Stone Research Institute, which integrated data both from industry and dental practices.

Key-Stone analyzed the phenomenon thanks to an extensive survey, carried out on a representative sample of 2,878 Italians, aged between 20 and 50 years, representing more than half of the national population.

The study shows that 55% declare problems of malocclusion, already corrected in adulthood with orthodontic braces in 19% of cases. For that matter, this is a share also confirmed by plenty of international literature.

Malocclusion: the Italians’ perception

The Italians’ perception about this problem is very interesting, as well as the great desire to solve it. These aspects were investigated on over 1,000 individuals, that is 36% of the sample who reported a malocclusion yet untreated (at least 8 million people in the age group investigated).

Among them:

  • 60% complain of dental misalignment, considering it to be minor
  • 34% consider the problem as moderately severe
  • 6% consider the misalignment as very evident

The age group between 25 and 35 years is the most sensitive to the issue, judging the imperfection generally to be more evident.

Impact on the aesthetic and functional levels

Malocclusion mainly concerns aesthetics and, according to the interviewees, it worsens their appearance in 90% of cases, albeit with different levels of perceived severity.

Anyway, the problems mentioned by the sample are not only aesthetic. The survey provided for the possibility of reporting different symptoms (multiple choice):

  • in 28% of cases, difficulties in chewing were mentioned
  • in 28% of cases, gum problems emerge
  • difficult oral hygiene, as disclosed by about one third of the sample
  • orthopedic and postural issues, albeit to a lesser extent
  • only 20% do not report any functional problems related to malocclusion

The propensity to solve the problem

Although with different degrees of motivation, 72% of the sample affirmed to be interested in correcting their malocclusion or misalignment. In particular, half of them (36% of total respondents) show a high motivation. Translating this into numbers, it deals with over 3 million Italians, mostly women – twice as many as men – with a significant greater interest as the evidence of the defect increases.
The strong propensity to correct their smile exceeds 50% for those who complain of a very evident misalignment and, more generally, it is over 40% among those who have both aesthetic and functional problems.

Restoring a perfect smile with the aligners

Among those wishing to correct their smile, 62% would prefer to use a transparent aligner system. For another 30%, the type of device does not matter, but it would be very important to them to solve the problem of dental misalignment. It is above all those who present more serious dental conditions who want to solve the problem, regardless of the type of medical device the orthodontist will suggest.

Limits and forecasts

Slightly more than 70% of the interviewees have already considered the possibility to consult a dentist to solve the problem, but the economic barrier is the most named brake in accepting orthodontic treatments in the short term, particularly during this time of uncertainty due to the pandemic. Nowadays, part of the population is, in fact, more cautious when taking into consideration expenses likely impacting on the family budget.

In any case, 6% have already decided to go to the dental office to solve the problem and, if the doctor evaluates positively the need to carry out the alignment orthodontic treatment, it can be estimated that almost half a million people could undergo corrective treatments soon.

Over 150,000 treatments with aligners in 2021

According to Key-Stone researchers, this figure is consistent with the measurements carried out by the research institute itself, specialized in the dental sector at international level. In fact, data coming from industry and dental practices indicate that in 2019 over 80,000 treatments with aligners were carried out (in the vast majority of cases on adults). In 2021, over 150,000 treatments will be carried out, which is twice the previous figure, after having experienced an evident slowdown in growth in 2020, due to the pandemic.

According to Key-Stone’s estimates, this is an investment for Italians which will exceed 300 million Euros by 2021 and will continue its double-digit growth in the next few years.

Patients treated with aligners

Motivation for treatment

Within the starting sample, 200 cases involving subjects who recently underwent orthodontic treatment with transparent aligners were also studied. The goal is to evaluate the reasons leading them to the treatment and the overall perceived experience.

Considering the 200 patients treated, it emerged that the psychological component is absolutely dominant in the motivation for treatment:

  • 44% in fact stated that they wanted to solve the discomfort first of all with themselves
  • 35% claimed that they wanted to improve the relationship with others, showing a social discomfort as well.


In general, the experience and perception of the treatment outcome are very positive, with 34% of treated patients affirming to have achieved a better result than expected and, undoubtedly, beyond the initial expectations. The main factors causing satisfaction are:

  • first of all, the competence and interpersonal skills of the clinician and of the clinic staff in general
  • the final result, on average very satisfactory
  • comfort and transparency as distinctive elements of the treatment.

Overall, over 85% would re-undergo the treatment and recommend it to friends and family. This means that, in addition to the strong interest of a part of the population in solving their misalignment, the positive experience of friends and relatives generates a driving force in the sector, fostering positive references and organically stimulating the demand.

The market of dental Aligners in Italy

Since their debut on the market – in the late 1990s and early 2000s – it was evident that invisible aligners would revolutionize the world of orthodontics or at least make significant changes in the way we mean it.

First of all, this is due to the fact that in the aligners market the weight of services is greater than the weight of products, which is the opposite of what happens in traditional orthodontics.

Aligners vs traditional orthodontics

The graph below shows the progressive increase in the weight of aligners over the years, compared to traditional orthodontics (brackets, bands, wires, etc): in 2011 it was 27%, while in 2019 it exceeded 60%.

Furthermore, although the market is still dominated today by a large player – deserving the credit for having introduced the “Invisalign system” all over the world and for having built a previously nonexistent market -, other players from the orthodontic domain joining the market could change some dynamics.

Some of these companies, in fact, have a strong know-how in both digital and orthodontics. The business will therefore tend to shift the focus from the appliance to the planning system. The clinician will work with an increasingly integrated single digital system, which will let him approach orthodontic treatments (either with aligners, traditional solutions or hybrid ones) according to the complexity of the case and his/her level of competence (orthodontist or GP).

The offer of aligners: a “liquid market”

The offer varies widely: from the multinational corporation already operating in the dental sector and specialized in orthodontics (range extension), to the company focused on other specializations such as implantology (range diversification); from the local manufacturer with centralized production to the dental laboratory (sometimes organized in the form of a network), equipped with all the technologies necessary for the production of aligners.

We are therefore facing a “liquid market“: the boundaries between organizations and along the supply chain are becoming blurred. It is a business in which manufacturers and laboratories with different levels of production centralization operate and compete. On the one hand, there are companies featuring a centralized and industrialized production system where the structure of the processes is controlled, repeatable and organized process design. On the other hand, there are more local companies or those characterized by peripheral organizational and process dynamics.

Penetration of the aligners technique

A first survey carried out by Key-Stone in October 2020 on a sample of 400 generalist dental practices to evaluate the penetration of the technique and the main brands revealed a 79% of respondents who claim to suggest – even occasionally –aligners to their patients, even if only occasionally. Please consider that this percentage was 61% in 2018, according to a previous study in the same topic.

Production channels

A more in-depth analysis of the most used brands shows how the laboratories supply channel covers 28% of the dental practices procurements (although only 10% exclusively). Through the analysis of the brands mentioned by those clinicians supplied by laboratories, it emerges that most of them refer to in-house handcrafted productions.

The aligners market in Italy in 2020

It is estimated that more than 80,000 cases were performed in Italy in 2020, excluding purely handcrafted processes, which were not taken into consideration in the research conducted by Key-Stone at the end of 2020 on the aligners market in Italy. The market value is estimated at just under 85 million Euros (at sell-out level, at value to the dentist and VAT excl.), leaving out purely handcrafted manufacturing.

The growing trend in Italy

The most relevant growth was recorded in 2019, thanks to both Invisalign’s entry into the world of GPs and the commercial development of some companies relying on a very extensive sales network.

Positioning drivers

In fact, aligners deserve credit for making orthodontics “accessible” also to general dentists. Accurately supported by an excellent tutoring service, increasingly advanced and intuitive softwares, training courses and marketing activities made available by companies, dentists have decided to expand the range of treatments offered to their patients.

In the research conducted by Key-Stone at the end of 2020, the main positioning drivers emphasized by companies in their value proposition were analyzed as well. From this study it emerged that, in addition to the transparency and comfort of the aligners (now essential conditions), the positioning drivers are:

  • duration of treatment: if too long, the patient’s compliance decreases, as well as the revenue of the dental practice. If we consider the concept of time as applied to logistics, the companies are striving to reduce the time involved in planning treatments, manufacturing and shipping aligners to customers.
  • the service offered in different areas. Companies have invested enormously in assisting dentists in the design and set-up phases, but also in training (classes, webinars, presentations, certifications, etc.) and consulting, making available to the dentists teams of clinicians and / or specialized technicians throughout the treatment period.
  • the treatment planning and management software and the data sharing platforms can be owned by the company and therefore developed and implemented internally or multi-client, then purchased from external providers (3Shape, Age Solution etc.) and sometimes adapted to specific needs.
  • technological innovation represents a real differentiation driver. Companies of the sector with an industrial approach generally have a processes organization which is a great competitive advantage per se. Moreover, technologies available to manufacturers, due to the large investments required, are generally not found in laboratories or small companies: the gap on production quality is therefore widening.

Some future trends

A phenomenon that we are witnessing and that Key-Stone will try to monitor in the future is the “direct to consumer” business model, which involves physical stores or solutions that are directly delivered to the patient’s home, thus bypassing the dental office. In the USA, their diffusion has been successful, while in Europe the legislation on devices is more stringent, so the business model designed is different.

There is no doubt that artificial intelligence applied to orthodontic planning tools and the implementation of the digital workflow with the use of suitable technologies fosters these phenomena, making it nowadays possible to perform:

  • 3D diagnosis
  • virtual rendering of the treatment progress and outcome
  • design and production of the appliances
  • supervision – even remotely – during therapy
  • analysis and re-processing of the results for continuous improvement as well as for statistical purposes.
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