- Dr. David Alfaro
Clear braces, are they for you?
More and more adults are seeking orthodontic care nowadays, and one of the main driving forces in this trend is the emergence of various clear aligner systems, such as Invisalign. I am pretty sure that everyone reading this has heard of Invisalign and knows someone who has had it done and perhaps even considered it themselves.
Of course, being a dentist, whenever I run into someone who has Invisalign on, they want to chat about it, and I often find myself having to bite my tongue. Clear aligner systems are valid orthodontic techniques, but they definitely have their limitations. Case selection is key to success.
Unfortunately, I keep running into people who have clear aligners on, and without even completing an examination, I can tell that their malocclusions (misaligned bites) are way beyond what the indications of a clear aligner system are. And then I probe.....how long have you been in treatment? Over two years..... Are you happy with your smile? Yes, pretty much. How about your bite? mmmmm, well, it feels funny.
And the kicker.....ok, well who is your orthodontist?
My orthodontist? No, I did not see a specialist.......
Let us talk about clear aligner systems.
What are clear aligners?
The concept of using clear plastic trays to move and hold teeth in position has been around for decades, but recent advances in computer design and computer manufacturing processes have caused a significant boom in this industry since the late 1990's.
There are currently multiple clear aligner orthodontic systems on the market, with the most well known product being Invisalign. Generally, clear aligners work in this manner:
1. The dentist (or assistant usually) takes an impression of the teeth and submits the case to the company, along with photographs and radiographs. The impression can be made with the traditional impression pastes, or they can be taken with intraoral digital scanners.
2. The dentist then fills out an online "prescription" for the patient, where they indicate what teeth they want moved, and how. Most of the products have some sort of 3d modelling that you can show the patient to estimate what the final result will look like.
3. The company then makes a series of "trays", which the dentist is to deliver to the patient on a specific schedule. The dentist may have to make modifications to the teeth as treatment progresses, such as making teeth thinner or adding attachments that help control the forces.
Normal treatment times range from 6 months for simpler cases, to upwards of 2 years for more complicated scenarios.
What are the benefits of clear aligners?
There are many advantages of clear aligner systems in comparison to traditional braces.
1. People like the option of a clear tray
Patient acceptance is great, especially for adults. The trays are clear, and while not invisible, can be barely noticable at conversation distance. The ability to take them on and off for social settings and public speaking engagements is a huge advantage for adults and teens alike.
2. It is removable
Being removable appliances, clear aligner systems have significant advantages in terms of home care. Patients can continue with fairly normal brushing and flossing habits, and research has shown that clear aligner systems result in much less gum inflammation and plaque buildup in comparison to traditional braces. Furthermore, as there are no brackets and wires everywhere, there are no dietary restrictions like in traditional appliances.
3. It is simpler for the dentist in comparison to traditional braces
There are some advantages to the dentist as well, as appointment times tend to be shorter, less supplies are needed, there are less emergencies, and minimal training is required in comparison to what is necessary in order to properly learn how to provide traditional braces.
What are the disadvantages to clear aligners?
1. Clear aligners alone have limited indications
These clear tray systems are not meant for every type of "malocclusion". They are really best suited for minor cases of misalignment of the front teeth.
2. Advanced cases require a combination of clear aligners and traditional orthodontic techniques
Advanced users have developed techniques that allow them to take on more challenging cases, but they often include the use of buttons and elastics to help move teeth. The reason for this is very obvious: the trays cover the biting surfaces of the teeth.
Because the trays cover the teeth entirely, there is no way that the dentist can properly align the bite without using some sort of advanced technique. The tray often has to be sectioned, thus allowing the biting surfaces to come together. Some dentists allow the teeth to passively erupt to come in to place, which to me is way too arbitrary. Why would you spend months in these appliances to let the bite come together on its own?
More experienced clear aligner providers will therefore section the tray and apply buttons and elastics to the teeth to help close the "open bite" that often happens during this treatment. Some even tell their patients to expect a period in their treatment where they have to wear traditional braces to complete the movements that are just too challenging for the clear aligner systems.
This means that someone providing clear aligner treatment must have a good working knowledge of traditional orthodontics if they really want to be providing their patient with the best treatment possible.
3. Many of the systems require minimal training.
Orthodontics is complex dentistry; there is no arguing that. If someone tells you that orthodontics is simple, they have not seen the negative outcomes that can happen with poorly executed clear aligners and traditional orthodontic appliances.
Many of these clear aligner systems, however, require minimal training to start providing these treatments. It is usually as simple as taking a one day class, learning the submission protocols and technical requirements and you are good to go. There is no requirement of proof of competence in traditional orthodontic theory or techniques to be able to start moving peoples teeth with these clear aligner systems.
My orthodontic training consisted of me sitting upstairs in graduate orthodontics "observing" the graduate students bonding brackets, and at most making a couple of retainers. Yes, I took the Invisalign course and I even started a couple cases in the clinic under the supervision of someone who had completed thousands of cases in her own practice.
But.....do you really want me moving your teeth? No way. Go to someone with way more experience and training.
I am considering getting clear aligners, what should I take into consideration?
Be an informed consumer. Ask questions.
Would traditional braces be better for me?
If the answer is no right away.....that raises a flag!
Will I need buttons or elastics?
If the answer is no.....then ask how they plan on finishing the bite, considering the trays cover the biting surface.
Do you do traditional braces?
If the answer is no, they may not have the background knowledge required to fix things if the case starts going the wrong way.
Many dentists get to be pretty good at clear aligners by trouble shooting cases and going to study clubs, and there are many non-orthodontists that are very competent providers with advanced skill sets in clear aligner treatment. But, this comes with time, with the experience of working through many cases, and with the participation in lots of continuing education. Not everyone is there though....
The reality is that when the treatment starts straying away from what was planned, all the novice user has to do is "reboot" the case. These clear aligner companies have made it really simple for dentists who have little to no experience in traditional orthodontics to provide treatment. If things start going awry, all the dentist has to do is to take new impressions and new records and order a whole new set of trays. And then repeat until close enough.
That is not orthodontics.
Should I see a specialist?
Always consider a consultation with a specialist when you are contemplating complex dental treatments such as orthodontic tooth movement. Yes, general dentists can get the training and skills required to perform these advanced procedures, but there is no harm in getting the opinion of a certified specialist before starting your care.
Every good general dentist should have a comprehensive group of dental specialists that they work with, that are part of their team, that are colleagues, and that are resources that help them provide better care for their patients. If your general dentist is hesitant to refer you for a consultation, you have to ask yourself why.
There is a lot of competition in Vancouver, and people are afraid that they will "lose" the patient if they are referred for a specialist consultation, but it should not be considered so threatening. Getting a second opinion allows for a fresh look at the scenario, and can help identify potential challenges and limitations to the treatment options. Being informed is never a bad thing.
Your smile is worth a consultation with a specialist.
Thanks for reading!
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Certified Specialist in Prosthodontics