Tag: Invisalign Teen

If considering orthodontic treatment using Invisalign clear aligners, there are ten important facts that will assist you when making a treatment decision.  These facts fall into three categories; (1) the orthodontist’s role in successful Invisalign aligner treatment, (2) your or your child’s role in successful Invisalign aligner treatment, and (3) the alternative “invisible” appliance to Invisalign aligners, including its advantages and limitations.
 

1.  Invisalign is a powerful and effective tool for orthodontists, not a technological orthodontic treatment. 

What does this mean and why is it so important?

Invisalign’s technological aspect is found in the dashboard available to orthodontists (specialists who have completed post-doctoral orthodontic degrees and residencies) that allows them to create comprehensive, custom treatment plans for their patients using their own directions and inputs through that dashboard.  It is from these custom treatment plans that the clear aligners are produced.  What are clear aligners?  Aligners are transparent, plastic trays that completely cover the upper and lower teeth, moving them in incremental steps toward the final bite (occlusion). 

2.  Invisalign software does not replace or replicate the comprehensive treatment plan of an orthodontist.

An orthodontist plans the Invisalign treatment from the first to the last movement while considering a multitude of factors not “recognized” by Invisalign photographic scanning.  These include, but are not limited to:

  • facial structure, including relative positions of the upper and lower jaws (maxilla and mandible)
  • relationship of the facial bones and soft tissue and the effect of treatment on facial appearance
  • relative size of teeth to bones
  • current position of the teeth in the bones
  • inherited facial form and the corresponding changes likely with aging, whether for a growing child or an adult
  • periodontal (gum and bone) health and the likely safety and stability of tooth movements
  • actions necessary, including involvement of other specialists, to bring the teeth together into a stable occlusion/bite while enhancing facial appearance.

After considering the above, an orthodontist specifies the sequencing of tooth movements; the location and timing of attachments, which are placed on the teeth and engaged by the plastic aligner to direct force; and the specific movements to be made to place the teeth in the correct position for intermediate work by another practitioner or for the final occlusion. 
 

3.  Invisalign/aligner treatment may require coordinated work with other specialists.

Orthodontists providing Invisalign will discern the need for other specialists and will coordinate treatment with them and your general dentist to effect a safe and healthy orthodontic journey and successful arrival at the most stable and attractive destination for your or your child’s smile and face.

4.  Treatment plans using Invisalign aligners that do not address skeletal imbalances fail. 

Skeletal imbalances are one of the principal causes of crowded or spaced teeth.  An orthodontist is trained to both discern those imbalances and plan treatments to correct the imbalance through growth guidance for children or collaboration with an oral surgeon or periodontist for adults.  If these options are ruled out, either physically or by your choice, the orthodontist will compensate for the skeletal imbalance with non-intuitive, complex adjustment to the dentition, which requires awareness of the most stable occlusion possible, given the imbalance, and the impact of treatment on facial aesthetics.   The expertise acquired through the specialized schooling and experience of an orthodontist is required.

5.  Invisalign aligners do not move the roots of teeth well, especially molars. 

Root movements with Invisalign present complex challenges for the orthodontist that must be addressed through comprehensive planning, or the treatment will fail.  General dentists offering Invisalign most often use Invisalign Go, which intentionally prevents the practitioner from attempting to move molars due to the potential for poor outcomes due to lack of knowledge and experience, which is wise.  The ability to safely and effectively move roots is a requirement for successful treatment, however, and falls under an orthodontist’s purview. 

6.  Invisalign aligners require a high level of consistent wear.

Orthodontic tooth movement is a physiological response.  Six hours of force are required to begin tooth movement, with only two hours of removal of that force resulting in regression.  Interestingly and importantly, this regression does not mirror the original movement but leaves teeth in a new position, causing the current aligner to no longer fit or work properly. 

Also, Invisalign aligners must fit every tooth throughout treatment very intimately to avoid failure of tooth movement sequencing. 

To both prevent regression and keep aligners married to the teeth, aligners must be worn at all times except during meals when they are removed for eating.  After eating, the teeth are cleaned before the aligner is reinserted.  This becomes routine for most, with the side benefit of weight loss for those who consequently cut down on between-meal snacks. 😊

For some patients, the daily care and use of aligners such as Invisalign is an inconvenience.  If you think that might be true for you or your child, alternative, advanced orthodontic treatment tools, such as the invisible Brava appliance, which is attached to the back of the teeth, or braces with clear or tooth-color, custom-fit brackets, might be better options, particularly given their advantages in treatment efficiency and root movement. 

Note that “clear braces” are not clear aligners.  Clear braces are clear brackets applied to the front of the teeth that are engaged by an archwire running through those brackets.  The composition and tension of the wire exert a constant force that moves the teeth in a sweeping, rather than incremental, fashion.  Clear braces are an example of a fixed appliance, which is not removed by the patient during treatment.  Another fixed appliance is Brava, explored in fact #10, which is invisible to others.

7.  During aligner treatment, regular monitoring and periodic intervention by the orthodontist are required for success. 

Because teeth movement is a physiological process, all orthodontic methods require monitoring for potential adjustment due to the organic, non-linear nature of treatment.  If the orthodontist uses remote dental monitoring, as in my practice, you will simply be asked to submit periodic photographic scans of your teeth using your phone and will be prompted for an office visit when necessary.  Remote monitoring can significantly reduce the number of onsite appointments you must attend.  If your practitioner does not offer remote monitoring or if you are inconsistent in its use, you will need to schedule and keep regular in-office appointments.  Skipping self-scanning or scheduled appointments will lengthen treatment time and compromise your treatment result.  To have the result you desire, aligners must be worn, and monitoring of some type must occur regularly.
 

8.  Each Invisalign aligner has only a small range of motion.

Because of the small range of motion initiated by each aligner, significant movements take more time than when using fixed appliances, such as braces or the lingual (tongue-side) Brava, which generate more force and have larger, sweeping ranges of motion and correction.  Invisalign aligners do work, however!  Unless contraindicated, treatment with Invisalign will be effective given thorough treatment planning by the orthodontist and consistent wear on your or your child’s part.   
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9.  Combination-appliance treatment can hasten and improve outcomes.

Due to the limitations of aligners in tooth movement, many orthodontic cases would finish more quickly and ideally if Invisalign aligners were used in conjunction with other orthodontic tools, such as limited braces on a few teeth for a short time, or if another appliance were used throughout.  As noted above, fixed appliances such as precision braces using LightForce brackets or the lingual Brava appliance can exert more force over a longer range of movement than incremental, plastic aligners, allowing the orthodontist to move teeth more efficiently when needed or when desired by the patient.
 

10.  Invisalign is not the only “invisible” orthodontic appliance available:  Invisalign versus Brava.

 Invisalign is a powerful tool in the hands of an experienced orthodontist, who can treat you or your child discretely using clear aligners and tooth-colored attachments that are engaged by the aligners to exert force in specific directions. Treatment is well tolerated by patients and is a welcome alternative to traditional, wire-and-bracket braces for those who don’t want their orthodontics to be readily noticed.  In my practice, the majority of patients seek Invisalign, and I complete hundreds of cases per year using this innovative tool.  

There are, however, other options for invisible orthodontic treatment, such as the Brava fixed appliance, a fully discrete tool that is attached to the back of the teeth, completely unseen by onlookers.  Like braces and Invisalign, the orthodontist directs all tooth movements when using the Brava appliance. 

Advantages of the Brava appliance:

  • Convenience:  Some patients find the need to handle and clean aligners at every meal more a “hassle” than convenience.  A fixed appliance, such as Brava (or braces), eliminates these extra steps, requiring only a moderate addition to typical oral hygiene practices.  Moreover, since the Brava appliance has individual arms attached to each tooth, flossing between teeth requires no threading; flossing is fully accessible with the appliance in place.
  • Attachment-Free Smile:  The Brava appliance functions completely from behind the teeth.  Unlike Invisalign or braces, there are no attachments on the front of the teeth.
  • Plastic Free:  The Brava appliance itself is plastic free with only a final, finishing plastic aligner used for detailing at the end of treatment.  
  • Speed:  The Brava fixed appliance, like braces, is able to move teeth in a sweeping, continuous motion that shortens treatment length compared to aligners.  In addition, the Brava appliance, unlike braces or aligners such as Invisalign, moves each tooth independently, making it the fastest orthodontic treatment appliance to date.

Brava’s Disadvantage: 

It takes a varying amount of time for the patient to become accustomed to the Brava appliance behind the teeth.  The tongue will be irritated after treatment begins but for a relatively brief time.  The irritation fades over a one-to-three-week period.  Tolerance to the appliance is high and results are fast.

Conclusion

Not a technology-driven treatment, Invisalign is a tool requiring the specialized knowledge and training of an orthodontic specialist for proper use and a successful treatment for anything other than the simplest alignments in an already-stable and balanced bite. 

Successful aligner/Invisalign treatment also requires the ongoing participation of the patient in aligner wear, hygiene, and monitoring, whether remote or on site. 

Alternatives to Invisalign, such as treatment with the invisible Brava appliance or traditional braces, may be recommended or preferred for convenience or speed. 

Your orthodontist will thoroughly examine your or your child’s face, teeth, and bone structure before recommending treatment modalities for your consideration. 

If you should have further questions about Invisalign, Brava, or braces, or wish to schedule a complimentary examination in my Seattle office, please feel free to use the buttons below.

Introduction

Embarking on the journey to a straighter, more beautiful smile with Invisalign aligners is an exciting step toward improved oral health and self-confidence; however, achieving the best possible outcome requires more than simply slipping on those aligners.

This comprehensive guide will explore the key factors that can make or break the success of treatment with Invisalign. From understanding the physiological processes of tooth movement to the importance of precision and real-time monitoring, this article will equip you with the knowledge needed to ensure you receive the most out of your aligner treatment.

Orthodontic Tooth Movement is a Physiologic Process

To fully appreciate the art and science of orthodontic treatment with Invisalign aligners and your role in the process, it’s necessary to keep in mind that tooth movement is a physiological process. Teeth can be gently nudged into new positions over time; however, doing so requires sustained, specifically oriented, light force, directed to bring about a complex of precise movements for each tooth (e.g., crown tipping, rotation, root torque).

Movement is initiated by a biochemical response occurring when and where the tooth root is compressed against the supporting bone.  This initial biochemical process takes approximately six hours to reach the stage of physical tooth movement.

If the force is reduced for as little as two hours by, for example, the removal of an aligner, the six-hour process will revert.

Unfortunately, this reversion does not mirror the original movement. If reversion is allowed to occur, the aligner will no longer “seat” properly on the teeth, which is necessary to bring about the required tooth movements. When aligners are replaced, the orthodontic progress will no longer continue in the needed trajectory. 

Pro Tip: To prevent teeth reversion and the resulting ill-fitting, ineffective aligners, our patients are advised to wear their aligners at all times except when eating, after which the aligners are to be reinserted. This is necessary to keep tooth movement on track.

How Invisalign Works and Your Role

Invisalign Aligners Induce Physiologic Tooth Movement via Forces Produced by Stretched Aligners

Invisalign aligners deliver specific forces to teeth by creating strain in the aligner resulting from the difference in position between the active aligner and the teeth.  Patients feel tightness when fully seating the active aligners onto the teeth.  This tightness arises from precisely prescribed directions of force on specific points of particular teeth or attachments (small tooth-colored shapes bonded to teeth).

Invisalign Aligners Must Fit the Tooth Extremely Well

For Invisalign to work effectively, the aligners must fit snugly around your teeth. The clear, removable aligners transmit precise directional forces to your body. If they do not fit properly, these forces are ineffective, resulting in a less successful treatment outcome.

Aligner fit is of paramount importance.  As you progress through the aligner sequence, the teeth must remain seated in the aligner to allow the necessary physiological process of bone remodeling to take place. 

The number of days a set of aligners will be worn will vary depending upon several factors, including which tooth is being moved (small front teeth versus large-rooted back teeth), what type of movement is being induced (crown versus root movements), and how many hours a day the aligners are worn.

Consistent wear of twenty-two hours per day is needed to maintain proper aligner fit and function. 

Clear Aligners that Do Not Fit Properly Will Extend Treatment Length and May Result in an Unhealthy Bite

Suppose that an aligner is changed to the next in the sequence before all teeth have successfully moved to the positions anticipated for that next aligner. In that case, the new aligner will progressively lose grip on the slowest-moving teeth, necessitating the cessation of treatment, rescanning of the teeth, and a new treatment plan in order to recapture the teeth so that effective tooth movement can resume.  This will delay treatment for one or more months and add to treatment costs. 

Most importantly, if tooth movements are not completed according to the prescribed treatment plan, occlusion/bite or TMJ problems may develop in the future.

Invisalign Aligner Auxillaries Can Improve Clear Aligner Fit

Many orthodontists offer auxiliaries designed to help patients seat the aligners onto their teeth more fully (often at no cost). 

One common type is the “chewie,” which is shaped like a cotton roll but is more rubbery in texture.  Patients insert their aligners and then bite on the “chewies” to get the aligners fully onto the teeth to increase the stretch of the aligner plastic and, thus, increase the activation of orthodontic forces. 

Another extremely effective option is the Vpro appliance.  This device is motorized and vibrates while biting down on the inserted aligners for five minutes.  The vibratory motion seats the aligners exceptionally well, allowing aligners to be changed at an accelerated rate (aligners changes can be routinely reduced from every seven days to every 3-4 days).  Another positive effect of Vpro use is that orthodontic soreness is virtually eliminated.  However, there is a financial cost associated with the Vpro, which varies from office to office.

Related The Ten Most Important Facts about Invisalign: What to know before seeking treatment.

Monitoring the Fit of Your Clear Aligners in Real-Time:  The Difference Between Failure and Success

Real-time monitoring is essential to ensure your aligners maintain their optimum fit throughout your treatment.

Your teeth continually shift, but they must assume specific spatial positions within the aligners to ensure the treatment stays on track. Regular check-ins with your orthodontist will help ensure that your aligners remain in sync with your body’s ability to respond. 

Many orthodontists offer remote virtual check-ins to maximize treatment effectiveness and increase patient convenience.  My own practice offers complementary remote monitoring through a digital remote platform that utilizes pixel-level, photographic inspection of aligner fit, allowing us to review and monitor your progress. You are alerted if in-office visits are warranted and can move through treatment with confidence in your aligner efficacy.  Additionally, you are able to directly message the practice through the application regarding questions, feedback, or updates specific to your situation.

For those who are diligent in aligner wear, treatment can often be accomplished even if overseas, with a minimum of in-person visits. (The advisability of this approach will depend upon the details of treatment and the need for intervention by other specialists, such as periodontists, prosthodontists, and oral surgeons, or the use of appliances in addition to Invisalign aligners for efficiency and efficacy.)

The Importance of Choosing an Orthodontist for Invisalign Aligner Treatment

Comprehensive Understanding of the Biomechanics of Tooth Movement: Not Just a Path Between Initial and Final Positions

One of the fundamental principles of successful treatment with Invisalign aligners is that the prescribed tooth movement must reflect a thorough understanding of the biomechanics of teeth within the bone. This goes beyond simply plotting a path from initial tooth positions to your ideal outcome. Understanding the intricate mechanics involved in tooth movement allows orthodontists to create treatment plans that work with your body’s natural processes to accomplish complex, non-intuitive movements that are difficult to achieve from a biological viewpoint.  

With respect to Invisalign, complex tooth movements (e.g., an upper front tooth is to move downward and to the right with a thirty-degree rotation, with the root moving 2 mm more than the crown) will greatly increase the probability of losing grip with the aligner because 1) the movement requires multiple force vectors that create multiple ways that the aligner must stretch over that tooth and its attachments, and 2) the compound movements are more difficult for the body to accomplish (more bone remodeling is required on more surfaces of the root). 

An experienced orthodontist overrides the initial default plan of a software program, which is predictably fraught with undesired tooth movements and sequencing, to break down movements into sequenced components that reliably and safely lead to the desired change and a successful and healthy result.

Consideration of Physiological Limitations when Planning for Future Dental Health

Successful treatment with Invisalign aligners isn’t just achieving a beautiful smile; it includes the long-term stability and functionality of your bite.

A well-thought-out orthodontic treatment plan must consider the limitations of your body’s physiology, the most stable position given that physiology, and how treatment will affect your future oral health. This holistic approach ensures that you achieve the desired aesthetics and maintain healthy teeth and gums.

Invisalign’s scanning software does not account for the status, volume, type, or health of a patient’s gum tissue or supporting bone.  Nor does it register relative relationships of bones in the face or to the surrounding soft tissue. Because of this deficit, baseline treatment plans routinely result in final tooth positions that would cause short- and long-term damage to these tissues if they were to be carried out on a patient. 

To protect the patient’s oral health, a specialist in orthodontics must specify the course of treatment and the final occlusion/bite.  This is one of the most compelling reasons to seek clear aligner treatment with an experienced orthodontist.  Incidentally, according to Invisalign’s parent company, Aligntech, 93% of treatments by general dentists are attempted using unmodified initial treatment plans. 

When seeking Invisalign treatment, selecting the right healthcare provider is crucial. While general dentists may offer Invisalign, it is advisable to consult with an orthodontist who specializes in the science of tooth movement. Orthodontists are trained to understand the complex mechanics of tooth alignment and can provide the expertise needed for a successful outcome. 

Employment of Real-Time Monitoring and Individualized Modifications

To ensure the highest probability of success, choose an orthodontist who offers resources for real-time progress monitoring. This includes regular virtual check-ups and the flexibility to modify your treatment plan as needed. Your orthodontist should be attentive to your unique needs and adapt the treatment accordingly.

Specification of Comprehensive, Individualized Orthodontic Treatment Plans

A key differentiator between successful and unsuccessful treatment with Invisalign aligners is the quality of the treatment plan. Your treatment plan must be customized to your specific needs given your facial structure, tooth shape, periodontal health, and anticipated changes through growth or aging. Default plans generated by software do not account for the intricacies involved in your tooth movement or the nuances of your physiology.

Orthodontists create a personalized plan that addresses critical aspects and complex movements that are necessary to prevent lengthy and failed treatments.  In many cases, the result of “failed” aligner treatments is not limited to incomplete alignment of teeth but includes tooth pain, tooth damage, root canal, bone loss, tooth loss, and TMJ issues.

Finally, A Healthy, Functional, Aesthetically Pleasing Result

Ultimately, the goal of Invisalign treatment is to finish with a smile that is aesthetically pleasing but also healthy and functional. Your orthodontist’s expertise in understanding tooth movement mechanics, monitoring progress, and making real-time adjustments will contribute to a successful outcome that exceeds your expectations of tooth straightening.

Conclusion

Treatment with Invisalign aligners can be a transformative journey toward a better smile. Still, its success hinges on a thorough understanding of the physiological processes involved in tooth movement and the importance of precise biomechanical treatment design.

Pro Tip: To maximize the probability of achieving the desired outcome for yourself or your child, I recommend consulting an orthodontist who offers real-time monitoring and individualized, comprehensive treatment plans. Most orthodontists offer complimentary initial examinations; therefore, it’s advisable to seek a consultation with one or more recommended specialists in your area before embarking on treatment. With the right guidance and care, you can confidently look forward to a healthier, more beautiful smile.

If you would like to learn more about treatment with Invisalign aligners, see my blog posts, The Ten Most Important Facts about Invisalign:  What to Know Before Seeking Treatment, and The Updated Seattle Insider’s Guide to Invisalign Treatment.

If you’re ready to explore treatment, I would be happy to work with you. Contact my Seattle office, Dr. Keith B. Wong, DDS, MS, Specialist in Orthodontics, or use the buttons below to schedule a complimentary examination or begin a virtual consultation.

For those considering changes to their smiles, the question to answer is how best to fix crooked teeth or correct one’s occlusion.  Is Invisalign effective?  Are braces required?  Are there any other methods?  And, finally, who should one see, a general dentist or an orthodontist?  

Human teeth have no “natural” pattern of occlusion or appearance that is consistent across individuals.  The appearance of the teeth depends upon idiosyncratic biological relationships of the upper and lower jaws (the maxilla and mandible) to one another and to the shape and size of the teeth erupting from them.  The advent of orthodontics, the first dental specialty to come into existence, created the possibility of arranging teeth in the jaws to enhance the function and stability of teeth over the lifespan and to create a smile that is aesthetically pleasing both to the patient and to others.  Due to the importance of a smile in conveying warmth and creating connections, as well as a greatly lengthened human lifespan, what began as an exciting possibility has evolved to become a standard of care, especially in wealthy nations such as the United States and others.  The methods to provide that care have greatly evolved, also, making orthodontics a sought-after specialty. 

How Orthodontists Straighten Crooked Teeth or Misaligned Bites

The methods available to effect changes to the bite and smile have greatly expanded, with the specialty of orthodontics now able to treat very complex problems through the use of a variety of oral appliances, surgical intervention, and coordination with other specialties such as periodontics, oral surgery, pedodontics, and prosthodontics.  The age range for treatment has also changed since the initial days of the specialty, with orthodontists employing advanced tools and methods that allow them to treat young children, teenagers, young adults, and older adults, including seniors.  Advanced orthodontic appliances that orthodontists employ include plastic aligners such as Invisalign, precision braces such as precision, custom brackets, and the Brava lingual, behind-the-teeth device, among others.  The choice of the appliance is individual to the patient, with the orthodontist presenting the appropriate and best options to achieve the patient’s goals.

Can Invisalign Effectively Straighten Teeth?  Are Braces Required?

A majority of patients visiting an orthodontist for an examination inquire about aligner treatment, most commonly known through the Invisalign brand name.  Invisalign is a powerful tool in the hands of a skilled orthodontist who specifies tooth movements from the beginning to the end of treatment within the Invisalign dashboard by using its virtual tools to customize treatment for each patient.  Invisalign’s software generates only a baseline treatment that is insufficient and is overwritten by the orthodontist.  Orthodontic training and expertise are required to address anything more complex than very mild crowding in an otherwise balanced bite (occlusion).  This limitation explains both early failures with Invisalign aligners and the current problems experienced at times by general dentists, who are unfamiliar with comprehensive orthodontic treatment diagnosis and planning.  Invisalign in the experienced hands of an orthodontist can certainly be used in a wide variety of cases to straighten crooked, misaligned teeth and correct bites.

Straightening Teeth with Braces and Other Fixed Appliances

Invisalign is not the only treatment method for straightening crooked teeth and is not always the best choice for every patient. For reasons of treatment efficiency or convenience for the patient, fixed appliances may prove to be a better choice.  A skilled orthodontist can determine the best and appropriate options for each patient and will present those options during the initial examination.  The patient will be given the opportunity to choose from the recommended methods.

Options for fixed-appliance treatment, as mentioned above, included braces—individual brackets placed on each tooth and engaged by an archwire—and, in my own practice, the Brava lingual appliance that sits behind the teeth and is completely invisible to an onlooker.  Custom precision brackets, when used for braces, increase the precision of movement and shorten treatment time.  The Brava appliance moves each tooth individually, unlike either Invisalign aligners or braces, which has great advantages in terms of speed and proper sequencing of tooth movements.  One of these methods, due to the movements required for proper treatment or the patient’s assessment of treatment tolerance or willingness to handle and wear Invisalign aligners consistently, may prove to be a better choice.

Fixed appliances such as braces and Brava can create more force than the incremental plastic aligners of Invisalign and can move teeth in a consistent, sweeping motion, which speeds treatment, especially when large movements are required or when molars must be moved.  Molar movement is complex and is, consequently, not allowed in the Invisalign Go version supplied to general dentists.  An orthodontist, unlike a general dentist, can use Invisalign to move molars, as well as make other complex movements.  The advantages of fixed appliances, therefore, are speed and patient convenience for those who do not wish to handle and clean removable aligners.

Choices for Correcting Crooked Teeth or a Misaligned Bite

Invisalign aligners, custom precision brackets, and lingual appliances such as Brava can all be used to straighten teeth or create a proper occlusion or bite.  An experienced orthodontist will consider many factors, including current occlusion/bite, patient age and the corresponding anticipated facial changes, the present relationship of facial bones and teeth, periodontal conditions, and patient preferences before making recommendations.  In most cases, Invisalign can be used effectively by an experienced orthodontist, even when molars must be moved.  Fixed-appliance options such as precision braces and the behind-the-teeth Brava appliance may also be recommended and may be preferred by some patients. 

If you would like to learn more about options for orthodontic treatment or are ready to schedule a complimentary exam, feel free to reach out to my office below.

In this post, we will explore the principles behind tooth movement and the mechanisms orthodontists use to achieve desired outcomes.  A basic understanding of this process will inform your treatment decisions and aid you in understanding your orthodontist’s recommendations, which may include the following tools:

For instance, while aligner/Invisalign treatment can be very appealing to many orthodontic patients, it may or may not be mechanically appropriate for a given case.  Understanding the biological processes involved in orthodontic tooth movement is helpful in grasping why. 

Teeth are rooted in the alveolar bone within the jaws and are held in place by the periodontal ligament (PDL), a thin layer of connective tissue surrounding the tooth root and attaching it to the bone.  The PDL plays a crucial role in transmitting forces applied to the tooth and facilitating its movement.  Each orthodontic appliance applies force in a unique way, impacting the PDL differently than other appliances.

When orthodontic forces are exerted, the periodontal ligament or PDL undergoes remodeling, leading to changes in the bone surrounding the tooth root.  These changes include bone resorption where the force is applied and bone deposition on the opposite side of the tooth.  This remodeling process allows the tooth to move in the desired direction. 

Did you know?  

It takes approximately six hours of light, directed force to elicit biochemical responses in the periodontal ligament (PDL) that initiate orthodontic tooth movement, yet it takes only two hours, once the force is removed, for the six-hour-long process to reverse! 

To apply these forces, orthodontists use a variety of orthodontic appliances and techniques, including braces, clear plastic aligners such as Invisalign, and invisible applications to the back of the teeth such as the Brava appliance (see below) or lingual braces (brackets and wires).  Let’s briefly review these methods to illustrate their mechanical differences and why one treatment modality may be superior to another in a particular case.   

Braces:  Orthodontics with Wire and Brackets

An appliance with which most people are familiar is braces, which consist of small metal or clear brackets bonded to the teeth and connected by what are called archwires.  These wires provide a continuous force that acts on the teeth, guiding them into proper alignment.  The orthodontist adjusts the archwires periodically to control the direction and magnitude of the applied forces, facilitating the desired tooth movement.  Archwires vary in material, shape, thickness, and other properties, allowing the orthodontist to customize forces for specific situations.  Archwires may also be hand-bent to further facilitate fine detailing.  

Braces are able to move teeth over relatively long distances in a slow, sweeping motion, applying continuous force to the tooth and PDL.  Interestingly, fixed appliances, such as traditional braces and the Brava appliance, can deliver a stronger continuous force than that of removable appliances such as aligners, and can, therefore, move roots of teeth in the supporting bone much more effectively and efficiently.  Precision appliances such as custom brackets and doctor-customized wires, only increase this efficiency.  This factor becomes more important the greater the required movement of roots, especially that of molars.

The disadvantages of braces include visibility and hygiene.  Some patients, both youth and adult, are comfortable with the appearance of braces, but others are not.  Likewise, some are comfortable brushing around braces and flossing under wires, while others find both challenging. 

Invisalign:  Orthodontics with Clear Aligners

Due to aesthetic concerns with traditional braces, a popular alternative over the last ten years has been and continues to be the use of clear plastic aligners, such as those under the trade name Invisalign.  Aligners are removable trays that are custom-fabricated to the orthodontist’s specifications in order to apply controlled forces to the teeth.  Each aligner in the series is designed to move the teeth incrementally, and patients typically begin a new aligner each week or more frequently.  The aligners combine direct movement, tipping, rotation, and other forces to gradually shift teeth into the desired positions. 

Aligners are made of relatively thin, flexible plastic and move teeth via the forces created by the stretched plastic combined with fixed, tooth-color attachments that are specified and positioned by the orthodontist.  When the attachments are engaged by the plastic aligner, the direction and amount of force is altered according to the orthodontist’s treatment plan.   

Each new aligner must fit the teeth intimately.  If the fit is insufficient, the forces needed to move the teeth will not be produced.  As a result, each new aligner must represent an incremental change in tooth position.  Consequently, the range of motion for an aligner is very limited compared to the sweeping motion of braces or the Brava appliance.  As a result, the length of treatment for moderately complex or highly complex orthodontic cases may be greater with aligner treatment. 

The overriding advantage of aligner/Invisalign treatment for many patients is the freedom, both aesthetically and hygienically, afforded by removable appliances that are less visible than braces.  The disadvantage, however, is that, for some patients, this freedom results in an insufficient wearing of aligners, leading to longer or less successful treatment.  

(Knowing and communicating your likely tendencies and preferences to the orthodontist is important in determining if aligner treatment is right for you, as are the movements that will be required for your teeth and the ability of aligners to create that movement.  I have treated thousands of patients successfully with Invisalign, but it is not always the most effective choice.)    

Brava:  Orthodontics with an Invisible Appliance

The Brava appliance allows for an alternative mode of treatment that offers the mechanical advantages of fixed orthodontic appliances and an even greater aesthetic advantage than that of aligners.  Brava is a plastic-free, fixed orthodontic appliance placed on the tongue side of the teeth, making it invisible.  Treatment with the Brava appliance is not equivalent to lingual (tongue-side) braces, however.  

The Brava appliance differs from braces in that each tooth moves independently (not bound by its neighbor through an archwire).  The site-specific effect on the PDL and resulting movement of each tooth leads to treatment lengths roughly half as long as other methods in many cases.

The Brava appliance does not use an archwire; rather, independent arms are attached to each tooth from a wire band that sits on the gum.  Tooth and gumline hygiene is not inhibited by a wire as with braces. 

Brava independent orthodontic tooth movers are truly invisible and reduce treatment time by moving all teeth from day one
Brava independent orthodontic tooth movers are truly invisible (because they are on the tongue-side of the teeth) and reduce treatment time by moving all teeth from day one

The disadvantage of the Brava appliance is that, for some patients, it may be a few weeks before it’s presence becomes completely comfortable to the tongue.  Also, patients with large bony growths on the tongue side of the teeth cannot wear the Brava appliance, which will not fit properly.   

Note:  In addition to aligners, braces, and lingual appliances such as Brava, orthodontists may use auxiliary appliances, such as elastics or springs, to apply additional forces or modify the direction of tooth movement.  Elastics, for example, can be attached to braces, aligners, or Brava to exert force between upper and lower teeth, correcting bite discrepancies.

Remote Monitoring:  Checkups without Appointments

Regardless of the orthodontic appliance used, regular monitoring by an orthodontist is essential, allowing the orthodontist to make necessary adjustments as the treatment proceeds. 

My practice (Keith B. Wong, DDS, MS, Specialist in Orthodontics) uses remote monitoring of the teeth to assess progress and advise patients.  Remote monitoring involves scans made by the patients using their cell phones and a specialized application.  These scans are reviewed by both staff members and myself, with the patient contacted when an office visit is needed.  

Remote monitoring increases care, supervision, and communication while minimizing in-person office visits.  Gone are the days of monthly trips to the orthodontist!  Patients can be seen in our office as infrequently as every four months, and for non-local or international patients, this can be extended even further with adherence to the treatment protocol.  With remote monitoring, the importance of proximity of the orthodontist’s office is greatly reduced, allowing the patient greater choice in choosing a practitioner. 

With remote monitoring, the importance of proximity of the orthodontist’s office is greatly reduced, allowing the patient greater choice in choosing a practitioner.  

Where to Begin:  A Thorough Orthodontic Examination

The patient’s first visit is devoted to a thorough, complimentary examination and a discussion of desires and preferences.  The exam is concluded with an initial treatment recommendation, including choice of appliances, and the anticipated treatment length and its associated fee.  If the patient wishes to proceed at that time, flexible financial arrangements are discussed and, in many cases, treatment can be initiated that day if the patient desires.  If the patient prefers additional time or information, a second consultation may be arranged.    

Treatment recommendations are based upon a multitude of factors, including the presenting facial structure, age/anticipated growth, tooth position and bite, and patient goals and preferences.  Recommendations are informed by the orthodontist’s thorough understanding of tooth movement, which enable him or her to plan and execute treatment effectively, resulting in improved dental aesthetics, function, and overall oral health.  

When considering the options presented to you, recall that appliances differ in their abilities to move teeth, especially roots, and that you or your child’s experience with each appliance will also differ.  An option not previously considered may prove to be the best choice for effective treatment.   

 If you would like to learn more or schedule a consultation, please feel free to contact my office or use our online scheduling application.  

I hope this post has been informative!