If you are interested in starting Invisalign orthodontic treatment, the first step is to visit one or more orthodontists (specialists in the movement of teeth/orthodontics) in your area.
The orthodontist will conduct a complimentary examination and inform you if Invisalign aligners will be effective for your specific case and discuss the relative complexity of your orthodontic situation.
Invisalign aligners are great tools in the hands of an experienced orthodontist, who will customize every aspect of the treatment from the first to last aligner, including tooth attachments and aligner modifications, to create the proper forces in the proper sequence to achieve a stable, healthy, and attractive result for your face and smile.
Pro Tip: I recommend seeking an evaluation from the most experienced and qualified orthodontic specialist(s) available. If your case is relatively simple, he or she will inform you. If it is not, you will have the benefit of advice from a knowledgeable diagnostician.
Why? It is important to understand that case complexity is not apparent to the untrained eye, including that of general dentists, who have a different skill set and training than orthodontists. Orthodontists complete a two- to three-year post-doctorate (post-dental school) training and residency in the diagnosis and treatment of tooth movement within the bone. They are the only practitioners legally allowed to be designated as “orthodontist.”
Invisalign aligners can be used on young children, teenagers, and adults of any age.
Your orthodontist will evaluate if aligners are a good choice for you or your child based on the tooth movements that must be accomplished, the likelihood of consistent aligner wear, and the availability of other tools that may be more effective and/or better suited to you or your child.
Invisalign aligners are not the only “invisible” orthodontic treatment in an orthodontist’s toolbox.
The orthodontist may recommend a fixed appliance, such as Brava, that sits behind the teeth, as an invisible alternative to Invisalign. Fixed appliances actuate a sweeping arc rather than the incremental adjustments created by aligners and are much more efficient for some types of movements, potentially shortening treatment time significantly.
There is no specific age by which one must begin treatment with Invisalign aligners.
Early orthodontic evaluation and possible treatment for young children can be important, however. The position of teeth and jaws can potentially limit root growth or facial or occlusal (bite) development. Evaluation of a child by an orthodontist at age seven is typically recommended for this reason. Fortunately, such evaluations are commonly free of charge.
If you are interested in Invisalign aligners for yourself or an older child, there is no reason to think that age is a limiting factor. Rather, the movements required, and the likelihood of consistent aligner wear will be among the factors determining appropriateness of the Invisalign appliance.
How to Sign Up for Invisalign Treatment
Once an orthodontist is chosen from among those visited for an examination, you will be led through a process that will initiate treatment.
Diagnostic records, if not yet completed, will include an intraoral photographic scan, facial photographs, and necessary low-dose radiographs that the orthodontist will use when customizing your treatment plan through the Invisalign dashboard/control panel.
About your treatment plan:
An experienced orthodontist will specify all movements, their sequences, any necessary tooth attachments, and any other appliances to be used throughout the course of your orthodontic treatment; this process will result in a series of clear Invisalign aligners that are specific to you or your child’s needs.
During treatment planning, the orthodontist should take into account the impact of the proposed treatment on the appearance of your or your child’s face and its soft tissues, both now and over time.
Pro Tip: The goal of excellent treatment planning is to achieve the most aesthetically pleasing result for both the patient’s face and smile that is also stable throughout the patient’s lifespan using only standard retention practices.
To initiate treatment, you will be presented with a contract and payment options. Treatment fees are all inclusive; your fee covers all laboratory, oral appliance, appointment, and initial retention costs.
In most offices, as in ours, a treatment coordinator will review the orthodontist’s diagnosis and your fee with you, and a financial coordinator will assist you in utilizing insurance and choosing amongst your payment options.
Conclusion: How to Begin Invisalign Treatment
To start Invisalign treatment, visit one or more orthodontic specialists in your area for a complimentary initial exam.
You should expect a thorough examination including diagnostic records (photographs, low-dose x-rays), as well as physical evaluation of your teeth, occlusion (bite), and face, along with a series of questions about your goals, your dental history, and other queries depending upon your or your child’s age and stage of growth.
The examination should conclude with recommendations regarding treatment and appropriate appliances, including answers to your questions regarding Invisalign aligners and treatment with them.
If Invisalign aligners are a good choice for you or your child, you may choose to begin the process immediately or visit other orthodontists for additional opinions.
Choose the orthodontist that best suits you or your child.
Because of advanced appliances and techniques, orthodontic appointments are scheduled much further apart than in the past, which means that the location of the orthodontist’s office is of less importance than the orthodontist and your level of comfort with his or her treatment plan, experience, and thoroughness.
Pro Tips:
Orthodontists are specialists in the field of teeth alignment and must complete post-doctoral (i.e. post-dental school) education, training, and a hospital residency in the specialty to achieve that designation.
The skill set of orthodontists differs markedly from that of general dentists, enabling them to expertly diagnosis, treatment-plan, and execute orthodontic treatments for their patients.
Orthodontists can assess the relative complexity of each case, which is not discernable to general dentists, and have a multitude of techniques to employ to achieve optimal results.
Evaluation by one or more orthodontists is recommended before agreeing to any treatment with Invisalign or any other aligner.
Invisalign is a tool, not a treatment. It is a wonderful tool in the hands of experienced orthodontists and continues to be the orthodontist’s choice among aligner companies because of its well-developed dashboard (online input panel) that allows the orthodontist to control every aspect of the treatment from the first to last aligner.
Orthodontists have multiple tools, some of which may better suit you or your child’s treatment.
If you are in the Seattle area and would like to schedule an examination in my office to explore orthodontic treatment with Invisalign, use the buttons below. I would be happy to provide a comprehensive examination for you or your child.
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. .
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.
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’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.
Why See an Orthodontist for Orthodontic treatment with Invisalign
The use of Invisalign aligners is a popular and discreet alternative to traditional braces for correcting misaligned teeth, and since the expiration of the Invisalign company’s patents in 2017, many new companies have entered the clear aligner market. The competitive environment has led aligner companies, including Invisalign’s parent company, Aligntech, to aggressively encourage general dentists to attempt orthodontic treatment on their patients rather than refer their patients to an orthodontist who may not utilize that company’s aligners.
Sales representatives for the clear aligner companies attempt to allay the general dentist’s concerns over lack of orthodontic education and experience by touting the software sophistication of their “product” and advising to “treat only simple cases and refer all the more complex cases to an orthodontist.” This would seem reasonable except for two very important facts: 1. Software baseline treatment plans are formed on such limited information that a specialist in orthodontics must and does completely override those plans, and 2. The ability to recognize the level of complexity of an orthodontic case requires orthodontic training. It is not straightforward and is not revealed by the photographic scanning of the dentition used to create those baseline treatment plans. General dentists are being asked to learn clinical orthodontics on their patients.
Below we’ll explore why most orthodontic cases are NOT as straightforward as they may appear to the eye. and why consulting an experienced orthodontist for treatment with Invisalign aligners brings a wealth of benefits that go beyond just aesthetics.
Success with Invisalign aligner treatment is dependent upon an individualized plan created by an experienced orthodontist beyond the basic plan supplied by the Invisalign software
“Simple” Looking Cases Are Often Not Simple
It’s a common misconception that if your teeth appear only slightly crooked or spaced, your case is simple and can be easily managed without professional intervention beyond the level of a general dentist. However, even seemingly minor misalignments can have underlying complexities; the most common is that of a skeletal imbalance of the upper and lower jaws.
Crowded Teeth or Spaces Between Teeth Often Indicate Underlying Jaw Misalignment
Almost no one has perfectly balanced jaws in all three dimensions of space. When the jaws develop during childhood, the teeth (which are passengers in each jaw) move or lean within their bony foundations to compensatefor the fact that the upper and lower jaws grow at different rates and often mature into misaligned relationships. As a result, the teeth, when moving to maintain a functioning bite, develop crowding or spacing. This dental compensation continues throughout your life.
Attempting to Correct Crowded Teeth (or spaced teeth) Without Addressing Skeletal Balance Leads to Future Dental Problems and Instability
If the crowded teeth are straightened without taking the skeletal relationships into account, significant bite issues can develop that may lead to tooth wear, tooth chipping, root canals, gum recession, and even tooth loss. Short of these problems, treatment plans that do not account for skeletal relationships and the associated dental compensations lead to unnecessarily longer treatment times and more invasive treatments, such as extensive “smoothing” or interproximal reduction of the enamel of the teeth or unnecessary dental restorations (bonding, veneers, or crowns) to resolve less-than-ideal orthodontic results.
Specialized Tools and Knowledge are Required for All but the Most Simple Cases
An orthodontist’s comprehensive patient examination and evaluation of specialized orthodontic records is intended to identify issues that are not apparent. In addition to the status and position of the teeth, the orthodontist considers skeletal balance, bite alignment, airway issues, current and future facial aesthetics, periodontal health, and the types and complexity of needed tooth movements before making treatment recommendations that will result in a stable, healthy occlusion while enhancing both the smile and the face. This rigorous assessment ensures that treatment addresses all aspects of each patient’s unique situation.
Invisalign aligners can work wonders, but their successful use depends on proper treatment planning. If the patient’s case involves bite (occlusion) problems, skeletal imbalances, tooth rotations, or other issues, orthodontists are able to develop a comprehensive plan to achieve optimal results using Invisalign aligners in conjunction with helpful auxiliaries to increase efficacy and shorten treatment length. Their expertise ensures that treatment is effective and minimizes treatment length and the risk of complications.
Access to Aesthetic Treatments Beyond Invisalign
Orthodontists are able to utilize appliances other than aligners that, depending upon the movements required, may prove to be both more efficient and more convenient for the patient. While Invisalign aligners can be very effective—I successfully treat hundreds of patients per year using aligners—aligners have a short range of motion, unlike fixed appliances, and have greater difficulty bringing about root movement, both of which lengthen treatment time and may compromise its result. Your or your child’s orthodontic treatment may benefit from complementary methods that accelerate the treatment process. Alternatively, your orthodontist may recommend a different tool altogether, such as the Brava lingual appliance, which is fixed behind the teeth and, therefore, completely invisible to the onlooker. An example of the former would be limited clear braces on a small number of teeth to accomplish complex movements beyond the capabilities of clear aligners, allowing a patient who had been deemed “not a good candidate for Invisalign” to become an ideal candidate for aligner treatment. By combining their expertise with innovative tools and techniques, orthodontists can significantly reduce treatment times while delivering aesthetically pleasing and healthy results.
Under the guidance of an experienced orthodontist, Invisalign aligners can be used safely and effectively; issues that may not be apparent can be accurately diagnosed and treated. An orthodontist possesses the knowledge, tools, and expertise to address even the most intricate cases, ensuring the effectiveness of your treatment, and offers access to additional aesthetic appliances that potentially shorten treatment time and enhance the overall outcome for the most beautiful smile, optimal oral health, and long-lasting results.
Most orthodontists offer complimentary examinations. I encourage you to seek consultations before deciding upon a practitioner for orthodontic work regardless of the treatment type.
Does Treatment with Invisalign work?
Yes, but the answer is complicated. When introduced, Invisalign aligners were seen as an innovative and technically sophisticated tool with a certain aesthetic elegance, not unlike an iPhone; therefore, many have assumed that Invisalign is similar to an iPhone in that where it is acquired is unimportant. In reality, Invisalign is of greater similarity to a surgical robot or a Boeing aircraft—technically advanced, yet dependent upon the experience and judgment of the operator. However, given that Invisalign is a commercial product, developed and marketed directly to the public and that the chance of morbidity is non-existent, the threshold of qualification to become an Invisalign provider has been loosely regulated. This is a complicating factor in the performance of aligner/Invisalign treatment due to several issues.
Firstly, the Invisalign technology has been marketed to both orthodontists and general dentists under the mistaken belief that the computer-programmed Invisalign baseline is sufficiently sophisticated to produce satisfactory results in non-complex cases without significant doctor modification. This has not proven to be true. The Invisalign baseline considers only the position of the dentition without reference to bone and soft tissue status and relationship, factors that greatly impact treatment planning, the sequencing of tooth movement, and the overall impact of treatment on the face and smile. Secondly, the mechanics of the Invisalign aligners (the capacity for, and application of, force) are unique and require that the practitioner have a comprehensive understanding of tooth movement and repositioning. Thirdly, a further complication for non-orthodontists is that their ability to determine the relative complexity of an orthodontic case and treatment plan is limited. These skills are developed not through the general education of the dentist but through the two to three years of post-doctoral education and residency in orthodontics and subsequent specialized practice of the orthodontist.
The fact that the question remains, “Does Invisalign work?” points to the issues discussed above and the resulting inconsistency in treatment outcomes. A significant number of Invisalign cases have been and continue to be attempted by those who do not have the adequate diagnostic skills, mechanical understanding, and/or experience to complete these treatments. However, when utilized by an orthodontic clinician who is both experienced in the specific biomechanics associated with aligner treatment and who has the diagnostic ability to recognize appropriate clinical indications, the use of Invisalign aligners is very effective and reliable.
Do Invisalign aligners only work in certain cases?
Invisalign aligners are one of several tools that an orthodontist may use to move teeth, as are fixed appliances, with each tool having both advantages and disadvantages. Certain tooth movements are not accomplished effectively by Invisalign aligners. Due to the specific mechanical properties of the Invisalign appliance, which differ substantially from that of fixed appliances such as precision braces or the Brava lingual appliance, aligners are a poor choice for moving large rooted teeth and do not rotate teeth efficiently. In such cases where aligners are not appropriate, difficult movements may be accomplished using limited clear or tooth-color braces (often, on a few teeth for a brief period), resulting in a case that can then be successfully completed with Invisalign, or by using an alternative appliance such as Brava. By integrating modalities, experienced orthodontists are able to treat a wide variety of cases with Invisalign and achieve ideal results.
Seeking Invisalign Aligner Treatment
Invisalign aligners are very thin, clear, removable, and intimately approximated to the teeth; they are extremely “aesthetic” compared to traditional or even clear braces.
Clinical Advantages of Aligner Treatment
In certain cases the use of Invisalign presents a clinical advantage, such as (1) when enhanced control of teeth is required—Invisalign is quite effective in creating space of exact size, e.g. where precise widths are needed for post-orthodontic restorations, (2) when braces would not remain on the teeth well (e.g. patients with numerous crowns or veneers, patients with abnormal tooth enamel), (3) when access for particular dental procedures during orthodontic treatment is important, (4) when indications of root resorption necessitate the isolation of certain teeth, (5) when there exists an anterior open bite in which the patient cannot bite the front teeth together (e.g., to incise lettuce); and (6) when there exists a deep bite in which there is an excessive vertical overlap of the upper and lower incisors causing wear to the teeth or gums.
Keith B Wong is a Seattle orthodontist that specializes in aligner orthodontics
Does Invisalign cost more than braces?
Fee structures vary across the country. In some regions, such as our own, Invisalign is priced similarly to fixed appliance treatment.
Does Invisalign treatment take longer than braces?
Cases that include movements difficult for Invisalign to accomplish, thus necessitating limited fixed appliances in a hybrid Invisalign/fixed appliance treatment, experience an overall duration similar to that of fixed appliance treatment. Certain types of cases, however, are best and more quickly treated with fixed appliances alone.
What is Involved in Initiating Invisalign Treatment?
Each patient, regardless of treatment type, should receive a comprehensive examination of his or her facial structures (hard and soft tissue), teeth and dental alignment, jaw joint (temporomandibular joint), periodontal structures (hard and soft tissue), and a meaningful discussion covering his or her goals for treatment and other salient issues. Invisalign patients will have diagnostic records taken including a digital intraoral scan (which will later be used to create aligners). These records are sent to Aligntech (the parent company of Invisalign) with an initial treatment prescription provided by the orthodontist. To initiate the aligner creation process, a baseline treatment plan is generated by Invisalign software. The software used for this preliminary treatment plan cannot, however, determine what is clinically realistic or advisable; therefore, this treatment plan is extensively modified by the orthodontist, who is experienced in both diagnostics and Invisalign biomechanics. (The preliminary treatment plan would commonly lead to case failure if implemented without modification: this is why I recommend that Invisalign treatment be sought from a qualified practitioner [see “Does Invisalign Work?” above].) Once the orthodontist has sufficiently modified the treatment plan for the case in question, he or she will approve the plan (known as a Clincheck) and the construction of aligners will commence. Aligners arrive two to three weeks after the taking of diagnostic records.
What happens when I receive the Invisalign aligners?
At the first appointment, the aligners will be checked to confirm fit and you will be instructed on their placement and removal. The rate of change from one aligner to the next will also be discussed. Two cases will be provided and you will be asked to store all of your used aligners in their individual packages in case any should be needed in the future. You will also be shown how to clean the aligners and given tips to help you incorporate the aligners into your everyday life. This is an exciting and relatively short appointment.
What will I notice once I begin wearing the aligners?
First, you may be surprised at how difficult it is to see the aligners once on and how closely they fit the teeth (the fit will become even closer as your teeth adjust to the aligners). You will probably note a mild increase in salivation because your mouth senses something new; this phenomenon usually lasts one to two days. As you speak while wearing the aligners, we advise that attention be brought to any changes in your speech; if such changes occur, we recommend practicing those sounds that require adaptation. Speech adaptation usually takes a few days, as well.
Is Invisalign treatment painful?
The perception of discomfort or pain varies widely among individuals, but, given that orthodontic tooth movement requires force to elicit a biological response, initial discomfort will be experienced. However, due to the nature of the force applied by aligners, patients who seek retreatment with Invisalign tend to report less discomfort as compared to their prior treatment with braces. Nevertheless, there is likely to be an initial period of low-level discomfort around the teeth when the dentition goes from unperturbed to orthodontically mobile. Once the Invisalign orthodontic process begins, however, this discomfort lessens.
How many hours per day are the Invisalign aligners to be worn?
The ideal amount is 22+ hours per day. Patients are advised to remove the aligners only to eat, clean their teeth, clean the aligners, and speak or perform in special situations. Aligners should be worn at all other times, including when asleep. The number of times the aligners are removed each day should be minimized. Due to the biomechanics of tooth movement, changes brought about through six hours of force on the teeth revert in only two hours when that force is absent.
Does Invisalign treatment involve anything that is attached to your teeth?
At some point in treatment, most patients are provided with small, tooth-colored attachments that have very specific shapes and are positioned precisely at certain spots on designated teeth. These attachments will correspond to similarly shaped forms in the aligners to allow specific force vectors to be delivered to each tooth to bring about precise patterns of orchestrated tooth movements through space and time. In addition, auxiliaries such as bonded buttons or hooks may be used in concert with the aligners to allow the use of other force-generating units, such as elastics.
What if I have a nightguard/bite plate?
Your nightguard/bite plate will not fit your teeth as they begin to move. Therefore, you will be asked to wear the aligners at night. The aligners (which cover the chewing surfaces of the teeth) will serve as a new nightguard/biteplate. Because each set of aligners is typically worn for only two weeks, even vigorous tooth grinders will not wear through the material.
What if I have crowns, bonding, or veneers?
In general, Invisalign aligners are better suited for those patients with significant dental work of this type because these restorations present a more difficult bonding surface than the natural tooth. Invisalign aligners work equally well with restored and unrestored teeth.
What if I have bridges or implants?
If fixed teeth exist, such as implants or ankylosed teeth (teeth that have fused to the bone, usually after trauma), these teeth must be considered in the overall treatment plan whether that treatment involves Invisalign, precision braces, or the Brava lingual appliance. If these teeth are to remain in their present position at the conclusion of treatment, they can be extremely helpful “anchors” from which to move other teeth. If these bridges or implants would ideally be repositioned, the decision must be made whether or not to do so as part of the comprehensive treatment plan. In the case of bridges that must be repositioned, the abutment teeth can be moved individually after the pontic(s) are removed. (Pontics are the synthetic teeth between the abutting teeth.)
Should I have a dental check-up before Invisalign?
Yes. It is important that dental issues such as decay, gum disease, infection, tartar build-up, or any procedure that would necessitate altering the shape of any tooth be completed before your aligners are fabricated. A very intimate fit of the aligners results in the most efficient and effective transfer of orthodontic forces and, therefore, the most ideal orthodontic result. In addition, the dental check-up allows your dentist and orthodontist to collaborate in planning your overall long-term treatment relative to aesthetics, function, and health.
Can I wear the aligners just at night for more weeks and get an ideal result?
No. The orthodontic process is a biologic reaction to the presence of force; therefore, when the stimulus of force is removed, aspects of the biologic (and orthodontic) process begin to reverse. To complicate matters, different teeth will move and revert at different rates. This means that each tooth will shift to a different stage in treatment and no single aligner will fit all of the teeth as well as it should. If this “non-tracking” is caught early on, extremely consistent wear of the best-fitting aligner can recapture the dentition. If the situation has gone too far, rescanning is necessary to create a new treatment plan and set of aligners; this lengthens treatment and, at some point, an additional fee will be charged.
The best advice is to commit to the recommended level of aligner wear—22+ hours per day. If this seems unlikely, a viable alternative is to consider the use of fixed appliances such as the invisible Brava lingual appliance, which fits behind the teeth, or precision, LightForce 3-D printed, tooth-color brackets and wires. The convenience of fixed appliances includes the absence of loose parts to handle and the ease of maintenance (the appliance itself is cleaned when brushing the teeth and is not removed and repositioned when eating). Once the initial period of adjustment has occurred, a fixed-appliance protocol is typically found to be very satisfactory.
Are Invisalign Aligners for Adults Only?
No. In fact, teenagers often make the best patients. The biologic fact that teens have active bone metabolism, facial growth, and tooth eruption means that their dentition is quite malleable. This makes the teenager an excellent candidate for Invisalign (except in such cases that Invisalign is not diagnostically recommended). In assessing the appropriateness of Invisalign for a teen, one must consider both the orthodontic situation and the patient’s level of dedication and commitment to achieving treatment goals. Many teens are highly motivated, responsible, and willing. For this type of teen, Invisalign is not only more aesthetic and convenient, it also allows for better oral hygiene and less interference with daily activities (e.g. athletics, playing certain musical instruments, or eating specific foods) than braces. For the peace of mind of parents, in our practice, it is made clear to the teen that we are committed and obligated to the best orthodontic result possible. Therefore, if aligner wear is insufficient, the treatment will revert to traditional braces. While this type of motivation is typically not needed for the adult patient, it can be very helpful in solidifying the teen’s commitment to consistent wear and hygiene.
If neither braces nor aligners are deemed appropriate, the lingual Brava appliance which is invisible to onlookers may be the best alternative.
Conclusion
Much of this guide has focused on the advantages of seeking treatment with an orthodontist because that is the information missing from advertisements and dental office brochures. Invisalign aligners are a tool, not a treatment. They are a tool that can be used effectively when employed by a skilled and experienced orthodontic practitioner who specifies the entire treatment plan to correspond with the biological idiosyncrasies of the face and dentition. Orthodontists provide a suite of options and will plan your treatment to meet unapparent challenges both today and in the future. I encourage you to seek consultation for yourself or your child with an experienced orthodontist before seeking treatment; most offer complimentary examinations.
If you have further questions or wish to explore treatment, I would be pleased to work with you. Contact my 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.
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 (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 examinationand 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!
If you are interested in orthodontic treatment for yourself or your child and wish to avoid traditional braces, the options have been made more extensive with the recent (2022) addition of the Brava appliance that is currently available from a limited number of orthodontists.
Pro Tip: No longer is treatment with aligners such as Invisalign the only discreet option for adults and teens. The Brava appliance presents significant advantages and is the first true alternative to the use of aligners, whether Invisalign or otherwise.
What is the Brava Orthodontic Appliance
The Brava tool is a lightweight, fixed appliance that sits against the soft tissue beneath and behind the teeth. It is completely invisible to onlookers with no attachments to the visible surface of any tooth. Each tooth is engaged by a curved arm that is shaped to deliver the exact, measured movements (tipping, rotation, retraction, expansion, etc.) prescribed by your orthodontist to be in the proper sequence with the correct results in both crown (visible tooth) and root movement.
The Brava appliance is the next generation in orthodontic tools, not only in aesthetics but also in tooth movement. The technological aspect of this tool resides in the associated software that converts the orthodontist’s comprehensive, detailed instructions into the exact arm shape that is required for each tooth.
As with Invisalign and braces, the orthodontist applies extensive, specialized knowledge to direct tooth movements from the beginning to the end of treatment when using the Brava invisible appliance.
Like Invisalign and braces, the Brava appliance is NOT a treatment, rather, it is a tool for orthodontists to use to quickly and correctly reposition teeth for a stable, healthy, and attractive smile and face.
The Brava Appliance versus Invisalign Aligners: Five Facts to Know
1. Unlike Invisalign, the Brava appliance is completely invisible to the onlooker.
The Brava appliance neither covers the teeth like an aligner nor does it require any attachments to the front of the teeth. Treatment with aligners, if properly prescribed, most often requires tooth-color attachments to the fronts of a limited number of teeth to enable the aligner to exert the required force in the required direction.
2. Unlike Invisalign aligners, the Brava appliance is fixed to the teeth with no parts to handle or remove when eating or for cleaning.
During treatment with aligners, the plastic aligner trays must stay seated on the teeth, i.e., fit very intimately, for the aligners to exert the necessary forces in the correct sequence. For this to occur, the aligners must remain on the teeth for at least 22 hours per day and be removed for short periods only. Removal must occur for eating, and the teeth and aligners must be cleaned before reinsertion to protect the teeth and gums from bacterial and tartar build-up on the teeth under the aligner and at the gum line.
The Brava appliance is not removed. It remains in place throughout treatment and is cleaned when brushing the teeth. Also, because the lightweight bar from which the curved arms extend sits below the teeth, the space between the teeth and beneath the gumline can be flossed in a normal manner with the appliance in place, unlike with braces.
3. A distinguishing feature of the Brava appliance compared to Invisalign aligners is that it is free of plastic.
The active appliance is composed of a thin, specialty metal, with metal attachments on the back of each tooth to which the curved arms are anchored. The only plastic used throughout treatment is the finishing aligner used by the orthodontist to make detailing adjustments at the treatment’s conclusion.
4. With each tooth engaged by an independent arm on a fixed appliance, the Brava tool exerts a very specific force for each tooth in a long, sweeping motion that creates fast movement.
This is in contrast to aligners, which move each tooth incrementally due to the manner in which the aligner must stretch over the teeth to effect change. The greater flexibility in tooth movement of the Brava tool means that the orthodontist’s treatment plan is executed more quickly. The result is a substantially reduced treatment time.
5. The only disadvantage: Unlike Invisalign aligners, the location of the Brava appliance creates temporary (two- to four-week) irritation to the tongue, which brushes against the curved arms and metal anchoring attachments on the back of the teeth.
Fortunately, this irritation fades and eventually resolves over a period of two to four weeks. The Brava appliance is well tolerated by patients. A comfort kit is supplied in my practice to aid patients during this adjustment period.
Conclusion
The Brava appliance is lightweight, flexible, and sits below and behind the teeth. Each tooth is moved by an independent arm, and the treatment proceeds without any outward sign.
Your smile is never compromised, and treatment is fast and effective.
The position of the appliance, with no wire to preclude flossing, also means full hygiene access without the removal of an aligner or wire.
There is no plastic and nothing to remove and replace.
See Brava in action: Yourtreatment plan executed using the Brava appliance results in efficient, invisible alignment, as illustrated in the video below.
The Invisible Brava Orthodontic Appliance in Action
As one of the pioneer Brava users, I would be happy to consult with you about this innovative treatment tool. If you would like to learn more or explore treatment, contact my Seattle office to schedule a complimentary examination.
Is there an official Invisalign Orthodontist?
There is a very meaningful difference between an orthodontist who has mastered the specific and unique way one needs to approach any case with Invisalign and one who has not completed the associated “learning curve.” There is an even greater (and more crucial) difference between an orthodontist who has expertise utilizing this clear orthodontic aligner modality and a general dentist who promotes him or herself as a “certified Invisalign provider.” Unfortunately, there is currently no official designation that can point to an ideal Invisalign practitioner with 100% accuracy, however, there are several steps one can take to locate an excellent provider; steps I will cover below. First, some context is needed.
The educational/experiential difference between an orthodontist and a general dentist:
According to Aligntech, the parent company that makes Invisalign aligners, the typical general dentist who holds him or herself out as an “Invisalign doctor” has completed a weekend course limited to instruction in logging onto the Invisalign doctor site, submitting records for a prospective case, and accepting and paying for that case. Furthermore, this type of practitioner starts, on average, only 3 cases per year. (Several years ago, Aligntech, in response to a glut of unsatisfactory results produced by unskilled providers, attempted to institute minimum criteria to remain certified as an Invisalign doctor, but failed to stand firm in this when confronted with an eruption of discontent from a subset of general dentists.)
The difficulty for general dentists rests in the fact that Invisalign, although utilizing computer technology to produce a series of aligners, is in no way a comprehensive orthodontic treatment-planning program, as commonly believed. Well-meaning general dentists have had no fundamental training in comprehensive orthodontics (the average number of comprehensive orthodontic cases that a dental student in the US treats and finishes is ZERO). Why? Dental students must become proficient in general dentistry, which includes numerous other subjects that are unrelated to the biomechanical process of moving teeth orthodontically. Orthodontics is a dental specialty pursued through post-graduate education. Orthodontists, like other dental specialists, have completed dental school and been accepted into highly competitive graduate programs and residencies that focus exclusively on the practice of that specialty. To illustrate the different curricula of an undergraduate dental school and that of a graduate orthodontic specialty program, I have included links to examples of each:
Only 2 of the 106 classes in the University of Minnesota dental school program are related to orthodontics; in addition, only half the dental students can choose an orthodontic rotation to observe what orthodontists generally do. There is no specialized education or experience in the complexities of tooth movement or skeletal growth and aging as it relates to tooth position, facial forms, and long term dental stability.
By comparison, all 33 classes of the post-doctoral orthodontics residency program at the Arizona School of Dentistry & Oral Health focus on orthodontics. These subjects include the biological basis of orthodontic tooth movement, the biomechanical principles of orthodontic appliances, the clinical strategies of orthodontic treatment, and current orthodontic research. Orthodontic residents also actively treat patients under the supervision of practicing orthodontists as part of their training.
The stark difference between the education of a general dentist versus that of an orthodontist helps one understand why seeking an orthodontist for Invisalign aligner treatment is strongly advised. Invisalign aligners are a tool in the hands of knowledgeable and experienced orthodontists, not a stand-alone treatment.
The educational/experiential difference between an orthodontist that is expert in clear aligner orthodontics and a non-expert orthodontist:
The basis of difference between two orthodontists, one an expert Invisalign clinician and one less skilled in its use, is in the level of knowledge regarding clinical capabilities and limitations of orthodontic aligners as a specific modality of treatment and the differences, which are many, between that modality and the use of braces/fixed appliances. These differences are not trivial. For example, because braces can push and pull whereas orthodontic aligners can only push, the phasing of treatment when using aligners must often be quite different than when using conventional treatment. This, and other distinctions, mean that treatment planning, which must be completed at treatment onset, is highly dependent upon a thorough understanding of Invisalign as a separate and unique appliance.
In addition, clear aligner tooth movement is distinctly intermittent in comparison to braces. This implies that Invisalign treatment alone, in cases where a more sweeping, larger range of motion is required (e.g. alignment of a distant impacted tooth or correction of a significant rotation), is insufficient. To make this determination and address the situation, a practitioner must not only be an orthodontist, who, unlike a general dentist, can combine treatment modalities, but one experienced in the use of Invisalign, familiar with its capabilities and limitations, and proficient in the proper combining of aligners with other treatment modalities.
Further, there are numerous idiosyncratic aspects of excellent clinical orthodontic aligner treatment that require the surrender of assumptions associated with fixed appliance treatment (braces). These aspects are mastered by: 1) attending advanced Invisalign-specific courses; 2) collaborating at advanced peer-to-peer symposia; 3) intently adapting ongoing treatments as indicated; 4) appropriately integrating new technologies to enhance the efficacy of the specific biomechanics of Invisalign; and 5) creatively integrating known orthodontic modalities with Invisalign treatment to address all aspects of a given case by the most effective means available (i.e. combining treatment methods to offset biomechanical deficiencies of any given modality).
In Summary: The learning curve for effective and efficient Invisalign use is significant.
Why aren’t all orthodontists expert clear aligner orthodontists?
First, it must be said that, just as in any field, not all orthodontists are experts, regardless of modality.
Second, in addition to experience, becoming an expert in the use of Invisalign aligners requires interest, focus, and energy. The orthodontist must commit him or herself and staff to continual learning while maintaining motivation for excellence. Not everyone can, or desires, to do this. Invisalign aligners have inherent limitations due to their mechanical actions, and the orthodontist must develop means to achieve excellent results despite these limitations.
Third, orthodontic residency programs vary significantly in their approach to training aligner utilization. A few programs, like Univ. of the Pacific, have an excellent Invisalign education but most are limited and some even ignore aligners altogether. Some recent graduates are not only relative neophytes in traditional clinical orthodontics but absolute neophytes in the optimum use of aligners.
The evolution of Invisalign into an excellent orthodontic treatment option:
At present, Invisalign aligners are a very efficacious and predictable orthodontic modality when used knowledgeably. It is important to note that Aligntech has spent approximately one billion dollars in research & development since Invisalign’s inception in 1999. In one of the most important moves in Invisalign’s history, Aligntech hired the preeminent research-orthodontist in the field of Biomechanics (the study of the mechanical laws relating to the movement or structure of living organisms, specifically teeth in this case), John Morton, away from the University of Connecticut. Since then, he has led the way to numerous technical and biomechanical innovations.
Invisalign has developed a sophisticated dashboard that gives the orthodontist control of treatment from the first to the last aligner, allowing full customization of treatment. But like all modalities, there are strengths and limitations. Aligntech has recognized that to move the technology forward, it is crucial to have experienced orthodontists who are committed to using and developing the best treatment practices with Invisalign. To that end, Aligntech has created the Key Provider Program (KPP) that both assists specific practitioners in providing the most advanced treatment and, also, partners with them in the development of Invisalign aligners as a treatment tool. The list of those in the KPP is not public. However, there are ways by which a patient or parent may assess an orthodontist’s skill.
How to choose an Invisalign Orthodontist
First, to reduce the field of prospective clinicians, choose an orthodontist to do your orthodontics. If you skipped over the links to the respective curricula of the dental student and the orthodontic resident (who had previously graduated from dental school), I recommend that you peruse them below. These illustrate, most pointedly, the educational hurdle for the well-meaning dentist who would like to add orthodontics to his or her practice:
Second, attempt to determine which orthodontists are excellent orthodontists. Online resources such as Yelp can give you a glimpse into comparative practices prior to making contact. By reading reviews one can get a sense of whether a doctor is a definite “no” or a “let’s see.” You can search “Orthodontist,” “Invisalign,” or “Invisalign orthodontist” directly on Yelp, or another system. Reviews such as these are not definitive, of course, and only a starting point.
Third, visit the Invisalign Doctor Locator. Aligntech assigns classifications to practices (unfortunately, not individual practitioners) based upon the number of historical and recent cases. Current designations range from Bronze to VIP Diamond Plus (Bronze, Silver, Silver Plus, Gold, Gold Plus, Platinum, Platinum Plus, Diamond, Diamond Plus, and VIP Diamond Plus). Higher designations are awarded based on the number and type of cases treated over the most recent six-month recording period and total experience. Dr. Wong is a VIP Diamond Plus Invisalign orthodontist and achieved this status as a sole practitioner. He is recognized as one of the top <1% providers in North America.
Keith B Wong is a Diamond level orthodontic specialist
Differences across Invisalign provider levels are significant. The approximate number of Inivsalign starts per six months for each level is listed below:
Bronze<5 in six months
Silver<24
Gold<30
Gold Plus<60
Platinum<100
Platinum Plus<140
Diamond<200
Diamond Plus>200
VIP Diamond Plus>200 plus the “Valued Invisalign Provider” distinction awarded by Invisalign based on historical usage and other factors. These are the most experienced providers.
Note: Some caution should be used when interpreting this type of classification. While it is true that one needs a certain mass of experience to become an expert, it does not necessarily follow that case experience implies expertise. For example, every expert golfer has golfed many, many times, but many more golfers golf as frequently and are still self-proclaimed “hackers.” Usually, these “hackers” have not invested time, effort, and energy into critical analysis and improvement (i.e. lessons and focused practice). This is true in any endeavor or field. Seeking multiple complimentary examinations from orthodontists is recommended for this reason.
In addition, as noted above, in a multi-practitioner office, these classifications reflect aggregate practice volume, not that of each doctor. Thus, in a multi-doctor practice, a high-volume practice, or a clinic/corporate setting, the classification may be “Diamond Plus” but the doctor you see may not be expert or especially experienced. In addition, the high-volume classification may be associated with a practice culture that you would not otherwise choose, such as the sharing of patients across practitioners, or high-volume tactics designed for profit maximization. As an example, an orthodontist who had been classified in the leading category, and who perpetually offered Groupon Invisalign at significantly lower-than-market fees, made the news in 2017 by closing his doors without warning, leaving his patients without recourse.
Fourth, request personal or professional referrals from friends or your dentist/hygienist. It is recommended, however, as with all sorting methods, that one confirm these recommendations with other sources. There are several reasons for this: 1) your friend or dental professional may not appreciate the same attributes in an orthodontist as do you; 2) he or she may have a bias, pro or con, regarding Invisalign; and/or 3) his or her favored orthodontist may not be adept at Invisalign.
Finally, at your investigation’s conclusion, schedule and attend complimentary examinations with the practitioner or practitioners identified through the above. Do not make assumptions. An examination, its thoroughness, the professionalism of the doctor and his or her staff, and the recommendations made, will greatly inform you as to the most appropriate choice. In an age of online shopping, it is second nature to make choices based upon superficial impressions. Health care is not the place for superficiality, however, and make no mistake, orthodontics is healthcare. The difference between proper and improper treatment is not only appearance but the stability and longevity of one’s teeth. Improper alignment leads to tooth fractures, gum disease, and eventual tooth loss. Proper alignment results in not only a beautiful smile but a healthy one. Orthodontists, just as with all professionals, are not interchangeable. Your on-site assessment is the best means of determining if the practitioner is truly skilled and someone with whom you wish to begin such a relationship. Fortunately, such examinations are given free of charge; so, take advantage of this in making your decision. (Note: Free of charge does not mean “can be canceled”. Orthodontists have limited time for examinations and must use that time effectively. If an examination is missed, you may or may not be allowed to reschedule. Office policies differ and the reason for cancellation is often considered; however, if you wish to be treated, examinations should be considered as commitments.)
In conclusion: Consider all information noted above; seek complimentary examinations with likely practitioners; employ common sense—and smile; you’re halfway there, already!
I hope this post has been of help to you in choosing an Invisalign provider. Please see Seattle Insider’s Guide to Invisalign for additional information.
Dr Wong extends the capabilities of orthodontic aligner treatment through advanced techniques
