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Braces V. Aligners: As Technology Evolves So Do Patient Choices by Donna Galante

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The use of aligners is certainly a hot topic these days, especially in the dental/orthodontic community as more and more patients are requesting clear aligners to help them achieve their smile and dental-health goals.

But before we dive into this controversy, let's take a brief but interesting look back at the history of braces. You may be surprised to know they have been around for a very long time.

Smile, Rameses!
The use of braces goes back to the days of Egyptian pharaohs. Yes, mummified remains have been found with crude metal bands wrapped around their teeth.

Fast-forward to 1728 when a French dentist, Pierre Fauchard, published a book titled, "The Surgeon Dentist." In this book he describes a device called a "bandeau," which was used to expand the upper arch. In 1819, Christophe Delabarre came up with "the wire crib," which is much closer to the braces we know today.

Over the next 100 years, braces remained the same until the middle of the 20th century, when great technological and material improvements were made to the design, shape, size, structure and materials of braces. Adhesives and direct bonding to the teeth became a mainstay of orthodontic practices in the late '70s and early '80s.

Since then, development in the design and type of appliance has given us even greater choices in appliances, including the latest technology: clear aligners.

A clear controversy
In 2000, Align Technology introduced clear, plastic aligners to the world of adult orthodontics. This initial entry into the orthodontic appliance marketplace was restricted to adults and certain types of cases.

Most orthodontists were already familiar with clear, Essix-type retainers and many of us had been using them routinely for years. We felt comfortable using them to move a single tooth or two back into position. It never occurred to us that it was possible to use a clear, removable, Essix-type retainer to accurately move teeth and correct bite problems.

Clear-aligner therapy is often met with some skepticism by doctors, staff and patients. My purpose in writing this article is to do an overview of the advantages and disadvantages of both types of appliances and to give you an opportunity to decide for yourself if one is better than the other, or if they both have a place for orthodontic treatment in our adult and teen patients.

Brace yourself
Obviously the advantage to braces for us as doctors is that we feel more in control and have a better grasp of how to treat a particular malocclusion. The patient has an appliance glued to his or her teeth and therefore it is always on. We have the patient come in for adjustments and wire changes so we can see on a regular basis how the teeth are moving and make changes as needed.

Some patients, of course, like the convenience of not having to worry about something removable. They like the colors on the braces (especially younger patients) or they look at braces as a status symbol or to show others they are taking care of their smile. Once the excitement wears off, however, many patients ask at each visit when the braces are coming off, or they forget to brush after meals and continue to eat candy, causing breakage and more appointments. The patient may need to wear elastics or other auxiliaries to get a complete bite correction. Compliance from the patient is still very much required for exceptional results.

But a significant number of patients are interested in improving their smile without the burden of fixed braces on their teeth. This huge, untapped market is where you will find many patients opting for clear aligners. The benefits are obvious: the patient can remove them for eating and brushing, as long as he or she keeps them in place 21-22 hours a day. Many aligners are cosmetically appealing and virtually invisible, definitely cause less discomfort than traditional braces and generally require fewer appointments and less time in the office.

The only downside is the fact that they are removable and patients can choose not to wear them the recommended hours per day, thus influencing the results and treatment times.

Many of my colleagues also say the results just are not as good as fixed appliances.

I used to believe and say the same thing. And while clear aligners may not solve all the orthodontic problems of the world, with a thorough treatment plan, a ClinCheck set up properly and a very compliant patient, you will get results as good as, and sometimes even better than, your fixed appliance, and with fewer appointments.

In our offices, if we have a compliant patient and the aligners are fitting well, we often schedule appointments out 10-12 weeks and give the patient the appropriate number of aligners until the next visit.

If there are compliance issues, we will normally give a patient one or two sets at the most, and have him or her back at two to four weeks to evaluate their wear. Many times, patients start to wear them as required and get back on the appointment cycle of 10–12 weeks, which they prefer.

You can get exceptional results with a series of great-fitting aligners, a very compliant patient and, most important, the knowledge and skill needed to set the case up for success.

A case study
I'd like to share the story of a typical adult patient like those we see on a regular basis in our offices. Jessica, at age 42, did not like her smile and was concerned about wear on her lower front teeth, but she did not want traditional braces.

She presented with a deep anterior overbite, upper and lower crowding, retroclined upper central incisors and wear on her anterior teeth (see photos on this page). The treatment plan was Invisalign for 15-18 months.

Here you can see her initial photos and the extreme deep bite.

Jessica was compliant, wearing her aligners as prescribed, 22 hours a day. Her total treatment time was 15 months, with a total of 33 aligners. She had eight active treatment appointments, no refinements, and is now in retention.

As you can see, her deep bite was corrected, the alignment significantly improved and there was a slight change in her profile due to the change in her bite (see photos on this page). How many of us never would have thought this possible with clear aligners?

So here we are in 2015 with other options besides the traditional metal braces and wires.

Innovation and new technology drive the world today. As clinicians, we need to embrace these new technologies and use them to our benefit, both professionally and personally.


Dr. Donna Galante owns four orthodontic practices in Northern California and is a member of the Orthotown Magazine advisory board. In 1986, Galante received her orthodontic specialty certification at the University of Pennsylvania and opened her first private practice in King Of Prussia, Pennsylvania. From 1986 through 1993, she was a clinical instructor at the University of Pennsylvania's Department of Orthodontics where she worked directly with graduate students. She was twice voted "instructor of the year" by the orthodontics residents. In 1992, Galante became a diplomate of the American Board of Orthodontics.



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