Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

Braces vs. Aligners: The Science of Picking the Best Appliance by Daniel Grob, DDS, MS, Editorial Director

View Comments (3) More by this author (76)
Header: Braces VS. Aligners
by Daniel Grob, DDS, MS, Orthotown editorial director

Clear aligners or fixed appliances
Consider the following scenario:

Several orthodontists have told your patient that the only way to straighten her teeth is with full braces lasting at least two years. To make things even more complicated, treatment will also involve surgery to widen the jaw, and perhaps even the removal of some permanent teeth.

You, the family dentist, are asked for an opinion. What do you do?

Situations like this plague my practice on a daily basis. As an orthodontist, I've seen many of these patients, and I've either started or denied treatment based on several pieces of objective criteria. My decisions are based on experience with both fixed appliances and clear aligners, resulting in successful treatment for several thousand patients.

Hopefully, understanding the limitations of orthodontic appliances will help you decide whether to treat patients in your practice or refer them to your local orthodontist.

My experience has shown that different appliances accomplish different tooth movements—and some work more effectively than others. I've tried and succeeded with almost every necessary tooth movement using clear aligners as well as fixed appliances, but sometimes at a high price.

At some point you need to strike a balance between what you and the patient will tolerate in terms of compliance, wearing of auxiliaries and time in treatment.

The three things I focus on when making the decision to proceed with either clear-aligner therapy or fixed appliances are tooth movements, jaw discrepancies and side effects.

Tooth movements
Side-to-side or mesial-distal movement is easily accomplished with aligners or braces. An example of this movement would be closing an anterior diastema (Fig. 1).

Twist and turn, or rotation, is a little more difficult, and attachments may have to be added to aligners to maintain the close fit of the aligners and ensure accurate tooth movement. Some patients may find this objectionable.

Making enough room by first widening the space, expanding the arch or utilizing interproximal reduction is essential with both appliances. An example of this movement would be rotating the central incisors.

A combination of all three movements, called a third-order movement, is probably the most difficult and is best done with fixed appliances. An example of this would be cuspids or bicuspids that have erupted into an undesirable position. Since most roots should be finished distal to the crown, teeth with roots to the mesial are difficult to treat with aligners only (Fig. 2).

Root torque is possible with both appliances—however, achieving accurate tracking of the clear aligner may require many anterior attachments, which patients may object to.

Intruding and extruding individual teeth are often done more efficiently with fixed appliances (Figs. 3 and 4).

Without special wire-bending skills and extra chair time (which these days is not as common as in the stainless-steel-wire days), the act of placing new heat-activated and superelastic wires into the bracket slots introduces tooth movement across the arches.

However, custom archwires (SureSmile) created from 3D scans have allowed orthodontists to cleverly control tooth movement and eliminate some unwanted side effects.

Clear-aligner therapy can control this unwanted movement and more precisely place pressure where needed to achieve a specific tooth movement. This is especially useful when there are complex treatment goals, especially in prerestorative cases.

Attachments, auxiliaries and cooperation are larger variables in aligner therapy because of the removable nature of the appliance.

Clinicians who facilitate functional arch development utilizing proper tongue posture and relaxed lip pressure (as in self-ligated appliances) find their philosophy best served with fixed-appliance therapy, because the computer-aided aligner software is not yet capable of figuring the functional neutral zone into the treatment outcome. The value of articulator-mounted casts is invaluable in these situations.

Figs. 1, 2

Jaw discrepancies
Skeletal imbalance is best treated with fixed appliances and auxiliaries. The aligner companies are capable of treatment-planning skeletal movement with elastics, but the computer visualization and patient result are not always correlated (Fig. 5).

Proclination of lower anterior teeth will assist both types of devices in opening the anterior deep bite and camouflaging the initial overjet.

Sagittal movement is accomplished with both appliances, and larger movements are possible with fixed appliances.

An example is space closure in an extraction site. Root parallelism is possible, but is more successful if the roots are pointing toward the extraction site at treatment initiation, resulting in uprighting of the teeth during movement. Many attachments may be necessary.

Widening the most terminal teeth using clear-aligner therapy presents limitations because of the lack of anchorage in this area. A separate phase of arch expansion could be utilized before clear-aligner therapy.

Side effects
Single-tooth buccal or lingual cross-bites are treated well with either device. An occlusal bite raiser is utilized (thick sealant) with fixed appliances (Fig. 6).

Coincidentally, the wearing of an opposing aligner serves to disengage the bite for jumping of the bite. I prefer to pause opposing-arch tooth movement during the jumping phase for ease of computer simulation and fixed-appliance therapy (Fig. 7).

Theoretically, skeletal deep bites are made worse with Invisalign, so their treatment is best done with fixed appliances and bite plates. Bite ramps are available on aligners that are working, to not only intrude the anterior segment but also encourage eruption of the posterior teeth.

Open bites in the posterior are one of the side effects of aligner treatment. This may be used to advantage in the closure of slight open bites and eliminate interfering occlusal contacts. I have found this movement to be unpredictable because of influences of muscle pressure (Fig. 8).

Figs. 3, 4

Fig. 5

Figs. 6, 7

Conclusion
I hope that this brief summary of tips and tricks for selecting clear-aligner or fixed-appliance therapy will open clinicians' eyes to what is possible.

It is safe to say that outstanding results have been achieved with the vast majority of fixed and removable appliances available to the clinician.

As with all of dentistry, as one becomes more proficient with specific techniques, the ease of attainment and quality of the result will certainly improve.
Dr. Daniel Grob
Dr. Daniel Grob, Orthotown editorial director, is a trained prosthodontist. After teaching and practicing for several years, Grob returned to Marquette University School of Dentistry to earn a master's degree and board certification in the specialty of orthodontics. After practicing both specialties in Milwaukee for two years, he and his wife moved to Tucson, Arizona in 1985 to care for patients and raise three children. While in Tucson, Grob and his business partner, Dr. Mark Donovan, grew a small practice into a three-office, three-doctor enterprise that was recently sold to two young orthodontists. Grob relocated to Scottsdale, Arizona, where he continues to treat patients, with a special emphasis on comprehensive care and education.



Dentaltown Magazine
September 2025
Dentaltown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie Perks
Townie® Poll
Who or what do you turn to for most financial advice regarding your practice?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds Dental News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Dentaltown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450