As fixed appliances (aka Braces) have been around for more than a century, they appear to be a known quantity in the world of orthodontics. Invisalign ( introduced around 1999/2000) is a relative newcomer. Sometimes, patients want to know “which of these appliances is better”? The answer is…
The question of “which appliance is better?” depends on who is asking the question – why they’re asking it and what they hope to get out of the appliance itself. If that sounds slightly too philosophical, consider that both Braces and Invisalign each have their own strengths and weaknesses. Depending on your own clinical scenario or goals or preferences each might be the “better” appliance for you. An orthodontist tends to view these appliances a bit more dispassionately. They tend to see each as just another “tool in their toolbox” to move teeth. Sometimes tools are better at one thing than another. Some jobs can be accomplished by any number of tools. Sometimes contractors have their own favorite set of tools. Orthodontists are similar in this regard. To illuminate this topic let’s consider some “Pros and Cons” of each tool.
Braces – PROS
- Braces are well known and mastered by the vast majority of the orthodontic community and even some dentists
- Braces accommodate a number of other auxiliary components that allow for the finishing of difficult “jobs”. These are things added to bands or attached to the archwires themselves or even added to other appliance components in the oral cavity (TADs, etc).
- Braces allow for multiple mechanisms to “correct the bite” (from a front-to-back perspective) as well as accomplish width and significant vertical changes
- Braces can range from quite expensive to fairly affordable and therefore help an orthodontist keep their fees lower (supply costs)
- Braces can incorporate newer technological advances such as custom bases (individualized brackets), or custom archwires (robotically bent and customized for an individual patient) as well as very specific bonding (designed outside the mouth) to speed up the longer initial appointments and overall treatment duration (efficiency).
- Braces can be very esthetic (almost invisible – including the archwires) and even placed on the tongue side (inside) of the teeth allowing for a nearly invisible treatment.
- Braces allow an orthodontist to master certain clinical scenarios better than almost any appliance. They are fantastic for patients who need dramatic width changes. They are also great for patients who suffer from “deep bites” and others would benefit from teeth erupting vertically during treatment as this happens very naturally. They are also very quick to resolve crowding (aka align teeth) and patients really value this as that typically drives them to the orthodontist in the first place.
Braces – CONS
- Oral hygiene is more difficult when an appliance is fixed (glued) on the teeth. Patients must spend much more time brushing and flossing to prevent white spots from developing
- The force(s) applied to teeth are usually given via the standardized archwires that engage the individual brackets glued to a tooth. Despite the fact that standard-archwires have been improving dramatically (in terms of comfort) in the last 2 decades, these forces are somewhat difficult to control and do result in a temporary and small amount of discomfort following an appliance adjustment (regular appointment)
- Hygienists typically will request archwires to be removed prior to a cleaning appointment which can result in a longer set of appointments if an archwire must be removed, cleaning performed, and then an archwire replaced later that day.
- Sometimes, dentists will have more challenges detecting potential developing cavities if the appliance itself interferes with clinical examination or radiographic evaluation (the metal portion obscuring the lesion).
- Braces struggle (at times) with efficiency. Although this can be a reflection of the clinician themself, this appliance plays a large role. There are typically very distinct stages of treatment: (1) leveling and aligning, (2) bite-correction, and then (3) finishing and detailing. While there may be some overlap the majority of each one of these stages is separate and distinct. Because all of the teeth are (typically) attached to the same wire and different wires are used for different stages, it becomes difficult for one set of teeth to move on to the next stage if another section of teeth are still working on a prior stage. There are some exceptions to this (naturally) but the general rule of thumb is that you finish one stage before advancing to the next stage and that can create a “bottleneck” of sorts where you’re only as fast as your slowest team-member (or tooth in this case).
Invisalign – PROS
- Invisalign by its very nature is an esthetic appliance. It’s clear plastic that allows your teeth to shine through. The most anyone will see is a slight “sheen” or reflection on your teeth. Many adults are looking for a type of orthodontic treatment that isn’t terribly visible and that can appeal to them.
- Invisalign is removable. This can also be a “con” (see below) but this is extremely beneficial for patients who already suffer from periodontal disease and must take great pains to ensure that their dentition remain in a healthy state. This is also (potentially) great for children and adolescents. No longer do they have the excuse that it’s really hard to floss around their braces. They can simply pop out their aligners and brush and floss like normal. Patients who need a break for a (quick) speech, presentation, or a hot-date can pop out their aligner and replace it when finished with the task at hand.
- Invisalign is highly configurable. Since each appliance is custom-made to a patient’s own specific scenario, the treatment can be customized down to the n-nth degree. Teeth that are periodontally compromised can be held steady (or moved at a very low rate). Teeth that are adjacent to thin (delicate) gum tissue can have their movements limited to guard against potential recession.
- Aligner treatment has a limitation as far as tooth movement rate is concerned. Because the parent company wants this treatment to be successful they limit the magnitude of each tooth to move only a fraction of a millimeter per aligner. While this increases the predictability and success of clear aligner treatment it also has another benefit in that most patients find it to be incredibly comfortable. Once the initial inflammatory process is started and the tooth socket is widened slightly (as is normal), clear aligner patients are very comfortable throughout treatment. Patients who switch from Braces to Invisalign are typically very happy while the same can not always be said of the opposite transition.
- Invisalign is really good at handling certain scenarios – particularly open-bite scenarios. The two layers of plastic act as a “cushion” which can help avoid the tendency of teeth to erupt during treatment (as with braces) and even provide capability to close open-bites if used appropriately.
- Invisalign can help patients with mild temperomandibular disorder (TMD) symptoms. TMD is a highly mutlifactorial disease and associated etiology but for patients with mild symptoms, having two layers of plastic covering the back teeth can provide some (temporary) relief as the layers can act as a type of thin nightguard (worn all day long).
- Invisalign aligners aren’t constrained by archwires. This means that they can theoretically address multiple stages of treatment at one time. An orthodontist can be dialing-in the front teeth (as in the last stage “finish and detail”) while correcting the bite and also working out rotations (as in the “leveling and aligning stages”). It’s not that this doesn’t happen to some degree or other with braces, it’s that this can happen seemlessly with this type of appliance.
Invisalign – CONS
- Invisalign is a removable appliance. While this can be beneficial for many patients who struggle with oral hygiene (see above), it may be problematic for patients who are forgetful or not diligent enough to replace their aligners following meals and snacks.
- Invisalign aligners can stain. Patients should at the very least rinse their mouth out following a meal and even more preferably brush after every meal. Failure to do so can leave organic debris (food residue) on the teeth which can in turn stain aligners (typically turning them a faint yellow-orange). Red wines, curries, and red sauce are distinctly notorious for causing this type of insult.
- Invisalign aligners do take some getting used to especially with regards to insertion and removal. Initially, most aligners do not have bumps to push and pull the teeth (attachments) but after the bumps are added most patients will discover that slightly more effort is needed to remove the aligners. We often jokingly refer to this as “the Invisalign diet” because during the initial portion of treatment a patient will have to really want to struggle with removing their aligner to eat those snacks at work or school. Invisalign patients whether children or adults must account for this extra time to remove their aligners prior to a meal and clean up and insert their aligners following a meal. The good news is that stained aligners can be replaced at the next aligner change – typically one week later.
- Invisalign introduces a thin layer of plastic to encompass or envelop the teeth. This plastic extends to the tongue-side of the teeth as well. While most patients adapt quite well, very few will find they struggle with a slight lisp during treatment. Practicing reading out loud is typically the best way to eliminate this phenomenon.
- Invisalign struggles with certain tooth movements. Invisalign has historically struggled with width changes as well as front tooth angulation changes. Teeth with large roots (think canines or eye-teeth) may not respond as well to certain movements. Teeth with small crowns (think the front side teeth) will typically require some type of bump to hold onto the plastic along with careful observation throughout the course of treatment.
- Front-to-back bite shifts can be more challenging. Any shift over 2mm requires more than elastics (a type of synchronized shuffle of teeth) and anything more than 4mm requires some extra help from another appliance component or auxiliary. Major front-to-back bite shifts tend to be in the 5-6mm range so this may limit some patients unless they are young and have some growth potential remaining or are willing to consider other paths to bite correction.
This comparison (Pros and Cons) was not meant to be an exhaustive list but rather an illumination of the various factors that may lead one patient to choose one appliance or another. An orthodontist can view both appliances as “tools in their toolbox”. Some tools are better for some jobs while another tool is better for a different set of jobs but many jobs can be accomplished with both tools. Patients with open-bites, may experience better results with Invisalign. Patients with severe crowding may have faster outcomes with braces. For patients with periodontally compromised teeth Invisalign may be better suited. For patients with deep bites, braces may be more efficient. Occasionally a patient will present who would benefit from Invisalign but they don’t trust themself to wear the aligners the requisite 20-22 hours a day and braces are a better fit for them. Another patient will understand that their treatment will take longer with aligners but they are adamant that they will consider no other appliance. Invisalign is the best option for them. Ultimately, an orthodontist’s job is such that they empower a patient to understand the tradeoffs present and make their own best decision. The answer to the question “which appliance is better – Invisalign or Braces” is always followed with the answer…