There is no question that the introduction of clear aligner therapy (Invisalign) back in the late 1990’s changed the orthodontic landscape forever. Not only did the technology extend orthodontic treatment to patients who didn’t want braces (mostly adults), but it also expanded the number of providers since at first glance clear aligners appear easier to use. Not only did many general dentists begin offering orthodontic treatment in their offices, but several direct-to-consumer (DTC) companies also appeared that offered to straighten teeth through the mail.

While non-specialists may be able to use clear aligners to align the front teeth, resolve some crowding, and close some spaces between the teeth, there are still a lot of conditions that require the expertise of an specialist with advanced training. Here are just a few:

Developmental Problems
Orthodontists are dental specialists with additional training in the development of the teeth, jaws, and face, and have the tools to determine when things are not normal. Examples of developmental issues include extra teeth, missing teeth, malformed teeth, as well as problems with the growth of the jaws.

Orthodontists can identify these issues early and take steps to address them before it is too late. Extra teeth can be removed to allow normal development of the remaining teeth. Removing primary teeth early can encourage the movement of underlying teeth to addressing missing ones. General dentists and DTC companies rarely address these issues.

Eruption Problems
Examples of eruption problems include teeth that don’t develop where they should or later move into positions where they don’t belong. Ectopically erupting teeth come in where they shouldn’t. Impacted teeth usually don’t come in at all without help.

Merely aligning the teeth that are visible in the mouth will not usually address these conditions. Most DTC companies don’t require x-rays as part of their protocols, so they rarely identify or address impacted teeth. Although general dentists do take x-rays, rescuing ectopically erupted or impacted teeth with aligners is usually not possible. Orthodontists are trained to work with oral surgeons and other dental specialists to resolve these complications.

Excessive Crowding or Protrusion
Most cosmetic orthodontic problems arise because the teeth are bigger than the amount of space available. This discrepancy results in teeth that either overlap (crowded) or stick out (protrusive). Ironically, the process of merely aligning crowded teeth makes them MORE protrusive. Although aligners may make the teeth straighter, they usually look and feel like they stick out further than before treatment. This is a side-effect that is rarely addressed by non-specialists.

The only remedy that non-specialists have for reducing protrusion after the teeth are aligned is interproximal reduction (IPR) or air rotor stripping (ARS). While this procedure may slightly improve dental flaring, the amount of improvement is minimal. Dentists can move the front teeth back only 1mm for every 2mm of enamel removed with diamond discs or burs. If your teeth move forward 3mm after alignment (a common amount), your dentist would have to shave away 6mm of enamel to reverse that change. Interproximal reduction is not an option available with DTC aligners. Orthodontists are trained to address crowding and protrusion with more advanced techniques like expansion or the removal of teeth.

Bite Problems
While clear aligners may be proficient at aligning the teeth in a single arch, they are not as good at correcting bite problems (how the upper and lower teeth come together). Some bite issues that are more difficult to address with clear aligners are deep bites (the front teeth overlap too much), open bites (the front teeth don’t overlap enough), overbites (the lower jaw is too far back), underbites (the lower jaw is too far forward), and crossbites (the upper and lower jaw widths don’t match). While aligners may be able to improve these conditions when they are due to misaligned teeth, they are not as effective as other techniques when the jaw sizes are at fault. In fact, aligning the teeth without addressing an underlying jaw discrepancy may actually make the bite worse.

Orthodontists are dental specialists trained to correct overbites, underbites, crossbites, deep bites, and open bites. Not only are they experts at using clear aligners when appropriate, but they also understand how and when to use expanders, functional appliances, braces, extractions, and surgery when necessary. You only have one set of teeth. Shouldn’t you see a real orthodontist?

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist in the private practice of orthodontics in Rio Rancho and Albuquerque, New Mexico. He was trained at BYU, Washington University in St. Louis, and the University of Iowa. Dr. Jorgensen's 30 years of specialty practice and 10,000+ finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog is for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor select treatment plans for readers. The opinions expressed here are protected by copyright laws and can only be used with the author's written permission.