No More Brace Face? Teens Increasingly Use Clear Aligners

No More Brace Face? Teens Increasingly Use Clear Aligners

As treatment with aligners moves from the adult to the younger market, orthodontists are treating more children without traditional wire braces.

Dr. Julissa Demorizi and Dr. Elliott Moskowitz show a clear aligner to a 12-year-old patient, Lila Hertzberg, in their Manhattan office.

By Jill Werman Harris

When Carly Feinstein was in ninth grade, her dentist sent her to an orthodontist.

“I cried for three hours when I heard I had to get braces,” said Carly, now 16, who lives in New York City. “I worried about how I would look. It would have been so embarrassing.”

But like an increasing number of adolescents, she was delighted to learn that she did not need to get traditional metal braces after all. She was treated with clear aligners instead.

The American Association of Orthodontists estimates that nearly 4.3 million patients 17 years old and younger were treated in North America in 2016, a 66 percent increase since 1989.

But as treatment with removable clear plastic aligners moves from the adult to the younger market, orthodontists are treating more children without using traditional fixed bracket and wire braces. And now the treatment is becoming available to younger patients, even some children who still have baby teeth.

Align Technology, the maker of the brand Invisalign, reports that from 2013 to 2017 sales of its products for teenagers increased from approximately 100,000 to over 235,000. In the last two years, Invisalign’s volume of teen and tween patients grew faster than that of adults.

In July, the company introduced a new product called Invisalign First for children who have both baby teeth and permanent ones, known as mixed dentition. Children tend to lose their primary teeth between the ages of 6 and 12, and many orthodontists wait to use a complete set of traditional braces until most baby teeth have come out. Aligners could be used in kids as young as 6.

But some experts are skeptical about their use in such young children because baby teeth have less surface area for aligners to hold on to, said Dr. Brent Larson, president of the American Association of Orthodontists and director of the division of orthodontics at the University of Minnesota School of Dentistry. Many orthodontists feel that the jury is still out on using aligners while teeth are still falling out and coming in.

“Adolescents who have lost all their baby teeth have done well, but nobody quite knows for sure what’s going to work predictably and what’s not for mixed dentition,” Dr. Larson said.

And unlike metal braces, aligners can be taken out in the school cafeteria, left on a lunch tray and accidentally thrown away — a risk parents of children in elementary school may need to consider.

Clear aligners, around since the 1970s, can now be generated from 3-D scans electronically sent to a manufacturer along with X-rays, photos and a detailed prescription from the orthodontist directing how to address misaligned teeth, known as malocclusions. The patient gets a series of sequential, snug-fitting, clear plastic aligner trays, which usually can move the teeth into the desired position in six to 18 months depending on the complexity of the case.

Aligners initially were marketed as braces for adults, but as the products improved, manufacturers saw an opportunity to sell them to an appearance-conscious younger market. Invisalign Teen was introduced in 2017.

“I think it started out by orthodontists who used aligners aggressively in their practice of adults, and started experimenting with teens,” Dr. Larson said.

Consumer demand is a big factor driving the trend, energized by a culture of social media in which teens increasingly feel they are defined by how others perceive their physical appearance. Direct-to-consumer advertising and technology allowing for customization also play a part.

According to Dr. Larson, there are not many well-designed clinical trials showing the effectiveness of aligners for adults, and even fewer for teens, but there is a lot of clinical evidence and experience showing that for certain types of dental problems, aligners can be very effective.

When clear aligners first arrived on the scene, the technology was inefficient and orthodontists were skeptical. “Now, after years of thinking they were an inferior appliance in all cases, we see them being equivalent in many cases and superior in some cases,” said Dr. Alexander Waldman, an orthodontist in private practice in Los Angeles.

The advantages of clear aligners include invisibility, removability and less pain. “There’s no teenager who wants braces. It’s awkward to wear them. The little kids sometimes don’t mind as much but if I have a 14-year-old girl in my chair, it better be a clear aligner case,” said Dr. Elliott Moskowitz, a clinical professor in orthodontics at New York University College of Dentistry who is also in private practice in New York City.

“Five years ago, my practice was 100 percent fixed traditional braces. Today it’s 80 percent clear aligners,” he added.

Orthodontists say that traditional brackets exert more force on the teeth, so patients can experience more pain. And metal pieces rubbing against the cheeks can cause irritation and sore spots.

“In our office there are fewer emergencies and extra visits to fix broken components and fewer appointments to complete treatment with clear aligners,” Dr. Waldman said. “That means much less time off from school and after-school activities.”

Oral hygiene is also generally better with clear aligners because patients take them out to eat and brush their teeth, whereas it can be challenging for kids to floss and clean around wire braces.

While removability is a perk, especially for those tween and teen coming-of-age events, manufacturers recommend wearing clear aligners for 22 hours each day to produce high-quality and long-lasting results. Patient compliance is critical as the control over outcome shifts from the orthodontist to the patient.

“With braces, without cooperation, we get straight teeth. With aligners and a lack of cooperation you get nothing but a bill that you have to pay for something that has not been completed,” said Dr. John Marchetto, an orthodontist in private practice in Weston, Fla.

Some orthodontists don’t think it’s worth the trouble.

“There’s a lot more diligence required with clear aligners. You have to take them out even when you drink colored beverages. When you eat, you don’t want to shove it back in your mouth and have food in between the aligner and your teeth,” said Dr. Bina Park, an orthodontist in private practice in New York City and Greenwich, Conn.

If a patient loses an aligner, which is not uncommon, it can take up to two weeks for the replacement to arrive. Dr. Park said, “This can lead toward a longer treatment time. With braces there’s no delay.”

Beth Laboe Edgar, custom orthodontics business director at 3M Oral Care Solutions Division, which manufactures traditional wire braces and clear aligners, points out that many patients use multiple appliances.

“An orthodontist may deploy brackets early on and then switch to aligners later. Patients really shouldn’t be seeking one option or the other. It’s really about the specific case and how to treat that case,” she said.

“Orthodontists aren’t in the braces business,” Dr. Moskowitz said. “We’re in the tooth movement business. We have to evolve and be open or we’re going to be left behind in old technology.”

Experts recommend understanding all of the options and mapping out a long-term strategy with your orthodontist based on treatment goals and lifestyle preferences. “You have to be careful of appliance-driven therapy,” Dr. Waldman said. The treatment plan determines the appliance used. “Neither patients nor orthodontists should decide on the tool and then figure out what can be built with it.”


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