The "Dark" Side of Invisalign®

The "Dark" Side of Invisalign ®

or "What is so Bad About Invisalign®?"

Social media and advertisements may portray that Invisalign is an amazing experience regardless of specific needs. If it is, why doesn't it replace conventional braces completely? And why does anyone still choose braces at all? In fact, statistics show (as of current time ) that a larger percentage of people (with all age groups included) still use traditional braces more than Invisalign and other clear aligners (data source: Henry Schein Ortho).

Even with the most cutting-edge technology of the day, Invisalign may not be the perfect option for everyone. Dr. Nicely would like to list the most important considerations that you need to pay attention to and list some pros and cons of Invisalign treatment so that you might have a better understanding of your choices.

One systemic review of research studies in 2019 concluded that, in simpler words: some of the less complex teeth movements and limited changes are more likely to be achievable with Invisalign (or other clear aligners) than more complex movements; the bigger changes are not as likely or as effective with Invisalign compared to with braces; and even if those bigger changes are made with your teeth by clear aligners, the results may not last as long. [1]

(The original language of the studies says: "Clear aligners (i.e. Invisalign etc.) had advantage in segmented movement of teeth and shortened treatment duration, but were not as effective as braces in achieving great improvements, producing adequate occlusal contacts, controlling teeth torque, increasing transverse width, and retention."[See reference 1.Keet. al.])

Another recent systemic review of research studies concluded that clear aligners (including Invisalign) are not as accurate in treating many complex teeth alignment issues as braces. [2]

(The original language of the studies says: "Although it is possible to treat complex malocclusions with plastic systems (i.e. clear aligners like Invisalign), the results are less accurate than those achieved with fixed appliances (i.e. braces)." [2]

Q. You may ask Dr. Nicely: How big or complex are the movements needed for my teeth?

A. - Well, only your consulting orthodontic specialist can tell you after looking into your mouth and seeing some of your x-rays - and most orthodontic offices offer free consultations, so please feel free to make an appointment with Dr. Nicely or another orthodontist!

Q. You may ask Dr. Nicely: I heard that Invisalign hurts less than braces; is that true?

A. - Another systemic review of research studies concluded that the difference in pain (or discomfort) with clear aligners (like Invisalign) and braces only exist within the first few days of starting treatments.[3] Basically, braces only hurt a little more than clear aligners for a short few days; afterwards, you will have more "pain"(on your mind) with brushing & cleaning with Invisalign multiple times a day compared to braces.

You will understand this point better after reading the next few paragraphs.

And if you think a short few days of sore mouth, (which can be compared to what we often get by eating a hot pizza in a hurry), is the determining factor of not-having braces, then you will probably not be suitable with Invisalign either. Why? -You ask Dr. Nicely... - It's because there are also many chances of having a sore mouth for a few days with Invisalign, too!

Now let's look at the most important disadvantages of Invisalign in detail.

• ♦ 1. First "Dark" side of Invisalign - You need to take your trays out EVERY TIME you decide to eat or drink*, AND you need to brush and floss afterwards before putting trays back on! That is every time you eat or drink*, every day during Invisalign!

(*It means every time you have something that is not just pure water** in your mouth...)

(**What we call in this article "pure water" means: purified (or filtered) drinking water without any additions. [Minuscule amount of factory-added "flavor-enhancing minerals" that comes with those bottled purified drinking water (simple forms) are negligible.] Most other drinks contain either sugar, sugar alternatives (which are acidic), carbonic acid (like in carbonated water), or other cavity-promoting elements, so they have to be removed from the teeth, mouth and Invisalign trays after each meal time, before placing clean trays back on teeth; therefore they are considered "meal-related" drinks, or simply called "drinks" in this article. )

Only "pure water" alone is approved for all-day fluid consumption with Invisalign trays in mouth.

In summary: all other forms of drinks should only be consumed during meal time, with trays out!)

And because Invisalign trays need to be worn 20-22 hours or MORE each day to be effective, you only have limited meal times to take the trays out for eating and drinking purposes: it is recommended that you have three regular meals, with less than 45-60 minutes spent on each meal on average, per day, (or a total of 2-3 hrs of meal time per day with brushing).

Therefore: Invisalign is Not For Frequent Snackers or Sippers At All!

One of the smart patients from Dr. Nicely's office summarized this as a "long pain vs. short pain" choice, as follows:

i. Choosing Invisalign, you have a lot of things that you have to do for each time of eating/drinking (except pure water alone) - i.e. the 3 times a day "Invisalign routine"(for each meal or drink every day, throughout the Invisalign treatment):

The 3 times a day "Invisalign Routine" -

• a)    You have to take your Invisalign trays out of your mouth and secure them, then
• b)    Eat and drink (relatively quickly), then
• c)    Brush teeth and floss, and
• d)   Cleanse your trays, then
• e)   Place the trays back on your teeth after each meal for your accumulated 22 hours per day wear.

If you eat/drink more than 3 times a day, you will have to do this whole routine more than 3 times a day! Don't forget: It's best to have all meal times totaling less than 4 hours each day (including brushing time) so that your trays are actually moving your teeth effectively. You cannot eat nor drink anything (but only drink pure water) for those 20-22 hrs/day tray-wearing times. This can be too limiting for regular coffee (or drink) sippers, for sure!

ii. Choosing braces, there is both good and bad news. The dreaded “do-not-eat with braces” list is the bad news for most people at the beginning; however, Dr. Nicely gives you the good news: after your initial two weeks of "overwhelming" transitional period with new braces is over, and you are getting comfortable with taking care of your braces, IF you practice excellent oral hygiene daily (especially before bedtime) and pay attention to the amount of pressure you place on those teeth with those things that you chew, you may slowly add back some of those softer "forbidden" foods carefully, adding one or two items back to your diet a few days at a time. That way, you will be able to figure out what foods you can carefully eat without breaking off any brackets. Of course, those super hard foods like popcorn kernels, ice, and certain sticky foods may still need to be avoided; it becomes a very short list, though, if you are careful! Then you won't feel like you are missing out on good foods.

So the transitional "training" period for braces is only about 3-4 weeks; afterward, as long as you are brushing your teeth really well for at least 1-2 times a day (and flossing, especially before bedtime), you are good! A couple of snacks a day besides regular mealtimes are probably ok for braces!

Therefore this wise patient (from Dr. Nicely's office) chose braces for himself. But your choice is still your decision!

• ♦  2. Second "Dark" side of Invisalign - You need to be absolutely great at keeping track of your trays, taking care of your trays, and not losing them!

If you lose one tray and have another previous tray to replace it (because you are great at keeping track of your old trays too), you may be slowing down your treatment by a couple of weeks. But if you lose trays more than that, or if your dog(s) chew your trays or your waiters at restaurants are throwing away your trays, or your trays are getting warped by heat in the sun or by someone sitting on them... (BELIEVE it or not: all of those are very real happenings of people's trays, and very possibly happening to you!)... Then your Invisalign treatment will only be a high price sticker that you are paying for, but not reaping any benefits of!

Invisalign trays, or called "aligners", require an average of 22 hours per day wear in order to do something good. Therefore, losing trays means not wearing the right trays for those 22 hrs/day. It will put a few weeks of set-back on your treatment progress each time, or up to a few months depending on the complications of your treatment.

If you are someone who tends to lose your keys or wallets (e.g. more than once a year), you might as well not start any Invisalign treatment, or plan on having a very slow-progressing treatment for a very long time!

A great alternative for those forgetful or care-free people (who are a wonderful bunch in our own families) braces! You are more than likely forgetting about even having braces on after a few weeks of getting used to them. As long as you are good at taking care of your teeth, brushing (and flossing), you won't have to worry about forgetting anything! - They do the work for you, all on their own (24/7)!

• ♦ 3. Third "Dark" side of Invisalign - It is usually more expensive than braces.

The average cost of Invisalign is higher than the average cost of braces. Even though the average treatment time for Invisalign is shorter (because they are usually used for less teeth movements, like for limited treatments), the higher cost may prevent some budget-conscious folks from choosing it, if they can also get the same things done with braces at the same speed at a lower cost.

(Dr. Nicely also perform limited orthodontics at lower costs than regular full treatment. Invisalign or braces.)

• ♦ 4. Fourth "Dark" side of Invisalign - Speaking with those trays may take practice.

This may not be a big deal for most people, it just takes a few days of practice speaking well with those trays on. But if you have an important business presentation coming up soon after your new Invisalign treatment will start, you might have to reschedule one or the other, because you won't want to leave a bad business impression (or an impression that you have a "lisp" when talking).

• ♦ 5. Fifth "Dark" side of Invisalign - If you don't wear those trays faithfully as prescribed, nothing good will happen!

The hard truth is: if you don't wear those trays faithfully (average 22+hr/day), it will not work for you. Then your Invisalign treatment will only be a high price sticker that you are paying for, but not reaping any benefits of! 

Now that you see the potential disadvantages or "Dark" side(s) of Invisalign, let's talk about the potential benefits or advantages of Invisalign!

A. First Benefit of Invisalign - They’re Nearly Invisible!

Invisalign, as its name stands, should be invisible, right? Well, it depends on what you mean by "invisible". People sitting in other cars on the road will not be able to detect any part of your Invisalign components while looking at your smile when you are in your car. But if your friend is speaking privately with you at a closer distance, he/she can still tell that "there is something on your teeth". Moreover, there are many Invisalign treatments accomplished with bonded buttons on teeth (or called "attachments") needed, and even though they might be tooth-colored materials bonded on top of teeth surfaces, they are definitely visible in photography situations or alike. (So you do have to keep that in mind.) Not that people can tell exactly what you have in your mouth, but that they, as your close family or friends, can tell a difference that you are wearing something that they didn't see before. And if you need esthetic professional photos taken, you might just have to plan ahead around that occasion with your orthodontist or have the photographer do some skilled touch-up with the finished photos (which can usually be done at a reasonable fee).

Alternative solution: Similar to the "invisible" properties of Invisalign, "Clear Braces" that use brackets made with porcelain or clear composite materials are also very esthetic and can be a much more effective treatment alternative compared to Invisalign (which means that those braces can finish your treatment faster and may make the result last longer). For those who don’t love the “bling” look of braces, this is a great alternative!

B. Second Benefit of Invisalign - Less food or dietary restrictions; however, you need to eat less frequently. In fact, Invisalign is Not For Frequent Snackers or Sippers At All!

As stated before, only pure water alone is approved for all-day fluid consumption with Invisalign. Pretty much all other forms of drinks are considered "meal-related" drinks or simply referred to as "drinks" here because they should only be consumed during mealtime - You have to take the trays out for mealtimes, and do the Invisalign routine outlined previously!

Remember that Invisalign trays need to be worn about 22 hrs or more each day to be effective, therefore you only have limited meal times to take the trays out for eating and drinking purposes: it is recommended that you have three regular meals, with less than 45-60min spent on each meal on average, per day, (or a total of 2-3 hrs of mealtime per day including brushing & flossing).

So is this a real benefit of Invisalign? Probably not for most people who like to eat or drink!

C. Third Benefit of Invisalign - Brushing and flossing is easier; however, you need to brush and floss much more frequently! Before having Invisalign, consider having to do the previously-mentioned Invisalign "routine" every time you eat/drink while having it!

Some people will therefore learn to eat/drink on a fixed schedule, which is less frequent compared with most people having braces.

Brushing and flossing with braces is slightly more difficult (or requiring slightly more skilled practice). But after you learn the correct way and practice for a few days (with just a few more minutes of care than before brace, i.e. a little more than 2-3 minutes a day), braces can be taken good care of. 

Contrasting that with Invisalign, on the other hand, you need to brush every single time you eat and drink (anything that's not pure water), and you will also need to brush or clean your Invisalign trays daily. So the overall "time-saved" calculations can easily go to the winner - braces, not Invisalign! In fact, after most people have had Invisalign for a few months, (which is after the initial "excitement" stage wears off), they would more likely to be tired of having to take off Invisalign trays and to take care of them and teeth EVERY SINGLE TIME that they eat and drink, wishing to be off from the Invisalign treatment already. While you will notice that people with braces will start to ENJOY having color choices and getting into the easier routines of taking care of braces.

You may have heard horror stories of kids (or adults) who don’t brush their teeth well with braces or Invisalign. Some of the scary consequences  include:

• White spots on teeth (left around previous brackets)
• Cavities
• Swollen gums or gum disease

They are all from the result of poor oral hygiene habits.

With Invisalign, you can just as easily have those problems if you do not follow the proper hygiene instructions. It's true that with Invisalign, there are no brackets and wires to trap food. But those trays can trap bad things just as easily! If people with Invisalign neglect to brush and cleanse trays after each meal, or if they drink meal-related fluids while wearing trays (which is not during meal times),  plaque and damaging fluids will soak around their teeth and trays and cause all the same problems listed above even faster, besides possibly staining their trays.

D. Fourth Benefit of Invisalign - Fewer appointments. This is probably the only greater benefit of Invisalign; however, it is only true for those people who don't lose any trays AND are compliant with their tray-wearing rules, in addition to NOT needing adjustments to their treatment plans within short periods (for example, 6 months). This is a great benefit for people who have to travel a long distance for an appointment, or those who have tight work schedules. If you don't meet all of those above-mentioned requirements at the same time though, you probably don't get this benefit: you may end up having the same amount, or possibly more appointments compared to having braces.

If you tend to be forgetful, tend to misplace things once in a while, or have trouble following instructions with Invisalign, you will not be able to benefit from Invisalign as much as you'd from braces, as you will be returning to the office over and over again for missing trays or treatment adjustments.

Some people report having shorter appointments with Invisalign compared to having braces. But it is only true for approximately 30% of the Invisalign users because it depends on the treatment needed. If they need some slenderizing of teeth (a.k.a. Interproximal reduction or IPR), or treatment adjustments that involve new tray designs, then they wouldn't have shorter appointments compared to having braces.

Remember, as mentioned at the beginning of this article, some bite problems or tooth positions are difficult to correct with Invisalign, therefore it is more suitable for people who have less significant teeth movements to accomplish.

Q: How about Mail-Order Invisalign, DIY Orthodontics, or “Mail-Order” Aligners?

A: In General, Dr. Nicely has no objections to people trying to do more on their own. It’s either a tough economy or a tight budget driving these solutions. If you have any doubts about doing those things on your own at all, (especially for career promotions), you have a 99% chance not to be happy with such DIY orthodontics. So it’s a big gamble with your hard-earned money to try them; it’s your choice!  You will, however, not likely to be able to get that money back to apply toward your real Invisalign or braces if the DIY treatment fails though.

Any Questions About Invisalign?

Please feel free to ask Dr. Nicely, or get a free consultation!

•    Will Invisalign work for me?
•    What costs should I expect?
•    How long will the treatment take?
•    Any other questions you may have.

References:

1.Ke Y, Zhu Y, Zhu M. A comparison of treatment effectiveness between clear aligner and fixed appliance therapies. BMC Oral Health. 2019;19(1):24.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343314/

2. Galan-Lopez L, Barcia-Gonzalez J, Plasencia E. A systematic review of the accuracy and efficiency of dental movements with Invisalign®. Korean J Orthodontics. 2019;49:140-149. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533182/

3. Cardoso PC, Espinosa DG, Mecenas P, Flores-Mir C, Normando D. Pain level between clear aligners and fixed appliances: a systematic review. Prog Orthodontics. 2020;21(1):3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6970090/