Can You Straighten Your Teeth Through the Mail? A dentist explains the pros and cons of direct to consumer orthodontics
Mailbox! They put tooth straighteners in these thingys now!
Disclaimer: The information presented in this article is for educational purposes only and is NOT intended or implied as a substitute for professional medical advice, diagnosis, or treatment from your dentist, physician, or any other healthcare professional. You should NOT use the information presented here for diagnosing or treating any health problem or disease. Never disregard advice from your personal medical care provider(s) or delay contacting your dentist/other healthcare providers because of anything you read or heard here. Reading this article and/or utilizing any of the information presented in any way does NOT create a doctor-patient relationship between you and the article creator or with any of the healthcare professionals in any way affiliated with this article. You use this information at your own risk. You should contact your dentist/healthcare professionals before beginning any new treatment or practice to address a health problem or improve your health. The author is not responsible for information on external websites linked to from this article or for the information on external websites that link to this article.
You hate the dentist. You think I suck, and you’re not afraid to say it to my face. Those mean, nasty, evil dental people are even scarier than clowns. You hate clowns! You hate people who are associated with smiles and smiling! What’s with both of them tying balloon animals for children? That’s so creepy! Down with clowns and dentists! You don’t understand what I do or why it costs so much for me to do it. Surely, there has to be a better way?
You see a commercial for a beautiful new solution: straighten your teeth without ever having to see a mean, nasty, evil dentist person. Eureka! The people in the commercial are all smiling. This is it! I’ll bypass those awful dental clowns. No anxiety! And it’s way less expensive too! This is awesome!
Then you show up in my office a few months later with jaw pain and fresh cavities, and you’re wondering what went wrong. This was supposed to help you avoid me. Now you have bigger problems that mean you have to see me more often. What the heck?!
Full disclosure up front: I don’t do orthodontic treatment myself. I’m a general dentist in the United States. That means I graduated from a four-year dental college after I finished four years of undergraduate education. General dentists are allowed to perform orthodontic treatment. However, to do it well, you need to take continuing education courses to learn the intricacies of moving teeth around in someone’s jawbones. It’s not covered in enough detail in the typical dental school curriculum. It may not be rocket science, but it is a very specialized area of knowledge, and if you don’t know what you’re doing, a lot of things can go very wrong. I do not want a lot of things to go very wrong, so this is not a treatment I perform on patients.
I don’t straighten patients’ teeth, so I don’t really have a horse in this race.
An orthodontist is a specialist who completed an orthodontic residency after completing dental school. They spent 2–3 years focused on learning all about orthodontics and treating orthodontic patients. Then, they practice doing those treatments on lots of different patients throughout their careers. They gradually gain the knowledge and expertise to handle more complicated cases. That takes a lot of time, money, and energy to learn how to perform these treatments well. I’m not saying that it doesn’t suck that braces are expensive, but it isn’t easy to learn how to do these treatments well within our current educational system. It’s a marathon slog. That drives up cost.
New technologies have changed some aspects of orthodontics (if you haven’t caught on yet, that’s a fancy word for tooth straightening). We have digital technologies that can scan your teeth. We have software programs that can calculate what types of movements would be necessary to move those teeth into a straighter position. So much for needing an orthodontist, right? Why not just let a hyper-intelligent computer program design the treatment? We have machine learning algorithms at this point that can outpace human minds; why not just keep feeding the software program diverse cases until it has the perfect solution to every possible orthodontic problem?
There is some promise in this idea. These are amazing tools. We haven’t managed to perfect them just yet, though. The other problem is that even if the software can calculate all the right forces to apply to the teeth to make them move correctly, that doesn’t mean that the plastic trays that it designs are capable of delivering those forces to the teeth. That’s kind of important.
It’s cute for me to be able to tell you, “That tooth would look nice right there, and we could get it there if we did X, Y, and Z.” Then you look at me and say, “Sounds great, let’s do it.” Then I look at you and say, “Oh, I know what we’re supposed to do, but I didn’t say I knew how to actually make it happen in the real world. Now just mail me $2,000, and we’ll call it a day. Deal?”¹ That’s when you would appropriately look at me and tell me to kick rocks.
So, I’m not telling you to come see me to help straighten your teeth. I can’t really help you with that. There are other general dentists more skillful and experienced than myself who may be able to help you. An orthodontist can definitely help you. That’s their specialty. They live and die by the art of straightening teeth.
You are welcome to take an impression of your teeth or get them scanned by a computer technician outside a dental office. It will technically cost you less money to do that. I just want you to understand that the results could range from pretty good to not much change at all to outright disaster. It’s more of a gamble. I’d make sure you read the fine print before you send anyone any money.
If you find that upsetting, your time would be best spent finding a way to decrease the costs and barriers to orthodontic education and licensing. The only way to bring down the costs is to improve the incentive structure of the people going into the profession. If you try to drop the treatment cost but keep it incredibly time-consuming and expensive to become licensed as an orthodontist, you’ll just end up decreasing the quality of orthodontic care because talented people won’t have an incentive to pursue the career. That’s basic economics y’all. I’m sorry human nature is so messed up and whatnot.
Moving teeth to straighten them is difficult and takes years of study and practice to get good at. Computer software is improving rapidly but has not yet reached a point where it can replace the human mind in treatment planning complex orthodontic cases.
What Problems Can Come Up With Clear Aligners Through the Mail?
Messing Up Your Bite and TMJ — Every patient’s bite (the way your upper and lower teeth come together) is different. Overbites, underbites, open bites, crossbites, crowding, spacing…these issues are not all addressed in the same way. If you are inexperienced in moving teeth, you won’t see all the potential pitfalls that could arise.
The jaw joint is complicated. As you open your mouth, there is a disc of cartilage that your jaw bone “surfs” on, allowing it to slide down and forward. If you start moving teeth with clear aligners or braces and the teeth start bumping into each other in different ways, all of a sudden, the relationship between the disc and the jawbone and the skull can be thrown out of whack. Now you have muscle pain and headaches. It hurts to chew. You crack a tooth because you’re putting excessive pressure grinding and clenching on it. You’re stressed out. No bueno.
I’m not making this up. I have seen several patients who thought aligners through the mail would be a great idea, and they have suffered lots of jaw pain and problems. My only solution has been to refer them to an orthodontist who now has a more complicated problem to try to fix. That won’t be less expensive either.
If you don’t believe me, spend some time searching around on Facebook and other online platforms for reviews of the products you are considering. You’ll discover lots of patients with similar experiences. It’s not fun for me to tell a patient that the thing they just spent a bunch of money on is causing them all sorts of problems that will cost even more money for them to fix.
If you have ANY current issues with your jaw joint or a history of problems with your jaw muscles or grinding/clenching of your teeth, I would STRONGLY advise against having orthodontic treatment that is not properly supervised by a dental professional you know in person and can trust. But that’s just my two cents. What do I know? I’m just some biased son of a gun dental clown.
Partnering with an orthodontist can also be a much better customer service experience if your teeth aren’t moving how you hoped. With an orthodontist, you have someone who you can talk to face to face if/when issues arise. You get personal service and faster re-evaluation if treatment needs to be adjusted. I’ve seen lots of reviews of remote services where patients had felt ignored when their treatment wasn’t tracking as expected.
Cavities — If you are going to start ANY orthodontic treatment, whether through the mail, with a dentist, with an orthodontist, or DIY on your own based on something you saw on Pinterest, you better have TOP NOTCH dietary habits and oral hygiene. Why? When you have braces on the teeth, you create a new surface for food to cling to. That means food sticks around on your teeth longer. The braces can also be a barrier to getting all the plaque off of your teeth. That means more bacteria turning that food into acid that gives you cavities.
It’s not just braces. Clear aligners can also be a problem. If you don’t brush and floss after meals and put the clear aligners back on, guess what gets pinned up against the teeth for a long time? Lots of food particles. If you weren’t wearing the aligners, saliva would typically wash the food away within about 20 minutes. Trap the food under the aligners, and it’s there for hours. I saw a patient who had 14 cavities within a few months of getting aligners. I’m confident that never would have happened if it weren’t for the aligners.
I have a whole series of videos offering advice on protecting your teeth and NEVER getting any cavities. Nutrition is WAY more important than anything else. It’s also about the way you eat and drink food, not just what you eat and drink.
Gum Disease and Bone Health — Before you get braces, you should get your gums and bones around the teeth evaluated to make sure they are healthy. The process of moving teeth involves the teeth pushing on the bone around them. That bone resorbs, allowing the tooth to shift, then new bone forms.
If you have active gum disease, that means you have damage to the bone and gums around your teeth. If you try to move teeth and resorb bone when there is active disease, you may end up causing even more damage to the bone. Your teeth could end up being abnormally loose, and the bone around them may never recover properly. You may see large black spaces show up in between the teeth where the gums used to be.
For orthodontics with clear aligners to be really effective, you need to be able to do a few things with a patient’s teeth in person.
Need for Extractions — If you don’t have enough room in your jaw for the teeth to be aligned properly, sometimes you need to have a tooth or two removed to align the teeth well. That’s a precision calculation and not a decision to be taken lightly. You want to make sure the person overseeing your treatment knows what they are doing before you start taking permanent adult teeth out.
I actually had to have four permanent teeth removed (in addition to my wisdom teeth) when I had orthodontic treatment. If you don’t remove these teeth and have limited space, the only solution is to move the teeth outward through the jawbone and widen the smile's arch. The problem here is that you run out of bone for the teeth to be housed in, and you end up with gum tissue recession and bone loss. You “blow out” the bone on the cheek and lip side of the tissue. This doesn’t look good. It can cause sensitivity. It makes you more vulnerable to future problems and breakdown of the teeth and gums.
Again, maybe clear aligners through the mail can straighten your teeth some, but what are the other potential consequences? I respect the postal service as much as anyone, but last I checked, they weren’t typically trained to remove your teeth to help out with the orthodontic treatment being delivered to you.
It just makes cents!
Airway Issues — You know how I just told you sometimes you need to take teeth out to straighten teeth without wrecking the gum and bone tissue facing outwards in your smile? Well, sometimes there can also be problems when you remove teeth. Does this ever get any less complicated? Not really. There’s a reason orthodontists study nothing other than how to move teeth.
See, when you take out teeth, it’s great because now you have all kinds of room to move the remaining teeth exactly where you want them. However, you end up doing what we call narrowing the dental arch. The teeth move back toward the tongue to help close the spaces between the teeth. What’s the big deal?
Normally it’s fine, but if you struggle with an airway issue such as sleep apnea, this could make your apnea worse, and that can have serious health consequences. The problem is that the teeth could now be pushing back on and crowding out the tongue so that the tongue more easily closes off and blocks your airway.
These are subtle but important individual factors in treatment that are easily missed when you’re not working with an experienced professional. When you move teeth, you can’t just think about the teeth by themselves. You have to think about how this could affect many other aspects of the oral environment and beyond.
Implants and Bridges — If you have any implants, you cannot move them with orthodontics. Once an implant is in the bone, it is stuck there. A computer scan or impression of your teeth can’t tell the software program you have an implant. If you are thinking about orthodontic treatment and have missing teeth, it is best to do the orthodontic treatment first and then replace the missing teeth with implants AFTER the teeth are in the new ideal position.
If you have bridges connecting teeth, orthodontic movement of these teeth can be more difficult.
The other thing to consider is that if you use clear aligners of any kind, you need to wear them all day and all night (except when eating — make sure you brush and floss before you put them back in) in order for them to work.
Not Getting Good Results — There are a select few patients with limited treatment needs who will be able to get good results from clear aligners without seeing a dentist or orthodontist. These are patients that have pretty straight teeth already; they just want some minor changes.
There are LOTS of other patients who will not get ideal results from clear aligners through the mail. You WILL likely see some improvement in your smile, but it isn’t going to be ideal.
Why is that? For orthodontics with clear aligners to be really effective, you need to be able to do a few things with a patient’s teeth in person. This involves what we call interproximal reduction (IPR) and composite button placement.
IPR — This is our dentisty way of saying “shaving down the sides of the teeth.” Sometimes there is not enough room to move the teeth where we want them to go. Your mouth just isn’t wide enough. What’s a potential solution? Make the teeth a teeny bit smaller in a way that no one will ever notice.
A hyper-intelligent machine learning algorithm in a clear aligner software program can’t shave down the sides of your teeth with a dental drill yet. Maybe it will be able to in the future, and then I’ll be out of a job completely, just like everyone who is going to be put out on the streets by self-driving cars. When the time comes, I’ll be right there with you to lead the revolution against the machines à la The Terminator and The Matrix. But for now, I don’t think we have to panic about it.
I know it may scare the bejeezus out of you to think about having your teeth shaved down with a dental drill, but I promise it’s easy enough and not at all painful. The amount of tooth shaved down is minuscule. You typically don’t even have to be numb for this procedure.
Composite Buttons — This was the great leap forward (and I don’t mean that ironically as a historical reference to Mao Zedong’s social engineering. There will be no genocide with composite buttons, I promise) for clear aligner therapy. We bond the same white material we use for fillings on teeth to the outer surface of the teeth. This gives the clear aligners something to “grab” onto and pull and push against to help move the teeth.
Without composite buttons, you can’t apply the same variety of torques to the teeth. It’s not rocket science to bond composite buttons onto teeth, but you do need to have someone do this for you in person. Until that changes, you’re going to get inferior results with clear aligners sent through the mail. You just can’t create the same forces on the teeth to move them where you want them.
Composite buttons were a major innovation that helped clear aligners catch up a little bit with traditional braces. You still can’t generate the same forces with clear aligners as you can with traditional braces bonded on with brackets, but composite buttons do a reasonable job. Without composite buttons bonded onto the teeth, I don’t know man, that just doesn’t even make sense to me. You can’t apply very strong forces to the teeth, and you have minimal control over the direction of the forces.
Elastics — Sometimes, you need to add elastic bands that stretch across teeth to exert more force on them because the clear aligners can’t generate enough force on their own. Elastics often need to be supported by composite buttons.
TAD’s — Temporary anchorage devices (TAD’s) are little mini-implanted devices that an orthodontist places in your jaw bone. You can then attach an elastic or wire to the TAD to exert more force on a tooth that you couldn’t generate with clear aligners or even with traditional braces.
So, especially without IPR and composite buttons, expect to get a less than great result with your clear aligners. I’m not saying you won’t see any improvement at all. You might. It still will not likely look how you’re imagining it should in the end, though.
There are some conditions that you simply cannot treat well with clear aligners compared to traditional braces. Anterior crossbites (where your front top teeth are behind your bottom teeth) get tricky to treat if it’s more than one tooth. I saw a patient who had paid for direct-to-consumer orthodontics, and all of his anterior teeth were in severe crossbite. There was no possible way the aligners were correcting that. He needed help from both an oral surgeon and orthodontist. His case was very complex and difficult and no one told him that before he paid for these direct-to-consumer aligners.
Fine Tuning Cosmetics — There can be a lot more to improving and idealizing your smile than just straightening teeth.
Some patients don’t like how much gum tissue they show when they smile.
Some patients don’t like the shape/size/color of their individual teeth.
Some patients don’t like the “black triangles” of space that can show up between their teeth above the gum tissue after orthodontic treatment.
Some patients don’t like that their teeth don’t seem to fill up their whole mouth when they smile.
Some patients don’t like the way their lips rest on their teeth and want fuller lip support.
Some patients have worn down teeth from grinding or misaligned bite relationships.
Straightening your teeth won’t necessarily fix any of those problems. You may need to work with a general dentist, periodontist, oral surgeon, or prosthodontist to correct those issues in conjunction with getting braces. I realize that these things can all be expensive and that most people cannot afford these treatments. I’m not here to make you feel bad about any of that. I just want you to be informed and have realistic expectations.
I decided to start writing and making videos online because I realized how incredibly massive the unmet dental needs of patients all over the world are. It’s endless how many issues patients are struggling with, and I can only do so much with my two poor wickle hands in my rinky-dink dental practice.
The best solution I have for most people at this point is for you to protect your existing dental health so that you don’t have to struggle with costly repairs throughout your life. If you do decide to invest your money in dental treatment, I would advise thoroughly vetting your chosen treatment solution before you make a decision.
Summary:
I don’t straighten patients’ teeth, so I don’t really have a horse in this race other than I want to provide you with valuable information so that you keep reading my articles and watching my videos, and sharing with friends and family.
Moving teeth to straighten them is difficult and takes years of study and practice to get good at. Computer software is improving rapidly but has not yet reached a point where it can replace the human mind in treatment planning complex orthodontic cases.
Poorly done orthodontics with clear aligners can mess up your bite, jaw joint, jaw muscles, and teeth.
You NEED to take GREAT CARE of your teeth and gums while having ANY orthodontic treatment because you are at increased risk for cavities and worsening gum disease when undergoing this treatment.
If you need to replace teeth with implants, do it AFTER you finish orthodontic treatment.
Orthodontic treatment with an orthodontist will give you ideal results but cost more money. Most orthodontists offer complimentary consultations for treatment.
The other thing to consider is that if you use clear aligners of any kind, you need to wear them all day and all night (except when eating — make sure you brush and floss before you put them back in) for them to work. Sometimes it’s a really good idea to be partnered with an orthodontist to track your progress and keep you motivated about treatment. I see plenty of patients who aren’t all that diligent about wearing their aligners. You can always slap some braces on there if you don’t trust yourself to wear your aligners faithfully.
Partnering with an orthodontist can also be a much better customer service experience if your teeth aren’t moving how you hoped. With an orthodontist, you have someone who you can talk to face to face if/when issues arise. You get personal service and faster re-evaluation if treatment needs to be adjusted. I’ve seen lots of reviews of remote services where patients had felt ignored when their treatment wasn’t tracking as expected.
Even after you straighten your teeth, there may be other things you want to improve about your smile. The shapes of individual teeth are not changed by orthodontics. The appearance of your gum tissue is unlikely to be changed by orthodontics.
Do your research online and read reviews from other patients before you decide on treatment.
I hope this was helpful.
Thanks for reading.²
RAWR!
Footnotes:
¹ Also, this may cause cavities, jaw pain, headaches, cracked teeth, and never actually straighten your teeth.
² Further reading — Links to American Association of Orthodontists Resources:
https://www.aaoinfo.org/blog/is-there-a-benefit-to-early-treatment/