teenager with orthodontics

A couple of years ago, when an amiable local dentist suggested that this writer consider orthodontia, he nearly lost a finger. Adults don’t wear braces and the writer had done his time in adolescence with a metal smile, complete with rubber bands and headgear.

Adults may not (often) wear braces, many are choosing to wear other appliances to straighten out their teeth. The number of adults undergoing orthodontia has risen by 40 percent in the past decade, according to the American Association of Orthodontists. Tooth straightening devices are not a ritual of adolescence anymore. In 2014, one in four people who began orthodontic treatment was a grownup.

A combination of relatively lower prices and newer, less clunky products has shifted the cost-benefit analysis for adults considering orthodontia.

In the 1950s, orthodontic treatment cost about as much as a new car. But since then car prices have risen quite a bit while the cost of orthodontia has not.

“The relative cost really has changed. That has allowed more people to get involved,” said Morris Poole, DDS, president of the American Association of Orthodontists who has practiced for more than 35 years.

Most adult patients he sees are between the ages of 25 and 35. With the average age of marriage and childbearing years on the rise, they have more disposable income at that stage in their lives to spend on themselves.

“The other interesting thing is, on the other end, there are people 65 and above saying I’ve wanted to do this my whole life and I never had the money,” Poole told Healthline.

Many had braces earlier in life, only to see their straight teeth wander. The jaw shrinks about a millimeter every decade, gradually crowding teeth.

Some adults are driven to orthodontia out of a fear of false teeth.

“I really don’t want to be 80 and chewing with dentures,” is a common rationale among those whose teeth are wearing unevenly as a result of misalignment, Poole said.

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But the real game changer for adults has been the rise of orthodontic options other than braces, a symbol of adolescent misery.

“Patients nowadays don’t really want to be walking around with braces, even clear braces,” Kjeld Aamodt, DDS, an assistant professor of orthodontia at the University of California San Francisco, told Healthline.

Tooth doctors today offer clear, removable retainers that gradually corral the teeth into a straighter smile. The dominant brand is Invisalign, which made its commercial debut in 1998, although other brands are emerging.

Self-conscious adults can also opt for transparent brackets or brackets that go on the back of the teeth, called lingual braces.

Most adults choose removable, clear aligners because they are less obvious than transparent braces and significantly cheaper than lingual braces. More than three-quarters of those who use Invisalign are adults.

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Clear aligners like those made by Invisalign, and now ClearCorrect, were slow to gain traction with orthodontists. Doctors were reluctant to cede control of the process to patients and computers.

It wasn’t intuitive that patients could be entrusted to use a removable device for 22 of the 24 hours in a day.

“When braces were glued on the teeth, the power was in the hands of the orthodontist,” Aamodt said. “But now with clear aligners, the power is almost entirely in the hands of the patient to straighten his or her own teeth. Aligners won't straighten teeth if they're not worn.”

Adults generally do follow instructions — which include brushing, and ideally flossing, after each meal and wearing the devices virtually all the time.

“If it’s an adult, you generally don’t have the issues that you do with a child,” Poole said.

In 1998, the Invisalign approach seemed almost space-age, coming from a company based in the Silicon Valley.

The retainer trays are made from specifications obtained with a three-dimensional scan of the patient’s teeth, rather than from the earlier plaster of Paris molds. They’re custom printed using 3D printers. As the teeth move, computer software updates the trays.

The company that makes Invisalign, Align Technologies, has opened up its training directly to dentists, spurring professional rivalries with orthodontists, Poole said.  

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Steven Bornfeld, DDS, and his twin brother, Mark, also a dentist, gave the procedure a try with mixed results. In 2002, shortly after Invisalign training opened to dentists, Mark decided he would try it, and Steven would be his first patient.

Invisalign is sort of a tooth-fix-in-a-kit: The company sends detailed instructions to doctors. Sometimes the process includes filing teeth down to create additional space between them. As Mark followed these instructions on Steven, something seemed wrong to him. So he did half the filing and told his brother he’d do the rest later.

But he never did, because it was unnecessary. Steven is happy with the results, but he was left with some space between his teeth after his treatment was completed.

“The instructions were clearly wrong,” he said.

While the method Align uses to generate those instructions has changed, the Bornfelds decided not to venture into orthodontia. They felt their patients would be better served by someone who had deeper experience in orthodontia and could use other devices if the situation called for it.

“There are good dentists who do good work and know their limitations. That’s the most important thing,” Poole said. But, he added, “at least get an opinion from an orthodontist.”

Invisalign has won over orthodontists by building into its software the company’s expertise on how teeth actually move. And clear aligners have become just another device that is a standard part of the additional two years of training that orthodontists complete after dental school.

Now these aligners have shown themselves to be handy solutions to a wide range of dental problems. Once only used to fix mild overcrowding, today only the most severe bite problems remain out of reach for the aligners in the hands of an experienced orthodontist.

“Now, the overwhelming understanding is that it’s what patients desire,” Aamodt said.

The collaboration has been good for Align, which is now a publicly traded company reporting $27 million in quarterly profits. It’s also been good for orthodontists, whose annual incomes have risen faster over the past decade than those of other specialized dentists, according to statistics from the American Dental Association.

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Common knowledge has it that orthodontia improves teeth structural integrity and, as such, easier to clean. Adults can wave away questions about orthodontia by saying, “This is going to make my dental health much better,” Poole said.

It’s a great cover story, but most adults are in it for a more attractive smile.

“Aesthetic standards are so high for people now. The Hollywood smile is almost a prerequisite,” Aamodt said.

But newer research suggests straighter teeth don’t really improve oral health — at least not directly. Rather, patients who are happier with their smiles are more motivated to brush and floss better, so they end up with healthier teeth.

Even so, adult patients probably won’t stop heading to orthodontists’ offices anytime soon. The cost of clear aligners will likely drop as competitors continue to challenge Align’s market dominance. And more than half of U.S. adults could benefit from straighter teeth, according to one study.

“If you think you need braces, you're probably right,” Aamodt said. “Much of the burden of crooked teeth has to do with self-perception.”