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By Sabrina Tullo
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In recent years, orthodontics has undergone rapid technological change, especially with the rise of artificial intelligence. A 2024 report in Dentistry Journal explains the expanding role of artificial intelligence in orthodontics, particularly in automated treatment planning, cephalometric analysis and predictive modeling. These systems can process large datasets with speed and consistency, offering clinicians new ways to simulate outcomes and optimize aligner staging. However, the report also emphasizes that AI remains dependent on the quality of input data and lacks the contextual understanding required for complex biological variability.
At the same time, digital dentistry more broadly is experiencing widespread adoption across clinical practice. The American Dental Association (ADA) highlights how technologies such as intraoral scanning, cone beam computed tomography (CBCT) and computer-aided design and manufacturing (CAD/CAM) are reshaping diagnostics and treatment delivery. These tools improve visualization and workflow efficiency, allowing for more precise measurements and streamlined appliance fabrication. Yet even within this digital ecosystem, clinical oversight remains central to interpreting findings and making appropriate treatment decisions.
Clear aligner therapy, one of the fastest-growing segments of orthodontics, has also been the subject of increasing scientific scrutiny. A recent study published in the International Dental Journal examines the biomechanics of aligner-based tooth movement, highlighting both its effectiveness and its limitations. While aligners offer advantages in aesthetics and patient comfort, the research notes that certain types of tooth movements, such as root torque and complex rotations, can be less predictable compared to traditional fixed appliances. This reinforces the need for careful case selection and ongoing clinical monitoring.
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Yet beneath all this momentum lies a fundamental constraint that technology cannot override. Teeth still move through bone governed by biology that has remained unchanged for centuries.
For Dr. Bella Shen Garnett, founder of Bella Smile, this tension defines the current moment in orthodontics. “Technology has changed orthodontics, but biology hasn’t changed,” she says. “Teeth still move through living bone. Growth still matters. Muscle and soft tissue still matter. Biology will always determine the outcome.”
According to Garnett, this gap between innovation and physiology carries real implications for patients. While digital tools can generate treatment plans and monitor changes, they cannot diagnose the underlying reasons a case may succeed or fail. “Technology can tell me a tooth isn’t tracking,” Garnett says. “But only experience can tell me the why behind it.”
Her perspective is grounded in more than two decades of clinical practice and a body of published research that challenges long-held assumptions in the field. In one of her most significant contributions, Garnett led a multi-year study on skeletal anterior open bite cases, historically considered among the most difficult orthodontic conditions to treat. Many patients have traditionally been advised to undergo jaw surgery, use temporary anchorage devices, or accept complex mechanical interventions.
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Garnett questioned that paradigm. Drawing on years of clinical observation, she explored whether clear aligner therapy could achieve stable outcomes without surgery. The results were striking. Her research, published in the American Journal of Orthodontics and Dentofacial Orthopedics, demonstrated approximately 94 percent stability at one to five years post-treatment, with many patients maintaining results a decade later. These outcomes compare favorably to surgical relapse rates reported in existing literature.
“Research matters because it tells us what works over time,” Garnett says. “Innovation should always be supported by evidence.”
For patients, the implications are significant. Garnett recalls cases where individuals were told surgery was their only option, only to achieve successful outcomes through alternative approaches. These decisions extend far beyond aesthetics. Untreated bite issues can contribute to long-term complications, including tooth wear and functional problems that may require restorative treatment over time.
At the same time, the rise of remote and direct-to-consumer orthodontic models has introduced new risks. Many of these systems rely on limited data, often without comprehensive imaging or in-person evaluation. Garnett cautions that monitoring alone does not equate to clinical management.
“AI can see if a scan has changed or if aligners fit,” she explains. “It cannot determine whether teeth are moving safely through bone, whether growth is helping or hurting treatment, or when a bite is actually stable.”
This distinction is critical. Diagnosis remains the most important step in orthodontic care, requiring a synthesis of imaging, clinical examination and experience. Technology can gather information, but interpreting that information and adjusting treatment in real time still depends on an engaged clinician.
Garnett’s work also reflects a broader philosophy of questioning established norms. In cases involving crowding or overjet, for example, traditional approaches often default to extracting premolars. Garnett has explored alternative strategies, including the use of wisdom tooth space to reposition the dental arch more conservatively. “We have to ask why we do things a certain way,” she says. “If technology allows us to see more clearly, we should use it to create better options for patients.”
This mindset extends to her approach to innovation itself. While some practitioners view new technologies with skepticism and others adopt them uncritically, Garnett emphasizes integration. Tools such as cone beam computed tomography and digital treatment planning can enhance precision, but only when guided by a deep understanding of biological limits.
“Technology should improve access and efficiency,” she says. “It cannot replace judgment, and it cannot replace accountability.”
That question of accountability is becoming increasingly urgent as health care delivery models evolve. In highly automated or decentralized systems, patients may struggle to identify who is ultimately responsible for their care. Garnett encourages patients to ask direct questions: who is reviewing my records? Who adjusts my treatment if something changes? Who do I contact if I have concerns?
These are not abstract considerations. They shape outcomes in ways that may not be immediately visible but can have lasting consequences.
Garnett’s message is not a rejection of technological progress. It is a call for balance. The future of orthodontics, she believes, lies in combining advanced tools with clinical expertise, rigorous research and a commitment to individualized care.
Patients, she insists, have a role to play in that future. By asking informed questions, seeking second opinions and understanding the rationale behind their treatment plans, they can move from passive recipients to active participants in their care.
“Patients deserve options, explanations and transparency,” Garnett says. “Technology can give us information. Only experience can turn that into the right decision.”
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