Rethinking ‘Am I a Candidate?’ by Dr. Kevin Baharvand

Why it’s the wrong question

by Dr. Kevin Baharvand

‘You’re not a candidate for aligners’
A patient repeated that sentence to me recently, the verdict she’d been given at another office. She had come to us for a second opinion, not quite ready to accept that braces were her only path. After reviewing her records, we started her in aligners.

Let me be clear about where I stand, because it matters for everything that follows. I speak on behalf of an aligner company, so I’ll name that bias up front rather than pretend it isn’t there. But this isn’t a pitch for aligners in every case. I treat a great many cases with braces, and I recommend them often and without hesitation when they are the better tool. My objection is not to one appliance over another. It is to that one sentence, “you are not a candidate,” and to how easily it gets said.

My patient is not unusual. People arrive at our practice regularly carrying that same verdict, issued elsewhere, confident and clinical-sounding, and far more often than we’d like to admit, incomplete. The difference is that most patients don’t seek a second opinion. They simply accept the door as closed.

The shift I’m arguing for is narrow but important: away from “you are not a candidate” and toward “here are your options, and here is what I can do best for you.” Or more honestly, what I can do best in my hands. That phrase matters too, because candidacy is not a fixed property of the patient. It depends on who is planning and delivering the treatment.


What this is not
A provider recommending braces because they believe it is the best treatment for that patient is practicing good dentistry. We are supposed to have clinical opinions and to advocate for them. The problem is not the recommendation. The problem is the framing. There is a meaningful difference between “I think braces are the best choice for you, and here’s why” and “you are not a candidate for anything else.” The first is clinical judgment. The second forecloses a conversation that, in today’s environment, often shouldn’t be foreclosed at all.


The real limiting factor
Here is the uncomfortable truth worth sitting with: In modern practice, candidacy is rarely the issue. With current aligner systems, refined attachment and auxiliary protocols, and disciplined treatment planning, we can successfully treat the large majority of cases, including complex ones, with aligners.

When a case fails or stalls, the cause is seldom that the patient was inherently unsuited to aligners. Far more often it traces back to the treatment plan, the mechanics, the case selection, or patient compliance. Each of these is something we influence. The plan and the mechanics are ours to get right. Compliance is something we set up through patient selection, education, and follow-through rather than something we simply hope for. The limiting factor is usually one of these, not the malocclusion itself.

That reframing matters. “Is this patient a candidate?” puts the burden on the patient and treats the answer as fixed. “Have we planned this correctly for this patient, and can I deliver it well?” puts the responsibility where it belongs and treats the outcome as something we shape. The second question is harder. It is also the right one.

We see this in our own practice regularly. A meaningful share of our complex aligner cases arrive as second or third opinions, patients who were told plainly that aligners could not fix their problem. Many of them go on to finish in aligners with excellent results.

There is a second dimension to “what I can do best” worth naming, which is how and where I can deliver care. A good example is what I think of as a Day-One protocol: Rather than aligning the teeth first and addressing the bite later, I start correcting the most difficult dimension of the case from the very first aligner, using elastics run from buttons integrated directly into the aligners. The logic is that patient compliance and enthusiasm are highest at the start of treatment, so that is exactly when the hardest movements should be underway, not deferred to a later phase when motivation has waned. Paired with virtual monitoring, this kind of workflow lets me treat patients I simply could not manage on a traditional chairside-adjustment schedule, including patients at a distance or with complicated logistics. Candidacy, in other words, is not only about the malocclusion. It is also about whether the way we practice can meet the patient where they actually are.


Educate, then decide together
The alternative to handing patients a verdict is bringing them into the decision. Our job is to lay out the real options, what each can and can’t accomplish, the trade-offs in time, compliance, and cost, and our honest recommendation with the reasoning behind it. Then we decide together. Patients who understand why a plan was chosen are more invested in it, more compliant with it, and more satisfied with the result. Shared decision-making isn’t a courtesy. It’s part of the treatment.


The language is the fix
Much of this comes down to wording, and the wording is worth getting right. Consider the difference. Instead of “you are not a candidate for aligners,” try “I can treat you most effectively with braces, and here’s why, but let’s talk through your options.” Instead of “aligners won’t fix this,” try “aligners are one possibility here; in my judgment this particular case is better served by braces in my hands, and I want to walk you through how I’m weighing that.” Instead of closing the door, name your recommendation, give the reasoning, and leave room for the conversation.

The shift is small on the surface and large in what it communicates. One version tells patients what they cannot have. The other tells them what you believe is best while respecting that the choice, ultimately, is made with them and not for them.


Cases that were told ‘no’
Each of the following patients was told they needed braces. Two were told they needed orthognathic surgery as well. Each presented with a malocclusion of the type frequently deemed unsuitable for clear aligner therapy, and each was treated to a sound finish with aligners and appropriate planning, without surgery. Records are presented as pretreatment and post-treatment (debond) comparisons.


Patient A: Class III with anterior and posterior crossbite
Adult female presenting with a Class III malocclusion, both dental and skeletal, with anterior and posterior crossbite, an edge-to-edge incisal relationship, and an associated traumatic bite (Figs. 1a–2b). She had been told she needed braces, and that the crossbites and underlying skeletal pattern would require orthognathic surgery to correct. A Class III presentation with combined anterior and posterior crossbite is one of the most common bases for a surgical recommendation, on the premise that the transverse and sagittal corrections are beyond what aligners can deliver.

We began correcting the sagittal discrepancy from Day One, running Class III elastics from buttons integrated into the aligners rather than saving the bite correction for later. The case finished in 13 months with the crossbites corrected and a stable, atraumatic occlusion, and no surgery. What had been presented to her as an operating-room problem turned out to be a planning-and-sequencing problem.

Figs. 1a-b: Patient A, frontal intraoral view. Pretreatment edge-to-edge incisal relationship with anterior crossbite tendency and a traumatic bite (left); post-treatment positive overjet and overbite with a stable, atraumatic incisal relationship (right).

Figs. 2a-b: Patient A, left buccal view. Pretreatment Class III tendency with posterior crossbite (left); post-treatment corrected transverse relationship and a stable, intercuspated occlusion (right).

Patient B: Deep bite with crowding, treated across state lines
Adolescent presenting with an increased overbite and anterior crowding (Figs. 3a–4b). She had been told she needed braces, and specifically that a deep bite was not something aligners could fix. The claim that aligners cannot correct a deep bite is one of the most persistent myths about clear aligner therapy.

We corrected the overbite by leveling the curve of Spee, again on a Day-One protocol with Class II elastics from integrated buttons, and the case finished in 11 months.

The mechanics, though, are not really the point of this case. The point is that this patient lived in another state. Her parents were divorced, her time was split between two households, and frequent in-office visits were never going to happen. We managed the case largely through virtual sessions from the beginning and finished it without the steady cadence of chairside adjustments that braces require. Picture this same patient in fixed appliances at that distance: A bracket debonds, a wire pokes, something breaks on a weekend, and the nearest office that knows her case is in another state. The logistics alone would have made braces a poor and even risky choice, regardless of whether they could move the teeth. I will be candid: This is a patient I could not have treated well with braces. The appliance and the remote workflow were not a compromise. They were what made treatment possible at all.

Figs. 3a-b: Patient B, frontal intraoral view. Pretreatment deep overbite with anterior crowding (left); post-treatment corrected overbite with aligned, well-displayed incisors (right).

Figs. 4a-b: Patient B, right buccal view. Pretreatment deep bite and crowding (left); post-treatment corrected overbite and a settled, well-interdigitated occlusion (right).

Patient C: Anterior open bite
Adult presenting with an anterior open bite and a blocked-out upper right lateral incisor because of crowding (Figs. 5a–6b). He had been told he needed braces, and that the severity of the open bite would require orthognathic surgery to close. He also had a tongue thrust and declined a referral to a myofunctional therapist, which is worth stating plainly, because it is exactly the kind of real-world wrinkle that makes a case messier than the textbook version. Anterior open bite, especially a severe one in an adult, is perhaps the classic “aligners cannot do this” malocclusion.

We worked on the open bite from Day One by improving the occlusal planes, putting the hardest, most compliance-dependent movements at the front of treatment rather than the end. Despite the untreated tongue thrust, the case finished in 17 months with a positive overbite and overjet and a stable occlusion, and again, no surgery.

Figs. 5a-b: Patient C, frontal intraoral view. Pretreatment anterior open bite with a blocked-out upper right lateral incisor (left); post-treatment closure with positive overbite and overjet and an aligned arch (right).

Figs. 6a-b: Patient C, right buccal view. Pretreatment anterior open bite with posterior-only contact (left); post-treatment positive anterior overlap and a stable, intercuspated occlusion (right).

None of these patients was a different candidate by the time they reached us. The clinical facts hadn’t changed. Only the planning, and the willingness to attempt it, had.


Aligners are not just for adults
It’s worth naming a misconception directly, because it drives a great deal of poor candidacy framing: the idea that aligner therapy belongs to adults. It does not. Teens and children can benefit substantially, provided we select cases thoughtfully and account for compliance, eruption, and growth. The adolescent patient above, treated remotely across state lines for a deep bite and crowding, is a case in point. Writing off an entire age group isn’t caution. It’s a habit we’ve stopped questioning.


Changing the tone is our job
This is ultimately a question of how we talk to patients. We can hold strong clinical opinions and still leave the door open. We can recommend braces and still acknowledge that aligners might work. What we should not do is convert a planning challenge into a patient deficiency and send people into the world repeating a verdict that may not be true.

The fix costs us nothing but humility. Before the next “you’re not a candidate,” it’s worth asking whether the patient is truly unsuited, or whether we simply haven’t planned the case yet, or whether someone else might plan it differently. In today’s environment, with the right plan and the right patient, the answer is far more often the latter.

The technology has moved. Our language should too. 

Dr. Kevin Baharvand is the founder of White Glove Orthodontist (WGO) and the owner and orthodontist at Elate Orthodontics in Dallas–Fort Worth. In collaboration with other dental groups, Baharvand has successfully initiated multiple orthodontic startups, overseeing every detail. His diverse background, including clinical acumen and a master’s degree in organizational leadership, serves as the foundation of WGO. Baharvand’s mission is to make startup consulting more comprehensive, fostering the independence of orthodontic practices while ensuring affordability.