Volume 9, Issue 3, March – 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24MAR1741

Inhouse Aligners-A Review Article

Sharath Kumar Shetty1; Mahesh Kumar Y2; Suchithra B K3*
1
Professor & HOD, Department of Orthodontics & Dentofacial Orthopaedics, K. V. G Dental College & Hospital, Sullia, Karnataka,
India
2
Professor, Department of Orthodontics & Dentofacial Orthopaedics, K.V.G Dental College & Hospital, Sullia, Karnataka, India
3
Post Graduate Student, Department of Orthodontics & Dentofacial Orthopaedics, K. V. G Dental College & Hospital, Sullia,
Karnataka, India

Abstract:- An increasing number of people are looking for account in-house aligner manufacture can only be
alternatives to fixed orthodontic appliances as the demand advantageous to patients and orthodontists. Using an intraoral
for cosmetic treatments rises. The past ten years have seen scanner and generic aligner programming tools, in-house
a rise in the use of aligners due to consumer preference aligners may be created by digitally cutting the models and
and orthodontists' desire of reduced chair time. As the simulating motions.5
price for having all machinery needed to fabricate aligners
has decreased, orthodontists may choose to fabricate CA has dramatically changed since the late 1990s with
aligners in-house. When aligners can be manufactured in- the introduction of computer-aided design (CAD) and
house, it will benefit patients as well as orthodontists. computer-aided manufacturing (CAM) technology, as well as
Thus, this article reviews the various aspects of the in- the Invisalign system by Align Technology, Inc.6,7 Clinicians
house aligners. are now more inclined to produce their patients' aligners
internally as orthodontic treatment planning software, three-
Keywords:- Aligners,3D Printing, Inhouse Fabrication, dimensional (3D) scanners, and a variety of 3D verified
Workflow, Tooth Movements, Invivo Ageing printers and printing materials are readily available in dental
offices.8
I. INTRODUCTION
II. HISTORY
Fixed appliances have been a part of orthodontic therapy
for a long time. Nevertheless, the need for aesthetics during The history of clear aligner therapy began in the
orthodontic treatment has prompted the creation of transparent twentieth century, when dental physicians began
aligners.1 These aligners cover the buccal, lingual/palatal, and experimenting with using clear plastic aligners to straighten
occlusal surfaces of the teeth and are composed of a thin, teeth.9
translucent plastic. Traditionally, they are replaced every two
weeks and worn for at least 20 hours per day. 2 In the early 1940s, Kesling Introduced clear aligner.
However, due to skepticism and a lack of advertising at the
Through the so-called "shape molding effect," which time, it did not become very popular. Clear aligners gained
results from pre-existing mismatches between the aligner's popularity as dental materials and 3D technology advanced. 10
shape and the dental tooth/arch geometry, aligners move teeth
in orthodontic alignment. This force system is generated at the Sheridan established the use of interproximal tooth
interface between the aligner and the tooth.1 reduction (IPR) in conjunction with clear aligners in the early
1990s. Every tooth movement required a fresh setup. As a
The use of clear aligners has revolutionized orthodontics, result, in order to produce a new aligner, a fresh imprint
challenging accepted wisdom regarding how orthodontists needed to be obtained at each visit, which added time to the
should move teeth.3 The United States of America invented a procedure and increased laboratory effort. 11 In 1997, Zia
computerized aligner system called Invisalign toward the end Chishti and Kelsey Wirth founded the Align Company, which
of the 1990s. Zia Chishti and Kelsey Wirth, two Stanford introduced the Invisalign aligner system (Align Technology,
students, came up with the idea for the system. Clear aligners Santa Clara, California). They did this by combining the usage
have changed dramatically since they were first put on the of plastic foils (Essix) with the idea of a tooth positioner. The
market in 1999.4 Invisalign System, the first orthodontic appliance to combine
computer-aided design (CAD) and computer-aided
The cost and duration of the entire process is one of the manufacturing (CAM), was launched in 1999 when align
main disadvantages of aligners. Shipping is another major technology obtained FDA certification.12
concern during these pandemic times. Therefore, taking into

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Volume 9, Issue 3, March – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24MAR1741

The early Invisalign system's utilization of computer therapy assessment is made possible by the flexibility to
technology to build the aligners was one of its primary take intraoral scans as needed, as demonstrated in.
benefits.13 To generate a virtual model of the patient's bite, a  Fusing a CBCT (converted to an STL format file) with the
digital scan or imprint of the patient's teeth was first utilized. intraoral scan is a feature available in certain CAD
The alignment of the aligners and the precise movements software applications, such as Maestro Dental Studio.
required to get the intended outcome were planned using this When repositioning the crowns during the setup process,
virtual model.14 The early Invisalign system's use of this aids the orthodontist in seeing the tooth roots.
"SmartTrack" material, which was created especially to offer  There is almost no limit to the quantity of aligners that
the best force and control during tooth movement, was another may be created in the office.
crucial component.9  When compared to aligners produced by a company
outside of the clinic, the big advantage of in-house aligners
 Advantages of Clear Aligners Over Conventional Braces is that the clinician quickly makes the aligning and staging
Patients could eat, brush, and floss normally without which is in his mind instead of writing a recipe to the
needing to get around brackets and wires since the aligners company technician, who is most of the time not even a
were removable.16 In addition to making the treatment dental technician.
procedure more pleasant and easy for the patients, this also  The self-sufficiency of in-house aligner production is even
lessened the chance of gum disease and tooth decay, which more advantageous in situations or clinical settings where
may be issues with traditional braces.17 All things considered, access to external aligner companies is discontinued or
the original Invisalign system was intended to be a more limited (for example, during a pandemic lockdown).
aesthetically attractive, practical, and pleasant substitute for
conventional metal braces. It showed great promise and is still  Fabrication of Inhouse Aligners.
in widespread usage today. Although 3D printing offers many practical benefits, the
process of printing orthodontic appliances in-house, including
III. INHOUSE ALIGNERS its physical and mechanical properties, ageing pattern,
chemical stability, and wider biological profile, is fraught with
In-house aligner systems (IHAs), alternatively known as uncertainty due to technical aspects of the printing process and
in-office aligners (IOA), in the strictest sense, refer to material properties.
clear aligner systems wherein every aspect of the aligner
fabrication from digital treatment planning (DTP) to the In general, there are three types of aligner treatment:
delivery of the orthodontic care is managed in  Complete aligner treatment.
the orthodontic office itself.  Hybrid aligner therapy, in which fixed appliances are used
initially and aligners are used in the end (or vice versa).
The cost and duration of the entire process is one of the
 Aligner therapy in instances of recurrence.
main disadvantages of aligners. Taking these disadvantages
into account, the orthodontist and the patient benefited from
The process for designing clear aligners is the same
the in-house aligner manufacture.5 Using an intraoral scanner across all orthodontic software applications. Aligner resin can
and generic aligner programming tools, in-house aligners may be used to build aligners for direct 3D digital printing with
be created by digitally cutting the models and simulating certain software programs. The process of creating aligners
motions. Every model file can be ready for 3D printing when
was explained using DeltaFace softwareTM; however,
the aligner phases have been designed. Although the files may
biomechanical factors were not covered in detail. With several
also be sent to a lab for printing, it has been demonstrated that
options to assist the orthodontist in creating the study models
internal manufacturing is more economical over an extended required for aligner production or in designing the aligners for
length of time.13 After the models are produced, a direct 3D printing, the program is user-friendly and effective. 15
thermoforming machine and a handpiece for cutting are
needed. Materials are an essential component of domestic  Workflow of Inhouse Aligners
manufacturing, and research has shown that polyethylene The complete workflow for the fabrication of IHAs
terephthalate exhibits the least amount of deformation in a
essentially consists of the following steps:
variety of circumstances.
 Intraoral scan;
 Advantages of In-House Aligners  Digital treatment planning (DTP);
 Exporting serial aligner models;
 In comparison to purchasing aligners from companies, the
cost of aligners produced by the physician is significantly  3D printing;
lower.  Thermoforming of aligners;
 The orthodontist may monitor each step of treatment and  Trimming of thermoformed aligners;
modify the plan as necessary while using in-office  Packing and labeling.
aligners. By superimposing the data on earlier scans,

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Volume 9, Issue 3, March – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24MAR1741

 The dental arches are first digitalized, often with the use of  Defining Tooth Reference Axes: The operator modifies the
an intraoral scanner. In situations where polyvinyl siloxane teeth's center point in this stage. Every tooth's center point,
imprints were taken, a desktop scanner may be employed. often known as the "red point," serves as the benchmark
Plaster casts may be poured and scanned, or the for measuring all rotations and translations throughout the
impressions might be scanned straight. setup phase. The program itself makes calculations to
determine the general location of each tooth's root in the
You may use a filament or a resin substance to create a space.
3D model. Fused Deposition Modeling, or FDM, printers are
used to make models while utilizing the filament. The filament The dental arches' virtual setup is the next stage. Similar
model's primary benefit over the resin variant is its tenfold tools are included in all software applications of this kind, and
cost savings.16 The filament model also has the significant the teeth can be changed independently using a tooth
benefit of being used right away upon printing. manipulator or by mathematically describing the change in
angulation. IPR will be required when teeth are virtually
 Curing and Labeling: The resin sculpture is assembled shifted into a space-constrained region. When this is tried, the
layer by layer by gentle curing of the resin. As a result, the software determines the required space and shows it on the
resin model is not completely cured after printing. A final mesial and/or distal side of the tooth. The required quantity of
light curing is required. The models should be exposed to IPR must be indicated in the software where it belongs. The
UV light for around 30 minutes in order to complete the division of the tooth motions into phases is one of the most
curing process. The models are prepared for the aligner crucial aspects of CAT design.17
forming process following final curing. Before exporting
the STL files from the program, each model needs to be The maxillary molars must shift in distinct stages if we
labeled since several patient models at different stages of want to distalize them and generate room. The initial phase of
therapy could be printed simultaneously on the same table. movement must include the molars. The crowded teeth must
Labeling is a simple process that involves using software then be relocated into the space provided by the distalized
to add bespoke text at a suitable location on the model to molars in a second step. The "Add sequence" button in the
be engraved or embossed at a desired font size and depth. present program can be used for this. It is necessary to
carefully prepare and stage each and every tooth movement in
 Plastic Foils for Aligner Fabrication: Several varieties of order to accurately direct the software.17
plastic foils are produced for the manufacture of aligners.
These include variants of polyurethane, PET (polyethylene It is possible to place attachments "in" (negative
terephthalate), and PET-G. Businesses are concentrating attachment) or "on" the teeth. The program also allows you to
on enhancing the plastic foils' elasticity, toughness, and import attachments that were made by third parties.1
resistance to color fading and microcracking in an oral
environment and under force. Additionally, attachments serve a crucial function in
stabilizing the aligners during tooth movement through the
 If necessary, modify the occlusion in the second step. appropriate utilization of these anchoring locations. An further
However, with intraoral scanning, the occlusion is key benefit of aligner therapy is the ability to employ every
characterized accurately the majority of the time. tooth as an anchor against the movement of one or two teeth.
 Creation of Model Bases and Border Cleaning: In this Sequential labeling of each virtual model to be produced is the
phase, the virtual dental models' borders should be either final step. To ensure that the number is written on each
manually or automatically cleaned. Model bases are also aligner, it is helpful to write the number on the buccal surface
produced, giving the dental model its final shape.17 of the final molar that will not be relocated. The operator can
 Tooth Numbering and Segmentation: The definition of the see how many aligners will be required for the therapy once
teeth that will be segmented by enabling them is the fourth this series of setup steps has been completed.
phase in the process. Subsequently, the program prompts
the user to specify the distal and mesial surfaces of every  Exporting Files: The orthodontist must now specify
tooth. The program establishes the teeth's default angle and whether dental casts, which will be used to construct
thereby isolates each tooth from its neighbor or neighbors. aligners, will be produced from or straight onto a 3D
printer. If the latter is done, material can be saved by
Segmentation is the final step. The program computes fabricating the printed functional models to be hollow and
and displays each tooth that will be moved during the setup baseless.
phase in a variety of colors. It is imperative that each and
every tooth be examined. If segmentation is done incorrectly,  Dental Model Printing: Undigitization – It is now possible
the operator can manually fix the issue. to print—that is, to transform the virtual dental models into
a tangible thing by undigitizing them.

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 Volume 9, Issue 3, March – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24MAR1741

The dental cast is cleaned with 91% isopropyl alcohol Based on a finite element evaluation, Gomez et al.
after printing, and postprinting curing is the next step. proposed that tooth movement with only the aligner and no
Working model printing is less common with FDM (FUSED other modifications (e.g., attachments) has poor control on the
DEPOSITION MODELLING) printers. They do, however, inclination of teeth.20
offer the benefit of being less expensive than resin printing
techniques and not requiring additional post-printing steps.  Forces and Moments Generatred by 3D Printed Direct
Aligners
Positioning Thermoforming Aligner thermoforming Two primary raw materials are used in the production of
comes next after functioning model printing. Various the numerous commercial products that are currently on the
thermoforming plastic foils are used in conjunction with market: polyurethane-based polymeric material and
vacuum or positive pressure thermoforming equipment in this polyethylene glycol terephthalate (PETG) polymeric material.
method. The standard air pressure at sea level, which is Compared to PETG materials, the former has a better hardness
between 0 and 1 bar, cannot be applied by vacuum and elasticity modulus but a lower creep resistance.
thermoforming devices. On the other hand, the pressure that
positive thermoforming pressure machines may apply is The limits of the material's ability to exert a constant
infinite. To precisely manufacture the aligners, a force, even for the anticipated short intraoral service period,
thermoforming machine that can generate the right pressure is are set by the adverse effects of intraoral ageing on hardness,
essential. elastic modulus, and relaxation resistance, as demonstrated by
the analysis of clinically aged Invisalign appliances from
Using the superimposition capability, the orthodontist Align Technology, Santa Clara, California. Therefore, before
may track at any point during the aligner treatment process using an unknown resin in 3D printed products, its
and obtain a fresh intraoral scan to compare to the first one. composition, characteristics, structure, and the impact of
Additionally, superimposition between the updated intraoral intraoral ageing must all be fully characterised.
scan and the matching virtual dental cast is possible.
Changes in the mechanical characteristics of in-house 3D
The orthodontist must complete a multi-step technique printed orthodontic aligners with intraoral ageing were
called "in-house aligner design and fabrication." The steps that examined in a 2021 study by Esad Can et al. Comparing the
are necessary for a good treatment outcome include intraoral 3DPIN and Invisalign® appliances to traditional
scanning, clinical assessment, capturing radiographs and thermoformed aligners, they may offer more counter forces
clinical photos, using CAD software, printing dental models in under the same tension. Compared to Invisalign® (40.0–
three dimensions, and thermoforming the aligners.17 40.8%) and traditional thermoformed aligners (34.0–35.9%)
(20–22), the 3DPIN material's elastic index (29.4%), which
IV. ACCURACY OF TOOTH MOVEMENTS WITH measures the material's brittleness, was found to be
ATTACHMENTS11 significantly lower, suggesting a more ductile behaviour.
However, compared to Invisalign®, the relaxation index was
According to a study by Shivaporn Sachdev et al., for found to be significantly higher, indicating a higher decay of
each of the six types of tooth movement, achieved tooth orthodontic pressures. Invisalign® and traditional
movements were considerably smaller than expected tooth thermoformed aligner materials had significantly lower
movements. This result were complementary to the studies indentation relaxation than 3DPIN material, indicating that the
that found discrepancies between predicted and post treatment latter may be more prone to secondary reactions.
results. In a comparable manner, Krieger et al. discovered that
planned tooth movement was superior than the actual result. Even though intraoral service did not significantly alter
Notably different rotational movements were accomplished the mechanical properties of 3DPIN aligners, there are still a
and anticipated in another work by Charalampakis et al. The number of issues that need to be looked into further before this
majority of clear aligner treatments did not fully establish the method of aligner production is accepted as a substitute for
desired tooth movement as intended. traditional aligner treatment. These issues include printing
conditions, printer type, and ways to ensure quality control of
With anterior clear aligners, the overall accuracy of tooth the printed material.
movement was 56.18%. Mesiodistal movement was the most
accurate tooth movement (72.33%), while intrusion movement The stresses and moments produced are altered by
was the least accurate (43.28%). Since clear aligners work by targeted thickness increases in direct 3D-printed aligners,
applying pressure to teeth, they must push against the however they do so in intricate and unpredictable ways. It
attachment surfaces in order to extrude a tooth. The majority appears possible to maximise the recommended orthodontic
of research has focused on the poor extrusion efficiency of movements while reducing undesired tooth movements by
transparent aligners. adjusting the labiolingual thicknesses of DPAs, which will
increase the predictability of tooth movements.21

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Volume 9, Issue 3, March – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24MAR1741

Furthermore, force and moment side effects on [5]. Shah MJ, Kubavat AK, Patel KV, Prajapati NH.
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conventional (thermoformed) aligners exhibit distinct [7]. Hajeer MY, Millett DT, Ayoub AF, Siebert JP:
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This mechanism has already been documented in aligners fixed appliances in achieving good occlusion in complex
based on polyurethane or polyethylene terephthalate glycol orthodontic cases: a randomized control clinical trial.
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