This document discusses fully customized orthodontic appliances. It outlines several technologies used, including digital imaging, computer modeling, and robotics. Techniques for creating customized appliances involve taking digital records, impressions, and using cone beam CT or intraoral scanners. Fully customized appliances are designed specifically for each patient's malocclusion and may include customized brackets, archwires, and aligners. Examples mentioned are Insignia, Incognito, and SureSmile appliances. Semi-customized appliances use a mixed prescription approach rather than being fully customized.

1. Fully Customized Appliances
Presentation by: Dr. Noor Haddadin
Supervised by: Dr. Ahmad Al Tarawneh
Dr Jumana Tbaishat
Dr. Bashar Al Momani
Dr. Anwar Al Rahamneh
18 September 2017

2. Outline
• Introduction
• Technologies used
• Techniques
• Customized precision prescriptions
• Semi-customed appliances
• Fully customized appliances
• Bonding, placement, light cure and removal techniques
• Summary

3. Introduction

4. Introduction
The power, speed, low cost and portability of modern computers has made substantial
computing power readily available while digital design and manufacturing techniques
are now transferable into orthodontic practice.
Customisation types
Customised precision prescription appliances or orthodontic treatment can be
delivered by either:
• Customising or individualising brackets to the patient’s tooth morphology
• Customising the bracket-tooth surface composite/resin interface to the patient’s
tooth morphology and planned treatment needs
• Customising the archwires to the patient’s tooth morphology and planned
treatment needs.
• Using selected prescriptions to semi-customise the appliance
• A combination of the above
• Aligners

5. Some providers of precision prescription appliances
Manufacturer Product
Type of
appliance
Method of data
acquisition
Customisation
3M unitek Incognito lingual PVS impression
Brackets
Archwires
Align
Technologies
invisalign aligner PVS impression aligners
Cadent
OrthoCAD
IQ
labial
PVS impression
Itero intraoral
scanners
Selective
prescription
Geodigm
Eplan &
eplacement
labial
5 days alginate
impression
none
Orametrix SureSmile labial
Orascan intraoral
scanner
archwires
Ormco Insignia labial PVS impression
Brackets (full or
semi)
Archwires

6. Technologies Used

7. Technologies Used
• Digital imaging
Photographs and radiographs now makes it easy to transmit or upload patient data to
sites that are geographically distant
• Computer modelling
Ability to visualise, manipulate and test treatment outcomes
• Robotics
Archwire fabrication
• High technology materials and manufacturing technique
Metal injection moulding and nickel titanium archwires

8. Techniques

9. Techniques
• Records
o Digital photographs
o Digital radiographs
o Impressions

10. Techniques
• Records
o Impressions
In order to select the size of tray required to fit the patient, the bite registration is
done first and then use to select the tray size as described in the Align Technology
PVS Impressions Overview.
Errors in impressions
Loupes are recommended for inspecting the impressions prior to sending them off
to the service provider.
 gingival margins
 occlusal surfaces
 molar area
 material adhesion
 tooth by tooth inspection

11. Techniques
• Patient preparation
o Ask patient to remove any lip stick or lip balm as this will interfere with the setting
of the PVS impression materials
o Ask the patient to brush their teeth
o Ask the patient to rinse with a mouthwash such as Listerine to get rid of any ropey
saliva.

12. Techniques
• Cone beam CT
o One advantage of this technique is that it brings distortion-free representation of
the subsurface anatomy to SureSmile’s 3D virtual setup simulations.
o The use of CBCT involves the use of ionizing radiation but allows the incorporation
of subsurface detail into the 3D data capture.

13. Techniques
• Cone beam CT
o It would eliminate the use of impressions or an intra-oral scanner.
o Kau et al (2010)investigated the difference between digital models derived from
CBCT using anatomage InVivo Dental software and compared these with
OrthoCAD models generated from dental impressions.
o Results: linear anatomical measurements were not significantly different between
the two methods although resolution of dental anatomy was less good from CBCT
than from digital models derived from impressions.

14. Techniques
• Intra-oral scanners
o Allow direct capture of tooth anatomy and eliminate the need for impressions.
o Several intraoral scanning systems are available or in advanced stages of
development:
 Cadent iTero™
 3M Lava™ COS
 DImensional Photonics International 3D
 Orametrix Orascanner™
 D4D Technologies Intraoral Digitizer

15. Intraoral Scanners

16. 3M Lava™ COS
This system, unlike other intra-oral scanners, uses a video stream to capture 20 3D
data sets per second and then process and display these in real time.

17. Cadent iTero™
The Cadent unit includes a computer, software, wand, and a built-in air compressor.

18. Customised precision prescriptions

19. Customised precision prescriptions
• Information about the patient specific prescription will be required. This may be
completed online but a printed copy is normally required to be sent with the PVS
impressions to the service provider
o Demographic details of patient
o Orthodontist’s details
o Preferred appliances
o Selective torque values
o Teeth to be bonded
o Teeth to be extracted
o Buccal segment relationship required at the end of treatment
o Final overbite and overjet required at the end of treatment
o Any spacing to be left
o Planned tooth replacements or restorations
o Planned interproximal reduction
o Expansion or contraction of molar widths
o Mesial or distal molar movement
o Upper incisor edge alignment

20. Constructing computer model from impressions
• CT scanning
oThe impression can be scanned using and industrial CT scanner
• Surface scanning
o 3D surface scanning
• Destructive scanning
o Removes slices about 0.003 inch wide and a digital camera then takes a 2D scan
after each slice. A computer stacks together around 300 of these digital images to
create the 3D model.

21. Accuracy of computer models
• The reliability of the OrthoCAD system and plaster models.
o The authors concluded that digital models seem to be a clinically acceptable
alternative to stone casts for the routine measurements used in orthodontic
practice.
Santoro et al 2003
Quimby et al 2004

22. Limitations of digital models
• Observing crossbites.
• Detail of midlines, occlusal anatomy and wear facets.
• Quantifying precise interdigitation.

23. Approving the prescription
• The jig grouping (Insignia) should be selected; the preferred grouping is [7654] [321]
[123] [4567].
• Ensure that the jig grouping does not include teeth where the path of removal of the
jig is significantly different.
• The opaque jigs provide sufficient rigidity to allow clear space mesially and distally
around the bracket to facilitate clean-up.

24. Approving the prescription
OrthoCAD, the choice is where the trays are sectioned; this seems to work best if they
are sectioned in the midline giving four separate bonding trays, one for each quadrant.

25. Approving the set-up
• Check start of treatment digital models and occlusion for accuracy (and with intra-
oral photographs if available).
• Review post-treatment set-up from all angles and take note of any comments from
service provider; note alterations to be made in set-up.
• Review mandibular occlusal view and adjust any tooth rotations as required.
• Review mandibular dentition from labial, occlusal and lingual views and adjust tooth
heights, tooth angulation and tooth inclination as required. It is helpful to refer to the
OPG and cephalogram at this stage.

26. Approving the set-up
• Review maxillary occlusal view and adjust any tooth rotations as required
• Review maxillary dentition from labial, occlusal and lingual views and adjust tooth
heights, tooth angulation and tooth inclination as required. It is helpful to refer to the
OPG and cephalogram at this stage
• Using the clipping tool, work round the arch checking each tooth contact and adjust
as necessary
• Check occlusion with digital set-up in occlusion for accuracy of end of treatment
position
• Check occlusion with digital set-up in occlusion for bracket interferences and adjust
as required using wire plane tool
• Add any special comments to the Notes field
• Submit set-up electronically and approve for manufacture.

27. Semi-customed appliances

28. Semi-customed appliances
The term semi customised appliances is used to describe the variations from standard
straight wire technique, such as inverting brackets or mixing of brackets from different
prescriptions in order to produce specific tooth movements of individual patient’s
needs .

29. Semi-customed appliances
• More variability than fully programed appliances .
• Not fabricated specifically to the pts needs.
• Uses mixed prescription Straight Wire appliance.

30. Fully-customed appliances

31. Fully-customed appliances
Designed to meet the spesific needs of the pt’s malocclusion
• Oramco –Insignia
• Incognito –custom made lingual appliances
• Custom SL appliances
• Clear aligners
• OrthoCAD
• SureSmile

32. Insignia
• Insignia currently offers fully customized set-up for conventional twin brackets for
each individual tooth and for Damon self ligating brackets.(custom prescription with
standard base and pad
• Insignia provides five sets of customised
archwires; these are marked at the midline and
on the right hand side to ensure that they are
fitted with the correct orientation.
• The digital information is used to cut each
bracket precisely using CAD/CAM technology
so the bracket has the appropriate thickness,
inclination, torque needed for ideal positioning
for that tooth.
• Bonding jigs are fabricated that each bracket can be placed in the planned location

33. Insignia
• Preliminary data indicate that treatment time is reduced in comparison to treatment
with conventional prescription brackets ,but some adjustment of the final archwires
is still required.
• If the pt debonded one of the customed brackets a replacement bracket and bonding
template can be available within 2-3 weeks.

34. Insignia
Every Insignia case is
accompanied with new clear
Jigs manufactured to fit like a
puzzle piece onto each
patient's unique occlusal
anatomy.
Simplified light curing- cure from
any direction, even the occlusal

35. Incognito
• It is mainly fully programmed appliance (means that all SWT feature are involved)
and either semi or fully customized to the patient( customed prescription ,base and
pad)
• Wire sequence smaller than usual because of the reduced interbracket distance (012,
016, 16*16 NITI then 16*16 SS)
• It is considered a hybrid slot orientation appliance (Ribbon arch slot–vertically
oriented placement of the AW similar to Begg brackets - in the anterior teeth and
edgewise slot- horizontal oriented placement of the AW similar to Angle Edgewise
brackets- in the posterior teeth.
(Custom Lingual Appliance)

36. Incognito
• Incognito slot size is 0.018 × 0.025 inch because of the reduced interbracket distance.
• Feature of the bracket system are: Fully custom made bracket, Fully custom made
wire, Thin profile leading to little discomfort
• Incognito arch wires are used in a ribbon-wise configuration. A vertical slot insertion
in the anterior region from canine to canine and a horizontal slot insertion in the
lateral segments.
• Order bends: The vertical height, angulation and torque are pre-set into each bracket
so the need for maximum individuality is met and the patient’s individual
prescription is designed into the brackets.
Features of incognito

37. Incognito
• With the Incognito system, an indirect bonding protocol is used for the initial bond-
up; extractions are usually only carried out after the appliance has been bonded.
• Occlusal pads helps in: providing greater bond strength, act as bite plate, allowing for
a direct rebonding procedure without the need of transfer trays or jigs.
• To improve anchorage, control splints can be made to lock teeth together.
Features of incognito

38. Incognito
• Aesthetic
• Less enamel decalcification
• Efficient in OB reduction
• Good outcome compared to conventional.
• (Romano 1999, Ling 2005)
• No difference in treatment times have been observed with the use of labial and
lingual orthodontic treatment techniques. Treatment goals and treatment planning
are also identical.
Advantages

39. Incognito
• Cost
• Accessibility
• Speech problem and discomfortibility
• Cleaning problem
• Variable lingual morphology make bracket fitness problematic
• Canine offset which need mushrooming of the AW.
• Reduced interbracket distance causing reduction in the AW flexibility. This might be
associated with more OIIRR.
• Finishing and torque control very difficult and need precision since any error could be
exaggerated because the force of application nearer the centre of resistance than
conventional labial bracket system.
Disadvantages

40. Incognito
Archwire in place after robotic
fabrication

41. Clear Aligners
• History
oThe idea originally described by Sheridan in 1980 and 1990
oThe Invisalign system was introduced by Align Technology (Santa Clara,Calif) in
1998.
• Philosophy
o It is an orthodontic technique used a succession of clear aligner to position the
teeth
o It is used 24/7 and replaced every 2 weeks with aiming to move the teeth by
0.25mm each time.
o The system uses CAD/CAM stereolithographic (STL) technology to predict
treatment outcome and creates custom made aligners from a single impression
Invisalign

42. Evidences
• Align Technology would suggest that 20-30% of patients may require mid-course fixed
appliance orthodontic appliance correction to achieve the predicted treatment
outcome.
• Many orthodontists, however, report that 70-80% of patients require case refinement
and /or detailing with fixed appliances.
• The mean accuracy of Invisalign for all tooth movements was estimated at 41% in a
recent prospective clinical study, Kravitz 2009
• Djeu et al 2010 retrospective comparison of outcomes of non-extraction Invisalign
and fixed appliance treatments, using the ABO objective grading system (1998),
found a significant difference in the pass rate of Invisalign compared to Tip-Edge
treatment (20.8%, 47.9%, respectively) and the time for Invisalign at 1.4 years
compared to 1.7 years for Tip-Edge treatment. So Invisalign is shorter in the duration
of treatment BUT with poor outcomes and expensive!!!!!! The reason why it is
shorter in time because they are moving the teeth without round tripping to the
defined final position.

43. How aligners are made?
• Patients teeth are scanned with intraoral scanners that combines laser and optical
scanning to create the digital model produce a matching series of stereolithoraphic
casts for aligner fabrication .
• At the digital treatment facility the teeth are digitally sectioned and cleaned up
dental arches are related to each other gingiva is added, movement is staged
according to the doctor’s plan.
• The set of digital models is transferred to the cast production facility were model for
each step is fabricated.
• A clear plastic aligner is formed over each model with careful planning this would
result in a sequence of aligners that could correct more complex problems.

44. Classification of invisalign system
• Invisalign Full
Maximum flexibility in treatment of a wide range of malocclusions
• Invisalign Teen
Treatment for teenager patients.
The device has unique Innovative features that address patient compliance.
• Invisalign Anterior
Treatment limited to moving upper and lower anterior teeth (canine to canine) with
crowding or spacing of 4 mm or less per arch
• Invisalign Lite
Treatment for
Minor crowding or spacing
Orthodontic relapse
Only allows use of 14 aligners or less
• Vivera Retainers
Retainer made by Invisalign at the end of treatment
(Malek 2013)

45. What to tell your patient?
• Things TO DO During Invisalign Treatment
o Wear each set of trays for at least 2wks, unless otherwise instructed
o Wear each set of trays for 18- 20 hours a day, unless otherwise instructed
o Use denture cleaner tablets to clean trays at least once a day
o Always place trays in case when not in your mouth
o Always remove trays by starting from the back molars
o Always place trays in from the front of your mouth first, and then move to the
back molars
o You may drink water while wearing trays or use a straw for dark liquids
o If possible, brush or rinse before placing trays back in your mouth
o Clenching into trays w/ your aligner chewies during the first 2-3 days helps teeth
move faster and relieve pressure. Only clench for 30-40 sec each quadrant, and
repeat for 5-10 min, but only do this if you have no history of jaw problems
o Wear trays as instructed in sequential order.
o Keep 2 to 3 of your previous trays in a clean plastic bag.
Clear Aligner Patient Instructions

46. What to tell your patient?
• Things NOT TO DO During Invisalign Treatment:
o Throw away trays
o Leave trays out of mouth for long periods of time
o Chew gum with aligners in your mouth
o Leave trays in hot vehicle, or boil them (They are plastic!)
o Leave trays sitting out for pets or small children to chew on
o Wrap trays in a napkin (You will throw them away!)
o Place trays in your pocket without a case
o Have dental work done while in treatment, EXCEPT for regular checkups and
cleanings
o Eat while wearing trays
o Remove trays from the front teeth first
o Drink dark teas, coffee or soda with trays in (Use a straw)
o Set trays on table at a restaurant
o Bite trays into position, this may damage them
o Use mouthwash or toothpaste on trays
Clear Aligner Patient Instructions

47. Indication of Invisalign
• Mild-moderate crowding and mal-alignment problems (1-5 mm).
• Close mild to moderate spacing (1-5 mm).
• Deep overbite problems (class II division 2) where the overbite can be reduced by
intrusion and advancement of the incisors.
• Narrow arches that can be expanded without tipping the teeth too much (posterior
dental expansion)
• Absolute intrusion (1-2 teeth only)
• Tip molar distally
• Lowe incisor extraction for severe crowding.

48. Contraindication of Invisalign
• Crowding over 5 mm.
• Extrusion of incisors
• Dental expansion for blocked out teeth
• High canines
• Leveling by relative intrusion
• Spacing over 5 mm.
• Anterior-posterior discrepancies of more than 2 mm.
• Open bite correction.
• Severely rotated teeth more than 20 degrees.
• Severely tipped teeth, more than 45 degrees.
• Teeth with short clinical crowns.
• Closure of premolar extraction spaces (possible using attachments)

49. Advantages of Invisalign
• Ideal aesthetics.
• Less pain
• Improved periodontal health due to cleansibility.
• Less decalcification
• Less OIRR
• Shorter treatment duration.

50. Disadvantages of Invisalign
• Poor control over root movements resulting in problems with root parallelling, severe
rotations, tooth uprighting and extrusion
• Not suitable for the use in anteriorposterior discrepancies greater than 2 mm as
intermaxillary correction is very limited.
• Lack of operator control. Once the treatment is underway and the aligners have been
made, if changes to treatment are needed new impressions and aligners will need to
be produced.

51. Invisalign
• The use of attachments that are bonded to selected teeth greatly extends the
possible tooth movement with aligners
• Increasing trend toward a combination to complex treatment using short phase of
partial fixed appliances or auxiliaries in addition to the sequence of aligners
• IPR to obtain space for aligning crowded teeth is often part of the treatment plan.
• Patients should be monitored carefully to verify tooth movement is tracking with the
series of aligners
• Aligners cover the teeth like a bleaching tray and they can be used to bleach during
treatment .
Consideration in clinical use

52. SureSmile
• Suresmile is used for labial orthodontics (OraMetrix,Rich-ardson,TX) uses data
acquired via an intraoral scan to shape finishing archwires to the desired arch form
and adjust it at each bracket to provide correct in –out , angulation, and torque
bends.
• Uses traditional not customised brackets

53. SureSmile
• Intraoral scan of the patient’s teeth is used (instead of scan of dental casts) to provide
information for archwire preparation
• Wire bending robot making the precise bends in custum archwire
• Precise positioning of the brackets and special bracket prescriptions are not needed
• Bends compensating for descripancies in bracket height and root positioning bends.
What is Done in Suresmile system

54. SureSmile
Agroup of 63 conventially finished patients were compared with 69 Suresmile patients
treated in the same office by the same clinician .
• The suresmile group had a significantly shorter time in fixed appliances (23 versus 32
months)
• The study concluded that the shorter treatment time with suresmile was due at least
in part to less severe malocclusion and less detailed finishing.
Study at University of Indiana

55. Bonding, placement, light cure
and removal techniques

56. Bonding
• Cleaning the teeth
• Moisture control
• Etching (30 sec)
• Primer
• Adhesive.

57. Placement technique
• Angle the jigs so that the bracket base is at about 30 to the tooth surface and then
roll it down into place. Insignia jigs seat very precisely. Use a microsponge to clean
any excess adhesive from the mesial, distal and gingival edges of the bracket. Ensure
that firm pressure is applied both from the occlusal and the buccal to ensure close
adaptation between bracket and tooth surface.
Insignia

58. Placement technique
• the transfer tray has to be seated in an almost vertical direction and it is not possible
to remove any excess adhesive from the mesial and distal surfaces of the brackets,
only from the gingival edge.
OrthoCAD

59. Indirect Bonding
1.Brackets are placed precisely on a cast of the teeth
and held in place with a fitted resin.
2.After the brackets are cured in the ideal position, a
transfer tray is formed and placed on the working cast.
3. The trays are removed from the working cast after
soaking in warm water and trimmed.

60. Indirect Bonding
4. The teeth are isolated , etched, and a chemically
cured two paste resin is painted on the etched enamel
and brackets.
5. After the resin has completely set , the trays are
carefully removed , leaving the brackets bonded to the
teeth.

61. Light curing
• Insignia cure from the gingival, the mesial and distal where possible and also from
the lingual. Complete the cure once the jigs have been removed
• OrthoCAD has a two part tray with a hard outer shell and flexible inner liner that
holds the brackets. Cure each tooth through the outer hard tray and then remove it.
Complete the cure by curing each tooth through the soft inner liner.

62. Jig or transfer tray removal
• To remove Insignia jigs, grip the jig across the centre buccolingually with a pair of
Weingart pliers.
• For OrthoCAD, the outer hard tray is easily removed using fingers. The inner tray is
flexible and can be gently disengaged from each bracket in turn.

63. Summary

64. Summary
Customised precision prescription appliances offer several potential advantages .The
extent to which they are translated into tangible benefits is as yet unclear.
Overall, we are impressed with the early experiences with this technique and are
convinced it will become the preferred way of placing fixed appliances in the future.
The learning curve in the early stages is sheepish but perseverance makes orthodontics
even more enjoyable! Well worth a try.

65. References
• Customized precision prescription appliances
Excellence in orthodontics 2012.
• Postgraduate Notes inOrthodontics (University Of Bristol).
• Contemporary Orthodontics by William Proffit,chapter 10 .