TECHNO BYTES

Computer-aided design and

manufacture of hyrax devices: Can
we really go digital?
a b c b
Simon Graf, Marie A. Cornelis, Gustavo Hauber Gameiro, and Paolo M. Cattaneo

Belp, Switzerland, Aarhus, Denmark, and Porto Alegre, Brazil

The aim of this pilot study was to illustrate the feasibility of a new digital procedure to fabricate
metallic orthodon- tic appliances. Hyrax appliances for rapid palatal expansion were produced
for 3 patients using a CAD/CAM pro- cedure without physical impressions or printed models. The
work flow consisted of intraoral scanning, digital design with incorporation of a scanned
prefabricated expansion screw, direct 3-dimensional metal printing via laser melting, welding of
an expansion screw, insertion, and finally activation in the patients’ mouths. Finite element
analyses of the actual hyrax appliances were performed to ensure that the printable material
used in combination with the chosen design would withstand the stress generated during
activation. The results of these analyses were positive. The clinical results showed that this
procedure is an efficient and viable digital way for constructing metallic orthodontic appliances.
The flexibility of the digital appliance design, together with the biocompatibility and strength of
the chosen material, offers a huge potential for more advanced appliance design. (Am J Orthod
Dentofacial Orthop 2017;152:870-4)

D
igital models were introduced commercially into the orthodontic market in 1999

by OrthoCad (Cadent, Carlstadt, NJ). They were initially pro- duced by scanning plaster
casts created by pouring the impressions and later by scanning the impressions
directly. The advantages of digital casts are mainly the possibility of more precise cast
analysis (especially space analysis and Bolton discrepancy), the reduced need for
storage, and the ease of handling, sharing, and sending them.1,2

One of the first intraoral scanners for orthodontic purposes was the iTero, introduced in
2007 (Align Tech- nology, Santa Clara, Calif). In addition to their high pre- cision, 3-5
intraoral scanners provide increased comfort to the patient because of reduced risk of
the gag reflex, despite the longer scanning time compared with the 20 to 30 seconds
needed for a classic alginate impression. 6 For clinicians, the advantages are mostly

a
Private practice, Belp, Switzerland.
b
Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark.
c
Department of Physiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Three authors
reported no potential conflicts of interest; Dr Graf reported a patent pending, PCT/EP2015/061156.
Address correspondence to: Paolo M. Cattaneo, Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus
University, Vennelyst Boulevard, 9, Aarhus C DK-8000, Denmark; e-mail, paolo.cattaneo@dent.au.dk. Submitted, February
2017; revised and accepted, June 2017. 0889-5406/$36.00
! 2017 by the American Association of Orthodontists. All rights reserved. http://dx.doi.org/10.1016/j.ajodo.2017.06.016

related to the practical aspects: less chair-side material (eg, different sizes and jaw
specific impression trays), overall less chair-side time, and fewer issues with cross
infection.7 The work flow after scanning is also much quicker, since the data (models)
are immediately avail- able for the orthodontist. 2 Moreover, there is no need to
physically pack and send the impressions trays to a dental laboratory.

CAD/CAM technology has been used in dentistry, more specifically in prosthodontics,

since 1985, with the Cerec system from Sirona (Siemens, Bensheim, Germany), initially
for manufacturing single crowns and later for complete bridges. 8 In orthodontics, CAD/
CAM technology was first used for individual bracket base manufacturing (eg,
Incognito; 3M Unitek, Monro- via, Calif), robot wire bending (eg, SureSmile; OraMetrix,
Richardson, Tex), and aligners (eg, Invisalign, Align Technology). Nowadays, digital
setups can be produced in dental laboratories, and aligners can be manufactured from
printed casts.

Yet, traditional orthodontic appliances such as hyrax, lingual and transpalatal arches,
Herbst appliances, and so on are still routinely produced with analog impres- sions and
conventional laboratory techniques. To explore the possibilities offered by CAD/CAM
technology to achieve a complete digital work flow to produce such appliances, a
simple device was needed: the hyrax appli- ance was thus chosen. The goal was to
avoid not only the analog impression, but also the traditional, plaster model based
production of a printed cast.

870

Graf et al 871

Fig 1. Design of the basic structure of the hyrax and digital positioning of the transversal screw.
Conventional molar bands were replaced by printed clasps (arrow 1). The design extends to the
palatal side to the deciduous canines (arrow 2). Small hooks are designed to facilitate debonding
of the appliance (arrow 3). The bonding gap appears in green (0.05 mm).

The aim of this clinical pilot study was to investigate the feasibility of a fully digital
production of a hyrax appliance. See Supplemental Materials for a short video
presentation about this study.
MATERIAL AND METHODS

The first step consisted of taking digital impressions of both jaws and an occlusal bite,
using an intraoral scanner (Trios Pod Version; 3Shape, Copenhagen, Denmark). After
the scanning process, the digital model was checked with the colored output on the
scanner's screen. The digital impressions were then sent to the technician using the
direct upload link.

After instructions of the orthodontist (S.G.), the hyrax was designed using the 3Shape
Appliance Designer soft- ware by the laboratory technician. Conventional molar bands
had to be replaced by printed clasps to obtain a fully digital procedure: the clasps were
modeled sur- rounding the molars and extending on the palatal side to the deciduous
canines, but not into the interdental spaces (Fig 1). The surfaces covering the teeth
were de- signed as large as possible to improve the retention of the appliance. On the
other hand, to facilitate debonding of the appliance, small hooks were designed on the
buccal sides of the molars and on the palatal sides of the deciduous first molars (Fig 1).
Some areas with a thinner section at the molar clasp level were designed to facilitate
separation in case of difficulties in debond- ing. The bonding gap was designed to be
0.05 mm. Since an expansion screw cannot yet be produced by printing, a 12-mm self-
locking screw (Forestadent, Pforzheim, Germany; 0.9 mm, complete turn) was digitally
inserted.

Fig 2. Printed hyrax. Note the welded area around the screw.

The appliance was designed with ideal welding area to accommodate the screw (Fig 2).
The design and exten- sion of the appliance were then checked and finally accepted by
the orthodontist.

The final digital design was then sent to the laser- melting (printing) machine. The
material chosen for creating the appliance was Remanium Star (Dentaurum, Ispringen,
Germany), a metal alloy that comes in a pow- der. This material is widely used by
prosthodontic dental laboratories.9

After laser melting, the appliance was electro pol- ished, and the expansion screw was
welded onto the pre- pared area. The bonding surfaces were then sandblasted.

Clinical cases

Three patients treated with hyrax appliances, all produced following the above-
described method, are presented in this section.

Patient 1 was a girl (age, 8.3 years) in the mixed dentition, with a unilateral crossbite
on the left side, a transversal discrepancy of 7 mm at the molar level, and a 2-mm lack
of space in the maxillary arch. She had a convex profile and a mandibular shift to the
left due to premature contact of the deciduous left canines. She was normodivergent
with a skeletal Class I.

The hyrax surface was prepared with Scotchbond universal adhesive (3M Unitek) and
subsequently bonded with Transbond XT (3M Unitek). The patient's parents were
instructed to activate the hyrax a quarter turn twice a day (morning and evening) for
20 days, producing 9 mm of expansion, corresponding to 2 mm of overcorrection of
the crossbite, since a small relapse was expected.

At the end of the 20-day activation period, the hyrax was left in situ for 6 months for
retention before debonding (Fig 3).

Patient 2 was a boy (age, 8.5 years) with a 6-mm transversal discrepancy at the molar
level. He was in the mixed dentition and had a right and left Class I molar
American Journal of Orthodontics and Dentofacial Orthopedics December 2017 Vol
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872 Graf et al

Fig 3. A, Initial intraoral picture of the maxillary arch of patient 1; B, printed hyrax in place
before activation; C, printed hyrax still in place 6 months after the end of screw activation.

relationship. He had a unilateral crossbite on the right side. He showed a straight

profile and had a mandibular shift to the right due to premature contact of the decid-
uous canines on the right side. There was no lack of space in the maxillary arch.

The previously described bonding materials were used. The hyrax was activated a
quarter turn twice a day (morning and evening) for 18 days, producing 8.1 mm of
expansion. Again, 2 mm of overcorrection was planned to account for relapse.

The hyrax was left for 6 more months as a retainer at the end of the activation period
(Fig 4).

Patient 3 was a girl (age, 10 years) in the mixed denti- tion with a unilateral crossbite
on the right side and a transversal discrepancy of 6 mm at the molar level. She had no
mandibular shift: the unilateral crossbite was only due to the constricted maxilla. She
had a straight profile and a Class I molar relationship. There was 3 mm of space
missing in the maxillary arch and a space excess of 1 mm in the mandibular arch.

Again, the same bonding materials were used. The hyrax was activated a quarter turn
twice a day (morning and evening) for 14 days, producing 6.3 mm of expan- sion until
the crossbite was solved. The hyrax was then left for retention for 6 months (Fig 5).

Finite element models

To test whether the design of the appliance combined with the material used
(Remanium Star) would be strong enough to withstand the forces produced during the
acti- vation phase, appliance-specific finite element models were generated from the
original 3-dimensional digital appliance models using Mimics software (release 17;
Materialise, Leuven, Belgium). The actual activation was simulated, and the stresses
and strains were calcu- lated in NASTRAN (MSC Software, Newport Beach, Calif).

RESULTS

Clinically, all 3 appliances fit perfectly, and no break- ages were registered. All
appliances could be debonded

easily at the end of treatment. Thus, although the hyrax appliances were designed
with some areas characterized by a thinner section, as previously described, it was not
necessary to cut them for debonding.

The finite element analyses showed that the maximum stress concentrations (\3 MPa)
were far below the yield strength of the material (with a ratio of more than 200), thus
making failure caused by overload highly improbable (Fig 6). The results of the finite
element analysis confirmed what was observed clinically.

DISCUSSION

These clinical cases illustrate the possibilities offered by a fully digital work flow based
on CAD/CAM for build- ing orthodontic appliances such as the hyrax.

This technique has the advantage of eliminating all the conventional impression
drawbacks: gag reflex, pa- tient discomfort, and impression material (with the related
dimensional changes and air entrapment during pouring). Another advantage is that
no separators are needed—eg, for conventional molars bands—because the printed
hyrax is modeled digitally so that the bands surround the molars, without the need to
extend into the interdental space. One visit is thus saved, and no printing of the
physical study models is needed. Moreover, there is no need for a new imprint in case
of breakage of the appliance, since a copy from the digital archive would be sufficient.

This technique gives the possibility to accurately con- trol the appliance in all
dimensions, thus eliminating the uncertainties of fitting it at the chair: all 3 hyrax appli-
ances fit perfectly, and debonding was problem-free. The latter may also be related to
the fact that the bonding gap was designed to be 0.05 mm: from a clin- ical trial-and-
error approach, it was observed that either a smaller or larger gap would result in a
higher failure rate or debonding problems.

The design of the appliances can be adapted accord- ing to the clinician's preferences
(number of teeth to be bonded, permanent or deciduous teeth, positioning of
December 2017 Vol 152 Issue 6 American Journal of Orthodontics and Dentofacial
Orthopedics
Graf et al 873
Fig 4. A, Initial intraoral picture of the maxillary arch patient 2; B, printed hyrax in place before
activation; C, printed hyrax still in place 6 months after the end of screw activation.

Fig 5. A, Initial intraoral picture of the maxillary arch of patient 3; B, printed hyrax in place
before activation; C, maxillary arch just after debonding of the hyrax.

Fig 6. Result of the finite element analysis of the hyrax used for patient 3. The Von Mises
stresses are depicted. Note that the peak is in the range of 3 MPa or less.

the expansion screw, and so on), exactly as for conven- tional laboratory-produced
appliances. Moreover, the orthodontist can design the appliances so that a differ-
ential force can be transferred to the dentition: by changing the thickness or the
design of the arms of the hyrax, it is possible to alter the force distribution on the
dentition. The stress concentration could easily be seen in the finite element models: it
is thus possible

to individualize the way the forces are transferred from the expansion screw to the
dentition. The possibility of having the detailed 3-dimensional shape already during the
appliance drawing renders it possible to design the appliances according to the real
clinical needs: the arms can be modeled so that the forces are transferred in the most
optimal way according to the type of expan- sion needed.
American Journal of Orthodontics and Dentofacial Orthopedics December 2017 Vol
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874 Graf et al
It has been shown that removable appliances can also be designed digitally. 7 However,
the metallic materials available for laser melting are at the moment not very resilient;
therefore, robot wire bending must be used to fabricate clasps.

This procedure for metal-based orthodontic appli- ances opens the door to the digital
production of any conventional metallic orthodontic appliance, such as in- dividual
molar bands, lingual arches, transpalatal arches, Herbst appliances, and so on.

CONCLUSIONS

With this pilot study, the feasibility of generating hyrax appliances using a CAD/CAM
approach was illus- trated. These appliances have been shown to clinically function as
conventional orthodontic appliances. This fully digital approach may generate a faster
work flow, possibly more predictable appliances, and certainly quicker replacement in
case of loss or breakage of appliances. Finally, this technique may facilitate and
improve the collaboration between the orthodontist and the laboratory technician
during the appliance design, ultimately providing a better treat- ment to the patient.

ACKNOWLEDGMENT

We thank Roland Kiss, DENTAL DIGITAL GmbH, Switzerland, for the laboratory work.

SUPPLEMENTARY DATA

Supplementary data related to this article can be found at

http://dx.doi.org/10.1016/j.ajodo.2017.06. 016.

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Orthopedics