TagedEnSeminars in Orthodontics 29 (2023) 34−42

Contents lists available at ScienceDirect

TagedFiur TagedEn Seminars in Orthodontics TagedFiur TagedEn

journal homepage: www.elsevier.com/locate/sodo

TagedH13D Metal Printing in Orthodontics: Current Trends, Biomaterials, Workflows

and Clinical ImplicationsTagedEn
T imon Graf a, Digant Thakkar b, Ismaeel Hansa c, Srirengalakshmi Muthuswamy Pandian d,
agedPS
Samar M. Adel e,*TagedEn
TagedP Smile AG, Eichenweg 23, Belp CH-3123, Switzerland
a

b
Private Practice Silver Smile Dental Specialists, Product Specialist Digant’s 3D Orthodontics, Manav Rachna International Institute of Research and Studies (MRIIRS), Raj-
kot, Gujarat India
c
Durban, South Africa
d
Department of Orthodontics, Saveetha Dental College, Saveetha Insitute of Medical and Technical Sciences, Chennai, India
e
Department of Orthodontics, Faculty of Dentistry, Alexandria University, Champolion St, El Azarita, Alexandria, Egypt
TagedEn
TAGEDPA R T I C L E I N F O TAGEDN A B S T R A C T

Three-dimensional (3D) metal printing of customized orthodontic appliances is at the cutting edge of orthodontic
technology. Different additive techniques as well as materials have been employed in order to directly 3D metal
print an orthodontic appliance. The potential advantages of 3D metal printed appliances include greater treatment
efficiency, increased patient’s comfort, reduced orthodontic appointments, reduced workflow steps, thus reducing
the chances of error and resulting in a more accurate fit and better standardization. This article aims to describe
the current trends, biomaterials, workflows and clinical implications of metal 3D printing, in order to aid clini-
cians in gaining some insight on this novel technology and to allow for greater incorporation in contemporary dig-
ital orthodontic workflows.

TagedH1IntroductionTagedEn
TagedPThe field of orthodontics continues its inexorable technological
advancement with the development and uptake of metal 3D printing.1
3D metal printing is a type of additive manufacturing that creates 3D
metal parts by adding sequential layers of metal powder. This technol-
ogy has revolutionized the way metal parts are designed and manufac-
tured, allowing for greater design flexibility and faster production times.
With 3D metal printing, complex shapes and internal structures can be
created that would be impossible to achieve using traditional
manufacturing techniques. The process starts with a 3D design, which is
then sliced into digital cross-sections and sent to the 3D printer. The 3D
printer then deposits layers of metal material, which are fused together
using heat or a binding agent. This creates the finished metal part, which
can be used in a variety of applications, from aerospace and automotive
to medical and dental appliances.2TagedEn
TagedPMetal 3D printing can be performed by a variety of processes. Direct
Metal Laser Sintering (DMLS) and Direct Metal Laser Melting (DMLM)
are the most commonly used technologies in orthodontic manufacturing,
and involve the application of a thin layer of metal powder (20-60
micron layers), followed by melting of the metal powder layer into a
TagedEnPsolid one using a laser beam. The printed part is built up incrementally
layer by layer, each time applying more powder and then melting it
again. This additive process allows metal parts to be grown out of a bed
of powdered metal.3TagedEn
TagedPElectron Beam Melting (EBM) uses a similar process; however,
the metal powder is melted using an electron beam instead of a
laser as in DMLS and DMLM. Binder Jetting (BJ) is the other com-
monly used technique that deposits a binder over metal powder
layers and requires additional steps involving de-powdering, sinter-
ing, and annealing of the object. BJ is currently the cheapest method
of 3D printing and was also found to have the highest dimensional
accuracy and the smoothest surfaces, however the strength of these
products is less than those of DMLS or EBM.3 Additionally, scanning
electron microscopy found greater surface porosities which may
increase plaque accumulation.4 Although metal 3D printing has been
utilized since the mid-1990’s, this technology has only recently
become mainstream due to the advancement in Computer-Auto-
mated Design/ Computer-Aided Manufacturing (CAD/CAM) technol-
ogy and software. Metal 3D printing is ideal for manufacturing low-
volume, small, precise parts which appears to perfectly suit ortho-
dontic use.TagedEn

TagedEn * Corresponding author.

E-mail address: orthosamar@gmail.com (S.M. Adel).

https://doi.org/10.1053/j.sodo.2023.01.001

1073-8746/© 2023 Elsevier Inc. All rights reserved.

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedEnS. Graf et al.
TagedPAnother crucial factor influencing the adoption of 3D printing in
general is the improvement and remarkable advances of 3D intra-
oral scanning. This combination of intra-oral scanning and CAD/
CAM technology has allowed for the development of numerous
orthodontic products, such as individual bracket base manufactur-
ing, automated wire bending, and clear aligner appliances.5,6 Cus-
tomized metal orthodontic appliances however, are still routinely
produced traditionally using analogue impressions and conventional
laboratory techniques. Progressing to 3D printed appliances may
allow for greater treatment efficiency and patient comfort. The
orthodontic workflow can be streamlined and by limiting the steps
in the manufacturing process, this reduces the probability of error,
thus resulting in greater accuracy. Communication between the lab
and the clinician is also improved and adjustments can be custom-
ized based on each patient’s requirements. Furthermore, the design
is not limited to what the technician can physically manipulate.
Clinicians could, in the future, use this technology to fabricate appli-
ances in-house, bringing financial and practical advantages. Patient
comfort is also improved, as a traditional impression, and it’s associ-
ated drawbacks, are not necessary. Likewise, separators, one of the
chief causes of orthodontic discomfort, can be avoided in addition
to the extra office visits required.TagedEn
TagedPThe use of 3D printed metal appliances was first described in the ortho-
dontic literature by Graf et al. in 2017.7 They reported on 3 cases that used
a 3D printed Hyrax appliance and found promising results. A thesis at the
University of North Carolina,8 also in 2017, investigated the accuracy and
performance of 3D metal printed brackets and described some advantages
and disadvantages of its usage in that form of application.TagedEn
TagedPAs a new and developing technology in the orthodontic field,
metal 3D printing is still unfamiliar to the majority of the ortho-
dontic community. This article thus aims to describe the current
trends, biomaterials, workflows and clinical implications of metal
3D printing, to aid clinicians in gaining some insight on this novel
technology to be more widely incorporated in the digital ortho-
dontic workflows.TagedEn
TagedH2Current trendsTagedEn
TagedPThe contemporary trend in the orthodontic fraternity is the “in-
house” method of fabricating orthodontic appliances. The rapid
uptake of 3D intra-oral scanners coupled with improvements and
reduced costs of CAD/CAM software and 3D printers have encour-
aged clinicians to attempt to manufacture appliances (specifically
clear aligners) without the need for outsourcing. This trend may
well continue to metal 3D printed customized appliances. However,
this technology is not yet so well developed, nor is the equipment
cost reduced to such an extent that makes this a viable in-house
product at this moment in time. With continued development, metal
printers may well follow the trend of resin printers, and could con-
siderably reduce in cost.TagedEn
TagedPThe potential of CAD/CAM allows for limitless creativity of
design and customization. Currently however, the metals commonly
used in 3D printed appliances are extremely rigid, and hence can
only be indicated in some instances. The Hyrax appliance was one
of the first, and is still the most popular, 3D printed appliance
described in the literature.7 Simpler appliances such as transpalatal
arches and lingual arches (both active and passive) and space main-
tainers can all be produced.9,10 Flexible alloys are not, as of now,
able to be 3D printed, and thus require addition of supplementary
components (usually via laser welding) if active tooth movement is
desired. More complicated (albeit still rigid) usage, such as mini-
screw retained appliances and components of the Herbst appliance
have also been described in the literature.11−13 Attempts to use
metal 3D printing on high volume items such as brackets have been
investigated. However, greater variation in slot size, as well as a
lack of cost effectiveness have been documented.8TagedEn
35
Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
Seminars in Orthodontics 29 (2023) 34−42
TagedH2BiomaterialsTagedEn
TagedPAt this current timepoint, there are only few printable metal alloy
powders available such as Cobalt-Chromium (CoCr) alloys and Titanium
alloys, with the CoCr alloy being most commonly used. The appliances
described by Graf et al.4,7,9,11,12,14,15 were printed with Remanium® Star
CL (Dentaurum, Ispringen, Germany), a CoCr alloy powder with some
Tungsten and Selenium. As with most novel technologies implemented in
orthodontics, there remains a dearth of evidence in the scientific literature
regarding this technology and the materials utilized. Eliades and Zinelis16
pointed out that the properties of CoCr 3D printed appliances, their aging
pattern, and their corrosion potential and release of ions have not been
sufficiently investigated. The corrosion resistance and resultant ion
release of metal appliances are primarily based on their electrochemical
and mechanical properties, which are determined by the type of alloy
used, and the method of 3D printing. Nevertheless, the unique and harsh
intra-oral environment consists of wide temperature and pH fluctuations,
as well as mechanical loads and microbial interactions that have unknown
effects on corrosion and ion release of CoCr alloys.TagedEn
TagedPIn a study by Graf et al.,7 a 3D printed Hyrax was tested for its yield
strength in three patients requiring expansion. In all these patients a sim-
ilar protocol for bonding of the Hyrax appliances was used and activa-
tion was done as per the requirement for correction of crossbites. No
breakage was observed in 3D printed Hyrax appliances and the finite
element analysis showed that the maximum stress concentrations were
far below the yield strength of the material.TagedEn
TagedPThe mechanical and electrochemical properties of the material used
for fabrication of 3D printed metallic appliances have a great influence
on the success of the treatment. These properties should be tested for
appliances fabricated by 3D printing to observe the longevity of these
appliances. This is possible by subjecting the 3D printed appliance to
intraoral ageing and observing the surface changes using the Scanning
Electron Microscopy (SEM) and mechanical properties using Instrumen-
tation Indentation Technique (IIT), as well as electrochemical changes
using an artificial saliva. A study by Zinelis et al in 202217 studied the
mechanical and electrochemical properties of 3D printed molar distali-
zation appliances made of CoCr. They observed that intraorally aged
appliances had no gross porosity and similar strength as the controls,
however they did lose the protective passivation layer when being com-
pared to the controls. This implies that 3D printed appliances have good
mechanical and surface properties to achieve clinical success and that
the harsh intra-oral environment did not greatly influence their proper-
ties.TagedEn
TagedPIn addition to the different techniques employed for the fabrication
of orthodontic appliances, the toxicity of metal ion release raises a con-
cern on the biocompatibility of these materials and the patient safety.
Different metals such as Nickel Titanium, Cobalt Chromium, Stainless
Steel and Titanium have been used extensively for fabrication of ortho-
dontic appliances. The toxicity from these materials, if not within the
tolerated daily intake, can greatly produce cytotoxic effects. The metal
ion leaching from the orthodontic materials can be assessed by Atomic
Absorption Spectroscopy (AAS), Inductively Coupled Plasma Optical
Emission Spectrometry (ICP-OES), Inductively Coupled Plasma Mass
Spectrometry (ICP-MS), Flame Atomic Absorption Spectrometry (FAAS),
and Graphite Furnace Atomic Absorption Spectrometry (GFAAS). Ortho-
dontic appliances can be thermo-cycled against artificial saliva or other
immersing solutions like lactic acid etc., and studied for their cytotoxic
effects using any one of the aforementioned methods. Therefore, it is
mandatory to test for cytotoxicity and genotoxicity which can be done
by using the modified comet assays before clinical application.18TagedEn
TagedH2Clinical applications and digital workflows of different types and designs of
3D metal printed appliancesTagedEn
TagedPA plethora of software are used for designing appliances and Table 1
describes the salient features of the available software. The presented
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

TagedEn Table 1
Summary of the various utilized CAD software.

Software name One-time license* Annual license** Subscription model*** Orthodontic software Dental software

1 3Shape Ortho Analyzer Yes No Yes Yes Yes

2 Onyx Ortho Apps Yes Yes Yes Yes Yes
3 Deltaface Yes Yes Yes Yes Yes
4 3D Leone Designer No Yes No Yes Yes
5 Blender for dental Yes Yes No No Yes
6 Exocad Yes No Yes No Yes
7 Rhino 3d Yes Yes Yes No No
8 Fusion 360 No Yes No No No
9 Meshmixer Free Free Yes No No

* Pay once and software is valid for life

** License valid for one year only
** Fixed sum to be paid yearly to receive regular software updates

TagedEnPsoftware can all be used for designing appliances for metal 3D printing;
however, some are geared towards general usage, and their usage may
be complicated and time-consuming when designing orthodontic appli-
ances. Other software are very specific to orthodontics, and are usually
easier to use and time-efficient when designing orthodontic appliances.
These are however, usually more expensive. Each software has its own
pros and cons, and demoing the software is recommended prior to pur-
chasing a license.TagedEn
TagedP3D metal printed orthodontic appliances can be broadly catego-
rized into TAD based appliances (Temporary Anchorage Device)
TagedFiur
TagedEnPand non-TAD based appliances. The TAD based appliances can be
further subcategorized into either TAD first workflow or Appliance
first workflow according to whether the TAD or the appliance will
be inserted first inside the patient’s mouth and the subsequent dig-
ital workflow. A workflow is a great way to explain and clarify the
processes involved in 3D metal printing appliances. Fig. 1 shows
the workflow for normal 3D printed metal appliances. Fig. 2 dis-
plays the workflow for TAD-first metal appliances and Fig. 3
shows the workflow for the Appliance-first approach of TAD-based
appliances.TagedEn

Fig. 1. Digital workflow for customised orthodontic appliances.TagedEn

TagedFiur

Fig. 2. Digital workflow for TAD-first approach of TAD-based customised orthodontic appliances.TagedEn

36

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedFiur
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

Fig. 3. Digital workflow for the Appliance-first approach of TAD-based customised orthodontic appliances.TagedEn
TagedFiur
Fig. 4. Broken band and loop space maintainer.TagedEn
TagedH1Non-TAD based 3D metal printed orthodontic appliancesTagedEn
TagedH2Space maintainers (SMs)TagedEn
T pace maintainers are placed to maintain the space created by pre-
agedPS
mature loss of primary teeth. Among the various fixed types of SMs, the
band and loop type of SMs is the most frequently used appliance.19 Sol-
der failure, caries formation along the margins of band and long con-
struction time are some of the complications and disadvantages
associated with this type of SMs.20 (Fig. 4)TagedEn
TagedFiur
TagedPFabricating a one-piece metal 3D printed appliances from dental
alloys like CoCr can reduce the chances of appliance breakage and
thereby reducing orthodontic emergencies. The appliance is designed
digitally using any commercially available CAD software (Fig. 5).TagedEn
TagedPThe 3D printed band thickness in designing is kept at 0.55 mm with
a luting cement gap of 0.05 mm, the loop is 0.75 mm in diameter, start-
ing in the middle 3rd of the band on the side of extracted/missing tooth,
progressing close to the gingiva and contacting the middle 3rd of the
opposite tooth. Occlusally the loop is kept wide Bucco-lingually approxi-
mating the size of erupting permanent successor. Similar to a band and
loop space maintainer, various types of space maintainers such as the
lingual arch (Fig. 6), transpalatal arch, functional space maintainer
(Fig. 7) and Nance palatal arch (Figs. 8 and 9) can be digitally designed
and 3D printed with similar band and wire dimensions.TagedEn
TagedH2Tooth borne expandersTagedEn
TagedPSimilar to the space maintainer design workflow, a digital scan of the
maxillary arch is loaded in the CAD software of choice. In the 3D print-
ing of orthodontic expanders, a prefabricated Hyrax of choice is used,
the connecting arms and bands are 3D printed and then joining of the
printed framework and Hyrax screw are performed by laser welding.7
First, the digital file of the Hyrax screw (Fig. 10) can be requested from
manufacturers, which is usually provided readily. In fact, many CAD

Figs. 5. Figs. a, b, and c show the digital design of space maintainer and Figs d and e show the 3D metal printed space maintainer inserted inside the patient’s mouth.TagedEn

37

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedFiur
TagedEnS. Graf et al. TagedFiur Seminars in Orthodontics 29 (2023) 34−42

Fig. 9. Nance palatal arch space maintainer with anterior bite platform.TagedEn

Fig. 6. Lingual arch space maintainer.TagedEn

TagedFiur TagedFiur

Fig. 10. Forestadent, Pforzheim, Germany; 12 mm expansion; 0.9 mm/turn

Hyrax digital file.TagedEn

TagedEnPsoftware have these files from affiliated manufactures already present on

the system. The Hyrax is then digitally placed on the palatal vault (Fig.
11). The band thickness for the Hyrax workflow is 0.75 mm and the
cement gap remains at 0.05mm. Additional calculation of undercuts,
digital surveying and path of insertion should be considered as multiple
teeth have bands and the rigid nature of the appliance will not allow for
any modification. The connecting arms between the bands and Hyrax
are 2mm in diameter. Finally, the connecting arms join the bands and
the Hyrax (Figs. 12−14).TagedEn

TagedH1TAD based 3D metal printed orthodontic appliancesTagedEn

Fig. 7. Functional space maintainer.TagedEn

TagedH2MARPE (miniscrew-assisted rapid palatal expander)TagedEn
TagedFiur
TagedPRapid maxillary expansion devices have been routinely used in cor-
TagedFiurrection of transverse discrepancies such as unilateral and bilateral

Fig. 8. Nance palatal arch space maintainer.TagedEn Fig. 11. Hyrax expander placed on the palatal vault.TagedEn

38

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedFiur
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

TagedEnPcrossbites in young individuals.21 However, managing problems in the

transverse dimension in adults has always been a challenge. To over-
come this, Miniscrew-Assisted Rapid Palate Expansion (MARPE) was
introduced.22 Many pre-fabricated MARPE are available in the market,
however, they have serious limitations in narrow and high arched palate
as it cannot reach the full depth of the palate. Additionally, if the minis-
crews are not properly engaged in the cortex of the palate, the appliance
success may be considerably affected.23 Using digital technologies,
proper engagement of miniscrews can be assured through use of CBCT
guidance superimposed with 3D intra-oral scans.23−25 (Fig. 15)TagedEn
TagedPOnce placement of the TADs is performed, the remaining workflow is
similar to designing a Hyrax expander. The design is similar to Hybrid
Hyrax.26 Several illustrations of MARPE can be seen in the following
images (Figs. 16 and 17).TagedEn
Fig. 12. Final Hyrax appliance digital design.TagedEn
TagedFiur TagedH2DistalizersTagedEn

TagedPMolar distalization is considered a preferred treatment option for

patients having Class II molar relationship with mild maxillary protru-
sion when upper premolar extractions are contraindicated. Hilgers
developed the Pendulum and Pendex appliance that rely on the curva-
ture of the anterior hard palate and the upper premolars to provide
anchorage. This design has been associated with anchorage loss by ante-
rior movement of the upper premolars.27,28 To minimize such anchorage
loss, mini-implants, usually placed in the anterior palate, have been
incorporated into the design of maxillary distalization appliances.29
Wilmes and colleagues have introduced a method for distalizing the
molars without adverse effects on the anterior dentition, coupling two
implants in the anterior hard palate with a prefabricated framework that
Fig. 13. 3D printed metal framework on plastic model.TagedEn can be adapted for individual patients.30−32TagedEn
TagedP3D metal printing is used to design and manufacture a distalizer
TagedFiur based on the appliance design of Wilmes and colleagues. The MARPE
TADs are also placed based on CBCT guidance, preferably in the midpa-
late or paramedian areas, based on bicortical engagement for maximum
stability. Similar to the Hyrax, MARPE bands are 0.75mm thick with a
0.05mm cement gap. Bands are fabricated only on the molars to be dis-
talized (Fig. 18). A mini/slimline Hyrax screw is used and placed paral-
lel to the arch form occlusally and parallel to the occlusal plane when
viewed sagittaly (Fig. 19). The orientation of this Hyrax screw can be
altered in the sagittal direction to obtain posterior intrusion or extrusion
as required. The Hyrax screw is laser welded to the 3D metal printed
appliance. Alternatively, a slider assembly like the BeneSlider can also
be printed and an open coil spring with activation locks can be used to
distalize the molars (Fig. 20). Activation of the Hyrax screw is a quar-
ter-turn twice a week, and the open coil spring, if used, can be activated
by 3mm at each visit. Fig. 21 shows an appliance first approach, where
the appliance is digitally designed, and TAD placement was planned
optimally with CBCT and 3D intra-oral scan superimpositions. This
appliance is cemented in place and then TADs are placed through the
Fig. 14. Laser welded Hyrax appliance after printed metal polishing.TagedEn metal collars.TagedEn
TagedFiur

Fig. 15. Bicortical anchorage of miniscrews using CBCT guidance in a. superior, b. lateral and c. posterior views.TagedEn

39

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedFiur
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

Fig. 16. Despite having a broad Hyrax that is away from the base of the palate, the arms of the MARPE still adapt well to the base of the palate.TagedEn

TagedFiur

Fig. 17. Various customised designs of MARPE.TagedEn

TagedPFuture of metal 3D printing in orthodonticsTagedEn
TagedPDMLS 3D printed appliances in orthodontics are mainly made
from CoCr alloy and can also be made from Titanium. However,
both metals are rigid and non-formable/malleable once they are in
final form. This is an advantage for appliances like expanders and
distalizers but limits its usage in appliances for space regainers and
for transpalatal arches used to derotate molars. L. Xue et al.,33 have
studied laser powder bed fusion for defect free NiTi Shape Memory
alloy. Though the system still needs refinements and would take a
bit of time before becoming mainstream, the possibility of its usage
in orthodontics is very promising. A simple band and loop space
maintainer can couple as a space regainer also, a trans-palatal arch
can be used to de-rotate molars. How? Just move the teeth using
software to final position of interest, fabricate the appliance on this
TagedEnPtooth position, manufacture with a NiTi alloy powder bed fusion.
Cementing the appliance will deform the appliances and the shape
memory of NiTi alloy will gradually move the teeth to the planned
position.TagedEn
TagedPGreater integration with Artificial Intelligence (AI) may also play a
role in the future.34,35 AI could be used to automate the design process.
In addition, we could perhaps see a comprehensive 3D printed fixed
appliance which moves teeth according to pre-programmed steps deter-
mined by AI. This could be in the form of 3D printed traditional labial
appliances, or a completely new appliance design altogether.5 Remote
AI monitoring of tooth movement or adverse effects can also be used in
conjunction with 3D printed appliances to increase efficiency.36−38 3D
printed metal appliances show great potential to augment the way
orthodontics is practiced and the road ahead looks promising.TagedEn

40

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedFiur
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

Fig. 18. 3D digital appliance design: a, b: TADs are placed median; c: TADs are placed paramedian.TagedEn

TagedFiur

Fig. 19. Hyrax orientation (a) parallel to arch form (b) parallel to occlusal plane.TagedEn
TagedFiur TagedFiur

Fig. 20. Slider designed for 3D metal printing.TagedEn

TagedH1SummaryTagedEn

TagedPThe rapid and remarkable advances of 3D intraoral scanning and

CAD/CAM technology have allowed for greater incorporation of 3D
printed, customized orthodontic appliances. The additive technology of
3D metal printing has revolutionized the way metal parts are designed
and manufactured, allowing for greater design flexibility, customization
and faster production times. Progressing to 3D printed metal appliances
may allow for greater treatment efficiency due to its greatest advantage
which is customization. Patient comfort during seating of appliances,
reduced orthodontic appointments by eliminating the need for separa-
tors, together with good mechanical and surface properties of these
materials intraorally are added advantages to achieve excellent clinical
success. Moreover, the reduced digital orthodontic workflow steps can
reduce the chances of error and thus results in a more accurate fit and
better standardization. Adjustments can be customized based on each
Fig. 21. Appliance fabricated and cemented in patient’s mouth.TagedEn
TagedEnPpatient’s requirements and the design is not limited to what a technician
can physically manipulate. Clinicians could, in the near future, use this
additive technology to fabricate appliances in-house, bringing financial
and practical advantages. The different digital designs and types of
metallic appliances have been outlined in this article in order to help
clinicians better understand the whole digital workflow and current
trends for 3D printing of these appliances.TagedEn

41

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
TagedEnS. Graf et al. Seminars in Orthodontics 29 (2023) 34−42

TagedH1Patient consentTagedEn TagedP14. Graf S. Clinical guidelines for direct printed metal orthodontic appliances. Semin
Orthod. Elsevier; 2018.TagedEn
TagedP15. Graf S, Tarraf NE. Advantages and disadvantages of the three-dimensional metal
TagedPPatient consent was obtained.TagedEn printed orthodontic appliances. J World Fed Orthod. 2022;11:197–201.TagedEn
TagedP16. Eliades T, Zinelis S. Three-dimensional printing and in-house appliance fabrication:
TagedH1FundingTagedEn between innovation and stepping into the unknown. Am J Orthod Dentofacial Orthop.
2021;159:1–3.TagedEn
TagedP17. Zinelis S, Polychronis G, Papadopoulos F, Kokkinos C, Economou A, Panayi N, et al.
TagedPNo funding or grant support.TagedEn Mechanical and electrochemical characterization of 3D printed orthodontic metallic
appliances after in vivo ageing. Dent Mater. 2022;38:1721–1727.TagedEn
gedP1 Ta 8. Martín-Camean A, Jos A,  Mellado-García P, Iglesias-Linares A, Solano E, Camean AM. In
TagedH1Author contributionsTagedEn
vitro and in vivo evidence of the cytotoxic and genotoxic effects of metal ions released by
orthodontic appliances: a review. Environ Toxicol Pharmacol. 2015;40:86–113.TagedEn
TagedPAll authors attest that they meet the current ICMJE criteria for TagedP19. Wright GZ, Kennedy DB. Space control in the primary and mixed dentitions. Dent Clin
Authorship.TagedEn North Am. 1978;22:579–601.TagedEn
TagedP20. Kirzio urk MS. Success of reinforced fiber material space maintainers. J Dent
glu Z, Ert€
Child (Chic). 2004;71:158–162.TagedEn
TagedH1Declaration of competing interestTagedEn TagedP21. Lagravere MO, Carey J, Heo G, Toogood RW, Major PW. Transverse, vertical, and
anteroposterior changes from bone-anchored maxillary expansion vs traditional rapid
maxillary expansion: a randomized clinical trial. Am J Orthod Dentofacial Orthop.
TagedPThe authors reported no competing financial interests or personal
2010;137:304.. e1-12discussion -5.TagedEn
relationships that could appear to influence the work reported in this TagedP22. MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W. The effects of micro-
paper.TagedEn implant assisted rapid palatal expansion (MARPE) on the nasomaxillary complex−a
finite element method (FEM) analysis. Prog Orthod. 2014;15:52.TagedEn
TagedP23. Li N, Sun W, Li Q, Dong W, Martin D, Guo J. Skeletal effects of monocortical and
TagedH1Editorial policy declarationTagedEn bicortical mini-implant anchorage on maxillary expansion using cone-beam com-
puted tomography in young adults. Am J Orthod Dentofacial Orthop.
TagedPGiven his/her/their role as Editorial Board Members, Ismaeel Hansa 2020;157:651–661.TagedEn
TagedP24. Thakkar D, Ghosh A, Keshwani T. Digital workflow for CBCT-guided customized min-
and Samar M. Adel had no involvement in the peer-review of this article iscrew-assisted rapid palatal expansion (3D digital MARPE): a clinical innovation. J
and had no access to information regarding its peer review or final deci- Indian Orthod Soc. 2020;54:262–266.TagedEn
sion made.TagedEn TagedP25. Graf S, Hansa I. Clinical guidelines to integrate temporary Anchorage devices for bone-
borne orthodontic appliances in the digital workflow. APOS Trends Orthod.
2019;9:182–189.TagedEn
TagedH1ReferencesTagedEn TagedP26. Wilmes B, Nienkemper M, Drescher D. Application and effectiveness of a mini-
implant- and tooth-borne rapid palatal expansion device: the hybrid hyrax. World J
TagedP 1. Vaid NR. Digital technologies in orthodontics−an update. Seminars in Orthodontics. Orthod. 2010;11:323–330.TagedEn
Elsevier; 2018:373–375.TagedEn TagedP27. Bussick TJ, McNamara Jr JA. Dentoalveolar and skeletal changes associated with the
TagedP 2. Mishra S, Chandini K, Sireesha M, Bhavana S, Naffizuddin M. Applications of 3D print- pendulum appliance. Am J Orthod Dentofacial Orthop. 2000;117:333–343.TagedEn
ing in medicine. J Evol Med Dent Sci. 2020:13–24.TagedEn TagedP28. Ghosh J, Nanda RS. Evaluation of an intraoral maxillary molar distalization technique.
TagedP 3. Nancharaiah T. A review paper on metal 3D printing technology. Advances in Materials Am J Orthod Dentofacial Orthop. 1996;110:639–646.TagedEn
Processing and Manufacturing. Singapore: Springer; 2021:251–259.TagedEn TagedP29. Byloff FK, K€archer H, Clar E, Stoff F. An implant to eliminate anchorage loss during
TagedP 4. Graf S, Berger M, Rohr N. Influence of printing procedure and printing axis of dental molar distalization: a case report involving the Graz implant-supported pendulum. Int
alloys on dimensional accuracy, surface roughness, and porosity. APOS Trends Orthod. J Adult Orthodon Orthognath Surg. 2000;15:129–137.TagedEn
2022;12.TagedEn TagedP30. Wilmes B, Drescher D. A miniscrew system with interchangeable abutments. J Clin
TagedP 5. Awad MG, Ellouze S, Ashley S, Vaid N, Makki L, Ferguson DJ. Accuracy of digital pre- Orthod. 2008;42:574–580. quiz 95.TagedEn
dictions with CAD/CAM labial and lingual appliances: a retrospective cohort study. TagedP31. Wilmes B, Drescher D, Nienkemper M. A miniplate system for improved stability of
Seminars in Orthodontics. Elsevier; 2018:393–406.TagedEn skeletal anchorage. J Clin Orthod. 2009;43:494–501.TagedEn
TagedP 6. Vaid N.R., Orthod A.T., Flores-Mir C., Lin J.H., Chang C.H., Eugene R.W., et al. The TagedP32. Wilmes B, Drescher D. Application and effectiveness of the Beneslider: a device to
emperor's new clothes! APOS Trends in Orthodontics 2019. p. 1−3.TagedEn move molars distally. World J Orthod. 2010;11:331–340.TagedEn
TagedP 7. Graf S, Cornelis MA, Hauber Gameiro G, Cattaneo PM. Computer-aided design and TagedP33. Xue L, Atli K, Zhang C, Hite N, Srivastava A, Leff A, et al. Laser powder bed fusion of
manufacture of hyrax devices: can we really go digital? Am J Orthod Dentofacial defect-free NiTi shape memory alloy parts with superior tensile superelasticity. Acta
Orthop. 2017;152:870–874.TagedEn Mater. 2022;229: 117781.TagedEn
TagedP 8. Jackson C.. Accuracy and performance of a novel 3d metal printed orthodontic TagedP34. Bichu YM, Hansa I, Bichu AY, Premjani P, Flores-Mir C, Vaid NR. Applications of artifi-
bracket. Available at: 10.17615/9p7q-ce64. 2017.TagedEn cial intelligence and machine learning in orthodontics: a scoping review. Prog Orthod.
TagedP 9. Graf S. Direct printed metal devices-the next level of computer-aided design and com- 2021;22:18.TagedEn
puter-aided manufacturing applications in the orthodontic care. APOS Trends Orthod. TagedP35. Vaid NR. Artificial Intelligence (AI) driven orthodontic care: A quest toward utopia?
2017;7:253.TagedEn Seminars in Orthodontics. Elsevier; 2021.TagedEn
TagedP10. Shannon T, Groth C. Be your own manufacturer: 3D printing intraoral appliances. TagedP36. Hansa I, Katyal V, Semaan SJ, Coyne R, Vaid NR. Artificial intelligence driven remote
Seminars in Orthodontics. Elsevier; 2021.TagedEn monitoring of orthodontic patients: clinical applicability and rationale. Seminars in
TagedP11. Graf S, Vasudavan S, Wilmes B. CAD-CAM design and 3-dimensional printing of mini- Orthodontics. Elsevier; 2021:138–156.TagedEn
implant retained orthodontic appliances. Am J Orthod Dentofacial Orthop. 2018;154:877– gedP3 Ta 7. Hansa I, Semaan SJ, Vaid NR, Ferguson DJ. Remote monitoring and “Tele-
882.TagedEn orthodontics”: concept, scope and applications. Seminars in Orthodontics. Elsevier;
TagedP12. Graf S, Tarraf NE, Kravitz ND. Three-dimensional metal printed orthodontic labora- 2018.TagedEn
tory appliances. Semin Orthod. Elsevier; 2021.TagedEn TagedP38. Kuriakose P, Greenlee GM, Heaton LJ, Khosravi R, Tressel W, Bollen AM. The assess-
TagedP13. K€ uffer M, Drescher D, Becker K. Application of the digital workflow in orofacial orthopedics ment of rapid palatal expansion using a remote monitoring software. J World Fed
and orthodontics: printed appliances with skeletal anchorage. Appl Sci. 2022;12:3820.TagedEn Orthod. 2019;8:165–170.TagedEn

42

Downloaded for Anonymous User (n/a) at King George's Medical University from ClinicalKey.com by Elsevier on May 29,
2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.