©2023 JCO, Inc. May not be distributed without permission. www.jco-online.
com
Direct Printing of Clear Aligners
KI BEOM KIM, DDS, MSD, PhD
SIMON GRAF, MDent
D
irect three-dimensional print-
ing of clear aligners has be-
come possible thanks to the
introduction of new photocurable
clear resins—including Tera Harz
TC-85,* the first 3D-printable resin
designed specifically for aligners
(Fig. 1).
Direct-printed aligners have several potential
advantages over conventional thermoformed align-
ers. First, the use of 3D-printing technology allows
customization of material thicknesses, surface
patterns, and shapes to enable more control over
tooth movements. For instance, the aligner thick-
ness can be increased in a specific region to facil-
itate an intended movement while unwanted tooth
movements are minimized in other regions. Sec-
ond, by eliminating the intermediate steps of print-
ed models and subsequent thermoforming, the
clinician can avoid cumulative errors. Third,
direct-­printed aligners can be more environmen-
tally sustainable, as compared to the waste gener-
ated from printing resin models and thermoform-
ing clear plastic sheets.1
*Graphy, Inc., Seoul, South Korea; www.itgraphy.com.
450
Physical Properties
Thermoplastic shape-memory polymers
have great potential for orthodontic applications.2,3
TC-85 becomes flexible and then returns to its
original shape in warm temperatures; as the tem-
perature increases, the material will return to its
shape more quickly. In a study by Lee and col-
leagues, the Tg (glass transition temperature) of
TC-85 was 69.45°C.4 At body temperature, about
50% of the deformation was recovered within the
first minute, and 90% of the deformation within
10 minutes. Thus, the material has the advantage
of reversing any aligner deformation that occurs
during insertion and removal or from the forces
of mastication.
KRAVITZ KEYS
³³Tera Harz TC-85 is a thermoplastic shape-­memory
polymer used for direct printing of aligners.
³³Because of its flexibility, this polymer can apply
a lighter force as compared with thermoformed
plastics.
³³In warm temperatures, 90% of Tera Harz TC-85
deformation will recover in less than 10 minutes.
³³Direct-printed aligners can be printed with more
thickness in certain regions to help control tooth
movements.
© 2023 JCO, Inc. JCO/august 2023
Dr. Kim is a Professor, a Program Director, and the Dr. Lysle Johnston Endowed Chair in
Orthodontics, Department of Orthodontics, Center for Advanced Dental Education, St. Louis
University, 3320 Rutger St., St. Louis, MO 63104; e-mail: kkim8@slu.edu. Dr. Graf is in the
private practice of orthodontics at Smile AG, Belp, Switzerland.
Dr. Kim Dr. Graf

Fig. 2 Increasing aligner thickness near long axes of

lower incisors can facilitate intrusion.

flexibility and viscoelastic properties.4 Therefore,

each set of TC-85 clear aligners can produce great-
Fig. 1 Direct-printed aligners fabricated from Tera er tooth movements without permanent deforma-
Harz TC-85* resin. tion, and the required total number of aligners is
significantly reduced.

Hertan compared the vertical forces deliv-

ered by direct-printed aligners to those of thermo-
formed aligners under controlled temperatures
simulating the oral environment.5 A .2mm activa-
tion of a thermoformed aligner created a much
greater force than the same activation of a direct-­
printed aligner (9.77N vs. 1.18N). Direct-­printed
aligners displayed a more consistent force profile,
which would be considered more bio­compatible
with orthodontic tooth movement.5 Lee and col-
leagues showed that TC-85 also applies a lighter
force than thermoformed material, thanks to its
Vertical Movements
The use of clear aligners to achieve vertical
movements—particularly intrusion—is known to
be difficult and unpredictable.6-9 Deep-bite correc-
tion with aligners has traditionally relied on a com-
bination of lower-incisor proclination, upper-­
incisor intrusion, and lower-molar extrusion.7
Direct-printed aligners can now be customized to
increase the aligner thickness near the long axes
of the lower incisors, promoting intrusion of these
teeth (Fig. 2).

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DIRECT PRINTING OF CLEAR ALIGNERS

Another strategy for deep-bite correction is
to incorporate bite stops in the upper aligners (Fig.
3). These will add intrusive force to the lower in-
cisors and allow the premolars and molars to ex-
trude, thereby correcting the deep bite. With
direct-­printed aligners, the bite stops can be ex-
tended to the size of an anterior bite plane, as
found in removable appliances. To keep the thick-
ness of this bite ramp from affecting individual
tooth movements, it can be attached to the upper

c
Fig. 3 A. Bite stops on upper aligners add intrusive force to lower incisors, allowing premolars and molars to extrude
for correction of deep bite. B. 18-year-old deep-bite patient before treatment. C. Bite stops on lingual side of
upper central incisors and increased aligner thickness on lower incisors promote intrusion of lower incisors.

Fig. 4 A. Anterior bite stops in close

contact with upper aligner. B. Ante-
rior bite stops with spot connections
to upper aligner.

a b

452 JCO/august 2023

 KIM, GRAF

aligner with only a few spot connections (Fig. 4).
Anterior extrusion is one mechanism used to
close open bites with clear aligner therapy,7 but is
difficult to achieve with aligners.10,11 A common
strategy to facilitate anterior extrusion is to apply
intrusive force to the posterior teeth. This can be
achieved with direct-printed aligners by increasing
the aligner thickness on the posterior occlusal sur-
faces (Fig. 5).
Sagittal Movements
Clinicians have attempted to incorporate
anterior bite repositioning from functional appli-
ances into clear aligner therapy, but have had
limited success because of the poor fit of the
vacuformed sheets to the short crowns of the de­
cid­u­ous teeth. Direct-printed aligners allow a
Twin Block** design to be added to the posterior
occlusal surfaces (Fig. 6), or solid bite wings to
be attached to the buccal sides of the aligners
(Fig. 7). Unlike the classic functional appliance,
which allows only a single activation, the bite-
wing aligner enables the sagittal movement to be
increased with each tray.12
If this approach is used in a growing patient,
a freer elongation and eruption of the molars can
be accommodated by designing the aligners with
empty spaces on the occlusal side of the molars.13
Transverse Movements
Clear aligners have been used to resolve non-
functional crossbites without sutural opening. Even
though direct-printed aligners are not attached to
**Trademark of Protec Dental Laboratories Ltd., Vancouver, BC;
www.protecdental.com.

Fig. 5 A. Aligner thickness increased

on occlusal surfaces of posterior
teeth to produce posterior intrusion
and thus facilitate anterior extrusion
for open-bite correction. B. 16-year-
old male open-bite patient before
treatment. C. Patient after 36 weeks
of wearing aligners with increased
posterior thickness.
a

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DIRECT PRINTING OF CLEAR ALIGNERS

b
Fig. 6 A. 9-year-old female Class II patient before treatment. B. Twin Block**-type aligners in place.

b
Fig. 7 A. 9-year-old female Class II patient before treatment. B. Bite-wing aligners in place.

the dental arch, their shape-memory effect can be
employed to achieve active dental expansion (Fig.
8). Straight transverse bars are added across the
palate to push the teeth buccally as the shape mem-
ory is expressed. Torque should be increased on the
buccal side to prevent undesirable buccal tipping.
A similar design can be used in the lower arch, but
the transverse bar must follow the lower anterior
contour to avoid interference with the tongue.
This design can also be used for torquing
movements. For example, in a case requiring buc-
cal crown torque of the incisors, the aligner can
be reinforced with elastic-like structures in the
incisal labial area, and expansion can be added in
the gingival area.
Attachments
Although most patients prefer not to have at-
**Trademark of Protec Dental Laboratories Ltd., Vancouver, BC;
www.protecdental.com.

454 JCO/august 2023

 KIM, GRAF

a b

Fig. 8 A. Direct-printed aligner with overcorrection for active expansion.

B. After active expansion. C. Expansion aligner with transverse bars added
for buccal pushing effect.

Fig. 9 Divot placed inside direct-­

printed aligner for rotation control.

tachments with their clear aligners,14 it is difficult Fit

to produce certain orthodontic tooth movements
without attachments.15-18 Rotation of rounded teeth
is among the least predictable movements to achieve
with traditional clear aligners.10,19 Direct-­printed
aligners allow rotation to be controlled by placing
divots inside the trays (Fig. 9). In the absence of
attachments for retention, a tight fit can still be en-
sured by carefully designing the undercuts.
The accuracy of orthodontic tooth move-
ment with clear aligners depends on intimate con-
tact between the aligners and the teeth. While
.25mm of tooth movement per aligner is com-
monly prescribed, 20 the prescribed movements
will be inaccurate if there is a discrepancy in fit
between the pretreatment models and the aligners.

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DIRECT PRINTING OF CLEAR ALIGNERS
Several studies have shown significant discrep-
ancies between models and the corresponding
devices fabricated from commonly used thermo-
plastic materials.21-23 For example, Johal and col-
leagues, comparing the fit of four types of thermo­
formed maxillary retainers, found mean in­-
accuracies ranging from .014mm to .557mm. 21
Lombardo and colleagues measured the fit of six
different aligner systems and also noted signifi-
cant discrepancies, ranging from .047mm to
.625mm. 23 Inaccuracies of as much as 56% in
planned orthodontic movements could be attribut-
ed to this lack of fit.6,11
Jindal and colleagues showed that 3D-­printed
retainers are geometrically more accurate than
thermoformed retainers.24 Koenig and colleagues
demonstrated a greater accuracy of fit with
3D-printed aligners than with traditional thermo-
formed aligners.25 Therefore, it can be assumed
that 3D-printed aligners will produce more accu-
rate orthodontic tooth movements.
Case Report
A 14-year-old male who had previously
under­gone orthodontic treatment presented with
the chief complaint of rotational relapse of the
Fig. 10 14-year-old male patient with
rotational relapse of mandibular left
first premolar, Class II subdivision left
canine relationship, and lower midline
shifted 2mm to left before treatment.
456
mandibular left first premolar (Fig. 10). The patient
had a Class II subdivision left canine relationship,
with the lower midline shifted 2mm to the left and
a slight curve of Spee. Because he was satisfied
with his maxillary dentition and wanted only to
correct the rotation of the premolar, no antero­
posterior correction or leveling of the curve of
Spee was planned.
The goals of the digital setup were to correct
the rotation of the mandibular left first premolar
and align the dental midlines. Fourteen direct-­
printed aligners were designed to produce 32.6° of
mesial-in rotation of the mandibular left first pre-
molar. Mesial and distal movements of the anteri-
or teeth, along with selective interproximal reduc-
tion, were planned to correct the midline. A
horizontal attachment was bonded to the mandib-
ular left canine for retention, and an angled attach-
ment was added at the mandibular left first pre­
molar for rotation and tipping. Each aligner was
worn for one week.
After 14 weeks, two additional overcorrec-
tion aligners were prescribed, to be worn for one
week each. A lower 4-4 retainer wire was then
bonded, and an overlay vacuformed retainer was
delivered (Fig. 11).
JCO/august 2023

a b
b
Fig. 11 A. Patient after 16 weeks of treatment with direct-printed aligners. B. Comparison of pretreatment (tan)
and post-treatment (green) intraoral scans.
Conclusion
Direct printing offers many new possibilities
to improve the efficiency and efficacy of clear
aligner therapy. Further studies on the mechanical
and physical properties of photocurable materials
should be undertaken, along with clinical trials and
case studies.
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