N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me January-February 2021 | No. 1, Vol. 11 In-office aligners: Taking control of orthodontic laboratory expenses By Nathalie Schüller, Dental Tribune International Dentistry has seen its share of chang- es in 2020, and the future will surely bring additional challenges to how we interact with patients. Dentists throughout the world have been tasked with treating their patients under new rules and regulations, and must negotiate these to find a way to meet patients’ expectations regarding the treatment results and the patient experience. One of the fastest evolving areas of dentistry is clear aligner therapy in orthodontics. Clear aligner therapy and remote monitoring have continued to de- velop during these uncertain times. The offices of many clinicians were closed temporarily owing to concerns of exposure to SARS-CoV-2 and associ- ated regulatory challenges. Some still continued to work during these lock- downs by seeking out new avenues of practice, such as taking the entire process of clear aligner production into their own hands and learning aligner design and fabrication. This describes Dr Melissa Shotell, a board- certified orthodontist who practises in a rural community in California in the US and has many patients from outlying areas who travel long dis- tances for treatment. From a desire to surpass their expectations, Dr Shotell implemented a digital workflow for in-office clear aligners, allowing her to provide same-day initial aligners. In this interview with Dental Tribune In- ternational, she provides the answers to the major questions clinicians con- sidering starting with in-office clear aligners may have. What encouraged you to start using in-office clear aligners in your practice? In my practice, I wanted to take control of the entire workflow for clear aligners in order to create pre- dictable outcomes and minimise the number of treatment revisions. When starting a clear aligner case, I was often not satisfied with the set-up I received from many of the major aligner companies; I found that, even with a clearly defined treatment goal and instructions, I was spending hours going back and forth with the technicians to create the treatment set-up. By creating my own treatment set-up, I was able to streamline the process of start- ing my clear aligner cases. With full control of the treatment set-up and sequencing tooth movements to my preferences, I found that cases progressed on schedule and the number of treatment revisions was minimised. Have you found any additional benefits of in-office clear align- er production? Yes, my office is in a very rural area, and it takes extra time for shipping to and from a major laboratory. I have found that by offering in-office clear aligners I am able to start my patients’ cases much more quickly. Some patients come to my office hoping to start aligner treatment the same day, and it is very exciting to such a patient to hear that I can have the first aligner ready on the same day or early the next morn- ing, depending on the appointment time. Owing to the rural environ- Printing features of desktop style 3D printers can allow for large volume aligner model printing. r e r e h c S l e a h c i M © ment, many patients will travel for 1–2 hours to reach my office, so being able to deliver a same-day aligner will exceed my patients’ expecta- tions. What is the single greatest tech- nological advancement that allowed you to begin working with in-office clear aligners? There have been so many techno- logical advancements, including 3D printing, intra-oral optical scanning, and advances in treatment planning software usability, that it is chal- lenging for me to choose only one technology. All of these technologies played a significant role in the devel- opment of in-office clear aligners. If I have to consider a single techno- logical advancement in relation to in-office aligners, I would say the ad- vent of affordable desktop-style 3D printers. Industrial 3D printing has been around for almost 40 years, but was only used by major laboratories and in special industry historically owing to the equipment expense and cost of implementation, com- plexity of systems and printers, and high resin material costs due to mo- nopolisation. The introduction of open-architecture, smaller form fac- tor desktop 3D printers brought an affordable and user-friendly option for 3D-printing models into the den- tal office. As a result, innovation and cost reduction have helped facilitate the advancement of in-office clear aligners. What is the major equipment that an office will need in order to start offering in-office clear aligners? The easiest way to get started with in-office clear aligners is with a digi- tal workflow. Taking the patient’s im- pressions using an intra-oral optical scanner will generate the digital files necessary for creating the patient’s digital set-up. There are two options available for the digital set-up: the dentist can utilise treatment plan- ning software and create his or her own digital design, or he or she can outsource to a laboratory for design service. The office will also need to have a 3D printer for printing aligner models and a vacuum forming unit. One of the major considerations when starting with in-office align- ers is the in-office laboratory space necessary for fabricating in-office aligners. How do you explain in-office clear aligners to patients who come in asking for aligners by brand name? In my office, I focus on the technol- ogy that we have readily available in our office to begin the patient’s clear aligner journey. I let the patient know that I prefer to use custom- made aligners from my in-office laboratory so that I can control all the fine details of design to create a beautiful smile. I find most patients ask for aligners by brand name only because these are the advertise- ments they see on television and online, but when I explain that I have my own clear aligners, they are eager to have custom-made aligners from my office. How have in-office aligners been an advantage for your practice? One of the biggest advantages for my office has been the ability to start cases at the initial appointment. May patients are very excited when they decide to start clear aligner treat- ment and do not want to wait for weeks to receive their aligners. With r e r e h c S l e a h c i M © Software has made it possible for the doctor to create treatment set-ups and stage orthodontic tooth movement. Technology has made same-day aligner treatment a reality. l l e t o h S a s s i l e M © l l e t o h S a s s i l e M © l l e t o h S a s s i l e M © Desktop style 3D printers are used for aligner model printing in-office. Vacuum former for in-office aligner fabrication. ÿPage B2