Design and Print Your Own Customized Orthodontic Brackets!

A customized orthodontic appliance is one that is made specifically for an individual patient to effect a predetermined orthodontic result. Such custom orthodontic appliance systems are based on a “setup” of the dentition, which affords the clinician a direct method of visualizing multiple treatment outcomes, “keeping the end in mind.” The orthodontist can predict the final occlusal result in the setup, which will also serve as the basis for the designing and printing of the conceptualized customized fixed appliances. This digital customization can be applied to even the most basic orthodontic appliance—the bracket itself (Fig 1).

Fig 1 (a) Canine customized bracket. (b) Customized bracket base.

Any customized appliance requires special technologies and materials. In a scenario where an orthodontist would be able to design and manufacture customized orthodontic brackets, the following would be needed:

• Surface scans of the dental arches
• Digital panoramic and cephalometric radiographs or CBCT scans
• Digital photographs
• Orthodontic CAD software in order to perform the digital setup
• Predesigned virtual orthodontic brackets that would be customizable
• Dedicated orthodontic software that would virtually place and adapt customized orthodontic brackets onto the digitized teeth
• Special materials for 3D printing or milling
• 3D printer or milling machine for the manufacture of the customized brackets
• IDB tray for bracket bonding
• Wire-bending robot for the manufacture of wires or a prototype wire exported from the orthodontic CAD software that would be manually copied and used in all treatment stages

This is a long list indeed, and so the question becomes: Why should orthodontists invest in all of this new technology and the learning curve to use it? After all, the usefulness and efficacy of customized fixed orthodontic appliances remain a point of controversy in the orthodontic literature. However, multiple studies have shown that appliance customization enables the orthodontist to deliver optimal, efficient, safe, and reproducible orthodontic treatment, reducing round-tripping tooth movements by reducing bracket repositioning or wire bending. With customization, the value lies in the predictability.

UBrackets software

A dedicated orthodontic CAD software is needed in order to bring the in-house bracket customization concept to reality. This software must be user-friendly and fast and offer automations and tools for performing the needed bracket customization. Orthodontic CAD company Coruo has partnered with Nearchos C. Panayi, author of DIY Orthodontics: Design It Yourself, to create the UBrackets software for in-house customized bracket design. The first stage in bracket customization with UBrackets is to perform a digital setup in the software adhering to the following steps:

1. Maxillary and mandibular dental scan importing
2. Dental model bases design
3. Segmentation
4. Local axes definition
5. Setup procedure

In the next stage, the operator chooses the customization procedure, selecting between the customized bracket bases option and the customized brackets option.

Steps in the customized brackets module

The customized brackets module shares approximately the same interface as the customized bases module. The steps of the module are as follows:

1. The operator chooses the customized brackets option.
2. The orthodontist has to specify which kind of orthodontic treatment will be undertaken—labial or lingual.
3. The bracket brand is selected.
4. The software will automatically align the slots of the brackets in a continuous arch-shaped wire (0.018 × 0.025 inch). The brackets are now at a distance from the teeth, which will be filled by the extrusion of the base to the tooth surface in order to create a customized base. The same archwire will be exported as an STL file and a 1:1 image file. This will be the prototype wire that will be replicated for the rest of the archwires throughout the orthodontic treatment.
5. Manipulation of the whole bracket-archwire complex provides the ability to move them in a vertical direction or in a left and right differential vertical movement (upward movement for the left buccal segment and downward movement for the right segment or opposite). In addition, each bracket can be manipulated mesially or distally, labially or lingually, or horizontally rotated, with the slot kept in the same line while sliding on the wire. The operator can also define the center of rotation of the archwire-bracket complex in such a way that the entire complex can be moved around this center of rotation.
6. A tool exists to show the brackets bonded to the setup or to the initial malocclusion.
7. Design of the IDB tray can be done in one, two, or multiple units.
8. The software is able to calculate the volume of each bracket in mm³.
9. The files that can be exported are:

• The STL files of the brackets
• The archwire in STL and 1:1 image file
• The IDB trays
• The initial and setup model (brackets and dental model)
• The initial and setup model (brackets, dental model, and archwires)

The brackets are then sent/exported for printing or milling to be printed in metal or resin. The initial models, including the brackets, can be printed in order to manually create the IDB tray using transparent silicone impression material.

Labial customized brackets

Just before Dr Panayi’s book went to press, he was able to accomplish something really exciting: He was able to PRINT labial orthodontic brackets designed in the UBrackets software in-office! The author used Formlabs 3B SLA printer using Formlabs’s permanent crown resin in A3 color.

The author designed the fixed orthodontic appliances in the UBrackets software for a healthy 13-year-old boy. UBrackets in its latest version will include a tool to design positioning tooth keys for each bracket to be bonded. In this way, there is no need for IDB tray manufacture. Another option that is included in the UBrackets software is the connecting bar tool. This tool gives the ability to design bars that connect the bracket keys or any other part of the printed brackets. In this way, all the brackets and positioning keys are connected together, forming a “bracket-keys-bar net.” The advantage of this configuration is that the IDB tray is avoided and that less composite is used for bonding, avoiding composite flowing around the bracket (compared to the conventional IDB tray).

The author separated the “net” into three pieces: the four anterior teeth, the right teeth, and the left teeth (canine to molar; Fig 2a). In this way, printing was easier and more accurate. Figure 8-2b presents the maxillary incisors’ IDB net bonded, while Fig 2c shows the brackets without the bar and the keys. The composite used to bond the brackets was Enlight (Ormco). The individual brackets and the bracket-keys-bar net were placed on the Preform software in a specific orientation (Fig 2d), and they were printed using the permanent crown resin by Formlabs.

Figure 2e presents a printed bracket with its supports and base after the postprinting procedure (IPA washing, UV curing, polishing, etc). The mandibular teeth were bonded using the bracket positioning key configuration (Figs 2f and 2g). Continuously, the positioning keys were removed and a 0.012 Ni-Ti wire was inserted (Figs 8-2h and 8-2i).

Fig 2 (a) The IDB net (bracket, positioning key, bar) in three pieces. (b) The IDB net (bracket, positioning key, bar) bonded on the teeth. (c) The positioning keys and the bars are removed. (d) Placement of the virtual brackets on the platform of the Preform software. (e) Close-up photograph of a printed bracket with its supports and base after the postprinting procedure. (f) Frontal view of the brackets and positioning keys bonded on the mandibular teeth. (g) Occlusal view of the brackets and positioning keys. (h) Occlusal view of the brackets after removal of the positioning keys and insertion of the Ni-Ti wire. (i) Left lateral view of the brackets after the removal of the positioning keys and insertion of the Ni-Ti wire.

It is a fact that the permanent crown resin used here is not intended to be used as a material for bracket printing. However, the author’s intention is to present the capabilities of 3D technology in bracket 3D printing, not the problems involved; further studies are currently being carried out in order to be able to have a consistent bracket printing outcome.

Learn what is possible with digital

This article offers just a glimpse into the world of digital design and customization. To learn what is truly possible with digital technology, check out Dr Panayi’s new book, available now. To preview the book, click here.

Nearly any appliance can be customized and printed for the benefit of your patients, and you owe it to them to keep yourself informed and educated on the possibilities in the field. But remember: Digital technology can make a good orthodontist better, but it will not transform a bad orthodontist into a good one. Technology is an aid to better treatment, not a replacement for understanding the basic principles of orthodontic mechanics.

Nearchos C. Panayi, DDS, DOrth, MOrth, is an orthodontist based in Limassol, Cyprus, and is currently a PhD candidate in the Experimental Surgery Department at the National and Kapodistrian University of Athens Medical School (Greece). He studied dentistry at Athens Dental School (1992–1997) and orthodontics at Tel Aviv University (1998–2001) before building his private practice, which has grown into two fully digital orthodontic offices in Limassol and Larnaca, Cyprus. His passion for digital technology encouraged him to use it in orthodontics, and as a huge fan of the in-house 3D designing and printing concept in orthodontics, Dr Panayi has helped develop concepts, ideas, and methods that will transform traditional orthodontics to customized-centered digital orthodontics. He is the inventor of the orthodontic CAD software UBrackets for in-house designing of customized fixed orthodontic appliances, and he introduced the use of general-purpose CAD software in orthodontics for orthodontic appliance design. Dr Panayi is also a researcher for direct aligner printing. He is married and has six children.

DIY Orthodontics: Design It Yourself
Nearchos C. Panayi

Since its recognition as the first specialty of dentistry, the practice of orthodontics has been influenced by the development of new materials, techniques, bracket designs and prescriptions, appliances, and software. However, never before has there been as revolutionary a change as digitization. Digitization and automation are transforming the entire landscape of how orthodontics is practiced, and the consequence is the “do it yourself” concept. With the technology available today with intraoral scanning, CBCT imaging, and CAD software, we can create the virtual patient and manipulate dental models virtually. Not only does this enable better and more precise treatment planning, but it also facilitates better communication with the patient. Perhaps most exciting is that it permits in-house designing and printing of the majority of orthodontic appliances. This book describes the current digital technology that is used in orthodontics, including volume and surface scanning, 3D printing, CAD software, and artificial intelligence, before delving into a “design it yourself” guide presenting the application of this technology in all aspects of orthodontic treatment. It describes all the necessary technologic ingredients to be used in a self-sufficient digital orthodontic clinic, and it focuses on the in-house design and production of tailor-made appliances by digitally diagnosing and evaluating the virtual patient and then creating an individualized treatment plan. Now you can design your own expanders, retainers, clear aligners, brackets, indirect bonding trays, and even wires with a wire-bending robot. It is incredible what technology has to offer; we just have to have the courage to learn and experiment with it. For the benefit of our patients, the challenge is laid.

232 pp; 534 illus; © 2021; ISBN 978-1-64724-051-6 (B0516); US $155