DIGITAL ORTHODONTICS

Three-dimensional assessment of virtual

bracket removal for orthodontic
retainers: A prospective clinical study
Kaitlin Marsh,a Andre Weissheimer,a Kaifeng Yin,b Alexandra Chamberlain-Umanoff,c Hongsheng Tong,a
and Glenn T. Sameshimaa
Los Angeles and Redlands, Calif, and Houston, Tex

Introduction: Computer-aided design and manufacturing of orthodontic retainers from digitally debonded
models can be used to facilitate same-day delivery. The purpose of this prospective clinical study was to
validate a novel technique for virtual bracket removal (VBR) in-office, comparing the accuracy with 2
orthodontic laboratories that use VBR for retainer fabrication in the digital workflow. Methods: The sample con-
sisted of 40 intraoral scans of 20 patients. Four groups were compared. The scans without brackets were used
as a control group. VBR was performed by 3 groups: In-office VBR (Software Meshmixer, version 3.5.474;
Autodesk, San Rafael, Calif), Orthodent Laboratory (ODL; Buffalo, NY), and New England Orthodontic
Laboratory (NEOLab; Andover, Mass). The virtually debonded models were superimposed onto the control
models using surface-based registration. Regional 3-dimensional Euclidean distances between surface
points of superimposed models were calculated for comparative analysis of surface changes after VBR using
Vector Analysis Module (Canfield Scientific, Fairfield, NJ) software. Results: The accuracy of VBR using the
Meshmixer did not differ significantly from the VBR protocols used by the 2 laboratories. However, there was
a statistically significant difference between the 2 laboratories, with ODL showing lower accuracy than NEOLab.
Although some differences were statistically significant, they were very small and not considered clinically rele-
vant. There was also a statistically significant difference between the 3 tooth segments (incisors, canines/pre-
molars, and first molars), with VBR of the first molars and second premolars showing the least accuracy.
Conclusions: The VBR techniques using the in-office Meshmixer, ODL, and NEOLab were considered
accurate enough for the clinical use of orthodontic retainers fabricated from printed models. (Am J Orthod
Dentofacial Orthop 2021;160:302-11)

O
ne of the greatest orthodontic challenges is
maintaining tooth position after debonding,
and thus, ensuring timely manufacturing of re-
tainers is key to the success and longevity of orthodontic
treatment.1 Orthodontic retainers should be placed
immediately after the removal of the appliances because
some relapse may occur in a few hours.2,3 Traditionally,
retainer fabrication workflow has involved taking an
alginate impression before bracket removal or after
a
Advanced Orthodontic Program, Herman Ostrow School of Dentistry, University
of Southern California, Los Angeles, Calif.
b
c
Private practice, Houston, Tex.
Private practice, Redlands, Calif.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Andre Weissheimer, Department of Orthodontics,
Herman Ostrow School of Dentistry, University of Southern California, 925 W
34th St, Los Angeles, CA 90089; e-mail, weisshei@usc.edu.
Submitted, May 2020; revised, August 2020; accepted, September 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.09.027
bracket removal, pouring the impression up in stone,
physically carving the brackets off if the impression was
taken before bracket removal, and fabricating the
retainer on the stone model. Problems during the stone
model fabrication may occur, requiring the patient to
come back to the office for a new impression. With the
introduction of intraoral scanners and software for
computer-aided design (CAD) and computer-aided
manufacturing, orthodontic appliance fabrication tech-
niques have evolved and have become digital.4,5 Advan-
tages of 3-dimensional (3D) digital scanning include
simplicity, accuracy, longevity,6 reduced patient discom-
fort, elimination of impression material in inventory,
reduced storage issues, and minimization of cross-
contamination.7 Moreover, the intraoral scan can be 3D
printed in resin and used for appliance fabrication.
With 3D printing gaining traction in the orthodontic
community, many private practices have been investing
in in-office digital laboratories for 3D-printing models
and fabrication of appliances to increase efficiency and

302
Marsh et al
reduce the number of appointments for patients.7-10
Using the digital workflow, high-quality retainers can
be fabricated from 3D printed models.7-11
In the digital workflow, the retainer fabrication involves
the acquisition of the patient’s intraoral scan, postprocess-
ing of the digital models in stereolithography (STL) file
format, virtual bracket removal (VBR) procedure in CAD
software, model 3D-printing, and fabrication of the
retainer before the debonding appointment. The first
step in this workflow is to acquire an accurate intraoral
scan, which is critical. There are many intraoral scanners
in the market that possess trueness and precision sufficient
for orthodontic applications.12 Among them, TRIOS 3
(3Shape, Copenhagen, Denmark) is a popular intraoral
scanner that has shown good trueness and precision even
when scanning arches with bonded buccal brackets.11
Studies have shown that digital impressions and models
accomplish equal or higher precision than some conven-
tional impression materials and stone models.14-17 After
the acquisition of the intraoral scan, digital model
postprocessing is necessary to remove artifacts such as
noise, outliers, holes, or ghost geometry,18,19 preparing
the models for the next step: VBR, which is a new procedure
in orthodontics in which the brackets are digitally selected
and removed from the tooth surface to produce a digital
model without brackets. VBR can be performed using
many different CAD software programs, such as Meshmixer
(Autodesk, San Rafael, Calif) and OrthoAnalyzer (3Shape).
VBR may take 4-5 minutes per arch, depending on the soft-
ware used and the operator’s skill. Once VBR is performed,
the digital model can be 3D printed to serve as a physical
model for retainer fabrication.8 VBR before the debonding
appointment has the important advantage of same-day
delivery of a well-fitting fixed or removable retainer, with
the added advantage of eliminating an office visit.
VBR can be performed either in-office or by an ortho-
dontic laboratory that provides this new digital service in
lieu of physical carving of brackets from traditional plas-
ter models. Because VBR is a novel technique, there are
no studies that have tested this procedure to produce ac-
curate 3D-printed models for retainer fabrication. Thus,
this prospective clinical study aimed to validate a novel
technique for VBR in-office, comparing the accuracy
with 2 orthodontic laboratories that use VBR for re-
tainers fabrication in the digital workflow.
The hypothesis is VBR can be performed accurately
enough to be used for orthodontic retainers, indepen-
dently of the software program or laboratory.
MATERIAL AND METHODS
The University Park Institutional Review Board of the
University of Southern California (USC) approved this
American Journal of Orthodontics and Dentofacial Orthopedics
303
study. Informed consent and assent were obtained
from the legal guardians and patients, respectively.
The inclusion criteria for this prospective clinical study
were as follows: (1) patients starting or finishing ortho-
dontic treatment, allowing for intraoral scans done on
the same day as bonding or debonding, (2) full fixed
labial appliances bonded at least from maxillary left first
molar to maxillary right first molar, and (3) at least one
tooth per segment (incisors, canine/premolars, and first
molar). In this study, 2 patients were excluded because
of poor scan quality and the presence of a band on a first
molar. The sample consisted of 40 maxillary dentition
intraoral scans of 20 patients of the USC Advanced Or-
thodontic Clinic. Two maxillary intraoral scans of each
patient, one with brackets and one without brackets,
were acquired at the same appointment during either
the beginning (before and after bonding, 2 of 20 pa-
tients) or at the completion of orthodontic treatment
(before and after debonding, 18 of 20 patients) using
the TRIOS 3 intraoral scanner. The scanner’s software
postprocessed the intraoral scans, exporting them as
digital models in the STL format. Four groups were
compared (all subject participants were included in
each group). Group 1 was the control group that
consisted of intraoral digital models without brackets
(postdebonding scans/prebonding scans). Group 2 was
post-VBR digital models from the in-office Meshmixer
VBR protocol. Group 3 was post-VBR digital models
from Orthodent Laboratory (ODL; Buffalo, NY), and
group 4 was post-VBR digital models from New England
Orthodontic Laboratory (NEOLab; Andover, Mass)
(Fig 1).
The Meshmixer VBR protocol used in this study was
developed and validated in vitro in a previous prelimi-
nary typodont study.20 Meshmixer is freeware software
that can be downloaded at www.meshmixer.com. After
importing the STL files into the Meshmixer software,
the first step was the model preparation, which includes
digitally removing scan artifacts connected to brackets
before VBR. Per the VBR protocol, surface lasso selection
mode allows surface faces to be selected without “paint-
ing.”21 These selection boundaries can be refined using
the smooth boundary tool. Once the boundary around
the bracket is smoothed, the erase and fill tool is selected
to virtually erase the bracket. Figure 2 details the proto-
col for VBR using Meshmixer, which was performed from
maxillary right first molar to maxillary left first molar.
There are a few outside orthodontic laboratories that
offer digital bracket removal. Two of these laboratories
were selected on the basis of their advertised capability
to digitally remove brackets: ODL and NEOLab. Each sub-
ject participant’s digital model was coded with a number
as not to reveal the subject’s name (eg, VBR #2). All
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Fig 1. Workflow for VBR clinical study.

Fig 2. VBR with Meshmixer: A, intraoral scan with brackets; B, bracket selection using surface lasso
tool; C, smooth boundary tool (hotkey B) was applied; D, The irregular selection boundary around the
bracket was refined; E, virtual removal of the bracket using the erase and fill operation (hotkey F) set to
property panel defaults; F, visualization of a tooth after VBR.

digital models of the bracketed maxillary arch for each
subject participant were sent to both laboratories. These
laboratories performed digital bracket removal using Or-
thoAnalyzer software with their own VBR protocols and
attached a digital model in STL format for each patient
after bracket removal. To avoid the risk of bias, neither
laboratory was aware of the study.
For 3D evaluation of VBR accuracy, the digital
models of all groups were imported into the 3-matic
3D modeling software (Materialise, Leuven, Belgium)
for 3D superimposition. Although STL models do not
contain any volumetric data, their triangulated surface
data can be used for the superimposition of 3D surface
data of digital models.22-25 The scans of groups 2-4
were superimposed onto the group 1 control models
using the surface-based registration technique, which
provides the best fit between the models (Fig 3). The su-
perimposition accuracy on the areas not affected by the
VBR was evaluated by the iterative closest point algo-
rithm and color-coded maps (6 300 mm visualization
range). To complement the visual inspection, the mea-
sure analysis locally tool was used to quantify the super-
imposition error in the stable areas (green color) where
surface changes were not expected (Fig 3, D). If the

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Marsh et al 305

Fig 3. Superimposition onto control: A, all digital models registration using surface superimposition; B,
digital models of group 3 (pink) and control group 1 (purple) before superimposition; C, after superim-
position; D, superimposition accuracy confirmation using color-coded maps (green hues indicates no
surface changes; blue or red indicates surface changes $ 0.3 mm in different directions).

registration error ranged from 0 to 0.05 mm, the model’s
superimposition accuracy was confirmed. Then, the dig-
ital models were exported as STL files and transferred to
the Vector Analysis Module (VAM; Canfield Scientific,
Fairfield, NJ) for 3D assessment of the VBR accuracy.
The entire VBR procedure was performed once by
each group. All the measurements for VBR accuracy
assessment (40 maxillary intraoral scans) were per-
formed by 2 separate investigators using VAM to ensure
interexaminer reliability. The investigators were third-
year orthodontic residents previously trained by 1 expe-
rienced orthodontist (AW) on how to use the software for
VBR evaluation. Each investigator repeated all of the
measurements twice (40 maxillary intraoral scans) after
a 2-week interval to ensure intraexaminer reliability.
Four groups of maxillary arch digital models were thus
identified for the measurements: (1) a control group of
clinically debonded or prebonding, (2) VBR performed
in-office by Meshmixer protocol, (3) VBR performed by
ODL, and (4) VBR performed by NEOLab. Regional 3D
Euclidean distances between surface points of the super-
imposed control and debonded models were measured
using VAM software. The superimposed control and
virtually debonded models were measured on the labial
surface using an iterative closest point algorithm for
comparative analysis of surface changes after VBR. The
color surface by distance tool (6 300 mm visualization
range) was used to display and to indicate the areas
with surface changes to be included in the measurement.
For each tooth, the paint area selection tool was used to
select the area where the bracket was virtually removed,
previously indicated by the color maps (Fig 4). A regional
color-coded map (6 300 mm visualization range) of the
selected area illustrated the linear surface changes after
VBR. VAM automatically calculated the minimum,
maximum, root mean square (RMS), and mean values
with a standard deviation for each selected area. Com-
parisons were made between the 3 VBR techniques
(Meshmixer, ODL, and NEOLab), the tooth segments,
and individual teeth. An overview of the whole workflow
for the VBR process and 3D evaluation is shown in
Figure 5.
The 3 models that underwent VBR in each sample
were randomized and coded by 1 of the authors to
ensure blinding of the examiners performing the mea-
surements. The 3 VBR models in each sample were given
the codes U, X, or Y, each corresponding to a specific lab-
oratory that was unknown by the examiner performing
the measurements. The coding system was revealed
only after the statistical analysis was complete.
Statistical analysis
The RMS values, which best represented the overall
magnitudes of surface change irrespective of the direc-
tion of change of the 3 techniques, were compared.
Descriptive statistical analysis was performed with
SPSS (version 20.0; IBM, Armonk, NY) for linear surface
changes because of VBR. Interexaminer (Cronbach
alpha) and intraexaminer (Cronbach alpha) reliability
were determined. The Shapiro-Wilk test was used to
evaluate the normality of the data. Multiple linear
regression analysis with tooth/segment and laboratory

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306 Marsh et al

Fig 4. Regional evaluation of VBR using VAM software: A, semitransparent original model showing the
brackets position in relation to the VBR displayed by the color maps; B, same color maps showing the
superimposed control and post-VBR scan to indicate the area to be measured; C, paint area tool over
the greatest surface changes indicated by the color maps; D, regional color maps of the painted area
and the linear surface changes measurements of the VBR. Color map (6 300 mm): Red hues indicate a
negative value where unintentional tooth surface removal occurred. Blue hues indicate positive values
where insufficient bracket removal occurred.

as independent variables was first attempted. Because

the laboratory was identified to contribute insignifi-
cantly to the total variance, 3 separate 1-way analysis
of variance (ANOVA) tests26 were used to detect the po-
tential differences between 3 VBR protocols/labora-
tories, separate teeth, and tooth segments (incisors,
canines/premolars, and first molars). Statistical differ-
ences between the test groups were further analyzed
with Scheff
e post-hoc test (⍺ 5 0.05).27

Fig 5. Overview of the VBR measurement workflow: A,
digital model of the control group; B, digital model with
brackets before VBR; C, digital model after VBR; D,
VBR model and its corresponding control model superim-
posed; E, models superimposition confirmation; F, selec-
tion of area for the VBR; G, regional color map of linear
surface changes after VBR. Color map (6 300 mm):
Red hues indicate a negative value where unintentional
tooth surface removal occurred; blue hues indicate posi-
tive values where insufficient bracket removal occurred.
RESULTS
Interexaminer and intraexaminer reliability were
determined to be high (.0.9). Because there were no
significant interexaminer and intraexaminer differences
in the VBR measurement reliability, the RMS values
from both operators and measurement trials were aver-
aged by tooth for each VBR group. One-way ANOVA
used averaged RMS surface changes by tooth, from cen-
tral incisor to first molar (1-6), and significance was
determined at P \0.05. RMS surface changes ranged
from 0.10 mm to 0.30 mm, with first molars exhibiting
the greatest amount of surface change and central inci-
sors exhibiting the least amount of surface change re-
sulting from VBR (Fig 6). The first molars and the
second premolar showed the greatest distribution of sur-
face change, indicating the largest error in VBR. Post-
hoc analysis with Scheff
e test (Table I) showed a pairwise

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Marsh et al 307

Fig 6. Boxplot illustrating RMS surface changes distribu-
tions by tooth: (1) central incisor, (2) lateral incisor, (3)
canine, (4) first premolar, (5) second premolar, and (6)
first molar. The distribution of RMS surface change
values was greatest for tooth 5 and 6, with tooth 6
showing the greatest distribution and highest median.
o
an outlier; *an extreme outlier.
Fig 7. Boxplot illustrating RMS surface change values
distribution by tooth segment: (0) incisors segment; (1)
canine/premolars segment; (2) first molars. First molars
displayed the greatest distribution of RMS values for sur-
face changes and the greatest median value or greatest
error. oan outlier; *an extreme outlier.

and first molars) is illustrated in Figure 7. The first molar

statistically significant difference (P \0.05) in averaged segment showed the greatest distribution of surface
RMS values between the second premolar and all other change, indicating the largest error in VBR. Post-hoc
teeth in the arch as well as the first molar and all other analysis with Scheff
e test (Table II) showed a pairwise
teeth in the arch. statistically significant difference (P \0.05) in averaged
The 1-way ANOVA of the tooth segments (incisors, RMS values between the first molar segment and the in-
canine/premolars, and first molar) using averaged RMS cisors as well as the first molar segment and the canine/
surface changes and a significance determined at premolar segment.
P \0.05 showed RMS surface changes ranging from In evaluating the differences between the in-office
0.12 mm to 0.33 mm, with the first molars exhibiting Meshmixer method and 2 laboratories, a 1-way ANOVA
the greatest amount of surface change and the incisors was performed using averaged RMS surface changes by
exhibiting the least amount of surface change resulting laboratory (Meshmixer, ODL, and NEOLab). Significance
from VBR. The pattern of distribution of the surface was determined at P \0.05. VBR produced surface
changes for each segment (incisors, canine/premolars, changes that ranged from 0.15 mm to 0.19 mm, with
NEOLab exhibiting the least amount of surface changes
and ODL exhibiting the greatest amount of surface
Table I. Scheff

e post-hoc analysis of RMS by tooth change (RMS). The pattern of distribution of the surface
Pair Mean difference Standard error P value change is illustrated by a boxplot in Figure 8. The in-
1 vs 2 0.03 0.01 0.405 office method and the 2 laboratories showed a similar
1 vs 3 0.01 0.01 0.930 distribution of surface change which indicates a similar
1 vs 4 0.01 0.01 0.984
1 vs 5 0.09 0.01 \0.001*
1 vs 6 0.23 0.01 \0.001*
2 vs 3 0.01 0.01 0.944 Table II. Scheff

e post-hoc analysis of RMS by tooth
2 vs 4 0.02 0.01 0.897 segment
2 vs 5 0.06 0.01 0.001*
2 vs 6 0.20 0.01 \0.001* Mean Standard
3 vs 4 0.00 0.01 1.000 Pair difference error P value
3 vs 5 0.08 0.01 \0.001 Incisors vs canine/ 0.03 0.01 0.013*
3 vs 6 0.21 0.01 \0.001* premolar
4 vs 5 0.08 0.01 \0.001* Incisor vs first molar 0.21 0.01 \0.001***
4 vs 6 0.22 0.01 \0.001* Canine/premolar vs first 0.19 0.01 \0.001***
5 vs 6 0.14 0.01 \0.001* molar

Note. Values in millimeters. The mean difference is significant at the Note. Values in millimeters. The mean difference is significant at the
0.05 level. Tooth 1-6: central incisor to first molar. 0.05 level.
*P #0.001. *P #0.05; ***P #0.001.

American Journal of Orthodontics and Dentofacial Orthopedics August 2021  Vol 160  Issue 2
308
Fig 8. Boxplot illustrating RMS values distribution by lab-
oratory: (0) Meshmixer VBR; (1) ODL VBR; (2) NEOLab
VBR. oan outlier; *an extreme outlier.
error in VBR. Post-hoc analysis with the Scheff
e test
showed a pairwise statistically significant difference
(P \0.05) in averaged RMS values between ODL and
NEOLab (Table III). No statistically significant difference
was found between the Meshmixer and ODL as well as
Meshmixer and NEOLab.
The net negative and positive values from the raw
data measurements were added up, and the percentage
of negative and positive surface changes was calculated
for each laboratory (Table IV). Of the total sample of 223
teeth, NEOLab exhibited the greatest percentage of un-
intentional tooth surface removal (29.7%), followed by
ODL (13.7%) and Meshmixer (8.9%). Meshmixer showed
the greatest percentage of insufficient bracket removal
(91.1%), followed by ODL (86.3%) and NEOLab (70.3%).
DISCUSSION
As orthodontics moves from analog to digital, some
orthodontic laboratories have started offering VBR as a
digital service. However, there is no scientific evidence
regarding the accuracy of VBR, which has been recently
introduced and used for 3D printed models for same-day
retainer delivery. In our previous preliminary study on ty-
podonts, VBR was shown to be accurate and reproduc-
ible with in-office protocols established using either
Table III. Scheff

e post-hoc analysis of RMS by
laboratory
Pair Mean difference Standard error
Meshmixer vs ODL 0.02 0.01
Meshmixer vs NEOLab 0.02 0.01
ODL vs NEOLab 0.03 0.01
Note. Values in millimeters. The mean difference is significant at the
0.05 level.
*P #0.05.
August 2021  Vol 160  Issue 2
Marsh et al
Table IV. Percentage negative and positive tooth sur-
face change after VBR per laboratory
Tooth surface change Meshmixer ODL NEOLab
Negative surface change (% of 223) 8.9 13.7 29.7
Positive surface change (% of 223) 91.1 86.3 70.3
Note. Values are %. Negative surface changes mean unintentional
tooth surface removal. Positive surface changes mean insufficient
bracket removal.
Meshmixer or OrthoAnalyzer software.20 In this clinical
study, the in-office VBR with Meshmixer was compared
with 2 orthodontic laboratories that used OrthoAnalyzer.
Meshmixer was chosen because it is a widely-used soft-
ware, user-friendly, and free-to-download, whereas
OrthoAnalyzer is available at a high cost to be used for
in-office VBR for retainer fabrication.
VBR is performed on digital models obtained by any
intraoral scanner. Although several commercially avail-
able intraoral scanners generate reliable digital
models,16,17,28-31 TRIOS 3 was used in this clinical
study because it was the intraoral scanner available at
the USC orthodontic clinic. Some studies evaluated the
influence of scanning technique.28,32,33 TRIOS 3 is less
likely to be influenced by scanning technique.28,33
Moreover, it has also demonstrated reliable scanning ac-
curacy of dentitions with fixed labial appliances,12,13,34
which was critical for this study.
The accuracy of VBR processes is evaluated best by
superimposing the digital models using surface-based
registration and calculating the distances between sur-
face points, further illustrated by color map-
ping.14,22-25,35,36 The ability to make meaningful
conclusions about the error due to VBR relied on the
3D superimposition accuracy. Therefore, 3D surface-
based superimposition of the control and virtually
bonded models was performed using 3-magic software,
and the superimposition accuracy verified using color-
coded maps, ensuring any change on the labial surface
of the teeth would be the result of VBR and not because
of superimposition errors between the digital models. If
the registration error was greater than 0.05 mm, quanti-
fied by the measure analysis locally tool, the model’s su-
perimposition was repeated. When the registration
accuracy was confirmed (error ranging from 0 mm to
0.05 mm), the digital models were exported as STL files
P value and transferred to VAM software. The accuracy of VBR
0.341 was assessed 3-dimensionally using VAM’s color surface
0.356 by distance tool (6 300 mm visualization range) to
0.015* display and measure linear surface changes between
the superimposed digital models. The paint area selec-
tion tool, which is designed for identifying regions of
dimensional differences,37 was used to generate regional
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Marsh et al
color-coded maps on the labial surfaces where the
brackets were virtually removed for quantitative analysis
of the minimum values, maximum values, RMS values,
and standard deviations. To ensure reproducibility, the
paint area selection tool remained the same shape and
size for each bracket area selection. This procedure was
supported by the results, which showed a high degree
of intraexaminer and interexaminer reliability. The red
hues in the VAM software indicated negative values,
which represented zones of unintentional tooth surface
removal, and blue hues indicated positive values, which
represented zones of insufficient bracket removal. Aver-
aged RMS values, and not the average of mean values,
were used because RMS represents the overall magni-
tude of surface changes, regardless of the direction of
change. Conversely, the greatest value of minimum or
maximum for each tooth detailed the net direction of
change. RMS was used in accordance with a previous
study that measured surface changes between superim-
posed condyles using VAM software.37
The results of this study show that the accuracy of VBR
decreases from the anterior teeth to the posterior teeth. All
3 segments of teeth showed a statistically significant dif-
ference when compared with each other. The first molar
segment displayed the highest RMS value of 0.33 mm,
whereas the incisors showed the smallest RMS value of
0.12 mm, demonstrating that VBR is the least accurate
in the posterior segment. Furthermore, color mapping
showed a higher prevalence of blue hues in the posterior
segments, implying that there is a tendency to have insuf-
ficient bracket removal in the posterior teeth when
compared with the anterior teeth. The proximity between
the posterior brackets and the gingival margins may have
interfered with the algorithm used by the software when
computing the selected area and removing the bracket.
Canines and incisors have brackets positioned in the mid-
dle of the crown and away from the gingival margins,
which may explain the better results for VBR accuracy.
In addition, the greatest error in the first molar region
could also be explained by the presence of the buccal
groove and the inability of the virtual removal software
to navigate big changes in surface curvature and remove
adhesive inside the groove.20,36 Studies have shown that
intraoral scanning with TRIOS 3 is least accurate in the
molar region14,28,29,38; however, the scanning error is
less than 0.10 mm at the distal tooth, which is not signif-
icant.15 Because scanning accuracy was verified to be
within 0.10 mm, surface changes seen at all 3 segments
were likely because of VBR error and not because of scan-
ning inaccuracy. Although the VBR surface changes (RMS
values) for all 3 tooth segments were greater than 0.1 mm,
they were all within the reported accuracy for orthodontic
casts, which is 0.3-0.5 mm.39
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309
The comparison of the in-office Meshmixer with the
2 laboratories showed that ODL had the highest RMS
value of surface change (0.19 mm), followed by Mesh-
mixer (0.17 mm) and NEOLab (0.15 mm). Despite the
statistically significant difference between ODL and
NEOLab, the surface changes due to VBR are small and
may not be clinically significant (Table III). Regarding
the direction of surface changes after VBR, whether un-
intentional tooth surface removal or insufficient bracket
removal, all 3 VBR techniques showed a higher percent-
age of insufficient bracket removal, being 91.1% for
Meshmixer, 86.3% for ODL, and 70.3% for NEOLab
(Table IV). Minor insufficient bracket removal ranging
from 0.1 mm to 0.3 mm can be more favorable from a
clinical and from a retainer manufacturing standpoint
than unintentional tooth surface removal, which can
make the retainer insertion difficult. NEOLab displayed
the highest percentage of unintentional tooth surface
removal with 29.7%, followed by ODL with 13.7% and
the in-office Meshmixer with 8.9%. Although uninten-
tional tooth surface removal may be unfavorable
because vacuum-formed thermoplastic retainers may
not adapt well, these retainers have a certain elasticity,
and this may not be an issue. In the current study, the
ODL laboratory provided a thermoform retainer with
each VBR model delivered to patients. The clinical
assessment, although subjective, showed a proper fit of
the retainer on the maxillary dentition. However, future
studies should evaluate and measure the fit of the re-
tainers fabricated from VBR models, using methods of
fit evaluation outlined by previous studies.39 One limita-
tion of this clinical study was the possible variations that
may have occurred during the debonding procedure,
such as unintentional removal of tooth structure or the
presence of some residual adhesive. Using only prebond-
ing digital models as control would have the advantage
of no residual adhesive. However, using postbonding
digital models allowed for clinical assessment of the
retainer fit in the patient’s maxillary arch. Because of
the novelty of this research, there is a lack of published
articles to compare and discuss the results. The only
available data for comparison was our preliminary
in vitro typodont study in 3D printed models.20 In the
current clinical study, the VBR was less accurate in the
posterior segment with a tendency toward average pos-
itive change, which indicates insufficient bracket
removal across all groups. Conversely, the in vitro typo-
dont study found a negative change in the first molars
and incisors, indicating unintentional bracket removal
but positive changes for the premolars and canines.20
The difference between the in vitro and the clinical
studies may be attributed to the sample evaluated. The
former used 3D printed models in gray resin, whereas
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Table V. Multifactorial comparison between Meshmixer, ODL, and NEOLab
Factor Meshmixer
VBR software used Meshmixer
Cost Free software 1 3D-printed model
$2, retainer clear material
$2 1 labor work 1 other
variables. Estimation: $10-15
Turnaround time ~ 10 min for VBR 1 time to send
out to print or perform in-office
Practical application VBR only 1 print in-office for
retainer or send out to print
the latter used real tooth surfaces where the enamel was
the surface evaluated.
Regarding the accuracy of VBR techniques using in-
office Meshmixer, ODL, or NEOLab, although some dif-
ferences were statistically significant, they were very
small and not considered clinically relevant. Despite
the similar accuracy of the 3 techniques for VBR, other
attributes may also be important for the decision-
making regarding the technique of choice. Table V
outlines some features of the in-office VBR and the 2
laboratories, including the cost analysis. In-office VBR
using Meshmixer has the advantage of being free soft-
ware, and it has quicker turnaround time if the 3D-print
models and retainers are fabricated in-office as well.
ODL has a faster turnaround time than NEOLab and is
comparable in price. Both ODL and NEOLab use Ortho
Analyzer to perform VBR.
Future studies could focus on VBR of other bracket
materials not evaluated in this study, such as clear
ceramic brackets, lingual brackets,40 and aligner attach-
ments. Moreover, orthodontic bands with tubes were not
utilized in this study.
CONCLUSIONS
In this prospective clinical study, the hypothesis that
VBR is accurate to be used for orthodontic retainers,
independently of the software or laboratory, was
confirmed. The VBR techniques using the in-office
Meshmixer VBR protocol or by the orthodontic labora-
tories, ODL and NEOLab, were considered accurate
enough for the clinical use of orthodontic retainers
fabricated from 3D-printed models.
AUTHOR CREDIT STATEMENT
Kaitlin Marsh: investigation and writing original
draft; Andre Weissheimer: conceptualization, methodol-
ogy, investigation, writing, reviewing, editing, and visu-
alization; Kaifeng Yin: formal analysis; Alexandra
Chamberlain-Umanoff: preliminary typodont study;
August 2021  Vol 160  Issue 2
Marsh et al
ODL NEOLab
OrthoAnalyzer OrthoAnalyzer
$48.50 (1 arch VBR 1 printed $45 single arch package or $90
model 1 Essix) full arch package (includes VBR,
3D models, and Essix retainer)
~ 7-10 d ~ 14 d
Offers VBR 1 3D-printed Offers VBR only or VBR 1 3D-
model 1 Essix retainer as a printed model 1 Essix retainer
package
Hongsheng Tong: reviewing and editing; and Glenn T.
Sameshima: supervision, reviewing, and editing.
ACKNOWLEDGMENTS
This study was approved by the University of South-
ern California Institutional Review Board (no. HS-19-
00590). This study did not receive any specific grant
from funding agencies in the public, commercial, or
not-for-profit sectors.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2020.09.027.
REFERENCES
1. Kravitz ND, Groth C, Jones PE, Graham JW, Redmond WR. Intrao-
ral digital scanners. J Clin Orthod 2014;48:337-47.
2. Reitan K. Principles of retention and avoidance of posttreatment
relapse. Am J Orthod 1969;55:776-90.
3. Brain WE. The effect of surgical transsection of free gingival fibers
on the regression of orthodontically rotated teeth in the dog. Am J
Orthod 1969;55:50-70.
4. Jheon AH, Oberoi S, Solem RC, Kapila S. Moving towards precision
orthodontics: an evolving paradigm shift in the planning and de-
livery of customized orthodontic therapy. Orthod Craniofac Res
2017;20(Suppl 1):106-13.
5. Vaid NR. Digital technologies in orthodontics–an update. Semin
Orthod 2018;24:373-5.
6. Hazeveld A, Huddleston Slater JJR, Ren Y. Accuracy and reproduc-
ibility of dental replica models reconstructed by different rapid
prototyping techniques. Am J Orthod Dentofacial Orthop 2014;
145:108-15.
7. Vasudavan S, Sullivan SR, Sonis AL. Comparison of intraoral 3D
scanning and conventional impressions for fabrication of ortho-
dontic retainers. J Clin Orthod 2010;44:495-7.
8. Groth C, Kravitz ND, Shirck JM. Incorporating three-dimensional
printing in orthodontics. J Clin Orthod 2018;52:28-33.
9. Tarraf NE, Ali DM. Present and the future of digital orthodontics✰.
Semin Orthod 2018;24:376-85.
10. Nakano H, Kato R, Kakami C, Okamoto H, Mamada K, Maki K.
Development of biocompatible resins for 3D printing of direct
aligners. J Photopol Sci Technol 2019;32:209-16.
American Journal of Orthodontics and Dentofacial Orthopedics
Marsh et al
11. Tahir NM, Wan Hassan WN, Saub R. Comparing retainers con-
structed on conventional stone models and on 3D printed models:
a randomization crossover clinical study. Eur J Orthod 2018;2019:
370-80.
12. Claus D, Radeke J, Zint M, Vogel AB, Satravaha Y, Kilic F, et al.
Generation of 3D digital models of the dental arches using optical
scanning techniques. Semin Orthod 2018;24:416-29.
13. Park JM, Choi SA, Myung JY, Chun YS, Kim M. Impact of ortho-
dontic brackets on the intraoral scan data accuracy. BioMed Res
Int 2016;2016:5075182.
14. Ender A, Attin T, Mehl A. In vivo precision of conventional and dig-
ital methods of obtaining complete-arch dental impressions. J
Prosthet Dent 2016;115:313-20.
15. Burzynski JA, Firestone AR, Beck FM, Fields HW Jr, Deguchi T.
Comparison of digital intraoral scanners and alginate impressions:
time and patient satisfaction. Am J Orthod Dentofacial Orthop
2018;153:534-41.
16. Sousa MVS, Vasconcelos EC, Janson G, Garib D, Pinzan A. Accu-
racy and reproducibility of 3-dimensional digital model measure-
ments. Am J Orthod Dentofacial Orthop 2012;142:269-73.
17. Wiranto MG, Engelbrecht WP, Tutein Nolthenius HE, van der
Meer WJ, Ren Y. Validity, reliability, and reproducibility of linear
measurements on digital models obtained from intraoral and
cone-beam computed tomography scans of alginate impressions.
Am J Orthod Dentofacial Orthop 2013;143:140-7.
18. Weyrich T, Pauly M, Keiser R, Heinzle S, Scandella S, Gross M. Post-
processing of scanned 3D surface data. In: Alexa M, Gross M,
Pfister H, Rusinkiewicz S, editors. Eurographics Symposium on
Point-Based Graphics. Aire-la-Ville, Switzerland: The Euro-
graphics Association; 2004. p. 83-94.
19. 3Shape. Ortho System 2020.1. Orthodontic Solution. Technical
Documentation. 3Shape A/S.. OS-85.0-B-EN. 3Shape; 2020.
Available at: www.3shape.com. Accessed June 2 2021.
20. Chamberlain-Umanoff A. Assessment of 3D surface changes
following virtual bracket removal [thesis]. Los Angeles: University
of Southern California; 2019.
21. Available at: http://help.autodesk.com/view/MSHMXR/2019/
ENU/?guid5GUID-6EE3D65F-F5E2-4097-87A5-3BA0750AFE
C5. Accessed June 2 2021.
22. Gkantidis N, Schauseil M, Pazera P, Zorkun B, Katsaros C,
Ludwig B. Evaluation of 3-dimensional superimposition tech-
niques on various skeletal structures of the head using surface
models. PLoS One 2015;10:e0118810.
23. Brown LG. A survey of image registration techniques. ACM Com-
put Surv 1992;24:325-76.
24. Ghoneima A, Cho H, Farouk K, Kula K. Accuracy and reliability of
landmark-based, surface-based and voxel-based 3D cone-beam
computed tomography superimposition methods. Orthod Cranio-
fac Res 2017;20:227-36.
American Journal of Orthodontics and Dentofacial Orthopedics
311
25. Lin HH, Chiang WC, Lo LJ, Wang CH. A new method for the inte-
gration of digital dental models and cone-beam computed tomog-
raphy images. Annu Int Conf IEEE Eng Med Biol Soc 2013;2013:
2328-31.
26. Kao LS, Green CE. Analysis of variance: is there a difference in
means and what does it mean? J Surg Res 2008;144:158-70.
27. Scheff
e H. The Analysis of Variance. New York: Wiley; 1959.
28. Anh JW, Park JM, Chun YS, Kim M, Kim M. A comparison of the
precision of three-dimensional images acquired by 2 digital intrao-
ral scanners: effects of tooth irregularity and scanning direction.
Korean J Orthod 2016;46:3-12.
29. Fl€
ugge TV, Schlager S, Nelson K, Nahles S, Metzger MC. Precision
of intraoral digital dental impressions with iTero and extraoral
digitization with the iTero and a model scanner. Am J Orthod Den-
tofacial Orthop 2013;144:471-8.
30. Gan N, Xiong Y, Jiao T. Accuracy of intraoral digital impressions for
whole upper jaws, including full dentitions and palatal soft tissues.
PLoS One 2016;11:e0158800.
31. Lim JH, Park JM, Kim M, Heo SJ, Myung JY. Comparison of
digital intraoral scanner reproducibility and image trueness
considering repetitive experience. J Prosthet Dent 2018;119:
225-32.
32. Ender A, Mehl A. Influence of scanning strategies on the accuracy
of digital intraoral scanning systems. Int J Comput Dent 2013;16:
11-21.
33. Michelinakis G, Apostolakis D, Tsagarakis A, Kourakis G,
Pavlakis E. A comparison of accuracy of 3 intraoral scanners: a
single-blinded in vitro study. J Prosthet Dent 2020;124:581-8.
34. Jung YR, Park JM, Chun YS, Lee KN, Kim M. Accuracy of four
different digital intraoral scanners: effects of the presence of or-
thodontic brackets and wire. Int J Comput Dent 2016;19:203-15.
35. Besl PJ, McKay ND. A method for registration of 3-D shapes. IEEE
Trans Pattern Anal Mach Intell 1992;14:239-56.
36. Zitov
a B, Flusser J. Image registration methods: a survey. Image
Vis Comput 2003;21:977-1000.
37. Claus JDP, Koerich L, Weissheimer A, Almeida MS, Belle de
Oliveira R. Assessment of condylar changes after orthognathic sur-
gery using computed tomography regional superimposition. Int J
Oral Maxillofac Surg 2019;48:1201-8.
38. Rudolph H, Luthardt RG, Walter MH. Computer-aided analysis
of the influence of digitizing and surfacing on the accuracy
in dental CAD/CAM technology. Comput Biol Med 2007;37:
579-87.
ufekçi E. Evaluation of fit
39. Cole D, Bencharit S, Carrico CK, Arias A, T€
for 3D-printed retainers compared with thermoform retainers. Am
J Orthod Dentofacial Orthop 2019;155:592-9.
40. Tong H, Weissheimer A, Pham J, Lee R, Redmond WR. Lingual or-
thodontics redefined with automation and friction-free me-
chanics. J Clin Orthod 2019;53:214-24.
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