An Historical Overview of

Clear Aligner Therapy The

Evolution of Clear Aligners
September 14, 2020
by Tiantong Lou, DMD, MSc, FRCDC (Ortho); Anthony Mair DDS, MClD

Although the clear aligners may seem like a relatively new modality of treatment
in orthodontics, the initial concept dates as far back as the early 20th century. It
began with the “Flex-O-Tite” appliance by Remensnyder 2, from this, Kesling4 in
1945 created a rubber-based tooth positioner appliance and proposed the
concept of using them in successive series for incremental tooth movements. It
wasn’t until the 1960s that Nahoum3 would introduce the first clear thermoplastic
appliance capable of orthodontic tooth movement. Based on his idea, Ponitz
developed the first “invisible retainer”5 in the 1970s, which was then later
refined by McNamara in the 1980s. A similar appliance known as the Essix
retainer was developed by Sheridan in 1993.6
With the rise of the digital age of the 21st century, we have since been able to
integrate modern technology with the these earlier fundamental principles to
create a variety of contemporary clear aligner systems that allow for a more
comprehensive approach to orthodontic treatment. 7,8

Remensnyder’s Dental Massage Device

In 1925, Orrin Remensnyder developed the dental massage device, with the
intended use of exercising and stimulating the gingiva, such as in treatment of
periodontitis.2 It was a device made out of soft rubber, covering the clinical
crowns, the marginal gingiva and marketed as the “Flex-O-Tite” gum-massaging
appliance. In the subsequent years, he reported observations of minor tooth
movement occurring with the use of this appliance. 9
Kesling’s The Tooth Positioning Appliance
The fundamental concepts of modern clear aligner therapy can be traced back
to Herald Dean Kesling in 1945.4 The desire for this type of treatment was
driven by Kesling’s vision of a simple appliance that would guide the movement
of all teeth into their ideal positions with relation to one another, without the
interferences from any traditional bands or wires. This led to the conception of a
device known as the “Tooth Positioning Appliance”. It is an active orthodontic
appliance used for final artistic positioning of teeth as well as serving as an
effective retainer. As a finishing appliance, the positioner took advantage of the
fact that most teeth are still unstable and mobile from the on-going treatment
and should respond readily to its influence. A modern-day version of the Tooth
Positioner Appliance is still available from TP Orthodontics, Inc., an orthodontic
supply company founded by Kesling.
The positioner appliance is originally fabricated from a one-piece pliable rubber
material from a wax set up for which it can be patterned over. It is designed to
completely fill the freeway space, as well as covering the labial and lingual
surfaces of the maxillary and mandibular dentition. The appliance was intended
for the correction of mild dental discrepancies, such as spacing, residual
overbites, and mesial-distal or buccal-lingual relationships. Although its scope of
possible tooth movements was limited, Kesling made a remark that was far
ahead of his time, in that:

“Major tooth movements could be accomplished with a series of

positioners by changing the teeth on the setup slightly as
treatment progresses. At present this type of treatment does not
seem to be practical. It remains a possibility, however, and the
technique for its practical application might be developed in the
future.”
– H.D. Kesling, 1945
However, as with all new appliances, the tooth positioner also had its share
drawbacks.10 This includes reliance on patient compliance, the foul taste of the
rubber material, deepening of the overbite, lack of proper inter-digitation and
poor settling of the occlusion.11-15
Nahoum’s Dental Contour Appliance
The first documented clear thermoplastic appliance for the use in dentistry was
developed by Henry Isaac Nahoum in 1959,3 fabricated using an industrial-
grade vacuum former.16 It was known as the dental contour appliance as it was
originally designed to maintain or change contours. 17 The process could
accommodate various materials, including acetates, vinyl, styrene,
polyethylene, and butyrate, with translucent, clear or colored sheets. 1 For its
fabrication, an altered cast is formed by using a jeweler’s saw to section the
teeth and baseplate wax is used to hold them in their new position. From here,
the contour appliance is formed over the model. The resiliency of the appliance
material will exert pressure until the teeth have attained their predetermined
positions.
Nahoum postulated that this appliance could be used in orthodontics both as a
retainer and for achieving minor orthodontic tooth movements, such as minor
rotations and space closure. He built on Kesling’s idea of using a series of
appliances in an incremental fashion for progressively achieving a desired tooth
movement. This concept was developed with the realization that some tooth
movements were too great to be corrected in one step. He made progressive
adjustments to the teeth on the altered cast by gradually moving them through
the wax and fabricated a new vacuum-formed retainer for each step. This
method was recommended for usage predominantly in the anterior dentition.
The auxiliary elements used in today’s clear aligner therapy also had origins in
Nahoum’s methodology. For example, when both arches are treated, he
suggested the use of acrylic buttons on the appliance for the attachment of
interarch elastics.
In addition to its function as an orthodontic positioner and retainer, Nahoum also
proposed the use of the contour appliance for various other aspects of
dentistry.18 Such as splints, bite plates, surgical pack holders, medicament
carriers and provisional crowns.19-21
Ponitz’s Invisible Retainers
In 1971, Robert John Ponitz proposed a vacuum-formed clear plastic appliance
that can be used for finishing and retention of orthodontic cases. 5 The material
for these appliances was proposed to be made out of cellulose acetate butyrate,
polyurethane, polyvinylacetate-polyethylene polymer, polycarbonate-cycolac,
and latex. The fabrication procedure involved preheating a clear plastic material
in an oven and using a vacuum unit to form the material to the shape of the
dental arch from a cast.
Ponitz proposed that teeth can be moved and repositioned on the cast using
wax prior to the formation of the retainer, thus allowing for the patient’s teeth to
be moved to new positions by the means of the appliance. Moreover, acrylic
bite planes can be formed over or under the appliance and secured with self-
curing acrylic liquid. In cases involving edentulous regions, denture teeth can
also be attached to the retainer by the same method.
The main advantages of these clear invisible retainers included: ease of
fabrication; speed of insertion; minimal chair side adjustment; as well as
reparability via heat guns. These appliances, at the time, were also used as
holders for periodontal dressing, surgical splints, temporary partial dentures, as
well as splints for occlusal trauma and bruxism. 22,23
McNamara’s Invisible Retainers
Ponitz’s technique for fabricating invisible retainers for retention and final
detailing were later refined by James A. McNamara in 1985. 24 He reported the
fabrication of these appliances using 1 mm thick Biocryl TM polymers with a
Biostar forming machine. Rather than the vacuum pressure technique described
by Ponitz, the Biostar machine used positive air pressure to adapt the
thermoplastic BiocrylTM to the surface of the cast. This appliance was reported to
be used in 80% of his private practice cases. 20 McNamara ultimately concluded
that although clear removable retainers had their advantages, they did not have
the same long-term durability of traditional acrylic or bonded retainers.
Sheridan’s Essix Retainers
In 1993, John J. Sheridan introduced his variation of to the family of
thermoplastic appliances, known as the Essix retainer, designed to function
both as a retainer and positioner.6 It was fabricated using a 0.030” sheet of
thermoplastic copolyester from Raintree Products. He advocated the use of a
positive air pressure method for the thermoforming process, which will reduce
the thickness of the sheet to 0.015” after completion.
In contrast to Nahoum’s idea of using serial appliances for successive
movements, the fundamental principle of the Essix system is based on the use
of a single appliance for in-course adjustments to achieve treatment goals. The
two primary methods of creating tooth movement in the Essix system are via
alterations in the aligner or the tooth surface. The first method involves spot-
thermoforming the aligners via Hilliard thermopliers. The second method, known
as mounding, involves alterations to create projections on the tooth surface,
such that a force will be exerted as the resiliency of the aligner material presses
against it. This is usually achieved by bonding composite materials, in the
shape of a mound.
Contemporary Clear Aligners
Although the concept of using aligners in orthodontics has existed for many
decades, the planning and fabrication processes were done manually, through
tedious and laborious procedures such as sequential wax set-ups. 8 The major
limitation of these manual fabrication processes is at the aligners are limited to
only a small subset, and thus cannot be used for comprehensive orthodontic
treatments. The recent advancements in computer-aided design & computer-
aided manufacturing (CAD/CAM) and rapid prototyping techniques has allowed
for an industrial approach8 to the treatment planning and manufacturing of clear
thermoplastic aligners.25,26
Contemporary aligners of the 21st century combines the principles pioneered by
Remensnyder9, Kesling4, Nahoum3 and others5,6,24 and integrates them with the
modern CAD/CAM technology. Today’s aligners are made using transparent
and thermoplastic polymeric materials, custom fabricated to the patients’
individual dental arches.27 This approach achieve orthodontic tooth movement
through the usage of a plurality of successive aligners, where each aligner
incrementally moves teeth by a predetermined amount. The force system of
aligners is generated when there is a pre-established geometric mismatch
between the shape of the aligner tray and the dental arch. 8 The force system of
aligners can vary by the mechanical properties of the thermoplastic material,
thickness of the aligners, amount of activation as well as the addition of auxiliary
elements.
The CAD-based process involves multiple steps, beginning from the 3-
dimensional reconstruction of the patients’ oral anatomy to the manufacturing of
the aligners. The digital reconstructions are performed through either intra-oral
scanning or digital scanning of a study model.28 The computer algorithm will
then segment the individual clinical crowns from the rest of the digitized 3-
dimensional model. The orthodontic treatment plan is then developed and
partitioned into a sequence of smaller movements by the CAD software. 126 The
manufacturing of the physical molds of the dentition at each stage of treatment
is performed using the rapid prototyping technique. 25,26 The customized aligners
are then produced using a thermoforming process and trimmed to the final
configurations.8
The InvisalignTM System
The idea of introducing a mainstream and contemporary CAD/CAM based clear
aligner system to the mass market was first conceived by Zia Chishti, an MBA
student from Stanford University. After completion of his orthodontic treatment,
he did not consistently wear his clear removable retainer as prescribed by his
orthodontist and not surprisingly, he experienced relapse of crowding of his
lower anterior teeth. Chishti attempted to use his current retainer to realign his
teeth but was frustrated with the progress. This inspired him to develop a
computer-aided system that designed a series of these clear appliances to
incrementally move teeth. From this concept, Chishti and Kelsey Wirth, another
Stanford MBA student, along with two orthodontists founded Align Technology
in 1997 in a garage in Palo Alto. The InvisalignTM system was soon developed
by Align Technology thereafter.31 It first came to the market in 1999 with initial
availability limited to orthodontists but later expanded to general practitioners.31
The Invisalign appliance consists of a series of clear thermoplastic aligners that
are worn for 1-2-weeks each. Each aligner was staged to achieve
approximately 0.25-0.30 mm of orthodontic tooth movement per tray.
The first iteration of Invisalign worked behind a displacement-driven system 34,
where they were solely dependent on its shape to achieve results. 35 No auxiliary
elements were incorporated at that time. Limited research is available on
efficacy of tooth movement by first generation aligners, with the only study done
by Djeu et al. in 2005.36 The second generation of Invisalign began the use of
various auxiliary elements for the purposes of enhancing the efficacy of
orthodontic tooth movement.35 These included the use of attachments,
incorporation of composite buttons and the use of inter-maxillary elastics. The
third generation of Invisalign further enhanced this concept by introducing
optimized attachments that can be placed automatically by manufacturer’s
software.35 They are intended to improve control of tooth movements by
adapting their shape with consideration to the individual tooth morphology. 70
Categories of Contemporary Clear Aligners
There are currently four major categories of clear aligner products, classified
based on their clinical applicability and method of delivery to the patient. These
aligner systems range from those available direct to the consumer to
comprehensive systems designed to treat more complex malocclusions.
Direct-to-Consumer Aligner Systems
Direct-to-consumer aligner systems are marketed directly to patients, designed
for patients to treat themselves “at home”. These systems require the patient to
take photographic records and make their own impressions of their dental
arches. The resulting aligners are subsequently fabricated and delivered to the
patient, without the direct supervision of a dental professional. As more of these
“do-it-yourself” or over-the-counter aligner products arise, some researchers
have expressed concern over the patients’ safety without a health care provider
supervising their treatment.30 According to a recent consumer alert by AAO,
patients may be subjecting themselves to increased risk of damage to their
teeth, periodontium, and even adverse events, such as allergenic reactions,
some of which could be life-threatening.
Minor Tooth Movement (MTM) Aligner Systems
MTM aligners are designed to provide limited clinical treatment, such as single
arch or anterior alignment only. These systems have been marketed as a less
expensive and faster alternative to comprehensive clear aligner therapy.
In-House Fabricated Aligner Systems
In-house fabricated aligners are created by companies that provide the 3D
treatment planning software to the orthodontist’s office. This software can be
integrated with 3D scanners and printers to allow the orthodontist to fabricate
their own aligners directly.
Comprehensive Aligner Systems
Comprehensive aligner systems allow for 3D interactive treatment planning via
incorporation of 3D CAD CAM tooth movements. They include usage of various
auxiliary elements, such as bonded resin attachments, and slits for elastics.
These systems provide various additional features that allow for more complex
tooth movements in all planes of space and more comprehensive treatment
than the previous options.
Conclusion
Clear aligner therapy has evolved immensely since its initial conception in the in
the early 1900s. Many of its fundamental concepts, such as attachments,
auxiliaries and the progressive use of aligners were derived from the ideas of
Kesling, Nahoum, Sheridan and others. The arrival of the digital age has
facilitated mass production of aligners and improved its availability to the
general public. Its rapid rise in popularity among prospective new patients has
made clear aligners a mainstay in contemporary orthodontics.
Oral Health welcomes this original article.
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