TagedEnSeminars in Orthodontics 29 (2023) 60−67

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TagedFiur TagedEn Seminars in Orthodontics TagedFiur TagedEn

journal homepage: www.elsevier.com/locate/sodo

TagedH1Evaluating the Accuracy of Automated Orthodontic Digital Setup ModelsTagedEn

TagedPHyein Woo a, Nayansi Jha a,b, Yoon-Ji Kim a,b,*, Sang-Jin Sung a,bTagedEn
TagedPa Department of Orthodontics, Asan Medical Center, Seoul, Korea
b
University of Ulsan College of Medicine, Seoul, Korea
TagedEn
TAGEDPN A B S T R A C T

Orthodontic tooth setup provides the orthodontist an insight into the possibilities and limitations of treatment and
enables visualization of the final goal of treatment. Lately, artificial intelligence techniques have been applied to
the digital setup software to automate the process of tooth segmentation and alignment. The purpose of this study
was to evaluate the accuracy and efficiency of automated digital setup software. The diagnostic digital impression
data of 30 patients (mean age, 29.8 ± 14.4 y) who underwent non-extraction orthodontic treatment from 2020 to
2022 were collected. Three automated digital setup software programs, Autolign (Diorco, Yongin, Korea), Out-
come Simulator Pro (Align Technology, Inc., Arizona, USA), and Ortho Simulation (Medit, Seoul Korea) were
tested and compared to the manual setup model using the Maestro 3D Dental Studio software (AGE Solutions S.r.
l., Pontedera, Italy). The linear and angular transposition with respect to six dimensions of tooth movements,
including occlusal-gingival, facial-lingual, and mesial-distal bodily movement, as well as crown rotation, mesial-
distal crown tip, and facial-lingual crown torque, were calculated. The mean error for linear and angular move-
ment ranged 0.39 − 1.40 mm and 3.25 − 7.80 °, respectively. The effectiveness of automated digital setup sys-
tems varies among software, tooth type, and the dimension of movement. Although the setup results have shown
improvement in the occlusion indices, further manual adjustments may be needed for clinical use, such as indirect
bonding and clear aligner therapy.

TagedH1IntroductionTagedEn TagedEnPextraction or non-extraction treatment. Orthodontic tooth setup mod-

TagedPAn orthodontic diagnosis is a crucial step, wherein the patient is
examined using different modalities, such as radiographs, computed
tomography, photos, and dental impressions.1 In addition to the image
data, patients’ health records and questionnaires regarding orofacial
functions are collected to classify the type of malocclusion and plan for
treatment. Tooth impressions provide clinicians with detailed informa-
tion on the dental arches, such as molar relationships, overjet and
overbite, tooth angulation and inclination, and arch asymmetries,
which are considered in treatment planning. Also, dental models may
be used to simulate the orthodontic treatment by separating individ-
ual teeth from the dental casts and aligning them in the desired posi-
tion. This procedure, known as the “orthodontic tooth setup,” which
was originated by Kesling2 provides the orthodontist an insight into
the possibilities and limitations of treatment and enables visualiza-
tion of the final goal of treatment. The orthodontic tooth setup may
be helpful, especially in cases that require critical decision-making,
such as patients with a congenitally missing tooth, complex malocclu-
sions with severe skeletal discrepancies, and borderline cases for
els can also be used to fabricate orthodontic appliances such as indi-
rect bonding systems and clear aligners.TagedEn
TagedH2Digital setupTagedEn
TagedPA digital setup technique using digital impression data is replacing
the conventional method using plaster casts. Digital setup eliminates the
process of working with the plaster models, which is time-consuming
and labor-intensive. Additionally, the digital setup provides accurate
information on the changes in tooth position and arch forms, allows 3D
superimposition to visualize the treatment changes, and enables precise
assessment of the intra-arch and inter-arch relationships.3. Also, differ-
ent versions of the setups can be made and compared to help determine
the final treatment plan.TagedEn
TagedPDigital models can be manipulated to obtain a digital tooth setup
model by segmenting and repositioning the teeth in the desired position,
which is similar to the conventional setup models but only in the virtual
space. There are numerous software available for analyzing the digital
impression data and constructing a setup model. The reliability of digital

TagedEn * Corresponding author at: Department of Orthodontics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul
05505, Korea.
E-mail address: yn0331@gmail.com (Y.-J. Kim).

https://doi.org/10.1053/j.sodo.2022.12.010

1073-8746/© 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/)
TagedEnH. Woo et al. TagedFiur Seminars in Orthodontics 29 (2023) 60−67

TagedEnPmodels has been proven to be as effective and accurate as conventional

models.3−5TagedEn

TagedH2Manual vs. automated digital setupTagedEn

TagedPAlthough intraoral scanners can capture the tooth anatomy with

greater accuracy than conventional alginate impressions, the interproxi-
mal area is not captured because of the stereo-vision system of the scan-
ner head.6. As a result, the teeth are connected as one body, like the
plaster model. Therefore, each tooth has to be separated by a software.
After setting the occlusal plane, the individual tooth is aligned by trans-
lating and rotating the tooth (Fig. 1).TagedEn
TagedPLately, artificial intelligence techniques have been applied to the dig- Fig. 3. Outcome Simulator Pro software (Align Technology, Inc., Arizona, USA)
ital setup software to automate the process of tooth segmentation and is a fully automated setup software, which is embedded in the iTero scanner.
From the intraoral scan data, after checking facial axes of the clinical crown, it
alignment.7. Autolign software (Diorco.Co., Yongin, South Korea), auto-
creates setup results in an end-to-end manner.TagedEn
matically segments the teeth and detects the facial axes of the clinical TagedFiur
crown (FACC), the most prominent portion of the central lobe on the
facial surface for the incisors and premolars, and buccal groove for
molars.8 After adjusting the FACC of each tooth and setting the occlusal
plane and desired arch form (Fig. 2), tooth alignment is done automati-
cally by the software. This type of software, which requires the user to
review the reference axes of each tooth, set the occlusal plane, and deter-
mine the arch form before alignment, may be considered semi-auto-
mated setup software.TagedEn
TagedPA fully automated setup software automatically segments and aligns
the teeth from the intraoral scan data in an end-to-end manner. Outcome
Simulator Pro software (Align Technology, Inc., Arizona, USA), an exam-
ple of a fully automated setup software, is embedded in the iTero
TagedFiur
Fig. 4. Ortho Simulation (Medit, Seoul, South Korea) is another example of
fully automated setup software, which is embedded in i500. After importing the
intraoral scanning data, the clinician has to adjust the upper and lower dental
midlines. Then, the software segments and aligns teeth.TagedEn

TagedEnPScanner and provides an automated tooth setup in several minutes fol-

Fig. 1. The digital setup consists of tooth segmentation, orientation of occlusal
plane, and tooth alignment by translation and rotation. Maestro 3D Dental Stu-
dio (v3, AGE Solutions S.r.l., Pontedera, Italy) requires segmentation of teeth,
defining the occlusal plane, and aligning individual teeth manually.TagedEn
TagedFiur
lowing the intraoral scan without having the clinician define the FACC,
occlusal plane, and the arch form (Fig. 3).TagedEn
TagedPOrtho Simulation (Medit, Seoul, South Korea) is another example of
fully automated setup software. Similar to the Outcome Simulator Pro,
Ortho Simulation is embedded in Medit’s intraoral scanner software and
only accepts scans acquired by Medit’s intraoral scanners, the i500 and
i700. After importing the scan data, the clinician has to define the upper
and lower dental midlines. Then, the software recognizes tooth numbers
and performs the setup (Fig. 4).TagedEn
TagedPWith the advancement of artificial intelligence technologies, digital
setup software is rapidly evolving to automate previously manual tasks
such as tooth segmentation and alignment. Previous research found that
digital setup models manually completed by clinicians had a high level
of reliability.9,10. To our knowledge, however, no study has assessed the
performance of the automated setup softwares. Therefore, this study
aimed to evaluate the quality of the setup model by using a fully auto-
mated setup model to ascertain the possibility of applying the setup
results to clinical practice. The purpose of this study was to evaluate the
accuracy and efficiency of automated digital setup softwares and com-
pare it with the manual digital setup models performed by a clinician.TagedEn

TagedH1Materials and methodsTagedEn

TagedPThis study was approved by the institutional review board of Asan

Fig. 2. Autolign (Diorco.Co., Yongin, South Korea), an example of semi-auto-
mated setup software, automatically segments the teeth and detects the facial
axes of the clinical crown (FACC). After adjusting the FACC of each tooth and
setting the occlusal plane and desired arch form, the alignment is done automati-
cally by the software.TagedEn
Medical Center (2022-1051). Due to the retrospective nature of the
study, informed consent from the patients was waived.TagedEn
TagedPThe diagnostic digital impression data of 30 patients (mean age, 29.8
± 14.4 y) who underwent non-extraction orthodontic treatment from
2020 to 2022 were collected. The intraoral scan data were obtained
either by using the Trios 3 Pod (3Shape, Copenhagen, Denmark) or the
iTero Element 5D (Align Technology, Inc., Arizona, USA). The inclusion

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TagedEnPcriteria were: i) permanent dentition; ii) treated by non-extraction; iii)
skeletal Class I (ANB 0 to 4); iv) mild to moderate crowding (arch length
discrepancies of 2−5 mm); and v) less than 3 missing teeth. Exclusion
criteria were: i) craniofacial anomalies and ii) presence of prostheses.TagedEn
TagedH2Digital setup softwareTagedEn
TagedPWe performed a manual digital setup (MS) using Maestro 3D Dental
Studio (v3, AGE Solutions S.r.l., Pontedera, Italy), which is considered
the gold standard. The patient’s initial digital impression data was
imported. The occlusal plane was adjusted, and the teeth were seg-
mented by identifying the mesiodistal proximal contact points. The teeth
were leveled and aligned by molar distalization, arch expansion, and
incisor proclination as needed considering the molar and canine rela-
tionship and the incisor inclination.TagedEn
TagedPTo assess the performance of the automated digital setup models,
three commercial software programs, Autolign (semi-automated setup,
SS), Outcome Simulator Pro (fully automated setup 1, FS1), and Ortho
Simulation (fully automated setup 2, FS2), were used.TagedEn
TagedPFor Autolign, initial intraoral scan data was imported first. The soft-
ware automatically segmented teeth and detected the FACC and mesiodis-
tal axis, then the investigator (HW) reviewed and adjusted the reference
lines as needed. Using the ideal arch template, the arch width and form
were selected considering the patient’s initial arch form. The “Auto Align”
function aligned the teeth along the pre-determined arch form. After the
automated alignment, no manual adjustments were made.TagedEn
TagedPFor Outcome Simulator Pro, the teeth must be scanned with the iTero
intraoral scanner. For the patients whose diagnostic intraoral scan was
done with the Trios 3, the scan data was 3D printed by using an FDM
printer, the Cubicreator 4 (Cubicon, Sungnam, South Korea). Then the
3D-printed models were scanned using an iTero scanner. After importing
the scan, the software automatically segmented the teeth, detected the
FACCs, and aligned the teeth. After the initial automated setup, no man-
ual adjustments were made.TagedEn
TagedPThe Ortho Simulation software also required the scanning of the teeth
using the Medit’s intraoral scanner. Therefore, the 3D-printed models
were scanned using the i500 (Medit, Seoul, South Korea) scanner. After
importing the scan data into the software, the upper and lower dental
midlines were identified by the user. Then the software automatically
detected and segmented the teeth, but some adjustments for the segmen-
tation were needed. After segmentation, automated alignment was done.
After the initial automated alignment, no manual adjustments were made.TagedEn
TagedH2Accuracy and efficiency analysisTagedEn
TagedPThe linear and angular transposition with respect to six dimensions
of tooth movement, including occlusal-gingival, facial-lingual, and
mesial-distal bodily movement, as well as crown rotation, mesial-distal
crown tip, and facial-lingual crown torque, were calculated. The linear
translation movement was calculated in reference to the center of the
clinical crown. The angular changes were analyzed using the long axis
of the tooth that passes through the center of the crown parallel to the
FACC. Positive values indicate occlusal, facial, and mesial for linear
movement and mesial-out rotation, mesial angulation, and facial inclina-
tion for angular movement. To estimate the error of the automated setup
model, the difference in the values of linear and angular tooth move-
ment in the MS and the three automated setup software (SS, FS1, and
FS2) was calculated. Because there were positive and negative values for
each dimension of movement, the mean error was calculated using the
absolute values to prevent underestimating the error.TagedEn
TagedH2Quality of the setupTagedEn
TagedPTo evaluate alignment quality, the setup models were assessed using
the Peer Assessment Rating (PAR) index, which quantifies objectively
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Seminars in Orthodontics 29 (2023) 60−67
TagedEnPthe malocclusion using five categories: Displacement, Buccal occlusion,
Overjet, Overbite, and Centerline.11,12.TagedEn
TagedH2Statistical analysisTagedEn
TagedPDescriptive statistics were used to describe baseline demographic
and clinical characteristics. The differences in tooth positions between
SS and MS, FS1 and MS, and FS2 and MS were tested using the paired t-
test. The Bonferroni correction was applied to multiple comparisons. A
p-value of <0.05 was considered to indicate significance. The statistical
analysis was performed using the Statistical Package for the Social Scien-
ces software (version 22.0, IBM, Armonk, NY).TagedEn
TagedH1ResultsTagedEn
TagedPMean errors of linear and angular tooth movement as a result of auto-
mated setup are shown in Fig. 5.TagedEn
TagedPCompared to the MS models, the setup models from SS showed intru-
sion of the maxillary premolars and molars and extrusion of the mandib-
ular premolars and molars. Incisors and molars were positioned
lingually, and premolars were positioned more buccally than in the MS
models. All teeth were located distally. For angular movements, mandib-
ular incisors and premolars were angulated mesially more than the MS.
Maxillary molars were angulated mesially, and mandibular molars were
angulated distally. All teeth were inclined lingually.TagedEn
TagedPIn the FS1 models, maxillary incisors were extruded and positioned
labially. Mandibular incisors were also located labially. All teeth were
positioned mesial to those in the MS models. Vertical and bucco-lingual
translative movement of upper and lower molars were smaller than SS
and FS2. For angular movements, all teeth were distally rotated. Maxil-
lary incisors and premolars were distally angulated, and the other tooth
groups showed mesial angulation. Maxillary incisors were lingually
inclined, and lower incisors were labially inclined. Maxillary molars
were buccally inclined, and mandibular molars were lingually inclined.TagedEn
TagedPIn the FS2 models, maxillary incisors were intruded, and maxillary
molars were extruded. All teeth were positioned lingually. Both maxil-
lary and mandibular molars were located mesially. Angular changes
have shown distal rotation in all the teeth, with mesial angulation of the
maxillary and mandibular incisors and mesial and distal angulations for
the maxillary and mandibular molars, respectively. The incisors showed
a more labial inclination.TagedEn
TagedPThe mean absolute errors for linear and angular movement between the
automated setup software and the MS and the paired comparison of the
automated setup software are shown in Table 1.TagedEn
TagedPThe lowest linear and angular absolute discrepancies were observed
in FS1 in all directions, except for the upper incisors and upper premo-
lars. The absolute mean linear error ranged from 0.54 mm to 1.25 mm.
Linear errors among the software programs were statistically significant
(p < 0.05), except for vertical errors between SS and FS2. Absolute mean
angular errors ranged from 3.25° to 7.78°, with a significant difference
among the software programs except for crown tip errors between FS1
and FS2.TagedEn
TagedPFigs. 6 and 7 show the Bland-Altman plots of the tooth position errors,
which illustrate the tendency of error for each software according to the
type of tooth movement. The X-axis means the average of the tooth move-
ments, and the Y-axis means the difference in tooth movement between
software programs. Negative values indicate an automated tooth setup posi-
tion with the facial surface rotated more distally, with a smaller mesial tip,
or with less buccal crown torque than the manual digital setup (MS).TagedEn
TagedPMost of the tooth positions were within the range of 95% confidence
levels. An upward-sloping trend was observed in all the plots, which
indicates that as the average tooth movement increased, the tooth move-
ment error increased.TagedEn
TagedPThe PAR indices for setup quality assessment are shown in Table 2.
Mean PAR index of the initial models was 26.2. The PAR indices of SS, FS1,
FS2, and MS (the reference model) were 1.60 ± 1.13, 3.97 ± 5.40, 2.47 ±
TagedFiur
TagedEnH. Woo et al. Seminars in Orthodontics 29 (2023) 60−67

Fig. 5. Linear and angular movement errors as a result of automated setup by using (A) Autolign (semi-automated setup, SS), (B) Outcome Simulator Pro (fully auto-
mated setup, FS1), and (C) Ortho Simulation (fully automated setup, FS2). For linear movement errors, positive values indicate an automated setup position that is
more extrusive, buccal, and mesial; negative values indicate an automated setup position that is more intrusive, lingual, and distal. For angular movement errors, posi-
tive values indicate automated setup position more mesially rotated, mesially angulated, and buccally inclined; Negative values indicate automated setup position
more distally rotated, distally angulated and lingually inclined.TagedEn

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TagedEn Table 1
Mean absolute error of tooth movement discrepancies between the automated setup software and the manual setup software, and the differences
among the automated setup software programs.

1. Autolign (SS) 2. Outcome 3. Ortho Difference (1-2) Difference (1-3) Difference (2-3)
Simulator (FS1) simulation (FS2)

Vertical, mm Upper incisors 0.75 ± 0.61 1.11 ± 0.72 1.30 ± 1.10

Upper premolars 1.20 ± 0.67 0.31 ± 0.33 0.77 ± 0.60
Upper molars 0.95 ± 0.58 0.30 ± 0.38 0.91 ± 0.68
Lower incisors 0.67 ± 0.50 0.61 ± 0.49 0.78 ± 0.60
Lower premolars 0.68 ± 0.53 0.38 ± 0.45 0.65 ± 0.48
Lower molars 0.73 ± 0.52 0.22 ± 0.32 0.73 ± 0.63
Total 0.81 ± 0.59 0.54 ± 0.59 0.88 ± 0.77 -0.29 ± 1.09* -0.05 ± 1.58 0.24 ± 1.50*
Buccal-lingual, mm Upper incisors 0.75 ± 0.61 0.86 ± 0.74 0.80 ± 0.54
Upper premolars 0.72 ± 0.57 0.75 ± 0.66 0.78 ± 0.63
Upper molars 0.75 ± 0.58 0.45 ± 0.55 0.79 ± 0.55
Lower incisors 0.77 ± 0.58 0.91 ± 0.84 0.94 ± 0.67
Lower premolars 0.93 ± 0.68 0.68 ± 0.61 1.05 ± 0.80
Lower molars 0.87 ± 0.62 0.39 ± 0.55 1.40 ± 0.93
Total 0.79 ± 0.61 0.71 ± 0.71 0.95 ± 0.72 -0.41 ± 1.29* 0.24 ± 1.83* 0.65 ± 1.67*
Mesial-Distal, mm Upper incisors 0.86 ± 0.69 0.68 ± 0.51 0.69 ± 0.54
Upper premolars 1.16 ± 0.87 0.94 ± 0.83 0.97 ± 0.64
Upper molars 1.38 ± 1.01 0.85 ± 0.88 1.19 ± 0.85
Lower incisors 1.14 ± 1.13 0.55 ± 0.54 0.91 ± 0.87
Lower premolars 1.62 ± 1.26 0.87 ± 1.03 0.98 ± 0.88
Lower molars 1.59 ± 1.27 0.97 ± 1.24 1.23 ± 1.06
Total 1.25 ± 1.07 0.78 ± 0.85 0.97 ± 0.83 -1.31 ± 1.89* -0.83 ± 2.38* 0.48 ± 1.73*
Rotation, ° Upper incisors 5.60 ± 4.03 4.64 ± 3.73 6.24 ± 5.25
Upper premolars 4.43 ± 3.71 4.99 ± 4.66 5.07 ± 6.49
Upper molars 4.99 ± 4.34 2.36 ± 3.25 11.02 ± 6.56
Lower incisors 6.28 ± 5.21 5.05 ± 3.89 7.18 ± 5.72
Lower premolars 7.43 ± 5.23 5.50 ± 4.57 10.18 ± 9.27
Lower molars 4.71 ± 3.74 2.81 ± 3.69 8.29 ± 6.7
Total 5.63 ± 4.55 4.32 ± 4.12 7.80 ± 6.89 2.25 ± 7.74* 4.59 ± 17.84* 2.33 ± 16.5*
Tip, ° Upper incisors 4.69 ± 4.78 3.90 ± 3.29 6.14 ± 4.99
Upper premolars 4.52 ± 3.02 4.17 ± 3.00 4.87 ± 4.6
Upper molars 4.55 ± 3.74 2.50 ± 3.79 5.74 ± 4.59
Lower incisors 3.58 ± 2.85 3.26 ± 2.82 6.03 ± 5.02
Lower premolars 4.48 ± 3.73 3.44 ± 2.68 4.98 ± 4.77
Lower molars 4.61 ± 3.97 1.89 ± 3.16 7.00 ± 5.72
Total 4.37 ± 3.78 3.25 ± 3.21 5.83 ± 5.00 -1.20 ± 5.96* -1.33 ± 10.34* -0.09 ± 9.43
Torque, ° Upper incisors 8.58 ± 5.79 4.40 ± 4.13 5.02 ± 4.61
Upper premolars 6.55 ± 4.84 3.93 ± 3.06 5.00 ± 3.75
Upper molars 7.97 ± 6.4 3.30 ± 4.92 7.91 ± 5.88
Lower incisors 6.02 ± 4.82 5.58 ± 4.77 7.23 ± 5.42
Lower premolars 5.55 ± 4.54 4.87 ± 3.96 6.27 ± 5.04
Lower molars 8.89 ± 6.46 3.34 ± 4.91 6.29 ± 4.99
Total 7.26 ± 5.63 4.35 ± 4.42 6.26 ± 5.09 -3.94 ± 7.21* -2.76 ± 12.34* 1.17 ± 9.89*

* p < 0.016, indicating a statistically significant difference between software after Bonferroni correction.MS, manual setup (Maestro 3D); SS,
semi-automated setup (Autolign); FS1, fully automated setup 1 (Outcome Simulator Pro), FS2, fully automated setup 2 (Ortho Simulation).

TagedEnP1.74, and 0.77 ± 1.89 respectively. Buccal occlusion category accounted for
the differences among the automated setup software programs.TagedEn
TagedPThe mean setup time is shown in Table 3. The mean setup time of
MS, SS, FS1, and FS2 were 19.80 ± 3.05, 12.00 ± 2.15, 1.11 ± 0.18, and
3.11 ± 1.01 respectively.TagedEn
TagedH1DiscussionTagedEn
TagedPA digital setup model can visualize the final occlusion of ortho-
dontic treatment goals, making accurate diagnosis and precise treat-
ment planning possible. It can be used in conjunction with other
types of patient data, such as clinical photos and radiographs, to
determine the extraction, the tooth to be extracted if it is decided to
extract, and the plan for anchorage to achieve a favorable outcome.
The digital setup model can be combined with other 3D modalities,
such as CBCT, in complex cases, such as tooth impaction, to visual-
ize the impacted tooth to be aligned. It may also be used for virtual
simulation surgery for skeletal malocclusion patients undergoing
orthognathic surgery.13TagedEn
TagedPThe latest CAD/CAM technologies for digital setup have been aug-
mented by applying AI algorithms to automate the tedious tasks that are
TagedEnPrequired to be done by users. Tooth segmentation is an essential step for
the reconstruction of a 3D tooth model, and digital models employ tooth
segmentation methods wherein the recording of mesiodistal width and
the proximal surface of the tooth is dependent on surface data, and areas
that are not scanned may not be recorded accurately.14. Close contacts
between adjacent teeth, misalignment, and crowding can make auto-
mated tooth segmentation time-consuming and difficult.15. There have
been advancements in automated segmentation algorithms using
machine learning and deep learning. Recent studies have been done for
automated tooth segmentation14−18. using deep learning techniques that
have shown improved segmentation from an intraoral scanned image.18.
Im et al14. compared automatic segmentation using landmark-based
method (Ortho analyzer), tooth designation method (Autoalign), and
deep learning and found the highest success rate (97.26%) using deep
learning. Kim et al16. proposed an automated segmentation tool for rec-
reating missing data of interdental areas for an intraoral scanner using
generative adversarial networks and reported a higher than conven-
tional method using plaster casts. Wu et al17. employed mesh deep learn-
ing for automated tooth segmentation on 3D intraoral scans with a high
segmentation accuracy measured with a dice similarity coefficient
(DSC) of 0.964 ± 0.054.TagedEn

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TagedFiur
TagedEnH. Woo et al.
TagedFiur
TagedPContrary to the vast amount of research for automated tooth segmen-
tations, there are few reports in the academic field on the algorithms for
automated tooth alignment and their accuracy. As the fully automated
software claims to be used for consultation purposes only, we aimed to
evaluate how well the automated setup software worked and look into
the possibilities for using it for clinical purposes such as making clear
aligners and indirect bonding jigs.TagedEn
TagedPThe commercial software we have used for the assessment of auto-
mated alignment has shown different results. The semi-automated setup
software used in this study, Autolign, performed automatic alignment
based on the FACC and the mesiodistal axis of each tooth that was auto-
matically detected and fine-tuned by the user. After the user defined the
65
Seminars in Orthodontics 29 (2023) 60−67
Fig 6. Bland-Altman plots of linear tooth movement dis-
crepancies between automated setup software and the
manual digital setup software. (MS, manual setup; SS,
semi-automated setup; FS1, fully automated setup 1, FS2,
fully automated setup 2.)TagedEn
Fig. 7. Bland-Altman plots of angular tooth movement
discrepancies between automated setup software and man-
ual digital setup software. (MS, manual setup; SS, semi-
automated setup; FS1, fully automated setup 1, FS2, fully
automated setup 2.)TagedEn
TagedEnPocclusal plane, the teeth were automatically arranged along an ideal line
of occlusion, and the curve of Spee was flattened. There are options
that the software follows to perform the setup, such as the shape of
the arch (normal, wide, and tapered), and these rules set by clini-
cians will determine the final setup result. Tooth angulation and
inclination were set as ideal values according to the preset prescrip-
tion; therefore, in non-extraction cases, crowding was resolved pri-
marily by molar distalization. An expansion could be done by
setting a wide arch form, and manual adjustments for interproximal
reduction or incisor proclination are possible after the initial align-
ment. We believe that the rule-based algorithm of the Autolign,
which uses the ideal arch form, accounts for a greater error in tooth
TagedEnH. Woo et al. Seminars in Orthodontics 29 (2023) 60−67

TagedEn Table 2
The mean Peer Assessment Ratings indices of initial models and the setup models by using manual, semi-automated, and
fully automated software.

Displacement Buccal occlusion Overjet Overbite Centerline Total

(X 1) (X 1) (X 6) (X 2) (X 4)

Initial 10.67 ± 3.77 1.63 ± 1.52 1.80 ± 1.19 1.00 ± 1.17 0.37 ± 0.56 26.17 ± 8.69
Maestro 3D (MS) 0.20 ± 0.61 0.17 ± 0.38 0.03 ± 0.18 0.03 ± 0.18 0.03 ± 0.18 0.77 ± 1.89
Autolign (SS) 0.10 ± 0.31 1.40 ± 1.10 0.00 ± 0.00 0.03 ± 0.18 0.00 ± 0.00 1.60 ± 1.13
Outcome Simulator Pro (FS1) 0.03 ± 0.18 1.60 ± 1.33 0.37 ± 0.81 0.10 ± 0.31 0.00 ± 0.00 3.97 ± 5.40
Ortho simulation (FS2) 1.03 ± 1.10 1.30 ± 0.75 0.00 ± 0.00 0.07 ± 0.25 0.07 ± 0.25 2.47 ± 1.74

MS, manual setup (Maestro 3D); SS, semi-automated setup (Autolign); FS1, fully automated setup 1 (Outcome Simulator
Pro), FS2, fully automated setup 2 (Ortho Simulation).

TagedEn Table 3 TagedEnPRichmond et al12. stated that to demonstrate a high standard of treat-
The mean setup time of software. The mean ment for a practitioner, the mean percentage reduction in weighted PAR
setup time of MS, SS, FS1, and FS2 were 19.80 index should be greater than 70% for the “greatly improved” category,
± 3.05, 12.00 ± 2.15, 1.11 ± 0.18, and 3.11 ± and more than 30% for the “improved” category. The automated setup
1.01 respectively. results in this study showed a reduction in the PAR indices by 94%,
Setup software Time (min) 85%, and 91% for Autolign, Outcome Simulator, and Ortho Simulation,
respectively, and this falls under the "greatly improved" category accord-
Maestro 3D (MS) 19.80 ± 3.05
Autolign (SS) 12.00 ± 2.15
ing to Richmond.TagedEn
Outcome Simulator Pro (FS1) 1.11 ± 0.18 TagedPThere are a few limitations to the study. First, the MS model may not
Ortho simulation (FS2) 3.11 ± 1.01 be considered the ideal setup depending on the clinician and their treat-
MS, manual setup; SS, semi-automated setup; ment philosophies. Also, we used the 3D printed diagnostic models of
FS1, fully automated setup 1, FS2, fully auto- patients and scanned them for Outcome Simulator Pro and Ortho Simu-
mated setup 2. lation, and this has affected the accuracy of detecting the reference
planes such as FACC and mesiodistal proximal contact points for the

TagedEnPposition than the two fully automated setup software programs that
TagedFiur
automated setup software. Another limitation is that we used the
amount of tooth movement generated by each software, and there might
preserved the patients’ original arch forms.TagedEn
TagedPThe Outcome Simulator Pro software also detected the FACC of the
teeth automatically but was more accurate and did not allow manual
adjustments. It was done in an end-to-end manner, indicating that there
were no additional options to be inputted for the process of automated
setup. However, it tended to resolve crowding primarily by interproxi-
mal reduction from all teeth from mesial to the first molar to the mesial
of the contralateral first molar and focused on matching the upper and
lower dental midlines. This may be associated with the fact that this soft-
ware was designed for consultation purposes only, so the incisor align-
ment is important. Also, upper incisors were extruded and lower incisors
were intruded in most cases to form a proper overbite. The second
molars were not fully corrected (Fig. 8). Additionally, the software
focused on the incisor occlusion, and the first molar occlusion was not
always corrected to Angle’s Class I.TagedEn
TagedPOrtho Simulation software intrudes the upper incisors, which is dif-
ferent from other software. All teeth were lingually inclined and mesial-
ized. As a result, the arch form became narrower than it was before the
treatment. The reason for the lingual and mesial movement of the teeth
was due to the decreased mesiodistal widths of the teeth during the seg-
mentation stage (Fig. 9). Contrary to the Outcome Simulator Pro soft-
ware, Ortho Simulation corrected the inclination of the second molars.TagedEn
TagedPThe total setup time was drastically reduced when using the fully
automated setup software. The semi-automated software, Autolign,
showed a mean setup time of 12 min, while Outcome Simulator Pro and
Ortho Simulation showed a mean setup time of 1.1 and 3.1 min, respec-
tively. Increased time in the Autolign software was due to the process of
confirming the FACC and mesiodistal axis of each tooth and setting the
occlusal plane orientation and the arch form. Despite the short setup
time for fully automated software programs, manual adjustments are
required afterward, which should be considered when using it in clinical
practice. The manual setup using Maestro 3D Dental Studio showed a
mean time of 19.8 minutes, and this was done by an experienced clini-
cian. Therefore, it may take longer for new users.TagedEn
TagedPThe quality of the setup results was favorable for all the automated Fig. 8. The Outcome Simulator Pro software did not fully correct the occlusion
setup software programs, with the PAR indices ranging from 1.6 to 4.0. of second molars.TagedEn

66
TagedFiur
TagedEnH. Woo et al.
Fig. 9. Ortho Simulation software could not recognize the mesial and distal bor-
ders of the teeth.TagedEn
TagedEnPbe a difference between the center of the crown and the reference axis
detected from the software, and this might have affected the analysis of
tooth movements. Since the software has a default option of non-extrac-
tion for the digital setup, we only included the patients who were indi-
cated for the non-extraction treatment and who had moderate crowding
and no sagittal skeletal discrepancies. Therefore, the inclusion of com-
plex cases with skeletal discrepancies may reveal a greater amount of
error. However, since the software does not have patients' clinical infor-
mation, such as skeletal patterns, functional problems, periodontal con-
ditions, and facial soft tissues, it would be feasible to assess the
capabilities of aligning and leveling the arches only. Also, it has no infor-
mation on the biological limitation of tooth movement. Therefore, it is
the role of the clinician to diagnose the patient and make decisions
about the treatment. The automated setup software should be used to
support the clinicians by visualizing the treatment outcome based on the
objectives set by the clinician.TagedEn
TagedH1ConclusionTagedEn
TagedPThe effectiveness of automated digital setup systems varies among
software, tooth type, and the dimension of movement. The time effi-
ciency has been considerably improved. Although the setup results have
shown improvement in the PAR indices, further manual adjustments
may be needed for clinical use, such as indirect bonding and clear
aligner therapy.TagedEn
67
Seminars in Orthodontics 29 (2023) 60−67
TagedH1Patient consentTagedEn
TagedPPatient consent was obtained.TagedEn
TagedH1FundingTagedEn
TagedPNo funding or grant support.TagedEn
TagedH1Author contributionsTagedEn
TagedPAll authors attest that they meet the current ICMJE criteria for
Authorship.TagedEn
TagedH1Declaration of competing interestTagedEn
TagedPThe authors reported no competing financial interests or personal
relationships that could appear to influence the work reported in this
paper.TagedEn
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