ORIGINAL ARTICLE

Three-dimensional assessment of virtual

clear aligner attachment removal: A
prospective clinical study
Jeremy Dock,a,b Flavio Copello,c Iman Shirmohammadi,c and Jose A. Bosioc
Cincinnati, Ohio, and Baltimore, Md

Introduction: In digital dentistry, virtual attachment removal (VAR) optimizes clear aligner therapy by enhancing
efficiency for refinements and enabling prefabricated retainer production through the removal of attachments
from a digital scan before the clinical removal of clear aligner attachments. This prospective clinical study aimed
to evaluate the accuracy of VAR in the maxillary arch. Methods: A total of 110 teeth were analyzed from a sam-
ple of 54 maxillary scans from 25 subjects. Models with attachments were virtually debonded using Meshmixer
(Autodesk, San Rafael, Calif) and superimposed over the control group in MeshLab. Vector Analysis Module
(Canfield Scientific, Fairfield, NJ) was used to calculate and analyze 3-dimensional Euclidean distances on
the buccal surfaces between the superimposed models. Statistical analysis was performed using SPSS
(version 23.0, IBM, Armonk, NY). The Shapiro-Wilkes (a 5 0.05) test determined a nonnormal distribution of
results. The Kruskal-Wallis (a 5 0.05) was used to determine differences between different tooth types and
the number of attachments. Results: The VAR protocol showed no statistical differences in the root mean
square between different tooth segments with an overall tendency for inadequate attachment removal. No dif-
ference between the groups was found regarding the number of attachments when used as a main factor.
Conclusions: The VAR technique is precise enough for the fabrication of retainers from printed dental models
in a clinical setting and is not affected by the number of attachments on the tooth. (Am J Orthod Dentofacial
Orthop 2024;166:15-25)

T
eeth have been shown to move hours after
removing fixed appliances.1 Therefore, the reten-
tion of the final tooth position is essential for
maintaining orthodontic treatment results.2 This re-
quires the use of retention appliances, which can be
fabricated from many different materials and have
many different shapes.3-5
Lately, the most used orthodontic retention appliance
is the thermoformed plastic (Essix; Dentsply Sirona, Char-
lotte, NC) retainer.6 A recent survey in Australia has found
that 92% of orthodontists include a thermoformed
a the adoption of intraoral scanning and 3-dimensional
Formerly, Division of Orthodontics, Department of Orthodontics and Pediatric
Dentistry, University of Maryland School of Dentistry, Baltimore, Md.
b
Currently, Private practice, Cincinnati, Ohio.
c
Division of Orthodontics, Department of Orthodontics and Pediatric Dentistry,
University of Maryland School of Dentistry, Baltimore, Md.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Jeremy Dock, Division of Orthodontics, Department
of Orthodontics and Pediatric Dentistry, University of Maryland School of
Dentistry, 650 W Baltimore St, Baltimore, MD 21201; e-mail, jeremydock@
gmail.com.
Submitted, June 2023; revised and accepted, February 2024.
0889-5406/$36.00
Ó 2024 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2024.02.006
retainer as part of their retention protocol after clear
aligner therapy (CAT).7 For years, the traditional method
for fabrication of Essix retainers was to take an alginate
dental impression at the braces or aligner removal
appointment and proceed to make a plaster stone model
used as a template to fabricate the retainer. This method
presents many inefficiencies and inconveniences, such as
long or multiple patient visits, uncomfortable impression
procedures, messy laboratory materials, delayed retention
appliance delivery, distortion of the plaster model, and/or
stone model breakage.8,9
The global integration of digital dentistry has spurred
(3D) printing for dental arches, transforming dental of-
fices.8,10 This technological shift offers enhanced patient
experiences, material and time efficiency, and improved
infection control and eliminates physical storage
needs.8,10,11 This trend has fueled the popularity of
CAT,12-14 favored for esthetic appeal, dietary flexibility,
easy maintenance, and heightened convenience.15 Or-
thodontists are drawn to clear aligners for reduced office
visits16,17 and the ability to treat a wider range of maloc-
clusions compared with past limitations of CAT.18 The

15
16
growing interest in CAT is evidenced by the increasing
number of options for both doctors and patients.12
Leveraging the benefits of digital dentistry, ortho-
dontic providers can prefabricate retainers before treat-
ment conclusion using virtual bracket or attachment
removal (VBR or VAR). This involves obtaining a digital
dental scan before treatment completion, followed by
the virtual removal of brackets or attachments through
computer software. VAR is widely used in many ortho-
dontic settings, including clear aligner companies,
dental laboratories, and private practices. Notably, VAR
finds frequent use in CAT refinements. In private prac-
tice, orthodontists can employ VAR through diverse op-
tions, such as Vivera (Align Technology Inc, San Jose,
Calif), offering VAR with retainer purchases,19 or using
software options with VAR capabilities such as EasyRx
3D (EasyRx LLC, Atlanta, Ga), uDesign (version 7.0;
uLab Systems, Inc, Memphis, Tenn), or Clear Aligner Stu-
dio (3Shape, Copenhagen, Denmark) if retainers are
made in-house.
VAR can be done at no cost with Meshmixer (Auto-
desk, San Rafael, Calif), a free computer-aided design
and manufacturing software that can be used for gen-
eral 3D mesh manipulation.20 The accuracy of this pro-
cess using Meshmixer was recently evaluated for
traditional metal bracket removal and was shown to be
accurate enough for the fabrication of clinical retainers
from 3D-printed models.19
To the best of our knowledge, no published study has
examined the accuracy of virtually removing clear
aligner attachments or VAR. These attachments are
auxiliary devices comparable to brackets and bonded
to the enamel of a tooth similarly to help facilitate tooth
movement. However, unlike brackets, attachments come
in many different shapes, sizes, and numbers per tooth.
With CAT commanding up to 20% of the global ortho-
dontic market and increasing in popularity, orthodon-
tists should expect more retention of patients who
were treated with clear aligners.20-24 It is important to
understand the accuracy of VAR to analyze potential
factors that may lead to negative clinical implications
during and after active orthodontic treatment.
This study aimed to measure the accuracy of VAR in the
maxillary arch and compare this accuracy across different
tooth types and the number of attachments per tooth. The
hypothesis is that VAR will be accurate to use for the fabri-
cation of clinically acceptable orthodontic retainers.
MATERIAL AND METHODS
The prospective clinical investigation was conducted
at the University of Maryland School of Dentistry, Divi-
sion of Orthodontics, under the Institutional Review
July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Dock et al
Board no. HP-00098656. Informed consent and assent
were obtained from the patients and legal guardians of
the participants in the study who met the inclusion
and exclusion criteria. The inclusion criteria were as fol-
lows: (1) orthodontic patients from the University of
Maryland School of Dentistry who were about to start
or end treatment and/or refinement with CAT, (2) pa-
tients with bonded attachments on the maxillary arch,
and (3) patients who agreed to take at least 2 intraoral
scans. Exclusion criteria included (1) patients who were
not being orthodontically treated with clear aligners,
(2) patients who did not have any attachments or plan
to have any attachments bonded to teeth as part of
CAT, (3) scans that did not fully capture adequate anat-
omy for superimposition or measurement, or (4) scans
taken .30 days apart.
The sample consisted of 54 maxillary scans from 25
subjects, which equated to 216 teeth. Maxillary teeth
were divided into 5 different tooth types for measure-
ment: central incisors, lateral incisors, canines, premo-
lars, and molars. Central incisors were separated from
lateral incisors because of the large difference in size
and anatomy. First and second premolars, as well as first
and second molars, have comparatively similar buccal
surface anatomy that no differentiation was required.
A sample size calculation was run with a power of
90% and a 5 0.05. For a statistically meaningful sam-
ple, it was determined that 22 teeth in each tooth type
(110 teeth total) needed to be measured. Because the
data were collected for 216 teeth with attachments, a
randomization protocol was used to identify the 22 teeth
per tooth type that would be analyzed (www.
randomizer.org/).
Each subject agreed to have at least 2 digital scans of
the maxillary dentition, 1 with attachments and the
other without attachments. The maxillary arch was
exclusively used as its unique anatomic soft-tissue land-
marks on the palate allowed for easier superimposition.
Scans without the attachments comprised the control
group, and scans with the attachments were defined as
the experimental group (Fig 1). All attachments were
previously planned as a part of the digital treatment
plan. The control and experimental scans were taken
less than 30 days apart to ensure minimal natural tooth
movement.
All digital scans were acquired with an iTero Element
2 (Align Technology Inc, San Jose, Calif), which is the
scanner available at the University of Maryland ortho-
dontic clinic. The scanner has been shown to have a
scanning trueness of 0.0435 mm and a precision of
0.0512 mm.20 The scans were processed, automatically
uploaded, and stored on the servers of myaligntech.
Dock et al
com, in which they could be exported as standard tessel-
lation language (STL) files. These files were de-identified
from patient information and saved to a digitally en-
crypted folder.
The VAR protocol is nearly identical to that in a
similar study that evaluated VBR using Meshmixer.25
The experimental group scans were uploaded to Mesh-
mixer. Each attachment was selected via the surface
lasso or brush selection tool. If extra composite or flash
was seen on the scan, it was also included in the digital
selection. The boundary was smoothed using the smooth
boundary tool. The content inside this boundary was
erased using the default program values of the erase
and fill tool (Fig 2). Teeth that had bonded buttons for
intermaxillary elastics were sometimes present. In this
instance, the buttons were virtually removed for super-
imposition, but those teeth were excluded from any
future measurements. Only the teeth with attachments
and buttons were manipulated in Meshmixer. After
completion, a new file was created and renamed to
acknowledge the completion of VAR.
Superimposition of the control and experimental
VAR STL files was completed and verified with MeshLab
(version 2022.02)26 using the iterative closest point al-
gorithm with an accepted error of \0.1 mm. The super-
imposition protocol was very similar to that in another
study also using MeshLab.27 After uploading the STL
files into the software, the option to “unify all vertices”
Fig 1. Workflow of VAR procedures. Mx, maxillary.
American Journal of Orthodontics and Dentofacial Orthopedics
17
was unselected. The align tab was selected in the toolbar,
and the first scanned digital file was “glued” in place so
the second digital file could be superimposed over the
top using an iterative closest point algorithm. To in-
crease the likelihood of accurate alignment, 7 points
were selected each time, although the software only re-
quires 4 points. These points included 4 on the teeth (ie,
molar, premolar, canine, and incisors) and 3 points on
the soft-tissue palate (left, middle, and right rugae).
Points were selected on the basis of their ease of identi-
fication. For example, the greatest convexity of rugae
and distinct occlusal anatomies were frequently used
(Fig 3). The STL files were frozen in MeshLab to maintain
positional vertices for superimposition, saved, and up-
loaded to the Vectra Analysis Module (VAM) (Canefield
Scientific, Fairfield, NJ) for 3D assessment of VAR accu-
racy. In addition, VAM was used for the validation of su-
perimposition using color-coded maps (Fig 4) and by
measuring the surface difference at a nonspecific spot
on the lingual surface of a central incisor. Superimposi-
tion differences ranging 0.0-0.1 mm were accepted.
The VAM software measures the surface difference
between the superimposed control and experimental
group digital models. The surface differences were
measured 1 tooth at a time. It was sometimes difficult
to determine which areas of the teeth had attachments
removed, so the entire buccal surface of the tooth was
selected for measurement with the paint area selection
July 2024  Vol 166  Issue 1
18 Dock et al

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Dock et al
tool. The color surface by distance mode was used for the
generation of a color-coded map (6300 mm visualiza-
tion range) on the selected buccal surface (Fig 5, D).
The following values were automatically calculated:
minimum difference, maximum difference, and root
mean squared (RMS). These measurements were re-
corded and secured in a Microsoft Excel file (Microsoft
Corporation, Redmond, Wash).
A calibrated author (I.S.) was trained on how to use
all 3 software programs and was completely responsible
for virtually removing attachments in Meshmixer,
superimposing the control and experimental groups
in MeshLab, and analyzing the surface differences in
VAM. Intrarater reliability was assessed by remeasuring
30% of the teeth in VAM 2 weeks after the initial mea-
surement.
Statistical analysis
Minimum, maximum, and RMS values were all re-
corded and analyzed. Descriptive statistics were per-
formed with SPSS (version 23.0, IBM, Armonk, NY).
Intrarater reliability (Cronbach a) was determined. The
Shapiro-Wilkes test determined a nonnormal distribu-
tion of results, and the Kruskal-Wallis (a 5 0.05) was
used to determine statistical differences between
different tooth types and the number of attachments.
RESULTS
The intrarater reliability was determined to be high
(.0.98) for all 3 measured metrics of minimum,
maximum, and RMS. The medians and interquartile
ranges can be seen in Table I. The Kruskal-Wallis
(a 5 0.05) showed P values all .0.05, indicating that
there were no statistically significant differences between
different tooth types in the minimum (P 5 0.282),
maximum (P 5 0.493), or RMS (P 5 0.425) values. Molar
teeth had the largest median values for minimum
( 0.090 6 0.096 mm), maximum (0.279 6 0.270
mm), and RMS (0.095 6 0.101) (Table I).
Of the 110 teeth measured, 98 had 1 attachment, and
12 teeth had 2 attachments. Of the teeth with 2 attach-
ments, 8 were central incisors, 3 were canines, and 1 was
a premolar. The Kruskal-Wallis (a 5 0.05) showed no
statistical difference between teeth with 1 or 2 attach-
ments in minimum (P 5 0.638), maximum (P 5 0.73),
or RMS (P 5 0.508) values (Table II).
The range and distribution of values for minimum,
maximum, and RMS can be seen in Figure 6 and
Fig 2. VAR in Meshmixer: A, Intraoral scan with attachments; B, Attachment selection using the sur-
face lasso tool; C, Smooth boundary tool; D, Virtual removal of the attachment with the erase and fill
tool; E, Completion of VAR.
American Journal of Orthodontics and Dentofacial Orthopedics
19
Table III. When looking at the minimum values, the
central and lateral incisors had the largest absolute
minimum values of 0.266 mm and 0.243 mm,
respectively, indicating too much VAR. The canine had
the largest absolute maximum value of 0.815 mm, indi-
cating not enough attachment removal.
The sum of the raw data measurements was used to
compute the total values of both positive and negative
surface changes as an absolute number. From there,
the proportion of each type of change was determined
as a percentage. Overall, 75.7% of the surface change
was due to insufficient attachment removal, whereas
24.3% exhibited unintentional tooth removal.
DISCUSSION
There has been a significant increase in the use of
CAT, and expected growth is projected to reach $16.11
billion by 2029.14 Recent data indicate that 93% of or-
thodontists have incorporated this treatment modality
into their practice, representing 25% of their overall
caseload.7 Given this trend, it is important to examine
the potential benefits and challenges of CAT, including
the use of VAR, to enhance the overall treatment effi-
ciency and effectiveness.
Immediate fabrication of retainers after debonding is
desirable to limit the chances of immediate tooth move-
ment1 and to avoid the need for a separate retainer de-
livery appointment. With the help of VAR, retainers can
be prefabricated and easily delivered immediately after
the orthodontist removes the attachments from the
teeth chairside. Several companies, laboratories, and
software programs possess VAR features with different
options for pricing and processing time requirements.
The most seamless option would be to outsource the
retainer fabrication to an outside company such as Align
Technology, Inc, the manufacturers of Vivera retainers,
or ClearCorrect from Straumann. Many laboratories or
companies will provide VAR for free with the purchase
of retainers. This may be a good option for orthodontists
owning an intraoral scanner but not a 3D printer.
Orthodontists with 3D printers have more options for
VAR. Offices with in-house aligner programs typically
possess software tools capable of generating digital
treatment plans, including advanced functionalities
such as VBR and VAR. Offices or laboratories using
SprintRay 3D printers have access to their exclusive soft-
ware, RayWare (SprintRay Inc, Los Angeles, Calif), which
has a built-in tool to remove brackets and attachments.
July 2024  Vol 166  Issue 1
20 Dock et al

Fig 3. Superimposition of maxillary arches in Meshlab: A, Macro view of side-by-side comparison of

experimental group and control group in the align tab in Meshlab; B, Close-up view showing selected
points on the cingulum of the canines. This is 1 of 7 areas used to superimpose using the iterative
closest point algorithm; C, Final superimposition.

Meshmixer is another viable option for virtually
removing brackets, as shown by Marsh et al,25 with ac-
curacy ranging from 0.12 mm in the central incisors to
0.33 mm in the molars, which was determined to be clin-
ically acceptable.25 Virtually removing attachments can
also be completed with Meshmixer. In this study, the ac-
curacy of VAR using Meshmixer was deemed to be
clinically acceptable on the basis of several previous
studies determining the clinical acceptability of ortho-
dontic models to be #0.3 mm.28-31 If the observed
differences fall within or below the level of significance
established for orthodontic casts, this indicates that
the accuracy aligns with conventional methods of cast
fabrication devoid of VAR for retainer production.

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Dock et al 21

Fig 4. Superimposition accuracy confirmation in VAM using the color surface by distance tool. Blue
hues indicate positive surface change, red hues indicate negative surface change, green hues indicate
little or no surface change, and white hues indicate surface changes .0.3 mm in either direction.

Fig 5. A, Control digital model group of lateral incisor without an attachment; B, Same lateral incisor
with an attachment before VAR. Notice the position of the attachment is not in the center of the tooth
and the extensive amount of excess composite flash extending in all directions; C, The surface of the
tooth after VAR. There is a noticeable protrusive bulge from in which the attachment and flash were
removed; D, After VAR, the entire facial surface of the lateral incisor is being measured in VAM using
the color surface by distal tool. A color-coded map is generated with a visualization range of 6300 mm.
Blue hues indicate positive surface change, green hues indicate little to no surface change, red and
yellow hues indicate negative surface change, and white hues indicate surface change .300 mm.

In this study, Meshmixer was the software of choice
for measuring VAR because of its ease of accessibility,
no cost, and ability to compare results with Marsh
et al,25 which demonstrated that the accuracy of virtually
removing brackets was independent of the technician
using the same Meshmixer protocol. It is important to
note that this protocol did not alter any of the default
values associated with the erase and fill tool in Mesh-
mixer. Thus, only a single technician was used to com-
plete both the VAR and the surface difference
measurements in the VAM. This was validated by a
high intrarater reliability (.0.98) with 30% of the mea-
surements taken 2 weeks apart.
VAM compared surface differences after VAR by
measuring the 3D Euclidean distances on the buccal sur-
faces between the control and experimental superim-
posed models. The color surface by distance mode can
display a color-coded visualization spectrum that corre-
sponds to surface changes between 2-dimensional and
3D digital meshes. Red hues indicate negative surface

American Journal of Orthodontics and Dentofacial Orthopedics July 2024  Vol 166  Issue 1
22 Dock et al

The RMS medians across tooth types were all below

Table I. Descriptive statistics of the results given as
the threshold for clinical significance of 60.3 mm with
median 6 IQR
a range of 0.071 6 0.088 mm in the incisors to 0.095
Tooth type Minimum Maximum RMS 6 0.101 mm in the molars. No statistical significance
Central incisor 0.068 6 0.058 0.182 6 0.201 0.071 6 0.088 was found between the different tooth types; however,
Lateral incisor 0.063 6 0.077 0.199 6 0.171 0.077 6 0.072 an overall trend of increased RMS values was found
Canine 0.060 6 0.041 0.212 6 0.294 0.073 6 0.133
moving from the anterior incisors to the posterior mo-
Premolar 0.069 6 0.065 0.188 6 0.154 0.078 6 0.050
Molar 0.090 6 0.096 0.279 6 0.270 0.095 6 0.101 lars. A new study with a larger sample size would be
P value 0.282 0.493 0.425 beneficial to evaluate this potential trend. Marsh
Note. There were no statistically significant differences (P \0.05) et al25 found significant differences between tooth
between groups in the table as determined by the Kruskal-Wallis types, which may be explained for several reasons. First,
test. posterior teeth tend to have gingival margins that cover
IQR, interquartile range. more of the tooth surface, which limits the amount of
tooth structure Meshmixer can sample with the erase
and fill tool. Second, the buccal groove of the molars
Table II. Descriptive statistics of teeth with 1 or 2 at- is frequently covered by attachments, bonded buttons,
tachments given as median 6 IQR or excess composite flash, making it difficult for Mesh-
Attachments Minimum Maximum RMS mixer to predict and sample correctly. As a result, the
1 0.070 6 0.71 0.214 6 0.252 0.077 6 0.094 software replaces the buccal surface anatomy with no
2 0.063 6 0.047 0.214 6 0.133 0.074 6 0.048 buccal groove. This is the source of increased RMS and
P value 0.638 0.730 0.508 maximum values in the molars (Fig 7).
Note. There were no statistically significant differences (P \0.05) No statistical differences were found regarding the
between groups in the table as determined by the Kruskal-Wallis number of attachments per tooth. There were 12 teeth
test. out of 110 with multiple attachments on the buccal sur-
IQR, interquartile range. face, and 8 were central incisors. The RMS values were
comparable to those of the incisors with 1 attachment.
changes, suggesting excessive removal of attachments Caution should be taken when interpreting the RMS
and accidental removal of tooth structure, whereas values as they may not fully capture the clinical signifi-
blue hues indicate positive changes, suggesting insuffi- cance of the findings. Although only 3 individual teeth
cient attachment removal. The green hues indicated no (2.7%) showed an RMS value more than 60.3 mm, there
change in surface morphology. This feature enabled a were several instances in which some teeth exhibited a
rapid visualization of the entire arch to confirm the su- minimum or a maximum surface difference surpassing
perimposition (Fig 4). 60.3 mm. Among the 110 measured teeth, 35 teeth
The entire buccal surface was selected for the mea- contained a maximum positive value .0.3 mm. In
surement of each tooth because of challenges in distin- contrast, none of the teeth demonstrated minimum
guishing areas subject to VAR. In addition, the flash was values exceeding the clinical threshold. Some of these
frequently sprawling, asymmetrical, and sometimes extreme measured values could potentially have a clin-
covered most of the buccal surface (Fig 5, B). Therefore, ical impact. For example, teeth with higher maximum
the measurement of the entire surface was necessary to values because of incomplete attachment removal can
ensure all areas were included, thus increasing the result in looser fitting retainers, thus enhancing patient
chance of reproducibility. comfort and minimizing potential areas of higher force
VAM can calculate the largest minimum and application that could result in inadvertent tooth move-
maximum surface differences, RMS, median, and stan- ment. Conversely, teeth showing increased minimum
dard deviation values for the selected field. However, values could result in a tight-fitting retainer that may
median and standard deviation were excluded because fail to seat fully, potentially leading to unwanted force
of the lack of significance to this study. This research application and unintended tooth movement. A recent
focused on RMS, which is a quantitative measurement thesis showed that increased pressure on the lingual
reflecting the degree of deviation of 2 sets of data side of clear aligner trays correlated with an increase in
from 0. It represents the overall magnitude of surface thickness and surface area of excess composite flash
change regardless of positive or negative direction. It is on the buccal surface.33 A large minimum value has
regarded as the standard for the evaluation of scanning the potential to mimic this same effect and could rotate
accuracy in many studies31,32 and enabled direct com- or move the tooth lingually or intrude teeth depending
parison to the Marsh et al25 study results. on the location on the tooth surface. Overall, it would

July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Dock et al 23

Fig 6. Box and whisker plot showing the distribution of RMS values by tooth type.

Table III. Range of measured values (mm) by tooth

type
Tooth type Minimum Maximum RMS
Central incisor 0.014 to 0.266 0.582-0.033 0.272-0.026
Lateral incisor 0.008 to 0.243 0.450-0.110 0.204-0.033
Canine 0.006 to 0.195 0.815-0.086 0.331-0.033
Premolar 0.005 to 0.131 0.681-0.070 0.339-0.036
Molar 0.015 to 0.210 0.741-0.029 0.297-0.040

be better to have insufficient attachment removal rather

than too much removal. Future research should examine
the fit of retainers after VAR or VBR.
The overall net positives and negative surface
changes were calculated at 75.7% and 24.4%, respec-
tively, whereas Marsh et al25 calculated 91.1% positive
and 8.9% negative surface changes. A reason for this dif-
ference might be attributed to the surface area measured
in the VAM software. As outlined earlier, the entire
buccal surface was measured in this study, whereas
Marsh et al25 only measured the center of the tooth in
which the bracket was removed. A larger selected surface
will tend to have a lower RMS as the magnitudes of the
positive and negative peaks and valleys will be averaged
by the areas not affected by VAR.
A trend of large areas of flash around the attach-
ments was observed in this study. The samples were
derived from different residents who were inexperienced
with CAT. Residents were not trained in a uniform way
on how to bond attachments, which might explain the
variation in the amount of flash noted. However, excess
flash may be a common finding with CAT in general.
Fig 7. Buccal surface differences measured in the color
surface by the distance tool in VAM. The white hue over
the buccal groove was a common finding with VAR, as
Meshmixer was not able to replicate the original anatomy
if VAR was completed in that area.
Weckman et al34 found that excess flash ranged 7-21
mm2 around clear aligner attachments, whereas Arm-
strong et al35 measured flash to be 10.5-15.7 mm2
around metal brackets. This is due to the ease of
removing flash-around brackets before the composite
adhesive is light-cured, which is not possible while
bonding attachments.
This study found that some teeth contained little
flash around the attachments, whereas others showed
generous amounts. The teeth with the largest maximum
values well above clinical significance tended to have the

American Journal of Orthodontics and Dentofacial Orthopedics July 2024  Vol 166  Issue 1
24
largest amount of excess flash around the attachment.
Conversely, teeth with the smallest amount of flash
showed the largest minimum values; however, none ex-
ceeded clinical significance.
Visually, there appears to be a correlation between the
size and location of the attachment and/or flash and the
accuracy of VAR in Meshmixer, which could be from
Meshmixer’s inability to sample a sufficient surface area
for the erase and fill tool. This phenomenon is less likely
to occur while virtually removing brackets, as the brackets
are in the center of the tooth, providing the software with
a plenty of surface to sample. Future research could
examine the correlation between the accuracy of VAR
and the amount of flash-around attachments.
If clinicians decide to use either VAR or VBR in-office,
they can choose from many options, each with its advan-
tages and disadvantages. Meshmixer may come at no
cost but may not be the best software for VAR. On
average, it took around 5-10 minutes to perform VAR
per arch.
It is important to note that many of the software op-
tions that can virtually remove brackets or attachments,
including Meshmixer, come with a function to manipu-
late the model further with sculpting and smoothing
tools. These tools trim away any remaining defects after
the virtual removal process (Fig 5, C) and smoothen the
transition to the natural surface of the tooth. However,
too much sculpting has the risk of unintentional virtual
enamel removal. The results of this study showed that
insufficient attachment removal is more likely; therefore,
the use of the smoothing tool could potentially be bene-
ficial. In this study, none of the tools for manipulating the
model after VAR implementation were employed, as stan-
dardization would pose a challenge. Nevertheless,
exploring the effects of such manipulation could prove
advantageous for future research.
Despite the importance of VAR during refinements,
no published data are currently available regarding the
accuracy of different software or companies. Future
research should aim to address this gap and focus on
comparing the accuracy of virtually removing brackets
and attachments on different software options,
thereby guiding clinicians in making the best treat-
ment decisions.
This investigation was limited to the maxillary arch
because of the ease and predictability of superimposition
using the palatal rugae. In addition, there might have
also been inconsistencies when the clinician removed at-
tachments intraorally, such as iatrogenic enamel
removal or incomplete attachment removal. This could
be eliminated if the control group models were collected
before attachment bonding at the start rather than at the
July 2024  Vol 166  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Dock et al
refinement stage or completion of treatment. Further-
more, the RMS values could appear artificially lower
because of measuring the entire buccal surface rather
than the precise location of VAR. Future research on
VAR should focus on measuring RMS only in the areas
in which VAR was performed. Finally, it should be noted
that the VAR results in this study apply only to the Mesh-
mixer software.
CONCLUSIONS
This prospective clinical investigation demonstrated
that VAR is precise enough to be used to virtually remove
attachments on the maxillary dentition for the fabrica-
tion of orthodontic retainers from printed digital
models. Notably, the accuracy of VAR was not affected
by the number of attachments on the tooth or the
different tooth types. However, the accuracy of VAR us-
ing Meshmixer may be influenced by the size and loca-
tion of the attachment, as well as the amount of excess
composite flash around the attachment. At a clinical sig-
nificance of 0.3 mm, this study’s findings align effec-
tively with those of Marsh et al25 concerning VBR.
Additional research is needed to compare different soft-
ware programs that use VAR as an option for CAT. Over-
all, the results of this study demonstrated the potential
benefits of using VAR in orthodontic practice, particu-
larly for the fabrication of orthodontic retainers from
printed digital models, with implications for enhancing
clinical efficiency and patient satisfaction.
AUTHOR CREDIT STATEMENT
Jeremy Dock contributed to conceptualization,
methodology, data curation, visualization, original draft
preparation, and manuscript review and editing; Flavio
Copello contributed to formal analysis and supervision;
Iman Shirmohammadi contributed to investigation;
and Jose A. Bosio contributed to supervision and manu-
script review and editing.
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