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Bringing Direct-Print Aligners In-Office: Lessons from the Early Adopters · Orthodontic Products Podcast

• Alison Werner (00:03) Hello and welcome to the Orthodontic Products podcast. I'm your host, Alison Werner. In this episode, we're going to talk about how 3D printing continues to change orthodontics, specifically the move to direct print aligners. My guest, Dr. Jeremy Manuele, is a Las Vegas-based orthodontist and early adopter of in-office 3D printing technology. He shares how his practice made the leap to direct print aligners, what he's learned along the way, and what orthodontists should know before they bring this technology in-house. Here's our conversation. Alison Werner (00:30) Dr. Manuele, thank you again for joining me. I really appreciate it. Dr. Jeremy Manuele (00:33) Awesome. Thanks, Alison Glad to be here. Alison Werner (00:35) Yeah, so before we get started, can you tell me about your journey with 3D printing and your practice? Dr. Jeremy Manuele (00:41) Yes, so I mean our journey started about seven years ago or so and like many docs at the time, we were using alginate and experiencing all of the appliance fit issues that often accompany that technology, whether it's the impression, having a mistake or the stone models. And so we just wanted our appliances to fit better. And so we're like, hey, well, let's look into this. And so we ended up doing some research. I think the first printer we purchased was the ⁓ It wasn't the SprintRay, was even before that. I forgot the name of it by now. Formlabs, was the Formlabs, it was the early Formlabs printer. Yeah, that was the first one we got. And we started printing ⁓ models to send to the lab for our different appliances to be made, because those were always made locally and at the time our lab didn't even have a printer. And so that was the start of it. Our appliances came back and they started fitting amazing. Like every single time we weren't adjusting them, they weren't rocking. And it may have been closer to eight or nine years ago. But yeah, it was eye opening for us. like, hey, there's something here. And for us, was really like, as soon as we got into printing, ⁓ it was a no-brainer. It's like, why didn't we do this sooner? And one of the big concerns I had, I remember this initially, when we first got our first printer, was like, man, this is... What is this gonna be like? Is it gonna kill all my time? Am I gonna be spending hours and hours working through and training and doing all this? And the cool thing is even back then, it was almost plug and play. My team had some training with, again, with Formlabs at the time, but by and large, it was plug and play. I was so not involved in the process and it took so little of my time to get it off the ground and I was just experiencing better fitting appliances. Alison Werner (02:07) Hmm. Dr. Jeremy Manuele (02:21) So that was kind of like where it all started for me. then, know, shortly after that, we started to have the software companies come around that were like, hey, well, we can digitally move teeth. And this is back in the days of like mesh mixer, right? Like that was like, you had some dentists and orthodontists, they were like playing around, hey, this is how you can move this tooth in this 3D design software. And I looked into that a little bit, but it was like quite a cumbersome process. You had to learn the software. And then even then it's like, you're trying to make a 3D modeling software work for dentistry when really it wasn't intended for dentistry. Alison Werner (02:33) Mm-hmm. Yep. Yeah. Dr. Jeremy Manuele (02:51) or orthodontics and so I didn't spend too much time in mesh mixer but shortly thereafter you started to have some actual software companies develop tooth moving software specifically and that's when we started to do our retainers, our clear aligners, limited cases like well let's set these up, let's print a series of models and let's suck down the models and maybe we can avoid having to pay $500 for a limited aligner case or whatever we were paying at the time and so that was sort of what got us ⁓ initially into the world of 3D printing. And then from there, from the time we actually started fabricating appliances in our office, ⁓ specifically clear aligners, that's when the learning, know, like that's when your learning really starts to accelerate because you start to experience and understand things that you never had to think about before, right? So when you're ordering aligners from a company, you just, they just, do a setup and they send them to you and like, you just put them on. Like you don't think about Alison Werner (03:38) Huh. Dr. Jeremy Manuele (03:45) Well, where should that trim line be? Or what about like this set of teeth compared to this one? These ones have more undercuts. Or what if I use this thickness of material compared to this one? Or this type of material compared to this one? So you have a world of options at your fingertips when you start to take some of these workflows on into your office. And by having these abilities, it can be overwhelming to some extent because there's so many choices. Like what do I choose? But if you do spend some time and start to figure out like, hey, well, this works better in this situation, this works better in this situation, well, now you can start to customize your treatment plan, you can start to customize your systems, and now you can come up with something that's actually working better in your office that's costing you less and helping patients get through treatment even faster. And so that was sort of like when things started to take off and from there, we've just progressed to better softwares, better printers, better resins, better everything, and that's the journey that we're still on today. Alison Werner (04:37) Yeah, OK. So where are you now with 3D Direct Print Aligners in your practice? Dr. Jeremy Manuele (04:45) Yes, so with 3D Direct Printers, we onboarded that technology in the beginning of this year, the end of last year. So the end of last year, we bought a printer. was like December, 2024, we bought a printer. I think it was delivered January of this year. And that was kind of our first experience with Direct Print Aligners. And at that point, a year ago or so, even still, this is pretty new technology. mean, there's been some docs in Asia that are using it here and there, and a handful of doctors here and there doing a couple little things with it. So our expectations were pretty low. Now ironically, the reason that, one of the biggest reasons I decided to get a 3D printer is I wanted to change my phase one retainers. Because with these materials, you can customize them and make them whatever design you want. Turns out the workflow for that is not so simple and due to some issues that come up with staining and things like that, we actually haven't even done that. But we did start to direct print aligners for our patients and we started out with limited cases. Alison Werner (05:33) You Okay. Dr. Jeremy Manuele (05:43) And then now, the last three months or so, the only cases that I've started, all comprehensive cases, moderate cases, limited cases, everything has been indirect print aligners. And from what I've learned even just over the last year, I truly feel like this is the way everybody's going to be going. ⁓ If you asked me, do you think it's there right now today? Is the technology here ready to plug and play, plug it into my office and start going tomorrow? I would say no. I would say there are definitely still things that need to be worked out now. Alison Werner (06:02) Yeah. Dr. Jeremy Manuele (06:12) Can it be plug and played? Yes, but just know that it's not really plug and play. It's like, plug, flip this, switch that, switch, turn this on, hold this thing right. You know what I mean? There's some workarounds that you have to know about in order to make this successful in your practice. But as of the last three months, that's the only aligner system that we've generated in our practice. And so it's definitely possible. And the bugs, so to speak, that we're working through will continue to be worked through. Things will continue to get better. ⁓ And the potential is there. That's the most important thing. For me, it's all about what is the ⁓ capability of the system. Is it capable of producing either A, better results, or B, ⁓ results with less hassle, less attachments, ⁓ or C, like better fit, aesthetics, ⁓ better patient experience, shorter treatment times. So if it can provide all of those things, Alison Werner (06:47) Mm-hmm. Mm-hmm. Dr. Jeremy Manuele (07:03) Well, I want to be on the forefront of that. I want to learn how to get all of that value, even if it's at the expense of working through the current problems in the systems that are there today. And we can dig into as many of those, both sides of that equation as you'd like. So, yeah. Alison Werner (07:13) Yeah. Yeah. Yeah. Yeah. Well, let's before we go further on that, talk to me about how these direct printed aligners are different from traditional aligners. Dr. Jeremy Manuele (07:25) Yeah, so traditional, traditional aligners were made on a stone model. You pour up the stone model, you use the plastic, you heat it up, you suck it down over the top. That's like original, the OG clear aligners So that transformed into then using a 3D printed model, right? So you can make it out of, most commonly it's out of resin. Some of the bigger companies use nylons and other materials like that. But essentially you 3D print a model and then you have the model of the teeth. Instead of being in stone, it's in a resin. And then you use a sheet of plastic and it goes and forms over that as well. ⁓ And you can use it over and over again, right? So that plastic doesn't deteriorate, it doesn't break when you pull the aligner off of the model. And so if you need an extra one, you can just do another suck down or you can have two or three retainers made off the same model. So that was a pretty big breakthrough. It was also much more accurate, right? From an overall accuracy standpoint. even though it is more accurate, it's actually in some ways less defined. So when you have a stone model that is accurate, that's captured correctly, that there's no bubbles, you'll see very, very precise anatomy on these models. And with 3D printed ⁓ models, you'll often see those layers or ridges of where the print is happening, and so it's not quite as refined. If you're not careful with that, with your settings and the type of printer you use, you can actually create an aligner that's not as good. Alison Werner (08:38) Right. Mm-hmm. Dr. Jeremy Manuele (08:46) that maybe is not as retentive or doesn't work as good. But by and large, they work just as good if not better because overall they are more accurate. Like one tooth is not going to have a bubble in it for instance. If you capture the scan correctly, it's going to be printed accurately even though it may not be quite as high resolution ⁓ routinely as like a plasterstone model was if that makes sense. Now mean you could print them at a super high resolution with the printers that we have now but most people don't because what we found is that you don't need to, right? There's a certain level of resolution that's fine for those cases. So that's typically what we print at so that we can just have the volume and have our workflows not be slowed down by waiting 15 hours for like a one micron print to go through or So, and I would say today, most doctors who are doing 3D printing are 3D printing the model and then they do the suck down. And that works very well for what most people would call in-house aligners. So now with direct 3D printed aligners, the system is just like it sounds. So instead of printing any intermediary model, anything like that, literally off the printer build shelf itself is going to be your clear aligner Of course it'll have supports and whatnot in order to maintain its accuracy. But literally the resin itself is transformed into the aligner itself via direct printing. And so this is unlike any other material. Other suck downs in any other aligner companies up to this point have been a suck down material over something else. Now these materials are directly printed. So ⁓ it's not one sheet of plastic forming, it's literally hundreds of layers being built throughout that whole process. And understanding that helps us to understand then why the mechanical properties are different. why the problems that we see are different with these aligners compared to traditional aligners, and then you can start to understand the positives and the negatives that go along with having this new system. Alison Werner (10:35) Yeah. Okay. And as I understand it with direct 3D printed aligners, you can control in theory the thickness of the aligner in different parts of the aligner. You can also incorporate features directly like cutouts, bite ramps, undercuts, all those. Can you talk a little bit about that? Dr. Jeremy Manuele (10:55) Yeah, absolutely. And I wouldn't even say in theory, like this is absolutely in practice today. You can control the thickness of the aligners in any of the, 100%. Yeah, and you can do even like gradient occlusal surfaces, for instance. I mean, that's one of the features within the software that we use, meaning that it'll kind of thin out the material in the occlusal of the posterior and make it little bit thicker as it moves more anteriorly. And that allows for the aligner to be a little bit more comfortable because if it's too thick in the back, Alison Werner (11:00) Okay. Okay, so you are able to. Okay. Okay. Dr. Jeremy Manuele (11:22) then patients, you know, they tend to hit on the back only and it can be uncomfortable. And again, these are things you don't think about when you're doing a suck down because one of the differences between the suck down is that the thickness is not uniform, right? The material itself is going to stretch more over the incisal edges than it does in an undercut or on the flat surface of the tooth. So if you were to get out your Bully gauge and measure every single individual point of a suck down aligner, you would see it's all over the map. The material may have started out one millimeter or three quarter millimeters. But if you actually measure the actual thickness in all these different places, it's very variable. With a direct print aligner, the thickness by default is 100 % uniform. So if you say 0.75 millimeters, that means every single surface of that aligner is 0.75 millimeters. And so that's when they realize, hey, well, maybe we don't need 0.75 millimeters everywhere. And that makes it a little bit more uncomfortable for the patient, because now they're just hitting in the back instead of kind of like they're used to feeling and hitting more of the teeth together. So now they'll thin out the material in the software itself, make it thinner in the back and thicker in the front. But to your point about adding auxiliaries yes, you can add a button anywhere you want on the aligner and it's going to integrate, it's going to be directly printed. So it's almost like a direct bonded composite onto another big clob of composite. It's solid, it's not coming off, almost turns it into one piece. And so your buttons are stable and you can design those in a way that you can make sure that the aligners are retentive. Alison Werner (12:38) Yeah. Right. Dr. Jeremy Manuele (12:48) And I would say one of the most ⁓ interesting and probably most powerful things that we're just starting to harness is the ability to engage undercuts. So an undercut is any surface of the tooth that creates retention, meaning that if you're looking straight down at the teeth, you'll see the teeth, but there's some part of the tooth underneath what you're seeing that kind of curves inward. And those undercuts are what allows us to grip onto those teeth. And so traditionally with sucked down materials, the material itself does not engage the undercut completely. And that's good in a lot of ways because if it did engage the undercut completely and you were using sucked down plastic like all the other aligner companies have, and if it actually engaged those, that aligner material is so rigid and so thick that you wouldn't be able to get the aligner off. You probably couldn't get it on, but even if you did get it on, you wouldn't be able to get it off because it's just too much force in those undercuts. Well, now we have the ability to precisely Alison Werner (13:34) Hmm. Yeah. Dr. Jeremy Manuele (13:43) hug those undercuts, we can 360 degree wrap around that tooth. And at the same time, we can start to control the force that we place on that to make it to where you can get it on and off. And that to me is one of the biggest game changers as far as how we practice orthodontics and how we use clear aligners to get to the end result. Because in theory, and again, this part is in theory, in theory, we can dial that in so precisely that we need no attachments on any teeth ever. Alison Werner (14:12) Mm. Dr. Jeremy Manuele (14:12) Right? So that's the theory. Now in practice, the comprehensive cases that I've been doing over the last few months range anywhere from two attachments, like maybe just on the maxillary canines, ⁓ to I think the most I've done on a direct print case is like eight, like four per arch, like two on each side, two on each quadrant. Compared to my traditional suck down aligners routinely have 12 plus attachments. ⁓ And so it's definitely different. When the posterior teeth have significant undercuts, Alison Werner (14:28) Okay. Dr. Jeremy Manuele (14:39) and there's not significant rotations or anything else like that going on, then those teeth will attract. They can move, can upright, and they don't require attachments like they used to. Alison Werner (14:47) Okay, yeah, because that was going be my next question. Do these typically require more or less attachments? So Dr. Jeremy Manuele (14:53) by far. Yeah, by far less and for those reasons precisely. And that's where, know, what I've really been trying to experiment with, you know, I had one case that I was like, you know, we've never been able to just move a lateral incisor down. Like we always try to do that. We have to hook a button to it, a rubber band, you know, tip it forward and then move it back. So I tried to just like moving it down in the software and, you know, it moved down a little bit, but like, you know, so we're not... Alison Werner (15:13) Mm-hmm. Dr. Jeremy Manuele (15:17) quite there yet, like it kind of just started to pop off the tooth and even with the reactivation, which we haven't talked about a lot yet, but even with that reactivation, I wasn't able to just pull it straight down. So I'm like, okay, so we went ahead and rescan and now I'm going to try like, again, no attachment, I'm going to try a protocol where we tip it facially first, create a little space and then move it down and back at the same time. So that's like the typical staging protocol that we would use with our former thermoform plastic aligners, but without an attachment. So it didn't seem like there was enough undercut to Alison Werner (15:18) Yeah. Dr. Jeremy Manuele (15:47) pull it straight down or enough force to pull it straight down, but I'm hoping that we can tip it forward and then pull it back again without attachments because you know lateral incisors if you talk to most orthodontists who do a lot of clear aligners, that's one of the pain points right getting those teeth to track predictably and end up where they're supposed to can be quite difficult even with attachments and so you know that would be a breakthrough as well if we can come up with a system that works without attachments in that area as well. Alison Werner (16:07) Yeah. So is that a question of software or material? Dr. Jeremy Manuele (16:16) Mostly, so material and then software workflow, right? So the material has to be strong enough ⁓ to create the force on the tooth. In order to hug the tooth or put the force on the tooth, you have to have an undercut. So there are something like peg lateral incisors, for instance, there's no way we're gonna be able to pull those down because there's nowhere to pull from. But most lateral incisors do have undercut. And so it's a combination of how much undercut do we need, Alison Werner (16:20) Okay. Dr. Jeremy Manuele (16:44) how much force do we need at those undercuts and what staging movements do we need to make it happen. So the more undercut we have and the more ability we have to add force to that undercut, i.e. maybe making the aligner margin a little bit more gingival so it adds rigidity in that area, maybe making that portion of the aligner a little bit thicker so that it again is more rigid in that area, and then using a good staging protocol like we mentioned, maybe tipping it forward, creating a little bit space and then moving it. down and back at the same time, so you're almost creating more of a surface to push from. Between the combination of those things, I'm optimistic that eventually we will figure it out. We'll figure out how to do it predictably. Alison Werner (17:22) Okay, so let's talk about the resins and those are key to all this. How did the materials kind of in your opinion, the materials used in these aligners differ in terms of like flexibility, durability, force delivery? What are you seeing? Dr. Jeremy Manuele (17:38) Absolutely, yeah. The resins in 3D printing in general, that's been transformative over the last decade. I there are so many new resins coming out. We started out with just a resin to print models with. That was huge. It like, oh, we can print models. And then it was like, oh, now we can do splints. And now we can print in different colors and do dentures. And now we can print fake teeth and glue them onto the teeth. As it relates to orthodontics specifically, another breakthrough was direct indirect bonding, printing those indirect bonding trays. So they came up with Resins to do that. So now we're talking about the Resins for these direct print aligners. And really there's only two on the market in the United States that they're really getting much hype or buzz. There might be more, but there's really two options that when people are looking into implementing into this practice, they're looking at either Graphy or LuxCreo, and they're very similar in their properties. And so basically they both work off of the same principles. Each of them have their own proprietary formula, compilation, whatever. Alison Werner (18:25) Yeah. Dr. Jeremy Manuele (18:35) ⁓ but it's a multi-layer material and they're both thermodynamic. think Graphy calls theirs shape memory, ⁓ LuxCreo might call theirs active memory, something like that. But this is important for if you've never heard about these Direct Print aligners or you've never heard anything about Direct Print aligners, this is one of their most unique features that unless you've researched it, you probably would have no idea about. So what this thermodynamic nature of the aligner means is that when the aligner distorts, Alison Werner (18:42) Yep. ⁓ Mm. Dr. Jeremy Manuele (19:04) or becomes crushed or you run it over with a car like you're not going to do that right but when you put on your teeth the teeth do stretch out the aligner a little bit it distorts the aligner and when the aligner is distorted of course it's not able to produce the same forces that it was before it was distorted and that's a problem with every single aligner material we use Alison Werner (19:22) Yep. Dr. Jeremy Manuele (19:22) And with the suck down materials, we tried a lot of different things to overcome that. You do like multi-layers. It's like thick on the outside, thin on the inside. This one's squishy. Like there's a lot of great inventions and ingenuity that have come about trying to solve the problem of force decay. Meaning like, hey, the force started out great, but toward the end of the aligner, it was gone. And so when you think about that with traditional thermoform plastics, if you lose a little bit of, you have a force decay on the first aligner, well now the second aligner has to make up for that force decay. Alison Werner (19:39) Yeah. Dr. Jeremy Manuele (19:50) and then the third aligner has to make up for the force to gain the second aligner. So you're constantly chasing your tail essentially. And by the time you get to your 30th aligner or your 40th aligner or your 50th aligner, that is one of the underlying causes of why these teeth tend to get so off track. It's because even if the forces were designed perfectly in the beginning, that force decay stage after stage after stage after stage after stage adds up to the point where it's like, well, now the force is not sufficient. to actually make the movement that we need because these aligners have distorted so much. And everybody that does clear aligners has seen this. The patient comes in, they're on aligner number 40, and they get it on somehow, they smash it on, they bite it down, they basically immediately distort their retainer. Their teeth are clearly not straight, but they're wearing their aligners, they're putting them on, and if you wear your aligners three hours a day, that's what will happen. You'll have force decay and you won't have movement of the teeth. So compare that with direct print aligners. Yes, you have force decay, and in fact, Alison Werner (20:31) Right. Dr. Jeremy Manuele (20:46) direct print aligner forces per thickness are actually less, almost about half. So when you look at like if I just were to take like an Invisalign aligner or whatever, an Angel aligner, a ULab aligner, like if I were to just take one of those and pop them on my teeth, the force of those aligners would be almost double what it is if I take a direct print aligner and pop it on my teeth. So initially that seems like bad. It's like oh geez, are these even gonna have enough force to move teeth? But it turns out that both amounts of force are Alison Werner (20:49) Hmm Okay. Dr. Jeremy Manuele (21:14) plenty. In fact, the suck down materials have more force than is needed to move teeth. They have that because again, they're trying to eliminate that force decay. If you start out with more force than you need, well as the force decays, hopefully you still have enough force to move the teeth. That's the theory. With the direct print aligner materials like Graphy and LuxCreo what their approach is, is yes, the force is less, but that force can be renewed. That's where that thermodynamic properties come into play, the shape memory, the active memory, what happens is when these aligners are distorted, and we can link a video, I don't know if you know, we can link a video in the description, whatever, I'll send it to you, and I'll show you a video of an aligner that's literally like almost tied into a bow, it looks like a ribbon, it's so distorted, and we did that on purpose just to demonstrate it. We throw it in a glass of boiling water, and boom, it's right back to its original shape. And that's the material properties itself, and I'm not privy to how they designed that, Alison Werner (21:45) Yeah. Yeah, absolutely. Mm-hmm. Yeah. Dr. Jeremy Manuele (22:10) why it does it, but there's enough elasticity in there that it reacts to heat. So when it reacts to heat, it goes back to its original shape. And then once it's at its original shape, then once that water cools down, ⁓ then it hardens. So basically the hot water makes it back to its original shape, which restores its original shape. And then it hardens, which restores those original forces. So now it's as if every time you do that boiling protocol, you're getting a brand new aligner, a brand new set of forces. So even if there was force decay throughout the day, which there is, by time you do this day after day after day after day, by time you go from aligner one to aligner two, there's almost no force decay left over, if that makes sense. And that's where it's so promising as far as getting through our cases faster. Because if we could get through every single case with zero forced decay, then we would literally only ever have one set of aligners, assuming we staged the case correctly. We would have the aligners that move the teeth, assuming all the movements were possible, we staged it correctly. Alison Werner (22:48) Yeah. Right. Dr. Jeremy Manuele (23:05) We would get that result every single time. And so that is the direction it's headed. Are we there yet? No. Are we there on some of these cases? Yes. I've had cases where I set up one set of aligners and we get to the end and their teeth look exactly like it does in that last set of aligners. I learned this the hard way because with every other system I've ever used, I've planned force decay into my movements, meaning that I know that if the tooth starts out mesiolingual, then if I program it to perfect, it's still gonna be a little mesialingual because of the force decay. So what I do is over-correct that, right? A lot of us will do that. We'll over-correct the rotations, we'll over-correct intrusion, we'll make all these extra forces in the aligner system because we know that the force is going to decay. Well, I started using my Direct Print aligners in that same way. I started doing these over-corrections, but then I'm going and I'm looking when these limited cases are done and I'm like, dang, the tooth is actually over-corrected. Like it actually moved to the point where I put it and I'm like, wow, that is fascinating. Alison Werner (23:57) Yeah. Dr. Jeremy Manuele (24:00) And so yeah, that was when I really started to know like this is where this is going. Like this ability to move teeth in this unique way is yes, it's at its infancy now. It's still just barely getting off the ground. But I believe in five years, like this is going to be like most of the progressive practices across the country are going to be doing this. And I would have said the same thing 10 years ago about printing. And I think that's correct. 10 years ago, were one of the earlier docs to get a 3D printer. Alison Werner (24:30) Yeah. Dr. Jeremy Manuele (24:30) And then five years later, everybody's got a printer. At least all the progressive practice, they have a printer. And I think that's where we're at with direct printer aligners right now. I think that right now you have a few people that are working through the kinks, like myself. And we haven't talked about the kinks yet, but we should because it's important. But in five years from now, I think a lot of these things are going to be worked out. And you're going to see practice after practice. You're going to see a lot of practices using it. And I'm excited for that because the more practices that jump into this, the more we learn. Alison Werner (24:32) You Yeah. Mm-hmm. Yep, be well. Yep. Mm-hmm. Dr. Jeremy Manuele (24:57) and the more we share with each other and the faster this progresses. you know, some days I feel like, you know, a Lone Ranger. There's like 10 of us across the country who are doing much of this. And it's like, okay, well, that's great, but like we need like a thousand of us, you know, like let's join together and like really get this off the ground because again, I think this is where it's going. Alison Werner (25:05) You Yeah. Well, I was going to ask you about how this has affected staging your cases. Dr. Jeremy Manuele (25:16) how does it affect the staging or how does it change the staging? That is what I'm still experimenting with. So the question is how much can you move the teeth per stage? Now force decay has a big part of that equation. So the more force decay that you have, the less you can move per stage because the force decay is too much. You need to kind of like... Alison Werner (25:29) Right. Dr. Jeremy Manuele (25:38) replicate that same movement in the next stage to a certain extent and you have to have those movements close enough together that when this part decays it'll kind of get picked up with the next aligner and then when that one decays it'll get picked up with the next aligner. But the less force decay that you have, theoretically the faster you can move the teeth per stage. So if you have an aligner that you know can be thermally activated every single night, well instead of like 0.1 millimeters per stage can we do 0.2 or 0.3 or maybe even 0.4? Like how much can we push it? That would help to drive down our costs, right? Because we're less material. It's also more friendly for our environment. So I think that both of those things are important. Right now, I basically kept the staging the same as what I do with my thermoform suck down materials as I'm working through all of the other things about using direct print aligners. But once we get some of these other things dialed in, that's to me like the next step. Like how far can we push it? Like can we do double? Can we do double the amount of movement? Alison Werner (26:20) Okay. Yeah. Dr. Jeremy Manuele (26:35) ⁓ There's that balance, right? If you do too much movement, it is going to be too much force, too much force decay, and it won't be able to recover. Eventually, you boil these things. I would imagine if you boil them 100 times, they would probably break more, crack more. I'm sure they have some sort of wear them out effect. How long they take to get worn out, what that force decay is, that will determine how much we can move per stage the aligners. For me, at this point, that's not the most important thing because I can print more aligners. It's not so cost prohibitive that I need to Alison Werner (26:39) Okay. Yeah. Dr. Jeremy Manuele (27:04) know, skip three aligners, you know, print 1369, like I can just do .1, .2. My standard is .25, a quarter millimeter linear movement or two and a half degrees angular. So that's kind of like my normal go-to velocity, which is actually quite a bit faster than a lot of aligner companies do still. So yeah. Alison Werner (27:15) Yeah. Okay. I know you've mentioned in talking here with the shape memory ⁓ using heat or hot water. Are you, and I know from my own research and interviewing some other people in the past on this technology, typically the patient would put it in some kind of hot water to reactivate. Are you having them do that with this, these materials and these aligners that you're printing? Dr. Jeremy Manuele (27:31) Yes. Yes, and I think that this is super, super important. I think if you skip this step, your experience with direct print, you're going to try it. And I've talked to docs who have done this. They've said, hey, well, yeah, I just want to do direct print aligners because that's cool. Whatever, less waste, it's fine. And it's easier. I can just print directly, less cleanup. But they just give them to their patients and pretend like they're the normal thermoformed aligners. And they're going to act the same way, and they don't. Alison Werner (28:06) Right. Dr. Jeremy Manuele (28:09) There is force decay on these direct print aligners just like there is on thermoform and there's less force So you're have more problems with this system if you never reactivate that force if you just try to like give them the aligner and say go You're gonna have more problems because there's less force ⁓ Than than with a traditional system. So in my opinion, it's critical now You have a couple of options on how you do it. So currently we do just we give we print out a little paper It has the instructions like hey, you know, these are like the most advanced aligners available Alison Werner (28:28) Mm-hmm. Dr. Jeremy Manuele (28:37) Like these are reprogrammed every single night and this is how you reprogram it. It restores it so it restores the forces of a brand new aligner. I say it probably way better than that on the paper because I think I had ChatGPT help me. But that's the nuts and the bolts of it, right? It's like, okay, these are cool and this is what you have to do to make sure that they work well for you. And so we have them just boil some water, put it in either a mug or a bowl and you throw them in there for five minutes. And then you can either let the water cool completely, like leave them in for 20 minutes, or you can like cool the water down, just put cold water in after that five minutes. And that's it, pop them back in. Alison Werner (28:45) Yeah. ⁓ Dr. Jeremy Manuele (29:07) We also have instructions for how to clean them because that's not something we've talked about yet, but staining is an issue regardless of what any company may tell you. 100 % it's an issue, but that's an issue that we are working through and we can talk more about that too if you want. Alison Werner (29:11) Yeah. Okay. Okay. Yeah, definitely. OK, so let's before we go down that path, let's talk about you just talked a little bit about this, but what are the biggest pros and cons compared to the other aligner systems on the market? Dr. Jeremy Manuele (29:31) Yeah, let's break it down. know, the biggest pros, right? So the biggest pro in my opinion is the ability to use less or no attachments and the ability for the teeth to track more precisely and achieve movements that we otherwise couldn't or less predictably achieve. So those are the biggest benefits. As an orthodontist, it's like those are my, those are the biggest takeaway nuggets. I can get through my cases more predictably with less attachments, like 100%. Those are the big ones. Now, other benefits, yeah, mean, less waste to the environment. You can print them directly in your office, so turnaround times can be very short. ⁓ It's easier as far as manual labor goes. You're not trimming models with instruments and slipping and accidentally hitting your finger, whatever. So from a safety standpoint, those are all good benefits as well, but kind of more incidental. The big things is like, hey, I can move these teeth better. I can move these teeth faster. I can move these teeth with more precision and cost, right? Like if you can dial the system in, Alison Werner (30:16) Mm-hmm. Yeah. Dr. Jeremy Manuele (30:31) and you can use less aligners and less treatment time, you're going to pay less because you won't need $1,000 per case. You won't need that many aligners. You can finish much, much faster. So those are the big, big benefits. Now let's talk about the drawbacks. And again, this is as we're recording. September 25th, 2025 is when we recorded this, right? So drawbacks as of this date, right? So I would say one of the biggest drawbacks is staining. And again, staining is, and a lot of docs are like, okay, well they stain, I'm not going to use them. Well, okay, that's fine. But like, Alison Werner (30:38) Mm-hmm. Yeah. Dr. Jeremy Manuele (31:00) Staining in my opinion is a pretty minimal trade off and also something that you can work through. So that's what we've been doing. When we first got the aligners we noticed that many of them would stain. I put them in my own mouth after I brushed my teeth only as retainers. I didn't eat food, I didn't drink anything and literally the aligners would stain to some extent. Now was it severely stained? No, but it was stained noticeably. You look at it, it's like, that's not as clear as it used to be. So the reason that these aligners stain is because it is a layered material. It is not Alison Werner (31:17) okay, okay. Dr. Jeremy Manuele (31:28) one sheet of plastic that, like a window, mean, like your windshield doesn't stain, right? mean, everything just slides off of it. A sheet of plastic typically doesn't stain because it's one continuous sheet. These aligners are printed in layers. So even though you can't see the microscopic layers, they are there. And little small particles of food and saliva and whatever else that's in your mouth goes into those little microspaces and causes it to yellow, causes it to, you all the things. Alison Werner (31:40) Right. Dr. Jeremy Manuele (31:57) So, for most patients, I would say 80 % of patients, if they are using either a little bit of peroxide or an efferdent tab, and I tell patients to use the efferdent, polident, retainer right one of those, just because in addition to the staining, it actually makes the taste better too, which can be an issue as well. We can talk more about that. So, 80 % of patients, if they do that, they're not going to have issues with staining. So, that eliminates four fifths of the problem right there. So, now we have that last 20%. Alison Werner (32:13) Yeah. Okay. Mm-hmm. Dr. Jeremy Manuele (32:25) So, you know, and maybe it's closer to 15, but there are some patients whose aligners stain very quickly and very severely. I mean, you would have to show some pictures online, like dark, dark, like darker than you've ever seen a retainer, essentially. It's pretty wild. Yeah. So for those patients, what we have found works the best ⁓ is 3 % hydrogen peroxide mixed with an effluent tap. So instead of mixing it with water, you mix it with peroxide. Alison Werner (32:34) Ha. Okay, okay. Dr. Jeremy Manuele (32:53) Now you can't boil peroxide, it gets all foamy all over the place, so you kind of have to do your boiling protocol and then your cleaning protocol or the opposite. You do your cleaning protocol and then your boiling protocol. You can't do them both at the same time if you're using 100 % peroxide. But we even have experimented, you can get 12 % peroxide on Amazon and pretty much like that'll kill anything. I'm not recommending that to my patients because you get it on your hands and your hands are turning white. It's bleaching everything. Alison Werner (33:16) God. Dr. Jeremy Manuele (33:20) So yeah, it's very, very strong. But yes, typically with just a regular 3 % peroxide and a cleansing tablet, it's going to take care of that extra 15 to 20 % that do stain more. And initially, we didn't know how bad this was. So we had patients come back, and they're like, I'm not wearing these. I can't wear these to school. Look at this. I'm like, oh, OK. Well, we got to figure this out. So that's when we started just trying things out. What's working? Alison Werner (33:39) Yeah. Dr. Jeremy Manuele (33:45) enzymatic tabs that we had ordered I think from Henry Schein. Like we were chatting between, we were researching like what can we do to get rid of the staining and that's what we came up with that seems to work the best ⁓ is the hydrogen peroxide with the disclosure or with a cleaning tablet and ultrasonic. Sorry, I should mention and ultrasonic. So we put those in your typical ultrasonic cleaner. So LuxCreo does make ⁓ an ultrasonic cleaner that does heat up but I don't know if it's like Alison Werner (33:48) Yeah, Yeah. Okay. Okay. Dr. Jeremy Manuele (34:15) widely available yet. So we ordered one and kind of tried it out, but we're not providing it for our patients yet. If you go on Amazon, they make some really good ones. like $35. It's an ultrasonic and it also has a UV light. The UV light actually does interact with hydrogen peroxide to that. That's like, you know, zoom whitening. That's the same principle, right? So you have the bleach and then you have the light and those two together work best. That's the same thing. You get a $35 ultrasonic UV light cleaner on Amazon. Alison Werner (34:16) Okay. Yeah. Mm-hmm. Mm. Yeah. Dr. Jeremy Manuele (34:41) You put some hydrogen peroxide and a disclosing tablet in there and it takes care of the sanding. So yeah, it works great. Alison Werner (34:47) Okay. Okay. And then the aligner quality is holding up for the for that stage with no problem. Dr. Jeremy Manuele (34:51) Yes, we have not had any issues with degradation ⁓ of the aligner quality due to the cleaning. So we haven't talked about breakage yet, that's a thing as well. And so we'll go through that. But no, due to the cleaning itself, there's been no patterns of like, well, I did this many boiling sessions or whatever. And in fact, we have had patients that just aren't as compliant, that instead of changing them out every week or two weeks, mean, they may change them out every three weeks to a month, and they're still boiling them every night, and the aligners are still holding up. Alison Werner (34:57) Okay. Okay. Dr. Jeremy Manuele (35:20) I don't think that that process is super degrading to the aligner itself. I'm sure at some point it causes stress on it, but that's not the biggest thing. Breakage is caused for other reasons. Yeah. Alison Werner (35:27) Okay, Okay, so talk to me a little bit more about the drawbacks. So we did staining breakage. Dr. Jeremy Manuele (35:34) Yeah, so we can talk about breakage. So we've all had aligners that can crack, right? That's something that we're familiar with from traditional sucked down aligners. Things can crack and things can break off of clear aligners as well. The longer that you have sucked down clear aligners, the more likely things are to fracture. If you don't believe me, just have one of your patients come in that has had a retainer for two years and try squeezing the back of it to adjust it, it's going to snap most likely. So ⁓ they start out very more flexible and then over time they get more rigid. with the 3D Direct Front Aligner material, ⁓ there is ⁓ a certain level of rigidity that I would say is, ⁓ I don't know how to describe it, but we'll have issues with certain patients where when the force is high enough, you will see failure fracture of the aligner material itself. So for instance, maybe they're a clincher and they're biting down on their maxillary or their mandibular right second molar, and then they just bite, bite, bite, bite, bite, and they hit this one spot all the time. Alison Werner (36:21) Okay. Dr. Jeremy Manuele (36:32) Well, it can cause basically that piece to of like fracture off essentially. We've seen that a handful of times. ⁓ Some other interesting things, and this is something I had never seen before. You're familiar with the concept of turbos to open a bite, which basically means that we build in the aligner, not on the teeth, but we build in the aligner these little ramps. And these ramps are what the lower teeth bite into. And the idea is that as you're biting on these ramps, it's either pushing the upper teeth up into the gums or the lower teeth down into the gums, and the bite is opening. Alison Werner (36:37) Okay. Dr. Jeremy Manuele (37:01) So we've used these turbos forever in order to correct deep bites and they're very, very effective. But most of the time with your turbos, ⁓ it's a hollow turbo, right? It's made on a suck down. So the turbo is printed on the model and then the suck down is done over the model. So the turbo thickness is the same thickness as the rest of the aligner. Well, with these direct print aligners, you don't have to do it that way. You can actually fill in that turbo. So now you have a solid turbo instead of a hollow turbo. Alison Werner (37:19) Yeah. Okay. Dr. Jeremy Manuele (37:27) So the hollow turbos, they would just crush. Like if you had too much force on them, they would just crush down and that one would be distorted. And I talk about the force decay, that would be distorted. And then you move on to the next aligner and you get some good force for a minute, then they crush it. And that's kind of how it went. And patients who crushed them really quickly tended to get less benefit from it. And patients who tended to just keep gentle forces on those turbos tended to get more benefit because it allowed time for that force to actually move the teeth. Well, now with these direct print turbos, that turbo is one solid block. Alison Werner (37:40) Okay. All Dr. Jeremy Manuele (37:56) So you can bite down on it, but it's not crushing, right? I mean, it's very, very solid. So if the turbo doesn't crush, then what we've discovered is, well, the other part of the aligner that's hitting the turbo can quote unquote crush or, you know, for lack of a better description, like fillet opens. We had this come in like last week. The patient's like, every time this aligner, it just splits in half. And I was like, it splits in half? Alison Werner (38:00) Yeah, yeah. Dr. Jeremy Manuele (38:19) I was thinking, okay, well maybe there's a crack somewhere, right? That can happen. Maybe they're pulling it off a certain way. But I look at the aligner and literally it's kind of split in half right at the canine And I'm looking at the case and I'm like, dang, there's a turbo right above that. And I have her bite down with a new set of aligners in and sure enough, that is the point where she's hitting. And it's just like because the turbo itself doesn't decay, all of that force is right on that one area. So what we did, and again, because we can customize this, is we made a note in her chart. Alison Werner (38:21) Okay. Yeah. ⁓ Dr. Jeremy Manuele (38:47) And my lab technician, Melanie, she is phenomenal. So she keeps notes on every single patient, on every single setting that we use, how tight the gap fill, the thickness of the material, gradient or not. And so anytime we have any issues with patients, she will write it down. We're not printing all the aligners at once. We're printing like the first three upper, three lower, and then we'll print six upper, six lower. And as we're going along, we're taking notes and we're making the aligner better and better and better and better. Alison Werner (39:07) Okay. Mm, okay. Dr. Jeremy Manuele (39:14) So as we get through treatment, it's only fitting better and it's only holding up better. So for that patient that we saw last week, we went ahead and made a note and said, hey, go ahead and do two things. So one, we're going to move that turbo ⁓ more palately or gingerly, however you want to think about it, so that it's not the only one hitting because there was other turbos as well. They just weren't hitting on them. So we adjusted those turbos to where they were more even. And we had her thicken up the incisal edge of that canine so that if they hit on that, it's not going to be as likely to split open. So again, you have the ability to do that now ⁓ when you notice that there is a problem with a case cracking or breaking. Yeah. Alison Werner (39:52) Okay, okay. Any other drawbacks? Dr. Jeremy Manuele (39:56) Let's see, we talked about staining we talked about breakage. ⁓ Okay, taste, taste can be a drawback. Now, I think that that is ⁓ mostly a post-processing issue. Yeah, so if you're post-processing correctly, ⁓ I don't think you're gonna have issues with taste. At least that's been my experience with LuxCreo I don't know, I haven't used Graphy enough to know. ⁓ I've only ever tried them out, they sent me a sample pair. ⁓ But with LuxCreo if you do the post-processing correctly, I don't see that as being an issue. ⁓ But if you're worried about it, then I would say those those cleaning tablets are good not only for the staining But it also is usually their minty right so when you pull it out of the cleaning tablet And you've done an ultrasonic like all that mintiness is you know throughout your whole aligner So we have not had issues with taste knock on wood, ⁓ but again we do recommend they use a cleaning tablet so that that could that could help with that ⁓ Yeah, other drawbacks we clear breakage. Alison Werner (40:36) Yeah, Okay. Dr. Jeremy Manuele (40:49) Yeah, so one of the other things is that these aligners do feel noticeably different in your mouth while you're wearing them. So traditional suck down aligners are smooth. It's one piece of material and so the external surface of the aligner is also very smooth. Like you can't really feel anything except for smooth surface and your teeth just sort of feel the same way but with plastic over them. So with these direct print aligner materials, it is printed in layers. Now granted the layers are a lot closer together. So like if you look at them with the magnifying glass, like the layers aren't as big as they are, let's say with a thermo form or with a direct print model that prints in bigger layers. But there are layers and when that actually prints, you can feel it in your mouth. So it kind of feels, it doesn't feel like sandpaper, but it definitely feels more rough compared to the feeling of a thermoplastic material. So if you have a patient who has been wearing traditional sucked down type of aligners, and then you give them a direct print aligner material and you don't say anything, they're going to notice. And they may or may not like that. I would say they would be more likely not to like that than they would be to like that because again, we tend to like smooth things. So when you feel something that rough, feel like plaque on your teeth feels rough. So it's not a feeling that you want to feel necessarily. So that's something again that you're going to want to get ahead of. You're going to want to preface that. You're to want to tell them, ⁓ Alison Werner (41:46) Mm. Okay. Dr. Jeremy Manuele (42:05) If they've worn aligners in the past or retainers in the past, just like, this is the brand new material. It's going to feel different on your teeth. This is why. And again, explain these are the properties that allow us to reactivate the memory, help your teeth move better so you don't have have attachments all over. Just start going over all the benefits again so that they understand, yeah, this is OK. Alison Werner (42:17) you Yeah, okay. So talk to me some more about how you're prepping the patient for this type of a aligner. Dr. Jeremy Manuele (42:28) Yes, so basically every time we have a new problem, we add that to the list of things we talk to them about in the beginning. At the end of the day, it's like we don't want to over promise and under deliver. We want them to have a great experience. We want them to get a great result. And we want to make sure that we're as transparent as possible. So the benefits of these systems are real. They will finish with less attachments. They will finish earlier. Their teeth will track better. Alison Werner (42:32) Okay. Dr. Jeremy Manuele (42:57) But there are these drawbacks as well. They might break. We have to customize them. It feels a little bit different. They can stain, all these different things. And I think that is the biggest reason why this hasn't taken off more than it has. Because the companies behind it are oftentimes, they're underselling the problems. They're only talking about the benefits. And when doctors actually start to use them, well, they see the problems. Alison Werner (43:17) Mm-hmm. Dr. Jeremy Manuele (43:21) But a lot of docs aren't as motivated or interested in fixing them, right? So it's like, this is a problem. I don't need a problem right now. I'm just going to go back to what I was doing or go to something else. I think that for any direct print aligner company out there, like I think that they should be very, very upfront with the current challenges. I mean, this is not like they're not going to find out. Like if they're using a lot of these aligners, they're going to see all of these things happen. So I would rather, you know, them be on board with helping us deal with these complications rather than us have to take these on ourselves and figure out every little thing that can happen. Alison Werner (43:38) Mm-hmm. Yeah. Dr. Jeremy Manuele (43:51) And so that, you know, and that's the thing. mean, like I'm not like working directly with, ⁓ look, I use LuxCreo Now that's the printer that I have. That's the aligners that I use. I chose them because all things considered, their force levels are a little bit higher than Graphy per aligner. And I felt that was a benefit, but like I'm not like on their clinical board of directors or whatnot. I mean, like if I have a big issue, I can email them. But I mean, truthfully, I probably should work closer with them so that in addition to just solving the problems in our practice, we could actually hopefully make some more, you know, systemic changes. Alison Werner (43:58) Yeah. Okay. Yeah. Yeah. Dr. Jeremy Manuele (44:20) and resolve some of these products more globally or some of the problems more globally. Yeah. Alison Werner (44:22) Yeah. Yeah. So, ⁓ so do you, okay, I'm just curious, do you send the patients home with any kind of extras? Or what are the instructions you're sending them home with? Because you mentioned the staining. What do you what are you telling them? Dr. Jeremy Manuele (44:33) Yeah. Yep. Yeah. So we have all the in-house, you know, branded aligner bags, blah, blah. So they get, they send them with their aligners and we also give them like basically a starter kit of Effordent tabs. So they have some, you know what I mean? Cause we want that with the last thing we want them to do is we tell them to do something and then they don't do it. And again, they have that negative experience, whether it's because, you know, they didn't do it or, or, or, or just because I would rather provide them with the potential experience right off the bat. So we'll give them whatever it is, three, four, five, six, seven ⁓ cleansing tablets so that starting day one they can use it. So now they know what that's like. Now if they run out and they choose not to use it afterwards, well at least they know that if they use it they'll be fine. And it may not be big deal to them. Maybe they stain a little bit, it's not a huge deal, they taste great, they're not worried about it, and that's fine, that's their choice, but I want them to have that at the beginning. So we give them that. Alison Werner (45:16) Yeah, right. Dr. Jeremy Manuele (45:27) And then we talk to them about the process and we give them written instructions on how to do that cleansing process. So it goes through the boiling, the procedure, like why, all the things is written out and we explain that to them before they go. And so yeah, that's kind of the process that we use when we deliver the aligners. Yeah. Alison Werner (45:42) Okay, and then in terms of patient feedback and just ⁓ appointments, how is that going? Dr. Jeremy Manuele (45:50) Yeah, we use direct remote monitoring. so, yeah, so all these patients, typically if they're more than six stages, if they're anything more than like a very limited case, they're all gonna be scanning weekly ⁓ or bi-weekly. So we'll have them, basically we'll be checking the fit, we'll be giving them feedback about wearing them, about doing the boiling protocol. Like we'll check in on all those things to make sure, hopefully make sure they're compliant. Alison Werner (46:12) So now let's talk about the workflow for the doctor and the staff. Is it more efficient or more demanding? You talked a little bit there about how with your lab tech, she's only printing so many at a time. So tell us more. Dr. Jeremy Manuele (46:17) Yes. Yes, yes. So yeah, so it's a great question. So to answer that directly, as of right now, it is definitely more demanding from a computer standpoint, 100%. Like probably doubly more demanding from a computer standpoint. But it's quite less demanding from a fabrication standpoint. So basically the way that it works is you have to kind of have ⁓ two or three different softwares. Alison Werner (46:39) Okay. Okay. Dr. Jeremy Manuele (46:52) So you have to have your tooth moving software, right? So I use uLab there are other ones out there, but you have to have your tooth moving software. ⁓ LuxCreo, think, has their own kind of tooth moving software as well that I haven't really used or experimented with, but you have to have something to actually move the teeth. So once you move the teeth and you have the stages, you have like, okay, here's our 10 stages that we're gonna do. Now you have to export that into the software that will then generate the actual aligner. So the aligner shell itself has to be Alison Werner (47:05) Okay. Okay. Dr. Jeremy Manuele (47:22) generated. It's not just like you give it the model and it's like, let me spit out an aligner for you. That'd be great. Maybe one day that'll be what it is. But as of right now, ⁓ the beauty of it is you can customize it. But the bad part about it is you have to do it for every single stage. So if you have 20 stages, then you have to go through and design every one of those aligners. labeling and thickness, if you add it here versus there, all the settings, they have to be copied to each individual stage. Alison Werner (47:26) Yeah. Okay. Dr. Jeremy Manuele (47:49) So there is like an AI feature that sort of like automates some of that for you and can spit out aligners much faster. But if you do that, again, you lose a lot of the customization. And so again, like a lot of docs are like, ⁓ this sounds great. I just want to use the AI. the company is like, you know, they're selling this AI as if it's like, know, work on everybody. And it may work on like a lot of patients, but there's a lot of patients that it won't. So like if you really want to have consistent quality results, like right now with the current systems, you have to customize it to some extent. Alison Werner (47:53) Okay. Okay. Uh-huh. Okay. Okay. Dr. Jeremy Manuele (48:18) and that takes time. Now a lot of docs are trying to take that on themselves and I think that's a mistake. Like that part doesn't have to be done by you. In fact, I don't even hardly know how to use that software at all. Like I've only, I like I trained on it like once when we first got the printer. I haven't opened the aligner designer software since January when we trained on it. Like my lab technician, Melanie, she's like, she's amazing. She does everything. So she like, know, she like I'll make notes to her. say, Hey, you know, Alison Werner (48:26) Okay. Okay. huh. Okay. Dr. Jeremy Manuele (48:44) print it this percent or do like extra tight or not tight or do like ⁓ trim the aligner ⁓ scalloped or straight or extended this much. I'll give notes about what I think might be needed for that case based on their anatomy, based on how proclined the teeth are. So I'll give her some ideas. But again, she's been the one collecting feedback and data. So every time we get feedback on how it fits, it goes into that binder. She's pulling up the case and looking at it. It's like, Well, those crowns were pretty short and it fit this way. So next time let's try this. So she's actually able to dial it in probably better than me. So I give her feedback based on what I think and then she kind of meshes that feedback that I give her with her own experience and the data she's gotten from the patients as we give her chair side feedback. Alison Werner (49:28) Okay, and talk to me about like, what was her experience before you started using direct printer aligners? Dr. Jeremy Manuele (49:34) Yeah, so she'd done quite a bit with 3D printing in general. So she was around when we ordered our first 3D printer, right? So she had gone through different softwares, uLab Arcad, all the things, and she went through onboarding model printing, and then she went through onboarding indirect bonding tray printing. So she had already done both of those. We use SprintRays for those two processes. So I actually have three printers. One I use to print models, one I use to print digital indirect bonding trays, and then one we use to print the direct models because I hate swapping out resins. I mean, the LuxCreo printer can do all three. We could print everything that we need on one printer, but then you've got to swap out resins and it's mess. So we have three different processes. So LuxCreo was the third process that she had integrated into our practice. So she did have experience with 3D printing in general. Alison Werner (50:05) Okay. Mm-hmm. Right, yeah. Okay. Dr. Jeremy Manuele (50:23) but just not that specific type. And there are some differences. For instance, the build plate is more of a membrane. The build plate is almost made out of ⁓ a nylon, Kevlar-type material. It's not metal. You don't scrape it like you do with the metal ones. So there are definitely some nuances, some differences, because the precision of these aligners is much, much higher. And when it came for me, ⁓ onboarding this process, one of the reasons I decided to go with LuxCreo is that they have a completely Alison Werner (50:38) her. Dr. Jeremy Manuele (50:52) integrated system, meaning that every single step of the process is controlled by them and you use their stuff. So the design of it to the printing of it to the post processing of it to everything. So Graphy is open source. So essentially you can use different like Graphy is a material and you can use different printers to use it. And so the plus of that is that you can probably get involved with it and use some of the equipment that you already have. But the downside of it is you do lose a little bit of the ⁓ Alison Werner (51:11) Mm. Dr. Jeremy Manuele (51:21) I don't know I want to say quality control, but the predictability of having the same system. Everything about LuxCreo has been designed from start to finish for that specific system. Whereas with Graphy, it's a material and then the printers and the different things are kind of like worked backwards to fit that resin, if that makes sense. Yeah. Alison Werner (51:24) Mm. Okay. Okay, yeah. Okay. And so in terms of her workflow, she's doing that CAD design then. understands that software. And then she's doing the printing. ⁓ What's the post-processing like? Dr. Jeremy Manuele (51:46) Yes, yes, yes. Yeah, so the post-processing is more involved than model printing. essentially, there's multiple alcohol baths instead of just one. have basically, it's kind of like an initial alcohol bath and then a final alcohol bath. And then they have the curing unit induces heat as well as light. So the post-processing does take longer than with a traditional model. So I think the total post-processing time is about an hour-ish, like a total. Yeah, so in the printing time, you know, it's probably like 25 minutes. You can fit about 12 arches on a build plate. So basically you can spit out about 12 arches per, let's say, hour and a half. ⁓ So we routinely will do next day deliveries. And sometimes even same day. Like if it's the early morning, she can get it done by the afternoon if a patient wants to start same day. But routinely we'll do next day. So let's say they come in and they want to get started. So we can generate the quick three, which is like the first three aligners. We get those files out. She designs them, gets them printed. Alison Werner (52:38) okay. Dr. Jeremy Manuele (52:50) ⁓ By the that whole workflow is done, it's probably four to six hours. If we do it by the next day, that's great. That's pretty easy to do. Alison Werner (52:56) Yeah. Okay. And then you said before that she's only printing so many aligners at a time for the patient. So like maybe the first three or something like that. Dr. Jeremy Manuele (53:02) Yep. Yep. Yeah, so we always start out with a quick three and the quick three, that's a ⁓ protocol that we used even before direct print aligners for anything that was in house. The quick three, what it does is even before we were using direct print aligners and when we using more attachments, the first three aligners were just quick, they were easy, the patient can get started and it does a couple things. So one is it kind of starts the physiology of the tooth movement. So they're wearing aligners, the teeth are starting to move. So you're kind of activating all the processes if that makes sense. Two, it allows them to get used to the aligners without attachments on them. Alison Werner (53:36) Yeah. Dr. Jeremy Manuele (53:36) So, you know, they don't have like attachments, rubber bands, IPR, like whatever else may be involved in the case. Like that doesn't start until six weeks in when they're already very comfortable wearing, you know, aligners at that point. ⁓ And so, you know, when we switched to direct front aligners and when we started using more of those, we just continued that same workflow. ⁓ But the difference is like now come that six week visit, there are a number of cases we don't add any attachments to. Like if the clinical crowns are a little bit longer or there's significant undercuts, like we don't add attachments. We just let the undercuts and the crowns ⁓ you know, use that as undercut. ⁓ If the crowns are short and they're like little nubby teeth, like then we will make the gingival margins longer. So we'll extend the gingival margin of the aligner so it covers the gums a little bit and we'll thicken the area where the small bit of undercut is so we can get again good retention and we'll shrink the model down a little bit. So we'll do all those things to get better retention on short clinical crowns. Alison Werner (54:28) Okay. All right. Big question. How does in-house printing affect costs, lab fees and profitability for practices? Let's talk about cost. Dr. Jeremy Manuele (54:37) That is that that yeah That is a great question and out of all the things that I nerd out on like cost is one of those things that I just I Don't nerd out on that quite as much so I so Bill Layman He uses LuxCreo and and I know he's dialed it down to like the penny Calculating in the staff time with the computer with the waste with everything I want to say that the like the material costs are around six dollars an aligner The resin is the most expensive part I want to say like and it's way more expensive than model resin for sure Alison Werner (55:03) Okay. Okay. Dr. Jeremy Manuele (55:07) So I want to say that the actual average aligner, it's between $4 $6 per aligner is just the resin portion of it. Then you have to add of course the purchase of the machine and the longevity of the machine and when you have to swap out the membranes and again your staff time. So I don't know, mean it's probably somewhere between $12 and $16 if I had to guess. ⁓ But it's way less than $1799 a case or whatever. You know what mean? That's all I focus on. ⁓ Alison Werner (55:14) Okay. Yeah. Okay. Right. Yeah. Dr. Jeremy Manuele (55:35) paying way less than I would be ordering a case from any aligner company. so yeah, the math pencil's out for me. But for me, it's more like, this is super cool. It allows me to do some things that I haven't been able to do in the past. And yeah, the costs are only gonna get better, right? As technology improves, there's gonna be more competition, there's gonna be more resin companies that come out, there's gonna be more printers capable of doing things at lower costs. So I figure if it's already cheaper now, it's only gonna get cheaper than that. Alison Werner (55:38) Mm-hmm. Yeah. Dr. Jeremy Manuele (56:03) And so, yeah, so I see the cost as definitely an overall net positive, but that wouldn't be the reason I would do it. Because if the reason you're doing it is cost, you're not going to spend the time that you need to to work through some of the kinks. You just want it to work the same or something and pay less, that's not the answer for you. Yeah. Yep. Yep. Alison Werner (56:08) Yeah. Okay. Mm-hmm. Yeah. Okay. So what's next for you in terms of moving this process forward and integrating it further? Dr. Jeremy Manuele (56:25) Yeah, so my next thoughts are we need to work with companies to get this integrated in a way where some of this manual process that we're currently doing is now a plug and play and or we do have actual systems or rules where we can order a case and depending on how many teeth they have, depending on how many teeth they're missing, depending on how tipped the teeth are, depending on how long the clinical crowns are, depending on how much undercut there are. Like the software, especially with AI, it should be able to figure that stuff out for us. Like if we give it some guidelines, it should be able to produce an aligner that fits every time and that has the appropriate amount of retention per tooth. Now know it's not simple, I know it's not easy, otherwise someone would have already done it, but it is possible. And so for me, I want to integrate with companies who are willing to listen and to make changes and get this material better on a more global level because that's what we're going to need. Alison Werner (57:01) Mm-hmm. Yeah. Dr. Jeremy Manuele (57:21) if we're going to have more broad adaptation. But it's the same thing that happened with direct print models. When we were first printing models, you had a handful of us out there that were printing models, and everybody else was like, man, they're dealing with a lot of stuff. Man, these guys are dealing with a lot of And we were, right? But we worked through that, and again, more companies came on the scene, more innovation happened. Every time a new company joins the market, better stuff happens. Alison Werner (57:34) Yeah. Mm-hmm. Yeah. Dr. Jeremy Manuele (57:45) I mean, you saw that with Invisalign. For years, they were the only player in town. Now there's 100 aligner companies. And look how far aligners have come since that happened. So yeah, the more companies that get in the game, the more orthodontists that get in the game, I want to collaborate with more like-minded people like that in order to really advance this and make it even better than what we're doing today, not only from its potential capabilities, but actually the entire system be better. And I think that's where it's going. Yeah. Alison Werner (57:49) Yeah. Okay, and then final question. What's your advice to your peers who are thinking of onboarding this type of technology? Dr. Jeremy Manuele (58:19) Yeah, well, so one thing would be like, wouldn't make this my first printing technology, truthfully. Like, I would start with models. You know, like, just get comfortable doing, yeah. Yeah, yeah, 100%. Yeah, so my advice, I would do your own research, right? I mean, like they say, the two big players are Graphy and LuxCreo . There are pros and cons to both of them. So I would do your research and figure out what's gonna work best for you ⁓ as far as, you know, there's software differences, for instance. So depending on what you're doing, I would definitely Alison Werner (58:24) Definitely, yeah. Yeah. Let's assume they have a 3D lab already. Dr. Jeremy Manuele (58:49) do some homework there. And then I would say like honestly like if you're at a volume where you can justify the cost of the printer, I think the printers are around 20 grand or so, like if you're gonna make that up in a couple months cases for instance, like I would just do it. Like schedule some time and like just jump in because you're not gonna learn until you actually get your feet wet so to speak. The onboarding process was very good with LuxCreo. Like you have to go through this whole ⁓ video like four hour training process, like to even unbox it. They're like, hey, don't touch this box until you've watched these videos. So Melanie and I, we watched them together, but it's good. I mean, we learned a lot of stuff. We're taking notes because again, the processes are different. So that's important. But yeah, I I would do it. have a doc reach out to me last week and actually, I don't want to say this. I'm not offering to do this for anybody, so don't email me. But he was on the fence about whether to order one. I'm like, dude, just send me a case. I'll print it for you. You can try it out. Alison Werner (59:24) Okay. Dr. Jeremy Manuele (59:47) And LuxCreo might do that for you, or Graphy might do that for you, I don't know. If they will, great, take them up on it. But just know that it'll allow you to try a case, but it's not going to allow you to try a case ⁓ with a lot of customization. You have to do that on your own right now. So if you're going to have those companies try out a case, I would say try out a crowded case with normal length teeth. So not too long with a ton of recession, not too short. just do like a normal length with that get good decent, know, normal mild to moderate amount of crowding and try it out with that because the AI settings that they use are pretty good for that type of case. So yeah, I would say if you want to just try one, try it out like that. But honestly, like you're not going to get really good at this nor you're going to see like a ton of benefit from this unless you actually do it. So yeah. Alison Werner (1:00:32) All right, well, Dr. Manuele thank you so much for your expertise and sharing your experience with this technology. Really appreciate it. Dr. Jeremy Manuele (1:00:40) Thanks Alison, glad to be here and yeah, we'll catch up again soon. Alison Werner (1:00:43) Definitely.