In-Office Clear Aligner Therapy in Orthodontics: A Systematic Review of Digital Workflows, Clinical Effectiveness and Cost-Efficiency

Abstract

Objective: To systematically review and appraise the available evidence regarding the clinical effectiveness, digital workflows, manufacturing processes and cost-efficiency of in-office clear aligner therapy compared with commercially outsourced aligner systems and conventional fixed orthodontic appliances. Methods: A comprehensive literature search was conducted across PubMed, Scopus, Web of Science, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar for publications up to March 2026. Studies evaluating in-office or in-house clear aligner fabrication, digital orthodontic workflows, clinical outcomes and cost analyses were included. Reporting followed the PRISMA 2020 statement. Methodological quality was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomized controlled trials, the ROBINS-I tool for non-randomized studies and the AMSTAR 2 checklist for systematic reviews. Because of substantial clinical and methodological heterogeneity across studies, data were synthesized narratively; a formal quantitative meta-analysis was not undertaken. Results: Twenty-eight studies met the inclusion criteria. In-office aligner fabrication was associated with enhanced clinician control, reduced turnaround times and lower per-case costs compared with outsourced commercial systems. Digital workflows integrating intraoral scanning, computer-aided design software and three-dimensional printing produced clinical results comparable to those of commercial aligner systems for mild-to-moderate malocclusions. Directly three-dimensional-printed aligners demonstrated promising dimensional accuracy and reduced manufacturing steps, although clinical evidence remains limited. The overall quality of available evidence ranged from low to moderate. Conclusion: In-office clear aligner therapy represents a viable and cost-effective alternative to commercially outsourced systems, offering increased practitioner autonomy and faster treatment delivery. However, the evidence base remains limited and further high-quality randomized controlled trials are necessary to establish standardized protocols and confirm long-term clinical outcomes.