lingual orthodontics

Seminar by:Dr. Tony Pious

LINGUAL ORTHODONTICS

CONTENTS• Introduction

• Historical perspective

• Bracket system

• Patient selection and Diagnostic considerations

• Bonding technique and Different lab procedures

• Biomechanics and comparative biomechanics

• Extraction and non extraction mechanics

• Lingual straight wire technique

• Keys to success in lingual therapy

• Conclusion

• References

INTRODUCTION

Why Lingual Orthodontics ???

With more number of adult patients desiring orthodontic treatment, special aesthetic demands of the patients pose a great challenge to the orthodontists.

These patients have professional and social commitments and cannot accept ‘visible braces’ even for a short time.

To serve such patients, the orthodontic community came out with the ultimate aesthetic solution – Lingual Orthodontics.

Lingual orthodontics, apart from offering the aesthetic benefit, also provides several mechanical advantages. Since its inception in the 1970s, great advances have been made in this modality.

At present, Lingual orthodontics is a complete system in itself and encompasses accurate diagnosis, treatment protocol, clinical and laboratory procedures.

Historical perspective

• In 1726, Pierre Fauchard suggested the possibility of

using appliances on the lingual surfaces

• In 1841, Pierre Joachim Lefoulon designed the first

lingual arch for expansion and alignment of the teeth.

• Mershon – Lingual arch.

• Goshgarian – Transpalatal arch.

• Ricketts – Quad helix.

• Wilson – 3D Modular Enhanced Orthodontics.

• Submitted concept in 1967

• In December 1979, Dr. Kinya Fujita, of

Kanagawa Dental University, Japan.

• First lingual multi-bracket system with mushroom

shaped archwires.

1967

1980

Patent for the Fujita lingual bracket (US patent No. 4,209,906).

Dr. Craven Kurz (UCLA)

1973-1975

Anterior inclined plane (missing link)

• Shearing force converted to compressive force

1982

Patent for the Craven Kurz lingual bracket (US patent No. 4,337,037).

• In December 1980, Ormco decided to put together a team of orthodontists (the

Task Force ) to study the appliance further and make suggestions regarding

improvements.

• The Task Force members :

i. Dr. C. Moody Alexander

ii. Dr. Richard (Wick) Alexander

iii. Dr. John Gorman

iv. Dr. James Hilgers

v. Dr. Craven Kurz

vi. Dr. Robert Scholz

vii. Dr. John (Bob) Smith.

• The Task Force was initially charged with the responsibilities of evaluating the

appliance design over a two-year period.

• Their specific objectives were:

1. To help refine bracket design (dimensions, torques, angulations, thickness, etc.).

2. To develop mechanotherapy techniques.

3. To create archwire designs.

4. To discuss treatment sequences.

5. To determine case selection criteria.

• Kelly (1982), who used Unitek labial Brackets on the lingual surfaces.

• Paige (1982), who used Begg light wire brackets on the lingual surfaces.

• 1984 TARG machine launched by Ormco as an important aid in laboratory

technique.

• 1986 Didier Fillion developed Electronic TARG

• Société Française d’Orthodontie Linguale (SFOL),-1986

• The American Lingual Orthodontics Association (ALOA),-1987

Lingual fever

• Public interest continued to grow.• Rushed the product to the market immaturely.

The Fall

• Following this initial euphoria-a period of frustration, disappointment and rejection due to poor stantard of completed cases.

• A truly clear, stain-resistant labial bracket was introduced – Star fire by A company

• Enthusiasm for lingual therapy waned in the profession, and commercial interest also declined

The original Ormco Task Force was reduced to just three members by 1988 Dr. Kurz, Gorman, Smith named KGS Ormco Task Force 2

• The lingual appliance had been made available to the public before testing was complete.

• Orthodontists inadequately trained with lingual therapy were treating patients in record numbers.

• The public had high expectations from this treatment and demanded it from the profession immediately

Difficulties encountered during the development of the lingual appliance:

1. Tissue Irritation and speech difficulties

2. Gingival Impingement

3. Occlusal Interference

4. Appliance Control

5. Base pad Adaptation

6. Appliance placement and bonding

7. Appliance Prescription

8. Wire placement

9. Ligation

10.Attachments

• Creekmore (1989) developed a complete technique with vertical slot lingual

brackets, together with a laboratory system.

• European Society of Lingual Orthodontics (ESLO)-1992

• British Society of Lingual Orthodontics (BLOS),

• World Society of Lingual Orthodontics (WSLO)

• Associazione Italiana de Ortodonzia Linguale (AIOL)

1987-1996

• In Israel, Lingual Bracket Jig for direct and indirect bonding was introduced.

• Rafi Romano-edited a book presenting an update on the state of the art

of lingual orthodontics.

Furthermore, they founded the virtual journal www.lingualnews.com and a

lingual orthodontics forum that facilitates the interchange of information

between interested clinicians.

Relauncn• In 1996 Craven Kurz founded Lingual Study Group with

aim of relaunching lingual orthodontics in United States.

• ALOA was reactivated in 1997

• Korean Society of Lingual Orthodontics (KSLO).

• The Japanese Lingual Orthodontics Association (JLOA)

Renaissance• 7 generations of Kurz lingual brackets• 2D and 3D brackets• Lingual self ligating brackets• STB brackets• Lingual staight wire system• Improved indirect bonding procedures• Improved lab procedures• CAD/CAM in lingual orthodontics

• During the last decade, the percentage of patients treated with lingual orthodontics has increased and the technique has developed to such an extend that in some cases its easier, quicker and more accurate than traditional buccal orthodontics.

BRACKET SYSTEMS

GENERATION 1

1976

018" slot that face lingualy

• Flat maxillary occlusal bite plane from canine to canine and rounded margins.

• Lower incisor & PM brackets were low profile & half round.

• No hooks on any brackets

DR. KURZ AND COWORKERS

GENERATION 21980

Hooks were added to all canine brackets

GENERATION 31981

• Hooks were added to all anterior & PM brackets.

• The first molar had bracket with internal hook.

• The second molar had terminal sheath without hook.

GENERATION 41982-1984

Low profile anterior inclined plane in central & lateral incisor.

Hooks were optional based on treatment needs & hygiene concerns

GENERATION 51985- 1986

• Increased labial torque in the maxillary anterior region.

• Bite plane became more pronounced

• Molar brackets included an accessory tube for a transpalatal bar

GENERATION 6

• Hooks were elongated.• TPA attachment is

optional.• Hinge cap tube for the

second molars.

1987- 1990

GENERATION 7

• The square bite plane became rhomboid shaped, increasing the interbracket distance.

• Premolar brackets were widened mesiodistally for better angulation & rotational control.

1990 to present

The lingual appliance most widely used today is the generation VII appliance,

developed in 1990 by Ormco Corp.

• The VIIth generation brackets are much refined, low profile, patient friendly

brackets.

• They have a horizontal slot, and are offered in either an 0.018" or 0.022"

slot size.

• The bite plane on the maxillary anterior brackets is heart-shaped. It is

parallel to the archwire and occlusal plane.

Significance: The bite plane allows placement of all brackets during initial

bonding even in cases with severe deep bites. The patient’s occlusion is

located on the bite planes of the anterior brackets. • Possibility of repositioning the mandible.• Extrusion of the molars, intrusion of the incisors and facilitating any

expansion and mesiodistal movement of molars uninhibited by occlusal forces.

• Correction of crossbites, bites, rotations and space closure can be achieved at an accelerated pace without the interference of occlusion.

• At the same time, anchorage loss, bowing of the buccal segment, loss of arch coordination and extrusion of molars are made easier without the controlling effect of the forces of occlusion.

• Multiple molar attachments are available, including a tube, a twin bracket and a hinge cap or terminal sheath (a convertible bracket that can function as a tube or a self-ligating slot).

• All brackets have a gingival ball hook which facilitates elastic ligature placement, rotation control and placement of intra- and inter-maxillary elastics.

• The ideal archwire has a mushroom shape. This is due to the large constriction in arch width that occurs as one proceeds distally from the lingual surface of the canine to the bicuspid.

FUJITA LINGUAL BRACKET

RYOON KI HONG, HEE WOOK SOHN, JCO/MARCH 1999

(OS = 0.019 “; LS = 0.018” ×0.025”; VS = 0.016”)

The presently available Fujita system is still based on an occlusal slot opening, but has multiple slots.

• Brackets for the anterior teeth and premolars now have

three slots: occlusal, lingual, and vertical.

• Molar brackets have five slots: one occlusal, two lingual, and two vertical.

• Each of the three types of archwire slots provides different capabilities for efficient tooth movements.

BEGG’S LINGUAL BRACKETS

• Dr. Stephen Paige introduced the Lingual

Light Wire technique in 1982.

• The bracket currently used in the Begg system is the Unipoint combination bracket (Unitek), with the slot oriented in the occlusal direction.

• The Unipoint bracket has a gingival "wing" to place elastic modules on continuous elastic chains.

(JCO1982)

Molar Tube Design:

• Oval tube with a mesiogingival hook.

• The squashed oval tube has some advantages in that it allows molar control, and will accept a ribbon arch.

CONCEAL BRACKETS

Thomas Creekmore

STEALTH BRACKETS

• Compact size and smooth contours for

increased patient comfort and better hygiene

• Full wire control with reduced friction

• An integrated vertical slot from anteriors

through first molars yields expanded versatility

and treatment options

• Reduced mesio-distal dimensions means

greater interbracket distance

• Takemoto and Scuzzo in 2001 found that the bucco-lingual distances at the gingival margins do not vary substantially. This led them to conclude that straight archwires could be used in lingual orthodontics if they were placed as close to the gingival margin as possible.

JCO 2001

STB (SCUZZO- TAKEMOTO BRACKET)

• STb system comprises of the most advanced lingual technology

• Incredibly comfortable for pt, minimal impact on tongue, speech

• Easy to use

• Utilizes a passive self ligation design that dramatically reduces friction & delivers lighter forces.

• STb social 6 easy to learn and use for beginners

• Flossing is easier as the archwire is farther from the lingual surface and incisal edge.

• Mesio-distal width of the bracket is smaller, allowing adequate inter-bracket distances.

• Rotations can be more easily accomplished as the archwire can be tied tightly to the bottom of bracket slots.

• Torque control is improved.

PHILIPPE SELF LIGATING LINGUAL BRACKETS

• First described by Macchi et al in 2002, the Philippe Self Ligating Lingual Brackets (Forestadent, St. Louis, MO) can be bonded directly to the lingual tooth surfaces.

• Since they do not have slots, only first- and second-order movements are possible.

• Four types of Philippe brackets are available:

- Standard medium twin bracket (most commonly used).

- Narrow single-wing bracket for lower incisors.

- Large twin bracket.

- Three- wing bracket for attachment of intermaxillary elastics and

application of simple third-order movements.

• Clinical applications:

- Post – treatment retention.- Closure of minor spaces.- Limited intrusion.- Correction of simple tooth malalignments

and mild crowding, especially in the mandibular arch.

FORESTADENT 3D BRACKETS

ADENTA- Germany-Hatto Loidl

• Self ligating

• Easy handling & archwire changes

• Closing springs designed as bite planes for lower incisors

• Perfect transmission of torque & angulation

• Occlusal archwire insertion

• Hygenic

IN- OVATION- L BRACKET FROM GAC

• Twin self lig bracket system gives a complete range

of control options simply by changing archwire

Advantages

• low profile

• Anatomically correct base design

• No plaque build up or periodontal impact due to

small size

• Fast easy placement of archwires

Disadvantages

• Due to small size ,diff to visualize spring clip

• Bracket base of lower anteriors too wide causing

difficulty in bonding smaller teeth

PHANTOM POLYCERAMIC SELF-LIGATING BRACKETS

• First tooth colored SL direct bonding lingual bracket made of composite polymer

• Tubes on pre molars to avoid speech difficulties

• Esthetic & cheaper than present indirect techniques

IBRACES (INCOGNITO)

• Print out of three-dimensional bracket-positioning chart assists in rebonding

ilingual

Armamentarium

Lingual ligature cutter (angulated 45º)

Lingual ligature cutter (angulated 90º)

• Utility plier

• Arch wire cutter

Mosquito forceps

Light ligature plier

• Lingual hinge cap opening tool

• Debonding plier

• Tongue retractor & saliva ejector

• First order bending fork

• Second order bendng fork

• Module remover

Advantages of Lingual Orthodontics

• Facial surfaces of the teeth are not damaged from bonding, debonding,

adhesive removal,

• decalcification from plaque retained around labial appliances.

• Facial gingival tissues are not adversely affected.

• The position of the teeth can be more precisely seen when their surfaces

are not obstructed by brackets and arch wires.

• Facial contours are truly visualized since the contour and drape of the lips are not distorted by protruding labial appliances.

• Tongue thrust habits are easily managed.

• Mandibular repositioning therapy.

Disadvantages of Lingual Orthodontics• More chair time is required.

• Cost generally is one-third more than labial treatment.

• Mandibular auto-rotation occurs because of the bite plane on the maxillary

anterior brackets.

• Vertical and transverse control of buccal segments often is difficult when the

teeth are disoccluded.

Lingual appliances are effective than labial appliance in following

– Intrusion of anterior teeth– Maxillary arch expansion– Combining mandibular repositioning therapy with

orthodontic movements– Distalization of maxillary molars

Patient selection & Diagnostic considerations

Patient selection

• Majority of malocclusions can be treated with lingual orthodontics, but certain cases are more amenable than others.

• Favourable cases• Unfavourable cases

Favourable Cases

• Mild incisor crowding and with anterior deep bite.

• Long and uniform tooth surfaces without fillings, crowns, or bridges.

• Good gingival and periodontal health

• Keen, complaint patient.

• Skeletal class I pattern.

• Mesocephalic or mild/moderate brachycephalic skeletal pattern.

• Patients who are able to adequately open their mouths and extend their

neck.

Unfavourable Cases

• Dolicocephalic skeletal pattern

• Maximum anchorage cases, unless treated with micro implants.

• Short, abraded, and irregular lingual tooth surfaces.

• Presence of multiple crowns, bridges, and large restorations.

• Patients with low level compliance.

• Patients with limited ability to open the mouth (trismus).

• Patients with cervical ankylosis or other neck injuries that prevent neck

extension.

Diagnosis

• General, with particular reference to esthetics

• Periodontal and gingival

• Dental, with particular reference to the presence of crowns and

large restorations

• Dentoalveolar discrepancy

• Vertical skeletal/dental problems

• Anteroposterior skeletal/dental problems

• Transverse skeletal/dental problems

• Surgical cases

• Preprosthetic cases

Vertical Considerations

• Using kurz 7th generation lingual bracket the built-in bite planes on the

upper incisor and cuspid brackets will interfere with the occlusion and result

in a posterior open bite.

• The lingual brackets on the maxillary incisors should be bonded to allow a

vertical distance of 2 mm from the incisal edge to the bracket, which allows

the case to finish with a normal overbite and good posterior occlusion.

• STB brackets do not have a bite plane.

• Stealth brackets have a removable bite plane.

Anteroposterior discrepancy

• Skeletal class I with Normal overjet

Skeletal class I with Increased overjet

Skeletal class I with Decreased Overjet

Skeletal class II and class III• In relatively mild malocclusions, they can be corrected

with extractions or intermaxillary elastics.

• Severe skeletal discrepancy require orthognathic surgery.

Transverse considerations

• Posterior cross bites can be treated before starting the lingual treatment

Surgical cases

• Consultation and joint planning with the oral surgeon should be performed

before the start up of treatment

• With these cases the best possible presurgical tooth position should be

achieved to minimize the post surgical orthodontic treatment time

• The patient must be consulted on the possibility of bonding labial brackets

just before the surgery to assist with the postsurgical fixation.

Bonding Techniques in Lingual Orthodontics

Direct Bonding Technique (JCO 1984)

Indirect bonding systemThese include:

1. Torque angulation reference guide (TARG).

2. Fillion’s indirect bonding system.

3. The customized lingual appliance setup service (CLASS) system.

4. The slot machine

5. Hiro system

6. The Ray set system

7. The lingual bracket jig.

8. The mushroom bracket positioner

9. TAD-BPD machine.

Torque angulation reference guide (TARG)

• Didier Fillion improved this method in 1987 by adding an electronic

device to the TARG machine with purpose of measuring labial-lingual

thickness

• This improvement reduced the number of first order bends in the wire,

compensating for the difference in tooth thickness

BONDING WITH EQUAL SPECIFIC THICKNESS (BEST)

TARG device Thickness measuring appliance ELECTRONIC TARG

• Using his DALI (Dessin Arc Linguale Informatise) computer program he produces an individualized archwire template

The Slot Machine

• Introduced by Dr. T.D.Creekmore in 1986, the Slot Machine was

meant to be used with the Conceal

bracket system.

• It also used a labial reference to

position the brackets like the TARG

machine.

The Customized Lingual Appliance Setup Service (CLASS) system

• Described by Scott Huge

• Brackets are placed on the idealized

model set up of patient malocclusion

• A flat metal plate helps positioning of

the anterior brackets

• Separate posterior device to position

the posterior brackets

CLASS SYSTEM

• Individual transfer tray is made for each tooth

• Brackets are transferred to the teeth of patient directly, or transferred to the

casts by using the cap technique and then to the patient using a full arch

transfer tray

• Adv – visualization of final occlusion on the articulated set-up

• Drawback- lengthy and tedious procedure

HIRO SYSTEM• Introduced by Toshiaki Hiro and later improved by Takemoto and

Scuzzo.• Method:

- An ideal archwire is made on the setup using a full size rectangular

archwire.

- The lingual brackets are transferred onto this wire and secured with

elastic ligatures.

- Single rigid transfer trays are fabricated for each tooth.

- The archwire is then removed and custom bases for brackets are made.

• Advantages:

- There is no need to transfer brackets from the setup model to the original

malocclusion model.

- Accuracy is improved due to individual transfer trays.

- Bonding of one tooth is not affected by position of other teeth.

- Rebonding is easier.

The Ray Set system

• This system utilizes a 3-dimensional goniometer for analysis of the

first-, second-, and third-order values of each individual tooth.

• Both pre- and post-setup values of individual teeth are evaluated

and the amount of orthodontic tooth movement for each tooth on the

setup model is calculated.

The Lingual Bracket JigDr. Silvia Geron in 1999 introduced lingual bracket jig

which is a chairside direct bonding system.

• It is used with a horizontal slot bracket.

• The jig transfers the Andrews Straight-Wire Appliance

labial bracket prescription to the lingual surface.

The LBJ consists of:

• A set of six jigs, one for each

of the six maxillary anterior

teeth, which present the most

morphological variation of the

lingual surfaces.

• An accessory universal LBJ for

the maxillary posterior teeth

(no torque or angulation

prescribed).

LBJ transfers labial bracket prescriptions to lingual brackets

A. Labial arm of LBJ positioned

on labial surface of tooth,

duplicating location of labial

bracket relative to LA point.

B. Lingual bracket automatically

placed in correct position.

ADVANTAGES:

- Lingual bracket positioning with the LBJ is simple and quick, and

requires no special training.

- The LBJ automatically incorporates the Straight-Wire labial

prescription into the bonded lingual brackets in all dimensions.

- This allows the orthodontist to perform direct as well as indirect

bonding as in-office procedures.

KOREAN INDIRECT BONDING SET UP SYSTEM (KIS)

• Developed by members of KSLO.

• Uses bracket positioning machine that allows positioning of all

brackets at once.

Advantages

Very precise & attainment of high standard of treatment

Allows for bracket hight difference between anterior and post teeth

Simpler and faster

KIS System

The Mushroom Bracket Positioner

• Developed by Kyung et al, in 2002, the mushroom bracket

positioner is a machine for accurate bracket placement on an ideal

setup.

• At present, 5th generation of MBP is available which places brackets

to accept a straight wire.

Simplified Technique

LINGUAL INDIRECT BONDING USING THE TAD AND BPD

CAD/CAM SYSTEMS IN LINGUAL ORTHODONTICS

BENDING ART SYSTEM

THE ORAPIX® SYSTEM

Virtual setup checking Brackets arranged together for the Straight-Wire technique

Virtual transfer jig. Real transfer jig.

Incognito

Dr. Wiechmann

• Brackets and wires are CAD/CAM customized on a model of the

patient’s setup at the beginning of treatment.

• Laboratory technicians fabricate a setup model according to the

orthodontist’s prescription.

• These models are used as a template to design virtual brackets and

wires.

• Virtual brackets are printed in wax and cast in a gold alloy.

• Archwires are formed by a wire-bending robot.

• Dental casts, brackets, and wires are delivered to the orthodontist

The Lingual Jet® system

Dr. Gualano and Dr. Baron

BONDING PROCEDURE

BANDING

BIOMECHANICS

NORMAL INCLINATION

LABIAL INCLINATION

LINGUAL INCLINATION

Lingual appliances are effective than labial appliance in following

– Intrusion of anterior teeth– Maxillary arch expansion– Combining mandibular repositioning therapy with orthodontic

movements– Distalization of maxillary molars

INTRUSION OF ANTERIOR TEETH

Severe deep bite correction

Anterior and lateral concern

• Patients with severe tongue thrust habit, the lingual appliance, due to the discomfort associated with tongue contact, redirects the tongue tip to the palatal vault in speech and swallowing.

• Anterior tongue thrust habit is eliminated and normal muscle balance is restored.

• Lingual appliance and lingual elastics create a fencing of the tongue musculature from the dentition FENCE EFFECT

• It increases the anchorage values

The six anchorage keys

1. Standard lingual bracket jig prescription for the anterior teeth, incorporating slight

extrapalatal root torque , molar tube placed off-center in a more mesial position and

incorporating a mesial tip to encourage molar tip back.

2. Reduced friction, using sliding mechanics together with bidimensional archwires

incorporating a rectangular anterior sections and round posterior sections or using

standard archwire and placing brackets on the posterior teeth with larger slot sizes

3. Posterior bite stops placed on molar teeth to open the bite.

4. Light class I, II or III forces for retraction or space closure.

5. In corporation of second molars in the anchorage unit

6. Incorporation of an exaggerated curve of Spee in the maxillary space-closing archwire

WJO - Geron, Vardimon

• Takemoto compared the anchorage loss in labial versus lingual extraction cases

treated with loop mechanics and found higher anchorage value of the posterior

dentition in lingual cases

Due to the proximity of lingual brackets to the center of resistance of the tooth .

Direction of forces during the space closure creates a degree of buccal root

torque and distopalatal rotation of the molar crown, which in turn produces

cortical bone anchorage.

Stages of treatment

Choice of extraction

Lower molar tip distally as the arch is levelled and this changes class 1 to

class2, therefore in class1 cases upper 1 pm and lower 2 pm is advised

In class 2 cases it is desirable to avoid extraction in lower arch, if crowding

is severe one or more lower incisors may be considered

In class 3 cases pm extn facilitates lingual tipping of lower ant teeth, distal

tipping of molars improves class lll molar relation.

Treatment Sequence— General1. Leveling, aligning, rotational control, and bite opening.2. Torque control.3. Consolidation and retraction.4. Detailing and finishing.

• These phases are generally characterized by a progressive increase in wire stiffness.

Wire sequence in lingual orthodontics

• First initial wire; .o16 NiTi - first initial wire

• Second initial wire;.o16 wilcocks heat treated special plus SS wire.

• Intermediate wire;.017x.025 TMA wire

• Finishing wire;.017x.025 or .016x.025 SS

• Detailing wire ; o16 wilcocks heat treated special plus SS wire

1)0.016 NiTi with increased crowding 0.016 Wilcocks sp+

Minimal crowding all Teeth bracketed

2) 0.017x0.025 TMA

3) 0.017 x 0.025 SS

4) 0.016 Wilcocks special + Finishing arch if necessary

If all teeth were initially bracketed

Bond all teeth initially unbracketted

a) Adv loopsb) Stops at 1st molars

a)0.016 x 0.022 ssb)0.018 sp +

EXTRACTION AND NON EXTRACTION

Second initial wire

Intermediate wire

Finishing wire

Stage I. Leveling, Aligning, Rotational Control, and Bite Opening.

Objectives

1. Initiate tooth movement with light forces,

2. Provide for a period of patient adaptation,

3. Eliminate rotations,

4. Level and align individual arches to permit wire progression,

5. Obtain initial torque control when required,

6. Establish posterior anchorage units with buccal segments,

7. Initiate posterior segment control with extraoral traction and transpalatal arch

when required,

8. Reduce any excessive overbite, and

9. Gain space for rotations and additional bracket bonding.

• This is achieved using lingual archwires having a low wire stiffness,

combined with complete seating of the archwire within the bracket slot.

• However, a common problem with lingual edgewise brackets is the difficulty

in obtaining complete archwire engagement and the tendency for the

archwire to be pulled out of the bracket slot.

HIGHLY TIPPED CANINE

DISTALLY TIPPED CANINE

HIGHLY and DISTALLY TIPPED CANINE

Partial canine retraction

Rotation correction

DOUBLE-OVER TIE LIGATION

ROTATION TIE

TORQUING LEVELLING

Two types1. Canines and incisors separately2. Enmasse retraction

Retraction mechanics

Sliding mechanics Vs loop mechanics during en masse retraction

Sliding mechanics Loop mechanics• Wire friction and uncontrolled Requires lot of skill retraction forces results in Difficult to bend the wires

anchorage loss different loops

Increased treatment time

LOOP MECHANICS DURING EN MASSE RETRACTION

Sliding mechanics

Maximum anchorage upper arch

• loop mechanics, combined with

TPA and buccal sectional arch

wire from 1st and 2nd molars for

stabilization

Moderate anchorage upper arch

• L loop mechanics combined with TPA

• The anterior segment and posterior

segments are figure eighted with

ligature wire

• In sliding mechanics, power chain is

placed from lingual of canine to the

lingual of 2nd premolar in 1st premolar

xn

MINIMUM ANCHORAGE UPPER ARCH

• Power chain is placed on both

buccal and lingual of the canine

and first premolar

• Class III elastics enhance the

mesial movement

Maximum anchorage lower arch

• An elastic power chain on the lingual side with buccal sectional arch for stabilization

• 0.017 x 0.025 TMA or 0.016 x 0.022 SS

• Class III elastics on buccal and lingual side

Moderate anchorage lower arch

• Sliding mechanics with reciprocal elastic forces

Minimum anchorage lower arch

• An elastic power chain is placed from

the lingual of the 1st molar, encircling

the canine and attaching to the buccal

of the 1st molar

• Class 2 elastic facilitate the mesial

movement of the molar

DETAILING

The Straight-Wire Concept in Lingual Orthodontics

1. Li-Point

2. Embrasure Line 3.Lingual Crown Height (LCH) 4.Lingual Straight Plane (L-S Plane) 5. Bracket Height (H

Advantages

Flossing is easier

Mesiodistal width is much smaller, allowing adequate interbracket distances

Less composite is needed on the mandibular molars to raise the bite

Rotations can be more easily accomplished because the archwire can be

tied tightly to the bottom of the bracket slots

Expansion in an anterior direction is more effective because the most

labially positioned tooth is ligated first.

Lingual retainers

1st Generation Retainer

• Plain ,round .032” - .036” Blue

Elgiloy wire with loop at each end

bonded only to canines

2nd Generation Retainer

• Three – stranded .032”wire without terminal loops which is bonded to canines.

3rd Generation Retainer

• Plain round .030” to .032”

diameter stainless steel wire with

sandblasted ends

Keys to Success in Lingual Therapy

JCO 1986 Craven Kurz et al

Key 1• Patient Selection.

• Oral Hygiene - Lingual patients must be well educated in oral hygiene and motivated from the beginning.

• Speech Adaptation and Tongue Irritation - Patients must be forewarned of temporary speech alteration.

• Variations in Tooth Size and Anatomy.

Key 2• Bracket Placement Accuracy – use of the TARG for accurate

bracket placement.

Key 3• Indirect bonding methods for bracket adhesion.

Key 4 • Maintaining vertical and transverse control of buccal segments.

Key 5• Double over ties on anterior teeth.

Key 6• Buccal and lingual molar attachments.

Key 7• Correction of rotations.

Key 8• Arch form and archwire sequence.

Key 9• Archwire stiffness and torque control.

Key 10• En masse retraction.Key 11• Light, resilient wire for detailing.

Key 12• Gnathologic positioner and retention.

Conclusion Lingual Orthodontics is the most aesthetic  treatment modality , and is the best

treatment option for adult patients, since the brackets are invisible, it provides a high

level of control, and is excellent for the treatment of all kinds of malocclusions.

Over the past 25 years there have been many improvements in appliance

design, laboratory and bonding procedures, and in clinical, mechanical techniques,

that simplify the lingual treatment. Thanks to the pioneers of Lingual Orthodontics,

Dr. Craven Kurz, Dr. Fujita and the Lingual Task Force of ORMCO company.

• thanks to the recent developments:  CAD CAM, small comfortable

and reduced friction brackets,   the lingual technique today is very

reliable and almost as easy as the labial technique.

• The history of lingual orthodontics has not been a smooth one. There was aperiod of initial euphoria as the technique made its clinical debut; this wasfollowed by a period of frustration, disappointment, and rejection. Thanks tothe effort of several dedicated clinicians, many of the issues responsible forthis decline have been overcome. We are now in a period of resurgence, thetechnique has become more sophisticated, the clinical results achieved canstand on an equal footing with the best of conventional labial techniques,and the acceptance of technique by the profession is growing rapidly. Thehistory of this technique is peppered by individuals who have shown perseveranceand ingenuity

Lingual orthodontics has come of age; its acceptance by both the profession

and the patient population continues to grow internationally. The future oflingual orthodontics is dependent on the following three important

issues:(1) advances in technology related to appliance design and laboratory

protocols;(2) demographic changes in population age groups—the growth inthe number of adult patients seeking orthodontic treatment associated

withan increase in affluence and disposable income will create a patient-

drivendemand for more esthetically acceptable appliances; and (3) attitudinalchanges of orthodontists.

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