nterior lingual braces, placed canine-to-canine,offer a noncompliant, aesthetic alternative to re-movable orthodontic aligners. While the originof lingual braces dates back more than 30 years,

they have had a low level of popularity outside of Europe,Asia, and Australia until a recent resurgence in lingual ortho-dontics among American professionals and manufacturerswho are competing with and addressing the limitations oforthodontic aligners. This article will provide a briefoverview of two anterior lingual systems, Ormco’s STb Social6TM and GAC’s Innovation®-LMTM, and compare their advan-tages to those of removable aligners.

Historical PerspectiveLingual braces began in the 1970s when two independ-

ently working orthodontists—the late Craven Kurz, DDS, ofBeverly Hills, Calif, and Professor Kinja Fujita of KanagawaDental University in Japan—developed their own systemsfor placing braces on the inside surfaces of teeth.1

Interestingly, in Japan, the development of a lingual appli-ance was not a result of an aesthetic demand as in the UnitedStates, but was rather to protect the lips and cheeks of pa-tients who participated in martial arts.2 The first lingual pro-totypes were simply modified labial braces.1 In 1976, Kurzsubmitted the first lingual appliance patent to the US PatentOffice, and 3 years later, with the collaborative work of CraigAndreiko, DDS, MS, and Ormco Corp, the popular Ormco-Kurz lingual bracket system (1979) was fabricated.1,2

In the 1980s, lingual orthodontics developed slowly inNorth America as orthodontists struggled with the lingualtechnique, which required different treatment planningand a different approach to biomechanics, as well as chal-lenges with ergonomics and treatment efficacy. With theconcomitant development of “tooth-colored” labial brack-ets made from single-crystal sapphire and later from ce-ramics, the early excitement of lingual orthodontictreatment dimmed, and much of the advancement of lin-gual orthodontics occurred outside the United States. Since2000, with the boom of Invisalign®, removable orthodon-

tic aligners rather than lingualbraces have become the treatmentalternative for patients seeking in-visible orthodontics.

Lingual orthodontics is un-dergoing a process of simplifica-tion due to advancements inindirect bonding and bracket de-sign.3 In particular, there has beena recent growing interest in lin-gual braces limited to the anteriorteeth as an easy-to-learn, non-

compliant, invisible alternative to removable orthodonticaligners.

Reason for the Lingual ResurgenceThe recent resurgence in lingual orthodontics is likely

attributed to clinicians seeking a more economical, effective,and efficient treatment alternative to removable aligners.The most notable limitations of aligners are the high labora-tory costs, the dependency on patient compliance, and thelimitations in tooth movements.

Clinical studies have shown the least predictable toothmovements with removable aligners are incisor extrusion,canine/premolar rotation, and root uprighting.4,5

Additionally, such tooth movements often require bulkytooth attachments (to increase the tooth’s geometric massand enhance undercuts within the aligner), which many pa-tients find unsightly. Therefore, even a simple Class I maloc-clusion that requires extrusion of the maxillary lateralincisors or derotation of the mandibular canines may not besuitable for removable orthodontic aligner treatment.

STb Social 6 and In-Ovation-LMTM

Clinicians experienced with removable aligners knowthat the predicted treat-ment results are often notachieved clinically, eitherdue to limitations in thealigner material or poorpatient compliance. Finaldetailing often requirescostly refinement or a briefperiod of traditional labialorthodontics, which isoften frustrating for both the patient and the clinician. Insearch of a more cost-effective and efficient treatment foraddressing the “social six” an-terior teeth, many clinicianshave turned to segmental ante-rior lingual orthodontics, suchas the STb Social 6 and the In-Ovation-LMTM.

The STb was developed forOrmco by two of the leading lin-gual practitioners in the world—Giuseppe Scuzzo, MD, DDS,(third president of the EuropeanSociety or Lingual Ortho-dontics, ESLO) and KyotoTakemoto, DDS—as the first lingual straightwire bracket andtechnique. The STb (Scuzzo/Takemoto bracket) is a full-archlingual bracket system. It has a low 1.5-mm profile and

AANTERIOR Lingual Braces

Neal D. Kravitz,DMD, MS

By Neal D. Kravitz, DMD, MSRegaining control of invisible tooth movement

July 2008 OrthodonticProductsOnline.com 1

Figure 1: An STb Social 6bracket.

Figure 2: An In-Ovation-LMTM bracket.

OrthodonticProductsOnline.com July 20082

rounded contours to reduce lingual interference and minimizespeech difficulties. In addition to its small size, its design is asignificant advancement in the field of lingual orthodontics,because it facilitates the use of light forces and low friction.2, 6

The STb Social 6 (Figure 1, page 41) is an anterior lin-gual bracket, indirectly bonded either canine-to-canine orfirst premolar-to-first premolar, designed for correctingminor-to-moderate anterior crowding or spacing with max-imum control. Often, no more than two wires are needed tounravel the teeth, without the need for finishing bends.

The In-Ovation-L was developed in 2007 by RonRoncone, DDS, MS, and GAC International as a lingual brack-et utilizing the patented Passive-Interactive-Active self-ligatingclip of the popular In-Ovation-R bracket. The In-Ovation-L,like STb, is a full-arch lingual system. In 2008, with the collab-orative efforts of Roncone, the In-Ovation-LMTM (Minor ToothMovement) anterior lingual bracket was developed for ad-dressing minor misalignments canine-to-canine. The In-Ovation-LMTM maintains the passive-active self-ligating clip ofthe progenitor bracket, with a smaller pad size for easier place-ment and improved patient comfort (Figure 2, page 41).

Clinical IndicationsThe STb Social 6 and the In-Ovation-LMTM systems are

appropriate for the following conditions:1) Crowding of 6 mm or less;2) spacing of 3 mm or less;3) midline correction of 2 mm or less; and4) rotations of 25º or less.

Getting StartedYou can order STb Social 6 brackets through AOA

Laboratory. AOA also will provide the indirect bonding setupand transfer tray for its lingual brackets. In-Ovation-LMTM

brackets are directly bonded to the patient. Currently, no lab-oratory provides indirect bonding for the In-Ovation-LMTM.

1) For the STb Social 6, take upper and lower polyvinylsiloxane impressions with a bite registration. Fill out the STbSocial 6 prescription form, which is available online atwww.aoalab.com/index/AOAlab-Education. You can even re-quest the laboratory to return chairside adhesive with thetransfer tray.

Check “STb Social 6” in the first box of the prescriptionform, and complete any special instructions as needed. Ifyou are derotating canines or consolidating space distal tothe canine, request the addition of first premolar brackets.

The indirect setup provided by AOA Laboratory is adouble tray using a clear 0.30 AQ INCH? hard outer tray anda translucent polyvinylsiloxane inner tray to allow for lightcuring. All STb Social 6 and most STb cases do not requirefull Torque Angulation Reference Guide (TARG) or CustomLingual Appliance Setup Service (CLASS) setups for indirectbonding. This simplifies the indirect bonding setup and re-duces the laboratory cost.

Typically, if the brackets are bonded to the lingual sur-faces without a setup, the archform must be customized tothe shape of the patient’s dentition.7 However, the combina-tion of the straightwire STb system with AOA Laboratory’sindirect bonding allows for prefabricated nickel-titanium,TMA, or stainless-steel wires.

2) Bond or indirect bond the brackets. After bonding,thoroughly clean interproximally and at the palatal or lingualgingival margin, where flash often accumulates. I recom-mend using interproximal strips (.006 AQ INCHES?) with aserrated edge to saw between contacts (Figure 3).

If you are bonding the upper anterior teeth, check forlower incisor contact against the brackets; if contact is heavy,consider occlusal buildups on the posterior teeth (Figure 4).You may consider using blue-colored occlusal buildup mate-rial (I use Ultra Band-lok from Reliance OrthodonticProducts). This stops the patient from thinking that his orher tooth has fractured if the buildup comes off during treatment.

3) For crowdedcases, begin with thestraight-length 0.013-inch CuNiTi wire forthe STb Social 6 orthe straight-length0.12-inch Sentalloyfor the In-Ovation-LMTM, which come in-cluded with purchaseof the brackets. Forspacing cases, consid-er starting with 0.016-inch lingual NiTi. You may considerusing a traditional (labial) lower-arch NiTi extending canineto canine. The only disadvantage of using a labial wire ratherthan a mushroom-shaped lingual wire is that the caninesmay expand and roll out distally if left unmonitored.

4) Following tooth leveling and alignment, a 0.016-inch

Figure 3: IDB bonding of STb Social 6. First line: Isolation, etching,and application of Ortho Solo. Second line: placement of OrthoSolo on bracket pad, placement of composite on bracket pad, in-sertion of the transfer tray. Third line: curing of the transfer tray withlingual pressure, removal of the hard outer tray, removal of the softinner tray. Fourth line: removal of flash, cleaning interproximallywith serrated strips, wire insertion (straight-length 0.013 NiTi). Fifthline: space consolidation with energy chain on 0.017 x 0.017 TMA.

Figure 4: Occlusal buildups canprevent contact of lower incisaledges.

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stainless-steel or 0.017 x 0.017-inch TMA wire can beplaced for finishing bends and space closure. The STbSocial 6 brackets are ligated with standard alastic AQELASTIC? ties, while In-Ovation-LMTM uses a self-ligatingclip. Due to the short interbracket distance, I recommendclosed Energy Chain® (Rocky Mountain Orthodontics)for space consolidation.

5) Treatment duration with either of these systemsis approximately 3 to 9 months, often requiring only oneor two wires. At the completion of treatment, the brack-ets are easily debonded with a pin and ligature cutter.

Anterior Lingual Braces Versus Removable Aligners

Anterior lingual brackets offer the following advantagesover removable aligners:

1) Anterior lingual braces do not require patient compli-ance other than following dietary and hygiene instructions.

2) All tooth movements, including translation, rota-tions, and extrusions, are highly predictable.

3) Lingual braces are 100% invisible, unlike aligners,which can become cloudy or require the use of bulky attach-ments. (Figure 5).

4) The low profile of the STb system allows for properintercuspation during alignment, unlike aligners, whichoften result in a posterior open bite at the commencementof treatment.

5) The laboratory expense is approximately $200, whichis one-fifth the cost of aligners.

6) Anterior lingual systems often require fewer appoint-ments and shorter treatment time.

In short, the STb Social 6 and In-Ovation-LMTM systemsoffer a simplified lingual solution for addressing aestheticconcerns without compromising treatment results.z

Neal D. Kravitz, DMD, MS, is in private practice in WhitePlains, Md, and South Riding, Va. He is a diplomate of theAmerican Board of Orthodontics, and is on the faculty at theUniversity of Maryland and Washington Hospital Center. Hecan be reached at nealkravitz@gmail.com.

Figure 5: Intraoral photos of a patient currently in treatment inupper and lower STb Social 6. Note the invisibility of the bracketsand proper rotational correction of the canines. The lower rightcentral incisor still needs more alignment prior to debonding.

References for this article areavailable with the online version at OOrrtthhooddoonnttiiccPPrroodduuccttssOOnnlliinnee..ccoomm.