LINGUAL ORTHODONTICS

By:
Visshishta
Guided by
Dr. SRIKANTH A
1
 CONTENTS

■ Introduction
■ Historical Perspective
■ Various generations of Lingual Appliance
■ Diagnosis and Treatment Planning
■ Advantages of Lingual Appliance
■ Disadvantages of Lingual Appliance
■ Armamentarium

2
■ Lingual Bracket Placement
■ Lingual Bracket Placement Systems
■ Bonding Techniques in Lingual Orthodontics
■ Mechanotherapy.
■ Keys to success in lingual therapy
■ Conclusion
■ References

3
 INTRODUCTION
■ The increasing demand for an esthetic appearance among adult
orthodontic patients, even during orthodontic treatment period
has led to the advent of invisible orthodontic treatment.
■ Tooth colored brackets and archwires, clear aligner therapy and
lingual orthodontic treatment are the invisible way of treating
the malocclusion so far available.
■ However, these brackets and archwires are invisible from a
certain distance only. Also, the clear aligners are not purely
invisible as it is a transparent sheet closely adapted to the teeth.

4
■ The lingual orthodontic appliances are in a true sense the only
invisible appliance system available.
■ This appliance system consists of placing specially designed
lingual brackets onto the palatal / lingual surface of the teeth.(Int J
of Adv Health Sci)
■ One of the most important challenges in orthodontics is to attain
excellence in treatment with comfortable and esthetic appliances.
From the esthetic perspective, lingual orthodontics provides the
best option for comprehensive treatment of most malocclusions
while maintaining full three-dimensional control of the dentition.
(JIDENT 2014)

5
At present, Lingual orthodontics is a complete system in itself
and encompasses accurate diagnosis, treatment protocol, clinical
and laboratory procedures.

Lingual Orthodontics thus represent the best solution for

meeting the needs of the patients without the risk of damaging
biomechanical efficiency.
6
 HISTORICAL PERSPECTIVE

■ In 1975, Dr. Craven Kurz of Beverly Hills,

California created his own lingual appliances
by modifying labial edgewise appliances, and
utilized them on a limited basis in his practice.
Dr. Craven Kurz
■ He limited his treatment to the mandibular arch
for fear that the forces of occlusion would
dislodge brackets placed on the lingual surface

of the maxillary anterior teeth

7
 Later in 1976, Dr. Kurz submitted specific designs and concepts to the

U.S. Patent Office for the patent rights to his unique edgewise lingual

appliance.

 He joined with Ormco Corporation to develop and produce a prototype

of this appliance.

8
 In December 1979, Dr. Kinya Fujita, of Kanagawa

Dental University, Japan, published an article describing

appliances with a lingual bracket design and mushroom

shaped archwires.
Dr. Kinya Fujita

 His work confirmed the experiences of Dr. Kurz and Ormco that, certainly with

refinements, lingual appliances were a viable adjunct to the orthodontist's

armamentarium.
9
 10/95

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 consisted of:

Dr. Craven Kruz Dr. Jack Gorman Dr. J.R.Bob smith Dr. Wick Alexander

Dr. Moody Alexander Dr. James Hilgers Dr. Bob Scholtz 10

 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.

11
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
12
 The shear forces acting on the maxillary anterior brackets.

 Hence they incorporated an anterior inclined plane. It converted the shear

forces to compressive forces applied in an intrusive and labial direction

13
VARIOUS GENERATIONS OF LINGUAL
APPLIANCE

1ST GENERATION 1976 (1st Kurz Lingual Appliance by

Ormco)
 Had no hook
 Flat maxillary occlusal bite plane from canine to canine
 Lower incisor and premolar bracket had low profile and half round

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GENERATION #2- 1980
■ Hooks were added to all canine brackets.

15
GENERATION #3- 1981
■ Hooks were added to all anterior and premolar brackets.
■ The 1st molar had a bracket with an internal hook. The
2nd molar had a terminal sheath without a hook but had a
terminal recess for elastic traction.

16
GENERATION #4- 1982-84
■ This generation show the addition of a low profile
anterior inclined plane on the central and lateral incisor
brackets. Hooks were optional, based upon individual
treatment needs and hygiene concerns

17
GENERATION #5- 1985-86

■ The anterior inclined plane became more

pronounced, with an increase in labial
torque in the maxillary anterior region.

■ The canine also had an inclined plane ;

however, it was believed to allow
intercuspation of the maxillary cusp with
the embrasure between the mandibular
canine and the first premolar. Hooks were Generation #5—1985–86. A transpalatal bar
optional. attachment was now available for the first
molar bracket.

■ A transpalatal bar attachment was now

available for the first molar bracket.

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GENERATION #6- 1987-90
■ The anterior inclined plane became more square in shape.
Hooks on the anteriors and premolars were elongated.
Hooks were now available for all the brackets.
■ The transpalatal bar attachment for the 1st molar band was
optional. A hinge cap, allowing ease of archwire
manipulation, was now available for molar brackets.

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7TH GENERATION 1990- PRESENT

 Maxillary anterior inclined plane is now heart shaped with short hooks
 The lower anterior brackets have larger inclined plane with short hooks
 The premolar brackets were widened mesiodistally and hooks were shortened
 The increased width of Premolar bracket allows better angulation and
rotation control
 Molar brackets are available with a hinge cap or terminal sheath .

20
VARIOUS GENERATIONS OF LINGUAL APPLIANCE

21
ADVANTAGES AND DISADVANTAGES

Advantages of Lingual Orthodontics

■ Facial surfaces of the teeth are not damaged from

bonding, debonding, adhesive removal, or 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.

22
■ Four distinct situations exist where lingual appliances may
be more effective than labial appliances because of their
unique mechanical characteristics. These include:
1. Intrusion of anterior teeth.
2. Maxillary arch expansion.
3.Combining mandibular repositioning therapy with
orthodontic movements.
4. Distalization of maxillary molars

23
Disadvantages of Lingual Orthodontics

■ One of the most significant drawbacks to lingual therapy

appears to be the discomfort to the tongue, and with it,
difficulty in speech, both of which usually improve after 2
to 3 weeks of appliance placement.
■ Also, the sensitivity of the laboratory techniques and the
extended chair time needed for appliance placement and
adjustments have made the treatment prohibitively
expensive for many patients.

24
 Diagnosis & Treatment Planning
Diagnosis

■ Case diagnosis is conducted in a manner similar to established procedures.

■ Additional diagnostic input may be required from the periodontist,

restorative dentist, and orthognathic surgeon, as well as some additional
psychological acumen on the part of the orthodontist.

Gorman JC, Hilgers JJ, Smith JR. Lingual Orthodontics: a status report: Part 4-Diagnosis and Treatment Planning. J Clin
Ortho 1983; 17(1): 26-35. 25
CASE SELECTION- INDICATION AND
CONTRAINDICATION

26
 Treatment Planning

■ The treatment plan is based upon the diagnosis, the cost and time factors,
and the patient's desires.

 Patient Selection:

The most important factors in selecting patients for lingual treatment are
their personalities and reasons for seeking treatment.

Gorman JC, Hilgers JJ, Smith JR. Lingual Orthodontics: a status report: Part 4-Diagnosis and Treatment
27
Planning. J Clin Ortho 1983; 17(1): 26-35.
■ After the patients are informed of the treatment rationale and effects of the
lingual appliance (speech, soreness, bite opening), their attitude should be
one of understanding and a desire to do whatever is necessary to
accomplish the optimum results.

 Time & Cost Factors:

1. Examination, diagnosis, consultation, and treatment planning time are

increased.

2. Laboratory procedures for the indirect appliance setup increase the fixed
costs.
3. Orthodontist and staff time increases by 30-50%.
28
Periodontal considerations:

■ The status of the periodontium must be carefully evaluated.

■ Short lingual clinical crowns can present a contraindication to optimum lingual

bracket positioning.

■ The lingual appliance can cause gingival hypertrophy, as the brackets are
bonded close to the gingival crest. Brackets must be 1mm away from gingiva.

■ Patients with a history of periodontal problems or in whom oral hygiene

motivation is questionable may not be the best candidates for lingual therapy.

Gorman JC, Hilgers JJ, Smith JR. Lingual Orthodontics: a status report: Part 4-Diagnosis and Treatment Planning. J Clin
Ortho 1983; 17(1): 26-35. 29
Restorative considerations:

■ In cases where there is a loss of several teeth, extreme tipping, and

multiple or complex bridgework, the lingual appliance may be
contraindicated.

■ Porcelain-fused-to-metal crowns or other metallic restorations may need to

be replaced with provisional plastic crowns to permit lingual bonding.

30
Dental considerations:

■ The most suitable teeth are those with long smooth surfaces

■ Incisors with lingual surface shorter than 7mm should be reconstructed

■ The presence of prominent cingulae, marked marginal ridges, or prominent

cusp of carabelli are unfavorable and if possible they should be reduced or

reconstructed

■ Teeth with crowns and large restorations need to be treated with special

bonding techniques.
31
Temperomandibular joint considerations:

■ Lingual orthodontic treatment can lead to relief of joint symptoms,

probably due to the disarticulating effect of the anterior brackets.

32
Extraction vs. Non-extraction considerations:

■ In lingual orthodontics, strong molar anchorage, especially in the lower arch, makes
mesial movement of molar difficult.

■ Hence, in Class I cases, extraction of upper first and lower second premolars is
preferred.

■ In Class II cases, it is better to avoid lower arch extractions.

■ In open bite and Class III cases, four first premolar extractions are considered.

33
Speech:

■ Lingual The lingual appliance has a mild overall effect on speech.

■ The "s", "sh", "t-d", and "th" sounds are slightly distorted.

■ Lingual patients subjective opinion is “speech is not normal until the

tongue becomes comfortable”.

34
Lingual cases into 3 levels of difficulty
( Ormco lingual task force)

Ideal Lingual Cases

Nonextraction:

• Deep bite, Class I with mild crowding, good facial pattern.

• Deep bite, Class I with generalized spacing, good facial pattern.

• Deep bite, mild Class II, good facial pattern.

• Class II division 2 with retruded mandible

• Cases requiring expansion.

• Consolidation (diastema) cases.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.
35
 Extraction:

• Class II, maxillary first bicuspid and mandibular second bicuspid

extractions.

• Maxillary first bicuspid only extractions.

• Mild double protrusions with four first bicuspid extraction.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.

36
More Difficult Lingual Cases

• Surgical cases.

• Class III tendencies.

• Mesiofacial patterns and/or moderate mandibular plane angles.

• Cases with multiple restorative work.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.

37
Cases Contraindicated for Lingual Therapy

 Mutilated posterior occlusions.

 High angle/dolichofacial patterns.

 Extensive anterior prosthesis.

 Short clinical crowns.

 Severe Class II discrepancies.

 Poor oral hygiene or unresolved periodontal involvement.

 Unadaptable or demanding personality type.

 Patients with limited ability to open mouth

 Patients with cervical ankylosis / neck injury

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.
38
Advantages of Lingual Orthodontics

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

adhesive removal, or decalcification from plaque retained around labial

appliances.

■ Facial gingival tissues are not adversely affected.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.

39
■ The position of the teeth can be more precisely seen when their surfaces

are not obstructed by brackets and arch wires.

■ Tongue thrust habits are easily managed.

■ Mandibular repositioning therapy.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.

40
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.

Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual Orthodontics KDJ2000. :.3 :2:3-9.

41
Armamentarium

■ Completed bracket transfer trays that have been tried in to ensure accurate fit.

■ Composite filling syringe (e.g., CR Syringe).

■ Orthodontic bonding adhesive.

■ Refrigerated mixing slab.

■ Saliva ejector or Svedopter and high speed evacuator.

■ Antisialogogue (Banthine or Pro-Banthine tablets).

■ Tongue shields (Svedopter or Dri-Angles).

■ Scaler and explorer.

■ Dental floss, cotton rolls, and cotton pellets.

Rafi Romano.Lingual orthodontics 1998.B.C.Decker , Hamilton . London 42
 Lingual ligature cutter

(angulated 45degrees)

Lingual ligature cutter

(angulated 90degrees)

Rafi Romano.Lingual orthodontics 1998.B.C.Decker , Hamilton . London 43

 Utility plier

Arch wire cutter

Rafi Romano.Lingual orthodontics 1998.B.C.Decker , Hamilton . London 44

 Mosquito forceps

Light ligature plier

45
Lingual hinge cap
opening tool

Debonding plier

46
 Tongue retractor &
saliva ejector

First order
bending fork

47
Second order
bending fork

Module remover

48
 Lingual Bracket Placement

■ Considering the difficulty of access, irregularity and variability of lingual

tooth morphology, it is difficult to locate exact bracket positions, even on
plaster casts.

■ Michael Diamond ( JCO1998)described the critical aspects of lingual

bracket placement as follows:

49
■ Variation in height (y) has a direct effect
on the labiolingual position of the bracket
(x).

■ Placement of the bracket closer to the

incisal edge (y') shortens the labiolingual
distance (x').

Diamond M. Critical aspects of lingual bracket placement. J Clin Orthod. 1983; 17(10): 688-691
50
■ Variation in tooth thickness at the same
distance from the incisal edge affects
bracket placement by varying the
distance from the labial surface.

■ Tooth A is thicker than tooth B at height

y, and the distance x' is greater than x.

51
■ Variation in height alters the effective
torque in the bracket, with either a vertical
or a horizontal insertion of the archwire.

■ Brackets placed at the same height (y) on

different lingual slope angulations will be
located at various distances from the
incisal edge (C).

A is greater than B.

52
■ Altering the angle of the bracket-
positioning instrument can vary the
amount of torque in the bracket slot.

53
Lingual Bracket Placement Systems

These 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. 54

 Torque angulation reference guide (TARG)
■ This technique of bracket placement was developed by
Ormco in 1984.

■ It permits bonding of brackets in the laboratory, at an

accurate distance from the occlusal edge of each tooth with
respect to a horizontal reference plane.

■ A labial reference gauge is used to orient individual teeth.

■ Using only one unique angulation model, the TARG did not
allow pre-programming of in and out bends

of individual teeth.

Giuseppe Scuzzo, Kyoto Takemoto. Invisible orthodontics: current concepts and solutions in Orthodontics:
Quintessenz Verlagmbh, 2003 edition 55
■ Advantages:

- It is an accurate and quantified two-dimensional system.

- Allows accurate placement of the brackets on the cast without need to

cut out the teeth and place in wax.

■ Disadvantages:

- The system does not take into account the labio-lingual thickness of
teeth.

- The distance of the bracket base and the labial surface varies according
to the level of bonding.

56
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.

Silvia Geron,Romano.R.Bracket positioning in lingual orthodontics-critical reviewof different

57
techniques.Korean journal of clinical orthodontics 1986,57-63
 Fillion’s Lingual Indirect Bonding System

■ This system was developed by Dr. Didier Fillion of France in 1987.

■ Also known as ‘Bonding with Equalized Specific Thickness’ (BEST).

■ It was designed to consider the labio-lingual thickness of the individual teeth

during bracket placement.

■ A caliper is added as the thickness measurement system.

.
Scholz RP, Swartz M. Lingual Orthodontics: a status report: Part 3- Indirect Bonding – laboratory and clinical procedures.
58
Clin Orthod. 1982; 16(12): 812-820.
■ 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

59
TARG device Thickness measuring

appliance
ELECTRONIC TARG

60
 ■ Using his DALI (Dessin Arc Linguale Informatise) computer program he
produces an individualized archwire template

Advantages:
-Relates the labio-lingual thickness of tooth to bracket position

-Allows working directly on the malocclusion model

61
The Customized Lingual Appliance Setup Service
(CLASS) system

■ Described by Scott Huge, this technique involves an integrated method of lingual bracket
placement and indirect bonding.

■ Method:

- An ideal setup is made from the original malocclusion cast and brackets are placed on this
setup.
- These are later transferred to the original cast by individual transfer trays.
- An indirect bonding tray is fabricated for bonding.

■ Advantage: It takes into account the anatomical discrepancies in the lingual surfaces of the
teeth.

Romano.R,Geron.S.Bracket positioning in lingual orthodontics-critica review .The Korean journal of clinical

62
orthodontics.2005:57-68
Hiro system

■ Introduced by 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.

63
64
- 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.

65
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.

•
66
The Lingual Bracket Jig

■ Dr. Silvia Geron in 1999 introduced lingual bracket jig which is a chairside
direct bonding system.

■ It is used with a horizontal slot bracket.

■ The basic idea behind the lingual bracket jig (LBJ) is that lingual tooth
anatomy and inter-tooth relationships are amenable to a lingual preadjusted
edgewise approach.

67
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).

68
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.

69
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.

70
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 Mushroom Bracket Positioner is available

which places brackets to accept a straight wire.

Kyung HM. The Mushoom Braket Positioner for Lingual Orthodontics. J Clin Orthod. 2002; 36(6): 320-328.
71
Transfer Optimized Positioning System

■ Introduced by Wiechmann et al in 2003, this system utilizes CAD/CAM

technology.

■ It scans the lingual surfaces of the teeth on the ideal diagnostic setup via
3D optical scanner. The data obtained from the scan is used to fabricate
fully customized bracket with adapting base pads and built-in prescription.

Seminars in Orthodontics, Vol 12, No 3 (September), 2006: pp 203-210

72
The Orapix System

■ Newest lingual orthodontic technique

■ Scanner scan patients model and create 3D data file

■ Using 3-Txer soft ware visualize 3Dmodel and create virtual set

up

■ Concept- make use of precise bracket positioning produced by

computer software

Bhandari.P,Anbuselvan GJ,Karthi M History of lingual orthodontics –From past,present and Future JIDENT 2014 ;
2:2:1-5. 73
 Various Lingual Appliance
FUJITA LINGUAL BRACKET(1979)

■ The presently available Fujita system is

still based on an occlusal slot opening,

but has multiple slots.

■ Anterior teeth and premolars have three slots:

occlusal, lingual, and vertical.

■ Molar brackets have five slots:

one occlusal, two lingual, and two vertical

. 74
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
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. Dr. Stephen Paige

Paige SF. A Lingual Light-Wire Technique. J. Clin Orthod 1982 ;534 – 544 75
CONCEAL BRACKETS(1989)

■ Foundation of design is opening of archwire

slots to the occlusal aspect rather lingual aspect

■ 3 slot width for 3 different functions :

Creekmore T
■ tip,

■ torque,

■ rotations

76
STB (SCUZZO- TAKEMOTO BRACKET)

■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.

■Flossing is easier.

■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
Takemoto to theG.bottom
K, Scuzzo of bracket
The Straight slots.
Wire concept in Lingual Orthodontics. J Clin Orthod. 2001; 35(1): 46-52.
77
 SELF-LIGATING LINGUAL BRACKETS

Macchi et al (2002)

Standard medium twin bracket

■ Narrow single

■ Large twin bracket.

■ Three- wing bracket

Clinical applications:

■ Post – treatment retention.

■ Closure of minor spaces.

■ Limited intrusion.

■ Correction of simple tooth malalignments.

78
Incognito

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

setup at the beginning of treatment.-Developed by Drik wiechmann
• 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

Bhandari.P,Anbuselvan GJ,Karthi M History of lingual orthodontics –From past,present and Future JIDENT 2014 ;
79
2:2:1-5.
 Bonding Techniques in Lingual Orthodontics

Direct Bonding Technique:

■ Introduced by Dr. Michael Diamond in 1984.

■ He devised a Peri/Reflector for simplified direct bonding

in the upper arch.

■ Peri/Reflector is a combined mirror, tongue retractor, and

saliva ejector that can simplify bonding procedures in the
upper arch.

■ It isolates the operating area, increases brightness, and

enables one to see the entire

area while keeping both hands free.

80
Indirect Bonding Techniques –why preferred

■ The irregular lingual tooth morphology creates a requirement for custom

contouring of lingual bracket bases.

■ The variation in lingual tooth morphology creates the need for custom
measurement for selection of appropriate bracket base thickness and torque.

■ The practitioner’s lack of familiarity with lingual tooth morphology makes it

difficult for him to visualize angulations and bracket heights, and these
angulations must be related to the more uniform labial surfaces.

Scholz RP, Swartz M. Lingual Orthodontics: a status report: Part 3- Indirect Bonding – laboratory and clinical
procedure. J Clin Orthod. 1982; 16(12): 812-820. 81
■ It is difficult to obtain a direct line of sight for bonding on lingual surfaces.

■ Increased accuracy in bracket placement is required, because compensating

lingual arch wire bends are more difficult and time consuming to form.

■ Consists of two phase :

■ Lab phase

■ Clinical phase

82
 LAB PHASE:

■ Lingual bracket slot heights are first determined.

■ Optimum bracket placement :clearing the gingival crest by a least 1.5mm and
allowing 2mm between the incisal edge and the bracket bite plane on
maxillary incisors.

■ The lingual brackets are attached to the model with the bracket slot bisecting
the reference mark, using water-subtle temporary cement or bonding material
of choice; the brackets are sealed in place, using a water soluble film former.

83
 The indirect transfer tray is fabricated, using a low-viscosity silicone
to encapsulate the brackets and silicone putty as the indexing
medium and fray bulk.

 Then, the water-soluble temporary bracket cement and sealant are

dissolved, and the tray is removed and trimmed.

84
CLINICAL PHASE:

A. Teeth are cleaned, isolated, and

etched.

B. A thorough rinsing, using an air-

water spray and high-speed
evacuator, is essential.

85
 C. Sealant application. D. The adhesive is injected into the bracket
mesh.

F. After 10 minutes, the tray is removed,

E. The tray is seated with firm pressure
the brackets inspected, and any deficient
and held with light, steady pressure for 3
areas filled in with a thin mix of bonding
minutes. 86
adhesive.
 Changes induced by the lingual appliance:

1. Vertical changes

■ The most immediate and readily apparent appliance-induced change is the

bite opening resulting from the lower incisors occluding on the maxillary
incisor bracket bite planes.

■ This bite opening is beneficial in brachyfacial cases, TMD cases and rapid
tooth movement due to posterior disocclusion.

Giuseppe Scuzzo, Kyoto Takemoto. Invisible orthodontics: current concepts and solutions in Orthodontics
Quintessenz Verlagsb 2003 edition
87
 2. Antero-posterior changes

■ Because of the vertical opening and the immediate rotation of the

mandible (down and back), the lingual appliance also induces a Class II
tendency.

■ With bite opening, A-P molar correction is easier.

Giuseppe Scuzzo, Kyoto Takemoto. Invisible orthodontics: current concepts and solutions in Orthodontics
Quintessenz Verlagsb 2003 edition 88
3. Transverse changes

■ The lingual appliance has an expansive nature. This is coupled by posterior

disoclusion.

■ There is tendency to cause mesio-buccal molar rotation during space closure.

Thus, placement of transpalatal arch is important.

■ Bowing Effect :Anterior teeth to tip lingually ,posterior teeth to tip mesially
and posterior bite to open .

■ Retraction is always done on stiffer wires to prevent “bowing effect”, both

in the transverse and vertical planes.
89
Solutions to avoid bowing effect:
–Using stiffer wires (0.016x0.022 s.s)

–Compensating horizontal and vertical wire bending

–Applying short span forces

–Not to connect chains to terminal molars

–Add anchorage :palatal bars ,nance button ,etc

–Loop mechanics

–Waiting till molars erupt to come into contact for better anchorage.

–Band second molars

–Bond anchor unit passively : there is no force between all the teeth in anchor unit they serve as good

anchor

–Load anchor unit later in treatment

–Add torque(lab or wire)

90
Lingual Mechanotherapy

Treatment Sequence

1. Leveling, aligning, rotational control, and bite opening.

2. Torque control.

3. Consolidation and retraction.

4. Detailing and finishing. 91

Lingual archwires.

■ Typically mushroom-shaped.

■ Compensating bends are made.

■ First order bends between cuspids and bicuspids are made at right angles,
with a generous step to allow for the differences in labiolingual thickness
between cuspids and premolars.

■ First order bends contacting the mesiolingual of bicuspids or first molars

can also act as archwire stops.

■ These can provide an advancing or expansive force to the arch.

92
A. First and second order bends
contacting the teeth or brackets
can act as stops and result in an
expansion force as arch wire
length is gained through
alignment.

B. First and second order bends

should be made with sufficient
spacing to prevent anterior
advancement or to provide for
retraction mechanics.

93
 94/95

The lingual appliance has a tendency to induce an anterior

maxillary open bite.
■ This tendency is difficult to control, but its prevention is
very important.
■ Prevention includes:
1. Early control of posterior extrusion with high-pull
headgear and the early establishment of buccal segment
control.
2. Minimizing anterior advancement until the rectangular
archwire stage.
3. Patient education on tongue positioning.

94
4. Prevention of vertical archwire bowing by avoiding intra-
and intermaxillary elastics until stiffer rectangular
archwires are used.

5. Coordination of arches to maintain the relation of maxillary

incisor bracket bite plane to mandibular incisor.

6. Early use of vertical lingual elastics on suspect cases.

7. Delaying the treatment of maxillary second molars until

finishing arches.

95
 Stage I. Leveling, Aligning, Rotational Control, and
Bite Opening.

■ The objectives of this initial phase of therapy are to:

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.

Alexander CM, Alexander RG, Gorman JC et al. Lingual orthodontics: A status report.-5 J Clin Orthod. 1982; 16(4):
255-262. 96
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.

97
■ However, a common problem with lingual brackets is the difficulty in
archwire engagement and the tendency for the archwire to be pulled
out of the bracket slot.

■ A ligation method termed the double-over tie has been effective with
both metal and elastic ligatures in directing the ligating force more
directly along the bracket-slot angle.

98
Double Over Tie:
The double over ligation method applies the
ligation force along the bracket slot to seat the
archwire. Double over elastic ties also exert twice
the force of a conventional ligation.

A. Teeth may first be ligated together with .009"

steel ligature wire. Two or more segments of
elastic chain are used on each tooth, with one
segment placed over the bracket before the
archwire is placed. The other segment of the chain

serves as a handle.

99
 .

B. The archwire is then inserted C. The elastic chain module is then

over the previously placed elastic stretched out of the gingival bracket
chain modules tie wings and over the archwire.

D. The elastic chain module is then

inserted into the incisal tie wing.

100
 E. The excess chain is cut

.
F. The remaining elastic ligature
originates and ends at the incisal tie
wing and exerts a force directly along
the archwire slot.

101
■ The immediate bite opening can present some difficulties, e.g., vertical

and antero-posterior changes.

■ However, it is beneficial in deep bite correction and can be used to

advantage in other instances.

■ The immediate posterior disoclusion allows rapid molar uprighting, any

mesial posterior movement desired, and crossbite corrections.

102
Stage II. Retraction/Consolidation Mechanics

■ This is achieved using either sliding mechanics, closing loop arches, or

combinations.

■ The lingual archwires used for retraction are .016" round stainless steel, .0175" × .
0175" TMA and .016" × .016" stainless steel.

103
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-T loop,closed helical loop

Increased treatment time

104
COMPARISON BETWEEN LOOP MECHANICS & SLIDING
MECHANICS

 Loop mechanics
- friction – not affected
- bends – easy to place
- easy to visualize amount of loop
activation, thus easy to control
- bite opening – suitable
- discomfort – more
- wire bending – diff
 Sliding mechanics
- friction – affected
- bending – need to minimize wire friction, limitation in placing bends
- diff to quantify force level of a power
chain
- bite opening – unsuitable
- less discomfort
- wire bending - easy
Stage III. Torque Control

 Torque control is initiated early in treatment using .016" × .022" or .

017" × .025" and maintained throughout treatment.

 Typically, lingual archwires used in finishing and torque control are .

016" × .022" stainless steel for moderate torque and .017" × .025"

TMA for full torque.

107
Stage IV. Detailing / Finishing.

 Finishing archwires are usually .016" × .022" stainless steel, .017" × .

025" TMA, or .016" and .018" TMA when additional detailing of the

occlusion is required

108
Retention following lingual therapy

Removable "invisible" retainer.

Fixed lingual retainer.

109
Spring retainer

Circular type retainer

110
 Keys to Success in Lingual Therapy

Key 1 :
■ Patient Selection.
■ Oral Hygiene and Gingival Irritation - 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.
■ Bite Opening and Mandibular Rotation.
■ Headgear and Elastics - headgear is a vital adjunct to lingual
mechanotherapy to counteract mandibular autorotation.

111
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.

112
Key 7:
■ Correction of rotations
– Smith Rotation Tie
– Bend loops
– Use of Power arm

Key 8:
■ Arch form and archwire sequence.

Key 9:
■ Archwire stiffness and torque control.
– Establish torque before retraction to counteract bowing effect.
– An area with different torque may interfere with smooth
retraction
113
Key 10:
■ En masse retraction.
– As space does not open between lateral and canine and in addition space
available distal to canine ,the insets placed into the archwire between canine
and premolar required in lingual orthodontics.
Key 11:
■ Light, resilient wire for detailing .
– A rigid rectangular wire with precise bends to correct individual tooth
positions is difficult to engage into bracket slots –apply excess forces and
incorrect torque to tooth

Key 12:
■ Gnathologic positioner and retention.
114
Based on the results of the study, the magnitude of apical root resorption in the
maxillary incisors was similar regardless of the orthodontic technique used, lingual or
conventional

Both techniques resulted in apical rounding; however, this effect was clinically
insignificant.

In an other study,The double-wire technique with an extended lever arm provided

advantages over the single-wire technique with the same lever arm length in preventing
torque loss and extrusion of the anterior
teeth during en masse retraction in lingual orthodontics

Comparative study of root resorption of maxillary incisors in patients treated with lingual and buccal
orthodontics
Carlos Eduardo Nassifa ; et alPedrinc Angle Orthodontist, Vol 89, No 4, 2017

Hung BQ, Hong M, Yu W, Kyung HM. Comparison of inclination and vertical changes between 115
single-wire and double-wire retraction techniques in lingual orthodontics. The Korean Journal
 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.

 Correct diagnosis and treatment planning ,patient selection and with

the help of lingual orthodontic service laboratories the quality of results
obtained with Lingual appliance is comparable to ones achieved with
labial orthodontics

116
References
1. Rafi Romano.Lingual orthodontics 1998.B.C.Decker , Hamilton . London

2. Giuseppe Scuzzo, Kyoto Takemoto. Invisible orthodontics: current concepts and

solutions in Orthodontics: Quintessenz Verlagsb 2003 edition

3. Alexander CM, Alexander RG, Gorman JC et al. Lingual orthodontics: A status

report. J Clin Orthod. 1982; 16(4): 255-262

4. Paige SF. A Lingual Light-Wire Technique. J. Clin Orthod 1982 ;534 – 544.

5. Gorman JC, Hilgers JJ, Smith JR. Lingual Orthodontics: a status report: Part 4-
Diagnosis and Treatment Planning. J Clin Ortho 1983; 17(1): 26-35.

6. Silvia Geron,Romano.R.Bracket positioning in lingual orthodontics-critical reviewof

different techniques.Korean journal of clinical orthodontics 1986,57-63
117
7. Diamond M. Critical aspects of lingual bracket placement. J Clin Orthod.

1983; 17(10): 688-691

8. Creekmore T. Lingual orthodontics – Its renaissance. Am J Orthod

Dentofac Orthop 1989; 95: 514-5207. Geron S. the Lingual Bracket Jig. J

Clin Orthod. 1984; 33(8): 814-815

9. Nimitpornsuko.C, Viwattanatipa.N Introduction to Lingual

Orthodontics KDJ2000. :.3 :2:3-9, 9. Takemoto K, Scuzzo G. The Straight

Wire concept in Lingual Orthodontics. J Clin Orthod. 2001; 35(1): 46-52.

10. Kyung HM. The Mushoom Braket Positioner for Lingual Orthodontics.

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11. Revisiting the History of Lingual Orthodontics: A Basis for the Future;

Pablo Echarri; Semin Orthod, Vol 12, No 3 (September), 2006: pp 153-159

12. Bhandari.P,Anbuselvan GJ,Karthi M History of lingual orthodontics –

From past,present and Future JIDENT 2014 ;2:2:1-5

13. Hegde: Extraction mechanics in lingual orthodontics: Challenges and

solutions.APOS Trends in Orthodontics March 2016; Vol 6 -Issue 2

14. Comparative study of root resorption of maxillary incisors in patients treated

with lingual and buccal orthodontics Angle Orthodontist, Vol 89, No 4, 2017

119
 15.Naragond AS, Naragond SA. Lingual Orthodontic Bracket Design
Modification and Their Development-A Review. IOSR Journal of Dental and
Medical Sciences,(2019) Volume 18, Issue 1

16.Gallone M, Robiony M, Bordonali D, Bruno G, De Stefani A, Gracco A.

Multidisciplinary treatment with a customized lingual appliance for an adult
patient with severe Class III malocclusion and multiple missing teeth. American
Journal of Orthodontics and Dentofacial Orthopedics. 2019 Sep 1;156(3):401-11.

17.Kyung HM. Progress of Anchorage in Lingual Orthodontic Treatment.

Temporary Anchorage Devices in Clinical Orthodontics. 2020 Apr 6:489-96.

18.Hung BQ, Hong M, Yu W, Kyung HM. Comparison of inclination and

vertical changes between single-wire and double-wire retraction techniques in
lingual orthodontics. The Korean Journal of Orthodontics. 2020 Jan
1;50(1):26-32.

120
THANK YOU

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