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LINGUAL
LINGUAL
ORTHODONTICS
LINGUAL
ORTHODONTICS
R A F I R O M A N O, D M D, M S c
..
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herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice
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Contributors
Preface . . . . . . . . . . . . . . . . . . . .
SECTION 1 SECTION 3
Index. . . . . . . . . . . . . . . . . . . . . .
Preface
The Preface to Lingual Orthodontics (LO) should have been actually called: A short
explanation why Lingual Orthodontics is the first complete English textbook ever pub-
lished on LO.
The idea to edit Lingual Orthodontics arose in October 1995, at the Italian
Association of Lingual Orthodontics (AIOL) meeting in Rome, where many of the
best clinicians who practice LO were in attendance.
When surveying the literature published on LO, it is surprising to discover that
most of it was written from 19821985, immediately after Dr. Kurz from USA and
Dr. Fujita from Japan developed the prototype lingual system and ORMCO founded
the original Task Force. These years saw the very first steps with the new system,
observed with the critical eyes of the orthodontic community and with exaggerated
expectations from the public and media. While most orthodontists found interest in
the new system, it was still undeveloped, without any finished cases, any protocol, and
presented many technical problems. More than 12 years have passed since silence
concerning LO was declared in the scientific journals, in all of the important ortho-
dontic meetings, and in orthodontic offices. The media had completely stopped men-
tioning the subject and because of the small number of orthodontists who continued
to treat patients with LO during this period, we are now again in a situation charac-
terized by a lack of knowledge in the dental community and among the public. The
technique of lingual orthodontics, which is the only option we can give to those patients
who want their orthodontic treatment to be done behind closed curtains, was really
left with the curtains closed.
The fault is partly due to the rapid decline in the number of orthodontists who
offer LO as a treatment option in their office and partly due to the small efforts that
were made by those who did practice LO to teach, to write, to do research, or to con-
tribute from their knowledge to all of their colleagues.
Excellent work is done all over the world with LO. Some clinicians have even
decided to devote their practice exclusively to LO and can now present excellent clinical
results with a long follow-up. Much new material that has not yet been published exists
as well as tremendous experience that was gained in the field in the last 15 years. Much
of this is known only to a small group of orthodontists who come to LO meetings all
over the world. This book is published to change this situation because we believe that
lingual orthodontics is the ultimate esthetic solution in orthodontics today.
Many of the best clinicians who practice LO contributed to this book. They come
from all over the worldfrom the USA, Australia, Japan, France, Italy, Spain, Germany,
and Denmark. I would like to thank each one of them personally for the tremendous
help, good will, and patience they have exhibited in the long process of creating an
international book. They have all agreed to share their knowledge and experience with
our readers. Many clinical tips and experience were gathered and are now disseminated
for the first time. Almost every possible aspect of LO is covered, including history,
mechanics, extraction cases, nonextraction cases, pediatric patients, interdisciplinary
cases, orthognathic surgery, practice management, laboratory procedures, and more. All
of them are described in full detail and enhanced with color figures.
This is not a recipe book, and it is not intended to teach LO. One should take
accredited courses, come to LO meetings, and gain experience before adopting the
system completely into his or her practice. Once a thorough knowledge and clinical
experience are obtained, one will gain excellent clinical results, not less than he or she
was used to with labial orthodontics, and with all the mechanical and esthetic advan-
tages that are unique to LO. I have included all of the references I could find on LO
to help the clinicians find their way in this new system. I do apologize to any author
whose article I did not mention here.
The advantages of LO over labial orthodontics are many. While better esthetics
during treatment is the most obvious, some advantages are purely mechanical, like
more efficient distal movement, much easier intrusion, increased expansion, and the
built-in capability in the bracket design to reposition the mandible and tempero-
mandibular jaw when needed.
Some clinicians still claim that LO is not a legitimate option and that lingual
orthodontic results are inferior to those achieved with labial orthodontics. In fact, the
opposite is frequently true. We do believe that the advantages of LO as a treatment
option are greater than the disadvantages, and it should be considered as a legitimate,
equally good option to every other treatment modality.
Still, there is much more to be done in the field of LO other than publishing
more textbooks. Some disadvantages still to be overcome are:
Further improvement of the design of the brackets to make them smaller, more
easily ligated, and smoother to the tongue.
Reduction in speech distortion during the early stages of treatment, which can
be distressing to the patient.
The addition of training in lingual orthodontics to the graduate or postgrad-
uate orthodontic programs in the universities around the world.
Reduction of the high fees by improvements in design and technique which
will, in turn, reduce the chairtime of the orthodontist.
I do hope this book will have a uniting influence on the clinicians using LO. The
world has become a very small place since people began traveling extensively. Some of
my patients come from Japan, USA, and Europe, and they expect each orthodontist
to have the same knowledge and skills as his or her colleagues. Easy, rapid communi-
cation tools exist and should be used to teach, to inform, and to unite. Teaching other
orthodontists the secrets of our technique will, in the long run, bring us more accep-
tance and more work. When more orthodontists use LO in their offices, patients will
become more aware of it and ask for it. This phenomenon occurred in general den-
tistry with porcelain veneers and bonding. When it became more popular, the dentists
who were the first to do it became the leaders in esthetic dentistry all over the world.
I hope that Lingual Orthodontics will become towards the year 2000 an essential
part of orthodontic offices and university libraries, to be used by doctors and patients,
and to be a part of the esthetic dentistry postgraduate studies.
Preface
I again thank all my colleagues who participated in writing this book, especially
Dr. Didier Fillion, a friend and one of the best clinicians in LO in the world today;
my Israeli colleague, Dr. Sylvia Geron, who helped me and supported me all the way;
Prof. Adrian Becker, one of the most talented orthodontists I know, who inspired me
tremendously; Dr. Linda Hallman, who helped review the material; Dr. Nitzan Bichacho,
Dr. Paul Miara, and Dr. Bernard Touati who helped me enter the fascinating world of
esthetic dentistry; and my wife, who warmly supported me. The book is dedicated to
my father, Dr. Albert Romano.
Lingual Orthodontics:
Historical Perspective . . . . . . . . . .
Craven Kurz and Rafi Romano
Lingual Orthodontics in a
Labial Orthodontics Office . . . . .
Courtney Gorman
Lingual Orthodontics:
Historical Perspective
C R AV E N K U R Z , D D S , P hD , A N D R A F I RO M A N O , D M D , M S c
The 1970s was an exciting decade for orthodontics. The straight wire appliance was
developed, treatment demands had increased, and adults were seeking treatment in
greater numbers. This increasing demand for adult treatment brought unique con-
cerns to the profession. Esthetics was then and continues to be a primary concern of
patients. To address these esthetic concerns, manufacturers introduced clear plastic
brackets; unfortunately, however, staining of the bracket and the tooth presented a
significant problem. The search for improved esthetic alternatives to metal or clear
plastic brackets continued.
During the early 1970s, Dr. Craven Kurz, an orthodontist, then assistant professor
of occlusion and gnathology at the UCLA School of Dentistry, found his private
orthodontic practice to be increasingly dominated by adult patients. As many of his
patients were public figures, esthetics became a major concern. A particular patient,
who was an employee of the Playboy Bunny Club, presented to his practice requesting
treatment. Because of her public position she refused metal or plastic labial appliances
on esthetic grounds. From her demand for an appliance that did not show, the con-
cept of a lingually bonded appliance was born.
After much advice and consultation from orthodontic colleagues, particularly
Dr. Jim Mulick, also at the UCLA School of Dentistry, Dr. Kurz developed the first
true lingual appliance. The appliance consisted of plastic Lee Fisher brackets bonded
to the lingual aspect of the anterior dentition and metal brackets bonded to the
lingual aspect of the posterior dentition (Figures 11a and b). The plastic anterior
brackets were selected because of the ease of recontouring and reshaping them to
avoid direct contact with the opposing teeth. Treatment progress was closely moni-
tored during this initial attempt at lingual treatment. Not surprisingly, Dr. Kurz
found that occlusal forces produced a shearing force on the maxillary incisor brackets,
creating a high bond failure rate. Additionally, the brackets were uncomfortable and
irritating to the patients tongue. By the mid-1970s, Dr. Kurz found that by smooth-
ing the exposed surface of the brackets using a heatless stone, patient comfort and
acceptance increased.
Not surprisingly, commercial interest was rapidly developing for this new appliance
and approach to orthodontic treatment. Many clinicians and commercial companies
were in the process of developing some version of a lingual appliance. During these
early stages, Ormco, a company in California, created a product development team
consisting of Mr. Frank Miller and Mr. Craig Andreiko to work with Dr. Kurz and his
new appliance. Historically, Ormcos interest in the concept of lingual orthodontic
treatment was well established. In the early 1970s, in conjunction with Dr. Jim
- . Dr. Kurz 19731975 labial appliance modified for lingual application.
Wildman, they attempted to develop a system to align the dentition using the lingual
approach. This system consisted of a Pedicle positioner, rather than a multibracketed
system. Although innovative, inherent limitations in this system prevented it from
gaining widespread popularity in the orthodontic community.
With the new product development team now in place, prototypes of lingual
brackets were developed to attempt to improve on the design of the original appliance.
The prototypes were initially carved from wooden blocks at a scale of 40:1 and then
recreated in appropriate materials in scaled-down versions to fit the mouth. It was
quickly found that the problems that plagued all previous attempts at developing a
usable appliance remainednamely, a high bond failure rate due the shearing forces,
and patient discomfort from the roughness against the tongue. The turning point in
the development of the appliance was the addition of an anterior inclined plane as an
integral part of the maxillary anterior brackets (Figure 12). This inclined plane con-
verted the shearing forces produced by the mandibular incisors to compressive forces
applied in an intrusive and labial direction. These forces also produced a natural
physiological bone resorption in the maxillary and mandibular incisor area, allowing
the teeth to intrude at generally less than 100 milligrams in force each time the
patient swallowed (approximately 2000 times per day).
Bond failures decreased dramatically. Redirecting the forces by the use of an ante-
rior inclined plane appeared to be the missing link in the development of a viable lin-
gual appliance. It was with this design that Dr. Kurz applied for a patent for the Kurz
Lingual Appliance on November 15, 1976. Product development began in earnest in
1978, and Ormco manufactured a usable metal bracket by 1979. Initial clinical test-
ing began in Dr. Kurzs private office, with approximately 100 cases tested over a three-
year period. All appliances were direct bonded, and a treatment protocol was estab-
lished. From the initial testing, the appliance appeared to be viable and showed much
promise in providing the profession with an esthetic alternative to labial appliances.
The next logical step in product development and improvement was to establish
beta test sites. Fifty selected orthodontists were invited to attend an Ormco-sponsored
symposium on lingual orthodontic therapy. Here, Dr. Kurz presented the concept of
lingual treatment, the appliance, and his treatment results from the initial 100 cases
tested to the professional community. From this group, the original Lingual Task
Force was developed. This group was under the administrative guidance of Mr. Floyd
Pickrel, Mr. Ernie Strauch, and Dr. Michael Scwartz, all from Ormco. Their charge was
to guide and administrate the research and development team while a commercially
viable lingual appliance was being developed. They appointed, in addition to Dr. Craven
Kurz of Beverly Hills, California (Figure 13), the late Dr. Jack Gorman of Marion,
Indiana (Figure 14), Dr. Bob Smith of Stanford, Florida (Figure 15), Dr. Richard
(Wick) Alexander (Figure 16) and Dr. Moody Alexander (Figure 17), both from
Dallas, Texas, Dr. James Hilgers of Mission Viejo, California (Figure 18), and Dr. Bob
Scholz of Alemeda, California (Figure 19) to provide beta test sites for the appliance.
presented with a full treatment protocol; their results were therefore more acceptable
than those presented earlier to the American doctors. In 1983, Ormco sold 5000
lingual cases, and by 1986 they had sold 18,000 lingual cases!
At this time, thousands of orthodontists worldwide were attending courses and
beginning treatment using the lingual technique. The technique and appliance were
still in their infancies, and, in fact, beta testing had not yet been completed. Public
demand and commercial interest rushed the product to the market, perhaps prema-
turely. In 1986 the French Orthodontic Society founded the Socit Franais
Orthodontie Linguale (SFOL, or French Orthodontic Society for Lingual Orthodontics).
In 1987, at the American Association of Orthodontists annual meeting in
Montreal, Canada, Dr. Kurz was on the program to discuss lingual orthodontic therapy.
The lecture topic was timely in that many orthodontists had now tried the appliance
and lingual therapy without much success. There seemed to be widespread problems
with appliance placement through direct bonding techniques and manipulation of
archwires on open buccal segments with no occlusion because of the bite plane effect
of the anterior inclined plane. Many clinicians had experienced a loss of control in
cases treated with the lingual approach. Dr. Kurzs lecture was well attended because
many clinicians were looking for solutions to the problems that were preventing
them from finishing cases to the same standard of excellence they had come to expect
from labial appliances. At this same meeting, an alternative esthetic solution was pro-
vided to the clinicians. A truly clear, stain-resistant labial bracket was introduced by
A Company. This bracket, called Starfire, provided a reasonable alternative for patients
who were concerned with the poor esthetics of conventional metal labial brackets.
A sigh of relief was heard throughout the orthodontic community. Orthodontists
could now offer to patients an option that provided improved esthetics over metal
brackets with efficient and high-quality treatment.
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, Drs. Kurz, Gorman, and Smith. They restructured the group and were renamed
KGS Ormco Task Force Number Two. Their new charge was to define the problems
that plagued the current status of lingual therapy and develop solutions to these prob-
lems. These were the problems they identified:
Lingual Orthodontics: Historical Perspective
1. The lingual appliance had been made available to the public before testing was
complete.
2. Orthodontists inadequately trained with lingual therapy were treating patients
in record numbers.
3. The public had high expectations from this treatment and demanded it from
the profession immediately.
A solution was to have smaller classes taught by more experienced lingual practi-
tioners. Longer courses were developed with a typodont (hands-on) component, and
continuing education was stressed, with support provided by study clubs, journals,
and professional meetings.
The American Lingual Orthodontic Association (ALOA) was established on
November 14, 1987, by a core group of six hundred American orthodontists. Member-
ship quickly grew to over 800 members in 17 countries. The ALOA provided quarterly
journals, study club assistance, patient brochures, yearly conventions, and professional
lectures. The first annual meeting of ALOA was held in Washington in 1987, and in
Palm Springs the following year. Additionally, a Dental Lingual Assistant Association
was formed to provided support for staff members employed by lingual orthodontic
practitioners. The new professional associations were smaller than the original groups
but remained active in their support of lingual therapy. Continuing educational pro-
grams were now offered in Europe and Japan by the KGS group. Enthusiasm for lin-
gual therapy was still strong in these professional communities. Some European and
Japanese university programs offered training in lingual therapy and these were soon
followed by courses in Korea, South America, Mexico, and Denmark.
The European Society of Lingual Orthodontics (ESLO) was founded in 1992, in
Venice, Italy, and hundreds of people participated in the first European lingual asso-
ciation congress in Venice. In the same year, an Italian society was founded; the
Associazione Italiana Ortodonzia Linguale (AIOL) or the Italian Association of
Lingual Orthodontics has been one of the most active ever since. The Asian lingual asso-
ciation is also very active. Dr. Lorenzo Favero, Italy, was the first to treat children and
adolescents with LO, and now it is a legitimate treatment option for all.
Today, lingual orthodontics has a small but strong following in the United States,
Europe, and Asia. The ALOA is active again, after few years of silence, with annual
conventions, availability of patient educational materials, and the publication of a
professional quarterly, the JALOA. The French Lingual Orthodontic Society and the
Italian Lingual Orthodontic Society currently hold annual meetings. The ESLO
sponsored the last international meeting in Monaco, Monte Carlo in 1996 and the
next meeting is scheduled for June, 1998 in Rome. Many courses are given in various
locations throughout the world, mainly by Drs. Didier Fillion (France), Courtney
Gorman (USA), Giuseppe Scuzzo (Italy), Kyoto Takemoto (Japan), Echarri Pablo
Lobiondo (Spain), Bob Baker (USA), Mario Paz (USA), and John Napolitano (USA).
The following is a summary listing of some of the difficulties encountered during
the development of lingual orthodontic therapy and the current solutions:
redesigned with smooth exterior surfaces and a low profile. The increased comfort
allows normal tongue activity, hence speech is not affected significantly.
2. Gingival Impingement
Earlier generations of the lingual appliance had a broad bonding base extending
towards the gingival margin (Figure 112). Access for adequate oral hygiene and the
self-cleansing nature of the oral cavity were compromised. Brackets have been
redesigned to be more self-cleansing. The base now extends incisally and mesiodistally,
providing adequate bond strength, yet retaining hygienic qualities. The mandibular
anterior teeth are particularly vulnerable to calculus accumulation due to their close
proximity to the submandibular salivary glands. These brackets have 1.5 to 2 mm
clearance between the base and the gingival margin. Additionally, the bracket hooks
have been redesigned with a lower profile and are located several millimeters from the
gingival margin (Figures 113a and b).
3. Occlusal Interference
A predominant problem with the original appliance was the effect of the shearing
forces on the brackets, particularly in the maxillary anterior dentition. (In the absence
of a cross-bite, the lingual aspect of the mandibular dentition is generally not in direct
contact with the maxillary dentition; therefore, the shearing forces were not a problem
(Figure 114). Likewise, the relatively high maxillary crown height and low mandibular
cusp height in the posterior segments allow adequate clearance to avoid the severe
shearing forces seen in the maxillary anterior region.) The bracket was redesigned with
an inclined or bite plane strategically placed to redirect the vertical shearing forces to a
horizontal seating force (Figure 115). The location of the inclined plane is such that
when a 1 mm overjet and overbite relationship is obtained, all mandibular anterior
contact with the inclined plane is eliminated. To avoid deleterious effects caused by
tooth contact with the archwire, the inclined plane is located incisal to the slot.
Patient tolerance of the bite plane effect of the inclined plane has been favorable.
- . Photo of Kurz #7 bracket bonded on typodont, with close-up of mandibular and maxillary incisors.
4. Appliance Control
Since the introduction of lingual therapy, control has been a concern. To allow better
control of tooth movements, the appliance was fabricated in high tensile metal which
provides a greater degree of accuracy. First and second molar bands were manufactured,
allowing control from both the buccal and lingual sides of the posterior segments.
An initial treatment approach joined the buccal and lingual attachment when the wire
was engaged. This coupling was thought to prevent vertical and horizontal rotation
of the buccal segments (Figure 116). Clinically, however, this coupling proved to be
unnecessary because one full arch wire from 7-7 was able to offer much more stability.
Currently, transpalatal bars are used for additional stability. They can be attached to
either the first or second molar.
treatment. Topographic maps were constructed for each tooth and individual bracket
base curvatures were calculated (Figure 117).
7. Appliance Prescription
In the early 1970s, Dr. Lawrence Andrews developed and patented a fully programmed
orthodontic appliance, which he introduced as the Straight Wire Appliance. This
philosophy involves programming all the elements necessary to achieve an optimal
occlusion into each bracket.
Lingual Orthodontics: Historical Perspective
The in-out values varied dramatically between the anterior and posterior segments.
To adjust for this with bracket design alone would make the anterior brackets thicker
than is reasonable, so a true straight wire was not feasible. A first order bend was
placed at the junctions of the canine and premolar, and the premolar and molar.
These wires could be prefabricated in the laboratory.
8. Wire Placement
Access for the placement of wires in the molar tubes from the lingual was limited. The
tubes were redesigned by widening the mesial aperture of the slot of the first molar
bracket, creating a funnel effect (Figure 118).
9. Ligation
To permit stable ligation with ligature wires or A elastics, ligature locking grooves that
are both deep set and easy to hook have been designed. When teeth are crowded and
slot engagement is especially difficult, a vertical slot is provided so the archwire can
be attached to the bracket even through the initial stages of leveling and aligning
(Figure 119). A double over-tie with metal is used when a tooth is to be an attach-
ment for anchorage or rotation of the other teeth.
10. Attachments
A gingival hook is an integral part of the bracket and provides rotational control. The
original hook was large and in close proximity to the gingival margin, impeding access
for hygiene. This hook was redesigned with a lower profile and moved away from the
gingival margin.
G ENERATION #21980
Hooks were added to all canine brackets (Figure 122).
G ENERATION #31981
Hooks were added to all anterior and premolar brackets. The first molar had a bracket
with an internal hook. The second molar had a terminal sheath without a hook but
had a terminal recess for elastic traction (Figure 123).
- . Generation #11976.
Flat maxillary occlusal bite plane from canine to canine.
- . Generation #11976.
The lower anteriors and premolars had low profile, half-round brackets.
There were no hooks on any brackets.
G ENERATION #4198284
This generation saw the addition of a low profile anterior inclined plane on the cen-
tral and lateral incisor brackets. Hooks were optional, based upon individual treat-
ment needs and hygiene concerns (Figure 124 and 25).
G ENERATION #5198586
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 bibeveled to allow intercuspation of the maxillary cusp with the embrasure between
the mandibular canine and the first premolar. Hooks were optional. A transpalatal bar
attachment was now available for the first molar bracket (Figure 126 to 28).
G ENERATION #6198790
The inclined plane on the maxillary anteriors become more square in shape (Figures
129 and 30). Hooks on the anteriors and premolars were elongated. Hooks were
now available for all the brackets. The transpalatal bar attachment for the first molar
band was optional. A hinge cap, allowing ease of archwire manipulation, was now
available for molar brackets.
Bracket
slot for
Bracket archwire
Ball hook
Bracket slot
for archwire
Ball hook
Bracket
- . Generation #6198790. The inclined plane on the maxillary anteriors became more square in shape.
Hooks were elongated and were available for all the brackets.
Lingual Orthodontics: Historical Perspective
Bracket Bracket
slot for
archwire
Ball hook
Bracket slot
Ball hook
Bracket
- . Generation #71990present. The maxillary anterior inclined plane is
heart-shaped with short hooks. The lower anterior brackets have a larger inclined plane with short hooks
and all hooks have a greater recess/access for ligation.
Bibliography
Alexander RG. Lingual orthodontics. In: The Alexander Discipline. Ormco Corporation, 1986;
13:371430.
Andrews LF. The straight wire appliance: syllabus of physiology and techniques. 2nd Ed., USA,
1975.
Fillion D. Orthodontie linguale et Mini-Plaques, esthetique et confort dans les traitments chirur-
gio-orthodontiques. L`Information Dentaire n 20 du 17 mai 1990.
Gorman JC. Treatment with lingual appliance: the alternative for adult patients. Int J Adult
Orthod Orthognath Surg 1987;2:131149.
Gorman JC, Kurz C, Smith JR. Lingual orthodontics, cases, principals and practice. 3-hr.
Videotape produced by Ormco Corporation, Glendora, California.
Gorman JC, Kurz C, Smith JR. Lingual case reports. J Clin Orthod 1983;17:5.
Gorman JC, Kurz C, Smith JR. Lingual mechanotherapy. J Clin Orthod 1983;17:2.
Gorman JC, Kurz C, Smith JR, Dunn RM. Keys to success in lingual therapy. J Clin Orthod
1986;20:45.
Gorman JC, Smith JR, et al. Lingual orthodontics, a status report. J Clin Orthod 1982;16:4.
Kurz C. Lingual orthodontics. In: Marks M, Corn H, eds. Atlas of adult orthodontics.
Philadelphia, London: Lea & Febiger, 1989.
Kurz C, Bennett R. Scientific report. J Am Ling Orthod 1988;1:3.
Smith JR. Twelve key principles for lingual orthodontic therapy. J Am Ling Orthod 1988;1:2.
Present Clinical Reality
M A S S I M O RO N C H I N , M D , D D S
During the evolution of lingual appliance therapy, the technique has moved in and
out of public and professional favor. Over the years, the appliance and the techniques
have been improved dramatically and, as a result, a reliable system has emerged. It has
now undergone many years of clinical experience and has been shown to consistently
produce satisfactory results.
Esthetic concerns were initially responsible for the development of the appliance
system and they continue to remain at the forefront for a significant segment of
patients seeking orthodontic treatment. Appearance is undoubtedly the most impor-
tant motivating factor for adults whether it is termed facial appearance, dental
appearance, or straight teeth.
Research has shown that physically attractive people achieve higher levels of
success in many aspects of life than unattractive people.3 This advantage starts at birth
and continues into adulthood. The added positive attention given to attractive indi-
viduals by teachers and peers, for example, can have profound effects on personality
development and self-image. Improvement in ones physical appearance, as is common
with orthodontic treatment, can positively affect social and professional interactions.19
At the same time, deterioration in ones physical appearance, as with the use of unat-
tractive labial orthodontic appliances, can negatively affect ones self-esteem. This is
particularly true during the formative years of adolescence and young adulthood.
Many patients, if given the choice, would opt for an appliance that was not visible,
provided the course of treatment and the quality of the results were the same as with a
conventional treatment. This service offered in the private orthodontic office allows
the patient several treatment options, and provides the orthodontist with a competitive
advantage over colleagues not offering the option of lingual appliances.
-. The very severe deep-bite occlusion of the patient, -. Occlusal view of the mandibular arch, just after
before treatment. the partial lingual bonding; the molars were banded afterwards.
through the center of resistance of the tooth. As the mandibular anterior dentition
occludes with the anterior horizontal plane of the maxillary anterior brackets, a bite
plane effect results. Since the appliance is bonded, the bite plane is always present.
The net effect appears to be a light, continuous, intrusive force. In addition to these
active intrusive forces on the anterior dentition, a passive extrusion occurs in the pos-
terior segments. Deep-bite correction through this passive increase in posterior vertical
dimension and active decrease in anterior vertical dimension occurs quickly and easily.
Malocclusions requiring open-bite correction obviously would not benefit from this
technique. To prevent the passive extrusion of the posterior segments in these patients,
acrylic posterior overlays are used.
Figure 22 shows the intrusive effect of the appliance in correcting a severe dento-
alveolar deep bite in a 38-year-old female. This patient had a class II occlusion with a
skeletal and dental deep-bite pattern and severe crowding in both arches. The maxil-
lary dental midline looked deviated towards the left-hand side because of the extreme
Class II relationship on that side (Figure 22a). Partial lingual appliances were placed
in both arches (Figures 22b and c). As with labial bracket placement, ideal placement
-. The upper arch, just after the initial partial -. Frontal intraoral view, three months after
lingual bonding. starting lingual mechanics.
is not always possible at initial bonding due to the severity of the malocclusion, so
appliances should be repositioned during treatment when it becomes possible. Figure
22d shows the treatment progress three months after appliance placement, and
Figure 22e shows the final occlusion. Total treatment time was 15 months.
Deep-bite correction was facilitated by the active anterior intrusive forces and the
passive posterior extrusive forces. The correction was stabilized by prosthetic restora-
tions in the posterior segments.
- . Lower and upper occlusal photographs, before treatment.
-. Right and left intraoral views, during the initial phases of mechanics, after the extraction of the first lower molars.
-. The upper arch (occlusal view), just after placing -. The upper arch (four months after Figure 24a),
the first superelastic Twist-Flex type archwire. with a rectangular wire. Notice the amount of the transverse
and sagittal expansion.
the force is more palatal than the center of resistance of the tooth.
The following case shows a 30-year-old female who had a Class III occlusal rela-
tionship with a prognathic profile and a protruding lower lip (Figure 23a), an anterior
cross-bite of several mandibular teeth, upper arch contraction, and a total lack of
space for the lower left central incisor which was lingually placed and completely hid-
den by the adjacent incisors (Figures 23b and c).
Since it was a Class III malocclusion, the upper arch underwent a nonextraction
treatment. The lower arch was treated with extraction of the first molars to gain more
space to solve the crowding and to achieve more successful intercuspation. The upper
third molars would subsequently be extracted (Figures 23d and e). Lingual braces
were bonded to the upper arch with an initial Twist-Flex type archwire (Figure 24a).
Four months later, the extent of the dentoalveolar expansion obtained is quite
remarkable, both transversally and anteriorly (Figure 24b). Further expansion was
achieved with a rectangular archwire. The results show substantial improvement in the
patient profile and occlusion (Figures 24c and d).
- . Frontal, right, and left intraoral photos, before treatment.
-. The patient, wearing the splint, is maintained -. The upper arch, after the expansion, with a full size
in the same therapeutic position. The lower arch is fully bonded. rectangular archwire. The acrylic repositioning build-ups on the
first molars are visible.
and 7 demonstrate the use of the lingual appliance in treating patients with TMD.
This 18-year-old patient presented some TMD signs and symptoms and a history of
past orthodontic extraction treatment. She had an early reciprocal clicking in the left
TMJ and also suffered from muscular hyperactivity. Both the right and the left masseter
muscles and the anterior belly of the left temporal muscle felt tender to palpation. She
had mild to moderate anterior crowding, a Class I canine and molar relationship on
the right, an end-on Class II canine and molar relationship on the left, normal overjet,
and an increased overbite (Figures 26a to c). A mandibular repositioner was fabricated
and worn until her TMD symptoms disappeared (Figure 26d) and she was main-
tained symptom free for four months before orthodontic treatment was initiated. The
lower arch was then bonded (Figure 26e). Two months later the upper splint was
- . Frontal, right, and left intraoral views, a few weeks after treatment is completed.
-. The center of resistance of the second -. The distal movement takes place quite bodily; only
upper molar is located in correspondence with the palatal root later can a slight buccal rotation be observed.
(see the yellow dot), close to the lingual wall.
removed, the maxillary arch bonded, and flat acrylic supports were placed (Figure
26f ). These two posterior elevations, combined with the bite plane effect of the ante-
rior brackets and the Class II elastics allow mandibular repositioning while also allow-
ing orthodontic treatment to progress. Figures 27a to c show the finished case several
-. For the second stage, a buccal sectional -. A doubled Class II elastic (lingual and buccal)
archwire can be used. is very effective for the retracting mechanics.
Present Clinical Reality
months after debonding. The patient remained symptom free. This is an interesting
aspect of lingual appliance therapy that warrants consideration.
-. Frontal view of the malocclusion before treatment. -. A round archwire is initially used in the upper arch.
- . The anterior bite effect of the lingual braces and the acrylic posterior minisupports.
duce more bodily movement of the tooth and less distal tipping. Because of the angu-
lation of the multiple roots of maxillary molars, the center of resistance is found just
lingual to the average long axis of the roots (Figure 28a). In this example of a second
molar being distalized with the use of an open coil spring, lingual and labial tech-
niques are sequentially employed. Figure 28b shows the force being applied from the
lingual surface; here the CR is found in the palatal root. In fact, a rather bodily distal
migration takes place. Afterwards, a labial force (Figure 28c) can very easily correct
the rotation. Bodily movement is the most efficient form of tooth movement.
Clinically, this can be accomplished by placing an open coil spring between the first
and second molars. To counteract the mesial displacement of the first molars, a verti-
cal loop is placed against the lingual twin bracket (Figure 29a). For derotating the
second molar and continuing to distalize the tooth, two buccal brackets and a section-
al archwire can be placed. This will allow Class II elastics to be used on both the buc-
cal and lingual aspects (Figure 29b). The balance of these forces counteracts the rota-
tional forces.
As an additional case, we present the 20-year-old female in Figures 210 to 13 who
presents a rather retrusive chin (Figure 210a). We are faced with a Class II deep bite
malocclusion with a slight anterior crowding (Figure 210b). At first, only the maxil-
lary arch was lingually bonded, with the purposes of alleviating the crowding, intrud-
ing the anterior group, and expanding the maxillary arch (Figure 210c). Some poste-
rior acrylic minisupports are noticeable in the intraoral lateral photographs (Figures
210d and e). As previously described, these supports tripodize the occlusion through
an anterior contact on the brackets and through posterior contacts on the flat elevations
and produce an anterior mandibular displacement during the use of Class II elastics.
In addition, this distribution of the occlusal load is comfortable for the patient. After
having banded the lower arch, Class II mechanics was applied (Figure 210f ). In the
upper arch, a lingual archwire can be used (Figure 211). In Figure 212 we see a
remarkable improvement in the patients profile at the end of treatment. Her chin
looks more advanced and her lips are more harmonious. We successfully obtained a
full Class I occlusal relationship and the anterior deep bite was corrected (Figure 213).
In todays clinical orthodontic practice, the lingual appliance can offer many
advantages over the labial appliance to both the patient and the practitioner. Enamel
surfaces are protected, some treatments (such as deep bite correction) can occur faster,
molar distalization appears to take place more efficiently, and TMD patients can pro-
ceed with orthodontic treatment in a timely manner.
References
1. Alexander CM, Alexander RG, Gorman JR. Lingual orthodontics: a status report, part 1.
J Clin Orthod 1982;16:255262.
2. Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report, part 6:
patient and practice management. J Clin Orthod 1983;17:240246.
3. Breece G, Nieberg L. Motivations for adult orthodontic treatment. J Clin Orthod 1986;
3:166171.
4. Bercheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119131.
5. Fujita K. New orthodontic treatment with lingual brackets and mushroom arch wire appli-
ance. Am J Orthod 1979;76:657675.
6. Genone B, Siciliani G. Trattamenti ortodontici a collocazione linguale. Mondo Ortodontico
1984;3:1427.
7. Gorman JR, Hilgers JJ, Smith JR. Lingual orthodontics: a status report, part 4: diagnosis and
treatment planning. J Clin Orthod 1983;17:2635.
ruin the accuracy of the indirect bonding. This means no separators, no extractions, and
no heavy cleaning. The last item should have been accomplished prior to the impres-
sions, and the first two items should be completed after the initial bracket placement.
Appliance Placement
The bonding procedure for the initial bracket placement is as follows:
1. Paint all of the brackets with the bracket-side portion of the bonding adhesive.
2. Microetch the lingual surface of all teeth to be bonded.
3. Isolate one-third of the dental arch. (Some clinicians may prefer to bond the
entire arch simultaneously.)
4. Acid etch the teeth for 20 to 30 seconds.
5. Rinse each tooth for 20 seconds.
6. Dry the teeth with an air syringe. At the same time use a hair dryer to displace
the moisture from the breath.
7. Paint the teeth with the tooth-side portion of the adhesive.
8. Reapply the bracket-side portion of the adhesive.
9. Fully and firmly seat the bonding tray and hold in place for one minute.
10. Repeat procedures 3 to 9 for the remaining segments.
11. Remove the hard shells of the bonding trays.
12. Using a sharp scaler, remove the soft undertrays.
After the bonding procedure is complete and before removal of the isolation, each
bracket is checked by pulling on it with an elastic. If there is a failure, cut the section
of the tray from which that bracket came into a single-tooth tray, discard the hard
shell and place the bracket back into the single-tooth soft tray, microetch the bracket
and tooth, reapply bracket side adhesive to the bracket, acid etch the tooth, rinse the
tooth, reapply tooth side adhesive, reapply the bracket side adhesive, seat the tray,
hold for two minutes and then remove the tray. It is advisable to retain the soft trays
for any future repairs. In cases with a porcelain jacket crown, the crown should be
conditioned with a porcelain etchant for four minutes and then rinsed. Apply some
normal etchant to the crown and blow off the excess followed by the silane primer
(it is important not to skip the etch as the acid activates the silane). Now apply the
adhesive bond to the bracket and bond it to the crown.
Before placing the initial archwires, the clinician must first determine which teeth
are to be engaged. Elastic chains are placed over the brackets on each of those teeth.
The chain is precut into two- or three-unit sections. Then, using a hemostat, it is
stretched over the brackets with the extra lumen pointing towards the gingiva. The
initial wires are then bent using a 1:1 photograph of the original malocclusion as a
guide. In most cases this wire will be a .0175 Respond wire (Ormco). When the proper
shape and length have been achieved, the distal ends are slid into the hinge caps or
tubes. The wire is then engaged into one of the anterior brackets, and the chain is
pulled back over the bracket so that a single lumen now encircles the archwire, form-
ing the double over-tie. Now with the wire stabilized, the rest of the brackets can be
engaged and the distal ends trimmed.
The patient is instructed how to care for their appliances and instructed on the
use of wax to prevent ulceration of the tongue. At this time it is important to encourage
the patient and assure him or her that the function and speech will return to normal.
Lingual Orthodontics in a Labial Orthodontics Office
The patient is then reappointed for a 40-minute visit approximately eight weeks later.
If there are teeth to be banded, wire separators are placed before the patient is dis-
missed and is reappointed one week later for the banding.
Forty-minute appointments are scheduled during the course of treatment for wire
changes, adjustments, or single-tooth bonding or banding. Changes of power products
or checks of elastic wear are scheduled for 20-minute appointments. At each appoint-
ment the assistant first checks the patient for any loose or broken appliances. If there
are none, she proceeds with the removal of the archwire to be adjusted or replaced.
This information should be noted in the chart and the doctor can now examine and
confirm the treatment noted in the chart. If any changes are to be made they can be
initiated now. Any adjustments to the wire can also be made at this time. The assistant
then reinserts the archwire (usually only one wire is adjusted during a single appoint-
ment) and applies any necessary power products.
are fully engaged. This wire is used in conjunction with rotation ties until all rotations
have been corrected. To develop torque and to continue leveling, a .0175 .0175
TMA is placed. In the maxilla, it is common to follow this wire with a .017 .025
TMA to achieve adequate torque.
When the dentition is fully leveled and aligned space closure is begun, .016 .022
stainless steel archwires with a Curve of Spee in the maxilla arch and a reverse curve in
the mandibular arch are used. The anterior segments are figure-eighted together using
a steel ligature. Power tubes and power chains are then placed from cuspid to second
bicuspid to supply the necessary force for space closure (sliding mechanics). It is
important to figure-eight the segments so the power products can be used over the
shortest possible distance. Failure to do so can result in unwanted bowing of the dental
arches in both the vertical and horizontal planes. Once all of the space has been closed,
the patient can be prepared for elastics by placing a .017 .025 stainless steel archwire
with omega tiebacks in the mandible. In the maxillary arch, figure-eight and power
products can be removed and brass electrodes soldered to the wire to act as tiebacks.
When a Class I occlusion has been achieved, .016 stainless steel finishing arches
can be placed. These wires should also have some type of tieback to ensure that no
spaces reopen. If the buccal segments do not have maximum interdigitation at this
point, a tooth positioner can be utilized. While a tooth positioner is very effective for
socking in an occlusion, they are inadequate to complete space closure or for correc-
tions of anterior positions. Four weeks after the delivery of the positioner, impressions
for retainers are made. Clear overlay retainers are used. They are excellent for retaining
alignment and provide exceptional esthetics.
Practice Promotion
Lingual appliances give the orthodontist a distinct competitive advantage. There are
many individuals who need and desire orthodontic treatment but are not willing to
wear conventional appliances. Many of these patients have gone for years hiding their
smiles and neglecting their oral health. By offering them treatment with lingual appli-
ances, the orthodontist provides a valuable and unique service. Many lingual patients
are high-profile individuals. While they are willing to pay a premium for their lingual
braces that others cannot see, they also openly discuss their treatment with their
friends, colleagues, relatives, and sometimes even strangers. They can become great
referral sources and goodwill emissaries for your practice. Referring dentists will also
appreciate that you are able to provide their patients with a service that the other
orthodontists cannot. They will be more likely to refer more of their patients to a full
service orthodontist.
Before the practice benefits from these and other advantages that lingual ortho-
dontics brings, it is important that the staff and the orthodontist feel confident and
comfortable with the lingual technique. The first step is to attend a complete
typodont course during which a step-by-step method to treat lingual cases is taught.
Once the orthodontist and his staff have achieved a high level of clinical proficiency,
the lingual patients can be incorporated into the normal schedule. They can be treated
side by side with the labial patients. Other than allowing adequate time, there are no
other special requirements for these patients.
Lingual Orthodontics in a Labial Orthodontics Office
Conclusion
Lingual braces have been and are a viable treatment option. With these appliances the
practitioner can achieve excellent results while providing his or her patients with a
unique and valuable service. To successfully incorporate lingual patients into a labial
practice the doctor and staff must develop the skills to successfully treat these patients.
Then the treatment must be presented in such a way that the prospective patient will
be receptive. This includes having models with lingual braces, having a treatment
coordinator who believes in the treatment, and encouraging patients when lingual
appliances are the better option. Having appropriate fees is also important to your
practice. Lingual patients require approximately 25% more chairtime for the same
treatment. Thus, a premium should be added to the usual fee. We add approximately
27% for the first arch and an additional 20% for the second arch. In this way both
the additional laboratory expense and chairtime are covered. If the practitioner will
make the commitment to make lingual orthodontics a part of his or her practice, the
practice will grow.
SECTION 2
Basic Principles
. Wire Sequencing in
Lingual Orthodontics . . . . . . . . .
H. Stuart McCrostie
Instruments Used in
Lingual Orthodontics . . . . . . . . .
Craven Kurz
Enhanced Facial Esthetics
using Kurz Lingual Appliance
C R AV E N K U R Z , D D S , P hD
Bite Plane
An upfront, full smile always attracts attention. Dr. Grant Bowbeer had found that
a bite plane in combination with labial orthodontic appliances helps to expand the
maxilla and consequently, to achieve an esthetic occlusion. The inclined plane in the
upper incisor lingual brackets was designed for the purpose of avoiding shearing forces
and subsequent debonding of the maxillary brackets. However, if used properly, it can
also achieve correct positioning of anterior teeth in the optimal esthetic A-P and lateral
positions.
The esthetic advantages of the bite plane are:
1. It can be used as a functional appliance to facilitate the unlocking of a retruded
mandible.
2. It can help expand the arch. This is a clinical observation and the possible
explanations are elimination of posterior contacts or decrease in the lateral
space in the palatal vault (Figures 42a to c).
3. It helps extrusion of posterior segments and intrusion of lower incisors in deep
bite cases, giving the lower lip better support from the lower incisor and bal-
ance with the maxillary lip in closure (Figures 43a and b).
4. Easier translation of teeth around the arch when the midline is off centered
due to the smooth contact with the flat metal plate on the incisor brackets.
- . Maxillary arch expansion: occlusal view before, during, and after lingual treatment.
Note wide horseshoe arch.
Enhanced Facial Esthetics using Kurz Lingual Appliance
- . Extrusion of posterior segments and intrusion of lower incisors in deep bite case:
occlusal view before and during lingual treatment.
Bibliography
Bowbeer GRN. The five keys to facial beauty and TMJ health. The Functional Orthodontist 1985;
2:1229.
Eirew HL. An orthodontic challenge. Int J Orthod 1976;14:2125.
Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 1977;72:599616.
Luzi V. The CV value (combines variation) in the analysis of sagittal malocclusions. Am J Orthod
1982;81:478480.
McNamara JC. Components of Class II malocclusion in children 810 years of age. Angle
Orthodontists, 1981;51:177202.
Moyers et al. Differential diagnosis of Class II malocclusions. Am J Orthod 1980;78:477494.
Advanced Lingual Prescription:
Technique and Design
RO B E RT B A K E R J R ., D M D
Lingual orthodontics in the 21st century will involve several new innovations, includ-
ing new players in the treatment field, new appliances and auxiliaries, and enhanced
laboratory techniques, design, and communication. Still, the most important aspect of
any labial, lingual removable or functional orthodontic treatment system is, of course,
the thought process of the orthodontist. As all well-trained orthodontists know, any
single orthodontic treatment system can work to move teeth, manage growth, or gain
space; however, even the best system that is poorly thought out and does not use
sound scientific principles can face failure.
In the 20 years since the original lingual appliance was invented, we have been
through seven generations of the original Ormco bracket and approximately a dozen
other bracket designs from other companies. By necessity, treatment mechanics have
been tailored to the available bracket systems. Many treatment philosophies are influ-
enced by edgewise mechanics, Begg and Bioprogressive systems, and the straight wire
system, after which the original bracket was designed. The individual orthodontist must
take responsibility for his or her treatment.
One of the main problems that lingual orthodontists have to overcome is to not
overstandardize treatment plans. Although standardization sometimes can be of some
advantage in streamlining a practice and allowing orthodontists to keep supplies, staff,
and treatment well-coordinated, treatments should stay very case specific with an indi-
vidual treatment modality for each patient. Cookbook orthodontics, especially for
lingual treatment, has never worked. A thorough, individual treatment plan must be
formulated, and the type of mechanics to be used must be selected from the very
beginning of treatment. This involves a tooth-by-tooth, individual prescription that
anticipates all positive and negative reactions to the type of biomechanics that the
orthodontist will be using. To achieve such accuracy, a lingual orthodontist must have
intimate knowledge of individual bracket positions over the center of resistance of
each specific tooth and the knowledge of how that will either expedite or impede
treatment goals. This will enhance treatment planning and case progress. Eventually,
treatment time and chairtime can be significantly reduced, and patient comfort and
satisfaction can be greatly increased.
Anchorage must be carefully prepared and developed, using the Tweed method or
others. Parisi (1989) proved that anchorage was enhanced from the lingual aspect when
compared to the use of standard direct-bonded labial edgewise appliances without the
use of extra anchorage auxiliaries.
Factors like anatomical variation of teeth and functional habits like mastication
and swallowing should be taken into account while planning the correct placement of
the lingual brackets. The biomechanics of choice must be carefully selected. For
example, if an orthodontist is using loop mechanics, continuous arch mechanics, or
sectional mechanics to retract teeth into an extraction space, the laboratory setup
could be different for each retraction method due to the differing effects on the teeth
and underlying bone. One of the advantages of advanced laboratory case design and
technique is the virtual elimination of appliance auxiliaries like rotation ties or
double over-ties.
Case Presentations
The following cases demonstrate diagnosis and the establishment of treatment goals
through selective individual tooth prescriptions, using the CLASS System design for
indirect bonding preparation.
- . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion.
Note the unesthetic smile, anterior open bite, and crowding.
Advanced Lingual Prescription: Technique and Design
C ASE 1: D.P.
A 31-year-old male presented with a Class I malocclusion, anterior open bite, and mild
upper and lower crowding (Figures 51a to e). The cephalometric and panoramic x-ray
revealed no unusual findings. The treatment plan consisted of placing upper and lower
lingual appliances to level and align the occlusion. The crowding was to be resolved
using a nonextraction approach with air rotor stripping on the upper and lower first
premolars. The prescription for the laboratory (specialty appliance) was made as follows:
Patient Name DP
Case description Air Rotor Stripping (ARS) on upper and lower premolars
Appliance Upper and lower .018 Ormco lingual brackets
Prescription Upper arch: (right=RT; left=LT)
RT 1 2 deg. distolingual rotation, 10 deg lingual crown torque
LT 1 3 deg. mesiolingual rotation, 10 deg lingual crown torque
RT & LT 2 8 deg. lingual crown torque
RT & LT 4 0.75 mm ARS mesial & distal
RT 6 3 deg. distobuccal rotation
LT 6 5 deg. distobuccal rotation
RT & LT 7 5 deg. mesial crown tip, Hinge Cap attachments
Lower arch: (right=RT; left=LT)
RT & LT 2 2 deg. mesiolingual rotation
RT & LT 3 3 deg. mesiolingual rotation
RT & LT 4 0.75 mm ARS mesial & distal
- . Frontal and lateral views during treatment.
- . During treatment: upper and lower occlusal view of lingual appliance.
Upper and lower lingual appliances were bonded (Ormco, generation #7, .018
slot) (Figures 52a and b). Treatment time was only 12 months, with 14 visits to the
Eastman Dental Center. No auxiliaries were used. The results show a balanced and
esthetic occlusion (Figures 53a to e).
- . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion.
Note the balanced and esthetic occlusion.
Advanced Lingual Prescription: Technique and Design
C ASE 2: A.M.C.
A 31-year-old female presented with a Class I malocclusion, mild upper and lower
crowding, and upper right dental midline shift. The upper right lateral incisor was
severely rotated distobuccally. (Figures 54a to e). The cephalometric and panoramic
x-ray revealed no unusual findings. The treatment plan consisted of extracting the
maxillary right first premolar to alleviate crowding and aid in the midline correction.
The occlusal plane was to be leveled. Continuous arch mechanics were to be used for
extraction space closure. The prescription for the laboratory (specialty appliance) was
made as follows:
- . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion.
Note the unesthetic smile, rotated upper right lateral incisor, and midline shift.
- . Frontal and lateral views during treatment.
- . During treatment: occlusal views of the upper lingual appliance and lower transparent labial appliance.
Advanced Lingual Prescription: Technique and Design
- . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion.
Note the balanced and esthetic occlusion.
was 18 months, with 18 visits. No auxiliaries or wire bending was needed during the
treatment and chairtime was the same as with a full labial appliance. The end results
show a balanced and esthetic occlusion (Figures 56a to e).
These cases demonstrate the use of goal-oriented diagnosis, individualized bracket
prescriptions, and specific mechanics to provide more efficient treatment with the lin-
gual appliance. Of course, lingual treatment can be affected by the same factors as in
labial treatment, such as inadequate patient cooperation, bracket failures, etc. Wire
bending and the use of auxiliaries can be eliminated with the judicious selection of the
appliance prescription. Studies are ongoing to improve appliance prescriptions and
custom laboratory-fabricated archwires. These and continued studies will advance the
art and science of lingual orthodontics and will continue to make it more user- and
patient-friendly.
.
Shape Memory Wires in
Lingual Orthodontics
CHRISTIAN DEMANGE, DCD, SQODE, CECSMO
The term Shape Memory Alloys (SMA) is applied to the group of metallic materials
which demonstrate the ability to return to some previously defined shape or size when
subjected to the appropriate thermal procedure.1 Generally, these materials can be
plastically deformed at some relatively low temperature and, upon exposure to higher
temperature, will return to their shape prior to the deformation (Figure 6.11). Shape
memory alloys, such as nickel titanium, undergo a transformation in their crystal
structure when cooled from the stronger, high temperature form (austenite) to the
weaker, low temperature form (martensite) (Figure 6.12). This inherent phase trans-
formation is the basis for the unique properties of these alloys: shape memory and
superelasticity.
Shape Memory
When a shape memory alloy is in its martensite form, it is easily deformed to a new
shape. However, when the alloy is heated through its transformation temperature, it
reverts to austenite and recovers its previous shape with a net force delivered (Figure
6.13). This process can be repeated millions of times. A typical transformation versus
temperature curve under constant load is shown in Figure 6.14.1 Most of the trans-
formation occurs over a relatively narrow temperature range, although the beginning
and end of the transformation during heating or cooling actually extends over a much
larger temperature range. The transformation also exhibits hysteresis (shown as T1) in
that the transformations on heating and on cooling do not overlap. This transforma-
g Co
atin olin
He g
Face centered
.-. The shape memory effect. .-. Transformation of alloy crystals of shape memory
alloys from hot to cold phase.
Austenite
Martensite
tion hysteresis (T1) varies with the alloy system. The most common SMA wires used
are NeoSentalloy or Bioforce (GAC) and Copper Ni-Ti 35C (Ormco).
Superelasticity
These unique alloys also show a superelastic behavior if they are deformed at a tem-
perature which is slightly above their transformation temperature. This effect is caused
by stress, inducing the formation of some martensite. Because it has been formed
above its normal temperature, the martensite reverts immediately to undeformed
austenite as soon as the stress is removed. This process provides a very springy, rubber-
like elasticity in these alloys (Figure 6.15).
B. U SE ELASTIC WIRES
Reduce the cross-section of the wire (which reduces control), or change the physical
properties of the wire (yielding a low Youngs modulus).
Shape memory alloys are ideal materials because they have low Youngs modulus,
present a very small stress/strain ratio, and have a large cross-section of wire to achieve
a maximum of control. The mechanical properties of SMA wires are different in the
austenite and martensite forms. Youngs modulus is highly nonlinear with temperature.
The approximate elastic modulus is about 80 GPa at high temperature (austenite), and
30 GPa at low temperature (martensite). (Figure 6.17). The Youngs modulus of shape
memory alloys is difficult to define between the martensite and the austenite transforma-
tion temperatures because at these temperatures the alloys exhibit nonlinear elasticity,
and the Youngs modulus is both temperature and strain dependent.
In lingual orthodontics, bends should be made to obtain a mushroom shape in
the archwire (Figure 6.18). The wires must be bent to a strain greater than 8% in
elongation to achieve a permanent deformation in a superelastic material (Figure
6.19).2 The elongation at failure is about 15%. This allows wires to be bent without
any clinical fracturing. The yield strength is about 600 MPa in austenite and 100 MPa
in martensite (Figure 6.110). The bend can be performed either when the wire is hot
or cold. However, it is much easier to bend it when it is cold. Some of the bend
straightens when the wire returns to room temperature; therefore, the wire should be
overbent (approximately twice). In this way, no thermal machine (like Archmate) is
used to bend SMA wires. The mushroom shape is a little smoother but is still possible
to obtain (Figure 6.18). The wire near the bend will be stiffer and more brittle after
bending; however, the area of the bend falls between the canine and premolar and is
not significant. To allow easy placement into bracket slots, the wire is refreshed with
40 spray to obtain martensite.
.-. 020 .020 Bioforce is placed immediately after .-. One month in treatment (2nd appointment):
bonding of lingual brackets. Double over-ties to reactivate the wire.
.-. Before treatment. Note anterior crowding. .-. Occlusal view of maxillary arch before
debonding. Space closure was done with .019 .025 SMA wire.
because they can immediately control root inclination and angulation. The superelas-
ticity properties of the wire is used to reactivate the wire (production of martensite
under strain) by placing double over-ties on all teeth.
C LINICAL C ASE
A 25-year-old female presented with a Class I malocclusion and upper anterior
crowding. A lingual appliance (Ormco, generation #7, slot .022) was bonded and
.020 .020 Bioforce was used (Figure 6.111a). One month later, reactivation was
done with double over-ties. (Figure 6.111b). Two months after the beginning of
treatment, almost full alignment was achieved (Figure 6.111c).
.-. Occlusal view of maxillary arch: Immediately .-. Occlusal view of maxillary arch: Two months in
after bonding: .016 Ni.-Ti. treatment: .019 .025 SMA wire is used for space closure.
Shape Memory Wires in Lingual Orthodontics
.-. Occlusal view of maxillary arch: 20 months in .-. Occlusal view of maxillary arch after debonding
treatment: the same wire (.019 .025 SMA) is still used. of brackets and bonding of fixed retainer.
wires immediately after bonding even when treatment has considerably progressed
(Figure 6.112).
Conclusion
Shape memory alloys used in lingual orthodontics at an early stage of treatment can
reduce the archwire sequence and obtain more rapid alignment, leveling and, in some
cases, space closureusing the same wire. Root control is maintained from the very
beginning of treatment. Treatment time is shorter, and so is chairtime.
References
1. Hodgson DE, Wu Ming H, Biermann RJ. Shape memory alloys. Shape Memory Applications,
Inc., 1995.
2. OBrien WJ. Dental materials: properties and selection. Quintessence Publishing, 1989;58.
.
Wire Sequencing in
Lingual Orthodontics
H . S T UA RT M c C RO S T I E , D D S
I NITIAL A RCHWIRES
Initial archwires are the most important in the sequence and their application can
often be time consuming. The goals to be achieved at this stage are initial levelling,
alignment, derotations and tip control, to allow maximum bracket slot engagement.
When crowding is severe, a second initial wire is required to ensure full bracket slot
engagement. The Wilcocks (Australian) .016 Special-Plus wire is employed here with
advancement loops or stops mesial to the first molars (Figure 2a).
It is essential that steel ligation be used for bicuspid and molar attachments when-
ever advancement loops or molar stops are required (Figures 6.23a and b). Anterior
bite opening is remarkably enhanced by the use of Wilcocks (Australian) .016 Special-
Plus wire, especially with an additional reverse Curve of Spee. Where the anterior
teeth are moderately rotated, a steel double over-tie maybe employed to a Ni-Ti wire
(Figures 6.24a to c). Double over-ties are also used for ligation of anterior teeth.
I NTERMEDIATE W IRES
Intermediate wires like .017 .025 TMA may occasionally be used as finishing wires as
well, especially in nonextraction cases. In extraction cases, the arch form in the initial
wires should be modified to ensure that the cuspid-bicuspid offset is placed just distal to
the canine bracket to allow space closure (Figure 6.25). The buccolingual compensatory
curve is reduced in the intermediate wire since it is relatively stiffer than the initial wire.
.- . Molar steel ligation.
Wire Sequencing in Lingual Orthodontics
.- . Double over-tie steel ligation of anterior teeth.
Elastic forces may be applied at this stage of treatment to initiate A-P control. However,
TMA wires are not suitable for prolonged or heavy elastic forces, either intra- or interar-
ch. If Class II elastics are required, an extra buccal compensatory bend should be
made to negate the rotational effect of the elastic forces on the lower second molars.
The anterior segment must be figure-eighted to prevent space opening during the
use of elastic force. With rectangular archwires, steel ligation is essential to ensure full
bracket slot engagement and full expression of appliance prescription. Steel ligation also
prevents rerotation of lateral incisors and canines during the application of elastic force.
Conclusion
The success of defensive archwire sequencing depends on the following:
1. Correct treatment planning and well-planned goals.
2. Allowing sufficient time for each archwire to do its work completely.
3. Steel ligation is required with all rectangular archwires.
These measures help to reduce stress to the patient, doctor and the materials used,
increase patient comfort and satisfaction, cut costs and enhance efficiency, predictabil-
ity, standard of results, and profitability.
-. ETM8007.
- . ETM8006.
- . ETM8011.
- . ETM8010.
Instruments Used in Lingual Orthodontics
- . ETM8003.
-. ETM8014.
- . Lingual hinge cap opening tool.
- . Direct bond removing plier (lingual).
- . ETM8004L.
Instruments Used in Lingual Orthodontics
- . ETM8201.
- . ETM8202L.
- . ETM2108.
This instrument allows both second order intraoral bends and right-angled bends at
the distal sheath (Figures 711a and b).
Reference
ETM Lingual Plier Co., Monrovia, CA.
SECTION 3
Treatment
Approaches
and Mechanics
. Case Presentation:
Loop Mechanics. . . . . . . . . . . .
Giuseppe Scuzzo
. Case Presentation:
Sliding Mechanics . . . . . . . . . .
J. Courtney Gorman
Lingual Orthodontics in
Pediatric Patients . . . . . . . . . . .
Lorenzo Favero
U1 Int. = L1L2
L1 Int. = L3L4
-. Pretreatment (green) and post-treatment (yellow) -. Pretreatment (green) and post-treatment (yellow)
superimposition of the maxilla on the palatal plane at point ANS superimposition of the maxilla on the palatal plane at point ANS
and of the mandible on the mandibular plane at point Menton: and of the mandible on the mandibular plane at point Menton:
incisor and 1st molar horizontal changes measured at the incisor vertical changes measured at the center of resistance.
incisal edges and the distal end of the first molars.
Anchorage Control in Lingual Orthodontics
-. Applied intrusion force to the upper molars -. Distal rotation can be easily established with the
resulting in cortical bone anchorage. posterior teeth by retraction forces.
-. Anchorage preparation for a maximum anchorage -. Anchorage preparation for a maximum anchorage
case with helical loop mechanics in the upper arch, using a case with T-loop mechanics in the upper arch.
.017 .025 TMA with a transpalatal arch and buccal sectional arch
from 6-7. High-pull headgear and Class II elastics are also used.
be used. This includes Class III malocclusions treated nonsurgically, where dental
compensations by tipping the anteriors lingually may be needed, when the right and
left extraction spaces are not symmetric, or when the space closure cannot be accom-
plished with sliding mechanics because of root contact with the cortical bone. In these
latter cases, the lower six anterior teeth are tipped lingually with loop mechanics.
-. Anchorage preparation for a moderate anchorage case -. Anchorage preparation for a moderate anchorage
with L-loop mechanics in the upper arch. A transpalatal arch is added case with sliding mechanics in the upper arch. To eliminate the
to prevent a transverse bowing effect. The anterior segment (3-3) and transverse bowing effect, a power chain is used from the lingual of the
the posterior segment (5-7) is figure-eighted with ligature wire. canine to the buccal of the first molar, to rotate the first molars mesially.
Without a doubt, the debate between the extraction and nonextraction orthodontic
treatment approaches has been, and will continue to be, the subject of a great deal of
controversy. The literature on this topic is simultaneously abundant and controversial.
The gap between extraction and nonextraction treatment decisions seems to widen
more among cases in which there is no clear cut distinction between the two treat-
ment modalities. There are important diagnostic considerations that can help ortho-
dontists make treatment decisions although they are not always defined as we would
like them to be defined. Among some of these considerations are: cephalometric mea-
surements, skeletal discrepancies, tooth to basal bone relationship, severity of dental
crowding, and facial and profile considerations.
The cosmetic changes that result with a nonextraction approach can be quite
favorable; however, this does not underestimate the functional and cosmetic value of
extraction therapy. Nonextraction treatment, in many cases, is more difficult to exe-
cute than extraction therapy; particularly in cases where space limitation is consider-
able and growth has been completed.
Historical Perspective
Appreciation for facial esthetics is not new to the orthodontic profession. The face of
Apollo Belvedere was considered by Angle1 as an ideal standard of facial beauty for the
orthodontic profession. Peck and Peck made a beautiful recollection of the different
concepts of beauty from a historical perspective.2 For example, the facial esthetic
concept of an ideal profile has undergone changes through history from a mild
Class II, retrognathic, flat, and often concave profile during the time of ancient Greece
to severe Class II profiles during the Renaissance period. Contemporary standards of
facial esthetics tend toward profiles with slightly more fullness (Figures 9.11a to d).
The desire for a fuller profile has made the nonextraction treatment approach
more attractive to prospective orthodontic patients. In some carefully selected cases,
ideal cosmetic treatment may dictate opening previously closed extraction spaces in
order to decrease an existing concave profile (Figures 9.12a and b). The available
nonextraction treatment methods that can be used independently or in combination
to achieve satisfactory expansion results are:
1. Crozat expansion
2. Enamel reproximation
3. Archwire expansion
4. Molar distalization
5. Surgical rapid palatal expansion (RPE)
Expansion Techniques
Although many methods exist to expand the dental arches, a particularly effective
method is with the use of the Crozat appliance. A modified basic and effective version
of the Crozat appliance (personal communication and design by Duane Grummons,
Marina Del Rey, CA) is used (Figure 9.13). Some of the advantages of using the
Crozat appliance prior to lingual treatment are:
patients first introduction to lingual treatment with an esthetic removable
appliance
.- . Series of views demonstrating a range of facial profiles from full to concave.
Preserving the Hollywood Smile and Facial Profile
.-. Patient profile view depicting a .-. Patient profile shows improvement
concave profile due to previous orthodontic treatment and a moderate increase in lip support as a result of
with bicuspid extractions. extraction spaces being opened orthodontically.
Although enamel reproximation has had both negative3,4 and positive57 reviews in
the orthodontic literature, it remains an effective way to increase arch length and maxi-
mize the cosmetic result. Some important factors to take into consideration when
doing enamel reproximation are:
1. Age: Younger patients are likely to be more sensitive to enamel reduction than
older patients. Large pulp chambers and dentinal tubules are contributing fac-
tors to this sensitivity. Radiographs should be evaluated to determine adequate
enamel width and dentinal proximity before enamel reduction is performed
(Figure 9.16).
2. Hygiene: Rough interproximal areas will increase plaque accumulation and,
therefore, caries susceptibility in patients with poor oral hygiene. Enamel
reproximation should only be used in patients demonstrating good oral
hygiene and in areas with adequate access for hygiene.
3. Enamel sensitivity: Enamel reduction in patients with a low threshold of sensi-
tivity may be uncomfortable. The use of desensitizing agents should be consid-
ered with this patient population.
4. Size of teeth and amount of crowding: Enamel reproximation should be avoid-
ed in patients with small teeth and severe crowding. Also, the shape of the
tooth should be considered. Triangular crowns are more amenable to enamel
reduction than narrow, rectangular crowns. Presence of porcelain crowns,
porcelain veneers, and root proximity should also be taken into consideration.
Case Report
The following case demonstrates the use of a combination of techniques used to
achieve a non-extraction treatment in a crowded malocclusion. A 35-year-old female
patient presented with the chief complaint of I would like a broader smile and my
teeth are too crowded.
Clinical examination revealed a mesognathic profile with a narrow and restricted
smile line (Figures 9.17a and b), a Class I malocclusion with 4 to 5 mm of upper
crowding and moderate-to-severe (7 to 9 mm) lower crowding (Figures 9.17c and d).
Preserving the Hollywood Smile and Facial Profile
.- . Crozat activation: (a) mesiobuccal rotation, (b) bicuspid arms moved away
to allow molar rotation, (c) appliance fully activated.
Cephalometric measurements were within normal standards except for some moderate
incisor proclination. Narrow dental arches and an accentuated Curve of Wilson made
this an excellent case for Crozat expansion. Large-size teeth, substantial radiographic
enamel width, and good oral hygiene also made this patient a candidate for the enamel
reproximation technique. Archwire expansion can be an effective method to reduce
the existing shadowed premolar regions upon smiling. Treatment decisions were based
upon the use of a combination of these techniques.
The primary treatment goal was to increase arch length. A modified Crozat
appliance was worn for four months to rotate first molars mesiobuccally and upright
.- . Occlusal views during Crozat expansion just before lingual appliance bonding.
.- . Initial facial photographs. Note restricted smile.
.- . Initial occlusal photographs.
Note minimal upper crowding and moderate-to-severe lower crowding.
Preserving the Hollywood Smile and Facial Profile
.- . Treatment progressmaxillary and mandibular occlusal views.
Note expanded archwires with no crowding.
the lingually inclined buccal segments. Lingual impressions were taken at the comple-
tion of the expansion phase, and a vacuformed retainer was worn until the date of
placement of the lingual appliances. Enamel reproximation combined with archwire
.- . Final intraoral photographs. Note Class I molar and canine relationship and aligned arches.
.- . Final facial photographs. Note nice, progressive, round and broad Hollywood smile.
expansion completed the expansion necessary to achieve the desired arch length
(Figures 9.18a and b).
Total treatment time was 20 months, four months of Crozat wear and 16 months
of lingual appliances. The Class I molar and canine relationship was maintained, the
crowding was relieved, and the arches were aligned (Figures 9.19a to e). The incisor
relationship to the denture base was normalized. Tooth morphology, facial profile, and
lip position were maintained. A broad, unrestricted, and happy Hollywood smile
was achieved (Figures 9.19f and g).
References
1. Angle EH. Treatment of malocclusion of the teeth. 7th Ed. Philadelphia: SS White Dental
Manufacturing, 1907.
2. Peck S, Peck L. Selected aspects of the Art and Science of Facial Esthetics Seminar in
Orthodontics, 1995;105126.
3. Radlanski RJ, Ralph R, Jager A, Zimmer B. Plaque accumulation caused by interdental strip-
ping. Am J Orthod Dentofac Orthop 1988;94:416420.
4. Twesme DA, et al. Air rotor stripping and enamel demineralization in vitro. Am J Orthod
1994;105:142152.
5. Radlanski RJ, Jager A, Zimmer B. Morphology of interdentally stripped enamel one year after
treatment. J Clin Orthod 1989;23:748750.
6. El-Mangoury NH, Moussa MM, Mostafa YA. In vitro remineralization after air rotor strip-
ping. J Clin Orthod 1991;25:7578.
7. Thordasson A, Zachrisson BU, Mjor IA. Remodeling of canines to the shape of lateral incisors
by grinding: a long-term clinical and radiographic evaluation. Am J Orthod Dentofac Orthop
1991;100:123132.
.
Distalization of Molars
in Nonextraction Cases
G I U S E P PE S C U Z ZO , M D , D D S , A N D M AU R I Z I O C A N N AVO , M D
In the adult patient there is no clinically significant growth in the bone structure;
therefore, alternative solutions must be found to obtain space in which to move the
teeth to correct the malocclusion. Treatment options may differ depending on the
amount of crowding, and whether the crowding has occurred in the maxilla or mandible.
Most commonly, teeth are extracted to create the space needed to relieve crowding.
Arch expansion or reproximation of anterior and posterior teeth are alternative methods
used to create adequate space. Less frequently, the posterior teeth are distalized to create
more space anteriorly.
Distalization Treatment
Several different treatment modalities may be employed to distalize the posterior
dentition. Possibilities include fixed appliances with coil springs or Nitinol wires, and
removable appliances such as a modified Cetlin appliance. This type of appliance has
a high acceptance among adult patients because it facilitates good oral hygiene and
allows adaptation to lingual appliance during the initial phase.
The removable Cetlin appliance is constructed from 2 Adams clasps on the first
premolars, distalizing springs on the second premolars and on the first molars, distaliz-
ing screws between the first and second premolars, and an anterior bite plane. The
appliance does not include any metal clasps from cuspid to cuspid due to esthetic
considerations (Figures 9.21a and b). Other effective methods for distalizing molars
are described in detail in Chapter 2.
The following case presents the use of this modified Cetlin appliance for gaining
space by distalizing the molars. A 24-year-old female presented with the chief com-
plaint of unesthetic smile and crowded teeth. She had a Class II Division II deep bite
malocclusion with great crowding on the upper arch, a retained deciduous upper cus-
pid, palatally erupted upper cuspids, in cross-bite with the lower cuspids, and crowd-
ing on the lower arch (Figures 9.22a to c, 3a, 4a). The treatment plan included
upper and lower lingual orthodontic appliances. No extractions were indicated (except
for removal of the deciduous cuspid). The treatment began with a distalizing therapy
on the upper molars by applying a modified Cetlin appliance. The appliance was
.- . At initial orthodontic examination: intraoral views.
Distalization of Molars in Nonextraction Cases
worn for six months until the upper molars and premolars had moved and enough
space was created. A fixed upper lingual appliance (Ormco, 7th generation) replaced
the modified Cetlin appliance to finish the distalization and alignment of the teeth
(Figures 9.23a to d). On the lower arch, a segmental technique was used with labial
.- . Occlusal views of the maxillary arch: (a) At initial orthodontic examination.
(b) After six months with modified Cetlin appliance. Note spaces between the molars, second bicuspids, and
first bicuspids. (c) Bonding of lingual appliance (Ormco-Kurz generation 7). .016 SS archwire with transpalatal
arch. Only the central incisors were bonded in the anterior region due to the crowding and rotations of the lateral
incisors and cuspids. (d) Bicuspid retraction and alignment of the left lateral incisor and cuspid. (e) Before debonding:
.016 .022 SS archwire for en mass retraction with Class II elastics and loops mechanics. (f ) After debonding.
Note the broad and harmonious arch.
.- . Occlusal view of the mandibulary arch: (a) At initial orthodontic examination.
(b) Cross-over technique: labial brackets on posterior segments and lingual brackets on the anterior segment.
Note the extraction of second right molar due to prosthetic considerations. (c) Before debonding. (d) After debonding.
brackets from the first premolar to the second molar. Later, it was combined with
cross-over technique (lingual brackets from cuspid to cuspid and labial brackets on the
posterior segments) (Figures 9.24a to d). Lingual brackets were mounted by using
.- . Completion of orthodontic treatment: clinical facial and profile views.
Distalization of Molars in Nonextraction Cases
the CLASS laboratory method. Twenty-four months after the treatment had started, a
Class I relationship (molars and cuspids), a functional occlusion, and an esthetic smile
had been established (Figures 9.25a to c). Superimposition of the cephalometric trac-
ings before and after the treatment shows almost no change in the incisors and distal-
ization of the molars. (Figure 9.25d).
.
Interproximal Enamel
Reduction in Lingual
Orthodontics
DIDIER FILLION, DDS
Principles
The principles discussed here have been inspired by the publications of Sheridan on
air-rotor stripping. They have also been largely influenced by the desire to maintain
the cosmetic aspect of the orthodontic treatment.
.- . Reduction of temporary prosthetic crowns and fillings in the posterior segments of the arch.
Interproximal Enamel Reduction in Lingual Orthodontics
maximally reducing the posterior teeth, the natural and esthetic morphology of the
anterior teeth is maintained, especially that of the lower incisors, which may be thin
and malpositioned. Interproximal reduction of these teeth can result in dentin expo-
sure, sensitivity, increased caries potential, and improper tooth proportions. Oral
hygiene should be maintained due to the embrasure changes in the molar area.
.- . Brass wire used under the contact point for gingival protection.
Based on the lowest values recommended by Hudson, we have adopted the fol-
lowing recommendations:
Upper arch: Up to 0.6 mm per proximal surface from the mesial face of the first
molar to the distal face of the cuspids and 0.3 mm per proximal face of the anterior
teeth, which allows us to obtain about 10 mm of available space.
Lower arch: 0.6 mm from molar to bicuspid and 0.3 mm on the cuspids which
allows us to obtain about 7 mm of available space.
When all the principles are observed and considered, enamel reduction presents
certain advantages: it can help avoid extractions, and so no extra efforts are necessary
to close in the extraction site, there is no risk of space reopening, the reduction corre-
sponds exactly to the crowding, and the length of treatment time is reduced by 30 to
50%, which is important in decreasing the potential of root resorption.
Periodontists typically dread enamel reduction for fear of a reduction of the
embrasure width and the creation of root proximity. In fact, in the case of an anterior
crowding, there often already exist root proximities. Even if the reduction is done on
the lower anterior teeth, the amount of enamel reduced never exceeds the amount of
crowding. Thus, the root proximity is never worsened. On the contrary, the septum
ends up being enlarged. In the lateral zones, the reduction should always be done so as
to allow the use of interproximal tooth brushes.
Operative Protocol
1. A RCHFORM SELECTION AND LINGUAL ARCHWIRE TRACING
The final archforms are determined from the initial forms, which are either maintained
or modified. The lingual archwire tracings are obtained by computer, after using a
specific laboratory procedure which allows us to measure the thicknesses of the tooth
with its brackets, that is, the distance between the labial face and the bottom of the
slot. These tracings serve as a guide for all the treatment steps (Figure 9.34).
3. A LIGNMENT PHASE
Only the teeth that are going to be reduced will be aligned, principally the bicuspids.
The rotation of the upper molars will be corrected, if necessary (Figures 9.35a to c).
In the anterior segment, the initial crowding can be decreased by arch-form modifica-
tion and by labial tipping, if this was excepted in the treatment plan. The archwire is
fabricated with small expansion loops mesial to the first molars that will allow a slight
labial tipping of the anterior teeth.
.- . Correction of the rotated teeth which have to be reduced: (a) At the beginning of treatment.
(b) After derotation of rotated teeth. (c) After reproximation procedure.
ing procedure. The periphery of the reduction zone is rounded to have a better tooth
morphology. The reduction between the first molar and the second bicuspid is between
the minimum value of 0.7 mm and maximum value of 1 mm, taking into account the
fact that polishing with multibladed burs create a further reduction of at least 0.1 mm.
The use of calibrated thickness gauges allows us to control the reduction.
.-. Reduction between the first bicuspid and cuspid. .-. Retraction of the cuspid.
9. C USPID DISTALIZATION
A steel ligature is placed around the brackets of the two bicuspids and the two molars.
The distance of the distal movement of the cuspid can reach 3.5 mm (Figure 9.313).
Case History
Figures 9.316a to m demonstrate the use of interproximal reduction in a case, with
crowded teeth and multidisciplinary problems.
A 45-year-old male had severe crowding in both arches, missing teeth (17,31,36,
37,47), and gingival recession on 33.
.-. Diamond disk used for reproximation in the .-. Lip and gingiva protection during
upper incisor region. (Evident-Paris) anterior reduction.
Interproximal Enamel Reduction in Lingual Orthodontics
D ISCUSSION
The recommended reduction protocol is long and the alignment of the anterior zone
can only start after several months of treatment, but it is progressive and the enamel
.- . Consecutive sequences of reduction in a crowded case: (a) Front view of the occlusion
before treatment. (b) Occlusal view of the maxillary arch before treatment. (c) Occlusal view of the maxillary arch
after bicuspid reduction and retraction. (d) Occlusal view of the maxillary arch after alignment of all of the teeth.
(e) Occlusal view of the maxillary arch after bracket-debonding and fixed retainer bonding.
(f ) Occlusal view of the mandibulary-arch before treatment.
.- . Consecutive sequences of reduction in a crowded case: (g) Occlusal view of the
mandibulary-arch with Ormco lingual brackets. (h) Occlusal view of the maxillary arch after alignment of all of
the teeth. (i) Occlusal view of the mandibular arch after bracket-debonding and fixed retainer bonding. Note the
posterior implants. (jl) Front and profile views of the occlusion at the end of treatment. (m) Porcelain laminates.
(Dr. P. Miara, Paris, France)
Interproximal Enamel Reduction in Lingual Orthodontics
Bibliography
Alexander RG. The Alexander discipline, contemporary concepts and philosophies. Angel GA, ed.
1986.
Barrer HG. Protecting the integrity of mandibular incisor position through keystoning procedure
and spring retainer appliance. J Clin Orthod 1975;9:486494.
Boese LR. Fiberotomy and reproximation without lower retention, nine years in retrospect, Part I.
Angle Orthod 1980;50:8897.
Boese LR. Fiberotomy and reproximation without lower retention, nine years in retrospect, Part II.
Angle Orthod 1980;50:169178.
Fillion D. Orthodontie linguale Rflexions cliniques. Rev Orthop Faciale 1990;24:475498.
Fillion D. Apport de la sculpture amlaire interproximale lorthodontie de ladulte (premire partie).
Rev Orthop Dento Faciale 1992;26:279293.
Fillion D. Apport de la sculpture amlaire interproximale lorthodontie de ladulte (deuxime partie).
Rev Orthop Dento Faciale 1993;27:189214.
Fillion D. Apport de la sculpture amlaire interproximale lorthodontie de ladulte (troisime partie).
Rev Orthop Dento Faciale 1993;27:353367.
Gillings B, Buonocore M. An investigation of enamel thickness in human lower incisor teeth.
J Dent Res 1961;40:105118.
Hudson AL. A study of the effects of mesiodistal reduction of mandibular anterior teeth. Am J
Orthod 1956;42:615624.
Paskow H. Self-alignment following interproximal stripping. Am J Orthod 1970;58:240249.
Philippe J. Lorthodontie de ladulte. S.D.I. d., Paris, 1989.
Sheridan JJ. Air-rotor stripping. J Clin Orthod 1985;19:4359.
Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1987;21:781788.
Sinclair PM. The readers corner. J Clin Orthod 1989;23:110111.
Tuverson DL. Anterior interocclusal relations: part I. Am J Orthod 1980;78:361370.
.
Sliding Mechanics versus
Loop Mechanics During
En Masse Retraction in
Extraction Cases
K YOTO TA K E M OTO , D D S
Since Dr. Kinya Fujita, associate professor at Kanagawa Dental College, developed his
lingual mechanics in 1970, the number of the lingual orthodontics patients has con-
stantly risen in Japan (Figure 10.11). Eighty-one percent of adult cases in Japan are
extraction cases (Figure 10.12). Therefore, a lot of attention must be given to the
mechanics used to close spaces. In labial orthodontics, the mechanics usually described
in the literature involves canine retraction, and once it is accomplished, upper and
lower incisors are retracted. Lingual patients, however, strongly demand that esthetics
will be maintained throughout the treatment, which means, in addition to the invisi-
ble braces, avoiding opening spaces between the lateral incisors and canines during
treatment. Therefore, the anterior segment is retracted as one unit.
En masse retraction can cause many mechanical problems such as bowing effect
(vertical and transverse) and anchorage control. The vertical bowing effect is the most
serious problem, since it cannot be avoided with simple auxiliaries like transpalatal
arches. When a strong retraction force is used in an anteriorposterior direction
(Figure 10.13), the upper anterior segment (3-3) may tip lingually. The bite plane
effect of the upper lingual brackets can cause posterior disclusion and consequently
1000
960
920
520
420
340
140
88 89 90 91 92 93 94
Non-Ext
19%
Ext
81%
loss of lateral occlusal function. As a result, bowing effect occurs. When the same
amount of force is applied in both systems (labial and lingual) and the intrusion force
(FI) equals the retraction force (FR), the net force vector is pointed directly towards
the center of resistance (CR) in a labial system (Figure 10.14a) but not in a lingual
system. The net force vector in lingual orthodontics will produce a lingual tipping
force and vertical bowing effect (Figure 10.14b). Thus, the retraction force should be
minimized during en masse retraction, and more intrusion and torquing force is need-
ed to retract the anteriors in lingual orthodontics than in a labial system.
A-P retraction
Posterior disclusion
in applying the technique to unusual extraction cases where different teeth are extracted
on the right and left sides, and increased retraction time and consequently increased
treatment time. The technique of sliding mechanics has the advantage of being simple
and effective for preventing transverse bowing effects without using a transpalatal arch.
Loops mechanics are very effective for closing space without wire friction. In addi-
tion, the mechanics allow us to incorporate a bigger tipping bend into the archwire.
However, it is quite complicated to bend the wires with the different loops, and it
requires a lot of skill from the orthodontist. The mechanical and cephalometric fea-
tures of sliding and loop mechanics were compared in a study.
Sliding Loop
U1 to FH 11.7 4.9 (max) 6.1 7.1* (T-loop)
21.3 8.1 (closed helical)
U anchorage 1.3 0.7 (max) 0.5 0.8*
L1 to mand. pl. 2.6 1.3 (max) 1.4 0.8* (T-loop)
FX 0.1 0.8 0.2 0.4
Ret. term 12.6 3.7 9.2 3.7*
* = P < 0.05; = P < 0.01
Sliding Mechanics versus Loop Mechanics During En Masse Retraction in Extraction Cases
time for en masse retraction was measured. The differences in the amount of anterior
intrusion toward the center of resistance was measured before and after treatment
(Figure 10.16). Statistical t-tests were used to compare the incremental changes
between sliding and loop mechanics. The significance level for statistical comparisons
was predetermined at P < 0.05 and P < 0.01.
Results
The results are summarized in Table 10.11.
Discussion
There was no significant difference in the skeletal pattern between sliding and loop
mechanics. Upper anterior torque (U1 to FH) was maintained better with T-loop
mechanics compared to sliding mechanics (P < 0.05) and worse with closed helical
loops (P < 0.01). Anchorage (U6 anchorage) was controlled better with all loop
mechanics (P < 0.05). Lower anterior intrusion (lower incisor to mandibular plane)
was significantly smaller with T-loop mechanics (P < 0.05). There were no significant
differences in facial axis (FX) between both mechanics which means that there is no
cl III el cl III el
.- . Closing mechanics (closed helical loops) .- . Closing mechanics (T-loops) for upper arch.
for upper arch.
opening of the mandible with any of the mechanics. Retraction was accomplished in
a shorter time with loop mechanics than with sliding mechanics (P = 0.05).
Based on these results, the following protocol for the use of sliding and loop
mechanics is recommended:
cl II el cl II el
300
SS
250
TMA
150
100 Ni-Ti
50
10 20 30 40 50 60 70 80 90
Deflection (degrees)
A 30-year-old female presented with skeletal Class I and dental Class II malocclusion,
high mandibular plane angle, deep overbite (5 mm), rotated left upper central, ectopic
erupted upper cuspids, and mild to severe anterior upper and lower crowding. The
treatment plan included upper and lower lingual orthodontic appliance (Ormco gen-
eration #7) with upper first bicuspid and lower second bicuspid extractions.
.- . At initial orthodontic examination: Facial and profile views. Note unesthetic smile.
.- . At initial orthodontic examination: intraoral views.
Note deep bite, severe crowding and rotations, and midline shift.
Treatment Sequence
Maxillary Mandibular
1) leveling 4) leveling
2) torque adjusting 5) torque adjusting
3) space closure and en masse retraction 6) space closure
Active treatment time: 36 months
Case Presentation: Loop Mechanics
.-. .014 Ni-Ti archwire for leveling. Partial engage- .- . .016 SS archwire fully engaged.
ment of the wire in the anterior region. Power chain from premolars Retraction is continued.
to molars for partial retraction.
.- . At the end of orthodontic treatment: facial and profile views.
Note the pleasant and esthetic smile.
Case Presentation: Loop Mechanics
.- . At the end of orthodontic treatment: intraoral views.
Note cuspid and molar Class I occlusion, arch integrity and correct midline. Lower fixed retainer
(3-3) was bonded and clear vacuum retainer was provided for the upper arch.
A 53-year-old female presented with slight crowding in both dental arches, Class II
Division I malocclusion with excessive overjet and extensive dental restorations.
The treatment plan included placement of maxillary and mandibulary lingual
appliances (Ormco, generation #7). In the maxilla, the left first bicuspid and right sec-
ond bicuspid were to be extracted. The decision to extract the right second bicuspid
was based on the condition of the crown; although it had recently been placed it was
determined that the long-term prognosis would be improved with its removal. No
teeth were to be extracted in the mandible. The patient was treated to a Class II molar
and Class I cuspid relationship.
Fourteen days after the records and face bow transfer were taken, all brackets were
bonded. Upper and lower .0175 Respond sectional archwires were placed in the upper
arch from 3-3 and in the lower arch from 5-5. Upper extractions were completed
immediately afterwards.
One month after the initial bonding, separators were placed for banding of both
maxillary first molars and left second molar. In the mandible, the corresponding teeth
were also banded. (All banded molars had been crowned.)
Upper and lower .016 TMA wires were placed to begin leveling and alignment
(Figures 10.31a to e). Four weeks later, an upper .016 .022 SS archwire was
placed. In the maxilla, the wire was not fully engaged to the anterior rotated teeth
(Figures 10.32a and b). The SS rectangular wire allows controlled and complete
retraction of the right first bicuspid and preliminary retraction of the left cuspid. The
upper buccal molar segments were ligated together to act as anchorage units. Power
tubes and power chains were placed to provide force (sliding mechanics). The patient
was seen every 3 to 4 weeks for the next 3 months to replace the power products.
Once adequate space had been gained to correct the alignment of the upper incisors,
the original .016 TMA was replaced, and all rotations were corrected (Figures 10.33a
and b).
Three month later, the upper .016 .022 SS archwire was replaced and a trans-
parent labial button bracket was bonded to the right first bicuspid. A power chain was
added from this button to the labial molar tubes. This enabled dual force mechanics
without rotation of the tooth during the retraction (Figure 10.34).
After another 3 months, the bicuspid was completely retracted. The right buccal
segment was figure-eighted to include the bicuspid in the posterior anchorage unit
and the anterior segment was also figure-eighted with stainless steel ligature wire.
Power tube and power chain were placed from bicuspid to cuspid to supply the force
for the en masse retraction of the anterior segment (Figure 10.35a and b).
.- . One month after the initial bonding; .016 TMA wire was placed in both arches:
(a) Frontal occlusal view. (b) Left buccal view. Note the enlarged overjet and asymmetric extraction sites.
(c) Right buccal view. (d) Occlusal view of the mandibular arch, .016 TMA wire was placed on both arches.
(e) Occlusal view of the maxillary arch.
.- . Two months in treatment.
Note upper .016 .022 SS archwire is not fully engaged in the anterior rotated teeth.
Case Presentation: Sliding Mechanics
.- . Five months in treatment. The upper original .016 TMA was replaced to
correct all rotations. Lower alignment continues with .016 TMA.
.- . Eleven months in treatment. The right upper buccal segment was figure-eighted
to include the bicuspid in the posterior anchorage unit. The anterior segment was figure-eighted as well.
A lower .016 .022 SS archwire was placed.
.- . Eleven months in treatment (before debonding).
(a) Frontal occlusal view. (b) Occlusal view of the maxillary arch. (c) Occlusal view of the mandibular arch.
It took another 14 months to complete the space closure and final detailing of the
teeth. During this time, the process was interrupted two times for repair of loose
brackets. During the last 5 months, the patient wore a 6 oz 1/4'' Class II elastic on the
left side, from the lingual bracket of the left upper lateral incisor to the labial hook of
the lower second molar. All appliances were removed after 26 months of treatment,
2 months ahead of the pretreatment estimate (Figures 10.36a to c). Clear overlay
retainers were delivered on the same day of debonding, and the patient was instructed
to wear them full-time for 2 months and then nights only. The patient was very
pleased with the results. She stated on many occasions that the lingual appliance was
the only reason she was willing to undergo treatment.
Lingual Orthodontics
in Pediatric Patients
LO R E N ZO FAV E RO , M D , D D S , M S c
out having to go through an ugly duckling period. In the illustrations made by the
youngest patients, the patients face was drawn without any visible appliance, and hap-
piness and appreciation are symbolized.
Therapeutic Indications
There are some malocclusions in mixed dentition that are suitable for early treatment
with a lingual appliance:
Skeletal Class I with dentoalveolar open bite (caused by atypical deglutition,
thumb sucking, and tongue thrusting); skeletal Class I with dentoalveolar deep bite;
moderate occlusal Class II Division I with dentoalveolar deep bite; Class II Division II
with dentoalveolar deep bite; pseudo Class III with functional anterior shift (i.e., skeletal
Class I and dental Class III); and skeletal Class III with hypomaxilla.
Other malocclusions can also be resolved with lingual appliances without any
limits. Particular care and practice are necessary in more difficult cases like Class I with
serious crowding, Class II Division I open bite caused from mandibular divergence,
or skeletal Class III with a mandibular component.
Operative Protocol
Lingual orthodontics in young patients is frequently used in the upper arch and seldom
in the lower arch. The upper molars and the central and lateral incisors are usually
bonded as would be done in an adult patient. A buccal tube on the molars is necessary in
case of extraoral traction or the use of auxiliary superstructures. Bonding of the primary
- . Pendulum F (Favero). - . Molar bands provided with a double tube for later
placement of transpalatal bar, after distalization with Pendulum F.
Lingual Orthodontics in Pediatric Patients
- . Pendulum F. The acrylic part is larger than - . Pendulum F. Contraction TMA loops in an
usual to give support for the TMA archwire section which is used to open-bite case.
align the front teeth.
second molars is highly recommended since these teeth will be present in the arch for
a long time, have good clinical crowns and anatomical dimensions, and have high
anchorage value.
Bonding of the first primary molars and primary cuspids must be avoided as they
are small and often exfoliate during the treatment. In the course of therapy, the first
permanent premolars can be utilized while they are erupting. Their insufficient clinical
crowns can be visualized with retraction cord inserted in their eruptive pseudopocket
while taking the impression. This method is also used when the upper lateral incisors
are partially erupted or have anomalous inclinations.
One must also consider the interbracket distance between the upper lateral incisors
and primary second molars. This space is not wide because the deciduous canine and
the first primary molar present smaller mesiodistal dimensions compared to their
permanent successors. The wire offset between the primary cuspid and the primary molar
is very small because of the anatomical arrangement of deciduous teeth in the arch and
the absence of the canine protuberance, and because the contraction loops that are used
- . Pendulum F. The anterior bite effect of the - . Pendulum F. A tongue crib is inserted into the
anterior lingual brackets facilitates molar distalization. Sagittal acrylic button in cases of open-bite and tongue-thrust habits.
screw to activate the appliance.
mesially to the primary second molars to increase the resilience in this area and to apply
more gradual strength at a distance also occupy some of the interbracket space.
Pendulum F Mechanics
One of the advantages of early treatment is reduced treatment time due to the use of
specific mechanics from the early phases of the therapy. The Pendulum appliance that
was described by Hilghers was adapted and modified by the author for the lingual
technique and called Pendulum F (Figure 111). The lingual part of the bands are
provided with a double tube (Figure 112). The larger tube is used for stabilizing the
molars after distalization by means of a transpalatal bar. The acrylic part is larger than
usual to give support for a TMA archwire section which is used to align the front
teeth, through the lingual brackets, which have been bonded since the beginning of
treatment (Figure 113). This type of archwire can be bent in various ways according
to its use, with expansion or contraction loops and intrusion or extrusion forces
(Figure 114). It permits immediate, decisive alignment and increases the anchorage
to the appliance. Thanks to the bite effect of the anterior lingual brackets, the arch is set
free, allowing a greater molar distalization (Figure 115). A tongue crib can be inserted
into the acrylic button in cases of open-bite and tongue-thrust habits (Figure 116).
Pendulum F can be also used as an orthopedic maxillary expander (Figure 117).
Laboratory Procedures
Specific instructions to the laboratory should be given for young patients with decidu-
ous teeth:
1. The diagnostic program of each patient should be described since we are deal-
ing with an interceptive treatment.
2. The deciduous dental elements that will be extracted or reduced in size should
be taken into consideration while preparing the set-up, such as the deciduous
canines that may be extracted or stripped mesially to obtain a correct position-
ing of the incisors at the midline.
3. The use of the retraction cord in partially erupted, crowded, or rotated teeth
- . Retraction cord is used in partially erupted, crowded, or rotated teeth:
(a) Before insertion of the retraction cord. (b) After insertion.
(Figures 118a and b) is not always possible, and a new impression should be
taken at a later stage.
4. Late erupting teeth like the first permanent premolars should be bonded
separately.
C ASE REPORT
A 10-year-old girl presented with Class I malocclusion, anterior cross-bite (2 | 2)
and midline deviation (Figures 119a and b). The maxillary arch (Figure 1110) was
aligned with a lingual appliance (Ormco, generation #7) bonded on the upper central
and lateral incisors, second primary molars and first molars (Figure 1111). The
mandibular arch (Figure 1112) was treated with the same appliance bonded with the
CLASS technique on the incisors, cuspids, and first molars, combined with a lip
bumper (Figures 1113a and b). Cervical traction and Class II elastics were added
(Figure 1114). Harmonic and balanced occlusion was achieved, and the midline was
corrected (Figures 1115a and b).
- . Facial and lateral clinical views before treatment:
Note Class I malocclusion, anterior cross-bite and midline deviation.
- . Pretreatment view of the maxillary arch. - . Lingual appliance (Ormco, generation #7)
bonded on the upper central and lateral incisors, second primary
molars, and first molars.
- . CLASS technique used for indirect bonding of - . Lingual appliance (Ormco, generation #7)
mandibular arch with lip bumper. Stripping of the second deciduous bonded on the incisors, cuspids, and first molars.
molar to gain leeway space.
Lingual Orthodontics in Pediatric Patients
- . Facial and lateral clinical views after treatment:
Note harmonic and balanced occlusion with a corrected midline.
Conclusion
Lingual therapy in the pediatric patient shows simple, modern, and diversified use.
The numerous advantages are represented by a remarkable psychological acceptability,
smaller interferences with removable appliances, a shorter treatment time, biomechan-
ical advantages (such as increase of sagittal and transverse expansive effects), a greater
effectiveness of superstructures such as elastic bands, and a greater consideration for
esthetics that translates into a greater acceptance of orthodontic therapy.
Bibliography
Alexander CM, Alexander RG, Gorman JC, et al. Lingual orthodontics: a status report. J Clin
Orthod 1982;16:255.
Favero L. Lortodonzia linguale nel paziente giovane. Atti del 3 Congresso Nazionale del Collegio
dei Docenti di Odontoiatria Roma 1996.
Favero L. Proper mechanics in pediatric lingual orthodontics. 2nd Symposium European Society of
Lingual Orthodontics Principaut de Monaco 1996.
Favero L, Tagliapietra S. Lingual orthodontics in paediatric patient. The First ESLO Congress.
Proceedings and abstracts. Venice 1993.
Fujita K. Multilingual-bracket and mushroom archwire technique. Am J Orthod 1982;
82(2):120140.
Nidoli G, Macchi A, Lazzati M. Migliora lestetica con lincollaggio linguale dei brackets. Attualit
dent. 1988;4(18).
Pedersen E, Andersen K, Melsen B. Tooth displacement analysed on human autopsy material by
means of a strain gauge technique. Euro J Orthod 1991;13:6574.
Ronchin M. Tecnica individuale di montaggio indiretto degli attacchi linguali. Ediz. Audiovisive
Medical Video. Milano 1991.
Siciliani G. Apparecchiature ortodontiche linguali esperienze cliniche. Dental Cadmos, 1988;
18:1741.
Siciliani G, Fassetta F, Mula L. Problematiche fonetiche nelle apparecchiature ortodontiche ad
approccio linguale. Quaderni di Odontostomatologia, Anno IV:1, 1987.
Velo S, Dal Broi G, Piubelli. Lingual technique silent and invisible orthodontics. The First ESLO
Congress. Venice 1993.
.
The Lingual Technique
in Orthognathic Surgery
A L E S S A N D RO S I LV E S T R I , M D , D D S , E N T
The existing close relationship between maxillofacial surgery and orthodontics allows a
precise and complete resolution of most dental and maxillofacial deformities and the
overall restoration of a harmonious structural and functional stomathognatic apparatus.
In the last few years, the close collaboration of these two disciplines has been further
enhanced by the mutual evolutions of the Rigid Internal Fixation (RIF) technique
of the maxillofacial surgeon and the lingual technique of orthodontics. By using RIF
as a means of surgical retention of the skeletal segments which are mobilized in the
treatment of the maxillomandibular malformation, it is not necessary, as in the past,
to provide intermaxillary fixation at the end of a surgical operation. This allows the
orthodontist to use the lingual technique in the pre- and postoperative treatments of
such pathologies.
The esthetic requirements of many adult patients are definitively met by such a
combined therapy. These esthetic needs are important and should be taken into con-
sideration by the doctors involved in their treatment. In the case of presurgical ortho-
dontics, such needs can be met by employing the lingual technique in a traditionally
rigid method.
The lingual brackets are indirectly applied by the employment of transfering
masks constructed by means of articulated mounting casts, surgicalorthodontic
VTO, and set-up of dental casts (CLASS Method), and then indirectly bonded.
The purpose of the presurgical orthodontic therapy with the lingual technique are
the same as those using a labial techniqueto prepare the dental arches prior to
manipulation of the skeletal bases. Therefore, it is necessary to first eliminate as many
of the dentalalveolar components of the malocclusion as possible, leaving only the
malformed skeletal components to be corrected by the maxillofacial surgery.
.- . Frontal and lateral facial views at the beginning of treatment.
Note the small esthetic anomalies (midline shift of the chin and long face syndrome).
When expansion of the maxillary arch is needed as part of the presurgical lingual
technique, there are two treatment options:
1. If the traverse expansion is accomplished in the presurgical orthodontic phase
with a Quad-Helix (QH) or a Rapid Palatal Expansion (RPE) appliance, the
.- . Pre-treatment front and laterals views of the occlusion. Note the Class III malocclusion
with an anterior open bite and posterior cross-bite caused by a real contraction of the upper arch.
The Lingual Technique in Orthognathic Surgery
.- . Lower lingual appliance (Ormco, generation #7). .- . Quad-Helix in the maxillary arch for bilateral
.016 TMA archwire with vertical loop to obtain the rotation of expansion.
the right lower cuspid.
impression for the lingual appliance is taken only after this first expansion
phase is completed.
2. Surgical expansion can be accomplished together with the repositioning of the
maxillary components with an intermaxillary disjunction LeFort I osteotomy
technique. In this case, the initial set-up of the dental casts will be for the
presurgical, nonexpansion orthodontic phase, and once the orthodontic prepa-
ration is completed, a second presurgical set-up will be constructed with which
the intermaxillary corrections will be planned. On this set-up, a surgical splint
will then be constructed, and this will serve as the guide for the correct reposi-
tioning of the skeletal maxillary segments.
sary intermaxillary anchorage in the operating room, it will also allow, in the postsur-
gical phase, the possibility of applying intermaxillary elastics, which are normally used
for the neuromuscular rehabilitation, to optimize the dental intercuspation. In case of
maxillary surgical expansion as with labial orthodontics, the lingual orthodontic
patient will be surgically treated via two upper sectional arches to facilitate the inter-
maxillary disjunction and the repositioning of the two skeletal segments so that it is
not necessary for the surgeon to section the orthodontic arch. The occlusal splint can
be removed quickly after the operation or, at the latest, 7 to 10 days postsurgically. At
this time, a continuous archwire should be applied in the place of two upper sectional
arches to stabilize the maxillary arch. Rigid internal fixation with the use of plates and
screws eliminates the need for postsurgical intermaxillary blockage.
Some surgeons still use postsurgical intermaxillary blockage, which does not allow
postoperative examination of the site nor the proper hygiene of the lingual orthodon-
tic appliance, causing great inconvenience to the patient who is already inconvenienced
by the blockage itself. Therefore, the lingual orthodontic technique is indicated only
in cases when the surgeon uses rigid internal fixation.
Case Presentation
A 28-year-old female presented with very slight esthetic problems including profile
alterations (Figures 12.11a and b). Her occlusal and radiographic findings revealed a
Class III malocclusion, an anterior open bite, upper dental crowding, and a posterior
bilateral cross-bite (Figures 12.12a to c).
The presurgical orthodontic lingual treatment plan included alignment of the
lower arch with a lingual appliance (Figure 12.13). The upper arch was expanded
with Quad-Helix (Figure 12.14). Alignment and leveling of the arch were completed
with the lingual appliance (Figure 12.15). Facebow registration and set-up VTO
models were prepared before the surgery (Figures 12.16a and b). Ceramic brackets
.- . Front and lateral facial views at the end of treatment.
Note the shorter face and pleasant profile.
.- . Post-treatment views of the occlusion.
Note the Class I occlusion, correct sagittal and vertical relationships, and nice smile line.
were bonded two days before the surgery (Figure 12.17). The maxillofacial surgery
has anticipated in the maxilla a LeFort-I osteotomy with impaction of 4 mm in the
posterior region and 1.5 mm in the anterior region. In the mandible, a bilateral sagit-
tal osteotomy was performed with a counterclockwise rotation of the mandible.
Surgical retention was gained by RIF (Figure 12.18).
The surgery was followed by an orthodontic phase of neuromuscular rehabilita-
tion and the perfection of the occlusion (Figures 12.19a to d).
.
Orthodontic-Surgical
RPE Camouflage on an
Orthognathic Case
M A R I O E . PA Z , D D S , M S
Case Report
A 27-year-old male presented with dental and skeletal Class III malocclusion with
anterior open bite, maxillary transverse and antero-posterior deficiency, bilateral poste-
rior and anterior cross-bite and mandibular crowding (Figure 12.21). Since the
mandibular position was good and did not reflect the severity of the Class III dental
occlusion, a more conservative approach which involved surgical RPE was considered.
Impressions for lingual appliances were taken, and immediately after bonding of the
lingual brackets another impression was taken and the Hyrax RPE appliance was
bonded (Figure 12.22). After adequate consultation, the patient was referred to the
oral surgeon (Dr. Stephen Nahigian) and the surgery was performed under light anes-
.- . Occlusal view during treatment: the lingual appli- .- . Initial laser dissection with exposure of
ance from cuspid to cuspid, and Hyrax is attached to the first bicuspids maxillary wall.
and molars along with the posterior segmental labial appliance.
thesia supplemented by a local anesthetic nerve block. An incision was made in the
height of the buccal vestibule from the mesial aspect of the first molar to the distal
aspect of the canine (Figure 12.23). The lateral maxillary wall was exposed by
mucoperiosteal elevation from the piriform anteriorly across the zygomatic maxillary
buttress, then posterior to the pterygomaxillary fissure via a subperiosteal tunneling
technique. A fissure bur was used to effect an osteotomy approximately 5 mm above
the apices of the teeth from the piriform rim to the zygomatic maxillary buttress, end-
ing just anterior to the pterygoid fissure. Special care should be taken at the anterior
aspect of the osteotomy to avoid tearing of the nasal mucoperiosteum by using a freer
elevator as a tissue guard. Prophylactic antibiotics, nasal decongestants, and analgesics
were prescribed.
The appliance was activated four turns (1 mm) at the time of surgery to absorb
some of the elastic properties of the appliance. On the third postoperative day, the
patient was instructed to activate one turn in the morning and then one turn in the
.- . One week postoperative
expansion: clinical and radiographic view.
Orthodontic-Surgical RPE Camouflage on an Orthognathic Case
evening, until adequate expansion had been achieved (Figures 12.24a and b). The
appliance was left in place for 12 weeks in a passive position. At this time routine
orthodontic procedures can be initiated or continued. If needed, extraction of the
bicuspids can be made at the same time as the surgical RPE.
Results showed a marked cosmetic and functional improvement in the dental
occlusion and smile line (Figure 12.25). The cross-bites, open bite, and crowding
were improved, and the profile was maintained. (The cosmetic restorative treatment
was done by Dr. Soheil Goel.)
A double jaw orthognathic surgical procedure could have achieved a similar, or
better, result but would have also increased morbidity and financial costs. Surgical
RPE can be considered a safe, simple, and reliable procedure for achieving a perma-
nent increase in skeletal maxillary width in adult patients.
Bibliography
Basdra EK, Zoller JE, Komposch G. Surgically assisted rapid palatal expansion. JCO 1995;
29:762766.
Glassman AS, Nahigian SJ, et al. Conservative surgical orthodontic rapid palatal expansion: sixteen
cases. Am J Orthod 1984;86:207213.
Isaacson RJ, Murphy TD. Some effects of rapid maxillary expansion in cleft lip and palate patients.
Angle Orthod 1964;34:143154.
Isaacson RJ, et al. Forces produced by rapid maxillary expansion. Angle Orthod 1969;34:256269.
.
Segmental Lingual
Orthodontics in
Multidisciplinary Cases
PA B LO A . E C H A R R I , D D S
1'' ARCO
.- . Anterior incisor forced eruption. Note the temporary crown to enhance esthetics.
Transpalatal bars and temporary bridges are used to enhance anchorage. When a
forced eruption of an upper anterior incisor is done, a temporary crown will improve
the appearance during the treatment. Composite coverage of exposed metal will do
the same (Figures 13.16a and b). Small indirect bonding transfers are made the same
way as in full arch bonding (Figure 13.17). A small vacuform retainer is made at the
end of the minor teeth movement, on the day of debonding, to facilitate the subse-
quent prosthetic treatment (Figure 13.18). The design of the fixed retainer is made
by all the experts that are involved in the case, including the orthodontist, perio-
dontist, and prosthodontist. Lingual bonded retainers, fixed bridges, and implants are
used to retain the orthodontic results. Bonded porcelain veneers can also be used
when deep-bite malocclusions are treated (Figures 13.19a and b).
The keys for a successful segmental lingual preprosthetic treatment are:
1. the anomaly affecting only a single tooth or a small, isolated group of teeth
2. only simple tooth movements required
3. the use of indirect bonding of brackets to the teeth
4. immediate retention with a clear vacuform retainer.
.- . Esthetic coverage of metal band with composite material.
The short treatment time, good esthetics, and low cost make the segmental lingual
preprosthetic treatment an excellent option for the lingual orthodontist.
.- . Bonded porcelain veneers used to retain deep bite malocclusion treatment.
Bibliography
Burgos G, Moreu J. Ignacio Garcia Espona Alargamiento coronario vs. erupcion forzada. Archivos
de Odonto Estomatologia 1995;11:509515.
Echarri LP. Syllabus de ortodoncia: Biomecnica 2, Aparatologa Fija. 4th Ed. Badalona, Espana: Ed.
Ladent SL, 1995:921,3035,4749.
Gollner P, Bantleon H-P, Ingervall B. Force delivery from a transpalatal arch for the correction of
unilateral first molar cross bite. European J Orthod 1993;15:411420.
Marcotte MR. Biomechanics in orthodontics, Spanish version. Burlington, Ontario: BC Decker,
1992:144,127152.
Proffit WR, Fields HW Jr., Ackerman JL, et al. Contemporary orthodontics. St. Louis, Missouri:
CV Mosby, 1986:472518.
.
Combined Orthodontic-
Prosthetic Treatment of
Malpositioned Anterior Teeth
R A F I RO M A N O , D M D , M S c , A N D N I T Z A N B I C H AC H O , D M D
Most lingual orthodontic patients have greater demands and expectations than do labial
orthodontic patients since they are usually adults, esthetics is sometimes a crucial factor
in their profession (models, TV performers, etc.), very few orthodontists practice lingual
orthodontics, and the price is much higher. Even those who can easily afford it, want
to receive more than the usual patient. Good esthetics and normal function are two
goals to consider, not only at the end of treatment but also during the treatment
course, especially in type A personality patients (Sinclair, 1986). Esthetic demands
during treatment include preservation of arch integrity, no opening of space, and no
unesthetic auxiliaries. Normal function during the treatment includes minimal speech
disturbances and elimination of pain.
Many of these aspects have been previously discussed, and the protocol of treat-
ment has been accepted worldwide. Still, on occasion, improvisations and changes
need to be made to the usual protocol because of unexpected patient reactions. Speech
problems are of primary concern, especially during the first month or two. Support of
the patients during this uneasy initial period is imperative to encourage them and to
evaluate the adaptation and adjustment period.
Case Presentation
The following case presents an alternative orthodonticprosthodontic treatment. A
26-year-old male TV performer and singer presented with skeletal and dental Class I
malocclusion with deep bite and increased overjet. He was complaining of an unes-
thetic appearance due to rotated upper cuspids and to spaces that were left after the
previous extraction of retained deciduous upper cuspids (Figures 13.21a to c).
The initial treatment plan consisted of opening the bite, rotating the cuspids, and
retracting the anterior segment en masse. The treatment included an upper lingual
appliance, Ormco Kurz (generation #7), bonded to teeth 7-7 in the upper arch only.
The patient was sent to a myofunctional therapist before and immediately after plac-
ing the appliance to help him adjust to the appliance and attempt to compensate for
his anticipated speech difficulties.
Although most of his speech disturbances completely disappeared, only 4 weeks
after the appliance bonding and after several meetings, the patient insisted on stop-
ping the treatment and debonding the appliance because he could not perform on
stage as before.
.- . At initial orthodontic examination: frontal and lateral views.
Note the unesthetic space between the cuspid and first premolar, and the rotated cuspid.
Eventually, he was convinced to debond only four of the anterior brackets (2-2),
and, fortunately, this improved his reaction. The treatment plan was changed to
accommodate the new circumstances.
A combined orthodonticprosthetic solution was suggested because space closure
by retraction of the anterior segment and overjet closure was now excluded due to the
anterior bracket removal. The new immediate treatment plan was to orthodontically
retract the cuspids distally and at the same time to prosthetically restore the spaces
that would now open between the cuspids and the lateral incisors. The use of a hybrid
composite resin to close the spaces would allow periodic adjustments during ortho-
dontic movement to maintain normal and esthetic function.
.- . Lateral views during treatment. Note the space opening during the cuspid retraction.
The final treatment plan was to bring the cuspids to their optimal position with
no rotation and with minimal spaces from them to the lateral incisors and to the
premolars. Porcelain laminates would then be made for the cuspids and first premolars
to fill the proximal spaces. Porcelain laminates were chosen because they would pro-
vide a stable and long lasting esthetic solution while conserving tooth structure.
A segmental technique was used to retract the cuspids, and the lingual buttons
that were bonded on the cuspids were replaced with Kurz-Ormco lingual brackets as
soon as enough retraction was accomplished to enable single-tooth indirect bonding
(Figure 13.22). Because the retraction of the cuspids caused an unesthetic appearance
after 3 months of treatment (Figures 13.23a and b), the patient was referred to the
prosthodontist to close the spaces temporarily. Since the tooth rotation was not yet
fully corrected, large spaces were evident in the interdental papillae areas. Using a
hybrid composite resin (Prodigy, Kerr, Glendora, CA), the distocervical surfaces of the
lateral incisors were widened (Figures 13.24a and b). The mesial surfaces of the cus-
pids were augmented with the resin to create rotation illusion in a distobuccal direc-
tion and to close the existing spaces, allowing the formation of a healthy interdental
papillae. Since most natural cuspids are asymmetrical, this discrepancy between the
homological teeth was used to create a natural and balanced asymmetry. Four months
later, when the cuspids were orthodontically brought to their final positions, the
patient was referred again to the prosthodontist for completion of the treatment.
.- . Temporary composite resin restorations: Hybrid composite resin bonded incrementally
to the distocervical surfaces of the lateral incisors, and mesial aspects of the canine.
Upon completion of the orthodontic treatment, spaces existed between the first
premolars and the cuspids and between the cuspids and lateral incisors. It was decided
to close these spaces permanently, by changing the contours of the first premolars and
cuspids. The treatment of choice was bonding of porcelain laminate veneers, in order
to conserve tooth structure and obtain excellent long-term stability (Figures 13.25a
to e). A 1-mm-thick vacuformed retainer was provided for retention at night.
The overall treatment time was 8 months, a comparatively short time. The patients
main problem was fully solved, and his appearance was maintained during all stages of
the treatment.
.- . Porcelain laminate veneers fabrication stages: (a) Diagnostic wax-up on plaster model.
(b) Provisional composite resin laminates. (c-e) At the end of treatment: single porcelain veneers, frontal and
lateral views. Note the harmonic and esthetic occlusion.
Lingual Orthodontics:
Esthetics and Function
C H I O R I H A S H I B A , D D S , P hD
A functional and esthetic occlusion is the ultimate goal of every orthodontic treatment.
There are many methods used by orthodontists and prosthodontists to evaluate the
functional occlusion during and after orthodontic treatment. An evaluation is usually
based on the mandibular position and the border jaw movements. Functions to be
evaluated are chewing, swallowing, speech, and facial expressions. These functions do
not use border jaw movements. In order to examine the real functional movement,
the mandibular movement is recorded during chewing and speech by using the
Sirognathograph Analyzing System (SGG/AS), a device developed by Prof. Takao
Maruyama of Osaka University in Japan, which tracks and analyzes the jaw movements
(Figure 141).
- . A magnet is attached to the patients lower - . The antenna is placed on the patients head.
central incisors.
Each species of mammal has a distinct, inherent chewing movement (Figure 145).
Humans have two chewing patterns; chopping and grinding (Figure 146). These
chewing movements are controlled by the pattern generator, a grouping of cells
believed to exist in the brainstem and controlled by the central nervous system (CNS).
On the other hand, the factors that control chewing movement exist in the peripheral
nervous system and are influenced by occlusal guidance, TMJ guidance, and mastica-
tory muscle guidance. The occlusal guidance may be classified as anteroposterior,
lateral, and vertical guidance (Figure 147).
Case Report
A 19-year-old female presented with skeletal Class II malocclusion with severe overjet
(Figures 148a to c). The patient refused to have orthognathic treatment. A com-
promise orthodontic treatment was suggested, and two upper first bicuspids were
Little
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Camel10 Goat11
Anteroposterior guidance
Lateral guidance
Vertical guidance
Muscles and the TMJ will both be affected when a dysfunctional occlusion is not
properly treated. Every masticatory muscle comprises a closing muscle and an opening
muscle and each of them has two functions, yielding protrusive and retrusive forces.
An abnormal protrusive shift will cause pain and spasm in the lateral pterygoid muscle;
if this continues, the articular disk may be dislocated and cause TMJ dysfunction.
- . At initial orthodontic examination: frontal and lateral views.
Note the open bite, crowding, and enlarged overjet.
Lingual Orthodontics: Esthetics and Function
- . At completion of orthodontic treatment: frontal and lateral views. Note the Class II occlusion.
- . Close-up view of the lips: (a) Before treatment. (b) After treatment.
Note the significant changes in lips closure.
- . Serial close-up views of the overjet during treatment.
concave opening paths can be caused by premature contact on the nonworking side
between the upper and lower second molars (Figure 1416). When closing paths
- . (a) At initial orthodontic examination. (b) At completion of orthodontic treatment.
Note the successful treatment.
show a concave closing pattern instead of a convex pattern, by using the Palculator,
one can recognize the abnormal contact on the nonworking side (Figure 1417a). If
an abnormal nonworking side contact on the second molars exists during opening,
opening chewing patterns will be concave to avoid premature contact. This is due to
the sensitivity of the periodontium to the abnormal direction of chewing pressure.
When chewing on the working side, the opening path is normal, but the closing path
is concave (Figure 1417b). It is caused by the interference of the nonworking side
in closing.
Function should be examined for every patient with the sirognathograph analyzing
system before removing the braces to avoid TMJ and occlusal interference symptoms.
Flat
Steep
Concave opening
The CLASS technique offers a method of lingual bracket placement that takes into
account the anatomical discrepancies in the lingual surfaces of the teeth. This is
accomplished by first constructing an ideal diagnostic set-up from a duplicate set-up
model of the patients original malocclusion. This ideal set-up or template is then used
as a physical guide to place the lingual brackets in an ideal configuration. The brackets
are placed on the diagnostic set-up using composite adhesive, which acts as a spacer
between the metal mesh pad and the individual dental surfaces. After the brackets are
placed on the ideal diagnostic set-up, they are next transferred back to the malocclusion
cast. At this point, transfer trays are fabricated so the brackets can be delivered clinically
via the indirect bonding method.
Technique
1. Accurate models must be obtained from the patient using a high quality algi-
nate or rubber base impression material (Figure 151). The models should
next be poured in a hard model material such as die stone (Figure 152). The
models must be extremely accurate for optimum clinical bonding and treat-
ment results. Once accurate models are obtained, the clinician completes the
prescription sheet which is the specific diagnostic instructions to the laboratory
- . Accurate models are obtained from the patient - . The models poured in a hard model material
using a high quality alginate or rubber based impression material. such as die stone.
- . The clinician completes the prescription
sheet which is the specific diagnostic instructions to the laboratory.
The Customized Lingual Appliance Set-Up Service (CLASS) System
- . The original models are duplicated. - . The duplicates are dried in the oven.
to the laboratory. The more complete the information provided from the clin-
ician to the laboratory technician, the better the results will be.
2. In the laboratory, the doctors original models are duplicated. This process is
completed using hydrocolloid duplicating material, which provides the most
accurate duplicate for the set-up models. The set-up models are poured in
orthodontic stone (Figure 155) and then dried in the oven (Figure 156).
3. The duplicate casts are identified by each individual tooth and sectioned, as
illustrated, to fabricate the diagnostic set-up (Figure 157). Depending upon
the equipment available to the laboratory technician, a combination of hand
saws and grinding wheels can be used to section and trim the teeth.
4. The individual teeth are placed on a preformed set-up base which facilitates
the overall set-up process (Figure 158). The technician then arranges and
resets the teeth according to the doctors prescription. The technician must
coordinate overall arch form, occlusal plane dimensions, anterior tip and
torque, spacing considerations, overbite and overjet, and individual dental
alignment and rotation (Figure 159).
- . Individual teeth are placed on a preformed set-up base. The technician must coordinate overall arch form
according to the doctors prescription.
5. Once the set-up is completed, it is given a final check by the senior laboratory
technician who re-evaluates the doctors prescription and the progress set-up
(Figure 1510).
6. A final wax restoration of the gingiva is then completed. The lingual surfaces
must then be completely cleaned using a wax solvent to insure the surfaces
will adequately reflect the exact dental anatomy of the original models
(Figure 1511).
7. A model release is applied directly to the set-up, and the set-up is dried in an
oven at approximately 100 degrees F for 1 hour (Figure 1512). The applica-
tion of this release coat will ensure that the brackets placed with composite
will easily separate from the set-up model.
8. The next step is the placement of the lingual brackets on the ideal set-up
model. The model is placed in a model holder as illustrated and set with the
occlusal plane parallel to a fixed horizontal reference (Figure 1513). The goal
is to establish an ideal vertical plane to which all brackets can be placed and
coordinated. Sample lingual brackets are next trial-fitted to individual teeth in
sections to ensure that proper heights are established from the anterior, posterior,
- . The final set-up is checked. - . The lingual surfaces must be completely cleaned
using a wax solvent.
The Customized Lingual Appliance Set-Up Service (CLASS) System
- . The set-up is dried in an oven at approximately - . The model is placed in a model holder and set
100 degrees F. for 1 hour. with the occlusal plane parallel to a fixed horizontal reference.
and right and left sides. Slight adjustments may be necessary in the overall
leveling of the model to ensure a level and coordinated plane for all brackets.
9. The brackets are bonded to the set-up model using a two-part heavy body
paste, such as Phase II from Reliance Orthodontic Products or Concise from
3M Dental (Figures 1514 and 15). Both of these materials provide an excel-
lent medium, allowing the technician to seat the brackets in small groups of
2 or 3 with sufficient working time to place and fine tune the final position of
the brackets. The brackets are set to the model using an ideal template blade
made of .018 or .022 stainless steel (Figure 1516). With this system, the
brackets fit in the blade which simulates the final archwire. Since the blade is
fabricated in an ideal anterior arc, the technician can move the brackets along
the arc to center them perfectly on each tooth in the set-up.
10. Once the anterior brackets are placed (Figure 1517), the posterior brackets
are set using the same overall technique (Figure 1518). Straight-line blades
are used in the bicuspids and molars to place the brackets and ensure a straight
alignment in these sections while maintaining the uniform vertical plane of
all the brackets. As each bracket position is finalized, the excess adhesive is
- . Phase II from Reliance Orthodontic Products. - . The adhesion is applied to the mesh pads
on each bracket.
trimmed from the edges using a dental explorer as shown (Figure 1519).
Care taken with this step will save considerable time later in the process in
cleaning the excessive adhesive from the bracket edges.
11. A one-to-one photographic copy is made using a camera or a copying machine
(Figure 1520). This occlusal recorder will serve as a guide to fabricate the
- . An ideal template blade is made of .018 - . The anterior brackets are placed.
or .022 stainless steel.
- . The posterior brackets are set. - . Excess adhesive is trimmed from the edges using
a dental explorer.
ideal arch template. This template will provide the clinician a way to measure
and bend the archwires.
12. The next laboratory step in the sequence is to transfer the brackets from the
ideal set-up back to the malocclusion. There are several methods to accom-
plish this goal. The system used here employs acrylic caps on each tooth
(Figure 1521). A small strip of light-cured acrylic is cut and laid over the top
of each bracket and indexed to the incisal or occlusal surface of each tooth
(Figures 1522 and 23). These caps are easily cured using a hand-held bond-
ing light or light chamber. This can be done quickly with great accuracy. Each
bracket is then easily removed from the set-up tooth and transferred to its
individual duplicate on the malocclusion model (Figures 1524 and 25). The
custom composite base formed in the bracket-placing stage serves as the guide
to ensure the bracket orientation back on the malocclusion model. At this
point the brackets are secured to the malocclusion model using a water soluble
adhesive (Figures 1526 and 27).
13. The cast is then placed in a warm oven for approximately 1 hour to make sure
the transfer adhesive has fully set. At this point the acrylic caps can easily be
removed by first holding the bracket in place with a spatula and lightly prying
the transferring caps away.
- . A small strip of light-cured acrylic is cut and laid over the top of each bracket.
- . Each bracket is easily removed from the set-up tooth and transferred to
its individual duplicate on the malocclusion model.
- . Brackets are secured to the malocclusion model using a water soluble adhesive.
14. The malocclusion models with the transferred brackets are next placed back
on the copying machine for a second occlusal record (Figure 1528). This
copy will act as the initial guide to help the clinician fabricate the first series
of lingual archwires.
15. Transfer trays are now made on the malocclusion cast. At the present time
the recommended transfer tray technique is a two-tray system processed on
the Biostar machine. The inner tray is a 1.5 mm Bioplast and the outer tray is
a 1.0 Biocryl. This combination gives the best overall clinical results. The clin-
ician should first seat the Bioplast tray and bend it as needed to gain initial
placement (Figure 1529). Once each flexible section is seated, the hard
acrylic tray is immediately placed over it and pressure is applied to bring the
adhesive and dental surfaces into complete contact. In addition, the trays are
sectioned in two or three pieces per arch to allow the clinician complete control
over the clinical bonding process (Figures 1530 and 31). The specific fabrica-
tion technique is detailed in the next several steps.
16. The first step in tray fabrication is model preparation. Any deep interproximal
areas or potential defects in the model must be blocked out. An ideal material
is a light-cured gel applied with a wax spatula. This material is easily moldable
and quickly cured with the light to minimize the laboratory time required.
17. The lingual ball hooks must then be blocked out. In this technique, an
injectable silicone is used in a plastic syringe (Figure 1532). This allows the
- . A copying machine is used to make a second - . The clinician can bend the Bioplast tray as
occlusal record. needed to gain initial placement.
The Customized Lingual Appliance Set-Up Service (CLASS) System
technician to easily control the flow of the material so as to not block out too
much of the bracket undercut and at the same time to ensure that the brackets
will release from the bonding trays.
18. Overall model release is then painted on the surfaces of the cast. This will ensure
that the Biostar trim releases from the construction model (Figure 1533).
19. The model is then placed in a Biostar unit where the first 1.5 mm Bioplast
tray is formed. The technician should follow the general use instructions
supplied by Great Lakes Products in using the Biostar (Figure 1534).
20. The cast is removed from the Biostar and the excess peripheral Bioplast material
trimmed using scissors. The tray is not removed from the laboratory model at
this stage; just the excess material is removed in preparation for the hard tray
process.
21. The 1.5 mm Biocryl tray is next formed after the cast is reseated in the Biostar
unit. A light coat of spray silicone must be applied prior to forming the outer
tray so the two trays will release. The Biocryl tray is formed again using stan-
dard Biostar procedures.
22. The trays are then removed from the model by first soaking the cast in warm
water for approximately 30 minutes. This will help release the brackets from
the construction cast (Figure 1535).
23. The trays are then cut and sectioned using a high-speed handpiece. A small
diamond wheel is the ideal tool to trim the edges of the trays. A sharp knife
can also be heated over a laboratory flame and used to section the soft
Bioplast inner trays.
24. With the tray fabrication now completed, the trays are placed in the ultrasonic
with warm soapy water to remove any excess residue from the material and
composite bases. After this initial cleaning, the composite bases should be
lightly abraded using a microedger (Figure 1536). This will remove any stone
residue from the composite as well as prepare the adhesive for optimum bond-
ing. The trays are returned to the ultrasonic where they are cleaned in plain
water for 1 to 2 minutes.
25. The trays should be labeled and placed in a clean, sealed, plastic bag where
they will remain until the patients bonding appointment.
26. Depending upon the clinicians preference, an optional laboratory step is fabri-
cation of the lingual archwires. This utilizes the templates made from the ideal
set-up and malocclusion photographs (Figures 1537 and 38).
- . The trays are removed from the model by soaking - . The bracket braces are abraded using
the cast in warm water for approximately 30 minutes. a microetcher.
The Customized Lingual Appliance Set-Up Service (CLASS) System
- . Templates are made from the ideal set-up and malocclusion photographs.
An acetate sheet is placed over these templates and an ideal arch template traced
from the record of the brackets on the ideal diagnostic set-up. This template is then
compared to the bracket position on the malocclusion model which will show the
exact position of the offsets that are necessary, distal to the canines. The technician
can then estimate the amount of wire required in the anterior arch from the beginning
wire, such as a .0175 Respond, up through the stages of treatment where heavier wires
will be required (Figure 1539). The final heavy finishing wire should approximate
the ideal arch template made from the diagnostic set-up template, as this record
reflects the brackets in their final ideal alignment.
Summary
The overall CLASS lingual technique demands maximum accuracy from the original
models and instructions provided by the clinician. In addition, the laboratory techni-
cian must have a complete understanding of dental anatomy, set-up techniques and
goals, and overall bracketing positioning. Tremendous attention to detail must be
exercised at all steps to avoid inaccuracies in bracket placement and consequent less-
than-ideal clinical results.
Considering the difficulty of access and the irregularity and variability of lingual tooth
morphology, lingual orthodontics could only develop with the indirect bonding tech-
nique, which allows us to control bracket placement at the laboratory. Nevertheless, this
indirect technique requires a precise transfer procedure of the brackets in order to clin-
ically bond them in the exact position which has been set at the laboratory stage. Here,
we will show an indirect bonding technique that we have been using for the last 10 years
with great success. We have been able to take many different kinds of malocclusions
and achieve the same excellent results as those obtained with labial orthodontics.
This technique has been developed by taking into account the advantages and pit-
falls of the TARG (Torque Angulation Reference Guide), an apparatus developed by
Ormco in 1984 for lingual bracket bonding (Figure 161).
1. The TARG
The TARG, despite the anatomic variations of the lingual tooth surfaces, permits us to
bond brackets in the laboratory at an accurate distance from the occlusal edge of each
tooth with respect to a horizontal occlusal plane. The tooth orientation is made with a
gauge or torque blade. The model is tipped on the swivel base until the long axis of
the labial face of the tooth aligns with the specific gauge curvature at the middle third
of the tooth (Figures 162a and b).
This orientation allows us to preprogram torque and angulation (tip) before start-
ing the treatment.
- . The long axis of the labial face aligns with - . The gauge or torque blade orientates the tooth
the curvature of the specific gauge. in its final position.
After the TARG horizontal blade is engaged into the bracket slot, it is moved
toward the varnished plaster at the bonding level determined by the laboratory tech-
nician with respect to the function of the teeth and the anatomy of the periodontium
(Figure 163). The bracket is bonded to the plaster with a filled resin, which allows
the gap between the lingual tooth surface and the metal base of the bracket to be
completely filled (Figures 164a to c). A new resin base which accurately follows the
lingual anatomy of each tooth is therefore integrated to each bracket.
Once all the brackets are bonded to the model, a transfer tray is fabricated. Using
only one unique malocclusion model, the TARG permits achieving a virtual set-up
without the need to cut the teeth and mount them on wax. It is an accurate and
quantified two-dimensional system. The torque, angulation (tip), and height
measurements are registered by the technician. Nevertheless, we have found that a
correct alignment can only be obtained by adding a great number of first-order bends,
because the TARG does not take into account the labiolingual thickness of the teeth.
In Figure 165, one can note that not only does distance B (the distance between the
bottom of the bracket slot and the labial tooth surface) vary for each tooth according to
the height level of bonding but also that it varies according to the tooth type despite
the fact that all the brackets are manufactured with specific, variable thicknesses.
- . The bracket is moved toward the plaster. - . The gap is filled with macrofilled resin.
- . Distance B varies according to the level of bonding - . The TARG with the Thickness Measurement
(distance A) and tooth type. System.
- . The two blades of the Thickness Measurement - . The selected thickness appears on the screen.
System.
- . The gap is filled with resin. - . The resin excesses are removed before
polymerization.
The Thickness Measurement System with the DALI Program
2. By redoing an individual bonding tray in the laboratory with the same protocol
and information determined at the beginning of the treatment (height, torque,
angulation, and thickness). A small silicone unitary tray unit is then used.
- . The transfer tray. - . The rigidity of the transfer tray allows bonding
of the entire arch at one time.
- . After bonding on teeth, we can find back the same resin pads as on the plaster.
- . Difficulty in engaging the wire in the bracket of - . In case of crowding, the bracket is decentered
a crowded tooth when the bracket is centered on the tooth. or rotated.
The Thickness Measurement System with the DALI Program
- . DALI program: Example of an extraction case:
(a) Copy of brackets bonded on the model. (b) Ideal archwire. (c and d) First wire bent with the copy for
location and length of the first-order bends and with DALI program for the form of the arch.
The Thickness Measurement System with the DALI Program
- () . (e and f ) Retraction stainless steel wire bent on ideal archwire form.
(g and h) Finishing wire. All the wires are bent extraorally.
first-order bends placed between the cuspids and bicuspids, and between the
bicuspids and molars.
3. During treatment, it allows us to know the ideal arch shape needed to achieve
a good occlusion, especially in asymmetric cases.
4. It permits us to preform all archwires with great precision, except for the first
ones which are bent from the copy of the bonded brackets on the initial model.
5. It is not necessary to coordinate the archwires during treatment because the
drawing of the upper and lower archwires are made from the same labial arch
curves (Figures 1618a to h).
The DALI program cannot work without the Thickness Measurement System,
since it is essential to know the distance between the bracket slot and the labial tooth
surface.
The TARG, the Thickness Measurement System, and the DALI program form a
coherent and interdependent system, with the following advantages:
1) Easy and accurate
Use of one single model, no transfer, no set-up, no duplicate; bonding with
unfilled resin; no iatrogenic effect on the gingiva; and accurate rebonding with
a unitary transfer tray.
2) Reduces chairtime, increases clinical efficiency
Equal thickness (teeth and brackets) for the six anterior teeth, bicuspids and
molars; decreases first order bends except between cuspidbicuspid and bicuspid
molar; very accurate measurement of first-order bends; gives the ideal (final)
archwire shape; and provides a copy of the model with bonded brackets to
bend first archwires.
Conclusion
We were seeking a simple and efficient laboratory bracket-positioning system. The sys-
tem that we have developed answers this need by giving us, with the help of computer
science, the essential information needed to treat orthodontic patients more easily,
accurately, and successfully, using the lingual technique.
To this day, within our exclusive lingual practice, lingual appliances have been
placed on more than 4000 arches with this protocol, using one of the European
Lingual Orthodontic Service laboratories which use our system. The quality of the
obtained results, comparable to the ones achieved with labial orthodontics, shows its
reliability for any kind of malocclusions.
Lingual Treatment with
the Bending Art System
PAUL - GEORG JOST- BRINKMANN , DMD , PhD , VITTORIO CACCIAFESTA , DDS ,
AND FRIEDRICH RIEMEIER
The Bending Art System (BAS) was designed by the Bending Art Medizintechnik in
cooperation with the University of Kiel. It is the first CAD/CAM device for ortho-
dontic treatment planning and bending of individual archwires. It consists of three
components: an intraoral stereoscopic camera, a computer program, and a wire bend-
ing unit (Figure 171). Thus, it allows individual archwires to be manufactured with
first-, second- and third-order bends, which have proven to be very accurate.1 The BAS
can be universally used with all edgewise brackets on the buccal or lingual side, irre-
spective of their slot-sizes (0.018'' 0.025'' or 0.022'' 0.028'').
The wire bending unit (Figure 172) is able to produce individual archwires auto-
matically from straight segments of stainless steel, TMA, and Ni-Ti wires of various
dimensions.
Treatment planning is carried out directly on the computer monitor. According to
the instructions from the orthodontist, the system computes the arch geometry. The
required three-dimensional data are supplied by the intraoral stereoscopic CCD camera
(Figure 173) at the beginning of treatment. To program any wire with the BAS, one
must take occlusal scans of the right and left sides of the patients jaws with the stereo-
scopic camera. These partial scans are later merged by the computer program so that
only one occlusal photograph is displayed on the monitor.
Before taking the occlusal scans, stainless steel measuring plates, available for 0.018''
or 0.022'' slot size bracket systems, must be inserted into the bracket slots as a precon-
Therapeutic Concept
A characteristic feature of the Bending Art System is that, after registration of all the
initial data, the planned result of therapy (treatment target) is designed. Consequently,
the treatment is performed in individual steps. Two methods for specification of the
treatment target are offered: the ideal arch method and the set-up procedure.
- . Occlusal view of the passive lingual arch on the - . Occlusal view of the target arch on the monitor
monitor of the BAS. of the BAS.
- . Intraoral frontal and lateral views of the occlusion before treatment. Note the Class I
malocclusion with a large upper central diastema.
limited to controlling the patients progress and insertion of the archwires, which have
been already bent by the system.
Treatment Planning
There is no difference between the labial and the lingual approach in planning the
orthodontic treatment. This is determined by the following factors:
1. Number of archwires. The number of archwires to be used is defined by the
orthodontist. However, it can be modified during treatment, as needed.
2. Distribution of tooth movement among the archwires. The required tooth
movements can either be distributed proportionally by the system among all the
planned archwires, or be modified during treatment according to the patients
needs. Specifically, that means the orthodontist can program tooth movements
from 0% (no movement), if an entirely passive segment is required as anchorage,
to 100% (full movement). The system automatically calculates the required
mesiodistal sliding distances in order to perform such movements.
3. Wire material. The bending unit works with straight segments of stainless
steel, TMA, and Ni-Ti wires of various dimensions. Every wire is exactly
shaped as series of consecutive bends according to the geometric data calculat-
ed by the computer program. After the bending process, superelastic wires
must be heat-treated to keep the bends and torquing permanently as otherwise
the archwire will return to its original shape due to the memory effect.
4. Design of the archwires. The BAS is able to produce wires in a great variety
of arch shapes. A very valuable feature is the ability of the system to bend
completely passive segments and archwires, which are necessary for anchorage
purposes when using a segmented arch approach and for patients before they
undergo orthognathic surgery. The system enables the orthodontist to correct
also the sweep and width of a patients arch, when needed. It allows a couple of
brackets to be bypassed, for example, to bend utility arches. Another feature of
the BAS is the fabrication of loops, which are prebent by the bending unit and
need only to be finished by hand.
- . Occlusal views of the maxilla and the mandible. Note the rotated upper central incisors and spacing in both jaws.
Case Report
As the first case lingually treated with the BAS in our department, a female patient
presented with a Class I malocclusion with a large upper central diastema was selected
(Figures 176a to c). The upper and lower first premolars had been previously extract-
ed and the postextraction spaces were still present. The upper central incisors were
rotated mesiobucally (Figures 177a to b). The set-up BAS method was used to pre-
pare lingual bonded brackets. First, an ideal set-up was produced and measuring plates
and template-caps were placed for transferring the brackets to the working model
(Figure 178a). The position of each bracket on the set-up model was measured with
the BAS. Next, the brackets were transformed to the malocclusion model (Figure
178b). Due to the rotations of teeth 21 and 22, interferences were observed between
their measuring plates. BAS scannings were made separately for each tooth. When
tooth 21 was scanned, the bracket on tooth 22 was left out. Subsequently, the bracket
- . A working model. Brackets were transferred from - . A transfer tray for indirect bonding was prepared,
the set-up with BAS measuring plates. after removing the measuring plates from the bracket slots.
Lingual Treatment with the Bending Art System
for 21 was temporarily removed whereas the one for 22 was set, allowing the measure-
ment of this tooth in relation to the other brackets already scanned by the BAS.
After removing the measuring plates from the bracket slots, a transfer tray for
indirect bonding was produced (Figure 178c). The template-caps of the brackets
were covered with silicone (Memosil, Heraeus Kulzer, Dormagen, FRG). A total of
four wires for each jaw were bent for treating this case: two 0.016'' round wires and
two 0.016'' stainless steel wires. Each wire was designed by the BAS to carry the teeth
25% further towards their final position, as defined by the set-up. Every 4 weeks, the
subsequent archwire was put in (Figures 179a to c). The treatment progress was very
rapid, as one can see in the sequential views at 2 months (Figures 1710a and b),
4 months (Figures 1711a and b), and at the end of treatment, after 5 months
(Figures 1712a and b). Satisfactory final results were achieved within 5 months
(Figure 1713a to c).
- . Occlusal views of the maxillary arch and the mandibular arch: immediately after placing the wires.
- . Occlusal views of the upper and lower arches: 2 months in treatment.
- . Occlusal views of the upper and lower arches: 4 months in treatment.
- . Occlusal views of the upper and lower arches: 5 months in treatment (end of treatment).
Lingual Treatment with the Bending Art System
- . Intraoral frontal and lateral views of the occlusion at the end of treatment (after 5 months).
References
1. Fischer-Brandies H, Orthuber W, Pohle L, Sellenrieck D. Biege-und Torsionsgenauigkeit des
Bending Art System (BAS). Fortschr Kieferorthop 1996;57:1623.
2. Cacciafesta V, Miethke R-R, Jost-Brinkmann, P-G. Bending Art System: state of the art and
first impressions. Kieferorthop 1995;9:247254.
3. Creekmore T. Lingual orthodonticsits renaissance. Am J Orthod Dentofac Orthop 1989;
96:120137.
SECTION 5
Appendix
Bibliography (19701997) . . . .
Bibliography (19701997)
A
Aguirre MJ, King GJ, Waldron JM. Assessment of bracket placement and bond
strength when comparing direct bonding and indirect bonding techniques. Am J
Orthod 1982;82:269276.
Aguirre MJ. Indirect bonding for lingual cases. J Clin Orthod 1984;18:565569.
Aknin JJ. Arch forms and D.D.M. Proceedings and Abstracts: First Congress of the
European Society of Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
Alexander RG. The Alexander discipline, contemporary concepts and philosophies. In:
Angel GA, ed. 1986.
Alexander CM, Alexander RG, Gorman JC, et al. Lingual orthodontics: a status
report, No. 5, lingual mechanotherapy. J Clin Orthod 1983;17:99115.
Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report,
part 6, patient and practice management. J Clin Orthod 1983;17:240246.
Alexander CM, et al. Lingual orthodontics: a status report, part 1, J Clin Orthod
1982;16:255262.
Altoinian G. About the set up. Proceedings and Abstracts: First Congress of the
European Society of Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
B
Baker RW. The eastman programa comprehensive approach. Clinical Impressions
1994;3:27, 19.
Baker RW Jr. The lingual appliance: molar eruption vs incisor depression (Masters
thesis). Rochester: Eastman Dental Center, 1987.
Behrents RG, Wendt SL, Fox DM, et al. A transillumination technique for lingual
bonding. J Clin Orthod 1987;91:324325.
Bennet RK. A study of deep overbite correction with lingual orthodontics, (masters
thesis). Loma Linda: Loma Linda University, 1988.
Bobic R. Case report of the lingual appliance. Clinical Impressions (Orange) 1986;
7:14.
Breece GL, Nieberg LG. Motivations for adult orthodontic treatment. J Clin Orthod
1986;20:166171.
Burstone CJ. The precision lingual arch: hinge cap attachment. J Clin Orthod 1994;
105:151158.
Burstone CJ. Precision lingual arches. Active applications. J Clin Orthod 1989;
23:101109.
C
Cantor RJ. The periodontal effect of the lingual appliance (masters thesis). Rochester:
Eastman Dental Center, 1984.
Chaconas SJ, Caputo AA, Brunetto AR. Force transmission characteristics of lingual
appliances. J Clin Orthod 1990;97:3643.
Chumak L, Galil KA, Way DC, et al. An in vitro investigation of lingual bonding.
Am J Orthod Dentofac Orthop 1989;95:2028.
Creekmore TD. Precision placement of lingual and labial brackets. J.A.L.O.A. 1988;
1:2,68.
Creekmore TD. Straightwire limitations: compensations for conceal with the slot
machine. Proceedings and Abstracts: First Congress of the European Society of
Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
D
Darmon JC. Orthodontie Linguale: Pour ou contre? Inf Dent 1992;74:427429.
Bibliography
Diamond M. Improved vision and isolation for direct lingual bonding of the upper
arch. J Clin Orthod 1984;18:814815.
F
Favero L, Tagliapietra S. Lingual orthodontics in pediatric patient. Proceedings and
Abstracts: First Congress of the European Society of Lingual Orthodontics, Lido
di Venezia, June 1820, 1993.
Fujita K. Brushing method for the lingual-bracket technique with Fujita. J Jpn Orthod
Soc 1978;37:4146.
Fujita K. Multi lingual bracket and mushroom arch wire technique. Am J Orthod
1982;82:120140.
Fujita K. New orthodontic treatment with lingual bracket and mushroom arch wire
appliance. Am J Orthod 1979;76:657675.
Fulmer DT, Kuftinec MM. Cephalometric appraisal of patients treated with fixed lin-
gual orthodontic appliances: historical review and analysis of cases. Am J Orthod
Dentofac Orthop 1989;95:514520.
G
Garber S, Speidel M, Seigel G, Miller E. The effects of presentation of noise and den-
tal appliances on speech. J Speech Hear Res 1980;23:838852.
Garino GB. Surgical orthodontic treatment with lingual technique on skeletal class III
with TMJ dysfunction. Proceedings and Abstracts: First Congress of the European
Society of Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
Geiger AM, Gorelick L, Gwinnett A. Bond failure rates of facial and lingual attach-
ments. J Clin Orthod 1983;83:165169.
Giorgio N. Lingual technique under the biomechanic and aesthetical point of view.
Proceedings and Abstracts: First Congress of the European Society of Lingual
Orthodontics, Lido di Venezia, June 1820, 1993.
Gorman JC, Kurz C, Dunn RM. Les cles du succes en therapeutique a attaches
linguales. Rev DO.D.F. 1986;20:3.
Bibliography
Gorman JC. Treatment with lingual appliances: the alternative for adult patients. Int J
Adult Orthod Orthognath Surg 1987;2:131149.
Gorman JC, Kurz C, Smith JR, Dunn RM. Keys to success in lingual therapyPart 2.
J Clin Orthod 1986;89:330340.
Gorman JC, Smith RJ. Comparison of treatment effects with labial and lingual fixed
appliances. Am J Orthod Dentofac Orthop 1991;99:202209.
Gorman JC. Dispelling some myths about lingual orthodontics. Is it time you took
another look? Clinical Impressions 1993;2:25, 1618.
Gorman JC, Hilgers JJ, Smith JR. Lingual orthodontics a status report, part 4: diag-
nosis and treatment planning. J Clin Orthod 1983;17:2635.
Gorman JC. Treatment of adults with lingual appliances. Dent Clin North Am 1988;
32:589620.
H
Hamlet S, Stone M. Compensatory alveolar consonant production induced by wear-
ing a dental prosthesis. J Phon 1978;6:227248.
I
Incorvaty C, Spoon M. Post-retention cephalometric evaluation of orthodontic
correction after treatment with fixed lingual appliance. Proceedings and Abstracts:
First Congress of the European Society of Lingual Orthodontics, Lido di Venezia,
June 1820, 1993.
Isaacson RJ, Lindauer SJ, Rubenstein LK. Moments with the edgewise appliance:
incisor torque control. Am J Orthod Dentofacial Orthop 1993;103:428438.
J
Jyen PK. A lingual Begg lightwire technique. J Clin Orthod 1986;90:786791.
K
Kaley J, Philips C. Factors related to root resorption in edgewise practice. Angle
Orthod 1991;61:125132.
Kazley SM. The effects of lingual appliance treatment on the skeleton, dentition, and
TMJ (master thesis). Rochester: Eastman Dental Center, 1984.
Kelly VM. Eclipsing the treatment a history. Proceedings and Abstracts: First Congress
of the European Society of Lingual Orthodontics, Lido di Venezia, June 1820,
1993.
King L, Smith RT, Wendt SL, Behrents RG. Bond strengths of lingual orthodontic
brackets bonded with light-cured composite resins cured by transillumination.
Am J Orthod 1987;91:312315.
Kurz C. Lingual orthodontics. In: Marks M, Corn H, eds. Atlas of adult orthodontics.
Philadelphia, London: Lea & Febiger, 1989.
Kurz C, Gorman JC. Lingual orthodontics: a status report: part 7A case reports
nonextraction. J Clin Orthod 1983;83:310321.
L
Leclerc JF. Story of three clinical cases: infant cases, a severe class I, a 60 year old class
III. Proceedings and Abstracts: First Congress of the European Society of Lingual
Orthodontics, Lido di Venezia, June 1820, 1993.
Lew KK. Technique clinic customized template for prefabricating initial lingual arch-
wires. J Clin Orthod 1993;104:426.
Lew KK. Changes in lip contour following treatment maxillary protrusion with
esthetic orthodontic appliances. J Esthet Dent 1992;4:1623.
Lew KK. Initial alignment with .008 pulse straightened supreme Wicock wire in
lingual orthodontics. Aust Orthod J 1991;12:5354.
M
Macchi A. Biomechanic aspects in the upper cuspid retraction. Proceedings and
Abstracts: First Congress of the European Society of Lingual Orthodontics, Lido
di Venezia, June 1820, 1993.
Bibliography
Mariotti J, Subtelny JD, Baker R, Mariotti M. The speech effect of the lingual appli-
ance (unpublished report). Ormco, Glendora, CA, 1984.
Mariotti J. The speech effect of the lingual appliance (masters thesis). Rochester:
Eastman Dental Center, 1983.
Moran KL. Technique clinic: effective steel ligation for lingual appliances.
J Clin Orthod 1984;18:733.
Mori Y, Sakayori M. Severe Cl. II treatment with the lingual-multi system: case-report
of extraction treatment. Proceedings and Abstracts: First Congress of the
European Society of Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
Muller G, Rossiwall B. Reading time and articulation under masking noise and altered
spatial conditions in the oral cavity. Folia Phoniatr 1977;29:233239.
N
Navarro CF. Twelve service keys to a successful lingual practice. Dallas, U.S.A.
Proceedings and Abstracts: First Congress of the European Society of Lingual
Orthodontics, Lido di Venezia, June 1820, 1993.
P
Paige SF. A lingual light-wire technique. J Clin Orthod 1982;16:534544.
Parisi BM. A three dimensional view of the lingual appliance (master thesis).
Rochester: Eastman Dental Center, 1989.
Paz, M.E. Multi-uses of the Ormco lingual appliance, Clinical Impressions 1992;
1(4):68, 15.
Pierce JS. The periodontal effect of lingual appliance part II (masters thesis).
Rochester: Eastern Dental Center, 1985.
R
Ronchin M. Tecnica individuale di montaggio indiretto degli attacchi linguali. Ediz
Audiovisive Medical Video, Milano, 1991.
Ronchin M. Present horizons and a future outlook on lingual approach: the four-
wheel-drive biomechanics. Proceedings and Abstracts: First Congress of the
European Society of Lingual Orthodontics, Lido di Venezia, June 1820, 1993.
S
Scholz RP, Swartz ML. Lingual orthodontics: a status report, part 3: indirect bond-
inglaboratory and clinical procedures. J Clin Orthod 1982;16:812820.
Sirianni AA, Graziano JP, Epstein MB. Invisible lingual orthodontic appliance. NY
State Dent J 1985;51:480481.
Smith JR, Dunn RM. Retention of the lingual patient. J.A.L.O.A. 1987;1:1,47.
Smith JR, Gorman JC, Kurz C, Dunn RM. Keys to success in lingual therapypart 1.
J Clin Orthod 1986;89:252261.
Smith JR. Twelve key principles of lingual orthodontic therapy. J Am Ling Orthod
Assoc 1988:1(2).
T
Takemoto K. Textbook and syllabusa lingual orthodontics: clinical problems and
solutions of lingual orthodontics.
Bibliography
Trucer AV, Erturk N. The treatment of cross bites in the angle class I cases with mod-
ular 3-D lingual appliances. Turk Orthodonti Derg 1990;3:129134.
V
Velo S, Dal Bori G, Piubelli C. Lingual technique: silent and invisible orthodontics.
Veneziani A. The Pacon system: a new technical method for the placement of
the brackets on the set-up for lingual technique. Proceedings and Abstracts:
First Congress of the European Society of Lingual Orthodontics, Lido di Venezia,
June 1820, 1993.
W
Wildman AJ. The future of lingual orthodontics. Orthodontics: evaluation and future.
Moorrees and Van der Linden, Ed. 1988:261281.
Z
Zachrisson BU, Brobakken BO. Clinical comparison of direct versus indirect bonding
with different bracket types and adhesives. Am J Orthod 1978;74:6278.
Index