The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Original Title
Lingual Orthodontics / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
1726 Pierre Fauchard first suggestion 1841 LeFoulon first lingual arch for expansion & alignment Combination of lingual with labial appliances Appliance system 1970s It was major competing appliance in early 20 th century
Lingual arch introduced by John Mershon-1908
round Labial arch Lloyd S. Lourie Sr (1877-1959),; Oren A. Oliver (1887-1965) Lowrie J.Porter (1895-1981),
refined by Oren A. Oliver who incorporated fixed guide planes JOHN MERSHON OREN A. OLIVER 1. Lingual arch wire 2. Auxiliary spring 3. Lingual locking wire 4. Half round vertical post 5. Intermaxillary elastic hooks
6 Molar bands 7 Intermaxillary elastic hooks 8 Labial arch 9 Vertical spring loop 10 Buccal tubes To protect sumo wrestlers from soft-tissue injury from labial appliances Concept in 1967, published the method 1978 First lingual multi-bracket system with mushroom shaped archwires 3 slots occlusal, horizontal, vertical Fujita K. New orth. Tr. with ling. brt mushroom arch wire appl. Am J Orthod 1979; 76: 657-675. 1975 plastic brackets on lingual surface easy to reshape for better fit (Lee Fischer Brackets) Bonding failure, patient discomfort ORMCO Craven Kurz, Craig Andreiko, Frank Miller - first generation Kurz bracket in 1976 Craven Kurz Jack Gorman Bob Smith Wick Alexander Moody Alexander James Hilgers Bob Scholz
to help refine bracket design (dimensions, torques, angulations, thickness, etc.), to develop mechanotherapy techniques, to create archwire designs, to discuss treatment sequences, and to determine case selection criteria.
SFOL: Societe Francais Orthodontic Linguale ( France) 1986 ALOA: American Lingual Orthodontic Association 1987 ESLO: European Society of Lingual Orthodontics - 1992 Following this initial euphoria- a period of frustration, disappointment and rejection, Due to poor standard of completed cases Reasons - Inadequate training, - poorly developed laboratory system, - unavailability better materials
1996- Craven Kurz, Creekmore, Wildman, Scuzzo together with other clinicians founded lingual study group
Relaunching LO Scuzzo and Takemoto- published series of articles & text book
Also developed lingual striaght bracket & technique, STb Reduced B-L dimensions Reduced O-G dimension Twin design for rotation control Easy arch wire insertion Easy ligation Active spring clip Passive ligation- low friction Conventional ligation SW slot Stability of the archwire in slot Hooks for ligatures and elastics A bite plane
1 st Generation - 1976 - Bite plane Rounded margins Hooks absent Large brackets 2 nd 1980 Hooks on canine brackets
3 rd 1981 Hooks on all brackets
4 th 1982-84 lower profile
5 th 1985-86 bite plane more pronounced and torque increased; Molar brackets had accessory tubes for TPA
6 th 1987-90 Elongated hooks, TPA tube optional Hinge cap tube for 2 nd molar
Stephan Paige- preferred edgewise appliance labially, Begg light wire brackets more suitable on lingual surfaces
Unipoint Combination Brackets Bonding Direct Capable of controlling tip and rotations Torque control varying hieght on lingual surface Auxillaries kuttydentist@yahoo.com kuttydentist@yahoo.com kuttydentist@yahoo.com kuttydentist@yahoo.com kuttydentist@yahoo.com kuttydentist@yahoo.com Logically the right and left brackets have to be transposed to allow for distal tipping when required. Tipping is minimal, possibly due to very gingival bracket placement upper 3-3.
Dr ZJ Weber - http://www.bracesbehind.co.za Lingual Orthodontics Lingual Orthodontics State-of-the-art maxillary incisor bracket with vertical insertion direction. In this version, ligating can be done with simple elastic module or with German overtie. Positioning software allows optimum angulation of hook. Accessory occlusal hook is optional. First-generation premolar bracket with horizontal insertion direction (left) and state- of-the-art premolar bracket with vertical insertion direction (right). Bracket bodies (blue) are loaded from bracket archive to dental arch fitted with individual bases (yellow). Whereas second and third order are preset, bracket body can now be shifted and turned in slot plane for optimal positioning. Bracket body and bracket base are then virtually fused. In rapid prototyping, brackets are first produced in wax, applied in 0.02 mm layers. Red support wax required for 3D production is removed thermally. B, Wax lingual brackets before casting. C, Gold lingual brackets after casting. System Includes iBracket Customized Brackets Low profile brackets for patient comfort Large, anatomical-shaped bracket base to reduce bracket loss Easy to bond and to remove. iWire Precision Archwires A three or four-wire sequence is designed with a dental CAD/CAM system and then fabricated using robotic wire bending technology. SMA wires for initial stages Stainless steel or TMA for finishing. Precise wire fabrication means few if any wire adjustments at chairside. iTray Indirect Bonding Trays Indirect bonding trays are included with each bracket set to ensure easy, precise bracket placement every time. Most malocclusions can be treated but not all patients particularly pts with low discomfort tolerance.
LO is technically sensitive and clinicians needs to be slective. Mild crowding and Ant deepbite. Long & uniform lingual tooth surfaces. Good gingival & periodontal health Compliant pt Skeletal cl I malocclusion Normo or hypo divergent growth pattren Pts who are able to open mouth widely & extend their necks
Hyperdivergent growth pattern- open bite cases Short, abraded & irregular lingual surfaces Presence of multiple crowns, bridges & large fillings Pts with low level compliance Pts with limited mouth opening & Cervical ankylosis Surgical cases
Very Short clinical crowns Pts with severe TMD Pts with severe periodontal diseases
Evaluate pts level of co-operation and level of discomfort tolerance
Most of the LO pts have mutilated malocclusions
Special considerations are needed
Pt should be warned about Speech difficulties 2-4 weeks Tongue irritation Initial wt loss Strict oral hygiene instructions
General Periodontal & gingival Presence of crowns & large restorations Dentoalveolar discrepancy Vertical, Ant post and transverse skeletal/dental problems Surgical cases Preprosthetic cases
Teeth movement slower in adults- less trabeculted bone Pt should have healthy periodontium & able maintain Gingival inflammation is more - proximity of brackets - failure to remove flash LO indicated in pts with a predisposition to gingival recession
Gingival inflammation can be minimized by Bending hooks to reduce gingival impingement Prophylaxis at each archwire change Use of liquid adhesive & correct quantity of adhesive Carefully maintain & control the effect of tooth movement on gingival tissues Pts with high risk of caries & with decalcifications can be treated with LO Lingual surfaces of incisors < 7mm & bicuspids with short lingual surfaces should be reconstructed Gingivectomy to increase crown height Recontour prominent cinguli, cusps of Carabelli
Special bonding techniques for plastic, metallic, porcelain surfaces Replace metallic crowns with acrylic crowns Section bridges Provisional restoration for fractured or microdontic teeth
Built-in bite-planes Posterior open-bite
Open-bite 2 mm occlusion re-establishes in 20-30 days Bite-blocks on lower molars when - Posterior open-bite > 3 mm Only one lower incisor contacts upper bite plane- periodontium cannot withstand trauma - TRIPODING
Measures for vertical molar anchorage control in hyperdivergent cases bite blocks on second molars TPA Headgear Minimal use of intermaxillary elastics
Skeletal Class I easiest Downward & backward rotation of mandible- Class I to Class II Important to assess initial overjet and overbite before starting treatment
Class I reverse overjet Class I with excessive overjet Skeletal Class II and Class III Mild cases treated successfully by camouflage Severe cases orthognathic surgery
Posterior cross bites should be treated before starting LO Expansion should maintained stable b/n Impressions & bonding Many surgeons may refuse to carryout surgery with LO Best possible Presurgical tooth position should be achieved to minimize post surgical Rx Possibility of labial brackets just before surgery Surgical fixation can be done with miniplates & screws Takemoto bonds SS wires with crimpable hooks
Preprosthetic segmental LO mechanics are rapid, economical and comfortable LO techniques can be successfully combined with micro implants in preprosthetic cases Smith, Gorman, Kurz and Richard Dunn 1) Patient selection 2) Bracket placement accuracy 3) Indirect bonding 4) Vertical & transverse control of buccal segments 5) Double-over ties on anterior teeth 6) Buccal & lingual molar attachments
7) Correcting rotations 8) Arch form & archwire sequence 9) Archwire stiffness and torque control 10) Enmass retraction 11) Light, resilient wire for detailing 12) Gnathologic positioner and retention
LO provide stronger anchorage control than labial appliances
A-P anchorage Anchorage Vertical anchorage
Lower anchorage > upper anchorage
Takemoto cortical bone anchorage by distal rotation & buccal root torque of molars
Removal of tongue pressure reinforces the anchorage Alexander, Gorman et al bite plane effect reduces anchorage achieved with LO
Craven Kurz- superior anchorage control because of small arch perimeter Silvia Geron- 6 anchorage keys
1) Extra palatal root torque for ant, molar tubes placed off-center in more mesial position.
2) Reduced friction by using bidimensional archwires- rectangular ant section & round post section or Larger slot size for post teeth
3) Bite blocks on molar teeth
4) Light cl I, II, III forces for retraction
5) Incorporation of second molars
6) Exaggerated curve of spee in max arch wire
I. Extra palatal root torque for ant, molar tubes placed off-center in more mesial position II. Reduced friction by using bi-dimensional archwires Rectangular ant section & round post section or Larger slot size for post teeth III. Bite blocks on molar teeth IV. Light cl I, II, III forces for retraction V. Incorporation of second molars VI. Exaggerated curve of Spee in max arch wire S. Geron, A.D.Vardimon. Six anchorage keys in lingual orthodontic sliding mechanics. World Journal of Orthodontics Vol.4, 2003 (pp. 258-265).
Difficult of directly viewing and access, particularly of retroclined teeth Variation in morphology of the lingual surfaces, especially the maxillary anterior teeth Wide range of labio-lingual thickness from 4.6mm LI to 9.2mm in canines numerous in-out bends Critical relationship between the vertical height of the lingual brackets and the labial surface torque, due to the distance of the lingual brackets from he labial surfaces Much smaller inter bracket distance in the anterior region, making compensatory bends difficult Reduces chair side time Shortens treatment time Improves final result Programmed brackets - spatial position of bracket slot final tooth position Position final tip, torque , height and rotation
Tooth morphology of lingual surface is highly variable Can alter built in tip and torque Same bracket ht on diff lingual surfaces produce diff torque values TARG (Torque/Angulation Reference Guide) BEST ( Bonding with Equal Specific Thickness) CLASS (Custom Lingual Appliance Set-up Service) Slot machine KIS (Korean Indirect bonding Set-up system) Ray Set Hiro TAD/BPD By Ormco in 1984 Brackets are placed on malocclusion model Torque blades prescribe torque & angulations for each bracket Does not consider diff thickness of the teeth 1 st order archwire bends are necessary
Creekmore Orients the arch wire slot of bracket according to the facial surface of the tooth Accomplished by holding the arch wire slot stationary while manipulating each tooth to any tip, torque angle, rotation angle and height through the use of orientation templates and a rotation guide. Both horizontal/ vertical slot brackets can be used In 1987- Didier Fillion improved TARG by adding electronic device Measures labio-lingual thickness DALI { Dessin Arc Linguale Informatise} - Computer generated arch wire tracing Electronic TARG & the DALI BEST system Set-up is done according to doctors prescription Special device used to place brackets considering all planes of space Custom bases for each made 3-D goniometer control system determines 1 st , 2 nd & 3 rd
values for each tooth Models mounted on hinge articulator Ray Set template to check the degree of rotation Tip assessment 0 tip Required tip Vertical precision gauge to determine bracket ht Torque assessment Set-up with over corrections Invented by Toshiaki Hiro, improved by Takemoto & Scuzzo
No need to purchase costly electronic devices
Uses 018 025 SS wire as a transfer tool Set-up model Vertical arch position- Ray Set
Maxillary arch mark mid points molars & extend line on to the anteriors line with in lower 3 rd of incisors Gingival clearance 1.5mm
Mand arch- mid points of premolars Inscisors middle third Ideal arch forms prepared for both arches & co-ordinated Individual trays-ultra band-lok Customizing the bracket base 3-D reference arch wire Ideal set up model Brackets bonded using lingual bracket positioner holds brackets at the same level Transferred to malocclusion model Ready made convertible resin core (CRC)
ideal set up model Brackets bonded - set up model slot ss measuring plates and stereoscopic camera Robot designs archwire passively fits bracket
Dirk Wieshmann Customized Archwires ECO- lingual therapy Reduces number of archwires required 0.016x0.022 Cu NiTi 0.016x0.022 SS - retraction 0.0175x0.0175 finishing TARG Pro Reduces bracket losss Reduced gingival irritation Increased patien comfort Simplified finishing process
Isolation dry field system
Etching Apply Primer & bracket adhesive Removing core Bracket ht marked- Anderson gauge Weld tube slightly mesial on upper molars, center for lower molars
Interbracket distance in LO lesser
Stiffness of arch wire increases
Rotational moment decreases Clinical implications of this More difficult to correct rotations difficult to achieve efficient coupling
More resilient, lower size wires necessary to correct crowding More crown rotations of posteriors Miner tendency of anterior rotation when force applied in M-D direction
Prevention Reduce retraction forces Increasing intrusive forces Increasing lingual root torque Allow the wire to express torque for 6-8 weeks should not be retracted on round wires Introduction Patient selection and diagnostic considerations Lingual laboratory procedures Clinical bonding technique Special biomechanical considerations in LO Anchorage in LO Extraction mechanics Finishing protocol Retention
Extraction choices often differ in LO Cl I cases Upper 1 st premolars & lower 2 nd premolars Cl II cases Max anchorage - 4 4 4 4 ext, lower stripping 4 4 ext, lower incisor ext / one premolar Moderate anchorage 4 4 5 5 Cl III cases - distal tip lower molars improves cl lII - 4 4 5 5 4 4 4 4 4 4 - incisor only - surgery or Timing of Xn of lower II premolars after leveling Esthetic pontics 1) Anterior leveling Partial canine retraction
Lingual arch Full arch wire with loops (014NT, 016 NT, 016 TMA) Sectional wire(016 x 022 NT, 0175 x 0175 TMA) Anterior leveling (016 Cu-NiTi, 017x017 Cu-NiTi) Rotation correction Power arm - Smiths rotation tie Torque leveling (0175 x 0175 TMA, 0175 X025 TMA)
Torque leveling is complete- bite planes are parallel to occlusal plane
Inadequate torque anchorage loss Enmass retraction (upper arch- 017 x 025 TMA)
Upper arch Max- TPA, Headgear, cl II elastics 5-7 race- back tie Minimum anchorage- 3-6 circular elastics cl lll elastics
Anchorage control in lower arch- strong anchorage often difficult to move mesially Minimum anchorage cl II elastics in combination with open coil sprigs b/n 1 st & 2 nd molars & circular elastics
Ideal arch form after space closure Ideal arch coordination Lingual st wire brackets to reduce cumbersome wire bending More lingually and more gingivally placed Comparison b/n Kurz bracket & STb bracket Rotation correction Expansion Rebonding Difficulties encountered in finishing are derived from 1. Patient characteristics - Restorative & Periodontal complications - Thickness of tooth varies - Compensating bends are less accurate & less effective
2. Anatomy of lingual surfaces
3. Mechanics of LO Uprighting Torque Rotations
Prevention of finishing problems Correct diagnosis & Rx planning- asymmetric extractions Precise bracket bonding Light forces to avoid side effects
Silvia Geron systematic finishing protocol Step 1 of finishing protocol - Reuse of resilient arch wire for 3-4 months(017x017 Cu-NiTi) - Reposition the brackets Step II finishing protocol Settling the occlusion, midline correction, A-P & vertical discrepancies Lower 0175 x 0175 TMA, upper 014 sectional wire canine-canine Vertical elastics for 4-6 weeks Step lll finishing protocol
Final detailing & finishing bends Pablo Echarri- finishing wire bends on models Upper arch 0175 x 0175 TMA Lower- 016TMA Adult patients -esthetically demanding
Clear retainers Wrap around plastic retainer- QCM wire Bonded lingual retainer-0.012 SS wire Zachrisson-0.030SSwire bonded only to canines Positioners - detailing Smith, Gorman, Kurz and Richard Dunn 1) Patient selection 2) Bracket placement accuracy 3) Indirect bonding 4) Vertical & transverse control of buccal segments 5) Double-over ties on anterior teeth 6) Buccal & lingual molar attachments
7) Correcting rotations 8) Arch form & archwire sequence 9) Archwire stiffness and torque control 10) Enmass retraction 11) Light, resilient wire for detailing 12) Gnathologic positioner and retention
Pre Rx Post Rx Revisiting the history of lingual orthodontics: Abasis for the future- Pablo Echarri ; Seminar orthod 2006;12:153-159 Lingual orthodontics: patient selection and diagnostic considerations. Pablo Echarri, Seminar orthod;2006;12:160- 166 An overall view of the different laboratory procedures used in conjunction with lingual orthodontics. Buso-Frost and didier fillion
Invisible orthodontics-current concepts and in lingual orthodontics; Giuseppe Scuzzo, Kyoto Takemoto Anchorage considerations in lingual orthodontics. Silvia Geron: Seminar orthod 2006;12:167-177 Concepts on control of the anterior teeth using the lingual appliance; Rafi Romano. Seminar orthod 2006;12:178-185
Keys to success in lingual therapy part 1; smith, Gorman, craven Kurz and Richard Dunn; J Clin Orthod 20;252- 261,1986.
Keys to success in lingual therapy part 2; smith, Gorman,craven Kurz and Richard Dunn; J Clin Orthod 20;330- 340,1986.
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