You are on page 1of 280

INDIAN DENTAL ACADEMY

Leader in continuing dental education


www.indiandentalacademy.com

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

7
th
1990 square bite plane changed to heart shaped
premolar brackets widened


Kinja Fujita 1979
Anterior teeth and premolars 3 slots
Occlusal Slot - 0.019 square
Rotation control & Archform control
Lingual Slot - 0.018x0.025 edgewise
Vertical, Torque and Tip control
Vertical Slot - 0.016 square
Auxillaries
Molar Bracket 5 Slots - Occlusal, 2 Lingual & 2 Vertical
Thoams Creekmore 1989
Archwire slot opening in occlusal ascpect
Unitwin bracket centered slot concept

AJO-DO Volume 1989 Aug (120 - 137): Lingual orthodontics Its renaissance - Creekmore

Scuzzo Takemoto
Light Lingual Philosophy
STb Comparison
Less Lab Procedures
Low Friction
Low Forces

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

Gingival recession, missing teeth, occlusal wear requires
dental procedures

Limited time to wear retainers


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.



Thank you

For more details please visit
www.indiandentalacademy.com

You might also like