Lingual Orthodontics Khush

LINGUAL
ORTHODONTICS
Presented by:
Dr Khushbu Agrawal

CONTENT
• Introduction
• History
• Evolution of lingual appliance
• Bracket designs
• Different lingual appliances
• Patient selection, Diagnostic considerations
• Changes induced by lingual orthodontics
• Indications and contraindications
• Advantages and disadvantages of lingual orthodontics
• Bracket placement systems
• Bonding techniques
2

CONTENT..
• Lingual mechanotherapy
• Anchorage considerations
• Conventional
• Microimplants
• Control of anterior teeth
• Lingual Vs Labial biomechanics
• Wire sequencing
• Treatment sequence
• Keys to success
• Improving patient comfort
• Conclusion
• References 3

INTRODUCTION
• Ever increasing demand for aesthetic appliance
• Patient compliance
• Patients’ demand high quality orthodontic treatment
• “Invisible braces” – Dr Craven Kruz in 1975
4

HISTORY
• 1889 – John Farrar "lingual removable arch"
• 1918 – Dr. John Mershon "The Removable Lingual Arch as an
Appliance for the Treatment of Malocclusion of the Teeth"
• 1922 – Mershon's presentation on labial and lingual arches with
finger springs
• 1942 – Dr. Oren Oliver gave a clinic on a labiolingual appliance
5

• 1967 – Kinja Fujita of Japan submitted his concepts on lingual
orthodontics
• He began research in 1971, “Fujita method” in 1978
6
Ecchari P. Revisiting the History of Lingual Orthodontics: A Basis for the Future Seminars in Orthodontics 2006;12(3):153-159

• 1975 – Dr Craven Kurz began investigations, developed first
generation lingual brackets
7

• 1976 – Dr Jim Wildman treated first lingual patient in US
• 1978 – Lingual archform studied topographically describing tip
and torque values
• 1979 – first edgewise lingual prototype
• 1990 – TASK FORCE by Ormco – to further study the appliance
– make suggestions for improvements
8

• Members of Task Force:
- Moody Alexander
- Richard Wick
- Jack Gorman
- James Hilger
- Craven Kurz
- Robert Scholz
- John Bob Smith
9

• Main objectives:
- To help refine bracket design
- To develop mechanotherapy techniques
- To create archwire designs
- To discuss treatment sequences
- To determine case selection criteria
10

Difficulties encountered during the
development of lingual appliance
Tissue irritation and speech difficulties
Gingival impingement and Occlusal interferences
Appliance control
Base pad adaptation and Appliance placement and bonding
Appliance prescription
Wire placement
Ligation and Attachments 11

EVOLUTION OF LINGUAL APPLIANCE
SYSTEM
12

BRACKET DESIGNS
• Evolution of the Craven Kurz lingual bracket: principal
characteristics:
- a bite plane,
- a base pad adapted to the anatomic characteristics of the
lingual surfaces of the teeth,
- and a preangulated slot according to the conversion of the
torque used on the labial surface.
13

• First generation brackets (1976)
- Bite plane and rounded margins
- Large brackets
- Advantages: bite opening anteriorly,
facilitating expansion or mesiodistal molar
movement
14

• Second generation brackets (1980)
- Hooks were added to canine brackets
15

• Third generation brackets (1981)
- Hooks were added to all brackets
- First molar had bracket with intraoral hook
- Second molar had terminal sheath without hook
16

• Fourth generation brackets (1982-84)
- Low profile brackets
- Hooks were optional
17

• Fifth generation brackets (1985-86)
- Bite plane pronounced
- Torque increased – maxillary anteriors
- Molar brackets with accessory tube for
transpalatal arch
18

• Sixth generation brackets (1987-1990)
- Hooks were elongated
- TPA attachment was optional
- Hinge-cap tube for second molar (self-ligated)
19

• Seventh generation brackets (1990) -
Present
- Rhomboid bite plane
- Increased inter-bracket distance
- Premolar brackets widened mesiodistally
20

DIFFERENT LINGUAL BRACKET SYSTEMS
22

1] Fujita’s Lingual Bracket System
(AJO1979)
Kinya Fujita’s purpose for lingual bracket system, apart from
aesthetics, was to prevent injury with labial brackets during sports.
• The first Fujita lingual bracket was introduced in 1979.
• It featured a slot that opened toward the occlusal.
23

A. Lingual insertion B. Occlusal insertion 24

The presently available Fujita system is still based on an occlusal
slot opening, but has multiple slots.
• Brackets for the anterior teeth and premolars now have three slots:
occlusal, lingual, and vertical.
• Molar brackets have five slots: one occlusal, two lingual, and two
vertical.
• Each of the three types of archwire slots provides different
capabilities for efficient tooth movements.
26

Fujita lingual brackets
(OS = occlusal slot; LS = lingual slot; VS = vertical slot;
OW = occlusal wing; GW = gingival wing).
27

• The basic purpose of incorporating multiple slots is to use Tandem
wire mechanics.
This entails use of multiple wires in different slots to bring
about desired tooth movements without side effects.
28

2] Begg’s Lingual Brackets
(JCO1982)
• Dr. Stephen Paige introduced the Lingual Light Wire
technique in 1982.
• Initially, he used the Begg’s TP 256-500 labial brackets.
30

• The bracket currently used in
the Begg system is the
Unipoint combination bracket
(Unitek), with the slot oriented
in the occlusal-incisal direction.
• The Unipoint bracket has a
gingival "wing" to place elastic
modules on continuous elastic
chains.
THE UNIPOINT BRACKET 31

Molar Tube Design:
• Oval tube with a mesiogingival
hook.
• The squashed oval tube has
some advantages in that it
increases patient comfort,
allows molar control, and will
accept a ribbon arch.
OVAL TUBE 32

Mushroom arches with horizontal
loops for elastics
• Archwires:
The general shape of the
archwires – mushroom shape
as proposed by Fujita, except
that when use of elastics to the
archwire is required, a
horizontal loop has been
added distal to the cuspids.
33

3] Creekmore’s Lingual System
(AJODO1989)
• Described by Thomas
Creekmore in 1989.
• The foundation of the
design is the opening of
the arch wire slots to the
occlusal aspect rather
than to the lingual
aspect.
34

UNITWIN BRACKET-CENTERED ARCH WIRE SLOT
35

• A critical breakthrough was the
design of premolar and molar
brackets, with occlusal tie
wings projecting mesially and
distally instead of labiolingually.
37

4] Straight Wire Lingual Brackets
(JCO2001)
• Takemoto and Scuzzo in 2001 found that the bucco-lingual
distances at the gingival margins do not vary substantially.
This led them to conclude that straight archwires could be
used in lingual orthodontics if they were placed as close to
the gingival margin as possible.
• Compared to other lingual brackets, archwire insertion in
this design is from the top instead of the bottom.
38

Advantages:
- Flossing is easier as the archwire is farther from the lingual surface
and incisal edge.
- Mesio-distal width of the bracket is smaller, allowing adequate
inter-bracket distances.
- Less composite is needed to raise the bite, since the brackets are
placed more gingivally.
- Rotations can be more easily accomplished as the archwire can be
tied tightly to the bottom of bracket slots.
39

- Torque control is improved.
- Rebonding is easier as the archwire does not have to be
removed.
- Pre-formed archwires can be used with a few additional bends,
reducing chairtime and allowing the use of sliding mechanics.
40

5] Self-ligating Lingual Brackets
(JCO2002)
• First described by Macchi et al the Philippe Self Ligating
Lingual Brackets (Forestadent, St. Louis, MO) can be
bonded directly to the lingual tooth surfaces.
• Since they do not have slots, only first- and second-order
movements are possible.
41

Four types of Philippe brackets are available:
- Standard medium twin bracket (most commonly used).
- Narrow single-wing bracket for lower incisors.
- Large twin bracket.
- Three- wing bracket for attachment of intermaxillary elastics
and application of simple third-order movements.
42

Clinical applications:
- Post – treatment retention.
- Closure of minor spaces.
- Limited intrusion.
- Correction of simple tooth malalignments and mild crowding,
especially in the mandibular arch.
43

6] Customised Brackets & Archwires For Lingual Orthodontic Treatment
(AJODO2003)
• Developed by Derk Weichmann et al.
• The processes of bracket fabrication and optimized
positioning of the fabricated brackets on the tooth are fused
into one unit.
• Each tooth has its own customized bracket, made with
state-of-the-art CAD/CAM software coupled with high-end,
rapid prototyping techniques. 44

7] iLINGUAL 3D
(JIOS2007)
• Developed by Jignesh Kothari in 2007
• The brackets were made by CAD design
manufactured with rapid prototyping and
casted in gold alloy.
45

• In 2009 iLingual ribbon arch stock bracket (0.025″ × 0.0175″
slot size) was introduced with vertical insertion in anteriors and
horizontal insertion in posteriors, the same was used with the
modified target set up for individualization.
• In 2011 the bracket design was integrated with a digital
workflow to create India's first CAD/CAM lingual appliance the
iLingual 3D.
46

• In 2012 the design was modified to make it more rounded from
all dimensions to make it more acceptable to the tongue.
• In 2014, they reworked the design to make it 25% smaller in
dimension yet retaining the functionality of the system.
• Also downsized the slot size form 0.0175 × 0.025″ to 0.016″ ×
0.022″ with the final slot-filling wire being 0.022″ × 0.016″ TMA
47

PATIENT SELECTION AND DIAGNOSTIC
CONSIDERATION
48

Indications For Lingual Orthodontic Treatment
Ideal Lingual Cases
Nonextraction:
• Deep bite, Class I with mild crowding, good facial pattern.
• Deep bite, Class I with generalized spacing, good facial pattern.
• Deep bite, mild Class II, good facial pattern.
• Class II division 2 with retruded mandible
• Cases requiring expansion.
• Consolidation (diastema) cases.
49

Extraction:
• Class II, maxillary first bicuspid and mandibular second bicuspid
extractions.
• Maxillary first bicuspid only extractions.
• Mild double protrusions with four first bicuspid extractions, wherein
anchorage is not critical.
50

More Difficult Lingual Cases
• Surgical cases.
• Class III tendencies.
• Class II, four first bicuspid extractions.
• Mesiofacial patterns and/or moderate mandibular plane angles.
• Cases with multiple restorative work.
51

• Acute TMJ dysfunction.
• Mutilated posterior occlusions.
• High angle/dolichofacial patterns.
• Extensive anterior prosthesis.
• Short clinical crowns.
• Critical anchorage cases.
• Severe Class II discrepancies.
• Poor oral hygiene or unresolved periodontal involvement.
• Unadaptable or demanding personality types.
Cases Contraindicated For Lingual Therapy
52

53
General, with particular reference to esthetics
Periodontal and gingival
Dental, with particular reference to the presence of crowns and large
restorations
Dentoalveolar discrepancy
Vertical skeletal/dental problems
Anteroposterior skeletal/dental problem
Transverse skeletal/dental problems
Diagnostic considerations:

ADVANTAGES AND DISADVANTAGES
OF LINGUAL ORTHODONTICS
54

ADVANTAGES
• Facial surfaces of the teeth are not damaged from bonding,
debonding, adhesive removal, or decalcification from plaque
retained around labial appliances.
• Facial gingival tissues are not adversely affected.
• The position of the teeth can be more precisely seen when their
surfaces are not obstructed by brackets and arch wires.
55

• Facial contours are truly visualized since the contour and drape
of the lips are not distorted by protruding labial appliances.
• Most adult and many young patients would prefer "invisible"
lingual appliances if costs, treatment times, and results were
comparable to those of labial appliance treatment. Given these
advantages for patients, the perfection of lingual treatment
seems worthwhile.
56

DISADVANTAGES
• More chair time is required.
• Cost generally is one-third more than labial treatment.
• Mandibular auto-rotation occurs because of the bite plane on the
maxillary anterior brackets.
• Vertical and transverse control of buccal segments often is difficult
when the teeth are disoccluded.
57

CHANGES INDUCED BY THE LINGUAL APPLIANCE
1. Vertical changes
• The most immediate – bite opening.
• Beneficial in brachyfacial cases, TMD cases and rapid tooth
movement due to posterior disclusion.
58

Bite Plane Effect
Treatment time - 3 months.
59

2. Antero-posterior changes
• Because of the vertical opening and the immediate rotation of the
mandible (down and back) – Class II tendency.
• With bite opening, A-P molar correction is easier.
60

3. Transverse changes
• The lingual appliance - expansive nature - posterior disclusion.
• Tendency to cause mesio-buccal molar rotation during space
closure.
• Retraction is always done on stiffer wires to prevent “bowing
effect,” both in the transverse and vertical planes.
61

• Considering the difficulty of access, irregularity and variability of
lingual tooth morphology, it is difficult to locate exact bracket
positions, even on plaster casts.
• Michael Diamond (JCO 1983) described the critical aspects of
lingual bracket placement as follows:
65

1) Variation in height (y) has a
direct effect on the
labiolingual position of the
bracket (x).
Placement of the bracket
closer to the incisal edge (y')
shortens the labiolingual
distance (x').
66

2) Variation in tooth
thickness at the same
distance from the incisal
edge affects bracket
placement by varying the
distance from the labial
surface.
Tooth A is thicker than
tooth B at height y, and the
distance x' is greater than x.
67

3) Variation in height alters
the effective torque in the
bracket, with either a
vertical or a horizontal
insertion of the archwire.
68

4) Brackets placed at the
same height (y) on different
lingual slope angulations
will be located at various
distances from the incisal
edge (C).
A is greater than B.
69

5) Altering the angle of the
bracket-positioning
instrument can vary the
amount of torque in the
bracket slot.
70

71
LINGUAL BRACKET PLACEMENT
SYSTEMS

These include:
1. Torque angulation reference guide (TARG)
2. The slot machine
3. Fillion’s indirect bonding system
4. The customized lingual appliance setup service (CLASS)
system
5. Hiro system
6. The Ray set system
7. The lingual bracket jig
8. The mushroom bracket positioner
72

1]Torque angulation reference guide (TARG)
• Developed by Ormco in 1984.
• It permits bonding of brackets in the laboratory, at an accurate
distance from the occlusal edge of each tooth with respect to a
horizontal reference plane.
• A labial reference gauge is used to orient individual teeth.
• Using only one unique angulation model, the TARG allows pre-
programming of tip and torque before the start of treatment.
73

Torque Angulation
Reference Guide.
74

• Advantages:
- It is an accurate and quantified two-dimensional system.
- Allows accurate placement of the brackets on the cast without
need to cut out the teeth and place in wax.
• Disadvantages:
- The system does not take into account the labio-lingual thickness
of teeth.
- The distance of the bracket base and the labial surface varies
according to the level of bonding.
75

2]The Slot Machine
• Introduced by Dr. T.D.
Creekmore in 1986, the Slot
Machine was meant to be used
with the Conceal bracket system.
• It also used a labial reference to
position the brackets like the
TARG machine.
76

3]Fillion’s Lingual Indirect Bonding System
• This system was developed by Dr. Didier Fillion of France in
1987.
• Also known as ‘Bonding with Equalized Specific Thickness’
(BEST).
• It was designed to consider the labio-lingual thickness of the
individual teeth during bracket placement.
• A caliper is added as the thickness measurement system.
77

• Advantages:
- Relates the labio-lingual thickness of tooth to bracket position.
- Allows working directly on the malocclusion model.
78

4]The Customized Lingual Appliance Setup Service
(CLASS) System
• Described by Scott Huge, this technique involves an integrated
method of lingual bracket placement and indirect bonding.
79

• Method:
- An ideal setup is made from the original malocclusion cast and
brackets are placed on this setup.
- These are later transferred to the original cast by individual
transfer trays.
- An indirect bonding tray is fabricated for bonding.
• Advantage: It takes into account the anatomical discrepancies
in the lingual surfaces of the teeth.
80

5] Hiro System
• Introduced by Hiro and later improved by Takemoto and Scuzzo.
• Method:
- An ideal archwire is made on the setup using a full size rectangular
archwire.
- The lingual brackets are transferred onto this wire and secured
with elastic ligatures.
81

- Single rigid transfer trays are fabricated for each tooth.
- The archwire is then removed and custom bases for brackets are
made.
82

• Advantages:
- There is no need to transfer brackets from the setup model to the
original malocclusion model.
- Accuracy is improved due to individual transfer trays.
- Bonding of one tooth is not affected by position of other teeth.
- Rebonding is easier.
83

6] The Ray Set System
• This system utilizes a 3-dimensional goniometer for analysis of the
first-, second-, and third-order values of each individual tooth.
• Both pre- and post-setup values of individual teeth are evaluated
and the amount of orthodontic tooth movement for each tooth on
the setup model is calculated.
84

7] The Lingual Bracket Jig
• Dr. Silvia Geron in 1999 introduced lingual bracket jig which is a
chairside direct bonding system.
• It is used with a horizontal slot bracket.
• The basic idea (LBJ) – lingual tooth anatomy and inter-tooth
relationships are amenable to a lingual preadjusted edgewise
approach. 85

• The jig transfers the Andrews Straight-Wire Appliance labial
bracket prescription to the lingual surface.
• Thus, the bracket slots line up around the arch, parallel to one
another and to the occlusal plane, while the prescription provides
tip, torque, rotation, and in-out.
86

The LBJ consists of:
• A set of six jigs, one for each of the
six maxillary anterior teeth, which
present the most morphological
variation of the lingual surfaces.
• An accessory universal LBJ for the
maxillary posterior teeth (no torque
or angulation prescribed).
87

A. Labial arm of LBJ positioned
on labial surface of tooth,
duplicating location of labial
bracket relative to LA point.
B. Lingual bracket automatically
placed in correct position.
89

ADVANTAGES:
- LBJ is simple and quick, and requires no special training.
- The LBJ automatically incorporates the Straight-Wire labial
prescription into the bonded lingual brackets in all dimensions.
- This allows the orthodontist to perform direct as well as indirect
bonding as in-office procedures.
90

8] The Mushroom Bracket Positioner
• Developed by Kyung et al in 2002, the mushroom bracket
positioner is a machine for accurate bracket placement on an ideal
setup.
• At present, 5th generation of MBP is available which places
brackets to accept a straight wire.
91

9] Transfer Optimized Positioning System
• Introduced by Wiechmann et al in 2003, this system utilizes
CAD/CAM technology.
• It scans the lingual surfaces of the teeth on the ideal diagnostic
setup via 3D optical scanner. The data obtained from the scan is
used to fabricate fully customized bracket with adapting base pads
and built-in prescription.
92

BONDING TECHNIQUES IN LINGUAL
ORTHODONTICS
94

• Introduced by Dr. Michael Diamond in 1984.
• He devised a Peri/Reflector for simplified direct bonding in the
upper arch.
• Peri/Reflector is a combined mirror, tongue retractor, and saliva
ejector that can simplify bonding procedures in the upper arch. It
isolates the operating area, increases brightness, and enables one
to see the entire area while keeping both hands free.
DIRECT BONDING TECHNIQUE
(JCO1984)
95

Peri/Reflector in patient's mouth. 96

Bracket placement using Peri/Reflector.
97

INDIRECT BONDING TECHNIQUES
• Preferred technique for lingual bracket placement
• Because of the irregular morphology of the lingual tooth surfaces
and the difficulty of access
• Research on lingual indirect bonding started with the work of the
Lingual Task Force.
• They used indirect bonding with Two Component Mix systems like
ENDUR, Concise and No Mix systems like SYSTEM 1, Insta-
Bond.
98

Indirect bonding method:
A. Teeth are cleaned, isolated,
and etched.
B. A thorough rinsing, using an
air-water spray and high-
speed evacuator, is essential.
99

C. Sealant application.
D. The adhesive is injected into
the bracket mesh.
100

E. The tray is seated with firm
pressure and held with light,
steady pressure for 3 minutes.
F. After 10 minutes, the tray is
removed, the brackets inspected,
and any deficient areas filled in
with a thin mix of bonding
adhesive.
101

NEWER MODIFICATIONS OF THE INDIRECT
BONDING TECHNIQUE:
I. Bonding in CLASS system
In this, a silicone or biostar tray is used for the final bracket
placement.
102

II. Hiro’s Method
(Resin Core Indirect Bonding System)
• Described by Hong et al in 1996.
• This technique makes it possible
to add customized torque and in-
out values to the indirect setup.
Customized torque and in-out are built
into resin (*) on each bracket base.
103

• Upper anterior bracket slots
are lined up on surveyor with
flat plate.
• Transfer wires are inserted into
bracket slots and extended to
approximate incisal edges or
buccal cusp tips.
104

• Inlay pattern resin indexes
each transfer wire to tooth
(a = elastomeric ligature; b = transfer
wire; c = inlay pattern resin).
• Complete set of customized
transfer trays
105

III. Individual Indirect Bonding Technique
• In this system, each tooth is bonded individually.
• Customized trays are made for each tooth.
• Advantage: The bracket position on each tooth is not affected by
the position of other teeth. Also, rebonding of a single bracket
becomes easier.
106

IV. Customized Indirect Bonding Method
• Described by Michael Aguirre
in1994.
• This method makes use of an
orientation card for bracket
placement.
Orientation Card
107

V. Convertible Resin Core System (CRCS)
• Developed by Hong et al in 2000.
• They incorporated stainless steel wires into the transfer trays.
108

VI. New Customized Indirect Bonding Method
• Introduced by Kim et al in 2000.
• They incorporated elastomeric ligatures into the transfer trays
during the indirect bonding procedure.
109

Rebonding can be done in 2 ways:
1. By using the initial trays again. Individual tooth regions can
be sectioned and positioned.
2. By redoing an individual bonding tray using the same
protocol.
110

Anchorage Considerations
• Takemoto (1995-1998)
- higher anchorage value of posterior dentition in lingual
- proximity of lingual brackets to COR
- Cortical anchorage of molars
112

• Geron (2003)
- Anchorage loss is multifactorial
- No difference in first or second premolar extraction cases for
lingual
- Retraction of six teeth – enmasse
- Six anchorage keys
113

“Six anchorage keys” by Silvia Geron (2003)
1. Slight extra palatal root torque for anterior
2. Bidimensional technique
3. Posterior bite stops placed on the molar teeth
4. Light Class I, II, or III forces for retraction
5. Incorporation of the second molars
6. Exaggerated curve of Spee in the maxillary space-closing
archwire
114

Comparison of labial and lingual appliance
116

• Reduced interbracket distance in the incisor area in LO
(around 40% of BO) also influences the MOF, and therefore it
is more difficult to rotate, upright, or to level the anterior teeth
117

• Some malocclusions are easier to treat
119
Sequence of action and reaction to
close an open bite with LO

• A general guide,
a) for maxillary microimplants – at least 6 mm
of the screw portion should be placed into
the bone
b) Mandibular microimplants – at least 5 mm
of the screw shank should be placed in
bone
120
Microimplants In Lingual Orthodontics

121
Various locations for implant placement

General guide and recommendations:
• Palatal mucosal thickness of 6 mm, use a 12-mm screw.
• Midpalatal thinner mucosa, use a 6- to 7-mm screw.
• Buccal alveolar region, attached gingivae, use 7- to 8-mm screw.
• Adult patients with thick dense cortical bone, use a 7-mm screw.
• Young patients, less dense cortical bone, use an 8-mm screw.
• Labial aspect of maxillary incisors, good quality bone and not subjected
to occlusal forces, use a 6-mm screw.
122

1. First initial archwires: .016” Ni-Ti (Rarely an 0.015” or .0175”
Respond)
2. Second initial archwire: .016” Special-Plus Wilcock
(Australian) heat-treated stainless steel
3. Intermediate wires: .017” x .025” TMA
4. Finishing wires: .017” x .025” or .016” x .022 SS 5) Detailing
wires: Wilcocks (Australian) .016” or .018” Special- Plus
123
Wire Sequencing In Lingual Orthodontics

Treatment Sequence
• Four primary phases of edgewise lingual mechanics:
1. Leveling, aligning, rotational control, and bite opening.
2. Torque control.
3. Consolidation and retraction.
4. Detailing and finishing.
124

Stage I. Leveling, Aligning, Rotational Control, and Bite Opening.
• The objectives of this initial phase of therapy are to:
1. Initiate tooth movement with light forces,
2. Provide for a period of patient adaptation,
3. Eliminate rotations,
4. Level and align individual arches to permit wire progression,
125

5. Obtain initial torque control when required,
6. Establish posterior anchorage units with buccal segments,
7. Initiate posterior segment control with extraoral traction and
transpalatal arch when required,
8. Reduce any excessive overbite, and
9. Gain space for rotations and additional bracket bonding.
126

Elastic ligature and archwire force
vectors, labial versus lingual.
Conventional ligation of lingual
brackets does not exert a force
along the high torque angled
bracket slot .
127

• A ligation method termed the double-over tie has been effective
with both metal and elastic ligatures in directing the ligating
force more directly along the bracket-slot angle.
128

Stage II. Torque Control
• Torque control is initiated early in treatment using .016" × .022"
or .017" × .025“ TMA and maintained throughout treatment.
• Typically – .016" × .022" stainless steel for moderate torque
and .017" × .025" TMA for full torque.
129

Stage III. Retraction/Consolidation Mechanics
• This is achieved using either sliding mechanics, closing
loop arches, or combinations.
• The lingual archwires used for retraction are .016" round
stainless steel, .0175" × .0175" TMA and .016" × .016"
stainless steel.
130

Stage IV. Detailing / Finishing.
Difficulties encountered in finishing are derived from
• Patient characteristics
- Restorative & Periodontal complications
- Thickness of tooth varies
- Compensating bends are less accurate & less effective
137

• Anatomy of lingual surfaces
• Mechanics of Lingual orthodontics –
- The point of application of force is at some distance from the labial
surface which actually defines the final alignment
- difficulty to give finishing bends due to shrt archwire
- Uprighting ,torque and rotation movements are difficult to achieve
138

Retention Following Lingual Therapy
1. Removable "invisible" retainer 140

2. Cemented chrome cobalt
retainer.
3. Fixed lingual retainer.
141

KEYS TO SUCCESS IN LINGUAL THERAPY
142

Key 1
• Patient Selection.
• Oral Hygiene and Gingival Irritation
• Speech Adaptation and Tongue Irritation
• Variations in Tooth Size and Anatomy.
• Bite Opening and Mandibular Rotation.
• Headgear and Elastics
143

Key 2
• Bracket Placement Accuracy – use of the TARG for accurate
bracket placement.
Key 3
• Indirect bonding methods for bracket adhesion.
Key 4
• Maintaining vertical and transverse control of buccal segments
144

Key 5
• Double over ties on anterior teeth.
Key 6
• Buccal and lingual molar attachments.
Key 7
• Correction of rotations.
Key 8
• Arch form and archwire sequence. 145

Key 9
• Archwire stiffness and torque control.
Key 10
• En masse retraction.
Key 11
• Light, resilient wire for detailing.
Key 12
• Gnathologic positioner and retention.
146

• The following tendencies with respect to discomfort are observed:
• Tongue soreness, difficulty in chewing fibrous food.
• Difficulty in pronouncing the ‘s’ and ‘t’ sounds.
• Difficulty in tooth brushing.
148

• Didier Fillion (JCO, 1997) - methods of relieving these irritation
factors during lingual therapy
I. The most irritating brackets can be covered with a light-cured
periodontal protective paste (Barricacid)
149

II. A silicone paste (Ortho Pack)
Ortho pack placed over irritating
brackets by patient.
150

III. Patients with strong tongue-thrust habits and large tongues have
more trouble adapting to lingual appliances. In such cases, a soft
splint made from a 1.5mm-thick silicone material may be
prescribed.
151

IV. Plastic tubing placed over
archwire 152
V. 1st-order bends between cuspids and
bicuspids are less irritating if placed closer
to bicuspids.

CONCLUSION
• History of lingual orthodontics – not a smooth one
• Case selection is of utmost importance
• Variety of techniques available for bracket placement
and bonding
• Importance of lingual mechanics
• Scope for improvising and innovations
153

“It is not the appliance that determines the standard of final result, it
is the clinician who handles the appliance that determines the final
result”.
Eliakim Mizrahi
154
CONCLUSION

REFERENCES
• Ecchari P. Revisiting the History of Lingual Orthodontics: A Basis for the
Future. Seminars in Orthodontics 2006;12(3):153-159
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Orthop 1989; 95: 514-520.
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report. J Clin Orthod. 1982; 16(4): 255-262.
• Kurz C, Swartz ML, Andreiko C. Lingual Orthodontics: A Status Report Part 2
Research and Development. J Clin Orthod. 1982; 16(11): 735-740.
155

• Alexander CM, Alexander RG, Gorman JC et al. Lingual orthodontics: A status
report Part 5 – Lingual Mechanotherapy. J Clin Orthod 1983; 17(2): 99-115.
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an update. J Intl Coll Dentists. 2003.
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• J. Clin Orthod 1982 Aug534 – 544.
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wire appliance. Am J Orthod. 1979; 76(6); 657.
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clinical report. Am J Orthod Dentofac Orthop. 1982; 82(2): 120-140.
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136-142.
156

• Yen PKJ. A lingual Begg light wire technique. J Clin Orthod. 1986; 20(11):
786-791.
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Clin Orthod. 2001; 35(1): 46-52.
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Orthod 1996; 30(11): 650-652.
• Hong RK. A new Customized Lingual indirect bonding system. J Clin Orthod.
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2000; 33(6):348-350.
157

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