Evolution of lingual orthodontics

EVOLUTION OF
LINGUAL
ORTHODONTICS
www.indiandentalacademy.com

CONTENTS
 Introduction
 History
 Characteristics of the bracket
 Advantages of Lingual Appliances Over Labial
Appliances
 Difficulties with lingual appliances
 Patient selection and Diagnostic considerations
 Keys to success of lingual orthodontic treatment
 Wire Sequencing in Lingual Orthodontics
 Biomechanics and comparative biomechanics
 Anchorage considerations in Lingual Orthodontics
 Treatment Sequence
 Finishing and Detailing
 Retention in Lingual orthodontics
 Lingual Laboratory procedures for Bracket
positioning
 Future of Lingual orthodontics
 Summary
 References

INTRODUCTION
 Nothing stays the same in life ,given time everything changes,so
it is with orthodontics
 The popularity of adult orthodontics has dramatically increased
over the last decade .The reason for this increased acceptance is
most likely due to changes in social values regarding appearance,
and increased acceptance of braces particularly with the advent
of cosmetic alternatives.
 The cosmetic braces options currently available include clear or
tooth colored braces and wires , and the so called ‘Invisible
braces or Lingual braces’.
 In the early days of its evolution,the lingual technique went
through some difficult times,however since then it has evolved
into a sophisticated technique capable of treating most
malocclusions.

YEAR DEVELOPMENT
1726 Pierre Fauchard suggested using
appliance on the lingual surface
1841 Pierre Lefoulon desined the first
lingual arch for expansion
1889 John Farrar published Lingual
Removable arch
1918 Dr John Mershon published a paper
on Removable lingual arch
1942 Dr Oren Oliver gave a clinic on a
Labio lingual technique.
1970 Dr Craven Kurz developed the first
Lingual appliance
1976 Ormco deveoped Non Edgewise
lingual appliance
1979 Dr Kinya Fujita developed Lingual
bracket design and Mushroom
shaped arch wire
HISTORY

HISTORY OF DEVELOPMENT OF
DIFFERENT LINGUAL SOCIETIES
YEAR SOCIETY
1980 Lingual Task Force was
established
1981 Ormco held first lingual appliance
seminar
1985 Japanese lingual orthodontic
association formed ,its currently
the largest orthodontic society
1987 American lingual orthodontic
association developed
1992 European society of lingual
orthodontics developed
1996 Lingual study group developed by
Carven Kurz,William Laughlin,
Thomas Creekmore,Jim
Wildman .Didier Fillion

HISTORY OF EVOLUTION OF
LINGUAL BRACKETS
GENERATION #1—1976
The first Kurz Lingual Appliance was manufactured by Ormco. This
appliance had a flat maxillary occlusal bite plane from canine to canine.
The lower incisor and premolar brackets were low profile and half-
round and there were no hooks on any brackets.

Generation #2—1980
Hooks were added to all canine brackets
Generation #3—1981
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

Generation #4—1982–84
This generation saw the addition of a low profile anterior inclined
plane on the central and lateral incisor brackets. Hooks were
optional, based upon individual treat-ment needs and hygiene
concerns

Generation #5—1985–86
The anterior inclined plane became more pronounced, with an increase in labial
torque in the maxillary anterior region. The canine also had an inclined plane;
however, it was 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

GENERATION #6—1987–90
The inclined plane on the maxillary anteriors become more square in
shape Hooks on the anteriors and premolars were elongated. Hooks
were now available for all the brackets. The transpalatal bar
attachment for the first molar band was optional. A hinge cap,
allowing ease of archwire manipulation, was now available for molar
brackets.

GENERATION #7—1990 TO PRESENT
The maxillary anterior inclined plane is now heart-shaped with short hooks.
The lower anterior brackets have a larger inclined plane with short hooks. All
hooks have a greater recess/access for ligation. The premolar brackets were
widened mesiodistally and the hooks were shortened. The increased width of
the premolar bracket allows better angulation and rotation control. The molar
brackets now come with either a hinge cap or a terminal sheath.

 Giuseppe Scuzzo together with Kyoto
Takemoto from Japan developed a prototype of
a lingual straight wire bracket and technique
the STb (Scuzzo/Takemoto bracket,Ormco)
STb

 Massimo Roncnin from Italy in 1994 developed a
self ligating lingual bracket based on Begg
technique,(Frostadent).
 Dirk Wiechmann from Germany developed the
Incognita brackets.
 Hatto Loidl from Germany developed a self
ligating lingual bracket ,Evolution LT (Adenta)

CHARACTERISTICS OF THE
BRACKET
 Bite plane
 Base pad
 Preangulated slot

ADVANTAGES OF LINGUAL
APPLIANCES OVER LABIAL
APPLIANCES
 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.
 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.

 Four distinct situations exist where lingual
appliances may be more effective than labial
appliances-
 Intrusion of anterior teeth
 Maxillary arch expansion
 Combining mandibular repositioning therapy with
orthodontic movements.
 Distalization of maxillary molars

INTRUSION OF ANTERIOR TEETH
 Lingual brackets are positioned closer to the
Center of resistance (Cr) than is found with
labial brackets.
 As a result the intrusive force vector passes
through the Cr ,as the dentition occludes due to
the bite plane effect there is a light continuous
,intrusive force on the anteriors and extrusion
occurs in the posterior segment.

Maxillary arch expansion
 Dentoalveolar expansion with lingual technique
is more as compared to labial technique.Some
possible reasons for this are-
 The force which is developed is of centrifugal type
,from inside towards the outside of the arch.
 Thickness of the brackets which interpose themselves
between the tonge and lingual wall of the teeth can
result in expansive effect.
 Shorter interbracket distance may play a significant
role.

Combining mandibular repositioning
therapy with orthodontic movements.
 When treating patients with Temporomandibular
disorders(TMDs),treatment is carried out in two
phases.
 First correction of TMD,second correction of
occlusion
 Orthodontic phase of treatment is tedious and
time consuming as labial appliances are placed
on one arch ad positioning splint on the opposite.
 While using lingual appliance both the arches
can be treated simultaneously while maintaining
the effect of the splints due to presence of bite
planes and posterior build ups.

Distalization of maxillary molars
 Lingual brackets are placed closer to the Cr of
tooth than labial brackets.
 Hence molar distalization in lingual technique
produces bodily tooth movement and less distal
tipping.

DRAWBACKS OF LINGUAL
ORTHODONTIC TECHNIQUE
 Discomfort to the tongue.
 Difficulty in speech which usually improves
within 2-3 wks of therapy.
 Extended chair side time needed for appliance
placement and adjustment.
 Difficulty of insertion and removal of arch wires
 Technique sensitive
 Increased armamentarium required.
 Expensive.

DIFFICULTIES ENCOUNTERED
DURING THE LINGUAL
ORTHODONTIC THERAPY
1. Tissue Irritation and Speech Difficulties
 The earlier brackets placed on the lingual surface of the
teeth were irritating to the tongue and impeded normal
speech.
 The current generation of brackets has been 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.
 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. Additionally, the
bracket hooks have been redesigned with a lower profile and
are located several millimeters from the gingival margin

3.Occlusal Interference
 The bracket was redesigned
with an inclined or bite plane
strategically placed to redirect
the vertical shearing forces to
a horizontal seating force.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.
The incline plane. The red arrows
represent the primary force applied,
and the broken black lines
represent the secondary/resultant
forces exerted

4. Appliance control & Base Pad Adaptation
 As with all appliances, accurate contour of base pads improves
not only retentive capabilities but also the accuracy of bracket
placement and therefore the quality of treatment Topographic
maps were constructed for each tooth and individual bracket
base curvatures were calculated.
5. Appliance Placement and Bonding
 The original appliances were direct bonded. With the
variability of lingual tooth con-tours, accurate bracket
placement was difficult. This approach produced unpredictable
tooth alignment with tremendous variations in tip, torque,
and tooth height. Initially, the Torque Angulation Referencing
Guide (TARG) system was used. A more sophisticated sys-tem,
using a diagnostic set-up constructed from articulated models
was developed and has met with considerable success. This
method, the Custom Lingual Appliance Set-Up Service
(CLASS), involves indirect bonding set-up on a diagnostic or
ideal model of the teeth.

6. 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.
7. 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 1–19). 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.
8. 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

PATIENT SELECTION AND
DIAGNOSTIC CONSIDERATIONS
Patient Selection
Favourable Cases
 Mild incisor crowding and anterior deep bite
 Long uniform lingual tooth surfaces without fillings ,crowns or
bridges
 Good gingival and periodontal health
 Compliant patient
 Skeletal Class I pattern
 Mesocephalic /mild Brachycephalic skeletal pattern
 Patients who are able to adequately open their mouth and extend
their neck.
Unfavourable cases
 Dolichocephalic skeletal pattern
 Maximum anchorage cases unless treated with micro implants
 Short abraed and irregular lingual tooth surfaces,multiple
crowns /restorations
 Limited mouth opening
 Low level of compliance

DIAGNOSIS
Diagnosis and treatment planning is an important issue
for all orthodontic treatment techniques.
It essentially involves establishing an ideal goal and then
determining a method of achieving the goal.
Diagnostic considerations for lingual orthodontics are
under following headings-:
 General, with preference to esthetics and periodontal
and gingival condition
 Dental ,with reference to presence of crowns and large
restorations
 Dentoalveolar discrepancy
 Vertical skeletal/dental problems
 Anteroposterior skeletal/dental problems
 Transverse skeletal/dental problems
 Surgical cases
 Preprosthetic cases

GENERAL CONSIDERATIONS
Esthetic Factors
Requirements for achieveing a beautifull smile are as follows-:
 Beautiful individual teeth
 Beautifully aligned and leveled teeth
 Sufficient dental arch width
 Sufficient lip support
 Beautiful teeth and gingival exposure in rest position
,conversation and smiling.
Periodontal and gingival considerations
 The patient should have a healthy periodontium and should
be able to maintain oral hygiene.
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

DENTAL CONSIDERATIONS
 Patients with high risk for caries or with colour alterations
of teeth or with decacifications can be treated with lingual
orthodontics.since the risk for all this is transferred to the
lingual side and labial surface is kept intact.
 Most suitable teeth for lingual orthodontics are those with
long and smooth lingual surfaces.In general the lingual
surface should be more than 7mm, but now a days STb
brackets are reasonably small and can be used on short
teeths.
 Lingual surfaces of incisors < 7mm & bicuspids with short
lingual surfaces should be reconstructed
 In exceptional cases molars with very short lingual surface
may be bonded on buccal aspect {Takemoto technique}
 The presence of crowns ,bridges and large restorations
impact negatively on achieving good adhesion of brackets.

DENTOALVEOLAR
DISCREPANCY
 Methods used in labial orthodontics for correction
of dentoalveolar discrepancies can also be used in
lingual therapy.
 Protrusion,expansion,stripping,distalization or
extractions are all modalities of treatment that
can be applied to both labial as well as lingual
techniques.

VERTICAL CONSIDERATIONS
 The built-in bite planes on the
upper incisor and cuspid will
interfere with occlusion and result
in a posterior open bite the extent
of which depends on the intial
overbite.
 The lingual brackets on the
maxillary incisors should be
bonded to allow a vertical distance
of 2mm from the incisal edge to
the bracket, which allows the case
to finish with a normal overbite
and good posterior occlusion.

Management of the posterior open bite created after
bracket placement is dependent on the degree of
disocclusion.
 Open-bite – 2 mm – occlusion re-establishes in 20-30 days
 If only one lower incisor contacts upper bite plane and/or
Posterior open-bite > 3 mm –then it can lead to periodontal
trauma- So advisable to build bite blocks on the lower molars
(Tripodisation)
With a combination of molar extrusion and a incisor intrusion
there will be an increase in anterior facial height which is
desirable in brachycephalic morphology, but care has to be
taken in patients with increased anterior facial height to
control vertical molar anchorage by considering occlusal build
up,TPAs and minimum use of Class II &III elastics.

ANTEROPOSTERIOR
CONSIDERATIONS
Skeletal Class I
 Easiest group to treat, but it should be remembered that
due to bite opening effect of bite plane mandibular
posterior rotation can occur which in turn increases the
overjet and leads to lingual tipping of incisors.
 Anterior open bite on a Class I skeletal base does not
present any problem regarding the initial bonding,
irrespective of the overjet.
 Deep overbite on a Class I skeletal base presents three
options depending on overjet.
 Normal overjet- If posterior disocclusion does not exceed 3mm
and there is anterior contact between two or more lower
incisors, with same number of maxillary incisors then bite
blocks not necessary.
-If posterior disocclusion exceeds 3mm or there is only one
incisor contact then ,tripodisation is required by build up on
occlusal surface of lower molars. The height of build up is
reduced regularly as more anterior incisor contact develops.

 Increased overjet-In such
cases there is no anterior contact
,but as the maxillary incisors are
retracted and overjet reduced the
maxillary brackets can become
interposed between upper and
lower teethand contribute to
debonding, it can also lead to
TMJ problems .
- In such cases build up is
indicated on occlusal surface of
left and right lower molars and
first bicuspids, Occlusion is
stabilized with four duly
balanced contacts.
 Decreased overjet-In case of
anterior crossbite and deepbite it
is indicated to build up four point
occlusal contact.

Skeletal Class II and Class III –
 Mild cases treated successfully by
camouflage
 Severe cases – orthognathic surgery

TRANSVERSE
CONSIDERATIONS
 Posterior cross bites should be treated before
starting Lingual treatment
 In case rapid maxillary expansion is
undertaken ,then impression for bracket
positioning should not be taken till expansion is
completed.

PREPROSTHETIC CASES
 Preprosthetic segmental Lingual orthodontic
mechanics are rapid, economical and
comfortable.
 Lingual orthodontic techniques can be
successfully combined with micro implants in
preprosthetic cases.

KEYS TO SUCCESS OF LINGUAL
ORTHODONTIC TREATMENT
 Case selection
 Set up
 Indirect Bonding
 Rotation correction
 Ligatures
 Force system
 Retention

CASE SELECTION
 Lingual orthodontic treatment is different from
that of labial orthodontics because of a larger
amount of anchorage available in lingual
orthodontics.
 Vectors of orthodontic forces applied to lingual
brackets pass lingually to the centers of rotation of
the teeth, which increases lingual crown torque on
the anterior teeth and forces the posterior teeth
into an upright position.

 A case requiring extraction in labial orthodontics may be
treatable by non-extrac-tion in lingual orthodontics. A case
indicated for surgery in the labial approach may be treated
non-surgically in the lingual approach
 Ideal Lingual cases
Non extraction cases
 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 div 2 with retruded mandible
 Cases requiring expansion
 Consolidation (diastema) cases
Extraction cases
 Class II,maxillary first bicuspid and mandibular
second bicuspid extractions
 Maxillary first bicuspid only extractions
 Mild double protrusions with four first bicuspid extractions,where in
anchorage is not critical.
More difficult cases
 Surgical cases
 Class III tendencies
 Class II, four first bicuspid extractions
 Moderate mandibular plane angles
 Cases with multiple restorative work

CASES CONTRAINDICATED
FOR
LINGUAL THERAPY
 Acute TMJ dysfunction.
 Mutilated posterior occlusion.
 High angle or dolicofacial patterns.
 Extensive anterior prosthesis.
 Short clinical crowns.
 Critical anchorage cases.
 Severe class II discrepancies.
 Poor oral hygiene or Unresolved
periodontal involvement.

SET-UP
 Set-up models are essential for lingual
orthodontic treatment: they provide a means of
identifying plans and goals of treatment, and
determine bracket positions. Bracket positions
hold the key to success of the treatment . For
example a slight change in bracket position or
height will result in a large variation in the
torque.
 These problems can be overcome by use of set up
models to determine the bracket position and the
amount of torque or movement required.

INDIRECT BONDING
 The lingual surface of teeth has a unique
morphology that makes it difficult to place
brackets in the ideal position.
 Indirect bonding has become the established
method of overcoming these discrepancies.

ARCH
FORM
 Cuspid to bicuspid offset-a 2 to
4 mm 90 degree bend is placed
between cuspid and bicuspid.
 Molar offset- a lingual offset of
about 1mm is often indicated
between the bicuspids and
molars.
 In some cases ,the maxillary
lateral incisors may require a
labial offset(0.5-1mm)to
compensate for a significant
change in facio-lingo thickness
from the centrals to the laterals.

ROTATION CORRECTION
 The span between two brackets placed on
lingual tooth surfaces is very short because of
the lingual anatomies of the teeth. The
following methods are available for efficient
rotation correction-
 Smith's rotation tie
 A power chain is passed between the wire
and the gingiva. One end of the power chain
is threaded through the first link at the other
end to secure it to the wire. The power chain
is brought to the labial side, passed through
the opposite proximal surface and placed on
the hook at the bottom of the brack-et.
 The power chain should be tied to the wire on
the distal side and placed on the hook from
the mesial side for a mesially rotated tooth,
and in the opposite direction for a distally
rotated tooth.
 but it has several disadvan-tages: the power
chain shows on the labial side, may slip
incisaily on the canine due to its morphol-
ogy, and may risk devitalizing the tooth if
pulled too tight

Bend loops
 The wire length between
brackets can be
increased with loops
bent into the archwire to
make up for a short
inter-bracket span.
Bracket spans are
particularly short
between the lower
anterior teeth.
Use of a power arm
 A short bracket span
shortens the horizontal
moment of orthodontic
force. The use of a power
arm lengthens this
moment arm to correct
rotations. This is a very
effective method in the
lingual approach.

LIGATURE
S
 Once accurate set-up models are made and brackets are
correctly positioned, it is essential to tie an archwire securely to
the brackets in order to transmit forces efficiently.
 Double-over ties should be used on the six anterior teeth to
engage the wire to the bottom of each bracket slot, and the wire
firmly tied. Loose ties would decrease the efficiency of force
transmission from the wire to the teeth, slowing down the
leveling process.

FORCE SYSTEM
 The mechanics of tooth movement from the lingual
side has different characteristics from the labial
mechanics.
 The appliance is located on the lingual side, vectors
of forces to the teeth are directed lingually to the
center of rotation of each tooth, which puts labial
root torque on anterior teeth. Consequently, anterior
teeth tip lingually, in reaction to which posterior
teeth become upright distally. In the horizontal
plane, forces are applied that rotate posterior teeth
distally. Cortical bone anchorage is established when
roots approach the cortical bone. This cortical bone
anchorage is increased in lingual orthodontics,
particularly in the lower arch which has thicker
cortical bone than the upper arch.

 During anterior retraction and
space closure, the phenomena
called "vertical bowing effect"
and "transverse bowing effect"
occur, causing archwires to
deform three-dimensionally,
which in turn causes anterior
teeth to tip lingually, posterior
teeth to tip mesially and the
posterior bite to open. In the
horizontal plane, the inter
premolar width is expanded
(flared out).
 A good understanding of the
mechanics of tooth movement
and attention to the following
holds the key to successful
treatment.

Establish torque before retraction of anterior
teeth
 Establish adequate torque (lingual root torque) to
counteract the bowing effect during retraction. An
area with different torque becomes an anchor and
may interfere with smooth retraction. The wire used
are .0175x.0175 or .017x.025 TMA
Do not use round wire for anterior retraction
 Retraction with a round wire causes only the crowns
of anterior teeth to tip lingually producing the vertical
bowing effect. To counteract this effect, anlerior teeth
should be retracted with a rectangular wire of
sufficient rigidity (.017 x .025 TMA)

Use light wires for detailing
 A rigid rectangular wire with precise bends to correct
individual tooth positions is difficult to engage into bracket
slots and ligate securely due to short inter-bracket spans.
Such wires also apply exces-sive forces and incorrect torque
to the teeth. Light wires should therefore be used to allow
physiolog-ical tooth movement during detailing.
Utilize en masse retraction
 This method of retraction is esthetically more acceptable
since a space does not open between the lateral and canine.
In addition, when space is available distal to the canine,
the insets placed into the archwire between the canine and
premolar, which are required in lingual orthodontics, do
not get in the way during retraction.
 The retraction force should be minimized during en masse
retraction, and more intrusion and torquing force is needed
to retract the anteriors in lingual orthodontics than in a
labial system.

RETENTION
Since most lingual orthodontic patients are adults.
Retention in adult patients has the following
characteristics:
 Adult patients are likely to be esthetically more
demanding and do not like visible retainers.
 Many adult patients have dental problems such as
gingival recession, occlusal wear, poor restorations and
missing teeth, requiring dental procedures during
retention.
 Adult patients have limited time to wear retainers
owing to social restrictions.
Ideally the use of retainers should be started on the day
braces are removed. It is important fully o explain
the importance of retainers, proper handling and
regular check-ups to patients.

WIRE SEQUENCING IN LINGUAL
ORTHODONTICS
 Successful lingual orthodontic treatment, more than any other
orthodontic treatment modalities, requires the rigid adherence to a
series of protocols among all the protocols, the most important one is
defensive archwire sequencing.
 The archwire sequencing program uses very few wires, each selected
to perform specific tasks during treatment. The following protocols
maximize the potential of each wire and reduce archwire changes to
a minimum, at the same time effecting high quality results.
1) First initial archwires: .016 Ni-Ti (Rarely an 0.0155 or .0175
Respond)
2) Second initial archwire: .016 Special-Plus Wilcocks
(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
 This sequence is followed for all cases: Class I, II, or III
malocclusions, and extraction or nonextraction cases

INITIAL ARCHWIRES
 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.

INTERMEDIATE WIRES
 Intermediate wires like .017 ´ .025 TMA may occasionally be
used as finishing wires, 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.
 The buccolingual compensatory curve is reduced in the
intermediate wire since it is relatively stiffer than the initial
wire.
 Elastic forces may be applied at this stage of treatment to initiate
A-P control.TMA wires are not suitable for prolonged or heavy
elastic forces, either intra- or interarch. 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.
 With rectangular archwires, steel ligation is essential to ensure
full bracket slot engagement and full expression of appliance
prescription.

FINISHING AND DETAILING
WIRES
 Stainless steel archwires are used to complete arch
recontouring and space closure, and to eliminate any side
effects noticed earlier in the procedure.
 Providing original treat-ment prescription and
compensatory archwire modifications are adequate.
 Treatment should be be completed with .017 ´x.025
upper arch and .016 ´x .022 lower stainless steel
archwires, except in Class III cases where the upper and
lower archwires are reversed.
 The archform of stainless steel wires is the same as the
intermediate archwire, with subtleadjustments to the
canine or molar offsets, if required, and compensatory
bends to facilitate completion of space and interarch
adjustment.
 More flexible wires are required for final detailing, or for
individual tooth overcompensation. These archwires could
be Wilcocks (Australian) .016 or .018 Special-Plus.

 The success of defensive archwire sequencing depends
on the following:
 Correct treatment planning and well-planned goals.
 Allowing sufficient time for each archwire to do its work
completely.
 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

BIOMECHANICS AND
COMPARATIVE BIOMECHANICS
 Lingual multibracket appliances, besides solving esthetic
needs, have biomechanical advantages so far as the point
of application of the force in relation to the Center of
resistance (Cr) of the teeth.
 A single rooted tooth has its center of resistance located
almost in the middle of the root, at approximately 40% the
distance from the alveolar crest to the apex.
 Unlike the labial technique, the lingual bracket rests on
the upper incisors in the vertical position, which is more in
line with the Cr, thus allowing easier movement whenever
an occlusal force is applied. Moreover, the lingual bracket
has a posi-tion closer to the long axis which passes through
the center of resistance than does the labial one.
 Unwanted or inefficient tooth movement during
orthodontic therapy results from individual variation in
biological response and the improper use of forces.

SAGITTAL
PLANE
 The location of the Cr of a tooth is not related to the
technique ,the relation between the Cr location and
bracket placement directly influences the magnitude and
the direction of moments created by the applied forces
 The distance in sagittal plane between a lingual bracket
and the Cr (D2) is much shorter than between a buccal
bracket and the Cr (D1).Hence pure intrusion movement
in Lingual orthodontics will be closer to bodily movement
than in buccal orthodontics
Lingual appliance
D2

VERTICAL PLANE
 The distance in vertical plane between alingual
bracket and the Cr (D4) is greater than between
a buccal bracket and the Cr (D3).Therefore the
retraction movement in lingual orthodontics will
result in a greater moment of force than in buccal
orthodontics for the same applied load.
D3D4
Labial appliance

 In normally inclined incisors, a vertical force of 40 g
applied on the labial side, at 7 mm from the CR (in
the horizontal plane), produces a counter-clockwise
moment of 280 g mm (7 mm ,x 40 g = 280g mm}.
 The same amount of vertical force applied on the
lingual side, at 1 mm from the CR (in the hori-zontal
plane), produces a counter-clockwise moment of 40 g
mm (1 mm x 40g = 40g mm)

 Clinical orthodontic movements are not pure vertical or sagittal in
direction.The orthodontic movement is a cognizant of the resultant
force generated by the vertical and sagittal forces.
 In buccal orthodontics the net force is generally ahead of the
Cr,while in lingual orthodontics it is behind the Cr.
 Hence tendency for retroclination of anterior teeth is more
pronounced in lingual orthodontics,in certain cases it is necessary to
counteract this tendency by creating a negative buccal force by
incorporating a labial crown torque (palatal root torque)

 In the lower arch the lingual bracket slot is closer to the axis
passing through the Cr, in normally inclined lower incisors, as
compared to one on the labial side. For this reason, during the
leveling phase of treatment, the lingual application of the force
allows easier intrusion coupled with less labial inclination of the
crown, when compared with the labial application of the force.
 The lingual technique will cause more distal inclination of the
lower molar crowns and more lingual tipping of the lower
incisors .

HORIZONTAL PLANE
 The teeth are positioned along geometrically elliptical
arches in the occlusal plane (parallel to the horizontal
plane).
 In the occlusal plane the interbracket distance in lingual
orthodontics is shorter than in labial. For this reason the
archwire stiffness increases and the rotational moment is
less on lingual than on the labial side.
 It is more difficult to have an efficient coupling of forces on
the lingual side during rotational movement.
 In cases of crowding it is more difficult to engage the
archwire in the lingual brackets than in the labial, so we
need to use more resilient wire

ANCHORAGE CONSIDERATIONS
IN LINGUAL ORTHODONTICS
 Anchorage provision and control is key requirement for
successful treatment of most malocclusions.
 Lingual technique a specific problems relating to the
provision of adequate anchorage due to a number of
factors like
 Most patients seeking lingual orthodontics are non growing
adults
 Many have mutilated malocclusion
 Compromised periodontal condition
 These patients have a high esthetic demands precluding the
use of many anchorage devices like extraoral appliances,
pendulum,lip bumper or intermaxillary elastics.
 Bite plane effect causes loss of occlusion and intercuspation
which causes loss of anchorage.

 Generally, lingual appliances provide good
anchorage control, because of the smaller arch
perimeter which in turn increases the rigidity of
lingual archwires during retraction.
 Takemoto compared anchorage loss in labial versus
lingual extraction cases treated with loop mechanics
and found higher anchorage value of posterior
dentition in lingual cases.
 Due to proximity of lingual brackets to centre of
resistance of tooth.
 Also the direction of force during space closure
creates a degree of buccal root torque and
distopalatal rotation of the molar crown ,which in
turn produes cortical bone anchorage.

SIX KEYS FOR ANCHORAGE
CONTROL IN LINGUAL
MECHANICS
1. Standard lingual bracket jig prescription for anterior
teeth ,incorporating slight extra palatal root torque,
molar tubes placed off center in a more mesial position
incorporating a mesial tip to encourage molar tip
back(uprighting).
2. Reduced friction, using sliding mechanics together with
bidimensional archwires incorporating a rectangular
anterior section & round posterior section or using a
standard archwire and placing brackets with larger slot
size for posterior teeth.
3. Bite blocks on molar teeth to open the bite
4. Light Class I, II, III forces for retraction or space
closure
5. Incorporation of second molars
6. Exaggerated curve of spee in maxillary space closing
arch wire

MECHANICS USED TO CONTROL
ANCHORAGE IN THE UPPER
ARCH
 Mechanical advantages gained from
lingual treatment are buccal root
torque and distal rotation of the
molars, especially due to the easily
established cortical bone anchorage.
 Also, an intrusive force is applied to
the functional or lingual cusps of the
upper molars because the appliance
is placed near these cusps. Therefore,
the COCR discrepancy caused by the
primary initial contact and the
mandibular clockwise rotation
caused by the elongation of molars
due to bite planes are reduced.
 Combinations of loops, elastics,
transpalatal arches, and headgear
have been used to successfully
control both the horizontal and
vertical anchorage in both the upper
and lower arches.
Applied intrusion force to the upper molars
resulting in cortical bone anchorage.
Distal rotation can be easily
established with the posterior teeth by
retraction forces.

 MAXIMUM ANCHORAGE (UPPER ARCH)
Helical loop and Tloop mechanics (.017 ´ .025 TMA)
are combined with a transpalatal arch and a buccal
sectional arch from first to second upper molars for
stabilization. Also, highpull headgear and Class II
elastics are used.
Anchorage preparation for a maximum
anchorage case with helical loop
mechanics in the upper arch, using a .
017 .025 TMA with a transpalatal arch
and buccal sectional arch from 6-7.
High-pull headgear and Class II elastics
are also used
Anchorage preparation for a
maximum anchorage case with T-
loop mechanics in the upper
arch.

MODERATE ANCHORAGE (UPPER
ARCH)
Anchorage preparation for a moderate
anchorage case with L-loop mechanics in
the upper arch. A transpalatal arch is
added to prevent a transverse bowing
effect. The anterior segment (3-3) and the
posterior segment (5-7) is “figure-eighted”
with ligature wire.
Anchorage preparation for a moderate
anchorage case with sliding mechanics in
the upper arch. To eliminate the
transverse bowing effect a power chain is
used from the lingual of the canine to the
buccal of the first molar, to rotate the first
molars mesially.

MINIMUM ANCHORAGE (UPPER
ARCH)
 Extraction spaces are closed
by a reciprocal elastic force,
with a power chain placed on
both the buccal and lingual of
the canine and first molar The
anterior segment (usually 4 |
4) is “figureeighted” with
ligature wire. Frequently,
cases requiring minimum
anchorage control are those in
which second premolars have
been extracted and mesial
molar movement is
encouraged. Sometimes Class
III elastics are used to
enhance mesial movement of
the molars.

MECHANICS USED TO CONTROL
ANCHORAGE IN THE LOWER
ARCH
 The anchorage value of the lower arch is higher than that of the
upper arch because the mandible has a thicker cortical layer and
thinner cancellous layer of bone. Because of this difference in
anchorage value, a buccal sectional arch is usually placed on the
posterior teeth to control the functional or buccal cusp.
 Sliding mechanics using a .016 ´x .022 stainless steel archwire are
used most frequently for space closure. Sliding mechanics
minimize the bowing effect and avoid tongue irritation from loops.
 When sliding mechanics are not the optimum choice for space
closure, loop mechanics may 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 accomplished with sliding mechanics because of
root contact with the cortical bone.
 In these cases, the lower six anterior teeth are tipped lingually
with loop mechanics.

MAXIMUM ANCHORAGE (LOWER
ARCH)
 Anchorage preparation for a
maximum anchorage case with
sliding mechanics in the lower
arch. An elastic power chain is
used on .017X .025 TMA or .016X
.022 SS archwires.
 A buccal sectional arch is used
for stabilization and the anterior
segment (33) and the posterior
segment (57) is “figureeighted”
with ligature wire. Class III
elastics are used both buccally
and lingually usually with extra
oral force traction for reinforced
anchorage.

MODERATE ANCHORAGE (LOWER
ARCH)
 Anchorage preparation
for a moderate
anchorage case with
sliding mechanics in the
lower arch. The anterior
segment (3|3) and the
posterior segment (7–5|
5–7) are “figureeighted”
with ligature wire.
 Reciprocal elastic forces
are used and buccal
segmental wires are not
needed.

MINIMUM ANCHORAGE (LOWER
ARCH)
 Most cases requiring minimum
anchorage are those in which
second premolars have been
extracted.
 An elastic power chain is placed
circularly from the lingual of the
first molar, encircling the
canine, and attaching to the
buccal of the first molar. Class II
elastics are used to facilitate
mesial movement of the molars.
 The anterior segment (4 |4) is
“figureeighted” with ligature
wire. As the molars move
mesially, gingival recession over
the mesial root of the first molar
should be prevented.

ANTERIOR AND LATERAL
CONCERNS
 Patients with severe anterior tongue thrust often present a
challenge when attempting to retract the anterior dentition. The
lingual appliance, due to the discomfort associated with tongue
contact, redirects the tongue tip to the palatal vault in speech
and swallowing. Therefore, the anterior thrust component is
eliminated, and normal muscle balance is restored.
 The excessive pressure from the tongue against the anteriors is
minimized while retraction is facilitated. A similar effect is seen
with the use of lingual elastics.
 This has been termed the “fence effect,” in which the lingual
appliance or the elastics create a fencing of the tongue
musculature from the dentition.The fence effect contributes to
the increase in anchorage values with lingual appliances as
opposed to labial appliances.
 Another factor contributing to anchorage control is the lateral
occlusal function. The lateral occlusion prevents the transverse
bowing effect which is often seen during lingual treatment. The
anteriorposterior forces used for retraction should be light,
minimizing anchorage loss while maintaining lateral occlusal
function.

TREATMENT SEQUENCE
 Leveling,aligning,rotational control and bite
opening.
 Torque control.
 Consolidation and retraction.
 Detailing and finishing.

LEVELING, ALIGNING, ROTATIONAL
CONTROL AND BITE OPENING
 Initiate tooth movement with light forces.
 Provide for a period of patient adaptation.
 Correct rotations.
 Level and align individual arches to permit wire
progression.
 Obtain initial torque control when required.
 Establish posterior anchorage units with buccal segments.
 Initiate posterior segment control with extra oral traction
and TPA when required.
 Reduce any excessive overbite.
 Gain space for rotations.

LEVELING
 The first stage in lingual orthodontic treatment is partial
canine retraction to eliminate crowding and create space for
the alignment of the four incisors in both the upper and lower
arches.
 Partial retraction prevents space from opening between
lateral incisor and canine for esthetic reason and leaves
adequate room for activation during enmasse retraction of the
anterior teeth.
 Following this stage,the six anterior teeth are leveled with a
full arch wire.
 During anterior leveling,care must be taken to prevent the
vertical bowing effect.

TORQUE LEVELING
 Once anterior leveling has been achieved,torque leveling of
the six anterior teeth is necessary prior to en masse
retraction.
 The wire used are .017x.025TMA or.0175x.0175 TMA.
 It is important that the wire is fully engaged into bracket
slots.
 The six anterior teeth need double over ties for effective
torquing.

EN MASSE RETRACTION
 Two methods are available for en masse retraction.
Loop mechanics.
Sliding mechanics.

SLIDING MECHANICS VERSUS LOOP
MECHANICS DURING EN MASSE
RETRACTION
 In labial orthodontics, the mechanics usually
involves canine retraction, and once it is
accomplished, upper and lower incisors are
retracted.
 Lingual patients, however, strongly demand that
esthetics be maintained throughout the
treatment,so in addition to the invisible braces,
care needs to be taken to avoid 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 anterior–
posterior direction , the upper anterior segment (33) may
tip lingually. The bite plane effect of the upper lingual
brackets can cause posterior disocclusion and consequently
loss of lateral occlusal function. As a result, bowing effect
occurs.

En masse retraction can be performed with sliding
mechanics
Advantages of sliding mechanics :
 Simple and effective for preventing transverse bowing
effects without using a transpalatal arch.
Disadvantages of sliding mechanics:
 Wire friction and uncontrolled retraction force
 Anchor loss
 Increased depression of lower anteriors due to the force
applied by the anterior bite plane while retracting the
upper incisors.
 Difficulty in applying the technique to unusual extraction
cases where different teeth are extracted on the right and
left sides.
 Increased retraction time and consequently increased
treatment time.

SLIDING MECHANICS
 Archwire: .016 ´x.022 SS
 Indications: Minimum or moderate anchorage
cases with upper second bicuspid extraction
 Nervous patients who do not want auxiliaries
like loops
 Lower arch extraction cases.

In en masse retraction with loop mechanics ,three
different kinds of loops are commonly used: closed
loop, helical loop and Lloop.
Advantage of Loop mechanics :
 Effective in closing space without wire friction.
 Bigger tipping bends can be incorporated in to
archwire
Disadvantages of sliding mechanics:
 Complicated to bend the wires with the different
loops
 Requires a lot of skill from the orthodontist.

CONSIDERATIONS IN LOOP MECHANICS
 Care must be taken to prevent the loops from impinging on
the palatal mucosa.
 Bend the loops 45 to 60 degree away from the tissue.
 Activate the loops about 1mm once every 8 weeks (never
activate them every month).
 No activation is necessary on the day the loop wire is
placed.

CLOSED HELICAL LOOP OR L-LOOP MECHANICS
 Archwire: .016 X .022 SS or .017 ´ .025 TMA
 Indications: Open bite cases with little need for upper
anterior torque control or active tipping of anteriors
 Closure of small spaces.
T-LOOP MECHANICS
 Archwire: .017 X .025 TMA
 Indications: When maximum anterior retraction is needed
while maintaining anterior torque.
 When active intrusion of anteriors is indicated
 In seventy percent of total extraction cases.

In a study done to compare Loop and sliding mechanics
it was found that
 No significant difference in the skeletal pattern
between sliding and loop mechanics.
 Upper anterior torque (U1 to FH) was maintained
better with Tloop mechanics compared to sliding
mechanics and worse with closed helical loops.
 Anchorage was controlled better with all loop
mechanics.
 Lower anterior intrusion was significantly smaller
with Tloop mechanics.
 There were no significant differences in facial axis
between both mechanics which means that there is no
opening of mandible.
 Retraction was accomplished in a shorter time with
loop mechanics than with sliding mechanics

Loop mechanics Sliding
mechanics
Wire friction Not affected Affected
Untipping bend Easy to place Limitation in placing
bens to minimize wire
friction
Control of
retraction force
Easy to control
depending on loop
activation
Hard to control as
difficult to quantify
force level
Unusual extraction
case
Suitable Unsuitable
Bite opening
control
Suitable Unsuitable
Discomfort Much discomfort Little
Wire bending Difficult Easy

DETAILING
 After en masse retraction is complete, detailing is required to
obtain solid intercuspation and arch coordination.
 The wire sizes used here are .0175x.0175 TMA or.016
TMA,Wilcocks 0.016 /0.018 special plus
 Rigid rectangular wires are not appropriate for detailing
because it is often difficult to engage those wires fully into
bracket slots, even with small inout step and torque bends,
due to the short interbracket span.
 It is necessary to figureeight the canine and second premolar
and cinch back the wire ends to prevent the extraction sites
from reopening.

EXTRACTION MECHANICS
 Due to the unique biomechanics of lingual
orthodontics extraction choices often differ from
those in labial orthodontics

FINISHING AND DETAILING
Difficulties encountered in finishing are derived from
Patient characteristics
- Restorative & Periodontal complications
- Thickness of tooth varies
- Compensating bends are less accurate & less effective
Anatomy of lingual surfaces
Mechanics of Lingual orthodontics
- -The point of application of force is at some distnce
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

Prevention of finishing problems
 Correct diagnosis & Rx planning- asymmetric
extractions
 Precise bracket bonding
 Light forces to avoid side effects

SYSTEMATIC FINISHING
PROTOCOL
Step 1 of finishing protocol
- Reuse of initial resilient rectagular arch wire for 3-4
months(017x017 Cu-NiTi for 0.018”brackets)
- Problems deriving from treatment errors such as torque of
incisors,expansion and some of the rotations can be corrected
with this procedure.
Step II finishing protocol
-Settling the occlusion by establishing correct interdigitation ,
correction of minor midline, A-P & vertical discrepancies.
- Settling in the occlusion can be done by using a lower stabilizing
arch, SS or 0.0175 x 0.0175 TMA and an upper 0.014 round
sectional wire from canine-canine or lateral incisor to lateral
incisor
-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- 016”TMA

ORTHODONTICS
 Patient undergoing lingual orthodontic
treatment are often esthetically demanding
and donot like visible retainers.
 Hence Clear retainers made of 0.4”/0.5” thick
thermoplastic material can be used.
Advantages-
 Comfortable
 Decreased speech interference
Disadvantages-
 Breakage
 Deformation
 Cannot be used for long time
Recommendation-
 Clear retainer during day time
 Hawleys retainer during night time
 For lower arch Scuzzo and Takemoto prefer
0.012” Australian arch wire fixed lingual
retainer
Advantage-
 Encourages PDL rearrangement
 Corrects minor incisor malalignment

LINGUAL LABORATORY
PROCEDURES FOR BRACKET
POSITIONING
 The irregular lingual tooth morphology creates a
requirement for custom contouring of lingual
bracket bases with appropriate bracket base
thickness and torque
 Various procedure have been developed for this like-
 CLASS (Custom lingual appliance setup service)
 TARG (Torque angulation reference guide)
 Slot Machine
 BEST – Bonding with Equal Specific Thickness system
 Ray Set Biaggini bracket positioner
 Lingual bracket jig
 Mushroom bracket positioner
 Hiro system

CLASS (CUSTOM LINGUAL APPLIANCE SETUP
SERVICE)
 A pretreatment diagnostic
setup is manufactured and
then used as a template for
definitive bracket fitting.
 After determining ideal
anterior tooth position in
the setup, the technician
then places the brackets in
their correct
preprogrammed position.
 Adv- placing anterior brackets
using an arch radius with the
CLASS system,the in-out
discrepancies along the arch
are compensated for by filling
the gaps between the mesh
pads and lingual surfaces of
the teeth with composite
material.

TARG (TORQUE ANGULATION REFERENCE
GUIDE)
 Machine developed by
Ormco in 1984 for lingual
bracket positioning.
 The machines torque blades
are used to define a
horizontal plane and torque
for all teeth, using this the
brackets can be placed at a
proper vertical distance
from the occlusal edges and
in a central position on each
tooth.
 The draw back was that the
original TARG machine did
not allow preprogramming
of in-and out-bends for
individual teeth.
 Does not consider different
thickness of the teeth
 1st
order archwire bends are
necessary

SLOT MACHINE
 Introduced in the year 1986 by,Dr.TD
Creekmore; the slot machine is to be used with
the conceal bracket system , it also used a labial
reference to position the lingual brackets like the
TARG machine

 Fillions Lingual Indirect bonding system
 Didier Fillion improved this method in 1987 by
adding an electronic device to the TARG
machine with the purpose of measuring labio-
lingual thickness of tooth.
 This improvement reduced the number of first-
order bends in the wire.
BEST –
Bonding with Equal
Specific Thickness system

 Thickness Measurement System records the thickness (the
width of the teeth with bracket) of the six anterior teeth. The
greatest thickness is chosen as the standard thickness.
 Because of the standardization of thickness, this system permits
us to avoid all first-order bends, except the ones between the
cuspids and bicuspids and between the bicuspids and molars.

 The macrofilled resin is applied to the bracket base; then the
bracket, placed on the blade, is moved toward the plaster
until the selected thickness measurement appears on the
screen.
 The resin excesses, even on the gingival margins, are
removed before polymerization. By this technique, we
achieve a thickness standardization while the brackets are
each supported on resin pads of different thicknesses.
 For bicuspids and molars, the thicknesses are standardized
in the same way

The Transfer System
 The transfer tray allows us to transfer the brackets
which have been bonded on the malocclusion model to
the patient’s mouth. This tray can be made of
different materials, but we use a low-viscosity silicone
that does not apply any pressure on the brackets and
can guarantee a bracket’s total stability during this
stage.

The Bonding Procedure
 The bonding is performed very rapidly because of the
precision and reliability of the laboratory procedure
and with unfilled resins only. It is very important in
lingual orthodontics to know that the bonding height
is reduced by 13% and that the brackets are placed
close to the gingival margin.

THE DALI PROGRAM (DESSIN DEL’ ARC
LINGUAL INFORMATISÉ OR
COMPUTERIZED DRAWING OF THE
LINGUAL ARCHWIRE)
 It uses the measurements of the tooth widths performed at the
laboratory by the technician, and with the help of a computer
develops a detailed drawing of the ideal lingual archwire, with
all the teeth perfectly aligned. The clinician can choose an
arch form in function for the initial arch form and a final one
that is more ideal for the end of the treatment.
 It permits us to obtain an extremely accurate tracing of the
finishing archwire, at a 1:1 ratio.
 It allows us to know with a very high accuracy (with 0.1 mm)
the width of the first-order bends placed between the cuspids
and bicuspids, and between the bicuspids and molars.
 During treatment, it allows us to know the ideal arch shape
needed to achieve a good occlusion, especially in asymmetric
cases.
 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.
 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

RAY SET BIAGGINI BRACKET
POSITIONER
 A 3-dimensional goniometer control system
determines 1st
, 2nd
& 3rd
order values for each
tooth. Both pre and post set up values of each tooth are
evaluated and the amount of orthodontic tooth movement
for each tooth on set up model is calculated.

LINGUAL BRACKET JIG
 Developed by Dr.Silvia Geron in 1999.
 It is a chair side direct bonding system
 Is used with horizontal slot brackets,it transfers
the Andrews SWA labial bracket prescription to
the lingual surface.
 Its main advantage is that it allows orthodontist
to perform direct as well as indirect bonding with
no special training.

THE MUSHROOM BRACKET POSITIONER FOR
LINGUAL ORTHODONTICS.
 Developed by Kyung etal in 2002
 The MBP consists of a setup model
holder with horizontal and vertical
arms.
 Two mushroom shaped horizontal
plates with long,narrow slots and
lingual bracket holders.
 Each plate comes with two curved
anterior bracket holders,two single
bracket holders,and two posterior
bracket holders.
 The anterior bracket holders are
curved so that the 4 anterior teeth
can be bonded at the same time if
there is no great variation in the
lingual surfaces
 Canine and posterior brackets can be
placed in the large posterior bracket
holders
 Single bracket holders are used for
canines or abnormally shaped teethwww.indiandentalacademy.com

HIRO SYSTEM
 It was invented by Dr.Toshiaki Hiro, and was later
improved by Dr. Kyoto Takemoto and Dr.Giuseppe
Scuzzo ,and brought about a break through in indirect
bonding.
 Bracket placement
o Bracket placement starts with six anterior teeth
ligated to the full size arch wire with elastic ligatures.
o Place the wire complete ith the brackets on the set
up,with each bracket properly centerd on its tooth
wnd smallest possible gap between the mesh pad and
lingual tooth surface.
o Set the posterior teeth in the same way and fix the
archwire to the model with orthodontic wax.

 Making cores (Individual hard trays)
o Separator is applied to the set up model.
o Ultra band-lok,blue /white, a fluoride releasing
GIC or a chemical cure acrylic resin can be used
for making individual hard trays.
o Chosen material is applied with a brush to cap an
area which varies according to tooth morphology.

o On the anteriors cap is built few millimeters from the
labial surface on to the occlusal surface ,upto the
occlusal margin of the brackets. While in posteriors
only the occlusal surface is capped.
o Once all the caps have been light cured they are
numbered and the archwire with brackets with the
resin cores are carefully removed as a unit from the
set model. The elastic ligature is cut and each bracket
separated from the wire.

 Customizing bracket
base
o Small spaces which exist
between the bracket base
and the lingual tooth
surface are filled with
composite material and
cured on the set up model.
Remove the excess from
the sides.
o These bases are exact
reproduction of the
lingual dental anatomy of
the teeth and will fit
precisely.

STEPS IN INDIRECT BONDING
1) Isolation is very
important for successful
bonding
2) Apply etchent on lingual
surface
3)Rinse and dry the
field
4) Apply primer 5) Apply primer and bracket
adhesive

6) Setting an individual tray and light
curing
8)Removal of individual tray and placement of wire
7) Bonding
complete

ADVANTAGES AND
IMPROVEMENTS OF HIRO
TECHNIQUE
 No electronic equipment required.
 No need to transfer brackets from set up model to
original cast as in CLASS technique.
 Extractions ,expansions distallizations can be carried
out bet impressions and bonding
 Individual hard tray is small and provides accuracy
 Limited composite overflow makes hygiene easier
 Easier in case of severe crowding as separate
sequential bonding can be done.
 Core is customized for each tooth so precise
 Rebonding is quick and accurate.
 Cost is low.

Other techniques are
 Converible resin core technique
 Hybrid core system
 Simplified technique associated with new Stb
brackets
 Orapix system

FUTURE OF LINGUAL
ORTHODONTICS
Three areas of change will affect the future of
lingual orthodontics-
 Technology
 Appliance design and manufacture
 Laboratory protocols
 Demography
 Falling birth rates
 Increasing aging population
 Attitude
 A change in public and professional attitudesto
lingual orthodontics

SUMMARY
 We are all aware that there are still many short comings in
our knowledge and management of the skeletal and soft
tissue components of the orofacial complex.
 But currently we do have the ability to efficiently move teeth
and correct malocclusions within the limitations of the
skeletal and soft tissue boundaries imposed on us by
individual patients.
 Research ,development and ingenuity of people in the field of
orthodontics have undoubtedly provided orthodontists with
efficient tooth moving appliances and techniques,but
continuing progress is based on stretching the boundaries
,disturbing the comfort zone and creating new challenges.
 Lingual orthodontics has definetly added a new dimension
into orthodontics, its now on us to move out of our comfort
zone and take up the challenges of this technique for the
progress of orthodontics and satisfaction of our patients.

REFERENCES
1. Scuzzo G and Takemoto K-Invisible Orthodontics current concepts
and solutions in lingual orthodontics .Quintessenz 1st
edition
2. Romano R-Lingual orthodontics .BC DECKER 1st
edition
3. Mzrahi E – Lingual orthodontics .Sem in Ortho 151-214;12;3,2006
4. Echarri P- Revisiting the history of lingual orthodontics. Sem in
Ortho 153-159;12;3.2006
Abstracts-:
1. Alexander C M,Gorman J C- Lingual Orthodontics-A Status report
JCO1982 Apr 255-262.
2. Kurz C,Swartz M- Lingual Orthodontics; A Status report Part-2
Research and development ,JCO-1982 Nov 735-740.
3. Scholz R P,Swartz M-Lingual Orthodontics;A Status report Part-3
Indirect bonding laboratory and clinical procedures JCO 1982 Dec
812-820.
4. Gorman J C,Hilgers J J-Lingual Orthodontics; A Status Report Part-
4 Diagnosis and Treatment planning –JCO 1983 Jan 26-35
5. Alexander R.G,Gorman J.C;Lingual Orthodontics-A Status Report
Part-5 Lingual Mechanotherapy-JCO 1983 Feb 99-115

6. Alexander C.M,Alexander R.G-Lingual orthodontics; A
Status Report Part-6 Patient and practice management-JCO
1983 Apr 240-246.
7. Smith J.R –Lingual orthodontics;A Status Report –Part 7
Case report-Extraction ;JCO 1983 Jul 464-473.
8. Smith J.R,Gorman J.C,Kurz C-Keys to success in lingual
therapy-Part 1;JCO 1986 Apr 252-261.
9. Smith J.R,Gorman J.C,Kurz C-Keys to success in lingual
therapy-Part 2;JCO 1986 May 330-340.
10. Creekmore T.Lingual orthodontics-Its renaissance;AJO DO
1989 120-137.
11. Kyung H M,Park H S,Sung J H;The mushroom bracket
positioner for lingual orthodontics;JCO 2002 Jun 320-328
12. Kyung H M,Park H S,Sung J H;The plain wire mushroom
bracket positioner for lingual orthodontics;JCO 2004 July
388-395.

Evolution of lingual orthodontics

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