various techniques used in lingual orthodontics for anchorage control are described here.. and various cases of lingual orthodontics in which different techniques were used for anchorage control are discussed here..

1. By – Dr. parag S. Deshmukh
Seminars in Orthodontics, Vol 12, No 3 (September), 2006: pp 167-177

2. Contents:
• Introduction to anchorage.
• Anchorage in labial orthodontics.
• Introduction to lingual anchorage technique.
• Various techniques for anchorage conservation in lingual orthodontics.
• Main article.
• Case report.
• Conclusion.
• Refrences.

3. Introduction:
ANCHORAGE
• Louis Ottofy(1923) – Base against which orthodontic force or reaction of
orthodontic force is applied.
• According to White and Gardiner anchorage is the site of delivery from
which the force is exerted.
• Graber defined anchorage as the nature & degree of resistance to
displacement offered by an anatomic unit for the purpose of affecting tooth
movement.
• According to Proffit it is resistance to unwanted tooth movement
• Nanda has define anchorage as – ‘The amount of movement of posterior
teeth to close the extraction space in order to achieve selected treatment
goals.’

4.  All orthodontic applicants said to have 2
components namely the active component & the
resistance component.
 Active component is responsible for generating the
force.
 Resistance component is responsible for providing
the resistance to make this force effective.

5.  There are anatomical units or regions which are
used for the purpose of providing the resistance to
movement i.e. anchorage.
• Further divided into 2 groups depending upon their
location.
1) Intraoral sources of anchorage.
 Anchorage units lie within oral cavity
 Alveolar Bone
 Teeth
 Basal Bone
 Cortical Bone
 Musculature
SOURCE OF ANCHORAGE

6.  Extra oral sources –
• Can be utilized as sources of anchorage to bring about
orthodontic or orthopaedic changes.
• Used when adequate resistance cannot be obtained
from intra-oral sources for the purpose of anchorage.
• Include cranium, back of the neck & facial bones.

7. According to manner of force application :
a. Simple anchorage -
• Dental unit is utilized as anchor unit or
source of resistance without tipping
control.
• The resistance of anchorage unit to
tipping is needed to move another tooth
or teeth.
• Resistance offered by an anchorage unit
is greater than that offered by reactive
units that are being moved

8. b. Stationary anchorage -
• Dental anchorage in which anchor
units are not permitted to tip
• The displacement of the anchor
unit caused by the force if at all has
to occur, results in bodily
movement of anchor unit.

9. c. Reciprocal anchorage –
• Here two teeth or two
groups of teeth of equal
anchorage value are used
against each other.
• Closure of midline
diastema, use of crossbite
elastics

10. INTRAMAXILLARY ANCHORAGE
• All resistance unit are situated in the same jaw
• Teeth to be moved and anchorage are all situated either
entirely in the maxillary or mandibular arches.
INTER MAXILLARY ANCHORAGE
• Resistance unit are situated in one jaw and tooth/ teeth to be
moved are situated in the opposing jaw.
• Class II elastic traction applied between the lower molar and
upper anteriors
• Class III elastic traction applied between the upper molars and
the lower anteriors.

11.  According to number of anchorage units:
a. Single or primary anchorage:
• Single tooth as a resistance unit.
b. Compound anchorage:
• Anchor unit is formed by more than one tooth.
c. Reinforced or multiple anchorage:
• More than one type of resistance unit is utilized.

12.  According to Marcotte and Burstone:
• Depending on how much of the anchorage unit contributes to
space closure.

13. 13
•The anchorage value of the posterior teeth in the
anterior-posterior and vertical directions appear to be
higher in lingual orthodontics than in labial
orthodontics (Takemoto, unpublished data, 1997).
•In a randomized study of 44 adult Class II, division 1
malocclusions or bimaxillary protrusion
malocclusions, the anchorage value was significantly
higher in lingually treated case than in those treated
with labial techniques.
 Differences in Anchorage Value:
Lingual versus Labial Orthodontics -

14. Labial Orthodontics Lingual
Orthodontics
24 cases: 20 cases:
2-extraction of teeth 14,24 (4–4) 3-extraction of teeth 14,24 (4–4)
15-extraction of teeth 14,24,34,44 10-extraction of teeth 14,24,34,44
7-extraction of teeth 14,24,35,45 7-extraction of teeth 14,24,35,45
Treated with straight wire appliance Treated by en masse retraction
Canine retraction with sliding mechanics Retraction with loop mechanics
Anterior segment retraction with loop
Mostly with T -loop mechanics

15. • Rickets cephalometric analysis was used to determine the amount of retraction of the
upper and lower incisors, the amount of intrusion, and the value of anchorage loss of
upper and lower first molars.
Pretreatment (green) and posttreatment (yellow)
superimposition of maxilla on palatal plane at point ANS
and of the mandible on the mandibular plane at point
menton:
Incisors and first molars horizontal changes measured at the
incisal edges and the distal end of first molars.
Pretreatment (green) and posttreatment (yellow)
superimposition of maxilla on palatal plane at point ANS
and of the mandible on the mandibular plane at point
menton:
Incisor vertical changes measured at the center of resistance.

16. Results - upper Results - lower
Statistical values shows that in upper arch the
anchorage value of the first molar, and the anterior
retraction and intrusion were significantly greater in the
lingual group as compared to the labial group. Headgear
and Class II elastics were used for shorter period of
time in the lingual group.
Statistical values shows that in lower arch the
anchorage value of the first molar, and the anterior
retraction and intrusion were significantly greater in
the lingual group as compared to the labial group.
Class II elastics were used for shorter period of time in
the lingual group (both in first and second premolar
extraction) than in the labial group.

17. 17
ANCHORAGE
Anchorage
Anteroposterior Vertical

18. Horizontal anchorage:
• Vectors of orthodontic forces applied to
anterior teeth with a lingual appliance are
directed lingually to the center of rotation of
each tooth, providing anterior teeth with a
lingual crown torque. As a result, distally
uprighting forces are applied to posterior
teeth through the archwire, which makes
posterior teeth more resistant to anchorage
loss.
• Posterior anchorage is lost as posterior teeth rotate
mesially.
• Distally rotating forces are constantly applied to
molars during en masse retraction and through the
use of headgear, thus providing a greater amount
of molar anchorage than in labial orthodontics.

19. Vertical Anchorage:
• With brackets placed on lingual surfaces, it is easier to control lingual cusps
through the constant application of buccal root torque (vertical anchorage)
which tips molars lingually.
• In the upper arch, the vertical height of lingual cusps, which are functional
cusps, can be maintained without extrusion through the application of
intrusive forces.
• This is particularly helpful in controlling the lingual cusps of the upper second
molars, which are most likely to cause interference.
• Also an intrusive force is applied to the functional or lingual cusps of upper
molars because appliance is placed near these cusps.
• Therefore, the CO-CR discrepancy caused by the primarily initial contact and
the mandibular clockwise rotation caused by the elongation of molars are
reduced

20. 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.
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.

21.  MAXIMUM ANCHORAGE (UPPER ARCH):
• Helical loop and T-Loop mechanics (.017 X .025 TMA) are combined with
a transpalatal arch and a buccal sectional arch from first to second upper
molars for stabilization. Also, high-pull 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
X .025 TMA with a transpalatal arch
are also used.
Anchorage preparation for a maximum
anchorage case with T-loop mechanics in
the upper arch.

22.  MODERATE ANCHORAGE (UPPER ARCH)
• L-Loop mechanics are combined with a transpalatal arch to prevent a
transverse bowing effect. The anterior segment and the posterior segment
are "figure eighted“ with ligature wire.

23. • When a transpalatal arch is not used,
sliding mechanics are used by placing a
power chain from the lingual of the canine
to the lingual of the second premolar in
first premolar extraction cases.
• The sliding mechanics are used with a .016
X .022 stainless steel archwire. If the
transverse bowing occurs, a power chain
can be used from the lingual of the canine
to the buccal of the first molar to rotate the
first molars mesially.

24.  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 is "figure-
eighted" 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.

25.  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.

26. • 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.

27.  MAXIMUM ANCHORAGE (LOWER ARCH)
• An elastic power chain is used
on the lingual, with a buccal
sectional arch for stabilization
(.017 X .025 TMA or .016 X
.022 SS).
• The anterior segment and the
posterior segment is "figure-
eighted" with ligature wire.
• Class III elastics are used both
buccally and lingually for
reinforced anchorage.

28.  MODERATE ANCHORAGE (LOWER ARCH)
• Sliding mechanics are used with
reciprocal elastic forces (power
chains from 3-5 on both sides).
• The anterior segment and the
posterior segment are "figure-
eighted" with ligature wire.
• Buccal segmental wires are not
needed.

29.  MINIMUM ANCHORAGE (LOWER ARCH)
• 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 is "figure-
eighted" with ligature wire.
• As the molars move mesially, gingival
recession over the mesial root of the
first molar should be prevented.

30. 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.

31. “FENCE EFFECT"
• The lingual appliance or the elastics create a
fencing of the tongue musculature from the
dentition.
• This contributes to the increase in anchorage
values seen with lingual appliances as opposed
to labial appliances.

32. Transverse Control
• With the use of lingual appliance most undesirable
expansion occurs in buccal segments.
• Lingual appliance has a tendency to cause
Mesiobuccal molar rotation during space closure
• Intermolar dimension becomes more. This effect is
also called – “TRANSVERSE BOWING EFFECT”

33. MEASURES TO MINIMISE TRANSVERSE
BOWING
 Use of Transpalatal arches.
 Use of Heavy vestibular arches through buccal headgear tubes
 Crossover technique
 Most effective method is a continuous archwire from second
molar to second molar.
 Advantages; -
• Maintenance of proper arch from
• Reduction of post interferences from dental arch bowing.

34. Lateral occlusal function
• The lateral occlusion prevents the transverse bowing
effect and contributes to anchorage.
• Forces used for retraction should be light,
minimizing anchorage loss while maintaining lateral
occlusal function.

35. Anchorage Considerations in Lingual
Orthodontics
Silvia Geron
Seminars in Orthodontics, Vol 12, No 3 (September), 2006: pp 167-177

36. Introduction:
•Anchorage provision and control is a key
requirement for the successful treatment of most
malocclusions irrespective of the treatment
technique.
•When using the lingual technique, specific problems
relating to the provision of adequate anchorage may
be attributed to a number of factors.

37. ● The majority of patients seeking lingual orthodontics are
nongrowing adults.
● Many have mutilated malocclusions with one or more missing
teeth.
● Often there is a compromised periodontal condition with
reduced alveolar bone levels reducing the anchorage value of
the posterior dentition.
● These patients as a group have high esthetic demands
precluding the use of many conventional orthodontic
anchorage devices such as extraoral appliances, pendulum, lip
bumper, or intermaxillary elastics.

38. • The placement of lingual brackets invariably causes anterior bite
opening and posterior disocclusion in cases with normal or deep
overbite. While the contribution of an intercuspated occlusion to the
provision of a degree of anchorage may be debatable and vary with
different malocclusions, the bite plane effect of the lingual
appliance with resulting loss of occlusion and intercuspation may in
certain cases reduce the anchorage achieved with the lingual
technique.
• It has been suggested that the lingual technique provides superior
anchorage control because of the smaller arch perimeter, which in
turn increases the rigidity of lingual archwires during retraction.

39. • Takemoto compared anchorage loss in labial versus lingual extraction cases
treated with loop mechanics and found higher anchorage value of the posterior
dentition in lingual cases.
Takemoto K: Anchorage control in lingual orthodontics, in Romano R (ed): Lingual Orthodontics. Hamilton,
Canada, BC Decker, 1998, pp 75-82
• He suggested that the anchorage value of posterior teeth in the lingual technique
is higher than that of the labial technique due to the proximity of the lingual
brackets to the center of resistance of the tooth.
• In addition, the direction of forces during space closure creates a degree of
buccal root torque and distopalatal rotation of the molar crown, which in turn
produces cortical bone anchorage.
• In certain cases where anchorage needs to be reinforced, a modified pendulum
appliance can be placed to reduce anchorage loss.
Echarri P, Scuzzo G, Cirulli N: A modified pendulum appliance for anterior anchorage control. J Clin Orthod
37:352-359, 2003.

40.  6 Anchorage keys:
• Standard lingual bracket jig prescription for the anterior
teeth, incorporating slight extra palatal root torque and no
extra tip for extraction cases; molar tubes placed off-center in
a more mesial position and incorporating a mesial tip to
encourage molar tip back (uprighting)
• Reduced friction, using sliding mechanics together with bi
dimensional archwires incorporating a rectangular anterior
section and round posterior sections or using a standard
archwire and placing brackets on the posterior teeth with
larger slot sizes

41. • Posterior bite stops placed on the molar teeth to open
the bite
• Light Class I, II, or III forces for retraction or space
closure
• Incorporation of the second molars in the anchorage
unit
• Incorporation of an exaggerated curve of Spee in the
maxillary space-closing archwire

42. Case 1:
• A 25-year-old female patient presented with a chief complaint of
dental protrusion and difficulty in closing her lips.
• Extraoral examination showed a long face with a convex
profile, retrognathic mandible, bimaxillary protrusion, and
incompetent lips with reduced tonicity

43. Intraoral views show half cusp Class II occlusion on the right and left sides,
anterior open bite, and proclination of upper and lower incisors
Cephalometric measurements confirm the clinical signs, mild skeletal Class II
with a high mandibular plane angle and upper and lower incisor proclination.

44. Treatment goal :
• To reduce incisor and lip protrusion.
Treatment plan:
• Extraction of four second premolars and incisor retraction using maximum
anchorage mechanics.
• On the premise that there is no difference in anchorage loss between first and
second premolar extractions, the second premolars were selected for
extraction as an esthetic consideration.
• First premolar extraction sites are more noticeable than second premolar
extraction sites
• The selection of the second premolars for extraction also simplifies the space
closure mechanics in lingual cases, because the premolar offset placed
between the canine and premolar may interfere with the final space closure in
first premolar extraction cases.

45. Anchorage Strategy:
• The second molars were included in the anchorage unit.
• A bi dimensional bracket system was used to reduce friction during
space closure, 0.018 inch slot brackets for anterior teeth from canine
to canine and 0.022 inch for all the posterior brackets.
• Bracket positioning was performed by using the lingual bracket jig
(LBJ) in an indirect in-office procedure.
• Anterior brackets were positioned with slight extra torque
prescription.
• Molar brackets were positioned with 5° mesial inclination (to
encourage molar tip back).

46. • Space closure was performed by en mass retraction of the eight anterior teeth
by using sliding mechanics with light intra arch elastics.
• En masse retraction is the routine space closure mechanics used in lingual
orthodontics because the esthetic requirement of the patient does not permit
retracting the canines and premolars separately with resulting opening of
unsightly spaces in the anterior region.
Treatment Progress
• Upper and lower lingual brackets were bonded indirectly at the same
appointment.
• The initial archwires were Copper Niti 0.017 inch followed by steel 0.016 X
0.022 inch archwires (Ormco Corp, Orange, CA).
• The anterior teeth and the posterior group of teeth were laced with steel
ligature wire and space closure was performed by using elastic chains tied
between the first premolars and the first molars with an initial force level of
150 gm of force.

47. • The elastic chains were replaced every 6 weeks.
• Nine months after bonding, the spaces were almost closed and the overjet and
overbite were corrected.

48. Treatment Results
• A functional occlusion was achieved with overjet and overbite within
normal limits. Final radiographs showed correct root positions.
Superimposition of the pre- and post-treatment cephalometric tracings
indicated significant retraction of the upper incisors and slight lingual
tipping of lower incisors due to the tip back position of the molar
brackets. Upper molars were found to have moved mesially about 1/3
of the extraction space, which is compatible with the anchorage
requirements of the case. Incisor and lip protrusion were significantly
improved and lip competence was achieved with concomitant
reduction in lip strain.

50. • The main treatment goals were achieved with an esthetic, simple lingual orthodontic
appliance in a comparatively short treatment time of 14 months.

51. Case 2:
• A 27-year-old male patient presented with a chief complaint of an
unesthetic smile.
• Extraoral examination showed an increased lower facial height with
straight to mildly retrusive lips and an obtuse nasolabial angle.
• Analysis of the smile revealed insufficient exposure of the incisors
and a reversed smile line

52. • Intraoral examination showed a full Class II occlusion with an overjet of 10 mm and an
anterior open bite of –4 mm.
• The patient also presented with extensive restorations in both arches and a periapical
lesion on the roots of the upper left first molar necessitating the extraction of this tooth.

53. • The cephalometric analysis indicated a skeletal Class II jaw
relationship with a high mandibular plane angle and proclination
of the upper incisors.
• The main treatment goals were retraction and extrusion of the
upper incisors for overjet and overbite correction.
• The treatment plan included extraction of the upper right second
premolar and the upper left first molar and the retraction of the
incisors with maximum anchorage mechanics.

54. Anchorage Strategy
• This case required maximum anchorage due to the large overjet and
anterior open bite.
• The anterior open bite with the tongue interposition is a complicating
factor that may contribute to anchorage loss during treatment.
• The anchorage problem was further complicated by the extraction of
the upper left first molar.
• The second molar on the right side and the third molar on the left
side were included in the anchor unit.

55. • Spaces were closed by enmass retraction of the nine anterior teeth, including
the first right premolar, first and second left premolars, canines, and incisors
as one unit.
• Sliding mechanics was used with a light intra arch elastic chain. Class II elastics
were also used at night.
• The Class II elastics were attached to the lingual hook of lateral incisor
brackets and to a lower clear vacuum formed plate, since there were no
brackets on the lower arch, as brackets were placed in the maxillary arch only

56. Treatment Progress:
• Immediately after brackets were bonded the patient was instructed to
position his tongue behind the brackets, on the palate, and to practice
tongue positioning during swallowing.
• Lingual brackets can help in correcting anterior open bite because of
the tongue crib effect.
• The first arch wire was 0.017 inch Copper Niti, followed by a steel
0.016 X 0.022 inch archwire for space closure.
• The finishing wire was 0.016 TMA lingual arch wire (Ormco Corp,
Orange CA).

57. Treatment Results:
• Treatment time was 20 months.
• Despite the severity of the malocclusion and the anchorage
difficulties, it was possible to achieve most of the treatment goals, that
is, ideal overjet and overbite, Class I canine and Class II molar
relationships, although a slight maxillary midline deviation to the left
side is evident.
• Cephalometric analysis and superimpositions revealed retraction of
the maxillary incisors with only slight mesial movement of the
molars. Posttreatment facial pictures show significant esthetic
improvement of the smile, full face, and profile. The incisor retraction
inevitably affected the nasolabial angle; however, the straight profile
still appears harmonious and acceptable.

60. Case 3:
• A 28-year-old female presented with a chief complaint of severe upper
incisor protrusion.
• The patient had orthodontic treatment as a child.
• Extraoral examination shows a straight profile acute nasolabial angle,
and the lower lip trapped behind the maxillary incisors

61. • Intraoral examination shows severe proclination of the upper incisors with a large
overjet of 12 mm, a deep overbite, asymmetric arches, and some spacing in the upper
and lower arches.

62. • Cephalometric analysis indicated a Class II skeletal relationship,
with severe proclination of maxillary and mandibular incisors.
• The main treatment goal was to reduce the overjet and correct the
incisor inclination.
• The treatment plan included extraction of the upper second
premolars and interproximal reduction in the lower arch

63. Anchorage Strategy:
• This was a maximum anchorage case complicated by a large overjet
and the lower incisors occluding distal to the maxillary incisor
brackets.
• If the lower incisors occlude directly on the bite planes of the
maxillary brackets, the occlusal forces may aggravate the proclination
of the incisors since the intrusive forces applied by the lower incisors
are directed anterior to the center of resistance of the maxillary
incisors.
• To avoid these potential complications, posterior bite blocks were
bonded to the molars at the bonding appointment.
• Space closure was achieved by en masse retraction of the eight
anterior teeth.
• Sliding mechanics was used with light intramaxillary forces and Class
II elastics were used at night.

64. Treatment Progress:
• After achieving normal inclination of the incisors, the posterior bite blocks
were progressively reduced.
Treatment Results:
• The overjet and incisor proclination was fully corrected and good posterior
occlusion was achieved.
• Superimposition of pre- and post-treatment cephalometric tracings showed
tipping and retraction of the maxillary incisors with only slight forward
movement of the molars.
• Facial photos show a significant improvement in the incisal exposure at rest,
profile, smile, and facial appearance of the patient.
• Treatment objectives were fully achieved in a comparatively short treatment
time (21months).

67. CASE REPORT :
Micro-Implant Anchorage for Lingual Treatment of a Skeletal Class II
Malocclusion
JANG SEOP LEE, DDS, MSD HYO-SANG PARK, DDS, MSD, PHD HEE-MOON KYUNG, DDS, MSD, PHD
JCO/OCTOBER 2001

68. • A 19-year-old female presented with the chief complaint of lip protrusion.
• She displayed a severe overjet (10mm) and anterior open bite (–2mm), and was
diagnosed as a skeletal Class II malocclusion with open bite and bialveolar protrusion.
• The dental relationships were Class II in the canine region and a mild Class III in the
molar region, due to linguoversion of the mandibular second premolars.
• The dental midline was deviated to the right because of rotation of the right
maxillary first premolar.

70. CEPHALOMETRIC ANALYSIS:

71. Treatment plan:
• The treatment plan involved maxillary first and mandibular second
premolar extractions, followed by Class II mechanics with a high-pull
J hook headgear.
• The patient preferred to be treated with lingual appliances.
Treatment Progress:
• The Class II canine relationship and overjet proved difficult to correct due
to poor cooperation with the headgear.
• They therefore decided to implant microscrews (1.2mm in diameter,
10mm in length) in the palatal alveolar bone between the maxillary first
and second molars.
• Because of the thick palatal mucosa, a palatal microimplant must be
longer than a buccal micro-implant.

73. • Two weeks after implantation, nickel titanium coil springs were attached
between the microscrews and hooks on the anterior part of the archwire

74. • Seven months after microscrew implantation, a Class I canine relationship
had been achieved.
• Total active treatment time was 16 months.

76. • Superimpositions of cephalometric tracings.
A. Before and after treatment.
B. After microscrew implantation and after treatment.

77. Results :
•Normal overjet and overbite were achieved.
•The profile was helped by the retraction of the
maxillary anterior teeth, although further
improvement was required.
•If mandibular micro-implants had been used, a more
pronounced profile change might have been
expected because of better vertical control of the
mandibular posterior teeth.

78. Discussion :
• Although a transpalatal arch was used during the initial stages of
treatment, the patient felt more comfortable with the micro-implants
than with the transpalatal arch.
• Anchorage requirements are even more critical in lingual orthodontics
than in labial treatment because of the anatomical relationship
between the tongue and cortical bone.
• The maxillary posterior teeth, which are used for anchorage in
conventional mechanics, were actually moved distally in this patient,
while the anterior teeth were retracted simultaneously.
• This case demonstrates that micro-implants can provide reliable,
absolute anchorage for lingual orthodontic treatment as well as labial
treatment.

79. A Miniscrew-Assisted Transpalatal Arch for Use
in Lingual Orthodontics:
HYUN SANG PARK, DDS, MSD (JCO/JANUARY 2006)

80. Appliance Design:
• On the working cast, solder an .036" round stainless steel
wire to the first molar bands and to an .028" round stainless
steel connecting wire.
• Solder brass hooks to the TPA for application of the anterior
retraction force.
• This is supplied by closed-coil springs or elastic chain
attached to anterior lever arms, which are connected to the
lingual archwire.
• After inserting a palatal miniscrew, sandblast the screw
head for better mechanical retention.
• Bond the connecting wire directly to the screw head with
composite resin.
• The appliance should be checked in the mouth to ensure
that it does not cause discomfort or gingival irritation and
that it will not compmise oral hygiene.

81. • Even if the point of retraction
force application and the line of
action of the force are
asymmetrical, most of the reactive
force will be transmitted to the
miniscrew rather than to the first
molars.
• If the bond fails during treatment,
a ligature wire can be added
between the miniscrew and
connecting wire before rebonding.

82. Case Report
• A 23-year-old female presented with the chief complaint of lip
protrusion. She displayed 2mm of maxillary crowding; the lower
dental midline was deviated 4mm to the right.

83. • The lower left second deciduous molar was retained, and 1mm of space remained
between the lower right canine and second premolar due to a congenitally missing first
premolar.

85. • Extraction of both upper first premolars and the lower left second primary
molar was planned, followed by maximum retraction of the upper anterior
teeth.
• After initial dental alignment, a miniscrew-assisted TPA was placed as
described above.
• The lever arms were connected to an .018” X.025" stainless steel lingual
archwire for sliding mechanics.

86. Patient after eight months of anterior retraction.

87. • Treatment was interrupted twice because of the patient’s personal problems, but anterior
retraction took a total of about eight months.
• After about 23 months of treatment, the patient showed Class I canine and molar relationships,
2mm of overbite, and 3mm of overjet .
• The dental midlines were coincident with the facial midline; the upper lip was retracted
4.5mm and the lower lip 6.8mm, so that the patient’s appearance improved dramatically.
• A lower lingual fixed retainer and an upper wraparound retainer were delivered.

89. Discussion:
• In this patient, the single miniscrew provided effective anchorage
during anterior retraction with lingual orthodontics.
• The connecting wire remained attached to the miniscrew throughout
treatment.
• Since the patient presented with minor mesial tipping of both first
molars, the reactive force was used for tipback movement.
• In Author experience, locating the miniscrew behind the TPA
provides a better biomechanical point of retraction force application
than when anchorage is supported extraorally.

90. Conclusions:
• Good anchorage control can be achieved with lingual orthodontic
sliding mechanics when following simple anchorage principles. Cases
presenting with difficult anchorage situations and with unusual
extraction sites can be treated successfully with this technique. The
cases presented demonstrate that lingual orthodontics is an efficient
tool for the treatment of adult cases with severe malocclusions,
difficult anchorage problems, and high esthetic requirements.

91. References
• Lingual orthodontics by Romano.
• Lingual orthodontics by Takimoto.
• Anchorage Considerations in Lingual Orthodontics - Silvia Geron Seminars
in Orthodontics, Vol 12, No 3 (September), 2006.
• Micro-Implant Anchorage for Lingual Treatment of a Skeletal Class II
Malocclusion - JANG SEOP LEE, DDS, MSD HYO-SANG PARK, DDS, MSD, PHD HEE-MOON KYUNG,
DDS, MSD, PHD; JCO/OCTOBER 2001
• Concepts on Control of the Anterior Teeth Using the Lingual
Appliance- Rafi Romano Semin Orthod 2006;12:178-185
• A Miniscrew-Assisted Transpalatal Arch for Use in Lingual
Orthodontics - HYUN SANG PARK, DDS, MSD. JCO/JANUARY 2006

92. THANK YOU