Lingual course syllabus oct 2012 Romano-GeronDocument Transcript
Basic, Advanced and Laboratory
Geron S., Romano R.
2. Introduction …………………………………………………………………………………
3. Treatment principles
A. Lingual appliances: Stealth, Harmony- American Orthodontics (5);
2D-Forestadent (7); Fujita 98); STB (Ormco) (11); Evolution-Adenta
(14); Incognito (16); E-brace (20); Innovation-L, MTM, E-Clips-GAC
(22) Kurtz- 7th Generation-Ormco (24); ORG-ORJ 3M (25); Magic-
Dentarum (27); Phantom-Gestenco (28); Lingual Jet- RMO; IdealLeone; Medix 21- Hiro (29)
B. Lingual arch form………………………………………………………………
C. Ligation ………………………………………………………………………………
D. Treatment steps………………………………………………………………
E. Case selection……………………………………………………………………
F. Guidelines for lingual treatment: ………………………………..
1. Proper patient selection
2. Correct brackets & lab preparation
3. Correct clinical treatment
4. Laboratory and clinical procedure
A. CLASS system (40); TARG (41); Slot Machine (42);
Lingual Bracket Jig (43); KSLO (45); Mushroom (MBP) (45);
TOP ; HIRO (48); Modified HIRO (53)…………..…..
B. Bonding Procedure……………………………………………………..………
C. Banding and Welding………………………………………………..…..…..
D. Esthetic Pontic…………………………………………………………………..
5. Typodont exercise
A. Preparation for Typodont Exercise: …………………………..………….
Double Overtie; Ligature Overtie; Rotation Tie; Chain Overtie
B. Extraction case: Steps 1-5 (from Alignment to Finishing) ……
Torquing with 2D plus … Forestadent ………………………………………………
6. Advanced course - Guidelines for Lingual Orthodontics treatment….
Appendix I: Recommended Course Materials…………………………………………
Appendix II: Instructions for LO patient after bonding……………………
Appendix III: Indirect Bonding with the Lingual Bracket Jig………....
Appendix IV: List of laboratories for Lingual Orthodontics ……….….
Dr. Silvia Geron is a specialist in Orthodontics and Dentofacial Orthopedics.
Dr. Geron maintains a private practice limited to orthodontics, Emphasizing Lingual and adult
Orthodontics. She is the Director of Lingual Orthodontics in the international postgraduate
orthodontic program in Tel-Aviv University, and Tel-Hashomer Hospital, IDF, Israel, Presidentelect of the Israeli Orthodontic Society (IOS), Secretary and founding member of WSLO (world
society of Lingual Orthodontics (www.wslo.org), Examiner of the Israeli Dental Association
Scientific Council-Orthodontic Examination Committee, Reviewer for the American Journal of
Orthodontics and Dentofacial Orthopedics, Reviewer for the Angle Orthodontics. The founder and
the editor of the electronic Adult and Lingual Orthodontics journal (www.Lingualnews.com), and
was the founder and scientific editor of the Journal of Israel Orthodontic Society (JIOS).
Dr. Geron invented a unique technique and device that enables direct and indirect lingual bonding.
She is an active member of the European Society of Lingual Orthodontics (ESLO), the American
Association of Orthodontists (AAO), the World Federation of Orthodontists (WFO), the
American Lingual Orthodontists Association (ALOA) and the Israeli Orthodontic Society (IOS).
Dr Geron runs courses and lectures on the subjects of Adult and Lingual Orthodontics
The essential element of her lingual treatment is simplification of the lingual technique.
Dr. Rafi Romano is a specialist in orthodontics and dentofacial orthopedics, earned at The Dental
Faculty, Hebrew University, Hadassah Jerusalem. He maintains a private practice in Tel Aviv,
Israel, limited to orthodontics, with an emphasis on adult and esthetic orthodontics.
Dr. Romano is the Editor-in-chief of "Orthodontics: The Art and Practice of Dentofacial
Enhancement," Quintessence publishing (formerly, “World Journal of Orthodontics” –WJO)
He is also a clinical instructor in the Department of Orthodontics, Tel-Hashomer Hospital, IDF,
Israel. Dr. Romano is past president of the Israeli Orthodontic Society (IOS) and past secretarytreasurer of the International Federation of Esthetic Dentistry (IFED). Dr Romano is an active
member of the European Academy of Aesthetic Dentistry- EAED, the American Association of
Orthodontists- AAO and the World Federation of Orthodontists - WFO.
He is former editor of the Journal of the Israeli Orthodontic Society, and editor of four books:
Lingual Orthodontics, (Decker, 1998), The Art of the Smile (Quintessence, 2005), The Art of
Treatment Planning (Quintessence 2009) and Lingual & Esthetic Orthodontics, (Quintessence
2011). A fifth book, The Art of Detailing, is now in the pipeline, also to be published by
Quintessence. Dr. Romano is an Invited Professor at the Department of Facial Orthopedics and
Orthodontics, Specialization and Master course, University Paulista UNIP, Sao Paulo, Brazil. He is
also Visiting Professor of Lingual Orthodontics at the University at Alcalá, Madrid, Spain.
He lectures worldwide on esthetic orthodontics and adult multidisciplinary orthodontic treatment
and conducts courses in lingual orthodontics around the globe. He lectures all over the world on the
topics of lingual orthodontics and adult multidisciplinary orthodontic treatment.
Esthetics is one of the major goals in orthodontic treatment. Lingual Orthodontics is the
only treatment modality that does not deteriorate the physical appearance of the
patient during the treatment. For the patient, Lingual Orthodontics has several obvious
advantages over labial appliances. Many adults would prefer to have invisible brackets,
when recommended by their clinician, as an appliance that will give them comparable
results to the labial appliance treatment. There are also some mechanical advantages of
the lingual appliance in cases of deep bite cases.
However, orthodontists have been hesitant to use Lingual Orthodontics because of its
complexity. There are many differences in the lingual aspect that make lingual
treatment more complex than the labial. Over the last 20 years there have been many
improvements in appliance design, laboratory and bonding procedures, and in clinical
mechanical technique, that simplifies the lingual treatment.
Thanks to the pioneers in Lingual Orthodontics, Dr. Craven Kurz,
Dr. Fujita and the Lingual Task Force of ORMCO Company, the lingual technique today is
almost as easy as the labial technique, and with the same degree of control.
The aim of this course is to introduce the Lingual Orthodontics concepts and treatment
in a simplified way, in order to encourage the orthodontist to use this important
treatment modality regularly in his practice.
3. Treatment principles
1. Stealth (American Orthodontics)
•The Stealth lingual bracket
system combines clinical design
concepts with American's
technology to produce a clearly
superior bracket for the lingual
• Compact size and smooth
contours for increased patient
comfort and better hygiene
• Full wire control with reduced friction
• An integrated vertical slot from anteriors through first molars yields
expanded versatility and treatment options
• Reduced mesio-distal dimensions means greater interbracket distance
• Generous pad size for increased bond strength and adaptability to varying
Stealth Bite Plane
• Inserts into vertical slot and held in place by ligature
• Effective to open bite in deep bite cases
• Sold in packages of 12
Downloads: Catalog Pages
2. Harmony (American Orthodontics)
The HARMONY System attaches to the interior side of your teeth, so no one
knows you are wearing braces but you.
Your orthodontist designs your perfect smile using state of the art technology.
The process begins with a digital scan of your teeth, which are ideally aligned
following your orthodontist’s treatment plan. A fully customized solution,
including robotically bent arch wires are created just for you.
Each HARMONY System is uniquely customized to achieve your perfect smile
quickly and efficiently.
The HARMONY System offers many benefits.
Fast treatment time
The HARMONY System is engineered to be small and smooth, which helps you
adapt quickly and comfortably to your orthodontic treatment. The self ligating
technology that is built into the HARMONY System offers more control in the
hands of your orthodontist to achieve precise tooth alignment. Self ligating
technology does away with elastic O-rings, so friction in the system is reduced
which leads to a more comfortable experience throughout treatment.
Outstanding patient comfort
Forestadent lingual brackets are available as 2Dbrackets for treating less complex and 3Dbrackets for complex cases. They have an
extremely low profile and are barely noticeable
for the patient.
Easy to use
The 2D and 3D lingual-brackets are easy to use
self ligating-brackets with a vertical slot for fast
and easy archwire insertion.
The 2D -lingual brackets are ideally suited for
clinicians who would like to gain experience in
lingual orthodontics treating less complex cases.
Because of the unique bracket design no large
inventory is required helping to control cost. The
2D Philippe lingual bracket system is a cost
effective way to introduce lingual orthodontics in
3D torque lingual brackets
An indirect laboratory based lingual setup with
pre programmed lingual NiTi archwires for
excellent treatment results. Forestadent 3D torque
lingual brackets have an extremely low profile
and are barely noticeable for the patient. The
unique design permits fast treatment progress
through excellent biomechanics.
•Main Vertical slot
•Auxiliary vertical slot
Update on the Fujita lingual bracket.
Hong RK, Sohn HW.
J Clin Orthod. 1999 Mar;33(3):136-42
Department of Orthodontics, Seoul, Korea.
5. STB (ORMCO)
The STb Light Lingual System delivers superior outcomes –
efficient, simplified and faster treatment as well as greater patient
comfort – for all levels of cases. A first in lingual orthodontics,
STb utilizes a new passive self-ligation design for dramatically
reduced friction and lighter forces.
Developed by two of the leading lingual practitioners in the world, Drs. Giuseppe
Scuzzo and Kyoto Takemoto, the STb system comprises the most advanced lingual
technology, making it incredibly comfortable for the patient and very easy to use –
even for clinicians new to lingual.
With STb, patient compliance issues disappear as you no longer need to worry
about misplaced aligners or interruptions in treatment time.
Unique to lingual brackets, STb has minimal impact on tongue position and
speech; clinical studies have demonstrated that the negligible speech difficulty
disappears within a few days of bonding. STb brackets have the lowest bracket
profile at just 1.5 mm.
STb is the ideal solution for those cases that are not suitable for aligner
treatment, because they require the high level of control that only fixed
appliances can provide.
The STb Light Lingual System is applicable to all levels of cases, and our
recently introduced STb Social 6 is ideal for minor to moderate cases
involving anterior teeth.
STb cases can be prepared with a standard indirect setup by AOA Lab or in
your own practice. In most cases STb does not require a full T.A.R.G. or
C.L.A.S.S. setup, making it far simpler and nearly half the cost of other lingual
Because the size of the STB bracket is approximately half the
size of the Generation #7 bracket and is rounder in shape, the
well known problems of eating, speaking and cleaning with lingual
appliances almost disappear.
6. Adenta – Evolution
Welcome to the next Evolution in Lingual Orthodontics...The Evolution Selfligating bracket system provides you with a complete and precise indirect Hiro
bonding technique, partnered with the Evolution Self-ligating Lingual bracket.
But this is NO ORDINARY SELF-LIGATING bracket!
An interactive flexible self-ligating clip plays a key role - Conventional brackets
tied with a ligature produce considerable friction, we all know that friction slows
down the leveling and unraveling process.
Unlike many other self-ligating brackets that only lock closed and no longer play
a role, the Adenta self-ligating bracket was designed with a flexible type clip,
chosen for its ability to work for you actively through-out treatment.
Programed to hold even a non-seated wire securely with just the right amount of
pressure, continuously pushing the archwire to the base of the bracket slot.
This constant pressure produces the torque, angulation and in-out control
required to finish your cases quickly and efficiently.
Evolution Self-ligating Lingual Bracket Prescription These high performance
self-ligating clips have added benefits...
Passive and Active
•Passive with wires smaller than .018” producing near frictionless movement,
increasing the efficiency of the leveling stage.
•Activated with wires larger than .018”, early torque control increase treatment
time and efficiency.
Built in Safety Release
•Self-ligating clip is designed specifically to not overpower the periodontium,
this insures the protection of the peridont, a force higher than 1100gms will
release and alleviate pressure appropriately.
•Enables the insertion of larger wires early in treatment of rotated teeth.
•More comfortable for the patient as pressure is alleviated on over stressed
Gauge of clip
•Clip produces an average of 650gms of force when active, optimal force needed
to control treatment.
•Sturdy clip withstands the rigors of numerous wire changes.
Easy to open and close
•The self-ligating clip is designed to work like a spring, very little force is
needed to open and close the bracket, creating optimum handling for the doctor
and comfort for the patient. Evolution in-direct SMART bonding system...
faster, cleaner, precise and re-usable
Straight wire appliances make it imperative that the brackets be positioned with
accuracy in order to fully exploit the interaction of their written prescription.
The Evolution in-direct SMART bonding system assures the total compliance of
the doctor’s prescription, using each tooth’s individual morphologic anatomy,
while allowing the newly prescribed set-up to retain the doctor’s values. The new
torque and axis inclinations created through the set-up allow more precise
biomechanics, giving the clinician accurate and predictable control during the
different phases of the lingual treatment.
Evolution in-direct SMART bonding system... faster, cleaner, precise and reusable!
7. Incognito 3M
Our new INCOGNITO Bracket System differs fundamentally both in
design and in manufacturing methods from existing appliances. Using
state-of-the-art CAD/CAM technology, the two normally separate
processes of bracket production and bracket positioning are fused
into one unit. In this process, the demand for maximum individuality
with simultaneously minimized space requirements is put consistently
into practice. In addition, bracket manufacture by a Rapid
Prototyping technique permits direct transfer to clinically purposeful
The new INCOGNITO Bracket System is based on digital
registration of the malocclusion situation. The brackets are then
individually designed and optimally positioned in the computer. Stateof-the-art Rapid Prototyping technology is used for the actual
manufacturing of the lingual brackets. The single production stages
are illustrated and described under production.
The new INCOGNITO Bracket System presented here is designed to
deal, among other aspects, with the three main problems of lingual
1. patient discomfort during the adaptation phase.
2. difficulties in exact indirect rebonding in the event of bracket
3. exact finishing.
4. lower profile
The thickness of the appliance obviously has a substantial
influence on the scale of the impairment to the patients'
comfort regarding speech disturbances and irritation of the
tongue. Our main objective was therefore to develop as lowprofile an appliance as possible, one that is not much thicker
than a bonded retainer especially in the buccal segment. The
three development stages set out below are of crucial
a. Each bracket body is designed independently of the
bracket base, on which it is optimally positioned. Filler
spaces such as those occurring in the individualized
positioning of prefabricated brackets can thus be
avoided. This also makes the lingual appliance decidedly
more favorable for good oral hygiene.
b. The fact that the archwire runs parallel to the tooth
surface gives it its characteristic platform shape in the
anterior segment. The actual bracket body can
consequently be much more delicately shaped (see
production). The resulting archwire morphology differs
substantially from the previously customary design.
Such archwires can be precision-manufactured using
the bending robot described under production.
c. Maxillary bite plateaus are used selectively: only in
cases of deep bite and even then only in the canine
region (Figure 5).
The enhanced wearing comfort resulting from these
innovations is clearly reflected in clinical terms
especially in patients being treated with conventional
brackets in one arch and with the new bracket
system in the other. They all find the new bracket
system substantially more comfortable, reporting
fewer problems and shorter adaptation times in the
relevant arch. In addition to the enhanced wearing
comfort, a lower-profile design also contributes to a
reduced bracket loss rate due to the consequently
shorter lever arm in the event of masticationinduced shearing.
The extensive individualized base of the new lingual bracket,
which covers much of the lingual tooth surface, allows each
single bracket to be directly bonded. This means that a
bracket can be directly rebonded without the additional
support of positioning aids such as unitary silicone trays in the
case of a single bracket being lost. The exact correspondence
of the interfaces results in a positive lock when the bracket is
pressed onto the tooth, making incorrect positioning unlikely.
In addition, in cases of less characteristic tooth morphology,
as found in particular in the mandibular anterior region, the
exact direct positioning of the lingual brackets can be
controlled by means of screen shots from the manufacturing
one major problem in the finishing of a lingual case is the
production-induced inaccuracy of the slot and archwire
dimension. In most cases the archwires are smaller than
specified, while the bracket slots tend to be larger than
specified. This results in varying torque play, which may lead
to substantial finishing problems in some cases even when
nominally slot-filling archwires are used. If the appliance is at
a greater distance from the labial surface of the tooth in
terms of a greater positioning thickness, these problems are
increased more or less proportionately. Especially the impact
of an incorrect torque on second-order aspects is of very
great clinical significance. For instance, a torque deviating by
only 10° in the anterior region results in a mean vertical
deviation of 1.2 mm. Because of the greater positioning
thickness, this correlation is even more pronounced in the
buccal region. As the new lingual brackets are manufactured
by a Rapid Prototyping technique, the size of the bracket slot
can be adapted individually and exactly to the dimension of the
finishing archwire. In addition, the single bracket slots are
more precisely dimensioned. According to provisional
measurements, the difference in size between the smallest
and the largest slot in the anterior region is only 0.008 mm,
corresponding to a calculated angle of rotation of only 0.7°. As
the archwire moreover Contacts the teeth much more closely
with the new bracket series, the residual inaccuracy will have a
less pronounced clinical impact.
Finishing problems resulting from primarily incorrectly
positioned brackets, as may occur sporadically with
conventional laboratory processes, are almost completely ruled
out in the purely virtual procedure presented here. As the new
brackets can also be directly precision-bonded on account of
their large base, bracket loss is less likely to lead to
inaccurately rebonded brackets.
In addition to the at least partial solution to the main problems
previously existing, the innovative design of this lingual bracket
series provides further features improving clinical handling
1. Another advantage of our new INCOGNITO Bracket System is
the vertical slot. With it corrective derotation of teeth can be
performed along the archwire even without the additional
application of lasso elastics. The ligation itself is performed
with so-called German Overties (GOT). In the ligation process,
the archwire is clearly deflected, thus contributing in addition
to enlargement of the dental arch. This procedure is
increasingly superseding more complex mechanics such as the
frequently used advancement stops.
2. Furthermore the modular bracket structure of our new system
allows the single components (base, bracket body, hook) to be
positioned independently of one another, thus differing
markedly from previous systems. Even in cases of rotated
teeth and short clinical crowns, the available enamel area of
the tooth can be optimally utilized.
3. Manufacturing the new bracket system by a Rapid Prototyping
technique gives it great flexibility. Each individual bracket
series can be adapted not only to the patient but also to the
orthodontist. In addition, clinically promising modifications and
further developments can be implemented immediately with
minimum resource input and without involving any changes in
the production process.
4. As the brackets are made of an alloy with a high gold content,
they offer an interesting alternative especially for patients
who are allergic to nickel.
5. The production costs are comparable with those involved in
the manufacture and laboratory positioning of existing
E-Brace Lingual Bracket System Guangzhou Riton Biotech Co.,Ltd.
Add: 301 R, 3/F, Building B, Industrial and Commercial trading park, Hainan
town, Huadi Nan Road, Fangcun, Liwan District, Guangzhou, Guangdong, China
TEL: 0086-20-81508200 FAX: 0086-20-81509362
What is eBrace?
EBrace Lingual System, one kind of customized lingual appliace can quickly and
easily handle a great variety of clinical cases for orthodontists, the resulting
short chair times as well as the highest patient comfort that is technically
possible at present.
A perfect smile means confidence and success in both your private and public
life. You feel smile great not only it is amazing but it is healthy. Keeping teeth
regular and clean is easier to give you a healthy smile.
EBrace is completely invisible and easy to keep clean. It is designed according to
each patient's teeth and can suffciently fix to the particular teeth surface.
Both the brackets and the wires of the eBrace appliance are made individually
with the latest state-of-the-art CAD/CAM technology. The remarkable flat
design of the dental alloy brackets significantly improves the comfort to
eBrace – is it for me?
Would you like to own great smile and healthy teeth? EBrace is capable of
aligning your teeth neatly and bring you back a perfect smile.
If your answer is yes then eBrace is for you:
Any malocclusion can be corrected whether you are a teenager or an adult
the eBrace is the only truly invisible orthodontic appliance
the brackets are easy to clean
the treatment provides high-quality results
the individually flat design of the brackets and archwires ensures the
maximum comfort to orthodontic correction.
Where can I get eBrace?
EBrace lingual system is exclusively used by certified orthodontists around the
world. The certification ensures the successful treatment with excellent
results. In case of using ebrace lingual appliance for tooth correction, please
contact the certified doctor around your area to receive further details.
9. Innovation-L, MTM, E-Clips
GAC recently introduced a lingual bracket, the
In-Ovation-L (IOL), with innovative
characteristics that improve the patient's
comfort and takes into consideration these
-Proper oral hygiene and gingival irritation
-Lingual irritation and Transient speech
-Differences in tooth size and morphology
The In-Ovation-L (IOL) brackets are small
enough to allow sufficient inter-bracket
distance, yet wide enough to have good rotation
correcting control. This provides more space
between the bracket and the gingival margin,
thus allowing the patient to achieve better oral
the In-Ovation-L (IOL) anterior brackets can
be placed in the deepest portion of the lingual
fossa, better adapting to the anatomical
contours. In particular the forked design built
into the base, allow the base pad to be easily
bent to fit to the complicated lingual shape of
the cuspid securely.
This adaptation reduces excess bonding
material (resin) and decreases the area for
plaque and calculus deposits to occur. Smaller
bracket with smaller bracket base are available
for the lower incisors.
this bracket makes it possible by bending the
base pad. Furthermore, it is possible to change
the bracket torque and the position to be
bonded easily by adjusting the angle of the
extended base pad
10. Ormco – 7th generation (Kurtz)
The brackets are straight wire brackets, and they are available with .018’’ or
.022’’ slot width.
The characteristics of the brackets:
Rounded facial contours, to avoid lingual
Large hook enables attachment of
springs and power chains.
Rounded opening to the slot to improve
Increased tie wing area, to enable
double over tie
Bracket base is large to improve bonding.
Horizontal slot allows easier torque control.
Bite plan in the upper anterior brackets, is parallel to the
occlusal plan and to the bracket’s slot. The bite plan directs
the occlusal forces through the center of resistance of the
anterior teeth, opening the bite and creating intrusion of the
upper and lower anterior teeth.
Molar brackets are twin brackets with mesial ball hooks.
There are also brackets with hinge cap molar tube to allow
easier wire insertion. When transpalatal arches are desired, a
special molar bracket with transpalatal sheath is used, a
terminal tube is also available.
11. ORG – ORJ 3M- (Romano-Geron)
1) Designed on recommendation of two famous lingual orthodontists and developed by
ORJ, it includes all advantages of existed lingual brackets at present.
2) Smaller than 7th generation brackets and therefore less problems of irritation to
the tongue and speech problems, patients will feel more comfortable.
3) Hooks of one-piece construction in all teeth to enable better ligation and less
emergencies due to wire disengagement
4) Flatter bracket enables better oral hygiene and less occlusal contact interference.
5) Made of super hardness Stainless Steel 17-4 PH to avoid deformation of the
6) The design of 0.018 slots in anterior brackets and 0.022 slots in posterior brackets
and tubes can close distance of posterior teeth easily because of low friction.
All the ORG brackets are processed by casting and automatic welding procedure.
8) 1st and 2nd molar lingual bondable tubes with 0.022” slots are available upon ordering
1. Hooks of one-piece construction for all teeth to enable better ligation and
less emergencies due to wire disengagement.
2. Flat bracket enables better oral hygiene and less occlusion contact
3. The design of 0.018 slots in anterior brackets and 0.022 slots in both
posterior brackets and molar tubes makes lower friction so as to close space of
posterior teeth easily.
4. Smaller than conventional lingual brackets, therefore less problems on
tongue and talk problem, patients will feel more comfortable with rounded hooks
and lower profile.
Hangzhou ORJ Medical Instrument & Material Co., Ltd. locates in the beautiful
city Hangzhou. ORJ team was the developer of the first generation orthodontic
brackets in China. They had engaged in the subjects of designing and
manufacturing orthodontic products for the domestic market at the beginning
of 1990. And ORJ has the strong self-innovation capability, possesses the whole
sets of modernized technology and process equipment after nearly 20 years of
In the past years, ORJ has already obtained QMS certificate of ISO13485 and
registration certificate of FDA for medical device. And our orthodontic
brackets, tubes and bands had achieved CE certificate already. Our focus on
research and development has transferred from a single orthodontic bracket
into a complete orthodontic product system, which has been widely accepted by
the people all around the world in the recent years.
ORJ main products: orthodontic brackets, tubes, bands, pliers and orthodontic
Through cooperation with local famous orthodontists from universities and
hospitals and promotion on the ability of key technology, ORJ has enhanced the
foundation for the advanced scientific theory and the solid clinical practice of
the excellent orthodontic products.
12. Magic –Dentarum
During the development of Dentaurum’s magic® Lingual-System, the main
emphasis was not only placed upon the importance of comfort for the patient,
but also upon creating a simple procedure for the clinician. This user-friendly
system stands out above other systems available on the market due to its large
selection of primary and secondary products. It has the largest spectrum of
products worldwide. All the individual components are perfectly suited and
coordinated with one another, which enables effective and time saving
13. Phantom- Gestenco
14. Lingual Jet- RMO
Lingualjet - 4 technological innovations for the quality of the treatment.
Articulated around 4 innovations, it allows to savetime and more precision
compared to the current techniques, this offering the practionner a complete
control of the reconstruction. The treatment is invisible, the line is perfect, the
result is optimum
The combination of four technological means offers a unique appliance collecting
several advantages from each of them. Lingualjet reduces cost and chairtime.
Its purpose is to make lingual orthodontics easier, more powerful and more
comfortable for the patient as well as for the practitioner.
3d custom made brackets
The brackets are manufactured applying CAD/CAF technology. 3D software is
used to design every virtual bracket characterised by an extended surface of
bonding on the lingual crown of the tooth and perfectly adapted to its anatomy.
Re-bonding phase is facilitated. Open pores through the pad can be performed
using a specific technology. Because of specific properties of retention on the
pad, the RMO® - LingualjetTM brackets provide a high strength of bonding.
All the slots are related to the virtual arch wire and are extruded of round
shaped brackets with smoothed outlines providing optimal patient comfort.
Virtual brackets are then cast in metal via a step of conversion of the digital
objects into a resin or wax models by a Rapid Prototyping machine. Gold alloy is
preferentially used. For particular metals like zircon, the real brackets can be
directly obtained after the transfer of digital data to a machine tool which
directly cuts out the brackets from pre-formed pieces of material. No matter
what metal the practitioner chooses, each bracket is fully individualized both to
the tooth and to the arch wire by the complete manufacturing process.
A NUMERICAL SET UP
The dental arches of the patient are digitalized from a PVS impression. A
numerical set-up of the final positions of teeth is performed by using
appropriated software. The practitioner then has the possibility to check the
set-up and can simulate specific requirements of placement if necessary. Then,
the numerical set-up constitutes the working model for the engineering step.
The high resolution and the accuracy of the method of tooth positioning provide
a top of the range procedure in regards to the precision and the personalization
of the appliance.
The numerical set-up is a very user friendly and precise tool for defining the
terminal dental arches. In addition, the numerical relocation of brackets on the
initial deformation can be calculated and a resin model with the brackets on is
prototyped to make the transfer tray.
A FLAT ARCHWIRE
Another improvement to lingual orthodontics is the use of a flat wire in the
transversal direction, which can be slightly rotated on the sagittal plane in case
of specific demand. The archwire chart is drawn respecting a standardized
shape wire and exactly intersects the axis of each bracket at the centre of the
slot. Thus, the appliance is completely adapted for the use of straight wires
which can be chosen by the orthodontist with variant grade of elasticity in all
phases of treatment. This confers to the system all the properties of a very
secure and accurate straight wire technique.
3D FACIAL IMAGERY
Moreover, in some special clinical situations, or complicated cases, for greater
efficiency the practitioner can order a radiographic CT scan or a volumetric
acquisition (Cone Beam technology).
Then after a 3D imaging treatment of the original scan data, more individualized
parameters can be computerized for the highest level of individualization. In
this way, anatomical maxillo-facial elements such as teeth, bones and skin are
reconstructed as well as the anatomical landmarks of the TREIL’s maxillo-facial
frame. Subsequently, facial features can be related to bone structures, bone to
teeth, and inversely, from teeth to the face. As well, 3DT cephalometrics are
available for quantitative analysis and many geometrical parameters are
measured allowing numerical applications of therapeutic aid. This imagery makes
a new perception of facial aesthetics and takes into account the real impact of
dental structure on the facial balance. A fantastic opportunity is available to
apply an innovative and full-purpose biometry of the face, maxillaries and teeth.
15. Ideal- Leone
Idea-L lingual brackets feature small mesio-distal sizes and 1,4 mm thickness to
ensure patient acceptance and minimize speech issues starting from the first
treatment. The special design of the bracket makes the application of Slide™*
simple and keeps it in place during treatment.
The use of Slide™* ligatures offers several advantages:
• Slide™* ligatures embody the profile of the bracket, making it smooth and
• Slide™* ligatures allow to take advantage of
the biomechanical features of Low
Friction with the application of light forces
• Slide™* ligatures make treatment time shorter.
In most cases the use of a round wire Memoria® .012” is sufficient to get the
resolution of the overcrowding of the teeth and the aesthetical improvement of
In cases where dental rotations and/or major misplacements are present, wires
of higher diameter, like Memoria® or Beta Memoria®, and conventional ligatures
may also be used to increase biomechanical control.
Designed for 2D biomechanics with the use of round wires only, Leone lingual
system doesn’t require any elaborate and expensive set up of models.
To get a perfect alignment and levelling of the frontal teeth, an accurate
of the bracket is necessary; it is therefore advisable to use an indirect bonding
technique with arch transfer trays realized in the laboratory or with the special
conceived for this technique.
Plastic jigs are manufactured in six sizes to allow the choice of the most correct
position according to the anatomy of the lingual surface of the tooth.
16. Hiro- Medix 21
HIRO BRACKETS introduce all the technical improvements offered nowadays in
the lingual orthodontics industry. Dr. HIRO, one of the world´s main specialists
in lingual orthodontics, has been responsible for the design of the brackets. The
outcome is a Bracket that brings along multiple functional advances, allowing
orthodontist to optimise the effects of treatment and granting patients´
comfort, through their anathomical design and reduced size.
In this way, HIRO BRACKETS appear as a
solution to the deficiencies (technical and competitive deficiences) detected in
the existing offer at present. As the lingual brackets with best technical
features, smallest size and most competitive price, HIRO BRACKETS are
deemed to become the new reference in the market of lingual orthodontics
Hirobrackets was born in 1996, in order to improve the difficulties associated
They are as follows;
1. To make Double Over Tie unnecessary
2. To improve pronunciation difficulties
3. To reduce Tongue Irritations
4. To avoid brackets’ interference with other teeth
5. To reduce the frequent of brackets’ broken off from the teeth
6. To reduce the costs
Why are Hirobrackets only 6x6?
Hiro brackets is delivered only 6 to 6, Upper and lower. This is because so
many options are exist for the second molars. Some doctors are using small
tube for o Hinge cap molar tubes for terminal molars. Please use your favorite
molar tubes for second molars.
B. Lingual arch form
Typical maxillary and
mandibular lingual arch
form, and arch form
The ideal lingual arch form is mushroom-like.
There is a 3-4 mm inset between the canine and the first bicuspid in the upper arch, and
a 2-3 mm inset in the lower arch. A smaller inset is made between the second premolar
and the first molar.
Double overtie ligation
used for the anterior
Chain with Double overtie
ligation used for closing
Rotation tie used for
Standard ligation is not sufficient to seat and hold the bracket into the
lingual bracket slot, the ligation method in LO is double over-tie, and it is
done with both metal and elastic ligatures.
D. Treatment steps
Initial diagnosis and case selection
Skeletal and growth pattern
Periodontal and Prosthetic evaluation
Periodontal initial preparation
Restorations and prosthesis:
Old amalgam restorations can be replaced
with composite restorations.
Bridges can be separated to units, or used
as one unit if not separated.
Root treated teeth should be prepared
with posts and temporary crowns.
appliance to lingual, a retainer is needed
to avoid inaccuracy of the models.
Lingual tooth surfaces should be reformed
when deep fosse or pronounced bulges are
The laboratory procedure allows individual adaptation of
the brackets to each tooth.
Chair side Indirect bonding
Extraction (timing is important)
Leveling, aligning, rotational control and
Consolidation and Retraction (En masse
Detailing and finishing
Follow-up documentation: photos, models, x-rays
E. Case Selection
Lingual Orthodontics is relatively easy in the following cases:
Deep bite, Class I cases with mild crowding, good facial
Deep bite, Class I with spacing or diastema, good facial
Deep bite, mild Class II, good facial pattern
Class II division 2 with retruded mandible
Class II, maxillary first, mandibular second bicuspid
Class II, maxillary first bicuspid extraction
Mild bimaxillary protrusion with four first bicuspid
Class III tendency with deep bite
Lingual Orthodontics is relatively difficult in the following cases:
Open bite cases
Periodontal involvement with reduced bone level
Class III high angle case
Class II high angle cases
Severe Class II discrepancies
Cases with multiple restorative work
Short clinical crown
Poor oral hygiene
Mutilated posterior occlusion
Lingual (and buccal) Orthodontics should be avoided in the following cases
Acute TMJ dysfunction
Unresolved periodontal problems
Inadaptable personality type
F. Guidelines for lingual treatment
1. Proper patient selection
2. Correct brackets and laboratory preparation
Select 2 dimensional small brackets if torque control is not needed
Over-corrections for tip and rotations incorporated in bracket
positioning (especially when undesired movements need to be
avoided, in retraction mechanism for example).
Extra torque and angulation built in bracket position in extraction
cases (between 4-10 degrees extra torque for incisors, 2, 4, 6
degree extra distal root angulation for the central, lateral and
canine, and 6 degree mesial root angulation for the bicuspids and
molars- individual differences, according to initial condition)
3. Correct clinical treatment
Creating space before rotations (extractions, interproximal
reduction, advancement loops)
Maintain proper arch form (Using individualized templates, or
estimation of the arch form, by submitting the tooth width from
the labial arch form)
Anterior teeth are ligated with double over-tie
Whenever elastic traction is applied to a tooth, that tooth should
be tied with steel ligature.
Minimal archwire changing and wire bending is kept by following
proper archwire sequence.
Compensation for vertical and transverse bowing effect
Improved sliding and torque control by using .018 slot in the
anterior teeth and .022 in the premolar and molar.
Retraction in short span of wire between the elastic power tied
Elastic power is not applied on terminal molar.
Molar inset (1-2 mm), and is applied only after the space closure is
1. Bite Plane-always present
2. Light & Continuous intrusive force
3. Passive posterior extrusion (to prevent it- acrylic posterior
4. Application point closer to CR
5. Shearing forces- Compressive Force
1. Centrifugal Type Force (QH, RPE)
2. Thickness of the Brackets
3. Elimination of Occlusal Contacts
4. Application point closer to the CR (Bodily Movement)
1. Anterior inclined Plane
2. Acrylic mini-support
3. Flat-------- Class II elastics
4. Occlusal Indentations----Mandibular Guidance
1. No Occlusal Contact
2. Force Application
3. Labial- Distal Moment
4. Lingual- Mesial Moment
Short arch perimeter
Small interbracket distance
How to avoid (or treat) vertical and transverse bowing effect?
1. Use Stiffer wires (.016x.022 S.S)
2. Compensating horizontal and vertical wire
3. Apply short-span forces
4. Do not connect chains to terminal molar
5. Add anchorage: palatal bars, Nance button,
buccal segment, head gear, auxiliary wires to
HG tubes with Class II elastics
6. Laboratory prescription (bracket inclination)
7. Loop mechanics
8. Palatal molars cusps add anchorage
9. Bond second molars
10. Bond anchor unit passively
11. Load anchor unit later in treatment
12. Add torque (laboratory or wires)
Anchorage Control in Sliding Mechanics:
Including the 2nd molars
Head gear, Nance
Tip back in bracket positioning
Accentuated or reversed curve of spee
Reduced friction: .018&.022 slot
Reduced pressure on posterior anchorage:
light forces for space closure
less anterior tip and torque
The smaller IBD makes the same wire stiffer in
LO relative to the BO. According to Moran the
decreased IBD associated with LO makes a wire
approximately 3 times stiffer for first and
second order bends than when used with BO, and
approximately 1.5 times stiffer for third order
Moran K. I. Relative wire stiffness due to lingual
versus labial interbracket distance. Am. J. Orthod.
Dentofac. Orthop.: 1987; 92: 24-32
4. Laboratory & Clinical Procedure
A. CLASS system
(Customized Lingual Appliance Set-Up Service)
Developed by ORMCO and Specialty Appliances, Atlanta.
In the Class system the brackets are
bonded to an ideal set up model of the
case, and then transferred back to the
original model, for transfer tray
The stone model is sent to the Lab with specific instructions for bonding,
including extraction sites, anchorage, over corrections required. The
original model is duplicated and a set-up model is
prepared from the duplicated model.
2. The brackets
the teeth in the set-up model, after
choosing the best horizontal plan
that will suit all the teeth from the
anterior and posterior regions.
3. When all the brackets are bonded to the ideal
set-up model, a one-to-one photographic picture is
made to fabricate the ideal arch template.
4. The brackets from the ideal set up model are
transferred to the malocclusion model, using an
acrylic cap on each tooth as an index.
When all the brackets were transferred to the malocclusion model,
another one-to-one picture is made.
The next step is the transfer tray preparation
B. TARG system
(Torque Angulations Reference Guide)
In this system the brackets are bonded directly to the malocclusion model, using
the TARG machine to relate the lingual surfaces to the labial.
The malocclusion model is mounted on a swivel base and
tipped until the buccal long axis of the tooth is aligned
with a specific blade that was previously tilted to the
desired torque and angulation of that tooth.
2. The ideal bonding level is determined prior to the bonding
stage, by measuring the distance from the incisal edges to
the slots. The labio-lingual thickness of the teeth is also
determined by measuring it with a micrometer mounted on
the TARG (Electronic
3. After the trial of each bracket and after the in-out and
height level is determined, the brackets are bonded to
the malocclusion model with composite material.
4. A one-to-one photocopy or scanning is done on the
malocclusion model with the brackets on it, to allow the
tracing of the arch form template.
5. The model is now ready for the
C. Slot Machine
This is another laboratory device for precise lingual bracket
bonding, similar to the TARG, specially designed for Conceal
brackets and lately was adapted for Ormco brackets by Dr.
Pablo Echarri from Spain.
Multiple prescription styluses are available to provide many
prescription capabilities. This instrument serves for labial
indirect bonding as well.
Taken from www.centroladent.com
One of the currently most spread orthodontic techniques is the Straight Wire
Technique. The excellence of the obtained results and treatment objectives fulfillment
with this technique depend on two pillars that support the "Straight Wire", and they
are: the accuracy of the diagnosis and precision of the brackets positioning and bonding
on the teeth.
Desired and foreseen results normally are not achieved once the finishing archwire is
not active any more, so the orthodontists have to carry out different types of
compensations: Finishing "bends" ; Brackets repositioning and rebonding; Finishing
positioners and many other things, in order to obtain the best occlusion in patient.
The differences between treatment goals and obtained results appear due to:
The imprecision of the brackets positioning
Anatomic variations of the teeth that provoke maladjustments between the
tooth and the bracket base
The necessity for overcorrection of some movements, and mechanical
deficiencies of the Straight Wire: impossibility to position the bracket in the
very same resistance center of the tooth, movement range ("play") of the
archwire in the slot and decrease of the force carried out by the archwire as it
regains its original shape.
The advantages of Indirect Bonding are:
Accurate brackets positioning
The adhesive cannot be infected by the saliva and the brackets remain immobile
during the curing, the reason why the bonding quality increases and the number
of "debondings" decreases, and the chairtime reduces, too.
The Indirect bonding consists of brackets positioning and fixing on the plaster model
cast, transference tray fabrication, and brackets bonding of the whole arch into the
mouth at the only one appointment. The brackets positioning on the model cast is carried
out with a sophisticated and precise instrument: "The Slot Machine", designed by Dr.
D. The Lingual Bracket Jig - LBJ
The LBJ is a precision device for lingual bracket positioning.
It offers both advantages:
1. A relatively simple, yet, accurate chair-side direct bonding
2. A simple laboratory system to prepare the tray for the
indirect Bonding technique.
The concept behind the LBJ
The LBJ is based on the principles of the Straight Wire (Andrews) labial bracket
positioning. It actually copies the labial bracket slot prescription and translates it to the
The device consists of:
1. A set of six jigs, one for each of the six maxillary anterior
teeth, which present the main problem of morphological
variation on the lingual surfaces.
2. A special millimeter ruler, with up to 0.1 mm accuracy
Each jig has a labial arm and a lingual arm. The tip of the labial arm has a
prescription similar to a labial bracket. The lingual arm, which holds the lingual
bracket slides into the labial arm. Therefore, when the lingual bracket is
mounted on the LBJ, the lingual archwire slot is parallel to the labial slot.
When the labial arm is positioned correctly, exactly as a labial bracket is
positioned, according to the LA point, the lingual bracket is automatically placed
The LBJ fits both 0.018” and 0.022” slot brackets, after delicate manipulation
of the lingual extension
Sliding all the anterior jigs to the same B-L distance controls the
in-out position of the lingual bracket.
The height of Lingual bracket placement is controlled with an
adjustable occlusal stopper. The zero position of the occlusal
stopper is programmed to enable an overbite of 1 mm at the end of
The prescription of the LBJ is described in table 1.
Table 1: Jig’s prescription
Extra torque is incorporated in the LBJ to allow earlier torque control with lighter
wires. And to compensate the tendency to retrocline anterior teeth during space
Bracket positioning is simple, quick and does not require special training.
The orthodontist is offered the opportunity to perform direct as well as indirect
bonding as an in-office procedure, allowing him to maintain individual control over
E. KSLO Indirect Bonding & Set-up System (KISS)
F. Mushroom Bracket Positioner (MBP)
G. HIRO Technique
Implementing the Hiro Technique for Lingual
Indirect Bonding Dr. Kyoto Takemoto, Dr. Guiseppe Scuzzo. Clinical Impression, Volume
12 (2003) No. 1
INDIRECT BONDING SYSTEMS ? Precise Indirect BPrecise
Indirect Bonding Systems was started with one aim..improve
the precision of indirect bonding. Our first step to do this was
obvious make some new tools that will reduce the error by the
technician or assistant, depending where you like to do your
set-ups and the situation until 2004 as far as equipment goes
was pretty grim compared to that of other dental technology
sectors. On the lingual side, where there is a necessity for
indirect bonding, the main instrument was the TARG which had
been around since 1984 …20 years! During which time slight
improvements had been added, unfortunately the
improvements had missed one of the critical areas important
for reducing the time spent wire bending by the
Orthodontist…the Torque and Angulation. During this time
span Other various devices had been attempted but all lacking
in “ease of use” and or Precisiononding Systems was started with
one aim..improve the precision of indirect bonding. Our first step to
do her various devices had been attempted but all lacking in “ease of
use” and or Precision.
It’s true the wonderful
Incognito system had been created, being the first CAD / CAM
system for Lingual Orthodontics, however this only increased the
It’s true the wonderful Incognito system had been created,
being the first CAD / CAM system for Lingual Orthodontics,
however this only increased the cost to the Dr and therefore
the patient. Perhaps the main reason for its birth had been
directed at Dr’s who did not want to do the traditional ground
work and wanted a system that would think for them, but with
Gold prices sky rocketing, not to mention bonding issues and
bracket strength , this would only mean higher prices. Our
question was How could we better use mass produced brackets
like the Ormco STb or Dentsply’s Innovation or the 3M
Unitek? to mention a few and the answer came via the
invention of the TAD and BPDts birth had been directed at Dr’s
who did not want to do the traditional ground work and wanted a
system that would think for them, but with Gold prices sky rocketing,
not to mention bonding issues and bracket strength , this would only
mean higher prices. Our question was How could we better use mass
produced brackets like the Ormco STb or Dentsply’s Innovation or
the 3M Unitek? to mention a few and the answer came via the
invention of the TAD and BPD
I. Modified Hiro (for Adenta brackets)
Orthodontic lingual technique offers an attractive alternative for patients not
willing to permit the use of metal braces. Primarily, adult patients often do not
accept labial brackets due to the demands of their jobs or because they don’t
want to look like teenagers.
Since the introduction of the lingual treatment by KINYA FUJITA in the early
70`s, efforts were made to simplify brackets and treatment systems. There are
some well-evaluated and controllable lingual systems available, but the lingual
treatment is complicated and time consuming for the orthodontist as well as for
the patients. Therefore, the aim of further developments and improvements
should be to simplify the technique and to reduce chair time as well as the
number of appointments.
Comparing labial with the lingual technique, the differences
become obvious. The structures of the labial surfaces do not
differ very much between teeth or even different patients. In
contrast to that the lingual surface varies considerably between
teeth, consequently every bracket must be bonded using a
customized base to fit each tooth. The customized base can be
manufactured in the laboratory and transferred to the lingual
teeth surfaces by using transfer trays.
The lingual arch wires are mushroom shaped and have two offets
in order to level out the step between the canines and the first
bicuspid. It’s apparent that the placing and handling of lingual
appliances is more complex than that of labial appliances.
Self-ligating Bracket Features
A new self-ligating lingual bracket has been engineered
specifically to simplify brackets and treatment
systems. This new self-ligating bracket has proved to
be effective during treatment and has simplified the
handling of the appliance, creating a reproducible and
reliable treatment result. Consequently, the time
between appointments is extended. The lingual
technique can now be implemented even in busy
To engage the arch wires in the bracket slots, stainless spring clips
are used. The time consuming use of elastomeric ligatures, chains
and power thread can be eliminated. This elimination of ties and
chains presents an advantage for dental hygiene.
The closing movement of the clips is limited by a miniature step on
top of the slot, so the performance of the bracket can be
manipulated perfectly for each stage of the treatment. Small
diameter round wires are used during the levelling stage. These
arch wires do not touch the closing spring or any other structure of
the bracket slot. Consequently, the friction in the slot is at a
minimum level and the first stage of the treatment can be
performed in a very short time.
As the treatment progresses, the diameters of the arch wire
increase and change from round to rectangular. These arch wires
now touch the spring clips, and begin to lift them off the step. The
power of the spring clips increases, and the arch wires are pressed
down to the preadjusted bottom of the bracket slots. Torque,
angulation and in/out values are transmitted to the teeth.
One of the major obstacles in lingual treatment is oral hygience As brackets are
placed on the lingual surfaces of the teeth, the accessibility to the appliance
and to the teeth, for the patients as well as for the dental hygienists, is
difficult and time consuming than with the labial technique. The shape of the
brackets should be as smooth and as simple as possible to enable the patients
and the dental hygienists to keep a high level of oral hygiene.
Most lingual brackets are equipped with hooks for elastic chains and ligatures.
These hooks often overlap the marginal gingival, increasing the possibility of
plaque accumulation and consequently inflammation in the marginal gingival. Due
to the self-ligating design these hooks are not required, and oral hygiene can
now be performed with ease.
There are different
possibilities to find a
correct bracket position
on the lingual surfaces of
the teeth. We recommend
a customised Hiro system
that was specifically
developed for a self-ligating lingual bracket.
Start by creating an ideal set-up, this defines
treatment torque and angulation. At this early
stage all over correction can be fixed.
Subsequently an ideal arch wire (stainless
steel, 0,0018 X 0,0025 inch) is adjusted to the
lingual shape of the arch. The
ideal arch wire serves multiple functions. On one hand it is used to define the
correct bracket position and to create the customized bracket bases, on the
other hand it can be used as a template for all arch wires that are used during
the treatment. As the ideal arch wire must be reproducible for the entire
treatment period, it must be bended accurately, without inserting torque or any
other additional bends except the offsets in the region of the canines.
A small amount of Transbond LR composite is
now applied to the bracket base forming your
customised base for each individual lingual
tooth surface. The whole system is as close as
possible to the lingual surfaces of the teeth,
each bracket is adjusted and the composite is
There are different possibilities
to find a correct bracket position
on the lingual surfaces of the
teeth. We recommend a
customised Hiro system that was
specifically developed for a self-ligating lingual
bracket. Start by creating an ideal set-up, this
defines treatment torque and angulation. At
this early stage all over correction can be
fixed. Subsequently an ideal arch wire
(stainless steel, 0,0018 X 0,0025 inch) is
adjusted to the lingual shape of the arch. The
After creating single transfer trays for each tooth, the
brackets and the transfer trays are disconnected from the
ideal arch wire and the customized bases are sand blasted
for proper bonding to the teeth.
Transferring the Brackets
Bonding preparation remains the same as with the labial technique. It is not
necessary to sandblast the teeth. After mounting a Dry Field, normal etching
and conditioning can be performed. A Self- Etching Primer is highly
recommended. Since the transfer trays are exact replicas of each tooth, the
correct position of the bracket can be easily detected.
The brackets are then bonded with a light-curing
You may section the tray into 2-3 pieces or
bond as one piece. The possibility to
achieve dry field and the type of the
bonding material will determine whether to
bond in one piece or should you section the
tray. Make sure that the hooks of the
brackets are released from the transfer
2. Try the tray in the patient mouth, and then
dry and clean the custom bases. (Alcohol or
Acetone can be used).
3. Prepare the patient like you do for buccal
orthodontics: Clean the teeth, etch, rinse,
dry and isolate. Dry field is one of the keys
to success in the bonding procedure. Dry or
wet Microetching with sandblast (30
recommended on tough areas like metal fillings, crowns, porcelain and poor thin
coat of plastic conditioner can be applied on
the composite base to enhance the bonding
strength. Let it dry for at least 1 minute.
4. Chemical Cure: Many chemical cure
materials are available. Like Custom IQ,
Phase II, Maximum Cure (Reliance Inc.)
They are recommended when the transfer
tray is made from opaque materials. Apply
paste on both sides (tooth and composite
pad), and seat the tray immediately. Place
firm pressure from the occlusal to fully
seat the tray. Hold the tray in place 1
minute and leave passively for another 4
minutes. Do not have patient bite on the
tray or cotton rolls.
5. Light Cure: Transbond XT Paste (Unitek) with Ortho-Solo primer (Ormco) is
highly recommended when the transfer tray is transparent but you can use every
orthodontic light cure material that you have. Apply primer on tooth and on
composite pad, add paste and cure. Make sure that the tray fit the teeth
surface tightly and accurately.
6. Gently remove the tray by peeling it
from gingival towards the incisal.
Bonding failure: If one of the brackets
bonding failed, the transfer tray is cut
and the bracket is inserted into its
cavity in the segment for rebonding.
The bracket’s base is cleaned with acetone, alcohol or sandblast and bonded again as
If the segment is not suitable for reusing, it is possible to rebond directly with the
Lingual Bracket Jig (LBJ), or to take an impression and ask the laboratory for an
individual transfer tray for this tooth.
The transfer tray has to be restored for rebonding, in case of bracket fail.
Banding and welding
In cases of short clinical crowns, or Head Gear therapy, molars are
banded. The separation with separating modules is done only after
the bonding of the anterior teeth.
Molar bands incisal edge should fit the marginal ridgeline. The band
should not be fitted too gingivally, otherwise excessive lingual root
torque will be provided.
The bracket or tube is welded on the occlusal edge of the upper and lower molar band,
slightly on the mesial of upper molar band (To prevent rotations), and in the middle of
the lower molar band. (A guideline for the point of zero angulations is to align the ball
hook to the labial long axis of the mesio-buccal cusp)
In extraction cases extra (–6) degree of angulation (mesial root angulation) has to be
incorporated, in order to get tip back and improve posterior anchorage, to achieve root
parallelism and prevent bowing effect.
Lingual patients are more esthetically oriented, and
extractions sites are much more obvious when brackets are
invisible. Therefore a plastic or resin Pontic is placed after the
extractions to maintain aesthetics throughout treatment.
During the retraction phase, about 1 mm is removed from the
distal aspect of the pontics.
Acrylic teeth can be used as pontics or they can be built with
composite material. They are usually bonded to the bicuspids
with orthodontic adhesive material.
Debonding is done using bracket removing plier
(Ormco #801-0027) or using ligature cutter.
The resin is taken of with Tungsten Bur. Use
polishing and finishing burrs to smoothen the
enamel and apply prophylaxis agents.
A Positioner may be used to detail and idealize the occlusion.
The positioner is worn continuously for 48 hours after bracket
removal. Then it is worn for twelve hours a day for one month.
Then impressions are taken for retainer fabrication. Invisible
retention is used whenever possible.
Usually a bonded retainer is bonded to the lower anterior segment, and clear retainer is
delivered for the upper arch. Extraction sites are bonded to avoid space opening.
In case of rotated anterior teeth, a circumferential supracrestal fiberotomy (CSF) is
performed six weeks prior to bracket removal.
A. Preparation for Typodont Exercise
B. Extraction Case
A set of four progressive models, with bracket attached, has been
prepared to demonstrate the basic Extraction and Non Extraction
The typodont represents an example of a maxillary first bicuspid
Class II Division 2 with slight deep bite on a non-growing patient.
Treatment objectives are to obtain Class II molar relations, with Class I
cuspids, Bite opening, correct overbite and over jet. Lower crowding is to
be managed via interproximal enamel reduction combined with incisor
A. Preparation for typodont exercise
Kurz had and Ormco Company had developed some instruments special for
Lingual Orthodontics. A Korean company IVtech recently developed a new
line of very small pliers, especially designed for the lingual technique.
Module director (ETM 800-2108)
Lingual Utility Plier
Lingual Flush Distal
End Cutter (IVtech)
Lingual Pin & Ligature
Standard ligation is not sufficient to seat and hold
the bracket into the lingual bracket slot, The
ligation method in LO is double over-tie, and it is
done with both metal and elastic ligatures.
The double over-tie improves the rotation and
torque control. The bicuspids are ligated with a
conventional tie. To accomplish a double over-tie
ligation three-unit power chain is mounted on each anterior bracket. The
wire is then inserted and the chain is stretched over the wire. The
excessive two pieces of the chain is cut with scissors.
Steel ligature Over-Tie
The same procedure is done using a ligature wire.
This is the most efficient method used to correct a
rotated tooth in lingual Therapy. A five to seven unit
power chain is first tied to the archwire at the
interproximal junction in the direction in which the
tooth is to rotate. The last lumen of the chain is slipped
over the end of the archwire if it was removed from the
mouth. A slipknot may be formed over the archwire, by passing one end of
the chain through the expanded lumen at the other end of the chain. The
chain is then brought around the labial surface, through the interproximal
contact, using a floss threader, under the archwire, and attached to the
When using a chain for space closure, a similar technique is
used: the chain is mounted on the brackets prior to the wire
insertion. The wire is engaged, and then each fragment of the
chain is stretched over the wire.
B. Extraction Case
TYPICAL CASE WIRE SEQUENCE
(in 0.018 Slot or combination of 0.018 Slot for 3-3 and 0.022 for 4-7)
1a.0.012-0.014-0.016 NiTi, 0.017x0.017 Copper
NiTi, 0.016 TMA, 0.0175 Respond
Leveling and alignment
1b.016 SS,016x.022 SS
Initial cuspid retraction
1c. 0.012-0.014-0.016 NiTi, 0.017x0.017 Copper
NiTi, 0.016 TMA, 0.0175 Respond
Back to leveling
2. 0.0175x0.0175 TMA, 0.0175x0.025 TMA
3. 0.016 x0.022 SS
4. 0.016 TMA, 0.0175x0.0175 TMA
1.0.012-0.014-0.016 NiTi, 0.017x0.017 Copper
NiTi, 0.016 TMA, 0.0175 Respond
Leveling and alignment
2. 0.0175x0.0175 TMA, 0.0175x0.025 TMA
3. 0.016 x0.022 SS
4. 0.016 TMA, 0.0175x0.0175 TMA
Step 1: Alignment and Leveling - Initial archwire: Respond
.0175 (or NiTi with special archform plier)
Minimal forces on the still maturing bonds
Initiate cellular response with light resilient archwire
A period of patient adaptation
1. Select the lingual typodont # 1.
2. Form a maxillary .0175 Respond and mandibular lingual .0175
Respond wire using the 1:1 photographs as a guide. Mark the midline
and distal ends of the cuspids on the archwires
3. Mandibular arch - .0175 Respond
Using a bird beak plier, place a 90 degree first order bend, toward
the lingual, at the interproximal space between the cuspids and the
bicuspids. Make another 90 degree bend toward the distal forming
a 2 mm offset.
Make advancement loops, mesial to the mandibular first molar. It
will be used to advance the lower incisors and reduce the anterior
crowding. Arch length is increased in order to achieve space for
rotations, prior to reproximation,. No first order bends will be
made mesial to the molar in the non-extraction arch form, until the
last finishing archwires.
Cut the distal ends of the wire leaving approximately 2 mm of wire
of extending distal to the second molar tube, so that a tight right
angled bend can be made.
4. Maxillary arch -.0175 Respond
Make similar first order bends in the maxillary archwire. The first
order bend should be made more distal to the cuspids to allow
space for any initial alignment.
The lingual offset on the maxillary arch, in this case is 3-4 mm.
(The amount depends on the labio-lingual thickness of cuspids and
Compensation for transverse bowing effect:
The arch form should bow lingually from cuspids to bicuspids and
then return facially at the middle of the first molar. This lingual
bow prevents the mesial buccal rotation of the molars during
retraction of the anteriors.
Cut the distal wire excess so that approximately 2 mm of wire will
protrude distal to the second molar tubes when the wire is fully
seated in place. No first order bend will be made mesial to the
first molars in the extraction case at this time.
5. Initial archwire ligation
Use double over-tie in the anterior teeth and conventional ligation
on the bicuspids, using the 45-degree utility plier.
In the maxillary arch, you will notice that it will not be possible to
engage the laterals at this time. This is a common clinical
occurrence in moderate to severely crowded dentition.
Cut the wire approximately 2 mm distal to the second molar tubes and
bend these distal wire extensions tight behind the second molar.
Step 2: Alignment and Leveling – Initial Cuspid
Retraction: 0.016 TMA, 0.016x0.022 S.S, 0.016 NiTi
Increase arch perimeter
Establish arch form
Obtain complete wire engagement
Mandibular arch- .016 TMA
With advancement loops
1. Use the archform template and the just removed Respond
archwire to form a .016 TMA archwire, with the ideal first
2. Place advancing loops mesial to the first molars. Cut the
distal extensions leaving about 2 mm of wire to bend
3. Ligate the anterior teeth with double over-tie, and bicuspids
and molars with single ties.
Maxillary Arch - .016x.022 SS
For initial cuspid retraction
1. In case of severe rotations, a NiTi wire is used following the
initial .0175 Respond.
2. A .016x.022 SS wire will be used to obtain sufficient cuspid
retraction to gain the space necessary to engage the lateral
Form a .016x.022 SS wire on the archform template. Make
the cuspid first order bends close to the second bicuspids to
allow cuspid retraction.
3. Ligate the centrals with elastrometric double over tie. Tie
the bicuspids to the molars with steel ligature, before the
archwire is placed, to prevent rotations. Then insert the wire
and ligate the cuspids with steel ligature double over tie, and
the bicuspids and molars with o-rings.
4. Cut the arch 2-3 mm distal to the terminal tube and bend
the distal end buccally.
5. Cuspid retraction is conducted with elastomeric thread or
two-segment elastomer chain, from maxillary second bicuspid
to the cuspid.
Maxillary arch –0.016 NiTi
For alignment and corrections of rotations. Following initial cuspid
retraction, space was created for the lateral incisor engagement.
1. Select maxillary model #2.
2. Ligate NiTi .016 with elastomeric double over tie on the
anterior segment, and single elastomeric ties on the molars
3. Place a rotation tie on the left lateral using a segment of
clear power chain.
Step 3: Torque control 0.0175x0.0175 TMA or 0.017x0.025
The results obtained with the previous steps: The bite opened,
rotations resolved, maxillary centrals tipped labials, cuspids retracted
to allow engagement of the laterals.
Continue arch leveling
Complete corrections of rotations
Initial torque control
Mandibular arch- 0.0175x0.0175 TMA
With ideal arch form
1. Use the arch form template and the previous wire to form
the TMA ideal arch form, including first order bend mesial
to the molars. On typodont #3.
2. Ligate the wire with elastomeric double over-tie on the
anteriors, and single elastomeric ties on the bicuspid and
Maxillary arch - 0.0175x0.0175 TMA
Bent-back or tied-back omega loop
1. Bend a 0.0175x0.0175 TMA wire as previously, with cuspid
first order bends, and without molar first order bends.
2. Incorporate a slight accentuated curve of spee in the arch,
to exert more torque in the anteriors.
3. Ligate the wire with elastomeric double over-tie in the
anterior region and elastomeric o rings in the bicuspids and
4. Make a tight bend behind the second molar.
Step 4: Space Closure: 0.016x0.022 SS
Mandibular arch - 0.016x0.022 S.S
1. Form a 0.016x0.022 SS archwire using previous archwires
and the template.
2. Place a slight reverse curve in the arch, for additional
3. Ligate the anteriors with elastomeric double over-tie and
the bicuspids and molars with single ties.
Maxillary Arch 0.016x0.022 SS
For space closure
1. Form a 0.016x0.022 SS archwire using the previous
archwire and the template. The cuspid first order bend is
located just distal to the cuspid bracket. No molar first
order bend is made.
2. Incorporate in the arch an accentuated curve of spee, for
more torque control, and compensation curve for
transverse bowing effect.
3. Tie the six anterior teeth together with steel ligature, as a
unit. Then tie the second bicuspids to the first and second
molar as a unit.
4. Ligate the centrals and laterals with elastic double over
tie, insert the wire and tie the canine with double over-tie
steel ligature, and the bicuspid and molars with steel
5. Retraction is done with elastic chain from the second
bicuspid to the hook on the cuspid.
Step 5: Finishing & Detailing: 0.0175x0.0175 TMA,
0.017x0.025 TMA, 0.016 TMA, 0.016 SS
1. Place first order bends for the cuspids and molars,
coordinated with the upper arc.
1. Place cuspid and molar first order bends, coordinated with
the lower arch.
2. Bend back to prevent reopening of the spaces.
Upper and lower
Torquing with 2D plus brackets Forestadent
Advanced course - Guidelines for Lingual Orthodontics
1. Proper patient selection
2. Laboratory preparation
Over-corrections for tip and rotations, whenever possible,
incorporated in bracket positioning (especially when undesired
movements need to be avoided, in retraction mechanism for example.
2. Extra torque built in bracket position (about 40 extra torque for
incisors and canines)
3. Molar bracket position with 50 tip back and anti-rotation
4. PM and M brackets are aligned with the marginal ridges
Bi-dimensional orthodontics for improved sliding and torque control
(.018 slot from cuspid to cuspid and .022 in the premolar and molar).
2. Creating space before rotations (extractions, interproximal
reduction, advancement loops). No bends.
3. Rectangular full engagement wires for alignment and “Lace backs”
to avoid proclination
4. Maintain proper arch form (Using individualized templates, or
estimation of the arch form, by submitting the tooth width from
the labial arch form)
5. Anterior teeth are ligated with double over-tie
6. Use posterior bite plane for retroclined/proclined cases
7. Whenever elastic traction is applied to a tooth, that tooth should be tied
with steel ligature.
8. Minimal archwire changing and wire bending is kept
by following proper archwire sequence.
9. Space closure by en masse retraction, only on rigid wires, curve of
Spee compensation and anti-transverse bowing effect
10. Retraction with light elastic chain force, in short span of wire
between the elastic power tied brackets.
11. Elastic power is never applied on terminal molar.
12. Molar inset (1-2 mm) is applied if necessary only after the space
closure is completed (finishing stage)
13. Finishing bends: better with rectangular resilient wire. If round
wire is used, then an inset bend should be wide and with intrusion
component, and an offset bend: narrow and extrusion component.
4. Laboratory tips
1. Add 1 mm height to the cuspid and premolar to compensate for bowing effect
and to create occlusion at the end of treatment
2. In open bite cases: more height in the front and less in the back
3. When lower proclination is needed, incisal edge will move down, so bracket
height should be increased in 0.5-1 mm and another 0.5 mm to the cuspid to get
4. In incisor extraction, add height to lower laterals and cuspid (0.5 mm) and 1
mm to the central to avoid teeth tendency to move down.
5. In extraction of upper 4-4 add –6 deg. To molars to have tip back effect.
This may cause a step between premolar and molar!
5. Brackets placement
1. Ormco bracket is around 5 mm height-may cause problems in short crowns
2. The distance between the bite plane and the incisal edge is 1.2 mm
3. Bracket is usually placed 2.5 mm from incisal edge, which will give 1.3 mm OB
4. Short crowns may lead to very small OB!
5. In Deep Bite cases, mandible moves back after bonding6. Place tubes on 7-7
(preferably small one like speed tubes)
7. Place hinge caps on 7-7 when there is big discrepancy between 6-7 positions
8. Use crimpable hooks to “lock” the wire
9. When crown is short in 7, a button or band is bonded
10. When premolar bracket tend to fall- add resin on the cusp and on metal
6. Recommendations for successful treatment
1. Same treatment goals as in buccal orthodontics
2. Plan to treat only what you are sure you can get…
3. Decide on your treatment plan in advance (and do not “reevaluate” your
treatment plan later…)
4. Update the patient in advance what kind of cooperation he will be needed
5. A compromise treatment results are acceptable as long it is agreed before.
Recommended Materials for typodonts course: (brought by the
1. Ligature cutter
3. Arch wire cutter
2. Utility plier for inserting and removing the wires
3. Light wire plier
4. Mosquito forceps
5. Lingual debonding plier (ETM 800-0431)
6. Module remover (or explorer)
7. Ligature Director (ETM 800-2108 or similar)
8. Hollow chop contouring plier (ETM 800-2032 or similar)
9. Bending plier for NiTi wires, Hu-Friedy 678-302
Wires and Elastics for typodonts course: Supplied by Ormco
(See Ormco Catalog)
Respond .0175 # 203-0007
Ni-Ti .016 Upper (size 2) # 205-0023
Ni-Ti .016 Lower (size 2) # 205-0023
TMA .016 # 202-0025
TMA .0175x.0175 # 202-0018
TMA .017x.025 # 202-0020
Copper Ni-Ti .017x.017 Upper (size 2) # 205-0075
Copper Ni-Ti .017x.017 Lower (size 2) # 205-0078
S.S .014 # 206-0000
S.S .016 # 206-0001
S.S .016x.022 # 206-0006
Gray Power Chain Ii #639-0011
Gray Power O #640-0078
Metal Wire Ligature #270-0010
Lingual Hinge Cap Bracket Opening Tool #802-1001
Appendix II: Instructions for LO patient after bonding
The first days of orthodontic treatment may be difficult. Reading the following
instructions might help and ease the adaptation of the new patient to the LO appliance.
What are the problems LO patients have to deal with?
The presence of brackets (labial or lingual) in the oral environment may alter
tongue and lips movements causing a slightly distorted sound, especially in “s”,
“ch”, “th”, “t”, “z”, and “d” sounds. Most patients adapt to the brackets and their
speech becomes close to normal within several hours or days. Practicing will help
you to accommodate. It is advised to practice 15 minutes a day immediately
following the placement of the lingual appliance. One has to read loudly and
slowly, using recording devices to enable mistakes correction. In case the
adaptation is too slow, it is advised to consult with speech therapist who
specializes in speech problems.
2. General soreness in the mouth is normal after archwires are changed or
adjusted. This can be relieved by tooth and gum brushing and by rinsing with
salted water. Wax is used to cover irritating parts of the appliance. Within
several days the tongue will find its place in the mouth and will automatically
avoid irritating parts.
3. Eating will be difficult at the first days of treatment. At the first days it is
recommended to eat only soft foods like soups, pasta, mashed potatoes, yogurt.
Biting with the anterior teeth should be avoided, and food should be cut with a
knife or with the fingers. Sometimes the posterior teeth will not be in contact
due to the contact between the anterior teeth and the brackets. These
problems will be solved usually within 4-12 weeks.
4. Emergency – If a wire or a bracket comes loose and it irritates the tongue or
cheeks, wax can be placed over it and earlier appointment should be scheduled.
Broken pieces should be kept and brought back to the office. Tooth loosening is
to be expected throughout treatment and is part of the orthodontic movement.
The teeth will become stable again in their new position when treatment is
5. Remember: the success of the LO treatment depends on the patient as well as
the orthodontist. The teeth, gums and appliance should be kept as clean as
possible. Doctor’s instructions should be kept, and hard and sticky food should
be avoided throughout the whole treatment.
Appendix III: Indirect bonding instructions with the Lingual
A. Taking impression
Take an accurate impression of the arch to be bonded. Pour up in stone.
B. Preparing models
Draw the long axis of the labial surfaces of the teeth, extend the line to the palatal side
and to the palate. Coat the surface with a 50-50 mix of liquid foil separator and water
(Cold Mold Seal). Allow separator to dry at least 6 hours.
C. Preparing brackets
Clean the brackets' base (acetone or alcohol) and mount the brackets on their JIG.
D. Vertical position
Determine the vertical position of the brackets by
measuring the distance between the vertical stopper and
the incisal edge of the labial part (x).
E. In-out position
Using the LBJ with the bracket mounted on
it, determine the in-out distance by
measuring the width of the widest tooth
(Central incisor or canine) and fix the in-out
stopper. Then slide the Jigs of all the six
anterior teeth to the same in-out distance
using the millimeter ruler.
F. Seating brackets
Using a small flat instrument such as an
adhesive spatula, place a small amount of a
light cure orthodontic adhesive (Transbond
Unitek 3M)) on the base of the bracket. The
paste is pushed into the mesh . Place a small
additional amount of adhesive onto the
bracket base and make sure the base is
Slide the labial arm along the labial surface of the tooth
while long axes of the tooth and the labial arm of the JIG
coincide, until the labial arm is fully seated, and the
occlusal stopper is in contact with the incisal edge of the
tooth. Then press gently against the in-out stopper. Clean
off any excess around the bracket base, and light cure for
ten seconds. Hold the bracket with an explorer and slide
the JIG out of the bracket gently. Place all brackets in
G. Posterior brackets & Lower arch
The lower brackets are positioned on the stone model using a simple tweezers. The
brackets are aligned by eyeballing considering the long axis of the teeth, the incisal
edges and the marginal ridges
H. Transfer tray preparation and bonding
The transfer tray is made on the malocclusion model. It allows transferring the brackets
from the malocclusion model to the mouth. The transfer tray is made of two layers. The
inner layer, which holds the brackets, is a soft flexible layer, and the outer layer, which
provides stability during bonding is a rigid layer. The transfer tray can be made of soft
and hard silicone impression materials or from clear 1.5 mm Bioplast and Biocryl in the
Biostar machine, or combination of clear resilient silicone (Memosil 2- Kulzer) and
omnivac plate (Soft Mouth guard 3 mm.).
I. Silicone tray
The light body of the silicone tray surrounds the brackets and includes
the base, tie wings and any exposed portion of the brackets.
Heavy body putty (or, alternatively a soft 3 mm Omnivac plate) is laced
directly over the soft body material. Coverage includes the lingual,
occlusal and half of the labial surfaces.
Place the working in a bowl of warm (not hot) water and let soak for 15
Minutes, and then remove the tray from the model.
Light cure the composite bases again for 20 seconds.
Lightly abrade the custom base surface with Micro-etcher, and wash
with soap and water.
Dry with compressed air.
Use a sharp knife to generally trim tray and make releasing cuts near
the brackets hooks.
Store the completed tray in a zip lock bag to prevent contamination.
Some teeth cannot be bonded initially due to overlapping, and individual
trays with brackets in their ideal position are made and bonded later,
when adequate space is gained.
Recommended materials needed:
1 Clear Silicone impression material (Memosil 2- Kulzer)
2 3 mm soft mouth-guard clear material
Appendix IV: List of laboratories for Lingual Orthodontics
Address: Archform Orthodontics Pty Ltd ABN 75 096 014 694 , Suite 4/875
South Caulfield, VIC 3162, Australia
Fax: +61 3 9532 4704
Contact Person: Mr. Ari Sciacca
e –mail: email@example.com
Address: 145 Rue Louis Rouquier
Phone: +33 141 066688
Fax: +33 155 902112
Contact Person: Dr. Didier Fillion
e –mail: firstname.lastname@example.org
Address: AOA Orthodontic Appliances
P.O. Box 725, Sturtevant, WI 53177
Contact Person: Mr. Max Hall
Address: Kamelya 2-3 D.1 D.2 Atasehır, 34758 Istanbul
Phone: +90 216 4558898
Fax: +90 216 4552649
Address: 8 phoenix business centre
ripon, north yorkshire hg4 1ns
Phone: +44 1765 698300
Fax: +44 1765 609088
Address: Ladent, S.L.
C/. Museu, 6, 1º-1º , 08912 Badalona (Barcelona)
Phone: +34 93 384 47 05
Fax: +34 93 464 22 42
Address: P.za Aspromonte, 35, 20131Milano
Phone: +39 2 295 27081
Fax: +39 2 295 21189
Thomas Halblich Lingualtechnik (Adenta)
Address: RauschstraBe 69, 13509 Berlin
Phone: +49 30 618 22 98
Fax: +49 30 618 71 10
Silam (Lingual Bracket Jig)
Contact Person: Dr. Silvia Geron
T.O.P. Service für Lingualtechnik GmbH
Address: T.O.P. Service für Lingualtechnik GmbH
Lindenstr. 42 , 49152 Bad Essen
The Torque and Angulation Lab
Address: 9/72 Bantor Suandokmak, T. Sansailuang
A. Sansai, Chiang Mai 50210
Contact person: Peter Sheffield
Tel: +66 53 491302
Fax: +66 53 49135
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