Bracket placement in lingual orthodontics

Bracket Placement in LingualBracket Placement in Lingual
OrthodonticsOrthodontics
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IntroductionIntroduction
Starting from 1970 is the decade whereStarting from 1970 is the decade where
adults seeking orthodontic treatmentadults seeking orthodontic treatment
where greatly increased.where greatly increased.
Esthetic became a primary concern toEsthetic became a primary concern to
patientspatients
Plastic brackets were introduced.Plastic brackets were introduced.

HISTORYHISTORY
Dr. Craven Kurz and Dr .Jim MilickDr. Craven Kurz and Dr .Jim Milick ––
First developed the concept of lingual bondingFirst developed the concept of lingual bonding
appliance in 1970; he created his own lingual appliance byappliance in 1970; he created his own lingual appliance by
modifying the labial appliance. And named it a “true lingualmodifying the labial appliance. And named it a “true lingual
appliance”.appliance”.
Brackets used were plastic lee fisher brackets-Brackets used were plastic lee fisher brackets-
This later resulted in high bond failure,This later resulted in high bond failure,
uncomfortable to patient and irritation to patient tongue.uncomfortable to patient and irritation to patient tongue.

LaterLater ORMCOORMCO - joined with- joined with frank miller, Craig andreikofrank miller, Craig andreiko
with kurzwith kurz and his new appliance. Here they used woodedand his new appliance. Here they used wooded
blocks which were scaled to 40:1, to fit into mouth.blocks which were scaled to 40:1, to fit into mouth.
Wooded blocks 40:1Wooded blocks 40:1
Anterior inclined plane effectAnterior inclined plane effect
Compressive forceCompressive force
Maxillary Anteriors intrusive and labial directionMaxillary Anteriors intrusive and labial direction

 Bond failures decreased, 1979 were after intense testingBond failures decreased, 1979 were after intense testing
a treatment protocol was established.a treatment protocol was established.
 lingual task force was formed in 1980.lingual task force was formed in 1980.
 The task force consists of Dr. Moody Alexander,The task force consists of Dr. Moody Alexander,
Dr.Richard Alexander, Dr.John Gorman,Dr.Richard Alexander, Dr.John Gorman,
Dr.Craven kurz and Dr.John Smith in collaborationDr.Craven kurz and Dr.John Smith in collaboration
with ORMCO.with ORMCO.

THE TASK FORCE OBJECTIVESTHE TASK FORCE OBJECTIVES
1.1. To refine bracket design (dimensions, torque, angulationsTo refine bracket design (dimensions, torque, angulations
thickness, etc.)thickness, etc.)
2.2. To develop mechanic therapy techniquesTo develop mechanic therapy techniques
3.3. To create arch wire designTo create arch wire design
4.4. To discuss the treatment sequencesTo discuss the treatment sequences
5.5. To determine the case selection criteriaTo determine the case selection criteria

1983- Ormco introduced this appliance to Europe1983- Ormco introduced this appliance to Europe
1988- Original ORMCO was reestablished by three member1988- Original ORMCO was reestablished by three member
panel of dr. kurz, Dr.Gorman and Dr.Smith, calledpanel of dr. kurz, Dr.Gorman and Dr.Smith, called KGSKGS
ORMCO TASK FORCE.ORMCO TASK FORCE.

TOOTH MORPHOLOGYTOOTH MORPHOLOGY
All tooth crowns exhibit some curvature above the cervical line.All tooth crowns exhibit some curvature above the cervical line.
This is called the cervical bulge.This is called the cervical bulge.
Mandibular posteriors and occasionally maxillary posteriors haveMandibular posteriors and occasionally maxillary posteriors have
a lingual curvature of approximately 1 mm width, the crest ofa lingual curvature of approximately 1 mm width, the crest of
curvature at the middle third of the crown.curvature at the middle third of the crown.
Mandible anterior shows less curvature on the crown aboveMandible anterior shows less curvature on the crown above
cervical line, usually it is less than 0.5mm and it is so slight itcervical line, usually it is less than 0.5mm and it is so slight it
is hardly distinguishable.is hardly distinguishable.
The mandible canines may show a little more curvature thanThe mandible canines may show a little more curvature than
central and lateral incisors.central and lateral incisors.www.indiandentalacademy.comwww.indiandentalacademy.com

Lingual aspect maxillary central incisor labial aspect.Lingual aspect maxillary central incisor labial aspect.
Labial aspect- the surface is smooth generallyLabial aspect- the surface is smooth generally
The lingual aspect has convexities and a concavityThe lingual aspect has convexities and a concavity
The lateral incisors have a very slight concavity between theThe lateral incisors have a very slight concavity between the
marginal ridges.marginal ridges.
The lingual surface is flat and the convexity gradually progress toThe lingual surface is flat and the convexity gradually progress to
the cervical third.the cervical third.
Maxillary and mandibular centralMaxillary and mandibular central
and lateral incisorsand lateral incisors

Maxillary and mandibular canineMaxillary and mandibular canine
The cingulum is large and pointed like a cuspThe cingulum is large and pointed like a cusp
Definite ridges and inbetween ridge the concavities are calledDefinite ridges and inbetween ridge the concavities are called
lingual fosse.lingual fosse.
Mandibular canine, it is slightly flatter. Simulating the lingualMandibular canine, it is slightly flatter. Simulating the lingual
surface of mandibular incisors.surface of mandibular incisors.
The cingulum is smooth and poorly developed.The cingulum is smooth and poorly developed.

Maxillary and mandible premolarsMaxillary and mandible premolars
The maxillary first premolar is reverse of the gross outline of theThe maxillary first premolar is reverse of the gross outline of the
buccal aspect. The lingual cusp is narrower meiso distallybuccal aspect. The lingual cusp is narrower meiso distally
than the buccal cusp with the spheroid shape.than the buccal cusp with the spheroid shape.
Lingual portion of the crown is more convex.Lingual portion of the crown is more convex.
In addition maxillary second premolar gives slightly roundedIn addition maxillary second premolar gives slightly rounded
effect.effect.
1. The mandibular premolar tapers towards the lingual side.1. The mandibular premolar tapers towards the lingual side.
2. The lingual cusp is always small that makes it resemble as if2. The lingual cusp is always small that makes it resemble as if
canine, cervical portion is narrow , convex and pointed tip.canine, cervical portion is narrow , convex and pointed tip.www.indiandentalacademy.comwww.indiandentalacademy.com

MAXILLARY AND MANDIBULAR MOLARS
Lingual cusp is the only cusps to be seen from theLingual cusp is the only cusps to be seen from the
lingual aspect,lingual aspect,
The lingual developmental groove starts approximatelyThe lingual developmental groove starts approximately
in the center of the lingual surface mesio distally.in the center of the lingual surface mesio distally.
The lingual root is conical. The mandibular molarsThe lingual root is conical. The mandibular molars
havehave three cuspsthree cusps, two lingual cusps and one distal, two lingual cusps and one distal
cuspcusp

The distal outline of the crown is straight.The distal outline of the crown is straight.
The surface is concave at the side of the lingual groove above theThe surface is concave at the side of the lingual groove above the
center of the crown lingual. Below this point, the surface ofcenter of the crown lingual. Below this point, the surface of
the crown becomes almost flat as it approaches the cervicalthe crown becomes almost flat as it approaches the cervical
line.line.

PRINCIPLES OFPRINCIPLES OF
LINGUALORTHODONTICSLINGUALORTHODONTICS
PRIMARY REASONPRIMARY REASON
Facial Esthetics Public image.Facial Esthetics Public image.
The basic principle that are involved in the lingual orthodontics areThe basic principle that are involved in the lingual orthodontics are
ENHANCED FACIAL AESTHETICS, Advanced lingualENHANCED FACIAL AESTHETICS, Advanced lingual
technique, Shape memory wirestechnique, Shape memory wires in lingual orthodontics, Wirein lingual orthodontics, Wire
sequences and the Instruments used in lingual orthodontics.sequences and the Instruments used in lingual orthodontics.

BITE PLANEBITE PLANE
The bite plane in combination with labial appliances is used forThe bite plane in combination with labial appliances is used for
better aesthetic occlusion, by the maxillary arch expansion.better aesthetic occlusion, by the maxillary arch expansion.
The inclined plane in the lingual brackets is designed forThe inclined plane in the lingual brackets is designed for
avoiding the shear force and debonding of the lingual bracketsavoiding the shear force and debonding of the lingual brackets
in maxillary arch.in maxillary arch.
It expands the arch by eliminating the posterior contacts,It expands the arch by eliminating the posterior contacts,
extrusion of posterior segments and intrusion of lower incisorsextrusion of posterior segments and intrusion of lower incisors

The red arrows shows theThe red arrows shows the
primary force applied, and blackprimary force applied, and black
lines shows the resultant forcelines shows the resultant force

One of the main problems that lingual orthodontists have to overOne of the main problems that lingual orthodontists have to over
come is, not to over standardize treatment plans.come is, not to over standardize treatment plans.
A complete treatment plan is formulated with the type ofA complete treatment plan is formulated with the type of
mechanics, individual tooth and their center of resistance.mechanics, individual tooth and their center of resistance.

THE CUSTOMIZED LINGUAL APPLIANCETHE CUSTOMIZED LINGUAL APPLIANCE
SET UP SERVICE [CLASS]SET UP SERVICE [CLASS]
The class technique offers a method of lingual bracket placementThe class technique offers a method of lingual bracket placement
that takes into account the anatomical discrepancies in thethat takes into account the anatomical discrepancies in the
lingual surfaces of the teeth.lingual surfaces of the teeth.
This is accompanied by first constructing an ideal diagnostic setThis is accompanied by first constructing an ideal diagnostic set
up, from a duplicate set up model of the patients originalup, from a duplicate set up model of the patients original
malocclusion.malocclusion.
This ideal set up or template is then used as a physical guide toThis ideal set up or template is then used as a physical guide to
place the lingual brackets in an ideal configuration.place the lingual brackets in an ideal configuration.

An Ideal template bladeAn Ideal template blade

The brackets were placed on the diagnostic set up usingThe brackets were placed on the diagnostic set up using
composite adhesive, which acts as a spacer betweencomposite adhesive, which acts as a spacer between
the metal mesh pad and the individual dental surfaces.the metal mesh pad and the individual dental surfaces.
After the brackets were placed in the ideal diagnosticAfter the brackets were placed in the ideal diagnostic
set up, they are transferred back to the malocclusionset up, they are transferred back to the malocclusion
cast.cast.
At this point transfer trays are fabricated, so theAt this point transfer trays are fabricated, so the
brackets can be delivered clinically via the indirectbrackets can be delivered clinically via the indirect
bonding methodbonding method

THICKNESS MEASUREMENT SYSTEMTHICKNESS MEASUREMENT SYSTEM
This technique has been developed, by taking into account theThis technique has been developed, by taking into account the
advantages and pit fa]]s of the TARG (Torque Angulationsadvantages and pit fa]]s of the TARG (Torque Angulations
Reference Guide) an apparatus developed by ORMCO in 1984Reference Guide) an apparatus developed by ORMCO in 1984
for Lingual Bracket Bonding.for Lingual Bracket Bonding.
The T ARG despite the anatomical variations of the lingual toothThe T ARG despite the anatomical variations of the lingual tooth
surface, permits us to bond brackets In the laboratory at ansurface, permits us to bond brackets In the laboratory at an
accurate distance from the occlusal edge of each tooth withaccurate distance from the occlusal edge of each tooth with
resp.ect to the horizontal plane.resp.ect to the horizontal plane.
The tooth orientation is made with a gauge or torque blade.The tooth orientation is made with a gauge or torque blade.

The TARG developed by OrmcoThe TARG developed by Ormco

The model is kept in such a way that the long axis of the labialThe model is kept in such a way that the long axis of the labial
face of the tooth aligns with the specific gauge curvature at theface of the tooth aligns with the specific gauge curvature at the
middle third of the tooth.middle third of the tooth.
This orientation allows us to pre program torque andThis orientation allows us to pre program torque and
angulations before starting the treatment.angulations before starting the treatment.

PROCEDUREPROCEDURE
The tooth is tilted until the labial surface coincides with theThe tooth is tilted until the labial surface coincides with the
gauge curvature.gauge curvature.
The T ARG horizontal blade is engaged in the bracket slot andThe T ARG horizontal blade is engaged in the bracket slot and
moved towards the model coinciding with the function of themoved towards the model coinciding with the function of the
teeth, periodontium, and the bracket is filled with the resin toteeth, periodontium, and the bracket is filled with the resin to
bond on plaster in the base.bond on plaster in the base.

First order bends added to obtain the correct alignment because the TFirst order bends added to obtain the correct alignment because the T
ARG does not take the labio lingual thickness of the teeth. ItARG does not take the labio lingual thickness of the teeth. It
varies according to the height and level of bonding and the toothvaries according to the height and level of bonding and the tooth
type, even though the brackets are made with specific variabletype, even though the brackets are made with specific variable
thickness.thickness.

FILLION'S LINGUAL INDIRECT BONDING SYSTEMFILLION'S LINGUAL INDIRECT BONDING SYSTEM
This system developed in 1987 is essentially composedThis system developed in 1987 is essentially composed
of two elements a thickness measurement systemof two elements a thickness measurement system
(adapted from TARG) and the DALI program.(adapted from TARG) and the DALI program.
THICKNESS MEASUREMENT SYSTEMTHICKNESS MEASUREMENT SYSTEM
Since the T ARG is unable to compensate for theSince the T ARG is unable to compensate for the
unequal distance between the bracket slot and the labialunequal distance between the bracket slot and the labial
tooth surface, we added a caliper (mutation) to thetooth surface, we added a caliper (mutation) to the
TARG central axis and modified it to present twoTARG central axis and modified it to present two
horizontal blades. One is engaged into the bracket slot,horizontal blades. One is engaged into the bracket slot,
and the other one is attached to the labial tooth surface.and the other one is attached to the labial tooth surface.
The TARG with the Thickness Measurement systemThe TARG with the Thickness Measurement system

The macro filled resin is applied to the bracket base. When theThe macro filled resin is applied to the bracket base. When the
bracket placed on the blade is moved towards the plaster unit thebracket placed on the blade is moved towards the plaster unit the
selected thickness measurement appears on the screen. The resinselected thickness measurement appears on the screen. The resin
excess even on the gingival margins is removed beforeexcess even on the gingival margins is removed before
polymerization.polymerization.

THE DAILI PROGRAMTHE DAILI PROGRAM
((Computerized drawing of the lingual arch wire)
The program helps us to obtain a detailed drawing of the ideal
lingual arch wire with the entire tooth perfectly aligned. This is
possible from the measurement of tooth width with the help of a
computer, and the thickness measurement performed at the
laboratory by the technician.
The clinician has the choice to choose both initial arch form and the
final one that is ideal for the end of the treatment.www.indiandentalacademy.comwww.indiandentalacademy.com

LINGUAL TREATMENT WITH THE BENDING ARTLINGUAL TREATMENT WITH THE BENDING ART
SYSTEMSYSTEM
The bending art system (BAS) was designed by the bendingThe bending art system (BAS) was designed by the bending
art medicine technique in co-operation with the University ofart medicine technique in co-operation with the University of
Kiel. It is the first CAD/CAM device for orthodontic treatmentKiel. It is the first CAD/CAM device for orthodontic treatment
planning and bending of individual arch wires.planning and bending of individual arch wires.
It consists of three components:It consists of three components:
i.i. An intra oral stereoscopic camera,An intra oral stereoscopic camera,
ii.ii. A computer programA computer program
iii.iii. Wire bending unit.Wire bending unit.

BRACKET GENERATIONSBRACKET GENERATIONS
GENERATION # 1GENERATION # 1
The first Kurz Lingual Appliance was manufactured by ORMCO inThe first Kurz Lingual Appliance was manufactured by ORMCO in
1976. This appliance had a flat maxillary occlusal bite plane from1976. This appliance had a flat maxillary occlusal bite plane from
canine to canine, which transfers the shearing force directly to thecanine to canine, which transfers the shearing force directly to the
bracket.bracket.
Flat maxillary occlusal bite plane from canine to canine.Flat maxillary occlusal bite plane from canine to canine.www.indiandentalacademy.comwww.indiandentalacademy.com

The lower incisor and pre molar brackets were low profile andThe lower incisor and pre molar brackets were low profile and
half-round. These earlier brackets on the lingual surface of thehalf-round. These earlier brackets on the lingual surface of the
teeth were irritating to the tongue and impeded normal speech.teeth were irritating to the tongue and impeded normal speech.
There were no hooks on any brackets.There were no hooks on any brackets.

GENETRA TION#2GENETRA TION#2
This was revived in 1980, in which the hooks were added to allThis was revived in 1980, in which the hooks were added to all
canine brackets. A gingival hook is an integral part of thecanine brackets. A gingival hook is an integral part of the
bracket and provides rotational control.bracket and provides rotational control.
The Original hook was large and, in close proximity to theThe Original hook was large and, in close proximity to the
gingival margin, impeding access for hygiene.gingival margin, impeding access for hygiene.

Later hook was redesigned with a lower profile and moved awayLater hook was redesigned with a lower profile and moved away
from the gingival margin.Hooks was added for all caninefrom the gingival margin.Hooks was added for all canine
brackets.brackets.

GENERATION #3GENERATION #3
It was introduced in 1981, in which hooks were added to allIt was introduced in 1981, in which hooks were added to all
anterior and premolar brackets.anterior and premolar brackets.
To allow better control of tooth movements, the first molar had aTo allow better control of tooth movements, the first molar had a
bracket with an internal hook.bracket with an internal hook.
The second molar had a terminal sheath without a hook but had aThe second molar had a terminal sheath without a hook but had a
terminal recess for elastic traction. The appliance was fabricatedterminal recess for elastic traction. The appliance was fabricated
in high tensile metal which provides a greater degree ofin high tensile metal which provides a greater degree of
accuracy.accuracy.

Hooks were added to all anterior and premolar bracketsHooks were added to all anterior and premolar brackets

GENERA TION#4GENERA TION#4
This generation in 1982 - 1984 saw the addition of lowThis generation in 1982 - 1984 saw the addition of low
profile anterior inclined plane on central and lateralprofile anterior inclined plane on central and lateral
incisor brackets. The inclined or biteplane strategicallyincisor brackets. The inclined or biteplane strategically
placed to redirect the vertical shearing forces to aplaced to redirect the vertical shearing forces to a
horizontal seating force.horizontal seating force.
The location of inclined plane is such that when a 1 mmThe location of inclined plane is such that when a 1 mm
overjet and overbite relationship is obtained; alloverjet and overbite relationship is obtained; all
mandibular anterior contact with the inclined plane ismandibular anterior contact with the inclined plane is
eliminated. Hooks were optional, based upon individualeliminated. Hooks were optional, based upon individual
treatment needs and hygiene.treatment needs and hygiene.

Addition of a low profile anterior inclined planeAddition of a low profile anterior inclined plane

GENERATION#5GENERATION#5
It was introduced in 1985-86 with pronounced anteriorIt was introduced in 1985-86 with pronounced anterior
inclined plane, with an increase in labial torque in theinclined plane, with an increase in labial torque in the
maxillary anterior region, accurate contour of base pads,maxillary anterior region, accurate contour of base pads,
improving not only retentive capabilities but alsoimproving not only retentive capabilities but also
accuracy of bracket placement.accuracy of bracket placement.
The canine also had an inclined plane, it was bibeveledThe canine also had an inclined plane, it was bibeveled
to allow interception of the maxillary cusp withto allow interception of the maxillary cusp with
embrasure between the mandibular canine and firstembrasure between the mandibular canine and first
premolar. Hooks were optional.premolar. Hooks were optional.
A Transpalatal bar attachment was available for firstA Transpalatal bar attachment was available for first
molar bracket.molar bracket. www.indiandentalacademy.comwww.indiandentalacademy.com

Transpalatal bar attachmentTranspalatal bar attachment

GENERA TION#6GENERA TION#6
This was introduced in 1987-90. The inclined plane on theThis was introduced in 1987-90. The inclined plane on the
maxillary anterior becomes more square in shape. Hooks onmaxillary anterior becomes more square in shape. Hooks on
anterior and premolars were elongated. Hooks were placed foranterior and premolars were elongated. Hooks were placed for
all the brackets.all the brackets.
The Transpalatal bar - was optional.The Transpalatal bar - was optional.

Inclined plane on the maxillary anteriors became more square inInclined plane on the maxillary anteriors became more square in
shape; Hooks were elongated for all the bracketshape; Hooks were elongated for all the bracket

GENERATION#7GENERATION#7
Present generation first modified in 1990. The maxillary anteriorPresent generation first modified in 1990. The maxillary anterior
inclined plane is now heart shaped with short hooks.inclined plane is now heart shaped with short hooks.
The lower anterior brackets have larger inclined plane with shortThe lower anterior brackets have larger inclined plane with short
hooks.hooks.
Ligature locking grooves that are both deep set and easy to hookLigature locking grooves that are both deep set and easy to hook
have been designed.have been designed.
The pre molar brackets were widened mesiodistally and hooksThe pre molar brackets were widened mesiodistally and hooks
were shortened.were shortened.

The base extends mesiodistally providing adequate bond strength,The base extends mesiodistally providing adequate bond strength,
retaining hygienic qualities. These brackets have 1.5 - 2mm clearanceretaining hygienic qualities. These brackets have 1.5 - 2mm clearance
between the base and the gingival margin.between the base and the gingival margin.
The maxillary anterior inclined plane is now heart shaped with shortThe maxillary anterior inclined plane is now heart shaped with short
hooks.hooks.

Indirect bondingIndirect bonding
Indirect bonding of orthodontic brackets gained popularity as aIndirect bonding of orthodontic brackets gained popularity as a
result of the efforts of Dr.Silverman and Cohen. The choice ofresult of the efforts of Dr.Silverman and Cohen. The choice of
indirect bonding of labial brackets is elective, for bonding ofindirect bonding of labial brackets is elective, for bonding of
lingual brackets the preferred, if not the mandatory.lingual brackets the preferred, if not the mandatory.
Indirect procedure is preferred b’cos….Indirect procedure is preferred b’cos….
o The irregular lingual tooth morphology creates a requirementThe irregular lingual tooth morphology creates a requirement
for custom contouring of lingual bracket braces.for custom contouring of lingual bracket braces.
o The variation in lingual tooth morphology creates the need forThe variation in lingual tooth morphology creates the need for
custom measurement for selection of appropriate bracket basecustom measurement for selection of appropriate bracket base
thickness and torque.thickness and torque.

o The practitioner’s lack of familiarity with lingual toothThe practitioner’s lack of familiarity with lingual tooth
morphology makes it difficult for him to visualize angulations andmorphology makes it difficult for him to visualize angulations and
bracket heights and these angulations and heights must be relatedbracket heights and these angulations and heights must be related
to the more uniform labial surfaces.to the more uniform labial surfaces.
o It is difficult to obtain a direct line of sight for bonding on lingualIt is difficult to obtain a direct line of sight for bonding on lingual
surfaces .surfaces .
o Increased accuracury in bracket placement is required, becauseIncreased accuracury in bracket placement is required, because
compensating; omega; arch wire bends are more difficult and timecompensating; omega; arch wire bends are more difficult and time
consuming to form.consuming to form.

Problems Encountered in Direct BondingProblems Encountered in Direct Bonding
1. Height gauges used in direct bonding has proved to be inaccurate1. Height gauges used in direct bonding has proved to be inaccurate
for lingual height dermination. When the distance is increasedfor lingual height dermination. When the distance is increased
from the point of measurement (incisal edge), to the lingualfrom the point of measurement (incisal edge), to the lingual
slope greater the chance for error.slope greater the chance for error.
2.2. Bracket torque change relative to height placementBracket torque change relative to height placement
3. Variation of bracket height on labial surfaces will change the3. Variation of bracket height on labial surfaces will change the
bracket torque only a few degrees, with the exception of bell –bracket torque only a few degrees, with the exception of bell –
shaped lower bicuspids.shaped lower bicuspids.
4.4. Bracket placement in an precise means of bracket placement isBracket placement in an precise means of bracket placement is
the difficulty in visualizing crown and tooth angulations solelythe difficulty in visualizing crown and tooth angulations solely
from lingual crown anatomyfrom lingual crown anatomy
The indirect bonding has been modified considerably for lingualThe indirect bonding has been modified considerably for lingual
application by virtue of the experience and input of the lingualapplication by virtue of the experience and input of the lingual
task force.task force.

Case preparationCase preparation
1.1. Patient to undergo a thorough scaling and prophylaxisPatient to undergo a thorough scaling and prophylaxis
2.2. Large cingulae or rudimentary cusps, often seen on maxillaryLarge cingulae or rudimentary cusps, often seen on maxillary
cuspids, which interfere with proper bracket placement.Thesecuspids, which interfere with proper bracket placement.These
cingualae are reduced prior to impression taking.(12-flutedcingualae are reduced prior to impression taking.(12-fluted
carbide bur)carbide bur)
3.3. Unusually concave lingual surfaces, spoon-shaped incisors can beUnusually concave lingual surfaces, spoon-shaped incisors can be
filled using an acid-etch composite build up.filled using an acid-etch composite build up.
4.4. Metal coping exposed porcelain fused metal are often replaced toMetal coping exposed porcelain fused metal are often replaced to
plastic jacket crown.plastic jacket crown.
5.5. Provisional crown should be made of acrylic and cemented withProvisional crown should be made of acrylic and cemented with
zinc phosphate or polycarbonate cement.zinc phosphate or polycarbonate cement.
6.6. Dens-in-Dente or dens invaginatis –an incomplete fusion of theDens-in-Dente or dens invaginatis –an incomplete fusion of the
loves leading to a lingual pit of or clefting ,should ve restored withloves leading to a lingual pit of or clefting ,should ve restored with
composite restorative material or root canal treated.composite restorative material or root canal treated.

7. Existing amalgam restorations should be removed and7. Existing amalgam restorations should be removed and
restored with composite material.restored with composite material.
8. procedures that can cause tooth movement, separation ,8. procedures that can cause tooth movement, separation ,
extractions, removable appliances, - should be postponedextractions, removable appliances, - should be postponed
until after the lingual appliance is bonded.until after the lingual appliance is bonded.
9.9. Alginate Impressions are taken with a Rigid, Well-FittingAlginate Impressions are taken with a Rigid, Well-Fitting
Tray.Tray.
• extend at least to the mucogingical junction.extend at least to the mucogingical junction.
• Clear reproduction of lingual surfaces and gingival crest.Clear reproduction of lingual surfaces and gingival crest.
• Drying the gingival sulcus with air and wiping theDrying the gingival sulcus with air and wiping the
alginate into the lingual surfaces will aid in providingalginate into the lingual surfaces will aid in providing
clear, well-defined impressions.clear, well-defined impressions.
• Models are poured immediately in dental stone.Models are poured immediately in dental stone.
Minimizing the time between impressions and indirectMinimizing the time between impressions and indirect
bonding of the case will help ensure accurate seating ofbonding of the case will help ensure accurate seating of
the indirect tray.the indirect tray.

LABARATORY PROCEDURESLABARATORY PROCEDURES
Lingual bracket slot heights are first determinedLingual bracket slot heights are first determined – this is based on the– this is based on the
shortest lingual crown available in both the anterior and posteriorshortest lingual crown available in both the anterior and posterior
segments.segments.
Optimal bracket placement criteria includeOptimal bracket placement criteria include clearing the gingival crestclearing the gingival crest
by atleast 1.5 mm, and allowing 2mm between the incisal edgeby atleast 1.5 mm, and allowing 2mm between the incisal edge
and the bracket bite plane on maxillary incisorsand the bracket bite plane on maxillary incisors
TARG – are used to align the lingual surfaces relative to the labialTARG – are used to align the lingual surfaces relative to the labial
crown inclinations.crown inclinations.
Crown long axisCrown long axis is marked on the labial surfacesis marked on the labial surfaces

The lingual brackets are attached to the model with the bracket slotThe lingual brackets are attached to the model with the bracket slot
bisecting the reference mark, using water-soluble temporary cementbisecting the reference mark, using water-soluble temporary cement
or bonding material of choice; the brackets are sealed in place,or bonding material of choice; the brackets are sealed in place,
using a water-soluble film former.using a water-soluble film former.
The indirect transfer try is fabricated, using a low –viscosity siliconeThe indirect transfer try is fabricated, using a low –viscosity silicone
to encapsulate the brackets and silicone putty as the indexingto encapsulate the brackets and silicone putty as the indexing
medium and tray bulk.medium and tray bulk.
Then, the water-soluble temporary bracket cement and sealant areThen, the water-soluble temporary bracket cement and sealant are
dissolved, and the tray is removed and trimmed.dissolved, and the tray is removed and trimmed.

Chair side ProceduresChair side Procedures
 Special attention must be paid, however, to properSpecial attention must be paid, however, to proper isolationisolation andand salivasaliva
controlcontrol of mandibular teeth and to the special concerns when bondingof mandibular teeth and to the special concerns when bonding
in close proximity to the gingiva.in close proximity to the gingiva.
 There appears to be less plaque accumulation on the lingual, butThere appears to be less plaque accumulation on the lingual, but
lingual brackets on the lower anteriors do promote greater calculuslingual brackets on the lower anteriors do promote greater calculus
buildup.buildup.
 A number of lingual orthodontic patients may be adults with exposedA number of lingual orthodontic patients may be adults with exposed
cementum.cementum.
 Phosphoric acid in contact with the cementenamel junction duringPhosphoric acid in contact with the cementenamel junction during
etching can cause a painful, but transitory, reaction.etching can cause a painful, but transitory, reaction.
 This can be eliminated if the exposed root surface is first coated withThis can be eliminated if the exposed root surface is first coated with
a cavity varnish such asa cavity varnish such as CopaliteCopalite,, taking care not to coat the enameltaking care not to coat the enamel
surface that is to be etched.surface that is to be etched.www.indiandentalacademy.comwww.indiandentalacademy.com

PREBONDING PROCEDURESPREBONDING PROCEDURES
 Before beginning the bonding procedure, the indirect bracket transferBefore beginning the bonding procedure, the indirect bracket transfer
tray is tried in to ensure complete seating. After try-in, the tray istray is tried in to ensure complete seating. After try-in, the tray is
flushed with water and the brackets cleaned withflushed with water and the brackets cleaned with acetone.acetone.
 An antisialogogue is indicated on patients with excessive salivaryAn antisialogogue is indicated on patients with excessive salivary
flow,flow, Banthine (Banthine (lOOlOOmg) or Pro-Banthine (mg) or Pro-Banthine (3030mg)mg) tablets,tablets,
administered 60 minutes prior to bonding, have been most valuableadministered 60 minutes prior to bonding, have been most valuable
in establishing a dry bonding field.in establishing a dry bonding field.
(These drugs are contraindicated in patients with glaucoma, cardiovascular disease, and(These drugs are contraindicated in patients with glaucoma, cardiovascular disease, and
known allergic reactions to anticholinergics.)known allergic reactions to anticholinergics.)

 Special attention must be given to etching, drying, and theSpecial attention must be given to etching, drying, and the
sealant application adjacent to the gingiva. The gingiva must besealant application adjacent to the gingiva. The gingiva must be
firm and non-hemorrhagic. When pumicing the teeth, a rubberfirm and non-hemorrhagic. When pumicing the teeth, a rubber
cup is used, carrying the pumice into the gingival sulcus. Whencup is used, carrying the pumice into the gingival sulcus. When
etching, the solution is applied up to the gingival crest.etching, the solution is applied up to the gingival crest.
 A thorough rinsing is conducted, directing the air-water sprayA thorough rinsing is conducted, directing the air-water spray
into the gingival sulcus.into the gingival sulcus.
 The rinsed teeth are then dried thoroughly, using a syringe withThe rinsed teeth are then dried thoroughly, using a syringe with
clean, dry air directed into the sulcus. The etched enamel isclean, dry air directed into the sulcus. The etched enamel is
further desiccated with the warm-air blower.further desiccated with the warm-air blower.
 The bonding sealant is applied to the dried surface as close asThe bonding sealant is applied to the dried surface as close as
possible to the gingival crest.possible to the gingival crest.

Indirect Bonding ProceduresIndirect Bonding Procedures
1.1. Two-Component Mix SystemsTwo-Component Mix Systems
a. Prophylaxis and fine pumice and water mixture is used with aa. Prophylaxis and fine pumice and water mixture is used with a
rubber cup on a slow-speed hand piece. Sub gingival cleaning isrubber cup on a slow-speed hand piece. Sub gingival cleaning is
performed on those teeth where the bracket will be in closeperformed on those teeth where the bracket will be in close
approximation to the gingiva.approximation to the gingiva.
b. The pumice is then rinsed, and cotton rolls are placed under theb. The pumice is then rinsed, and cotton rolls are placed under the
lips.lips.
c. The maxillary teeth are dried with clean air.c. The maxillary teeth are dried with clean air.
d. The maxillary teeth are then etched for the required time (60d. The maxillary teeth are then etched for the required time (60
seconds), with a continuous light dabbing of the solution on aseconds), with a continuous light dabbing of the solution on a
cotton pellet or a fine brush. It is important that the etchingcotton pellet or a fine brush. It is important that the etching
solution be applied at least up to the gingival crest.solution be applied at least up to the gingival crest.
e. A forceful air-water spray is used to rinse and spray into thee. A forceful air-water spray is used to rinse and spray into the
gingival sulcus. A high speed evacuator is essential to preventgingival sulcus. A high speed evacuator is essential to prevent
pooling of the rinse, particularly on the lower arch.pooling of the rinse, particularly on the lower arch.

f. The etched teeth are completely dried, with particular attentionf. The etched teeth are completely dried, with particular attention
to a thorough drying of the gingival sulcus. The air syringeto a thorough drying of the gingival sulcus. The air syringe
must deliver clean, dry air. A warm blower will greatlymust deliver clean, dry air. A warm blower will greatly
facilitate the drying operation.facilitate the drying operation.
g. A thin coat of the bonding sealant is applied to all theg. A thin coat of the bonding sealant is applied to all the
maxillary teeth to be bonded, carrying the sealant to themaxillary teeth to be bonded, carrying the sealant to the
gingival crest.gingival crest.
h. While the sealant is being applied, the adhesive is mixedh. While the sealant is being applied, the adhesive is mixed
and applied to the brackets in the indirect tray. Equaland applied to the brackets in the indirect tray. Equal
proportions of the two adhesive components are dispensedproportions of the two adhesive components are dispensed
onto a cold mixing slab, using enough adhesive to fill theonto a cold mixing slab, using enough adhesive to fill the
plastic nozzle of the CR filling syringe.plastic nozzle of the CR filling syringe.

• The two components are blended together for approximatelyThe two components are blended together for approximately
15 to 20 seconds, and loaded into the CR Syringe nozzle by15 to 20 seconds, and loaded into the CR Syringe nozzle by
pressing the open end into the mixed adhesive.pressing the open end into the mixed adhesive.
• The syringe is enough adhesive is injected into the mesh ofThe syringe is enough adhesive is injected into the mesh of
each bracket to provide slight excess. Slightly more adhesiveeach bracket to provide slight excess. Slightly more adhesive
is added on teeth with concave lingual surfaces. The tray isis added on teeth with concave lingual surfaces. The tray is
then inspected and seated on the prepared arch.then inspected and seated on the prepared arch.
• Total time for this operation should not exceed 70 secondsTotal time for this operation should not exceed 70 seconds

ISOLATION, DRYING, BONDING OF THEISOLATION, DRYING, BONDING OF THE
MANDIBULAR ARCHMANDIBULAR ARCH
 Procedures are the same for the mandibular arch;Procedures are the same for the mandibular arch;
however, the tongue, saliva, and the floor of thehowever, the tongue, saliva, and the floor of the
mouth make this bonding more difficult. The use ofmouth make this bonding more difficult. The use of
anan antisialogogueantisialogogue will greatly aid in preventing thewill greatly aid in preventing the
pooling of saliva from the submandibular glands.pooling of saliva from the submandibular glands.
 For isolation, aFor isolation, a Hygroformic saliva ejectorHygroformic saliva ejector or theor the
Unitek lingual saliva ejectorUnitek lingual saliva ejector is used to keep theis used to keep the
tongue retracted and to control moisture.tongue retracted and to control moisture.

REBONDING OF SINGLEREBONDING OF SINGLE
BRACKETSBRACKETS
- If the original indirect transfer tray is intact, it is retained- If the original indirect transfer tray is intact, it is retained
along with the surveyed working models for use inalong with the surveyed working models for use in
rebonding any lost brackets.rebonding any lost brackets.
- Whenever possible, the original bracket is re-used, as it has- Whenever possible, the original bracket is re-used, as it has
been customized for the tooth. The adhesive on the back ofbeen customized for the tooth. The adhesive on the back of
the bracket is lightly ground, using a fine stone.the bracket is lightly ground, using a fine stone.
Care is taken not to grind into the mesh. The bracket isCare is taken not to grind into the mesh. The bracket is
flushed with acetone to clean the remaining adhesive.flushed with acetone to clean the remaining adhesive.

- The original tray is then sectioned for the individual tooth and the- The original tray is then sectioned for the individual tooth and the
bracket replaced in the tray.bracket replaced in the tray.
- The tooth is prepared and rebonded using the individual tooth- The tooth is prepared and rebonded using the individual tooth
index.index.
- If the original tray is not suitable for re-use, or if it is-a first-time- If the original tray is not suitable for re-use, or if it is-a first-time
bracket placement:bracket placement:

- The archwire is removed and a snap alginate impression of theThe archwire is removed and a snap alginate impression of the
area is taken and poured in fast-set stone. The model is thenarea is taken and poured in fast-set stone. The model is then
dried in a microwave oven for 4 minutes.dried in a microwave oven for 4 minutes.
- The bracket is positioned on the stone model. Positioning isThe bracket is positioned on the stone model. Positioning is
aided by the marked working models.aided by the marked working models.
- A small single tooth silicone putty matrix is made to capture theA small single tooth silicone putty matrix is made to capture the
bracket position.bracket position.
- The case is immersed in hot water to remove the siliconeThe case is immersed in hot water to remove the silicone
matrix with the bracket imbedded.matrix with the bracket imbedded.
- The single bracket is then indirect-bonded as described.The single bracket is then indirect-bonded as described.
- If access and visibility permit, some brackets can, of course, be direct-If access and visibility permit, some brackets can, of course, be direct-
bonded. The proper bracket position and reference landmarks arebonded. The proper bracket position and reference landmarks are
determined by referring to the surveyed study model.determined by referring to the surveyed study model.

MOLAR TUBE DESIGNMOLAR TUBE DESIGN
A CONVENTIONAL oval tube with a mesiogingiaval hook isA CONVENTIONAL oval tube with a mesiogingiaval hook is
used.used.
The squashed oval tube has some advantages in that itThe squashed oval tube has some advantages in that it
increases patient comfort, allows molar control, and will accept aincreases patient comfort, allows molar control, and will accept a
ribbon arch.ribbon arch.

• The use of oval tube is recommended, first molar and second molarThe use of oval tube is recommended, first molar and second molar
areare
• banded if needed in a normal position.banded if needed in a normal position.
• The oval tube is centered mesiodistally and should be placed asThe oval tube is centered mesiodistally and should be placed as
occlusally as possible on the band.occlusally as possible on the band.
• Lingual cleats are welded on the buccal portion of the band forLingual cleats are welded on the buccal portion of the band for
rotation control, cross bite corrections, and placement of elasticsrotation control, cross bite corrections, and placement of elastics

PATIENT TREATMENTPATIENT TREATMENT
The goals of the first phase of treatment should be to……….The goals of the first phase of treatment should be to……….
1-1- Open the biteOpen the bite as necessary,as necessary,
2-2- Unravel the crowdingUnravel the crowding as necessary,as necessary,
3- Obtain3- Obtain molar relationshipmolar relationship..
Early bite opening is important. In any technique that uses lingualEarly bite opening is important. In any technique that uses lingual
attachments because of anterior occlusion.attachments because of anterior occlusion.
Phase I mechanics to accomplish these goals will differ dependingPhase I mechanics to accomplish these goals will differ depending
on the type of malocclusion to be treated.on the type of malocclusion to be treated.

Open BiteOpen Bite depth situations with little or no crowding require nodepth situations with little or no crowding require no
special considerations for placement of brackets.special considerations for placement of brackets.
All maxillary and mandibular teeth may be bracketed with littleAll maxillary and mandibular teeth may be bracketed with little
interference from occlusion. Although the maxillary andinterference from occlusion. Although the maxillary and
mandibular molars were banded on patients, direct bonding ismandibular molars were banded on patients, direct bonding is
definitely feasible.definitely feasible.
The more narrow the bracket the sooner the remaining teeth canThe more narrow the bracket the sooner the remaining teeth can
be bracketed, which is an advantage for the very narrow Beggbe bracketed, which is an advantage for the very narrow Begg
type bracket.type bracket.

Deep BiteDeep Bite situations present the most challenging mechanicssituations present the most challenging mechanics
for bracketing.for bracketing.
InIn extraction casesextraction cases, the goal is to move the maxillary cuspids to a, the goal is to move the maxillary cuspids to a
position where the lingual surface is not in occlusion so thatposition where the lingual surface is not in occlusion so that
these teeth may be bracketed.these teeth may be bracketed.
InIn nonextractionnonextraction cases, it may not be possible to bracket any ofcases, it may not be possible to bracket any of
the maxillary anterior teeth because of occlusal interferences.the maxillary anterior teeth because of occlusal interferences.
It has been suggested byIt has been suggested by Dr. Craven KurzDr. Craven Kurz of Los Angeles,of Los Angeles,
California that the brackets themselves could serve as a meansCalifornia that the brackets themselves could serve as a means
of bite opening, such as a bite plane might do.of bite opening, such as a bite plane might do.

DEBONDING OF LINGUAL BRACKETSDEBONDING OF LINGUAL BRACKETS
Follows the same principles as debondingFollows the same principles as debonding
labially applied brackets, but requires several differentlabially applied brackets, but requires several different
instruments, due to the limited access and concave lingual toothinstruments, due to the limited access and concave lingual tooth
morphology.morphology.
It is a two-step procedure:It is a two-step procedure:
1. Bracket removal.1. Bracket removal.
2. Adhesive resin removal.2. Adhesive resin removal.
1.1. Bracket RemovalBracket Removal the lingual brackets are removed bythe lingual brackets are removed by
exerting a peel force on the bonding base, causing the bondingexerting a peel force on the bonding base, causing the bonding
adhesive to fracture from the retentive mesh.adhesive to fracture from the retentive mesh.
A specially manufactured lingual Debonding Plier has been effectiveA specially manufactured lingual Debonding Plier has been effective
in bracket removal.in bracket removal.

This instrument engages the gingival edge of the bonding baseThis instrument engages the gingival edge of the bonding base
and exerts a lingual-incisal peeling, with a reciprocal force of theand exerts a lingual-incisal peeling, with a reciprocal force of the
plier on the incisal edge of the tooth.plier on the incisal edge of the tooth.
22. Adhesive Resin Removal. Adhesive Resin Removal -a large,-a large, multi flutedmulti fluted carbidecarbide
finishing burfinishing bur is used for the initial adhesive removal. This bur isis used for the initial adhesive removal. This bur is
large enough to reach into the concave areas of the incisors. Thelarge enough to reach into the concave areas of the incisors. The
remaining resin is then removed and polished, using abrasiveremaining resin is then removed and polished, using abrasive
rubber cups.rubber cups.
A final polishing with pumice or a prophy paste will restore theA final polishing with pumice or a prophy paste will restore the
enamel luster.enamel luster.

Improving patient comfort withImproving patient comfort with
lingual bracketslingual brackets
Patient EducationPatient Education
In general, lingual appliances not be placed on both arches at theIn general, lingual appliances not be placed on both arches at the
same time. At least two months are usually needed for thesame time. At least two months are usually needed for the
patient to adjust completely to the first set of brackets beforepatient to adjust completely to the first set of brackets before
the second one is introduced. Before any appliance is placed,the second one is introduced. Before any appliance is placed,
however, it is essential to explain precisely what the patienthowever, it is essential to explain precisely what the patient
will feel.will feel.

For those with severe craniofacial disorders, most patients can waitFor those with severe craniofacial disorders, most patients can wait
until the timing is best for them.until the timing is best for them.
It would be a mistake to place an appliance on a business person whoIt would be a mistake to place an appliance on a business person who
is planning to deliver a lecture a week later, or on a student who isis planning to deliver a lecture a week later, or on a student who is
about to take an important exam.about to take an important exam.
Patient education should focus on problems that are most likely toPatient education should focus on problems that are most likely to
occur after appliance placement: tongue contact, mastication, andoccur after appliance placement: tongue contact, mastication, and
speech.speech.

ConclusionConclusion
Use of the lingual appliance as presented here hasUse of the lingual appliance as presented here has
some distinct advantages over conventional therapysome distinct advantages over conventional therapy
on the buccal surfaces. The treatment time will beon the buccal surfaces. The treatment time will be
equal to conventional buccal treatmentequal to conventional buccal treatment time withtime with
increased experience. Although treatment withincreased experience. Although treatment with
lingually placed brackets maylingually placed brackets may not be suitable for allnot be suitable for all
patientspatients, limited experience indicates that it may be, limited experience indicates that it may be
effective and desirable enough for most patients toeffective and desirable enough for most patients to
become routine in most orthodontic offices.become routine in most orthodontic offices.

Bracket placement in lingual orthodontics

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