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This document provides a preface for the textbook "Lingual Orthodontics". It discusses the need for a comprehensive English language textbook on lingual orthodontics, as most existing literature was published in the early 1980s when the technique was first developing. It aims to disseminate the wealth of clinical experience and knowledge that has been gained by clinicians practicing lingual orthodontics over the past 15+ years. The preface acknowledges the contributions from international clinicians and aims to cover all aspects of lingual orthodontics, from history to mechanics to different case types. It positions the book as a resource to help more orthodontists adopt lingual techniques rather than a recipe book. The preface argues that with proper training

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 LINGUAL ORTHODONTICS 
LINGUAL ORTHODONTICS
LINGUAL ORTHODONTICS R A F I RO M A N O, D M D, M S c      .  .       Hamilton • London
B.C. Decker Inc. 4 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017 Fax: 905-522-7839 e-mail: info@bcdecker.com website: http://www.bcdecker.com © 1998 Rafi Romano All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, with- out prior written permission from the publisher. 98 99 00 01 / BP / 9 8 7 6 5 4 3 2 1 ISBN 1-55009-040-2 Printed in Canada SALES AND DISTRIBUTION United States U.K., Europe, Scandinavia, Middle East B.C. Decker Inc. Harcourt-Brace & Company Ltd. P.O. Box 785 24–28 Oval Road Lewiston, NY 14092-0785 London, NW1 7DX United Kingdom Tel: 71-267-4466 Fax: 71-482-2291 Canada Korea B.C. Decker Inc. Jee Sung Publishing Company 4 Hughson Street South 236-15, Neung-Dong P.O. Box 620, L.C.D. 1 Seung Dong-Ku, Seoul Hamilton, Ontario L8N 3K7 Korea Tel: 905-522-7017 Tel: 02 424-5463 Fax: 905-522-7839 Fax: 02 456-5058 Japan India Ishiyaku Publishers Inc. Jaypee Brothers Medical Publishers Ltd. 7–10, Honkomagome 1-Chome B-3, EMCA House, Bunkyo-ku, Tokyo 113 23/23B Ansari Road, Daryaganj, Japan P.B. 7193, New Delhi-110002, India Tel: 03 5395-7604 Tel: 11 3272143 Fax: 03 5395-7606 Fax: 11 3276490 Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs.
Robert W. Baker Jr., DMD Lingual Appliance Course Director University of Rochester Eastman Dental Center Private Practice, Limited to Orthodontics New York, USA Nitzan Bichacho, DMD Private Practice, Limited to Prosthodontics Tel Aviv, Israel Paul-Georg Jost Brinkman, DMD, PhD Associate Professor, Department of Orthodontics of the Free University Berlin, Dental School Berlin, Germany Vittorio Cacciafesta, DDS Postgraduate Orthodontic Residence Department of Orthodontics Royal Dental College Arhus University, Denmark Maurizio Cannavo, MD Visiting Professor in Lingual Orthodontics Specialization School of Orthodontics University of Ferrara, Italy Christian Demange, DCD, SQODE, CECSMO Orthodontiste Spécialiste Qualifié Docteur en Chirurgie Dentaire Docteur de l’Université Claude Bernard Maître de Conférences des Universités Practicien Hospitalier—Faculté de Lyon Lyon, France Pablo A. Echarri, DDS Private Practice, Limited to Orthodontics Barcelona, Spain Lorenzo Favero, MD, DDS, MSc Professor, Pediatric Dentistry Department University of Padua Padua, Italy Didier Fillion, DDS Private Practice, Limited to Lingual Orthodontics Paris, France J. Courtney Gorman, DDS, MS Private Practice, Limited to Orthodontics Marion, Indiana, USA Chiori Hashiba, DDS, PhD Private Practice, Limited to Orthodontics Tokyo, Japan Scott A. Huge Owner and President, Specialty Appliances Inc. Orthodontic Laboratory Norcross, Georgia, USA Craven Kurz, DDS, PhD President Emeritus of the American Lingual Orthodontic Association Private Practice, Marina del Rey California, USA Stuart McCrostie, DDS Specialist Orthodontist Waitara NSW, Australia Mario E. Paz, DDS, MS Course Director, Lingual Orthodontic Program University of California Los Angeles California, USA Friedrich Riemeier Manager, Bending Art Company Berlin, Germany Rafi Romano, DMD, MSc Private Practice, Limited to Orthodontics, Emphasizing Adult and Lingual Orthodontics Tel Aviv, Israel Massimo Ronchin, MD, DDS Assistant Professor in Orthodontics Cagliari University Visiting Professor University of Ferrara, Italy Guiseppe Scuzzo, MD, DDS Visiting Professor in Lingual Orthodontics Specialization School of Orthodontics University of Ferrara, Italy Alessandro Silvestri, MD, DDS, ENT Chief, Pre- and Postsurgical Orthodontic Service Department of Maxillo-Facial Surgery University of Rome “La Sapienza” Rome, Italy Kyoto Takemoto, DDS Private Practice, Limited to Lingual Orthodontics Chiba-ken, Japan Contributors
Contents Preface . . . . . . . . . . . . . . . . . . . .  SECTION 1 Introduction  Lingual Orthodontics: Historical Perspective . . . . . . . . . .  Craven Kurz, DDS, PhD, Rafi Romano, DMD, MSc  Present Clinical Reality . . . . . . . .  Massimo Ronchin, MD, DDS  Lingual Orthodontics in a Labial Orthodontics Office . . . . .  J. Courtney Gorman, DDS, MS SECTION 2 Basic Principles  Enhanced Facial Esthetics using Kurz Lingual Appliance. . . . . . . .  Craven Kurz, DDS, PhD  Advanced Lingual Prescription: Technique and Design . . . . . . . .  Robert Baker Jr., DMD . Shape Memory Wires in Lingual Orthodontics . . . . . . . . .  Christian Demange, DCD, SQODE, CECSMO . Wire Sequencing in Lingual Orthodontics . . . . . . . . . . . . . . .  H. Stuart McCrostie, DDS  Instruments Used in Lingual Appliance. . . . . . . . . . . . . . . . . .  Craven Kurz, DDS, PhD SECTION 3 Treatment Approaches and Mechanics  Anchorage Control in Lingual Orthodontics . . . . . . . . . . . . . . .  Kyoto Takemoto, DDS . Preserving the “Hollywood Smile” and Facial Profile . . . . . . . . . . . .  Mario E. Paz, DDS, MS . Distalization of Molars in Nonextraction Cases . . . . . . . . . .  Guiseppe Scuzzo, MD, DDS, Maurizio Cannavo, MD . Interproximal Enamel Reduction in Lingual Orthodontics . . . . . . .  Didier Fillion, DDS . Sliding Mechanics versus Loop Mechanics During En Masse Retraction in Extraction Cases. .  Kyoto Takemoto, DDS . Case Presentation: Loop Mechanics . . . . . . . . . . . .  Guiseppe Scuzzo, MD, DDS . Case Presentation: Sliding Mechanics . . . . . . . . . . .  J. Courtney Gorman, DDS, MS  Lingual Orthodontics in Pediatric Patients. . . . . . . . . . . .  Lorenzo Favero, MD, DDS, MSc
. The Lingual Technique in Orthognathic Surgery . . . . . . . .  Alessandro Silvestri, MD, DDS, ENT . Orthodontic-Surgical RPE Camouflage on an Orthognathic Case . . . . . . . . . . . . . . . . . . . . .  Mario E. Paz, DDS, MS . Segmental Lingual Orthodontics in Multidisciplinary Cases . . . . .  Pablo A. Echarri, DDS . Combined Orthodontic-Prosthetic Treatment of Malpositioned Anterior Teeth. . . . . . . . . . . . . .  Rafi Romano, DMD, MSc, Nitzan Bichacho, DMD  Lingual Orthodontics: Esthetics and Function. . . . . . . .  Chiori Hashiba, DDS, PhD SECTION 4 Laboratory Procedures  The Customized Lingual Appliance Set-Up Service (CLASS) System . . . . . . . . . . . . .  Scott A. Huge  The Thickness Measurement System with the DALI Program . . .  Didier Fillion, DDS  Lingual Treatment with the Bending Art System . . . . . . . . . . .  Paul-Georg Jost-Brinkmann, DMD, PhD, Vittorio Cacciafesta, DDS, Friedrich Riemeier SECTION 5 Appendix Bibliography . . . . . . . . . . . . . . . .  Index. . . . . . . . . . . . . . . . . . . . . . 
 The Preface to Lingual Orthodontics (LO) should have been actually called: “A short explanation why Lingual Orthodontics is the first complete English textbook ever pub- lished on LO.” The idea to edit Lingual Orthodontics arose in October 1995, at the Italian Association of Lingual Orthodontics (AIOL) meeting in Rome, where many of the best clinicians who practice LO were in attendance. When surveying the literature published on LO, it is surprising to discover that most of it was written from 1982–1985, immediately after Dr. Kurz from USA and Dr. Fujita from Japan developed the prototype lingual system and ORMCO founded the original Task Force. These years saw the very first steps with the new system, observed with the critical eyes of the orthodontic community and with exaggerated expectations from the public and media. While most orthodontists found interest in the new system, it was still undeveloped, without any finished cases, any protocol, and presented many technical problems. More than 12 years have passed since “silence” concerning LO was declared in the scientific journals, in all of the important ortho- dontic meetings, and in orthodontic offices. The media had completely stopped men- tioning the subject and because of the small number of orthodontists who continued to treat patients with LO during this period, we are now again in a situation charac- terized by a lack of knowledge in the dental community and among the public. The technique of lingual orthodontics, which is the only option we can give to those patients who want their orthodontic treatment to be done behind closed curtains, was really left with the curtains closed. The fault is partly due to the rapid decline in the number of orthodontists who offer LO as a treatment option in their office and partly due to the small efforts that were made by those who did practice LO to teach, to write, to do research, or to con- tribute from their knowledge to all of their colleagues. Excellent work is done all over the world with LO. Some clinicians have even decided to devote their practice exclusively to LO and can now present excellent clinical results with a long follow-up. Much new material that has not yet been published exists as well as tremendous experience that was gained in the field in the last 15 years. Much of this is known only to a small group of orthodontists who come to LO meetings all over the world. This book is published to change this situation because we believe that lingual orthodontics is the ultimate esthetic solution in orthodontics today. Many of the best clinicians who practice LO contributed to this book. They come from all over the world—from the USA, Australia, Japan, France, Italy, Spain, Germany, and Denmark. I would like to thank each one of them personally for the tremendous help, good will, and patience they have exhibited in the long process of creating an international book. They have all agreed to share their knowledge and experience with our readers. Many clinical tips and experience were gathered and are now disseminated Preface
  for the first time. Almost every possible aspect of LO is covered, including history, mechanics, extraction cases, nonextraction cases, pediatric patients, interdisciplinary cases, orthognathic surgery, practice management, laboratory procedures, and more. All of them are described in full detail and enhanced with color figures. This is not a recipe book, and it is not intended to teach LO. One should take accredited courses, come to LO meetings, and gain experience before adopting the system completely into his or her practice. Once a thorough knowledge and clinical experience are obtained, one will gain excellent clinical results, not less than he or she was used to with labial orthodontics, and with all the mechanical and esthetic advan- tages that are unique to LO. I have included all of the references I could find on LO to help the clinicians find their way in this new system. I do apologize to any author whose article I did not mention here. The advantages of LO over labial orthodontics are many. While better esthetics during treatment is the most obvious, some advantages are purely mechanical, like more efficient distal movement, much easier intrusion, increased expansion, and the built-in capability in the bracket design to reposition the mandible and tempero- mandibular jaw when needed. Some clinicians still claim that LO is not a legitimate option and that lingual orthodontic results are inferior to those achieved with labial orthodontics. In fact, the opposite is frequently true. We do believe that the advantages of LO as a treatment option are greater than the disadvantages, and it should be considered as a legitimate, equally good option to every other treatment modality. Still, there is much more to be done in the field of LO other than publishing more textbooks. Some disadvantages still to be overcome are: • Further improvement of the design of the brackets to make them smaller, more easily ligated, and smoother to the tongue. • Reduction in speech distortion during the early stages of treatment, which can be distressing to the patient. • The addition of training in lingual orthodontics to the graduate or postgrad- uate orthodontic programs in the universities around the world. • Reduction of the high fees by improvements in design and technique which will, in turn, reduce the chairtime of the orthodontist. I do hope this book will have a uniting influence on the clinicians using LO. The world has become a very small place since people began traveling extensively. Some of my patients come from Japan, USA, and Europe, and they expect each orthodontist to have the same knowledge and skills as his or her colleagues. Easy, rapid communi- cation tools exist and should be used to teach, to inform, and to unite. Teaching other orthodontists the “secrets” of our technique will, in the long run, bring us more accep- tance and more work. When more orthodontists use LO in their offices, patients will become more aware of it and ask for it. This phenomenon occurred in general den- tistry with porcelain veneers and bonding. When it became more popular, the dentists who were the first to do it became the leaders in esthetic dentistry all over the world. I hope that Lingual Orthodontics will become towards the year 2000 an essential part of orthodontic offices and university libraries, to be used by doctors and patients, and to be a part of the esthetic dentistry postgraduate studies.
Preface  I again thank all my colleagues who participated in writing this book, especially Dr. Didier Fillion, a friend and one of the best clinicians in LO in the world today; my Israeli colleague, Dr. Sylvia Geron, who helped me and supported me all the way; Prof. Adrian Becker, one of the most talented orthodontists I know, who inspired me tremendously; Dr. Linda Hallman, who helped review the material; Dr. Nitzan Bichacho, Dr. Paul Miara, and Dr. Bernard Touati who helped me enter the fascinating world of esthetic dentistry; and my wife, who warmly supported me. The book is dedicated to my father, Dr. Albert Romano. Rafi Romano, DMD, MSc
 Lingual Orthodontics: Historical Perspective. . . . . . . . . .  Craven Kurz and Rafi Romano  Present Clinical Reality. . . . . . . .  Massimo Ronchin  Lingual Orthodontics in a Labial Orthodontics Office. . . . .  Courtney Gorman SECTION 1 Introduction
   Lingual Orthodontics: Historical Perspective CRAVEN KURZ, DDS, PhD, AND RAFI ROMANO, DMD, MSc The 1970s was an exciting decade for orthodontics. The straight wire appliance was developed, treatment demands had increased, and adults were seeking treatment in greater numbers. This increasing demand for adult treatment brought unique con- cerns to the profession. Esthetics was then and continues to be a primary concern of patients. To address these esthetic concerns, manufacturers introduced clear plastic brackets; unfortunately, however, staining of the bracket and the tooth presented a significant problem. The search for improved esthetic alternatives to metal or clear plastic brackets continued. During the early 1970s, Dr. Craven Kurz, an orthodontist, then assistant professor of occlusion and gnathology at the UCLA School of Dentistry, found his private orthodontic practice to be increasingly dominated by adult patients. As many of his patients were public figures, esthetics became a major concern. A particular patient, who was an employee of the Playboy Bunny Club, presented to his practice requesting treatment. Because of her public position she refused metal or plastic labial appliances on esthetic grounds. From her demand for an appliance that did not show, the con- cept of a lingually bonded appliance was born. After much advice and consultation from orthodontic colleagues, particularly Dr. Jim Mulick, also at the UCLA School of Dentistry, Dr. Kurz developed the first true lingual appliance. The appliance consisted of plastic Lee Fisher brackets bonded to the lingual aspect of the anterior dentition and metal brackets bonded to the lingual aspect of the posterior dentition (Figures 1–1a and b). The plastic anterior brackets were selected because of the ease of recontouring and reshaping them to avoid direct contact with the opposing teeth. Treatment progress was closely moni- tored during this initial attempt at lingual treatment. Not surprisingly, Dr. Kurz found that occlusal forces produced a shearing force on the maxillary incisor brackets, creating a high bond failure rate. Additionally, the brackets were uncomfortable and irritating to the patient’s tongue. By the mid-1970s, Dr. Kurz found that by smooth- ing the exposed surface of the brackets using a heatless stone, patient comfort and acceptance increased. Not surprisingly, commercial interest was rapidly developing for this new appliance and approach to orthodontic treatment. Many clinicians and commercial companies were in the process of developing some version of a lingual appliance. During these early stages, Ormco, a company in California, created a product development team consisting of Mr. Frank Miller and Mr. Craig Andreiko to work with Dr. Kurz and his new appliance. Historically, Ormco’s interest in the concept of lingual orthodontic treatment was well established. In the early 1970s, in conjunction with Dr. Jim
  Wildman, they attempted to develop a system to align the dentition using the lingual approach. This system consisted of a Pedicle positioner, rather than a multibracketed system. Although innovative, inherent limitations in this system prevented it from gaining widespread popularity in the orthodontic community. With the new product development team now in place, prototypes of lingual brackets were developed to attempt to improve on the design of the original appliance. The prototypes were initially carved from wooden blocks at a scale of 40:1 and then recreated in appropriate materials in scaled-down versions to fit the mouth. It was quickly found that the problems that plagued all previous attempts at developing a usable appliance remained—namely, a high bond failure rate due the shearing forces, and patient discomfort from the roughness against the tongue. The turning point in the development of the appliance was the addition of an anterior inclined plane as an integral part of the maxillary anterior brackets (Figure 1–2). This inclined plane con- verted the shearing forces produced by the mandibular incisors to compressive forces applied in an intrusive and labial direction. These forces also produced a natural physiological bone resorption in the maxillary and mandibular incisor area, allowing the teeth to intrude at generally less than 100 milligrams in force each time the patient swallowed (approximately 2000 times per day).    -  . Dr. Kurz 1973–1975 labial appliance modified for lingual application.  -. The incline plane.
Lingual Orthodontics: Historical Perspective  Bond failures decreased dramatically. Redirecting the forces by the use of an ante- rior inclined plane appeared to be the missing link in the development of a viable lin- gual appliance. It was with this design that Dr. Kurz applied for a patent for the Kurz Lingual Appliance on November 15, 1976. Product development began in earnest in 1978, and Ormco manufactured a usable metal bracket by 1979. Initial clinical test- ing began in Dr. Kurz’s private office, with approximately 100 cases tested over a three- year period. All appliances were direct bonded, and a treatment protocol was estab- lished. From the initial testing, the appliance appeared to be viable and showed much promise in providing the profession with an esthetic alternative to labial appliances. The next logical step in product development and improvement was to establish beta test sites. Fifty selected orthodontists were invited to attend an Ormco-sponsored  -. Dr. Craven Kurz  -. Dr. Jack Gorman  -. Dr. J.R. Bob Smith
  symposium on lingual orthodontic therapy. Here, Dr. Kurz presented the concept of lingual treatment, the appliance, and his treatment results from the initial 100 cases tested to the professional community. From this group, the original Lingual Task Force was developed. This group was under the administrative guidance of Mr. Floyd Pickrel, Mr. Ernie Strauch, and Dr. Michael Scwartz, all from Ormco. Their charge was to guide and administrate the research and development team while a commercially viable lingual appliance was being developed. They appointed, in addition to Dr. Craven Kurz of Beverly Hills, California (Figure 1–3), the late Dr. Jack Gorman of Marion, Indiana (Figure 1–4), Dr. Bob Smith of Stanford, Florida (Figure 1–5), Dr. Richard (Wick) Alexander (Figure 1–6) and Dr. Moody Alexander (Figure 1–7), both from Dallas, Texas, Dr. James Hilgers of Mission Viejo, California (Figure 1–8), and Dr. Bob Scholz of Alemeda, California (Figure 1–9) to provide beta test sites for the appliance.  -. Dr. James Hilgers  -. Dr. Bob Scholtz  -. Dr. Wick Alexander  -. Dr. Moody Alexander
Lingual Orthodontics: Historical Perspective  Excitement about an esthetic alternative to traditional orthodontic treatment was growing within the dental profession. This plus public demands for this alternative treatment forced an urgency on the research and development team to provide the appliance for wide-scale use as quickly as possible. By the early fall of 1981, the task force was presenting regular seminars on the lingual appliance in Newport Beach, California. That same year, Dr. K. Fujita of Japan, published an article on lingual therapy in the American Journal of Orthodontics. Commercial interest was spreading. Unitek supported a Lingual Clinical Project under the direction of Dr. Vince Kelly of Oklahoma. Dr. Steve Paige of Florida began giving courses using a Begg appliance lingually. Forestodent, and American Orthodontics all began to market lingual brackets and accessories. Public interest continued to grow. The news media reported the development of the new “invisible braces” in major magazines and broadcasts on both television and radio (Figure 1–10). The Ormco task force conducted a news conference at the Waldorf Astoria in New York, touting the benefits of this new type of orthodontic therapy. The interest of the public was heightened even more, and they demanded the appliance from the profession. Commercial companies were competing to be at the forefront of this “lingual fever.” Even Unitek now had a lingual appliance. Dentists were demanding more information and training in the lingual technique. The courses presented by the Lingual Task Force continued to grow in size, with over 1000 orthodontists in atten- dance at each lecture (Figure 1–11). By 1983, the task force was giving courses and news conferences in most major cities in America. In 1982, Ormco organized a task force of two doctors from every country in Europe. In 1983, this group introduced the appliance to Europe at a meeting in Geneva, Switzerland, followed by courses in Japan. Several well-known European orthodontists, Dr. Klaus Gerkhardt of Germany, Dr. Lennart Lagerstrom of Sweden, and Dr. Jorn Perregaard of Denmark were added to the European task force. The European doctors insisted on seeing finished cases. In 1983, the task force conducted seminars for 300 doctors. All the finished cases were  -. Various magazines exalting the virtues of the lingual appliance.
  presented with a full treatment protocol; their results were therefore more acceptable than those presented earlier to the American doctors. In 1983, Ormco sold 5000 lingual cases, and by 1986 they had sold 18,000 lingual cases! At this time, thousands of orthodontists worldwide were attending courses and beginning treatment using the lingual technique. The technique and appliance were still in their infancies, and, in fact, beta testing had not yet been completed. Public demand and commercial interest rushed the product to the market, perhaps prema- turely. In 1986 the French Orthodontic Society founded the Société Français Orthodontie Linguale (SFOL, or French Orthodontic Society for Lingual Orthodontics). In 1987, at the American Association of Orthodontists’ annual meeting in Montreal, Canada, Dr. Kurz was on the program to discuss lingual orthodontic therapy. The lecture topic was timely in that many orthodontists had now tried the appliance and lingual therapy without much success. There seemed to be widespread problems with appliance placement through direct bonding techniques and manipulation of archwires on open buccal segments with no occlusion because of the bite plane effect of the anterior inclined plane. Many clinicians had experienced a loss of control in cases treated with the lingual approach. Dr. Kurz’s lecture was well attended because many clinicians were looking for solutions to the problems that were preventing them from finishing cases to the same standard of excellence they had come to expect from labial appliances. At this same meeting, an alternative esthetic solution was pro- vided to the clinicians. A truly clear, stain-resistant labial bracket was introduced by A Company. This bracket, called Starfire, provided a reasonable alternative for patients who were concerned with the poor esthetics of conventional metal labial brackets. A sigh of relief was heard throughout the orthodontic community. Orthodontists could now offer to patients an option that provided improved esthetics over metal brackets with efficient and high-quality treatment. Enthusiasm for lingual therapy waned in the profession, and commercial interest also declined. The original Ormco Task Force was reduced to just three members by 1988, Drs. Kurz, Gorman, and Smith. They restructured the group and were renamed KGS Ormco Task Force Number Two. Their new charge was to define the problems that plagued the current status of lingual therapy and develop solutions to these prob- lems. These were the problems they identified:  -. Classes in a Newport beach hotel.
Lingual Orthodontics: Historical Perspective  1. The lingual appliance had been made available to the public before testing was complete. 2. Orthodontists inadequately trained with lingual therapy were treating patients in record numbers. 3. The public had high expectations from this treatment and demanded it from the profession immediately. A solution was to have smaller classes taught by more experienced lingual practi- tioners. Longer courses were developed with a typodont (hands-on) component, and continuing education was stressed, with support provided by study clubs, journals, and professional meetings. The American Lingual Orthodontic Association (ALOA) was established on November 14, 1987, by a core group of six hundred American orthodontists. Member- ship quickly grew to over 800 members in 17 countries. The ALOA provided quarterly journals, study club assistance, patient brochures, yearly conventions, and professional lectures. The first annual meeting of ALOA was held in Washington in 1987, and in Palm Springs the following year. Additionally, a Dental Lingual Assistant Association was formed to provided support for staff members employed by lingual orthodontic practitioners. The new professional associations were smaller than the original groups but remained active in their support of lingual therapy. Continuing educational pro- grams were now offered in Europe and Japan by the KGS group. Enthusiasm for lin- gual therapy was still strong in these professional communities. Some European and Japanese university programs offered training in lingual therapy and these were soon followed by courses in Korea, South America, Mexico, and Denmark. The European Society of Lingual Orthodontics (ESLO) was founded in 1992, in Venice, Italy, and hundreds of people participated in the first European lingual asso- ciation congress in Venice. In the same year, an Italian society was founded; the Associazione Italiana Ortodonzia Linguale (AIOL) or the Italian Association of Lingual Orthodontics has been one of the most active ever since. The Asian lingual asso- ciation is also very active. Dr. Lorenzo Favero, Italy, was the first to treat children and adolescents with LO, and now it is a legitimate treatment option for all. Today, lingual orthodontics has a small but strong following in the United States, Europe, and Asia. The ALOA is active again, after few years of silence, with annual conventions, availability of patient educational materials, and the publication of a professional quarterly, the JALOA. The French Lingual Orthodontic Society and the Italian Lingual Orthodontic Society currently hold annual meetings. The ESLO sponsored the last international meeting in Monaco, Monte Carlo in 1996 and the next meeting is scheduled for June, 1998 in Rome. Many courses are given in various locations throughout the world, mainly by Drs. Didier Fillion (France), Courtney Gorman (USA), Giuseppe Scuzzo (Italy), Kyoto Takemoto (Japan), Echarri Pablo Lobiondo (Spain), Bob Baker (USA), Mario Paz (USA), and John Napolitano (USA). The following is a summary listing of some of the difficulties encountered during the development of lingual orthodontic therapy and the current solutions: 1. Tissue Irritation and Speech Difficulties The earlier brackets placed on the lingual surface of the teeth were irritating to the tongue and impeded normal speech. The current generation of brackets has been
 -. Initially, anterior brackets had long gingival hooks responsible for calculus build-up.   redesigned with smooth exterior surfaces and a low profile. The increased comfort allows normal tongue activity, hence speech is not affected significantly. 2. Gingival Impingement Earlier generations of the lingual appliance had a broad bonding base extending towards the gingival margin (Figure 1–12). Access for adequate oral hygiene and the self-cleansing nature of the oral cavity were compromised. Brackets have been redesigned to be more self-cleansing. The base now extends incisally and mesiodistally, providing adequate bond strength, yet retaining hygienic qualities. The mandibular anterior teeth are particularly vulnerable to calculus accumulation due to their close proximity to the submandibular salivary glands. These brackets have 1.5 to 2 mm clearance between the base and the gingival margin. Additionally, the bracket hooks have been redesigned with a lower profile and are located several millimeters from the gingival margin (Figures 1–13a and b). 3. Occlusal Interference A predominant problem with the original appliance was the effect of the shearing forces on the brackets, particularly in the maxillary anterior dentition. (In the absence of a cross-bite, the lingual aspect of the mandibular dentition is generally not in direct contact with the maxillary dentition; therefore, the shearing forces were not a problem (Figure 1–14). Likewise, the relatively high maxillary crown height and low mandibular cusp height in the posterior segments allow adequate clearance to avoid the severe shearing forces seen in the maxillary anterior region.) The bracket was redesigned with an inclined or bite plane strategically placed to redirect the vertical shearing forces to a horizontal seating force (Figure 1–15). The location of the inclined plane is such that when a 1 mm overjet and overbite relationship is obtained, all mandibular anterior contact with the inclined plane is eliminated. To avoid deleterious effects caused by tooth contact with the archwire, the inclined plane is located incisal to the slot. Patient tolerance of the bite plane effect of the inclined plane has been favorable.
Lingual Orthodontics: Historical Perspective  4. Appliance Control Since the introduction of lingual therapy, control has been a concern. To allow better control of tooth movements, the appliance was fabricated in high tensile metal which provides a greater degree of accuracy. First and second molar bands were manufactured, allowing control from both the buccal and lingual sides of the posterior segments. An initial treatment approach joined the buccal and lingual attachment when the wire was engaged. This coupling was thought to prevent vertical and horizontal rotation of the buccal segments (Figure 1–16). Clinically, however, this coupling proved to be unnecessary because one full arch wire from 7-7 was able to offer much more stability. Currently, transpalatal bars are used for additional stability. They can be attached to either the first or second molar. 5. Base Pad Adaptation As with all appliances, accurate contour of base pads improves not only retentive capabilities but also the accuracy of bracket placement and therefore the quality of  -. Cast illustration of the mandibular teeth showing no problem with occlusal interference.    -  . Photo of Kurz #7 bracket bonded on typodont, with close-up of mandibular and maxillary incisors.
  treatment. Topographic maps were constructed for each tooth and individual bracket base curvatures were calculated (Figure 1–17). 6. Appliance Placement and Bonding The original appliances were direct bonded. With the variability of lingual tooth con- tours, accurate bracket placement was difficult. This approach produced unpredictable tooth alignment with tremendous variations in tip, torque, and tooth height. Initially, the Torque Angulation Referencing Guide (TARG) system was used. The TARG instrument was designed to place brackets on the lingual surfaces using conventional landmarks as references. Although substantial improvements were made in the accuracy and efficiency of bonding, the system was still inadequate. A more sophisticated sys- tem, using a diagnostic set-up constructed from articulated models was developed and has met with considerable success. This method, the Custom Lingual Appliance Set-Up Service (CLASS), involves indirect bonding set-up on a diagnostic or ideal model of the teeth. The brackets are then transferred back to the original malocclusion, and transfer trays prepared. These methods will be explained in detail in Chapter 15. 7. Appliance Prescription In the early 1970s, Dr. Lawrence Andrews developed and patented a fully programmed orthodontic appliance, which he introduced as the Straight Wire Appliance. This philosophy involves programming all the elements necessary to achieve an optimal occlusion into each bracket.  -. The incline plane. The red arrows represent the primary force applied, and the broken black lines represent the secondary/resultant forces exerted.
Lingual Orthodontics: Historical Perspective  The initial lingual appliance used a custom-modified labial appliance bonded to the lingual surface. Tip and torque angulations were not ideal. A similar philosophy was used to design the Kurz Lingual Appliance. A site was selected on the lingual surface of each tooth. It was consecutively transferred from the lingual first molar, as high as it could go, without missing the rounded lingual anatomy. Reciprocal tip and torque values to Andrew’s published values were used to establish the prescription. There was no grand procedure used in obtaining the reciprocal lingual reference of angles with regard to Andrew’s published values. It was a simple matter of mathemati- cally milling a hundred molds to a constant labial vertical.  -. Locking of the molars to the lingual attachment was thought to give greater appliance control.  -. Topographical illustration used to study the lingual dental anatomy for the purpose of construction of lingual appliance bases.
   -. Frontal view of the lingual bracket designed for the maxillary anteriors. The in-out values varied dramatically between the anterior and posterior segments. To adjust for this with bracket design alone would make the anterior brackets thicker than is reasonable, so a true straight wire was not feasible. A first order bend was placed at the junctions of the canine and premolar, and the premolar and molar. These wires could be prefabricated in the laboratory. 8. Wire Placement Access for the placement of wires in the molar tubes from the lingual was limited. The tubes were redesigned by widening the mesial aperture of the slot of the first molar bracket, creating a funnel effect (Figure 1–18).  -. Widening of the mesial aperture to provide ease of wire insertion.
Lingual Orthodontics: Historical Perspective  9. Ligation To permit stable ligation with ligature wires or A elastics, ligature locking grooves that are both deep set and easy to hook have been designed. When teeth are crowded and slot engagement is especially difficult, a vertical slot is provided so the archwire can be attached to the bracket even through the initial stages of leveling and aligning (Figure 1–19). A double over-tie with metal is used when a tooth is to be an attach- ment for anchorage or rotation of the other teeth. 10. Attachments A gingival hook is an integral part of the bracket and provides rotational control. The original hook was large and in close proximity to the gingival margin, impeding access for hygiene. This hook was redesigned with a lower profile and moved away from the gingival margin. From Generation #1 to Generation #7—A Summary of Progress GENERATION #1—1976 The first Kurz Lingual Appliance was manufactured by Ormco. This appliance had a flat maxillary occlusal bite plane from canine to canine (Figure 1–20). The lower incisor and premolar brackets were low profile and half-round (Figure 1–21), and there were no hooks on any brackets. GENERATION #2—1980 Hooks were added to all canine brackets (Figure 1–22). GENERATION #3—1981 Hooks were added to all anterior and premolar brackets. The first molar had a bracket with an internal hook. The second molar had a terminal sheath without a hook but had a terminal recess for elastic traction (Figure 1–23).  -. Generation #1—1976. Flat maxillary occlusal bite plane from canine to canine.
  GENERATION #4—1982–84 This generation saw the addition of a low profile anterior inclined plane on the cen- tral and lateral incisor brackets. Hooks were optional, based upon individual treat- ment needs and hygiene concerns (Figure 1–24 and 25). GENERATION #5—1985–86 The anterior inclined plane became more pronounced, with an increase in labial torque in the maxillary anterior region. The canine also had an inclined plane; however, it was bibeveled to allow intercuspation of the maxillary cusp with the embrasure between the mandibular canine and the first premolar. Hooks were optional. A transpalatal bar attachment was now available for the first molar bracket (Figure 1–26 to 28).  -. Generation #1—1976. The lower anteriors and premolars had low profile, half-round brackets. There were no hooks on any brackets.  -. Generation #3—1981. Hooks were added to all anterior and premolar brackets.  -. Generation #2—1980. Hooks were added to all canine brackets.
Lingual Orthodontics: Historical Perspective  GENERATION #6—1987–90 The inclined plane on the maxillary anteriors become more square in shape (Figures 1–29 and 30). Hooks on the anteriors and premolars were elongated. Hooks were now available for all the brackets. The transpalatal bar attachment for the first molar band was optional. A hinge cap, allowing ease of archwire manipulation, was now available for molar brackets.  -  . Generation #4—1982–84. Additional of a low profile anterior inclined plane on the central and lateral incisors. Hooks were optional.  -  . Generation #5—1985–86. The anterior inclined plane was more pronounced, Upper Central Torque: +68° Angulation: +5° Rotation: 0 In–Out: 0 Slot size: .018 Pad: Special lingual design Upper Cuspid Torque: +55° Angulation: +12° Rotation: 0 In–Out: .010 Slot size: .018 Pad: Special lingual design
  GENERATION #7—1990 TO PRESENT The maxillary anterior inclined plane is now heart-shaped with short hooks. The lower anterior brackets have a larger inclined plane with short hooks. All hooks have a greater recess/access for ligation. The premolar brackets were widened mesiodistally and the hooks were shortened. The increased width of the premolar bracket allows better angulation and rotation control. The molar brackets now come with either a hinge cap or a terminal sheath (Figures 1–31 and 32).  -. Generation #5—1985–86. A transpalatal bar attachment was now available for the first molar bracket.  -  . Generation #6—1987–90. The inclined plane on the maxillary anteriors became more square in shape. Hooks were elongated and were available for all the brackets. Ball hook Ball hook Bracket slot for archwire Bracket slot for archwireBracket Bracket
Lingual Orthodontics: Historical Perspective  Bibliography Alexander RG. Lingual orthodontics. In: The Alexander Discipline. Ormco Corporation, 1986; 13:371–430. Andrews LF. The straight wire appliance: syllabus of physiology and techniques. 2nd Ed., USA, 1975. Fillion D. Orthodontie linguale et Mini-Plaques, esthetique et confort dans les traitments chirur- gio-orthodontiques. L`Information Dentaire n 20 du 17 mai 1990. Gorman JC. Treatment with lingual appliance: the alternative for adult patients. Int J Adult Orthod Orthognath Surg 1987;2:131–149. Gorman JC, Kurz C, Smith JR. Lingual orthodontics, cases, principals and practice. 3-hr. Videotape produced by Ormco Corporation, Glendora, California. Gorman JC, Kurz C, Smith JR. Lingual case reports. J Clin Orthod 1983;17:5. Gorman JC, Kurz C, Smith JR. Lingual mechanotherapy. J Clin Orthod 1983;17:2. Gorman JC, Kurz C, Smith JR, Dunn RM. Keys to success in lingual therapy. J Clin Orthod 1986;20:4–5. Gorman JC, Smith JR, et al. Lingual orthodontics, a status report. J Clin Orthod 1982;16:4. Kurz C. Lingual orthodontics. In: Marks M, Corn H, eds. Atlas of adult orthodontics. Philadelphia, London: Lea & Febiger, 1989. Kurz C, Bennett R. Scientific report. J Am Ling Orthod 1988;1:3. Smith JR. Twelve key principles for lingual orthodontic therapy. J Am Ling Orthod 1988;1:2.  -  . Generation #7—1990–present. The maxillary anterior inclined plane is heart-shaped with short hooks. The lower anterior brackets have a larger inclined plane with short hooks and all hooks have a greater recess/access for ligation. Ball hook Bracket slot Bracket Ball hook Bracket slot for archwire Bracket
 During the evolution of lingual appliance therapy, the technique has moved in and out of public and professional favor. Over the years, the appliance and the techniques have been improved dramatically and, as a result, a reliable system has emerged. It has now undergone many years of clinical experience and has been shown to consistently produce satisfactory results. Esthetic concerns were initially responsible for the development of the appliance system and they continue to remain at the forefront for a significant segment of patients seeking orthodontic treatment. Appearance is undoubtedly the most impor- tant motivating factor for adults whether it is termed “facial appearance,” “dental appearance,” or “straight teeth.” Research has shown that physically attractive people achieve higher levels of success in many aspects of life than unattractive people.3 This advantage starts at birth and continues into adulthood. The added positive attention given to attractive indi- viduals by teachers and peers, for example, can have profound effects on personality development and self-image. Improvement in one’s physical appearance, as is common with orthodontic treatment, can positively affect social and professional interactions.1–9 At the same time, deterioration in one’s physical appearance, as with the use of unat- tractive labial orthodontic appliances, can negatively affect one’s self-esteem. This is particularly true during the formative years of adolescence and young adulthood. Many patients, if given the choice, would opt for an appliance that was not visible, provided the course of treatment and the quality of the results were the same as with a conventional treatment. This service offered in the private orthodontic office allows the patient several treatment options, and provides the orthodontist with a competitive advantage over colleagues not offering the option of lingual appliances. Advantages and Disadvantages of Lingual Therapy One of the most significant drawbacks to lingual therapy appears to be the discomfort to the tongue, and with it, difficulty in speech, both of which usually improve after 2 to 3 weeks of appliance placement. Also, the sensitivity of the laboratory techniques and the extended chairtime needed for appliance placement and adjustments have made the treatment prohibitively expensive for many patients. However, lingual treatment has obvious advantages over labial treatment. The labial enamel surface of the anterior teeth plays an important esthetic role. By placing labial appliances, the susceptibility of this enamel surface to chemical insults from etchant materials and to environmental influences from plaque accumulation in patients with poor oral hygiene is increased. Permanent and unsightly decalcification marks can result. Lingual appliances allow easy access for routine oral hygiene proce- dures on these labial surfaces. Additionally, the self-cleansing nature of the stomatog-   Present Clinical Reality MASSIMO RONCHIN, MD, DDS
  nathic system is maintained. Clinical judgment of treatment progress can be enhanced. Evaluation of individual tooth positions can be easily accomplished by hav- ing the labial surfaces free of distracting metal or plastic brackets. Soft tissue responses of the lips and cheeks to treatment can be judged accurately because there is no distor- tion of shape or irritation caused by a labial appliance. Four distinct situations exist where lingual appliances may be more effective than labial appliances because of their unique mechanical characteristics. These include: 1. Intrusion of anterior teeth. 2. Maxillary arch expansion. 3. Combining mandibular repositioning therapy with orthodontic movements. 4. Distalization of maxillary molars. 1. Intrusion of Anterior Teeth The biomechanics of lingual techniques differ considerably from labial biomechanics. Both arch circumference and interbracket distance are reduced, requiring lighter force application for tooth movement.5–9 Lingual bracket position, which is dictated by the morphology of the lingual surface of the tooth, places the bracket closer to the center of resistance of the tooth than is found with labial bracket placement (Figure 2–1).10 An important clinical implication of this unique bracket position and design is that the intrusive force vector is directed  -. The center of resistance of the tooth is located closer to the lingual bracket.
Present Clinical Reality  through the center of resistance of the tooth. As the mandibular anterior dentition occludes with the anterior horizontal plane of the maxillary anterior brackets, a bite plane effect results. Since the appliance is bonded, the bite plane is always present. The net effect appears to be a light, continuous, intrusive force. In addition to these active intrusive forces on the anterior dentition, a passive extrusion occurs in the pos- terior segments. Deep-bite correction through this passive increase in posterior vertical dimension and active decrease in anterior vertical dimension occurs quickly and easily. Malocclusions requiring open-bite correction obviously would not benefit from this technique. To prevent the passive extrusion of the posterior segments in these patients, acrylic posterior overlays are used. Figure 2–2 shows the intrusive effect of the appliance in correcting a severe dento- alveolar deep bite in a 38-year-old female. This patient had a class II occlusion with a skeletal and dental deep-bite pattern and severe crowding in both arches. The maxil- lary dental midline looked deviated towards the left-hand side because of the extreme Class II relationship on that side (Figure 2–2a). Partial lingual appliances were placed in both arches (Figures 2–2b and c). As with labial bracket placement, ideal placement  -. The very severe deep-bite occlusion of the patient, before treatment.  -. Occlusal view of the mandibular arch, just after the partial lingual bonding; the molars were banded afterwards.  -. The upper arch, just after the initial partial lingual bonding.  -. Frontal intraoral view, three months after starting lingual mechanics.
  is not always possible at initial bonding due to the severity of the malocclusion, so appliances should be repositioned during treatment when it becomes possible. Figure 2–2d shows the treatment progress three months after appliance placement, and Figure 2–2e shows the final occlusion. Total treatment time was 15 months. Deep-bite correction was facilitated by the active anterior intrusive forces and the passive posterior extrusive forces. The correction was stabilized by prosthetic restora- tions in the posterior segments. 2. Maxillary Arch Expansion With some kinds of malocclusions we are occasionally faced with the need to expand the upper arch both transversally and sagittally. It is not yet totally clear why but, clin- ically, we obtain more remarkable dentoalveolar expansions through lingual mechanics than through labial mechanics.11–12  -. The occlusal situation six months after the end of the treatment.  -. Profile view of the patient, before treatment.
Present Clinical Reality  Some possible reasons are: 1. The force which is developed is of a centrifugal type, from the inside towards the outside of the arch. The same occurs with the Quad-Helix and the Rapid Palatal Expansion (RPE) devices. 2. Some authors point out that the thickness of the brackets, which interpose themselves between the tongue and the lingual wall of the teeth, can con- tribute to this expansive effect.7–9 3. It is even likely that the shorter interbracket distance may play a significant role in this effect.5 In fact, by using this method, not only is the expansive effect so evident but also the teeth do not become too labially tipped.10 The tooth movement probably takes place without incurring a significant labial inclination because the application point of  -  . Lower and upper occlusal photographs, before treatment.    -‒. Right and left intraoral views, during the initial phases of mechanics, after the extraction of the first lower molars.  
  the force is more palatal than the center of resistance of the tooth. The following case shows a 30-year-old female who had a Class III occlusal rela- tionship with a prognathic profile and a protruding lower lip (Figure 2–3a), an anterior cross-bite of several mandibular teeth, upper arch contraction, and a total lack of space for the lower left central incisor which was lingually placed and completely hid- den by the adjacent incisors (Figures 2–3b and c). Since it was a Class III malocclusion, the upper arch underwent a nonextraction treatment. The lower arch was treated with extraction of the first molars to gain more space to solve the crowding and to achieve more successful intercuspation. The upper third molars would subsequently be extracted (Figures 2–3d and e). Lingual braces were bonded to the upper arch with an initial Twist-Flex type archwire (Figure 2–4a). Four months later, the extent of the dentoalveolar expansion obtained is quite  -. The upper arch (occlusal view), just after placing the first superelastic Twist-Flex type archwire.  -. The upper arch (four months after Figure 2–4a), with a rectangular wire. Notice the amount of the transverse and sagittal expansion.  -. The patient’s profile after treatment.
Present Clinical Reality  remarkable, both transversally and anteriorly (Figure 2–4b). Further expansion was achieved with a rectangular archwire. The results show substantial improvement in the patient profile and occlusion (Figures 2–4c and d). 3. Combining Mandibular Repositioning Therapy with Orthodontic Movements When patients have temporomandibular dysfunction (TMD), it is often necessary to treat in two distinct clinical phases. The initial phase of treatment addresses the TMD and associated pain symptoms. It is often accomplished with splint therapy until the muscle and joint symptoms resolve. Depending on the practitioner, the patient is then maintained, symptom free for a period of time from several months to more than a year. The second clinical phase of treatment addresses changes in the occlusion as a result of the new mandibular position. It generally involves orthodontics, prosthodon- tics, and/or orthognatic surgery. The orthodontic phase of treatment is often tedious and time consuming. Often, labial appliances are placed on one arch, and a positioning splint is kept on the oppos- ing arch to maintain the maxillomandibular relationship. This is then reversed with appliances placed on the opposite arch and a splint fabricated for the opposing arch. Obviously, treatment times can be significantly extended.  -. Frontal intraoral view at the end of treatment.  -. Left intraoral view during the last phases of the Class II mechanics.
  The lingual appliance system allows both arches to be treated simultaneously, while maintaining the effects of the splint. The anterior occlusally oriented inclined plane functions as a bite plane. As seen previously, this device has an active intrusive effect, while allowing passive eruption of the posterior segments. Many patients with TMD require stability with anterior and posterior contacts on their splint. For these patients to remain comfortable, this relationship must be maintained during orthodon- tic treatment. Flat acrylic minisupports can be added to the first and/or second molars, producing a tripod effect. This combination of anterior bite plane and posterior acrylic supports can simulate the action of the conventional splint, thereby allowing treatment to progress simultaneously in both arches. The supports can be flat, thereby helping the Class II elastics (Figure 2–5), or they can be fabricated with some occlusal indentations which can guide the mandible into the desired position.12–14 Figures 2–6    -  . Frontal, right, and left intraoral photos, before treatment.   -. Frontal view of the occlusion, with the upper splint. The midlines are centered, and the mandible is slightly advanced.
Present Clinical Reality  and 7 demonstrate the use of the lingual appliance in treating patients with TMD. This 18-year-old patient presented some TMD signs and symptoms and a history of past orthodontic extraction treatment. She had an early reciprocal clicking in the left TMJ and also suffered from muscular hyperactivity. Both the right and the left masseter muscles and the anterior belly of the left temporal muscle felt tender to palpation. She had mild to moderate anterior crowding, a Class I canine and molar relationship on the right, an end-on Class II canine and molar relationship on the left, normal overjet, and an increased overbite (Figures 2–6a to c). A mandibular repositioner was fabricated and worn until her TMD symptoms disappeared (Figure 2–6d) and she was main- tained symptom free for four months before orthodontic treatment was initiated. The lower arch was then bonded (Figure 2–6e). Two months later the upper splint was  -. The patient, wearing the splint, is maintained in the same therapeutic position. The lower arch is fully bonded.  -. The upper arch, after the expansion, with a full size rectangular archwire. The acrylic repositioning build-ups on the first molars are visible.    -  . Frontal, right, and left intraoral views, a few weeks after treatment is completed. 
  removed, the maxillary arch bonded, and flat acrylic supports were placed (Figure 2–6f). These two posterior elevations, combined with the bite plane effect of the ante- rior brackets and the Class II elastics allow mandibular repositioning while also allow- ing orthodontic treatment to progress. Figures 2–7a to c show the finished case several  -. The center of resistance of the second upper molar is located in correspondence with the palatal root (see the yellow dot), close to the lingual wall.  -. During the second stage, the distal movement of the buccal roots takes place very easily.  -. The distal movement takes place quite bodily; only later can a slight buccal rotation be observed.  -. For the second stage, a buccal sectional archwire can be used.  -. A doubled Class II elastic (lingual and buccal) is very effective for the retracting mechanics.
Present Clinical Reality  months after debonding. The patient remained symptom free. This is an interesting aspect of lingual appliance therapy that warrants consideration. 4. Distalization of Maxillary Molars Lingual brackets are placed closer to the center of rotation (CR) of the tooth than labial brackets. It is possible that molar distalization through lingual techniques pro-  -. Profile view before treatment.  -. Frontal view of the malocclusion before treatment.  -. A round archwire is initially used in the upper arch.  -  . The anterior bite effect of the lingual braces and the acrylic posterior minisupports.  
  duce more bodily movement of the tooth and less distal tipping. Because of the angu- lation of the multiple roots of maxillary molars, the center of resistance is found just lingual to the average long axis of the roots (Figure 2–8a). In this example of a second molar being distalized with the use of an open coil spring, lingual and labial tech- niques are sequentially employed. Figure 2–8b shows the force being applied from the lingual surface; here the CR is found in the palatal root. In fact, a rather bodily distal migration takes place. Afterwards, a labial force (Figure 2–8c) can very easily correct the rotation. Bodily movement is the most efficient form of tooth movement. Clinically, this can be accomplished by placing an open coil spring between the first and second molars. To counteract the mesial displacement of the first molars, a verti- cal loop is placed against the lingual twin bracket (Figure 2–9a). For derotating the second molar and continuing to distalize the tooth, two buccal brackets and a section- al archwire can be placed. This will allow Class II elastics to be used on both the buc- cal and lingual aspects (Figure 2–9b). The balance of these forces counteracts the rota- tional forces. As an additional case, we present the 20-year-old female in Figures 2–10 to 13 who presents a rather retrusive chin (Figure 2–10a). We are faced with a Class II deep bite  -. An Australian archwire (.016 inches), producing a 20-toe-in, and two horizontal round loops is used during the last stage.  -. Profile of the patient at the end of treatment.  -. The Class II mechanics at the final phase of the treatment.
Present Clinical Reality  malocclusion with a slight anterior crowding (Figure 2–10b). At first, only the maxil- lary arch was lingually bonded, with the purposes of alleviating the crowding, intrud- ing the anterior group, and expanding the maxillary arch (Figure 2–10c). Some poste- rior acrylic minisupports are noticeable in the intraoral lateral photographs (Figures 2–10d and e). As previously described, these supports tripodize the occlusion through an anterior contact on the brackets and through posterior contacts on the flat elevations and produce an anterior mandibular displacement during the use of Class II elastics. In addition, this distribution of the occlusal load is comfortable for the patient. After having banded the lower arch, Class II mechanics was applied (Figure 2–10f). In the upper arch, a lingual archwire can be used (Figure 2–11). In Figure 2–12 we see a remarkable improvement in the patient’s profile at the end of treatment. Her chin looks more advanced and her lips are more harmonious. We successfully obtained a full Class I occlusal relationship and the anterior deep bite was corrected (Figure 2–13). In today’s clinical orthodontic practice, the lingual appliance can offer many advantages over the labial appliance to both the patient and the practitioner. Enamel surfaces are protected, some treatments (such as deep bite correction) can occur faster, molar distalization appears to take place more efficiently, and TMD patients can pro- ceed with orthodontic treatment in a timely manner. References 1. Alexander CM, Alexander RG, Gorman JR. Lingual orthodontics: a status report, part 1. J Clin Orthod 1982;16:255–262. 2. Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report, part 6: patient and practice management. J Clin Orthod 1983;17:240–246. 3. Breece G, Nieberg L. Motivations for adult orthodontic treatment. J Clin Orthod 1986; 3:166–171. 4. Bercheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119–131. 5. Fujita K. New orthodontic treatment with lingual brackets and mushroom arch wire appli- ance. Am J Orthod 1979;76:657–675. 6. Genone B, Siciliani G. Trattamenti ortodontici a collocazione linguale. Mondo Ortodontico 1984;3:14–27. 7. Gorman JR, Hilgers JJ, Smith JR. Lingual orthodontics: a status report, part 4: diagnosis and treatment planning. J Clin Orthod 1983;17:26–35.  -. The occlusal result.
  8. Kelly VM. Interviews on lingual orthodontics. J Clin Orthod 1982;16:461–476. 9. Kurz C, Gorman JR. Lingual orthodontics: a status report, part 7: case report. J Clin Orthod 1983;17:310–331. 10. Nidoli G. Lingual technique under the biomechanical and aesthetical point of view. Proceedings and abstracts: I. Congress of the European Society of Lingual Orthodontics, Lido di Venezia, June 18–20, 1993. 11. Ronchin M, Oddini Carboni S, Dessi S. Nuovi Orizzonti terapeutici con la biomeccanica lin- guale. Proceedings of the V Giornate Mediterranee di Odontoiatria, Naples, February 26–28, 1983. 12. Ronchin M. Present horizons and a future outlook on lingual approach. Proceedings and Abstracts: First Congress of the European Society of Lingual Orthodontics, Lido di Venezia, June 18–20, 1993. 13. Ronchin M. Aesthetics with lingual orthodontics: resolving class II malocclusions with molar distalisation. Pract Perio Aesthet Dent 1994;6:51–58. 14. Siciliani G. Ortodonzia Linguale. Milano, Italy: Masson. 1992.
 Lingual orthodontics is a viable option in a modern orthodontic practice. In 1979, when Drs. Kurz and Fujita first began experimenting, appliances and techniques were in their infancy. Today, modern, well-developed appliances, laboratory procedures, and treatment mechanics are available. Doctors have the ability to include lingual appli- ances in the treatment plans of their patients, and assure exceptional results with con- fidence. Problems like prolonged treatment times and compromised results are similar to those with treatment with labial appliances by an experienced practitioner and, as with any technique, can be overcome with an accumulation of experience. Today’s practitioner must find a way to treat his lingual patients without disrupt- ing his practice. In fact, these lingual patients should enhance an already thriving practice and revive a dwindling one. The article will provide a clear and precise expla- nation of how we practice lingual orthodontics in our office, how lingual patients affect the practice of labial orthodontics, and what one can do to avoid problems dur- ing his early lingual experience. The Clinical Experience All patients are treated the same way during their initial examination. After viewing a video tape which has been mailed to them prior to the first appointment, patients arrive at the office with some of their questions already answered and a familiarity with our office and procedures. The appropriate forms are then completed, a high- quality panoramic radiograph is taken and developed, and intraoral and extraoral video images are captured. The patient is then invited to the consultation room. Meanwhile, a preliminary diagnosis is made using the radiograph, and the video images. Different treatment options are considered including extractions, orthosurgery, and labial or lingual treatment. All the mechanical advantages of lingual treatment (in treating deep-bites, cross-bites, and expansion), and disadvantages (in treating open- bites or high angle cases) are carefully evaluated for that specific clinical case. After the preliminary diagnosis is made, the clinician enters the consultation room where all the clinical, radiographic, and visual aids are prepared. If lingual appliance treatment is one of the options and the patient wants to be treated this way, a separate appointment is made to complete the records. An extra set of impressions is made and poured immediately in a pink stone. A face bow transfer is also made so the models can be properly mounted. Using all records, the diagnosis and treatment plan are finalized. The proper laboratory prescription for the appliances is prepared, and two weeks later the patient is scheduled for the initial bonding. During the two weeks fol- lowing the impressions, it is critical that no tooth movement takes place as this would   Lingual Orthodontics in a Labial Orthodontics Office J. COURTNEY GORMAN, DDS, MS
  ruin the accuracy of the indirect bonding. This means no separators, no extractions, and no heavy cleaning. The last item should have been accomplished prior to the impres- sions, and the first two items should be completed after the initial bracket placement. Appliance Placement The bonding procedure for the initial bracket placement is as follows: 1. Paint all of the brackets with the bracket-side portion of the bonding adhesive. 2. Microetch the lingual surface of all teeth to be bonded. 3. Isolate one-third of the dental arch. (Some clinicians may prefer to bond the entire arch simultaneously.) 4. Acid etch the teeth for 20 to 30 seconds. 5. Rinse each tooth for 20 seconds. 6. Dry the teeth with an air syringe. At the same time use a hair dryer to displace the moisture from the breath. 7. Paint the teeth with the tooth-side portion of the adhesive. 8. Reapply the bracket-side portion of the adhesive. 9. Fully and firmly seat the bonding tray and hold in place for one minute. 10. Repeat procedures 3 to 9 for the remaining segments. 11. Remove the hard shells of the bonding trays. 12. Using a sharp scaler, remove the soft undertrays. After the bonding procedure is complete and before removal of the isolation, each bracket is checked by pulling on it with an elastic. If there is a failure, cut the section of the tray from which that bracket came into a single-tooth tray, discard the hard shell and place the bracket back into the single-tooth soft tray, microetch the bracket and tooth, reapply bracket side adhesive to the bracket, acid etch the tooth, rinse the tooth, reapply tooth side adhesive, reapply the bracket side adhesive, seat the tray, hold for two minutes and then remove the tray. It is advisable to retain the soft trays for any future repairs. In cases with a porcelain jacket crown, the crown should be conditioned with a porcelain etchant for four minutes and then rinsed. Apply some normal etchant to the crown and blow off the excess followed by the silane primer (it is important not to skip the etch as the acid activates the silane). Now apply the adhesive bond to the bracket and bond it to the crown. Before placing the initial archwires, the clinician must first determine which teeth are to be engaged. Elastic chains are placed over the brackets on each of those teeth. The chain is precut into two- or three-unit sections. Then, using a hemostat, it is stretched over the brackets with the extra lumen pointing towards the gingiva. The initial wires are then bent using a 1:1 photograph of the original malocclusion as a guide. In most cases this wire will be a .0175 Respond wire (Ormco). When the proper shape and length have been achieved, the distal ends are slid into the hinge caps or tubes. The wire is then engaged into one of the anterior brackets, and the chain is pulled back over the bracket so that a single lumen now encircles the archwire, form- ing the double over-tie. Now with the wire stabilized, the rest of the brackets can be engaged and the distal ends trimmed. The patient is instructed how to care for their appliances and instructed on the use of wax to prevent ulceration of the tongue. At this time it is important to encourage the patient and assure him or her that the function and speech will return to normal.
Lingual Orthodontics in a Labial Orthodontics Office  The patient is then reappointed for a 40-minute visit approximately eight weeks later. If there are teeth to be banded, wire separators are placed before the patient is dis- missed and is reappointed one week later for the banding. Forty-minute appointments are scheduled during the course of treatment for wire changes, adjustments, or single-tooth bonding or banding. Changes of power products or checks of elastic wear are scheduled for 20-minute appointments. At each appoint- ment the assistant first checks the patient for any loose or broken appliances. If there are none, she proceeds with the removal of the archwire to be adjusted or replaced. This information should be noted in the chart and the doctor can now examine and confirm the treatment noted in the chart. If any changes are to be made they can be initiated now. Any adjustments to the wire can also be made at this time. The assistant then reinserts the archwire (usually only one wire is adjusted during a single appoint- ment) and applies any necessary power products. Treatment Sequences (Extraction and Nonextraction) After the appliances have been placed, the initial archwires are added. These are typi- cally .0175 Respond (Ormco) arches. In nonextraction cases, the wire will engage all the posterior teeth; in extraction treatment, it will form a sectional arch engaging only those brackets anterior to the extraction sight. Minimal movement is expected from these first wires. Their main purpose is to fill the space while the patient becomes accustomed to the new appliances. In nonextraction cases with crowding, the second arch is .016 TMA (Ormco) wires with advancement loops (U-shaped loops which are compressed when fully engaged) anterior to the first or second molars. These wires use the energy stored in the compressed loops to expand the arch in an anterior direction. Full engagement of the teeth can take place after sufficient space has been created. At this point rotations can be corrected. After initial leveling and correction of rotations, a square or rectan- gular wire is used to continue the leveling process and to torque any teeth in need. The wire of choice is usually a .0175 × .0175 TMA (Ormco). This wire enables full engagement of all brackets to complete the leveling and establish necessary torque. In simple nonextraction treatment in which the patient maintains a Class I buccal segment, this wire can be the final archwire. In cases requiring elastics, the square TMA archwire should be followed by a .017 × .025 stainless steel archwire with tiebacks in the mandible to ensure arch stability during elastic use. In the maxilla, a .016 × .022 stainless steel archwire with a Curve of Spee is usually adequate to main- tain arch integrity. After a Class I occlusion has been achieved, the patient is ready for final detailing which can be done with a .016 stainless steel archwire. In extraction treatment, the second arch is also a .016 TMA but without advance- ment loops. Once again, only those teeth readily engaged are ligated. After initial alignment, the TMA wire is removed, and a .016 × .022 stainless steel wire is bent and placed in the mouth, engaging as many brackets as possible. The posterior seg- ments are figure-eighted together using a steel ligature. Wire ligations are used on the cuspids, and a power tube is tied in a figure-eight from the cuspids to the second bicuspids. The cuspids are retracted until adequate space is available to completely align the anterior segment. At this time, it is important to avoid complete retraction of the cuspids as this will interfere with en masse retraction of the anterior segment. After initial cuspid retraction, the original .016 TMA arch is replaced, and all brackets
  are fully engaged. This wire is used in conjunction with rotation ties until all rotations have been corrected. To develop torque and to continue leveling, a .0175 × .0175 TMA is placed. In the maxilla, it is common to follow this wire with a .017 × .025 TMA to achieve adequate torque. When the dentition is fully leveled and aligned space closure is begun, .016 × .022 stainless steel archwires with a Curve of Spee in the maxilla arch and a reverse curve in the mandibular arch are used. The anterior segments are figure-eighted together using a steel ligature. Power tubes and power chains are then placed from cuspid to second bicuspid to supply the necessary force for space closure (sliding mechanics). It is important to figure-eight the segments so the power products can be used over the shortest possible distance. Failure to do so can result in unwanted bowing of the dental arches in both the vertical and horizontal planes. Once all of the space has been closed, the patient can be prepared for elastics by placing a .017 × .025 stainless steel archwire with omega tiebacks in the mandible. In the maxillary arch, figure-eight and power products can be removed and brass electrodes soldered to the wire to act as tiebacks. When a Class I occlusion has been achieved, .016 stainless steel finishing arches can be placed. These wires should also have some type of tieback to ensure that no spaces reopen. If the buccal segments do not have maximum interdigitation at this point, a tooth positioner can be utilized. While a tooth positioner is very effective for “socking in” an occlusion, they are inadequate to complete space closure or for correc- tions of anterior positions. Four weeks after the delivery of the positioner, impressions for retainers are made. Clear overlay retainers are used. They are excellent for retaining alignment and provide exceptional esthetics. Practice Promotion Lingual appliances give the orthodontist a distinct competitive advantage. There are many individuals who need and desire orthodontic treatment but are not willing to wear conventional appliances. Many of these patients have gone for years hiding their smiles and neglecting their oral health. By offering them treatment with lingual appli- ances, the orthodontist provides a valuable and unique service. Many lingual patients are high-profile individuals. While they are willing to pay a premium for their lingual braces that others cannot see, they also openly discuss their treatment with their friends, colleagues, relatives, and sometimes even strangers. They can become great referral sources and goodwill emissaries for your practice. Referring dentists will also appreciate that you are able to provide their patients with a service that the other orthodontists cannot. They will be more likely to refer more of their patients to a full service orthodontist. Before the practice benefits from these and other advantages that lingual ortho- dontics brings, it is important that the staff and the orthodontist feel confident and comfortable with the lingual technique. The first step is to attend a complete typodont course during which a step-by-step method to treat lingual cases is taught. Once the orthodontist and his staff have achieved a high level of clinical proficiency, the lingual patients can be incorporated into the normal schedule. They can be treated side by side with the labial patients. Other than allowing adequate time, there are no other special requirements for these patients.
Lingual Orthodontics in a Labial Orthodontics Office  Conclusion Lingual braces have been and are a viable treatment option. With these appliances the practitioner can achieve excellent results while providing his or her patients with a unique and valuable service. To successfully incorporate lingual patients into a labial practice the doctor and staff must develop the skills to successfully treat these patients. Then the treatment must be presented in such a way that the prospective patient will be receptive. This includes having models with lingual braces, having a treatment coordinator who believes in the treatment, and encouraging patients when lingual appliances are the better option. Having appropriate fees is also important to your practice. Lingual patients require approximately 25% more chairtime for the same treatment. Thus, a premium should be added to the usual fee. We add approximately 27% for the first arch and an additional 20% for the second arch. In this way both the additional laboratory expense and chairtime are covered. If the practitioner will make the commitment to make lingual orthodontics a part of his or her practice, the practice will grow.
 Enhanced Facial Esthetics using Kurz Lingual Appliance . .  Craven Kurz  Advanced Lingual Prescription: Technique and Design . . . . . . .  Robert Baker Jr. . Shape Memory Wires in Lingual Orthodontics . . . . . . . .  Christian Demange . Wire Sequencing in Lingual Orthodontics . . . . . . . . .  H. Stuart McCrostie  Instruments Used in Lingual Orthodontics . . . . . . . . .  Craven Kurz SECTION 2 Basic Principles
 A primary reason a patient seeks orthodontic treatment is to improve facial esthetics (Figure 4–1). A lingual appliance and bite plane may be used specifically to achieve this goal. The success of the orthodontic treatment is directly related to how attractive the patients find themselves after treatment, especially since the vast majority of lingual orthodontic patients are in careers that involve a public image. The traditional cephalo- metric models leave much to be desired as a direction to follow to obtain facial beauty. Studies of contemporary fashion models, movie stars, and beauty contest winners indi- cate that a much fuller profile than the conventional 1900s ideals is more popular with today’s public. Face studies made by Sassouni indicate that facial beauty is related to protrusive faces with a straight line relationship between the maxilla and mandible in well-balanced faces. Articles by Liddle, Luzi, Eirew, McNamara, and Moyers demonstrate that the maxilla is usually in the proper A-P position in the skull and in harmony with its biological environment. It rarely protrudes in any malocclusion, regardless of how much the dental overjet is. Thus, the use of backward-pulling head- gear of Class II elastics and/or bicuspid extractions would result in poor esthetics if used to try to fit a normal maxilla to a retruded mandible. Bite Plane An upfront, full smile always attracts attention. Dr. Grant Bowbeer had found that a bite plane in combination with labial orthodontic appliances helps to expand the   Enhanced Facial Esthetics using Kurz Lingual Appliance CRAVEN KURZ, DDS, PhD  -. Michelangelo’s faces in balance with today’s contemporary beauty analysis.
  maxilla and consequently, to achieve an esthetic occlusion. The inclined plane in the upper incisor lingual brackets was designed for the purpose of avoiding shearing forces and subsequent debonding of the maxillary brackets. However, if used properly, it can also achieve correct positioning of anterior teeth in the optimal esthetic A-P and lateral positions. The esthetic advantages of the bite plane are: 1. It can be used as a functional appliance to facilitate the unlocking of a retruded mandible. 2. It can help expand the arch. This is a clinical observation and the possible explanations are elimination of posterior contacts or decrease in the lateral space in the palatal vault (Figures 4–2a to c). 3. It helps extrusion of posterior segments and intrusion of lower incisors in deep bite cases, giving the lower lip better support from the lower incisor and bal- ance with the maxillary lip in closure (Figures 4–3a and b). 4. Easier translation of teeth around the arch when the midline is off centered due to the smooth contact with the flat metal plate on the incisor brackets.  -  . Maxillary arch expansion: occlusal view before, during, and after lingual treatment. Note wide horseshoe arch.   
Enhanced Facial Esthetics using Kurz Lingual Appliance  Bibliography Bowbeer GRN. The five keys to facial beauty and TMJ health. The Functional Orthodontist 1985; 2:12–29. Eirew HL. An orthodontic challenge. Int J Orthod 1976;14:21–25. Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 1977;72:599–616. Luzi V. The CV value (combines variation) in the analysis of sagittal malocclusions. Am J Orthod 1982;81:478–480. McNamara JC. Components of Class II malocclusion in children 8–10 years of age. Angle Orthodontists, 1981;51:177–202. Moyers et al. Differential diagnosis of Class II malocclusions. Am J Orthod 1980;78:477–494.  -  . Extrusion of posterior segments and intrusion of lower incisors in deep bite case: occlusal view before and during lingual treatment.  
 Lingual orthodontics in the 21st century will involve several new innovations, includ- ing new players in the treatment field, new appliances and auxiliaries, and enhanced laboratory techniques, design, and communication. Still, the most important aspect of any labial, lingual removable or functional orthodontic treatment system is, of course, the thought process of the orthodontist. As all well-trained orthodontists know, any single orthodontic treatment system can work to move teeth, manage growth, or gain space; however, even the best system that is poorly thought out and does not use sound scientific principles can face failure. In the 20 years since the original lingual appliance was invented, we have been through seven generations of the original Ormco bracket and approximately a dozen other bracket designs from other companies. By necessity, treatment mechanics have been tailored to the available bracket systems. Many treatment philosophies are influ- enced by edgewise mechanics, Begg and Bioprogressive systems, and the straight wire system, after which the original bracket was designed. The individual orthodontist must take responsibility for his or her treatment. One of the main problems that lingual orthodontists have to overcome is to not overstandardize treatment plans. Although standardization sometimes can be of some advantage in streamlining a practice and allowing orthodontists to keep supplies, staff, and treatment well-coordinated, treatments should stay very case specific with an indi- vidual treatment modality for each patient. “Cookbook” orthodontics, especially for lingual treatment, has never worked. A thorough, individual treatment plan must be formulated, and the type of mechanics to be used must be selected from the very beginning of treatment. This involves a tooth-by-tooth, individual prescription that anticipates all positive and negative reactions to the type of biomechanics that the orthodontist will be using. To achieve such accuracy, a lingual orthodontist must have intimate knowledge of individual bracket positions over the center of resistance of each specific tooth and the knowledge of how that will either expedite or impede treatment goals. This will enhance treatment planning and case progress. Eventually, treatment time and chairtime can be significantly reduced, and patient comfort and satisfaction can be greatly increased. Anchorage must be carefully prepared and developed, using the Tweed method or others. Parisi (1989) proved that anchorage was enhanced from the lingual aspect when compared to the use of standard direct-bonded labial edgewise appliances without the use of extra anchorage auxiliaries. Factors like anatomical variation of teeth and functional habits like mastication and swallowing should be taken into account while planning the correct placement of   Advanced Lingual Prescription: Technique and Design ROBERT BAKER JR., DMD
  the lingual brackets. The biomechanics of choice must be carefully selected. For example, if an orthodontist is using loop mechanics, continuous arch mechanics, or sectional mechanics to retract teeth into an extraction space, the laboratory setup could be different for each retraction method due to the differing effects on the teeth and underlying bone. One of the advantages of advanced laboratory case design and technique is the virtual elimination of appliance auxiliaries like rotation ties or double over-ties. Case Presentations The following cases demonstrate diagnosis and the establishment of treatment goals through selective individual tooth prescriptions, using the CLASS System design for indirect bonding preparation.  -  . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, anterior open bite, and crowding.     
Advanced Lingual Prescription: Technique and Design  CASE 1: D.P. A 31-year-old male presented with a Class I malocclusion, anterior open bite, and mild upper and lower crowding (Figures 5–1a to e). The cephalometric and panoramic x-ray revealed no unusual findings. The treatment plan consisted of placing upper and lower lingual appliances to level and align the occlusion. The crowding was to be resolved using a nonextraction approach with air rotor stripping on the upper and lower first premolars. The prescription for the laboratory (specialty appliance) was made as follows: Patient Name DP Case description Air Rotor Stripping (ARS) on upper and lower premolars Appliance Upper and lower .018 Ormco lingual brackets Prescription Upper arch: (right=RT; left=LT) RT 1 2 deg. distolingual rotation, 10 deg lingual crown torque LT 1 3 deg. mesiolingual rotation, 10 deg lingual crown torque RT & LT 2 8 deg. lingual crown torque RT & LT 4 –0.75 mm ARS mesial & distal RT 6 3 deg. distobuccal rotation LT 6 5 deg. distobuccal rotation RT & LT 7 5 deg. mesial crown tip, Hinge Cap attachments Lower arch: (right=RT; left=LT) RT & LT 2 2 deg. mesiolingual rotation RT & LT 3 3 deg. mesiolingual rotation RT & LT 4 –0.75 mm ARS mesial & distal  -  . Frontal and lateral views during treatment.   
  Upper and lower lingual appliances were bonded (Ormco, generation #7, .018 slot) (Figures 5–2a and b). Treatment time was only 12 months, with 14 visits to the Eastman Dental Center. No auxiliaries were used. The results show a balanced and esthetic occlusion (Figures 5–3a to e).  -  . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.       -  . During treatment: upper and lower occlusal view of lingual appliance.  
Advanced Lingual Prescription: Technique and Design  CASE 2: A.M.C. A 31-year-old female presented with a Class I malocclusion, mild upper and lower crowding, and upper right dental midline shift. The upper right lateral incisor was severely rotated distobuccally. (Figures 5–4a to e). The cephalometric and panoramic x-ray revealed no unusual findings. The treatment plan consisted of extracting the maxillary right first premolar to alleviate crowding and aid in the midline correction. The occlusal plane was to be leveled. Continuous arch mechanics were to be used for extraction space closure. The prescription for the laboratory (specialty appliance) was made as follows: Patient Name AMC Case description Extraction upper right 4. Retraction with continuous arch mechanics Appliance Upper .018 Ormco lingual brackets, lower .022 Ormco labial brackets Prescription Upper arch: (right=RT; left=LT) RT 7 Add 14 deg. mesial root tip, add 6 deg. buccal root torque RT 6 18 deg. mesiobuccal rotation, 6 deg. buccal root torque, add 18 deg. mesial root tip  -  . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, rotated upper right lateral incisor, and midline shift.     
  RT 5 4 deg. mesiobuccal rotation, 15 deg. mesial root tip RT 3 8 deg. mesiolingual rotation, add 12 deg. distal root tip RT 2 12 deg. lingual root torque, 5 deg. distal root tip RT 1 Add 2 deg. distal root tip, 11 deg. lingual root torque LT 1 11 deg. lingual root torque, 8 deg. mesial root tip, intrude 1 mm LT 2 6 deg. mesiobuccal rotation, 10 deg. lingual root torque LT 3 6 deg. mesiobuccal rotation LT 5 9 deg. mesiobuccal rotation LT 6 12 deg. mesiobuccal rotation RT & LT 7 Please use Hinge Caps. The appliances chosen consisted of maxillary lingual brackets (Ormco, .018) and mandibular labial appliances (Ormco, .018 Spirit) (Figures 5–5a to b). Treatment time  -  . During treatment: occlusal views of the upper lingual appliance and lower transparent labial appliance.    -  . Frontal and lateral views during treatment.   
Advanced Lingual Prescription: Technique and Design   -  . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.      was 18 months, with 18 visits. No auxiliaries or wire bending was needed during the treatment and chairtime was the same as with a full labial appliance. The end results show a balanced and esthetic occlusion (Figures 5–6a to e). These cases demonstrate the use of goal-oriented diagnosis, individualized bracket prescriptions, and specific mechanics to provide more efficient treatment with the lin- gual appliance. Of course, lingual treatment can be affected by the same factors as in labial treatment, such as inadequate patient cooperation, bracket failures, etc. Wire bending and the use of auxiliaries can be eliminated with the judicious selection of the appliance prescription. Studies are ongoing to improve appliance prescriptions and custom laboratory-fabricated archwires. These and continued studies will advance the art and science of lingual orthodontics and will continue to make it more user- and patient-friendly.
 The term Shape Memory Alloys (SMA) is applied to the group of metallic materials which demonstrate the ability to return to some previously defined shape or size when subjected to the appropriate thermal procedure.1 Generally, these materials can be plastically deformed at some relatively low temperature and, upon exposure to higher temperature, will return to their shape prior to the deformation (Figure 6.1–1). Shape memory alloys, such as nickel titanium, undergo a transformation in their crystal structure when cooled from the stronger, high temperature form (austenite) to the weaker, low temperature form (martensite) (Figure 6.1–2). This inherent phase trans- formation is the basis for the unique properties of these alloys: shape memory and superelasticity. Shape Memory When a shape memory alloy is in its martensite form, it is easily deformed to a new shape. However, when the alloy is heated through its transformation temperature, it reverts to austenite and recovers its previous shape with a net force delivered (Figure 6.1–3). This process can be repeated millions of times. A typical transformation versus temperature curve under constant load is shown in Figure 6.1–4.1 Most of the trans- formation occurs over a relatively narrow temperature range, although the beginning and end of the transformation during heating or cooling actually extends over a much larger temperature range. The transformation also exhibits hysteresis (shown as T1) in that the transformations on heating and on cooling do not overlap. This transforma-  . Shape Memory Wires in Lingual Orthodontics CHRISTIAN DEMANGE, DCD, SQODE, CECSMO  .-. The shape memory effect.  .-. Transformation of alloy crystals of shape memory alloys from hot to cold phase. Heating Cooling Cold turns to Hot Face centered Body centered
  tion hysteresis (T1) varies with the alloy system. The most common SMA wires used are NeoSentalloy or Bioforce (GAC) and Copper Ni-Ti 35°C (Ormco). Superelasticity These unique alloys also show a superelastic behavior if they are deformed at a tem- perature which is slightly above their transformation temperature. This effect is caused by stress, inducing the formation of some martensite. Because it has been formed above its normal temperature, the martensite reverts immediately to undeformed austenite as soon as the stress is removed. This process provides a very springy, rubber- like elasticity in these alloys (Figure 6.1–5). SMA Wires in Lingual Orthodontics The main problem in the biomechanics of lingual orthodontics is the short interbracket distances (Figure 6.1–6). Orthodontists ideally want to accomplish biological tooth movement with a low and continuous force and a constant moment/force ratio in order to maintain a low stress/strain ratio. Two different ways exist to obtain this goal:  .-. The two phases of shape memory alloys with temperature: martensite and austenite.  .-. Typical loading and unloading behavior of superelastic Ni-Ti.  .-. Typical transformation versus temperature curve for a specimen under constant load (stress) as it is cooled and heated. T1: transformation hysteresis; Ms: martensite start; Mf: martensite finish; As: austenite start, Af: austenite finish. Austenite Martensite
Shape Memory Wires in Lingual Orthodontics  A. INCREASE WIRE LENGTH This can be done using loops (which are difficult to do, time consuming, demonstrate poor reproducibility, and do not conform to the straight wire appliance philosophy used in lingual appliances), or increase the interbracket distances (which is almost impossible since the brackets are quite large and arch form is narrow). B. USE ELASTIC WIRES Reduce the cross-section of the wire (which reduces control), or change the physical properties of the wire (yielding a low Young’s modulus). Shape memory alloys are ideal materials because they have low Young’s modulus, present a very small stress/strain ratio, and have a large cross-section of wire to achieve a maximum of control. The mechanical properties of SMA wires are different in the austenite and martensite forms. Young’s modulus is highly nonlinear with temperature. The approximate elastic modulus is about 80 GPa at high temperature (austenite), and 30 GPa at low temperature (martensite). (Figure 6.1–7). The Young’s modulus of shape memory alloys is difficult to define between the martensite and the austenite transforma-  .-. Short interbracket distances with lingual appliance.  .-. Young’s modulus of SMA wires are different in austenite and martensite.
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Lingual (2)

  • 3. LINGUAL ORTHODONTICS R A F I RO M A N O, D M D, M S c      .  .       Hamilton • London
  • 4. B.C. Decker Inc. 4 Hughson Street South P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017 Fax: 905-522-7839 e-mail: info@bcdecker.com website: http://www.bcdecker.com © 1998 Rafi Romano All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans- mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, with- out prior written permission from the publisher. 98 99 00 01 / BP / 9 8 7 6 5 4 3 2 1 ISBN 1-55009-040-2 Printed in Canada SALES AND DISTRIBUTION United States U.K., Europe, Scandinavia, Middle East B.C. Decker Inc. Harcourt-Brace & Company Ltd. P.O. Box 785 24–28 Oval Road Lewiston, NY 14092-0785 London, NW1 7DX United Kingdom Tel: 71-267-4466 Fax: 71-482-2291 Canada Korea B.C. Decker Inc. Jee Sung Publishing Company 4 Hughson Street South 236-15, Neung-Dong P.O. Box 620, L.C.D. 1 Seung Dong-Ku, Seoul Hamilton, Ontario L8N 3K7 Korea Tel: 905-522-7017 Tel: 02 424-5463 Fax: 905-522-7839 Fax: 02 456-5058 Japan India Ishiyaku Publishers Inc. Jaypee Brothers Medical Publishers Ltd. 7–10, Honkomagome 1-Chome B-3, EMCA House, Bunkyo-ku, Tokyo 113 23/23B Ansari Road, Daryaganj, Japan P.B. 7193, New Delhi-110002, India Tel: 03 5395-7604 Tel: 11 3272143 Fax: 03 5395-7606 Fax: 11 3276490 Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs.
  • 5. Robert W. Baker Jr., DMD Lingual Appliance Course Director University of Rochester Eastman Dental Center Private Practice, Limited to Orthodontics New York, USA Nitzan Bichacho, DMD Private Practice, Limited to Prosthodontics Tel Aviv, Israel Paul-Georg Jost Brinkman, DMD, PhD Associate Professor, Department of Orthodontics of the Free University Berlin, Dental School Berlin, Germany Vittorio Cacciafesta, DDS Postgraduate Orthodontic Residence Department of Orthodontics Royal Dental College Arhus University, Denmark Maurizio Cannavo, MD Visiting Professor in Lingual Orthodontics Specialization School of Orthodontics University of Ferrara, Italy Christian Demange, DCD, SQODE, CECSMO Orthodontiste Spécialiste Qualifié Docteur en Chirurgie Dentaire Docteur de l’Université Claude Bernard Maître de Conférences des Universités Practicien Hospitalier—Faculté de Lyon Lyon, France Pablo A. Echarri, DDS Private Practice, Limited to Orthodontics Barcelona, Spain Lorenzo Favero, MD, DDS, MSc Professor, Pediatric Dentistry Department University of Padua Padua, Italy Didier Fillion, DDS Private Practice, Limited to Lingual Orthodontics Paris, France J. Courtney Gorman, DDS, MS Private Practice, Limited to Orthodontics Marion, Indiana, USA Chiori Hashiba, DDS, PhD Private Practice, Limited to Orthodontics Tokyo, Japan Scott A. Huge Owner and President, Specialty Appliances Inc. Orthodontic Laboratory Norcross, Georgia, USA Craven Kurz, DDS, PhD President Emeritus of the American Lingual Orthodontic Association Private Practice, Marina del Rey California, USA Stuart McCrostie, DDS Specialist Orthodontist Waitara NSW, Australia Mario E. Paz, DDS, MS Course Director, Lingual Orthodontic Program University of California Los Angeles California, USA Friedrich Riemeier Manager, Bending Art Company Berlin, Germany Rafi Romano, DMD, MSc Private Practice, Limited to Orthodontics, Emphasizing Adult and Lingual Orthodontics Tel Aviv, Israel Massimo Ronchin, MD, DDS Assistant Professor in Orthodontics Cagliari University Visiting Professor University of Ferrara, Italy Guiseppe Scuzzo, MD, DDS Visiting Professor in Lingual Orthodontics Specialization School of Orthodontics University of Ferrara, Italy Alessandro Silvestri, MD, DDS, ENT Chief, Pre- and Postsurgical Orthodontic Service Department of Maxillo-Facial Surgery University of Rome “La Sapienza” Rome, Italy Kyoto Takemoto, DDS Private Practice, Limited to Lingual Orthodontics Chiba-ken, Japan Contributors
  • 6. Contents Preface . . . . . . . . . . . . . . . . . . . .  SECTION 1 Introduction  Lingual Orthodontics: Historical Perspective . . . . . . . . . .  Craven Kurz, DDS, PhD, Rafi Romano, DMD, MSc  Present Clinical Reality . . . . . . . .  Massimo Ronchin, MD, DDS  Lingual Orthodontics in a Labial Orthodontics Office . . . . .  J. Courtney Gorman, DDS, MS SECTION 2 Basic Principles  Enhanced Facial Esthetics using Kurz Lingual Appliance. . . . . . . .  Craven Kurz, DDS, PhD  Advanced Lingual Prescription: Technique and Design . . . . . . . .  Robert Baker Jr., DMD . Shape Memory Wires in Lingual Orthodontics . . . . . . . . .  Christian Demange, DCD, SQODE, CECSMO . Wire Sequencing in Lingual Orthodontics . . . . . . . . . . . . . . .  H. Stuart McCrostie, DDS  Instruments Used in Lingual Appliance. . . . . . . . . . . . . . . . . .  Craven Kurz, DDS, PhD SECTION 3 Treatment Approaches and Mechanics  Anchorage Control in Lingual Orthodontics . . . . . . . . . . . . . . .  Kyoto Takemoto, DDS . Preserving the “Hollywood Smile” and Facial Profile . . . . . . . . . . . .  Mario E. Paz, DDS, MS . Distalization of Molars in Nonextraction Cases . . . . . . . . . .  Guiseppe Scuzzo, MD, DDS, Maurizio Cannavo, MD . Interproximal Enamel Reduction in Lingual Orthodontics . . . . . . .  Didier Fillion, DDS . Sliding Mechanics versus Loop Mechanics During En Masse Retraction in Extraction Cases. .  Kyoto Takemoto, DDS . Case Presentation: Loop Mechanics . . . . . . . . . . . .  Guiseppe Scuzzo, MD, DDS . Case Presentation: Sliding Mechanics . . . . . . . . . . .  J. Courtney Gorman, DDS, MS  Lingual Orthodontics in Pediatric Patients. . . . . . . . . . . .  Lorenzo Favero, MD, DDS, MSc
  • 7. . The Lingual Technique in Orthognathic Surgery . . . . . . . .  Alessandro Silvestri, MD, DDS, ENT . Orthodontic-Surgical RPE Camouflage on an Orthognathic Case . . . . . . . . . . . . . . . . . . . . .  Mario E. Paz, DDS, MS . Segmental Lingual Orthodontics in Multidisciplinary Cases . . . . .  Pablo A. Echarri, DDS . Combined Orthodontic-Prosthetic Treatment of Malpositioned Anterior Teeth. . . . . . . . . . . . . .  Rafi Romano, DMD, MSc, Nitzan Bichacho, DMD  Lingual Orthodontics: Esthetics and Function. . . . . . . .  Chiori Hashiba, DDS, PhD SECTION 4 Laboratory Procedures  The Customized Lingual Appliance Set-Up Service (CLASS) System . . . . . . . . . . . . .  Scott A. Huge  The Thickness Measurement System with the DALI Program . . .  Didier Fillion, DDS  Lingual Treatment with the Bending Art System . . . . . . . . . . .  Paul-Georg Jost-Brinkmann, DMD, PhD, Vittorio Cacciafesta, DDS, Friedrich Riemeier SECTION 5 Appendix Bibliography . . . . . . . . . . . . . . . .  Index. . . . . . . . . . . . . . . . . . . . . . 
  • 8.  The Preface to Lingual Orthodontics (LO) should have been actually called: “A short explanation why Lingual Orthodontics is the first complete English textbook ever pub- lished on LO.” The idea to edit Lingual Orthodontics arose in October 1995, at the Italian Association of Lingual Orthodontics (AIOL) meeting in Rome, where many of the best clinicians who practice LO were in attendance. When surveying the literature published on LO, it is surprising to discover that most of it was written from 1982–1985, immediately after Dr. Kurz from USA and Dr. Fujita from Japan developed the prototype lingual system and ORMCO founded the original Task Force. These years saw the very first steps with the new system, observed with the critical eyes of the orthodontic community and with exaggerated expectations from the public and media. While most orthodontists found interest in the new system, it was still undeveloped, without any finished cases, any protocol, and presented many technical problems. More than 12 years have passed since “silence” concerning LO was declared in the scientific journals, in all of the important ortho- dontic meetings, and in orthodontic offices. The media had completely stopped men- tioning the subject and because of the small number of orthodontists who continued to treat patients with LO during this period, we are now again in a situation charac- terized by a lack of knowledge in the dental community and among the public. The technique of lingual orthodontics, which is the only option we can give to those patients who want their orthodontic treatment to be done behind closed curtains, was really left with the curtains closed. The fault is partly due to the rapid decline in the number of orthodontists who offer LO as a treatment option in their office and partly due to the small efforts that were made by those who did practice LO to teach, to write, to do research, or to con- tribute from their knowledge to all of their colleagues. Excellent work is done all over the world with LO. Some clinicians have even decided to devote their practice exclusively to LO and can now present excellent clinical results with a long follow-up. Much new material that has not yet been published exists as well as tremendous experience that was gained in the field in the last 15 years. Much of this is known only to a small group of orthodontists who come to LO meetings all over the world. This book is published to change this situation because we believe that lingual orthodontics is the ultimate esthetic solution in orthodontics today. Many of the best clinicians who practice LO contributed to this book. They come from all over the world—from the USA, Australia, Japan, France, Italy, Spain, Germany, and Denmark. I would like to thank each one of them personally for the tremendous help, good will, and patience they have exhibited in the long process of creating an international book. They have all agreed to share their knowledge and experience with our readers. Many clinical tips and experience were gathered and are now disseminated Preface
  • 9.   for the first time. Almost every possible aspect of LO is covered, including history, mechanics, extraction cases, nonextraction cases, pediatric patients, interdisciplinary cases, orthognathic surgery, practice management, laboratory procedures, and more. All of them are described in full detail and enhanced with color figures. This is not a recipe book, and it is not intended to teach LO. One should take accredited courses, come to LO meetings, and gain experience before adopting the system completely into his or her practice. Once a thorough knowledge and clinical experience are obtained, one will gain excellent clinical results, not less than he or she was used to with labial orthodontics, and with all the mechanical and esthetic advan- tages that are unique to LO. I have included all of the references I could find on LO to help the clinicians find their way in this new system. I do apologize to any author whose article I did not mention here. The advantages of LO over labial orthodontics are many. While better esthetics during treatment is the most obvious, some advantages are purely mechanical, like more efficient distal movement, much easier intrusion, increased expansion, and the built-in capability in the bracket design to reposition the mandible and tempero- mandibular jaw when needed. Some clinicians still claim that LO is not a legitimate option and that lingual orthodontic results are inferior to those achieved with labial orthodontics. In fact, the opposite is frequently true. We do believe that the advantages of LO as a treatment option are greater than the disadvantages, and it should be considered as a legitimate, equally good option to every other treatment modality. Still, there is much more to be done in the field of LO other than publishing more textbooks. Some disadvantages still to be overcome are: • Further improvement of the design of the brackets to make them smaller, more easily ligated, and smoother to the tongue. • Reduction in speech distortion during the early stages of treatment, which can be distressing to the patient. • The addition of training in lingual orthodontics to the graduate or postgrad- uate orthodontic programs in the universities around the world. • Reduction of the high fees by improvements in design and technique which will, in turn, reduce the chairtime of the orthodontist. I do hope this book will have a uniting influence on the clinicians using LO. The world has become a very small place since people began traveling extensively. Some of my patients come from Japan, USA, and Europe, and they expect each orthodontist to have the same knowledge and skills as his or her colleagues. Easy, rapid communi- cation tools exist and should be used to teach, to inform, and to unite. Teaching other orthodontists the “secrets” of our technique will, in the long run, bring us more accep- tance and more work. When more orthodontists use LO in their offices, patients will become more aware of it and ask for it. This phenomenon occurred in general den- tistry with porcelain veneers and bonding. When it became more popular, the dentists who were the first to do it became the leaders in esthetic dentistry all over the world. I hope that Lingual Orthodontics will become towards the year 2000 an essential part of orthodontic offices and university libraries, to be used by doctors and patients, and to be a part of the esthetic dentistry postgraduate studies.
  • 10. Preface  I again thank all my colleagues who participated in writing this book, especially Dr. Didier Fillion, a friend and one of the best clinicians in LO in the world today; my Israeli colleague, Dr. Sylvia Geron, who helped me and supported me all the way; Prof. Adrian Becker, one of the most talented orthodontists I know, who inspired me tremendously; Dr. Linda Hallman, who helped review the material; Dr. Nitzan Bichacho, Dr. Paul Miara, and Dr. Bernard Touati who helped me enter the fascinating world of esthetic dentistry; and my wife, who warmly supported me. The book is dedicated to my father, Dr. Albert Romano. Rafi Romano, DMD, MSc
  • 11.  Lingual Orthodontics: Historical Perspective. . . . . . . . . .  Craven Kurz and Rafi Romano  Present Clinical Reality. . . . . . . .  Massimo Ronchin  Lingual Orthodontics in a Labial Orthodontics Office. . . . .  Courtney Gorman SECTION 1 Introduction
  • 12.    Lingual Orthodontics: Historical Perspective CRAVEN KURZ, DDS, PhD, AND RAFI ROMANO, DMD, MSc The 1970s was an exciting decade for orthodontics. The straight wire appliance was developed, treatment demands had increased, and adults were seeking treatment in greater numbers. This increasing demand for adult treatment brought unique con- cerns to the profession. Esthetics was then and continues to be a primary concern of patients. To address these esthetic concerns, manufacturers introduced clear plastic brackets; unfortunately, however, staining of the bracket and the tooth presented a significant problem. The search for improved esthetic alternatives to metal or clear plastic brackets continued. During the early 1970s, Dr. Craven Kurz, an orthodontist, then assistant professor of occlusion and gnathology at the UCLA School of Dentistry, found his private orthodontic practice to be increasingly dominated by adult patients. As many of his patients were public figures, esthetics became a major concern. A particular patient, who was an employee of the Playboy Bunny Club, presented to his practice requesting treatment. Because of her public position she refused metal or plastic labial appliances on esthetic grounds. From her demand for an appliance that did not show, the con- cept of a lingually bonded appliance was born. After much advice and consultation from orthodontic colleagues, particularly Dr. Jim Mulick, also at the UCLA School of Dentistry, Dr. Kurz developed the first true lingual appliance. The appliance consisted of plastic Lee Fisher brackets bonded to the lingual aspect of the anterior dentition and metal brackets bonded to the lingual aspect of the posterior dentition (Figures 1–1a and b). The plastic anterior brackets were selected because of the ease of recontouring and reshaping them to avoid direct contact with the opposing teeth. Treatment progress was closely moni- tored during this initial attempt at lingual treatment. Not surprisingly, Dr. Kurz found that occlusal forces produced a shearing force on the maxillary incisor brackets, creating a high bond failure rate. Additionally, the brackets were uncomfortable and irritating to the patient’s tongue. By the mid-1970s, Dr. Kurz found that by smooth- ing the exposed surface of the brackets using a heatless stone, patient comfort and acceptance increased. Not surprisingly, commercial interest was rapidly developing for this new appliance and approach to orthodontic treatment. Many clinicians and commercial companies were in the process of developing some version of a lingual appliance. During these early stages, Ormco, a company in California, created a product development team consisting of Mr. Frank Miller and Mr. Craig Andreiko to work with Dr. Kurz and his new appliance. Historically, Ormco’s interest in the concept of lingual orthodontic treatment was well established. In the early 1970s, in conjunction with Dr. Jim
  • 13.   Wildman, they attempted to develop a system to align the dentition using the lingual approach. This system consisted of a Pedicle positioner, rather than a multibracketed system. Although innovative, inherent limitations in this system prevented it from gaining widespread popularity in the orthodontic community. With the new product development team now in place, prototypes of lingual brackets were developed to attempt to improve on the design of the original appliance. The prototypes were initially carved from wooden blocks at a scale of 40:1 and then recreated in appropriate materials in scaled-down versions to fit the mouth. It was quickly found that the problems that plagued all previous attempts at developing a usable appliance remained—namely, a high bond failure rate due the shearing forces, and patient discomfort from the roughness against the tongue. The turning point in the development of the appliance was the addition of an anterior inclined plane as an integral part of the maxillary anterior brackets (Figure 1–2). This inclined plane con- verted the shearing forces produced by the mandibular incisors to compressive forces applied in an intrusive and labial direction. These forces also produced a natural physiological bone resorption in the maxillary and mandibular incisor area, allowing the teeth to intrude at generally less than 100 milligrams in force each time the patient swallowed (approximately 2000 times per day).    -  . Dr. Kurz 1973–1975 labial appliance modified for lingual application.  -. The incline plane.
  • 14. Lingual Orthodontics: Historical Perspective  Bond failures decreased dramatically. Redirecting the forces by the use of an ante- rior inclined plane appeared to be the missing link in the development of a viable lin- gual appliance. It was with this design that Dr. Kurz applied for a patent for the Kurz Lingual Appliance on November 15, 1976. Product development began in earnest in 1978, and Ormco manufactured a usable metal bracket by 1979. Initial clinical test- ing began in Dr. Kurz’s private office, with approximately 100 cases tested over a three- year period. All appliances were direct bonded, and a treatment protocol was estab- lished. From the initial testing, the appliance appeared to be viable and showed much promise in providing the profession with an esthetic alternative to labial appliances. The next logical step in product development and improvement was to establish beta test sites. Fifty selected orthodontists were invited to attend an Ormco-sponsored  -. Dr. Craven Kurz  -. Dr. Jack Gorman  -. Dr. J.R. Bob Smith
  • 15.   symposium on lingual orthodontic therapy. Here, Dr. Kurz presented the concept of lingual treatment, the appliance, and his treatment results from the initial 100 cases tested to the professional community. From this group, the original Lingual Task Force was developed. This group was under the administrative guidance of Mr. Floyd Pickrel, Mr. Ernie Strauch, and Dr. Michael Scwartz, all from Ormco. Their charge was to guide and administrate the research and development team while a commercially viable lingual appliance was being developed. They appointed, in addition to Dr. Craven Kurz of Beverly Hills, California (Figure 1–3), the late Dr. Jack Gorman of Marion, Indiana (Figure 1–4), Dr. Bob Smith of Stanford, Florida (Figure 1–5), Dr. Richard (Wick) Alexander (Figure 1–6) and Dr. Moody Alexander (Figure 1–7), both from Dallas, Texas, Dr. James Hilgers of Mission Viejo, California (Figure 1–8), and Dr. Bob Scholz of Alemeda, California (Figure 1–9) to provide beta test sites for the appliance.  -. Dr. James Hilgers  -. Dr. Bob Scholtz  -. Dr. Wick Alexander  -. Dr. Moody Alexander
  • 16. Lingual Orthodontics: Historical Perspective  Excitement about an esthetic alternative to traditional orthodontic treatment was growing within the dental profession. This plus public demands for this alternative treatment forced an urgency on the research and development team to provide the appliance for wide-scale use as quickly as possible. By the early fall of 1981, the task force was presenting regular seminars on the lingual appliance in Newport Beach, California. That same year, Dr. K. Fujita of Japan, published an article on lingual therapy in the American Journal of Orthodontics. Commercial interest was spreading. Unitek supported a Lingual Clinical Project under the direction of Dr. Vince Kelly of Oklahoma. Dr. Steve Paige of Florida began giving courses using a Begg appliance lingually. Forestodent, and American Orthodontics all began to market lingual brackets and accessories. Public interest continued to grow. The news media reported the development of the new “invisible braces” in major magazines and broadcasts on both television and radio (Figure 1–10). The Ormco task force conducted a news conference at the Waldorf Astoria in New York, touting the benefits of this new type of orthodontic therapy. The interest of the public was heightened even more, and they demanded the appliance from the profession. Commercial companies were competing to be at the forefront of this “lingual fever.” Even Unitek now had a lingual appliance. Dentists were demanding more information and training in the lingual technique. The courses presented by the Lingual Task Force continued to grow in size, with over 1000 orthodontists in atten- dance at each lecture (Figure 1–11). By 1983, the task force was giving courses and news conferences in most major cities in America. In 1982, Ormco organized a task force of two doctors from every country in Europe. In 1983, this group introduced the appliance to Europe at a meeting in Geneva, Switzerland, followed by courses in Japan. Several well-known European orthodontists, Dr. Klaus Gerkhardt of Germany, Dr. Lennart Lagerstrom of Sweden, and Dr. Jorn Perregaard of Denmark were added to the European task force. The European doctors insisted on seeing finished cases. In 1983, the task force conducted seminars for 300 doctors. All the finished cases were  -. Various magazines exalting the virtues of the lingual appliance.
  • 17.   presented with a full treatment protocol; their results were therefore more acceptable than those presented earlier to the American doctors. In 1983, Ormco sold 5000 lingual cases, and by 1986 they had sold 18,000 lingual cases! At this time, thousands of orthodontists worldwide were attending courses and beginning treatment using the lingual technique. The technique and appliance were still in their infancies, and, in fact, beta testing had not yet been completed. Public demand and commercial interest rushed the product to the market, perhaps prema- turely. In 1986 the French Orthodontic Society founded the Société Français Orthodontie Linguale (SFOL, or French Orthodontic Society for Lingual Orthodontics). In 1987, at the American Association of Orthodontists’ annual meeting in Montreal, Canada, Dr. Kurz was on the program to discuss lingual orthodontic therapy. The lecture topic was timely in that many orthodontists had now tried the appliance and lingual therapy without much success. There seemed to be widespread problems with appliance placement through direct bonding techniques and manipulation of archwires on open buccal segments with no occlusion because of the bite plane effect of the anterior inclined plane. Many clinicians had experienced a loss of control in cases treated with the lingual approach. Dr. Kurz’s lecture was well attended because many clinicians were looking for solutions to the problems that were preventing them from finishing cases to the same standard of excellence they had come to expect from labial appliances. At this same meeting, an alternative esthetic solution was pro- vided to the clinicians. A truly clear, stain-resistant labial bracket was introduced by A Company. This bracket, called Starfire, provided a reasonable alternative for patients who were concerned with the poor esthetics of conventional metal labial brackets. A sigh of relief was heard throughout the orthodontic community. Orthodontists could now offer to patients an option that provided improved esthetics over metal brackets with efficient and high-quality treatment. Enthusiasm for lingual therapy waned in the profession, and commercial interest also declined. The original Ormco Task Force was reduced to just three members by 1988, Drs. Kurz, Gorman, and Smith. They restructured the group and were renamed KGS Ormco Task Force Number Two. Their new charge was to define the problems that plagued the current status of lingual therapy and develop solutions to these prob- lems. These were the problems they identified:  -. Classes in a Newport beach hotel.
  • 18. Lingual Orthodontics: Historical Perspective  1. The lingual appliance had been made available to the public before testing was complete. 2. Orthodontists inadequately trained with lingual therapy were treating patients in record numbers. 3. The public had high expectations from this treatment and demanded it from the profession immediately. A solution was to have smaller classes taught by more experienced lingual practi- tioners. Longer courses were developed with a typodont (hands-on) component, and continuing education was stressed, with support provided by study clubs, journals, and professional meetings. The American Lingual Orthodontic Association (ALOA) was established on November 14, 1987, by a core group of six hundred American orthodontists. Member- ship quickly grew to over 800 members in 17 countries. The ALOA provided quarterly journals, study club assistance, patient brochures, yearly conventions, and professional lectures. The first annual meeting of ALOA was held in Washington in 1987, and in Palm Springs the following year. Additionally, a Dental Lingual Assistant Association was formed to provided support for staff members employed by lingual orthodontic practitioners. The new professional associations were smaller than the original groups but remained active in their support of lingual therapy. Continuing educational pro- grams were now offered in Europe and Japan by the KGS group. Enthusiasm for lin- gual therapy was still strong in these professional communities. Some European and Japanese university programs offered training in lingual therapy and these were soon followed by courses in Korea, South America, Mexico, and Denmark. The European Society of Lingual Orthodontics (ESLO) was founded in 1992, in Venice, Italy, and hundreds of people participated in the first European lingual asso- ciation congress in Venice. In the same year, an Italian society was founded; the Associazione Italiana Ortodonzia Linguale (AIOL) or the Italian Association of Lingual Orthodontics has been one of the most active ever since. The Asian lingual asso- ciation is also very active. Dr. Lorenzo Favero, Italy, was the first to treat children and adolescents with LO, and now it is a legitimate treatment option for all. Today, lingual orthodontics has a small but strong following in the United States, Europe, and Asia. The ALOA is active again, after few years of silence, with annual conventions, availability of patient educational materials, and the publication of a professional quarterly, the JALOA. The French Lingual Orthodontic Society and the Italian Lingual Orthodontic Society currently hold annual meetings. The ESLO sponsored the last international meeting in Monaco, Monte Carlo in 1996 and the next meeting is scheduled for June, 1998 in Rome. Many courses are given in various locations throughout the world, mainly by Drs. Didier Fillion (France), Courtney Gorman (USA), Giuseppe Scuzzo (Italy), Kyoto Takemoto (Japan), Echarri Pablo Lobiondo (Spain), Bob Baker (USA), Mario Paz (USA), and John Napolitano (USA). The following is a summary listing of some of the difficulties encountered during the development of lingual orthodontic therapy and the current solutions: 1. Tissue Irritation and Speech Difficulties The earlier brackets placed on the lingual surface of the teeth were irritating to the tongue and impeded normal speech. The current generation of brackets has been
  • 19.  -. Initially, anterior brackets had long gingival hooks responsible for calculus build-up.   redesigned with smooth exterior surfaces and a low profile. The increased comfort allows normal tongue activity, hence speech is not affected significantly. 2. Gingival Impingement Earlier generations of the lingual appliance had a broad bonding base extending towards the gingival margin (Figure 1–12). Access for adequate oral hygiene and the self-cleansing nature of the oral cavity were compromised. Brackets have been redesigned to be more self-cleansing. The base now extends incisally and mesiodistally, providing adequate bond strength, yet retaining hygienic qualities. The mandibular anterior teeth are particularly vulnerable to calculus accumulation due to their close proximity to the submandibular salivary glands. These brackets have 1.5 to 2 mm clearance between the base and the gingival margin. Additionally, the bracket hooks have been redesigned with a lower profile and are located several millimeters from the gingival margin (Figures 1–13a and b). 3. Occlusal Interference A predominant problem with the original appliance was the effect of the shearing forces on the brackets, particularly in the maxillary anterior dentition. (In the absence of a cross-bite, the lingual aspect of the mandibular dentition is generally not in direct contact with the maxillary dentition; therefore, the shearing forces were not a problem (Figure 1–14). Likewise, the relatively high maxillary crown height and low mandibular cusp height in the posterior segments allow adequate clearance to avoid the severe shearing forces seen in the maxillary anterior region.) The bracket was redesigned with an inclined or bite plane strategically placed to redirect the vertical shearing forces to a horizontal seating force (Figure 1–15). The location of the inclined plane is such that when a 1 mm overjet and overbite relationship is obtained, all mandibular anterior contact with the inclined plane is eliminated. To avoid deleterious effects caused by tooth contact with the archwire, the inclined plane is located incisal to the slot. Patient tolerance of the bite plane effect of the inclined plane has been favorable.
  • 20. Lingual Orthodontics: Historical Perspective  4. Appliance Control Since the introduction of lingual therapy, control has been a concern. To allow better control of tooth movements, the appliance was fabricated in high tensile metal which provides a greater degree of accuracy. First and second molar bands were manufactured, allowing control from both the buccal and lingual sides of the posterior segments. An initial treatment approach joined the buccal and lingual attachment when the wire was engaged. This coupling was thought to prevent vertical and horizontal rotation of the buccal segments (Figure 1–16). Clinically, however, this coupling proved to be unnecessary because one full arch wire from 7-7 was able to offer much more stability. Currently, transpalatal bars are used for additional stability. They can be attached to either the first or second molar. 5. Base Pad Adaptation As with all appliances, accurate contour of base pads improves not only retentive capabilities but also the accuracy of bracket placement and therefore the quality of  -. Cast illustration of the mandibular teeth showing no problem with occlusal interference.    -  . Photo of Kurz #7 bracket bonded on typodont, with close-up of mandibular and maxillary incisors.
  • 21.   treatment. Topographic maps were constructed for each tooth and individual bracket base curvatures were calculated (Figure 1–17). 6. Appliance Placement and Bonding The original appliances were direct bonded. With the variability of lingual tooth con- tours, accurate bracket placement was difficult. This approach produced unpredictable tooth alignment with tremendous variations in tip, torque, and tooth height. Initially, the Torque Angulation Referencing Guide (TARG) system was used. The TARG instrument was designed to place brackets on the lingual surfaces using conventional landmarks as references. Although substantial improvements were made in the accuracy and efficiency of bonding, the system was still inadequate. A more sophisticated sys- tem, using a diagnostic set-up constructed from articulated models was developed and has met with considerable success. This method, the Custom Lingual Appliance Set-Up Service (CLASS), involves indirect bonding set-up on a diagnostic or ideal model of the teeth. The brackets are then transferred back to the original malocclusion, and transfer trays prepared. These methods will be explained in detail in Chapter 15. 7. Appliance Prescription In the early 1970s, Dr. Lawrence Andrews developed and patented a fully programmed orthodontic appliance, which he introduced as the Straight Wire Appliance. This philosophy involves programming all the elements necessary to achieve an optimal occlusion into each bracket.  -. The incline plane. The red arrows represent the primary force applied, and the broken black lines represent the secondary/resultant forces exerted.
  • 22. Lingual Orthodontics: Historical Perspective  The initial lingual appliance used a custom-modified labial appliance bonded to the lingual surface. Tip and torque angulations were not ideal. A similar philosophy was used to design the Kurz Lingual Appliance. A site was selected on the lingual surface of each tooth. It was consecutively transferred from the lingual first molar, as high as it could go, without missing the rounded lingual anatomy. Reciprocal tip and torque values to Andrew’s published values were used to establish the prescription. There was no grand procedure used in obtaining the reciprocal lingual reference of angles with regard to Andrew’s published values. It was a simple matter of mathemati- cally milling a hundred molds to a constant labial vertical.  -. Locking of the molars to the lingual attachment was thought to give greater appliance control.  -. Topographical illustration used to study the lingual dental anatomy for the purpose of construction of lingual appliance bases.
  • 23.    -. Frontal view of the lingual bracket designed for the maxillary anteriors. The in-out values varied dramatically between the anterior and posterior segments. To adjust for this with bracket design alone would make the anterior brackets thicker than is reasonable, so a true straight wire was not feasible. A first order bend was placed at the junctions of the canine and premolar, and the premolar and molar. These wires could be prefabricated in the laboratory. 8. Wire Placement Access for the placement of wires in the molar tubes from the lingual was limited. The tubes were redesigned by widening the mesial aperture of the slot of the first molar bracket, creating a funnel effect (Figure 1–18).  -. Widening of the mesial aperture to provide ease of wire insertion.
  • 24. Lingual Orthodontics: Historical Perspective  9. Ligation To permit stable ligation with ligature wires or A elastics, ligature locking grooves that are both deep set and easy to hook have been designed. When teeth are crowded and slot engagement is especially difficult, a vertical slot is provided so the archwire can be attached to the bracket even through the initial stages of leveling and aligning (Figure 1–19). A double over-tie with metal is used when a tooth is to be an attach- ment for anchorage or rotation of the other teeth. 10. Attachments A gingival hook is an integral part of the bracket and provides rotational control. The original hook was large and in close proximity to the gingival margin, impeding access for hygiene. This hook was redesigned with a lower profile and moved away from the gingival margin. From Generation #1 to Generation #7—A Summary of Progress GENERATION #1—1976 The first Kurz Lingual Appliance was manufactured by Ormco. This appliance had a flat maxillary occlusal bite plane from canine to canine (Figure 1–20). The lower incisor and premolar brackets were low profile and half-round (Figure 1–21), and there were no hooks on any brackets. GENERATION #2—1980 Hooks were added to all canine brackets (Figure 1–22). GENERATION #3—1981 Hooks were added to all anterior and premolar brackets. The first molar had a bracket with an internal hook. The second molar had a terminal sheath without a hook but had a terminal recess for elastic traction (Figure 1–23).  -. Generation #1—1976. Flat maxillary occlusal bite plane from canine to canine.
  • 25.   GENERATION #4—1982–84 This generation saw the addition of a low profile anterior inclined plane on the cen- tral and lateral incisor brackets. Hooks were optional, based upon individual treat- ment needs and hygiene concerns (Figure 1–24 and 25). GENERATION #5—1985–86 The anterior inclined plane became more pronounced, with an increase in labial torque in the maxillary anterior region. The canine also had an inclined plane; however, it was bibeveled to allow intercuspation of the maxillary cusp with the embrasure between the mandibular canine and the first premolar. Hooks were optional. A transpalatal bar attachment was now available for the first molar bracket (Figure 1–26 to 28).  -. Generation #1—1976. The lower anteriors and premolars had low profile, half-round brackets. There were no hooks on any brackets.  -. Generation #3—1981. Hooks were added to all anterior and premolar brackets.  -. Generation #2—1980. Hooks were added to all canine brackets.
  • 26. Lingual Orthodontics: Historical Perspective  GENERATION #6—1987–90 The inclined plane on the maxillary anteriors become more square in shape (Figures 1–29 and 30). Hooks on the anteriors and premolars were elongated. Hooks were now available for all the brackets. The transpalatal bar attachment for the first molar band was optional. A hinge cap, allowing ease of archwire manipulation, was now available for molar brackets.  -  . Generation #4—1982–84. Additional of a low profile anterior inclined plane on the central and lateral incisors. Hooks were optional.  -  . Generation #5—1985–86. The anterior inclined plane was more pronounced, Upper Central Torque: +68° Angulation: +5° Rotation: 0 In–Out: 0 Slot size: .018 Pad: Special lingual design Upper Cuspid Torque: +55° Angulation: +12° Rotation: 0 In–Out: .010 Slot size: .018 Pad: Special lingual design
  • 27.   GENERATION #7—1990 TO PRESENT The maxillary anterior inclined plane is now heart-shaped with short hooks. The lower anterior brackets have a larger inclined plane with short hooks. All hooks have a greater recess/access for ligation. The premolar brackets were widened mesiodistally and the hooks were shortened. The increased width of the premolar bracket allows better angulation and rotation control. The molar brackets now come with either a hinge cap or a terminal sheath (Figures 1–31 and 32).  -. Generation #5—1985–86. A transpalatal bar attachment was now available for the first molar bracket.  -  . Generation #6—1987–90. The inclined plane on the maxillary anteriors became more square in shape. Hooks were elongated and were available for all the brackets. Ball hook Ball hook Bracket slot for archwire Bracket slot for archwireBracket Bracket
  • 28. Lingual Orthodontics: Historical Perspective  Bibliography Alexander RG. Lingual orthodontics. In: The Alexander Discipline. Ormco Corporation, 1986; 13:371–430. Andrews LF. The straight wire appliance: syllabus of physiology and techniques. 2nd Ed., USA, 1975. Fillion D. Orthodontie linguale et Mini-Plaques, esthetique et confort dans les traitments chirur- gio-orthodontiques. L`Information Dentaire n 20 du 17 mai 1990. Gorman JC. Treatment with lingual appliance: the alternative for adult patients. Int J Adult Orthod Orthognath Surg 1987;2:131–149. Gorman JC, Kurz C, Smith JR. Lingual orthodontics, cases, principals and practice. 3-hr. Videotape produced by Ormco Corporation, Glendora, California. Gorman JC, Kurz C, Smith JR. Lingual case reports. J Clin Orthod 1983;17:5. Gorman JC, Kurz C, Smith JR. Lingual mechanotherapy. J Clin Orthod 1983;17:2. Gorman JC, Kurz C, Smith JR, Dunn RM. Keys to success in lingual therapy. J Clin Orthod 1986;20:4–5. Gorman JC, Smith JR, et al. Lingual orthodontics, a status report. J Clin Orthod 1982;16:4. Kurz C. Lingual orthodontics. In: Marks M, Corn H, eds. Atlas of adult orthodontics. Philadelphia, London: Lea & Febiger, 1989. Kurz C, Bennett R. Scientific report. J Am Ling Orthod 1988;1:3. Smith JR. Twelve key principles for lingual orthodontic therapy. J Am Ling Orthod 1988;1:2.  -  . Generation #7—1990–present. The maxillary anterior inclined plane is heart-shaped with short hooks. The lower anterior brackets have a larger inclined plane with short hooks and all hooks have a greater recess/access for ligation. Ball hook Bracket slot Bracket Ball hook Bracket slot for archwire Bracket
  • 29.  During the evolution of lingual appliance therapy, the technique has moved in and out of public and professional favor. Over the years, the appliance and the techniques have been improved dramatically and, as a result, a reliable system has emerged. It has now undergone many years of clinical experience and has been shown to consistently produce satisfactory results. Esthetic concerns were initially responsible for the development of the appliance system and they continue to remain at the forefront for a significant segment of patients seeking orthodontic treatment. Appearance is undoubtedly the most impor- tant motivating factor for adults whether it is termed “facial appearance,” “dental appearance,” or “straight teeth.” Research has shown that physically attractive people achieve higher levels of success in many aspects of life than unattractive people.3 This advantage starts at birth and continues into adulthood. The added positive attention given to attractive indi- viduals by teachers and peers, for example, can have profound effects on personality development and self-image. Improvement in one’s physical appearance, as is common with orthodontic treatment, can positively affect social and professional interactions.1–9 At the same time, deterioration in one’s physical appearance, as with the use of unat- tractive labial orthodontic appliances, can negatively affect one’s self-esteem. This is particularly true during the formative years of adolescence and young adulthood. Many patients, if given the choice, would opt for an appliance that was not visible, provided the course of treatment and the quality of the results were the same as with a conventional treatment. This service offered in the private orthodontic office allows the patient several treatment options, and provides the orthodontist with a competitive advantage over colleagues not offering the option of lingual appliances. Advantages and Disadvantages of Lingual Therapy One of the most significant drawbacks to lingual therapy appears to be the discomfort to the tongue, and with it, difficulty in speech, both of which usually improve after 2 to 3 weeks of appliance placement. Also, the sensitivity of the laboratory techniques and the extended chairtime needed for appliance placement and adjustments have made the treatment prohibitively expensive for many patients. However, lingual treatment has obvious advantages over labial treatment. The labial enamel surface of the anterior teeth plays an important esthetic role. By placing labial appliances, the susceptibility of this enamel surface to chemical insults from etchant materials and to environmental influences from plaque accumulation in patients with poor oral hygiene is increased. Permanent and unsightly decalcification marks can result. Lingual appliances allow easy access for routine oral hygiene proce- dures on these labial surfaces. Additionally, the self-cleansing nature of the stomatog-   Present Clinical Reality MASSIMO RONCHIN, MD, DDS
  • 30.   nathic system is maintained. Clinical judgment of treatment progress can be enhanced. Evaluation of individual tooth positions can be easily accomplished by hav- ing the labial surfaces free of distracting metal or plastic brackets. Soft tissue responses of the lips and cheeks to treatment can be judged accurately because there is no distor- tion of shape or irritation caused by a labial appliance. Four distinct situations exist where lingual appliances may be more effective than labial appliances because of their unique mechanical characteristics. These include: 1. Intrusion of anterior teeth. 2. Maxillary arch expansion. 3. Combining mandibular repositioning therapy with orthodontic movements. 4. Distalization of maxillary molars. 1. Intrusion of Anterior Teeth The biomechanics of lingual techniques differ considerably from labial biomechanics. Both arch circumference and interbracket distance are reduced, requiring lighter force application for tooth movement.5–9 Lingual bracket position, which is dictated by the morphology of the lingual surface of the tooth, places the bracket closer to the center of resistance of the tooth than is found with labial bracket placement (Figure 2–1).10 An important clinical implication of this unique bracket position and design is that the intrusive force vector is directed  -. The center of resistance of the tooth is located closer to the lingual bracket.
  • 31. Present Clinical Reality  through the center of resistance of the tooth. As the mandibular anterior dentition occludes with the anterior horizontal plane of the maxillary anterior brackets, a bite plane effect results. Since the appliance is bonded, the bite plane is always present. The net effect appears to be a light, continuous, intrusive force. In addition to these active intrusive forces on the anterior dentition, a passive extrusion occurs in the pos- terior segments. Deep-bite correction through this passive increase in posterior vertical dimension and active decrease in anterior vertical dimension occurs quickly and easily. Malocclusions requiring open-bite correction obviously would not benefit from this technique. To prevent the passive extrusion of the posterior segments in these patients, acrylic posterior overlays are used. Figure 2–2 shows the intrusive effect of the appliance in correcting a severe dento- alveolar deep bite in a 38-year-old female. This patient had a class II occlusion with a skeletal and dental deep-bite pattern and severe crowding in both arches. The maxil- lary dental midline looked deviated towards the left-hand side because of the extreme Class II relationship on that side (Figure 2–2a). Partial lingual appliances were placed in both arches (Figures 2–2b and c). As with labial bracket placement, ideal placement  -. The very severe deep-bite occlusion of the patient, before treatment.  -. Occlusal view of the mandibular arch, just after the partial lingual bonding; the molars were banded afterwards.  -. The upper arch, just after the initial partial lingual bonding.  -. Frontal intraoral view, three months after starting lingual mechanics.
  • 32.   is not always possible at initial bonding due to the severity of the malocclusion, so appliances should be repositioned during treatment when it becomes possible. Figure 2–2d shows the treatment progress three months after appliance placement, and Figure 2–2e shows the final occlusion. Total treatment time was 15 months. Deep-bite correction was facilitated by the active anterior intrusive forces and the passive posterior extrusive forces. The correction was stabilized by prosthetic restora- tions in the posterior segments. 2. Maxillary Arch Expansion With some kinds of malocclusions we are occasionally faced with the need to expand the upper arch both transversally and sagittally. It is not yet totally clear why but, clin- ically, we obtain more remarkable dentoalveolar expansions through lingual mechanics than through labial mechanics.11–12  -. The occlusal situation six months after the end of the treatment.  -. Profile view of the patient, before treatment.
  • 33. Present Clinical Reality  Some possible reasons are: 1. The force which is developed is of a centrifugal type, from the inside towards the outside of the arch. The same occurs with the Quad-Helix and the Rapid Palatal Expansion (RPE) devices. 2. Some authors point out that the thickness of the brackets, which interpose themselves between the tongue and the lingual wall of the teeth, can con- tribute to this expansive effect.7–9 3. It is even likely that the shorter interbracket distance may play a significant role in this effect.5 In fact, by using this method, not only is the expansive effect so evident but also the teeth do not become too labially tipped.10 The tooth movement probably takes place without incurring a significant labial inclination because the application point of  -  . Lower and upper occlusal photographs, before treatment.    -‒. Right and left intraoral views, during the initial phases of mechanics, after the extraction of the first lower molars.  
  • 34.   the force is more palatal than the center of resistance of the tooth. The following case shows a 30-year-old female who had a Class III occlusal rela- tionship with a prognathic profile and a protruding lower lip (Figure 2–3a), an anterior cross-bite of several mandibular teeth, upper arch contraction, and a total lack of space for the lower left central incisor which was lingually placed and completely hid- den by the adjacent incisors (Figures 2–3b and c). Since it was a Class III malocclusion, the upper arch underwent a nonextraction treatment. The lower arch was treated with extraction of the first molars to gain more space to solve the crowding and to achieve more successful intercuspation. The upper third molars would subsequently be extracted (Figures 2–3d and e). Lingual braces were bonded to the upper arch with an initial Twist-Flex type archwire (Figure 2–4a). Four months later, the extent of the dentoalveolar expansion obtained is quite  -. The upper arch (occlusal view), just after placing the first superelastic Twist-Flex type archwire.  -. The upper arch (four months after Figure 2–4a), with a rectangular wire. Notice the amount of the transverse and sagittal expansion.  -. The patient’s profile after treatment.
  • 35. Present Clinical Reality  remarkable, both transversally and anteriorly (Figure 2–4b). Further expansion was achieved with a rectangular archwire. The results show substantial improvement in the patient profile and occlusion (Figures 2–4c and d). 3. Combining Mandibular Repositioning Therapy with Orthodontic Movements When patients have temporomandibular dysfunction (TMD), it is often necessary to treat in two distinct clinical phases. The initial phase of treatment addresses the TMD and associated pain symptoms. It is often accomplished with splint therapy until the muscle and joint symptoms resolve. Depending on the practitioner, the patient is then maintained, symptom free for a period of time from several months to more than a year. The second clinical phase of treatment addresses changes in the occlusion as a result of the new mandibular position. It generally involves orthodontics, prosthodon- tics, and/or orthognatic surgery. The orthodontic phase of treatment is often tedious and time consuming. Often, labial appliances are placed on one arch, and a positioning splint is kept on the oppos- ing arch to maintain the maxillomandibular relationship. This is then reversed with appliances placed on the opposite arch and a splint fabricated for the opposing arch. Obviously, treatment times can be significantly extended.  -. Frontal intraoral view at the end of treatment.  -. Left intraoral view during the last phases of the Class II mechanics.
  • 36.   The lingual appliance system allows both arches to be treated simultaneously, while maintaining the effects of the splint. The anterior occlusally oriented inclined plane functions as a bite plane. As seen previously, this device has an active intrusive effect, while allowing passive eruption of the posterior segments. Many patients with TMD require stability with anterior and posterior contacts on their splint. For these patients to remain comfortable, this relationship must be maintained during orthodon- tic treatment. Flat acrylic minisupports can be added to the first and/or second molars, producing a tripod effect. This combination of anterior bite plane and posterior acrylic supports can simulate the action of the conventional splint, thereby allowing treatment to progress simultaneously in both arches. The supports can be flat, thereby helping the Class II elastics (Figure 2–5), or they can be fabricated with some occlusal indentations which can guide the mandible into the desired position.12–14 Figures 2–6    -  . Frontal, right, and left intraoral photos, before treatment.   -. Frontal view of the occlusion, with the upper splint. The midlines are centered, and the mandible is slightly advanced.
  • 37. Present Clinical Reality  and 7 demonstrate the use of the lingual appliance in treating patients with TMD. This 18-year-old patient presented some TMD signs and symptoms and a history of past orthodontic extraction treatment. She had an early reciprocal clicking in the left TMJ and also suffered from muscular hyperactivity. Both the right and the left masseter muscles and the anterior belly of the left temporal muscle felt tender to palpation. She had mild to moderate anterior crowding, a Class I canine and molar relationship on the right, an end-on Class II canine and molar relationship on the left, normal overjet, and an increased overbite (Figures 2–6a to c). A mandibular repositioner was fabricated and worn until her TMD symptoms disappeared (Figure 2–6d) and she was main- tained symptom free for four months before orthodontic treatment was initiated. The lower arch was then bonded (Figure 2–6e). Two months later the upper splint was  -. The patient, wearing the splint, is maintained in the same therapeutic position. The lower arch is fully bonded.  -. The upper arch, after the expansion, with a full size rectangular archwire. The acrylic repositioning build-ups on the first molars are visible.    -  . Frontal, right, and left intraoral views, a few weeks after treatment is completed. 
  • 38.   removed, the maxillary arch bonded, and flat acrylic supports were placed (Figure 2–6f). These two posterior elevations, combined with the bite plane effect of the ante- rior brackets and the Class II elastics allow mandibular repositioning while also allow- ing orthodontic treatment to progress. Figures 2–7a to c show the finished case several  -. The center of resistance of the second upper molar is located in correspondence with the palatal root (see the yellow dot), close to the lingual wall.  -. During the second stage, the distal movement of the buccal roots takes place very easily.  -. The distal movement takes place quite bodily; only later can a slight buccal rotation be observed.  -. For the second stage, a buccal sectional archwire can be used.  -. A doubled Class II elastic (lingual and buccal) is very effective for the retracting mechanics.
  • 39. Present Clinical Reality  months after debonding. The patient remained symptom free. This is an interesting aspect of lingual appliance therapy that warrants consideration. 4. Distalization of Maxillary Molars Lingual brackets are placed closer to the center of rotation (CR) of the tooth than labial brackets. It is possible that molar distalization through lingual techniques pro-  -. Profile view before treatment.  -. Frontal view of the malocclusion before treatment.  -. A round archwire is initially used in the upper arch.  -  . The anterior bite effect of the lingual braces and the acrylic posterior minisupports.  
  • 40.   duce more bodily movement of the tooth and less distal tipping. Because of the angu- lation of the multiple roots of maxillary molars, the center of resistance is found just lingual to the average long axis of the roots (Figure 2–8a). In this example of a second molar being distalized with the use of an open coil spring, lingual and labial tech- niques are sequentially employed. Figure 2–8b shows the force being applied from the lingual surface; here the CR is found in the palatal root. In fact, a rather bodily distal migration takes place. Afterwards, a labial force (Figure 2–8c) can very easily correct the rotation. Bodily movement is the most efficient form of tooth movement. Clinically, this can be accomplished by placing an open coil spring between the first and second molars. To counteract the mesial displacement of the first molars, a verti- cal loop is placed against the lingual twin bracket (Figure 2–9a). For derotating the second molar and continuing to distalize the tooth, two buccal brackets and a section- al archwire can be placed. This will allow Class II elastics to be used on both the buc- cal and lingual aspects (Figure 2–9b). The balance of these forces counteracts the rota- tional forces. As an additional case, we present the 20-year-old female in Figures 2–10 to 13 who presents a rather retrusive chin (Figure 2–10a). We are faced with a Class II deep bite  -. An Australian archwire (.016 inches), producing a 20-toe-in, and two horizontal round loops is used during the last stage.  -. Profile of the patient at the end of treatment.  -. The Class II mechanics at the final phase of the treatment.
  • 41. Present Clinical Reality  malocclusion with a slight anterior crowding (Figure 2–10b). At first, only the maxil- lary arch was lingually bonded, with the purposes of alleviating the crowding, intrud- ing the anterior group, and expanding the maxillary arch (Figure 2–10c). Some poste- rior acrylic minisupports are noticeable in the intraoral lateral photographs (Figures 2–10d and e). As previously described, these supports tripodize the occlusion through an anterior contact on the brackets and through posterior contacts on the flat elevations and produce an anterior mandibular displacement during the use of Class II elastics. In addition, this distribution of the occlusal load is comfortable for the patient. After having banded the lower arch, Class II mechanics was applied (Figure 2–10f). In the upper arch, a lingual archwire can be used (Figure 2–11). In Figure 2–12 we see a remarkable improvement in the patient’s profile at the end of treatment. Her chin looks more advanced and her lips are more harmonious. We successfully obtained a full Class I occlusal relationship and the anterior deep bite was corrected (Figure 2–13). In today’s clinical orthodontic practice, the lingual appliance can offer many advantages over the labial appliance to both the patient and the practitioner. Enamel surfaces are protected, some treatments (such as deep bite correction) can occur faster, molar distalization appears to take place more efficiently, and TMD patients can pro- ceed with orthodontic treatment in a timely manner. References 1. Alexander CM, Alexander RG, Gorman JR. Lingual orthodontics: a status report, part 1. J Clin Orthod 1982;16:255–262. 2. Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report, part 6: patient and practice management. J Clin Orthod 1983;17:240–246. 3. Breece G, Nieberg L. Motivations for adult orthodontic treatment. J Clin Orthod 1986; 3:166–171. 4. Bercheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119–131. 5. Fujita K. New orthodontic treatment with lingual brackets and mushroom arch wire appli- ance. Am J Orthod 1979;76:657–675. 6. Genone B, Siciliani G. Trattamenti ortodontici a collocazione linguale. Mondo Ortodontico 1984;3:14–27. 7. Gorman JR, Hilgers JJ, Smith JR. Lingual orthodontics: a status report, part 4: diagnosis and treatment planning. J Clin Orthod 1983;17:26–35.  -. The occlusal result.
  • 42.   8. Kelly VM. Interviews on lingual orthodontics. J Clin Orthod 1982;16:461–476. 9. Kurz C, Gorman JR. Lingual orthodontics: a status report, part 7: case report. J Clin Orthod 1983;17:310–331. 10. Nidoli G. Lingual technique under the biomechanical and aesthetical point of view. Proceedings and abstracts: I. Congress of the European Society of Lingual Orthodontics, Lido di Venezia, June 18–20, 1993. 11. Ronchin M, Oddini Carboni S, Dessi S. Nuovi Orizzonti terapeutici con la biomeccanica lin- guale. Proceedings of the V Giornate Mediterranee di Odontoiatria, Naples, February 26–28, 1983. 12. Ronchin M. Present horizons and a future outlook on lingual approach. Proceedings and Abstracts: First Congress of the European Society of Lingual Orthodontics, Lido di Venezia, June 18–20, 1993. 13. Ronchin M. Aesthetics with lingual orthodontics: resolving class II malocclusions with molar distalisation. Pract Perio Aesthet Dent 1994;6:51–58. 14. Siciliani G. Ortodonzia Linguale. Milano, Italy: Masson. 1992.
  • 43.  Lingual orthodontics is a viable option in a modern orthodontic practice. In 1979, when Drs. Kurz and Fujita first began experimenting, appliances and techniques were in their infancy. Today, modern, well-developed appliances, laboratory procedures, and treatment mechanics are available. Doctors have the ability to include lingual appli- ances in the treatment plans of their patients, and assure exceptional results with con- fidence. Problems like prolonged treatment times and compromised results are similar to those with treatment with labial appliances by an experienced practitioner and, as with any technique, can be overcome with an accumulation of experience. Today’s practitioner must find a way to treat his lingual patients without disrupt- ing his practice. In fact, these lingual patients should enhance an already thriving practice and revive a dwindling one. The article will provide a clear and precise expla- nation of how we practice lingual orthodontics in our office, how lingual patients affect the practice of labial orthodontics, and what one can do to avoid problems dur- ing his early lingual experience. The Clinical Experience All patients are treated the same way during their initial examination. After viewing a video tape which has been mailed to them prior to the first appointment, patients arrive at the office with some of their questions already answered and a familiarity with our office and procedures. The appropriate forms are then completed, a high- quality panoramic radiograph is taken and developed, and intraoral and extraoral video images are captured. The patient is then invited to the consultation room. Meanwhile, a preliminary diagnosis is made using the radiograph, and the video images. Different treatment options are considered including extractions, orthosurgery, and labial or lingual treatment. All the mechanical advantages of lingual treatment (in treating deep-bites, cross-bites, and expansion), and disadvantages (in treating open- bites or high angle cases) are carefully evaluated for that specific clinical case. After the preliminary diagnosis is made, the clinician enters the consultation room where all the clinical, radiographic, and visual aids are prepared. If lingual appliance treatment is one of the options and the patient wants to be treated this way, a separate appointment is made to complete the records. An extra set of impressions is made and poured immediately in a pink stone. A face bow transfer is also made so the models can be properly mounted. Using all records, the diagnosis and treatment plan are finalized. The proper laboratory prescription for the appliances is prepared, and two weeks later the patient is scheduled for the initial bonding. During the two weeks fol- lowing the impressions, it is critical that no tooth movement takes place as this would   Lingual Orthodontics in a Labial Orthodontics Office J. COURTNEY GORMAN, DDS, MS
  • 44.   ruin the accuracy of the indirect bonding. This means no separators, no extractions, and no heavy cleaning. The last item should have been accomplished prior to the impres- sions, and the first two items should be completed after the initial bracket placement. Appliance Placement The bonding procedure for the initial bracket placement is as follows: 1. Paint all of the brackets with the bracket-side portion of the bonding adhesive. 2. Microetch the lingual surface of all teeth to be bonded. 3. Isolate one-third of the dental arch. (Some clinicians may prefer to bond the entire arch simultaneously.) 4. Acid etch the teeth for 20 to 30 seconds. 5. Rinse each tooth for 20 seconds. 6. Dry the teeth with an air syringe. At the same time use a hair dryer to displace the moisture from the breath. 7. Paint the teeth with the tooth-side portion of the adhesive. 8. Reapply the bracket-side portion of the adhesive. 9. Fully and firmly seat the bonding tray and hold in place for one minute. 10. Repeat procedures 3 to 9 for the remaining segments. 11. Remove the hard shells of the bonding trays. 12. Using a sharp scaler, remove the soft undertrays. After the bonding procedure is complete and before removal of the isolation, each bracket is checked by pulling on it with an elastic. If there is a failure, cut the section of the tray from which that bracket came into a single-tooth tray, discard the hard shell and place the bracket back into the single-tooth soft tray, microetch the bracket and tooth, reapply bracket side adhesive to the bracket, acid etch the tooth, rinse the tooth, reapply tooth side adhesive, reapply the bracket side adhesive, seat the tray, hold for two minutes and then remove the tray. It is advisable to retain the soft trays for any future repairs. In cases with a porcelain jacket crown, the crown should be conditioned with a porcelain etchant for four minutes and then rinsed. Apply some normal etchant to the crown and blow off the excess followed by the silane primer (it is important not to skip the etch as the acid activates the silane). Now apply the adhesive bond to the bracket and bond it to the crown. Before placing the initial archwires, the clinician must first determine which teeth are to be engaged. Elastic chains are placed over the brackets on each of those teeth. The chain is precut into two- or three-unit sections. Then, using a hemostat, it is stretched over the brackets with the extra lumen pointing towards the gingiva. The initial wires are then bent using a 1:1 photograph of the original malocclusion as a guide. In most cases this wire will be a .0175 Respond wire (Ormco). When the proper shape and length have been achieved, the distal ends are slid into the hinge caps or tubes. The wire is then engaged into one of the anterior brackets, and the chain is pulled back over the bracket so that a single lumen now encircles the archwire, form- ing the double over-tie. Now with the wire stabilized, the rest of the brackets can be engaged and the distal ends trimmed. The patient is instructed how to care for their appliances and instructed on the use of wax to prevent ulceration of the tongue. At this time it is important to encourage the patient and assure him or her that the function and speech will return to normal.
  • 45. Lingual Orthodontics in a Labial Orthodontics Office  The patient is then reappointed for a 40-minute visit approximately eight weeks later. If there are teeth to be banded, wire separators are placed before the patient is dis- missed and is reappointed one week later for the banding. Forty-minute appointments are scheduled during the course of treatment for wire changes, adjustments, or single-tooth bonding or banding. Changes of power products or checks of elastic wear are scheduled for 20-minute appointments. At each appoint- ment the assistant first checks the patient for any loose or broken appliances. If there are none, she proceeds with the removal of the archwire to be adjusted or replaced. This information should be noted in the chart and the doctor can now examine and confirm the treatment noted in the chart. If any changes are to be made they can be initiated now. Any adjustments to the wire can also be made at this time. The assistant then reinserts the archwire (usually only one wire is adjusted during a single appoint- ment) and applies any necessary power products. Treatment Sequences (Extraction and Nonextraction) After the appliances have been placed, the initial archwires are added. These are typi- cally .0175 Respond (Ormco) arches. In nonextraction cases, the wire will engage all the posterior teeth; in extraction treatment, it will form a sectional arch engaging only those brackets anterior to the extraction sight. Minimal movement is expected from these first wires. Their main purpose is to fill the space while the patient becomes accustomed to the new appliances. In nonextraction cases with crowding, the second arch is .016 TMA (Ormco) wires with advancement loops (U-shaped loops which are compressed when fully engaged) anterior to the first or second molars. These wires use the energy stored in the compressed loops to expand the arch in an anterior direction. Full engagement of the teeth can take place after sufficient space has been created. At this point rotations can be corrected. After initial leveling and correction of rotations, a square or rectan- gular wire is used to continue the leveling process and to torque any teeth in need. The wire of choice is usually a .0175 × .0175 TMA (Ormco). This wire enables full engagement of all brackets to complete the leveling and establish necessary torque. In simple nonextraction treatment in which the patient maintains a Class I buccal segment, this wire can be the final archwire. In cases requiring elastics, the square TMA archwire should be followed by a .017 × .025 stainless steel archwire with tiebacks in the mandible to ensure arch stability during elastic use. In the maxilla, a .016 × .022 stainless steel archwire with a Curve of Spee is usually adequate to main- tain arch integrity. After a Class I occlusion has been achieved, the patient is ready for final detailing which can be done with a .016 stainless steel archwire. In extraction treatment, the second arch is also a .016 TMA but without advance- ment loops. Once again, only those teeth readily engaged are ligated. After initial alignment, the TMA wire is removed, and a .016 × .022 stainless steel wire is bent and placed in the mouth, engaging as many brackets as possible. The posterior seg- ments are figure-eighted together using a steel ligature. Wire ligations are used on the cuspids, and a power tube is tied in a figure-eight from the cuspids to the second bicuspids. The cuspids are retracted until adequate space is available to completely align the anterior segment. At this time, it is important to avoid complete retraction of the cuspids as this will interfere with en masse retraction of the anterior segment. After initial cuspid retraction, the original .016 TMA arch is replaced, and all brackets
  • 46.   are fully engaged. This wire is used in conjunction with rotation ties until all rotations have been corrected. To develop torque and to continue leveling, a .0175 × .0175 TMA is placed. In the maxilla, it is common to follow this wire with a .017 × .025 TMA to achieve adequate torque. When the dentition is fully leveled and aligned space closure is begun, .016 × .022 stainless steel archwires with a Curve of Spee in the maxilla arch and a reverse curve in the mandibular arch are used. The anterior segments are figure-eighted together using a steel ligature. Power tubes and power chains are then placed from cuspid to second bicuspid to supply the necessary force for space closure (sliding mechanics). It is important to figure-eight the segments so the power products can be used over the shortest possible distance. Failure to do so can result in unwanted bowing of the dental arches in both the vertical and horizontal planes. Once all of the space has been closed, the patient can be prepared for elastics by placing a .017 × .025 stainless steel archwire with omega tiebacks in the mandible. In the maxillary arch, figure-eight and power products can be removed and brass electrodes soldered to the wire to act as tiebacks. When a Class I occlusion has been achieved, .016 stainless steel finishing arches can be placed. These wires should also have some type of tieback to ensure that no spaces reopen. If the buccal segments do not have maximum interdigitation at this point, a tooth positioner can be utilized. While a tooth positioner is very effective for “socking in” an occlusion, they are inadequate to complete space closure or for correc- tions of anterior positions. Four weeks after the delivery of the positioner, impressions for retainers are made. Clear overlay retainers are used. They are excellent for retaining alignment and provide exceptional esthetics. Practice Promotion Lingual appliances give the orthodontist a distinct competitive advantage. There are many individuals who need and desire orthodontic treatment but are not willing to wear conventional appliances. Many of these patients have gone for years hiding their smiles and neglecting their oral health. By offering them treatment with lingual appli- ances, the orthodontist provides a valuable and unique service. Many lingual patients are high-profile individuals. While they are willing to pay a premium for their lingual braces that others cannot see, they also openly discuss their treatment with their friends, colleagues, relatives, and sometimes even strangers. They can become great referral sources and goodwill emissaries for your practice. Referring dentists will also appreciate that you are able to provide their patients with a service that the other orthodontists cannot. They will be more likely to refer more of their patients to a full service orthodontist. Before the practice benefits from these and other advantages that lingual ortho- dontics brings, it is important that the staff and the orthodontist feel confident and comfortable with the lingual technique. The first step is to attend a complete typodont course during which a step-by-step method to treat lingual cases is taught. Once the orthodontist and his staff have achieved a high level of clinical proficiency, the lingual patients can be incorporated into the normal schedule. They can be treated side by side with the labial patients. Other than allowing adequate time, there are no other special requirements for these patients.
  • 47. Lingual Orthodontics in a Labial Orthodontics Office  Conclusion Lingual braces have been and are a viable treatment option. With these appliances the practitioner can achieve excellent results while providing his or her patients with a unique and valuable service. To successfully incorporate lingual patients into a labial practice the doctor and staff must develop the skills to successfully treat these patients. Then the treatment must be presented in such a way that the prospective patient will be receptive. This includes having models with lingual braces, having a treatment coordinator who believes in the treatment, and encouraging patients when lingual appliances are the better option. Having appropriate fees is also important to your practice. Lingual patients require approximately 25% more chairtime for the same treatment. Thus, a premium should be added to the usual fee. We add approximately 27% for the first arch and an additional 20% for the second arch. In this way both the additional laboratory expense and chairtime are covered. If the practitioner will make the commitment to make lingual orthodontics a part of his or her practice, the practice will grow.
  • 48.  Enhanced Facial Esthetics using Kurz Lingual Appliance . .  Craven Kurz  Advanced Lingual Prescription: Technique and Design . . . . . . .  Robert Baker Jr. . Shape Memory Wires in Lingual Orthodontics . . . . . . . .  Christian Demange . Wire Sequencing in Lingual Orthodontics . . . . . . . . .  H. Stuart McCrostie  Instruments Used in Lingual Orthodontics . . . . . . . . .  Craven Kurz SECTION 2 Basic Principles
  • 49.  A primary reason a patient seeks orthodontic treatment is to improve facial esthetics (Figure 4–1). A lingual appliance and bite plane may be used specifically to achieve this goal. The success of the orthodontic treatment is directly related to how attractive the patients find themselves after treatment, especially since the vast majority of lingual orthodontic patients are in careers that involve a public image. The traditional cephalo- metric models leave much to be desired as a direction to follow to obtain facial beauty. Studies of contemporary fashion models, movie stars, and beauty contest winners indi- cate that a much fuller profile than the conventional 1900s ideals is more popular with today’s public. Face studies made by Sassouni indicate that facial beauty is related to protrusive faces with a straight line relationship between the maxilla and mandible in well-balanced faces. Articles by Liddle, Luzi, Eirew, McNamara, and Moyers demonstrate that the maxilla is usually in the proper A-P position in the skull and in harmony with its biological environment. It rarely protrudes in any malocclusion, regardless of how much the dental overjet is. Thus, the use of backward-pulling head- gear of Class II elastics and/or bicuspid extractions would result in poor esthetics if used to try to fit a normal maxilla to a retruded mandible. Bite Plane An upfront, full smile always attracts attention. Dr. Grant Bowbeer had found that a bite plane in combination with labial orthodontic appliances helps to expand the   Enhanced Facial Esthetics using Kurz Lingual Appliance CRAVEN KURZ, DDS, PhD  -. Michelangelo’s faces in balance with today’s contemporary beauty analysis.
  • 50.   maxilla and consequently, to achieve an esthetic occlusion. The inclined plane in the upper incisor lingual brackets was designed for the purpose of avoiding shearing forces and subsequent debonding of the maxillary brackets. However, if used properly, it can also achieve correct positioning of anterior teeth in the optimal esthetic A-P and lateral positions. The esthetic advantages of the bite plane are: 1. It can be used as a functional appliance to facilitate the unlocking of a retruded mandible. 2. It can help expand the arch. This is a clinical observation and the possible explanations are elimination of posterior contacts or decrease in the lateral space in the palatal vault (Figures 4–2a to c). 3. It helps extrusion of posterior segments and intrusion of lower incisors in deep bite cases, giving the lower lip better support from the lower incisor and bal- ance with the maxillary lip in closure (Figures 4–3a and b). 4. Easier translation of teeth around the arch when the midline is off centered due to the smooth contact with the flat metal plate on the incisor brackets.  -  . Maxillary arch expansion: occlusal view before, during, and after lingual treatment. Note wide horseshoe arch.   
  • 51. Enhanced Facial Esthetics using Kurz Lingual Appliance  Bibliography Bowbeer GRN. The five keys to facial beauty and TMJ health. The Functional Orthodontist 1985; 2:12–29. Eirew HL. An orthodontic challenge. Int J Orthod 1976;14:21–25. Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 1977;72:599–616. Luzi V. The CV value (combines variation) in the analysis of sagittal malocclusions. Am J Orthod 1982;81:478–480. McNamara JC. Components of Class II malocclusion in children 8–10 years of age. Angle Orthodontists, 1981;51:177–202. Moyers et al. Differential diagnosis of Class II malocclusions. Am J Orthod 1980;78:477–494.  -  . Extrusion of posterior segments and intrusion of lower incisors in deep bite case: occlusal view before and during lingual treatment.  
  • 52.  Lingual orthodontics in the 21st century will involve several new innovations, includ- ing new players in the treatment field, new appliances and auxiliaries, and enhanced laboratory techniques, design, and communication. Still, the most important aspect of any labial, lingual removable or functional orthodontic treatment system is, of course, the thought process of the orthodontist. As all well-trained orthodontists know, any single orthodontic treatment system can work to move teeth, manage growth, or gain space; however, even the best system that is poorly thought out and does not use sound scientific principles can face failure. In the 20 years since the original lingual appliance was invented, we have been through seven generations of the original Ormco bracket and approximately a dozen other bracket designs from other companies. By necessity, treatment mechanics have been tailored to the available bracket systems. Many treatment philosophies are influ- enced by edgewise mechanics, Begg and Bioprogressive systems, and the straight wire system, after which the original bracket was designed. The individual orthodontist must take responsibility for his or her treatment. One of the main problems that lingual orthodontists have to overcome is to not overstandardize treatment plans. Although standardization sometimes can be of some advantage in streamlining a practice and allowing orthodontists to keep supplies, staff, and treatment well-coordinated, treatments should stay very case specific with an indi- vidual treatment modality for each patient. “Cookbook” orthodontics, especially for lingual treatment, has never worked. A thorough, individual treatment plan must be formulated, and the type of mechanics to be used must be selected from the very beginning of treatment. This involves a tooth-by-tooth, individual prescription that anticipates all positive and negative reactions to the type of biomechanics that the orthodontist will be using. To achieve such accuracy, a lingual orthodontist must have intimate knowledge of individual bracket positions over the center of resistance of each specific tooth and the knowledge of how that will either expedite or impede treatment goals. This will enhance treatment planning and case progress. Eventually, treatment time and chairtime can be significantly reduced, and patient comfort and satisfaction can be greatly increased. Anchorage must be carefully prepared and developed, using the Tweed method or others. Parisi (1989) proved that anchorage was enhanced from the lingual aspect when compared to the use of standard direct-bonded labial edgewise appliances without the use of extra anchorage auxiliaries. Factors like anatomical variation of teeth and functional habits like mastication and swallowing should be taken into account while planning the correct placement of   Advanced Lingual Prescription: Technique and Design ROBERT BAKER JR., DMD
  • 53.   the lingual brackets. The biomechanics of choice must be carefully selected. For example, if an orthodontist is using loop mechanics, continuous arch mechanics, or sectional mechanics to retract teeth into an extraction space, the laboratory setup could be different for each retraction method due to the differing effects on the teeth and underlying bone. One of the advantages of advanced laboratory case design and technique is the virtual elimination of appliance auxiliaries like rotation ties or double over-ties. Case Presentations The following cases demonstrate diagnosis and the establishment of treatment goals through selective individual tooth prescriptions, using the CLASS System design for indirect bonding preparation.  -  . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, anterior open bite, and crowding.     
  • 54. Advanced Lingual Prescription: Technique and Design  CASE 1: D.P. A 31-year-old male presented with a Class I malocclusion, anterior open bite, and mild upper and lower crowding (Figures 5–1a to e). The cephalometric and panoramic x-ray revealed no unusual findings. The treatment plan consisted of placing upper and lower lingual appliances to level and align the occlusion. The crowding was to be resolved using a nonextraction approach with air rotor stripping on the upper and lower first premolars. The prescription for the laboratory (specialty appliance) was made as follows: Patient Name DP Case description Air Rotor Stripping (ARS) on upper and lower premolars Appliance Upper and lower .018 Ormco lingual brackets Prescription Upper arch: (right=RT; left=LT) RT 1 2 deg. distolingual rotation, 10 deg lingual crown torque LT 1 3 deg. mesiolingual rotation, 10 deg lingual crown torque RT & LT 2 8 deg. lingual crown torque RT & LT 4 –0.75 mm ARS mesial & distal RT 6 3 deg. distobuccal rotation LT 6 5 deg. distobuccal rotation RT & LT 7 5 deg. mesial crown tip, Hinge Cap attachments Lower arch: (right=RT; left=LT) RT & LT 2 2 deg. mesiolingual rotation RT & LT 3 3 deg. mesiolingual rotation RT & LT 4 –0.75 mm ARS mesial & distal  -  . Frontal and lateral views during treatment.   
  • 55.   Upper and lower lingual appliances were bonded (Ormco, generation #7, .018 slot) (Figures 5–2a and b). Treatment time was only 12 months, with 14 visits to the Eastman Dental Center. No auxiliaries were used. The results show a balanced and esthetic occlusion (Figures 5–3a to e).  -  . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.       -  . During treatment: upper and lower occlusal view of lingual appliance.  
  • 56. Advanced Lingual Prescription: Technique and Design  CASE 2: A.M.C. A 31-year-old female presented with a Class I malocclusion, mild upper and lower crowding, and upper right dental midline shift. The upper right lateral incisor was severely rotated distobuccally. (Figures 5–4a to e). The cephalometric and panoramic x-ray revealed no unusual findings. The treatment plan consisted of extracting the maxillary right first premolar to alleviate crowding and aid in the midline correction. The occlusal plane was to be leveled. Continuous arch mechanics were to be used for extraction space closure. The prescription for the laboratory (specialty appliance) was made as follows: Patient Name AMC Case description Extraction upper right 4. Retraction with continuous arch mechanics Appliance Upper .018 Ormco lingual brackets, lower .022 Ormco labial brackets Prescription Upper arch: (right=RT; left=LT) RT 7 Add 14 deg. mesial root tip, add 6 deg. buccal root torque RT 6 18 deg. mesiobuccal rotation, 6 deg. buccal root torque, add 18 deg. mesial root tip  -  . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, rotated upper right lateral incisor, and midline shift.     
  • 57.   RT 5 4 deg. mesiobuccal rotation, 15 deg. mesial root tip RT 3 8 deg. mesiolingual rotation, add 12 deg. distal root tip RT 2 12 deg. lingual root torque, 5 deg. distal root tip RT 1 Add 2 deg. distal root tip, 11 deg. lingual root torque LT 1 11 deg. lingual root torque, 8 deg. mesial root tip, intrude 1 mm LT 2 6 deg. mesiobuccal rotation, 10 deg. lingual root torque LT 3 6 deg. mesiobuccal rotation LT 5 9 deg. mesiobuccal rotation LT 6 12 deg. mesiobuccal rotation RT & LT 7 Please use Hinge Caps. The appliances chosen consisted of maxillary lingual brackets (Ormco, .018) and mandibular labial appliances (Ormco, .018 Spirit) (Figures 5–5a to b). Treatment time  -  . During treatment: occlusal views of the upper lingual appliance and lower transparent labial appliance.    -  . Frontal and lateral views during treatment.   
  • 58. Advanced Lingual Prescription: Technique and Design   -  . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.      was 18 months, with 18 visits. No auxiliaries or wire bending was needed during the treatment and chairtime was the same as with a full labial appliance. The end results show a balanced and esthetic occlusion (Figures 5–6a to e). These cases demonstrate the use of goal-oriented diagnosis, individualized bracket prescriptions, and specific mechanics to provide more efficient treatment with the lin- gual appliance. Of course, lingual treatment can be affected by the same factors as in labial treatment, such as inadequate patient cooperation, bracket failures, etc. Wire bending and the use of auxiliaries can be eliminated with the judicious selection of the appliance prescription. Studies are ongoing to improve appliance prescriptions and custom laboratory-fabricated archwires. These and continued studies will advance the art and science of lingual orthodontics and will continue to make it more user- and patient-friendly.
  • 59.  The term Shape Memory Alloys (SMA) is applied to the group of metallic materials which demonstrate the ability to return to some previously defined shape or size when subjected to the appropriate thermal procedure.1 Generally, these materials can be plastically deformed at some relatively low temperature and, upon exposure to higher temperature, will return to their shape prior to the deformation (Figure 6.1–1). Shape memory alloys, such as nickel titanium, undergo a transformation in their crystal structure when cooled from the stronger, high temperature form (austenite) to the weaker, low temperature form (martensite) (Figure 6.1–2). This inherent phase trans- formation is the basis for the unique properties of these alloys: shape memory and superelasticity. Shape Memory When a shape memory alloy is in its martensite form, it is easily deformed to a new shape. However, when the alloy is heated through its transformation temperature, it reverts to austenite and recovers its previous shape with a net force delivered (Figure 6.1–3). This process can be repeated millions of times. A typical transformation versus temperature curve under constant load is shown in Figure 6.1–4.1 Most of the trans- formation occurs over a relatively narrow temperature range, although the beginning and end of the transformation during heating or cooling actually extends over a much larger temperature range. The transformation also exhibits hysteresis (shown as T1) in that the transformations on heating and on cooling do not overlap. This transforma-  . Shape Memory Wires in Lingual Orthodontics CHRISTIAN DEMANGE, DCD, SQODE, CECSMO  .-. The shape memory effect.  .-. Transformation of alloy crystals of shape memory alloys from hot to cold phase. Heating Cooling Cold turns to Hot Face centered Body centered
  • 60.   tion hysteresis (T1) varies with the alloy system. The most common SMA wires used are NeoSentalloy or Bioforce (GAC) and Copper Ni-Ti 35°C (Ormco). Superelasticity These unique alloys also show a superelastic behavior if they are deformed at a tem- perature which is slightly above their transformation temperature. This effect is caused by stress, inducing the formation of some martensite. Because it has been formed above its normal temperature, the martensite reverts immediately to undeformed austenite as soon as the stress is removed. This process provides a very springy, rubber- like elasticity in these alloys (Figure 6.1–5). SMA Wires in Lingual Orthodontics The main problem in the biomechanics of lingual orthodontics is the short interbracket distances (Figure 6.1–6). Orthodontists ideally want to accomplish biological tooth movement with a low and continuous force and a constant moment/force ratio in order to maintain a low stress/strain ratio. Two different ways exist to obtain this goal:  .-. The two phases of shape memory alloys with temperature: martensite and austenite.  .-. Typical loading and unloading behavior of superelastic Ni-Ti.  .-. Typical transformation versus temperature curve for a specimen under constant load (stress) as it is cooled and heated. T1: transformation hysteresis; Ms: martensite start; Mf: martensite finish; As: austenite start, Af: austenite finish. Austenite Martensite
  • 61. Shape Memory Wires in Lingual Orthodontics  A. INCREASE WIRE LENGTH This can be done using loops (which are difficult to do, time consuming, demonstrate poor reproducibility, and do not conform to the straight wire appliance philosophy used in lingual appliances), or increase the interbracket distances (which is almost impossible since the brackets are quite large and arch form is narrow). B. USE ELASTIC WIRES Reduce the cross-section of the wire (which reduces control), or change the physical properties of the wire (yielding a low Young’s modulus). Shape memory alloys are ideal materials because they have low Young’s modulus, present a very small stress/strain ratio, and have a large cross-section of wire to achieve a maximum of control. The mechanical properties of SMA wires are different in the austenite and martensite forms. Young’s modulus is highly nonlinear with temperature. The approximate elastic modulus is about 80 GPa at high temperature (austenite), and 30 GPa at low temperature (martensite). (Figure 6.1–7). The Young’s modulus of shape memory alloys is difficult to define between the martensite and the austenite transforma-  .-. Short interbracket distances with lingual appliance.  .-. Young’s modulus of SMA wires are different in austenite and martensite.