Lingual orthodontics /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
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• 1726 – Pierre Fauchard – first suggestion

• 1841 – LeFoulon – first lingual arch for expansion &
alignment
• Combination of lingual with labial appliances
• Appliance system – 1970s

• It was major competing appliance in early 20th
century
• Lingual arch introduced by John Mershon-1908
JOHN MERSHON

•

round Labial arch –

– Lloyd S. Lourie Sr (1877-1959),;
– Oren A. Oliver (1887-1965)
– Lowrie J.Porter (1895-1981),
•

refined by Oren A. Oliver
who incorporated fixed guide planes
OREN A. OLIVER

1.
2.
3.
4.
5.

Lingual arch wire
Auxiliary spring
Lingual locking wire
Half round vertical post
Intermaxillary elastic hooks

6
7
8
9
10

Molar bands
Intermaxillary elastic hooks
Labial arch
Vertical spring loop
Buccal tubes

• To protect sumo wrestlers from soft-tissue injury from labial
appliances
• Concept in 1967, published the method – 1978
• First lingual multi-bracket system with mushroom shaped

archwires
• 3 slots – occlusal, horizontal, vertical

Fujita K. New orth. Tr. with ling. brt mushroom arch wire appl. Am J Orthod 1979; 76: 657-675.

• 1975 – plastic brackets on lingual surface – easy to reshape
for better fit (Lee Fischer Brackets)
• Bonding failure, patient discomfort
• ORMCO – Craven Kurz, Craig Andreiko, Frank Miller first generation Kurz bracket in 1976

• Craven Kurz

• Jack Gorman
• Bob Smith
• Wick Alexander
• Moody Alexander
• James Hilgers

• Bob Scholz

• to help refine bracket design (dimensions, torques,

angulations, thickness, etc.),
• to develop mechanotherapy techniques,
• to create archwire designs,
• to discuss treatment sequences, and
• to determine case selection criteria.

• SFOL: Societe Francais Orthodontic Linguale ( France) – 1986
• ALOA: American Lingual Orthodontic Association – 1987
• ESLO: European Society of Lingual Orthodontics - 1992

• Following this initial euphoria- a period of frustration,

disappointment and rejection,
• Due to poor standard of completed cases
• Reasons
- Inadequate training,
- poorly developed laboratory system,
- unavailability better materials

• 1996- Craven Kurz, Creekmore, Wildman, Scuzzo together

with other clinicians founded lingual study group

• Relaunching LO

• Scuzzo and Takemoto-

published series of
articles & text book

• Also developed lingual
striaght bracket &

technique, STb

 Reduced B-L dimensions

 Conventional ligation

 Reduced O-G dimension

 SW slot

 Twin design for rotation

 Stability of the archwire in

control

 Easy arch wire insertion
 Easy ligation
 Active spring clip
 Passive ligation- low friction

slot

 Hooks for ligatures and
elastics
 A bite plane

1st Generation
- 1976 -

• Bite plane
• Rounded margins
• Hooks absent
• Large brackets

2nd – 1980 – Hooks on
canine brackets

3rd – 1981 – Hooks on all
brackets

4th – 1982-84 – lower
profile

• 5th – 1985-86 – bite

plane more pronounced
and torque increased;
Molar brackets had
accessory tubes for TPA

6th – 1987-90 – Elongated hooks, TPA tube optional

Hinge cap tube for 2nd molar

7th – 1990 – square bite plane changed to heart shaped

premolar brackets widened

• Kinja Fujita – 1979

• Anterior teeth and premolars – 3 slots
– Occlusal Slot

- 0.019” square

• Rotation control & Archform control
– Lingual Slot

- 0.018”x0.025” edgewise

• Vertical, Torque and Tip control
– Vertical Slot
• Auxillaries

- 0.016” square

Molar Bracket – 5 Slots - Occlusal, 2 Lingual & 2 Vertical

• Thoams Creekmore – 1989

• Archwire slot opening in occlusal ascpect
• Unitwin bracket “centered slot” concept

AJO-DO Volume 1989 Aug (120 - 137): Lingual orthodontics Its renaissance - Creekmore

Scuzzo

Takemoto

“Light Lingual Philosophy”

• Less Lab Procedures

• Low Friction
• Low Forces

• Stephan Paige- preferred edgewise appliance labially,

Begg light wire brackets more suitable on lingual surfaces

• Unipoint Combination Brackets

• Bonding – Direct
• Capable of controlling tip and rotations
• Torque control – varying hieght on lingual surface
• Auxillaries

• Logically the right and left brackets have to be transposed to

allow for distal tipping when required.
• Tipping is minimal, possibly due to very gingival bracket
placement upper 3-3.

Dr ZJ Weber - http://www.bracesbehind.co.za

State-of-the-art maxillary incisor
bracket with vertical insertion direction.
In this version, ligating can be done with
simple elastic module or with German
overtie. Positioning software allows
optimum angulation of hook. Accessory
occlusal hook is optional.

First-generation premolar bracket with
horizontal insertion direction (left) and stateof-the-art premolar bracket with vertical
insertion direction (right).

Bracket bodies (blue) are loaded from
bracket archive to dental arch fitted with
individual bases (yellow). Whereas second
and third order are preset, bracket body
can now be shifted and turned in slot
plane for optimal positioning.

Bracket body and bracket base are then
virtually fused.

In rapid prototyping, brackets are first produced in wax, applied in 0.02 mm layers.
Red support wax required for 3D production is removed thermally.
B, Wax lingual brackets before casting.
C, Gold lingual brackets after casting.

System Includes

•

iBracket Customized Brackets
– Low profile brackets for patient comfort
– Large, anatomical-shaped bracket base to reduce bracket loss
– Easy to bond and to remove.

•

iWire Precision Archwires
– A three or four-wire sequence is designed with a dental CAD/CAM
system and then fabricated using robotic wire bending technology.

– SMA wires for initial stages
– Stainless steel or TMA for finishing.
– Precise wire fabrication means few if any wire adjustments at chairside.
•

iTray Indirect Bonding Trays
– Indirect bonding trays are included with each bracket set to ensure easy,
precise bracket placement every time.

• Most malocclusions can be treated but not all patients

particularly pts with low discomfort tolerance.

• LO is technically sensitive and clinicians needs to be slective.

• Mild crowding and Ant deepbite.
• Long & uniform lingual tooth surfaces.
• Good gingival & periodontal health
• Compliant pt
• Skeletal cl I malocclusion

• Normo or hypo divergent growth pattren
• Pts who are able to open mouth widely & extend their necks

• Hyperdivergent growth pattern- open bite cases

• Short, abraded & irregular lingual surfaces
• Presence of multiple crowns, bridges & large fillings
• Pts with low level compliance
• Pts with limited mouth opening & Cervical ankylosis
• Surgical cases

• Very Short clinical crowns

• Pts with severe TMD
• Pts with severe periodontal diseases

• Evaluate pts level of co-operation and level of discomfort

tolerance

• Most of the LO pts have mutilated malocclusions

• Special considerations are needed

Pt should be warned about

• Speech difficulties – 2-4 weeks
• Tongue irritation
• Initial wt loss
• Strict oral hygiene instructions

• General
• Periodontal & gingival
• Presence of crowns & large restorations

• Dentoalveolar discrepancy
• Vertical, Ant –post and transverse skeletal/dental problems
• Surgical cases
• Preprosthetic cases

• Teeth movement slower in adults- less trabeculted bone

• Pt should have healthy periodontium & able maintain

• Gingival inflammation is more - proximity of brackets
- failure to remove flash
• LO indicated in pts with a predisposition to gingival recession

Gingival inflammation can be minimized by

• Bending hooks to reduce gingival impingement
• Prophylaxis at each archwire change
• Use of liquid adhesive & correct quantity of adhesive
• Carefully maintain & control the effect of tooth movement
on gingival tissues

• Pts with high risk of caries & with decalcifications can be
treated with LO
• Lingual surfaces of incisors < 7mm & bicuspids with short
lingual surfaces should be reconstructed
• Gingivectomy to increase crown height
• Recontour – prominent cinguli, cusps of Carabelli

• Special bonding techniques for plastic, metallic, porcelain

surfaces
• Replace metallic crowns with acrylic crowns
• Section bridges
• Provisional restoration for fractured or microdontic teeth

• Built-in bite-planes –
Posterior open-bite

• Open-bite – 2 mm –
occlusion re-establishes in
20-30 days

Bite-blocks on lower molars when -

• Posterior open-bite > 3 mm
• Only one lower incisor contacts upper bite planeperiodontium cannot withstand trauma - TRIPODING

Measures for vertical molar anchorage control in

hyperdivergent cases
• bite blocks on second molars
• TPA
• Headgear
• Minimal use of intermaxillary elastics

• Skeletal Class I – easiest

• Downward & backward rotation of mandible- Class I to Class
II
• Important to assess initial overjet and overbite before
starting treatment

Class I with excessive overjet

Class I reverse overjet

Skeletal Class II and Class III –

• Mild cases treated successfully by camouflage
• Severe cases – orthognathic surgery

• Posterior cross bites should be treated before starting LO

• Expansion should maintained stable b/n Impressions &
bonding

• Many surgeons may refuse to carryout surgery with LO

• Best possible Presurgical tooth position should be achieved
to minimize post surgical Rx
• Possibility of labial brackets just before surgery
• Surgical fixation can be done with miniplates & screws

• Takemoto bonds SS wires with crimpable hooks

• Preprosthetic segmental LO mechanics are rapid,

economical and comfortable
• LO techniques can be successfully combined with micro
implants in preprosthetic cases

Smith, Gorman, Kurz and Richard Dunn

1) Patient selection
2) Bracket placement accuracy
3) Indirect bonding
4) Vertical & transverse control of buccal segments
5) Double-over ties on anterior teeth

6) Buccal & lingual molar attachments

7) Correcting rotations
8) Arch form & archwire sequence
9) Archwire stiffness and torque control

10) Enmass retraction
11) Light, resilient wire for detailing
12) Gnathologic positioner and retention

• LO provide stronger anchorage control than labial appliances

A-P anchorage
• Anchorage
Vertical anchorage

Lower anchorage > upper anchorage

• Takemoto – cortical bone anchorage by distal rotation &

buccal root torque of molars

• Removal of tongue pressure – reinforces the anchorage

• Alexander, Gorman et al –bite plane effect reduces

anchorage achieved with LO

• Craven Kurz- superior anchorage control because of small
arch perimeter

Silvia Geron- 6 anchorage keys
1) Extra palatal root torque for ant, molar tubes placed
off-center in more mesial position.
2) Reduced friction by using bidimensional archwiresrectangular ant section & round post section or Larger
slot size for post teeth
3) Bite blocks on molar teeth

4) Light cl I, II, III forces for retraction

5) Incorporation of second molars

6) Exaggerated curve of spee in max arch wire

I.

Extra palatal root torque for ant, molar tubes placed off-center in more mesial
position

II.

Reduced friction by using bi-dimensional archwires
Rectangular ant section & round post section or
Larger slot size for post teeth

III.

Bite blocks on molar teeth

IV. Light cl I, II, III forces for retraction
V.

Incorporation of second molars

VI. Exaggerated curve of Spee in max arch wire
S. Geron, A.D.Vardimon. Six anchorage keys in lingual orthodontic sliding mechanics.
World Journal of Orthodontics Vol.4, 2003 (pp. 258-265).

• Difficult of directly viewing and access, particularly of retroclined teeth
• Variation in morphology of the lingual surfaces, especially the maxillary
anterior teeth
• Wide range of labio-lingual thickness from 4.6mm LI to 9.2mm in canines
– numerous in-out bends
• Critical relationship between the vertical height of the lingual brackets
and the labial surface torque, due to the distance of the lingual brackets
from he labial surfaces

• Much smaller inter bracket distance in the anterior region, making
compensatory bends difficult

• Reduces chair side time

• Shortens treatment time
• Improves final result
Programmed brackets - spatial position of bracket slot – final
tooth position
Position – final tip, torque , height and rotation

• Tooth morphology of lingual surface is highly variable

• Can alter built in tip and torque

• Same bracket ht on diff lingual surfaces produce diff torque

values

• TARG (Torque/Angulation Reference Guide)

• BEST ( Bonding with Equal Specific Thickness)
• CLASS (Custom Lingual Appliance Set-up Service)
• Slot machine
• KIS (Korean Indirect bonding Set-up system)
• Ray Set
• Hiro
• TAD/BPD

• By Ormco in 1984

• Brackets are placed on
malocclusion model

• Torque blades prescribe torque & angulations for each

bracket
• Does not consider diff thickness of the teeth
• 1st order archwire bends are necessary

• Creekmore

• Orients the arch wire slot of bracket according to the facial
surface of the tooth
• Accomplished by holding the arch wire slot stationary while
manipulating each tooth to any tip, torque angle, rotation
angle and height through the use of orientation templates
and a rotation guide.

• Both horizontal/ vertical slot brackets can be used

• In 1987- Didier Fillion improved TARG by adding electronic
device

• Measures labio-lingual thickness
• DALI { Dessin Arc Linguale Informatise} - Computer generated
arch wire tracing

• Electronic TARG & the DALI – BEST system

• Set-up is done according to doctors prescription
• Special device used to place brackets considering all planes of
space

• Custom bases for each made

• 3-D goniometer control system determines 1st , 2nd & 3rd

values for each tooth

• Models mounted on hinge articulator

• Ray Set template to check the degree of rotation

• Tip assessment

“0” tip

Required tip

• Vertical precision gauge
to determine bracket ht

• Set-up with over corrections

• Invented by Toshiaki Hiro, improved by Takemoto & Scuzzo

• No need to purchase costly electronic devices

• Uses 018 ×025” SS wire as a transfer tool

• Set-up model
• Vertical arch position- Ray Set

Maxillary arch – mark mid points molars & extend line on to the
anteriors
• line – with in lower 3rd of incisors
• Gingival clearance – 1.5mm

Mand arch- mid points of premolars
• Inscisors – middle third

• Ideal arch forms prepared for both arches & co-ordinated

• Individual trays-ultra

band-lok

• Customizing the bracket base

• Ideal set up model

• Brackets bonded using lingual bracket positioner – holds
brackets at the same level
• Transferred to malocclusion model – Ready made
convertible resin core (CRC)

• ideal set up model
•Brackets bonded - set up model – slot ss measuring plates and stereoscopic
camera
•Robot designs archwire – passively fits bracket
•

• Dirk Wieshmann

• Customized Archwires
• ECO- lingual therapy
• Reduces number of archwires required

– 0.016x0.022 Cu NiTi
– 0.016x0.022 SS - retraction
– 0.0175x0.0175 – finishing

• TARG Pro

• Reduces bracket losss

• Reduced gingival irritation
• Increased patien comfort
• Simplified finishing process

• Isolation –dry field system

Etching

Apply Primer & bracket adhesive

• Bracket ht marked- Anderson gauge

• Weld tube slightly mesial on upper molars, center for

lower molars

Interbracket distance in LO lesser

Stiffness of arch wire increases

Rotational moment decreases

Clinical implications of this –

• More difficult to correct rotations – difficult to achieve
efficient coupling
• More resilient, lower size wires necessary to correct
crowding

Miner tendency of anterior rotation when force
applied in M-D direction

More crown rotations of posteriors

Prevention
Reduce retraction forces
Increasing intrusive forces
Increasing lingual root
torque
Allow the wire to express

torque for 6-8 weeks
 should not be retracted on
round wires

• Introduction
• Patient selection and diagnostic considerations
• Lingual laboratory procedures
• Clinical bonding technique
• Special biomechanical considerations in LO
• Anchorage in LO

• Extraction mechanics
• Finishing protocol
• Retention

• Extraction choices often differ in LO
• Cl I cases
• Upper 1st premolars & lower 2nd premolars
• Cl II cases
Max anchorage - 4 4

4 4 ext, lower stripping
4 4 ext, lower incisor ext / one
premolar
Moderate anchorage

4 4
5 5

• Cl III cases - distal tip lower molars improves cl lII

- 4 4
5 5

4 4

4 4

4 4

- incisor only
- surgery

or

• Timing of Xn of lower II premolars – after leveling

1) Anterior leveling

• Partial canine retraction

Lingual arch

Full arch wire with loops (014NT, 016 NT, 016 TMA)

• Sectional wire(016 x 022 NT, 0175 x 0175 TMA)

Anterior leveling (016 Cu-NiTi, 017x017 Cu-NiTi)

• Rotation correction
• Power arm -

• Torque leveling (0175 x 0175 TMA, 0175 X025 TMA)

• Torque leveling is complete- bite planes are parallel to

occlusal plane

• Inadequate torque – anchorage loss

• Enmass retraction (upper arch- 017 x 025 TMA)

Upper arch –
Max- TPA, Headgear, cl II elastics
5-7 race- back tie
Minimum anchorage-

3-6 circular elastics
cl lll elastics

• Anchorage control in lower arch- strong anchorage –
often difficult to move mesially
• Minimum anchorage – cl II elastics in combination
with open coil sprigs b/n 1st & 2nd molars & circular
elastics

Ideal arch form after space closure

• Lingual st wire brackets – to reduce cumbersome

wire bending
• More lingually and more gingivally placed

• Comparison b/n Kurz bracket & STb bracket

Difficulties encountered in finishing are derived from

1. Patient characteristics
- Restorative & Periodontal complications
- Thickness of tooth varies
- Compensating bends are less accurate & less effective

2. Anatomy of lingual surfaces

3. Mechanics of LO
Uprighting
Torque
Rotations

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

Silvia Geron – systematic
finishing protocol
Step 1 of finishing protocol

- Reuse of resilient arch wire for
3-4 months(017x017 Cu-NiTi)
- Reposition the brackets

Step II finishing protocol
• Settling the occlusion, midline correction, A-P &

vertical discrepancies
• Lower 0175 x 0175 TMA, upper 014 sectional wire
canine-canine
• Vertical elastics for 4-6 weeks

Step lll finishing protocol

• Final detailing & finishing bends
• Pablo Echarri- finishing wire bends on models

• Upper arch 0175 x 0175 TMA
• Lower- 016”TMA

• Adult patients -esthetically demanding

• Gingival recession, missing teeth, occlusal wear – requires
dental procedures

• Limited time to wear retainers

• Wrap around plastic retainer- QCM wire

• Bonded lingual retainer-0.012 SS wire

• Zachrisson-0.030”SSwire bonded only to canines

• Revisiting the history of lingual orthodontics: Abasis for the
future- Pablo Echarri ; Seminar orthod 2006;12:153-159
• Lingual orthodontics: patient selection and diagnostic
considerations. Pablo Echarri, Seminar orthod;2006;12:160166
• An overall view of the different laboratory procedures used
in conjunction with lingual orthodontics. Buso-Frost and
didier fillion

• Invisible orthodontics-current concepts and in lingual

orthodontics; Giuseppe Scuzzo, Kyoto Takemoto
• Anchorage considerations in lingual orthodontics. Silvia
Geron: Seminar orthod 2006;12:167-177
• Concepts on control of the anterior teeth using the lingual
appliance; Rafi Romano. Seminar orthod 2006;12:178-185

• Keys to success in lingual therapy –part 1; smith, Gorman,

craven Kurz and Richard Dunn; J Clin Orthod 20;252261,1986.

• Keys to success in lingual therapy –part 2; smith,
Gorman,craven Kurz and Richard Dunn; J Clin Orthod 20;330340,1986.

Thank you

For more details please visit
www.indiandentalacademy.com

Lingual orthodontics /certified fixed orthodontic courses by Indian dental academy

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