Achieving clinical success in lingual orthodontics

There is no need for special instruments when using the lingual technique, but taking into account the reduced interbracket distance and the small dimension of the brackets, it is easier

Achieving Clinical Success in Lingual Orthodontics

123 Julia Harfi n Augusto Ureña

Achieving Clinical Success in Lingual Orthodontics

Julia Harfi n • Augusto Ureña

Achieving Clinical Success

Argentina

ISBN 978-3-319-06831-2 ISBN 978-3-319-06832-9 (eBook)

DOI 10.1007/978-3-319-06832-9

Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2014952676

© Springer International Publishing Switzerland 2015

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To Luis whose unconditional support and dedication made this possible

To my daughters Viviana, Nora, and Adriana; to my sons-in-law Gabriel (!) , Javier, and Hugo; and to my grandchildren Ari, Damian, Esteban, Nicolas, and Emma for understanding the time that could not be shared

To my students that encouraged me to continue teaching and to my professors for having given me their knowledge and wisdom and for showing me that study and hard work are the only way to fulfi ll our dreams

Julia Harfi n

God, for blessing me once again

To my parents and brothers for their unconditional support over the years

To my students, for the constant feedback and

reciprocity in learning

Dr Harfi n Julia, my mentor, for allowing me to travel along this wonderful experience in Lingual Technique for 24 years and share a passion for orthodontics

To all working colleagues, for a world without borders and to all who dare to cross them So blessed!!

Augusto Ureña

Pref ace

This book was written with the intention of helping and encouraging orthodontists

to use lingual appliances without recurring to expensive outside laboratories

It provides detailed descriptions of procedures step by step, and it will enable orthodontists the best results in a very simple and predictable manner

Why lingual orthodontics?

In general, many adolescents and adults do not seek orthodontic treatment because they do not like to use “outside braces”, even though they are aesthetic (plastic, ceramic, zafi ro, etc.)

Today, the lingual technique is a very successful approach to treat all types of patients (children, adolescents, and adults), no matter what type of the initial maloc-clusion or the amount of periodontal attachment

After comparing all the aesthetic appliances, lingual orthodontics is the most aesthetic and can be considered the truly invisible appliance (Poon 1998; Chatoo 2013)

Normally lingual patients make more aesthetic demands during the whole ment, but after a few months, when they observe the results, they are very collabora-tive, and they highly recommend this treatment to their friends

Although there is an adaptation period, the patient’s enthusiasm about the ible braces seems to help them to go through the fi rst speech diffi culties (Miyawaki 1999; Wiechmann 2008) After no more than 10 days, the patient can speak and eat without any diffi culties, and they strongly appreciate the improvement of their self- image since they never consider using classic labial orthodontics at this age (Fillol

invis-1997, 1998)

There is no need for special instruments when using the lingual technique, but taking into account the reduced interbracket distance and the small dimension of the brackets, it is easier to use angulated pliers

Angled heads facilitate access to the lingual surfaces, especially at the bicuspid and molar areas, and long handles improve visibility in the lateral zones

Due to the variability of the lingual tooth anatomy and the diffi culty in viewing the palatal or lingual surfaces of the teeth, indirect bonding is mandatory Careful and precise indirect bonding allows total control of fi rst- and third-order tooth movement and also the torque that is more diffi cult to achieve due to the reduced interbracket distance (Gorman and Smith 1991)

The set-up laboratory procedure is one of the most reliable The correct position

of the brackets is the cornerstone to achieve successful treatment outcomes

A comprehensive understanding of lingual biomechanics is imperative to ing successful results (Kurz 1998; Harfi n and Ureña 2010)

From the biomechanical point of view, one of the main differences between labial and lingual brackets is the interbracket distance, which plays an important role in relation to the amount of force exerted by the orthodontic wires A small reduction in the slot width can increase the elasticity of the wire, and, as a conse-quence, lighter forces are used (Smith 1986; Kusy 2000)

It has been well established that dental plaque represents a risk factor in the gression of periodontal disease

The installation of lingual orthodontic appliances increases the amount of palatal and lingual plaque, which results in the formation of gingival hyperplasia and pseudopockets

Sometimes, this situation changes the subgingival ecosystem and facilitates the infl ammatory response of the periodontal tissues

In order to control or avoid gingivo-periodontal problems, it is important to inform the patient how he/she has to control it, and the orthodontist has to reinforce oral hygiene at every appointment

Also, root resorption is not higher when using lingual appliances

It is important that the periodontal status of every patient should be evaluated before treatment begins and periodically during the whole orthodontic treatment

In combination with an accurate diagnosis and treatment planning, it is ideal to use a bracket-wire system that gives us the possibility of reducing force and friction, improving rotation control, obtaining easier sliding mechanics, lowering patient discomfort, and reducing chair and treatment time

It is possible to achieve the same high standard in the fi nishing stages as when labial brackets are used -

Bibliography

Chatoo A A view from behind: a history of lingual orthodontics J Orthod Suppl 2013;51:S2–7 Fillol D Improving patient comfort with lingual brackets J Clin Orthod 1997;31:689–94 Fillol D The resurgence of lingual orthodontics Clin Impression 1998;7:2–9

Gorman JC, Smith RJ Comparison of treatment effects with labial and lingual fi xed appliances

Am J Orthod Dentofacial Orthop 1991;99:202–9

Harfi n J, Ureña A Ortodoncia Lingual: procedimientos y aplicación clinica Buenos Aires: Editorial Médica Panamericana; 2010

Kurz C, Romano R Lingual orthodontics: historical perspective In: Romano R, editor Lingual Orthodontics Hamilton: BC Decker; 1998 p 3–20

Kusy RP Ongoing innovations in biomechanics and materials for the new millenium Angle Orthod 2000;70:366–76

Miyawaki S, Yasuhara M, Koh Y Disconfort caused by bonded lingual orthodontic appliances in adult patients as examined by retrospective questionnaire Am J Orthod Dentofacial Orthop 1999;115:83–8

Poon KC, Taverne AA Lingual orthodontics: a review of its history Aust Orthod J 1998;15:101–4

Smith JR Gorman JC, Kurz C, Dunn RM Keys to success in lingual therapy J Clin Orthod 1986;20:252–61

Wiechmann D, Gerb J, Stamm T, Hohoff A Prediction of oral discomfort and dysfunction in gual orthodontics A preliminary report Am J Orthod Dentofacial Orthop 2008;133:359–64 Preface

Contents

1 Biomechanics 1

How to Take the Silicone Impression 1

Laboratory Procedures 3

Indirect Bonding 12

Methods of Ligation 15

Phase I 16

Lingual Utility Arch 17

Use of Quad Helix in Lingual Orthodontics 19

Partial Canine Retraction 20

Use of Coil Springs 22

How to Correct Rotated Teeth 24

Phase II 29

Anchorage Control 29

Use of Elastics 37

Tips on How to Reposition a Lingual Bracket 40

Transverse Control of the Position of the Upper First Molars 44

Phase III 45

Conclusion 45

Bibliography 45

2 Treatment of the Lower Anterior Crowding by Stripping Procedures 47

Case Study 1 48

Case Study 2 51

Case Study 3 56

Conclusion 57

Bibliography 58

3 Deep Overbite 59

Case Study 1 60

Case Study 2 68

Conclusions 73

Bibliography 73

4 Effi cient Treatment of Open Bite in Nongrowing Patients 75

Case Study 1 76

Case Study 2 79

Case Study 3 87

Conclusion 97

Bibliography 98

5 Use of Pendulum with Lingual Appliances 99

Case Study 1 101

Case Study 2 109

Conclusion 117

Bibliography 117

6 Impacted Canines 119

Conclusions 130

Bibliography 131

7 Clinical Cases 133

Case Study 1 134

Case Study 2 143

Case Study 3 152

Conclusions 163

Bibliography 163

8 Finishing 165

Conclusions 172

Bibliography 173

9 Summary and Outlook 175

Bibliography 177

Index 179

© Springer International Publishing Switzerland 2015

J Harfi n, A Ureña, Achieving Clinical Success in Lingual Orthodontics,

This is a very important item that is sometimes not taken into account by cians The adhesion of the brackets to the lingual and palatal surfaces of the teeth requires careful preparation

Some patients have deep grooves not only near the cingulum of the central, eral incisors and canines but also on the palatal surfaces of the 1st and 2nd molars That is why sealing them before taking the impressions is advisable

Also, the normalization of the palatal marginal rims is important Occasionally, their shape and size don’t allow brackets to adapt correctly

Gingival tissues also need to be normalized since infl ammation caused by vitis can alter the proper position of the brackets Working with a periodontist before, during, and after the treatment is necessary

How to Take the Silicone Impression

Before impressions are taken, careful hygiene of the teeth has to be performed by the orthodontist in order to eliminate all the biofi lm

A two-phase technique silicone impression is recommendable to take an rate one The impression tray has to be rigid and nondeformable The adhesion of the impression material to the impression tray is a crucial phase in which errors must be avoided

1

Biomechanics

Mix uniformly into homogeneous state before use (Fig 1.1a, b ).

It should be correctly extended on the tray in order to obtain a good surface detail

Incorporating mostly all anatomical landmarks is required to create an ideal impression (Fig 1.2a, b )

For the second phase, regular body silicone impression material is suggested Mix the two components (base and catalyst) in a gentle way for fullfi lled the fi rst impression, following the indications of each silicone brand (Fig 1.3a, b )

It is highly recommended to disinfect the silicone impression after taking it and

to follow the manufacturer’s instructions of your choice, and for best results, wait for 30 min before casting the impression, knowing that the impression remains dimensionally stable for a minimum of 7 days and a maximum of 14 days

Laboratory Procedures

It is generally accepted by orthodontists that the indirect technique is the best option when lingual brackets are used Several methods with different systems have been described during the last 25 years

In this section, vital information on how to achieve excellent results with in- offi ce indirect method will be described step by step

No expensive outside laboratories will be needed and consistent results will be seen

A careful setup has to be made taking into account the patient’s diagnosis, nosis, and treatment plan

When silicone is used, the impressions have to be taken in two stages for a better defi nition It is important to control the defi nition of the impression in order to check for the absence of bubbles and the precise contour of the teeth (Fig 1.4a )

The second step is to mark the center of each tooth to determine the exact tion of each dowel pin (Fig 1.4b )

In patients with mild or severe crowding, it is recommendable to perform two cast models, to maintain the correct anatomy of the mesial and distal margins of each crowded tooth

To avoid fractures during the laboratory process, extra-hard plaster or densita gypsum rock is suggested

Fig 1.4 ( a , b ) Silicone impression have to be taken in two stages and with the dowel pins in place

Laboratory Procedures

To obtain the best copy of the teeth, it is better to make two plaster models, inserting the dowel pins sorting one tooth from another (Fig 1.5a, b ).

A perfect copy of the teeth can be obtained with this method (Fig 1.6a, b )

After the vertical cut of the plaster, stump of each tooth should be stripped with

a steel or tungsten dental bur, slenderizing the stone while carefully preserving the mesial-distal dimension of each tooth without removing the dental gingival limit (Fig 1.7a, b )

After reshaping and numbering each tooth, they have to be put in place in the original silicone impression, and then a horseshoe dental wax has to cover all the dowel pins (Fig 1.8a, b )

The next step is to remove the dental wax with all the teeth fully covered with it (Fig 1.9a, b ).

The following step is to prepare a solid base with stone gypsum to avoid any undesirable teeth movement (Fig 1.10a )

It is essential to remember that all the teeth have to be numbered to avoid any undesirable position mistakes (Fig 1.10b )

Lateral views to control de occlusal plane (Fig 1.11a, b )

The teeth have to be slightly moved to their fi nal position, straightening the teeth and checking the contact points between them, and rotations of the premolars and molars have to be fulfi lled (Fig 1.13a, b ).

In order to achieve a more ideal and individual patient tooth alignment according

to the previous diagnosis and treatment plan, an ideal chart plate can be helpful (Fig 1.14a, b )

After that, a silicone spray (any brand) should be placed to facilitate the bracket debonding (Fig 1.15a, b )

The model should be poured to prepare a key plaster to avoid undesirable nations when the brackets and the wire are bonded to the cast model (Fig 1.16a, b )

The following step is to insert the brackets into a 0.017″ × 0.025″ TMA archwire

A ligature tying plier is very useful at this point (Fig 1.17a, b )

The distocanine and mesiomolar bends have to be done after all the brackets are inserted in the 0.017″ × 0.025″ TMA wire (Fig 1.18a, b )

The measure of the distal canine bend is related to the width differences between the cuspids and fi rst premolars in every patient Sometimes it could be different between the right and left sides It is advisable to control the wire torque to maintain the same occlusal plane (Fig 1.19a, b )

After all the bends are performed, the archwire has to be stabilized in the setup with acrylic keys (Fig 1.20a, b ).

If the diagnosis requires extra anterior torque and before the lingual brackets are placed on the cast model, the orthodontist can manage it with an easy and controlled method Extratorque labial anterior brackets (Ricketts brackets technique) are placed on the labial surface of the six anterior upper teeth with a rectangular 0.16″ × 0.22″ Ni-Ti wire (Fig 1.21a, b )

Indirect Bonding

Indirect method is highly recommended due to the great difference in the palatal and lingual tooth anatomy It must be easy to make, permit accurate bonding, have control of the possible failures, easy to rebond when it is necessary, and have high precision and reduced cost

The fi rst step is to clean the enamel surface using a pumice paste with a rubber cup or a polishing brush (Fig 1.24a, b )

The second step is to rinse with water to remove any pumice paste and to dry thoroughly with oil-free air

Cheek, lip, and tongue retractors are very helpful to maintain a completely dry

fi eld during all the bonding process (Fig 1.25 )

Fig 1.25 Cheek, lip, and

tongue retractors

Fig 1.24 ( a , b ) A low-speed handpiece with a cleansing brush is recommended

Thirty-seven percent phosphoric acid gel for about 30″ is used for enamel tioning Acid gel provides more control on the surface to be etched Since the enamel surface must not be contaminated with saliva, a wet gauze to remove the acid gel is recommended (Fig 1.26a, b )

Then the enamel surface has to be dried very carefully until it acquires a frosty white appearance In almost all patients, no micro-etching is necessary (Fig 1.27a, b )

After this, a small amount of primer is applied to the tooth and to the bracket base

at the same time

Light-curing primer with fi lling microparticles is highly recommendable in order to diminish enamel decalcifi cations or carious lesions under the brackets (Fig 1.28a, b )

It is important that all the excess adhesive is carefully removed to improve oral hygiene and less gingival infl ammation or decalcifi cation around the bracket

It is preferred to start transferring individual caps from the last molar to midline avoiding unnecessary contamination risks (Fig 1.29a, b )

The cap can be easily removed with a thin dental explorer instrument from sal to gingival (Fig 1.30a, b )

The double-tie ligature allows the full insertion of the archwire into the bracket slot avoiding the archwire to slip off the bracket

First, the ligature has to be placed behind the wire and the bracket in order to embrace and insert the wire at the end of the bracket slot (Fig 1.31a, b )

Cross ligature around the bracket and pull up the ends in order to twist them on the side of the bracket (Fig 1.32a, b )

With a cutting plier, loose ends should be cut and pressed behind the bracket, venting any discomfort for patients A ligature director or a Mathieu plier is helpful

It is important that the excess wire is cut after twisting the ligature under the bracket (Fig 1.33a, b )

Lingual Utility Arch

The intrusion of lower incisors is a real challenge not only in adolescents but in adults too The use of a lingual utility arch is highly recommendable and easy to manage

It is fabricated with 0.016″ × 0.016″ blue Elgiloy wire which is the same as used

in labial orthodontics, described by Ricketts many years ago An activation with 15° tip back bends mesial to the fi rst molar is advisable (Fig 1.36a, b )

Fig 1.35 ( a , b ) After the alignment was completed, a TMA 0.0175″ × 0.0175″ was suggested until the retention was placed

Fig 1.36 ( a , b ) Lower lingual utility arches

Lingual Utility Arch

The importance of the utility arch is that it gives us the possibility to intrude the lower incisors in a very easy and controllable manner (Fig 1.37a, b ).

In order to keep premolar and cuspids aligned, a sectional wire 0.016″ SS should

be placed including the 2nd molar in order to maintain the lateral alignment (Fig 1.38a, b )

Lateral views with the two sectional and utility arches in place, before activation (Fig 1.39a, b )

The comparison before and after the activation shows the action of the utility arch The amount of intrusion could be decided according to the treatment plan (Fig 1.40a, b )

Use of Quad Helix in Lingual Orthodontics

When mild orthodontic expansion is needed, the use of the quad-helix appliance is very recommendable, especially in adult patients

This appliance was fi rst developed by Dr Herbst and popularized by Dr Ricketts, and it is used for symmetrical or asymmetrical expansion of the maxillary dental arch Normally, it is made with 0.036″ SS or TMA wire and welded to the 1st molar bands If a removable one is decided on, it is possible to attach it to palatal tubes Two months after the results are achieved, it can be removed and the brackets have to be placed on the same day in order to avoid losing the results achieved This is a clear example that shows the benefi ts of the use of a quad helix in a 34-year-old patient with a narrow maxilla, before extractions were done A 4–6- week activation was suggested (Fig 1.41a, b )

Fig 1.40 ( a , b ) Before and after the activation of the utility arch

Fig 1.41 ( a , b ) Pretreatment occlusal photograph, with the quad helix in place

Use of Quad Helix in Lingual Orthodontics

In this particular patient after three activations, the quad helix was replaced for a transpalatal arch, and then upper bicuspid extractions were performed

Sliding mechanics was recommended for the retraction of the anterior teeth

At the end of the treatment, a fi xed retention wire (0.0195″) was suggested The improvement of the transverse dimension was clearly visible (Fig 1.42a, b )

Partial Canine Retraction

In patients with moderate or severe crowding or when canines have to move distally

in conjunction to maximum anchorage, an individualized arch has to be designed to move only the canine distally

The arch (SS 0.014″ or TMA 0.016″) has a small round loop just in front of the bicuspid An elastomeric chain is placed from the canine to the loop to move it dis-tally (Fig 1.43 )

The following patient is a clear example

The chief complaint of the patient was midline deviation The upper fi rst right bicuspid had been extracted when she was a child during her fi rst orthodontic treat-ment The extraction of the upper left fi rst bicuspid was recommended in order to correct the midline

Fig 1.43 Partial canine

retraction arch

Fig 1.42 ( a , b ) During and after extraction sliding mechanics

Fig 1.44 ( a , b ) Partial retraction canine arch at the beginning and 3 months after

Fig 1.45 ( a , b ) Six and nine months in treatment

Partial Canine Retraction

The results showed the normalization of the midline and the complete closure of the extraction space A fi xed retention wire was placed the same day the brackets were removed (Fig 1.46a, b ).

Use of Coil Springs

The use of coil springs is based on the same criteria as used in the labial technique Nickel-titanium open coil springs are recommendable because they release low and continuous forces in comparison to stainless steel coil springs

Its activation has to be smaller since the interbracket distance is shorter

More control is necessary in adult patients with reduced periodontal attachment

to avoid undesirable rotations that take a lot of time and effort to recover

A 45-year-old patient with a severe lack of space in the anterior region came to the offi ce for a non-extraction treatment It was preferable to start gaining the space for the right upper incisor and after that for the canine Ni-Ti open coil spring in conjunction with a 0.016″ TMA wire was recommended (Fig 1.47a, b )

When the space was recovered, a 0.0175″ × 0.0175″ TMA for torque control was suggested At the end of the treatment, a fi xed retention wire from the right fi rst bicuspid to the left fi rst bicuspid was placed for a long period of time (Fig 1.48a, b )

The same procedure can be used in the lower arch

This patient had a lack of space for his lower lateral incisor As always, Ni-Ti open coil spring is preferable because a more continuous and controlled force was released

When the space was recovered, the bracket on the lateral incisor was bonded with indirect method as usual (Fig 1.49a, b )

Fig 1.48 ( a , b ) A 0.0175″ × 0.0175″ TMA for alignment and torque expression and with the fi xed

retention wire in place

Fig 1.49 ( a , b ) Lower arch with the Ni-Ti coil spring in place

Use of Coil Springs

After realignment and leveling the lower arch, a rectangular wire (0.0175″ × 0.1|75″ TMA) was placed As always, a fi xed retention wire is recommended (Fig 1.50a, b ) from fi rst right lower bicuspid to the left one.

How to Correct Rotated Teeth

The correction of rotated teeth is not always easy to manage The short interbracket distance in conjunction with the small width of the lingual bracket increases the dif-

fi culties in correcting them

Three techniques can be used: cemented bracket with composite compensation, Scott ligature, or coupled effect

Before even thinking about biomechanics, the necessary space has to be made before the correction of a rotated tooth begins

When the patient has a mild rotation, a full engagement of a round Ni-Ti-Cu archwire with a double over-tie ligature is advisable

If small rotation is present, some rotation bend in the TMA 0.016″ archwire is recommendable, but the most predictable method is the Scott ligature in patients with mild to severe rotations

She is a 34-year-old patient whose right lower lateral incisor was disto-rotated Because of the lack of space, a Ni-Ti coil spring was used for 2 months (Fig 1.51a, b )

Fig 1.51 ( a , b ) Use of the Ni-Ti coil spring for gaining space in order to bond the lingual bracket

on the lower lateral right incisor

Fig 1.50 ( a , b ) Final archwire for torque control and retention wire bonded

After the space was achieved, the use of a Scott ligature was recommendable

A piece of an elastomeric chain was placed using an explorer in order to tie in the knot around the wire

The elastomer link was threaded through the other end over the archwire (Fig 1.52a, b )

Since the mesial side of the lateral lower incisor is lingualized, the knot has to be placed on the opposite side of the movement that is needed to be achieved

After that, the elastic chain has to be placed under the distal contact point of the lateral incisor and has to embrace the labial surface to the mesial side in order to reach the bracket hook (Fig 1.53a, b )

Fig 1.52 ( a , b ) Elastomeric chain to initiate the Scott ligature

Fig 1.53 ( a , b ) A Mathieu plier is useful to perform this ligature

How to Correct Rotated Teeth

At Fig 1.54a , the couple effect is activated: A labial point of fl owable restorative material may be useful in order to maintain the elastomeric segment on the labial surface in place (Fig 1.54b ).

Two months later, the normalization of the incisor is evident For some patients, the elastomeric chain ligature has to be changed for esthetic reasons, every 2–3 weeks (Fig 1.55a, b )

The same procedure has to be done to correct a rotated tooth in the maxilla The chief complaint of this patient is the rotation of the upper right lateral incisor due to a relapse of a previous orthodontic treatment The most controllable proce-dure is the same method used in the Scott ligature as was described in the lower incisor rotation discussed in the previous patient (Fig 1.56a, b )

As was described before, it is necessary to have the correct amount of space to normalize the position of the tooth (Fig 1.57a, b )

Fig 1.56 ( a , b ) A section of an esthetic ligature chain to rotate the upper right lateral incisor

Fig 1.57 ( a , b ) Initial steps of the Scott ligature

How to Correct Rotated Teeth