Lingual orthodontics ROMANO

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 F

LINGUAL ORTHODONTICS

LINGUAL ORTHODONTICS

LINGUAL ORTHODONTICS

R A F I R O M A N O , D M D , M S c

   

       

Ha m i l t o n • L o n d o n

trans-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

Lewiston, NY 14092-0785 London, NW1 7DX

United Kingdom Tel: 71-267-4466 Fax: 71-482-2291

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

7–10, Honkomagome 1-Chome B-3, EMCA House,

Bunkyo-ku, Tokyo 113 23/23B Ansari Road, Daryaganj,

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

Private Practice, Limited to Orthodontics

Marion, Indiana, USA

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”

 Enhanced Facial Esthetics using

Kurz Lingual Appliance 

Craven Kurz, DDS, PhD

 Advanced Lingual Prescription:

Technique and Design 

 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

. The Lingual Technique in

 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,

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 thebest clinicians who practice LO were in attendance

When surveying the literature published on LO, it is surprising to discover thatmost 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 foundedthe 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 exaggeratedexpectations from the public and media While most orthodontists found interest inthe new system, it was still undeveloped, without any finished cases, any protocol, andpresented 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 terized by a lack of knowledge in the dental community and among the public Thetechnique of lingual orthodontics, which is the only option we can give to those patients

charac-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 whooffer LO as a treatment option in their office and partly due to the small efforts thatwere 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 evendecided to devote their practice exclusively to LO and can now present excellent clinicalresults 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 allover the world This book is published to change this situation because we believe thatlingual orthodontics is the ultimate esthetic solution in orthodontics today

Many of the best clinicians who practice LO contributed to this book They comefrom 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 tremendoushelp, good will, and patience they have exhibited in the long process of creating aninternational book They have all agreed to share their knowledge and experience withour 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, interdisciplinarycases, 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 takeaccredited courses, come to LO meetings, and gain experience before adopting thesystem completely into his or her practice Once a thorough knowledge and clinicalexperience are obtained, one will gain excellent clinical results, not less than he or shewas 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 authorwhose article I did not mention here

The advantages of LO over labial orthodontics are many While better estheticsduring treatment is the most obvious, some advantages are purely mechanical, likemore efficient distal movement, much easier intrusion, increased expansion, and thebuilt-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 lingualorthodontic results are inferior to those achieved with labial orthodontics In fact, theopposite is frequently true We do believe that the advantages of LO as a treatmentoption 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 publishingmore textbooks Some disadvantages still to be overcome are:

• Further improvement of the design of the brackets to make them smaller, moreeasily 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 uate orthodontic programs in the universities around the world

postgrad-• Reduction of the high fees by improvements in design and technique whichwill, in turn, reduce the chairtime of the orthodontist

I do hope this book will have a uniting influence on the clinicians using LO Theworld 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 cation tools exist and should be used to teach, to inform, and to unite Teaching otherorthodontists 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 willbecome 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 dentistswho were the first to do it became the leaders in esthetic dentistry all over the world

communi-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 metremendously; 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 ofesthetic 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 

During the early 1970s, Dr Craven Kurz, an orthodontist, then assistant professor

of occlusion and gnathology at the UCLA School of Dentistry, found his privateorthodontic practice to be increasingly dominated by adult patients As many of hispatients were public figures, esthetics became a major concern A particular patient,who was an employee of the Playboy Bunny Club, presented to his practice requestingtreatment 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 cept of a lingually bonded appliance was born

con-After much advice and consultation from orthodontic colleagues, particularly

Dr Jim Mulick, also at the UCLA School of Dentistry, Dr Kurz developed the firsttrue 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 anteriorbrackets were selected because of the ease of recontouring and reshaping them toavoid 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 andirritating 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 andacceptance increased

Not surprisingly, commercial interest was rapidly developing for this new applianceand approach to orthodontic treatment Many clinicians and commercial companieswere in the process of developing some version of a lingual appliance During theseearly stages, Ormco, a company in California, created a product development teamconsisting of Mr Frank Miller and Mr Craig Andreiko to work with Dr Kurz and hisnew appliance Historically, Ormco’s interest in the concept of lingual orthodontictreatment 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 lingualapproach This system consisted of a Pedicle positioner, rather than a multibracketedsystem Although innovative, inherent limitations in this system prevented it fromgaining widespread popularity in the orthodontic community

With the new product development team now in place, prototypes of lingualbrackets 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 thenrecreated in appropriate materials in scaled-down versions to fit the mouth It wasquickly found that the problems that plagued all previous attempts at developing ausable appliance remained—namely, a high bond failure rate due the shearing forces,and patient discomfort from the roughness against the tongue The turning point inthe development of the appliance was the addition of an anterior inclined plane as anintegral part of the maxillary anterior brackets (Figure 1–2) This inclined plane con-verted the shearing forces produced by the mandibular incisors to compressive forcesapplied in an intrusive and labial direction These forces also produced a naturalphysiological bone resorption in the maxillary and mandibular incisor area, allowingthe 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 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 KurzLingual Appliance on November 15, 1976 Product development began in earnest in

ante-1978, and Ormco manufactured a usable metal bracket by 1979 Initial clinical 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 muchpromise in providing the profession with an esthetic alternative to labial appliances The next logical step in product development and improvement was to establishbeta test sites Fifty selected orthodontists were invited to attend an Ormco-sponsored

test- - Dr Craven Kurz

 - Dr Jack Gorman  - Dr J.R Bob Smith

 



symposium on lingual orthodontic therapy Here, Dr Kurz presented the concept oflingual treatment, the appliance, and his treatment results from the initial 100 casestested to the professional community From this group, the original Lingual TaskForce was developed This group was under the administrative guidance of Mr FloydPickrel, Mr Ernie Strauch, and Dr Michael Scwartz, all from Ormco Their charge was

to guide and administrate the research and development team while a commerciallyviable lingual appliance was being developed They appointed, in addition to Dr CravenKurz 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 fromDallas, Texas, Dr James Hilgers of Mission Viejo, California (Figure 1–8), and Dr BobScholz 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 wasgrowing within the dental profession This plus public demands for this alternativetreatment forced an urgency on the research and development team to provide theappliance for wide-scale use as quickly as possible By the early fall of 1981, the taskforce was presenting regular seminars on the lingual appliance in Newport Beach,California That same year, Dr K Fujita of Japan, published an article on lingualtherapy in the American Journal of Orthodontics Commercial interest was spreading.Unitek supported a Lingual Clinical Project under the direction of Dr Vince Kelly ofOklahoma Dr Steve Paige of Florida began giving courses using a Begg appliance lingually Forestodent, and American Orthodontics all began to market lingual bracketsand accessories

Public interest continued to grow The news media reported the development ofthe new “invisible braces” in major magazines and broadcasts on both television andradio (Figure 1–10) The Ormco task force conducted a news conference at theWaldorf Astoria in New York, touting the benefits of this new type of orthodontictherapy The interest of the public was heightened even more, and they demanded theappliance from the profession

Commercial companies were competing to be at the forefront of this “lingualfever.” Even Unitek now had a lingual appliance Dentists were demanding moreinformation and training in the lingual technique The courses presented by theLingual 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 andnews conferences in most major cities in America In 1982, Ormco organized a taskforce of two doctors from every country in Europe In 1983, this group introducedthe appliance to Europe at a meeting in Geneva, Switzerland, followed by courses inJapan 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 acceptablethan 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 andbeginning treatment using the lingual technique The technique and appliance werestill in their infancies, and, in fact, beta testing had not yet been completed Publicdemand 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 applianceand lingual therapy without much success There seemed to be widespread problemswith appliance placement through direct bonding techniques and manipulation ofarchwires 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 incases treated with the lingual approach Dr Kurz’s lecture was well attended becausemany 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 expectfrom 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 patientswho were concerned with the poor esthetics of conventional metal labial brackets

A sigh of relief was heard throughout the orthodontic community Orthodontistscould now offer to patients an option that provided improved esthetics over metalbrackets with efficient and high-quality treatment

Enthusiasm for lingual therapy waned in the profession, and commercial interestalso 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 renamedKGS Ormco Task Force Number Two Their new charge was to define the problemsthat 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

practi-The American Lingual Orthodontic Association (ALOA) was established onNovember 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 quarterlyjournals, study club assistance, patient brochures, yearly conventions, and professionallectures The first annual meeting of ALOA was held in Washington in 1987, and inPalm Springs the following year Additionally, a Dental Lingual Assistant Associationwas formed to provided support for staff members employed by lingual orthodonticpractitioners The new professional associations were smaller than the original groupsbut 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 andJapanese university programs offered training in lingual therapy and these were soonfollowed by courses in Korea, South America, Mexico, and Denmark

The European Society of Lingual Orthodontics (ESLO) was founded in 1992, inVenice, 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; theAssociazione Italiana Ortodonzia Linguale (AIOL) or the Italian Association of

Lingual Orthodontics has been one of the most active ever since The Asian lingual ciation is also very active Dr Lorenzo Favero, Italy, was the first to treat children andadolescents with LO, and now it is a legitimate treatment option for all

asso-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 annualconventions, availability of patient educational materials, and the publication of a professional quarterly, the JALOA The French Lingual Orthodontic Society and theItalian Lingual Orthodontic Society currently hold annual meetings The ESLO sponsored the last international meeting in Monaco, Monte Carlo in 1996 and thenext meeting is scheduled for June, 1998 in Rome Many courses are given in various locations throughout the world, mainly by Drs Didier Fillion (France), CourtneyGorman (USA), Giuseppe Scuzzo (Italy), Kyoto Takemoto (Japan), Echarri PabloLobiondo (Spain), Bob Baker (USA), Mario Paz (USA), and John Napolitano (USA) The following is a summary listing of some of the difficulties encountered duringthe 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 thetongue and impeded normal speech The current generation of brackets has been

 - Initially, anterior brackets had long

gingival hooks responsible for calculus build-up.

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 theself-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 mandibularanterior teeth are particularly vulnerable to calculus accumulation due to their closeproximity to the submandibular salivary glands These brackets have 1.5 to 2 mmclearance between the base and the gingival margin Additionally, the bracket hookshave been redesigned with a lower profile and are located several millimeters from thegingival margin (Figures 1–13a and b)

an inclined or bite plane strategically placed to redirect the vertical shearing forces to ahorizontal seating force (Figure 1–15) The location of the inclined plane is such thatwhen a 1 mm overjet and overbite relationship is obtained, all mandibular anteriorcontact with the inclined plane is eliminated To avoid deleterious effects caused bytooth 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 bettercontrol of tooth movements, the appliance was fabricated in high tensile metal whichprovides 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 wirewas engaged This coupling was thought to prevent vertical and horizontal rotation

of the buccal segments (Figure 1–16) Clinically, however, this coupling proved to beunnecessary 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 toeither 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 bracketbase curvatures were calculated (Figure 1–17)

6 Appliance Placement and Bonding

The original appliances were direct bonded With the variability of lingual tooth tours, accurate bracket placement was difficult This approach produced unpredictabletooth alignment with tremendous variations in tip, torque, and tooth height Initially,the Torque Angulation Referencing Guide (TARG) system was used The TARGinstrument was designed to place brackets on the lingual surfaces using conventionallandmarks as references Although substantial improvements were made in the accuracyand efficiency of bonding, the system was still inadequate A more sophisticated sys-tem, using a diagnostic set-up constructed from articulated models was developed andhas 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

con-7 Appliance Prescription

In the early 1970s, Dr Lawrence Andrews developed and patented a fully programmedorthodontic appliance, which he introduced as the Straight Wire Appliance This philosophy involves programming all the elements necessary to achieve an optimalocclusion 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 tothe lingual surface Tip and torque angulations were not ideal A similar philosophywas 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, ashigh as it could go, without missing the rounded lingual anatomy Reciprocal tip andtorque values to Andrew’s published values were used to establish the prescription.There was no grand procedure used in obtaining the reciprocal lingual reference ofangles 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 thickerthan is reasonable, so a true straight wire was not feasible A first order bend wasplaced 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 Thetubes were redesigned by widening the mesial aperture of the slot of the first molarbracket, 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 thatare both deep set and easy to hook have been designed When teeth are crowded andslot 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 Theoriginal hook was large and in close proximity to the gingival margin, impeding accessfor hygiene This hook was redesigned with a lower profile and moved away from thegingival margin

From Generation #1 to Generation #7—A Summary of Progress

The first Kurz Lingual Appliance was manufactured by Ormco This appliance had aflat maxillary occlusal bite plane from canine to canine (Figure 1–20) The lower incisorand premolar brackets were low profile and half-round (Figure 1–21), and there were

no hooks on any brackets

 - Generation #1—1976

Flat maxillary occlusal bite plane from canine to canine.

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, itwas bibeveled to allow intercuspation of the maxillary cusp with the embrasure betweenthe mandibular canine and the first premolar Hooks were optional A transpalatal barattachment 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 

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,

 



G ENERATION #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 archwire Bracket

Bracket

Lingual Orthodontics: Historical Perspective 

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 andout of public and professional favor Over the years, the appliance and the techniqueshave been improved dramatically and, as a result, a reliable system has emerged It hasnow undergone many years of clinical experience and has been shown to consistentlyproduce satisfactory results

Esthetic concerns were initially responsible for the development of the appliancesystem and they continue to remain at the forefront for a significant segment ofpatients seeking orthodontic treatment Appearance is undoubtedly the most impor-tant motivating factor for adults whether it is termed “facial appearance,” “dentalappearance,” or “straight teeth.”

Research has shown that physically attractive people achieve higher levels of success in many aspects of life than unattractive people.3This advantage starts at birthand continues into adulthood The added positive attention given to attractive indi-viduals by teachers and peers, for example, can have profound effects on personalitydevelopment and self-image Improvement in one’s physical appearance, as is commonwith 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 tractive labial orthodontic appliances, can negatively affect one’s self-esteem This isparticularly 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 aconventional treatment This service offered in the private orthodontic office allowsthe patient several treatment options, and provides the orthodontist with a competitiveadvantage over colleagues not offering the option of lingual appliances

unat-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 techniquesand the extended chairtime needed for appliance placement and adjustments havemade the treatment prohibitively expensive for many patients

However, lingual treatment has obvious advantages over labial treatment Thelabial enamel surface of the anterior teeth plays an important esthetic role By placinglabial appliances, the susceptibility of this enamel surface to chemical insults frometchant materials and to environmental influences from plaque accumulation inpatients with poor oral hygiene is increased Permanent and unsightly decalcificationmarks 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

M A S S I M O RO N C H I N , M D , D D S

 



nathic system is maintained Clinical judgment of treatment progress can be

enhanced Evaluation of individual tooth positions can be easily accomplished by ing the labial surfaces free of distracting metal or plastic brackets Soft tissue responses

hav-of the lips and cheeks to treatment can be judged accurately because there is no tion of shape or irritation caused by a labial appliance

distor-Four distinct situations exist where lingual appliances may be more effective thanlabial 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 forceapplication 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 isfound with labial bracket placement (Figure 2–1).10An 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 pospos-terior 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, soappliances should be repositioned during treatment when it becomes possible Figure2–2d shows the treatment progress three months after appliance placement, andFigure 2–2e shows the final occlusion Total treatment time was 15 months

Deep-bite correction was facilitated by the active anterior intrusive forces and thepassive 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 expandthe upper arch both transversally and sagittally It is not yet totally clear why but, clin-ically, we obtain more remarkable dentoalveolar expansions through lingual mechanicsthan 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 RapidPalatal 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 tribute to this expansive effect.7–9

con-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.10The 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 wasachieved with a rectangular archwire The results show substantial improvement in thepatient 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 totreat in two distinct clinical phases The initial phase of treatment addresses the TMDand associated pain symptoms It is often accomplished with splint therapy until themuscle and joint symptoms resolve Depending on the practitioner, the patient is thenmaintained, symptom free for a period of time from several months to more than ayear The second clinical phase of treatment addresses changes in the occlusion as aresult 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 withappliances 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 inclinedplane functions as a bite plane As seen previously, this device has an active intrusiveeffect, while allowing passive eruption of the posterior segments Many patients withTMD require stability with anterior and posterior contacts on their splint For thesepatients 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 posterioracrylic supports can simulate the action of the conventional splint, thereby allowingtreatment to progress simultaneously in both arches The supports can be flat, therebyhelping the Class II elastics (Figure 2–5), or they can be fabricated with some occlusalindentations which can guide the mandible into the desired position.12–14Figures 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 lation of the multiple roots of maxillary molars, the center of resistance is found justlingual to the average long axis of the roots (Figure 2–8a) In this example of a secondmolar 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 thelingual surface; here the CR is found in the palatal root In fact, a rather bodily distalmigration takes place Afterwards, a labial force (Figure 2–8c) can very easily correctthe rotation Bodily movement is the most efficient form of tooth movement

angu-Clinically, this can be accomplished by placing an open coil spring between the firstand 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 thesecond 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 cal and lingual aspects (Figure 2–9b) The balance of these forces counteracts the rota-tional forces

buc-As an additional case, we present the 20-year-old female in Figures 2–10 to 13 whopresents 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