Romano Lingual Orthodontics

LINGUALORTHODONTICS

LINGUALORTHODONTICS

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

. . Hamil ton • London

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© 1998 Rafi RomanoAll rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or trans-mitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, with-out prior written permission from the publisher.

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Notice: The authors and publisher have made every effort to ensure that the patient care recommendedherein, including choice of drugs and drug dosages, is in accord with the accepted standard and practiceat the time of publication. However, since research and regulation constantly change clinical standards, thereader is urged to check the product information sheet included in the package of each drug, whichincludes recommended doses, warnings, and contraindications. This is particularly important with new orinfrequently used drugs.

Robert W. Baker Jr., DMDLingual Appliance Course DirectorUniversity of Rochester Eastman Dental CenterPrivate Practice, Limited to OrthodonticsNew York, USA

Nitzan Bichacho, DMDPrivate Practice, Limited to ProsthodonticsTel Aviv, Israel

Paul-Georg Jost Brinkman, DMD, PhDAssociate Professor, Department of Orthodontics of the Free University

Berlin, Dental SchoolBerlin, Germany

Vittorio Cacciafesta, DDSPostgraduate Orthodontic ResidenceDepartment of OrthodonticsRoyal Dental CollegeArhus University, Denmark

Maurizio Cannavo, MDVisiting Professor in Lingual OrthodonticsSpecialization School of OrthodonticsUniversity of Ferrara, Italy

Christian Demange, DCD, SQODE, CECSMOOrthodontiste Spécialiste QualifiéDocteur en Chirurgie DentaireDocteur de l’Université Claude BernardMaître de Conférences des UniversitésPracticien Hospitalier—Faculté de LyonLyon, France

Pablo A. Echarri, DDSPrivate Practice, Limited to OrthodonticsBarcelona, Spain

Lorenzo Favero, MD, DDS, MScProfessor, Pediatric Dentistry DepartmentUniversity of PaduaPadua, Italy

Didier Fillion, DDSPrivate Practice, Limited to Lingual

OrthodonticsParis, France

J. Courtney Gorman, DDS, MSPrivate Practice, Limited to OrthodonticsMarion, Indiana, USA

Chiori Hashiba, DDS, PhDPrivate Practice, Limited to OrthodonticsTokyo, Japan

Scott A. HugeOwner and President, Specialty Appliances Inc.Orthodontic LaboratoryNorcross, Georgia, USA

Craven Kurz, DDS, PhDPresident Emeritus of the American Lingual

Orthodontic AssociationPrivate Practice, Marina del ReyCalifornia, USA

Stuart McCrostie, DDSSpecialist Orthodontist Waitara NSW, Australia

Mario E. Paz, DDS, MSCourse Director, Lingual Orthodontic ProgramUniversity of California Los AngelesCalifornia, USA

Friedrich RiemeierManager, Bending Art CompanyBerlin, Germany

Rafi Romano, DMD, MScPrivate Practice, Limited to Orthodontics,

Emphasizing Adult and Lingual OrthodonticsTel Aviv, Israel

Massimo Ronchin, MD, DDSAssistant Professor in OrthodonticsCagliari UniversityVisiting ProfessorUniversity of Ferrara, Italy

Guiseppe Scuzzo, MD, DDSVisiting Professor in Lingual OrthodonticsSpecialization School of OrthodonticsUniversity of Ferrara, Italy

Alessandro Silvestri, MD, DDS, ENTChief, Pre- and Postsurgical Orthodontic ServiceDepartment of Maxillo-Facial SurgeryUniversity of Rome “La Sapienza”Rome, Italy

Kyoto Takemoto, DDSPrivate Practice, Limited to Lingual OrthodonticsChiba-ken, Japan

Contributors

Contents

Preface . . . . . . . . . . . . . . . . . . . .

SECTION 1

Introduction Lingual Orthodontics:

Historical Perspective . . . . . . . . . . Craven Kurz, DDS, PhD, Rafi Romano, DMD, MSc

Present Clinical Reality . . . . . . . .

Massimo Ronchin, MD, DDS

Lingual Orthodontics in a Labial Orthodontics Office . . . . .

J. Courtney Gorman, DDS, MS

SECTION 2

Basic Principles Enhanced Facial Esthetics using

Kurz Lingual Appliance. . . . . . . .

Craven Kurz, DDS, PhD

Advanced Lingual Prescription:Technique and Design . . . . . . . .

Robert Baker Jr., DMD

. Shape Memory Wires in Lingual Orthodontics . . . . . . . . .

Christian Demange, DCD, SQODE, CECSMO

. Wire Sequencing in LingualOrthodontics . . . . . . . . . . . . . . .

H. Stuart McCrostie, DDS

Instruments Used in LingualAppliance. . . . . . . . . . . . . . . . . .

Craven Kurz, DDS, PhD

SECTION 3

Treatment Approaches and Mechanics Anchorage Control in Lingual

Orthodontics . . . . . . . . . . . . . . .

Kyoto Takemoto, DDS

. Preserving the “Hollywood Smile”and Facial Profile . . . . . . . . . . . .

Mario E. Paz, DDS, MS

. Distalization of Molars inNonextraction Cases . . . . . . . . . .

Guiseppe Scuzzo, MD, DDS,Maurizio Cannavo, MD

. Interproximal Enamel Reductionin Lingual Orthodontics . . . . . . .

Didier Fillion, DDS

. Sliding Mechanics versus Loop Mechanics During En MasseRetraction in Extraction Cases . .

Kyoto Takemoto, DDS

. Case Presentation: Loop Mechanics . . . . . . . . . . . . Guiseppe Scuzzo, MD, DDS

. Case Presentation: Sliding Mechanics . . . . . . . . . . .

J. Courtney Gorman, DDS, MS

Lingual Orthodontics in Pediatric Patients. . . . . . . . . . . .

Lorenzo Favero, MD, DDS, MSc

. The Lingual Technique in Orthognathic Surgery . . . . . . . .

Alessandro Silvestri, MD, DDS, ENT

. Orthodontic-Surgical RPECamouflage on an Orthognathic Case . . . . . . . . . . . . . . . . . . . . .

Mario E. Paz, DDS, MS

. Segmental Lingual Orthodontics in Multidisciplinary Cases . . . . .

Pablo A. Echarri, DDS

. Combined Orthodontic-ProstheticTreatment of MalpositionedAnterior Teeth. . . . . . . . . . . . . .

Rafi Romano, DMD, MSc,Nitzan Bichacho, DMD

Lingual Orthodontics:Esthetics and Function . . . . . . . .

Chiori Hashiba, DDS, PhD

SECTION 4

Laboratory Procedures The Customized Lingual

Appliance Set-Up Service (CLASS) System . . . . . . . . . . . . .

Scott A. Huge

The Thickness Measurement System with the DALI Program . . .

Didier Fillion, DDS

Lingual Treatment with the Bending Art System . . . . . . . . . . .

Paul-Georg Jost-Brinkmann, DMD, PhD,Vittorio Cacciafesta, DDS,Friedrich Riemeier

SECTION 5

AppendixBibliography . . . . . . . . . . . . . . . .

Index. . . . . . . . . . . . . . . . . . . . . .

The Preface to Lingual Orthodontics (LO) should have been actually called: “A shortexplanation 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 ItalianAssociation 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 continuedto treat patients with LO during this period, we are now again in a situation charac-terized by a lack of knowledge in the dental community and among the public. Thetechnique of lingual orthodontics, which is the only option we can give to those patientswho want their orthodontic treatment to be done behind closed curtains, was reallyleft 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 existsas well as tremendous experience that was gained in the field in the last 15 years. Muchof 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. Allof 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 LOto 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 canbe distressing to the patient.

• The addition of training in lingual orthodontics to the graduate or postgrad-uate orthodontic programs in the universities around the world.

• Reduction of the high fees by improvements in design and technique 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 ofmy patients come from Japan, USA, and Europe, and they expect each orthodontistto have the same knowledge and skills as his or her colleagues. Easy, rapid communi-cation tools exist and should be used to teach, to inform, and to unite. Teaching 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.

I hope that Lingual Orthodontics will become towards the year 2000 an essentialpart 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, especiallyDr. 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 tomy father, Dr. Albert Romano.

Rafi Romano, DMD, MSc

Lingual Orthodontics:Historical Perspective . . . . . . . . . . Craven Kurz and Rafi Romano

Present Clinical Reality. . . . . . . .

Massimo Ronchin

Lingual Orthodontics in aLabial Orthodontics Office . . . . .

Courtney Gorman

SECTION 1

Introduction

Lingual Orthodontics:Historical PerspectiveCRAVEN KURZ, DDS, PhD, AND RAFI ROMANO, DMD, MSc

The 1970s was an exciting decade for orthodontics. The straight wire appliance wasdeveloped, treatment demands had increased, and adults were seeking treatment ingreater numbers. This increasing demand for adult treatment brought unique con-cerns to the profession. Esthetics was then and continues to be a primary concern ofpatients. To address these esthetic concerns, manufacturers introduced clear plasticbrackets; unfortunately, however, staining of the bracket and the tooth presented a significant problem. The search for improved esthetic alternatives to metal or clearplastic brackets continued.

During the early 1970s, Dr. Craven Kurz, an orthodontist, then assistant professorof 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 applianceson esthetic grounds. From her demand for an appliance that did not show, the con-cept of a lingually bonded appliance was born.

After much advice and consultation from orthodontic colleagues, particularly Dr. Jim Mulick, also at the UCLA School of Dentistry, Dr. Kurz developed the firsttrue lingual appliance. The appliance consisted of plastic Lee Fisher brackets bondedto 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 thepatient swallowed (approximately 2000 times per day).

- . Dr. Kurz 1973–1975 labial appliance modified for lingual application.

- . The incline plane.

Lingual Orthodontics: Historical Perspective

Bond failures decreased dramatically. Redirecting the forces by the use of an ante-rior inclined plane appeared to be the missing link in the development of a viable lin-gual appliance. It was with this design that Dr. Kurz applied for a patent for the KurzLingual Appliance on November 15, 1976. Product development began in earnest in1978, and Ormco manufactured a usable metal bracket by 1979. Initial clinical test-ing began in Dr. Kurz’s private office, with approximately 100 cases tested over a three-year period. All appliances were direct bonded, and a treatment protocol was estab-lished. From the initial testing, the appliance appeared to be viable and showed 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

- . 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 wasto 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


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 addedto the European task force. The European doctors insisted on seeing finished cases. In1983, 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 FrançaisOrthodontie Linguale (SFOL, or French Orthodontic Society for Lingual Orthodontics).

In 1987, at the American Association of Orthodontists’ annual meeting inMontreal, 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 effectof 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 by1988, 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.


1. The lingual appliance had been made available to the public before testing was complete.

2. Orthodontists inadequately trained with lingual therapy were treating patientsin record numbers.

3. The public had high expectations from this treatment and demanded it from the profession immediately.

A solution was to have smaller classes taught by more experienced lingual practi-tioners. Longer courses were developed with a typodont (hands-on) component, andcontinuing education was stressed, with support provided by study clubs, journals,and professional meetings.

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

Today, lingual orthodontics has a small but strong following in the United States,Europe, and Asia. The ALOA is active again, after few years of silence, with 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 DifficultiesThe 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 longgingival hooks responsible for calculus build-up.

redesigned with smooth exterior surfaces and a low profile. The increased comfortallows normal tongue activity, hence speech is not affected significantly.

2. Gingival ImpingementEarlier generations of the lingual appliance had a broad bonding base extendingtowards the gingival margin (Figure 1–12). Access for adequate oral hygiene and theself-cleansing nature of the oral cavity were compromised. Brackets have beenredesigned 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).

3. Occlusal InterferenceA predominant problem with the original appliance was the effect of the shearingforces on the brackets, particularly in the maxillary anterior dentition. (In the absenceof a cross-bite, the lingual aspect of the mandibular dentition is generally not in direct contact with the maxillary dentition; therefore, the shearing forces were not a problem(Figure 1–14). Likewise, the relatively high maxillary crown height and low mandibularcusp height in the posterior segments allow adequate clearance to avoid the severeshearing forces seen in the maxillary anterior region.) The bracket was redesigned withan 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.


4. Appliance ControlSince 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 AdaptationAs 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 BondingThe original appliances were direct bonded. With the variability of lingual tooth con-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.

7. Appliance PrescriptionIn 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 arrowsrepresent the primary force applied, and the broken

black lines represent the secondary/resultant forces exerted.


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 wasthought 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 PlacementAccess 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.


9. LigationTo 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. AttachmentsA 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 ProgressGENERATION #1—1976The 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 wereno hooks on any brackets.

GENERATION #2—1980Hooks were added to all canine brackets (Figure 1–22).

GENERATION #3—1981Hooks were added to all anterior and premolar brackets. The first molar had a bracketwith an internal hook. The second molar had a terminal sheath without a hook buthad a terminal recess for elastic traction (Figure 1–23).

- . Generation #1—1976. Flat maxillary occlusal bite plane from canine to canine.

GENERATION #4—1982–84This generation saw the addition of a low profile anterior inclined plane on the cen-tral and lateral incisor brackets. Hooks were optional, based upon individual treat-ment needs and hygiene concerns (Figure 1–24 and 25).

GENERATION #5—1985–86The anterior inclined plane became more pronounced, with an increase in labial torquein 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 wereadded to all anterior and premolar brackets.

- . Generation #2—1980. Hooks were added to all canine brackets.


GENERATION #6—1987–90The inclined plane on the maxillary anteriors become more square in shape (Figures1–29 and 30). Hooks on the anteriors and premolars were elongated. Hooks werenow available for all the brackets. The transpalatal bar attachment for the first molarband was optional. A hinge cap, allowing ease of archwire manipulation, was nowavailable for molar brackets.

- . Generation #4—1982–84. Additional of a low profile anterior inclined plane on the central and lateral incisors. Hooks were optional.

- . Generation #5—1985–86. The anterior inclined plane was more pronounced,

Upper Central

Torque: +68°Angulation: +5°Rotation: 0In–Out: 0Slot size: .018Pad: Special lingual design

Upper Cuspid

Torque: +55°Angulation: +12°Rotation: 0In–Out: .010Slot size: .018Pad: Special lingual design

GENERATION #7—1990 TO PRESENT

The maxillary anterior inclined plane is now heart-shaped with short hooks. Thelower anterior brackets have a larger inclined plane with short hooks. All hooks have a greater recess/access for ligation. The premolar brackets were widened mesiodistallyand the hooks were shortened. The increased width of the premolar bracket allowsbetter angulation and rotation control. The molar brackets now come with either ahinge cap or a terminal sheath (Figures 1–31 and 32).

- . Generation #5—1985–86. A transpalatal bar attachmentwas 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 slotfor archwire

Bracketslot for archwireBracket

Bracket


BibliographyAlexander RG. Lingual orthodontics. In: The Alexander Discipline. Ormco Corporation, 1986;

13:371–430.

Andrews LF. The straight wire appliance: syllabus of physiology and techniques. 2nd Ed., USA,1975.

Fillion D. Orthodontie linguale et Mini-Plaques, esthetique et confort dans les traitments chirur-gio-orthodontiques. L`Information Dentaire n 20 du 17 mai 1990.

Gorman JC. Treatment with lingual appliance: the alternative for adult patients. Int J AdultOrthod 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 Orthod1986;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.3 This 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 unat-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.

Advantages and Disadvantages of Lingual TherapyOne of the most significant drawbacks to lingual therapy appears to be the discomfortto the tongue, and with it, difficulty in speech, both of which usually improve after 2to 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 RealityMASSIMO RONCHIN, MD, DDS

nathic system is maintained. Clinical judgment of treatment progress can beenhanced. Evaluation of individual tooth positions can be easily accomplished by hav-ing the labial surfaces free of distracting metal or plastic brackets. Soft tissue responsesof the lips and cheeks to treatment can be judged accurately because there is no distor-tion of shape or irritation caused by a labial appliance.

Four distinct situations exist where lingual appliances may be more effective 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 surfaceof the tooth, places the bracket closer to the center of resistance of the tooth than isfound with labial bracket placement (Figure 2–1).10 An important clinical implicationof this unique bracket position and design is that the intrusive force vector is directed

-. The center of resistance of the tooth islocated closer to the lingual bracket.

Present Clinical Reality

through the center of resistance of the tooth. As the mandibular anterior dentitionoccludes with the anterior horizontal plane of the maxillary anterior brackets, a biteplane 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 theseactive intrusive forces on the anterior dentition, a passive extrusion occurs in the pos-terior segments. Deep-bite correction through this passive increase in posterior verticaldimension and active decrease in anterior vertical dimension occurs quickly and easily.Malocclusions requiring open-bite correction obviously would not benefit from thistechnique. 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 askeletal 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 extremeClass II relationship on that side (Figure 2–2a). Partial lingual appliances were placedin 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 ExpansionWith 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.


Some possible reasons are:

1. The force which is developed is of a centrifugal type, from the inside towardsthe 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 interposethemselves between the tongue and the lingual wall of the teeth, can con-tribute to this expansive effect.7–9

3. It is even likely that the shorter interbracket distance may play a significantrole in this effect.5

In fact, by using this method, not only is the expansive effect so evident but alsothe teeth do not become too labially tipped.10 The tooth movement probably takesplace 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 anteriorcross-bite of several mandibular teeth, upper arch contraction, and a total lack ofspace 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 nonextractiontreatment. The lower arch was treated with extraction of the first molars to gain morespace to solve the crowding and to achieve more successful intercuspation. The upperthird molars would subsequently be extracted (Figures 2–3d and e). Lingual braceswere 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 placingthe 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.


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 withOrthodontic MovementsWhen 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.12–14 Figures 2–6

- . Frontal, right, and left intraoral photos, before treatment.

-. Frontal view of the occlusion, with the upper splint.The midlines are centered, and the mandible is slightly advanced.


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 ofpast orthodontic extraction treatment. She had an early reciprocal clicking in the leftTMJ and also suffered from muscular hyperactivity. Both the right and the left massetermuscles and the anterior belly of the left temporal muscle felt tender to palpation. Shehad mild to moderate anterior crowding, a Class I canine and molar relationship onthe 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 fabricatedand worn until her TMD symptoms disappeared (Figure 2–6d) and she was main-tained symptom free for four months before orthodontic treatment was initiated. Thelower 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 sizerectangular 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 (Figure2–6f ). 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 movementof the buccal roots takes place very easily.

-. The distal movement takes place quite bodily; onlylater 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.


months after debonding. The patient remained symptom free. This is an interestingaspect of lingual appliance therapy that warrants consideration.

4. Distalization of Maxillary MolarsLingual brackets are placed closer to the center of rotation (CR) of the tooth thanlabial brackets. It is possible that molar distalization through lingual techniques pro-

-. Profile view before treatment.

-. Frontal view of the malocclusion before treatment. -. A round archwire is initially used in the upper arch.

- . The anterior bite effect of the lingual braces and the acrylic posterior minisupports.

duce more bodily movement of the tooth and less distal tipping. Because of the angu-lation of the multiple roots of maxillary molars, the center of resistance is found 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.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 buc-cal and lingual aspects (Figure 2–9b). The balance of these forces counteracts the rota-tional forces.

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


malocclusion with a slight anterior crowding (Figure 2–10b). At first, only the maxil-lary arch was lingually bonded, with the purposes of alleviating the crowding, intrud-ing the anterior group, and expanding the maxillary arch (Figure 2–10c). Some poste-rior acrylic minisupports are noticeable in the intraoral lateral photographs (Figures2–10d and e). As previously described, these supports tripodize the occlusion throughan anterior contact on the brackets and through posterior contacts on the flat elevationsand produce an anterior mandibular displacement during the use of Class II elastics.In addition, this distribution of the occlusal load is comfortable for the patient. Afterhaving banded the lower arch, Class II mechanics was applied (Figure 2–10f ). In theupper arch, a lingual archwire can be used (Figure 2–11). In Figure 2–12 we see aremarkable improvement in the patient’s profile at the end of treatment. Her chinlooks more advanced and her lips are more harmonious. We successfully obtained afull Class I occlusal relationship and the anterior deep bite was corrected (Figure 2–13).

In today’s clinical orthodontic practice, the lingual appliance can offer manyadvantages over the labial appliance to both the patient and the practitioner. Enamelsurfaces are protected, some treatments (such as deep bite correction) can occur faster,molar distalization appears to take place more efficiently, and TMD patients can pro-ceed with orthodontic treatment in a timely manner.

References1. Alexander CM, Alexander RG, Gorman JR. Lingual orthodontics: a status report, part 1.

J Clin Orthod 1982;16:255–262.

2. Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report, part 6:patient and practice management. J Clin Orthod 1983;17:240–246.

3. Breece G, Nieberg L. Motivations for adult orthodontic treatment. J Clin Orthod 1986;3:166–171.

4. Bercheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119–131.

5. Fujita K. New orthodontic treatment with lingual brackets and mushroom arch wire appli-ance. Am J Orthod 1979;76:657–675.

6. Genone B, Siciliani G. Trattamenti ortodontici a collocazione linguale. Mondo Ortodontico1984;3:14–27.

7. Gorman JR, Hilgers JJ, Smith JR. Lingual orthodontics: a status report, part 4: diagnosis andtreatment planning. J Clin Orthod 1983;17:26–35.

-. The occlusal result.

8. Kelly VM. Interviews on lingual orthodontics. J Clin Orthod 1982;16:461–476.

9. Kurz C, Gorman JR. Lingual orthodontics: a status report, part 7: case report. J Clin Orthod1983;17:310–331.

10. Nidoli G. Lingual technique under the biomechanical and aesthetical point of view.Proceedings and abstracts: I. Congress of the European Society of Lingual Orthodontics, Lido di Venezia, June 18–20, 1993.

11. Ronchin M, Oddini Carboni S, Dessi S. Nuovi Orizzonti terapeutici con la biomeccanica lin-guale. Proceedings of the V Giornate Mediterranee di Odontoiatria, Naples, February 26–28,1983.

12. Ronchin M. Present horizons and a future outlook on lingual approach. Proceedings andAbstracts: First Congress of the European Society of Lingual Orthodontics, Lido di Venezia,June 18–20, 1993.

13. Ronchin M. Aesthetics with lingual orthodontics: resolving class II malocclusions with molardistalisation. Pract Perio Aesthet Dent 1994;6:51–58.

14. Siciliani G. Ortodonzia Linguale. Milano, Italy: Masson. 1992.

Lingual orthodontics is a viable option in a modern orthodontic practice. In 1979,when Drs. Kurz and Fujita first began experimenting, appliances and techniques werein their infancy. Today, modern, well-developed appliances, laboratory procedures, andtreatment mechanics are available. Doctors have the ability to include lingual appli-ances in the treatment plans of their patients, and assure exceptional results with con-fidence. Problems like prolonged treatment times and compromised results are similarto those with treatment with labial appliances by an experienced practitioner and, aswith any technique, can be overcome with an accumulation of experience.

Today’s practitioner must find a way to treat his lingual patients without disrupt-ing his practice. In fact, these lingual patients should enhance an already thrivingpractice and revive a dwindling one. The article will provide a clear and precise expla-nation of how we practice lingual orthodontics in our office, how lingual patientsaffect the practice of labial orthodontics, and what one can do to avoid problems dur-ing his early lingual experience.

The Clinical Experience All patients are treated the same way during their initial examination. After viewing a video tape which has been mailed to them prior to the first appointment, patientsarrive at the office with some of their questions already answered and a familiaritywith our office and procedures. The appropriate forms are then completed, a high-quality panoramic radiograph is taken and developed, and intraoral and extraoralvideo images are captured. The patient is then invited to the consultation room.

Meanwhile, a preliminary diagnosis is made using the radiograph, and the videoimages. Different treatment options are considered including extractions, orthosurgery,and labial or lingual treatment. All the mechanical advantages of lingual treatment (intreating deep-bites, cross-bites, and expansion), and disadvantages (in treating open-bites or high angle cases) are carefully evaluated for that specific clinical case.

After the preliminary diagnosis is made, the clinician enters the consultation roomwhere all the clinical, radiographic, and visual aids are prepared. If lingual appliancetreatment is one of the options and the patient wants to be treated this way, a separateappointment is made to complete the records. An extra set of impressions is made andpoured immediately in a pink stone. A face bow transfer is also made so the modelscan be properly mounted. Using all records, the diagnosis and treatment plan arefinalized. The proper laboratory prescription for the appliances is prepared, and twoweeks later the patient is scheduled for the initial bonding. During the two weeks fol-lowing the impressions, it is critical that no tooth movement takes place as this would

Lingual Orthodontics in aLabial Orthodontics OfficeJ. COURTNEY GORMAN, DDS, MS

ruin the accuracy of the indirect bonding. This means no separators, no extractions, andno heavy cleaning. The last item should have been accomplished prior to the impres-sions, and the first two items should be completed after the initial bracket placement.

Appliance PlacementThe bonding procedure for the initial bracket placement is as follows:

1. Paint all of the brackets with the bracket-side portion of the bonding adhesive.2. Microetch the lingual surface of all teeth to be bonded.3. Isolate one-third of the dental arch. (Some clinicians may prefer to bond the

entire arch simultaneously.)4. Acid etch the teeth for 20 to 30 seconds.5. Rinse each tooth for 20 seconds.6. Dry the teeth with an air syringe. At the same time use a hair dryer to displace

the moisture from the breath.7. Paint the teeth with the tooth-side portion of the adhesive.8. Reapply the bracket-side portion of the adhesive.9. Fully and firmly seat the bonding tray and hold in place for one minute.10. Repeat procedures 3 to 9 for the remaining segments.11. Remove the hard shells of the bonding trays.12. Using a sharp scaler, remove the soft undertrays.

After the bonding procedure is complete and before removal of the isolation, eachbracket is checked by pulling on it with an elastic. If there is a failure, cut the sectionof the tray from which that bracket came into a single-tooth tray, discard the hardshell and place the bracket back into the single-tooth soft tray, microetch the bracketand tooth, reapply bracket side adhesive to the bracket, acid etch the tooth, rinse thetooth, reapply tooth side adhesive, reapply the bracket side adhesive, seat the tray,hold for two minutes and then remove the tray. It is advisable to retain the soft traysfor any future repairs. In cases with a porcelain jacket crown, the crown should beconditioned with a porcelain etchant for four minutes and then rinsed. Apply somenormal etchant to the crown and blow off the excess followed by the silane primer (it is important not to skip the etch as the acid activates the silane). Now apply theadhesive bond to the bracket and bond it to the crown.

Before placing the initial archwires, the clinician must first determine which teethare to be engaged. Elastic chains are placed over the brackets on each of those teeth.The chain is precut into two- or three-unit sections. Then, using a hemostat, it isstretched over the brackets with the extra lumen pointing towards the gingiva. Theinitial wires are then bent using a 1:1 photograph of the original malocclusion as aguide. In most cases this wire will be a .0175 Respond wire (Ormco). When the propershape and length have been achieved, the distal ends are slid into the hinge caps ortubes. The wire is then engaged into one of the anterior brackets, and the chain ispulled back over the bracket so that a single lumen now encircles the archwire, form-ing the double over-tie. Now with the wire stabilized, the rest of the brackets can beengaged and the distal ends trimmed.

The patient is instructed how to care for their appliances and instructed on theuse of wax to prevent ulceration of the tongue. At this time it is important to encouragethe patient and assure him or her that the function and speech will return to normal.

Lingual Orthodontics in a Labial Orthodontics Office

The patient is then reappointed for a 40-minute visit approximately eight weeks later.If there are teeth to be banded, wire separators are placed before the patient is dis-missed and is reappointed one week later for the banding.

Forty-minute appointments are scheduled during the course of treatment for wirechanges, adjustments, or single-tooth bonding or banding. Changes of power productsor checks of elastic wear are scheduled for 20-minute appointments. At each appoint-ment the assistant first checks the patient for any loose or broken appliances. If thereare none, she proceeds with the removal of the archwire to be adjusted or replaced.This information should be noted in the chart and the doctor can now examine andconfirm the treatment noted in the chart. If any changes are to be made they can beinitiated now. Any adjustments to the wire can also be made at this time. The assistantthen reinserts the archwire (usually only one wire is adjusted during a single appoint-ment) and applies any necessary power products.

Treatment Sequences (Extraction and Nonextraction)After the appliances have been placed, the initial archwires are added. These are typi-cally .0175 Respond (Ormco) arches. In nonextraction cases, the wire will engage allthe posterior teeth; in extraction treatment, it will form a sectional arch engaging onlythose brackets anterior to the extraction sight. Minimal movement is expected fromthese first wires. Their main purpose is to fill the space while the patient becomesaccustomed to the new appliances.

In nonextraction cases with crowding, the second arch is .016 TMA (Ormco)wires with advancement loops (U-shaped loops which are compressed when fullyengaged) anterior to the first or second molars. These wires use the energy stored inthe compressed loops to expand the arch in an anterior direction. Full engagement ofthe teeth can take place after sufficient space has been created. At this point rotationscan be corrected. After initial leveling and correction of rotations, a square or rectan-gular wire is used to continue the leveling process and to torque any teeth in need.The wire of choice is usually a .0175 × .0175 TMA (Ormco). This wire enables fullengagement of all brackets to complete the leveling and establish necessary torque.

In simple nonextraction treatment in which the patient maintains a Class I buccalsegment, this wire can be the final archwire. In cases requiring elastics, the squareTMA archwire should be followed by a .017 × .025 stainless steel archwire withtiebacks in the mandible to ensure arch stability during elastic use. In the maxilla, a.016 × .022 stainless steel archwire with a Curve of Spee is usually adequate to main-tain arch integrity. After a Class I occlusion has been achieved, the patient is ready forfinal detailing which can be done with a .016 stainless steel archwire.

In extraction treatment, the second arch is also a .016 TMA but without advance-ment loops. Once again, only those teeth readily engaged are ligated. After initialalignment, the TMA wire is removed, and a .016 × .022 stainless steel wire is bentand placed in the mouth, engaging as many brackets as possible. The posterior seg-ments are figure-eighted together using a steel ligature. Wire ligations are used on thecuspids, and a power tube is tied in a figure-eight from the cuspids to the secondbicuspids. The cuspids are retracted until adequate space is available to completelyalign the anterior segment. At this time, it is important to avoid complete retractionof the cuspids as this will interfere with en masse retraction of the anterior segment.After initial cuspid retraction, the original .016 TMA arch is replaced, and all brackets

are fully engaged. This wire is used in conjunction with rotation ties until all rotationshave been corrected. To develop torque and to continue leveling, a .0175 × .0175TMA is placed. In the maxilla, it is common to follow this wire with a .017 × .025TMA to achieve adequate torque.

When the dentition is fully leveled and aligned space closure is begun, .016 × .022stainless steel archwires with a Curve of Spee in the maxilla arch and a reverse curve inthe mandibular arch are used. The anterior segments are figure-eighted together usinga steel ligature. Power tubes and power chains are then placed from cuspid to secondbicuspid to supply the necessary force for space closure (sliding mechanics). It isimportant to figure-eight the segments so the power products can be used over theshortest possible distance. Failure to do so can result in unwanted bowing of the dentalarches in both the vertical and horizontal planes. Once all of the space has been closed,the patient can be prepared for elastics by placing a .017 × .025 stainless steel archwirewith omega tiebacks in the mandible. In the maxillary arch, figure-eight and powerproducts can be removed and brass electrodes soldered to the wire to act as tiebacks.

When a Class I occlusion has been achieved, .016 stainless steel finishing archescan be placed. These wires should also have some type of tieback to ensure that nospaces reopen. If the buccal segments do not have maximum interdigitation at thispoint, a tooth positioner can be utilized. While a tooth positioner is very effective for“socking in” an occlusion, they are inadequate to complete space closure or for correc-tions of anterior positions. Four weeks after the delivery of the positioner, impressionsfor retainers are made. Clear overlay retainers are used. They are excellent for retainingalignment and provide exceptional esthetics.

Practice Promotion Lingual appliances give the orthodontist a distinct competitive advantage. There aremany individuals who need and desire orthodontic treatment but are not willing towear conventional appliances. Many of these patients have gone for years hiding theirsmiles and neglecting their oral health. By offering them treatment with lingual appli-ances, the orthodontist provides a valuable and unique service. Many lingual patientsare high-profile individuals. While they are willing to pay a premium for their lingualbraces that others cannot see, they also openly discuss their treatment with theirfriends, colleagues, relatives, and sometimes even strangers. They can become greatreferral sources and goodwill emissaries for your practice. Referring dentists will alsoappreciate that you are able to provide their patients with a service that the otherorthodontists cannot. They will be more likely to refer more of their patients to a fullservice orthodontist.

Before the practice benefits from these and other advantages that lingual ortho-dontics brings, it is important that the staff and the orthodontist feel confident andcomfortable with the lingual technique. The first step is to attend a completetypodont course during which a step-by-step method to treat lingual cases is taught.Once the orthodontist and his staff have achieved a high level of clinical proficiency,the lingual patients can be incorporated into the normal schedule. They can be treatedside by side with the labial patients. Other than allowing adequate time, there are noother special requirements for these patients.

Lingual Orthodontics in a Labial Orthodontics Office

ConclusionLingual braces have been and are a viable treatment option. With these appliances thepractitioner can achieve excellent results while providing his or her patients with aunique and valuable service. To successfully incorporate lingual patients into a labialpractice the doctor and staff must develop the skills to successfully treat these patients.Then the treatment must be presented in such a way that the prospective patient willbe receptive. This includes having models with lingual braces, having a treatmentcoordinator who believes in the treatment, and encouraging patients when lingualappliances are the better option. Having appropriate fees is also important to yourpractice. Lingual patients require approximately 25% more chairtime for the sametreatment. Thus, a premium should be added to the usual fee. We add approximately27% for the first arch and an additional 20% for the second arch. In this way boththe additional laboratory expense and chairtime are covered. If the practitioner willmake the commitment to make lingual orthodontics a part of his or her practice, thepractice will grow.

Enhanced Facial Estheticsusing Kurz Lingual Appliance . .

Craven Kurz

Advanced Lingual Prescription:Technique and Design . . . . . . .

Robert Baker Jr.

. Shape Memory Wires in Lingual Orthodontics . . . . . . . .

Christian Demange

. Wire Sequencing inLingual Orthodontics . . . . . . . . .

H. Stuart McCrostie

Instruments Used inLingual Orthodontics . . . . . . . . .

Craven Kurz

SECTION 2

Basic Principles

A primary reason a patient seeks orthodontic treatment is to improve facial esthetics(Figure 4–1). A lingual appliance and bite plane may be used specifically to achievethis goal. The success of the orthodontic treatment is directly related to how attractivethe patients find themselves after treatment, especially since the vast majority of lingualorthodontic patients are in careers that involve a public image. The traditional cephalo-metric models leave much to be desired as a direction to follow to obtain facial beauty.Studies of contemporary fashion models, movie stars, and beauty contest winners indi-cate that a much fuller profile than the conventional 1900s ideals is more popularwith today’s public. Face studies made by Sassouni indicate that facial beauty is relatedto protrusive faces with a straight line relationship between the maxilla and mandiblein well-balanced faces. Articles by Liddle, Luzi, Eirew, McNamara, and Moyersdemonstrate that the maxilla is usually in the proper A-P position in the skull and inharmony with its biological environment. It rarely protrudes in any malocclusion,regardless of how much the dental overjet is. Thus, the use of backward-pulling head-gear of Class II elastics and/or bicuspid extractions would result in poor esthetics ifused to try to fit a normal maxilla to a retruded mandible.

Bite PlaneAn upfront, full smile always attracts attention. Dr. Grant Bowbeer had found that a bite plane in combination with labial orthodontic appliances helps to expand the

Enhanced Facial Estheticsusing Kurz Lingual ApplianceCRAVEN KURZ, DDS, PhD

-. Michelangelo’s faces in balance with today’s contemporarybeauty analysis.

maxilla and consequently, to achieve an esthetic occlusion. The inclined plane in theupper incisor lingual brackets was designed for the purpose of avoiding shearing forcesand subsequent debonding of the maxillary brackets. However, if used properly, it canalso achieve correct positioning of anterior teeth in the optimal esthetic A-P and lateralpositions.

The esthetic advantages of the bite plane are:

1. It can be used as a functional appliance to facilitate the unlocking of a retrudedmandible.

2. It can help expand the arch. This is a clinical observation and the possibleexplanations are elimination of posterior contacts or decrease in the lateralspace in the palatal vault (Figures 4–2a to c).

3. It helps extrusion of posterior segments and intrusion of lower incisors in deepbite cases, giving the lower lip better support from the lower incisor and bal-ance with the maxillary lip in closure (Figures 4–3a and b).

4. Easier translation of teeth around the arch when the midline is off centereddue to the smooth contact with the flat metal plate on the incisor brackets.

- . Maxillary arch expansion: occlusal view before, during, and after lingual treatment. Note wide horseshoe arch.

Enhanced Facial Esthetics using Kurz Lingual Appliance

BibliographyBowbeer GRN. The five keys to facial beauty and TMJ health. The Functional Orthodontist 1985;

2:12–29.

Eirew HL. An orthodontic challenge. Int J Orthod 1976;14:21–25.

Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 1977;72:599–616.

Luzi V. The CV value (combines variation) in the analysis of sagittal malocclusions. Am J Orthod1982;81:478–480.

McNamara JC. Components of Class II malocclusion in children 8–10 years of age. AngleOrthodontists, 1981;51:177–202.

Moyers et al. Differential diagnosis of Class II malocclusions. Am J Orthod 1980;78:477–494.

- . Extrusion of posterior segments and intrusion of lower incisors in deep bite case: occlusal view before and during lingual treatment.

Lingual orthodontics in the 21st century will involve several new innovations, includ-ing new players in the treatment field, new appliances and auxiliaries, and enhancedlaboratory techniques, design, and communication. Still, the most important aspect ofany labial, lingual removable or functional orthodontic treatment system is, of course,the thought process of the orthodontist. As all well-trained orthodontists know, anysingle orthodontic treatment system can work to move teeth, manage growth, or gainspace; however, even the best system that is poorly thought out and does not use sound scientific principles can face failure.

In the 20 years since the original lingual appliance was invented, we have beenthrough seven generations of the original Ormco bracket and approximately a dozenother bracket designs from other companies. By necessity, treatment mechanics havebeen tailored to the available bracket systems. Many treatment philosophies are influ-enced by edgewise mechanics, Begg and Bioprogressive systems, and the straight wiresystem, after which the original bracket was designed. The individual orthodontist musttake responsibility for his or her treatment.

One of the main problems that lingual orthodontists have to overcome is to notoverstandardize treatment plans. Although standardization sometimes can be of someadvantage in streamlining a practice and allowing orthodontists to keep supplies, staff,and treatment well-coordinated, treatments should stay very case specific with an indi-vidual treatment modality for each patient. “Cookbook” orthodontics, especially forlingual treatment, has never worked. A thorough, individual treatment plan must beformulated, and the type of mechanics to be used must be selected from the verybeginning of treatment. This involves a tooth-by-tooth, individual prescription thatanticipates all positive and negative reactions to the type of biomechanics that theorthodontist will be using. To achieve such accuracy, a lingual orthodontist must haveintimate knowledge of individual bracket positions over the center of resistance ofeach specific tooth and the knowledge of how that will either expedite or impedetreatment goals. This will enhance treatment planning and case progress. Eventually,treatment time and chairtime can be significantly reduced, and patient comfort andsatisfaction can be greatly increased.

Anchorage must be carefully prepared and developed, using the Tweed method orothers. Parisi (1989) proved that anchorage was enhanced from the lingual aspect whencompared to the use of standard direct-bonded labial edgewise appliances without theuse of extra anchorage auxiliaries.

Factors like anatomical variation of teeth and functional habits like masticationand swallowing should be taken into account while planning the correct placement of

Advanced Lingual Prescription:Technique and DesignROBERT BAKER JR., DMD

the lingual brackets. The biomechanics of choice must be carefully selected. For example, if an orthodontist is using loop mechanics, continuous arch mechanics, orsectional mechanics to retract teeth into an extraction space, the laboratory setupcould be different for each retraction method due to the differing effects on the teethand underlying bone. One of the advantages of advanced laboratory case design andtechnique is the virtual elimination of appliance auxiliaries like rotation ties or double over-ties.

Case PresentationsThe following cases demonstrate diagnosis and the establishment of treatment goalsthrough selective individual tooth prescriptions, using the CLASS System design forindirect bonding preparation.

- . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, anterior open bite, and crowding.

Advanced Lingual Prescription: Technique and Design

CASE 1: D.P.A 31-year-old male presented with a Class I malocclusion, anterior open bite, and mildupper and lower crowding (Figures 5–1a to e). The cephalometric and panoramic x-rayrevealed no unusual findings. The treatment plan consisted of placing upper and lowerlingual appliances to level and align the occlusion. The crowding was to be resolvedusing a nonextraction approach with air rotor stripping on the upper and lower firstpremolars. The prescription for the laboratory (specialty appliance) was made as follows:

Patient Name DPCase description Air Rotor Stripping (ARS) on upper and lower premolarsAppliance Upper and lower .018 Ormco lingual bracketsPrescription Upper arch: (right=RT; left=LT)

RT 1 2 deg. distolingual rotation, 10 deg lingual crown torqueLT 1 3 deg. mesiolingual rotation, 10 deg lingual crown torqueRT & LT 2 8 deg. lingual crown torqueRT & LT 4 –0.75 mm ARS mesial & distalRT 6 3 deg. distobuccal rotationLT 6 5 deg. distobuccal rotationRT & LT 7 5 deg. mesial crown tip, Hinge Cap attachments

Lower arch: (right=RT; left=LT)RT & LT 2 2 deg. mesiolingual rotationRT & LT 3 3 deg. mesiolingual rotationRT & LT 4 –0.75 mm ARS mesial & distal

- . Frontal and lateral views during treatment.

Upper and lower lingual appliances were bonded (Ormco, generation #7, .018slot) (Figures 5–2a and b). Treatment time was only 12 months, with 14 visits to theEastman Dental Center. No auxiliaries were used. The results show a balanced andesthetic occlusion (Figures 5–3a to e).

- . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.

- . During treatment: upper and lower occlusal view of lingual appliance.


CASE 2: A.M.C.A 31-year-old female presented with a Class I malocclusion, mild upper and lowercrowding, and upper right dental midline shift. The upper right lateral incisor wasseverely rotated distobuccally. (Figures 5–4a to e). The cephalometric and panoramic x-ray revealed no unusual findings. The treatment plan consisted of extracting themaxillary right first premolar to alleviate crowding and aid in the midline correction.The occlusal plane was to be leveled. Continuous arch mechanics were to be used forextraction space closure. The prescription for the laboratory (specialty appliance) wasmade as follows:

Patient Name AMCCase description Extraction upper right 4. Retraction with continuous arch mechanicsAppliance Upper .018 Ormco lingual brackets, lower .022 Ormco labial bracketsPrescription Upper arch: (right=RT; left=LT)

RT 7 Add 14 deg. mesial root tip, add 6 deg. buccal root torqueRT 6 18 deg. mesiobuccal rotation, 6 deg. buccal root torque,

add 18 deg. mesial root tip

- . At initial orthodontic examination: frontal, lateral, and occlusal views of the occlusion. Note the unesthetic smile, rotated upper right lateral incisor, and midline shift.

RT 5 4 deg. mesiobuccal rotation, 15 deg. mesial root tipRT 3 8 deg. mesiolingual rotation, add 12 deg. distal root tipRT 2 12 deg. lingual root torque, 5 deg. distal root tipRT 1 Add 2 deg. distal root tip, 11 deg. lingual root torqueLT 1 11 deg. lingual root torque, 8 deg. mesial root tip, intrude 1 mmLT 2 6 deg. mesiobuccal rotation, 10 deg. lingual root torqueLT 3 6 deg. mesiobuccal rotationLT 5 9 deg. mesiobuccal rotationLT 6 12 deg. mesiobuccal rotationRT & LT 7 Please use Hinge Caps.

The appliances chosen consisted of maxillary lingual brackets (Ormco, .018) andmandibular labial appliances (Ormco, .018 Spirit) (Figures 5–5a to b). Treatment time

- . During treatment: occlusal views of the upper lingual appliance and lower transparent labial appliance.

- . Frontal and lateral views during treatment.


- . At completion of orthodontic treatment: frontal, lateral, and occlusal views of the occlusion. Note the balanced and esthetic occlusion.

was 18 months, with 18 visits. No auxiliaries or wire bending was needed during thetreatment and chairtime was the same as with a full labial appliance. The end resultsshow a balanced and esthetic occlusion (Figures 5–6a to e).

These cases demonstrate the use of goal-oriented diagnosis, individualized bracketprescriptions, and specific mechanics to provide more efficient treatment with the lin-gual appliance. Of course, lingual treatment can be affected by the same factors as inlabial treatment, such as inadequate patient cooperation, bracket failures, etc. Wirebending and the use of auxiliaries can be eliminated with the judicious selection of theappliance prescription. Studies are ongoing to improve appliance prescriptions andcustom laboratory-fabricated archwires. These and continued studies will advance theart and science of lingual orthodontics and will continue to make it more user- andpatient-friendly.

The term Shape Memory Alloys (SMA) is applied to the group of metallic materialswhich demonstrate the ability to return to some previously defined shape or size whensubjected to the appropriate thermal procedure.1 Generally, these materials can beplastically deformed at some relatively low temperature and, upon exposure to highertemperature, will return to their shape prior to the deformation (Figure 6.1–1). Shapememory alloys, such as nickel titanium, undergo a transformation in their crystalstructure when cooled from the stronger, high temperature form (austenite) to theweaker, low temperature form (martensite) (Figure 6.1–2). This inherent phase trans-formation is the basis for the unique properties of these alloys: shape memory andsuperelasticity.

Shape Memory When a shape memory alloy is in its martensite form, it is easily deformed to a newshape. However, when the alloy is heated through its transformation temperature, itreverts to austenite and recovers its previous shape with a net force delivered (Figure6.1–3). This process can be repeated millions of times. A typical transformation versustemperature curve under constant load is shown in Figure 6.1–4.1 Most of the trans-formation occurs over a relatively narrow temperature range, although the beginningand end of the transformation during heating or cooling actually extends over a muchlarger temperature range. The transformation also exhibits hysteresis (shown as T1) inthat the transformations on heating and on cooling do not overlap. This transforma-

.

Shape Memory Wires inLingual OrthodonticsCHRISTIAN DEMANGE, DCD, SQODE, CECSMO

.-. The shape memory effect. .-. Transformation of alloy crystals of shape memoryalloys from hot to cold phase.

Heating Cooling

Cold turns to Hot

Face centered

Body centered

tion hysteresis (T1) varies with the alloy system. The most common SMA wires usedare NeoSentalloy or Bioforce (GAC) and Copper Ni-Ti 35°C (Ormco).

Superelasticity These unique alloys also show a superelastic behavior if they are deformed at a tem-perature which is slightly above their transformation temperature. This effect is causedby stress, inducing the formation of some martensite. Because it has been formedabove its normal temperature, the martensite reverts immediately to undeformedaustenite as soon as the stress is removed. This process provides a very springy, rubber-like elasticity in these alloys (Figure 6.1–5).

SMA Wires in Lingual OrthodonticsThe main problem in the biomechanics of lingual orthodontics is the short interbracketdistances (Figure 6.1–6). Orthodontists ideally want to accomplish biological toothmovement with a low and continuous force and a constant moment/force ratio inorder to maintain a low stress/strain ratio. Two different ways exist to obtain this goal:

.-. The two phases of shape memory alloys with temperature: martensite and austenite.

.-. Typical loading and unloading behavior of superelastic Ni-Ti.

.-. Typical transformation versus temperature curve for a specimen under constant load (stress) as it is cooled and heated. T1: transformation hysteresis; Ms: martensite start; Mf: martensite finish; As: austenite start, Af: austenite finish.

Austenite

Martensite

Shape Memory Wires in Lingual Orthodontics

A. INCREASE WIRE LENGTH

This can be done using loops (which are difficult to do, time consuming, demonstratepoor reproducibility, and do not conform to the straight wire appliance philosophyused in lingual appliances), or increase the interbracket distances (which is almostimpossible since the brackets are quite large and arch form is narrow).

B. USE ELASTIC WIRES

Reduce the cross-section of the wire (which reduces control), or change the physicalproperties of the wire (yielding a low Young’s modulus).

Shape memory alloys are ideal materials because they have low Young’s modulus,present a very small stress/strain ratio, and have a large cross-section of wire to achievea maximum of control. The mechanical properties of SMA wires are different in theaustenite and martensite forms. Young’s modulus is highly nonlinear with temperature.The approximate elastic modulus is about 80 GPa at high temperature (austenite), and30 GPa at low temperature (martensite). (Figure 6.1–7). The Young’s modulus of shapememory alloys is difficult to define between the martensite and the austenite transforma-

.-. Short interbracket distances with lingual appliance.

.-. Young’s modulus of SMA wires are different inaustenite and martensite.

tion temperatures because at these temperatures the alloys exhibit nonlinear elasticity,and the Young’s modulus is both temperature and strain dependent.

In lingual orthodontics, bends should be made to obtain a mushroom shape inthe archwire (Figure 6.1–8). The wires must be bent to a strain greater than 8% inelongation to achieve a permanent deformation in a superelastic material (Figure6.1–9).2 The elongation at failure is about 15%. This allows wires to be bent withoutany clinical fracturing. The yield strength is about 600 MPa in austenite and 100 MPain martensite (Figure 6.1–10). The bend can be performed either when the wire is hotor cold. However, it is much easier to bend it when it is cold. Some of the bendstraightens when the wire returns to room temperature; therefore, the wire should beoverbent (approximately twice). In this way, no thermal machine (like Archmate®) isused to bend SMA wires. The mushroom shape is a little smoother but is still possibleto obtain (Figure 6.1–8). The wire near the bend will be stiffer and more brittle afterbending; however, the area of the bend falls between the canine and premolar and isnot significant. To allow easy placement into bracket slots, the wire is refreshed with–40° spray to obtain martensite.

.-. Yield strength of SMA. .-. Percentage of elongation to permanent deformation and failure in SMA.

.-. Mushroom shape of an archwire in shape memory alloys.


Alignment with SMAShape memory alloy wires are the optimal wires for first stage alignment. The Bioforce®

wire delivers 100g in the middle area of the arch (even if the wire is deformed to engageall slots) and 300g in the distal area. Rectangular wires are preferable over round wires

.-. One month in treatment (2nd appointment):Double over-ties to reactivate the wire.

.-. Two months in treatment (3rd appointment).Note almost full alignment.

.-. 16 months in treatment: .019 × .025 SMA isplaced immediately after bonding of second molars.

.-. 020 × .020 Bioforce is placed immediately afterbonding of lingual brackets.

because they can immediately control root inclination and angulation. The superelas-ticity properties of the wire is used to reactivate the wire (production of martensiteunder strain) by placing double over-ties on all teeth.

CLINICAL CASE

A 25-year-old female presented with a Class I malocclusion and upper anterior crowding. A lingual appliance (Ormco, generation #7, slot .022) was bonded and.020 × .020 Bioforce was used (Figure 6.1–11a). One month later, reactivation wasdone with double over-ties. (Figure 6.1–11b). Two months after the beginning oftreatment, almost full alignment was achieved (Figure 6.1–11c).

Bonding Second MolarsAnother use of SMA wires is when a second molar (or any other tooth) is bonded in a later stage of treatment. Shape memory alloy wires enable usage of nearly full-size

.-. Occlusal view of maxillary arch before debonding. Space closure was done with .019 × .025 SMA wire.

.-. Before treatment. Note anterior crowding.

.-. Occlusal view of maxillary arch: Two months intreatment: .019 × .025 SMA wire is used for space closure.

.-. Occlusal view of maxillary arch: Immediatelyafter bonding: .016 Ni.-Ti.


wires immediately after bonding even when treatment has considerably progressed(Figure 6.1–12).

SMA Wire for Space ClosureSpace closure can be easily done with .018 × .025 Bioforce. The force is 300g on themolars and with a horizontal and vertical antibowing effect curve, one can preventexpansion, tipping, and rotation of the upper molars when en masse retraction andsliding mechanics are used (Figures 6.1–13a and b, Figures 6.1–14a to d).

Conclusion Shape memory alloys used in lingual orthodontics at an early stage of treatment canreduce the archwire sequence and obtain more rapid alignment, leveling and, in somecases, space closure—using the same wire. Root control is maintained from the verybeginning of treatment. Treatment time is shorter, and so is chairtime.

References1. Hodgson DE, Wu Ming H, Biermann RJ. Shape memory alloys. Shape Memory Applications,

Inc., 1995.

2. O’Brien WJ. Dental materials: properties and selection. Quintessence Publishing, 1989;58.

.-. Occlusal view of maxillary arch after debondingof brackets and bonding of fixed retainer.

.-. Occlusal view of maxillary arch: 20 months intreatment: the same wire (.019 × .025 SMA) is still used.

.

Wire Sequencing in Lingual OrthodonticsH. STUART McCROSTIE, DDS

.-. A schematic representation of sequence of wires used inlingual orthodontics.

Defensive Archwire Sequencing Successful lingual orthodontic treatment, more than any other orthodontic treatmentmodalities, requires the rigid adherence to a series of protocols of both intellectual andmechanical nature. Among all the protocols, the most important one is defensivearchwire sequencing. This archwire sequencing program uses very few wires, eachselected to perform specific tasks during treatment. The following protocols maximizethe potential of each wire and reduce archwire changes to a minimum, at the sametime effecting high quality results.

• First initial archwires: .016 Ni-Ti (Rarely an 0.0155 or .0175 Respond)• Second initial archwire: .016 Special-Plus Wilcocks (Australian) heat-treated

stainless steel• Intermediate wires: .017 × .025 TMA• Finishing wires: .017 × .025 or .016 × .022 SS• Detailing wires: Wilcocks (Australian) .016 or .018 Special-Plus

This sequence is followed for all cases: Class I, II, or III malocclusions, and extraction or nonextraction cases (Figure 6.2–1).

INITIAL ARCHWIRES

Initial archwires are the most important in the sequence and their application canoften be time consuming. The goals to be achieved at this stage are initial levelling,

EXTRACTION AND NON-EXTRACTION

1) 0.016 NiTi with increased 0.016 Wilcocks crowding Special +

minimal crowding BOND—all teeth a) advancement loopsall teeth bracketed initially unbracketed 6 6

b) stops at 6 6

2) 0.017 X 0.025 TMAif all teeth were

initially bracketed

3) 0.017 X 0.025 S/S a) .016 X 0.022 s/sb) 0.018 Wilcocks Special Plus

4) 0.016 Wilcocks Special +Finishing arch if necessary

➤

➞

➞

➤

➤

➤

➤

➤➤

➤➤

.- . Wilcocks (Australian) .016 Special-Plus wire with advancement loops in a nonextraction case. Note steel ligation

in molar and first premolar.

alignment, derotations and tip control, to allow maximum bracket slot engagement.When crowding is severe, a second initial wire is required to ensure full bracket slotengagement. The Wilcocks (Australian) .016 Special-Plus wire is employed here withadvancement loops or stops mesial to the first molars (Figure 2a).

It is essential that steel ligation be used for bicuspid and molar attachments when-ever advancement loops or molar stops are required (Figures 6.2–3a and b). Anteriorbite opening is remarkably enhanced by the use of Wilcocks (Australian) .016 Special-Plus wire, especially with an additional reverse Curve of Spee. Where the anteriorteeth are moderately rotated, a steel double over-tie maybe employed to a Ni-Ti wire(Figures 6.2–4a to c). Double over-ties are also used for ligation of anterior teeth.

INTERMEDIATE WIRES

Intermediate wires like .017 × .025 TMA may occasionally be used as finishing wires aswell, especially in nonextraction cases. In extraction cases, the arch form in the initialwires should be modified to ensure that the cuspid-bicuspid offset is placed just distal tothe canine bracket to allow space closure (Figure 6.2–5). The buccolingual compensatorycurve is reduced in the intermediate wire since it is relatively stiffer than the initial wire.

.- . Molar steel ligation.

Wire Sequencing in Lingual Orthodontics

Elastic forces may be applied at this stage of treatment to initiate A-P control. However,TMA wires are not suitable for prolonged or heavy elastic forces, either intra- or interar-ch. If Class II elastics are required, an extra buccal compensatory bend should bemade to negate the rotational effect of the elastic forces on the lower second molars.The anterior segment must be “figure-eighted” to prevent space opening during theuse of elastic force. With rectangular archwires, steel ligation is essential to ensure fullbracket slot engagement and full expression of appliance prescription. Steel ligation alsoprevents rerotation of lateral incisors and canines during the application of elastic force.

FINISHING AND DETAILING WIRES

Stainless steel archwires are used to complete arch recontouring and space closure, andto eliminate any side effects noticed earlier in the procedure. Providing original treat-ment prescription and compensatory archwire modifications are adequate. Treatmentshould be be completed with .017 × .025 upper arch and .016 × .022 lower stainlesssteel archwires, except in Class III cases where the upper and lower archwires are reversed.Rarely, an .018 × .025 SS archwire is used, especially where maxillary anterior torquecontrol is difficult to achieve, and lengthy Class II elastics are to be employed. Thearchform of stainless steel wires is the same as the intermediate archwire, with subtle

.- . Double over-tie steel ligation of anterior teeth.

adjustments to the canine or molar offsets, if required, and compensatory bends tofacilitate completion of space and interarch adjustment (Figure 6.2–6). If necessary,individual torque may also be added at this time. With stainless steel archwires thebuccal compensatory bends bring the wire across the mesiolingual cusp of the distalmolar (see Figure 6.2–6). Occasionally, more flexible wires are required for final detail-ing, or for individual tooth overcompensation. These archwires could be Wilcocks(Australian) .016 or .018 Special-Plus.

ConclusionThe success of defensive archwire sequencing depends on the following:

1. Correct treatment planning and well-planned goals.2. Allowing sufficient time for each archwire to do its work completely.3. Steel ligation is required with all rectangular archwires.

These measures help to reduce stress to the patient, doctor and the materials used,increase patient comfort and satisfaction, cut costs and enhance efficiency, predictabil-ity, standard of results, and profitability.

.- . TMA archwires with compensatory bends.

.-. Stainless steel archwires with compensatory bends.

Lingual orthodontics presents a challenge in using traditional orthodontic instrumen-tation. Instrument requirements differ dramatically due to the difficult access of thelingual surface of the teeth, both anterior and posterior. Many years of research anddevelopment have resulted in a specialized series of instruments designed specificallyfor the needs of the lingual orthodontist. Most instruments have a 45° and 90° angleto facilitate access to the lingual surface. The majority of the original instruments weremanufactured by the ETM Corp.

The following is a list of the historical instrumentation that was available 15 yearsago. Only few are still manufactured today due to lack of demand. Further increase inthe prevalence of lingual orthodontics will force the companies to make at least someof these instruments again.

1. ETM–8007 LINGUAL LIGATURE CUTTER (ANGULATED 45°) This is the standard cutter used in lingual orthodontics. The 45° angle provides easyaccess for cutting ligature wires. Also, the unique design allows tucking of the ligaturewire ends with the same cutting instrument (Figure 7–1).

2. ETM–8006 KURZ LIGATURE WIRE CUTTER (ANGULATED 90°) This ligature cutter works much like the 45° cutter, but provides easier access to someareas (Figures 7–2a and b).

Instruments Used in Lingual OrthodonticsCRAVEN KURZ, DDS, PhD

-. ETM–8007.

3. ETM–8011 KURZ UTILITY PLIER

This plier is designed much like the traditional Weingart utility plier with the addedadvantage of a 45° angle to facilitate access to the lingual brackets (Figures 7–3a and b).

4. ETM–8010 KURZ ARCHWIRE CUTTER

This plier functions as a distal-end cutting plier. It was designed with a long body so itcan reach back into the depth of the mouth (Figures 7–4a and b).

- . ETM–8006.

- . ETM–8011.

- . ETM–8010.

Instruments Used in Lingual Orthodontics

5. ETM–8003 KURZ MOSQUITO FORCEPS (CURVED) This mosquito forceps has 45° angle at its end and that facilitates the placement ofelastics and elastic chains (Figures 7–5a and b).

6. ETM–8014 LIGHT LIGATURE PLIER, MATHIEU STYLE PLIER

(The same as the mosquito but Mathieu Style [Figure 7–6].)

7. LINGUAL HINGE CAP OPENING TOOL (Figures 7–7a and b)

- . Lingual hinge cap opening tool.

- . ETM–8003.

-. ETM–8014.

8. DIRECT BOND REMOVING PLIER (LINGUAL) Due to the unique shape of the KURZ-Ormco brackets, the plier was designed to fitthe brackets under the lingual hooks, putting no torque pain on the tooth while thebracket is removed (Figures 7–8a and b).

9. ETM–8004L KURZ TONGUE RETRACTOR AND SALIVA EJECTOR

It provides the practitioner a dry working field, keeps the tongue away from the lingualsurfaces of the teeth and isolates them from saliva contamination. Still, it allows thepractitioner enough space and access to place the indirect bonding material (Figures7–9a and b).

10. ETM–8201 KURZ FIRST ORDER BENDING FORK

This tool allows the practitioner to place first order bends on the wire while it is stillin the mouth. Although the braces are indirectly bonded, sometimes there is a need tomake first and second order bends due to misplacement of the bracket in the laboratory,direct rebonding, or some esthetic needs. This tools allows the practitioner to bendthe wire in the mouth without the need to replace all the modules or metal ligatures(Figures 7–10a and b).

11. ETM–8202L – SILVER, KURZ SECOND ORDER BENDING FORK

- . Direct bond removing plier (lingual).

- . ETM–8004L.

Instruments Used in Lingual Orthodontics

- . ETM–8201.

- . ETM–8202L.

- . ETM–2108.

This instrument allows both second order intraoral bends and right-angled bends atthe distal sheath (Figures 7–11a and b).

12. ETM–2108 – MODULE REMOVER (Figures 7–12a and b)

ReferenceETM Lingual Plier Co., Monrovia, CA.

. Case Presentation:Loop Mechanics. . . . . . . . . . . . Giuseppe Scuzzo

. Case Presentation:Sliding Mechanics . . . . . . . . . .

J. Courtney Gorman

Lingual Orthodontics inPediatric Patients . . . . . . . . . . .

Lorenzo Favero

. The Lingual Technique inOrthognathic Surgery . . . . . . . .

Alessandro Silvestri

. Orthodontic-Surgical RPECamouflage on an Orthognathic Case . . . . . . . . . .

Mario E. Paz

. Segmental Lingual Orthodonticsin Multidisciplinary Cases . . . .

Pablo A. Echarri

. Combined Orthodontic-Prosthetic Treatment of MalpositionedAnterior Teeth . . . . . . . . . . . . .

Rafi Romano and Nitzan Bichacho

Lingual Orthodontics:Esthetics and Function . . . . . . .

Chiori Hashiba

Anchorage Control inLingual Orthodontics . . . . . . . . .

Kyoto Takemoto

. Preserving the “HollywoodSmile” and Facial Profile . . . . . . .

Mario E. Paz

. Distalization of Molars inNonextraction Cases. . . . . . . . . .

Giuseppe Scuzzo and Maurizio Cannavo

. Interproximal Enamel Reduction in Lingual Orthodontics . . . . . . .

Didier Fillion

. Sliding Mechanics versus LoopMechanics During En MasseRetraction in Extraction Cases . .

Kyoto Takemoto

SECTION 3

TreatmentApproaches and Mechanics

Vertical and Horizontal AnchorageHorizontal anchorage in orthodontics is traditionally considered as the resistance ofthe molars to anterior or posterior movement. In addition, orthodontists are concernedwith the concept of vertical anchorage, or maintaining the molar position in the verti-cal dimension.

When the vertical molar position changes, as is seen with molar elongation, aclockwise rotation of the mandible can occur, creating a Class II molar relationshipand an anterior open bite. In both labial and lingual treatments, it is often desirable to minimize the amount of molar elongation. Lingual orthodontics has the advantageof minimizing maxillary first molar elongation, as will be explained in detail later.Elongation of the molars can occur due to the presence of the anterior bite plane, andit can be avoided with posterior acrylic supports.

In lingual as well as labial orthodontics, maintaining anchorage during treatmentcan be challenging. Many treatment modalities are demanding on the molar anchor-age. For example, extraction spaces are often closed using en masse retraction of theanterior teeth. This retraction method, while being sensitive to esthetic concerns,demands maximum anchorage control to minimize molar anchorage loss. Other tech-niques used in lingual orthodontics to close spaces, such as the use of different typesof loops, demands moderate to minimum anchorage. The differences between the twotechniques are explained in Chapter 10.1.

Differences in Anchorage Value: Lingual versus Labial OrthodonticsThe anchorage value of the posterior teeth in the anterior-posterior and vertical direc-tions appear to be higher in lingual orthodontics than in labial orthodontics (Takemoto,unpublished data, 1997). In a randomized study of 44 adult Class II, division 1 mal-occlusions or bimaxillary protrusion malocclusions, the anchorage value was signifi-cantly higher in lingually treated case than in those treated with labial techniques.

Labial Orthodontics Lingual Orthodontics24 cases: 20 cases:2-extraction of teeth 14,24 (4–4) 3-extraction of teeth 14,24 (4–4)15-extraction of teeth 14,24,34,44 10-extraction of teeth 14,24,34,44 7-extraction of teeth 14,24,35,45 7-extraction of teeth 14,24,35,45Treated with straight wire appliance Treated by en masse retractionCanine retraction with sliding mechanics Retraction with loop mechanicsAnterior segment retraction with loop Mostly with T-loop mechanics

mechanics

Anchorage Control in Lingual OrthodonticsKYOTO TAKEMOTO, DDS

(4 4)5 5 (4 4)5 5

(4 4)4 4 (4 4)4 4

Figure 8–1 shows an example of the lingual appliance. Rickets cephalometricanalysis (Rocky Mountain Data System Inc. Spring 1969) was used to determine theamount of retraction of the upper and lower incisors, the amount of intrusion, and thevalue of the anchorage loss of the upper and lower first molars (Figures 8–2a and b).Statistical analysis showed that in the upper arch the anchorage value of the first molaras well as the anterior retraction and intrusion were significantly greater in the lingualgroup as compared to the labial group (Table 8–1). In the lower arch, the anchoragevalue of the first molar was the same as that in the upper arch (Table 8–2).

-. Lingual appliance: extraction of first premolars, T Loops with transpalatal arch and buccal segment 6-7.

-. Pretreatment (green) and post-treatment (yellow)superimposition of the maxilla on the palatal plane at point ANSand of the mandible on the mandibular plane at point Menton:

incisor and 1st molar horizontal changes measured at the incisal edges and the distal end of the first molars.

-. Pretreatment (green) and post-treatment (yellow)superimposition of the maxilla on the palatal plane at point ANSand of the mandible on the mandibular plane at point Menton:

incisor vertical changes measured at the center of resistance.

Palatal pl. at ANS

Mand pl. at Me

Palatal pl. at ANS

Mand pl. at Me

U1 Int. = L1–L2

L1 Int. = L3–L4

Anchorage Control in Lingual Orthodontics

Mechanics Used to Control Anchorage in the Upper ArchMechanical advantages gained from lingual treatment are buccal root torque and distalrotation of the molars, especially due to the easily established cortical bone anchorage(Figures 8–3a and b). Also, an intrusive force is applied to the functional or lingualcusps of the upper molars because the appliance is placed near these cusps. Therefore,the CO-CR discrepancy caused by the primarily initial contact and the mandibularclockwise rotation caused by the elongation of molars are reduced.

Combinations of loops, elastics, transpalatal arches, and headgear have been usedto successfully control both the horizontal and vertical anchorage in both the upperand lower arches.

-. Applied intrusion force to the upper molars resulting in cortical bone anchorage.

-. Distal rotation can be easily established with theposterior teeth by retraction forces.

Table 8–1. Results: Upper

Labial Lingual

U6 anchorage 2.0 ± 0.9 0.1 ± 0.5†

U1 retraction 5.0 ± 1.6 7.9 ± 2.0†

U1 intrusion 0.9 ± 0.9 1.8 ± 1.6*

Facial axis –0.1 ± 0.8 0.1 ± 0.3

Head gear 16.3 ± 6.1 11.3 ± 7.3

Class II elastics 7.5 ± 6.2 5.3 ± 4.8

mean ± S.D.* = P < 0.05; † = P < 0.01Statistical analysis shows that in the upper arch the anchorage value of thefirst molar, and the anterior retraction and intrusion were significantlygreater in the lingual group as compared to the labial group. Headgear andClass II elastics were used for shorter period of time in the lingual groupthan in the labial group.

Table 8–2. Results: Lower

Labial Lingual

L1 retraction 3.6 ± 1.9 4.1 ± 1.4

1.4 ± 1.9 3.6 ± 1.3*

U6 anchorage 2.0 ± 1.3 0.9 ± 0.7*

2.1 ± 1.8 1.8 ± 0.8

L1 intrusion 2.4 ± 1.3 3.1 ± 1.0

2.2 ± 1.4 2.1 ± 0.3

Class II elastics 6.1 ± 6.1 5.6 ± 5.0

10.8 ± 6.8 7.6 ± 4.0

mean ± S.D.* = P < 0.05Statistical analysis shows that in the lower arch the anchorage value of thefirst molar and the anterior retraction and intrusion were significantly greaterin the lingual group as compared to the labial group. Class II elastics wereused for shorter period of time in the lingual group (both in first and secondpremolar extractions) than in the labial group.

MAXIMUM ANCHORAGE (UPPER ARCH)Helical loop (Figure 8–4a) and T-loop mechanics (Figure 8–4b) (.017 × .025 TMA) arecombined with a transpalatal arch and a buccal sectional arch from first to secondupper molars for stabilization. Also, high-pull headgear and Class II elastics are used.

MODERATE ANCHORAGE (UPPER ARCH)L-loop mechanics are combined with a transpalatal arch to prevent a transverse bowingeffect. The anterior segment (3|3) and the posterior segment (7–5|5–7) are “figure-eighted” with ligature wire (Figure 8–5a). When a transpalatal arch cannot be used,sliding mechanics are used by placing a power chain from the lingual of the canine tothe lingual of the second premolar in first premolar extraction cases (Figure 8–5b).The sliding mechanics are used with a .016 × .022 stainless steel archwire. If thetransverse bowing occurs, a power chain can be used from the lingual of the canine tothe buccal of the first molar to rotate the first molars mesially (Figure 8–5c).

MINIMUM ANCHORAGE (UPPER ARCH)Extraction spaces are closed by a reciprocal elastic force, with a power chain placed onboth the buccal and lingual of the canine and first molar (Figure 8–6). The anteriorsegment (usually 4 |4) is “figure-eighted” with ligature wire. Frequently, cases requiringminimum anchorage control are those in which second premolars have been extractedand mesial molar movement is encouraged. Sometimes Class III elastics are used toenhance mesial movement of the molars.

Mechanics Used to Control Anchorage in the Lower ArchThe anchorage value of the lower arch is higher than that of the upper arch becausethe mandible has a thicker cortical layer and thinner cancellous layer of bone. Becauseof this difference in anchorage value, a buccal sectional arch is usually placed on theposterior teeth to control the functional or buccal cusp. Sliding mechanics using a.016 × .022 stainless steel archwire are used most frequently for space closure. Slidingmechanics minimize the bowing effect and avoid tongue irritation from loops. Whensliding mechanics are not the optimum choice for space closure, loop mechanics may

-. Anchorage preparation for a maximum anchoragecase with helical loop mechanics in the upper arch, using a

.017 .025 TMA with a transpalatal arch and buccal sectional archfrom 6-7. High-pull headgear and Class II elastics are also used.

-. Anchorage preparation for a maximum anchoragecase with T-loop mechanics in the upper arch.


be used. This includes Class III malocclusions treated nonsurgically, where dentalcompensations by tipping the anteriors lingually may be needed, when the right andleft extraction spaces are not symmetric, or when the space closure cannot be accom-plished with sliding mechanics because of root contact with the cortical bone. In theselatter cases, the lower six anterior teeth are tipped lingually with loop mechanics.

MAXIMUM ANCHORAGE (LOWER ARCH)An elastic power chain is used on the lingual, with a buccal sectional arch for stabi-lization (.017 × .025 TMA or .016 × .022 SS). The anterior segment (3|3) and theposterior segment (7–5|5–7) is “figure-eighted” with ligature wire. Class III elasticsare used both buccally and lingually for reinforced anchorage (Figure 8–7).

-. Anchorage preparation for a moderate anchorage casewith L-loop mechanics in the upper arch. A transpalatal arch is addedto prevent a transverse bowing effect. The anterior segment (3-3) and

the posterior segment (5-7) is “figure-eighted” with ligature wire.

-. Anchorage preparation for a moderate anchoragecase with sliding mechanics in the upper arch. To eliminate the

transverse bowing effect, a power chain is used from the lingual of thecanine to the buccal of the first molar, to rotate the first molars mesially.

-. Anchorage preparation for a moderate anchorage casewith sliding mechanics in the upper arch. To eliminate the transversebowing effect a power chain is used from the lingual of the canine to

the buccal of the first molar, to rotate the first molars mesially.

MODERATE ANCHORAGE (LOWER ARCH) Sliding mechanics are used with reciprocal elastic forces (power chains from 3-5 onboth sides). The anterior segment (3|3) and the posterior segment (7–5|5–7) are “figure-eighted” with ligature wire. However, buccal segmental wires are not needed(Figure 8–8).

MINIMUM ANCHORAGE (LOWER ARCH) Most cases requiring minimum anchorage are those in which second premolars havebeen extracted. An elastic power chain is placed circularly from the lingual of the firstmolar, encircling the canine, and attaching to the buccal of the first molar. Class IIelastics are used to facilitate mesial movement of the molars. The anterior segment (4 |4) is “figure-eighted” with ligature wire. As the molars move mesially, gingivalrecession over the mesial root of the first molar should be prevented (Figure 8–9).

-. Anchorage preparation for a minimum anchorage case withsliding mechanics in the upper arch. Reciprocal elastic force, with a powerchain placed on both the buccal and lingual of the canine and first molar

is used. The anterior segment is “figure-eighted” with ligature wire.

-. Anchorage preparation for a maximum anchorage case with sliding mechanics in the lower arch. An elastic power chain is used on.017 × .025 TMA or .016 × .022 SS archwires. A buccal sectional arch is

used for stabilization and the anterior segment (3-3) and the posterior segment (5-7) is “figure-eighted” with ligature wire. Class III elastics areused both buccally and lingually usually with extra oral force traction

for reinforced anchorage.


Anterior and Lateral ConcernsPatients with severe anterior tongue thrust often present a challenge when attemptingto retract the anterior dentition. The lingual appliance, due to the discomfort associatedwith tongue contact, redirects the tongue tip to the palatal vault in speech and swal-lowing. Therefore, the anterior thrust component is eliminated, and normal musclebalance is restored. The excessive pressure from the tongue against the anteriors isminimized while retraction is facilitated. A similar effect is seen with the use of lingualelastics. This has been termed the “fence effect,” in that the lingual appliance or theelastics create a fencing of the tongue musculature from the dentition. It is believedthat the fence effect contributes to the increase in anchorage values seen with lingualappliances as opposed to labial appliances.

-. Anchorage preparation for a minimum anchorage case with sliding mechanics in lower arch. An elastic power chain is placed circularly from the lingual of the first molar, encircling the canine andattaching to the buccal of the first molar. Class II elastics are used to

facilitate mesial movement of the molars. The anterior segment is “figure-eighted” with ligature wire.

-. Anchorage preparation for a moderate anchorage casewith sliding mechanics in the lower arch. Reciprocal elastic forces are

used and buccal segmental wires are not needed.

Another factor contributing to anchorage control is the lateral occlusal function.The lateral occlusion prevents the transverse bowing effect which is often seen duringlingual treatment. The anterior-posterior forces used for retraction should be light,minimizing anchorage loss while maintaining lateral occlusal function.

Without a doubt, the debate between the extraction and nonextraction orthodontictreatment approaches has been, and will continue to be, the subject of a great deal ofcontroversy. The literature on this topic is simultaneously abundant and controversial.The gap between extraction and nonextraction treatment decisions seems to widenmore among cases in which there is no clear cut distinction between the two treat-ment modalities. There are important diagnostic considerations that can help ortho-dontists make treatment decisions although they are not always defined as we wouldlike them to be defined. Among some of these considerations are: cephalometric mea-surements, skeletal discrepancies, tooth to basal bone relationship, severity of dentalcrowding, and facial and profile considerations.

The cosmetic changes that result with a nonextraction approach can be quitefavorable; however, this does not underestimate the functional and cosmetic value ofextraction therapy. Nonextraction treatment, in many cases, is more difficult to exe-cute than extraction therapy; particularly in cases where space limitation is consider-able and growth has been completed.

Historical PerspectiveAppreciation for facial esthetics is not new to the orthodontic profession. The face ofApollo Belvedere was considered by Angle1 as an ideal standard of facial beauty for theorthodontic profession. Peck and Peck made a beautiful recollection of the differentconcepts of beauty from a historical perspective.2 For example, the facial esthetic concept of an ideal profile has undergone changes through history from a mild Class II, retrognathic, flat, and often concave profile during the time of ancient Greeceto severe Class II profiles during the Renaissance period. Contemporary standards offacial esthetics tend toward profiles with slightly more fullness (Figures 9.1–1a to d).

The desire for a fuller profile has made the nonextraction treatment approachmore attractive to prospective orthodontic patients. In some carefully selected cases,ideal cosmetic treatment may dictate opening previously closed extraction spaces inorder to decrease an existing concave profile (Figures 9.1–2a and b). The availablenonextraction treatment methods that can be used independently or in combinationto achieve satisfactory expansion results are:

.

Preserving the “HollywoodSmile” and Facial ProfileMARIO E. PAZ, DDS, MS

1. Crozat expansion2. Enamel reproximation3. Archwire expansion4. Molar distalization5. Surgical rapid palatal expansion (RPE)

Expansion TechniquesAlthough many methods exist to expand the dental arches, a particularly effectivemethod is with the use of the Crozat appliance. A modified basic and effective versionof the Crozat appliance (personal communication and design by Duane Grummons,Marina Del Rey, CA) is used (Figure 9.1–3). Some of the advantages of using theCrozat appliance prior to lingual treatment are:

• patient’s first introduction to lingual treatment with an esthetic removableappliance

.- . Series of views demonstrating a range of facial profiles from full to concave.

Preserving the “Hollywood Smile” and Facial Profile

• expansion more efficient than with archwires• effective molar distalization and rotation when desired• incisor proclination when needed• little if any speech interference• decreases treatment time with fixed appliances

Clinicians should also be aware of the limitations of the Crozat appliance:

• careful case selection is needed• full-time wear is indicated, except while eating• activations every 3 weeks for 4 to 5 months• too much activation can lead to tissue impingement resulting in pain and more

tipping forces• early-release enamel reproximation may be needed

Appliance activation with the use of a three-pronged plier is relatively simple asshown in Figures 9.1–4a to c.

After the desired arch length increase has been achieved (Figures 9.1–5a and b), theappliance is removed and lingual impressions taken. A clear 1 mm vacuform type ofretainer is used until the placement of the lingual appliance. Retention prior to bond-ing is critical, otherwise, the lingual bonding trays from the laboratory will not fitaccurately. Arch length increase is continued or maintained after the bonding of theappliance by archwire expansion and/or enamel reproximation.

Another nonextraction technique is enamel reproximation. This technique is alsoknown as interproximal reduction or air rotor stripping. The technique, once rarelyused, seemed to resurface with the increased number of adults seeking lingual ortho-dontic therapy. Adult orthodontics often eliminates treatment options that requirecooperation and are not cosmetically acceptable. Adult patients generally havedemanding life schedules; therefore, treatment plans should be designed to place feweradditional demands on regular activities and should require minimal cooperation.

.-. Patient profile view depicting aconcave profile due to previous orthodontic treatment

with bicuspid extractions.

.-. Patient profile shows improvementand a moderate increase in lip support as a result of

extraction spaces being opened orthodontically.

Although enamel reproximation has had both negative3,4 and positive5–7 reviews inthe orthodontic literature, it remains an effective way to increase arch length and maxi-mize the cosmetic result. Some important factors to take into consideration whendoing enamel reproximation are:

1. Age: Younger patients are likely to be more sensitive to enamel reduction thanolder patients. Large pulp chambers and dentinal tubules are contributing fac-tors to this sensitivity. Radiographs should be evaluated to determine adequateenamel width and dentinal proximity before enamel reduction is performed(Figure 9.1–6).

2. Hygiene: Rough interproximal areas will increase plaque accumulation and,therefore, caries susceptibility in patients with poor oral hygiene. Enamelreproximation should only be used in patients demonstrating good oralhygiene and in areas with adequate access for hygiene.

3. Enamel sensitivity: Enamel reduction in patients with a low threshold of sensi-tivity may be uncomfortable. The use of desensitizing agents should be consid-ered with this patient population.

4. Size of teeth and amount of crowding: Enamel reproximation should be avoid-ed in patients with small teeth and severe crowding. Also, the shape of thetooth should be considered. Triangular crowns are more amenable to enamelreduction than narrow, rectangular crowns. Presence of porcelain crowns,porcelain veneers, and root proximity should also be taken into consideration.

The enamel reproximation technique is described in detail in Chapter 9.3.

Case ReportThe following case demonstrates the use of a combination of techniques used toachieve a non-extraction treatment in a crowded malocclusion. A 35-year-old femalepatient presented with the chief complaint of “I would like a broader smile and myteeth are too crowded.”

Clinical examination revealed a mesognathic profile with a narrow and restrictedsmile line (Figures 9.1–7a and b), a Class I malocclusion with 4 to 5 mm of uppercrowding and moderate-to-severe (7 to 9 mm) lower crowding (Figures 9.1–7c and d).

.-. Occlusal view of modified Crozat appliance. Lingualanterior sweeps are added only if incisor proclination is desired.


Cephalometric measurements were within normal standards except for some moderateincisor proclination. Narrow dental arches and an accentuated Curve of Wilson madethis an excellent case for Crozat expansion. Large-size teeth, substantial radiographicenamel width, and good oral hygiene also made this patient a candidate for the enamelreproximation technique. Archwire expansion can be an effective method to reducethe existing shadowed premolar regions upon smiling. Treatment decisions were basedupon the use of a combination of these techniques.

The primary treatment goal was to increase arch length. A modified Crozat appliance was worn for four months to rotate first molars mesiobuccally and upright

.- . Crozat activation: (a) mesiobuccal rotation, (b) bicuspid arms moved away to allow molar rotation, (c) appliance fully activated.

.- . Occlusal views during Crozat expansion just before lingual appliance bonding.

.- . Initial facial photographs. Note restricted smile.

.- . Initial occlusal photographs. Note minimal upper crowding and moderate-to-severe lower crowding.

.-. Radiographic views of incisor teeth of 15-year-old.Notice broad pulp chamber size, and relatively narrow dentin and

enamel width.

.- . Final intraoral photographs. Note Class I molar and canine relationship and aligned arches.


the lingually inclined buccal segments. Lingual impressions were taken at the comple-tion of the expansion phase, and a vacuformed retainer was worn until the date ofplacement of the lingual appliances. Enamel reproximation combined with archwire

.- . Treatment progress—maxillary and mandibular occlusal views. Note expanded archwires with no crowding.

expansion completed the expansion necessary to achieve the desired arch length(Figures 9.1–8a and b).

Total treatment time was 20 months, four months of Crozat wear and 16 monthsof lingual appliances. The Class I molar and canine relationship was maintained, thecrowding was relieved, and the arches were aligned (Figures 9.1–9a to e). The incisorrelationship to the denture base was normalized. Tooth morphology, facial profile, andlip position were maintained. A broad, unrestricted, and happy “Hollywood” smilewas achieved (Figures 9.1–9f and g).

References1. Angle EH. Treatment of malocclusion of the teeth. 7th Ed. Philadelphia: SS White Dental

Manufacturing, 1907.

2. Peck S, Peck L. Selected aspects of the Art and Science of Facial Esthetics Seminar inOrthodontics, 1995;105–126.

3. Radlanski RJ, Ralph R, Jager A, Zimmer B. Plaque accumulation caused by interdental strip-ping. Am J Orthod Dentofac Orthop 1988;94:416–420.

4. Twesme DA, et al. Air rotor stripping and enamel demineralization in vitro. Am J Orthod1994;105:142–152.

5. Radlanski RJ, Jager A, Zimmer B. Morphology of interdentally stripped enamel one year aftertreatment. J Clin Orthod 1989;23:748–750.

6. El-Mangoury NH, Moussa MM, Mostafa YA. In vitro remineralization after air rotor strip-ping. J Clin Orthod 1991;25:75–78.

7. Thordasson A, Zachrisson BU, Mjor IA. Remodeling of canines to the shape of lateral incisorsby grinding: a long-term clinical and radiographic evaluation. Am J Orthod Dentofac Orthop1991;100:123–132.

.- . Final facial photographs. Note nice, progressive, round and broad “Hollywood” smile.

In the adult patient there is no clinically significant growth in the bone structure;therefore, alternative solutions must be found to obtain space in which to move theteeth to correct the malocclusion. Treatment options may differ depending on theamount of crowding, and whether the crowding has occurred in the maxilla or mandible.Most commonly, teeth are extracted to create the space needed to relieve crowding.Arch expansion or reproximation of anterior and posterior teeth are alternative methodsused to create adequate space. Less frequently, the posterior teeth are distalized to createmore space anteriorly.

Distalization TreatmentSeveral different treatment modalities may be employed to distalize the posterior dentition. Possibilities include fixed appliances with coil springs or Nitinol wires, andremovable appliances such as a modified Cetlin appliance. This type of appliance has a high acceptance among adult patients because it facilitates good oral hygiene andallows adaptation to lingual appliance during the initial phase.

The removable Cetlin appliance is constructed from 2 Adams clasps on the firstpremolars, distalizing springs on the second premolars and on the first molars, distaliz-ing screws between the first and second premolars, and an anterior bite plane. Theappliance does not include any metal clasps from cuspid to cuspid due to esthetic considerations (Figures 9.2–1a and b). Other effective methods for distalizing molarsare described in detail in Chapter 2.

.

Distalization of Molars in Nonextraction CasesGIUSEPPE SCUZZO, MD, DDS, AND MAURIZIO CANNAVO, MD

.-. Modified Cetlin appliance. Note the distalization screws.

The following case presents the use of this modified Cetlin appliance for gainingspace by distalizing the molars. A 24-year-old female presented with the chief com-plaint of unesthetic smile and crowded teeth. She had a Class II Division II deep bitemalocclusion with great crowding on the upper arch, a retained deciduous upper cus-pid, palatally erupted upper cuspids, in cross-bite with the lower cuspids, and crowd-ing on the lower arch (Figures 9.2–2a to c, 3a, 4a). The treatment plan includedupper and lower lingual orthodontic appliances. No extractions were indicated (exceptfor removal of the deciduous cuspid). The treatment began with a distalizing therapyon the upper molars by applying a modified Cetlin appliance. The appliance was

.- . At initial orthodontic examination: intraoral views.

.-. Clinical view: upper modified Cetlin appliance and lower cross-over technique. Note the esthetic

anterior appearance without any visible appliance.

Distalization of Molars in Nonextraction Cases

.- . Occlusal views of the maxillary arch: (a) At initial orthodontic examination. (b) After six months with modified Cetlin appliance. Note spaces between the molars, second bicuspids, and

first bicuspids. (c) Bonding of lingual appliance (Ormco-Kurz generation 7). .016 SS archwire with transpalatalarch. Only the central incisors were bonded in the anterior region due to the crowding and rotations of the lateral

incisors and cuspids. (d) Bicuspid retraction and alignment of the left lateral incisor and cuspid. (e) Before debonding:.016 × .022 SS archwire for en mass retraction with Class II elastics and loops mechanics. (f ) After debonding.

Note the broad and harmonious arch.

worn for six months until the upper molars and premolars had moved and enoughspace was created. A fixed upper lingual appliance (Ormco, 7th generation) replacedthe modified Cetlin appliance to finish the distalization and alignment of the teeth(Figures 9.2–3a to d). On the lower arch, a segmental technique was used with labial

brackets from the first premolar to the second molar. Later, it was combined withcross-over technique (lingual brackets from cuspid to cuspid and labial brackets on theposterior segments) (Figures 9.2–4a to d). Lingual brackets were mounted by using

.- . Completion of orthodontic treatment: clinical facial and profile views.

.- . Occlusal view of the mandibulary arch: (a) At initial orthodontic examination.(b) Cross-over technique: labial brackets on posterior segments and lingual brackets on the anterior segment.

Note the extraction of second right molar due to prosthetic considerations. (c) Before debonding. (d) After debonding.

Distalization of Molars in Nonextraction Cases

.-. Cephalometric superimposition tracing: before and after the treatment.

the CLASS laboratory method. Twenty-four months after the treatment had started, aClass I relationship (molars and cuspids), a functional occlusion, and an esthetic smilehad been established (Figures 9.2–5a to c). Superimposition of the cephalometric trac-ings before and after the treatment shows almost no change in the incisors and distal-ization of the molars. (Figure 9.2–5d).

Interproximal enamel reduction has long been a forbidden procedure in orthodontics;however, many practitioners were doing it without acknowledging it. Interproximalenamel reduction is a very simple technique to use in orthodontics, contrary to otherspace-gaining systems. However, while the procedure itself can be performed ratherquickly, it is mandatory to thoroughly know its effects on the enamel layer. Studies onthe effects of cutting instruments on the enamel layer have convinced us that thisreduction cannot be done in an uncontrolled manner or at any time.

PrinciplesThe principles discussed here have been inspired by the publications of Sheridan onair-rotor stripping. They have also been largely influenced by the desire to maintainthe cosmetic aspect of the orthodontic treatment.

1. NEVER REDUCE BEFORE APPLIANCE PLACEMENT

The position of the teeth should not be changed in order to allow a perfect fit to thedental arches during indirect bonding; we must be sure that the patient can toleratethe appliance before doing any enamel reduction. Any space gained runs the risk ofbeing lost if the enamel reduction is done before archwire placement. Space opening byenamel reduction must also be avoided before the teeth have started to move because theamount of enamel to be removed cannot be precisely evaluated before treatment starts.

2. CALCULATE THE AMOUNT OF ENAMEL TO BE REDUCED

The width of the teeth should be recorded. While it is quite difficult to measure thewidth of teeth that are in contact or crowded, accuracy in the anterior measurement is very important. A variation of 2 to 4 mm is crucial when calculating the sum of thewidths of the six anterior teeth. The amount of crowding is also dependent upon thearch form. This amount will be more pronounced on cinched arches. The availablespace can be increased by rounding the arch form in the bicuspid area and the positionof the anterior teeth can be in a more protrusive position in an adult. The use ofOrmco lingual brackets with a bite plane will provide a slight sagittal shift of the upperand lower arches (Figure 9.3–1). The effect of this possible forward movement is areduction of the crowding and, therefore, in the amount of enamel to be removed.Again, the amount of enamel to be removed cannot be known precisely before theplacement of the initial archwires.

.

Interproximal EnamelReduction in LingualOrthodonticsDIDIER FILLION, DDS

3. DO NOT REDUCE ROTATED TEETH

Normal interproximal zones of contact may be damaged and the physiological contactpoint should be maintained. The best evaluation of the necessary reduction is achievedafter derotation of the teeth.

4. REDUCE MOLARS AND BICUSPIDS FIRST

The enamel thickness and the inter-radicular space is the greatest in these teeth. Theseteeth also usually present the most restorations in adults (Figures 9.3–2a to c). By first

.-. Anterior bite plane of the Ormco’s lingual brackets.

.- . Reduction of temporary prosthetic crowns and fillings in the posterior segments of the arch.

Interproximal Enamel Reduction in Lingual Orthodontics

maximally reducing the posterior teeth, the natural and esthetic morphology of theanterior teeth is maintained, especially that of the lower incisors, which may be thinand malpositioned. Interproximal reduction of these teeth can result in dentin expo-sure, sensitivity, increased caries potential, and improper tooth proportions. Oralhygiene should be maintained due to the embrasure changes in the molar area.

5. USE THE APPROPRIATE INSTRUMENTS

Always use burs with a known thickness and a known reducing effect on the enamellayer. Do not use abrasive strips because they can create deep grooves which cannot beeliminated.

6. DO NOT REDUCE WITHOUT GINGIVAL AND LABIAL PROTECTION

This protection allows the instrument to go below the contact point without causingdamage to the gingiva and helps the clinician to avoid the formation of an enamel over-hang. It permits a painless reduction without gingival bleeding (Figures 9.3–3a and b).

7. RESPECT THE LIMITS OF THE REDUCTION

Boese recommends not to reduce beyond one half of the thickness of the enamel layerof the lower incisors without giving any precision on the thicknesses used for reference.Barrer advocates a maximum of 4 mm total reduction of the lower incisors, that is 0.5 mm from each proximal tooth surface. Paskow mentions a reduction of 0.25 mmto 0.37 mm. Hudson proposes 0.20 mm on the proximals of the centrals, 0.25 mmfor the laterals and 0.35 mm for the cuspids, that is, a total reduction of 3 mm in theanterior zone. Tuverson (1980) suggests the reduction of 0.3 mm without any dangeron the proximals of the four mandibular incisors and 0.4 mm on the cuspids, whichallows a total of 4 mm in the anterior zone. Alexander limits himself to 0.25 mm oneach tooth. Finally, Sheridan reduces up to 0.8 mm for the lateral zones and 0.25 mmfor the anterior teeth, that is a total gain of 8.9 mm.

Enamel is a highly mineralized tissue, which explains its protective function forthe underlying tissues, but this mineralization is most important at the surface. Byeliminating the highly mineralized external layer, we run the risk of slightly weakeningthe enamel resistance to caries. The general tendency is to consider that the maximumamount of enamel that can be removed corresponds to half of the enamel thickness.This idea seems reasonable to us in order to ensure sufficient protection of the tooth.

.- . Brass wire used under the contact point for gingival protection.

Based on the lowest values recommended by Hudson, we have adopted the fol-lowing recommendations:

Upper arch: Up to 0.6 mm per proximal surface from the mesial face of the firstmolar to the distal face of the cuspids and 0.3 mm per proximal face of the anteriorteeth, which allows us to obtain about 10 mm of available space.

Lower arch: 0.6 mm from molar to bicuspid and 0.3 mm on the cuspids whichallows us to obtain about 7 mm of available space.

When all the principles are observed and considered, enamel reduction presentscertain advantages: it can help avoid extractions, and so no extra efforts are necessaryto close in the extraction site, there is no risk of space reopening, the reduction corre-sponds exactly to the crowding, and the length of treatment time is reduced by 30 to50%, which is important in decreasing the potential of root resorption.

Periodontists typically dread enamel reduction for fear of a reduction of theembrasure width and the creation of root proximity. In fact, in the case of an anteriorcrowding, there often already exist root proximities. Even if the reduction is done onthe lower anterior teeth, the amount of enamel reduced never exceeds the amount ofcrowding. Thus, the root proximity is never worsened. On the contrary, the septumends up being enlarged. In the lateral zones, the reduction should always be done so asto allow the use of interproximal tooth brushes.

Operative Protocol1. ARCHFORM SELECTION AND LINGUAL ARCHWIRE TRACING

The final archforms are determined from the initial forms, which are either maintainedor modified. The lingual archwire tracings are obtained by computer, after using aspecific laboratory procedure which allows us to measure the thicknesses of the toothwith its brackets, that is, the distance between the labial face and the bottom of theslot. These tracings serve as a guide for all the treatment steps (Figure 9.3–4).

2. BONDING OF THE LINGUAL APPLIANCES

Bonding is done by an indirect method. All the teeth are bonded except those present-ing an excessively severe rotation. At this point, we act differently from Sheridan whoinitially bonds only the lateral and posterior zones. We prefer to work with a continuousarchwire in order to correctly lock the first molars and to allow arch-form modificationfrom the beginning of treatment.

.-. Tracing of the final lingual archwire obtained by computer (D.A.L.I. program).


3. ALIGNMENT PHASE

Only the teeth that are going to be reduced will be aligned, principally the bicuspids.The rotation of the upper molars will be corrected, if necessary (Figures 9.3–5a to c).In the anterior segment, the initial crowding can be decreased by arch-form modifica-tion and by labial tipping, if this was excepted in the treatment plan. The archwire isfabricated with small expansion loops mesial to the first molars that will allow a slightlabial tipping of the anterior teeth.

4. INTERPROXIMAL ENAMEL REDUCTION BETWEEN FIRST MOLAR AND SECOND BICUSPID

The reduction is carried out with a tungsten carbide bur, type 699 L (Figure 9.3–6),and the polishing is done with a bur with tungsten carbide blades (Komet) (Figure9.3–7). After a brass wire is placed to protect the gingiva and to keep the lips away,the bur is vertically positioned (perpendicular to the occlusal plane), and the move-ment takes place labiolingually with progressive “nibbling” at the enamel with succes-sive movements (Figure 9.3–8). The same movement can be done in a lingual–labialdirection. In the vertical plane, the movement is limited by the brass wire. Someauthors have recommended doing the reduction with vertical movements from bottomto top, placing the bur under the contact point and moving occlusally. On youngadults, there is, danger of compressing the papilla with the protecting wire and render-ing it a painful procedure. Moreover, the “nibbling” movement cannot be done verti-cally, and there is the risk of overheating the bur and tooth by the continuous action.

Polishing is done by horizontal and vertical movements in order to eliminate anyoverhanging enamel which could be formed under the contact point during the reduc-

.- . Correction of the rotated teeth which have to be reduced: (a) At the beginning of treatment.(b) After derotation of rotated teeth. (c) After reproximation procedure.

ing procedure. The periphery of the reduction zone is rounded to have a better toothmorphology. The reduction between the first molar and the second bicuspid is betweenthe minimum value of 0.7 mm and maximum value of 1 mm, taking into account thefact that polishing with multibladed burs create a further reduction of at least 0.1 mm.The use of calibrated thickness gauges allows us to control the reduction.

5. DISTALIZATION OF THE SECOND BICUSPID

The movement to be done has a maximum distance of 1.2 mm, which seems insignif-icant, but it is of the utmost importance not to lose any of the space gained. A figure-eight ligature is tied around the brackets of the first and second molars. The archwireis ligated with stainless steel ligatures on the molar and bicuspid brackets to preventany rotation. An elastic chain is hooked from the first molar to the second bicuspidfor distalization of the biscuspid (Figure 9.3–9).

.-. Carbide bur recommended forreduction (Komet 699 L).

.-. Carbide polishing burs.

.-. Reduction between the first molar and secondbicuspid with a 699 L carbide bur.


6. ENAMEL REDUCTION BETWEEN THE FIRST AND SECOND BICUSPIDS

About 1 mm of space is created between the first and second bicuspids following thedistalization of the second bicuspid. The reduction of the mesial surface of the secondbicuspid and of the distal surface of the first bicuspid is then carried out in the samemanner as in step 4 (Figure 9.3–10). The reduction will be easier to do because thetwo bicuspids will no longer be in contact, but it will be more difficult to preciselylimit the amount of reduction on each surface. At this stage, the reduction is done bynibbling as before, or by placing the bur on the brass wire under the contact pointand then directing the bur occlusally.

7. DISTALIZATION OF THE FIRST BICUSPID

This time, a figure-eight ligature is placed around the brackets of the second bicuspidand the two molars. An elastic chain is hooked from the first to second bicuspid(Figure 9.3–11). The distance of the movement can be more than 2 mm.

8. ENAMEL REDUCTION BETWEEN CUSPID AND FIRST BICUSPID

The same procedure is done on the mesial surface of the first bicuspid and on the distal surface of the cuspid, if the amount of crowding demands a reduction greaterthan 4.8 mm (2.4 mm on each side) (Figure 9.3–12).

.-. Reduction between the first and second bicuspids.

.-. Use of a figure-eight metal ligature around the brackets of the first and second molars and an elastic chain to

retract the second bicuspid.

.-. Use of a figure-eight metal ligature around the brackets of the second bicuspid and molars and an elastic chain

to retract the first bicuspid.

9. CUSPID DISTALIZATION

A steel ligature is placed around the brackets of the two bicuspids and the two molars.The distance of the distal movement of the cuspid can reach 3.5 mm (Figure 9.3–13).

10. ENAMEL REDUCTION OF THE UPPER INCISORS

If necessary, this reduction is done with a diamond disk on the labial side of themesial surfaces and on the lingual side of the distal surfaces. (Evident-Paris: EV 400–100,400–101, 400–102) (Figure 9.3–14). The double gingival and labial protection pre-vents accidents due to slipping of the disk caused by the rotation of the contra-angle(Figure 9.3–15). Enamel sculpting of the lower incisors should be avoided, if possible.If necessary, it is done in the same way as for the upper incisors.

11. ALIGNMENT OF THE ANTERIOR ZONE

An aligning archwire is engaged this time into all the brackets. Rotational elastomericchains are tied to rapidly correct any malposition of the incisors.

Case HistoryFigures 9.3–16a to m demonstrate the use of interproximal reduction in a case, withcrowded teeth and multidisciplinary problems.

A 45-year-old male had severe crowding in both arches, missing teeth (17,31,36,37,47), and gingival recession on 33.

.-. Reduction between the first bicuspid and cuspid. .-. Retraction of the cuspid.

.-. Diamond disk used for reproximation in theupper incisor region. (Evident-Paris)

.-. Lip and gingiva protection duringanterior reduction.


.- . Consecutive sequences of reduction in a crowded case: (a) Front view of the occlusionbefore treatment. (b) Occlusal view of the maxillary arch before treatment. (c) Occlusal view of the maxillary archafter bicuspid reduction and retraction. (d) Occlusal view of the maxillary arch after alignment of all of the teeth.

(e) Occlusal view of the maxillary arch after bracket-debonding and fixed retainer bonding. (f ) Occlusal view of the mandibulary-arch before treatment.

The treatment plan included periodontal treatment (Dr. Kadiri, Casablanca,Morocco) interproximal enamel reduction on both arches after bonding the lingualappliance (Ormco, generation 7 brackets), implants in the lower arch (Dr. P. Khayat,Paris, France), and porcelain laminates (Dr. P. Miara, Paris, France). Total treatmenttime was 18 months, much shorter than usually expected in such cases due to the veryclear and simple interproximal reduction protocol.

DISCUSSION

The recommended reduction protocol is long and the alignment of the anterior zonecan only start after several months of treatment, but it is progressive and the enamel

layer in the anterior region, where it is thinnest, is preserved. Unless contraindicatedfor anatomical or periodontal reasons, the maximum amounts to be reduced on themolars and bicuspids is 1.2 mm, using the 699 L and finishing burs. The decisionwhether to do the interproximal reduction procedure in the anterior zone is clinical

.- . Consecutive sequences of reduction in a crowded case: (g) Occlusal view of themandibulary-arch with Ormco lingual brackets. (h) Occlusal view of the maxillary arch after alignment of all of the teeth. (i) Occlusal view of the mandibular arch after bracket-debonding and fixed retainer bonding. Note the

posterior implants. (j–l) Front and profile views of the occlusion at the end of treatment. (m) Porcelain laminates.(Dr. P. Miara, Paris, France)


and is contemplated during the distalization of the bicuspids. Contrary to Sheridan’smethod, springs are not used either to open spaces between the teeth before reductionor for distalizing the bicuspids. Taking into consideration the small amplitude of themovement of the bicuspids, the molars form a strong anchorage unit, using a continu-ous archwire on which stops will be placed mesial to the first molars. If the anchorageis limited to only one molar, it can be reinforced by the use of auxiliaries like a lipbumper or a labial archwire associated with Class II elastics. After distalization of thesecond bicuspid, the anchorage is reinforced by this second bicuspid.

In spite of the unproven common idea that flattening of the contact points allowsa better stabilization of the anterior teeth, a fixed retainer (cuspid to cuspid) is bondedon all our patients and is kept in the mouth as long as possible. No space reopening inthe reduced zones is observed. Office application of fluoride followed by 2 to 3 weeksof home use of a concentrated fluoride gel is highly recommended during the reduc-tion period to enhance remineralization.

Bibliography

Alexander RG. The Alexander discipline, contemporary concepts and philosophies. Angel GA, ed.1986.

Barrer HG. Protecting the integrity of mandibular incisor position through keystoning procedureand spring retainer appliance. J Clin Orthod 1975;9:486–494.

Boese LR. Fiberotomy and reproximation without lower retention, nine years in retrospect, Part I.Angle Orthod 1980;50:88–97.

Boese LR. Fiberotomy and reproximation without lower retention, nine years in retrospect, Part II.Angle Orthod 1980;50:169–178.

Fillion D. Orthodontie linguale Réflexions cliniques. Rev Orthop Faciale 1990;24:475–498.

Fillion D. Apport de la sculpture amélaire interproximale à l’orthodontie de l’adulte (première partie).Rev Orthop Dento Faciale 1992;26:279–293.

Fillion D. Apport de la sculpture amélaire interproximale à l’orthodontie de l’adulte (deuxième partie).Rev Orthop Dento Faciale 1993;27:189–214.

Fillion D. Apport de la sculpture amélaire interproximale à l’orthodontie de l’adulte (troisième partie).Rev Orthop Dento Faciale 1993;27:353–367.

Gillings B, Buonocore M. An investigation of enamel thickness in human lower incisor teeth. J Dent Res 1961;40:105–118.

Hudson AL. A study of the effects of mesiodistal reduction of mandibular anterior teeth. Am JOrthod 1956;42:615–624.

Paskow H. Self-alignment following interproximal stripping. Am J Orthod 1970;58:240–249.

Philippe J. L’orthodontie de l’adulte. S.D.I. éd., Paris, 1989.

Sheridan JJ. Air-rotor stripping. J Clin Orthod 1985;19:43–59.

Sheridan JJ. Air-rotor stripping update. J Clin Orthod 1987;21:781–788.

Sinclair PM. The reader’s corner. J Clin Orthod 1989;23:110–111.

Tuverson DL. Anterior interocclusal relations: part I. Am J Orthod 1980;78:361–370.

Since Dr. Kinya Fujita, associate professor at Kanagawa Dental College, developed hislingual mechanics in 1970, the number of the lingual orthodontics patients has con-stantly risen in Japan (Figure 10.1–1). Eighty-one percent of adult cases in Japan areextraction cases (Figure 10.1–2). Therefore, a lot of attention must be given to themechanics used to close spaces. In labial orthodontics, the mechanics usually describedin the literature involves canine retraction, and once it is accomplished, upper andlower incisors are retracted. Lingual patients, however, strongly demand that estheticswill be maintained throughout the treatment, which means, in addition to the invisi-ble braces, avoiding opening spaces between the lateral incisors and canines duringtreatment. Therefore, the anterior segment is retracted as one unit.

En masse retraction can cause many mechanical problems such as bowing effect(vertical and transverse) and anchorage control. The vertical bowing effect is the mostserious problem, since it cannot be avoided with simple auxiliaries like transpalatalarches. When a strong retraction force is used in an anterior–posterior direction(Figure 10.1–3), the upper anterior segment (3-3) may tip lingually. The bite planeeffect of the upper lingual brackets can cause posterior disclusion and consequently

.

Sliding Mechanics versusLoop Mechanics During En Masse Retraction inExtraction CasesKYOTO TAKEMOTO, DDS

.- . The number of lingual orthodontists in Japan in the years 1988–1994.

’88 ’89 ’90 ’91 ’92 ’93 ’94

140

340420

520

920960

1000

loss of lateral occlusal function. As a result, bowing effect occurs. When the sameamount of force is applied in both systems (labial and lingual) and the intrusion force(FI) equals the retraction force (FR), the net force vector is pointed directly towardsthe center of resistance (CR) in a labial system (Figure 10.1–4a) but not in a lingualsystem. The net force vector in lingual orthodontics will produce a lingual tippingforce and vertical bowing effect (Figure 10.1–4b). Thus, the retraction force should beminimized during en masse retraction, and more intrusion and torquing force is need-ed to retract the anteriors in lingual orthodontics than in a labial system.

Sliding Mechanics and Loop MechanicsEn masse retraction is performed with sliding mechanics or loop mechanics. Threedifferent kinds of loops are commonly used: closed helical loop (Figure 10.1–5a), L-loop(Figure 10.1–5b), and T-loop (Figure 10.1–5c). Wire friction and uncontrolled retrac-tion force are the main disadvantages of sliding mechanics. As a result, anchorage lossis apt to occur. Other disadvantages are increased depression of lower anteriors due to theforce applied by the anterior bite plane while retracting the upper incisors, the difficulty

.-. Comparison of extraction vs. nonextraction casesin the Takemoto orthodontic office.

.-. Vertical bowing effect.

Non-Ext19%

Ext81%

Posterior disclusion

A-P retraction

Sliding Mechanics versus Loop Mechanics During En Masse Retraction in Extraction Cases

in applying the technique to unusual extraction cases where different teeth are extractedon the right and left sides, and increased retraction time and consequently increasedtreatment time. The technique of sliding mechanics has the advantage of being simpleand effective for preventing transverse bowing effects without using a transpalatal arch.

.-. Momentum analysis of anterior retraction in labial mechanics.

.-. Momentum analysis of anterior retraction in lingual mechanics.

.-. Archwires used for en masseretraction: Closed helical loops mechanics.

.-. Archwires used for en masseretraction: L-loops mechanics.

.-. Archwires used for en masseretraction: T-loops mechanics.

Labial Appliance

O: center of resistanceFR: retraction forceFI: intrusion forceM1: momentD0: Distance to FR

D1: Distance to FI

M1 = D0 • FR – D1 • FI = 0

Intrusion force in LabialAppliance will affect thebodily movement of teeth.

Lingual Appliance

O: center of resistanceFR: retraction forceFI: intrusion forceM2: momentD0: Distance to FR

D2: Distance to FI

M2 = D0 • FR – D2 • FI > 0

However, it may alsoreact as tipping force inLingual Appliance due tothe differences in forcedirection.

O OM1

M2

FRFR

FI

FI

D1

D2

D0D0

Loops mechanics are very effective for closing space without wire friction. In addi-tion, the mechanics allow us to incorporate a bigger tipping bend into the archwire.However, it is quite complicated to bend the wires with the different loops, and itrequires a lot of skill from the orthodontist. The mechanical and cephalometric fea-tures of sliding and loop mechanics were compared in a study.

Material and MethodsFourteen extraction cases were treated with sliding mechanics: 7 cases with maximumanchorage and 7 cases with minimum anchorage.

Thirty extraction cases were treated with loop mechanics: 10 cases with closedhelical loops, 10 cases with L-loops, and 10 cases with T-loops.

Ricket’s cephalometric analysis was used, and 11 different factors were examined:facial axis, facial depth, mandibular plane angle, lower facial height, mandibular arc,lower lip to E-line, total facial height, maxillary convexity, lower incisor to A-pogo-nion (mm), lower incisor to A-pogonion (deg.), and upper molar to PTV.

Anterior incisor torque control, the amount of anterior retraction, anterior intru-sion, and anchorage loss of the upper molars were measured. In addition, treatment

.-. Superimposition of cephalometric tracings to analyze the amount of intrusion.

Table 10.1–1. Results of the Comparison between Sliding Mechanics and Loop Mechanics

Sliding Loop

U1 to FH 11.7 ± 4.9 (max) 6.1 ± 7.1* (T-loop)

21.3 ± 8.1† (closed helical)

U anchorage 1.3 ± 0.7 (max) 0.5 ± 0.8*

L1 to mand. pl. 2.6 ± 1.3 (max) 1.4 ± 0.8* (T-loop)

FX 0.1 ± 0.8 –0.2 ± 0.4

Ret. term 12.6 ± 3.7 9.2 ± 3.7*

* = P < 0.05; † = P < 0.01


time for en masse retraction was measured. The differences in the amount of anteriorintrusion toward the center of resistance was measured before and after treatment(Figure 10.1–6). Statistical t-tests were used to compare the incremental changesbetween sliding and loop mechanics. The significance level for statistical comparisonswas predetermined at P < 0.05 and P < 0.01.

ResultsThe results are summarized in Table 10.1–1.

DiscussionThere was no significant difference in the skeletal pattern between sliding and loopmechanics. Upper anterior torque (U1 to FH) was maintained better with T-loopmechanics compared to sliding mechanics (P < 0.05) and worse with closed helicalloops (P < 0.01). Anchorage (U6 anchorage) was controlled better with all loopmechanics (P < 0.05). Lower anterior intrusion (lower incisor to mandibular plane)was significantly smaller with T-loop mechanics (P < 0.05). There were no significantdifferences in facial axis (FX) between both mechanics which means that there is no

.-. Sliding mechanics for upper arch.

.-. Anchorage control in the upper arch in a mini-mum anchorage case with sliding mechanics.

cl III el cl III el

opening of the mandible with any of the mechanics. Retraction was accomplished in a shorter time with loop mechanics than with sliding mechanics (P = 0.05).

Based on these results, the following protocol for the use of sliding and loopmechanics is recommended:

SLIDING MECHANICS (FIGURE 10.1–7) Archwire: .016 × .022 SS Indications: 1. Minimum or moderate anchorage cases with upper second bicuspidextraction (Figure 10.1–8); 2. nervous patients who do not want auxiliaries like loops;and 3. lower arch extraction cases.

CLOSED HELICAL LOOP OR L-LOOP MECHANICS (FIGURE 10.1–9)Archwire: .016 X .022 SS or .017 × .025 TMAIndications: 1. Open bite cases with little need for upper anterior torque control oractive tipping of anteriors; and 2. closure of small spaces.

T-LOOP MECHANICS (FIGURE 10.1–10)Archwire: .017 X .025 TMAIndications: 1. When maximum anterior retraction is needed while maintaining ante-rior torque; 2. when active intrusion of anteriors is indicated (Figure 10.1–11); and 3. in seventy percent of total extraction cases.

.-. Closing mechanics (closed helical loops)for upper arch.

.- . Closing mechanics (T-loops) for upper arch.

.- . Anchorage control in the upper arch in a maxi-mum anchorage case with T-loop mechanics.

cl II el cl II el


Use of TMA ArchwiresThe wire stiffness of TMA archwire is in the middle of SS and Ni-Ti archwires (Figure 10.1–12). By incorporating T-loops into TMA archwire, the retraction force isreduced to less than half of that of SS and light continuous retraction force is applied.Therefore, the TMA minimizes the reaction on molars when cinching back at the endof the T-loops for activation. When a bigger bowing arch form and a transpalatal archare added into the T-loop TMA, the occurrence of the transverse bowing effect is mini-mized, and the occlusal function in the molars is not lost.

In addition, a TMA archwire has greater resilience and more gable bends, or com-pensative curves can be incorporated into the T-loops to provide anterior intrusionforce. Therefore, when accomplishing bite opening, the anteriors are retracted by theintrusion force while maintaining the dental axis, and there is no need to rely on thebite plane effect of the lingual brackets. As a result, the occurrence of vertical bowingeffect is also minimized while maintaining lateral occlusal function.

.- . The force/deflection graph of different archwires: SS, TMA, and Ni-Ti.

10 20 30 40 50 60 70 80 90

300

250

200

150

100

50

Deflection (degrees)

SS

TMA

Ni-Ti

Ap

pro

xim

ate

forc

e (g

ram

s)

A 30-year-old female presented with skeletal Class I and dental Class II malocclusion,high mandibular plane angle, deep overbite (5 mm), rotated left upper central, ectopicerupted upper cuspids, and mild to severe anterior upper and lower crowding. Thetreatment plan included upper and lower lingual orthodontic appliance (Ormco gen-eration #7) with upper first bicuspid and lower second bicuspid extractions.

Maxillary Archwire Sequence1) .014 Ni-Ti Leveling2) .016 TMA Eliminating rotations3) .016 SS Partial cuspid retraction4) .0175 × .0175 TMA Torque adjusting5) .016 × .022 SS; .017 × .025 TMA En masse retraction with class II elastics 6) .016 TMA Finishing

Mandibular Archwire Sequence1) .014 Ni-Ti Leveling2) .016 TMA Eliminating rotations3) .016 SS Partial cuspid retraction

.

Case Presentation: Loop MechanicsGIUSEPPE SCUZZO, MD, DDS

.- . At initial orthodontic examination: Facial and profile views. Note unesthetic smile.

4) .0175 × .0175 TMA Torque adjusting5) .016 × .022 SS Closing spaces, with class I elastics6) .016 SS Finishing

Treatment SequenceMaxillary Mandibular1) leveling 4) leveling2) torque adjusting 5) torque adjusting3) space closure and en masse retraction 6) space closure

Active treatment time: 36 months

.- . At initial orthodontic examination: intraoral views. Note deep bite, severe crowding and rotations, and midline shift.

Case Presentation: Loop Mechanics

.-. Partial cuspid retraction: .016 SS archwire,transpalatal arch, labial transparent button, elastic power chain fromcuspids to molars, partial engagement of the wire in the anterior region.

.-. .016 × .022 SS archwire for en masse retraction.L-loop mechanics with class II elastics. Posterior and anterior

segments are figure-eighted with SS ligature wire.

.-. .016 SS archwire. Cuspids partially retracted,anterior alignment.

.- .-. Treatment sequence in the maxillary arch.

.-. .016 SS archwire fully engaged. Retraction is continued.

.-. .016 SS archwire. Note power chain from lingual hook of the right cuspid to the buccal metal button of the

right molar for retraction and rotation.

.- . At the end of orthodontic treatment: facial and profile views. Note the pleasant and esthetic smile.

.-. .014 Ni-Ti archwire for leveling. Partial engage-ment of the wire in the anterior region. Power chain from premolars

to molars for partial retraction.

.- .-. Treatment sequence in the mandibular arch.

Case Presentation: Loop Mechanics

.- . At the end of orthodontic treatment: intraoral views. Note cuspid and molar Class I occlusion, arch integrity and correct midline. Lower fixed retainer

(3-3) was bonded and clear vacuum retainer was provided for the upper arch.

.-. Cephalometric superimposition tracing: beforeand after the treatment. Note the minimal change in the molars,

retraction of the upper centrals, and intrusion of the lower centrals.

A 53-year-old female presented with slight crowding in both dental arches, Class IIDivision I malocclusion with excessive overjet and extensive dental restorations.

The treatment plan included placement of maxillary and mandibulary lingualappliances (Ormco, generation #7). In the maxilla, the left first bicuspid and right sec-ond bicuspid were to be extracted. The decision to extract the right second bicuspidwas based on the condition of the crown; although it had recently been placed it wasdetermined that the long-term prognosis would be improved with its removal. Noteeth were to be extracted in the mandible. The patient was treated to a Class II molarand Class I cuspid relationship.

Fourteen days after the records and face bow transfer were taken, all brackets werebonded. Upper and lower .0175 Respond sectional archwires were placed in the upperarch from 3-3 and in the lower arch from 5-5. Upper extractions were completedimmediately afterwards.

One month after the initial bonding, separators were placed for banding of bothmaxillary first molars and left second molar. In the mandible, the corresponding teethwere also banded. (All banded molars had been crowned.)

Upper and lower .016 TMA wires were placed to begin leveling and alignment(Figures 10.3–1a to e). Four weeks later, an upper .016 × .022 SS archwire wasplaced. In the maxilla, the wire was not fully engaged to the anterior rotated teeth(Figures 10.3–2a and b). The SS rectangular wire allows controlled and completeretraction of the right first bicuspid and preliminary retraction of the left cuspid. Theupper buccal molar segments were ligated together to act as anchorage units. Powertubes and power chains were placed to provide force (sliding mechanics). The patientwas seen every 3 to 4 weeks for the next 3 months to replace the power products.Once adequate space had been gained to correct the alignment of the upper incisors,the original .016 TMA was replaced, and all rotations were corrected (Figures 10.3–3aand b).

Three month later, the upper .016 × .022 SS archwire was replaced and a trans-parent labial button bracket was bonded to the right first bicuspid. A power chain wasadded from this button to the labial molar tubes. This enabled dual force mechanicswithout rotation of the tooth during the retraction (Figure 10.3–4).

After another 3 months, the bicuspid was completely retracted. The right buccalsegment was figure-eighted to include the bicuspid in the posterior anchorage unitand the anterior segment was also figure-eighted with stainless steel ligature wire.Power tube and power chain were placed from bicuspid to cuspid to supply the forcefor the en masse retraction of the anterior segment (Figure 10.3–5a and b).

.

Case Presentation: Sliding MechanicsJ. COURTNEY GORMAN, DDS, MS

.- . One month after the initial bonding; .016 TMA wire was placed in both arches: (a) Frontal occlusal view. (b) Left buccal view. Note the enlarged overjet and asymmetric extraction sites.

(c) Right buccal view. (d) Occlusal view of the mandibular arch, .016 TMA wire was placed on both arches. (e) Occlusal view of the maxillary arch.

.- . Two months in treatment. Note upper .016 × .022 SS archwire is not fully engaged in the anterior rotated teeth.

Case Presentation: Sliding Mechanics

.- . Eleven months in treatment. The right upper buccal segment was figure-eighted to include the bicuspid in the posterior anchorage unit. The anterior segment was figure-eighted as well.

A lower .016 × .022 SS archwire was placed.

.- . Five months in treatment. The upper original .016 TMA was replaced to correct all rotations. Lower alignment continues with .016 TMA.

.-. Eight months in treatment. The upper .016 × .022 SS archwire was replaced and a transparent labial but-

ton bracket was bonded to the right first bicuspid for retraction.

It took another 14 months to complete the space closure and final detailing of theteeth. During this time, the process was interrupted two times for repair of loosebrackets. During the last 5 months, the patient wore a 6 oz 1/4'' Class II elastic on theleft side, from the lingual bracket of the left upper lateral incisor to the labial hook ofthe lower second molar. All appliances were removed after 26 months of treatment, 2 months ahead of the pretreatment estimate (Figures 10.3–6a to c). Clear overlayretainers were delivered on the same day of debonding, and the patient was instructedto wear them full-time for 2 months and then nights only. The patient was verypleased with the results. She stated on many occasions that the lingual appliance wasthe only reason she was willing to undergo treatment.

.- . Eleven months in treatment (before debonding). (a) Frontal occlusal view. (b) Occlusal view of the maxillary arch. (c) Occlusal view of the mandibular arch.

Lingual orthodontics has developed as a result of the ever-increasing demand for anorthodontic therapy with acceptable esthetics. Even though at the beginning the lin-gual technique was addressed almost exclusively to adult patients to avoid discomfortand the embarrassment of wearing a labial appliance, it is also applicable in mixeddentition malocclusions. Not every patient is a suitable candidate for such a treatment,and the following criteria are recommended:

1. Age: Children who have at least concluded the first period of secondary dentition,which means full eruption of the four permanent incisors (about 8 to 9 years).Patients in late mixed dentition are extremely sensitive about their appearance.

2. Responsibility or motivation: The sense of responsibility and motivation must bevery high, as this technique requires a stricter regimen and more constant collaborationcompared to classic labial techniques. An initial interview with the child and his/her parents will help the patient selection.

3. Oral hygiene: A motivation towards good oral hygiene is fundamental. Poororal hygiene is an absolute contraindication to any orthodontic therapy, especially lingualorthodontic therapy which requires much more effort from the patient. Since the“critical” zone is located exclusively at the upper incisors, a few simple devices andauxiliaries are indicated.

4. Phonetics: Some authors deem that such appliances can give rise to problems in speaking. Our clinical observation after many years of treating children with lingualorthodontics is that after the expected initial discomfort period, the speech returns tothe same as it was prior to bonding. Patients with severe problems of dyslalia are notrecommended to be treated with lingual appliances.

5. Esthetics: The concept of self-image plays an important role in adolescence, andthe esthetic needs of the young patient has an effect on his or her personality andbehavior. In this respect, some extremely positive data has emerged from unpublishedresearch carried out by the author on young patients treated with lingual appliances.Tests were given, including drawings and questionnaires, concerning esthetic appear-ance, oral hygiene, and phonetics. The youngest patients were happy to have an invisi-ble appliance but did not keep it a secret from their friends like adults usually do. Onthe contrary, they were proud to belong to a “brace” group of friends, even if in amore exclusive way. In adolescence, on the other hand, when a psychological relation-ship with the opposite sex begins, the lingual appliance is kept secret. It helps to avoidthe embarrassment which arises when smiling with a traditional appliance. This is theperiod during which young people continually look at themselves in the mirror, and itis satisfying for them to be able to see an improvement taking place day by day, with-

Lingual Orthodontics in Pediatric PatientsLORENZO FAVERO, MD, DDS, MSc

out having to go through an “ugly duckling” period. In the illustrations made by theyoungest patients, the patient’s face was drawn without any visible appliance, and hap-piness and appreciation are symbolized.

Therapeutic IndicationsThere are some malocclusions in mixed dentition that are suitable for early treatmentwith a lingual appliance:

Skeletal Class I with dentoalveolar open bite (caused by atypical deglutition,thumb sucking, and tongue thrusting); skeletal Class I with dentoalveolar deep bite;moderate occlusal Class II Division I with dentoalveolar deep bite; Class II Division IIwith dentoalveolar deep bite; pseudo Class III with functional anterior shift (i.e., skeletalClass I and dental Class III); and skeletal Class III with hypomaxilla.

Other malocclusions can also be resolved with lingual appliances without any limits. Particular care and practice are necessary in more difficult cases like Class I withserious crowding, Class II Division I open bite caused from mandibular divergence, or skeletal Class III with a mandibular component.

Anatomical and Biomechanical EvaluationsAll the known advantages of lingual orthodontics are more evident in young patients.From the biomechanical point of view, the center of resistance (CR) of the tooth isnearer the point of application of the force compared to adults, as demonstrated bythe work of Pederson et al. (EJO 1991; 13:65–74); as a result, the moments arediminished, and the bodily movement of the dental elements is much easier and moreimmediate.

Operative ProtocolLingual orthodontics in young patients is frequently used in the upper arch and seldomin the lower arch. The upper molars and the central and lateral incisors are usuallybonded as would be done in an adult patient. A buccal tube on the molars is necessary incase of extraoral traction or the use of auxiliary superstructures. Bonding of the primary

- . Pendulum “F” (Favero). -. Molar bands provided with a double tube for laterplacement of transpalatal bar, after distalization with Pendulum “F”.

Lingual Orthodontics in Pediatric Patients

second molars is highly recommended since these teeth will be present in the arch fora long time, have good clinical crowns and anatomical dimensions, and have highanchorage value.

Bonding of the first primary molars and primary cuspids must be avoided as theyare small and often exfoliate during the treatment. In the course of therapy, the firstpermanent premolars can be utilized while they are erupting. Their insufficient clinicalcrowns can be visualized with retraction cord inserted in their eruptive pseudopocketwhile taking the impression. This method is also used when the upper lateral incisorsare partially erupted or have anomalous inclinations.

One must also consider the interbracket distance between the upper lateral incisorsand primary second molars. This space is not wide because the deciduous canine andthe first primary molar present smaller mesiodistal dimensions compared to their permanent successors. The wire offset between the primary cuspid and the primary molaris very small because of the anatomical arrangement of deciduous teeth in the arch andthe absence of the canine protuberance, and because the contraction loops that are used

-. Pendulum “F.” The acrylic part is larger than usual to give support for the TMA archwire section which is used to

align the front teeth.

-. Pendulum “F.” Contraction TMA loops in an open-bite case.

-. Pendulum “F.” The anterior bite effect of the anterior lingual brackets facilitates molar distalization. Sagittal

screw to activate the appliance.

-. Pendulum “F.” A tongue crib is inserted into theacrylic button in cases of open-bite and tongue-thrust habits.

mesially to the primary second molars to increase the resilience in this area and to applymore gradual strength at a distance also occupy some of the interbracket space.

Pendulum “F” MechanicsOne of the advantages of early treatment is reduced treatment time due to the use ofspecific mechanics from the early phases of the therapy. The Pendulum appliance thatwas described by Hilghers was adapted and modified by the author for the lingualtechnique and called Pendulum F (Figure 11–1). The lingual part of the bands areprovided with a double tube (Figure 11–2). The larger tube is used for stabilizing themolars after distalization by means of a transpalatal bar. The acrylic part is larger thanusual to give support for a TMA archwire section which is used to align the frontteeth, through the lingual brackets, which have been bonded since the beginning oftreatment (Figure 11–3). This type of archwire can be bent in various ways accordingto its use, with expansion or contraction loops and intrusion or extrusion forces(Figure 11–4). It permits immediate, decisive alignment and increases the anchorageto the appliance. Thanks to the bite effect of the anterior lingual brackets, the arch is setfree, allowing a greater molar distalization (Figure 11–5). A tongue crib can be insertedinto the acrylic button in cases of open-bite and tongue-thrust habits (Figure 11–6).Pendulum F can be also used as an orthopedic maxillary expander (Figure 11–7).

Laboratory ProceduresSpecific instructions to the laboratory should be given for young patients with decidu-ous teeth:

1. The diagnostic program of each patient should be described since we are deal-ing with an interceptive treatment.

2. The deciduous dental elements that will be extracted or reduced in size shouldbe taken into consideration while preparing the set-up, such as the deciduouscanines that may be extracted or stripped mesially to obtain a correct position-ing of the incisors at the midline.

3. The use of the retraction cord in partially erupted, crowded, or rotated teeth

-. Pendulum F used as an orthopedic maxillaryexpander.


(Figures 11–8a and b) is not always possible, and a new impression should betaken at a later stage.

4. Late erupting teeth like the first permanent premolars should be bonded separately.

CASE REPORT

A 10-year-old girl presented with Class I malocclusion, anterior cross-bite (2|2) and midline deviation (Figures 11–9a and b). The maxillary arch (Figure 11–10) wasaligned with a lingual appliance (Ormco, generation #7) bonded on the upper centraland lateral incisors, second primary molars and first molars (Figure 11–11). Themandibular arch (Figure 11–12) was treated with the same appliance bonded with theCLASS technique on the incisors, cuspids, and first molars, combined with a lipbumper (Figures 11–13a and b). Cervical traction and Class II elastics were added(Figure 11–14). Harmonic and balanced occlusion was achieved, and the midline wascorrected (Figures 11–15a and b).

- . Facial and lateral clinical views before treatment: Note Class I malocclusion, anterior cross-bite and midline deviation.

- . Retraction cord is used in partially erupted, crowded, or rotated teeth: (a) Before insertion of the retraction cord. (b) After insertion.

- . Pretreatment view of the maxillary arch.

- . Pretreatment view of the mandibular arch.

- . Lingual appliance (Ormco, generation #7) bonded on the upper central and lateral incisors, second primary

molars, and first molars.

- . CLASS technique used for indirect bonding ofmandibular arch with lip bumper. Stripping of the second deciduous

molar to gain leeway space.

- . Lingual appliance (Ormco, generation #7)bonded on the incisors, cuspids, and first molars.


ConclusionLingual therapy in the pediatric patient shows simple, modern, and diversified use.The numerous advantages are represented by a remarkable psychological acceptability,smaller interferences with removable appliances, a shorter treatment time, biomechan-ical advantages (such as increase of sagittal and transverse expansive effects), a greatereffectiveness of superstructures such as elastic bands, and a greater consideration foresthetics that translates into a greater acceptance of orthodontic therapy.

BibliographyAlexander CM, Alexander RG, Gorman JC, et al. Lingual orthodontics: a status report. J Clin

Orthod 1982;16:255.

Favero L. L’ortodonzia linguale nel paziente giovane. Atti del 3° Congresso Nazionale del “Collegiodei Docenti di Odontoiatria” Roma 1996.

Favero L. Proper mechanics in pediatric lingual orthodontics. 2nd Symposium European Society ofLingual Orthodontics Principaut de Monaco 1996.

Favero L, Tagliapietra S. Lingual orthodontics in paediatric patient. The First ESLO Congress.Proceedings and abstracts. Venice 1993.

Fujita K. Multilingual-bracket and mushroom archwire technique. Am J Orthod 1982;82(2):120–140.

- . Cervical traction and Class II elastics were added.

- . Facial and lateral clinical views after treatment: Note harmonic and balanced occlusion with a corrected midline.

Nidoli G, Macchi A, Lazzati M. Migliora l’estetica con l’incollaggio linguale dei brackets. Attualitàdent. 1988;4(18).

Pedersen E, Andersen K, Melsen B. Tooth displacement analysed on human autopsy material bymeans of a strain gauge technique. Euro J Orthod 1991;13:65–74.

Ronchin M. Tecnica individuale di montaggio indiretto degli attacchi linguali. Ediz. AudiovisiveMedical Video. Milano 1991.

Siciliani G. Apparecchiature ortodontiche linguali esperienze cliniche. Dental Cadmos, 1988;18:17–41.

Siciliani G, Fassetta F, Mula L. “Problematiche fonetiche nelle apparecchiature ortodontiche adapproccio linguale.” Quaderni di Odontostomatologia, Anno IV:1, 1987.

Velo S, Dal Broi G, Piubelli. Lingual technique silent and invisible orthodontics. The First ESLOCongress. Venice 1993.

The existing close relationship between maxillofacial surgery and orthodontics allows aprecise and complete resolution of most dental and maxillofacial deformities and theoverall restoration of a harmonious structural and functional stomathognatic apparatus.

In the last few years, the close collaboration of these two disciplines has been furtherenhanced by the mutual evolutions of the Rigid Internal Fixation (RIF) technique of the maxillofacial surgeon and the lingual technique of orthodontics. By using RIFas a means of surgical retention of the skeletal segments which are mobilized in thetreatment of the maxillomandibular malformation, it is not necessary, as in the past,to provide intermaxillary fixation at the end of a surgical operation. This allows theorthodontist to use the lingual technique in the pre- and postoperative treatments ofsuch pathologies.

The esthetic requirements of many adult patients are definitively met by such acombined therapy. These esthetic needs are important and should be taken into con-sideration by the doctors involved in their treatment. In the case of presurgical ortho-dontics, such needs can be met by employing the lingual technique in a traditionallyrigid method.

The lingual brackets are indirectly applied by the employment of transferingmasks constructed by means of articulated mounting casts, surgical–orthodonticVTO, and set-up of dental casts (CLASS Method), and then indirectly bonded.

The purpose of the presurgical orthodontic therapy with the lingual technique arethe same as those using a labial technique—to prepare the dental arches prior tomanipulation of the skeletal bases. Therefore, it is necessary to first eliminate as manyof the dental–alveolar components of the malocclusion as possible, leaving only themalformed skeletal components to be corrected by the maxillofacial surgery.

Orthodontic Operative Protocol The alignment and leveling of the arches will be carried out by initially proceedingwith light wild-cat type or .016 TMA, following by stronger archwires (rectangular.016 × .022 SS or .018 × .025 SS). In cases of crowding, the dental extractions willproceed as usual only in cases of real dental–skeletal discrepancy. We should try toposition the upper and lower incisors in correct axial relation to the respective skeletalbases (bispinal level and mandibular level) so that at the end of the presurgical prepa-ration, the sagittal discrepancy at the interincisor level corresponds to the sagittal dis-crepancy on the skeletal bases (points A and B). Therefore, the occlusal set-up of thedental casts and the preparation of the transferring masks are of primary importance,both for efficient presurgical orthodontics and for a valid structural and esthetic result.

.

The Lingual Techniquein Orthognathic SurgeryALESSANDRO SILVESTRI, MD, DDS, ENT

When expansion of the maxillary arch is needed as part of the presurgical lingualtechnique, there are two treatment options:

1. If the traverse expansion is accomplished in the presurgical orthodontic phasewith a Quad-Helix (QH) or a Rapid Palatal Expansion (RPE) appliance, the

.- . Frontal and lateral facial views at the beginning of treatment. Note the small esthetic anomalies (midline shift of the chin and long face syndrome).

.- . Pre-treatment front and laterals views of the occlusion. Note the Class III malocclusionwith an anterior open bite and posterior cross-bite caused by a real contraction of the upper arch.

The Lingual Technique in Orthognathic Surgery

impression for the lingual appliance is taken only after this first expansionphase is completed.

2. Surgical expansion can be accomplished together with the repositioning of themaxillary components with an intermaxillary disjunction LeFort I osteotomytechnique. In this case, the initial set-up of the dental casts will be for thepresurgical, nonexpansion orthodontic phase, and once the orthodontic prepa-ration is completed, a second presurgical set-up will be constructed with whichthe intermaxillary corrections will be planned. On this set-up, a surgical splintwill then be constructed, and this will serve as the guide for the correct reposi-tioning of the skeletal maxillary segments.

Surgical Operative Protocol The orthodontist should apply vestibular buttons with an esthetic material (like poly-carbonate, glass, or ceramic) just prior to the surgery to offer the surgeon an anchorduring the operation. They should be symmetrically positioned on both sides of thearch on the canines, first premolars and central incisors. As well as offering the neces-

.-. Lower lingual appliance (Ormco, generation #7)..016 TMA archwire with vertical loop to obtain the rotation of

the right lower cuspid.

.-. Quad-Helix in the maxillary arch for bilateralexpansion.

.-. Upper lingual appliance (Ormco, generation #7).016 TMA archwire.

sary intermaxillary anchorage in the operating room, it will also allow, in the postsur-gical phase, the possibility of applying intermaxillary elastics, which are normally usedfor the neuromuscular rehabilitation, to optimize the dental intercuspation. In case ofmaxillary surgical expansion as with labial orthodontics, the lingual orthodonticpatient will be surgically treated via two upper sectional arches to facilitate the inter-maxillary disjunction and the repositioning of the two skeletal segments so that it isnot necessary for the surgeon to section the orthodontic arch. The occlusal splint canbe removed quickly after the operation or, at the latest, 7 to 10 days postsurgically. Atthis time, a continuous archwire should be applied in the place of two upper sectionalarches to stabilize the maxillary arch. Rigid internal fixation with the use of plates andscrews eliminates the need for postsurgical intermaxillary blockage.

.-. Facebow registration before the surgery.

.-. Set-up VTO cast models before the surgery.

The Lingual Technique in Orthognathic Surgery

Some surgeons still use postsurgical intermaxillary blockage, which does not allowpostoperative examination of the site nor the proper hygiene of the lingual orthodon-tic appliance, causing great inconvenience to the patient who is already inconveniencedby the blockage itself. Therefore, the lingual orthodontic technique is indicated onlyin cases when the surgeon uses rigid internal fixation.

Case PresentationA 28-year-old female presented with very slight esthetic problems including profilealterations (Figures 12.1–1a and b). Her occlusal and radiographic findings revealed aClass III malocclusion, an anterior open bite, upper dental crowding, and a posteriorbilateral cross-bite (Figures 12.1–2a to c).

The presurgical orthodontic lingual treatment plan included alignment of thelower arch with a lingual appliance (Figure 12.1–3). The upper arch was expandedwith Quad-Helix (Figure 12.1–4). Alignment and leveling of the arch were completedwith the lingual appliance (Figure 12.1–5). Facebow registration and set-up VTOmodels were prepared before the surgery (Figures 12.1–6a and b). Ceramic brackets

.-. Front view of the occlusion before surgery withthe esthetic labial brackets.

.-. Lateral cephalometric radiograph. Plates and screws for the RIF are visible.

were bonded two days before the surgery (Figure 12.1–7). The maxillofacial surgeryhas anticipated in the maxilla a LeFort-I osteotomy with impaction of 4 mm in theposterior region and 1.5 mm in the anterior region. In the mandible, a bilateral sagit-tal osteotomy was performed with a counterclockwise rotation of the mandible.Surgical retention was gained by RIF (Figure 12.1–8).

The surgery was followed by an orthodontic phase of neuromuscular rehabilita-tion and the perfection of the occlusion (Figures 12.1–9a to d).

.- . Post-treatment views of the occlusion. Note the Class I occlusion, correct sagittal and vertical relationships, and nice smile line.

.- . Front and lateral facial views at the end of treatment.Note the shorter face and pleasant profile.

Surgical Rapid Maxillary Expansion (RPE) is a procedure relatively well known toorthodontists and oral surgeons alike. Its purpose is to help achieve maxillary expansionin adult cases. Some of the advantages of this technique are less morbidity than incomplete LeFort procedures; it can be done as an outpatient procedure; a midpalatalincision is avoided; and a fixed expansion appliance (Hyrax) can be placed prior tosurgery. Surgical RPE is also less costly, and patient recuperation time is reduced. Inlingual orthodontic treatments, a different protocol should be used since both theRPE and the orthodontic appliance are bonded on the same side of the teeth.

Case ReportA 27-year-old male presented with dental and skeletal Class III malocclusion withanterior open bite, maxillary transverse and antero-posterior deficiency, bilateral poste-rior and anterior cross-bite and mandibular crowding (Figure 12.2–1). Since themandibular position was good and did not reflect the severity of the Class III dentalocclusion, a more conservative approach which involved surgical RPE was considered.Impressions for lingual appliances were taken, and immediately after bonding of thelingual brackets another impression was taken and the Hyrax RPE appliance wasbonded (Figure 12.2–2). After adequate consultation, the patient was referred to theoral surgeon (Dr. Stephen Nahigian) and the surgery was performed under light anes-

.

Orthodontic-Surgical RPE Camouflage on anOrthognathic CaseMARIO E. PAZ, DDS, MS

.-. Frontal view before treatment: Note the open bite and anterior and bilateral posterior cross-bites.

thesia supplemented by a local anesthetic nerve block. An incision was made in theheight of the buccal vestibule from the mesial aspect of the first molar to the distalaspect of the canine (Figure 12.2–3). The lateral maxillary wall was exposed bymucoperiosteal elevation from the piriform anteriorly across the zygomatic maxillarybuttress, then posterior to the pterygomaxillary fissure via a subperiosteal tunnelingtechnique. A fissure bur was used to effect an osteotomy approximately 5 mm abovethe apices of the teeth from the piriform rim to the zygomatic maxillary buttress, end-ing just anterior to the pterygoid fissure. Special care should be taken at the anterioraspect of the osteotomy to avoid tearing of the nasal mucoperiosteum by using a freerelevator as a tissue guard. Prophylactic antibiotics, nasal decongestants, and analgesicswere prescribed.

The appliance was activated four turns (1 mm) at the time of surgery to absorbsome of the elastic properties of the appliance. On the third postoperative day, thepatient was instructed to activate one turn in the morning and then one turn in the

.-. Occlusal view during treatment: the lingual appli-ance from cuspid to cuspid, and Hyrax is attached to the first bicuspids

and molars along with the posterior segmental labial appliance.

.-. Initial laser dissection with exposure of maxillary wall.

.- . One week postoperativeexpansion: clinical and radiographic view.

Orthodontic-Surgical RPE Camouflage on an Orthognathic Case

evening, until adequate expansion had been achieved (Figures 12.2–4a and b). Theappliance was left in place for 12 weeks in a passive position. At this time routineorthodontic procedures can be initiated or continued. If needed, extraction of thebicuspids can be made at the same time as the surgical RPE.

Results showed a marked cosmetic and functional improvement in the dentalocclusion and smile line (Figure 12.2–5). The cross-bites, open bite, and crowdingwere improved, and the profile was maintained. (The cosmetic restorative treatmentwas done by Dr. Soheil Goel.)

A double jaw orthognathic surgical procedure could have achieved a similar, orbetter, result but would have also increased morbidity and financial costs. SurgicalRPE can be considered a safe, simple, and reliable procedure for achieving a perma-nent increase in skeletal maxillary width in adult patients.

BibliographyBasdra EK, Zoller JE, Komposch G. Surgically assisted rapid palatal expansion. JCO 1995;

29:762–766.

Glassman AS, Nahigian SJ, et al. Conservative surgical orthodontic rapid palatal expansion: sixteencases. Am J Orthod 1984;86:207–213.

Isaacson RJ, Murphy TD. Some effects of rapid maxillary expansion in cleft lip and palate patients.Angle Orthod 1964;34:143–154.

Isaacson RJ, et al. Forces produced by rapid maxillary expansion. Angle Orthod 1969;34:256–269.

.-. Frontal view after treatment. Note the harmonic and esthetic occlusion.

Prosthetic orthodontics, orthodontic treatment that is usually done in prosthetic cases,has many advantages. Treatment is usually very short, retention is permanent via thefixed prosthesis, and it is another important source of patients. The lingual appliancehas an advantage in prosthetic patients because they are usually adults who do notwish to have any visible labial appliances. However, the high cost of the treatment andthe speech difficulties that arise in certain stages of the lingual treatment are some-times crucial disadvantages of the lingual appliance therapy in those patients.

Segmental lingual preprosthetic orthodontics can overcome these disadvantages.Good esthetics is achieved with the lingual brackets, the cost of a segmental treatmentis lower compared to a full treatment, and it is more comfortable for the patient withfewer speech problems. Small orthodontic problems can be solved easily and quicklywith the segmental technique. Some of the most frequent problems that the prostho-dontists ask the orthodontists to treat, and which can be easily solved with segmentedlingual appliance are:

1. Uprighting of molars with space closure (Figure 13.1–1) or with space opening(Figure 13.1–2).

2. Forced eruption (Figures 13.1–3a and b).3. Lingual or buccal cross-bites (Figure 13.1–4).4. Teeth rotations (Figure 13.1–5).

.

Segmental LingualOrthodontics inMultidisciplinary CasesPABLO A. ECHARRI, DDS

.- . Uprighting of a mesially tipped molar with space closure.

.-. Uprighting of a mesially tipped molar with space opening.

1'' ARCO

Transpalatal bars and temporary bridges are used to enhance anchorage. When aforced eruption of an upper anterior incisor is done, a temporary crown will improvethe appearance during the treatment. Composite coverage of exposed metal will dothe same (Figures 13.1–6a and b). Small indirect bonding transfers are made the sameway as in full arch bonding (Figure 13.1–7). A small vacuform retainer is made at theend of the minor teeth movement, on the day of debonding, to facilitate the subse-quent prosthetic treatment (Figure 13.1–8). The design of the fixed retainer is madeby all the experts that are involved in the case, including the orthodontist, perio-dontist, and prosthodontist. Lingual bonded retainers, fixed bridges, and implants areused to retain the orthodontic results. Bonded porcelain veneers can also be usedwhen deep-bite malocclusions are treated (Figures 13.1–9a and b).

The keys for a successful segmental lingual preprosthetic treatment are:

1. the anomaly affecting only a single tooth or a small, isolated group of teeth2. only simple tooth movements required 3. the use of indirect bonding of brackets to the teeth4. immediate retention with a clear vacuform retainer.

.- . Anterior incisor forced eruption. Note the temporary crown to enhance esthetics.

.-. Molar cross-bite treated withtranspalatal bar and segmental lingual brackets

for anchorage.

.-. Rotation of cuspids. Anchorage isgained by posterior temporary bridges.

Segmental Lingual Orthodontics in Multidisciplinary Cases

The short treatment time, good esthetics, and low cost make the segmental lingualpreprosthetic treatment an excellent option for the lingual orthodontist.

.- . Esthetic coverage of metal band with composite material.

.-. Indirect bonding transfer tray. .-. Vacuform retainer used on theday of debonding.

.- . Bonded porcelain veneers used to retain deep bite malocclusion treatment.

BibliographyBurgos G, Moreu J. Ignacio Garcia Espona Alargamiento coronario vs. erupcion forzada. Archivos

de Odonto Estomatologia 1995;11:509–515.

Echarri LP. Syllabus de ortodoncia: Biomecnica 2, Aparatologa Fija. 4th Ed. Badalona, Espana: Ed.Ladent SL, 1995:9–21,30–35,47–49.

Gollner P, Bantleon H-P, Ingervall B. Force delivery from a transpalatal arch for the correction ofunilateral first molar cross bite. European J Orthod 1993;15:411–420.

Marcotte MR. Biomechanics in orthodontics, Spanish version. Burlington, Ontario: BC Decker,1992:1–44,127–152.

Proffit WR, Fields HW Jr., Ackerman JL, et al. Contemporary orthodontics. St. Louis, Missouri:CV Mosby, 1986:472–518.

Most lingual orthodontic patients have greater demands and expectations than do labialorthodontic patients since they are usually adults, esthetics is sometimes a crucial factorin their profession (models, TV performers, etc.), very few orthodontists practice lingualorthodontics, and the price is much higher. Even those who can easily afford it, wantto receive more than the usual patient. Good esthetics and normal function are twogoals to consider, not only at the end of treatment but also during the treatmentcourse, especially in type A personality patients (Sinclair, 1986). Esthetic demandsduring treatment include preservation of arch integrity, no opening of space, and nounesthetic auxiliaries. Normal function during the treatment includes minimal speechdisturbances and elimination of pain.

Many of these aspects have been previously discussed, and the protocol of treat-ment has been accepted worldwide. Still, on occasion, improvisations and changesneed to be made to the usual protocol because of unexpected patient reactions. Speechproblems are of primary concern, especially during the first month or two. Support ofthe patients during this uneasy initial period is imperative to encourage them and toevaluate the adaptation and adjustment period.

Case PresentationThe following case presents an alternative orthodontic–prosthodontic treatment. A26-year-old male TV performer and singer presented with skeletal and dental Class Imalocclusion with deep bite and increased overjet. He was complaining of an unes-thetic appearance due to rotated upper cuspids and to spaces that were left after theprevious extraction of retained deciduous upper cuspids (Figures 13.2–1a to c).

The initial treatment plan consisted of opening the bite, rotating the cuspids, andretracting the anterior segment en masse. The treatment included an upper lingualappliance, Ormco Kurz (generation #7), bonded to teeth 7-7 in the upper arch only.The patient was sent to a myofunctional therapist before and immediately after plac-ing the appliance to help him adjust to the appliance and attempt to compensate forhis anticipated speech difficulties.

Although most of his speech disturbances completely disappeared, only 4 weeksafter the appliance bonding and after several meetings, the patient insisted on stop-ping the treatment and debonding the appliance because he could not perform onstage as before.

.

Combined Orthodontic-Prosthetic Treatment ofMalpositioned Anterior TeethRAFI ROMANO, DMD, MSc, AND NITZAN BICHACHO, DMD

Eventually, he was convinced to debond only four of the anterior brackets (2-2),and, fortunately, this improved his reaction. The treatment plan was changed toaccommodate the new circumstances.

A combined orthodontic–prosthetic solution was suggested because space closureby retraction of the anterior segment and overjet closure was now excluded due to theanterior bracket removal. The new immediate treatment plan was to orthodonticallyretract the cuspids distally and at the same time to prosthetically restore the spacesthat would now open between the cuspids and the lateral incisors. The use of a hybridcomposite resin to close the spaces would allow periodic adjustments during ortho-dontic movement to maintain normal and esthetic function.

.- . At initial orthodontic examination: frontal and lateral views. Note the unesthetic space between the cuspid and first premolar, and the rotated cuspid.

.-. Occlusal maxillary view: lingual Ormco brackets, segmental technique.

Combined Orthodontic-Prosthetic Treatment of Malpositioned Anterior Teeth

The final treatment plan was to bring the cuspids to their optimal position withno rotation and with minimal spaces from them to the lateral incisors and to the premolars. Porcelain laminates would then be made for the cuspids and first premolarsto fill the proximal spaces. Porcelain laminates were chosen because they would pro-vide a stable and long lasting esthetic solution while conserving tooth structure.

A segmental technique was used to retract the cuspids, and the lingual buttonsthat were bonded on the cuspids were replaced with Kurz-Ormco lingual brackets assoon as enough retraction was accomplished to enable single-tooth indirect bonding(Figure 13.2–2). Because the retraction of the cuspids caused an unesthetic appearanceafter 3 months of treatment (Figures 13.2–3a and b), the patient was referred to theprosthodontist to close the spaces temporarily. Since the tooth rotation was not yetfully corrected, large spaces were evident in the interdental papillae areas. Using ahybrid composite resin (Prodigy, Kerr, Glendora, CA), the distocervical surfaces of thelateral incisors were widened (Figures 13.2–4a and b). The mesial surfaces of the cus-pids were augmented with the resin to create rotation illusion in a distobuccal direc-tion and to close the existing spaces, allowing the formation of a healthy interdentalpapillae. Since most natural cuspids are asymmetrical, this discrepancy between thehomological teeth was used to create a natural and balanced asymmetry. Four monthslater, when the cuspids were orthodontically brought to their final positions, thepatient was referred again to the prosthodontist for completion of the treatment.

.- . Lateral views during treatment. Note the space opening during the cuspid retraction.

.- . Temporary composite resin restorations: Hybrid composite resin bonded incrementally to the distocervical surfaces of the lateral incisors, and mesial aspects of the canine.

Upon completion of the orthodontic treatment, spaces existed between the firstpremolars and the cuspids and between the cuspids and lateral incisors. It was decidedto close these spaces permanently, by changing the contours of the first premolars andcuspids. The treatment of choice was bonding of porcelain laminate veneers, in orderto conserve tooth structure and obtain excellent long-term stability (Figures 13.2–5ato e). A 1-mm-thick vacuformed retainer was provided for retention at night.

The overall treatment time was 8 months, a comparatively short time. The patient’smain problem was fully solved, and his appearance was maintained during all stages ofthe treatment.

.- . Porcelain laminate veneers fabrication stages: (a) Diagnostic wax-up on plaster model.(b) Provisional composite resin laminates. (c-e) At the end of treatment: single porcelain veneers, frontal and

lateral views. Note the harmonic and esthetic occlusion.

A functional and esthetic occlusion is the ultimate goal of every orthodontic treatment.There are many methods used by orthodontists and prosthodontists to evaluate thefunctional occlusion during and after orthodontic treatment. An evaluation is usuallybased on the mandibular position and the border jaw movements. Functions to beevaluated are chewing, swallowing, speech, and facial expressions. These functions donot use border jaw movements. In order to examine the real functional movement, the mandibular movement is recorded during chewing and speech by using theSirognathograph Analyzing System (SGG/AS), a device developed by Prof. TakaoMaruyama of Osaka University in Japan, which tracks and analyzes the jaw movements(Figure 14–1).

Sirognathograph Analyzing SystemA magnet is attached to the patient’s lower central incisors (Figure 14–2), and anantenna is placed on the patient’s head (Figure 14–3). When the patient chews gum,the movements of the magnet are displayed on a computer screen.

Figure 14–4 shows normal chewing patterns which appear in the SGG/AS whenchewing on the left side. The blue line indicates the opening path and the red lineindicates the closing path, and both paths are convex. The peak of velocity is generallywithin the first one-third of the opening path and the first one-third of the closing path.

Lingual Orthodontics:Esthetics and FunctionCHIORI HASHIBA, DDS, PhD

-. The Sirognathograph Analyzing System (SGG/AS).

Each species of mammal has a distinct, inherent chewing movement (Figure 14–5).Humans have two chewing patterns; chopping and grinding (Figure 14–6). Thesechewing movements are controlled by the “pattern generator,” a grouping of cellsbelieved to exist in the brainstem and controlled by the central nervous system (CNS).On the other hand, the factors that control chewing movement exist in the peripheralnervous system and are influenced by occlusal guidance, TMJ guidance, and mastica-tory muscle guidance. The occlusal guidance may be classified as anteroposterior, lateral, and vertical guidance (Figure 14–7).

Case ReportA 19-year-old female presented with skeletal Class II malocclusion with severe overjet(Figures 14–8a to c). The patient refused to have orthognathic treatment. A com-promise orthodontic treatment was suggested, and two upper first bicuspids were

-. A magnet is attached to the patient’s lower central incisors.

-. The antenna is placed on the patient’s head.

-. Optimum chewing movement as registered on a computer screenrecorded by SGG/AS (by Maruyama). The blue line indicates the opening path

and the red line indicates the closing path.

Lingual Orthodontics: Esthetics and Function

extracted. The post-treatment occlusal results show significant esthetic improvement(Figures 14–9a to c). A close-up view of the lips before and after the treatment(Figures 14–10a and b) and at the serial changes of her overjet (Figures 14–11a to c)show that a balanced profile and corrected morphology were achieved.

The sirognathograph analyzing system was used to analyze her chewing patternswhen gum was chewed (Figure 14–12). Both chewing patterns, opening and closing,were abnormal in this case, without rhythm and with low velocity. This is a typicallypoor functional case, even though the occlusion looked good morphologically andborder movements were good. In such cases, patients sometimes complain of theirpoor chewing function and suffer from TMJ pain disorders (TMD).

Another successful orthodontic treatment is shown in Figures 14–13a and b.Abnormal chewing patterns were observed here as well (Figure 14–14). Ignoring suchabnormal chewing patterns could result in muscle and joint pains.

-. Human chewing patterns (by Maruyama).

-. Chewing patterns of different mammals (by Maruyama).

Cat2 Treeshrew3

Camel10Rat9

Goat11

2P A

6 34

1

5

5

2

34 1

6 Giantforest hog8

Rhesusmonkey6

Man

Spidermonkey3

Littlebrown bat4

Squirrelmonkey3Galago3

Pig7

Opossum1

- . At initial orthodontic examination: frontal and lateral views. Note the open bite, crowding, and enlarged overjet.

Muscles and the TMJ will both be affected when a dysfunctional occlusion is notproperly treated. Every masticatory muscle comprises a closing muscle and an openingmuscle and each of them has two functions, yielding protrusive and retrusive forces.An abnormal protrusive shift will cause pain and spasm in the lateral pterygoid muscle;if this continues, the articular disk may be dislocated and cause TMJ dysfunction.

-. Occlusal guidance of chewing movement (by Maruyama).

Anteroposterior guidance

Lateral guidance

Vertical guidance


An articulator called a Palculator is used for checking movements when poorocclusion exists (Figure 14–15). Dental casts can be moved freely without limitationon the Palculator and chewing movement can be simulated. In many cases, abnormal

- . At completion of orthodontic treatment: frontal and lateral views. Note the Class II occlusion.

- . Close-up view of the lips: (a) Before treatment. (b) After treatment.Note the significant changes in lips closure.

-. Chewing patterns using sirognathograph analyzing system when gum is chewed.

- . Serial close-up views of the overjet during treatment.

concave opening paths can be caused by premature contact on the nonworking sidebetween the upper and lower second molars (Figure 14–16). When closing paths


show a concave closing pattern instead of a convex pattern, by using the Palculator,one can recognize the abnormal contact on the nonworking side (Figure 14–17a). Ifan abnormal nonworking side contact on the second molars exists during opening,opening chewing patterns will be concave to avoid premature contact. This is due tothe sensitivity of the periodontium to the abnormal direction of chewing pressure.When chewing on the working side, the opening path is normal, but the closing pathis concave (Figure 14–17b). It is caused by the interference of the nonworking side in closing.

Function should be examined for every patient with the sirognathograph analyzingsystem before removing the braces to avoid TMJ and occlusal interference symptoms.

-. Abnormal chewing patterns: the red line is the opening path and the blue line is the closing path.

- . (a) At initial orthodontic examination. (b) At completion of orthodontic treatment. Note the successful treatment.

-. The Palculator articulator. -. Chewing movements can be simulated withthe Palculator.

- . Nonworking side interference: a) Interference side. (b) Normal side. (by Maruyama)

UPPER: Buccally inclinedLOWER: Lingualy inclined

UPPER: Buccally inclinedLOWER: Lingualy inclined

Steep

Normal

Normal

Flat

Concave opening

Concave closingWorking side Nonworking side

The Customized Lingual Appliance Set-Up Service (CLASS) System. . . . . . . . . . . .

Scott A. Huge

The Thickness MeasurementSystem with the DALI Program . . . . . . . . . . . . . . . . . .

Didier Fillion

Lingual Treatment with theBending Art System . . . . . . . . .

Paul-Georg Jost-Brinkmann, Vittorio Cacciafesta, and Friedrich Riemeier

SECTION 4

LaboratoryProcedures

The CLASS technique offers a method of lingual bracket placement that takes intoaccount the anatomical discrepancies in the lingual surfaces of the teeth. This isaccomplished by first constructing an ideal diagnostic set-up from a duplicate set-upmodel of the patient’s original malocclusion. This ideal set-up or template is then usedas a physical guide to place the lingual brackets in an ideal configuration. The bracketsare placed on the diagnostic set-up using composite adhesive, which acts as a spacerbetween the metal mesh pad and the individual dental surfaces. After the brackets areplaced on the ideal diagnostic set-up, they are next transferred back to the malocclusioncast. At this point, transfer trays are fabricated so the brackets can be delivered clinicallyvia the indirect bonding method.

Technique1. Accurate models must be obtained from the patient using a high quality algi-

nate or rubber base impression material (Figure 15–1). The models shouldnext be poured in a hard model material such as die stone (Figure 15–2). Themodels must be extremely accurate for optimum clinical bonding and treat-ment results. Once accurate models are obtained, the clinician completes theprescription sheet which is the specific diagnostic instructions to the laboratory

The Customized LingualAppliance Set-Up Service(CLASS) SystemSCOTT A. HUGE

-. Accurate models are obtained from the patientusing a high quality alginate or rubber based impression material.

-. The models poured in a hard model material such as die stone.

(Figures 15–3 and 4). Included in this information is a detailed prescriptionof how the teeth should be reset and what the eventual treatment goals are.Additional information such as overcorrection of individual tooth rotations orpost-treatment procedures that are anticipated should also be communicated

- . The clinician completes the prescriptionsheet which is the specific diagnostic instructions to the laboratory.

The Customized Lingual Appliance Set-Up Service (CLASS) System

to the laboratory. The more complete the information provided from the clin-ician to the laboratory technician, the better the results will be.

2. In the laboratory, the doctor’s original models are duplicated. This process iscompleted using hydrocolloid duplicating material, which provides the mostaccurate duplicate for the set-up models. The set-up models are poured inorthodontic stone (Figure 15–5) and then dried in the oven (Figure 15–6).

3. The duplicate casts are identified by each individual tooth and sectioned, as illustrated, to fabricate the diagnostic set-up (Figure 15–7). Depending uponthe equipment available to the laboratory technician, a combination of handsaws and grinding wheels can be used to section and trim the teeth.

4. The individual teeth are placed on a preformed set-up base which facilitatesthe overall set-up process (Figure 15–8). The technician then arranges andresets the teeth according to the doctor’s prescription. The technician mustcoordinate overall arch form, occlusal plane dimensions, anterior tip andtorque, spacing considerations, overbite and overjet, and individual dentalalignment and rotation (Figure 15–9).

-. The original models are duplicated.

-. The duplicate casts are identified by each individ-ual tooth and sectioned to fabricate the diagnostic set-up.

-. The duplicates are dried in the oven.

5. Once the set-up is completed, it is given a final check by the senior laboratorytechnician who re-evaluates the doctor’s prescription and the progress set-up(Figure 15–10).

6. A final wax restoration of the gingiva is then completed. The lingual surfacesmust then be completely cleaned using a wax solvent to insure the surfaces will adequately reflect the exact dental anatomy of the original models (Figure 15–11).

7. A model release is applied directly to the set-up, and the set-up is dried in anoven at approximately 100 degrees F for 1 hour (Figure 15–12). The applica-tion of this release coat will ensure that the brackets placed with compositewill easily separate from the set-up model.

8. The next step is the placement of the lingual brackets on the ideal set-upmodel. The model is placed in a model holder as illustrated and set with theocclusal plane parallel to a fixed horizontal reference (Figure 15–13). The goalis to establish an ideal vertical plane to which all brackets can be placed andcoordinated. Sample lingual brackets are next trial-fitted to individual teeth insections to ensure that proper heights are established from the anterior, posterior,

-. The final set-up is checked. -. The lingual surfaces must be completely cleanedusing a wax solvent.

- . Individual teeth are placed on a preformed set-up base. The technician must coordinate overall arch form according to the doctor’s prescription.


and right and left sides. Slight adjustments may be necessary in the overall leveling of the model to ensure a level and coordinated plane for all brackets.

9. The brackets are bonded to the set-up model using a two-part heavy bodypaste, such as Phase II from Reliance Orthodontic Products or Concise from3M Dental (Figures 15–14 and 15). Both of these materials provide an excel-lent medium, allowing the technician to seat the brackets in small groups of 2 or 3 with sufficient working time to place and fine tune the final position ofthe brackets. The brackets are set to the model using an ideal template blademade of .018 or .022 stainless steel (Figure 15–16). With this system, thebrackets fit in the blade which simulates the final archwire. Since the blade isfabricated in an ideal anterior arc, the technician can move the brackets alongthe arc to center them perfectly on each tooth in the set-up.

10. Once the anterior brackets are placed (Figure 15–17), the posterior bracketsare set using the same overall technique (Figure 15–18). Straight-line bladesare used in the bicuspids and molars to place the brackets and ensure a straightalignment in these sections while maintaining the uniform vertical plane of all the brackets. As each bracket position is finalized, the excess adhesive is

-. Phase II from Reliance Orthodontic Products. - . The adhesion is applied to the mesh pads on each bracket.

-. The set-up is dried in an oven at approximately100 degrees F. for 1 hour.

-. The model is placed in a model holder and setwith the occlusal plane parallel to a fixed horizontal reference.

trimmed from the edges using a dental explorer as shown (Figure 15–19).Care taken with this step will save considerable time later in the process incleaning the excessive adhesive from the bracket edges.

11. A one-to-one photographic copy is made using a camera or a copying machine(Figure 15–20). This occlusal recorder will serve as a guide to fabricate the

-. An ideal template blade is made of .018 or .022 stainless steel.

- . The anterior brackets are placed.

-. A photocopy is made using a camera or a copying machine.

-. Acrylic caps are constructed.

-. The posterior brackets are set. -. Excess adhesive is trimmed from the edges usinga dental explorer.


ideal arch template. This template will provide the clinician a way to measureand bend the archwires.

12. The next laboratory step in the sequence is to transfer the brackets from theideal set-up back to the malocclusion. There are several methods to accom-plish this goal. The system used here employs acrylic caps on each tooth(Figure 15–21). A small strip of light-cured acrylic is cut and laid over the topof each bracket and indexed to the incisal or occlusal surface of each tooth(Figures 15–22 and 23). These caps are easily cured using a hand-held bond-ing light or light chamber. This can be done quickly with great accuracy. Eachbracket is then easily removed from the set-up tooth and transferred to itsindividual duplicate on the malocclusion model (Figures 15–24 and 25). Thecustom composite base formed in the bracket-placing stage serves as the guideto ensure the bracket orientation back on the malocclusion model. At thispoint the brackets are secured to the malocclusion model using a water solubleadhesive (Figures 15–26 and 27).

13. The cast is then placed in a warm oven for approximately 1 hour to make surethe transfer adhesive has fully set. At this point the acrylic caps can easily beremoved by first holding the bracket in place with a spatula and lightly pryingthe transferring caps away.

- . Each bracket is easily removed from the set-up tooth and transferred to its individual duplicate on the malocclusion model.

- . A small strip of light-cured acrylic is cut and laid over the top of each bracket.

14. The malocclusion models with the transferred brackets are next placed backon the copying machine for a second occlusal record (Figure 15–28). Thiscopy will act as the initial guide to help the clinician fabricate the first seriesof lingual archwires.

15. Transfer trays are now made on the malocclusion cast. At the present time the recommended transfer tray technique is a two-tray system processed onthe Biostar machine. The inner tray is a 1.5 mm Bioplast and the outer tray isa 1.0 Biocryl. This combination gives the best overall clinical results. The clin-ician should first seat the Bioplast tray and bend it as needed to gain initialplacement (Figure 15–29). Once each flexible section is seated, the hardacrylic tray is immediately placed over it and pressure is applied to bring theadhesive and dental surfaces into complete contact. In addition, the trays aresectioned in two or three pieces per arch to allow the clinician complete controlover the clinical bonding process (Figures 15–30 and 31). The specific fabrica-tion technique is detailed in the next several steps.

16. The first step in tray fabrication is model preparation. Any deep interproximalareas or potential defects in the model must be blocked out. An ideal materialis a light-cured gel applied with a wax spatula. This material is easily moldableand quickly cured with the light to minimize the laboratory time required.

17. The lingual ball hooks must then be blocked out. In this technique, aninjectable silicone is used in a plastic syringe (Figure 15–32). This allows the

- . Brackets are secured to the malocclusion model using a water soluble adhesive.

-. The clinician can bend the Bioplast tray asneeded to gain initial placement.

-. A copying machine is used to make a secondocclusal record.


technician to easily control the flow of the material so as to not block out toomuch of the bracket undercut and at the same time to ensure that the bracketswill release from the bonding trays.

18. Overall model release is then painted on the surfaces of the cast. This will ensurethat the Biostar trim releases from the construction model (Figure 15–33).

19. The model is then placed in a Biostar unit where the first 1.5 mm Bioplasttray is formed. The technician should follow the general use instructions supplied by Great Lakes Products in using the Biostar (Figure 15–34).

20. The cast is removed from the Biostar and the excess peripheral Bioplast materialtrimmed using scissors. The tray is not removed from the laboratory model atthis stage; just the excess material is removed in preparation for the hard trayprocess.

21. The 1.5 mm Biocryl tray is next formed after the cast is reseated in the Biostarunit. A light coat of spray silicone must be applied prior to forming the outertray so the two trays will release. The Biocryl tray is formed again using stan-dard Biostar procedures.

22. The trays are then removed from the model by first soaking the cast in warmwater for approximately 30 minutes. This will help release the brackets fromthe construction cast (Figure 15–35).

-. Injectable silicone is used in a plastic syringe.

- . Trays are sectioned in two or three pieces per arch.

23. The trays are then cut and sectioned using a high-speed handpiece. A smalldiamond wheel is the ideal tool to trim the edges of the trays. A sharp knifecan also be heated over a laboratory flame and used to section the softBioplast inner trays.

24. With the tray fabrication now completed, the trays are placed in the ultrasonicwith warm soapy water to remove any excess residue from the material andcomposite bases. After this initial cleaning, the composite bases should belightly abraded using a microedger (Figure 15–36). This will remove any stoneresidue from the composite as well as prepare the adhesive for optimum bond-ing. The trays are returned to the ultrasonic where they are cleaned in plainwater for 1 to 2 minutes.

25. The trays should be labeled and placed in a clean, sealed, plastic bag wherethey will remain until the patient’s bonding appointment.

26. Depending upon the clinicians preference, an optional laboratory step is fabri-cation of the lingual archwires. This utilizes the templates made from the idealset-up and malocclusion photographs (Figures 15–37 and 38).

-. Model release is painted on the surfaces of the cast. -. Biostar machine.

-. The trays are removed from the model by soakingthe cast in warm water for approximately 30 minutes.

-. The bracket braces are abraded using a microetcher.


An acetate sheet is placed over these templates and an ideal arch template tracedfrom the record of the brackets on the ideal diagnostic set-up. This template is thencompared to the bracket position on the malocclusion model which will show theexact position of the offsets that are necessary, distal to the canines. The techniciancan then estimate the amount of wire required in the anterior arch from the beginningwire, such as a .0175 Respond, up through the stages of treatment where heavier wireswill be required (Figure 15–39). The final heavy finishing wire should approximatethe ideal arch template made from the diagnostic set-up template, as this recordreflects the brackets in their final ideal alignment.

SummaryThe overall CLASS lingual technique demands maximum accuracy from the originalmodels and instructions provided by the clinician. In addition, the laboratory techni-cian must have a complete understanding of dental anatomy, set-up techniques andgoals, and overall bracketing positioning. Tremendous attention to detail must beexercised at all steps to avoid inaccuracies in bracket placement and consequent less-than-ideal clinical results.

- . Templates are made from the ideal set-up and malocclusion photographs.

-. Wires required from the beginning wire throughthe successive stages of treatment.

Considering the difficulty of access and the irregularity and variability of lingual toothmorphology, lingual orthodontics could only develop with the indirect bonding tech-nique, which allows us to control bracket placement at the laboratory. Nevertheless, thisindirect technique requires a precise transfer procedure of the brackets in order to clin-ically bond them in the exact position which has been set at the laboratory stage. Here,we will show an indirect bonding technique that we have been using for the last 10 yearswith great success. We have been able to take many different kinds of malocclusionsand achieve the same excellent results as those obtained with labial orthodontics.

This technique has been developed by taking into account the advantages and pit-falls of the TARG (Torque Angulation Reference Guide), an apparatus developed byOrmco in 1984 for lingual bracket bonding (Figure 16–1).

1. The TARGThe TARG, despite the anatomic variations of the lingual tooth surfaces, permits us tobond brackets in the laboratory at an accurate distance from the occlusal edge of eachtooth with respect to a horizontal occlusal plane. The tooth orientation is made with agauge or torque blade. The model is tipped on the swivel base until the long axis ofthe labial face of the tooth aligns with the specific gauge curvature at the middle thirdof the tooth (Figures 16–2a and b).

This orientation allows us to preprogram torque and angulation (tip) before start-ing the treatment.

The Thickness MeasurementSystem with the DALI ProgramDIDIER FILLION, DDS

-. The TARG developed by Ormco.

After the TARG horizontal blade is engaged into the bracket slot, it is movedtoward the varnished plaster at the bonding level determined by the laboratory tech-nician with respect to the function of the teeth and the anatomy of the periodontium(Figure 16–3). The bracket is bonded to the plaster with a filled resin, which allowsthe gap between the lingual tooth surface and the metal base of the bracket to becompletely filled (Figures 16–4a to c). A new resin base which accurately follows thelingual anatomy of each tooth is therefore integrated to each bracket.

Once all the brackets are bonded to the model, a transfer tray is fabricated. Usingonly one unique malocclusion model, the TARG permits achieving a virtual set-upwithout the need to cut the teeth and mount them on wax. It is an accurate andquantified two-dimensional system. The torque, angulation (tip), and height measurements are registered by the technician. Nevertheless, we have found that a correct alignment can only be obtained by adding a great number of first-order bends,because the TARG does not take into account the labiolingual thickness of the teeth.In Figure 16–5, one can note that not only does distance B (the distance between thebottom of the bracket slot and the labial tooth surface) vary for each tooth according tothe height level of bonding but also that it varies according to the tooth type despitethe fact that all the brackets are manufactured with specific, variable thicknesses.

-. The long axis of the labial face aligns with the curvature of the specific gauge.

-. The gauge or torque blade orientates the toothin its final position.

-. The technician determines the ideal bonding level.

The Thickness Measurement System with the DALI Program

2. Fillion’s Lingual Indirect Bonding SystemThe system that we developed in 1987 is essentially composed of two elements—aThickness Measurement System (adapted for the TARG) and the DALI program(Figure 16–6).

-. The bracket is moved toward the plaster. -. The gap is filled with macrofilled resin.

-. The prebonded bracket with its resin pad.

-. Distance B varies according to the level of bonding(distance A) and tooth type.

-. The TARG with the Thickness MeasurementSystem.

A. THICKNESS MEASUREMENT SYSTEM

Since the TARG is unable to compensate for the unequal distances between the bracketslots and the labial tooth surface, we added a caliper (MITUTOYO) to the TARGcentral axis and modified it to present two horizontal blades. One is engaged into thebracket slot, and the other one is applied to the labial tooth surface (Figures 16–7a andb). For a selected height bonding level, the Thickness Measurement System recordsthe thickness B (the width of the teeth with bracket) of the six anterior teeth. Thegreatest thickness is chosen as the standard thickness. The macrofilled resin is appliedto the bracket base; then the bracket, placed on the blade, is moved toward the plasteruntil the selected thickness measurement appears on the screen. The resin excesses,even on the gingival margins, are removed before polymerization (Figures 16–8a andb). By this technique, we achieve a thickness standardization while the brackets areeach supported on resin pads of different thicknesses. For bicuspids and molars, thethicknesses are standardized in the same way (Figure 16–9).

The concept is simple because it eliminates the necessity to prepare a set-up, and thebonding is performed directly on the malocclusion model. The technique is accuratesince there is neither duplication nor transfer from one model to another.

-. The two blades of the Thickness MeasurementSystem.

-. The selected thickness appears on the screen.

-. The gap is filled with resin. -. The resin excesses are removed before polymerization.


Because of the standardization of thickness, this system permits us to avoid allfirst-order bends, except the ones between the cuspids and bicuspids and between thebicuspids and molars. This considerably reduces chairtime during archwire bending.Because the brackets are directly bonded to the malocclusion model, a copy of thearch form with the brackets on it can be made to help the clinician bend the firstarchwires of the treatment.

Everything is measured and registered: height, angulation (tip), torque, and thick-ness. The concept allows us to quantify all the information and obtain custom-madebrackets accurately positioned in the three dimensions of space.

The Transfer SystemThe transfer tray allows us to transfer the brackets which have been bonded on themalocclusion model to the patient’s mouth. This tray can be made of different materials,but we use a low-viscosity silicone that does not apply any pressure on the bracketsand can guarantee a bracket’s total stability during this stage (Figure 16–10). The low-viscosity silicone is then covered with a high-viscosity silicone. This material with astrength of 90 degrees shore-A because of its great stability, allows us to bond theentire arch at one time without the need to make sections of the tray. This saves agreat amount of time during bonding (Figure 16–11).

The Bonding ProcedureThe bonding is performed very rapidly because of the precision and reliability of thelaboratory procedure (Figure 16–12), and with unfilled resins only. It is very impor-tant in lingual orthodontics to know that the bonding height is reduced by 13% andthat the brackets are placed close to the gingival margin. The unfilled resin excess canbe easily removed with dental floss when it is impossible to do so with filled resins incrowding cases. In the mouth, the set-up looks the same as it did at the laboratorystage. The resin pads, perfectly defined in the laboratory, do not present any bondingmaterial excess; therefore, we avoid any deleterious iatrogenic effect on the gingiva(Figures 16–13a and b).

Rebonding can be done in two ways:

1. By again using the initial transfer tray. The clinician can reposition the bracketinto the transfer tray after sectioning and separating the specific tooth area.

-. Thickness standardization is accomplished byvarying the thickness of the resin pad.

-. The brackets are covered by low-viscosity silicone.

2. By redoing an individual bonding tray in the laboratory with the same protocoland information determined at the beginning of the treatment (height, torque,angulation, and thickness). A small silicone unitary tray unit is then used.

Bracket Placement on Crowded TeethIn a crowding case, the correction of rotations can be obtained in three ways:

1. Centering the bracket on the labiolingual axis of the tooth (Figure 16–14).

-. The transfer tray. -. The rigidity of the transfer tray allows bondingof the entire arch at one time.

-. Difficulty in engaging the wire in the bracket ofa crowded tooth when the bracket is centered on the tooth.

-. In case of crowding, the bracket is decentered or rotated.

- . After bonding on teeth, we can find back the same resin pads as on the plaster.


2. Overcorrecting the bracket position by moving it mesially or distally, with thebracket slot left parallel to the labial tooth surface or by rotating it with respectto the labial tooth surface of the amount equal to the rotation (Figure 16–15).

3. If the dental crowding and the closeness of the adjacent brackets do not allowus to ideally position the bracket at the beginning of the treatment, initiallyposition the bracket at the best fit, and once the rotation is partially corrected,change the position of the bracket. A unitary bonding at the laboratory istherefore needed after the part of the adjacent tooth causing the interferencehas been removed (Figures 16–16a and b).

-. On the right incisor, the bracket is moved distally for overcorrecting. On the lateral, the bracket is bonded

mesially to begin correction of the rotation.

-. Once the rotation is partiallycorrected, the bracket is centered after the adjacent

tooth has been adjusted.

The versatility of this system, allowing us to work directly on the malocclusionmodel, along with an experienced laboratory technician, permits the selection and theuse of the most appropriate procedure leading to a fast and efficient tooth realignment.

- . DALI program: Example of an extraction case: (a) Copy of brackets bonded on the model. (b) Ideal archwire. (c and d) First wire bent with the copy for

location and length of the first-order bends and with DALI program for the form of the arch.

-. The ideal (final) archwire shape isobtained by the DALI program.


B. THE DALI PROGRAM (DESSIN DEL’ ARC LINGUAL INFORMATISÉ OR

COMPUTERIZED DRAWING OF THE LINGUAL ARCHWIRE)From the thickness measurements performed at the laboratory by the technician, fromthe measurements of the tooth widths, and with the help of a computer, it is possibleto obtain a detailed drawing of the ideal lingual archwire, with all the teeth perfectlyaligned. The clinician can choose an arch form in function for the initial arch formand a final one that is more ideal for the end of the treatment. On the arch form, theteeth and their brackets take their individual positions from the midpoint of a triangle,which represents the width of the bracket, the width of the tooth, and the distancebetween the bracket slot and the labial tooth surface. Once all the teeth are represented,the program traces a “best-fit” archwire to the triangles, creating the ideal archwirewhich will allow a perfect tooth alignment (Figure 16–17).

Why is the DALI program irreplaceable and essential?

1. It permits us to obtain an extremely accurate tracing of the finishing archwire,at a 1:1 ratio.

2. It allows us to know with a very high accuracy (with 0.1 mm) the width of the

- () . (e and f ) Retraction stainless steel wire bent on ideal archwire form. (g and h) Finishing wire. All the wires are bent extraorally.

first-order bends placed between the cuspids and bicuspids, and between thebicuspids and molars.

3. During treatment, it allows us to know the ideal arch shape needed to achievea good occlusion, especially in asymmetric cases.

4. It permits us to preform all archwires with great precision, except for the firstones which are bent from the copy of the bonded brackets on the initial model.

5. It is not necessary to coordinate the archwires during treatment because thedrawing of the upper and lower archwires are made from the same labial archcurves (Figures 16–18a to h).

The DALI program cannot work without the Thickness Measurement System,since it is essential to know the distance between the bracket slot and the labial toothsurface.

The TARG, the Thickness Measurement System, and the DALI program form acoherent and interdependent system, with the following advantages:

1) Easy and accurateUse of one single model, no transfer, no set-up, no duplicate; bonding withunfilled resin; no iatrogenic effect on the gingiva; and accurate rebonding witha unitary transfer tray.

2) Reduces chairtime, increases clinical efficiencyEqual thickness (teeth and brackets) for the six anterior teeth, bicuspids andmolars; decreases first order bends except between cuspid–bicuspid and bicuspid–molar; very accurate measurement of first-order bends; gives the ideal (final)archwire shape; and provides a copy of the model with bonded brackets tobend first archwires.

ConclusionWe were seeking a simple and efficient laboratory bracket-positioning system. The sys-tem that we have developed answers this need by giving us, with the help of computerscience, the essential information needed to treat orthodontic patients more easily,accurately, and successfully, using the lingual technique.

To this day, within our exclusive lingual practice, lingual appliances have beenplaced on more than 4000 arches with this protocol, using one of the EuropeanLingual Orthodontic Service laboratories which use our system. The quality of theobtained results, comparable to the ones achieved with labial orthodontics, shows itsreliability for any kind of malocclusions.

The Bending Art System (BAS) was designed by the Bending Art Medizintechnik incooperation with the University of Kiel. It is the first CAD/CAM device for ortho-dontic treatment planning and bending of individual archwires. It consists of threecomponents: an intraoral stereoscopic camera, a computer program, and a wire bend-ing unit (Figure 17–1). Thus, it allows individual archwires to be manufactured withfirst-, second- and third-order bends, which have proven to be very accurate.1 The BAScan be universally used with all edgewise brackets on the buccal or lingual side, irre-spective of their slot-sizes (0.018'' × 0.025'' or 0.022'' × 0.028'').

The wire bending unit (Figure 17–2) is able to produce individual archwires auto-matically from straight segments of stainless steel, TMA, and Ni-Ti wires of variousdimensions.

Treatment planning is carried out directly on the computer monitor. According tothe instructions from the orthodontist, the system computes the arch geometry. Therequired three-dimensional data are supplied by the intraoral stereoscopic CCD camera(Figure 17–3) at the beginning of treatment. To program any wire with the BAS, onemust take occlusal scans of the right and left sides of the patient’s jaws with the stereo-scopic camera. These partial scans are later merged by the computer program so thatonly one occlusal photograph is displayed on the monitor.

Before taking the occlusal scans, stainless steel measuring plates, available for 0.018''or 0.022'' slot size bracket systems, must be inserted into the bracket slots as a precon-

Lingual Treatment with the Bending Art SystemPAUL-GEORG JOST-BRINKMANN, DMD, PhD, VITTORIO CACCIAFESTA, DDS,AND FRIEDRICH RIEMEIER

-. View of the complete Bending Art System.

dition to calculate the three-dimensional position of each individual bracket. Thisbecomes feasible by four reference punch marks, which are identified by a patternrecognition program during the registration process.

After exact registration of the bracket position and its confirmation by the user,the occlusal scans of the maxillary and mandibular dental arches are stored by thecomputer and displayed on the screen to assist treatment planning. The orthodontistthen determines, tooth by tooth, the desired three-dimensional tooth position which,in turn, produces the appropriate wire design.2

Therapeutic ConceptA characteristic feature of the Bending Art System is that, after registration of all theinitial data, the planned result of therapy (treatment target) is designed. Consequently,the treatment is performed in individual steps. Two methods for specification of thetreatment target are offered: the ideal arch method and the set-up procedure.

-. The wire bending unit.

-. The intraoral stereoscopic CCD camera.

Lingual Treatment with the Bending Art System

The Ideal Arch MethodThe ideal arch method was adapted to lingual orthodontics from the labial technique.The user selects the basic ideal arch shape which afterwards is automatically adaptedto the size of the patient’s dentition and displayed on the monitor in the occlusal view.This arch shape is named “ideal arch” in the computer program. The values for allparameters, including torque, angulation, and rotation, can either come from a select-ed treatment technique (Andrews, Ricketts, Roth, etc.) or be specified individually.Often, the ideal arch does not produce an optimal occlusion. Consequently, additionalthree-dimensional individualization has to be performed for ideal finishing. This indi-vidualized final archwire is called the target arch.

Due to the great variability of the tooth lingual surfaces, this method is not directlyapplicable to the lingual arch shape. Because of this, a supplementary software, whichuses a labial reference arch, has been developed in cooperation with Dr. Didier Fillion.

Using the mesiodistal tooth widths and the measured individual labiolingual distances from the lingual bracket slots to the labial surfaces (including bracket baseand thickness of adhesive), the system computes reference points on the labial surfaceof each tooth. These reference points, which correspond to the slot positions of thehypothetical labial brackets, determine the shape of the ideal arch (Figures 17–4 and 5).Designing and bending of all the archwires takes into consideration the thickness ofthe adhesive layer between the bracket base and the tooth surface. Therefore, theadhesive layer thickness does not play a significant role, in contrast to other techniqueslike the slot-machine that is based on the Straight Wire technique.3

If the brackets are not bonded according to the Straight Wire concept, specifica-tion of corrective values for torque, angulation, and rotation are required to avoidundesired tooth movements. Consequently, all these compensatory bends are createdautomatically. For every single tooth, the computer allows editing of its position in thethree dimensions of space. Furthermore, since it is very easy to keep the original archsize while changing the position of each individual tooth three-dimensionally, whererequired, the most immediate advantage of the BAS becomes obvious when used fordetailing during the finishing phase of treatment. If further movements are necessary

-. Occlusal view of the passive lingual arch on themonitor of the BAS.

-. Occlusal view of the target arch on the monitor of the BAS.

at a subsequent appointment, all previous wire characteristics are precisely reproducedwith the new ones added.

The Set-Up MethodFor this method, an ideal set-up of the patient’s models is required as a first step.Next, brackets are bonded on the set-up model and the position of the bracket slots isdetermined with the BAS. An archwire that fits passively into the brackets on the set-up model is then designed. If this wire is inserted into the patient’s mouth as a finalarchwire, it will produce the same tooth position as on the set-up.

The bonding position of each bracket can be deliberately chosen, thus minimizingthe patient’s discomfort. Subsequently, the brackets are transferred, one by one, to theworking models (representing the original malocclusion) using individual templates.Then, the bracket position is measured again, and the transfer tray for indirect bond-ing is produced. The difference in bracket position between the original and the set-up model represents the amount of movement for each tooth.

Although this method is much more time consuming as compared with the idealarch procedure, it offers considerable advantages such as the exact determination ofthe situation at the end of treatment (not considering corrective values for bracketplacement). Additionally, this work can be more or less completely delegated to thelaboratory staff. The arch sequence for every treatment is produced automatically bysplitting the difference between the initial and final positions into a number ofsteps/arches, according to the patient’s needs. During treatment, chairtime is therefore

- . Intraoral frontal and lateral views of the occlusion before treatment. Note the Class I malocclusion with a large upper central diastema.


limited to controlling the patient’s progress and insertion of the archwires, which havebeen already bent by the system.

Treatment PlanningThere is no difference between the labial and the lingual approach in planning theorthodontic treatment. This is determined by the following factors:

1. Number of archwires. The number of archwires to be used is defined by theorthodontist. However, it can be modified during treatment, as needed.

2. Distribution of tooth movement among the archwires. The required toothmovements can either be distributed proportionally by the system among all theplanned archwires, or be modified during treatment according to the patient’sneeds. Specifically, that means the orthodontist can program tooth movementsfrom 0% (no movement), if an entirely passive segment is required as anchorage,to 100% (full movement). The system automatically calculates the requiredmesiodistal sliding distances in order to perform such movements.

3. Wire material. The bending unit works with straight segments of stainlesssteel, TMA, and Ni-Ti wires of various dimensions. Every wire is exactlyshaped as series of consecutive bends according to the geometric data calculat-ed by the computer program. After the bending process, superelastic wiresmust be heat-treated to keep the bends and torquing permanently as otherwisethe archwire will return to its original shape due to the memory effect.

4. Design of the archwires. The BAS is able to produce wires in a great variety of arch shapes. A very valuable feature is the ability of the system to bend completely passive segments and archwires, which are necessary for anchoragepurposes when using a segmented arch approach and for patients before theyundergo orthognathic surgery. The system enables the orthodontist to correctalso the sweep and width of a patient’s arch, when needed. It allows a couple ofbrackets to be bypassed, for example, to bend utility arches. Another feature ofthe BAS is the fabrication of loops, which are prebent by the bending unit andneed only to be finished by hand.

- . Occlusal views of the maxilla and the mandible. Note the rotated upper central incisors and spacing in both jaws.

Case ReportAs the first case lingually treated with the BAS in our department, a female patientpresented with a Class I malocclusion with a large upper central diastema was selected(Figures 17–6a to c). The upper and lower first premolars had been previously extract-ed and the postextraction spaces were still present. The upper central incisors wererotated mesiobucally (Figures 17–7a to b). The set-up BAS method was used to pre-pare lingual bonded brackets. First, an ideal set-up was produced and measuring platesand template-caps were placed for transferring the brackets to the working model(Figure 17–8a). The position of each bracket on the set-up model was measured withthe BAS. Next, the brackets were transformed to the malocclusion model (Figure17–8b). Due to the rotations of teeth 21 and 22, interferences were observed betweentheir measuring plates. BAS scannings were made separately for each tooth. Whentooth 21 was scanned, the bracket on tooth 22 was left out. Subsequently, the bracket

-. Maxillary set-up model with bonded brackets,measuring plates, and template-caps for transferring the brackets to

the working model.

-. A working model. Brackets were transferred fromthe set-up with BAS measuring plates.

-. A transfer tray for indirect bonding was prepared,after removing the measuring plates from the bracket slots.


for 21 was temporarily removed whereas the one for 22 was set, allowing the measure-ment of this tooth in relation to the other brackets already scanned by the BAS.

After removing the measuring plates from the bracket slots, a transfer tray forindirect bonding was produced (Figure 17–8c). The template-caps of the bracketswere covered with silicone (Memosil, Heraeus Kulzer, Dormagen, FRG). A total offour wires for each jaw were bent for treating this case: two 0.016'' round wires andtwo 0.016'' stainless steel wires. Each wire was designed by the BAS to carry the teeth25% further towards their final position, as defined by the set-up. Every 4 weeks, thesubsequent archwire was put in (Figures 17–9a to c). The treatment progress was veryrapid, as one can see in the sequential views at 2 months (Figures 17–10a and b), 4 months (Figures 17–11a and b), and at the end of treatment, after 5 months(Figures 17–12a and b). Satisfactory final results were achieved within 5 months(Figure 17–13a to c).

-. The upper 0.016 × 0.016 SS archwire, completely passive in relation to the bracket slots on the set-up

model, as designed with the BAS.

- . Occlusal views of the maxillary arch and the mandibular arch: immediately after placing the wires.

- . Occlusal views of the upper and lower arches: 2 months in treatment.

- . Occlusal views of the upper and lower arches: 4 months in treatment.

- . Occlusal views of the upper and lower arches: 5 months in treatment (end of treatment).


- . Intraoral frontal and lateral views of the occlusion at the end of treatment (after 5 months).

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SECTION 5

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with different bracket types and adhesives. Am J Orthod 1978;74:62–78.

Abrasive strips, 99Acrylic caps, 169Air rotor stripping, 85Alexander, Dr. Moody, 6Alexander, Dr. Richard (Wick), 6Alignment, 63

enamel reduction and, 104ideal, 173

American Lingual Orthodontic Association, 9

American Orthodontics, 7Anatomy, lingual dental, 13Anchorage, 47

bridges, 146control, 76–81, 109horizontal, 75lower arch, 78–80transpalatal bars, 146upper arch, 77–78vertical, 75

Anchorage value, 75Andrews, Dr. Lawrence, 13Andriko, Craig, 3Appliances

labial, 21, 43lingual, 21, 29, 43placement, 36–37

Arch, expanding the, 44recontouring, 65sagittal shift, 97target, 187template, 169

Arch geometry, 185Archwire

BAS, 185–193bending, 185–193“best fit”, 183Class III cases, 65computerized drawing of, 183design, 189detailing, 65–66fabrication of, 172–173final, 183finishing, 64, 65–66, 173

ideal, 183initial, 63–64, 170, 183intermediate, 64–65sequencing, 63–66, 117–118target arch, 187TMA, 115, 123–125tracing, 100

Attachments, 15Austenite, 55, 57–58

yield strength, 58

Baker, Dr. Bob, 9Base pad

adaptation, 11Bending art system, 185–193

advantages, 189case report, 190–193ideal arch method, 187–188set-up method, 188–189therapeutic concept, 186treatment planning, 189

Biocryl tray, 170Biomechanics, 47–48Bioplast, 171Bioplast tray, 170Bite, anterior open, 49, 64, 139, 141Bite plane, 43–45Bonding procedure, 36, 179

enamel reduction and, 100in pediatric patients, 128–130indirect, 175molars, 60

Bowbeer, Dr. Grant, 43Bowing

transverse bowing, 78, 79, 81vertical and transverse, 109

Bracketfailure, 36initial placement, 36interbracket distance, 22, 25, 56, 129Kurz #7, 11Lee Fisher, 3molar, 17, 18placement, 180

Index

placement on model, 176position, 22–23Starfire, 8

Buccolingual compensatory curve, 64Bur, 101–102

CAD/CAM, 185Canine/molar relationship

Class I, 29Class II, 29

Case historyinterproximal reduction, 104–107

Case presentationsloop mechanics, 117–121orthodontics-prosthodontics treatment,

149–152orthognathic surgery, 139–140sliding mechanics, 123–126treatment goals, 48–53

Case reportbending art system, 190–193Class I malocclusion 190–193nonextraction techniques, 86–90pediatric, 131–133Sirognathograph, 154–159

Center of resistance, 22, 47Cephalometric analysis, 76, 112Cephalometric models, 43Cetlin appliance, 91–93Chewing patterns, 153–159

abnormal, 159case report, 154–159Palculator, 157–159

Class I occlusion, achieving, 37–38Clinical experience, the, 35–36CO-CR discrepancy, 77Composite base, 169Concise body paste, 167Control, appliance, 11

anchorage, 75–82, 109Crossbite, 139, 141, 145Crowding

anterior, 33bracket placement, 180–182enamel reproximation and, 86interproximal reduction, 104–107mandibular, 141severe, 64severity of, 83upper and lower, 49, 117upper anterior, 60upper arch, 92

Crown, porcelain, 36Crozat appliance, 84, 87–90Custom Lingual Appliance Set-Up Service

(CLASS), 12, 48, 94–95, 131technique, 163–173

Cutterarchwire, 68ligature, 67ligature wire, 67

DALI program, 183–184advantages, 184

Deformities, 135Dental Lingual Assistant Association, 9Derotating, 32Derotation, 63Dessin del’ arc lingual informatisé (DALI),

183 See DALIDiastema, 188, 190Displacement,

anterior mandibular, 33counteracting mesial, 32

Distalizationbicuspid, 102, 103, 107cuspid, 104

En masse retraction, 109–115Enamel, 99Enamel reproximation, 85–86Eruption, forced, 145Esthetics, 83Esthetics and function, 153–159ETM Corp., 67–71European Society of Lingual Orthodontics,

9Examination, initial, 35Expansion techniques, 84–90Extraction vs nonextraction, 83

Favero, Dr. Lorenzo, 9“Fence effect”, 81Fillion, Dr. Didier, 9, 187Fillion’s indirect bonding system, 177–182Force, shearing, 4, 10, 44

anterior-posterior, 82elastic, 65, 80intrusion, 110protrusive, 156retraction, 111retrusive, 156

Forceps, mosquito, 69

Index

Forestodent, 7Fork

first order bending, 70second order bending, 71

French Lingual Orthodontic Society, 9Fujita, Dr. Kinya, 7, 109

Gerkhardt, Dr. Klaus, 7Gingival impingement, 10Gorman, Dr. Courtney, 9Gorman, Dr. Jack, 5, 6

Helical loop, 78, 110protocol, 114

Hilgers, Dr. James, 6Hinge cap opening tool, 69Hooks, 15–18

ball, 19gingival, 15

Hydrocolloid, 165Hyrax RPE appliance, 141–143

“Ideal arch”, 187Ideal arch method, 187–188Ideal arch template, 173Implants, 146Interarch adjustment, 66Interference, occlusal, 158Interproximal reduction, 85, 97–107

alignment, 101appliance bonding, 100bicuspid/bicuspid, 103cuspid/bicuspid, 103incisors, 104limits, 99lower arch, 100molar/bicuspid, 101operative protocol, 100–104principles, 97–100protection, 99upper arch, 100

Intrusion, anterior teeth, 22Irritation, tissue, 9–10Italian Association of Lingual Orthodontics,

9

Jaw movements, 153

Kelly, Dr. Vince, 7KGS Ormco Task Force Number Two, 8–9Kurz, Dr. Craven, 3–6, 8

Kurz lingual appliance, the, 13, 14, 15L-loop, 78, 110

protocol, 114Labiolingual distances, 187Labiolingual thickness, 176Laboratory technician, 165–173Lagerstrom, Dr. Lennart, 7Lateral occlusal function, 81LeFort I osteotomy, 137, 140Levelling, 63Ligation, 15Lingual Task Force, 6Lingual therapy

advantages, 21–22, 133disadvantages, 21–22

Lobiondo, Dr. Echarri P., 10Loop mechanics, 109–115

protocol, 114Loops, advancement, 37

Malocclusion, 23, 32–33Class I, 49–53, 60, 86–90, 188, 190Class II, 92, 117, 123Class III, 79, 139, 141skeletal Class I, 117skeletal Class II, 154

Mandible, retruded, 44Martensite, 55, 57–58

yield strength, 58Maruyama, Prof. Takao, 153Maxillary arch

expansion, 24–27, 33, 130, 136, 141–143

Measuring plates, 190, 191Mechanics, treatment, 47

anchorage, 77–80Mesiodistal tooth widths, 187Mesognathic profile, 86–90Microetch, 36Midline shift, 51Miller, Frank, 3Model, set-up, 166

die stone, 163impression material, 163lingual brackets, placement of, 166removal of excess adhesive, 167

Molars, distalization of, 31–33mesial movement of, 80

Movement, orthodontic, 27Mulick, Dr. Jim, 3Multidisciplinary cases, 145–148

Napolitano, Dr. John, 9

Occlusal interference, 10Occlusal plane dimensions, 165Occlusal record, 168, 170Occlusal scans, 186Occlusion

Class II, 23, 32–33Class III, 26deep bite, 23–24, 32–33, 44

Ormco, 3–8, 15Ormco Task Force, 8Orthodontic-prosthetic treatment combined,

149–152Orthognathic surgery, 135–140

case presentation, 139–140orthodontic operative protocol, 135–137surgical operative protocol, 137

Overjet, 123, 149, 154

Paige, Dr. Steve, 7Palculator, 157–159“Pattern generator”, 154Paz, Dr. Mario, 9Pediatrics, 127–134

candidate criteria, 127case report, 131–133evaluations, 128laboratory procedures, 130–131protocol, 128–130therapeutic indications, 128

Pendulum “F”, 128–130mechanics, 130

Perregaard, Dr. Jorn, 7Phase II body paste, 167Pickrel, Floyd, 6Placement, appliance, 12, 36–37

problems, 9–15planning, 47–48

Placement, wire, 14Plane

anterior inclined, 16–18inclined in brackets, 44maxillary, 18–19

Plierbond removing, 70Mathieu style, 69utility, 68

Porcelain crowns, 86Positioner, pedicle, 4Practice promotion, 38

Preprosthetic treatment, 146–147Prescription, appliance, 12–14Prescription sheet, 164Prosthetic orthodontics, 145Protrusive shift, 156

Quad-Helix device, 25, 136

Radiograph, panoramic, 35Rapid palatal expansion device, 25, 136Rebonding, 179–180Remover, module, 71Repositioning, mandibular, 27, 30Rerotation

preventing, 65Resin, 150, 176, 179Retractor, tongue, and saliva ejector, 70Rigid internal fixation technique, 135Rotation, 145

correction, 32crowding, 180overcorrecting bracket, 181

Scholz, Dr. Bob, 6Scuzzo, Dr. Guiseppe, 9Scwartz, Dr. Michael, 6Segmental technique, 151Set-up method, 188–189

advantages, 188Shape memory wires, 55–61

alignment with, 59–60alloys, 55, 57elastic modulus, 57superelasticity, 56

Silane, 36Silicone, 179Sirognathograph, 153–154, 158Sliding mechanics, 38, 61, 78

advantages, 111case presentation, 123–126disadvantages, 110during en masse retraction, 109–115protocol, 114

Smith, Dr. Bob, 5, 6Space closure, 38, 51–53, 60–61, 64, 65, 78

en masse retraction, 109–115extraction, 78hybrid composite resin, 150–151porcelain laminate veneers, 152uprighting of molars, 145

Speech difficulties, 9, 10, 149

Index

Torque and angulation, 175, 176Torque angulation referencing guide

(TARG) system, 12, 175–177advantages 184

Transfer system, 179Transfer trays, 170

cutting, 172fabrication, 170–171, 176model preparation, 170sectioning, 172

Transpalatal bar, 16–17Treatment planning, 185

archwire design, 189distribution of tooth movement, 189number of archwires, 189wire material, 189

Treatment sequence, 37–38Treatment target, 186

ideal arch method, 187–188set-up method, 188–189

Ulcerationpreventing, 36

Unitek, 7

Wildman, Dr. Jim, 3–4

Young’s modulus, 57

Splint, 28Stability, 179Stabilization, 78Stereoscopic camera, 185Straight wire appliance, 13, 47Straight wire concept, 187Strauch, Ernie, 6Support, posterior acrylic, 28, 75Surgical rapid maxillary expansion, 141–143

T-loop, 78, 110protocol, 114

Takemoto, Dr. Kyoto, 10TARG. See Torque angulation referencing

guideTemplate, 163Template caps, 190, 191Temporomandibular dysfunction, 27Thickness measurement system, 177–182,

184advantages, 184bonding procedure, 179rebonding, 179–180standardization, 178transfer system, 179

Tip, 175, 176Tip control, 63Tongue thrust, 81Torque, 66, 175

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