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16

ingual Orthodontics: The Future. Stuart McCrostie

Lingual orthodontics has come of age; its acceptance by both the profession

and the patient population continues to grow internationally. The future of

lingual orthodontics is dependent on the following three important issues:

(1) advances in technology related to appliance design and laboratory pro-

tocols; (2) demographic changes in population age groups—the growth in

the number of adult patients seeking orthodontic treatment associated with

an increase in affluence and disposable income will create a patient-driven

demand for more esthetically acceptable appliances; and (3) attitudinal

changes of orthodontists. There has in some countries been a reluctance of

the profession to embrace the lingual technique. With education and train-

ing this resistance is starting to erode and an increasing number of clinicians

are learning and adopting the lingual technique. (Semin Orthod 2006;12:

211-214.) © 2006 Elsevier Inc. All rights reserved.

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t the “Congress Internationale D’OrthodontieLinguale,” the first international lingual orth-

dontic meeting held in Paris (1991) after almostdecade of practicing lingual orthodontics, Iade the following statement: “Lingual orthodon-

ics or invisible braces is an efficient, legitimatereatment modality that should be part of the ar-

amentarium of any modern, caring, comprehen-ive orthodontic practice. ” Now, 14 years later, weay ask the question “Is lingual orthodontics a

ream, wishful thinking, or foolhardy?”For many of us who practice lingual orth-

dontics, it is no longer a dream, but reality. In995 Kyoto Takemoto stated: “Lingual orth-dontics, I am sure, is the ultimate goal forrthodontics, as most patients want to be treatedy invisible braces. Lingual treatment processes,herefore, should be as simple as labial, and weeed to become accustomed to them. It is nec-ssary to train ourselves diligently and try torovide our patients with invisible orthodontics,

Specialist Clinical Associate (Lingual Orthodontics), Universityf Sydney, Sydney, Australia.

Address correspondence to H. Stuart McCrostie, BDS, PO Box653 Hornsby, Westfield, NSW 1635, Australia. Phone: 61 2 9489000; Fax: 61 2 9989 8244; E-mail: mcrostie@ozemail.com.au

© 2006 Elsevier Inc. All rights reserved.1073-8746/06/1203-0$30.00/0

fdoi:10.1053/j.sodo.2006.05.009

Seminars in Orthodontics, Vol 12, No

iving them the ultimate in comfort and happi-ess.”1

Since the introduction of lingual orthodon-ics in the early 1980s, there have been manyapid and significant changes to lingual therapy.he very early understanding of bracket design,

he introduction of the CLASS bonding system,ickel-titanium wires and later copper nickel-

itanium and more recently bendable nickel-ti-anium wires, the development of several systemsor accurate bracket placement, enhanced labo-atory systems, and ever-improving adhesivesave created the lingual orthodontic appliancef today.

Highly efficient and often the treatment ofhoice, the lingual appliance is now easily andccurately placed and simply manipulated, deliv-ring excellent treatment outcomes in treat-ent times no longer than that of labial treat-ents.While this is all true, there are still some

ownsides to our present lingual orthodonticrt—such as initial patient discomfort on place-ent of appliances and the transient speech andasticatory problems many patients endure.hese concerns are often mostly eliminated by

pending time talking patients through theironcerns, particularly before they occur. Re-ember the old sayings “Inform before you per-

orm” and “Prevention is better than a cure.”

2113 (September), 2006: pp 211-214

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212 H. S. McCrostie

he Future of Lingual Orthodontics

he following are the three areas of change thatill affect the future of lingual orthodontics:

. Technologya. Appliance design and manufactureb. Laboratory protocols

. Demographya. Falling birth ratesb. Increasing aging populations

. AttitudeA change in public and professional atti-

tudes to lingual orthodontics

racket Design and Manufacture

rthodontists have been well served by thermco Generation 7 (Ormco Corp, 1332 Southone Hill Ave, Fairview, NJ 07022) bracket sys-

em during almost two decades; but today a se-ies of new bracket designs are appearing, allith the same aims of greater efficiency andomfort for the patient.

cuzzo Takemoto Bracket Appliance

Ormco Corp)This recently introduced smaller, more com-

ortable bracketed appliance still requires indi-ect bracket placement in the manner devel-ped over the past two decades. The STbppliance maximizes the interbracket distancend uses very light forces to create very rapidnitial alignment following past tried and provedrinciples contributing to excellent results inomparatively short treatment times. It has beenuggested that for certain nonextraction maloc-lusions, the STb appliance may be easily set upn the malocclusion model without a sophisti-ated laboratory set-up procedure. Assuminghat the bracket slot-height is correct, the treat-

ent may be completed with round wires only.uch a treatment protocol would reduce labora-ory procedures, resulting in lower laboratoryees, and therefore lessen the cost to the patient.n an extraction treatment program, the use of aore sophisticated diagnostic set-up is to be rec-

mmended. c

ncognito Appliance2

his computer-generated appliance uses three-imensional (3D) computer scanning to ensurefficiency of tooth movement by designingrackets and bonding pads specifically for each

ndividual tooth with the bracket slot in the mostdvantageous position on the lingual surface ofhe dentition. A series of archwires is then cre-ted by a wire-bending robot to achieve the orth-dontist’s treatment goals; bending archwires byand would be difficult and reduce the effi-iency of this appliance. It is my understandinghat such computer-generated lingual appli-nces are expensive to the orthodontist andherefore a cost that must be eventually borne byhe patient.

volution Lingual Technique Appliance

Adenta Gmbh, Gutenbergstrasse 9-11, D-82205ilching, Germany)Self-ligating brackets have a great appeal; but

o be successful as a lingual bracket, they mustave a robust, durable opening/closing mecha-ism. In a malocclusion with crowded lower in-isors, the bracket width encroaches on the in-erbracket space to the extent that the physicaliameter of the archwire, even with “spider-web”ickel-titanium wires, may prevent closure of theracket’s mechanism thus reducing initial effi-iency. This appliance is designed to accept aux-liary springs for extra torque and tip controlhen necessary.

nvisalign

Align Technology, Inc, Santa Clara, CA)While not a lingual orthodontic appliance,

nvisalign it is an esthetic appliance, which hasighlighted the public perception of estheticrthodontics with a very well conducted andunded public relations campaign. This cam-aign, while initially affecting lingual orthodon-ic referrals, has ultimately assisted in heighten-ng interest by the public and general dentist insthetic orthodontics.

aboratory Protocols

omputer technology has developed to allowxtremely accurate 3D scanning, software for the

reation of a virtual model, bracket placement,

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213The Future

nd the construction of transfer trays (Orapix byorea Computer Information Company Ltd,02 Myoungin Building, 234-27 Nohyun-dong,angnomi-gu, Korea). This protocol allows therthodontist the opportunity to adjust on theomputer screen in virtual dimension the finalooth position before bracket placement andray construction. The virtual images used in theonsulting office are also an excellent patientncouragement and education instrument.

A second, but presently unheralded, techno-ogical advance is the bracket-positioning robot,hich uses sophisticated 3D scanning devices toreate a virtual dentition onto which any bracketan be placed with a high degree of accuracy.ransfer trays are then fabricated for bondingrackets to the dental surfaces. Such technologyliminates many of the possible inaccuracies thatould occur with the creation of an ideal diag-ostic set-up on a plaster model, where our tech-ical colleagues place the brackets by hand oremimechanically. The bracket placement robothat presently exists for labial bracket placements currently being trialed with lingual bracketlacement.

Both of these computerized systems continueo allow the orthodontist to bend his or her ownrchwires and to personally control the treat-ent. Many of us would believe this is a more

raditional approach to our patients’ treatment.Each of these high-tech computer systems,

he Incognito appliance system, bracket-posi-ioning software and hardware, and archwire ro-otics, will be superb tools in future orthodon-ics; but to allow the accurate creation of theustomized lingual orthodontic appliances, allystems will still rely on accurate, fully detailedndividualized prescriptions being written by therthodontist for input into the computers. Thisas been the case in the past with more manualystems. The lack of accurately developed pre-criptions has been a major difficulty for theaboratories since the advent of the CLASS sys-em in 1986 (Specialty Appliances Inc, 4905ammond Industrial Dr, Cumming, GA 30041;ww.specialtyappliances.com), with the techni-ians being left “to treat as you see fit” by manyrthodontists.3 This tendency with the comput-rized systems will continue to be a great temp-ation; but remember the old saying, “garbagen—garbage out”—our patients deserve better

han this. a

emographics

t is a well-established fact that in most Westerneveloped societies the populations are aging. As

he average age of our population increases, so theumber of potential adult lingual orthodontic pa-

ients will increase compared with the pool of ex-sting and developing adolescent patient popula-ion. Currently, society in general is more affluent,as more disposable income, and is more con-erned with facial esthetics than in the past. Theseactors taken together are creating a growing de-

and for more esthetically acceptable orthodonticppliances, and as the demand becomes moreatient-driven, so orthodontists will be obliged torovide such a service for their patients. However,

he bright future for lingual orthodontics is only airage unless much effort is made to ensure that

hese increasing numbers of potential lingual orth-dontic patients spend their discretionary dollar inur offices.

ttitude

nfortunately, several of our ill-advised, non-lin-ual orthodontic colleagues summarize lingualrthodontics as “inefficient, takes too long, andannot achieve excellent results.” This negativettitude is passed on to their referring generalentists and, further, to the population at large.

It is essential for practitioners of the lingualechnique to use all public relations tools atheir disposal to educate the public and generalentists regarding the benefits and advantagesf the most successful invisible appliances weave today.

Without education, and teaching and promot-ng our appliances, no matter of which design orow sophisticated they or our laboratory protocolsre, lingual orthodontics will not advance at theate it deserves despite an increased target popu-ation.

Lingual orthodontics or invisible braces is anfficient, legitimate treatment modality thathould be part of the armamentarium of anyodern, caring, comprehensive orthodontic

ractice. Good results and a more widespreadcceptance of this form of treatment can bechieved—not just with improved brackets,ires, and sophisticated technology, but alsoith public relations exercises to win the hearts

nd minds of the general dentist and the lay

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214 H. S. McCrostie

opulation over the misinformation and disin-ormation that covers lingual orthodontics in

any countries.As the Roman philosopher Seneca said many

housand years ago, “It is not because things areifficult that we do not dare. It is because we doot dare that they are difficult.” For our futureatients and for the future of lingual orthodon-

ics, we must keep on daring!

eferences. Kyoto Takemoto: Lingual Orthodontic Extraction Ther-

apy. Ormco Corporation, Clinical Impressions, Volume4(3), 1995

. Magali M, Fauquet C, Galletti C, Palot C, Wiechmann D,Mah J: Digital design and manufacturing of the Lingual-care bracket system. J Clin Orthod 39:375-382, 2005

. Huge SA: The customized lingual appliance set-up service(CLASS) system, in Romano R (ed): Lingual Orthodon-

tics. London, BC Decker, 1998, pp 163-173