lingual orthodontics.pdf

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LINGUALORTHODONTICS


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LINGUAL

ORTHODONTICS


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LINGUAL

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

. . Hamil ton London


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B.C. Decker Inc.4 Hughson Street SouthP.O. Box 620, L.C.D. 1Hamilton, Ontario L8N 3K7Tel: 905-522-7017Fax: 905-522-7839e-mail: [email protected]

website: http://www.bcdecker.com

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.

98 99 00 01 / BP / 9 8 7 6 5 4 3 2 1ISBN 1-55009-040-2Printed in Canada

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United States U.K., Europe, Scandinavia, Middle East

B.C. Decker Inc. Harcourt-Brace & Company Ltd.P.O. Box 785 2428 Oval RoadLewiston, NY 14092-0785 London, NW1 7DX

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B.C. Decker Inc. Jee Sung Publishing Company 4 Hughson Street South 236-15, Neung-Dong P.O. Box 620, L.C.D. 1 Seung Dong-Ku, Seoul

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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.


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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 ofOrthodontics of the Free University

Berlin, Dental SchoolBerlin, Germany

Vittorio Cacciafesta, DDSPostgraduate Orthodontic ResidenceDepartment of OrthodonticsRoyal Dental College

Arhus University, Denmark

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

Christian Demange, DCD, SQODE, CECSMOOrthodontiste Spcialiste QualifiDocteur en Chirurgie DentaireDocteur de lUniversit Claude BernardMatre de Confrences des UniversitsPracticien HospitalierFacult de LyonLyon, France

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

Lorenzo Favero, MD, DDS, MSc

Professor, 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 Orthodontics

Specialization School of OrthodonticsUniversity of Ferrara, Italy

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

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

Contributors


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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 aLabial Orthodontics Office . . . . . J. Courtney Gorman, DDS, MS

SECTION 2

Basic Principles

Enhanced Facial Esthetics usingKurz Lingual Appliance. . . . . . . . Craven Kurz, DDS, PhD

Advanced Lingual Prescription:Technique and Design . . . . . . . . Robert Baker Jr., DMD

. Shape Memory Wires inLingual 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 Approachesand Mechanics

Anchorage Control in LingualOrthodontics . . . . . . . . . . . . . . .

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 Reduction

in Lingual Orthodontics . . . . . . . Didier Fillion, DDS

. Sliding Mechanics versus LoopMechanics 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 inPediatric Patients. . . . . . . . . . . . Lorenzo Favero, MD, DDS, MSc


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. The Lingual Technique inOrthognathic Surgery . . . . . . . . Alessandro Silvestri, MD, DDS, ENT

. Orthodontic-Surgical RPECamouflage on an OrthognathicCase . . . . . . . . . . . . . . . . . . . . . Mario E. Paz, DDS, MS

. Segmental Lingual Orthodonticsin 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 LingualAppliance Set-Up Service(CLASS) System . . . . . . . . . . . . . Scott A. Huge

The Thickness Measurement

System with the DALI Program . . . Didier Fillion, DDS

Lingual Treatment with theBending Art System . . . . . . . . . . . Paul-Georg Jost-Brinkmann, DMD, PhD,Vittorio Cacciafesta, DDS,Friedrich Riemeier

SECTION 5

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

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


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The Preface to Lingual Orthodontics(LO) should have been actually called: A shortexplanation why Lingual Orthodonticsis the first complete English textbook ever pub-lished on LO.

The idea to edit Lingual Orthodonticsarose 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 19821985, 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 silenceconcerning 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. The

technique 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. Much

of this is known only to a small group of orthodontists who come to LO meetings allover the world. This book is published to change this situation because we believe thatlingual orthodontics is the ultimate esthetic solution in orthodontics today.

Many of the best clinicians who practice LO contributed to this book. They comefrom all over the worldfrom 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


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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 take

accredited 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 lingual

orthodontic 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 Orthodonticswill 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.


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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


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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


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Lingual Orthodontics:

Historical PerspectiveC RAV EN K UR Z, DDS, PhD , AND RAFI RO MANO , DM D, 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 plastic

brackets; unfortunately, however, staining of the bracket and the tooth presented asignificant 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, particularlyDr. 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 thelingual aspect of the posterior dentition(Figures 11a 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. Kurzfound 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 patients 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, Ormcos interest in the concept of lingual orthodontictreatment was well established. In the early 1970s, in conjunction with Dr. Jim


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Wildman, they attempted to develop a system to align the dentition using the lingualapproach. This system consisted of a Pedicle positioner, rather than a multibracketed

system. 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 remainednamely, 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 12). 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 19731975 labial appliance modified for lingual application.

-. The incline plane.


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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. Kurzs 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


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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 13),the late Dr. Jack Gorman of Marion,Indiana(Figure 14),Dr. Bob Smith of Stanford, Florida(Figure 15), Dr. Richard(Wick) Alexander (Figure 16) and Dr. Moody Alexander (Figure 17), both from

Dallas, Texas, Dr. James Hilgers of Mission Viejo, California (Figure 18), and Dr. BobScholz of Alemeda, California (Figure 19) to provide beta test sites for the appliance.

-. Dr. James Hilgers -. Dr. Bob Scholtz

-. Dr. Wick Alexander -. Dr. Moody Alexander


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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 appliancelingually. 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 110). 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 the

appliance 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 111). By 1983, the task force was giving courses andnews conferences in most major cities in America. In 1982, Ormco organized a taskforce of two doctors from every country in Europe. In 1983, this group introducedthe appliance to Europe at a meeting in Geneva, Switzerland, followed by courses inJapan. Several well-known European orthodontists, Dr. Klaus Gerkhardt of Germany,Dr. Lennart Lagerstrom of Sweden, and Dr. Jorn Perregaard of Denmark were added

to the European task force. The European doctors insisted on seeing finished cases. In1983, the task force conducted seminars for 300 doctors. All the finished cases were

-. Various magazines exalting the virtues ofthe lingual appliance.


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presented with a full treatment protocol; their results were therefore more acceptablethan those presented earlier to the American doctors. In 1983, Ormco sold 5000lingual 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 Socit FranaisOrthodontie 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 appliance

and 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. Kurzs lecture was well attended becausemany clinicians were looking for solutions to the problems that were preventingthem 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 byA 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.


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

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 Association

was formed to provided support for staff members employed by lingual orthodonticpractitioners. The new professional associations were smaller than the original groupsbut remained active in their support of lingual therapy. Continuing educational pro-grams were now offered in Europe and Japan by the KGS group. Enthusiasm for lin-gual therapy was still strong in these professional communities. Some European andJapanese university programs offered training in lingual therapy and these were soonfollowed by courses in Korea, South America, Mexico, and Denmark.

The European Society of Lingual Orthodontics (ESLO) was founded in 1992, inVenice, Italy, and hundreds of people participated in the first European lingual asso-ciation congress in Venice. In the same year, an Italian society was founded; theAssociazione Italiana Ortodonzia Linguale (AIOL) or the Italian Association of

Lingual Orthodontics has been one of the most active ever since. The Asian lingual 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 aprofessional quarterly, the JALOA. The French Lingual Orthodontic Society and theItalian Lingual Orthodontic Society currently hold annual meetings. The ESLOsponsored 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 variouslocations throughout the world, mainly by Drs. Didier Fillion (France), Courtney

Gorman (USA), Giuseppe Scuzzo (Italy), Kyoto Takemoto (Japan), Echarri PabloLobiondo (Spain), Bob Baker (USA), Mario Paz (USA), and John Napolitano (USA).

The following is a summary listing of some of the difficulties encountered duringthe development of lingual orthodontic therapy and the current solutions:

1. Tissue Irritation and Speech Difficulties

The earlier brackets placed on the lingual surface of the teeth were irritating to thetongue and impeded normal speech. The current generation of brackets has been


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-. 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 Impingement

Earlier generations of the lingual appliance had a broad bonding base extending

towards the gingival margin (Figure 112). 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 113a and b).

3. Occlusal Interference

A 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 directcontact with the maxillary dentition; therefore, the shearing forces were not a problem(Figure 114). 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 115). 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.


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4. Appliance Control

Since the introduction of lingual therapy, control has been a concern. To allow bettercontrol of tooth movements, the appliance was fabricated in high tensile metal whichprovides a greater degree of accuracy. First and second molar bands were manufactured,allowing control from both the buccal and lingual sides of the posterior segments.An initial treatment approach joined the buccal and lingual attachment when the wirewas engaged. This coupling was thought to prevent vertical and horizontal rotationof the buccal segments(Figure 116).Clinically, however, this coupling proved to beunnecessary because one full arch wire from 7-7 was able to offer much more stability.Currently, transpalatal bars are used for additional stability. They can be attached toeither the first or second molar.

5. Base Pad Adaptation

As with all appliances, accurate contour of base pads improves not only retentivecapabilities but also the accuracy of bracket placement and therefore the quality of

-. Cast illustration of the mandibular teeth showingno problem with occlusal interference.

- . Photo of Kurz #7 bracket bonded on typodont, with close-up of mandibular and maxillary incisors.


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treatment. Topographic maps were constructed for each tooth and individual bracketbase curvatures were calculated(Figure 117).

6. Appliance Placement and Bonding

The 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 idealmodel 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 Prescription

In the early 1970s, Dr. Lawrence Andrews developed and patented a fully programmedorthodontic appliance, which he introduced as the Straight Wire Appliance. Thisphilosophy 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/resultantforces exerted.


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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 lingualsurface 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 Andrews published values were used to establish the prescription.There was no grand procedure used in obtaining the reciprocal lingual reference ofangles with regard to Andrews 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 thelingual dental anatomy for the purpose of construction of

lingual appliance bases.


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-. Frontal view of the lingual bracket designed forthe maxillary anteriors.

The in-out values varied dramatically between the anterior and posterior segments.To adjust for this with bracket design alone would make the anterior brackets thickerthan is reasonable, so a true straight wire was not feasible. A first order bend wasplaced at the junctions of the canine and premolar, and the premolar and molar.These wires could be prefabricated in the laboratory.

8. Wire Placement

Access for the placement of wires in the molar tubes from the lingual was limited. The

tubes were redesigned by widening the mesial aperture of the slot of the first molarbracket, creating a funnel effect (Figure 118).

-. Widening of the mesial aperture to provide easeof wire insertion.


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9. Ligation

To permit stable ligation with ligature wires or A elastics, ligature locking grooves thatare both deep set and easy to hook have been designed. When teeth are crowded andslot engagement is especially difficult, a vertical slot is provided so the archwire canbe attached to the bracket even through the initial stages of leveling and aligning

(Figure 119).A double over-tie with metal is used when a tooth is to be an attach-ment for anchorage or rotation of the other teeth.

10. Attachments

A gingival hook is an integral part of the bracket and provides rotational control. Theoriginal hook was large and in close proximity to the gingival margin, impeding accessfor hygiene. This hook was redesigned with a lower profile and moved away from thegingival margin.

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

GENERATION #11976The first Kurz Lingual Appliance was manufactured by Ormco. This appliance had aflat maxillary occlusal bite plane from canine to canine (Figure 120). The lower incisorand premolar brackets were low profile and half-round(Figure 121),and there wereno hooks on any brackets.

GENERATION #21980

Hooks were added to all canine brackets (Figure 122).

GENERATION #31981

Hooks were added to all anterior and premolar brackets. The first molar had a bracket

with an internal hook. The second molar had a terminal sheath without a hook buthad a terminal recess for elastic traction(Figure 123).

-. Generation #11976.Flat maxillary occlusal bite plane from canine to canine.


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GENERATION #4198284

This 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 124 and 25).

GENERATION #5198586

The 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 bar

attachment was now available for the first molar bracket(Figure 126 to 28).

-. Generation #11976.The lower anteriors and premolars had low profile, half-round brackets.

There were no hooks on any brackets.

-. Generation #31981. Hooks wereadded to all anterior and premolar brackets.

-. Generation #21980.Hooks were added to all canine brackets.


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GENERATION #6198790

The inclined plane on the maxillary anteriors become more square in shape(Figures129 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 #4198284. Additional of a low profile anterior inclined planeon the central and lateral incisors. Hooks were optional.

- . Generation #5198586. The anterior inclined plane was more pronounced,

Upper Central

Torque: +68Angulation: +5Rotation: 0InOut: 0Slot size: .018Pad: Special lingual design

Upper Cuspid

Torque: +55Angulation: +12Rotation: 0InOut: .010Slot size: .018Pad: Special lingual design


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GENERATION #71990 TO PRESENTThe maxillary anterior inclined plane is now heart-shaped with short hooks. Thelower anterior brackets have a larger inclined plane with short hooks. All hooks havea 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 131 and 32).

-. Generation #51985 86. A transpalatal bar attachmentwas now available for the first molar bracket.

- . Generation #6198790. 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 forarchwireBracket

Bracket


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

13:371430.

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;2:131149.

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;20:45.

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 #71990present. The maxillary anterior inclined plane isheart-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

Bracketslot forarchwire

Bracket


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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 of

patients 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 ofsuccess 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 ones physical appearance, as is commonwith orthodontic treatment, can positively affect social and professional interactions.19

At the same time, deterioration in ones physical appearance, as with the use of unat-tractive labial orthodontic appliances, can negatively affect ones self-esteem. This is

particularly 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 Therapy

One 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


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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 force

application for tooth movement.59Lingual bracket position, which is dictated by the morphology of the lingual surface

of the tooth, places the bracket closer to the center of resistance of the tooth than isfound with labial bracket placement (Figure 21).10An 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.


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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 22 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 extreme

Class II relationship on that side (Figure 22a). Partial lingual appliances were placedin both arches (Figures 22b 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 afterthe partial lingual bonding; the molars were banded afterwards.

-. The upper arch, just after the initial partiallingual bonding.

-. Frontal intraoral view, three months afterstarting lingual mechanics.


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is not always possible at initial bonding due to the severity of the malocclusion, soappliances should be repositioned during treatment when it becomes possible. Figure22d shows the treatment progress three months after appliance placement, andFigure 22e shows the final occlusion. Total treatment time was 15 months.

Deep-bite correction was facilitated by the active anterior intrusive forces and thepassive posterior extrusive forces. The correction was stabilized by prosthetic restora-tions in the posterior segments.

2. Maxillary Arch Expansion

With some kinds of malocclusions we are occasionally faced with the need to expandthe upper arch both transversally and sagittally. It is not yet totally clear why but, clin-ically, we obtain more remarkable dentoalveolar expansions through lingual mechanicsthan through labial mechanics.1112

-. The occlusal situation six months after the endof the treatment.

-. Profile view of the patient,before treatment.


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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.79

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.


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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 23a), 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 23b 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 23d and e).Lingual braceswere bonded to the upper arch with an initial Twist-Flex type archwire (Figure 24a).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 24a),with a rectangular wire. Notice the amount of the transverse

and sagittal expansion.

-. The patients profile after treatment.


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remarkable, both transversally and anteriorly (Figure 24b).Further expansion wasachieved with a rectangular archwire. The results show substantial improvement in thepatient profile and occlusion(Figures 24c and d).

3. Combining Mandibular Repositioning Therapy withOrthodontic Movements

When patients have temporomandibular dysfunction (TMD), it is often necessary totreat in two distinct clinical phases. The initial phase of treatment addresses the TMDand associated pain symptoms. It is often accomplished with splint therapy until themuscle and joint symptoms resolve. Depending on the practitioner, the patient is thenmaintained, symptom free for a period of time from several months to more than ayear. The second clinical phase of treatment addresses changes in the occlusion as aresult of the new mandibular position. It generally involves orthodontics, prosthodon-

tics, and/or orthognatic surgery.The orthodontic phase of treatment is often tedious and time consuming. Often,

labial appliances are placed on one arch, and a positioning splint is kept on the oppos-ing arch to maintain the maxillomandibular relationship. This is then reversed withappliances placed on the opposite arch and a splint fabricated for the opposing arch.Obviously, treatment times can be significantly extended.

-. Frontal intraoral view at the end of treatment.

-. Left intraoral view during the last phases of theClass II mechanics.


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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 these

patients 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 25),or they can be fabricated with some occlusalindentations which can guide the mandible into the desired position.1214 Figures 26

- . 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.


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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 26a to c).A mandibular repositioner was fabricatedand worn until her TMD symptoms disappeared (Figure 26d) and she was main-tained symptom free for four months before orthodontic treatment was initiated. Thelower arch was then bonded (Figure 26e). Two months later the upper splint was

-. The patient, wearing the splint, is maintainedin 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.


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removed, the maxillary arch bonded, and flat acrylic supports were placed(Figure

26f).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 27a to c show the finished case several

-. The center of resistance of the secondupper 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 sectionalarchwire can be used.

-. A doubled Class II elastic (lingual and buccal)is very effective for the retracting mechanics.


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

4. Distalization of Maxillary Molars

Lingual brackets are placed closer to the center of rotation (CR) of the tooth 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.


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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 28a). 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 28b 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 28c) 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 29a). 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 29b). The balance of these forces counteracts the rota-tional forces.

As an additional case, we present the 20-year-old female inFigures 210 to 13whopresents a rather retrusive chin(Figure 210a).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 endof treatment.

-. The Class II mechanics at the final phase ofthe treatment.


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malocclusion with a slight anterior crowding(Figure 210b).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 210c). Some poste-rior acrylic minisupports are noticeable in the intraoral lateral photographs(Figures

210d 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 210f). In theupper arch, a lingual archwire can be used(Figure 211). InFigure 212we see aremarkable improvement in the patients 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 213).

In todays clinical orthodontic practice, the lingual appliance can offer manyadvantages over the labial appliance to both the patient and the practitioner. Enamel

surfaces 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;16:255262.

2. Alexander CM, Alexander RG, Sinclair PM. Lingual orthodontics: a status report, part 6:patient and practice management. J Clin Orthod 1983;17:240246.

3. Breece G, Nieberg L. Motivations for adult orthodontic treatment. J Clin Orthod 1986;3:166171.

4. Bercheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119131.

5. Fujita K. New orthodontic treatment with lingual brackets and mushroom arch wire appli-ance. Am J Orthod 1979;76:657675.

6. Genone B, Siciliani G. Trattamenti ortodontici a collocazione linguale. Mondo Ortodontico1984;3:1427.

7. Gorman JR, Hilgers JJ, Smith JR. Lingual orthodontics: a status report, part 4: diagnosis andtreatment planning. J Clin Orthod 1983;17:2635.

-. The occlusal result.


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8. Kelly VM. Interviews on lingual orthodontics. J Clin Orthod 1982;16:461476.

9. Kurz C, Gorman JR. Lingual orthodontics: a status report, part 7: case report. J Clin Orthod1983;17:310331.

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 1820, 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 2628,1983.

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 1820, 1993.

13. Ronchin M. Aesthetics with lingual orthodontics: resolving class II malocclusions with molardistalisation. Pract Perio Aesthet Dent 1994;6:5158.

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


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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.

Todays 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 viewinga 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 a

Labial Orthodontics OfficeJ. COURTNEY GORMAN, DDS, MS


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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 Placement

The 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 a

guide. 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.


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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 products

or 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


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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 .022

stainless 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 arches

can 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 forsocking 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 to

wear 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.


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Lingual Orthodontics in a Labial Orthodontics Office

Conclusion

Lingual 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.


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Enhanced Facial Estheticsusing Kurz Lingual Appliance . . Craven Kurz

Advanced Lingual Prescription:Technique and Design . . . . . . . Robert Baker Jr.

. Shape Memory Wires inLingual Orthodontics . . . . . . . . Christian Demange

. Wire Sequencing inLingual Orthodontics . . . . . . . . . H. Stuart McCrostie

Instruments Used inLingual Orthodontics . . . . . . . . . Craven Kurz

SECTION 2

Basic Principles


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A primary reason a patient seeks orthodontic treatment is to improve facial esthetics(Figure 41). 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 todays 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 Plane

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

Enhanced Facial Esthetics

using Kurz Lingual ApplianceC RAV EN K UR Z, DDS, PhD

-. Michelangelos faces in balance with todays contemporarybeauty analysis.


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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 retruded

mandible.2. It can help expand the arch. This is a clinical observation and the possible

explanations are elimination of posterior contacts or decrease in the lateralspace in the palatal vault (Figures 42a 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 43a 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.


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Enhanced Facial Esthetics using Kurz Lingual Appliance

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

2:1229.Eirew HL. An orthodontic challenge. Int J Orthod 1976;14:2125.

Liddle DW. Second molar extraction in orthodontic treatment. Am J Orthod 1977;72:599616.

Luzi V. The CV value (combines variation) in the analysis of sagittal malocclusions. Am J Orthod1982;81:478480.

McNamara JC. Components of Class II malocclusion in children 810 years of age. AngleOrthodontists, 1981;51:177202.

Moyers et al. Differential diagnosis of Class II malocclusions. Am J Orthod 1980;78:477494.

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


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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, any

single 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 usesound 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 not

overstandardize 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 impede

treatment 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 DesignRO BE RT B AK ER J R . , DMD


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the lingual brackets. The biomechanics of choice must be carefully selected. Forexample, 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 and

technique is the virtual elimination of appliance auxiliaries like rotation ties ordouble over-ties.

Case Presentations

The following cases demonstrate diagnosis and the establishment of treatment goalsthrou

lingual orthodontics.pdf

Documents