Finishing in Lingual Orthodontics

9. Finishing in lingual orthodontics:

Labial and lingual techniques are similar in many respects with regard to finishing
and detailing; with both techniques the clinician must consider all dynamic, cephalometric,
esthetic, and functional factors. However, there are specific factors complicating the lingual
finishing phase, making it longer and more difficult. Finishing of a case treated with the
lingual appliance is a clinical challenge.
Factors contributing to difficulties that may be encountered at the finishing stage of
treatment are related to lingual bracket positioning, mechanical limitations of the lingual
appliances, and the characteristics of adult patients seeking orthodontic treatment with lingual
appliances. Many of the finishing problems originate during the earlier stages of treatment
and can be anticipated and avoided.
A major advantage of the lingual appliance over the labial appliance at this stage of
treatment is the absence of brackets, wires, and sometimes gingival hypertrophy masking the
labial surfaces and possibly misleading clinical judgment. With the lingual appliance, the
labial surfaces and gingival margins are more clearly visualized.

The difficulties encountered at the finishing phase of lingual orthodontics derive from the
following three main sources: 77
1. Patients characteristics.
2. Anatomy of the lingual surfaces.
3. Mechanics of lingual treatment.

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1. Patient characteristics:
Most of the patients receiving lingual orthodontics are adults who present with
specific personal requirements often associated with general dental and periodontal problems
requiring a multidisciplinary approach. Generally it is difficult to achieve a good final result
with abraded teeth, missing teeth, uneven spaces, and periodontal and restorative
complications. With the lingual technique it is even more difficult since the lingual anatomy
is more affected in these situations.
In certain cases restorations on the lingual surfaces of teeth may not be finished to
the same standard as those on the labial surfaces. Teeth restored with crowns are sometimes
thicker, projecting toward the lingual side, or thinner than normal teeth. Lingual bracket
positioning is affected by this condition and the initial archwire for these cases may include
many compensatory bends, which have to be duplicated for each subsequent archwire
throughout treatment. Similar problems arise with bracket positioning in cases of severe
abrasion of the incisal edges and associated passive eruption of the abraded teeth.
Compensating for the resulting buccolingual difference between teeth requires a
thicker bracket base for the thinner teeth, which in turn may increase patient discomfort,
reduce interbracket distance. Adult patients who have selected lingual appliances are
generally more demanding, have higher esthetic expectations, and are more conscious of their
appearance throughout orthodontic treatment.
Therefore, many finishing procedures need to accommodate these demands and, if
possible, should be performed earlier during treatment and not delayed to the final finishing
stage so as to reduce the treatment time. For example, alignment of bone height, or gingival
margins in the upper esthetic zone, should be performed early in treatment. Intrusion or
extrusion of the incisors cannot be done by simply modifying the bracket height as with the
labial technique.
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Finishing in Lingual Orthodontics

Modification of the lingual bracket height is difficult due to short occluso-gingival
dimension and the complexity of the lingual surface contour. Therefore, extrusion or
intrusion it is usually done by progressive wire bending. The anatomy of the lingual surfaces
of the anterior teeth with its complex curvature requires three-dimensional bends to achieve a
simple extrusive or intrusive movement. Step-up bend to intrude an incisor will move the
crown labially as well. To avoid the labial crown movement, the step-up should have an inset
component. Offset bend for labial movement will move the crown gingivally as well. To
avoid the upward crown movement, the offset bend should have a downward component

Anatomy of the Lingual Surfaces:

The anatomy of the lingual surfaces of anterior teeth in the natural dentition differs
greatly from the uniform labial surfaces. The irregular palatal surface is the main reason for
inaccuracy of lingual bracket positioning, which in turn is a major factor affecting the
finishing stage.
Several indirect bracket positioning procedures were developed for the lingual
technique; however, bracket positioning cannot always be ideal in different malocclusions
because of the smaller space available for the brackets on the short lingual arch perimeter,
even when using small brackets like the new Scuzzo Takemoto brackets.

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Finishing in Lingual Orthodontics

Furthermore bracket loss which occasionally occurs during treatment, followed by
inaccurate rebonding procedures may further add to the inaccuracy. Compensation for these
inaccuracies requires precise three-dimensional bending of the finishing wires. The use of a
computerized robot (Orthomate System) to fabricate the individual complex finishing wires
has been described. This system will reduce chair side time but is associated with a
complicated and expensive laboratory procedure.

The Mechanical Difficulties in the Lingual Technique:

The lingual surfaces of anterior teeth have a greater slope than the corresponding
labial surfaces. The point of force application (the lingual bracket slot) is at some distance
from the labial surface, which actually defines the final alignment. The point of force
application is also at a distance from the center of resistance; therefore, bending the arch in
one direction may create movements of the tooth in an unwanted direction.
Specific to the lingual technique, certain side effects may appear during treatment.
It is not rare to see up righted incisors after retraction, molars tipped mesially, lateral bite
opening (known as the vertical bowing effect), or arch expansion and distolingual molar
rotation (known as transverse bowing effect). These side effects need to be prevented during
treatment or corrected during the finishing stage.

Prevention of Finishing Problems:

Correct patient selection is a key factor for the success of lingual orthodontic
treatment and has a major bearing on the finishing process. Easier finishing procedures can
be expected with a cooperative patient with good oral hygiene and large healthy teeth
compared with a patient with damaged teeth, attrition, restorations, or periodontal
involvement.
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Finishing in Lingual Orthodontics

The importance of the laboratory procedure, the accuracy of bracket positioning and
correct bonding procedures is crucial for successful finishing. Every mistake in bracket
positioning will be expressed and magnified in the finishing stage. However, even with ideal
bracket positioning, if the bonding procedure is not good enough, if brackets fail and have to
be repeatedly rebonded, then all the bracket positioning accuracy is worthless.
Treatment mechanics need to be carefully executed and monitored. Light forces will
avoid anchorage loss, avoid bowing effects, and avoid having to reestablish lost torque during
the finishing stage. It takes a great deal of time and effort tocorrect unwanted side effects in
lingual treatment; it is much easier to avoid than to correct the mistakes. For example, space
closure with chain elastic may create disto lingual rotation of the terminal tooth. This is a
common finishing problem, which is difficult to correct; it can be avoided simply by tying the
two terminal teeth with a figure-eight ligature and then engaging the chain elastic to the
mesial of the second last tooth.

Systematic finishing procedure:

The most common finishing problems in lingual orthodontic treatment usually
includes one or more of the following: alignment, leveling and rotations, transverse arch
coordination, lateral open bite, torque of one or several teeth, molar rotations, spaces,
anteroposterior discrepancy, or midline deviation.
These problems often derive from inaccurate bracket positioning or inaccurate wire
bends. They can also be due to incomplete bracket engagement. For example, molar rotation
at the end of space closure is frequently a result of disengagement of the wire during space
closure, if the molar was not tightly tied with steel ligature.

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Step I of Finishing Protocol:
Since it is difficult to distinguish between torque problems and vertical problems,
bracket positioning inaccuracy or treatment errors, and since each finishing problem requires
a different approach, it is necessary to first eliminate problems that derive from wire
disengagement and again allow expression of bracket prescription by using a full engagement
resilient archwire. The first step in the finishing stage is therefore to reuse the initial resilient
rectangular archwire for a period on 3 to 4 months (copper NiTi 0.017 x 0.017 inch for 0.018
inch brackets), after steel ligating across the extraction spaces.
This will regain control by full bracket engagement of the wire. Problems deriving
from treatment errors, such as torque of the incisors, expansion, and some of the rotations
will be corrected with this procedure demonstrates correction of the extrusion and lingual
tipping of a lower central incisor by reestablishing full archwire engagement.

The typical vertical bowing effect shown in was adequately corrected by regaining
control with the correct archwire. At the end of this step it may be necessary to reposition
brackets, but normally any necessary bracket repositioning should have been done earlier in
treatment, at the alignment and leveling stage.

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Step II of Finishing Protocol:
The second step in finishing a case is settling in the occlusion, with the
establishment of correct interdigitation, correction of minor midline, anterior posterior and
vertical discrepancies.When rectangular wires have been in place for a long time, the teeth
are often unable to settle into an ideally finished position. Settling in the occlusion is done by
using a lower stabilizing arch, stainless steel or 0.0175 x 0.0175 inch TMA wire and an upper
0.014-inch round sectional wire from canine to canine or lateral incisor to lateral incisor.
The posterior segments are ligated with figure-eight steel ligature wire to avoid
accidental swallowing of brackets. This is accompanied by vertical elastics tied to lingual
brackets or to clear labial buttons. If the teeth have settled correctly after 4 to 6 weeks, then
the final stage of detailing bends is done.

Step III of Finishing Protocol:

The third step in the finishing procedure is final detailing and finishing bends. At
this stage finishing bends are preferred over bracket repositioning since accurate
repositioning for a minor correction is difficult to achieve. As this is the final archwire, it
should not be necessary to reproduce these corrective bends in subsequent arches.When all
desired changes have been noted, the orthodontist must decide whether to bend the detailing
wire at the chair side or whether to-do so during non patient time by bending a detailing wire
on the model. The recommended finishing wire for the upper arch is 0.0175 x 0.0175-inch
TMA. This wire cannot be used for the lower arch due to the very small interbracket distance;
a round 0.016-inch TMA arch wire is preferable is more efficient to place all the bends at one
appointment.

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