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INDIAN DENTAL ACADEMY

Leader in continuing dental education


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Seminar by:
Dr. Sandhya Anand

Done under the guidance of:
Dr. Ashima Valiathan BDS (Pb), DDS, MS (USA)
Professor and Head
Director of postgraduate studies
Dept. of Orthodontics and Dentofacial Orthopedics
Manipal College of Dental Sciences, Manipal

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Contents
Introduction.
Historical perspective.
The lingual appliance.
Diagnosis and treatment planning.
Lingual bracket placement.
Bonding techniques.
Lingual mechanotherapy.
Keys to success in lingual therapy.
Improving patient comfort.
Conclusions.
References.



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Aesthetics has always been a catchword among
patients. With more number of adult patients
desiring orthodontic treatment, special aesthetic
demands of the patients pose a great challenge
to the orthodontic community. These patients
have professional and social commitments and
cannot accept visible braces even for a short
time.
To be able to serve such patients, the orthodontic
community came out with the ultimate aesthetic
solution Lingual Orthodontics.
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Lingual orthodontics, apart from offering the
aesthetic benefit, also provides several
mechanical advantages. Since its inception in
the 1970s, great advances have been made in
this modality.
At present, Lingual orthodontics is a complete
system in itself and encompasses accurate
diagnosis, treatment protocol, clinical and
laboratory procedures.
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Historical perspective
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As early as the late 1880s, the dental
literature extolled the advantages of moving
teeth with lingual appliances. These early
appliances were removable and designed to
expand the dental arches.

The first reference to lingual mechanics dates
back to 1889, when John Farrar introduced the
Lingual removable arch.
In 1918, Dr. John Mershon published a paper
entitled "The Removable Lingual Arch as an
Appliance for the Treatment of Malocclusion of
the Teeth".

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In March 1942, Dr. Oren Oliver introduced the
labiolingual appliance.
In the mid-'50s, Dr. William Wilson
demonstrated a labio-loop-lingual appliance that
was a forerunner of the Wilson modular
appliance system.
The Crozat appliance, conventional acrylic
removable appliances, Nance buttons, trans-
palatal arches and lingual attachments were the
results of efforts of clinicians to use the
mechanical advantage of lingual aspect of teeth
to bring about desired tooth movement.
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However, all these appliances were used as a
supplement to labial mechanics, with no
cosmetic incentive.


With the advent of orthodontic bracket bonding in
the early 1970s, the possibility of a fixed lingual
appliance occurred to several orthodontists
working independently.
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In 1975, Dr. Craven Kurz of Beverly Hills,
California created his own lingual appliances by
modifying labial edgewise appliances, and
utilized them on a limited basis in his practice.
He limited his treatment to the mandibular arch
for fear that the forces of occlusion would
dislodge brackets placed on the lingual surface
of the maxillary anterior teeth.
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Later in 1976, Dr. Kurz submitted specific
designs and concepts to the U.S. Patent Office
for the patent rights to his unique edgewise
lingual appliance. He joined with Ormco
Corporation (Orange, CA) to develop and
produce a prototype of this appliance.

Among the unique features of this appliance
were a bite plane incorporated in the maxillary
anterior brackets, mesh bonding pads designed
to adapt to the lingual surface of the teeth, and
pre-torqued archwire slots based on a
conversion of commonly used labial torque
values.

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In December 1979, Dr. Kinya Fujita, of
Kanagawa Dental University, Japan, published
an article describing appliances with a lingual
bracket design and mushroom shaped
archwires.
His work confirmed the experiences of Dr. Kurz
and Ormco that, certainly with refinements,
lingual appliances were a viable adjunct to the
orthodontist's armamentarium.
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In December 1980, Ormco decided to put
together a team of orthodontists (the Task
Force ) to study the appliance further and
make suggestions regarding improvements.
The Task Force consisted of:
i. Dr. C. Moody Alexander
ii. Dr. Richard (Wick) Alexander
iii. Dr. John Gorman
iv. Dr. James Hilgers
v. Dr. Craven Kurz
vi. Dr. Robert Scholz
vii. Dr. John (Bob) Smith.

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The Task Force was initially charged with the
responsibilities of evaluating the appliance
design over a two-year period.

Their specific objectives were:
1. To help refine bracket design (dimensions,
torques, angulations, thickness, etc.).
2. To develop mechanotherapy techniques.
3. To create archwire designs.
4. To discuss treatment sequences.
5. To determine case selection criteria.

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The Lingual Appliance
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In 1976, the I
st
generation of lingual brackets
were produced by Ormco.

The Ist generation brackets or First Kurz
Appliance had an .018" slot size for
conservation of incisal-gingival bracket
dimension and for compatibility with existing
archwires.
Development by Kurz & co-workers
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The incisal wing of the maxillary incisor brackets
incorporated a bite plane which served the dual
purpose of assisting in opening deep bites and
redirecting the forces of occlusion to prevent
shearing of the bond.
As a result, bond failure was dramatically lower
than before.
The brackets were bonded according to
reciprocal tip and torque values to Andrews
published values.

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The lingual appliance most widely used today is
the generation VII appliance, developed in
1990 by Ormco Corp.

The VII
th
generation brackets are much refined,
low profile, patient friendly brackets.
They have a horizontal slot, and are offered in
either an 0.018" or 0.022" slot size.
The premolar brackets have increased width to
allow better angulation and rotation control.


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Modifications in lingual bracket design.

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Multiple molar attachments are available,
including a tube, a twin bracket and a hinge cap
or terminal sheath (a convertible bracket that
can function as a tube or a self-ligating slot).
All brackets have a gingival ball hook which
facilitates elastic ligature placement, rotation
control and placement of intra- and inter-
maxillary elastics.

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Roll cap bracket on
first molar.

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The bite plane on the maxillary anterior brackets
is heart-shaped. It is parallel to the archwire and
occlusal plane.

Significance: The bite plane allows placement
of all brackets during initial bonding even in
cases with severe deep bites. The patients
occlusion is located on the bite planes of the
anterior brackets.

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Typical lingual appliance

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The bite planes cause immediate disclusion of
the posterior teeth, removing the forces of
occlusion from the biomechanical formula. Thus,
the correction of crossbites, deepbites, rotations
and space closure can be achieved at an
accelerated pace without the interference of
occlusion.
At the same time, anchorage loss, bowing of
the buccal segment, loss of arch coordination
and extrusion of molars are made easier without
the controlling effect of the forces of occlusion.



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Interbracket distances are reversed with the
lingual appliance.
There is less interbracket distance in the
anterior, but in the posterior region, the
interbracket distances are increased mesio-
distally.
This can hinder full bracket engagement in
the anterior and reduces the relative stiffness of
the archwire in the posterior segment.

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Interbracket width is reduced on the lingual.


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Wide buccolingual
dimension makes lingual
bracket placement
difficult.







Short interbracket span
in lingual treatment.

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The brackets have a custom pad that is
fabricated in the laboratory. This ensures proper
bracket placement and maximizes bond strength
by minimizing the space between bracket and
tooth.
This pad makes each lingual bracket unique
and gives the orthodontist the ability to prescribe
specific tooth movement for each patient.
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The ideal archwire has a mushroom shape. This
is due to the large constriction in arch width that
occurs as one proceeds distally from the lingual
surface of the canine to the bicuspid. Since the
brackets are designed to minimize bracket
profiles, it is necessary to place compensating
first order bends interproximally at the cuspid-
bicuspid and bicuspid-molar locations.
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Mushroom shaped archwire
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In cases with short clinical crowns, or if there is a
problem with incisal clearance, a second order
bend, or step-down, may also be needed
between cuspids and bicuspids.
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Fujitas lingual bracket system
(AJO 1979)
Kinya Fujitas purpose for lingual
bracket system, apart from aesthetics, was to
prevent injury with labial brackets during sports.
The first Fujita lingual bracket was introduced in
1979.
It featured a slot that opened toward the
occlusal. The occlusal approach makes arch
wire insertion, seating, and removal easier than
arch wire insertion with lingually opening slots.
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A. Lingual insertion. B. Occlusal insertion.


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A lock pin was inserted mesiodistally into a
groove in the slot to secure the archwire, in
conjunction with a conventional elastomeric or
steel ligature.
Auxiliary groove was set in the occluso-gingival
direction to facilitate correction of the mesio-
distal tipping of the teeth.


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The presently available Fujita system is still based
on an occlusal slot opening, but has multiple
slots.
Brackets for the anterior teeth and premolars
now have three slots: occlusal, lingual, and
vertical.
Molar brackets have five slots: one occlusal, two
lingual, and two vertical.
Each of the three types of archwire slots
provides different capabilities for efficient tooth
movements.
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Fujita lingual brackets
(OS = occlusal slot; LS = lingual slot; VS = vertical slot;
OW = occlusal wing; GW = gingival wing).

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The basic purpose of incorporating multiple slots
is to use Tandem wire mechanics.

This entails use of multiple wires in different
slots to bring about desired tooth movements
without side effects.
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The Fujita system is advantageous:

i. In cases in which esthetic considerations are
important.
ii. In cases in which the patient is engaged in
sports activities (less trauma to the lips).
iii. In undertaking minor tooth movement as a
preliminary to prosthodontic treatment.
iv. For orthodontic treatment and fixation as
treatment for periodontal disease.
v. Because it makes use of the lingual-bracket
and mushroom-arch appliance in lieu of a
retaining appliance.


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Beggs lingual brackets
(JCO1982)
Dr. Stephen Paige introduced the Lingual
Light Wire technique in 1982.

Initially, he used the Beggs TP 256-500
labial brackets.
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The bracket currently
used in the Begg
system is the
Unipoint combination
bracket (Unitek),
with the slot oriented
in the occlusal-incisal
direction.
The Unipoint bracket
has a gingival "wing"
to place elastic
modules on
continuous elastic
chains.

The Unipoint Bracket
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Molar Tube Design:

Oval tube with a
mesiogingival hook.
The squashed oval
tube has some
advantages in that it
increases patient
comfort, allows molar
control, and will
accept a ribbon arch.

Oval Tube
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Mushroom arches with
horizontal loops for elastics.


Archwires:
The general shape
of the archwires
resembles the
mushroom shape as
proposed by Fujita,
except that when use
of elastics to the
archwire is required, a
horizontal loop has
been added distal to
the cuspids.

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Creekmores Lingual System
(AJODO 1989)
Described by
Thomas
Creekmore in
1989.
The foundation of
the design is the
opening of the arch
wire slots to the
occlusal aspect
rather than to the
lingual aspect.
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Unitwin bracket-centered arch
wire slot.

Conceal brackets are
designed around the Unitwin
bracket "centered slot"
concept.
The Unitwin bracket is, in
effect, a single bracket
without tie wings in the center
of a 0.045 inch twin bracket.
It uses the advantages of
both single and twin brackets
by allowing maximum
interbracket distance for
optimal tip and torque
functions, while providing twin
tie wings for rotation control.
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Each Conceal bracket
has three different
slot widths for the
three different
functions of tip (A-B),
torque (E-F) and
rotation (C-F or E-D).
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A critical
breakthrough was the
design of premolar
and molar brackets,
with occlusal tie wings
projecting mesially
and distally instead of
labiolingually.

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Straight Wire Lingual Brackets
(JCO 2001)
Takemoto and Scuzzo in 2001 found
that the bucco-lingual distances at the gingival
margins do not vary substantially. This led them
to conclude that straight archwires could be
used in lingual orthodontics if they were placed
as close to the gingival margin as possible.
Compared to other lingual brackets, archwire
insertion in this design is from the top instead of
the bottom.
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Advantages:
- Flossing is easier as the archwire is farther from
the lingual surface and incisal edge.
- Mesio-distal with of the bracket is smaller,
allowing adequate inter-bracket distances.
- Less composite is needed to raise the bite, since
the brackets are placed more gingivally.
- Rotations can be more easily accomplished as
the archwire can be tied tightly to the bottom of
bracket slots.
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- Torque control is improved.
- Rebonding is easier as the archwire does not
have to be removed.
- Pre-formed archwires can be used with a few
additional bends, reducing chairtime and
allowing the use of sliding mechanics.
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Self-ligating Lingual Brackets
(JCO 2002)
First described by Macchi et al in
2002, the Philippe Self Ligating Lingual
Brackets (Forestadent, St. Louis, MO) can be
bonded directly to the lingual tooth surfaces.

Since they do not have slots, only first- and
second-order movements are possible.

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Four types of Philippe brackets are available:

- Standard medium twin bracket (most commonly
used).
- Narrow single-wing bracket for lower incisors.
- Large twin bracket.
- Three- wing bracket for attachmentof
intermaxillary elastics and application of simple
third-order movements.

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Clinical applications:

- Post treatment retention.
- Closure of minor spaces.
- Limited intrusion.
- Correction of simple tooth malalignments and
mild crowding, especially in the mandibular arch.

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Customised brackets & archwires for lingual orthodontic
treatment
(AJODO 2003)
Developed by Weichmann et al in 2003.
In this technique, the processes of bracket
fabrication and optimized positioning of the
fabricated brackets on the tooth are fused into
one unit.
Each tooth has its own customized bracket,
made with state-of-the-art CAD/CAM software
coupled with high-end, rapid prototyping
techniques.

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Diagnosis & Treatment Planning
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Case diagnosis is conducted in a manner similar
to established procedures.
Additional diagnostic input may be required from
the periodontist, restorative dentist, and
orthognathic surgeon, as well as some
additional psychological acumen on the part of
the orthodontist.
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The treatment plan is based upon the diagnosis,
the cost and time factors, and the patient's
desires.

Patient Selection.

The most important factors in selecting
patients for lingual treatment are their
personalities and reasons for seeking treatment.
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After the patients are informed of the treatment
rationale and effects of the lingual appliance
(speech, soreness, bite opening), their attitude
should be one of understanding and a desire to
do whatever is necessary to accomplish the
optimum results.

Time & Cost Factors.

1. Examination, diagnosis, consultation, and
treatment planning time are increased by 30 to
45 minutes.
2. Laboratory procedures for the indirect appliance
setup increase the fixed costs.
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3. Orthodontist and staff time increases by 30-
50%.
4. It may be necessary to finish some patients with
a conventional labial appliance.
5. A fully articulated positioner appliance may be
required for detailing the lingual case.

Due to these factors, a treatment fee of 30-
50% more than the orthodontist's usual adult
patient fee is considered realistic, reasonable,
and fair.

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Periodontal considerations.

The status of the periodontium must be carefully
evaluated.
Short lingual clinical crowns can present a
contraindication to optimum lingual bracket
positioning.
The lingual appliance can cause gingival
hypertrophy, as the brackets are bonded close
to the gingival crest.
Patients with a history of periodontal problems or
in whom oral hygiene motivation is questionable
may not be the best candidates for lingual
therapy.
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Restorative considerations.

In cases where there is a loss of several teeth,
extreme tipping, and multiple or complex
bridgework, the lingual appliance may be
contraindicated.
Porcelain-fused-to-metal crowns or other
metallic restorations may need to be replaced
with provisional plastic crowns to permit lingual
bonding.
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Lingual crown height.

7mm of lingual crown height is necessary on the
maxillary incisors in order to achieve optimum
bracket placement.
Attention should be given to:
Extreme brachyfacial types with short alveolar
and crown height dimensions
Partially erupted teeth in the young adolescent
patient
Crown heights that have been diminished by
excessive wear, trauma, or restorative work
Diminutive teeth, i.e., peg laterals

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Extraction vs. Non-extraction
considerations.

In lingual orthodontics, strong molar anchorage,
especially in the lower arch, makes mesial
movement of molar difficult.
Hence, in Class I cases, extraction of upper first
and lower second premolars is preferred.
In Class II cases, it is better to avoid lower arch
extractions.
In open bite and Class III cases, four first
premolar extractions are considered.
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Temperomandibular joint considerations.

Lingual orthodontic treatment can lead to
relief of joint symptoms, probably due the
disarticulating effect of the anterior brackets.

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Changes induced by the lingual appliance.

1. Vertical changes.
The most immediate and readily apparent
appliance-induced change is the bite opening
resulting from the lower incisors occluding on
the maxillary incisor bracket bite planes.
This bite opening is beneficial in brachyfacial
cases, TMD cases and rapid tooth movement
due to posterior disclusion.
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Bite Plane Effect
Treatment time - 3 months.

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2. Antero-posterior changes.

Because of the vertical opening and the
immediate rotation of the mandible (down and
back), the lingual appliance also induces a Class
II tendency.
With bite opening, A-P molar correction is
easier.

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3. Transverse changes.

The lingual appliance has an expansive nature.
This is coupled by posterior disclusion.
There is tendency to cause mesio-buccal molar
rotation during space closure. Thus, placement
of transpalatal arch is important.
Retraction is always done on stiffer wires to
prevent bowing effect, both in the transverse
and vertical planes.
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First molar rotation and second molar flaring
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Transverse bowing
resulting from space
closure on wires of
insufficient stiffness.



Vertical bowing effects
resulting from space
closure on light, resilient
archwires.

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Indications for lingual orthodontic
treatment
Ideal Lingual Cases

Nonextraction:
Deep bite, Class I with mild crowding, good
facial pattern.
Deep bite, Class I with generalized spacing,
good facial pattern.
Deep bite, mild Class II, good facial pattern.
Class II division 2 with retruded mandible
Cases requiring expansion.
Consolidation (diastema) cases.
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Extraction:

Class II, maxillary first bicuspid and mandibular
second bicuspid extractions.
Maxillary first bicuspid only extractions.
Mild double protrusions with four first bicuspid
extractions, wherein anchorage is not critical.

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More Difficult Lingual Cases

Surgical cases.
Class III tendencies.
Class II, four first bicuspid extractions.
Mesiofacial patterns and/or moderate
mandibular plane angles.
Cases with multiple restorative work.
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Acute TMJ dysfunction.
Mutilated posterior occlusions.
High angle/dolichofacial patterns.
Extensive anterior prosthesis.
Short clinical crowns.
Critical anchorage cases.
Severe Class II discrepancies.
Poor oral hygiene or unresolved periodontal
involvement.
Unadaptable or demanding personality types.
Cases Contraindicated for Lingual
Therapy
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Lingual Bracket Placement
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Considering the difficulty of access, irregularity
and variability of lingual tooth morphology, it is
difficult to locate exact bracket positions, even
on plaster casts.

Michael Diamond (J Clin Orthod,
1983) described the critical aspects of lingual
bracket placement as follows:

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1.) Variation in height
(y) has a direct
effect on the
labiolingual position
of the bracket (x).
Placement of the
bracket closer to the
incisal edge (y')
shortens the
labiolingual
distance (x').

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2.) Variation in
tooth thickness at
the same distance
from the incisal
edge affects bracket
placement by
varying the distance
from the labial
surface.
Tooth A is thicker
than tooth B at
height y, and the
distance x' is greater
than x.

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3.) Variation in height
alters the effective
torque in the
bracket, with either
a vertical or a
horizontal insertion
of the archwire.
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4.) Brackets placed at
the same height (y)
on different lingual
slope angulations
will be located at
various distances
from the incisal
edge (C).
A is greater than B.

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5.) Altering the
angle of the
bracket-
positioning
instrument can
vary the amount
of torque in the
bracket slot.

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Lingual Bracket Placement
Systems
These include:
1. Torque angulation reference guide (TARG).
2. Fillions indirect bonding system.
3. The customized lingual appliance setup
service (CLASS) system.
4. The slot machine
5. Hiro system
6. The Ray set system
7. The lingual bracket jig.
8. The mushroom bracket positioner. www.indiandentalacademy.com

This technique of bracket placement was
developed by Ormco in 1984.
It permits bonding of brackets in the laboratory,
at an accurate distance from the occlusal edge
of each tooth with respect to a horizontal
reference plane.
A labial reference gauge is used to orient
individual teeth.
Using only one unique angulation model, the
TARG allows pre-programming of tip and torque
before the start of treatment.
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Torque Angulation
Reference Guide.

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Advantages:
- It is an accurate and quantified two-dimensional
system.
- Allows accurate placement of the brackets on
the cast without need to cut out the teeth and
place in wax.
Disadvantages:
- The system does not take into account the labio-
lingual thickness of teeth.
- The distance of the bracket base and the labial
surface varies according to the level of bonding.
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Introduced by Dr.
T.D.Creekmore in
1986, the Slot Machine
was meant to be used
with the Conceal
bracket system.
It also used a labial
reference to position
the brackets like the
TARG machine.
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This system was developed by Dr. Didier Fillion
of France in 1987.
Also known as Bonding with Equalized Specific
Thickness (BEST).
It was designed to consider the labio-lingual
thickness of the individual teeth during bracket
placement.
A caliper is added as the thickness
measurement system.

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Advantages:
- Relates the labio-lingual thickness of tooth to
bracket position.
- Allows working directly on the malocclusion
model.
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Described by Scott Huge, this technique
involves an integrated method of lingual bracket
placement and indirect bonding.
Method:
- An ideal setup is made from the original
malocclusion cast and brackets are placed on
this setup.

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- These are later transferred to the original cast by
individual transfer trays.
- An indirect bonding tray is fabricated for
bonding.

Advantage: It takes into account the anatomical
discrepancies in the lingual surfaces of the teeth.
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Hiro system
Introduced by Hiro and later improved by
Takemoto and Scuzzo.
Method:
- An ideal archwire is made on the setup using a
full size rectangular archwire.
- The lingual brackets are transferred onto this
wire and secured with elastic ligatures.
- Single rigid transfer trays are fabricated for each
tooth.
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- The archwire is then removed and custom bases
for brackets are made.

Advantages:
- There is no need to transfer brackets from the
setup model to the original malocclusion model.
- Accuracy is improved due to individual transfer
trays.
- Bonding of one tooth is not affected by position of
other teeth.
- Rebonding is easier.
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The Ray Set system
This system utilizes a 3-dimensional goniometer
for analysis of the first-, second-, and third-order
values of each individual tooth.

Both pre- and post-setup values of individual
teeth are evaluated and the amount of
orthodontic tooth movement for each tooth on
the setup model is calculated.

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The Lingual Bracket Jig
Dr. Silvia Geron in 1999 introduced lingual
bracket jig which is a chairside direct bonding
system.

It is used with a horizontal slot bracket.
The basic idea behind the lingual bracket jig
(LBJ) is that lingual tooth anatomy and inter-
tooth relationships are amenable to a lingual
preadjusted edgewise approach.

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The jig transfers the Andrews Straight-Wire
Appliance labial bracket prescription to the
lingual surface. Thus, the bracket slots line up
around the arch, parallel to one another and to
the occlusal plane, while the prescription
provides tip, torque, rotation, and in-out.

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LBJ transfers labial bracket prescriptions to lingual brackets

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The LBJ consists of:
A set of six jigs, one for
each of the six maxillary
anterior teeth, which
present the most
morphological
variation of the lingual
surfaces.
An accessory universal
LBJ for the maxillary
posterior teeth (no torque
or angulation prescribed).

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Each jig has a labial arm and a lingual arm.
The tip of the labial arm incorporates a
prescription, similar to that of a preadjusted
labial bracket.
The lingual arm, which holds the lingual bracket,
slides into the labial arm.
When the lingual bracket is mounted on the LBJ,
the lingual bracket slot is parallel to the labial
slot. When the labial arm is positioned correctly,
the lingual bracket is automatically placed in its
correct position.

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A. Labial arm of LBJ
positioned on labial
surface of tooth,
duplicating location of
labial bracket relative
to LA point.


B. Lingual bracket
automatically placed in
correct position.

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Advantages:
- Lingual bracket positioning with the LBJ is
simple and quick, and requires no special
training.
- The LBJ automatically incorporates the
Straight-Wire labial prescription into the bonded
lingual brackets in all dimensions.
- This allows the orthodontist to perform direct as
well as indirect bonding as in-office procedures.
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The Mushroom Bracket Positioner
Developed by Kyung et al, in 2002, the
mushroom bracket positioner is a machine for
accurate bracket placement on an ideal setup.

At present, 5
th
generation of MBP is available
which places brackets to accept a straight wire.
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Introduced by Wiechmann et al in 2003, this
system utilizes CAD/CAM technology.
It scans the lingual surfaces of the teeth on the
ideal diagnostic setup via 3D optical scanner.
The data obtained from the scan is used to
fabricate fully customized bracket with adapting
base pads and built-in prescription.
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Bonding Techniques in Lingual Orthodontics
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Introduced by Dr. Michael Diamond in 1984.
He devised a Peri/Reflector for simplified direct
bonding in the upper arch.
Peri/Reflector is a combined mirror, tongue
retractor, and saliva ejector that can simplify
bonding procedures in the upper arch. It isolates
the operating area, increases brightness, and
enables one to see the entire area while keeping
both hands free.
Direct Bonding Technique
(JCO 1984)
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Peri/Reflector in patient's mouth.


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Bracket placement using Peri/Reflector.


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Indirect Bonding Techniques
Indirect bonding is the preferred technique for
lingual bracket placement Because of the
irregular morphology of the lingual tooth
surfaces and the difficulty of access Research
on lingual indirect bonding started with the work
of the Lingual Task Force.
They used indirect bonding with Two Component
Mix systems like ENDUR, Concise and No Mix
systems like SYSTEM 1, Insta-Bond.
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Indirect bonding method:

A. Teeth are cleaned,
isolated, and etched.



B. A thorough rinsing,
using an air-water
spray and high-speed
evacuator, is
essential.
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C. Sealant application.





D. The adhesive is
injected into the
bracket mesh.
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E. The tray is seated with
firm pressure and held
with light, steady
pressure for 3 minutes.


F. After 10 minutes, the
tray is removed, the
brackets inspected,
and any deficient areas
filled in with a thin mix
of bonding adhesive.

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Newer modifications of the indirect bonding
technique:
I. Bonding in CLASS system.

In this, a silicone or biostar tray is used for
the final bracket placement.

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II. HIROS method (Resin Core Indirect
Bonding system).
Described by Hong et
al in 1996.
This technique makes it
possible to add
customized torque and
in-out values to the
indirect setup.

Customized torque and in-out
are built into resin (*) on
each bracket base.

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Upper anterior
bracket slots are lined
up on surveyor with
flat plate.


Transfer wires are
inserted into bracket
slots and extended to
approximate incisal
edges or buccal cusp
tips.

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Inlay pattern resin
indexes each transfer
wire to tooth
(a = elastomeric ligature; b
= transfer wire; c = inlay
pattern resin).


Complete set of
customized transfer
trays
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III. Individual Indirect Bonding Technique.

In this system, each tooth is bonded
individually. Customized trays are made for each
tooth.

Advantage: The bracket position on each tooth
is not affected by the position of other teeth.
Also, rebonding of a single bracket becomes
easier.
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IV. Customized Indirect Bonding method.


Described by Michael
Aguirre in1994.
This method makes
use of an orientation
card for bracket
placement.


Orientation Card


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V. Convertible Resin Core system (CRCS).
Developed by Hong et al in 2000.
They incorporated stainless steel wires into the
transfer trays.

VI. New Customized Indirect Bonding
Method.
Introduced by Kim et al in 2000.
They incorporated elastomeric ligatures into the
transfer trays during the indirect bonding
procedure.

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Rebonding can be done in 2 ways:

1. By using the initial trays again. Individual tooth
regions can be sectioned and positioned.
2. By redoing an individual bonding tray using the
same protocol.
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Lingual Mechanotherapy
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Treatment Sequence General

Four primary phases of edgewise lingual
mechanics:
1. Leveling, aligning, rotational control, and bite
opening.
2. Torque control.
3. Consolidation and retraction.
4. Detailing and finishing.

These phases are generally characterized by a
progressive increase in wire stiffness.
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Lingual archwires.

Typically mushroom-shaped.
Compensating bends are made.
First order bends between cuspids and
bicuspids are made at right angles, with a
generous step to allow for the differences in
labiolingual thickness between cuspids and
premolars.
First order bends contacting the mesiolingual of
bicuspids or first molars can also act as archwire
stops. These can provide an advancing or
expansive force to the arch.
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A. First and second
order bends
contacting the teeth
or brackets can act
as stops and result in
an expansion force
as arch wire length is
gained through
alignment.
B. First and second
order bends should
be made with
sufficient spacing to
prevent anterior
advancement or to
provide for retraction
mechanics.


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The lingual appliance has a tendency to induce an
anterior maxillary open bite.
This tendency is difficult to control, but its
prevention is very important.
Prevention includes:
1. Early control of posterior extrusion with high-pull
headgear and the early establishment of buccal
segment control.
2. Minimizing anterior advancement until the
rectangular archwire stage.
3. Patient education on tongue positioning.
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4. Prevention of vertical archwire bowing by
avoiding intra- and intermaxillary elastics until
stiffer rectangular archwires are used.
5. Coordination of arches to maintain the relation
of maxillary incisor bracket bite plane to
mandibular incisor.
6. Early use of vertical lingual elastics on suspect
cases.
7. Delaying the treatment of maxillary second
molars until finishing arches.

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Stage I. Leveling, Aligning, Rotational Control, and
Bite Opening.

The objectives of this initial phase of therapy are
to:
1. Initiate tooth movement with light forces,
2. Provide for a period of patient adaptation,
3. Eliminate rotations,
4. Level and align individual arches to permit wire
progression,
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5. Obtain initial torque control when required,
6. Establish posterior anchorage units with buccal
segments,
7. Initiate posterior segment control with extraoral
traction and transpalatal arch when required,
8. Reduce any excessive overbite, and
9. Gain space for rotations and additional bracket
bonding.

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This is achieved using lingual archwires having
a wire stiffness of less than 200 mil, combined
with complete seating of the archwire within the
bracket slot.
However, a common problem with lingual
edgewise brackets is the difficulty in obtaining
complete archwire engagement and the
tendency for the archwire to be pulled out of the
bracket slot.
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Elastic ligature and
archwire force vectors,
labial versus lingual.

Conventional ligation of
lingual brackets does
not exert a force along
the high torque angled
bracket slot .

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A ligation method termed the double-over tie has
been effective with both metal and elastic
ligatures in directing the ligating force more
directly along the bracket-slot angle.

This ligating technique has greatly improved the
ability to eliminate rotations and maintain
archwire engagement throughout treatment.
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Double Over Tie.

The double over ligation
method applies the
ligation force along the
bracket slot to seat the
archwire. Double over
elastic ties also exert
twice the force of a
conventional ligation.

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Double-over Ligation Tie
A. Teeth may first be ligated
together with .009" steel
ligature wire. Two or
more segments of elastic
chain are used on each
tooth, with one segment
placed over the bracket
before the archwire is
placed. The other
segment of the chain
serves as a handle.
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B. The archwire is then
inserted over the
previously placed elastic
chain modules.



C. The elastic chain module
is then stretched out of
the gingival bracket tie
wings and over the
archwire.
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D. The elastic chain module
is then inserted into the
incisal tie wing.




E. The excess chain is cut.
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F. The remaining elastic
ligature originates and
ends at the incisal tie
wing and exerts a force
directly along the
archwire slot.


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The immediate bite opening can present some
difficulties, e.g., vertical and antero-posterior
changes.
However, it is beneficial in deep bite correction
and can be used to advantage in other
instances.
The immediate posterior disclusion allows rapid
molar uprighting, any mesial posterior
movement desired, and crossbite corrections.
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Stage II. Retraction/Consolidation Mechanics

This is achieved using either sliding mechanics,
closing loop arches, or combinations.

The lingual archwires used for retraction are
.016" round stainless steel, .0175" .0175" TMA
and .016" .016" stainless steel.

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Closing loop mechanics, .017" x .025" TMA.
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Sliding mechanics: 0.016" TMA with Class I
elastic thread.

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Stage III. Torque Control

Torque control is initiated early in treatment
using .016" .022" or .017" .025" and
maintained throughout treatment.
Typically, lingual archwires used in finishing and
torque control are .016" .022" stainless steel
for moderate torque and .017" .025" TMA for
full torque.
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Stage IV. Detailing / Finishing.

Finishing archwires are usually .016" .022"
stainless steel, .017" .025" TMA, or .016" and
.018" TMA when additional detailing of the
occlusion is required.
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Retention following lingual therapy
1. Removable "invisible" retainer.









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2. Cemented chrome
cobalt retainer.




3. Fixed lingual
retainer.


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Keys to Success in Lingual Therapy
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Key 1

Patient Selection.
Oral Hygiene and Gingival Irritation - Lingual
patients must be well educated in oral hygiene
and motivated from the beginning.
Speech Adaptation and Tongue Irritation -
Patients must be forewarned of temporary
speech alteration.

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Variations in Tooth Size and Anatomy.
Bite Opening and Mandibular Rotation.
Headgear and Elastics - headgear is a vital
adjunct to lingual mechanotherapy to counteract
mandibular autorotation.

Key 2
Bracket Placement Accuracy use of the TARG
for accurate bracket placement.



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Key 3
Indirect bonding methods for bracket adhesion.

Key 4
Maintaining vertical and transverse control of
buccal segments.

Key 5
Double over ties on anterior teeth.

Key 6
Buccal and lingual molar attachments.
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Key 7
Correction of rotations.

Key 8
Arch form and archwire sequence.

Key 9
Archwire stiffness and torque control.

Key 10
En masse retraction.
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Key 11
Light, resilient wire for detailing.

Key 12
Gnathologic positioner and retention.
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Improving Patient Comfort

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The following tendencies with respect to
discomfort are observed in patients after the
application of bonded lingual orthodontic
appliances when compared with those with
edgewise labial appliances:

Tongue soreness, difficulty in chewing fibrous
food.
Difficulty in pronouncing the s and t sounds.
Difficulty in tooth brushing.



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Didier Fillion (JCO, 1997) suggested
several methods of relieving these irritation
factors during lingual therapy.

I. The most irritating brackets (generally bicuspids
and molars) can be covered with a light-cured
periodontal protective paste (Barricaid).
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Barricaid pellet preparation www.indiandentalacademy.com
II. Patients can cover
their own brackets
with a silicone paste
(Ortho Pack) in case
of severe irritation,
appliance breakage,
or the need to speak
in public.
Ortho Pack placed over irritating
brackets by patient.

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III. Patients with strong tongue-thrust habits and
large tongues have more trouble adapting to
lingual appliances. In such cases, a soft splint
made from a 1.5mm-thick silicone material may
be prescribed.
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Fabrication of soft protective splint. A. Brackets bonded to working
cast. B. Brackets covered with low-viscosity silicone material.
C. Splint thermoformed over cast. D. Finished splint in place.


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Plastic tubing placed over archwire
IV. In extraction cases, the
more posterior the
extraction sites, the more
the tongue tends to
spread out over them at
rest and during sleep.
The resulting irritation can
be alleviated by placing a
plastic protective tube
over the archwire at the
level of the edentulous
area.
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1st-order bends between cuspids and
bicuspids are less irritating if placed closer
to bicuspids.

V. In first-bicuspid
extraction cases, the
1st-order bend will be
more comfortable if it
is placed as close as
possible to the
bicuspid without
restricting its
movement.
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Advantages of Lingual Orthodontics
Facial surfaces of the teeth are not damaged
from bonding, debonding, adhesive removal, or
decalcification from plaque retained around
labial appliances.
Facial gingival tissues are not adversely
affected.
The position of the teeth can be more precisely
seen when their surfaces are not obstructed by
brackets and arch wires.
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Facial contours are truly visualized since the
contour and drape of the lips are not distorted
by protruding labial appliances.
Most adult and many young patients would
prefer "invisible" lingual appliances if costs,
treatment times, and results were comparable
to those of labial appliance treatment. Given
these advantages for patients, the perfection of
lingual treatment seems worthwhile.



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Disadvantages of Lingual Orthodontics
More chair time is required.
Cost generally is one-third more than labial
treatment.
Mandibular auto-rotation occurs because of the
bite plane on the maxillary anterior brackets.
Vertical and transverse control of buccal
segments often is difficult when the teeth are
disoccluded.
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Conclusion
The lingual appliance is no panacea; but if patients
are carefully selected, lingual braces can be a
valuable addition to the contemporary
orthodontists armamentarium and provide
much-needed care for that segment of the
population who need orthodontic services but,
up to now, would not consider any type of
orthodontic correction due to aesthetic concerns.

Thus, the value of invisible braces is lies not in
the hardware, but perhapsis best expressed by
the word invisible.
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References
1. Creekmore T. Lingual orthodontics Its
renaissance. Am J Orthod Dentofac Orthop
1989; 95: 514-520.
2. Alexander CM, Alexander RG, Gorman JC et
al. Lingual orthodontics: A status report.
J Clin Orthod. 1982; 16(4): 255-262.
3. Kurz C, Swartz ML, Andreiko C. Lingual
Orthodontics: A Status Report Part 2 Research
and Development. J Clin Orthod. 1982; 16(11):
735-740.


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4. Alexander CM, Alexander RG, Gorman JC et al.
Lingual orthodontics: A status report Part 5
Lingual Mechanotherapy. J Clin Orthod 1983;
17(2): 99-115.

5. Valiathan A, Sivakumar A. Lingual mechanics
turning orthodontics outside in: an update. J Intl
Coll Dentists. 2003.

6. Paige SF. A Lingual Light-Wire Technique.
J. Clin Orthod 1982 Aug534 544.

www.indiandentalacademy.com
7. Kinya Fujita. New orthodontic treatment with
lingual bracket mushroom arch wire appliance.
Am J Orthod. 1979; 76(6); 657.

8. Kinya Fujita. Multilingual bracket and mushroom
arch wire technique: a clinical report. Am J
Orthod Dentofac Orthop. 1982; 82(2): 120-140.

9. Hong K. Update on the Fujita Lingual Bracket.
J Clin Orthod 1999; 33(3): 136-142.

www.indiandentalacademy.com
10. Yen PKJ. A lingual Begg light wire technique.
J Clin Orthod. 1986; 20(11): 786-791.

11. JCO interviews. Dr. Vincent M. Kelly on
Lingual Orthodontics. J Clin Orthod. 1982; 16(7):
461-476.

12. Takemoto K, Scuzzo G. The Straight Wire
concept in Lingual Orthodontics. J Clin Orthod.
2001; 35(1): 46-52.
www.indiandentalacademy.com
13. Macchi A, Tagliabue A, Levrini L, Trezzi G.
Philippe Self-Ligating Lingual Brackets.
J Clin Orthod. 2002; 36(1): 42-45.

14. Wiechmann D, Rummel V, Thalheim A, Simon
JS, Weichmann L. Customized brackets and
archwires for lingual orthodontic treatment. Am J
Orthod Dentofac Orthop. 2003; 124: 593-599.

15. Diamond M. Critical aspects of lingual bracket
placement. J Clin Orthod. 1983; 17(10): 688-
691.

www.indiandentalacademy.com
16. Smith JR, Gorman JC, Kurz C, Dunn RM. Keys
to success in Lingual Therapy: Part I.
J Clin Orthod. 1986; 20(4): 252-261.

17. Smith JR, Gorman JC, Kurz C, Dunn RM. Keys
to success in Lingual Therapy: Part II.
J Clin Orthod. 1986; 20(5): 330-340.

18. Sachdeva RCL, Weichmann D, Rummel V.
Precision finishing in Lingual Orthodontics.
J Clin Orthod. 1999; 33(2): 101-113.


www.indiandentalacademy.com
19. Gorman JC, Hilgers JJ, Smith JR. Lingual
Orthodontics: a status report: Part 4-Diagnosis
and Treatment Planning. J Clin Ortho 1983;
17(1): 26-35.

20. Gorman JC. Treatment of adults with Lingual
Orthodontic Appliances. Dent Clin N Amer.
1988; 32(3): 589-620.

21. Hohoff A, Fillion D, Stamm T. Speech
performance in lingual orthodontic patients
measured by sonography and auditive analysis.
Am J Orthod Dentfac Orthop. 2003; 123: 146-
152.
www.indiandentalacademy.com
22. Chaconas SJ, Caputo AA, Ademir RB. Force
transmission characteristics of lingual
appliances. J Clin Orthod 1990; 24: 26-43.

23. Miyawaki S, Yasuhara M, Koh Y, Discomfort
caused by bonded lingual orthodontic
appliances in adult patients as examined by
retrospective questionnaire. Am J Orthod
Dentofac Orthop. 1999; 115(1): 83-88.

24. Geron S. the Lingual Bracket Jig.
J Clin Orthod. 1984; 33(8): 814-815.



www.indiandentalacademy.com
25. Kyung HM. The Mushoom Braket Positioner
for Lingual Orthodontics. J Clin Orthod. 2002;
36(6): 320-328.

26. Diamond M. Improved vision and isolation for
direct lingual bonding of the upper arch.
J Clin Orthod. 1984; 18(11): 814-815.

27. Scholz RP, Swartz M. Lingual Orthodontics: a
status report: Part 3- Indirect Bonding
laboratory and clinical procedures.
J Clin Orthod. 1982; 16(12): 812-820.

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28. Hong RK. Customized indirect bonding method
for Lingual Orthodontics. J Clin Orthod 1996;
30(11): 650-652.

29. Hong RK. A new Customized Lingual indirect
bonding system. J Clin Orthod. 2000; 34(8): 456-
460.

30. Kim TW. New indirect bonding method for
Lingual Orthodontics. J Clin Orthod 2000;
33(6):348-350.
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31. Aguirre M. Indirect bonding for lingual cases.
J Clin Orthod 1984; 18(8): 565-569.
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