Lingual orthodontics

orthodontics

1. Seminar by : Dr. Tony Pious LINGUAL ORTHODONTICS

2. CONTENTS Introduction Historical perspective Bracket system Patient selection and Diagnostic considerations Bonding technique and Different lab procedures Biomechanics and comparative biomechanics Extraction and non extraction mechanics Lingual straight wire technique Keys to success in lingual therapy Conclusion References

3. INTRODUCTION

4. Why Lingual Orthodontics ??? With more number of adult patients desiring orthodontic treatment, special aesthetic demands of the patients pose a great challenge to the orthodontists. These patients have professional and social commitments and cannot accept ‘visible braces’ even for a short time. To serve such patients, the orthodontic community came out with the ultimate aesthetic solution – Lingual Orthodontics .

5. 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.

6. Historical perspective

7. In 1726, Pierre Fauchard suggested the possibility of using appliances on the lingual surfaces In 1841, Pierre Joachim Lefoulon designed the first lingual arch for expansion and alignment of the teeth. Mershon – Lingual arch. Goshgarian – Transpalatal arch. Ricketts – Quad helix. Wilson – 3D Modular Enhanced Orthodontics.

8. Submitted concept in 1967 In December 1979, Dr. Kinya Fujita , of Kanagawa Dental University, Japan. First lingual multi-bracket system with mushroom shaped archwires . 1967

9. 1980 Patent for the Fujita lingual bracket (US patent No. 4,209,906).

10. Dr. Craven Kurz (UCLA)

11. 1973-1975

12. Anterior inclined plane (missing link) Shearing force converted to compressive force

13. 1982 Patent for the Craven Kurz lingual bracket (US patent No. 4,337,037).

14. 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 members : Dr. C. Moody Alexander Dr. Richard (Wick) Alexander Dr. John Gorman Dr. James Hilgers Dr. Craven Kurz Dr. Robert Scholz Dr. John (Bob) Smith.

15. 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.

16. Kelly (1982), who used Unitek labial Brackets on the lingual surfaces. Paige (1982), who used Begg light wire brackets on the lingual surfaces. 1984 TARG machine launched by Ormco as an important aid in laboratory technique. 1986 Didier Fillion developed Electronic TARG Société Française d’Orthodontie Linguale (SFOL),-1986 The American Lingual Orthodontics Association (ALOA),-1987

17. Lingual fever Public interest continued to grow. Rushed the product to the market immaturely.

18. The Fall Following this initial euphoria-a period of frustration, disappointment and rejection due to poor stantard of completed cases. A truly clear, stain-resistant labial bracket was introduced – Star fire by A company

19. Enthusiasm for lingual therapy waned in the profession, and commercial interest also declined

20. The original Ormco Task Force was reduced to just three members by 1988 Dr. Kurz , Gorman, Smith named KGS Ormco Task Force 2 The lingual appliance had been made available to the public before testing was complete. Orthodontists inadequately trained with lingual therapy were treating patients in record numbers. The public had high expectations from this treatment and demanded it from the profession immediately

21. Difficulties encountered during the development of the lingual appliance : Tissue Irritation and speech difficulties Gingival Impingement Occlusal Interference Appliance Control Base pad Adaptation Appliance placement and bonding Appliance Prescription Wire placement Ligation Attachments

22. Creekmore (1989) developed a complete technique with vertical slot lingual brackets, together with a laboratory system. European Society of Lingual Orthodontics (ESLO)-1992 British Society of Lingual Orthodontics (BLOS), World Society of Lingual Orthodontics (WSLO) Associazione Italiana de Ortodonzia Linguale (AIOL) 1987-1996

23. In Israel, Lingual Bracket Jig for direct and indirect bonding was introduced. Rafi Romano-edited a book presenting an update on the state of the art of lingual orthodontics. Furthermore, they founded the virtual journal www.lingualnews.com and a lingual orthodontics forum that facilitates the interchange of information between interested clinicians.

24. Relauncn In 1996 Craven Kurz founded Lingual Study Group with aim of relaunching lingual orthodontics in United States. ALOA was reactivated in 1997 Korean Society of Lingual Orthodontics (KSLO). The Japanese Lingual Orthodontics Association (JLOA)

25. Renaissance 7 generations of Kurz lingual brackets 2D and 3D brackets Lingual self ligating brackets STB brackets Lingual staight wire system Improved indirect bonding procedures Improved lab procedures CAD/CAM in lingual orthodontics

26. During the last decade, the percentage of patients treated with lingual orthodontics has increased and the technique has developed to such an extend that in some cases its easier, quicker and more accurate than traditional buccal orthodontics.

27. BRACKET SYSTEMS

28. GENERATION 1 1976 018" slot that face lingualy Flat maxillary occlusal bite plane from canine to canine and rounded margins. Lower incisor & PM brackets were low profile & half round. No hooks on any brackets DR. KURZ AND COWORKERS

29. GENERATION 2 1980 Hooks were added to all canine brackets

30. GENERATION 3 1981 Hooks were added to all anterior & PM brackets. The first molar had bracket with internal hook. The second molar had terminal sheath without hook.

31. GENERATION 4 1982-1984 Low profile anterior inclined plane in central & lateral incisor. Hooks were optional based on treatment needs & hygiene concerns

32. GENERATION 5 1985- 1986 Increased labial torque in the maxillary anterior region. Bite plane became more pronounced Molar brackets included an accessory tube for a transpalatal bar

33. GENERATION 6 Hooks were elongated. TPA attachment is optional. Hinge cap tube for the second molars. 1987- 1990

34. GENERATION 7 The square bite plane became rhomboid shaped, increasing the interbracket distance. Premolar brackets were widened mesiodistally for better angulation & rotational control. 1990 to present

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

36. Significance : The bite plane allows placement of all brackets during initial bonding even in cases with severe deep bites. The patient’s occlusion is located on the bite planes of the anterior brackets . Possibility of repositioning the mandible. Extrusion of the molars, intrusion of the incisors and facilitating any expansion and mesiodistal movement of molars uninhibited by occlusal forces. Correction of crossbites , bites, 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.

37. 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.

38. 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.

39. FUJITA LINGUAL BRACKET

40. RYOON KI HONG, HEE WOOK SOHN, JCO/MARCH 1999 (OS = 0.019 “; LS = 0.018” ×0.025”; VS = 0.016”)

41. 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.

42. BEGG’S LINGUAL BRACKETS Dr. Stephen Paige introduced the Lingual Light Wire technique in 1982 . The bracket currently used in the Begg system is the Unipoint combination bracket ( Unitek ), with the slot oriented in the occlusal direction. The Unipoint bracket has a gingival "wing" to place elastic modules on continuous elastic chains. (JCO1982)

43. Molar Tube Design : Oval tube with a mesiogingival hook. The squashed oval tube has some advantages in that it allows molar control, and will accept a ribbon arch.

44. CONCEAL BRACKETS Thomas Creekmore

45. STEALTH BRACKETS Compact size and smooth contours for increased patient comfort and better hygiene Full wire control with reduced friction An integrated vertical slot from anteriors through first molars yields expanded versatility and treatment options Reduced mesio -distal dimensions means greater interbracket distance

46. 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. JCO 2001 STB (SCUZZO- TAKEMOTO BRACKET)

47. STb system comprises of the most advanced lingual technology Incredibly comfortable for pt, minimal impact on tongue, speech Easy to use Utilizes a passive self ligation design that dramatically reduces friction & delivers lighter forces. STb social 6 easy to learn and use for beginners

48. Flossing is easier as the archwire is farther from the lingual surface and incisal edge. Mesio -distal width of the bracket is smaller, allowing adequate inter-bracket distances. Rotations can be more easily accomplished as the archwire can be tied tightly to the bottom of bracket slots. Torque control is improved.

49. PHILIPPE SELF LIGATING LINGUAL BRACKETS 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.

50. 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 attachment of intermaxillary elastics and application of simple third-order movements.

51. Clinical applications: Post – treatment retention. Closure of minor spaces. Limited intrusion. Correction of simple tooth malalignments and mild crowding, especially in the mandibular arch.

52. FORESTADENT 3D BRACKETS

53. ADENTA- Germany- Hatto Loidl Self ligating Easy handling & archwire changes Closing springs designed as bite planes for lower incisors Perfect transmission of torque & angulation Occlusal archwire insertion Hygenic

54. IN- OVATION- L BRACKET FROM GAC Twin self lig bracket system gives a complete range of control options simply by changing archwire Advantages low profile Anatomically correct base design No plaque build up or periodontal impact due to small size Fast easy placement of archwires Disadvantages Due to small size ,diff to visualize spring clip Bracket base of lower anteriors too wide causing difficulty in bonding smaller teeth

55. PHANTOM POLYCERAMIC SELF-LIGATING BRACKETS First tooth colored SL direct bonding lingual bracket made of composite polymer Tubes on pre molars to avoid speech difficulties Esthetic & cheaper than present indirect techniques

56. IBRACES (INCOGNITO)

57. Print out of three-dimensional bracket-positioning chart assists in rebonding

58. ilingual

59. Armamentarium

60. Lingual ligature cutter (angulated 45º) Lingual ligature cutter (angulated 90º)

61. Utility plier Arch wire cutter

62. Mosquito forceps Light ligature plier

63. Lingual hinge cap opening tool Debonding plier

64. Tongue retractor & saliva ejector First order bending fork

65. Second order bendng fork Module remover

66. Advantages of Lingual Orthodontics Facial surfaces of the teeth are not damaged from bonding, debonding , adhesive removal , 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.

67. Facial contours are truly visualized since the contour and drape of the lips are not distorted by protruding labial appliances. Tongue thrust habits are easily managed. Mandibular repositioning therapy.

68. 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 .

69. Lingual appliances are effective than labial appliance in following Intrusion of anterior teeth Maxillary arch expansion Combining mandibular repositioning therapy with orthodontic movements Distalization of maxillary molars

70. Patient selection & Diagnostic considerations

71. Patient selection Majority of malocclusions can be treated with lingual orthodontics, but certain cases are more amenable than others. Favourable cases Unfavourable cases

72. Favourable Cases Mild incisor crowding and with anterior deep bite. Long and uniform tooth surfaces without fillings, crowns, or bridges. Good gingival and periodontal health Keen, complaint patient. Skeletal class I pattern. Mesocephalic or mild/moderate brachycephalic skeletal pattern. Patients who are able to adequately open their mouths and extend their neck.

73. Unfavourable Cases Dolicocephalic skeletal pattern Maximum anchorage cases, unless treated with micro implants. Short, abraded, and irregular lingual tooth surfaces. Presence of multiple crowns, bridges, and large restorations. Patients with low level compliance. Patients with limited ability to open the mouth ( trismus ). Patients with cervical ankylosis or other neck injuries that prevent neck extension.

74. Diagnosis General, with particular reference to esthetics Periodontal and gingival Dental, with particular reference to the presence of crowns and large restorations Dentoalveolar discrepancy Vertical skeletal/dental problems Anteroposterior skeletal/dental problems Transverse skeletal/dental problems Surgical cases Preprosthetic cases

75. Vertical Considerations Using kurz 7 th generation lingual bracket the built-in bite planes on the upper incisor and cuspid brackets will interfere with the occlusion and result in a posterior open bite. The lingual brackets on the maxillary incisors should be bonded to allow a vertical distance of 2 mm from the incisal edge to the bracket, which allows the case to finish with a normal overbite and good posterior occlusion. STB brackets do not have a bite plane. Stealth brackets have a removable bite plane.

76. Anteroposterior discrepancy Skeletal class I with Normal overjet

77. Skeletal class I with Increased overjet

78. Skeletal class I with Decreased Overjet

79. Skeletal class II and class III In relatively mild malocclusions, they can be corrected with extractions or intermaxillary elastics. Severe skeletal discrepancy require orthognathic surgery.

80. Transverse considerations Posterior cross bites can be treated before starting the lingual treatment

81. Surgical cases Consultation and joint planning with the oral surgeon should be performed before the start up of treatment With these cases the best possible presurgical tooth position should be achieved to minimize the post surgical orthodontic treatment time The patient must be consulted on the possibility of bonding labial brackets just before the surgery to assist with the postsurgical fixation.

82. Bonding Techniques in Lingual Orthodontics

83. Direct Bonding Technique (JCO 1984)

84. Indirect bonding system These include: Torque angulation reference guide (TARG). Fillion’s indirect bonding system. The customized lingual appliance setup service (CLASS) system. The slot machine Hiro system The Ray set system The lingual bracket jig. The mushroom bracket positioner TAD-BPD machine.

85. Torque angulation reference guide (TARG)

86. Didier Fillion improved this method in 1987 by adding an electronic device to the TARG machine with purpose of measuring labial-lingual thickness This improvement reduced the number of first order bends in the wire, compensating for the difference in tooth thickness BONDING WITH EQUAL SPECIFIC THICKNESS (BEST)

87. TARG device Thickness measuring appliance ELECTRONIC TARG

88. Using his DALI (Dessin Arc Linguale Informatise) computer program he produces an individualized archwire template

89. The Slot Machine 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.

90. The Customized Lingual Appliance Setup Service (CLASS) system

91. Described by Scott Huge Brackets are placed on the idealized model set up of patient malocclusion A flat metal plate helps positioning of the anterior brackets Separate posterior device to position the posterior brackets CLASS SYSTEM

92. Individual transfer tray is made for each tooth Brackets are transferred to the teeth of patient directly, or transferred to the casts by using the cap technique and then to the patient using a full arch transfer tray Adv – visualization of final occlusion on the articulated set-up Drawback- lengthy and tedious procedure

93. HIRO SYSTEM Introduced by Toshiaki 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.

94. 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.

95. 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.

96. 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 jig transfers the Andrews Straight-Wire Appliance labial bracket prescription to the lingual surface.

97. 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).

98. LBJ transfers labial bracket prescriptions to lingual brackets

99. 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.

100. 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.

101. KOREAN INDIRECT BONDING SET UP SYSTEM (KIS) Developed by members of KSLO. Uses bracket positioning machine that allows positioning of all brackets at once. Advantages Very precise & attainment of high standard of treatment Allows for bracket hight difference between anterior and post teeth Simpler and faster

102. KIS System

103. 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.

104. Simplified Technique

105. LINGUAL INDIRECT BONDING USING THE TAD AND BPD

106. CAD/CAM SYSTEMS IN LINGUAL ORTHODONTICS

107. BENDING ART SYSTEM

108. THE ORAPIX® SYSTEM Virtual setup checking Brackets arranged together for the Straight-Wire technique

109. Virtual transfer jig. Real transfer jig.

110. Incognito Dr. Wiechmann

111. Brackets and wires are CAD/CAM customized on a model of the patient’s setup at the beginning of treatment. Laboratory technicians fabricate a setup model according to the orthodontist’s prescription. These models are used as a template to design virtual brackets and wires. Virtual brackets are printed in wax and cast in a gold alloy. Archwires are formed by a wire-bending robot. Dental casts, brackets, and wires are delivered to the orthodontist

112. The Lingual Jet® system Dr. Gualano and Dr. Baron

113. BONDING PROCEDURE

114. BANDING

115. BIOMECHANICS

116. NORMAL INCLINATION

117. LABIAL INCLINATION

118. LINGUAL INCLINATION

119. Lingual appliances are effective than labial appliance in following Intrusion of anterior teeth Maxillary arch expansion Combining mandibular repositioning therapy with orthodontic movements Distalization of maxillary molars

120. INTRUSION OF ANTERIOR TEETH

121. Severe deep bite correction

122. Anterior and lateral concern Patients with severe tongue thrust habit, the lingual appliance, due to the discomfort associated with tongue contact, redirects the tongue tip to the palatal vault in speech and swallowing. Anterior tongue thrust habit is eliminated and normal muscle balance is restored. Lingual appliance and lingual elastics create a fencing of the tongue musculature from the dentition FENCE EFFECT It increases the anchorage values

123. The six anchorage keys Standard lingual bracket jig prescription for the anterior teeth, incorporating slight extrapalatal root torque , molar tube placed off-center in a more mesial position and incorporating a mesial tip to encourage molar tip back. Reduced friction, using sliding mechanics together with bidimensional archwires incorporating a rectangular anterior sections and round posterior sections or using standard archwire and placing brackets on the posterior teeth with larger slot sizes Posterior bite stops placed on molar teeth to open the bite. Light class I, II or III forces for retraction or space closure. In corporation of second molars in the anchorage unit Incorporation of an exaggerated curve of Spee in the maxillary space-closing archwire WJO - Geron , Vardimon

124. Takemoto compared the anchorage loss in labial versus lingual extraction cases treated with loop mechanics and found higher anchorage value of the posterior dentition in lingual cases Due to the proximity of lingual brackets to the center of resistance of the tooth . Direction of forces during the space closure creates a degree of buccal root torque and distopalatal rotation of the molar crown, which in turn produces cortical bone anchorage.

125. Stages of treatment

126. Choice of extraction Lower molar tip distally as the arch is levelled and this changes class 1 to class2, therefore in class1 cases upper 1 pm and lower 2 pm is advised In class 2 cases it is desirable to avoid extraction in lower arch, if crowding is severe one or more lower incisors may be considered In class 3 cases pm extn facilitates lingual tipping of lower ant teeth, distal tipping of molars improves class lll molar relation.

127. Treatment Sequence— General 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.

128. Wire sequence in lingual orthodontics First initial wire; .o16 NiTi - first initial wire Second initial wire;.o16 wilcocks heat treated special plus SS wire. Intermediate wire;.017x.025 TMA wire Finishing wire;.017x.025 or .016x.025 SS Detailing wire ; o16 wilcocks heat treated special plus SS wire

129. 1)0.016 NiTi with increased crowding 0.016 Wilcocks sp+ Minimal crowding all Teeth bracketed 2) 0.017x0.025 TMA 3) 0.017 x 0.025 SS 4) 0.016 Wilcocks special + Finishing arch if necessary If all teeth were initially bracketed Bond all teeth initially unbracketted Adv loops Stops at 1 st molars a)0.016 x 0.022 ss b)0.018 sp + EXTRACTION AND NON EXTRACTION

130. Second initial wire

131. Intermediate wire

132. Finishing wire

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

134. This is achieved using lingual archwires having a low wire stiffness, 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.

135. HIGHLY TIPPED CANINE

136. DISTALLY TIPPED CANINE

137. HIGHLY and DISTALLY TIPPED CANINE

138. Partial canine retraction

139. Rotation correction

140. DOUBLE-OVER TIE LIGATION

141. ROTATION TIE

142. TORQUING LEVELLING

143. Two types 1. Canines and incisors separately 2. Enmasse retraction Retraction mechanics

144. Sliding mechanics Vs loop mechanics during en masse retraction Sliding mechanics Loop mechanics Wire friction and uncontrolled Requires lot of skill retraction forces results in Difficult to bend the wires anchorage loss different loops Increased treatment time

145. LOOP MECHANICS DURING EN MASSE RETRACTION

146. Sliding mechanics

147. Maximum anchorage upper arch loop mechanics, combined with TPA and buccal sectional arch wire from 1 st and 2 nd molars for stabilization

148. Moderate anchorage upper arch L loop mechanics combined with TPA The anterior segment and posterior segments are figure eighted with ligature wire In sliding mechanics, power chain is placed from lingual of canine to the lingual of 2 nd premolar in 1 st premolar x n

149. MINIMUM ANCHORAGE UPPER ARCH Power chain is placed on both buccal and lingual of the canine and first premolar Class III elastics enhance the mesial movement

150. Maximum anchorage lower arch An elastic power chain on the lingual side with buccal sectional arch for stabilization 0.017 x 0.025 TMA or 0.016 x 0.022 SS Class III elastics on buccal and lingual side

151. Moderate anchorage lower arch Sliding mechanics with reciprocal elastic forces

152. Minimum anchorage lower arch An elastic power chain is placed from the lingual of the 1 st molar, encircling the canine and attaching to the buccal of the 1 st molar Class 2 elastic facilitate the mesial movement of the molar

153. DETAILING

154. The Straight-Wire Concept in Lingual Orthodontics Li-Point 2. Embrasure Line 3.Lingual Crown Height (LCH) 4.Lingual Straight Plane (L-S Plane) 5. Bracket Height (H

155. Advantages Flossing is easier Mesiodistal width is much smaller, allowing adequate interbracket distances Less composite is needed on the mandibular molars to raise the bite Rotations can be more easily accomplished because the archwire can be tied tightly to the bottom of the bracket slots Expansion in an anterior direction is more effective because the most labially positioned tooth is ligated first.

156. Lingual retainers 1 st Generation Retainer Plain ,round .032” - .036” Blue Elgiloy wire with loop at each end bonded only to canines

157. 2 nd Generation Retainer Three – stranded .032”wire without terminal loops which is bonded to canines.

158. 3 rd Generation Retainer Plain round .030” to .032” diameter stainless steel wire with sandblasted ends

159. Keys to Success in Lingual Therapy JCO 1986 Craven Kurz et al

160. Key 1 Patient Selection. Oral Hygiene - 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. Variations in Tooth Size and Anatomy.

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

162. Key 7 Correction of rotations. Key 8 Arch form and archwire sequence. Key 9 Archwire stiffness and torque control. Key 10 En masse retraction. Key 11 Light, resilient wire for detailing. Key 12 Gnathologic positioner and retention.

163. Conclusion Lingual Orthodontics is the most aesthetic  treatment modality , and is the best treatment option for adult patients, since the brackets are invisible, it provides a high level of control, and is excellent for the treatment of all kinds of malocclusions. Over the past 25 years there have been many improvements in appliance design, laboratory and bonding procedures, and in clinical, mechanical techniques, that simplify the lingual treatment. Thanks to the pioneers of Lingual Orthodontics , Dr . Craven Kurz , Dr. Fujita and the Lingual Task Force of ORMCO company.

164. thanks to the recent developments:   CAD CAM, small comfortable and reduced friction brackets,    the lingual technique today is very reliable and almost as easy as the labial technique.

165. The history of lingual orthodontics has not been a smooth one. There was a period of initial euphoria as the technique made its clinical debut; this was followed by a period of frustration, disappointment, and rejection. Thanks to the effort of several dedicated clinicians, many of the issues responsible for this decline have been overcome. We are now in a period of resurgence, the technique has become more sophisticated, the clinical results achieved can stand on an equal footing with the best of conventional labial techniques, and the acceptance of technique by the profession is growing rapidly. The history of this technique is peppered by individuals who have shown perseverance and ingenuity

166. Lingual orthodontics has come of age; its acceptance by both the profession and the patient population continues to grow internationally. The future of lingual orthodontics is dependent on the following three important issues: (1) advances in technology related to appliance design and laboratory protocols; (2) demographic changes in population age groups—the growth in the number of adult patients seeking orthodontic treatment associated with an increase in affluence and disposable income will create a patient-driven demand for more esthetically acceptable appliances; and (3) attitudinal changes of orthodontists.

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