1. Lingual Orthodontics By
Dr. Zaid Al-Dewachi

2. Historical perspective

3. 1967
Submitted concept in 1967
In December 1979, Dr. Kinya Fujita, of Kanagawa Dental University, Japan.
First lingual multi-bracket system with mushroom shaped archwires.

5. BRACKET SYSTEMS

6. DR. KURZ AND COWORKERS
1976
GENERATION 1
018" slot that face lingualy

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

8. 1981 Hooks were added to all anterior & PM brackets.
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.

9.
GENERATION 4
Low profile anterior inclined plane in central & lateral incisor.
Hooks were optional based on treatment needs & hygiene concerns

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

11. TPA attachment is optional.
GENERATION 6
Hooks were elongated.
TPA attachment is optional.
Hinge cap tube for the second molars.

12. 1990 to present
GENERATION 7
The square bite plane became rhomboid shaped, increasing the interbracket distance.
Premolar brackets were widened mesiodistally for better angulation & rotational control.

13. The ideal archwire has a mushroom shape
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.

14. FUJITA LINGUAL BRACKET

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

16. 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.

17. CONCEAL BRACKETS
Thomas Creekmore

18. STB (SCUZZO- TAKEMOTO BRACKET)
JCO 2001
Takemoto and Scuzzo in 2001.

19. STb system comprises of the most advanced lingual technology
Very 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

20. 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.

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

22. FORESTADENT 3D BRACKETS

23. 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

24. 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

25. 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

26. IBRACES (INCOGNITO)

31. 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.

32. The ideal archwire has a mushroom shape
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.

33. Interbracket width is reduced on the lingual.

34. Diagnosis & Treatment Planning

35. Diagnosis
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.

36. Treatment Planning Patient Selection.
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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

42. 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.

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

44. 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.

45. • Maxillary first bicuspid only extractions.
• 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.

46. 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.

47. Cases Contraindicated for Lingual Therapy
• 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.