VOLUME XLVI NUMBER 4 203 ROUNDTABLE ON LINGUAL PART I

VOLUME XLVI NUMBER 4 203

DR. LUDWIG As long ago as 1982, JCO published a multipart series called “Lingual Orthodontics: A Status Report”.1 The authors of this series, known as the Ormco Lingual Task Force, sparked a great deal of interest in lingual treatment; unfortunately, many clinicians became frustrated with the difficulties of the technique and dropped lingual orthodontics in favor of other forms of esthetic treatment.

JCO kept pace with developments on the lingual scene, publishing articles on new appliance systems such as Hong’s adaptation of the famous Fujita bracketa in 1999,2 the straightwire lingual system from Scuzzo and Takemoto in 2001,3 and the 2D Philippe bracketb in 2002.4 The first fully customized lingual system, Incognito,c was introduced in JCO in 20055 (Fig. 1), and the virtually designed and customized Orapixd system was described by Fillion in 2011.6 Clinical modifications such as the “bihelix” opening spring,7 tips for using the 2D Lingualb technique,8 and a simplified lingual system9 have also been published, along with an “inoffice wirebending robot”e developed by Gilbert.10

Taking advantage of these technological and mechanical advances, many clinicians, especially in Europe and Asia, have brought lingual orthodontics back into their practices. For that reason,

JCO invited a panel of lingual experts from around the world to participate in a twopart Roundtable on the subject. I began the discussion with this question: Have you seen an increasing demand for lingual or other esthetic appliances?

DR. FILLION Since the publication of the first article in JCO in 1982,1 I have been fascinated by lingual orthodontics, and my professional goal was to practice this technique intensively. To reach that goal, I attended the course given by Drs. Kurz, Gorman, and Smith seven times from 1984 to 1989. I decided to limit my practice to lingual orthodontics in Paris in 1987, and in London in 1997. I have seen an increasing demand for lingual

© 2012 JCO, Inc.

JCO ROUNDTABLE

Lingual OrthodonticsPart 1BJÖRN LUDWIG, DMD, MSD, ModeratorJ. CLIFTON ALEXANDER, DDS, MSVITTORIO CACCIAFESTA, DDS, MSC, PHDDIDIER FILLION, DCDALFREDO GILBERT, DDS, MSRANDALL C. MOLES, DDS, MSMARIO E. PAZ, DDS, MS SILVIA M. SILLI, DMD, DMEDKYOTO TAKEMOTO, DDS, PHD

Fig. 1 Incognitoc customized lingual bracket system.

©2012 JCO, Inc. May not be distributed without permission. www.jco-online.com

appliances during the last 10 years. Many articles have been published in the media about aligners, and adults realize that they could benefit from orthodontic treatment. Moreover, in the past three to five years, the Internet has provided information to patients about the results we can obtain with the lingual technique.

DR. TAKEMOTO Ever since I opened my first clinic in 1983, I have seen a steadily increasing demand for lingual treatment. In 1987, due to patient demand and my own personal interest in lingual treatment, I decided to open the first exclusively lingual orthodontic clinic in Japan, in the center of Tokyo. By this time, I believed that I had sufficient skill and confidence to open a lingual

clinic that only treats adult patients. In my original clinic, I treat patients with both lingual and labial orthodontics, both children and adults. But due to the state of the economy and the increased number of doctors performing lingual treatment in Tokyo, the number of lingual cases has leveled off.

DR. GILBERT In my experience, the increase in demand for esthetic orthodontic treatment began in the early years of the previous decade. I would attribute this to a greater awareness of the existence of lingual orthodontics and other esthetic treatment options among the general public. I be lieve there are many adults who desire to improve their image and/or resolve occlusal problems, but are unwilling to wear labial appliances. These adults only seek orthodontic treatment when they discover more esthetic treatment options.

DR. CACCIAFESTA I saw an increasing de mand for lingual appliances starting from the end of the 1990s and the beginning of the 2000s. Today in my private office, all adults ask for lingual treatment, and we do have some young teens with lingual braces, too. The major reasons for this trend are increased esthetic demand and requests thanks to the media, improved socioeconomic standards, and the need for preprosthetic orthodontic treatments.

DR. ALEXANDER There has definitely been an

204 JCO/APRIL 2012

JCO ROUNDTABLE

Dr. Ludwig

Dr. Ludwig is a Contributing Editor of the Journal of Clinical Orthodontics; an Instructor, Department of Orthodontics, University of Homburg, Saar, Germany; and in the private practice of orthodontics at Am Bahnhof 54, 56841 Traben-Trarbach, Germany; e-mail: [email protected]. Dr. Alexander is in the private practice of orthodontics at 5500 Preston Road, Suite 360, Dallas, TX 75205; e-mail: [email protected]. Dr. Cacciafesta is a Contributing Editor of the Journal of Clinical Orthodontics and in the private practice of lingual orthodontics at Viale Papiniano, 44, 20123 Milan, Italy; e-mail: [email protected]. Dr. Fillion practices exclusively lingual orthodontics in Paris, London, and Geneva. He was Director of the Lingual Orthodontics Postgraduate Program at Paris V University from 1996 to 2010 and is a founding member of the French, British, European, and World lingual orthodontic societies. The first President of the World Society of Lingual Orthodontics, he is the chairman of the next meeting, to be held in Paris in July 2013. He contributed to the development of the Orapix system. Contact him at 22 rue Cortambert, 75116 Paris, France; e-mail: [email protected]. Dr. Gilbert is coordinator of lingual orthodontic courses, Facultad de Estudios Superiores, Universidad Nacional Autónoma de México, Campus Zaragoza, Mexico City; President of the Mexican Association of Lingual Orthodontics; head of the Research and Innovation Program, Smile Center Institution, supported by the National Board of Science and Technology of Mexico; and in the private practice of lingual orthodontics at Tampico #8 Colonia Roma, Mexico City; [email protected]. Dr. Gilbert invented and developed the LAMDABOT. Dr. Moles is an original member of the “Ormco Insiders” Lingual Development Group and an OraMetrix faculty member who teaches proprietary courses on SureSmile labial and lingual techniques. He is in the private practice of orthodontics at 8555 Forest Home Ave., Milwaukee, WI 53228; e-mail: [email protected]. Dr. Paz worked closely with Dr. Craven Kurz in the original Ormco Lingual Task Force and main-tains a lingual/Invisalign cosmetic orthodontic practice at 8920 Wilshire Blvd., Suite 700, Beverly Hills, CA 90211; e-mail: [email protected]. He was a founding Board Member of the World Society of Lingual Orthodontics and is President of the American Lingual Orthodontic Association. Dr. Silli is in the private practice of orthodontics, specializing in adult and lingual treatment, and is cofounder and consultant, Orthorobot Medical Technology, Vienna. Contact her at Waidhausenstrasse 11, 1140 Vienna, Austria; e-mail: [email protected]. Dr. Takemoto is a visiting professor, Faculty of Medicine and Surgery, Ferrara University, Ferrara, Italy, and Faculty of Dentistry, University of Hong Kong; former president of the World Society of Lingual Orthodontics; and in the private practice of lingual orthodontics at 2-5-7, Kudanminami, Chiyoda, Tokyo 102-0074, Japan; e-mail: [email protected]. He is one of the developers of the STb lingual bracket.

increased demand for esthetic/invisible treatment over the last six or seven years. I believe it is because of the birth of new technologies that allow us to make customized and very small appliances. These technologies make the appliance easier for the patient, doctor, and staff.

DR. PAZ I have seen an increase in both adults and teens seeking lingual braces as an alternative to labial and Invisalign.f Lingual treatment reached its peak in the 1980s, then started to decline abruptly in the following years due to frustrations regarding the technique and appliance design. The return of lingual braces started around the year 2000, mostly motivated by improvements in appliance design and increased use in Asian and European markets. Lately, its use has increased signif icantly in the U.S., due to greater adult and teen populations seeking esthetic orthodontic treatment alternatives, orthodontists seeking a reliable fixed esthetic alternative in cases where the use of Invisalign would provide a compromised treatment result, and education campaigns by lingual companies. I would still like to see lingual techniques taught at the university level in more orthodontic residency programs, since that is the best way to learn the technique properly.

DR. SILLI For about 10 years, we have also registered an increasing demand for esthetic and lingual appliances. One reason is that more and more adults ask for orthodontic treatment. On the other hand, we are sure that advertising efforts, especially on the Internet, add to the increasing demand.

DR. MOLES I have definitely seen an increase in the demand for esthetic appliances over the past 10 years. In my estimation, the introduction of the Invisalign system has greatly increased public awareness and demand for esthetic treatments.

DR. LUDWIG Do patients specifically ask for lingual brackets, as opposed to clear aligners or ceramic brackets?

DR. CACCIAFESTA In my clinic they do, as we are specialized for lingual treatment. So my job is relatively easier—they simply ask for that as the

one and only solution.

DR. TAKEMOTO My patients are always treated with lingual brackets as well.

DR. FILLION Most of the adult patients in Europe would not like to wear ceramic labial brackets or even clear aligners, because they are still visible. They ask for a completely invisible appliance. The patients I see in my practice know that I will offer only lingual appliances; this is the reason they come to see me. They do not want any other option. They have been informed by their dentist about the differences between clear aligners and lingual appliances.

DR. SILLI In our office, only a small number of patients specifically ask for lingual treatment. Most adults just wish to have an esthetic treatment regardless of the appliance used.

DR. MOLES The majority of our patients ask for clear aligners. However, we are starting to see some patients who come in asking about lingual appliances. This is especially true for those who have been correctly told that their problem is not easily treatable with Invisalign.

DR. PAZ This is true in my practice as well; most adult patients at their initial consultation ask for Invisalign, although some specifically ask for lingual braces. Most of their research has been done on the Internet or through word of mouth. These patients may feel their case is complex, or they’ve been turned down by Invisalign providers,


Lingual Orthodontics

Dr. Alexander

or they feel that wearing aligners is too complicated for them and prefer a technique that does not require cooperation.

DR. ALEXANDER Many people in the U.S. are still unaware that there is such a thing as lingual appliances. Patients want straight teeth with the most esthetic solution possible. You have to educate them on the options that will solve their treatment problem.

DR. GILBERT I find that some patients have investigated the various esthetic treatment options, generally on the Internet, and come to the clinic to ask my advice about which is best for them. However, a relevant point here is that many patients are coming for a second treatment, having already undergone labial orthodontic treatment as adolescents, and thus are rather familiar with the idea of wearing brackets.

DR. LUDWIG What efforts do you make to promote lingual treatment as an option in your practice?

DR. GILBERT I regularly impart courses on the lingual technique. I often give talks at conferences in Mexico and in other countries. I undertake research into various aspects of lingual orthodontics, sponsored by Mexico’s National Board of Science and Technology. Every fortnight, I host a radio program in which I talk about a wide range of topics in the areas of dentistry and orthodontics. I am a firm believer in the benefits of

lingual orthodontics, and I’m sure this carries through to conference participants, to the listeners of my radio program, and to my patients. The best publicity—word of mouth—always keeps me busy.

DR. SILLI Most of our patients find us through recommendation by patients who were already treated lingually in our practice. Our promotional activities can be therefore kept to a minimum of website and brochure promotion.

DR. CACCIAFESTA My website is dedicated to such promotion, together with posters and brochures in the waiting room.

DR. ALEXANDER We make an effort to educate all patients and parents about lingual treatment and have brochures available in the office. We also make our generaldental referral sources knowledgeable about them. We have just started some externalmarketing efforts to introduce the lingual option to prospective patients who may not be aware of it.

DR. MOLES We have sent mailings out to the local dentists and hygienists about how SureSmile QTg lingual works. Of course, we have brochures about it in the reception area. However, the majority of our promotion is just presenting it as an option to patients who are very concerned about esthetics.

DR. PAZ We do not make too much of an effort besides making patients understand that it is a comparable technique to any other fixed orthodontic treatment alternative and, in a good number of cases, better than any removable technique. Not pricing it astronomically high also helps. We have some treated lingual cases available for them to see, and a variety of appliances for them to choose. It is always interesting to see the expressions on the face of older teenage and adult patients when they realize there is an orthodontic option that is not visible.

DR. LUDWIG What are your criteria for treating a patient with lingual brackets, other than the patient’s preference?

DR. FILLION I treat all patients who ring my

206 JCO/APRIL 2012

JCO ROUNDTABLE

Dr. Cacciafesta

doorbell with lingual appliances—no restriction, no limitation, no contraindication. Some patients are more difficult to treat—for example, patients with small teeth, due to the reduced interbracket distance.

DR. TAKEMOTO We always try to treat lingually, so long as the patient is not contraindicated. In some cases, we might use crossover techniques with a combination of lingual and labial treatments (Fig. 2).

DR. ALEXANDER I can treat any type of malocclusion using the same auxiliary appliances that I use with my labial cases. I can treat Class I, II, III, extraction cases, and surgical cases with the same degree of quality. The only cases I typically don’t treat are children in the mixed to early permanent dentition. It really helps if the teeth are fully erupted. I have done a few 2 × 4 Phase I cases for patients who are models, actors, or actresses.

DR. GILBERT In general, almost any case that can be treated with labial brackets can also be treated with lingual orthodontics. One important exception is patients with a strong bruxism habit, who tend to debond the brackets. Before refusing to treat these patients, however, I try to resolve the causes of their bruxism, which are often emotional in nature.

Biomechanically, Class II subdivision cases tend to be the simplest, because the bite plane helps procline the upper anterior teeth, and the lower brackets can be bonded in a manner comfortable

for the patient. Class I, division 1 cases are usually more complicated when it comes to closing spaces, because the retraction of large spaces can affect torque control. With Class I patients, it is necessary to take great care with anchorage and to evaluate the lingual height of the lower bicuspids. If the height is too reduced, I prefer to avoid the lingual technique. Class III cases, both orthognathic and orthodontic, can be effectively corrected with the lingual technique. Class III patients in particular value the invisibility of the technique.

DR. MOLES I initially limited lingual treatment to Class I nonextraction cases. As time has gone on and my comfort level has increased, I will now treat virtually any malocclusion with lingual appliances. The only limiting criterion for me is the attitude of the patient—that they are reasonable in their expectations and seeming to be tolerant of lingual appliances.

DR. SILLI Regardless of the patient’s initial preference, I suggest lingual treatment if the resulting force system is favorable for correction of the malocclusion. In other words, the biomechanical requirements may indicate lingual treatment. Furthermore, I always verify in advance that the crown morphologies and the surface conditions allow for proper lingual bracket positioning.

DR. PAZ In our office, we give the patients several appliance choices, lingual being only one of them. There are certain malocclusions that are most likely treated faster with lingual braces, but



Dr. Fillion

Fig. 2 Crossover technique, using combination of lingual and labial appliances.

we do not push patients toward a specific technique. We let the patient choose. I personally think that lingual braces are great expansion appliances and also very effective for labial incisal proclination, so I may point this out to patients to aid in their appliance selection.

DR. LUDWIG How old are the youngest patients you treat with lingual appliances?

DR. PAZ My youngest lingual patients are in Phase I treatment at 89 years of age (Fig. 3). It is slightly more challenging due to situations in which a long arch span may be an issue. I prefer labial at this early age, but some patients may need lingual due to their lifestyle or occupation.

DR. TAKEMOTO The very youngest patients that we have treated at my original clinic have been 910 years old, but more commonly 12 years old and above.

DR. MOLES I have treated a Phase I patient with 2 × 4 lingual appliances who was a professional model. I will treat patients of any age with lingual appliances. The only agelimiting factors are the lingual tissue heights and, of course, the maturity and motivation of the patient.

DR. FILLION I treated my three children with lingual appliances when they were 12 years old. Usually I treat 90% adults, 10% teenagers.

DR. CACCIAFESTA My youngest are 1314 years old.

DR. SILLI My youngest patients are about 14; normally, I start lingual treatment only after all

permanent teeth have fully erupted. We haven’t received requests from younger patients for lingual treatment in our office.

DR. GILBERT When I began my lingual practice, all my patients were adults. Now approximately 5% of my patients are adolescents. My youngest patient began treatment at age 15.

DR. LUDWIG How do your patients initially adapt to lingual appliances in terms of speech problems and softtissue irritation?

DR. ALEXANDER Communication on this issue is very important, and the timing of it even more so. At the newpatient exam, if the patient is considering lingual appliances, we explain how they will definitely irritate the tongue; when the tongue gets irritated, speech may be influenced. However, we emphasize that it’s only temporary in most cases, and within a week or two they will be over the hump. That is the magic number: two weeks. I have found recently that this is far less of an issue than with previous appliances because of the reduction in size that a digitally customized system allows.

DR. FILLION Today, the adaptation period to lingual brackets is easier than 25 years ago, for two reasons: first, because of the size of the brackets I use—only 1.5mm thick; and second, because I use a straightwire technique that eliminates wire bends, so the appliance is more comfortable. Softtissue irritation can last a week; speech problems are quickly resolved for 90% of the patients within 48 hours, while 10% need a week. I always bond one arch at a time; we bond the second two months later.

208 JCO/APRIL 2012

JCO ROUNDTABLE

Fig. 3 Mixed-dentition patient undergoing Phase I lingual orthodontic therapy.

DR. CACCIAFESTA Normally, our patients need about one week to get fully adapted to the lingual brackets I am using (Forestadent 2Db). Those are the smallest lingual braces on the market.

DR. TAKEMOTO We now use the STb Self Ligationh bracket (our new prototype bracket), which has a very low profile, so that patients experience few problems with speech or softtissue irritation. This appliance is used with straight wires, so there is less impact on the patient.

DR. PAZ With the advent of much smaller appliances, their adaptation is easier and faster. We normally bond one arch at a time, three to four weeks apart, to let them get used to one arch first. Some patients respond better than others, and their attitude toward it plays an important role. We cater to them significantly to avoid potential frustration.

DR. GILBERT I find that patients usually need a couple of weeks to adapt to their lingual appliances. The more extroverted and easygoing pa tients tend to adapt more rapidly; the less stressed they are, the less they tend to clench their teeth. It is essential to explain that they will adapt more quickly to the appliances if they stay relaxed and maintain a positive attitude. A deep bite and a large tongue—in general, all those characteristics that reduce the space for the tongue—increase the possibility of irritation and speech problems. Patients who suffer from dry lips or reduced saliva flow also tend to suffer from softtissue irritation.

Bracket shape is probably more important than bracket size in determining adaptation time. The smallest available bracket may not always be the best choice. In many cases, brackets with a wide base are more effective at closing spaces. Additionally, the bite planes of the upper anterior brackets are extremely useful for resolving Class II, division 2 cases. In a word, I give more importance to the buccolingual width of the bracket than to the mesiodistal width.

DR. SILLI I hardly ever see softtissue irritation, due to a careful bracket selection and customization in the lab, but also due to clinical precautions such as covering wire endings with composite or adapting hooks.

DR. MOLES I strongly encourage patients to go with lingual on the upper arch and clear ceramics on the lower arch. This reduces most of the issues associated with the tongue against the lingual surfaces of the lower teeth. Patients adapt within a few days to this type of lingual setup.

DR. LUDWIG What special recommendations do you make to your patients to help them adapt to lingual brackets during the first few days?

DR. CACCIAFESTA They simply are told to use some silicone or wax if they feel some discomfort with the tongue.

DR. SILLI I always recommend not putting too much burden on the tongue during the first few days—for example, patients should avoid meetings lasting for hours.

DR. FILLION I recommend that they be patient for one week to get used to their appliance. We have material that we can place on some parts of the appliance to make it less uncomfortable. I also recommend that they speak more slowly than they are used to.

DR. TAKEMOTO We explain that there will be some initial speech problems, but that the best way to overcome these is to speak as much as possible.

DR. PAZ We emphasize the use of wax for the initial days, especially at night when the tongue is most active. We also place comfort bumpers and separators, avoiding any sharp archwire ends or



Dr. Gilbert

corners, and smoothing materials such as Barricaidi on sensitive areas. If the tongue gets sore, speech will be affected more.

DR. ALEXANDER We give them a product called Gishy Goo,j which is a lightbody, fastset polyvinyl siloxane (PVS) material—a “super wax”, if you will. We also instruct them to do as many warm saltwater rinses a day as possible for the first week. The salt in the water helps soothe and heal the soft tissues, while the warmth of the water helps the soreness of the teeth. “A Jacuzzi for the mouth” is what we say!

DR. MOLES Since patients adapt so well to the lingual appliance, we don’t make any special recommendations, with the exception of impressing upon them how important good hygiene will be to their comfort during treatment. I have also found that Gishy Goo has been very helpful to these patients.

DR. GILBERT I always give my patients a simple explanation of how the adaptation reflexes function, and how they allow the masticatory muscles to adapt to the lingual brackets without the patient being aware of the adaptation process. In some cases, particularly when the patient presents with a deep bite or a tendency to clench the teeth, I include four to six TENS sessions aimed at promoting relaxation11,12 (Fig. 4). If required, I prescribe a muscle relaxant to be taken before the patient goes to bed. I always insist that the patient follow a softfood diet for at least five days. I rec

ommend using orthodontic wax to smooth bracket edges. In the case of speech problems, I rec ommend phonetic exercises.

DR. LUDWIG Do you have other instructions for lingual patients that are different from labialbracket instructions?

DR. SILLI No, except the advice to stay patient.

DR. PAZ We encourage them to return to our office soon if there is an irritating factor or broken bracket. Loose appliances on the lingual are more affected by chewing forces than those on the labial. The tongue responds more aggressively to injury than the cheeks, and if the irritation continues, it can ultimately affect the patient’s throat.

DR. CACCIAFESTA Patients are told to avoid biting on hard food anteriorly and to maintain an excellent oralhygiene protocol.

DR. TAKEMOTO With the STb SL bracket and the straightwire technique, the wire is sometimes close to the gingival margin, so we stress the need for patients to clean their teeth carefully and properly. They receive special instruction from our dental hygienists on how to brush their teeth to prevent gum inflammation.

DR. ALEXANDER We also focus on hygiene, because when they can’t see the plaque or debris, they may not realize it’s there and become more lax in their daily regimen.

DR. GILBERT Lingual orthodontic patients must modify their brushing technique to account for the reduced lingual arch perimeter and the increased difficulty of accessing the lingual surfaces. Flossing is also essential. I demonstrate the correct brushing and flossing techniques to my lingual patients using a typodont.

DR. LUDWIG Have you ever had to debond a lingual appliance because of nonacceptance?

DR. CACCIAFESTA No, never.

DR. MOLES I haven’t either.

DR. TAKEMOTO This has happened, but ex

210 JCO/APRIL 2012

JCO ROUNDTABLE

Dr. Moles

tremely rarely—perhaps one time a year, or less than .5% of our patients. It has always occurred within the first week after bonding. So long as the patient can continue with the treatment long enough to become familiar with the appliance, there are no problems.

DR. SILLI I had one patient who was a speech trainer and had a very important qualifying examination one day after we inserted the lingual appliance. She was afraid to fail at the examination. Of course, this debonding was not really a matter of nonacceptance, but wrong timing.

DR. GILBERT One patient complained that the brackets were very uncomfortable and caused a great deal of anxiety. I had previously classified this as a relatively simple lingual case. Upon talking with the patient, I had the impression that I would have had to discontinue the case even if I had bonded labial brackets. As I mentioned before, in my opinion patient acceptance depends more on the attitude of the patient than the choice of ortho

dontic technique.

DR. ALEXANDER I’ve prematurely debonded lingual patients only twice in my 14year career. Both were our fault, because we did not have that communication that we just talked about with the tongue irritation and speech interference. The first patient was at our door the next morning after the bonding, demanding to have them off. He was not prepared for the irritation and speech issue and was almost having a panic attack. We removed the appliances and converted to clear appliances. That was years ago, with the traditional appliance. The only other instance was rather recently and, again, was our fault. We placed the appliances on a thirdgrade teacher right before school started. She corrals those kids and talks all day and has to have parent conferences the first week of school. Had we started her earlier in the summer, it never would have been a problem. Communication and timing!

DR. FILLION I have debonded probably a dozen patients in their first week of treatment in the past



Fig. 4 A. Adult male patient prior to lingual bracket placement. B. Lin-gual brackets placed after four weeks of weekly 20-minute TENS sessions; note muscle relaxation, bite opening, leveling of curve of Spee, and disappearance of lower gummy smile. C. Pa tient during TENS session.

A B C

25 years. The biggest complaint was, “I cannot cope with the appliance.” The main reason is that they decided too quickly to start treatment, and they were not prepared enough. The patient has to select a good time to do it.

DR. PAZ Of course, the more lingual cases you start, the more you will, unfortunately, have to revisit this uncomfortable issue. The most common complaints are due to the patient’s lack of understanding of what to expect—speech interference and tongue irritation with added discomfort. Proper case selection anatomically and psychologically is most important. If handled properly and timely by the office and the orthodontist, it may be possible to avoid early debonds. Catering to the patient during this initial adaptation period is key.

DR. LUDWIG Do you find hygiene compliance to be better or worse with lingual appliances compared to labial systems?

DR. FILLION I think oral hygiene is neither better nor worse. In lingual, we treat mainly adults, and they usually are more careful of oral hygiene.

DR. PAZ It just will take patients slightly longer to brush and floss their teeth. Most of our debonded lingual patients are similar in gingival conditions to our labial cases. Our hygienecontrol regimes are equal, or even have stricter standards on the lingual.

DR. SILLI For financial or biomechanical reasons, a lot of my patients have lingual brackets only in the upper jaw and labial brackets in the lower, or vice versa. Any differences in the oral hygiene would be immediately recognizable. In my experience, the quality of oral hygiene does not depend on the type or location of an appliance. It solely depends on individual factors like thoroughness, skillfulness, and how conscious someone is about his hygiene.

DR. MOLES Lingual appliances are by nature harder to keep clean due to shorter interbracket distances and the inability to visualize the back of the teeth. We make a special point of going over this at every visit with the patient.

DR. TAKEMOTO It is true that lingual treatment can bring about inflammation of the gums around the lingual brackets. Patients have to be instructed to brush both the teeth and the lingual brackets carefully. However, the caries risk around the lingual brackets is much lower than that of labial brackets—in fact, almost zero.

DR. GILBERT One might expect the oral hy giene of patients with lingual brackets to be worse, because cleaning the lingual surfaces of the teeth is rather difficult. On the other hand, most of my lingual patients are adults, and as such tend to take greater care of their teeth and brackets. Adult patients, unlike adolescents, generally pay for the treatment themselves, and this provides an additional incentive.

DR. CACCIAFESTA I agree that lingual patients are sometimes more motivated to maintain good oral hygiene.

DR. ALEXANDER If the patient is diligent in their hygiene routine, it can be much better—you have other factors that help when you go to the lingual, like the natural cleansing action of the tongue and salivary gland output. Decalcification is an absolute nonissue with lingual. As I said earlier, however, if they get lax in their routine, it can get worse.

DR. LUDWIG Has lingual therapy required any

212 JCO/APRIL 2012

JCO ROUNDTABLE

Dr. Paz

reorganization of your practice routines?

DR. ALEXANDER No, we have not reorganized anything other than increasing the time for some procedures by 10 or 15 minutes. We recommend that new doctors add more time than that when they first get started, but with some experience those times should be reduced.

DR. PAZ Initially we had to schedule different chairtimes, staff, and columns, but not afterward. Our routine adjustment appointments are approximately 15 minutes longer for lingual cases than labial cases. Our bonding procedures on the lingual are 3045 minutes longer, since lingual bonding is more critical and technique sensitive.

DR. SILLI When I started treating lingually, I saw all my patients outside normal working hours, because I could not yet estimate the time needed for indirect bonding, wire changing, etc. This is long ago; today we appoint our patients regardless of their appliance. It brings variety to daily work—for my staff, for me, and for my spine!

DR. GILBERT When I first started practicing lingual orthodontics, consultation times were generally longer than for labial patients. As I gained experience, appointment lengths shortened and are now about the same as for labial patients. The lingual treatment protocol is notably different from the labial treatment protocol. Lingual cases require a setup model and the manufacture of transfer guides, and consequently at least two or more ap pointments before the appliances can be bonded.

DR. MOLES We directbond our labial cases, but we indirectbond our lingual cases. This has changed our protocol for these cases slightly. We have also increased our chairtime for lingual archwire changes to about 10 minutes more than our labial appointments.

DR. LUDWIG Do you work with silicone im pressions, or do you use intraoral scanners or digital files for diagnostics and treatment setup?

DR. TAKEMOTO We use silicone impressions at present.

DR. PAZ I am using silicone impressions for now, but will be moving to scanners in the near future. A virtual digital setup is what lingual treatment is moving toward. New products are under development, and others have just arrived in the U.S. orthodontic markets. One that we are excited about is Harmonyk from American Orthodontics—the first digitally customized selfligating lingual system.

DR. ALEXANDER We currently work with silicone impressions for lingual. I do think there will be a time when we convert to alldigital, but that is still in the works.

DR. SILLI For reasons of precision, we don’t yet use intraoral scanners for fullarch scanning. At the moment, my laboratory Orthorobotl creates manual setups, which are digitized and analyzed for symmetry of the archform to minimize human error (Fig. 5). Soon, all Orthorobot clients will be able to create virtual setups by themselves. I don’t discriminate between buccal or lingual treatment when creating a setup; I use the Onyx Cephm software for my treatment planning. As far as I know, it is the only software that implements all scientifically acknowledged principles of static and dynamic occlusion—curve of Spee, curve of Wilson, occlusal plane, apical basis, inclination of upper and lower incisors, and a quantitative de scription of every tooth position, canine guidance, condylar path inclination, etc.

DR. FILLION I am still working with silicone



Dr. Silli

impressions. I scan models and make a virtual setup and bracket positioning with the 3D software of Orapixd6 (Fig. 6).

DR. CACCIAFESTA It depends on the lingual brackets that will be used in the specific case. Forestadent 2D braces do not need any laboratory work, whereas all the 3D brackets need it.

DR. GILBERT After doing the manual setup, I always verify the positions of the model using the Ray Setn or the Clear Aligner Model Checker.o I never work solely with a virtual setup. This combination of techniques allows me to design the prescription according to the specific characteristics of the patient. I use a software program I de signed myself to verify the setup and design of the archwires, both in the setup phase and during active treatment.e Experience has shown that the program facilitates archwire design and manufacture (Fig. 7).

DR. MOLES With SureSmile QTg lingual, we can scan the patient using 3D conebeam computed tomography (Fig. 8). I do a quick diagnostic setup, and the program will place virtual brackets on the teeth in approximate positions. I then adjust the brackets to their ideal positions. I can also make sure they will be positioned in such a way as to minimize bends in the lingual wires, which greatly simplifies seating the wires during treatment.

DR. LUDWIG Do you work on a model of the malocclusion or a setup model when preparing the lingual appliances?

DR. PAZ Both, actually—an ideal virtual or manual model is made, and then brackets are transferred to the malocclusion, where indirectbonding trays are made (Fig. 9).

DR. ALEXANDER We send the PVS impressions to the lab, and they pour them up and reset the teeth into our prescription, totally customized, for the ideal setup. Then they place the brackets

214 JCO/APRIL 2012

JCO ROUNDTABLE

Fig. 5 Orthorobot digital archform analysis.

Fig. 6 Digital setup with Orapixd system.

Fig. 7 LAMDAe software for lingual setup and archwire design.

back on the malocclusion models for fabrication of the indirectbonding trays.

DR. MOLES I use an ideal virtual setup to determine the ideal bracket positions and then place the brackets in those positions on the malocclusion model, from which the indirectbonding trays are made (Fig. 10).

DR. SILLI The Orthorobot works with pinmodels so that it can switch between the malocclusion and the setup situation (Fig. 11A). Bond ing is done on the setup model (Fig. 11B).

DR. GILBERT I always work on a setup model, even for the simplest cases. Experience has taught me that the worst decision one can make is to un derestimate the difficulty of a case and attempt to take shortcuts with the protocol. I don’t like having to make adjustments to the archwire inside the mouth, and I try to avoid this as much as possible.

DR. CACCIAFESTA With 3D brackets, we use a setup model. With Forestadent 2Db braces, we use the malocclusion model for simplified indirect procedures, or we can perform direct bonding as well (Fig. 12).

DR. FILLION I decide the position of the brackets on the virtual setup in order to use straight wires. By doing it on the computer, it is easier to place the brackets as close as possible to the enamel. Only the upper canine and second premolar are placed away from the enamel (an average of .6mm) to get a straight wire. Then we transfer this position to the malocclusion plaster model using jigs made by CAD/CAM technology.

DR. TAKEMOTO I usually work on a plaster setup model, using a silicone impression material to create an accurate model.

DR. LUDWIG Do you customize the lingual bracket base, the wire, or both?

DR. ALEXANDER Both.

DR. CACCIAFESTA Both.

DR. PAZ Most new lingual brackets being made now have customized bracket bases and archwires.



Fig. 10 Indirect-bonding trays produced with SureSmile QT system.

Fig. 9 Ideal straightwire STbh setup with indirect bonding trays from AOA Laboratories.p

Fig. 8 SureSmile QTg lingual/labial diagnostic setup with virtual brackets in place.

DR. FILLION As you know, the lingual surfaces have a different anatomy, so since the beginning of the lingual technique, all brackets have been customized with composite resin pads, which means that the base of the bracket is perfectly adapted to the lingual surface. Today, some are customized with composite, some with metal. I use

standard brackets customized with composite pads. I can choose the brackets I want and even use different brackets on the same patient. I need only four weeks to prepare the appliance, and the cost is almost half the cost of metal customized bracket systems. All the wires I use are customized, since the form is designed by the 3D Orapix software after the virtual bracket placement. The wires are preformed—flat and without bends.

DR. TAKEMOTO We customize the lingual bracket base. To reduce wire bending, we use plain archwires that fill the slot as fully as possible. By reducing wire play, this gives much greater control over the outcome of the lingual treatment. With the STb SL brackets, the slot size has been reduced to .018" × .018", rather than the more common .018" × .025" with a passive selfligation system. This requires a very accurate setup model.

DR. GILBERT I customize the bracket base during the setup stage and the wire by means of my

216 JCO/APRIL 2012

JCO ROUNDTABLE

Fig. 12 A. Indirect bonding of 2D Lingualb brackets with double silicone transfer tray. B. Indirect bonding of 2D Lingual brackets with vacuum-formed transfer tray. C. Direct bonding of 2D Lingual brackets.

Fig. 11 A. Pin-models of malocclusion and setup. B. Brackets bonded on setup pin-model.

Dr. Takemoto

A B C

A B

software program. I believe customization of the various elements of the system is fundamental to the success of lingual orthodontic treatment.

DR. SILLI We customize both the bracket base and the wire. The brackets are bonded on the model with a robot, which has an accuracy of .02mm for repeated placement (Fig. 13). When bonding the brackets, a thin resin layer is created that stays on the bracket and individualizes it for the given tooth. We then use the coordinates from

the bonding to calculate the finishing wires. The individual archwires are also bent by a robot.

DR. MOLES When placing the brackets on the models, we use a thick composite (Point 4q) that forms a nice base. With SureSmile QT, however, there is no need to create an idealized custom bracket, since all 1st, 2nd, and 3rdorder bends are built into the robotically fabricated custom wires (Fig. 14).

(TO BE CONTINUED)

REFERENCES

1. Alexander, C.M.; Alexander, R.G.; Gorman, J.C.; Hilgers, J.J.; Kurz, C.; Scholz, R.P.; and Smith, J.R.: Lingual orthodontics: A status report, Part 1, J. Clin. Orthod. 16:255262, 1982.

2. Hong, R.K. and Sohn, H.W.: Update on the Fujita lingual bracket, J. Clin. Orthod. 33:136142, 1999.

3. Takemoto, K. and Scuzzo, G.: The straightwire concept in lingual orthodontics, J. Clin. Orthod. 35:4652, 2001.

4. Macchi, A.; Tagliabue, A.; Levrini, L.; and Trezzi, G.: Philippe selfligating lingual brackets, J. Clin. Orthod. 36:4245, 2002.

5. Mujagic, M.; Fauquet, C.; Galletti, C.; Palot, C.; Wiechmann, D.; and Mah, J.: Digital design and manufacturing of the Lingualcare bracket system, J. Clin. Orthod. 39:375382, 2005.

6. Fillion, D.: Lingual straightwire treatment with the Orapix system, J. Clin. Orthod. 45:488497, 2011.

7. Amm, E.W.: The bihelix opening spring for lingual orthodontics, J. Clin. Orthod. 44:617620, 2010.

8. Ludwig, B.; Glasl, B.; Lisson, J.A.; and Kinzinger, G.S.: Clinical tips for improving 2D lingual treatment, J. Clin. Orthod. 44:360362, 2010.

9. Franchi, L.; Giuntoli, F.; Fortini, A.; Chiodo, B.P.; and Baccetti, T.: A simplified lingual technique, J. Clin. Orthod. 44:183189, 2010.

10. Gilbert, A.: An inoffice wirebending robot for lingual orthodontics, J. Clin. Orthod. 45:230234, 2011.

11. Chesterton, L.S.; Foster, N.E.; Wright, C.C.; Baxter, G.D.; and Barlas, P.: Effects of TENS frequency, intensity and stimulation site parameter manipulation on pressure pain thresholds in healthy human subjects, Pain 106:7380, 2003.

12. Ersek, R.A.: Transcutaneous electrical neurostimulation: A new therapeutic modality for controlling pain, Clin. Orthop. Relat. Res. 128:314324, 1977.


Fig. 14 Robotically fabricated custom lingual wire produced with SureSmile system.

Fig. 13 Lingual brackets bonded with robot.

aCitizen Corporation, Iwate, Japan.bForestadent GmbH, Pforzheim, Germany; www.forestadent.de. 2D is a registered trademark.cIncognito Hidden Braces, trademark of 3M Unitek, Monrovia, CA; www.3Munitek.com.dOrapix Co., Ltd., Seoul, Korea; www.orapix.com.eLAMDA, Gilsot SA de CV, Mexicali, Mexico; email: [email protected] trademark of Align Technology, Inc., San Jose, CA; www.invisalign.com.gRegistered trademark of OraMetrix, Inc., Richardson, TX; www.suresmile.com.hTrademark of Ormco Corporation, Orange, CA; www.ormco.com.iRegistered trademark of Dentsply Caulk, Milford, DE; www.caulk.com.jTrademark of Opal Orthodontics, South Jordan, UT; www. opalorthodontics.com.kHarmony, Paris, France. Distributed by American Orthodontics, Sheboygan, WI; www.americanortho.com.lRegistered trademark of Orthorobot Medical Technology, Vienna, Austria; www.orthorobot.com.mTrademark of Image Instruments GmbH, Chemnitz, Germany; www.imageinstruments.de.nRegistered trademark of Biaggini Medical Devices, Arcola, Italy; www.rayset.it.oScheuDental GmbH, Iserlohn, Germany; www.scheudental.de.pAOA Orthodontic Appliances, Sturtevant, WI; www.ormco.com.qTrademark of Kerr Dental, Orange, CA; www.kerrdental.com.


VOLUME XLVI NUMBER 4 203 ROUNDTABLE ON LINGUAL PART I

Documents

Transcript of VOLUME XLVI NUMBER 4 203 ROUNDTABLE ON LINGUAL PART I