Journal of Orthodontics, Vol.

40, 2013, S60–S67

LINGUAL The 2D lingual appliance system

SUPPLEMENT

Vittorio Cacciafesta
Viale Papiniano, Milano, Italy

The two-dimensional (2D) lingual bracket system represents a valuable treatment option for adult patients seeking a
completely invisible orthodontic appliance. The ease of direct or simplified indirect bonding of 2D lingual brackets in
combination with low friction mechanics makes it possible to achieve a good functional and aesthetic occlusion, even in the
presence of a severe malocclusion. The use of a self-ligating bracket significantly reduces chair-side time for the orthodontist,
and the low-profile bracket design greatly improves patient comfort.
Key words: Lingual orthodontics, lingual brackets, aesthetics, new technologies, Ni–Ti archwires

Introduction lingual orthodontics is no longer a technique for limited

In the late 1970s, lingual orthodontics started to become
a treatment option for adults, and the number of cases
increased exponentially. However, within a few years,
the number of lingual orthodontic cases decreased
greatly, due to the fact that most doctors could not
achieve satisfactory results with a lingual technique. As
time has passed and problem solving associated with
lingual appliances has improved, lingual orthodontics
has expanded around the globe, especially in Asian and
European countries.1–3
Today, the lingual technique provides a very success-
ful approach in the orthodontic treatment of adult
patients, although it is considered to be one of the most
difficult, as it requires great manual skill and experience,
more chair-side time than labial treatments and often
longer treatment times. The reason for this success
might be the fact that lingual orthodontics is superior in
aesthetics to all the other treatment options, as it is the
only technique which can be considered completely
‘invisible’.1
In lingual orthodontics, first- and third-order tooth
movements are more complicated because of the varia-
bility of lingual tooth anatomy.2 Torque control is also
more difficult because of the reduced inter-bracket
distance, and even small variations in bracket height
can have a considerable effect on applied torque. These
factors have led to the development of various indirect
bracket-transferring methods, such as TARG (SDS/
Ormco, Orange, CA, USA) and CLASS (Specialty Appli-
ances, Norcross, GA, USA),3,4 or very sophisticated fully
individualized systems, such as IncognitoTM.5 Today,
numbers of orthodontists. One of the most dramatic
changes can be found in the evolution of bonding pro-
cedures. Current bonding procedures are totally different
from those of 10 years ago. Lingual brackets can be
bonded directly, just like labial brackets, or indirectly
depending on the system used and the severity of the
malocclusion.1
In order to avoid unnecessary costs, the two-dimen-
sional (2D) lingual technique (Forestadent, Pforzheim,
Germany) has been developed as an inexpensive lingual
approach, aiming to bypass many factors complicating
conventional lingual treatment, but still providing
favorable results (Table 1).6–10 Clinical bonding of the
2D lingual brackets can be done directly or indirectly,
without the need for an expensive and time-consuming
laboratory set-up. Moreover, these brackets are
designed to be as comfortable for the patient as possible.
If they are too high or bulky, lingual brackets can be
uncomfortable and also affect pronunciation, causing
speech problems for the patient. This clinical report will
present the design, characteristics and clinical applica-
tions of 2D lingual brackets.
The 2D lingual system
The 2D lingual technique employs a number of com-
ponents (Table 2), but the key feature is a simple self-
ligating lingual bracket that does not have a traditional
rectangular slot in the base; instead, the bracket has
two clips on the lingual surface to trap the archwire
(Figure 1). Because they do not have rectangular slots,
only first- and second-order movements are possible.

Address for correspondence: Vittorio Cacciafesta, Viale Papiniano

44, 20123 Milano, Italy.
Email: vcacciafesta@hotmail.com
# 2013 British Orthodontic Society DOI 10.1179/1465312513Z.000000000107
 JO September 2013 Lingual Supplement 2D lingual orthodontics S61

Figure 1 Forestadent 2D lingual brackets in the upper and lower arches

Figure 2 Forestadent 2D lingual bracket range: (A) medium twin standard bracket; (B) narrow single bracket; (C) mini-ant bracket; (D)
medium twin with gingival hook; (E) 2D Plus lingual bracket; (F) molar tubes

The clips can be opened with a modified spatula that has
been previously customized by thinning the ends with a
grinder or a specific probe, which allows the archwire to
be inserted or removed from the slot. Brackets are easily
closed with a Weingart utility plier; but it is recom-
mended to close only one lip at a time to reduce the
risk of accidental debonding or damage. A cotton roll
Table 1 Main characteristics of 2D lingual brackets.
should be held against the labial surfaces of the teeth to
avoid any slipping of the plier.
2D lingual bracket types
Several different types of 2D lingual bracket exist: the
medium twin standard bracket can be used on all teeth
and is indicated particularly for relapse cases that do not
require the use of power chains or when comfort is a
must (Figure 2A), the narrow single (Figure 2B) and

1. Brackets can be used for all teeth, since there is no prescription Table 2 Components of the 2D lingual technique.
2. It is a self-ligating system, with progressive friction
3. They allow a vertical insertion of the archwire 1. 2D lingual brackets
4. Able to engage wires with maximum diameter of 0.022060.0160 2. Titanol superelastic or biolingual archwires
5. The total thickness is 1.4 mm, including the base (0.4 mm) 3. Light wire mechanics
6. They allow the use of thin power chains 4. Low friction and light forces
7. 2D plus brackets allow applying torque when needed 5. Direct or indirect bonding (without the need for any set-up)
 S62 Cacciafesta Lingual Supplement JO September 2013

mini-ant bracket (Figure 2C), which are used in cases

with severe crowding or rotations, whenever space is too
limited for a standard bracket; the medium twin
(Figure 2D), which has a gingival hook and is indicated
for more complex treatment where power chain or inter-
maxillary elastics are needed (this bracket also allows for
the use of auxiliary torquing springs for simple third
order movements) and the 2D Plus lingual bracket
(Figure 2E), which has a rectangular slot that allows the
application of torque on single teeth. There are different
torque options to make the set-up relatively simple for
each affected tooth. Molar tubes complete the available
brackets and are extremely flat and chamfered for
excellent comfort (Figure 2F).
The absence of the slot in the base has made it possible
to reduce the total thickness of the bracket to only
1.4 mm, which allows the archwire to be almost tangent
to the lingual surface. These characteristics, together
with the use of round/squared wires and correct bracket
positioning, compensate for the different labio-lingual
thickness normally present on the front teeth, particu-
larly in the maxillary arch. Figure 3 Opening and closing 2D lingual brackets: (A) opening
brackets with a customized Haideman spatula; (B) closing brackets
Opening and closing 2D lingual brackets with a Weingart plier

Opening and closing of the clips is very easy and fast. A

modified spatula or the special explorer has to be inserted
into the notch on the right side of the clip, thus opening
the bracket by mechanical deformation (Figure 3A). The
force of the explorer should always be directed toward the
bracket pad to avoid debonding. The clips are laser-
welded on the pad and the material is tested to withstand
at least 20 normal opening and closing cycles. Once the
archwire is inserted, the clips can be closed. Weingart
ultralight wire pliers are especially suitable. It is
recommended to close only one clip at a time and to
protect the enamel by using a cotton roll or a protection
cap on the outer beak of the plier (Figure 3B).
Direct bonding procedures for 2D
lingual brackets
A major difference between the 2D lingual system and
other lingual techniques is that no laboratory set-up is
required. After some practice and experience, all the
necessary steps can be very easily done at the chair side,
in a similar manner to the clinical steps required to bond
conventional labial brackets.
For bracket application, conventional college tweezers or
thin bracket holders can be employed. It is important to
slightly open the bracket clip before holding it with the
tweezers. Once the bracket is firmly held, rotate the tweezers
in order to show the base surface. Successful bonding
requires careful attention to three essential components: the
tooth surface and its preparation, the design of the bracket
base and the bonding agent. The steps involved for optimal
performance of direct bonding for lingual orthodontic
attachments are as follows: cleaning, enamel conditioning,
sealing, bonding and light curing (if necessary).
Cleaning
Before bonding the brackets, it is essential to remove the
organic pellicle that normally covers the surface of all
teeth. This is accomplished by cleaning the enamel
surface using a mix of pumice and water or prophylactic
paste, with a rubber cup or a polishing brush mounted
on a low-speed rotary instrument. The tooth is subse-
quently rinsed with water to remove any pumice debris,
and thoroughly dried with a stream of oil-free air.
During this procedure, cheek and lip retractors, saliva
ejectors and cotton or gauze rolls should be used.
If there is a need to increase bond strength, it is
recommended that a microetcher (sandblaster) is used
on the enamel surface for three seconds.
Enamel conditioning
After moisture control, it is necessary to maintain a
completely dry working field and to create irregularities
 JO September 2013 Lingual Supplement 2D lingual orthodontics S63

on the enamel surface. This is accomplished by covering

the entire enamel surface with 37% orthophosphoric
acid for about 30 seconds; longer etching periods
provide no more, but actually less retention, because
of the loss of surface structure. The simplicity of the
etching procedure is increased with the use of acid gels
rather than acid solutions; gels provide better control
for restricting the working field and avoid insulting the
gingival margin and initiating bleeding. The enamel
surface must not be contaminated with saliva, which
promotes immediate remineralization, until bonding is
completed; otherwise re-etching is required. After
rinsing the enamel again in order to completely remove
the etch, the tooth surface must be dried with a
moisture-and-oil-free source to obtain a uniform and Figure 4 Bonding in the mandibular arch with the aid of a
frosty white appearance. Recent advances indicate that placement gauge
microetching is also essential for successful treatment.
the incisal edge (Figure 4). In the maxillary arch, because
Sealing of the more complex anatomy and limited visibility, we
A liquid resin is then applied with a small foam pellet or suggest that a vacuum-formed soft sheet is used as a
brush with a single gingivo-incisal stroke on each etched reference guide or to perform indirect bonding. Bracket
inclinations can be indicated on the tray by marking the
tooth. The resin is able to penetrate into the irregula-
long axes of the teeth. This system will allow brackets to
rities created in the etched enamel surface, allowing the
be positioned at the correct height, thus avoiding occlusal
bonding material to mechanically interlock with the
interferences from the overbite (Figure 5).
tooth surface.

Bonding Indirect bonding procedures for 2D

lingual brackets
After application of the liquid resin, a small quantity of
adhesive is applied to the bracket base, which is then The long axes of the clinical crowns, occlusal margins and
pressed against the enamel in its correct position. bracket positions are marked on the plaster malocclusion
Depending on the type of bonding material, it can set model. After isolating the plaster model with a separating
either by a self-curing process or by light-curing. An liquid, the brackets can be bonded on the model using
adhesive should have sufficient viscosity so that the light-cure composite. After light-curing the brackets, a
bonded attachments do not drift out of position before transfer tray can be fabricated with silicone (Figure 6) or
the adhesive has set. Light curing composite resins, such a vacuum-forming machine (Figure 7). After removing
as Transbond XT (Unitek/3M, Monrovia, CA, USA) or the tray from the plaster model, the bracket composite
Kurasper F (Kuraray, Tokyo, Japan) are preferable. pads have to be cleaned with acetone. The patient’s teeth
The bracket bonding procedure consists of transfer,
positioning, fitting, removal of excess adhesive and light-
curing. When excess adhesive is carefully removed and
good oral hygiene is maintained, the gingival condition
is not adversely influenced by bonded lingual appliances;
however, when excess adhesive is close to the gingival
margin, it will produce periodontal damage (gingival
inflammation and hyperplastic gingival changes) and the
possibility of decalcification around the periphery of the
bonding base. Direct bonding is easier, faster (especially
if only a few teeth are to be bonded) and less expensive
than indirect bonding.
In the mandibular arch, direct bonding is performed Figure 5 Bonding in the maxillary arch with a vacuum-formed
using a placement gauge to mark the desired height from soft sheet as a reference guide
 S64 Cacciafesta Lingual Supplement JO September 2013

Figure 6 (A–D) Indirect bonding with a silicone double tray technique

have to be prepared as in the direct bonding procedure.
Make sure not to use too much composite to avoid an
excess after removing the tray. Remove the tray carefully
from the brackets.
Main characteristics of Titanol lingual
archwires
The nickel–titanium archwires normally used in combi-
nation with the 2D lingual brackets are Titanol lingual
archwires (Forestadent, Pforzheim, Germany) in three
classic shapes (small, medium and large, with sections
of 0.012, 0.014 and 0.016 inch, respectively). These

Figure 7 Indirect bonding with a vacuum-formed sheet

Figure 8 Titanol lingual archwires Figure 9 Biolingual nickel–titanium archwires

 JO September 2013 Lingual Supplement 2D lingual orthodontics S65

Figure 10 Treatment of mandibular incisor crowding

archwires are pre-curved from canine to canine, both for
the maxillary and mandibular arch, and allow precise
insertion of a first-order bend between the canine and
first premolar in order to produce the typical mushroom
arch configuration.11 We have developed a method
for adding simple first or second-order bends to the
preformed archwire by overbending the wire whilst it is
in its martensitic (cold) phase. If the wire is then gently
heated with a flame (up to approximately 60–70uC), it
will regain its austenitic phase, and the effective amount
of bending can be checked. This is a very easy clinical
procedure that requires only a few minutes of chair
working time (Figure 8).8 Alternatively, biolingual wires
can be employed, which are mushroom-shaped lingual
archwires available in five different shapes and four
different wire dimensions with a template to determine
the correct shape (Figure 9).
The use of nickel–titanium archwires enables the
clinician to produce low levels of applied force and to
achieve a more consistent tooth movement during the

Figure 11 Treatment of a palatally impacted UR3 in an adult: (A) pre-treatment OPG; (B) post-eruption OPG; (C) intra-oral view
following exposure and bonding of the UR3; (D) accommodation of the UR3 into the arch; (E) alignment of the UR3
 S66 Cacciafesta Lingual Supplement JO September 2013

Figure 12 Treatment of an anterior bilateral crossbite associated with the upper canine teeth in an adult: (A, B) pre-treatment; (C, D)
mid-treatment; (E, F) post-treatment

first phase of treatment (levelling and aligning), because ectopic canines (Figure 11), correction of anterior and
these wires have a wide range of deactivation, thus lateral crossbites (Figure 12) pre-orthognathic set-up and
significantly reducing the number of appointments and minor torque control (Figure 13).
reactivations.

Clinical applications
The 2D lingual system can be effectively used in a number
of clinical situations, including post-treatment retention,
closure of minor spaces and diastemas and the limited
correction of deep bites. It is useful for the correction of
crowding, particularly in the mandibular arch (Figure 10)
and can also be successfully used for more complex tooth
movements, including the alignment of impacted or
Conclusions
Lingual orthodontics satisfies aesthetic criteria by
positioning the fixed appliance on the lingual surfaces
of the teeth. It demands special biomechanical expertise
and technical skills, such as indirect bracket bonding
and customized arch bending. However, 2D lingual
brackets are a valid alternative to conventional lingual
brackets in adult cases that do not require third-order
tooth movements. Indications for using these brackets

Figure 13 Adult presenting with anterior negative torque and a severe deep bite. (A, B) Pre- and post-treatment occlusion, respectively
 JO September 2013 Lingual Supplement
include post-treatment retention, closure of minor
spaces, correction of deep bites, and correction of
crowding and crossbites. Additional malocclusions that
can be treated with this technique include management
of impacted/ectopic canines or pre-orthognathic surgical
patients. Once the clinician’s familiarity with lingual
techniques has improved, he or she will be able to treat
more difficult cases with more sophisticated 3D brackets
and indirect bonding.
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