Seminars in Orthodontics
VOL 24, NO 3
Lingual orthodontics: Adding value to the
care we offer our patients
O ver the last twenty years there has been an
increasing demand for esthetic orthodon-
tic treatment. This demand is driven by several
factors, including an increasing number of adult
orthodontic patients as well as advertising by the
Clear Aligner industry. Many of these prospective
adult patients approach an orthodontic provider
and are told that they are not candidates for
orthodontic treatment with clear aligners. The
vast majority of these patients are offered an
“esthetic” buccal ceramic orthodontic appliance;
these patients are not informed that there are
other treatment options involving lingual fixed
appliances. Patients are forced to make a choice
between a buccal appliance or no treatment at
all. This false choice results in thousands of
patients not benefiting from the treatment they
desire and frequently need.
There are two compelling reasons why all
orthodontic specialists should have some basic
capability to employ lingual fixed appliances. (1)
For many patients, there is a difference between
“excellent treatment” and “excellent treatment
outcome”; an excellent treatment outcome is
necessary not sufficient to satisfy these patients.
(2) There are many circumstances where only a
lingual fixed appliance will provide the most effi-
cient treatment.
Let me address the former point first; I fre-
quently hear orthodontists complaining that
non-orthodontic specialists are delivering a
greater fraction of orthodontic care, at the same
time, from the patient’s perspective, as a profes-
sion are we offering our patients the best possible
treatment? The Generalist is offering treatment
with a relatively esthetic clear aligner system,
while the orthodontist is left to argue, in order to
deliver the best possible treatment outcome, the
© 2018 Published by Elsevier Inc.
https://doi.org/10.1053/j.sodo.2018.08.009
Seminars in Orthodontics, Vol 24, No 3, 2018: pp 269 270
SEPTEMBER 2018
patient requires brackets on the outside of the
teeth. But in most cases, this is a false choice! As
a profession we should strive to provide not only
excellent treatment results but what the patient
would consider excellent esthetic treatment!
As for the second point, there are many cir-
cumstances where only a lingual fixed appli-
ance will provide the most efficient treatment
option. This increased efficiency can be due
biomechanical or logistical factors. For exam-
ple, when managing a fixed appliance in the
presences of impinging deepbites there is a sig-
nificant logistical advantage to placing brackets
out of occlusion on the lingual of the lower
arch. Consider the biomechanical advantage
that lingual appliances present when intruding
anterior teeth. When employing buccal fixed
appliances for the intrusion of anterior teeth a
significant moment is induced resulting in a
tendency for “tipping” or further proclination
of the teeth. On the other hand, the use of a lin-
gual fixed appliance system can minimize or in
some cases eliminate adverse moments that are
generated due to the point of force application
with respect to the center of resistance of the
tooth. Why do orthodontists struggle to intrude
teeth and counteract adverse proclination with
buccal appliances when they could employ a
lingual appliance system that is superior biome-
chanically? Most orthodontist do not use lin-
gual appliances even when they offer clear
biomechanical and esthetic advantages because
the majority of orthodontic specialists are not
educated and trained to use lingual appliances.
Should orthodontic specialists offer the same
poor esthetic treatment alternatives to their
patient as non-specialists? Should we make the
same inefficient tactical choice as our generalist
colleagues? Does this situation reflect well on
our profession? Shouldn’t we differentiate our-
selves from our generalist colleagues through
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superior mechanical and esthetic choices for
our patients?
In this issue of Seminars in Orthodontics we
make the argument that a basic level of compe-
tence using lingual fixed appliances is the hall-
mark of a modern orthodontic specialist. We
also are attempting to provide an overview of
what is possible with modern lingual appliance
systems. An important message of this issue is: It
does not matter which lingual system
is employed by a practitioner. What is important
is the practitioners’ knowledge of the strengths
and weaknesses of the particular lingual system.
In the first paper of this issue we have attempted
to outline the biomechanical issues related to lin-
gual mechanics and how modern lingual appliance
systems compensate for these issues. In the second
paper Dr. Fillion presents the advantages of a
straight wire system, Lingual Liberty. A series of
clinical papers follow by Drs. Warshawsky, Riolo
and Schulhof respectively. These papers demon-
strate the range of clinical issues that can be
Riolo
addressed with lingual mechanics. Dr Nicolay
offers a glimpse of hybrid treatment in his paper.
One of the advantages of custom appliance treat-
ment is the ability to coordinate and integrate com-
binations of lingual, buccal and clear aligner
therapy within a single patients’ treatment, using
each appliance system to their particular strengths.
Dr. Khosravi wraps up this special lingual issue with
a discussion of the current state of lingual mechan-
ics and glimpse at the future.
We would like to thank Elliott Moskowitz, the
editor and chief of Seminars in Orthodontics for
recognizing the importance of lingual appliance
therapy for our patients and profession.
Christopher Riolo1,2
1
Affiliate Associate Professor, University of
Washington, School of Dentistry, Department of
Orthodontics, Seattle, WA. United States
2
Private Practice, Seattle, WA. United States
E-mail: criolo@umich.edu