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LINGUAL
ORTHODONTICS

INDIAN DENTAL ACADEMY

Leader in continuing dental education
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LINGUAL
ORTHODONTICS
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List of contents
Introduction
History
Research & Development
Generations
Advantages & Disadvantages
Patient selection
INDICATIONS
CONTRAINDICATIONS
Lab procedures
TARG
CLASS
RAY SET
Fillion's Bonding with Equal Specific Thickness (BEST) system
using the modified TARG
The German Transfer Optimized Positioning (TOP) System
HIRO System
Diagnostic and therapeutic considerations
BIOMECHANICS Labial vs Lingual
Loops Vs Sliding
Esthetic considerations
Pontics
Retainers
Treatment planning
RETENTION PLAN
OTHER APPLIANCE SYSTEMS
PENDULUM
Lingual Beggs
LINGUAL STRAIGHT WIRE APPLIANCE
2-D brackets by FORESTADENT
Incognito system
Conclusion
References

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Introduction
Many individuals would like to have the
benefits offered by high-quality orthodontic
treatment, but do not want to have braces that are
visible to their friends and colleagues. This
avalanche of interest is primarily patient-motivated
by those who are visually and cosmetically aware.
In this age of self-improvement with its emphasis
on health, there has been an explosion of interest
in exercise programs, diet and nutrition, etc., as
well as a realization that personal appearance has
much to do with professional success.
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As we all know, there's an increased interest in
adult orthodontics, and everybody is striving for the
utmost in esthetics as well as functional excellence.
Current development of lingual orthodontics began
in earnest by 1975, when it became apparent that
bonding of brackets was a viable procedure, and that
"esthetic" plastic brackets were a compromise.
Adult patients present with unique challenge, of
wanting to look good even during orthodontic
treatment and search for alternatives to metal or clear
brackets continued and then Dr. Craven Kurz of
Beverly Hills, California, used lingual bonded
edgewise appliance for the first time and a significant
contribution to adult orthodontics was made and the
foundation for LINGUAL ORTHODONTICS was
made. He created his own lingual appliances by
modifying labial appliances.
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Lingual History
While the various current bonded lingual
appliances are a direct result of recent bonding
technology, lingual mechanics is nothing new.

1889 by John Farrar. "lingual removable arch"
1918, Dr. John Mershon "The Removable Lingual Arch as
an Appliance for the Treatment of Malocclusion of the
Teeth".
1922 Mershon's presentation on labial and lingual arches
with finger springs
March 1942 , Dr. Oren Oliver gave a clinic on a labiolingual
appliance
mid-'50s, Dr. William Wilson demonstrated a labio-loop-
lingual appliance

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In the current "invisible braces" belongs to
many but the foundation was first kept In 1975, by
Dr.Craven Kurz who used a lingual bonded
edgewise appliance for the first time and made a
significant contribution to adult orthodontics. He
created his own lingual appliances by modifying
labial appliances.
In 1976, Ormco started its research and
development in close cooperation with Dr.
Alexander (Jim) Wildman
Later in 1976, Dr. Kurz submitted specific
designs and concepts to the U.S. Patent Office for
the patent rights to his unique edgewise lingual
appliance.
Thereafter, Dr. Kurz and Ormco bring it from a
dream to reality.


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In 1978, lingual arch form
was studied
topographically, to
establish lingual torque
and tip angulations in
reference to accepted
labial measurements.
From this accumulated
data and using a design
concept to assure proper
function and patient
comfort, the initial lingual
edgewise prototype was
manufactured in 1979.
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In December 1979, Dr. Kinya Fujita, of Kanagawa
Dental University, Japan, published an article
describing appliances with a lingual bracket design
and mushroom shaped archwires.
Obviously, no one is yet in a position to give an
objective, complete appliance. It appears,
however, that many of the major obstacles have
been overcome, and the remaining task of defining
treatment modalities will be complete in the near
future.
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Research & Development
Initial Brackets
An .018" slot size
Conservation of incisal-gingival bracket dimension
Compatibility with existing archwires
Modification was made in the bite plane on the
maxillary cuspids, from a flat plane to a bi-beveled
plane, in order to minimize bracket-cuspid interference
in the final Class I cuspid relationship
The Lingual Task Force was established in
December 1980 to provide additional input on design
considerations and to expand the treatment
modalities. Ball hooks were added to all lingual
brackets at this time. Ball hooks, while aiding greatly
in placing elastic ligatures and elastics ALSO cause
gingival hyperplasia
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Later Modifications
Maxillary anterior brackets incorporate a bite
plane designed into the incisal edge of the
bracket. The bite plane is parallel to the archwire
and the occlusal plane.
All brackets have a gingival ball hook which
greatly facilitates elastic ligature placement,
rotation control, and placement of intra- and
intermaxillary elastics and starting from 1
st

generation today we are using 7
th
generation with
lots of improvement from previous ones and more
advances to be made in near future.


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BRACKETS
First generation
1976
Flat maxillary
occlusal bite plane
from C-C
Lower incisor and
premolar bracket
had low profile
and half round
Had no hooks
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BRACKETS
Second generation
1980
Hooks were added
to canine brackets
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BRACKETS
Third generation
1981
Hooks added to all
anteriors and premolar
brackets
The first molar had a
bracket with internal
hook
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BRACKETS
Fourth generation
1982-84
Addition of low profile
anterior inclined plane
Hooks were optional
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BRACKETS
Fifth generation
1985-86
Anterior inclined plane
became pronounced
Increase in labial torque
in maxillary anterior
region
Attachment for TPA
provided
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BRACKETS
SIXTH generation 1987-90
Inclined plane became more square in shape
Hooks on anterios and premolars were elongated
Hooks on all brackets
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BRACKETS
Seventh generation 1990- Present
Maxillary anterior inclined plane is now heart shaped with short
hooks
The lower anterior brackets have larger inclined plane with short
hooks
The premolar brackets were widened mesiodistally and hooks were
shortened the increased width of Premolar bracket allows better
angulation and rotation control
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Disadvantages
Discomfort to the tongue
Difficulty in speech, which usually
improves after 2-3 weeks of appliance
placement
Extended chair side time needed for
appliance placement and adjustments
Expensive

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Advantages
The labial surface of anterior teeth plays an important
esthetic role.
In labially placed brackets, the susceptibility of enamel
surface to chemical results and plaque accumulation with
poor oral hygiene is increased.
Permanent and unsightly decalcification marks can result
in labial.
Easy access for routine oral hygiene procedures on the
labial surfaces.
Clinical judgement of treatment progress can be enhanced.
Evaluation of individual tooth position can be easily
accomplished by having labial surface free of distracting
metal or plastic brackets.
Soft tissue responses of the lips and cheeks to treatment
can be judged accurately because there is no distortion of
shape or irritation caused by labial appliance.
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Guidelines For Case Selection
To summarize the patient selection criteria and influences
of appliance design parameters on treatment planning, the
following guidelines, based upon our clinical experience thus
far, may be of assistance in the case selection process:

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
Extraction
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
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Guidelines For Case Selection
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
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
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BRACKET POSITIONING
DEVICES
1. The Torque Angulation Reference Guide
(TARG)
developed in 1984 by Ormco
2. The Custom Lingual Appliance Setup Service
(CLASS)
3. Fillion's Bonding with Equal Specific
Thickness (BEST) system
using the modified TARG
4. The German Transfer Optimized Positioning
(TOP) System
5. RAY SET
6. The HIRO System from Japan
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TARG
'Mitutoyo' Digital Indicator and Caliper with
clear LCD displays.
Fine adjustments using the 'Up & Down Fine
Adjustment Screw' with a precision linear
slide allowing bracket-positioning up/down
by increments of 0.01mm. No danger of
further movement whilst fixing the bracket in
place.
The Digital Indicator measuring height
operates freely under no stress, thereby
giving precise and repeatable readings
every time.
The Calipers measuring thickness are firmly
supported, allowing free slide movement for
easy bracket positioning without any
movement of the horizontal axis.
Precise to 0.01mm in vertical & horizontal
axis Strong, repeatable and easy to use

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CLASS
(Custom Lingual Appliance Set-up Service)

More accurate than TARG system
Prepare model setup
Prepare BASES FOR BRACKET
Transfer bracket back to original malocclusion
model
Silicone or thermoplastic trays are made to
transfer brackets from malocclusion model to
the mouth
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RAY SET
First, second and third
order values are
evaluated for each an
every tooth individually
on the cast as if it is a
separate unit
Gives 100% of the
orthodontists
prescription
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Laboratory procedures

Impressions
Rubber base
High quality alginate



Cast poured upto 8mm
thickness


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BASE FORMING & ARTICULATION
Base is formed
Articulation done
Mid-axis of the teeth
marked extending upto
base of the cast for
reference
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SETUP MODEL
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ARCH WIRE FABRICATION
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HIRO SYSTEM
Advantages
No electronic equipment needed for bracket positioning and tray
making.
No need to transfer brackets from the setup model to the original
cast as in the CLASS system.
Extractions , elastic separation, expansion and/or distalization can
be carried out between impressions and bonding.
Individual hard tray is very small and rigid making bonding very
accurate.
The resin core has no relationship with the tooth alignment.
Limited composite overflow makes oral hygiene more easier for
patient to maintain and more comfortable.
In cases of severe crowding, sequential bonding is easier to
manage than in other lingual indirect bonding procedures.
Rebonding is very quick and accurate, with the setup model and 3-
D archwire, and can be done in a few minutes.
It is much cheaper.
The core, made for each individual teeth is not affected by the
position of other teeth allow precise bonding of any tooth at any
time.
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TRAY FABRICATION
HIRO SYSTEM
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BONDING & BANDING
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MOLAR BONDING
EXTRACTION AND NONEXTRACTION CONSIDERATIONS
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Rebonding procedure
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Diagnostic and therapeutic
considerations
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Soft tissue and histological
considerations
Three months required for
adult bone to get
conditioned for effective
orthodontic tooth
movement.
Adult bones, less
trabeculated, reduced
blood supply and hence
slower movement than in
adolescents.
Facial profile with age will
become flatter.
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Anterior bite plane effect
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hygiene considerations

the gingival edge of the bracket should be
about 1.5mm from the crest.
Removal of adhesive flash.
patients must be well educated in oral
hygiene and motivated from the beginning.
Oral hygiene instructions should cover the
use of floss and floss threaders, dietary
restrictions, a fluoride regime, and routine
prophylaxis.
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Speech
A study by the Eastman Dental Center
These conclusions were reported:
The lingual appliance has a mild overall effect on speech.
The "s", "sh", "t-d", and "th" sounds are slightly distorted less than 10
percent of the time with lingual appliances. This distortion usually
disappears within a month of appliance placement.
From one to nine months after appliance placement ------ insignificant
residual distortion of sounds.
Lingual patients' subjective opinion is speech is not normal until the
tongue becomes comfortable.
Patients with only maxillary lingual appliances have fewer, milder
errors of speech and adapt sooner than patients with both arches
bonded.
Speech distortion is significantly greater and lasts longer with lingual
appliances than with labial appliances.
Initial tongue irritation has also been a complaint of lingual
patients. The recently introduced "Generation 7" lingual bracket
appears to reduce both tongue irritation and gingival inflammation
because of its modified size and shape and increased gingival
clearance.
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BIOMECHANICS

Lingual Vs Labial
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Lingual Vs Labial
Anterior Retraction
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Lingual Vs Labial
Vertical Plane
Normal Inclination
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Lingual Vs Labial
Vertical Plane
Labial Inclination
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Lingual Vs Labial
Vertical Plane
Lingual Inclination
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Lingual Vs Labial
Sagittal Plane
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Lingual Vs Labial
Horizontal Plane
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Lingual Vs Labial
Lower Arch
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LEVER ARM PRINCIPLES
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Anchorage - Microimplants
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Extraction Mechanics
Class I cases
High angle cases
Distal tipping of lower
molars changes molar
relationship into Class II

Extraction of
4 4
5 5
Class II

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Class III

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DOUBLE OVERTIES

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Rotational correction
Smiths rotation tie
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Rotation correction with loops

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Esthetic considerations

Pontics (Dr. Smith)
To treat black holes formed after Xn
Make impression of cast where
extracted tooth is present, and in it
build up the composite pontic and the
attached veneer using a lightcured,
microfilled composite for the inner
layer and a fluid composite for the
external layer
Prepare the buccal surface of the
tooth to which the esthetic veneer is
to be bonded as usual with an acid
etchant, primer, and lightcured
adhesive Attach the veneer to that
surface, and cure the adhesive
Remove any occlusal prematurities
that could dislodge the temporary
esthetic prosthesis
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Treatment planning


To arrive at a definitive treatment plan and reach a
conclusion as to labial versus lingual, it is first
necessary to review the characteristics, known to
date, that distinguish conventional fixed
appliances from lingual appliance
mechanotherapy.
Periodontal Considerations
Restorative Considerations
Lingual Crown Height
TMJ Considerations
Extraction Versus Nonextraction Considerations
Vertical
Anteroposterior
Transverse
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Periodontal Considerations
Short lingual clinical crowns can present a
contraindication to optimum lingual bracket
positioning. The periodontist may, in certain cases,
be able to provide additional clinical crown length
through reduction of inflammation orappropriate
surgical procedures.
Lingual appliance can cause gingival hypertrophy
caused by the bracket and bonding resin flash

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Restorative Considerations
naturally more increased in the adult patient
replacing porcelain-fused-to-metal crowns or
other metallic restorations with provisional
plastic crowns to permit lingual bonding
must be closely evaluated
loss of several teeth, extreme tipping, and
multiple or complex bridgework, the lingual
appliance may be contraindicated

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Lingual Crown Height
Lingual clinical crown heights on the average patient are
approximately 30% shorter than the available crown on the
labial surfaces.
7mm of lingual crown height is necessary on the maxillary
incisors in order to achieve optimum bracket placement.
Particular attention should be given in the following
instances:
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
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TMJ Considerations
relief of joint symptoms following lingual appliance
placement because of the disarticulation of
posterior interferences, creation of freedom of
movement of the "locked" mandible, and changes
in muscle position and length due to different
posturing of the mandible.
sophisticated evaluation of the TMJ is needed.
The net effect of bite opening, posterior extrusion,
and mandibular rotation must be carefully
considered.
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Extraction Versus Nonextraction
Considerations
especially Class I deep bites, are excellent
candidates
An ideal extraction case
anchorage is not critical
Class II correction could be achieved principally
as a result of the extractions.

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Vertical

This bite opening produces both positive and negative
effects.
In the low angle brachyfacial patterns, the bite opening is usually
desirable. Many deep bite cases have low mandibular plane
angles, and benefit from posterior extrusion.
In the Mesofacial and dolicofacial types, where bite opening may
not be desirable, use of high-pull headgear becomes a critical part
of the treatment plan to maintain posterior control. According to
Dr.Gorman, "It is amazing to find that adults accept this unsightly
appliance (headgear), when the primary reason for wanting the
lingual appliance was cosmetic.
The posterior disclusion, resulting from the anterior bite
plane opening, permits a rapid eruption of the molars and
bicuspids, with posterior occlusion reestablishing in
approximately 3 to 4 months.
Brings about initial relief of TMJ symptoms
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Anteroposterior

Because of the vertical opening and the immediate rotation
of the mandible (down and back), the lingual appliance
also induces a Class II tendency. This may be desirable in
certain cases, but in most instances it exerts additional
pressure on the orthodontist to control anchorage.
resulting anterior open bite and a developing Class II
dental relationship ,occuring as the result of the mandibular
rotation and the posterior disclusion .
When Class II elastics are planned, it is important to
prepare the mandibular arch level with adequate
anchorage and an archwire of sufficient stiffness to prevent
any mesiocclusal movement of the lower molars, band
second molars whenever possible, and give long span
elastics.

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Transverse
With the initial posterior disclusion, the expansive nature of
the lingual appliance, and a tendency to cause mesiobuccal
molar rotation during space closure, intermolar dimension
becomes more important to control which can be easily done
with help of transpalatal arch bars
Interarch retraction forces on more flexible wire can cause a
"bowing" effect, resulting in the bicuspids being displaced
buccally and the molars rotating to the mesiobuccal resulting
in
functional interference and
further aggravation of the anteroposterior discrepancy
This same "bowing" effect can also occur in the vertical
direction, potentially causing loss of anterior torque control,
tipping, and further bite opening. One technique utilized to
offset this bowing effect (Dr. Smith) is to place a
compensating lingually directed curvature in the closing
archwire form.
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Vertical bowing Cause & Prevention

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LOOP MECHANICS
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VARIOUS LOOPS
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SLIDING MECHANICS
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LOOP Vs SLIDING
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LOOP Vs SLIDING
ANCHORAGE

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Sliding Mechanics
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Esthetic considerations

Retainers ESSIX


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RETENTION PLAN
TRU FORM
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Retention plan
CIRCULAR TYPE RETAINER
SPRING RETAINER
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OTHER LINGUAL APPLIANCES
PENDULUM
Non-extraction Mechanics
LINGUAL BEGGS APPLIANCE
LINGUAL STRAIGHT WIRE APPLIANCE
2D BRACKET APPLIANCE
INCOGNITO SYSTEM
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PENDULUM

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Lingual Beggs
-STEPHEN F. PAIGE
Unipoint combination
bracket (Unitek), with the
slot oriented in the
occlusal-incisal direction
TP 256-500 Begg
Bracket
gingival "wing" to place
elastic modules
vertical slots for arch
auxiliaries
Molar Tube Design oval
tube with a
mesiogingival hook
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buccolingual distance
minimal would also have
advantages, since a small
buccolingual dimension
will increase interbracket
distance.
doubled -over O-ring
elastics, Pins and steel
ligatures
In crowded situations,
more brackets could be
placed
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safety-hold uprighting
spring
a torqued ribbon arch
Beta titanium, stainless
steel, and Elgiloy
rectangular wire may
also be very useful for
this purpose
torquing auxiliary


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Lingual straight wire (LSW)

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References Points
The following are taken into consideration
1. Li-Pointthe most prominent point of the
lingual surface or the tip of the protuberance of
each tooth (horizontal bracket position).
2. Embrasure Linea line connecting all the
contact points, as defined by Andrews.
3. Lingual Crown Height (LCH)the vertical
dimension of each clinical crown.
4. Lingual Straight Plane (L-S Plane)the
plane of vertical bracket slot positions, formed by
connecting the centers of the posterior lingual
clinical crowns and extending the line to the A
anterior segment.
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LSW appliance Vs Kurz appliance
Advantages
Allows ease of flossing.
Gingival portion of bracket has fewer undercuts such as hooks, resulting in
improved oral hygiene in the cervical region of lower anterior teeth.
Distance of contact point from the wire is long enough to permit proximal slicing
without removing the wire.
Without bite planes it is easy to establish adequate overbite during detailing
stage.
Opposite direction of wire insertion helps in easy rotational correction.
Bracket rebondinig is easier as it doesnt require removal of archwire.
Torque control is better as the wire is pushed into the slot during application of
the retraction forces.
Ease of anterior expansion.
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Ease of flossing and proximal slicing
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Without bite planes it is easy to establish
adequate overbite during detailing stage.

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Method of archwire ligation


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Rotational correction

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Anterior expansion

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Rebonding
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Latest in LSW
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2 D Lingual brackets
-FORESTADENT
2D-Lingualbrackets
The 2D lingual brackets are ideally
suited for clinicians who would like to
gain experience in lingual
orthodontics treating less complex
cases. Because of the unique bracket
design no large inventory is required
helping to control cost.
Outstanding patient Comfort
Lingual brackets have an extremely
low profi le and are barely noticeable
for the patient.

Easy to use
The 2D lingual brackets are easy to
use self ligating brackets with a
vertical slot for fast and easy archwire
insertion.

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INCOGNITO
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CONCLUSION
A great deal has been learned and much remains to
be done.
We need to:
1. To ultimately offer the same degree of control as is
obtainable with conventional fixed appliances,
2. To develop a smooth, low-profile appliance with
minimal interference with soft tissue, for patient
comfort, and
3. To develop a lingual appliance with the least
deviation from familiar, well-established labial
edgewise principles, if possible with a straight-
wire approach.
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REFERENCES
Keys to Success in Lingual Therapy- Part 1 - JOHN R. SMITH, DDS, MSD; JOHN C.
GORMAN, DMD, MS; CRAVEN KURZ, DDS; RICHARD M. D
JCO Volume 1986 Apr(252 - 261)

Lingual Orthodontics: A Status Report Part 2 Research and Development
JCO Volume 1982 Nov(735 - 740)

Essix Retainers: Fabrication and Supervision for Permanent Retention - JOHN J.
SHERIDAN, DDS, MSD, WILLIAM LEDOUX, DDS, ROBE
JCO Volume 1993 Jan(37 - 45)

Lingual Orthodontics: A Status Report DR. C. MOODY ALEXANDER,DR. RICHARD G.
ALEXANDER, DR. JOHN C. GORMAN, DR. JAMES J. HILGERS, DR. CRAVEN KURZ,
DR. ROBERT P. SCHOLZ, DR. JOHN R. SMITH.
JCO Volume 1982 Apr(255 - 262)

A Modified Pendulum Appliance for Anterior Anchorage Control PABLO ECHARRI, DDS,
GIUSEPPE SCUZZO, DDS, NUNZIO CIRULLI, DDS
JCO VOLUME 37 : (352-359)

Temporary Esthetic Composite Pontic DANIELA VASSALLO, DDS, SERGIO
TERRANOVA, MD, DDS, MS
JCO/MAY 2003

Lingual Orthodontics: A Status Report Part 6 Patient and Practice management
JCO Volume 1983 Apr(240 - 246):

A Modified Pendulum Appliance for Anterior Anchorage Control
JCO VOLUME 37 : NUMBER 07 : PAGES (352-359)

A Lingual Light-Wire Technique STEPHEN F. PAIGE, DDS
JCO Volume 1982 Aug(534 - 544)

Micro-Implant Anchorage for Lingual Treatment of a Skeletal Class II Malocclusion
JCO VOLUME XXXV NUMBER 10 2001

Lingual Orthodontics: A Status Report Part 4 Diagnosis and Treatment Planning
JCO Volume 1983 Jan(26 - 35)

Lingual Orthodontics:History, Misconceptions and Clarification
J Can Dent Assoc 2005; 71(2):99102

The Straight-Wire Concept in Lingual Orthodontics
JCO/JANUARY 2001

Lever-Arm Mechanics in Lingual
JCO OrthodonticsVOLUME XXXIV NUMBER 10 2000

CLINICLA IMPRESSIONS published by ORMCO CORPORATION VOL.6 No.4 1997

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