Source: JCO on CD-ROM (Copyright © 1998 JCO, Inc.

), Volume 1986 Apr(252 -

261): Keys to Success in Lingual Therapy- Part 1 - JOHN R. SMITH, DDS, MSD; JOHN
C. GORMAN, DMD, MS; CRAVEN KURZ, DDS; RICHARD M. D
--------------------------------
Keys to Success in Lingual Therapy

The following keys to success reflect this additional experience and should assist
the orthodontist who is trying to integrate lingual orthodontics into his or her practice.

Key 1
Patient Selection
Lingual orthodontics differs enough from labial orthodontics to require a different
approach to case selection and treatment planning. The differences result primarily from
the bite-opening effect of the maxillary anterior lingual brackets on the lower incisors and
from the mechanical responses of the lingual brackets and wires.
The clinician should become thoroughly familiar with appliance characteristics to
minimize problems during treatment and, more important, to select proper cases and
instruct patients before treatment.
Oral Hygiene and Gingival Irritation

Unlike most labial brackets, lingual brackets must always be placed close to the
gingival crest. This is particularly true with maxillary lateral incisors, mandibular
incisors, worn cuspids, mandibular bicuspids, and second molars.
Ideally, the gingival edge of the bracket should be about 1.5mm from the crest.
When this is not possible— as is often the case— gingival inflammation can ensue,
apparently because of direct mechanical irritation by the bracket and/or bonding
adhesive. This reaction is, of course, exaggerated by plaque and calculus deposits.
Removal of adhesive flash, a major factor in gingival irritation, must be thorough.
This disadvantage of indirect bonding has been alleviated with the introduction of the
Advance bonding system.
Lingual patients must be well educated in oral hygiene and motivated from the
beginning. Poor oral hygiene, particularly when coupled with short clinical crowns,
should exclude an individual from lingual treatment. Oral hygiene instructions should
cover the use of floss and floss threaders, dietary restrictions, a fluoride regime, and
routine prophylaxis by the general dentist.
Speech Adaptation and Tongue Irritation

A common complaint of lingual patients is temporary speech alteration. Patients

must be forewarned of this possibility.
A study by the Eastman Dental Center13 compared the speech of lingual and labial
patients. 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, there is a clinically
insignificant residual distortion of sounds.
• Lingual patients' subjective opinion is also that speech is affected for less than a
month, and that 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 (Fig. 1) appears to reduce both tongue irritation
and gingival inflammation because of its modified size and shape and increased gingival
clearance.
Variations in Tooth Size and Anatomy

Although the most recent laboratory procedures compensate for minor variations in
lingual tooth morphology, any gross variations such as rudimentary cusps on cuspids or
exceedingly large cingulae should be reduced before taking impressions for laboratory
models. Any plastic or porcelain restoration that can be bonded should be recontoured to
approximate its original form and facial-lingual thickness where the lingual anatomy
differs from that of the contralateral tooth.
Lingual clinical crown height can often be 30 percent less than that of the same
tooth's facial surface. Inadequate lingual crown height (less than about 7mm on maxillary
incisors) might eliminate a patient from consideration for lingual treatment.
Partially erupted, fractured, or worn teeth and congenitally small teeth, such as peg
laterals, present many problems for bracket placement. Not only is it difficult to get the
bracket high enough to clear opposing teeth and avoid the gingiva, but the bracket must
be placed farther gingivally on a thicker portion of the tooth. Particularly on incisors, this
can greatly affect the torque and in-out relationship to adjacent teeth. Such a compound
effect is frequently seen on worn cuspids, where adequate overbite is an important
treatment objective.
In some instances, the clinical crown can be increased by exposing more of the
anatomical crown with a gingivectomy.
Bite Opening and Mandibular Rotation

Anteroposterior and vertical changes become evident immediately upon bonding

lingual brackets to the maxillary teeth. The bite plane built into the maxillary anterior
brackets usually causes disclusion of the posterior segments. Generally the molars
extrude, the incisors intrude, and posterior occlusion is reestablished within 90 days.
This bite opening may require treatment mechanics different from conventional
therapy. In certain cases, such as a low mandibular plane angle and deep bite, the bite
opening is beneficial. Posterior disclusion has been noted to help relieve myofacial pain
associated with occlusal disharmonies in deep bite cases.
There are, of course, times when the bite opening is not desirable— as with a high
mandibular plane angle. Such a patient may already have a downward mandibular growth
pattern, and further downward and backward rotation exacerbates the problem. Treatment
must then be planned accordingly. For instance, a high-pull facebow can provide
anchorage and reduce extrusion of the maxillary molars to counter this Class II tendency.
If the outer bow is cut anterior to the first molar and bent upward from the inner bow, this
will also aid in intruding maxillary molars and incisors.14
In Class I cases with excessive overjet or maxillary anterior crowding, the
autorotation of the mandible may make the occlusion Class II, and maxillary bicuspids
may need to be extracted to establish proper anterior guidance.
In certain Class II, division 1 cases, the bite plane on the maxillary anterior brackets
is not contacted initially and the mandible is actually locked behind the brackets. This can
be a particular problem if the patient has internal derangement of the TMJ. Anterior
repositioning mechanics, as with a Herbst appliance, can position the mandible forward
to the bite plane (Fig. 2).
Headgear and Elastics

Headgear is a vital adjunct to lingual mechanotherapy, just as it is to labial

treatment. The use of high-pull headgear to counteract mandibular autorotation has
already been mentioned. Convincing a patient who is primarily motivated by cosmetics to
wear a highly visible extraoral device can be challenging. The most effective response to
objections about headgear is that in most social situations the headgear can be removed
and the lingual appliances will still be unseen.
Unless archwires of sufficient stiffness (e.g., .016" square or .016" ´ .025" stainless
steel) can be placed, intra-arch and especially interarch elastics should be avoided. A
possible exception would be light elastics from the lingual to the opposing buccal bracket
when correcting posterior crossbite. Vertical elastics can also be used on light wires in
the finishing stages to bring opposing teeth into occlusion without the inhibition of the
archwire. In these situations, it is best to use steel ligature wire to prevent archwire
disengagement, rotations, or loss of torque control.
Interarch elastics can be effective for making sagittal changes when attached to the
hook on the terminal tooth's lingual tube and extended to the gingival hook on the lingual
cuspid bracket. To prevent rotations and opening space mesial to the cuspid, the six
anterior teeth should be ligated as a unit with .009" stainless steel wire. In addition, the
cuspid brackets-should be ligated to the archwire using a double-over tie with steel wire.
Clear plastic buttons can be bonded on the labial to provide additional elastic force
or prevent a possible tongue irritation. These should be placed toward the distogingival of
the cuspids to minimize tipping and rotation (Fig. 3)
Another method is to extend the intermaxillary elastic from the lingual of the molar
to a labial button on the cuspid. This crossover elastic does not appear to have any
detrimental effect, provided the archwire is rigid enough, and the direction of pull aids in
preventing labial flaring of the cuspids.
Key 2
Bracket Placement Accuracy
Decreased arch radius, decreased interbracket distance, compound lingual
geometry, highly variable tooth morphology, and limited access and visibility all
combine to make accurate compensating bends exceedingly difficult with a lingual
appliance. Indirect bonding is therefore essential, and laboratory techniques must
incorporate a means of precisely determining bracket locations.
 The TARG (Torque and Angulation Reference Guide) technique3 (Fig. 4) was a
step in the right direction. More recent refinements have adjusted for torque variations
resulting from irregular lingual morphology, and have compensated somewhat for in-out
discrepancies, by customizing the fit of individual brackets with Advance adhesive. The
result has been a further reduction in the number of compensating archwire bends.
The TARG instrumentation is designed to transfer bracket prescriptions from the
more reliable labial surfaces of each tooth to the lingual at a given bracket height. This is
in effect a method of doing a diagnostic set-up without sectioning the model, and it al
lows the laboratory technician to set customized torque and angulations for each
individual prescription.
For example, a Class II, division 2 case requiring additional torque in the maxillary
anteriors is so noted on the prescription. The technician then "dials" in the prescribed
torque on the TARG, locating the lingual bracket at an increased torque angle from the
averaged bracket values. The fit of the lingual bracket base is then compensated for with
the Advance adhesive.
Key 3
Indirect Bonding
An early concern with lingual orthodontics was excessive bond failure, primarily
with maxillary incisor brackets. Experience has shown, however, that bracket failure rates
are no higher with lingual than with labial brackets.
As more lingual molar bonding has been attempted, more bond failures have been
seen— similar to the experience with buccally bonded molar attachments. These failures
are undoubtedly due to a combination of greater biting forces and greater difficulty in
obtaining good isolation during bonding. Therefore, it is often advisable to band molars,
particularly when using transpalatal arches or other auxiliaries.
Some additional preparation of the teeth may be required before taking impressions
for indirect bonding models. Maxillary lateral incisors should be examined for the
possibility of making or replacing restorations of the dens in dente or dens invaginalis.
Deep pits should be filled, and any existing amalgam restorations replaced, with a
composite material.
Exposed metal, of course, cannot be bonded. Metal crowns can be replaced with
provisional plastic crowns, or a window can be cut in the metal and restored with
composite. Porcelain can be successfully bonded if a silane primer is used.
Extremely short lingual crowns on mandibular first bicuspids can now be managed
by the laboratory under the Advance system. Lingual cusps are built up with thermally
cured laboratory adhesive to provide more room for bracket placement.
Cleats, buttons, and hooks have been successfully bonded on the lingual for years.
It is important, however, to recognize the extra attention needed for etching, drying, and
bonding close to the gingiva.
Patients should certainly be advised that an immediate bite opening usually occurs.
Because of the posterior disclusion, most patients switch to a soft diet and gradually work
up to harder and coarser foods. Bonding failures will be reduced, however, if all patients
are told to eliminate hard and sticky foods from their diets.
The Advance technique incorporates a thermally cured, filled, diacrylic resin that is
applied to the bracket mesh in the laboratory to fill in the gap between the bracket base
and the stone model of the tooth. Because it is thermally cured in the laboratory, the resin
achieves about a 40 percent greater degree of polymerization than the self-curing resins
previously used. It therefore has greater cohesive strength and can be used to customize
brackets, within limits, to permit in-out and torque compensations as dictated by the
TARG instrument.
The indirect set-up of the lingual brackets is followed by the fabrication of a
precision-fitting tray that can accurately position an entire quadrant of brackets. The
brackets are embedded in the indirect tray material and returned to the clinician at
chairside. The tray can be sectioned for ease of isolation and placement (Fig. 5).
If no significant tooth movement has occurred, the customized bracket bases should
intimately contact the teeth at the time of bonding. Only a thin layer of unfilled, self-
curing adhesive is then required to adhere the bracket to the etched enamel.
The chairside bonding adhesive is a two-component, single-use system (Fig. 6-).
One component ("bracket side") is applied to the previously cured laboratory adhesive on
the brackets. The other("tooth side") is applied to the prepared enamel surfaces. When the
tray is seated, the two components come into contact and polymerization occurs rapidly.
This resin system eliminates flash, because bonding is done with a thin coating of
unfilled resin and polymerization occurs only after the tray is seated. Timing is not as
critical as with previous systems. Debonding is also easier in many instances, because the
resin fracture can now occur between the unfilled resin and the higher-strength laboratory
resin.
Following these guidelines will insure bonding success:
Model-Taking

1. Use a rigid, well-fitting tray— not a foam tray.

2. Improve definition by wiping alginate into the linguogingival sulcus with a finger
before seating the tray.
3. Check the impression immediately for bubbles on lingual surfaces, and retake if
in doubt.
4. Use a high-quality artificial die stone such as Kerr Vel-Mix, following the
manufacturer's mixing ratios precisely to insure proper dimension. Plaster models will
not withstand some laboratory procedures.
5. Pour the cast immediately. Do not use a second pour for laboratory construction.
6. Check for absence of pouring voids.

Preparation for Bonding

1. Start with the upper arch. Moisture control is easier, allowing the patient to adapt.
2. Pumice teeth to be bonded extremely well near the gingivae. Isolate and etch for
90 seconds.
3. Etch and bond only one quadrant at a time. Breath moisture can contaminate
another quadrant while the first is held in place for two minutes.
4. After etching, rinse each tooth thoroughly (at least six to eight seconds). Remove
all acid and demineralized by-products. Do not rub the tooth surface during rinsing or
drying.
5. Before drying, check the air syringe for total dryness by blowing it against a
mouth mirror. A warm-air blow dryer can be used.
 6. Do not try in the tray before bonding (because of the surface conditioner applied
to the cured adhesive at the laboratory).
7. At least 10, but not more than 30, minutes before bonding, paint a thin coat of the
"bracket side" adhesive component with a disposable brush onto the cured adhesive
material of each bracket base in the bonding tray. Do not allow puddling. This step can be
done before pumicing and etching.
8. After the "bracket side" adhesive has been on for at least 10 minutes, paint a thin
coat of the "tooth side" component onto each etched tooth.

Tray Seating

1. Try to find the occlusal rest first while holding the lingual of the tray away from
the tooth. This avoids wiping off the "bracket side" adhesive before seating.
2. Once the tray is fully seated, apply firm, even pressure with two or three fingers
perpendicular to the etched surfaces.
3. Do not vary the pressure while holding the tray in place for two minutes
(obviously, do not change hands or persons holding the tray). Any tooth movement may
create a gap greater than the unfilled resin can accommodate, and bond failures can then
occur.
4. Release, but do not remove, the first quadrant. Move to the next quadrant and
proceed as before.
5. After the second quadrant has been held for two minutes, the first quadrant can
be carefully removed and inspected. Bonds must mature for a total of four minutes.
6. Proceed to the lower arch, paying particular attention to tongue position and
control.

Rebonding

1. If a bond fails but isolation is maintained, section the tray around the failed
bracket. Reapply "bracket side" adhesive; no waiting time is necessary. Reapply "tooth
side" adhesive and bond.
2. If isolation is not maintained, clean the bracket base with acetone or alcohol.
Section the tray around the area to be rebonded and replace the original bracket in the
tray. Reapply "bracket side" adhesive to the bracket base and wait at least 10 minutes.
Pumice, etch, rinse, and dry the tooth to be bonded. Reapply "tooth side" adhesive and
bond.
3. If a bond fails after the initial visit, the bracket must be rebonded with an
adhesive such as Endur, Concise, or System 1 + . If the original indirect tray was saved,
the bracket can be bonded indirectly; if not, it must be bonded directly. In either case,
lightly grind the bracket's resin base and clean the surface with acetone or alcohol before
the bonding procedure.

This bonding procedure requires close contact between the tooth and the
customized bracket base, so accurate models and alginate impressions are obviously
essential. Any modifications to restorations or enamel must be done before taking
impressions, and any separation for banding or extraction must be done after bonding.
 Key 4
Vertical and Transverse Control of Buccal Segments
Initial clinical reports of expansion with the lingual appliance were probably due to
iatrogenic and other extrinsic factors. Insufficient constriction of the archwires in the
anterior segments, particularly during initial leveling and alignment, certainly contributes
to anterior expansion. Placing the 1st order cuspid-bicuspid offset too far to the distal can
also lead to anterior expansion.
However, most undesirable expansion has occurred in the buccal segments.
Although the interbracket distance in the anteriors is less with lingual than with labial
appliances, the interbracket distance in the bicuspids is significantly greater. A resilient
archwire needed for anterior bracket engagement may be too flexible for the buccal
segments. Combined with posterior disclusion and the removal of the limiting
intercuspation, this can allow the bicuspids to flare buccally. Such an effect would be
compounded if the 1st order cuspid offset were insufficient.
Vertical and transverse control of the buccal segments can be lost during space
closure and anterior retraction. Low load/deflection archwires, required for the minimal
interbracket distance of the anteriors, were in retrospect poor choices for space closure.
The lower load/deflection archwires used with sliding mechanics and Class I elastics can
permit both vertical and transverse bowing (Fig. 7). A compensating lingual "bow-in"
placed in the archwire can correct this problem.
Molar rotation, lateral displacement of teeth adjacent to extraction sites, posterior
interferences, and crossbites can also result from loss of transverse control. Adverse
vertical effects can include loss of anterior torque, tipping of teeth toward extraction sites,
and further extrusion of incisors and molars with a resulting increase in bite opening. Of
course, most of these problems resulted from violating basic principles of maintaining
moment-to-force ratios and archwire load/deflection rates appropriate to the stage of
treatment.
We strongly recommend that second molars be bonded or banded and incorporated
into a continuous archwire. An exception would be an anterior open bite case, where
aligning the second molars could worsen the open bite. When second molars are
incorporated into the archwire, a twin or roll-cap bracket (Fig. 8) should be used on first
molars to facilitate archwire placement.
Transpalatal arches, heavy vestibular arches through buccal headgear tubes, and
"crossover" techniques (lingual to buccal appliances) have all been attempted to control
the transverse dimension. Still, the easiest and most effective method is a continuous
archwire from second molar to second molar. Including second molars has other benefits:
maintenance of proper arch form, reduction of posterior interferences from dental arch
bowing, and anchorage control during retraction of anterior teeth.
The "crossover" technique should be avoided except in very specific instances.
When the lingual appliance was first introduced, most clinicians felt the anterior teeth
should be bonded lingually and the posterior teeth labially. However, it became evident
that arch form was difficult to maintain and that expansion of bicuspids occurred with
this technique (Fig. 9).
Lingual bonding or banding of all teeth, including second molars, eliminates these
problems. Additional attachments on the buccal surfaces can be beneficial in special
cases, such as: closing space after extraction of second bicuspids or first molars (Fig. 10);
opening space in the maxillary or mandibular second bicuspid and first molar areas;
uprighting tipped molars; placing labial auxiliary appliances like the Herbst.