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Dr. Varun Grover INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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IntroductionIntroduction
Goals of orthodontic treatment
Desire for esthetics during treatment
Lingual orthodontics
End of treatment
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Search for absolute estheticsSearch for absolute esthetics
Advancement in orthodontics
Pinching of the bands Direct bonding (Miura – 1971) Plastic and ceramic brackets Lingual brackets
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Search for absolute estheticsSearch for absolute esthetics
Bands on all teeth
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Search for absolute estheticsSearch for absolute esthetics
Metallic display
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Search for absolute estheticsSearch for absolute esthetics
Ceramic brackets – relatively esthetic
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Search for absolute estheticsSearch for absolute esthetics
Lingual brackets
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Search for absolute estheticsSearch for absolute esthetics
Good fortune of orthodontist
Reduced costLower arch – judge the progress Reduced demands on the practitioner
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Historic perspectiveHistoric perspective John Farrar – lingual removable arch (1889)
Mershon – LRA with finger springs
Owen Oliver – Labiolingual app
Crozat app
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Historic perspectiveHistoric perspective
Nance button TPA – Robert Goshgarian Lingual arch - Wilson
Note – supplement labial orthodontics
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LO – As a complete systemLO – As a complete system
Vision of 2 key innovators
Craven Kurz – USA
Kinya Fujita – Japan Kanagawa uni.
1970s
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LO – As a complete systemLO – As a complete system
Fujita system -1971 Advantages
Lip injuryLip relation RetentionLittle anchorage loss
Brackets placed close to the functional line for forcesto pass through C res.
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LO – As a complete systemLO – As a complete system
Fujita system -1971 Disadvantages
AJO 1979 – LO with Mushroom shaped archwires
Longer durationSpeech difficultiesInitial discomfortOral hygiene
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LO – As a complete systemLO – As a complete system
Key features – Fujita system Slots facing occlusally
Easy insertion and removal Prevents deformation
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LO – As a complete systemLO – As a complete system
Grooves for insertion of lockpins
Auxilliary grooves
Mesiodistally
Occlusogingivally
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LO – As a complete systemLO – As a complete system
Multiple slots – Less publicized Ant. And Pm bracket – 3 slots
Molar bracket – 5 slots
OcclusalLingualvertical
1 occlusal 2 lingual2 vertical
Tandem wire mechanics
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LO – As a complete systemLO – As a complete system
Do lingual appliances hampers speech???
Sample – 1 patient
Class I crowding All 4s extraction
Pronunciation of vowels Real time third octave analyzer
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LO – As a complete systemLO – As a complete system
A and O – no effect
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LO – As a complete systemLO – As a complete system
I, E, U – disturbed on 1st and 4th day
Normal by 6th day
S, T, R and L – affected Consonants were not
studied
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Craven kurzCraven kurz
Ormco 1976 – introduced lingual app Slots facing palatally Worked as a part of LTF (1990)
Scholz Gorman Kelly AlexanderSmith ArtunGreekmore
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Craven kurzCraven kurz
1976 – 1st generation of lingual brackets
1990 – 7th generation
Larger profileCrude prescription
Low profileRefined prescriptionMx bite plane – heart shaped, smaller hooksInc width of Pm bracketsVariety of molar brackets
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Craven kurzCraven kurz
Slot size – 018 Greatest innovation
Shearing forces
Addition of bite plane
Compressive forces
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Lingual bracketsLingual brackets
Mx anterior brackets
Built in bite planePropping open the biteAdv in deep bite cases
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Lingual bracketsLingual brackets
Mand anterior brackets
Ball hook extends away from the tissueEase in maintaining oral hygiene
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Lingual bracketsLingual brackets
Bicuspid brackets - wider
Better rotational and tip controlMore uniform interbracket widthBall hooks – shortened and flattened
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Lingual bracketsLingual brackets
Molar brackets – variety Twin bracket recommended when both 1st and 2nd molars are
bonded Twin bracket with auxiliary tube
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Lingual bracketsLingual brackets
Hinge cap
Latest Ideal attachment for terminal toothHinge cap tool
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Lingual bracketsLingual brackets
Terminal tube
Used initiallyCrown height is less
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Lingual instrumentsLingual instruments
Lingual utility plier Ligature cutter Curved mosquito hemostat Small distal end cutter Lingual bracket remover Hinge cap opening tool
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Lingual Begg bracketsLingual Begg brackets
Fujita and Craven kurz
Stephen Paige – 1982 Begg appliance suits well to LO
Edgewise slot
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Lingual Begg bracketsLingual Begg brackets
Vertical slot facing occlusally
Use of round arch wires
No built in tip and torque TP – (256 – 500) labial Begg bracket
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Lingual Begg bracketsLingual Begg brackets
Anatomic considerations
Interbracket distance – precise measurement of the arch wires
Difficult to position the bracket
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Lingual Begg bracketsLingual Begg brackets
Low profile lingual Begg bracket
Plastic buttons on labial surfaces – assist lingual app
Difficult to close the open bite
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Lingual Begg bracketsLingual Begg brackets
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Lingual Begg bracketsLingual Begg brackets
Lockpins – softer and thinner (014)
Seated – using a two hand instrument Wire tucker
Weingart plier
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Lingual Begg mechanicsLingual Begg mechanics
Low angle cases – favorable md rotation High angle cases
Smith (1986 )- HPHGCash and Blackwood (1991) – JJJenner (1995) – Post bite plane Convenient surface for mastication Prevents molar extrusion
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Lingual Begg mechanicsLingual Begg mechanics
Lingual archforms – Mushroom shaped Key hole shaped Bicuspid offset Molar offset Anchor bends Distal ends Elastics
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Lingual Begg mechanicsLingual Begg mechanics
Stage 1 archwires No crowding - 016ss
Addition of vertical loops Smaller diameter archwires
Niti or Cu Niti wires Elastics – stiffer wires
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Lingual Begg mechanicsLingual Begg mechanics
Stage II archwires – 018, 020 Stage III archwires – 020 Torquing auxiliaries Uprighting springs
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Lingual Begg mechanicsLingual Begg mechanics
Lingual root torque for upper incisors
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Lingual Begg mechanicsLingual Begg mechanics
Labial root torque of upper lateral incisors
Lingual root torque of the canines
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Lingual Begg mechanicsLingual Begg mechanics
Uprighting springs Stage III – Mesiodistal root movement Braking mechanics – stage II 010 mini springs
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Conceal systemConceal system
Thomas Creekmore (AJODO 1989) Unitek, Monrovia, California Advantages
Facial tooth surfaces are not damagedFacial gingival tissues healthThe position of the teeth can be precisely seenDrape of the lips – not distortedinvisible
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Conceal systemConceal system
An acceptable LOA must include following key elements
Align Apparatus to position the brackets precisely
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Conceal systemConceal system
Accurate indirect bonding system Preformed arches Specifically designed pliers Torquing keys
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Conceal systemConceal system
Slots opens occlusally
The first 1mm of the molar tube opens to the occlusal aspect
Direct guidance for insertion
Easier to insert stiffer archwires Eliminates the need of double over
ties
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Conceal systemConceal system
Design of Pm and molar bracket
Occlusal tie wings projecting mesially and distallyMesial and distal undercuts II base of the slotChanges the direction of ligature pull – 90
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Conceal systemConceal system
Conceal brackets are designed around the Unitwin bracket
Centered slot conceptSingle bracket without tie wings Centre of a 0.045 inch twin bracketMaximum interbracket distance for optimum tip and torqueTwin tie wings – rotational control
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Conceal systemConceal system
Each conceal bracket has 3 different slot widths
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Conceal systemConceal system
Tip control in an occlusally inserting system is analogous to rotational control in labial system
Rotational control – length of the lever arm – 0.100 inch
Slot width – 0.100 inch Excellent control in the tipping plane
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Conceal systemConceal system
The width of the slot for rotation – 0.070 inch
Analogous to tip control in the labial system
Torque control is same for both the systems
Width of the slot for torque – 0.035 inch
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Conceal systemConceal system
Play Maximum arch wire size
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Conceal system – slot machineConceal system – slot machine
Lingual surfaces – irregular Labiolingual thickness Slot machine Holds the lingual bracket by its slot, which is oriented
to the labial surface of each tooth for- Torque, tip, rotation, height and labiolingual thickness Bracket is bonded on the model – gap is filled Customized base
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Patient selectionPatient selection
Adults Missing teeth Complex restorative needs Periodontal problems
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Patient selectionPatient selection Possible speech difficulty – 2 to 4 wks
Absolute need for perfect speech
Tongue irritation
Opening up of the spaces
Oral hygiene considerations
Initial weight loss www.indiandentalacademy.com
Patient selectionPatient selection
Deep bite cases are ideal for LO Short clinical crown height – relative CI Initial practitioners
Non XnDeep biteMild crowdingUpper palatal lower labial appLow anchorage demandsUnilateral Xn cases
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Patient selectionPatient selection
Deep bite Vs
Brachycephalic Euryprosopic Bite plane effect Favorable Md rotation
Open bite
Dolichocephic Leptoprosopic Difficult cases Cross elatics
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Patient selectionPatient selection
Biomechanical differences
For normally inclined or proclined upper incisors, intrusive forces for lingual app are closer to Cres
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Patient selectionPatient selection
For retroclined anteriors
Advancing loops in initial archwires
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Patient selectionPatient selection
Effects of vertical extrusive forces Labial appliance – extrusion
Lingual app – incisors are inclined more than 20 º to the occlusal plane
Labial root torque
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Patient selectionPatient selection
Effects in antero-posterior relation Lingual appliances
Vertical openingMd rotationInduce Class II tendency
Vertical bowing effectwww.indiandentalacademy.com
Patient selectionPatient selection
Contraindications
Short clinical crowns Unresolved periodontal problems Mutilated posterior occlusion High angle cases Severe class II discrepancy with acute TMJ problems
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Patient selectionPatient selection
Effects in transverse dimension
LA – expansive nature coupled by posterior disclusion
Mesiobuccal molar rotation – space closure
Transverse bowing effect
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Bracket placementBracket placement
Indirect bonding Why not direct bonding???
Customized resin beneath the brackets
AccessIrregular lingual surfaceVariation in lingual tooth morphology
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Bracket placementBracket placement
Methods of bonding
TARG – Torque Angulation Reference Guide CLASS – Custom Lingual Appliance Set up Service Fillion LIBS Slot machine Hiro system Ray set system
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Bracket placement - CLASSBracket placement - CLASS
Scott huge Ideal set up is created
Brackets placed
All planes of space considered
Custom bracket baseswww.indiandentalacademy.com
Bracket placement - CLASSBracket placement - CLASS
Brackets transferred to the original cast
Another indirect bonding tray is fabricated
Ideal set up – patients motivation
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Bracket placement - CLASS Bracket placement - CLASS
Steps
Precise impressions Wax bite Articulate the casts Fill the prescription Immobilization of the teeth is a must
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Bracket placement - CLASS Bracket placement - CLASS
Prescription form
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Bracket placement - CLASS Bracket placement - CLASS
Ideal set up
Teeth act as reference
2nd molars and single incisor in each arch
Class I canine and molarEstablish adequate tipTorqueEliminate rotationsTight contacts
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Bracket placement - CLASS Bracket placement - CLASS
Filling the prescription
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Bracket placement - CLASS Bracket placement - CLASS
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Bracket placement - CLASS Bracket placement - CLASS
Transfer trays Sectioning of the trays
Preference – Vinyl
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Bracket placement - CLASS Bracket placement - CLASS
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Bracket placement - CLASSBracket placement - CLASS
OverbiteIdealIncreasedDecreased
OverjetIdealIncreasedDecreased
Lower occlusal planeFlatMaintainDeep
Arch widthMaintainWidenConstrict
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Bracket placement - CLASSBracket placement - CLASS
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Bracket placement - TARGBracket placement - TARG
Dev by Ormco, 1984
Bracket placed with respect to horizontal reference plane
Labial reference gauge to orient the bracket
The orientation allows preprogramming
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Bracket placement - TARGBracket placement - TARG
Advantages Accurate and quantified 2 dimensional system Accurate positioning of bracket without cutting the
tooth and placing it in wax
Disadvantages Labiolingual thickness – not considered
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Bracket placement - BESTBracket placement - BEST
Bonding with Equalized Specific Thickness
Fillion, 1987
Overcomes the disadvantage of TARG A caliper is added
Direct working on the malocclusion cast
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Bracket placement – Bracket placement – Hiro systemHiro system
Modified CLASS techniqueIntroduced by HIROImproved by Takemoto and Scuzzo
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Clinical bondingClinical bonding
Lingual side of the arch
Moisture contaminationCalculus depositionPre bonding scaling
Use of antisailogougesProbanthine – 15 mg 45 min prior to bonding
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Clinical bondingClinical bonding
If it is desirable to bond one arch Mandibular arch Special considerations
Porcelain restorationPresence of aluminium – HF acidComposite bondable surfaceGold crownsLarge amalgam fillings
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Clinical bondingClinical bonding
Bonding materials
2 part sealant – Maxi cure
Filled paste – EXCEL, Reliance orthodontic product
Light cure adhesives
Bracket side – tooth side adhesive
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Clinical bondingClinical bonding
Steps Isolation Etching 10 min before bonding, apply conditioner on exposed
adhesive material on bracket base Mix the bonding material Place the trays
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Thank you
For more details please visit www.indiandentalacademy.com
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