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3. Patient Selection and Diagnostic Considerations:

Most malocclusions that can be treated by conventional labial techniques can also
be treated with lingual orthodontic techniques; however, not all patients can be treated with
lingual orthodontics, particularly in patients with expected low discomfort tolerance. The
latest advances in bracket design, new metal alloys for arch wires and new mechanics have
not only simplified the technical aspect of lingual orthodontics but have also contributed to a
marked reduction in patient discomfort. The majority of malocclusions can be treated with
lingual orthodontics, but certain cases are more amenable than others.66, 67.

Ideal cases:
1.
2.
3.
4.
5.

Low angle deep bite cases with brachyfacail or mesofacial pattern

Class II upper bicuspid extraction cases
Class I minor crowding and midline diastema cases.
Long and uniform lingual tooth surfaces without fillings, crowns, bridges.
Good gingival and periodontal health.

Difficult cases:
1.
2.
3.
4.
5.
6.

Four bicuspid extraction cases

Dolichocephalic pattern (high angle case)
Short, abraded, and irregular lingual tooth surfaces
Presence of multiple crowns, bridges, and large restorations
Patients with a low level of compliance.
Surgical and Posterior cross bite cases

Contraindicated cases:
1.
2.
3.
4.
5.

Very short clinical crown

Severs periodontal health
Severe Temporomandibular disorders
Patients with limited ability to open the mouth(trismus)
Patients with cervical ankylosis or other neck injuries

Diagnostic considerations in lingual orthodontics: 66

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Diagnosis is an important issue for all orthodontic treatment techniques and even
more so in lingual orthodontics. Essentially it involves establishing an ideal goal and then
determining a method of achieving the goal. As we are dealing primarily with the nongrowing adult patient, additional diagnostic input may be required from the periodontist,
restorative dentist and orthognathic surgeon as well as some additional psychological acumen
on the part of the orthodontist.

Dental considerations:
Lingual crown height:
1. Lingual crown heights are usually 30% shorter than their labial surfaces, The most
suitable teeth for lingual orthodontics are those with long and smooth surfaces with at
least 7mm of lingual crown height of incisors and incisors with lingual surfaces
shorter than 7 mm should be reconstructed.
2. Mandibular bicuspids with short lingual surfaces may be modified by provisional
reconstruction of a lingual cusp to facilitate bracket placement.
3. In exceptional cases, molars with very short lingual surfaces may be bonded on the
buccal aspect (Takemoto technique)
4. The presence of prominent cingulae, marked marginal ridges, or prominent cusps of
Carabelli are unfavorable, if possible they should be reduced or recontoured.
5. In certain malocclusions some teeth may show excessive linguoversion (negative
torque). This problem can be solved by an initial stage of selective expansion to
facilitate lingual bonding; if indicated, these teeth may be allowed to relapse or moved
back to their original position.
6. The new STb brackets (Ormco Corp) are reasonably small and can be accommodated
on shorter teeth now a day.
Periodontal and gingival considerations:
Before starting active orthodontic treatment, the patient should have a healthy
periodontium and should be able to maintain a high level of oral hygiene. It may be necessary
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to refer the patient to a periodontist to achieve and maintain the best possible periodontal
status. When establishing a treatment plan the clinician should be mindful of the tooth
movements that will occur and their effect on the periodontal and gingival tissues with
particular reference to intrusion, extrusion and space closure.
1. Gingival recession is generally more frequent on the labial tooth surface than on
lingual tooth surface and consequently the lingual technique is often indicated in
patients with a predisposition to gingival recession on labial surface. So with lingual
brackets, the risk of gingival inflammation is transferred to the lingual aspect, where
bone resorption and gingival recession are generally less frequent.
2. Lingual brackets are bonded appreciably closer to the gingival crest than their labial
bracket counterparts. While the natural cleansing action of the tongue seems to
maintain the lingual appliance with less plaque relative to the labial appliance. But
once brackets are placed on the lingual surfaces, the risk of possible gingival
inflammation may increase due to difficulty with oral hygiene maintenance, proximity
of the brackets to the gingival margin, and failure to remove the flash paste
3. Gingival inflammation and bunching up of the soft tissues is also observed during
closure of a diastema or extraction space.
Gingival irritation can be minimized by taking the following precautions:
1. Bend the lingual bracket hooks when positioning them on the plaster cast, to avoid
gingival impingement and reduce tongue irritation. New brackets, such as the Scuzzo
Takemoto bracket have no hooks, which in turn reduce possible pressure on the
gingival tissues and facilitate good oral hygiene.
2. Teach the patient correct oral hygiene techniques and provide the patient with the
necessary elements for good oral hygiene, such as adequate toothbrushes (inter
proximal toothbrushes), floss and mouthwash.
3. Carry out prophylaxis, especially at each archwire change.
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4. During space closure, carefully maintain and control the effect of tooth movement on
the gingival tissues to minimize any possible inflammation.
Restorative considerations:
1. The likelihood of encountering more extensive restorative and prosthetic work is
naturally increased in the adult patient. Many of the adult cases presenting for lingual
orthodontics have mutilated malocclusions, and treatment planning for these cases,
particularly when using the lingual technique, requires special consideration.
2. The presence of crowns, bridges, and large restorations impact negatively on
achieving good adhesion and these needs to be treated with special bonding
techniques for plastic, metallic, or porcelain surfaces.
3. Bridges may be sectioned, taking into account the dental movements that are planned
and the anchorage implications
4. Fractured or microdontic teeth should be provisionally reconstructed before starting
the treatment, or immediately after gaining the necessary space, and substituted by
definitive crowns at the end of the treatment.
5. It may be necessary to consider the replacement of existing prostheses to achieve a
satisfactory post orthodontic occlusion and center line correction.
6. In cases where there is a loss of several teeth, extreme tipping, and multiple or
complex bridgework, the lingual appliance may be contraindicated.
7. Dental restorative replacements should form part of the initial treatment plan and the
patient should be appropriately informed.

The primary changes induced by the lingual appliance can best be categorized as those
dynamic effects on vertical, anteroposterior, and transverse planes.

Vertical considerations:
Use of the lingual brackets with built-in bite planes on the upper incisor and cuspid
brackets will interfere with the occlusion and result in a posterior open bite the extent of
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which will vary with the degree of initial overbite. So, the most immediate and readily
apparent appliance-induced change is the bite opening.The lingual brackets on the maxillary
incisors should be bonded to allow a vertical distance of 2 mm from the incisal edge to the
bracket, which allows the case to finish with a normal overbite and good posterior occlusion.

The posterior disocclusion, resulting from the anterior bite plane opening, permits a
rapid eruption of the molars and bicuspids, management of the posterior open bite created
after bracket placement is dependent on the degree of disocclusion. The greater the posterior
disocclusion, the more time it takes to restore posterior occlusal contact. The molars are
separated by approximately 2 mm, the posteriorocclusion will be reestablished in
approximately 20 to 30 days from bonding.
If at least three lower incisors make contact with upper bracket bite planes and the
posterior disocclusion is not excessive (2mm), the protective proprioceptor mechanism within
the periodontium will prevent any periodontal trauma. However, if only one lower incisor
makes the contact with the upper incisor bracket bite planes (due to incisor irregularity) or
posterior disocclusion exceeds 3 mm the patient will feel some discomfort and there is a
possibility of periodontal trauma.
In such cases it is advisable to build up the occlusal surface of the lower left and
right first molars with a light-cure resin or glass ionomer cement to balance the occlusion
until the alignment of the mandibular incisors is corrected. As the appliance reduces the
overbite, the posterior occlusal buildup should be progressively trimmed.
This bite opening produces both positive and negative effects. With a combination of
molar extrusion and a little incisor intrusion, there will be an increase in the anterior facial
vertical dimension. In the low angle brachyfacial patterns (many deep bite cases have low
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mandibular plane angles), the bite opening is usually desirable and benefit from posterior
extrusion. This bite opening effect is contraindicated in patients who have a predisposition to
increased anterior vertical facial pattern (doliocofacial patterns). In such patients, it is
necessary to carefully control the vertical molar anchorage by considering occlusal buildup
on the second molars, the use of transpalatal bars, space closure as well as minimal use of
Class II, III, or vertical intermaxillary elastics.
At the treatment planning stage, the clinician should be aware that molar extrusion
may contribute to mandibular posterior rotation, which in turn increases the overjet and may
lead to excessive lingual tipping of the maxillary incisors.

Anterioposterior considerations:
Skeletal Class I
Because of the vertical opening and the immediate rotation of the mandible (down
and back), the lingual appliance also induces a Class II tendency. An anterior open bite on a
Class I skeletal base, although one of the most difficult malocclusions to treat in lingual
orthodontics, does not present any problem regarding the initial bonding, irrespective of the
overjet.Deep overbite malocclusion on a Class I skeletal base may present with three options,
depending on the overjet. Deep overbite malocclusion on a Class I skeletal base may present
with three options, depending on the overjet.

Normal overjet:
If after bonding the maxillary brackets, the posterior disocclusion does not exceed 3
mm and there is anterior contact between two or more lower incisors with the same number
of maxillary incisor bracket bite planes, not necessary to add molar occlusal buildup. If
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disocclusion exceeds 3 mm, or there is only one incisor contact, then the occlusal surface of
the mandibular left and right molars should be built up creating three occlusal contacts These
posterior cement onlays or buildups should be progressively reduced as more incisor occlusal
contacts are achieved the anterior deep bite is corrected.

Increased overjet:
In such cases there is no anterior contact, but as the maxillary incisors are retracted
and the overjet reduced, the maxillary brackets can become interposed between the upper and
lower teeth, and contribute to accidental debonding, lower incisor tooth wear, or in some
cases, because of proprioceptive reflexes, guide the mandible into a more posterior position.
This may in turn contribute to the development of temporomandibular joint (TMJ)
symptoms; in such cases there is an indication to build up the occlusal surfaces of the left and
right first mandibular molars and the first bicuspids. Since the occlusion cannot be stabilized
with three contacts (one anterior and two posteriors), as in the case described previously, it
should be stabilized with four duly balanced contacts.

Decreased overjet:
If a patient presents with an anterior cross bite and a deep bite, it is necessary to
create four points of occlusal contact by building up the occlusal surface of the posterior
teeth; this also facilitates the correction of negative overjet.

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Therefore
, Lingual orthodontics is a component of general orthodontics and as such it is subject to all
the principles that govern correct patient selection and diagnosis. However, when compared
with labial techniques, there are considerable differences in the technique and the clinical
demands.

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