Lingual orthodontics: Understanding

the issues is the key to success with

lingual mechanics
D1X XChristopher RioloD2X X, D3X XSamuel A. FinklemanD4X X, and D5X XCali KaltschmidtD6X X

Clear aligners disrupted the orthodontic marketplace almost twenty years

ago.1 The result of this disruption has been a significant increase in the
demand for adult esthetic orthodontic treatment.2,3 Today, we are in the
midst of another disruption in orthodontics; direct to patient orthodontic
care. Direct to patient care is a result of the evolution of digital orthodontics,
which has led to the development of custom orthodontic appliances. Besides
the disruption of the orthodontic marketplace, custom appliances also offer
an opportunity to add value to the care that we offer our patients through
the development of appliances systems that are superior in esthetics and in
certain circumstances offer biomechanical advantages4 In this paper, we will
present issues related successful lingual mechanics, one of the custom appli-
ance opportunities available to us that add value to the care we offer our
patients. We will consider the problem associated with lingual mechanics
and the solutions offered by custom lingual appliance systems. (Semin
Orthod 2018; 24:271–285) © 2018 Published by Elsevier Inc.

Introduction In this paper, we will first present why lingual

L
ingual orthodontics has traditionally been
considered difficult for practitioners and
patients, alike.5 7 This is a result of experience
gained using stock lingual systems, without using
a treatment setup to accurately “build in” or “cus-
tomize” the system of brackets and wires. An
orthodontist, who bonds stock brackets to the lin-
gual surface of teeth to conventionally treat a
patient, will quickly acquire an appreciation for
the issues associated with lingual orthodontics. A
“stock” lingual appliance is not practical for the
correction of any, but the most basic orthodontic
problems. The key to success with lingual ortho-
dontics is to understand why lingual mechanics
are difficult and how these challenges can be
overcome with modern custom appliance
systems.8,9
University of Washington, School of Dentistry, Department of
Orthodontics, Seattle, WA, USA; Private Practice in Seattle, WA,
USA.
Corresponding author. E-mail: criolo@umich.edu
© 2018 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2018.08.001
orthodontics is challenging. Then, we will discuss
how modern, custom lingual systems are
designed to overcome these difficulties. Modern,
lingual appliance systems are an example of how
orthodontics is changing today.
Why is lingual orthodontics difficult?
The reasons why lingual orthodontics is difficult
can be broadly organized into four categories: 1)
Biomechanical issues; 2) Bracket design
choices/constraints; 3) Lingual anatomy and 4)
Logistical issues. As I mentioned above, the bio-
mechanical difficulties associated with lingual
mechanics arise from either anatomical issues or
constraints imposed by bracket design choices;
all these choices involve tradeoffs. Understand-
ing these choices and their consequences is the
key to understanding the strengths and weak-
nesses of the various lingual systems you have
chosen and, thereby, being on the “road of evi-
dence based clinical experience” to your destina-
tion “clinical expertise” with lingual mechanics.
We will categorize the biomechanical issues
that are imposed by the lingual anatomy of the
teeth into five categories: 1st order problems,

Seminars in Orthodontics, Vol 24, No 3, 2018: pp 271 285 271

272 Riolo et al

2nd order problems, 3rd order problems, prob- order problems. If you consider the anatomy of
lems involving the point of force application vs. the buccal surfaces of the teeth, there are similar-
the center of resistance, and problems related to ities from tooth-to-tooth (see Fig. 1); all the teeth
inter-bracket distance. Let us begin with 1st have convex surfaces. Thus, if we apply a zero Rx

Figure 1. Illustrates the similarity of the buccal anatomy of teeth. The differences in the buccal-lingual dimension
of teeth requires a buccal lingual “offset” to align the buccal surfaces of the teeth.
 Lingual orthodontics: Understanding the issues 273

Figure 2. Demonstrates the alignment of the dental arches possible by using stock brackets on the buccal surface
of the teeth with a natural arch formed stock wire. This is not possible using stock bracket on the lingual surface of
the teeth without a buccal-lingual “offset” to align the buccal surfaces of the teeth.

Figure 3. Shows the three common lingual arch wire configurations: Completely customized with a unique bend
between each tooth, the Fujita “mushroom archform, and a straight wire. Each of these arch wire configurations
has biomechanical implications.

bracket, in a reasonable position, to the buccal
surface of teeth and insert a generic arch formed
wire, the teeth will generally align (see Fig. 2).
This is not the case for the lingual appliances.
The lingual surfaces of the teeth are concave,
convex, and frequently both concave and con-
vex. Furthermore, the teeth are highly variable
in terms of their buccal lingual dimension. As
we are trying to align the buccal surfaces of these
teeth not the lingual surfaces, an “offset” (see
Fig. 1) is needed when working from the lingual.
This buccal offset can be place in the bracket,
the wire, or both.
Dr. Fujita published the first description of an
attempt to compensate for this 1st order discrep-
ancy using “straight wire mechanics”.13 Small
compensations were placed in the base of the
bracket with composite, allowing the use of a
mushroom-shaped wire on the lingual. This
mushroom-shaped arch form is still available
today from wire vendors. Other systems, such as
the “lingual liberty” system, use similar composite
bases to achieve a “straight wire” lingual appli-
ance (see Fig. 3).
The required buccal-lingual offsets are
affected by the choice of the wire plane. For
example, when the wire plane is placed more
cervical, the required “canine offset” can fre-
quently be minimized. The choice of the wire
plane is also dictated by the occlusion and the
amount of crown available due to crown anat-
omy, altered passive eruption, and/or hyper-
plastic gingiva. In general, bracket placement
that minimizes buccal-lingual compensations
also results in a wire plane in which the amount
of occlusal interferences with the brackets is min-
imized. When bracket placement choices are
made, considerations of the trade-offs between
274 Riolo et al

Figure 4. Shows a completely customized wire; the heighted areas indicate portions of the wire that are “Unbend-
able” by the wire bending robots. These wires bending limitations effect bracket placement, frequently bracket
position choices must be considered in the context of wire bending limitations when using a lingual system with
completely customized wires.

1st order discrepancies, 2nd order discrepancies,
and occlusal interferences with brackets must be
considered. In addition, robotic wire bending
limitations must be considered (see Fig. 4).
The 2nd and 3rd order lingual problems are
related.14 This relationship is due to differences
in both the anatomy of the lingual and buccal
surfaces of the teeth and the topology of the lin-
gual surfaces of neighboring teeth (consider
the lingual surface topology of the canines rela-
tive to that of the first premolars, see Fig. 1a).
Following a particular wire plane from tooth-to-
tooth the lingual surfaces may change from con-
cave to convex (see Fig. 1). This variation in lin-
gual topology may cause the slot orientation to
be quite different from one tooth to the next.
These extreme differences in slot orientation
due to individual lingual surface anatomy is
complicated further if you allow the wire plane
to vary in the incisogingival dimension (See
Fig. 5). As displayed in Fig. 5, if the wire plane is
varied by 1 mm with a buccal appliance, you
may experience a difference in slot orientation
of perhaps 5°.
This is well within the amount of slot play nor-
mally present when using a 19 £ 25SS and the
most precise buccal, fixed appliance.15 In other
words, it is extremely rare to notice these differ-
ences in slot orientation when working on the
buccal surface, even when a more incisal ori-
ented wire plane is used versus a more gingivally
oriented wire plane. A common illustration of
this issue on the buccal involves canine torque;
most of us have experienced adverse canine tor-
que due to extreme incisal or gingival bracket
placement when using a buccal fixed appliance.
This is because of the relatively extreme convex-
ity of the buccal surface of the canine, at least
compared to the incisors, and the amount of slot
play that is invariably present in our buccal appli-
ances.15 To understand why adverse anatomical
torque is not usually expressed when using a buc-
cal fixed appliance,16 consider the mathematics
of the slot-wire interface shown in Fig. 6 and the
resulting values shown in Table 1. This equation
is a simplified mathematical representation of
the wire-bracket interface. This simplified equa-
tion assumes ideal wire and bracket slot geome-
try. These assumptions are unrealistic for all
bracket systems.17 21 In Fig. 6, u represents the
engagement angle of the wire with the slot of the
bracket.
As the size and shape of the wire varies, the
engagement angle, u varies. Cash et al. showed
us that bracket geometry varies considerably.17
Only 27% of brackets that they examined had
parallel slot walls, thus brackets with parallel slot
wall are the exception not the norm. Brackets
 Lingual orthodontics: Understanding the issues 275

Figure 5. Shows the difference in bracket slot orientation (torque expression) with a small change position in an
incisogingival direction. On the buccal surface a small change in position may result in up to a 5° change the ori-
entation of the bracket slot while on the lingual this same change in position can result is a slot orientation change
of 20°.

slots are invariably oversized by as much as 24%; geometry and our brackets are among the 27%
the best brackets were 5% oversized. If we do the that have decent slot geometry and 2) the wire
math assuming that 1) our wires have perfect slots of our brackets are only 5% oversized, the

Figure 6. Illustrates the geometry associated “slot play”. The equation shown here describes the relationship
between the engagement angle, u and wire size (a and b) for a given slot size, c.
276 Riolo et al
Table 1. Best case theoretical engagement angle with
5% and 15% oversized slots (Assuming ideal
geometry)
Wire Slot size 5% 10%
16 £ 22 0.018 8° 13°
17 £ 25 0.018 4° 9°
19 £ 25 0.022 10° 16°
engagement angle or amount of slot play is, at
best, 10° (see Table 1). In reality, under the best
of circumstances, the engagement angle is, at
least, 15° due to wire geometry variation.15
Therefore, a 5° change in the orientation of the
bracket slot due to anatomical variation or a
change in the incisal-gingival wire plane is rarely
expressed with buccal appliances. However, con-
sider a 20° change in slot orientation, which is
not uncommon when using a stock lingual fixed
appliance due to either variation in topology of
the lingual surfaces of neighboring teeth or
changes in the vertical position of the wire plane
(see Fig. 7).
The clinical implications of these facts are
clear. A standard prescription can work for our
patients using stock buccal fixed appliances but
trying to use a stock lingual fixed appliance will
invariably results in an unmanageable problem
involving anatomical torque. Once the first
Figure 7. Illustrate the “anatomical torque” problem. Along a fixed wire plane on the lingual, difference in the
lingual surface anatomy from tooth to neighboring tooth result in large differences in slot orientation and there-
fore torque expression when using a stock lingual brackets.
rectangular wire is placed in a stock lingual fixed
appliance system, the adverse anatomic torque
will begin to express. In addition to the adverse
anatomic torque, other complicating factors,
such as decreased interbracket distance, further
increases the difficulty of using stock lingual
brackets, bending the wires by hand, and engag-
ing said wire!
So far, we have considered what I refer to as
“anatomical torque”, but there is another type of
torque problem that needs to be managed when
treating patients with a lingual appliance system.
I will refer to this as the “bio-mechanical torque”
problem (See Fig. 8). Unfortunately, with a stock
lingual system these two types of torque prob-
lems can only be addressed by mutually exclusive
solutions.
With a stock system, the more you “fill” the
bracket slot (minimize the engagement angle),
the more problems you will have with anatomical
torque and the more complicated the wire bend-
ing requirements become. At the same time, due
to the decreased interbracket distance, it is very
difficult to engage these full size rectangular
wires with numerous 1st, 2nd and 3rd order
bends. One may be tempted to think that
smaller, less slot filling wires will make a stock lin-
gual system more manageable from a wire bend-
ing and engaging perspective. This is true and is
exactly why, when a stock lingual system is used
 Lingual orthodontics: Understanding the issues 277

Figure 8. Shows the different force vectors associated with incisor intrusion and retraction using lingual and buc-
cal mechanics. There is a well-documented22,33,24 increased tendency for “torque loss” through lingual tipping
and extrusion when implementing lingual mechanics versus conventional mechanics.

for limited treatment (say alignment relapsed
lower anterior teeth), it is best to stay in round
wire. The use of round wire will facilitate align-
ment of relapsed lower anterior teeth, the wires
are simple to bend and engage, and there is no
chance of expressing adverse anatomical torque.
The problem with this solution, in general, is
there is no torque control. As we are about to
see, excellent torque control is especially impor-
tant in lingual mechanics.
The “biomechanical torque problem” is
related to the point of force application in lin-
gual mechanic compared to the center of resis-
tance of the teeth (see Fig. 8). This relationship
results in an increased tendency for extrusion
and lingual “dumping” when either retracting
anterior teeth in extraction treatments or using
heavy Cl II mechanics with a lingual fixed appli-
ances system. This biomechanical issue is well
documented in the literature; these papers can
be categorized into two types; Mathematical
modeling papers22 and finite element analysis
(computer modeling) papers.23,24 The literature
is replete with papers examining the difference
in biomechanics between lingual and buccal
appliance systems and there is no disagreement
on this issue; when using a lingual fixed appli-
ance system, there is a significantly increased ten-
dency for both extrusion of the anterior teeth
and torque loss during space closure and during
the use of Cl II mechanics.
This means that we must pay special attention to
the expression of torque in these types of treat-
ments. The most obvious means to maintain excel-
lent torque control is the use of full-sized wires that
fill the brackets slots, but as we have seen this will
aggravate the anatomical torque problem! So here
we are with two types of torque issues, one that ide-
ally requires slot filling wires and one that certainly
does not! Early lingual practitioners dealt with this
contradiction when using stock systems, which is
exactly why lingual orthodontics has a reputation
for being difficult. The solution to reconcile these
two torque issues is customization of the lingual
appliance to each individual patient, thereby elimi-
nating the anatomical torque problem (not to
mention, at the same time, deal with the first order
issue presented earlier) and allowing the ortho-
dontist to use a slot filling wire for biomechanical
torque control.
Decreased interbracket distance is a major
issue when working from the lingual surfaces of
278 Riolo et al
the teeth. The difference between buccal and lin-
gual interbracket distance was outlined by
Moran, in 1987.25 Moran measured the lingual
interbracket distance to be 35.4% less than the
buccal interbracket distance in the maxilla and
27.7% less in the mandible. This decreased inter-
bracket distance significantly effects how the
wires behave. Specifically, the decreased inter-
bracket distance results in a 3-fold increase in
the stiffness of the wire for 1st and 2nd order dis-
placements and a 40% increase in the stiffness of
the wire for 3rd order displacements.
The biomechanical difficulties of lingual
mechanics in five categories: 1st order problems,
2nd order problems, 3rd order problems, prob-
lems involving the point of force application vs.
the center of resistance, and problems related to
inter-bracket distance. Let us begin with 1st
order problems. The first three categories of
problems result in the need for additional 1st,
2nd, and 3rd order bends to compensate for the
anatomical issues outlined above. At the same
time, extra torque is required to compensate for
the increased tendency for lingual crown tipping
due to the point of force application vs. center of
resistance issue. On top of these difficulties, the
wires that behave as if they are extra stiff because
of the reduce interbracket distance. All these fac-
tors combined make it almost impossible to use
stock brackets bonded directly to the lingual sur-
faces of the teeth and hand bend wires to treat
patients. The solution is to customize the appli-
ance by building as much correction into the
brackets and wires as possible. This is exactly
what modern lingual appliance systems do so
well. These systems employ custom brackets, cus-
tom composite bases for the stock brackets, and/
or custom robotically bend wires.9 Each system
has its own strengths and weaknesses, which we
must understand.
I will briefly outline some of the logistical
issues but will not consider them in depth in this
paper. Logistical issues include but are not lim-
ited to: training both staff and orthodontist,
scheduling difficulties, cost issues, and patient
management issues. The learning curve for lin-
gual orthodontics can be steep for both ortho-
dontists and staff. Staff training is critical because
for most busy orthodontic practices the ortho-
dontist cannot afford to be randomly tied up for
30 40 min to deal with a lingual appliance emer-
gency. It is critical that there is staff trained to
implement solutions with indirect supervision by
the orthodontist.
Training in lingual mechanic for the ortho-
dontist is a problem. Most residencies do not
have either the resources or the time to compre-
hensively prepare residents in lingual mechanics.
There are four university based post-doctoral lin-
gual orthodontic programs in Europe and one in
North America. All of the European programs
admit qualified orthodontists for training using
with lingual appliances.10 The European pro-
grams are the master’s degree program (MAS)
in lingual orthodontics at the University of Basel,
Switzerland, the program offered by Hanover
Medical School, Lingual Post-Graduate Course,
Paris V. University, Paris, and the Master of Lin-
gual Orthodontics post doc program at the Uni-
versitat de Val
encia, Spain. In North America,
the University of Texas at San Antonio, School of
Dentistry offers an 18-month post doc fellowship
in lingual orthodontics.
Each year, there are several international
meetings each year dedicated to lingual ortho-
dontics.11,12 The European Society of Lingual
Orthodontics (ESLO) and the World Society of
Lingual Orthodontics (WSLO) hold their bien-
nial meetings. In North America, lingual meet-
ings tend to be corporate sponsored (for
example, annual Incognito users meetings and
SureSmile user meetings). These meetings fre-
quently offer hands on sessions for orthodontists
and staff, covering common techniques
employed for the specific lingual system
involved.10
Scheduling can also be difficult for established
practices. Lingual procedures tend to run longer
than buccal those involving traditional, buccal
fixed appliance procedures and broken lingual
appliances most often result in an emergency
appointment due to tissue irritation. Of course,
if you choose to only train your most talented
assistants in lingual orthodontics, then your
emergency lingual appointments will tie up
either you or your most talented assistants. The
solution. . . is to train all your assistants to be at
least minimally competent with your lingual
appliance of choice. That means, all your assis-
tants in your office should be able to do a basic
lingual retie and deal with basic lingual emergen-
cies to get the patient comfortable. Most of the
lingual orthodontic practices, with which I am
familiar, train all their staff in lingual
 Lingual orthodontics: Understanding the issues
orthodontic procedures just like any other com-
mon procedure employed in their office. As in
with all change, this training will take some
effort, but it will pay off in the long run allowing
your practice to thrive.
The cost of providing orthodontic treatment
with a custom, lingual orthodontic system is sig-
nificantly higher than a buccal stock system. The
lab cost of the custom appliance is just the begin-
ning; Unlike a stock buccal fixed appliance sys-
tem, there is a significant amount of work
involved in the setup and planning of treatment
with a custom lingual appliance. Lingual ortho-
dontic appointments tend to be longer than buc-
cal appointment, depending on the lingual
system. Furthermore, you and your team should
be compensated for the skills that you so dili-
gently worked to obtain with lingual systems. Do
not hesitate to charge a premium for your serv-
ices using lingual fixed appliances. Not only do
these patients expect to pay, but they also will
often demand the highest level of customer ser-
vice and they can be difficult patients to manage.
For example, we rarely extract first premolars in
the maxillary arch without a plan to deliver provi-
sional pontics that will be reduced as the space is
closed; lingual patients will demand that these
spaces be managed with pontics. Patients choose
a lingual appliance because of their esthetic con-
cerns and they will demand the highest level of
esthetic treatment. Patients that demand the
highest level of esthetic orthodontic treatment
will consume a disproportionate percentage of
your time and the time of your staff. Do not
resent this! On the contrary, enjoy providing the
best possible clinical care and highest level of ser-
vice using the most esthetically appliances avail-
able. Providing esthetic orthodontic treatment is
one aspect of functioning at the highest level of
our profession.
Implicit and explicit design choices in
lingual orthodontic appliance systems
Custom orthodontics is changing the way ortho-
dontists provide and think about treatment.4
The resurgence of lingual orthodontics using
custom lingual appliances is an example of how
custom appliances are changing the profession.8
The most common custom appliances in ortho-
dontics are clear aligners. However, clear align-
ers such as Invisalign and their storefronts, Smile
279
Direct Club and Candid Co, are disrupting the
orthodontic profession. It is “digital orthodon-
tics” that has made possible mass production of
custom orthodontic appliances. I am going to
define Digital Orthodontics as “the planning and
execution of orthodontic treatment using digital
orthodontic records”. Digital orthodontics only
requires that we are using digital radiography,
photography and intraoral scanning when col-
lecting records on our patients. It is only a matter
of time before 100% of orthodontists are
completely “digital”. Although digital orthodon-
tics can be as simple as taking digital records, it
can be as involved as using these records to digi-
tally “setup” a patient’s treatment, manufactur-
ing a custom appliance, and 3D printing the
final intraoral scans to fabricate Essix type
retainers. I have referenced “custom appliances”
throughout this paper; what are custom applian-
ces and what is custom orthodontics? I am going
to define Custom Orthodontics as “the use of a
pre-programmed, orthodontic appliance to treat
a patient to a precisely predetermined occlusal
outcome”. The preprogrammed orthodontic
appliance referred to in the previous definition
is a “Custom Appliance System”.
All custom appliances are fabricated using a
treatment setup. This is true of clear aligner sys-
tems such as Invisalign and Clear Correct, buccal
systems like SureSmile and Insignia, and lingual
systems like Incognito and Lingual Liberty. The
treatment setup is used to fabricate the custom
appliance, incorporating individualized correc-
tion either in the brackets, wires, or both. In lin-
gual orthodontic system this customization is
used to compensate for issues such as the “ana-
tomical torque” problem. Using a treatment
setup has other benefits for the patient and the
practitioner. The treatment objectives are implic-
itly described by the setup itself. The treatment
setup also serves to describe essential detail of
the planned treatment, such as IPR (amount and
surfaces), expansion, tooth inclinations, torque
requirements, space appropriation issues, and
anchorage requirements. In many instances, the
process of developing the treatment setup allows
the orthodontist to consider the plausibility of
the proposed correction as well as examine treat-
ment alternatives. With interdisciplinary treat-
ment, a treatment setup is an essential tool to
effectively collaborate with the other providers
and communicate with patients.26 Digital
280 Riolo et al
orthodontics has made custom orthodontics pos-
sible and custom orthodontics is driving the para-
digm shift from “Reactive Treatment Planning”
to “Proactive Treatment Planning”. Proactive
treatment planning involves a treatment setup.
This treatment setup has many benefits,
including:
 Implicitly codifying the treatment objectives.
 Communication with patients.
 Communication with other care providers/
Interdisciplinary treatment.
 Facilitating an understanding of the mechan-
ics/ anchorage requirements of the proposed
treatment.
Reactive treatment planning does not involve
a “treatment setup”. It involves a general treat-
ment plan, perhaps specifying extraction vs. non-
extraction, IPR, and Cl II or Cl III mechanics.
Decisions are made step by step throughout
treatment; each decision tends to reduce the
degrees of freedom that the orthodontist has
with respect to the remaining treatment. For
example, if lower incisor proclination occurs as a
result of Cl II mechanics during treatment, the
orthodontist may decide to compromise the
overjet or perform additional IPR. These types of
decisions are made at each appointment, usually
with minimum of consideration. Reactive treat-
ment planning is employed by default and, in
general, it works well when treating children and
adolescents. However, reactive treatment plan-
ning does not tend to produce optimal results
when treating patients with debilitated, severely
worn or highly restored dentitions or the
instance of complex orthodontic treatment, such
as interdisciplinary treatment.
Digital orthodontics has allowed the develop-
ment of custom orthodontics and it is custom
orthodontics that has made lingual orthodontics
possible for the average orthodontist. Digital
orthodontics has driven the resurgence of lin-
gual orthodontics as well as custom, clear aligner
systems.1 It was Invisalign that first disrupted the
orthodontic profession in the early 2000’s by
marketing of their clear aligner system to
patients and general dentist. At that time, ortho-
dontists did not realize that Invisalign was creat-
ing the esthetic, adult orthodontic market.
Through its national and international market-
ing efforts, Invisalign has been driving the
demand for esthetic, adult orthodontic treat-
ment options. These efforts raise awareness of
esthetic orthodontic treatment options and drive
patients desiring these types of treatments into
our orthodontic practices.3 One of the obvious
treatment options for a patient who desires an
esthetic appliance, but is not a candidate for
clear aligner therapy, is treatment with a lingual
appliance system.
It is useful to discuss the various custom lin-
gual systems in context of the choices that are
universal with the systems. These choices remain
as appliances system change; there is no perfect
appliance system for all patients and there never
will be. However, these systems will continue to
improve, and the day is coming in which the
treatment setup will be used to design custom
treatment for every patient. Orthodontists that
ignore lingual orthodontics will be giving up a
powerful tool that differentiates us from the gen-
eralist by adding value to what we offer patients.
In the previous section, we reviewed why lin-
gual orthodontics is difficult. Modern lingual sys-
tems have evolved to deal with these challenges
through “customization”. The reasons why lin-
gual orthodontics therapy is difficult to accom-
plish with stock appliances are invariant, whereas
these custom appliance systems are not. In the
future, lingual systems will change. They will
improve both with respect to the physical tech-
nology, such as the brackets and the wires, but
also with respect to the software that is used to
design these appliances. In the last section of this
paper, we will review the choices that are made
when selecting and designing a custom lingual
appliances system. We will discuss the implication
of using a treatment setup to design these appli-
ances and discuss the how these setup force us to
start planning proactively, rather than reactively
when implementing orthodontic treatment.
In the literature, people have tried to present
indications and contraindications for the use of
lingual orthodontics.27,28 Virtually all patients
can be treated with a custom lingual appliance
system. The limiting factor is the knowledge of
the practitioner regarding the strengths and
weaknesses of the particular system employed,
not the system itself. In other words, excellent
clinical results29 can be obtained with all the
modern custom systems. There are numerus sys-
tems that have been developed around the
world. Some systems are more popular in Europe
 Lingual orthodontics: Understanding the issues 281

Table 2.
Brackets
SureSmile  Stock brackets used. Stock
bracket choices unlimited.
Any bracket can be used on
any tooth. All customization
is placed in the wires.
Incognito  Custom cast base, SL on
in lower anterior for 012 N
and 014N
 Vertical slot in anterior,
Horizontal slot in Posterior,
25 £ 18
Wires
 Unlimited included with
case
 1st, 2nd, 3rd order bends
in Niti, TMA and elgiloy
 Each wire can be
completely customized
 Charged per wire
 1st order bends in Niti
 1st, 2nd and 3rd order
bends in TMA and SS
 Wires can vary in terms of
customizing the wire bends
Software
 Digital indirect bracket placement, Indirect trans-
fer tray printing
 Overlay and sophisticated metric and analysis
available
 Control over individual tooth movement
 Export STL files, No specialized communication
features
 Integration of roots and Alveolar bone from CBCT
data in treatment setups
 Coordinate Buccal, Lingual and Clear Aligners
 TMP Software for digital case submission/
ordering
 Basic overlay and 3D model manipulation
 Dental metrics available with analysis
 Some communication features/ export STL files
 Only setup lingual fixed appliances at this time, no
ability to integrate Clear Aligners or Buccal fixed
appliances

and Asia, such as Win, Alias, eBraces and the Lin-
gual Liberty systems. We compare two of the
more popular systems in North America, Sure-
Smile by Orametrix and Incognito (3 M Unitek)
in Table 2. Each system has its advantages and
disadvantages (see Table 2); when selecting a lin-
gual system, both implicit and explicit design
choices will be made. For example, with Incog-
nito, you are implicitly choosing to use a ribbon
arch wire and vertical slots in the anterior, rather
than the traditional edgewise wire/slot interface
seen most commonly in lingual brackets. There
are implications to this choice; for example, it
may be easier to engage a full-sized wire for bio-
mechanical torque control in a system with ante-
rior vertical slots. However, it is more difficult to
control angulation and place bends by hand in
ribbon arch wires with vertically oriented slots.
There are also explicit choices that must be
made when using these lingual systems. For
example, with Incognito, do you want a hook or
no hook on a particular first or second molar?
Do you want a tube or a bracket on a particular
tooth? Do you want to cover the lingual surface
of the tooth with the custom base or do you want
half occlusal, or even full occlusal, coverage of
the tooth by the custom base? With the Sure-
Smile system, you will need to choose a stock
bracket system; this bracket system may be self-
ligating or not. You can choose combinations of
stock systems on a single case. You may decide to
use a self-ligating bicuspid bracket on the second
molar due to the lingual anatomy of a particular
tooth. Again, there are consequences to these
explicit choices. A self-ligation bracket may have
a larger mesio-distal dimension and, thereby,
reduce the interbracket distance. While the non-
self ligating bracket may be problematic for an
office where the staff has limited experience with
lingual ligation techniques.
All major, fixed lingual systems have custom
features in one or more of three essential compo-
nents of the system: 1) Brackets, 2) Wires and 3)
Software. This variation makes each system
unique with respected to one another. In Table 1,
we compare two popular North American sys-
tems with respect to brackets, wire, and software.
Brackets
There are significant differences between the
brackets used by SureSmile and Incognito.
282
SureSmile employs stock brackets. There are a
myriad of stock lingual brackets in their library
from which to choose, including multiple
examples of both self-ligating and conventional
ligating brackets. If, by chance, your brackets
or prescription is not currently available in
their library, it can be added. Almost any stock
lingual bracket that you choose to employ with
SureSmile will be manufactured using metal
injection molding (MIM). SureSmile has con-
centrated its innovation into their wires and
software; currently, their technology in these
areas is unsurpassed. SureSmile puts 100% of
the customization into the wires. Therefore,
each bracket will have a small compensating
bend to the mesial and distal of the bracket.
While custom brackets allow the use of straight
wire mechanics; they rarely result in treatment
that does not require some compensations in
the wire. This is especially true in the correc-
tion of gingival balance issue (see Fig. 9a).
Figure 9. A shows an altered gingival balance due to extrusion of the maxillary anterior teeth. Fig 9b is a image of
a corrected gingival balance.
Riolo et al
A unique strength of the SureSmile system is
the fact that 1st, 2nd, and 3rd order bends can
be placed in NiTi wires, in addition to stainless
steel, TMA, and elgaloy. The software allows the
orthodontist to easily make changes to the wires
and the overall plan. This may be the ideal sys-
tem when finishing details cannot easily be esti-
mated before treatment is initiated. One of the
disadvantages of the SureSmile system is the fact
that you are forced to employ stock brackets. It
can be difficult or impossible to bond to non-
enamel surfaces with stock orthodontic brackets.
Therefore, a patient with a heavily restored or
debilitated dentition may not be an ideal candi-
date for this system.
Alternatively, the Incognito system employs
custom brackets with custom bracket bases. This
allows bonding to virtually any surface including
gold, amalgam, non-precious metal, composite,
ceramic, as well as a combination of materials.
Properly designed brackets minimize the
 Lingual orthodontics: Understanding the issues
frequency of debonded brackets on even the
most difficult surfaces. The custom bases can be
extended to maximize surface area on the lin-
gual and occlusal surfaces. The bases can even
extend to the buccal surfaces of the posterior
teeth. While all lingual appliance systems employ
a 018 slot size, the brackets of the Incognito sys-
tem are different than most lingual systems with
respect the their slot orientation. Incognito uses
a ribbon arch wire and vertically oriented slots in
the anterior and horizontal slots in the posterior.
There are similar systems to Incognito, such as
eBrace and Winn, that employ an anterior verti-
cal slot. The lower anterior Incognito brackets
do have a quasi-self-ligating feature that allows
012NiTi and 014NiTi wires to be inserted behind
the bracket wings of the six lower anterior teeth.
Self-ligating brackets are a huge advantage for
busy practices without staff trained in the various
ligation techniques employed with horizontal
and vertical slot lingual bracket systems.30 Most
self ligating lingual brackets are made using
Metal Injection Molding, MIM and we have dis-
cussed the limitation of these brackets with
respect to the accuracy of the slot and its effect
on the engagement angle of the wire.17,19,21
Therefore, if extra biomechanical torque is
required, it must be added by hand. The Incog-
nito brackets are not MIM’ed. Instead, Incognito
3D prints the patterns, casts the brackets using a
lost material technique, then finishes the slot of
the anterior brackets using an Electronic Dis-
charge Machining (EDM). These anterior brack-
ets tend to have tight tolerances (low
engagement angles) at the bracket/wire inter-
face. In theory, this should translate into more
predictable torque expression15 and, in turn, less
need to place post hoc torque into the maxillary
stainless steel wires during space closure and
when using heavy Cl II mechanics.
Wires
The SureSmile system does 100% of the custom
compensations in the wires, using stock lingual
brackets. Currently, there is only company that
has the ability to place 1st, 2nd and 3rd order
bends in NiTi wires. The ability to place 3rd
order bends in NiTi wire allows SureSmile to
compensate for the anatomical torque problem,
facilitating the transition from round to rectan-
gular NiTi wires using stock lingual brackets. The
283
SureSmile wire robots can also place all three
orders of bends in stainless steel, TMA, and elga-
loy wires. Alternatively, Incognito compensates
for anatomical torque discrepancies using their
custom brackets. Other approaches are
employed by other systems. With Lingual Liberty,
the anatomical torque (see Fig. 6) issue is
addressed through a custom composite “pad”
between a stock lingual bracket and the tooth
surface. In fact, Lingual Liberty also uses this cus-
tom composite pad to make first order compen-
sations, which allows the use of a “universal” arch
wire. This “straight wire” technique allows the
orthodontist to operate in a familiar way in unfa-
miliar territory, the lingual surfaces of the teeth.
On the other hand, Incognito employs a ribbon
arch wire. It can be very difficult to place post
hoc torque in the 16 £ 24SS ribbon arch wire
due to existing robotically bend compensations
in the wires in addition to the tight fit between
the anterior custom bracket slots and the full size
ribbon arch wires. Due to these difficulties, when
using a 16 £ 24SS ribbon arch wire to retract
anterior teeth, it is recommended to request that
extra torque is placed robotically. Incognito
wires are charged ala cart and not all wires have
the same bends. The initial round and rectangu-
lar NiTi wire will have 1st order bends, while 2nd
and 3rd order bends are not placed until stain-
less steel and TMA wires. The choice of a particu-
lar lingual system for a patient should also
depend on the treatment objective and the
required tooth movements. For example, if a
treatment objective is to correct a  4 mm mid-
line discrepancy in the upper arch, a system that
employs a horizontal slot rather than a vertical
slot in the anterior may be advantageous. Let’s
again consider the smile in Fig. 9a, we have a sig-
nificant disturbance in the gingival balance due
to extrusion of the upper anterior teeth and
probably also altered passive eruption. It is not
possible to know exactly how much intrusion will
be required, until after crown lengthening. Addi-
tionally, the apical migration of the gingiva is not
1:1 with intrusion of the crown; intrusion of
1 mm may result in 0.8 mm of gingival migration.
Therefore, it is not possible to fabricate a custom
appliance system that will achieve an optimal
treatment result without modification of the orig-
inal treatment setup. In situations like this, a lin-
gual appliance system that allows flexibility
should be selected to be able to make the
284 Riolo et al
required modifications easily and inexpensively.
For a treatment involving correction of gingival
imbalance, a system with a horizontal slot, the
ability to modify wires either digitally or by hand,
and excellent software to interface between the
setup and the lab is desired.
Software
The third component of a custom lingual appli-
ance system is the software. At first, the impor-
tance of the software associated with a custom
appliance system is easy to overlook. However,
the software is as important as any of the other
components of the system. As the sophistication
of these programs improve, we will be able to
integrate buccal fixed appliances and clear align-
ers with lingual fixed appliance into a custom sys-
tem to optimize orthodontic treatment for our
patients. Elemetrix, the software system
employed by SureSmile, can be used to integrate
these three treatment modalities, today. 3 M
claims that their Clarity Aligners will be inte-
grated with their fixed lingual system, Incognito,
very soon. Software is used to communicate with
the lab to produce the treatment setup, which, in
turn, is used to fabricate the custom appliance
system. The communication with the lab is criti-
cal. It is not possible to create a custom appliance
without excellent communication and control
over the treatment setup. The treatment setup
can also be used as a platform to communicate
with other dental professional for interdisciplin-
ary case. Finally, the treatment setup can be used
to communicate with patient regarding the treat-
ment objectives. The quality of the software expe-
rience varies tremendously from one appliance
system to another.
The treatment setup can also be used to simu-
late various treatment options. For example, vari-
ous extraction patterns can be explored, as
opposed to interproximal reduction (IPR), or in
conjunction with IPR. When treating adult
patients with varying degrees of tooth attrition
and complex restorative histories, determining
the best occlusal outcome without a treatment
setup is, at best, a guess. Interdisciplinary treat-
ment requires collaboration between two or
more dental professionals and a treatment setup
is a necessary component of interdisciplinary
treatment planning.26 These treatment setups
not only serve to clarify the details of the
orthodontic treatment, but are also used to plan
the restorative phase of treatment. In this case,
the software performs a crucial function in com-
munication with both other dental professionals
as well as the patient. Each of the lingual appli-
ance systems employs software to develop and
present the treatment setup. SureSmile uses Ele-
mentrix, whereas Incognito uses TMP.
Conclusions
While all lingual systems have strengths and
weaknesses, the choice of a particular system is
secondary to having a proper understanding of
the system used; as well as, the proper armenta-
rium and clinical experience to implement the
treatment plan. In this paper, we have outlined
the basic knowledge required to evaluate and
select a lingual system that best fits the patient,
orthodontist and his or her team. With the cur-
rent disruption in the orthodontic marketplace
it is important that orthodontic specialists
employ the benefits that digital orthodontics and
custom orthodontic appliance system offer in
order provide the best possible care in the com-
petitive environment in which most of us prac-
tice today. Lingual mechanics provides added
value for our patients that truly differentiates the
orthodontic specialist from the generalist as well
as direct to patient modalities.
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