Lingual orthodontics (LO) versus buccal orthodontics (BO): biomechnical and clinical aspects

S. Goren, R. Zoizner, S. Geron, R. Romano Orthodontic Department, Israel Defense Force, Tel-Hashomer, Israel

Lingual orthodontic appliances represent an excellent alternative to labial appliances for esthetically conscious patients. The mechanotherapy involved is altered in some respects, because of the difference in the position of the brackets [1]. The purpose of this article is to describe the biomechanical aspects that one must consider when the traditional labial appliances are replaced by lingual appliances.

INTRODUCTION In every orthodontic force system when the line of force does not pass through the center of resistance (Cr), a moment is created [2]. The magnitude and the direction of that moment are dependent on the direction of the applied force, its magnitude, and its perpendicular distance from the Cr [3] (Fig. 1). Many analytic and experimental studies have been carried out in order to determine the location of the Cr. According to most of these studies, the Cr in a single root tooth is located at 0.240.55 of the root length measured from the alveolar crest, or slightly apically to it in teeth with more than a single root [310]. The location of the Cr depends on many factors, such as the root shape and length [9], the alveolar bone height [11], and the direction and the magnitude of the applied force. The materials and methods were different in all the above-mentioned studies, and therefore we found it difcult to compare their ndings. The location of the Cr in a tooth is not related to the technique used to straighten it. Nevertheless, the relationships between the Cr location and the bracket placement (buccal or lingual) directly inuence the

magnitude and the direction of the moments created by the applied forces (Fig. 2). BONDING As in buccal orthodontics (BO), accurate bracket placement in lingual orthodontics (LO) is of the utmost importance. The bonding process in LO is much more complicated, and is usually done using the indirect technique, for the following reasons: 1. The lingual aspects of the teeth show great variability in tooth size and morphology. In addition, the cingulum, the marginal ridge

Figure 1. The magnitude and the direction of the moment are dependent on the direction of the applied force, its magnitude, and its perpendicular distance from the Cr.

(a)
D1=Distance of a buccal bracket from the Cr in the sagittal plane

(b)
D3=Distance of a buccal bracket from the Cr in the vertical plane D4=Distance of a lingual bracket from the Cr in the vertical plane

Cr

D2=Distance of a lingual bracket from the Cr in the sagittal plane

Cr

D4

D3

D1 D2

Figure 2. (a) The sagittal distance between the buccal bracket (D1) or the lingual bracket (D2) and the Cr determine the magnitude of the moments created when force is applied. (b) The vertical distance between the buccal bracket (D3) or the lingual bracket (D4) and the Cr determine the magnitude of the moments created when force is applied.

anatomy and the steep curvature of the lingual surface make direct assessment of the correct position of the brackets impossible [12] (Fig. 3a,b). 2. Since the correct and esthetic alignment of the buccal surface of the teeth is our treatment goal, brackets should be placed at variable distances from the incisal edge, due to the different angulations on the lingual aspects [13]. 3. A smaller interbracket distance (IBD) in LO, especially in the anterior region, makes the use of compensatory bends very difcult [1, 1315]. Since indirect bonding is more accurate, less wire bending is required (Fig. 3c). THE WIRE STIFFNESS When the brackets are placed on the lingual surface instead of on the labial surfaces, the IBD in the anterior region of the arch is decreased signicantly. The overall ratio of anterior lingual distance to labial interbracket distance was calculated to be 1:1.47. Mandibular ratios are signicantly smaller than maxillary ratios [1]. The load/deection ratio
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is determined by the modulus of elasticity of the wire, the wire cross-sectional area, and the wire length. The smaller IBD makes the same wire stiffer in LO than in BO. According to Moran [1], the decreased IBD associated with LO makes a wire approximately three times stiffer for rst- and second-order bends than when used with BO, and approximately 1.5 times stiffer for third-order bends. MOVEMENTS IN THE VERTICAL DIRECTION: INTRUSIONEXTRUSION OF A SINGLE ROOT TOOTH When the intrusiveextrusive line of force passes buccally or lingually to the Cr, a moment is created. This moment direction can be clockwise (CW) or counter-clockwise (CCW), depending on the direction of the force vector relative to the Cr. The tooths crown can therefore move lingually or buccally. The magnitude of the moment in LO is much smaller than that in BO, due to the smaller distance between the lingual bracket and the Cr (Fig. 4). One must estimate, for each treated case, if the line of force is passing labially, lingually or right through the
Journal of Lingual Orthodontics, Volume 3 Number 1

(a)

(b)

(c)

Figure 3. (a) The lingual aspects of the teeth show great variability in tooth size and morphology. In addition, the cingulum, the marginal ridge anatomy and the steep curvature of the lingual surface make direct assessment of the correct position of the brackets impossible. (b) In LO, brackets should be placed at variable distances to avoid the necessity for rst- and second-order bends. (c) A smaller interbracket distance (IBD) in LO, especially in the anterior region, makes the use of compensatory bends very difcult.

Cr, and evaluate whether the moments that will be created by the intrusionextrusion mechanics are desired or should be compensated by changing the bracket torque, angulation and inclination at the laboratory stage, or by clinical modications. According to Geron et al [16], applying an intrusive force in BO on a tooth that is initially positioned between retroclination of 20 and proclination of 45 will create a lingual root movement (proclination). In LO, labial root moment (retroclination) will occur when the tooth is retroclined more than 20. The composite pad on the lingual bracket might change the distance between the point of force applicaS. Goren et al

tion and the Cr and can therefore minimize the moment magnitude and even reverse the moment direction (Fig. 5). MOVEMENTS IN THE SAGITTAL DIRECTION In both systems, LO and BO, the direction of force applied passes relatively far from the Cr, and therefore a moment is created. The moment tends to move the crown in the force direction and the apex in the opposite direction. In this sense, there is no difference between LO and BO. The sagittal force also creates a moment in the buccallingual
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Lingual orthodontics (LO) versus buccal orthodontics (BO)

DB DL Moment Direction

Intrusion force Force Direction Moment Direction

Composite Pad

Force DirectionNo Moment

Figure 4. The magnitude of the moment in LO is much smaller than that in BO, due to the smaller distance between the lingual bracket and the Cr (DL) compared to the distance between the buccal bracket and the Cr (DB).

Figure 5. The composite pad on the lingual bracket might change the distance between the point of force application and the Cr, and therefore minimize the moment magnitude and even reverse the moment direction.

direction, which tends to rotate the tooth. In BO, the vector of force passes buccal to the Cr, and in the LO, it passes lingual to it. Therefore, the directions of these rotations are opposite. For example, retracting a premolar in BO will tend to rotate the tooth in a distallingual direction. In LO, the same retraction will create a mesiallingual rotation of the tooth (Fig. 6). The clinical implication is that the over-corrections applied to the teeth in the laboratory or clinical stages are opposite in LO and BO. MOVEMENTS IN THE TRANSVERSAL DIRECTION In both systems, the vectors of force are passing similarly relative to the Cr, and hence produce similar moments: the moment tends to create a movement of the crown in the force direction and a root movement in the opposite direction. Clinically, it seems that expansion is easier in LO than in BO, due to the elimination of posterior occlusion caused by the anterior bite plane and the equilibrium change in LO between the tongue and the lips.
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FRICTION Many studies have been conducted to evaluate the principal factors that may inuence frictional resistance. The most important factors are bracket and wire materials [1719], type and force of ligation [2022], the relative bracketwire clearance [23], and the archwire size as related to stiffness [24]. The wire and bracket materials in LO are the same as in BO. The type of ligation is different between LO and BO. In LO, the double overtie is commonly used with metal or elastic ligatures in order to hold the wire in the bracket slot. There is a lack of information concerning the normal force created when using this ligation technique. As mentioned before, the smaller IBD makes the same wire stiffer in LO than in BO [1]. According to some researchers [25,26], stiffer wires reduce the binding and thus reduce the resistance to friction. On the other hand, Creekmoore [27] and Articolo and Kusy [28] suggest that stiffer wires will increase resistance to sliding in tipped brackets. One must remember, however, that most of the
Journal of Lingual Orthodontics, Volume 3 Number 1

(a)

(b)

Figure 6. (a) Retracting a premolar in BO will tend to rotate the tooth in a distallingual direction. (b) In LO, the same retraction will create a mesiallingual rotation of the tooth.

sliding procedure is done clinically at the posterior regions, where the difference in IBD between LO and BO is less . CLINICAL IMPLICATIONS
CL II/1 malocclusion

The upper anterior bite-planes in LO create intrusive forces on the upper and lower incisors and simultaneously encourage eruption of the posterior teeth. Because the upper incisors are retroclined, the vector of the anterior intrusive force can pass palatinally to the Cr and hence worsen the retroclination. SUMMARY LO has some advantages and disadvantages relative to BO. Among the advantages is the improved esthetic appearance, and among the disadvantages is the difculty in direct viewing and access. However, most of the unique features of LO can be considered either as advantages or disadvantages, depending on the malocclusion and according to the specic goals of treatment. Teeth move under the force we apply according to biomechanical principles and the biological environment. Bracket position does not change the need to understand basic biomechanical rules. As clinicians, we must analyze in each case the forces we apply and try to predict the tooth movement. REFERENCES
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The classical manifestations of CL II/1 malocclusion are class II molar relationships, increased overjet, upper incisors normally inclined or proclined, and a constricted maxilla in relation to the mandible [29]. When CL II/1 malocclusion is treated with LO, attention must be paid to the contacts between the lower incisors and the biteplanes of the upper incisor brackets. When the upper incisors are proclined, the vector of force could pass labial to the Cr, which would create a moment that will worsen the proclination. The anterior-bite plane, created by the LO brackets, can make the expansion of the upper dentition easier, due to the posterior disarticulation. The vertical opening and the CCW rotation of the mandible (down and back) caused by LO induces a Class II tendency [28]. CL II/2 malocclusion The classical manifestations of CL II/2 malocclusion are Class II molar relationships, upper incisor retroclination, and an anterior deep bite [29].
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Reprint requests: Dr Ra Romano, Orthodontic Department, Israel Defense Force, 34 Habarzel, Tel-Aviv 69710, Israel.

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Lingual orthodontics (LO) versus buccal orthodontics (BO)