2D Lingual Appliance - Cacciafesta JO 2013

Download as pdf or txt
Download as pdf or txt
You are on page 1of 8

Journal of Orthodontics, Vol.

40, 2013, S60–S67

LINGUAL The 2D lingual appliance system


SUPPLEMENT

Vittorio Cacciafesta
Viale Papiniano, Milano, Italy

The two-dimensional (2D) lingual bracket system represents a valuable treatment option for adult patients seeking a
completely invisible orthodontic appliance. The ease of direct or simplified indirect bonding of 2D lingual brackets in
combination with low friction mechanics makes it possible to achieve a good functional and aesthetic occlusion, even in the
presence of a severe malocclusion. The use of a self-ligating bracket significantly reduces chair-side time for the orthodontist,
and the low-profile bracket design greatly improves patient comfort.
Key words: Lingual orthodontics, lingual brackets, aesthetics, new technologies, Ni–Ti archwires

Introduction lingual orthodontics is no longer a technique for limited


numbers of orthodontists. One of the most dramatic
In the late 1970s, lingual orthodontics started to become changes can be found in the evolution of bonding pro-
a treatment option for adults, and the number of cases cedures. Current bonding procedures are totally different
increased exponentially. However, within a few years, from those of 10 years ago. Lingual brackets can be
the number of lingual orthodontic cases decreased bonded directly, just like labial brackets, or indirectly
greatly, due to the fact that most doctors could not depending on the system used and the severity of the
achieve satisfactory results with a lingual technique. As malocclusion.1
time has passed and problem solving associated with In order to avoid unnecessary costs, the two-dimen-
lingual appliances has improved, lingual orthodontics sional (2D) lingual technique (Forestadent, Pforzheim,
has expanded around the globe, especially in Asian and Germany) has been developed as an inexpensive lingual
European countries.1–3 approach, aiming to bypass many factors complicating
Today, the lingual technique provides a very success- conventional lingual treatment, but still providing
ful approach in the orthodontic treatment of adult favorable results (Table 1).6–10 Clinical bonding of the
patients, although it is considered to be one of the most 2D lingual brackets can be done directly or indirectly,
difficult, as it requires great manual skill and experience, without the need for an expensive and time-consuming
more chair-side time than labial treatments and often laboratory set-up. Moreover, these brackets are
longer treatment times. The reason for this success designed to be as comfortable for the patient as possible.
might be the fact that lingual orthodontics is superior in If they are too high or bulky, lingual brackets can be
aesthetics to all the other treatment options, as it is the uncomfortable and also affect pronunciation, causing
only technique which can be considered completely speech problems for the patient. This clinical report will
‘invisible’.1 present the design, characteristics and clinical applica-
In lingual orthodontics, first- and third-order tooth tions of 2D lingual brackets.
movements are more complicated because of the varia-
bility of lingual tooth anatomy.2 Torque control is also The 2D lingual system
more difficult because of the reduced inter-bracket
distance, and even small variations in bracket height The 2D lingual technique employs a number of com-
can have a considerable effect on applied torque. These ponents (Table 2), but the key feature is a simple self-
factors have led to the development of various indirect ligating lingual bracket that does not have a traditional
bracket-transferring methods, such as TARG (SDS/ rectangular slot in the base; instead, the bracket has
Ormco, Orange, CA, USA) and CLASS (Specialty Appli- two clips on the lingual surface to trap the archwire
ances, Norcross, GA, USA),3,4 or very sophisticated fully (Figure 1). Because they do not have rectangular slots,
individualized systems, such as IncognitoTM.5 Today, only first- and second-order movements are possible.

Address for correspondence: Vittorio Cacciafesta, Viale Papiniano


44, 20123 Milano, Italy.
Email: [email protected]
# 2013 British Orthodontic Society DOI 10.1179/1465312513Z.000000000107
JO September 2013 Lingual Supplement 2D lingual orthodontics S61

Figure 1 Forestadent 2D lingual brackets in the upper and lower arches

Figure 2 Forestadent 2D lingual bracket range: (A) medium twin standard bracket; (B) narrow single bracket; (C) mini-ant bracket; (D)
medium twin with gingival hook; (E) 2D Plus lingual bracket; (F) molar tubes

The clips can be opened with a modified spatula that has should be held against the labial surfaces of the teeth to
been previously customized by thinning the ends with a avoid any slipping of the plier.
grinder or a specific probe, which allows the archwire to
be inserted or removed from the slot. Brackets are easily 2D lingual bracket types
closed with a Weingart utility plier; but it is recom-
mended to close only one lip at a time to reduce the Several different types of 2D lingual bracket exist: the
risk of accidental debonding or damage. A cotton roll medium twin standard bracket can be used on all teeth
and is indicated particularly for relapse cases that do not
require the use of power chains or when comfort is a
Table 1 Main characteristics of 2D lingual brackets. must (Figure 2A), the narrow single (Figure 2B) and

1. Brackets can be used for all teeth, since there is no prescription Table 2 Components of the 2D lingual technique.
2. It is a self-ligating system, with progressive friction
3. They allow a vertical insertion of the archwire 1. 2D lingual brackets
4. Able to engage wires with maximum diameter of 0.022060.0160 2. Titanol superelastic or biolingual archwires
5. The total thickness is 1.4 mm, including the base (0.4 mm) 3. Light wire mechanics
6. They allow the use of thin power chains 4. Low friction and light forces
7. 2D plus brackets allow applying torque when needed 5. Direct or indirect bonding (without the need for any set-up)
S62 Cacciafesta Lingual Supplement JO September 2013

mini-ant bracket (Figure 2C), which are used in cases


with severe crowding or rotations, whenever space is too
limited for a standard bracket; the medium twin
(Figure 2D), which has a gingival hook and is indicated
for more complex treatment where power chain or inter-
maxillary elastics are needed (this bracket also allows for
the use of auxiliary torquing springs for simple third
order movements) and the 2D Plus lingual bracket
(Figure 2E), which has a rectangular slot that allows the
application of torque on single teeth. There are different
torque options to make the set-up relatively simple for
each affected tooth. Molar tubes complete the available
brackets and are extremely flat and chamfered for
excellent comfort (Figure 2F).
The absence of the slot in the base has made it possible
to reduce the total thickness of the bracket to only
1.4 mm, which allows the archwire to be almost tangent
to the lingual surface. These characteristics, together
with the use of round/squared wires and correct bracket
positioning, compensate for the different labio-lingual
thickness normally present on the front teeth, particu-
larly in the maxillary arch. Figure 3 Opening and closing 2D lingual brackets: (A) opening
brackets with a customized Haideman spatula; (B) closing brackets
Opening and closing 2D lingual brackets with a Weingart plier

Opening and closing of the clips is very easy and fast. A


modified spatula or the special explorer has to be inserted requires careful attention to three essential components: the
into the notch on the right side of the clip, thus opening tooth surface and its preparation, the design of the bracket
the bracket by mechanical deformation (Figure 3A). The base and the bonding agent. The steps involved for optimal
force of the explorer should always be directed toward the performance of direct bonding for lingual orthodontic
bracket pad to avoid debonding. The clips are laser- attachments are as follows: cleaning, enamel conditioning,
welded on the pad and the material is tested to withstand sealing, bonding and light curing (if necessary).
at least 20 normal opening and closing cycles. Once the
archwire is inserted, the clips can be closed. Weingart Cleaning
ultralight wire pliers are especially suitable. It is
recommended to close only one clip at a time and to Before bonding the brackets, it is essential to remove the
protect the enamel by using a cotton roll or a protection organic pellicle that normally covers the surface of all
cap on the outer beak of the plier (Figure 3B). teeth. This is accomplished by cleaning the enamel
surface using a mix of pumice and water or prophylactic
Direct bonding procedures for 2D paste, with a rubber cup or a polishing brush mounted
on a low-speed rotary instrument. The tooth is subse-
lingual brackets
quently rinsed with water to remove any pumice debris,
A major difference between the 2D lingual system and and thoroughly dried with a stream of oil-free air.
other lingual techniques is that no laboratory set-up is During this procedure, cheek and lip retractors, saliva
required. After some practice and experience, all the ejectors and cotton or gauze rolls should be used.
necessary steps can be very easily done at the chair side, If there is a need to increase bond strength, it is
in a similar manner to the clinical steps required to bond recommended that a microetcher (sandblaster) is used
conventional labial brackets. on the enamel surface for three seconds.
For bracket application, conventional college tweezers or
thin bracket holders can be employed. It is important to Enamel conditioning
slightly open the bracket clip before holding it with the
tweezers. Once the bracket is firmly held, rotate the tweezers After moisture control, it is necessary to maintain a
in order to show the base surface. Successful bonding completely dry working field and to create irregularities
JO September 2013 Lingual Supplement 2D lingual orthodontics S63

on the enamel surface. This is accomplished by covering


the entire enamel surface with 37% orthophosphoric
acid for about 30 seconds; longer etching periods
provide no more, but actually less retention, because
of the loss of surface structure. The simplicity of the
etching procedure is increased with the use of acid gels
rather than acid solutions; gels provide better control
for restricting the working field and avoid insulting the
gingival margin and initiating bleeding. The enamel
surface must not be contaminated with saliva, which
promotes immediate remineralization, until bonding is
completed; otherwise re-etching is required. After
rinsing the enamel again in order to completely remove
the etch, the tooth surface must be dried with a
moisture-and-oil-free source to obtain a uniform and Figure 4 Bonding in the mandibular arch with the aid of a
frosty white appearance. Recent advances indicate that placement gauge
microetching is also essential for successful treatment.
the incisal edge (Figure 4). In the maxillary arch, because
Sealing of the more complex anatomy and limited visibility, we
A liquid resin is then applied with a small foam pellet or suggest that a vacuum-formed soft sheet is used as a
brush with a single gingivo-incisal stroke on each etched reference guide or to perform indirect bonding. Bracket
inclinations can be indicated on the tray by marking the
tooth. The resin is able to penetrate into the irregula-
long axes of the teeth. This system will allow brackets to
rities created in the etched enamel surface, allowing the
be positioned at the correct height, thus avoiding occlusal
bonding material to mechanically interlock with the
interferences from the overbite (Figure 5).
tooth surface.

Bonding Indirect bonding procedures for 2D


lingual brackets
After application of the liquid resin, a small quantity of
adhesive is applied to the bracket base, which is then The long axes of the clinical crowns, occlusal margins and
pressed against the enamel in its correct position. bracket positions are marked on the plaster malocclusion
Depending on the type of bonding material, it can set model. After isolating the plaster model with a separating
either by a self-curing process or by light-curing. An liquid, the brackets can be bonded on the model using
adhesive should have sufficient viscosity so that the light-cure composite. After light-curing the brackets, a
bonded attachments do not drift out of position before transfer tray can be fabricated with silicone (Figure 6) or
the adhesive has set. Light curing composite resins, such a vacuum-forming machine (Figure 7). After removing
as Transbond XT (Unitek/3M, Monrovia, CA, USA) or the tray from the plaster model, the bracket composite
Kurasper F (Kuraray, Tokyo, Japan) are preferable. pads have to be cleaned with acetone. The patient’s teeth
The bracket bonding procedure consists of transfer,
positioning, fitting, removal of excess adhesive and light-
curing. When excess adhesive is carefully removed and
good oral hygiene is maintained, the gingival condition
is not adversely influenced by bonded lingual appliances;
however, when excess adhesive is close to the gingival
margin, it will produce periodontal damage (gingival
inflammation and hyperplastic gingival changes) and the
possibility of decalcification around the periphery of the
bonding base. Direct bonding is easier, faster (especially
if only a few teeth are to be bonded) and less expensive
than indirect bonding.
In the mandibular arch, direct bonding is performed Figure 5 Bonding in the maxillary arch with a vacuum-formed
using a placement gauge to mark the desired height from soft sheet as a reference guide
S64 Cacciafesta Lingual Supplement JO September 2013

Figure 6 (A–D) Indirect bonding with a silicone double tray technique

have to be prepared as in the direct bonding procedure. Main characteristics of Titanol lingual
Make sure not to use too much composite to avoid an archwires
excess after removing the tray. Remove the tray carefully
from the brackets. The nickel–titanium archwires normally used in combi-
nation with the 2D lingual brackets are Titanol lingual
archwires (Forestadent, Pforzheim, Germany) in three
classic shapes (small, medium and large, with sections
of 0.012, 0.014 and 0.016 inch, respectively). These

Figure 7 Indirect bonding with a vacuum-formed sheet

Figure 8 Titanol lingual archwires Figure 9 Biolingual nickel–titanium archwires


JO September 2013 Lingual Supplement 2D lingual orthodontics S65

Figure 10 Treatment of mandibular incisor crowding

archwires are pre-curved from canine to canine, both for of bending can be checked. This is a very easy clinical
the maxillary and mandibular arch, and allow precise procedure that requires only a few minutes of chair
insertion of a first-order bend between the canine and working time (Figure 8).8 Alternatively, biolingual wires
first premolar in order to produce the typical mushroom can be employed, which are mushroom-shaped lingual
arch configuration.11 We have developed a method archwires available in five different shapes and four
for adding simple first or second-order bends to the different wire dimensions with a template to determine
preformed archwire by overbending the wire whilst it is the correct shape (Figure 9).
in its martensitic (cold) phase. If the wire is then gently The use of nickel–titanium archwires enables the
heated with a flame (up to approximately 60–70uC), it clinician to produce low levels of applied force and to
will regain its austenitic phase, and the effective amount achieve a more consistent tooth movement during the

Figure 11 Treatment of a palatally impacted UR3 in an adult: (A) pre-treatment OPG; (B) post-eruption OPG; (C) intra-oral view
following exposure and bonding of the UR3; (D) accommodation of the UR3 into the arch; (E) alignment of the UR3
S66 Cacciafesta Lingual Supplement JO September 2013

Figure 12 Treatment of an anterior bilateral crossbite associated with the upper canine teeth in an adult: (A, B) pre-treatment; (C, D)
mid-treatment; (E, F) post-treatment

first phase of treatment (levelling and aligning), because ectopic canines (Figure 11), correction of anterior and
these wires have a wide range of deactivation, thus lateral crossbites (Figure 12) pre-orthognathic set-up and
significantly reducing the number of appointments and minor torque control (Figure 13).
reactivations.

Conclusions
Clinical applications
Lingual orthodontics satisfies aesthetic criteria by
The 2D lingual system can be effectively used in a number positioning the fixed appliance on the lingual surfaces
of clinical situations, including post-treatment retention, of the teeth. It demands special biomechanical expertise
closure of minor spaces and diastemas and the limited and technical skills, such as indirect bracket bonding
correction of deep bites. It is useful for the correction of and customized arch bending. However, 2D lingual
crowding, particularly in the mandibular arch (Figure 10) brackets are a valid alternative to conventional lingual
and can also be successfully used for more complex tooth brackets in adult cases that do not require third-order
movements, including the alignment of impacted or tooth movements. Indications for using these brackets

Figure 13 Adult presenting with anterior negative torque and a severe deep bite. (A, B) Pre- and post-treatment occlusion, respectively
JO September 2013 Lingual Supplement 2D lingual orthodontics S67

include post-treatment retention, closure of minor 5. Wiechmann D. A new bracket system for lingual ortho-
spaces, correction of deep bites, and correction of dontic treatment. Part 1 – Theoretical background and
crowding and crossbites. Additional malocclusions that development. J Orofac Orthop/Fortschr Kieferorthop 2002;
can be treated with this technique include management 63: 234–45.
of impacted/ectopic canines or pre-orthognathic surgical 6. Tagliabue A, Levrini L, Macchi A. Attacchi linguali
patients. Once the clinician’s familiarity with lingual Philippe: considerazioni cliniche. Mondo Ortod 2000; 25:
techniques has improved, he or she will be able to treat 187–92.
more difficult cases with more sophisticated 3D brackets 7. Macchi A, Tagliabue A, Levrini L, Trezzi G. Philippe self-
ligating lingual brackets. J Clin Orthod 2002; 36: 42–
and indirect bonding.
45.
8. Macchi A, Norcini A, Cacciafesta V, Dolci F. The use of
References ‘bidimensional’ brackets in lingual orthodontics: new
horizons in the treatment of adult patients. Orthodontics
1. Nidoli G, Lazzati M, Macchi A. Migliora l’estetica con 2004; 1: 21–32.
l’incollaggio linguale dei bracket. Attualita Dent 1988; 18: 9. Cacciafesta V, Sfondrini MF, Norcini A, Macchi A. Fiber
12–20. reinforced composites in lingual orthodontics. J Clin Orthod
2. Nidoli G, Lazzati M, Macchi A, Castoldi A. Analisi clinico- 2005; 39: 710–14.
statistica della morfologia dentale in rapporto al posizio- 10. Cacciafesta V, Sfondrini MF. One-appointment correction
namento dei bracket linguali. Mondo Ortod 1985; 10: 45–53. of a scissor bite with 2D lingual brackets and fiber-
3. Alexander CM, Alexander RG, Gorman JC, et al. Lingual reinforced composites. J Clin Orthod 2006; 40: 409–11.
orthodontics: a status report. J Clin Orthod 1982; 16: 255–62. 11. Fujita K. New orthodontic treatment with lingual bracket
4. Nidoli G, Lazzati M, Macchi A. Applicazione diretta o mushroom archwire appliance. Am J Orthod 1979; 76: 657–
indiretta dei bracket linguali. Mondo Ortod 1984; 9: 63–72. 75.

You might also like